By Rebecca Bowers
The American College of Obstetricians and Gynecologists has released a practice bulletin to help providers use scientific evidence to guide women with coexisting medical conditions in making the most effective choices.
- The publication aims to help clinicians use the rating system offered in the U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC). The 2016 US MEC contains more than 1,800 recommendations for more than 60 conditions in clinical practice.
- The guidance addresses topics such as use of hormonal contraception in women with a history of venous thromboembolism and contraceptive options for women of older reproductive age.
For women with coexisting medical conditions, decisions regarding contraception are critical. Chronic medical conditions can cause maternal and fetal health complications during pregnancy, which can make pregnancies that are unintended or mistimed especially problematic.1 A 2016 study indicated that among females ages 14-25 who received prescriptions for teratogenic medications, fewer than 30% also had contraceptive use documented.2 In an analysis of a nationwide healthcare claims database of reproductive-age women who were enrolled in private insurance in 2004-2011, researchers found that, despite the potential for serious pregnancy-associated maternal and fetal risks, contraceptive use among women with medical conditions was not optimal.3
The American College of Obstetricians and Gynecologists (ACOG) recently has released a practice bulletin to help providers use scientific evidence in guiding affected patients to make the most effective choices.4 The publication aims to help clinicians use the rating system offered in the U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC), published by the Centers for Disease Control and Prevention.5 The 2016 US MEC contains more than 1,800 recommendations for more than 60 conditions in clinical practice.
The US MEC is the leading resource in determining contraceptive eligibility, notes Anita Nelson, MD, professor and chair, Obstetrics and Gynecology, Western University of Health Sciences in Pomona, CA. The new bulletin provides more background information for readers, she explains.
“For example, the diagnostic criteria for migraine and migraine with aura headaches is useful,” says Nelson. “Having a separate ACOG bulletin may popularize these recommendations.”
The US MEC includes information about medical conditions and the use of contraceptive methods that are rated on a scale of 1 to 4 regarding safety. A category 1 designation indicates that there are no restrictions for using the contraceptive method, while a category 4 rating indicates that the method could present an unacceptable health risk for the patient. (See the box for an explanation of the four categories.)
Work Through the Options
Use of hormonal contraception in women with a history of venous thromboembolism (VTE) or at risk of a thromboembolic event is addressed in the new publication. Women with the following conditions associated with VTE should be counseled about nonhormonal or progestin-only contraceptives:
- Smoking and age 35 years or older;
- Less than 21 days after giving birth or 21-42 days after giving birth with other risk factors (such as age 35 years or older, previous VTE, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, body mass index of 30 or greater, postpartum hemorrhage, post-cesarean delivery, preeclampsia, or smoking);
- Major surgery with prolonged immobilization;
- History of deep vein thrombosis or pulmonary embolism;
- Hereditary thrombophilia (including anti-phospholipid syndrome);
- Inflammatory bowel disease with active or extensive disease, surgery, immobilization, corticosteroid use, vitamin deficiencies, or fluid depletion;
- Systemic lupus erythematosus with positive (or unknown) antiphospholipid antibodies;
- Superficial venous thrombosis (acute or history).5
The US MEC classifies the use of combined hormonal contraceptives in these women as category 3 (indicating that theoretical or proven risks usually outweigh the advantages of using the method) or category 4 (indicating that a condition represents an unacceptable health risk if the contraceptive method is used). Use of combined hormonal contraceptives is contraindicated in women with known familial thrombophilias, placing this condition in category 4.
How can clinicians counsel such patients in selecting appropriate contraceptive methods? Counseling for progestin-only or nonhormonal methods such as the copper intrauterine device (IUD) is similar to all contraceptive counseling, says Rebecca Allen, MD, MPH, associate professor of obstetrics and gynecology in the Warren Alpert Medical School of Brown University.
“It is important to elicit the patient’s values and desires regarding a contraceptive method in terms of what matters most to the patient, for example, efficacy, bleeding profile, or ease of use, as well as inquiring about past contraceptive history and obtaining a full understanding of their current medical condition,” says Allen, a co-author of the current bulletin. “Women who value having monthly withdrawal bleeds should be steered towards the copper IUD if all else is equal.”
For progestin-only methods, the 52-mg dose levonorgestrel IUD can offer lighter or no withdrawal bleeding and treatment of heavy menstrual bleeding, which may be an issue if the patient is using anticoagulants, states Allen. The etonogestrel implant can cause unpredictable bleeding and spotting, but this spotting typically is light for most women. The progestin-only pill is effective with strict daily adherence, but also may cause irregular bleeding and spotting, she notes. Depot medroxyprogesterone acetate requires injections every three months, and ultimately can lead to high rates of amenorrhea with continued use. Barrier methods also are an option for motivated patients, states Allen.
Consider Options for Perimenopause
What are the contraceptive options for women of older reproductive age? There are no contraindications to the use of any hormonal contraceptives based on age alone, says Andrew Kaunitz, MD, associate chair of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine-Jacksonville and medical director of the UF Health Women’s Specialists – Emerson. That acknowledged, age is an important risk factor for many medical conditions, he notes.
For instance, among women of older reproductive age (above age 35), those who smoke, have hypertension, are significantly obese, or have migraine headaches with aura should avoid combination estrogen-progestin contraceptives (which the US MEC categorizes as 3-4 for these conditions), states Kaunitz. In contrast, healthy, nonsmoking women without specific risk factors for cardiovascular disease can safely continue combination hormonal contraceptives until ages 50-55.
“In my practice, women without contraindications to combination contraceptives and who continue to need contraception often choose to continue their method until age 55, when the likelihood of fecundability becomes very low,” observes Kaunitz. “Although often performed, checking FSH levels is not useful in this clinical setting. Upon achieving age 55, some women in my practice choose to seamlessly transition from combination contraceptives to estrogen-progestin menopausal hormone therapy.”
Perimenopausal women who are appropriate candidates can benefit not only from effective contraception provided by combination methods, but also from the positive effect on bone mineral density, prevention/treatment of abnormal uterine bleeding, suppressed vasomotor symptoms, and the reduced future risk of ovarian and endometrial cancer associated with using combined hormonal contraceptives, Kaunitz comments. The 52-mg levonorgestrel IUD, which can be used regardless of the presence of contraindications to combination hormonal contraceptives, is effective in managing abnormal uterine bleeding, which is common among women of older reproductive age, he states.
- Teal SB, Ginosar DM. Contraception for women with chronic medical conditions. Obstet Gynecol Clin North Am 2007;34:113-126.
- Stancil SL, Miller M, Briggs H, et al. Contraceptive provision to adolescent females prescribed teratogenic medications. Pediatrics 2016;137:1-8.
- Champaloux SW, Tepper NK, Curtis KM, et al. Contraceptive use among women with medical conditions in a nationwide privately insured population. Obstet Gynecol 2015;126:1151-1159.
- [No authors listed]. ACOG Practice Bulletin No. 206: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol 2019;133:e128-e150.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65:1-103.