Importance of Patient-Centered Approach to Contraceptive Selection


Kate White, MD, MPH, and Harold Bays, MD, provide their thoughts on the importance of a patient-centered approach when selecting a contraceptive option in patients of child-bearing age.

Kate White, MD, MPH: There are a lot of ways to group contraceptive methods together when you’re talking with patients. One of the ways I like to group them together is by how a patient can access them, which was incredibly important during the [COVID-19] pandemic when access to a health care provider’s office was limited. We can think about methods that a patient can start and stop on their own, which include things like emergency contraception and barrier methods. Then, there are medications, or birth control methods that you need a prescription to start, but you can stop on your own like birth control pills, patches, and rings as well as one form of emergency contraception, and the new vaginal pH Modulator. Then, there’s the Depo-Provera [medroxyprogesterone acetate] injection, which is one that you tend to use a visit to start, but you could stop on your own by just not having future injections. There are the methods that require a provider visit both to start and generally stop the IUDs [intrauterine devices] and the implants.

It’s either called, the contraceptive injection, or the generic name would be Depo medroxyprogesterone acetate, which is a real mouthful. Once I’ve been able to get a patient’s comprehensive history about what they’ve used in the past, what their medical history is, and what their preferences are, then, I try to translate all of that into the methods that might align best with their health history and what they want to use in a method. I use a paper contraceptive decision aid because using decision aids are the best practice in medicine. It’s a good way to organize all of the countless birth control methods that there are, which can be hard for patients to follow along in conversation. I’ll use this aid to sort of circle which methods are safest for a patient to use based on their health history and align that with what they want to use in a method. Then, if there are methods that aren’t as perfect for a patient based on these factors, I’ll talk about why. For instance, if a patient has migraines with aura, then methods that contain contraception pose them at an increased risk of stroke. So most patients would not want to use those methods because of that risk. I’ll put little Xs on those boxes, but it’s always a conversation with the patient so that they understand why I’m making the recommendations I am because then they are the ones who get to sort of weigh the risks and the benefits of any given method before they make their choice.

Harold Bays, MD: My name is Dr Harold Bays, medical director and president of the Louisville Metabolic and Atherosclerosis Research Center located in Louisville, Kentucky. As with prescribing any medication, you have to take a patient-centered approach. You have to ask, what are the pros? What are the cons? What are the potential benefits? What are the potential risks? With that discussion with the patient, go over those and see if they can come to an agreement as to which therapeutic approach is safest, sufficiently effective, and in the best interest of the patient.

Kate White, MD, MPH: What goes into that decision? It’s different for every patient. Some patients are going to lead with I can’t get pregnant no matter what. Efficacy is the most important thing in a method and these patients are very often drawn to long-acting reversible methods like IUDs and implants. Other patients are concerned about side effects. They want their bleeding patterns to be predictable and they may then want to use methods that contain estrogen, which tends to have the best bleeding profiles. Some patients then are driven by risk. They’re worried about the risk of a particular contraceptive method and that method may just have intrinsic risks with it or may have elevated risks depending on their own health history. Then, those patients may be drawn to methods that reduce their risk of adverse events.

Transcript Edited for Clarity

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