WENDY GRUBE, PHD, CRNPUNIVERSITY OF PENNSYLVANIA

SCHOOL OF NURSING

Contraception and Chronic Disease: Which Patient, Which

Method?

US Medical Eligibility Criteria for Contraceptive Use, 2010

No Conflicts of Interest

Disclosure

Contraception

Half of pregnancies are unintended

Half of unintended pregnancies result from inconsistent or incorrect contraceptive use

Risk of method vs. risk of pregnancy

What is the most important issue for the clinician prescribing contraception?

Unintended Pregnancy Poses Increased Risks for Adverse Health Events in…

Breast Cancer Complicated valvular

heart disease IDDM with complications Endometrial/ovarian

cancer Epilepsy Hypertension (systolic

>160, diastolic >100) Bariatric surgery in past

2 years HIV/AIDS Ischemic HD Malignant gestational

trophoblastic disease

Hepatic malignancies Peripartum

cardiomyopathy Schistosomiasis with liver

fibrosis Severe cirrhosis Sickle cell disease Solid organ transplant in

past 2 years Stroke SLE Thrombogenic mutations Tuberculosis

CDC, MMWR, May 28, 2010

CDC: US MEC 2010

BASED ON THE CURRENT SCIENTIFIC EVIDENCE

Category 1: No restrictions for use

Category 2: Advantages of method outweigh the theoretical or

proven risks: careful follow-up may be requiredCategory 3:

Theoretical or proven risks outweigh the advantage of a method: generally not recommended

Category 4: Unacceptable health risk if method used

ModificationsModifications AdditionsAdditions

VTEValvular heart

diseaseOvarian cancerUterine fibroidsPostpartumBreastfeeding

RABariatric surgeryPeripartum

cardiomyopathyEndometrial

hyperplasiaIBDSolid organ

transplant

CDC Changes from WHO MEC

CDC, MMWR, May 28, 2010

PILLS, PATCHES, AND RINGS

Combined Hormonal Contraception

Age

Menarche to <40 yearsCategory 1

> 40 years oldCategory 2

Smoking<35 and smoke: 2>35 and smoke

<15/day: 3>35 and smoke >

15/day: 4

Breastfeeding

< 1 month postpartumCategory 3

1-6 months postpartumCategory 2

6 months postpartumCategory 2

Postpartum & Postabortion

Postpartum:< 21 daysCategory 321 daysCategory 1PostabortionImmediately post

abortion1st or 2nd trimesterCategory 1

Obesity

BMI > 30Category 2 Possible increased

risk of VTE, MI, stokeInconsistent evidence

about body wt and efficacy

NOT more likely to gain

Bariatric Surgery

Restrictive procedures: gastric band or sleeve

Category 1

Malabsorptive procedures

COCs: Category 3P/R: Category 1

CVD: Hypertension

Adequately controlled:Category 3Elevated BP levels:S 140-159 OR D 90-99Category 3S > 160 OR D > 100Category 4Vascular diseaseCategory 4Hypertension during

pregnancyCategory 2

CVD: DVT & PE

Hx of DVT/PE NOT on anticoagulant

Higher risk of recurrence• Estrogen associated• Pregnancy associated• Idiopathic• Thrombophilia• Cancer• Hx recurrenceCategory 4Lower risk for recurrenceCategory 3

CVD: DVT & PE

Acute DVT/PECategory 4DVT/PE on

anticoagulant for at least 3 months

Higher risk of recurrence• Thrombophilia• Cancer• RecurrenceCategory 4Lower risk of recurrenceNo risk factorsCategory 3

CVD: DVT & PE

Family History: 1st degreeCategory 2Major surgeryProlonged

immobilization Category 4

No prolonged immobilization Category 2

Minor surgery: no immobilization

Category 1

Known thrombotic mutations

Category 4 COC users had a 2-20

fold high risk for thrombosis

Superficial venous thrombosis

Varicose veins Category 1

Superficial thrombophlebitis Category 2

CVD and CHC

Ischemic heart disease: current or history

Category 4

StrokeCategory 4

Known hyperlipidemiasCategory 2/3 Depends on type,

severity, other risk factors

Valvular heart diseaseUncomplicated

Category 2Complicated

Peripartum cardiomyopathy: mild

< 6 months Category 4

> 6 months Category 3

Moderate or severe Category 4

Rheumatic Diseases

SLEPositive or unknown

APL antibodies: C4Thrombocytopenia:

C2Immunosuppression:

C2None of above: C2

RAImmunosuppression:

C2Non-suppressed: C2

Neurologic Conditions

HeadachesNot migraines:Initiate: C1 Continue: C2Migraines: No aura<35 years oldInitiate: C2 Continue: C3> 35 years oldInitiate: C3 Continue: C4Migraines: with aura, and

ageInitiate or continue: C4

EpilepsyCategory 1Watch drug

interactions

Depressive disordersCategory 1No data on bipolar or

postpartum disorders

Reproductive Tract Disorders

Category 1 Irregular, heavy, or

prolonged bleeding Endometriosis Benign ovarian tumors Severe dysmenorrhea Gestational trophoblastic

disease Benign breast disease, or

FHx of cancer STIs/PID/HIV/AIDS Endometrial hyperplasia Endometrial or ovarian

cancer Fibroids

Category 2 Unexplained vaginal

bleeding Undiagnosed breast mass CIN/cervical cancer

awaiting treatment

Category 3 Past breast cancer with

no evidence of disease for 5 years

Category 4 Current breast cancer

Endocrine & GI Disorders

DiabetesGestational Category 1Nonvascular disease Category 2Vascular disease Categories 3/4 Depends on severityThyroid disorders Category 1________________________Liver tumors Benign

Focal nodular hyperplasia: C2 Hepatocellular adenoma: C4

Malignant : C4

Inflammatory bowel disease Category 2/3 Depends on risk for VTEGallbladder disease Asymptomatic: C2 Symptomatic, surgery: C2 Medical treatment: C3Cholestasis Pregnancy related: C2 COC related: C3Cirrhosis Mild: C1 Severe: C4Viral Hepatitis Acute: C3/4 (with severity) Chronic/carrier: C1

Other Conditions

AnemiasThalassemiaCategory 1Iron deficiencyCategory 1Sickle cell diseaseCategory 2

Solid organ transplant

Complicated (rejection, graft failure)Category 4

Uncomplicated Category 2

Drug Interactions with CHC

Antiretroviral therapyNRTIs: Category 1NNRTIs: Category 2Ritonavir-boosted

protease inhibitors: C3Anticonvulsant therapyDecrease effectivenessMinimum 30μg EE useLamictil: possible

increased seizures

Antimicrobial therapyBroad-spectrum

antibiotics: Category 1Antifungals: Category 1Antiparasitics:

Category 1Rifampin: Category 3

PILLS, INJECTIONS, IMPLANTS

Progestin-Only Contraceptives

Conditions

Age: C1 POP, C2 DMPA <18 or >45

Breastfeeding< 1 month: Category 2> 1 month: Category 1Postpartum: Category 1Postabortion: Category 1Past ectopic: C2 for POP

onlySmoking: Category 1Obesity: C1; C2 <18Bariatric: C3 for

malabsorptive procedures

Cardiovascular Disease

HypertensionAdequately controlledPOP, I: Category 1DMPA: Category 2Elevated BP levelsS 140-159/D 90-99POP, I: Category 1DMPA: Category 2S > 160/D > 100POP/I: Category 2DMPA: Category 3HBP during pregnancy:

C1

DVT/PEHistory or acuteCategory 2On or off anticoagulantCategory 2Major

surgery/immobilizedCategory 2Thrombotic mutationsCategory 2Family HistoryCategory 1Superficial thrombosisCategory 1

Cardiovascular Disease

Ischemic heart diseaseInitiation: POP, I: C2

DMPA: C3

Continuation: POP, I: C3

StrokeSame as IHD

HyperlipidemiaCategory 3 for all

Valvular heart diseaseCategory 1 for all

Peripartum cardiomyopathy

Mild: Category 1Moderate/severe: C2

RheumaticRheumatic NeurologicNeurologic

SLEPositive or unknown

APL antibodies: C3Severe

thrombocytopenia: C3Immunosuppressed:

C2

RAC1 for POP, IC2 for DMPA

Headaches, non-migraineCategory 1, all

MigrainesNo aura, C2 (C1 start OC)Aura: C2 start, C3

continue

Epilepsy: C1Depressive disorders: C1

Other Conditions

Reproductive Tract Conditions

Category 1: Endometriosis Benign ovarian tumors Severe dysmenorrhea Gestational trophoblastic

disease Benign breast disease FHx breast cancer Endometrial hyperplasia

or cancer Ovarian cancer Uterine fibroids STIs, PID HIV/AIDS

Category 2: Irregular, heavy, or

prolonged vaginal bleeding

CIN/Cervical cancer (DMPA)

Undiagnosed breast mass

Category 3: Past breast cancer (>5

years) Unexplained vaginal

bleeding

Category 4:Current breast cancer

EndocrineEndocrine GIGI

Thyroid: Category 1DiabetesGestational: C1No vascular

disease: C2Vascular disease:

POP, I: C2 DMPA: C3

Inflammatory bowel disease:

POP, DMPA: C2Implants: C1Gallbladder disease: C2COC-related cholestasisCategory 2Viral hepatitis: C1Severe cirrhosis: C3Liver tumors: C2/3

Endocrine and GI Conditions

Other Conditions

AnemiasCategory 1

Solid organ transplantCategory 2

Drug interactions:Anticonvulsants:

Lamotrogine: C1 Others: DMPA: C1 Implant: C2 POPs: C3

Antiretroviral therapyDMPA: C1 for allNRTIs: C1 for all

methodsNNRTIs: C2 POPs and IRitonavir-boosted PIs:

C3 for POPs; C2 for I

Antimicrobials: all C1 except

Rifampin: C1 DMPAC2 ImplantC3 POPs

Emergency Contraceptive Pills

Category 1BreastfeedingHx ectopicBariatric surgeryRAIBDSolid organ

transplantRepeated useRape

Category 2Severe CVDAnginaMigraineSevere liver disease

COPPER AND LEVONORGESTREL-RELEASING

Intrauterine Devices

Conditions

AgeMenarche to <20: C2> 20: Category 1Nulliparous women: C2Postpartum: Category 2Cu: C1 < 10 minutes

PPPuerperal sepsis: C4PostabortionFirst trimester: C1Second trimester: C2

Past ectopic historyCategory 1SmokingCategory 1ObesityCategory 1Bariatric surgeryCategory 1

Cardiovascular Disease

HypertensionCategory 1 exceptS >160/D>100 &

vascular disease: LNG C2

DVT/PECu: Category 1LNG: Category 2Acute DVT/PE: C2 bothKnown thrombogenicCategory 2

Ischemic heart diseaseCategory 2: LNGCategory 1: CuStroke, hyperlipidemiaCategory 2: LNGCategory 1: CuValvular heart diseaseCategory 1No antibiotic

prophylaxisPeripartum

cardiomyopathy: C2 both

RheumaticRheumatic NeurologicNeurologic

SLEPositive APL antibodies

LNG: C3 Cu: C1Severe

thrombocytopenia LNG: C2 Cu: C3

Immunosuppressed Both: C2

RA Immunosuppressed: C2Not suppressed: C1

MigraineWith/without aura

LNG: C2 Cu: C1

EpilepsyCategory 1 (both)Depressive disordersCategory 1 (both)

Other Conditions

Reproductive Tract Conditions

Irregular bleeding Category 1 (both)Heavy, prolonged LNG: C1 Cu: C2Unexplained bleeding Category 4 initiationEndometriosis LNG: C1 Cu: C2Benign ovarian tumors Category 1 (both)Severe dysmenorrhea LNG: C1 Cu: C2STIs: C2 CT/GC: C4

(initiation)PID: Hx: C1 with subsequent

pregnancy; C2 without Current: C4

Gestational trophoblastic Dx Category ¾CIN LNG: C2 Cu: C1Cervical cancer (await Rx) Category 4: initiationBreast mass, cancer LNG: C2/3/4 Cu: C1Endometrial hyperplasia Category 1 (both)Endometrial cancer: C4Ovarian cancer: C1Uterine fibroids: C2Anatomic abnormalities: C4HIV: C2 AIDS: C3Pelvic Tb: Category 4

Endocrine and GI Disorders

DiabetesGestational: C1 Treatment: Cu: C1

LNG: C2ThyroidCategory 1

IBD: Category 1Gallbladder diseaseCu: C1 LNG: C2Viral hepatitis: C1Cirrhosis: Mild, C1Severe: LNG: C3 Cu:

C1Liver tumors: Cu: C1FNH: LNG: C2Adenoma, hepatoma:

LNG: C3

Other Issues

AnemiasLNG: C1 Cu: C2

Solid organ transplantUncomplicated

Category 2 (both)Complicated

Category 3 initiation

Drug interactionsAntiretroviral therapy

Clinically well on ARV: initiation drops to C2

Anticonvulsants Category 1

Antimicrobials Category 1

CONDOMS, SPERMICIDES, DIAPHRAGMS

Barrier Methods

Category 1 Except…

Cervical cap +/- diaphragm

Parous women: C2Complicated valvular

HDHigh risk for HIV: C4HIV/AIDS: C3Toxic shock Hx: C3UTI: C2Allergy to latex: C3

SpermicidesCervical cancer: C2High risk for HIV: C4HIV/AIDS: C3

Thank you for

your attentio

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