Emergency Contraception and Adolescents

1. Emergency Contraception and Adolescents

2. Objectives • By the end of this presentation, participants will be able to: • Discuss need for EC among adolescents • Describe clinical components of EC • Understand the challenges and opportunities for increasing EC use at the patient, provider, and health systems level

3. What Is Emergency Contraception (EC)?

4. Adolescents Need EC • The U.S. has one of the highest teen pregnancy rate in the industrialized world. • 82% of teen pregnancies are unplanned

5. Teen Pregnancy Rates Worldwide, 2000 Per 1000

6. Unprotected Sex Happens

7. Female Contraceptive Use at 1st Intercourse by Year of 1st Sex 2002 National Survey of Family Growth

8. HS Students Contraceptive Use at Last Intercourse YRBS 2007 *This data only reflects oral contraceptives and not rates of injectable contraceptives use

9. Sexual Assault and EC

10. Indications for EC

11. Human Error • Inconsistent contraceptive use • Incorrect contraceptive use • Unplanned intercourse

12. Method Failure: Patch • Patch off for 24 hours or more during patch-on weeks • More than two days late changing a patch • Late putting patch back on after patch-free week

13. Method Failure: Ring • Taken out for more than 3 hours during ring-in weeks • Same ring left in more than 5 weeks in a row • Late putting ring back after ring-out week

14. Method Failure: Others • Condom breaks or slips • 2 or more missed active OCPs • DMPA shot 14 or more weeks ago • Expelled IUD • 3 > = hours late taking a POP • Diaphragm or cervical cap dislodges

15. Methods of EC

16. Brand Name Levonorgestrel ECPs • Dedicated Product: Plan B One-Step • FDA approved July 2009 • ingle tablet formulation 1.5mg of levonorgestrel • Original Plan B • Two tabs of 750 mcg levonorgestrel • Approved in 1999 • Approved for OTC 18 and older in 2006 • Both are now OTC for 17 and older

17. GenericLevonorgestrel EC • Next ChoiceTM, a generic dedicated product approved June 2009 • Two tabs of 750 mcg levonorgestrel • For prescription use by women 16 and younger • OTC for women 17 and older

18. Summary: FDA Approved Dedicated EC Products • Plan B OneStep • Single dose • NextChoice • Generic • Original PlanB • Now discontinued

19. Combined Oral Contraceptives as ECPs • Yuzpe method • Combined oral contraceptive pills (OCPs) containing combined ethinyl estradiol and either norgestrel or levonorgestrel

20. The Copper-T Intrauterine Device • Insert within 5 days • Highly effective: Reduces risk of pregnancy by more than 99% • Rarely used for EC alone • Cannot use levonorgestrel IUD (Mirena) for EC

21. Clinical Components of EC • Regimens • Efficacy • Mechanism of action

22. Levonorgestrel-Only Regimen

23. ECP Efficacy

24. How Long After the Morning After? 2002 WHO Trial of Levonorgestrel-Only EC Regimen Taken in Single Dose p=.16 Von Hertzen H, et al. Lancet 2002;360:1803-1810

25. Mechanism of Action of Levonorgestrel-Only EC • Disrupts normal follicular development and maturation • Results in ovulation or delayed ovulation with deficient luteal function • May also interfere w/sperm migration and function at all levels of the genital tract

26. Does ECPrevent Implantation?

27. Does Levonorgestrel-Only EC Prevent Implantation? • Studies in animals: Levonorgestrel administered in doses that inhibit ovulation has no post-fertilization effect

28. Mechanism of Action: Combined ECPs • Can inhibit or delay ovulation • Older studies have shown histologic or biochemical alterations in the endometrium. • More recent studies have found no such effects on the endometrium.

29. Mechanism of Action: Combined ECPs *No clinical data exist regarding these mechanisms

30. Side Effects & Complications:Levonorgestrel v. Yuzpe Significant at p<0.01

31. EC is Safe

32. Few Contraindications

33. Adolescent Access to EC:Challenges & Opportunities

34. Challenges and Opportunities • To utilize EC, young women (under 18) must • Be aware of the option • Locate a provider • Obtain a prescription • Find the money to pay for the pills • Fill prescription at a pharmacy that has EC • Take pills at correct time

35. Challenges and Opportunities • Patient Level • Provider Level • Health Systems and Public Policy Level

36. Patient Level

37. Few Young Women Are Aware of EC

38. Patient Misconceptions Create Barriers to EC Use • Beliefs that EC functions as an abortifacient • Fear that the drug would harm fetus • Confusion over fertility cycle and timing

39. Other Barriers • Perceived lack of confidentiality • Lack of money and/or insurance • Lack of transportation • Inability to locate a healthcare provider w/in the limited and effective timeframe • Belief that pelvic examination is mandatory • OTC exclusion of minors

40. Provider Level

41. Many Providers Do Not Discuss EC w/ Young Patients

42. Providers Need More Training About EC

43. Provider Misconceptions Can Discourage Use

44. Providers Can Remove Clinical Barriers to EC • No pelvic examination or pregnancy test required by ACOG or FDA • Pregnancy test prior to EC treatment is recommended only if: • Other episodes of unprotected sex occurred that cycle • LMP (last menstrual period) was not normal in duration, timing, or flow

45. Providers Can to Facilitate Use

46. Providers Can Facilitate Use • Providers must take into account patient’s: • Knowledge of reproductive physiology • Ability to understand the regimen • Moral perceptions of contraception • Misconceptions about the drug’s mechanism of action • Barriers that may restrict access

47. Providers Can Facilitate Use

48. Counseling Key Points

49. Facilitating Use in Practice

50. Facilitating Use in Practice • Train office staff on EC • Importance of timely appointments • Lack of required exam for prescriptions • OTC for patients over 18