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 Risk Level 1 Method can be used without restriction 2 Advantages generally outweigh theoretical or proven risk 3 Method usually not recommended unless other, more appropriate methods are not available or not acceptable 4 http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf Method not to be used Amy • 24 year old G2P0020 female who comes to the office with a UTI • Wants to try the patch. • BMI = 34 • History of Hyperlipidemia: LDL = 170 http://www.everystockphoto.com/photo.php?ima geId=12048627&searchId=d200ace9910e021dc 23256f155816f1f&npos=39 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/ever ystockphoto/sxc2/17/72/7/afric an-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?imageI d=8685&searchId=56609ab6ba04048adc2cbfafbe 745e10&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.wired.com/2011/07/ff_iud/ http://www.voanews.com/content/fda-makes-contraceptive-pillavailable-to-girls-15-and-older/1652135.html http://optionsforwomenphc.com/wp-content/uploads/2012/07/ella.jpg 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=31 2641&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/fashionoutdoors-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&s earchId=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(RR4):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.