WENDY GRUBE, PHD, CRNP UNIVERSITY OF PENNSYLVANIA SCHOOL OF NURSING Contraception and Chronic Disease: Which Patient, Which Method? US Medical Eligibility Criteria for Contraceptive Use, 2010

No Conflicts of Interest Disclosure

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 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, MMWR, May 28, 2010

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

Modifications Additions VTE Valvular heart disease Ovarian cancer Uterine fibroids Postpartum Breastfeeding RA Bariatric surgery Peripartum cardiomyopathy Endometrial hyperplasia IBD Solid organ transplant CDC Changes from WHO MEC CDC, MMWR, May 28, 2010

PILLS, PATCHES, AND RINGS Combined Hormonal Contraception

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 months postpartum Category 2 6 months postpartum Category 2

Postpartum & Postabortion Postpartum: < 21 days Category 3 21 days Category 1 Postabortion Immediately post abortion 1 st or 2 nd 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 OR D 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: 1 st 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 Stroke Category 4 Known hyperlipidemias Category 2/3 Depends on type, severity, other risk factors Valvular heart disease Uncomplicated  Category 2 Complicated Peripartum cardiomyopathy: mild < 6 months  Category 4 > 6 months  Category 3 Moderate or severe  Category 4

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

PILLS, INJECTIONS, IMPLANTS Progestin-Only Contraceptives

Conditions Age: C1 POP, C2 DMPA 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 /D 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 DMPA: C3 Continuation: POP, I: C3 Stroke Same as IHD Hyperlipidemia Category 3 for all Valvular heart disease Category 1 for all Peripartum cardiomyopathy Mild: Category 1 Moderate/severe: C2

Rheumatic Neurologic SLE Positive or unknown APL antibodies: C3 Severe thrombocytopenia: C3 Immunosuppressed: C2 RA C1 for POP, I C2 for DMPA Headaches, non-migraine Category 1, all Migraines No aura, C2 (C1 start OC) Aura: C2 start, C3 continue Epilepsy: C1 Depressive disorders: C1 Other Conditions

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 GI Thyroid: Category 1 Diabetes Gestational: C1 No vascular disease: C2 Vascular disease:  POP, I: C2  DMPA: C3 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 Endocrine and GI Conditions

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

COPPER AND LEVONORGESTREL-RELEASING Intrauterine Devices

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

Rheumatic Neurologic 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) Other Conditions

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 Solid organ transplant Uncomplicated  Category 2 (both) Complicated  Category 3 initiation Drug interactions Antiretroviral therapy  Clinically well on ARV: initiation drops to C2 Anticonvulsants  Category 1 Antimicrobials  Category 1

CONDOMS, SPERMICIDES, DIAPHRAGMS Barrier Methods

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