What is the best approach for contraception counseling in a female patient of reproductive age with no significant medical history, considering various contraceptive methods, potential side effects, and contraindications?

Contraception Counseling Guide for Providers

Follow the CDC's structured 5-step approach to contraceptive counseling, prioritizing long-acting reversible contraception (LARC) methods first due to their superior effectiveness, then working through hormonal and barrier methods based on medical eligibility and patient preferences. 1

Step 1: Establish Rapport and Create a Safe Environment

• Use open-ended questions and ensure privacy and confidentiality 1
• Explain how personal information will be used and encourage questions 1
• Demonstrate empathy, trustworthiness, and accessibility throughout the encounter 1
• For adolescents specifically, ensure confidential discussion of family planning needs, as they are significantly less likely to use services without confidentiality assurances 2

Step 2: Obtain Essential Clinical and Social Information

Medical History Components

For female patients, obtain:

• Menstrual history: last menstrual period, frequency, length and amount of bleeding 1
• Gynecologic/obstetric history: pregnancies, deliveries, miscarriages, terminations 1
• Current contraceptive use and past experiences: what methods used, difficulties encountered, side effects, compliance issues 1
• Allergies to medications or latex 1
• Recent sexual activity and timing of last intercourse 1
• Chronic health conditions: hypertension, diabetes, migraines, liver disease, thrombophlebitis, breast cancer history 1, 3
• For combined hormonal contraception candidates: smoking status and age (critical contraindication if >35 years and smoking) 1, 3
• Breastfeeding status if postpartum 1

Reproductive Life Plan Assessment

• Ask directly: "Do you want to have any or more children? If so, when?" 1
• Clarify desired timing and spacing of future pregnancies 1

Sexual Health Assessment

• Assess STD risk: sexual practices, number of partners, past STD history, prevention steps taken 1
• Emphasize that hormonal contraception does not protect against STDs 3
• Recommend consistent condom use for anyone at STD risk, regardless of contraceptive method chosen 1, 2

Step 3: Present Methods Interactively, Starting with Most Effective

Present Methods in Order of Effectiveness

Tier 1: Long-Acting Reversible Contraception (LARC) - <1% failure rate

Levonorgestrel IUD:

• Effectiveness: 71-95% reduction in menstrual blood loss, comparable to endometrial ablation 2
• Side effects: Irregular bleeding initially (decreases over time), possible amenorrhea 1
• Contraindications: Current purulent cervicitis, chlamydia, or gonorrhea infection 1
• Backup contraception needed: Only if inserted >7 days after menses starts (7 days backup required) 2, 4
• Ideal for: Heavy menstrual bleeding, desire for long-term contraception (up to 5-8 years depending on type) 2

Copper IUD:

• Effectiveness: Most effective emergency contraception method, can be left for 10 years 5
• Side effects: May increase menstrual bleeding and cramping 1
• Management of bleeding: NSAIDs for 5-7 days 1
• Contraindications: Same as LNG-IUD 1

Subdermal Implant:

• Effectiveness: <1% failure rate per year 6
• Side effects: Irregular bleeding (most common reason for discontinuation) 1
• Management of bleeding: NSAIDs 5-7 days for spotting/light bleeding; for heavy bleeding consider NSAIDs, hormonal treatment (low-dose COCs or estrogen 10-20 days), or antifibrinolytic agents 1
• No examination required before insertion 4

Tier 2: Short-Acting Hormonal Methods - 4-7% failure rate with typical use

Combined Oral Contraceptives (COCs):

Absolute contraindications (DO NOT prescribe): 3

• Current or history of thrombophlebitis/thromboembolic disorders
• Cerebrovascular or coronary artery disease
• Current or history of breast cancer
• Undiagnosed abnormal genital bleeding
• Cholestatic jaundice of pregnancy or with prior pill use
• Hepatic adenomas or carcinomas
• Age >35 years AND smoking 3
• Receiving hepatitis C treatment with ombitasvir/paritaprevir/ritonavir 3

Recommended formulation: Monophasic pills with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 2

Key counseling points:

• Take one tablet daily at the same time every day 3
• If pills missed: Take most recently missed pill immediately; remember 7 consecutive hormone pills needed to prevent ovulation 2
• Backup contraception needed for 7 days if starting >5 days after menses begins 2
• VTE risk increases 3-4 fold (from 2 per 10,000 to 7-10 per 10,000 woman-years) 2, 6
• Greatest VTE risk occurs when initially starting or restarting after ≥4 week interruption 3
• Common transient side effects: Irregular bleeding, headache, nausea, breast pain (usually resolve within 3-6 months) 2
• Benefits: Reduces menstrual blood loss, improves acne, reduces endometrial and ovarian cancer risk 2
• Extended/continuous regimens: Take active pills for 3-4 months, then 4-7 day hormone-free interval 2
• If breakthrough bleeding with extended regimen: Can take 3-4 day hormone-free interval (NOT during first 21 days, NOT more than once per month) 1, 2

Progestin-Only Pills (POPs):

• Ideal for: Breastfeeding women, those with contraindications to estrogen 7
• Must be taken at same time daily (less forgiveness than COCs) 7
• No examination required before prescribing 4

Depot Medroxyprogesterone Acetate (DMPA/Depo-Provera):

• Dosing: 150 mg IM every 12 weeks (can give up to 15 weeks without backup contraception) 4
• Can start immediately when switching from COCs without waiting for period 4
• Backup contraception: Only needed if given >7 days after menses starts (7 days backup) 4
• Side effects: Irregular bleeding initially, amenorrhea common after ≥1 year (87% reduction in menstrual blood loss) 2
• Management of heavy bleeding: NSAIDs for 5-7 days 1, 2
• Contraindication: Heart failure (causes fluid retention) 2
• No examination or lab tests required before initiating 4
• Enhanced counseling about expected bleeding patterns improves continuation rates 2

Contraceptive Vaginal Ring:

• Releases 15 μg ethinyl estradiol and 120 μg etonogestrel daily 2
• Simpler regimen: Once monthly insertion 2
• Same contraindications as COCs 3

Tier 3: Barrier Methods - 13-18% failure rate with typical use

Condoms:

• Essential for STD protection regardless of other contraceptive method 1, 2
• Medical history should not be a barrier to making condoms available 1
• No formal visit required to obtain condoms 1

Step 4: Physical Assessment - Only When Warranted

Most methods do NOT require examination before initiation: 1, 4

No examination needed for:

• Condoms 1
• Progestin-only pills 4
• DMPA 4
• Combined hormonal contraceptives (blood pressure can be self-reported from pharmacy/fire station) 1

Bimanual examination and cervical inspection required ONLY for:

• IUD insertion 1
• Cervical cap fitting 1

NOT required before initiating contraception: 1

• Clinical breast examination
• Pelvic examination (except for IUD/cervical cap)
• Papanicolaou smear
• Glucose, lipids, liver enzymes, hemoglobin testing
• Thrombogenic mutation testing
• STD screening (though recommended based on risk assessment)

Step 5: Provide Method with Clear Instructions and Follow-Up Plan

Dispensing Strategies

• Provide onsite dispensing whenever possible 1
• Prescribe multiple cycles: Ideally full year's supply for pills/patch/ring 1
• "Quick start" method: Begin contraception at visit rather than waiting for next menses if reasonably certain not pregnant 1

Reasonable Certainty of No Pregnancy (can start method immediately): 1

• ≤7 days after start of normal menses
• Has not had intercourse since last normal menses
• Using reliable contraception correctly and consistently
• ≤7 days after abortion
• Within 4 weeks postpartum
• Fully/nearly fully breastfeeding, amenorrheic, and <6 months postpartum

When Uncertain About Pregnancy Status

For DMPA, implant, CHC, and POP: Benefits of starting likely exceed any risk; start method and perform follow-up pregnancy test in 2-4 weeks 1, 4

Managing Breakthrough Bleeding

Before treating, rule out: 1, 2

• Pregnancy
• STDs
• Medication interactions
• Thyroid disorders
• New pathologic uterine conditions (polyps, fibroids)

Treatment options by method: 1

• COCs (extended regimen): 3-4 day hormone-free interval (not during first 21 days, not >once/month)
• DMPA: NSAIDs 5-7 days
• Implant: NSAIDs 5-7 days for light bleeding; for heavy bleeding add hormonal treatment or antifibrinolytics
• LNG-IUD: No specific interventions identified
• Copper IUD: NSAIDs 5-7 days

Follow-Up Guidance

• No routine follow-up visit required 2
• Patient should return if: Side effects, concerns, or health status changes 2
• For COC users: Monitor blood pressure at follow-up visits 2
• Assess satisfaction with method and any health changes at follow-up 2

Essential Counseling Before Discharge

• Confirm patient understanding of correct and consistent use 1
• Provide written instructions about what to do if doses missed 2
• Counsel about expected bleeding changes (especially for hormonal methods) 2
• Reassure that amenorrhea with hormonal contraceptives is not harmful 2
• Emphasize condom use for STD protection 1, 2
• Discuss enzyme inducer interactions (may need backup contraception) 3
• For breastfeeding women on COCs: May reduce milk production (less likely if breastfeeding well-established) 3
• For postpartum women without period: Use backup method until 7 consecutive days of active pills taken 3
• Warn about smoking risk with COCs: Increases serious cardiovascular events 3
• For patients with depression history: Depression may recur; contact provider if occurs 3

Common Pitfalls to Avoid

• Do not require unnecessary examinations or tests that create barriers to contraceptive access 1, 4
• Do not delay method initiation waiting for menses when reasonably certain patient not pregnant 4
• Do not forget to counsel about STD protection - hormonal methods do not protect against infections 3
• Do not prescribe COCs to women >35 who smoke - absolute contraindication 3
• Do not treat breakthrough bleeding during first 3-6 months unless patient desires - usually resolves with continued use 1, 2
• Do not forget to provide strategies for adherence: Cell phone alarms, family member support 2