Transcript: Contraceptive Counseling For Primary Care NPs

​Liz Rohr:
Well, hey there. It's Liz Rohr from Real World NP, and you're watching NP Practice Made Simple. The weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients.

In this video, I want to talk about the approach to contraceptive counseling. I've made a couple of different videos so far. One about IUD Nexplanon and oral contraceptives specifically. But in this video I want to focus on the approach to the contraceptive counseling conversation and a couple of highlights of pearls of practice as well as a couple of different resources to investigate.

This is a real pet peeve or important issue to my heart because I think that it really frustrates me when I see primary care providers feeling really uncomfortable with the situation to the point of disregarding it. I don't know if it comes from the disregard or if it comes from the discomfort and lack of knowledge, but I want to put an end to that.

If you're watching this, that probably isn't you, but if that is you, then thank you so much for watching. If it's not you, hopefully you can feel as awesome about contraceptive counseling as you can so that you can share that knowledge with reluctant providers because reproductive justice is really, really important.

Anyway, in the contraceptive counseling conversation, the general conception is about women, cis women, but I think that this is a topic that we can talk about with all genders, and I think there's an easy way to approach it to just start and then have another resource for you to utilize if you want to dig into it further.

The general approach that I have for contraceptive counseling is a couple of different questions, and I learned this from Patty Cason and I'm going to link to her resource down below. She did a lecture for me when I was in my grad program. She's a reproductive health lecturer, but she talks about three different questions, so I want to pay homage to her. She talks about three main questions, and I think I want to start by saying these feel like they might be really... You're setting yourself up for a really long visit, and I know your time is short, but in fact, these questions actually can help you get to the root of the question and the issue much faster.

The main thing to start with is, "Do you plan on having children?" You can ask anybody this. "Do you plan on having children and do you have a time in mind of when you might like to do that?" Yes, if that answer is yes. Then the third question is, "How important is it for you to wait until that time for that to happen? "

You get a variety of answers for that because some people say, "If it happens, it happens." Some people will say, "Oh my God, absolutely. That is so important." That will really guide your conversation because I think one of the things that people can do is just spew a lot of information at patients, and that's not really that helpful. I think what's important for us when it comes to contraceptive counseling is understanding where they're coming from, very permission based, very not coercion based, because I see a lot of that too, where it's kind of, "Just do this." You're asking from the patient what their perspective is, what their desires are, and you're matching up the options based on that information instead of, "Here is the huge menu of options that you have for your contraceptive desires." No, that's too much information. The brain will not hold onto it. I've seen the deer in the headlights enough doing that method that I use this approach instead.

Depending on their answer, it will guide you further into... If you get the answer, "If it happens, it happens." "Would you like to talk about pre-conception counseling or would you like to talk about planning your potential pregnancy," if you're talking to a patient with a uterus and ovaries. "Do you want to talk about the family planning that goes into that? Do you want to talk about healthy pregnancy and the things to set you up for success in that endeavor?" Versus, "Oh, no, that's really, really important to me because I'm in grad school and I have too much on my plate, all that stuff." Then that kind of helps you figure out, depending on the person in front of you, again, open to all genders because we don't necessarily talk about it with male patients as much as we could in terms of vasectomy and other methods.

Then the next steps are really assessing further what their preferences are. A lot of these questions next coming up apply to patients with a uterus and ovaries more so than cis male patients. But you can ask them, "What are their preferences? What is important to you about your contraceptives? Is having a period important to you? Is having hormones or not hormone?" You can give options of things of what's important to them. If they look at you of like, "Oh, what does that even mean?" But a lot of people will tell you things like, "Oh, I am really worried about taking something every day. I'm really worried about having something in my body. I don't want any devices in my body." So they can typically volunteer that. But those are potential options of things to talk about.

For example, some people want a method that is really effective. Some people want a method that they can conceal from either their parents or their partner et cetera, et cetera, that gives them full freedom. Some people are really concerned about having a device in their body, a foreign object in their body. Some people are worried about their risk for fertility in the future, and that brings up further questions and concerns that people have and their desires.

I think a lot of places recommend and guidelines recommend doing top-down counseling that is LARC specific. So long-acting reversible contraceptives, prioritizing that first, which I appreciate. But also, it's really important to not be coercive. We're not trying to push things on people. We're trying to assess what their needs are, and it is a wise idea to lead with the most effective options. However, it all has to match together.

I think one of the things that I want to impart about these conversations is they're very person-based, patient-based, and that we let them lead and we try to guide them. So other potential things that people think about. Some people, it's really important that they have a period every month. Some people to not have a period. Some people are worried about their ability to stop at any time. I think that I've seen a little bit of an issue with that, too, where patients have those long-acting reversible contraceptive options like an IUD or an Nexplanon or something like that, and they're worried about that possibility, and I can't guarantee other providers act however they act, but I always let them know that they are able to remove them but some people feel uncomfortable with that prospect, and so they'd much rather have the complete control of something like a Depo-Provera injection where they can just decide not to have one anymore versus they're dependent on another provider or somebody else to remove it for them.

Download this video. I'm going to link to a presentation from Patty, actually, that is really, really helpful and it really gets... This is the place to start. Definitely start with those questions for your patients and then consider the next steps involved. I think the other main highlights that she gets into that are really helpful is how to have patient conversations in a counseling way that is open-ended, as well as some frameworks to use about how to give information as well as how to address concerns that patients have. Also, things that they've found online that may or may not be evidence-based, and how to have those conversations in a way that is very supportive and keeps the flow of conversation there so that you are empowering a patient and you're not shutting down the conversation or it doesn't feel like it's coercion of any kind or negation of any kind. It's a little bit delicate.

Anyway, hopefully that, hopefully that presentation is really helpful, but hopefully this also gives you a way to start that conversation comfortably. Like I said, if you want to go check out the Nexplanon IUD and oral contraceptive videos that I've made so far to fully understand those methods yourself so that you can bring that knowledge to these conversations with patients, then hopefully that will be helpful.
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Thank you so much for watching. Hang in there and I'll see you soon.