CCFP Topic: Contraception Part I

A few key considerations when counselling a patient regarding permanent contraceptives include:

• is the patient aware of Long-Acting Reversible Contraceptives (LARCs)? 
• Is the patient aware that there is a failure rate with permanent contraception options? 
• Is the patient aware of the surgical risks of permanent contraceptive options?

It is important to remember and inform patients that permanent contraceptives do have a failure rate, which varies according to method. This failure rate is around 0.9% over 20 cumulative years according to a Canadian study.

It is important in any discussion regarding permanent contraception to alert women to the existence of LARCs, which includes the intrauterine contraceptives (IUCs), comprising the non-hormonal copper intrauterine devices (IUD) and the hormonal intrauterine systems (IUS), as well as the implant (Nexplanon), which was only newly approved in Canada in 2020. 

IUS’s have a failure rate of 0.2% and IUDs have a failure rate of 0.8%. You also explain that IUC insertions can happen in the family doctor clinic without the need for any anesthetic . While there are procedural risks, such as uterine perforation and infection, these risks must be considered against the surgical and anesthetic risks of permanent contraceptive options.

Some key considerations when considering IUC options are the impacts they can have on bleeding. With either option, spotting is a common side effect in the first month and up to 6 months. 

Copper IUD users may experience up to a 65% increase in menstrual bleeding, whereas LNG-IUS users may have a 74-98% reduction in bleeding with some women not getting periods at all. 

Similarly copper IUD users may have a slight increase in pain with their periods, while LNG-IUS users may have a decrease. A consideration with the LNG-IUS options is that while there is less systemic absorption as compared to pill and patch forms, some women will experience systemic hormonal effects such as headaches, acne, and breast tenderness. 

With respect to the exclusion of pregnancy prior to IUC insertion, this can be achieved with an in-office high sensitivity urine pregnancy test, or alternatively a good history can obviate the need for testing.

If any one of the following are true, a pregnancy test is not required prior to IUD insertion 

1. Is less than 7 days after the start of a normal menses
2. Has not been sexually active since last normal menses 
3. Is consistently and correctly using an effective method of contraception
4. Is less than 7 days of a spontaneous or induced first or second trimester abortion 
5. Is within 4 weeks postpartum 
6. Is fully or nearly fully breastfeeding, amenorrheic and < 6 months postpartum (SOGC, Canadian Contraception Consensus (Part 3 of 4): Chapter 7 – Intrauterine contraception, p. 191)

A key component of IUD insertion is informing the patient regarding the procedure risks, which include: perforation, pain with insertion, infection, and expulsion. 

You explain that the risk of perforation is reduced by first palpating the uterus position, using a tenaculum to straighten the cervical canal, and slow application of pressure during insertion.

The risk of infection is mitigated by using sterile instruments, cleaning the cervix with iodine, and a no-touch technique. 

STI testing is not required before or at the time of testing, but can be done as part of your routine screening. The incidence of PID remains low even when an IUC is inserted in the presence of asymptomatic chlamydial infection. Swabs may be taken at time of insertion and treatment initiated only in the context of positive results. Antibiotic prophylaxis in the absence of testing and a subsequent positive result is not required. 

The risk of expulsion is highest in the first three months following insertion, however fortunately, Maria has few of the risk factors for expulsion which include: 

• heavy menstrual bleeding, 
• dysmenorrhea, 
• young age, 
• previous expulsions, 
• abnormal uterine shape and 
• leiomyomas. 

Pelvic ultrasound prior to insertion to assess for shape and leiomyomas is not required, however it can be beneficial to pass the sound into the uterus prior to opening the IUC packaging to ensure that you are able to effectively enter the uterus to an adequate depth for IUC deployment. 

You tell her that the copper IUD starts working immediately and that she does not need to use any back-up contraception.

• This is in contrast to the LNG-IUS placement which necessitates 7 days of back up contraception post-insertion.

Case trivia questions: 

If Maria presented 2 years later with Pelvic Inflammatory Disease, does the IUD need to be removed?

• NO. An antibiotic trial with IUD in place should first be undertaken. If there is no clinical improvement after 48-72 hours of appropriate therapy, then the IUD should be removed. 

If Maria presents 5 years later with worsening menses and intermenstrual bleeding, and an endometrial biopsy is required for complete evaluation of these new symptoms, do you need to remove the IUD?

• NO. 

If Maria is part of the 0.08% who becomes pregnant while using an IUD what are your first steps of action?

1. Rule out ectopic. If pregnancy occurs using an IUD, the risk that that pregnancy is ectopic is higher than without an IUD in place
2. If the patient wishes to proceed with the pregnancy, IUD removal is recommended to reduce the risks of PTL, SA, PROM, and chorioamnionitis.

Emma is a 16 year-old grade 10 student and works part-time at Tim Hortons. She is in for a routine check-up and you complete a HEADSS assessment, during which she reveals to you that she recently became sexually active with her boyfriend. You ask Emma to tell you a little more about this, namely what has she been using as contraceptive so far?

I only had sex twice and we did use condoms both times, but I would like to start on birth control because I am still worried about getting pregnant. Some of my friends are on “The Pill” and wonder if this is good for me too?

Having just read the Canadian Pediatric Society’s position statement on Contraceptive Care for Canadian Youth, you wonder if Emma knows about long-acting reversible contraceptives, such as IUCs and implants, as these are recommended as first line agents in this population. You decide to explore Emma’s thoughts about birth control options. You ask her what other birth control options she has heard of and she tells you “only the pill and condoms”. You reassure Emma that you can absolutely get her started on a contraceptive, but would first like to discuss with her the many options she has available to her. 

You start by explaining that there are hormonal and non-hormonal options. 

Of the hormonal options there are:

•  patches, 
• pills, 
• rings, 
• implants, and 
• Intrauterine Contraceptives(IUCs) 

and non-hormonal options which includes:

•  the copper IUD, 
• condoms, 
• sponges, 
• cervical caps, 
• diaphragms and 
• spermicides. 

You explain that some of these options are short-acting reversible contraceptives, which includes everything that is used at the time of intercourse to pills, rings, and patches, which are used on a monthly basis. Some of the options, IUCs and implants are what is known as long-acting contraceptives and can stay in place, providing reliable contraception for 3-7 years.  

Emma tells I had no idea there were so many options. I think a longer-acting agent might be really beneficial but is a little nervous about the procedures. She says she would like to learn a little bit more and decide. 

You reassure Emma that this sounds like a great idea and that she is welcome to come back and discuss options at any point. You provide her with the SOGC sexandu website and show her the itsaplan feature so she can spend some time looking over things on her own time. You offer to start her on a short-acting agent in the meantime to prevent unintended pregnancy while she looks over the options. Emma agrees she would be more comfortable starting something right away and would be comfortable starting on the combined oral contraceptive pill (COC). 

You tell Emma you just need to ask her a few questions to make sure it is safe to start her on the COC. You will also be taking her blood pressure. A blood pressure is the ONLY test required before starting someone on contraceptives. You may also choose to take a height and weight so you can trend BMI. Otherwise, that is all that is required for physical examination.

You know that the CDC has an excellent app US MEC to help decide on contraceptives and it ranks medical conditions into 4 categories based on level of risk for starting contraceptive options. 

• Level 1 meaning there is no restriction to starting the contraceptive method in question.
• Level 2 meaning the advantages generally outweigh the theoretical or proven risks. 
• Level 3 where the theoretical or proven risks usually outweigh the advantages and 
• Level 4 where there is an unacceptable health risk and the contraceptive in question should NOT be used. 

Key Questions to ask for ANYONE starting COC include those conditions ranked as Category 4. These include: 

1.     Migraine with aura – very important to ask youth. Or migraine in >35 (increased risk of CVA)

2.     Hypertension 

3.     Smoking. With respect to smoking, the category 4 risk is for those women 35 and older who smoke 15 or more cigarettes a day, however irrespective of age smoking does add some risk with COC use, and should always be asked about. Smoking is considered category 3 risk in any female 35 and older smoking any amount. 

4.     Personal history of DVT or PE (family history is category 2 risk)

5.     Personal history of breast cancer (family history is category 1)

6.     Severe cirrhosis (and acute hepatitis or liver tumour – benign or malignant)

7.     Diabetes > 20 years duration or with complications 

8.     Cardiac disease including ischemic heart disease and valvular heart disease 

9.     Breastfeeding 

Emma tells you I don’t smoke and none of these medical conditions apply to me. You tell her that the risk of DVT is highest during the first year of using COC, but that in the advent of starting and stopping the contraceptive repeatedly, each restart confers an increased VTE risk for the ensuing year. While she can absolutely change her contraceptive choice, including switching to a LARC at any point, you reaffirm that ideally she should plan to stay on the COC long-term as opposed to starting and stopping use. You reassure her that you can always discuss this more at another appointment if she has any questions. You advise her on the signs and symptoms of DVT/PE.

You also review with her the ACHES acronym of early danger signs she may experience: 

• Abdo pain, severe (gallbladder dz, pancreatitis, hepatic adenoma, thrombosis);, 
• chest or arm pain or SOB (PE or MI);, 
• headaches (stroke, HTN, migraine), 
• eye problems (blurred vision, diplopia, flashing lights – eg. stroke, HTN, vascular insufficiency), 
• swelling/redness/numbness in leg (ie. DVT). 

You also review that some side effects are common with pretty much any contraceptive method, and her decision about staying on an individual therapy is based on the tolerability of the side effects. 

Common side effects including breakthrough bleeding, breast tenderness, weight gain, nausea, headache, acne, mood changes, chloasma. Most of these are present initially after starting OCP and go away after the first few months. 

Next you counsel Emma on how to take the oral contraceptive pill. You explain that most pills come as with 24 or 21 day packs, which means she takes hormone pills for 24 days with 4 days placebo or 21 days of hormone pills with 7 days placebo. She can expect to get her period on the placebo days. Emma would prefer a 21/7 pill and so knowing that the CPS recommends a pill with >/=30ug of ethinylestradiol (EE) due to concerns about bone mineralization you recommend accordingly. You also have a sample pack in your office and can give her the first month supply so she can start right away.  

You can also take 21-day continuously, without a placebo period, which means patients won’t have a period, which is safe. 

You ask Emma when her last period was, and she tells you it ended 3 days ago. You tell Emma that she can start taking the pill today or tomorrow morning at a time that is convenient and easy for her to remember. She should try and take the pill within the same 3 hour window each day. You recommend that some people choose to set an alarm or always take their pill when they brush their teeth to help them remember. Because she is not currently in the first 5 days of her menses you tell her she must use a backup method for the first 7 days. You also remind her, that condoms are the only way to prevent STIs and so it is always recommended to use condoms even once the contraceptive can be considered reliable.

On this subject you also check that Emma has had the HPV vaccine and do a quick screen for STI symptoms including abnormal discharge, dyspareunia, pruritis, dysuria, bleeding changes, or any visible lesions. She has no symptoms of STI. 

Without symptoms, STI screening is not required prior to contraceptive initiation, though it can be offered. Furthermore pregnancy does not need  to be excluded with the same criteria as preceding IUC insertion. If there are concerns regarding pregnancy, the risks to the fetus are likely outweighed by the risks of delaying COC start and  a follow-up pregnancy test can be done 2-4 weeks later, as needed, with  COC still started as planned.  

You tell Emma that with perfect use, the COC has a 0.3% failure rate, but the typical use failure rate is 9%. You explain that typical use accounts for errors in pill taking, such as missed pills. You can normalize this with her and state that it is a common issue that many people have. 

Emma asks you what she should do if she misses a pill. You tell her that this varies depending on when in the pill pack she misses a dose. Generally speaking a missed pill in the first week means that you should take the next pill as soon as possible and use a back up method for 7 days. If the pill is missed in the second or third week, resume use as soon as possible and a barrier method is not required. Because this can sometimes be confusing you tell Emma about the SOGC’s stay on schedule website which gives step-by-step instructions on what to do in the advent of missed pills. It is available through the sexandu website. Another resource is the cdc.gov recommendations for late or missed OCP.

You know side-effects can be a big reason why people stop using contraceptives and so you carefully review some of the most common COC side effects with Emma. These include: 

1.     Abnormal uterine bleeding/spotting (21%) – unscheduled bleeding is more commonly with lower dose preparations, inconsistent use and smoking. Some women will experience reduced bleeding time or lighter periods. Amenorrhea is more common when the COC contains < 20ug EE and regimens with shorter hormone free intervals. 

2.     Nausea (7%) – low evidence

3.     Mood changes (5%) 

4.     Breast tenderness (4%) – poor evidence

5.     Headache (4%) 

You reassure Emma that most of these side effects should resolve after 3 months of use. If she is still experiencing any problems she should come back and you can work to manage these side effects or change her to a different hormone dose level (e.g. increasing estrogen content) or switching to a different type of progesterone of a different estrogen to progesterone ratio. You also review that some side effects are common with pretty much any contraceptive method, and her decision about staying on an individual therapy is based on the tolerability of the side effects.

You tell her that “the pill” does not typically cause weight gain, but rather she should be aware that she may gain some weight and notice some body changes over the next few years as a normal part of development.

You also tell Emma that she may experience some benefits in taking the COC including decreased acne, less painful periods, and decreased risk of ovarian and endometrial cancers. 

Finally, you ask Emma if she has any questions or concerns about starting the pill and specifically about how she plans to purchase her pills. You know from reading the CPS position statement, that cost is the single most important barrier to contraceptive access and is particularly an issue for youth. 

She tells you she doesn’t want her parents to know right now. I can pay for my pills with money from work. To make this cheaper for her, you prescribe a generic form of Yasmin 21 – Drospirenone and EE 21. You mark this discussion down in your notes with a note to inquire again about affordability when you see Emma in follow-up. 

You know there are a few options for cost-support, including the SOGC’s Compassionate Contraceptive Assistance Program which can serve as a last resort to support those for whom cost is a barrier. You recognize that upfront cost can be particularly challenging for youth access to LARCs. 

Finally, remembering that adherence is improved with longer prescriptions you provide Emma with a year-long prescription. Providing a year-long prescription at the initial visit is encouraged even when follow-up is planned. OCPs are also the only prescription that can be provided for longer than 1 yr in some jurisdictions, so check what is the case in your jurisdiction and you may be able to prescribe for 2 yrs at a time. 

You ask Emma to come back and see you in 1-2 months  or sooner if she has any concerns. You reaffirm the role for condoms in STI prevention for oral, vaginal, and anal intercourse irrespective of contraceptive use. Finally, you thank Emma for feeling comfortable to have discussed all of this with you today and give her a sample pack of Yasmin21 as discussed. 

Because today’s appointment has already been quite long and information-laden you make a note to yourself to ask more about Emma’s relationship at the next appointment and screen for any interpersonal safety concerns. You will follow-up on barrier contraceptive use at this visit also.

1. SOGC sexandu website – contraceptive information, its a plan contraception decision aid, and stay on schedule for navigating missed pills and the need for emergency contraception.
2. CDC contraception app – US MEC US SPR CDC. Can look up medical conditions and suitability of various contraceptive options. 
3. SOGC Compassionate Contraceptive Assistance Program – to help with cost concerns
4. Canadian Contraception Consensus https://www.jogc.com/article/S1701-2163(16)30033-0/fulltext