Tahshann S. Richards, DO, MPHAttending PhysicianDepartment of Family MedicineUnion Community Health CenterOctober 18, 2012

National Youth Risk Behavior Study 47.4% of students had ever had sexual

intercourse 33.7% of students had sexual intercourse

with at least one person during the 3 mo before the survey (currently sexually active)

6.2% of he students had sexual intercourse for the first time before 13 years old

15.3% had sexual intercourse with ≥4 persons during their life

National Youth Risk Behavior Study Among 33.7% sexually active students

reported that during their last sexual encounter they or their partner had used the following:

Condom (60%) Birth control pills (18%) Injectable birth control, birth control ring, or

intrauterine device (IUD) (5.3%) Condom plus any of the above (9.5%)

82% of adolescent pregnancies are unplanned

Accounts for 1/5 of all unintended pregnancies in the US

106 Bronx teens / 1,000 get pregnant 30% more than the national rate about 2x frequency in Staten Island Teen births -4 per 1,000 in the Bronx

2x rates in Queens and Manhattan

Start the talk early!! Preadolescence

Puberty Provide health info to preteens and family

Adolescence Attitudes/knowledge about sex Sexual activity Use of contraception

Talking about contraceptive DOES NOT: Increase rate of sexual activity Reduce the age of coitarche Increase number of sexual

partners Increase sexual experimentation

Promote healthy and responsible sexual decision making (including abstinence)

Be supportive and non-judgmental Good history taking Careful listening KISS (Keep it Simple Silly) method

Know Teens Rights When is confidentiality waived? Guidelines for reimbursement for services Medical record access Appointment scheduling Office policy regarding information

disclosure

For sexually active teens using contraceptives Support compliance Manage side effects Change method of contraception

accordingly Provide referral and frequent follow up Counsel and screen periodically for STIs

Abstinence Most effective Delay initiation of sexual activity until

adulthood Efficacy of abstinence based education

controversial

Condoms Mechanical barrier method Reduce transmission of STDs; therefore

NOT optional Pros

Easily accessible No Rx required Inexpensive Legally purchased by minors Young men share responsibility for

contraception

Female condoms Barrier method Effective in prevention of STDs Cons

Costly Limited accessibility Difficult to insert Squeaks

Spermicides Contains nonoxynol 9 and octoxynol 9 High contraceptive failure rate when used alone Effective in reducing pregnancy and STDs when

used with condoms Efficacy comparative to OCPS if used with

condoms Pros

No Rx required Inexpensive

Oral Contraceptive Pills (“The Pill” or OCPs) Monophasic (Ortho Cyclen), Multiphasic

(Ortho TriCyclen, Loestrin) Best for teens who:

Desire regular menses Motivated and organized to take pill every day

Condom must be used to protect against STI

OCPs Pros

Helps dysmenorrhea Regulates menses Treat DUB Decrease risk of osteoporosis Treat Acne Protection against:

Ovarian and endometrial CA Ectopic pregnancy Ovarian Cysts Iron deficiency anemia Benign breast disease

OCPs Quick start

Gyn exam and PAP (if indicated ) within next 3 mo

Frequent follow up and monitoring

 Enhance compliance with patient education and problem solving

If teens miss 1–2 pills: Take a pill as soon as pt remembers Take the next pill at the usual time

If teens miss 3 or more pills: Do not finish pack Throw away remaining pills Start next pack

Depo Provera (“The Shot”) Medroxyprogesterone Acetate) Long acting progestin Suppresses ovulation Thickens cervical mucus Creates a thin, atrophic endometrium Given 150 mg IM dose every 12 weeks Best for teens who:

Chronic illness (sickle cell, seizures, MR) Are lactating At risk for complication with estrogen Pts who do not remember to take pills

Depo Provera Pros

Protection against endometrial cancer and iron deficiency anemia

Convenient Effective pregnancy prevention

Cons Irregular menses Need for injection Side effects- weight gain, headaches, bloating,

depression and mood changes Associated with delayed return to fertility Possibly reversible osteopenia

Nuvaring (“The Ring”) Combined hormonal ring Etonogestrel and Ethinyl estradiol Inserted once a month

Stays in vagina for 3 weeks Must be removed 21 d after insertion New ring is inserted 7 d later

Ortho Evra Patch(“The Patch)

Norelgestramin/ethinyl estradial Transdermal

Change once a wk Avoid placing on breast

Pros Easy to remember Effective

Cons Increased risk of thromboembolic events Not flesh colored

Long Acting Reversible Contraception (LARC) Pros

Safe, Effective Higher continuation rate (LARC 86% vs short

acting 55%) Decrease unintended pregnancy rate (22x

higher for short acting contraceptives vs LARC) Barriers

Inaccessible The provider!

Intrauterine Device (IUD) Mirena (Levonorgestrol) Reversible Protection up to 5 years Expulsion rate range from 5-22 % Changes in menstrual bleeding esp. in 1st

month

Implant (Implanon, Etonogestrel) Reversible, up to 3 years High rates of infrequent bleeding or

amenorrhea Higher hemoglobin levels

Reduction in dysmenorrhea and pelvic pain Minimal or no weight gain

Emergency Contraceptive Pills (Plan B) Levonorgestrel Progestin only pill Effective up to 72 hrs after sex Pregnancy test done before administration

of pills and 3 weeks after administration to detect

Rx required for <18 yrs old Provide refill for future use

Follow Up Annual Pap Screen for STIs every 6 mo-1 yr Follow up Quarterly (sooner when initiating

contraceptives) CONDOMS, CONDOMS, CONDOMS…

References

ACOG. Adolescents and Long-Acting Reversible Contracpetion: Implants and Intrauterine Devices. Number 539. October 2012

CDC. Youth Risk Behavior Surveillance Unite dstates 2011. MMWR vol 62. no 4 June 2012

AAFP. Managing Adverse Effects of Hormonal Contraceptiin Am Fam Physician 15:82 (12) 1499-1506. December 2010

AAP. Contrapception and Adolescents. Pediatrics Vol 104 No. 5 November 1999

http://www.nydailynews.com/opinion/astronomical-bronx-teen-pregnancy-rate-cries-action-article-1.979415#ixzz29dxRv5B8