Chapter 18: Contraception

KEY CONCEPTS

• Unintended pregnancy is a public health issue. A majority of unintended pregnancies that occur are due to inconsistent use or nonuse of contraceptives.

• Contraception implies the prevention of pregnancy.

• The following must be considered when selecting a contraceptive method: the effectiveness of the method, the noncontraceptive benefits and side effects of the method, attitude of the patient and of the sexual partner toward a contraceptive method, the ability to use the method correctly (which may alter the effectiveness of the method), and the ability to pay for the method.

• Patient-specific factors (eg, frequency of intercourse, age, smoking status, desire for return to fertility, concomitant diseases, medications, and drug–drug interactions) must be evaluated when selecting a contraceptive method.

• A variety of contraceptive methods are available. Nonhormonal methods include fertility awareness, barriers, spermicides, and the copper intrauterine device. Hormonal methods include estrogen/progestin products or progestin-only methods.

• Adverse effects or difficulties in using the selected method should be monitored carefully and managed in consideration of patient-specific factors.

• Some medications may alter the effects of hormonal contraceptives or vice versa; therefore, a patient’s concomitant medications should be assessed for drug–drug interactions with hormonal contraceptives.

• Accurate and timely counseling on the management of missed doses is critical for contraceptive effectiveness.

• Counseling on the optimal use of the contraceptive method and providing strategies for minimizing sexually transmitted infections/diseases (STIs/STDs) must be provided to all patients being initiated on contraceptives and for those also using contraception on an ongoing basis.

• Emergency contraception (EC) may prevent pregnancy after unprotected intercourse or when regular contraceptive methods have failed.

• Mifepristone, misoprostol, and methotrexate may be used in regimens for medical abortion.

Patient Care Process for Contraception

Collect

• Patient characteristics (eg, age, sex, date of last menstrual period, pregnant, recently postpartum, breastfeeding, desire for pregnancy/return to fertility)

• Patient medical history (personal and family)

• Medication allergies

• Social history (eg, tobacco/ethanol use, relationships, sexual history)

• Current medications including over-the-counter (OTC), herbal products, dietary supplements

• Previous or current use of contraceptives

• Objective data: blood pressure (BP), height, weight

Assess

• Pregnancy status

• Effectiveness of previous contraceptive methods used (Tables 18-1 and 18-2)

• Blood pressure

• Weight and optimal method for use

• Precautions and contraindications to various types of contraceptives utilizing the CDC Medical Eligibility for Contraceptive Use, 2016 (see Table 18-6)

• Venous thromboembolism (VTE) risk factors (eg, recent surgery, plaster casting of lower extremity, cancer, prolonged immobility, recent hospitalization, recently postpartum)

• Drug interactions with various forms of contraception (see Table 18-6 for a select listing of drug interactions)

• Patient ability/willingness to use, adhere, or pay for various forms of contraception (Tables 18-1 and 18-2)

Plan^*

• Drug therapy regimen including specific contraceptive dosage forms, dose, route, ...