Chapters Transcript Updates to Contraceptive Use Guidelines Dr. Jennifer Reeves provides and overview of changes in guidelines for contraceptive use and considerations to take when prescribing contraceptives. OK. Well, it is 2 o'clock, so I'm gonna go ahead and introduce our next speaker, since she is on. Dr. Jennifer Reeves completed her medical degree at Washington University School of Medicine in St. Louis, Missouri. She did her OBGYN residency at the University of Missouri in Kansas City, Missouri, and then moved to Atlanta, Georgia for her fellowship in complex family planning at Emory University School of Medicine. Doctor Reese is currently an assistant professor with the Obstetrics and gynecology division of Family Planning and the Complex Family Planning Fellowship Program director at Barnes Jewish Hospital. That's a mouthful, with the Wall Street physicians. She specializes in adolescent care, contraception, family planning, and general gynecology, seeing patients at the Central West End and Wash Specialty Care Center in North County. So thank you so much, Doctor Reeves. We really appreciate you taking the time to educate us on some of these things. Yes, thank you for the introduction. Happy to be here. Um, and I chose to talk about national contraceptive use guidelines, namely, uh, two guideline documents that come from CDC, um, well, my, after my fellowship, my first faculty position was at Emory, and I was also guest researcher at CDC, so contributed directly to some of these, um, guidelines which were most recently updated in 2024. So we'll dive in. There we go. All right. I have no financial disclosures. I did adapt some of these slides from uh CDC's publicly available slide sets. If you look now, they aren't there. Um, but that's a whole different discussion. And I should say that these slides are my own, um, culling of the medical data and do not represent the formal position of the Centers for Disease Control and Prevention. These are some of the objectives, as you all saw in your program, we'll introduce these two conscious guideline documents, the MEC and the SPR and discuss how to use the guidance documents, uh, including a video that is available on YouTube that I helped design when I was there as a researcher. Finally, we'll talk about, well, how can you send patients to come see us down here, um, at Barnes and in North County for GYN contraceptive, and family planning. So for a little bit of background, uh, yes, people need contraception, specifically people assigned female at birth, capable of pregnancy, you'll see me use. Women or say women throughout, um, some of that is convention in my own biases, but just to point out that yes, people who have body parts may or may not identify as women. But people who are capable of pregnancy have a long life of a potential pregnancy. If the average age of menarchy in the United States is age 12, and the average age of menopause is age 52, then people may spend close to 40 years capable of pregnancy, timing, planning, avoiding pregnancy. Further, there are epidemiological data to show that people in the United States um desire 1 to 2 children. And so, if you subtract 40 years from, you know, 2 years of being pregnant, um, that is, again, 30+ years that people are potentially trying to avoid pregnancy. So yes, contraception is needed, uh, and many, many people use it. Never mind the very common use of contraception to prevent delay space pregnancies, just to call out that there are numerous non-contraceptive reasons that people use contraception, uh, namely hormonal contraception, and those could be around menstrual conditions, risk reduction of cancers, um, or to improve mental health conditions like PMS PMDD. Hopefully, some of these methods look familiar to you, and although this is not a talk about the ins and outs of contraception and how to use them, um, very briefly, you'll hear me refer to pretty common contraceptive methods like the IUD intrauterine device featured on the top left here that comes in hormonal and non-hormonal varieties. There's a contraceptive implant, the next one on, which is a progestin only method that can be good for up to 5 years of birth control. Depo-Provera, Depoedroxyprogesterone acetate, abbreviated DMPA is an injectable contraception that you can take every 3 months and is available in an intramuscular or subcutaneous form. Never mind, pills, patch, rings, condoms. There's even a few apps that are FDA approved as birth control, permanent sterilization, spermicides and uh vaginal gels, emergency contraception, and yes, withdrawal featured on that bottom right with the party popper. Is also a form of contraception. So there's a million 1 options for contraception, but it is not usually so easy just to say, OK, here's a prescription, go and be on your way. There are other medical conditions that we as women have. Uh, we are not just our reproductive capability, uh, but, uh, these other medical conditions that we Uh, obtained over years of our life, uh, may impact the safety of contraception. Enter in some national guidelines. Here we're gonna mostly talk about CDC. The US medical eligibility criteria for contraceptive use, as well as its companion document, the selected Practice Recommendations, or SPR. So let's uh talk a little bit about what each of these documents do, and then uh we'll talk about some of the updates for the most recent guidelines update in 2024. So the US MEC was actually first derived from the WHO, the World Health Organization's medical eligibility criteria in 1995, and approximately every 5 years, it has been updated in the United States, um, after being adapted from the global contents. So you'll see and may, may hear or see both, the WHO MEC and the CDC MEC. They're pretty similar, but the US MEC is actually uh set for the US context. What this document does is that it provides guidelines for the safe use of contraceptive methods in people with certain characteristics or medical conditions. The target audience for this document is us as healthcare providers to provide a resource of like, well, what is the summary of data on uh cautions or precautions or to remove barriers in order to use contraceptive safely. There are more than 1800 recommendations over across 120 conditions and subconditions, so a pretty hefty document. Why? Do we need evidence-based guidance for contraception? This really helps us standardize uh best practices for family planning, address misconceptions like I alluded to, uh, people may assume that they're not candidates for a certain contraceptive because of a condition that they carry, but what does the data actually say? Related contraceptive guidelines can also help reduce unnecessary medical barriers. Again, oh, I always assumed I couldn't have an IUD because I have a fibroid. Well, what does the uh literature say? And this is where the SPR probably comes in. How can I help my patient get access, manage side effects in order for them to safely continue the contraceptive of their choice. So we reviewed some of these already, but um just, just to say that all hormonal and non-hormonal methods are featured in the US MEC um and so you can see some of those common contraceptions and their abbreviations there. Just to call out, if it's not familiar for folks, combined hormonal contraception, CHC includes all contraceptives that have both estrogen and progesterone in them. Um, so that usually includes the combo pill, the birth control patch, and the vaginal ring. Nuva ring or anovera are the two trade names. The MEC also assesses safety of contraception or eligibility for somebody to use a certain contraceptive based off of a 1 through 4 category listed here. So these numbers reflect kind of this increasing degree of theoretical or proven risks for a particular contraceptive method for a person with a particular condition or subcondition. Typically ones and twos, green, good to go. One is that there are no known contraindications and that person can safely use that contraceptive method. 2 usually refers to benefits outweigh risks. There's even or or to say that there is a theoretical or documented uh research to prove that these methods are beneficial um over risks. Category 3 approximates a relative contraindication when risks may start to outweigh benefits. Again, this is where your friendly family planner comes in. Sometimes we actually will prescribe category 3 medications if other options are not appropriate for the patient or is unacceptable to the patient. Whereas category 4 really represents an absolute contraindication, and the method should not be used due to unacceptable health risks. Some of you who have uh seen the MEC before may have seen this chart. This is a summary chart across all of the major conditions and subconditions and all of the major contraceptive categories, and so that you can have a quick reference guide. OK. Is it green, 1, 2s, good to go? 3 4s, when do we need to talk about um some of these contraindications or refer to the family planning specialist? These are easily available online. There's a little QR code at the top. You can also Google uh summary chart, USMEC and it should pop up pretty quickly. As we'll talk about kind of towards the end where you can get some of these resources, um, actually sometime not right now I checked and it's not available, but you can get printed copies of these like actual color copied, or just download it from the internet that way you can save it on your computer for future reference. Let's hone in on a specific category, and just to walk through how to read this summary chart and some of the things that uh CDC can tell us. So this is an example of the recommendations for smoking, tobacco use, and contraceptive use. Down the left side, you can see that smoking is categorized by age and volume or uh frequency of smoking. Across the top are the various contraceptive methods, copper IUD, leave estal IUD, implant, depot, POP progestin only pill, and combined hormonal contraceptives, which, like I said, includes the estrogen and progestin combo pill, patch and ring. So, most of these are category one. The progestin only contraceptives are safe and no restrictions for use for any age and Packs per day. That said, CHCs combined hormonal contraceptives do vary by how much cigarettes you're smoking and by age. So, for example, in folks who are less than age 35, CHC uses a category 2. Benefits probably outweigh the risks, but we know tobacco is an independent risk factor for arterial clots, MI, heart attack, or stroke, um, never mind cardiovascular, uh, vasculopathy due to um atherosclerosis. A smoker over the age of 35, if they are smoking less than 1.5 packs per day, 15 cigarettes a day, that recommendation for combined hormonal contraceptive use changes to a 3. now we're starting to cross that threshold. Risks may outweigh the benefits. First is folks who are smoking more than 15 cigarettes a day and are older than age 35, they've got a double hit. There's that risk of um atherosclerosis from the tobacco, risk of atherosclerosis, arteriovenous clot, um, because of age. In which case, now combined hormonal contraceptive use is an unacceptable risk. And maybe I didn't say this, but that really, the real big distinction here, and you'll see kind of throughout the guidelines is really between estrogen-containing contraceptives, um, versus non-estrogen containing contraceptives because it is that estrogen component that um affects your uh coagulation factors at the level of the liver and can be procoagulant. We know folks who use combined hormonal contraceptive, um, by itself is an independent risk factor for VTE. If the average population has a risk of a venal thromboembolus uh embolic event of 1 to 2 out of 100,000, that increase is about 6 per 100,000 with CHCUs. So that's really some of the rationale for a lot of these guidelines is increasing risk if you have other conditions that also independently risk, uh, increase your risk for clot. That's a big one there, but obviously there's also other nuances and considerations, some of which we'll go over. All of this is set in context though, of like, well, what is the risk of the contraception compared to the risk of pregnancy? Um, and if any of you have had children yourself or have spent any time on a labor and delivery unit, um, hopefully, most of you have done so in your training, that there are many, many, many, many conditions that also complicate pregnancy or for whom pregnancy is life-threatening. So CDC does provide some information, and this is a non-exhaustive list of some conditions for which The risks of this disease progressing during pregnancy is much, much, much higher than the risk of those conditions and contraceptive use. So always important to keep that in mind. If a person desires to avoid pregnancy because of their medical conditions, uh, we should not be holding contraception hostage because of our concerns of those risks, if the risks of pregnancy outweigh the risks of the contraceptive use. To transition to the SPR, the selected practice recommendations. If the MEC is who can safely use contraception, the SPR is how. We can safely use contraception. Again, this guideline uh document is written for healthcare providers and its purpose is to assist healthcare providers in how to counsel starting, managing, and other nuances for the care of contraception. We'll go through some of these, but I do, uh, again, there's some really great takeaways on the website and on the app, which we'll showcase here, um, one of which that I refer to all the time, especially when teaching medical students residents, or how do I know someone is not pregnant, and I can safely start contraception for them. So, probably most of this should be common sense, but I'll walk through them anyway. Uh, if somebody is within the 1st 7 days of the start of their normal menstrual period, they are at incredibly low risk of pregnancy. You can be reasonably certain that person is not pregnant. Even if they're, you know, if cycle day number 1 is the first day of full flow of someone's menstrual cycle, even if their cycles are 3 to 5 days and they're no longer bleeding on day 7. The research shows that the earliest that someone ovulates is day 10, and average day of ovulation is day 14 in a standard 28 day cycle. So ovulation is that highest risk of someone becoming pregnant if they are having sex. So, uh, research shows that within the 1st 7 days of that menstrual cycle, you're pretty damn sure that that person is not pregnant. Likewise, if they have not had sex since their menstrual period. And then it doesn't matter where you are in your cycle. If you have not had sex since that last menstrual period and you have normal regular periods, pretty dang sure you're not pregnant. If someone has been correctly and consistently using a reliable form of contraception. So somebody who comes in and says, well, well, I've been on the pills for years, but now my cardiologist tells me I can't have that because I'm on, um, I'm on I have hypertension and I'm on 3 different meds. Well, I've been using this contraception day in, day out of I've never missed a pill. OK, let's talk about options, and usually that gives me the healthcare provider permission to go ahead and start that next form of contraception. I don't have to wait till that person's next period or or some other uh predesigned time point. The last bucket of when you can be reasonably certain someone is not pregnant is um after pregnancy itself. So in the first or second trimester after a spontaneous or induced abortion, as long as they're within 7 days of that, um, that, that pregnancy loss, you're safe to start a contraception. Again, knowing that people can ovulate as early as 10 days, even after a 1 or 2nd trimester pregnancy loss. At term, that's extended to a little bit more, 4 weeks, usually also because of lactation, nursing, um, your elevated prolactin levels that um naturally suppress people's periods in the postpartum period. And although we won't talk about it, lactational amenorrhea method is a form of contraception. However, you must be strictly nearly or fully uh breast or exclusively breastfeeding greater than 85% of feeds, not have any periods and be less than 6 months postpartum. Even people who are greater than 6 months have continued to breastfeed into 2 years. That's not gonna protect you, especially if your periods come back. Um, so if somebody is using lamb within the 1st 6 months of postpartum and they meet these other criteria. You can be reasonably certain that they are not pregnant. Likewise, there's a summary table on when you can start somebody um on a contraception, and I know we just went through all of the exhaustive reasons to know when someone is reasonably not pregnant, and it's pretty free. Look, you can start this contraception anytime that you are reasonably certain that someone's not pregnant. I'll also tell you that you can usually start any contraception at any phase of the menstrual cycle, even if like, oh, you had sex 2 weeks ago, your period is more than it was 3 weeks ago. Sure, do a pregnancy test today, repeat it in 2 weeks, but don't hold birth control hostage. You can still safely use most forms of birth control. The big asterisk here is IUDs. You should not put anything inside the uterus if you are not sure that that person is not pregnant. The last uh uh piece of the SPR that I'm gonna highlight is management of bleeding irregularities, because I think this comes up a lot, particularly with hormonal contraception, but mainly also the copper IUD. Uh, we usually, before starting, uh, someone on an IUD counsel them on what the expectation is for bleeding profile. Namely, for the copper IUD. We expect that folks may experience um heavier or crampier bleeding, especially in those 1st 3 to 6 months. But breakthrough bleeding can also happen because of progestin only contraception, continuous use of a birth control pill, and CDC provides guidance on uh what are the studied evidence-based recommendations to try to mediate or mitigate people's irregular bleeding. The last thing I'll say about this slide is, again, I'm just in the same way that we should not hold birth control hostage, we should increase access to timely birth control for folks who wish to avoid pregnancy. We also shouldn't hold a device removal hostage. So, just to emphasize that if people are having bleeding problems, yes, we have a number of things that we can try. But if somebody wants their IUD out, they want their implant out, even if it hasn't been the full use of time, even if they haven't used it for 6 months. We can't hold removal hostage. People should have access to safe, timely removal of their contraceptive devices, if that's what they choose. So that's a brief introduction to what those guidelines are, the types of information that you can find there. Um, let's talk about the new updates. So 2024, last year is the most recent update, uh, previous to 2024, the last time this document was updated wholesale was 2016. So what is new in the MEC, the medical eligibility criteria? We have a new condition, chronic kidney disease has been added with subconditions of nephrotic syndrome, hemodialysis, and peritoneal dialysis. We'll go through and look at those recommendations in just a second. The CDC team also revised recommendations for a number of different conditions based off of newer data that are available. We'll go through uh lupus, systemic lupus erythematosis, uh, in the next few slides. Finally, CDC also included updated or new methods of contraception, including the vaginal pH modulator, FEI, the lactic acid, citric acid gel that is used each time with sex, um, a little bit safer on the vagina than your classic spermicides, but functions in very much the same way. So let's look at the 2024 update for chronic kidney disease. So again, to orient you to the table, you can see the condition, the sub-condition, the different contraceptive methods across the top. And then the recommendations for each of those contraceptive methods. Um, it'll come up in the next slide or in the next example a little bit better, but there's also different recommendations sometimes if you are initiating I initiating a contraception, or C, continuing a contraception. And we'll go into a little bit more details with the next example. In general, how CDC reviewed these data, although, although there was no direct evidence, no RCTs observational studies looking at safety outcomes for folks with chronic kidney disease and nephrotic syndrome using contraception, they were able to extrapolate other known data, especially that nephrotic syndrome protonuria is an independent risk factor for a uh a vascular disease or like damage, right, um, to, um, The endothelium of those blood vessels. And therefore, that might be an an independent risk factor for VTE. Therefore, things that have an increased risk of VTE, namely, estrogen containing contraceptives, are a category 4, or initiators or continuers. Calling out Depo, Depo-Provera, is a uh depoeddroxyprogesterone acetate is a progestin. There's no estrogen whatsoever in it, but it is a relatively higher dose of progestin compared to other progestin-only methods, and there is some peripheral conversion, right, of progestin to other steroid hormones, namely estrogen. Therefore, Depot gets a category 3. Risks may outweigh benefits because of that theoretical risk that it is a slightly more thrombogenic progestin um than the other progestin only contraceptives. The last thing I'll call, second to last thing I'll call out on this slide is uh the category 2/4 for POPs, progestin-only pills. And that's because there are now two different um types of POPs, progestin-only pills available on the market. For a long, long, long, long time, we just had noriendrone. You might have heard of that as the mini pill. It also comes, you know, we can treat abnormal uterine bleeding with things like Aestin, Provera. Um, And but, but there's a newer POP on the market, slit, which is drosperinone. It's a 4th generation progesterone that is derived from spironolactone. So, uh, for folks who have hyperkalemia, uh, slit is specifically a category 4. You don't want something else that's also going to increase someone's potassium due to that, uh, being derived from spironolactone. As an aside, I actually, this is a complex contraceptive patient that I took care of um when I started here in 21. Um, young woman, uh, yeah, iatrogenic kidney failure, had a kidney transplant, and normal K at the time. Um, but her first provider was like, well, I don't know if I wanna start estrogen. Because you have chronic kidney disease, solid organ transplant, that seems like you have some risk factors for BTE already. Let me start you on a POP, but aha, we have this new POP on the market that's a little bit, and we won't go to the forgiving, then you're no and drone. You have a little bit larger window of error with that, which is why I think a lot of us like this pill. But my friend started getting increased uh hyperkalemia, and so I had to switch her back to a standard POP Northro. The last thing I'll say about this slide is that this is just one guideline in isolation, and people with chronic kidney disease may also have other conditions, diabetes, hypertension, lupus. And as we'll talk about, CDC can provide you guidance for these individual characteristics, but we are not a monolith, right? We've got a lot of conditions that we have to consider, and although the CDC does not give us, OK, well, if it's a 3 here and a 3 here, that's got to equal a 4 there. It does not give us combination results that really does rely on us as clinical providers to use our clinical judgment to say, well, maybe this is a 3 here and a 3 here, but I'm not comfortable using that because of that potential double hit on um whatever that risk factor is, BTE for example. All right. So speaking of lupus, let's uh go into a little bit of the nitty gritty here. For CDC, it really is people with lupus who have positive or unknown antiphospholipid antibodies. So that's your anticardiolipin, beta 2 microglobulin, or um um Lupus anticoagulant. Whether regardless if you have APLS antiphospholipid antibody syndrome, with pregnancy loss, clots, all of those things, even having the antibody positivity by itself is an independent risk factor for VTE, which drives the recommendations to make CHC of 4, combined hormonal contraceptives, and Depo-Provera a 3. Risks may outweigh the benefits. The other nuance here that I'll call out is uh copper IUD use for folks with lupus who have severe thrombocytopedia. And this is where that initiation versus continuation comes into play. So say I had a person who came into my office with lupus and who um She has been on a copper IUD for 5 years. It's good through 12 years. Very satisfied with the methods. Yeah, maybe she had some heavier bleeding at first, but it's stable now. She's not anemic, she's doing fine with it. And she subsequently develops thrombocytopenia, low platelets. As long as she doesn't have any changes to her bleeding profile. Continuing the copper IUD is a category 2. Benefits probably outweigh the risks, versus if I saw this person who was interested in starting a copper IUD but has thrombocytopenia, I'm a little bit more hesitant to start that contraception because I'm worried, especially knowing the profile, the bleeding profile of copper IUDs resulting in heavier or crampier bleeding, especially in the 1st 3 to 6 months. Uh, I'm gonna be a little bit more hesitant there, but the risks may outweigh the benefits. Although we're focusing a lot of our attention today on the CDC contraceptive guidelines, there are a lot of other individual societies who release their own recommendations based off of specific conditions. Um, so I wanted to call out the American College of Rheumatology who in 2020 released a large, uh, um, guideline document on a lot of reproductive health issues for folks with rheumatic conditions, primarily lupus, but certainly all uh uh a lot of other conditions, rheumatoid, etc. Um, so they include guidelines not just on contraception, which you can see here, but also ART Advanced Reproductive technologies, and pregnancy. Um, so really great guidelines, uh, to review too if you have folks, uh, that you see with rheumatic conditions, namely lupus. We won't spend too, too much time here, but just to say that the ACR recommendations around contraceptive use are mostly aligned with CDC but are a little different. Here they primarily stratify first by APL status, then disease status, versus CDC says lupus with positive antiphospholipid antibodies. And that's because there are some rheumatic conditions um that may have APL antibodies without a full diagnosis of lupus. So first thing, APL, yes or no. If you have a positive test, then you should avoid contra contraception that has estrogen and progesterone in it. And here they are a little bit more um I, I'll take my editorial out of it. They recommend IUDs uh over other forms of contraception. That said, if you are negative for your APL status, any of those antibodies, and you have a non-lupus rheumatic disease, all contraceptive methods are available, strongly recommend, conditionally recommend IUDs and progestin implant as first line. Then lupus with low disease activity and lupus with moderate or high disease activity. The red box that I'll call out here is avoid the estrogen patch. And that is because the um combination patch, estrogen and progesterone patch, uh because it avoids first pass metabolism and the medications are absorbed transdermally, the relative serum dose of estradiol is higher in contraceptive patch users caution there's a new patch on the market, Torla, which studies do not show this. But that's where that recommendation comes from, that the relative concentration of the serum estradiol is higher in combo patch users compared to combo pill users. So folks who may have some inherent Coagulopathy, AKA folks with lupus. Uh, ACR namely recommends to avoid the estrogen patch. But CDC doesn't do that. They call that CHC is still twos for most folks and fours only for folks who have antis lipid antibody positivity. So all this to say is that we have these guidelines, but yes, we still rely on our clinical judgment to determine uh what may or may not be the safest, uh a safe contraception method for that person to use. OK. So what's new in the US uh excuse me, the SPR, the selected practice recommendations, how we use and manage contraception. There is updated recommendations on the provision of medications for IUD placement, which will go into a little bit more detail. And some minor uh modifications to how to manage bleeding irregularities during implant use. There are also new recommendations on testosterone use. Um, so, to think about our transgender and gender diverse folks who may be using testosterone. Testosterone by itself has not been studied to be an effective contraception. And what can those folks, how do you manage um contraceptive use while someone is also using testosterone? Finally, and I name dropped this a little bit earlier, um, but, uh, there is subcutaneous and intramuscular formulations for Depo-Provera, but there's a specific guideline now about, um, basically eliminating barriers, people can self-administer this, just as they do any other self-administrative subcutaneous injection, like testosterone, like insulin, uh, like FSH for um ART Advanced reproductive technologies. For this section, I wanted to focus a little bit about medications for IUD placement. One, misoprostol is a prostaglandin E1 analog that is used commonly in labor induction, right, to induce contractions and help facilitate delivery. It also has a dozen and one different other uses, namely in gynecology for cervical softening, cervical ripening, either pre-op for A pregnancy loss abortion, or for people with cervical stenosis and you need to do um cervical procedures to try to help dilate that cervix. There are specific evidence to suggest that routine mesoprostol use, um, is not beneficial for IUD placement, mainly because it increases your risk of side effects, cramping, pain, loose stools, diarrhea, all the things that prostaglandins do, without much benefit. So no studied effect on ease of placement according to the provider's perspective, decreased pain during the procedure because of passing instruments through the cervix. That said, CDC does provide a caveat there is, yes, there may be room for mesoprostol in folks who've had a uh previous failed placement. So sometimes we'll see referrals from uh folks who said, well, I tried to place an IUD and I couldn't do it. I couldn't get around the cervix, I couldn't figure it out. We actually may give them misoprostol before we reattempt an IUD placement. Again, just for that cervical softening piece of it for folks who have had a pre-identified problem uh with cervical uh dilation. The bigger change for the SPR was more of an emphasis on pain control for IUDs and I probably don't need to tell this audience, but we've had a real reckoning, uh, an ongoing reckoning in OBGYN, especially the undervalument of pain and expecting female bodies to go through painful procedures. So, CDC provides more uh detailed evidence regarding lidocaine in a paracervical block. Um, or topical lidocaine, using viscous lidocaine or even a lidocaine, like benzocaine spray, um, as an option for pain control during IUD placements. And they, uh, part of that recommendation is every person should have discussion around pain and pain control options for IUD placement, and that's really great to see. All right. So let's talk about, OK, we have these guidelines. Where do we find them? How do we use them? First thing I'll point you to is the MEC SPR app. This is free and available to download on Android and Apple devices. Look for uh CDC contraception, and it should pop up. This houses both the MEC and the SPR in a mobile-friendly format and also links to the full guidelines, the full summary charts. You can search the MEC by condition. OK, I've got a person in my office, she has lupus. I wanna know what what the guidelines are on which contraception she can use. So I can look at MEC by condition. Or, you know what, I want to know more about combined hormonal contraceptives. And so let me look this by method and then look into the details uh there. The SPR uh has some of those summary charts that we went, we walked through. How you can be reasonably certain how, uh, uh, someone is not pregnant. How do you manage irregular bleeding with a hormonal IUD? When can I start an injection? Any of those, um, um, Uh, they're all available in the app. And then this is where I'm going to switch to my YouTube because, oh dang, let me pull back up. OK. Uh, because, and I already said it like this is one of my, my projects when I was, um, a guest researcher at CDC was to design this tutorial on how to use the MEC SPR app. It's embedded in the app, you can totally look it up, um, and I put this on 1.5 speed, so, but bear with me here, we're gonna, we're gonna watch it. This tutorial demonstrates the basic features of the CDC contraception app, referencing the US medical eligibility criteria for contraceptive use, MEC, and the US selected practice recommendations for contraceptive use, SPR. There are links to the full version of these documents in the app and the CDC Division of Reproductive Health website. The US MEC contains recommendations for contraceptive methods for women with select medical conditions or characteristics. These guidelines are intended to assist providers in counseling patients in combination with their clinical judgment and a patient's values and preferences. When you open the app, you can search the US MEC by selecting MEC by condition or MEC by method. US MEC recommendations are divided into four categories. Category 1, there is no restriction to use that contraceptive. Category 2, the advantages of using the method generally outweigh the risks. Category 3, the risks of a method generally outweigh the advantages, and Category 4, there is an unacceptable health risk for using that method with that specific condition. For some conditions, there are different recommendations for initiating a method and continuing with that method, if a patient is already using it when she develops the condition. For example, if a patient has a current chlamydial infection, IUDs are designated as category 4 and should not be used. If a patient is diagnosed with chlamydial infection while using an IUD, continuing to use an IUD is designated as category 2. The USSPR is an evidence-based source of clinical guidance that answers common contraceptive management questions. To access these recommendations, click SPR on the main menu, then select a contraceptive method. The app will display relevant topics like contraceptive initiation, medically indicated exams and tests, and follow-up care. In the main menu, you will find provider tools where you can access clinical guidance charts for topics like how to be reasonably certain that a woman is not pregnant and late or missed combined oral contraceptives. Let's talk through a hypothetical patient to demonstrate how to use the app in a clinical setting. A 19 year old niperous woman with a BMI of 35 and migraine without Aura comes to your office for a wellness visit. She's interested in starting contraception. She's considering birth control pills because she has used them before. You open the CDC contraception app and navigate to the US MEC by condition page. You can select up to 3 conditions to compare recommendations. Choose the subconditions that match the patient's history. For this patient, you want to see recommendations for age, obesity, and headache. Then select continue. The recommendations for each condition you selected are now displayed. You can move between the conditions by clicking the left and right arrows. Combined hormonal contraceptives or CHCs are category one for age. And category 2 for both obesity and migraine without aura. Considering these recommendations, CHCs are a relatively safe option for this patient. For more information on a specific recommendation, you can see the clarifications, evidence or comments by clicking the row, number, or plus sign for a given condition and method. The patient tells you she has not been sexually active since her last menstrual period, which was 2 weeks ago. You want to know how to counsel her on when to start her contraceptive pills. From the US MEC recommendations page, you can view the US SPR by selecting the SPR button, or you can return to the main menu and select SPR. Choose combined hormonal contraception and initiation. The US SPR recommends that CHCs can be initiated at any time if it is reasonably certain that the woman is not pregnant. For more information, click box 2 to confirm that it is safe to start the patient on pills today, since she has not had sexual intercourse since the start of Last Normal menses. For more information or assistance, please check out the in-app menu or visit the CDC Division of Reproductive Health website. Awesome. Thanks for indulging me. Let's get this back up. So hopefully that kind of um hit home some of the things that we've already talked about and obviously it's also a walkthrough of oops let's share. There we go. Um, walkthrough of how to use the app. The last thing I'll do before we wrap up here is just to call out some of the other resources that are available. So online, on the CDC website, you can find the MEC summary table, the SPR tables, um, as I maybe hinted at the top, there is some printed copies of these. They actually just ran out of the 2024 summary chart. I tried to buy more. Uh, it's free. I tried to request more, um, but there are some printouts for the provider tools for the SPR Super handy to have on hand in, in, in your clinic, uh, or like I said, you can always search for those reference charts, look into your app or other places if you want a quick reference. The website has all of the full guidelines in their um like research manuscript form, a summary of guidelines, and all the provider tools that we've talked about. So the last thing that I will cover, and then we'll have time for questions, is when and how to refer to us at Way Family Planning. We have some mission, visions and values. We've existed since 2005, although some of us have come and gone. Here's who we are currently. Uh, Doctor Eisenberg is our division chief. I've been here now for going on 4 years. We just hired a new, uh, provider, Doctor Katherine Thomas, who just joined us from Pittsburgh in the last year. And we have one, women's health nurse practitioner, Susan, who primarily staffs our C3 clinic, which I'll talk about. We also have a fellowship program, um, as you heard from Nicole. Uh, and we have two clinical fellows at any given time, a 1 year and a 2nd year. So Doctor Shetty is soon to graduate and we will soon welcome Doctor Corbessa, who's gonna be our incoming fellow starting in August. So you may interact with any and all of us. We also are not just the clinicians, but all of the behind the scenes and patient facing uh folks, including program coordinators, schedulers, uh MA's, and clinic administrators. So what are the things that we do? Uh, our division covers complex family planning, which is contraception, abortion, pregnancy loss, but also general gynecology, as you heard. So, yes, we are um the provider for procedural abortion, AKA DNA, dilation and evacuation for folks with pregnancy loss um in the second trimester. Currently, we are still only providing induced abortion for medical emergencies, although if you any of you are attuned, um, uh, Amendment 3, which passed in Missouri, does allow normal abortion. We, we do not perform that at WashU. We also see folks for complex contraceptive visits. So, yes, you are now fully equipped to take care of the person with lupus and thrombocytopenia and obesity and But please refer them to us if you would prefer, uh, because that's our wheelhouse. We, we, we love the nuance, we love the nitty gritty of, of determining contraceptive use and access. Some of the patient benefits besides all of the things that we have to offer, is that we usually can offer a same day LAC placement, so rather than having to have a consult visit first and then come see us for an IUD we can often do that same day. We, the three faculty, uh Doctor Thomas, Doctor Eisenberg, and myself are the adult, uh, transgender GYN providers. So folks who are transgender, gender diverse who don't want to be seen in a classic women's health space, um, can see us in our gender neutral space in the Center for Advanced Medicine. We also provide uh surgical consultations for gender confirming hysterectomies. Here's our number. Please call us anytime. But there's also a new EPI referral. So if you go into Epic and search for ambulatory referral complex family planning, this is the screen that will pop up. Just like any referral, you can mention, you know, some of the specifications when you think somebody needs to be seen. I'll call out that the priority routine versus urgent. Please leave the urgent button for folks who are experiencing pregnancy loss or have a potential medical emergency, and they may qualify for an induced abortion. Um, the next button I will direct your attention to is whether you want specifically to refer to the transgender clinic or everything else. Uh, there's just two different schedulers that look at that. So if it's specifically for transgender, gender diverse services, please click that. All others, contraception, pregnancy loss. Sterilization, complex gynecology. You can send uh select complex family planning. Besides our private practice, we also had the contraceptive Choice Center, which is a federally funded Title 10 clinic that provides contra uh family planning services uh largely well-woman exams, Pap smears, colposcopies, STI screening and treatment for men, people assigned to male at birth, we can see in our C3 clinic. And this is a really great resource for folks who are uninsured, underinsured, or for whom insurance does not cover contraceptive costs, uh, yes, um, and you can see some of the services that we have here. We just opened a new site for C3 at the spot uh down in the Central West End, supporting positive opportunities for teens in order to increase access for adolescent patients. And that's what I've got for you. Created by Presenters Jennifer Reeves, MD, MPH Obstetrics & Gynecology, Gynecology View full profile
