Continuing Education

Individualizing contraception

By Melanie Deal, MSN, WHNP-BC, FNP; Anne Moore, DNP, APN, FAANP; and Carolyn Sutton, MS, WHNP-BC, FAANP

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In this article, the authors focus on helping women choose a birth control method that will be the most suitable and effective for each of them—at each successive stage of their lives. Many useful tips regarding patient-centered counseling are offered. In addition, the authors discuss emergency contraceptives, including the products that are available and
the ways that healthcare practitioners can explain these options to their patients.

Contraceptive counseling: Why is it so important?

The disconnect between two seemingly contradictory facts—effective contraception is widely available, but almost half of pregnancies in the United States are unintended—highlights the need for better communication between healthcare practitioners (HCPs) and their patients about contraception and the development of strategies to increase patient adherence to and satisfaction with contraceptive regimens. Women also need more information about how to use and obtain emergency contraceptives (ECs).

Among the 6.4 million pregnancies that occur in the United States each year, 49% are unintended.1 Of these unintended pregnancies, 29% happen earlier than desired and 20% happen after women have reached their desired family size. In addition, of these unintended pregnancies, 52% occur in the absence of the use of contraception, 43% occur with inconsistent or incorrect use, and 5% occur with consistent use and method failure. When asked about reasons for their nonuse of contraception, women report problems accessing or using methods (40%), infrequent sex (19%), lack of caring about whether pregnancy occurs (18%), underestimation of the risk of pregnancy (7%), and other reasons (16%).1

Contraceptives vary in terms of efficacy. Although all contraceptives are highly effective with perfect use, the most effective agents—the hormonal intrauterine contraceptive (IUC), the copper T-380A intrauterine device (IUD), and the subdermal implant—have high levels of efficacy with typical use because there is no user component that may result in incorrect or inconsistent use. Based on typical-use data, the oral contraceptive (OC), the vaginal ring, the patch, and the injection are less effective than IUCs and the implant—primarily because they require user actions and decision making. The least effective options are those that are coitus dependent: condoms, withdrawal, other barrier methods, and spermicides.2 Of note, the highest levels of satisfaction with contraceptives are reported by users of IUCs and the ring.3

Forty-six percent of women discontinue a birth control method because of dissatisfaction.4 To reduce this discontinuation rate, HCPs need to provide effective counseling. Such counseling requires asking patients about their goals and attitudes regarding contraception and then listening carefully to their answers. That way, HCPs can be confident that they are prescribing the form of contraception that will best meet patients’ needs and with which they will be most satisfied. Reports suggest that inconsistent use of combined OCs (COCs)—that is, those containing an estrogen and a progestogen—is more common among women who are not completely satisfied with their method.4

Healthcare practitioners must provide each patient with a knowledge base so that she can make informed decisions about birth control and birth control options. In the process, HCPs may need to correct deeply entrenched misinformation. HCPs also must provide anticipatory guidance about the use and the side effects of contraceptives and ECs. The bottom line: Patients need to leave the office knowing what to expect from the contraceptive they have selected and they need to know how to obtain and use an EC in the event of contraceptive mishap (e.g., torn condom, dislodged diaphragm) or nonadherence.

Strategies for selecting a contraceptive

Strategy 1: Set the stage for an effective visit. Although HCPs are pressed for time, they can obtain key information to help them partner with a patient and help her select the most appropriate contraceptive option for her before she even enters the examination room. When a patient calls to schedule an appointment with a goal of contraceptive counseling, she can be referred to the Association of Reproductive Health Professionals method match website. This website will enable the patient to become familiar with the options and evaluate them prior to her visit.

On standard forms that a patient completes in the waiting room, HCPs can include questions about pregnancy plans. Do you desire a pregnancy within 1 year? Within 1-3 years? Within 3-5 years? Not for 5-10 years or more? Not at all? Her answer will help you narrow down the list of options. Next, ask the patient about her contraceptive history: What forms of contraception have you used? What did you like/dislike about each method?

Discuss contraception prior to the physical examination, while the patient is still clothed; she is unlikely to give you her full attention if she is trying to keep the paper drape closed. Have samples of the contraceptive products in the exam room so that the patient can see and handle them.

Strategy 2: Analyze perfect use versus typical use. The level of participation and decision making required of patients in the use of a contraceptive method accounts for the gap between perfect use and typical use. The more user participation that is needed (e.g., remembering to take a pill every day), the greater the gap between perfect use and typical use. Although all contraceptives used correctly and consistently offer excellent efficacy, first-year rates of unintended pregnancy associated with typical use range from 8% with OCs to less than 1% for long-acting reversible contraceptives (LARCs; i.e., IUCs and implants) that require no patient participation or decision making.5

Therefore, each patient should be asked about how she will manage the use of contraceptives that require daily, monthly, or quarterly actions on her part. Ask her, “If you choose condoms or OCs, will you be able to manage them? These forms of contraception take more work on your part. Conversely, a long-acting method frees you from having to think about it; put it in and forget it.” The rate of non-LARC contraceptive failure is particularly high for adolescents. Among users of OCs, the patch, or the ring, the yearly failure rate in the first year of use is 8.2% among women aged 30 years or older and 13.4% among adolescents.6,7Strategy 3: Teach patients that LARCs are more effective than other methods in preventing unplanned pregnancy, especially over time. Long-term use of agents that require decision making on a patient’s part, as compared with long-term use of LARCs, is associated with increased risk of incorrect or inconsistent use and pregnancy. This finding was confirmed in a recent study of 7,486 women using LARCs (i.e., IUCs or implants) or another commonly prescribed contraceptive (OC, patch, ring, or depot medroxyprogesterone ace­tate [DMPA] injection).7 The contraceptive failure rate among participants using non-LARCs—that is, OCs, the patch, or the ring—was 4.55 per 100 participant-years, as compared with 0.27 among participants using LARCs (adjusted hazard ratio [HR], 21.8; 95% confidence interval (CI), 13.7-34.9). Rates of unintended pregnancy were similarly low among participants receiving the DMPA injection and those using an IUD or an implant. In this investigation, for users of OCs, the patch, or the ring, the contraceptive failure rate increased over time, from about 5% in year 1 to nearly 8% in year 2 and more than 9% in year 3. LARCs, including DMPA, had failure rates of less than 1% for each of the 3 years. Therefore, the need for correct and consistent use of contraception should be reviewed at each patient visit, year after year.

Strategy 4: Assess the options that best meet an individual patient’s needs. Ask each patient how the methods that interest her will fit into her life—now and, in light of ongoing concerns regarding adherence, in the future. How will each method fit into her schedule? For example, how will she remember to take the pill or change the patch? Which bleeding patterns will be acceptable? If, in the first few months, a patient does not know when bleeding is likely to occur, will this be a problem for her? Is privacy of the method a concern? Are there any financial barriers? If so, are there assistance programs or installment payment plans available? Review the patient’s record for any conditions (e.g., dysmenorrhea, heavy menstrual bleeding, menstrual migraine, acne) that could be simultaneously managed by specific methods. Finally, determine whether the patient has any contraindications to any birth control methods. For example, use of combined hormonal contraceptives is contraindicated in patients with migraine with aura and in users of certain types of anticonvulsants.

Strategy 5: Dispel myths, especially those related to IUCs. To dispel common misconceptions about IUCs, discuss their mechanism of action with patients. These devices prevent fertilization; they do not cause abortions.2,8 Another myth to dispel is any association between IUC use and an increased risk of ectopic pregnancy. The contraceptive effectiveness of these devices is 99.9%; the risk of pregnancy is very small. In the event that pregnancy should occur, the possibility of an ectopic pregnancy is of concern, but the likelihood of such an occurrence is minute.2,8

Testing for sexually transmitted infections (STIs) in women scheduled to undergo IUC insertion is generally not done unless they are at risk for chlamydia and gonorrhea (e.g., women aged 25 years or younger). Risk of pelvic inflammatory disease is higher at IUC insertion only if a woman tests positive for chlamydia or gonorrhea.2,8Strategy 6: Help your patient be successful in adhering to her contraceptive regimen. Once a woman has selected a contraceptive, help her be successful in its use. This checklist can help ensure that she has the tools she needs for success. Your patient…
? Leaves the office knowing, in simple terms, how the option she has selected works;
? Understands how to use the method correctly;
? Is aware of the side effects, which you have explained using simple terms;
? Knows the warning signs that signal potential complications and what her course of action should be;
? Understands the indications for EC use and knows where and how to obtain an EC;
? Realizes that, if she doesn’t like her contraceptive choice, she can return to your office for assistance in choosing a different method that is better suited to her needs;
? Has resources to help her remember key points about the contraceptive she has chosen, including handouts and information about websites that provide accurate information;
? Knows that she will still need to protect herself against STIs.

Emergency contraception

Many HCPs are uncomfortable with the topic of emergency contraception and do not discuss it unless a patient asks about it. In patients’ best interest, though, HCPs need to use every visit as an opportunity to discuss contraception and the potential need for an EC. ECs are defined as contraceptives intended to prevent pregnancy within the first few days of unprotected sex. The most commonly used ECs contain oral levonorgestrel (LNG). Ulipristal acetate, a selective progesterone receptor modulator, is another oral EC. Another effective method of EC available is the copper IUD, which is used off label for this indication.

Levonorgestrel agents are available in two over-the-counter dosing regimens.9-14 The one-tablet regimen contains LNG 1.5 mg. On label, this product is taken within 72 hours after unprotected intercourse, when it is most effective. Off label, it can be used up to 120 hours after intercourse. The second regimen is a two-tablet product that also contains a total of 1.5 mg of LNG (0.75 mg per pill). The package labeling states that one pill is taken immediately after unprotected intercourse and the second pill, 12 hours later. Off-label directions are to take both pills at once, preferably within 72 hours of unprotected intercourse. For both LNG regimens, greatest efficacy is achieved when the medication is taken within 72 hours of unprotected intercourse, but efficacy has been demonstrated up to 120 hours after unprotected intercourse. After EC use, a highly effective contraceptive should be started; a backup method (e.g., condoms) is needed for 7 days.

Ulipristal acetate 30 mg is available by prescription.13-16 This product can be used during the first 120 hours after unprotected intercourse. Unlike other agents, ulipristal acetate maintains efficacy during the full 120 hours after intercourse. This EC, which is highly effective in obese women as well as their normal-weight counterparts, may be ordered from an online prescription service. After use, a highly effective contraceptive should be started; a backup method is needed for 14 days.

The copper IUD can provide emergency contraception within 5 days of unprotected intercourse. Although use of the copper IUD is off label for this indication, one advantage is that this product can then be retained as a long-acting contraceptive. Efficacy of this EC method was shown in a prospective study of 542 women who presented for emergency contraception.17 The 1-year cumulative pregnancy rate in women choosing the copper IUD was 6.5%, as compared with 12.2% in those choosing oral LNG (HR, 0.53; 95% CI, 0.29-0.97; P = .041]. Thus, 1 year after presenting for emergency contraception, women choosing the copper IUD were half as likely as those choosing oral LNG to have a pregnancy.

Strategy 7: Ensure access to ECs. Results of a 2013 patient survey by NPWH have shown that more than 75% of HCPs do not discuss emergency contraception with their patients. However, patients who find themselves in need of an EC should learn about it through communication with their HCP. Furthermore, a 2011 survey distributed to the email database of NPWH (N = 10,800) and completed by 699 clinicians showed important gaps in best practices in patient care among the respondents:
• 55.3% reported that they review EC options with each reproductive-aged patient.
• Although 88.2% of respondents said that they tell patients about LNG, only 26.5% reported discussing ulipristal acetate; 21.9%, the copper IUD; and 16.1%, the Yuzpe method.
• Only 44.3% of respondents said that they provide information and/or a prescription for an EC to all patients who do not desire pregnancy.

In view of the fact that 49% of pregnancies in the U.S. are unintended, HCPs are advised to review EC use and availability at each office visit by (1) explaining what EC does, how it works, and when to use it; (2) providing an anticipatory prescription; and (3) reviewing and dispelling myths about ECs. Concerns about ECs’ mechanisms of action remain associated with major barriers to use.14 Many women believe that ECs are abortifacients with long-term effects on health and fertility.18 A patient’s poor understanding of reproductive physiology may result in confusion as to when ECs are most effective.19,20

Case studies

Case 1: Tanya is 24 years old, is 5’5″, weighs 121 lb (body mass index [BMI], 20.1 kg/m2), and has no prior pregnancies or health problems. Tanya schedules a visit to request a different OC because of bothersome light bleeding for the past 3 months. She currently uses a COC containing ethinyl estradiol 20 mcg and norethindrone. Further discussion reveals that Tanya skips taking her birth control pill no more than once a week. She has had three male partners in the past 3 months and reports condom use about half the time. She reports smoking about 10 cigarettes a day.

Assessment. Begin by doing a workup concerning the abnormal bleeding, which may or may not be related to the COC regimen. Rule out pregnancy and STIs and perform speculum and bimanual examinations. Because Tanya has no mucopurulent cervicitis, discharge, or tenderness, and her test results are all negative, you conclude that the irregular bleeding is a side effect of the COC use. As you recall, the longer a patient uses a method, the more likely she is to use it incorrectly.

Counseling. Develop strategies to encourage correct and consistent COC use. In this case, consider changing formulations to reduce side effects. Review all the options with Tanya. Take this opportunity to discuss nondaily methods. Although Tanya is not a heavy smoker, remind her that her nicotine intake could be sufficient to induce breakthrough bleeding. Discuss safer sex and the importance of protecting herself from STIs. Review the indications for EC use. Make sure she knows how and where to obtain an EC. Provide a prescription for an EC product.

Patient decision. Tanya is interested in using a nondaily contraceptive and wants to try the ring. Discuss the use, side effects, and warning signs, and reinforce the fact that the ring will not protect against STIs. If the device is expelled or if Tanya is not punctual about replacing the ring, she will need to use an EC following unprotected intercourse. Schedule a follow-up visit to discuss Tanya’s satisfaction with the ring. At a follow-up visit, Tanya indicates that she likes the ring and has had no episodes of unscheduled bleeding.
Case 2: Annette is 17 years old, is 5’7″, weighs 220 lb (BMI, 34.5 kg/m2), and has had no prior pregnancies. Annette has scheduled her appointment for contraceptive counseling and looks to you for advice.

Assessment. Annette’s history includes obesity, migraine with aura, dysmenorrhea, and menorrhagia. Her partner uses condoms about half the time. She worries about weight gain with hormonal contraceptives. She is uncertain about her ability to remember to take a daily pill. Because of her migraine with aura, methods that contain estrogen are contraindicated. A patient with migraine without aura could use estrogen products as long as her blood pressure is monitored and her headache severity and frequency are not adversely affected. Pro­gestin-only pills (POPs) would be a good option if Annette had indicated a willingness to use them consistently. DMPA can be associated with weight gain, which is already a concern for her.

The LNG intrauterine system (IUS) represents a good option because it may help alleviate Annette’s cramping and bleeding, which would be likely to increase her satisfaction with this method. An implant might be a good choice, but she likes the longer duration associated with the LNG IUS. The 10-year duration of the copper IUD appeals to her, but she would like the reduction in menstrual problems that may result from use of the LNG IUS.

Patient decision. Annette selects the LNG IUS. Review the mechanism of action, side effects, and warnings, with an emphasis on the transitional bleeding interval. Although bleeding patterns will likely normalize within 3 months, tell her that it may take 6 months. This strategy accounts for the variability in duration and reduces the potential for frustration. Review safer sex and condom use at the initial discussion and before and after placement of the device.

Case 3: Regina is 44 years old, is 5’5″, weighs 200 lb (BMI, 33.3 kg/m2), and has no history of pregnancy. Regina has scheduled a visit for her well-woman examination. She has not been sexually active since her divorce, but she has started a relationship that she believes may become serious. Therefore, you initiate a discussion about contraception.

Assessment. Regina’s history is unremarkable except for a cholecystectomy at age 30. Her menstrual history remains normal, with menses marked by predictable intervals, duration, and cramps, all of which indicate ovulation. She takes naproxen sodium for moderate to severe cramps. Regina has a demanding job in advertising and travels often, noting fatigue associated with erratic schedules and frequent time zone changes. Her variable schedule makes it difficult to sustain an exercise regimen. She indicates that she would like to exercise more regularly to lose weight. Regina and her husband got divorced 5 years ago; early in the marriage, they had decided not to have children. He underwent a vasectomy. A nonsmoker, she drinks wine 1-2 times a week in social settings.

Counseling. Regina does not use contraception. However, data show that unplanned pregnancy is most likely among younger and older women. Convey to Regina that in women of her age, pregnancy is associated with an increased risk for maternal mortality, spontaneous abortion, and fetal abnormalities. Discuss ECs, safer sex, and STI risk.

Patient decision. Based on her profile, Regina is eligible for any contraceptive, although the patch may be less effective because she weighs more than 198 lb. Other less-than-optimal choices are COCs or POPs because she has indicated that she has an irregular daily routine and schedule. She is most interested in an IUD; either the LNG IUS or the copper IUD is appropriate for her. She considers each option: 5-year versus 10-year efficacy and hormonal versus nonhormonal characteristics.

Regina wants to do some research on her own. Refer her to a reliable website such as www.arhp.org/methodmatch. She plans to start Weight Watchers and a swimming routine that she can implement in many of the hotels at which she stays. You and Regina decide that she will call you as soon as she makes her decision about which IUC to use, and that, in the meantime, she will keep condoms available for use if needed. At her next visit, Regina informs you that she has decided to use the copper IUD because she prefers a nonhormonal method.

A final word about contraceptives and weight gain

Two of the three cases discussed in this article involve women who are obese. Sixty-four percent of women in this country are overweight and 36% are obese.21 Therefore, body weight may be an important consideration when choosing a contraceptive; some options may be associated with a tendency for weight gain and some may not be as effective in obese women.

In terms of the former concern, four randomized, placebo-controlled trials showed no evidence supporting a causal association between use of COCs or a combination patch and weight gain.22 Results of a similar review were inconclusive with regard to progestin-only contraceptives.23 However, a prospective study of 450 adolescents showed that among those using DMPA, those who were already obese gained significantly more weight than did their non-obese counterparts.24 Also, the obese DMPA users gained significantly more weight than did obese COC users or obese nonusers of hormonal contraception. With regard to contraceptive efficacy, the patch may be less effective in women weighing 198 lb or more.25 With regard to EC efficacy in obese women, ulipristal acetate may be a better choice than LNG-containing ECs.26

Conclusion

Even though information about contraceptives is readily available in print and online, and even though contraceptives themselves are easily available and, in many cases, fully covered by health insurance payments to pharmacies, many adolescents and women are not using these products correctly, consistently, and persistently. HCPs, including nurse practitioners, can fill in the knowledge gap by making sure to discuss contraceptive needs with all their patients, and to find the product or products that will work best for them.

References
1. Frost JJ, Darroch JE, Remez L. Improving contraceptive use in the United States. In Brief. Guttmacher Institute. 2008. www.guttmacher.org/pubs/2008/05/09/ImprovingContraceptiveUse.pdf

2. Hatcher RA, Trussell J, Nelson AL, et al, eds. Contraceptive Technology: Twentieth Revised Edition. New York, NY: Ardent Media, Inc.; 2011.

3. Revisiting Your Women’s Health Care Visit. Harris Interactive for the Association of Reproductive Health Professionals. Conducted June 30–July 14, 2004.

4. Moreau C, Cleland K, Trussell J. Contraceptive discontinuation attributed to method dissatisfaction in the United States. Contraception. 2007; 76(4):267-272.

5. Trussell J, Guthrie KA. Choosing a contraceptive: efficacy, safety, and personal considerations. In: Hatcher RA, Trussell J, Nelson AL, et al, eds. Contraceptive Technology: Twentieth Revised Edition. New York, NY: Ardent Media; 2011:45-74.

6. Kost K, Singh S, Vaughan B, et al. Estimates of contraceptive failure from the 2002 National Survey of Family Growth. Contraception. 2008;77(1):10-21.

7. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998-2007.

8. Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet. 2000;356(9234):1013-1019.

9. Arowojolu AO, Okewole IA, Adekunle AO. Comparative evaluation of the effectiveness and safety of two regimens of levonorgestrel for emergency contraception in Nigerians. Contraception. 2002;66(4):269-273.

10. Piaggio G, von Hertzen H, Grimes DA, Van Look PF. Timing of emergency contraception with levo­norgestrel or the Yuzpe regimen. Task Force on Postovulatory Methods of Fertility Regulation. Lancet. 1999;353(9154):721.

11. von Hertzen H, Piaggio G, Ding J, et al; WHO Research Group on Post-ovulatory Methods of Fertility Regulation. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet. 2002;360(9348):1803-1810.

12. Ngai SW, Fan S, Li S, et al. A randomized trial to compare 24 h versus 12 h double dose regimen of levo­norgestrel for emergency contraception. Hum Reprod. 2005;20(1):307-311.

13. The Emergency Contraception Website. www.not-2-late.com

14. Reproductive Health Technologies Project website. www.rhtp.org

15. Glasier A, Cameron ST, Blithe D, et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception. 2011;84(4):363-367.

16. Moreau C, Trussell J. Results from pooled Phase III studies of ulipristal acetate for emergency contraception. Contraception. 2012;86(6): 673-680.

17. Turok DK, Jacobson JC, Dermish AI, et al. Emergency contraception with a copper IUD or oral levo­norgestrel: an observational study of 1-year pregnancy rates. Contraception. 2013 Nov 22. Epub ahead of print.

18. Corbett PO, Mitchell CP, Taylor JS, Kemppainen J. Emergency contraception: knowledge and perceptions in a university population. J Am Acad Nurse Pract. 2006;18(4):161-168.

19. Gemzell-Danielsson K, Berger C, P G L L. Emergency contraception — mechanisms of action. Contraception. 2013;87(3):300-308.

20. Shoveller J, Chabot C, Soon JA, et al. Identifying barriers to emergency contraception use among young women from various sociocultural groups in British Columbia, Canada. Perspect Sex Reprod Health. 2007;39(1):13-20.

21. National Institute of Diabetes and Digestive and Kidney Diseases. Weight-control Information Network. Overweight and Obesity among Adults Age 20 and Older, United States, 2009–2010. http://win.niddk.nih.gov/statistics/#b

22. Gallo MF, Lopez LM, Grimes DA, et al. Combination contraceptives: effects on weight. Cochrane Database Syst Rev. 2011;(9):CD003987.

23. Lopez LM, Edelman A, Chen-Mok M, et al. Progestin-only contraceptives: effects on weight. Cochrane Database Syst Rev. 2011;(4):CD008815.

24. Bonny AE, Ziegler J, Harvey R, et al. Weight gain in obese and non­obese adolescent girls initiating depot medroxyprogesterone, oral contraceptive pills, or no hormonal contraceptive method. Arch Pediatr Adolesc Med. 2006;160(1):40-45.

25. Ortho Evra website. Janssen Pharmaceuticals, Inc. 2014. http://
www.orthoevra.com/

26. Batur P. Emergency contraception: separating fact from fiction. Cleve Clin J Med. 2012;79(11):771-776.

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