Medically Complex

Contraceptive Care

Does 2+2=2 or 3 or 4?

Learning Objectives

• Define medical contraindications to contraceptive use using the CDC Medical Eligibility Criteria for Initiating Contraception

• Analyze these guidelines using the referenced literature

• Accurately discuss the risks and benefits of medically complex contraception care with both patients and colleagues

United States Medical Eligibility Criteria for Contraceptive Use

http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf

Risk Level

1 Method can be used without restriction

2Advantages generally outweigh theoretical or proven risk

3Method usually not recommended unless other, more appropriate methods are not available or not acceptable

4 Method not to be used

Amy

http://www.everystockphoto.com/photo.php?imageId=12048627&searchId=d200ace9910e021dc23256f155816f1f&npos=39

• Wants to try the patch.

• History of Hyperlipidemia: LDL = 170

• BMI = 34

• 24 year old G2P0020 female who comes to the office with a UTI

Learning points

• Use every opportunity to ask about family planning to prevent unintended pregnancies

• Assess pathophysiology of medical contraindications

• 2 + 2 sometimes equals 2• Antibiotics do not decrease efficacy of

contraceptives (except rifampin)

Doreen• 46 year-old G2P2.

• Would like to remove her copper IUD and try “the shot”

• PMH significant for asymptomatic gallstones and cervical cancer awaiting treatment

http://s3.amazonaws.com/everystockphoto/sxc2/17/72/7/african-american-black-17727-l.jpg

Learning Points

• 2 + 2 + 2 can still = 2

• Progestin only methods are almost always safer than combined estrogen/progestin methods

Rosa• 16 year old G0P0 with a

history of sickle cell disease presents to your office to discuss contraception.

• Thinks she would like to try the IUD “without hormones”

• Detailed history reveals she was treated for PID last year

• She had unprotected sex 4 days ago, LMP is 3 weeks ago

http://www.everystockphoto.com/photo.php?imageId=8685&searchId=56609ab6ba04048adc2cbfafbe745e10&npos=380

Category 4 Conditions for IUDs

• Current PID, gonorrhea, chlamydia. (Category 4 for initiation only).

• Certain anatomic abnormalities. (May interfere with proper IUD placement).

• Endometrial cancer. (Initiation only).

• Cervical cancer awaiting treatment. (Initiation only).

• Active pregnancy.

• Unexplained vaginal bleeding. (Suspicious for serious condition).

Quick Start: Progestin IUD or Implant

Emergency Contraception

• Factors that will affect the efficacy of the emergency contraception (EC) pill: – LMP

– Last unprotected sex

– BMI

http://www.voanews.com/content/fda-makes-contraceptive-pill-available-to-girls-15-and-older/1652135.html

http://optionsforwomenphc.com/wp-content/uploads/2012/07/ella.jpghttp://www.wired.com/2011/07/ff_iud/

Learning Points

• IUDs OK in nullips, teens (even first line!)

• OK to test for STIs at the time of insertion as long as not very high risk or mucopurulent cervix

• The best Emergency Contraception is the Copper IUD, second best is ulipristal acetate

Audrey

• 33 year old G3P3• Happy with her Combined

Oral Contraceptives• Migraines without aura for

many years• Newly diagnosed with

Lupus, so far uncomplicated

http://www.everystockphoto.com/photo.php?imageId=312641&searchId=56609ab6ba04048adc2cbfafbe745e10&npos=1577

Learning Point

• Remember to assess pathway of “2” recommendation

• Pregnancy is always a higher risk than the birth control method

• Vasectomy is an option to recommend!

Katie• 28 year old G0P0 comes to you for

her well woman exam. In a new relationship and would like to have contraception she doesn’t have to think about.

• Likes the idea of the progestin implant

• She has a history of a seizure disorder which is stable on carbamazepine, and Type 1 Diabetes which was diagnosed at age 12

http://s3.amazonaws.com/everystockphoto/fspid30/15/05/38/1/fashion-outdoors-antiquecars-1505381-o.jpg

Learning points

• Keep track of age – many recommendations change with age

• Danger of anti-convulsants is decreasing efficacy of contraceptives (except lamictal)

Jenny

• 38 years old and recently diagnosed with colon cancer. She is scheduled for surgery in 2 weeks.

• Requests a refill prescription for birth control pills

• Mother has a history of DVT http://www.everystockphoto.com/photo.php?imageId=13214175&searchId=56609ab6ba04048adc2cbfafbe745e10&npos=782

Key take home points

• Progestin methods safer than combined estrogen + progestin

• Pregnancy is higher risk than birth control

• Copper IUD generally the safest method under the woman’s control

• Vasectomy is VERY safe!

References and Resources

• Hatcher et al, Contraceptive Technology 2007• Centers for Disease Control and Prevention (CDC). U.S. Medical Eligibility

Criteria for Contraceptive Use, 2010. MMWR Recom Rep. 2010 Jun 18;59(RR-4):1-86.

• Managing Contraception – book online @ www.managingcontraception.org• Medical Eligibility Criteria for Contraceptive Use 2010 by WHO

www.who.int/reproductive-health • Association of Reproductive Health Professionals www.arhp.org • Alan Guttmacher Institute www.agi-usa.org• Planned Parenthood www.plannedparenthood.org• The Cochrane Collaboration www.cochrane.org• www.Not-2-Late.com• Reproductive Health Access Project www.reproductiveaccess.org• http://www.i-h-s.org/upload/ct_clas/ihc_II_main_no_print.pdf.