The past five years have brought many new, highly effective contraceptive products that provide women more options for choice. New modalities for delivery of hormones such as the patch and the ring, lower dose pills, pills with new compounds, and discussions regarding extended cycles of use and emergency contraception are now available. Intrauterine contraceptive devices are having a resurgence of interest to women and their health care providers because of their excellent efficacy and low side effect profile. But all of these methods need the support and the framework of counseling and education in order to maximize their potential for success.

Unintended pregnancy is an issue that requires many and varied approaches. The individual personal toll and the broader societal impact of unplanned (and often unwanted) pregnancies can be staggering. The economic impact to a woman who is not prepared to be pregnant can derail her personal, educational, and professional life. Whereas, decreasing the rate of unintended pregnancies by utilizing multiple strategies is a macro public health goal, to an individual woman, the choice and use of a contraceptive method may seem to be a microdecision, one of many she must make and fit into a busy life. The magnitude of the importance of that choice can be lost in the hurry up and go of the world with so many conflicting demands on her time, coupled with a health care delivery system that often limits the opportunity for thoughtful conversations.

Today's Contraceptive Options

What women want

Women consistently have said they desire contraception that is safe, effective, easily reversible, and does not interfere with sexual spontaneity. Unspoken issues that are also important to explore are partner acceptance, bleeding, and personal/ partner beliefs regarding bleeding prohibitions to intercourse. Another critical element that needs to be respected is that contraceptive choices are best made taking into account the current context and style of her life and the acceptance that this will change over time. Women's lives are fluid and dynamic, and the best contraceptive match is one that will go with the change so she can meet her life goals.

"There are so many choices and so little time" is a sentiment that can be felt by both the patient and the provider. Although contraceptive methods have become easier to use, many patients are still unsure of how these methods work or how to correctly use them. For example, the ring technology is also a seemingly simple method, but a woman's understanding of her reproductive and vaginal anatomy may be limited, and this will likely impact her comfort and use of this method. The pills have passed the initiation of time and now three generations of women's use. But many women consistently report that its daily use is a major drawback, and many state that they have never really understood how it works. A method chosen in the absence of understanding is likely to be a method that will fail the test of confidence and continuation.

Counseling

Helping your patient choose

A previously unsuccessful contraceptive experience for herself, a friend or family member, bad publicity about a certain method, and even provider bias can taint all the other methods. Counseling about methods should be fair and evenhanded, and it can be an opportunity to correct misunderstandings about a particular contraceptive (even if it is not the one she is currently choosing or using, it could be a good choice for her in the future).

Cultural differences

Sensitive topics such as sex, sexuality, and contraceptive choices are an even harder counseling challenge when there are cultural differences between the patient and the provider. Counseling and health care services do not take place in a vacuum that is separated and isolated from the social and political influences and pressures of the larger society. Both the patient and the provider are affected by previous cross-cultural exchanges that may have been successful, or stressful and disappointing. Since the 1970s, there has been an effort to recognize the need to develop culturally sensitive, relevant approaches and services. The 70s also ushered in the time of the modern contraceptive movement so these two issues actually have the opportunity to meet, intertwine, and possibly clash. Researchers in the area of culturally sensitive strategies all seem to endorse and support the idea that various cultural groups may require techniques and approaches that are quite different than those of the white Anglo-Saxon middle class. Minority patients may prefer and respond to directive rather than non-directive approaches, which is different than what was considered a cornerstone to family planning counseling that espoused the non-directive style. These experts also propose counseling approaches that are active rather than passive, are more effective, and that a structured, explicit style may be more productive than an unstructured ambiguous one. Another key difference is that the minority patient may respond more positively to a counselor/clinician who discloses his or her own thoughts, feelings, and personal experiences.

Drafting the Blueprint

Like any important structure, the construction of choice needs a blueprint. This blueprint serves as a guide. It outlines the design/model, and it includes all the elements for building the support that is needed. The guide is you and your comprehensive evaluation, counseling, and information that you impart about contraception. The design/model is the method itself; how it works; what it looks like; how much it costs; how it feels; and how it changes over time. The nuts and bolts needed to support the framework of a solid choice are the educational materials, videos, handouts, and even Web sites that assist the patient to be thoroughly informed about her choice.

You are the guide

As her health care provider, you are the guide. How many times have you heard a patient ask you, "What do you think is the best method?" She may be thinking that best equates with effectiveness, but you as an experienced guide know that best is relative to not only effectiveness, but tolerability, side effect profile, cost, impact on the sexual domain of her life, and a myriad of other important features and factors. You will seek or already have information about her previous contraceptive experiences, successes, and difficulties. This a good time to correct any misinformation she may have about methods, and address any misgivings or anxiety she may have regarding contraception, fertility, or other critical issues. It is a patient's right and our responsibility to discuss all the methods, and to come to a decision about her best choice. It is our professional and personal privilege to assist her in such an important decision.

The blueprint design/model is the method itself. What it will look like, and how it will feel are important to the woman. She may also want to know how long it has been available; how much it costs over the short term and long term; its track record; and the strengths and shortcomings of the method. This is a key time to give anticipatory guidance regarding the more common and expected side effects. For instance, an informed woman who knows what to expect and has heard this from her trusted clinician guide is much more likely to successfully tolerate minor and transient symptoms, such as spotting or breast tenderness.

Counseling Tools

The building/framework elements are the important educational materials that are provided to inform her about her method. These essential materials, such as handouts, booklets, and videos, serve to reinforce our guided messages, and are there to support her when she has questions. They act as a bridge between our clinical service and her real life at home. Women should also be encouraged to access information from Web-based sites, such as those prepared by the manufacturers and also from noncommercial sites of professional organizations such as ACOG (www.acog.org), ARHP (www. arhp.org), and the NPWH (www.npwh.org).

Communication with your patient is an essential step in ensuring patient compliance in her choice of contraception. The Female Patient and Berlex Laboratories have created a special patient edition to aid in this educational process, and to specifically discuss the option of intrauterine contraception.

"Researching Your Contraceptive Options: The IUS"—Anita Nelson, MD, highlights the advantages and disadvantages of intrauterine contraception and provides an overview of the different options on the market today, such as the levonorgestrel-releasing intrauterine system (Mirena; IUS). The IUS has a convenience advantage over intrauterine devices and hormonal and barrier methods; is low in cost; and is an effective, reversible method of contraception.

"A New Way to Manage Menstruation"—Patricia J. Sulak, MD, highlights the advantages of contraceptives in managing menstruation with special consideration given to the IUS. The IUS does not inhibit monthly ovulation, but rather thins the uterine lining, leaving little to shed during monthly menstruation. In fact, many women will experience amenorrhea after one year of use.

"A Healthy Approach to Contraception"—Andrew M. Kaunitz, MD, discusses the contraceptive and noncontraceptive benefits of the IUS, including use during menopause, and as a safe, reversible alternative to surgical sterilization. Since the IUS does not contain estrogen, it is an appropriate option for women whose medical conditions contraindicate use of estrogen-containing contraceptives.

"Contraception Plus Therapy"—Raquel D. Arias, MD, focuses on the use of the IUS in patients suffering from menstrual disorders such as menorrhagia, dysmenorrhea, adenomyosis, and endometriosis. As the IUS lessens or eliminates menstrual blood flow, it helps to ameliorate many of the symptoms women suffer in these disorders. In addition, it also provides a less invasive and safer alternative to hysterectomy and uterine ablation in resolving many of these disorders.

The Plan

Even the best laid plan can come undone because of hidden forces. These are the things not even on the drawing board. The whims and abuses of politics, the pressures of industry market share, the unfathomable issues of insurance coverage for contraceptives, and even the apathy and ambivalence toward hard won reproductive rights are examples of tensions that can negatively affect contraceptive choice. Both the public and our profession need to be vigilant and active to ensure that women hold and gain ground regarding their reproductive rights, options, and services.

Let us hope that the next five years and every five years to follow will bring women and those of us who serve them even more new and effective contraceptive methods. However, no matter how cutting edge contraceptive technology may become, the basic need for education and respectful, thoughtful care will always be required.

Linda Dominguez, RNC, BSN, CNP, is assistant medical director, Planned Parenthood of New Mexico, Albuquerque, and in private practice, Southwest Women's Health, Albuquerque.

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