NABEEL BONDAGJI, MD, NABEEL BONDAGJI, MD, FRCSCFRCSC

CONSULTANT PERINATOLOGISTCONSULTANT PERINATOLOGIST

KFSH&RC - JEDDAHKFSH&RC - JEDDAH

““CONTRACEPTION IN CONTRACEPTION IN WOMEN WITH WOMEN WITH

MEDICAL MEDICAL DISORDERS”DISORDERS”

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

Evaluation of the Evaluation of the Evidence Based On:Evidence Based On:

Evidence obtained from at least one properly Evidence obtained from at least one properly designed randomized controlled trial. designed randomized controlled trial.

Evidence obtained from well-designed Evidence obtained from well-designed controlled trials without randomization.controlled trials without randomization.

Evidence obtained from well-designed cohort Evidence obtained from well-designed cohort or case-control analytic studies, preferably or case-control analytic studies, preferably from more than one center or research from more than one center or research group.group.

..

(Cont’d - Evaluation of (Cont’d - Evaluation of the Studies Based On:the Studies Based On:

Evidence obtained from multiple time series with or without the intervention.

Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

.

Evaluation of the Evaluation of the recommendation Based recommendation Based

On:On: Based on the highest level of evidence Based on the highest level of evidence found in the data, recommendations are found in the data, recommendations are provided and graded according to the provided and graded according to the following categories:following categories:

Level A -Level A - Recommendations are based on Recommendations are based on good and consistent scientific evidence.good and consistent scientific evidence.

Level B -Level B - Recommendations are based on Recommendations are based on limited or inconsistent scientific evidence.limited or inconsistent scientific evidence.

Level C -Level C - Recommendations are based Recommendations are based primarily on consensus and expert opinion.primarily on consensus and expert opinion.

MEDICAL DISORDERSMEDICAL DISORDERS

D.M.D.M. HypertensionHypertension Venous thrombosisVenous thrombosis Migraine headacheMigraine headache Fibrocystic breast changesFibrocystic breast changes Fibro adenomaFibro adenoma Family history of breast CaFamily history of breast Ca

( Cont’d) - MEDICAL ( Cont’d) - MEDICAL DISORDERSDISORDERS

HyperlipidemiaHyperlipidemia Sickle cell diseaseSickle cell disease SLESLE Patients who underwent Patients who underwent

valvular cardiac valvular cardiac replacementreplacement

Patients on MedicationsPatients on Medications

Anticoagulant Anticoagulant therapytherapy

DrugsDrugs

AntibioticsAntibiotics

D.M.D.M.Concerns:Concerns:CBCPCBCP

Theoretically impairment of Theoretically impairment of carbohydratecarbohydrate

progesterone component.progesterone component. Increased insulin and increased glucoseIncreased insulin and increased glucose Increase in the peripheral resistance to Increase in the peripheral resistance to

insulininsulin

Progesterone only pills (minipills)Progesterone only pills (minipills)

ImplantsImplants

DMPADMPASame Concern

I.U.C.DI.U.C.D .. Immunity compromisedImmunity compromised Increased risk of infectionIncreased risk of infection

Mechanical barriers Mechanical barriers methodsmethods

Permanent MethodsPermanent MethodsNo major concerns

Evidence in D. M.Evidence in D. M.The use of low does BCP did not alter The use of low does BCP did not alter the blood sugar content nor the blood sugar content nor accelerate the complications. accelerate the complications. Evidence Level IIEvidence Level II

No increased risk in CBCP user to No increased risk in CBCP user to developdevelop DM. DM.

Evidence Level IIEvidence Level II

Progesterone only pills- Progesterone only pills- No No conclusive evidence.conclusive evidence.

I.U.C.D. in well-controlled D.M. – No I.U.C.D. in well-controlled D.M. – No major difference in the risk of major difference in the risk of infection.infection.

Evidence Level IIEvidence Level II

RecommendationsRecommendationsMechanical barriersMechanical barriers

Permanent sterilizationPermanent sterilization

Low dose CPCP in:Low dose CPCP in: Non-smokerNon-smoker 35 years old or younger35 years old or younger No hypertension, retinopathy, or No hypertension, retinopathy, or

vascular diseasevascular disease Level BLevel B

I.U.C.D.I.U.C.D. Level BLevel B

HypertensionHypertensionConcerns:Concerns: CBCPCBCP

Increase in blood pressure 8/6 Increase in blood pressure 8/6 mmHgmmHg

Increased risk of vascular Increased risk of vascular events, increased three (3) fold events, increased three (3) fold in hypertensive on CBCPin hypertensive on CBCP

Increased risk of IHDIncreased risk of IHD

Minipills Same concerns

I.U.C.D. No major concerns

Mechanical barriers No major concerns

(Cont’d) - (Cont’d) - HypertensionHypertension

RecommendationsRecommendationsBCP

Women who have: Well-controlled BP

35 years old or younger

Non-smoker

No end organ damage Are allowed to have a trial of CBCP for a

few months if BP remains controlled to continue.

Level B

(Cont’d) - (Cont’d) - RecommendationsRecommendations

I.U.C.D. No contraindication but no compelling

evidence of its safety (no major studies) Mechanical Barriers Permanent Sterilization

Women with Fibrocystic Breast Women with Fibrocystic Breast Changes, Fibroderoma, Family Changes, Fibroderoma, Family

History of Breast CaHistory of Breast CaConcerns:Concerns:

CBCPCBCP Increased risk of breast Ca, small Increased risk of breast Ca, small

but not significantbut not significant Estrogen componentEstrogen component

Progesterone pill, implants DMPAProgesterone pill, implants DMPA No major concernsNo major concerns

I.U.C.D.I.U.C.D. No major concernsNo major concerns

RecommendationsRecommendations CBCPCBCP

Women with fibroadenoma or benign Women with fibroadenoma or benign breast disease or family history of breast disease or family history of breast Ca can use CBbreast Ca can use CBCPCP safely. safely.

Level ALevel A

Progesterone only pillProgesterone only pill SafeSafe

I.U.C.D.I.U.C.D. SafeSafe

Barriers and permanent Barriers and permanent sterilizationsterilization SafeSafe

Migraine HeadacheMigraine HeadacheConcerns:Concerns:

CBCPCBCP

In women with focal neurological signs four(4) fold In women with focal neurological signs four(4) fold increase in ischemic stroke.increase in ischemic stroke.

Risks increase in smokers thirty-four (34) fold. Risks increase in smokers thirty-four (34) fold. (Level II)(Level II)

Women with no focal neurological signs, no major Women with no focal neurological signs, no major increase in risk. increase in risk. (Level II) (Level II)

Progesterone containing BC method – same concern.Progesterone containing BC method – same concern.

I.U.C.D. – no major concern.I.U.C.D. – no major concern.

Mechanical barriers or permanent sterilization – no Mechanical barriers or permanent sterilization – no major concerns.major concerns.

RecommendationsRecommendationsCBCP

Contraindicated in patients with migraine headache with neurological signs and can be used in patients without neurological signs, non-smoker, and younger than 35 years old.

To be discontinued if they develop

increase in headaches.

Level B

(Cont’d) - (Cont’d) - RecommendationsRecommendations

I.U.C.D. Safe

Mechanical barriers or permanent sterilization Safe

Patients who have Patients who have Undergone Cardiac Undergone Cardiac

Valvular ReplacementValvular ReplacementConcerns:Concerns:CBCPCBCP

Micro-emboli Estrogen effectMicro-emboli Estrogen effect I.U.C.D.I.U.C.D.

Risk of SBERisk of SBE

Barriers and permanent sterilizationBarriers and permanent sterilization No major concernsNo major concerns

RecommendationsRecommendationsCBCPCBCP

ContraindicatedContraindicated

Level ALevel A

Progesterone only pillProgesterone only pill May be usedMay be used

Level BLevel B

I.U.C.D.I.U.C.D. No evidence to state that increased rate of SBE, No evidence to state that increased rate of SBE,

therefore, may be used therefore, may be used Level CLevel C

Patients on Anti-Patients on Anti-Coagulants Coagulants

RecommendationsRecommendations CBCPCBCP

May be usedMay be used

Level BLevel B

Progesterone only pillProgesterone only pill May be usedMay be used

Level ALevel A

(Cont’d) - Patients on Anti-(Cont’d) - Patients on Anti-Coagulants Coagulants

RecommendationsRecommendations

I.U.C.D. No major data

Can be used

Level C

Women with Women with HyperlipidemiaHyperlipidemia

Concerns:Concerns:CBCPCBCP

Progesterone componentProgesterone component Increased LDL, decreased HDLIncreased LDL, decreased HDL Estrogen componentEstrogen component Decreased LDL, increased HDLDecreased LDL, increased HDL

Progesterone only pillProgesterone only pill Increased riskIncreased risk

I.U.C.D.I.U.C.D. No effectNo effect

Mechanical barriersMechanical barriers No effectNo effect

RecommendationsRecommendations Women with controlled lipid profile may Women with controlled lipid profile may used CBCP.used CBCP. Women with uncontrolled lipid profile Women with uncontrolled lipid profile should not use CBCP.should not use CBCP.

Level CLevel C Progesterone containing agent, Progesterone containing agent, contraindicatedcontraindicated

Level BLevel B I.U.C.D., safeI.U.C.D., safe

Level ALevel A

Women with SLEWomen with SLEConcerns:Concerns:

CBCPCBCP Increased flare up attacksIncreased flare up attacks Increased incidence of DVTIncreased incidence of DVT

Level IVLevel IV

Progesterone only pillProgesterone only pill No increased riskNo increased risk

Level IILevel II

RecommendationsRecommendationsCBCPCBCP

To be avoidedTo be avoided Level BLevel B

ProgesteroneProgesterone only pill, DMPA, and implants are the only pill, DMPA, and implants are the methods of choice for SLE patients.methods of choice for SLE patients.

Level BLevel B

I.U.C.D.,I.U.C.D., barrier method, permanent sterilization. barrier method, permanent sterilization. SafeSafe

Sickle Cell DiseaseSickle Cell DiseaseCBCPCBCP

Increased risk of vaso-occlusive Increased risk of vaso-occlusive

crisiscrisis

Level IIILevel III No major evidenceNo major evidence

DMPADMPA Decreased incidence of vaso-Decreased incidence of vaso-

occlusiveocclusive

crisiscrisis

Level IILevel II

(Cont.’d) - Sickle Cell (Cont.’d) - Sickle Cell DiseaseDisease

I.U.C.D. No major concerns No data

Mechanical and permanent Safe

Level II

RecommendationsRecommendations

CBCPCBCP To be avoidedTo be avoided

Level CLevel C

DMPADMPA To be usedTo be used

Level BLevel B

Patients with History ofPatients with History of Venous ThrombosisVenous Thrombosis

Concerns:CBCP

Increased risk of venous thrombosis four (4) fold than non-users.

Mainly the estrogen component.

Progesterone only pills No major concerns

(Cont’d) - Patients with (Cont’d) - Patients with History ofHistory of

Venous ThrombosisVenous ThrombosisConcerns:Mechanical barriers or

permanent sterilization. No major concerns

MPA and implants (hematoma)

I.U.C.D. menorrhagia in patient on anti-coagulant therapy

RecommendationsRecommendationsCBCP

Contraindicated except during anti- coagulation therapy

Level A

Progesterone only pills Recommended in patients with VTE

Level A

DMPA implants should be avoided

Level A

(Cont’d) - (Cont’d) - RecommendationsRecommendations

I.U.C.D. Can be used in patients who are off anti-

coagulation therapy May be used during anti-coagulation

therapy provided that patient does not develop significant menorrhagia

Mechanical barrier and permanent

sterilization methods allowed.

Thank Thank You..You..