1. Contraception Case Studies

2. VETERANS HEALTH ADMINISTRATION Case Study 1 Ashley, a 23-year-old unmarried veteran comes for an initial visit to request birth control. She asks about birth control pills, but also wants information about the newer hormonal methods on the market. Vital signs: 5 feet 6 inches tall, 210 lbs., BMI 33.9, HR 76, RR 16, 98.7 F, 142/88 2 2

3. VETERANS HEALTH ADMINISTRATION 1.Blood pressure 2.Smoking history 3.Pap smear and pelvic exam 4.History of migraines with auras 5.All of the above are needed prior to starting hormonal contraception Q1. What information do you NOT need prior to starting Ashley on hormonal contraception? 3

4. VETERANS HEALTH ADMINISTRATION 1.Blood pressure 2.Smoking history 3.Pap smear and pelvic exam 4.History of migraines with auras 5.All of the above are needed prior to starting hormonal contraception Q1. What information do you NOT need prior to starting Ashley on hormonal contraception? 4

5. VETERANS HEALTH ADMINISTRATION Prior to starting COC, check for the following: Blood pressure measurement Family history of thrombotic disorders Migraines with aura Smoking history (not necessary for Ashley who is 23 yo, but important for women ≥35 or approaching this age) It is NOT necessary to do a Pap smear and pelvic exam prior to initiation This might be a good time to discuss the HPV vaccine since the patient is under age 26 Discussion Points 5

6. VETERANS HEALTH ADMINISTRATION Q2. Which of the following is NOT an absolute contraindication for oral contraceptives? 1.Smoking and age ≥35 2.Acute liver disease 3.Migraine without aura 4.History of clots, stroke, or heart disease 5.Undiagnosed abnormal vaginal bleeding 6

7. VETERANS HEALTH ADMINISTRATION Q2. Which of the following is NOT an absolute contraindication for oral contraceptives? 1.Smoking and age ≥35 2.Acute liver disease 3.Migraine without aura 4.History of clots, stroke, or heart disease 5.Undiagnosed abnormal vaginal bleeding 7

8. VETERANS HEALTH ADMINISTRATION Absolute contraindications include: Breast cancer history History of blood clots, stroke, heart disease Undiagnosed abnormal vaginal bleeding Pregnancy Acute liver disease Migraine with aura Smoking & age ≥ 35 Discussion Points 8

9. VETERANS HEALTH ADMINISTRATION Relative contraindications include: Migraine – “classic” High blood pressure High cholesterol Diabetes Obesity Breastfeeding Discussion Points 9

10. VETERANS HEALTH ADMINISTRATION Ashley thinks she may like to go on “the pill”, as many of her friends are happy with it. She has seen advertisements on TV for Yasmin®, and would like to try it because she gets very moody around the time of her period. Case 1, continued 10

11. VETERANS HEALTH ADMINISTRATION 1.Mid-dose (30-35 mcg ethinyl estradiol) pills 2.Low-dose (20 mcg ethinyl estradiol) pills 3.Extended cycle (13 week) pills 4.Drosperinone-containing pills 5.All of the above are options Q3. Which of the following are options for her? 11

12. VETERANS HEALTH ADMINISTRATION 1.Mid-dose (30-35 mcg ethinyl estradiol) pills 2.Low-dose (20 mcg ethinyl estradiol) pills 3.Extended cycle (13 week) pills 4.Drosperinone-containing pills 5.All of the above are options Q3. Which of the following are options for her? 12

13. VETERANS HEALTH ADMINISTRATION Low-dose (20 mcg of ethinyl estradiol) pills – More breakthrough bleeding when initially started compared to mid-dose estrogen – Not shown to be associated with fewer thrombotic events Mid-dose pills contain 30-35 mcg of ethinyl estradiol Non-contraceptive benefits of COCs include: – Regular cycles – Decreased: bleeding, dysmenorrhea, acne, risk of endometrial and ovarian cancers Discussion Points 13

14. VETERANS HEALTH ADMINISTRATION Yasmin® − Contains “drosperinone”, a spironolactone derivative progestin with anti-mineralicorticoid and anti-andrenergic effects Drosperinone-containing COCs may be associated with higher risk for blood clots than COCs containing other progestins − May be better than placebo for PMDD − Few head-to-head studies comparing Yasmin® to other COCs that may also help with PMDD − Use caution when prescribing to women at risk for hyperkalemia COCs appear to protect against ovarian and uterine cancer (5 yrs: 50% and 60% reduction) and colon cancer. Literature is mixed with regard to risk of breast cancer. Do not protect against cervical cancers. Discussion Points 14

15. VETERANS HEALTH ADMINISTRATION 1.Reduce frequency of menses 2.Manipulate timing of menses 3.Control menorrhagia 4.Manage dysmenorrhea 5.All of the above Q4. Extended cycle use of combined oral contraceptives is useful to: 15

16. VETERANS HEALTH ADMINISTRATION 1.Reduce frequency of menses 2.Manipulate timing of menses 3.Control menorrhagia 4.Manage dysmenorrhea 5.All of the above Q4. Extended cycle use of combined oral contraceptives is useful to: 16

17. VETERANS HEALTH ADMINISTRATION Traditional COCs have 21 days of active pills and 7 days of placebo pills. Extended cycle COCs have 13-week cycles. Advantages of an extended cycle: Only four periods a year Desirable for women who travel frequently or have menstrual- related problems (heavy bleeding, mood swings, acne) Breakthrough bleeding can occur, especially at 9-12 weeks Note: Many COCs can be taken continuously without placebo pills. This requires prescribing 4 pill packs for a 90-day supply. Discussion Points 17

18. VETERANS HEALTH ADMINISTRATION 1.Headache and nausea 2.Spotting 3.Breast tenderness 4.Decreased libido 5.All of the above are side effects of the pill Q5. Ashley should watch for all of the following side effects with an OCP EXCEPT? 18

19. VETERANS HEALTH ADMINISTRATION 1.Headache and nausea 2.Spotting 3.Breast tenderness 4.Decreased libido 5.All of the above are side effects of the pill Q5. Ashley should watch for all of the following side effects with an OCP EXCEPT? 19

20. VETERANS HEALTH ADMINISTRATION OCP side effects include headache, nausea, spotting, and breast tenderness Placebo-controlled trials have NOT found mood changes or weight gain to be more frequent on OCPs compared to placebo If she is not happy with her OCP, but wants to continue taking a pill, it is reasonable to try another formulation with either a different dose of estrogen or a different progestin before switching to a different method Discussion Points 20

21. VETERANS HEALTH ADMINISTRATION After listening to your instructions on how to use an oral contraceptive, Ashley worries that she will not be reliable in taking the pill every day, and asks about other options. Case 1, continued 21

22. VETERANS HEALTH ADMINISTRATION 1.Irregular bleeding is uncommon during the first 6-9 months of use 2.DMPA never causes amenorrhea 3.Fertility may be delayed after discontinuation 4.DMPA increases the risk of gynecologic cancers 5.DMPA does not affect bone mineral density 6.Weight gain is not a reported side effect Q6. Which of the following side effects is TRUE about depot medroxyprogesterone acetate (DMPA, Depo-Provera ® )? 22

23. VETERANS HEALTH ADMINISTRATION 1.Irregular bleeding is uncommon during the first 6-9 months of use 2.DMPA never causes amenorrhea 3.Fertility may be delayed after discontinuation 4.DMPA increases the risk of gynecologic cancers 5.DMPA does not affect bone mineral density 6.Weight gain is not a reported side effect Q6. Which of the following side effects is TRUE about depot medroxyprogesterone acetate (DMPA, Depo-Provera ® )? 23

24. VETERANS HEALTH ADMINISTRATION Irregular bleeding; amenorrhea with prolonged use Delay in return to ovulation after cessation (avg time is 10 mos) Nausea, breast tenderness, headaches, decreased libido, weight gain Avg weight gain is 5.4 pounds in first year; weight gain is greater for women already obese Decreases menstrual cramps, endometriosis pain, endometrial cancer risk, and possibly ovarian cancer risk Good choice for women who can’t use estrogen, safe to use during lactation, decreases sickle cell crisis, may reduce seizures in epileptics Discussion Points 24

25. VETERANS HEALTH ADMINISTRATION Q7. Which of the following options might be less suitable for Ashley? 1.Ortho Evra® patch 2.NuvaRing® 3.Depo-Provera® 4.Implanon® 25

26. VETERANS HEALTH ADMINISTRATION Q7. Which of the following options might be less suitable for Ashley? 1.Ortho Evra® patch 2.NuvaRing® 3.Depo-Provera® 4.Implanon® 26

27. VETERANS HEALTH ADMINISTRATION Of the 15 pregnancies that occurred during the clinical trial of Ortho Evra®, five were in women greater than 90 kg. Thus, patch may not be as effective in obese women. However, contraceptives are only effective if patient will use them, so shared decision-making is very important in this case. Average weight gain with Depo-Provera® is 5.4 pounds in first year. Weight gain is greater for women already obese. Discussion Points 27

28. VETERANS HEALTH ADMINISTRATION Kanisha, a 35-year-old female comes to your clinic to ask about contraception. She and her husband have one child. She wants some type of birth control that she doesn't have to think about for as long as possible. She is otherwise healthy, and her only complaint is heavy periods. She is currently using the “rhythm method” and adding condoms during high-risk times. Case 2 28

29. VETERANS HEALTH ADMINISTRATION Q8. Which of the following contraceptives would you recommend? 1.Ortho Evra® patch 2.NuvaRing® 3.Depo-Provera® 4.Implanon® 5.ParaGard® 6.Mirena® 29

30. VETERANS HEALTH ADMINISTRATION Q8. Which of the following contraceptives would you recommend? 1.Ortho Evra® patch 2.NuvaRing® 3.Depo-Provera® 4.Implanon® 5.ParaGard® 6.Mirena® 30

31. VETERANS HEALTH ADMINISTRATION ParaGard® IUD provides contraception for 10 years, and is a good choice for women who do not or cannot tolerate hormones, smokers, or women who have other contraindications to oral contraceptives. However, cramping and heavier periods may occur with ParaGard®. Mirena® IUD/IUS provides contraception for 5 years and is a good choice for women with heavy periods, as the progestin component can lead to amenorrhea. It can also be used by women for whom estrogen-containing contraception is contraindicated, such as smokers over the age of 35. Women may experience irregular bleeding while using Mirena®. Discussion Points 31

32. VETERANS HEALTH ADMINISTRATION Q9. Would your recommendations change if Kanisha had never been pregnant? 1.Yes 2.No 32

33. VETERANS HEALTH ADMINISTRATION Nulliparous women can safely use an IUD Discussion Point 33

34. VETERANS HEALTH ADMINISTRATION Q10. Would your recommendations change if Kanisha has a history of chlamydia one year ago? 1.Yes 2.No 34

35. VETERANS HEALTH ADMINISTRATION Only women at very high risk for STIs would not be candidates for IUD placement (i.e., sex workers). A past history of an STI does not preclude a woman from having an IUD inserted. Additionally, cultures are obtained prior to having the IUD placed to decrease the risk of infection during the most high-risk part which is IUD placement. Discussion Points 35

36. VETERANS HEALTH ADMINISTRATION Q11. Would your recommendations change if Kanisha was unmarried? 1.Yes 2.No 36

37. VETERANS HEALTH ADMINISTRATION Previously, it was thought that only married women were candidates for an IUD based on the premise that having only one partner would decrease the potential risk for infection. Also, married women were likely parous (experienced childbirth) and thus would be less affected in case of infection- related infertility. Today, we know that unmarried women can be good candidates for IUD placement, after the usual risk/benefit discussion with the patient. If a woman meets criteria, then the IUD can be placed regardless of marital status. Discussion Points 37

38. VETERANS HEALTH ADMINISTRATION Ginger, a 32-year-old veteran, calls on Monday morning to ask about the “morning after pill”. She had unprotected sex on Saturday night. Case 3 38

39. VETERANS HEALTH ADMINISTRATION Q12. Which of the following statements about Plan B ® is FALSE? 1.Plan B is thought to work mainly by delaying ovulation. 2.If Ginger is already pregnant, Plan B will not harm the fetus or cause an abortion. 3.Plan B can be used up to 5 days after unprotected intercourse. Plan B’s two pills can be taken simultaneously if this is more convenient for the patient 4.Plan B® use is associated with an increased incidence of unprotected sex and STIs 5.Plan B is on the VA National Formulary 39

40. VETERANS HEALTH ADMINISTRATION Q12. Which of the following statements about Plan B ® is FALSE? 1.Plan B is thought to work mainly by delaying ovulation. 2.If Ginger is already pregnant, Plan B will not harm the fetus or cause an abortion. 3.Plan B can be used up to 5 days after unprotected intercourse. Plan B’s two pills can be taken simultaneously if this is more convenient for the patient. 4.Plan B® use is associated with an increased incidence of unprotected sex and STIs. 5.Plan B is on the VA National Formulary. 40

41. VETERANS HEALTH ADMINISTRATION Plan B: Levonorgestrel 150 mcg/dose Plan B is on the VA National Formulary Taken as a single dose within 5 days Mechanism − Delayed ovulation − Depending on timing of administration, inhibits ovulation, fertilization, or implantation No risk to developing fetus if patient should be pregnant; Plan B will not cause an abortion Side effects: Nausea, abdominal pain, fatigue, headache Discussion Points 41

42. VETERANS HEALTH ADMINISTRATION Q13. Is there anything else you’d discuss with Ginger? 1.Yes 2.No 42

43. VETERANS HEALTH ADMINISTRATION Ask Ginger about her sexual practices − Does she have multiple sexual partners? − Are all of her sexual encounters consensual? − What are the settings in which she has sex? − Try to ascertain her motives for having multiple sexual partners. Discuss her high risk of STI exposure due to unprotected sex Discuss contraception Discussion Points 43