Contraception: Counseling Principles

Published on 30/05/2015 by admin

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Chapter 4 Contraception: Counseling Principles

THE CHALLENGE

Assisting couples in identifying and using the most appropriate method of controlling fertility is an important challenge. Changing patterns of sexual expression, new technologies, increased consumerism, and heightened cost pressures all affect the choices made in the search for fertility control. The very nature of the topic gives contraception personal, religious, and political overtones that often lead to conflict, emotionality, and confusion.

SCOPE OF THE PROBLEM

In the United States, more than half (56%) of all pregnancies are unplanned, despite the fact that 90% of women at risk (fertile, sexually active, and neither pregnant nor seeking pregnancy) are using some form of contraception. The 10% or so of women not using contraception account for more than half of these unintended pregnancies. The remaining unplanned pregnancies occur as a result of either failure of the contraceptive method used or the improper or inconsistent use of the method.

OBJECTIVES OF COUNSELING

No “ideal” contraceptive method exists. Although efficacy and an acceptable risk of side effects are important in the choice of contraceptive methods, these are often not the factors on which the final choice is made. Motivation to use, or continue to use, a contraceptive method is based on education; cultural background; cost; and individual needs, preferences, and prejudices. Factors such as availability, cost, coital dependence, personal acceptability, and the patient’s perception of the risk all have a role in the final choice of methods.

TACTICS

Relevant Pathophysiology

Currently available contraceptive methods seek to prevent pregnancy by preventing the sperm and egg from uniting or by preventing implantation and growth. These goals are accomplished by preventing the development and release of the egg (oral and nonoral hormonal contraceptives, long-acting hormonal methods), preventing union of sperm and egg by imposing a mechanical, chemical, or temporal barrier between sperm and egg (condom, diaphragm, foam, intrauterine devices, rhythm, withdrawal, postcoital oral contraception), or altering the likelihood of implantation or growth (RU-486). Relative efficacy (first-year failure, both real and theoretical) is shown in the accompanying table.

CONTRACEPTIVE USE AMONG U.S. WOMEN, 2002

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Strategies

For a couple to use a method, it must be accessible, immediately available (especially in coitally dependent or “use-oriented” methods), and of reasonable cost. The impact of a method on spontaneity, or the modes of sexual expression preferred by the patient and her partner, may also be important considerations. A decision tree based on these concepts is presented in the accompanying figure.

Patient Education

American College of Obstetricians and Gynecologists: Birth Control. ACOG Patient Education Booklet AP005.
American College of Obstetricians and Gynecologists: Birth Control (Especially for Teens). ACOG Patient Education Booklet AP112.
American College of Obstetricians and Gynecologists: Sterilization for Women and Men. ACOG Patient Education Booklet AP011.
American College of Obstetricians and Gynecologists: The Intrauterine Device. ACOG Patient Education Booklet AP014.
American College of Obstetricians and Gynecologists: Birth Control Pills. ACOG Patient Education Booklet AP021.
American College of Obstetricians and Gynecologists: Barrier Methods of Contraception. ACOG Patient Education Booklet AP022.
American College of Obstetricians and Gynecologists: Natural Family Planning. ACOG Patient Education Booklet AP024.
American College of Obstetricians and Gynecologists: Sterilization by Laparoscopy. ACOG Patient Education Booklet AP035.
American College of Obstetricians and Gynecologists: Postpartum Sterilization. ACOG Patient Education Booklet AP052.
American College of Obstetricians and Gynecologists: Emergency Contraception. ACOG Patient Education Booklet AP114.
American College of Obstetricians and Gynecologists: Hormonal Contraception Injections, Rings, and Patches. ACOG Patient Education Booklet AP159.

IMPLEMENTATION

Special Considerations

Adolescent patients require reliable contraception but often have problems with compliance. Careful counseling about options (including abstinence), the risks of pregnancy and STDs, and the need for both contraception and disease protection must be provided. These patients may be better served by methods that rely less on the user for reliability (intrauterine devices or long-acting hormonal agents such as injections, ring, patches, and implants) than those that depend on consistent use (use-oriented methods and those that are time sensitive such as progestin-only contraceptives).

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Contraception for breastfeeding mothers may include oral contraceptives if milk flow is well established. (Long-acting progesterone contraceptives may actually result in a slight increase in breast milk production.) Barrier contraceptives are not contraindicated in these patients. An intrauterine device, copper or hormone containing, may also be placed once the uterus has returned to normal.

Patients older than age 35 years may continue to use low-dose oral contraceptives if they have no other risk factors and do not smoke. Compliance concerns are generally less in these patients, making use-oriented methods more acceptable and reliable. Long-term methods (intrauterine devices, long-acting progesterone contraception, or sterilization) may also be appropriate. Until menopause is confirmed by clinical or laboratory methods, contraception must be continued if pregnancy is not desired.

Ovulation may occur as soon as 2 weeks following abortion (spontaneous or induced). If oral contraceptives are chosen as the contraceptive method, they should be started immediately after the loss.

REFERENCES

Level III

American College of Obstetricians and Gynecologists. Emergency contraception. ACOG Practice Bulletin 69. Washington, DC: ACOG, 2005.

American College of Obstetricians and Gynecologists. Use of hormonal contraception in women with coexisting medical conditions. ACOG Practice Bulletin 73. Washington, DC: ACOG, 2006.

Benagiano G, Bastianelli C, Farris M. Contraception today. Ann N Y Acad Sci. 2006;1092:1.

Deligeoroglou E, Christopoulos P, Creatsas G. Contraception in adolescence. Ann N Y Acad Sci. 2006;1092:78.

Draper BH, Morroni C, Hoffman M, et al. Depot medroxyprogesterone versus norethisterone oenanthate for long-acting progestogenic contraception. Cochrane Database Syst Rev. 2006:3. CD005214.

Glasier A, Gulmezoglu AM, Schmid GP, et al. Sexual and reproductive health: A matter of life and death. Lancet. 2006;368:1595.

Hansen LB, Saseen JJ, Teal SB. Levonorgestrel-only dosing strategies for emergency contraception. Pharmacotherapy. 2007;27:278.

Kulier R, Helmerhorst FM, O’Brien P, et al. Copper containing, framed intra-uterine devices for contraception. Cochrane Database Syst Rev. 3, 2006. CD005347

Lesnewski R, Prine L. Initiating hormonal contraception. Am Fam Physician. 2006;74:105.

Masimasi N, Sivanandy MS, Thacker HL. Update on hormonal contraception. Cleve Clin J Med. 2007;74:186. 188, 193 passim. Review

McNamee K. The vaginal ring and transdermal patch: New methods of contraception. Sex Health. 2006;3:135.

Nelson AL. Reversible female contraception: current options and new developments. Expert Rev Med Devices. 2007;4:241.

Practice Committee of the American Society for Reproductive Medicine. Hormonal contraception: recent advances and controversies. Fertil Steril. 2006;86(5 Suppl):S229.

Smith RP. Gynecology in Primary Care. Baltimore: Williams & Wilkins, 1997;209.

Szarewski A. Hormonal contraception: Recent advances. J Fam Health Care. 2006;16:35.

The Alan Guttmacher Institute. Contraceptive use. Facts in Brief. New York: AGI, 2006.

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