Guideline:
Contraceptive choices for women with inflammatory bowel disease
Bibliographic Source(s)
- Contraceptive choices for women with inflammatory bowel disease. J Fam Plann Reprod Health Care 2003 Jul;29(3):127-34. [76 references] PubMed
Guideline Status
This is the current release of the guideline.
Guideline Category
Counseling
Management
Prevention
Intended Users
Advanced Practice Nurses
Nurses
Patients
Physician Assistants
Physicians
Guideline Objective(s)
- To provide information on the effects of inflammatory bowel disease (IBD) in women of reproductive age with particular reference to contraceptive choices fertility and pregnancy
- To provide recommendations on contraceptive choices for women with IBD
Target Population
Women of reproductive age with inflammatory bowel disease
Interventions and Practices Considered
- Discussing the potential effects of inflammatory bowel disease (IBD) on reproductive health pregnancy and contraceptive requirements
- Contraceptive use:
- Combined oral contraception (COC)
- Progestogen-only pill (POP)
- Depot medroxyprogesterone acetate (DMPA) (not recommended in women with low bone density or who have had repeated courses of corticosteroids)
- Progestogen-only implants
- Levonorgestrel-releasing intrauterine system (IUS)
- Copper-bearing intrauterine device (IUD)
- Laparoscopic sterilization (most appropriate at the time of elective surgery; not recommended in women who have had previous pelvic or abdominal surgery)
- Barrier methods (inappropriate alone in women using potentially teratogenic drugs)
- Progestogen-only emergency contraception
- Referral for pre-pregnancy counseling
- A multidisciplinary approach to improve IBD management
Major Outcomes Considered
- Effect of medications used for treatment of inflammatory bowel disease (IBD) on fertility pregnancy and contraception
- Effect of surgery for IBD on fertility pregnancy and contraceptive use
- Risks and benefits of contraceptive use in women with inflammatory bowel disease
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Electronic searches were performed for: MEDLINE (CD Ovid version) (1996-2003); EMBASE (1996-2003); PubMed (1996-2003); the Cochrane Library (to 2003) and the US National Guideline Clearing House. The searches were performed using relevant medical subject headings (MeSH) terms and text words. The Cochrane Library was searched for systematic reviews meta-analyses and controlled trials relevant to emergency contraception. Previously existing guidelines from the Faculty of Family Planning and Reproductive Health Care (FFPRHC) the Royal College of Obstetricians and Gynaecologists (RCOG) the World Health Organization (WHO) and reference lists of identified publications were also searched. Similar search strategies have been used in the development of other national guidelines.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Not Given)
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence
Selected key publications were appraised according to standard methodological checklists before conclusions were considered as evidence. Evidence was graded using a scheme similar to that adopted by the Royal College of Obstetricians and Gynaecologists (RCOG) and other guideline development organizations.
Evidence tables (available on the Faculty Web site [www.ffprhc.org.uk]) summarise relevant published evidence on inflammatory bowel disease which was identified and appraised in the development of this Guidance.
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Grades of Recommendation based on levels of evidence as follows:
A: Evidence based on randomised controlled trials (RCTs)
B: Evidence based on other robust experimental or observational studies
C: Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities
Good Practice Point where no evidence exists but where best practice is based on the clinical experience of the Expert Group
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Not stated
Major Recommendations
Definitions of the grades of recommendation based on levels of evidence (A-C Good Practice Point) are provided at the end of the "Major Recommendations" field.
What effect does inflammatory bowel disease (IBD) have on reproductive health?
- Health professionals managing women with IBD should discuss its potential effect on reproductive health pregnancy and contraceptive requirements (Grade C).
Does IBD have an effect on menstrual cycle fertility and pregnancy?
- Pregnancy in women with IBD should be a planned event when disease is well controlled (Grade B).
Do medications used in the treatment of IBD affect fertility pregnancy or contraception?
- Effective contraception must be used while taking methotrexate and for at least 3 months after its discontinuation (Grade C).
- Women using combined oral contraception (COC) should use additional contraception while taking non-enzyme-inducing antibiotic courses of less than 3 weeks and for 7 days after they are discontinued (Grade C).
- COC users who are established on non-enzyme-inducing antibiotics for more than 3 weeks do not require additional contraception unless they change to a different antibiotic (Grade C).
- Women using progestogen-only methods of contraception do not need additional contraceptive protection when taking non-enzyme-inducing antibiotics for any duration (Grade C).
How does surgery for IBD affect fertility and pregnancy?
- The risk of subfertility following surgical intervention should be discussed with women with IBD as this may influence decisions regarding the timing of childbearing (Good Practice Point).
- Clinicians should consider ectopic pregnancy in their differential diagnosis of abdominal pain in sexually active women with IBD (Good Practice Point).
How does pregnancy affect IBD?
- Appropriate referral for pre-pregnancy counselling should be available to all women with IBD to optimise management before conception (Good Practice Point).
How might IBD affect contraceptive use?
- Women should be advised that the efficacy of oral contraception is unlikely to be reduced by large bowel disease but may potentially be reduced in women with Crohn's disease (CD) who have small bowel disease and malabsorption (Good Practice Point).
How might extra-intestinal manifestations of IBD affect contraceptive use?
- Co-existing disorders in women with IBD should be considered when assessing eligibility for contraceptive use (Grade C).
Women with IBD who have additional risk factors for osteoporosis should have bone mineral density (BMD) measured (Good Practice Point).
How might surgery for IBD affect contraceptive use?
- Women with IBD should stop COC at least 4 weeks before major elective surgery and alternative contraception should be provided (Good Practice Point).
- Women with IBD using progestogen-only contraception need not discontinue it prior to major elective surgery (Good Practice Point).
What are the contraceptive options for women with IBD?
- Women with IBD should be offered the same contraceptive choices as women without IBD. Certain contraceptive methods may have specific cautions for disorders associated with IBD (Grade C).
- Women with ulcerative colitis (UC) can use oral contraception (Grade C).
- Women with Crohn's Disease who have small bowel involvement or malabsorption may have a reduced efficacy of oral contraception (Grade C).
- Women with IBD with low bone density or who have had repeat courses of corticosteroids or malabsorption should be advised against the use of depot medroxyprogesterone acetate (DMPA) (Grade C).
- Laparoscopic sterilisation is an inappropriate method of contraception for women with IBD who have had previous pelvic or abdominal surgery (Grade B).
Barrier methods may be inappropriate for women with IBD who are using potentially teratogenic drugs or in whom disease is active and severe (Good Practice Point).
Does contraceptive use influence IBD?
- Women can be reassured that a pathogenic role for COC in IBD is unsubstantiated (Grade B).
How does IBD affect self-esteem self-image and psychosexual health?
- Health professionals should provide an opportunity for women to discuss issues relating to sexuality and body image and know where to refer locally when appropriate (Good Practice Point).
How might a multidisciplinary approach improve IBD management?
- Managed clinical care pathways should be developed locally to promote integrated working between different service providers to ensure that all reproductive health care needs of women with IBD are met (Good Practice Point).
Definitions
Grades of Recommendation based on levels of evidence as follows:
A: Evidence based on randomised controlled trials (RCTs)
B: Evidence based on other robust experimental or observational studies
C: Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities
Good Practice Point where no evidence exists but where best practice is based on the clinical experience of the Expert Group
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified for each recommendation (see "Major Recommendations" field).
Potential Benefits
- Improved knowledge of the effects of inflammatory bowel disease (IBD) on contraceptive choices fertility and pregnancy in women of reproductive age
- Appropriate medical advice regarding contraceptive options for women with IBD
Potential Harms
- The efficacy of combined oral contraception (COC) may be reduced by non-enzyme-inducing antibiotics and St. John's Wort.
- COC may increase serum levels of cyclosporin.
- The risk of venous thromboembolism for women using COC containing norethisterone or levonorgestrel is increased three-fold to 15 per 100000. Use of a third-generation COC (containing desogestrel or gestodene) increases the risk to 25 per 100000.
- COC and progestogen-only pill (POP) absorption may be reduced in women with small bowel involvement and malabsorption.
- Laparoscopic sterilization is associated with increased complications in women who had previous abdominal or pelvic surgery.
- Barrier methods of contraception have high failure rates and are inappropriate in women using potentially teratogenic drugs.
Contraindications
- Combined oral contraception progestogen-only pills and implants depot medroxyprogesterone acetate and levonorgestrel-releasing intrauterine system are contraindicated in primary sclerosing cholangitis.
- Combined oral contraception should not be used by women with personal history of venous thromboembolism or undergoing major surgery with immobilization.
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- Contraceptive choices for women with inflammatory bowel disease. J Fam Plann Reprod Health Care 2003 Jul;29(3):127-34. [76 references] PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
Faculty of Family Planning and Reproductive Health Care
Guideline Committee
Clinical Effectiveness Committee
Composition of Group that Authored the Guideline
Clinical Effectiveness Unit (CEU): Dr Gillian Penney (Director) Dr Susan Brechin (Co-ordinator); and Alison de Souza (Research Assistant)
Clinical Effectiveness Committee: Professor Anna Glasier (Chair); Dr Chris Wilkinson (ex-officio); Dr David Hicks; Dr Joanne Protheroe; Dr Jo Power; Ms Toni Belfield; Catronia Sutherland
Expert Group: Toni Belfield (Director of Information fpa London); Christine Finlay (Stoma Care Nurse Foresterhill Health Centre Aberdeen); Louise Kane (Specialist Registrar in Public Health Wolverhampton City PCT/FFPRHC Education Committee Member); Ruth McKee (Consultant Colorectal Surgeon Glasgow Royal Infirmary); Perminder Phull (Consultant Gastroenterologist Aberdeen Royal Infirmary); Ros Tolcher (Consultant Family Planning and Reproductive Health/Clinical Director Contraception and Sexual Health Service Southampton); Steve Twaddle (General Practitioner Abronhill Health Centre Cumbernauld)
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the Faculty of Family Planning and Reproductive Health Care Web site.
Print copies: Available from the Faculty of Family Planning and Reproductive Health Care 27 Sussex Place Regent's Park London NW1 4RG
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on July 5 2005.
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This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.
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