Download - US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

Transcript
Page 1: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

US Medical Eligibility Criteria for

Contraceptive Use

Kathryn M. Curtis, PhD

Division of Reproductive Health

Centers for Disease Control and

Prevention

Page 2: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 3: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 4: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 5: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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)

Page 6: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 7: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 8: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 9: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 10: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 11: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

U.S. Medical Eligibility Criteria

for Contraceptive Use (MEC)

Page 12: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 13: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 14: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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.

Page 15: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

Smoking and Contraceptive Use

SMOKING

a) Age<35

b) Age>35

(i) <15 cigarettes/day

(ii) >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

Page 16: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 17: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 18: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

Updated CDC guidance

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

Page 19: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 20: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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)

Page 21: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 22: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 23: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 24: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 25: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 26: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 27: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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

Page 28: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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.

Page 29: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

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?

Answer:

A. Yes (Category 1)

Page 30: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

Cinical scenario #3

21 year old female, history of multiple sexual

partners, living in an area of high HIV prevalence,

and is at high risk of contracting HIV. In addition to

strong and supportive counseling about risk

reduction and condom use, she also needs a highly

effective contraceptive method. What options are

available to her?

A. Progestin-only implants

B. Progestin-only injectables

C. Combined hormonal methods (pill, patch, ring)

Page 31: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

WHO and US Recommendations prior to Feb 2012

Condition Combined

methods

Progestin-only

pills

Progestin-only

injectables

Progestin-

only implants

a) High risk

for HIV

1 1 1 1

b) HIV

infection

1* 1* 1* 1*

c) AIDS 1* 1* 1* 1*

*Drug interactions might exist between hormonal contraceptives and ARV

drugs; refer to the section on drug interactions.

Page 32: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

WHO Consultation, Jan 31-Feb 1, 2012

Triggered by new data, including publication by

Heffron et al, Oct 2011

Concerns about hormonal contraception and HIV

Increased risk of HIV acquisition among non-infected women?

Increased risk of HIV disease progression among HIV-infected

women?

Increased risk of HIV transmission from infected women to non-

infected male partners?

Interactions between hormonal contraception and antiretrovirals?

Page 33: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

WHO Consultation, Jan 31-Feb 1, 2012

75 global experts met in Geneva

Reviewed, biologic evidence, epidemiologic

evidence, programmatic issues, competing risks

Determined that numeric recommendations should

not change, but that a strong clarification should be

added to the recommendation for women at high risk

for HIV and use of progestin-only injectables

http://www.who.int/reproductivehealth/topics/family_

planning/hc_hiv/en/index.html

Page 34: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

WHO Recommendations Feb 2012

Condition Combined

methods

Progestin-only

pills

Progestin-only

injectables

Progestin-

only implants

a) High risk

for HIV

1 1 1** 1

b) HIV

infection

1* 1* 1* 1*

c) AIDS 1* 1* 1* 1*

* *Some studies suggest that women using progestin-only injectable contraception

may be at increased risk of HIV acquisition, other studies do not report this

association. A WHO expert group reviewed all the available evidence and agreed

that the data were not sufficiently conclusive to change current guidance.

However, because of the inconclusive nature of the body of evidence on possible

increased risk of HIV acquisition, women using progestin-only injectable

contraception should be strongly advised to also always use condoms, male

or female, and other HIV preventive measures. Expansion of contraceptive

method mix and further research on the relationship between hormonal

contraception and HIV infection is essential. These recommendations will be

continually reviewed in the light of new evidence.

Page 35: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

Next Steps for US MEC

Review evidence and WHO recommendation

Determine whether any changes need to be made for

US recommendations

Any changes will be published as an update to the

US MEC

Page 36: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

Scenario 3 21 year old female, history of multiple sexual

partners, living in an area of high HIV prevalence,

and is at high risk of contracting HIV. In addition to

strong and supportive counseling about risk

reduction and condom use, she also needs a highly

effective contraceptive method. What options are

available to her?

A. Progestin-only implants

B. Progestin-only injectables

C. Combined hormonal methods (pill, patch, ring)

D. All of the above

Dual protection

Page 37: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

Next Steps

• Work with partners: dissemination, implementation, evaluation – Color-coded chart – PDA – Wheel – CME in MMWR

• Keeping guidance up to date

• Research gaps

• US adaptation of the WHO Selected Practice Recommendations for Contraceptive Use

Page 38: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive
Page 39: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

Resources

• US MEC published in CDC’s Morbidity

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

.htm?s_cid=rr5904a1_w

• CDC evidence-based family planning

guidance documents: http://www.cdc.gov/reproductivehealth/UnintendedPre

gnancy/USMEC.htm

Page 40: US Medical Eligibility Criteria for Contraceptive Usepsep.weebly.com/uploads/7/8/5/5/7855589/curtis4_24_12.pdf · Objectives •Describe the US Medical Eligibility Criteria for Contraceptive

The findings and conclusions in this

presentation have not been formally

disseminated by the Centers for

Disease Control and Prevention

and should not be construed to

represent any agency determination

or policy.