What is your favorite recommendation for birth control for women with migraines? For women who are breastfeeding? For women with a history of pelvic inflammatory disease? For women with obesity? Deciding on the perfect contraceptive recommendation for each of these clinical scenarios can be difficult. Contraception is a personal choice for every woman. However, in certain situations, medical comorbidities or unique situations may skew a physician's recommendations towards certain options. This week I harness the full power of Twitter polls to find your favorite recommendations for each of the above clinical scenarios, paired with some useful factoids about each situation.
My Twitter poll showed that the IUD was the big favorite for women with migraines. The copper IUD garnered 44% of the vote, and the Mirena IUD clocked in at 37% of the vote. In assessing a patient with complaints of headaches, characterizing the type of headache is the first important step. Differentiating migraine with aura from other headaches is essential because migraine with aura is a contraindication for any birth control containing estrogen due to the increased risk of stroke.
During their training, most OBGYN's are taught that estrogen during breast-feeding is a no-no because it cuts the breast milk supply. Our results reflect this common teaching. The combined hormonal contraceptives pill, which has estrogen, earned 0% of the vote. Studies have resulted in conflicting evidence about the effects of estrogen on milk volume, but the CDC reports that the effects are thought to be greatest in the first 3 weeks after birth. The Twitter vote was split between the remaining options, all of which either included only progesterone or no hormones at all. Four weeks postpartum, both the copper and hormonal IUDs are recommended forms of birth control, regardless of breastfeeding status. At 6-8 weeks postpartum, placement of a Copper vs. hormonal IUD has been shown not to affect breastfeeding continuation or infant growth. Studies have also shown that the implant does not have negative effects on breastfeeding duration or exclusivity.
Pelvic Inflammatory Disease
Of all of the clinical scenarios, this poll was the most split between the four options. There is concern about an increased risk of "seeding" pelvic infections into the uterus during insertion of an IUD. Respondents did not shy away from the IUD, however, recognizing that a history of PID is not a contraindication to an IUD. The risk of PID from insertion of an IUD is 1.6 per 1000 and occurs within 3 weeks. That risk is not ameliorated by prophylactic antibiotics or by screening for gonorrhea/chlamydia prior to insertion. Of course, IUD placement is contraindicated during acute, active PID.
My poll respondents avoided the combined hormonal pill for their patients with obesity, favoring instead IUDs. Perhaps this finding reveals a general preference for LARC, or it may reflect physicians' reluctance to use the oral contraceptive pill when the dosing may not be adequate for patients with higher BMI. Both the copper and hormonal IUDs act locally within the uterus. Therefore, their mechanism of action is independent of systemic hormone levels, which could be affected by BMI. To back up this claim, the CHOICE project demonstrated that IUDs were equally efficacious regardless of BMI in the 6,000 women enrolled in the study. The implant came in third place in the poll with 13% of the vote. The CHOICE project showed no significant difference in efficacy of the implant by BMI. Combined hormonal contraceptives are less strongly recommended by the CDC for women with obesity due to concerns about efficacy and increased risk of blood clots. Obesity more than doubles the risk of venous thromboembolism associated with combined hormonal contraceptives pills.
We want to hear from you! Do you agree with the poll findings? What are your best recommendations for the above clinical scenarios?