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U.S. Selected Practice Recommendations for Contraceptive Use PowerPoint Presentation

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Description : Check out this medical presentation on sexual health, which is titled "U.S. Selected Practice Recommendations for Contraceptive Use", to learn about US Selected Practice Recommendations for Contraceptive Use, 2013 (US SPR), identify intended use and target audience, understand how to use the US SPR, and apply the guidance in specific situations, based on clinical scenarios.

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Published on : Jun 20, 2022 | Views : 1391 | Downloads : 0

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U.S. Selected Practice Recommendations for Contraceptive Use, 2013 Division of Reproductive Health Centers for Disease Control and Prevention August 1, 2013 National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health
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Learning Objectives Participants will be able to: Describe the US Selected Practice Recommendations for Contraceptive Use, 2013 (US SPR) Identify intended use and target audience Understand how to use the US SPR Apply the guidance in specific situations, based on clinical scenarios
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US Selected Practice Recommendations for Contraceptive Use, 2013 Follow-up to US Medical Eligibility Criteria for Contraceptive Use, 2010 (US MEC): Recommendations for who can safely use contraception Adapted from World Health Organization (WHO) SPR Intent: Evidence-based guidance for common, yet controversial, contraceptive management questions When to start Missed pills Bleeding problems Exams and tests Follow-up How to be reasonably certain that a woman is not pregnant
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US Selected Practice Recommendations for Contraceptive Use, 2013 Target audience: health-care providers Purpose: to assist health care providers when they counsel patients about contraceptive use Selected Recommendations NOT comprehensive textbook NOT the US MEC NOT rigid guidelines NOT well-woman care
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US Adaptation of WHO SPR October, 2010, Small expert meeting Chose which existing WHO recommendations to adapt Chose new clinical questions to add Systematic reviews for each topic Peer reviewed October 4-7, 2011, Expert meeting 36 experts from US For each topic: Systematic review presentation Discussion Draft recommendation Research gaps
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US Adaptation of WHO SPR Much of the guidance is the same as or very similar to the guidance in the WHO SPR Adaptations include: length of the grace period for progestin-only injectable contraceptives (DMPA), differences in some of the examinations and tests recommended prior to contraceptive method initiation, differences in recommendations for management of bleeding irregularities based on new data and drug availability in the US, simplified missed pill algorithms
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US Adaptation of WHO SPR The US SPR includes additional guidance: Recommendations on patch and ring How to start regular contraception after taking emergency contraceptive pills Management of bleeding irregularities among women using extended or continuous combined hormonal contraceptives (CHCs) When a woman can rely on female sterilization for contraception When a woman can stop contracepting
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US Adaptation of WHO SPR Format Arranged by method For each recommendation: Recommendation itself Comments and evidence summary Simplified text of actual recommendations Bullets, tables, flowcharts, algorithms
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Resources CDC evidence-based family planning guidance documents: http://www.cdc.gov/reproductivehealth/unintendedpregnancy/USMEC.htm http://www.cdc.gov/reproductivehealth/unintendedpregnancy/USSPR.htm Sign up to receive alerts! WHO evidence-based family planning guidance documents: http://www.who.int/reproductivehealth/publications/family_planning/en/index.html
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CLINICAL SCENARIOS
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Clinical scenario 1: When to start a contraceptive method 24 y.o. female comes to office desiring contraception and wants to start pills Q: When can she start?
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When to start a contraceptive method Barriers to starting Filling a prescription Starting during menses Coming back for a second (or more) visit Starting when woman requests contraception (“Quick start”) May reduce time woman is at risk for pregnancy May reduce barriers to starting
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Evidence for Risk of Pregnancy Two types of risk: Risk of already being pregnant Risk that woman already pregnant with “Quick start” of CHCs low Risk of becoming pregnant Risk of pregnancy with “Quick start” of CHCs low Brahmi, Contraception, 2013.
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Other findings Starting CHCs on different days of the cycle does not affect bleeding changes or other side effects “Quick start” may increase continuation of combined oral contraceptives (COCs) and patch in the short term; this difference disappears over time Brahmi, Contraception, 2013.
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Exposure in early pregnancy No increased risk for adverse outcomes (congenital anomalies, neonatal death, infant death) among infants exposed in utero to COCs Bracken, Obstet Gynecol. 1990;76:552-7.
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Need for back-up contraception Later start days are associated with greater follicular activity, but not ovulation, through day 5 (implications for back up) Brahmi, Contraception, 2013.
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US SPRWhen to start a contraceptive method
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Guidance for Special Considerations Amenorrheic Postpartum Breastfeeding Not breastfeeding Postabortion Switching from another contraceptive method
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Clinical scenario 1: When to start a contraceptive method ? 24 y.o. female comes to office desiring contraception and wants to start pills Q: When can she start? A: Anytime, if reasonably certain she is not pregnant. If it has been more than 5 days since menstrual bleeding started, she will need to abstain from sex or use additional contraceptive protection for the next 7 days
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Evidence: Pregnancy test limitations Pregnancy detection rates can vary based on sensitivity of test and timing with respect to missed menses Pregnancy test not able to detect pregnancy resulting from recent intercourse Pregnancy test may remain positive several weeks after pregnancy ends Cervinski, Clin Chem Lab Med. 2010;48:935-42. Cole LA, Expert Rev Mol Diagn. 2009;9:721-47. Wilcox, JAMA. 2001;286:1759-61. Korhonen, Clin Chem. 1997;43:2155-63. Reyes, Am J Obstet Gynecol. 1985;153:486-9. Steier, Obstet Gynecol. 1984;64:391-4.`
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Evidence on Pregnancy Checklist (PC) Stanback, Lancet, 1999;354:566. Stanback, J Fam Plann Reprod Health Care, 2006;32:27. Stanback, Rev Panam Salud Publica, 2008;23:116. Torpey, BMC Public Health, 2010;10:249.
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Clinical scenario 2: How to be reasonably certain that a woman is not pregnant 24 y.o. female comes to office desiring contraception and wants to start pills Q: How can you be reasonably certain she is not pregnant? A: If she has no signs or symptoms of pregnancy and fulfills one of criteria, a provider can be reasonably certain that the woman is not pregnant.
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US SPRExams and tests prior to initiation Unnecessary tests may be barrier to starting Women (adolescents) may not be comfortable with pelvic exam Coming back for a second (or more) visit to receive test results Recommendations address exams and tests needed prior to initiation Class A = essential and mandatory Class B = contributes substantially to safe and effective use, but implementation may be considered within the public health and/or service context Class C = does not contribute substantially to safe and effective use of the contraceptive method
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US SPR Exams and tests prior to initiation
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US SPR Exams and tests prior to initiation
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Evidence: BP measurement 6 case-control studies Women who did not have blood pressure check prior to COC initiation had higher odds of acute myocardial infarction and ischemic stroke than women who had blood pressure check No increased risk for hemorrhagic stroke based on whether or not blood pressure measured No evidence identified on other hormonal methods Tepper, Contraception, 2012.
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US SPR Exams and tests prior to initiation
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Clinical scenario 4: Management of IUD in woman with PID Evidence 3 RCTs and one cohort study, copper-IUD or non-hormonal IUD Compared PID outcomes among women who had the IUD removed compared with those who retained IUD Overall, similar outcomes between groups 3 studies found that women with IUD removal had no difference in clinical or lab outcomes 2 of these showed women with IUD removal had longer hospitalization times 1 study found that women with IUD removal experienced improved recovery in clinical signs of PID Tepper et al., Contraception 2013.
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US SPR Recommendation Treat the PID according to the CDC STD Treatment Guidelines. Provide comprehensive management for STDs, including counseling about condom use. The IUD does not need to be removed immediately Reassess in 48-72 hours If not improvement, continue antibiotics and consider IUD removal If woman does not want to keep the IUD, remove it after antibiotic treatment has been started. If the IUD is removed, consider using emergency contraceptive pills and counsel on alternative methods US Selected Practice Recommendations, 2013. http://www.cdc.gov/std/treatment
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Clinical scenario 5: When to stop contracepting 46 y.o. female with a history of hypertension has been using progestin-only pills and wants to know when she can stop her contraception. Q: When can a woman stop contracepting?
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Evidence There are no reliable tests to confirm a woman’s definitive loss of fertility FSH levels may not be accurate The median age of menopause is approximately 51 years in North America with a range of 40-60 years Hillard, American College of Obstetricians and Gynecologists, 2007. The North American Menopause Society, 2010. TeVelde, Hum Reprod Update, 2002.
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Evidence Most pregnancies after hysteroscopic sterilization occurred when there was deviation from FDA directions: Early follicular phase placement Imaging at three months Effective alternative contraception until documented occlusion Hysterosalpingogram confirmation necessary for contraceptive reliance Very few pregnancies occurred among women with confirmed bilateral occlusion Cleary et al, Contraception 2012.
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Clinical scenario 6: When to rely on Female Sterilization A 38 y.o. obese female with three prior cesarean deliveries has completed childbearing and decided she wants hysteroscopic sterilization to replace her DMPA. Q: When can she rely on her sterilization for contraception? A: She can rely on her hysteroscopic sterilization when hysterosalpingogram at 3 months confirms bilateral tubal occlusion. Continue DMPA till then.
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Evidence Anticipatory counseling decreases method discontinuation from bleeding irregularities with DMPA Hormone-free Interval (HFI) of 3-4 days improves bleeding after 2 weeks Doxycycline has not been shown to improve bleeding
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Four options for EC available in the US Intrauterine device copper intrauterine device (Cu-IUD) Emergency contraceptive pills (ECPs) ulipristal acetate (UPA) available in a single dose (30 mg) levonorgestrel (LNG) in a single dose combined estrogen/progestin in 2 doses
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SPR Recommendation on Effectiveness Large systematic review of 42 studies showed that the pregnancy rate among emergency IUD users is 0.09% UPA and LNG ECPs have similar effectiveness when taken within 3 days after unprotected intercourse UPA has been shown to be more effective than the LNG formulation between 3 and 5 days after unprotected intercourse. UPA may be more effective than LNG for women who are obese. The combined estrogen/progestin regimen is less effective than UPA or LNG and is associated with more frequent side effects
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Clinical scenario 8 : Emergency Contraception 38 y.o. obese female had unprotected intercourse 4 days ago and is worried about pregnancy. Q: What are her emergency contraception options? A: Copper IUD Ulipristal acetate Levonorgestrel ECPs Combination estrogen/progestin pills
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Clinical scenario 8 : Initiation of regular contraception after emergency contraception pills 38 y.o. obese female had unprotected intercourse 4 days ago and is worried about pregnancy. She has chosen to take UPA Q: When can she start regular contraception after ECPs?
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Evidence Data limited to expert opinion and product labeling. Theoretical concerns for decreased effectiveness of systemic hormonal contraception after UPA use. The resumption or initiation of regular hormonal contraception following ECP use involves consideration of the risk of pregnancy if ECPs fail.
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US SPR Recommendation:When to initiate regular contraception after emergency contraception pills Any regular contraceptive method can be started immediately after the use of ECPs. Advise the woman to have a pregnancy test, if she does not have a withdrawal bleed within 3 weeks. UPA The woman will need to abstain from sex or use barrier contraception for 14 days or her next menses, whichever comes first. LNG and combined estrogen/progestin formulations The woman will need to abstain from sex or use barrier contraception for 7 days.
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Provider tools and learning aids Summary tables and clinical algorithms E-book and other electronic versions Continuing Education Activities Speaker-ready slides Contraceptive Effectiveness Chart
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Continuing Educationhttp://www.cdc.gov/mmwr/
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Take Home Messages Most women can start most methods anytime Few, if any, exams or tests are needed Recommendations for anticipatory counseling for potential bleeding problems and proper management provided Routine follow-up generally not required Many circumstances call for consideration of emergency contraception use Regular contraception should be started after EC
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Why the US SPR is important Evidence-based guidance Quality family planning care Help individuals use methods correctly and consistently Decrease medical barriers to contraceptive use
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http://www.cdc.gov/reproductivehealth/unintendedpregnancy/USSPR.htm National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health