Contraception and chronic disease which patient which method
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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


Contraception and chronic disease which patient which method

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


    Contraception and chronic disease which patient which method

    Thank you for your attention


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