Upda te s in Co ntra c e ptio n: Adva nc e s in T e c hnic a l a nd - PDF document

Disc lo sure s Upda te s in Co ntra c e ptio n: Adva nc e s in T e c hnic a l a nd • No fina nc ia l disc lo sure s to re po rt I nte rpe rso na l Ca re • I disc uss o ff-la b e l use o f so me c o ntra c e ptive me tho ds. Christine De hle ndo rf, MD MAS De partme nt o f F amily and Co mmunity Me dic ine and Obste tric s, Gyne c o lo gy and Re pro duc tive S c ie nc e s Are yo u fa milia r with the US Ca n my pa tie nt use this Me dic a l E lig ib ility Crite ria fo r me tho d? Co ntra c e ptio n? US Medical Eligibility Criteria (MEC) a . Ye s b . No 1 Can use the method No restrictions 2 Can use the method Advantages generally outweigh theoretical or proven risks. 3 Should not use method Theoretical or proven risks unless no other method generally outweigh is appropriate or advantages acceptable 4 Should not use method Unacceptable health risk

Ca n a wo ma n with mig ra ine s witho ut a ura use e stro g e n- c o nta ining c o ntra c e ptive s? A 35 year-old woman comes to you for a . Ye s contraception counseling. She has a h/o of migraines without aura. Can she b . No use an estrogen containing method? c . I t de pe nds ME C a nd He a da c he s Birth Control Methods Medical Condition MEC Category

2016 ME C Upda te s: I UDs 2016 ME C Upda te s • Wo me n a t risk fo r se xua lly tra nsmitte d dise a se no • Additio n o f re c o mme nda tio ns fo r wo me n with:  lo ng e r a se pa ra te c a te g o ry with mo re c o nc e rns Cystic fib ro sis (De po is c a te g o ry 2)  with I UDs Multiple sc le ro sis (CHCs a re c a te g o ry 2 with immo b ility)  Use o f SSRIs a nd St. Jo hn’ s wo rt (CHC a nd impla nt a 2 fo r SJW)  Sta te s “risk fo r PID with risk fa c to rs fo r ST Ds is lo w” • Re visio ns to the re c o mme nda tio ns fo r: • I UDs no w a c a te g o ry 2 fo r wo me n with AI Ds (fro m 3)  Wo me n with: • Dyslipide mia s (no w inc lude d in wo me n with multiple c a rdio va sc ula r risks) • Mig ra ine he a da c he s  Wo me n who a re re c e iving a ntire tro vira l the ra py (CHCs no w c a te g o ry 2 with Rito na vir-b o o ste d ARVs) Co ntra c e ptio n a nd De pre ssio n • Re c o mme nda tio ns b a se d o n syste ma tic re vie w o f six studie s (1 RCT a nd 5 c o ho rt studie s) o f wo me n with b ipo la r diso rde r o r de pre ssio n • Ove ra ll po o r to fa ir q ua lity studie s Pagano, Contraception , 2016.

Ca n o ve r a millio n Da nish Do e s this ma ke se nse ? wo me n b e wro ng ? • Pre vio us lite ra ture did no t sho w a de finitive • Pro spe c tive c o ho rt study o f 1,061,997 wo me n in a sso c ia tio n fo r a ny me tho ds De nma rk • So me b io lo g ic a l e vide nc e suppo rting pro g e stin a nd • Use rs (within the la st six mo nths) o f c o mb ine d e stro g e n influe nc e o n mo o d ho rmo na l c o ntra c e ptio n/ pro g e stin o nly c o ntra c e ptio n ha d: • HOWE VE R, we kno w tha t so me wo me n re po rt  An RR o f 1.23 (95% CI 1.22-1.25)/ 1.34 (95% CI 1.27-1.40) fo r first use mo o d c ha ng e s with me tho ds, a nd ma ny a re o f a n a ntide pre ssa nt wo rrie d a b o ut e ffe c ts o n the ir mo o d  An RR o f 1.1 (95% CI 1.08-1.14)/ 1.2 (95% CI 1.04-1.31) fo r dia g no sis  o f de pre ssio n Re se a rc h o n wo me n’ s e xpe rie nc e s during c o unse ling do c ume nts tha t ma ny fe e l the ir c o nc e rns a re dismisse d witho ut due c o nside ra tio n • RR de c re a se d with a g e o f the use r Skovlund, JAMA Psychiatry, 2016. Hall, AJOG, 2015; Dehlendorf, Contraception, 2013 Schaffir, Eur J Contracept Reprod Health Care, 2016 Ho w do we put this a ll to g e the r? Whe re do yo u find the US ME C? • While hig h q ua lity study, no t ra ndo mize d  Co nfo unding b y unme a sure d c ha ra c te ristic s o f individua ls?  Co nfo unding b y re la tio nship c o nte xt? (No da ta o n no n-ho rmo na l c o ntra c e p tive me tho d (e .g . c o ppe r IUD) pro vide d a s c o mpa riso n) • T he re fo re , c a nno t dra w de finitive c a usa l c o nc lusio n  De finitive e vide nc e is unlike ly, g ive n diffic ulty (e thic s? ) o f ra ndo mizing c o ntra c e p tio n • If it is re a l, wha t is the ma g nitude ?  1.7% vs. 2.2% o ve ra ll – NNH o f 200 • We need to honor women’s concerns/experiences around mood effects of contraception, acknowledging the lack of definitive data • We can provide reassurance that at worst, few women are impacted

Yo u de te rmine a me tho d is sa fe . Wha t is the b e st a ppro a c h to c o ntra c e ptive de c isio n ma king ? No w wha t? • ME C is NOT de sig ne d to pro vide insig ht into wha t me tho d is rig ht fo r a g ive n pa tie nt a . E nc o ura g e wo me n to c ho o se the mo st hig hly e ffe c tive me tho ds b . Give the m info rma tio n a b o ut a ll me tho ds a nd le t • Co ntra c e ptive c o unse ling invo lve s e duc a tio n a nd the m de c ide fo r the mse lve s de c isio n suppo rt to he lp pa tie nts unde rsta nd the ir o ptio ns a nd ma ke a se le c tio n c . Give the m whic he ve r me tho d the y sa y the y wa nt d. No ne o f the se • Do c ume nte d impa c t o f c o ntra c e ptive c o unse ling o n me tho d se le c tio n a nd c o ntinua tio n De hle ndo rf: AJ OG , 2016 Harpe r: PE C , 2010 Co ntra c e ptive Co unse ling : I s “L ARC F irst” c o unse ling L ARC F irst? pa tie nt-c e nte re d? • I nc re a sing e mpha sis o n/ pro mo tio n o f L ARC me tho ds • Wo me n ha ve stro ng a nd va rie d pre fe re nc e s fo r in fa mily pla nning c o ntra c e ptive fe a ture s • E xa mple s :  • Re la te to diffe re nt a sse ssme nts o f po te ntia l T ie re d e ffe c tive ne ss: Pre se nt me tho ds in o rde r o f e ffe c tive ne ss o utc o me s, suc h a s side e ffe c ts • Mo tiva tio na l inte rvie wing : Pa tie nt-c e nte re d a ppro a c h to a c hie ving b e ha vio r c ha ng e • Also re la te s to diffe re nt a sse ssme nts o f the impo rta nc e o f a vo iding a n uninte nde d pre g na nc y L e ssa rd: PS RH, 2012 Ma dde n: AJ OG , 2015

Ho w do wo me n think a b o ut I s a n uninte nde d pre g na nc y a lwa ys pre g na nc y? a b a d thing ? • Intentions : T iming -b a se d ide a s a b o ut if/ whe n to g e t pre g na nt a . Ye s • Plans: De c isio ns a b o ut whe n to g e t pre g na nt a nd b . No fo rmula tio n o f a c tio ns • Desires: Stre ng th o f inc lina tio n to g e t pre g na nt o r a vo id pre g na nc y • Feelings: E mo tio na l o rie nta tio ns to wa rds pre g na nc y Aike n: PS RH, 2016 A Multidime nsio na l Co nc e pt Pla nning Ma y No t Be De sira b le “I guess one of the reasons that I haven’t Plans ≠ Intentions ≠ Desires ≠ Feelings gotten an IUD yet is like, I don’t know, having one kid already and being in a long-term committed relationship, it takes the element of surprise out of when we would have our next • All diffe re nt c o nc e pts kid, which I kind of want. I’m in that weird • Wo me n ma y find a ll o r o nly so me me a ning ful position. I just don’t want to put too much thought and planning into when I have my next • Ofte n a ppe a r inc o nsiste nt with e a c h o the r kid.” Hig g ins e t a l. In Pre pa ra tio n

Amb iva le nt a nd I ndiffe re nt Uninte nde d Ma y b e We lc o me De sire s “I don’t want more kids...We can’t afford “I already got a kid so you know I’m another one. But if it happened I’d still be not opposed to having children. If it happy. I’d be really excited. We’d rise to the happens, it happens…. I’d prefer occasion…nothing would really change.” we don’t have children right now but if it happens, okay.” Go me z e t al . Yo ung Co uple s Study Aike n: S o c ial S c ie nc e & Me dic ine , 2015 2016 But sho uldn’ t we g e t wo me n to Co nc e rns with dire c tive c o unse ling a ppro a c he s pla n “fo r the ir o wn g o o d”? • I s a n uninte nde d pre g na nc y a unive rsa lly ne g a tive • Assuming wo me n sho uld wa nt to use c e rta in he a lth o utc o me ? me tho ds:  Ig no re s va ria b ility in pre fe re nc e s, inc luding a ro und • L ittle da ta to suppo rt this a ssumptio n impo rta nc e o f a vo iding uninte nde d pre g na nc y  Ma ny studie s sho w no a sso c ia tio n with so c ia l o r he a lth  Do e s no t prio ritize a uto no my o utc o me s  So me studie s sho w a sso c ia tio ns with lo w b irth we ig ht a nd • Pre ssure to use spe c ific me tho ds c a n b e pre te rm b irth c o unte rpro duc tive  Ho we ve r, g e ne ra lly no t we ll-de sig ne d a nd we ll-c o ntro lle d  Pe rc e ive d pre ssure inc re a se s risk o f me tho d disc o ntinua tio n  Mo st e xa mine o nly re tro spe c tive inte ntio ns  Pe rc e iving pro vide a s ha ving a pre fe re nc e a sso c ia te d with lo we r sa tisfa c tio n with me tho d Ha ll, Ma te rn Child He a lth J, 2017 K a lmuss: F am Plann Pe rspe c t , 1996 De hle ndo rf: Co ntrac e ptio n , 2017 Gipso n e t a l. Studie s in F a mily Pla nning , 2008 Sha h e t a l. Ma te rn Child He a lth J, 2011