Latebreakers - Contraceptive Technology

These scenarios, while not common, are certainly not uncommon for the average clinician. Becca Allen and Carrie Cwiak walk us through the U.S. Medical Eligibility Criteria to shed light on these more complex issues.[1]

Case 1: A 35-year-old patient with systemic lupus erythematosus presents for contraception. She is negative for anti-phospholipid antibodies and is not taking immunosuppressants. She does have severe thrombocytopenia with platelets measuring 30,000.

Certain U.S. MEC recommendations are subdivided into two subcategories: Initiation (I) of a new contraceptive method and Continuation (C) of a currently used contraceptive method. If an individual’s condition changes or she develops a new medical condition while using a contraceptive, the category rating and risk-benefit profile may change.

Both the copper IUD and DMPA are given a category 3 rating for initiation of the method in this setting. This is due to concerns for menstrual bleeding with severe thrombocytopenia that may be worsened by the copper IUD, and the potential for irregular bleeding with DMPA, a medication that cannot be reversed rapidly. However, if a patient already has a copper IUD in place or is on DMPA and develops severe thrombocytopenia, the recommendation changes to a category 2 rating. In this case, if the patient is already tolerating the method, one can consider continuing and observing for any signs of worsening bleeding.

Case 2: A 40-year-old patient with long-standing Crohn’s disease presents for contraception. How do you guide decision-making?

Though this patient has a chronic medical condition, she is a good candidate for IUDs or progestin-only methods. But would combined hormonal contraceptives be ruled out if she wanted them? Some U.S. MEC recommendations include two ratings for a single condition. In this case, it is the clinical circumstances or severity of the condition that will dictate which rating applies.

For this patient, use of combined hormonal contraception will depend on the severity of her disease. Women with inflammatory bowel disease are at baseline at a higher risk for VTE compared to unaffected women.[2] Nevertheless, for patients with mild inflammatory bowel disease and no other risk factors for VTE, the benefits of combined hormonal contraception generally outweigh the risks, so a rating of 2 is given.[3] However, for those women with severe inflammatory bowel disease or other risk factors for VTE such as surgery or immobilization, the rating is increased to a 3 because the risks generally outweigh the benefits.

Case 3: A 25-year-old obese patient recently diagnosed with Type 2 diabetes mellitus presents for contraception. She is currently taking metformin for diabetes. She also has a history of migraines with aura.

When patients present with multiple medical conditions, the condition with the highest category number should determine the safety of the contraceptive choice for the patient. The U.S. MEC does have a category that helpfully provides recommendations for the patient with multiple conditions. The category is entitled “multiple risk factors for atherosclerotic cardiovascular disease, “and it takes into account older age, smoking, diabetes, hypertension, low HDL, high LDL, or high triglyceride levels.

Based on U.S. MEC recommendations, combined hormonal contraception is contraindicated in patients with migraines with aura due to the increased risk of stroke.[4] This patient is therefore a candidate for an IUD or a progestin-only method.

What to do if your patient presents with a medical condition not covered in the 60 listed in the U.S. Medical Eligibility Criteria? Allen and Cwiak took a clinical problem-solving approach to determining a contraceptive fit for patients in a previous LateBreaker entry:

http://www.contraceptivetechnology.org/latebreakers/finding-way-theres-no-easy-answer/

[1] Allen RH, Cwiak C. Contraception for women with medical conditions. 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.

[2] Sridhar A, Cwiak CA, Kaunitz AM, Allen RH. Contraceptive considerations for women with gastrointestinal disorders. Digest Dis Sci 2017;62:54–63.

[3] Zapata LB, Paulen ME, Cansino C, Marchbanks PA, Curtis KM. Contraceptive use among women with inflammatory bowel disease: A systematic review. Contraception 2010;82:72–85.

[4] “Champaloux SW, Tepper NK, Monsour M, et al. Use of combined hormonal contraceptives among women with migraines and risk of ischemic stroke. Am J Obstet Gynecol 2017;216:489 e1–e7.