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Provision of Contraception: Key Recommendations from the CDC DAVID A

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Provision of Contraception: Key Recommendations from the CDC DAVID A Provision of Contraception: Key Recommendations from the CDC DAVID A. KLEIN, MD, MPH; JAMES J. ARNOLD, DO; and ERIKA S. REESE, MD National Capital Consortium Family Medicine Residency, Fort Belvoir Community Hospital, Fort Belvoir, Virginia The Centers for Disease Control and Prevention has released comprehensive recommendations for provision of family planning services. Contraceptive services may be addressed in five steps, and counseling may be provided in a tiered approach, whereby the most effective options are presented before less effective options. Clinicians should discuss all contraceptive methods that can be used safely by the patient, regardless of whether a method is available on site and even if the patient is an adolescent or a nulliparous woman. Physical assessment is usually limited to blood pressure evaluation before starting hormonal contraceptives or pelvic examination before placing an intra- uterine device. Monitoring the patient’s weight also may be helpful. If it is reasonably certain that the patient is not pregnant, any contraceptive may be started immediately. When hormonal contraceptives are selected, one year’s supply should be prescribed to reduce barriers to use. Condoms should be made readily available. Documentation of visits for contraception should include patient understanding of use, benefits, and risks, plus an individualized follow-up plan. Bleeding irregularities generally are not harmful and may resolve with continued use of the contra- ceptive method. All patients—including adolescents; those who identify as lesbian, gay, bisexual, or transgender; and patients with disabilities or limited English proficiency—should receivehigh-quality care in an accommodat- ing, nonjudgmental environment. The Centers for Disease Control and Prevention supports advance provision of emergency contraceptives. Because no test reliably verifies cessation of fertility, it is prudent to consider contracep- tive use until menopause, or at least until 50 to 55 years of age. (Am Fam Physician. 2015;91(9):625-633. Copyright © 2015 American Academy of Family Physicians.) More online amily physicians are uniquely suited To help clinicians provide optimal sexual at http://www. aafp.org/afp. to deliver comprehensive, unfrag- and reproductive health services, the Centers mented family planning services for Disease Control and Prevention (CDC) has CME This clinical content 1 conforms to AAFP criteria to patients of all ages. With access released comprehensive, evidence-based rec- for continuing medical Fto an increasingly robust evidence base on ommendations that have been methodically education (CME). See ways to prevent or achieve pregnancy and and scientifically established by technical and CME Quiz Questions 4 on page 606. treat sexually transmitted infections (STIs), expert panels (eTable A). Recommendations clinicians are challenged to offer and man- pertaining to contraceptive management are Author disclosure: No rel- evant financial affiliation. age the safest and most effective options addressed in this review. At every health care ▲ available for patients with various medical visit, clinicians should discuss family plan- Patient information: Available at http://www. conditions, social circumstances, adherence ning needs with patients of reproductive age aafp.org/afp/2015/0501/ patterns, and financial barriers to care. and provide requested services as appropriate.4 p625-s1.html. Approximately one-half of the 6.6 mil- lion pregnancies each year in the United Provision of Contraception States are unintended, and the rates are The CDC recommends a systematic highest among young, poor, and minority approach to contraceptive counseling and women.2 In 2008, women 15 to 44 years of education to ensure safe, high-quality care. age with incomes at or below the federal Figure 1 includes a summary of the five steps poverty level were five times more likely clinicians should take when providing con- than women at the highest income level to traception to patients.4 become pregnant unintentionally.2 Women who use contraception consistently and STEP 1: ESTABLISH RAPPORT correctly account for only 5% of unin- Family planning discussions can be inher- tended pregnancies.3 ently sensitive; therefore, establishing and MayDownloaded 1, 2015 from ◆ Volume the American 91, Number Family Physician 9 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2015 American Academy of FamilyAmerican Physicians. Family For the Physician private, noncom 625- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Contraception maintaining rapport is critical for success.4-8 Steps in Providing Contraceptive Services Clinicians should ask open-ended questions; demonstrate expertise, trustworthiness, Step 1: Establish and maintain rapport accessibility, and empathy; ensure privacy Ask open-ended questions Explain how personal information will and confidentiality; explain how personal Demonstrate expertise, be used information will be used; and encourage trustworthiness, accessibility Encourage patient to ask questions patients to ask questions. Ensure privacy and confidentiality Demonstrate empathy: listen, observe, withhold judgment STEP 2: OBTAIN CLINICAL AND SOCIAL INFORMATION Step 2: Obtain clinical and social information Contraceptive recommendations should be Medical history: Future pregnancy intention personalized, focusing on the patient’s safety 4 Menstruation Contraceptive experiences and and reproductive life plan. The interview Pregnancy, breastfeeding, recent preferences should elicit, at minimum, menstrual, gyne- intercourse Sexual health: cologic, and obstetric history; medication Chronic disease (e.g., hypertension), Sexual practices, current and recent allergies; infectious or chronic health condi- drug allergies partners, condom use tions; and tobacco use. These may alter the Risk factors for thromboembolic Previous sexually transmitted disease infections patient’s medical eligibility for a particular method9,10 (eTable B). Knowing the patient’s contraceptive expe- Step 3: Work interactively: select most effective medically appropriate rience and intentions regarding pregnancy is method useful. A sexual health assessment—includ- Offer all methods that can be used Identify barriers to success: social- ing practices, partners, STI status, condom safely behavioral, mental health, substance use, and recent intercourse—may aid in Include long-acting methods for abuse, and partner violence factors; adolescents these may guide decisions selecting and safely initiating appropriate 4 Use a tiered approach (discuss most Discuss adverse effects contraception. effective methods first) Recommend dual-method use Discuss correct and consistent use; (hormonal and barrier method) STEP 3: WORK INTERACTIVELY TO HELP THE consider patient’s reported ability Discuss any noncontraceptive benefits PATIENT SELECT THE MOST EFFECTIVE AND to adhere (e.g., treating abnormal uterine APPROPRIATE METHOD bleeding) Clinicians should discuss all available con- traceptive methods that the patient can Step 4: Physical assessment, when warranted use safely, regardless of which are avail- 4,11 Blood pressure before initiating To avoid causing logistical, emotional, able on site. The CDC encourages a combined hormonal contraceptives or financial burdens, omit pelvic tiered approach to counseling, whereby the Pregnancy testing if needed; history is examination (unless inserting most effective and medically appropriate usually satisfactory an intrauterine device), cervical cytology, breast examination, and options are presented before less effective Weight measurement for monitoring metabolic studies 4,12-15 changes options (eFigure A). Other factors that may be important to the patient should be considered, such as Step 5: Provide method, instructions, and follow-up plan; confirm her ability to use the method correctly and 4 understanding consistently, and possible adverse effects. Begin method at time of visit (“quick Make condoms easily available Information on noncontraceptive ben- start”) if reasonably certain patient Strategize for anticipated struggles efits of various methods, such as a poten- is not pregnant; bridge until (e.g., phone alarms for adherence) long-acting method can be safely tial reduction in dysmenorrhea, abnormal Individualize follow-up plan, established, if necessary considering needs and risk of uterine bleeding, or acne, may help patients 4 Prescribe one full year supply discontinuation select and adhere to medication regimens. For patients with or at risk of an STI, dual-method contraception, which com- Figure 1. Steps in providing contraceptive services. bines condoms and another method, should Information from reference 4. be discussed.4,16 626 American Family Physician www.aafp.org/afp Volume 91, Number 9 ◆ May 1, 2015 Contraception Medication adherence concerns apply to patients Monitoring weight may be useful, although weight with substance use, mental illness, difficulties with does not preclude eligibility for any contraceptive medication regimens, and sociobehavioral factors.4 For method.4,9,17 A recent Cochrane review suggested that example, if intimate partner violence is suspected, in mean weight gain from progestin-only methods was less addition to providing appropriate safety referrals (e.g., than 2 kg (4.4 lb) at 12-month follow-up.20 to law enforcement and violence support groups), clini- cians may offer long-acting
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