Reversible contraception: Clinical sciences

Reversible contraception refers to any method of pregnancy prevention that doesn’t impact future fertility. Options for reversible contraception include hormonal birth control pills, patches, vaginal rings, and injections; long-acting-reversible-contraceptives, or LARC’s, such as implants and IUDs; and non-hormonal, non-LARC options like spermicides, fertility awareness, withdrawal and barrier methods. All individuals who desire contraception should be offered comprehensive counseling, with a focus on their values, preferences, and lived experiences. Shared decision-making is recommended when providing care to help individuals achieve their reproductive goals.

When a patient presents for reversible contraception, start with a focused history and physical exam. First, assess your patient’s preference and provide patient-centered contraceptive counseling. Be sure to incorporate a reproductive justice framework, which is focused on the understanding that all people have a fundamental right to bodily autonomy, to have or not have children, and to parent their children in safe and sustainable communities. Part of acknowledging this framework is awareness of the systemic and structural barriers that people of different descent, low incomes, mental illness, and incarceration have been subject to throughout history. Specifically, marginalized groups have undergone contraceptive experimentation without informed consent, government-sponsored forced sterilization, and other mistreatment.

As such, counseling should be viewed as an opportunity to review your patient's individual values, preferences, and lived experiences, in an open and safe environment. Additionally, take time to reflect and recognize any of your own unconscious or explicit biases that may influence the efficacy of your counseling. Finally, be sure to incorporate shared decision-making into your practice.

Next, assess your patient's medical eligibility criteria, or MEC, for each contraceptive method. The MEC is a set of standards that provides recommendations on the safety of contraceptives in the setting of different medical conditions.

During your history, assess the patient’s age and first day of their last menstrual period. Review their sexual history and 5 Ps, or partners, practices, past history of sexually transmitted infections, or STIs, prevention of STIs, and prevention of pregnancy. While this information is not absolutely required for contraception, it can help guide conversations on safe sexual practices and provide informed counseling.

Next, review medical conditions that are contraindicated for systemic hormonal contraception, including migraines with aura, hypertension, tobacco use, breast cancer, undiagnosed abnormal uterine bleeding, and acute liver disease.

Following this, assess for mental health conditions, specifically mood disorders like depression or bipolar disorder, as some patients may have worsening of symptoms with hormonal contraceptives. Also evaluate for mental or physical disabilities, which may limit a patient’s ability to reliably use contraceptives or tolerate placement of a LARC.

Additionally, review the patient's breastfeeding and postpartum status, as this will limit contraceptive options. Finally, review all medications, because certain anti-epileptic drugs, antibiotics, and antiretrovirals can reduce the efficacy of combined oral contraceptive pills, or COCs.

On physical exam, assess blood pressure and BMI. While routine pelvic exam and/or ultrasound is not necessary prior to prescribing contraception, you may opt to perform them if the patient desires an IUD to assess uterine size. If performing a pelvic exam, you can also evaluate for evidence of an active STI. For labs, obtain a pregnancy test and consider STI screening. If history and/or physical exam warrants further work-up, a pelvic ultrasound might be recommended.

Okay, if the pregnancy test is positive… perform individualized counseling. If negative, counsel on all reversible contraceptive options.

Let’s start with patients who desire hormonal, non-LARC, contraception. This includes combined oral contraceptive pills, or COCs, which contain both estrogen and progestin; and progestin-only pills, called POPs. There are also options for a combined estrogen-progestin contraceptive patch or vaginal ring, and a progestin-only injection called depot medroxyprogesterone acetate, or DMPA for short.

COCs work primarily by preventing ovulation, while also thickening cervical mucus making it more difficult for sperm to enter the uterus, and thinning the endometrium. Benefits of COCs include ease of access and use, plus non-contraceptive benefits like regular, lighter, and shorter menses, reduced menstrual cramps, and decreased risk of uterine, ovarian, and colon cancer. The biggest disadvantage is that patients must remember to take their pills at the same time every day!

Risks to COCs and other methods of combined hormonal contraception like the patch and vaginal ring, are rare but include a small increase in venous thromboembolism, or VTE, myocardial infarction, and stroke. This risk is highest in individuals over 35 years old who smoke more than 15 cigarettes a day, or in people with multiple cardiovascular risk factors or a history of migraines with aura.

Also, if your patient is postpartum, refrain from COCs for at least 21 days following delivery due to increased VTE risk, and avoid COCs in breastfeeding individuals as estrogen may affect milk production.