What s new in adolescent contraception
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What’s New in Adolescent Contraception?. Rachel S-D Fortune, MD, FAAP Medical Director, Newport Academy. Pretest questions. All of the following are ABSOLUTE contraindications to the use of combined hormonal contraceptives in adolescents, EXCEPT:

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What s new in adolescent contraception

What’s New in Adolescent Contraception?

Rachel S-D Fortune, MD, FAAP

Medical Director, Newport Academy


Pretest questions

Pretest questions

All of the following are ABSOLUTE contraindications to the use of combined hormonal contraceptives in adolescents, EXCEPT:

Known thromboembolic mutation (i.e. factor V leiden, protein C, protein S, etc)

Current cigarette smoker (<35 years of age)

Family history of DVT/PE

Personal medical history of stroke

True or False: Intrauterine devices can be safely used in adolescent patients:

True

False


What s new in adolescent contraception

Rachel S-D Fortune, MD, FAAP

Medical Director, Newport Academy


Disclosures

Disclosures

I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.


Objectives

Objectives

  • Review current trends in adolescent sexual activity

  • Explore eligibility criteria for various contraceptive methods

  • Provide update on hormonal and non-hormonal methods of contraception

  • Explore long acting reversible contraceptive (LARC) methods in depth


Youth risk behavior surveillance survey 2011 trends in adolescent sexual behaviors

Youth Risk Behavior Surveillance Survey 2011Trends in Adolescent Sexual Behaviors


Trends in adolescent pregnancy rates

Trends in Adolescent Pregnancy Rates

Among 15-19 yo, pregnancy rates declined 27% from 1991  2000

117

68


Trends in adolescent pregnancy rates1

Trends in Adolescent Pregnancy Rates

86% attributable to changes in contraceptive prescribing

Decreased pregnancy rate for 15-19yo

14% attributable to decreased sexual activity


Selecting a contraceptive

Selecting a Contraceptive

  • Eligibility

  • Availability/Cost

  • Mechanism of Action

  • Feasibility

  • Effectiveness

  • Reversibility

  • Side Effects


Contraceptive eligibility

Contraceptive Eligibility

Eligibility

Availability/Cost

Effectiveness

Mechanism of Action

Feasibility

Reversibility

Side Effects

Gordon and Pitts, 2012


Contraceptive eligibility1

Contraceptive Eligibility


Contraceptive eligibility2

Contraceptive Eligibility


Contraceptive eligibility3

Contraceptive Eligibility


Availability cost

Availability/Cost

  • Medicaid covers:

    • Long Acting Reversible Contraceptives (LARC)

    • OCPs, NuvaRing, Ortho Evra patch

    • Depoprovera shots

  • Private insurance companies cover*:

    • Long Acting Reversible Contraceptives (LARC)

    • OCPs, NuvaRing, Ortho Evra patch

    • Depoprovera shot

  • For patients who cannot use their insurance:

    • Planned Parenthood provides services at a cost

Eligibility

Availability/Cost

Effectiveness

Mechanism of Action

Feasibility

Reversibility

Side Effects


Effectiveness

Effectiveness

Eligibility

Availability/Cost

Effectiveness

Mechanism of Action

Feasibility

Reversibility

Side Effects


The basics

The Basics

  • Abstinence

    • 100% effective

  • Condoms

    • Perfect use is only 85% effective

    • Should be used in combination with all other methods

  • Emergency Contraception (Plan B)

    • Available to all

    • No contraindications for anyone

    • Very effective within 72 hours of unprotected sex

    • Works by delaying ovulation; no effect on existing pregnancy


Combined hormonal contraceptives

Combined Hormonal Contraceptives

  • Oral contraceptive pills

    • Vary in concentration of ethinyl estradiol

    • Vary in type of progestin

    • Mechanism of action:

      • Ovulation inhibition

      • Changes in cervical mucous (thickens)

    • Needs high level of compliance

      • Difficult for adolescent adherence

      • Complex schedule for forgotten doses

    • ~91% effective at preventing pregnancy

    • Quick return to fertility


Combined hormonal contraceptives1

Combined Hormonal Contraceptives

  • Side Effects

    • 3-4x increase in risk of thromboembolic event

    • Headaches

    • Nausea

    • Minor weight gain

  • Contraindications

    • Migraine with aura

    • Past medical history of thromboembolism

    • Untreated hypertension

    • Lupus with vascular disease, nephritis or antiphospholipid Abs

    • Less than 3 weeks post partum

    • High triglycerides


Combined hormonal contraceptives2

Combined Hormonal Contraceptives

  • Important points:

    • Understand how/when to start OCPs*

    • Counsel on minor side effects to avoid self discontinuation

    • Low dose OCs may reduce bone mineral density

    • Familiarize yourself with a couple of “go-to”, cheap pill options, such as Ortho Cyclen

    • Follow up blood pressure and weight after 2-3 months

    • Give plenty of refills!

Be familiar with what is out there in the popular press!


Combined hormonal contraceptives3

Combined Hormonal Contraceptives

  • OrthoEvra transdermal patch

    • 150 mcg norelgestromin and 20 mcg ethinyl estradiol

    • Mechanism of action:

      • Ovulation inhibition

      • Changes in cervical mucous (thickens)

    • Needs a moderate level of compliance – once weekly

    • ~91% effective at preventing pregnancy

    • Quick return to fertility


Combined hormonal contraception

Combined Hormonal Contraception

  • Side Effects

    • 3-4x increase in risk of thromboembolic event– may be higher

    • Headaches

    • Minor weight gain

    • Site irritation

  • Contraindications

    • Migraine with aura

    • Past medical history of thromboembolism

    • Untreated hypertension

    • Lupus with vascular disease, nephritis or antiphospholipid Abs

    • Less than 3 weeks post partum

    • High triglycerides

    • Should not be used in patients >90kg (relative)

    • Allergy to component of patch


Combined hormonal contraception1

Combined Hormonal Contraception

  • NuvaRingintravaginal ring

    • 120 mcg etonogestrel and 15 mcg ethinyl estradiol

    • Mechanism of action:

      • Ovulation inhibition

      • Changes in cervical mucous (thickens)

    • Needs a moderate level of compliance – once monthly

      • Requires a high level of comfort with body

    • ~91% effective at preventing pregnancy

    • Quick return to fertility


Combined hormonal contraception2

Combined Hormonal Contraception

  • Side Effects

    • 3-4x increase in risk of thromboembolic event – may be higher

    • Headaches

    • Leukorrhea

  • Contraindications

    • Migraine with aura

    • Past medical history of thromboembolism

    • Untreated hypertension

    • Lupus with vascular disease, nephritis or antiphospholipid Abs

    • Less than 3 weeks post partum

    • High triglycerides


Progestin only pills pops

Progestin-only pills (POPs)

  • Progestin only pills

    • 0.35 mg norethindrone

    • Mechanism of action

      • Ovulation suppression

      • Changes in cervical mucous (thickening)

      • Endometrial thinning

    • Needs a HIGH level of compliance – very short half life

    • Quick return to fertility

    • Safe for patients with estrogen contraindication


Progestin only pills pops1

Progestin-only pills (POPs)

  • Side effects

    • Headache

    • Breast tenderness

    • Acne/Hirsutism

    • Nausea

    • Spotting

  • Contraindications

    • Known or suspected pregnancy

    • Genital bleeding of unknown etiology

    • Liver tumors

    • Acute liver disease


Depo provera

Depo Provera

  • Depo Provera – “birth control shot”, DMPA

    • 150 mg medroxyprogesterone acetate IM every 12 weeks

    • Mechanism of Action

      • Ovulation inhibition

      • Changes in cervical mucous (thickens)

    • Requires a lower level of compliance – every 12 weeks

    • ~97% effective at preventing pregnancy

    • Delayed return to fertility


Depo provera1

Depo Provera

  • Side Effects

    • Irregular bleeding

    • Weight gain (can be significant)

    • Hair loss

    • Bone loss

    • Headaches

    • Acne

  • Contraindications

    • Known or suspected pregnancy

    • History of thromboembolic events

    • Liver disease

    • Genital bleeding of unknown etiology


The land of larc

The Land of LARC


Why larc is best

Why LARC is BEST!

  • Contraceptive Choice Project

    • 9,256 adolescents and women (St Louis)

    • 23% age 14-20

    • 69% of 14-17 year olds chose LARC

      • Implant>IUD

    • 61% of 18-20 year olds chose LARC

      • IUD>Implant

    • Continuation rates better than non-LARC methods

      • Copper IUD 75%

      • Levonorgestrel IUD 81%

      • Implant 82%


Why larc is best1

Why LARC is BEST!


Implanon nexplanon

Implanon/Nexplanon

  • Etonogestrel implant

    • Implanted in upper arm

      • Placed by trained provider

      • Simple office procedure

    • Mechanism of action

      • Ovulation inhibition

      • Changes cervical mucous (thickens)

      • Thins endometrium

    • Prevents pregnancy at >99% for 3 years

    • Rapid return to fertility after quick removal


Implanon nexplanon1

Implanon/Nexplanon

  • Side Effects:

    • Irregular bleeding

    • Headache

    • Weight gain

    • Acne

  • Contraindications

    • Known or suspected pregnancy

    • PMH of deep vein thrombosis

    • Liver tumors

    • Genital bleeding of unknown etiology

    • >130% IBW (relative)


Levonogestrel intrauterine device mirena iud skyla iud

Levonogestrel Intrauterine Device (Mirena IUD/Skyla IUD)

  • Levonogestrel-releasing IUD (5 years and 3 years)

    • Inserted into uterus

      • Office procedure

      • Tolerated by nulliparous women

    • Mechanism of Action

      • Changes cervical mucous (thickens)

      • Inhibits sperm from reaching or fertilizing your egg

      • Thins uterine lining

    • >99% effective at preventing pregnancy

    • Rapid return to fertility after removal of IUD


Levonogestrel intrauterine device mirena iud skyla iud1

Levonogestrel Intrauterine Device (Mirena IUD/Skyla IUD)

  • Side effects

    • Expulsion

    • Irregular bleeding

    • Ovarian cyst

    • Acne

  • Contraindications

    • Pregnancy or suspicion of pregnancy

    • Uterine anomaly

    • Acute pelvic inflammatory disease (PID) or high risk of developing PID

    • Recent infected abortion in past 3 months

    • Known or suspected uterine or cervical neoplasia or abnormal Pap smear

    • Genital bleeding of unknown etiology

    • Untreated cervicitis


Copper iud paragard

Copper IUD (Paragard)

  • Copper IUD (10 years) – continuous release of copper into uterus

    • Inserted into uterus

      • Office procedure

      • Safe for nulliparous women

    • Mechanism of Action

      • Prevents sperm from reaching/fertilizing egg

      • May prevent egg from attaching to the uterus

    • >99% effective at preventing pregnancy

    • Rapid return to fertility after removal of IUD


Copper iud paragard1

Copper IUD (Paragard)

  • Side effects

    • Expulsion

    • Heavier, crampier periods

    • Anemia

    • Vaginitis and/or vaginal discharge

  • Contraindications

    • Pregnancy or suspicion of pregnancy

    • Uterine anomaly

    • Acute PID or high risk of developing PID

    • Recent infected abortion in past 3 months

    • Known or suspected uterine or cervical neoplasia or abnormal Pap smear

    • Genital bleeding of unknown etiology

    • Untreated cervicitis

    • Wilson’s Disease


Quick start approach

Quick Start Approach


Post test questions

Post-test questions

  • All of the following are ABSOLUTE contraindications to the use of combined hormonal contraceptives in adolescents, EXCEPT:

  • Known thromboembolic mutation (i.e. factor V leiden, protein C, protein S, etc)

  • Current cigarette smoker (<35 years of age)

  • Family history of DVT/PE

  • Personal medical history of stroke

  • True or False: Intrauterine devices can be safely used in adolescent patients:

  • True 

  • False


Summary

Summary

  • Contraception should be addressed with all adolescent patients in a primary care setting

  • Knowledge of your patients current needs and medical history will guide your contraceptive decisions

  • Being aware of emergency contraception and quick start contraceptive initiation WILL help prevent pregnancy in your patients


Thank you

Thank You


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