Some physicians may not address the topic, thinking that patients will ask if they have questions.9 Some evidence suggests that patients often desire such counseling, but often rely on their doctors to bring up the subject.12 Some patients may be interested but simply forget to ask, or they may not realize how relevant the topic is to their rheumatologic disease.9
Dr. Birru Talabi recommends patient-centered, nonjudgmental, open-ended questions when discussing family planning. She suggests that the following phrasing may work well: “Tell me a bit about your life and where pregnancy fits in your plans. I ask because I’d like to work with you to try to make sure things turn out the way you’d like them to.”
She notes that many women aren’t clear about their reproductive goals. She advocates empowering women to come up with a pregnancy plan if they do want to become pregnant or formulate a contraceptive plan if they do not.
She also warns not to make assumptions about who needs family planning conversations. “I think we should have these conversations with everybody, all women of reproductive age, no matter what their sexual orientation is, no matter their age, whether or not they are married and whether or not they are on Medicaid, don’t have insurance or don’t have a job.” She notes that even women with severe disease may be having sex and at risk of unintended pregnancy. These women may be the least likely to get contraceptive counseling, though they are the ones who may most be in need of it.3
Birth Control Methods
Dr. Sammaritano emphasizes that patients and physicians must realize that not all contraceptive options are equally effective. She notes, “The choice of contraception should be based on what is most effective and what is safe and acceptable for each individual patient.” She adds, “Long-acting reversible contraceptives—IUDs and subdermal implants—are the most effective, and they should be encouraged when possible.” When picking a method, clinicians and patients should also consider reversibility of the method, any noncontraceptive benefits, side effects, costs and convenience of the method.2
There are relatively few true birth control contraindications for women with rheumatic disease. Because of the increased risk of thrombosis, certain populations should avoid combined contraceptives containing estrogen. These include women with uncontrolled lupus or women with increased risk of thrombosis due to positive antiphospholipid antibody (aPL), due to history of vasculitis, nephritis or thrombosis, or from other factors.6
