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Transcript of US Medical Eligibility Criteria for Contraceptive · PDF file Objectives •Describe the US...

  • US Medical Eligibility Criteria for

    Contraceptive Use

    Kathryn M. Curtis, PhD

    Division of Reproductive Health

    Centers for Disease Control and

    Prevention

  • Objectives

    • Describe the US Medical Eligibility Criteria

    for Contraceptive Use

    • Describe the current evidence-based

    recommendations about the safety of

    contraceptive methods for adolescents

    • Be able to apply the US MEC

    recommendations in certain situations

  • Unintended Pregnancy

     49% of pregnancies in the United States are

    unintended

     Little change over time

     Unintended pregnancy associated with adverse

    maternal and infant outcomes

     Rates of unintended pregnancy among women with

    alcohol or drug dependency unknown

    Finer, 2011

  • So why are unintended

    pregnancy rates so high?

    • 52% due to non-use of contraception

    • 48% due to contraceptive failure

    – Effectiveness of method

    – Consistent and correct use

    Finer, 2006

  • Long Acting Reversible Contraception

    (LARC) • “Forgettable contraception”

    • Not dependent on compliance/adherence

    • Available in US: – IUDs: copper and hormonal

    – Implant

    • “expanding access to LARC for young women has been declared a national priority” (IOM)

    • “Encourage implants and IUDs for all appropriate candidates, including nulliparous women and adolescents.” (ACOG 2009)

  • Typical Effectiveness of Family Planning Methods

    Adapted from: WHO. Family Planning: A Global Handbook

    Long acting reversible contraceptives (LARCs)

    Tier 1

    Tier 2

    Tier 4

    Tier 3

  • Contraceptive Use in US Current Method Use, 2006-2008, women ages 15-44 Percentage

    Female sterilization 16.7

    Male sterilization 6.1

    Pill 17.3

    Implant, Lunelle, Patch 0.7

    DMPA 2.0

    Ring 1.5

    IUD 3.4

    Condom 10.0

    Other 4.0

    No use, at risk 7.3

    NSFG, http://www.cdc.gov/NCHS/data/series/sr_23/sr23_029.pdf

  • Contraceptive Use in US Current Method Use, 2006-2008, women ages 15-44 Percentage

    Female sterilization 16.7

    Male sterilization 6.1

    Pill 17.3

    Implant, Lunelle, Patch 0.7

    DMPA 2.0

    Ring 1.5

    IUD 3.4

    Condom 10.0

    Other 4.0

    No use, at risk 7.3

    NSFG, http://www.cdc.gov/NCHS/data/series/sr_23/sr23_029.pdf

  • Contraceptive Use in US Current Method Use, 2006-2008, women ages 15-44 Percentage

    Female sterilization 16.7

    Male sterilization 6.1

    Pill 17.3 (Tier 2)

    Implant, Lunelle, Patch 0.7

    DMPA 2.0

    Ring 1.5

    IUD 3.4

    Condom 10.0 (Tier 3)

    Other 4.0

    No use, at risk 7.3

    NSFG, http://www.cdc.gov/NCHS/data/series/sr_23/sr23_029.pdf

  • Contraceptive Use in US Current Method Use, 2006-2008, women ages 15-44 Percentage

    Female sterilization 16.7

    Male sterilization 6.1

    Pill 17.3

    Implant, Lunelle, Patch 0.7 (Tiers 1-2)

    DMPA 2.0

    Ring 1.5

    IUD 3.4 (Tier 1)

    Condom 10.0

    Other 4.0

    No use, at risk 7.3

    NSFG, http://www.cdc.gov/NCHS/data/series/sr_23/sr23_029.pdf

  • U.S. Medical Eligibility Criteria

    for Contraceptive Use (MEC)

  • Why is evidence-based

    guidance needed?

    • To base family planning practices on the best

    available evidence

    • To address misconceptions regarding who

    can safely use contraception

    • To reduce medical barriers

    • To improve access and quality of care in

    family planning

  • US MEC

     Evidence-based recommendations on the use of

    contraceptive methods among women with medical

    conditions or other characteristics

     Adapted from global guidance, World Health

    Organization

     Purpose of recommendations:

     To assist health care providers in counseling about contraceptive

    method choice

     To serve as source of clinical guidance

     Health care providers should always consider

    individual clinical circumstances

  • MEC Categories 1. A condition for which there is no restriction for the

    use of the contraceptive method.

    2. A condition where the advantages of using the

    method generally outweigh the theoretical or proven

    risks.

    3. A condition where the theoretical or proven risks

    usually outweigh the advantages of using the

    method.

    4. A condition which represents an unacceptable health

    risk if the contraceptive method is used.

  • Smoking and Contraceptive Use

    SMOKING

    a) Age35

    (i) 15 cigarettes/day

    Cu-IUD

    1

    1

    1

    1

    1 1

    POPCONDITION CHC LNG-IUDDMPA

    1

    1

    IMP

    11

    1

    1

    1

    2

    3

    4

    1

    1

  • US MEC

    • Box 2: Conditions associated with

    increased risk for adverse health events as

    a result of unintended pregnancy.

    – Long-acting, highly effective contraceptive

    methods may be the best choice

    – Sole use of barrier and behavior-based methods

    may not be the most appropriate choice

    because of their relatively higher typical-use

    rates of failure

  • A 30 y.o. female is PPD#2, ready to be discharged from hospital and desires

    contraception. She plans to breastfeed.

    Which hormonal methods are safe for her

    to use?

    A. Combined methods only

    B. Progestin-only methods only

    C. Any hormonal method

    Clinical scenario #1

  • Updated CDC guidance

    CDC, MMWR, 2011; 60(878-883)

  • Risk of Venous Thromboembolism

     Risk of VTE high in postpartum period

     Range: 25-99 per 10,000 women

     22-84 times as high as non-pregnant, non-postpartum woman

     Decreases over time, especially in first 3 weeks

     Unclear when baseline risk is reached, probably around 42 days

     Risk of VTE with combined hormonal contraceptive

    use

     ~3-7 times as high as non-CHC users

     Overall risk low: 1-10 per 10,000 women

    Jackson, 2011

  • Breastfeeding

    • Two considerations for contraception and

    breastfeeding

    – Potential effect on breastfeeding performance

    (initiation, maintenance, duration of lactation

    and need for supplementation)

    – Potential effect on infant health and

    development (infant weight, infant length,

    physical findings, health problems, and

    psychomotor development)

  • Breastfeeding- evidence

    • Progestin-only methods

    – 43 studies

    – POPs, DMPA, implants, and LNG-IUD

    – No adverse effect on breastfeeding

    performance

    – No adverse effect on infant growth,

    health, or development through 6 years

    of age

    Kapp, 2010

  • Breastfeeding- evidence

    • Combined hormonal methods

    – 10 studies of COCs

    – 4 studies reported decreased duration

    and higher rates of supplemental feeding

    – 1 study no difference in breastfeeding

    performance

    – No adverse effect on infant growth,

    health, or development through 8 years

    of age Kapp, 2010

  • Breastfeeding- gaps

    • Most observational studies

    • Methodologic concerns

    • No consistent definitions of breastfeeding

    • No consensus on outcome measures for

    breastfeeding or infant health

    • No inclusion of ill or premature infants

    • Need longer follow up

  • CDC, MMWR, 2011; 60(878-883)

  • CDC, MMWR, 2011; 60(878-883)

  • A 30 y.o. female is PPD#2, ready to be

    discharged from hospital and desires

    contraception. She plans to breastfeed.

    Which hormonal methods are safe for her

    to use?

    Answer:

    B. Progestin-only methods only (Category 2)

    Clinical scenario #1

  • Clinical scenario #2

    A 25 y.o. female with depression desires

    long-term reversible contraception and is

    thinking about the levonorgestrel-releasing

    IUD. Is this method safe for her?

    A. Yes

    B. No

  • Depression

    CONDITION COC/P

    /R

    POP DMPA Implants LNG-

    IUD

    Cu-IUD

    Depression 1* 1* 1* 1* 1* 1

    *This classification is based on data for women with selected depressive

    disorders. No data on bipolar disorder or postpartum deprresion were

    available. A potential for drug interactions between certain antidepressant

    medications and hormonal contraceptives.

  • Clinical scenario #2

    A 25 y.o. female with depress