How to Counsel on Family Planning

Ask whether they want to be pregnant (in a clinic or postpartum setting) in the next few years. Based on the respose, talk about the three types of family planning methods: long-acting, short-acting, and natural. Long-acting includes nexplanon (3 years), mirena (5 years), pargard (10 years), and depo (3 months). Short-acting includes the pill, the patch, and the nuvaring.

You have to explain natural a little more, because Sex Ed and Bedsider haven't already. I explain FABMs like this: "There are fertility awareness methods that researchers have found to be effective. Our bodies are smart: we can only get pregnant a few days a month, and our bodies give us signs about which days these are. You can learn to pick up on these signs and know every day whether you can get pregnant that day, or whether you can't. And based on that, you use that day for intercourse or not. Some women find it really empowering."

If they express interest in FABMs, I always add: "It's neat because you'll be able to use it all your life. But to get that confident with your own feritlity, you do meet with a teacher. Maybe decades ago women knew this, but our mothers haven't taught us! Do you have the time and transportation to meet with a teacher? Usually it's every two weeks, then every month, and it takes about six or eight months to feel really confident." (Some are online if the answer is no.)

Method	Effectiveness		The Good	The Bad	Lasts	Cautions/ Contraindications	Cost (cash)
	Method	Typical
OCPs	0.1%	3-5%	Some with Fe, folic acid	Effectiveness based on pt (applies to all short acting and FABMs)	24+ h	Lactation, estrogen warnings (never in daily smoker > 35 yo, h/o DVT/PE/CVA/MI, SLE with APA, migraine w aura + FNDs)	$10-62/ mo
POPs (progestin-only pills)	0.5%	3-5%	Safe in lactation (applies to all progestin-only)	Intermenstrual bleeding, spotting	24 h		$10-50/ mo
Ortho evra (patch)	1.07%	9%	Simpler than pills	Doesn’t work well >90kg, double risk VTE compared w/ OCPs	7 d	Lactation, estrogen warnings	$82/mo
Nuvaring	1.28%	9%	Simpler than pills	Vaginal discharge	7 d	Lactation, estrogen warnings	$83/mo
Depo provera	0.3%	6%	Amenorrhea in 55% at 1 yr, 68% by 2. Decreases crises in SCD	Irregular bleeding, wt gain 3lb/yr, reversible bone loss	3 mo	possible pregnancy, local cellulitis	$50-95/ shot
Nexplanon	0.05%		No GU tract procedure. Palpable by patient	Unpredictable bleeding that doesn’t Δ w/ time. 10% rule for 1) irreg bleeding, 2) wt gain, and 3) acne	3 yr	possible pregnancy, local cellulitis	$500-750
Mirena/ Skyla	0.2% for yr 1 0.7% by yr 5		Amenorrhea in 20% and oligo in 60% at 1 yr	Irregular bleeding first 3-6 months	5 yr/ 3yr	IUD contraindications (<6wks postpartum, uterus sounds >8cm, possible pregnancy, untreated GU infxn incl PID in past 3 mo) plus brca, anticoagulant use, liver dz/tumor	$400-900
Paragard	0.6-0.8%		No hormones	Increased bleeding with natural cycle	10 yr	IUD contraindications plus Wilson’s	$500-900
Creighton	0.14-0.5%		Translates into GYN managmt, distance teaching	Very involved charting and follow-up	∞	Language barrier, h/o noncompliance
Billings	1.1-3.2%	10.5-22%	Simple	Needs follow-up	∞	Language barrier, h/o noncompliance
Marquette	2.1%	14.2%	Objective, online teaching available	Monitor $200 Strips $35/30 (need 10+/mo)	∞	Language barrier, h/o noncompliance, not good with devices
CCL	0.4-0.6%	1.43-2.2%	Thermom $10 Couples only	Most difficult rules	∞	Language barrier, h/o noncompliance

I always put something in her hand if she wants to try a natural method. That's the way the prescriptions and devices work: there's always a pill pack, a crisp, robust brochure, or a prescription at the end of conversations for contraceptives. When I refer a patient to an NFP teacher, I hand her a nifty little packet (I made a bunch of these) with the person's business card and a page detailing her new method of family planning and singing its praises.

Prices for FABMS vary by location and teacher. I called around to get prices for each of the teachers I refer to (MM, CrMS, and BOM in my new metroplex) so that I can tell the patient what to expect.

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Sources: the chart is reprinted from FACTS with the author's permission. Her sources:
Cost estimates: 1 and 2.

Mirena data: PI.

Depo data: PI.

Nexplanon data: PI. (No pregnancy rate, so I used the norplant datum from the paragard PI, which matched the CDC data linked below.)

Nuvaring data: PI.

Patch data: PI. 

Paraguard PI is here, but there aren't any numbers on increased bleeding.

Effectiveness: CDC (6% for depo)

The big chart you might see everywhere is from Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Stewart F, Cates W, Stewart GK, Kowel D, Guest F. Contraceptive Technology: Seventeenth Revised Edition. New York, NY: Irvington Publishers; 1998.

FABM review here.