Case Presentation
Katherine is a 45-year-old woman, married with 3 children, and experiencing the onset of perimenopause. She used oral contraceptives until age 35 when she stopped because she “was afraid of having a stroke.” She used the diaphragm after discontinuing oral contraceptives for birth control but acknowledges that she did not always use it every time. However, she thought “it was less risky than oral contraceptive or other hormonal methods of contraception.” She unexpectedly became pregnant with her daughter at age 37 and had an uneventful pregnancy and delivery.
She presents to you because she has begun to notice irregular periods, fatigue, vaginal dryness, mood swings, and decreased libido. She laughingly describes herself as a ‘couch potato’ about exercise but indicates that she stays very busy with her part-time job as a substitute school teacher, taking care of her family, and volunteering at her church and her children’s schools. Katherine understands that while she is 45, she is still at risk of pregnancy and wants to discuss both effective and safe contraceptive methods as well as the recent changes in her health. She states that she is not interested in oral contraceptives because she “feels they are too risky for a woman my age.”
A misperception of risks about contraception may unnecessarily limit a woman’s choices. Decision aids can facilitate risk communication by increasing the individual’s involvement in the decision-making process and improving the likelihood that they will make informed, values-based decisions. One example of a decision aid to help you to discuss the risks and benefits of hormonal contraception with your patients is based on the following four steps.
- Clarify the situation.
- Provide information on benefits and harms.
- Clarify patient values.
- Screen for implementation problems.
Katherine’s physical exam and history reveals that she has a body mass index of 24 and she reports that she abstains from use of alcohol and tobacco products. She has an unremarkable personal medical history with no family history of cancer, diabetes, cardiovascular disease, or hypertension. After you complete your exam, you clarify the situation with Katherine by stating “I understand you are concerned about some recent changes in your health as well as are interested in a safe method of contraception.”
You then explain to Katherine that the symptoms she is experiencing are associated with perimenopause, the stage in her reproductive life that begins several years before menopause with the symptoms due to decreased production of estrogen by her body. You also explain that despite the onset of perimenopause, Katherine is still at risk of becoming pregnant if she does not use a contraceptive method. You provide her with information about options available to her including the permanent sterilization since she has completed child-bearing, a low-dose oral contraceptive that is safe, effective, and can alleviate some of her perimenopausal symptoms, the LNG IUS, and the diaphragm, which she previously used.
As you discuss Katherine’s current health and her contraceptive options, you review steps that she can take to reduce her risk of any adverse events. Remember to present absolute risk and use different forms of numerical data to explain risk as well as verbal and visual formats to improve perception and understanding of risk. Be aware of framing effects. For example, the way a message is expressed can influence an individual’s perception of risk by presenting favorable (positive framing) rather than unfavorable outcomes (negative framing) such as the risk of surviving or avoiding a complication versus risk of dying or experiencing a complication.
Remember these basic principles of effective communication as you discuss contraceptive options with Katherine. Know that your purpose is to help Katherine reach the decision that is best for her. Remember to be an active listener and demonstrate your interest through eye contact, posture, and facial expression. Be certain that there are no internal and external distractions that might interfere with your communication with Katherine. Finally, ensure understanding of the risk information you have presented by asking Katherine to repeat what she heard.
You explore Katherine’s preferences regarding the best method of contraception for her at this time of her life. Katherine declines permanent sterilization because she ‘does not want to have any surgery’. Katherine also is not interested in trying the diaphragm again; pointing out that she was not very successful in her efforts to regularly use it when she was younger. Katherine is surprised to learn that there are lower dose oral contraceptives and expresses an interest in learning more about the effectiveness, side effects, and benefits of these. She is particularly pleased to learn that the lower doses have a good safety profile for women her age and also offer the benefit of relieving some of the symptoms caused by perimenopause. Katherine expresses interest in the LNG IUS, but prefers the low-dose oral contraceptive because it may also relieve some of her perimenopausal symptoms.
You then screen for implementation problems by asking Katherine to consider the information you have just discussed with her and ask her which of these 4 methods of contraception will work best for her. Katherine explains that her husband takes daily medications for hypertension and 2 of her children are on daily medications for allergies. She describes herself as a very organized person and expresses confidence in her ability to use daily oral contraceptives noting that she will just include her medication along with the daily medications she gives to her husband and children. She notes that she will be particularly motivated to remember to take her contraceptive pill daily if it does offer some relief for her perimenopausal symptoms. Katherine schedules a follow-up appointment with you in 3 months to assess her satisfaction with the low dose oral contraceptive and evaluate whether her perimenopausal symptoms have improved.
References
- Farley TMM, Collins J, Schlesselman JJ. Hormonal contraception and risk of cardiovascular disease: an international perspective. Contraception. 1998;57(3):211-30.
- Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ. 2003;327(7417):741-4.
- Grimes DA, Snively GR. Patients’ understanding of medical risks: implications for genetic counseling. Obstet Gynecol. 1999;93(6):910-4.
- Lipkus IM. Numeric, verbal, and visual formats of conveying health risks: suggested best practices and future recommendations. Med Decis Making. 2007 Sep-Oct;27(5):696-713.
- Mills A. Combined oral contraception and the risk of venous thromboembolism. Hum Reprod. 1997;12(12):2595–2598.
- Morton RF, Hebel JR, McCarter RJ. A Study Guide to Epidemiology and Biostatistics, 4th Edition. Aspen Publishers, Inc. Gaithersberg, MD; 1996.
- O'Connor AM, Bennett CL, Stacey D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2009;(3):CD001431.
- O’Connor A, Legare F, Stacey D. Risk communication in practice: the contribution of decision aids. BMJ. 2003;327(7417):736-40.
- Rabe T, Luxembourg B, Ludwig M, et al. Contraception and thrombophilia—A statement from the German Society for Gynecological Endocrinology and Reproductive Medicine (DGGEF e.V.) and the Professional Association of German Gynaecologists (BVF e.V). J Reproduktionsmed Endokrinol. 2011;8(special issue 1):178-218.
Communicating Numeric Risk about Contraceptive Choice
