Medically Complex Contraceptive Care: Does 2+2=2 or 3 or 4?

1. Medically Complex Contraceptive Care: Does 2+2=2 or 3 or 4? Kelita Fox MD Erin Hendriks MD Linda Prine MD

2. 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

3. United States Medical Eligibility Criteria for Contraceptive Use http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf

4. Amy • 24 year old G2P0020 female who comes to the office with a UTI • Wants to try the patch. • History of Hyperlipidemia: LDL = 170 • BMI = 34 http://www.everystockphoto.com/photo.php?imageId=12048627&searchId=d200ace9910e021dc23256f155816f1f&npos=39

5. 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)

6. 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

7. Learning Points • 2 + 2 + 2 can still = 2 • Progestin only methods are almost always safer than combined estrogen/progestin methods

8. 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

9. 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).

10. Quick Start: Progestin IUD or Implant

11. 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.jpg http://www.wired.com/2011/07/ff_iud/

12. 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

13. 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

14. 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!

15. 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

16. Learning points • Keep track of age – many recommendations change with age • Danger of anti-convulsants is decreasing efficacy of contraceptives (except lamictal)

17. 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

18. 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!

19. 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.