Charisse Loder, MD, MSc

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Fertility awareness-based contraceptive methods (FABM) are behavioral methods of contraception that are used by approximately 2.2% to 3.2% of sexually active women.

 This low usage rate may be due to provider and patient knowledge and beliefs. One concern providers may have is that the typical use efficacy rate is lower than for other contraceptive methods. In addition, providers may be uncomfortablen counseling patients about appropriate usage.

Women who use FABM may choose it because they have values and/or beliefs that are aligned with using non-pharmacologic contraception. However, we must consider that the best form of contraception is the one the patient feels works for her. Given that FABM may be used as a contraceptive, and that there are patients who will choose it, ob/gyns must be familiar with it and ready to counsel about its use.

Nonjudgmental and open conversation with patients about their priorities is critical to all contraceptive counseling, particularly when discussing FABM. Generally, FABM is most suitable for patients who have regular menses (although some methods, such as TwoDay

, may not require this) and for whom variance in efficacy of a method-and therefore the real possibility of an unplanned pregnancy-is acceptable.

As such, an important part of counseling is reviewing medical comorbidities, obstetric history, and current medications so that the patient understands the risks of unplanned pregnancy to their health and the health of the fetus. Given that FABM requires abstinence or use of barrier methods on certain days, the ability to have open communication with a partner is paramount. Considering this, FABM may work best for patients whose partner(s) is highly motivated to avoid pregnancy and willing to avoid unprotected sex on certain days.

Thirty-six percent of women in the United States suffer sexual violence and coercion

; behavioral methods cannot protect against pregnancy in these cases. In addition, FABM does not offer protection against sexually transmitted infections.

It is important to note that studies of FABM effectiveness vary in quality, which makes it difficult to compare efficacy between specific methods.

 Overall, FABM collectively has a 15% typical-use first-year failure rate, but it can vary as much as 2% to 23%.

 There are many factors that impact effectiveness of FABM.

These include the ability of the provider to adequately counsel on how to use the method and the ability of the patient to follow and use the method instructions appropriately.

 Given that most studies show high first-year discontinuation rates for FABM,

 shared decision-making and clear instructions on how to properly use each technique are critical to successful patient use. Table 1 summarizes the methods and key requirements for each method.

Patients who choose FABM over other methods are likely doing so for reasons beyond its efficacy. It is well-studied that contraceptive counseling and recommendations should be patient-centered.

 If a patient is aware that FABM has variable efficacy rates, has been counseled on the factors that make a good FABM candidate, and accepts the risk of unintended pregnancy, there is no reason a clinician should be uncomfortable with aiding her in using that method.  

Advantages to FABM include little to no financial investment, few if any medical contraindications to use, no medications or devices needed, and possible alliance with religious and cultural beliefs about family planning.

In addition, many patients may choose to educate themselves about and use behavioral methods in the time leading up to planning a pregnancy. This is because these methods require more awareness of the body and the fertile time, which helps a patient to prevent pregnancy and also to become pregnant when she is ready.

The crux of FABM is understanding the menstrual cycle and using biological knowledge and cues to predict when fertilization is most likely.

 We know that ovulation most often occurs in the middle of a menstrual cycle; given that sperm can persist for 3 to 5 days in the female reproductive tract and the ovum has a lifespan of 12 to 24 hours, the fertile window lasts for approximately 6 days.

In cycles with lengths of 26 to 32 days, 78% of women will have a fertile window between Days 8 and 21.

 There are various methods that can be used to predict the fertility window-and therefore the period of “at-risk” days for pregnancy-during a menstrual cycle.

to predict these days, it is vital to discuss how they will avoid unprotected intercourse during the 10 to 17 “at-risk” days of their menstrual cycle.

 If they are interested in barrier methods (condom, diaphragm), ensuring proper instruction on how to use them is needed to ensure effectiveness of FABM.

Elena is a 28-year-old G0 who is considering pregnancy in the next 1 to 2 years. She and her husband prefer a method that does not involve exogenous hormones or medical devices. She asks you about using a fertility awareness-based method (FABM) for contraception She has tracked her regular periods for many years and is detail-oriented. Elena has no medical problems and takes a multivitamin daily.

Which of the following do you tell her is important to the success of using an FABM method?

B. Ability to avoid unprotected intercourse

C. Adequate knowledge about how to determine “at-risk” days

Patients are most likely to have success using FABM if they are able and committed to meticulous, daily attention and recording of various aspects of their cycle (depends on what method), able to avoid unprotected intercourse, and are well-informed about the specific method they are using.

For these reasons, we recommend the Standard Days® (CycleBeads®) method or the TwoDay® method, as they are the most straightforward methods for providers and patients.

The Standard Days Method® requires 6 months of menstrual cycle tracking prior to initiation. It requires that a menstrual cycle is between 26 and 32 days long. Patients who are breastfeeding or who have recently stopped hormonal contraception may not have anticipated efficacy with this method and should wait to observe their cycles before starting.

The Standard Days Method® relies on the fact that unprotected intercourse has a low likelihood of causing pregnancy on menstrual cycle Days 1 to 7 and from Day 20 until the end of the cycle. The patient should abstain from intercourse or use a barrier method on Days 8 to 19.

Cyclebeads® are a helpful way for a patient and her partner to keep track of cycles together; bead colors may indicate fertile and less fertile days, so they know when unprotected intercourse will avoid pregnancy. She can place the beads in a common area as a way to communicate with her partner. With perfect use, this method is 95% effective and with typical use, it is 88% effective.

The TwoDay Method® relies on a patient’s comfort, awareness, and tracking of vaginal secretions and on the fact that thin, watery, secretions make it possible for sperm to travel through the female reproductive tract and survive for several days.

The cervical fluid around the time of ovulation is particularly characteristic in that it is abundant, clear, and stretchy.

 Therefore, when a patient is dry or lacks vaginal secretions, it has been theorized she is less likely to become pregnant. A patient may use touch to assess for secretions, or observe them on underwear or a menstrual pad. If she does not experience vaginal secretions for 2 days in a row, the risk of pregnancy is low.

Patients should abstain from or use barrier methods for 3 days following unprotected intercourse, as the ejaculate interferes with the ability to assess for presence of vaginal secretions. Benefits of this method are that it can be used by women who have irregular cycles and that it is simple to understand and execute.

Patients should be warned that vaginal infections can interfere with symptom assessment. With perfect use, the TwoDay Method® is 97.5% effective, and with typical use, it is 86% effective.

For Elena, we can counsel her that both of these methods have similar perfect and typical use, are easy to understand, can help her 

Educating her about the Standard Days Method® may provide her with more information about ovulation and a fertile window, while the TwoDay Method® can inform her about the role of cervical mucous in fertility. Ultimately, we can discuss which method she feels most comfortable with and provide her with supplemental reading material.

The world of contraception is constantly changing, with improving technologies, new devices, and more options than ever before. In addition to staying up to date within the evolving field of Family Planning, ob/gyns should also be prepared to counsel and support patients who choose to use FABM.

These methods require an ob/gyn to be knowledgeable about it and able to engage in shared decision-making with the patient to determine which method is appropriate. There are many resources ob/gyns can use to refresh their knowledge about these methods-many of which are cited in this review.

We feel the Standard Days Method® (CycleBeads®) and TwoDay Method® are the simplest to use and counsel about and the easiest for patients to understand. With proper counseling and education, FABM may be a satisfactory option for your patient.

1. Polis CB, Jones RK. Multiple contraceptive method use and prevalence of fertility awareness based method use in the United States, 2013-2015. 

2. Lawrence RE, Rasinski KA, Yoon JD, Curlin FA. Obstetrician-gynecologists' views on contraception and natural family planning: a national survey. 

3. Smith SG, Zhang X, Kathleen C. Basile, et al. National Intimate Partner and Sexual Violence Survey: 2015 Data Brief-Update Release. [National Center for Injury Prevention and Control and Centers for Disease Control and Prevention]. 2018; https://www.cdc.gov/violenceprevention/pdf/2015data-brief508.pdf. Accessed January 21, 2020.

4. Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual intercourse in relation to ovulation. Effects on the probability of conception, survival of the pregnancy, and sex of the baby. 

5. ArÃ©valo M, Sinai I, Jennings V. A fixed formula to define the fertile window of the menstrual cycle as the basis of a simple method of natural family planning. 

6. Nelson AL, Sokol DC. Behavioral Methods of Contraception. In: Jensen JT, Creinin MD, eds. 

Speroff & Darney’s Clinical Guide to Contraception

. 6th ed. Philadelphia, PA: Wolters Kluwer; 2020.

7. Peragallo Urrutia R, Polis CB, Jensen ET, Greene ME, Kennedy E, Stanford JB. Effectiveness of Fertility Awareness-Based Methods for Pregnancy Prevention: A Systematic Review. 

8. Hatcher RA, Kowal D, Nelson AL, et al, eds. 

 21st ed. Atlanta, GA: Managing Contraception, LLC; 2018.

9. Kambic RT, Lamprecht V. Calendar rhythm efficacy: a review. 

10. Trussell J, Grummer-Strawn L. Contraceptive failure of the ovulation method of periodic abstinence. 

11. Wilcox AJ, Dunson D, Baird DD. The timing of the "fertile window" in the menstrual cycle: day specific estimates from a prospective study. 

12. Frank-Herrmann P, Freundl G, Gnoth C, et al. Natural family planning with and without barrier method use in the fertile phase: efficacy in relation to sexual behavior: a German prospective long-term study. 

13. ArÃ©valo M, Jennings V, Sinai I. Efficacy of a new method of family planning: the Standard Days Method. 

14. Freundl G, Sivin I, Batar I. State-of-the-art of non-hormonal methods of contraception: IV. Natural family planning. 

15. Bhargava H, Bhatia JC, Ramachandran L, Rohatgi P, Sinha A. Field trial of billings ovulation method of natural family planning. 

16. A prospective multicentre trial of the ovulation method of natural family planning. II. The effectiveness phase. 

17. Grimes DA, Gallo MF, Grigorieva V, Nanda K, Schulz KF. Fertility awareness-based methods for contraception. 

18. ArÃ©valo M, Jennings V, Nikula M, Sinai I. Efficacy of the new TwoDay Method of family planning. 

19. Frank-Herrmann P, Freundl G, Baur S, et al. Effectiveness and acceptibility of the symptothermal method of natural family planning in Germany. 

20. Frank-Herrmann P, Heil J, Gnoth C, et al. The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple's sexual behaviour during the fertile time: a prospective longitudinal study. 

21. Lamprecht VM, Grummer-Strawn L. Development of new formulas to identify the fertile time of the menstrual cycle. 

Articles

Behavioral methods of contraception are used by less than 3.2% of sexually active women; careful counseling could change that.

Familiarizing yourself with fertility awareness as a birth control option

Hypertension is a primary contributor to cardiovascular disease (CVD), which is a major cause of death in women. Traditionally defined as an average blood pressure of at least 140/90 mm Hg or use of antihypertensive medication, hypertension affects about 30% of US adults aged 18 or older.

 While the 140/90 mm Hg cutoff is used in the 

2004 Joint National Commission (JNC) report on hypertension

, more recently, the American College of Cardiology and the American Heart Association (ACC/AHA) 

 lowering the defining blood pressure for hypertension to 130/80 mm Hg.

 According to the new ACC/AHA guidelines, stage I hypertension is diagnosed by a systolic blood pressure of 130 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg.  A blood pressure of ≥ 140 mm Hg systolic or 90 mm Hg diastolic defines stage II hypertension. Blood pressure should be taken by trained personnel who ensure that the patient has been at rest and seated in a chair with feet on the floor and has an empty bladder. A properly sized cuff encircles 75% to 100% of the patient’s arm. The diagnosis can be made by averaging at least two readings on at least two separate occasions using readings from ambulatory blood pressure monitoring, home self-monitoring, and/or a follow-up visit.

American College of Obstetricians and Gynecologists

 the new, lower diagnostic threshold for hypertension in its bulletin on chronic hypertension in pregnancy and recommends that patients diagnosed with hypertension using these values be managed in pregnancy using the guidelines for chronic hypertension. However, because ACOG adheres to the JNC cutoff in its definition of gestational hypertension, and given that the data currently available utilize the 140/90 threshold, we will also utilize the 140/90 cutoff in this article.

Among women, prevalence of hypertension rises from 10% in the 20- to 44-year-old age range to 78% by age 75.

 Significant disparities exist in medical treatment of hypertension. Approximately half of all adults (53.5%) and 52.1% of women have uncontrolled hypertension.

 Hypertension is more common among black adults (38.6% prevalence) and is less likely to be treated in this population. Women aged 18 to 39 are less likely than older women to have controlled hypertension, potentially predisposing women in this age group to pregnancy complications related to their hypertension. In addition, people who are Mexican-American, lack a usual medical care site, receive medical care less than twice per year, or lack health insurance are less likely to receive medical treatment for hypertension than other people with hypertension.

 Moreover, groups already at disproportionate risk of adverse pregnancy outcomes, such as black women and women lacking health insurance, are more likely to experience complications of hypertension. Given that many reproductive-aged women choose to receive their primary healthcare through their ob/gyn, there is an opportunity to diagnose, counsel on, and treat hypertension during the health maintenance exam. We have opportunities to engage in innovative patient-centered management of hypertension before, during, and after pregnancy to reduce disparities.


	Lifestyle modifications such as weight loss (for overweight or obese patients), a heart-healthy diet, sodium reduction, increased physical activity, and limitation of alcohol consumption

 are recommended for first-line management of hypertension. The first-line pharmacologic classes of antihypertensives are thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, and calcium channel blockers.

 However, among women seeking pregnancy or who are currently pregnant, the preferred antihypertensive medications are methyldopa, nifedipine, and/or labetalol per the ACC/AHA.

 In clinical practice, methyldopa is less frequently used; per ACOG, it is less effective in the control of chronic hypertension and more likely to have side effects (drowsiness, headache, orthostatic hypotension).

 Women with hypertension should not be treated with ACE inhibitors, angiotensin receptor blockers, or direct renin inhibitors in pregnancy because of the risk of fetal renal damage.

 Exposure to these medications in the second and third trimesters is most concerning because of the risk of impaired fetal kidney function leading to oligohydramnios, which may in turn impair lung development. Data are less clear regarding exposure risk in the first trimester; however, most studies show a slight increased risk in congenital malformations with medications affecting the renin-angiotenin-aldosterone system.


	Hypertension is a risk factor for CVD, which itself is the top cause of death in the United States.

 Cardiovascular disorders are a top cause of maternal mortality in the United States and hypertensive disorders of pregnancy are specifically responsible for 9.4% of maternal deaths. Patients with a history of preeclampsia have quadruple the risk of developing chronic hypertension.


	Although most people with hypertension have no associated complications in pregnancy, hypertension is associated with increased risk for adverse health events as a result of pregnancy. In particular, chronic hypertension is associated with increased risk of gestational diabetes, postpartum hemorrhage, planned cesarean section, and preeclampsia.

 Given the increased risk of preeclampsia, women with chronic hypertension should initiate low-dose aspirin daily prior to 16 weeks’ gestation for preeclampsia prophylaxis per ACOG and the US Preventive Services Task Force.

 Chronic hypertension also carries fetal risks; growth restriction, stillbirth, and preterm birth are more common in pregnancies exposed to chronic hypertension.

 Both treated and untreated hypertension are associated with an increase in fetal congenital heart defects (RR 2, 95% CI [1.5-2.7] and RR 1.4, [1.2-1.7] respectively).


	In the following segments, we discuss the safety of various forms of contraception for people with different types of hypertension. Contraceptive counseling should be patient-centered, taking into account a woman‘s reproductive health goals and desires. Providers should consider a patient’s blood pressure control and overall cardiovascular health when discussing the risks and benefits of contraceptive methods as compared to the risks of an unintended pregnancy. Please note that the safety profiles mentioned here assume that the patient has no other comorbidities affecting the safety and suitability of these methods. We recommend a useful tool, the US Centers for Disease Control and Prevention’s Medical Eligibility Criteria (US MEC), which provides guidelines surrounding the safety of contraceptive methods for a range of given medical conditions. We have used these recommendations to inform our discussion of contraceptive methods for women with hypertension. It is important to note that the US MEC states that patients with hypertension and systolic pressures ≥ 160 mm Hg or diastolic pressure ≥ 100 mm Hg are at increased risk of adverse health events with pregnancy. As such, providers should take contraceptive efficacy into account when counseling patients. US MEC categories 1 and 2 indicate that a contraceptive method is safe and without restrictions for the specific medical condition and the advantages of the method generally outweigh any theoretical risks, respectively. Meanwhile, contraceptive methods in categories 3 and 4 should be avoided. Category 3 suggests that the theoretical or proven risks of the contraceptive method outweigh the benefits. Category 4 means that there is an unacceptable risk to the patient with use of the contraceptive method.

US MEC recommendations for hypertensive disease and contraceptive are presented in Table 1. 


	Estrogen therapy should be avoided in those with hypertension because it increases blood pressure while also increasing the risks of myocardial infarction and ischemic stroke.

 These relationships are thought to be dose-dependent, with higher doses of ethinyl estradiol posing a greater risk of CVD when compared to lower doses. Estrogen is theorized to activate the renin-angiotensin system and can increase systolic blood pressure by an average of 8 mm Hg.

The US MEC states that combined hormonal contraception (CHC) poses an increased risk (category 3) for those with hypertensive disorders.

 For those with systolic blood pressure ≥ 160 mm Hg or diastolic ≥ 100 mm Hg, the risks outweigh the advantages. Additionally, the US MEC states there are unacceptable risks in using CHC in those with blood pressures above 160/100 (category 4). It is important to note that even those with blood pressure that is well-controlled with antihypertensives are still at increased risk for CVD with estrogen use.


	Progestin methods are generally considered safe in patients with hypertension. For patients with adequately controlled hypertension, progestin-only pills (POPs), etonogestrel implants, and hormonal intrauterine devices are US MEC category 1. Injectable progestin contraception, depo medroxyprogesterone acetate (DMPA) is category 2, meaning that its advantages generally outweigh theoretical or proven risks. These categories hold for patients without a formal diagnosis of hypertension who have elevated blood pressure measurements < 160 mm Hg systolic or < 100 mm Hg diastolic. However, the risk/benefit balance tips when we consider use of DMPA for patients with a systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 100 mmHg with patients who have vascular complications from hypertension. For these patients, DMPA is US MEC category 3 and all other forms of progestin are category 2. In addition, some data show that DMPA increases lipid levels with long-term use; therefore, patients with multiple risk factors for CVD-including hypertension, hyperlipidemia, diabetes, smoking, and obesity-should avoid using injectables.


	Nonhormonal methods such as behavioral methods, condoms, withdrawal, the copper intrauterine device (IUD) and permanent contraception via (partial) salpingectomy or vasectomy are safe for hypertensive patients. Regardless of the type of hypertension, the copper intrauterine device (IUD) is US MEC category 1.

 Although the copper IUD and permanent contraception have failure rates less than 1%, these other nonhormonal methods have higher failure rates and patients who choose to use barrier and behavioral methods of contraception should be informed of the failure rates of these methods in typical use.  The US MEC notes that long-acting reversible contraceptives like IUDs and implants may be the best choice for patients with hypertension, likely due to their high efficacy and good safety profiles. While those are important considerations, so are a patient’s values and preferences for a contraceptive method.  However, it is important to keep in mind that when weighing the risks of contraception that the alternative is potential pregnancy with its own set of risks and benefits. Shared decision-making with patients using validated tools for reproductive life planning and patient-centered guidelines for communication

 (Table 2) can improve patient satisfaction with contraceptive care.

A 34-year-old G2P2 presents to the office for her well-woman exam. She reports being in general good health. However, her primary care physician has been “keeping an eye on her blood pressure,” which was 142/78 at the woman’s last check-up. The only medication she is currently taking is an oral contraceptive pill. She is happy with this method and is considering a pregnancy in the next
	6 months. Her blood pressure is 164/100.


	A. You recommend treating her hypertension and keeping her contraceptive method.
	B. You recommend switching to a POP method of contraception, given the patient’s expressed preferences for pregnancy timing and medical history.
	C. You recommend switching to the progestin injectable.

Centers for Disease Control and Prevention (CDC). Vital Signs: Prevalence, Treatment, and Control of Hypertension – United States. 1999-2002 and 2005-2008. 

National Institutes of Health, National Heart, Lung and Blood Institute, National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.  

https://www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf

Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. 

ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. 

Centers for Disease Control and Prevention (CDC). Vital signs: awareness and treatment of uncontrolled hypertension among adults--United States, 2003-2010. 

D’Alton ME, Friedman AM, Bernstein PS, et al. Putting the “M” back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States. 

Aliskiren. In: Micromedex. Greenwood Village (CO): Truven Health Analytics; publication year [2019]. Available from: www.micromedexsolutions.com. Subscription required to view.

Brahmbhatt Y, Gupta M, Hamrahian S. Hypertension in Premenopausal and Postmenopausal Women. 

U.S. Preventive Services Task Force. Final Recommendation Statement: Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia: Preventive Medication. 

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication

Ramakrishnan A, Lee LJ, Mitchell LE, Agopian AJ. Maternal Hypertension During Pregnancy and the Risk of Congenital Heart Defects in Offspring: A Systematic Review and Meta-analysis. 

Centers for Disease Control and Prevention. Contraceptive guidance for health care providers.

https://www.cdc.gov/reproductivehealth/contraception/contraception_guidance.htm

Curtis KM, Mohllajee AP, Martins SL, Peterson HB. Combined oral contraceptive use among women with hypertension: a systematic review. 

Cardoso F, Polonia J, Santos A, Silva-Carvalho J, Ferreira-de-Almeida J. Low-dose oral contraceptives and 24-hour ambulatory blood pressure. 

Centers for Disease Control and Prevention. Reproductive Health: Classifications for Combined Hormonal Contraceptives. 

https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/appendixD.html#mec_cardio

Dilshad H, Yousuf RI, Shoaib MH, Jamil S, Khatoon H. Cardiovascular disease risk associated with the long-term use of depot medroxyprogesterone acetate. 

Dehlendorf C, Krajewski C, Borrero S. Contraceptive counseling: Best practices to ensure quality communication and enable effective contraceptive use. 

This installment of our Complex Contraceptives series examines contraception considerations for patients with high-blood pressure.

Tips for counseling hypertensive patients on contraception

Women with no significant medical history have many medically appropriate forms of contraception from which to choose. The options narrow when counseling a woman with episodic or chronic health conditions such as headache disorders. Hormonal options are the most widely used forms of contraception among US women; over 40% of women aged 15 to 44 use hormone-containing forms of birth control, including the pill, intrauterine device, implant, injectable, ring, or patch.

 With up to 20% of reproductive-aged women affected by migraine, it is important for ob/gyns to understand the risks and benefits of contraceptive hormone use in this population.

Migraine must be distinguished from other types of headaches, such as tension-type headache,  prior to contraceptive counseling (Table 1). Migraine headaches are diagnosed clinically and are classified as a recurrent disorder. The 

 (IHS) provides diagnostic criteria for migraine using the the 

International Classification of Headache Disorders III criteria 

 Migraine without aura is the most common subset of migraine, with a 1-year prevalence in women of 11%.

 Migraine with aura includes all of the outlined migraine criteria, with the addition of a variety of neurological symptoms that can occur immediately before or with onset of the headache. Aura symptoms are reversible and can include visual, sensory, speech, language, motor, brainstem, and retinal symptoms.

 Though less common, migraine with aura has a 1-year prevalence of 5% in females (Table 3).


					A 27-year-old G1P1 presents for initiation of contraception. She has no significant medical history but on review of systems, reports experiencing headaches twice monthly. Prior to her headache onset, the patient sometimes sees shimmering lines and other shapes in her vision. Her headaches last 4 to 6 hours and she has associated nausea and occasional vomiting. The woman’s headaches resolve after she lies in a dark quiet room and sleeps. She has a 1-year-old son, is no longer breastfeeding, and would like to wait 1 to 2 years before another pregnancy, and is hoping to start combined hormonal oral contraceptive pills.

 Which of the patient’s symptoms would cause you to recommend against estrogen-containing contraceptive methods?


	Migraine is a risk factor for ischemic stroke.

 Though the overall absolute risk of stroke in reproductive-aged women is low-between 3.5 and 19.0 per 100,000-migraine may be the only risk factor for stroke in younger women.

 Women older than 35 years are likely to have other classic risk factors for stroke, such as hypertension, diabetes, and hyperlipidemia that contribute more to stroke risk than migraine alone.

aura is associated with an elevated relative risk of stroke when compared to migraine without aura. A meta-analysis of 11 case control studies demonstrated that migraine with aura had a relative risk of 2.27 (95% CI, 1.61–3.19) for ischemic stroke, while migraine without aura had a relative risk of 1.83 (95% CI, 1.06–3.15).

 The overall stroke risk is still low, with only 3.8 additional cases of stroke per year per 10,000 women attributed to migraine with aura.

 A complete medical and social history can help elucidate all potential risk factors for stroke before contraception is prescribed.

Migraine/stroke link more complex than originally thought


	The association between hormonal contraception and stroke risk is estrogen dose-dependent. It has been demonstrated that lower-dose estrogen-containing oral contraceptive pills (OCPs) (<50 ug ethinyl estradiol) are not independently associated with increased risk of stroke, but formulations with high levels of estrogen are.

 Use of the patch and ring also may result in an increased risk of stroke.

 Neither level nor type of progestin in combined OCPs appears to contribute to stroke risk.

 There is no evidence that progestin-only contraceptives increase risk of stroke and they are considered safe for use in women with stroke risk factors, including migraine with aura.

Estrogen-containing hormonal contraception 


	In addition, use of combined hormonal contraception increases risk of stroke in women with 

 type of migraine. Multiple studies have indicated an increased odds ratio, ranging from 2 to 14, for ischemic stroke in women with migraine (not separated by subtype) who use combined hormonal contraceptives, as compared to women without migraine who use the drugs.

 Risk of ischemic stroke is further magnified in migraineurs who smoke and use combined hormonal contraceptives, with odds ratios ranging from 3.7 to 34.4.

More recently, a meta-analysis of nine studies suggested that even women younger than age 45 who are migraineurs have an increased relative risk (3.6-7.0) of stroke when using combined hormonal contraception.

However, much data supporting these findings do not reflect new formulations of OCPs. Because low-dose (20- to 30-Î¼g of ethinyl estradiol) and ultra-low-dose (10- to 15-Î¼g of ethinyl estradiol) formulations conceivably have less stroke risk, further research needs to be undertaken on these formulations. 

When type of migraine is further delineated, it appears that the combination of migraine with aura and combined hormonal contraception maximizes risk of stroke. One study found risk of ischemic stroke to be increased by six-fold in women with migraine with aura on combined hormonal contraceptives compared to those without aura-demonstrating safety concerns when prescribing combined hormonal contraception in migraneurs with aura.

 Thus, assessment of migraine type when performing contraceptive counseling is a clinical necessity.


	Given the increased risk of ischemic stroke in women with migraine with aura-and added risk when combined with hormonal contraceptive use-the 

Centers for Disease Control and Prevention

 (US MEC) have listed migraine with aura as an absolute contraindication to using combined hormonal contraception (Table 4).

 The US MEC is a helpful resource when providing contraceptive counseling services to women with a history of or existing medical conditions. The summary chart risk-stratifies different forms of contraception based on current and past medical conditions into four different categories. Categories 1 and 2 suggest that the advantages of the method usually outweigh the risk and that a method is safe. Category 3 suggests that the risks outweigh the benefits of using a contraceptive method. Category 4 indicates that there is an unacceptable risk to the patient. Common medical conditions used in the chart include headaches, hypertension, diabetes, and depression. 

Combined hormonal contraception is acceptable in women with migraine without aura who have no additional risk factors for stroke.

 Moreover, ACOG’s recommendations are based on data using old formulations of combined hormonal contraception that include more than 35 µg of ethinyl estradiol (Table 4). Many of today’s popular formulations contain less than 30 µg of ethinyl estradiol and are not independently associated with stroke risk.

The International Headache Society has more lenient guidelines for use of combined hormonal contraception in patients with migraine with aura and recommends an individualized assessment of risk depending on the number of other risk factors a woman has for ischemic stroke (including age > 35, tobacco use, hypertension, obesity, diabetes, and hyperlipidemia). Per these guidelines, patients with migraine with aura who smoke should quit smoking prior to starting combined hormonal contraceptives and those with risk factors such as hypertension, diabetes, and hyperlipidemia should be treated for these conditions prior to starting combined hormonal contraceptives.

 Similarly, the American Headache Society indicates that use of low-dose estrogen-containing formulations can be individualized based on patient risks and benefits because the absolute risk of stroke is low.

It is always important to compare the risk of unintended pregnancy in patients with chronic medical conditions with the risk of contraceptives. Patients should be adequately counseled and the discussion should be documented in the medical record.

 In all cases, once a woman with migraines has been started on a method of combined hormonal contraception, if her migraines worsen or she develops new-onset aura, the formulation should be discontinued.
	 


	During contraceptive counseling, it is important to consider possible medication interactions in women who have headaches. Many classes of medications are used for migraine prophylaxis, including beta blockers, calcium channel blockers, tricyclic antidepressants, and antiepileptic drugs (AEDs). Some AEDs specifically alter the efficacy of combined hormonal contraception through the Cytochrome P450 system. They act as P450 inducers and increase metabolism of contraceptive steroids. Topiramate is a commonly used migraine prophylaxis agent that also decreases efficacy of contraceptives by reducing the circulating dose of ethinyl estradiol. Specifically at doses > 200 mg daily, topiramate decreases efficacy of combined hormonal contraceptives, as well as of progestin-only pills and the progestin implant.

The authors report no potential conflicts of interest with regard to this article.

Kavanaugh ML, Jerman J. Contraceptive method use in the United States: trends and characteristics between 2008, 2012 and 2014. 

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Many factors must be considered before prescribing hormones to women affected by migraine.

Migraine headache and hormonal contraception

Slideshows

Immediate postplacental insertion of an IUD is not only convenient for the patient, but also safe and effective for postpartum contraception. Here's what to be mindful of when performing the procedure following cesarean delivery.

Author | Charisse Loder, MD, MSc

Articles

Familiarizing yourself with fertility awareness as a birth control option

Tips for counseling hypertensive patients on contraception

Migraine headache and hormonal contraception

6 steps for IUD placement at the time of a cesarean delivery