contraceptive update: cdc medical eligibility criteria for women with certain characteristics and...
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Contraceptive Update: CDC Medical Eligibility Criteria for Women With Certain Characteristics and Medical ConditionsARHP Learning Lab May 18, 2011
Emily Godfrey, MD, MPH
Expert Medical Advisory Committee
Melanie Deal, WHNPStudent Health Services, SF State UniversitySan Francisco, CA
David Grimes, MD University of North Carolina School of MedicineChapel Hill, North Carolina
David Turok, MDUniversity of Utah, Dept. of Ob/GynSalt Lake City, UT
Susan Wysocki, WHNP-BC, FAANPNational Association of NPs in Women’s Health Washington, DC
Learning Objectives• List the 4 levels in the numeric scheme
described in the US Medical Eligibility Criteria for Contraceptive Use, 2010
• Explain the application of the numeric scheme to prescriptive practices for women with co-morbid conditions
• Describe the risks and benefits of the different contraceptive methods against the risks of pregnancy in women with health-related concerns
Unplanned pregnancy – U.S. Unintended Pregnancy
Intended
Unintended (49%)6.4 million pregnancies
51%
7%
20%
22%
Fetal Loss
Abortion
Birth
Finer LB, et al. Persp Sex Reprod Health. 2006.
1.2 million
1.4 million
Goals to Address Unintended Pregnancy
• Healthy People 2020▪ Increase proportion of pregnancies that are intended
▫ 51% 56%▪ Reduce proportion of females experiencing pregnancy despite
reversible contraception use▫ 12.4% 9.9%
• CDC Winnable Battles▪ Public health priorities with large-scale impact on health and with
known, effective strategies to intervene ▪ To identify optimal strategies and to rally resources and partnerships
to accelerate a measurable impact on health▪ Prevention of teen pregnancy is one of the 6 winnable battles
http://healthypeople.gov/2020/http://www.cdc.gov/winnablebattles/teenpregnancy/index.html
Typical Effectiveness of Contraception
Adapted from: WHO. Family Planning: A Global Handbook
Long acting reversible contraceptives (LARCs)
Tier 1
Tier 2
Tier 4
Tier 3
Contraception Use
Mosher, W et al. 2010.
Improving Contraception Access• Improve access to and use of the most effective
contraceptives• Address barriers to use of Long Acting Reversible
Contraceptives (LARC)• Educate Providers
▪ Ensure dissemination of US MEC▪ Recommend that young women and nulliparous may be eligible to
use LARC methods
• Increase interest and acceptance through education and social marketing
• Address cost barriers to ensure publically funded services include LARC
http://www.cdc.gov/winnablebattles/teenpregnancy/index.html
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
http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm
WHOCDC US MEC
Existing WHO guidance• 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
WHOCDC US MEC
New medical conditions• Rheumatoid arthritis• Endometrial hyperplasia• Inflammatory bowel disease• Bariatric surgery• Solid organ transplantation• Peripartum cardiomyopathy
US Medical Eligibility Criteria for Contraceptive Use
US Medical Eligibility Criteria: Organization• Criteria are organized according to:
– Contraceptive method
– Patient characteristics (age, smoking status, etc.)
– Preexisting conditions (hypertension, epilepsy, etc.)
• Criteria use a numeric scheme to provide the recommendations for contraceptives being used for contraceptive purposes only, not for treatment of medical conditions
http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf
1 No restriction for the use of the contraceptive method for a woman with that medical condition
2Advantages of using the method generally outweigh the theoretical or proven risks
3
Theoretical or proven risks of the method usually outweigh the advantages – or that there are no other methods that are available or acceptable to the women with that medical condition
4Unacceptable health risk if the contraceptive method is used by a woman with that medical condition
US Medical Eligibility Criteria: Categories
http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf
Conditions Associated w/ ↑ Risk for Adverse Heath Events as a Result of Unintended Pregnancy
Breast cancerMalignant liver tumors (hepatoma) and hepatocellular carcinoma of the liver
Complicated valvular heart disease Peripartum cardiomyopathy
Diabetes: insulin dependent; with nephropathy/retinopathy/neuropathy or other vascular disease; or of >20 years’ duration
Schistosomiasis with fibrosis of the liver
Endometrial or ovarian cancer Severe (decompensated) cirrhosis
Epilepsy Sickle cell disease
Hypertension (systolic > 160 mm Hg or diastolic > 100 mm Hg)Solid organ transplantation within the past 2 years
History of bariatric surgery within past 2 years Stroke
HIV/AIDS Systemic lupus erythematosus
Ischemic heart disease Thrombogenic mutations
Malignant gestational trophoblastic disease Tuberculosis
http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf
US Medical Eligibility Criteria: ↑ Risk for Adverse Health Events
Should consider long-acting, highly-
effective contraception for
these patients
Pregnancy-Related Mortality• Increase in pregnancy-related mortality, 1998-2005
▪ De-identified death certificates of women who died during or within 1 year of pregnancy
▪ Matched birth or fetal death certificates
• Pregnancy-related mortality ▪ 14.5 per 100,000 live births
▫ African American, 3-4 times greater risk▫ Decreased deaths due to hemorrhage and hypertensive
disorders▫ Increased deaths due to medical conditions, especially
CVD
Berg, CJ et al. Obstet Gynecol. 2010;116:1302-1309.
Case Presentation 1
• Which hormonal methods are safe for her to use?A. Combined hormonal
methods onlyB. Progestin-only
methods onlyC. Any hormonal method
• 30-year-old
• PPD #2
• Ready to be
discharged
from hospital
& desires contraception
• Plans to breastfeed
Breastfeeding
Case Presentation 1
• Which hormonal methods are safe for her to use?A. Combined hormonal
methods onlyB. Progestin-only
methods onlyC. Any hormonal method
• 30-year-old
• PPD #2
• Ready to be
discharged
from hospital
& desires contraception
• Plans to breastfeed
Case Presentation 2
• Is this method safe for her?A. YesB. No
• 25-year-old
• Has Crohn’s
disease
• Desires long-
term reversible
contraception
• Thinking about
levonorgestrel-
releasing IUD
Inflammatory Bowel Disease
Case Presentation 2
• Is this method safe for her?A. Yes (Category 1)B. No
• 25-year-old
• Has Crohn’s
disease
• Desires long-
term reversible
contraception
• Thinking about
levonorgestrel-
releasing IUD
Case Presentation 3• What do you need to
know before deciding whether to recommend this method?A. How much weight has
she lost?B. What type of surgery did
she have?C. What pill formulation did
she use previously?
• 30-year-old
• History of bariatric surgery 6 months ago
• Was using
COCs before
surgery &
wants to restart
Bariatric surgery
• Most effective weight loss treatment for morbid obesity
• From 1998 to 2005, incidence increased 800%
• Women account for 83% of procedures among reproductive age (ages 18-45)
Types of Bariatric surgery
• Restrictive procedures:▪ Decrease storage capacity of stomach▪ Ex: vertical banded gastroplasty, laparoscopic
adjustable gastric band, laparoscopic sleeve gastrectomy
• Malabsorptive procedures:▪ Decrease absorption of nutrients and calories by
shortening functional length of small intestine▪ Ex: Roux-en-Y gastric bypass (most common in
US), biliopancreatic diversion
Bariatric Surgery
• Consensus: Pregnancy should be avoided for 12-24 months after surgery
Paulen, ME et al. Contraception 82 (2010) 86-94.
History of Bariatric Surgery
Case Presentation 3• What do you need to
know before deciding whether to recommend this method?A. How much weight has
she lost?B. What type of surgery did
she have? C. What pill formulation did
she use previously?
• 30-year-old
• History of bariatric surgery 6 months ago
• Was using
COCs before
surgery &
wants to restart
Next Steps
• Work with partners: ▪ dissemination▪ implementation
• Keeping guidance up to date
Updated Guidance from WHOSeptember 2010
What increased risk is posed by use of Combined Hormonal Contraceptives?
• No data specifically delineates risk of CHC use during the postpartum
• Baseline risk of VTE in non-pregnant, non-postpartum women:▪ 2.4-10/10,000 WY
• CHC use increases risk:▪ 3-7 fold
• Risk most pronounced in the first year of use
Previous WHO MEC recommendation
CHCs in postpartum women
< 21 days postpartum 3
≥ 21 days postpartum 1
CHCs for women during the postpartum period
Condition Recommendation Clarification
Postpartum
a. < 21 days
Without other risk factors for VTE
3
With other risk factors for VTE
3/4 The category should be assessed according to the number, severity, and combination of VTE risk factors present.
b. > 21 days to 42 days
Without other risk factors for VTE
2
With other risk factors for VTE
2/3 The category should be assessed according to the number, severity, and combination of VTE risk factors present.
c. > 42 days 1
US MEC-Postpartum period
• New evidence• Updated recommendations from WHO
▪ CDC held consultation in Jan 2011▪ Substantial increased risk in early weeks
postpartum with no benefit ▪ Multiple risk factors
• Access issues• Safety of other contraceptive methods • Will be published as MMWR
Next Steps
• Work with partners: ▪ dissemination▪ implementation
• Keeping guidance up to date• Research gaps• US adaptation of WHO Selected Practice
Recommendations for Contraceptive Use
Resources
• US MEC published in CDC’s Morbidity and Mortality Weekly Report (MMWR):▪ http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a1.ht
m?s_cid=rr5904a1_w
• CDC evidence-based family planning guidance documents:▪ http://www.cdc.gov/reproductivehealth/UnintendedPregna
ncy/USMEC.htm
• WHO evidence-based family planning guidance documents:▪ http://www.who.int/reproductivehealth/publications/family_
planning/en/index.html
Additional Resources
• Association of Reproductive Health Professionals (ARHP)▪ www.arhp.org
• National Association of Nurse Practitioners in Women’s Health (NPWH)▪ www.npwh.org