1. Meeting the Contraceptive Needs of Women Students: Bringing the Evidence into Practice Sara H. Lee, MD Case Western Reserve University April 10, 2015

2. Welcome! Please fill out the pre-test while you are getting settled.

3. Agenda What are the gaps? Guidelines and evidence for improving practice What exists and how to get it What do the guidelines look like, and how do you use them to solve problems Case studies

4. Defining the problem 7.3% of college students did not use contraception at last vaginal intercourse 1% of college students had an unintentional pregnancy American College Health Association. American College Health Association-National College Health Assessment II: Reference Group Executive Summary Spring 2014. Hanover, MD: American College Health Association; 2014.

5. Defining the problem: barriers to contraception Student level Ambivalence Cost Access Privacy concerns Provider level Unnecessary testing Availability of methods

6. Guidelines and Evidence for Improving Practice

7. CDC Contraceptive Guidance for Healthcare Providers CDC Medical Eligibility Criteria (MEC) CDC Selected Practice Recommendations for Contraceptive Use (SPR)

8. CDC US Medical Eligibility Criteria Evidence-based source of clinical guidance for the safe use of contraceptive methods by women with various characteristics and medical conditions. Developed in 2010 – adapted from WHO guidelines. Includes over 1800 recommendations for more than 60 conditions and also includes information on certain drug interactions.

9. “Although these recommendations are meant to serve as a source of clinical guidance, health-care providers should always consider the individual clinical circumstances of each person seeking family planning services.”

10. US MEC Categories

11. Example: Cigarette Smoking ConditionCOC/P/RPOPDMPAImplantCu-IUDLNG-IUD Smoking a. Age <35 2 11111 b. Age >35 i. <15 cig/day 3 11111 ii. >15 cig/day 4 11111 http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf

12. Initiation and Continuation Separate columns if recommendations differ for Initiation criteria (preexisting conditions) Continuation criteria (condition develops or worsens) Combined Hormonal Contraceptives HeadacheInitiationContinuation Non-migrainous (mild or severe) 12 Migraine Without aura Age < 35 years 2 3 Age >= 35 years 3 4 With aura, at any age 4 4

13. CDC US Selected Practice Recommendations Published in 2013 as companion to US MEC. Also adapted from WHO. Offers evidence-based guidance for contraceptive management.

15. Take Home Messages  Most women can start most methods anytime  Few, if any, exams or tests are needed  Recommendations for anticipatory counseling for potential bleeding problems and proper management provided  Routine follow-up generally not required  Many circumstances call for consideration of emergency contraception use  Regular contraception should be started after EC

16. US SPR and MEC: Strengths and Limitations Limitations Long, wordy, repetitive Intended for adults Hard to find Strengths Thorough and evidence-based Can be used as protocol Apps!

17. Locating CDC contraception guidance http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USSPR.htm

20. Install App and download SPR

21. Prescribing contraception using the US SPR and MEC

22. Prescribing Oral Contraceptives 18 year old freshman wants birth control pills. Her last period was 6 days ago, and she last had sex 2 weeks ago with a condom. She has a history of migraines WITHOUT aura.

23. Can she have the pills?

34. Does she need an exam? Any exam? Did she need to come in to your office today? Does she need any testing?

35. US SPR – Exams and Tests Class A = essential and mandatory Class B = contributes substantially to safe and effective use, but implementation may be considered within the public health and/or service context Class C = does not contribute substantially to safe and effective use of the contraceptive method

36. Examination or testContraceptive method and class Examination LNG and Cu-IUD ImplantInjectable CHCPOPCondom Diaphragm or cervical cap Spermicid e Blood pressureCCCA*CCCC Weight (BMI)— † —†—† —†—† —†—† —†—† CCC Clinical breast examination CCCCCCCC Bimanual examination and cervical inspection ACCCCCAC Laboratory test GlucoseCCCCCCCC LipidsCCCCCCCC Liver enzymesCCCCCCCC HemoglobinCCCCCCCC Thrombogenic mutations CCCCCCCC Cervical cytology (Papanicolaou smear) CCCCCCCC STD screening with laboratory tests —§—§ CCCCCCC HIV screening with laboratory tests CCCCCCCC Appendix C (p. 56)

37. College Students as Emerging Young Adults College students are emerging young adults Ages 18 to 25 Brain is still developing Still completing developmental tasks The New Adolescents: An Analysis of Health Conditions, Behaviors, Risks, and Access to Services among Emerging Young Adults Lawrence S. Neinstein, MD 2013

38. College Students as Emerging Young Adults Establishing identity Developing independence More risk-taking behaviors Depression

39. Chlamydia—Rates by Age and Sex, United States, 2012 2012-Fig 5. SR, Pg 11

40. Gonorrhea—Rates by Age and Sex, United States, 2012 2012-Fig 21. SR, Pg 21

41. Examination or testContraceptive method and class Examination LNG and Cu-IUD ImplantInjectable CHCPOPCondom Diaphragm or cervical cap Spermicid e Blood pressureCCCA*CCCC Weight (BMI)— † —†—† —†—† —†—† —†—† CCC Clinical breast examination CCCCCCCC Bimanual examination and cervical inspection ACCCCCAC Laboratory test GlucoseCCCCCCCC LipidsCCCCCCCC Liver enzymesCCCCCCCC HemoglobinCCCCCCCC Thrombogenic mutations CCCCCCCC Cervical cytology (Papanicolaou smear) CCCCCCCC STD screening with laboratory tests —§—§ CCCCCCC HIV screening with laboratory tests CCCCCCCC Appendix C (p. 56)

42. Does she need an exam? Any exam? Did she need to come in to your office today? Does she need any testing? _______________________________________________________ Only blood pressure is required. Anything else is OPTIONAL even if it is a good idea.

43. Next Question When can she start the pills?

44. Contracepti ve Method When to start, if provider is reasonably certain woman is not pregnant Back-up needed LNG IUDAny time If > 7 days of cycle, use back-up method or abstain for 7 days Copper IUDAny timeNot needed Implant (etonogestre l) Any time If > 5 days of cycle, use back-up method or abstain for 7 days InjectableAny time If > 7 days of cycle, use back-up method or abstain for 7 days CHCAny time If > 5 days of cycle, use back-up method or abstain for 7 days Progestin- Only Pills (POPs) Any time If > 5 days of cycle, use back-up method or abstain for 2 days Appendix B (p. 55)

45. Page 5

46. Her last period was 6 days ago, and she last had sex 2 weeks ago with a condom.

47. How long does she need to use a back-up method?

48. Contracepti ve Method When to start, if provider is reasonably certain woman is not pregnant Back-up needed LNG IUDAny time If > 7 days of cycle, use back-up method or abstain for 7 days Copper IUDAny timeNot needed Implant (etonogestre l) Any time If > 5 days of cycle, use back-up method or abstain for 7 days InjectableAny time If > 7 days of cycle, use back-up method or abstain for 7 days CHCAny time If > 5 days of cycle, use back-up method or abstain for 7 days Progestin- Only Pills (POPs) Any time If > 5 days of cycle, use back-up method or abstain for 2 days Appendix B (p. 55)

49. How many packs are you going to give her? What is her follow-up?

50. Page 26

51. What about blood pressure checks? No evidence exists regarding whether a routine follow-up visit after initiating combined hormonal contraceptives improves correct or continued use. Monitoring blood pressure is important for combined hormonal contraceptive users. Health-care providers might consider recommending women obtain blood pressure measurements in nonclinical settings (e.g., pharmacy or fire station). A systematic review identified five studies that examined the incidence of hypertension among women who began using a COC versus those who started a nonhormonal method of contraception or a placebo (17). Few women developed hypertension after initiating COCs, and studies examining increases in blood pressure after COC initiation found mixed results. No studies were identified that examined changes in blood pressure among patch or vaginal ring users (Level of evidence: I, fair, to II-2, fair, indirect).

52. How many packs are you going to give her? What is her follow-up? “Specific populations that might benefit from more frequent follow- up visits include adolescents, those with certain medical conditions or characteristics, and those with multiple medical conditions.”

53. Prioritizing Tasks at the Visit Prescribing contraception STI screening Screening for sexual assault and intimate partner violence Depression screening Establishing a primary care relationship

54. How are you going to give her ALL of this information? When to start How to take the pills Back up method Side effects Missed pills Anticipatory guidance about unscheduled bleeding

55. Effective Communication (“Health Literacy”) Limit information provided to two or three important points at a time. (Joint Commission) 40–80% of medical information provided by healthcare practitioners is forgotten immediately. The greater the amount of information presented, the lower the proportion correctly recalled. Almost half of the information that is remembered is incorrect Kessels RP. Patients' memory for medical information. J R Soc Med. 2003 May; 96(5): 219–222.

56. How are you going to give her ALL of this information? Face to face Video Handout Text E-mail

57. CDC SPR: Clinic Protocols and Policies A 21 year old junior presents today for her fourth DMPA injection. The last one was given 2/01/2014. Can she have the injection?

58. Page 21

59. CDC SPR: Clinic Protocols and Policies A 21 year old junior presents today for her fourth DMPA injection. The last one was given 2/01/2014. Can she have the injection? Can develop a protocol or policy based on SPR guidelines

60. Prescribing EC A 23 year-old graduate student with no medical problems had unprotected sex 36 hours ago and presents for emergency contraception. What are her options?

61. Page 34

62. She decides she wants to start OCPs – when can she start them?

63. Page 35

64. Take Home Messages  Most women can start most methods anytime  Few, if any, exams or tests are needed  Recommendations for anticipatory counseling for potential bleeding problems and proper management provided  Routine follow-up generally not required  Many circumstances call for consideration of emergency contraception use  Regular contraception should be started after EC

65. Long-Acting Reversible Contraception (LARC) IUD or Implant Most effective Page 6

68. LARC Myths and Misconceptions IUDs cause PID and infertility LARC causes menstrual irregularities IUDs are only for women who have had a pregnancy Adolescents and young adults prefer OCPs

69. LARC and US SPR A 21 year old art student wants a levonorgestrel-releasing IUD (LNG- IUD). Her last period was 2 weeks ago, and she last had sex 1 month ago. Can she have an IUD today?

70. Contracepti ve Method When to start, if provider is reasonably certain woman is not pregnant Back-up needed LNG IUDAny time If > 7 days of cycle, use back-up method or abstain for 7 days Copper IUDAny timeNot needed Implant (etonogestre l) Any time If > 5 days of cycle, use back-up method or abstain for 7 days InjectableAny time If > 7 days of cycle, use back-up method or abstain for 7 days CHCAny time If > 5 days of cycle, use back-up method or abstain for 7 days Progestin- Only Pills (POPs) Any time If > 5 days of cycle, use back-up method or abstain for 2 days Appendix B (p. 55)

71. If you need to refer her, does she need any testing? Should you do an exam?

72. Examination or testContraceptive method and class Examination LNG and Cu-IUD ImplantInjectable CHCPOPCondom Diaphragm or cervical cap Spermicid e Blood pressureCCCA*CCCC Weight (BMI)— † —†—† —†—† —†—† —†—† CCC Clinical breast examination CCCCCCCC Bimanual examination and cervical inspection ACCCCCAC Laboratory test GlucoseCCCCCCCC LipidsCCCCCCCC Liver enzymesCCCCCCCC HemoglobinCCCCCCCC Thrombogenic mutations CCCCCCCC Cervical cytology (Papanicolaou smear) CCCCCCCC STD screening with laboratory tests —§—§ CCCCCCC HIV screening with laboratory tests CCCCCCCC Appendix C (p. 56)

73. Take Home Messages  Most women can start most methods anytime  Few, if any, exams or tests are needed  Recommendations for anticipatory counseling for potential bleeding problems and proper management provided  Routine follow-up generally not required  Many circumstances call for consideration of emergency contraception use  Regular contraception should be started after EC

74. How Can We Use Guidelines and Evidence Successfully in a College Health Setting?

75. Case 1: Start to Finish You are seeing a 20 year old sophomore who wants to start contraception. She had sex 2 nights ago and thinks she used a condom. Her last period was 1 week ago. She has well-controlled type I diabetes. She wants birth control pills, but she remembers her endocrinologist telling her years ago that people with diabetes “can’t have those.” What are her options today? What testing does she need? What instructions should she receive?

76. Case 2: Unscheduled Bleeding A 20 year old junior started the hormonal implant (Nexplanon) 4 months ago and comes in worried about spotting. She hates spotting. What can you recommend?

78. Case 3: On Call Ms. Smith is a third year college student. She has been seen in the health center once for a refill on her birth control. She was prescribed a three month supply of her OCP and advised to schedule an annual women’s health exam. You are the on-call clinician and received a call from Nurse Response – Ms. Smith will run out of her birth control on Sunday. How would you handle this situation?

79. Does your health center have a formal policy? Can you use the evidence to develop one?

80. True or False? Question 1: The CDC US Medical Eligibility Criteria provides recommendations for the safety of contraceptive methods for women with various medical conditions. Question 2: According to the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 (US SPR), women who receive a prescription for oral contraceptive pills are required to have their blood pressure checked in 3 to 4 months. Question 3: Most contraceptive methods require a “waiting period” prior to initiation. Question 4: Regular contraception should be started after emergency contraception. Question 5: Nothing can be done for women with unscheduled bleeding who use the implant or injection as contraception other than changing methods.