contraception in medical diseases dr.prerna kumari dr.vatsla dadhwal dr.murali
TRANSCRIPT
Contraception in medical diseases
DrPrerna kumariDrVatsla Dadhwal
DrMurali
Contraception
Half of pregnancies are unintended
Half of unintended pregnancies result from inconsistent or incorrect contraceptive use
Risk of method vs risk of pregnancy
What is the most important issue for the clinician prescribing contraception
Objectives
ndash Easily access evidence-based recommendations for contraception in women with medical illness
ndash Understand the underlying evidence for these recommendations
ndash Balance the risks of contraception against the risks of pregnancy in these women
WHO Eligibility Criteria for Use of Reversible Contraceptive Methodbull No restrictionndashUse the method
bull Advantages of method outweigh the risksndashGenerally use the method
bull Risks outweigh the advantagesndashUse only if no other method available
bull Unacceptable health risk if method usedndashDo not use the method
Medical Eligibility Criteria for Contraceptive Use 2009 (wwwwhointreproductive-Medical Eligibility Criteria for Contraceptive Use 2009 (wwwwhointreproductive-health)health)
1
2
3
4
Sterilization
bull Accept(A)- There is no medical region to deny sterilization to a person with this condition
bull Caution(C)-The procedure is normally conducted in a routine setting but with extra preparation amp precautions
bull Delay(D)-procedure is delayed until the condition is evaluated andor corrected
bull Special(S)-Procedure should be undertaken in a well equipped setting
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Which patientWhich methodhellip
bull Personal characteristics amp Reproductive history (AgeSmokingObesityParityPostpartumPostabortion)
bull Cardiovascular diseasebull DVTPEbull Neurologic conditionsbull Endocrine conditionsbull Gastrointestinal diseasebull Malignanciesbull Rheumatologic diseasebull Reproductive tract disorders and infectionsbull Anemiasbull Drug interactions
Personal characteristics amp Reproductive history
bull Age-No relation of contraception with age- except in patient ge40 years-CHCrsquos-
bull Menarche to lt18 yrs ampgt45yrs-DMPANET-EN-
bull Menarche to lt20yrs(IUD)-
2
2Bone mineraldensity
decreases with long term use of DMPA
2 Risk of expulsion due to nulliparityRisk of STIrsquos
SMOKING
CHCrsquoSlt35 and smoke C2gt35 and smoke lt15dayC3gt35 and smoke gt 15day C4(COC users who smoke are at increased
risk for CVD and MI risk increases with number of cigarettes smoked)
POCrsquoS ampIUDrsquoS are safe
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Obesity
CHCrsquoSBMI gt 30kgm2bull Possible increased risk of
VTE MI stokebull Inconsistent evidence about
body wt and efficacybull NOT more likely to gainbull POCrsquoS- C1 C2 lt18NET-
EN(Potential effect of NET-EN on bone mineral density)
IUDrsquoS-
Because of elevated risk for dysfunctional uterine bleeding and
endometrial neoplasia use of levonorgestrel intrauterine system may be a particularly sound choice
for obese women
1
2
Bariatric Surgery(US-MEC)
Restrictive procedures gastric band or sleeve
bull CHCrsquoS-
Malabsorptive proceduresbull COCs bull PatchRings
1
3
1
Postpartum -BreastfeedingCHCrsquos-lt 6weeks postpartum-ge6weeks to lt6 months postpartum-ge6 months postpartum-C1POCrsquoSlt6 weeks IUDrsquoslt48hrs-C3 for LNG-IUD (Concern
regarding steroid exposure to neonate)
gt48 hrs to lt4weeks-C3 for LNG-IUDampcu-T bothPueperal sepsis- 4
2
4
3
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Postpartum Nonbreastfeeding
CHCrsquoS-lt 21 days-
gt21 days- POCrsquos- SafeIUDrsquos-gt48 hrs tolt4weeks-
3
3
1
Increased risk of thrombosis up to 3 weeks postpartum
Increased risk of expulsion
Lideggard o et alHormonal contraception and risk of venous thromboembolismnational follow up studyBritish Medical Journal2009339
Postabortion
Immediately post abortion1st or 2nd trimester- hormonal
contraception-
IUDrsquoS-2nd trimester abortion-
Immediate Post septic abortion-
1
4
2
Gaffield ME et alUse of combined oral contraceptivespostabortionContraception200980
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Contraception
Half of pregnancies are unintended
Half of unintended pregnancies result from inconsistent or incorrect contraceptive use
Risk of method vs risk of pregnancy
What is the most important issue for the clinician prescribing contraception
Objectives
ndash Easily access evidence-based recommendations for contraception in women with medical illness
ndash Understand the underlying evidence for these recommendations
ndash Balance the risks of contraception against the risks of pregnancy in these women
WHO Eligibility Criteria for Use of Reversible Contraceptive Methodbull No restrictionndashUse the method
bull Advantages of method outweigh the risksndashGenerally use the method
bull Risks outweigh the advantagesndashUse only if no other method available
bull Unacceptable health risk if method usedndashDo not use the method
Medical Eligibility Criteria for Contraceptive Use 2009 (wwwwhointreproductive-Medical Eligibility Criteria for Contraceptive Use 2009 (wwwwhointreproductive-health)health)
1
2
3
4
Sterilization
bull Accept(A)- There is no medical region to deny sterilization to a person with this condition
bull Caution(C)-The procedure is normally conducted in a routine setting but with extra preparation amp precautions
bull Delay(D)-procedure is delayed until the condition is evaluated andor corrected
bull Special(S)-Procedure should be undertaken in a well equipped setting
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Which patientWhich methodhellip
bull Personal characteristics amp Reproductive history (AgeSmokingObesityParityPostpartumPostabortion)
bull Cardiovascular diseasebull DVTPEbull Neurologic conditionsbull Endocrine conditionsbull Gastrointestinal diseasebull Malignanciesbull Rheumatologic diseasebull Reproductive tract disorders and infectionsbull Anemiasbull Drug interactions
Personal characteristics amp Reproductive history
bull Age-No relation of contraception with age- except in patient ge40 years-CHCrsquos-
bull Menarche to lt18 yrs ampgt45yrs-DMPANET-EN-
bull Menarche to lt20yrs(IUD)-
2
2Bone mineraldensity
decreases with long term use of DMPA
2 Risk of expulsion due to nulliparityRisk of STIrsquos
SMOKING
CHCrsquoSlt35 and smoke C2gt35 and smoke lt15dayC3gt35 and smoke gt 15day C4(COC users who smoke are at increased
risk for CVD and MI risk increases with number of cigarettes smoked)
POCrsquoS ampIUDrsquoS are safe
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Obesity
CHCrsquoSBMI gt 30kgm2bull Possible increased risk of
VTE MI stokebull Inconsistent evidence about
body wt and efficacybull NOT more likely to gainbull POCrsquoS- C1 C2 lt18NET-
EN(Potential effect of NET-EN on bone mineral density)
IUDrsquoS-
Because of elevated risk for dysfunctional uterine bleeding and
endometrial neoplasia use of levonorgestrel intrauterine system may be a particularly sound choice
for obese women
1
2
Bariatric Surgery(US-MEC)
Restrictive procedures gastric band or sleeve
bull CHCrsquoS-
Malabsorptive proceduresbull COCs bull PatchRings
1
3
1
Postpartum -BreastfeedingCHCrsquos-lt 6weeks postpartum-ge6weeks to lt6 months postpartum-ge6 months postpartum-C1POCrsquoSlt6 weeks IUDrsquoslt48hrs-C3 for LNG-IUD (Concern
regarding steroid exposure to neonate)
gt48 hrs to lt4weeks-C3 for LNG-IUDampcu-T bothPueperal sepsis- 4
2
4
3
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Postpartum Nonbreastfeeding
CHCrsquoS-lt 21 days-
gt21 days- POCrsquos- SafeIUDrsquos-gt48 hrs tolt4weeks-
3
3
1
Increased risk of thrombosis up to 3 weeks postpartum
Increased risk of expulsion
Lideggard o et alHormonal contraception and risk of venous thromboembolismnational follow up studyBritish Medical Journal2009339
Postabortion
Immediately post abortion1st or 2nd trimester- hormonal
contraception-
IUDrsquoS-2nd trimester abortion-
Immediate Post septic abortion-
1
4
2
Gaffield ME et alUse of combined oral contraceptivespostabortionContraception200980
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Objectives
ndash Easily access evidence-based recommendations for contraception in women with medical illness
ndash Understand the underlying evidence for these recommendations
ndash Balance the risks of contraception against the risks of pregnancy in these women
WHO Eligibility Criteria for Use of Reversible Contraceptive Methodbull No restrictionndashUse the method
bull Advantages of method outweigh the risksndashGenerally use the method
bull Risks outweigh the advantagesndashUse only if no other method available
bull Unacceptable health risk if method usedndashDo not use the method
Medical Eligibility Criteria for Contraceptive Use 2009 (wwwwhointreproductive-Medical Eligibility Criteria for Contraceptive Use 2009 (wwwwhointreproductive-health)health)
1
2
3
4
Sterilization
bull Accept(A)- There is no medical region to deny sterilization to a person with this condition
bull Caution(C)-The procedure is normally conducted in a routine setting but with extra preparation amp precautions
bull Delay(D)-procedure is delayed until the condition is evaluated andor corrected
bull Special(S)-Procedure should be undertaken in a well equipped setting
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Which patientWhich methodhellip
bull Personal characteristics amp Reproductive history (AgeSmokingObesityParityPostpartumPostabortion)
bull Cardiovascular diseasebull DVTPEbull Neurologic conditionsbull Endocrine conditionsbull Gastrointestinal diseasebull Malignanciesbull Rheumatologic diseasebull Reproductive tract disorders and infectionsbull Anemiasbull Drug interactions
Personal characteristics amp Reproductive history
bull Age-No relation of contraception with age- except in patient ge40 years-CHCrsquos-
bull Menarche to lt18 yrs ampgt45yrs-DMPANET-EN-
bull Menarche to lt20yrs(IUD)-
2
2Bone mineraldensity
decreases with long term use of DMPA
2 Risk of expulsion due to nulliparityRisk of STIrsquos
SMOKING
CHCrsquoSlt35 and smoke C2gt35 and smoke lt15dayC3gt35 and smoke gt 15day C4(COC users who smoke are at increased
risk for CVD and MI risk increases with number of cigarettes smoked)
POCrsquoS ampIUDrsquoS are safe
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Obesity
CHCrsquoSBMI gt 30kgm2bull Possible increased risk of
VTE MI stokebull Inconsistent evidence about
body wt and efficacybull NOT more likely to gainbull POCrsquoS- C1 C2 lt18NET-
EN(Potential effect of NET-EN on bone mineral density)
IUDrsquoS-
Because of elevated risk for dysfunctional uterine bleeding and
endometrial neoplasia use of levonorgestrel intrauterine system may be a particularly sound choice
for obese women
1
2
Bariatric Surgery(US-MEC)
Restrictive procedures gastric band or sleeve
bull CHCrsquoS-
Malabsorptive proceduresbull COCs bull PatchRings
1
3
1
Postpartum -BreastfeedingCHCrsquos-lt 6weeks postpartum-ge6weeks to lt6 months postpartum-ge6 months postpartum-C1POCrsquoSlt6 weeks IUDrsquoslt48hrs-C3 for LNG-IUD (Concern
regarding steroid exposure to neonate)
gt48 hrs to lt4weeks-C3 for LNG-IUDampcu-T bothPueperal sepsis- 4
2
4
3
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Postpartum Nonbreastfeeding
CHCrsquoS-lt 21 days-
gt21 days- POCrsquos- SafeIUDrsquos-gt48 hrs tolt4weeks-
3
3
1
Increased risk of thrombosis up to 3 weeks postpartum
Increased risk of expulsion
Lideggard o et alHormonal contraception and risk of venous thromboembolismnational follow up studyBritish Medical Journal2009339
Postabortion
Immediately post abortion1st or 2nd trimester- hormonal
contraception-
IUDrsquoS-2nd trimester abortion-
Immediate Post septic abortion-
1
4
2
Gaffield ME et alUse of combined oral contraceptivespostabortionContraception200980
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
WHO Eligibility Criteria for Use of Reversible Contraceptive Methodbull No restrictionndashUse the method
bull Advantages of method outweigh the risksndashGenerally use the method
bull Risks outweigh the advantagesndashUse only if no other method available
bull Unacceptable health risk if method usedndashDo not use the method
Medical Eligibility Criteria for Contraceptive Use 2009 (wwwwhointreproductive-Medical Eligibility Criteria for Contraceptive Use 2009 (wwwwhointreproductive-health)health)
1
2
3
4
Sterilization
bull Accept(A)- There is no medical region to deny sterilization to a person with this condition
bull Caution(C)-The procedure is normally conducted in a routine setting but with extra preparation amp precautions
bull Delay(D)-procedure is delayed until the condition is evaluated andor corrected
bull Special(S)-Procedure should be undertaken in a well equipped setting
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Which patientWhich methodhellip
bull Personal characteristics amp Reproductive history (AgeSmokingObesityParityPostpartumPostabortion)
bull Cardiovascular diseasebull DVTPEbull Neurologic conditionsbull Endocrine conditionsbull Gastrointestinal diseasebull Malignanciesbull Rheumatologic diseasebull Reproductive tract disorders and infectionsbull Anemiasbull Drug interactions
Personal characteristics amp Reproductive history
bull Age-No relation of contraception with age- except in patient ge40 years-CHCrsquos-
bull Menarche to lt18 yrs ampgt45yrs-DMPANET-EN-
bull Menarche to lt20yrs(IUD)-
2
2Bone mineraldensity
decreases with long term use of DMPA
2 Risk of expulsion due to nulliparityRisk of STIrsquos
SMOKING
CHCrsquoSlt35 and smoke C2gt35 and smoke lt15dayC3gt35 and smoke gt 15day C4(COC users who smoke are at increased
risk for CVD and MI risk increases with number of cigarettes smoked)
POCrsquoS ampIUDrsquoS are safe
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Obesity
CHCrsquoSBMI gt 30kgm2bull Possible increased risk of
VTE MI stokebull Inconsistent evidence about
body wt and efficacybull NOT more likely to gainbull POCrsquoS- C1 C2 lt18NET-
EN(Potential effect of NET-EN on bone mineral density)
IUDrsquoS-
Because of elevated risk for dysfunctional uterine bleeding and
endometrial neoplasia use of levonorgestrel intrauterine system may be a particularly sound choice
for obese women
1
2
Bariatric Surgery(US-MEC)
Restrictive procedures gastric band or sleeve
bull CHCrsquoS-
Malabsorptive proceduresbull COCs bull PatchRings
1
3
1
Postpartum -BreastfeedingCHCrsquos-lt 6weeks postpartum-ge6weeks to lt6 months postpartum-ge6 months postpartum-C1POCrsquoSlt6 weeks IUDrsquoslt48hrs-C3 for LNG-IUD (Concern
regarding steroid exposure to neonate)
gt48 hrs to lt4weeks-C3 for LNG-IUDampcu-T bothPueperal sepsis- 4
2
4
3
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Postpartum Nonbreastfeeding
CHCrsquoS-lt 21 days-
gt21 days- POCrsquos- SafeIUDrsquos-gt48 hrs tolt4weeks-
3
3
1
Increased risk of thrombosis up to 3 weeks postpartum
Increased risk of expulsion
Lideggard o et alHormonal contraception and risk of venous thromboembolismnational follow up studyBritish Medical Journal2009339
Postabortion
Immediately post abortion1st or 2nd trimester- hormonal
contraception-
IUDrsquoS-2nd trimester abortion-
Immediate Post septic abortion-
1
4
2
Gaffield ME et alUse of combined oral contraceptivespostabortionContraception200980
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Sterilization
bull Accept(A)- There is no medical region to deny sterilization to a person with this condition
bull Caution(C)-The procedure is normally conducted in a routine setting but with extra preparation amp precautions
bull Delay(D)-procedure is delayed until the condition is evaluated andor corrected
bull Special(S)-Procedure should be undertaken in a well equipped setting
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Which patientWhich methodhellip
bull Personal characteristics amp Reproductive history (AgeSmokingObesityParityPostpartumPostabortion)
bull Cardiovascular diseasebull DVTPEbull Neurologic conditionsbull Endocrine conditionsbull Gastrointestinal diseasebull Malignanciesbull Rheumatologic diseasebull Reproductive tract disorders and infectionsbull Anemiasbull Drug interactions
Personal characteristics amp Reproductive history
bull Age-No relation of contraception with age- except in patient ge40 years-CHCrsquos-
bull Menarche to lt18 yrs ampgt45yrs-DMPANET-EN-
bull Menarche to lt20yrs(IUD)-
2
2Bone mineraldensity
decreases with long term use of DMPA
2 Risk of expulsion due to nulliparityRisk of STIrsquos
SMOKING
CHCrsquoSlt35 and smoke C2gt35 and smoke lt15dayC3gt35 and smoke gt 15day C4(COC users who smoke are at increased
risk for CVD and MI risk increases with number of cigarettes smoked)
POCrsquoS ampIUDrsquoS are safe
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Obesity
CHCrsquoSBMI gt 30kgm2bull Possible increased risk of
VTE MI stokebull Inconsistent evidence about
body wt and efficacybull NOT more likely to gainbull POCrsquoS- C1 C2 lt18NET-
EN(Potential effect of NET-EN on bone mineral density)
IUDrsquoS-
Because of elevated risk for dysfunctional uterine bleeding and
endometrial neoplasia use of levonorgestrel intrauterine system may be a particularly sound choice
for obese women
1
2
Bariatric Surgery(US-MEC)
Restrictive procedures gastric band or sleeve
bull CHCrsquoS-
Malabsorptive proceduresbull COCs bull PatchRings
1
3
1
Postpartum -BreastfeedingCHCrsquos-lt 6weeks postpartum-ge6weeks to lt6 months postpartum-ge6 months postpartum-C1POCrsquoSlt6 weeks IUDrsquoslt48hrs-C3 for LNG-IUD (Concern
regarding steroid exposure to neonate)
gt48 hrs to lt4weeks-C3 for LNG-IUDampcu-T bothPueperal sepsis- 4
2
4
3
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Postpartum Nonbreastfeeding
CHCrsquoS-lt 21 days-
gt21 days- POCrsquos- SafeIUDrsquos-gt48 hrs tolt4weeks-
3
3
1
Increased risk of thrombosis up to 3 weeks postpartum
Increased risk of expulsion
Lideggard o et alHormonal contraception and risk of venous thromboembolismnational follow up studyBritish Medical Journal2009339
Postabortion
Immediately post abortion1st or 2nd trimester- hormonal
contraception-
IUDrsquoS-2nd trimester abortion-
Immediate Post septic abortion-
1
4
2
Gaffield ME et alUse of combined oral contraceptivespostabortionContraception200980
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Which patientWhich methodhellip
bull Personal characteristics amp Reproductive history (AgeSmokingObesityParityPostpartumPostabortion)
bull Cardiovascular diseasebull DVTPEbull Neurologic conditionsbull Endocrine conditionsbull Gastrointestinal diseasebull Malignanciesbull Rheumatologic diseasebull Reproductive tract disorders and infectionsbull Anemiasbull Drug interactions
Personal characteristics amp Reproductive history
bull Age-No relation of contraception with age- except in patient ge40 years-CHCrsquos-
bull Menarche to lt18 yrs ampgt45yrs-DMPANET-EN-
bull Menarche to lt20yrs(IUD)-
2
2Bone mineraldensity
decreases with long term use of DMPA
2 Risk of expulsion due to nulliparityRisk of STIrsquos
SMOKING
CHCrsquoSlt35 and smoke C2gt35 and smoke lt15dayC3gt35 and smoke gt 15day C4(COC users who smoke are at increased
risk for CVD and MI risk increases with number of cigarettes smoked)
POCrsquoS ampIUDrsquoS are safe
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Obesity
CHCrsquoSBMI gt 30kgm2bull Possible increased risk of
VTE MI stokebull Inconsistent evidence about
body wt and efficacybull NOT more likely to gainbull POCrsquoS- C1 C2 lt18NET-
EN(Potential effect of NET-EN on bone mineral density)
IUDrsquoS-
Because of elevated risk for dysfunctional uterine bleeding and
endometrial neoplasia use of levonorgestrel intrauterine system may be a particularly sound choice
for obese women
1
2
Bariatric Surgery(US-MEC)
Restrictive procedures gastric band or sleeve
bull CHCrsquoS-
Malabsorptive proceduresbull COCs bull PatchRings
1
3
1
Postpartum -BreastfeedingCHCrsquos-lt 6weeks postpartum-ge6weeks to lt6 months postpartum-ge6 months postpartum-C1POCrsquoSlt6 weeks IUDrsquoslt48hrs-C3 for LNG-IUD (Concern
regarding steroid exposure to neonate)
gt48 hrs to lt4weeks-C3 for LNG-IUDampcu-T bothPueperal sepsis- 4
2
4
3
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Postpartum Nonbreastfeeding
CHCrsquoS-lt 21 days-
gt21 days- POCrsquos- SafeIUDrsquos-gt48 hrs tolt4weeks-
3
3
1
Increased risk of thrombosis up to 3 weeks postpartum
Increased risk of expulsion
Lideggard o et alHormonal contraception and risk of venous thromboembolismnational follow up studyBritish Medical Journal2009339
Postabortion
Immediately post abortion1st or 2nd trimester- hormonal
contraception-
IUDrsquoS-2nd trimester abortion-
Immediate Post septic abortion-
1
4
2
Gaffield ME et alUse of combined oral contraceptivespostabortionContraception200980
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Personal characteristics amp Reproductive history
bull Age-No relation of contraception with age- except in patient ge40 years-CHCrsquos-
bull Menarche to lt18 yrs ampgt45yrs-DMPANET-EN-
bull Menarche to lt20yrs(IUD)-
2
2Bone mineraldensity
decreases with long term use of DMPA
2 Risk of expulsion due to nulliparityRisk of STIrsquos
SMOKING
CHCrsquoSlt35 and smoke C2gt35 and smoke lt15dayC3gt35 and smoke gt 15day C4(COC users who smoke are at increased
risk for CVD and MI risk increases with number of cigarettes smoked)
POCrsquoS ampIUDrsquoS are safe
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Obesity
CHCrsquoSBMI gt 30kgm2bull Possible increased risk of
VTE MI stokebull Inconsistent evidence about
body wt and efficacybull NOT more likely to gainbull POCrsquoS- C1 C2 lt18NET-
EN(Potential effect of NET-EN on bone mineral density)
IUDrsquoS-
Because of elevated risk for dysfunctional uterine bleeding and
endometrial neoplasia use of levonorgestrel intrauterine system may be a particularly sound choice
for obese women
1
2
Bariatric Surgery(US-MEC)
Restrictive procedures gastric band or sleeve
bull CHCrsquoS-
Malabsorptive proceduresbull COCs bull PatchRings
1
3
1
Postpartum -BreastfeedingCHCrsquos-lt 6weeks postpartum-ge6weeks to lt6 months postpartum-ge6 months postpartum-C1POCrsquoSlt6 weeks IUDrsquoslt48hrs-C3 for LNG-IUD (Concern
regarding steroid exposure to neonate)
gt48 hrs to lt4weeks-C3 for LNG-IUDampcu-T bothPueperal sepsis- 4
2
4
3
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Postpartum Nonbreastfeeding
CHCrsquoS-lt 21 days-
gt21 days- POCrsquos- SafeIUDrsquos-gt48 hrs tolt4weeks-
3
3
1
Increased risk of thrombosis up to 3 weeks postpartum
Increased risk of expulsion
Lideggard o et alHormonal contraception and risk of venous thromboembolismnational follow up studyBritish Medical Journal2009339
Postabortion
Immediately post abortion1st or 2nd trimester- hormonal
contraception-
IUDrsquoS-2nd trimester abortion-
Immediate Post septic abortion-
1
4
2
Gaffield ME et alUse of combined oral contraceptivespostabortionContraception200980
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
SMOKING
CHCrsquoSlt35 and smoke C2gt35 and smoke lt15dayC3gt35 and smoke gt 15day C4(COC users who smoke are at increased
risk for CVD and MI risk increases with number of cigarettes smoked)
POCrsquoS ampIUDrsquoS are safe
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Obesity
CHCrsquoSBMI gt 30kgm2bull Possible increased risk of
VTE MI stokebull Inconsistent evidence about
body wt and efficacybull NOT more likely to gainbull POCrsquoS- C1 C2 lt18NET-
EN(Potential effect of NET-EN on bone mineral density)
IUDrsquoS-
Because of elevated risk for dysfunctional uterine bleeding and
endometrial neoplasia use of levonorgestrel intrauterine system may be a particularly sound choice
for obese women
1
2
Bariatric Surgery(US-MEC)
Restrictive procedures gastric band or sleeve
bull CHCrsquoS-
Malabsorptive proceduresbull COCs bull PatchRings
1
3
1
Postpartum -BreastfeedingCHCrsquos-lt 6weeks postpartum-ge6weeks to lt6 months postpartum-ge6 months postpartum-C1POCrsquoSlt6 weeks IUDrsquoslt48hrs-C3 for LNG-IUD (Concern
regarding steroid exposure to neonate)
gt48 hrs to lt4weeks-C3 for LNG-IUDampcu-T bothPueperal sepsis- 4
2
4
3
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Postpartum Nonbreastfeeding
CHCrsquoS-lt 21 days-
gt21 days- POCrsquos- SafeIUDrsquos-gt48 hrs tolt4weeks-
3
3
1
Increased risk of thrombosis up to 3 weeks postpartum
Increased risk of expulsion
Lideggard o et alHormonal contraception and risk of venous thromboembolismnational follow up studyBritish Medical Journal2009339
Postabortion
Immediately post abortion1st or 2nd trimester- hormonal
contraception-
IUDrsquoS-2nd trimester abortion-
Immediate Post septic abortion-
1
4
2
Gaffield ME et alUse of combined oral contraceptivespostabortionContraception200980
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Obesity
CHCrsquoSBMI gt 30kgm2bull Possible increased risk of
VTE MI stokebull Inconsistent evidence about
body wt and efficacybull NOT more likely to gainbull POCrsquoS- C1 C2 lt18NET-
EN(Potential effect of NET-EN on bone mineral density)
IUDrsquoS-
Because of elevated risk for dysfunctional uterine bleeding and
endometrial neoplasia use of levonorgestrel intrauterine system may be a particularly sound choice
for obese women
1
2
Bariatric Surgery(US-MEC)
Restrictive procedures gastric band or sleeve
bull CHCrsquoS-
Malabsorptive proceduresbull COCs bull PatchRings
1
3
1
Postpartum -BreastfeedingCHCrsquos-lt 6weeks postpartum-ge6weeks to lt6 months postpartum-ge6 months postpartum-C1POCrsquoSlt6 weeks IUDrsquoslt48hrs-C3 for LNG-IUD (Concern
regarding steroid exposure to neonate)
gt48 hrs to lt4weeks-C3 for LNG-IUDampcu-T bothPueperal sepsis- 4
2
4
3
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Postpartum Nonbreastfeeding
CHCrsquoS-lt 21 days-
gt21 days- POCrsquos- SafeIUDrsquos-gt48 hrs tolt4weeks-
3
3
1
Increased risk of thrombosis up to 3 weeks postpartum
Increased risk of expulsion
Lideggard o et alHormonal contraception and risk of venous thromboembolismnational follow up studyBritish Medical Journal2009339
Postabortion
Immediately post abortion1st or 2nd trimester- hormonal
contraception-
IUDrsquoS-2nd trimester abortion-
Immediate Post septic abortion-
1
4
2
Gaffield ME et alUse of combined oral contraceptivespostabortionContraception200980
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Bariatric Surgery(US-MEC)
Restrictive procedures gastric band or sleeve
bull CHCrsquoS-
Malabsorptive proceduresbull COCs bull PatchRings
1
3
1
Postpartum -BreastfeedingCHCrsquos-lt 6weeks postpartum-ge6weeks to lt6 months postpartum-ge6 months postpartum-C1POCrsquoSlt6 weeks IUDrsquoslt48hrs-C3 for LNG-IUD (Concern
regarding steroid exposure to neonate)
gt48 hrs to lt4weeks-C3 for LNG-IUDampcu-T bothPueperal sepsis- 4
2
4
3
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Postpartum Nonbreastfeeding
CHCrsquoS-lt 21 days-
gt21 days- POCrsquos- SafeIUDrsquos-gt48 hrs tolt4weeks-
3
3
1
Increased risk of thrombosis up to 3 weeks postpartum
Increased risk of expulsion
Lideggard o et alHormonal contraception and risk of venous thromboembolismnational follow up studyBritish Medical Journal2009339
Postabortion
Immediately post abortion1st or 2nd trimester- hormonal
contraception-
IUDrsquoS-2nd trimester abortion-
Immediate Post septic abortion-
1
4
2
Gaffield ME et alUse of combined oral contraceptivespostabortionContraception200980
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Postpartum -BreastfeedingCHCrsquos-lt 6weeks postpartum-ge6weeks to lt6 months postpartum-ge6 months postpartum-C1POCrsquoSlt6 weeks IUDrsquoslt48hrs-C3 for LNG-IUD (Concern
regarding steroid exposure to neonate)
gt48 hrs to lt4weeks-C3 for LNG-IUDampcu-T bothPueperal sepsis- 4
2
4
3
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Postpartum Nonbreastfeeding
CHCrsquoS-lt 21 days-
gt21 days- POCrsquos- SafeIUDrsquos-gt48 hrs tolt4weeks-
3
3
1
Increased risk of thrombosis up to 3 weeks postpartum
Increased risk of expulsion
Lideggard o et alHormonal contraception and risk of venous thromboembolismnational follow up studyBritish Medical Journal2009339
Postabortion
Immediately post abortion1st or 2nd trimester- hormonal
contraception-
IUDrsquoS-2nd trimester abortion-
Immediate Post septic abortion-
1
4
2
Gaffield ME et alUse of combined oral contraceptivespostabortionContraception200980
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Postpartum Nonbreastfeeding
CHCrsquoS-lt 21 days-
gt21 days- POCrsquos- SafeIUDrsquos-gt48 hrs tolt4weeks-
3
3
1
Increased risk of thrombosis up to 3 weeks postpartum
Increased risk of expulsion
Lideggard o et alHormonal contraception and risk of venous thromboembolismnational follow up studyBritish Medical Journal2009339
Postabortion
Immediately post abortion1st or 2nd trimester- hormonal
contraception-
IUDrsquoS-2nd trimester abortion-
Immediate Post septic abortion-
1
4
2
Gaffield ME et alUse of combined oral contraceptivespostabortionContraception200980
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Postabortion
Immediately post abortion1st or 2nd trimester- hormonal
contraception-
IUDrsquoS-2nd trimester abortion-
Immediate Post septic abortion-
1
4
2
Gaffield ME et alUse of combined oral contraceptivespostabortionContraception200980
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
CVD Hypertension
Adequately controlledHistory of hypertension where blood pressure canrsquot be evaluated
Elevated BP levelsSBP140-159 OR DBP 90-99-SBP gt 160 OR DBP gt 100-Vascular disease- C4Hypertension during
pregnancy- C2
CHCrsquoS 3
4
3
2
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Hypertension Contdhelliphellip
POCrsquoSAdequately controlledElevated BP levels SBP
140-159DBP 90-99POP I C1 DMPA C2ImplantsC1SBP gt 160DBP gt 100POPI C2 DMPA C3ImplantsC2High BP during pregnancy C1IUDrsquos-cu-C1 LNG-C2
Concern with DMPA hypoestrogenic states and reduced HDL levels especially as they persist for a while after discontinuation not a problem with POPs DVTPEno direct evidence exists POPs and DVTPE findings on risk inconsistent
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
bull ACOG recommends -non-smoking women with blood pressure well controlled by antihypertensive agents under age 35 and otherwise healthy may try combination hormonal contraceptive methods with careful monitoring if blood pressure remains controlled use can be continued Use of combination hormonal methods in women with severe (ie uncontrolled) hypertension is contraindicated Progestin-only methods barrier methods and IUDs are appropriate options for women with either controlled or uncontrolled hypertension
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
DVTPE
bull Incidence
Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100000 women per yearSulman LP et alThe truth about oral contraceptive and VTEJournal of reproductive Medicine200348930-938
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
CVD DVT amp PE
CHC-Hx of DVTPE NOT on
anticoagulant Higher risk of
recurrencebull Estrogen associatedbull Pregnancy associatedbull Idiopathicbull Thrombophiliabull Cancerbull Hx recurrenceLower risk for
recurrenc-
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
CVD DVT amp PE
Acute DVTPE-DVTPE on anticoagulant
for at least 3 monthsHigher risk of recurrence-bull Thrombophiliabull Cancerbull Recurrence
Lower risk of recurrence-No risk factors
4
4
3
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
DVTPE
POCrsquoS-History or acute- On or off anticoagulantMajor
surgeriesimmobilizedThrombotic mutations- Family History Superficial thrombosis- IUDrsquosCu LNG C2Acute DVTPE C2 bothKnown thrombogenic mutation-
2
2
2
1
Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)Medical Eligibility Criteria for Contraceptive Use (wwwwhointreproductive-health)
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Heart diseaseWHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition
Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population
Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk
Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of methodother methods preferable
Significant increased risk of maternal mortalityamp morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk
Pregnancy contraindicated
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Think
Safety and efficacy both are important
bull 1st-whether COC is safebull 2nd-Which POCrsquos may be recommendedbull 3rd-whether there is risk of
endocarditishemodynamic collapsehematoma formation
bull Level of contraception desiredbull Womenrsquos lifestylebull Efficacy of method should also be considered
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Counselling
bull Must present all the suitable options to the patients
bull Benefits and risks of contraceptionbull Risk of pregnancy versus risk of use of
contraception
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Heart disease and contraception
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
ContraceptionContraceptionMethod Valvular heart
disease uncomplicated
Valvular heart disease complicated
Ischemic heart disease
CHCrsquoS 2 4 4
Progesterone only 1 1 I-2C-3 DMPANE-3
IUCD 1 2 1 LNG(I-2C-3)
Barrier 1 12dagger 1
Sterilization C S Current - D HO CAD - C
Emergency contraception
2
WHO Risk Category 2009WHO Risk Category 2009
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Heart disease Heart disease ampContraception ampContraception
bull Intrauterine devices are not indicated in patients at risk for endocarditis valvular prostheses or receiving chronic anticoagulation
bull Hormonal contraception thrombosis -15 in cyanotic patients
bull Interaction between OCP and anticoagulants (warfarin)
bull Interaction between Bosentan and POPsbull Parenteral contraception(Mirena) - low
profile of complications
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
IUDrsquosamp pulmonary vascular disease
Cardiovascular risk is confined to the time of insertionin particular to instrumentation of the cervixvasovagal reaction (5) may cause potentially fatal cardiovascular collapse in patients with pulmonary vascular disease
To reduce the riskuse of paracervical block
combined spinal amp epidural recommended for women with pulmonary vascular
disease
Implanon is to be preferred
Heart 200692Sara Thorne etalRisks of contraception and pregnancy in heart disease
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Congenital heart disease and conraception
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
DYSLIPIDEMIA
bull No need to measure lipid levels prior to prescribing CHCrsquos unless a woman has known dyslipidemia other CVD risks (eg smoking diabetes obesity hypertension) or history of pancreatitis
bull Oestrogen usually increase HDL and decreases LDLIn contrast progestins decreases HDL and increases LDL amp total cholesterol
bull Pills containing desogesterol norgestimate amp gestodene improve HDLLDL ratio
Bushnell CDOestrogen and stroke assessment of riskLancet neurol20054743-751
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
SLE amp CONTRACEPTION
Positive or unknown antiphospholipid antibodies-CHC-C4POC-C3IUD-CU-C1LNG-C3
Severe thrombocytopenia-CHC-C2POP-C2PICrsquoS-C3CU-IUD-C3
Immunosuppression- All are C12bull ACOG recommends that estrogen-containing
contraceptives not be used by women with SLE and a history of vascular disease nephritis or presence of antiphospholipid antibodies Progestin-only methods barrier methods and IUD are appropriate methods for these women
Culwell KRCurtis KM et alSafety of contraceptive method use among women with SLEObstetrics and Gynecology 2009114
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Neurologic disease
CHCrsquoSHeadacheNot migrainesInitiate C1 Continue C2Migraines No auralt35 years oldInitiate C2 Continue C3gt 35 years oldInitiate C3 Continue C4Migraines with aura Initiate or continue C4
Any new headache or marked change in Headaches should be evaluated
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
bull ACOG guidelines state that CHCrsquos may be used by women with migraine headaches who
do not have focal neurologic symptoms do not smoke are otherwise healthy and are
younger than age 35 POCrsquos are appropriate options for women with migraine with aura
who have no other risk factors for stroke (eg smoking hypertension) IUDs may be used by women with migraine with or without aura Barrier methods are preferred in migraine
patients with aura
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Headache
Agelt35 Agege35
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
EpilepsyCHCrsquoSPOP IUD-C1Watch drug interactionsFor patient on-
phenytoincarbamazepinebarbituratesprimidonetopiramateoxcarbamazepine
CHCrsquoS amp POPrsquos -C3DMPA-C1NE amp Implant -C2IUDrsquoS-C1Lamotrigine-levels decrease significantly during COC (C3)use and
increase significantly during pill free interval but no drug interactions have been reported with POP(C1) use
valproic acid gabapentin tiagabine levetiracetam vigabatrin and zonisamide does not appear to decrease serum levels of contraceptive steroids in women using combination oral contraceptives
Reimers A Helde G Brodtkorb E Ethinyl estradiol not progestogens reduces lamotrigine serum concentrations Epilepsia 2005 461414-1417
1
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
bull No evidence that combination hormonal methods increase the frequency of epileptic seizures bull use of DMPA has been found to reduce seizure
frequency in women with seizure disorders
bullVessey M etalOral contraception and epilepsy findings in a large cohort study Contraception 20026677-79
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
STROKE
bull CHCrsquos-C4bull POCrsquos-POPampImplants-I-C2C-C3bull DMPANE-C3bull IUDrsquos-CU-C1LNG-C2bull Sterilization-Caution
Concern with LNG IUD and PICrsquos lies with theoretical concerns over lipid changesInconsistent findings on POC and thrombosis
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Multiple sclerosis
bull no progression and possible amelioration of MS during combination hormonal contraceptive useProgestin-only contraceptive methods barrier methods and IUDs are also appropriate options for women with MS
bullHolmqvist P Wallberg M Hammar M et al Symptoms of multiple sclerosis in women in relation to sex steroid exposure Maturitas 200654149-153
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Psychiatric disorders
Depressive disordersCategory 1No data on bipolar or postpartum disordersbull no clinical evidence that concomitant use of
combination oral contraceptives and fluoxetine affects the safety or efficacy to either agent
bullKoke SC Brown EB Miner CM Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy Am J Obstet Gynecol 2002187551-555
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
VAGINAL BLEEDING
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Endocrine disorders
CHCrsquosHO GDM-C1Nonvascular disease- non-insulin dependent-C2 insulin dependent-C2Nephropathyretinopathyneuropathy-C34Other vascular disease or diabetes of gt20 years
duration-C34
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
CHCrsquos
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Combination oral contraceptivesbull Data is limited to short-term studiesbull Low-dose estrogen and less androgenic
progestins may have less effect on the diabetic control and lipids
bull No evidence of a negative effect on diabetic sequellae in women with type 1 diabetes
bull 1048708 No studies in women with type 2 diabetesCagnacci A et alContraception 2009 Jul80(1)34-9
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
POCrsquosHO GDM-C1Nonvascular disease-C2Nephropathyretinopathy
neuropathy- POPamp implants -C2DMPANE-C3
Other vascular diseasediabetes of gt20 years duration- POPamp implants -C2DMPANE-C3
IUDrsquosHO GDM-C1Nonvascular disease-non-insulin dependent insulin dependent- CU-
C1LNG-C2Nephropathyretinopathy
neuropathyOther vascular disease or diabetes of gt20 years duration- CU-C1LNG-C2
Nelson AL et alIntermediate ndashterm glucose tolerance in women with history of gestational diabetes natural history and potential associations with breast feeding and contraceptionAmerican journal of Obstetrics ampGynecology2008198
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Diabetes Mellutus
bull progestin-only contraceptivesbull 1048708 Injectable DMPA is associated with unfavorable changes in insulin
resistance and glucose controlbull 1048708 Oral progestin (norethindrone) can be used based on available
databull IUDbull 1048708 Levonorgesterel IUD has been avoided due to limitedbull data however recent studies demonstrated its safetybull in diabetic womenbull 1048708 Copper IUD is metabolically neutralbull Rogovskaya S et alObstet Gynecol 2005 Apr105(4)811-5bull Xiang AH et alDiabetes Care 2006 Mar29(3)613-7
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Diabetes
ACOG recommends- use of CHCrsquos in women with diabetes should be limited to non-smoking otherwise healthy women who are younger than 35 and have no evidence of hypertension nephropathy or retinopathy For women with diabetes with or without vascular disease or hypertension use of intrauterine contraceptive devices (IUDs) or progestin-only contraceptive methods or barrier methods is not contraindicated
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Gastrointestinal conditions
CirrhosisCHCrsquoS-Mild C1Severe C4 POCrsquoS-Severe-C3IUDrsquoS- Mild C1bull Severe LNG C3 Cu C1
Viral HepatitisCHCrsquoSPOCrsquoSAcute C34 (with severity)Chroniccarrier C1IUD-C1
Hormonal contraceptive use has no minimal effect on
chronic hepatitis or its sequelae
Nathelie et alEffect of hormonal contraceptive use among women with viral hepatitis or cirrhosis of livera systematic review Contraception200980381-386
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Gallbladder diseaseCHCAsymptomatic C2bull Symptomatic-surgery C2 Medical
treatment C3POPrsquoS-C2IUD- Cu C1 LNG C2
CholestasisCHCPregnancy related C2COC related C3POCrsquoS-COC-related cholestasis C2
Inflammatory bowel disease (USMEC)CHCrsquos-Category 23POP DMPA C2Implants C1IUD- C1
Depends on risk for VTE
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Malignancies
Gestational trophoblastic disease Decreasing or undetectable beta HCG-IUDrsquoS
are C3 Persistently elevated betaHCGMalignant
disease-IUDrsquoS are C4
CHCrsquoS amp POPrsquos are safe
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Liver tumors
CHCrsquoSBenign
Focal nodular hyperplasia C2Hepatocellular adenoma C4
Malignant C4POCrsquos-C23IUDrsquoS Cu C1bull FNH LNG C2bull Adenoma hepatoma LNG C3
Hormonal contrceptive use in patients with FNH does
not influence prolression or regression of liver lesion
Nathalie et alHormonal contraceptive use in women with liver tumorsConraception200980387-390
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Breast diseases
CHCrsquoS POCrsquoSampLNG-IUD-bull Undiagnosed massbenign breast diseaseFamily history of cancer-C12bull Breast cancer- Current ndashC4 Past amp no evidence of current
disease for 5 years-C3
Evaluation should be persued as early
as possible
Gaffield MECulwell KR et alOral contraceptives and family history of breast cancerContraception200969372-380
Cu IUD is category 1 in patients with breast cancer
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Ovarian Cancer
bull Reduced risk of ovarian cancer among users of all formulations of oral contraceptives regardless of content or potency
bull bull Barrier and Hormonal contraception are safebull IUDrsquos-I-C3C-C2
Joellen et alEffect of estrgen and progestin potency in oral contraceptive on ovarian cancer riskJournal of national cancer institute200294
WHO Risk Category 2009WHO Risk Category 2009
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
ENDOMETRIAL CANCER
bull IUDrsquoS-C4 for initiation and C2 for continuationbull CHCrsquos POPrsquos amp barrier method are safebull COC use reduces the risk of developing
endometrial cancer and have no effect on growth of fibroids
bull Uterinefibroids with distortion of cavity-LNGIUD-C4
WHO Risk Category 2009WHO Risk Category 2009
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Cervical cancer
bull IUDrsquos- C4 for initiation and C2 for continuationbull CIN-POP-C1 Implants ampDMPA-C2Barrier method-cap should not be used
Among women with persistent HPV infection long term DMPA use (ge5
years)may increase the risk of carcinoma in situ and invasive carcinoma
Smith JSCervical cancer and use of hormonal contraceptiona systematic reviewLancet20033611159-1167
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Drug interactions
bull Antiretroviral therapy
Drug CHC POC IUD Barrier
NRTI 1 1
CU-I-C23C-2LNG-I-C23C-C2
Spermicide amp DiaphragmC3
NNRTI 2 2DMPA-1
Ritonavir boosted protease inhibiter
3 POP-3DMPA-1Implant--2
AIDS as a condition is classified as category 3 for insertion ampcategory 2 for continuation
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Drug interactions
bull Antimicrobial therapy
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Patient with disability
bull Must take into account- nature of method nature of method amp expressed desire of the individualbull Barrier method may be difficult for patient with limited
manual dexterityCOCrsquoS may not be preferable for patients with impaired circulation
bull Patientrsquos with mental health disabilities who have difficulty remembering to take daily medications contraception other than OCPrsquoS should be preferred
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Modifications Additions
bull VTEbull Valvular heart diseasebull Ovarian cancerbull Uterine fibroidsbull Postpartumbull Breastfeeding
bull RAbull Bariatric surgerybull Peripartum cardiomyopathybull Endometrial hyperplasiabull IBDbull Solid organ transplant
CDC Changes from WHO MEC
CDC MMWR May 28 2010
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
ACNE
bull Estrophasic(Estrostep)-Combines low dose of progestin with gradually
increasing dose of estrogenMarked increase in SHBGVery low androgen
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
Sickle cell disease
bull DMPA may be a particularly appropriate contraceptive for women with sickle cell disease
bullAmerican College of Obstetricians and Gynecologists Use of hormonal contraception in women with coexisting medical conditions ACOG Practice Bulletin number 73 Obstet Gynecol 20061071453
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-
- Contraception in medical diseases
- Contraception
- Objectives
- WHO Eligibility Criteria for Use of Reversible Contraceptive Method
- Sterilization
- Which patientWhich methodhellip
- Personal characteristics amp Reproductive history
- SMOKING
- Obesity
- Bariatric Surgery(US-MEC)
- Postpartum -Breastfeeding
- Postpartum Nonbreastfeeding
- Postabortion
- CVD Hypertension
- Hypertension Contdhelliphellip
- PowerPoint Presentation
- DVTPE
- CVD DVT amp PE
- Slide 19
- Slide 20
- Heart disease
- Think
- Counselling
- Heart disease and contraception
- Slide 25
- Heart disease ampContraception
- Slide 27
- Slide 28
- IUDrsquosamp pulmonary vascular disease
- Congenital heart disease and conraception
- DYSLIPIDEMIA
- SLE amp CONTRACEPTION
- Neurologic disease
- Slide 34
- Headache
- Epilepsy
- Slide 37
- STROKE
- Multiple sclerosis
- Psychiatric disorders
- VAGINAL BLEEDING
- Endocrine disorders
- Slide 43
- Slide 44
- Slide 45
- Diabetes Mellutus
- Diabetes
- Gastrointestinal conditions
- Slide 49
- Malignancies
- Liver tumors
- Breast diseases
- Ovarian Cancer
- ENDOMETRIAL CANCER
- Cervical cancer
- Drug interactions
- Slide 57
- Patient with disability
- CDC Changes from WHO MEC
- ACNE
- Sickle cell disease
- Slide 62
-