In medical practice today, we have all types of providers in charge of birth control counseling and treatment: medical doctors, nurse practitioners, registered nurses, licensed vocational nurses, and even medical assistants who report to their licensed providers. Having a standardized questionnaire that all providers can easily use and incorporate into their practice would help safeguard against regretful avoidable mistakes. Taking a good history is cheap. Health care costs for strokes or blood clots that could have been prevented are expensive.
A hard stop should be considered, prompting the provider to ask pertinent questions prior to ordering contraceptive treatment. The questionnaire should be written in simple language. There are risks to prescribing combined oral contraceptive pills or synthetic progesterone to any young individual without proper screening. This includes those going through the transgender process, for which there could be a potential compounded risk.
The most common birth control pill is a combined oral contraceptive (COC), containing estrogen and progesterone. Besides contraception, COCs are used to treat secondary amenorrhea, heavy periods, breakthrough bleeding, bleeding post miscarriage or post-abortion, acne, PCOS, endometriosis, and dysmenorrhea. Due to the estrogen content in COC, there are contraindications and precautions. The person who presents for birth control may have a history contraindicated to prescribing COCs or progesterone-only medications but not be aware of it. Add to this that the provider may not be aware — by not taking an adequate history.
A great example is the current case of Hailey Bieber, published in People, April 2022, who had a blood clot at age 22.
Contraindications or precautions to prescribing COCs include having elevated lipoprotein A levels, a personal and or family history of thrombophilia, history of breast cancer, valvular heart disease, gallbladder disease, diabetes with nephropathy, neuropathy or retinopathy, personal history of lupus, history of migraines with aura or even the rare case of solid organ transplant.
Contraindications and precautions to prescribing progestin or synthetic progesterone include liver tumors, breast disease, history of lupus, and history of unexplained vaginal bleeding.
The questionnaire could include the following questions (based on U.S. eligibility criteria):
Do you or a family member have a history of:
- Blood clot, deep vein thrombosis or pulmonary embolism
- Breastfeeding and postpartum < or = 42days (DOB of child)
- Cirrhosis, liver disease or liver tumor
- Major surgery with prolonged immobilization, Bariatric surgery
- Diabetes with kidney, eye or neurological problems
- Gallbladder disease, gallstones or bile problems
- Headaches with hallucinations, smelling things or movements
- Inflammatory bowel disease, Crohn’s, or ulcerative colitis
- History of high blood pressure
- Personal or family history of heart attack or stroke
- Cardiomyopathy, heart problems after childbirth
- Personal or family history of stroke
- Personal history solid organ transplant (kidney, heart, liver, lung, pancreas, intestines)
- History of Lupus
- History of multiple sclerosis with prolonged immobility
- History of valvular heart disease
- History of active hepatitis (viral hepatitis: acute or flare-up)
Are you on any of these medications:
- Seizure medications
- Rifampin or rifabutin
- Antiviral therapy for HIV
If considering starting Depo-Provera or Nexplanon, the questionnaire would be as follows:
- History of liver tumors
- History of breast disease
- Diabetes with nephropathy and vascular complication
- High blood pressure
- History of stroke
- History of ischemic heart disease cardiomyopathy
- History of lupus
Any questions answered “yes” on the questionnaire would prompt the provider to consider alternative contraception. Since Nexplanon is placed for three to five years, patients should be aware that this medication should be removed if they develop thrombosis or breast cancer while having Nexplanon in their system.
The workflow would be:
USTI: urine sexually transmitted infection
MAP: morning after pill
BC: birth control
A challenge today in hormone therapy for teens is the transgender patient. Transgender teens have a compounded risk as they are on hormones for multiple reasons: gender change, contraception, and undesired effects. This is a vulnerable group that needs adequate assessment for cardiovascular disease prior to treatment. This is important, as these individuals are typically on hormone therapy for years — if not for life. A family history of early myocardial infarction, personal history of elevated lipoprotein A levels, and factor V Leiden is more pervasive than we think. Factor V Leiden is in 4 to 6 percent of the U.S. population and is one of the most common causes of thrombophilia.
What is the significance of elevated lipoprotein A? It is an inherited genetic condition that predisposes an individual to have a heart attack or stroke early on. In a study of more than 500,000 patients, 24 percent had elevated levels.
Arthur Ashe, the famous tennis player, had a heart attack in his 40s due to elevated lipoprotein A levels. Today, heart attacks and strokes continue to occur at younger ages. Another high-risk teen is the athlete with prolonged immobilization due to surgery, fracture, or injury, who may be traveling across continents on long flights for a tournament. Prolonged immobilization from surgery or travel is occurring not just in the elderly but in young people: a perfect setting for a blood clot.
Given the risk of stroke and myocardial infarction, obtaining informed consent prior to hormone therapy becomes necessary. The use of simple, lay terms helps the teen understand. Time is challenging. Merits of having a workflow that is consistently used to obtain accurate health information from our teens are paramount. Minimizing room for errors and increasing overall efficiency is our goal. Allowing time for the “teach back moment” is rewarding and closes the loop of communication.
Vitals, a pregnancy test, and a recent physical exam within a year provide a safety net for undiagnosed conditions that may be contraindications or precautions to taking COCs or progesterone-containing medications. With the Covid pandemic, it has been found that patients who had COVID-19 disease are at risk of a range of cardiovascular disorders, including myocardial infarction and thromboembolism. More studies need to be done in this arena and precautions taken.
In conclusion, treating a patient with hormones is not benign. A hard stop should prompt a provider to ask pertinent questions before ordering contraceptive treatment.
A good history and physical, including screening, can prevent consequences that burden a patient’s daily life and increase health care costs. Assessing cardiovascular risk is a key part of the evaluation. Transgender individuals may have a compounded risk. Awareness and education for both the patient and the provider are vital. Currently and in the future, given the gender fluidity of society, we need to be aware and not make assumptions about a patient’s gender. Finally, we cannot discount informed consent. The young individual involved in hormonal treatment must understand not just the benefits but also the risks.
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