Strategies to Improve Patient Communication About the Vaginal pH Modulator

Announcer:
Welcome to CME on ReachMD. This activity, entitled “Strategies to Improve Patient Communication about the Vaginal pH Modulator” is provided by Omnia Education.

Prior to beginning the activity, please be sure to review the faculty and commercial support disclosure statements as well as the learning objectives.  

Ms. Cason:
Hi. I’m Patty Cason, and I’d like to welcome you to our Patient-Clinician Connection on Strategies to Improve Patient Communication about the Vaginal pH Modulator. I’m a family nurse practitioner with a specialty in sexual and reproductive health. I’m an assistant clinical professor at the School of Nursing at UCLA, and joining me is my dear friend and colleague, Joely Pritzker, also a nurse practitioner, who share a passion for patient-centered care.

Joely’s going to be role-playing different patients, and they are going to be representing pretty much a reproductive lifespan, and I will be modeling the role of the provider. Before we do that, I’m going to briefly go into a little bit of a history around contraception counseling, just to briefly touch on what the various types of theories behind contraception counseling have been to date. These visits are being conducted via telemedicine.

Briefly, when we think about the history of contraception counseling, when I graduated, when I was in school, I was taught that we essentially talk to the patient about what their lives are like, and what their medical situation is, and then we recommended a type of birth control for them. And at that time, there weren’t that many types, so it wasn’t that hard. We call this directive counseling. In other words, that we as the providers are telling the patient what the best contraceptive method is for them. And then, because we were very concerned that patients should have the decision-making role in their contraception, there became a different technique, which is really called a menu approach. There’s many different names for it, but it’s essentially that you tell the patient about every single method, and then they just are meant to decide which one they would like from that long list. Now that is a little problematic because the patients don’t really know enough about all the various methods to be making a truly informed choice, and even more important, perhaps, you’re giving the patient a tremendous amount of information that may not be relevant to their particular preferences and values and needs. So instead of approaching it from telling the person about all the methods and having them choose, if you engage in a back-and-forth conversation, that we’re going to be demonstrating to you and discussing, what we call a shared decision-making approach, it really allows them to get the information that they need in order to make an informed choice.

Now when you’re having these conversations, the thing that we advise within the PATH framework [Parenthood/Pregnancy, Attitude, Timing, How important?] is that you also bring something called a shared decision-making sandwich into that conversation, and that’s a way to package all the counseling skills that we know and love into one thing to remember, which is a sandwich. And the sandwich is very simple. The top piece of bread in the sandwich is acknowledgment – acknowledging something about what the patient has said or an emotion that the patient has expressed. So it’s either an empathy statement or an agreement of some kind with something they’ve said or potentially supporting something positive about a healthcare maintenance thing that they have done.

So you acknowledge something first. Then the middle of the sandwich is giving them that information that you know they need based on the things that they’ve told you that they’re interested in and that are important to them. So based on what is important to them, we’re going to know what the relevant information is that they need, and we can give it to them in the middle of that sandwich. But not a lot of information at one go, because you can’t fit a big sandwich, with a lot of information, into your mouth. So we just want to give enough information in a patient-centered way that they’re going to be able to take in that information. And then follow it with a question before giving more information. And then do it all over again. Acknowledge what they say, give them a little bit of digestible information, and ask a follow-up question.

So we’re going to go ahead and proceed with our vignettes, and we’re going to see Joely now as the first patient, who is a young woman named Molly.

Molly is a G0, 22-year-old, cis woman with no medical problems. She does use condoms almost all the time due to a history of chlamydia at the age of 17. And we come into the middle of our visit, and we’ve already taken a sexual history using the Five “P”s from CDC’s “A Guide to Taking a Sexual History,” which is a companion to the STI treatment guidelines that just came out in 2021. The guide recommends a series of inclusive, nonjudgmental questions, and based on this sexual history, we know that she’s having vaginal intercourse and is not in a committed relationship at this time.

Ms. Cason:
Molly, do you think you might like to have children at some point?

Ms. Pritzker:
Yeah, yeah. Yeah, definitely. I’ve always thought that I wanted to have a family.

Ms. Cason:
You seem really sure about that. And when do you think that might be?

Ms. Pritzker:
Oh, not – I have so much going on with, like, school and work, and I really kind of want to feel a lot more settled before I start that part of my life.

Ms. Cason:
I hear you. And given that, how important is it to you to prevent pregnancy until then?

Ms. Pritzker:
It’s really important. I wouldn’t want to have to deal with that, with getting pregnant, if I wasn’t kind of, you know, if it wasn’t something I was thinking about. So, yeah, I’d say it’s really important.

Ms. Cason:
So would you like to engage in a conversation around birth control, ways to prevent pregnancy?

Ms. Pritzker:
Yeah, that would be great.

Ms. Cason:
Great. So I’m assuming that one of the things you’re looking for in a contraceptive method is that it’s really good at preventing pregnancy. Do you have a sense of what else you might be looking for in a birth control method?

Ms. Pritzker:
Hmm. Well, yeah, definitely something that works, because that seems like a good thing. I use, you know, most of the time when I’m having sex, I’m using condoms because, you know, protecting myself against STDs feels really important. I had chlamydia when I was younger, and I really would like that to not happen again. And so I use condoms most of the time, so that’s been an important piece of it, too, is something that helps, you know, protect my body, too.

Ms. Cason:
You’re doing an amazing job of protecting yourself, and it sounds like you took the experience you had when you were 17 and really applied something in your life to make sure that wasn’t going to happen again. So how’s it going for you, using condoms? How’s it going sexually? How’s it going in your life? How is that?

Ms. Pritzker:
Yeah, it’s okay. I mean, sometimes it’s a little bit awkward, especially with newer partners, but I, you know, feel like it’s been fine. But I think it would be nice to have something else other than just condoms.

Ms. Cason:
Something that’s going to protect you, as well, against getting pregnant as you are being protected against sexually transmitted infections.

Ms. Pritzker:
Yeah.

Ms. Cason:
So do you have a sense of what might be important to you? We are pretty clear that you’re going to continue to use condoms, and do you have a sense of what else might be important to you about your contraception?

Ms. Pritzker:
Well, I haven’t really talked about this, like, you know, before with a provider, but my periods are super heavy. Like really, really heavy – like it’s really hard for me to even go – you know, get up for class sometimes when I’m having my period. So if there was something that could help me with that, that would be awesome.

Ms. Cason:
Well, that sounds like it’s a real drag. And we do have methods of birth control that actually can help change the way your periods come, and they can sometimes, some of them, help with decreasing the amount of blood you have when you are having your period. And it’s amazing you know that. I’m really glad you know about some of the things that contraception can do for you, in addition to keeping you from getting pregnant. So that’s important. Anything else that you can think of that you’re either looking for in a contraceptive method or things that you know are important to you?

Ms. Pritzker:
I think that was it. I think those were the main things that I wanted to check in about with birth control.

Ms. Cason:
Well, the things that would help reduce your amount that you’re bleeding when you get your period would be things that have hormones in them, and one of the easiest things to have is something that you don’t have to do every day or every week or every month. I mean, there are hormonal methods that you would need to take every day like a pill or place on your body every week like a patch or use once a month like a ring.

So those are possible, and another possibility is a small, plastic device called an IUD [intrauterine device] that we would place inside of your uterus, and then you would not have to worry about it ever. You don’t actually have to think about it or do anything if that’s something that is important to you. And that can actually reduce your amount of blood really quite a bit – almost by, you know, 90% by the end of a year. Is that something that you would be interested in? I can show you one. This is is actually what they look like.

Ms. Pritzker:
Yeah, actually one of my roommates got one a while back, and she’s been pretty happy with it, so it’s definitely something I had kind of been thinking about. And if it would help my periods, that would be great.

Ms. Cason:
Yeah, and we have to talk about what the specific types of bleeding patterns, you know, what kind of effects it might have on your period. But it sounds like something that we should probably have a conversation about. And I was thinking you said that you wanted extra protection for pregnancy. Another option to add to that, if you’re interested in adding anything to that, is a new gel that we have, that is placed – you would place it in your vagina just before you have sex. And, actually, we have some new scientific information saying that it can reduce your risk of chlamydia and gonorrhea, also, in addition to the condom.

Ms. Pritzker:
Wait, seriously?

Ms. Cason:
It’s very new. It actually acts as a lubricant, also. And it’s a contraceptive, so you would have all those various things that it’s helping you with.

Ms. Pritzker:
Yeah, I hadn’t even heard about that before.

Ms. Cason:
Yeah, probably not very many people have heard about it; it’s really very new.

Ms. Pritzker:
Yeah, I’d love to talk about that.

Ms. Cason:
Great.

Announcer:
For those just tuning in, you’re listening to CME on ReachMD. We’re here with two renowned thought-leaders on contraception—Patty Cason and Joely Pritzker. We’re just about to dive into the next counseling vignette.

Ms. Cason:
And now we’re going to do our next vignette, where you’ll meet Kim. She is a G2 P2, cis woman. She is divorced, and she has fairly recently started a relationship with someone new.

Ms. Cason:
Kim, do you think you might like to have more children at some point?

Ms. Pritzker:
No. That ship has sailed for me. I think I’m happy. My two kids are wonderful, and I am happy with them at this point.

Ms. Cason:
I hear you. And so how important is it to you to prevent pregnancy?

Ms. Pritzker:
It’s really important, and, you know, I hadn’t been thinking about it because I’m in my 40s, and I didn’t really think, you know, I had to worry about it all that much. But then my sister, who’s just a couple years younger, got pregnant in her 40s, and maybe that was a little bit of a wake-up call that I still need to be thinking about it.

Ms. Cason:
Yeah. I hear you. So given that, would you like to have a conversation today about birth control?

Ms. Pritzker:
Yeah, I guess so. You know, I didn’t think I needed to, but I think that would be a good idea.

Ms. Cason:
Do you have a sense of what’s important to you about your birth control?

Ms. Pritzker:
You know, I’ve used a lot of things over the years, and some – you know, they’ve all been, I guess, fine. I think at this point, though, I’m pretty clear that I don’t really want to use anything with hormones. I’ve had some friends recently get diagnosed with breast cancer, and that’s just kind of, you know, freaked me out a little bit.

Ms. Cason:
I’m so sorry. And do you have a sense of what else is important to you about your birth control?

Ms. Pritzker:
Hmm. Well, so when my sister got pregnant and I started worrying about getting pregnant myself, and with my new partner, who – he’s awesome; he’s been really great. I asked him if we could use condoms, and he was open to it. But he’s a little bit older than I am, and, you know, I don’t know if it’s that, that he’s in his 50s, but when we tried to use condoms, he kind of – he kind of lost it. And that kind of has been a mood killer.

Ms. Cason:
Yeah, I can see why that would be a mood killer, especially in a new relationship. And it’s, just to tell you, it’s really common for people as they get older to have difficulty maintaining an erection with a condom. So other than that, how are things going for you sexually with him?

Ms. Pritzker:
I mean, in general, really good. I’ve been really happy with him. You know, I have noticed, as I’ve gotten a little bit older, that sometimes I need to add a little bit of extra lubrication, so I’ve just gotten, like, an over-the-counter lube from the pharmacy, and that’s definitely been helpful.

Ms. Cason:
That’s great. And any sense of what else might be important to you about your birth control? Anything else that you might be looking for?

Ms. Pritzker:
I don’t think so. I think that’s, you know, those are the most important things.

Ms. Cason:
And I would like you to know that there are condoms that don’t actually get put on the penis – what we traditionally call male condoms, the things that you’re familiar with being a condom. There’s another condom available, the internal condom that you would put in your vagina, and it’s not likely to have the same problem with him being able to maintain an erection because he’s not putting it on his penis. I don’t know if that’s something that would be interesting to you, but we can talk about that some more.

Ms. Pritzker:
Maybe. Like, it sounds a little different, but I’m – yeah, maybe.

Ms. Cason:
And I’m also thinking, you know, there’s a new gel that’s available that can both provide lubrication and contraception. Is that something that you would be interested in talking more about?

Ms. Pritzker:
Sure. I hadn’t – like, it’s not a spermicide?

Ms. Cason:
No, actually, it’s brand new. Spermicides, we have found, are actually not great for the skin inside the vagina. So we’re very, very fortunate that we have a new gel that we can use in the vagina, and it is actually a contraceptive.

Ms. Pritzker:
Huh. Yeah, maybe – can we talk about the internal condom that you were talking about and also that gel? Because those are both kind of new to me.

Ms. Cason:
Yeah.

Ms. Cason:
We really hope that you enjoyed this program and that you can utilize some of the tips that we demonstrated for you today in your conversations with patients. Also, I’m really optimistic that you’ll be enthusiastic about the shared decision-making sandwich and that you’ll be inspired to use it early and often in all of your interactions with your patients.

Ms. Pritzker:
Thanks, everyone, for joining us today, and we look forward to seeing you again for future Omnia programs.

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