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What’s New in Adolescent Contraception?

What’s New in Adolescent Contraception?. Rachel S-D Fortune, MD, FAAP Medical Director, Newport Academy. Pretest questions. All of the following are ABSOLUTE contraindications to the use of combined hormonal contraceptives in adolescents, EXCEPT:

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What’s New in Adolescent Contraception?

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  1. What’s New in Adolescent Contraception? Rachel S-D Fortune, MD, FAAP Medical Director, Newport Academy

  2. Pretest questions All of the following are ABSOLUTE contraindications to the use of combined hormonal contraceptives in adolescents, EXCEPT: Known thromboembolic mutation (i.e. factor V leiden, protein C, protein S, etc) Current cigarette smoker (<35 years of age) Family history of DVT/PE Personal medical history of stroke True or False: Intrauterine devices can be safely used in adolescent patients: True False

  3. Rachel S-D Fortune, MD, FAAP Medical Director, Newport Academy

  4. Disclosures I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

  5. 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

  6. Youth Risk Behavior Surveillance Survey 2011Trends in Adolescent Sexual Behaviors

  7. Trends in Adolescent Pregnancy Rates Among 15-19 yo, pregnancy rates declined 27% from 1991  2000 117 68

  8. Trends in Adolescent Pregnancy Rates 86% attributable to changes in contraceptive prescribing Decreased pregnancy rate for 15-19yo 14% attributable to decreased sexual activity

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

  10. Contraceptive Eligibility Eligibility Availability/Cost Effectiveness Mechanism of Action Feasibility Reversibility Side Effects Gordon and Pitts, 2012

  11. Contraceptive Eligibility

  12. Contraceptive Eligibility

  13. Contraceptive Eligibility

  14. Availability/Cost • Medicaid covers: • Long Acting Reversible Contraceptives (LARC) • OCPs, NuvaRing, Ortho Evra patch • Depoprovera shots • Private insurance companies cover*: • Long Acting Reversible Contraceptives (LARC) • OCPs, NuvaRing, Ortho Evra patch • Depoprovera shot • For patients who cannot use their insurance: • Planned Parenthood provides services at a cost Eligibility Availability/Cost Effectiveness Mechanism of Action Feasibility Reversibility Side Effects

  15. Effectiveness Eligibility Availability/Cost Effectiveness Mechanism of Action Feasibility Reversibility Side Effects

  16. 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

  17. 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

  18. 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

  19. 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!

  20. 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

  21. 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

  22. Combined Hormonal Contraception • NuvaRingintravaginal 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. The Land of LARC

  29. 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%

  30. Why LARC is BEST!

  31. 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

  32. 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)

  33. 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

  34. 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

  35. 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

  36. 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

  37. Quick Start Approach

  38. Post-test questions • All of the following are ABSOLUTE contraindications to the use of combined hormonal contraceptives in adolescents, EXCEPT: • Known thromboembolic mutation (i.e. factor V leiden, protein C, protein S, etc) • Current cigarette smoker (<35 years of age) • Family history of DVT/PE • Personal medical history of stroke • True or False: Intrauterine devices can be safely used in adolescent patients: • True  • False

  39. 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

  40. Thank You

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