Enhance your practice by adding Selected Practice Recommendations
Get recommendations for common contraceptive management issues
Financial Disclosure: Consulting Editor Robert A. Hatcher, MD, MPH, Author Rebecca Bowers, and Executive Editor Joy Dickinson report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Sharon Schnare, Nurse Reviewer, discloses that she is a retained consultant for Watson Laboratories and Dopomed; on the speakers’ bureau for Meda Pharmaceuticals, Merck Sharpe & Dohme Corp., and Teva Women’s Health; and on the speakers bureau and a retained consultant for Bayer HealthCare Pharmaceuticals. Melanie Gold, guest columnist, discloses that she is on the speakers bureau for Novartis Pharmaceuticals Corp. Anita Brakman, guest columnist, and Diana Taylor, RNP, PhD, FAAN, guest columnist, have no relevant disclosures.
Providers have a new clinical resource: the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 (US SPR).1 The publication provides guidance on how contraceptive methods can be used, and it focuses on how to remove unnecessary barriers for patients in accessing and successfully using contraceptive methods.
Adapted from global guidance provided by the World Health Organization, the Centers for Disease Control and Prevention (CDC) publication is meant to serve as a source of clinical support for healthcare providers. In preparing the guidance, CDC staff conducted systematic reviews of the scientific evidence for each of the topics. It also convened a 2011 multidisciplinary meeting of experts who assisted in guideline development.
While the U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC) provides guidance on who can use various methods of contraception, the US SPR provides guidance on how contraceptive methods can be used.2
"This new evidence-based guidance from the CDC will improve and streamline how we provide contraceptive services to our patients," says Andrew Kaunitz, MD, professor and associate chair in the Obstetrics and Gynecology Department at the University of Florida College of Medicine — Jacksonville. Kaunitz was one of 36 outside participants who participated in the multidisciplinary meeting.
The CDC is disseminating the US SPR in several ways, including announcements to more than 110,000 individuals signed up to receive alerts when new contraceptive guidance is released, says Kathryn Curtis, PhD, a health scientist in the CDC’s Women’s Health and Fertility Branch in the Division of Reproductive Health. (To sign up for such alerts, go to http://bit.ly/12WRuj4.) Information about the SPR is being presented at conferences of professional organizations, and it is being published in professional newsletters and journals, says Curtis. Continuing education credits are being offered as well. Go to http://1.usa.gov/RnxUKo. Under "U.S. Selected Practice Recommendations for Contraceptive Use, 2013," select "CE available at TCEO." Tools also are being developed, such as electronic resources and speaker-ready slides, says Curtis. (As resources are provided, they will be posted at http://1.usa.gov/12WO1FD.)
"We also rely heavily on our federal and professional partner organizations to get the word out to the constituents," states Curtis. "Many of our partners have sent e-blasts to members, added links to the US SPR on their websites, and are planning their own presentations on the new guidance at annual meetings."
How to use the SPR
Healthcare providers can use the US MEC and the SPR when counseling women, men, and couples about contraceptive method choice and use, and in the management of problems with contraceptive use, says Curtis. Specifically, the U.S SPR provides evidence-based guidance on how providers can best help patients initiate and continue contraceptive method use by removing unnecessary barriers to access, she states.
"The US MEC and SPR are sources of clinical guidance. Healthcare providers should always consider the individual clinical circumstances of each person seeking family planning services," Curtis says.
In the SPR, routine testing requirements have been reduced, but clinicians still need to individualize care, says Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles. "For example, routine blood pressure [BP] measurements for intrauterine devices [IUDs] is not necessary, but the day a woman with hypertension comes in to have her IUD placed, it would be good to know her BP is not 200/100," observes Nelson. "Just keep it real."
Your questions answered
The CDC guidance governs hormonal, intrauterine, surgical, and natural methods of contraception, notes Kaunitz. It offer practical advice for everyday issues encountered by clinicians, such as what to do when an woman with IUD is diagnosed with pelvic inflammatory disease (PID) and timing of repeat depot medroxyprogesterone acetate (DMPA) injections.
When a woman using an IUD is found to have PID, many clinicians immediately will remove the device as they initiate antibiotics, observes Kaunitz. The CDC indicates clinicians should treat the PID according to the Sexually Transmitted Diseases Treatment Guidelines, and it states the IUD does not need to be removed immediately if the woman needs ongoing contraception.3 If no clinical improvement has occurred at the time of clinical reassessment in two to three days, providers should continue antibiotics and, at that time, consider removal of the IUD, the guidance states.
Confusion occurs with the timing of repeat DMPA injections, Kaunitz observes. Routinely, clinicians should provide repeat DMPA injections every three months or 13 weeks. However, for patient convenience, it is fine to provide repeat DMPA injections early, notes Kaunitz.
A more common scenario is the patient returning late for her repeat injection. The CDC guidance indicates clinicians can repeat contraceptive injections up to two weeks late, or 15 weeks from the last injection, without requiring additional contraceptive protection.1 If the woman is more than two weeks late for her repeat DMPA injection, which is to say more than 15 weeks from the last injection, the guidance indicates clinicians can proceed with reinjection if it is reasonably certain that the patient is not pregnant. (See how to tell if a woman is not pregnant in box above.) Such patients will need to use additional back-up contraceptive protection for the next seven days, the guidance notes.1 (For information on what the SPR means for teens, see column, right.)
1. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. U.S. Selected Practice Recommendations for Contraceptive Use, 2013: adapted from the World Health Organization Selected Practice Recommendations for Contraceptive Use, second edition. MMWR Recomm Rep 2013; 62(RR-05):1-60.
2. Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR 2010; 59(RR04):1-6.
3. Workowski KA, Berman S. Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 59(RR-12):1-110.