Melanie Cole (Host): Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole, and today our discussion focuses on complex contraception and patient centered care.

Joining me is Dr. Tracy Chen. She's a specialist in Obstetrics and Gynecology at the Allegheny Health Network. Dr. Chen, thank you so much for joining us today. As we get into this topic, can you start by telling us what is complex contraception? Define it for us and differentiate it from routine contraceptive counseling. 

Tracy X. Chen, MD: First off, Melanie, thank you so much for having me on today. I really appreciate it and I'm very excited to talk about this topic. I did my OBGYN residency at the Thomas Jefferson University in Philly and completed my specialization in complex family planning at the University of Hawaii.

For me, complex contraception is about the next tier up from routine contraceptive counseling. I think many people have that experience of going to their doctor, whether it's their family doctor or pediatrician or OBGYN when they are in high school or coming out of high school, going to college, talking about birth control, being handed a birth control pill prescription.

Complex contraception is sort of one step above that for patients who have other complex health conditions, cardiac conditions, autoimmune conditions, who've had surgeries before that perhaps make it more relevant for them and more important to be more careful about when they choose to have a pregnancy.

And myself as a complex contraception specialist, we're perfectly suited to be able to help care for those patients. 

Host: Can you provide examples of patients who may need complex contraception support, whether it's heart conditions, transplants, cancer history? Tell us a little bit about the patients for whom this is indicated. 

Tracy X. Chen, MD: Yeah, I had actually the joy of meeting such a patient this last week. She was a patient who came to me as a referral from a dermatologist and she had a condition called Hidradenitis suppurativa. She was being treated with some IV infusions as well as spironolactone, which is an antiandrogenic medication, and her dermatologist thought that she could benefit from contraceptive counseling on top of that.

The interesting thing about this patient was in addition to this condition, she also had hypertension, she also had a history of a gastric bypass, and all of these conditions together meant that her options were actually quite limited, and for her we had to not only reference our usual guidelines for how to handle contraceptive counseling in people with hypertension, but actually dive into what type of gastric bypass surgery she had, what exactly was anastomosed with what in order to be able to find the best choice for her, because she was not, again, like a typical patient that you could just give a prescription for birth control pills. And after we finished her consultation, I had the joy of being able to get back to her dermatologist and we had a lovely conversation about further treatment for this patient and how we would follow up with her and what her future plans were going to be with regards to pregnancy.

So I feel like that is a patient that I don't know necessarily falls within the scope of routine contraceptive counseling. 

Host: So, you mentioned that you then have this multidisciplinary approach in meeting with other physicians that are involved in managing the chronic conditions of the patient to prevent pregnancy. Tell us a little bit about how that multidisciplinary approach works and how you navigate that intersection of managing those chronic conditions and comorbid situations for these patients. 

Tracy X. Chen, MD: One of the interesting things about contraception and contraceptive care is that one, most patients don't really think of it as like a chronic condition that is to be managed, but in reality, if you are a person with a uterus and ovaries and of reproductive age, that is always a risk that you incur, and we know that pregnancy can be very risky for some people, so for folks with chronic heart conditions who are on anticoagulation, who have lupus, they incur much higher risk during pregnancy than most regular folks.

So beginning with complex contraceptive counseling is really talking about pregnancy intentions, what this person imagines for themselves in the future, whether they want to carry a pregnancy, whether they see themselves in that role. Oftentimes it means pre connecting them with people in perinatology so that they understand the risks of pregnancy.

Sometimes this also involves connecting them to infertility, when they need like artificial reproductive technologies in order to get pregnant. And then it also means coordinating with their specialists; so their specialists understand the medications that they're being placed on and the follow up and treatment plan.

I am not a cardiac specialist. I'm not a hematologist. Those fields are beyond me, but I know that a lot of the work that I do overlaps with these folks. And part of appropriately taking care of the patient is communicating with their specialist who they've seen for a while that this medication is safe for them to be on, what the evidence is for this kind of medication, and that the risks of pregnancy for them are going to be higher than this particular medication at this point during their life. 

Host: Dr. Chen, as we're thinking about personalized contraceptive care, and the importance of individualized care based on patient's needs, goals, life stages; there's also pain management and future family planning that come into play. Can you speak where in this continuum of care do those things and your practice's commitment to evidence based pain management strategies come into play for these patients? 

Tracy X. Chen, MD: Yes, one of the things I often tell patients is that finding the right birth control method for them is often like finding the perfect pair of shoes. For shoes, you're not going to need the same pair or want the same pair throughout your entire lifetime. Your body may change, your needs might change, and the only way to sort of find the perfect pair of shoes for you is often to try them out. You can't necessarily take the recommendations of your friends or your family.

And that is part of the personalized care of contraceptive care, which is addressing the patient's needs, what their health conditions are, and what their pain thresholds are. I know that pain with regards to gynecologic procedures has been a really big issue, and I think it's finally getting the attention that it deserves in the media.

I think we're understanding that just because this pain from this procedure is not enough, that it's so severe that it's a 10 out of 10 pain, but that even, like a six out of 10 pain deserves to be treated. And so our practice, or our dedication to that, look at all of the various methods that have been studied so far, and we do offer them to patients.

I think the other thing that patients feel, or don't quite realize, is the fact that lots of pain modalities have been studied, including guided imagery, acupuncture, like vaginal lidocaine, intranasal fentanyl, I feel that it's up to us as complex contraceptive specialists to be able to navigate all of that data and present the ones that may be most effective to patients. 

Host: So as we're talking about all of these strategies as you work with patients, tell us how you address patient anxiety related to pregnancy timing and management while they're going through this. 

Tracy X. Chen, MD: I think that a lot of patients feel as if contraception is kind of a one stop shop that you just come in and you have to get an IUD or you have to be on birth control pills. And what I really try and communicate to my patients is that they don't have to do anything. The joy of doing contraceptive care is that it truly is in some ways, although, the word elective has many different meanings.

It is sort of an elective management plan or care plan. It is perfectly fine and acceptable to do nothing. And I encourage patients, think about what you really want from your medications because it's sure, fine and dandy to say that you want to prevent pregnancy, but there's so much more that contraception can offer you, whether it be like reduction in acne or benefits in menstrual cramping or mood changes during your menstrual cycle, alleviation of menstrual migraines, you really should be able to expect more.

And If you feel like your method is not satisfying those needs, then you do have other options that you can reach out for. And I think that does alleviate some people's anxieties that there is nothing about contraception that necessarily is like permanent and irreversible. And even for those permanent and irreversible procedures like tubal sterilization, empowering patients to understand that the human experience is different. And like, even patients that say that they regret their tubal sterilizations, we found in research, if you ask them whether they would have made the same decision regarding that surgery, if they were able to go back in time and change things, they would have still chosen that choice.

So honoring that for the patient and supporting them, I think can go a long way towards alleviating their anxiety. And of course, making sure that they have all of the options available to them in order to be able to reach those goals. 

Host: It's really such important information. Dr. Chen, as we wrap up, please explain for us how complex contraception care integrates with future family planning needs when we're talking about infertility care and high risk pregnancies. Tell us a little bit about how this all comes together and the key takeaways, what you'd like other providers to take away from this very important information on complex contraception. 

Tracy X. Chen, MD: We touched on it a little bit earlier, but I really think of complex contraception as sort of a transitional point or in between state, almost like a baseline where most people are going to spend their lives not in the pregnancy state or not attempting pregnancy. But for most people, pregnancy and going through pregnancy and motherhood are going to be big events during their life.

So we're in essence, kind of like a fallback person, kind of like a planner when things are going well, to be able to look into the future and say, this is what I am envisioning in the next five or 10 years. And I feel like as people's lives change, as their bodies evolve, as they acquire a new diagnosis or two; we're the best people to say, like, okay, well, this has happened now in your life.

Maybe the plan that you had for pregnancy beginning when you were coming out of school at age 25 is not necessarily like a plan that needs to happen right now. Or maybe you're just getting married and you're thinking you might want to have children, but now you're 33 and you're wondering if sure, I need some contraception right now, but what does this mean for the future in terms of should I be thinking about freezing my eggs?

I think, part of this like baseline is being able to connect patients to other people, whether they be in infertility or high risk pregnancy, and then also being able to make sure that when they're living their everyday lives, they're walking towards the future that they envision. 

Host: Thank you so much, Dr. Chen, for joining us today and sharing your expertise on this topic that not everybody really knows that much about. So thank you so much. And to learn more or to refer a patient, please call 844-MD REFER or you can visit ahn.org. Thank you so much for listening to this edition of AHN MedTalks with the Allegheny Health Network. I'm Melanie Cole.