Case Presentation
Alyssa Smith is a 25-year-old woman, married with 3 children. She presents to your office seeking to establish a relationship with a new healthcare provider and explore alternative birth control methods. She had been a satisfied user of depot medroxyprogesterone acetate (DMPA) for 3 years following the birth of her youngest child. She found it convenient and easy to use and comments that it “did not get in the way of having spontaneous sex” with her husband. While she does not plan to have another child in the near future, she notes that she is only 25 and she and her husband plan to have a fourth child in the next few years. She appreciated the fact that DMPA is reversible and was not associated with decreased fertility following discontinuation.
However, Alyssa reports that she recently read an article in a woman’s magazine about different contraceptive methods and noted that the article described a number of side effects were associated with DMPA. In addition, her previous healthcare provider had advised her to discontinue DMPA, indicating that it was associated with bone problems. Alyssa explains that her mother is severely crippled with arthritis and she is worried that this family history of bone problems will increase her own risk of poor bone health if she resumes use of DMPA. All of these events have raised Alyssa’s concerns about the safety of DMPA.
Health information is available to consumers from a variety of sources with healthcare providers and the media among the leading sources of health information. Her previous healthcare provider did not have time to develop an alternative birth control option for Alyssa and recommended she make another appointment for this discussion. Alyssa was concerned about the information she had learned from her healthcare provider and wondered why she had not been told about the risk of “bone problems” before she started using DMPA, especially since he “should have known that I have a family history of bone problems.” She felt she could not trust her previous healthcare provider and decided that she would be more comfortable making an informed health decision with a caregiver who provided accurate and timely information.
You perform a physical exam and obtain a personal and family medical history from Alyssa. She reports that she abstains from smoking and also exercises for about 30 minutes a day 3 to 5 days a week. Her exercise primarily involves walking about but she also engages in sports activities with her children. You also review the contraceptive methods she has used in the past. The patch caused her to feel nauseous. She tried a short course of oral contraceptives for about 3 months but discontinued these because she had problems remembering to take her pill at the same time each day. You discuss an IUD and barrier methods but Alyssa indicates that these are “not for her.” She dislikes the IUD because she doesn’t like the idea of having something inside her uterus all the time while barrier methods seem messy and unappealing.
You demonstrate your understanding of Alyssa’s concerns by stating “I hear that you are concerned about the possibility that continued use of DMPA for contraception will harm the health of your bones and may have other side effects.” You inform Alyssa that some long-term users of DMPA may experience decreased bone density while explaining that this effect is usually temporary and reversible. You explain that the risk of bone loss is greatest for women who use DMPA for longer durations and possibly for those who are adolescents or young adults when the process of new bone formation is still occurring. You point out that Alyssa is at a good weight for her height and age and that her commitment to weight-bearing exercise and the fact that she does not smoke cigarettes are factors that will help protect the health of her bones. You also note that Alyssa can further protect the health of her bones by engaging in weight-bearing exercise such as her walking routine and by increasing the amount of calcium and vitamin D in her diet. You also explain the difference between arthritis and low bone density, which is reassuring to Alyssa.
You summarize: “On the benefit side, DMPA is very good at preventing pregnancy and many women find it easy to use as you did. This made it easy for you to incorporate effective contraception into your daily life.” “On the harm side, there is some evidence that DMPA may cause temporary and reversible changes in bone health. However, you are past the age of bone formation, do not have other risk factors of low bone mass, and are taking steps to protect the health of your bones, such as getting regular exercise.” In an effort to clarify Alyssa’s values regarding her choice of contraception methods, you ask “Do you think the benefits of DMPA are more important to you than the chance of causing harm to your bones?”
You screen for implementation problems by asking Alyssa “With the information we have just discussed in mind, how important is it to you to switch from DMPA to another method of contraception?” After reviewing the risk of bone problems, understanding that they may be temporary and reversible, and also understanding that s regular physical activity and increased intake of calcium and vitamin D can protect the health of her bones, Alyssa is confident that she would like to resume using DMPA as her contraceptive method. She is also delighted to have the benefits of DMPA available to her once again. Remember when provided with accurate information, some people may simply want to change. Informing them of all their options is part of risk communication and providing excellent comprehensive care.
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The Impact of Risk Perceptions on Contraceptive Choice
