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Contraception and Chronic Disease: Which Patient, Which Method?. US Medical Eligibility Criteria for Contraceptive Use, 2010. Wendy Grube, PhD, CRNP University of Pennsylvania School of Nursing. Disclosure. No Conflicts of Interest. Contraception. Half of pregnancies are unintended

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contraception and chronic disease which patient which method

Contraception and Chronic Disease: Which Patient, Which Method?

US Medical Eligibility Criteria for Contraceptive Use, 2010

Wendy Grube, PhD, CRNP

University of Pennsylvania

School of Nursing

disclosure

Disclosure

No Conflicts of Interest

contraception
Contraception
  • Half of pregnancies are unintended
  • Half of unintended pregnancies result from inconsistent or incorrect contraceptive use
  • Risk of method vs. risk of pregnancy
  • What is the most important issuefor the clinician prescribing contraception?
unintended pregnancy poses increased risks for adverse health events in
Unintended Pregnancy Poses Increased Risks for Adverse Health Events in…
  • Breast Cancer
  • Complicated valvular heart disease
  • IDDM with complications
  • Endometrial/ovarian cancer
  • Epilepsy
  • Hypertension (systolic >160, diastolic >100)
  • Bariatric surgery in past 2 years
  • HIV/AIDS
  • Ischemic HD
  • Malignant gestational trophoblastic disease
  • Hepatic malignancies
  • Peripartum cardiomyopathy
  • Schistosomiasis with liver fibrosis
  • Severe cirrhosis
  • Sickle cell disease
  • Solid organ transplant in past 2 years
  • Stroke
  • SLE
  • Thrombogenic mutations
  • Tuberculosis

CDC, MMWR, May 28, 2010

cdc us mec 2010
CDC: US MEC 2010

BASED ON THE CURRENT SCIENTIFIC EVIDENCE

  • Category 1:
    • No restrictions for use
  • Category 2:
    • Advantages of method outweigh the theoretical or proven risks: careful follow-up may be required
  • Category 3:
    • Theoretical or proven risks outweigh the advantage of a method: generally not recommended
  • Category 4:
    • Unacceptable health risk if method used
cdc changes from who mec
CDC Changes from WHO MEC

Modifications

Additions

  • VTE
  • Valvular heart disease
  • Ovarian cancer
  • Uterine fibroids
  • Postpartum
  • Breastfeeding
  • RA
  • Bariatric surgery
  • Peripartum cardiomyopathy
  • Endometrial hyperplasia
  • IBD
  • Solid organ transplant

CDC, MMWR, May 28, 2010

combined hormonal contraception

Combined Hormonal Contraception

Pills, patches, and rings

slide8
Age

Menarche to <40 years

  • Category 1

> 40 years old

  • Category 2

Smoking

  • <35 and smoke: 2
  • >35 and smoke <15/day: 3
  • >35 and smoke > 15/day: 4
breastfeeding
Breastfeeding

< 1 month postpartum

  • Category 3

1-6 months postpartum

  • Category 2

6 months postpartum

  • Category 2
postpartum postabortion
Postpartum & Postabortion

Postpartum:

< 21 days

  • Category 3

21 days

  • Category 1

Postabortion

Immediately post abortion

1st or 2nd trimester

  • Category 1
obesity
Obesity

BMI > 30

  • Category 2
  • Possible increased risk of VTE, MI, stoke
  • Inconsistent evidence about body wt and efficacy
  • NOT more likely to gain
bariatric surgery
Bariatric Surgery

Restrictive procedures: gastric band or sleeve

  • Category 1

Malabsorptive procedures

  • COCs: Category 3
  • P/R: Category 1
cvd hypertension
CVD: Hypertension

Adequately controlled:

  • Category 3

Elevated BP levels:

S 140-159 OR D 90-99

  • Category 3

S > 160 OR D > 100

  • Category 4

Vascular disease

  • Category 4

Hypertension during pregnancy

  • Category 2
cvd dvt pe
CVD: DVT & PE

Hx of DVT/PE NOT on anticoagulant

Higher risk of recurrence

  • Estrogen associated
  • Pregnancy associated
  • Idiopathic
  • Thrombophilia
  • Cancer
  • Hx recurrence

Category 4

Lower risk for recurrence

Category 3

cvd dvt pe1
CVD: DVT & PE

Acute DVT/PE

  • Category 4

DVT/PE on anticoagulant for at least 3 months

Higher risk of recurrence

  • Thrombophilia
  • Cancer
  • Recurrence

Category 4

Lower risk of recurrence

  • No risk factors

Category 3

cvd dvt pe2
CVD: DVT & PE

Family History: 1st degree

  • Category 2

Major surgery

  • Prolonged immobilization
    • Category 4
  • No prolonged immobilization
    • Category 2

Minor surgery: no immobilization

  • Category 1

Known thrombotic mutations

  • Category 4
  • COC users had a 2-20 fold high risk for thrombosis

Superficial venous thrombosis

  • Varicose veins
    • Category 1
  • Superficial thrombophlebitis
    • Category 2
cvd and chc
CVD and CHC

Ischemic heart disease: current or history

  • Category 4

Stroke

  • Category 4

Known hyperlipidemias

  • Category 2/3
  • Depends on type, severity, other risk factors

Valvular heart disease

  • Uncomplicated
    • Category 2
  • Complicated

Peripartum cardiomyopathy: mild

  • < 6 months
    • Category 4
  • > 6 months
    • Category 3
  • Moderate or severe
    • Category 4
rheumatic diseases
Rheumatic Diseases

SLE

  • Positive or unknown APL antibodies: C4
  • Thrombocytopenia: C2
  • Immunosuppression: C2
  • None of above: C2

RA

  • Immunosuppression: C2
  • Non-suppressed: C2
neurologic conditions
Neurologic Conditions

Headaches

Not migraines:

Initiate: C1 Continue: C2

Migraines: No aura

<35 years old

Initiate: C2 Continue: C3

> 35 years old

Initiate: C3 Continue: C4

Migraines: with aura, and age

Initiate or continue: C4

Epilepsy

  • Category 1
  • Watch drug interactions

Depressive disorders

  • Category 1
  • No data on bipolar or postpartum disorders
reproductive tract disorders
Reproductive Tract Disorders

Category 1

  • Irregular, heavy, or prolonged bleeding
  • Endometriosis
  • Benign ovarian tumors
  • Severe dysmenorrhea
  • Gestational trophoblastic disease
  • Benign breast disease, or FHx of cancer
  • STIs/PID/HIV/AIDS
  • Endometrial hyperplasia
  • Endometrial or ovarian cancer
  • Fibroids

Category 2

  • Unexplained vaginal bleeding
  • Undiagnosed breast mass
  • CIN/cervical cancer awaiting treatment

Category 3

  • Past breast cancer with no evidence of disease for 5 years

Category 4

  • Current breast cancer
endocrine gi disorders
Endocrine & GI Disorders

Diabetes

Gestational

  • Category 1

Nonvascular disease

  • Category 2

Vascular disease

  • Categories 3/4
  • Depends on severity

Thyroid disorders

  • Category 1

________________________

Liver tumors

  • Benign
    • Focal nodular hyperplasia: C2
    • Hepatocellular adenoma: C4
  • Malignant : C4

Inflammatory bowel disease

  • Category 2/3
  • Depends on risk for VTE

Gallbladder disease

  • Asymptomatic: C2
  • Symptomatic, surgery: C2
  • Medical treatment: C3

Cholestasis

  • Pregnancy related: C2
  • COC related: C3

Cirrhosis

  • Mild: C1
  • Severe: C4

Viral Hepatitis

  • Acute: C3/4 (with severity)
  • Chronic/carrier: C1
other conditions
Other Conditions

Anemias

Thalassemia

  • Category 1

Iron deficiency

  • Category 1

Sickle cell disease

  • Category 2

Solid organ transplant

  • Complicated (rejection, graft failure)
      • Category 4
  • Uncomplicated
    • Category 2
drug interactions with chc
Drug Interactions with CHC

Antiretroviral therapy

  • NRTIs: Category 1
  • NNRTIs: Category 2
  • Ritonavir-boosted protease inhibitors: C3

Anticonvulsant therapy

  • Decrease effectiveness
  • Minimum 30μg EE use
  • Lamictil: possible increased seizures

Antimicrobial therapy

  • Broad-spectrum antibiotics: Category 1
  • Antifungals: Category 1
  • Antiparasitics: Category 1
  • Rifampin: Category 3
progestin only contraceptives

Progestin-Only Contraceptives

Pills, injections, implants

conditions
Conditions

Age: C1 POP, C2 DMPA <18 or >45

Breastfeeding

  • < 1 month: Category 2
  • > 1 month: Category 1

Postpartum: Category 1

Postabortion: Category 1

Past ectopic: C2 for POP only

Smoking: Category 1

Obesity: C1; C2 <18

Bariatric: C3 for malabsorptive procedures

cardiovascular disease
Cardiovascular Disease

Hypertension

Adequately controlled

  • POP, I: Category 1
  • DMPA: Category 2

Elevated BP levels

S 140-159/D 90-99

  • POP, I: Category 1
  • DMPA: Category 2

S > 160/D > 100

  • POP/I: Category 2
  • DMPA: Category 3

HBP during pregnancy: C1

DVT/PE

History or acute

  • Category 2

On or off anticoagulant

  • Category 2

Major surgery/immobilized

  • Category 2

Thrombotic mutations

  • Category 2

Family History

  • Category 1

Superficial thrombosis

  • Category 1
cardiovascular disease1
Cardiovascular Disease

Ischemic heart disease

  • Initiation: POP, I: C2
      • DMPA: C3
  • Continuation: POP, I: C3

Stroke

  • Same as IHD

Hyperlipidemia

  • Category 3 for all

Valvular heart disease

  • Category 1 for all

Peripartum cardiomyopathy

  • Mild: Category 1
  • Moderate/severe: C2
other conditions1
Other Conditions

Rheumatic

Neurologic

SLE

  • Positive or unknown APL antibodies: C3
  • Severe thrombocytopenia: C3
  • Immunosuppressed: C2

RA

  • C1 for POP, I
  • C2 for DMPA

Headaches, non-migraine

  • Category 1, all

Migraines

  • No aura, C2 (C1 start OC)
  • Aura: C2 start, C3 continue

Epilepsy: C1

Depressive disorders: C1

reproductive tract conditions
Reproductive Tract Conditions

Category 1:

  • Endometriosis
  • Benign ovarian tumors
  • Severe dysmenorrhea
  • Gestational trophoblastic disease
  • Benign breast disease
  • FHx breast cancer
  • Endometrial hyperplasia or cancer
  • Ovarian cancer
  • Uterine fibroids
  • STIs, PID
  • HIV/AIDS

Category 2:

  • Irregular, heavy, or prolonged vaginal bleeding
  • CIN/Cervical cancer (DMPA)
  • Undiagnosed breast mass

Category 3:

  • Past breast cancer (>5 years)
  • Unexplained vaginal bleeding

Category 4:

Current breast cancer

endocrine and gi conditions
Endocrine and GI Conditions

Endocrine

GI

Thyroid: Category 1

Diabetes

  • Gestational: C1
  • No vascular disease: C2
  • Vascular disease:
    • POP, I: C2
    • DMPA: C3

Inflammatory bowel disease:

  • POP, DMPA: C2
  • Implants: C1

Gallbladder disease: C2

COC-related cholestasis

  • Category 2

Viral hepatitis: C1

Severe cirrhosis: C3

Liver tumors: C2/3

other conditions2
Other Conditions

Anemias

  • Category 1

Solid organ transplant

  • Category 2

Drug interactions:

  • Anticonvulsants:
    • Lamotrogine: C1
    • Others: DMPA: C1
    • Implant: C2
    • POPs: C3

Antiretroviral therapy

  • DMPA: C1 for all
  • NRTIs: C1 for all methods
  • NNRTIs: C2 POPs and I
  • Ritonavir-boosted PIs: C3 for POPs; C2 for I

Antimicrobials: all C1 except

  • Rifampin: C1 DMPA
  • C2 Implant
  • C3 POPs
emergency contraceptive pills
Emergency Contraceptive Pills

Category 1

  • Breastfeeding
  • Hx ectopic
  • Bariatric surgery
  • RA
  • IBD
  • Solid organ transplant
  • Repeated use
  • Rape

Category 2

  • Severe CVD
  • Angina
  • Migraine
  • Severe liver disease
intrauterine devices

Intrauterine Devices

Copper and levonorgestrel-releasing

conditions1
Conditions

Age

  • Menarche to <20: C2
  • > 20: Category 1

Nulliparous women: C2

Postpartum: Category 2

  • Cu: C1 < 10 minutes PP
  • Puerperal sepsis: C4

Postabortion

  • First trimester: C1
  • Second trimester: C2

Past ectopic history

  • Category 1

Smoking

  • Category 1

Obesity

  • Category 1

Bariatric surgery

  • Category 1
cardiovascular disease2
Cardiovascular Disease

Hypertension

  • Category 1 except
  • S >160/D>100 & vascular disease: LNG C2

DVT/PE

  • Cu: Category 1
  • LNG: Category 2

Acute DVT/PE: C2 both

Known thrombogenic

  • Category 2

Ischemic heart disease

  • Category 2: LNG
  • Category 1: Cu

Stroke, hyperlipidemia

  • Category 2: LNG
  • Category 1: Cu

Valvular heart disease

  • Category 1
  • No antibiotic prophylaxis

Peripartum cardiomyopathy: C2 both

other conditions3
Other Conditions

Rheumatic

Neurologic

SLE

  • Positive APL antibodies
    • LNG: C3 Cu: C1
  • Severe thrombocytopenia
    • LNG: C2 Cu: C3
  • Immunosuppressed
    • Both: C2

RA

  • Immunosuppressed: C2
  • Not suppressed: C1

Migraine

  • With/without aura
    • LNG: C2 Cu: C1

Epilepsy

  • Category 1 (both)

Depressive disorders

  • Category 1 (both)
reproductive tract conditions1
Reproductive Tract Conditions

Irregular bleeding

  • Category 1 (both)

Heavy, prolonged

  • LNG: C1 Cu: C2

Unexplained bleeding

  • Category 4 initiation

Endometriosis

  • LNG: C1 Cu: C2

Benign ovarian tumors

  • Category 1 (both)

Severe dysmenorrhea

  • LNG: C1 Cu: C2

STIs: C2 CT/GC: C4 (initiation)

PID: Hx: C1 with subsequent pregnancy; C2 without

  • Current: C4

Gestational trophoblastic Dx

  • Category ¾

CIN

  • LNG: C2 Cu: C1

Cervical cancer (await Rx)

  • Category 4: initiation

Breast mass, cancer

  • LNG: C2/3/4 Cu: C1

Endometrial hyperplasia

  • Category 1 (both)

Endometrial cancer: C4

Ovarian cancer: C1

Uterine fibroids: C2

Anatomic abnormalities: C4

HIV: C2 AIDS: C3

Pelvic Tb: Category 4

endocrine and gi disorders
Endocrine and GI Disorders

Diabetes

  • Gestational: C1
  • Treatment: Cu: C1

LNG: C2

Thyroid

  • Category 1

IBD: Category 1

Gallbladder disease

  • Cu: C1 LNG: C2

Viral hepatitis: C1

Cirrhosis: Mild, C1

  • Severe: LNG: C3 Cu: C1

Liver tumors: Cu: C1

  • FNH: LNG: C2
  • Adenoma, hepatoma: LNG: C3
other issues
Other Issues

Anemias

  • LNG: C1 Cu: C2

Solid organ transplant

  • Uncomplicated
    • Category 2 (both)
  • Complicated
    • Category 3 initiation

Drug interactions

  • Antiretroviral therapy
    • Clinically well on ARV: initiation drops to C2
  • Anticonvulsants
    • Category 1
  • Antimicrobials
    • Category 1
barrier methods

Barrier Methods

Condoms, Spermicides, diaphragms

category 1 except
Category 1 Except…

Cervical cap +/- diaphragm

  • Parous women: C2
  • Complicated valvular HD
  • High risk for HIV: C4
  • HIV/AIDS: C3
  • Toxic shock Hx: C3
  • UTI: C2
  • Allergy to latex: C3

Spermicides

  • Cervical cancer: C2
  • High risk for HIV: C4
  • HIV/AIDS: C3
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