PEDIATRIC BOARD REVIEW COURSE ADOLESCENT MEDICINE

1. PEDIATRIC BOARD REVIEW COURSE ADOLESCENT MEDICINE WARREN M. SEIGEL M.D., F.A.A.P., F.S.A.M. Chairman, Department of Pediatrics Director of Adolescent Medicine Coney Island Hospital Brooklyn, NY

2. CASE #1 Katherine is a 14 year old female who presents for a routine examination for sports. She has no complaints. Her past medical history and family history are unremarkable. On physical examination, you note that she has Tanner 3 breasts and Tanner 4 pubic hair.

3. QUESTIONS What is your differential diagnosis? Are Katherine’s physical findings normal? How would you describe “Tanner 3” breast development? How would you describe “Tanner 4” pubic hair development? Has Katherine completed her growth spurt? What actions would you take next?

4. PUBERTY Physical changes associated with development Sequence of change is similar for all adolescents Variations in tempo and timing are common Physical changes reflect underlying hormonal changes

5. SEQUENCE OF PUBERTY GIRLS Breast Buds Pubic Hair Appears Growth Spurt Axillary Hair Pubic Hair Matures Breasts Mature Menarche (First Period) Adult Height BOYS Testicular enlargement Growth of penis/scrotum Appearance of pubic hair Axillary Hair First ejaculations Growth spurt Facial hair Adult Height

6. Features of Female Development Onset: 10 years (8-13) Growth spurt: Tanner 2 - 3 Height Achieved: 4 inches per year Menarche: 12 years Acne: common at Tanner 3 - 4

7. Features of Male Puberty Onset: 9-13 years (average = 12) Peak Height Velocity: Tanner 3 - 4 First Ejaculations: Tanner 3 Average Height Gained: 5-7 inches/ year Strength Peak: Tanner 4 - 5 Gynecomastia occurs in approximately 60%

8. CASE #1(continued) Later in the course of your history, you find out that Katherine has tried tobacco, drinks alcohol “on weekends with my friends” and “smokes weed once in a blue”.

9. QUESTIONS From a psychosocial perspective, in what stage of adolescent development is Katherine? What are some of the high risk behaviors that she is most likely to be at risk for in the near future? What are the leading causes of morbidity and mortality in Katherine’s age group? What actions would you take next?

10. FEATURES OF EARLY ADOLESCENCE(Am I Normal?) Physical Changes and Concerns Sense of Being “Center Stage” Sense of Invulnerability Wide Mood Swings Rejection of Childhood Things Beginnings of Emancipation Non-Parent Adult Role Models Same-Sex Friendships Concrete Thinking

11. FEATURES OF MIDDLE ADOLESCENCE(Am I Liked?) Puberty (Almost) Complete Testing/Showing Off “New Body” Independence-Dependence Conflicts Strong Peer Attachments Concern With Sexual Appeal Experimentation/Risk-Taking Abstract Thinking Begins

12. FEATURES OF LATE ADOLESCENCE(Am I Loved?) Definition of Adult Role in Society Definition of Adult Role in Family Mainly Independent Decisions, Actions Established, Realistic, Self-Identity Realization of Vulnerability, Limitations Abstract Thinking Well Established

13. Mortality and Morbidity Mortality rate among males twice that of females Accidents- most common 80% automobile Homicide Suicide- most often due to firearms

14. High Risk Behaviors Sexual Activity Males 20% by age 13 50% by age 15 80% by age 19 Females 8% by age 13 33% by age 15 66% by age 19 Both- 67% never use condoms

15. High Risk Behaviors Substance Abuse Alcohol 75% of all adolescents acknowledge use Cigarettes use increasing among females Marijuana use increased among all age groups Cocaine level use

16. CASE # 2 Jonathon is a 16 year old male who comes to your office complaining of a clear urethral discharge and burning on urination for the past 1 week. He admits to being sexually active, the last time being 10 days ago.

17. QUESTIONS What is your differential diagnosis? What additional history would you like to obtain? What will you look for on your physical examination? What actions would you take next?

18. CHLAMYDIA TRACHOMATIS MALES Asymptomatic Urethritis Epididymitis FEMALES Asymptomatic Cervictis

19. CHLAMYDIA: SITE OF INFECTION Male: Prostate, Epididymis Female: Cervix, Uterus, Tubes (PID) Both: Eyes, Urethra, Rectum Infant: Eyes, Pneumonia

20. CHLAMYDIA: SIGNS AND SYMPTOMS MALE: Burning, Urethral Discharge, Pain in Epididymis FEMALE: Vaginal/Cervical Discharge, Pelvic Pain, Painful Intercourse, Burning MAY BE NO SYMPTOMS IN MALE OR FEMALE.

21. CHLAMYDIA TRACHOMATIS DIAGNOSIS Culture: “gold standard” Leukocyte esterase; urine dip in males Enzyme linked assay (EIA or ELISA) Direct Fluorescent Antibody (DFA) DNA probes Nucleic Acid Amplification Tests (NAATs)

22. CHLAMYDIA TRACHOMATIS TREATMENT Azithromycin 1 gm single dose by mouth Doxycycline 100 mg by mouth twice daily for 7 days PARTNER TREATMENT!!! Follow-up “Test of Cure” recommended

24. GONORRHEA: SIGNS AND SYMPTOMS MALE: Yellow “Drip” from Penis, Burning, Pain in Epididymis FEMALE: Vaginal/Cervical discharge, Heavy Menses, Painful Intercourse, Burning, Frequency MAY BE NO SYMPTOMS IN MALE OR FEMALE

25. Neisseria Gonorrhea MALE Urethritis Epididymitis FEMALES Asymptomatic Cervicitis Bartholin’s gland abscess Pelvic Inflammatory Disease (PID)

26. NEISSERIA GONORRHEA DIAGNOSIS Culture: “Gold Standard” Leukocyte esterase suggestive in males DNA probes, PCR, EIA are all available Nucleic Acid Amplification Tests (NAATs)

27. NEISSERIA GONORRHEA TREATMENT Ceftriaxone 125 mg IM in single dose Cefixime 400 mg PO in single dose Ofloxacin 400 mg PO in single dose Ciprofloxacin 500 mg PO in single dose ADDITIONAL TREAMENT FOR CHLAMYDIA TRACHOMATIS IS TYPICAL

28. SYPHILIS: SITE OF INFECTION MALE: Penis, Anus, Mouth, Lips FEMALE: Vulva, Vagina, Cervix, Anus, Mouth, Lips INFANT: Acquired During Pregnancy, Birth Defects, Death Spread to entire body in male and female including heart and brain!

29. SYPHILIS: SIGNS AND SYMPTOMS PRIMARY SYPHILIS Chancre on sex organs SECONDARY SYPHILIS Fever, rashes, generalized illness TERTIARY SYPHILIS Infection of brain, blood vessels

30. SYPHILIS PRESENTATION Primary chancre Indurated ulcer with smooth borders Painless Incubation of approximately 3 weeks Healing in approximately 6 weeks

31. SECONDARY SYPHILIS CONSTITUTIONAL SYMPTOMS Fever, malaise, adenopathy, musculoskeletal SKIN AND MUCOUS MEMBRANE FINDINGS Rash – begins on trunk Rash – involves palms and soles Condyloma lata – moist plaques Alopecia SKIN LESIONS ARE HIGHLY INFECTIOUS!

32. Diagnosis – Syphilis Serologic – nontreponemal RPR, VDRL, ART Serologic – treponemal FTA-ABS, MHATP,TPHA

33. Treatment – Syphilis Less than 1 year duration – Benzathine Penicillin-G 2.4 million units IM Greater than 1 year duration – Benzathine Penicillin-G 7.2 million units, 3 divided doses

34. Trichomonas Males Generally asymptomatic Females Malodorous vaginal discharge Cervicitis Vulvitis with labial edema

35. Trichomonas Diagnosis Observation of flagellate on saline wet mount Treatment Metronidazole 2 gm po x 1 dose

36. Bacterial Vaginosis Non-gonococcal Non-chlamydial Non-trichomonal Non-candidal Due to Gardnerella vaginalis

37. Bacterial Vaginosis Symptoms Vaginal discharge- grey-white, thin , watery Pruritis and itching may accompany Worsens with intercourse Malodorous Diagnosis Saline wet prep with “clue” cells

38. Bacterial Vaginosis Treatment Metronidazole 500 mg PO bid X 7 days

39. Genital Herpes: Site of Infection Males: Blisters on Penis, Scrotum, Buttocks Females: Blisters on Vulva, Vagina, Cervix, Buttocks Infants: Systemic

40. Genital Herpes: Signs and Symptoms Primary Infection: Very Painful Painful Urination 1-3 weeks Repeat Infections: Less Painful 1 Week or less

41. Herpes Simplex - HSV Skin lesions appear at site within 2-14 days Grouped papules on erythematous base Ulceration Erosion Very painful Constitutional symptoms

42. Genital Herpes: Treatment Treat Virus Treat Symptoms No sex until 1 week after blisters heal Treat partner only if infected

43. Treatment:Genital Herpes Primary Acyclovir 400 mg oral tid X 7-10 days Recurrent Acyclovir 400 mg oral tid X 5 days Prophylaxis Acyclovir 400 mg oral bid

44. Genital Herpes 1.First Episode Acyclovir (ACV) 200 mg (400mg for proctitis) PO 5x per day for 7-10 days 2. Recurrent Episodes – usually no treatment, if necessary: A) ACV 200 mg PO 5x per day for 5 days B) ACV 400 mg PO TID for 5 days C) ACV 800 mg PO BID for 5 days 3. Suppressive Therapy A) ACV 400 mg PO BID B) ACV 200 mg po 2-5 times/day 4.Severe disease ACV 5 -10 mg/kg IV every 8 hours X 5-7 days 5. No role for topical ACV

45. Human Papilloma Virus Most common STI Increasing prevalence among teens Associated with majority of Pap smear abnormalities

46. Human Papilloma Virus Treatment Podophyllin Cryotherapy with liquid nitrogen Podofilox ( home treatment ) Interferon available (not currently recommended)

47. CASE # 3 Over the past 6 months, Marianne, a 15 year old girl in your practice, has missed 8 days of school because of severe, episodic lower abdominal pain that coincides with menses. Menarche was at age 13 and menses are regular. She states that she is not sexually active. Findings on physical exam are normal.

48. QUESTIONS What is your differential diagnosis? What will you look for on physical examination? What actions would you take next?

49. Normal Menstruation Normal menstruation is an indication that the hypothalamic--pituitary--ovarian--uterine axis is intact and responsive.

50. Physiology of Menses FSH - stimulates the maturation of ovarian follicles - directs the conversion of androgens in the granulosa cells of the ovary to estrogens LH - stimulates theca cells of the ovary to produce androgens - midcycle LH surge stimulates ovulation

51. Physiology of Menses Estrogens- stimulate the proliferation of endometrial epithelial and stromal cells. Stimulate glandular formation. Progesterone- produced by corpus luteum, causes the endometrium to function in a secretory manner, leading to increased blood vessel growth and tortuosity.

52. Normal Menstrual Cycles Follicular Phase Ovulatory Phase Luteal Phase

53. Follicular Phase Endometrial proliferation under estrogen influence Endometrial stroma becomes compact Estrogen triggers midcycle LH surge Cervical mucus is watery

54. Ovulatory Phase Following ovulation, corpus luteum produces both Estrogen and Progesterone. Progesterone exerts suppressive effect on Estrogen resulting in the conversion of the endometrium to a secretory state.

55. Ovulatory Phase Vaginal secretions and Cervical mucus are copious and clear. Secretions placed on glass slide will demonstrate “ferning” pattern when allowed to dry. (know this !)

56. Case # 3(continued) Upon further questioning, Marianne admits that her last menstrual period was approximately 8 weeks ago. She is sexually active with a single male partner and does not use condoms consistently.

57. QUESTIONS What is your differential diagnosis? What will you look for on physical examination? What actions would you take next?

58. Menstrual Abnormalities Primary Amenorrhea Secondary Amenorrhea Dysmenorrhea Dysfunctional Uterine Bleeding Polycystic Ovary Disease

59. Amenorrhea Definition: Amenorrhea is the absence of menses.

60. Amenorrhea Primary Amenorrhea: The lack of menses by age 14 with the absence of secondary sexual characteristics. The lack of menses by age 16 regardless of the status of secondary sexual characteristics.

61. Amenorrhea Secondary Amenorrhea: Absence of menses for a period of at least 3 cycle lengths or for a period of 6 months.

62. Primary Amenorrhea Differential Diagnosis Hypothalamus Pituitary Ovary Uterus & Outflow Tract

63. Primary Amenorrhea Hypothalamic Causes Physiologic delay – often familial Systemic disease – often chronic Stress Athletics Eating Disorders Obesity Drugs Cytoxin, Phenothiazines, Isotretinoin, Amphetamines Steroids, Opiates

64. Primary Amenorrhea Pituitary Causes Idiopathic Hypopituitarism Tumor Hemochromatosis

65. Primary Amenorrhea Thyroid and Adrenal Gland Causes Hypothyroidism Hyperthyroidism Congenital Adrenal Hyperplasia Tumor

66. Primary Amenorrhea Gonadal Causes Turner Syndrome and Mosaicism Pure Gonadal Dysgenesis Testicular Feminization Syndrome Hermaphroditism Ovarian Failure

67. Primary Amenorrhea Uterus and Outflow Tract Causes Synechiae Pregnancy Agenesis Imperforate Hymen

68. Evaluation of Primary Amenorrhea History Physical Examination Pelvic Examination Ultrasound if needed to define anatomy FSH, LH, Prolactin, Testosterone Bone Age Karyotype

69. Secondary Amenorrhea Think Pregnancy Pregnancy Pregnancy

70. Secondary Amenorrhea Hypothalamic Causes Stress Exercise Obesity Eating disorders Drugs Cytoxin, Phenothiazines, Isotretinoin, Amphetamines Steroids, Opiates Systemic Enteritis, colitis Diabetes CF, renal disease

71. Secondary Amenorrhea Pituitary Causes Hyperprolactinemia Pituitary Adenoma Post-Oral Contraception

72. Secondary Amenorrhea Thyroid Causes Hyperthyroidism Hypothyroidism

73. Secondary Amenorrhea Adrenal Causes Congenital Adrenal Hyperplasia Adrenal Tumor

74. Secondary Amenorrhea Gonadal Causes Polycystic Ovary Syndrome Gonadal Dysgenesis Ovarian Failure

75. Secondary Amenorrhea Uterus and Outflow Tract Causes Asherman Syndrome scarring from D&C Tumor

76. Evaluation of Secondary Amenorrhea Complete History & Physical Exam Pelvic Examination Pregnancy Test

77. Evaluation of Secondary Amenorrhea Pregnancy Test NEGATIVE: Provera, 10 mg BID X 5 days Withdrawal bleed indicates: Ovaries produce adequate estrogen to stimulate endometrial proliferation in the uterus. Also indicates that the outflow tract is intact and functioning normally.

78. Evaluation of Secondary Amenorrhea Lab Evaluation: CBC with diff, ESR UA FSH, LH, prolactin Radiologic Evaluation: pelvic ultrasound

79. Dysmenorrhea Definition – pain associated with menses Etiology: Prostaglandin PGE2 and PGF2 implicated Endometriosis Onset within 6-12 months following Menarche

80. Dysmenorrhea Lower abdominal to back/thigh pain reported Polyps, benign tumors Infection

81. Dysmenorrhea Differential Diagnosis Endometriosis Pelvic Inflammatory Disease Benign Tumor Anatomic abnormality

82. Workup for Dysmenorrhea Complete physical examination including pelvic exam CBC with differential, ESR GC/chlamydia screen Wet mount of discharge if present

83. Management of Dysmenorrhea Infection – treat Endometriosis – refer to GYN No abnormality on evaluation Non-steroidal anti-inflammatory agent Reassurance If no improvement with NSAIDS, estrogen/progesterone combination contraceptive

84. CASE #4 Adrienne is a 14 year old female who complains of vaginal bleeding for the past month. She states that she has been using approximately 6 – 8 pads per day and that her bleeding has been heavier than usual. Menarche was at 13 years. She denies sexual activity.

85. QUESTIONS What is your differential diagnosis? What additional history would you want to obtain? What will you look for on physical examination? What actions would you take next?

86. Dysfunctional Uterine Bleeding Polymenorrhea – bleeding which occurs at regular intervals of less than 21 days Menorrhagia – prolonged or excessive bleeding at regular intervals of 21-35 days Metrorrhagia – irregular interval bleeding

87. Dysfunctional Uterine Bleeding Etiology – anovulatory bleeding secondary to immature hypothalamic-pituitary-ovarian axis

88. Dysfunctional Uterine Bleeding Differential Diagnosis Anovulatory Bleeding Pregnancy complications Ectopic, spontaneous abortion Endometritis Malignancy Iatrogenic Ovarian

89. Dysfunctional Uterine Bleeding Evaluation Complete History and Physical Exam Menstrual and Sexual History Pregnancy Test CBC with differential Platelet Count PT/PTT

90. Management of Dysfunctional Uterine Bleeding If Hemoglobin is stable Observation and reassurance Begin Iron Therapy Combination estrogen/progestin contraceptive pills

91. Management of Dysfunctional Uterine Bleeding If bleeding is severe, Hemoglobin unstable Estrogen every 4-6 hours until bleeding is stopped The begin Estrogen containing pills as maintenance

92. Polycystic Ovary Disease Anovulatory cycles with irregular bleeding Suspect in the mid adolescent with menstrual irregularity

93. Polycystic Ovary Disease Etiology: Defect in gonadotropin secretion leading to elevated LH. FSH is normal/borderline low. Acyclic estrogen/progesterone secretion Elevated Androgen secretion Anovulation

94. Polycystic Ovary Disease Presentation Amenorrhea Hirsuitism Obesity Infertility

95. Polycystic Ovary Disease Differential Diagnosis Familial Hirsuitism Cushing’s Syndrome Androgen excess Late onset CAH (21-hydroxylase deficiency) Androgen producing tumor Anabolic steroid use

96. Polycystic Ovary Disease Evaluation History including PMH Medication History Menstrual History Sexual History including pregnancy, infection, abortion Physical Exam Obesity Hirsuitism Clitoromegaly

97. Polycystic Ovary Disease Pelvic Examination Size of ovaries Laboratory Evaluation LH/FSH, E2, DHEAS, Testosterone, 17-OH Progesterone Ultrasound Size of Ovaries

98. Polycystic Ovary Disease Treatment Normalization of Menses Estrogen dominant Oral Contraceptive Pill Hirsuitism Weight Loss Cosmetics Fertility Clomid Metformin

99. CASE #5 Mark is a 15 year old boy who comes to your office for a routine physical examination. His mother asks to meet with you alone and says that a few weeks ago she found a plastic baggy with marijuana under his bed. She requests that you perform a drug test without telling her son.

100. QUESTIONS Will you perform the drug test without telling Mark? If not, what will you tell Mark as an alternative? What will you tell Mark about drug testing?

101. Substance Abuse Definition: The persistent use of illicit substances despite experiencing negative consequences from their use. Substance abuse is a multi-dimensional disorder with a complex biopsychosocial etiology.

102. Multiple Drug Use Adolescents rarely report a “drug of choice” but rather use multiple substances.

103. Age at First Use The age of first use for US teens is 11-12 years of age.

104. Case #5(continued) Mark’s grades have been falling and he quit the football team recently. He has a new group of friends that he never brings home. Mark tells you that he occasionally smokes marijuana but he denies using any other drugs. He admits to being sexually active and drinking beer with his friends on weekends.

105. QUESTIONS What is your differential diagnosis? What will you look for on physical examination? What actions would you take next?

106. Risk Factors for Illicit Drug Use Family Tolerance Peer Influences- The most positive predictor of drug and alcohol use among teens, is a positive history of use among peers. Other Factors Early Academic Failure Isolation Criminal Activity

107. Recognizing Substance Abuse Problems Behavioral Change Unexpected Decline in School Performance School Problems & Behavioral Concerns Isolation from peers Outbursts of anger or abusive behavior without remorse

108. Obtaining the History With the teen separated from parent/s With assurance that the substance use history is part of a routine interview (it should be !) With appropriate lead in questions...

109. Lead Ins….. Many teens your age go to parties where alcohol is available…do you ? Have you ever consumed a drink containing alcohol ? Have you ever been drunk ?

110. The CAGE C = the need to CUT DOWN A = has someone been ANNOYED because of alcohol or drug use G = have you felt GUILTY because of something which happened E = have you ever used in the morning as an EYE OPENER

111. The “C.R.A.F.F.T.” C -- Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs? R -- Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? A -- Do you ever use alcohol or drugs while you are by yourself, ALONE? F -- Do you ever FORGET things you did while using alcohol or drugs? F -- Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? T -- Have you gotten into TROUBLE while you were using alcohol or drugs

112. Drug Screening Ethical Issues- screening without the knowledge and consent will likely have a negative effect on the doctor-patient relationship. The AAP does not endorse such “non-informed” screening.

113. Drug Screening... Obtain the appropriate sample Either urine or serum are adequate for general screening. The use of hair for screening is more sophisticated than generally necessary for routine screening.

114. Drug Screening... How long will drug screening remain positive ? Amphetamines- < 48 hours Barbiturates- 3-4 days Cocaine- 2-4 days maximum Ethanol- 2-14 hours Opiates- 2 days Cannabinoids- 10 - 20 days maximum

115. FIVE STAGES OF SUBSTANCE ABUSE STAGE 1 CURIOSITY STAGE 2 EXPERIMENTATION STAGE 3 REGULAR USE STAGE 4 PSYCHOLOGIC OR CHEMICAL DEPENDENCY STAGE 5 USING DRUGS TO FEEL “NORMAL”

116. CASE #6 Adrienne is a 13 year old female who is brought to you by her mother for a physical examination. She has no complaints and her past medical history is unremarkable. The mother requests that you examine her daughter “to see if she’s a virgin” and if not, the mother requests that you start her on some form of contraception.

117. QUESTIONS What is your differential diagnosis? What additional history would you want to obtain? What will you look for on physical examination? What actions would you take next?

118. Adolescent Sexual Behavior 80% of Males and 70% of Females have intercourse before age 20 Average age of first intercourse is 16 Often a series of single partners

119. Considerations in Contraceptive choice for Adolescents Frequency of Intercourse Number of Partners Acceptability Motivation and Self-Discipline Access to Medical Care Effectiveness Safety vs. Risk Cost

120. Prevention: Abstinence Effective No Cost Applicable for all Requires Willpower for Both Partners

121. Prevention: Withdrawal Penile withdrawal before Ejaculation No cost Effectiveness 77-84% Does Not Prevent STIs Always Available Choice of last resort for adolescents

122. Prevention: Fertility Awareness Recognition of Fertile and Safe Times in Cycle Effectiveness 76-98% No Major Health Concerns No Cost Difficult if Irregular Cycles Requires Discipline in Both Partners Poor Choice for Adolescents

123. Prevention: Condoms Condoms Prevent Sperm from entering Vagina Must be in place prior to contact with vagina and during withdrawal Effectiveness 90-98% Over-the-counter Availability Best protection against STIs Requires Motivated Couple Appropriate for Casual Sex Partner Appropriate for Motivated Male

124. Prevention: Diaphragm Barrier to Cervix Must be fitted professionally Must be in place prior to sexual contact and 6 hours after Effectiveness 81-98% Requires physical exam Can be inconvenient Appropriate for very motivated teen in Stable Relationship

125. Prevention: Intrauterine Device (IUD) Prevents Implantation (Theory) Device placed inside Uterus Effectiveness 95-98% Limited availability Requires Medical Surveillance Increases risk of PID, infertility Rarely appropriate for adolescents

126. Prevention: Sponge Disposable Barrier to Cervix Moistened Sponge used similar to Diaphragm Effectiveness 80-91% Over-the-counter availability Some protection form STDS Expensive if Frequent Intercourse Appropriate for Motivated teen Good Back-up Method

127. Prevention: Foam and Spermicides Chemical destruction of sperm in vagina Must be in place prior to intercourse Effectiveness 82-97% Over-the-Counter availability Some protection From STIs Requires Motivated couple Appropriate for Motivated adolescents

128. Prevention: Sterilization Permanent Surgical Sterilization Male or Female Effectiveness more than 99% Medically performed Not appropriate for adolescents

129. Prevention: Injectable Hormones Suppresses Hormone Cycle Injection every 1-3 month 98-99% effective Long Lasting, Unrelated to Intercourse Requires More Frequent Medical Visits

130. Module #8-15 Prevention: Morning After Pill Taken Post Intercourse to prevent implantation Effectiveness 99% Emergency Method for Rape, Contraceptive Failure Not regular Birth Control Method Requires Medical Evaluation Appropriate for Emergency Use in Adolescents

131. Prevention: Emergency Contraception (EC) Taken Post Intercourse to prevent implantation Effectiveness 99% Emergency Method for Rape, Contraceptive Failure Not regular Birth Control Method Requires Medical Evaluation Appropriate for Emergency Use in Adolescents

132. Module #8-14 Prevention: Hormonal Contraceptives Hormonal Prevention of Ovulation Requires regular Professional Care Effectiveness 98-99% Multiple Health Benefits Risk of Medical Complications lowest in Adolescents Must be taken Every Day Minor Side Effect Possible Often Method of Choice for Adolescents

133. Contraceptive PatchEstrogen and Progestin Delivery Patch contains 6.00 mg norelgestromin and 0.75 mg ethinyl estradiol Delivers continuous systemic doses of hormones 150 µg norelgestromin (NGMN) + 20 µg ethinyl estradiol (EE) per day Abrams L, et al. FASEB J. 2000;14;A1479.

134. Etongestrel/Ethinyl Estradiol Vaginal Ring Progestin: Etonogestrel: 120 µg/day Estrogen: Ethinyl Estradiol: 15 µg/day Worn for three out of four weeks Self insertion & removal Pregnancy rate 0.65 per 100 woman-years Roumen FJ, et al. JUM Reprod. 2001;16(3):469-475.

135. Absolute Contraindications for Hormonal Contraception Past or current history of Thromboembolic disorder Cerebrovascular disease Breast cancer Estrogen dependent neoplasia Prolonged immobilization Acute liver function impairment Pregnancy

136. Relative Contraindications Vascular or migraine headaches Collagen vascular diseases Severe hypertension Chronic heart disease Sickle cell disease Severe renal disease Diabetes mellitus

137. GOOD LUCK!