(Published June 2006)

Guidance for Communicating Risk About Hormonal Contraceptives

The committee that developed this Clinical Proceedings included individuals with expertise in clinical care, risk communication, statistics, health education, and contraceptive research. Drawing on their varied fields of expertise, the committee developed guidance for providers communicating with patients about the risks associated with hormonal contraceptives.

Case Study: Using a Decision Aid for Risk Communication²

Michelle Gavin is a 19-year-old college student who had been using the contraceptive patch for six months when she came to your office, saying, “I want to stop the patch—it killed that girl in New York.”

Step 1: Clarify the decision.

Say, “I hear that you’re concerned about the possibility of a serious problem with the patch.”
Say, “It’s your choice to stop or keep using the patch, but let me put the possibility of a serious problem with the patch into perspective.”

Step 2: Provide information.

Say, “On the benefit side, the patch is very good at preventing pregnancy and because women find it easy to use, they are more likely to remember to use it. Pregnancy itself increases the risk of blood clots, heart attack, and stroke—although these problems are not common.”
Say, “On the harm side, the chance of having a serious problem like heart attack, stroke, or blood clot is greater for women using hormonal contraceptives like the patch than for women who don’t use them. This is especially true if they smoke or have had a blood clot before. But the chance is still very small and is actually smaller than the chance of these problems happening when a woman is pregnant.”

Step 3: Clarify patient values.

Say, “Tell me your thoughts about the risks and benefits. What are your concerns?”

Step 4: Screen for implementation problems.

Say, “How important is it to you to make this change (to remain on patch or stop patch), on a scale of 1 to 10, with 10 being the most important?”

This guidance is based on expert opinion; as yet there is little evidence from randomized controlled trials that enhanced counseling improves adherence to contraceptives.¹ Nevertheless, this guidance may help providers optimize risk communication with patients until data from randomized controlled trials are available. The steps are:

Have a clear understanding of risk yourself. Review risk calculations so that you can provide a simple description if needed.
Identify a trusted resource, such as the ARHP or Planned Parenthood Federation of America Web sites or Contraceptive Technology Update, that reviews breaking media stories about contraceptives and places them in a medically accurate context.
Ensure an environment conducive to conversation. Build a relationship of trust.
Put risks in context. Remind patients that life has inherent risks. Provide comparisons with the risks associated with relevant events (such as use of less effective contraception). Note that the absolute risk of serious events with hormonal contraceptives is small for most women.
Be aware of cultural, literacy, and developmental issues that may affect a woman’s perception of risk.
When providing information about risk, be sure to discuss risk reduction strategies as well.
Use multiple forms of numerical data to explain risk.
Do not present relative risk alone. Present the absolute risk as well.
Be aware of framing effects.
Use risk comparisons with care.
Ensure that you have multiple, complementary tools available for risk communication.
Tailor the information provided to the woman’s needs and wants; very few women will need to hear or see all possible risk examples. Discussion of risks can be expanded or contracted, as appropriate to each woman.
Decision aids can be helpful in communications about risk. One such aid suggests that providers use a four-step model for risk communication.²

Providers should:

Clarify the situation or decision: What does the patient need?
Provide information on both the benefits and the risks associated with the treatment or intervention under discussion.
Clarify the patient’s values: What benefits or risks will be most salient based on the patient’s needs and desires?
Screen for implementation problems: Will it be difficult for the patient to access or use the treatment? See the case study for an illustration of the use of this decision aid.

In addition to conversations about risk prompted by individual patients, providers may need to communicate about alarmist media reports on hormonal contraceptives. The first step for providers to take in developing a response to such reports is to gather information from reputable sources. These may include the American College of Obstetricians and Gynecologists, ARHP, the Centers for Disease Control and Prevention, Planned Parenthood Federation of America, and other advisory organizations. Searching for and reviewing relevant editorials in peer-reviewed journals also can be helpful. Providers can use this information to help patients gain perspective on the degree of risk reported in the media by highlighting the absolute risk or by comparing the reported risk with truly relevant alternatives.

References

Halpern V, Grimes DA, Lopez L, Gallo MF. Strategies to improve adherence and acceptability of hormonal methods of contraception. The Cochrane Database of Systematic Reviews. 2006; Issue 1. Art. No.: CD004317.pub2. DOI: 10.1002/14651858.CD004317.pub2.
O’Connor A, Legare F, Stacey D. Risk communication in practice: the contribution of decision aids. BMJ. 2003;327:736-40.