Contraception

Key clinical point: Three countries that implemented an immediate postpartum family planning (IPPFP) intervention that focused on long-acting reversible contraception (LARC) showed a significant increase in the number of girls and women who opted for an IUD or implant within 48 hours of delivery. 

Major finding: The mean percentage of IPP LARC adoption among all deliveries in the countries that implemented the intervention programs was 10.01%, compared to 0.77% in countries providing standard postpartum care without the intervention.

Study details: The data come from a review of immediate postpartum long-acting reversible contraception (IPP LARC) from 2016 to 2019 in three countries that focused on LARC intervention (Democratic Republic of Congo, Somalia, and Pakistan) including training delivery-room providers on counseling and provision of IPPFP; and three countries the did not implement this intervention (Rwanda, Syria, and Yemen).

Disclosures: The study was supported by an anonymous foundation. The researchers had no financial conflicts to disclose.

Source: Gallagher MC et al. Front Glob Womens Health. 2021 Apr 6. doi: 10.3389/fgwh.2021.613338.

Key clinical point: Three countries that implemented an immediate postpartum family planning (IPPFP) intervention that focused on long-acting reversible contraception (LARC) showed a significant increase in the number of girls and women who opted for an IUD or implant within 48 hours of delivery. 

Major finding: The mean percentage of IPP LARC adoption among all deliveries in the countries that implemented the intervention programs was 10.01%, compared to 0.77% in countries providing standard postpartum care without the intervention.

Study details: The data come from a review of immediate postpartum long-acting reversible contraception (IPP LARC) from 2016 to 2019 in three countries that focused on LARC intervention (Democratic Republic of Congo, Somalia, and Pakistan) including training delivery-room providers on counseling and provision of IPPFP; and three countries the did not implement this intervention (Rwanda, Syria, and Yemen).

Disclosures: The study was supported by an anonymous foundation. The researchers had no financial conflicts to disclose.

Source: Gallagher MC et al. Front Glob Womens Health. 2021 Apr 6. doi: 10.3389/fgwh.2021.613338.

Key clinical point: Three countries that implemented an immediate postpartum family planning (IPPFP) intervention that focused on long-acting reversible contraception (LARC) showed a significant increase in the number of girls and women who opted for an IUD or implant within 48 hours of delivery. 

Major finding: The mean percentage of IPP LARC adoption among all deliveries in the countries that implemented the intervention programs was 10.01%, compared to 0.77% in countries providing standard postpartum care without the intervention.

Study details: The data come from a review of immediate postpartum long-acting reversible contraception (IPP LARC) from 2016 to 2019 in three countries that focused on LARC intervention (Democratic Republic of Congo, Somalia, and Pakistan) including training delivery-room providers on counseling and provision of IPPFP; and three countries the did not implement this intervention (Rwanda, Syria, and Yemen).

Disclosures: The study was supported by an anonymous foundation. The researchers had no financial conflicts to disclose.

Source: Gallagher MC et al. Front Glob Womens Health. 2021 Apr 6. doi: 10.3389/fgwh.2021.613338.

Key clinical point: Contraceptive use among adolescents in the United States increased overall from 2006 to 2019, although consistent condom use declined.

Major finding: From 2006-2010 to 2015-2019, adolescents aged 15 to 19 years reported an 86% increased use of any contraception, a 26% increased use of multiple contraception methods, and a 3% increased use of IUDs or implants. 

Study details: The data come from a review of adolescents aged 15 to 19 years from the National Surveys of Family Growth, including 4,662 individuals from 2006-2010, 4,134 from 2011-2015, and 3,182 from 2015-2019.

Disclosures: The study was supported by an anonymous foundation. The researchers had no financial conflicts to disclose.

Source: Lindberg LD et al. Contraception: X. 2021 Apr 8. doi: 10.1016/j.conx.2021.100064.

Key clinical point: Contraceptive use among adolescents in the United States increased overall from 2006 to 2019, although consistent condom use declined.

Major finding: From 2006-2010 to 2015-2019, adolescents aged 15 to 19 years reported an 86% increased use of any contraception, a 26% increased use of multiple contraception methods, and a 3% increased use of IUDs or implants. 

Study details: The data come from a review of adolescents aged 15 to 19 years from the National Surveys of Family Growth, including 4,662 individuals from 2006-2010, 4,134 from 2011-2015, and 3,182 from 2015-2019.

Disclosures: The study was supported by an anonymous foundation. The researchers had no financial conflicts to disclose.

Source: Lindberg LD et al. Contraception: X. 2021 Apr 8. doi: 10.1016/j.conx.2021.100064.

Key clinical point: Contraceptive use among adolescents in the United States increased overall from 2006 to 2019, although consistent condom use declined.

Major finding: From 2006-2010 to 2015-2019, adolescents aged 15 to 19 years reported an 86% increased use of any contraception, a 26% increased use of multiple contraception methods, and a 3% increased use of IUDs or implants. 

Study details: The data come from a review of adolescents aged 15 to 19 years from the National Surveys of Family Growth, including 4,662 individuals from 2006-2010, 4,134 from 2011-2015, and 3,182 from 2015-2019.

Disclosures: The study was supported by an anonymous foundation. The researchers had no financial conflicts to disclose.

Source: Lindberg LD et al. Contraception: X. 2021 Apr 8. doi: 10.1016/j.conx.2021.100064.

Key clinical point: The generally positive attitudes towards contraception but low levels of use highlight the need for greater communication about behavior change among health professionals and medical students to increase their roles as change agents in their communities.

Major finding: Although 58% of the respondents were sexually active, only 18% were using a contraceptive at the time of the survey; however, 83% of contraceptive users were satisfied with past use. In addition, approximately half of respondents discussed contraception with their partners and four-fifths said they would encourage others in contraceptive use, although only 18% were involved in providing family planning methods.

Study details: The data come from a cross-sectional survey of 400 health workers and clinical care medical students in Ghana between January 1, 2018, and June 30, 2018.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Agbeno EK et al. Int J Reprod Med. 2021 Mar 22. doi: 10.1155/2021/6631790. 

Key clinical point: The generally positive attitudes towards contraception but low levels of use highlight the need for greater communication about behavior change among health professionals and medical students to increase their roles as change agents in their communities.

Major finding: Although 58% of the respondents were sexually active, only 18% were using a contraceptive at the time of the survey; however, 83% of contraceptive users were satisfied with past use. In addition, approximately half of respondents discussed contraception with their partners and four-fifths said they would encourage others in contraceptive use, although only 18% were involved in providing family planning methods.

Study details: The data come from a cross-sectional survey of 400 health workers and clinical care medical students in Ghana between January 1, 2018, and June 30, 2018.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Agbeno EK et al. Int J Reprod Med. 2021 Mar 22. doi: 10.1155/2021/6631790. 

Key clinical point: The generally positive attitudes towards contraception but low levels of use highlight the need for greater communication about behavior change among health professionals and medical students to increase their roles as change agents in their communities.

Major finding: Although 58% of the respondents were sexually active, only 18% were using a contraceptive at the time of the survey; however, 83% of contraceptive users were satisfied with past use. In addition, approximately half of respondents discussed contraception with their partners and four-fifths said they would encourage others in contraceptive use, although only 18% were involved in providing family planning methods.

Study details: The data come from a cross-sectional survey of 400 health workers and clinical care medical students in Ghana between January 1, 2018, and June 30, 2018.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Agbeno EK et al. Int J Reprod Med. 2021 Mar 22. doi: 10.1155/2021/6631790. 

Key clinical point: Levonorgestrel was noninferior to copper IUD for emergency contraception, with similar pregnancy rates and adverse events reported for both methods.

Major finding: Pregnancy rates were 1 in 317 (0.3%) in the levonorgestrel group and 0 in 321 (0%) in the copper IUD group in the modified intent-to-treat analysis.

Study details: The data come from a randomized trial of 317 women who received levonorgestrel IUD and 321 who received copper IUDs and provided 1-month outcome data.

Disclosures: The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD); the University of Utah, with funding in part from the National Institutes of Health (NIH) National Center for Research Resources and National Center for Advancing Translational Sciences; and grants to the lead author and several coauthors from the NIH Office of Research on Women’s Health and the Eunice Kennedy Shriver NICHD.

Source:  Turok DK et al.  N Engl J Med. 2021 Jan 28. doi: 10.1056/NEJMoa2022141.

Key clinical point: Levonorgestrel was noninferior to copper IUD for emergency contraception, with similar pregnancy rates and adverse events reported for both methods.

Major finding: Pregnancy rates were 1 in 317 (0.3%) in the levonorgestrel group and 0 in 321 (0%) in the copper IUD group in the modified intent-to-treat analysis.

Study details: The data come from a randomized trial of 317 women who received levonorgestrel IUD and 321 who received copper IUDs and provided 1-month outcome data.

Disclosures: The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD); the University of Utah, with funding in part from the National Institutes of Health (NIH) National Center for Research Resources and National Center for Advancing Translational Sciences; and grants to the lead author and several coauthors from the NIH Office of Research on Women’s Health and the Eunice Kennedy Shriver NICHD.

Source:  Turok DK et al.  N Engl J Med. 2021 Jan 28. doi: 10.1056/NEJMoa2022141.

Key clinical point: Levonorgestrel was noninferior to copper IUD for emergency contraception, with similar pregnancy rates and adverse events reported for both methods.

Major finding: Pregnancy rates were 1 in 317 (0.3%) in the levonorgestrel group and 0 in 321 (0%) in the copper IUD group in the modified intent-to-treat analysis.

Study details: The data come from a randomized trial of 317 women who received levonorgestrel IUD and 321 who received copper IUDs and provided 1-month outcome data.

Disclosures: The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD); the University of Utah, with funding in part from the National Institutes of Health (NIH) National Center for Research Resources and National Center for Advancing Translational Sciences; and grants to the lead author and several coauthors from the NIH Office of Research on Women’s Health and the Eunice Kennedy Shriver NICHD.

Source:  Turok DK et al.  N Engl J Med. 2021 Jan 28. doi: 10.1056/NEJMoa2022141.

Key clinical point: Use of progestin-only contraception was associated with greater breast hypertrophy and pain in adolescents with macromastia.

Major finding: Compared to controls, macromastia patients who used progestin-only contraceptives were 500% more likely to report breast pain (odds ratio 4.94); macromastia patients who used progestin-only contraception also had significantly more breast tissue resected during mammaplasty and greater musculoskeletal pain. 

Study details: The data come from a retrospective study of 378 macromastia patients aged 12 to 21 years and 378 controls; 5.3% of macromastia patients and 28.0% of controls used progestin-only contraception.

Disclosures: The study was supported in part by the Plastic Surgery Foundation. The researchers had no financial conflicts to disclose.

Source: Nuzzi LC et al. Plast Reconstr Surg Glob Open. 2021 Feb 12. doi: 10.1097/GOX.0000000000003421.

Key clinical point: Use of progestin-only contraception was associated with greater breast hypertrophy and pain in adolescents with macromastia.

Major finding: Compared to controls, macromastia patients who used progestin-only contraceptives were 500% more likely to report breast pain (odds ratio 4.94); macromastia patients who used progestin-only contraception also had significantly more breast tissue resected during mammaplasty and greater musculoskeletal pain. 

Study details: The data come from a retrospective study of 378 macromastia patients aged 12 to 21 years and 378 controls; 5.3% of macromastia patients and 28.0% of controls used progestin-only contraception.

Disclosures: The study was supported in part by the Plastic Surgery Foundation. The researchers had no financial conflicts to disclose.

Source: Nuzzi LC et al. Plast Reconstr Surg Glob Open. 2021 Feb 12. doi: 10.1097/GOX.0000000000003421.

Key clinical point: Use of progestin-only contraception was associated with greater breast hypertrophy and pain in adolescents with macromastia.

Major finding: Compared to controls, macromastia patients who used progestin-only contraceptives were 500% more likely to report breast pain (odds ratio 4.94); macromastia patients who used progestin-only contraception also had significantly more breast tissue resected during mammaplasty and greater musculoskeletal pain. 

Study details: The data come from a retrospective study of 378 macromastia patients aged 12 to 21 years and 378 controls; 5.3% of macromastia patients and 28.0% of controls used progestin-only contraception.

Disclosures: The study was supported in part by the Plastic Surgery Foundation. The researchers had no financial conflicts to disclose.

Source: Nuzzi LC et al. Plast Reconstr Surg Glob Open. 2021 Feb 12. doi: 10.1097/GOX.0000000000003421.

Key clinical point: Among healthy young women taking oral contraceptives, pulse wave velocity was lower in active women compared with inactive women, suggesting that physical activity may mitigate the risk of arterial stiffness associated with OC use.   

Major finding: Pulse wave velocity as an indicator of arterial stiffness was similar in oral contraceptive users and non-users, however, PWV was significantly lower in active women vs. inactive women (5.4 ms ^-1 vs. 6.3 ms ^-1).

Study details: The data come from a cross-sectional study of 49 healthy young women with an average age of 21.9 years, divided into four groups (inactive vs. active, OC use vs. non-OC use).

Disclosures: The study was supported in part by the European Union and the New Aquitaine region through the Habisan program (CPER-FEDER). The researchers had no financial conflicts to disclose.

Source: Enea C et al. Int J Environ Res Public Health. 2021 Mar 25. doi: 10.3390/ijerph18073393.

Key clinical point: Among healthy young women taking oral contraceptives, pulse wave velocity was lower in active women compared with inactive women, suggesting that physical activity may mitigate the risk of arterial stiffness associated with OC use.   

Major finding: Pulse wave velocity as an indicator of arterial stiffness was similar in oral contraceptive users and non-users, however, PWV was significantly lower in active women vs. inactive women (5.4 ms ^-1 vs. 6.3 ms ^-1).

Study details: The data come from a cross-sectional study of 49 healthy young women with an average age of 21.9 years, divided into four groups (inactive vs. active, OC use vs. non-OC use).

Disclosures: The study was supported in part by the European Union and the New Aquitaine region through the Habisan program (CPER-FEDER). The researchers had no financial conflicts to disclose.

Source: Enea C et al. Int J Environ Res Public Health. 2021 Mar 25. doi: 10.3390/ijerph18073393.

Key clinical point: Among healthy young women taking oral contraceptives, pulse wave velocity was lower in active women compared with inactive women, suggesting that physical activity may mitigate the risk of arterial stiffness associated with OC use.   

Major finding: Pulse wave velocity as an indicator of arterial stiffness was similar in oral contraceptive users and non-users, however, PWV was significantly lower in active women vs. inactive women (5.4 ms ^-1 vs. 6.3 ms ^-1).

Study details: The data come from a cross-sectional study of 49 healthy young women with an average age of 21.9 years, divided into four groups (inactive vs. active, OC use vs. non-OC use).

Disclosures: The study was supported in part by the European Union and the New Aquitaine region through the Habisan program (CPER-FEDER). The researchers had no financial conflicts to disclose.

Source: Enea C et al. Int J Environ Res Public Health. 2021 Mar 25. doi: 10.3390/ijerph18073393.

Key clinical point: In a biomechanical ex vivo analysis, metal uterine sounds caused uterine perforation, but the manufacturer’s plastic intrauterine device placement rod did not.

Major finding: The lowest mean maximum force generated for IUD placement was 12.3 Newtons with the levonorgestrel intrauterine system placement instrument, followed by 14.1 Newtons with the copper T380A intrauterine device placement instrument 14.1 Newtons; the highest mean maximum force of 17.9 N occurred with the metal sound (P < 0.01).

Study details: The data come from 16 premenopausal women with benign conditions who provided hysterectomy sections at a single center.

Disclosures: The study was funded indirectly through grants to the University of Utah from Bayer, Bioceptive, Sebela, Medicines 360, Merck, and Cooper Surgical. Lead author Dr. Duncan had no financial conflicts to disclose.

Source: Duncan J et al. BMC Womens Health. 2021 Apr 7. doi: 10.1186/s12905-021-01285-6.

Key clinical point: In a biomechanical ex vivo analysis, metal uterine sounds caused uterine perforation, but the manufacturer’s plastic intrauterine device placement rod did not.

Major finding: The lowest mean maximum force generated for IUD placement was 12.3 Newtons with the levonorgestrel intrauterine system placement instrument, followed by 14.1 Newtons with the copper T380A intrauterine device placement instrument 14.1 Newtons; the highest mean maximum force of 17.9 N occurred with the metal sound (P < 0.01).

Study details: The data come from 16 premenopausal women with benign conditions who provided hysterectomy sections at a single center.

Disclosures: The study was funded indirectly through grants to the University of Utah from Bayer, Bioceptive, Sebela, Medicines 360, Merck, and Cooper Surgical. Lead author Dr. Duncan had no financial conflicts to disclose.

Source: Duncan J et al. BMC Womens Health. 2021 Apr 7. doi: 10.1186/s12905-021-01285-6.

Key clinical point: In a biomechanical ex vivo analysis, metal uterine sounds caused uterine perforation, but the manufacturer’s plastic intrauterine device placement rod did not.

Major finding: The lowest mean maximum force generated for IUD placement was 12.3 Newtons with the levonorgestrel intrauterine system placement instrument, followed by 14.1 Newtons with the copper T380A intrauterine device placement instrument 14.1 Newtons; the highest mean maximum force of 17.9 N occurred with the metal sound (P < 0.01).

Study details: The data come from 16 premenopausal women with benign conditions who provided hysterectomy sections at a single center.

Disclosures: The study was funded indirectly through grants to the University of Utah from Bayer, Bioceptive, Sebela, Medicines 360, Merck, and Cooper Surgical. Lead author Dr. Duncan had no financial conflicts to disclose.

Source: Duncan J et al. BMC Womens Health. 2021 Apr 7. doi: 10.1186/s12905-021-01285-6.

Key clinical point: Use of oral contraceptives by women of reproductive age was not associated with increased risk of heart failure later in life, but the potential impact of different formulations and dosages deserves further research.

Major finding:  Over an average of 12 years’ follow-up, the researchers identified 138 incident cases of heart failure. The incidence of heart failure was not significantly associated with heart failure in multivariate analysis (hazard ratio 0.96); however, any OC use was positively associated with left ventricular end-diastolic mass (P = 0.006) and stroke volume (P = 0.01 and P = 0.005 for left and right ventricles, respectively).

Study details: The data come from a retrospective study of 3,594 women with an average age of 62 years who were enrolled in the Multi‐Ethnic Study of Atherosclerosis and could provide data on oral contraceptive use.

Disclosures: The study was supported by the Guangdong Peak Project, the Science and Technology Planning Project of Guangdong Province, Natural Science Foundation of Guangdong Province, and the National Key Research and Development Program of China. The researchers had no financial conflicts to disclose.

Source: Luo D et al. ESC Heart Fail. 2021 Apr 9. doi: 10.1002/ehf2.13328.

Key clinical point: Use of oral contraceptives by women of reproductive age was not associated with increased risk of heart failure later in life, but the potential impact of different formulations and dosages deserves further research.

Major finding:  Over an average of 12 years’ follow-up, the researchers identified 138 incident cases of heart failure. The incidence of heart failure was not significantly associated with heart failure in multivariate analysis (hazard ratio 0.96); however, any OC use was positively associated with left ventricular end-diastolic mass (P = 0.006) and stroke volume (P = 0.01 and P = 0.005 for left and right ventricles, respectively).

Study details: The data come from a retrospective study of 3,594 women with an average age of 62 years who were enrolled in the Multi‐Ethnic Study of Atherosclerosis and could provide data on oral contraceptive use.

Disclosures: The study was supported by the Guangdong Peak Project, the Science and Technology Planning Project of Guangdong Province, Natural Science Foundation of Guangdong Province, and the National Key Research and Development Program of China. The researchers had no financial conflicts to disclose.

Source: Luo D et al. ESC Heart Fail. 2021 Apr 9. doi: 10.1002/ehf2.13328.

Key clinical point: Use of oral contraceptives by women of reproductive age was not associated with increased risk of heart failure later in life, but the potential impact of different formulations and dosages deserves further research.

Major finding:  Over an average of 12 years’ follow-up, the researchers identified 138 incident cases of heart failure. The incidence of heart failure was not significantly associated with heart failure in multivariate analysis (hazard ratio 0.96); however, any OC use was positively associated with left ventricular end-diastolic mass (P = 0.006) and stroke volume (P = 0.01 and P = 0.005 for left and right ventricles, respectively).

Study details: The data come from a retrospective study of 3,594 women with an average age of 62 years who were enrolled in the Multi‐Ethnic Study of Atherosclerosis and could provide data on oral contraceptive use.

Disclosures: The study was supported by the Guangdong Peak Project, the Science and Technology Planning Project of Guangdong Province, Natural Science Foundation of Guangdong Province, and the National Key Research and Development Program of China. The researchers had no financial conflicts to disclose.

Source: Luo D et al. ESC Heart Fail. 2021 Apr 9. doi: 10.1002/ehf2.13328.

The Food and Drug Administration has approved a new estrogen for the first time in more than 50 years.

The novel combined oral contraceptive, marketed as Nextstellis, contains 3 mg drospirenone (DRSP) and 14.2 mg of estetrol (E4) in tablet form. Estetrol is an estrogen that is naturally produced during pregnancy, but will now be produced from a plant source; it has not previously been used in oral contraceptives.

Approval of the unique estetrol/drospirenone combination was based on data from a pair of phase 3 clinical trials including 3,725 women. Overall, Nextstellis was safe and effective while meeting its primary endpoint of pregnancy prevention, according to a company press release. Participants also reported favorable results on secondary endpoints including cycle control, bleeding profile, safety, and tolerability.

Although many women take short-acting contraceptives containing estrogen and progestin, concerns persist about side effects, said Mitchell Creinin, MD, of the University of California, in the press release. In addition to providing effective contraception, the drug showed minimal impact on specific markers of concern, including triglycerides, cholesterol, and glucose, as well as weight and endocrine markers, Dr. Creinin said.

Nextstellis was developed by the Belgian biotech company Mithra Pharmaceuticals, and the drug is licensed for distribution in Australia and the United States by Mayne Pharma, with an expected launch at the end of June 2021.

The Food and Drug Administration has approved a new estrogen for the first time in more than 50 years.

The novel combined oral contraceptive, marketed as Nextstellis, contains 3 mg drospirenone (DRSP) and 14.2 mg of estetrol (E4) in tablet form. Estetrol is an estrogen that is naturally produced during pregnancy, but will now be produced from a plant source; it has not previously been used in oral contraceptives.

Approval of the unique estetrol/drospirenone combination was based on data from a pair of phase 3 clinical trials including 3,725 women. Overall, Nextstellis was safe and effective while meeting its primary endpoint of pregnancy prevention, according to a company press release. Participants also reported favorable results on secondary endpoints including cycle control, bleeding profile, safety, and tolerability.

Although many women take short-acting contraceptives containing estrogen and progestin, concerns persist about side effects, said Mitchell Creinin, MD, of the University of California, in the press release. In addition to providing effective contraception, the drug showed minimal impact on specific markers of concern, including triglycerides, cholesterol, and glucose, as well as weight and endocrine markers, Dr. Creinin said.

Nextstellis was developed by the Belgian biotech company Mithra Pharmaceuticals, and the drug is licensed for distribution in Australia and the United States by Mayne Pharma, with an expected launch at the end of June 2021.

The Food and Drug Administration has approved a new estrogen for the first time in more than 50 years.

The novel combined oral contraceptive, marketed as Nextstellis, contains 3 mg drospirenone (DRSP) and 14.2 mg of estetrol (E4) in tablet form. Estetrol is an estrogen that is naturally produced during pregnancy, but will now be produced from a plant source; it has not previously been used in oral contraceptives.

Approval of the unique estetrol/drospirenone combination was based on data from a pair of phase 3 clinical trials including 3,725 women. Overall, Nextstellis was safe and effective while meeting its primary endpoint of pregnancy prevention, according to a company press release. Participants also reported favorable results on secondary endpoints including cycle control, bleeding profile, safety, and tolerability.

Although many women take short-acting contraceptives containing estrogen and progestin, concerns persist about side effects, said Mitchell Creinin, MD, of the University of California, in the press release. In addition to providing effective contraception, the drug showed minimal impact on specific markers of concern, including triglycerides, cholesterol, and glucose, as well as weight and endocrine markers, Dr. Creinin said.

Nextstellis was developed by the Belgian biotech company Mithra Pharmaceuticals, and the drug is licensed for distribution in Australia and the United States by Mayne Pharma, with an expected launch at the end of June 2021.

CASE Patient-centered counseling for contraception

A 19-year-old woman (G0) with moderately well-controlled seizure disorder while taking levetiracetam, who reports migraines, and has a BMI of 32 kg/m² presents to your office seeking contraception. She is currently sexually active with her second lifetime partner and uses condoms inconsistently. She is otherwise healthy and has no problems to report. Her last menstrual period (LMP) was 1 week ago, and a pregnancy test today is negative. How do you approach counseling for this patient?

The modern contraceptive patient

Our patients are becoming increasingly medically and socially complicated. Meeting the contraceptive needs of patients with multiple comorbidities can be a daunting task. Doing so in a patient-centered way that also recognizes the social contexts and intimacy inherent to contraceptive care can feel overwhelming. However, by employing a systematic approach to each patient, we can provide safe, effective, individualized care to our medically complex patients. Having a few “go-to tools” can streamline the process.

Medically complex patients are often told that they need to avoid pregnancy or optimize their health conditions prior to becoming pregnant, but they may not receive medically-appropriate contraception.^1-3 Additionally, obesity rates in women of reproductive age in the United States are increasing, along with related medical complexities.⁴ Disparities in contraceptive access and use of particular methods exist by socioeconomic status, body mass index (BMI), age, and geography. ^5,6 Evidence-based, shared decision making can improve contraceptive satisfaction.⁷

Clinicians need to stay attuned to all options. Staying current on available contraceptive methods can broaden clinicians’ thinking and allow patients more choices that are compatible with their medical needs. In the last 2 years alone, a 1-year combined estrogen-progestin vaginal ring, a drospirinone-only pill, and a nonhormonal spermicide have become available for prescription.^8-10 Both 52 mg levonorgestrel-containing intrauterine devices (IUDs) are now US Food and Drug Administration (FDA)-approved for 6 years, and there is excellent data for off-label use to 7 years.¹¹

Tools are available for use. To ensure patient safety, we must evaluate the relative risks of each method given their specific medical history. The Centers for Disease Control and Prevention (CDC) Medical Eligibility Criteria (MEC) provides a comprehensive reference for using each contraceptive method category with preexisting medical conditions on a scale from 1 (no restrictions) to 4 (unacceptable health risk) (TABLE 1).¹² It is important to remember that pregnancy often poses a larger risk even than category 4 methods. With proper counseling and documentation, a category 3 method may be appropriate in some circumstances. The CDC MEC can serve as an excellent counseling tool and is available as a free smartphone app. The app can be downloaded via https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html (TABLE 2).

In a shared decision-making model, we contribute our medical knowledge, and the patient provides expertise on her own values and social context.¹³ By starting the contraceptive conversation with open-ended questions, we invite the patient to lead the discussion. We partner with them in finding a safe, effective method that is compatible with both the medical history and stated preferences. Bedsider.org has an interactive tool that allows patients to explore different contraceptive methods and compare their various characteristics. While tiered efficacy models may help us to organize our thinking as clinicians, it is important to recognize that patients may consider side effect profiles, nonreliance on clinicians for discontinuation, or other priorities above effectiveness.

Continue to: How to craft your approach...

How to craft your approach

Developing a systematic approach to the medically complex patient seeking contraception can help to change an initially daunting task into a fulfilling experience (FIGURE 1). Begin by eliciting patient priorities. Then frame the discussion around them, rather than around efficacy. Although anecdotal reasoning can initially be frustrating (“My best friend’s IUD was really painful and I don’t want anything like that inside me!”), learning about these experiences prior to counseling can be incredibly informative. Ask detailed questions about medical comorbidities, as these subtleties may change the relative safety of each method. Finally, engage the patient in a frank discussion of the relative merits, safety, and use of all medically appropriate contraceptive methods. The right method is the method that the patient will use.

CASE Continued: Applying our counseling method

Upon open-ended questioning, the patient tells you that she absolutely cannot be on a contraceptive method that will make her gain weight. She has several friends who told her that they gained weight on “the shot” and “the implant.” She wants to avoid these at all costs and thinks she might want to take “the pill.” She also tells you that she is in college and that her daily routine varies significantly between weekdays and weekends. She definitely does not want to get pregnant until she has completed her education, which will be at least 3 years from now.

To best counsel this patient and arrive at the most appropriate contraceptive option for her, clarify her medical history and employ shared decision-making for her chosen method.

Probe her seizure history

She tells you that she has had seizures since she was a child, and the last one occurred 4 months ago when she ran out of her anticonvulsant medication. Her seizures have never been associated with her menses. This is an important piece of information. The frequency of catamenial seizures can be decreased with use of any method that suppresses ovulation, such as depot-medroxyprogesterone (DMPA) injections, continuous combined hormonal contraceptive (CHC) pills or ring, or the implant. Noncatamenial seizures also can be suppressed by DMPA, which increases the seizure threshold.¹⁴ Many anticonvulsants are metabolized through cytochrome P450 in the liver and, therefore, interact with all oral contraceptive formulations. However, levetiracetam is not among them and may be safely taken with progestin-only pills. At this point, all contraceptive methods remain CDC MEC category 1 (FIGURE 2).¹²

Ask migraine specifics

It is important to clarify whether or not the patient experiences aura with her migraines. She says that she always knows when a migraine is coming on because she sees floaters in her vision for about 30 minutes prior to the onset of excruciating headache. One tool that may aid in the diagnosis of aura is the Visual Aura Rating Scale (VARS).¹⁵ The presence of aura renders all CHCs category 4 by the CDC MEC.¹² (See FIGURE 2.)

Discuss contraceptive pros and cons

Have a frank discussion about the relative risks and benefits of each method. For instance, although DMPA may improve the patient’s seizures, she has expressed a desire to avoid weight gain, and DMPA is the only method consistently shown in studies to do so.¹⁶ Her seizures are not associated with menses, so menstrual suppression is neither beneficial nor deleterious. Although her current medication levetiracetam does not influence the metabolism of contraceptive methods, many anticonvulsants do. Offer anticipatory guidance around seeking gynecologic consultation with any future seizure medication changes.

Allow for shared decision-making on a final choice

The patient indicated that she had been considering “the pill” when she made this appointment, but you have explained that CHCs are contraindicated for her. She is concerned that she will not be able to stick to the strict dosing schedule of a progestin-only pill. Although you inform her that the drospirinone-only pill has a more forgiving window, the patient decides that she wants a “set it and forget it” method and opts for an IUD. 

CASE Resolved

Following recommendations from the American College of Obstetricians and Gynecologists (ACOG), you provide for same-day insertion of a 52-mg levonorgestrel IUD.¹⁷ You use a paracervical block in addition to ibuprofen for pain control.¹⁸ The patient undergoes same-day testing for gonorrhea and chlamydia, and she understands that if a test is found to be positive, she can be treated without removing the IUD. You provide instruction on the importance of dual contraceptive use with barrier methods for the prevention of STIs. The patient is instructed on self-string checks, and she acknowledges that she will call if she has any concerns; no routine follow-up is required. She leaves her visit satisfied with her preferred, safe, effective contraceptive method in situ. ●

CASE Patient-centered counseling for contraception

A 19-year-old woman (G0) with moderately well-controlled seizure disorder while taking levetiracetam, who reports migraines, and has a BMI of 32 kg/m² presents to your office seeking contraception. She is currently sexually active with her second lifetime partner and uses condoms inconsistently. She is otherwise healthy and has no problems to report. Her last menstrual period (LMP) was 1 week ago, and a pregnancy test today is negative. How do you approach counseling for this patient?

The modern contraceptive patient

Our patients are becoming increasingly medically and socially complicated. Meeting the contraceptive needs of patients with multiple comorbidities can be a daunting task. Doing so in a patient-centered way that also recognizes the social contexts and intimacy inherent to contraceptive care can feel overwhelming. However, by employing a systematic approach to each patient, we can provide safe, effective, individualized care to our medically complex patients. Having a few “go-to tools” can streamline the process.

Medically complex patients are often told that they need to avoid pregnancy or optimize their health conditions prior to becoming pregnant, but they may not receive medically-appropriate contraception.^1-3 Additionally, obesity rates in women of reproductive age in the United States are increasing, along with related medical complexities.⁴ Disparities in contraceptive access and use of particular methods exist by socioeconomic status, body mass index (BMI), age, and geography. ^5,6 Evidence-based, shared decision making can improve contraceptive satisfaction.⁷

Clinicians need to stay attuned to all options. Staying current on available contraceptive methods can broaden clinicians’ thinking and allow patients more choices that are compatible with their medical needs. In the last 2 years alone, a 1-year combined estrogen-progestin vaginal ring, a drospirinone-only pill, and a nonhormonal spermicide have become available for prescription.^8-10 Both 52 mg levonorgestrel-containing intrauterine devices (IUDs) are now US Food and Drug Administration (FDA)-approved for 6 years, and there is excellent data for off-label use to 7 years.¹¹

Tools are available for use. To ensure patient safety, we must evaluate the relative risks of each method given their specific medical history. The Centers for Disease Control and Prevention (CDC) Medical Eligibility Criteria (MEC) provides a comprehensive reference for using each contraceptive method category with preexisting medical conditions on a scale from 1 (no restrictions) to 4 (unacceptable health risk) (TABLE 1).¹² It is important to remember that pregnancy often poses a larger risk even than category 4 methods. With proper counseling and documentation, a category 3 method may be appropriate in some circumstances. The CDC MEC can serve as an excellent counseling tool and is available as a free smartphone app. The app can be downloaded via https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html (TABLE 2).

In a shared decision-making model, we contribute our medical knowledge, and the patient provides expertise on her own values and social context.¹³ By starting the contraceptive conversation with open-ended questions, we invite the patient to lead the discussion. We partner with them in finding a safe, effective method that is compatible with both the medical history and stated preferences. Bedsider.org has an interactive tool that allows patients to explore different contraceptive methods and compare their various characteristics. While tiered efficacy models may help us to organize our thinking as clinicians, it is important to recognize that patients may consider side effect profiles, nonreliance on clinicians for discontinuation, or other priorities above effectiveness.

Continue to: How to craft your approach...

How to craft your approach

Developing a systematic approach to the medically complex patient seeking contraception can help to change an initially daunting task into a fulfilling experience (FIGURE 1). Begin by eliciting patient priorities. Then frame the discussion around them, rather than around efficacy. Although anecdotal reasoning can initially be frustrating (“My best friend’s IUD was really painful and I don’t want anything like that inside me!”), learning about these experiences prior to counseling can be incredibly informative. Ask detailed questions about medical comorbidities, as these subtleties may change the relative safety of each method. Finally, engage the patient in a frank discussion of the relative merits, safety, and use of all medically appropriate contraceptive methods. The right method is the method that the patient will use.

CASE Continued: Applying our counseling method

Upon open-ended questioning, the patient tells you that she absolutely cannot be on a contraceptive method that will make her gain weight. She has several friends who told her that they gained weight on “the shot” and “the implant.” She wants to avoid these at all costs and thinks she might want to take “the pill.” She also tells you that she is in college and that her daily routine varies significantly between weekdays and weekends. She definitely does not want to get pregnant until she has completed her education, which will be at least 3 years from now.

To best counsel this patient and arrive at the most appropriate contraceptive option for her, clarify her medical history and employ shared decision-making for her chosen method.

Probe her seizure history

She tells you that she has had seizures since she was a child, and the last one occurred 4 months ago when she ran out of her anticonvulsant medication. Her seizures have never been associated with her menses. This is an important piece of information. The frequency of catamenial seizures can be decreased with use of any method that suppresses ovulation, such as depot-medroxyprogesterone (DMPA) injections, continuous combined hormonal contraceptive (CHC) pills or ring, or the implant. Noncatamenial seizures also can be suppressed by DMPA, which increases the seizure threshold.¹⁴ Many anticonvulsants are metabolized through cytochrome P450 in the liver and, therefore, interact with all oral contraceptive formulations. However, levetiracetam is not among them and may be safely taken with progestin-only pills. At this point, all contraceptive methods remain CDC MEC category 1 (FIGURE 2).¹²

Ask migraine specifics

It is important to clarify whether or not the patient experiences aura with her migraines. She says that she always knows when a migraine is coming on because she sees floaters in her vision for about 30 minutes prior to the onset of excruciating headache. One tool that may aid in the diagnosis of aura is the Visual Aura Rating Scale (VARS).¹⁵ The presence of aura renders all CHCs category 4 by the CDC MEC.¹² (See FIGURE 2.)

Discuss contraceptive pros and cons

Have a frank discussion about the relative risks and benefits of each method. For instance, although DMPA may improve the patient’s seizures, she has expressed a desire to avoid weight gain, and DMPA is the only method consistently shown in studies to do so.¹⁶ Her seizures are not associated with menses, so menstrual suppression is neither beneficial nor deleterious. Although her current medication levetiracetam does not influence the metabolism of contraceptive methods, many anticonvulsants do. Offer anticipatory guidance around seeking gynecologic consultation with any future seizure medication changes.

Allow for shared decision-making on a final choice

The patient indicated that she had been considering “the pill” when she made this appointment, but you have explained that CHCs are contraindicated for her. She is concerned that she will not be able to stick to the strict dosing schedule of a progestin-only pill. Although you inform her that the drospirinone-only pill has a more forgiving window, the patient decides that she wants a “set it and forget it” method and opts for an IUD. 

CASE Resolved

Following recommendations from the American College of Obstetricians and Gynecologists (ACOG), you provide for same-day insertion of a 52-mg levonorgestrel IUD.¹⁷ You use a paracervical block in addition to ibuprofen for pain control.¹⁸ The patient undergoes same-day testing for gonorrhea and chlamydia, and she understands that if a test is found to be positive, she can be treated without removing the IUD. You provide instruction on the importance of dual contraceptive use with barrier methods for the prevention of STIs. The patient is instructed on self-string checks, and she acknowledges that she will call if she has any concerns; no routine follow-up is required. She leaves her visit satisfied with her preferred, safe, effective contraceptive method in situ. ●

CASE Patient-centered counseling for contraception

A 19-year-old woman (G0) with moderately well-controlled seizure disorder while taking levetiracetam, who reports migraines, and has a BMI of 32 kg/m² presents to your office seeking contraception. She is currently sexually active with her second lifetime partner and uses condoms inconsistently. She is otherwise healthy and has no problems to report. Her last menstrual period (LMP) was 1 week ago, and a pregnancy test today is negative. How do you approach counseling for this patient?

The modern contraceptive patient

Our patients are becoming increasingly medically and socially complicated. Meeting the contraceptive needs of patients with multiple comorbidities can be a daunting task. Doing so in a patient-centered way that also recognizes the social contexts and intimacy inherent to contraceptive care can feel overwhelming. However, by employing a systematic approach to each patient, we can provide safe, effective, individualized care to our medically complex patients. Having a few “go-to tools” can streamline the process.

Medically complex patients are often told that they need to avoid pregnancy or optimize their health conditions prior to becoming pregnant, but they may not receive medically-appropriate contraception.^1-3 Additionally, obesity rates in women of reproductive age in the United States are increasing, along with related medical complexities.⁴ Disparities in contraceptive access and use of particular methods exist by socioeconomic status, body mass index (BMI), age, and geography. ^5,6 Evidence-based, shared decision making can improve contraceptive satisfaction.⁷

Clinicians need to stay attuned to all options. Staying current on available contraceptive methods can broaden clinicians’ thinking and allow patients more choices that are compatible with their medical needs. In the last 2 years alone, a 1-year combined estrogen-progestin vaginal ring, a drospirinone-only pill, and a nonhormonal spermicide have become available for prescription.^8-10 Both 52 mg levonorgestrel-containing intrauterine devices (IUDs) are now US Food and Drug Administration (FDA)-approved for 6 years, and there is excellent data for off-label use to 7 years.¹¹

Tools are available for use. To ensure patient safety, we must evaluate the relative risks of each method given their specific medical history. The Centers for Disease Control and Prevention (CDC) Medical Eligibility Criteria (MEC) provides a comprehensive reference for using each contraceptive method category with preexisting medical conditions on a scale from 1 (no restrictions) to 4 (unacceptable health risk) (TABLE 1).¹² It is important to remember that pregnancy often poses a larger risk even than category 4 methods. With proper counseling and documentation, a category 3 method may be appropriate in some circumstances. The CDC MEC can serve as an excellent counseling tool and is available as a free smartphone app. The app can be downloaded via https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html (TABLE 2).

In a shared decision-making model, we contribute our medical knowledge, and the patient provides expertise on her own values and social context.¹³ By starting the contraceptive conversation with open-ended questions, we invite the patient to lead the discussion. We partner with them in finding a safe, effective method that is compatible with both the medical history and stated preferences. Bedsider.org has an interactive tool that allows patients to explore different contraceptive methods and compare their various characteristics. While tiered efficacy models may help us to organize our thinking as clinicians, it is important to recognize that patients may consider side effect profiles, nonreliance on clinicians for discontinuation, or other priorities above effectiveness.

Continue to: How to craft your approach...

How to craft your approach

Developing a systematic approach to the medically complex patient seeking contraception can help to change an initially daunting task into a fulfilling experience (FIGURE 1). Begin by eliciting patient priorities. Then frame the discussion around them, rather than around efficacy. Although anecdotal reasoning can initially be frustrating (“My best friend’s IUD was really painful and I don’t want anything like that inside me!”), learning about these experiences prior to counseling can be incredibly informative. Ask detailed questions about medical comorbidities, as these subtleties may change the relative safety of each method. Finally, engage the patient in a frank discussion of the relative merits, safety, and use of all medically appropriate contraceptive methods. The right method is the method that the patient will use.

CASE Continued: Applying our counseling method

Upon open-ended questioning, the patient tells you that she absolutely cannot be on a contraceptive method that will make her gain weight. She has several friends who told her that they gained weight on “the shot” and “the implant.” She wants to avoid these at all costs and thinks she might want to take “the pill.” She also tells you that she is in college and that her daily routine varies significantly between weekdays and weekends. She definitely does not want to get pregnant until she has completed her education, which will be at least 3 years from now.

To best counsel this patient and arrive at the most appropriate contraceptive option for her, clarify her medical history and employ shared decision-making for her chosen method.

Probe her seizure history

She tells you that she has had seizures since she was a child, and the last one occurred 4 months ago when she ran out of her anticonvulsant medication. Her seizures have never been associated with her menses. This is an important piece of information. The frequency of catamenial seizures can be decreased with use of any method that suppresses ovulation, such as depot-medroxyprogesterone (DMPA) injections, continuous combined hormonal contraceptive (CHC) pills or ring, or the implant. Noncatamenial seizures also can be suppressed by DMPA, which increases the seizure threshold.¹⁴ Many anticonvulsants are metabolized through cytochrome P450 in the liver and, therefore, interact with all oral contraceptive formulations. However, levetiracetam is not among them and may be safely taken with progestin-only pills. At this point, all contraceptive methods remain CDC MEC category 1 (FIGURE 2).¹²

Ask migraine specifics

It is important to clarify whether or not the patient experiences aura with her migraines. She says that she always knows when a migraine is coming on because she sees floaters in her vision for about 30 minutes prior to the onset of excruciating headache. One tool that may aid in the diagnosis of aura is the Visual Aura Rating Scale (VARS).¹⁵ The presence of aura renders all CHCs category 4 by the CDC MEC.¹² (See FIGURE 2.)

Discuss contraceptive pros and cons

Have a frank discussion about the relative risks and benefits of each method. For instance, although DMPA may improve the patient’s seizures, she has expressed a desire to avoid weight gain, and DMPA is the only method consistently shown in studies to do so.¹⁶ Her seizures are not associated with menses, so menstrual suppression is neither beneficial nor deleterious. Although her current medication levetiracetam does not influence the metabolism of contraceptive methods, many anticonvulsants do. Offer anticipatory guidance around seeking gynecologic consultation with any future seizure medication changes.

Allow for shared decision-making on a final choice

The patient indicated that she had been considering “the pill” when she made this appointment, but you have explained that CHCs are contraindicated for her. She is concerned that she will not be able to stick to the strict dosing schedule of a progestin-only pill. Although you inform her that the drospirinone-only pill has a more forgiving window, the patient decides that she wants a “set it and forget it” method and opts for an IUD. 

CASE Resolved

Following recommendations from the American College of Obstetricians and Gynecologists (ACOG), you provide for same-day insertion of a 52-mg levonorgestrel IUD.¹⁷ You use a paracervical block in addition to ibuprofen for pain control.¹⁸ The patient undergoes same-day testing for gonorrhea and chlamydia, and she understands that if a test is found to be positive, she can be treated without removing the IUD. You provide instruction on the importance of dual contraceptive use with barrier methods for the prevention of STIs. The patient is instructed on self-string checks, and she acknowledges that she will call if she has any concerns; no routine follow-up is required. She leaves her visit satisfied with her preferred, safe, effective contraceptive method in situ. ●