Transcript Slide 1

Contraception and
Reproductive Planning in
Women IBD
Lori Gawron, MD, MPH
Assistant Professor
Department of Obstetrics and Gynecology
University of Utah
Disclosures
• None
Objectives
• Introduce 2 important questions to
ask every reproductive-age woman
with IBD.
• Discuss the evidence behind the
importance of these questions.
• Review management options for
patient responses to these questions.
Question 1
Would you like to become
pregnant in the next year?
- One
Key Question®
Oregon Foundation for Reproductive Health
Pregnancy Intention
• Average of 2 children…
~ 5 years of trying
~ 30 years preventing
• Plan timing and spacing for social and
economic reasons
• Adverse maternal and child health outcomes
– delayed prenatal care
– premature birth
– negative physical and mental health effects for children
• Healthy People 2020
Pregnancy Intention in US
Guttmacher Institute 2013
Relevance
• By age 45…1
More than half of all American women will
have experienced an unintended pregnancy
– 1 in 3 American women will have had an
abortion (including women with IBD2)
– More than 99% of American women who
have ever had sexual intercourse have used
at least one contraceptive method
1Jones
Perspect Sex Repro Health 2014;
2Mahadevan Gastroenterol 2007
Pregnancy Outcomes and IBD
• Pregnancy MUST be planned
• Active disease at the time of conception
is associated with:
– Recurrent flares in pregnancy
– Miscarriage
– Preterm delivery
– Low birth weight
– Adverse outcomes with unintended
pregnancy
• “The condom broke. I know how stupid
that sounds. It's the reproductive version
of the dog ate my homework.”
― Jennifer Weiner, Little Earthquakes
Pregnancy Intention
Guttmacher Institute 2013
Contraceptive Efficacy
1 year of typical use
Lower
Failure
Rate
Higher
Failure
Rate
Less User
Dependent
More User
Dependent
Contraceptive Method
Percentage of Women
Experiencing an
Unintended Pregnancy
Levonorgestrel IUD
0.1%
Female sterilization
0.5%
Copper-T IUD
0.8%
Injectable
3%
Oral contraceptive
8%
Vaginal ring
8%
Patch
8%
Condom
15%
Diaphragm
16%
Fertility awareness
25%
Spermicide
29%
No method
85%
1
Combined Hormonal Contraceptives
• Daily, weekly,
monthly…
• Ethinyl
estradiol and
progestin
• Ovulatory
suppression
• Option to
continuously
cycle
1
Progestin-only Pills
• Daily…
• Progestin
only
• Inconsistent
ovulatory
suppression
1
Medroxyprogesterone
• 12 weeks…
• Progesterone
only
• Ovulatory
suppression
• Amenorrhea
• Consider chronic
steroids and
bone loss
1
Subdermal Implant
• 3 years…
• Progestin only
• Ovulatory
suppression
• Inconsistent
bleeding
profiles
Levonorgestrel Intrauterine
Contraceptives
• 5 years…3 years…
• Progestin only
• Inconsistent
ovulatory
suppression
• Fewer bleeding
days
• Potential chronic
pelvic pain benefits
1
Copper IUD
• 10 years…
• Non-hormonal
• No ovulatory
suppression
• Potential increase
in bleeding and
cramping
1
Summary Chart of U.S.
Medical Eligibility Criteria for
Contraceptive Use
US Medical Eligibility Criteria for Contraceptive Use. CDC 2010
Contraceptives and IBD
“… for women with IBD with increased risk for VTE
(e.g., those with active or extensive disease, surgery,
immobilization, corticosteroids, vitamin deficiencies, fluid
depletion) the risks for COC/P/R use generally
outweigh the benefits (Category 3).
US Medical Eligibility Criteria for Contraceptive Use. CDC 2010
1
VTE Risk
1. Heinemann Contraception 2007
2. Dinger Contraception 2007
3. Wilks Annals Pharmacol 2003
4. Heit Ann Int Med 2005
2
Contraception and IBD
Marri et al. Inflamm Bowel Dis 2007
Contraception utilization by
women with IBD
• Results: 162 women with IBD, “at-risk” for
unintended pregnancy
19%
23%
17%
No method
LARC
SARC
Barrier
41%
Gawron Contraception 2014
2
Reproductive counseling
• Women with IBD desire information on
pregnancy and contraception from their
gastroenterologist1
• Many women with IBD do not initiate
conversations regarding IBD and reproductive
health2
• Current educational interventions for women
with IBD do not have a contraceptive focus3
1Marri
Inflamm Bowel Dis 2007; 2Toomey Fam Pract 2013;
3Mountfield J Crohns Colitis 2014
Reproductive health
documentation
• Contraceptive method documentation is
sparse by gastroenterologists
• Reproductive counseling is primarily
patient-driven
Gawron Patient Educ Couns 2014
One Key Question®
Oregon Foundation for Reproductive Health
Question 2
Do you notice any cyclical patterns
to your disease-related
symptoms?
Menstrual symptoms and IBD
• Cyclical, disease-related symptoms are
common in women with IBD
Kane et al. Am J Gastroenterol 1998
Parlak et al. Turk J Gastroenterol 2003
Lim et al. Gut Liver 2013
Bernstein et al. Aliment Pharmacol Ther 2012
Saha et al. Inflam Bowel Dis 2014
Non-contraceptive benefits of
hormonal contraception
• Cancer Reduction
– Ovarian
– Endometrial
– Colorectal
• Prevention
– Bone Loss
– Fibrocystic/benign
breast disease
• Cycle-related
Conditions
– Menorrhagia
– Endometriosis
• Treatment
– Acne
– Hirsutism
– Menstrual
migraines
IBD symptoms by hormonal contraceptive
method in current and past users*
Total (n=133)
DMPA (n=8)
Symptomatic
worsening
Etonogestrel implant
(n=3)
Symptomatic
improvement
Levonorgestrel IUD
(n=15)
Progestin-only pill (n=2)
No effect
Combination
pills/patch/ring (n=97)
0
50
100
*Participants reporting different past and current hormonal methods are
counted for each exposure
Gawron Inflamm Bowel Dis 2014
2
9
Clinical bottom-line
• Keep a menstrual and symptom diary
• Consider hormonal contraception
– Reproductive planning
– Disease-related symptoms
Summary
• Every woman, every time…
– Would you like to become pregnant in the
next year?1
• Consider menstrual timing or hormonal
changes with symptom reports.
– Do you have cyclical, disease-related
symptoms?
1One
Key Question®. Oregon Foundation for Reproductive
Health
Questions
“You cannot have maternal health without
reproductive health. And reproductive
health includes contraception and family
planning and access to legal, safe
abortion.”
Hillary Clinton