Contraception Counseling

Dr. Nuha Qasem, Assistant professor

Family Medicine and Internal Medicine Department- Hashemite University
Higher Specialization in FM, University of Jordan
Fellowship in Child and Women Health, University of Bologna, Italy
Family Planning
• Effective use of contraceptives can prevent unintended pregnancies.
• Ensuring women’s access to quality family planning information and services
improves their health and well-being as well as that of their children.
• International studies have found that unplanned pregnancies are associated with
a number of negative consequences:
• Women with an unintended pregnancy are more likely to have delayed or
received inadequate prenatal care, which can affect the health of both
mother and child.
• Infants born of unintended pregnancies are more likely to have
• Birth defects
• Low birth weight
• Poor mental and physical functioning in early childhood
Unintended pregnancies
• The 2002 Jordan Population and Family Health Survey
(JPFHS) revealed that the proportion of unintended
pregnancies was 33% of births to ever-married women
within the 5 years preceding the survey.
• According to the 2012 JPFHS if all unwanted births were
prevented in Jordan, the total wanted fertility rate would
be 2.4 children per woman, or 1.1 child less than the
actual total fertility rate (TFR). That theoretical rate
implies that the TFR is inflated by 46 % because of
unwanted births.
• In the US 50% of pregnancies are unplanned
CONTRACEPTIVE EFFICACY
• Most effective
• Long-acting reversible contraception (LARC: intrauterine contraception and
contraceptive implants)
• Sterilization.
• Effective
• Injectable contraceptives have the highest effectiveness in this tier.
• Oral contraceptives, the transdermal patch, and the vaginal ring are also associated
with a very low pregnancy rate if they are used consistently and correctly, but actual
pregnancy rates are substantially higher because of inconsistent/incorrect use .
• Least effective
• Diaphragms, cervical caps, sponges, male and female condoms, spermicides, periodic
abstinence, and withdrawal are associated with actual pregnancy rates that are much
higher than perfect use rates.
Lactational Amenorrhea Method (LAM)
• Relies on breastfeeding as a contraceptive method.
• Women who are amenorrhoeic and exclusively breastfeed at regular
intervals have the same protection against pregnancy for the first 6 months
postpartum as women taking combined oral contraceptives (98% efficacy).
• Effective use of this method depends on several important points:
• 1) regular intervals are defined as no intervals greater than 4 hours
between feedings during the day or 6 hours at night
• 2) exclusive breastfeeding means that supplemental food should not
exceed 5-10 % of total feedings. Supplemental feeding increases the risk
of ovulation and pregnancy, even in women who are not menstruating.
Fertility Awareness-Based Methods ( FAMs)
• Also known as Natural Family Planning of periodic abstinence.
• It is a modern method of contraception
• Relies on realizing the fertile days of a female menstrual cycle
and abstaining from sexual activity or using barrier method
during that period.
• The failure rate in typical use is estimated to be approximately
25%.
FAMs
• Calendar (rhythm) method
• Standard days method (SDM)
• The TwoDay Method (TDM)
• Basal body temperature (BBT) method
• Cervical mucus method (Billings method)
• Hormone monitoring
• Combined (symptothermal) method
Calendar Method of FAMs
• Keep track of the length of the menstrual cycles for at least 6
periods.
• Can be used by women with irregular length menstrual cycles

• To predict the first fertile day:

• Find the shortest cycle in the record.
• Subtract 18 from the total number of days in that cycle.

• To predict the last fertile day:

• Find the longest cycle in the record.
• Subtract 11 from the total number of days in that cycle.
Standard Days method
• It is a kind of calendar method
• Can be used by women with regular menstrual cycles; with
cycle lengths between 26-32 days.

• It is simply based on avoiding sexual activity or using barrier

method between days 8 and 19 of each menstrual cycle.
The TwoDay Method
• More than 96% effective when used correctly
• Women are instructed to monitor their secretions each
afternoon and evening as soon as her menstrual bleeding stops
• She is not likely to get pregnant if no secretions felt or observed
today AND yesterday.
• Does not require having regular menstrual cycles.
• Rule out infections if secretions have been felt or observed for
>14 consecutive days
Mechanical Barriers
• Male and female condoms
• Cervical cap
• Diaphragm
• Spermicidal agents
• They are considered the least effective methods
• Female diaphragm and cervical cap may increase the risk of UTIs and their use for
more than 24-48 hours can be associated with toxic shock syndrome. Their use
requires professional fitting and training for use.
Hormonal methods
• Combined Hormonal Contraceptives (CHC)
• Combination Oral Contraceptive Pills (OCPs)
• Vaginal Ring
• Transdermal Patch
• Progesterone-only methods of contraception
• Progesterone-Only Pills (POPs)
• DMPA injections
• Implants
• LNG-IUS
Combination OCP
• A combination of ethinyl estradiol (20-35mcg) and a progesterone:
• 1st & 2nd generations: Norethindrone, Levonorgestrel, Norethindrone acetate and
Ethynodiol diacetate.
• 3rd generation: Norgestimate, Desogestrel and Gestodene
• 4th generation: Drospirenone and Cyproterone acetate.
• Can be monophasic or multiphasic
• Most of the formulations have 21 hormonally active pills followed by 7 placebo pills
• Prevention of ovulation is considered the dominant mechanism of action (MOA), they
also alter the consistency of cervical mucus, affect the endometrial lining, and alter tubal
transport.
• Failure rates :0.1% with perfect use, 5% with typical use
Vaginal Rings
• Can deliver progesterone or progesterone-estrogen combinations.
• NuvaRing: releases etonogestrel and ethinyl estradiol which are absorbed directly by the
reproductive organs.
• It is easily inserted and removed by the woman herself
• It is left in place for 3 weeks and 1 week without to produce a withdrawal bleed.
• If the ring has been out of vagina for more than 3 hours, a backup contraceptive method
should be used for 7 days.
• The hepatic first-pass metabolism of the hormones is prevented (absorbed directly to the
blood from the vagina), so no nausea or vomiting
• The ring may accidentally slip out during intercourse
Transdermal Patches
• Each patch contains norelgestromin and ethinyl estradiol.
• Applied weekly for 3 consecutive weeks, followed by a patch-free week
• Avoidance of the first-pass effect contributes to decreased nausea and vomiting
• It may be less effective for women who weigh more than 90 kg
• Disadvantages and contraindications are similar to those of combination OCPs.
• If a patch is detached for <24 hours, it can be reapplied at the same location or
replaced with a new patch immediately. If detachment lasts >24 hours, a new
patch should be applied.
Adverse effects of CHC
• Nausea, breast tenderness, breakthrough bleeding, amenorrhea, and headaches.
• A few months of delay of normal ovulatory cycles may occur after discontinuation of oral
contraceptives (up to 3 months)
• CVS:
• HTN
• IHD and stroke, venous thromboembolism
• Hepatocellular Adenoma
• Cancers:
• Increase in the risk of breast Cancer
• Minimal increase in the risk of cervical cancer particularly in women who are HPV positive
• Transdermal patches may be associated with more estrogen-related adverse events such as a
thromboembolic event compared with combined pills.
Absolute Contraindications of CHC
• Current breast cancer • HTN with BP >/= 160/100
• < 21 days postpartum • Current or history of IHD or stroke
• Decompensated liver cirrhosis • Multiple risk factors for CVD
• Hepatocellular adenoma or HCC • Complicated valvular heart disease
• Acute or flare of viral hepatitis • Known thrombogenic mutation
• Acute or history of DVT with high risk of • Migraine headache with aura
recurrence • Cigarette smoking of >/=15/day in women
• Major surgery with prolonged immobilization aged 35 or older
• Diabetes >20-year duration or with • SLE with positive (or unknown)
microvascular complications antiphospholipid antibodies
Relative Contraindications of CHC
• History of breast cancer and no • History of COC-related cholestasis in the
evidence of recurrence in the last 5 past
years. • HTN: adequately controlled or
• 21-30 days postpartum BP>140/90
• 30-42 days postpartum with other • IBD
risk factor for VTE • Cigarette smoking of < 15/day in women
aged 35 or older
• History of DVT with low risk of
recurrence • Acute or history of superficial venous
thrombosis
• Medically treated Gall Bladder
Disease • Use of anticonvulsants or rifampin
Progesterone-only Pills (Minipills)
• Norethindrone or desogestrel-containing pills
• Candidates for use include women who are breastfeeding and women with C/I to estrogen use (e.g. CVD, HTN)
• Taken continuously without pill-free interval
• MOA: An increase in cervical mucus viscosity, suppression of ovulation (not uniformly in all cycles), prevention of
endometrial growth and development and a reduction in cilia motility in the fallopian tube.
• Failure rates with typical use are estimated to be 9% in the first year of use.
• A backup method of contraception should be used for 48 hours if a pill is missed or taken late (more than 3 hours
after the time of administration (>12 hours with use od desogestrel).
• Disadvantages: Unscheduled bleeding and spotting (common even with correct use), nausea, breast tenderness,
headache, and amenorrhea.
• Absolutely contraindicated in patients with current breast cancer
• Relative C/I: past history of breast cancer with no recurrence in the last 5 years, IHD, stroke, hepatocellular
adenoma, HCC, decompensated liver cirrhosis, SLE with APA, and the use of anticonvulsants or rifampicin.
Implants
• The rod is inserted subcutaneously, usually in the woman's upper
arm, it releases etonogestrel (an active metabolite of desogestrel)
• Its effect lasts for 3 years.
• MOA: a combination of suppression of ovulation, development of
viscous and scant cervical mucus, and prevention of endometrial
growth and development.
• Side Effects/Disadvantages: minor surgical procedure, menstrual
irregularities are common, headache, breast tenderness and
moodiness are less common
DMPA
• Depo Medroxy Progesterone Acetate (e.g.Depo-provera) can be administered IM or SQ
• MOA: suppression of ovulation
• Disadvantages:
• Delay in the return to fertility (after 10 months of discontinuation 50% regain fertility but it may be delayed up to
18 months)
• Weight gain, depression, and menstrual irregularities that may continue for as long as 1 year after the last
injection.
• Reduced BMD in current users, this might increase the long-term risk of fractures years after discontinuation of
the drug, particularly in three groups of women :
• Young women, who have not yet attained their peak bone mass
• Perimenopausal women, who may be starting to lose bone mass and who may have reached menopause by
the time of DMPA discontinuation, with no opportunity to regain the lost bone mass
• Adolescents/women who are immobilized/wheelchair-bound.
Copper IUDs
• MOA: A foreign-body reaction creates a toxic intrauterine milieu, preventing fertilization
• Efficacy lasts for 10 years
• Advantage:
• Produce no adverse systemic effects.
• Reduced risks of endometrial and ovarian cancer .
• Disadvantages:
• Associated with a risk of uterine perforation at the time of insertion (1%).
• Increased dysmenorrhea and blood loss may occur in the first few cycles.
• Ectopic pregnancies are reduced overall; however, the ratio of extrauterine to intrauterine pregnancy is increased if
conception does occur.
• Absolute contraindications: current STD or PID, postpartum sepsis or immediate postseptic abortion, pelvic TB,
unexplained vaginal bleeding, distorted uterine cavity and cervical or endometrial cancers.
LNG-IUS
• MOA: causes cervical mucus to be thicker in consistency, thereby altering sperm
migration and prevents endometrial growth
• Efficacy lasts for 5 years (Mirena) or 3 years (Skyla)
• The Mirena device now has FDA labelling for treating menorrhagia as well
• It also decreases the risks of endometrial and ovarian cancer
• Absolute Contraindications:
• Same as for copper IUD
• Current breast cancer
• Follow-up 1-3 months after IUD insertion
METHOD SELECTION
• Patient preferences
• Timeframe for pregnancy
• Noncontraceptive benefits
Patient Preferences
• Personal preferences, including • Social and cultural factors (eg,
privacy, tolerance of side effects, religious beliefs)
and speed to return of fertility • Ability to acquire and use the method
after method cessation successfully
• Effect on menstrual pattern and • Method-specific experiences or
bleeding concerns
• Childbearing plans (number of • Tolerance for daily, vaginal,
children, timing of next pregnancy) transdermal, injectable, or coital-
• Pattern of sexual activity related medication
(frequency of sex) • Concomitant need to prevent STI
• Partner influences and concerns • Supportive care from the healthcare
provider
Timeframe for Pregnancy
Women who desire pregnancy within 1 year:
• Begin discussion with the most effective short-acting reversible
contraceptives (ie, pill, patch, and vaginal ring)
• For women who cannot use or do not want hormonal methods, or for
women who desire contraception only when they need it, discuss the
barrier methods
• Avoid depot DMPA injections in women who desire pregnancy in the
near future because this medication can be associated with a delayed
return to fertility.
• For women who choose a short-acting method, educate about use of
and access to emergency contraception
 Timeframe for Pregnancy, cont’d
Women who do not desire pregnancy within 1 year
• Begin discussion by reviewing the most effective and longest-acting
contraceptives: the implant, IUDs, and sterilization.
• Educate couples who desire permanent contraception (sterilization) that
vasectomy is equally effective, but less morbid and costly, than female
tubal occlusion.
• For women who desire reversible contraception but do not want one of
the LARC methods, then continue the discussion listed above for short-
acting reversible contraception.
 Noncontraceptive Benefits of CHC methods
E/P combined contraceptive use can reduce the risk of the following:
• Dysmenorrhea, pelvic pain related to endometriosis
• Menorrhaghea: improvement in IDA
• Ectopic pregnancy
• Symptoms associated with PMS and premenstrual dysphoric disorder
• Benign breast diseases
• Development of new ovarian cysts, but no effect on existing cysts
• Moderate acne and hirsutism
• Ovarian, endometrial and colorectal cancers
 Noncontraceptive Benefits, cont’d
• Condoms provide the best protection against acquisition or transmission of STIs.
• Progestin-only contraceptives (ie, pills, injection, and implant) result in
• Lighter menstrual bleeding and reduced IDA
• Protection against endometrial cancer
• Possibly a reduction in risk of upper genital tract infections.

• levonorgestrel-releasing IUDs reduce

• Heavy menstrual bleeding, anemia, dysmenorrhea
• Endometriosis-related pain
• Endometrial hyperplasia
• Pelvic inflammatory disease
• Possibly reduce the risk of endometrial cancer (copper- and levonorgestrel-
releasing devices).
 Medical Issues
• When possible, use LARCs for medically complex women
• History of Cancer
• Women with active cancer or who have been treated for cancer within 6 months :
• Avoid CHC contraceptives because both cancer and these contraceptives are risk factors for
venous thrombosis.
• Women who have a history of chest wall irradiation for cancer:
• Avoid systemic estrogen and/or progestin contraceptives because these women are at
increased risk of developing breast cancer and the risk could be greater in women who take
exogenous hormones.
• Women with a history of breast cancer:
• Use a copper IUD.
• If the pt is taking tamoxifen, off-label use of a LNG- IUS is preferred to reduce the risk of
tamoxifen-induced endometrial changes without increasing the risk of breast cancer
recurrence.
 Medical Issues, cont’d
• Women with anemia :
• Use a LNG-releasing IUD to minimize menstrual blood loss.
• Women with osteopenia or osteoporosis
• Avoid injectable DMPA.
• Unless C/I , women with osteopenia or OP benefit from the effects of an estrogen-
containing contraceptive on BMD.
• Women who are immunosuppressed
• Intrauterine contraception is not C/I.
• Women at risk of breast cancer or recurrence
• Emergency contraceptive pills are not C/I.
STARTING CONTRACEPTION
• Examination and testing
• Prior to insertion of an IUD, a bimanual pelvic examination with
cervical inspection is performed.
• Screening for STI is done as per the CDC guidelines.
• BP before CHC prescription
• BMI for hormonal contraceptives to monitor changes over time and
counsel women who might incorrectly assume that weight gain is
associated with their contraceptive method.
• Exclude pregnancy
Excluding Pregnancy
• This is can be assured when the woman doesn’t have
symptoms/signs of pregnancy and meets any of the
following:
• No intercourse since the LMP
• Has been using correctly a reliable method of contraception
• She is within 7 days of the LMP or post-abortion
• She is within 4 weeks postpartum
• Fully or near-fully breast feeding, amenorrhoeic and < 6mo
postpartum.
COC Initiation
• The quick start method : the woman begins taking COCs on the day that she is
given the prescription, as long as pregnancy is reasonably excluded .
• The Sunday start approach: the woman starts the pill on the first Sunday after
her period begins (this is fairly convenient because most pill packs are arranged
for a Sunday start to avoid withdrawal bleeding on a weekend).
• With these first two options, the pill is often started >5 days after the onset of
menses. When this occurs, back-up contraception is recommended for the
first 7 days of the cycle..
• The first day start method: start the pill within the first 5 days of the menstrual
cycle. No need for backup method.
COC Missed pills
• Missing 1 pill: take the missed pill as soon as remembered followed by the regularly
scheduled pill.
• Missing 2 or more consecutive pills:
• Take the last missed pill
• A backup method of contraception for the next 7 days
• If they are missed in the 1st week of the cycle and unprotected intercourse
occurs during this week, use of EC could decrease the risk of pregnancy.
• If she is in the 3rd week of active pills, she should continue the active pill through
the placebo week.
 • Used for women who have had recent
unprotected intercourse, including those
who have had a failure of another method
of contraception.

Emergency • MOA:
• Oral (hormonal) EC act primarily by
Contraception delaying ovulation
• Copper intrauterine contraception
(EC) inhibits fertilization by affecting sperm
viability and function, and impairs
implantation

• Oral and IUD methods are effective only

before a pregnancy has implanted.
EC Efficacy
• Copper IUD EC method is the most effective, followed by ulipristal method, followed by
Levonorgestrel method and finally the Yuzpe method.

• When used within 72 hours of intercourse it is estimated that:

• Copper IUD prevents over 95 % of expected pregnancies
• Ulipristal acetate prevents 2/3 of expected pregnancies
• Levonorgestrel prevents around 50 % of pregnancies

• The risk of pregnancy following the use of hormonal methods depends on:
• Body weight/BMI
• Timing of the menstrual cycle and hence conception probability
• Further intercourse after EC
Hormonal EC Methods
• Levonorgestrel (Plan B)
• 1.5mg single dose or 2 (0.75mg ) doses separated by 12hr.

• Estradiol plus levonorgestrel (Yuzpe regimen)

• Take the equivalent of 100 mcg of ethinyl estradiol plus 0.50 mg of levonorgestrel
followed by the same pill regimen 12 hours later.

• Antiprogestins:
• Ulipristal (selective progesterone receptor modulator ): A single 30 mg tablet.
• Mifepristone: 25-50mg single dose

• The dose of hormonal EC should be repeatd w antiemetic if vomited within 3 hr.

• For both the Plan B and Yuzpe regimens, the effectiveness of EC is highest when taken
within 12 hours of intercourse and declines over time
 EC Indications
• When no contraception was used during sexual intercourse w/n the previous 120
hr.
• When there is contraception failure or incorrect use within the previous 120 hr.:
• Condom breakage, slippage or incorrect use
• Missing 2 or more COCP
• POP taken > 3 hours late
• More than 2 weeks late for DMPA injection
• Failed coitus interruptus
• Miscalculation or failure to abstain during the fertile days of the cycle
• Expulsion of IUD
EC Administration
• Neither P/E nor any lab. tests are needed before providing oral hormonal EC.

• Pregnancy should be excluded before prescribing ulipristal or placing an IUD. If

pregnancy cannot be excluded based on history and/or P/E, pregnancy testing
should be performed.

• Any contraceptive method can be started immediately after the use of

levonorgestrel or Yuzpe EC

• Hormonal contraception should be started no sooner than 5 days after use of

ulipristal acetate
EC
• No known absolute C/I to any of these methods because exposure
to the high dose of hormones is short lived.

• Menstrual bleeding after EC typically occurs within 1 week of the

expected time.

• No follow-up is required; however, the lady should perform a

pregnancy test if she doesn’t have menses within 3-4 weeks of the
EC use.

• No evidence of an increase in risk of ectopic pregnancy or of

teratogenic effects
 • Contraceptive counseling and selection,
UpToDate
• Risks and side effects associated with combined
estrogen-progesterone oral contraceptives,
UpToDate
References • U.S. Medical Eligibility Criteria for Contraceptive
Use, 2016
• Contraception, Medscape 2018
• Emergency contraception, UpToDate