1 / 38

ARHP Learning Lab May 18, 2011 Emily Godfrey, MD, MPH

Contraceptive Update: CDC Medical Eligibility Criteria for Women With Certain Characteristics and Medical Conditions. ARHP Learning Lab May 18, 2011 Emily Godfrey, MD, MPH. Expert Medical Advisory Committee. Melanie Deal, WHNP Student Health Services, SF State University San Francisco, CA

gina
Download Presentation

ARHP Learning Lab May 18, 2011 Emily Godfrey, MD, MPH

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Contraceptive Update: CDC Medical Eligibility Criteria for Women With Certain Characteristics and Medical Conditions ARHP Learning Lab May 18, 2011 Emily Godfrey, MD, MPH

  2. Expert Medical Advisory Committee Melanie Deal, WHNP Student Health Services, SF State University San Francisco, CA David Grimes, MD University of North Carolina School of Medicine Chapel Hill, North Carolina David Turok, MD University of Utah, Dept. of Ob/Gyn Salt Lake City, UT Susan Wysocki, WHNP-BC, FAANP National Association of NPs in Women’s Health Washington, DC

  3. Learning Objectives • List the 4 levels in the numeric scheme described in the USMedical Eligibility Criteria for Contraceptive Use, 2010 • Explain the application of the numeric scheme to prescriptive practices for women with co-morbid conditions • Describe the risks and benefits of the different contraceptive methods against the risks of pregnancy in women with health-related concerns

  4. Fetal Loss 7% Abortion 20% 51% 22% Birth Unplanned pregnancy – U.S. Unintended Pregnancy 6.4 million pregnancies Unintended (49%) Intended 1.2 million 1.4 million Finer LB, et al. Persp Sex Reprod Health. 2006.

  5. Goals to Address Unintended Pregnancy • Healthy People 2020 • Increase proportion of pregnancies that are intended • 51%  56% • Reduce proportion of females experiencing pregnancy despite reversible contraception use • 12.4%  9.9% • CDC Winnable Battles • Public health priorities with large-scale impact on health and with known, effective strategies to intervene • To identify optimal strategies and to rally resources and partnerships to accelerate a measurable impact on health • Prevention of teen pregnancy is one of the 6 winnable battles http://healthypeople.gov/2020/ http://www.cdc.gov/winnablebattles/teenpregnancy/index.html

  6. Typical Effectiveness of Contraception Long acting reversible contraceptives (LARCs) Tier 1 Tier 2 Tier 3 Tier 4 Adapted from: WHO. Family Planning: A Global Handbook

  7. Contraception Use Mosher, W et al. 2010.

  8. Improving Contraception Access • Improve access to and use of the most effective contraceptives • Address barriers to use of Long Acting Reversible Contraceptives (LARC) • Educate Providers • Ensure dissemination of US MEC • Recommend that young women and nulliparous may be eligible to use LARC methods • Increase interest and acceptance through education and social marketing • Address cost barriers to ensure publically funded services include LARC http://www.cdc.gov/winnablebattles/teenpregnancy/index.html

  9. US Medical Eligibility Criteria for Contraceptive Use • CDC published criteria in June ‘10 • Based on the 4th edition of the World Health Organization guidelines from ‘09 • Adapted for US women by panel of experts and CDC • Recommendations for the use of specific contraceptives by women who have particular characteristics/medical conditions http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm

  10. WHOCDC US MEC Existing WHO guidance • Breastfeeding and hormonal methods • Valvular heart disease and IUDs • Postpartum IUD insertion • Ovarian cancer and IUDs • Fibroids and IUDs • DVT/PE and hormonal methods and IUDs

  11. WHOCDC US MEC New medical conditions • Rheumatoid arthritis • Endometrial hyperplasia • Inflammatory bowel disease • Bariatric surgery • Solid organ transplantation • Peripartum cardiomyopathy

  12. US Medical Eligibility Criteria for Contraceptive Use

  13. US Medical Eligibility Criteria: Organization • Criteria are organized according to: • Contraceptive method • Patient characteristics (age, smoking status, etc.) • Preexisting conditions (hypertension, epilepsy, etc.) • Criteria use a numeric scheme to provide the recommendations for contraceptives being used for contraceptive purposes only, not for treatment of medical conditions http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf

  14. US Medical Eligibility Criteria: Categories http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf

  15. US Medical Eligibility Criteria: ↑ Risk for Adverse Health Events Should consider long-acting, highly-effective contraception for these patients http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf

  16. Pregnancy-Related Mortality • Increase in pregnancy-related mortality, 1998-2005 • De-identified death certificates of women who died during or within 1 year of pregnancy • Matched birth or fetal death certificates • Pregnancy-related mortality • 14.5 per 100,000 live births • African American, 3-4 times greater risk • Decreased deaths due to hemorrhage and hypertensive disorders • Increased deaths due to medical conditions, especially CVD Berg, CJ et al. Obstet Gynecol. 2010;116:1302-1309.

  17. Case Presentation 1 • Which hormonal methods are safe for her to use? • Combined hormonal methods only • Progestin-only methods only • Any hormonal method • 30-year-old • PPD #2 • Ready to be discharged from hospital & desires contraception • Plans to breastfeed

  18. Breastfeeding

  19. Case Presentation 1 • Which hormonal methods are safe for her to use? • Combined hormonal methods only • Progestin-only methods only • Any hormonal method • 30-year-old • PPD #2 • Ready to be discharged from hospital & desires contraception • Plans to breastfeed

  20. Case Presentation 2 • Is this method safe for her? • Yes • No • 25-year-old • Has Crohn’s disease • Desires long-term reversible contraception • Thinking about levonorgestrel-releasing IUD

  21. Inflammatory Bowel Disease

  22. Case Presentation 2 • Is this method safe for her? • Yes (Category 1) • No • 25-year-old • Has Crohn’s disease • Desires long-term reversible contraception • Thinking about levonorgestrel-releasing IUD

  23. Case Presentation 3 • What do you need to know before deciding whether to recommend this method? • How much weight has she lost? • What type of surgery did she have? • What pill formulation did she use previously? • 30-year-old • History of bariatric surgery 6 months ago • Was using COCs before surgery & wants to restart

  24. Bariatric surgery • Most effective weight loss treatment for morbid obesity • From 1998 to 2005, incidence increased 800% • Women account for 83% of procedures among reproductive age (ages 18-45)

  25. Types of Bariatric surgery • Restrictive procedures: • Decrease storage capacity of stomach • Ex: vertical banded gastroplasty, laparoscopic adjustable gastric band, laparoscopic sleeve gastrectomy • Malabsorptive procedures: • Decrease absorption of nutrients and calories by shortening functional length of small intestine • Ex: Roux-en-Y gastric bypass (most common in US), biliopancreatic diversion

  26. Paulen, ME et al. Contraception 82 (2010) 86-94. Bariatric Surgery • Consensus: Pregnancy should be avoided for 12-24 months after surgery

  27. History of Bariatric Surgery

  28. Case Presentation 3 • What do you need to know before deciding whether to recommend this method? • How much weight has she lost? • What type of surgery did she have? • What pill formulation did she use previously? • 30-year-old • History of bariatric surgery 6 months ago • Was using COCs before surgery & wants to restart

  29. Next Steps • Work with partners: • dissemination • implementation • Keeping guidance up to date

  30. Updated Guidance from WHOSeptember 2010

  31. What increased risk is posed by use of Combined Hormonal Contraceptives? • No data specifically delineates risk of CHC use during the postpartum • Baseline risk of VTE in non-pregnant, non-postpartum women: • 2.4-10/10,000 WY • CHC use increases risk: • 3-7 fold • Risk most pronounced in the first year of use

  32. Previous WHO MEC recommendation CHCs in postpartum women

  33. US MEC-Postpartum period • New evidence • Updated recommendations from WHO • CDC held consultation in Jan 2011 • Substantial increased risk in early weeks postpartum with no benefit • Multiple risk factors • Access issues • Safety of other contraceptive methods • Will be published as MMWR

  34. Next Steps • Work with partners: • dissemination • implementation • Keeping guidance up to date • Research gaps • US adaptation of WHO Selected Practice Recommendations for Contraceptive Use

  35. Resources • US MEC published in CDC’s Morbidity and Mortality Weekly Report (MMWR): • http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a1.htm?s_cid=rr5904a1_w • CDC evidence-based family planning guidance documents: • http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm • WHO evidence-based family planning guidance documents: • http://www.who.int/reproductivehealth/publications/family_planning/en/index.html

  36. Additional Resources • Association of Reproductive Health Professionals (ARHP) • www.arhp.org • National Association of Nurse Practitioners in Women’s Health (NPWH) • www.npwh.org

More Related