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Adolescent Contraception. Marcia J. Nackenson, M.D. Section of Adolescent Medicine Department of Pediatrics New York Medical College. Adolescent Contraception. The Need Barriers to Adolescent Contraception Contraceptive Methods How to Provide Service.
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Adolescent Contraception Marcia J. Nackenson, M.D. Section of Adolescent Medicine Department of Pediatrics New York Medical College
Adolescent Contraception • The Need • Barriers to Adolescent Contraception • Contraceptive Methods • How to Provide Service
Adolescent Sexual ActivityAges 15 - 19 years • Females: 50% (1997) 55% (1990) • Males: 55% (1995) 60% (1988)
Adolescent Sexual ActivityBy School Grade (1996) • Grade 9: 37% • Grade 12: 66%
Adolescent Sexual ActivityBy Race and Gender • Males earlier than females • Blacks earlier than Hispanics earlier than Whites • Differences are lessening
Adolescent Contraceptive Behavior • 25% use no contraception at 1st intercourse. • 1 year intercourse before medical advice. • 50% adol preg in 1st 6 months of sexual activity.
Adolescent Pregnancy • 1 million pregnancies/year • 85% unintended • 50% live births • 35% elective abortions • 15% spontaneous abortions
But... • Pregnancy Rates Decline 12% (1995) 103/1000 ages 15 - 19 yrs • Abortion Rates Decline • Birth Rates Decline 15% 57/1000
Recent Trends in Adolescent Sexuality • Sexual Activity Down • Condom Use Up • Pill Use Down • Pregnancy Rates Down • Abortion Rates Down • Birth Rates Down • But…Condom & Pills 8%
Barriers to Adolescent Contraception • Psychological Factors • Availability • Demographic Factors
Psychological Factors • Immature cognitive functioning • Dependency, passivity • Difficulty in handling sexuality • Risk-taking behavior • Desire for pregnancy
Availability • Cost • Geographics • Clinic hours • Confidentiality issues
Demographic Factors • Age • Race • Poverty • Educational Plans • Cultural Patterns
Legal Issues I. Consent A. Emancipated Minor B. Mature Minor C. Reproductive Matters II. Confidentiality III. Payment IV. Abortion
Issues in Selecting a Contraceptive Method • Frequency of intercourse • Tolerance of route of delivery • Tolerance of side effects • Nature of relationship ie, monogamous, long-standing
Recommended Methods for Adolescents CONDOMS PLUS: 1. Oral Contraceptives 2. Injectable Progestin (Depo-Provera) 3. Subdermal Implants (Norplant) 4. Spermicide
Limited Methods for Adolescents 1. Diaphragm 2. Female condom 3. Cervical cap
Methods Not Recommended for Adolescents 1. IUD 2. Tubal ligation/vasectomy
Method Abstinence Implants Injectables Oral Contraceptives Vaginal Ring Patch IUD Pregnancy Rate % 0 0.09 0.3 0.1 0.1 1 1-2 Contraceptive EffectivenessMost Effective
Method Condom plus foam Condom alone Female condom Diaphragm Withdrawal Rhythm No Method Pregnancy Rate % 2 - 10 2 - 20 5 - 20 2 - 18 20 20 - 30 90 Contraceptive EffectivenessLess Effective
History of Oral Contraceptives 2000 yrs ago - Arsenic, mercury, & strychnine 1920’s - Progesterone & estrogen isolated. 1935 - Progesterone synthesized. 1940’s - 50’s - Syntex: steroid synthesis 1950’s - Margaret Sanger - clinical trials 1960 - Enovid approved by FDA
Mechanisms of Oral Contraceptives • CombinationOCP: estrogen, progestin • Inhibition of ovulation • Thickened cervical mucous • Endometrium less favorable for implantation • Decreased tubal motility
Estrogen in OCP’s • Ethinyl estradiol 20m 30-35m - Most “low dose” OCP’s 50m • Mestranol - converted to ethinyl estradiol 50m
Progestins in OCP’s • Varying progestational & androgenic potency • 6 different progestins available in U.S. • Newer progestins less androgenic?
Newer Progestins (‘92-’93) • Norgestimate - OrthoCyclen, Tricyclen • Desogestrel - OrthoCept, Desogen ‘95 UK warning VTE FDA, ACOG - no changes needed • Gestodene - Not available in US
Newer Progestins: Advantages • Decreased androgenicity • Increased SHBG • Decreased free testosterone • Improved LDL:HDL ratio • Best for hirsutism, acne
Triphasics vs. Monophasics • Less total hormone per month • No clear clinical advantage
Minor Side Effects of OCP’s • Breakthrough bleeding • Nausea • Breast soreness • Headache • Weight gain - NOT!
Major Side EffectsCardiovascular • Related to high estrogen content, early pills • Venous thromboemboli, MI, CVA • Hypertension 1-5%, reversible with DC • Esp. >35 yrs & smoker • Post-op thromboemboli: DC pills 4 wks pre-op
Major Side EffectsCancer • Dec. risk of endometrial & ovarian ca. • Breast & cervical ca. - no definitive inc. JAMA ‘01: +FH breast ca. & OCP’s Ô inc. risk of breast ca. BUT: Based on early hi dose pills • Hepatocellular adenoma - benign, 3-4/100,000
Other Side Effects • Lipid level changes - screen if hi risk • Carbohydrate metabolism - follow diabetics • Post-pill amenorrhea or infertility - disproven • Congenital anomalies - disproven
Beneficial Effects of OCP’s • Dec. acne • Dec. dysmenorrhea • Dec. ovarian cysts • Dec. fibrocystic disease of the breast • Dec. PID • Dec. endometrial and ovarian ca.
Absolute Contraindications • Thromboembolic disorders • Coronary artery disease • Estrogen-dependent neoplasia • Breast Cancer • Pregnancy • Active liver disease • Undiagnosed abnormal vaginal bleeding
Oral ContraceptivesSummary • Safe and effective for healthy adol. • Use low estrogen pill (20-35 mg) • 28 day pack and Sunday start method • Judicious advice about side effects • Frequent follow-ups.
Progestin Only Methods • The Minipill - daily pill • Depo-Provera - injectable • Norplant - subdermal implant
Progestin Only MethodsMechanisms • Blocks LH surge; inhibits ovulation • Thickens cervical mucous • Thin, atrophic endometrium
Progestin Only Pill • Taken every day - no placebo pills • Slightly less effective than combination pill; less forgiving of missed pill • Indications - estrogen contraindication, lactation • Disadvantages - unpredictable menses
Depo-Provera (Injectable Progestin) • FDA approved 1992 • Medroxyprogesterone acetate 150 mg. IM • 1st injection within 1st 5 days of menses; neg Urine preg test • Repeat q12 weeks ( up to 13.5 weeks) • Cost: $50/dose
Depo-ProveraMenstrual Changes • Irregular menses • Amenorrhea - 60% by 1 year • Treatment of irregular bleeding: 1. Counseling 2. OCP 3. Ibuprofen 4. Estrogen
Depo-ProveraOther Side Effects • Weight gain - 2-5 lbs./yr. • Delay to fertility - 9 mos. • Depression • Dec. libido • Breast tenderness • Decreased bone density - under study
NEW: Lunelle • Combination injectable: Estrogen and progestin • Given q28 days • Advantage - regular menses • Disadvantage - monthly visit
Subdermal Implants • Norplant -FDA 1990, 6 levonorgestrel rods -Effective 5 years -Insertion and removal procedures -Bad publicity • Implanon -Single rod, good for 3 years
Norplant Side Effects • Irregular menses - greatest in 1st yr. • Weight gain - less than Depo • Headaches • Acne • Insertion site problems • Depression • Hair changes
Condoms • Must always be recommended to prevent STD’s • Latex or polyurethane only Reservoir-tipped, spermicide • Effectiveness inc. with contraceptive foam • Advantages: Safe, cheap, available • Disadvantages: Coital dependent, male resistance
Condom Use12-19 yr males • 55% at first intercourse - Inc. from 20% in 1979 • 58% at last intercourse - Inc. from 21% in 1979 • BUT - most teens use condoms sometimes
Spermicides • Nonoxynol-9 • Foam preferred • When used with condoms, greatly inc. effectiveness.
Barrier Methods • Diaphragm • Sponge • Cervical cap • Lea’s shield
The Female Condom(1994) • Polyurethane • $3 each • 5 - 25% failure • Female controlled • Cumbersome
Emergency Contraception • Aka post-coital contraception, “morning after” pill • Indications: Rape Contraceptive failure (condom broke) Unprotected intercourse • 1997 FDA approved
Prescribing Emergency Contraception • Plan B preferred - progestin only • History, LMP,Urine preg test • 2 tabs 50m pill ASAP (within 72 hrs), repeat in 12 hrs. • Nausea (50%) and vomiting (20%), anti-emetics • Mechanism - prevents implantation