Contraception on the CCFP exam

Approach

• Raise birth control yourself, at any visit, with anyone who could have or cause a pregnancy.
• Teens: ask in private, and offer the most effective methods first. Long-acting methods suit people who struggle with a daily pill.
• Teenage boys and men: condoms share the job, and they protect against most STIs.
• After a birth, several methods may suit someone who breastfeeds. These include the progestin-only pill, an intrauterine device (IUD), the implant and depot medroxyprogesterone acetate (DMPA, the 3-monthly injection).
• Near menopause: the combined pill may ease symptoms, but not for smokers over 35. Progestin-only methods may suit them.
• Waiting for tubal surgery or a vasectomy? Use a reliable reversible method until it is done.

Approach

• Starting mid-cycle: use backup for at least 7 days after the first injection, and at least 48 hours after starting the progestin-only pill.
• Progestin-only pill: take it within the same 3-hour window each day.
• Injection: due every 12 to 13 weeks. One dose still protects up to 14 weeks after it is given.
• Patch or ring: the hormone-free gap must not go past 7 days. The patch may work less well over 90 kg.
• Enzyme inducers, such as carbamazepine, phenytoin, topiramate and rifampin, lower hormone levels. Offer a non-hormonal method, such as a copper IUD, or add a backup method.
• The injection is not affected by most medications.
• After the inducer stops, keep the non-hormonal backup for 28 more days.

Approach

• Before any method with estrogen, ask about smoking and take a blood pressure. One from the past year will do. No combined pill for smokers over 35.
• Ask about any past blood clot. The combined pill raises clot risk 2 to 3 times. A past clot is a strong reason to avoid estrogen.
• Progestin-only methods have few reasons to avoid them: current or recent breast cancer that is progesterone-receptor positive, severe cirrhosis, or a liver tumour (hepatic adenoma).
• No pelvic exam or Pap test is needed to start. Do not screen for cervical cancer under 25.
• Ask about partners and condom use. Pills, patches, rings, the injection, implants and IUDs do not protect against STIs; condoms protect against most.
• Ask about cost, drug coverage, privacy and beliefs. Condoms are cheap. An IUD costs more up front but is cost-effective.
• Warn about the early effects that make people quit: irregular bleeding on progestin methods and IUDs; nausea, breast tenderness and headache on the pill.

Approach

• Warn before the first dose: irregular bleeding is the commonest early effect of the injection, the implant and IUDs.
• Irregular bleeding is commonest in the first months. If it lasts past 3 to 6 months, rule out infection, pregnancy and other causes.
• Then offer estradiol 1 to 2 mg a day for 28 days, a combined pill for 1 to 3 months, or ibuprofen 800 mg twice daily for 5 days.
• Ask what she wants. Switching to the pill trades about 60 failures per 1,000 users a year for about 90.
• Bone density falls on the injection but may recover after stopping. The Society of Obstetricians and Gynaecologists of Canada (SOGC) sets no time limit on its use.
• Do not order a bone density scan for a low-risk patient.
• Fertility can take 6 to 10 months to return after the last injection. Say so to anyone planning a pregnancy soon.

Approach

• Raise emergency options with anyone relying on condoms, withdrawal, fertility tracking, or no method.
• Consider a prescription for ulipristal to keep at home.
• Name the reasons to use it: a condom that broke or slipped, a missed pill, patch or injection, or sexual assault.
• An enzyme inducer may make emergency pills work less well, but it does not rule them out. Offer a copper IUD too.
• Hormonal emergency pills have no absolute contraindications except pregnancy and allergy, even where estrogen is unsafe.
• Emergency pills are for occasional use. Plan an ongoing method at the same visit.

Approach

• Levonorgestrel: up to 5 days, best within 24 hours. No prescription needed.
• Ulipristal: up to 5 days, by prescription. It works better than levonorgestrel on days 4 and 5.
• Copper IUD: up to 7 days, and the most effective option. It then stays in as ongoing contraception.
• A body mass index (BMI) over 25 may weaken levonorgestrel. Ulipristal seems to work as well at a higher BMI.
• After a hormonal emergency pill, plan an ongoing method at the same visit. After levonorgestrel, a hormonal method can start that day or the next. After ulipristal, wait 5 days.
• Past both windows, emergency options are closed. Do a pregnancy test today. If it is negative, give the injection, use backup for 7 days, and repeat the test in 3 to 4 weeks.