Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
I am Dr. Rebecca Hu, and I am a Pediatric Resident at the University of Virginia.
Today, we will be reviewing what you need to know before you counsel about contraception options for the first time!
Let’s start with where, when, and why it’s important to talk about contraception. You’ll mainly be counseling in the outpatient setting, whether it be in the pediatric, adolescent medicine, OB/gyn, or adult primary care office, but it’s also useful information to know in the emergency department.
For the when, from a pediatric-specific perspective, I think about the average age of menarche in the US being 12-13 years old, which is typically within 2–3 years after thelarche (breast budding), at Tanner stage IV of breast development. ACOG, or the American College of Obstetricians and Gynecologists recommends an initial reproductive health visit between the ages of 13 and 15 and that this visit should include a discussion about contraception and sexually transmitted infections, or STIs. This incorporates well into our yearly well child checks around this age and when we start the conversation about menstrual and sexual health with our patients. Within the visit itself, I typically talk a bit about periods while the parent is in the room, then finish the rest of the HEADSSS (S for sex) questions when I am speaking alone with the adolescent, and I go deeper into questions and counseling about periods and contraception if needed at that time. As a reminder, HEADSSS is a mnemonic for obtaining the social history for an adolescent and stands for home, education, activities, drugs, safety, sex, and suicide. If you haven’t already, I would recommend that you listen to the Clerkship Ready – Pediatrics episodes on the adolescent well visit and on getting a sexual history. Of note, minors in most states, including Virginia, can consent to contraception and reproductive options without parental consent. But you should always double-check with your resident or attending to understand what the laws are in your state.
Why is it important to understand how to counsel on contraception? Contraception can serve a variety of purposes, from preventing pregnancy to helping treat hormonally driven conditions such as premenstrual dysphoric disorder (PMDD), heavy periods and abnormal uterine bleeding, acne, polycystic ovarian syndrome (PCOS), and endometriosis. Patients and parents come in with a wide range of experiences, opinions, and preconceptions on periods and contraception, so it’s important for us as providers to be able to counsel based on a full understanding of the physiology and evidence.
Before we dive into contraception, let’s do a quick review of normal menses. The normal length of a menstrual cycle is between 21 and 35 days from the first day of one period to another. The normal time of bleeding or what we generally call the period is between 3 to 7 days. Normal period blood flow or heaviness is about three to six pads or tampons per day, abnormal is soaking through more than one pad or tampon every 1–2 hours. In adolescents, there is some immaturity of the hypothalamic–pituitary–ovarian axis during the early years after menarche and cycles may be somewhat long, however, the majority will still be within 21–45 days and by the third year after menarche, 60–80% of menstrual cycles are in that normal range of 21–35 days.
Okay let’s talk about contraception. I think about contraception in 2 ways, hormonal vs nonhormonal and route of administration, pill, implant, IUD, et cetera. In terms of hormonal options, there’s combined estrogen and progestin vs progestin only, progestin being the term for synthetic progesterone. The most important medical consideration is whether the patient has contraindications to estrogen, which include history of clotting or a pro-clotting state from other medical conditions, migraine with aura (for which taking a combined oral contraceptive pill, or OCP, increases the risk of stroke), estrogen responsive breast cancer, as well as other clotting risk factors such as obesity, smoking, or age over 35 years. The CDC has a resource called the US MEC or Medical Eligibility Criteria for Contraceptive Use, which has detailed information on contraceptive methods and interactions with medical conditions and drug interactions with contraception. There is a link to this resource in the Show Notes.
Going into the physiology of how hormonal contraception works, progestin suppresses gonadotropin-releasing hormone from the hypothalamus, which in turn reduces secretion of luteinizing hormone and follicle-stimulating hormone from the pituitary, which in turn prevents the follicle development and the luteinizing hormone surge required for ovulation. In addition, progestins directly reduce cervical mucus permeability, endometrial receptivity, and sperm survival and transport to the fallopian tube. Estrogen also has some effect on reducing follicle stimulating hormone secretion via negative feedback, however it is not as prominent as progestin. When estrogen is added to progestin-based contraceptives it helps reduce irregular bleeding.
Now that we’ve reviewed the physiology, let’s talk about the route of administration, which is the bulk of the counseling that we do for most adolescents or patients without a significant medical history. OCPs or oral contraceptive pills are by far the best known and most prescribed, but there is a wide range of options and a lot of shared decision making that goes into selecting the best contraception option for each patient.
Going through the different routes of administration by efficacy of pregnancy prevention, there are 3 tiers. First tier, with the highest degree of pregnancy prevention, is long-acting reversible contraception or LARCs. There are 2 basic types of LARCs. The first is the progestin-containing implant, also known by the brand name Nexplanon, which is placed in the inner part of the upper arm. The second is the intrauterine device or IUD. We’ll talk a little bit more about these in a few minutes. Both the implant and IUD have an over 99% efficacy for pregnancy prevention or 1% chance of pregnancy.
Second tier are a variety of shorter- and longer-term methods which have an element of human use, and therefore human error. These include oral contraceptive pills (whether combined estrogen and progestin or progestin only) taken daily, progestin injections such as Depo Provera every 3 months, which is a shot given intramuscularly into the arm or buttocks, combined hormonal monthly vaginal rings, combined hormonal weekly transdermal patches, and diaphragms, which are placed intravaginally with each episode of intercourse and physically prevent sperm from entering the upper reproductive tract. The efficacy of these methods is about 88-94% within the first year with typical use or a 6-12% chance of pregnancy. Although birth control pills are what parents and patients are most familiar with, it is important to emphasize that they have this 6-12% chance of pregnancy with typical use.
Third tier are the least reliable methods of pregnancy prevention and rely heavily on use at the time of intercourse. These include male or female condoms, cervical caps, sponges, fertility awareness, withdrawal, and spermicide. The third-tier methods have less than 72% efficacy or a greater than 18% chance of pregnancy in a year.
Okay, so we’ve talked about where, when, why, and how. How do we put it all together to help our patient decide on the best option for contraception? As I mentioned earlier, shared decision making and motivational interviewing are crucial in this. What are their reasons and goals for contraception? Are they sexually active? What is their lifestyle and are there any challenges to adherence for their chosen method? Do they want to have a period or not? What other concerns do they have? Before I start counseling, I like to pull up the American College of Obstetricians and Gynecologists, or ACOG, chart of the different options in either paper or electronic form, and have physical props if possible to help them conceptualize what each method looks like.
For pregnancy prevention, I strongly recommend LARCs. The Nexplanon progestin implant is approved for up to 3 years but has shown to be effective for 5 years. Hormonal IUDs such as the Mirena are approved for up to 8 years and the copper IUD or Paragard, is approved for up to 10 years. The copper inhibits sperm migration and viability, but the Paragard has a major caveat that it not uncommonly causes heavy menstrual bleeding. Nexplanon can cause irregular bleeding and spotting, and after 1 year many patients may have no monthly bleeding at all. Progestin IUDs similarly may cause lighter bleeding, spotting, or no bleeding at all.
I’ve found that many patients are nervous about the procedural element or pain they’ve heard about with implants and IUDs. There is certainly associated discomfort, but there are multiple methods of mitigation, including local anesthetic. Some patients may have had traumatic experiences with speculum exams or sexual trauma in their past. I think it’s very important to have an open conversation about their concerns and weigh them against the benefits of the implant or IUD.
Counseling about the Nexplanon or progestin IUD possibly causing no bleeding at all often leads into a discussion about wanting a predictable period every month, being okay with irregular spotting, or wanting an option with a potential for no bleeding at all. With OCPs, they generally come in packs of 28 pills with 3 weeks of hormone containing medication, whether combined or progestin only, and 1 week of placebo pills. When the patient takes the placebo pills, they will have withdrawal bleeding. Some patients want to have a period every month for peace of mind that they are not pregnant. Other patients would prefer to not have a period, if possible, in which case it is safe to use OCPs continuously, skipping the placebo week and going to the next pack of pills.
After discussing the efficacy of pregnancy prevention, route of administration, and whether the patient would like to have a period every month or not, it comes down to patient preference. This is a ton of information and often someone who is just starting to think about contraception can get really overwhelmed. If possible, you can always offer a follow-up visit and provide them with some resources so that they can look into the options in more detail on their own. I’ll summarize some resources I like at the end of this episode, and they will also be available in the show notes.
It is also extremely important at this point to emphasize that effective contraception does NOT equal effective protection against HIV or sexually transmitted infections, for which condoms and barriers like dental dams are the best choice.
There are finer nuts and bolts about the dosing of estrogen and progestin or progestin only within the options, but I think the most important takeaways are understanding how to assess for contraindications to estrogen containing OCPs, thinking about the various routes of administration in terms of efficacy and human error, and entering the conversation with a shared decision-making model in your mind.
Any of these methods can be started at any time, as long as the patient is not pregnant. In terms of insurance coverage, contraception is a type of preventative care and under the Affordable Care Act, most health insurance plans must cover contraceptive methods and counseling for all women by an in-network provider, regardless of deductibles, copayment, or co-insurance. If not covered by insurance, there are also local family planning services and Planned Parenthood.
Okay, that was a lot of information. We’re almost done, but I want to round out this episode by discussing emergency contraception, myths about contraception that you may come across when you start counseling, other contraceptive methods, and some resources.
The most effective form of emergency contraception is the copper IUD or Paragard, which reduces pregnancy risk to 0.1% when placed within 5 days of unprotected intercourse but requires a provider to place. Other options are an oral progestin such as Plan B or the anti-progestin ulipristal acetate, brand name Ella, both of which work by blocking or delaying ovulation. They work the best the sooner they’re taken but can also be taken up to 5 days after unprotected intercourse. Plan B is available over the counter without age restriction, as well as online, Ella may require a prescription. There is recent limited evidence for the progestin IUD for emergency contraception, however given its lack of strong evidence, it should not be used as monotherapy at this time.
Now for some myths and misconceptions, which I pulled from Bedsider.org, a free birth control support network with lots of articles and information.
Myth #1. IUDs can’t be placed in women who haven’t had kids yet. False. There is also no evidence that IUDs cause an increase in sexually transmitted infections or infertility.
Myth #2. The partner will be able to feel the IUD strings. This depends, the IUD has plastic strings that are cut after placement and should be soft and not cause any discomfort for either the patient or the partner but can be adjusted as needed.
Myth #3. The implant can move to another part of your body. False, it can shift a little, but otherwise you should be able to feel it in the same spot.
Myth #4. Birth control will cause weight gain. This is false from a population level, there have been numerous studies and the thought is that people gain weight with age, but of course at an individual level there will be variation.
Myth #5. The pill affects mood. This is difficult to study, and everyone is different, so listen to your patient’s experience.
You may have noticed that there are a few contraceptive methods I haven’t mentioned. The majority of contraception options place the responsibility of pregnancy prevention on the female partner. Currently, the only options for male contraception are sterilization or condoms, but newer forms are in the works, including a compound that inhibits sperm function which has shown a lot of promise in mice studies, but has a way to go before use in humans. Lactational amenorrhea is a form of contraception in the first 6 months if the mom is exclusively breastfeeding, but it is not 100% effective. Surgical sterilization with a procedure like tubal ligation is very effective but given that it is a major procedure and difficult to reverse, it’s not something I counsel about in the pediatric world.
Finally, a few great resources to reach for if you want to refresh on anything you’ve learned during this episode. The American College of Obstetricians and Gynecologists, or ACOG, reproductive access.org, and bedsider.org are all great resources for both providers and patients, and you can always look up the in-depth Centers for Disease Control and Prevention chart for medical contraindications to estrogen.
OUTRO:
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