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?

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:

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


Rachel S-D Fortune, MD, FAAP

Medical Director, Newport Academy


Disclosures

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


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 2011Trends in Adolescent Sexual Behaviors


Trends in Adolescent Pregnancy Rates

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

117

68


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

  • Eligibility

  • Availability/Cost

  • Mechanism of Action

  • Feasibility

  • Effectiveness

  • Reversibility

  • Side Effects


Contraceptive Eligibility

Eligibility

Availability/Cost

Effectiveness

Mechanism of Action

Feasibility

Reversibility

Side Effects

Gordon and Pitts, 2012


Contraceptive Eligibility


Contraceptive Eligibility


Contraceptive Eligibility


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

Eligibility

Availability/Cost

Effectiveness

Mechanism of Action

Feasibility

Reversibility

Side Effects


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

  • 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 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 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 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

  • 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 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 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

    • 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 (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 – “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 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


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 BEST!


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/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-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 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 (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 (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


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

  • 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


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