Disclosures CONTRACEPTION COUNSELING IN MEDICALLY COMPLEX ADOLESCENTS. Aletha Akers, MD, MPH and Lyndsey Benson, MD, MS

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1 CONTRACEPTION COUNSELING IN MEDICALLY COMPLEX ADOLESCENTS Aletha Akers, MD, MPH and Lyndsey Benson, MD, MS Disclosures Aletha Akers Society of Family Planning Templeton Foundation National Institutes of Health Lyndsey Benson None 1

2 Objectives 1. Use up-to-date recommendations from the CDC s Medical Eligibility Criteria (MEC) and Selected Practice Recommendations (SPR) to manage medically complex patients 2. Manage patients whose medical conditions are not listed in the CDC MEC 3. Manage special populations, including LGBQT, homeless, and cognitively or physically impaired patients Unintended Pregnancy Despite significant decreases in teen pregnancy in recent decades, rates remain high especially in U.S. (60 per 1,000 women per year among year olds) 82% of these pregnancies are unintended 2

3 Adolescent Sexual Activity Mean age of first intercourse is 17 Condoms and OCPs are methods most commonly used by teens Implants and IUDs remain underutilized, d despite being endorsed as 1 st line methods by ACOG and AAP Twenty-Four Month Continuation O Neil-Callahan M, Obstet Gynecol

4 CDC Resources Free phone app 7 USING THE MEC AND OTHER RESOURCES 4

5 Case #1 A 26 year old HIV positive patient recently started on antiretroviral therapy is sent to you for a contraception consult. She has been taking birth control pills for contraception and wants to know if this is safe to continue with her new HIV medications. What do you recommend? Case #1 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 5

6 Case #1 - HIV Issues Medication review revealed this patient was taking ritonavir Ritonavir-boosted protease inhibitors cause CYP450 induction that results in decreased ethinyl estradiol and progestin effects Management Reviewed alterative options including LARC methods; patient considering copper IUD for future use Switched to a combination OCP including at least 30 mcg ethinyl estradiol Recommended using condoms for additional contraceptive benefit and for prevention of STI transmission CDC MEC 2010 Case #2 21 yo patient with history of migraines with aura desires highly effective contraception. After counseling she decides on the etonorgestrel contraceptive implant, which you place. She returns to your office because she has had two months of continued spotting. What do you recommend? 6

7 Case #2 Bleeding irregularities are common with the etonorgestrel contraceptive implant 1 22% amenorrhea 34% infrequent spotting 7% frequent bleeding 18% prolonged bleeding Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities are generally not harmful 2 Shown to reduce discontinuation 1. Mansour D et al. Eur J Contracept Reprod Health Care, Canto de Cetina TE et al. Contraception, 2001 and Lei ZW et al. Contraception, CDC Selected Practice Recommendations 7

8 CDC Selected Practice Recommendations Organized by contraceptive method Methods presented in order of effectiveness (highest to lowest) Each section provides: Recommendations for initiating the method Recommendations for management/continuation Issues unique to each specific method Comments and evidence Recommendations based on a series of systematic reviews published in Contraception (Vol 87, May 2013) What is included in the SPR? When during a woman s cycle can she start a method? What exams or tests are needed beforehand? What to do if she has bleeding problems? What to do if she misses a pill? What follow-up is needed? How can provider be reasonably certain a woman is not pregnant prior to initiating contraception? 8

9 Management of bleeding irregularities If bleeding persists, or if woman requests, medical treatment can be considered* Cu-IUD users LNG-IUD users Implant users Injectable (DMPA) users CHC users (extended or continuous regimen) For unscheduled spotting or light bleeding or heavy/prolonged bleeding: -NSAIDs (5-7 days of treatment) For unscheduled d spotting or light bleeding or heavy/prolonged bleeding: -NSAIDs (5-7 days of treatment) -Hormonal treatment (if medically eligible) with COCs or estrogen (10-20 days of treatment) For unscheduled spotting or light bleeding: -NSAIDs (5-7 days of treatment) For heavy/prolonged bleeding: -NSAIDs (5-7 days of treatment) -Hormonal treatment (if medically eligible) with COCs or estrogen (10-20 days of treatment) Hormone Free Interval (HFI) for 3-4 consecutive days Not recommended during the first 21 days of extended or continuous CHC use Not recommended > 1x/month, as contraceptive effectiveness may be reduced If bleeding disorder persists or woman finds it unacceptable Counsel on alternative methods, offer another method if desired *If clinically warranted, evaluate for underlying condition. Treat the condition or refer for care. Heavy or prolonged bleeding, either unscheduled or menstrual, is uncommon. Additional SPR resources CDC SPR 2013 A = essential/mandatory C = does not contribute to safe and effective use of the method * Blood pressure can be obtained in nonclinical setting if health care access is limited BMI measurement not necessary because all methods are U.S. MEC category 1 or 2 among obese women, but measuring baseline weight might be helpful for women concerned about perceived weight change Screen for STDs according to CDC s STD Treatment Guidelines. Do not delay IUD insertion to wait for screening results. 9

10 Case #2 Issues Irregular bleeding is common with contraceptive ti implant; up to 23% of users discontinue early due to bleeding Medical management of irregular bleeding can include NSAIDs and/or estrogen Management Management for this patient complication by her history of migraines with aura (contraindication to estrogen, MEC category 4) Trial of scheduled NSAIDs with no improvement in bleeding Subsequent removal of contraceptive implant and placement of levonorgestrel IUD Deokar AM et al. Int J Adolesc Med Health 2011; 23(1): Casey PM et al. Contraception 2011; 83: CDC MEC 2010 Case #3 15 yo non-sexually female presents for pregnancy prevention counseling prior to bariatric surgery. She weights 249 pounds (BMI 43.7, 165% ideal body weight (IBW) What do you recommend? 10

11 Medroxyprogesterone Acetate & Obesity Etonogestrel Implant & Obesity Premarketing studies included women up to 130% IBW Post marketing studies support use in obese and severely obese women, though data quality low 3-year failure rates <1 per 100 women-years and did not vary by BMI (Xu, Obs Gyn, 2012) Comparable ENG levels across a wide BMI range through year 3 (Morrell, Contraception, 2016) 11

12 Case #3 Issues There is some evidence for weight gain with DMPA use among adolescents, although data are mixed No evidence for weight gain associated with other contraceptive methods Studies of contraceptive effectiveness often not inclusive of obese adults/adolescents Management This patient elected to use contraceptive implant Case #4 18 yo sexually active female with a history of non-uc non-crohns inflammatory bowel disease s/p bowel resection with ileal pouch. Monthly, perimenstrual pouchitis characterized by nausea, vomiting, dehydration and bowel obstruction, and repeated hospitalization. What do you recommend? 12

13 Case #4 Inflammatory Bowel Disease Case #4 Inflammatory Bowel Disease Issues Not so straightforward IBD case: non-uc non-crohns Appropriateness of surgical management questioned, so applicability of guidelines unclear Management Comprehensive methods counseling, emphasizing most effective methods for BC Patient opted for levonorgestrel IUD Symptoms persisted Patient started on DMPA and now doing well 13

14 WHAT TO DO IF IT S NOT IN THE MEC?! If not in the MEC or SPR, then what? The MEC advises which methods are safe given specific medical condition The SPR gives advice on how to use and manage each method Neither give advice on non-contraceptive benefits for specific medical conditions 14

15 Case #5 A 17 year old patient with sickle cell disease reports frequent painful crises. She has also become sexually active recently for the first time. She has a friend with sickle cell disease who started the shot and thinks her pain crises have decreased. She wants to know if there is a birth control method that might improve her sickle cell disease. What do you recommend? Case #5 Sickle cell disease Issues Limited evidence regarding effect of contraceptive methods on frequency/severity of sickle cell pain crises Limited evidence that DMPA may reduce frequency of pain crises in women with sickle cell disease Single small (n = 25) randomized crossover study found that women using DMPA had less frequent sickle pain crises; findings limited by small sample size and poor description of study designs (blinding, randomization) Management Explained to patient that one study indicated a possible benefit with DMPA, no strong evidence of benefit with any other method She elects to use DMPA for contraception De Ceulaer K et al. Lancet 1982;2(8292):229. Manchikanti A et al. Cochrane Database Syst Rev

16 Case #6 19 yo admitted to pediatric hospital with spinal cord compression from neurofibromatosis. Reported being sexually active but not using contraception. You are consulted to provide recommendations. What do you recommend? Case #6 Neurofibromatosis What is it? Genetic condition that causes tumors on nerve tissue Tumors generally benign; occasionally malignant Symptoms Generally mild; can cause severe pain Café au lait spots, freckling, Lisch nodules, neurofibromas Can cause hearing or vision loss, learning impairment, cardiovascular problems, bone deformities, short stature Exacerbation after menarche, rare vascular problems 16

17 Case #6 Neurofibromatosis Safe to use contraception? Little data Lesions have progesterone receptors Experts conclude No lesion growth with COC Possible lesion growth with high dose progesterone Non-hormonal methods (copper IUD) recommended 1. Geller et al. Progesterone and Estrogen Receptors in Neurofibromas of Patients with NF1. Clin.Med.Pathol. 2008; 1: McLaughlin et al. Progesterone receptor expression in neurofibromas. Cancer Res 63(4): Lammert et al. Do hormonal contraceptives stimulate growth of neurofibromas? A survey on 59 NF1 patients. BMC.Cancer ; 5:16. Case #7 21 YO F with Acute Lymphocytic Leukemia and 52 mg Levonorgestrel IUD in place about to undergo BMT and hematology-oncology service is requesting IUD removal. Your service is the only one that knows the patient is sexually active. What do you do? 17

18 Case #7 Cancer there are limited guidelines to aide clinicians in managing the contraceptive needs in this special population studies of the safety and effectiveness of IUS use by women who are immunosuppressed would be useful Clinical Guidelines Cancer and contraception. Contraception 86 (2012) Case #7 Cancer Limited data on IUD use by women with immunosuppression due to cancer treatment WHO and CDC say IUDs safe in these women (CDC. U.S. MEC for contraceptive use, (Evidence Grade: III) WHO and CDC recommendations based on studies of IUD use in HIV+ women (Morrison, BJOG, 2001; Sinei, Lancet, 1998; Curtis, AIDS, 2009; Stringer, AJOG, 2007) PID and BC failure rare No increased risk of complications Clinical Guidelines Cancer and contraception. Contraception 86 (2012)

19 WHAT ABOUT UNIQUE POPULATIONS, ISSUES OF REPRODUCTIVE JUSTICE? Case #8 14 yo with severe cognitive delay who is non-verbal. Presents for contraceptive counseling pre-menarche. Family concerned that menses will be distressing to adolescent and present difficulty manage hygiene. Family wants to start contraception to prevent menstrual onset. What do you recommend? Quint, Obs & Gyn,

20 Adolescents with Cognitive Disabilities Goals of Therapy Pre-menarchal start? Amenorrhea Monthly cycling, continuous, etc. Method considerations Can they take pills? Liquid pill? Will they remove patch Hysterectomy? Quint, Obs & Gyn, 2014 Quint, Obs & Gyn,

21 Case #9 15 yo referred to you for contraception counseling from the local homeless shelter. She was previously on OCPs but was missing pills and switched to DMPA but gained weight. She restarted the pill but not been unable to access it since running away. She thinks she wants to go back on the pill, because she feels she is older now than 6 months ago and can do better remembering to take it. What do you recommend? Homeless Youth Higher pregnancy rates than non-homeless peers; rates increase with duration of homelessness (Andersen, Fam Plan Pers, 2994; Wagner, J Com Health, 2001; Milburn, Am J Com Psych, 2006; Green, JAH, 1998) Homeless youth more likely to rely on barrier contraception; less likely to use hormonal methods (Winetrobe, JPAG, 2013; Gelberg, Contraception, 2001) Sexual victimization and exchange sex higher among homeless youth (Haley, JPAG, 2004; Rice, JAH, 2010) Importance of considering access, coercion, insurance, consent, medical and potentially mental health comorbidities 21

22 Case #10 16 yo transgender male (natal female) presents to discuss menstrual suppression. He is distressed by his monthly menses and is planning to start testosterone (T). He is only attracted to females. He wants the shot because he has heard it stops periods. He plans to use it only until he starts T, which he has heard is great for contraception and menstrual suppression. What do you recommend? LGBTQ Youth Pi Priorities iti for hormone use in transgender males varies; important to assess goals No hormonal method 100% effective at inducing amenorrhea; DMPA has highest amenorrhea rate Testosterone contraception 22

23 12 Principles of Contraceptive Counseling for Adolescents Show expertise, trustworthiness, and accessibility Recommend dual protection with condoms Address confidentiality Give practical strategies to ensure accurate and consistent use Use skill-based strategies to educate; provide accessible, reliable information Address side effects early Address method choice, correct and consistent use, and method switching Encourage switches to equal or more effective options Make method choice manageable; prioritize more effective methods Arrange periodic follows ups Consider how method fits adolescents lifestyle Use quick-start option Summary CDC has excellent resources (MEC and SPR) for managing medically complex patients Many conditions are not included in the CDC guidelines CDC provides no recommendations for unique populations, such as homeless youth, those with cognitive disabilities, and LGBTQ youth We recommend: Consulting adolescent medicine and reproductive health experts Turning to the primary literature Having a thoughtful, informed discussions with your patients 23

24 THANK YOU Questions? Special thanks for Gina Sucato, MD for assistance with this presentation. 24