Can you give Depo or Nexplanon on the day of a medication abortion?

Mifepristone and misoprostol are commonly used for medication abortion in the United States, up to 70 days estimated gestational age. Currently, the WHO recommends giving any hormonal contraception, including progesterone implants or injections, on the day of mifepristone administration. [5] However, there is a theoretical concern that starting progesterone contraception on the day of mifepristone administration could decrease the success rate of the medication abortion. Mifepristone binds to progesterone receptors; its affinity for the receptor is higher than that of progesterone itself. Administering progesterone in the depot or implant form at the same time could potentially out-compete mifepristone and decrease its efficacy.  

A small 2013 study primarily examined satisfaction with the implant on the day of mifepristone; a secondary outcome was a successful abortion. Four out of 20 participants were lost to follow-up, but all 16 who did follow-up had successful medication abortions with no further intervention needed. [1] Another 2015 study (that has to date only been published in abstracted form) confirms the same outcome. Nearly 500 patients were randomized to receive the implant on the day of mifepristone or after the abortion was confirmed complete. There were no differences in failure of medication abortion between groups. Both were low (< 4%) and consistent with previously published research. [2] A similar European study confirmed the same, with a non-significant difference (p= 0.47) in abortion success between women who opted for same day etonogestrel implant placement vs delayed placement. [3]

To date there is only one published study looking at outcomes of depot medroxyprogesterone given on the day of mifepristone for medication abortion. Their primary outcome was again patient satisfaction, but they did evaluate success of abortion. 17 of 20 patients successfully completed their abortions. Two had incomplete abortions and one had a treatment failure; these three underwent surgical evacuation of the uterus. This data suggests against giving depot medroxyprogesterone on the day of the mifepristone; however, it is unclear if the two incomplete abortions would have completed on their own if given longer than the 7-day follow-up period. [4] 

With this limited data, it seems likely that giving progesterone contraception in the form of the current implant on the day of mifepristone for medication abortion will not alter the efficacy of the mifepristone abortion. This should be considered especially in low-resource areas or settings where patients are frequently lost to follow-up. It is probably prudent to wait for larger studies, however, to give depot medroxyprogesterone on the day of medication abortion.

References

1. Sonalkar S, Hou M, Borgatta L. Administration of the etonogestrel contraceptive implant on the day of mifepristone for medical abortion: a pilot study. Contraception, November 201; Volume 88, Pages 671-673.

2. Raymond EG, Weaver MA, Tan YL et al. Medical abortion outcomes following quickstart of contraceptive implants. Contraception, May 2015; Volume 91, issue 2, Page 429. Abstract only.

3. Barros Pereira I, Carvalho RM, Graca LM. Intra-abortion contraception with etonogestrel subdermal implant. European Journal of Obstetrics & Gynecology and Reproductive Biology, February 2015; Volume 185, pages 33-55

4. Sonalkar S, McClusky J, Hou M, Borgatta L. Administration of depot medroxyprogesterone acetate on the day of mifepristone for medical abortion: a pilot study. Contraception, February 2014; Volume 91, issue 2, Page 174-177.

5. WHO. (2012). Safe abortion: Technical and policy guidance for health systems (2nd ed). Geneva: World Health Organization.

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Insights into abortion and miscarriage care is a publication of the Reproductive Health Access Project and Innovating Education in Reproductive Health, a project of the Bixby Center for Global Reproductive Health, UCSF.
© 2015 Reproductive Health Access Project and Innovating Education in Reproductive Health.
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Animated Uterine Aspiration Simulation Workshop

This workshop is intended to teach the steps of first-trimester abortion using an animated video of the procedure.

This animation is an excellent introduction to the first-trimester abortion for pre-clinical medical students and can be used in conjunction with a Papaya Workshop to add a realistic element to the fruit model.

Learning Objectives:

By the end of this workshop, learners will be able to:

  • Identify the two types of pain control that can be used with tenaculum placement
    • Identify the location and depth of a intra cervical block
    • Identify the location and depth of a para cervical block injections
  • Determine what size dilator to use for a first-trimester abortion based on gestational age
  • Identify two methods used to preform first-trimester procedures

How to use these materials:

Begin by reviewing the anatomy of the of the uterus. If time allows, you can use the Introduction and Anatomy section or the Papaya Workshop Facilitation Guide or play the Introduction and Anatomy video from papayaworkshop.org. Next review the pain control options for first trimester abortion or ask students to review the Pain with Uterine Aspiration video lecture before the workshop.

Health Disparities in Abortion and Family Planning Workshop

This workshop is intended to teach about differences in abortion rates across racial and socioeconomic groups.

Workshop Objectives:

At the end of the workshop, learns will:

  • Understand the potential for a judgmental reaction to interfere with the patient-doctor relationship.
  • Identify strategies for maintaining a positive relationship with patients who make decisions about health care with which you may disagree.
  • Acknowledge implicit bias and develop strategies to minimize its interference with patient-doctor relationship.

How to use these materials:

Click here to download the Health Disparities in Family Planning and Abortion Workshop Facilitation Guide and Health Disparities in Family Planning and Abortion Learner Handout.

Activity 1: Applying a public health approach to abortion.

Video Lecture Learning objectives:

By the end of the video lecture, learners will be able to:

  • Identify primary and secondary prevention strategies to reduce disparities in abortion.
  • Describe 3 structural causes for disparities in unintended pregnancy and abortion access.
  • Describe the limitations of the public health approach to addressing disparities in abortion.

Case Study: 1

Directions: At time marker around 8:20 pause video lecture and break learners into groups of 3-4. Read the case aloud to the group and ask them to discuss the questions listed below.

Sarah is a 23 year old presents to the family planning clinic after an abortion. This was her 6th abortion. During the counseling session, when you ask her if she would like to discuss birth control at this visit she replies, “No” and makes it clear she does not wish to discuss this further.

  1. How would you proceed with this counseling session?
  2. What are some of the reasons Sarah would not wish to discuss contraception today?
  3. Are there aspects of the patient’s life (current or past situations, experiences, beliefs, feelings, values, environment) that may explain or help you understand their behaviors?
  4. What, if any, feelings do you have about Sarah’s decision?

Facilitation Notes: Teaching Points Case 1

  • You may have a desire to encourage contraceptive use in this high risk patient.
  • However, this can conflict with a focus on providing the care that is consistent with her preferences.
  • Maintaining a continuing relationship with patient may be best means of helping her meet her family planning needs.
  • Recognize that patients may prefer to risk pregnancy rather than use a method that is not acceptable to them.

Case Study 2

Directions: At time marker 16:00 pause video lecture and return to the larger group to read case number 2 aloud. Ask learners to return to their small groups to discuss the questions below.

Tania is 22 years old and presents at the clinic at 23 weeks. She is thoughtful and introspective. Her situation is complicated by the fact that she is losing her housing shortly and expects to be homeless. Tania grew up primarily in foster care. Neither her biological or foster families are willing to house her to continue the pregnancy. She has moral conflict with abortion and also desires to parent at this time.

  1. What are some things that you initially can say to Tania to establish rapport?
  2. How can you tactfully explore her moral conflict with abortion?
  3. Demonstrate how you would work with Tania to facilitate continuing this pregnancy given the publicly available resources in your community.
  4. What, if any, feelings do you have about Tania’s decision?

Facilitation Notes: Teaching Points Case 2

  • One pregnancy decision is not “more moral” than another; she is a good person making a moral decision for herself.
  • There is no knowledge that you possess about the answer to her dilemma that she does not.
  • Create a space where patients feel that it is safe to ask questions.
  • Building rapport with patients starts with establishing trust that you are giving them accurate unbiased information and don’t have an agenda.
  • Establish an environment free of stigma around pregnancy decisions by modeling unbiased language.

Activity 2: Health Disparities in Family Planning

Video Lecture Learning objectives

By the end of the video lecture, learners will be able to:

  • Define health disparities in family planning and describe examples of these disparities.
  • Describe the etiologies of disparities in family planning.
  • Describe ways in which their own biases can further perpetuate health disparities.

Directions: At time marker around 11:34 pause lecture and break learners into groups of 3-4.

Case study 3:

Michelle is in your clinic for discussion of vaginitis. After addressing her concerns you also take the time to discuss contraception. She relates to you that she has a partner for the past year and is unsure about whether she wants to be pregnant soon and but for now wants to continue with condom use. She tells you she graduated from high school and is currently working in a clothing store.

You feel the instinct to discuss different forms of contraception, specifically LARC methods. You try to start a conversation about contraception by discussing the efficacy of LARC and are immediately met with resistance.

  1. What are you assuming about Michelle’s life circumstances?
  2. Why might Michelle not want to use LARC?
  3. How can a providers values, beliefs, and bias effect patient-centered care?
  4. What, if any, feelings do you have about Michelle’s decision?

Facilitation Notes: Teaching Points Case 3

  • Patient preferences may stem from community, personal, family history of reproductive abuse or coercion.
  • Implicit attitudes affect verbal communication and non-verbal behavior (eye contact, indicators of friendliness).
  • When verbal and non-verbal do not match, patients rely on non-verbal cues believing verbal was not sincere.
  • Building rapport with patients greatly improves outcomes.
  • Studies show that patients who perceive their providers as kind and nonjudgmental are more likely to:
    • be satisfied
    • follow treatment plans
    • return for follow-up
    • take better care of themselves overall

Abortion after the First Trimester

Facilitator Guide with Quiz

Learning Objectives:

By the end of the session, learners will be able to:

  • State the proportion of abortions that take place after the first trimester in the US
  • Identify common reasons why women have abortions after the first trimester
  • Describe the unique challenges for women seeking abortion after the first trimester

Click here to download Abortion after the First Trimester Teaching Guide (pdf)

Flipped classroom video companion guides include learning objectives suggested readings; teaching points, discussion questions, and lesson plans.

Using Bedsider As a Teaching Tool with Medical Students

Many clinicians use Bedsider to help patients decide which method of contraception best fits their lifestyle. Bedsider is a free birth control support network that is dedicated to helping women stick with a method. Bedsider can be integrated into clinical practice in a variety of ways: contraceptive shared decision-making, and post-abortion contraceptive counseling, and birth control education. At UCSF we have also incorporated Bedsider into didactic teaching.

Real Stories

Real stories videos depict short interviews with young people about what method they or their partner use, and why. Patients have strong and diverse preferences about contraceptive methods; the best choice should reflect the patient’s values, and preferences, not those of the provider.

These videos can serve as the foundation for a small group activity that focuses on contraceptive counseling within a shared decision-making framework.

Before the small group activity, review key points of shared-decision making with learners. Key points can be found in our blog on Improving Contraceptive Counseling through a Shared Decision Making Approach: A New Medical Curriculum.

Break learners into groups of 2-3 and have them use this interactive tool, developed with Medical Students For Choice, to practice active listening in contraceptive counseling.

Have learners:

  1. Watch the Real Stories video and respond to comments heard in the video. For example, learners should address concerns about side effects without undermining a patients preferred method in favor of one with higher effectiveness.
  2. Take turns providing non-biased medically accurate information about the method discussed in the video. Learners can look up evidence-based information in the “Methods” section of Bedsider.
  3. Practice answering common patient questions using straightforward language. Refer to Bedsider’s comprehensive list of questions submitted by real people to get an idea of what kind of questions patients commonly ask and find the answers to questions that might not appear in standard medical curricula. Answers are written in colloquial language that is easy to understand.

Bedsider is a resource for educators and learners as well as for individuals seeking information about contraceptive methods. Using Bedsider’s Real Stories videos and the accompanying information can add a hands-on element to didactic teaching about contraception.