PATIENTCENTERED CONTRACEPTION Updates on the Evidence Objectives Discuss

PATIENT-CENTERED CONTRACEPTION: Updates on the Evidence

Objectives • Discuss rates of unintended pregnancy and contraceptive use in the US • Apply evidenced-based guidelines to contraceptive provision using the CDC MEC • Provide contraceptive options using patient centered care

Nearly half (45%) of pregnancies in the US are unintended Unintended – Mistimed 27% Intended 55% Unintended – Unwanted 18%

Unintended pregnancy by consistency of contraception use Consistent use 5% Nonuse 54% Inconsistent use 41%

One year failure rates Consistent use 5% Nonuse 54% Inconsistent use 41%

Pill F Sterilization M Condoms IUD M Sterilization Withdrawal Injectable Vaginal Ring Fertility Awareness Implant Patch EC Other None Contraceptive Methods in the US 25. 00% 20. 00% % of women at risk of unintended pregnancy* 15. 00% 10. 00% 5. 00% 0. 00%

THE MEC US Medical Eligibility Criteria (MEC) CDC recommendations for specific contraceptive methods with certain medical conditions

There’s an app for that: - Can be downloaded on i. OS and Android operating systems (https: //www. cdc. gov/mobileapp. html)

MEC Categories of Safety

Another helpful app… • Contraceptive Point-of-Care App

CASES In contraception management

Yolanda • 16 year old G 0 P 0 presents with UTI symptoms • Had unprotected sex 4 days ago • Urine pregnancy test is negative What do you do next?

Opportunity knocks! • Get a medical history • Ask about contraceptive or preconception needs

Emergency Contraception • Factors that will affect the efficacy of the emergency contraception (EC) pill: – LMP – Timing of last instance of unprotected sex – BMI

Yolanda choses her EC • Yolanda chooses Ella • But also wants to start contraception • When should she start?

Reproductive Health Access Project: Quick Start Algorithm

Contraceptives: What is needed before providing? Pap smear Pelvic/breast exam STI testing Hemoglobin Medical history REQUIRED NOT REQUIRED Blood pressure RECOMMENDED Stewart F, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA. 2001; 285: 2232 -9.

What about estrogen? • Estrogen absolute contraindications: – Migraine with aura – Uncontrolled hypertension – History of DVT/PE – Tobacco use*

What about Yolanda’s UTI?

Medication interactions

What does Yolanda want?

Impact of Choice Pariani S, Heer D, van Arsdol M. Does choice make a difference to contraceptive use? Stud Fam Plann 1991; 22(6): 384 -390.

Yolanda decides to start the pill • Does it matter which pill she starts?

The patch and ring are also similar options…

How many refills should we give Yolanda? Should we dispense one at a time?

Should Yolanda get a prescription for EC too?

Mari • • 17 year old, G 0 P 0 Doesn’t want to get pregnant until she finishes school Wants a contraception that she can hide from her mom Hates remembering to take pills • What are her choices?

Highly effective methods – not user dependent Effectiveness Contraceptive Typical-use pregnancy rate Perfect-use pregnancy rate Highly effective IUDs 0. 8 – 2% Injectable 0. 1 – 0. 3% Implant 0. 1 – 0. 3% Sterilization 0. 1 – 0. 3%

Progestin-Only Injection

Depo-Provera and Bone Density What are the real risks for teens? • Exercise and diet are more important Centers for Disease Control and Prevention. U. S. Selected Practice Recommendations for Contraceptive Use, 2013. MMWR 2013; 62. http: //www. cdc. gov/mmwr/pdf/rr/rr 62 e 0614. pdf. June 14, 2013.

Intrauterine Devices

IUD considerations • • Nulliparity STI Screening Timing of placement Desire for menses

IUD Considerations • Family planning timeline • Medication cost • Risk of ectopic

Progestin Implant • • • Highly effective and rapidly reversible Discreet Duration: 5 years Can be used during lactation Causes spotting

Jamie • Jamie is a 28 year old transgender man. He is interested in preventing pregnancy, and has both male and female partners. He has not had any surgeries, and is not on hormone therapy but may be interested in the future. • What are Jamie’s options?

Office Barriers to Adherence

Inconsistent Pill Use: Linked to low satisfaction with clinician and low continuity of care Percent of pill users who missed one or more pills during the past three months Landry, David. Public and private providers involvement in improving their patients contraceptive use Contraception 2008 Jul 78 (1) 42 -51.

Feeling Unable to Reach a Provider With Questions is Linked to Contraceptive Non-Use % of at-risk women experiencing contraceptive non-use in the past year Landry, David. Public and private providers involvement in improving their patients contraceptive use Contraception 2008 Jul 78 (1) 42 -51.

Take home message: Be proactive with contraception! • Ask about contraceptive or preconception needs at all types of visits • Discuss all methods - always honor a patient’s choice • De-link pap smears from contraception prescriptions • Prescribe 1 year supply with 3 packs at a time • Use Quick Start