By Melinda Young

The recommended ways of ruling out patient pregnancy before starting a new contraceptive include a pregnancy test, the date of the patient’s last unprotected sexual intercourse, and the patient’s symptoms. But there often are cases where it is difficult to rule out pregnancy.

The authors of a new study concluded that when medical providers cannot rely on standard practices for diagnosing a potential pregnancy, they might rely on anticipatory medicine by projecting possibilities.1

“Medical providers take this seriously and spend a lot of time ruling out pregnancy before contraception,” says Eliza Brown, MA, MPhil, researcher and doctoral candidate in sociology at New York University. “Ruling out pregnancy is often quite difficult, even if it seems like a preliminary step before moving on to determine the best mode of contraception. It might be too early to accurately use a urine pregnancy test.”

A provider may recommend emergency contraception for a patient soon after unprotected sex. “But for those who had unprotected sexual intercourse seven or eight days ago, the provider is in a bit of a tricky situation,” Brown explains. “It’s too late for emergency contraception and too early to accurately use a pregnancy test, but the patient still wants to go home with contraception. Providers lean on their theoretical knowledge about how pregnancy works.”

If a woman is pregnant and begins to take a contraceptive, it could pose a risk to her pregnancy. Then, because the woman is on hormonal birth control, she might not expect menstrual bleeding, so it could be months before she realizes she is pregnant, Brown explains.

“There might be a substantial period of time before they see a doctor about the pregnancy, and they might drink alcohol or have other behaviors they wouldn’t have if they knew they were pregnant,” Brown adds.

Anticipatory Medicine Possibilities

Using anticipatory medicine, clinicians can consider these possibilities:

  • If the patient wants an oral birth control method, there might be less concern about potential pregnancy than if the patient wanted a long-acting, reversible contraceptive (LARC), an implant, or injections, Brown says.
  • Providers could ask patients how they might feel if it turned out they were pregnant. “If they are interested in seeing if they really are pregnant because they’d be happy with pregnancy outcomes, then maybe they wouldn’t want to insert an IUD at that time,” Brown says. “That could be a point of decision.”
  • Providers could prescribe a birth control pill for two weeks and ask patients to take a second pregnancy test to confirm they are not pregnant.
  • Providers could defer contraception until a negative pregnancy test, but this would place the patients at risk of pregnancy if they continue to have unprotected sex.

“One of the interesting parts of the study’s findings is about what providers and patients make of patient reports,” Brown says. “For the most part, providers are putting a lot of trust in patients’ reports and making decisions based on their memory of whether they had sexual intercourse and when it occurred.”

Patients also report which protection they used (if any) and the length of their menstrual cycles. Providers base their decision on the information.

“But there are times when patients’ information might be interpreted differently by the provider and patient,” Brown explains. “Say the patient saw some vaginal bleeding, and say that is implantation bleeding.”

When patients report vaginal bleeding, providers need to rule out pregnancy as the cause, using some other criteria, such as whether the bleeding is lighter than the patient’s typical menstrual bleeding.

“Overall, providers and patients absolutely rely on one another,” Brown says. “Without having [certain] physical evidence, sometimes it’s difficult to come to a conclusion.”

When pregnancy is ruled out through a urine test, providers can begin discussing types of contraception. But if this is not possible, they need to rule out possibilities, she says.

“Providers can say, ‘Let’s talk about your cycle and the pull-out method,’” she adds. “It might be difficult to come to a resolution, so we can see how patients and providers will go back and forth to rule out pregnancy.”

Anticipatory medicine is a growing area of sociology and medicine in which medical care transitions to preventing and managing conditions that have not yet manifested, Brown says.

“Providers are in a situation where they need to project a diagnosis into the future,” Brown explains. “It’s unlike other areas, where there is a chance of XYZ happening, so let’s just wait and see later.”

Instead, providers want to make a decision that anticipates various possibilities. “This is so patients aren’t sent away without receiving the treatment they came in to seek in the first place,” Brown says. “You anticipate various scenarios and act according to what is the most likely scenario.”

Look Toward Theoretical Knowledge

Anticipatory medicine in contraceptive counseling involves turning toward theoretical knowledge about what might be occurring in the patient’s body. “It’s a way to look into the future, and there still is a lot of uncertainty,” Brown says.

For example, a patient might say there was no intercourse at all. “But relying on this self-report is complicated unless the provider knows this patient has never had sex or has been abstinent for a long period,” Brown says. “There are obstacles to determining those dates for sexual intercourse and last menstrual period.”

Some patients might track their periods on a cellphone app. This report could be more accurate, or at least give the provider more information to explore. The provider might say, “You said your last unprotected sexual intercourse was June 20, and your last period was June 18.”

The most surprising finding in the study was how much time providers spend ruling out pregnancy and how difficult it is to do that, Brown says.

“The previous recommendations seem kind of cut-and-dry until you get into the weeds of it,” Brown says. “Think about how complex it is to quickly go through the information with a patient about when they last had intercourse, the length of their menstrual cycle, when they took their last birth control pill, and when they had a miscarriage or thought they might be pregnant.”

REFERENCE

  1. Brown E. Projected diagnosis, anticipatory medicine, and uncertainty: How medical providers ‘rule out’ potential pregnancy in contraceptive counseling. Soc Sci Med 2020;258:113-118.