Medically Complex
Contraceptive
Care
Does 2+2=2 or 3 or 4?
Learning Objectives
• Define medical contraindications to
contraceptive use using the CDC Medical
Eligibility Criteria for Initiating Contraception
• Analyze these guidelines using the
referenced literature
• Accurately discuss the risks and benefits of
medically complex contraception care with
both patients and colleagues
United States Medical Eligibility Criteria
for Contraceptive Use
Risk Level
1
Method can be used without restriction
2
Advantages generally outweigh theoretical or
proven risk
3
Method usually not recommended unless other,
more appropriate methods are not available or
not acceptable
4
http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf
Method not to be
used
Amy
• 24 year old G2P0020
female who comes to the
office with a UTI
• Wants to try the patch.
• BMI = 34
• History of
Hyperlipidemia: LDL =
170
http://www.everystockphoto.com/photo.php?ima
geId=12048627&searchId=d200ace9910e021dc
23256f155816f1f&npos=39
Learning points
• Use every opportunity to ask about
family planning to prevent unintended
pregnancies
• Assess pathophysiology of medical
contraindications
• 2 + 2 sometimes equals 2
• Antibiotics do not decrease efficacy of
contraceptives (except rifampin)
Doreen
• 46 year-old G2P2.
• Would like to remove her
copper IUD and try “the
shot”
• PMH significant for
asymptomatic gallstones
and cervical cancer awaiting
treatment
http://s3.amazonaws.com/ever
ystockphoto/sxc2/17/72/7/afric
an-american-black-17727-l.jpg
Learning Points
• 2 + 2 + 2 can still = 2
• Progestin only methods are
almost always safer than
combined estrogen/progestin
methods
Rosa
• 16 year old G0P0 with a
history of sickle cell disease
presents to your office to
discuss contraception.
• Thinks she would like to try
the IUD “without hormones”
• Detailed history reveals she
was treated for PID last year
• She had unprotected sex 4
days ago, LMP is 3 weeks
ago
http://www.everystockphoto.com/photo.php?imageI
d=8685&searchId=56609ab6ba04048adc2cbfafbe
745e10&npos=380
Category 4 Conditions for IUDs
• Current PID, gonorrhea, chlamydia. (Category 4 for
initiation only).
• Certain anatomic abnormalities. (May interfere with
proper IUD placement).
• Endometrial cancer. (Initiation only).
• Cervical cancer awaiting treatment. (Initiation only).
• Active pregnancy.
• Unexplained vaginal bleeding. (Suspicious for serious
condition).
Quick Start: Progestin IUD or
Implant
Emergency Contraception
• Factors that will affect the efficacy of the
emergency contraception (EC) pill:
– LMP
– Last unprotected sex
– BMI
http://www.wired.com/2011/07/ff_iud/
http://www.voanews.com/content/fda-makes-contraceptive-pillavailable-to-girls-15-and-older/1652135.html
http://optionsforwomenphc.com/wp-content/uploads/2012/07/ella.jpg
Learning Points
• IUDs OK in nullips, teens (even first
line!)
• OK to test for STIs at the time of
insertion as long as not very high risk
or mucopurulent cervix
• The best Emergency Contraception is
the Copper IUD, second best is
ulipristal acetate
Audrey
• 33 year old G3P3
• Happy with her
Combined Oral
Contraceptives
• Migraines without aura
for many years
• Newly diagnosed with
Lupus, so far
uncomplicated
http://www.everystockphoto.com/photo.php?imageId=31
2641&searchId=56609ab6ba04048adc2cbfafbe745e10&
npos=1577
Learning Point
• Remember to assess pathway of
“2” recommendation
• Pregnancy is always a higher risk
than the birth control method
• Vasectomy is an option to
recommend!
Katie
• 28 year old G0P0 comes to you
for her well woman exam. In a
new relationship and would like
to have contraception she
doesn’t have to think about.
• Likes the idea of the progestin
implant
• She has a history of a seizure
disorder which is stable on
carbamazepine, and Type 1
Diabetes which was diagnosed at
age 12
http://s3.amazonaws.com/everystockphoto/fspid30/15/05/38/1/fashionoutdoors-antiquecars-1505381-o.jpg
Learning points
• Keep track of age – many
recommendations change with
age
• Danger of anti-convulsants is
decreasing efficacy of
contraceptives (except lamictal)
Jenny
• 38 years old and recently
diagnosed with colon cancer.
She is scheduled for surgery
in 2 weeks.
• Requests a refill prescription
for birth control pills
• Mother has a history of DVT
http://www.everystockphoto.com/photo.php?imageId=13214175&s
earchId=56609ab6ba04048adc2cbfafbe745e10&npos=782
Key take home points
• Progestin methods safer than combined
estrogen + progestin
• Pregnancy is higher risk than birth control
• Copper IUD generally the safest method
under the woman’s control
• Vasectomy is VERY safe!
References and Resources
•
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Hatcher et al, Contraceptive Technology 2007
Centers for Disease Control and Prevention (CDC). U.S. Medical Eligibility
Criteria for Contraceptive Use, 2010. MMWR Recom Rep. 2010 Jun 18;59(RR4):1-86.
Managing Contraception – book online @ www.managingcontraception.org
Medical Eligibility Criteria for Contraceptive Use 2010 by WHO
www.who.int/reproductive-health
Association of Reproductive Health Professionals www.arhp.org
Alan Guttmacher Institute www.agi-usa.org
Planned Parenthood www.plannedparenthood.org
The Cochrane Collaboration www.cochrane.org
www.Not-2-Late.com
Reproductive Health Access Project www.reproductiveaccess.org
http://www.i-h-s.org/upload/ct_clas/ihc_II_main_no_print.pdf.