“CONTRACEPTION IN WOMEN WITH MEDICAL DISORDERS”

1. “CONTRACEPTION IN WOMEN WITH MEDICAL DISORDERS” NABEEL BONDAGJI, MD, FRCSC CONSULTANT PERINATOLOGIST KFSH&RC - JEDDAH

2. INTRODUCTION • Pregnancy spacing or control. • Do no harm. • Select appropriate method to the appropriate patient. • Evidence based medicine with and against evidence. • Recommendation - strength of the recommendation.

3. Evaluation of the Evidence Based On: • Evidence obtained from at least one properly designed randomized controlled trial. • Evidence obtained from well-designed controlled trials without randomization. • Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. .

4. (Cont’d - Evaluation of the Studies Based On: • Evidence obtained from multiple time series with or without the intervention. • Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. .

5. Evaluation of the recommendation Based On: • Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories: Level A -Recommendations are based on good and consistent scientific evidence. Level B -Recommendations are based on limited or inconsistent scientific evidence. Level C -Recommendations are based primarily on consensus and expert opinion.

6. MEDICAL DISORDERS • D.M. • Hypertension • Venous thrombosis • Migraine headache • Fibrocystic breast changes • Fibro adenoma • Family history of breast Ca

7. ( Cont’d) - MEDICAL DISORDERS • Hyperlipidemia • Sickle cell disease • SLE • Patients who underwent valvular cardiac replacement

8. Patients on Medications • Anticoagulant therapy • Drugs • Antibiotics

9. D.M. Concerns: CBCP • Theoretically impairment of carbohydrate progesterone component. • Increased insulin and increased glucose • Increase in the peripheral resistance to insulin Progesterone only pills (minipills) Implants DMPA Same Concern

10. I.U.C.D. • Immunity compromised • Increased risk of infection Mechanical barriers methods Permanent Methods No major concerns

11. Evidence in D. M. • The use of low does BCP did not alter the blood sugar content nor accelerate the complications. Evidence Level II • No increased risk in CBCP user to developDM. Evidence Level II • Progesterone only pills- No conclusive evidence. • I.U.C.D. in well-controlled D.M. – No major difference in the risk of infection. Evidence Level II

12. Recommendations • Mechanical barriers • Permanent sterilization • Low dose CPCP in: • Non-smoker • 35 years old or younger • No hypertension, retinopathy, or vascular disease • Level B • I.U.C.D. • Level B

13. Hypertension Concerns: CBCP • Increase in blood pressure 8/6 mmHg • Increased risk of vascular events, increased three (3) fold in hypertensive on CBCP • Increased risk of IHD

14. (Cont’d) - Hypertension Minipills • Same concerns I.U.C.D. • No major concerns Mechanical barriers • No major concerns

15. Recommendations BCP • Women who have: Well-controlled BP 35 years old or younger Non-smoker No end organ damage • Are allowed to have a trial of CBCP for a few months if BP remains controlled to continue. Level B

16. (Cont’d) - Recommendations I.U.C.D. • No contraindication but no compelling evidence of its safety (no major studies) • Mechanical Barriers • Permanent Sterilization

17. Women with Fibrocystic Breast Changes, Fibroderoma, Family History of Breast Ca Concerns: CBCP • Increased risk of breast Ca, small but not significant • Estrogen component Progesterone pill, implants DMPA • No major concerns I.U.C.D. • No major concerns

18. Recommendations CBCP • Women with fibroadenoma or benign breast disease or family history of breast Ca can use CBCP safely. • Level A Progesterone only pill • Safe I.U.C.D. • Safe Barriers and permanent sterilization • Safe

19. Migraine Headache Concerns: CBCP • In women with focal neurological signs four(4) fold increase in ischemic stroke. • Risks increase in smokers thirty-four (34) fold. (Level II) • Women with no focal neurological signs, no major increase in risk. (Level II) • Progesterone containing BC method – same concern. • I.U.C.D. – no major concern. • Mechanical barriers or permanent sterilization – no major concerns.

20. Recommendations CBCP • Contraindicated in patients with migraine headache with neurological signs and can be used in patients without neurological signs, non-smoker, and younger than 35 years old. • To be discontinued if they develop increase in headaches. Level B

21. (Cont’d) - Recommendations I.U.C.D. • Safe Mechanical barriers or permanent sterilization • Safe

22. Patients who have Undergone Cardiac Valvular Replacement Concerns: CBCP • Micro-emboli Estrogen effect I.U.C.D. • Risk of SBE Barriers and permanent sterilization • No major concerns

23. Recommendations CBCP • Contraindicated Level A Progesterone only pill • May be used Level B I.U.C.D. • No evidence to state that increased rate of SBE, therefore, may be used • Level C

24. Patients on Anti-Coagulants Recommendations CBCP • May be used Level B Progesterone only pill • May be used Level A

25. (Cont’d) - Patients on Anti-Coagulants Recommendations I.U.C.D. • No major data • Can be used Level C

26. Women with Hyperlipidemia Concerns: CBCP • Progesterone component • Increased LDL, decreased HDL • Estrogen component • Decreased LDL, increased HDL Progesterone only pill • Increased risk I.U.C.D. • No effect Mechanical barriers • No effect

27. Recommendations • Women with controlled lipid profile may used CBCP. • Women with uncontrolled lipid profile should not use CBCP. Level C • Progesterone containing agent, contraindicated Level B • I.U.C.D., safe Level A

28. Women with SLE Concerns: CBCP • Increased flare up attacks • Increased incidence of DVT Level IV Progesterone only pill • No increased risk Level II

29. Recommendations CBCP • To be avoided Level B Progesterone only pill, DMPA, and implants are the methods of choice for SLE patients. Level B I.U.C.D., barrier method, permanent sterilization. • Safe

30. Sickle Cell Disease CBCP • Increased risk of vaso-occlusive crisis Level III • No major evidence DMPA • Decreased incidence of vaso-occlusive crisis Level II

31. (Cont.’d) - Sickle Cell Disease I.U.C.D. • No major concerns • No data Mechanical and permanent • Safe Level II

32. Recommendations CBCP • To be avoided Level C DMPA • To be used Level B

33. Patients with History of Venous Thrombosis Concerns: CBCP • Increased risk of venous thrombosis four (4) fold than non-users. • Mainly the estrogen component. Progesterone only pills • No major concerns

34. (Cont’d) - Patients with History of Venous Thrombosis Concerns: Mechanical barriers or permanent sterilization. • No major concerns MPA and implants (hematoma) I.U.C.D. menorrhagia in patient on anti-coagulant therapy

35. Recommendations CBCP • Contraindicated except during anti- coagulation therapy Level A Progesterone only pills • Recommended in patients with VTE Level A DMPA implants should be avoided Level A

36. (Cont’d) - Recommendations I.U.C.D. • Can be used in patients who are off anti-coagulation therapy • May be used during anti-coagulation therapy provided that patient does not develop significant menorrhagia Mechanical barrier and permanent sterilization methods allowed.

37. Thank You..