what’s new in adolescent contraception?

What’s New in Adolescent Contraception?Rachel S-D Fortune, MD, FAAPMedical Director, Newport Academy

Pretest questionsAll of the following are ABSOLUTE contraindications to the use of combined hormonal contraceptives in adolescents, EXCEPT:

a) Known thromboembolic mutation (i.e. factor V leiden, protein C, protein S, etc)

b) Current cigarette smoker (<35 years of age)

c) Family history of DVT/PEd) Personal medical history of stroke

True or False: Intrauterine devices can be safely used in adolescent patients:a) Trueb) False

Rachel S-D Fortune, MD, FAAPMedical Director, Newport Academy

Disclosures“I have no relevant financial relationships with the manufacturer(s) of any commercial product(s)and/or provider(s) of commercial services discussed in this CME activity.”

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

1991 2001 2009 201131.00%

33.00%

35.00%

37.00%

% of youth who are "currently sexually active"

% of youth who are "cur-rently sexually active"

1991 2001 2009 201140.00%

45.00%

50.00%

55.00%

% of students who had ever had sex

% of students who had ever had sex

1991 2001 2009 201116.00%

18.00%

20.00%

22.00%

% of sexually active youth who used OCPs with last sexual activity

% of sexually active youth who used OCPs with last sexual activity

2002 2007 20090.00%1.00%2.00%3.00%4.00%5.00%

% of Female Adolescents Using LARC methods

% of Female Adolescents Using LARC methods

Trends in Adolescent Pregnancy Rates

1990 20080

20

40

60

80

100

120

140

Pregnancies per 1,000 teen girls

Pregnancies per 1,000 teen girls

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

117

68

Trends in Adolescent Pregnancy Rates

Decreased pregnancy

rate for 15-19yo

86% attributable to changes

in contraceptive prescribing

14% attributable to

decreased sexual activity

Selecting a Contraceptive• Eligibility• Availability/Cost• Mechanism of Action• Feasibility• Effectiveness• Reversibility• Side Effects

Contraceptive Eligibility

Gordon and Pitts, 2012

EligibilityAvailability/CostEffectivenessMechanism of ActionFeasibilityReversibilitySide Effects

Contraceptive Eligibility

Contraceptive Eligibility

Contraceptive Eligibility

Availability/Cost• Medicaid covers:

• Long Acting Reversible Contraceptives (LARC)• OCPs, NuvaRing, Ortho Evra patch• Depo provera shots

• Private insurance companies cover*:• Long Acting Reversible Contraceptives (LARC)• OCPs, NuvaRing, Ortho Evra patch• Depo provera shot

• For patients who cannot use their insurance:• Planned Parenthood provides services at a cost

EligibilityAvailability/CostEffectivenessMechanism of ActionFeasibilityReversibilitySide Effects

Effectiveness

EligibilityAvailability/CostEffectivenessMechanism of ActionFeasibilityReversibilitySide 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• NuvaRing intravaginal 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 questionsAll of the following are ABSOLUTE contraindications to the use of combined hormonal contraceptives in adolescents, EXCEPT:

a) Known thromboembolic mutation (i.e. factor V leiden, protein C, protein S, etc)

b) Current cigarette smoker (<35 years of age)

c) Family history of DVT/PEd) Personal medical history of stroke

True or False: Intrauterine devices can be safely used in adolescent patients:a) True b) 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