CONTRACEPTION MANAGEMENT Mary Stark, DNP, FNP OBJECTIVES Describe - - PowerPoint PPT Presentation

Mary Stark, DNP, FNP

CONTRACEPTION MANAGEMENT

 Describe common side effects, contraindications, and special conditions of birth control methods  Identify expert resources, including patient handouts, on contraception found on the internet  Describe patient-centered counseling methods about contraception

OBJECTIVES

 BC = BCM = birth control or birth control method  CHC = combined hormonal contraceptive  COC = combined oral contraceptive  DMPA = Depo = depot medroxyprogesterone acetate  EC = emergency contraception  IUC = IUD = IUS = intrauterine contraceptive/device/system  LARC = long-acting reversible contraceptive(s) = any implant or IUC  LNG = levonorgestrel  PID = pelvic inflammatory disease  POP = progestin only pills

ABBREVIATIONS USED

 Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65(No. RR-3):1–104. DOI: http://dx.doi.org/10.15585/mmwr.rr6503a1  Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use,

• 2016. MMWR Recomm Rep 2016;65(No. RR-4):1–66.

DOI: http://dx.doi.org/10.15585/mmwr.rr6504a1

GUIDANCE DOCUMENTS

Tables summarizing eligibility of use of birth control methods based on patient history, condition, or risk factors Category 1 = No restrictions (use it) Category 2 = Advantages generally outweigh the theoretical or proven risks (use it) Category 3 = Theoretical or proven risks generally outweigh the advantages (use it if you must) Category 4 = Unacceptable health risk (don’t use it)

MEDICAL ELIGIBILITY CRITERIA

https://www.cdc.gov/reproductivehealth/contraceptio n/mmwr/mec/summary.html

Diabetes with nephropathy Lupus with antiphospholipid antibodies Breast cancer Cervicitis WHAT IS THE ONLY ABSOLUTE CONTRAINDICATION (CATEGORY 4) FOR ALL HORMONAL BIRTH CONTROL METHODS?

QUESTION:

CONTRACEPTIVE METHODS

Contain progestin and estrogen Only one patch and one ring formulation Many formulations of pills Have the most contraindications (estrogen) Return to fertility is quick after stopping method Woman is in control of using (or not using) the method Typical use: 92% effectiveness

COMBINED HORMONAL METHODS – THE PILL, THE PATCH, THE RING

Recently FDA approved vaginal ring Annovera! One ring for 13 cycles!

BREAKING NEWS

 Breast cancer  Cardiovascular disease (or high risk for it)

• Uncontrolled HTN, uncontrolled DM, h/o stroke or MI

 Severe liver disease – can’t process hormones  Think thrombosis risk/hypercoagulable states

• Just delivered a baby
• Thrombogenic mutation (Factor V Leiden)
• Prolonged immobilization
• Antiphospholipid antibodies
• DVT/PE history
• Heavy smoker age 35 or older
• Migraines with aura

CONTRAINDICATIONS TO CHC

 Breastfeeding  Thrombosis risk:

• DM with less vascular disease, DVT history at lower

risk for recurrence, Hypertension (controlled), Hyperlipidemia, Migraines w/o aura (age 35 and

• lder), Smoker (not heavy) age 35 and older

 Drugs – certain anticonvulsants, heavy-duty antibiotics, certain antiretrovirals  Gallbladder disease (active)  Less severe liver disease (hepatitis flare)  Malabsorptive bariatric surgery (orals only)

WEIGH THE RISKS VS. BENEFITS

Starts before the headache Usually lasts no more than an hour Stops with the onset of headache Almost always visual Ask her to describe it – look at her hands as she does Not the same as photophobia

MIGRAINES AND AURA

Aura Video Mayo Clinic

 Compatible with breastfeeding  Don’t take any days off of hormones  DMPA (Depo)

• Weird bleeding usually goes away after/within 2 shot cycles
• Most notorious for weight gain
• Users generally have very light or no bleeding
• Longest delay in return to fertility
• Only one type on the U.S. market – medroxyprogesterone acetate

 POP

• May or may not have periods
• Be persnickety about taking it at the same time every day
• Only need a 2 day back-up method
• Only one type on the U.S. market – norethindrone

PROGESTIN ONLY METHODS

Breast cancer

ABSOLUTE CONTRAINDICATIONS TO DMPA AND POPS

 Breast cancer history (> 5 years)  Liver disease (severe)/adenocarcinoma/malignant tumor  Think thrombosis risk:

• Cardiovascular disease, DM with

neuro/nephr/retinopathy or vascular disease, Hypertension (uncontrolled) or with vascular disease, Lupus with antiphospholipid antibodies, Stroke  Rheumatoid arthritis on immunosuppressive therapy  Unexplained vaginal bleeding

WEIGH THE RISKS AND BENEFITS TO DMPA

Breast cancer history (> 5 years) Liver disease (severe)/adenocarcinoma/malignant tumor Lupus with antiphospholipid antibodies Malabsorptive bariatric surgery

POSSIBLE CONTRAINDICATIONS TO POPS

 Most effective methods  Easy to use – set it and forget it!  Least contraindications  Quick return to fertility  More choices each year Fun fact: More providers use LARC methods than the general population (41.7% vs. 12.1%) (Stern, et al. 2015)

I LARC METHODS

Stern, L. et al. (2015). Differences in contraceptive use between family planning providers and the U.S. population: Results of a nationwide

• survey. Contraception, 91(6), 464-469.

IUC = IUD = IUS

Copper: ParaGard Levonorgestrel: 52 mg = Mirena, Liletta 5-7 years 20 mcg > 10 mcg (Mirena) 19.5 mg = Kyleena 5 years 17.5 mcg > 7.4 mcg 13.5 mg = Skyla 3 years 14 mcg > 5 mcg For comparison: a low dose LNG pill has 100 mcg levonorgestrel

 Genital tract is infected  Abnormally shaped uterine cavity  Cancer

• Untreated cervical
• Breast (LNG IUD only)

 Could lead to cancer: molar pregnancy with persistently elevated beta hCG levels  Pregnancy  Unexplained vaginal bleeding  Allergy to copper or Wilson’s disease (Copper IUD

• nly)

CONTRAINDICATIONS TO IUDS

Copper

• AIDS
• Lupus and severe

thrombocytopenia

• Complicated organ

transplant

• Molar pregnancy with

falling beta hCG levels

LNG

• Breast cancer history

(>5 years)

• Lupus w/

antiphospholipid antibodies

• Complicated organ

transplant

• Molar pregnancy with

falling beta hCG

WEIGH THE RISKS AND BENEFITS

RANDOM LARC TIDBITS

Routine pre-insertion use of misoprostol was not shown to decrease insertion pain Routine pre-insertion use of misoprostol was not shown to to improve ease of insertion

Swenson, C., et al. (2012). Self-Administered Misoprostol or Placebo Before Intrauterine Device Insertion in Nulliparous Women: A Randomized Controlled Trial. Obstet Gynecol, 2012(120), 341–7.

“Our findings indicate that PID among IUD users is most strongly related to the insertion process and to background risk of sexually transmissible disease. PID is an infrequent event beyond the first 20 days after insertion. ” Farley TM., et al. (1992). Lancet, 339, 785-88.

STUDIES ON PID RISK Several subsequent U.S. studies further support that the risk of PID with IUD use is low

Breast cancer

ABSOLUTE CONTRAINDICATIONS TO IMPLANT

Breast cancer history (> 5 years) Liver disease (severe)/adenocarcinoma/malignant tumor Lupus (pos or unknown antiphospholipid antibodies) Unexplained vaginal bleeding

POSSIBLE CONTRAINDICATIONS TO IMPLANT

 Breast cancer = stay away from hormones  Clotting event (currently or high risk) = stay away from estrogen, use progestin with caution (look up the many variants for DVT history)  Liver disease (severe) = stay away from hormones  Pregnancy = stay away from IUDs  Gallbladder = avoid estrogen  Lupus w/ antiphospholipid antibodies = stay away from hormones  Cardiovascular disease/risk = tally up all those risk factors to weigh the decision  Diabetes with complications = use hormones with caution (decision based on severity of complications)

GROUPING CONTRAINDICATIONS

Great handouts available from Reproductive Health Access Project (RHAP) Web-based info at PlannedParenthood.org CDC Handouts Association of Reproductive Health Professionals handouts

PATIENT (PROVIDER?) RESOURCES

MISPERCEPTIONS & MYTHS

 You need to do a Pap/Breast exam/Pregnancy test before starting BC  You need to wait for a period to start a BCM  All birth control makes you gain weight  You can only have an IUD if you are a married woman who has had a vaginal delivery  IUD users have a higher risk of PID or ectopic pregnancy  There’s something special about extended cycle or triphasic pills  There’s some sort of science behind selecting a first pill for a patient

MISPERCEPTIONS – PATIENT AND PROVIDER

Keep using contraception until...

• Menopause
• r
• Age 50-55

AT WHAT AGE CAN A WOMAN SAFELY STOP CONTRACEPTION?

What do women want?

SELECTING A METHOD

Let her goals for reproduction/contraception help guide the discussion She will ultimately decide, but may want you to be part of the decision making

WHAT’S MOST IMPORTANT FOR HER?

Dehlendorf, C. et al. (2013). Women’s preferences for contraceptive counseling and decision making. Contraception, 88(2013), 250-256

CDC Effectiveness chart Can group methods together to talk about effectiveness, side effects, risks

• Hit the high points (and low points)
• ...get started on a less effective method while

she’s still thinking about that LARC method?

SHARING INFORMATION WITH METHODS FROM MOST TO LEAST EFFECTIVE

LARC FIRST

So very many women are good candidates for LARC methods Super effective Better continuation rates than short-acting methods If you remove financial barriers – many more women choose LARC methods (75% in the Contraceptive CHOICE study!)

Birgisson, N.E., Zhao, Q., Secura, G.M., Madden, T., and Peipert, J. F. (2015). Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review. Journal of Women’s Health, 24(5), 349-353.

Eenie, meenie, miny, moe 28 x 12 = 336 28 x 13 = 364

PRESCRIBING PILLS

Clear instructions on how to use the method Clear instructions on back up methods (if needed) Common side effects Warning signs

• Head and shoulders, knees and toes it hurts

really bad, call or come in right away

• Infection symptoms post-IUD

How to fill her prescription or get refills

ONCE YOU’VE PICKED A METHOD

STARTING A METHOD

Blood Pressure Bimanual exam and cervical inspection prior to IUD insertion Pregnancy test if unprotected sex > 2-3 weeks ago EXAMINATIONS? TESTS?

• When was your last period?
• Have you had any sex without using

birth control or condoms since your period?

EXCLUDING PREGNANCY

U.S. SPR tells us that: EXCEPT for IUDs, benefit of starting a BC method likely outweighs the risk Start it, pregnancy test in 2-4 weeks JUST START IT

LNG EC (Plan B) – doesn’t interfere with

• ther hormones

Ella (ulipristal) – might interfere with

• ther hormones (and vice versa)

HAD SEX WITHOUT USING BC OR CONDOMS IN THE LAST 5 DAYS?

Viable sperm in vagina Take ella EC within 120 hours (5 days) Use condoms Start ongoing hormonal contraception Keep using condoms x 7 days

STARTING HORMONAL BC AFTER ELLA EC

Days 0-5, sperm is viable Take EC! Use condoms! Don’t start ongoing hormonal BC yet Day 6, sperm is not likely to be viable

Condoms or no sex

• 7 days for pill, patch, ring, DMPA, LNG

IUDs, implant

• 2 days for POPs
• None for copper IUD

Check a urine pregnancy test in 2-4 weeks if needed BACK-UP BIRTH CONTROL

Pills, Patch, Ring

HOW TO USE THE METHOD

Having a period is so last season So... How do I know I’m not pregnant?

• You took your pill
• You’re not having any pregnancy symptoms
• Taking the pill continuously actually

increases the effectiveness

I EXTENDED CYCLING

Use it every day without breaks Your uterus is in charge, if you start to bleed (for multiple days), take a short break and go right back in to using it

• RULES:
• Must take/use it for 3 full weeks before

taking any days off

• Must not take more than 7 days off in a

row CONTINUOUS USE PILL, PATCH, OR RING

Extended cycle: Same hormones as single-cycle packs Continuous cycling on triphasics is possible...

EXTENDED CYCLE, TRIPHASICS, QUADPHASICS

MANAGING SIDE EFFECTS

DMPA is a bit more notorious than the

• thers

Most methods are weight neutral When non-hormonal methods were studied, women gained weight with age WEIGHT GAIN

CHC use for women with high BMIs?

• U.S. SPR 2016 tells us it’s fine

WHILE WE’RE TALKING ABOUT WEIGHT

Jackie is 25 and taking Lutera continuously, she comes in because she wants a different method because she has been bleeding daily for about 3 and a half weeks and is totally over it! JACKIE

What time of day are you taking your pill? Are you pretty consistent taking it at that time? Any other symptoms, such as vaginal discharge/odor/itching? How many weeks/months have you been taking the pill continuously? QUESTIONS TO ASK

She is on time with her pill every day No vaginal infection symptoms, no new meds

• r anything new since we saw her 4 months

ago She has been taking pills every day for those 4 months because we told her to

JACKIE’S ANSWERS

Sorry, not that kind of a break Jackie likely needs to have a hormone free interval 3-4 days off and then right back in to taking it Remember: her uterus is still in control, don’t fight it

TAKE A BREAK

We look up Jackie’s pill... and discover she is

• n a pill that contains 1 mcg levonorgestrel

and 20 mcg ethinyl estradiol Our handy Managing Contraceptive Pill book by Dickey, R.P. (2014) tells us we need to increase estrogen if bleeding in days 1-9 of the pill pack and increase progestin in days 10-21 Find that pill’s big sister and take care of both!

ADJUST THE PILL

 http://stage.uspharmacist.com/article/selecting-and- monitoring-hormonal-contraceptives-an-overview-of-available- products

RESOURCE FOR ADJUSTING PILLS

Proge gestin Lit ittle le S Sis isters (20 mcg) g) Big S Sisters (30 o (30 or 35 35 mcg cg) Levonorgestrel Allesse, Aviane, Falmina, Lutera, Sronyx, Aubra, Lessina, Orsythia Nordette, Portia, Levora, Chateal, Marlissa, Kurvelo, Seasonale, Seasonique, Jolessa, Quasense (all the extended cycle monophasic pills) All above are 30 mcg pills, there are no 35 mcg pill formulations Norgestimate None (except triphasics) Ortho Cyclen, Sprintec, MonoNessa, Estarylla, Mono-Linyah, Previfem All above are 35 mcg pills, there are no 30 mcg pill formulations Desogestrel None (except triphasics) Ortho-Cept, Desogen, Reclipsen, Apri, Emoquette, Solia, Juleber All above are 30 mcg pills, there are no 35 mcg pill formulations Norethindrone acetate Loestrin 1/20 & FE & 24, Microgestin, Junel, Larin, Gildess, Tarina Everything listed on the left, but the package will say 1.5/30 There are 35 mcg pill formulations available Drospirenone Yaz, Gianvi, Loryna, Nikki, Beyaz Yasmin, Zarah, Ocella, Syeda

Levonorgestrel = the only hormone in IUDs Desogestrel = converted in to etonogestrel = NuvaRing and Implant Norgestimate = converted in to norelgestromin = Patch

HORMONE THINGS TO KNOW

Same thing:

• Ring out, rinse off, leave out for 3 days in that

little foil pouch

• Same ring goes back in (or a new one)
• You can keep the same ring change day if you

want

WHAT IF JACKIE’S USING THE RING OR PATCH?

Hysteroscopic tubal ligation (Essure)

• Need a good method of contraception for at

least 12 weeks post-procedure Vasectomy

• Need a good method of contraception for at

least 12 weeks post-procedure Tubal ligation (surgical)

PERMANENT METHODS

ICD-10 CODES TO KNOW

Diagnosi sis Co Code de Diagnosi sis Co Code de Pill start Z30.011 Pill continuation Z30.41 Injection (DMPA) start Z30.013 Injection (DMPA) continuation Z30.42 Ring start Z30.015 Ring continuation Z30.44 Patch start Z30.016 Patch continuation Z30.45 Implant start/consult/insert Z30.017 Implant surveillance/removal Z30.46 Other: Rx barrier Z30.018 Other: Rx barrier Z30.49 Emergency contraception Z30.012 IUD Consult/start Z30.014 IUD Insertion Z30.430 IUD Removal and Reinsertion Z30.433 IUD Removal only Z30.432 IUD Check Z30.431 Natural family planning Z30.02 General BC counseling Z30.09