Contraception
Terri D’Arrigo
CDC’s 2024 U.S. Selected Practice Recommendations of Contraceptive Use (SPR), published in Morbidity and Mortality Weekly Report on August 8, 2024, contains several changes from the 2016 SPR, especially with respect to the placement of intrauterine devices (IUDs).
Previously, CDC stated that misoprostol is not recommended for routine use, but lidocaine as a paracervical block might be helpful for reducing patient pain. In 2024, CDC added topical lidocaine as an intervention to reduce pain.
The new recommendations are as follows:
- Misoprostol is not recommended for routine use for IUD placement. Misoprostol might be useful in selected circumstances (e.g., in patients with a recent failed placement).
- Lidocaine (paracervical block or topical) for IUD placement might be useful for reducing patient pain.
“These are welcome changes, as some of us who practice [in reproductive health] have been talking about things like pain management during IUD insertion because it hasn’t been part of standard care,” said Veronica Vernon, PharmD, assistant professor and vice chair of pharmacy practice at Butler University College of Pharmacy and Health Sciences in Indianapolis. “We as pharmacists can always help educate patients on that and help patients advocate for themselves and ask for pain management.”
Vernon said that pharmacists should be aware of the regulations regarding misoprostol in their state.
“Misoprostol is more regulated than it used to be because of its use in medical abortion,” she said. “If you live in a state where medical abortion is prohibited, remember that misoprostol has other indications, like certain cases for IUD placement.”
Pharmacists who fill prescriptions for IUDs can also speak to the prescriber about offering pain management and ask if the health professional is planning to do a paracervical block with lidocaine, Vernon added.
Possible counseling points
Other changes where pharmacists may offer insight refer to the use of implants and include:
- Before an implant is placed, counsel patients that they may experience changes in bleeding patterns or not get their periods at all and that these changes may or may not decrease over time while the implant is still in use.
- Consider any underlying health conditions, such as interactions with other medications, STIs, pregnancy, thyroid disorders, or new pathologic uterine conditions (e.g., polyps or fibroids).
- Explore patient goals, including continued implant use (with or without treatment for bleeding irregularities) or implant removal.
- Offer counseling on treatments that may improve bleeding irregularities and align with patient goals.
- Reassure patients that amenorrhea does not require any medical treatment.
- Offer counseling on alternative contraceptive methods if the patient wants to have the implant removed.
With the changes, CDC also recommended that patients who use testosterone should be counseled that it may not prevent pregnancy among transgender, gender diverse, and nonbinary persons with a uterus who are using testosterone.
“[Patients who take testosterone] may want to use nonhormonal methods, especially methods that don’t have estrogen so it doesn’t affect the testosterone or any other hormones they may be taking. Or they may prefer progestin without estrogen. It depends on the patient,” Vernon said. “In contraception care, we have to focus on what is going to work for the patient and their goals and needs, taking into account any medications they are taking that may or may not make them a candidate for certain options.”
The final major change is that self-administered S.C. depot medroxyprogesterone acetate should be made available as an additional approach to deliver injectable contraception.
According to Kathryn M. Curtis, PhD, the SPR, along with the U.S. Medical Eligibility Criteria for Contraceptive Use, 2024, can support health care professionals, including pharmacists, in improving access to contraception by using evidence-based eligibility criteria and practice recommendations when they work with patients on contraceptive decision-making.
“The goal of these recommendations is to remove unnecessary medical barriers to accessing and using contraception,” said Curtis who is an epidemiologist in the Division of Reproductive Health at CDC’s National Center for Chronic Disease Prevention and Health Promotion. “Shared decision-making and person-centered approaches recognize the expertise of both the health care provider and the patient. Health care providers can support the contraceptive needs of all persons by using a person-centered framework and recognizing the many factors that influence individual decision-making about contraception.” ■