Transcript Title in Initial Caps: 40-point Arial

Choosing a Birth Control Method
SNAP, 2014
Learning Objectives
At the conclusion of this program, participants
will be able to:
• Describe contraceptives currently available in the U.S.
• Discuss pros, cons, and efficacy of appropriate methods
with patients
• Provide evidence-based contraceptive care
• Practice effective strategies to achieve patients’
contraceptive success
• Develop individualized strategies for provision of
contraception to patients
Unintended Pregnancy in the US
6.7 MILLION PREGNANCIES
over one year
Unintended 49%
Intended: 51%
51%
23%
Unintended births
21%
5%
Elective abortions
Fetal losses
Finer LB. Contraception. 2011; Finer LB. Fertil Steril. 2012; Finer LB. Perspect Sex Reprod
Health. 2006; Henshaw SK. Fam Plann Perspect. 1998.
Goals to Address Unintended
Pregnancy
• Healthy People 2020
▪
▪
Increase proportion of pregnancies that are intended
▫ 51%  56%
Reduce proportion of females experiencing pregnancy despite
reversible contraception use
▫ 12.4%  9.9%
• CDC Winnable Battles
▪
▪
▪
Public health priorities with large-scale impact on health and with
known, effective strategies to intervene
To identify optimal strategies and to rally resources and partnerships
to accelerate a measurable impact on health
Prevention of teen pregnancy is one of the 6 winnable battles
http://healthypeople.gov/2020/
http://www.cdc.gov/WinnableBattles/TeenPregnancy/index.htm
Contraception Use
Mosher, W et al. 2010.
Improving Contraception Access
• Improve access to and use of the most effective
contraceptives
• Address barriers to use of Long Acting Reversible
Contraceptives (LARC)
• Educate Providers
▪
▪
Ensure dissemination of US MEC
Recommend that young women and nulliparous may be eligible to use
LARC methods
• Increase interest and acceptance through education and
social marketing
• Address cost barriers to ensure publically funded services
include LARC
http://www.cdc.gov/WinnableBattles/TeenPregnancy/index.htm
US Medical Eligibility Criteria for
Contraceptive Use
Current Contraceptive Options
Extremely
effective
Very
effective
Moderately
effective
Effective
Effective
>99% of the
time
Effective
>92% of the
time
Effective
~80% of the
time
Effective up
to 75% of the
time
Male/Female
Sterilization
Pills
Injectables
Male/Female
Condom
Fertility
Awareness
IUD/IUS
Patch
Withdrawal
Cervical cap
Implants
Ring
Sponge
Spermicide
Diaphragm
Polling Question
Which contraceptive method do
you most often recommend to
your patients?
Typical Effectiveness of Contraception
Long acting reversible contraceptives (LARCs)
Tier 1
Tier 2
Tier 3
Tier 4
Adapted from: WHO. Family Planning: A Global Handbook
Case Study: Gwen
What would you recommend?
Extremely
Effective
Male Sterilization
Standard of care =
no-scalpel vasectomy
(NSV)
▪
▪
▪
▪
Small (few mms) opening
is made in the scrotal sac
skin to deliver vas
deferens
Ligate/cauterize
No scalpel
No sutures
Hillis SD. Obstet Gynecol. 1999. The New York Times 2009. Nirapathpongporn A. The Lancet.
1990. Peterson H. U.S. Collaborative Review of Sterilization. 1996. Pollack AE. Contraceptive
Technology. 2007. Trussel J. Contraceptive Technology. 2011.
Extremely
Effective
Female Sterilization:
Surgical Tubal Occlusion
Ligating
• Blocking (clips or rings)
• Cauterizing
•
Sterilization Regret
Peterson H. U.S. Collaborative Review of Sterilization. 1996. Hillis SD. Obstet Gynecol. 1999.
Pollack AE. Contraceptive Technology. 2007. Ogburn T. Obstet Gynecol Clin North Am. 2007. et
al.
Extremely
Effective
Female Sterilization:
Nonsurgical Tubal Occlusion
Brand name: Essure®
• Micro-inserts placed into proximal
fallopian tubes
• 99.83% effective
•
Choosing Essure. 2012. Pollack AE. Contraceptive Technology. 2007. Ogburn T. Obstet Gynecol
Clin North Am. 2007. et al.
Extremely
Effective
Levonorgestrel Intrauterine
System (LNG 52 IUS)
• Brand name: Mirena®
• 20 mcg levonorgestrel/day
• Approved for 5 years of use
• Amenorrhea in ~20% of users
by 1 year
www.youtube.com/watch?v=hlfV8tKgw6E
Mirena Prescribing Information. 2000.: Trussel J. Contraceptive Technology. 2011;
Hidalgo M. Contraception. 2002.
Extremely
Effective
Levonorgestrel Intrauterine
System (LNG 13.5 IUS)
• Brand name: Skyla®
• 14 mcg levonorgestrel/day
• Approved for 3 years of use
• Amenorrhea in ~6% of users
by 1 year
Skyla Prescribing Information. 2013. Trussel J. Contraceptive Technology. 2011
Extremely
Effective
Copper-T IUD
• Brand name: ParaGard®
• Copper ions
• Approved for 10 years of use
• Can be used as emergency
contraceptive
www.youtube.com/watch?v=FuPFbgSm0QQ
Thonneau, PF. Am J Obstet Gynecol. 2008. Forrtney JA. J Reprod Med. 1999. Trussel J.
Contraceptive Technology. 2011.
Extremely
Effective
Characteristics of
Intrauterine Contraception
• Very high patient
satisfaction
• Rapid return of fertility
• Safe
• Long-term protection
• Highly effective
• May be inserted after
delivery or abortion
Belhadj H, et al. Contraception. 1986.; Skjeldestad F, et al. Advances in Contraception.
1988.; Arumugam K, et al. Med Sci Res. 1991.; Tadesse E. Easr Afr Med J. 1996.
Extremely
Effective
Choosing Appropriate
Intrauterine Contraception
Copper-T IUD
LNG 13.5, LNG 52 IUS
• Wants regular menses
• Does not want hormones
• No history of
dysmenorrhea
• No history of menorrhagia
• Amenorrhea acceptable
• Irregular bleeding
tolerable
• History of dysmenorrhea
(LNG 52 IUS)
• History of menorrhagia
(LNG 52 IUS)
Extremely
Effective
Dispelling Myths about
Intrauterine Contraception
• Can be used:
•
•
•
•
•
•
•
in women with multiple partners
in women with history of STDs or PID
in nulliparous women
in teens
immediately postpartum
immediately post-abortion
in women with past ectopic pregnancy
MacIsaac L. Obstet Gynecol Clin N Am. 2007. Toma A. Pediatr Adolesc Gynecol. 2006.
Otero-Flores JB. Contraception. 2003. Suhonen S. Contraception. 2004. WHO. 2004.
Extremely
Effective
Intrauterine Contraception
and Fertility
~2000 women enrolled in case-control study
IUD use not associated with infertility (OR=0.9)
Chlamydia associated with infertility (OR=2.4)
Results confirmed by similar studies
Hubacher D, et al. NEJM. 2001.
Case Study: Nell
What would you recommend?
Extremely
Effective
Implant
• Brand name: Nexplanon®
• Contains etonogestrel
• Effective for 3 years
Trussell J, et al. In: Hatcher RA, et al., eds Contraceptive Technology, 20th Revised
Edition. 2011. NEXPLANON [package insert]. Whitehouse, NJ: N.V. Organon, Oss; 2012
Extremely
Effective
Timing of
IUD/IUS/Implant Insertion
Anytime during menstrual cycle when
pregnancy can be excluded (confirmed by
negative pregnancy test and no report of
unprotected sex in past two weeks)
Alvarez PJ. Ginecol Obstet Mex. 1994. O’Hanley K, et al. Contraception. 1992.
Typical Effectiveness of Contraception
Long acting reversible contraceptives (LARCs)
Tier 1
Tier 2
Tier 3
Tier 4
Adapted from: WHO. Family Planning: A Global Handbook
Case Study:
Johanna
What would you recommend?
Very
Effective
Combined Oral
Contraceptives
• Contain estrogen &
progestin
• Most newer formulations
contain 20 – 35 mcg of
ethinyl estradiol + 1 of 8
available progestins
Trussel J. Contraceptive Technology. 2011. Rosenberg MJ. Reprod Med. 1995. Potter L.
Fam Plann Perspect. 1996. Mosher WD. AdvanceData. 2004. Hardman JG. McGraw-Hill.
1996. Goldzieher JW. Fertil Steril. 1971. Moghissi KS. Fertil Steril. 1971.
Very
Effective
Progestin-Only Oral
Contraceptives
• Called the “mini-pill”
• Two formulations:
norethindrone & norgestrel
• No placebo week
• Timing of pill-taking is
crucial
Apgar BS. AFP. 2000. WHO MEC. 2004. Contraception Report. 1999. Apgar BS. AFP.
2000. et al.
Very
Effective
Extended Hormonal
Contraception
• Delays or eliminates
menstruation
• Menstrual and nonmenstrual
benefits
• Extended methods:
• Continuous use of COCs,
transdermal patch & vaginal ring
• Seasonale®, Seasonique ®,
Quartette™ & Lybrel ®, - dedicated
extended OC regimen
Anderson FD. Contraception. 2003. Kaunitz AM. Contraception. 2000. ARHP. 2003.
NuvaRing Product Information. 2001. Stewart FH. Obstet Gynecol. 2005. Kwiecien M.
Contraception. 2003. Sulak PJ. Am J Obstet Gynecol 2002.
Extended/Continuous COC Options:
Dedicated Products
Seasonale®
Seasonique®
Lybrel®
QuartetteTM
• 84 days
active pills
(30mcg EE +
150mcg LNG)
• 7 days
inactive
placebo pills
• 84 days
active pills
(30mcg EE +
150mcg LNG)
• 7 days lowdose
estrogen pills
• Full year of
continuous
active pills
(20mcg EE +
90mcg LNG)
42 days: 20mcg
EE + 150mcg
LNG
21 days: 25mcg
EE + 150 mcg
LNG
21 days: 30mcg
EE + 150 mcg
LNG
7 days: 10mcg
EE
Anderson et al. 2003; Stewart et al. 2005; Portman. 2012.
Case Study:
Brianna
What would you recommend?
Very
Effective
Transdermal Patch
• Brand name: OrthoEvra®
• Beige-colored patch applied
once/week
• 3 weeks on, 1 week off
• 9 days of medication in each
patch
Abrams LS. Fertil Steril. 2002. Ortho Evra Prescribing Information. Archer DF. Fertil Steril.
2002. Zacur HA, et al. Fertil Steril. 2002. Zieman M. Fertil Steril. 2002. Archer DF.
Contraception. 2004. Audet MC. JAMA. 2001.
Very
Effective
Vaginal Ring
• Brand name: NuvaRing®
• Flexible, unfitted ring placed
in vagina
• In 3 weeks/out 1 week
• 4 weeks of medication in ring
• Continuous use: change once
every 4 weeks
NuvaRing Prescribing Information. Organon. 2001: Timmer CJ. Clin Pharmacokinet. 2000.
Herndon EJ. Am Fam Physician. 2004: Dieben TO. Obstet Gynecol. 2002: Linn ES. Int J
Fertil. 2003. et al.
Very
Effective
Health Benefits: Combined
Hormonal Contraception
Menstrual-related health benefits:
•
Decreased dysmenorrhea
• Decreased menstrual blood loss and anemia
• May reduce PMS symptoms
Decreased risk of:
•
•
•
•
Ectopic pregnancies
Endometrial and ovarian cancer
Benign breast conditions
PID
Larsson G. Contraception. 1992. Parsey KS. Contraception 2000. Freeman EW. Fertil Steril.
2005. Davis A. Obstet Gynecol. 2005
Very
Effective
Side Effects:
Hormonal Contraception
Progestin-Related
• Bloating
• Anxiety
• Irritability
• Depression
• Menstrual irregularities
• Reduced libido
Estrogen-Related
• Breast tenderness
• Nausea
• Vomiting
• Headaches
• Elevated blood pressure
(rare)
Very
Effective
Contraindications: Combined
Hormonal Contraception
• Clotting disorders
• History of deep vein thrombosis or
pulmonary embolism
• Migraine with aura or focal neurological
deficit
• Uncontrolled hypertension
WHO. 2000.
Very
Effective
Quick Start: Improving
Contraceptive Initiation
• Start contraceptive method
(OCs, implant, patch, ring,
injection) in presence of
clinician or on day of visit
• Menstrual cycle timing not a
factor
• Use back-up method for 1st
7 days
Lara-Torre E. Contraception. 2002. Leeman L. Obstet Gynecol Clin N Am. 2007. Westoff C.
Contraception. 2002.
Very
Effective
Missed or Late Hormonal
Contraception
Combined Oral
Contraceptive
Pills
Progestin Only
Pills
• Take missed pill ASAP
• Take next pill at regular time
• Use back-up method for 1 week if missed1-2 pills at the start
of pack or 3 or more pills in the first 3 weeks of pack
• Take missed pill ASAP
• Take next pill at regular time
• Use back-up method for 2 days if pill is taken >3 hours past
regular time
Transdermal
Patch
• Use back-up method for 1 week if patch has been on >9 days,
off > 7 days or falls off and is not reaffixed within 24 hours
Vaginal Ring
• Use back-up method for 1 week if ring has been in >5 weeks,
out >7 days or falls out and is not reinserted within 3 hours
Case Study: Mikayla
What would you recommend?
Case Study: Mikayla (continued)
Key Points About DMPA:
• No evidence it causes
fracture increase
• Bone mineral density returns
to baseline after cessation of
DMPA
• Bone health largely
dependent on nutrition and
exercise
• ACOG and WHO support
long term use
ACOG practice bulletin. Obstet Gynecol. 2006. Cromer BA. Am J Obstet Gynecol. 2005.
DiVasta AD. Adolesc Med. 2006. Kaunitz AM. Contraception. 2008. Leeman L. Obstet
Gynecol Clin N Am. 2007. WHO. 2006
Very
Effective
Injectable
• Depot Medroxyprogesterone
Acetate (DMPA)
• Brand name: Depo-Provera®
• Intramuscular or subcutaneous injection every
3 months
Trussel J. Contraceptive Technology. 2011. Cromer BA. Am J Obstet Gynecol. 2005.
Trussel J. Contraception. 2004.; Westhoff C. Contraception. 2003. et al.
Protection from Pregnancy
Immediately:
•Copper T IUD
After 7 Days:
*Backup contraception is not needed when
either LNG IUS is inserted as directed
•LNG 52 IUS, LNG 13.5 IUS*
•Implant
•Pills
•Patch
•Ring
•Injectable
Typical Effectiveness of Contraception
Long acting reversible contraceptives (LARCs)
Tier 1
Tier 2
Tier 3
Tier 4
Adapted from: WHO. Family Planning: A Global Handbook
Moderately
Effective
Contraceptives
Male Condom, Withdrawal
Female Condom, Sponge, Cervical Cap
Diaphragm, Spermicide
Fertility Awareness
Satisfaction with Contraceptive
Methods
86
% Satisfied
87
80
79
75
60
4.6
4.5
4.1
4.1
3.9
Revisiting Your Regular Women’s Health Care Visit. 2004.
3.6
52
3.8
Case Study:
Heather
What would you recommend?
Emergency Contraception
LNG Pills
(Brand)
• Plan B® One
Step:
One 1.5mg
LNG pill
LNG Pills
(Generic)
• Next Choice
One Dose™ :
One 1.5mg
LNG pill
• My Way™:
One 1.5mg
LNG pill
• LNG tablets:
two 0.75mg
LNG pills
Ulipristal
acetate
• ella®: One 30
mg ulipristal
acetate pill
Copper T IUD
• Highly
effective
method of EC
• Can be used
as an ongoing
contraception
for 12 years
Trussell 2011; www.not-2-late.com; www.rhtp.org; Piaggio G. Lancet. 1999. Task Force on Postovulatory
Methods. Lancet. 1998. Grimes DA. Ann Intern Med. 2002. Croxatto HB. Contraceptin 2001. Raine T. Obstet
Gynecol. 2000. Gold MA. J Pediatr Adolesc Gynecol. 2004. Grimes DA. Ann Intern Med. 2002.
Dedicated Emergency
Contraception Pills Available
Glasier, et al. 2011; Moreau, Trussell 2011.
Case Study:
Margarite
What would you recommend?
PART II
CDC MEDICAL ELIGIBILITY CRITERIA
FOR WOMEN WITH CERTAIN
CHARACTERISTICS AND MEDICAL
CONDITIONS
Learning Objectives
• List the 4 levels in the numeric scheme
described in the US Medical Eligibility Criteria
for Contraceptive Use
• Explain the application of the numeric scheme
to prescriptive practices for women with
comorbid conditions
• Describe the risks and benefits of the different
contraceptive methods against the risks of
pregnancy in women with health-related
concerns
US Medical Eligibility Criteria for
Contraceptive Use
• CDC published criteria in June ‘10
• Based on the 4th edition of the World Health
Organization guidelines from ‘09
• Adapted for US women by panel of experts
and CDC
• Recommendations for the use of specific
contraceptives by women who have
particular characteristics/medical conditions
http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm
WHOCDC US MEC
Existing WHO guidance
• Breastfeeding and hormonal methods
• Valvular heart disease and IUDs
• Postpartum IUD insertion
• Ovarian cancer and IUDs
• Fibroids and IUDs
• DVT/PE and hormonal methods and IUDs
WHOCDC US MEC
New medical conditions
• Rheumatoid arthritis
• Endometrial hyperplasia
• Inflammatory bowel disease
• Bariatric surgery
• Solid organ transplantation
• Peripartum cardiomyopathy
US Medical Eligibility Criteria:
Organization
• Criteria are organized according to:
– Contraceptive method
– Patient characteristics (age, smoking status, etc.)
– Preexisting conditions (hypertension, epilepsy, etc.)
• Criteria use a numeric scheme to provide the
recommendations for contraceptives being used
for contraceptive purposes only, not for treatment
of medical conditions
http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf
US Medical Eligibility Criteria:
Categories
1
2
3
4
No restriction for the use of the contraceptive method
for a woman with that medical condition
Advantages of using the method generally outweigh
the theoretical or proven risks
Theoretical or proven risks of the method usually
outweigh the advantages – or that there are no other
methods that are available or acceptable to the
women with that medical condition
Unacceptable health risk if the contraceptive method
is used by a woman with that medical condition
http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf
US Medical Eligibility Criteria: ↑ Risk
for Adverse Health Events
Conditions Associated w/ ↑ Risk for Adverse Heath Events as a Result of Unintended Pregnancy
Malignant liver tumors (hepatoma) and
hepatocellular carcinoma of the liver
Breast cancer
Should consider longacting, highly-effective
contraception for these
patients
Complicated valvular heart disease
Peripartum cardiomyopathy
Diabetes: insulin dependent; with
nephropathy/retinopathy/neuropathy or other vascular disease;
or of >20 years’ duration
Schistosomiasis with fibrosis of the liver
Endometrial or ovarian cancer
Severe (decompensated) cirrhosis
Epilepsy
Sickle cell disease
Hypertension (systolic > 160 mm Hg or diastolic > 100 mm Hg)
Solid organ transplantation within the past
2 years
History of bariatric surgery within past 2 years
Stroke
HIV/AIDS
Systemic lupus erythematosus
Ischemic heart disease
Thrombogenic mutations
Malignant gestational trophoblastic disease
Tuberculosis
http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf
Pregnancy-Related Mortality
• Increase in pregnancy-related mortality, 1998-2005
▪
De-identified death certificates of women who died during
or within 1 year of pregnancy
▪
Matched birth or fetal death certificates
• Pregnancy-related mortality
▪
14.5 per 100,000 live births
▫ African American, 3-4 times greater risk
▫ Decreased deaths due to hemorrhage and hypertensive
disorders
▫ Increased deaths due to medical conditions, especially
CVD
Berg, CJ et al. Obstet Gynecol. 2010;116:1302-1309.
Case Presentation 1
• Which hormonal
methods are safe for
her to use?
A.
B.
C.
Combined hormonal
methods only
Progestin-only
methods only
Any hormonal method
Breastfeeding
Case Presentation 1
• Which hormonal
methods are safe for
her to use?
A.
B.
C.
Combined hormonal
methods only
Progestin-only
methods only
Any hormonal method
Case Presentation 2
• Is this method safe
for her?
A.
B.
Yes
No
Inflammatory Bowel Disease
Case Presentation 2
• Is this method safe
for her?
A.
B.
Yes (Category 1)
No
Case Presentation 3
• What do you need to
know before deciding
whether to recommend
this method?
A.
B.
C.
How much weight has
she lost?
What type of surgery did
she have?
What pill formulation did
she use previously?
Bariatric surgery
• Most effective weight loss treatment for
morbid obesity
• From 1998 to 2005, incidence increased
800%
• Women account for 83% of procedures
among reproductive age (ages 18-45)
Types of Bariatric surgery
• Restrictive procedures:
▪
▪
Decrease storage capacity of stomach
Ex: vertical banded gastroplasty, laparoscopic
adjustable gastric band, laparoscopic sleeve
gastrectomy
• Malabsorptive procedures:
▪
▪
Decrease absorption of nutrients and calories by
shortening functional length of small intestine
Ex: Roux-en-Y gastric bypass (most common in
US), biliopancreatic diversion
Bariatric Surgery
• Consensus: Pregnancy should be avoided
for 12-24 months after surgery
Paulen, ME et al. Contraception 82 (2010) 86-94.
History of Bariatric Surgery
Case Presentation 3
• What do you need to
know before deciding
whether to recommend
this method?
A.
B.
C.
How much weight has
she lost?
What type of surgery did
she have?
What pill formulation did
she use previously?
Next Steps
• Work with partners:
▪
▪
dissemination
implementation
• Keeping guidance up to date
Updated Guidance from WHO
September 2010
What increased risk is posed by use of
Combined Hormonal Contraceptives?
• No data specifically delineates risk of CHC
use during the postpartum
• Baseline risk of VTE in non-pregnant, nonpostpartum women:
▪
2.4-10/10,000 WY
• CHC use increases risk:
▪
3-7 fold
• Risk most pronounced in the first year of use
Previous WHO MEC
recommendation
CHCs in postpartum women
< 21 days postpartum
3
≥ 21 days postpartum
1
CHCs for women during the postpartum period
Condition
Recommendation
Clarification
Postpartum
a. < 21 days
Without other risk factors
for VTE
3
With other risk factors for
VTE
3/4
The category should be
assessed according to the
number, severity, and
combination of VTE risk factors
present.
b. > 21 days to 42 days
Without other risk factors
for VTE
2
With other risk factors for
VTE
2/3
c. > 42 days
1
The category should be
assessed according to the
number, severity, and
combination of VTE risk factors
present.
US MEC-Postpartum period
• New evidence
• Updated recommendations from WHO
▪
▪
▪
CDC held consultation in Jan 2011
Substantial increased risk in early weeks
postpartum with no benefit
Multiple risk factors
• Access issues
• Safety of other contraceptive methods
• Will be published as MMWR
Contraception:
It’s More Than a Prescription
The Importance of Collecting a
Sexual History
• Medical history
• Circumstances
• Lifestyle issues that
affect adherence
• Preconceptions
about contraceptive
methods
What Does Patient-Centered Care
Look Like?
Clinician Limitations
Patient Follow-up
• Schedule a recheck visit
• Ask follow-up questions:
•
•
•
Are you satisfied with your
contraceptive method?
Is there anything you would
change?
Are you having bleeding
problems or other side effects?
ARHP. Clinical Proceedings. 2004.
Recommendations for Providers
Provide ongoing support for contraceptive use
Improve women’s knowledge of contraceptive risk and benefits
Anticipate and manage side effects
Recognize fluidity in reproductive goals
Offer the widest range of contraceptive options
Address logistical and cost barriers
Enhance professional education and offer mutual support
Frost JJ. In Brief. 2008.
Next Steps
• Work with partners:
▪
▪
dissemination
implementation
• Keeping guidance up to date
• Research gaps
• US adaptation of WHO Selected Practice
Recommendations for Contraceptive Use
Resources
• US MEC published in CDC’s Morbidity and
Mortality Weekly Report (MMWR):
▪
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a1.ht
m?s_cid=rr5904a1_w
• CDC evidence-based family planning guidance
documents:
▪
http://www.cdc.gov/reproductivehealth/UnintendedPregna
ncy/USMEC.htm
• WHO evidence-based family planning guidance
documents:
▪
http://www.who.int/reproductivehealth/publications/family_
planning/en/index.html
Additional Resources
• Association of Reproductive Health
Professionals (ARHP)
▪
www.arhp.org
• National Association of Nurse Practitioners in
Women’s Health (NPWH)
▪
www.npwh.org