Holistic Birth Control Follow-Up Care in Young Adult Women
Gina Calo, University of St. Joseph
Abstract: Holistic care encompasses the treatment of the whole person, taking into account mental, social and physical factors. The purpose of this study was to assess the extent to which young adult females are given holistic follow-up care after being prescribed hormonal birth control. This retrospective study utilized a convenience sample of 65 eligible participants. Eligibility was acquired if participants were biological females between the ages of 18 and 25 who currently use, or historically have used, hormonal birth control methods. The questionnaire contained 23 closed-ended responses and 1 optional open-ended response. Survey information was obtained through the use of an electronic online tool, and all responses remained confidential with no personal identifiers from the participants being requested. Descriptive statistics were used to analyze the data. IRB approval was obtained from the University of Saint Joseph. Most participants (63.1%) reported not being confident that they receive holistic follow-up care after being prescribed hormonal contraceptives. Most participants who have changed hormonal birth control due to unfavorable side effects (68.4%) reported not being completely aware about the possibility prior to beginning the regimen. There is evidence to suggest a substantial gap in the current holistic standard of care for patients prescribed hormonal contraceptives. Those who prescribe contraceptives have a unique opportunity to support women through their clinical practices. Their efforts can have a meaningful impact on the future emotional and physical health of these patients. Future research should be conducted to identify and understand the reasons for these inconsistencies.
Introduction
Hormonal contraceptives are birth control methods which contain progestin and/or estrogen hormones to act on the endocrine system and prevent unwanted pregnancies. Examples of hormonal contraceptives include pills, patches, vaginal rings, shots, upper arm implants, and intrauterine devices (IUDs). According to the Centers for Disease Control and Prevention, it is recommended that those who prescribe hormonal contraceptives advise their patients to return at any time to discuss side effects or other problems, or if they want to change the method being used (Centers for Disease Control and Prevention, 2017). However, in the same paragraph they also explain that no routine follow-up visit is required and that no evidence currently exists regarding whether a routine follow-up visit after initiating combined hormonal contraceptives improves correct or continued use (Centers for Disease Control and Prevention, 2017). The only mention of side effects from hormonal contraceptives on the CDC’s website discusses unscheduled spotting or bleeding during the first 3-6 months of use (Centers for Disease Control and Prevention, 2017). No mental health assessments are discussed, as the focus is widely placed on physical symptoms.
Further research on this topic found a peer-reviewed article titled The Effect of Follow-Up Visits or Contacts after Contraceptive Initiation on Method Continuation and Correct Use. Results of this systematic analysis found that few studies investigate the effectiveness of follow-up appointments (Steenland et. al, 2012). This study concluded that it is difficult to determine what effect, if any, follow-up visits or contacts have on contraceptive method continuation or correct use (Steenland et. al, 2012).
Holistic care encompasses the treatment of the whole person, taking into account mental and social factors, rather than just the physical symptoms of a disease or treatment (Oxford University Press, 2022). The American Academy of Family Physicians recommends that documentation of visits for contraception should include patient understanding of use, benefits, risks, and an individualized follow-up plan (Klein et. al, 2015). A literature search was conducted using CINAHL and Pubmed journal databases. Searches used the following keywords: contraception, birth control, hormonal, holistic, mental health, side effects, follow-up, satisfaction. Searches were limited to include only peer-reviewed pieces published within the past 20 years. The results yielded no studies which assess the extent of follow-up care provided to women who are prescribed hormonal contraceptives. No published information currently exists evaluating the efficacy of this widely accepted standard of follow-up care.
The purpose of this study is to determine the extent to which young adult females feel they have received holistic birth control follow-up care. The results of this study may also be used to further assess the impact of this holistic follow-up care on correct or continued use of hormonal birth control. There is a significant lack of published research regarding the extent and importance of holistic follow-up care for women after being prescribed hormonal contraceptives. This study aims to identify a gap in current women’s health practices and provide baseline data for further improvement of contraceptive follow-up care.
Methods
A voluntary and anonymous electronic questionnaire was created. The questionnaire was composed of 23 multiple choice/select-all-that-apply items as well as 1 optional open-ended response for a total of 24 items. Respondents were not able to submit their survey unless all multiple choice/select-all-that-apply items were answered.
The study was approved by the University of Saint Joseph’s Institutional Review Board (IRB Protocol Number: 21_039) before being opened to the public. Participants were recruited through public social media outlets and provided a digital informed consent document as well as a list of mental health resources if they felt they needed it throughout the survey. Informed consent was obtained by all participants prior to starting the survey. Participants were notified of the requirements for eligibility: biological females between the ages of 18 and 25 that are currently or previously have been on hormonal contraceptives and have agreed to participate in the study. The questionnaire was opened to the public for two weeks between 10/19/2021 and 11/02/2021.
Results
Sixty-seven people (n=67) responded to the voluntary survey. Sixty-five of those responses (n=65) met the inclusion criteria for this study (table 1). One respondent did not meet the age requirement, and another respondent did not consent to participation in the study.
The majority of participants (73.8%) reported being prescribed hormonal contraceptives from their gynecologist (figure 1). 21.5% of participants do not have regular visits, at least once yearly, for their hormonal contraceptives. More than half of the participants (55.4%) have been prescribed 2 or more different hormonal contraceptives (figure 2) with the majority contraceptive method being hormonal pills (figure 3). The average length of participants taking hormonal contraceptives was over 4 years (figure 4).
Most participants reported physical side effects (92.3%) and mood changes (78.5%) while on hormonal contraceptives (figure 5). Almost half of participants (43.1%) reported changing their hormonal contraceptive at least once due to unfavorable side effects with the top three reasons for changing being weight gain (18.5%), irregular periods (16.9%), and mood changes (15.4%) (figure 6).
Many participants (68.4%) who have changed their hormonal birth control due to unfavorable side effects reported not being completely aware about the possibility of these side effects prior to beginning them (figure 7). Almost half of participants (46.2%) rated their providers poorly in education skills regarding possible hormonal contraceptive symptoms (figure 8).
Results indicated that 41.3% of participants who have had a follow-up visit after being prescribed hormonal contraceptives said that their prescribers ask about side effects experienced with their contraceptive at every visit (figure 9). Approximately half of this population said that their prescribers ask about their satisfaction with their hormonal contraceptive at every visit (50.8%) (figure 10) and that their providers address their emotional well-being at every appointment (49.2%) (figure 11). Most participants feel comfortable asking their providers questions regarding their hormonal contraceptive options (92.3%) and feel their provider is available for them when they need it (72.3%). Results showed that 20% of participants are considering changing their provider due to insufficient psychological follow-up care while another 17% of participants have already done so at least once for the same reason (figure 12).
The majority of participants (86.2%) believe women’s health appointments should be more frequent than once yearly. After being given a basic definition of holistic care, 49.2% of participants believe they have not received holistic follow-up care after being prescribed hormonal contraceptives, and an additional 13.8% of participants are not sure if they have. Only 36.9% of participants reported receiving holistic follow-up care after being prescribed hormonal contraceptives (figure 13). Eight participants chose to respond to the optional open-ended question by sharing their thoughts on hormonal contraceptive follow-up care (table 2).
Discussion
The results of this study indicate a need for improvement in holistic hormonal contraceptive care. The original purpose of this study was to investigate follow-up care associated with hormonal contraceptive use. However, the results also showed a gap in the initial education of potential side effects when hormonal birth control methods were prescribed. For example, the majority of participants (63%) are
not confident that they have received holistic follow-up care after being prescribed hormonal contraceptives (figure 13). In fact, 68.4% of participants who have changed birth control methods due to unfavorable side effects were not completely aware of the possibility of those side effects prior to beginning the regimen (figure 7). Although a portion of these respondents did report being “somewhat aware” of these side effects (44.7%), the goal is that all patients maintain a complete understanding of risks associated with hormonal contraceptives. Plus, 58.7% of
participants responded that their providers do not ask about side effects associated with their hormonal contraceptives at every visit (figure 9). Another 49.2% of participants responded that their providers do not ask about their satisfaction with their hormonal contraceptives at every visit (figure 10). Although the current standard of care is to assess mental and physical side effects for those patients prescribed hormonal contraceptives, the findings suggest that roughly half of providers are not doing so.
An overwhelming majority of participants (92.3%) reported feeling comfortable discussing birth control options with their providers. This is important to note, as patients do feel comfortable talking to their providers, but may not know what questions to ask them. The responsibility of having a discussion should not fall on the patient, but rather should be initiated by providers. Many patients do not know what questions to ask, or trust in their providers to offer up associated risks whenever applicable (Centers for Disease Control and Prevention, 2021). Those who prescribe birth control should become more effective at ensuring informed consent is obtained before the method is started. Informed consent continues to include options, potential risks, and common side effects (American Medical Association, 2022). Education on potential side effects should include both physical and mental symptoms in order to encompass true holistic care.
The results of this study also outline the lack of holistic care throughout contraceptive care management. Each patient’s emotional well-being should be discussed at every medical appointment, especially those which aim to evaluate the effectiveness of hormonal medications including contraceptives. Medical professionals including Dr. Sarah E. Hill agree that hormonal contraceptives have been
proven to cause an increase in anxiety and/or depression subsequently changing some patients’ overall personalities (Hill, 2020). Therefore, hormonal contraceptives should not be regarded as working effectively by simply preventing unwanted pregnancies in women. Rather, effectiveness should include an absence of unwanted side effects, including those of mental and emotional components, instead of solely physical symptoms.
The open-ended responses obtained in this study provided insight into the individual’s experiences with hormonal contraceptives. For example, a participant reflected on discontinuing their hormonal birth control method due to weight gain. This suggests that the respondent’s provider may not have educated them on the possibility of gaining weight prior to starting the regimen. It also suggests that the provider may not have suggested alternative contraceptive or lifestyle options when their patient discussed the unfavorable weight gain. Similarly, responses from other participants further demonstrated the lack of individuals’ knowledge of symptoms to expect with their new birth control regimens. These responses also highlight the probable inefficiencies associated with follow-up care after being prescribed hormonal contraceptives.
In addition, more responses consider the type of provider prescribing hormonal contraceptives. Some participants suggested that female providers and/or gynecologists may provide more focused care than male providers or primary care physicians. Further research should be completed inquiring about the impact of prescriber type on patient contraceptive management and satisfaction.
Providers should inquire about each patient’s use (or lack thereof) of other contraceptive methods during holistic follow-up care, especially related to sexually transmitted infection (STI) prevention. Doing so may help providers to evaluate each patient’s current knowledge on safe sex practices. That information can be used to provide targeted education in order to best help each patient remain free of sexually transmitted infections and unwanted pregnancies. More specific questions pertaining to any follow-up care received should be asked in future repetitions of this study in order to best evaluate the extent of holistic care given to patients.
Further investigation should be done to better understand why some patients are not receiving hormonal contraceptive follow-up care from their providers. Future work on this topic may include studies inquiring about patient difficulties accessing or affording contraceptive medications as well as investigating how providers feel about holistic care in the clinical setting.
Limitations
This study is limited in that it does not inquire about the racial demographics of participants. Acquiring racial demographic information could have revealed less holistic follow-up care provided to minority populations. Future repetitions of this study should include other patient demographic questions such as race and primary language in order to investigate these disparities more deeply.
Additionally, the surveyed population could be broadened in future repetitions of this study. Participants were required to be between the ages of 18 and 25. However, nationwide contraceptive use increased with age from 37.2% among females 15-19 years old to 73.7% among females 40-49 years old (Centers for Disease Control and Prevention, 2019). Therefore, it should be considered that the age requirement be broadened in future repetitions of this study to include other populations such as middle-aged women. Doing so would more closely resemble natural populations and subsequently increase the sample size and reliability of the study.
This study is also limited in that it does not inquire about specific topics which are recommended to be discussed in follow-up care. The age of the surveyed population may increase the importance of holistic follow-up care from providers. Young adult women ages 18-25 years old may be at an increased risk for situations including domestic violence, sexual abuse, and sexual pressure. In fact, women ages 18-24 are 3-4 times more likely than women of any age to be victims of rape, attempted rape, or sexual assault (Rape, Abuse & Incest National Network, 2022) and generally experience the highest rates of intimate partner violence (Centers for Disease Control and Prevention, 2010). It is the role of the provider to ensure their patients are beginning hormonal contraceptives for their own personal desires, without pressure from others including sexual partners. Providers can offer resources for those experiencing partner violence or sexual pressure.
Conclusion
The purpose of this study was to investigate follow-up care with hormonal contraceptive use. Ultimately, only 36.9% of eligible participants feel confident that they have received holistic follow-up care after being prescribed hormonal contraceptives. The results reveal that patients do feel comfortable having conversations with their providers regarding hormonal contraceptives and associated mental and physical side effects. This study has also found that an overwhelming number of women (86.2%) want to be seen more frequently than once yearly to discuss topics such as side effects, education, and mental health. Women are lacking the informative and emotional support aspects from their contraceptive providers. The results of this study demonstrate the importance of holistic follow-up care in the women’s health setting, and the gap that currently exists. It is recommended that current providers of hormonal contraceptives utilize the results of this study as a reminder to assess their own practices. Self-reflection is the only technique that will assist in widespread improvement of holistic follow-up care. More consistent and thorough follow-up procedures should be implemented on a national scale when prescribing hormonal contraceptives.
References
American Medical Association. (2022). Informed Consent. Ethics. Retrieved 2022, from https://www.ama-assn.org/delivering-care/ethics/informed-consent
Centers for Disease Control and Prevention. (2017, February 1). Combined Hormonal Contraceptives. CDC Contraceptive Guidance for Health Care Providers. Retrieved 2022, from https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/combined.html
Centers for Disease Control and Prevention. (2019, February 14). Current Contraceptive Status Among Women Aged 15–49: United States, 2015–2017. National Center for Health
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Centers for Disease Control and Prevention, Good Questions for Good Health (2021).
Centers for Disease Control and Prevention. (2010). National Intimate Partner and Sexual Violence Survey. 2010 Summary Report. Retrieved 2022, from https://www.cdc.gov/ViolencePrevention/pdf/NISVS_Report2010-a.pdf
Hill, S. E. (2020, March 26). Feel Like a Different Person on the Pill? Here's How it Affects Your Mood. Ideas.Ted.com. Retrieved 2022, from https://ideas.ted.com/how-the-birth-control-pill-affects-your-mood/
Klein, D. A., Arnold, J. J., & Reese, E. S. (2015, May 1). Provision of Contraception: Key Recommendations from the CDC. Retrieved 2022, from https://www.aafp.org/afp/2015/0501/p625.html
Oxford University Press. (2022). Holistic. Oxford Advanced Learner's Dictionary. Retrieved 2022, from https://www.oxfordlearnersdictionaries.com/us/definition/english/holistic
Rape, Abuse & Incest National Network. (2022). Victims of Sexual Violence: Statistics. RAINN. Retrieved 2022, from https://www.rainn.org/statistics/victims-sexual-violence
Steenland, M. W., Zapata, L. B., Brahmi, D., Marchbanks, P. A., & Curtis, K. M. (2012). The Effect of Follow-Up Visits or Contacts After Contraceptive Initiation on Method Continuation and Correct Use. NCBI - Contraception. https://doi.org/10.1016/j.contraception.2012.09.018