Latebreakers - Contraceptive Technology

While psychotic disorders like schizophrenia, bipolar disorder, and borderline personality disorder occur less commonly among reproductive-aged women than do mood and anxiety disorders,^[1],[2] these serious mental illnesses (SMIs) have important implications for patients’ family planning.^[3] Providers need to recognize and appropriately manage unique ethical considerations in addition to assessing whether the patient may successfully use any given contraceptive method due to cognitive/behavioral issues and to potential interaction between the contraceptive method and psychiatric or other drugs. These consequential concerns are addressed by Kelli Stidham Hall and Julia R. Steinberg in this short excerpt from their chapter in Contraceptive Technology.^[4]

Patients with SMI may experience cognitive impairments, impulsivity, self-destructive behaviors, poor judgment, deficits in reality testing (objective evaluation of an emotion or thought in context of real life), and co-occurring substance misuse that can affect contraceptive decision-making and behaviors.³^{,[5],[6],[7],[8]}Patients taking atypical antipsychotics may believe they are not at risk for pregnancy because of menstrual irregularities or they may believe that their antipsychotic medication offers contraceptive protection, neither of which is correct. While understudied, patients with SMI may be at greater risk of sex-associated adverse consequences than are patients without SMI. Patients with SMI tend to lack basic knowledge of sexuality and reproduction, have misperceptions about contraception, have limited access to contraceptive methods, and experience higher rates of non-adherence to contraceptive regimens, unintended pregnancy, sexually transmitted infections, and non-consensual and transactional sex.³^,⁴^,⁵^,⁶^,⁷ Thus, reproductive health providers can play an important role in health promotion and unintended pregnancy prevention for this vulnerable group.

Reproductive autonomy and coercion are concerns when providing contraceptive care for patients with SMI, whose dynamic individual reproductive desires and values should be weighed with their risk of unintended pregnancy. Reproductive health providers have an ethical responsibility to try to help these patients understand, to the extent possible, the adverse health and social consequences that unintended pregnancy can have for themselves and their offspring. ³^,⁴^,⁵ A comprehensive contraceptive education, counseling, and shared decision-making process can help patients with SMI optimize choices, taking into account co-occurring medical conditions, individual preferences, and the likelihood of method success. Routine mental status exams will ensure they are able to attend to, absorb, retain, and recall information disclosed in contraceptive counseling sessions, appreciate the information and its significance for their lives, evaluate the consequences, express both cognitive and evaluative understanding, and communicate a decision based upon that understanding.⁷ When shared decision-making and informed consent is not fully possible, providers should rely upon highly effective reversible contraceptive methods so that family planning needs in the context of a patient’s mental health status can be regularly re-evaluated.

Method Choice

The majority of patients with SMI are eligible for the wide range of available contraceptive methods. Permanent sterilization may not be ethically appropriate for many patients with SMI given their reduced decision-making and informed consent capacity, but LARC methods are highly effective and reversible alternatives. In most cases, levonorgestrel-releasing and copper-containing IUDs and the subdermal implant should be considered as first line methods for patients with SMI desiring contraception. Given high occurrence of SMI with other chronic disease comorbidities including diabetes, obesity, breast cancer, or hypertension, and smoking over 35 years of age, non-estrogen containing methods like LARCs also offer the safest options, and are highly effective, have few adherence issues, and little cardiovascular risk

On the other hand, LARCs require provider-controlled insertion and removal procedures, which may also present a dilemma for informed consent. Other progestin-only methods like the DMPA injectable and progestin-only pills (POPs) are intermediate or shorter-acting, effective methods that offer strong alternatives to LARCs for patients with SMI who have contraindications to estrogen. However, DMPA requires the patient to come back for a shot every 3 months, which may be hard for someone with an SMI. Patients using neuroleptics who have medical morbidities and are using DMPA may be at risk for weight gain, truncal fat deposit, and peripheral glucose intolerance, so monitoring is indicated.^[9],[10]

For patients with SMI who are eligible for estrogen-containing contraceptives and who do not want or have access to LARC, reasonable options include combined hormonal methods, including the vaginal ring, transdermal patch, and COCs. The effectiveness of these methods relies heavily on correct use. This is even more true for patients on POPs, which must be taken within a 3-hour time-frame daily for effectiveness and have irregular bleeding profiles with missed or late dosages. Highly user-dependent barrier methods like condoms and diaphragms should be considered low priority options for patients with SMIs. Although, given the elevated HIV/STI risk among this population, dual method use (i.e., condoms plus another effective contraceptive) should be encouraged. Emergency contraception offers a back-up strategy for unplanned, unprotected sex.

Another major consideration for contraceptive method selection for patients with SMIs is safety and drug interactions with medications used to treat schizophrenia and bipolar disorder. Mood stabilizers, including lamotrigine, carbamazepine, and topiramate, can induce CYP450 3A4 causing enhanced hepatic metabolism of contraceptive steroids, particularly those found in oral formulations, and potentially decreased contraceptive efficacy.⁸^,⁹ Antipsychotic medications, including clozapine and chlorpromazine, are metabolized by the liver, and contraceptive steroids can cause a significant increase in antipsychotic levels resulting in severe side effects such as hypotension, sedation, and tremor.^[11],[12] Serum circulating levels of anti-epileptics, such as valproate and lamotrigine, can be reduced by contraceptive steroids, rendering them less effective.^[13]Providers should monitor psychiatric drug levels and adjust dosages as needed for oral hormonal contraceptive users. For patients with SMIs and the potential for drug interactions, the local action of the IUDs or the high dose of the DMPA injectable offer effective alternative contraceptive options; both methods have comparable continuation rates and low rates of psychiatric complications and hospitalization.^[14],[15]

A final drug consideration for patients with SMI is hyperprolactinemia and suppression of the hypothalamic-pituitary-gonadal axis resulting from use of older atypical antipsychotics (risperidone>aripiprazole>ziprasidone). This suppression can cause menstrual irregularities, amenorrhoea, sexual dysfunction, infertility issues, and galactorrhoea.^[16],[17] For these patients, estradiol supplementation for neuroendocrine regulation is recommended, and some research has shown that estrogen, in the form of COCs, may be therapeutic in modulating the expression of psychotic symptoms.^[18],[19] Hypothalamic-pituitary-gonadal axis suppression is less of a concern for patients taking newer antipsychotics.¹⁵^,[20] Should COCs be used as primary contraception for patients on atypical antipsychotics, education and counseling should emphasize the importance of correct and continued use of the daily pill, along with the benefits of dual protection with condoms.

[1] National Alliance on Mental Illness. About mental illness. www.nami.org/template.cfm?section=about_mental_illness. Accessed June 2, 2013.

[2] National Institute of Mental Health Prevalence of serious mental illness among U.S. Adults by age, sex and race. www.nimh.nih.gov/statistics/SMI_AASR.shtml. Accessed August 20, 2013.

[3] Matevosyan NR. Reproductive health in women with serious mental illnesses: a review. Sexuality Disab 2009;27:109–18.

[4] Hall KS, Steinberg JR. Mental health and contraception. In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Edelman A, Aiken ARA, Marrazzo J, Kowal D, eds. Contraceptive technology. 21st ed. New York, NY: Ayer Company Publishers, Inc., 2018.

[5] Miller LJ, Finnerty M. Family planning knowledge, attitudes and practices in women with schizophrenic spectrum disorders. J Psychsom Obstet Gynecol 1998;19:210–217.

[6] Krumm S, Killan R, Becker T. Mentally ill women’s subjective views on social context of desire for children. A qualitative approach. Psychiatr Prax 2011;38:23–30.

[7] McCullough LB, Coverdale J, Bayer T, Chernenak FA. Ethically justified guidelines for family planning interventions to prevent pregnancy in female patients with chronic mental illness. Am J Obstet Gynecol 1992;167:19–25.

[8] Coverdale JH, Bayer TL, McCullough LB, Chervenak FA. Respecting the autonomy of chronic mentally ill women in decisions about contraception. Hosp Comm Psychiatr 1993;44:671–674.

[9] Crawford P. Interactions between antiepileptic drugs and hormonal contraception. CNS Drugs 2002;16:263–272.

[10] Dutton C, Foldvary-Schaefer N. Contraception in women with epilepsy: pharmacokinetic interactions, contraceptive options, and management. Int Rev Neurobiol 2008; 83:113–134.

[11] Gabbay V, O’Dowd MA, Mamamtavrishvili M, et al. Clozapine and oral contraceptives: A possible drug inter-action. J Clin Psychopharmacol 2002;22:621–2.

[12] Brown D, Goosen TC, Chetty M, et al. Effect of oral contraceptives on the transport of chlorpromazine across the CACO-2 intestinal epithelial cell line. Eur J Pharm Biopharm 2003;56:159–65.

[13] Reddy DS. Clinical pharmacokinetic interactions between antiepileptic drugs and hormonal contraceptives. Expert Rev Clin Pharmacol 2010;3:183–92.

[14] Cropsey KL, Matthews C, Campbel S, et al. Long-term, reversible contraception use among high-risk women treated in a university-based gynecology clinic: comparison between IUD and Depo-Provera. J Women’s Health 2010;19:349–53.

[15] Berenson AB, Asem H, Tan A, Wilkinson GS. Continuation rates and complications of intrauterine contraception in women diagnosed with bipolar disorder. Obstet Gynecol 2011;118:1331–1336.

[16] Seeman MV. Antipsychotic-induced amenorrhea. J Ment Health 2011;20:484–91.

[17] Richer-Rossler A, Schmid C, Bleuer S, Birkhauser M. Antipsychotics and hyperprolactinaemia: pathophysiology, clinical relevance, diagnosis and therapy. Neuropsychiatr 2009;23:71–83.

[18] Kulkarni J, de Castella A, Fitzgerald PB, et al. Estrogen in severe mental illness: A potential new treatment approach. Arch Gen Psychiatr 2008;65:955–60.

[19] Riecher-Rössler A, de Geyter C. The forthcoming role of treatment with oestrogens in mental health. Swiss Med Wkly 2007;137:565–72.

[20] Currier GW, Simpson GM. Psychopharmacology: Antipsychotic medications and fertility. Psychiatr Serv 1998;49:175–6