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Latebreakers

Selecting a Method When Guidance Isn’t Clear-cut

Healthcare in the Time of Digital Expansion

The Scoop on Two New FDA-Approved Contraceptive Methods

Pregnancy of unknown location—meeting the challenge

Big “yes” (with caveats) to CHCs during perimenopause

The role of IUDs (LNG IUDs, too!) in emergency contraception

Combined pills’ effect on mood disorders

Abortion in the U.S.: safe, declining, and under threat

Hope for ovarian cancer screening test

Breast cancer still a small risk with some hormonal contraceptives

New treatment modality for BV

Record rate of HPV-related throat cancer

Viruses in semen potentially transmissible

Don’t Abstain from Your Role in Abstinence

Teens births declining but geographic ‘hotspots’ defy trend

Online Medical Abortion Service Effective and Safe

Do Women Really Need to Wait That Long?

Reassuring news on depression and OC use

PMDD: Genetic clues may lead to improved treatment

Breast cancer risk when there is a family history

Body weight link to breast and endometrial cancers (and 11 others)

Family Planning in 2017 and Beyond

Make Me Cry: Depression Link (Again)?

Managing implant users’ bleeding and spotting

Zika: Updated guidance for providers

Pharmacist-prescribed contraceptives

Hot off the press! 2016 MEC and SPR

Zika virus fears prompt increased request for abortion in nations outlawing abortions

Opioid use epidemic among reproductive-age women

Good news on the family planning home front!

War Against Planned Parenthood Hurts Women

Win-win for both treatment and prevention

Center of the Storm

Ambivalence

Menopause, mood, mental acuity, and hormone therapy

Emergency contraception for teens

Postpartum Contraception: Now, Not Later

Reproductive tract infections, sexually transmitted infections, or sexually transmitted diseases: “a rose by any other name…”

Are we practicing what we preach?

Be alert to VTE in hormonal contraceptive users

LARC among teens increased 15-fold, but not enough

Brain cancer and hormonal contraception

Free tools: Easy access to the US Medical Eligibility Criteria for Contraceptive Use

Alcohol consumption when pregnancy is unwanted or unintended

Latest Data on Contraceptive Use in the United States

LateBreaker sampler from Contraceptive Technology conference

Emergency Contraceptive Pill Efficacy and BMI/Body Weight

Handout on Unintended Pregnancy and Contraceptive Choice

Ask About Withdrawal (Really!)

Rules to Practice By: Safety First and Cleanliness is Close to. . .

What’s Vanity Fair Got Against the NuvaRing?

Promising New Treatment for Hepatitis C

Numbers matter, so make them simple for patients

The Recession’s Effect on Unintended Pregnancies

Lessons Learned from the Contraceptive CHOICE Project: The Hull LARC Initiative

Applying the “New” Cervical Cytology Guidelines in Your Practice

Acute Excessive Uterine Bleeding: New Management Strategies

Medical indications for IUD use in teens

Whatever happened to PID?

Update on Emergency Contraception

Contraceptivetechnology.com New and Improved

Selecting a Method When Guidance Isn’t Clear-cut
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.)

 

Table 1.  Conditions that are generally not a contraindication for contraceptives
   Age    Benign breast cysts
   Past ectopic pregnancy    Family history of cancer
   Obesity    Ovarian cancer
   Gestational hypertension    Dysmenorrhea
   Gestational diabetes    Uterine fibroids
   Varicose veins    Cervical dysplasia
   Migraines without aura    HIV
   Epilepsy    Thyroid disease
   Depression    Cystic fibrosis
   Abnormal uterine bleeding    Sickle cell anemia
   Endometriosis    Iron deficiency anemia
   Benign ovarian cysts    Antibiotic use
Adapted from: Curtis KM, et al. (2016).

[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