Informed decisions

Lifestyle is key to choosing best birth control

Leading specialists in women's health education are calling for a new framework for choosing contraception that would involve both women and their physicians.

The array of additional contraception methods that have been introduced in the past two years, the growing cultural diversity of the United States, and the importance of matching contraceptive method to lifestyles and preferences should form the core of a realistic dialogue between a woman and her health care provider, according to a panel of clinicians representing obstetrics and gynecology, public health and nursing. The panel, which includes Dr. Ronald T. Burkman, professor and deputy chair of obstetrics and gynecology at Tufts School of Medicine, has met bi-annually for 30 years as part of a health education program sponsored by the Keck School of Medicine at the University of Southern California.

"The factors health providers use to guide their recommendations about different types of contraception and the factors women use to choose an option should not be limited solely to efficacy data," said Dr. Daniel R. Mishell Jr., professor and chairman of obstetrics and gynecology at Keck. "After nearly 50 years' experience with steroidal contraception, we know that most steroidal methods and IUDs work well, if used consistently and correctly; yet half of all pregnancies in this country are unintended. Side-effect profiles, convenience and perceived health risks or benefits of the method can have a profound impact on a woman's ability to use her contraceptive choice successfully."

Mishell heads the panel, which meets to design health education programs that clinicians can use to learn about contraceptive options and issues, including communication techniques for patient counseling. Other panelists are affiliated with the University of Illinois at Chicago School of Medicine, Columbia University and the National Association of Nurse Practitioners in Women's Health.

According to the panel, there are two primary themes for clinicians and their patients to address when evaluating options for contraception: the difference between efficacy and effectiveness and improving communication between women and their clinicians.

Efficacy rates from clinical studies shouldn't be the only factor in deciding on a contraception method, Burkman said. All hormonal contraceptives have roughly the same efficacy rates, and data from clinical studies usually reflect conditions of "perfect use" by women who are carefully monitored and better informed than the average user. Moreover, he explained that pregnancy data from many clinical studies are analyzed with a technique called the Pearl Index, a method of analysis that doesn't account for how long a contraceptive method has been used. "Although used by the FDA for product labeling, the Pearl Index should not be used to make comparisons among different methods of contraception," Burkman said.

Instead, experts are encouraging clinicians to analyze options for contraception within the context of their typical use by a woman. Accounting for incorrect or inconsistent use of a method—when a woman forgets to take her oral contraceptive pill for a day or two, or doesn't use her diaphragm correctly, for example—age, educational level, marital status, partner attitudes, motivation and ethnicity/cultural influences should all have greater weight in decision-making than comparing efficacy rates among the many contraceptive options available. Side effects and lifestyle preferences can affect discontinuation rates, perhaps the most important element to success or failure of a particular contraceptive, he said.

Due to the easy access to health information from a variety of sources, women are now proactively initiating a dialogue with their health care providers, the panel noted. Clinicians must also be more proactive and explore predictors that determine the patients most likely to use a method correctly, the panel said. With so many options available, it's important that women also offer information about lifestyle, needs and preferences when making contraceptive decisions. "When discussing a woman's lifestyle and how that corresponds to the contraceptive method she may be using presently, it is important that clinicians discuss all available methods, so that each woman can make realistic decisions about which contraceptive is most consistent with her personal needs," Mishell said.