Contraception Options and Counseling
Hello Joseph,
This is a very informative post, Joseph. There are various effective contraception options, presenting many choices for individuals. These can make patients indecisive over the perfect contraception method that meets their needs and reproductive goals. Each patient has individual health needs and reproductive goals. Unintended pregnancies can occur if a couple uses contraception incorrectly and inconsistently. Contraceptive counselling seeks to educate the patient on the various types of contraceptives available, how to use them, and the different pros and cons of each method. The approach selected for contraceptive education should be as person- and patient-centered as possible. Based on research evidence, in most contraception decisions, the patient is coerced to use certain contraceptives (Mahendra et al., 2019). Person- and patient-centred contraceptive education can assist in joint decision-making in which all partners are included. User- and family-centred counselling interventions significantly impact contraceptive preferences, choice decisions, and the willingness of partners to continue with contraception use (Karra & Zhang, 2021).
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References
Karra, M., & Zhang, K. (2021). User-Centered Counseling and Male Involvement in Contraceptive Decision Making: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2021;10(4):E24884 Https://Www.Researchprotocols.Org/2021/4/E24884, 10(4), e24884. https://doi.org/10.2196/24884
Mahendra, I. G. A. A., Wilopo, S. A., Sukamdi, & Putra, I. G. N. E. (2019). The role of decision-making pattern on the use of long-acting and permanent contraceptive methods among married women in Indonesia. Https://Doi.Org/10.1080/13625187.2019.1670345, 24(6), 480–486. https://doi.org/10.1080/13625187.2019.1670345
Hello Onpaneeya,
This is a good post. Couples or individual patients can choose to use either hormonal or non-hormonal contraception methods. Nonetheless, a majority of people are more likely to go for the non-hormonal methods of birth control. The choice of contraception methods is based on individual concerns. Some avoid hormonal contraception methods due to fears of the effects of the hormones on their fertility, their health, and effects on their children when breastfeeding. There is a lot of misinformation today, especially on the internet, on the impact of hormonal contraception methods and the ineffectiveness of non-hormonal methods that influence their decisions. Therefore, healthcare professionals need to provide proper education on hormonal and non-hormonal contraceptives, focusing on the effectiveness and risks associated with each method. However, the decision on contraception choice should be based on the individual patient’s preferences, values, personal health concerns, and lifestyle choices (Reyes-Martí et al., 2021).
References
Reyes-Martí, L., Rubio-Rico, L., Ortega-Sanz, L., Raigal-Aran, L., de la Flor-López, M., Roca-Biosca, A., Valls-Fonayet, F., Moharra-Francés, M., Escuriet-Peiro, R., & de Molina-Fernández, M. I. (2021).
Contraceptive counselling experiences in Spain in the process of creating a web-based contraceptive decision support tool: a qualitative study. Reproductive Health, 18(1), 1–17. https://doi.org/10.1186/S12978-021-01254-0/TABLES/6
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Question 
1. joseph
The selection of a contraceptive method is a complex matter; thus, contraceptive counselling plays a vital role in providing information and supporting patients’ decision-making regarding their choice of contraceptive methods and reproductive goals. When comparing contraceptive methods, counselling should consider their efficacy, safety, acceptability, availability, accessibility, and cost (Bansode et al., 2021). There are many contraception methods, but generally, pregnancy can be avoided by disrupting the menstrual cycle hormonally, such as with oral contraceptive pills and other medications, preventing implantation with intrauterine devices or subdermal implants, barrier methods, sterilization, and abstinence (Bansode et al., 2021).
Contraception Options and Counseling
Oral contraceptives containing estrogen and progestin (COCs), generally known as birth control pills, offer effective contraception and come in many preparations (Allen, 2022). Even though the perfect-use failure rate is 0.3%, the typical-use failure rate is closer to 7%, mostly owing to missing tablets or failure to continue medication after the pill-free time (Allen, 2022). In addition to their high contraceptive effectiveness, COCs provide other benefits, including quick reversibility, management of monthly flow, reduced menstrual blood loss, and dysmenorrhea, as well as decreases in the risk of ovarian and endometrial malignancies (Allen, 2022). Due to its capacity to inhibit ovulation, COCs also have a variety of non-contraceptive applications, including the treatment of menstrual cycle disorders such as polycystic ovary syndrome (PCOS), abnormal uterine bleeding, pelvic pain disorders, ovarian cysts, and hyperandrogenism (Allen, 2022).
When beginning a COC, patients may feel breast discomfort, nausea, and bloating (Allen, 2022). Typically, these symptoms disappear quickly (Allen, 2022). Other potential issues include spontaneous bleeding, which normally disappears after three months, as well as the possible influence of COCs on mood and sexual function (Allen, 2022). The usage of COCs has been linked to an increased risk of venous thromboembolism (VTE) (Allen, 2022). The risk changes with estrogen dosage and patient variables, including age, obesity, and smoking habits (Allen, 2022). While the relative risk is elevated, most women’s absolute risk remains low. It does not exceed the various advantages of this contraceptive method, especially when compared to the VTE risk during pregnancy and the postpartum period (Allen, 2022).
Hormonal contraception may be administered safely after conducting a medical history and measuring blood pressure (Allen, 2022). A pelvic examination is not necessary (Allen, 2022). It is important to screen for current medications, smoking, hypertension, diabetes, venous and arterial thromboembolism, migraine with aura, breast cancer, and postpartum status (Allen, 2022). COCs may be initiated at any point throughout the menstrual cycle if pregnancy is adequately excluded (Allen, 2022). The quick start method allows women to start COCs right when they receive their prescriptions. Still, they should be counselled to use backup contraception for the first seven days of the cycle as follicular development and breakthrough ovulation can occur (Allen, 2022). Alternatively, the first-day start method starts COCs on the first day of menses (Allen, 2022). This provides maximum contraceptive effect, and backup contraception is not necessary (Allen, 2022).
Transdermal contraceptive patches are a very effective estrogen-progestin contraception method (Burkman, 2022). Most women who seek a reversible, non-event-based form of contraception and have no contraindications to the use of estrogens or progestins may utilize this approach safely (Burkman, 2022). Contraindications to using a contraceptive patch are the same as other estrogen-progestin contraceptives, including a history of thromboembolism, an estrogen-dependent malignancy, and impaired liver function (Burkman, 2022). The mechanisms for contraceptive patches are similar to all combined estrogen-progestin methods (pills, patches, rings), and they are as effective as COCs in preventing pregnancy (Burkman, 2022).
The systemic adverse effects encountered by contraceptive patch users are typically well-tolerated and commonly improve after three to six months of treatment (Burkman, 2022). Like other estrogen-progestin contraceptives, this includes irregular uterine bleeding, weight gain, and mood changes (Burkman, 2022). And like COCs, patches pose a risk for VTE, although the overall risk is low (Burkman, 2022). Patches also have the same screening criteria as other estrogen-progestin hormonal contraceptives (Burkman, 2022). While breast exams and screening for sexually transmitted diseases and cervical cancer are essential, they are not required before initiating hormonal contraception (Burkman, 2022). The manufacturers recommend starting the patch on the first day of menstruation (first-day start) or the Sunday after the onset of menstruation (Sunday start) (Burkman, 2022). However, utilizing the quick start method as soon as the patch is received is appropriate and may lower the chance of unwanted pregnancy as long as pregnancy has been ruled out (Burkman, 2022). The patient should determine the manner of initiation. If the patch is started more than five days after the start of menstruation, abstinence or backup contraception, such as condoms or vaginal spermicides, should be used for the first seven days (Burkman, 2022).
Like other combined estrogen-progestin contraceptives, vaginal rings are safe and highly effective (Kerns & Darney, 2022). Contraceptive vaginal rings have the benefit of being easy to use and avoid the necessity of daily or weekly user compliance (Kerns & Darney, 2022). Vaginal rings are for women who want effective, reversible, noncoital contraception and have no estrogen or progestin contraindications (Kerns & Darney, 2022). The combined hormonal rings give the same advantages as combined COCs, including contraception, management of bleeding, endometrial protection, and relief of dysmenorrhea and endometriosis-related discomfort (Kerns & Darney, 2022). Again, risk factors for vaginal contraceptive rings are similar to other combined estrogen-progestin contraceptives and include a risk for VTE, particularly those over 35 years old who smoke, estrogen or progestin-sensitive cancers, and liver disease (Kerns & Darney, 2022). Contraceptive rings, like oral contraceptives, may be started at any time throughout the cycle when pregnancy has been ruled out. Still, a backup method such as condoms is recommended if the last menses was more than seven days prior or is uncertain (Barney, 2022).
Contraceptive counselling has progressed from clinician-led directive counselling to a tailored, patient-centred approach with shared decision-making (Dehlendorf, 2022). Thus, clinicians must educate on different contraceptive methods and elicit patient preferences while addressing misinformation (Dehlendorf, 2022). Personalized counselling should include all aspects of family planning, not just preventing unintended pregnancy (Dehlendorf, 2022). Clinicians should also assess for medical conditions that could affect the safety and efficacy of selected contraception (Dehlendorf, 2022). Personalized counselling and shared decision-making aim to provide care consistent with the individual’s values, beliefs, and preferences while optimizing health outcomes (Dehlendorf, 2022).
2. onpaneeya
Natural Family Planning or Fertility Awareness-Based Contraception (FAB)
The most natural form of contraception is fertility awareness-based contraception, which primarily includes tracking a woman’s menstrual cycle and either avoiding intercourse or using a barrier contraceptive method on days she is fertile, in and around her ovulation (Jennings, 2022). Since a man’s sperm can live for up to 5 days inside a woman’s cervical mucus and upper genital tract, and a woman’s ovum can be fertilized for up to 12 to 24 hours after release, the fertility period for most women is 6 days, with the most fertile period being the few days before ovulation leading up to that day (Jennings, 2022). Indications for this method include both partners agreeable to using it, both partners willing to abstain from sex or use barrier methods during the 6-day fertility period, the interest and ability of a woman to monitor and calculate her cycle effectively, and the ability of the couple to communicate about the process (Jennings, 2022). Contraindications include not having a supportive partner, desiring protection from STDs, not having regular menses, or lack of ability to track menses and physiological changes (Jennings, 2022). Risks include a generally higher rate of unintended pregnancy than other less natural methods (typically around 70%), as well as a lack of protection from STDs if not using a condom. In contrast, benefits include avoiding the side effects of less natural methods (Jennings, 2022). Though failure of this method to prevent pregnancy is higher than less natural methods, variations in these methods can approach success rates of 90-98%, especially those using smartphone apps which include monitoring of basal body temperature (BBT) combined with monitoring cervical secretions and period start date (Jennings, 2022).
Male Condoms
Male condoms are a form of barrier contraception used at the time of pregnancy that are effective at preventing pregnancy, are cost-effective, protect against STDs including HIV, do not interrupt fertility, do not require a prescription and are readily available, and are generally safe with little to no side effects (Warner et al., 2022). Condoms come in varying sizes, colours, thicknesses, and shapes, with a typical length of 7″ and are made of latex rubber, natural membranes or other synthetic material, with and without spermicide (Warner et al., 2022). Interestingly, studies show that condoms with external spermicide are no more effective than non-spermicide condoms and can cause increased UTIs in women (Warner et al., 2022). Though latex rubber is the most cost-effective form of condoms, those who are allergic to latex cannot use them, which is the only contraindication to condom use (Warner et al., 2022). The success rate of condoms ranges between 87-98% depending on the effectiveness of use. Though each condom is subject to quality control to prevent leakage or breaking, condoms can break (2%) or slip off (2%) during vaginal or anal sex, though slightly less so with anal sex (Warner et al., 2022). Some disadvantages include not having a supportive partner willing to wear them; some decreased sensitivity for the male, interruption of foreplay to put them on, lack of erection in some users, and fit issues (Warner et al., 2022).
Hormonal Contraceptive Vaginal Rings
The hormonal contraceptive vagina ring, or “ring,” is a combination estrogen-progestin product that can be inserted for 1 month at a time, not requiring daily or weekly monitoring or intervention, and can be removed temporarily for intercourse, making it one of the most effective and convenient to use contraceptive methods (Kerns, 2022). The 1-month product is called the NuvaRing, while the 1-year product is called the Annovera Ring (Kerns, 2022). The NuvaRing is 54mm in diameter and contains etonogestrel/ethinyl estradiol, and has a lower concentration of EE than other combined contraceptive products; it is worn vaginally for 3 weeks and then discarded for 1 week, with a success rate of 91-99.7% depending on how closely directions are followed (Kerns, 2022). The Annovera ring contains progesterone and Ethinyl estradiol, is 56mm, worn for 3 weeks and then not used for a week, but then reused for up to 13 menstrual cycles, with a success rate of 97% (Kerns, 2022). An advantage of these products is their success rates compared to oral contraceptives (OCs), without the hassle of remembering to take the pills every day, and also less dysmenorrhea and impact of insulin resistance (Kerns, 2022). The side effects are also similar to OCs: headaches and weight gain, with more vaginitis, vaginal wetness, and leukorrhea but less breast tenderness and nausea and better cycle management with less bleeding than OC or transdermal patch users (Kerns, 2022). Major risks for these and all other combined estrogen-progestin contraceptive products are cardiovascular and thromboembolic, including greater occurrences of stroke, both arterial and venous, thrombotic and hemorrhagic, as well as myocardial infarction and venous thrombotic events (VTEs) (Kerns, 2022). Contraindications include women who cannot take estrogens or progestins, are breastfeeding less than 6 months postpartum, are non-breastfeeding and are at least 6 weeks postpartum, and have a high risk of venous or arterial thromboembolic disease (including women over 35 who smoke), have breast cancer, have liver tumours or disease, have abnormal uterine bleeding, are pregnant, or have hepatitis C who are taking certain drug combinations (Kerns, 2022).
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