Transcript Complicated Contraception

Alexandra Hall MD [email protected]
Beth Kutler FNP
[email protected]
Cornell University
 Understanding the Data
 The New Pap Smear Guidelines
 The New Medical Eligibility Criteria
for Contraceptive Use
 Update on STI Treatment and Diagnosis
 What’s New in Emergency
Contraception
Understanding …. and Explaining the Data
Explaining Risk


Absolute Risk
Attributable Risk

Relative Risk
Absolute Risk
The percentage of people in a group who
experience a discrete event
Number of events experienced
Total exposure time of people at risk
Example of Absolute Risk
The “pill scare” of 1995…
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
Of 100,000 women using third generation progestins
(desogestrel, norgestimate), 30 people developed a VTE
(venous thromboembolic event) per year
Absolute Risk = 30 per 100,000 women
years (.03 %)
Attributable Risk


The difference in risk between those exposed
and those not exposed
Reflects extra risk associated with exposure
Risk in exposed – Risk in unexposed
Example of Attributable Risk



The absolute risk of VTE in women who took second generation
OCs (norgestrel, levonorgestrel) was 15 per 100,000 woman
years compared with 30 per 100,00 woman-years in those using
third generation OCs.
The attributable risk of VTE in women taking third generation
OCs is 15 per 100,000
30/100,000 - 15/100,000= 15/100,000
(.015%)
Relative Risk


Frequency of the outcome in the exposed group
divided by the frequency of the outcome in the
unexposed group.
Reflects the likelihood of developing an outcome
based on an exposure
Relative Risk Example
(30/100,000)
(15 / 100,000)
Absolute risk of taking third generation OCs
Absolute risk of taking second generation OCs
=2
Interpreting RR
Relative Risk
1.0
Interpretation
No increase in risk of outcome
in exposed group compared with
unexposed group
>1.0
Increased risk of outcome in
exposed group
<1.0
Decreased risk of outcome in
exposed group
Women taking 3rd generation OCs had a risk of VTE two times that of women
taking second-generation OCs.
Confidence Interval


Confidence Intervals are a way of taking data
from a sample and saying something about the
population from which the sample was drawn.
If the value 1.0 is in the range of the confidence
interval, it can be concluded that the data is not
statistically significant
Odds Ratio


Quantifies risk for case-control studies
in the same way that relative risk
quantifies risk for cohort studies
Frequently seen in medical studies
Pap Guidelines
What was ACOG thinking?!
Pap Screening for Cervical Cancer
• Is Effective (1)
– Cervical CA incidence has declined more than 50% since 1975 due to
the introduction of pap screening programs
• 1975: 14.9 per 100,000 women
• 2006: 6.5 per 100,000 women
– Mortality rates have similarly declined
• But only if you do it (2)
– 50% of those women diagnosed with cervical cancer have never been
screened
– Another 10% have not had a Pap within the past 5 years before
diagnosis
– 25% of cancer cases are in women over age 65 (30% of women over
age 60 report no pap in past 3 years)
– Uninsured, ethnic minorities (particularly Hispanic and Black
Americans) and poor women (esp rural) are also disproportionately
underscreened
(1) http://seer.cancer.gov.csr.1975_2006
(2) http://consensus.nih.gov/1996/1996CervicalCancer102PDF.pdf)
START SCREENING AT AGE 21,
REGARDLESS OF COITARCHE
Adolescents have a very high rate of
HPV infection
• Ho GY et al 1998 NEJM
– 608 women at New Brunswick State, NJ
– 6 month intervals for 3 years
– Cumulative incidence of HPV was 43%
• Woodman et al Lancet 2001
– 1075 women aged 15-19, initially HPV neg
– 6 month intervals for 3 years
– Cumulative incidence of HPV was 44%
Adolescents have a very high rate of
HPV infection
• Brown et al, J Infectious Dis 2005
– 60 adolescents aged 14-17, inner city, 85% Afr. Am.
– Q3 month exam + swab, weekly self-swab x 2 years
– Cumulative prevalence 82%
• Winer et al, Am J Epidemiol 2003
– 603 college students in Washington State over 10
years
– Q4 month visits for 4 years for most women
– 24-month cumulative incidence was 32%
– 60-month cumulative incidence was 60%
Cumulative HPV incidence among sexually active
women who were HPV negative at enrollment
Shouldn’t we be worried?
NOPE
Most adolescents will clear HPV
spontaneously
• Ho GY et al 1998 NEJM (college in NJ)
– Median duration of infection was 8 months
• Moscicki et al J Pediatrics 1998
– 618 young women positive for HPV, Q 4 month pap,
colpo, HPV
– 70% of women cleared HPV within 24 months
Most adolescents will clear HPV
spontaneously
• Brown et al, J Infectious Dis 2005 (teens)
– Average duration of HPV infection was 168 days
Most adolescents will clear HPV
spontaneously
• Insinga et al, Cancer Epidemiol Biomarkers
Prev 2007
– 2391 women aged 16-23 in HPV vaccine trial
placebo arm
– Q6 mo eval x 4 years
– Mean durations for HPV 16 and 18 were 18 and 16
months respectively
– 85-90% cleared within three years
Insinga et al
Cytologic (pap) abnormalities also
spontaneously clear in adolescents
• Moscicki 2004 Lancet, 187 women aged 13-22
– Median follow-up of 61 months
– 61% of LSIL regressed at 12 months
– 91% regressed by 36 months
Cytologic (pap) abnormalities also
spontaneously clear in adolescents
• Winer et al, J Infectious Dis 2005 (college)
– Mean duration of LSIL was 5 months
– 86% cleared their SIL
– less than 9% developed CIN 2/3 in 4 yrs
Even histologic dysplasia will
spontaneously clear in adolescents
• Moore 2007 AJOG
– 177 Adolescents with biopsy-proven CIN 2
– Given opportunity to choose LEEP or observation
– Followed for 18-26 months
Even histologic dysplasia will
spontaneously clear in adolescents
Fuchs 2007 J Pediatr
Adolesc Gyn
•
•
•
•
•
Adolescents with CIN2
Observed, not treated
39% regr at 1 yr
50% at 2 yrs
75% at 3 yrs
Even histologic dysplasia will
spontaneously clear in adolescents
Ok, but what about those 10-15% whose HPV
or dysplasia didn’t clear within 3-4 years?
NO WORRIES
Cervical Cancer takes time to develop
• Is a result of PERSISTENT HPV infection
• Adolescents get a lot of HPV, BUT in the majority, it
does not persist
• In those in whom it does persist, cervical cancer
takes years to develop (analogy to colon cancer)
• Remember, in the studies cited, none of the women
who were simply observed (including the 5% who
progressed) developed cancer
• Therefore, cervical cancer is virtually non-existent in
adolescents
Cervical CA is almost nonexistent
under age 21
Watson et al, Burden of cervical cancer in the United States 1998-2003. Cancer 2008
SEER Cervical Cancer Data
(Rates per 100,000
women)
Comparison of Cancer Incidence in
Adolescents (rate per 100,000)
12
9.9
10
Cervix
Breast
8
Testicle
Hodgkins
6
4.4
3.5
4
1.8
2
0
3.1
2.9
2.1
age 14-19
www.seer.cancer.gov
Leukemia
2.4 2.6 2.3
1.6
0.3
0.1 0.1
NHL
Brain/CNS
0.9
0.8
age 20-24
Colon
But can’t we just screen anyway?
•
•
•
•
It’d make me feel a lot better.
(I know she’s been having sex for years!)
And it’s just a pap smear!
I have to do a pelvic to screen for STI’s anyway, right?
Wrong!
• And don’t you have to do a pap smear before you
prescribe birth control pills?
NO!
• I mean really, what harm can it do?
Unnecessary screening and treatment
can have significant morbidity
• Cost, hassle
• Fear of exams & fear of providers = barrier to accessing
sexual health care (contraceptive counseling and
provision, STI counseling and testing, vaginal health)
• “Emotional impact of labeling an adolescent with both
a sexually transmitted infection and a potential
precancer must be considered because adolescence is a
time of heightened concern for self-image and
emerging sexuality.” (ACOG Practice Bulletin)
• Adverse obstetrical outcomes in a population whose
childbearing years are still ahead of them
Adverse OB outcomes from cervical cancer screening and
resultant treatment - Kyrgiou Lancet 2006
So….
• Screening for a disease that practically doesn’t
exist in that age group (under 21) does not
make sense
• And it can cause unnecessary grief and harm,
as well as cost
Start screening at 21
In short, we don’t want to know what’s
going on before then because it will
probably go away on its own!
(And we’re more likely to cause unnecessary harm than
we are to find significant disease.)
All we are saying… is give teens a chance!
SCREEN EVERY TWO YEARS
(AGES 21-29)
AFTER AGE 30, IF 3 CONSECUTIVE
NORMALS, SCREEN EVERY 3 YEARS
Exceptions
• The following groups typically need annual
pap screening due to increased risk of CIN:
– HIV positive
– Immunosuppression (transplant recipients)
– DES exposure (not relevant to student health)
– Previously treated for CIN2, CIN3, or Cancer
30-Somethings are different
from 20-somethings!
• More likely to be monogamous (not being
exposed to HPV, or at least not to new HPV)
• More likely to have already had HPV infection at
some point and perhaps have some immunity
• Less likely to be able to spontaneously clear a
new HPV infection
• Overall have a higher incidence of cervical cancer
(likely reflecting persistence of disease that began
in their 20’s)
Going the distance: How often to screen?
• How predictive is a normal pap smear?
• For how long after a normal pap smear can you
feel reasonably confident that you haven’t
developed cervical cancer?
• Depends on two factors:
– Sensitivity of the pap (how much faith can you put in a
normal one)
– Virulence or aggressiveness of HPV/cervical dysplasia
(how long does it take to turn really bad?)
Going the distance: How often to
screen?
• In the past 10 years, many studies have been
conducted to try to answer this question,
thanks, in large part, to a study done 15 years
ago…
Cancer 1987, Eddy
The Frequency of Cervical Cancer Screening
Comparison of a Mathematical Model with Empirical Data
Found that previous models under-estimated the
effectiveness of screening at less than annual
intervals, spurred interest in revisiting the wisdom of
annual screening.
Sawaya 2000 Obstetrics and Gynecology
Prospective cohort study of 128,000 women in the CDC Breast/Cervical Cancer
Program
Sawaya 2000
Prospective cohort study of 128,000 women in the CDC Breast/Cervical Cancer
Program
No statistically significant difference in rate of high grade
abnormalities among the different screening intervals.
Sasieni Br J Cancer 2003
Case-Control study of 1200 women with cancer and 2400 matched
controls
Sasieni Br J Cancer 2003
Case-Control study of 1200 women with cancer and 2400 matched
controls
• >938,000 women under age 65
• CDC National Breast and Cervical Cancer’s Early Detection
Program
– Provides pap screening to poor and low-income women
– Low SES is, in itself, a risk factor for cervical cancer so this group may
even have a slightly higher incidence of dysplasia than the general
population
• Looked at protective value of number of previous normal paps
Prevalence of CIN (in %)
0 prev nl pap
1 prev nl pap
2 prev nl pap
3 prev nl pap
NEJM 2003
• If you are less than 30:
– and have had one negative pap, the likelihood of
having cancer is virtually zero, but we knew that
already, as the overall risk of cancer in that age group
is so low.
– having had 2 or 3 previous normal paps is not more
“protective” against CIN 2 or 3 than having had one
previous normal pap.
• If you are 30-45:
– your risk of cancer is 0.01%, or 1 in 10,000.
– the more previous normal paps you have had, the
more “protected” you are from developing CIN 2 or 3.
NEJM 2003
Projected numbers for each 100,000 women
paps
colpos
# cancers
Depending on
how CIN 2 will
act
NEJM 2003
Risk of Cancer:
Annual Screening
Every 3 year screening
Age 30-44
2 in 100,000
5 in 100,000
Age 45-59
1 in 100,000
2 in 100,000
Age 60-64
1 in 100,000
1 in 100,000
• Overall, compared with annual screening for three years,
screening performed once 3 years after a normal in women
who have had >3 normals is associated with an average
excess risk of 3 in 100,000
• To avert one additional case of cancer by screening 100,000
women (aged 30-44) annually rather than every 3 years:
– 69,665 extra pap smears
– 3861 extra colposcopies
Sasieni BMJ 2009
Case-Control study of 4000+ women with cervical cancer, each matched to two controls
Looked at risk of cancer depending on whether last screen was 1-3 y. ago vs 3-5 y. ago
Sasieni BMJ 2009
• Negative screening in your 20’s is not really all that
“protective” – doesn’t predict a lower risk of getting
cervical cancer
– This makes sense due to likelihood of new incident HPV
infection from new sexual partners and overall very small
risk of cancer in this age group
• Screening in early 30’s, however, does give
meaningful predictions of decreased risk
– If you don’t have HPV now, you’re less likely to get it
anytime soon
When to screen
• ACOG guidelines reflect the data
– If 21-29, due to increased risk of new HPV infection
and lower likelihood of regression than in adolescents,
and data that shows that previous negative paps are
somewhat “protective” against CIN 2/3, but not as
“protective” against invasive cancer, screen every two
years to be safe (even though the overall incidence of
cancer is still really low)
– Over age 30, if have had three normals, it is very safe
to screen only every 3 years
So, as long as there are no contraindications to
“relaxed” screening (HIV, immunosuppression, h/o
high grade dysplasia)…
Age 21-29: pap every other year
Age>30: pap every 3 years once has
had 3 consecutive normals
My (own personal) Strategies
• Tell patients, ok so you’re an odd (or even) number year pap. (helps
them to remember which years they need a pap)
• Still recommend annual exams, especially for sexually active women
–
–
–
–
–
Contraceptive management
Sexual and Vaginal health
General health concerns
Health habits (caffeine, alcohol, drugs, exercise, sleep)
No internal exam unless symptomatic (can do urine for chlamydia
screening)
– Beth does usually do an internal exam and bimanual
– Usually do external genital exam (practice, surprising number of
surprises)
• Make sure to obtain prior records and not rely on patient report of
when last pap occurred or the actual result
Reminders
• For pap management guidelines, visit:
– www.asccp.org
– Click on: Consensus guidelines - cytologic
abnormalities - download pdf
Reminders
• No endocervical cells
– Just repeat in one year for most women
– Repeat in 6 months for
• Previous abnormal pap of >ASCUS without 3 subsequent
negative paps, at least one of which had ECC
• Previous pap with unexplained glandular abnormality
• Positive HR HPV test within past 12 months
• Clinician inability to clearly visualize and/or sample the
cervix
• Immunosuppression
• Insufficient previous screening (not participating in at least
every 2 year screening)
Reminder
• Cervicitis / Inflammation / partially obscured
– Repeat in 12 months for most women
– Repeat in 6 months for
• Previous abnormal pap of >ASCUS without 3 subsequent
negative paps, at least one of which had ECC
• Previous pap with unexplained glandular abnormality
• Positive HR HPV test within past 12 months
• Clinician inability to clearly visualize and/or sample the
cervix
• Immunosuppression
• Insufficient previous screening (not participating in at least
every 2 year screening)
• Similar obscuring factor in consecutive pap tests
Reminder
• Unsatisfactory pap
– It’s like not having done the pap at all!
– Repeat within 2-4 months
WHO Medical Eligibility Criteria
 Provides guidance regarding whether women with certain
medical conditions, characteristics or exposures can safely
use specific contraceptive methods
 Contains over 1800 individual recommendations addressing
18 contraceptive methods and over 160 medical conditions and subconditions
http://www.who.int/reproductivehealth/publications/mec/
MEC full guidelines and MEC wheel from WHO
Recommendations
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Category 1: No Restrictions
Category 2: Generally Use
(Benefits usually outweigh risk)
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Category 3: Usually Not Recommended
(clinical judgment and continuing access to clinical
services are required for use)

Category 4: Absolute Contraindication
US Medical Eligibility Criteria for Contraceptive Use, 2010
 Published May 2010
 First time CDC has issued national guidance on contraceptive practice
 Systematic reviews of the scientific evidence for each of the WHO
recommendations considered for adaptation and each of the medical
conditions considered for addition
 The vast majority of the US guidance is the same as the WHO
guidance. Modification were made to WHO recommendations for six
conditions and recommendations were developed for six new medical
conditions
http://www.cdc.gov/reproductivehealth/unintendedpregnancy/USMEC.htm
New Medical Conditions in CDC MEC
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History of bariatric surgery
Peripartum cardiomyopathy
Rheumatoid arthritis
Endometrial hyperplasia
Inflammatory bowel disease
Solid organ transplantation
Adaptations to WHO recommendations
 Breastfeeding and hormonal
contraception
 Postpartum IUD insertion
 Valvular heart disease and IUDs
 DVT/PE and hormonal
contraception
 Ovarian cancer and IUDs
College Concerns
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Obesity
Hypertension
Inflammatory Bowel
VTE
Smokers
Headache
Drug interactions
Drug Interactions
Anticonvulsantsphenytoin
barbituates
primidone
topiramate
oxycarbazepine
carbmazepine
Lamotrigine
Category 3 for CHC and POP
Category 2 for Implanon
May decrease contraceptive efficacy
Category 1 all other methods
Category 3 CHC
CHC use may decrease effect of lamotrigine
when used as monotherapy
Category 1 all other methods
Rifampicin or rifabutin
Category 3 CHC and POP
Category 2 Implanon
Contraceptive efficacy may be reduced
Antiretroviral Therapies
Many interactions- look them up
Broad Spectrum Antibiotics
Antifungals
Antiparasitics
All Category 1 for all methods
Don’t forget- St John’s Wort !
Any contraceptive failure while using antibiotics is more
likely related to…
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GI upset associated with antibiotics
Missing pills due to increased
medication taking demands
Confusion regarding effectiveness
Headaches
Recommendations are based
on accurate diagnosis of type
of headache
Non-Migrainous Headaches
Approximately 90% of all headaches are not migraines (eg, tension or
muscle-contraction headache)
Category 1 for all methods
Category 2 for combined hormonal contraception ( CHC) if woman
develops non-migrainous headaches while using
Migraine without aura, age <35
Category 2 for initiation of CHC
Category 3 if develops migraines while using CHC
Migraine without aura, age >=35
Category 3 for initiation of CHC
Category 4 if develops migraines while using CHC
All other contraceptive methods are category 2 or 3
Migraine with aura, any age
Migraine with aura, characterized by focal neurological deficits before and
during the attack, affects 30% of migraine sufferers
Category 4 for initiation or continuation of CHC
Category 2 for initiation of all other methods (except paraguard)
Category 3 if develops migraine while using other methods
Why ?
Pooled RR of ischemic stroke:
Migraine
Migraine
Migraine
Migraine
(any) women <45 = 2.16
with aura = 2.27
without aura = 1.83
(any) and COC use = 8.72
BMJ,doi:10.1136 Dec 2004
WHO studies found a statistically significant increase in the risk of ischemic stoke,
but not hemorrhagic stroke, among CHC users who experienced migraine with aura
(OR 3.0 95% CI 1.3-11.3)
A nonsignificant increase was found in CHC users who reported migraine without
aura (OR 3.9 95% CI 0.7-14.8)
We offer women their choice of all progestin-only methods and IUD
Hypertension
For all categories of hypertension,
recommendations are based on the assumption
that no other risk factors exist for cardiovascular
disease (ie. smoking, hyperlipidemia, diabetes)
Adequately controlled hypertension
Category 3 for CHC
Category 1 or 2 for all other methods
* COC ( 30EE, 150 lvg) increases SBP 8 mm Hg, DBP 6
mmHg on average
Elevated blood pressure levels (properly taken measurements)
140-159/ 90-99
Category 3 CHC
>= 160/ >= 100
Category 4 CHC
Category 3 DMPA
All other methods are category 1 or 2
Why ?
RR of hemorrhagic stroke is 1.2 for nonsmoking CHC users, 1.8 for those with mild or
controlled hypertension and 25.7 for users with severe hypertension
WHO Collaborative study of Cardiovascular Disease and Steroid Hormonal Contraceptive Lancet 1996
Smokers
Age <35 category 2 CHC
category 1 all other methods
Age >=35, < 15 cigs/day
category 3 CHC
category 1 all other methods
Age >= 35, >= 15 cigs/day
category 4 CHC
category 1 all other methods
Cardiovascular mortality attributable risk
to coc use:
In young nonsmokers= 1/370,000
In young smokers= 1/100,000
In older smokers = 10/100,000
Inflammatory Bowel Disease
Ulcerative colitis, Crohn’s disease
Category 2/3 for CHC
Category 2 - Women with mild IBD and no other risk factor for VTE
Category 3- Women at increase risk for VTE (those with extensive disease, steroid use,
vitamin deficiencies, fluid depletion
Category 2 -for POP and DMPA
Category 1- IUDs and Implanon
Absorption of coc’s among women with mild UC was similar to absorption among
healthy women. May not apply to women with Crohn’s or extensive bowel resections
Venous Thromboembolism
Risk factors
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Obesity
Previous venous compromise
Immobilization
Factor V Leiden Defect (30% of all VTE)
CHC Use
RatesYoung women
4-5/100,000
Pregnant women 123/100,000
Postpartum
320/100,000
Low dose CHC use 20-60/100,000
History of DVT/PE
Higher risk of recurrence
(1 or more risk factors)
Category 4
History of estrogen-associated DVT/PE
Pregnancy associated DVT/PE
Idiopathic DVT/PE
Known thrombophilia, including antiphospholipid syndrome
Active cancer
History of recurrent DVT/PE
Low risk for recurrence
(no risk factors)
Category 3
Weight Concerns
Gaining weight on method
Method Efficacy due to higher body weight
VTE risk due to higher body weight
CDC MEC: BMI >= 30
category 2 for CHC
category 2 for DMPA use when <18 yo and BMI >30
obese teens more likely to gain weight with DMPA
Category 1 all other methods
• 3 lb average gain - all CHC
• 5 lb cumulatively with DMPA
• Decrease effectiveness patch > 90 Kg (though still better than condoms)
• No decrease effectiveness with Nuva Ring, IUD
• Implanon- Not studied in greater than 130 % IBW (BMI>30)
• Decreased effectiveness with CHC ?
Body mass index, weight, and oral contraceptive failure risk.
Holt VL; Scholes D; Wicklund KG; Cushing-Haugen KL; Daling JR Obstet
Gynecol 2005 Jan;105(1):46-52.
N= 248 Risk of pregnancy was nearly 60% higher in BMI >27.3 = OR 1.58
“Suggest that being overweight may increase the risk of becoming pregnant while
using OCs. If causal, this association translates to an additional 2-4 pregnancies per
100 woman-years of use among overweight women, for whom consideration of
additional or effective alternative contraceptive methods may be warranted.”
Follow-up study… substantiated overall higher failure rates, did not claim any dosedependent relationship
The Role of Body Weight in Oral Contraceptive Failure: Results from the
1995 National Survey of Family Growth .
Annals of Epidemiology , Volume 15 , Issue 7 , Pages 492 - 499
L . Brunner , C . Hogue
Women with a BMI ≥ 30 had a statistically significant increased risk of
having an OC failure as compared to women with BMIs of 20 to 24.9
(OR = 1.80, 95% CI, 1.01- 3.20). However, after adjustment for age,
marital status, education, poverty, race/ethnicity, parity, and dual
method use, this increased risk was attenuated and no longer
statistically significant (OR = 1.51, 95% CI, 0.81- 2.82). Increasing
body weight was not associated with an increased risk of OC failure in
the unadjusted or adjusted models.
Retrospective study adjusted for confounding factors= no increased risk.
Body weight and risk of oral contraceptive failure.
Holt VL; Cushing-Haugen KL; Daling JR
Obstet Gynecol 2002 May;99(5 Pt 1):820-7.
N= 755 retrospective questionnaire. Women greater than 70.5 kg = RR 1.6
Obese Very low dose OC users = RR 4.5
“Suggest that body habitus may affect metabolism sufficiently to
compromise contraceptive effectiveness. Consideration of a
woman's weight may be an important element of OC prescription.”
Failures were highest in women >154# who use lower dose formulas
Contraceptive Technology 2007 recommends against routinely
prescribing high-dose COC to obese women due to VTE risk. It may
be better to decrease or eliminate the pill free interval for heavier
women
ACOG :
Advises caution in the use of estrogen-containing methods in obese
women (BMI>30) who are over age 35 due to VTE risk
Women weighing more than 176 # may have an increased risk of
unintended pregnancy when using low- dose COC
Practice Bulletin 351:November 2006
Heavier women have higher rates of
VTE, the potential for decreased efficacy
with lower dose COC’s and higher risk
for pregnancy related complications…..
With few exceptions, intrauterine devices offer the safest, most effective method for
many women- especially those with coexisting medical conditions
But … what about…
Risk of PID ?
The risk of PID postinsertion (9.7/1000) fell to background levels (1.4/1000) 20 days
after insertion and remained at that level at 8 year follow-up (Cochrane Database Syst Rev
200;(2). The irritative, mucous plugging effect of the IUD string may provide enhanced
protection from PID when exposed to STIs
CDC MEC= Category 4 for IUD placement with existing GC or CT
Category 2 if GC/CT acquired with IUD in place
Nulliparity ?
Once STIs were established as the causal agents for PID, the restriction against use of
IUC for nulliparous women had no basis in evidence. In 2005 Paraguard removed “having had at
least one child” from their labeling for recommended patient profile.
CDC MEC= Category 2 for nulliparity
History of Ectopic Pregnancy
?
The IUD significantly reduces a woman’s risk of an ectopic pregnancy, compared with
ectopic risk with no contraception. Pregnancy that do occur with an IUD in place (.14/100
women) are more likely to be ectopic
CDC MEC= Category 1 for past history of ectopic pregnancy
A 19 yo sophomore with a history of severe dysmenorrhea and iron
deficiency anemia. She gets ”bad headaches” that make her nauseous and
photophobic- usually with her periods. She denies any “warning sign” of her
headaches or symptoms such as visual changes or facial numbness. She is
requesting contraception.
What are her contraceptive options ?
18 year old Junior who had both Chlamydia and an ectopic pregnancy last year.
She is sexually active now and is frequently forgetting her pills. Her partner will
not use condoms.
What are her contraceptive options ?
A 24 yo grad student wants to start contraception. Her mother had breast
cancer. She smokes about 10 cigarettes a day and has irritable bowel syndrome
What are her contraceptive choices ?
34 year old G0P0 graduate student. She has a BMI of 32 and
has a blood pressure on 3 separate readings of 145/92. She
developed migraines without aura while using a COC 10 years
ago.
She is taking Dilantin for a recently diagnosed seizure disorder
and was told by her home healthcare provider to “get on birth
control” because she shouldn’t get pregnant while taking this
medication.
What are her contraceptive options ?
STI Update
CDC has not yet published the 2010
Guidelines, so here’s a taste of what
might be new…
Expedited Partner Therapy
• Expedited Partner Therapy (EPT) is the clinical
practice of treating the sex partners of
patients diagnosed with chlamydia or
gonorrhea by providing prescriptions or
medications to the patient to take to his/her
partner without the health care provider first
examining the partner.
Why would we do this?
• Between 12 and 26% of young women diagnosed
with chlamydia will be re-infected within 12
months
• Risk factors are young age (<25) and untreated
partners
– Risk for recurrence was due to resumption of sexual
activity, not due to new partners or other sexual
behavior risks (Whittington 2001)
• Studies have shown EPT to be safe and effective
Trelle, BMJ 2007, Improved effectiveness of partner notification for patients with
sexually transmitted infections: Sytematic review.
EPT is supported by CDC, AMA, AAP,
and the Society of Adolescent
Medicine
http://www.jahonline.org/article/S1054-139X(09)00205-5/fulltext
Legal Status of Expedited Partner Therapy
How do you do it?
• Incident patient must have confirmed chlamydia or gonorrhea
• Prescription/Medication:
– Give prescription for the partner to the patient
– Double the amount on the script for the patient
– Consider calling partner yourself and calling in a prescription after
discussing it with them
• Education, education, education
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Drug allergy & Drug interactions
If symptomatic, needs evaluation
Synchronicity of treatment and abstinence
Need for any other partners to also be treated
• www.cdc.gov/std/ept
• Consider internet partner notification
– www.inspot.org
Anticipated Changes in 2010 Guidelines
• Male circumcision for STI prevention
• Rescreen for CT, GC, and trich after treatment
in 3 months (remember, never sooner than 3
weeks if NAAT!)
• HPV vaccine for men and women
• Gonorrhea
– No more fluoroquinolones
– Use 250 mg Ceftriaxone dose instead of 125
Anticipated Changes in 2010 Guidelines
• More info on vaginitis, such as recurrent and
refractory BV and yeast
• Also added tinidazole as treatment for BV, 2
gm BID x 2 days
• Trichomonas
– New tx – tinidazole
– New Aptima NAAT test
• Info on mycoplasma genitalium
A final word…
• Remember, if a patient presents with
urethritis, cervicitis, PID, or proctitis that is
likely an STI…
–TREAT EMPIRICALLY
– Do NOT wait for test results to guide treatment
• Also, remember to retest in 3 months for
confirmed gonorrhea, chlamydia, and trich
Emergency Contraception
Introducing….
ella!
ella Emergency Contraceptive
•
Single 30 mg pill of uliprotsol, which is a progesterone
agonist/antagonist (as opposed to Plan B, which is a progestin,
so just a regular agonist), and it works by delaying/ inhibiting
ovulation and possibly also by changing the endometrium so
that implantation is hindered (this is no different than for Plan
B).
• It has no demonstrated decrease in effectiveness when taken
between 48 and 120 hours after intercourse (as opposed to
within 48 hrs), but effectiveness stays at about a 66%
reduction in possibility of pregnancy. (this is slightly less than
Plan B, which gives 75% reduction in the first 2-3 days, but
less effectiveness thereafter), so would be a potentially better
option at day 4 or 5 than Plan B.
ella Emergency Contraceptive
• Due to high affinity to the progesterone receptor and its
antagonistic effects, it may interfere with effectiveness of
regular hormonal contraception. Therefore, the woman
MUST use a barrier method for the entire remainder of that
menstrual cycle.
• It is likely less effective in women with a BMI greater than
30. We do not have sufficient numbers to give us surety or
estimates. This has not been well-studied for Plan B, so we
do not know if the same problem applies, but it likely does
based on preliminary data.
• Like Plan B, it can cause nausea and vomiting
(recommended to give repeat dose if woman vomits within
3 hours of taking it), and can cause a change or delay in the
next period.
ella Emergency Contraceptive
• Plasma concentration will be decreased if the woman is
also taking a med that induces hepatic enzymes, so, like
other progesterone methods, including Plan B, it will be
less effective if the woman is taking any of the following:
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barbiturates
bosentan
carbamazepine
felbamate
griseofulvin
oxcarbazepine
phenytoin
rifampin
St. John’s Wort
topiramate
ella Emergency Contraceptive
• Ella can only be taken once within the same menstrual
cycle – you cannot repeat it again, as we do not have safety
or efficacy data on that.
• So, overall, it’s medical utility above Plan B is not great,
save perhaps for the woman at day 4 or 5, for whom you
may get better efficacy than with Plan B. One kicker of
course is that it is prescription-only, which may make
women THINK that it is more effective, and also may be
minimally cheaper for someone with insurance than buying
OTC Plan B.
• Will be important for women to realize that earlier EC is
always better – just because you can take EC 4-5 days out
doesn’t mean that you should!
Thank you for your attention!
QUESTIONS…