Contraceptive Continuation

Continuation counselling aims to help patients keep using a method they want and to move quickly to another method when a method is not working for them. A large part of unintended pregnancy follows discontinuation without a replacement. Discontinuation counselling ensures that stopping is the patient's choice, safe, and followed by a plan.

Main reasons for discontinuation. Side effects (especially bleeding changes), fear of infertility or health risk, partner opposition, desire for pregnancy, stockouts and distance, and infrequent sex.

Principles.

• Ask about satisfaction at each visit and assess whether the method still meets the patient's needs.

• Treat side effects as causes for support and treatment, not as reasons to stop automatically.

• Allow removal or stopping on request at any time without conditions.

• Never leave a patient without protection when she is not seeking pregnancy.

Follow up. A review is reasonable at 3 months and then annually for pills, patch, ring and injectables; implants and IUDs need no routine follow up beyond the first return for problems or at replacement time, although a visit after the first menses or 3 to 6 weeks after IUD insertion is accepted.

Questions at each visit. Satisfaction with the method; bleeding pattern; side effects; missed pills or injections; new medical conditions or medicines; sexual activity and condom use; intention for pregnancy; any concerns.

Management of common side effects.

Return to fertility after stopping.

Persistent delay in return of fertility. Evaluate for tubal disease, ovulatory dysfunction, reduced ovarian reserve and male factors when pregnancy has not occurred after 12 months of regular unprotected sex, or 6 months at age over 35.

Handling a request to stop or remove.

• Ask the reason; offer treatment for problems and alternatives.

• Do not delay or refuse removal of an implant or IUD.

• If pregnancy is not wanted, provide another method on the same day.

• If pregnancy is wanted, stop the method, advise folic acid 400 micrograms orally daily from 1 month before conception, review chronic disease and medicines, and give return dates.

• For DMPA, tell the patient that conception may take up to a year or longer; if pregnancy is wanted soon, avoid starting DMPA.

After stopping. Provide condoms until the new method protects. Pill users who stop do not need a washout period before trying to conceive.

Stopping at menopause. Stop contraception after 12 months of amenorrhoea at age 50 or over, or after 24 months at age under 50, for non-hormonal methods. For hormonal methods that mask menses, switch to condoms or a copper IUD at age 50 to 55 and reassess. A copper IUD inserted at age 40 or over can remain until menopause. A levonorgestrel IUD inserted at age 45 or over can remain until menopause.

Common errors.

• Telling patients that amenorrhoea means abnormal accumulation of blood.

• Stopping a method for spotting without exclusion of pathology and a course of treatment.

• Delaying implant or IUD removal until the patient attends a specific clinic.

• Failing to provide a replacement method.

• Assuming that the pill must be stopped months before pregnancy.

Special groups. Adolescents have the highest rates of discontinuation; give a clear plan for switching. Patients on enzyme-inducing drugs need a method change rather than continuation of an unreliable one.

Referral and escalation. Refer for bleeding that persists after treatment, for removal difficulty (non-palpable implant, lost IUD strings), and for subfertility evaluation after the stated intervals.