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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

slide3
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
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

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
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%
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
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
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