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

CONTRACEPTION MANAGEMENT Mary Stark, DNP, FNP

OBJECTIVES  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

ABBREVIATIONS USED  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

GUIDANCE DOCUMENTS  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

MEDICAL ELIGIBILITY CRITERIA  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)

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

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

CONTRACEPTIVE METHODS

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

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

CONTRAINDICATIONS TO CHC  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

WEIGH THE RISKS VS. BENEFITS  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 older), 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)

MIGRAINES AND AURA  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 Aura Video Mayo Clinic

PROGESTIN ONLY METHODS  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

ABSOLUTE CONTRAINDICATIONS TO DMPA AND POPS  Breast cancer

WEIGH THE RISKS AND BENEFITS TO DMPA  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

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

I LARC METHODS  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) 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

CONTRAINDICATIONS TO IUDS  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 only)

WEIGH THE RISKS AND BENEFITS  Copper  LNG  AIDS  Breast cancer history (>5 years)  Lupus and severe thrombocytopenia  Lupus w/ antiphospholipid  Complicated organ antibodies transplant  Complicated organ  Molar pregnancy with transplant falling beta hCG levels  Molar pregnancy with falling beta hCG

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.

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

ABSOLUTE CONTRAINDICATIONS TO IMPLANT  Breast cancer

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

GROUPING CONTRAINDICATIONS  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)

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

MISPERCEPTIONS & MYTHS

MISPERCEPTIONS – PATIENT AND PROVIDER  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

AT WHAT AGE CAN A WOMAN SAFELY STOP CONTRACEPTION?  Keep using contraception until...  Menopause or  Age 50-55

What do SELECTING A METHOD women want?

WHAT’S MOST IMPORTANT FOR HER?  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 Dehlendorf, C. et al. (2013). Women’s preferences for contraceptive counseling and decision making. Contraception, 88(2013), 250-256