Contraception: Counseling and selection

INTRODUCTION — The choice of a contraceptive method is a complex decision; medical providers have an important role in providing information and supporting patients' decision-making about contraceptive methods through contraceptive counseling. In this topic, we will review the goals of quality contraceptive counseling, review different approaches to this counseling and their relationship to health equity, and provide a step-by-step guide to providing high-quality, patient-centered counseling. Information specific to each contraceptive method is presented in detail separately.

In this topic, we will focus on the counseling needs of those with the potential for pregnancy; specifically, all individuals with a uterus and ovaries, regardless of gender. We encourage the reader to consider the specific counseling needs of transgender and gender expansive individuals [1]. Clinicians should ask all patients who identify as male about their contraceptive needs as well. (See 'Special populations' below.)

GOALS — In broad strokes, the provision of family planning care is designed to help individuals achieve their reproductive goals. However, data suggest that family planning care should not have a singular focus of preventing unintended pregnancy, as this is not consistent with all patients' preferences or necessary to optimize health outcomes. Rather, providers can focus on people reach their desired reproductive outcomes by supporting them to make informed decisions about their fertility and contraceptive use that are aligned with their preferences and reproductive goals (table 1).

HOW TO DO CONTRACEPTIVE COUNSELING — The steps for providing patient-centered contraceptive counseling using shared decision-making are laid out in the figure (figure 1) and detailed below.

Personalized counseling with shared decision-making — Contraceptive counseling has evolved from either 1) providing clinical data on methods with no decision support or 2) directive counseling for specific methods to a shared conversation between patient and clinician that incorporates patient preferences into the selection process.

●Shift to shared decision-making – Contraceptive counseling has evolved from either clinician-level directive counseling toward the mostly highly effective methods or provision of education to personalized counseling using shared decision-making [2-5]. This approach, which is considered ideal for preference-sensitive decisions that are highly dependent on individual values and needs, is designed to assist patients in making the best decision for themselves [6,7].

In shared decision-making, patients are acknowledged as the experts on their preferences, while providers contribute their medical knowledge about the different options and the ways in which they relate to patients' preferences [5]. In this way, patient autonomy and the diversity of preferences for contraceptive method characteristics can be respected, while at the same time, patients are offered support in aligning their preferences with the available options (table 1).

Interventions to promote shared decision-making have been reported to improve patients' ability to make decisions that are informed and consistent with their values and to increase patient knowledge [8,9]. Research in contraception specifically has found that patients are more satisfied with the counseling experience and their method when they experience shared decision-making [10]. Initial studies suggest that telehealth visits can be as effective as in-person ones for contraceptive care [11].

●Incorporation of patient-centered care – A shift toward personalized counseling is consistent with the increasing emphasis on providing patient-centered care, which is defined by the National Academy of Medicine as care that is "respectful of, and responsive to, individual patient preferences, needs, and values" [12]. In addition to the ethical reasons for providing this type of care [13], in the context of family planning, the receipt of patient-centered care is also likely to positively impact patients' long-term health care engagement and outcomes. Evidence of long-term impact is provided by studies reporting that receiving patient-centered contraceptive counseling focused on individual preferences is associated with continuing a chosen contraceptive method and using a highly or moderately effective method six months after the visit [14]. Conversely, patients who felt pressured during contraceptive counseling reported being less likely to engage with future reproductive health care [15].

●Earlier counseling models – Prior counseling approaches focused on patient autonomy and contraceptive efficacy. These points have been incorporated into the shared decision-making model.

•Menu-based approach – An alternative approach to contraceptive counseling that is frequently discussed, especially in the context of low- and middle-income countries [16], is a menu, or consumer-driven, approach, in which the provider's role is only to provide education and not to influence decision-making [2]. While this approach is focused on patient autonomy, research has found that many women in fact value receiving support from providers in the decision-making process, as opposed to being left to make the decision on their own [17-21].

•Highly effective methods – Over the last decade, there has also been a movement toward directive models of counseling focused on promoting use of the most highly effective methods. These approaches have included applying motivational interviewing, a patient-centered directive counseling model developed in the context of addiction medicine, to contraceptive counseling designed to motivate use of specific methods [22]. Another prominent model has been a "tiered effectiveness" approach, which structures counseling according to the effectiveness of methods, with a corresponding emphasis on those that are most effective [23]. These approaches are not ideally patient-centered in that they do not prioritize patients' preferences for method characteristics and they make assumptions about the relative importance of effectiveness at preventing pregnancy.

Establish rapport — While a positive interpersonal relationship is essential for all aspects of medical care, it is of particular relevance in contraceptive counseling given its personal and sensitive context [17]. Communication behaviors, such as greeting patients warmly and making small talk, have been associated with contraceptive continuation [14], further indicating that this is an essential component of the contraceptive counseling encounter. We advise all providers to consciously incorporate small talk into the beginning of their visit to establish a positive therapeutic relationship with their patient.

Identify patient-centered reproductive goals — The first step in providing patient-centered contraceptive counseling is identifying patients for whom this counseling is appropriate [5]. In our practice, we ask patients if they wish to discuss contraception or pregnancy prevention (table 2).

●Identify patients who wish to discuss contraception or pregnancy prevention – To address the limitations of the approaches below, we encourage the use of the question "Do you want to discuss contraception or pregnancy prevention at your visit today?" as means of identifying those who may become pregnant and who would wish to discuss contraceptive options. Follow-up discussion could address those patients with unsure or ambivalent answers to help them receive the care that best meets their needs, as well as those patients who already have their pregnancy needs meet, whether through sterilization or other means of pregnancy prevention.

●One key question – A modified version of the Centers for Disease Control and Prevention's (CDC) reproductive life plan approach (bullet below) is the commonly cited "One Key Question" in which patients are asked if they would like to become pregnant in the next year [24]. This is responsive to some criticisms of the CDC's reproductive life planning model (bullet below) because it limits the time frame under consideration and also incorporates the possibility that patients may not have defined intentions through response options of "okay either way" or "unsure." However, it is not ideal for identifying patients' current need for contraceptive counseling, as someone who wishes to become pregnant in the next year may still desire birth control now, those who do not actively desire pregnancy may prefer not to use contraception, and individuals who do not wish to become pregnant may not be at risk for pregnancy due to previous sterilization or not having sex that could result in pregnancy (eg, having sex with an individual who does not produce sperm).

●Reproductive life plan – The CDC has promoted the use of a "Reproductive Life Plan" approach, in which individuals of reproductive age define how many children they wish to have, and when, as a means of determining which services (eg, preconception care, contraceptive care) are appropriate for an individual [25]. This approach has been criticized as being overly proscriptive and not reflecting the ways in which people develop and modify their reproductive goals over time, including the potential of welcoming an unintended pregnancy [26].

Opportunity for preconception counseling — In addition to identifying those who wish to use contraception, family planning providers have the opportunity to identify those in need of counseling related to the impact of their health and health behaviors on future pregnancies (eg, "preconception care"). Recommendations from the CDC and others encourage providing preconception counseling at all visits with women of reproductive age [27-29]. As this can be difficult in time-limited encounters, such assessments can be prioritized for those with chronic medical conditions or with social or environmental risks or exposures. (See "The preconception office visit".)

Providers can ask additional questions beyond the immediate need for contraception to identify those for whom counseling related to future reproduction may be appropriate. One approach that has been suggested is using the "PATH" questions [26], which address pregnancy attitudes and timing in a patient-centered way that acknowledges that many patients will not have a well-defined plan. The PATH questions are:

●Pregnancy Attitudes – Do you think you might like to have (more) children at some point?

●Timing – If the patient is considering future parenthood: When do you think that might be?

●How important is prevention – How important is it to you to prevent pregnancy (until then)?

Document medical history/potential contraindications — Once a patient is identified as being appropriate for and desirous of contraceptive counseling, providers can then assess for medical conditions that could affect the safety of specific methods. Common medical conditions to consider include smoking status, cardiovascular conditions (eg, hypertension or history of venous thrombosis), and history of migraine with aura [30].

Both the World Health Organization (WHO) and the CDC maintain evidence-based recommendations for use of contraceptive methods in the context of a range of medical conditions and personal characteristics [31,32]. The World Health Organization Medical Eligibility Criteria for Contraceptive Use and the US Medical Eligibility Criteria for Contraceptive Use are freely available, easy to use, and provide contraceptive prescribers with definitive guidance on safety across a broad range of conditions for different patient populations. Both label contraceptive methods as category 1, 2, 3, or 4 for each identified condition; those in categories 1 and 2 are considered generally safe and category 4 methods are contraindicated. For those classified as category 3, the recommendations state that the "method is usually not recommended unless other more appropriate methods are not available or acceptable." Importantly, this guidance takes into account whether another method that may be class 1 or class 2 is "acceptable" to the individual patient, and therefore, a category 3 rating should not discourage prescribing that method for a patient who has been informed of the risks and who determines that this method is the most acceptable for them.

Related topics on contraception selection in patients with specific health issues include:

●(See "Contraception: Counseling for women with inherited thrombophilias".)

●(See "Contraception: Counseling for females with obesity".)

●(See "Pregnancy and contraception in patients with nondialysis chronic kidney disease".)

●(See "Pregnancy in patients on dialysis", section on 'Contraception'.)

●(See "Bipolar disorder in women: Contraception and preconception assessment and counseling".)

●(See "Approach to the patient following treatment for breast cancer", section on 'Contraception after breast cancer'.)

●(See "HIV and women" and "HIV and women", section on 'Choice of contraception'.)

●(See "Overview of the management of epilepsy in adults" and "Overview of the management of epilepsy in adults", section on 'Contraception'.)

THE SHARED DECISION-MAKING PROCESS — After identifying that a patient should receive contraceptive counseling and identifying any conditions that may limit the range of methods available to her, providers of contraceptive counseling can then begin the process of selecting the method through a shared decision-making process [5]. Examples of how a shared decision-making interaction can proceed can be found in the table (table 3).

Initiate the conversation — We advise beginning the conversation with a question that explicitly lets patients know that their preferences will be respected in the counseling process, such as "Do you have a sense of what is important to you about your method?"

We acknowledge, and have experienced, that many patients will not have an answer to this question, in part because they may have experienced past counseling approaches that did not prioritize their preferences. Patients' lack of experience with this type of question underscores the importance of leading the conversation with the patient's values, communicating that their preferences will be at the forefront of the discussion, and beginning the process of them considering what in fact those preferences are. As discussed above, common approaches that highlight only specific methods or immediately attempt to narrow down the options do not engage patients in discussions of their preferences. (See 'Personalized counseling with shared decision-making' above.)

Of note, this question is also distinct from another commonly used approach, in which providers ask "Which method are you interested in?" While on the surface, this question appears to prioritize the patient's preferences, it also assumes that patients are aware of their options and how those options relate to their preferences for different method characteristics, such as changes in bleeding patterns or efficacy. This question then drives the conversation to specific methods, rather than opening the conversation around the patient's preferences. Keeping the conversation open is particularly important given that patients may not feel empowered to ask questions of providers if not explicitly given the opportunity [2,33].

When opening the conversation by asking patients if they have a sense of their preferences, some patients may, in their responses, communicate explicitly or implicitly a desire for a non-shared decision-making approach. For example, some may immediately indicate that they know which method they wish to begin and convey a lack of interest in further discussion (autonomous decision-making). By contrast, other patients may respond by asking providers which method they think is best is or which method they think they should use (provider-driven decision-making). In both cases, patient-centered clinicians need to be aware of and responsive to those decision-making preferences (table 3) [34]. However, given the personal nature of contraceptive use, as well as the complexity of contraceptive selection, clinicians should take care to ensure patients' decision-making ability is maintained. In the case of the patient who wishes to make an autonomous decision, clinicians can offer to discuss other contraceptive methods and thus maintain the patient's option of receiving further education. For the (less common) patients who wish to defer some or all of the decision-making to the clinician, clinicians can facilitate a preference-concordant decision by eliciting patient preferences, as described below, and then taking a more active role in mapping those preferences on to specific methods. (See 'Facilitate decision-making' below.)

Elicit informed preferences — Once the conversation has been opened by stating a focus on the patient's preferences, the next step in the shared decision-making process is to help individuals identify those preferences. These decisions should be informed by evidence, which necessitates an interactive educational conversation between the clinician and patient about the different ways that methods vary, including [35]:

●How they are taken

●How often they are taken

●Efficacy

●Effect on menstrual bleeding (including regularity and flow)

●Other side effects

●Noncontraceptive benefits

●Privacy

●Effect on future fertility

We begin with a general overview of how the contraceptive methods vary and use language-appropriate visual aids to provide additional information and start the conversation (figure 2) [36]. When starting this process, it is important to first respond to any priorities expressed in response to the initial question about preferences. For example, if a patient indicates that the most important thing about a method is that they do not have to remember it all the time, clinicians can acknowledge this preference, provide the range of options described above, and ask which of these options for frequency of remembering a method would be acceptable to them.

Next, we review general characteristics (eg, efficacy, how often the method is used, and resultant menstrual changes) and discuss the range of options within each characteristic. To avoid triggering preconceptions about specific methods, we advise using general descriptions, rather than identifying specific methods, with language such as "There are methods you take every day, every week, every month, every three months, or even less often. How do you feel about these different options?"

The degree to which the clinician should elicit patient preferences prior to moving to the next step will vary by patient. While ideally a clinician will ask about all of the above method characteristics, in many cases, a few strong preferences will be expressed which adequately narrow down the options. In that case, it may be appropriate to begin the decision-making process without reviewing all method characteristics, while being aware that additional preferences may emerge during the decision-making process that change the course of the conversation. As an example, for a patient who prioritizes getting regular periods and desires a method that will decrease acne, a clinician can begin the decision-making process by focusing on methods that align with these preferences, such as short-acting hormonal contraceptives (eg, oral contraceptive pill, contraceptive ring, and contraceptive patch). (See 'Facilitate decision-making' below.)

Discuss method characteristics — Below, we provide specific tips for how to discuss method efficacy, changes in menstrual bleeding, other side effects, noncontraceptive benefits, and effect on future fertility in order to elicit informed preferences for these characteristics.

●Efficacy – Misconceptions about both the absolute and relative efficacy of different methods to prevent pregnancy are common [37]. Therefore, understanding a patient's preferences around method efficacy, which is a high priority for many, is essential [38,39]. One data-supported strategy to improve patient knowledge is to review a tiered efficacy chart, such as that created by the United States Family Planning National Training Center (figure 2) [40]. In addition to the use of visual aids, best practices for risk communication include stating natural frequencies rather than percentages (eg, stating "with typical use, method efficacy varies from 1 in 100 to 20 in 100 women getting pregnant in one year of use"). While tiered efficacy charts are commonly used, they are not the only approach.

●Changes in menstrual bleeding – Available prescription methods all have some effect on menstrual bleeding (figure 2), and individuals have strong and varied preferences related to these changes [41,42]. Importantly, the same change, such as amenorrhea, can be viewed as a benefit by some individuals yet a negative side effect by others [43]. Therefore, we recommend specifically eliciting preferences about bleeding by asking a nondirective question such as "How do you feel about your method causing changes in your period, such as making it less regular, making it more or less heavy, or making it go away entirely?" Importantly, some patients' preferences are due to misconceptions about the safety of changes in their bleeding patterns, specifically with respect to amenorrhea [44-46]. Therefore, expressed preferences to avoid amenorrhea should be nonjudgmentally explored to determine whether this preference is based on misconceptions, while providing education to dispel any misinformation (table 3).

●Other side effects – People frequently receive information about contraceptive methods from their social networks, and negative information is more commonly communicated than positive [47-50]. Therefore, many patients have concerns about potential negative impacts on contraceptive methods that will influence their choice of method. While it is not possible to systematically go through all evidence for side effects for all methods in a standard contraceptive visit, we advise directly asking patients if they have concerns about side effects of specific methods. This approach will allow clinicians to both understand patients' preferences and to address any misconceptions. When providing evidence-based information, clinicians should be aware of, and sensitive to, how much people value and trust information received through social networks about the lived experience with a contraceptive method [48]. Clinicians should avoid being dismissive of such experiences, acknowledge that "everyone is different," and emphasize the evidence for what is common (table 3). By not discounting the experience relayed through peer networks, clinicians avoid triggering distrust and allow patients to hear the evidence and consider how it may relate to their experience with that method.

●Noncontraceptive benefits – In addition to preventing pregnancy, contraceptives have numerous noncontraceptive benefits that may influence patient selection (table 4).

●Impact on sexual experience – A prospective study of over 1800 female individuals initiating a no-fee contraceptive of their choice reported that positive sexual experience while using the contraceptive method was strongly correlated with patient satisfaction [51]. Sexual experience was a stronger correlate of satisfaction than reduction or elimination of vaginal bleeding. In presenting contraception selection, clinicians are encouraged to ask patients to consider whether specific method characteristics (such as whether or not the method is coitally dependent and whether the method causes irregular bleeding) may have an effect on their sexual satisfaction.

●Effect on future fertility – If not previously elicited, clinicians can assess whether pregnancy is desired in the short or long term. Such a conversation provides clinicians the opportunity to address common misconceptions about the effect of contraceptive methods on fertility [37,52]. We review that only sterilization has a permanent effect on fertility, while the contraceptive injection has a shorter term impact.

Facilitate decision-making — The goal of this phase of counseling is to help patients identify the most appropriate method for them given their preferences and the contraceptives' characteristics. Clinicians should be aware that preferences and planned contraceptive may change over time [53]. Specific scenarios that may be encountered during the decision-making process include:

●One strong preference – For a patient who has identified one dominant preference, such as the desire to use a highly effective method, this process can be as simple as informing the patient that given their preference, intrauterine devices (IUD), implants, and sterilization may be the best choices and asking follow-up questions to help them determine which of these is most appropriate.

●More than one expressed preference – In cases where patients have identified more than one preference, clinicians can educate them about how these values overlap with the characteristics of available methods. Again, visual aids (figure 2) can be helpful in this process, as can pelvic models or samples of contraceptive methods. For patients with preferences that align with one method (such as the desire to minimize acne and to have lighter, regular periods), clinicians can help patients choose among the appropriate methods (in this case, the contraceptive pill, patch, and ring) using follow-up questions. When preferences are in conflict (eg, the desire for the most highly effective method and the desire to have a method that is not placed into the body), clinicians can discuss how these preferences do not overlap and ask patients to consider how to weigh their preferences relative to each other. An example of this conversation is provided in the table (table 3).

●Newly disclosed preference – When patients reveal a new contraceptive preference during the process of decision-making, it may be necessary to move back and forth between determining preferences and facilitating decision-making in response to those preferences. These new preferences can then be incorporated into the decision-making process, as described in the previous bullet.

Specific issues that can arise during the decision-making process:

●Clinician preference or bias – In facilitating the decision-making process, we avoid expressing any partiality that does not reflect the patient's own expressed preferences. Indicating such a bias is not consistent with the preference-sensitive nature of contraceptive decision-making and is particularly problematic given that the priorities of clinicians around contraceptive methods have been found to vary significantly from those of patients [54]. In addition, as patients who feel their clinician had a method preference are less likely to be satisfied with their method [10], and those who felt pressured to use a contraceptive implant are more likely to discontinue their method [55], counseling in this way can interfere with patients' contraceptive use. Phrases such as "Based on what you are telling me, these methods may be a good fit" can help to avoid any appearance of partiality.

●Discussion of personal experience other than the patient's – The question of whether or not clinicians should disclose personal experience with contraceptive methods during the course of counseling can arise, either because patients directly ask clinicians or because clinicians want to use their lived experience as part of the educational process. In other areas of health care, whether or not clinicians should disclose personal information is a source of controversy, and the ethical issues are heightened in contraceptive counseling given its personal and social context [56]. However, one study using audio recordings of contraceptive counseling visits found that brief incidences of self-disclosure were not disruptive to the clinical encounter and did not elicit negative reactions from patients [56]. Whether or not such disclosures were beneficial to the patients' decision-making process could not be determined. One study did report that clinicians sharing personal experiences of IUDs was associated with increased uptake of this method [57]. As this suggests that self-disclosure has the potential to be influential, clinicians should be cautious when giving personal information to ensure that it does not inappropriately bias decision-making.

●Avoidance of less available or familiar methods – Clinicians should be conscious of a tendency to be less likely to counsel about methods with which they have less experience or do not provide in their clinics. Such selective counseling may lead to patients being less likely to be offered methods requiring procedures (such as IUDs, implants, and female and male sterilization) or nonprescription methods (such as fertility awareness-based methods) even if they are a good fit for the expressed preferences. Clinicians should be aware of resources in their communities to provide these methods and make appropriate referrals as needed. Detailed reviews of these contraceptive methods are presented in individual discussions.

•(See "Intrauterine contraception: Background and device types".)

•(See "Contraception: Etonogestrel implant".)

•(See "Overview of female permanent contraception".)

•(See "Vasectomy".)

•(See "Fertility awareness-based methods of pregnancy prevention".)

Selecting a method — While the process of eliciting preferences and mapping them to the available methods is shared, the ultimate decision about which method to use should be made by the patient, unless they explicitly ask for guidance from the clinician. In those cases, clinicians can rely on their knowledge of the patient's preferences to identify the method that is likely to be the best fit. Clinicians can precipitate the final decision by asking questions such as "Given what we talked about, and what is important to you about your method, what do you think would be the best choice for you at this time?"

Starting a method — We follow the Centers for Disease Control and Prevention (CDC) US Selected Practice Recommendations for Contraceptive Use (US SPR) to guide start time, assess the patient's need for contraceptive back-up, and identify any necessary preinitiation testing [58]. Most contraceptives can be started on the same day as the visit and require minimal examination or testing prior to initiation (table 5). Screening for sexually transmitted infections (STIs) is done per the CDC Sexually Transmitted Diseases Treatment Guideline [59]. The US SPR also provides guidance to reasonably exclude pregnancy prior to method initiation and to assess the need for back-up contraception (table 6). When it is not possible to reasonably exclude pregnancy, contraceptive methods other than the IUD can still be initiated immediately with appropriate counseling and consent (algorithm 1). The need for emergency contraception should be considered for all patients. If the patient is a candidate for emergency contraception and interested in the copper IUD, this method will provide emergency contraception and then can remain in place for continued contraception (the levonorgestrel-releasing IUDs do not provide emergency contraception). (See "Emergency contraception".)

New-start counseling should also include information and support to optimize the patient's correct use of the method in the context of their unique life circumstances (eg, how to best remember to take a pill every day given their life's demands). Additionally, the US SPR provides information about what to do if one or more doses of a short-acting contraceptive method is late or missed [58].

Counseling about side effects is a continuous process; we revisit this discussion once a method is chosen and at follow-up visits. Anticipatory counseling about potential side effects has been associated with both method satisfaction and method continuation [60,61]. We next discuss how to arrange timely follow-up visits and obtain contraceptive refills, if relevant. Lastly, we specifically inform patients of the acceptability of method switching (eg, that patients are welcome to come back at any time for a different method for any reason). Rather than framing discontinuation as a failure, we recognize that method discontinuation and switching is a normal occurrence among contraceptive users that helps ensure that individuals are comfortable accessing care when they need it [62].

Assess risk of sexually transmitted infections — We assess a patient's risk of acquiring an STI as a routine part of contraceptive counseling. All patients at risk for acquiring an STI are advised to use condoms (internal or external) in addition to their chosen method for pregnancy prevention. Detailed information on the prevention of STIs is presented separately. (See "Prevention of sexually transmitted infections".)

Additionally, concern has been raised that hormonal contraception, and particularly the contraceptive injection, could increase the risk of acquiring HIV infection. In the absence of definitive data, we agree with the World Health Organization (WHO) and CDC assessments that individuals at high risk of and living with HIV can continue to use all existing hormonal contraceptive methods, as the benefits generally outweigh the risk [63]. Although still a subject of debate, progestin-only contraceptive injection does not appear to increase the risk of HIV acquisition. (See "HIV and women", section on 'Risk factors for HIV acquisition'.)

SPECIAL POPULATIONS

●Adolescents – Adolescents and young adults have unique contraceptive needs that reflect variations in individual development, barriers to contraceptive access, and lack of information [37,64,65]. While there may be a tendency toward more directive counseling with adolescents because of their perceived higher risk for adverse reproductive health outcomes, adolescents are also resistant to authority, and counseling viewed as overbearing has the potential to interfere with engagement with reproductive health services in the short and long term. The contraceptive issues specific to adolescents are reviewed separately. (See "Contraception: Issues specific to adolescents".)

●Postpartum individuals – Best practices for the provision of peripartum contraceptive counseling include discussing contraceptive options multiple times over the course of prenatal care, providing patients with information about the safety of different contraceptive methods in the immediate postpartum period, and including the potential effect on lactation [31,66]. Patients should be provided with the option of immediate postpartum contraception, including insertion of intrauterine devices (IUDs; within ten minutes of delivery), and should be informed about the increased risk of expulsion when provided in this manner [67]. In addition, clinicians should discuss potential increased risks associated with a short interpregnancy interval and simultaneously recognize that each individual will weigh these risks differently with respect to their own reproductive goals.

•(See "Contraception: Postpartum counseling and methods".)

•(See "Interpregnancy interval: Optimizing time between pregnancies".)

●Individuals who have recently had an abortion – Surveys of patients receiving abortion care have found that over 60 percent do not wish to discuss contraception at the time of their abortion [68,69]. Therefore, while contraceptive methods should be available to all patients having an abortion, clinicians should be responsive to individual patients' preferences for information and decision support in the context of providing this care. Insisting on providing counseling when not desired by patients has the potential to contribute to further stigma associated with receiving abortion care. (See "Contraception: Postabortion".)

●Individuals who request IUD or implant removal – When individuals seek IUD or implant removal for reasons other than desiring a pregnancy, some clinicians may promote continued use of the IUD or implant because of high efficacy, despite the patient's expressed desire for removal [70-72]. We strongly advise against this practice as it has the potential to result in mistrust of family planning clinicians and impinges on the patient's autonomy. Instead, we first assure the patient that we will remove the method at their request. We then ask them if they would like to discuss their concerns or experiences of side effects prior to removal. This approach allows us to address any issues and provide additional education when appropriate and acceptable to the patient. For patients who still desire method removal, we then proceed as requested. (See "Intrauterine contraception: Management of side effects and complications" and "Evaluation and management of unscheduled bleeding in individuals using hormonal contraception".)

●Individuals with chronic medical conditions – As described above, the World Health Organization Medical Eligibility Criteria for Contraceptive Use and the US Medical Eligibility Criteria for Contraceptive Use review the safety of specific contraceptive methods in patients with chronic medical conditions [31,32]. While clinicians may wish to promote the most effective contraceptive methods for those at risk of medically complicated pregnancy, patient reproductive autonomy must be maintained. Careful education and detailed counseling about contraceptive efficacy, risks associated with pregnancy, possible role of emergency contraception, and the availability and safety of abortion in case an undesired pregnancy occurs can support patients in making autonomous, informed decisions.

●Individuals with obesity – Individuals with obesity can be offered all contraceptive options, including combined estrogen-progestin contraceptives [30,31]. (See "Contraception: Counseling for females with obesity".)

●Individuals with substance use disorders – As there is a documented unmet need for family planning services among patients with substance use orders, those providing care to these individuals should ensure they have access to quality contraceptive counseling and services [73-75]. Clinicians caring for these patients may be biased toward specific methods given the higher risk for pregnancy complications in this population [76]. However, this tendency can trigger the heightened mistrust of the medical community by those with substance use disorders and has the potential to interfere with reproductive autonomy [77]. Therefore, a shared decision-making model grounded in the patient's preferences can both build trust and help patients identify a method of contraception that is best suited to their social and medical contexts.

In giving decision support, providers should be aware of the association between use of opiates with menstrual disturbances, including prolonged amenorrhea [78]. As this amenorrhea may lead women to underestimate their risk of pregnancy, education about the possibility of ovulation and resulting pregnancy, even when menstruation is irregular or absent, should be provided. In addition, given the frequent co-occurrence of substance use disorders with experiences of intimate partner violence and other forms of trauma, as well as posttraumatic stress disorder, providing trauma-informed care can be particularly important for this population [79,80]. A discussion of trauma-informed care is presented separately. (See "Health care for female trauma survivors (with posttraumatic stress disorder or similarly severe symptoms)".)

●Individuals with intellectual or physical disability – Individuals with intellectual or physical disabilities have unique needs. The contraceptive selection process may involve a guardian as well as the patient. Data to guide the decision-making process are often lacking, and the benefits, risks, side effects, and consequences of an undesired pregnancy must be balanced against one another. As an example, the magnitude of thrombotic risk from estrogen-containing hormonal contraceptives in those with limited mobility (eg, patient in wheelchair) is not known. However, hormonal contraceptives can be desirable for these patients because they reduce menstrual frequency or flow in addition to preventing pregnancy. (See "Hormonal contraception for menstrual suppression".)

Additional challenges can include the patient's limited capacity (intellectual, physical, or both) to use a method, problems with menstrual hygiene, and inability to undergo an office-based examination or procedure. Some patients with intellectual disabilities cannot tolerate pelvic examinations, which makes pelvic examination or placement of an IUD in an office setting unrealistic.

Sterilization in patients with intellectual or physical disabilities raises the ethical issues of patient autonomy and informed consent [81]. Sterilization in patients with disabilities is reviewed separately. (See "Overview of female permanent contraception", section on 'Vulnerable populations'.)

●Individuals with history of cancer – In 2012, the Society of Family Planning (SFP) published clinical guidelines for contraception in patients with cancer [82]. While the subsequent World Health Organization Medical Eligibility Criteria for Contraceptive Use and the US Medical Eligibility Criteria for Contraceptive Use approved hormonal contraception for most non-hormone-dependent cancers (ie, except for breast cancer), the SFP guidelines contain additional considerations that we believe are important.

For the following groups, the SFP advised:

•Those with active cancer or who have been treated for cancer within six months – Avoid estrogen-progestin contraceptives because both cancer and combined hormonal contraception are risk factors for venous thrombosis. (See "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Effects on cancer development'.)

•Those with a history of breast cancer – Consider use of a copper IUD, unless they are taking tamoxifen. In the latter case, off-label use of a levonorgestrel-releasing IUD can reduce the risk of tamoxifen-induced endometrial changes without increasing the risk of breast cancer recurrence. (See "Approach to the patient following treatment for breast cancer", section on 'Contraception after breast cancer' and "Intrauterine contraception: Candidates and device selection", section on 'Endometrial protection'.)

•Those at risk of breast cancer or recurrence – Emergency contraceptive pills are not contraindicated. (See "Emergency contraception".)

●Transmasculine individuals – Not all people capable of pregnancy identify as women; transmasculine individuals have specific counseling needs [1]. These include considerations related to taking a gender-affirming sexual history and preferences for side effect profiles [1]. (See "Primary care of transgender individuals".)

MYTHS OF CONTRACEPTIVE COUNSELING — Over the past few decades, the goal of family planning has been interpreted as equivalent to helping individuals avoid unintended pregnancy; the assumption has been that unintended pregnancies are uniformly negative outcomes for individuals and for society [83-86]. To this end, many family planning programs and policies have prioritized use of the most highly effective methods [87,88]. Over time, the appropriateness of this focus has been questioned based on the diverse perspectives people have about the potential for pregnancy in their lives, data about the health impacts of pregnancy intention for mothers and babies, and what is known about people's preferences for contraceptive methods.

●Unintended pregnancy is not always unwelcome – Research on women's feelings about pregnancy intention in the current literature has advanced the assumption that an unintended pregnancy is an inherently bad outcome [89]. Rather, women have varying perspectives about whether, and to what degree, an unintended pregnancy would be a positive or negative experience in their lives [89-92]. In fact, some women embrace the lack of predictability of their fertility and consider unintended pregnancies to be welcome surprises [93].

●Unintended pregnancies are not necessarily unhealthy pregnancies – It is also increasingly understood that the literature about the association between pregnancy intention and poor maternal and child health outcomes is not as robust as previously thought, especially in developed countries [84,94]. This is consistent with the understanding that an unintended pregnancy does not result in the same negative reactions in all individuals [89]. In addition, it is likely that other factors (such as socioeconomic status) could confound the relationship between pregnancy intention and outcomes when attempting to assess the impact of pregnancy intention [94].

●Contraceptive efficacy is only one important contraceptive characteristic – Commensurate with the above findings about people's views on pregnancy, research has revealed that people have diverse and strong preferences for contraceptive methods [38,39,95]. Data indicate that efficacy is not the only, or always the most important, characteristic for people choosing a contraceptive method. For example, one study stated that, on average, those surveyed reported 11 characteristics that were important to them, with the following percentages noting these characteristics were "extremely important" [39]:

•Very effective at preventing pregnancy – 89 percent

•Easy to use – 80 percent

•Few or no side effects – 74 percent

•Woman has control over when and whether to use the method – 71 percent

•No one can tell that the woman is using the method – 55 percent

•No change in menstrual periods – 44 percent

PROMOTION OF HEALTH EQUITY — Contraceptive counseling occurs in an historical and social context in which family planning providers and services have participated in coercive and unethical practices designed to limit the fertility of specific populations, including women of color, poor women, and women with disabilities [96]. Examples include nonconsensual sterilization and targeted marketing of the contraceptive injection Depo-Provera [97,98]. This history remains in the consciousness of the communities impacted, with one study reporting that over 40 percent of Black and Hispanic Americans think that the government promotes birth control to limit minorities [37]. A different study documented that over one-third of Black women believe "medical and public health institutions use poor and minority people as guinea pigs to try out new birth control methods" [81].

While this history has the potential to affect how patients perceive contraceptive counseling regardless of the counseling provided, there is also evidence from studies of ongoing bias in counseling according to the race/ethnicity of the patient. These include findings that women of color are more likely to report being advised to limit their childbearing than are White women in the context of prenatal care [99], and that Black women are more likely than White women to report having been pressured by a clinician to use contraception [100]. In addition, studies using standardized case scenarios have found that providers are more likely to recommend the intrauterine device (IUD) to low-income Black and Hispanic women than to low-income White women [101], and are more likely to agree to sterilize women of color and poor women than White women or non-poor women [102]. These findings are consistent with the broader literature on health care disparities in the United States, which has documented that patients of color receive different, lower quality care than do White patients, even with identical clinical presentations and access to care [103]. (See "Racial and ethnic inequities in obstetric and gynecologic care and role of implicit biases".)

Given this history, the recent emphasis on directive counseling toward methods of contraception that require a provider to both insert and remove a device (ie, IUDs and implants) has raised concerns about the potential to recreate, or appear to recreate, historical injustices related to reproductive control [96]. This is particularly relevant given that women of color have been found to be less likely to desire a contraceptive method that they are unable to remove or discontinue on their own [39]. Therefore, directive counseling toward these methods is more poorly aligned with their preferences than it is for White patients, while also having the potential to heighten preexisting mistrust of family planning providers.

In contrast to directive counseling, shared decision-making provides a structure for counseling, described above, that protects against perceived or actual bias in counseling by explicitly focusing on women's expressed preferences. Given that bias can influence how decision support is provided, however, those practicing shared decision-making should be aware of the potential for bias to influence their counseling in subtle ways and should work to guard against overemphasizing specific methods based on assumptions about what women do or should want [5].

●(See 'Personalized counseling with shared decision-making' above.)

●(See "Racial and ethnic inequities in obstetric and gynecologic care and role of implicit biases", section on 'Mitigation of implicit bias'.)

RESOURCES FOR PATIENTS AND CLINICIANS

●bedsider.org: A free website developed by the National Campaign to Prevent Teen and Unplanned Pregnancy, a private nonprofit group

●The Family Planning National Training Center: The website for federally funded contraceptive resources developed with the support of the Office of Population Affairs

●Center for Young Women's Health: A free website run by Boston Children's Hospital that addresses reproductive health needs of teens and young adults

●Beyond the Pill: A free website run by the University of California San Francisco

●SexandU.ca: An educational site run by the Society of Obstetricians and Gynaecologists of Canada that includes descriptions of various methods and a tool to help with selection of birth control

●PICCK.org is a clinical and public health program designed to promote contraceptive choice and effective contraceptive counseling across the Commonwealth of Massachusetts with an emphasis on patient-centered care rooted in principles of autonomy, equity, and justice.

●Planned Parenthood: A nonprofit organization dedicated to reproductive health with resources for patients and clinicians

●ACOG Contraceptive FAQs: American College of Obstetricians and Gynecologists addresses frequently asked questions (FAQs) about contraception

●ACOG LARC Program: American College of Obstetricians and Gynecologists Long-Acting Reversible Contraception Program

●United States Medical Eligibility Criteria for Contraceptive Use

●United States Selected Practice Recommendations for Contraceptive Use

●World Health Organization Medical Eligibility Criteria for Contraceptive Use

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Contraception".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Choosing birth control (The Basics)" and "Patient education: Vasectomy (The Basics)" and "Patient education: Barrier methods of birth control (The Basics)")

●Beyond the Basics topics (see "Patient education: Birth control; which method is right for me? (Beyond the Basics)" and "Patient education: Vasectomy (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Personalized counseling and shared decision-making – Data suggest that family planning care should not have a singular focus of preventing unintended pregnancy, as this is not consistent with all individual's preferences or necessary to optimize health outcomes. Contraceptive counseling has evolved from clinician-led directive counseling and provision of education to personalized, patient-centered counseling that includes shared decision-making. (See 'Goals' above and 'Personalized counseling with shared decision-making' above.)

●Identify contraceptive need – The first step in providing patient-centered contraceptive counseling is identifying patients for whom this counseling is appropriate. In our practice, we ask patients if they wish to discuss contraception or pregnancy prevention (table 2). (See 'Identify patient-centered reproductive goals' above.)

●Assess medical conditions – Once a person is identified as being appropriate for and desirous of contraceptive counseling, providers can then assess for medical conditions that could affect the safety of specific methods. (See 'Document medical history/potential contraindications' above.)

Guidance on safety across a broad range of individual and medical conditions for different patient populations is available through:

•World Health Organization Medical Eligibility Criteria for Contraceptive Use and the

•US Medical Eligibility Criteria for Contraceptive Use

●Elicit patient preferences – Patient-centered contraceptive counseling using shared decision-making should first elicit informed preferences for method characteristics, and then support patients in considering how these characteristics relate to the available methods, while leaving the ultimate decision up to the patient. (See 'The shared decision-making process' above.)

•Method characteristics to consider – Preferences for characteristics of contraceptive methods to consider when providing counseling include those related to method effectiveness, how often the method is taken/used, how the method is taken/used, menstrual changes, other side effects, noncontraceptive benefits, return to fertility, and privacy. (See 'Elicit informed preferences' above.)

•Address misinformation – Providers can address misconceptions and misinformation about methods, especially those transmitted through social networks, in a respectful way that does not dismiss these concerns but provides evidence-based information about the known effects of specific methods. (See 'Discuss method characteristics' above.)

•Role of visual aids – Use of visual aids, such as the Title X contraceptive method options chart (figure 2), can help to structure and guide counseling. (See 'Facilitate decision-making' above.)

●Educate on use of selected method – Counseling after method selection should provide each individual with information about how to start their method, how to optimize their use of the method, side effects they may experience, how to access necessary follow-up care including refills, and how to access care if they wish to discuss discontinuation and/or method switching. Emergency contraception and protection from sexually transmitted infections are also discussed. (See 'Selecting a method' above and 'Starting a method' above and 'Assess risk of sexually transmitted infections' above.)

●Special populations – Counseling for specific populations, including adolescents, gender-expansive individuals, and/or individuals with substance use disorders, chronic medical conditions, and/or mental or intellectual disability, should prioritize these patients' reproductive autonomy and provide tailored education to support their informed decision-making. (See 'Special populations' above.)

●Potential impact of unconscious bias – Providers should be aware of the potential for unconscious bias about patients' race/ethnicity to influence their counseling. Use of a shared decision-making model explicitly focused on patient preferences can limit the impact of such bias. (See 'Promotion of health equity' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Mimi Zieman, MD, and Andrew Kaunitz, MD, who contributed to earlier versions of this topic review.