What factors should be considered when prescribing contraceptive (birth control) methods to determine the most suitable option for a patient?

From the Guidelines

When prescribing birth control, I consider the patient's medical history, preferences, lifestyle, and specific health needs, and recommend the most effective and appropriate contraceptive method based on these factors, with a focus on long-acting reversible contraceptives (LARCs) like IUDs and implants, which are over 99% effective. The best birth control method varies for each individual based on several factors. First, I assess medical contraindications by reviewing conditions like hypertension, history of blood clots, migraines with aura, liver disease, and breast cancer history, which may limit certain options, as recommended by the CDC and the U.S. Office of Population Affairs 1. I evaluate the patient's menstrual patterns, as hormonal methods can help manage heavy or painful periods. Effectiveness is crucial, with LARCs like IUDs and implants being over 99% effective compared to pills (91% with typical use) and condoms (82%), as noted in the 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases 1.

Some key factors to consider when selecting a birth control method include:

• Medical history, including conditions like hypertension, history of blood clots, and breast cancer
• Menstrual patterns, including heavy or painful periods
• Effectiveness of the method, with LARCs being the most effective
• Patient preferences, including daily maintenance, hormonal versus non-hormonal options, and reversibility
• Lifestyle needs, including convenience and ease of use
• Future fertility plans, including the desire for future pregnancy

For patients seeking hormonal options, combined oral contraceptives (containing estrogen and progestin) like Ortho Tri-Cyclen or Yaz are common, typically taken daily for 21 days followed by 7 placebo days, as described in the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 1. Progestin-only options include the mini-pill (taken daily without breaks), Depo-Provera injections (every 3 months), Nexplanon implant (effective for 3-5 years), or hormonal IUDs like Mirena or Kyleena (3-7 years depending on type), as noted in the 2018 AHA/ACC guideline for the management of adults with congenital heart disease 1. Non-hormonal options include copper IUDs (ParaGard, effective for 10+ years), barrier methods like condoms, or natural family planning. I also consider side effect profiles, as some patients experience mood changes, weight fluctuations, or breakthrough bleeding with hormonal methods, as discussed in the 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1.

The final decision should balance medical appropriateness with the patient's personal preferences, lifestyle needs, and future fertility plans, as recommended by the CDC and the U.S. Office of Population Affairs 1. According to the most recent guidelines, the best birth control method for a patient is one that is safe, effective, and aligns with their individual needs and preferences, and I recommend LARCs like IUDs and implants as a first-line option for most patients 1.

From the FDA Drug Label

To achieve maximum contraceptive and PMDD effectiveness, drospirenone and ethinyl estradiol tablets must be taken exactly as directed, in the order directed on the blister pack. The possibility of ovulation and conception prior to initiation of medication should be considered. If the patient has not adhered to the prescribed dosing schedule (missed one or more active tablets or started taking them on a day later than she should have), consider the possibility of pregnancy at the time of the first missed period and take appropriate diagnostic measures.

When prescribing birth control, key factors to consider include:

• The patient's medical history and current health status
• The patient's adherence to the prescribed dosing schedule
• The possibility of ovulation and conception prior to initiation of medication
• The risk of pregnancy if the patient misses one or more active tablets or starts taking them on a day later than she should have

To determine the best birth control for the patient, consider the following steps:

• Evaluate the patient's individual needs and health status
• Discuss the importance of adhering to the prescribed dosing schedule
• Consider the possibility of pregnancy if the patient misses one or more active tablets or starts taking them on a day later than she should have
• Rule out pregnancy if the patient has adhered to the prescribed regimen and misses two consecutive periods 2

From the Research

Determining the Best Birth Control for a Patient

When prescribing birth control, there are several factors to consider in order to determine the best method for a patient. These include:

• The patient's medical history and current health status
• The patient's lifestyle and personal preferences
• The patient's reproductive goals and needs
• The potential side effects and risks associated with different birth control methods

Patient-Centered Contraceptive Counseling

Patient-centered contraceptive counseling is a key component of determining the best birth control method for a patient 3. This approach involves working with the patient to identify her unique needs and preferences, and providing her with accurate and unbiased information about different birth control options. The shared decision-making model is a useful framework for patient-centered contraceptive counseling, as it allows the patient and provider to work together to make informed decisions about birth control 3.

Initiating Hormonal Contraception

When initiating hormonal contraception, it is generally recommended to start at any point in the menstrual cycle 4. A recent Papanicolaou test is not necessary before prescribing hormonal contraception, and most patients can begin using progestin-only contraceptives immediately after childbirth. Patients can begin any appropriate contraceptive method immediately after an abortion or early pregnancy loss, except for an intrauterine device following septic abortion.

Types of Birth Control

There are many different types of birth control available, each with its own unique benefits and risks. For example, the combined oral contraceptive pill containing ethinylestradiol and drospirenone has been shown to be effective in preventing pregnancy and improving symptoms of premenstrual dysphoric disorder (PMDD) 5, 6. This pill has also been shown to have a positive effect on acne and other skin conditions.

Comparing Different Birth Control Methods

Studies have compared the effects of different birth control methods on various parameters associated with well-being in healthy women. For example, one study found that the combined oral contraceptive pill containing ethinylestradiol and drospirenone had similar beneficial effects on symptoms of water retention and impaired concentration as the pill containing levonorgestrel, but was significantly better in alleviating negative affect symptoms during the menstrual phase 7. This study also found that the proportion of subjects with acne decreased in the drospirenone group but not in the levonorgestrel group.

Key Considerations

When determining the best birth control method for a patient, it is essential to consider the following key factors:

• The patient's individual needs and preferences
• The potential side effects and risks associated with different birth control methods
• The patient's medical history and current health status
• The patient's reproductive goals and needs
• The importance of patient-centered contraceptive counseling and shared decision-making 3, 4