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Contraceptive and Adolescence Your Role As Pediatrician

Tahshann S. Richards, DO, MPH Attending Physician Department of Family Medicine Union Community Health Center October 18, 2012. Contraceptive and Adolescence Your Role As Pediatrician. National Youth Risk Behavior Study 47.4% of students had ever had sexual intercourse

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Contraceptive and Adolescence Your Role As Pediatrician

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  1. Tahshann S. Richards, DO, MPH Attending Physician Department of Family Medicine Union Community Health Center October 18, 2012 Contraceptive and AdolescenceYour Role As Pediatrician

  2. National Youth Risk Behavior Study • 47.4% of students had ever had sexual intercourse • 33.7% of students had sexual intercourse with at least one person during the 3 mo before the survey (currently sexually active) • 6.2% of he students had sexual intercourse for the first time before 13 years old • 15.3% had sexual intercourse with ≥4 persons during their life

  3. National Youth Risk Behavior Study • Among 33.7% sexually active students reported that during their last sexual encounter they or their partner had used the following: • Condom (60%) • Birth control pills (18%) • Injectable birth control, birth control ring, or intrauterine device (IUD) (5.3%) • Condom plus any of the above (9.5%)

  4. 82% of adolescent pregnancies are unplanned • Accounts for 1/5 of all unintended pregnancies in the US • 106 Bronx teens / 1,000 get pregnant • 30% more than the national rate • about 2x frequency in Staten Island • Teen births -4 per 1,000 in the Bronx • 2x rates in Queens and Manhattan

  5. Start the talk early!! • Preadolescence • Puberty • Provide health info to preteens and family • Adolescence • Attitudes/knowledge about sex • Sexual activity • Use of contraception

  6. Talking about contraceptive DOES NOT: • Increase rate of sexual activity • Reduce the age of coitarche • Increase number of sexual partners • Increase sexual experimentation

  7. Promote healthy and responsible sexual decision making (including abstinence) Be supportive and non-judgmental Good history taking Careful listening KISS (Keep it Simple Silly) method

  8. Know Teens Rights • When is confidentiality waived? • Guidelines for reimbursement for services • Medical record access • Appointment scheduling • Office policy regarding information disclosure

  9. For sexually active teens using contraceptives • Support compliance • Manage side effects • Change method of contraception accordingly • Provide referral and frequent follow up • Counsel and screen periodically for STIs

  10. Abstinence • Most effective • Delay initiation of sexual activity until adulthood • Efficacy of abstinence based education controversial

  11. Condoms • Mechanical barrier method • Reduce transmission of STDs; therefore NOT optional • Pros • Easily accessible • No Rx required • Inexpensive • Legally purchased by minors • Young men share responsibility for contraception

  12. Female condoms • Barrier method • Effective in prevention of STDs • Cons • Costly • Limited accessibility • Difficult to insert • Squeaks 

  13. Spermicides • Contains nonoxynol 9 and octoxynol 9 • High contraceptive failure rate when used alone • Effective in reducing pregnancy and STDs when used with condoms • Efficacy comparative to OCPS if used with condoms • Pros • No Rx required • Inexpensive

  14. Oral Contraceptive Pills (“The Pill” or OCPs) • Monophasic (Ortho Cyclen), Multiphasic (Ortho TriCyclen, Loestrin) • Best for teens who: • Desire regular menses • Motivated and organized to take pill every day • Condom must be used to protect against STI

  15. OCPs • Pros • Helps dysmenorrhea • Regulates menses • Treat DUB • Decrease risk of osteoporosis • Treat Acne • Protection against: • Ovarian and endometrial CA • Ectopic pregnancy • Ovarian Cysts • Iron deficiency anemia • Benign breast disease

  16. OCPs • Quick start • Gyn exam and PAP (if indicated ) within next 3 mo • Frequent follow up and monitoring

  17. Enhance compliance with patient education and problem solving • If teens miss 1–2 pills: • Take a pill as soon as pt remembers • Take the next pill at the usual time • If teens miss 3 or more pills: • Do not finish pack • Throw away remaining pills • Start next pack

  18. Depo Provera (“The Shot”) • Medroxyprogesterone Acetate) • Long acting progestin • Suppresses ovulation • Thickens cervical mucus • Creates a thin, atrophic endometrium • Given 150 mg IM dose every 12 weeks • Best for teens who: • Chronic illness (sickle cell, seizures, MR) • Are lactating • At risk for complication with estrogen • Pts who do not remember to take pills

  19. Depo Provera • Pros • Protection against endometrial cancer and iron deficiency anemia • Convenient • Effective pregnancy prevention • Cons • Irregular menses • Need for injection • Side effects- weight gain, headaches, bloating, depression and mood changes • Associated with delayed return to fertility • Possibly reversible osteopenia

  20. Nuvaring (“The Ring”) • Combined hormonal ring • Etonogestrel and Ethinyl estradiol • Inserted once a month • Stays in vagina for 3 weeks • Must be removed 21 d after insertion • New ring is inserted 7 d later

  21. Ortho Evra Patch (“The Patch) • Norelgestramin/ethinyl estradial • Transdermal • Change once a wk • Avoid placing on breast • Pros • Easy to remember • Effective • Cons • Increased risk of thromboembolic events • Not flesh colored

  22. Long Acting Reversible Contraception (LARC) • Pros • Safe, Effective • Higher continuation rate (LARC 86% vs short acting 55%) • Decrease unintended pregnancy rate (22x higher for short acting contraceptives vs LARC) • Barriers • Inaccessible • The provider!

  23. Intrauterine Device (IUD) • Mirena (Levonorgestrol) • Reversible • Protection up to 5 years • Expulsion rate range from 5-22 % • Changes in menstrual bleeding esp. in 1st month

  24. Implant (Implanon, Etonogestrel) • Reversible, up to 3 years • High rates of infrequent bleeding or amenorrhea • Higher hemoglobin levels • Reduction in dysmenorrhea and pelvic pain • Minimal or no weight gain

  25. Emergency Contraceptive Pills (Plan B) • Levonorgestrel • Progestin only pill • Effective up to 72 hrs after sex • Pregnancy test done before administration of pills and 3 weeks after administration to detect • Rx required for <18 yrs old • Provide refill for future use

  26. Follow Up • Annual Pap • Screen for STIs every 6 mo-1 yr • Follow up Quarterly (sooner when initiating contraceptives) • CONDOMS, CONDOMS, CONDOMS…

  27. References ACOG. Adolescents and Long-Acting Reversible Contracpetion: Implants and Intrauterine Devices. Number 539. October 2012 CDC. Youth Risk Behavior Surveillance Unite dstates 2011. MMWR vol 62. no 4 June 2012 AAFP. Managing Adverse Effects of Hormonal Contraceptiin Am Fam Physician 15:82 (12) 1499-1506. December 2010 AAP. Contrapception and Adolescents. Pediatrics Vol 104 No. 5 November 1999 http://www.nydailynews.com/opinion/astronomical-bronx-teen-pregnancy-rate-cries-action-article-1.979415#ixzz29dxRv5B8

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