PATIENT-CENTERED

CONTRACEPTION:
Updates on the Evidence
Objectives
• Discuss rates of unintended pregnancy and
contraceptive use in the US
• Apply evidenced-based guidelines to
contraceptive provision using the CDC MEC
• Provide contraceptive options using patient
centered care
Nearly half (45%) of pregnancies in the US are
unintended

Unintended –
Mistimed 27%

Intended 55%
Unintended-
Unwanted
18%
Unintended pregnancy by consistency of
contraception use

Consistent use 5%

Inconsistent use 41%

Nonuse 54%
One year failure rates
Effectiveness Contraceptive Typical-use Perfect-use
pregnancy rate pregnancy rate
Ineffective Chance 85% 85%

Less effective Condoms 14% 3%

More effective Pill/patch/Ring 8% 1-3%

Highly effective IUDs 0.8 – 2% 0.8 – 2%

Injectable 0.1 – 0.3% 0.1 – 0.3%

Implant 0.1 – 0.3% 0.1 – 0.3%

Sterilization 0.1 – 0.3% 0.1 – 0.3%

(male and female)
Contraceptive Methods in the U.S.
25.00%

20.00%

% of women 15.00%
at risk of unintended pregnancy*
10.00%

5.00%

0.00%
THE MEC
US Medical Eligibility Criteria (MEC)
CDC recommendations for specific contraceptive
methods with certain medical conditions
There’s an APP for that:
- Can be downloaded on iOS and Android operating
systems (https://www.cdc.gov/mobile/mobileapp.html)
MEC Categories of Safety
Another helpful APP…
• Contraceptive Point-of-Care App
CASES
In contraception management
Yolanda
• 16 year old G0P0 presents with UTI symptoms
• Had unprotected sex 4 days ago
• Urine pregnancy test is negative

What do you do next?

Opportunity knocks!
• Get a medical history
• Ask about contraceptive or preconception needs
Emergency Contraception

• Factors that will affect the efficacy of the

emergency contraception (EC) pill:
• LMP
• Timing of last unprotected sex
• BMI
Yolanda choses her EC
• Yolanda chooses Ella
• But also wants to start contraception
• When should she start?
Reproductive Health Access Project: Quick Start
Algorithm
 Contraceptives: What is needed before providing?

Pap smear
Medical history Pelvic/breast exam
REQUIRED
STI testing
Hemoglobin
NOT REQUIRED

Blood pressure
RECOMMENDED

Stewart F, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence.
JAMA. 2001;285:2232-9.
What about estrogen?
• Estrogen absolute contraindications:
• Migraine with aura
• Uncontrolled hypertension
• History of DVT/PE
• Tobacco use*
What about Yolanda’s UTI?
Medication interactions
What does Yolanda want?
 Impact of Choice

Pariani S, Heer D, van Arsdol M. Does choice make a difference to contraceptive use? Stud Fam Plann 1991;22(6):384-390.
Yolanda decides to start the pill
• Does it matter which pill she starts?
The patch and ring are also similar options…
How many refill should we give Yolanda? Should we
dispense one at a time?
Should Yolanda get a prescription for EC too?
Mari
• 17 year old, G0P0
• Doesn’t want to get pregnant until she finishes school
• Wants a contraception that she can hide from her mom
• Hates remembering to take pills

• What are her choices?

Highly effective methods
NOT USER DEPENDENT

Effectiveness Contraceptive Typical-use Perfect-use

pregnancy rate pregnancy rate

Highly effective IUDs 0.8 – 2% 0.8 – 2%

Injectable 0.1 – 0.3% 0.1 – 0.3%

Implant 0.1 – 0.3% 0.1 – 0.3%
Sterilization 0.1 – 0.3% 0.1 – 0.3%
Progestin-Only Injection
 DEPO-PROVERA AND BONE DENSITY

What are the real

risks for teens?
exercise and diet
are more important

Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive
Use, 2013. MMWR 2013;62. http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. June 14, 2013.
Intrauterine Devices
IUD considerations
• Nulliparity
• STI Screening
• Timing of placement
• Desire for menses
IUD Considerations
• Family planning timeline
• Medication cost
• Risk of ectopic
Progestin Implant
• Highly effective and rapidly reversible
• Discreet
• Duration: 5 years
• Can be used during lactation
• Causes spotting
Jamie
• Jamie is a 28 year old transgender male. He is interested
in preventing pregnancy, and has both male and female
partners. He has not had any surgeries, and is not on
hormone therapy but may be interested in the future.
• What are Jamie’s options?
Office Barriers to Adherence
 Inconsistent Pill Use:
Linked to low satisfaction with clinician &
low continuity of care

Percent of pill users who missed one or more pills during the
past three months

Landry, David. Public and private providers involvement in improving their patients contraceptive use Contraception 2008 Jul 78 (1)
42-51.
 Feeling Unable to Reach a Provider With
Questions is Linked to Contraceptive Non-Use

% of at-risk women experiencing contraceptive non-use in the past year

Landry, David. Public and private providers involvement in improving their patients contraceptive use Contraception 2008 Jul 78 (1)
42-51.
Take home message: Be proactive with
contraception!
• Ask about contraceptive or
preconception needs at all
types of visits
• Discuss all methods -
always honor a patient’s
choice
• De-link pap smears from
contraception prescriptions
• Prescribe 1 year supply
with 3 packs at a time
• Use Quick Start