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Patient-Centered Contraception:

This presentation provides updates on rates of unintended pregnancy and contraceptive use in the US, as well as evidence-based guidelines for contraceptive provision using the CDC MEC. It also discusses patient-centered care and contraceptive options.

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Patient-Centered Contraception:

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  1. Patient-Centered Contraception: Updates on the Evidence

  2. Objectives • Discuss rates of unintended pregnancy and contraceptive use in the US • Apply evidenced-based guidelines to contraceptive provision using the CDC MEC • Provide contraceptive options using patient centered care

  3. Nearly half (45%) of pregnancies in the US are unintended

  4. Unintended pregnancy by consistency of contraception use

  5. One year failure rates

  6. Contraceptive Methods in the U.S.

  7. The MEC US Medical Eligibility Criteria (MEC) CDC recommendations for specific contraceptive methods with certain medical conditions

  8. There’s an APP for that: - Can be downloaded on iOS and Android operating systems (https://www.cdc.gov/mobile/mobileapp.html)

  9. MEC Categories of Safety

  10. Another helpful APP… • Contraceptive Point-of-Care App

  11. Cases In contraception management

  12. Yolanda • 16 year old G0P0 presents with UTI symptoms • Had unprotected sex 4 days ago • Urine pregnancy test is negative What do you do next?

  13. Opportunity knocks! • Get a medical history • Ask about contraceptive or preconception needs

  14. Emergency Contraception • Factors that will affect the efficacy of the emergency contraception (EC) pill: • LMP • Timing of last unprotected sex • BMI

  15. Yolanda choses her EC • Yolanda chooses Ella • But also wants to start contraception • When should she start?

  16. Reproductive Health Access Project: Quick Start Algorithm

  17. Contraceptives: What is needed before providing? Pap smear Pelvic/breast exam STI testing Hemoglobin NOT REQUIRED Medical history REQUIRED Blood pressure RECOMMENDED Stewart F, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA. 2001;285:2232-9.

  18. What about estrogen? • Estrogen absolute contraindications: • Migraine with aura • Uncontrolled hypertension • History of DVT/PE • Tobacco use*

  19. What about Yolanda’s UTI?

  20. Medication interactions

  21. What does Yolanda want?

  22. Impact of Choice Pariani S, Heer D, van Arsdol M. Does choice make a difference to contraceptive use? Stud Fam Plann 1991;22(6):384-390.

  23. Yolanda decides to start the pill • Does it matter which pill she starts?

  24. The patch and ring are also similar options…

  25. How many refill should we give Yolanda? Should we dispense one at a time?

  26. Should Yolanda get a prescription for EC too?

  27. Mari • 17 year old, G0P0 • Doesn’t want to get pregnant until she finishes school • Wants a contraception that she can hide from her mom • Hates remembering to take pills • What are her choices?

  28. Highly effective methodsNOT USER DEPENDENT

  29. Progestin-Only Injection

  30. Depo-Provera and Bone Density What are the real risks for teens? exercise and diet are more important Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2013. MMWR 2013;62. http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. June 14, 2013.

  31. Intrauterine Devices

  32. IUD considerations • Nulliparity • STI Screening • Timing of placement • Desire for menses

  33. IUD Considerations • Family planning timeline • Medication cost • Risk of ectopic

  34. Progestin Implant • Highly effective and rapidly reversible • Discreet • Duration: 5 years • Can be used during lactation • Causes spotting

  35. Jamie • Jamie is a 28 year old transgender male. He is interested in preventing pregnancy, and has both male and female partners. He has not had any surgeries, and is not on hormone therapy but may be interested in the future. • What are Jamie’s options?

  36. Office Barriers to Adherence

  37. Inconsistent Pill Use:Linked to low satisfaction with clinician & low continuity of care Percent of pill users who missed one or more pills during the past three months Landry, David. Public and private providers involvement in improving their patients contraceptive use Contraception 2008 Jul 78 (1) 42-51.

  38. Feeling Unable to Reach a Provider With Questions is Linked to Contraceptive Non-Use % of at-risk women experiencing contraceptive non-use in the past year Landry, David. Public and private providers involvement in improving their patients contraceptive use Contraception 2008 Jul 78 (1) 42-51.

  39. Take home message: Be proactive with contraception! • Ask about contraceptive or preconception needs at all types of visits • Discuss all methods - always honor a patient’s choice • De-link pap smears from contraception prescriptions • Prescribe 1 year supply with 3 packs at a time • Use Quick Start

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