1. Medically Complex Contraceptive Care Kelita Fox MD Erin Hendriks MD Natalie Hinchcliffe Linda Prine MD

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 29 year old G2P0020 female who comes to the office with a UTI BMI = 34 History of hyperlipidemia. Last lipid profile showed LDL: 143 Wants to try the patch. http://www.everystockphoto.com/photo.php?imageId=12048627&searchI d=d200ace9910e021dc23256f155816f1f&npos=39

5. Doreen 46 year-old G2P2. PMH significant for asymptomatic gallstones and cervical cancer awaiting treatment Would like to remove her copper IUD and try “the shot” http://s3.amazonaws.com/everystockphoto/ sxc2/17/72/7/african-american-black-17727- l.jpg

6. 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 http://www.everystockphoto.com/photo.php?imageId=8685&searchId=56 609ab6ba04048adc2cbfafbe745e10&npos=380

7. Category 4 Conditions for IUD 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).

8. 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/

9. Audrey 33 year old G3P3 Migraines without aura for many years Happy with her Combined Oral Contraceptives Newly diagnosed with Lupus, so far uncomplicated http://www.everystockphoto.com/photo.php?imageId=31 2641&searchId=56609ab6ba04048adc2cbfafbe745e10& npos=1577

10. 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 carbemazepine, 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

11. Jenny 36 years old and recently diagnosed with colon cancer. She is scheduled for surgery in 2 weeks. Mother has a history of DVT Requests a prescription for birth control pills http://www.everystockphoto.com/photo.php?imageId=13214175&sear chId=56609ab6ba04048adc2cbfafbe745e10&npos=782

12. 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.