Download Contraception in Adolescents

Contraception in Adolescents
Karen Soren, MD
Director, Adolescent Medicine
Associate Clinical Professor
Pediatrics & Public Health
Columbia University Medical Center
What are the barriers to teens
using contraception?
• Developmental issues:
– Early adolescence: present oriented, impulsive
– Middle adolescence: omnipotent, invincible
• Teens are spontaneous
• Teens may be ambivalent about pregnancy
• Teens have inadequate access to
information and confidential care; lack of
awareness of NYS rights
The conversation:
• AAP recommends postponement of sexual
activity, especially for young teens
• “But -if you are going to be sexually active,
you need protection!”
• Condoms are the best method for
protection against sexually transmitted
• Condoms are an imperfect method for
pregnancy –prevention
• You need a back-up for your condom…
The contraceptive visit : What do
you need to do?
• Reassure adolescents of confidentiality
• History
– PMH- rule out conditions that would not allow
safe use of estrogen-containing methods
– Sexual history
– History of previous contraceptive use
– Current medications
• Physical (very basic!)
– Weight, BP
– Gyn exam NOT required
How Methods are Chosen
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•
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Use by friends or relatives
Accessibility
Personal knowledge
Media
Fear of side effects
Physician recommendation
SUMMARY TABLE OF CONTRACEPTIVE EFFICACY
(In 100 women, # pregnancies in a year)
Method
Typical Use
Perfect Use
No contraception
85
85
Spermacides
29
18
Withdrawal
27
4
Diaphragm
16
6
Condom
15
2
Birth control pills
8
0.3
Ortho-Evra patch
8
0.3
Nuvaring
8
0.3
Depo Provera
3
0.3
Mirena IUD
0.2
0.2
Implanon
0.05
0.05
Barrier and Non-hormonal Methods
•
•
•
•
•
Male Condom
Female Condom
Diaphragm
Cervical Cap
IUD- Paragard
(Copper)
Male Condom
• STI protection
• Over the counter
• Imperfect method of contraception
– 85% effective
• Possible latex allergy (my need to use
polyurethane condoms)
• Many condoms now lubricated but do not
contain spermicide - issues with nonoxynol nine
– mucosal irritant
• Need a back-up method…
Plan B
• Large dose of levonorgestral
• Best taken as soon as possible after unprotected
intercourse
• Can take up to 5 days after mess-up (package
says 72 hours)
• Now Plan B One-Step – single pill
• 75-85% effective in reducing pregnancy if used
within 72 hours, less so if used later
• No serious side effects
• Over the counter now - >17 yo
Female Condom
This says it all…
Cervical Cap/Diaphragm
Hormonal Methods
• Combined hormonal methods (estrogen and
progesterone):
– Oral contraceptive pills
• Monophasic or multiphasic
– Ortho Evra Patch
– Nuvaring
• Progestin-only methods
– Depo-Provera injection
– Progestin-only pills (minipill)
– Implanon
– Mirena IUD
A little about estrogens…
• Older pill (1960’s) started with 150 mcg
mestranol – eventually decreased to 50 mcg
because of side effects
• Ethinyl estradiol introduced in 1970’s
• Dose varies from 50 mcg to 20 mcg, but most
pills now used are between 20 and 30 mcg
• Lower dose → less side effects, but more breakthrough bleeding, and less room for noncompliance
What about the progesterone type?
• First generation: (norethindrone, norethindrone
acetate)- medium androgenicity- in Loestrin
• Second generation: (levonorgestral) – higher
androgenicity -in Alesse, Lo-ovral, Seasonalle,
Seasonique, Lybrel, (norgestrel – Lo/Ovral)
• Third generation: (norgestimate, desogestrel) –
low androgenicity but slight increase risk of clots
– in Ortho tri-cyclin Lo (Acne), Desogen
• Drospirenone: (spironalactone analog)- helps
contact hirsuitism – in Yasmin, Yaz (PMDD)
WHO Guidelines - medical eligibility for each
contraceptive method- categories:
• 1 = a condition for which there is no restriction for
the use of the contraceptive method
• 2 = a condition where the advantages of using
the method generally outweigh the theoretical or
proven risks
• 3 = a condition where the theoretical or proven
risks usually outweigh the advantages of using
the method
• 4 = a condition which represents an
unacceptable health risk if the contraceptive
method is used
Contraindications to Estrogen
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Active liver disease (4)
Untreated gall bladder disease (asymptomatic -2, symptomatic -3)
Hypertension (140/90 or greater – 3, 160/100 or greater - 4)
Personal history of thrombosis (4)
Known thrombogenic mutations (4)
Family hx thrombosis (2)- investigate…
Migraine with aura (4)
Condition leading to venous stasis, immobilization (4)
Lupus with positive (or unknown) anti-phospholipid antibody
syndrome (4)
• Diabetes with vascular disease (3,4)
• Post- partum <21 days, +/- breastfeeding (4,3)
• Smokers >35 (<15 cigs/day -3, >15 cigs/day -4)
Migraines and estrogen-containing
methods:
Evidence: Among women with migraine,
women who also had aura had a higher risk
of stroke than those without aura.
Women with a history of migraine who use
COCs are about 2 to 4 times as likely to
have an ischemic stroke as non-users with
a history of migraine.
Conditions that have little or no
contraindications to estrogen use:
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•
•
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Depression (1)
Irregular bleeding in teens -after evaluation (1)
Dysmenorrhea (1)
Abnormal Pap (2)
Obesity (2 – some risks – but benefits outweigh
risks)
• Diabetes without vascular disease (2)
• Sickle cell disease (2): However, as sicklers
more at risk for strokes and acute chest and
bone infections – prefer progestin- only
methods
Medications
• Medications that decrease the
effectiveness of combined oral
contraceptives (and progestin-only pills,
implant)
– Anticonvulsants – phenytoin, phenobarbitol,
topiramate, carbamazepine, lamotrigine (3)
– Rifampin, rifabutin (3)
• However, little effect on pill metabolism in
users of most antibiotics (1)
Combined OCP’s
• Mechanism of action
– Progesterone inhibits LH, thickens cervical
mucus, atrophies endometrium
– Estrogen inhibits FSH
• Other actions of BCPs
– Increase SHBG and decrease free testosterone
– Inhibit 5- reductase in skin, decreasing
conversion of testosterone to DHT
Combined OCP’s
• PROS
–
–
–
–
Rapid return to fertility
No anticipation
Menstrual regularity
Decrease dysmenorrhea
and anemia
– Decrease ectopic
pregnancy rate
– Decrease PID
– Decrease ovarian and
endometrial cancer
• CONS
–
–
–
–
Daily medication
Regular supply needed
Multiple SEs
Multiple
contraindications
– CLOTS
Combined OCP Side Effects
• ESTROGEN
– Nausea
– Fluid retention
– Breast tenderness
– Increases clotting by
decreasing protein C,
S, antithrombin III
– HTN
• PROGESTERONE
– Increases appetite
– Depression
– Elevated lipids (TG)
How to prescribe OCP’s
• Become familiar with a few types of pills
• Rule out contraindications to estrogen
• Patient can start any day (but some prefer
Sundays or first day of period)
• Can give up to 6 packs at a time
• Bring back after 3-4 weeks to determine:
– If teen started pill and if it is taken correctly
– Any side effects
So what pill do I prescribe?
• Can start with a low-dose pill (Alesse,
Loestrin 1/20)
• If teen has acne or PCOS-type stigmata,
consider Ortho tri-cyclin Lo
• If teen has hirsuitism / PCOS, can use Yaz
or Yasmin instead
• For dysfunctional uterine bleeding, can
use Lo/Ovral – longer half-life of progestinstabilizes endometrium
Ortho Evra Patch
• Norelgestromin 6mg/ ethinyl estradiol
0.75mg in a transdermal delivery
system
• 1 patch weekly for 3 weeks, then
patch-free for 1 week
• Traditionally, Sunday or first day of
menses start- however, can start
anytime
• Menses usually 4 days after patch
removal
Ortho Evra
•
• PROS
– No need for daily med
– Teens like ease of
usage
CONS
– 2-3% detach
– Nausea/ vomiting
– Less effective if >90kg
– More complicated if
forget to change or falls
off
– Breast pain, rash
– CLOTS: 60% more
estrogen than a 35 mcg
pill (FDA alert)
NuvaRing
• Etonogestrel 120 mcg/d + ethinyl
estradiol 15 mcg/d
• Silastic ring inserted intravaginally for 3
weeks with 1 week off
• Less estrogen because more bioavailable
• Does not need to be put around cervix,
just in vaginal vault adjacent to mucosa
NuvaRing
• PROS
– Less estrogen
(15 mcg
equivalent)
– Protects for a full
cycle
• CONS
– No STI protection
– 18% of women,
30% of men feel
ring
– Most common
SE is leukorrhea
– Again - clots
Depo-Provera
• Medroxyprogesterone acetate
– 150 mg IM every 11-13 weeks (up to 14 weeks)
• Progesterone actions
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–
–
–
Suppresses LH and prevents ovulation
Thickens cervical mucus
Atrophies endometrium
Decreases cilia motility in fallopian tubes
• 50% amenorrheic at 1 year
Depo-Provera, cont
• CONS
• PROS
– SE can’t be
– Highly effective
immediately stopped
– No anticipation
– Delay in return to
– Can breast feed
fertility
– Decrease endometrial
– Irregular bleeding and
ca, yeast infection,
amenorrhea
PID, fibroids
– Hypo-estrogenic state
– Increases seizure
OSTEOPOROSIS
threshold
Depo-Provera, side effects
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Headache
Mood swings
Weight gain
Hair Loss
Irregular bleeding
One third discontinue use after one year
as a result of side effects
POPs
• Progestin-only pills (Micronor, Nor-QD)
• Small dose of progestin – works primarily by
increasing viscosity of cervical mucus
• Does not reliably inhibit ovulation
• Need to be taken carefully and consistently – if
more than 3 hours late with pill, will not be
effective
• Useful for teens with contraindications to
estrogen who will not accept Depo or Mirena
Implanon
• Contains 68 mg etonogestrel
• Single rod implanted subdermally on day
1-5 of cycle
• Last for 3 years.
• Works by thickening cervical mucus and
also inhibits ovulation
• No effects on bones or lipids
• Irregular bleeding common side effect
Mirena – progestin containing IUD
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IUD containing levonorgestral
Helpful for menorrhagia and dysmenorrhea
Effective for 5 years
Previously discouraged in teens because teens
more at risk for infection- liability concerns
• Movement to encourage IUD use in teens
currently
• Infection probably most related to insertion
• Can be inserted in nulliparous young womanslight risk that will be expelled – teens should
check for the string
So- what contraceptive method would you
recommend?
• 18 year old with no significant medical or family history
going off to college
• 14 year old coming in after an abortion – does not want
her mother to know she is sexually active
• Obese 17 year old with acne and irregular periods
• 15 year old with heavy bleeding for a month who comes to
the emergency room and has a hemoglobin of 8
• Amenorrheic 16 year old with facial hair
• 17 year old tampon user who cannot remember to take a
pill, and wants to keep her sexual activity from her mother
• 15 year old with migraines, and some preceding blurry
vision
• 18 year old with lupus who is non-compliant with her
medications