Our next speaker is Dr. Karen Dutton. She is an assistant professor and director of family planning in the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center in Boston. She has received numerous teaching awards, and one of her research interests is the relationship between hormones and seizures in women with epilepsy. Today, she will be talking to us about navigating the reproductive health care in a changing political landscape. Dr. Dutton. Thank you for the introduction and thank you especially for the invitation to be here as part of this conference and this panel. Is there something I pick up here? Here we go, the big green button. I have no relevant financial disclosures. Throughout this presentation, I will refer to females and women when reported datasets use this term, but I also want to acknowledge that there are many individuals who identify differently. The learning objectives for my portion of this talk will be to recognize the legal and logistical barriers to care for reproductive health in the US that are currently impacting our patients. We'll anticipate needs and discuss providing routine screening for pregnancy and tension in epilepsy patients, and I'll show you how to access and recommend resources for patients and their primary providers when reproductive health care needs arise. To do this, we will review the landscape in the US currently for reproductive health, find out how our patients and your patients are being impacted, discuss routine implementation of screening for reproductive health needs and review those resources I mentioned. Let's examine the landscape. All of us are very familiar with the maps that get published and shown to us in the media after every election with red states and blue states, as if there's a huge dichotomy between the people in those areas. But in fact, if you look at, and this map is based on election results, county by county after the 2012 elections, there is much more magenta and purple. It's not black and white, and on issues that we may disagree on, there are many people in the middle. Our goal as physicians is to provide the highest quality health care, and to support our patients in protecting their autonomy and their clinical decision-making. Dr. Johnson reviewed the legal restrictions impacting health care for patients seeking gender affirming therapy, and abortion too remains a divisive topic among US citizens. However, polls consistently show support with a majority of US adults, opposing laws banning abortion after six weeks of pregnancy, and a vast majority up to 80 percent opposing the criminalization of either provision or access to abortion. There have been a variety of federal laws over the years impacting abortion provision and access, and certainly our landscape has changed significantly. Since the decision in June of last year, Dobbs v. Jackson Women's Health Services, that changed the precedent of legal abortion in the United States, Roe v. Wade in 1973 established legal abortion across the US, up to 24 weeks on the basis of a right to privacy. However, there have been multiple laws over the years that have continued to impact that decision. Just a few years later, the Hyde Amendment to the Appropriations Budget of 1977 discontinued provision of any abortion services by federal dollars restricting Medicaid and Medicare patients or other patients with federal insurance. That stands to this day, there are 34 states for which Medicaid patients do not have abortion coverage and are required to pay out-of-pocket for their care. In 1992, the Casey decision restricted access to abortion based on state laws that did not impose an undue burden for patients. The partial birth abortion ban in 2007 restricted a specific surgical practice that was never shown to be less safe or harming patients requesting abortion care. Then more recently in Texas, SB 8 circumvented the legal precedent of Roe v. Wade by creating a bounty hunter law. Dobbs has changed the landscape, but these are just federal laws and state by state, there have also been restrictions. Immediately following the Dobbs decision, abortion bans went into effect in many US states and as of a few months ago, you can see the abortion is banned in 14 states in our country. In the yellow states, the gestational age limit for performing abortion is between 6-12 weeks. In the light blue states, between 15-22 weeks, and in the dark blue states, abortion remains legal beyond 22 weeks. Knowing that the majority of abortions are performed before 14 weeks over 90 percent, you can immediately see the huge impact on access to abortion care for patients across the country solely on the basis of geography. I mentioned state restrictions as well. Since Roe v. Wade, US states have enacted a variety of restrictions, and in the past decade alone, over half of those have been enacted. So what are the consequences of these changes? The Society of Family Planning, through its We Count project, has been tracking state by state and clinic by clinic, the volume of patients seen since and just prior to the Dobbs decision. So they recently published that 56,000 patients over the past part of a year, traveled to neighboring states for care, and overall, 80,000 experienced a disruption to abortion access. In addition, comparing their numbers, in the nine-month period following Dobbs, an estimated 25,000, at least, fewer patients have accessed abortion services. Other consequences, and these are well documented by providers in the states with significant restrictions, is that miscarriage management has been impacted. A patient will arrive at an emergency room bleeding and be sent home. Management of pregnancy-related emergencies, such as ectopic pregnancy or high-risk or complex pregnancy, these patients are often emergently being transferred out of state to get care. And all of this is due to fear on behalf of providers and hospitals and institutions. They want to avoid prosecution by their state laws, and they're very nervous about providing indicated and evidence-based care. There are also significant implications for training. So of resident applicants currently to OB-GYN, many are avoiding applying to programs in states where abortion is restricted. And in those states where we already have providers and trainees, we can't train them to provide safe care. Finally, there are potential impacts, particularly on in vitro fertilization. There's a lot of overlap in state laws between definitions of early pregnancy and abortion, and the very real fears about personhood amendments could impact IVF significantly. We also need to acknowledge the disproportionate impact of these laws on black, indigenous, and other people of color, disabled populations, incarcerated populations, low-income populations. And this is in the background of centuries of mistreatment in the U.S., often supported by our courts, instances of experimental surgery on non-consenting patients, forced sterilization, or mandatory contraception. There's a lot of mistrust among these populations. We know that those who obtain abortion are disproportionately patients of color and have lower income. And for them, the usual barriers are even higher, both logistical and financial. Many of these patients depend on Medicaid or Medicare funding. Our epilepsy patients often receive Medicare on the basis of disability. I can't even get an IUD put in Medicare patients and paid for, much less an abortion for them. And so narrowing it down to our patients with epilepsy, these are the ways in which DOBS will and could impact their care. We know already that at least 45% of all pregnancies each year in the U.S. are unplanned, unintended. For epilepsy patients, those numbers are the same or even higher, even though you would hope that somebody is addressing their risk of unplanned pregnancy. They also report lower rates of using highly effective contraceptive methods. And there is lack of knowledge, both by providers and patients, regarding potential interactions between their anti-seizure medications and hormonal contraception. This creates confusion and other barriers to accessing care. Finally, there are unique reproductive consequences for patients with epilepsy. Some anti-seizure medications carry risks of teratogenic and developmental effects, and a patient with uncontrolled epilepsy or an unplanned pregnancy risks poor pregnancy outcomes. Many anomalies are not even identifiable until the second trimester of pregnancy, when options for termination are even more limited. And given the time it takes to make that diagnosis, to go for a consultation, maybe genetic testing, additional imaging, there's a delay in care that may put someone past the gestational age limit in their state to obtain care. And while we recognize that not all patients will proceed with termination, we may also think that maybe there's an exception. You know, doesn't a state have an exception? A state law for making sure that these patients get care? But these risks or abnormal findings on ultrasound in the few states where there are exceptions would not meet the criteria for legal abortion. Let me back up for a second. So I want to reframe this a little bit. If you think about patients with epilepsy, given the risks of an unplanned pregnancy, both to the mother and the baby, and the outcomes for these patients with unplanned pregnancy, we really need to, as a community, focus on providing comprehensive care and address contraception. The demand for contraception among reproductive age patients is high. About two-thirds of women in the U.S. report that they are sexually active and not seeking to become pregnant. So if you then calculate the years of risk for pregnancy, for an unplanned pregnancy, subtracting the time for trying for pregnancy, for pregnancy itself, average 2.7 children, that means that need for contraception exists for each individual for at least 30 years. I would propose that we all implement and consider using this one key question as a screening question in our practices. The One Key Question Initiative was founded in Oregon, where they rolled it out to primary care practices across the state, and were able to demonstrate significant changes in access to especially highly effective contraception. By asking each patient not only what their fall risk is, but if they are of reproductive potential, would you like to be un-pregnant within the next year? And if they answer yes, refer for preconception counseling. If they answer no, refer for contraceptive counseling. Just think of the impact if we all went back, introduced this to our departments and our colleagues, all of the patients we could help avoid unplanned pregnancy. So, then the patient says, yes, I need contraception. Now what do you do? And I'm going to give you a few tips on how to counsel patients with epilepsy on contraceptive options. First, it is very important to reassure them that hormonal contraception is safe and appropriate. I have met numerous patients over the years who claim they were told by providers, I can't take birth control because of my epilepsy. I hope that they heard certain medicines may decrease the efficacy of your birth control pill and so you need to consider what the implication might have, but what they heard was that they can't take birth control. We need to help patients understand that it is safe. Some other common questions and concerns that come up when I talk to other subspecialists, IUDs for many years were thought to increase risk of infection inappropriately, however, that risk is due to exposure to sexually transmitted infection, not to having an IUD in place. And so IUDs can safely be used in patients with no prior pregnancies without any impact on future fertility. IUDs can also be used even if a patient has potential need for MRI. Another common question that comes up, particularly among patients who associate bleeding with seizure activity, possibly from catamenial pattern, is that unscheduled bleeding that may occur with some hormonal contraceptive methods, such as spotting, shouldn't trigger a seizure. It's from a different cause. Spotting is also not an indication that their method is not working, which I also hear from patients and providers. Finally, emergency contraception pills are safe. You can write a prescription. You can encourage patients to get those over the counter at any pharmacy, although in the setting of enzyme-inducing medications, we do not have data regarding their efficacy. Copper IUD is a form of emergency contraception if it's inserted within seven days. So if you can find a practice that will get a patient in quickly, that is one very effective method of emergency contraception. This is a chart, a flow sheet that goes through how to counsel patients with epilepsy regarding their contraceptive options. I'm going to have a QR code on the next slide so you can get a copy of this presentation and refer to this later. First, starting from a patient-centered focus, you want to discuss their contraceptive preferences and needs. And if they're using an anti-seizure medication, counsel based on their enzyme-inducing status. So for enzyme-inducing medications, the first choice, an IUD, will not be affected by this. Also Depo-Provera, Depo-Medroxyprogesterone acetate is unlikely to be affected by the enzyme-inducing agents. Second choice, and a lot of patients who are used to taking pills every day, who already have epilepsy and are very compliant, prefer to take pills. So even with an enzyme-inducing medicine, it is safe to use these. I always encourage 100% use of a barrier method. But at least that and a barrier method will be much more effective than no method alone. For non-inducing medications, any contraceptive method is safe and appropriate. And if you look over on the far right at the top, if a non-hormonal method is selected, there is no adjustment of their medications needed. However, for patients taking lamotrigine, if they are taking an estrogen-containing method, a combined hormonal method, such as the pill patch or ring, you need to monitor their lamotrigine levels closely. I also recommend for these patients that they use the method continuously because of the concern that during the pill-free interval at the end of each pack, when they usually expect their period, their lamotrigine levels may actually go up, and I've seen that in patients that I share with the neurologists. Finally, it's important to educate patients about the potential interactions, particularly if their therapy regimen changes or if their contraceptive method changes. That may change the recommendations. So here's the QR code to this presentation, and I'm hopeful that you'll use that to look back at that chart, but also to look at these resources I wanted to share with you. If you do have a patient with unplanned pregnancy, there's a great website. It's well-vetted, abortionfinder.org, that gives a list of locations or phone numbers they can call state-by-state based on their gestational age, their location. Also the National Abortion Federation hotline can provide pregnancy options counseling and referrals. If you're interested in implementing the one key question, you can look at the Power to Decide organization. And then if you have general questions about what contraceptive methods are appropriate for use in your patients, because often they have other medical conditions, the CDC publishes and updates the medical eligibility criteria for contraceptive use. Most all OBGYNs and PCPs have this app on their phones to refer to, and you can look up either medical conditions or specific contraceptive methods. If you look up the condition of epilepsy, every single contraceptive method is safe and appropriate for use. This is a patient-centered resource, a decision aid to help patients understand the complicated issues around their choice of contraception. It's published by IBIS Reproductive Health. It was developed about a decade ago now, and so some of the contraceptive methods or, for example, the fact that IEDs can be used longer than five or ten years is not quite up-to-date. And it's several pages, but it's at least something when someone comes to you with questions and you have nothing else to offer them, you could connect them with either the website or by printing it out and having it available in your office just to let them know that these are options and to normalize their experience. This same group also developed a great website for adolescents, girlswithnerve.com, that gives information on all types of sexual and reproductive health questions these patients may have. You can imagine for these teenagers who come to your office or are going to their pediatrician, the focus is almost entirely on their epilepsy, and they never get a chance to ask these questions. So I think we can agree that the landscape in the United States has significantly impacted clinical care. The increased restrictions on access to reproductive health services, including abortion, are going to disproportionately impact persons with epilepsy and many other populations. Epilepsy patients, because of their unique issues, face significant challenges, and unfortunately they often rely on less effective methods of contraception. And so by providing comprehensive care, referral, or assessing pregnancy intention will help our patients achieve their goals and keep everyone safe. These are some of my references. This is also another chance to scan this QR code. I'm particularly indebted to Dr. Weatherspoon and her colleagues for publishing in Epilepsy Currents earlier this year an excellent article that really summarizes this intersection of the issues around epilepsy, reproductive health, and abortion. Thank you very much.

reproductive healthcare

Dobbs v. Jackson

marginalized populations

epilepsy patients

contraceptive counseling

patient autonomy