Drs Kate White and Harold Bays share their approach to initiating conversations with patients on contraception options and suggest which practitioners might be best suited to these conversations.
Harold Bays, MD: With which particular clinicians do females feel most comfortable discussing contraception? That’s going to vary from location to location. It’s going to vary from patient to patient, and it’s going to vary as to the individual clinician, some may feel comfortable discussing this, and others not. I can just say from here that I don’t think cardiologists are the ones who engage in the most intensive discussions about the relative merits and risks of contraception. Cardiologists mainly have their own focus. Now, there are going to be exceptions. Say for example, you have a cardiologist who’s engaged in preventive cardiology, so maybe not a proceduralist, but mainly engaged in prevention. Maybe this cardiologist is attuned to that and has expertise in this area, or maybe in addition to being a preventive cardiologist, this cardiologist also happens to be female. Maybe that personal experience is something that can bring a type of perspective into counseling patients, specifically females, as to the most appropriate contraception for them, especially for females who either have heart or cardiovascular disease, or who are at risk for cardiovascular or heart disease.
It widely varies, but I suspect in general, most people would acknowledge that the clinicians who have the greatest expertise overall in the relative risks and benefits of oral contraception, or any type of contraceptives, would be the people who do this on a daily basis, and that would be the gynecologist, the obstetrician, these types of folks. But again, it’s going to vary. I concede that there may be certain clinicians, particularly preventive cardiologists and cardiologists who focus their practice on women’s health, who they may provide invaluable assistance in counseling and advising patients as to the safest and most effective contraception.
If you have a patient who has an increase in body mass index, they have the overweight or maybe even the obesity factors and they’re at risk for thrombosis, and they’re a cigarette smoker, which makes them even more at risk for thrombosis, then absolutely. You have to take those things into consideration when you’re considering the use of estrogen-containing oral contraception. Again, what happens with regard to the effects upon the clotting cascade and such, the essential effect of the estrogens is that it’s polarizing. It’s gravitating the thrombosis state more toward thrombosis as opposed to antithrombosis. This has to do with influences upon clotting factors and such. But the bottom line is that whenever you are counseling, whenever you are advising, whenever you’re considering prescribing any kind of a drug, whether it be oral contraceptives or whatever, you have to take a patient-centered approach. Included within that patient-centered approach has to be the patient history and other risk factors that may influence, or may accelerate a potential complication. In this case, one would think that smoking and estrogens are not a very good combination, particularly in females with an increase in body mass index.
If you have a female who has heart disease, or is at a high risk of heart disease, then absolutely. There needs to be a conversation between the patient and a clinician with regard to the potential risks and benefits of different types of contraceptive therapies. That just makes logical sense, and especially if you have a female who has heart disease of some kind, and we talked about what those were, whether it be valvular disease, or whether it be cardiac dysrhythmias. There’s a case where mostly any cardiologist, but particularly preventive cardiologists, are going to have an opinion about what type of approaches are best taken in that patient-centered discussion. As we previously talked about, included that discussion would be things like you shouldn’t be cigarette smoking. You can’t be doing that. And to the extent that there are ways for which the overweight and obesity factors can be addressed, whether it be through healthful nutrition, increasing physical activity, or maybe even pharmacotherapy, that’s a conversation that’s going to take place as well.
But then you layer on top of that, that the female is also going to have the same sort of conversation with their ob-gyn [obstetrician-gynecologist] clinician. That’s a good thing because when you hear similar messages coming from a variety of folks, that has more of an impact. To answer your question, yes, a conversation with the cardiologist makes a lot of sense. Having a conversation with the ob-gyn clinician makes a lot of sense. But I also think that having a conversation with the primary care clinician makes a lot of sense because there are going to be universal themes that come through from all of these clinicians, with the No. 1 objective being a patient-centered approach that results in therapeutic decision-making that’s in the best interest of the patient.
Kate White, MD, MPH: Every time I start a patient on a new birth control method for them, there are a couple of things that are important to go over. The first is method logistics: how to get the method and how to use it, what to do in the case of missed pills, what happens if your patch falls off, how long can you leave the vaginal ring out, and things like this. Then of course the logistics of, what pharmacy do I send it to, and if you’re going to go through your insurance, can you get more than 1 month at a time. Making sure that logistically a patient knows what to do with their birth control once they leave your office is important as they start it on their own at home.
The second category is just as important though, and this what I call method expectations. It’s setting a patient up to understand what’s going to happen to them once they start using this birth control method. May there be adverse effects that they feel in the first few months that will resolve with time? Might there be changes in their bleeding patterns that they need to look out for and be counseled that it’s normal to have irregular bleeding, for instance, at first and it is likely to resolve by 3 to 6 months. I’ve had a lot of patients over the years who stop birth control on their own because they experience adverse effects that they weren’t prepared for, or they thought the effects they were experiencing meant that either the method wasn’t working, or that it was making them sick, and they didn’t realize how normal it was to experience these things. After we’ve had this long conversation about methods and patients have made a choice, I want to make sure I’m setting them up to be happy with their method going forward, and a lot of that starts with the comprehensiveness of the counseling they get with me in the office.
Harold Bays, MD: Certainly, we don’t want to leave out the pharmacist. Because the pharmacist is the person who is going to be giving out the medications. The patient is either going through the drive-through, or going into the pharmacy and picking up the prescription. That’s a good place for the patient to get additional information. What kind of information am I going to get from the pharmacist? It would be nice if the pharmacy could give some sort of basic counseling over some of the points that we’ve already talked about. At minimum, when the pharmacist gives out prescriptions, in most cases, they give out educational material that talks about the relative risks and benefits of whatever medication is being prescribed, and that’s so important. Patients ought to take the time, in this case, females ought to take the time, read that material, get the facts, know what’s going on. Then, if the female has any additional questions or concerns, they can either go to the pharmacist, get some input there, or go back to the cardiologist, or to the ob-gyn, or to the primary care clinician, and get the facts so that a patient-centered approach can take place.
Transcript Edited for Clarity