Adolescent Contraception by r7Be86

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									Adolescent Contraception

      Marcia J. Nackenson, M.D.
    Section of Adolescent Medicine
       Department of Pediatrics
      New York Medical College
    Adolescent Contraception

• The Need
• Barriers to Adolescent
  Contraception
• Contraceptive Methods
• How to Provide Service
    Adolescent Sexual Activity
       Ages 15 - 19 years
• Females:   50% (1997)
             55% (1990)

• Males:     55% (1995)
             60% (1988)
     Adolescent Sexual Activity
      By School Grade (1996)
• Grade 9:    37%

• Grade 12:   66%
     Adolescent Sexual Activity
       By Race and Gender
• Males earlier than females

• Blacks earlier than Hispanics earlier
  than Whites

• Differences are lessening
Adolescent Contraceptive Behavior

• 25% use no contraception at 1st
     intercourse.
• 1 year intercourse before medical
     advice.
• 50% adol preg in 1st 6 months
     of sexual activity.
        Adolescent Pregnancy

•   1 million pregnancies/year
•   85% unintended
•   50% live births
•   35% elective abortions
•   15% spontaneous abortions
               But...
• Pregnancy Rates Decline 12% (1995)
     103/1000 ages 15 - 19 yrs
• Abortion Rates Decline
• Birth Rates Decline 15%
     57/1000
    Recent Trends in Adolescent Sexuality

•   Sexual Activity Down
•   Condom Use Up
•   Pill Use Down
•   Pregnancy Rates Down
•   Abortion Rates Down
•   Birth Rates Down
•   But…Condom & Pills 8%
Barriers to Adolescent Contraception

• Psychological Factors
• Availability
• Demographic Factors
          Psychological Factors

•   Immature cognitive functioning
•   Dependency, passivity
•   Difficulty in handling sexuality
•   Risk-taking behavior
•   Desire for pregnancy
              Availability

•   Cost
•   Geographics
•   Clinic hours
•   Confidentiality issues
        Demographic Factors

•   Age
•   Race
•   Poverty
•   Educational Plans
•   Cultural Patterns
            Legal Issues
I. Consent
    A. Emancipated Minor
    B. Mature Minor
    C. Reproductive Matters
II. Confidentiality
III. Payment
IV. Abortion
         Issues in Selecting a
        Contraceptive Method
•   Frequency of intercourse
•   Tolerance of route of delivery
•   Tolerance of side effects
•   Nature of relationship
       ie, monogamous, long-standing
     Recommended Methods for
          Adolescents
            CONDOMS PLUS:
1.   Oral Contraceptives
2.   Injectable Progestin (Depo-Provera)
3.   Subdermal Implants (Norplant)
4.   Spermicide
Limited Methods for Adolescents

1. Diaphragm

2. Female condom

3. Cervical cap
Methods Not Recommended for
        Adolescents

 1. IUD

 2. Tubal ligation/vasectomy
    Contraceptive Effectiveness
                Most Effective
      Method               Pregnancy Rate %
Abstinence                        0
Implants                          0.09
Injectables                       0.3
Oral Contraceptives               0.1
Vaginal Ring                      0.1
Patch                             1
IUD                               1-2
   Contraceptive Effectiveness
              Less Effective
      Method               Pregnancy Rate %
Condom plus foam                 2 - 10
Condom alone                     2 - 20
Female condom                    5 - 20
Diaphragm                        2 - 18
Withdrawal                       20
Rhythm                           20 - 30
No Method                        90
  History of Oral Contraceptives
2000 yrs ago - Arsenic, mercury, & strychnine
1920’s - Progesterone & estrogen isolated.
1935 - Progesterone synthesized.
1940’s - 50’s - Syntex: steroid synthesis
1950’s - Margaret Sanger - clinical trials
1960 - Enovid approved by FDA
Mechanisms of Oral Contraceptives

• Combination OCP: estrogen, progestin
• Inhibition of ovulation
• Thickened cervical mucous
• Endometrium less favorable for
     implantation
• Decreased tubal motility
        Estrogen in OCP’s
• Ethinyl estradiol
     20m
     30-35m - Most “low dose” OCP’s
     50m
• Mestranol - converted to ethinyl
  estradiol
     50m
         Progestins in OCP’s

• Varying progestational & androgenic
  potency

• 6 different progestins available in U.S.

• Newer progestins less androgenic?
   Newer Progestins (‘92-’93)
• Norgestimate - OrthoCyclen, Tricyclen
• Desogestrel - OrthoCept, Desogen
    ‘95 UK warning VTE
    FDA, ACOG - no changes needed
• Gestodene - Not available in US
    Newer Progestins: Advantages
•   Decreased androgenicity
•   Increased SHBG
•   Decreased free testosterone
•   Improved LDL:HDL ratio
•   Best for hirsutism, acne
   Triphasics vs. Monophasics
• Less total hormone per month

• No clear clinical advantage
     Minor Side Effects of OCP’s
•   Breakthrough bleeding
•   Nausea
•   Breast soreness
•   Headache
•   Weight gain - NOT!
            Major Side Effects
                Cardiovascular
•   Related to high estrogen content, early pills
•   Venous thromboemboli, MI, CVA
•   Hypertension 1-5%, reversible with DC
•   Esp. >35 yrs & smoker
•   Post-op thromboemboli:
       DC pills 4 wks pre-op
          Major Side Effects
                  Cancer
• Dec. risk of endometrial & ovarian ca.
• Breast & cervical ca. - no definitive inc.
     JAMA ‘01: +FH breast ca. & OCP’s 
           inc. risk of breast ca.
           BUT: Based on early hi dose pills
• Hepatocellular adenoma - benign,
     3-4/100,000
          Other Side Effects
• Lipid level changes - screen if hi risk
• Carbohydrate metabolism - follow diabetics
• Post-pill amenorrhea or infertility -
     disproven
• Congenital anomalies -
     disproven
     Beneficial Effects of OCP’s
•   Dec. acne
•   Dec. dysmenorrhea
•   Dec. ovarian cysts
•   Dec. fibrocystic disease of the breast
•   Dec. PID
•   Dec. endometrial and ovarian ca.
      Absolute Contraindications
•   Thromboembolic disorders
•   Coronary artery disease
•   Estrogen-dependent neoplasia
•   Breast Cancer
•   Pregnancy
•   Active liver disease
•   Undiagnosed abnormal vaginal bleeding
          Oral Contraceptives
             Summary
•   Safe and effective for healthy adol.
•   Use low estrogen pill (20-35 mg)
•   28 day pack and Sunday start method
•   Judicious advice about side effects
•   Frequent follow-ups.
     Progestin Only Methods

• The Minipill - daily pill

• Depo-Provera - injectable

• Norplant - subdermal implant
     Progestin Only Methods
          Mechanisms
• Blocks LH surge; inhibits ovulation

• Thickens cervical mucous

• Thin, atrophic endometrium
          Progestin Only Pill
• Taken every day - no placebo pills
• Slightly less effective than combination pill;
      less forgiving of missed pill
• Indications - estrogen contraindication,
      lactation
• Disadvantages - unpredictable menses
            Depo-Provera
        (Injectable Progestin)
• FDA approved 1992
• Medroxyprogesterone acetate 150 mg. IM
• 1st injection within 1st 5 days of menses;
      neg Urine preg test
• Repeat q12 weeks ( up to 13.5 weeks)
• Cost: $50/dose
           Depo-Provera
          Menstrual Changes
• Irregular menses
• Amenorrhea - 60% by 1 year
• Treatment of irregular bleeding:
      1. Counseling
      2. OCP
      3. Ibuprofen
      4. Estrogen
             Depo-Provera
            Other Side Effects
•   Weight gain - 2-5 lbs./yr.
•   Delay to fertility - 9 mos.
•   Depression
•   Dec. libido
•   Breast tenderness
•   Decreased bone density - under study
            NEW: Lunelle
• Combination injectable:
     Estrogen and progestin
• Given q28 days
• Advantage - regular menses
• Disadvantage - monthly visit
         Subdermal Implants
• Norplant
     -FDA 1990, 6 levonorgestrel rods
     -Effective 5 years
     -Insertion and removal procedures
     -Bad publicity
• Implanon
     -Single rod, good for 3 years
          Norplant Side Effects
•   Irregular menses - greatest in 1st yr.
•   Weight gain - less than Depo
•   Headaches
•   Acne
•   Insertion site problems
•   Depression
•   Hair changes
                Condoms
• Must always be recommended to prevent
     STD’s
• Latex or polyurethane only
     Reservoir-tipped, spermicide
• Effectiveness inc. with contraceptive foam
• Advantages: Safe, cheap, available
• Disadvantages: Coital dependent, male
     resistance
          Condom Use
         12-19 yr males
• 55% at first intercourse -
         Inc. from 20% in 1979
• 58% at last intercourse -
         Inc. from 21% in 1979
• BUT - most teens use condoms
  sometimes
            Spermicides
• Nonoxynol-9
• Foam preferred
• When used with condoms, greatly inc.
  effectiveness.
            Barrier Methods
•   Diaphragm
•   Sponge
•   Cervical cap
•   Lea’s shield
          The Female Condom
                (1994)
•   Polyurethane
•   $3 each
•   5 - 25% failure
•   Female controlled
•   Cumbersome
     Emergency Contraception
• Aka post-coital contraception,
     “morning after” pill
• Indications:
     Rape
     Contraceptive failure (condom broke)
     Unprotected intercourse
• 1997 FDA approved
       Prescribing Emergency
           Contraception
• Plan B preferred - progestin only
• History, LMP,Urine preg test
• 2 tabs 50m pill ASAP (within 72 hrs),
      repeat in 12 hrs.
• Nausea (50%) and vomiting (20%),
      anti-emetics
• Mechanism - prevents implantation
          Contraceptive Patch
• Ortho-Evra
• Available later 2002
• Estrogen & progestin
• Apply new patch
  weekly x 3
• 4th week - withdrawal
  bleed
                 Vaginal Ring
•   Nuvaring
•   Estrogen & progestin
•   Inserted for 3 weeks
•   Ring-free week -
    withdrawal bleed
           Ideal Contraceptive
•   100% effective
•   Completely reversible
•   No side effects
•   Inexpensive
•   Easy to use
•   Accesible
            Conclusions
• Encourage “adult attitudes” towards
  sexualtity.
• Any method is better than none.
• Compliance.
• Oral contraceptives vs. Depo-Provera
• Condoms must be used also.

								
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