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Latebreakers

Excess breast cancer deaths after COVID-19

Contraception for patients with medical conditions

Pelvic Floor Dysfunction

Treating vulvodynia

Puzzling Over the Hurt Down-Under

Serious Mental Illness and Contraception

New 13-Cycle Vaginal Contraceptive System

The Future of Family Planning in Post-COVID America

New ASCCP Guidelines: Implications for FP

On the alert: mood disorders during 2020 stressors

Sex in the Time of COVID-19

Challenges old and new during the pandemic

Reproductive health in the time of Covid-19

Talking about toys

Missed Pills: The Problem That Hasn’t Gone Away

Find the “yes! . . . and” rather than “no” or “but”

Digital Family Planning: the Future is Now

Irregular Bleeding Due to Contraceptives

When she’s low on libido…

Ouch! Best approaches to menstrual pain

Contraceptive efficacy: understanding how user and method characteristics play their part

Strategizing treatment for chronic heavy menstrual bleeding

Perimenopause

Untangling the literature on obesity and contraception

High tech apps for no-tech FABM

Menstrual exacerbation of other medical conditions

From Princeton University: Thomas James Trussell (1949-2018)

The Short and Long of IUD Use Duration

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

Contraception for patients with medical conditions
June 2021

 

Fever and pelvic pain in an IUD user.

Crohn’s disease in someone who wants the pill.

More than 1 risk factor—say Type 2 diabetes and headaches—in someone selecting a new method.

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.