General Considerations

It is unreasonable to assume that there is an ideal contraceptive method for each couple; more commonly, couples alternate among various methods over time. A number of general considerations can help to guide an individual (or couple) in the selection of an appropriate contraceptive method.

FREQUENCY OF SEXUAL INTERCOURSE. Couples who have frequent intercourse (arbitrarily defined as more than two to three episodes of intercourse per week) should consider the more continuous, non-coitusrelated methods of contraception: OCs, IUDs, implants, injectables, or if childbearing is completed, permanent sterilization. For less sexually active couples (those who have intercourse less than once per week), an episodic method, such as a barrier contraceptive, would provide protection without exposure to method-related risks at other times.

NUMBER OF SEXUAL PARTNERS. Individuals who have multiple sexual partners, or whose partners have other partners, should be advised to consider one or more barrier methods, with the dual purposes of protection against sexually transmitted infections (STIs) and prevention of pregnancy. For couples who desire an optimal degree of pregnancy prevention, a combined approach of a barrier method plus a highly effective contraceptive will compensate for the relatively high pregnancy rate associated with barrier methods. Additionally, women in this category should not wear an IUD, as the risk of pelvic inflammatory disease (PID) and tubal infertility in IUD wearers is increased significantly in women with multiple sexual partners. For couples who are involved in a mutually monogamous relationship, no method of reversible contraception, including the IUD, increases the risk of PID or tubal infertility.

USER ACCEPTABILITY. Personal attitudes regarding the acceptability of certain methods may influence the success of use. These include religious beliefs, which may preclude the use of "mechanical" and hormonal contraceptives; tolerance of "nuisance" side effects, such as breast changes and vaginal bleeding; willingness to touch the genitals (of self or partner); and aesthetic concerns, such as tolerance of the "messi-ness" of spermicidal creams and jellies.

MOTIVATION AND SELF-DISCIPLINE. The degree of motivation to avoid pregnancy has a strong impact upon the successful use of contraceptives. Women who contracept to delay pregnancy have a higher failure rate than those who are intent on pregnancy prevention. Self-discipline also must be assessed, as women who are highly motivated may do well with intercourse-related (barrier) methods, while individuals who are poorly motivated should choose continuous non-intercourse-related methods such as OCs, IUDs, implantable or injectable methods, or sterilization.

ACCESS TO MEDICAL CARE. Because of the risk of medical complications, certain methods should be used only on the condition of reasonable access to medical care. This concern centers mainly on IUDs and to a lesser extent, hormonal methods. Users of barrier methods, natural methods, and those who have been successfully surgically sterilized have a negligible risk of life-threatening method-related complications.

EFFECTIVENESS. Desire for high effectiveness versus willingness to accept a degree of risk of failure is a primary concern for many contraceptors. Those who insist upon a high degree of efficacy are best advised to use a combination OC (discussed below), an IUD, an implantable or injectable method, or sterilization. Alternatively, for individuals who will accept a higher method failure rate, coupled with an understanding that such failures will result in a choice between delivery and abortion, less effective methods, including barriers and natural methods, may be used.

SAFETY. Medical safety is a major concern for most contraceptors, and concerns regarding health risks are a major reason for discontinuation of use. Paradoxically, adolescents are more likely to avoid or prematurely discontinue contraceptives for fear of adverse health effects, yet they comprise the age group least likely to experience them. The risks associated with contraceptive use are dependent on the following four variables, with an example of each:

1. Age. The risk of arterial complications (adverse effect on the heart and blood vessels, e.g., heart attack) of OCs is age-related; this risk is greatly compounded by cigarette smoking.

2. Underlying medical conditions. Women with underlying cardiovascular risk factors (e.g., hypertension, glucose intolerance, hyperlipidemia, cigarette use) are more likely to experience myocardial infarction (heart attack) while using OCs.

3. Sexual behaviors. A pattern of multiple sexual partners increases the risk of STIs. In particular, IUD wearers would have a greater risk of PID resulting in primary tubal infertility (fallopian tubes blocked by scar tissue).

4. Method-specific risk. Complications are intrinsic to the method, regardless of age, health, and sexual behaviors. Examples include the risk of hepatic adenomas (liver tumors that are noncancerous but that may hemorrhage) in OC users; and pelvic actinomycosis (infection) in long-term IUD users.

A key component of contraceptive efficacy and safety resides in the quality and clarity of instruction and counseling given to the user. Initial instruction should include a description of the methods of contraception currently available, their relative effectiveness, the advantages and disadvantages of each method, and, if appropriate, a comparison of short- and long-term costs. Once a method has been chosen, instruction should center on method-specific advice, such as information regarding method use and danger signals that should be reported to the provider. If the individual will be learning the use of a relatively complex method, or one with an increased likelihood of side effects, it is prudent to provide a simple backup contraceptive method, such as condoms, should the user decide to abandon the initial method. Method-specific counseling should be supplemented with a written fact sheet or other instructional material at a reading and comprehension level appropriate to the individual. Finally, the user should be encouraged to telephone or visit the office of the provider, as necessary, for further advice or modification of contraceptive use.

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