Medical Eligibility for Contraception Use

Transcription

1 Medical Eligibility for Contraception Use DIVISION OF REPRODUCTIVE HEALTH CENTERS FOR DISEASE CONTROL AND PREVENTION 2016 US Medical Eligibility Criteria for Contraceptive Use (US MEC) Purpose To assist health care providers when they counsel patients regarding contraceptive use and to serve as a clinical resource for determining the best options for the patient There are more than 1800 recommendations for over 120 conditions/subconditions Contraceptive Methods Included in US MEC IUDs Progestin-only contraceptives Combined hormonal contraceptives Emergency contraceptives pills Barrier contraceptive methods Fertility awareness-based methods Lactational Amenorrhea method Coitus Interuptus Sterilization 1

2 CONTENTS Introduction...1 Methods...2 How to Use This Document...3 Keeping Guidance Up to Date...5 References...8 Abbreviations and Acronyms...9 Appendix A: Summary of Changes from U.S. Medical Eligibility Criteria for Contraceptive Use, Appendix B: Classifications for Intrauterine Devices...18 Appendix C: Classifications for Progestin-Only Contraceptive Appendix D: Classifications for Combined Hormonal Contraceptive.55 Appendix E: Classifications for Barrier Methods Appendix F: Classifications for Fertility Awareness Based Methods Appendix G: Lactational Amenorrhea Method Appendix H: Coitus Interruptus (Withdrawal) Appendix I: Female and Male Sterilization Appendix J: Classifications for Emergency Contraception Appendix K: Summary of Classifications for Hormonal Contraceptive Methods and Intrauterine Devices Effectiveness of Contraceptive Methods Meet the 0.2%... 2

3 General Contraceptive Management 2016 US Selected Practice Recommendations for Contraceptive Use (US SPR) Contraception Resource from the CDC; companion to US MEC Recommendations for contraceptive management questions Evidence based guidance for common management topics Resource with best available evidence to base family planning practices on Allow to address misconceptions regarding contraceptive use Remove unnecessary barriers to contraception Improve quality and access to family planning Contraceptive Methods Included in US SPR IUDs Progestin-only contraceptives Combined hormonal contraceptives Emergency contraception Fertility awareness-based methods Sterilization Examples of US SPR Guidance When to start specific contraceptive methods? How long is back up contraception needed? What examinations or test are needed before initiation of each type of contraception? What is appropriate follow up after initiation of contraception? 3

4 Exams and tests prior to initiation US SPR Take Home Points Most women can start most contraceptive methods anytime Few, if any, exams or tests are needed Routine follow-up generally not required Regular contraception should be started after emergency contraception Anticipatory counseling for women regarding potental bleeding problems and proper management are provided 4

5 2016 US Medical Eligibility Criteria for Contraceptive Use (US MEC) Purpose To assist health care providers when they counsel patients regarding contraceptive use and to serve as a clinical resource for determining the best options for the patient There are more than 1800 recommendations for over 120 conditions/subconditions Methods for 2016 US MEC Adapted from WHO guidelines On-going monitoring of published evidence Expert meeting in 2015 to review evidence and discuss recommendations CDC determined final recommendations These recommendations were informed by independent systematic reviews conducted by CDC staff and outside authors. 5

6 US MEC Categories for Contraceptive Use Example: Smoking and Contraceptive Use 3 4 Conditions Associated with Adverse Health Risk as a Result of Pregnancy Breast cancer Complicated valvular heart disease Cystic fibrosis Diabetes: insulin-dependent w/end organ damage Endometrial or ovarian cancer Seizure disorder Hypertension History of bariatric surgery (last 2 yr) HIV: not clinically well or not receiving antiretroviral therapy Ischemic heart disease Gestational trophoblastic disease Malignant liver tumors (hepatoma) Peripartum cardiomyopathy Schistosomiasis with fibrosis of the liver Severe (decompensated) cirrhosis Sickle cell disease Solid organ transplantation (last 2 yr) Stroke Systemic lupus erythematosus Thrombogenic mutations Tuberculosis 6

7 How do I access this knowledge? The CDC website: CDC Contraceptive Guidance for Health Care Providers ios and Android app- search CDC MEC 7

8 Abbreviations Contraceptive Copper IUD Levonorgestrel IUD Mirena, Skyla, Kyleena Implanted progestin device Nexplanon Depo-medroxyprogesterone acetate Progestin only pills Combined hormone contraceptives Combined oral contraceptives (COCs), transdermal patch, contraceptive vaginal ring Abbreviation Cu-IUD LNG-IUD Implant DPMA POPs CHCs Scenario 1 28 yr old G1P0 is pregnant and being counseled for postpartum family planning. She is not planning to breastfeed. What options are available to her postpartum? A. IUD B. Progestin only methods C. Combined hormonal methods 8

9 Why is postpartum contraception important? Avoid short birth interval and unintended pregnancy Timing is convenient- already seeing healthcare provider May be more motivated Hormonal Methods for Nonbreastfeeding Postpartum Women Postpartum Nonbreastfeeding <21 days CHCs Progestin Only Methods days WITH risk factors for VTE NO risk factors for VTE >42 days (6 weeks) Postpartum IUD Insertions Postpartum (including post C/S) <10 min after delivery of placenta Breastfeeding Nonbreastfeeding 10 min to < 4 weeks >/= 4 weeks Postpartum sepsis LNG-IUD Cu-IUD 9

10 Scenario 1 28 yr old G1P0 is pregnant and being counseled for postpartum family planning. She is not planning to breastfeed. What options are available to her postpartum? C. Combined hormonal methods Scenario 2 38 yr old G2P2 with diabetes has been using condoms for contraception and is looking for a more effective method. What methods are safe for her to use? A. IUD B. Progestin only methods C. Combined hormonal methods D. All of the above 10

11 Scenario 2 38 yr old G2P2 with diabetes has been using condoms fro contraception and is looking for a more effective method. What methods are safe for her to use? Scenario 3 A 30 yr old female has a history of migraine headaches with light sensitivity. She does not experience any visual warning signs for a coming headache. She is interested in starting contraception. What methods are safe for her to consider? A. Combined hormonal method B. Progestin implant C. IUD 11

12 Scenario 3 A 30 yr old female has a history of migraine headaches with light sensitivity. She does not experience any visual warning signs for a coming headache. She is interested in starting contraception. What methods are safe for her to consider? 12

13 Scenario 4 A 19 yr old female comes to the office desiring an IUD. She has a history of chlamydia 6 months ago that was treated, and reports one new partner since then. Can you place her IUD today given her STD risk factors? Sexually Transmitted Disease Classification * 2 2 Scenario 4 A 19 yr old female comes to the office desiring an IUD. She has a history of chlamydia 6 months ago that was treated, and reports one new partner since then. Can you place her IUD today given her STD risk factors? As long as she does not have purulent cervicitis on exam or other contraindications. Screening GC/Chlamydia should be done at the time of IUD insertion. 13

14 Brief Review of some of the 3s and 4s Condition Contraceptive Category Distorted Uterine Cavity IUD 4 Current Breast Cancer LNG-IUD, implant, DMPA, POP, CHC 4 Cu-IUD 1 Past Breast Cancer >5yr LNG-IUD, implant, DMPA, POP, CHC 3 Cu-IUD 1 Breast feeding CHC 4 if <21 days PP Severe cirrhosis LNG-IUD, implant, DMPA, POP 3 CHC 4 VTE hx CHC 4 Diabetes w/micro or macrovascular DMPA 3 CHC 3/4 3 if days PP Condition Contraceptive Category Liver Tumors LNG-IUD, implant, DMPA, POP, CHC CHC 4 HTN DMPA 3 if uncontrolled or PVD/CVD 3 CHC 3 / 4 if uncontrolled or PVD/CVD Peripartum cardiomyopathy CHC 4 if < 6 months, or sig impaired EF CHC Stroke history Implant, DMPA, POP 3 SLE Drug reactions (antiretrovirals, AED) CHC 4 LNG-IUD, implant, DMPA, POP CHC 4 POP, CHC 3 3 if > 6 months 3 Take Home Points for US MEC US MEC can help providers decrease barriers to choosing contraceptive methods Most women can safely use most contraceptive methods Certain conditions are associated with increased adverse health risk as the result of pregnancy 14

15 Questions? 15