#206 Use of Hormonal Contraception in Women with Coexisting Medical Conditions Flashcards
What are available progestin only contraceptive options?
DMPA injections, etonogestrel implant, progestin-only pills, and levonorgestrel-releasing intrauterine devices
How many USMEC categories are there?
4
What % of sexually active women will become pregnant within 1 year if not using contraceptives?
85%
What USMEC category means there is no restriction for a particular method?
1
What USMEC category is for a condition in which the advantages of using the method generally outweighs the theoretical or proven risks?
2
What USMEC category is for a condition for which the theoretical or proven risks usually outweigh the advantages of using the method?
3
What USMEC category is for a condition that represents an unacceptable health risk if the particular contraceptive method is used?
4
When patients present with multiple medical conditions, how do you determine the safety of a contraceptive choice?
The condition with the higher category number generally should be used to determine the safety of the contraceptive choice
Is the risk of VTE higher with use of combined oral contraceptives or in pregnancy? By how much?
Higher with pregnancy. Twice as high as risk with OCPs
Why do OCPs increase risk of VTE?
Estrogenic components increases hepatic production of serum globulins involved in coagulation (including factor VII, factor X, and fibrinogen)
How long after discontinuation of combined contraceptives do you observe normalization of clotting factors?
4-6 weeks
How does surgery affect USMEC category of combined hormonal contraceptives?
Major surgery with anticipated prolonged immobilization = USMEC category 4
If expected to be ambulatory post op, category 2
How does estrogen level compare between contraceptive patch users and OCPs?
Transdermal patch delivers total ethinyl estradiol serum concentrations that are higher, although peak concentrations are lower than in women using OCPs
How does the risk for VTE compare between OCPs, patch, and ring?
Appear to be similar
Does type of progestin in contraceptive method alter risk of VTE?
No, can be recommended as equivalent options
What is USMEC category is use of combined hormonal contraceptives in women with known familial thrombophilias?
USMEC category 4
Should you routinely screen for familial thrombotic disorders before initiating combined hormonal contraceptives?
No
How does the risk of clots compare between women with systemic lupus erythematosus and general population?
Increase risk of arterial and venous thrombosis
What is the risk of myocardial infarction in women with systemic lupus erythematosus compared to age-matched, sex-matched controls?
50-fold increased risk
If a woman with systemic lupus erythematosus asks to be started on OCPs, what should you do?
Test for antiphospholipid antibodies (in addition to thorough H&P)
What USMEC category is combined hormonal contraception in women with systemic lupus erythematosus and positive antiphospholipid antibodies?
USMEC category 4
What is the USMEC category for combined hormonal contraceptives in women with systemic lupus erythematosus without cardiovascular diseases risk factors
USMEC category 2
For women with systemic lupus eythematosus complicated by severe thrombocytopenia (<50k), for which contraceptive option is there increased caution?
DMPA is category 3. D/t concerns for menstrual bleeding with severe thrombocytopenia that may be worsened by the irregular bleeding with initiation of DMPA
When do you expect nonbreastfeeding postpartum women to ovulate (average and earliest)?
Typically 6 wks postpartum, but can be as early as 3 weeks postpartum
Regardless of breastfeeding status, for how long are combined hormonal contraceptives contraindicated postpartum? Why?
First 21 days because of the risk of VTE, category 4.
For postpartum women, who are not breastfeeding, and otherwise healthy/low risk, when can you start combined hormonal contraceptives?
Day 21 postpartum
For postpartum women, who are breastfeeding, and otherwise healthy/low risk, when can you start combined hormonal contraceptives?
Day 30; day 42 if other risk factors
When does the VTE risk return to baseline postpartum?
12 weeks postpartum
What are contraindications to immediate postpartum IUD placement?
Chorioamnionitis, postpartum endometritis, or sepsis
What is thought to be the trigger to prolactin secretion postpartum?
Withdrawal of progesterone after delivery
Until what age can you continue healthy, nonsmoking women without specific risk factors for CV disease on combined hormonal contraception?
Until age 50-55
Are there contraindications to the use of hormonal contraceptives on the basis of age?
No
What is the sterility rate at age 40? 45? 50?
Age 40 = 17%
Age 45 = 55%
Age 50 = 92%
Does FSH assist you in determining when to recommend stopping a women’s contraception?
No, can be misleading
Do combined hormonal contraceptives decrease the risk of any cancers?
Yes, decreases risk of ovarian and endometrial cancer
Is obesity a contraindication for certain types of contraceptives?
No
Is time needed to achieve steady state therapeutic levels of contraceptive steroids affected by body weight?
Yes, women with obesity require twice as long to reach steady state
What is USMEC category for oral contraceptives (combined, progestin-only) for women who undergo bariatric surgery (Roux-en-Y or biliopancreatic diversion)?
Category 3, may compromise absorption of oral medications
What is USMEC category for oral contraceptives (combined, progestin-only) for women who underwent restrictive types of bariatric surgery (eg vertical banded gastroplasty, LSC adjustable gastric band, LSC sleeve gastrectomy)?
USMEC category 1
How does USMEC category vary for different methods in women with depression, otherwise healthy?
All methods are category 1
Do depressive symptoms worsen with contraception?
No
What is the effect of combined hormonal contraceptives on fluoxetine?
Does not modify effectiveness
How do SSRIs or SNRIs affect metabolism of hormonal contraceptives?
Do not appear to interact
What is USMEC category for concomitant use of St. John’s wort and combined hormonal contraception, progestin-only pills, etonogestrel implant? Why?
USMEC category 2 for all listed.
Reason: St John’s wort, hepatic enzyme inducer, increased progestin and estrogen metabolism, increases breakthrough bleeding and likelihood of ovulation
What % of cases of migraine are migraine without aura?
75%
How do you diagnose migraine without aura?
A. At least five lifetime attacks fulfilling criteria B-D
B. HA attacks lasting 4-72h (untreated or unsuccessfully treated)
C. HA has at least 2 of the following: unilateral location, pulsating quality, mod or severe pain, aggravation by or causing avoidance of routine physical activity
D. During HA at least one of the following: nausea or vomiting, or both, or photophobia and phonophobia.
E. Not better accounted for by another ICHD-3 diagnosis
How do you diagnose migraine with aura?
A. At least 2 attacks fulfilling criteria B and C
B. One or more of the following fully reversible aura symptoms: visual, sensory, speech and/or language, motor, brainstem, retinal
C. At least 3 of the following: at least one aura symptom spreads gradually over 5 mins, two or more aura symptoms occur in succession, each individual aura symptom lasts 5-60mins, at least one aura symptom is unilateral, at least one symptom is positive, aura is accompanied by or followed within 60 mins by headache
D. Not better accounted for by another ICHD-3 diagnosis
What are the fully reversible aura symptoms?
Visual, sensory, speech and/or language, motor, brainstem, retinal
What are the headache characteristics of a migraine headache without aura?
Unilateral location, pulsating quality, moderate or severe pain intensity, aggravation by or causing avoidance of routine physical activity
What is the USMEC category for combined hormonal contraceptives in women with migraine without aura?
USMEC category 2
What is the USMEC category for combined hormonal contraceptives in women with migraine with aura?
USMEC category 4
What is the risk of stroke among women using combined hormonal contraceptives (per 100k women-years) in adolescents vs women 45-49yo
3.4 events per 100,000 women-years in adolescents to 64.4 events per 100,000 women-years among women aged 45-49yo
What USMEC category is use of combined hormonal contraceptives in women with HTN?
Depends:
Systolic 140-159 or diastolic 90-99mmHg Category 3
>160 systolic or diastolic >100mmHg or with vascular disease Category 4
The risk for what adverse event is increased when women with HTN use combined hormonal contraceptives?
Increased risk of acute myocardial infarction, by a factor of 12
What is the USMEC category for combined hormonal contraceptives in women with HTN controlled on meds?
USMEC category 3. There is no data on the use of combined hormonal contraceptives in this population
Are progesterone-only methods contraindicated in women with HTN?
In general no, except USMEC category 3 for DMPA in women with bp >160/100mmHg
What is USMEC category for combined hormonal contraception for patients with uncomplicated insulin-controlled diabetes, noninsulin-controlled diabetes?
USMEC category 2
In which cases of people with diabetes does combined hormonal contraception become category 3 or 4?
Duration of 20yrs+
Evidence of microvascular disease (retinopathy, nephropathy, or neuropathy)
Are progesterone-only contraceptive methods contraindicated in diabetes?
DMPA if DM for 20+ yrs or microvascualr dx given that DMPA increases lipoprotein profiles favorable to atherosclerosis
Is family hx of breast cancer a contraindication for hormonal contraception?
No, category 1
Is BRCA1 or BRCA2 mutation a contraindication to hormonal contraception?
No
What category does hormonal birth control get (USMEC) for use in women with current or recent breast cancer?
Category 4
What category does hormonal birth control get (USMEC) for use in women with hx of breast cancer with no evidence of disease for 5 years or more?
Category 3
What hormonal contraceptive options can be offered to women with cervical, endometrial, or ovarian cancer while awaiting treatment?
Combined and progesterone only methods. Continuation of IUDs ok, but initiation category 4 (apart from ovarian cancer, which is category 1)
What contraceptive options are contraindicated (Category 4) in gestational trophoblastic disease?
Placement of new IUD not appropriate in women with GTD for whom there is persistently elevated hcg levels or malignant disease when intrauterine disease is evident or suspected
What hormonal contraceptives can women taking rifampin or liver-enzyme inducing antiepileptic or certain antiretroviral medications?
DMPA and LNG-IUD (category 1)
Etonogestrel implant (category 2)
What hormonal contraceptives are contraindicated in women taking rifampin or liver-enzyme inducing antiepileptic or certain antiretroviral medications?
Combined hormonal contraception or progestin-only pills (Category 3)
For people with epilepsy, does seizure activity typically improve, worsen, or not change during pregnancy?
Typically worsens
What are some options for combined hormonal contraceptive use in women taking anti epileptics that reduce steroid levels?
Formulations with 30-35mcg ethinyl estradiol, longer half-life progestins (drospirenone, desogestrel, levonorgestrel), shorter hormone-free intervals (<7d) to minimize chance of escape ovulation
Which antiepileptic drugs are liver enzyme inducers?
Carbamazepine, felbamate, oxcarbazepine, phenobarbital, phenytoin, primidone, rufinamide
Which antiepileptic drugs are noninducers of liver enzymes?
Clobazam, clonazepam, ethosuximide, ezogabine, gabapetin, lacosamide, lamotrigine, levetiracetam, pregabalin, tiagabine, topiramate, valproate, vigabatrin, zonisamide
What is the only antiepileptic medication known to have its metabolism affected by estrogen-containing contraceptives?
Lamotrigine. OCPs can reduce its serum levels
Which antimicrobial agents are known to affect metabolism of estrogen and progestin (may affect contraception)?
Rifampin and rifabutitn
Can contraception be used in women on anticoagulation?
Yes. May need to be cautious with estrogen containing methods given increased risk for VTE
