Download Contraception and Clinical Disease

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
 Half of unintended pregnancies
result from inconsistent or
incorrect contraceptive use
 Risk of method vs. risk of
pregnancy
 What is the most
important issue for the
clinician prescribing
contraception?
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
CDC, MMWR, May 28, 2010
 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: 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
CDC Changes from WHO MEC
Additions
Modifications
 VTE
 RA
 Valvular heart disease
 Bariatric surgery
 Ovarian cancer
 Peripartum
 Uterine fibroids
cardiomyopathy
 Endometrial
hyperplasia
 IBD
 Solid organ transplant
 Postpartum
 Breastfeeding
CDC, MMWR, May 28, 2010
Combined Hormonal
Contraception
PILLS, PATCHES, AND RINGS
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
Breastfeeding
< 1 month postpartum
 Category 3
1-6 months postpartum
 Category 2
6 months postpartum
 Category 2
Postpartum & Postabortion
Postpartum:
< 21 days
 Category 3
21 days
 Category 1
Postabortion
Immediately post abortion
1st or 2nd trimester
 Category 1
Obesity
BMI > 30
 Category 2
 Possible increased risk of
VTE, MI, stoke
 Inconsistent evidence
about body wt and
efficacy
 NOT more likely to gain
Bariatric Surgery
Restrictive procedures:
gastric band or sleeve
 Category 1
Malabsorptive procedures
 COCs: Category 3
 P/R: Category 1
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
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
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
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
CVD and CHC
Ischemic heart disease:
current or history
 Category 4
Valvular heart disease
 Uncomplicated
 Category 2
 Complicated
Stroke
 Category 4
Peripartum cardiomyopathy:
mild
 < 6 months
 Category 4
 > 6 months
 Category 3
 Moderate or severe
 Category 4
Known hyperlipidemias
 Category 2/3
 Depends on type, severity,
other risk factors
Rheumatic Diseases
SLE
 Positive or unknown APL
antibodies: C4
 Thrombocytopenia: C2
 Immunosuppression: C2
 None of above: C2
RA
 Immunosuppression: C2
 Non-suppressed: C2
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
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
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
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
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
Progestin-Only Contraceptives
PILLS, INJECTIONS, IMPLANTS
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
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
Cardiovascular Disease
Ischemic heart disease
 Initiation: POP, I: C2
Valvular heart disease
 Category 1 for all
 DMPA: C3
 Continuation: POP, I: C3
Stroke
 Same as IHD
Hyperlipidemia
 Category 3 for all
Peripartum
cardiomyopathy
 Mild: Category 1
 Moderate/severe: C2
Other Conditions
Rheumatic
Neurologic
SLE
Headaches, non-migraine
 Positive or unknown APL
 Category 1, all
antibodies: C3
 Severe thrombocytopenia:
C3
 Immunosuppressed: C2
RA
 C1 for POP, I
 C2 for DMPA
Migraines
 No aura, C2 (C1 start OC)
 Aura: C2 start, C3 continue
Epilepsy: C1
Depressive disorders: C1
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
Endocrine and GI Conditions
Endocrine
Thyroid: Category 1
Diabetes
 Gestational: C1
 No vascular disease: C2
 Vascular disease:


POP, I: C2
DMPA: C3
GI
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
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
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
Intrauterine Devices
COPPER AND LEVONORGESTREL-RELEASING
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
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
Other Conditions
Neurologic
Rheumatic
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)
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
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
Other Issues
Anemias
 LNG: C1
Cu: C2
Drug interactions
 Antiretroviral therapy

Solid organ transplant
 Uncomplicated

Category 2 (both)
 Complicated

Category 3 initiation
Clinically well on ARV:
initiation drops to C2
 Anticonvulsants

Category 1
 Antimicrobials

Category 1
Barrier Methods
CONDOMS, SPERMICIDES, DIAPHRAGMS
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
Thank
you for
your
attention