"We broke up. I don't need birth control." I hear this from many of my heterosexual patients, particularly younger ones. Or more pointedly, "Well, I'm never having sex again." Famous last words.

In these types of situations, I used to think, If she changes her mind, hopefully she'll come back to see me. Framed this way, contraception is reactive: if you're not currently having sex, why worry about contraception? Instead, I've started reframing contraception in terms of empowerment.

Contraception is power

Using contraception should not be reactionary. It should have nothing to do with this guy or even this relationship. I hope that my patients do not get pregnant until they are ready. Instead of the default position being I will get pregnant unless I do something to prevent it, I want my patients to be able to say "I won't get pregnant until I am ready to get pregnant." This is the power of contraception used consistently and correctly. Particularly powerful contraceptives are the [long-acting reversible contraceptive (LARC) methods IUDs and the implant. LARC methods can help empower patients by removing common barriers to consistent use of other methods: patients don't have to remember whether they took the pill today or yesterday, when they need a refill, when the next shot is due, or when to swap the next patch or ring.

Contraception is about her, not him

When I talk to my patients, I ask them if they’re sexually active with men, women or both. For those who are at risk of pregnancy, I bring up IUDs and the implant. (Oftentimes I bring up these methods to patients who are not at risk of pregnancy, but thats a different conversation.)

Male partners can contribute to contraception in a number of different ways:

• He can wear condoms;
• He can help cover the costs of contraception, which remain patchy despite the ACA requirement for birth control coverage without out-of-pocket costs;
• He can educate himself about contraceptives and support his partner in using her method of choice.

But ultimately, contraception is the woman’s choice, and she can use a method without telling anyone else about it.

Resolving contraceptive ambivalence

Sometimes patients aren’t ready to commit to contraception. In that case, I use reproductive life planning questions and techniques from motivational interviewing. I ask, “How would you feel if you became pregnant?” This usually leads to some follow-up questions, especially when a patient reacts with dread. I try to show that the default can be automatic protection against pregnancy rather than: “If I decide to have sex, we can use condoms… Or maybe I’ll come back to the GYN and get something.” Sometimes it’s a revelation for a patient that she can be in control of her fertility.

Side effects or fringe benefits?

Most long-acting reversible methods are hormone-based. The levonorgestrel IUD (Mirena) has the effect of decreasing cramping and bleeding significantly. One in five women are amenorrheic at one year, and half don’t have any bleeding by year five. The implant has some irregular bleeding the first three months, but this largely goes away, and 10-20% of women will be amenorrheic with this method, too. Some patients love amenorrhea, especially when they have heavy or painful periods. For them, these “side effects” are actually benefits.

But can my patients afford it?

One of the biggest obstacles to contraception, especially the LARC methods, is their potentially high up-front cost. For a patient without health insurance, the IUD or subdermal implant can cost up to $1,200. The ACA requires that all new private health insurance plans cover contraception without out-of-pocket costs for patients. Most Medicaid programs cover LARC insertion and removal, and some academic medicine centers are able to provide free devices. It’s an injustice that a patient cannot get the contraceptive method she wants because of cost. If you have a patient who is having trouble getting her method covered, she can contact the National Women’s Law Center for help by calling 1-866-745-5487 or emailing coverher@nwlc.org. 

Contraception makes her strong, responsible

Because in the end, as I like to tell my patients, “You don't do it for him, you do it for you.”