Meeting the Contraceptive Needs of Women Students: Bringing the Evidence into Practice Sara H. Lee, MD Case Western Reserve University April 10, 2015

Meeting the Contraceptive Needs of Women Students: Bringing the Evidence into PracticeSara H. Lee, MDCase Western Reserve University April 10, 2015

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Agenda

What are the gaps?

Guidelines and evidence for improving practice What exists and how to get it What do the guidelines look like, and how do you use them to

solve problems

Case studies

Defining the problem

•7.3% of college students did not use contraception at last vaginal intercourse

•1% of college students had an unintentional pregnancy

American College Health Association. American College HealthAssociation-National College Health Assessment II: Reference GroupExecutive Summary Spring 2014. Hanover, MD: American College HealthAssociation; 2014.

Defining the problem: barriers to contraception•Student level

• Ambivalence

• Cost

• Access

• Privacy concerns

•Provider level• Unnecessary testing

• Availability of methods

Guidelines and Evidence for Improving Practice

CDC Contraceptive Guidance for Healthcare Providers•CDC Medical Eligibility Criteria (MEC)

•CDC Selected Practice Recommendations for Contraceptive Use (SPR)

CDC US Medical Eligibility Criteria

Evidence-based source of clinical guidance for the safe use of contraceptive methods by women with various characteristics and medical conditions.

Developed in 2010 – adapted from WHO guidelines.

Includes over 1800 recommendations for more than 60 conditions and also includes information on certain drug interactions.

“Although these recommendations are meant to serve as a source of clinical guidance, health-care providers should always consider the individual clinical circumstances of each person seeking family planning services.”

US MEC Categories

Example: Cigarette Smoking

Condition COC/P/R POP DMPA Implant Cu-IUD LNG-IUD

Smoking

a. Age <35 2 1 1 1 1 1

b. Age >35

i. <15 cig/day 3 1 1 1 1 1

ii. >15 cig/day 4 1 1 1 1 1

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

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

Initiation and Continuation

• Separate columns if recommendations differ for• Initiation criteria (preexisting conditions)• Continuation criteria (condition develops or worsens)

Combined Hormonal Contraceptives

Headache Initiation ContinuationNon-migrainous (mild or severe) 1 2

Migraine

Without aura

Age < 35 years 2 3

Age >= 35 years 3 4

With aura, at any age 4 4

CDC US Selected Practice Recommendations

Published in 2013 as companion to US MEC.

Also adapted from WHO.

Offers evidence-based guidance for contraceptive management.

Take Home MessagesTake Home Messages Most women can start most methods Most women can start most methods

anytimeanytime

Few, if any, exams or tests are needed Few, if any, exams or tests are needed

Recommendations for anticipatory Recommendations for anticipatory counseling for potential bleeding problems counseling for potential bleeding problems and proper management providedand proper management provided

Routine follow-up generally not requiredRoutine follow-up generally not required

Many circumstances call for consideration Many circumstances call for consideration of emergency contraception useof emergency contraception use

Regular contraception should be started Regular contraception should be started after ECafter EC

US SPR and MEC: Strengths and LimitationsLimitations

• Long, wordy, repetitive• Intended for adults

• Hard to find

Strengths• Thorough and evidence-

based• Can be used as protocol

• Apps!

Locating CDC contraception Locating CDC contraception guidanceguidance

http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USSPR.htmUSSPR.htm

Install App and download SPR

Prescribing contraception using the US SPR and MEC

Prescribing Oral Contraceptives

18 year old freshman wants birth control pills. Her last period was 6 days ago, and she last had sex 2 weeks ago with a condom. She has a history of migraines WITHOUT aura.

Can she have the pills?

Does she need an exam? Any exam? Did she need to come in to your office today?

Does she need any testing?

US SPR – Exams and Tests

Class A = essential and mandatory Class B = contributes substantially to safe and

effective use, but implementation may be considered within the public health and/or service context

Class C = does not contribute substantially to safe and effective use of the contraceptive method

Examination or test Contraceptive method and class

ExaminationLNG and Cu-IUD

ImplantInjectable

CHC POP Condom

Diaphragm or

cervical cap

Spermicide

Blood pressure C C C A* C C C CWeight (BMI) — † —† —† —† —† C C CClinical breast examination

C C C C C C C C

Bimanual examination and cervical inspection

A C C C C C A C

Laboratory testGlucose C C C C C C C CLipids C C C C C C C CLiver enzymes C C C C C C C CHemoglobin C C C C C C C CThrombogenic mutations

C C C C C C C C

Cervical cytology (Papanicolaou smear)

C C C C C C C C

STD screening with laboratory tests

—§ C C C C C C C

HIV screening with laboratory tests

C C C C C C C C

Appendix C (p. 56)

College Students as Emerging Young Adults

College students are emerging young adultsAges 18 to 25Brain is still developingStill completing developmental tasks

The New Adolescents: An Analysis of Health Conditions, Behaviors, Risks, and Access to Services among Emerging Young AdultsLawrence S. Neinstein, MD 2013

College Students as Emerging Young Adults

Establishing identityDeveloping independence

More risk-taking behaviorsDepression

Chlamydia—Rates by Age and Sex, United States, 2012

2012-Fig 5. SR, Pg 11

Gonorrhea—Rates by Age and Sex, United States, 2012

2012-Fig 21. SR, Pg 21



ImplantInjectable

CHC POP Condom

Diaphragm or

cervical cap

Spermicide


C C C C C C C C


A C C C C C A C


C C C C C C C C


C C C C C C C C


—§ C C C C C C C


C C C C C C C C

Appendix C (p. 56)

Does she need an exam? Any exam? Did she need to come in to your office today?

Does she need any testing?_______________________________________________________Only blood pressure is required. Anything else is

OPTIONAL even if it is a good idea.

Next Question

When can she start the pills?

Contraceptive

Method

When to start, if provider is reasonably

certain woman is not pregnant

Back-up needed

LNG IUD Any timeIf > 7 days of cycle, use back-up method or abstain for 7 days

Copper IUD

Any time Not needed

Implant (etonogestrel)

Any timeIf > 5 days of cycle, use back-up method or abstain for 7 days

Injectable Any timeIf > 7 days of cycle, use back-up method or abstain for 7 days

CHC Any timeIf > 5 days of cycle, use back-up method or abstain for 7 days

Progestin-Only Pills (POPs)


Appendix B (p. 55)

Page 5

Her last period was 6 days ago, and she last had sex 2 weeks ago with a condom.

How long does she need to use a back-up method?

Contraceptive

Method



Back-up needed


Copper IUD

Any time Not needed







Appendix B (p. 55)

How many packs are you going to give her? What is her follow-up?

Page 26

What about blood pressure checks?

No evidence exists regarding whether a routine follow-up visit after initiating combined hormonal contraceptives improves correct or continued use. Monitoring blood pressure is important for combined hormonal contraceptive users. Health-care providers might consider recommending women obtain blood pressure measurements in nonclinical settings (e.g., pharmacy or fire station).

A systematic review identified five studies that examined the incidence of hypertension among women who began using a COC versus those who started a nonhormonal method of contraception or a placebo (17). Few women developed hypertension after initiating COCs, and studies examining increases in blood pressure after COC initiation found mixed results. No studies were identified that examined changes in blood pressure among patch or vaginal ring users (Level of evidence: I, fair, to II-2, fair, indirect).

How many packs are you going to give her? What is her follow-up?

“Specific populations that might benefit from more frequent follow-up visits include adolescents, those with certain medical conditions or characteristics, and those with multiple medical conditions.”

Prioritizing Tasks at the Visit

Prescribing contraceptionSTI screeningScreening for sexual assault and intimate partner

violenceDepression screeningEstablishing a primary care relationship

How are you going to give her ALL of this information?

When to startHow to take the pillsBack up methodSide effectsMissed pillsAnticipatory guidance about unscheduled

bleeding

Effective Communication (“Health Literacy”)• Limit information provided to two or three important

points at a time. (Joint Commission)• 40–80% of medical information provided by healthcare

practitioners is forgotten immediately. • The greater the amount of information presented, the

lower the proportion correctly recalled. • Almost half of the information that is remembered is

incorrect

Kessels RP. Patients' memory for medical information. J R Soc Med. 2003 May; 96(5): 219–222.

How are you going to give her ALL of this information?

• Face to face• Video• Handout• Text• E-mail

CDC SPR: Clinic Protocols and Policies

A 21 year old junior presents today for her fourth DMPA injection. The last one was given 2/01/2014. Can she have the injection?

Page 21

CDC SPR: Clinic Protocols and Policies

A 21 year old junior presents today for her fourth DMPA injection. The last one was given 2/01/2014. Can she have the injection?

Can develop a protocol or policy based on SPR guidelines

Prescribing EC

A 23 year-old graduate student with no medical problems had unprotected sex 36 hours ago and presents for emergency contraception.

What are her options?

Page 34

She decides she wants to start OCPs – when can she start them?

Page 35


anytimeanytime






Long-Acting Reversible Contraception (LARC)IUD or Implant

Most effective

Page 6

LARC Myths and Misconceptions

IUDs cause PID and infertilityLARC causes menstrual irregularitiesIUDs are only for women who have had a pregnancyAdolescents and young adults prefer OCPs

LARC and US SPR

A 21 year old art student wants a levonorgestrel-releasing IUD (LNG-IUD). Her last period was 2 weeks ago, and she last had sex 1 month ago.

Can she have an IUD today?

Contraceptive

Method



Back-up needed


Copper IUD

Any time Not needed







Appendix B (p. 55)

If you need to refer her, does she need any testing?

Should you do an exam?



ImplantInjectable

CHC POP Condom

Diaphragm or

cervical cap

Spermicide


C C C C C C C C


A C C C C C A C


C C C C C C C C


C C C C C C C C


—§ C C C C C C C


C C C C C C C C

Appendix C (p. 56)


anytimeanytime






How Can We Use Guidelines and Evidence Successfully in a College Health Setting?

Case 1: Start to Finish

You are seeing a 20 year old sophomore who wants to start contraception. She had sex 2 nights ago and thinks she used a condom. Her last period was 1 week ago. She has well-controlled type I diabetes. She wants birth control pills, but she remembers her endocrinologist telling her years ago that people with diabetes “can’t have those.” What are her options today? What testing does she need? What instructions should she receive?

Case 2: Unscheduled Bleeding

A 20 year old junior started the hormonal implant (Nexplanon) 4 months ago and comes in worried about spotting. She hates spotting.

What can you recommend?

Case 3: On Call

Ms. Smith is a third year college student. She has been seen in the health center once for a refill on her birth control. She was prescribed a three month supply of her OCP and advised to schedule an annual women’s health exam. You are the on-call clinician and received a call from

Nurse Response – Ms. Smith will run out of her birth control on Sunday.

How would you handle this situation?

Does your health center have a formal policy? Can you use the evidence to develop one?

True or False?

Question 1: The CDC US Medical Eligibility Criteria provides recommendations for the safety of contraceptive methods for women with various medical conditions.

Question 2: According to the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 (US SPR), women who receive a prescription for oral contraceptive pills are required to have their blood pressure checked in 3 to 4 months.

Question 3: Most contraceptive methods require a “waiting period” prior to initiation.

Question 4: Regular contraception should be started after emergency contraception.

Question 5: Nothing can be done for women with unscheduled bleeding who use the implant or injection as contraception other than changing methods.

Documents

Meeting the Contraceptive Needs of Women Students: Bringing the Evidence into Practice Sara H. Lee, MD Case Western Reserve University April 10, 2015