complex contraception...lng-ius or copper iud pelvic inflammatory disease past pid, subsequent...
TRANSCRIPT
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Complex contraceptionJennifer Kerns, MD, MPHAssistant Professor, UCSFObstetrics, Gynecology and Reproductive SciencesSan Francisco General HospitalOctober 2014
Disclosures• I have no relevant financial disclosures
Objectives• To review resources for assessing the safety of contraceptive methods for particular women
• To review the evidence for selected practice recommendations for women with particular medical issues
• To emphasize the need for contraception especially for medically complicated women
Contraceptive Prevalence & Maternal Deaths
Ahmed et al. Lancet. 2012
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Are you familiar with the US Medical Eligibility Criteria for Contraception?
a. b.
16%
84%
a. Yesb. No
Are you familiar with the US Selected Practice Recommendations for Contraception?
a. b.
42%
58%a. Yesb. No
Can my patient use this method?
CDC Medical Eligibility Criteria• Evidence-based guidelines for safety of methods with co-existing conditions
• Similar to WHO but US-specific www.cdc.gov/mmwr/preview/mmwrhtml/rr59e0528a1.htm
CDC Medical Eligibility Criteria (MEC)
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MEC Categories1 Can use the method No restrictions2 Can use the method Advantages generally
outweigh theoretical/proven risks
3 Should not use method unless no other method is appropriate
Theoretical/proven risks generally outweigh advantages
4 Should not use method Unacceptable health risk
Medical Condition
Birth Control Methods
MEC Category
Where do you find the US MEC?
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ACOG Resource New Textbook
Case #119 yo G0, newly sexually active, wants to start the contraceptive vaginal ring. But she is concerned about what she has read in the news about the ring causing blood clots.
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DVT Risk with the Contraceptive Vaginal Ring (CVR)• Retrospective cohort: 9,429,128 woman years• Confirmed VTE events per 10 000 woman years▫ Non-users of hormonal contraception 2.1▫ Combined Oral Contraceptives 6.2 (RR 3.2)▫ Transdermal patches 9.7 (RR 7.9) ▫ Vaginal ring 7.8 (RR 6.5)
Ring +1.6 additional cases / 10,000 women-years. Adjusted Rate Ratio 1.9 (1.3-2.7) v. COC
Lidegaard et al. BMJ 2012
DVT Risk with the Contraceptive Vaginal Ring (CVR)
• Prospective cohort - 66 489 woman years of observation• Confirmed VTE events per 10 000 woman years▫ LNG COC 7.8▫ All COC 9.2▫ Vaginal ring 8.3
Ring - no increased risk compared with any pill. HR 0.8 (0.5-1.5)
Dinger et al. Obstet Gynecol 2013
DVT Risk with the Contraceptive Vaginal Ring (CVR)• Retrospective cohort - 573, 680 women• Confirmed VTE events per 10 000 woman years▫ All COC – new users 8.2 (7-9.6)▫ Vaginal ring 11.3 (4.26-32)
Ring - no increased risk compared with the pill (after adjustment)HR 1.1 (0.6-2.2)
Sidney et al. Contraception 2013
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Case #119 yo G0, newly sexually active, wants to start the
contraceptive vaginal ring. • Conflicting level 2 evidence – may cause slight
increase risk relative to COC• Attributable risk = very, very small• Level I evidence that women use it correctly
compared with pill• May cause fewer unintended pregnancies and
therefore fewer VTE overall
VTE & Oral Progestin Type• Desogestrel and drosperinone COCs may increase risk of VTE
• BUT. . . Absolute risk remains lowNon-pregnant, no COCs: 2-4 per 10,000 ♀- yrs• Levonorgestrel COCs: 5.0 per 10,000 ♀- yrs• Desogestrel COCs: 6.5 per 10,000 ♀- yrs• Drosperinone COCs: 7.8 per 10,000 ♀- yrs
Lidegaard BMJ 2009 Heinemann Contraception 2007
Choosing a COC• Careful with very low-dose estrogen – ↑ bleeding• Monophasic fine• Levonorgestrel may cause fewer VTE• No clear benefit of drospirenone▫ PMDD: fewer sxs 6 months – equivalent at 2 yr▫ Acne: Equivalent to other pills
• 30 or 35 mcg EE + levonorgestrel• Shortened or erased placebo week if possible• Monophasic
VanViet Cochrane 2006LaGuardia Contraception, 2003Freeman Womens Health 2001van Vloten Cutis 2002
CDC MEC
All progestin-only methods are safe even if:
1) Current VTE2) No anti-coagulation3) Provoked or unprovoked VTE
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Case #238 yo G2P1T1 woman is seeking contraception.
She had pre-eclampsia during her last pregnancy but otherwise reports she is healthy.
Wt= 226 lbsHt= 5’5” (BMI = 37.6)
BP=138/89
Obesity and Contraception
Institute of Medicine. Weight gain in pregnancy: Reexamining the guidelines
Efficacy•Pharmacokinetics•Oral vs. non-oral•Risk of pregnancy
Adverse events•Risk of VTE•Risk of CV events•Metabolic effects
–Weight gain? Lipid profiles?
Obesity & Contraceptive Efficacy
1 Lopez LM Cochrane 2010 2 McNicholas Obstet Gynecol 2013 3 Edelman Contraception, 20094 Westhoff Obstet Gynecol 2005 5 Zieman Fertil Steril 2002
DMPA: no difference1
Ring: no difference1,2
Implant: lower serum level, but still inhibitory1,4
IUC: no difference
OCs: no clear difference; longer time to steady state1,2
Patch: increased failure5 if >90kg• BUT BMI more relevant measure• No effect with BMI1,2
Obesity & Contraceptive Risks• VTE risk▫ COCs & obesity are independent risk factors for VTE� Obesity doubles risk of VTE
▫ No data show synergistic, increased risk ▫ Risk is lower than pregnancy (29/10,000 ♀-yrs)
Note: no safety information on women with BMI >40
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Contraception & Weight Gain• Pill, Patch, Ring: none or age-expected change1,2,3,6
• LNG-IUS: age-expected weight gain4
• ENG implant: minimal if any effect5
• DMPA:
1. O’Connell 2001 Contraception; 2. Gallo 2004 Obstet Gynecol; 3. Berenson AJOG 20094. Ronnerdag Acta Obstet Gynecol Scand 1999 5. Darney Fertil Steril 2009 6. Beksinka Contraception 20107. Pantoja Contraception 2010 8. Bonny Contraception 2010
Pantoja 2010
•Average 5-6 kg over 3-5yrs3,6•Baseline BMI:
•Nl and overwt = �risk7•No assoc for adolescents8
•Adolescents:•More pronounced wt gain5
•Early wt gain @ 6mo (>5%) predicts future wt gain8
BMI>30
BMI 25-30
BMI<25
Metabolic Syndrome• Constellation of findings which increase risk of CHD,
stroke, & type 2 DM
• 3 or more risk factors▫ Hypertension ▫ Insulin resistance▫ Central obesity▫ High triglycerides▫ Low HDL
≥130/85FBS ≥100Waist circumference ≥35”≥150 mg/dL≤ 50mg/dL
Metabolic Syndrome & ContraceptionLIPIDS CHC: �TGL, HDL, �LDL1
For PCOS, improved LDL/HDL ratio2
DMPA: transient worsening of lipids post-injection3
ENG Implant: � Chol, LDL, HDL4,5
BLOOD PRESSURE
OCP: 5% develop reversible HTN (7mm Hg)6
INSULIN RESISTANCE
No DM:• OCs, LNG-IUS, implant: No impact7
• Ring: improved IR in PCOS8
• DMPA: no effect9 vs. small increase in FBS (3mg/dL over 2yrs)10
For obese women: DMPA increased IR v. non-obese women+ DM:• DMPA: No RCTs. Increase in FBG 103-112• OCP: No increase in insulin requirement or end-organ damage11
1. Winkler 2009 Contraception 2. Falsetti 1995 Acta Obstet Gyn Scand 3. WHO 1993 Contraception4. Merki-Feld 2008 Clin Endocrinol 5. Inal 2008 Eur J Contr Reprod HC 6. Darney & Speroff 2005 Clin Guide for Contraception7. Grimes 2009 Cochrane 8. Battaglia 2009 Fertil Steril 9. Fahmy 1991 Contraception 10. Berenson 2011 Obstet Gynecol 11. Skouby 1984 Fertil Steril
CDC MEC
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Bariatric Surgery & Contraception• Advisable to wait 1-2 years after surgery
before planning pregnancy1• Fecundity & pregnancy rates often
increase after surgery2,3
▫ Especially in adolescents(13% vs. 6%)▫ Prevent unintended pregnancy
• Recommend non-oral methods for surgeries that impair GI absorption4
▫ Decreased absorption of OCPs1. ACOG Practice Bulletin 105, 20092. Merhi 2007 Fertil Steril3. Roeherig 2007 Obes Surg4. Mehri 2007 Gynecol Obstet Invest
CDC MEC
Oral absorption
Case #2
38 yo G2P1T1 obese woman desires birth control
• Assess for other risk factors• If none, all methods are safer than pregnancy• If smoker or other risk factors – may avoid CHC• DMPA – concern for insulin resistance and weight gain• For EC – recommend ulipristal acetate or Cu-IUD
Case #3An 18yo G0 presents having had unprotected sex the night before, requesting emergency contraception. Her BMI is 34.She had been using pills, but had a hard time remembering to take them.What do you offer her?
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Emergency Contraception Oral Emergency ContraceptionLNG: 120 mg x 1, up to 5 days
Ulipristal Acetate:• Selective progesterone receptor modulator• Mechanism:Delayed follicular rupture• Will not harm existing pregnancy• Dosing: 30mg, FDA-approved up to 5 days
1. Brache 2010 Hum Reprod
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EC pills (LNG) less effective for obese women
Glasier A et al. Contraception. 2011.
Misinformation about LARC
Percent of women pregnant after taking EC pills
Emergency contraception
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Case #423 yo G0 is interested in using an IUD.History of chlamydia in college.She has had 3 male partners in the past year.Do you screen her for GC/CT?
Can women who have no children use an IUD?
Yes!
Misinformation about LARC
Veldhuis H. Eur J Gen Pract. 2004.Suhonen S et al. Contraception. 2004.Thonneau P et al. Human Reprod. 2006.ACOG Committee Opinion 539. Obstet Gynecol. 2012.
Some considerations…• Skyla (13.5mg LNG, 3yrs)• Pre-insertion pain medication• Paracervical block
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Can women with a history of STIs use an IUD?Yes! Past infections are not a contraindication to any method of contraception.
Misinformation about LARC
ACOG Practice Bulletin. Obstet Gynecol. 2005.Skjeldestad, et al. Contraception. 1996.Centers for Disease Control. MMWR. 2010.
CDC Medical Eligibility for Initiating Contraception
ConditionLNG-IUS or Copper IUD
Sexually Transmitted Infections
Current vaginitis 2
Current chlamydia, gonorrhea, or purulent cervicitis
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Can women with a history of PID use an IUD?Yes! Women with PID history can use IUDs.Active PID is a contraindication
Misinformation about LARC
ACOG Practice Bulletin. Obstet Gynecol. 2005.Skjeldestad F et al. Contraception. 1996.Centers for Disease Control. MMWR. 2010.
CDC Medical Eligibility for Initiating Contraception
ConditionLNG-IUS or Copper IUD
Pelvic inflammatory disease
Past PID, subsequent pregnancy 1
Past PID, no subsequent pregnancy
2
Current PID 4
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What we know about IUDs and PID• Unprotected sex w/ infected partners� PID• Transient increased risk at insertion
▫ 22,908 insertions: � 9.7/1000 w/in 20 days � 1.4/1000 after 20 days
• Beyond time of insertion▫ Overall decreased risk with LNG IUS ▫ No increased risk with Copper IUD
Farley Lancet 1992Walsh Lancet 1998
Routine GC/CT screening not necessary
� Retrospective cohort, n=57,728 IUD insertions� Evidence-based STI screening, tx if + test
Sufrin et al Obstet Gynecol 2013
Among all women: Risk of PID
Non-screened = ScreenedOR= 1.05 (0.78, 1.43)
Among screened women:Risk of PID
Same day = Pre-insertionOR=0.99 (0.64, 1.54)
Women appropriately selected for non-screening
Most accurate screening time is day of insertion
Who should be screened?• CDC and USPSTF guidelines for GC/CT screening at IUD insertion▫ Annually if < 26 yo and sexually active▫ Any time if risk factors (new partner, sx’s, other STI)
• Screen on same day as insertion• No cases of PID when Planned Parenthood switched to same day screening
• No benefit to prophylactic antibioticsUSPSTF Am J Prev Med 2001 CDC MMWR #59 2010 Goodman Contraception 2008Grimes Contraception 1999
Conclusions• Contraception is important for women with medical problems
• There are many methods that are appropriate for any given medical problems
• Consult the appropriate resources to help guide contraception recommendations