AdolescentContraceptiVECARE Eliza Buyers, MD, FACOG Kaiser Permanente Department of OB/GYN firstname.lastname@example.org Office: 303-360-1576 COAPPP’s Raising the Bar Conference October 8&9, 2009
Disclosures • Eliza Buyers has no significant financial interests or other relationships with industry relative to the topics that will be discussed.
Learning objectives • Describe some of the common barriers that the adolescent population faces in obtaining reproductive health care and contraception. • Discuss common misperceptions about adolescent contraceptive care. • Describe the advantages, expected side effects, and contraindications of various methods. • Describe why long-acting methods are optimal for many adolescent patients.
Adolescent Contraceptive CareOVERVIEW • Background on adolescent pregnancy and the barriers to contraceptive care • Specific methods and overcoming barriers to care • Emergency Contraception (EC) • Quick Start • Extended/Continuous use OCPs/ring/patch • Update on Depo-Provera • IUDs (Levonorgestrel IUD) • Single-rod contraceptive implant (Implanon)
Miscarriage 14% 57% 29% Birth Abortion Adolescent Pregnancy OVERVIEWTeen pregnancy outcomes • Almost 1 million pregnancies. • 82% unplanned • - 3 in10 girls pregnant by age 20 • - 1 in 3 end in abortion Guttmacher Institute, Facts on American Teens’ Sexual and Reproductive Health, Sept, 2006
OP-ED COLUMNIST Let’s Talk About Sex By CHARLES M. BLOW Published: September 6, 2008
Providers’ Perspectives: Perceived Barriers to Contraceptive Use in Youth and Young Adults 1. Lack of provider training. 2. Outdated protocols and lack of continuing education. 3. Restrictive reimbursement procedures. 4. Lack of social marketing that promotes contraception. 5. Inadequate reproductive health services for men. www.thenationalcampaign.org/resources/pdf/BarrierstoContraception_FINAL.pdf
Barriers to Care: Lack of ConfidentialityTalking about Reproductive Health • MAJOR OBSTACLE: CONFIDENTIALITY • Most teens want care but NOT if their parents know. • If parents were notified: nearly 50% would not seek care but 99% would still have sex. • Assure confidentiality at the start of your visit. • Colorado law: minors have access to confidential services for contraception and STD testing. • Unless suicidal, homicidal or abuse involved. • Explain your office procedures to maintain this right. • Beware of billing and coding, private insurance.
Barriers to Care: How To Ask About SexTalking about Reproductive Health • First, assure confidentiality • Open-ended and open-minded • “Are you dating anyone or hooking up?” (how old?) • “Are your friends dating people?” • “Do you (or your friends) have any questions about sex?” • “Do you have sex with girls or boys or both?” • “I am so happy that you came in today. It is so important that you take responsibility for your own health and this includes your reproductive health.”
Barriers to Care: Magical ThinkingTalking about Reproductive Health • Assure confidentiality, Open-ended, open-minded • Address magical thinking: “I can’t get pregnant” • A sexually active teen who does not use contraception has a 90% chance of becoming pregnant in a year. • 1 in 3 girls pregnant at least once before age 20 • A single act of sexual intercourse: 8% chance of pregnancy. • Teens with a negative pregnancy test: 58% pregnant at least once within next 18 months. • Health care provider (YOU!) may be the ONLY source of accurate information.
Barriers to Care: Accurate InformationTalking about Reproductive Health • Parents beliefs about condoms and oral contraceptives • What parents think about condoms: • 47% effective in preventing HIV/STDs (fact: 98-100% ) • 40% effective to prevent pregnancy (fact: 97% perfect use) • What parents think about oral contraceptives: • 52% “highly effective” to prevent pregnancy (fact: 94-99%) • 39% thought almost all teens can use pills safely (fact: all healthy teens can!) • 39% thought teens could use pills as consistently as other age groups (fact: just as well!)
Adolescent Pregnancy OVERVIEWTalking about Reproductive Health www.stayteen.org (National Campaign) www.sexetc.org (Answer, from Rutgers Univ.) www.teenwire.com (Planned Parenthood) www.scarleteen.com (private funding)
Adolescent Pregnancy OVERVIEWSTDs • 19 million cases of STDs each year: One-half in persons ages 15-24 • 1 in 10 sexually active female adolescents have chlamydia • Chlamydia screening rates unacceptably LOW • 15-25 year olds: only 6.8% routine visit, 16% preventive visit, 23% at pap smear • 50% of new HIV infections in the US are among persons less than age 25 STD DIAGNOSIS = TEACHABLE MOMENT
Female Sterilization Vasectomy IUD Implants Comparing effectiveness of methods Most effective How to make your method most effective Generally 2 or fewer pregnancies per 100 women in one year One-time procedures. Nothing to do or remember. Need repeat injections every 1 to 3 months Injectables Must take a pill each day Pills Must follow LAM instructions LAM About 15 pregnancies per 100 women in one year Must use every time you have sex; requires partner’s cooperation. Male Condoms Must use every time you have sex Diaphragm Must use every time you have sex; requires partner’s cooperation. Female Condom Must abstain or use condoms on fertiledays; requires partner’s cooperation. Fertility Awareness-Based Methods About 30 pregnancies per 100 women in one year Must use every time you have sex Spermicides Least effective
Methods of Contraception and Overcoming Barriers • Emergency Contraception • Quick Start • Extended/Continuous use methods • Update on Depo-Provera • IUDs in adolescents • Single rod implant
Emergency Contraception (EC) • Over-the-counter for women 18 years and older. • PRESCRIPTION REQUIRED for women younger than 18 years. • The provision of EC does not alter adolescent sexual or contraceptive behavior. • If EC is available, it is more likely to be used in the event of unprotected intercourse and it is more likely to be used earlier.
Emergency Contraception (EC) • Plan B® (progesterone-only EC) • 2 pills containing 0.75 levonorgestrel • Take as one dose or 12-24 hours apart • Primary mechanism of action is delay of ovulation • Should use as soon after unprotected intercourse as possible to maximize efficacy (reduced chance of pregnancy by 60-94%) • Offer up to 120 hours (5 days) after unprotected intercourse • If taken within 3 days: reduces chance of pregnancy from 8% to 1%
Emergency Contraception (EC) • No deaths or serious complications have been linked to use • No drug interactions • WHO: no medical conditions where the risks of EC outweigh the benefits of use • MAY USE if breastfeeding, history of ectopic, liver disease, cardiovascular disease, migraines, history of DVT…
Emergency Contraception (EC) • No clinical exam or testing is required before EC is provided • Anti-emetics are not necessary for progesterone-only EC (Plan B) • EC may be used repeatedly, even within the same menstrual cycle • Offer an EC prescription with every pregnancy test, every STD evaluation…
Oral Contraceptive Pills (OCPs) • Most popular method of hormonal contraception. • The only method that many providers and patients consider. Overcoming Barriers: • “Quick start” over conventional start. • Highlight non-contraceptive benefits. • Offer extended and continuous use. • Think about access/refill issues. • All women can be “excellent” OCP users.
Contraceptive Use at Last Sex Among Sexually Active, Unmarried Women, NSFG 2002
Oral Contraceptive Pills (OCPs)Barrier: Getting Started • Why do 24% of adolescents never take the first pill after receiving the pack? • Confusion about starting instructions. • Waning motivation. • Become pregnant while waiting to start.
Oral Contraceptive Pills (OCPs) Quick Start (also for ring, patch, Depo) • If negative pregnancy test: swallow first pill under direct observation during visit (regardless of menstrual day). • Give Emergency Contraception if indicated (and usually Quick Start the next day). • Use back-up with condoms for 1 week. • Repeat pregnancy test if no withdrawal bleed, or follow-up pregnancy test in 2-4 weeks.
Quick StartDon’t fear rejection! • Women prefer it. (81%- 97%) • Higher initiation/continuance rates. • No bleeding differences based on day of initiation Westhoff. Bleeding Patterns, OC Compared With Vaginal Ring. Obstet Gynecol 2005.
Quick StartUnintended pregnancy (not “missed” pregnancy) is the issue. • Urine pregnancy tests are very good: • Implantation produces HCG (6-12 days after ovulation) • HCG detected at 20-50 mIU/mL. • No need for serum HCG • Very low pregnancy rates in first cycle with quick start even if recent unprotected intercourse (3% or lower). • Consider the impact on initiation rate: • 100% with observed quick start. • About 75% if pills dispensed (even lower if RX only) • Hormonal contraceptives are not teratogenic (or abortifacients) even if pregnancy does occur.
Oral Contraceptive Pills (OCPs) Number of OC Packs Dispensed Foster et al, 2006 • 82,000 women who received birth control pills. • Women were given a complete one, three, or 13-month supply of OCPs. • Women who received 13 cycles were 28% more likely to continue using oral contraceptives after 15 months than women who obtained a 3-month supply. • 13 cycle group: fewer gaps in OCP coverage than women prescribed shorter cycles • Only 4% had gaps compared to 16% (1 month) and 19% (3-month group)
Dispel Myths! • “It isn’t that safe.” • “The pill makes you fat.” • “The pill makes it harder to get pregnant later on.” • “It’s good to take a break from the pill.” • “It’s not safe because breast cancer runs in my family.” • “She’s too young to be on the pill.” • “It doesn’t really work.” • “I’ll need to use condoms anyway because I take antibiotics a lot.”
Oral Contraceptive Pills (OCPs) Which Pill for Adolescents? • No pill is inherently “better” than any other pill • All U.S. pills contain the same type of estrogen • EE = ethinyl estradiol • Differences are in type of progestin • Typical “low-dose” pill: 30-35 mcg EE • “ultra low-dose” pill: 20 mcg EE • NO DIFFERENCE IN EFFICACY 20ug vs. 30ug
Oral Contraception Pills (OCPs) Consider Cost • Intermediate progestational and low estrogenic activity • Generic substitute for Seasonale • $30/pack • Low progestational/androgenic and intermediate estrogenic (generic Ortho-Cyclen) • Good choice for acne, PCOS • TARGET: $9/pack; or $24 for 3 packs • High progestational and low estrogenic activity (amenorrhea is common)- ultra-low 20 mcg EE • Good choice for concerns about nausea, breast pain • $27/pack LEVORA PORTIA SPRINTEC JUNEL MICROGESTIN 1/20
Oral Contraceptive Pills (OCPs)Extended and Continuous Products • NOT a new therapy! • Patients have been prescribed OCPs “as directed” for decades • EXTENDED • Take active pills for longer than the traditional 21 days • CONTINUOUS • Active pill every day (no placebo breaks) • FDA Approved • Seasonale,®Seasonique,™ Lybrel™
Oral Contraceptives: Extended Use Counseling on Safety • Standard/traditional pill is 21 days active pills and 7 days placebo (21/7 regimen) • No medical rationale for 21/7 • Monthly withdrawal bleeding is designed to make the pill cycle feel “natural” • But, there is no ovulation on the pill • And, no menstrual lining “build up”
Oral Contraceptives: Extended Use Perceived Benefits of Menstruation • Myths about monthly menstruation • Necessary for “cleansing the system” • A “natural” state • A symbol of femininity, fertility, and youth • A sign a woman is not pregnant • Address safety concerns of the patient (her parents or partner) before prescribing extended OCPs.
Oral Contraceptives: Extended Use Who might benefit from reduced frequency of menstruation? • Women with menstrual-related disorders • dysmenorrhea, menorrhagia, PMS, menstrual migraines, cyclic breast pain… • Athletes • Women in the military • Developmentally delayed women • Any woman who chooses to bleed less frequently
Oral Contraceptives (any type, patch, ring)Review: Non-contraceptive Indications for Use • Dysmenorrhea • Menorrhagia (anemia) • Acne • Pelvic pain (unexplained and endometriosis-related) • Polycystic Ovarian Syndrome • PMS • Bone loss • Benign breast disease • Prevents cancer of the uterus and ovary
Oral Contraceptives: Extended UseMORE STUDIES NEEDED • Continuous administration of pills may improve OCP success • Especially in “poor” pill takers • Continuous administration of pills may help prevent ovarian follicular development (cysts) .
Oral Contraceptives: Extended UsePatient Counseling • Unpredictable breakthrough bleeding (BTB) similar to conventional OCPs • Will improve with each cycle of use • Take the pill the same time every day to prevent BTB • Never hesitate to do a pregnancy test • Tailor the extended regimen to your bleeding • On average >70% of patients satisfied with extended use of OCPs
Oral Contraceptives: Extended/Continuous • FDA approved: Seasonale, Seasonique, Lybrel • Can use ANY combined OCP • Sprintec, Necon, Zovia… • Can even use a triphasic but not sure why? • In one study of continuous users, norethindrone acetate OCs (Microgestin) were associated with less bleeding than levonorgestrel OCs (Levora) Edelman et al. Obstet Gynecol 2006.
Medical Options for Reducing Menstruation • Extended-use OCPs • Contraceptive vaginal ring: NuvaRing • Trans-dermal contraceptive patch: Ortho Evra • Injectable progestin-only contraception (DMPA) • Progestin-releasing intrauterine device (Mirena®) • Oral progestins (norethindrone acetate, Aygestin®) • Danazol (Danocrine®) • Gonadotropin-releasing hormone analogues (e.g., Leuprolide Acetate, Lupron Depot®) Kaunitz.. Contraception 2000.
Ring and Patch for Continuous/Extended Use • The contraceptive ring can be left in for 4 weeks and replaced immediately with another ring. • The patch can be used for more than 3 consecutive weeks. (“apply new patch each week x 9 weeks…”)
Oral Contraception: Extended UseConclusions • Many women would prefer to menstruate less if they knew it was safe. • Any OCPcan be taken in an extended or continuous fashion (or use the ring/patch). • Expect breakthrough bleeding which will improve over time.
Depo-Provera: Update • Still the best option for many of our patients. • EFFICACIOUS • (Almost) Forgettable • Non-contraceptive benefits (1 yr: 50% amenorrhea) • ACOG: “Concerns regarding…BMD should neither prevent practitioners from prescribing DMPA nor limit its use to 2 consecutive years.” • No role for DEXA scans • Partial or full recovery (like pregnancy, breastfeeding) • No data showing increase fracture risk
Depo and Weight Gain • Weight gain not explained only by Depo and different for each woman. (Westhoff, Contraception, 2003) • Black and/or obese women, postpartum adolescents may be at increased risk. • According to package insert, averages: • 5.4 lbs in 1st year; 13.8 lbs after 4 yrs • “Early” gainers (5% of body weight at 6 mo) will continue to gain at a higher rate (Le, 2009) • Risk factors for early weight gain: • BMI < 30, parity≥1, self-reported increased appetite
Bleeding with progestin-only methodsHow to treat it? • REASSURANCE and SUPPORT • Estrogen alone • OCPs • NSAIDs • Doxycycline (for Implanon) • Tranexamic acid • Antiprogestins (mifepristone)
IUD and AdolescentsRecommendations and benefits of use • World Health Organization (WHO) • American College of Obstetricians and Gynecologists (ACOG)
IUDs and Adolescents Why is IUD use is limited in the U.S.? COMMON MISPERCEPTIONS • “IUDs increase PID and STDs” • “They cause infertility” • “IUDs can’t be used in nulligravids” • “IUDs can’t be used in a woman with a previous ectopic pregnancy”
IUDs and AdolescentsDebunk the myths • The IUD does not increase an adolescent’s risk of PID and STDs. • Past experience with the Dalkon Shield has perpetuated this myth. • Studies that showed a causal relationship between IUDs and PID were fraught with methodological errors.
IUDs and AdolescentsDebunk the myths WHAT IS TRUE: The risk of PID is increased at the time of insertion. • Within the first 20 days of use • Risk of PID 9.7 per 1,000 women-years in users • Risk of PID 1.4 per 1,000 women-years in non-users
IUDs and AdolescentsDebunk the myths • IUD is not related to infertility • Chlamydia is related to infertility Tubal infertility by previous copper T IUD use and presence of chlamydia antibodies, nulligravid women Hubacher D, et al. NEJM. 2001.