Contraceptive Update: CDC Medical Eligibility Criteria for Women With Certain Characteristics and Medical ConditionsARHP Learning Lab May 18, 2011

Emily Godfrey, MD, MPH

Expert Medical Advisory Committee

Melanie Deal, WHNPStudent Health Services, SF State UniversitySan Francisco, CA

David Grimes, MD University of North Carolina School of MedicineChapel Hill, North Carolina

David Turok, MDUniversity of Utah, Dept. of Ob/GynSalt Lake City, UT

Susan Wysocki, WHNP-BC, FAANPNational Association of NPs in Women’s Health Washington, DC

Learning Objectives• List the 4 levels in the numeric scheme

described in the US Medical Eligibility Criteria for Contraceptive Use, 2010

• Explain the application of the numeric scheme to prescriptive practices for women with co-morbid conditions

• Describe the risks and benefits of the different contraceptive methods against the risks of pregnancy in women with health-related concerns

Unplanned pregnancy – U.S. Unintended Pregnancy

Intended

Unintended (49%)6.4 million pregnancies

51%

7%

20%

22%

Fetal Loss

Abortion

Birth

Finer LB, et al. Persp Sex Reprod Health. 2006.

1.2 million

1.4 million

Goals to Address Unintended Pregnancy• Healthy People 2020

▪ Increase proportion of pregnancies that are intended▫ 51% 56%

▪ Reduce proportion of females experiencing pregnancy despite reversible contraception use▫ 12.4% 9.9%

• CDC Winnable Battles▪ Public health priorities with large-scale impact on health and with

known, effective strategies to intervene ▪ To identify optimal strategies and to rally resources and partnerships

to accelerate a measurable impact on health▪ Prevention of teen pregnancy is one of the 6 winnable battles

http://healthypeople.gov/2020/http://www.cdc.gov/winnablebattles/teenpregnancy/index.html

Typical Effectiveness of Contraception

Adapted from: WHO. Family Planning: A Global Handbook

Long acting reversible contraceptives (LARCs)

Tier 1

Tier 2

Tier 4

Tier 3

Contraception Use

Mosher, W et al. 2010.

Improving Contraception Access• Improve access to and use of the most effective

contraceptives• Address barriers to use of Long Acting Reversible

Contraceptives (LARC)• Educate Providers

▪ Ensure dissemination of US MEC▪ Recommend that young women and nulliparous may be eligible to

use LARC methods• Increase interest and acceptance through education and

social marketing• Address cost barriers to ensure publically funded services

include LARC

http://www.cdc.gov/winnablebattles/teenpregnancy/index.html

US Medical Eligibility Criteria for Contraceptive Use

• CDC published criteria in June ‘10• Based on the 4th edition of the World Health

Organization guidelines from ‘09• Adapted for US women by panel of experts and

CDC• Recommendations for the use of specific

contraceptives by women who have particular characteristics/medical conditions

http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm

WHOCDC US MEC

Existing WHO guidance• Breastfeeding and hormonal methods• Valvular heart disease and IUDs• Postpartum IUD insertion• Ovarian cancer and IUDs• Fibroids and IUDs• DVT/PE and hormonal methods and IUDs

WHOCDC US MEC

New medical conditions• Rheumatoid arthritis• Endometrial hyperplasia• Inflammatory bowel disease• Bariatric surgery• Solid organ transplantation• Peripartum cardiomyopathy

US Medical Eligibility Criteria for Contraceptive Use

US Medical Eligibility Criteria: Organization• Criteria are organized according to:

– Contraceptive method– Patient characteristics (age, smoking status, etc.)– Preexisting conditions (hypertension, epilepsy, etc.)

• Criteria use a numeric scheme to provide the recommendations for contraceptives being used for contraceptive purposes only, not for treatment of medical conditions

http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf

1 No restriction for the use of the contraceptive method for a woman with that medical condition

2Advantages of using the method generally outweigh the theoretical or proven risks

3

Theoretical or proven risks of the method usually outweigh the advantages – or that there are no other methods that are available or acceptable to the women with that medical condition

4Unacceptable health risk if the contraceptive method is used by a woman with that medical condition

US Medical Eligibility Criteria: Categories

http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf

Conditions Associated w/ ↑ Risk for Adverse Heath Events as a Result of Unintended Pregnancy

Breast cancer Malignant liver tumors (hepatoma) and hepatocellular carcinoma of the liver

Complicated valvular heart disease Peripartum cardiomyopathy

Diabetes: insulin dependent; with nephropathy/retinopathy/neuropathy or other vascular disease; or of >20 years’ duration

Schistosomiasis with fibrosis of the liver

Endometrial or ovarian cancer Severe (decompensated) cirrhosis

Epilepsy Sickle cell disease

Hypertension (systolic > 160 mm Hg or diastolic > 100 mm Hg) Solid organ transplantation within the past 2 years

History of bariatric surgery within past 2 years Stroke

HIV/AIDS Systemic lupus erythematosus

Ischemic heart disease Thrombogenic mutations

Malignant gestational trophoblastic disease Tuberculosis

http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf

US Medical Eligibility Criteria: ↑ Risk for Adverse Health Events

Should consider long-acting, highly-

effective contraception for

these patients

Pregnancy-Related Mortality• Increase in pregnancy-related mortality, 1998-2005

▪ De-identified death certificates of women who died during or within 1 year of pregnancy

▪ Matched birth or fetal death certificates• Pregnancy-related mortality

▪ 14.5 per 100,000 live births▫ African American, 3-4 times greater risk▫ Decreased deaths due to hemorrhage and hypertensive

disorders▫ Increased deaths due to medical conditions, especially

CVD

Berg, CJ et al. Obstet Gynecol. 2010;116:1302-1309.

Case Presentation 1

• Which hormonal methods are safe for her to use?A. Combined hormonal

methods onlyB. Progestin-only

methods onlyC. Any hormonal method

• 30-year-old

• PPD #2• Ready to be

discharged from hospital & desires contraception

• Plans to breastfeed

Breastfeeding

Case Presentation 1

• Which hormonal methods are safe for her to use?A. Combined hormonal

methods onlyB. Progestin-only

methods onlyC. Any hormonal method

• 30-year-old

• PPD #2• Ready to be

discharged from hospital & desires contraception

• Plans to breastfeed

Case Presentation 2

• Is this method safe for her?A. YesB. No

• 25-year-old

• Has Crohn’s disease

• Desires long-term reversible

contraception

• Thinking about

levonorgestrel-

releasing IUD

Inflammatory Bowel Disease

Case Presentation 2

• Is this method safe for her?A. Yes (Category 1)B. No

• 25-year-old

• Has Crohn’s disease

• Desires long-term reversible

contraception

• Thinking about

levonorgestrel-

releasing IUD

Case Presentation 3• What do you need to

know before deciding whether to recommend this method?A. How much weight has

she lost?B. What type of surgery did

she have?C. What pill formulation did

she use previously?

• 30-year-old

• History of bariatric surgery 6 months ago

• Was using COCs before

surgery & wants to restart

Bariatric surgery

• Most effective weight loss treatment for morbid obesity

• From 1998 to 2005, incidence increased 800%

• Women account for 83% of procedures among reproductive age (ages 18-45)

Types of Bariatric surgery

• Restrictive procedures:▪ Decrease storage capacity of stomach▪ Ex: vertical banded gastroplasty, laparoscopic

adjustable gastric band, laparoscopic sleeve gastrectomy

• Malabsorptive procedures:▪ Decrease absorption of nutrients and calories by

shortening functional length of small intestine▪ Ex: Roux-en-Y gastric bypass (most common in

US), biliopancreatic diversion

Bariatric Surgery

• Consensus: Pregnancy should be avoided for 12-24 months after surgery

Paulen, ME et al. Contraception 82 (2010) 86-94.

History of Bariatric Surgery

Case Presentation 3• What do you need to

know before deciding whether to recommend this method?A. How much weight has

she lost?B. What type of surgery did

she have? C. What pill formulation did

she use previously?

• 30-year-old

• History of bariatric surgery 6 months ago

• Was using COCs before

surgery & wants to restart

Next Steps

• Work with partners: ▪ dissemination▪ implementation

• Keeping guidance up to date

Updated Guidance from WHOSeptember 2010

What increased risk is posed by use of Combined Hormonal Contraceptives?

• No data specifically delineates risk of CHC use during the postpartum

• Baseline risk of VTE in non-pregnant, non-postpartum women:▪ 2.4-10/10,000 WY

• CHC use increases risk:▪ 3-7 fold

• Risk most pronounced in the first year of use

Previous WHO MEC recommendation

CHCs in postpartum women

< 21 days postpartum 3

≥ 21 days postpartum 1

CHCs for women during the postpartum periodCondition Recommendation Clarification

Postpartum

a. < 21 days

Without other risk factors for VTE

3

With other risk factors for VTE

3/4 The category should be assessed according to the number, severity, and combination of VTE risk factors present.

b. > 21 days to 42 days

Without other risk factors for VTE

2

With other risk factors for VTE

2/3 The category should be assessed according to the number, severity, and combination of VTE risk factors present.

c. > 42 days 1

US MEC-Postpartum period

• New evidence• Updated recommendations from WHO

▪ CDC held consultation in Jan 2011▪ Substantial increased risk in early weeks

postpartum with no benefit ▪ Multiple risk factors

• Access issues• Safety of other contraceptive methods • Will be published as MMWR

Next Steps

• Work with partners: ▪ dissemination▪ implementation

• Keeping guidance up to date• Research gaps• US adaptation of WHO Selected Practice

Recommendations for Contraceptive Use

Resources• US MEC published in CDC’s Morbidity and

Mortality Weekly Report (MMWR):▪ http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a1.ht

m?s_cid=rr5904a1_w• CDC evidence-based family planning guidance

documents:▪ http://www.cdc.gov/reproductivehealth/UnintendedPregna

ncy/USMEC.htm• WHO evidence-based family planning guidance

documents:▪ http://www.who.int/reproductivehealth/publications/family_

planning/en/index.html

Additional Resources

• Association of Reproductive Health Professionals (ARHP)▪ www.arhp.org

• National Association of Nurse Practitioners in Women’s Health (NPWH)▪ www.npwh.org