Contraception in medical diseases

1
Contraception in medical diseases

• Dr.Prerna kumari
• Dr.Vatsla Dadhwal
• Dr.Murali

2
Contraception

• Half of pregnancies are unintended
• Half of unintended pregnancies result from
  inconsistent or incorrect contraceptive use
• Risk of method vs. risk of pregnancy
• What is the most important issue for the
  clinician prescribing contraception?

3
Objectives

• Easily access evidence-based recommendations for
  contraception in women with medical illness
• Understand the underlying evidence for these
  recommendations
• Balance the risks of contraception against the
  risks of pregnancy in these women

4
WHO Eligibility Criteria for Use of Reversible
Contraceptive Method

• No restriction
• Use the method
• Advantages of method outweigh the risks
• Generally use the method
• Risks outweigh the advantages
• Use only if no other method available
• Unacceptable health risk if method used
• Do not use the method

1
2
3
4

• Medical Eligibility Criteria for Contraceptive
  Use 2009 (www.who.int/reproductive-health)

5
Sterilization

• Accept(A)- There is no medical region to deny
  sterilization to a person with this condition
• Caution(C)-The procedure is normally conducted in
  a routine setting, but with extra preparation
  precautions
• Delay(D)-procedure is delayed until the condition
  is evaluated and/or corrected
• Special(S)-Procedure should be undertaken in a
  well equipped setting.

Medical Eligibility Criteria for Contraceptive
Use (www.who.int/reproductive-health)
6
Which patient,Which method?

• Personal characteristics Reproductive history
  (Age,Smoking,Obesity,Parity,Postpartum,Postabortio
  n)
• Cardiovascular disease
• DVT/PE
• Neurologic conditions
• Endocrine conditions
• Gastrointestinal disease
• Malignancies
• Rheumatologic disease
• Reproductive tract disorders and infections
• Anemias
• Drug interactions

7
Personal characteristics Reproductive history

• Age-
• No relation of contraception with age-
• except in patient 40 years-CHCs-
• Menarche to lt18 yrs gt45yrs-DMPA/NET-EN-
• Menarche to lt20yrs(IUD)-

Risk of cardiovascular disease increases with
age may also increase with COC use.
2
2
Bone mineraldensity decreases with long term use
of DMPA
2

• Risk of expulsion due to nulliparity
• Risk of STIs

8
SMOKING

• CHCS
• lt35 and smoke C2
• gt35 and smoke lt15/dayC3
• gt35 and smoke gt 15/day C4
• (COC users who smoke are at increased risk for
  CVD and MI risk increases with number of
  cigarettes smoked)
• POCS IUDS are safe.

Medical Eligibility Criteria for Contraceptive
Use (www.who.int/reproductive-health)
9
Obesity

• CHCS
• BMI gt 30kg/m2
• Possible increased risk of VTE, MI, stoke
• Inconsistent evidence about body wt and efficacy
• NOT more likely to gain
• POCS- C1 C2 lt18???NET-EN(Potential effect of
  NET-EN on bone mineral density)
• IUDS-

2
Because of elevated risk for dysfunctional
uterine bleeding and endometrial neoplasia, use
of levonorgestrel intrauterine system may be a
particularly sound choice for obese women
1
10
Bariatric Surgery(US-MEC)

• Restrictive procedures gastric band or sleeve
• CHCS-
• Malabsorptive procedures
• COCs
• Patch/Rings

1
3
1
11
Postpartum -Breastfeeding
4

• CHCs-
• lt 6weeks postpartum-
• 6weeks to lt6 months
• postpartum-
• 6 months postpartum-C1
• POCS
• lt6 weeks
• IUDs
• lt48hrs-C3 for LNG-IUD (Concern regarding steroid
  exposure to neonate)
• gt48 hrs to lt4weeks-C3 for LNG-IUD
• cu-T both
• Pueperal sepsis-

3
2
3
4
Medical Eligibility Criteria for Contraceptive
Use (www.who.int/reproductive-health)
12
Postpartum Nonbreastfeeding

• CHCS-
• lt 21 days-
• gt21 days-
• POCs- Safe
• IUDs-gt48 hrs tolt4weeks-

3
Increased risk of thrombosis up to 3 weeks
postpartum
1
Increased risk of expulsion
3
Lideggard o et al.Hormonal contraception and risk
of venous thromboembolismnational follow up
study.British Medical Journal,2009,339
13
Postabortion

• Immediately post abortion
• 1st or 2nd trimester- hormonal contraception-
• IUDS-
• 2nd trimester abortion-
• Immediate Post septic abortion-

1
2
4

• Gaffield ME et al.Use of combined oral
  contraceptivespostabortion.Contraception,200980.

14
CVD Hypertension

• Adequately controlled/History of hypertension
  where blood pressure cant be evaluated
• Elevated BP levels
• SBP140-159 OR DBP 90-99-
• SBP gt 160 OR DBP gt 100-
• Vascular disease- C4
• Hypertension during pregnancy- C2

CHCS
3
3
4
2
Medical Eligibility Criteria for Contraceptive
Use (www.who.int/reproductive-health)
15
Hypertension Contd.

• POCS
• Adequately controlled/Elevated BP levels SBP
  140-159/DBP 90-99
• POP, I C1, DMPA C2
• ImplantsC1
• SBP gt 160/DBP gt 100
• POP/I C2, DMPA C3
• ImplantsC2
• High BP during pregnancy C1
• IUDs-cu-C1
• LNG-C2

Concern with DMPA hypoestrogenic states and
reduced HDL levels, especially as they persist
for a while after discontinuation not a
problem with POPs DVT/PEno direct evidence
exists POPs and DVT/PE findings on risk
inconsistent
Medical Eligibility Criteria for Contraceptive
Use (www.who.int/reproductive-health)
16

• ACOG recommends -non-smoking women with blood
  pressure well controlled by antihypertensive
  agents, under age 35 and otherwise healthy may
  try combination hormonal contraceptive methods
  with careful monitoring if blood pressure
  remains controlled, use can be continued. Use of
  combination hormonal methods in women with severe
  (ie, uncontrolled) hypertension is
  contraindicated. Progestin-only methods, barrier
  methods and IUDs are appropriate options for
  women with either controlled or uncontrolled
  hypertension.

17
DVT/PE

• Incidence

Conditions Incidence VTE
No contraception 5-10
High dose OCP 24-50
Low dose OCP 12-20
Third gen OCP 9-21
Pregnancy 60-70
Incidence per 100,000 women per year Sulman LP
et al.The truth about oral contraceptive and
VTE.Journal of reproductive Medicine.200348930-
938
18
CVD DVT PE

• CHC-
• Hx of DVT/PE NOT on anticoagulant
• Higher risk of recurrence
• Estrogen associated
• Pregnancy associated
• Idiopathic
• Thrombophilia
• Cancer
• Hx recurrence
• Lower risk for recurrenc-

4
3
Medical Eligibility Criteria for Contraceptive
Use (www.who.int/reproductive-health)
19
CVD DVT PE
4

• Acute DVT/PE-
• DVT/PE on anticoagulant for at least 3 months
• Higher risk of recurrence-
• Thrombophilia
• Cancer
• Recurrence
• Lower risk of recurrence-
• No risk factors

4
3
Medical Eligibility Criteria for Contraceptive
Use (www.who.int/reproductive-health)
20
DVT/PE

• POCS-
• History or acute-
• On or off anticoagulant/Major surgeries/immobilize
  d/Thrombotic mutations-
• Family History/ Superficial thrombosis-
• IUDs
• Cu
• LNG C2
• Acute DVT/PE C2 both
• Known thrombogenic mutation-

2
2
1
2
Medical Eligibility Criteria for Contraceptive
Use (www.who.int/reproductive-health)
21
Heart disease
WHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease WHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease WHO Classification of risk from contraceptive use and pregnancy in cardiovascular disease
WHO Class Risk for contraceptive method by cardiac condition Pregnancy risk by cardiac condition
WHO 1 Always useable Risk no higher than general population Risk no higher than general population
WHO 2 Broadly useable Small increased risk advantages of method generally outweigh the risk Small increased risk of maternal mortality and morbidity
WHO3 Caution in use Risk usually outweigh advantages of method.other methods preferable. Significant increased risk of maternal mortality morbidity
WHO4 Do not use Method contraindicatedaccepts unacceptable health risk Pregnancy contraindicated.
22
Think?

• Safety and efficacy both are important.
• 1st-whether COC is safe
• 2nd-Which POCs may be recommended
• 3rd-whether there is risk of endocarditis/hemodyna
  mic collapse/hematoma formation
• Level of contraception desired
• Womens lifestyle
• Efficacy of method should also be considered.

23
Counselling

• Must present all the suitable options to the
  patients.
• Benefits and risks of contraception
• Risk of pregnancy versus risk of use of
  contraception.

24
Heart disease and contraception
25
Contraception
Method Valvular heart disease uncomplicated Valvular heart disease complicated Ischemic heart disease
CHCS 2 4 4
Progesterone only 1 1 I-2/C-3, DMPA/NE-3
IUCD 1 2 1 LNG(I-2/C-3)
Barrier 1 1/2 1
Sterilization C S Current - D H/O CAD - C
Emergency contraception 2
WHO Risk Category 2009
26
Heart disease Contraception

• Intrauterine devices are not indicated in
  patients at risk for endocarditis, valvular
  prostheses, or receiving chronic anticoagulation.
• Hormonal contraception thrombosis -15 in
  cyanotic patients
• Interaction between OCP and anticoagulants
  (warfarin).
• Interaction between Bosentan and POPs.
• ?Parenteral contraception(Mirena) - low profile
  of complications.

27
Heart 2006
28
Heart 2006
29
IUDs pulmonary vascular disease

• Cardiovascular risk is confined to the time of
  insertion,in particular to instrumentation of the
  cervix.vasovagal reaction (5) may cause
  potentially fatal cardiovascular collapse in
  patients with pulmonary vascular disease.

To reduce the risk,use of paracervical block /
combined spinal epidural recommended for
women with pulmonary vascular disease
Implanon is to be preferred
Heart 200692Sara Thorne et.al,Risks of
contraception and pregnancy in heart disease
30
Congenital heart disease and conraception
31
DYSLIPIDEMIA

• No need to measure lipid levels prior to
  prescribing CHCs unless a woman has known
  dyslipidemia, other CVD risks (eg, smoking,
  diabetes, obesity, hypertension), or history of
  pancreatitis
• Oestrogen usually increase HDL and decreases
  LDL.In contrast progestins decreases HDL and
  increases LDL total cholesterol.
• Pills containing desogesterol norgestimate
  gestodene improve HDL/LDL ratio.

Bushnell CD.Oestrogen and stroke assessment of
risk.Lancet neurol.20054743-751
32
SLE CONTRACEPTION

• Positive or unknown antiphospholipid
  antibodies-CHC-C4,POC-C3,IUD-CU-C1,LNG-C3.
• Severe thrombocytopenia-CHC-C2,POP-C2,PICS-C3,CU-
  IUD-C3
• Immunosuppression- All are C1/2.
• ACOG recommends that estrogen-containing
  contraceptives not be used by women with SLE and
  a history of vascular disease, nephritis, or
  presence of antiphospholipid antibodies.
  Progestin-only methods, barrier methods and IUD
  are appropriate methods for these women.

Culwell KR,Curtis KM et al.Safety of
contraceptive method use among women with
SLE Obstetrics and Gynecology ,2009,114.
33
Neurologic disease

• CHCS
• Headache
• Not migraines
• Initiate C1 Continue C2
• Migraines No aura
• lt35 years old
• Initiate C2 Continue C3
• gt 35 years old
• Initiate C3 Continue C4
• Migraines with aura,
• Initiate or continue C4

Any new headache or marked change in Headaches
should be evaluated
34

• ACOG guidelines state that CHCs may be used by
  women with migraine headaches who do not have
  focal neurologic symptoms, do not smoke, are
  otherwise healthy, and are younger than age 35.
  POCs are appropriate options for women with
  migraine with aura who have no other risk factors
  for stroke (eg, smoking, hypertension). IUDs may
  be used by women with migraine with or without
  aura. Barrier methods are preferred in migraine
  patients with aura

35
Headache
Agelt35
Age35
36
Epilepsy
1

• CHCS,POP, IUD-C1
• Watch drug interactions
• For patient on- phenytoin,carbamazepine,barbitur
  ates,primidone,topiramate,oxcarbamazepine
• CHCS POPs -C3
• DMPA-C1
• NE Implant -C2
• IUDS-C1
• Lamotrigine-levels decrease significantly during
  COC (C3)use and increase significantly during
  pill free interval but no drug interactions have
  been reported with POP(C1) use.

valproic acid, gabapentin, tiagabine,
levetiracetam, vigabatrin and zonisamide does not
appear to decrease serum levels of contraceptive
steroids in women using combination oral
contraceptives
Reimers A, Helde G, Brodtkorb E. Ethinyl
estradiol, not progestogens, reduces lamotrigine
serum concentrations. Epilepsia, 2005,
461414-1417
37

• No evidence that combination hormonal methods
  increase the frequency of epileptic seizures
• use of DMPA has been found to reduce seizure
  frequency in women with seizure disorders.

• Vessey M et.al.Oral contraception and epilepsy
  findings in a large cohort study.
• Contraception 20026677-79

38
STROKE

• CHCs-C4
• POCs-POPImplants-I-C2,C-C3
• DMPA/NE-C3
• IUDs-CU-C1,LNG-C2
• Sterilization-Caution

Concern with LNG IUD and PICs lies with
theoretical concerns over lipid
changes Inconsistent findings on POC and
thrombosis
39
Multiple sclerosis

• no progression and possible amelioration of MS
  during combination hormonal contraceptive
  use.Progestin-only contraceptive methods, barrier
  methods and IUDs are also appropriate options for
  women with MS

• Holmqvist P, Wallberg M, Hammar M et al. Symptoms
  of multiple sclerosis in women in relation to
• sex steroid exposure. Maturitas 200654149-153

40
Psychiatric disorders

• Depressive disorders
• Category 1
• No data on bipolar or postpartum disorders
• no clinical evidence that concomitant use of
  combination oral contraceptives and fluoxetine
  affects the safety or efficacy to either agent

• Koke SC, Brown EB, Miner CM. Safety and efficacy
  of fluoxetine in patients who receive oral
  contraceptive
• therapy. Am J Obstet Gynecol 2002187551-555

41
VAGINAL BLEEDING
42
Endocrine disorders

• CHCs
• H/O GDM-C1
• Nonvascular disease-
• non-insulin dependent-C2
• insulin dependent-C2
• Nephropathy/retinopathy/neuropathy-C3/4
• Other vascular disease or diabetes of gt20 years
  duration-C3/4

43
CHCs
44

• Combination oral contraceptives
• Data is limited to short-term studies
• Low-dose estrogen and less androgenic progestins
  may have less effect on the diabetic control and
  lipids
• No evidence of a negative effect on diabetic
  sequellae in women with type 1 diabetes
• ?? No studies in women with type 2 diabetes

Cagnacci A, et alContraception. 2009
Jul80(1)34-9
45

• POCs

• IUDs

• H/O GDM-C1
• Nonvascular disease-C2
• Nephropathy/retinopathy/neuropathy- POP implants
  -C2,DMPA/NE-C3
• Other vascular disease/diabetes of gt20 years
  duration- POP implants -C2,DMPA/NE-C3

• H/O GDM-C1
• Nonvascular disease-
• non-insulin dependent/
• insulin dependent- CU-C1,LNG-C2
• Nephropathy/retinopathy/neuropathy,Other vascular
  disease or diabetes of gt20 years duration-
  CU-C1,LNG-C2

Nelson AL et al.Intermediate term glucose
tolerance in women with history of gestational
diabetes natural history and potential
associations with breast feeding and
contraceptionAmerican journal of Obstetrics
Gynecology,2008198.
46
Diabetes Mellutus

• progestin-only contraceptives
• ?? Injectable DMPA is associated with unfavorable
  changes in insulin resistance and glucose control
• ?? Oral progestin (norethindrone) can be used
  based on available data
• IUD
• ?? Levonorgesterel IUD has been avoided due to
  limited
• data, however, recent studies demonstrated its
  safety
• in diabetic women
• ?? Copper IUD is metabolically neutral
• Rogovskaya S, et al.Obstet Gynecol. 2005
  Apr105(4)811-5.
• Xiang AH, et al.Diabetes Care. 2006
  Mar29(3)613-7.

47
Diabetes

• ACOG recommends- use of CHCs in women with
  diabetes should be limited to non-smoking,
  otherwise healthy women who are younger than 35
  and have no evidence of hypertension,
  nephropathy, or retinopathy. For women with
  diabetes, with or without vascular disease or
  hypertension use of intrauterine contraceptive
  devices (IUDs) or progestin-only contraceptive
  methods or barrier methods is not
  contraindicated.

48
Gastrointestinal conditions

• Cirrhosis
• CHCS-Mild C1,Severe C4
• POCS-Severe-C3
• IUDS- Mild, C1
• Severe LNG C3 Cu C1
• Viral Hepatitis
• CHCS/POCS
• Acute C3/4 (with severity)
• Chronic/carrier C1
• IUD-C1

Hormonal contraceptive use has no /minimal
effect on chronic hepatitis or its sequelae.
Nathelie et al.Effect of hormonal contraceptive
use among women with viral hepatitis or cirrhosis
of livera systematic review. Contraception20098
0381-386
49

• Gallbladder disease

• Inflammatory bowel disease (USMEC)

• CHCs-Category 2/3
• POP, DMPA C2
• Implants C1
• IUD- C1

• CHC
• Asymptomatic C2
• Symptomatic-surgery C2
• Medical
  treatment C3
• POPS-C2
• IUD- Cu C1 LNG C2
• Cholestasis
• CHC
• Pregnancy related C2
• COC related C3
• POCS-COC-related cholestasis C2

Depends on risk for VTE
50
Malignancies

• Gestational trophoblastic disease
• Decreasing or undetectable beta HCG-IUDS are C3.
• Persistently elevated betaHCG/Malignant
  disease-IUDS are C4

CHCS POPs are safe
51
Liver tumors
Hormonal contrceptive use in patients with FNH
does not influence prolression or regression of
liver lesion.

• CHCS
• Benign
• Focal nodular hyperplasia C2
• Hepatocellular adenoma C4
• Malignant C4
• POCs-C2/3
• IUDS Cu C1
• FNH LNG C2
• Adenoma, hepatoma LNG C3

Nathalie et al.Hormonal contraceptive use in
women with liver tumors.Conraception200980,387-39
0
52
Breast diseases
Evaluation should be persued as early as possible

• CHCS ,POCSLNG-IUD-
• Undiagnosed mass,
• benign breast disease,Family history of
  cancer-C1/2
• Breast cancer-
• Current C4
• Past no evidence of current
  disease for 5 years-C3

Cu IUD is category 1 in patients with breast
cancer
Gaffield ME,Culwell KR et al.Oral contraceptives
and family history of breast cancer. Contraception
,200969372-380
53
Ovarian Cancer

• Reduced risk of ovarian cancer among users of all
  formulations of oral contraceptives regardless of
  content or potency.
• Barrier and Hormonal contraception are safe.
• IUDs-I-C3,C-C2

Joellen et al.Effect of estrgen and progestin
potency in oral contraceptive on ovarian cancer
risk Journal of national cancer institute200294.
WHO Risk Category 2009
54
ENDOMETRIAL CANCER

• IUDS-C4 for initiation and C2 for continuation
• CHCs ,POPs barrier method are safe.
• COC use reduces the risk of developing
  endometrial cancer and have no effect on growth
  of fibroids.
• Uterinefibroids with distortion of
  cavity-LNGIUD-C4

WHO Risk Category 2009
55
Cervical cancer

• IUDs- C4 for initiation and C2 for continuation
• CIN-POP-C1
• Implants DMPA-C2
• Barrier method-cap should not be used

Among women with persistent HPV infection ,long
term DMPA use (5 years)may increase the risk of
carcinoma in situ and invasive carcinoma
Smith JS.Cervical cancer and use of hormonal
contraceptiona systematic review.Lancet,2003, 361
1159-1167
56
Drug interactions

• Antiretroviral therapy

Drug CHC POC IUD Barrier
NRTI 1 1 CU-I-C2/3 C-2 LNG-I-C2/3,C-C2 Spermicide Diaphragm C3
NNRTI 2 2 DMPA-1 CU-I-C2/3 C-2 LNG-I-C2/3,C-C2 Spermicide Diaphragm C3
Ritonavir boosted protease inhibiter 3 POP-3 DMPA-1 Implant--2 CU-I-C2/3 C-2 LNG-I-C2/3,C-C2 Spermicide Diaphragm C3
AIDS as a condition is classified as category 3
for insertion category 2 for continuation
57
Drug interactions

• Antimicrobial therapy

58
Patient with disability

• Must take into account-
• nature of method,
• nature of method
• expressed desire of the individual.
• Barrier method may be difficult for patient with
  limited manual dexterity,COCS may not be
  preferable for patients with impaired
  circulation.
• Patients with mental health disabilities who
  have difficulty remembering to take daily
  medications ,contraception other than OCPS
  should be preferred.

59
CDC Changes from WHO MEC

• Modifications

• Additions

• VTE
• Valvular heart disease
• Ovarian cancer
• Uterine fibroids
• Postpartum
• Breastfeeding

• RA
• Bariatric surgery
• Peripartum cardiomyopathy
• Endometrial hyperplasia
• IBD
• Solid organ transplant

CDC, MMWR, May 28, 2010
60
ACNE

• Estrophasic(Estrostep)-
• Combines low dose of progestin with gradually
  increasing dose of estrogen
• Marked increase in SHBG,Very low androgen.

61
Sickle cell disease

• DMPA may be a particularly appropriate
  contraceptive for women with sickle cell disease

• American College of Obstetricians and
  Gynecologists. Use of hormonal contraception in
  women with
• coexisting medical conditions. ACOG Practice
  Bulletin number 73. Obstet Gynecol 20061071453

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