Transforming Contraceptive Care: Using the Evidence to Provide Contraceptives to Patients with Common Medical Problems Noa’a Shimoni MD MPH Medical Director, Student Health Services at Rutgers Health Sciences Campus Associate Professor, Department of Family Medicine Rutgers New Jersey Medical School

Conflict of interest I have no actual or potential conflict of interest in relation to this program/presentation. I have received research funding from Bayer Healthcare,

Objectives Describe how to use the CDC’s Medical Eligibility Criteria to determine safety for patients with common medical problems Define categories of safety Cases: migraines, smoking, chlamydia, antibiotics. Describe how to use the CDC’s Selected Practice Recommendations How to be reasonably certain a woman is not pregnant When to start and switch contraception Which exams and tests are medically indicated Some content has been adapted from the CDC’s MEC speaker ready slideset.

Medical Eligibility Criteria (MEC) Evidence based guidance on contraceptives: which contraceptives are safe for which medical conditions Adapted from World Health Organization guidelines in 2010 Revised in 2016 Recommendations based on independent systematic reviews by CDC and outside authors New additions (2016): Cystic fibrosis Multiple sclerosis Women using selective serotonin reuptake inhibitors Women using St. John’s wort Emergency contraceptive: ulipristal acetate

Changes to the MEC Hormonal methods (Implants, DMPA, POP, CHCs) Migraine headaches Superficial venous disease Women using antiretroviral therapy Women with known dyslipidemia Intrauterine devices (Cu-IUD, LNG-IUD) Gestational trophoblastic disease Postpartum and breastfeeding women Human immunodeficiency virus Factors related to sexually transmitted diseases Cu IUD: Copper IUD; LNG-IUD: Levonorgestrel IUD; POPs: Progestin-only pills; DMPA: Depo-Medroxyprogesterone Acetate; CHCs: Combined hormonal contraceptives including pills, patch, and ring

MEC Categories 1 No restriction for the use of the contraceptive method for a woman with that condition 2 Advantages of using the method generally outweigh the theoretical or proven risks 3 Theoretical or proven risks of the method usually outweigh the advantages – not usually recommended unless more appropriate methods are not available or acceptable 4 Unacceptable health risk if the contraceptive method is used by a woman with that condition

It’s impossible to talk about the MEC without addressing contraceptive counseling. We’re able to offer our patients all the reversible methods in house, so we start off the discussion with the most effective methods. Questions for the audience: how many are able to offer all reversible methods? How many insert IUDs in-house? How many insert implants in-house?

Case 1: Headaches A 21 year old female with a history of migraine headaches and light sensitivity presents to the office. She does not experience any visual warning signs for a coming headache. She is interested in starting contraception.  What methods are safe for her to consider? Combined hormonal methods (pill, patch, ring) Progestin implant Intrauterine device All of the above

Headache * These recommendations rely upon accurate diagnosis of headache as migraine with or without aura. They are intended for women without other risk factors for stroke. Consult full guidance for additional clarification.

Headache A 21 year old female with a history of migraine headaches and light sensitivity presents to the office. She does not experience any visual warning signs for a coming headache. She is interested in starting contraception.  What methods are safe for her to consider? Answer: A. Combined hormonal methods (pill, patch, ring) B. Progestin implant Intrauterine device All of the above All of the above, so long as she does not have other risk factors for stroke. (If so, progestin-only methods and IUDs are safe or generally safe to use.)

How do we define a migraine with aura? At least two attacks of: Headache lasting 4 to 72 hours (untreated or unsuccessfully treated) Headache has at least two of the following characteristics: Unilateral location Pulsating quality Moderate or severe pain intensity Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs) One or more of the following fully reversible aura symptoms: Visual, sensory, speech and/or language, motor, brainstem, retinal At least two of the following four characteristics: At least one aura symptom spreads gradually over ≥5 minutes, and/or two or more symptoms occur in succession Each individual aura symptom lasts 5 to 60 minutes At least one aura symptom is unilateral The aura is accompanied, or followed within 60 minutes, by headache Not better accounted for by another ICHD-3 diagnosis, and transient ischemic attack has been excluded The International Classification of Headache Disorders, 3rd edition (ICHD-3)

Case 2: Smoking A 19 year old student presents to the office requesting oral contraceptive pills.  She is recently sexually active and has occasional acne flare-ups.  She smokes 15 cigarettes a day.   What methods are safe for her to consider? Answer: Combined hormonal methods (pill, patch, ring) Progestin implant Intrauterine device All of the above

Smoking Cu IUD: Copper IUD; LNG-IUD: Levonorgestrel IUD; DMPA: Depo-Medroxyprogesterone Acetate; POPs: Progestin-only pills; CHCs: Combined hormonal contraceptives including pills, patch, and ring

Smoking 19 year old student presents to the office requesting oral contraceptive pills.  She is recently sexually active and has occasional acne flare-ups.  She smokes 15 cigarettes a day.   What methods are safe for her to consider? Answer: Combined hormonal methods (pill, patch, ring) Progestin implant Intrauterine device All of the above All of the above, given her age.  Nevertheless, this is a good opportunity to discuss smoking cessation and to consider progestin-only methods, especially if she has other vascular risk factors. 

Case 3: Chlamydia A 19 year old comes to the office asking for an IUD.  She has a history of chlamydia 6 months ago that was treated, and reports one new partner since then.   Given her STI risk factors, can you place an IUD today?

Chlamydia Categories for sexually transmitted diseases in the 2016 US MEC have been streamlined to include the following: (1) current purulent cervicitis or chlamydial or gonococcal infection, (2) vaginitis including trichomonas vaginalis and bacterial vaginosis, and (3) other factors related to STDs.  All methods other than IUDs are category 1 for all STD categories.  IUD insertion is category 2 for all STDs except for current purulent cervicitis or known chlamydial/gonococcal infection, which is category 4 (contraindicated).  The category “increased risk of STIs” was removed in the 2016 US MEC.  In a systematic review, the CDC found that algorithms based on demographics, history and exam findings have very low predictive value for the diagnosis of gonococcal and chlamydial infection. Instead, if STD screening has not been performed according to CDC STD guidelines at the time of a contraceptive initiation visit, screening can be performed at that time. Provision of contraception, including intrauterine devices (IUDs), should not be delayed or restricted for asymptomatic women at risk for STDs. *Clarification: If a woman with risk factors for STDs has not been screened for gonorrhea and chlamydia according to CDC STD treatment guidelines, screening may be performed at the time of IUD insertion and insertion should not be delayed.

Chlamydia A 19 year old comes to the office asking for an IUD. She has a history of chlamydia 6 months ago that was treated, and reports one new partner since then. Given her STI risk factors, can you place an IUD today? Answer: Yes, so long as she does not have purulent cervicitis or other contraindications. Perform screening for gonorrhea and chlamydia at the time of IUD insertion. Refer to the SPR for guidelines on assessment of pregnancy and follow-up.

Chlamydia screening (CDC) Sexually active women aged <25 years: screen annually Sexually active women aged ≥25 years: if at increased risk for infection a new sex partner more than one sex partner a sex partner with concurrent partners a sex partner who has a sexually transmitted infection And…test for reinfection at 3 months, offer expedited partner therapy, and abstain for 7 days after treatment.

Chlamydia: guidance from SPR Class A: essential and mandatory in all circumstances for safe and effective use of the contraceptive method. Class B: contributes substantially to safe and effective use, but implementation may be considered within the public health and/or service context; risk of not performing an examination or test should be balanced against the benefits of making the contraceptive method available. Class C: does not contribute substantially to safe and effective use of the contraceptive method.

Case 4: Antibiotics 24 year old presents with symptoms of a lower urinary tract infection. She is using the ring for contraception. You mull over some of the antibiotic options: trimethoprim/sulfamethoxazole, nitrofurantoin, or ciprofloxacin. Should you be concerned about interactions between her contraception and antibiotics? No Yes

Antibiotics Clarification: Rifampin or rifabutin therapy is likely to reduce the effectiveness of CHCs. Use of other contraceptives should be encouraged for women who are long-term users of either of these drugs. When a COC is chosen, a preparation containing a minimum of 30 μg ethinyl estradiol should be used.

Case 4: Antibiotics 24 year old presents with symptoms of a lower urinary tract infection. She is using the ring for contraception. You mull over some of the antibiotic options: trimethoprim/sulfamethoxazole, nitrofurantoin, or ciprofloxacin. Should you be concerned about interactions between her contraception and antibiotics? Answer: No Yes No. None of the antibiotics listed above decrease the effectiveness of the contraceptive ring.

Where to go next…when the MEC is not enough The MEC gives guidance for who. Who can safely use the pill or the IUD, but it doesn’t give the how. The SPR gives the how. When can an IUD be inserted, and when can an OCP be started after ulipristal acetate?

Case 5: Ulipristal acetate 23 year old presents to the office after unprotected intercourse the previous night, requesting the morning after pill. She has a 28 day regular cycle and her LMP was about two weeks ago. You prescribe her ulipristal acetate. She was on the contraceptive patch before and would like to start it again. When should she start the patch? Tomorrow Five days after ulipristal acetate On the first day of her next menstrual cycle The Sunday after her menstrual cycle begins

Case 5: Ulipristal acetate When to start regular contraception after ulipristal acetate (UPA): No sooner than 5 days after use of UPA For methods requiring a visit to a health care provider (DMPA, implants, and IUDs), starting the method at the time of UPA use may be considered Risk: decreased effectiveness of UPA Weigh this against the risk of not starting a regular hormonal contraceptive method. Abstain from sexual intercourse or use barrier contraception for the next 7 days after starting or resuming regular contraception or until her next menses, whichever comes first. Any nonhormonal contraceptive method can be started immediately after the use of UPA. Advise the woman to have a pregnancy test if she does not have a withdrawal bleed within 3 weeks.

Case 5: Ulipristal acetate 23 year old presents to the office after unprotected intercourse the previous night, requesting the morning after pill. She has a 28 day regular cycle and her LMP was about two weeks ago. You prescribe her ulipristal acetate. She was on the contraceptive patch before and would like to start it again. When should she start the patch? Answer: Tomorrow Five days after ulipristal acetate On the first day of her next menstrual cycle The Sunday after her menstrual cycle begins

How to be reasonably certain… A health-care provider can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets any one of the following criteria: is ≤7 days after the start of normal menses has not had sex since the start of last normal menses has been correctly and consistently using a reliable method of contraception is ≤7 days after spontaneous or induced abortion is within 4 weeks postpartum is fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority [≥85%] of feeds are breastfeeds), amenorrheic, and <6 months postpartum

How to switch methods Reproductive Health Access Project www.reproductiveaccess.org