Disclosures. Objectives. Case: Anna. Case: Carla. Case: Beth. Contraception (for the Family Physician) 5/22/2015. Valary Gass, MD.

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1 Contraception (for the Family Physician) Disclosures None Valary Gass, MD For Family Medicine Update June 2015 Objectives Help a patient choose a contraceptive that fits her life Consider co-morbidities and selecting contraceptives in special populations Discuss LARC Be aware of options for emergency contraception Case: Anna Anna is a 16 year old G0 who comes in for contraception. Sexually active with her boyfriend, using condoms sometimes. Isn t sure what she wants to use, but says she could never remember a pill every day. Case: Beth Beth is a busy 28 year old mom of three who you are discharging after a vaginal delivery. She isn t sure about more children, but wants to keep the option open. She is breastfeeding well and doesn t want to use anything that will interfere with nursing. Case: Carla Carla is a 40 year old woman who comes in for follow up on her Lupus. She is sexually active with her finace and not using any contraception. She quit smoking when she was diagnosed with Lupus. 1

2 Case: Debbie Debbie is a 22 year old who has a history of ovarian cysts that burst and multiple ER visits. She also reports severe PMS and migraines that have started to interfere with her job. She has a family history of breast cancer. Case: Erica Erica is a 25 year old who comes in after unprotected sex 48 hours ago. She asks about emergency contraception. Her last period was ten days ago and she has regular cycles. What is it good for? What is it good for? What is it good for? So Many Choices Frequency Effectiveness Consideratio n Compliance Typical use Co-morbidity Continuation Perfect use Side effects 2

3 So Many Choices What s in it? Hormonal NonHormonal Planning Estrogen Latex Progesterone Silicone Progesterone Copper None Method x Compliance Rhythm/N FP/ Plan B/ Barriers Effectiveness Least Most Hormonal Sterilizatio n LARC Hyst/Meno pause So Many Choices After the Fact Contraception E+P Hormonal Pill Pill P Reversible Nonhormonal Permanent Vasectomy BTL Yutzpe Method Plan B Shot Patch Implant 3 yr IUD NFP/ Rhythm Barrier PP Copper IUD Ella Ring 5 yr IUD Copper IUD Laparo scopic Essure Case: Anna Age Forgetful 16 year old Menarche to to Menopause Healthy? Non-smoker? When do I stop? Risk VTE MI Mostly in those with other risk factors (e.g. smoking and obesity) Benefit Bone Density Vasomotor Symptoms Endometrial and Ovarian Cancer Protection 3

4 Medications Antibiotic Anticonvulsant No Effect Decrease No Effect Decrease Ampicillin Rifampin Ethosuximide Barbituates Doxycycline Gabapentin Carbamazepine Fluconazole Lamotrigine Felbamate Metronidazole Levetiracetam Phenytoin Quinolones Tiagabine Topiramate Tetracycline VPA Vigabatrin Medications Antibiotic Anticonvulsant No Effect Decrease No Effect Decrease Ampicillin Rifampin Ethosuximide Increased Barbituates Use BTB Doxycycline Use Gabapentin Carbamazepine condoms condoms also Fluconazole Lamotrigine No Felbamate ovulation Metronidazole or Levetiracetam Phenytoin or Quinolones Tiagabine No Topiramate Consider Consider accidental Tetracycline IUD pregnancy VPA Vigabatrin IUD Case: Anna Case: Beth Compliance! LARC (or other long-acting method) Encourage condom use despite contraception Busy new mom who is breastfeeding Postpartum Increased coagulability P: immediately okay E+P: 4 weeks 45% of women have sex before 6 weeks! Breastfeeding P by 6wks if exclusively BF Can start sooner May increase quality and duration of lactation P by 3 weeks if SOME BF P immediately if not BF E+P okay once supply established Mom should be well-nourished 4

5 Case: Beth Progesterone only immediately or by 6 weeks! can change to E+P at PP visit if supply established LARC can place before discharge or at PP visit 40 year old lupus patient Case: Carla Systemic Lupus Erythematosus Consider risks of pregnancy 25% of women with SLE will choose termination if they become pregnant Non-hormonal methods, P only, IUS E+P safe if no APLA Avoid if vascular disease, nephritis, APLA (Use P-only method) Hypercoaguability/Throm boembolism P only or non-hormonal E+P = 4x risk desogestrel x higher than LNG formulations still lower than VTE in pregnancy... Risk not increased with smoking, HTN, DM (A not V) Risk factors for VTE: exogenous E, age, personal/family history, prenancy/pp, obesity, surgery, air travel Consider patient history if single, explained VTE: may be candidate for E+P if unexplained/e/preg: P only unless anticoagulated Hypercoaguability/Throm boembolism For the anticoagulated woman: DMPA, 21mcg LNG IUS, OCP all reduce menstrual blood flow DMPA and OCP prevent ovulation Hypertension E+P may raise SBP 8mmHg, DBP 6mmHg Okay if <35, controlled, nonsmoker, and no end-organ damage Consider P-only and non-hormonal Balance risk of HTN in pregnancy with risk of contraceptive 5

6 Obesity OR 1.72 for failure of method (OCP, patch) Wt >90kg: patch has high failure rate Increased risk of VTE BMI >25 +OCP = 10x risk of lean, nonuser Increased anovulation/aub/endometrial cancer LNG IUS or DMPA may be helpful Hyperlipidemia E increases HDL and Trigs, lowers LDL No additional risk of atherosclerosis from trigs P decreases HDL and Trigs, increases LDL Less androgenic progesterones preferred Patch is same DMPA has no effect on trigs, but ^LDL, vhdl Monitor after initiation of method for control If uncontrolled, consider non-hormonal or DMPA Diabetes Smoking No effect on control or development of vascular disease E+P not for smokers or end-organ damaged OCPs don t increase risk for DM IUD is safe option (Copper or LNG) <35 + smoker: encourage cessation >35 + smoker: encourage cessation and consider P-only or non-hormonal methods OR for MI: 13.6 (2x smoking alone) Sickle Cell Disease Case: Carla Risk in pregnancy > OCP Benefit of decreased menstrual flow DMPA reduced pain crises Sterilization LARC P only E+P if candidate 6

7 Case: Debbie Migraines 22 year old with migraines, PMS, cysts, and family history of breast cancer. Some get better, some get worse Hormone free interval 2x-3x risk of CVA in OCP users vs non users Absolute risk still very low Avoid if focal neurologic signs, smoker, >35, or other risk factors Consider P-only, IUS, or barriers Depression Does not worsen symptoms May actually help - esp if method is continued >12 months St John s Wort may decrease effectiveness of OCP: BTB and ovulation Breast Disease Lower risk of benign breast disease No difference in malignancy BRCA-1&2 Conflicting studies re: breast ca for BRCA 1 only Reduces risk of ovarian cancer ACOG recommends FH Breast Ca not contraindication Surgery Uterine Fibroids 2x risk for VTE 6 weeks! Balance risk of pregnancy with VTE Consider prophylaxis (Heparin, LMWH) if not stopping Minor procedure with low-risk of VTE = don t stop! Decrease flow and dysmenorrhea DMPA may help avoid hysterectomy May also lower risk of getting fibroids Can use 21 mcg LNG IUS to reduce flow 7

8 Case: Debbie Case: Erica Extended cycle combination OCP DMPA Subdermal implant 25 year old needs emergency contraception HIV Case: Erica E+P may increase viral DNA shedding Unknown clinical impact P-only may have much lower effect with enzyme inducers than E+P methods Still add a barrier to prevent transmission of HIV to partner and STI to patient Plan B/Yutzpe Copper IUD Ella References ACOG Practice Bulletin: Special Considerations for Contraceptives ACOG Practice Bulletin: LARC ACOG Practice Bulletin: Sterilization Managing Contraception Current Contraception 8