1. MEDICALLY COMPLEX CONTRACEPTIVE CARE
Does 2+ 2 = 2 or 3 or 4?

2. Objectives
Apply evidenced-based guidelines to contraceptive provision using the CDC Medical Eligibility Criteria (MEC) resource
Explore contraception options in patients with a complex medical history
Accurately discuss the risks and benefits of medically complex contraception care with both patients and colleagues
Before we go on, lets dig a little on these issues.
Lets start with abortion: what do people say about women who get abortions? Who can do them? Where are they provided?
What about contraception? Does it work? Who uses it?

3. THE MEC US Medical Eligibility Criteria (MEC)
CDC recommendations for specific contraceptive methods with certain medical conditions
*Ideally participants will download the app prior to or during the talk, you may also choose to have copies of the Summary Chart for those without app access.

4. MEC categories of safety
With this in mind.
Category 1 is used freely
Category 4 is absolutely contraindicated
Category 2 Benefits traditionally outweigh the risk
Category 3 risks generally outweigh the benefits.
So, how do we look at contraceptive methods safety? The WHO has developed MEC. All methods for various medical conditions are given a number 1-4, where 1 is…

5. Notice all the green!

6. There’s an APP for that:
- Can be downloaded on iOS and Android operating systems (
Have participants pause and download the app or use the Summary Chart if they don’t have it already- will need it for the talk!
SPR = Selected Practice Recommendations

7. Amy 24 year old G2P0, comes into the office with a UTI
You ask her a pregnancy intention screening question and she is interested in restarting pills
Pregnancy intention screening may soon be a quality measure
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8. Amy BMI = 34 History of hyperlipidemia LDL = 170
Has a dirty UA, you’ll treat with
Nitrofurantoin.
Thinks starting birth control pills is a good idea

9. Antibiotics and Oral Contraceptives?
Only Rifampin or rifabutin decrease efficacy!

10. Also look at her Medical Eligibility
She has a BMI > 30
= 2
She has hyperlipidemia

11. Audience participation
What does equal? 2 3 4
From the MEC: Routine screening for hyperlipidemia is not appropriate because of the rarity of the conditions and the high cost of screening. Although some types of hyperlipidemias are risk factors for vascular disease, the category should be assessed according to the type, its severity, and the presence of other cardiovascular risk factors. The USPSTF recommends that people with BMIs>30 be screened for hyperlipidemia and the risk they discuss is CVD
Obese women who use COCs are more likely than obese women who do not use COCs to experience VTE. The absolute risk for VTE in healthy women of reproductive age is small. Limited evidence suggests that obese women who use COCs do not have a higher risk for acute myocardial infarction or stroke than do obese nonusers. Limited evidence is inconsistent about whether hormonal contraceptive effectiveness varies by body weight or BMI (Cochrane review). Limited evidence suggests obese women are no more likely to gain weight after 3 cycles of the vaginal ring or COC than overweight or normal weight women. A similar weight gain during the 3 months was noted between the COC group and the vaginal ring group across all BMI categories (166). The effectiveness of the patch decreased among women who weighed >90 kg; however, no association was found between pregnancy risk and BMI (18).
So…
Slightly increased risk of VTE in obese women on COCs + Slightly increased risk of vascular disease (MI, stroke, PAD) = = 2
And, to make you more comfortable, she is only 24. If she were 38 or over 40, that would start to get more risky

12. Learning Points
Use every opportunity to ask about family planning to prevent unintended pregnancies
Assess pathophysiology of medical contraindications
2 + 2 sometimes equals 2
Most antibiotics do not decrease efficacy of contraceptives

13. Doreen
41 year old G2P2
Would like to remove her copper IUD and try “the shot”
PMH significant for asymptomatic gallstones and hypertension controlled by medications
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14. Audience participation
What is the equation?
1 + 2
2 + 2
3 + 2
From the MEC: Controlled hypertension is a 2, asymptomatic gallstones are a 2
Hypertension is a concern for cardiovascular events, Gallstones are a concern that progestin may kick up the inflammation
So, is the right answer and it equals 2

15. Learning points 2 + 2 can still = 2
Progestin only methods are almost always safer than combined estrogen/progestin methods
can still = 2
Progestin only methods are almost always safer than combined estrogen/progestin methods

16. Rosa
20 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
From the MEC: Concern exists about an increased risk for those with sickle cell anemia and blood loss with Cu-IUDs. But only a “2”
From the MEC: IUDs do not protect against STI/HIV/PID. In women at low risk for STIs, IUD insertion poses little risk for PID. Current risk for STIs and desire for future pregnancy are relevant considerations.
Clarification for initiation: If a woman has a very high individual likelihood of exposure to gonorrhea or chlamydial infection, the condition is a Category 3.
Evidence: Using an algorithm to classify STI risk status among IUD users, 1 study reported that 11% of women at high risk for STIs experienced IUD-related complications compared with 5% of those not classified as high risk (107).
Morrison CS, Sekadde-Kigondu C, Miller WC, Weiner DH, Sinei SK. Use of sexually transmitted disease risk assessment algorithms for selection of intrauterine device candidates. Contraception 1999;59:97–106.
Copper IUD can be used as emergency contraception within 5 days of unprotected sex.
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17. 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)
Active pregnancy
Unexplained vaginal bleeding (Suspicious for serious condition)
*Note- nulliparity is NOT a contraindication to IUD placement

18. Emergency Contraception
Factors that will affect the efficacy of the emergency contraception (EC) pill:
LMP
Last unprotected sex
BMI
One more issue: Progestin interaction with Ella
Plan B (Levonorgestrel) – effective up to 3 days after unprotected sex, doesn’t work as well in women > 165 pounds.
Ella (ulipristal acetate) – more effective than Plan B, maintains nearly full efficacy on 4th and 5th day. Used up to 5 days after unprotected sex.
Copper IUD- most effective, can be placed up to 5 days post-unprotected sex.
Theoretical plus one study with a progestin we don’t have in the US that has higher binding affinity for receptors than our progestins

19. Rosa She can get a copper IUD, it is a “2” for sickle cell disease
A best practice is to insert it the same day she asks, and especially in this case when it is also for EC

20. Learning points
History of PID is a “2”, very high risk of STI is a “3”
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
*Both ACOG and AAFP have policy statements that LARC is safe in teens and should be offered.

21. Audrey 33 yo G3P3 Happy with her combined oral contraceptives
Migraine without aura for many years
Newly diagnosed with Lupus, so far uncomplicated
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22. Audience participation
What does equal? 2 3 4
From the MEC:
Migraines without aura are a 2
Lupus is a 2 if uncomplicated
Both increase risk of stroke
2+2 = 4

23. Learning points Remember to assess pathway of “2” recommendation
Pregnancy is always a higher risk than the birth control method
Vasectomy is an option to recommend!

24. Julie 17 year old 2 abortions, one while “on the pill”
History of chlamydia
Wants to know about IUD
Address nulliparous, STIs with IUDs
How to decide which IUD is right for her? Review shared decision making
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25. Intrauterine Devices
There are 2 types of IUDS available in the US: the copper IUD and the progestin IUD.
Copper IUD (paragard) – non-hormonal, lasts 12 years
Hormonal IUD (levonogestrel - mirena 52mg 7 years, liletta 52mg 5 years, kylena 19.5mg, skyla 13.5mg 3 years)
They’re both safe and highly effective.
Because IUDs’ side effects & advantages differ, RHAP uses a simple info sheet to help patients choose between the 2 types.
Accessed at:
References:
Sivin, et al. Prolonged intrauterine contraception: a seven-year randomized study of the levonorgestrel 20 mcg/day (LNg 20) and the Copper T380 Ag IUDS. Contraception Nov;44(5):
Chiou CF, Trussell J, Reyes E, Knight K, Wallace J, Udani J, Oda K, Borenstein J. Economic analysis of contraceptives for women. Contraception. 2003;68(1):3-10.
Hubacher D, Cheng D. Intrauterine devices and reproductive health: American women in feast and famine. Contraception Jun;69(6):
Hatcher RA, Zieman M et al. A Pocket Guide to Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2004

26. Shared Decision Making
Avoid pushing a method that a patient “heard bad things about” – reduces adherence
Provide non-judgmental information about all options, at appropriate literacy level, to empower patient to make their own decision
Be ready to remove LARC upon request, avoid coercion

27. Audience Participation
IUDs can be inserted:
A) During menses
B) within 7 days of LMP
C) anytime during the cycle if pregnancy has been reasonably ruled out
D) all of the above
Answer: D

28. Katie 28 year old G0P0 comes to you for her well-woman exam
She’s in a new relationship, wants a contraception method she doesn’t have to think about.
Likes the idea of a progestin implant
History of seizure disorder, on carbamazepine, and Type1 Diabetes.

29. Audience Participation
What does equal?
A) 2
B) 3
C) 4
Implant is a 2 for diabetes
Carbemazepine is a 2 for implant
Both are for different reasons, therefore = 2

30. Learning points
The danger of anti-convulsants is decreasing efficacy of contraceptives (except lamictal)
Almost always safer- progestin only methods
Remind everyone to look at the colors on the MEC handout

31. 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
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32. Audience Participation
What does equal
A) 2
B) 3
C) 4
From the MEC: Some conditions that increase the risk for DVT/PE are heritable.
Cancers can cause a hypercoagulable state…
Major surgery without prolonged immobilization = 2
All issues that relate to increase risk of VTE
2+2 = 4

33. More take-home points
Progestin methods safer than combined estrogen and progestin
Copper IUD generally the safest method
Vasectomy is VERY safe!
Birth control and abortion are both safer than pregnancy, especially with medical morbidities.
Abortion is 10 times safer than pregnancy!

34. More practice
35 year old G3P2 with history of Roux-en-Y gastric bypass and smokes 1 pack of cigarettes per day. Wants to restart COCs.
27 year old G1P0 with diabetic nephropathy and high risk for HIV transmission, wants to start depo.
33 year old G0P0 with chronic systolic blood pressure >160mmHg and history of ischemic heart disease wants to start hormonal IUD
Roux-en-Y is a 3 (decrease efficacy of COCs due to absorption), Smoking > 15 cigarettes per day in a person >/= 35 is a 4 (increased risk of CVD) = 4.
Diabetic nephropathy and DMPA is a 3 (concern about hypoestrogenic effects and reduced HDL levels, also potential increase risk for thrombosis), High risk for HIV transmission is a 1* (some studies show using DMPA may lead to increased risk of HIV transmission, CDC states inconclusive- but should strongly be advised to use condoms if also on DMPA) = 3
Uncontrolled HTN and hormonal IUD 2 (increased risk of CVD) and history of ischemic heart disease 2 (theoretical concern about effect of levonorgestrel on lipids) = 4

35. References and Resources
Centers for Disease Control and Prevention (CDC). U.S. Medical Eligibility Criteria for Contraceptive Use, Updated July 2016.
Hatcher et al, Contraceptive Technology 2007
Managing Contraception – book
CDC Selected Practice Recommendations 2014
Association of Reproductive Health Professionals
Alan Guttmacher Institute
Planned Parenthood
The Cochrane Collaboration
Reproductive Health Access Project

36. Updated 11/2017