Clinical Pearls for Contraceptive Management of Women with Developmental Disabilities

– Emeritus of obstetrics, gynecology and reproductive sciences
at the University of California, San Francisco
School of Medicine. Retired from practice in
September, I didn’t know that, after a 34 year career
as a clinician educator of OBGYN and primary care residence at San Francisco General Hospital. And since 2015, he’s
been a clinical fellow for the National Family Planning and Reproductive Health Association, providing advice on clinical issues and reproductive health policy, and I got his clinical
opinion at lunchtime. So Dr. Policar is gonna talk to us about contraception and other topics. Dr. Policar. – Thank you. (applause) Nice to actually be back in this room, it’s been quite a while. Thank you for the
invitation, and you’ve heard a little bit about my
connection to this issue of family planning and menstrual issues as they come up for women with
a variety of disabilities. At our clinic, at the San
Francisco General Hospital, our women’s health center on 5M, we were oftentimes a referral site for women who had a variety of conditions where they needed a gynecology consult, and we assisted in making the decisions about whether to use hormones
or not and IUD or not, what type and so on. So that is mainly the perspective that I’m going to bring to you today, as well as kind of what’s new in the world of family planning so
that you can think about how to apply that to your patients. However, before I jump in and get started, whenever I talk about contraception, sometimes when I talk about
it, everyone (mumbles). I like to tell you about my bike team. So there are a number of us
at the San Francisco General in the OBGYN department who have ridden in the Waves to Wine,
which is a fundraiser for multiple sclerosis. We’ve done that for 10 years, we’ve raised almost a million dollars in doing that. But I thought you’d be really interested in the name of our bike team. (audience laughter) So that is the actual back of our jersey. We’re pretty well known
between here and Santa Rosa, which is the termination
of the Waves to Wine. Our bike team even has a team motto. We are the best bike team period. (audience laughter) So I’m gonna be talking
about family planning, and we, you know, most of
the folks in the picture are my family planning colleagues
at San Francisco General, and also talking a lot about bleeding. But before I jump into
that, I wanna tell you about our go-to guidelines, the Centers for Disease Control, over the last decade, has developed some incredibly helpful evidence-based guidelines when
it comes to family planning. And there are two in particular
that we use every day. And the reason that I tell you about them is that some of the sections in both of these different
guidelines have to do with the safety and the efficacy
of contraceptive methods in women who have a variety
of chronic medical conditions, disabilities or sometimes both. The first and most important is called the CDC Medical Eligibility Criteria, its most recent update
was a couple of years ago. And it mainly looks at safety, so tells us about 10 or
11 different categories of contraception, and
then 60 different kinds of chronic conditions and the safety of using a contraceptive for each, a particular contraceptive
for each of those conditions. One of the reasons I tell you about it is that I’m going to be
using the MEC grading system as we go through three
different case studies. But the way that this works is that, if it’s MEC category
one or two, basically, it is safe to use a particular
method of contraception for a woman who has the specified disease. If it’s a category three, it means that sort of an equal balance
of benefit and harms, but always it’s safer to use
the method of contraception than it is to become pregnant. And then the fours are the ones where we avoid a particular
method of contraception when a woman has an
underlying medical condition, just because the risk
of the method is more, is clearly more harmful than it is for her to use it, sometimes even more than the risk of pregnancy. But you’ll see those numbers
again in just a moment. The other document that’s important is called the Selected
Practice Recommendations for Contraceptive Use,
originally published in 2013, but updated in 2016. That is much more oriented towards each individual method,
about when to start, when to stop, specifically
how to use the method and then using it in very
specific circumstances. So laid out in a slightly different way, but equally helpful. Now, the important thing is that, with your tax dollars at work,
the CDC actually put together a wonderful app that combines both the medical eligibility criteria and the selected practice recommendations. It’s completely free and the way to get it in the Apple Store or
in the Google Play Store if you have an Android
phone is just to type in the search term CDC and contraception. You can download this, and it’s just an incredibly helpful tool to have when you’re thinking about
what method of contraception might be the most
appropriate for your patient. And I know that our residents
at San Francisco General, most of the family planning people that I work with just
constantly refer to this as our evidence-based database
about safety and efficacy of various methods of contraception. So what I’ve done, and
based on the literature, this wasn’t entirely my
idea, is to put together an algorithm that has to
do with two separate issues that we might deal with in women who have developmental disabilities. One is menstrual period, periods, rather, and irregular menstrual bleeding and how to get that under control. The second is the issue of whether or not that person needs a
method of contraception. And then we can basically
put together a matrix that puts people in the
category of either having bleeding problems or not,
needing contraception or not. But it looks like this,
that it starts with a woman comes in for a visit
with her primary care provider or a woman’s health visit
in a family planning clinic or with an OBGYN. We ask about her sexual activity, her menstrual pattern and hygiene. And let’s say that she does
disclose or her caregiver discloses that she is having problems with menstrual regularity,
maybe very heavy menstrual periods that
are problematic for her. The next question is, is
she also sexually active? And if the answer is yes, there are specific contraceptive methods that I’ll go through
with you in more detail that will both reduce your bleeding, as well as give her very
effective contraception. On the other hand, she may
have menstrual problems, but she’s not sexually active yet, and contraception is not at the forefront. So there’s a slightly different list, and we’ll talk about using NSAIDs as a way of getting menstrual
bleeding under control, and then some of the other
hormonal methods you see would be used less for contraception, but more for menstrual cycle control. On the other hand, we have women who are not complaining
of menstrual problems who have regular periods,
or the amount of bleeding that they have is not
problematic for them. If they’re sexually active, they can use just about any method of contraception, with one or two exceptions
that I will cover. For example, using oral contraceptives or a patch or a ring in a woman who also has a problem
with a seizure disorder because of the possibility of interactions with her antiepileptic medication and the use of pills, patch or ring. And then the last part
of that two by two table is women who don’t have menstrual problems and who are not sexually active yet. And in that circumstance, of course, none of these hormonal approaches would be appropriate at this time until she discloses that she is interested in becoming sexually active. Now, you may have noticed the asterisk that was present on the question about do you need contraception or not, and Erica has done a really nice job of how to have those initial conversations about whether you are
sexually active, if not, whether you’re thinking about
becoming sexually active. So the way we would
start in our OBGYN clinic is to assess her capacity
to consent to having sex. And if she was having
non-consensual intercourse, then, of course, we would be
working with her caregiver and probably going through the
process of reporting abuse. But on the other hand, if she was having consensual sexual activity,
the kinds of topics that we would be covering
would have to do with intimacy and safety issues, physical
safety issues with her partner. Number two, whether there’s a possibility of having acquired a sexually
transmitted infection. Screening for that, of course, treating for it if it’s
needed, as well as providing some amount of education
about STD prevention. A slightly different conversation
about choosing a method of contraception for many patients. That is a much more detailed conversation based on shared decision making about going through the whole menu
of contraceptive methods and asking the question of
what are you really looking for in a contraceptive method. Not what method do you
want, but what do you want in a method, which is really
a much more important question in helping people to decide
which method she would like to be able to use. However, the kinds of things that we’re certainly gonna
cover in this discussion is what are the available
methods of contraception, the pros and cons of ones that
might be most appropriate. Of course, the issue of informed consent, whether that can be done
by the patient herself or whether there’s a
guardian or a caregiver that would help her with that, and instructions regarding the correct and consistent use of the method. And then always, always
agreeing to a follow-up plan so that, if she’s having bleeding or pain or other problems, that we
can address that promptly. So let’s start with the
first of our three patients, she’s Jena, 19 years old,
she was born prematurely at 26 weeks, she had a
birth weight of 1,100 grams. She has both visual and
hearing difficulties since childhood, which
may have been related to her very low birth
weight and the months that she spent in ICU. She now also has mood problems, she complains of irregular
heavy menstrual periods. Dysmenorrhea means that her periods are also quite painful and crampy. In general, would really
like her periods to stop if at all possible. She is sexually active
with a 19 year old male, and she feels safe and
comfortable in that relationship. On physical exam, her body
mass index or BMI is 34, so she’s somewhat overweight,
her blood pressure is normal, she has mild facial hirsutism. So when you put together
both her body weight, as well as her regular
periods and her facial hair, you think about chronic anovulation or polycystic ovary syndrome as a reason for her irregular menstrual periods. So with Jena, we have two
things that we wanna address, hopefully at the same time. Number one is to address her complaint about her heavy and irregular
periods, and number two, the fact that she’s sexually active and wants protection against pregnancy. So here we are in this
part of the algorithm where she does have menstrual problems, she is sexually active. And the most appropriate approaches would be a Levonorgestrel
Intrauterine System or IUD; DMPA, which is Depo-Provera; extended cycle oral
contraceptives; or POP, stands for progestin-only
birth control pills. Before we actually get to those methods, I wanna just preface that with a few other just quick remarks, and
then we’ll talk about how we’re going to manage Jena. One is, what are the variety of things that are available to us
in terms of helping her with her heavy and irregular
periods, and this comes from a really nice clinical practice guideline written by the American
Congress of Obstetricians and Gynecologists a few years ago called Menstrual
Manipulation of Adolescents with Physical and
Developmental Disabilities. I think it’s the best
guideline written in the US on that particular topic. So they first point out
that we can use hormones, sometimes even NSAIDs as a
way of making bleeding less, less frequent, later, but it’s difficult to actually completely
stop menstrual periods. But at least we can make
them way less frequent and way less heavy. Number two is that a non-hormonal approach is to use NSAIDs, that they
decrease ovulatory or even, for that matter, anovulatory
menstrual bleeding by at least a third. And I didn’t put it into your handout, but I knew I’d get a question about okay, which NSAID are you talking about? And the actual go-to NSAID
that we use to try to decrease both menstrual bleeding
and menstrual cramps is naproxen sodium in a
dose between 220 and 440 BID twice a day during the
period of menstrual bleeding, that there’s good evidence
that naproxen sodium actually works significantly
better than Ibuprofen in women to decrease
crampy menstrual periods. But of course, if that’s not
available as Aleve or one of the over the counter
naproxen sodium preparations, then Ibuprofen also
works not quite as well, but it’s gotta be given
in an intermediate dose of 400 to 600 milligrams
three times a day, but only during her menstrual period, only during the time that she’s bleeding. She won’t need it for
the rest of the month in order to anticipate bleeding. And then the ACOG guideline also mentions that we can give oral
contraceptives every single day, what’s called continuous
combined oral contraceptives, over an extended period,
and I’ll be telling you more about that in a few minutes. Progestin-only pills, which are, only one type is available
in the United States, but that’s one that
may go over the counter in the next few years. Works well as a method of contraception, the one problem is the fact
that it’s gotta be taken at the same time every day. So if a person is in a living situation where they may not be able to have the consistency of a daily pill
at the same time every day, then this is a method that
might actually eventuate in some amount of breakthrough bleeding. DMPA, you may know that
as a Depo-Provera shot that’s given every 12 weeks. Not only works really well
as a method of contraception, but it has a tendency to
completely stop periods and induce amenorrhea by the fourth dose, and it very commonly is used for women who have sort of more extreme
developmental disabilities where the idea is to try
to completely dry out menstrual periods if we can do that. The ACOG guideline also points out that the levonorgestrel IUD,
you may know that one by its trade name of
Mirena, but there are now four different levonorgestrel IUDs, are also a very very good choice, because they also induce
amenorrhea, as well as being remarkably effective
as a method of contraception. Which now brings up the
question of efficacy. In the family planning
world for the last 10 years, we have thought of
efficacy in three tears. Top tier are the methods that work so well that there’s less than one pregnancy per 100 couples per year. And those are mainly
contraceptive implants, one implant that goes under
the arm called Nexplanon. Any of the IUDs and tubal
occlusion or tubal ligation that we won’t discuss
today in our patients. Middle tier are the methods
that have a failure rate between 6 and 12 pregnancies
per 100 women per year. And those are drugs like Depo-Provera, the pill, the patch, the
ring and the diaphragm. And then the bottom tier,
with more than 18 pregnancies per 100 women per year,
are barrier methods and natural family planning. So in general, while it’s
not the sole determinant of the most appropriate
method for a woman, if efficacy is really important
to her, then of course, we’d like to go in the
direction of using one of the top tier methods. So for Jena, here are
the sort of pros and cons of each of the methods
that are available to her. A levonorgestrel IUS or
IUD is tier one efficacy, it works extremely well. Its advantage is that,
among the various products, there’s one that works for three years, many of them are FDA
labeled for five years, the evidence says that they
actually work all the way for seven years. So in particular, if a woman, let’s say, needs to go to a surgery
center to have an IUD inserted, you’d like to choose one that she can use for the longest period of time, and even though Mirena, LILETTA, some of the others are
labeled for five years, we know that they work for at least seven, probably even longer. As well as stopping menstrual periods, they also decrease pain
of menstrual periods, dysmenorrhea as well. The disadvantage is that
there are some women with developmental problems
who may not tolerate insertion of the IED in
an outpatient clinic, I’m gonna give some ideas
about how that could be done. But if not, it’s much better, I think, to do it under conscious sedation, either in a special clinic
or in a surgery center. And as well, there might initially be some breakthrough
bleeding, it has a tendency to clear up fairly quickly. Next is DMPA or
Depo-Provera, it doesn’t work quite as well as IUDs. Its advantages are one
shot every 12 weeks, so that means only four
times a year, basically, a little over four times a year. Great job of reducing bleeding and pain of menstrual periods. But one of the things you
may have heard about it is that it can cause weight gain, particularly in adolescents. So if weight gain is an issue, maybe for someone who’s already
on the obese side like Jena, it might not be the best approach. Next is extended oral contraceptives, and what that refers to is remember that birth control pill
packs are 21 days of hormones and then seven days of
a hormone-free interval, seven days off during which (mumbles) have a menstrual period. But extended OCs means
using an active pill every single day. One approach is to do
that for 84 days in a row and then have a 7 day menstrual period, that means you’ll have
four periods a year. Another approach is one
pill a day every single day all year, just no break, basically, and therefore, no periods. That works really well for contraception and really well for menstrual suppression, as long as you can remember
to take your pill every day. And with progestin-only pills, I would say that that’s
not as good a choice, because number one, it’s
tier two in efficacy and it has somewhat more
breakthrough bleeding, it’s important to remember
to take it every day at exactly the same time. But one of its advantages is that it has no estrogen-related side effects. So there are some women
who would like to use the pill, patch or ring, but maybe because they’ve had a DVT or a pulmonary embolism or they don’t like
estrogenic side effects, that they can use one of these methods that has progestin only,
and then not have to deal with the side effects of
something which is estrogenic. So bottom line is that for Jena, we have quite a number of
alternatives for her, both for contraception and to get
her bleeding under control. And I think most OBGYNs would tell you that the ideal approach for her, from our point of view, of course, it’s ultimately her decision, it would be a levonorgestrel IUD
because of its efficacy and inducing either
light menstrual periods, which are hypermenorrhea or amenorrhea, they work remarkably well. And it takes virtually no input from the patient herself
once the IED is in place, so it’s what’s called
forgettable contraception. So they have the IUD inserted
or the implant put in, and then you simply don’t have to worry about your birth control
method for the next anywhere between three
years and seven years. The challenges, of course, as I said, are a woman’s ability to
tolerate a pelvic exam in the outpatient clinic, if not, needing to go to a place where she can have conscious
sedation to have that done, and not only the exam, but
then the procedure itself of putting it in. So I added a few slides about the wisdom that we’ve learned from a
variety of sources and ACOG and others about the pelvic exam itself in women who have a
variety of disabilities. And this one is something that I’m sure all of you live every day. We need some reminders sometimes in the world of women’s
healthcare that the women, woman herself is the one who
entirely guides the exam. And what we have to do first is to ask her how she wants to be examined,
what position works best. Do you have any suggestions
for how we do this? And of course, for me, it’s not only true as it relates to, let’s
say, doing an IUD insertion, but I do a lot of colposcopy for women who have abnormal pap smears,
and significant number of women who were referred to us, let’s say, for example, in a wheelchair. And so always, my first question is what works best for you in terms of how we can transfer you to the exam table? What’s worked best for you when you have a speculum inserted in your vagina so that we can have a look
with a colposcope, for example. It’s virtually never our
decision as clinicians, 98% of the time, our patient
can tell us what’s worked, what hasn’t, and then we
follow her instruction, so it’s a matter of ask,
ask, ask in advance. And she has control. Can you lift the sheet so
that I can start the exam? Asking permission before
each step in the exam, especially for someone who’s
had sexual trauma in the past. Always lift the table
up so that she can see what’s going on instead of being supine or flat on the table, we
offer our patients a mirror so that she can look at
her vulva if she’d like to, and then bearing down with
the insertion of the speculum. So they’re all the mini tricks that we can do to help with the exam. Then another part of that is
a very thorough inspection on the outside because of the possibility of sexual abuse or self-mutilation. By the outside, of
course, I’m talking about on the initial inspection of the vulva. And then remembering about
temperature instability in some people and trying
to keep the room warm and offering a blanket to
be able to keep her warm. Now, I mentioned that, with Jenna, she had some problems since childhood with both vision and with hearing. So there are some things that
we specifically try to do in our clinic with patients
who are vision impaired, and that’s particularly
important in terms of where the helper, whether
that’s a medical assistant or someone that she’s
brought with her will be to be able to sort of explain to her, close to her ear, what’s going on. We offer the opportunity of
feeling the speculum in advance, and of course, being very clear about what we’re doing step by step. And for the hearing impaired patient, we wanna know where her interpreter, if she needs someone to help with signing. We’ll sit, usually it’s sort of a triangle between the clinician who’s
at the end of the exam table, the person who’s doing the sign language and the patient yourself, but you can see in this graphic about the
fact that she’s sitting up, which is a really important part of being able to do this exam,
and by the way, it does not impair your ability to do
a speculum exam at all. All right, now, the
last part of it then is are there any things that you can do to kind of help patients
with the discomfort that they may have, especially
in the circumstances that Erica was talking about a moment ago where someone may be
hypersensitive to pain, just the least amount of touch
is enough to feel painful. So we use a lot of
what’s called verbicaine. I’ll tell you more about
verbicaine in just a second, it just means talking to
people through their procedure, whoops, and distraction. Moving slowly, sometimes
using a local anesthetic at tenaculum side, we’re
doing cervical block. Occasionally, we’ll do oral
sedation in the office, but when we think that the
patient’s not gonna be able to tolerate that very well,
we’ll use conscious sedation in a surgery center. And then there’s some controversies,
particularly with IUDs, about whether or not pre-medication works. NSAIDs probably don’t help
very much with the procedure, although they help with
the cramping afterwards. And there’s a medication
called Misoprostol, you may know of it as Cytotec, which dilates the cervix and softens it. That’s mainly in women who are pregnant. And in non-pregnant women,
doesn’t seem to help as much, and there are six different studies that look at it as a way of
helping with IUD insertions, it doesn’t increase the success rate, it doesn’t make the pain any less, so we don’t use it for that purpose. But verbicaine’s important. Keep her talking. Calm, soothing vocal
tone, a slow, easy pace. I’ll talk to her about how
are the (mumbles) doing, tell me about where you live, the weather, just a variety of things that help. And we love cell phones. And what I mean by that
is if I’ve got a patient who’s having colposcopy
or having an IUD inserted and she’s texting on her cell
phone, I could not be happier. (audience laughter) Just because of the fact that it is a great form of
distraction, and of course, I’ll tell her what’s going on, but that’s a way of self-medication, and it usually will work very well. Now, just to finish up with Jena, Jena decided to have an IUD placed, but she missed her appointment. So she called and stated
that she had unprotected sex with her boyfriend two days ago and didn’t use a method of contraception, and she asked about
the morning after pill. And this obviously may come
up in other circumstances where one of your clients
has hopefully consensual sex, but wasn’t protected and asks you about emergency contraception. So there are two different kinds of emergency contraceptive pills
that I will tell you about. And we can also use a copper IUD, which is actually, by far and away, the most effective approach
to emergency contraception. So the one that’s been
out for the longest time is a levonorgestrel
emergency contraceptive pill. It is a single dose tablet,
you may have heard it referred to as Plan B. It’s supposed to be used within three days of unprotected intercourse. And it works reasonably well as long as you give it within three days, you can actually use that
all the way up to five days, but there’s kind of a drop off between 72 hours and 120 hours. And as I mentioned, Plan B is the generic, I’m sorry, the brand name version, there are many many generic versions that are available in pharmacies now. And you may have heard, remembered that two tablet versions
of Plan B, or even using birth control pills as
emergency contraception. Those are now considered to
be completely out of date. It’s just a single tablet. The other form of emergency contraception is called ulipristal acetate, UPA. So it prevents ovulation even right before that egg is ready to leave the ovary. And it prevents implantation
of a fertilized egg, although a much higher dose
of ulipristal is required. It’s taken as a single 30 milligram dose. And it’s labeled all
the way up to five days from the day of unprotected intercourse, and there’s a single product
out there called Ella and it has to be prescribed. And I’ve already mentioned
that a copper IUD can be used within five days
of unprotected intercourse. It is an off label use,
but widely performed. And it’s a very cost effective approach for the person who needs
both emergency contraception and then a longer term method
of contraception as well, and it works for a full 10 years, according to the package labeling. It actually works longer than
that, probably up to 12 years. Now, an important question
is how can your patient get a supply of emergency contraceptives, and the answer is is that,
with levonorgestrel pills, they’ve been available
over the counter for years, there are no age restrictions. Men and women can buy them, a person doesn’t need to show an ID that has anything to do with their age. The price range is anywhere
between $40 and $50. On the other hand,
ulipristal acetate or Ella does require a prescription. The good news is is that, as part of the Affordable Care Act,
women who have Medicaid, who have commercial
insurance, are entitled to 18 different methods of contraception, including emergency contraceptive pills, without any cost sharing. Thing is is that, in
order for the health plan or Medi-Cal to pay for the
emergency contraceptive pills, either type, prescription
has to be written, that’s mainly for bookkeeping purposes. But there are no out of pocket costs for emergency contraception, as long as you’re able to have a prescription for it. If you just buy it over the counter, then it may be that your health plan won’t pay for it in that circumstance. One last thing to mention
about emergency contraception, and we’ll go to our next patient, is there is a relationship between a person’s body weight
and the likelihood that the emergency contraception will fail. So remember, with Jena,
her BMI was over 30, okay. So basically, this algorithm is a patient asks for
emergency contraception. We counsel her about whether or not she’d be interested in a copper IUD. If she’s not, then the next question is what’s her BMI, her body mass index. If she’s got a BMI of under 35, any of the emergency contraceptive options are both acceptable and efficacious. If she’s a little overweight,
which is a BMI of 26 to 29, the levonorgestrel is less effective than the ulipristal acetate. For a BMI of 30 to 34, there’s no question that the levonorgestrel doesn’t work nearly as well as ulipristal. And many of us feel that
it shouldn’t even be used in a person who has a BMI of over 30, I would be way more in
favor of using ulipristal with Jena than I would
be using levonorgestrel because of her body weight
and the likelihood of failure. And then, for women who
have a BMI of over 35, neither of them work. And in that circumstance,
you really have to use a copper IUD if you wanna
do emergency contraception, ’cause its efficacy has no
relationship at all to weight. All right, well, that’s
what we’ll do for Jena. The next patient is Paula. So she is a 24 year old woman who has autism spectrum disorder. She’s virginal, she has no
interest in sexual activity. But she does have unpredictable menses and an aversion to
changing her menstrual pads and she doesn’t even wanna try tampon use. Given the fact that she’s
never had intercourse, she’s not comfortable putting a tampon in. She’s not had her first
pelvic exam, her BMI is 22. Her blood pressure is normal. And now we have two challenges in regard to Paula, number one, she’s really interested in her
menstrual periods stopping. Doesn’t need birth control. And the question comes up for this 24 year old virginal woman, does she need to have a pelvic exam in order to have her first pap smear, her first cervical cytology? So she fits in this part of the algorithm, where she does have menstrual problems, she’s not sexually active, and
these are our four choices, some of which we’ve already talked about. So NSAIDs by themselves will
decrease her flow and her pain. The only side effect are
some of the GI issues of stomach irritation
that come up with NSAIDs. So that may be all she needs, basically. A levonorgestrel IUD
can potentially make her entirely amenorrheic, but again, we’ve got issues regarding placement. Depo-Provera will do the same thing when we’re not so
worried about weight gain in her circumstance because
she’s slender already. But that’s another alternative in terms of completely stopping her periods. Or, again, she can go
with extended continuous oral contraceptive use every day as a way of stopping
her menstrual bleeding. So any of those are
reasonable choices for her. But in her circumstance, given the fact that she’s virginal, has
an aversion to having anything like put into her vagina, maybe isn’t ready for
her first pelvic exam. I think in her circumstance,
probably the optimal approach is continuous extended
oral contraceptives. And in that circumstance,
there’s simply no reason to insist that she have
a pelvic exam performed. Because it will give quite
effective suppression of her menstruation if she’s
able to take a pill every day. It’s more forgiving or a
missed pill than cycling, which means that, if she did
need it for birth control, when you’re taking a pill every single day and then miss it for a day or two, you’re unlikely to ovulate. Consistent every day pill taking may be relatively easy or hard, depending on her circumstances. No need for a pelvic examination, but her challenges will be to remember to take a pill every single day. Initially, acceptance of
breakthrough bleeding, which happens, usually,
for the first month or two of continuous birth control pills. And then sometimes, there are problems with getting a health plan, even Medi-Cal, to pay for a whole year,
16 cycles, basically, of oral contraceptives. They’re very used to paying for 13 cycles, they sometimes balk at the extra three. And the way to get around
that is really easy. You write a Medi-Cal TAR and say I need continuous birth
control pills for this patient and I need 16 cycles a
year, and the Medi-Cal TAR field office will almost always say yes, as long as you explain why you
need it in that circumstance. Now, one last thing to mention
about her circumstance is, does she need to have a first pap smear? So let me just take a
side bar for a second and talk about cancer screening in women who have developmental disabilities. And the first one is
specifically related to cytology, what I’m gonna tell you
about breast cancer screening and ovarian cancer screening
relates to everyone. So in virginal women, and
that’s defined as a woman who’s never had penetrative
vaginal intercourse, the risk of dysplasia,
which is a precursor to cervical cancer, is extremely low. But it’s not zero. So if you compare that to women who have had heterosexual
contact or who have had sex with women where the risk
is probably somewhat less, and women who have never
had penetrative sex, we’ve known for 500 years that their risk of cervical cancer is very low. But it can still happen,
it’s just extremely rare in that circumstance, okay. Now, most, I’m sorry,
it’s missing a G there, it should say most recent
guidelines are silent on whether or not virginal women should have a cervical cytology or not. There was an ACOG guideline
that was published in 2010 that said that, for
women who are virginal, irrespective of their
age, we should talk about the pros and cons of screening and leave the decision to
them as a shared decision. What I usually tell
virginal patients is that, again, your risk of cervical cancer is really low, it’s not zero. It’s perfectly reasonable if you do want a cervical cytology, but
if you wanna postpone that until you start sexual activity, that is absolutely as reasonable a choice. And the guidelines would
say that as well, whoops, wrong direction. Next question is what about
breast cancer screening? You know, this is an
area of great controversy at the moment, but basically,
the American Cancer Society says that clinical breast
exam is not recommended for women of any age. So a woman comes in
for a well woman visit, disabled or not, ACS is
saying there’s no evidence to support doing a screening
breast exam for those women, I think they got it exactly right. Even ACOG is now saying
that that should be a shared decision about
whether or not a woman decides that she wants to have a
breast exam done or not. Now, this, of course, is a screening exam, not a diagnostic exam
if you have breast pain or a breast lump, that sort of thing. And the mammography guidelines, of course, are the same for all women. All the guidelines say
basically start at 50, but that women between 40 and
49 should be given information about their pros and cons and be able to make their own choice. Finally, what about
ovarian cancer screening? And there’s quite a
vigorous debate out there about the value of screening pelvic exams. We are unquestionably
going in the direction of abandoning the screening pelvic exam in women who have no
symptoms, in women of any age. That it almost certainly
does more harm than good, it’s uncomfortable, there are
way too many false positives and it doesn’t change any outcomes at all. So if someone were to say okay, well, our patient doesn’t need a pap smear, but doesn’t she need a bimanual exam to screen for ovarian cancer
or a fibroid or something else? The answer to that is no. Whether she’s disabled or not, the guidelines are now
almost in uniform agreement about the fact that screening pelvic exam is unnecessary and probably
does more harm than good. All right, in our last patient then, we’ll talk about Elizabeth. She is 28 years of age. She has a history of cerebral palsy, sorry about the term wheelchair bound, she needs a wheelchair,
she uses a wheelchair. But she also has an issue with epilepsy, and that is controlled with carbamazepine, which is an anti-seizure medication. She’s sexually active with one partner. She wants to use oral contraceptives, but she’s open to using other methods. And here are the challenges
that we have with Elizabeth. Can she use oral contraceptives, given the fact that she
uses an anti-seizure drug which induces hepatic
enzymes that would make birth control pills less effective? Number two, does she need a pelvic exam? No. Number three is, how can
we do an IUD insertion in a woman who needs a wheelchair and are there any special
sort of accommodations that we need to make in that circumstance? So this is the third and
the last of the pathways that I’ll refer to, so she does
not have menstrual problems. She is sexually active. And therefore, we have a whole variety of contraceptive methods
that are available to her, most of which you’ve heard about already. So in going through that
list, the tier one efficacy, the ones that will work the
best for her, are a copper IUD. We haven’t talked about those much so far except for emergency contraception. They work for at least 10 years, probably closer to 12 years. But the one thing they do is they do not make periods lighter, if anything, they make periods a little heavier. Not in everyone, but at least
in some patients who use them. The levonorgestrel IUD
we’ve already talked about. That would be a reasonable choice, as well as a contraceptive implant, which is a single rod
that goes under the skin of the upper arm, and it works for three years, although
there may be some unpredictable breakthrough bleeding which is associated with it. It is the single most effective
reversible contraceptive that we have. In addition, we’ve
already discussed the DMPA or Depo-Provera. She could use the contraceptive patch. I did not include the
contraceptive vaginal ring because it might be a
little difficult for her to put in the ring and take it out. Not always, but that’s a possibility. She could use extended oral contraceptives or she could use progestin-only pills, which might be preferred
because of the fact that they lack estrogen. But what I wanna finish
up with is this discussion about the interaction
of anti-epileptic drugs or anti-seizure drugs and
hormonal contraceptives. Because I know many of your patients are not only using those
medications for seizures, but they might be using them
for a variety of other things. Oftentimes, psychiatrists think of them as mood stabilizers, and so they’re used with other medications as well. So when we have to make
decisions about contraception in women who have seizure disorders, our goals are, number one, to make sure that we’re working with
the primary care provider or the neurologist to make sure that the seizures are under control. Number two, we want to make sure that she’s using highly
effective contraception, because if she has an
unintended pregnancy, in utero exposure to some of those anti-seizure drugs is problematic because some of them are
actually teratogenic. Mildly so, but they’re
nonetheless teratogenic. And then we wanna
minimize this interaction between anti-epileptic
drugs and contraceptives, and they do that, by the way,
by the anti-epileptic drug, inducing cytochrome P450 in the liver. When that happens, estrogen is chewed up much more quickly, the
estrogen levels drop by half, and the method doesn’t work as well because of the lower blood levels of both estrogen and progestin. So here is a listing of the
various anti-epileptic drugs that are a problem with enzyme induction that may make hormonal
contraceptives less effective. I won’t read them to you,
but I’ve indicated in red the ones that are sort of the worst actors in terms of making
contraceptives less effective. On the other hand, there
are an equal number of anti-seizure medications that do not induce hepatic enzymes, and none of these are problematic. That’s why it’s a thumbs
up, ’cause none of these will have any interaction at all with hormonal contraceptives. Okay, so how do we
manage that circumstance? Elizabeth wants to use
birth control pills. She may be a very very
good candidate for that, I’m not so worried about the fact that she needs a wheelchair,
I’m more concerned about the issue of the interaction
with the carbamazepine. So her ideal contraceptives
would either be either of the IUDs. DMPA is an excellent choice for women who have seizure disorders because it not only works really
well and you don’t have to be reinjected every 12
weeks, it actually has a calming effect on the CNS, and it raises the seizure threshold. So women who have seizures,
a seizure problem, are actually less likely
to experience them if they use DMPA as their
method of contraception. Elizabeth can use birth control pills, we just need to use a higher dose. So we would use at least a 35 microgram estrogen birth control pill,
and instead of 21 days on, seven days off, we would choose either continuous birth control pills or what’s called 24/4, which is 24 days on and four days off, which
allows a menstrual period if Elizabeth wants to do that. And then, if you’re on any
of those enzyme-inducing anti-seizure drugs, we try to stay away from the contraceptive patch
or progestin-only pills because of the fact that the effect of the anti-seizure
medication on progestins may drop the blood levels of
progestin to the point where they’re not gonna be effective any longer. One last thing, let’s
assume that Elizabeth changes her mind. Now she’s interested in
having an IUD inserted, as we talked about earlier. So the kinds of things that we think about in women’s healthcare, this actually comes from a slide set from ACOG,
and you all are expert and I really don’t have to
remind you about this, but any women’s healthcare practice or family planning
clinic has to be prepared to be able to help women with transfers. Ideally, that’s gonna happen in a context where you have an electric table. San Francisco General,
probably half of our tables are electric in our clinic. And of course, we insist on using those in any case where we’re gonna need to do a wheelchair transfer. We try really hard not to
do any kind of physical exam in a wheelchair, including a breast exam. Unless the patient insists,
you know, I can’t, I won’t, it’s not a good time for me to do this. And then we’ll do our
best to try to examine our person in a wheelchair,
that’s really tough, really suboptimal, it’s much safer to try to do a transfer, and you’ll have a much more effective
exam in that circumstance. Have the patient empty her bladder first, and then get away from the stirrups, they usually do not help. The alternative positions
are much more effective. And so the kinds of things
that I would think about doing are to put in a speculum in a side lying knee-chest position, which
actually will give you a very very good view of the cervix without having to put a woman in stirrups, you literally put the
speculum upside down. And it’s not particularly uncomfortable, but it gives you an equally good view, particularly if you have a person who’s in a lateral decubitus position, what can really help is to have a medical assistant hold
one leg up, or sometimes the patient can hold her
own leg up with her arms. If she can’t do that,
then assistant, of course, has to help with being able to do that. Another thing that we
do in some circumstances is to move the patient all the way down to the end of the table
and do what’s called the diamond position,
and as long as her bottom is off the edge of the table, it allows a speculum examination
without the discomfort of having to use stirrups
in that circumstance. And Elizabeth might do perfectly
well with her IUD insertion with one of these
alternative positionings. So with that, I’ll go ahead and stop. This is the sleeve of our jersey. And the little uterus and the
few drops of menstrual blood coming out, but thanks very
much for your attention. (applause) – [Female Speaker] Thank you very much.

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