Monday, July 4, 2022

Contraception resources for physicians & patients

 - Jennifer Middleton, MD, MPH

Patients may be more interested in methods to prevent pregnancy after the United States (US) Supreme Court's recent decision to allow state legislatures to determine whether, and to what degree, to permit abortion. Nearly half of US states are banning, or plan to ban, most or all abortion services. Patients may also present with questions about accessing contraception, including emergency contraception, after some US retaliers instituted purchasing limits on over the counter (OTC) emergency contraception, fearing consumer stockpiling after the Supreme Court's decision. Contraception remains legal in the US, and family physicians have a range of options and resources to share with patients who desire pregnancy prevention.

This 2021 AFP article on "Initiating Hormonal Contraception" provides an overview of contraceptive pills, patches, injections, implants, and intrauterine devices (IUDs). Patients may initiate contraception at any point in their menstral cycle, and this Choosing Wisely recommendation reminds us that a pelvic examination is not necessary to prescribe contraceptive pills. The article also provides several useful algorithms for the "quick start" of pills, patches, injections, implants, and IUDs. Another AFP article, "Evidence-Based Contraception: Common Questions and Answers," was recently published online ahead of print and provides guidance on emergency contraception, fertility awareness methods, safety precautions in persons with migraine with aura, duration of long-acting reversible contraception (LARC), subcutaneous depot medroxyprogesterone acetate, and considerations for transgender and gender-diverse people. There's an AFP By Topic on Family Planning and Contraception with additional content including patient education handouts. 

Family physicians can also discuss contraception for families in between pregnancies to optimize outcomes for parents and infants. Breastfeeding (lactational amenorrhea method or "LAM") can prevent pregnancy, but only with "exclusive, frequent" breastfeeding in the first 6 months after birth. Persons desiring to prevent pregnancy after birth who are not breastfeeding frequently or exclusively, or who desire additional contraception in addition to LAM, have several safe options to choose from. Increasing intrapartum intervals to a minimum of 18 months is one of the aims of the March of Dimes' IMPLICIT project to reduce the prevalence of low birth weight infants. 

The US Centers for Disease Control and Prevention (CDC) has a "Contraceptive Guidance for Health Care Providers" website that includes a link to their US Medical Eligibility Criteria for Contraceptive Use (US MER) and US Selected Practice Recommendations for Contraceptive Use (US SPR) app. The app allows for convenient access to recommendations related to underlying medical conditions as well as "selected practice recommendations" regarding use and management of contraceptive methods.

For persons desiring irreversible contraception, family physicians can provide counseling regarding vasectomy and tubal ligationVasectomies are performed far less frequently than tubal ligations in the US despite the procedure's relative simplicity, safety, and inexpensive cost. The American Urological Association's Vasectomy Guideline (2015) describes optimal patient selection and post-procedure counseling, including recommended timing of postvasectomy semen analyses. Approximately 13% of vasectomies in the US are performed by family physicians, and the procedure can be learned in residency or following residency with a local mentor or skills course.

Lastly, the American Journal of Public Health just released a supplement to their June 2022 issue on "Reshaping Contraceptive Access Efforts By Centering Equity, Justice, and Autonomy." The issue "focuses on how contraceptive access policy is shaped, how policy is translated into practice, and how a focus on equity, justice, and autonomy has reshaped the field's approach to contraceptive access efforts." It's a resource to consider sharing with leaders in your healthcare system, state medical societies, and local and state government. The supplement includes descriptions of initiatives that successfully decreased adolescent pregnancy rates, used telehealth to "bridge gaps in contraceptive care deepened by COVID-19," and can promote health equity by "scaling up evidence-based practices in contraceptive access initiatives."