Effective Contraceptive Couns e ling for Primary Care Provide rs

b y Liz Rohr, FNP- BC

I’m Liz Rohr

● Family nurs e p rac titione r, MSN from UCLA, 20 15

● BSN from Bos ton Colle ge , 20 0 9● Found e r and CEO of Re a l World NP LLC● Online cours e s , pod cas t, YouTub e ,

Ins tagram & Face b ook channe ls

IN THIS PRESENTATIONWE WILL COVER

● Apply couns e ling te chnique s for s e le c ting contrace ptive me thods for pa tie nts

● Ide ntify e ffe c tive contrace ptive me thods for the pa tie nts accord ing to couns e ling conve rs a tions

● Managing common s ide e ffe c ts of contrace ptive me thods

Pitfalls● Only couns e ling c is - wome n● Making as s umptions ab out d e s ire for p re gnancy/contrace p tion● Ove rwhe lming pa tie nts with a huge lis t of op tions vs ta ilore d to

the ir ne e d s● Coe rc ion - pus hing pa tie nts toward s an op tion the y “s hould ” d o● Not as s e s s ing s e xua l his tory, ge nd e rs of pa rtne rs , ris k fac tors

History Questions

History questions● Do you p lan on having child re n?● Do you have an id e a of whe n you’d like to d o s o?● How important is it to you to wa it until the n?

● He alth cond itions - CDC Me d ica l Elig ib ility Crite ria● What’s important to you ab out contrace p tion?

○ Ble e d ing pre fe re nce s○ Partne rs /pa re nts /s a fe ty - ne e d to conce a l○ Effe c tive ne s s , d e vice in b od y, ne e d to take e ve ry d ay, re turn

to fe rtility, hormone s or not, ab ility to s top the ms e lve s

TOP DOWN APPROACH FROM MOST EFFECTIVE TO LEAST

● Long- ac ting re ve rs ib le contrace ption (LARCs ) -IUDs , ne xplanon

● OCPs /Nuvaring● Proge s tin- only p ills (POPs )/DMPA● Pe rmane nt contrace ption

Important notes

IUDs● Hormonal (le vonorge s tre l- re le as ing (LNG)

○ Mire na - 52mg LNG - (7 ye a rs )○ Lile tta - 52mg LNG - (6 ye a rs )○ Kyle e na - 19 .5 LNG (5 ye a rs )○ Skyla - 13 .5 LNG (3 ye a rs )

● Non -hormonal○ Paragard - coppe r - TCu3 80 A (10 - 12 ye ars )

IUDs● Mechanism of action : multip le , s te rile inflammatory re s pons e toxic to

s pe rm and ova , p re ve nts implanta tion.○ Stud ie s done have not found e mbryos or de te c t HCG, s o che mica l

pre gnancie s a re not s us pe cte d .● Key take home points : >9 9 % e ffe c tive ne s s , rap id ly re ve rs ib le ,

conce a lab le , initia l cos t may b e high b ut cos t- e ffe c tive ove r time , us ua lly cos t e ffe c tive a fte r 2 ye a rs○ Doe s n’t p rote c t aga ins t STIs , s lightly highe r ra te s of e c top ic

pre gnancy○ Can re move any time

IUDs● Contraindications : s e ve re d is tortion of the ute rine cavity, a cute pe lvic

infe c tion, known, s us pe cte d pre gnancy, une xpla ine d ute rine b le e d ing● Complications : e xpuls ion (3 - 6 %), PID (1- 0 .5%), fa ilure (0 .1- 0 .6 %),

pe rfora tion (0 .0 1%), ma lpos ition (10 %), pa in and irre gula r b le e d ing - ma in re a s ons for re mova l

○ For e ithe r IUD if the re ’s ongoing he avy b le e d ing and cramping , ne e d to e va lua te for ma lpos ition, e xpuls ion, p re gnancy, and ce rvica l d ys p la s ia

LNG IUD● Mechanism of action : Loca l e ffe c t of hormone s - p roge s tins

thicke n ce rvica l mucus , impa irs implanta tion, a ls o may inhib it b ind ing of s pe rm and e gg . Doe s n’t ne ce s s a rily inhib it ovula tion

● Side effects : uns che d ule d b le e d ing , b ut ge ne ra lly improve s with d ura tion of us e ; ame norrhe a (20 - 4 0 % of 52 mg LNG IUDs )

● Pearls of practice : re d uce s ris k of ce rvica l, e nd ome tria l and ovarian cance rs (a lte re d immune re s pons e ?), a s of Fe b ruary 20 21, 52 LNG IUDs can b e us e d as e me rge ncy contrace p tion (non- infe riority tria l NEJ M 20 21)

LNG IUD● Choice of which LNG to choose is based on the patient’s

preference, cost, availability○ Mire na - 52mg LNG - (7 ye a rs )○ Lile tta - 52mg LNG - (6 ye a rs )○ Kyle e na - 19 .5 LNG (5 ye a rs )○ Skyla - 13 .5 LNG (3 ye a rs )

● Lile tta /Mire na (LNG 52) have the lowe s t irre gula r b le e d ing ris k, highe s t chance of ame norrhe a

● Skyla (LNG 13 .5) has a s malle r d e vice s ize● All op tions can b e us e d in ad ole s ce nts , nullipa rous pa tie nts

Copper IUD● Mechanism of action : s te rile inflammatory re s pons e toxic to

s pe rm and ova , p re ve nts implanta tion, b ut a ls o coppe r e nhance s the e ffe c t and pre ve nts s pe rm motility

● Side effects : he avie r, longe r, more pa inful, e s pe c ia lly in the firs t 3 months b ut b y 6 months s ymptoms a re s imila r to the LNG IUD

● Duration of use: 10 ye ars (FDA) up to 12+ off- lab e l● Pearls of practice : can b e us e d as e me rge ncy contrace p tion up

to 120 hours from unprote c te d inte rcours e (5 d ays )

Nexplanon● Mechanism of action : 68mg etonogestrel, thickens cervical

mucus, suppress endometrial activity (less favorable to implantation), high doses of progestins inhibit follicle maturation and ovulation but not consistently towards the end of use

● Effectiveness : mos t e ffe c tive - le s s fa ilure ra te s than tub a l liga tion

● Duration of use : 3 ye a rs (FDA); d a ta s ugge s ts up to 4 - 5 ye a rs

Nexplanon● Contraindications : active or suspected breast cancer (or other

progestin - sensitive cancer), active liver disease, known or suspected pregnancy, undiagnosed abnormal uterine bleeding, allergies to any of the components○ Note ab out VTE - proge s tin- only acce p tab le , b ut the

package lab e ling lis ts pas t or curre nt VTE as contra ind ica tion- - b as e d off of s tud ie s with OCPs us ing s imila r p roge s tin

Nexplanon - side effects● Loca l s ite re ac tions (e rythe ma , he ma toma , b ruis ing, pa in, s we lling, ~9% tota l)● Uns che dule d b le e d ing (11%) - may or may not re duce ove r time , highe s t in the firs t

thre e months , can re duce ove r the firs t ye a r ● Ame norrhe a (20%)● He adache (16%)● We ight ga in (12- 14 %) - ~3 kg ove r 3 ye a rs for ne xplanon, LNG IUD vs 1kg coppe r

IUD● Acne (12%)● Bre as t te nde rne s s (10%)● Emotiona l lab ility (6%)● Abdomina l pa in (5%)

Nexplanon - side effects● Take home counseling points : among the most effective,

private, may lighten bleeding (but may cause unscheduled bleeding)○ Most bleeding patterns will persist after the first 3 months,

about 50% will improve if not going well

IUD vs Nexplanon● IUD - le s s uns che d ule d b le e d ing , fe we r hormona l s id e e ffe c ts ,

longe r d ura tion of ac tion, loca lize d ac tion of hormone s● Nexplanon - a g re a t op tion for pe ople who cannot us e IUDs ,

more e ffe c tive than othe r s hort- ac ting re ve rs ib le me thod s (OCPs , e tc )

● Amenorrhea - 20 - 4 0 % 52mg LNG IUDs vs 20 % ne xplanon us e rs

OCPs● Mechanism of action : s uppre s s e s ovula tion b y inhib iting GnRH,

LH and FSH, d is rup ting the mid - cyc le LH s urge , p rimarily b e caus e of e s troge n. Proge s tin re nd e rs e nd ome trium le s s favorab le to implanta tion, long- te rm us e can le ad to e nd ome tria l a trophy. Als o thicke ns ce rvica l mucus , impa irs tub a l motility

● Effectiveness : fa ilure ra te with pe rfe c t us e (0 .3 %, typ ica l is c los e r to 7%)

● Duration of use : can take until me nopaus e in non- s moking , BMI <25 , he a lthy pa tie nts . Ris k inc re as e s with age , s moking , highe r BMI

OCPs - contraindications● Absolute and relative - CDC Medical Eligibility Criteria● Age ≥3 5 ye a rs a nd s moking ≥15 c iga re tte s pe r da y● Multiple ris k fa c tors for ASCVD (olde r a ge , s moking, d ia be te s , a nd

hype rte ns ion),● Hype rte ns ion (s ys tolic ≥160 mmHg or d ia s tolic ≥100 mmHg),● VTE, his tory of s troke , MI● Va lvula r he a rt d is e a s e● Curre nt b re a s t ca nce r● De compe ns a te d c irrhos is , live r d is e a s e● Migra ine with a ura● Dia be te s with long dura tion or complica tions (>20 ye a rs , ne phropa thy,

re tinopa thy, or ne uropa thy)

OCPs - choosing what kind● Monophas ic vs multiphas ic● Cyclic vs e xte nde d - cycle vs continuous us e● Es troge n type and dos e - e s tra d iol 20 , 3 0 , 3 5mcg or le s s● Proge s tin type - multip le ge ne ra tions , third and fourth ge ne ra tion a re typica lly

lowe r s ide e ffe c ts (not phys iologica lly d iffe re nt, jus t whe n the y we re introduce d to the marke t).

○ Nore thind rone (1s t), Le vonorge s tre l (2nd), De s oge s tre l, Ge s tode ne , Norge s tima te (mod ifie d from le vonorge s tre l), d ros pire none (3 +)

○ The re a re s ome thought to be more antiand roge nic than othe rs (d ros pire none , a s pironola c tone a na log) but the re ’s not gre a t e vide nce tha t one type ove r anothe r is more e ffe c tive tha n a nothe r a t tre a ting hype randroge nic s ymptoms - acne , hirs utis m

OCPs● Side effects : unscheduled bleeding - more common in lower dose estrogen, more

common in continuous use OCPs (typically resolves within 3 months)○ Breast tenderness, nausea, bloating initially that can resolve with time

(~3mos)○ Incre a s e d ris k of VTE (va rie s with age , s moking s ta tus , e s troge n dos e , BMI),

abs olute ris k is s till low○ Incre a s e d ris k of HTN, MI, a nd s troke , abs olute ris k is low

● Pearls of practice: non- contrace ptive us e s : re gula tion of b le e d ing, pe lvic pa in d is orde rs , ova rian cys ts , hype randroge nis m, rapid re turn to fe rtility, re duce d ris k of ova rian and e ndome tria l cance r

OCPs - patient counseling● Taking at the same time every day● Quick start vs Sunday start vs menses start (with backup of 7 days)● Medical history and BP screening to start● Be mind ful of d rug inte rac tions - antis e izure me d s , rifampin, antifunga ls ,

antire trovira ls , St. J ohn’s wort● Mis s e d p ills

○ 1 day - take two the s ame da y, no backup re quire d○ 2 or more - backup me thod , and e me rge ncy contrace ptive s if in the firs t

we e k of the pills

Vaginal Ring● Same MOA as OCPs● Use : e tonoge s tre l/e thinyl e s trad iol ring (ENG/EE, NuvaRing , EluRyng)

worn vag ina lly for thre e we e ks and the n re move d (and d is ca rd e d) for one we e k

○ Se ge s te rone ace ta te /e thinyl e s trad iol (SA/EE, Annove ra ) is re us ab le for 1 ye a r. Worn for thre e we e ks , off 1 we e k, the n re us e d for 13 cycle s

● Failure rate : 0 .3 pe rce nt for pe rfe c t us e and 9 pe rce nt for typ ica l us e -s imila r to OCPs

Vaginal Ring● Side effects : s ame as OCPs

○ Inc re as e in vag initis , le ukorrhe a compare d with OCPs○ No inc re as e d ris k of vag ina l or ce rvica l infe c tions , inc lud ing

HIV, HPV● Complications : s ome cas e s of toxic s hock re porte d , a lthough

like ly re la te d to concurre nt tampon us e - ra re● Take home points : s ame s c re e ning as OCPs (me d ica l his tory,

BP, p re gnancy te s ting), high s a tis fac tion ra te , s ome b e ne fit for ins ulin- re s is tant pa tie nts

Vaginal Ring - patient counseling● Quick s ta rt vs Sund ay s ta rt vs me ns e s s ta rt● For ins e rtion, can us e a tampon ins e rte r, s hould not b e re move d d uring

inte rcours e .● If d e laye d re ins e rtion, <4 8 hrs d on’t ne e d b ackup

○ If > 4 8 hrs , ne e d b ackup for 7 d ays if >4 8hrs .● Can s a fe ly us e continuous ly, a lthough not s tud ie d in the SA/EE ring ye t,

b roke n rings a re s till e ffe c tive b ut more like ly to fa ll out● If it come s out for le s s than 3 hours , s till e ffe c tive , b ut if it’s >3 hrs , us e

b ackup in the firs t we e ks of the cycle● If it come s out for an unknown pe riod of time , che ck a p re gnancy te s t● Not compa tib le with s ilicone - b as e d lub ricants

Transdermal patch● Two types : Ethinyl estradiol -norelgestromin (EE/N) patch (Xulane,

Zafemy) and Ethinyl estradiol - levonorgestrel (EE/LNG) patch – (Twirla) released in 2020

● We e kly pa tch applie d for 3 we e ks , the n 1 we e k off, app lie d to b uttock, ab d ome n, uppe r tors o (not b re a s t tis s ue )

● Same MOA and e fficacy a s OCPs● Highe r d os e of e s troge n than OCPs for ave rage d os e , b ut lowe r pe ak

d os e than OCPs → pos s ib ility of highe r ris k for VTE● Contra ind ica te d in pa tie nts with BMI > or = 3 0

Progesterone -only pills● Pills taken every day without a break● Mechanism of action : thicke ning ce rvica l mucus work by thicke ning ce rvica l

mucus to inhib it s pe rm migra tion, s uppre s s ing ovula tion, s lowing move me nt of an e gg through the fa llopian tube s , and thinning the e ndome trium

○ Approximate ly ha lf of us e rs s till ovula te● Failure rate : 5%● Nore thind rone and d ros pire none a re both ava ilab le , no compa ris on s tud ie s but

may s how d ros pire none to be more e ffe c tive● Side effects : uns che dule d b le e d ing and change in me ns e s mos t common. Incre a s e

in ova rian cys ts and acne a ls o re porte d . No s ignificant we ight ga in or he a dache s .● Contraindications : known or s us pe cte d pre gnancy, known or s us pe cte d b re a s t

cance r, und iagnos e d ute rine b le e d ing, live r d is e a s e , c irrhos is , ba ria tric s urge ry or taking anticonvuls ants

Progesterone -only pills● Take home points: ne e d to b e take n e ve ry d ay within an hour or

s o - - s hort ha lf life● If more than 3 hours a fte r us ua l time , ne e d b ackup me thod for a t

le as t 4 8 hours● Can prote c t aga ins t e nd ome tria l cance r● Pos s ib le d e c re as e d e fficacy in pa tie nts with BMI >3 0

Permanent contraception● Mos t common is lapa ros copy - p lac ing c lips , rings on tube s ,

e le c tros urge ry or s a lp inge c tomy○ De vice s Es s ure and Ad iana no longe r be ing ne wly ins e rte d a s of 2019

● 1% fa ilure ra te (comparab le to LARCs and vas e c tomy) and more like ly to be e c topic if it fa ils , can be come pre gnant la te r by IVF or re ve rs a l

● Re ve rs a l ra te 1- 4 %, e xpe rie nce of re gre t a fte rwards va ry (s tud ie s s how 2- 26%, va riab le )

○ Pre gnancy a fte r re ve rs a l ra te s va ry 4 6 - 73 %, de cre a s ing with age , mos t occurre d within 2 ye a rs a fte r re ve rs a l

○ Limite d ava ilab ility of e ithe r re ve rs a l or IVF, a ls o cos t

Managing unscheduled bleeding● Expe ctant manage me nt, NSAIDs , OCPs● Nexplanon - e xpe ctant manage me nt, improve s ove r 6 - 12 months , no

s tud ie s on op tima l tre a tme nt, NSAIDs x 5- 10 d ays , othe rwis e a tria l of COCs for 3 - 6 months , or tria l of 10 - 20 d ays , monophas ic

● IUDs- NSAIDs , naproxe n 50 0 mg BID x 4 - 7 d ays on the firs t d ay of me ns e s or the fe w d ays b e fore

○ Als o op tions of antifib rionlytic age nts and d e s mopre s s in, b ut I d on’t fe e l comfortab le in p rimary ca re

● For e ithe r IUD if the re ’s ongoing he avy b le e d ing and cramping , ne e d to e va lua te for ma lpos ition, e xpuls ion, p re gnancy, and ce rvica l d ys p la s ia

Real World NP

realworldnp.com

Handout: www.realworldnp.com/NPA