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Adolescence Is…

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Adolescence Is… Powered By Docstoc
					           Adolescence Is…
                •A transition period between
                childhood and adulthood
                •Series of changes in physical
                maturity, sexuality, cognitive
                processes, emotional feelings,
                and relationships with others

• Generally accepted age group= 10 – 21 yrs.,
  however the Society for Adolescent Medicine
  (SAM) recently adopted a statement that
  declared that adolescent medicine covered ages
  10-25 yrs. in response to changes in biologic and
  social features of this age group




 ADOLESCENT DEVELOPMENTAL TASKS
• 1. Growth and Development
• 2. Coping with sexuality and sexual identity
• 3. Establishment of a moral code
• 4.Establishing independence from
  parents/family.
• 5.Choosing a vocational direction.




     Developmental Milestones for
              Teens
• Early Adolescence
    (10-13 years)


• Middle Adolescence
    (14-17 years)

• Late Adolescence
 (17-21 or 25 years)




                                                      1
         Early Adolescence
• Period of rapid growth
  and physical change
• Characteristics-
  egocentrism, concrete
  thinking
• Relations-same sex
  friends
• Problems-injuries




                             2
        Middle Adolescence
                           • Secondary sexual
                             characteristics
                             develop, growth rate
                             decreases
                           • Emancipation from
                             parents
                           • Abstract thought
                           • Opposite sex friends
                           • STD’s, MVA’s




          Late Adolescence
• Physically mature
• Vocational goals
  important
• Individual friendships
  over peer group
• Stress induced illness




            Causes of Adolescent
            Morbidity and Mortality
• Depression
                           • MVA’s
• Substance Use
                           • Suicide
• Eating Disorders
                           • Firearm fatalities




                                                    3
 Overview of the Adolescent
           Visit

 • During adolescence- visits to a health
   care provider may be limited
 • Goal of family planning provider is to to
   be aware of psychosocial and cognitive
   developmental level of adolescent
   patient
 • THINK Contraception and Prevention!




         Setting the Stage




         Setting the Stage
• Make the adolescent   • Use open-ended
  the primary             questions
  historian             • Be non-judgmental
• Establish             • Listen to the patient!
  confidentiality
• Use understandable
  language




                                                   4
                     Consent
• Age of majority- 18 years (most states)
• In DC a minor has the same capacity to
  consent for care as an adult for:
    – Treatment / counseling for an STD
    – Treatment /counseling for pregnancy and
      contraception
    – Treatment/ counseling for alcohol or drug use
    – Examination and treatment for rape or sexual offense




               Confidentiality
• Confidentiality of care can be broken:
   – “Without the consent of a minor, the physician
      may , but need not, give a parent of the minor
      information about treatment needed by or
      provided to the minor” (Maryland 20-102)
• If patient is homicidal, suicidal or abused.




           Obtaining a History
•   Chief Complaint
•   Past Medical History
•   Family Medical History
•   Psychosocial History
•   Menstrual/Sexual History




                                                             5
          Communication Tools
• HEADSS Format: Home, Health,
  Education, Employment, Activities, Diet,
  Drugs, Depression, Suicide, Sex, Safety,
  Sleep
• FISTS+: Fighting, Injuries, Sexual Threats,
  Self-Defense, Safe Internet
• CRAFFT (adolescent alcoholism): Car,
  Relax, Alone, Forgetful, Fighting, Trouble




        Psychosocial History
•   H-Home
•   E-Education
•   A-Activities
•   D-Diet,Drugs,Depression
•   S-Suicide, Sexuality,
      Safety, Sleep




             Skills - Review
• Providers should develop nonverbal skills
  of expressing and recognizing emotion.
• Techniques of communicating sensitivity
  to the patient’s feelings.
• Using bi-directional communications with
  adolescents.
• Asking psychosocial questions and
  listening attentively.




                                                6
        Sexual Exploration in Teens

• Sexual Education…
   – Readiness for both parties
   – Desire
   – HIV/AIDS preventive
     strategies
   – Gender roles
   – Risk taking
   – Sexual expression/ friendships between opposite sex
   – Encourage practical skills (i.e. critical thinking,
     communication and decision making)




                      SUMMARY
• Set the stage
• Establish confidentiality
• Engage teen with good
  bidirectional
  communication and
  attentive listening.
• Prevent High-risk
  Behaviors




         Adolescent Health Visit
• Adolescents had no preference if providers wore a white coat during
  the exam. Parents of adolescents preferred to have providers wear
  their white coats.
• Adolescents wanted to see their provider wash their hands before
  their examination.
• Adolescents did not feel that female providers needed to have
  chaperones during gynecologic exams to make them feel
  comfortable.
• Adolescents value privacy and confidentiality in clinics or ED’s. A
  clear understanding of when confidentiality must be breeched – life
  threatening situations, surgery or hospitalization and mandatory
  reporting situations including STI reporting and sexual abuse.




                                                                        7
                          2009 YRBS Results
                   Sexual Behaviors that Contribute to
             Unintended Pregnancy and Sexually Transmitted
                    Diseases, Including HIV Infection




             Percentage of High School Students Who Ever Had Sexual
                   Intercourse, by Sex and Race/Ethnicity,* 2009

            100



            80

                                                           65.2

            60
  Percent




                                                                    49.1
                  46.0          45.7        46.1
                                                   42.0
            40



            20



             0
                  Total        Female       Male   White   Black   Hispanic
*B>H>W


National Youth Risk Behavior Survey, 2009




                                                                              8
                Percentage of High School Students Who Ever Had Sexual
                                Intercourse, 1991 – 2009†
                 100



                       80



                       60       54.1   53.0   53.1
   Percent




                                                        48.4   49.9                          47.8
                                                                      45.6   46.7   46.8            46.0

                       40



                       20



                       0
                                1991   1993   1995    1997     1999   2001   2003   2005     2007   2009

† Decreased 1991–2009, p < 0.05.

National Youth Risk Behavior Surveys, 1991–2009




                       Range and Median Percentage of High School Students
                       Who Ever Had Sexual Intercourse, Across 36 States and
                                         19 Cities, 2009
                       100



                        80


                                                     61.0                                  63.5
                        60
             Percent




                                                                                           53.4
                                                     48.2
                        40                           39.0

                                                                                           28.7
                        20



                            0
                                               States                               Cities



State and Local Youth Risk Behavior Surveys, 2009




             Percentage of High School Students Who Ever Had Sexual
                                 Intercourse, 2009




                                                                                                    39.0% - 45.0%

                                                                                                    45.1% - 48.1%

                                                                                                    48.2% - 51.0%

                                                                                                    51.1% - 61.0%

                                                                                                      No Data




 State Youth Risk Behavior Surveys, 2009




                                                                                                                    9
       Percentage of High School Students Who Ever Had Sexual
                           Intercourse, 2009

                    Seattle




                                                                                                Boston
                                                       Milwaukee
                                                                                           New York City
                                                           Chicago      Detroit          Philadelphia
             San Francisco
                                                                                                           28.7% - 47.7%
                   Clark County
                                                                                                           47.8% - 53.3%

Los Angeles           San Bernardino                               Memphis                                 53.4% - 55.4%
                                                                                   Charlotte-
                                                                                  Mecklenburg
             San Diego                                                                                     55.5% - 63.5%
                                                                                    County
                                                                                                               No Data
                                              Dallas                               Duval County
                                                                                   Orange County
                                                                                      Palm Beach County
                                                                                        Broward County
                                                                              Miami-Dade County




Local Youth Risk Behavior Surveys, 2009




              Percentage of High School Students Who Had Sexual
                Intercourse for the First Time Before Age 13 Years,
             100        by Sex* and Race/Ethnicity,† 2009

             80



             60
   Percent




             40



             20                                                                            15.2
                                                        8.4                                              6.7
                         5.9                                                      3.4
                                        3.1
               0
                        Total          Female          Male                   White        Black    Hispanic

*M>F
†B>H>W


National Youth Risk Behavior Survey, 2009




                                                                                                                           10
                       Percentage of High School Students Who Had Sexual
                100     Intercourse for the First Time Before Age 13 Years,
                                            1991 – 2009*
                80



                60
   Percent




                40



                20
                      10.2     9.2    8.9               8.3
                                               7.2                6.6       7.4       6.2          7.1       5.9

                 0
                      1991     1993   1995    1997     1999      2001       2003      2005     2007         2009

*Decreased 1991–2009, p < 0.05.


National Youth Risk Behavior Surveys, 1991–2009




                        Percentage of High School Students Who Had
                      Sexual Intercourse with Four or More Persons During
                                           Their Life,
                100            by Sex* and Race/Ethnicity,† 2009

                 80



                 60
      Percent




                 40
                                                                                            28.6

                 20    13.8                           16.2                                                14.2
                                            11.2                              10.5


                  0
                       Total             Female       Male                    White       Black          Hispanic

*M>F
†B>H>W


National Youth Risk Behavior Survey, 2009




                   Percentage of High School Students Who Used Depo-
                  Provera (Injectable Birth Control) to Prevent Pregnancy
                100    Before Last Sexual Intercourse,* 1999 – 2009†

                80



                60
   Percent




                40



                20

                         3.3          4.4            3.7              2.9             2.8                 3.1
                 0
                        1999          2001           2003           2005              2007               2009
* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
† Decreased 1999–2009, p < 0.05.



National Youth Risk Behavior Surveys, 1999–2009




                                                                                                                    1
                  Percentage of High School Students Who Used Birth

                 Control Pills or Depo-Provera (Injectable Birth Control)
                100
                 to Prevent Pregnancy Before Last Sexual Intercourse,*
                           by Sex† and Race/Ethnicity,‡ 2009
                 80



                 60
      Percent




                 40
                                                27.4                          29.3
                          22.9
                                                          18.3
                 20                                                                       12.9        14.0


                  0
                          Total             Female        Male                White       Black     Hispanic
* Among the 34.2% of students nationwide who had sexual intercourse with at least one person during the 3 months
before the survey.
†F>M
‡ W > B, H

National Youth Risk Behavior Survey, 2009




                       Percentage of High School Students Who Used Birth

                      Control Pills or Depo-Provera (Injectable Birth Control)
                100 to  Prevent Pregnancy Before Last Sexual Intercourse,*
                                           1999 – 2009†
                 80



                 60
   Percent




                 40

                                         22.6            20.7        20.5                             22.9
                           19.5                                                       18.8
                 20



                  0
                           1999          2001            2003       2005              2007            2009
* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
† No change 1999–2009, p < 0.05.



National Youth Risk Behavior Surveys, 1991–2009




                         Percentage of High School Students Who Had Sexual
                          Intercourse with Four or More Persons During Their
                100
                                           Life, 1991 – 2009*


                 80



                 60
   Percent




                 40


                         18.7     18.7   17.8              16.2
                 20                               16.0            14.2      14.4      14.3     14.9     13.8



                  0
                         1991     1993   1995     1997    1999    2001      2003      2005    2007      2009

* Decreased 1991–2009, p < 0.05.


National Youth Risk Behavior Surveys, 1991–2009




                                                                                                                   2
                     Percentage of High School Students Who Were
                                         Currently
                                                                †
                100 Sexually Active,* by Sex and Race/Ethnicity, 2009



                 80



                 60
      Percent




                                                                                           47.7

                 40    34.2                  35.6                                                    34.6
                                                       32.6                     32.0


                 20



                  0
                       Total             Female        Male                    White       Black   Hispanic

* Had sexual intercourse with at least one person during the 3 months before the survey.
† B > W, H


National Youth Risk Behavior Survey, 2009




                Percentage of High School Students Who Were Currently
                            Sexually Active,* 1991 – 2009†
                100



                80



                60
   Percent




                      37.5     37.5   37.9               36.3
                40                             34.8                33.4      34.3      33.9   35.0     34.2



                20



                 0
                      1991     1993   1995     1997     1999      2001      2003       2005   2007     2009

* Had sexual intercourse with at least one person during the 3 months before the survey.
† Decreased 1991-2009, p < 0.05.

National Youth Risk Behavior Surveys, 1991–2009




                    Percentage of High School Students Who Used a
                  Condom During Last Sexual Intercourse,* by Sex† and
                100              Race/Ethnicity,‡ 2009

                 80
                                                       68.6
                       61.1                                                     63.3       62.4
                 60                          53.9                                                    54.9
      Percent




                 40



                 20



                  0
                       Total             Female        Male                    White       Black   Hispanic
* Among the 34.2% of students nationwide who had sexual intercourse with at least one person during the 3 months
before the survey.
†M>F
‡ W, B > H

National Youth Risk Behavior Survey, 2009




                                                                                                                   3
                   Percentage of High School Students Who Used a
                 Condom During Last Sexual Intercourse,* 1991 – 2009†
                100



                80

                                                                           63.0       62.8     61.5     61.1
                                               56.8     58.0     57.9
                60             52.8   54.4
   Percent




                      46.2

                40



                20



                 0
                      1991     1993   1995     1997    1999      2001      2003       2005     2007     2009

* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
† Increased 1991–2003, no change 2003–2009, p < 0.05.

National Youth Risk Behavior Surveys, 1991–2009




                               Percentage of High School Students Who Used

                100            Birth Control Pills to Prevent Pregnancy Before
                                     Last Sexual Intercourse,* by Sex† and
                 80                          Race/Ethnicity,‡ 2009

                 60
      Percent




                 40
                                                                              26.8
                                             23.0
                       19.8
                 20                                   16.5
                                                                                                      10.8
                                                                                             8.1

                  0
                       Total             Female       Male                    White       Black     Hispanic
* Among the 34.2% of students nationwide who had sexual intercourse with at least one person during the 3 months
before the survey.
†F>M
‡ W > B, H

National Youth Risk Behavior Survey, 2009




                  Percentage of High School Students Who Used Birth
                  Control Pills to Prevent Pregnancy Before Last Sexual
                100
                                 Intercourse,* 1991 – 2009†

                80



                60
   Percent




                40

                      20.8                                                                              19.8
                               18.4   17.4     16.6     16.2     18.2      17.0       17.6     16.0
                20



                 0
                      1991     1993   1995     1997    1999      2001      2003       2005     2007     2009
* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
† No change 1991–2007, increased 2007-2009, p < 0.05.



National Youth Risk Behavior Surveys, 1991–2009




                                                                                                                   4
                  Percentage of High School Students Who Used Depo-
                        Provera (Injectable Birth Control) to Prevent
                100
                    Pregnancy Before Last Sexual Intercourse,* by Sex†
                                 and Race/Ethnicity,‡ 2009
                 80



                 60
      Percent




                 40



                 20

                      3.1                  4.4                                 2.5          4.8        3.2
                                                       1.7
                  0
                      Total              Female       Male                    White       Black     Hispanic
* Among the 34.2% of students nationwide who had sexual intercourse with at least one person during the 3 months
before the survey.
†F>M
‡B>W

National Youth Risk Behavior Survey, 2009




                   Percentage of High School Students Who Used Depo-
                  Provera (Injectable Birth Control) to Prevent Pregnancy
                100    Before Last Sexual Intercourse,* 1999 – 2009†

                80



                60
   Percent




                40



                20

                        3.3          4.4             3.7              2.9             2.8             3.1
                 0
                       1999         2001            2003            2005              2007           2009
* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
† Decreased 1999–2009, p < 0.05.



National Youth Risk Behavior Surveys, 1999–2009




                 Percentage of High School Students Who Used Birth

                 Control Pills or Depo-Provera (Injectable Birth Control)
                100
                 to Prevent Pregnancy Before Last Sexual Intercourse,*
                           by Sex† and Race/Ethnicity,‡ 2009
                 80



                 60
      Percent




                 40
                                           27.4                               29.3
                      22.9
                                                      18.3
                 20                                                                         12.9      14.0


                  0
                      Total              Female       Male                    White       Black     Hispanic
* Among the 34.2% of students nationwide who had sexual intercourse with at least one person during the 3 months
before the survey.
†F>M
‡ W > B, H

National Youth Risk Behavior Survey, 2009




                                                                                                                   5
                                Percentage of High School Students Who Used Birth

                            Control Pills or Depo-Provera (Injectable Birth Control)
                  100 to      Prevent Pregnancy Before Last Sexual Intercourse,*
                                                 1999 – 2009†
                       80



                       60
   Percent




                       40

                                           22.6            20.7      20.5                            22.9
                                  19.5                                               18.8
                       20



                       0
                                  1999    2001             2003     2005            2007             2009
* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
† No change 1999–2009, p < 0.05.



National Youth Risk Behavior Surveys, 1991–2009




                                  Percentage of High School Students Who Used Both
                       100         a Condom and Birth Control Pills or Depo-Provera
                                     (Injectable Birth Control) to Prevent Pregnancy
                        80             Before Last Sexual Intercourse,* by Sex and
                                                  Race/Ethnicity,† 2009
                        60
             Percent




                        40



                        20
                                                   9.8                          12.0
                                   8.9                       7.8
                                                                                             4.6        3.5
                            0
                                  Total           Female     Male              White         Black   Hispanic

* Among the 34.2% of students nationwide who had sexual intercourse with at least one person during the 3 months
before the survey.
† W > B, H


National Youth Risk Behavior Survey, 2009




                    Percentage of High School Students Who Used Both a
                       Condom and Birth Control Pills or Depo-Provera
                    (Injectable Birth Control) to Prevent Pregnancy Before
                  100
                            Last Sexual Intercourse,* 1999 – 2009†
                       80



                       60
   Percent




                       40



                       20
                                           7.2             6.8        7.5                             8.9
                                   4.8                                                 6.1

                       0
                                  1999    2001             2003     2005            2007             2009
* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
† Increased 1999–2009, p < 0.05.



National Youth Risk Behavior Surveys, 1999–2009




                                                                                                                   6
                               Percentage of High School Students Who Used

                100            Birth Control Pills to Prevent Pregnancy Before
                                     Last Sexual Intercourse,* by Sex† and
                 80                          Race/Ethnicity,‡ 2009

                 60
      Percent




                 40
                                                                              26.8
                                             23.0
                       19.8
                 20                                   16.5
                                                                                                      10.8
                                                                                             8.1

                  0
                       Total             Female       Male                    White       Black     Hispanic
* Among the 34.2% of students nationwide who had sexual intercourse with at least one person during the 3 months
before the survey.
†F>M
‡ W > B, H

National Youth Risk Behavior Survey, 2009




                  Percentage of High School Students Who Used Birth
                  Control Pills to Prevent Pregnancy Before Last Sexual
                100
                                 Intercourse,* 1991 – 2009†

                80



                60
   Percent




                40

                      20.8                                                                              19.8
                               18.4   17.4     16.6     16.2     18.2      17.0       17.6     16.0
                20



                 0
                      1991     1993   1995     1997     1999     2001      2003       2005     2007     2009
* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
† No change 1991–2007, increased 2007-2009, p < 0.05.



National Youth Risk Behavior Surveys, 1991–2009




                  Percentage of High School Students Who Used Depo-
                        Provera (Injectable Birth Control) to Prevent
                100
                    Pregnancy Before Last Sexual Intercourse,* by Sex†
                                 and Race/Ethnicity,‡ 2009
                 80



                 60
      Percent




                 40



                 20

                       3.1                   4.4                               2.5           4.8       3.2
                                                       1.7
                  0
                       Total             Female       Male                    White       Black     Hispanic
* Among the 34.2% of students nationwide who had sexual intercourse with at least one person during the 3 months
before the survey.
†F>M
‡B>W

National Youth Risk Behavior Survey, 2009




                                                                                                                   7
                   Percentage of High School Students Who Used Depo-
                  Provera (Injectable Birth Control) to Prevent Pregnancy
                100    Before Last Sexual Intercourse,* 1999 – 2009†

                 80



                 60
   Percent




                 40



                 20

                           3.3       4.4             3.7              2.9             2.8             3.1
                  0
                          1999      2001            2003            2005              2007           2009
* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
† Decreased 1999–2009, p < 0.05.



National Youth Risk Behavior Surveys, 1999–2009




                  Percentage of High School Students Who Used Birth

                 Control Pills or Depo-Provera (Injectable Birth Control)
                100
                 to Prevent Pregnancy Before Last Sexual Intercourse,*
                           by Sex† and Race/Ethnicity,‡ 2009
                 80



                 60
      Percent




                 40
                                           27.4                               29.3
                         22.9
                                                      18.3
                 20                                                                         12.9      14.0


                  0
                         Total           Female       Male                    White       Black     Hispanic
* Among the 34.2% of students nationwide who had sexual intercourse with at least one person during the 3 months
before the survey.
†F>M
‡ W > B, H

National Youth Risk Behavior Survey, 2009




                       Percentage of High School Students Who Used Birth

                      Control Pills or Depo-Provera (Injectable Birth Control)
                100 to  Prevent Pregnancy Before Last Sexual Intercourse,*
                                           1999 – 2009†
                 80



                 60
   Percent




                 40

                                    22.6            20.7             20.5                            22.9
                          19.5                                                        18.8
                 20



                  0
                          1999      2001            2003            2005              2007           2009
* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
† No change 1999–2009, p < 0.05.



National Youth Risk Behavior Surveys, 1991–2009




                                                                                                                   8
                                 Percentage of High School Students Who Used Both
                       100        a Condom and Birth Control Pills or Depo-Provera
                                    (Injectable Birth Control) to Prevent Pregnancy
                        80            Before Last Sexual Intercourse,* by Sex and
                                                 Race/Ethnicity,† 2009
                        60
             Percent




                        40



                        20
                                                        9.8                         12.0
                                  8.9                             7.8
                                                                                                 4.6        3.5
                            0
                                 Total                 Female     Male             White         Black    Hispanic

* Among the 34.2% of students nationwide who had sexual intercourse with at least one person during the 3 months
before the survey.
† W > B, H


National Youth Risk Behavior Survey, 2009




                    Percentage of High School Students Who Used Both a
                       Condom and Birth Control Pills or Depo-Provera
                    (Injectable Birth Control) to Prevent Pregnancy Before
                  100
                            Last Sexual Intercourse,* 1999 – 2009†
                       80



                       60
   Percent




                       40



                       20
                                                7.2             6.8        7.5                            8.9
                                  4.8                                                      6.1

                       0
                                 1999           2001            2003      2005          2007              2009
* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
† Increased 1999–2009, p < 0.05.



National Youth Risk Behavior Surveys, 1999–2009




         Percentage of High School Students Who Were Ever Taught
             in School about AIDS or HIV Infection, 1991 – 2009*
                  100                                    91.5     90.6   89.0                      89.5
                                         86.1   86.3                             87.9   87.9                87.0
                                83.3
                       80



                       60
   Percent




                       40



                       20



                       0
                                1991     1993   1995     1997    1999    2001    2003   2005       2007     2009

* Increased 1991–1997, decreased 1997–2009, p < 0.05.


National Youth Risk Behavior Surveys, 1991–2009




                                                                                                                     9
                      Percentage of High School Students Who Were
                                     Tested for HIV,*
                100         by Sex† and Race/Ethnicity,‡ 2009

                 80



                 60
      Percent




                 40

                                                                       21.4
                 20   12.7                14.7
                                                 10.9          11.0              12.4


                  0
                      Total             Female   Male          White   Black    Hispanic

* Not counting tests done when donating blood.
†F>M
‡ B > W, H

National Youth Risk Behavior Survey, 2009




                      Percentage of High School Students Who Were
                                     Tested for HIV,*
                100                   2005 – 2009†

                80



                60
   Percent




                40



                20            11.9                      12.9             12.7


                 0
                              2005                      2007             2009

* Not counting tests done when donating blood.
† No change 2005–2009, p < 0.05.

National Youth Risk Behavior Surveys, 2005–2009




                         How Many Adolescents are in DC?

             • District of Columbia Teen Population
               Estimates (2009)
             • Females, 10-19 Years Old: 35,068
             • Males, 10-19 Years Old: 33,247
             • Reference: www.census.gov/popest/states




                                                                                           10
       The Number of Adolescents in DCPS
           (excludes Charter School Students)

• DC Public Schools Student Enrollment (2008
  – 2009)
• Grade 7 4,584        Grade 10 4,390
• Grade 8 4,540        Grade 11 3,723
• Grade 9 6,334        Grade 12 3,444
• 2007 – 2008 high school dropout rate: 5.5%
• 2007 – 2008 high school total dropouts: 1,175
• Reference:
  http://nces.ed.gov/ccd/pub_snf_report.asp




  Youth Risk Behavior Survey
      (2007) – DC DATA
• 57.6% of teens have had sexual intercourse
• 13.1% of teens had sexual intercourse before age 13
• 16.1% of teens had sexual intercourse with four or more
  people
• 17.4% teens who had sexual intercourse during the past
  three months drank alcohol or used drugs before last
  sexual intercourse
• 70.7% of teens who had sexual intercourse during the
  past three months used a condom
• 9.2% of teens who had sexual intercourse during the
  past three months, used birth control pills
• Reference: www.cdc.gov/yrbs




                                                            11
            Adolescent Contraception

• Objective 2 - To review the reasons for
  higher contraceptive method failure rates
  for women 19 years and younger by
  contraceptive method.




               District of Columbia
         Adolescent Pregnancy Data 2008

• Teen Pregnancies (2008)
• The number of pregnancies is the sum of live births,
  legally induced abortions, and fetal deaths.
• Total pregnancies (19 year-olds & younger)1,346
• Live births        1,115        82.8%
• Induced abortions 215           16.0%
• Fetal deaths         16         1.2%
• Reference:
  http://dchealth.dc.gov/doh/cwp/view,a,1374,q,602024.as
  p




  Unintended Pregnancy: New
 Estimates for the United States

            Lawrence B. Finer, Ph.D.
             Mia R.S. Zolna, M.P.H.




            RH 2010 • September 25, 2010




                                                           1
    Unintended (and intended)
 pregnancy rates have increased
                                                             2001          2006
% of pregnancies unintended                                  49%               49%
Unintended pregnancy rate                                      51                 55
Intended pregnancy rate                                        53                 56
% of unintended pregnancies
                                                             42%               34%
ending in abortion
Unintended birth rate                                          23                 26
Abortion rate                                                  21                 20




      Unintended and intended pregnancy
              rates vary by age
200
                                                               Intended
180                                                            Unintended
160
140                                  64
                                              109
120
                             28
100
                                                        99
80
60                                                              53
                                    108
                             95
40                 5                              75
20                 35                                   38                     17
        2                                                       28
                                                                               12
 0
       <15        15-17     18-19   20-24    25-29     30-34   35-39           >=40




          Unintended pregnancy rate:
            Declined among teens
        Increased among older women
80
                                                                           2001
                                      73      74                           2006
60           67
                       58
40

20
                                                                          20
                                                               13
  0
              15-19                       20-34                     35+




                                                                                       2
         Unintended pregnancy rate:
        Disparity by income is growing
140
                                                                         2001
120                  132                                                 2006
100         112
 80
                                        82        85
 60
 40
 20                                                                 29     26
  0
       <100% of poverty                100-199% of            ≥200% of poverty
                                         poverty




      Significant disparity by relationship
                     status
                      Unintended pregnancy rate

             0       20    40     60    80    100 120        140 160 180

                     32                                                         2001
   Married
                     32
                                                                                2006
                                                        138
Cohabiting
                                                              158
 Formerly                  47
  married                    56
   Never                    54
  married                    58




      Significant disparity by education

                                 Unintended pregnancy rate
                 0         20          40         60          80     100        120


 Not HS grad                                            76
                                                                         112

HS grad/GED                                  54
                                                   68                    2001
                                                                         2006
Some college                            47
                                              58

College grad                27
                                32




                                                                                       3
      Significant disparity by race/ethnicity

                            Unintended pregnancy rate
                0          20         40       60        80      100


       White                     36                                    2001
                                 37
                                                                       2006

   Hispanic                                         78
                                                          87

       Black                                                   98
                                                     81

       Other                           48
                                        50




                                 Summary

 • Half of pregnancies still unintended
 • Unintended and intended preg rates increased
     – Teen U.P. rate declining, but most teen pregnancies are
       unintended
     – Large (and sometimes growing) disparities by income,
       relationship, education, race
 • Decrease in percentage of unintended pregnancies
   ending in abortion
 • More regular updates coming (2008 ests next year)




                     Contraceptive Use
     23%
               19%              % of US women 15-44 years

                           11%


                                 3.3%        2.5% 1.3%
                                                              0.8% 0.8%
                 OC         Injectable      IUD         Other
Sterilization           Male       Withdrawal   Other   Hormonal
                       Condom                   Non-hormonal
 Chandra A, et al. 2005.




                                                                              4
     Current Contraceptive Options
      Most                        Very                   Moderately
    effective                   effective                 effective             Effective

   Prevents                    Prevents                   Prevents               Prevents
  pregnancy                   pregnancy                  pregnancy              pregnancy
 >99% of the                  ~91-99% of                 ~81-90% of            up to 80% of
     time                      the time                   the time               the time

 Male/Female                       Pills                Male/Female              Fertility
 Sterilization                 Injectables                Condom               awareness
  IUD/IUS                         Patch                   Sponge               Cervical cap
  Implants                         Ring                  Diaphragm             Spermicide




                   BMI Based on Height
                       and Weight


 Normal Weight                           Overweight                            Obese
     BMI                                    BMI                                 BMI




National Institutes of Health. Calculate Your Body Mass Index. Available at:
www.nhlbisupport.com/bmi/.




                                                                                              5
                        Obesity and Decreased
                        Effectiveness of COCs
                  •Attributable risk from obesity = 2-4
                  pregnancies per 100 woman-years
                 10
  Hazard ratio




                  1
                                 BMI>27.3                          Lbs >165

                 0.1
                                                                                      more…
Holt VL. Obstet Gynecol. 2005.




Obesity and Decreased
Effectiveness of COCs (continued)
                               Adjusted Risk of Pregnancy by Body Mass Index




                                <20         20-24.9                25-29.9              >=30
                                            (referent)
Brunner LR. Ann Epidemiol. 2005.




                           Typical Failure Rates
                       No Method                                                    85%
                       Spermicides                                                  29%
                       Diaphragm                                                    16%
                       Condom (male)                                                15%
                       Combined pill in obese women*                                13%
                       Combined pill and progestin-only pill                        8%
                       Contraceptive patch or vaginal ring                          8%
                       Copper IUD or LNG-IUS                                        <1%
                       Hormonal implant                                             <1%
                       Sterilization                                                <1%

*Includes data on combined oral contraceptives only; does not include progestin-only pills
Trussell J. In: Contraceptive Technology. 2007.




                                                                                               6
             Obesity and Combined
            Hormonal Contraceptives




          Effectiveness                 Effectiveness                      Data on
          may be lower                     same if                      effectiveness
           if woman is                    woman is                       and obesity
               obese                        obese                       not published


Jain J. Contraception. 2004; Croxatto HB. Hum Reprod. 1999; Funk S. Contraception. 2005;
Zieman M. Fertil Steril. 2002; Oddsson K. Contraception. 2005; Ahrendt HJ.
Contraception. 2006.




  Other Contraceptive Options for
         Obese Women
 –Copper IUDs
 –LNG-IUS
 –Barrier methods
 –Sterilization




Trussell J. Contraception for Obese Women [slide presentation]. 2007.




                Key Counseling Points
 –Provide risk information
 –Encourage practical steps for weight loss
 –Review reproductive health plan
 –Schedule follow-up visits for preventive health
  care




                                                                                           7
                                    Obesity and Risk of VTE




Trussell J. Contraception. 2008.




               Comparative Risk of Venous
                  Thromboembolism
     Incidence of VTE per 100,000




                                               60
                                                                        Pregnancy
                                                                        High-dose OC
                                                                        Low-dose OC
            woman-years




                                                                        General population
                                               40



                                               20



                                                 0



                                                                         Shulman LP, Goldzieher JW. J Reprod Med 2003.
                                                                         Chang J, et al. In: Surveillance Summaries 2003.




                                        Tools: Risk Comparisons
                  Annual Risk of Death (per 100,000)
                                    Skydiving                                                                               100
                                    Driving                                                                                  20
                                    Pregnancy                                                                               11.5
                                    Riding a bicycle                                                                        0.8
                                    Airplane crash                                                                           0.4
                                    Using OC*
                                    *Nonsmoker, under age 35
                                                                                                                            0.06

                                                                      Trussell J, Jordan B. Contraception in press.
                                                                               Chang J, et al. MMWR 2003.
                                                                         Harvard Center for Risk Analysis 2006.
                                                               Bennett P. In: Risk Communication and Public Health 1999.




                                                                                                                                   8
              OCP’s Marketed for
                Adolescents
     •   Yasmin contains 30 mcg.
         Ethinyl estradiol and 3.0 mg.
         Drospirenone. Drospirenone is
         a derivative of spironolactone,
         and has diuretic properties and
         anti-androgenic properties.
     •   Small studies have suggested
         better PMS relief with Yasmin,
         than other OCP’s. YAZ - 24
         active pills and 4 inactive was
         effective in preventing severe
         PMDD, has recently been
         approved by the FDA.
     •   Some clinicians recommend
         checking serum potassium
         levels if on interacting drugs or
         at risk for dehydration.




                       NEW OCP’S
                                         • Ortho Tricyclen-Lo is a lower
                                           dose version of the 35 mcg.
                                           Pill, Ortho-Tricyclen, that
                                           contains 25 mcg. Ethinyl
                                           estradiol and triphasic doses of
                                           progestin, norgestimate.
                                         • Some women and teens report
                                           more breakthrough bleeding
                                           on 20-25 mcg pills. Not
                                           supported in clinical studies of
                                           BTB.
                                         • Lower estrogen doses
                                           appealing for parents and
                                           younger women. Better side
                                           effect profile not yet proved.




                               OCPS
• Mircette is a 20 mcg.
  EE/.15 mg
  desogestrel
• Has only 2 hormone free
  days, 5 days of 10 mcg.
  EE. This product began
  the trend of no HFI
  (hormone free interval).




                                                                              9
Hormone-Free Interval (HFI)




  Hormone-Free Interval




                              10
                  Extended Hormonal
                    Contraception
 • Delays or eliminates
   menstruation
 • Menstrual and nonmenstrual
   benefits
 • Extended methods:
    • Continuous use of COCs, transdermal
      patch & vaginal ring
    • Seasonale® , Seasonique & Lybrel -
      dedicated extended OC regimen
Anderson FD. Contraception. 2003. Kaunitz AM. Contraception. 2000. ARHP. 2003.
NuvaRing Product Information. 2001. Stewart FH. Obstet Gynecol. 2005. Kwiecien M.
Contraception. 2003. Sulak PJ. Am J Obstet Gynecol 2002.




   Menstrual Suppression with Extended
                 Cycles




              Hormone-Free Interval




                                                                                    1
Extended Cycle Therapy




                         2
            Extended Cycle Therapy
•   Lybrel (Wyeth) is a 20 mcg EE/90
    mcg LNG OCP designed for 365
    day continuous use OCP. Each
    cycle contains 28 active hormone
    pills.
•   BTB can be expected in the first 6
    months, then decreases.
•   It may be difficult to determine if
    you are pregnant since no menses
    are expected. If pregnancy is
    suspected a screening test should
    be performed.




                           The Patch
       • Some concerns about lack of
         privacy for teens with family
         and partner with visible
         patch. Some partners and
         family glad to have evidence
         of contraception.
       • Once weekly changes may
         improve adherence over
         daily OCP. Offers
         alternative to needle phobic
         teens. Estrogen strength 20-
         25 mcg daily, but less
         nausea.
       • Less efficacious in women
         weighing > 90 kg (198lb).




                                          3
                           Pharmacodynamics




      Concerns About Extended Use of
              Patch or Ring
           • Risk of blood clots higher with
             pregnancy than with hormonal
             methods
           • More data needed to better define
             safety of extended use regimens with
             patch and ring




                  Bleeding Patterns and
                 Hormonal Contraception
Method                   Initial                             Longer Term
COCs                     Spotting or                         Regular menses
Ring                     breakthrough                        (except with continuous-use
Patch                    bleeding (BTB)                      COCs)
Progestin-               Spotting or BTB                     Irregular
only pills                                                   8% with absence of bleeding at
                                                             6 months
DMPA                     Spotting or BTB                     40-50% with absence of bleeding
                                                             at 12 months
Implanon                 Spotting or BTB                     Lessens over time
                                                             <20% with absence of
                                                             bleeding at 24 months
Hatcher RA. In: Contraceptive Technology. 2004a and 2004b; Nelson A. In: Contraceptive Technology. 2004; Nelson
A. In: Contraceptive Technology. 2007; Raymond EG. In: Contraceptive Technology. 2007; Goldberg AB. In:
Contraceptive Technology. 2007; Funk S. Contraception. 2005; Broome M. Contraception. 1990; Canto De Cetina
TE. Contraception. 2001; Mishell DR Jr. Am J Obstet Gynecol. 1977.




                                                                                                                  4
              Managing Breakthrough
                    Bleeding
 –Check for missed or mistimed pills
 –Rule out pregnancy and infection
 –Review medications
 –Evaluate for gastrointestinal disturbances
 –Change formulations, delivery route
 –Continue COC formulation with addition of
  NSAIDs or estrogen support


Hatcher RA. In: Contraceptive Technology. 2004; Roy SN. Drug Saf. 2004; Lethaby A.
Cochrane Database Syst Rev. 2002; Speroff L. In: A Clinical Guide for Contraception.
2005; Lopez LM. Cochrane Database Syst Rev. 2008.




       Hormonal Contraception and
           Unwanted Bleeding
 –Frequent when changing or initiating method
 –Common reason for discontinuation of COCs
 –Often caused by missed or delayed pills
 –Requires education in advance to avoid
  discontinuation




Nelson A. In: Contraceptive Technology. 2007; Raymond EG. In: Contraceptive
Technology. 2007.




         BTB May Signal Chlamydia

     • Chlamydial infections are common in
       women of childbearing age — detected
       in 9.2% of female military recruits
     • BTB in women previously well regulated
       on OCs is an added marker for
       chlamydial infection
           – 29% of OC users with BTB tested positive
             for Chlamydia trachomatis vs. 11% without
             BTB but at high risk
                                  1998;339:739-
   Gaydos CA et al. N Engl J Med. 1998;339:739-744; Krettek JE et al. Obstet Gynecol.
   1993;81:728-
   1993;81:728-731.                                                       www.contraceptiononline.




                                                                                                     5
                        HORMONAL CONTRACEPTION
                        INJECTABLE CONTRACEPTION


      • Injectable contraceptives, include progestin-only
        Depo-Provera 150 mg IM every 3 months. A lower
        dose,104 mg SC Depo-Provera has been released.
        Injectable contraception offers better adherence and
        improved efficacy for teens non-adherent to
        OCP’s.
        Depo-Provera side effects, include - irregular bleeding,
        amenorrhea, and weight gain. The FDA has put a
        “black box” warning about the risk of osteoporosis with
        use of Depo-Provera. Research studies show that
        post-treatment bone density returns to level of non-
        users, similar to findings in lactation.




                        INJECTABLES
 • Can be given to breast-feeding mothers after
   lactation has been established(2-6 weeks).
 • Depo-Provera must be given in the first 5 days
   of the menstrual cycle or the first 5 days after
   delivery (non-breastfeeding) or abortion.
 • Fertility returns within 6 months for 50% of
   women and 80% within one year.




        Bone Densitometry Testing
 –Studies of bone effects of DMPA are based on
  surrogate markers
 –Testing is NOT generally indicated in women
  who use DMPA
 –No standards exist for evaluating BMD in pre-
  menopausal women




Seeman E. Bone. 2007.




                                                                   6
           Contraceptive Implant:
                 Implanon
    • Single implant rod (4 cm in
      length and 2 mm in diameter)
      made of ethylene vinyl acetate
    • Contains 68 mg of
      etonogestrel
      (3-keto-desogestrel), the
      active metabolite of
      desogestrel
    • Effective for 3 years
    • Inhibits ovulation during the
      entire treatment period

                                       www.contraceptiononline.
                                       org




             IMPLANTABLES
• Implanon is a single
  rod implanted with a
  trocar. No scalpel is
  needed for insertion.
• Duration of efficacy is
  3 years.
• Removal with a
  pointed scalpel and
  clamp easily.




                       IUD’s




                                                                  7
          Inform Your Patients about
           Emergency Contraception
  • Prevents pregnancy after sex
  • Not an abortifacent
  • Not the same as abortion pill
    (RU-486/mifepristone)
  • Methods:
    •   Plan B (behind the counter for those > 18 years)
    •   High doses of OCs
    •   Copper-T IUD
    •   Ella (newly approved)


Piaggio G. Lancet. 1999. Task Force on Postovulatory Methods. Lancet. 1998. Grimes DA. Ann Intern
Med. 2002. Croxatto HB. Contraceptin 2001. Raine T. Obstet Gynecol. 2000. Gold MA. J Pediatr
Adolesc Gynecol. 2004. Grimes DA. Ann Intern Med. 2002. Plan B Prescribing Information. Et al.




                                                                                                    8
  EMERGECNCY CONTRACEPTION

• Studies have been done with use of ECP 120
  hours (5 days) after unprotected intercourse with
  50% prevention of pregnancy.
• Consider offering prescription pro-actively to
  sexually active teens, or college students. Any
  teen using only barrier methods (condoms, etc.)
  should get a yearly prescription for ECP with
  refills. Discuss with parents and parents of male
  partners about option.




  Emergency Contraception (ECP)




  Emergency Contraception (ECP)




                                                      9
 Emergency Contraception (ECP)




      Adolescent Contraception




 Quick Start: Improving Hormonal
     Contraceptive Initiation
Start contraceptive in presence of clinician
or on the day of visit, regardless of time in
cycle




                                                10
         Issues with Generic
            Contraceptives
• Pharmacies may
  provide different
  substitutions each
  month
• May/may not ↓
  costs for those
  paying out of
  pocket




   Management of Side Effects
 Preventive/Anticipatory Guidance
• Acknowledge that side effects can be
  bothersome and uncomfortable
• Discuss breakthrough bleeding, nausea,
  weight gain at initial visit
• Set realistic expectations and counsel
  – Most side effects improve over time
  – Acne improvement is not immediate



                                          www.contraceptiononline.




How to Improve Successful Use
           of OCs
• Emphasize the many noncontraceptive
  benefits
• Cue pill-taking to daily activity
• Provide spare pack; advise to keep as
  emergency backup
• Provide written instructions
• Train office contact person to respond to
  calls

                                          www.contraceptiononline.




                                                                     11
   Improving Successful OC Use
      Anticipatory Guidance
  • Individualize counseling to patient’s
    concerns and history
  • Breakthrough bleeding
  • Amenorrhea
  • Side effects decrease over time
  • Demonstrate how to use the actual pill pack
  • Missed pills
  • “Don’t stop taking the pills before calling
    me”
                                                                 www.contraceptiononline.




      Noncontraceptive Benefits of
    Combined Hormonal Contraception
• Prevention of:                            • Treatment of:
     – Bone loss                                 – Acne
     – Fibrocystic/benign                        – Hirsutism
       breast disease                            – Perimenopausal
     – Pelvic inflammatory                         symptoms
       disease (PID)
     – Ectopic pregnancy




Adapted from Grimes DA et al, eds. Modern Contraception:
Updates from The Contraception Report. Emron, 1997.
                                                                 www.contraceptiononline.




      Noncontraceptive Benefits of
    Combined Hormonal Contraception
• Cycle-related:                            • Cancer reduction:
     –   Irregular cycles                        – Ovarian
     –   Dysmenorrhea                            – Endometrial
     –   Menorrhagia                             – Colorectal
     –   Anemia
     –   Functional ovarian
         cysts


   Adapted from Grimes DA et al, eds. Modern Contraception:
                                          Emron;1997:1-
   Updates from The Contraception Report. Emron;1997:1-100



                                                                 www.contraceptiononline.




                                                                                            12
             Patient Needs & Concerns
    “How important is it to avoid pregnancy right now?”

  “Do you want your use of contraception to be private?”

“Do you have concerns about a particular contraceptive?”

              “What side effects are you willing to accept?”

                 “What methods have you used in the past?”
                         “Do you have new health issues?”

ARHP. Clinical Proceedings. 2004.




   Satisfaction with Contraceptive
               Methods
                             l
                         ina                   n
                       ag g IUD            tio
                      V in             jec               tch
                       R            In           OC    Pa
                      87       86                                     ms
                                    80        79                    do
                                                       75        on
        % Satisfied




                                                                               r
                                                               C             he
                                                               60          Ot
                                                                       52




                4.6  4.5   4.1              4.1        3.9  3.6 3.8
               MOST SATISFIED                         LEAST SATISFIED
Revisiting Your Regular Women’s Health Care Visit. 2004.




                                                                                   13
14
                     CHOICES

                                • 1. NO SEX
• IT IS YOUR                    • 2. SAFER SEX
  CHOICE -                      • 3. STI’S AND
                                  HIV/AIDS




        THE BEDSIDE STORY
• Tonight – 3,835 Americans get Gonorrhea.
• Tonight – 10,960 Americans get
                    Chlamydia.
• Tonight – 16,438 American women get
                        pregnant.
• TONIGHT – 89 AMERICANS GET
                    HIV/AIDS.




           SEXUALLY TRANSMITTED
                INFECTIONS
• In 2000 the CDC estimated that one quarter of the 15
  million sexually transmitted infections (STI) in the US
  occurred in adolescents 15-19 years old.
• Adolescents are the highest risk for STI because of
  biological and behavioral factors.
• Serious morbidity from STI’s for females include;chronic
  pelvic pain, infertility, ectopic pregnancy, genital cancers
  and HIV/AIDS.
• Adolescent males may also be at risk for infertility,
  genital cancers and HIV/AIDS.




                                                                 1
                CHOICES
• 2006 CDC STD statistics for gonorrhea- top 5
  counties were Chicago (12,065 cases), LA,
  Detroit, Houston, and Philadelphia. Baltimore
  ranked 14 with 3,332 cases, DC ranked 40th with
  1,887 cases, and PG ranked 54th with 1,486
  cases.
• 2006 CDC STD statistics for Chlamydia- top 5
  counties LA (with 42,943 cases), Chicago,
  Philadelphia, Phoenix, King County NY.
  Baltimore ranked 23rd with 6,307 cases, and PG
  ranked 28th with 5,422 cases,




      YOUTH AND HIV/AIDS
• Adolescent females are at higher biologic
  risk for STI’s and HIV/ AIDS because of
  biologic immaturity.
• Teens have significant areas of cervical
  ectopy and more anovulatory menstrual
  cycles. The lack of progesterone produces
  less mature cervical mucus.




                                                    2
                    District of Columbia
           Reportable Sexually Transmitted Infections
                        in Adolescents

• Sexually Transmitted Infections (2008)
• Number of Cases in DC - Percent of Total
                                       Cases in DC
• HIV/AIDS                62(Ages 13-19)       0.4%
• Chlamydia               2,846(Ages13- 19) 41.3%
• Gonorrhea               940(Ages 0-19)       35.5%
• Primary & Secondary Syphilis 7(Ages 15-19)   4.8%
• Hepatitis B             81(Ages 0-19)        2.3%
• Reference: www.doh.dc.gov/hahsta




                                                        3
          SEXUALLY TRANSMITTED
               INFECTIONS
• GONORRHEA
• Gonorrhea rates decreased significantly in the early 90’s,
  but rates have fluctuated in the late 90’s. GC rates are
  still lower than in the 1980’s.
• Non-Hispanic Blacks account for 3/4’s of all reported GC
  cases among 15-19 year olds. The Black GC rate is
  2,635.3/100,000, seven times that for AI/AN
  346.3/100,000, over eleven times the rate for Hispanics
  223.7/100,000 and over 23 times the rates for Whites
  114.3/100,000 and Asian/PI 93.2/100,000/




   GONOCOCCAL CERVICITIS




                                                               4
   GONOCOCCAL PHARYNGITIS
• The Gonococcus
  (GC) bacteria can be
  spread to the tonsils
  by oral sex.
• GC can live silently in
  the throat without
  causing pain, but can
  be spread to sexual
  partners.




            SEXUALLY TRANSMITTED
                 INFECTIONS
• CHLAMYDIA
• For most STI’s the rate of infection has been decreasing among
  youth 15-19 years old. There was a 33% increase in chlamydia rates
  between 1996 and 2001.
• Adolescents 15-19 years old account for 37% of all the chlamydia
  cases in the US.
• The reported prevalence rate for 15-19 year old non-Hispanic Blacks
  is 4,957.2/100,000, twice the rate of AI/AN 2,522.4/100,000; three
  times the rate of Hispanics 1,547.1/100,000 and seven times for
  Whites 689.0/100,000 and Asian/Pacific Islanders 567.1/100,000.
  (STDS, 2001-CDC, 2002)




                                                                        5
                                                                  Clinical Manifestations


                  Chlamydial Cervicitis




Source: STD/HIV Prevention Training Center at the University of
Washington/Connie Celum and Walter Stamm




                                                                                            6
7
           SEXUALLY TRANSMITTED
                INFECTIONS
• SYPHILIS
• Syphilis is less common than GC in all ages, including
  adolescents.
• The syphilis rate decreased in 15-19 year olds from
  6.1/100,000 in 1996 to 1.9/100,000 in 2001. (STDS, 2001-CDC
  2002)

• Black adolescent females have the highest rate of
  syphilis of adolescent women 13.3/100,000, which is 6-
  13 times higher than the rate for other teen women.




                     SYPHILIS




                                                                8
          SEXUALLY TRANSMITTED
               INFECTIONS
• The only viral STI’s reported to the CDC are HIV/AIDS
  and Hepatitis B (and C). Human papilloma virus (HPV)
  and herpes simplex virus (HSV) are not reportable. Data
  on these two STI’s must be estimated from surveillance
  data STD clinics and physician offices.
• HPV has become the leading viral STI pathogen with
  one half million to one million new cases each year.
  Spread by cutaneous and mucous membrane contact,
  HPV has been linked to genital cancers (50% of all
  cervical cancers caused by HPV16/18), and increasing
  rates of rectal squamous carcinomas in males and
  females.




                                                            9
HUMAN PAPILLOMA VIRUS (HPV)




                              1
     HUMAN PAPILLOMA VIRUS (HPV)
            ORAL LESIONS




                         HPV
                              • The HPV vaccine
                                (Gardasil) offers
                                protection from HPV 16,
                                18, 6, & 11). HPV 6 & 11
                                types are responsible for
                                90% of genital warts.
                                There are 40 types of
                                HPV that can infect the
                                genital area and over 100
                                types of HPV. So the
                                vaccine will not stop all
                                HPV disease.




          SEXUALLY TRANSMITTED
               INFECTIONS
• The herpes simplex virus (HSV) has two types; HSV
  Type 2 is usually associated with genital herpes.
• Seroprevalence data of HSV Type 2 from the late 1970’s
  was 0.96% among whites 12 to 19 years of age which
  increased to 4.5% by the mid-1990’s. This is a five fold
  increase.
• Seroprevalence in the mid-1990’s among black
  adolescents was 8.7%, nearly twice the rate among
  whites. (Fleming, et.al.,1997)




                                                             2
GENITAL HERPES




 ORAL HERPES
       • By age 6 years 90% of
         children have antibodies
         to HSV 1 from cold
         sores/fever blisters. So
         no one’s mouth is a
         “virgin” for HSV.
       • HSV 1 can cause genital
         infections. HSV 2 can
         cause new oral
         infections.




                                    3
YOUTH AND HIV/AIDS
         • Globally, every 14 seconds a
           youth becomes HIV infected.
         • 6,000 youth each day become
           infected. The majority are
           young women.
         • In the U.S. 2 youths every 30
           minutes become HIV infected.
           There are 20,000 new
           infections each year to youth
           under the age 25 years.




                                           4
             TODAY’S ABC's

• A = ABSTINENCE
• B = BEHAVIOR/
  BE FAITHFUL. Don’t
  use drugs or alcohol.
  They change your
  CHOICES.
• C = COMMUNICATE/
  CHOICE/CONDOMS.




                   CHOICES




                             5
       WEB SITES FOR YOUTH AND
               PARENTS

• WWW.IWANNAKNOW.ORG THE AMERICAN SOCIAL HEALTH
  ASSOCIATION SITE FOR TEENS
• WWW.NIAID.NIH.GOV/FACTSHEETS/STDINDO.HTM -
  NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS
  DISEASES FACT SHEET ON STD’S
• WWW.HEALTHYDEVIL.STUAFF.DUKE.EDU/INFO/HEALTHINF
  O.HTML - DUKE UNIVERSITY WEB SITE FOR COLLEGE
  STUDENTS
• WWW.CDC.GOV/HEALTH/WOMENSMENU.HTM - CDC’S
  WOMEN’S HEALTH HOME PAGE ON STD’S
• WWW.TEENWIRE.COM PPFA TEEN WEBSITE




Engaging Adolescents in Family Planning in
   DC – Challenges and Opportunities
• Part IV
• Influences of the Media on Adolescents
• New Technology to Aid Adherence




          HIV PREVENTION
 Can the internet, peer
 educators, and the
 media help in STI and
 HIV prevention?
 Students can get
 involved in school and
 community
 awareness programs.
 Be aware of media
 influences.




                                                    6
                         • Can the media
                           really tell the truth
                           about what can
                           happen on the OC,
                           MTV Spring Break,
                           Grey’s Anatomy
                           and Girls Gone
                           Wild videos after
                           the cameras stop?
                         • Be media smart!




    Music, Videos and Games
• Hip Hop Music “You the best – Best I ever
  had”. “Let me take you to my Sex Room.”
• Grand Theft Auto – pick up a “sex worker”
  have intercourse in car, physically assault
  female and push her out of car without
  paying fee.




         Tweens and Teens




• STRESSORS – Seeking perfection for
  parents and self
• BEST – Body, Clothes, Friends, Schools,
  Phones, Computers, Grades, Cars, Etc.




                                                   7
Engaging Adolescents in Family Planning in
   DC – Challenges and Opportunities
• Use of new social
  networking to reach
  adolescents




Engaging Adolescents in Family Planning in
   DC – Challenges and Opportunities
• Use of cell phones to
  set calendar for
  removal of Nuva Ring
  or weekly changes of
  patch.
• Use daily alarm to
  remind teen to take
  OCP dose.




        Engaging Adolescents in Contraception
                      CASES

• CASE 1
1. 16 year old female G2P0Ab2 just had a
   surgical termination of pregnancy 3 weeks ago
   at a local women’s clinic and is still bleeding.
   She wants to know when to start the birth
   control pill prescription she was given at the
   clinic. What do you tell her? What other
   information do you need to know to make your
   treatment plan?




                                                      8
              Engaging Adolescents in Contraception
                            CASES

• CASE 2
1. Two girls are waiting for you in the examination
   room. The 15 year old friend explains that the
   14 year old patient is so afraid of being
   examined that she asked her to stay with her
   during her family planning visit. What are some
   of the options that could be offered to the 14
   year old to make this a positive visit?




              Engaging Adolescents in Contraception
                            CASES

• CASE 3
1. A 15 year old female is in the exam room
   with her 20 year old boyfriend. She is
   here for a pregnancy test and birth
   control options. How do you proceed?




              Engaging Adolescents in Contraception
                            CASES

•   CASE 4
•   - A fifteen year old teen comes to your clinic without an appointment for a
    pregnancy test. Describe the flow of her visit from her eyes.
•   How does she find the Family Planning Clinic in your health center?
•   Is the registration staff – Teen Friendly if she does not have her insurance
    card?
•   How do you explain your walk-in flow versus your appointment schedule?
•   How teen friendly is the laboratory and/or nursing staff for this anxious
    teen?
•   Her first and last sexual activity was 4 days ago without a condom – how do
    you explain the meaning of today’s pregnancy test?
•   Is this a teachable moment about ECP or STI’s?




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