What factors should be considered when deciding on a birth control method to prescribe?

Selecting the Most Appropriate Birth Control Method

When prescribing birth control, providers should follow a systematic approach that prioritizes safety, effectiveness, and patient-specific factors to select the most appropriate contraceptive method based on the CDC's Medical Eligibility Criteria and the patient's individual circumstances. 1

Key Factors to Consider in Contraceptive Selection

1. Medical History and Safety Considerations

• Medical conditions: Assess for conditions that may contraindicate specific methods:

  • Cardiovascular risk factors (smoking, hypertension, migraines with aura) contraindicate estrogen-containing methods 2
  • History of thrombosis contraindicates combined hormonal methods 2
  • Substance use (cocaine, vaping) increases cardiovascular risk, making combined hormonal contraceptives less suitable (Category 3-4) 2

• Current medications: Check for interactions with:

  • Anticonvulsants (phenytoin, carbamazepine, barbiturates, etc.) - may reduce effectiveness of hormonal methods 1
  • Antimicrobials (rifampin/rifabutin) - may reduce effectiveness of hormonal methods 1
  • Antiretrovirals - may affect hormonal contraceptive efficacy 1

• Blood pressure measurement: Required before initiating combined hormonal contraceptives 1

2. Effectiveness and Patient Preferences

• Present options in order of effectiveness (tiered approach) 1:

  • Highest effectiveness (failure rate <1%): LARCs (IUDs, implants)
  • Moderate effectiveness (failure rate 0.3-9%): Injectables, combined hormonal methods, progestin-only pills
  • Lower effectiveness (failure rate 14-25%): Barrier methods, fertility awareness methods 2

• Consider patient's ability to adhere to method requirements:

  • Daily pill-taking vs. long-acting methods
  • Patients with substance use, mental illness, or medication adherence difficulties may benefit from LARCs 1

3. Reproductive Goals and Sexual Health

• Pregnancy intentions: Discuss short-term vs. long-term contraceptive needs
• STI risk: Recommend dual method use (hormonal + barrier) for those at risk of STIs 1
• Partner involvement: Consider whether method requires partner cooperation

Specific Method Considerations

Long-Acting Reversible Contraceptives (LARCs)

• Copper IUD:

  • Can be inserted anytime with no backup needed
  • Requires bimanual examination and cervical inspection before insertion 1
  • Appropriate for women with contraindications to hormonal methods

• Levonorgestrel IUD:

  • Requires backup method for 7 days if inserted >7 days after menses started
  • Requires bimanual examination and cervical inspection 1
  • Excellent for treating heavy menstrual bleeding 2

• Contraceptive Implant:

  • No examination needed before insertion
  • Requires backup for 7 days if inserted >5 days after menses started 1

Short-Acting Methods

• Injectable (DMPA):

  • No examination needed before initiation
  • Requires backup for 7 days if started >7 days after menses 1
  • Monitor for weight gain, especially in first 6 months 2

• Combined Hormonal Contraceptives:

  • Blood pressure measurement required before initiation
  • Requires backup for 7 days if started >5 days after menses 1
  • Contraindicated in women with multiple cardiovascular risk factors 2

• Progestin-Only Pills:

  • No examination needed before initiation
  • Different backup requirements based on formulation (2-7 days) 1

Managing Common Side Effects

Bleeding Irregularities

For unscheduled bleeding or spotting:

• Cu-IUD users: NSAIDs for 5-7 days 1
• LNG-IUD users: NSAIDs for 5-7 days 1
• Implant users: NSAIDs for 5-7 days; for heavy bleeding, consider hormonal treatment or tranexamic acid 1
• Injectable users: NSAIDs for 5-7 days 1
• CHC users on extended regimen: Consider hormone-free interval (not in first 21 days, not more than once monthly) 1

Follow-Up Recommendations

• No routine follow-up visit required for most methods 1
• Advise patients to return if they:
  • Experience side effects or problems
  • Want to change methods
  • Need IUD/implant removal or reinjection 1

Common Pitfalls to Avoid

1. Requiring unnecessary examinations or tests before initiating contraception, which creates barriers to access
2. Delaying initiation when reasonably certain the patient is not pregnant
3. Not discussing backup method requirements when starting mid-cycle
4. Failing to consider drug interactions that may reduce contraceptive effectiveness
5. Not addressing common side effects proactively, which may lead to discontinuation

By systematically evaluating these factors and using the CDC's Medical Eligibility Criteria, providers can help patients select the most appropriate contraceptive method that maximizes effectiveness while minimizing health risks, ultimately improving contraceptive continuation and reducing unintended pregnancy rates.