Get a “quick start” to improve adherence to oral contraceptives.
Westhoff C, Kerns J, Morroni C, et al. Quick start: novel oral contraceptive initiation method. Contraception. 2002;66(3):141–145.
Starting OC pills immediately—instead of waiting for the Sunday after the next menses—can improve the short-term continuation rate for women patients who choose an OC.
Consider a nondaily combined method, such as the transdermal patch or the vaginal ring, for current OC users.
Creinin MD, Meyn LA, Borgatta L, et al. Multicenter comparison of the contraceptive ring and patch: a randomized controlled trial. Obstet Gynecol. 2008;111(2 pt 1):267–277.
Many women who use an OC are satisfied with the positive effect the method has on menses and acne but find that they miss taking a pill some days; they might benefit from a method that involves nondaily administration. Studies show that switching from oral contraception to the transdermal patch (OrthoEvra) or vaginal ring (Nuvaring), for example, is acceptable to many women.
7. Preemptive prescribing
Prescribe emergency contraception before your patient needs it.
Jackson RA, Schwarz EB, Freedman L, Darney P. Advance supply of emergency contraception: effect on use and usual contraception—a randomized trial. Obstet Gynecol. 2003;102(1):8–16.
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 112: Emergency contraception. Obstet Gynecol. 2010;115(5):1100–1109.
Consider giving every sexually active woman a prescription for emergency contraception before she leaves your office. She can fill the prescription and keep it at home in case of an emergency.
8. Get to know ella
Become familiar with ulipristal acetate (ella) for emergency contraception.
Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010;375(9714):555–562.
Barbieri RL. Levonorgestrel or ulipristal: is one a better emergency contraceptive than the other? OBG Manage. 2011;23(3):8–11.
This new FDA-approved agent for emergency contraception is effective for as long as 5 days after intercourse and results in fewer pregnancies than levonorgestrel does. It is available by prescription only, however, and is more expensive than levonorgestrel.
9. Pursue two urogenital pathogens
When you are not performing a speculum examination, screen for N. gonorrhoeae and C. trachomatis with a vaginal swab specimen or urine-based specimen.
Johnson RE, Newhall WJ, Papp JR, et al. Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections–2002. MMWR Recomm Rep. 2002;51(RR-15):1–38; quiz CE1–4.
Schachter J, Chernesky MA, Willis DE, et al. Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transm Dis. 2005;32(12):725–728.
Under new screening guidelines for cervical cancer, Pap smears are not required for women who are younger than 21 years. Gonorrhea and chlamydial infection screening is still important in this population, however, and can be done without a speculum exam.The patient or provider collects a specimen for testing with a vaginal swab, or the patient submits a urine specimen.
10. Now not later: An IUD, post-evacuation
Consider immediate, rather than delayed, IUD insertion after uterine evacuation for spontaneous or elective abortion in women who desire this form of contraception.
Bednarek PH, Creinin MD, Reeves MF, et al. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med. 2011;364:2208-2217.
A recent clinical trial enrolled 575 women who underwent uterine aspiration for induced or spontaneous abortion at 5 to 12 weeks’ gestation and who desired an IUD. Subjects were randomized to IUD insertion immediately after the procedure or 2 to 6 weeks later. The 6-month expulsion rate was 5.0% after immediate insertion; 2.7%, after delayed insertion (P = NS). There were no differences in the rates of other adverse events. Only 71% of patients returned for their “delayed” IUD placement; five pregnancies occurred among these women. No pregnancies occurred in the immediate-insertion group.
Offer office-based hysteroscopic sterilization.
Levie M, Weiss G, Kaiser B, Daif J, Chudnoff SG. Analysis of pain and satisfaction with office-based hysteroscopic sterilization. Fertil Steril. 2010;94(4):1189–1194.
Office hysteroscopy is well tolerated. Two hysteroscopic sterilization systems, Essure and Adiana, are available for use in the office. The systems are especially valuable in women who are poor surgical candidates or who want to avoid the inconvenience, or the risks, of a more major surgical procedure.
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