January 26, 2023

How One Patient Regained Her Autonomy with FABMs

By: Claudia Silva

Editor’s Note:  This week we share an interview written by Claudia Silva, a FACTS Ambassador, and former FACTS elective student. She spoke with a woman who used a few different methods of birth control before finally discovering fertility awareness-based methods. The piece highlights the importance of providing women with accurate information about all family planning options and respecting patient autonomy. Research shows actively engaging patients in the decision-making process can increase the effectiveness of the treatment selected. [1], [2] FACTS offers a shared decision-making tool that clinicians can use to aid patients in selecting an effective FABM [3].

Choosing a method of family planning can feel overwhelming and intimidating because there are so many options to consider and side effects to investigate. Women and couples may not feel confident making the decision alone and might visit a physician to discuss which method is best for them. What if the option they thought was best does not seem to work or generates a host of harmful side effects? What if their clinician tells them they can’t find a problem and seems to dismiss their side effects and concerns as “normal” – the woman may ask: “Is there something wrong with me?”

These questions may commonly arise when the chosen method does not work as expected. My conversation with Diana* delves into the experience of a woman who tried just about everything before discovering fertility awareness-based methods (FABMs). These family planning methods changed her life, both personally and professionally.

“These fertility awareness-based methods of family planning changed her life, both  personally and professionally.”

Diana’s first experience with contraceptives was emergency contraception. She then switched to combined hormonal contraceptives, or oral contraceptive pills (OCPs), which she used for seven years without any complications. For a long time, she was interested in trying a hormonal intrauterine device (IUD) but could not afford it. She then heard about a research study that provided eligible participants with free IUD insertion. She was excited to finally use the method she wanted, but, unfortunately, she described this experience as the most painful thing to ever happen to her. From the moment the IUD was inserted, she knew it was not the method for her. Following insertion, the pain and bleeding were so intense doctors feared her uterus had ruptured. Despite the initial experience, Diana was not ready to give up on this method; she had waited so long for the opportunity that she decided to give it some time.

In the coming months, Diana experienced multiple yeast infections, constant breast tenderness, headaches, and skin irritation. As part of the study, Diana visited the clinic every month for a checkup, and she counted down the days until that first appointment to have her IUD removed. When she described her symptoms, she was told to wait a little longer, and that it would improve. For six months, she would insist that it did not feel right and that she would like it removed, but each time she was met with the same explanation.  During the six-month visit, the clinician verified the IUD strings were aligned correctly. Regardless, Diana insisted the IUD be removed, but was instead given instructions to schedule a separate appointment for the removal. She felt miserable and that her concerns had not been taken seriously. Something was truly wrong, but nobody seemed to be bothered. That same day, she went to a different clinic and had the IUD removed.

Grateful to have found these methods, Diana reached out to the professor who had first taught her about FABMs. She described her experience and how it inspired her career. The professor became her mentor, and she was able to work on an FABMs research project. This was just the beginning of her journey with FABMs. She has since collaborated in the development of the Dynamic Optimal Timing (DOT) Method, traveled the country and the world to educate others about FABMs, and continued learning about new research in fertility awareness. In her personal life, Diana used FABMs to plan her pregnancy and continued to use it postpartum.

“The ideal family-planning method differs for different people… and it is important to respect the autonomy of every patient.”

Diana’s experience is a testament to the reality that the ideal family-planning method differs for different people. There is a myriad of options to choose from, and it is important to respect the autonomy of every patient. Patient choice should not be limited to what works for most of the population, but rather, patients should be presented with all of the available options,  including counseling on the risks and benefits of the various methods available. In addition, if they request to change their method, their choice should be respected.

Speaking with Diana made me realize the danger of our society’s fixation on long-acting reversible contraceptives (LARCs). This approach does not work for everyone, and clinicians often fail to provide women and couples with the full spectrum of other effective, evidence-based methods of family planning, including FABMs — which are the only family planning methods with no medical side effects.[4]  Diana experienced side effects that interfered with her day-to-day life but, because they were not life-threatening, her symptoms were disregarded as a normal response. Despite these obstacles, Diana had the advantage of knowing about FABMs. Not every patient has that same opportunity.

“Clinicians often fail to provide women and couples with the full spectrum of other effective, evidence-based methods of family planning, including FABMs — which are the only family planning methods with no medical side effects.”

Being a minority myself, I have learned not to generalize based on what has been proven to work for the majority. Instead, I listen to my patients and ensure they feel heard. Taking the FACTS elective has prepared me to be a better physician. I look forward to guiding my patients to informed decisions based on their preferences and hope they feel comfortable expressing themselves if they change their mind.

*Name has been changed to respect the privacy of the interviewee, and all information is shared with permission.

Sources

[1] Stacey D, Légaré F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017;4(4):CD001431. Published 2017 Apr 12. doi:10.1002/14651858.CD001431.pub5

[2] Laurance J, Henderson S, Howitt PJ, et al. Patient engagement: four case studies that highlight the potential for improved health outcomes and reduced costs. Health Aff (Millwood). 2014;33(9):1627-1634. doi:10.1377/hlthaff.2014.0375

[3] Duane M, Martinez V, Berry M, Manhart M. “Evaluation of Fertility Awareness-Based Shared Decision-Making Tool Part 1:  Study Design and Impact on Clinician Knowledge,” PEC Innovations, Vol 1, Dec 2022.

[4] Festin MPR, Kiariea J, Solo J, Spieler J, Malarcher S, Van Look PFA, Temmerman M. Moving towards the goals of FP2020 — classifying the goals of contraception. Contraception. 2016; 94: 289-294.