Contraception: The Comprehensive Conversation Our Patients Deserve to Have

Transcript

Lauren Brown-Berchtold: Hello and welcome to CME on the Go, the podcast crafted specifically for family physicians by family physicians. Whether you're seeking clinical insights, professional development or simply a sense of camaraderie, you'll find it all here. Plus, you can earn CME credit with every listen. So grab a coffee, hit play and let's embark on this journey together.

I'm one of your co-hosts, Lauren Brown-Berchtold, and I'm the program director for BCME Family Medicine Residency in Modesto, California.

Tamaan Osbourne-Roberts: Hi, I am Tamaan Osbourne-Roberts, a federally qualified health center physician from Denver, Colorado, and occasional expert in policy and happiness.

Jason Marker: Hello, my name's Dr. Jason Marker, and I am a core faculty member at the Memorial Hospital Family Medicine Residency Program in South Bend, Indiana.

LBB: And I am just going to say that this is the second time we've had to start this episode today because I was so excited for our topic that, the first time we started recording, I just decided we weren't introducing ourselves, that we were going to dive right in.

Diving into birth control

LBB: I love talking about birth control. You guys might notice my excitement today, and this is so relevant for our listeners because birth control and contraceptive conversations come up multiple times throughout a routine clinic day.

As we go through this episode, we will be using various terms interchangeably. What we're talking about is people with a uterus, who menstruate and who require birth control. What we might do at various times is use terms like female or women, but we are definitely working to be inclusive and talking about anyone who might benefit from these therapies.

Right, but even more so, birth control and contraceptive conversations probably should come up even when our patients and families aren't the ones who are asking us about this. Because these are really important issues. And so what I brought to you, our listeners, and to Jason and Tamaan, are some clinical scenarios that might just be pretty routine for us to be encountering in the course of a normal day.

Clinical scenarios and contraceptive conversations

We might have a teenager who's being brought in by their parent, asking for the pill to prevent pregnancy in case she's going to become sexually active; a pregnant woman and her male partner, who are coming in for routine OB care, and either they're asking us or we are asking them: What's your plans for birth control once you deliver this babe? An adult female in her late thirties who's coming in to see you for high blood pressure follow up, and you just incidentally found out she's not using any form of contraception. You might be seeing in your clinic a transgender male, who's having regular menses that's causing emotional distress. And you might be talking to a female who's around the age of 50, who just really, really loves her IUD.

What are some other strange scenarios that y'all have seen where contraceptives and contraception are a great thing to be talking through?

TOR: You know, there's a couple of situations that come to mind that, that I've seen recently.

One is a patient coming in who is needing to be put on a teratogenic drug, a drug that may cause birth effects, and the need to discuss different forms of birth control. In that situation, I actually am seeing that one much more since I've started my practice in obesity medicine. It certainly is one.

In addition to that, I would also say an interesting one is a patient, oftentimes in their twenties or thirties, who's coming in, who's a refugee, who may have had a history of sexual violence and wanting to discuss contraception from that matter.

LBB: Yeah, those are great things to be bringing up. What about for you, Jason?

JM: I'll add a couple more into the list. I think sometimes the patient who's already got a birth control that isn't working well. They're having side effects and they wanna talk about, do we add on something in addition to this to stop my flow or, like, is there a different option for me? Like, there's a lot of conversational talking points about transitions of birth control that happen a lot.

And I also think that anytime I'm doing a wellness visit on a person with a uterus, there's a reason to have a conversation that might be sort of along the lines of: Are you interested in a conversation about birth control today, or a conversation about pre-pregnancy counseling? Like, you should be having one or the other of those too, especially in a wellness visit scenario where you're reconciling a medication list and, and thinking globally about that person's health and what their health needs are.

LBB: I love that the, you should be talking about a pre-pregnancy counseling or you should be talking about what are we going to initiate. Bcause there is no middle ground, right?

The other thing that you just brought up, which I didn't include into this episode but we'll take a second to talk about, is that as we're talking about women who are unhappy with their bleeding and with their cycles for whatever reason. When we talk about abnormal uterine bleeding, which again is not the focus of this episode but does play into how we think about medications for contraception and for bleeding, about 30% of women are pretty unhappy with how they're being treated for abnormal uterine bleeding and would not want to continue that bleeding pattern for the subsequent five years.

And so that, that's a really great nuance. And some of us might feel pretty unprepared for a lot of these conversations. So what I'd like for us to do, first of all in this conversation, is to just level set for all of our listeners by talking through some very broad groupings of contraceptive options.

Oral contraceptives: the pill

LBB: The first one is to chitchat about oral contraceptive pills, more broadly known as the pill. And who hasn't heard, even in layman's terms, about the pill, right? That is something is brought up so commonly in my practice. Do you guys get asked about this all the time?

JM: All the time. Yep. It's the starting place for almost everybody who would like some contraception, maybe because they don't know the language around the other options they have, or it is now a stand-in for all sorts of contraception, but yes, this seems like every conversation I have about this starts with the pill. And I'm usually the one expanding the conversation.

TOR: Much agreed.

LBB: It's not just me. I feel good about this. I will be talking about the expansion of the conversation in just a minute, because I agree: This is where the conversation that is being brought up by our patients starts and is commonly used as a stand-in.

And so, to take us back for a quick second, the first oral contraceptive was approved in 1960, and within just a couple of years, there were millions of Americans who were on this medication. And if you want to dive into some of the medicine as it interacts with the social nature of countries, it really was tied pretty tightly together with feminism because for the first time, people were able to control their ability to decide to give birth without using other perhaps natural family planning methods. And so this was a pretty exciting time.

Now that was 65 years ago that this medication was released, and so this medication has had various interpretations in the media and with doctors over time. We will later talk about some of the contraindications to OCPs, but what I would like us to say today is that all of us have been raised in the era of hormones. Are hormones good? Are hormones bad? We are living currently in an era of, Hey, we are only able to prescribe OCPs with a prescription. What's interesting is that data, and ACOG, appears to support the fact that these should be over-the-counter medications. Despite the fact that there are some very real contraindications, and again, we'll go into some of those in in greater depth late, there are very real contraindications to a lot of different medications, including something as simple as ibuprofen and kidney disease. And the data appears to support that OCPs should probably be an over-the-counter medication with safety warnings.

And, and so this is, this is really where people are starting, starting off at now when we're thinking about should we use or recommend OCPs with our patients. We are making sure it's the appropriately selected patient. We're also making sure more than anything, that they're able to be adherent to that. Because the biggest thing about OCPs is that you're taking a pill every day. And so when I'm talking to my patients, if I have a teenager who is sleeping through alarms and not able to regulate going to bed and forgetting other medications, perhaps I'm not going to be saying,” Hey, please go take a medication every day,” particularly one that really is tightly tied to the temporal time that you're taking it. If you’re off by much more than an hour or two with a combined OCP, then you are going to be losing effectiveness and be losing the ability to prevent unwanted pregnancy.

If I have an adult, like me, who also forgets medications, right, perhaps that's not going to be an appropriate medication to be reaching for.

Now, I want to go back to what you said, Jason, under this category, I do think that that we and patients tend to forget about the other combined options. That might include the vaginal ring, that might include the patch, and are probably going to be less familiar with the prescribing of that. And we have a lot of great options here. Anything else to add from y'all?

JM: I think saying that there are a lot of great options is almost an understatement. I don’t know how many of our listeners will have like seen a poster by some company that shows all of the different birth control options. I mean, there are literally hundreds of brands out there, different formulations, different strengths of different components within triphasic, quadriphasic. Like, there's just a lot there. And I think if you're doing the sort of care in the office that's going to lead you into a lot of these conversations, it's worth getting a little bit of signage in the rooms where you're going to have these conversations so that it's easy for a person to see the vast array of options that are before them, because it really would be impossible in anything like a regular office visit to kind of go over all of the options. And it's nice to get some of that in their mind with some good signage ahead of time, just because there are so many.

LBB: Mm-hmm. Yeah, and I want to reassure our listeners, you might be like, well, I just got no functional information. Please wait: At the end of this episode, after we level set about our broad options of contraceptive options, we're going to dive a little bit more into OCPs, including talking about the different formulations and why you might choose to reach for certain formulations.

Long-acting reversible contraception (LARCs)

LBB: With that said, Jason, I would like you to first take us through some thoughts on LARCs, OK?

JM: OK, let's do that. So LARCs, long-acting reversible contraception: If this is not a familiar phrase to you, let's talk about what that means. It's sort of inherent in its naming. So, these are long-acting forms of contraception that are reversible the moment you take them out of the person. That's a really powerful thing.

I think a lot of us will think about birth control pills that, you know, you need to maybe wait a cycle or two to make sure everything's going to come back online after you've stopped it for getting your fertility back. And that was a real concern for women. And it's a moment now where we can say, like, I've taken this thing out of your body, now you are fertile.

And that's a powerful thing, when a person is thinking about when they might want to have their child or just sort of the timing of conception. Like, there's a lot that's writing on that. So that's what LARCs stand for.

LARCs, for those who are not as familiar with that, this basically falls into two main categories: We're talking about IUDs, intrauterine devices and ther implantable devises that are not placed inside the uterus. The IUDs, as most will know, are hormonal or not hormonal, and implantables have continued to evolve over time. But the Nexplanon is today's implantable in the United States, more or less. For those of you who are over 50, like me, and trained at a time when the Norplant came available, that was sort of the first implantable LARC, an array of, I can't remember now, of half a dozen little plastic pieces that went under the skin and an array in the upper arm. The Nexplanon is sort of the modern equivalent of that, so that's what we're talking about when we're talking about LARCs. This is often the first-choice birth control for many sorts of people, including teens. It’s very, very easy to place.

There's a Nexplanon device that allows it to be implanted in the skin. I won't try to describe it here. I'd encourage you to reach out to YouTube if you're curious what I'm talking about here. But I will say that the manufacturer, Organon, is more than happy to make sure that people who want to be trained to place Nexplanon are trained and certified to do so.

The thing I was saying when we were getting ready for this episode is, if anybody listening to this is worried that you can't place an Nexplanon, you're wrong. These are very straightforward to place under the skin with a very small amount of training, and I'd encourage you to not be afraid of that and get yourself trained up to be able to do that.

Let's talk about IUDs just a little bit. I think for me, in my practice, the IUD has been more about breaking down IUD myths. When I think about placing an intrauterine device, I'm going to feel the strings. The strings are going to hurt my partner. I don't want that because there's a risk of ascending, sexually transmitted infection with this thing dangling out of my cervix.

There have been concerns intermittently over time about the fact that a copper IUD may be an abortifacient, that this causes abortions. That's how it works. And there are probably still reasons to have that conversation with a patient for whom that may be a particularly sensitive area of taking care of them.

There have been historical risks about infertility for folks who have used IUDs in the past. The modern IUDs do not have that baggage. All of the myths that I've been talking about here are things that are easily conversed with patients about, and if you're not up to speed on what some of those counter arguments may be, it's very easy to find your way to some of those.

But the strings are these little microplastics that are not felt generally. I've never heard a patient, and maybe one of you two wants to correct me, that have been able to feel the strings during intercourse, either partner. This is not a braided string that would allow ascending infection for sexually transmitted infections, and the return to fertility is as soon as these are removed from the body.

So, these are all things for you to be able to myth-bust about in the IUD world.

A couple of things I'd mention here in this would be, there's a new ACOG statement out there about the use of pain medicines for IUD insertion. We've attached that to the show notes for you. The old adage of, like, yeah, take a couple Advil before you come in: Like, that's actually been pretty well studied and often does not provide statistically significant pain relief for the procedure of placing an IUD. A paracervical block could be placed, but lidocaine sprays actually do about as well or maybe better in some research studies than a paracervical block and are often easier to do.

So do not forget to offer these patients adequate pain management for the insertion of their IUD with or without tenaculum use, which may be necessary for some IUD insertion. So keep that in mind. That ACOG statement is there. Actually, it's not just about these IUD placements. It's about a whole range of gynecologic procedures. If you're curious, we've attached the whole entire statement, not just the part about IUDs.

LBB: If I can just say, this statement that came out from ACOG and the studies behind it has really been a game changer. I do a lot with regard to these procedures and the arguments about, man, why am I marrying the burden of not just the medication but the pain associated with a birth control medication or procedure to place that birth control has been really distressing for people over the years. And a lot of the women that I talk to just feel like they haven't been believed. And so I think that the medical institution coming out and saying, no, no, no, no, no, we believe you, and our instruction to our physicians is to take this seriously without just throwing some ibuprofen, is, is very important.

The other thing that I want to add, Jason, is that I agree: A lot of people are worried about strings of IUDs hurting their partners, and that the hurt is not real. But I will say that it's possible for male partners to feel the strings during intercourse, and if that's the case, which is incredibly rare, that's why I set up string checks. It's not actually because I want to be setting up string checks or needing to be doing those string checks, but I acknowledge that in the rare circumstance that a male partner is feeling longer strings that haven't softened in the vaginal milieu yet, it might be really awkward for that patient to call the front office and try to explain the situation that requires them to come back in.

So I set everyone up for a string check and say, “Hey, if I need to trim those strings shorter, I will. And if you really want to just check your strings at home and cancel this appointment, that's also fine.”

JM: Absolutely. Great points. Tamaan?

TOR: Yeah, no. I actually just wanted to, to add to what Lauren was saying about the overall concept of believing women and believing their pain and the way they report things.

You know, inside of, unfortunately, all of the medical field, there's a longstanding history of when justice has done to various populations, women, women of color in particular, a lot of the general procedures that we continue to use in both obstetrics and gynecology, were actually pioneered on unwilling subjects, oftentimes enslaved people. And there's really something to be said for the restorative justice of saying, no, we believe you, we understand that there's something here and we're we're going to take it seriously

JM: I love that. Thank you for adding that to the conversation. This whole idea of long-acting reversible contraception is something that we really, we should, there's not a subset of people for whom we shouldn't be having this conversation.

This should be open for everyone, and clearly there's a lot of policy work around making sure these are available at the time of delivery for a person who's just delivered a child like these can be, a Nexplanon, for example, can be placed in a patient before discharge. And if you take proper time to do the consent that you need, and it's part of that pre-delivery conversation, like, there's no reason that can't happen in most places. Let's make sure we're offering these as often as we can.

A couple of final points about these LARCs. Many of them affect, all of them except for the copper IUD, Paraguard, have a hormonal element to them, and you'll want to make sure you're counseling about the potential side effects of these. Of course, you're putting a device under the arm, so there's some local, like just usual consent stuff you'll want to do about possible side effects of injecting a device under a person's skin.

But beyond that, you're talking about the same sorts of things that you would talk about with the birth control pills, the hormonal-related side effects that some people, but actually not very many, percentage-wise, are likely to experience, which could include acne, changes to mood swings, breast pain, nausea, weight gain, vaginitis, headaches, dizziness, like, the long list of things.

I think many of us will be used to talking with patients about with birth control pills, like, there would be a similar conversation that we'd be having about the LARCs. And really, we're talking about folks who are interested in a very reliable form of birth control, who are not interested in daily, weekly, monthly forms that they have to be changing or taking or remembering to deal with, who are looking for very low systemic hormonal effects or, in some cases, no systemic hormonal effects.

And as long as we can document things correctly in our electronic medical records to say, in three years this Nexplanon needs to be removed or replaced, most of our systems are pretty good at reminding us when the time is up on a particular device, but it's also a conversation I have with women. Sort of like, in the summer of 2028, we need to make sure this comes out and gets replaced with another one or some other form of contraception.

LBB: Yeah, I will say that I absolutely love the IUD in particular and for a long time had a practice IUD hanging from my badge, and it was a great conversation starter in the room because patients would be like, What is that? And I'd say, well, let me tell you what that is.

I also want to call out just very briefly that the hormonal IUD is very effective at achieving amenorrhea in a large percentage of patients. And so, going back to one of the clinical scenarios from when we introed this episode, if you have a transgender male who still has a uterus and is experiencing distress or just doesn't desire to have monthly menses, you could consider using a hormonal IUD for the purposes of amenorrhea, as opposed to purposes of birth control, and that's something that's pretty exciting for us to be having on hand.

Vasectomies: a permanent solution

Tamaan, I know that you have one form of contraception that you love talking about, right?

TOR: Whoa. Yes.

I will say, speaking of the concept of restorative justice, let's discuss vasectomies. Really honestly, vasectomies are an amazing and fantastic form of permanent birth control for couples. It's really, really just a wonderful, fantastic method. It is one of the most effective methods in terms of percentages by far.

Amongst the surgical methods, it's the least invasive and tends to have the lowest risk of side effects. It's a fantastic and wonderful form, and it's really the one form that is really intended to be only under control of a male partner or a partner, I should say, with testes and a penis.

The importance of vasectomy consultations

TOR: In regards to vasectomy, there are of course a lot of misperceptions about it. A lot of people do tend to worry, for instance, that they may not ejaculate after this, and there has to be an explanation of the anatomy and kind of how that works. Some folks are afraid that it will affect the libido or the quantity of testosterone that they're going to produce, which hasn't been shown to be the case.

Some folks may be worried that there's a risk, as there is with, say, prostate surgery, that they may, it may cause erectile dysfunction, which again, is not something that we see with this procedure. Some folks actually have perhaps maybe too rosy a view about this. Say, well, you know, I'll just reverse it later if I want kids. And it's important to explain that it's intended as a permanent form of sterilization and that it can be reversed, but that the reversal percentages, although better than they used to be, are still hovering around 50% and not really substantially better than that. So this really is a form of permanent birth control for men who are certain that either they don't want children or don't want any more children.

In talking people through those particular pieces, or even in introducing the subject, sometimes you really do get a little bit of pushback. It's like, well, I don't really want to, like, you're cutting into very sensitive parts of my body, Doc, and I'm not really certain that I want that to happen.

In those instances, I'll say, well, of course, and there are options of course that your partner could consider as well. But you know, let's think about two things. One thing that a lot of men, not all men, but a lot of men, are very responsive to, is the concept of really being a protector. And that this is a form of birth control where they can take ownership for what it means to do family planning.

It really is the one form I'd say, outside of condoms, where men can take ownership in this regard and deeply inside of that. And that really does appeal, that sense of control, that focus of, if you will, being traditionally masculine or manly, does, uh, work for a number of men.

Another thing that actually does come up as a consideration, and I feel perhaps a bit subversive saying that it oftentimes works even better shortly after a couple has welcomed a new child into their lives, or if they're both present, is to perhaps remind a man what his partner just went through in regards to bringing that new life into the world, assuming it was a biological birth, a genetically related birth, if you will. And sometimes that particular reminder, with a little gentle nudging about what it means to be a protector, does actually have an effect on the way the couple will think about their possible birth control options.

It's really just a fantastic method. I really do wish that we could put it in the water. But at the end of the day, I think it's one of those things that we really should be discussing along with all other forms of long-acting contraception.

LBB: Yeah. I also love this procedure. It was pretty cool. I was trained in this procedure when I was in residency and fellowship, and what I learned is that my perception of a vasectomy was very different from the reality, and that most people who are doing this on any sort of high-volume basis are doing no-scalpel vasectomies, so you can reassure your patients that no scalpel is going into that sensitive area.

There's no cutting, there is using other tools to make the spaces that are needed, but we're not slicing and dicing at all, and that this is an office-based procedure. We have no general anesthesia without any of the attendant risks that general anesthesia comes with, and that I recommend: Take a Valium that I'll prescribe, bring some headphones, please zone out for 30 minutes, and then take the next three days off to to just rest and relax and then go forth and live your life.

And it's pretty exciting that we have such an effective procedure that we as family docs could be trained in and doing, and that is office-based.

TOR: No, I very, very much agree and I think the headphones actually are a great idea because aside from the typical risk you'd expect with a minimally invasive procedure of bleeding, infection, and those sorts of things, surprised that nobody ever seems to put on con the consent, the risk of utterly terrible theme-specific dad jokes that either you or your physician will engage in, depending on who is more bold. Thank you for bringing that up, Lauren.

LBB: I can only imagine the dad jokes y'all would pull out.

JM: I think that the free vasectomy consultation is a really important doctor's visit to do well, to learn how to do well over time. You won't do it well initially. It takes a while of doing those to really feel comfortable with those, but the amount of myth-busting that I have done about vasectomies in these visits is really is a starting point actually for many years of ongoing conversations about men's health. This is sometimes the first men's health conversation that a man will have with a doctor, and so that makes it an opportunity for you to set the stage for how you wish to talk about the health of male genitals for the patients that you will take care of. So, great opportunity, I think, to begin that dialogue with patients. I often start off with the question, like, what have you been told by your friends about getting a vasectomy?

And, and then the things that follow from that back to me, tell me where I'm going to need to start from and how much work I have to do to get them ready for this procedure.

Effectiveness of various contraceptive methods

LBB: I love that. For all of our listeners, we've talked about three large, overarching options for contraception. We've talked about OCPs and more particularly combined hormonal contraceptives. We did not talk about Depo-Provera and progesterone-only pills, and we've got a lot to cover. We can't cover all of the things. We've talked about our LARCs and we've talked about vasectomy, which is something that the partner who does not have a uterus is going to be using for contraception. And if you are feeling overwhelmed, then that's OK.

What I would recommend is, please, please, please have a very low threshold to pull out and use the color-coded CDC contraception chart. I would recommend getting it laminated and putting it up in your office, putting it up in your workroom, because this is a really incredible resource that very succinctly summarizes medical conditions and what contraceptive option is or isn't able to be used for patients with those conditions. We have a link in the show notes, but it's very user-friendly and it can be really hard to just, off the top of your head, be thinking, man, I have this person in front of me with liver disease; am I able to use a combined hormonal contraceptive for this person? Or is there a contraindication?

And so with that said, I then start to think as we introduce these options, it might feel overwhelming from a clinical perspective. But it gets even more overwhelming when we think about the fact that (A) we as PCPs just have so much to do and so much to remember, and (B) that patients are all coming at us and these decisions with different levels of knowledge, beliefs and concerns.

When to refer

JM: I want to say something quickly here to some of our colleagues who might be listening who have some very strong, personal, religious, spiritual or otherwise beliefs about contraception just as a whole concept. There certainly are folks in my sphere of training where they don't prescribe. We want them, as residents, certainly to learn about contraceptive options, be able to do counseling in that space and help answer some patient questions, but they don't prescribe and they don't provide any of the, the services as far as implant, and that's OK. I mean, we have our rights of conscience as physicians, where that is well within our right to say, like, this is not an area that I lean into.

However, I think I may be, maybe this is editorial, but I do feel like we should all be able to have a little bit of a conversation and feel comfortable referring patients to other clinicians who can answer the rest of their questions and get them contraception, if that is something that they desire. I think that's a fairly low bar, even for folks who don't feel like personally, this is a space they want to be a part of, to help our patients get to other providers who can help them to get that along the way.

I think that's OK for us to be able to have that conversation. And I also, I think, for me, I don't know a lot about natural family planning, per se, but I know enough to know that it exists and that it's a useful form of contraception for a great many patients, and I should know enough about it to be able to acknowledge that that is a way of contraception that some patients desire, and that there are places in my community where I can refer patients to learn a whole lot more about it than they're able to learn from me.

I think it's a great moment of humility for us to say, What are the bounds of what we know? and help our patients get to that next step when they need it?

TOR: No, I definitely agree with that, Jason. I think it is really incumbent upon all of us to have an understanding of both what we know and the resources that we have available for our patients that may not occur entirely within our offices.

Resources and information to empower family physicians patients

TOR: Speaking of resources inside of the offices, I think much like we have many, many other sorts of posters and models and things like that, having a range of them related to contraception, and many of us have had those dropped off by well-meaning contraceptive-device or drug reps, and they can be actually really helpful in regards to these sorts of conversations.

Speaking of empowering people with information, one of the things that doesn't always come up in particular with people who may not feel comfortable with hormonal or device-oriented forms of contraception but do discuss things like fertility-based family planning or abstinence or the withdrawal method or other sorts of methods that may fit within different ethical or moral space for them, is the importance of really counseling patients on both real-world effectiveness and ideal effectiveness for really all of these methods.

So there is sometimes, I think, a tendency to kind of give percentages for both ideal use and then, what is typically more important to us and our patients', real-world effectiveness for any given method, whether that's a hormonal method, a barrier method, an implantable or insertable method, a permanent sterilization, those sorts of things.

But I would say that for somebody who is looking at methods such as abstinence, such as withdrawal, such as fertility, timing-based methods, it's really important to know the science and both the ideal and the real-world effectiveness of those methods, too, and to provide those to your patients so they really, really understand what the nature of several of these, you know, methods are.

It's one thing to have a one-in-100 rate of pregnancy on a given method. It's another to have one in four, which is an estimate for at least some studies for a withdrawal method. It's important that patients have that information. They're armed that with that information so they can make choices around what they want to do as a whole.

LBB: Yeah, and also educating that, of course condoms are important for preventing STI transmission, but that there are very significant variations in effectiveness. If we're talking about LARCs, we're thinking about, again, a 99% effectiveness and that condoms are much better at preventing infection as opposed to pregnancy compared to the other options that we have out there.

I love these thoughts that you guys just gave us and, and again, I feel like demystifying our contraceptive options, it's just an essential piece of helping physicians and patients think through their options in a cohesive manner. Jason?

JM: One last thing about this sort of the rabbit hole that we're down here, is to say that there was a time, I think when most people in the United States got some pretty decent health education in high school. Like, there was a certain understanding among men what a menstrual cycle was and when fertility occurred. And I think that there's a lot less of that now. And so sometimes our job is going to be to ask some questions about what their knowledge base is around the reproductive status of their partners for men and women both.

And I think we ought to be able to lean into some of those spaces and not make some assumptions that a person would know when their partner's open fertile window would be.

LBB: I'll share that apps are really effective for a lot of patients who are seeking fertility or seeking to avoid fertility, and that some of that education for me as a doctor was really made real when my partner and I were trying to get pregnant and I was using those apps and thinking about fertile windows. And so we have access to some different forms of education that aren't just talking to our patients in the exam room.

JM: Yeah, we should leverage those as well

Choosing the right birth control pill

TOR: Much agreed. And in regards to education, something that comes up specifically around pills, if we will, is which pill to choose, which brand, which type, which formulation. There are literally hundreds out there in the market with all sorts of different names. Most of us, you have probably seen a few and are kind of, you used to a few different ones.

I will say that the largest thing that comes up when I think we're choosing these as well, which brand, how am I going to, to choose between all of these. And what I really like to say in that primary decision is, you know, which is something that we've already discussed, is try kind of choosing between a combined oral contraceptive or a quote-unquote mini pill, a progestin-only contraceptive. And, you know, that's a whole set of counseling in and of itself.

But once you're past that, the best brand of birth control is the one that your patient can get. At the end of the day, almost every insurer seems to have a preferred brand or not, or preferred series of brands. Generally, they're fairly well similarly formulated at this point. There are some minor differences. Those minor differences don't necessarily make any consistent differences for patients.

If patients come to you and they say, I've tried this brand that worked really well for me, I tried another one, I had breakthrough bleeding, or I had this other series of side effects, OK, well, maybe you might want to consider the brand that they were on previously because the minor differences in formulations, maybe having an effect specifically for them.

But in terms of, if you will, first initiation or if you're looking at a patient who doesn't have a preference, the best one is the one that they can get and that they'll take.

LBB: Agreed. Agreed, 100%. Jason, I know this comes up for you a lot as you're teaching the residents.

OCP risk factors

JM: Yeah, we're we're talking about different types, all the kind they come from, our residents come from all over the country, and so they may have gotten used to one particular OCP in their local community that was commonly available and used by their local insurers and then we're starting sort of back at scratch with what we've are using in Indiana primarily.

One of the biggest things that I think we do a lot of teaching about at the residency is, like, these are medications that have some risk factors that go along with the selection process. Sometimes that often we just begin to assume, like, these are all the same and they're all fine, and what could possibly go wrong?

But it is smart for all of us who prescribe oral contraceptive pills to think through the various age-based risk factors. How old is too old to be on a birth control pill? What if they're a smoker? What if they're a vaper? Does that change things? What if they're just doing a few blunts a week of marijuana? How many cigarettes is enough for there to be risk there? What if their grandma had a blood clot in her leg when she was 85? What if their sister had a blood clot when they were 22? How do we think about these risk factors that could be important in our conversation and counseling about birth control pills?

Don't forget that. Tat's beyond the scope of what we want to talk about in this podcast today, but just realize that there are some risk factors out there that you shouldn't forget about in this conversation.

LBB: Wait, now I have to know. If you vape, can you use combined hormonal contraceptives? I don't know the answer.

JM: I don't think I know the answer to that, either. What about you, Tamaan?

TOR: We're 0 for 3 here.

JM: OK, here's what we're gonna do. You two carry on with the podcast. I'm gonna go find out and I'm gonna come right back.

LBB: This is what happens when, when it's a real conversation, is that we still gotta challenge each other. I love it.

The biggest things that are, are pretty broadly known, but I just wanna do a brief overview. If you have someone who is over the age of 30, overweight, smoking, at least cigarettes, and we will find out forthwith about the vaping and or has a history, a personal history of a blood clot, those are things that you're going to be saying, I don't think that the combined. OCP is going to be OK for you.

Now, if you need to look up the specifics and the specific combinations of things, that's OK. Go ahead and look it up to just make sure. But those are the symptoms or history components that should be setting off alarm bells that this might not be the appropriate choice of contraception.

Jason, it looks like you might have an answer for us.

JM: There's currently no direct evidence that vaping or e-cigarette use or marijuana smoking increases venous thromboembolic risk in women on combined oral contraceptives.

LBB: I love it. I absolutely love it.

TOR: All right, so spliffs and bowls are good too.

JM: Oh my, that's not the message I want you to take from this, but we will grab some of these resources and make sure they end up in the show notes as well

Combined formulations

LBB: So once you now know that the patient in front of you wants a combined oral contraceptive and that they're able to take them without significant contraindications, there are a few questions to think through and that your patients might be asking you about. You can have side effects, right, anytime you take any medication, but particularly for thinking about taking hormones, some of these side effects might include, with variable rates, some weight gain, some headaches.

I've had friends with significant mood swings when they're taking OCPs. Breakthrough bleeding, which can be very distressing to a lot of people. Some of my favorite formulations to talk about are the low-androgen formulations of birth control, because if you have a patient with acne who really, really, really wants to take OCPs, we have to be thinking about low androgen contraceptives.

In particular, we're talking about not the estrogen component; we're talking about the progesterone component. And so if you're nerdy and want to know those names, the drospirenone component is going to be low androgen, and that's in Yasmin and Yaz. The norgestimate is used in ortho tri-cyclen. And then Opry is a brand name that I have heard a lot more frequently over the last couple of years, and that's the other low-androgen formulation, which includes desogestural. the third low-androgen formulation. And so those brands are things that you can be reaching for or having stored in the back of your brain of, Hey, if I have a patient who has PCOS or has really bad acne, etc. etc., then these are the things that I'm going to be reaching for if they're set on OCPs.

You might also be thinking, Hey. Do I need to be using a low-estrogen formulation? So lower amounts of the estradiol component, it's about 20 micrograms instead of the 35 micrograms. What are the reasons that you might be thinking about using low estrogen? Sometimes I think about that with teens. And sometimes I think about that with my perimenopausal patients.

Now, the flip side is that you could have more breakthrough bleeding with the low-estrogen formulations. Alternatively, if you do have patients who are dealing with significant mood swings when they're on a normal level of OCPs, but for whatever reason they really want to be on the pill—or need to; that's the only remaining option that they have—that's also where you might think about saying, Hey, let's, let's try to reduce the amount of exposure and systemic absorption of the estrogen component.

What has your guys' experience been with that?

LBB: Deafening silence. I love it. I absolutely love it.

TOR: Guess we'll cut that, that piece.

LBB: No, no, no. It's staying in. It's staying in. Because this is real-world stuff, right? And these are the things that we're going to get asked about. And so that's OK for us to say, “I don't know.” I think that that's actually really important for us and our listeners to continue to know, is that in this wide world that sometimes feels like the wild, wild west of contraception and all of the options within it, it's OK to say, “Hey, I'm really just not sure and I'll go find out for you.”

Phasic vs. monophasic birth control pills

LBB: Here's one other thing that we might just not be sure about, is that within the many, many, many, many, many types of combined hormonal contraceptives that we have out there, we have something called phasic types, right? So monophasic, biphasic, triphasic and quadphasic.

And so you could imagine having a patient come in and saying, I want the type of OCP or birth control pill that has all of the different types of hormones in the different phases. The term for that would be triphasic or quadphasic. What does that even mean? Because you're gonna get asked about this at some point and be like, I have no freaking idea.

The question is, are the month set of pills trying to mimic different phases of hormone amounts that a menstruating body might normally experience throughout the monthlng course of going through menstruation and then building up and shutting that endometrial lining? Or if you have a monophasic pill, you either have one set of hormones and/or placebo and that's it. You're not going through various different types of hormone formulations. And there are a variety, right? Orthotricyclic is named because it is tri phasic and it has three different sets of hormone levels within the pill pack that you get for that month. There are a lot of very commonly used types that are monophasic.

There doesn't appear to be a significant benefit to increasing the number of phases of hormone levels within your birth control pills. And if your patient's really attached to something like that, you can go and look it up and say, “Hey, what are my options for this patient?”

Seasonal and continuous OCP use

TOR: Indeed. And you know, I will say you're not quite done with the wild, wild west of contraception because there's really one other sort of contraceptive method that does continue to come up for various folks, and that's seasonal or continuous OCPs, either attempting to limit the number of menstruations that patients have within a given year, typically seasonal. In fact, one of the first ones to come out, one of the first brand names in recent memory, was called Seasonale. Or continuous OCP use, oftentimes in an effort to limit menstrual symptoms or to stop menstruation entirely

So the first thing to know about this is that this has actually been a type of contraception investigated for a very long time, since the 1960s or 1970s, has been looked at, despite the fact that it's only really now lately gaining traction. It actually has a very, very long record of studies and a fair amount of safety behind it. These are appropriate and safe methods of contraception that do not appear to increase total risk compared to quote-unquote more traditional oral contraceptives, non-continuous, and in several cases for various patients, particularly patients who have particularly debilitating menstrual symptoms, can be extremely helpful for them.

They're appropriate to prescribe in this manner. There are brands that are designed this way, but in the event that there aren't brands available, traditional OCPs can be prescribed this way, provided you have patients not utilize the typical seven-day, nonhormonal portion of the pack. The way these are typically packaged, you say simply toss those ones out and begin an entirely new month, continuous hormones, and you should be able to have this type of treatment.

You know, it's less popular. I think, honestly, the only reason is because a lot of physicians know a lot less about it, and that is something that, as family docs, we really should have in our back pocket as yet another option for contraception for people who desire it.

LBB: I love it.

Describing conctraceptives

JM: One last point, and I think we're wrapping towards the end here, is to say that let's not forget to de-prescribe any of these forms of contraception. Well, except for vasectomy, you can't de-prescribe that. But these other forms of contraception, when the time is right for that. Maybe it's a couple where one partner has now had a vasectomy. Maybe it's in other situations where there's been a change of partner. Like, there's times before a woman would typically be in menopause, when there may be an opportunity to de-prescribe, so you want to ask about their birth control regularly at intervals, so maybe along with wellness visits or other times when they happen to be in the office. Certainly there's going to be a point when a person's fertility is going to stop. And that is a point where you do not need to continue to put contraception options into their body.

Certainly medicinal ones there are beyond the scope, again, of what we want to talk about today. But just realize if you have a, a person who's been on, for example, long-term OCPs, and they're 51 and a half and their periods are kind of weird and they've never had that on this OCP before, it probably is because that person is going through menopause and you begin to have a conversation with them about how you sort that out and how you de-prescribe and what to watch for if they're really not infertile yet naturally, and that's a whole other conversation.

But but don't forget to have that conversation with patients for whom you've been prescribing contraception.

Recap: pearls of information

LBB: Well, my CME on the Go partners and listeners, I know that I am very biased, but this was a really fun conversation, and we just had so much fun talking about all things birth control. I do want to close out by recapping some pearls here.

First one is that, if you're reaching for a birth control option, you should probably be reaching for a LARC, whether that's an IUD or a Nexplanon. And there are some nuances there, including do you need a non-hormonal option like ParaGuard. But really that is what we should be looking for, including with our teen patients.

Second is that vasectomy is an underutilized form of birth control for those patients who say, “I and my partner do not want to ever have another child.” It's very safe. It's very easy to do, and if you want to start doing it, you can get trained on those things pretty easily.

Third is that when you think about OCPs, and particularly combined hormonal contraceptives, there's a wide world out there and that can feel really, really overwhelming, and that's OK.

I would be open to saying things like I don't know if you're being confronted with patients that are asking you specific questions. But really what you need to know is general things that are red flags to say, “I should not be prescribing this medication.” And if I have a patient saying, “I don't have a preference about what OCPI want, but I just know that I want this,” and you as the physician are agreeing that this is a good candidate for an OCP, that you have two different brand names that you can reach into your back pocket and say, “I know my local pharmacies carry this and I know that my average insurance will cover this.”

Those are the things that are really, really going to be important for us. Any other pearls that you two want to add before we go to our gratitude?

Gratitude and conclusion

JM: I think mine is about learning how to have these conversations with patients that can be smooth and educational for either of the partners who may want to have questions answered about contraception options. They're really very, very valuable, and we should be the trusted resource, first line, for those answers.

TOR: I'll say, for my part, I am thankful for long-term, irreversible forms of contraception. I love both of my children. I want to love just them. And I love my wife enough to not make us both crazy by having any more.

LBB: I love that. And you jumped us into gratitude, Tamaan, and so I'm going to piggyback on that and say, I'm really grateful for being able to have so many options to offer our patients, depending on their clinical scenario and what's going on in their lives and what we see in front of us.

JM: This is arguably one of the most important areas where patients’ self-determination has really been a win over a few decades of time that did not exist before any of these were available. And what a blessing to live at a time when there are these multitude of options available for our patients.

LBB: I agree.

All right, well, that is all the time that we have. We appreciate you joining us on this journey to elevate family medicine, and to continue this journey, stay tuned for new content brought to you twice a month with CME on the Go. Visit the show notes for instructions on how to claim CME credit and find additional resources for today's episode.

Until next time, serve from your values, pursue your vision and check when your IUD might have expired. See you next time at CME on the Go, a production of Inside Family Medicine.