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Contraception and Chronic Disease: Which Patient, Which Method?

Contraception and Chronic Disease: Which Patient, Which Method?. US Medical Eligibility Criteria for Contraceptive Use, 2010. Wendy Grube, PhD, CRNP University of Pennsylvania School of Nursing. Disclosure. No Conflicts of Interest. Contraception. Half of pregnancies are unintended

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Contraception and Chronic Disease: Which Patient, Which Method?

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  1. Contraception and Chronic Disease: Which Patient, Which Method? US Medical Eligibility Criteria for Contraceptive Use, 2010 Wendy Grube, PhD, CRNP University of Pennsylvania School of Nursing

  2. Disclosure No Conflicts of Interest

  3. Contraception • Half of pregnancies are unintended • Half of unintended pregnancies result from inconsistent or incorrect contraceptive use • Risk of method vs. risk of pregnancy • What is the most important issuefor the clinician prescribing contraception?

  4. Unintended Pregnancy Poses Increased Risks for Adverse Health Events in… • Breast Cancer • Complicated valvular heart disease • IDDM with complications • Endometrial/ovarian cancer • Epilepsy • Hypertension (systolic >160, diastolic >100) • Bariatric surgery in past 2 years • HIV/AIDS • Ischemic HD • Malignant gestational trophoblastic disease • Hepatic malignancies • Peripartum cardiomyopathy • Schistosomiasis with liver fibrosis • Severe cirrhosis • Sickle cell disease • Solid organ transplant in past 2 years • Stroke • SLE • Thrombogenic mutations • Tuberculosis CDC, MMWR, May 28, 2010

  5. CDC: US MEC 2010 BASED ON THE CURRENT SCIENTIFIC EVIDENCE • Category 1: • No restrictions for use • Category 2: • Advantages of method outweigh the theoretical or proven risks: careful follow-up may be required • Category 3: • Theoretical or proven risks outweigh the advantage of a method: generally not recommended • Category 4: • Unacceptable health risk if method used

  6. CDC Changes from WHO MEC Modifications Additions • VTE • Valvular heart disease • Ovarian cancer • Uterine fibroids • Postpartum • Breastfeeding • RA • Bariatric surgery • Peripartum cardiomyopathy • Endometrial hyperplasia • IBD • Solid organ transplant CDC, MMWR, May 28, 2010

  7. Combined Hormonal Contraception Pills, patches, and rings

  8. Age Menarche to <40 years • Category 1 > 40 years old • Category 2 Smoking • <35 and smoke: 2 • >35 and smoke <15/day: 3 • >35 and smoke > 15/day: 4

  9. Breastfeeding < 1 month postpartum • Category 3 1-6 months postpartum • Category 2 6 months postpartum • Category 2

  10. Postpartum & Postabortion Postpartum: < 21 days • Category 3 21 days • Category 1 Postabortion Immediately post abortion 1st or 2nd trimester • Category 1

  11. Obesity BMI > 30 • Category 2 • Possible increased risk of VTE, MI, stoke • Inconsistent evidence about body wt and efficacy • NOT more likely to gain

  12. Bariatric Surgery Restrictive procedures: gastric band or sleeve • Category 1 Malabsorptive procedures • COCs: Category 3 • P/R: Category 1

  13. CVD: Hypertension Adequately controlled: • Category 3 Elevated BP levels: S 140-159 OR D 90-99 • Category 3 S > 160 OR D > 100 • Category 4 Vascular disease • Category 4 Hypertension during pregnancy • Category 2

  14. CVD: DVT & PE Hx of DVT/PE NOT on anticoagulant Higher risk of recurrence • Estrogen associated • Pregnancy associated • Idiopathic • Thrombophilia • Cancer • Hx recurrence Category 4 Lower risk for recurrence Category 3

  15. CVD: DVT & PE Acute DVT/PE • Category 4 DVT/PE on anticoagulant for at least 3 months Higher risk of recurrence • Thrombophilia • Cancer • Recurrence Category 4 Lower risk of recurrence • No risk factors Category 3

  16. CVD: DVT & PE Family History: 1st degree • Category 2 Major surgery • Prolonged immobilization • Category 4 • No prolonged immobilization • Category 2 Minor surgery: no immobilization • Category 1 Known thrombotic mutations • Category 4 • COC users had a 2-20 fold high risk for thrombosis Superficial venous thrombosis • Varicose veins • Category 1 • Superficial thrombophlebitis • Category 2

  17. CVD and CHC Ischemic heart disease: current or history • Category 4 Stroke • Category 4 Known hyperlipidemias • Category 2/3 • Depends on type, severity, other risk factors Valvular heart disease • Uncomplicated • Category 2 • Complicated Peripartum cardiomyopathy: mild • < 6 months • Category 4 • > 6 months • Category 3 • Moderate or severe • Category 4

  18. Rheumatic Diseases SLE • Positive or unknown APL antibodies: C4 • Thrombocytopenia: C2 • Immunosuppression: C2 • None of above: C2 RA • Immunosuppression: C2 • Non-suppressed: C2

  19. Neurologic Conditions Headaches Not migraines: Initiate: C1 Continue: C2 Migraines: No aura <35 years old Initiate: C2 Continue: C3 > 35 years old Initiate: C3 Continue: C4 Migraines: with aura, and age Initiate or continue: C4 Epilepsy • Category 1 • Watch drug interactions Depressive disorders • Category 1 • No data on bipolar or postpartum disorders

  20. Reproductive Tract Disorders Category 1 • Irregular, heavy, or prolonged bleeding • Endometriosis • Benign ovarian tumors • Severe dysmenorrhea • Gestational trophoblastic disease • Benign breast disease, or FHx of cancer • STIs/PID/HIV/AIDS • Endometrial hyperplasia • Endometrial or ovarian cancer • Fibroids Category 2 • Unexplained vaginal bleeding • Undiagnosed breast mass • CIN/cervical cancer awaiting treatment Category 3 • Past breast cancer with no evidence of disease for 5 years Category 4 • Current breast cancer

  21. Endocrine & GI Disorders Diabetes Gestational • Category 1 Nonvascular disease • Category 2 Vascular disease • Categories 3/4 • Depends on severity Thyroid disorders • Category 1 ________________________ Liver tumors • Benign • Focal nodular hyperplasia: C2 • Hepatocellular adenoma: C4 • Malignant : C4 Inflammatory bowel disease • Category 2/3 • Depends on risk for VTE Gallbladder disease • Asymptomatic: C2 • Symptomatic, surgery: C2 • Medical treatment: C3 Cholestasis • Pregnancy related: C2 • COC related: C3 Cirrhosis • Mild: C1 • Severe: C4 Viral Hepatitis • Acute: C3/4 (with severity) • Chronic/carrier: C1

  22. Other Conditions Anemias Thalassemia • Category 1 Iron deficiency • Category 1 Sickle cell disease • Category 2 Solid organ transplant • Complicated (rejection, graft failure) • Category 4 • Uncomplicated • Category 2

  23. Drug Interactions with CHC Antiretroviral therapy • NRTIs: Category 1 • NNRTIs: Category 2 • Ritonavir-boosted protease inhibitors: C3 Anticonvulsant therapy • Decrease effectiveness • Minimum 30μg EE use • Lamictil: possible increased seizures Antimicrobial therapy • Broad-spectrum antibiotics: Category 1 • Antifungals: Category 1 • Antiparasitics: Category 1 • Rifampin: Category 3

  24. Progestin-Only Contraceptives Pills, injections, implants

  25. Conditions Age: C1 POP, C2 DMPA <18 or >45 Breastfeeding • < 1 month: Category 2 • > 1 month: Category 1 Postpartum: Category 1 Postabortion: Category 1 Past ectopic: C2 for POP only Smoking: Category 1 Obesity: C1; C2 <18 Bariatric: C3 for malabsorptive procedures

  26. Cardiovascular Disease Hypertension Adequately controlled • POP, I: Category 1 • DMPA: Category 2 Elevated BP levels S 140-159/D 90-99 • POP, I: Category 1 • DMPA: Category 2 S > 160/D > 100 • POP/I: Category 2 • DMPA: Category 3 HBP during pregnancy: C1 DVT/PE History or acute • Category 2 On or off anticoagulant • Category 2 Major surgery/immobilized • Category 2 Thrombotic mutations • Category 2 Family History • Category 1 Superficial thrombosis • Category 1

  27. Cardiovascular Disease Ischemic heart disease • Initiation: POP, I: C2 • DMPA: C3 • Continuation: POP, I: C3 Stroke • Same as IHD Hyperlipidemia • Category 3 for all Valvular heart disease • Category 1 for all Peripartum cardiomyopathy • Mild: Category 1 • Moderate/severe: C2

  28. Other Conditions Rheumatic Neurologic SLE • Positive or unknown APL antibodies: C3 • Severe thrombocytopenia: C3 • Immunosuppressed: C2 RA • C1 for POP, I • C2 for DMPA Headaches, non-migraine • Category 1, all Migraines • No aura, C2 (C1 start OC) • Aura: C2 start, C3 continue Epilepsy: C1 Depressive disorders: C1

  29. Reproductive Tract Conditions Category 1: • Endometriosis • Benign ovarian tumors • Severe dysmenorrhea • Gestational trophoblastic disease • Benign breast disease • FHx breast cancer • Endometrial hyperplasia or cancer • Ovarian cancer • Uterine fibroids • STIs, PID • HIV/AIDS Category 2: • Irregular, heavy, or prolonged vaginal bleeding • CIN/Cervical cancer (DMPA) • Undiagnosed breast mass Category 3: • Past breast cancer (>5 years) • Unexplained vaginal bleeding Category 4: Current breast cancer

  30. Endocrine and GI Conditions Endocrine GI Thyroid: Category 1 Diabetes • Gestational: C1 • No vascular disease: C2 • Vascular disease: • POP, I: C2 • DMPA: C3 Inflammatory bowel disease: • POP, DMPA: C2 • Implants: C1 Gallbladder disease: C2 COC-related cholestasis • Category 2 Viral hepatitis: C1 Severe cirrhosis: C3 Liver tumors: C2/3

  31. Other Conditions Anemias • Category 1 Solid organ transplant • Category 2 Drug interactions: • Anticonvulsants: • Lamotrogine: C1 • Others: DMPA: C1 • Implant: C2 • POPs: C3 Antiretroviral therapy • DMPA: C1 for all • NRTIs: C1 for all methods • NNRTIs: C2 POPs and I • Ritonavir-boosted PIs: C3 for POPs; C2 for I Antimicrobials: all C1 except • Rifampin: C1 DMPA • C2 Implant • C3 POPs

  32. Emergency Contraceptive Pills Category 1 • Breastfeeding • Hx ectopic • Bariatric surgery • RA • IBD • Solid organ transplant • Repeated use • Rape Category 2 • Severe CVD • Angina • Migraine • Severe liver disease

  33. Intrauterine Devices Copper and levonorgestrel-releasing

  34. Conditions Age • Menarche to <20: C2 • > 20: Category 1 Nulliparous women: C2 Postpartum: Category 2 • Cu: C1 < 10 minutes PP • Puerperal sepsis: C4 Postabortion • First trimester: C1 • Second trimester: C2 Past ectopic history • Category 1 Smoking • Category 1 Obesity • Category 1 Bariatric surgery • Category 1

  35. Cardiovascular Disease Hypertension • Category 1 except • S >160/D>100 & vascular disease: LNG C2 DVT/PE • Cu: Category 1 • LNG: Category 2 Acute DVT/PE: C2 both Known thrombogenic • Category 2 Ischemic heart disease • Category 2: LNG • Category 1: Cu Stroke, hyperlipidemia • Category 2: LNG • Category 1: Cu Valvular heart disease • Category 1 • No antibiotic prophylaxis Peripartum cardiomyopathy: C2 both

  36. Other Conditions Rheumatic Neurologic SLE • Positive APL antibodies • LNG: C3 Cu: C1 • Severe thrombocytopenia • LNG: C2 Cu: C3 • Immunosuppressed • Both: C2 RA • Immunosuppressed: C2 • Not suppressed: C1 Migraine • With/without aura • LNG: C2 Cu: C1 Epilepsy • Category 1 (both) Depressive disorders • Category 1 (both)

  37. Reproductive Tract Conditions Irregular bleeding • Category 1 (both) Heavy, prolonged • LNG: C1 Cu: C2 Unexplained bleeding • Category 4 initiation Endometriosis • LNG: C1 Cu: C2 Benign ovarian tumors • Category 1 (both) Severe dysmenorrhea • LNG: C1 Cu: C2 STIs: C2 CT/GC: C4 (initiation) PID: Hx: C1 with subsequent pregnancy; C2 without • Current: C4 Gestational trophoblastic Dx • Category ¾ CIN • LNG: C2 Cu: C1 Cervical cancer (await Rx) • Category 4: initiation Breast mass, cancer • LNG: C2/3/4 Cu: C1 Endometrial hyperplasia • Category 1 (both) Endometrial cancer: C4 Ovarian cancer: C1 Uterine fibroids: C2 Anatomic abnormalities: C4 HIV: C2 AIDS: C3 Pelvic Tb: Category 4

  38. Endocrine and GI Disorders Diabetes • Gestational: C1 • Treatment: Cu: C1 LNG: C2 Thyroid • Category 1 IBD: Category 1 Gallbladder disease • Cu: C1 LNG: C2 Viral hepatitis: C1 Cirrhosis: Mild, C1 • Severe: LNG: C3 Cu: C1 Liver tumors: Cu: C1 • FNH: LNG: C2 • Adenoma, hepatoma: LNG: C3

  39. Other Issues Anemias • LNG: C1 Cu: C2 Solid organ transplant • Uncomplicated • Category 2 (both) • Complicated • Category 3 initiation Drug interactions • Antiretroviral therapy • Clinically well on ARV: initiation drops to C2 • Anticonvulsants • Category 1 • Antimicrobials • Category 1

  40. Barrier Methods Condoms, Spermicides, diaphragms

  41. Category 1 Except… Cervical cap +/- diaphragm • Parous women: C2 • Complicated valvular HD • High risk for HIV: C4 • HIV/AIDS: C3 • Toxic shock Hx: C3 • UTI: C2 • Allergy to latex: C3 Spermicides • Cervical cancer: C2 • High risk for HIV: C4 • HIV/AIDS: C3

  42. Thank you for your attention

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