Outpatient Contraception Counseling Approach
Classification of Concern
Contraception counseling is a preventive health service aimed at reducing unintended pregnancy through structured, patient-centered shared decision-making that prioritizes method effectiveness, safety, and patient preferences. 1
Concise History
Establish Rapport First
- Use open-ended questions to encourage dialogue 1
- Ensure privacy and confidentiality; explicitly explain how personal information will be used 1
- Demonstrate empathy by listening without judgment 1
Essential Clinical Information to Obtain
Medical History:
- Menstrual history: Last menstrual period, cycle frequency, bleeding duration/amount, abnormal bleeding patterns 1
- Obstetric/gynecologic history: Pregnancies, deliveries, miscarriages, terminations, recent intercourse 1
- Chronic conditions: Hypertension, diabetes, migraines (especially with aura), depression, thromboembolic disease, smoking status 1, 2
- Allergies: Particularly to latex or hormones 1
- Current medications that may interact with contraceptives 1
Reproductive Life Plan:
- Whether patient wants any/more children and desired timing/spacing 1
- This initiates the conversation but may not resonate with all patients 3
Contraceptive Experience:
- Current method(s) used, if any 1
- Past methods tried and difficulties experienced (side effects, adherence issues) 1
- Previous emergency contraception use 1
- Contraception use at last intercourse 1
- Partner preferences or involvement in decision-making 1
Sexual Health Assessment:
- Sexual practices (vaginal, anal, oral) 1
- Number, gender, and concurrency of partners 1
- Condom use patterns and barriers to use 1
- History of sexually transmitted infections 1
Differential Diagnosis
This section is not applicable for contraception counseling, as this is a preventive service rather than a diagnostic concern. The focus is on method selection based on patient preferences, medical eligibility, and effectiveness.
Diagnostic Workup
Physical Assessment (Minimal and Only When Warranted)
Blood pressure measurement before initiating combined hormonal contraceptives 1
Pregnancy testing only if history is unclear or uncertain 1
Weight measurement for monitoring changes over time 1
Pelvic examination is NOT required before starting most contraceptive methods; only needed before IUD placement 1
Laboratory Testing
- No routine labs required for most contraceptive methods 1
- Consider screening for STIs based on sexual health assessment 1
- Screen for personal/family history of blood clots before prescribing combined hormonal contraceptives 2
Empiric Treatment Options
Present Methods Using Tiered Effectiveness Approach
Start with most effective methods first (long-acting reversible contraception), then move to less effective options. 1, 2
Tier 1: Most Effective (>99% efficacy)
- Intrauterine devices (IUDs): Copper or hormonal (levonorgestrel) 1
- Contraceptive implant (etonogestrel) 1
- Sterilization: Tubal ligation or vasectomy 1
- Emphasize that LARCs are safe and effective for adolescents and nulliparous women 1
Tier 2: Moderately Effective (91-94% typical use)
- Combined hormonal contraceptives: Pills, patch, vaginal ring 1
- Progestin-only methods: Pills, injectable (DMPA) 1
Tier 3: Less Effective (depends heavily on adherence)
- Barrier methods: Condoms (male/female), diaphragm, cervical cap 1
- Fertility awareness methods 1
- Emergency contraception: Should be discussed and advance provision supported 1
Key Counseling Points for Each Method
Discuss for all methods:
- Effectiveness rates with typical vs. perfect use 1
- Correct and consistent use requirements 1
- Common side effects, especially bleeding irregularities (generally not harmful and may resolve with continued use) 1
- Non-contraceptive benefits (e.g., treating heavy menstrual bleeding, dysmenorrhea) 1
- Barriers to adherence: social-behavioral factors, mental health, substance abuse, partner violence 1
Recommend dual-method use (hormonal + barrier method) for STI protection when indicated 1
Same-Day Method Initiation ("Quick Start")
Provide the chosen method at the time of visit if reasonably certain patient is not pregnant. 1
Prescribe one year's supply of hormonal contraceptives to reduce barriers to use 1
Make condoms readily available without requiring a formal visit 1
Red Flag Symptoms to Discuss
Contraindications to Combined Hormonal Contraceptives
Absolute contraindications (do NOT prescribe):
- History of thromboembolic disease (DVT, PE, stroke) 2
- Uncontrolled hypertension 2
- Migraine with aura 2
- Current or history of breast cancer 2
- Active liver disease 2
- Smoking ≥15 cigarettes/day in women ≥35 years old 1
Warning Signs After Starting Contraception (ACHES mnemonic for combined hormonal contraceptives)
- Abdominal pain (severe) 1
- Chest pain or shortness of breath 1
- Headaches (severe or new onset) 1
- Eye problems (vision changes) 1
- Severe leg pain or swelling 1
When to Return Immediately
- Signs of venous thromboembolism (leg swelling, chest pain, shortness of breath) 2
- Severe abdominal pain (possible ectopic pregnancy or IUD complications) 1
- Heavy bleeding soaking through ≥2 pads/hour for ≥2 hours 1
- Signs of infection after IUD insertion (fever, severe pelvic pain, foul discharge) 1
Natural History/Untreated Prognosis
Without contraception, approximately 85% of sexually active women will become pregnant within one year. 1
Unintended pregnancy rates are highest among young, poor, and minority women (5 times higher in women at/below federal poverty level). 1
Women who use contraception consistently and correctly account for only 5% of unintended pregnancies. 1
Bleeding irregularities with hormonal methods generally resolve with continued use (3-6 months) and are not harmful. 1
Suggested Follow-Up
Initial Follow-Up After Method Initiation
3 months after starting any new contraceptive method to assess: 1, 2
- Satisfaction with method
- Side effects or concerns
- Correct use and adherence
- Any changes in health status
Ongoing Follow-Up
Annually for routine contraceptive care, including: 1
- Blood pressure check (for combined hormonal contraceptive users)
- Weight monitoring
- Reassessment of reproductive life plan
- STI screening based on risk factors
- Renewal of prescriptions (provide one year's supply)
IUD users: Check for expulsion at 3 months, then annually 1
Implant users: Annual check-in; replacement at 3 years 1
Injectable contraceptive (DMPA) users: Every 12-13 weeks for repeat injection 1
Special Populations
Adolescents: More frequent follow-up (every 3-6 months) to ensure adherence and address concerns 1
Perimenopausal women: Continue contraception until menopause confirmed or at least age 50-55 years (no test reliably verifies cessation of fertility) 1
Postpartum women: Discuss immediate postpartum LARC placement during prenatal care; if not placed immediately, schedule within 3-6 weeks postpartum 1
Critical Practice Points
Use shared decision-making framework that avoids coercion, especially for marginalized populations (low-income women, women of color, adolescents, LGBTQ+ patients, those with disabilities or limited English proficiency). 1, 3, 4
Discuss ALL medically appropriate methods regardless of on-site availability; establish strong referral links if needed. 1
Document patient understanding of use, benefits, risks, and individualized follow-up plan. 1
Confirm patient understanding before they leave the visit using teach-back method. 1
Provide anticipatory guidance about bleeding irregularities to prevent discontinuation. 1