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Finding the Right Contraceptive The  U.S. Medical Eligibility Criteria for Contraceptive Use

Finding the Right Contraceptive The  U.S. Medical Eligibility Criteria for Contraceptive Use. Jean E. Howe, MD, MPH Northern Navajo Medical Center July 24, 2012. Disclosures. No Financial D isclosures

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Finding the Right Contraceptive The  U.S. Medical Eligibility Criteria for Contraceptive Use

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  1. Finding the Right ContraceptiveThe U.S. Medical Eligibility Criteria for Contraceptive Use Jean E. Howe, MD, MPH Northern Navajo Medical Center July 24, 2012

  2. Disclosures • No Financial Disclosures • More info: ACOG/IHS Postgraduate Women’s Health Course, Salt Lake City, August 12 – 15, 2012 • Thanks to Tony Ogburn, Eve Espey, & ARHP

  3. Objectives • Discuss how to access and use the U.S. Medical Eligibility Criteria for Contraceptive Use guideline • Describe considerations inselecting contraceptivemethods for women with common medical conditions • Discuss newer contraceptive options and compare them with older methods

  4. Approximately what percent of pregnancies in the US are unintended? • 10 • 32 • 49 • 78 • 90

  5. Pregnancies in the United States(6.4 Million Annually) Intended Unintended Source: Finer, 2006

  6. What percentage of women who are sexually active used a contraceptive method in the last 3 months? • 11% • 35% • 47% • 66% • 89%

  7. What proportion of unintended pregnancies occur in women NOT using contraception? • 11% • 22% • 47% • 89%

  8. . . . account for roughly half of all unintended pregnancies The small proportion of women who do not use contraceptives Women at risk of unintended pregnancy, Women experiencing unintended pregnancies,

  9. 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.

  10. What do women report as the most important characteristic of a contraceptive method? • Affordable cost • Favorable side effect profile • Effectiveness • Lack of serious complications • Convenience

  11. 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

  12. Which 2 contraceptive methods have the highest continuation rate? • Patch and OCs • Implanon and IUDs • OCs and condoms • OCs and IUDs • DMPA and Implanon

  13. Continuation rates

  14. U.S. Contraceptive Use Guttmacher, 2010 (2006 Data)

  15. A 29 yo G0 with insulin dependent diabetes and retinopathy requests reversible contraception • Recommend combination OCs • Recommend Depo-Provera • Recommend a barrier method • Recommend a long acting reversible contraceptive (IUD or implant) • Consult the US MEC before making a recommendation

  16. 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 • Google  USMEC http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm

  17. WHOCDC US MEC Existing WHO guidance adapted for U.S. • 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

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

  19. US Medical Eligibility Criteria for Contraceptive Use

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

  21. US MEC Categories

  22. MEC – Diabetes Methods with Estrogen There is an increased risk of thrombosis for women with diabetes who have nephropathy, retinopathy, neuropathy, other vascular disease or diabetes of more than 20 year duration.

  23. MEC – DiabetesProgestin-Only Methods Some concern particularly with DMPA, that reduced HDL effects may be more prominent among diabetics with micro- and macro-vascular disease. Thus, older diabetic women and those with vascular disease should probably not use Depo because of increases risk profile for atherosclerosis.

  24. MEC – DiabetesIUDs IT’S ALL GREEN!!! Overweight women have excess estrogen which increases their risk for endometrial cancer. The LNG-IUS may lower this risk by providing balancing progesterone.

  25. Trudy 16 y/o G0 with 4 boyfriends in the last year; she’s been sexually active with 3 of them. She desires an LNG IUS because her older sister has one and likes it. She had chlamydia cervicitis diagnosed and treated 4 months ago. She asks what you recommend: • Pill, patch, ring • IUD with condoms • Depo with condoms • Stop having sex, you’re only 16!

  26. IUDs • LNG IUS (Mirena) • 5 years • 1% failure rate • Copper T380A (Paraguard) • 10 years • 1% failure rate

  27. Would you place an IUD for a patient with… • A history of PID? • Yes • No

  28. PID by duration of IUD use Rate per 1000 Woman- Years 21 days - 8 years 20 days Duration of Use n=20,000 women. Baseline PID risk: 1-2 cases /women yrs Adapted from Farley T, et al. Lancet. 1992;339:785-788.

  29. IUDs Do Not Cause PID Preexisting STI at time of insertion, not the IUD itself, increases risk No reason to restrict use based on sexual behaviors STI/PID risk similar with and without the IUD Category 2 Svensson L, et al. JAMA. 1984. Sivin I, et al. Contraception. 1991. Farley T, et al. Lancet. 1992. Grimes, DA, Lancet, 2000

  30. IUDs and Infertility The use of an IUD has what effect on future fertility? • Decreases it • Increases it • No effect

  31. IUDs do not appear to cause infertility • Case control study • > 1500 women with tubal infertility • No association with past IUD use • Positive association with antibody to chlamydia Hubacher, 1995

  32. IUDs and nulliparous women IUDs safe and effective in nulliparous women No increase in infertility LNG-IUS appropriate for nulliparous women with menorrhagia and/or dysmenorrhea IUD expulsion, bleeding, and pain are slightly more likely among nulliparous women Category 2

  33. Difficult insertions • Non-insertion • Reported incidence: < 1% to 8.8% • Non-insertion related to • Experience of provider • No prior vaginal delivery • Pain • RCT of ibuprofen vs. placebo 30-45 minutes before insertion • No reduced pain in either nullips or multips • Nullips experience more pain with insertion

  34. IUDs and teenagers Category 2 • Little data • Higher continuation with LARC than with shorter term methods (84.5% at 1 year) • ACOG: “First line” method • Adolescents are twice as likely as women > 30 to become pregnancy when using OCs • Continuation and satisfaction are high Deans, Contraception, 2002

  35. Key messages: FDA-approved “new” ParaGard label

  36. Would you place an IUD for a patient with… • A history of ectopic pregnancy? • Yes • No

  37. IUDs and ectopic pregnancy • Prior ectopic traditionally a contraindication • Mirena package insert • “Warning” • US MEC supports routine use of IUDs in women with a history of ectopic pregnancy Category 1

  38. Trudy decides on the LNG IUS, but says, by the way, I had unprotected sex 2 days ago…. A. Insert the LNG IUS • Give Ella and insert the LNG IUS C. Give Plan B and insert the LNG IUS • Give Plan B and have her return for insertion in 2 weeks after pregnancy test • Give Ella and have her return for insertion in 2 weeks after pregnancy test

  39. Emergency contraception • Levonorgestrel • Plan B One Step (1.5 mg LNG X 1) • Plan B (0.75 mg LNG x 2) • Next Choice (0.75 mg LNG x 2) • OTC for 17 and older • Ulipristal acetate • Ella - 30 mg ulipristal • Rx needed for all age groups • More effective up to 5 days after intercourse • Single pill, few side effects • Comparably priced @ $30-40

  40. Queen of EC! • Most effective • Works for long-term contraception • 412 women/adolescents asked about interest in copper IUD for EC: -12% desired same-day insertion -22% wanted more info about IUDs Schwarz, OB-GYN 2011

  41. When do you usually place an IUD? • Never • When a patient is on her menses • Anytime a patient wants one and she is not pregnant • After a separate visit for Pap/cultures • After a separate visit for Pap/cultures and on her menses

  42. IUD insertion screening Evidence supports no routine screening tests CT/GC in high risk or < 26 y/o Pregnancy test if at risk for pregnancy Pap smear only if due and not till age 21 Hematocrit only if anemia suspected Any screening test can be done on the day of IUD insertion Grimes, Lancet, 2004

  43. Timing of insertion • When she presents for contraception • Within minutes postpartum • 4-6 weeks postpartum • Post-abortion • Removal and reinsertion at same visit

  44. IUD Summary—First Line Contraception for Almost All Women • The IUD does not cause PID • The IUD does not cause infertility • The IUD does not increase risk for ectopic pregnancy • IUDs may be used in nulliparous women

  45. Samantha 17 year old who is breastfeeding the baby girl she delivered yesterday. Asking for the contraceptive implant before she goes home from the hospital. Do you: • Place the Implant? • Tell her she can get the implant at her PP visit? • Recommend birth control pills instead? • Recommend progesterone only pills instead? • Tell her not to have sex?

  46. MEC – Estrogen Containing Methods Immediately Postpartum < 21 days PP –category 4 21 – 42 days PP – risk factors – category 3 21 – 42 days PP – NO risk factors – category 2

  47. MEC – PostpartumProgestin-Only Methods • Breastfeeding: < 1 mo Category 2 > 1 mo Category 1 • Not Breastfeeding: <21 days Category 1 21 – 42 days Category 1

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