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Primary and Preventive Health Care for Female Adolescents

Primary and Preventive Health Care for Female Adolescents. Jessica H. Pittman, MD Assistant Professor, Obstetrics and Gynecology University of Utah School of Medicine. Objectives.

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Primary and Preventive Health Care for Female Adolescents

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  1. Primary and Preventive Health Care for Female Adolescents Jessica H. Pittman, MD Assistant Professor, Obstetrics and Gynecology University of Utah School of Medicine

  2. Objectives • Provide for the primary care needs of the adolescent, demonstrating knowledge in areas such as health guidance, screening and immunizations. • Describe most common STIs including diagnosis, treatment, and potential serious sequelae. • Develop understanding and use of the Centers for Disease Control and Prevention U.S. Medical Eligibility Criteria for contraceptive use.

  3. Health Guidance for adolescents www.healthypeople.gov

  4. Health Guidance Topics • Homicide • Suicide • Motor vehicle crashes, including those caused by drinking and driving • Substance use and abuse • Smoking • Sexually transmitted infections, including human immunodeficiency virus (HIV) • Teen and unplanned pregnancies • Homelessness

  5. “Panel urges cholesterol screening for kids” PEDIATRICS Vol. 128 No. Supplement 5 December 1, 2011 pp. S213 -S256

  6. ADA Screening Guidelines for Pre-diabetes and Diabetes in Medical Setting 10-17yo Age BMI Risk factors Screening tests Frequency Results American Diabetes Association Clinical Practice Recommendations 2007 Diabetes Care January 2007

  7. Who should be screened for diabetes? Children/Adolescents 10-17 years old AND Body Mass Index (BMI) is: • >85TH percentile for age & gender • Or >85th percentile weight for height • Or weight is >120% of ideal for height • ANDTwo (2) Risk Factors…

  8. Risk factors for Diabetes • Family history of type 2 diabetes (1st/2nd degree) • Race ethnicity Native American, African American, Hispanic American, Asian/South Pacific Islander • Signs of insulin resistance acanthosisnigricans, hypertension, dyslipidemia, polycystic ovary syndrome

  9. Screening tests The following results require additional testing*: • Fasting plasma glucose • Pre diabetes (100-125 mg/dL) • Diabetes (≥ 126 mg/dL) • Oral glucose tolerance test (2 hour, 75 gram) • Pre diabetes (>140-199) • Diabetes (>200) *includes repeating testing to confirm diagnosis.

  10. Abnormal test results • Repeat test on subsequent day to confirm results. • Implement treatment plan including lifestyle modification. • Screen and treat for other Cardiovascular Risk Factors: • Hypertension • Dyslipidemia • Tobacco use

  11. Initiate pap smear screening at age 21 • USPSTF (www.uspreventiveservicetaskforce.org) • ASCCP (www. asccp.org/consensus.html) • CDC (www.cdc.gov/cancer/cervical/basic_info/screening) • ACOG (www.acog.org) 19 June 2012 Annals of Internal Medicine Volume 156 • Number 12, pages 880-891

  12. Immunization • Saves33,000 lives. • Prevents 14 millioncases of disease. • Reducesdirecthealth care costs by $9.9 billion. • Saves $33.4 billion in indirectcosts.

  13. Despite progress, approximately 42,000 adults and 300 children in the United States die each year from vaccine-preventable diseases. www.healthypeople.gov

  14. Immunizations http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html

  15. HPV vaccination • FDA approved for administration to females ages 9-26 • FDA 2009 approval for males 9-26yo • Quadrivalent vaccine (types 6,11,16 and 18) • HPV 6 and 11: 90% of genital wart cases • HPV 16 and 18: 75% of cervical cancer cases • Series of 3 injections: 0,2 and 6 months • Can be administered with Hepatitis B vaccine series, meningococcal vaccine (Menactra) and Tdap (Adacel) Reisinger KS et al. iPediatrics. 2010 Jun;125(6):1142-51.

  16. Sexually transmitted infections: • Human Immunodeficiency viruses (HIV 1/2) • Herpes Simplex viruses (HSV 1/2) • Human Papilloma Viruses (HPV) • Hepatitis B and C viruses • Gonorrhea • Chalmydia • Syphillis • Trichimoniasis

  17. Drug resistant gonorrhea • CDC no longer recommends the oral antibiotic cefixime(Suprax) as a first-line treatment option for gonorrhea in the U.S. • Recommended drug proven effective for treating gonorrhea= injectable ceftriaxone • Close monitoring for treatment failures • retesting with a culture-based gonorrhea test if persistent symptoms after initial treatment www.cdc.gov/std/treatment

  18. Expedited Partner Treatment (EPT) • Allows third-party prescription without prior exam for STD treatment • Prescription requirements vary by state • In Utah, prescription order must include patient’s name and address. Prescription label must bear patient’s name. Utah Code Ann. 58-17b-602 • EPT is permissible in most states including: • Utah • Idaho • Nevada • Wyoming www.cdc.gov/std/ept/legal/utah/htm

  19. CDC Guidance for use of EPT • Support use of EPT for treatment of partners of Gonorrhea and chlamydial infections in women and men. • Advise against use of EPT for: • Gonorrhea and chlamydial infections in men who have sex with men • Women with trichomoniasis • Syphilis Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases. Atlanta, GA: US Department of Health and Human Services, 2006.

  20. Minor Consent Laws • All 50 states specifically allow minors to consent to testing and treatment for STDs, including HIV. • 25 states have laws or policies that explicitly give minors the authority to consent to contraceptive services (in one or more circumstances): • Utah state law confers the rights and responsibilities of adulthood to minors who are married. • Utah state funds may not be used to provide minors with confidential contraceptive services. http://le.utah.gov/~code/TITLE76/76_07.htm www.guttmacher.org

  21. Contraception • Oral contraceptive pills • Combined contraceptive Patch • Intra-vaginal ring • Depoprovera injection • Single implanted rod (Implanon/Nexplanon) • Intrauterine contraception (Mirena/Paragard) • Condoms

  22. Quick start initiation method • First pack in the office • Supervised ingestion of first pill • Improved compliance rate • Refills on weekdays vs. “Sunday Start”: • Decrease breakthrough bleeding • May delay initiation or never start • Engage in unprotected sex one more cycle • Refills on weekends Lara-Torre, E Contraception 2002;66:81 Westhoff C, Osborne LM, Schafer JE, Morroni C. ObstetGynecol 2005;106:89-96. Schafer JE, Osborne LM, Davis AR, Westhoff C. Contraception 2006;73:488-92.

  23. Unintended Pregnancy • 80 million unintended pregnancies occur worldwide each year • With typical use, the first year failure rate: • copper T 380A (ParaGard®) is 1% • LNG-IUS (Mirena®) is 0.1% • Implant (Implanon/Nexplanon®) is 0.1% • One-year continuation rates: • 78% for the copper T 380A • 80% for the LNG IUS • 84% for Implanon® Guttmacher Institute. Facts on contraceptive use. 2008. http://www.guttmacher.org TrussellJ. Contraceptive efficacy. Contraceptive technology 19th revised edition. New York: Ardent Media; 2007.

  24. LARC methods • Available LARC methods: • Hormonal contraceptive IUD (Mirena) • Nonhormonal contraceptive IUD with Copper (ParaGard) • Subdermal contraceptive implant (Implanon/Nexplanon) • Shorter-acting methods considered LARC: • Depot medroxyprogestone acetate (Depoprovera)

  25. Depot Medroxyprogesterone Acetate and Bone Mineral Density • Decreased bone density noted in teenagers • No increased risk of fractures • Recovery of BMD following discontinuation • May consider supplement calcium and vit D • Consider alternative method if at risk • Immobile, non-weight bearing, wheelchair bound • Underweight • Reassess after 2 years, continue DMPA if other methods are inadequate ACOG Committee Opinion No. 415. ObstetGynecol2008;112:727-30 Scholes D, et al. Arch PedAdol Med 2005;159(2):139-144

  26. Barriers to increased LARC use • Providers may lack information or are misinformed. • unsubstantiated risk related to STIs, ectopic pregnancy, infertility, use postpartum, use postabortion, use by nulliparous women, use by teens. • Providers lack adequate training in IUC and implant insertion • Patients' fears, misinformation and lack of knowledge have resulted in low demand. • LARC is expensive and provider reimbursement low, especially in the US. Speidel et al. Contraception 78 (2008) 197–200

  27. The Contraceptive CHOICE Project: • 5086 women ages 14-20 enrolled • Preferred LARC method by age: – 18-20 years (61% chose LARC) • Implant: 29% • IUD: 71% – 14-17 years (69% chose LARC) • Implant: 63% • IUD: 37% MestadR, et al. Contraception. 2011 Nov;84(5):493-8

  28. U.S.Medical eligibility criteria (MEC) http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf

  29. U.S. Medical eligibility criteria (MEC) • Comprehensive, evidence-based guidance on contraceptive use • Adapted from guidance previously developed by the World Health Organization • The U.S. MEC gives guidance to clinicians providing family planning services to women, especially women with medical conditions.

  30. Increased VTErisk and contraception • Communicating level of risk: • OCP and VTE risk: 20-30/100,000 • Pregnancy VTE risk: 100/100,000 • Postpartum VTE risk: 500/100,000 • If increased VTE risk factors, Progestin only methods preferred – Pills – Injectable – Implant – Intrauterine James AH. Pregnancy-associated thrombosis. Hematol 2009; 277-85 Seeger JD, Loughlin J, Eng PM, Clifford CR, Cutone J, Walker AM. Risk of thromboembolism in women taking ethinylestradiol/drospirenone and other oral contraceptives. ObstetGynecol 2007; 110(3):587-93.

  31. Drospirenone* and DVT risk *Drospirenone containing birth control pills include: Beyaz, Gianvi, Loryna, Ocella, Safyral, Syeda, Yasmin, Yaz, and Zarah. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm257175.htm

  32. Migraine Headaches MacClellan LR et al. Stroke. 2007; 38: 2438-2445

  33. Drug Interactions Foldvary-Schaefer N et al. Neurology 2003;61:S2-15 Foldvary-Schaefer N, et al. Cleve Clin J Med 2004;71 Suppl 2:S11-8

  34. Emergency Contraception • ParaGard (copper) IUD • Contraceptive pills (Yuzpe method) • 19 pill brands available for use in U.S. • Usually involves taking 4-5 pills, repeat in 12 hrs • Plan B (Levonorgesterol) • Next step • Generic form of Plan B One step (July 2012) • Ella (Ulipristal Acetate) Fine P, Mathé H, Ginde S, Cullins V, Morfesis J, Gainer E..Obstet Gynecol. 2010;115:257-63

  35. Plan B (Levonorgesterel) • Single dose of levonorgesterol 1.5 mg • Reduces pregnancy if taken within 72 hours of unprotected intercourse • FDA approved for OTC 2009 ( >17 yo) • December 7, 2011 – Dept. of HHS overrules decision of the Food and Drug Administration (FDA) to make the emergency contraception method known as • Plan B One-Step available for • purchase without a prescription • or age restriction.

  36. Emergency Contraceptive Pills • Plan B One-Step and Next Choice • Reduce the risk of pregnancy by 89% when started within 72 hours after unprotected sex • Continue to reduce the risk of pregnancy up to 120 hours after unprotected intercourse • Inhibits or delays ovulation • Less effective as time passes • Does not interrupt established pregnancy Rodrigues I, et al. Am J Obstet Gynecol. 2001;184:531‐7 Mikolajczyk RT, Stanford JB. FertilSteril. 2007;88:565‐71

  37. Ella (Ulipristal acetate) • Use up to 120 hours after unprotected intercourse • Progesterone antagonist • Delays ovulation • Maybe more effective than levonorgestrel • Especially 72-120 hour group • Prescription only

  38. I am every emotion times ten, I conform yet I'm rebellious, Always obeying but somehow still an outlaw, Always talking but never heard, I am a teenager. -- Author Unknown


  39. Additional resources • American College of Obstetricians and Gynecologists (www.acog.org) • North American Society for Pediatric and Adolescent Gynecology (www.naspag.org) • Boston Children’s Hospital – Center for Young Women’s Health (www.youngwomenshealth.org) • Centers for Disease Control (www.cdc.gov) • Planned Parenthood (www.plannedparenthood.org)

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