ARHP Learning Lab May 18 2011 Emily Godfrey MD MPH Expert Medical Advisory Committee Melanie Deal WHNP Student Health Services SF State University San Francisco CA David Grimes MD University of North Carolina School of Medicine ID: 192939
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Contraceptive Update: CDC Medical Eligibility Criteria for Women With Certain Characteristics and Medical Conditions
ARHP Learning Lab
May 18, 2011
Emily Godfrey, MD, MPHSlide2
Expert Medical Advisory Committee
Melanie Deal, WHNP
Student Health Services, SF State University
San Francisco, CADavid Grimes, MD University of North Carolina School of MedicineChapel Hill, North Carolina
David Turok, MD
University of Utah, Dept. of Ob/Gyn
Salt
Lake City, UT
Susan Wysocki, WHNP-BC, FAANP
National Association of NPs in Women’s Health
Washington, DCSlide3
Learning Objectives
List the 4 levels in the numeric scheme described in the US
Medical Eligibility Criteria for Contraceptive Use, 2010Explain the application of the numeric scheme to prescriptive practices for women with co-morbid conditionsDescribe the risks and benefits of the different contraceptive methods against the risks of pregnancy in women with health-related concernsSlide4
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 millionSlide5
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 use12.4% 9.9%CDC Winnable BattlesPublic 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.htmlSlide6
Typical Effectiveness of Contraception
Adapted from: WHO. Family Planning: A Global Handbook
Long acting reversible contraceptives (LARCs)
Tier 1
Tier 2
Tier 4
Tier 3Slide7
Contraception Use
Mosher, W et al. 2010.Slide8
Improving Contraception Access
Improve access to and use of the most effective contraceptives
Address barriers to use of Long Acting Reversible Contraceptives (LARC)
Educate ProvidersEnsure dissemination of US MECRecommend that young women and nulliparous may be eligible to use LARC methodsIncrease interest and acceptance through education and social marketingAddress cost barriers to ensure publically funded services include LARC
http://www.cdc.gov/winnablebattles/teenpregnancy/index.htmlSlide9
US Medical Eligibility Criteria for Contraceptive Use
CDC published criteria in June ‘10
Based on the 4
th edition of the World Health Organization guidelines from ‘09Adapted for US women by panel of experts and CDCRecommendations for the use of specific contraceptives by women who have particular characteristics/medical conditions
http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htmSlide10
WHOCDC US MEC
Existing WHO guidance
Breastfeeding and hormonal methods
Valvular heart disease and IUDsPostpartum IUD insertionOvarian cancer and IUDsFibroids and IUDsDVT/PE and hormonal methods and IUDsSlide11
WHOCDC US MEC
New medical conditions
Rheumatoid arthritis
Endometrial hyperplasiaInflammatory bowel diseaseBariatric surgerySolid organ transplantationPeripartum cardiomyopathySlide12
US Medical Eligibility Criteria for Contraceptive UseSlide13
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
Slide14
1
No restriction for the use of the contraceptive method for a woman with that
medical condition
2
Advantages 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 condition4
Unacceptable health risk if the contraceptive method is used by a woman with that medical conditionUS Medical Eligibility Criteria: Categories
http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf Slide15Slide16
Conditions Associated w/
↑
Risk for Adverse Heath Events as a Result of Unintended Pregnancy
Breast
cancer
Malignant liver tumors (
hepatoma
) and
hepatocellular
carcinoma of the liver
Complicated
valvular
heart disease
Peripartum cardiomyopathyDiabetes: insulin dependent; with nephropathy/retinopathy/neuropathy or other vascular disease; or of >20 years’ durationSchistosomiasis with fibrosis of the liver
Endometrial or ovarian cancerSevere (decompensated) cirrhosisEpilepsy
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/AIDSSystemic lupus erythematosusIschemic heart disease
Thrombogenic mutationsMalignant gestational trophoblastic disease
Tuberculosis
http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf US Medical Eligibility Criteria: ↑ Risk for Adverse Health EventsShould consider long-acting, highly-effective contraception for these patientsSlide17
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 certificatesPregnancy-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.Slide18
Case Presentation 1
Which hormonal methods are safe for her to use?
Combined hormonal methods only
Progestin-only methods onlyAny hormonal method
30-year-old
PPD #2
Ready to be discharged from hospital & desires contraception
Plans to breastfeedSlide19
BreastfeedingSlide20
Case Presentation 1
Which hormonal methods are safe for her to use?
Combined hormonal methods only
Progestin-only methods onlyAny hormonal method
30-year-old
PPD #2
Ready to be discharged from hospital & desires contraception
Plans to breastfeedSlide21
Case Presentation 2
Is this method safe for her?
Yes
No
25-year-old
Has
Crohn’s
disease
Desires long-term reversible contraception
Thinking about
levonorgestrel-releasing IUDSlide22
Inflammatory Bowel DiseaseSlide23
Case Presentation 2
Is this method safe for her?
Yes (Category 1)
No
25-year-old
Has
Crohn’s
disease
Desires long-term reversible contraception
Thinking about
levonorgestrel-releasing IUDSlide24
Case Presentation 3
What do you need to know before deciding whether to recommend this method?
How much weight has she lost?
What type of surgery did she have?What pill formulation did she use previously?
30-year-old
History of bariatric surgery 6 months ago
Was using COCs before surgery & wants to restartSlide25
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)Slide26
Types of Bariatric surgery
Restrictive procedures:
Decrease storage capacity of stomach
Ex: vertical banded gastroplasty, laparoscopic adjustable gastric band, laparoscopic sleeve gastrectomyMalabsorptive procedures:Decrease absorption of nutrients and calories by shortening functional length of small intestineEx: Roux-en-Y gastric bypass (most common in US), biliopancreatic diversionSlide27
Bariatric Surgery
Consensus: Pregnancy should be avoided for 12-24 months after surgery
Paulen, ME et al.
Contraception
82 (2010) 86-94.Slide28
History of Bariatric SurgerySlide29
Case Presentation 3
What do you need to know before deciding whether to recommend this method?
How much weight has she lost?
What type of surgery did she have? What pill formulation did she use previously?
30-year-old
History of bariatric surgery 6 months ago
Was using COCs before surgery & wants to restartSlide30
Next Steps
Work with partners:
dissemination
implementation Keeping guidance up to dateSlide31
Updated Guidance from WHOSeptember 2010Slide32
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 WYCHC use increases risk:3-7 foldRisk most pronounced in the first year of useSlide33
Previous WHO MEC recommendation
CHCs in postpartum women
< 21 days postpartum 3
≥ 21 days postpartum 1Slide34
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
3/4The 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 VTE2With other risk factors for VTE2/3The category
should be assessed according to the number, severity, and combination of VTE risk factors present.c. > 42 days1Slide35
US MEC-Postpartum period
New evidence
Updated recommendations from WHO
CDC held consultation in Jan 2011Substantial increased risk in early weeks postpartum with no benefit Multiple risk factorsAccess issuesSafety of other contraceptive methods Will be published as MMWRSlide36
Next Steps
Work with partners:
dissemination
implementation Keeping guidance up to dateResearch gapsUS adaptation of WHO Selected Practice Recommendations for Contraceptive UseSlide37
Resources
US MEC published in CDC’s Morbidity and Mortality Weekly Report (MMWR):
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a1.htm?s_cid=rr5904a1_w
CDC evidence-based family planning guidance documents:http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htmWHO evidence-based family planning guidance documents:http://www.who.int/reproductivehealth/publications/family_planning/en/index.html Slide38
Additional Resources
Association of Reproductive Health Professionals (ARHP)
www.arhp.org
National Association of Nurse Practitioners in Women’s Health (NPWH)www.npwh.org