Managing Contraception Counseling

Documents to Request

• Current medication list
• Medical/surgical history summary
• Blood pressure measurement (current visit)
• BMI calculation
• Prior contraceptive use history
• STI screening results (if recent)
• Postpartum/post-abortion records (if applicable)
• Coagulation history (if relevant — personal or family history of VTE)

Step 1: Review Contraceptive Effectiveness Tiers

Present methods in WHO tiered effectiveness framework:

Counsel on the difference between perfect-use and typical-use failure rates. Emphasize LARC (IUD, implant) as first-line for most patients per ACOG Committee Opinion No. 642.

Step 2: Apply CDC US Medical Eligibility Criteria (MEC)

The US MEC uses a four-category system:

Critical Category 4 Contraindications (combined hormonal methods):

Postpartum MEC Timing

Document the MEC category for the selected method and each condition evaluated.

Step 3: Method-Specific Counseling

For each method discussed, document:

1. Mechanism of action — hormonal suppression, barrier, copper toxicity, etc.
2. Administration — insertion procedure, prescription, self-administered
3. Expected side effects — bleeding pattern changes, hormonal effects
4. Warning signs requiring return — severe headache, leg swelling, chest pain for CHCs; expulsion signs for IUD; implant migration concerns
5. Duration of use / replacement schedule — Mirena (8 years), Liletta (8 years), ParaGard (10 years), Nexplanon (3 years), DMPA (every 12 weeks)
6. Return to fertility — immediate for most methods; DMPA may delay 10–18 months
7. STI protection — remind that only condoms protect against STIs; recommend dual use

Step 4: Special Populations

Adolescents

• LARC is first-line per ACOG and AAP
• Confidentiality considerations per state law
• Emergency contraception education mandatory

Immediate Postpartum / Post-Abortion

• IUD and implant can be placed immediately (within 10 minutes of placental delivery for IUD; before discharge for implant)
• Immediate post-placental IUD has slightly higher expulsion rate (10–15%) but dramatically improves access
• Document timing of placement relative to delivery

Perimenopause

• Continue contraception until 12 months of amenorrhea (if age > 50) or 24 months (if age < 50)
• Switch from CHCs to progestin-only or non-hormonal methods after age 50–55 when VTE risk increases
• FSH is unreliable for confirming menopause while on hormonal contraception

Step 5: Emergency Contraception

Document knowledge of and access to emergency contraception:

Note: levonorgestrel may be less effective in patients with BMI > 25; ulipristal acetate may be less effective with BMI > 35; copper IUD is effective regardless of weight.

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Are all relevant medical conditions screened against the US MEC criteria for the selected method?
2. Is the method's MEC category documented for each pertinent condition?
3. Is typical-use failure rate communicated (not just perfect-use)?
4. Is informed consent documented — risks, benefits, alternatives, and patient questions addressed?
5. Is the follow-up plan stated — return visit for IUD string check, BP recheck for CHC start, or injection schedule for DMPA?

Quality Audit

• Reproductive goals documented
• Medical conditions screened against US MEC criteria
• MEC category for selected method documented for all relevant conditions
• Category 4 contraindications excluded before prescribing combined hormonal methods
• Blood pressure documented (required before CHC initiation)
• BMI documented
• Smoking status and age documented (relevant for CHC eligibility)
• Method effectiveness communicated with typical-use failure rate
• Side effects and warning signs reviewed with patient
• STI protection discussed (dual-method use)
• Emergency contraception discussed and/or prescribed
• Follow-up plan documented
• Informed consent documented
• LARC offered as first-line option per ACOG recommendation

Guidelines

1. Always check MEC before prescribing — never prescribe combined hormonal contraception without evaluating Category 3 and 4 conditions.
2. Offer LARC first — per ACOG, IUDs and implants should be offered as first-line due to superior effectiveness and continuation rates.
3. Document the "no contraindication" assessment — record that BP was checked, smoking status assessed, and migraine history reviewed before starting CHCs.
4. Address the top reason for discontinuation — unacceptable bleeding patterns are the #1 reason patients stop contraception; counsel proactively about expected changes.
5. Quick-start when appropriate — per CDC Selected Practice Recommendations, most methods can be started on the same day as the visit with reasonable exclusion of pregnancy (no need to wait for next menses).
6. Use shared decision-making — present options within tiers, answer questions, and let the patient choose; avoid coercive language about any method.
7. Document refusal with respect — if a patient declines LARC or any recommended method, document the discussion and the patient's preference without judgment.
8. Review emergency contraception — all patients should leave with knowledge of EC options regardless of their chosen method.