Consider long-acting contraceptives for all women of reproductive age and at cardiometabolic risk
LAS VEGAS — Long-acting reversible contraceptives are the recommended option for women and adolescents with cardiometabolic risk, according to an expert here at the Cardiometabolic Risk Summit.
Jeffrey P. Levine, MD, MPH, professor and director of Women's Health Programs at the Rutgers Robert Wood Johnson Medical School, encouraged primary care providers to counsel patients regarding contraceptive options from "LARC down, not pill up."
He acknowledged that while the Affordable Care Act is still under fire, from a women's health perspective, it was helpful in providing women with insurance and preventive care, which includes FDA-approved contraceptive methods.
"About half of women in this country of reproductive age had unintended pregnancy, but we've cut it down to about 45%," Levine said. "But that number is still way too high. Two in five women with unintended pregnancy end with elective abortion. This is still a major public health issue."
He noted that unintended pregnancy reduces to 5% if women use contraceptives both consistently and correctly.
"From both a patient and clinician perspective, it's really hard to prevent pregnancy," he admitted. Over the course of a woman's reproductive timeline, if she has two kids, she's still trying to prevent pregnancy for about 28 years.
"But what does this have to do with cardiometabolic risk?" Levine asked. He pointed to a list of cardiometabolic conditions which included diabetes, hypertension and heart disease and said "if a woman were to get pregnant, it would not only put her at high risk for morbidity, but mortality as well — not only for her, but the fetus, too."
He urged providers to consider LARCs — both IUDs and implants — noting that the American College of Gynecology, the American Academy of Family Physicians and the American Academy of Pediatrics all recommend LARCs as a first-line contraceptive.
Levine said that there are a variety of reasons for this: patients don't have to remember it each day like they would with a pill-form contraceptive, they are highly effective for 3 to 10 years and they have high continuation rates because women are satisfied.
Despite this, Levine said, LARCs are still underutilized.
"It takes about 2 years for evidence to go into practice," he said. "For contraceptives, it can take 2 decades."
Levine said that in the United States there is a "dearth of trained and willing professionals to insert devices," as well as negative publicity, misconceptions, fear of litigation and a lack of awareness.
"Women are just not aware that this is an option for them, so they're not going to ask for it," he said. "If we don't learn how to talk to patients to help them understand the options, the unintended pregnancy rates probably won't change."
Levine recommended using a point-of-care tool similar to WHO's Medical eligibility criteria for contraceptive use to determine what kind of contraception is best for patients. The tool, the United States Medical Eligibility Criteria for Contraceptive Use, is provided by the CDC as a chart and smartphone app and covers a variety of conditions and situations such diabetes, cancer, hypertension, IBS, headaches, obese, pulmonary embolism or postpartum or breastfeeding status.
"It provides you very easy, immediate access when you're in the room with a patient who may have a comorbidity," he said. "What can I do with that patient to provide them with effective contraception?"
Levine said that many women with cardiometabolic conditions would be best served by LARCs, and it is important for providers to dispel myths.
IUDs are not abortifacients because they prevent conception, he said. In addition, they do not cause ectopic pregnancies or pelvic infections and do not affect fertility. They are not large and can be used by women who have not had children.
He told health care providers that they need to be taking a comprehensive contraceptive history, which includes their gender preference, frequency of intercourse, problems with past and current methods and information on their partner.
“But there are two things you absolutely need to start including,” he said, referring to their pregnancy intention and their ability to cope with contraceptive failure.
Levine said that any patient who wants to get pregnant within a year needs to leave the office with prenatal vitamins. But patients who are not looking to get pregnant long-term need to be counseled on contraceptive options, starting with LARC options.
Those options can include the Nexplanon implant (Merck) or IUDs such as Liletta (Allergan), Mirena (Bayer), Skyla (Bayer), ParaGard (Teva) and the recently approved Kyleena (Bayer).
He suggested counseling patients — especially those who may need more time to think about their choices.
"Patients don't always make up their mind right there," he said. "No matter what a great job you did, they're going to forget what you said as soon as they walk out that door. Give them unbranded, evidence-based information."
He encouraged physicians to share decision making with the patients — to provide the treatment options with their benefits and risks and take into account the patient’s preferences, values, concerns and lifestyle choices.
Levine said that if physicians keep up with the latest evidence, are effective in communication, are proactive about LARCs recommendations and become trained in LARC insertion or knowledgeable about providers that do, they will be able to provide women with adequate reproductive care and ultimately reduce unintended pregnancy.
"I want you to remember that life is sexually transmitted," Levine concluded. "I hope that you and your patients can adopt Planned Parenthood's philosophy that every child is a wanted one."– by Chelsea Frajerman Pardes
Disclosures: Levine reports being on the speaker’s bureau for Merck and is a Nexplanon trainer.
Levine JP. Contraceptive considerations for women at cardiometabolic risk. Presented at: Cardiometabolic Risk Summit Fall; Oct. 14-16, 2016; Las Vegas.
Summary Chart of US Medical Eligibility Criteria (USMEC) for Contraceptive Use.