Counseling can make a major difference in contraception choices and effectiveness. Oral contraceptives are the top choice for reversible contraception by U.S. women, but counseling can guide women to more effective choices.
“Health care providers have an important role to play,” said Rameet H. Singh, MD, MPH, chief of family planning at the University of New Mexico School of Medicine. “Many adolescents don’t know anything about long-acting reversible contraception. Many who that have heard of LARC think they may not be eligible because of age.”
Data from the Contraceptive CHOICE Project supports the role of counseling. The prospective study offered more than 9,200 women their choice of contraceptive methods, all free of charge. After tiered counseling that started with the most effective methods, three-quarters of the women chose a hormonal IUD (46 percent), a copper IUD (11.9 percent) or an implant (16.9 percent).
LARC also showed much higher rates of continuation, 86.2 percent vs. 54.7 percent for injections, oral contraceptives, rings and patches. Satisfaction was much higher with LARC, 80 percent, than other methods, 54 percent. And the risk of contraceptive failure was 20 times higher with pills, patches and rings compared to LARC.
“When women get the right counseling and have access, they choose LARC,” Dr. Singh said.
LARC is the more effective choice for contraception, she added. Participants in the CHOICE trial had between 4.4 and 7.5 abortions per 1,000 vs. 13.4 to 17 per 1,000 in the St. Louis region where the trial was based and 19.6 per 1,000 in the general U.S. population. The teen birth rate in the CHOICE population was 6.3 per 1,000 versus 34.1 per 1,000 in the general population.
Current IUD choices include Skyla, a T-shaped radiopaque polyethylene device containing 13.5 mg of levonorgestrel released at a rate of 14 mcg per day. Mirena and Liletta are similar devices containing 52 mg of levonorgestrel released at 20 and 19 mcg per day. The other alternative is Paraguard, a copper device.
Retrospective studies have found that all four devices are relatively easy to insert, Dr. Singh said. The most important factor related to difficult insertion or complications was physician experience rather than patient factors.
Routine misoprostol does not improve the ease of insertion, she said. The data show that routine misoprostol is associated with more pain pre-insertion and more nausea and shivering post-insertion.
Pain on insertion is a common worry among women, Dr. Singh said, and most interventions do not work. Studies show that topical lidocaine, intrauterine infusion of lidocaine, ibuprofen and misoprostol have little to no effect on insertion pain. She recommended a paracervical block using 20 mL of lidocaine or similar topical agent.
“Women are far more satisfied with the block than not,” she said.