November 2018

Patients with underlying chronic medical conditions can present a challenge for their providers. While the U.S. Medical Eligibility Criteria covers 60 medical conditions, some of those conditions fall in that gray zone requiring the weighing the advantages and disadvantages of a using contraceptive method. Yet other chronic medical conditions are not even listed in the U.S. MEC.[1] So what is a reasonable strategy for dealing with decisions about using a contraceptive method when a patient has one of the conditions not covered? Co-authors Rebecca Allen and Carrie Cwiak take a clinical problem-solving approach to determining a contraceptive fit for patients with chronic health issues in their new chapter on Contraception for Women with Medical Conditions in the just-published edition of Contraceptive Technology.[2]

 Health care providers may be concerned about the effects that contra­ceptives have on a patient’s medical condition, and therefore may avoid providing contraceptives or addressing family planning needs. However, adverse outcomes and disease progression are often greater during pregnancy, and especially unintended pregnancy, than during contraceptive use.

But even if the relative risk for a contraceptive-related side effect is very high, the absolute risk of an event may still be low, if the background risk in the population is low. For example, the relative risk of developing a benign liver tumor with COC use is 500. This risk appears to be quite high until you understand that this is such a rare occurrence that the chance that a COC user will develop a benign liver tumor (i.e., the absolute risk) is only 1 in 50,000 COC users.[3] In other words, a large multiple of a rare event is still a rare event.

In the presence of many chronic medical conditions, pregnancy significantly—even dramatically—increases the risks of complications such as VTE, uncon­trolled blood pressure, or stroke. Contraception in these instances is a vital preventive for both unintended pregnancy and the serious pregnancy-related complications that can develop in women with these medical conditions. In addition, contraception can help women plan for a more optimally timed pregnancy in those situations where a developing fetus may be harmed by an underlying illness or treatment for it.  For example, pregnancy loss and congenital defects are more likely in patients with poorly controlled dia­betes. Pregnancy in women taking teratogenic medications (e.g., antiepilep­tic drugs, isotretinoin) is associated with an elevated risk of birth defects.

When the U.S. MEC doesn’t list the condition

Some medical conditions are not listed in the U.S. MEC because there is not enough medical evidence on contraception use in that population of patients to inform recommendations. So how do health care providers manage the patient with a medical condition that is not listed in the U.S. MEC? In this case, the following options should be considered:

• Consider the risks inherent in the condition itself and review the recommendations for conditions that have similar risk. For exam­ple, cerebral aneurysm is not listed in the MEC but migraine with aura is, and so following the guidelines for migraine with aura might be prudent in order to avoid an increased risk of stroke with contraceptive use.
• Consider the themes of the U.S. MEC, including that—
  • Estrogen-containing contraceptives increase cardiovascular risk
  • Progestins generally do not
  • Nearly all women are eligible for at least one of the long-acting reversible contraceptive (LARC) methods
• Research other sources such as UpToDate, PubMed, etc. for guidance.
• Consult with the other health care providers involved in your patient’s care.

The U.S. MEC will have the greatest benefit for women if it is used by health care providers in everyday practice in order to decrease unnecessary barriers to contraceptive access. There is always a contraceptive method to choose that can be used safely by a women with a chronic medical condition. And there are a number of health issues for that pose no contraindications to contraceptive use. (See Table 1.)

[1] Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016;65:1–104.

[2] 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.

[3] Kapp N, Curtis KM. Hormonal contraceptive use among women with liver tumors: a systematic review. Contraception. 2009 Oct;80:387-90