UPDATE ON TECHNOLOGY

The cost for sterilization plus ablation in the office without anesthesia would be approximately $4,500 (including HSG) at Medicare rates. For a combined laparoscopic sterilization and endometrial ablation, costs would be higher because of the need for anesthesia and an ambulatory surgical facility. Another option that would address both the heavy bleeding and the need for contraception: oral contraceptives (OCs). The overall cost of this approach over 5 years would be $4,200 (60 months of OCs at $70/month), but it would be fully covered under the Affordable Care Act (ACA), so the patient would have no out-of-pocket expense. The cost of Mirena would be $1,000 ($850 for the device plus $150 for insertion), but it also would be fully covered under the ACA.

CASE 1: Resolved
You discuss the option of cyclic OCs with the patient. This approach would help control her irregular, heavy, and painful menses while providing good contraceptive coverage.

Although sterilization plus endometrial ablation is an option, you counsel the patient that the published “success” rates do not apply to her. Given her young age, obesity, and anovulatory status, endometrial ablation has a greater likelihood of failure. Further, when abnormal bleeding recurs, it may be difficult to assess this high-risk patient’s endometrium.

You also discuss Mirena, which would provide long-term contraception and also manage her menorrhagia and dysmenorrhea; indeed, it is FDA-approved for this indication. In fact, Mirena would address all of this patient’s concerns, offering superb contraception and reliable reductions in bleeding and pelvic pain in the setting of endometriosis and adenomyosis.

Overall, this woman is best served by a highly reliable approach that manages her contraceptive needs and her menorrhagia and dysmenorrhea while reducing her risk for endometrial hyperplasia and cancer. Given the long-term endometrial-sampling problems ablation would create, it is not an optimal solution for this woman.

What this evidence means for practice
When assessing technology, consider which patients it was tested in, your patient’s diagnosis and long-term health risks, the cost and success rate of the technology, and the availability of less invasive options.

How to assess new data on a technology or procedure

Gill SE, Mills BB. Physician opinions regarding elective bilateral salpingectomy with hysterectomy and for sterilization. JMIG. 2013;20(4):517–521.

CASE 2: A healthy patient seeks permanent contraception

At her annual well-woman visit, your 42-year-old patient (G3P3) asks to discuss permanent contraception now that she has completed her family. She has used OCs for more than 10 years without problems. She is a nonsmoker of normal weight (BMI of 22 kg/m²), with normal blood pressure and vital signs. Her family history is remarkable for the health of her parents and siblings: Her mother is 68 years old and well; her father, 70, also is healthy. There is no family history of breast or ovarian cancer, prostate cancer, or significant medical illness.

What options would you offer this patient? Given recent data suggesting that ovarian cancer may originate in the fallopian tubes, would you recommend prophylactic salpingectomy as her contraceptive method of choice?

This patient has many options. In describing them to her, it would be important to focus on the breadth of safe, reversible, long-acting contraceptives now available, including their respective risks, benefits, and long-term outcomes and costs. It also is important to consider the published data on these methods, weighing their relevance to her overall health and medical history. Although some data regarding the origin of ovarian cancer in the fallopian tubes may be especially compelling, it may not be wise to extrapolate it from a specific group of women to all patients, as we shall see.

Option 1: Cyclic OCs

This option should not be excluded, despite the need for daily dosing, because the patient has used it successfully for more than 10 years. OCs are highly effective and have the added benefits of reducing menstrual blood loss, alleviating cramps, and lowering the risks of endometrial and ovarian cancer.⁷

Option 2: LARC

Long-acting reversible contraceptive (LARC) methods include the LNG-IUS, the copper intrauterine device (IUD; ParaGard, Teva), and the etonogestrel implant (Nexplanon, Merck). Each of these contraceptives is similar to sterilization in terms of efficacy. None requires the interruption of sexual activity or weekly or monthly trips to the pharmacy.

The LNG-IUS and the etonogestrel implant have the added benefits of reducing menstrual blood loss and reducing or eliminating premenstrual symptoms and cramps in most women. In addition, they may reduce the risk of unopposed estrogen stimulation of the endometrium associated with perimenopausal anovulatory cycles.

Option 3: Transcervical tubal sterilization