Contraception Counselling

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Types of Contraception

Pills

Vaginal Ring

Implant

IUDs

Female Condoms

Patch

Male Condom

Injection

Contraceptive Trivia:

1. Which of the following is NOT a contraindication for a combined OCP?

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B. Age > 40 years

1. Migraine with Aura

Contraceptive Trivia:

2. Which of the following IS a contraindication for a copper IUD?

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1. Wilson’s Disease

B. Poorly Controlled HTN

Contraceptive Trivia:

3. Which of the following is more effective contraception?

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1. OCP with perfect use

B. Hormonal IUD with Typical Use

Contraceptive Trivia:

4. Which of the following is more effective contraception?

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1. Depo Provera typical use

B. Contraceptive Patch typical use

Contraceptive Trivia:

5. Which of the following is less effective contraception?

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1. OCP with typical use

B. Withdrawal method, typical use

Contraceptive Trivia:

6. Which of the following is less effective contraception?

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1. Copper IUD typical use

B. Hormonal IUD typical use

Contraceptive Trivia:

7. Which of the following is the biggest advantage of a salpingectomy compared to tubal ligation with Filshie clips?

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1. Decreased Surgical Complication Rate

B. Decreased Ovarian Cancer Risk

C. Clinically Significant Increase in Contraceptive Efficacy

Contraceptive Trivia:

8. Which of the following is not a mechanism by which hormonal (levonogestrel) IUD’s routinely prevent pregnancy?

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1. Thinning of endometrial lining
2. Inhibit GnRH pulsatility
3. Thickening of cervical mucus
4. Decreased beat frequency of cilia in Fallopian tubes

Contraceptive Trivia:

TIE BREAKER: What year was the sale of contraception medication decriminalized in Canada?

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CASE 1

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1. How would you start the conversation about contraception?

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1. What kind of options for contraception would you offer her?

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A 37-year old Cree woman comes to see you in clinic for her 6-week postpartum visit after an uncomplicated vaginal delivery. She has no concerns to bring up today, this is her fourth child and she has good supports at home. She is currently sexually active, so you wish to discuss contraception with her today.

CASE 1

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1. How would you counsel this patient?

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1. How can you incorporate aspects of trauma-informed and family-centred care?

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You open up the conversation about contraception and her mood immediately shifts and she gets defensive. She tells you that her mother was only 33 years old when she got her tubes tied, without knowing that it was an irreversible procedure. Her mother is traumatized, and still talks about it to this day.

Her last OBGYN also tried to pressure her into permanent contraception because “she already has enough on her plate” and “she’s too old to have more kids.” Knowing what her mom went through, she refused any physician administered contraception

“Health-care providers are responsible for conveying accurate, clear information, using language and methods that can be readily understood by the individual, together with noncoercive counselling, in order to facilitate full, free, and informed decision-making. In a rights-based family planning framework, the choice of contraception should be made by the woman herself based on information regarding safety, effectiveness, accessibility, and affordability. A woman’s personal beliefs, culture, preferences and ability to use the chosen method, must be respected.”

Statement from SOGC

COUNSELING TIPS

ACOG states that reproductive justice should be incorporated into contraceptive counseling by:

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1. Acknowledging reproductive injustices (past and ongoing) committed against people of colour, Indigenous peoples, and other marginalized groups.
2. Recognizing personal biases which implicitly/explicitly affect care, and make a conscious effort to minimize such biases.
3. Prioritize patients’ values, preferences, and lived experiences in selection, continuation, or discontinuation of contraceptive methods.

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RESOURCES ON REPRODUCTIVE JUSTICE

• SOGC statement on coercive contraception provision and patient autonomy in family planning decisions.

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• ACOG - Patient-centered Contraceptive Counselling

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• CTV News - Canada’s Indigenous women forcibly sterilized decades after other rich countries stopped

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• Free the Pill Campaign - Native American Women’s Health Education Resource Center

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• Sister Song - Reproductive Justice

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• Forced Sterilization of Indigenous Women Expert Meeting

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CASE 2

• Prior contraceptive methods tried? Any side-effects?
• Plans for getting pregnant in the next 5 years? (LARC vs SARC)
• Risk factors for VTE
• General contraindications to contraceptive methods
• PMHx, sexual history, family history.

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What would you like to clarify on history?

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A 21 year-old woman is coming into clinic today to discuss contraceptive methods. She has no history of blood clots, but has a family history of unprovoked blood clots and knows her mother was told to stay away from hormonal therapies.

HISTORY

ASK ABOUT RISK FACTORS FOR VTE

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• Smoking and age >=35 years
• <21 days after giving birth, or 21-42 days after giving birth with other risk factors (e.g. age >35yrs, prior VTE, Thrombophilia, immobility, postpartum transfusion, Peripartum Cardiomyopathy, BMI 30+, PPH, Post-CS, PEC, or smoking)
• Recent major surgery that prolonged immobilization
• Hx DVT/PE
• Superficial Venous Thrombosis (acute or history)
• Hereditary Thrombophilia (including factor V Leiden mutation, Prothrombin G20210A mutation, protein C, protein S, Antithrombin deficiency, or Antiphospholipid syndrome)
• Systemic Lupus Erythematosus with positive (or unknown) antiphospholipid antibodies
• IBD with active or extensive disease, surgery, immobilization, corticosteroid use, vitamin deficiencies, or fluid depletion.

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CASE 2

None necessary. But, FVL can be detected by:

• Genetic testing (definitive)
• Functional testing for APC resistance (initial screening)

What investigations would you like to get?

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Of note, ACOG does NOT recommend routine screening for familial thrombotic disorders before initiating combined hormonal contraceptives (ACOG Statement 206). This is due to love frequency of conditioning becoming symptomatic, and lack of safe long-term prophylaxis against VTE.

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A 21 year-old woman with known family history of Factor V Leiden is coming into clinic today to discuss contraceptive methods. She has no personal history of blood clots, but knows her mother has always been told to stay away from any hormonal therapies.

CASE 2 | CONSIDERATIONS

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A 21 year-old woman with known family history of Factor V Leiden is coming into clinic today to discuss contraceptive methods. She has no personal history of blood clots, but knows her mother has always been told to stay away from any hormonal therapies.

“The second case of a history of venous thromboembolism in a family member is difficult. Most of the hematologists recommend against screening for thrombophilia due to issues with obtaining insurance in the future.

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My understanding is that Canadian law protects patients from being discriminated against due to genetic abnormalities.

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However, insurance companies can sell insurance to whomever they want.

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I have a patient who is a former resident who tested + FVL due to her brother testing positive after a DVT . She is unable to increase her disability insurance or to buy any new life insurance!”

WHAT IS THE RISK?

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INDIVIDUALS WITH FACTOR V LEIDEN MUTATION

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• Are at risk of developing a VTE sooner after CHC initiation
• Have a 7-fold increased baseline risk of VTE than those without this mutation.
• Risk of VTE in women heterozygous for this mutation who used CHC was 15-30x higher than women who used non-hormonal contraceptives and were not carriers of the gene.

CASE 2

If FLV was confirmed on serologic testing, how would you counsel this patient?

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What kind of contraceptive methods could you offer her?

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A 21 year-old woman with known family history of Factor V Leiden is coming into clinic today to discuss contraceptive methods. She has no personal history of blood clots, but knows her mother has always been told to stay away from any hormonal therapies.

CASE 2:

Non-Hormonal Contraception:

• condoms (male/female)
• withdrawal method
• fertility awareness methods
• spermicide
• diaphragm
• sponge
• surgical sterilization (vasectomy/tubal ligation)
• copper IUD

Estrogen-Free Hormonal Contraception:

• progesterone-only pills (POP’s or “mini pills)
• hormonal IUD’s (levonogestrel)
• hormonal implant (Nexplanon or Implanon)

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Knowing these options is very important for counselling anyone who does not want hormonal birth control options!

However, you MUST counsel about rates of failure with typical and perfect use… they’re high

CLINICAL RECOMMENDATIONS

CHC is contraindicated in individuals with known familial thrombophilias.

Progestin-only methods and LNG-IUDs are acceptable alternatives for

individuals with thrombogenic mutations.

Routine screening for familial thrombophilias is not recommended prior to

initiating CHC.

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CASE 3

What is the most important question right now?

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How do you counsel this patient?

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The patient, Veronica Sawyer, is a 32 y/o G1P1 (1 x uncomplicated SVD 6 years ago) who presents to your office for a discussion on contraception. She has longstanding heavy menstrual bleeding and dysmenorrhea, but is otherwise healthy. Her BMI is 23. In your discussion, she notes that she is currently sexually active with a new male partner, and approximately 14 hours ago, a condom broke during intercourse.

EMERGENCY CONTRACEPTION

Terminology here is important:

Contraception: prevents ovulation, fertilization and/or implantation; prevents pregnancy in the first place.

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Abortion: termination of an established pregnancy

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EMERGENCY CONTRACEPTION

Let’s take a little history lesson…

EMERGENCY CONTRACEPTION

What options are available in Canada for emergency contraception?

“Morning After” Pills:

• LNG-EC pills (Plan B, Norlevo, Option 2, Next Choice)
• OTC
• Best efficacy within 24 hours, can be used up to 5 days after unprotected intercourse
• If the pregnancy is established, no harm to fetus
• UPA-EC (Ella)
• requires prescription
• better effectiveness up to 5 days
• equally effective for BMI > 25

Copper IUD:

• effective if inserted up to 7 days after unprotected intercourse
• requires prescription and professional insertion
• extremely effective
• long-lasting (3-10 years)
• can worsen HMB and menstrual cramps

EMERGENCY CONTRACEPTION

CASE 3

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For Veronica, how might you counsel her?

• Discuss all the options she has available to her with risks and benefits (including expectant management), as well as how the timeline impacts the efficacy of each option
• given her history, the Copper IUD might not be ideal for her symptoms
• both Plan B and ella would be appropriate medical therapies given the time since intercourse and her BMI - but the ulipristal acetate option has slightly higher efficacy and you are a physician
• You can discuss what options she has available to her should emergency contraception fail and she does not want to be pregnant
• If she does not want to be pregnant and chooses an option other than a copper IUD, you can discuss other contraceptive options for the longer term, which may have beneficial effects for her period symptoms
• Offer STBBI testing given this is a new partner
• Offer a PAP smear if she is not up to date

RESOURCES & REFERENCES

• JOGC - Canadian Contraception Consensus Chapter 6 Permanent Contraception

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• ACOG Practice Bulletin No. 206: Use of Hormonal Contraception in Women With Coexisting Medical Conditions

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• https://www.uptodate.com/contents/inherited-thrombophilias-in-pregnancy?sectionName=SELECTION%20OF%20PATIENTS%20FOR%20TESTING&search=factor%205%20leiden&topicRef=1355&anchor=H7898324&source=see_link#H7898324

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• https://www.sexandu.ca/ (this is a great resource for patients with accessible language and all information has been reviewed by the SOGC)

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AUTHOR(S)

Claudia Turco

Isis Lunsky

Jessalyn Rohs

Jonathan Tankel

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