Disclosures. Contraceptive Method Use, U.S. Best Practices in Contraception: Advances, Tips, and Tricks

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1 Best Practices in Contraception: Advances, Tips, and Tricks Disclosures I have no disclosures I may discuss off-label use of some contraceptives Biftu Mengesha MD MAS Department of Obstetrics, Gynecology & Reproductive Sciences University of California, San Francisco Presentation Title 1 Presentation Title 2 Objectives By the end of the session, you will: 1. Feel inspired to prioritize patient-centered contraceptive counseling and provision in your practice 2. Be comfortable using CDC Medical Eligibility Criteria and Selected Practice Recommendations 3. Summarize a couple new updates/controversies in contraceptive care 1: Safety provision resources 2: Counseling, SDM 3: Updates: Sterilization 4: Updates: EC Presentation Title 3 Contraceptive Method Use, U.S. *Among the 38 million women currently using birth control Presentation Title 4 Kavanaugh et al,

2 Contraceptive Prevalence & Maternal Deaths Best Practices in Contraception 1: Resources for safe, evidence based use 2: Counseling, SDM Presentation Title 5 Presentation Title 6 Ahmed, Lancet, Are you familiar with the US Medical Eligibility Criteria for Contraception? a. Yes b. No Are you familiar with the US Selected Practice Recommendations for Contraception? a. Yes b. No Presentation Title 7 Presentation Title 8

3 Case # 1 Can my patient use this method? US Medical Eligibility Criteria (MEC) A 35 year-old woman comes to you for contraception counseling. She has a h/o a DVT and is not on anticoagulation. Presentation Title 9 1 Can use the method No restrictions 2 Can use the method Advantages generally outweigh theoretical or proven risks. 3 Should not use method unless no other method is appropriate Theoretical or proven risks generally outweigh advantages 4 Should not use method Unacceptable health risk Presentation Title 10 Birth Control Methods Medical Condition Presentation Title 11 MEC Category Presentation Title 12

4 Where do you find the US MEC and SPR? Case # 1 After counseling she desires the contraceptive implant. She would like you to place it today. Presentation Title 13 Presentation Title 14 For each method how to use? When to start anytime if reasonably sure that she is not pregnant If/how long to use backup method Special considerations explain recommendations by MEC Missed or late doses Reasonably Sure Not Pregnant With exception of IUD can start and do pregnancy test in 2-4 weeks Presentation Title 15 Presentation Title 16

5 Case # 1 Case #2 You review the SPR guidelines and decide it is safe to insert today. A 32 yo G3P1T2 presents asking for birth control. She has used the pill before, liked it, and wants it again. She was using the pill the two times she became pregnant and had abortions. Presentation Title 17 Presentation Title 18 What evidence is there that contraceptive counseling matters? Counseling influences method selection Positive provider relationship = higher satisfaction Satisfaction correlated with choosing/using a method Quality of care correlated with method continuation Patient Centered Communication and Contraceptive Continuation Rosenberg, Fam Plann Perspect, Forrest, Fam Plann Perspect, Presentation Title Harper, Patient Ed Counsel, Presentation Title Dehlendorf, AJOG,

6 Contraceptive Counseling Basics -Preference-sensitive decision -Respect diverse priorities, concerns, experiences Control over method Safety questions Concern about or desire for side effects Route and frequency of administration Personal and friends /family members experiences Convenience Return to fertility Efficacy Contraceptive Counseling Basics -Don t assume women know their options -When discussing efficacy use simple language and pictures -Include information about most common side effects, especially menstrual effects Address concerns with respect -Acknowledge the possibility of dissatisfaction, and make a plan if that happens -Basic counseling skills: establish rapport, ask them if they have questions Presentation Title 21 Presentation Title 22 Are you familiar with Shared Decision Making? a. Yes b. No Do you use Shared Decision Making in contraception counseling? a. Yes b. No Presentation Title 23 Presentation Title 24

7 Shared Decision Making A collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient s values and preferences. This process provides patients with the support they need to make the best individualized care decisions. Shared Decision Making in Family Planning -Best method for an individual depends on her preferences e.g., Women will weigh effectiveness differently relative to other characteristics -Structure visit around patient preferences, not any particular characteristic of methods -Qualitative and quantitative data - consistent with many women s preferences for counseling Informed Medical Decisions Foundation Presentation Title 25 Presentation Title Dehlendorf: Contraception, Dehlendorf: Contraception, 2014 Examples of SDM facilitation Shared Decision Making Requires Self Awareness I am hearing you say that avoiding pregnancy is the most important thing to you right now. In that case, you may want to consider either an IUD or implant. Can I tell you more about those methods? You mentioned that it is really important to you to not have irregular bleeding. The pill, patch, ring and copper IUD are good options, if you want to hear more about those. Presentation Title 27 -We may have opinions about which method is best -We may be uncomfortable with patients priorities -We may feel more strongly about method choice for some patients than others -Some women feel pressured by us to choose a specific method Presentation Title 28

8 Provider Preference Decreases Use -Provider expressing a preference Lower likelihood of being satisfied with method - (56% vs. 67%, p=.02) -Choosing method that provider recommended associated with: Less satisfaction with method - (45% vs. 64%, p=.004) Lower chance of starting method - (66% vs. 81%, p=.05) May feel coercive Public Health Framework Does not prioritize autonomy Bias about superiority Ignores variability in preferences Presentation Title 29 Dehlendorf, AJOG, Presentation Title 30 Are women of color and poor women counseled differently? -Women of color are more likely to be report being dissatisfied with their family planning provider -Women of color and low-income women are more likely to report: Being pressured to use a birth control method Limit their family size -Disparities in IUD recommendations RCT of standardized patients Forest & Frost, Fam Plann Perspect, Thorbun & Bogart, Women s Health, Downing, AJPH, Presentation Title 31 Dehlendorf, AJOG, RCT: IUD Standardized Patients Presentation Title N=524, Dehlendorf, AJOG,

9 Percent of Providers Recommending IUC to Low SES Women, by Race/Ethnicity (n=173) clinic.mybirthcontrol.org 90 Low SES 63.0 Low SES % Recommending IUC Low SES 41.9 P< Presentation Title 33 Whites Blacks Latinas Dehlendorf, et al. AJOG, 2010 Presentation Title 34 Updates and Controversies in Contraception Essure Hysteroscopic Sterilization will be removed from the market December 31, : Updates: Sterilization 4: Updates: EC Presentation Title 35 Presentation Title 36

10 Escalating Patient Concern about Hysteroscopic Sterilization > 8,000 reports of complications 3,000 product liability lawsuits in United States Complaints include: Abdominal/pelvic pain Abnormal uterine bleeding Headache Fatigue Weight fluctuations Allergic reactions Autoimmune disorders McCarthy M. BMJ 2016;352:i1283. Presentation Title Dhruva SS, etal. N Engl J Med 2015;373:e US Food and Drug Administration. FDA activities: Essure. Hysteroscopic Sterilization Retrospective cohort study in France: n=105,000 Hysteroscopic Sterilization Laparoscopic Sterilization Odds Ratio* P-value Acute surgical 0.13% 0.78% 0.18 ( ) <.001 complication Acute medical 0.06% 0.11% 0.51 ( ).002 complication Uterine disorder 1.28% 1.50% 0.85 ( ).02 2 nd sterilization 4.10% 0.16% ( ) <.001 Pregnancy 0.24% 0.41% 0.70 ( ).02 No difference in autoimmune disease, h/s lower analgesic and benzo use, slightly higher allergy in pts with allergy hx. Presentation Title 38 *L/S is reference Emergency Contraception (EC) Copper IUD is still most effective EC method Oral method updates Ulipristal acetate (UPA) is more effective than levonorgestrel (LNG) for women >=156 lb and in all women when taken 3 5 days after unprotected sex Doubling the dose of LNG appears to correct the obesity-related pharmacokinetic changes* Organizations warn against starting hormonal contraception within 5 days of UPA EC and obesity Follicle rupture delayed for at least 5 days in: 14.6% LNG 58.8% UPA 4% placebo UPA is more effective than LNG and placebo in inhibiting follicular rupture (p=.0001) Presentation Title 39 *Edelman, et al Presentation Title 40 Brache et al 2013

11 EC and obesity EC and obesity 41 Presentation Title Praditpan et al 2017 Presentation Title 42 Praditpan et al 2017 EC and obesity Closed circle: Obese BMI with standard LNG Open triangle: Normal BMI with standard LNG Closed triangle: Obese BMI with double dose LNG EC and hormonal contraception Presentation Title 43 *Edelman, et al Presentation Title 44 Brache et al. 2015

12 Presentation Title 45 American Society for Emergency Contraception, 2016 Presentation Title 46 American Society for Emergency Contraception, 2016 Our Approach to EC Offer copper IUD first If prefers oral, use UPA Exception: starting hormonal method right away : - Weight<156 lb, give 1.5mg LNG - Weight>=156 lb, give 1.5mg x2 doses (total of 3mg) of LNG Conclusion Support women through shared decision making Use the many available resources Contraception saves women s lives Consider prescribing UPA instead of LNG EC for advanced provision of EC Presentation Title 47 Thanks to Phil Darney, Jody Steinauer, Mike Policar, Carolyn Sufrin, Nika Seidman, Valerie French, Merrie Warden, Christine Dehlendorf, Dan Grossman, and others Presentation Title 48

13 Resources Many easily accessible resources exist to help solve contraception quandaries.... UCSF Family Planning Consult Service (415) Presentation Title 49