With rates of both chronic illness and maternal mortality rising in the U.S., reproductive planning is an essential part of primary care. Offering a variety of approaches to these discussions, OB-GYN Tania Basu Serna, MD, MPH, breaks down contraceptive options and explains how to help individuals make the best choices for their lives. Includes an online CDC tool to ensure safe choices for patients with heart disease, diabetes and other conditions.
um So this talk is about addressing the needs of individuals with medical conditions um particularly surrounding contraception Because sometimes we have patients that come into our office and we're really kind of perplexed on what options are available that we should be discussing with them. So I'm hoping that we can discuss the medical conditions and um you know how to how to kind of navigate contraception counseling. Um nothing to disclose. So really the objective of this talk today is to discuss the importance of reproductive life planning with women of reproductive age especially in the context of medical conditions. And to demonstrate how to use the C. D. C. Medical eligibility criteria for contraceptive use as guidance when discussing contraceptive methods with women with medical problems. So as we all may be seeing in our clinics um we are seeing the patient population generally um getting sicker. There has been an increasing rate of obesity, diabetes, hypertension, chronic illnesses. Um the prevalence of diabetes has nearly tripled over the past 30 years and the number one killer is still heart disease and it counts for one in four deaths among women. And so because of that um when women with medical conditions become pregnant they have higher risk of having adverse pregnancy outcomes. So um when patients that have medical conditions get pregnant they're at increased risk of preeclampsia, preterm labor, preterm birth pregnancy loss, gestational diabetes and preterm and growth restriction and mortality or death. So when looking at the CDC pregnancy mortality data we see that the number one cause of death is cardiovascular disease followed by other non cardiovascular disease infection, sepsis and then hemorrhage. So um you know when we're talking about pregnancy complications, hemorrhage is the first thing that comes to mind. But really um uh cardiovascular disease is the number one killer. And as we all know in our country, the at the rate of maternal mortality is on the rise. I think we're really lucky to live in California where we're actually on the downward trend. Although we know that there's still um is the presence of huge racial disparities. As far as health care health care access goes and healthcare outcomes with maternity, maternal mortality being much higher among patients and women of color. So um this is some data from the World Health Organization. Again, just demonstrating how how desperate our data is. Um in regards to maternal mortality compared to other um other well resourced countries and um a huge factor is um are is due to racism in medicine. Um and one of the things that still is really kind of untouched as far as the ratio goes is unintended pregnancy rate in the US still continues to be almost approximately 45-50%. Um with with about 45% being um unintended, 27% being mistimed pregnancy and 18% being unwanted. So why are unintended pregnancy rates higher in women with medical conditions? There's two kind of general factors that we think about, as far as patient related factors that relates to unintended pregnancy Patients with medical conditions typically have a decreased perception of risk of pregnancy and this could be due to what they were told and many times patients are told by their provider that they have a low likelihood of getting pregnant or may may have trouble conceiving. And so that may cause this decreased perception of becoming pregnant. Um lack of knowledge regarding pregnancy risk as it pertains to their medical condition, lack of knowledge regarding what options are available to the many patients come to me and saying well everyone's always told me I'm not allowed to be on any hormonal contraception. And so they just thought that means they really are not amount are able to use any method of contraception which many times is not right. Um And then there's provider related factors so we all feel the time pressure with our visits. Um And contraception counseling is one of those topics where really it takes um sometimes multiple visits and really a lot of time and discussing with the patient what is important to them in relation to their family planning goals. Also there's a tent, there's a tendency to have lack of knowledge regarding what the safety profile is of different methods of contraception as it relates to medical conditions. So that may limit the way we counsel patients or feel inadequate to provide that contraception counselling due to this feeling of having lack of knowledge. So in the U. S. Um this is the data of contraceptive use in the most updated data that we have anyway for the national survey of family growth. Um And you can see here the left side it just shows the percentage. Um and the different colors are talking basically designating. Um what method of contraception on the bottom is used by women currently using contraception? 61.7% report using some method, while 38.3% report using not using any method. Although 19% report never having sexual intercourse are not having sex um in the past three months. So of those that are using contraception, the number one method that is used in this country is actually still female sterilization. Um Or actually the pill. Excuse me. Followed closely by for female sterilization. Um So the pill is the most most commonly used method, although we are seeing the uptick of utilization of I. E. D. S. And long acting reversible contraception. So this was a quote by the American College of O. B. G. Y. N. On the contraceptive counseling position statement. This was published back in 2016 which basically states that contraception reproductive life planning are are the responsibility of all physicians, not just an obstetrician gynecologist. Physicians treating women in reproductive age should be open to consultation with O. B. G. Y. N. As needed. And contraception is an important part of women's health throughout their childbearing years. And it is through collaboration that we can provide effective methods of contraception, other needed medications. So this is a really important the thing that I believe all all health care providers that are in contact with reproductive age women should be able to feel comfortable discussing this with them. So this is a slide just introducing the U. S. C. D. C. Medical eligibility criteria for contraceptive use. This was published in 2000 and 16 and was basically formatted very similar to the World Health Organization Medical eligibility criteria which was published in 2000 and 10. And the U. S. C. D. C. Put out their own guidelines um as well. And um basically it's really easy to use chart um There's an app and I recommend everybody um just downloading it onto their smartphone or device. Um And if you just type in US medical eligibility criteria, you sme ccbc this app um sign will come up um And basically you can look at it and um and type in or or look at whatever medical condition your patient can have has and it will list for you the different methods of contraception and place it in a category. So green or category one, meaning no restriction for use for or red being unacceptable health risk or the method really is contra indicated for that patient. And then there's category to where the benefits generally outweigh the risks. So these are methods that I would freely prescribed for the patient if they wanted. Um And then three where the category three which is kind of in the light red where the risk will outweigh the benefits. But but again if the patient is unwilling or unable to use any other method with careful counseling um you may want you may consider this method for them. So this is a list of different conditions that are associated with increased risk for adverse health events as a result of unintended pregnancy. Um So this includes breast cancer, complicated valvular heart disease, um Epilepsy, poorly controlled hypertension, um Ischemic heart disease, sickle cell. This is all listed here. And so for these patients that I see in clinic um I really spend time just informing them and and so that they understand what the risks of pregnancy are to them and that can also guide um you know what they decide that they want to use for contraception. And especially when you're thinking about um in in patients where really pregnancy maybe even a contra indication where the risk of mortality is really high like conditions like pulmonary hypertension, you may really want to consider something highly effective like a long long acting reversible contraception method for those patients. So again, just with careful counseling um and letting patients know what their options are. This is something that you can spend time counseling patients about. So this is just the summary chart of the U. S. Medical eligibility criteria for contraceptive use. I'm sorry, it's kind of fine print here but I just wanted to show you what this image looks like. Um um You can always pull it up whenever you're in clinic where again if you have that app on your phone um it's really easy to use. And again um it has conditions um you know ranging from if they if the patient has any history of breast disease, history of headaches um you know diabetes and it places the different methods of contraception categories which helps guide guide you when you're discussing methods of contraception. Another way to present patients the options is discussing efficacy by category categorizing the method of contraception based on efficacy. Um I find that you know um Although these charts can be helpful in some ways it's really helpful like if the patient is a visual learner and kind of wants to see providing charts like this but sometimes it can be kind of overwhelming with the different options. So many times I actually asked the patient themselves um had they heard about any method of contraception, what contraception are they interested in using. And then that helps kind of guide guide the conversation about the different methods rather than just you know giving a laundry list of the different methods based on efficacy. I find that that is not really very helpful and what's more more helpful is kind of catering the conversation that's more individualized for the patient. So this is just a chart. Another way to think about methods of contraception is whether or not it contains estrogen in it. So the oral contraceptive pill, combined hormonal contraception including the patch or the vaginal ring have both estrogen and progestin in it. Then next is the progestin only methods which are um again pretty safe to use especially for patients with contra indications to estrogen. So that would include um they leave in a gestural intra uterine device depot, majority progestin acetate or depo Provera. And then the progestin only pill. And then there's a non hormonal methods copper I. U. D. Various barrier methods and then um national natural family planning or withdrawal methods as well fit into this category. So the primary mechanism of action. And again it does vary from method to method. But majority of the methods, especially the hormonal methods suppress ovulation and the way this does that is by suppressing the LH FSH production thus inhibiting the mid cycle LH surge. But another huge huge method mechanism action especially for the progestin containing um contraceptive methods is thickening of the cervical mucus and that itself kind of acts as a barrier to sperm. Um The the different methods also cause endometrial thinning and that can prevent implantation and the intra uterine device like the copper I. D. Can cause a local inflammatory action. Um that can prevent a fertilization as well as implantation although there can be escape population um in patients using these methods of contraception. So this just kind of, let's list the metabolic effects of estrogen and progestin. I always like the side because then again it helps us differentiate the what is with the estrogen is causing what the progestin czar are doing um with estrogen in general um There is an increase in HDL decrease in LDL increase in triglycerides but there is also an increase in globulin synthesis and this includes many clotting factors. Um And that is why for patients that have any vascular disease. Generally we try to avoid any estrogen containing methods. So this these are the different contraindications to combined hormonal contraception. I always kind of think about it systematically from head to toe. So starting first in the head. Um If the patient has a history of stroke history of migraine with aura or if they have um uh migraines and are greater than age of 35 then you may want to you you would want to avoid estrogen containing methods because this increases the risk of um of C. B. A. Or stroke in these individuals. If the patient has a history of breast cancer especially that is estrogen receptor positive or has a current breast cancer that would be a contra indication because it is much estrogen is metabolized by the liver for any patients with severe liver disease cirrhosis, liver tumor complicated solid organ transplant that would be a contra indication. Having a history of an acute DVT um History of DVD would be another contra indication. Um and again, anything in the chest. So complicated valvular disease, history of cardio myopathy, poorly controlled hypertension, having a mechanical heart valve um would be a contra indication to estrogen. And then for smokers who are greater than the age of 35. Um that would be a contra indication because again it would increase the risk of clot um having a known from biogenic mutation like electrify light and lupus if they're anti possible like like anti fossil lipid antibody syndrome positive. Um that would be a contra indication or having diabetes with um and Oregon effects like vascular disease would be a better education to estrogen or having major surgery with prolonged immobilization. You don't want to have them on estrogen at the same time as that. Um So this is kind of a helpful kind of way to think about it, especially when you have a patient in front of you and you're making sure that they don't have any contraindications. Um Again, uh this this is from the ACOG practice bulletin on use of combining hormonal contraception. Women with coexisting medical problems. Again, just uh advising if the patient has any of these um syndromes are are conditions then these are conditions were progestin only method may be more appropriate for that patient. So now we're going to move into some case studies just to kind of help us when we're thinking about patients that present in her office. This is Michelle, she's 19 years old. She has a history of poorly controlled type two diabetes or hemoglobin. A one C is 11.1 and she's presenting with a Bme of 40. She was recently admitted for glucose control and states that she has a boyfriend and is sexually active. And so now she's here in your office. Um It's important at every healthcare visit to discuss with the patient if they are sexually active. If so I'm really getting a full sexual history. Who are their partners? Are they are they at risk of becoming pregnant if if they are sexually active and having sex? That puts them at risk of pregnancy. Um do they wish to get pregnant become pregnant this year? If not, are they using any effective method of contraception? And and the additional question I asked for patients with medical conditions is would it be safe for them to become pregnant right now? Um So um I just wanted to also mention that you know when we're discussing and getting the pregnancy history um and contraception history from a patient, um it is really important to to kind of discuss this like what are their plans? And the other way to discuss it or pose the question is um if you found out you're pregnant today, how would that make you feel? Um and this kind of helps um uh you know, kind of filter out whether or not the patient is ambivalent or has some ambivalence regarding uh pregnancy. I had a patient um come tell me say that they would really want to be on a method of contraception. But if they happen to find out they're pregnant today, they wouldn't pursue pregnancy termination and would probably be actually happy by it. And so even when I offered emergency contraception, they said that no they're not interested in that right now. Um but you know, later in two weeks as if they're not pregnant, then they will resume a method of contraception. So again, it just helps kind of frame, you know how they're feeling regarding pregnancy and pregnancy intention. So reproductive life plan is a set of personal goals regarding whether when and how to have Children based on priorities, resources and values. And again, you know, just kind of alluding to. I know we have limited time in the office, but you know, just like a quick check in with a patient how they're feeling regarding pregnancy, what their overall plans are. Many patients are. Do you have kind of in and uh kind of overall plan for themselves and it's important to obtain that information because that can really help you in counseling them on methods of contraception. So, going back to this patient regarding poorly controlled pre gestational diabetes. So we do know patients who become pregnant with an elevated hemoglobin a one c do have an increased risk of fetal anomalies. There's a higher risk of neural tube defects Um V. S. Ds. There's an increased risk of early miscarriage, pregnancy loss, fetal macros, Omiya, shoulder to social preterm labor, preeclampsia, cardiovascular disease and progression of disease. Um As well as D. K. A. And the goal preconception hemoglobin a one C. Is 6.5. So I always think that's really important to let our patients with diabetes know that this is a goal so when and if they are planning on having Children. Um This is this is something that we should aim on optimizing their health prior to getting pregnant. Um So this is the list of the CDC medical eligibility criteria that when you type in diabetes, this is what would come up. So as we can see here really all method most methods are pretty safe to use. And patients with diabetes excluding. Again the estrogen containing methods for patients that have um nephew apathy or vascular disease from their diet from the diabetes. So why is unintended pregnancy high uh unintended unintended pregnancy rates higher in patients with diabetes. We know that between one half and two thirds of women with diabetes do experience having an unintended pregnancy. Um This you know uh this analysis was done by the national survey of family growth which shows that women with diabetes compared to non diabetics have an increased likelihood of reporting not using a method of contraception. And part of this is again that perceived perception of having sub fertility or difficulty conceiving. Um And then when looking at women with B. M. I. Greater than 35 compared to Bme less than 25. Again higher likelihood of not using a method of contraception because they were told that um uh that they may have a decreased risk of becoming pregnant. So why is unintended? Another another reason why unintended pregnancy rates are high and in patients with diabetes is diabetes and obesity. Obesity are associated with pcos or polycystic ovarian syndrome. So many patients can have irregular cycles. So feel that Again that they are not ovulating regularly and thus have a decreased likelihood of getting pregnant. In a study conducted with teen teen women um with type one diabetes have reported having sex without any method of contraception. 36% felt that they had limited options in regarding to contraception. And then 43% incorrectly believed that contraception was less effective it because of their diabetes. So um and then less than half reported speaking to a health care provider regarding contraception. So again, just showing the unmet need for many, many patients with diabetes um and this ends up kind of showing up in um in you know what methods of contraception they're they're actually receiving. So this just shows um again comparing women with diabetes on the left compared to women with no other chronic condition, there was actually a higher incidence or rate of sterilization. Um in this patient population of those with diabetes. And you can see the no contraception prescriptions or no counseling up to one half of the patients Compared to 38%. So um again this number is still high but this one really is quite high which again just shows the need for contraception counseling. So um we know that rates of obesity are on the rise um again higher in um in our for our for our for our friends in the south compared to California, but it is still increasing in California as well. Um issues with providing contraception to women of different weights. Um So we don't have really great data on contraception efficacy as it pertains to different BME. There's a lot of um conflicting studies that are out there, but there is kind of a general general theory that contraception efficacy can be decreased by increased BME. But this is really difficult because many of the clinical trials excluded patients with a high BME. Um We do know that risk of B. T. E. Um is increased in patients who have been elevated B. M. I. Um and who are using an estrogen containing method. Um And obesity itself is an independent risk factor for BT And again the concern for weight gain with different methods of contraception is always a concern for patients as well. So are obese women at increased risk of pregnancy. Again the risk of pregnancy depends on several things. # one being method of contraception use. So um again um I was just sharing before that patients that fall into um Class two and Class three obese category had higher rates of non use compared to those that were non obese. Um And then when you look at sexual behavior though based on BMI there really is no difference in sexual behavior. And if anything, studies of adolescent behavior show increased number of partners and unprotected intercourse among obese teens. And one study um and regards to perceived risk, there was no difference among BME groups but focused groups have shown that obese women were not aware of increased risk with pregnancy in general. So looking at B. T. E. And B. M. I. When when you um not including um use usage of uh combined oral contraception, you can see that B. M. I. Itself as an independent risk factor for increasing risk of BTE here with A. B. M. I. A. Greater than 30 associated with 2.3 elevated risk A. B. T. Compared to uh normal B. M. I. And then when you add on the combined oral contraception it jumps up to 3.1 to 3.5 and U. S. Studies. So contraception of efficacy and obesity. What affects efficacy that would you know obviously include adherence, especially if they are on a user dependent method, sexual behavior, fecundity, inherent efficacy of that method of contraception. There's proposed theories of how obesity can affect contraceptive efficacy is, as I mentioned uh for adherence there's theory on increased hepatic metabolism decreased by availability, altered fat distribution and delusions secondary to increased blood volume. That again um there's a lot of conflicting data on this. Um With eight observational studies really just showing by with unchanged um advocacy. Three showing decreased um advocacy based on B. M. I. Um And again, you know because of this we don't necessarily use B. M. I. As a reason to not initiate a method of contraception. Um The only uh study that we have that did show that there may be decreased efficacy in patients who have who are greater than 90 kg is um 11 small PK study of the Ortho Evra patch or the combined oral contraceptive patch um or combined hormonal contraceptive patch. And because of that this is the one method that I do let patients know um They may have decreased efficacy in and may want to use another method of contraception. Um When looking at the ring. Um They saw that there was no difference really an efficacy compared to when you're looking at BME. This was based on a post marketing study that was done in um in at Washington University. So again, you know, looking at obesity. Um and for the medical eligibility criteria um you know unless they've had a history of bariatric surgery. Um Then then you you would want to avoid the progestin only pill or combined hormonal contraception but otherwise. Um in the U. S. C. D. C. Medical eligibility criteria B. M. I. Is not a contra indication to using a combined method. Um If you do look at the british um kind of british counterpart to this. They actually do list Bme to be a contra indication to using a combined method. Um So because of that again I think it's important to carefully counsel the patients on this. Um So Michelle, the patient tells you she's sexually active with her boyfriend but didn't think she can get pregnant because of her infrequent periods. She did not does not wish to get pregnant right now. You inform her the risk of pregnancy. Um Given her her current human woman a one C. And wait and goals that are recommended prior to pregnancy. She desires the leaving a gestural I. U. D. And is accepting of a progestin only pill until she can get an I. U. D. Appointment. Um So long acting reversible contraception. Um These are highly effective methods. We you know um You know when we're discussing these methods we we talk about it as set it and forget it methods meaning it's not user dependent. Um Although patients can be can be counseled on how to remove it if they didn't want to self remove the I. U. D. For instance um The benefits of these long acting reversible methods of contraception. The next one on and the various methods of I. U. D. Is that fertility quickly returns to baseline after removal and you can use it depending on the method from three years to up to 12 years for the copper I. U. D. For instance it's a great option for women with medical problems because again um not having systemic estrogen in the system. So how does leave an industrial I. E. D. Work. Um The primary mechanism action is actually thickening the cervical mucus. Um This is why the I. U. D. Even if it's in the cervix itself um still is effective as a method of contraception. Um Although if you do see one in the cervix um you should replace it and place in the proper position. But this is why the efficacy is so high. Another way it works is by inhibiting From from motility and function by thinning out the lining of the Uterus and some cycles. It can also inhibit population. The failure rate is extremely low at .1% at one year. And the other added benefit is that the patient can have decreased in menstrual bleeding and achieve a memory in 20% Of users by one year. Um And uh and probably higher after that as well. So this is just a little picture of what the I. U. D. Looks like it is. It has been approved for seven years of use. Um So this is a change and so I do let patients know who are coming in for I. E. D. Exchange. Um And they're coming in for their five year appointments that they can do extended use with no decrease in efficacy for up to seven years and many times they're happy to hear that and just reschedule their appointment. And um so I let patients know that um the other type of I. E. D. That's available is the skylight has a little bit lower dose of we've been adjust rel compared to the marina. This is a proof for three years. Um The benefit of this one is that it is a little bit of a smaller size. It also has this um you can see here on the top kind of this nickel um ring. So it's really easy to spot in an ultrasound shows up kind of bright white in that area. Um Now the amen area rate is lower for this this device of patients um want maybe lighter periods but not absent period. This may be a good option also because of the smaller size. Um They were really marketing towards militarists women but really any I. U. D. Um Nilla parody is not a communication to you. So um there's also one I don't have a picture here of Kalina which is kind of um similar to Skyla but approved for five years of use. Um This is a picture of the copper I. E. D. Or para guard. The way it works is really by creating the sterile sterile inflammatory reaction. That side of toxic to sperm. It prevents fertilization. It can also be used as emergency contraception. And this has been approved actually. Um It's FADA approved for 10 years but you can do extended use for 12 years. And so when you know thinking about you know debating and talking to patients about which method might be right for them as far as the I. E. D. The copyright idea is great for patients who still want regular cycles who really do not want any hormonal method. Um ideal patients or patients that don't have a history of dispensary A because the copper I. E. D. Can increase some cramping and bleeding towards uh during the cycle. So not ideal in patients who already have a history of heavy menstrual bleeding. Um Believe in industrial I. E. D. Particular marina is FDA approved for heavy menstrual bleeding. So this is great for those patients. Um And this is great for patients who really are wanting to achieve a main area or where um Ayman area is acceptable. Um So again um this can be used in patients that have had multiple partners in patients who have a history who have had a history of S. T. A. R. P. I. D. Um who are militarists teens if they are immediately postpartum or post abortion. Um And patients who have had a history of ectopic pregnancy. So just wanted to reiterate that these are not contraindications to use of I. E. D. Um I still see patients come in and say oh my doctor told me I shouldn't get this because I haven't had Children yet. Um So again that is um uh misinformation. It's important to let patients know that these are available. Um Other non non contraceptive benefits is it can decrease the risk of endometrial hyperplasia. Again the League One adjustable I. E. D. The marina has been FDA approved for heavy menstrual bleeding and anemia. Um And it can also be part as um uh used as a part of hormone replacement therapy as well for patients who still have their uterus but don't want to take systemic progestin or adjuvant therapy with tamoxifen as well. So this is the extended use guidelines for long acting reversible contraception um showing what the FDA approved number is an evidence based. So um I think this is really great especially right now when patients may be hesitant to come into the office for procedures. I think it's really important to spend the time and let them know that it is okay to um to do extended use of their method if they are wanting to continue that method. Um And so this is that list there. So the other option which is great for patients with medical conditions is a progestin only pill are also called the mini pill. This is north and joan acetate at 0.35 mg. Um You don't need to give any placebo week but the timing of the pill is really crucial. So again the the main mechanism of action is thickening the cervical mucus. So even if you're late by taking it by three hours, they should use um emergency contraception. Um This is great for patients who have contraindications to estrogen. There's no increased BTE risk. The downside though is that patients can experience breakthrough bleeding on this method that can lead to discontinuation. Um But the missed pill period is quite short, so only three hours. So I I always give patients in advanced prescription of emergency contraception as well because it is really hard in general to remember to take a pill every single day, let alone the same time every day. Um I did want to introduce another progestin only pill or just prayer known only pill called slimmed. Um This was FDA approved in May of 2000 and 19. And the benefit of this pill is that because there's 24 active pills and then four placebo pills. Um The breakthrough bleeding profile is is better with this pill compared to north and joan acetate and because the half life is longer there's a little bit more wiggle room. Um So meaning you can use this kind of similar to regular birth control pill and that if you miss one pill you can double up on the next pill and continue the pack without risk of operation of having breakthrough population. Um Just very known for milligrams also has been shown to suppress ovulation compared to north and Jonas state which again really just only thickens the cervical mucus. Um Just very known pill. Again, there's a 24 hour window compared to the three hour pill through a three hour miss pill window for northern generosity. So um I am starting to prescribe this a little bit more. Uh Insurance companies are still a little behind the times and coverage. So you do want to just check with the insurance carrier to make sure this is covered, but this should be covered by medical as well. Um And it's really great again for patients who have contraindications to estrogen and to have these options. Um It has been shown to decrease rates of dismount area, particularly among teens or young women. Um So just another, another method. Um and then another thing I wanted to remind everyone is when we initiate methods of contraception really. Um none of these are required. So used to have old patients hostage to come in for pap smears before initiating method of contraception, but really we should be able to safely quick start or start a method of contraception as soon as the patient is requesting a method um and really the way to do that is to um you know, as as a patient and make sure they feel reasonably certain they're not pregnant at that time. And on that app that I um that I asked you to upload. There is a little chart under the CDC selective practice recommendations on ways to ensure the patient does not pregnant. Um For instance if they have not had any unprotected intercourse since um there there last period or they've been using some alternate method of contraception. Um basically they can start the method immediately um and then use the backup method for the first seven several days. Um And if they basically don't have their cycle as they anticipate then it's recommended they they take a urine pregnancy test. Um And really for any of these methods you can also provide emergency contraception as soon as you start, you quick start a method of contraception as well if they have had unprotected intercourse within five days um presenting to the clinic. So important to educate this patient on optimizing medical condition diabetes prior to pregnancy addressing need of contraception even though she has irregular cycles. If she had the diabetes is well controlled. It's okay to use um combined methods and long acting reversible contraception is great. Um for patients that have contraindications to systemic hormonal therapy. Um so this is Melanie. She has two Children. She's 39 years old. She has a history of a DVD. She was recently admitted for poorly controlled hypertension. Currently she's using the withdrawal method she liked to use depot in the past. So again you know asking these questions is really important as far as um how she would feel if she did get pregnant. Um What is she using as a method of contraception and you know providing information on withdrawal method. What is the efficacy? Um What is the risk of her becoming pregnant? Um so withdrawal method depending on what what studies you're looking at. Um it is with perfect use can be effective but I quote to patients a failure rate of up to 15% with the withdrawal method which is similar to a male condom. Um So not ideal for patients who are on a transgenic medication which is the case of this patient. So in the U. U. S. Women of reproductive age received 11.7 million prescriptions for class D. Or X. Drugs. And less than 20% of these patients actually receive contraception counseling which I think this shocking um meaning 6% of pregnancies end up becoming exposed exposed to transgenic medication. So Um you know when we talk to internal medicine positions um you know only about 60% new which medications were considered category d. n. x. and 65% knew about contraceptive efficacy. So again, you know um again just relaying the importance of us as primary care physicians. I'm really spending the time and looking at the medication list seeing if there's any estrogenic or plasticity medications on there and then enquiring about contraception used and if they just say condoms or withdrawal method, you know spending a few moments and discussing what the implications are in case they do have an unintended pregnancy on the medication is really important. Um When you look at hypertension and we do know that combined hormonal contraception can increase blood pressure and users. So because of that that can then increase the risk of stroke up to 1.5 to 2 times. This is why for patients with poorly controlled hypertension, estrogen is contra indicated. Um And again the rumba filic effects is really an estrogen effect and is dose related um to the estrogen amount. So looking at B. T. E. And um combined oral contraception use again just showing the relative risk bumping up to 2 to 3. But again compared to pregnancy which is much higher than using any pill. Um You know this is why I really spend the time talking about birth control methods um if they really are you know mary you know really wanting that method of contraception um and they're not willing to use any other method. Again just documenting that and letting them know that the risk of beauty obviously is higher in pregnancy. So it's still low but it is higher than using a progestin only method. Um And again this is just showing that same data there. So um compared to be t with progestin only pill or depot which is really not as high. And so these are medications that I use for patients who have a history of DVT um this just shows the jump in the relative risk um When the patient has factor five leiden or from ophelia with estrogen it jumps up incredibly high. Um Does that mean we should screen all patients for factor five light in? No we shouldn't be routinely testing all patients that we started combined hormonal contraception. But it is really important to take a family history and if they have a family history of, oh yeah my mom had a lot in my leg and my aunt also was hospitalized for a pe then that may prompt to work up for trump ophelia prior to starting estrogen containing method. So again this is the chart for hypertension um depending on whether or not it's poorly controlled or vascular if they have vascular disease secondary to that. Again safe for most methods of contraception. Again um contraindicated for estrogen if it's poorly controlled or have they have vascular disease. Um And this just shows the chart for D. V. T. Again um where estrogen is contraindicated when they have a history. So Melanie states she's not interested in becoming pregnant anytime soon is interested in permanent contraception. Not a candidate for estrogen containing methods given reportedly controlled hypertension. You discuss the importance of being on some highly effective method given um given she's currently on transgenic methods you offer her long acting reversible methods and depot. Um And when you discuss differences um she desires the implant at the time. So next one on this contains even in jest real. It is approved for use for up to five years for extended use. Um The downside though is that the bleeding pattern with this method can be fairly unpredictable but the benefit is that the failure rate is extremely low. Um Depot is also safe to use for patients that have a contra indication to estrogen. Um I like to let patients know of both that I am dose or the subcutaneous if they wanted to in self inject. This is an option for patients with no change in efficacy and if anything it may increased access and adherence if they're able to pick up pick it up themselves and self inject. But this is another uh good method although you know again limited by needing to make clinic appointments if they're coming in for I am Uh dozing. Um Ayman area rate is um is as high as about 40%. It does inhibit ovulation. Which which can decrease the risk of human peritoneum, especially if they are on anti coagulation um Which can happen from ruptured cysts. Um So this is a good benefit of depo Provera. The bone loss that we see what difference Rivera is reversible. But there is a small percentage of women who will report weight gain from this from depot. So I do advise patients to monitor their weight while they're on this. Um So again some learning points are that women on transgenic medications really should be counseled on the risk of unintended pregnancy on while they're on this medication. Um And being on some highly effective method of contraception or if they're planning a pregnancy, how to transition off of that tragic medication. Um If they're on an anti coagulation, they should be counseled on methods of contraception that can decrease menstrual bleeding and decrease the risk of human peritoneum as well. So last patient when 43 years old, she has a history of breast cancer is admitted for recently admitted for chemotherapy. She and she had unprotected and of course yesterday and just does not desire um future fertility. Um This just goes through the cancer risk um with combined oral contraception which shows slightly elevated risk for cervical cancer likely due to patients are on a method of contraception, um decreased um barrier barrier methods like condom use. Um And this is just the summary chart of mortality risk with combined oral oral contraceptive use. Um Looking at a large cohort study Um which showed that really there was no increased risk of dying from cancer for patients who are on combined oral contraception. Um there was a study in the New England journal published in 2017 which showed that the overall risk, relative risk of invasive Breast cancer um was slightly elevated at 1.2. Um but again, this was when you look at the larger large numbers, this was one additional case for every 77,690 women using hormonal contraception and did not adjust for co founders such as breast feeding um and the the relative risk increased with duration of use. Um So I think it's important to share and discuss that with patients. Um When looking at female sterilization. Um The most common you the most common method is with tuba ligation and we usually uh schedule this as laproscopic procedures in the operating room, but the majority are done actually immediately postpartum right after vaginal birth or at the time of C. Section. Um We used to have a sure which was a way that we could um place history skeptic inserts into the fallopian tube. But that was taken off the market then several years ago. So if patients do want a tuba ligation they would need to see a gynecologist to schedule that. Um The other alternative that I discussed with patients is a vasectomy. Especially for patients who have medical conditions, may not be great candidates for surgery. Um That said to me is very safe, effective and easy to do in the office is outpatient setting um has a very low complication rate. The only thing I do let patients know though is that they do need to wait to confirm is a sperm mia um prior to having unprotected intercourse. And that could take up 3-6 months. So they should use on some other method of contraception during that time. Um Just a quick site about emergency contraception. So um there are different methods out there. The plan b one step or leave an industrial pill and you can get over the counter L. A. You have to write a prescription for. But it is um effective. Up to five days after unprotected intercourse. So it's a little bit more has a greater window of efficacy compared to leave an industrial. And now we have data that shows copper I. U. D. And actually the marina you D. Um to be effective as emergency contraception. Um So if the patient wants some longer acting method of contraception and presents these can be used as um emergency contraception as well. Um These are just some indications for emergency contraception. Um And so um for the learning points for Gwen I think it's really important again to assess whether or not a patient is an appropriate candidate for emergency contraception. Um The I. U. D. Um Now we have data that came out last year or this year that showed the leaving A. Just A. I. U. D. Is as effective as copper I. U. D. For emergency contraception. So it's important to discuss those methods as well as the oral methods of emergency contraception and it's really important for our patients who are in their 40s. Um and are not yet menopausal to let them know that they are still at risk of pregnancy when you look at unintended pregnancy rates. Um it kind of peaks in their early 20's, and then again in the late 40s, because of this, again, perceived um thought that there are not at risk of pregnancy, so just letting um letting patients know that if they are faced with an unintended pregnancy, um there are options for terminating, um and I'm happy to see them for that as well, um and as well as any referrals for complex contraception.
