2/4/2011. What is your specialty? A. Family practice B. Internal medicine and subs C. OB/GYN D. Peds E. Surgery and subs

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1 Steve P. Buchanan D.O. FACOOG(Dist.) TOMA Mid Winter February 11, 2011 Dallas,TX Associate Professor OB/GYN UNTHSC/TCOM present Executive Vice President, American College of Osteopathic Obstetricians and Gynecologists 1998-present Alumnus, TCOM 1982-present Native of Tarrant county- present No conflicts of interest of industry, products discussed to disclose My opinions are mine, not those of the organizations whom I serve nor the references I cite What is your specialty? A. Family practice B. Internal medicine and subs C. OB/GYN D. Peds E. Surgery and subs 1

2 ARE YOU? A. TCOM ALUM B. OTHER DO ALUM C. MD ALUM D. OTHER HEALTH CARE PROVIDER ARE YOU? A. Male B. Female American College of Obstetricians and Gynecologists Practice Bulletin Number 112,May Emergency Contraception ( 97 refs.) American College of Obstetricians and Gynecologists Practice Bulletin Number 73, June Use of Hormonal Contraception in Women With Coexisting Medical Conditions (179 refs.) 2

3 Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force: Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories: Level A Recommendations are based on good and consistent scientific evidence. Level B Recommendations are based on limited or inconsistent scientific evidence. Level C Recommendations are based primarily on consensus and expert opinion. Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force: I Evidence obtained from at least one properly designed randomized controlled trial. II-1 Evidence obtained from well-designed controlled trials without randomization. II-2 Evidence obtained from well-designed cohort or case control analytic studies, preferably from more than one center or research group. II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence. III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. 22 yo G2P2 presents for well women exam. Wants reversible contraception. Has failed with condoms and natural family planning. Experiencing increasing dysmenorrhea and menorrhagia. You offer her A. intra-vaginal ring B. depo-medroxy progesterone acetate IM (DMPA) C. combination oral contraceptives D. copper containing IUD E. levonorgestrel containing IUD 3

4 IUD offers similar contraceptive effectiveness as permanent tubal sterilization but it is immediately reversible when removed "IUD use among women is associated with a 40% reduction in the risk of endometrial cancer, similar to the cancer protection provided by oral contraceptives, yet many clinicians are not aware of that," said Dr. Grimes according to David A. Grimes, MD, of Chapel Hill, NC, who presented the 3rd Current Issues Update - "New Uses for IUDs: Contraception and Beyond" today at The American College of Obstetricians and Gynecologists' (ACOG) 56th Annual Clinical Meeting. Dr. Grimes said that the hormonal IUD is approved for the treatment of heavy menstrual bleeding in more than 80 countries (except the US). Method Ideal Actual use Chance combined OCs progestin only(mini pill) Depo-Provera Mirena IUS Paragard IUD Vaginal ring(nuva Ring) 0.77 U.S. 1.8 Europe 0.6 Transdermal patch 0.99 Spermicidal

5 Cervical cap Parous women Nulliparous women Diaphragm Female Condom Male Condom Spermicides Sponge Parous women Nulliparous women Coitus Interruptus Natural family planning Female Sterilization % lifetime Male Sterilization Essure 10% Mirena IUS Paragard IUD year old G1 P1 presents at 3 months postpartum for annual well women. She is fully breastfeeding and requests reversible contraception. She is amenorrheic. She has also resumed cigarette smoking. You offer her A. combination OCs B. progestin only OCs C. DMPA IM D. copper containing IUD E. levonorgestel containing IUD 5

6 When initiated immediately postpartum, use of DMPA does not adversely affect lactation (79, 81) or infant development (84, 85). Given the lack of procoagulation effect and the safety in breastfeeding women with DMPA and progestin-only pills, their use at 6 weeks postpartum in lactating women and immediately postpartum in nonlactating women appears reasonable. 20 yo G0 college student presents for STD screen and contraceptive counseling. She has a history of unilateral headaches with aura followed by nausea. These have been worked up in the past and told she has migraines. Her STD screen is negative. You offer her A. condoms and counseling for abstinence B. intravaginal ring C. combination OCs D. DMPA IM E. progestin only OCs Concerns remain that all women with migraines are at increased risk of stroke if they take combination contraceptives. However, because absolute risk remains low, the use of combination contraceptives may be considered for women with migraine headaches if they do not have focal neurologic signs, do not smoke, are otherwise healthy, and are younger than 35 years. 6

7 Although cerebrovascular events occur rarely among women with migraines who use combination oral contraceptives, the impact of a stroke is so devastating that clinicians also should consider the use of progestin-only, intrauterine, or barrier contraceptives in this setting. Because the transdermal and vaginal ring combination hormonal contraceptives are new, little if any data address their safety in women with underlying medical conditions. In the absence of specific evidence to the contrary, contraindications to the use of combination oral contraceptives also should be considered to apply to these newer combination methods 36 yo G1P1,BMI 32,o/w healthy. New relationship maybe wants a baby in a year or so. Wants contraception. You offer A. condoms B. progestin only OCs C. combination OCs D. levonorgestrel containing IUD E. DMPA IM 7

8 A case control study performed in a West Coast health maintenance organization observed a higher risk of oral contraceptive failure in obese women than in women with a normal BMI (odds ratio [OR], 1.72; 95% confidence interval [CI], ) Among overweight women, higher pregnancy rates have not been observed with use of the 150-mg intramuscular or 106-mg subcutaneous formulations of DMPA She insisted on combination OCs as they made her menses more predictable. Six months later, her orthopedic surgeon recommends arthroscopic procedure. You advise A. continue OCs B. Discontinue OCs day of surgery C. Delay surgery if possible for 30 days and dc OCs now D. Stop OCs, give DMPA IM E. Stop OCs, prophylaxis with heparin Accordingly, the benefits associated with stopping combination contraceptives 1 month or more before major surgery should be balanced against the risks of an unintended pregnancy (129). If oral contraceptives are continued before major surgical procedures, heparin prophylaxis should be considered (129). Use of oral contraceptives at the time of arthroscopic surgery has been observed to increase venous thromboembolism risk 8

9 Because obese women experience an elevated risk for dysfunctional uterine bleeding and endometrial neoplasia, use of the levonorgestrel intrauterine system may represent a particularly sound choice for obese women Migraine headaches, especially those with focal neurologic signs Cigarette smoking or obesity in women older than 35 years History of thromboembolic disease Hypertension in women with vascular disease or older than 35 years Systemic lupus erythematosus with vascular disease, nephritis, or antiphospholipid antibodies Less than 3 weeks postpartum* (non-ideal IUD candidate) Hypertriglyceridemia Coronary artery disease Congestive heart failure Cerebrovascular disease A history of benign breast disease or a positive family history of breast cancer should not be regarded as contraindications to oral contraceptive use. Combination oral contraceptives are safe for women with mild lupus who do not have antiphospholipid antibodies. Combination contraceptives are not recommended for women with a documented history of unexplained venous thromboembolism or venous thromboembolism associated with pregnancy or exogenous estrogen use, unless they are taking anticoagulants. Combination oral contraceptives should be prescribed with caution, if ever, to women who are older than 35 years and are smokers. Use of the levonorgestrel intrauterine system is appropriate for women with diabetes without retinopathy, nephropathy, or other vascular complications 9

10 the use of combination contraceptives by women with diabetes should be limited to such women who do not smoke, are younger than 35 years, and are otherwise healthy with no evidence of hypertension, nephropathy, retinopathy, or other vascular disease. The use of combination contraceptives may be considered for women with migraine headaches if they do not have focal neurologic signs, do not smoke, are otherwise healthy, and are younger than 35 years. Although cerebrovascular events rarely occur among women with migraines who use combination oral contraceptives, the impact of a stroke is so devastating that clinicians should consider the use of progestin-only, intrauterine, or barrier contraceptives in this setting. Because of the increased risk of venous thrombotic embolism, combination contraceptives should be used with caution in women older than 35 years who are obese. In women with depressive disorders, symptoms do not appear to worsen with use of hormonal methods of contraception. If oral contraceptives are continued before major surgery, heparin prophylaxis should be considered. Healthy, nonsmoking women doing well on a combination contraceptive can continue their method until the ages of years, after weighing the risks and benefits. Progestin-only oral contraceptives and DMPA can be initiated safely at 6 weeks postpartum in lactating women and immediately postpartum in nonbreastfeeding women. Combination contraceptives are not recommended as the first choice for breastfeeding women because of the possible negative impact of contraceptive doses of estrogen on lactation. However, use of combination contraceptives by well-nourished breastfeeding women does not appear to result in infant development problems; therefore, their use can be considered once milk flow is well established. Women with well-controlled and monitored hypertension who are aged 35 years or younger are appropriate candidates for a trial of combination contraceptives, provided they are otherwise healthy, show no evidence of end-organ vascular disease, and do not smoke. 21 yo G0 calls after office hours with report condom broke. You advise A. if expected period is one week late, get a home pregnancy test B. come to office for pregnancy test in the morning and a prescription for single dose 1.5 mg levonorgestrel pill morning after pill C. go to pharmacy and get OTC Plan B now D. prescribe two of combination OC tablets ASAP repeat dose in 12 hours 10

11 Both the combined regimen and the levonorgestrel-only regimen have been shown to inhibit or delay ovulation (22 28). Emergency contraception is sometimes confused with medical abortion (39). However, whereas medical abortion is used to terminate an existing pregnancy, emergency contraception is effective only before a pregnancy is established. Emergency contraception can prevent pregnancy during the 5 or more days between intercourse and implantation of a fertilized egg, but it is ineffective after implantation. Studies of high-dose oral contraceptives indicate that emergency contraception confers no increased risk to an established pregnancy or harm to a developing embryo (40). The levonorgestrel-only regimen is more effective and is associated with less nausea and vomiting; therefore, if available, it should be used in preference to the combined estrogen progestin regimen. The two 0.75-mg doses of the levonorgestrel-only regimen are equally effective if taken hours apart. The single-dose 1.5-mg levonorgestrel-only regimen is as effective as the two-dose regimen taken 12 hours apart. To reduce the chance of nausea with the combined estrogen progestin regimen, an antiemetic agent may be taken 1 hour before the first emergency contraception dose. Treatment with emergency contraception should be initiated as soon as possible after unprotected or inadequately protected intercourse to maximize efficacy. Emergency contraception should be made available to patients who request it up to 5 days after unprotected intercourse. No clinician examination or pregnancy testing is necessary before provision or prescription of emergency contraception. 11

12 What are the effects of DMPA on skeletal health? Use of DMPA in contraceptive doses suppresses ovarian production of estradiol (168). Thus, there has been concern that women using DMPA for contraception might increase their future risk of developing osteoporosis. In 2004, the FDA added a black box warning to DMPA regarding loss of bone mineral density, indicating that injectable contraception should be continued for more than 2 years only if other birth control methods are inadequate. A letter from the manufacturer suggested that dual-energy X-ray absorptiometry (DXA) studies might be used to monitor bone mineral density in DMPA users. Many studies have observed bone mineral density declines in current users of DMPA, which is seen as a surrogate marker for future osteoporosis and fracture ( ). None of these found evidence of osteoporosis or fractures in DMPA users. Two cross-sectional studies found that years after DMPA discontinuation, bone mineral density was similar in former and never users of DMPA (172, 173). A large U.S. prospective study of adult DMPA users found that within 30 months following DMPA discontinuation, bone mineral density of the spine and hip was similar to that of nonusers (171). As in adults, DMPA use in adolescents is associated with declines in bone mineral density (171, 174). A U.S. prospective study of 61 teens discontinuing DMPA noteadult women, supplementation with daily mg oral conjugated equine estrogen has been observed to prevent loss of bone mineral density associated with use of DMPA (175). Likewise, supplementation with monthly 5- mg intramuscular estradiol cypionate injections prevented loss of bone mineral density in teens using DMPA (176). The bone mineral density trends seen with DMPA seem to be similar to those noted during lactation in that no long-term decrease occurs (177, 178). Given the above observations, skeletal health concerns should not restrict use of DMPA in adult women. In adolescents, the advantages of DMPA likely outweigh the theoretical safety concerns regarding bone mineral density and fractures. However, in the absence of long-term data in this population, consideration of long-term use should be individualized. Regardless of age, d that within 12 months after discontinuation, bone mineral density was at least as high in former DMPA users as in nonusers (171). In short or long-term use of DMPA in healthy women likewise should not be considered an indication for DXA or other tests that assess bone mineral density (179). LOBBY EARLY AND OFTEN GIVE EARLY (TO YOUR ASSOCIATIONS) AND OFTEN VOTE ONCE BUT WATCH OUT TWICE APPRECIATE THE LIMITS OF YOUR BOUNTY 12