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Understand patient objectives, counseling resources when discussing contraception

NASHVILLE — Clinicians should focus on a patient’s goals and the risks associated with pregnancy, rather than advocating for a specific option, when advising on contraception options, according to a presenter at the American College of  Obstetricians and Gynecologists Annual Clinical and Scientific Meeting.

“It’s not all about effectiveness – people have many reasons for accessing contraception and our job is not to reduce unintended pregnancy, in fact that concept is not appealing to a lot of communities,” Eve Espey, MD, MPH, chair of the obstetrics and gynecology department at the University of New Mexico, told attendees. “The idea is that we empower women to use the birth control method that’s best for them.”

To facilitate these discussions, clinicians should take advantage of the resources available, most notably the US Medical Eligibility Criteria (MEC) and US Selected Practice Recommendations for Contraception Use (SPR), available on-line and as an app, she said.

The MEC helps the clinician to identify which options would be appropriate for a given patient given certain health parameters, such as age, blood pressure, and BMI, and behaviors, such as smoking history and postpartum breast-feeding considerations, Espey said. The app ranks the pill, ring and IUD options based on available evidence on a 1-4 scale, with 1 being always appropriate, 2 being the benefits outweigh the risks, 3 being the risks outweigh the benefits and 4 being always contraindicated. SPR addressed best practices in implementing a selected option.

Clinicians should have an eye toward the future when using the apps, Espey said, because an option that is appropriate at a given age may be less recommended when the patient is a few years older. Such considerations should be part of the conversation with the patient, as it may involve switching medications.

For patients who do not seem to be interested in discussing contraception at a given visit, Espey advises them of resources such as bedsider.org, which reviews all the patient’s options and can help guide future conversations.

When managing patients with significant chronic conditions, clinicians should educate them on the risks associated with pregnancy and encourage conversations around contraception.

A 2015 review of contraception use by US women aged 15 to 34 with chronic diseases found that 51% of women with hypertension, 56% of women with diabetes, 60% of women with a history of or risk factors for stroke, 63% of patients with epilepsy and 58% of women with thrombophilia, were not using any form of contraception.

“With our patients becoming more complex, with more comorbidities, we are seeing more and more patients who have a much more highly associated risk associated with pregnancy,” Espey said. “These are patients who really need a detailed counseling about contraception.”

In many cases, these more complicated patients are going to be referred to an OB/GYN, she added.

“Long-acting reversible contraception, just like permanent contraception, tend to be better choices medically for women with adverse pregnancy conditions because the estrogen component of combined hormonal contraception accounts for so much of the morbidity and increased risk of pills, patch and ring,” Espey said. -- by Chris Rosenberg

Reference: Espey E. “Contraception: What you need to know in 2019.” Presented at: American College of Obstetricians and Gynecologists Annual Clinical and Scientific Meeting; May 3-6, 2019; Nashville.

Disclosures: Healio Primary Care Today was unable to determine Epsey's relevant financial disclosures prior to publication.