ContraceptionintheAdolescent

JoyFriedmanMDOctober8,2017

Disclosures

• Ihavenoactualorpotentialconflictofinterestinrelationtothisprogramorpresentation.• Iwillmentionoff-labeluseofcontraceptivesincludinguseofcontraceptivesformenstrualmanagement,andextendeduseofshortandlongactingcontraceptivemethods.

Objectives

• Developstrategiestoengageadolescentsinconversationsaboutpregnancyriskandeffectivenessofcontraceptionmethods

• ApplytheCDC/WHOmedicaleligibilitycriteriaforcontraceptiveuse

• Explainthebenefitsandsideeffectprofilesforcontraceptivemethods

UUSSTTeeeennPPrreeggnnaanncciieess,,BBiirrtthhssaannddAAbboorrttiioonnss,,22001100..Kost KandHenshawS.www.guttmacher.org/pubs/USTPtrends10.pdf

BBiirrtthhrraatteessffoorrffeemmaalleessaaggeedd1155––1199,,bbyyrraacceeaannddHHiissppaanniiccoorriiggiinn::UUSS11999911––22001155

www.cdc.gov/nchs/products/databriefs/db259.htm

Birthsper1000FemalesAged15-19YearsbyRace,2007-2015

MartinJA,HamiltonBE,OstermanMJK,etal.Births:Finaldatafor2015.Nationalvitalstatisticsreport;vol 66,no1.Hyattsville,MD:NationalCenterforHealthStatistics.2017.

PPeerrcceennttaaggeeooffnneevveerr--mmaarrrriieeddtteeeennaaggeerrss1155--1199yyeeaarrssooffaaggeewwhhoohhaavveeeevveerrhhaaddiinntteerrccoouurrssee,,UUSSNNSSFFGGddaattaahttps://www.cdc.gov/nchs/data/nhsr/nhsr104.pdf

Females 2002 2006-2010 2011-201515-19years 45.5% 42.6% 42.4%15-17years 30.3% 27% 28.1%18-19years 68.8% 62.7% 62.9%

Males 2002 2006-2010 2011-2015

15-19years 45.7% 41.8% 44.2%15-17years 31.3% 28% 31.5%18-19years 64.3% 63.9% 64.3%

MMeetthhooddssooffccoonnttrraacceeppttiioonneevveerruusseeddaammoonnggffeemmaalleessaaggeedd1155––1199wwhhoohhaaddeevveerrhhaaddsseexxuuaalliinntteerrccoouurrssee::UUnniitteeddSSttaatteess,,22000022,,22000066––22001100,,aanndd22001111––22001133

https://www.cdc.gov/nchs/products/databriefs/db209.htm

Thepercentageoffemaleteenagerswhoeverusedemergencycontraceptionincreasedin2006–2010andin2011–2013(p <0.05).2DifferenceinpercentageoffemaleteenagerswhoeverusedDepo-Proveraorthepatchwassignificantlylowerin2011–2013thanin2006–2010(p <0.05).NOTES:Neitherthecontraceptiveringnortheimplantwereavailablein2002.ThenumberofteenagerswhohadeverusedtheIUDin2002wastoosmalltobestatisticallyreliable.

SOURCE:CDC/NCHS,NationalSurveyofFamilyGrowth,2002,2006–2010,and2011–2013.

Challengesinprovisionofcontraceptiontoteens

• Confidentialityissues:perceivedorreal• Privacyissues:EOBforprivatelyinsuredadolescents;EHRbreaches• Accessissues:distancetotraveltoclinics,hoursofoperation• Fundingforcontraceptionandfutureofmandatedcontraceptioncoveragewithnoco-payuncertain• Theteenagebrain:invincibility,rewardsofrisktakingbehaviors,attentionspan

Startingtheconversation

• Warmup:patient-centeredquestionstounderstandtheiragendabeforeaskingaboutsexualhistory• OneKeyQuestion:Wouldyouliketobecomepregnantinthenextoneyear?• RULEformotivationalinterviewing

• Resist the“rightingreflex”ortellingthepatientwhattodo• Understand thepatient’smotivations:openendedquestions• Listen andusereflectionstodemonstratediscrepanciesifneeded• Empower thepatienttomakechangesandsupportself-efficacy

USMECKey

2016USMECandSPRApp

UsingtheMECApp

TThhrroommbboossiiss::ssyynneerrggiissttiiccrriisskkffaaccttoorrssTrenor,Chungetal.Pediatrics,2011

Riskfactor RiskEstimate Riskestimate+COCCOC - 3-5xPregnancyandpostpartum

4.3-10x

FactorVLeidenheterozygote

4-8x 28-35x

ProthrombinG20210Aheterozygote

2-3x 16x

Trauma/surgery 2-5x 5-12.5xTravel 2-4x 14-20xObesity 1.7-2.4x 10-24xSmoking(15+cig/day) 1.4-3.3x 8.8x

RReellaattiivveerriisskkffoorrvveennoouusstthhrroommbbooeemmbboolliissmm::ASRM,Fertil Steril 2016

RRrelativetonon-users

RRrelativeToEE/LNG

Absoluterisk

Notpregnant,nottakinghormones

1 - VTE:1-5/10,000

EE/LNG 2.8(CI2.0-4.1) - EE/Drosperinone 3.8(CI2.7-5.4) 1.3(CI1.0-1.8) Pregnancy 4.29* VTE:5-20/10,000

PE:1Post-partum 4.29* VTE:40-65/10,000

PE:16/10,000*4.29CI(3.49-5.22)forpregnancyandpostpartum

VVTTEErriisskkiinnCCHHCCuusseerrssaaccccoorrddiinnggttootthheerroouutteeooffaaddmmiinniissttrraattiioonnaannddttyyppeeooffpprrooggeessttiinnSitruk-Ware.Hormonalcontraceptionandthrombosis.Fertil Steril 2016.

Author Drosperinone+EE NGMN+EE(patch) ETN+EE(ring)FDA-CDCcohort2012 RRofVTE95%CI

1.74(1.42-2.14)

1.55(1.17-2.07)

1.56(1.02-2.37)

Lidegaardcohort2012 RRvs.non-use95%CI

7.9(3.5-17.7)

6.5(4.7-8.9)

RRvs.LNGusers95%CI

2.3(1.0-5.2)

1.9(1.3-2.7)

Dinger AdjustedHRvs.OC95%CI

0.8a0.4-1.5

0.8b0.5-1.6

Jick2010 RRvs.LNGusers95%CI

1.1(0.6-2.1)

aAdjustedHRvs.LNGOC(2007) bAdjustedHRvs.OC(2013)

Paragard Mirena/Liletta Skyla KyleenaMechanismofaction/dose

Copperreleasing 52mgLNG(20mcgdaily)

13.5mgLNG(14mcgdaily)

19.5mgLNG(17.5mcgdaily)

YearapprovedbyFDA

1988 2001Mirena2015Liletta

2013 2016

Yearseffective 10-12 5-7Mirena3-7Liletta

3 5

BleedingPattern Heavier,longerduration,morecramps

Spottingandirregularbleedinginitially,lighterovertime

Spottingandirregularbleedinginitially,irregularbleedingmaypersist;lighterperiodsovertime

Spottingandirregularbleedinginitially,irregularbleedingmaypersist;lighterperiodsovertime

Likelihoodofamenorrhea

NA 20%atoneyear50%at5years

6%atoneyear12%at3years

12%atoneyear23%at5years

Notablecharacteristics

CanbeusedasECwithin5days

Bioequivalentdevices,Lilettalowercostandlabelledforallwomen

Slightlysmallerapplicatoranddevice,marketedtowardsnulliparouswomen

Slightlysmallerapplicatoranddevice,marketedtowardsnulliparouswomen

HowtoprepareyourpatientforanIUD

• ScreenforSTI(ideally)• Discusshormone-containingvscopper-containingoption• Prepareherforunpredictablebleedingwithhormone-containingIUD;donotpromiseamenorrhea• Reinforceabstinenceorconsistentcontraceptiveandcondomuseinmonthbeforeinsertion• Prepareherforsomecramping:NSAID1hourbeforetheprocedure

PostIUDcare

• Stringcheck• AnnualGyn exam• RoutineSTIscreening

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SubdermalImplant:Nexplanon®

• Effectiveforupto3years• >99.9%effectiveforpreventionofpregnancy• Rapidreturntofertility• Discrete– devicemaybeseenandshouldbepalpable• Mechanismofactionispreventionofovulation,thinningoftheendometrium,thickeningofcervicalmucus

Howtoprepareyourpatientforthesubdermalimplant

• Discusslikelysideeffectofunpredictablebleeding– fewerthan1/3willhaveheavyorprolongedbleeding• ScreenforSTI• Discussinsertionprocedure:lessthan5min,lidocaineinjectionisthemostuncomfortablepartoftheprocedure• Shewillhavetowearabandageonherarmfortherestofthedayandshouldwaittil thefollowingdaytoshower• Usecondomsorabstainforatleast1week

DDeeppoottmmeeddrrooxxyypprrooggeesstteerroonneeaacceettaattee(DMPA,DepoProvera®)

• Scheduleshotsevery11-13weeks• Efficacyintypical-usesettingis97%• Decreasedmenstrualbleedinginmostusersafter6-9monthsusewithamenorrheain46-55%ofusersafter1year• Private,convenientmethod• Progestinonly– canbeusedinpatientswithcontraindicationstoestrogenuse• Mechanismofactionispreventionofovulation,thickeningofcervicalmucus,thinningendometrium

DDMMPPAA

• Worksfor14weeksminimum• Takes7daystostartworking• Bonemineralizationisaffectedduringuse• Maybereversibleafterdiscontinuationinspine>hip

• Donotneedtodiscontinueuseafter2yearsforbonehealth• Nomonitoring(=NoDEXAscans)• Weightgainissignificantin25%ofusers

IItt’’ssookkttooQQuuiicckkSSttaarrtt

• Checkurinepregnancytest**• GivePlanBifindicatedsamedayastakingDepo• InformpatientthatittakesDepo7daystostartworking– usecondomsorabstain• Repeaturinepregnancytestin2-3weeks• Noevidenceofteratogenicity

CCoonnttrraacceeppttiivveeppaattcchh(OrthoEvra®/Xulane®)

CCoonnttrraacceeppttiivveeppaattcchh

• Efficacyintypical-usescenarioisthesimilartothepill– 91%• Takes7daystostartworking– usebackupcontraceptionorabstain• CanQuickStartthepatch(andprovidewithPlanBifneeded)• Commoncomplaintswithstartingincludenausea,breasttenderness,headaches,stickyresidue,marksontheskin• IncreasedsystemicexposuretoestrogenthanwithOCPalthoughlowerpeaklevelsofestrogen;maynottranslatetoincreasedriskofVTE• Mechanismofactionispreventingovulation,thickeningcervicalmucus• Maynotworkaswellinwomen>90kg

IInnttrraavvaaggiinnaallrriinngg::NNuuvvaarriinngg®®

• Sameasthepatchandpill– 3weeksofhormonesthen1weekoff• ORitcanbeusedcontinuously– usefor4weeksandskiphormonefreeinterval• Canusecardboardtamponapplicatortoinsertit• Limitring“holidays”to3hoursorusebackupcontraceptionfor7days• Commonsideeffectsincludeheadache,leukorrhea• LessestrogenexposurethanOCPbutriskofVTEsimilartoOCP

CCoommbbiinneeddoorraallccoonnttrraacceeppttiivveeppiillllss

• Mostcommonlyusedhormonalcontraceptivemethod• Typical-usefailurerateforadolescentwomeninoneyearofuseis9%• Mechanismofaction– thickeningthecervicalmucus,inhibitionofovulation,thinningendometrium• 7daystostartworking• Manyformulations• Tryamonophasicwith30-35mcgE2forteens• Lowerestradiol(E2):20mcgifsideeffects

CCoommbbiinneeddoorraallccoonnttrraacceeppttiivveeppiillllss

• Starttoday!OrSundayorfirstdayofmensesorwhenever– juststart!• If>5daysfromLMPthenusebackupcontraceptionfor7days

• Quickstartdemonstratedbetteroddsofstartingasecondpack,butnobetteradherenceat3and6months• NosignificantdifferenceinnumberofusersexperiencingbreakthroughbleedingwithQuickStartvs.conventionalstart• Demonstratewithactualpackageifpossible,asktoseetheirpackofpillsatfollowupvisitsifpatienthasitwithher• Anticipatemissingpillsanddiscusshowtomanage

CCOOCC::eexxtteennddeeddoorrccoonnttiinnuuoouussccyycclliinngg

• Patientsdothisallthetimewhetherwediscussitornot• Anotherreasontoprescribemonophasicpillsforteens

• Fewermenstrualsymptoms:headaches,PMS,dysmenorrhea,fewermissedpillsanddecreasedchancesforovulation• Insurancemaydictatepatient’sabilitytogetanotherpackifsheskipsplacebos;someinsurancecompaniescoverthe84/7packs• Ifthisisnotaproblem,patientcantry42/7,63/7or84/7orjusttakethemcontinuouslyuntilbreakthroughbleedingoccurs,thenstop7days

DDooeesstthheeppiillllccaauusseewweeiigghhttggaaiinn??

• StudiesshownoadditionalweightgaininOCPuserswhencomparedwithnon-users(onaverage)• Pillsdonothavecalories• Somepatientsmayfeelhungry– avoidfastfood,junkfood,increaseexerciseanddecreasescreentime

PPrrooggeessttiinnoonnllyyppiillllss((PPOOPPoorr““tthheemmiinniippiillll””))

• NorestrictionsforuseforpatientswithHTN,migrainewithaura,familyhistoryofVTEinfirstdegreerelative• Doesinteractwithenzymeinducinganticonvulsants• Notusefulforsuppressingformationofovariancysts• Noplaceboweek,mayresultinamenorrheaorunpredictablebleeding• Mechanismofaction:thickeningcervicalmucus• Shortdurationofaction– wait2hrs aftertakingthepilltohavesex• If>3hrs late,usebackupcontraceptionforthenext48hrs

RReemmeemmbbeerr??TThhiissiissyyoouurrrreemmiinnddeerr..

MenstrualCycle

UPA:DelaysLHsurgeLNG:PreventsLHsurge

UUlliipprriissttaall AAcceettaatteeiissmmoorreeeeffffeeccttiivveetthhaannLLNNGGEECCaatt7722hhoouurrss((aanndduuppttoo112200hhoouurrss))aafftteerruunnpprrootteecctteeddiinntteerrccoouurrssee

1.80%&2.60%&

5.50%&

0.00%&

1.00%&

2.00%&

3.00%&

4.00%&

5.00%&

6.00%&

Ulipristal&acetate& Levonorgestrel& No&treatment&

Pre

gnan

cy R

ate

(Per

cent

)

Pregnancy)Rate)

EECC::DDiissppeelllliinnggtthheemmyytthhss

• ECpillsareNOTabortifacientmedications• ECdoesnotharmanexistingpregnancy;Ulipristal Acetateisnotwellstudiedinpregnantwomen• Disruptnormalfolliculardevelopmentbydelayingorinhibitingovulation• ECPDONOTpreventfertilizationorimplantation• ECParenoteffectiveoncefertilizationoccurs• ECusedoesnotaffectfuturefertility,evenwithrepeatuse

PPrroovviissiioonnaallEEmmeerrggeennccyyCCoonnttrraacceeppttiioonn

• ProvideRxforECatthetimeofclinicvisit• Forpatientsusingcondomsonlyforcontraception• ForpatientsusingshortactingmethodsorDMPA• Forpatientswhoareunsureaboutbirthcontrolandthinkingitover

• InsuranceplansoftendictatecoverageandlackofavailabilityofElla®maylimitaccess• PlanB®andgenericsareavailableOTCwithoutascript– noagelimitbutiscostly:$40-$55atapharmacyandfor$25atafterpill.com• Ella®isavailablebyRxonlyandviaonlinepharmacyforpurchaseatkwikmed.com$67

Insummary• Beanapproachableadult• Askteensthe“onekeyquestion”routinely• Usemotivationalinterviewingtounderstandtheiragendaregardingcontraception• Considerifanycontraindicationstospecificcontraceptives• Offerthemosteffectivemethodsasfirstlinemethodsforteens• Anyeffectivecontraceptionisbetterthannocontraception!• Recommenddualprotectionwithcondomsandcontraceptives• Offerprovisionalemergencycontraceptionwhenappropriateandexplainwhenitwouldbeused

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