1. Medically Complex Contraceptive Care Does 2+2=2 or 3 or 4?

2. 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

3. United States Medical Eligibility Criteria for Contraceptive Use http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf Risk Level 1Method 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 4Method not to be used

4. Amy http://www.everystockphoto.com/photo.php?ima geId=12048627&searchId=d200ace9910e021dc 23256f155816f1f&npos=39 Wants to try the patch. History of Hyperlipidemia: LDL = 170 BMI = 34 24 year old G2P0020 female who comes to the office with a UTI

5. 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)

6. 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

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

8. 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

9. 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).

10. Quick Start: Progestin IUD or Implant

11. Emergency Contraception Factors that will affect the efficacy of the emergency contraception (EC) pill: –LMP –Last unprotected sex –BMI http://www.voanews.com/content/fda-makes-contraceptive-pill- available-to-girls-15-and-older/1652135.html http://optionsforwomenphc.com/wp-content/uploads/2012/07/ella.jpg http://www.wired.com/2011/07/ff_iud/

12. 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

13. 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

14. 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!

15. 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/fashion- outdoors-antiquecars-1505381-o.jpg

16. Learning points Keep track of age – many recommendations change with age Danger of anti-convulsants is decreasing efficacy of contraceptives (except lamictal)

17. 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

18. 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!

19. References and Resources 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(RR- 4):1-86. Managing Contraception – book online @ www.managingcontraception.orgwww.managingcontraception.org Medical Eligibility Criteria for Contraceptive Use 2010 by WHO www.who.int/reproductive-health Association of Reproductive Health Professionals www.arhp.orgwww.arhp.org Alan Guttmacher Institute www.agi-usa.orgwww.agi-usa.org Planned Parenthood www.plannedparenthood.orgwww.plannedparenthood.org The Cochrane Collaboration www.cochrane.orgwww.cochrane.org www.Not-2-Late.com Reproductive Health Access Project www.reproductiveaccess.orgwww.reproductiveaccess.org http://www.i-h-s.org/upload/ct_clas/ihc_II_main_no_print.pdf.