10/14/2015 Disclosures • I have no relevant financial disclosures Complex contraception Jennifer Kerns, MD, MPH Assistant Professor, UCSF Obstetrics, Gynecology and Reproductive Sciences San Francisco General Hospital October 2015 Contraceptive Prevalence & Objectives Maternal Deaths • To review resources for assessing the safety of contraceptive methods for particular women • To review the evidence for selected practice recommendations for women with particular medical issues ▫ Contraceptive counseling techniques ▫ Contraception for obese women ▫ Choosing the best COC ▫ Emergency contraception ▫ Unscheduled bleeding with nexplanon ▫ Updates: Liletta, Essure Ahmed et al. Lancet. 2012 1
10/14/2015 Benefits of avoiding unintended Are you familiar with the US Medical pregnancy Eligibility Criteria for Contraception? A. Yes 62% B. No 38% s o e N Y Frost and Lindberg Contraception 2012 CDC Medical Eligibility Criteria (MEC) Can my patient use this method? Just google this 1. CDC Medical Eligibility Criteria (CDC MEC) 2. U.S. Selected Practice Recommendations (US SPR) for Contraceptive Use, 2013 3. ACOG Practice Bulletin No. 73 4. Contraception for the Medically Challenged Patient, Rebecca Allen, Carrie Cwiak et al. 2
10/14/2015 Birth Control Methods MEC Categories 1 Can use the method No restrictions 2 Can use the method Advantages generally outweigh theoretical/proven risks Medical Condition 3 Should not use method Theoretical/proven risks unless no other generally outweigh method is appropriate advantages 4 Should not use method Unacceptable health risk MEC Category Where do you find the US MEC? 3
10/14/2015 Maya Approaches to counseling? • Information transfer • Maya is a 23 yo G5P2 • 6 weeks post-abortion • Provider recommendation • Interested in contraception. • Allowing patient to decide • Shared decision making • • 2 NSVDs, 2 abortions Paternalistic • Passive • Coercion • Unresponsive • BMI = 41 • LARC promotion Information transfer Shared decision making Provider recommendation Patient makes her decision Preference-sensitive decision � Obesity and contraception shared decision making Combined hormonal methods are considered • SDM means the provider does not insert her/his safe for obese women values into the counseling 90% • Counseling influences method selection A. True • Quality of family planning care associated with B. False use of contraception and satisfaction with method 10% • Patient-centeredness is the right thing to do False True Elwyn et al. Ann Fam Med 2014 Dehlendorf et al. Contraception 2013 Durand et al. PLoS One 2014 4
10/14/2015 Safety of combined hormonal methods Safety of other methods in obese in obese women women • CDC Medical Eligibility Criteria: 2 • CDC Medical Eligibility Criteria: 1, except… • Venous thromboembolism (VTE) risk increased: • DMPA in obese adolescents = 2 ▫ No evidence of synergistic effect ▫ Risk is less than that of pregnancy (29/10,000 ♀ yrs) ▫ No data on women with BMI>40 • No increased risk of Acute MI or stroke Obesity and oral contraceptives Obesity and contraception • YES (we think) – conflicting data for COCs • N>52,000 Combined hormonal methods have similar efficacy • RR 1.5 failure / BMI>35 in obese women compared to non-obese women • N=1500 58% • RR=1 failure (underpowered) A. True • Longer time to steady state 42% (10 vs 5 days) B. False • May be related to dosing (incr risk with prolonged pill-free interval) • Overall risk of failure still low • Can consider continuous dosing Dinger et al. Obstet Gynecol 2011 e e u s McNicholas et al. Obstet Gynecol 2013 l r a T F Lopez et al. Cochrane 2010 5
10/14/2015 Back to Maya… What other obesity- Obesity and other methods related conditions does she have? • Diabetes? • Ring : same efficacy ▫ Only contraindicated (MEC 3, 4) for all methods if � End-organ disease, or • Implant : same efficacy � >20 yrs duration • IUDs: same efficacy • Patch : decreased in women >90kg • Multiple cardiovascular RFs? (age, htn, smoking, DM) ▫ Pill, patch, ring, DMPA contraindicated ▫ Room for clinical judgment re: what constitutes multiple RFs Dinger et al. Obstet Gynecol 2011 CDC medical eligibility criteria McNicholas et al. Obstet Gynecol 2013 Lopez et al. Cochrane 2010 Maya’s contraceptive choice: COCs Progestin choice Apri, Azurette, Caziant, Cesia, Cyclessa, Desogen, Emoquette, Kariva, Mircette, Ortho-Cept, Reclipsen, Solia, Velivet, Viorele, Natazia, Gianvi, Loryna, Ocella, Syeda, Vestura, Yasmin, Yaz, Zarah, Beyaz, • Levonorgestrel � lowest risk of VTE Safyral, Kelnor, Zovia 1/35, Zovia 1/50, Altavera, Amethia, Amethia Lo, Amethyst, Aviane, Camrese, Camrese Lo, Daysee, Enpresse, • Remember. . . Absolute risk remains low Introvale, Jolessa, Kurvelo, Lessina, Levlite, Levora, LoSeasonique, Lutera, Lybrel, Marlissa, Myzilra, Nordette, Orsythia, Portia, Quartette, Quasense, Seasonale, Seasonique, Sronyx, Triphasil, • Balance with patient choice Trivora, Necon 1/50, Norinyl 1/50, Alyacen 1/35, Alyacen 7/7/7, Aranelle, Balziva, Brevicon, Briellyn, Cyclafem 1/35, Cyclafem 7/7/7, • No clear benefit of drospirenone with PMDD, acne Dasetta 1/35, Dasetta 7/7/7, Estrostep Fe, Femcon Fe, Generess Fe, Gildagia, Gildess Fe, Junel 21 1.5/30, Junel 21 1/20, Junel Fe 1.5/30, Junel Fe 1/20, Leena, Loestrin 21 1.5/30, Loestrin 21 1/20, Loestrin • Non-pregnant, no COCs: 24 Fe, Lo Loestrin Fe, Loestrin Fe 1.5/30, Loestrin Fe 1/20, 2-4 per 10,000 ♀ - yrs Microgestin 1/20, Microgestin 1.5/30, Microgestin Fe 1/20, • Levonorgestrel COCs: Microgestin Fe 1.5/30, Modicon, Necon 0.5/35, Necon 1/35, Necon 5.0 per 10,000 ♀ - yrs 10/11, Necon 7/7/7, Norinyl 1/35, Nortrel 0.5/35, Nortrel 1/35, • Desogestrel COCs: Nortrel 7/7/7, Ortho-Novum 1/35, Ortho-Novum 7/7/7, Ovcon 35, 6.5 per 10,000 ♀ - yrs Ovcon 50, Philith, Tilia Fe, Tri-Legest Fe, Tri-Norinyl, Wera, • Drosperinone COCs: 7.8 per 10,000 ♀ - yrs Zenchant, Zenchant Fe, Zeosa, Estarylla, Mono-Linyah, MonoNessa, Ortho Tri-Cyclen, Ortho Tri-Cyclen Lo, Ortho-Cyclen, Previfem, Sprintec, Tri-Estarylla, Tri-Linyah, Tri-Previfem, Tri-Sprintec, TriNessa, Cryselle, Elinest, Lo/Ovral-28, Low-Ogestrel, Ogestrel Lidegaard BMJ 2009 Heinemann Contraception 2007 6
10/14/2015 Maya’s contraceptive choice: COCs Ethinyl estradiol dose Levonorgestrel-containing COCs • Nearly all modern-day OCs are “low-dose” Apri, Azurette, Caziant, Cesia, Cyclessa, Desogen, Emoquette, Kariva, Mircette, Ortho-Cept, Reclipsen, Solia, Velivet, Viorele, Natazia, Gianvi, Loryna, Ocella, Syeda, Vestura, Yasmin, Yaz, Zarah, Beyaz, Safyral, • 30mcg EE � higher continuation (vs. 20mcg EE) Kelnor, Zovia 1/35, Zovia 1/50, Altavera, Amethia, Amethia Lo, Amethyst, Aviane, Camrese, Camrese Lo, Daysee, Enpresse, Introvale, Jolessa, Kurvelo, Lessina, Levlite, Levora, • Monophasic LoSeasonique, Lutera, Lybrel, Marlissa, Myzilra, Nordette, Orsythia, Portia, Quartette, Quasense, Seasonale, Seasonique, Sronyx, Triphasil, Trivora , Necon 1/50, Norinyl 1/50, Alyacen 1/35, • Option to shorten or eliminate placebo week Alyacen 7/7/7, Aranelle, Balziva, Brevicon, Briellyn, Cyclafem 1/35, Cyclafem 7/7/7, Dasetta 1/35, Dasetta 7/7/7, Estrostep Fe, Femcon Fe, Generess Fe, Gildagia, Gildess Fe, Junel 21 1.5/30, Junel 21 1/20, Junel Fe 1.5/30, Junel Fe 1/20, Leena, Loestrin 21 1.5/30, Loestrin 21 1/20, Loestrin 24 Fe, Lo Loestrin Fe, Loestrin Fe 1.5/30, Loestrin Fe 1/20, Microgestin 1/20, Microgestin 1.5/30, Microgestin Fe 1/20, Microgestin Fe 1.5/30, Modicon, Necon 0.5/35, Necon 1/35, Necon 10/11, Necon 7/7/7, Norinyl 1/35, Nortrel 0.5/35, Nortrel 1/35, Nortrel 7/7/7, Ortho- Novum 1/35, Ortho-Novum 7/7/7, Ovcon 35, Ovcon 50, Philith, Tilia Fe, Tri-Legest Fe, Tri-Norinyl, Wera, Zenchant, Zenchant Fe, Zeosa, VanViet Cochrane 2006 Estarylla, Mono-Linyah, MonoNessa, Ortho Tri-Cyclen, Ortho Tri-Cyclen LaGuardia Contraception , 2003 Lo, Ortho-Cyclen, Previfem, Sprintec, Tri-Estarylla, Tri-Linyah, Tri- Freeman Womens Health 2001 Previfem, Tri-Sprintec, TriNessa, Cryselle, Elinest, Lo/Ovral-28, Low- van Vloten Cutis 2002 Ogestrel, Ogestrel 3 months later… Oral Emergency Contraception Maya returns asking for emergency contraception because she missed pills LNG: 120 mg x 1, up to 5 days Choose the answer that lists the EC methods in Ulipristal Acetate: order of most effective to least effective • Selective progesterone receptor modulator • Mechanism : Delayed follicular rupture a. Ulipristal (Ella)… levonorgestrel (Plan B)… Copper IUD • Will not harm existing pregnancy b. Copper IUD… ulipristal… levonorgestrel • Dosing: 30mg, FDA-approved up to 5 days c. Levonorgestrel… Copper IUD… ulipristal 1. Brache 2010 Hum Reprod 7
10/14/2015 Misinformation about LARC Levonorgestrel less effective for obese Emergency contraception women Percent of women pregnant after taking LNG pills Glasier A et al. Contraception. 2011. 29 Etonogestrel implant and unscheduled Summarizing Maya’s visit bleeding • Used shared decision making for contraceptive counseling • Discontinuation common, largely because of unscheduled bleeding • Reviewed evidence of safety/ efficacy of contraception in obese women • Nearly 80% of women report some unscheduled • Used evidence to choose the best COC bleeding with ETG implant • Considered obesity in EC recommendation • Gave her resources – BEDSIDER! 8
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