Reversible contraception: Clinical sciences

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Introduction0:00–0:47

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.

Focused History and Physical0:47–4:28

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.

Pregnancy Test Results4:28–4:40

If negative, counsel on all reversible contraceptive options. Let’s start with patients who desire hormonal, non-LARC, contraception.

Hormonal, non-LARC4:40–10:16

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.
Options for COCs include cyclic and continuous pill packs. Cyclic packs contain a set number of pills with both estrogen and progestin, for example, 21 or 24 pills.
The remainder of the pack either contains hormone-free pills or pills with estrogen or iron. During this time patients will experience a withdrawal bleed or menses.
Continuous packs generally come in 3 month supply where the first 84 days contain active hormones and the last 7 days do not.
Patients taking these will have one menses every 3 months. There are also monophasic pill packs, which contain the same amount of estrogen throughout the month; and triphasic packs, which increase the estrogen levels throughout the month.
Common side effects include headache, nausea, breast tenderness, and breakthrough bleeding. Don’t be afraid to try a few to find the one that’s right, as this is not a “one pill fits all” situation!
Another option includes progestin-only pill or POP, also called the mini-pill. It works by inhibiting ovulation, thickening cervical mucus, slowing tubal motility, and thinning the endometrium.
The most common POP contains norethindrone, which due to its short half-life, only prevents ovulation in about half of individuals who take it.
Benefits include ease of access and use, plus safety for those who have contraindications to estrogen. POPs are contraindicated in patients with liver tumors, severe cirrhosis, or acute liver disease.
Some downsides are needing to remember to take them at the same time each day, and an increased risk of unscheduled bleeding.
Similar to COCs are the patch and vaginal ring, which contain estrogen and progestin, and function by preventing ovulation.
The contraceptive patch is an adhesive patch that’s applied once a week for 3 weeks a month. During the fourth week, patients will have their menses.
Benefits are needing to apply the patch only once a week, whereas risks include decreased efficacy in individuals weighing more than 198 pounds and skin irritation.
Side effects are similar to COCs. The vaginal ring is a flexible, plastic ring that’s inserted into the upper vagina.
It can be inserted for 21 days and removed for 7 days, during which time patients will have their period or used continuously for menstrual suppression.
Benefits include self-insertion and not needing to remember to take a daily pill, whereas side effects include vaginal discharge and irritation.
Finally, there’s depot medroxyprogesterone acetate, or DMPA, which is an injectable progestin administered once every 3 months.
Benefits include safe use for those who cannot tolerate estrogen; lighter, shorter periods; and reliable contraception for 3 months.
The negatives include need for office visit, irregular bleeding, especially during the first 6 to 12 months of use, and possible weight gain up to 5 pounds in the first year.
DMPA also lowers bone mineral density after 2 years of continuous use. Once stopped, patients may not have return of menses for 6 to 12 months, whereas menses generally return within weeks of discontinuing other methods.Let’s move on to LARCs.

Hormonal, LARC10:16–12:20

Options include the implant and IUD. The implant consists of a small rod that’s placed under the skin in the patient’s arm.
It releases a set daily amount of etonogestrel, a progestin, and works by inhibiting ovulation and thickening cervical mucus.
It provides contraception for up to 5 years and is the most efficacious method available! Benefits include ease of use, whereas the downside is that it needs to be placed and removed in the office, plus the common side effect of irregular bleeding.
Contraindications are the same as the POP. As for IUDs, there are two types; the copper IUD, which is hormone free; and the levonorgestrel IUD, which contains the progestin, levonorgestrel.
The copper IUD works by creating a toxic environment for sperm within the endometrial cavity; whereas the levonorgestrel IUD thickens cervical mucus, thins the endometrial lining, and inhibits sperm motility and viability.
Both methods are incredibly reliable at pregnancy prevention, however the disadvantage is that both also require an in person visit for insertion and removal.
Contraindications include active pregnancy, abnormal uterine anatomy, unexplained vaginal bleeding, or severe active pelvic infection.
Risks with the copper IUD are an increase in bleeding and cramping, especially following insertion, while benefits include 10 years of contraceptive effectiveness and avoidance of hormones.
Risks with the levonorgestrel IUD are irregular bleeding, especially in the first 90 days following insertion, while benefits include contraceptive efficacy for 3 to 8 years depending on the specific levonorgestrel device used.

Non-hormonal, non-LARC12:20–12:53

Let’s discuss patients who desire non-hormonal, non-LARC contraceptives. Options here include spermicide, which is placed in the vagina at or before intercourse; fertility awareness, which requires tracking of one’s menstrual cycle and avoidance of intercourse during the fertile window; withdrawal, which entails withholding ejaculation during penetration; and barrier methods like condoms.
As these methods require significant thought surrounding intercourse, they tend to be less effective. Alright, as a quick recap… When counseling patients on reversible contraception, assess their preference, use a patient-centered approach, and refer to their MEC to determine which contraceptive is safest.

Review12:53–13:22

Options include hormonal contraceptives like COCs, POPs, the patch, vaginal ring, or DMPA injection; LARCs like the implant and IUD; and non-hormonal, non-LARC methods like spermicides, fertility awareness,