important citations oral contraceptive pills (ocp’s)...breastfeeding and ocp’s ... microsoft...

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Oral Contraceptive Pills (OCP’s)

Barbara S. Apgar, MD, MS

Professor of Family Medicine

Michigan Medicine

University of Michigan Medical Center

Ann Arbor, Michigan

Important citations

1. US Medical Eligibility Criteria (MEC) for Contraceptive Use, 2016. MMWR 2016;65(3):1-108.

2. US Selective Practice Recommendations for Contraceptive Use, 2016. MMWR 2016;66 (4):1-72.

3. ACOG Committee Opinion. Understanding and Using the US Selected Practice Recommendations for Contraceptive Use, 2013. Obstet Gynecol 2013;122:1132-1133.

4. ACOG Practice Bulletin. Use of Hormonal Contraception in Women with Coexisting Medical Conditions. Obstet Gynecol 2006; 107(6):1453-68.

Women with unintended pregnancies

• Approximately 45% of all pregnancies in US are unintended.

• Higher proportions among adolescents and young women.

• Women who are racial/ethnic minorities

• Women with lower levels of education and income.

Gipson JD et al. Stud Fam Plann 2008;39:18-38.

Women with unintended pregnancies

• 50% are among women who were not using contraception at the time they became pregnant.

• 50% are among women who became pregnant despite reported use of contraception.

Finer LB et al. N Engl J Med 2016;374:843-852.

CDC 2016 MMWR 2012;61(2):1-30

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MMWR 2012;61(2):1-30

No-cost contraception of patient’s choice

• All methods of contraception offered but LARC effectiveness emphasized.

• Rate of teenage birth was 6.3/1000 in study vs 34.3/1000 in US.

• Abortion rates were < half of the regional and US rates.

• Significant reduction in abortion rates, repeat abortions and teenage birth rates.

Peipert JE et al. Obstet Gynecol 2012;120:1291-97

What about open access for OCPs?

• 68% of women at risk for unintended pregnancy

would use open access.

• 47% of uninsured women would support.

• 40% of low-income women who were not using

contraception, would use open access.

• Patients.• Worry they might lose insurance coverage.

• OTC costs (no data).

• Continuation rates are higher if given multiple packs at one time. Would they only get 1 pack at a time?

• Would they see PCP for health maintenance?ACOG Committee Opinion #544. Obstet Gynecol 2012;120:1527-8

What about open access for OCPs?

• Pharmacists.

• 85% were interested in OTC contraception

• May refuse to provide OTC for religious reasons.

• 66% concerned about reimbursement.

• Can women self-screen for contraindications?

• Biggest concern is about VTE.

• ACOG supports open access for OCPs.

ACOG Committee Opinion #544. Obstet Gynecol 2012;120:1527-8

How many OCP packs?

• Initial and return visits: 1 year supply.

• Restricting the number of packs can result in unwanted discontinuation of OCPs and risk of pregnancy.

• Greater number of pill packs associated with fewer pregnancy tests, fewer pregnancies and lower cost over 1 year.

Rosenstock JR et al. Obstet Gynecol 2012; 120:1298-305

N=7472

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Continuation rates at 12 months: LARC vs non-LARC


Satisfaction rates at 12 months: LARC vs non-LARCYoungest age group expressed less satisfaction with all methods


Medical Eligibility Criteria (MEC) for contraceptive use

• Describes who can safely use specific contraception methods.

• Provides recommendations for safety of contraceptive methods for women with various medical conditions (eg HTN, diabetes) and characteristics (eg age, parity, smoking)

US Medical Eligibility Criteria (MEC) for Contraceptive Use, 2016.

MMWR 2016; 65(3):1-108


MMWR 2016; 65(3):1-108

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Selective Practice Recommendations

WHO and CDC companion document to MEC.

Systematic reviews were conducted to assess whether a screening

test was associated with safe use.

Charts and algorithms were developed to summarize the guidance and

recommendations.

OCP's - Contraindications

• Smoking over age 35.

• Uncontrolled hypertension.

• Known thrombophilia.

• Diabetes with vascular disease.

• Migraine with aura.

• Current or personal history of venous thromboemboli, cerebral vascular or coronary disease.

• Major surgery with prolonged immobilization.

• Breast or uterine cancer.

ACOG Practice Bulletin. Obstet Gynecol 2006; 107(6):1453-1468

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Estrogen and Progestin in OCP’sCochrane update 2014

• Monophasic pills recommended as the first choice for women starting OCP's.

• Low-dose estrogen (20mcg) OCP’s cause more bleeding irregularities than > 20 mcg.

Switching from an IUD to OCPs

• If woman has had sex since the start of her current menstrual cycle and it has been > 5 days since period stated, residual sperm could be present.

• Retain the IUD for at least 7 days after OCPs are started and return for IUD removal.

• Abstain from sex or use a barrier for 7 days before IUD removal.

When can women stop OCP’s?

• ACOG and North Amer Menopause Soc (NAMS).

• Recommend that women continue contraception use until menopause (age 50-55 yrs).

• No reliable lab tests can confirm loss of fertility in women.

• FSH may not be accurate.

Pelvic exams and access to OCPs (n=1196)

• Survey to Ob-Gyn and FM physicians.

• 1/3 of OG (29%) and FM (33%) always required a pelvic exam when prescribing OCPs.

• APCs: 45% required pelvic exam.

• Older physicians more likely to require exam.

• Providers in private practice more likely to require than family planning or community clinics.

• Despite guidelines indicating exams unnecessary and

may pose barrier to contraceptive access.

Henderson JT et al. Obstet Gynecol 2010;116:1257-64.

Is bimanual exam or cervical cancer screening necessary for OCPs?

• Do Pap or cotesting if due.

• Pelvic exam does not facilitate detection of conditions for which OCPs would be unsafe.

• Delayed and immediate pelvic exam before OCPs.

• No differences in risk factors for cervical cancer or incidence of STDs, abnormal wet preps or Pap tests.

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39 year old obese (BMI 50) non smokng woman.

• Would you give her OCP’s?

Weight and OCPs

• Weight or BMI measurement are not needed to determine medical eligibility for any method of contraception because all methods can be used or generally used among obese women.

• Measuring weight or BMI might be helpful for monitoring any weight changes and counseling women who might think weight change is due to contraceptive.

Blood pressure and OCPs

• Contraindication: > 160 or >100 mm Hg or vascular disease.

• Do not use OCPs:

• Women with 140-159 or 90-99 mm Hg

• Adequately controlled HTN.

• Measure BP before starting OCPs.

• clinic or elsewhere.

US Medical Eligibility Criteria (MEC) for Contraceptive Use, 2016. MMWR 2016;

65(3):1-108.

Other screening before starting OCPs?

• Glucose: No evidence regarding outcomes among women screened or not screened before OCPs.

• Lipids: Unnecessary to screen before OCPs because of low prevalence of undiagnosed disease in women aged 22-44 years.

• No increased risk for adverse changes to lipid profiles in women with abnormal lipid levels at baseline.

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Other screening before starting OCPs?

• Liver enzymes: unnecessary because of the low prevalence of liver disease or the high likelihood that liver disease is already diagnosed.

• Thrombogenic mutations: unnecessary because not cost-effective and rarity of conditions.

• Breast exams: unnecessary in asymptomatic women; breast cancer incidence among women aged 20-49 = 72/100,000.

32 year old has type 2 DM well controlled on metformin. She is fearful

of LARC’s and wants your advice on contraception.

• Can she use OCP’s ?

Diabetes MEC 2016 Evidence: type 2 DM and OCP’s

• Development of non-insulin dependent DM in women with hx of gestational DM is not increased by use of OCP’s.

• Among women with insulin-dependent or non-insulin-dependent DM, OCP use has limited effect on daily insulin requirements and no effect on long-term DM control or progression to retinopathy.

• Lipid levels appear to be unaffected by OCPsUS Medical Eligibility Criteria (MEC) for Contraceptive Use, 2016. MMWR 2016;

65(3):1-108

22 year old has BV and uses OCP’s.

• Can she take metronidazole without using additional contraception?


MMWR 2016; 65(3):1-108

Antimicrobial Therapy MEC 2016

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ACOG Practice Bulletin. Use of Hormonal Contraception in Women with Coexisting Medical Conditions. Obstet Gynecol 2006; 107(6):1453-68.

19 year old using phenytoin for seizures.

• Can she use OCP’s?

ACOG Practice Bulletin. Obstet Gynecol 2006; 107(6):1453-1468

30 year old is using OCP’s and as been taking an SSRI for 6 months for

depression

• Should she discontinue the OCP?

SSRIs MEC 1


MMWR 2016; 65(3):1-108

Evidence: Limited clinical and pharmacologic

data do not demonstrate concern for SSRIs

decreasing the effectiveness or increasing

adverse events of oral contraceptives when

compared with women not using OCPs.

38 year old non-smoking woman has migraine headaches. She does not want

any LARC but would accept OCPs.

• Can she use OCPs?

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Evidence: Migraines and OCP use

• Women with migraines have about a 3-fold increased risk for ischemic stroke compared with non-users. Most studies do not specify migraine type or OCP formulation.

• Study specified migraine with aura: risk for ischemic stroke was increased.

• With aura, risks always outweigh benefits.

• Assume aura associated with ischemia.

• Do not use or stop if aura develops.ACOG Prac Bull. Obstet Gynecol 2006; 107(6):1453-68

US Medical Eligibility Criteria (MEC) for Contraceptive Use, 2016. MMWR 2016; 65(3):1-108

Migraines and OCP’s

• ACOG: Evid B.

• Although CV events rarely (absolute risk is low) occur among women with migraines who use OCP’s….

• Stroke is devastating.

• Consider use of progestin-only OC’s, LARC’s.

34 year old, non-smoker with controlled hypertension

• Should she use OCP’s?

US Medical Eligibility for Contraceptive Use, 2010.

22 year old breastfeeding woman.Will OCP's decrease her milk?

• Cochrane 2008.

• Poor methods, could not aggregate into meta-analysis.

• 5 trials met inclusion criteria but had methodological problems.

• No decreased milk with progestin-only.

• Decline in breast milk from combination OCP’s but high loss to follow-up.

• Insufficient to establish any effect from hormonal contraception on milk quality.

Breastfeeding and OCP’s

• Postpartum.

• Breastfeeding with supplements or no breastfeeding.

• Begin OCP's in the 3rd postpartum week.

• Full breastfeeding.

• Begin OCP's in the 3rd postpartum month (rare ovulation).

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Summary of MEC 2016

• Long acting highly effective contraception methods might be the best choice for women with conditions that are associated with increased risk for adverse events as a result of pregnancy.

• These women should be advised that sole use of barrier and behavior-based methods of contraception might not be appropriate choices because of their relatively higher typical use rates of failure.

Thanks!

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important citations oral contraceptive pills (ocp’s)...breastfeeding and ocp’s ... microsoft...

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