Five clinical pearls: How to counsel patients about long-acting reversible contraception

Counselling patients on the benefits and drawbacks of different long-acting reversible contraception takes skill and knowledge about what’s available. At the Society of Obstetricians and Gynecologists of Canada (SOGC) annual clinical conference in June, Dr. Amanda Black and Dr. Dustin Costescu provided some clinical pearls on key information to share. Dr. Black is a professor of obstetrics and gynecology at the University of Ottawa and Dr. Costescu is an associate professor in the department of obstetrics and gynecology at McMaster University in Hamilton, Ont. Needs-based counselling With contraception, first-line therapy doesn’t necessarily mean that treatment needs to be tried first before trying other therapies, but that it’s a viable option for most patients, Dr. Costescu explained. Long-acting reversible contraception can be used as a first-line option for all patients. In the past, a physician would recommend the most effective option for contraception, but now, physicians should listen to the patient about what they need, Dr. Costescu said. “My job is to give the patient the contraception that works for them, even if it’s not the most effective option,” he said. Patients are most interested in how the contraception will impact of their quality of life, Dr. Black said. When discussing options with patients, make sure patients are aware of side effects and offer solutions to those symptoms. Advise them how much time is needed for side effects to subside. If you’re going to prescribe off-label, be sure to tell the patient before they read the monograph. “I’m always surprised. I’m not sure how many physicians read the product monograph but patients will often read the product monograph,” Dr. Black said. As with other health subjects, physicians may have to deal with misinformation or misconceptions that patients have found online or through social media. It can cause worry about weight gain, cramping, uterine perforation, migration and others adverse events. Those are important things to address to give them reproductive autonomy, Dr. Black said. “We want them to be happy, to feel confident; they want to feel that they’re in control,” she said. One thing that is critically important is that physicians “pledge that you will remove it at any time, for any reason,” she said. It’s best if a patient doesn’t need to switch contraceptive methods. Research suggests that the more often they need to switch, the less satisfied they are with contraception method, Dr. Costescu said. Read: STIs on the rise: 'Pragmatic approach' recommended for managing chlamydia and gonorrhea Tic-Tac: asking relevant questions Dr. Costescu has a six-question system for discussing contraception with patients. The system uses the acronym Tic-Tac. First, start with three questions, the T.I.C.: Try: ask the patient what contraception they want to try Indications: Ask if there are any other benefits they’re hoping for, aside from contraception. For example, some people may want their skin to improve. Contraindications: Ask about any medical contraindications or side effects that would be unacceptable. Some patients will know about these beforehand, Dr. Costescu said. “Nowadays their research is actually pretty good.” If all that is fine, go ahead and prescribe. If more counselling is needed, continue with T.A.C.: Timeline: Ask when the patient wants to have a pregnancy, if ever. Acceptability: Ask what is acceptable to the patient in terms of route of administration, how often they need to take it, what hormones are involved. Coverage and cost: Ask if they are able to afford it. Finding the best fit: bleeding Long-acting reversable contraceptives are not created equal. While there are similarities between LARC methods, physicians should focus on the differences, including bleeding control, amount of progestin, administration and skills a physician needs to provide them, Dr. Costescu said. Some people want a period; some don’t. For the etonogestral-releasing implant (Nexplanon) and 19.5 mg levonorgestrel-releasing intrauterine system (IUS), amenorrhea can be expected in a quarter of users, and many users experience a more controlled cycle. With the 52 mg IUS, 40 to 60% of users experience amenorrhea, according to a slide presented by Dr. Costescu. Yet 17.7% of patients will experience prolonged bleeding with the etonogestral-releasing implant, according to the product monograph. Luckily, this tends to improve with time. Half of patients who found bleeding patterns unfavourable at three months report it being satisfactory at nine to 12 months, Dr. Black said. For unscheduled bleeding that’s a side effect with any long-acting contraception, make sure you reassure the patients that they are still getting effective contraception, Dr. Black said. Let them know that it may resolve with time. There are some pharmaceutical options to help with unscheduled bleeding, such as NSAIDS, mefenamic acid, tranexamic acid and doxycycline. You can also give patients other hormones, such as an oral contraceptive pill or a ring. Read: Adolescents can benefit from etonogestrel-releasing contraceptive implant: experts Finding the best fit: pain Patients who have dysmenorrhea at baseline may get relief with the etonogestral-releasing implant. In one trial, 77% of patients with dysmenorrhea had it resolved after getting the implant, according to a slide presented by Dr. Black. Almost all adolescents reported a decrease in period pain. Unfortunately, 7% of patients complain of new pain, according to the product monograph. Dr. Black said that for these patients, an NSAID or adding an oral contraceptive or progestin-only contraceptive may help. Consider conducting an ultrasound in adolescent patients with new dysmenorrhea with the implant, especially if they’ve never had imaging done before. “You don’t want to miss any rare, glaring anomalies out there,” she said. For IUDs, clinical trials suggest that 5% of patients will have new pain with the device, Dr. Black said. In these patients, order an ultrasound to confirm IUD placement. “You do not have to do an ultrasound routinely, but if they are having problems you may want to do one,” Dr. Black said. Some patients may have to change to a higher dose if they have dysmenorrhea at baseline. Recent media reports have centred on pain with IUD insertion. To deal with this fear, provide guidance before and during the procedure. During the procedure, take time and explain all the steps. Tell the patients that they are in control and can tell you to stop at any time, Dr. Black said. “Be honest and acknowledge that each person experience is different,” she said. “Do not minimize the pain or discomfort they may feel.” There’s no really effective method to reduce pain. Some methods that have been studied include NSAIDs, paracervical block and lidocaine spray or gel. Routine misoprostol before IUD insertion is not recommended. Dr. Black said physicians can offer individual patients relief that they think will help for that particular patient. Read: A different kind of 'morning after pill': An antibiotic to prevent certain STIs? Finding the best fit: weight Clinical trials suggest that no long-acting reversable contraceptive is associated with weight gain when compared to placebo or another non-hormonal therapy, Dr, Black said. “Unfortunately, we tend to gain weight over time,” she said. Regardless, some patients choose to switch contraceptive methods because of weight gain. Dr. Black said this may be due to progestin-mediated effects on appetite or changes in water retention that leads to a feeling of being bloated. It may also be because patients believe the contraception method is the cause of weight gain. Physicians can counsel patients about weight gain before they choose a method of long-acting reversible contraception. When something goes wrong Both implants and IUDs are placed successfully more than 99% of the time. Removals of implants are also successful 99% of the time, Dr. Black said. With implants, sometimes the IUD strings aren’t seen. The American College of Obstetricians and Gynecologists has a guideline on how to deal with this and other clinical challenges associated with long-acting reversible contraceptives. Many of the challenges can be dealt with in a physician’s office. Read: B.C. clinic says it can’t keep up with demand for IUDs

Five clinical pearls: How to counsel patients about long-acting reversible contraception

Register for free access or login.

Related Topics