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Base your family planning practice on evidence-based medicine in 2010
Use U.S. Medical Eligibility Criteria for Contraceptive Use for guidance
Strive to keep your practice up-to-date in 2010 with the publication of the U.S. Medical Eligibility Criteria for Contraceptive Use.1
Just released in late May 2010, the publication provides guidance on whether women and men with particular medical conditions or physical characteristics can safely use certain methods of contraception. The guidance is based upon the World Health Organization's (WHO) Medical Eligibility Criteria for Contraceptive Use, used by reproductive health clinicians around the world.2
The recommendations have been published in the Centers for Disease Control and Prevention's (CDC) MMWR Recommendations and Reports and are available for free on the publication's web site (www.cdc.gov/mmwr). A related CDC web site (www.cdc.gov/reproductivehealth) will provide updates and supporting information to clinicians as needed.
Over time, the agency plans to add other formats, such as those accessible by personal digital assistants, as well as offer job aids and tools for family planning providers, says Kathryn Curtis, PhD, a health scientist in the Women's Health and Fertility Branch of the Division of Reproductive Health at CDC, and a co-author of the U.S. guidance. The CDC is working with many partners who provide family planning services or who represent family planning providers to disseminate and implement the new guidance, states Curtis.
In determining the scope of the adaptation of the WHO material for use in the United States, those involved in the U.S. publication identified several medical conditions that are not included in the WHO criteria, but for which U.S. providers are seeking guidance, says Curtis. "We conducted systematic reviews of the evidence regarding the safety of contraceptive method use among women with these conditions, and this evidence was considered during the process of adapting the WHO guidance for the U.S.," she explains.
The U.S. guidance uses similar categories of medical eligibility criteria for contraception use as outlined in the WHO publication:
Note the differences
Most of the CDC recommendations do not differ from WHO guidance and cover more than 60 characteristics or medical conditions, observes Andrew Kaunitz, MD, professor and associate chair in the Obstetrics and Gynecology at the University of Florida College of Medicine Jacksonville. However, some WHO recommendations were modified for use in the United States, notes Kaunitz, who served as an invited participant in the development of the U.S. publication.
The recommendations for progestin-only methods for women with a history of deep venous thrombosis (DVT) and/or pulmonary embolism (PE) are the same in the WHO and the United States Medical Eligibility Criteria (US MEC), and they are all "2s" for progestin-only methods, consistent with American Congress of Obstetricians and Gynecologists guidelines. One area in which the CDC guidance contrasts with that of the WHO is in women with acute (recent history of) DVT and/or PE, says Kaunitz. CDC's guidelines state it is appropriate to use progestin-only methods, including minipills, DMPA (depot medroxyprogesterone acetate) injections, the progestin-only implant, as well as the levonorgestrel intrauterine device, in such women. The U.S. recommendations give use of such methods in this condition as a "2," while the WHO guidance ranks such use as "3."
"It's worth pointing out that package labeling for DMPA and the implant inappropriately list a history of DVT as contraindication to use," notes Kaunitz.
Kaunitz says it is not unusual in his practice to see patients with a history of DVT who are referred for contraception. If such women choose injectable or implantable contraception, he says he makes sure they are aware that this choice is consistent with the available evidence, but not with package labeling.
Other notable recommendations from the U.S. Medical Eligibility Criteria concern use of progestin-only methods shortly after childbirth in nursing mothers, says Kaunitz. In contrast to the WHO, the CDC guidance states it is appropriate to initiate progestin-only contraceptives less than one month postpartum in nursing mothers.3
Check added conditions
In addition to the medical conditions that are included in the WHO guidance, the U.S. recommendations also address additional medical conditions that might be present in American women. Examples of additional conditions in the U.S. guidance include rheumatoid arthritis, endometrial hyperplasia, inflammatory bowel disease (IBD), bariatric surgery, solid organ transplantation, and peripartum cardiomyopathy.
Curtis gave an overview of recommendations for such added conditions during her presentation at the 2010 Contraceptive Technology conference.4 She used the following hypothetical situation to illustrate the new guidance's use: A 25-year-old female with Crohn's disease desires contraception. She previously used combined oral contraceptives and desires to restart. Is this method safe for her?
With inflammatory bowel disease, risks include relapse; thrombosis (some studies show increased risk, while others do not); malabsorption; osteoporosis; and osteopenia. All such risks might be of concern for contraceptive use, Curtis noted. Experts reviewed 10 studies, which looked at relapse rates, exacerbation, and absorption in women with IBD. Gaps in knowledge include the small total number of pertinent studies, the dearth of studies examining thrombosis risk in women with IBD using hormonal contraceptives, the lack of studies including women with IBD looking at DMPA use and risk of bone loss/fracture, and the fact that available pharmacokinetic studies only looked at women with ulcerative colitis, which affects the large bowel.
With these elements in mind, the guidance notes that for women with mild IBD with no other risk factors for VTE, the benefits of combined oral contraceptive pills, patch, and ring general outweigh the risks, yielding a "Category 2" rating. However, for women with IBD with increased risk for VTE, such as those with active or extensive disease, surgery, immobilization, corticosteroid use, vitamin deficiencies, or fluid depletion, the risks of using the combined pill, patch, or ring generally outweigh the benefits, yielding a "Category 3" rating.4
Use clinical judgment
Based on scientific evidence and expert opinion, women of reproductive age with chronic diseases and other medical conditions can safely use most methods of contraception, says Curtis. The U.S. guidance helps provide a framework for these women to work with their health care provider to choose safe and effective contraception.
While safety is an important cornerstone of contraceptive choice, many other factors, such as effectiveness, availability, acceptability, and personal preference, should be considered in determining the most appropriate contraceptive method, the publication states. Clinicians should talk with women and men seeking birth control about the full range of contraceptive options to assess which methods can best meet their needs and provide optimal protection from unplanned pregnancy.
"This is an excellent source of clinical guidance; however, as always, health care providers should consider the individual clinical circumstances of each person to find an appropriate contraceptive method," states Curtis.