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An Evidence-based Approach to Contraception in Women with Medical Disease

An Evidence-based Approach to Contraception in Women with Medical Disease. Jody Steinauer, MD, MAS University of CA, San Francisco. Objectives. At the end of this talk you will be able to: Easily access evidence-based recommendations for contraception in women with medical illness

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An Evidence-based Approach to Contraception in Women with Medical Disease

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  1. An Evidence-based Approach to Contraception in Women with Medical Disease Jody Steinauer, MD, MAS University of CA, San Francisco

  2. Objectives • At the end of this talk you will be able to: • Easily access evidence-based recommendations for contraception in women with medical illness • Understand the underlying evidence for these recommendations • Balance the risks of contraception against the risks of pregnancy in these women

  3. Outline • Review WHO guidelines for contraception • Review evidence for specific medical situations and specific methods • Migraines • Diabetes, HTN, CAD risk factors • Postpartum • Drug interactions • Review contraindications by method • Combined hormonal, progestin, IUC

  4. Janet is a 24 yo woman with migraines who comes to you for an annual examination. She desires the patch for birth control. Can she use it?

  5. Reviewing Evidence for Contraception • Medical Eligibility Criteria for Contraceptive Use • www.who.int, full text on line or $23!! • Managing Contraception 2004-2005 • Includes the WHO guidelines! • Also includes the CDC STI guidelines and other important information.

  6. WHO Eligibility Criteria for Use of a Contraceptive Method • 1No restriction • Use the method • 2 Advantages of method outweigh the risks • Generally use the method • 3 Risks outweigh the advantages • Use only if no other method available • 4 Unacceptable health risk if method used • Do not use the method Medical Eligibility Criteria for Contraceptive Use (www.who.int/reproductive-health)

  7. Migraine Epidemiology • 18% of U.S. women had one or more migraines per year1 • Three times more common in women • Dutch women (population-based study2) • 33% ever had migraines • 25% in the last year • 18% of 20-24 year oldsever had migraines • 64% Migraine; 18% with Aura; 13% both 1. Stewart et al. Prevalence of migraine headaches in the US. JAMA 1992;267:64-69 2. Launer et al. The prevalence and characteristics of migraine in a population-based cohort, The GEM study. Neurology 1999;53:537-42

  8. Stroke • The absolute risk of stroke in young women is low at <1 per 10,000 women-years. • Risk factors: • Smoking • Age > 35, • Obesity, FH of stroke <45 • HTN, CVD, diabetes, hyperlipidemia • Migraine with and without aura The International Headache Society Task Force on Combined Oral Contraceptives and HRT. Recommendations on the risk of ischemic stroke associated with use of combined oral contraceptives and HRT in women with migraine. Cephalalgia 2000;20:155-56

  9. Migraine, OCPs, and Stroke Migraine and stroke: • Migraine1 (general): RR 2.2 – RR 3.52 • Migraine without aura: RR 1.61– RR 3.02 • Migraine with aura: RR 2.91– RR 6.22 COC and stroke: • RR 2.13 -3.52 1. Etminan et al. BMJ, 2005; 330(7482): 63. 2. Tzourio et al. BMJ, 1995; 310: 830-33. 3. Gillum et al. JAMA, 2000, 284:72-8.

  10. Migraine, OCPs, and Stroke Synergistic effect Migraine and COC: OR 1.9 (95% CI 1.3-2.7) 1 OR 8.7 (95% CI 5.0-15.0)2 OR 13.9 (95% CI 5.5-35.1) 3 1. Gillum et al. JAMA, 2000, 284:72-8. 2. Etminan et al. BMJ, January 8, 2005; 330(7482): 63. 3. Tzourio C et al. BMJ, 1995, 310:830-3.

  11. Attributable Risk from CHC • Absolute risks of stroke in young women: • 6 per 100,000 ♀ / year – healthy • 12 per 100,000 ♀ / year – migraine • 18 per 100,000 ♀ / year – migraine with aura • 12 per 100,000 ♀ / year – healthy and COC • 19 per 100,000 ♀ / year – migraine and COC • 30 per 100,000 ♀ / year – migraine with aura and COC • 34 per 100,000 ♀ / year – stroke in pregnancy • Attributable risk: 7-12 per 100,000 women per year • (Much higher in women who smoke too: OR 34!)

  12. WHO: Headaches and CHC Initiate Continue Non migranous (mild or severe) 1 2 Migraine (i) without focal neurologic symptoms Age < 35 2 3 Age > 35 3 4 (ii) with focal neurologic symptoms 4 4 (at any age) Prodrome = photo/phonophobia, N/V Focal symptoms = vision changes, numbness, parasthesias http://www.who.int/reproductive-health/publications/RHR_00_2_medical_eligibility_criteria_3rd/

  13. “AURA” • Focal neurological symptoms that occur just before or at the onset of the headache • Not the same as premonitory or resolution symptoms: (hypo- or hyperactivity, depression, food cravings, yawning, fatigue, difficulty concentrating) • Reversible symptoms that develop gradually over 5-20 minutes and last up to 60 minutes • Most common - visual

  14. Hormonal Contraception for Women with Migraines • Considerations for CHCs • Lower & consistent estrogen levels with ring • Consider 20 or 25 mcg pills • Consider eliminating the placebo week in women who have migraines triggered by withdrawal of estrogen • Regular follow-up in 1-3 months after initial Rx • Stress need to discontinue method if HAs worsen • Any Progestin-Only Method

  15. Janet is a 24 yo woman with migraines who comes to you for an annual examination. She desires the patch for birth control. Can she use it?

  16. Contraception and Medical Conditions • Diabetes • Hypertension • Cardiovascular Risk Factors • Postpartum • Other cases

  17. Diabetes CHC DMPA NIDDM 2 2 IDDM No vascular disease 2 2 Vascular disease 3/4 3 Duration > 20 years 3/4 3 Copper IUD - 1 Levonorgestrel IUS - 2

  18. Diabetes • Even if uncomplicated diabetes, when combined with other risk factor for CVD, no CHC • CHC: • Progestin competitive inhibitor of insulin – choose with low progesterone activity • Estrogen – decreases insulin release – low estrogen dose

  19. Hypertension

  20. Cardiovascular Risk Factors

  21. Cardiovascular Risk Factors (cont.)

  22. Postpartum and Breastfeeding * See below.

  23. Drug Interactions withCHCs, POPs and LNG-IUS • Induction of liver enzymes, increased metabolism of steroids: lower effectiveness • Other method or increased dose with shortened hormone-free interval • CHC, Progestin pill, Progestin Implant • 3: Rifampicin (Even if only given for 2 days, assume increased metabolism for 4 weeks, back-up method) • 3: Anticonvulsants: Phenytoin, barbiturates, carbamazepine, primadone, topiramate, oxcarbazepine • 2: Griseofulvin • 1: All Other Antibiotics

  24. Other Medical Conditions • Cases

  25. Contraindications by Method • Combined Hormonal Contraception • Progestin Injection • Intrauterine Contraception

  26. Combined Hormonal Contraception • Cardiovascular Disease • 3 / 4 Multiple risk factors • 3: HTN currently controlled, or systolic 140-159, diastolic 90-99 • 4: Systolic > 160, diastolic >100 • 4: Vascular Disease • 4: DVT (History of, or Current) • 4: Major surgery with prolonged immobilization • 4: Stroke, Ischaemic Heart Disease (History of or Current) • 4: Complicated Valvular disease

  27. Combined Hormonal Contraception • Breast Cancer • 4: Current breast cancer • 3: H/O breast cancer and NED for 5 years • Gastrointestinal Conditions • 4: Active hepatitis or severe cirrhosis • 4: Benign or malignant liver tumors • 3: Symptomatic gallbladder disease • Neurologic Conditions • 3: Migraine without Aura, >35 • 4: Migraine with Aura

  28. Progestin Injection • Cardiovascular Disease • 3: Current DVT or PE • 3: Systolic BP 160 or DBP 100 • 3: Vascular disease • 3: Current/ h/o ischemic heart disease • 3: Stroke • Breast Disease • 4: Current breast cancer • 3: H/o breast cancer and NED

  29. Progestin Injection (cont.) • Migraines • 3: Continuation if develops migraines with aura on injection • Gastrointestinal Conditions • 3: Active hepatitis or severe cirrhosis • 3: Benign or malignant liver tumors

  30. Intrauterine Contraception • Discrepancies between product labeling and WHO guidelines • Recent change in Copper T IUD labeling c/w WHO guidelines

  31. LNG-IUS “Recommended patient profile” From Package Insert • In a stable, mutually monogamous relationship • No history of pelvic inflammatory disease unless subsequent intrauterine pregnancy - WHO 2 • No history of ectopic pregnancy or condition that would predispose to ectopic pregnancy – WHO 1 • Have had at least one child – WHO 2 • No IV drug abuse, AIDS, leukemia – WHO 2 • No unresolved, abnormal pap smear – WHO 2 • No liver disease – WHO 3 for severe

  32. LNG-IUS and Risk of Ectopic Pregnancy • Mirena prevents intrauterine pregnancy more effectively than ectopic pregnancy • Pregnancy rate overall = 1-2/1000 • Even if ALL pregnancies were ectopic, rate would still be lower than population rate • WHO category 1

  33. Pregnancy or suspicion of pregnancy Distorted uterine cavity Acute PID or history of PID Post-partum endometritis or infected abortion in past 3 months Uterine or cervical cancer or unresolved abnormal Pap smear Genital bleeding of unknown source Untreated acute cervicitis or vaginitis Wilson’s disease Allergy to copper Patient or partner with multiple partners Increased susceptibility to infection (AIDS, leukemia, etc) Genital actinomycosis Current IUD in place Pregnancy or suspicion of pregnancy Distorted uterine cavity Acute PID or current behavior suggesting a high risk for PID Postpartum or postabortal endometritis in the past 3 months Known or suspected uterine or cervical malignancy Genital bleeding of unknown source Mucopurulent cervicitis Wilson’s disease Allergy to copper Previously placed intrauterine contraceptive that has not been removed Copper T “Contraindications” New Label Previous label New FDA-approved label

  34. Other IUC Cases • IUC for women with HIV • Often desire effective contraception • WHO category 2 for HIV or AIDS but clinically well on therapy • Women with an abnormal pap • 88% of women with an “abnormal” pap don’t need a LEEP or intervention • IUC strings can be tucked up for LEEP, then retrieved • WHO category 2

  35. LNG-IUS • Personal Characteristics and Reproductive History • 4: Pregnancy • 4: Immediate post-septic abortion • 4: Distorted uterine cavity • Neurologic Conditions • 2/3: Migraine with focal neurologic symptoms • Cardiovascular Disease • 3: Current DVT or PE • 2/3: Current/ h/o ischemic heart disease • Gastrointestinal Conditions • 3: Viral hepatitis • 3:Severe Cirrhosis • 3:Liver tumors

  36. LNG-IUS • HIV/AIDS • 2: HIV-positive • 3: AIDS – not clinically well • Reproductive Tract Infections and Disorders • 3 or 4:Cancer (cervical, endometrial, ovarian) • 4:Uterine fibroids with distortion of the uterine cavity • 4/2: PID – current or within the last three months • 4/2:STIs – current or within the last three months • 3:Increased risk of STIs (e.g. multiple partners) • 2: Past h/o PID with no pregnancy

  37. Copper IUD • Personal Characteristics and Reproductive History • 4: Pregnancy • 4: Immediate post-septic abortion • 4: Distorted uterine cavity • Reproductive Tract Infections and Disorders • 3 or 4:Cancer (cervical, endometrial, ovarian) • 4/2: PID – current or within the last three months • 4/2:STIs – current or within the last three months • 3:Increase risk of STIs (e.g. multiple partners) • 2: Past h/o PID with no pregnancy

  38. Copper IUD (cont.) • HIV/AIDS • 3: AIDS – not clinically well • Gastrointestinal Conditions • 3: Severe cirrhosis

  39. Conclusion • WHO publishes excellent, evidence-based resource of recommendations for contraception in medically complicated women. • Risks must be balanced with risks of pregnancy.

  40. Acknowledgements • Tina Raine • Felisa Preskill • Phil Darney, and fellows in family planning at UCSF

  41. Resources • UCSF Family Planning Consultation Service • 415 719-6318 • Medical Eligibility Criteria for Contraceptive Use • www.who.int, full text on line or $23!! • Books • Darney P and Speroff L. A Clinical Guide for Contraception 2001. • Hatcher RA, et al. Contraceptive Technology 2004. • Hatcher RA, et al. A Pocket Guide to Managing Contraception 2004-2005. • Guillebaud J. Contraception-Your Questions Answered 2004.

  42. Resources • UCSF Family Planning Consultation Service • 415 719-6318 • Medical Eligibility Criteria for Contraceptive Use • www.who.int, full text on line or $23!! • Books • Darney P and Speroff L. A Clinical Guide for Contraception 2001. • Hatcher RA, et al. Contraceptive Technology 2004. • Hatcher RA, et al. A Pocket Guide to Managing Contraception 2004-2005. • Guillebaud J. Contraception-Your Questions Answered 2004.

  43. On-line Resources • Medical Eligibility Criteria for Contraceptive Use by WHO (www.who.int), $23!! • ARHP (www.arhp.org) • Managing contraception (www.managingcontraception.org) • Alan Guttmacher Institute (www.agi-usa.org) • www.contraceptiononline.org • http://www.NOT-2-LATE.com

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