Adolescent Contraception_ Pills_ Shots_ Patches and Rings by hcj


									Contraceptive Update: Pills, Shots, Patches and Rings
John Kulig, MD, MPH Laurie Hornberger MD, MPH Job Corps Regional Medical Consultants

Sexual risk behavior  ever had sexual intercourse  grade 9  grade 10  grade 11  grade 12 

male 41% 42% 54% 61%

female 29% 39% 50% 60% female 6% 20%

>4 lifetime sexual partners male  grade 9 14%  grade 12 24% Source: CDC 2001 Youth Risk Behavior Survey

Sexual risk behavior  initiation of sexual intercourse before age 13 o male students 9% o female students 4% o white students 5% o black students 16% o Hispanic students 8% o all students 7% Source: CDC 2001 Youth Risk Behavior Survey

Sexual risk behavior  condom use during last sexual intercourse  white students 57%  black students 67%  Hispanic students 54%  alcohol or drug use at last sexual intercourse  male students 31%  female students 21%  white students 28%  black students 18%  Hispanic students 24% Source: CDC 2001 Youth Risk Behavior Survey

Adolescent Pregnancy “Have been pregnant or gotten someone pregnant.”  male 4%  female 5%  white 3%  black 11%  Hispanic 6% Source: CDC 2001 Youth Risk Behavior Survey OCs: New progestins  1st generation: norethindrone  2nd generation: norgestrel levonorgestrel  3rd generation: desogestrel norgestimate  new: drospirenone Noncontraceptive Benefits of OCs  decrease menstrual flow (lighter, shorter periods)  decrease menstrual cramps (no ovulation)  improve anemia (lighter, shorter periods)  improve acne (estrogen effect)  protect against ovarian and endometrial cancer  decrease benign breast disease  decrease ovarian cyst formation  prevent ectopic pregnancy  protect against some causes of PID  protect against osteoporosis Oral Contraceptives and Risk of Breast Cancer  study of 4575 women with breast cancer and 4682 controls - age 35 to 64 years at interview  relative risk 1.0 [0.8-1.3] for current OC users  relative risk 0.9 [0.8-1.0] for previous OC users  similar results in white and black women  relative risk did not increase with longer use or with higher estrogen dose  no increased risk associated with initiation of OC use in adolescence NEJM 2002;346:2025-2032


Drug Interactions with OCs  most anticonvulsants (except valproate)  rifampin  griseofulvin  St. John’s Wort Seasonale®  extended regimen combined oral contraceptive pills with ethinyl estradiol and levonorgestrel  91 day cycles - 84 days on - 7 days off  4 menstrual cycles per year - one each season  clinical trials underway
 FDA approval anticipated in 2004

What is the best method of emergency contraception (EC) for use by adolescents? Options:  Yuzpe method (1982)  combination oral contraceptive pills  progestin- only pills  dedicated emergency contraceptive pill products: Preven® and Plan B®  mifepristone (RU486)  insertion of intrauterine device How does EC work?  mechanism of action of levonorgestrel + ethinyl estradiol may depend upon timing during the menstrual cycle  principal mechanism is prevention of ovulation  may thicken cervical mucus  may interfere with transport of sperm, ova or zygote  may inhibit implantation  onset of pregnancy is medically defined as implantation of a fertilized ovum in the wall of the uterus (ACOG)  levonorgestrel + ethinyl estradiol is not effective once implantation occurs  levonorgestrel + ethinyl estradiol does not induce abortion How effective is EC? Pregnancy risk:  33% per cycle if sexually active qod  15% per cycle if sexually active once a week  condom failure reported by 4%-7% of couples during a three-month interval  EC use could prevent 2 million unintended births and 1 million induced abortions each year in the US


How effective is EC? Yutzpe regimen data:  EC efficacy 74% by meta analysis of ten studies  0.5%-1.5% observed vs 4.7%-5.5% expected pregnancy rate  no absolute contraindications except pregnancy  no demonstrable teratogenicity How effective is EC? Importance of timing: combined pill data  77% effective if taken within 24 hours of unprotected intercourse  efficacy declines to 36% if treatment is delayed 25-48 hours  efficacy declines to 31% if treatment is delayed beyond 48 hours How effective is EC? Importance of timing: Plan B® data  95% effective if taken within 24 hours of unprotected intercourse – reduces crude pregnancy rate from 8% to 0.4%  efficacy declines to 85% if treatment is delayed 25-48 hours  efficacy declines to 58%-61% if treatment is delayed beyond 48 hours Are there medical contraindications to EC use?  only absolute contraindication is pregnancy (because EC will not work)  no evidence of harm to a developing fetus  no concern about estrogen-related contraindications with progestin-only EC  potential drug interactions with certain anticonvulsants, rifampin and griseofulvin may reduce efficacy Is pregnancy testing necessary before using EC?  EC is ineffective if implantation has occurred  no evidence of harm to developing fetus if EC is taken inadvertently  routine pregnancy testing is not recommended  consider pregnancy testing prior to EC use if menses delayed  consider pregnancy testing after EC use if menses does not occur within 3 weeks Should an anti-emetic be prescribed with EC?  Nausea: Yuzpe regimen 50.5% ® Plan B 23.1%  Vomiting: Yuzpe regimen 18.8% Plan B® 5.6% Data from a multi-center randomized clinical trial of 1,998 women.


Should EC be prescribed in advance of need?  women receiving EC in advance are two to three times more likely to use them, but not to use them repeatedly (US/Scotland)  80% of women who received EC in advance began treatment within 24 hours of intercourse vs 40% of women who needed to fill an EC prescription  no more likely to engage in sexual activity  no more likely to use their regular contraceptive less consistently  fewer than one third of female adolescents have heard of EC (1998 data)  17% of young women report no use of contraception at most recent intercourse  20% of women report forced sexual intercourse and 72% were under age 20 at the time of the experience (NCHS)  lack of clinician availability on weekends may disproportionately affect adolescents Should EC be made available without a clinician’s prescription?  Citizen’s Petition filed with the FDA in February 2001 – 70 organizations  currently available over-the-counter in 13 industrialized nations  currently available from pharmacists in the states of California and Washington Ref: NEJM 2002;347:846-849 Should EC be made available without a clinician’s prescription? Arguments in favor of OTC availability:  improved public health  delays in treatment lead to more unintended pregnancies  easier access to EC 24 hours a day  safe for self-medication  same dose for all women  same medications safely used for contraception for decades  serious adverse effects do not occur, even with inappropriate use Arguments opposed to OTC availability:  no clinician contact to discuss potential side effects  missed opportunity for contraceptive counseling  may make refusal of sexual intercourse more difficult  EC is a euphemism for induced early abortion  EC might unintentionally be used in pregnancy  EC use might undermine use of non-emergency contraception, including barrier methods Does knowledge of EC alter adolescent sexual behavior?  study of 916 male and 852 female students age 14-15 in 12 schools in UK  single lesson on emergency contraception  improved knowledge persisted six months later in comparison with controls  no difference in sexual activity, intent to use EC or use of EC Ref: BMJ 2002:324:1179-1183


Emergency Contraception Resources  EC hotline 1.888.NOT.2.LATE  EC website  Clinician’s guide to providing EC -  Consortium for Emergency Contraception - Depo Provera []  depot medroxyprogesterone acetate150 mg IM once every 12 weeks  irregular bleeding => amenorrhea within 2 years (70%)  concerns: weight gain osteoporosis risk Combined injectable contraceptives Lunelle []  25 mg depot-medroxyprogesterone acetate and 5 mg estradiol cypionate injected (IM) once a month  0.5 mL IM q 30 days + 3 days  FDA approved in October 2000  prefilled syringes withdrawn from the market in October 2002 - potency concerns Lunelle : Contraceptive Benefits  highly effective (0.1-0.4 pregnancies per 100 women during the first year of use)  effective immediately  does not interfere with intercourse  few side effects  can be provided by trained nonmedical staff  no supplies needed by the patient Lunelle: When to Start  anytime you can be reasonably sure the patient is not pregnant  days 1 to 7 of the menstrual cycle  postpartum: o after 6 months if breastfeeding o after 3 - 6 weeks if not breastfeeding  postabortion (immediately or within 7 days) Ortho Evra []  seven day contraceptive patch  1 3/4 inch three layer adhesive patch  contains both estrogen and progestin  applied to the buttocks, lower abdomen or upper body  newly applied weekly for three weeks, then one week off for menses  less effective in women over 198 pounds  approved by the FDA in November 2001


Ortho Evra  Side effects leading to discontinuation: o nausea (2%) o moodiness (1.5%) o headache (1.1%) o breast discomfort (1%) o irritation at application site (1.9%)  Inadvertent detachment uncommon (1.9%), even with exercise, humid climates, saunas, hot tubs NuvaRing []  contraceptive vaginal ring - 2 inch diameter  worn for 21 days => removed for 7 days to allow menses => replaced with new ring  releases 120 mcg of etonogestrel and 15 mcg of ethinyl estradiol daily  one size only - does not require fitting  cannot be inserted incorrectly  no increase in vaginal infections/discharge  3 hour window after inadvertent removal Implanon  progestin-only contraceptive implant  single flexible 4 cm rod inserted under the skin of the upper arm  contains 68 mg etonogestrel - releases  40 mcg daily - 3 year efficacy  no pregnancies in 73,000 monthly cycles  irregular menstrual bleeding common  clinician visit for insertion and removal Mirena []  levonorgestrel-releasing intrauterine system - 20 mcg daily - 5 year efficacy  highest risk of PID within 20 days of insertion  irregular menstrual bleeding common in first 3-6 months  clinician visit for insertion and removal Condom Use and Hormonal Contraception  Consistent condom use o OCs 21% o DMPA 18% o Norplant 9%  Condom use at last intercourse o hormonal contraception 52% o no hormonal contraception 69%


Keeping current on reproductive health issues  The Contraception Report A quarterly update on what’s new in contraception. Profiles new products and updates information on existing ones. The report is now available online at or you can get a FREE subscription at

Sexually Transmitted Disease Guidelines 2002 In May 2002, the Centers for Disease Control and Prevention (CDC) presented their latest edition of guidelines for the evaluation and management of sexually transmitted diseases. The highlights are: Chlamydia  All sexually active teens and young adults should be screened annually, regardless of presence or absence of symptoms.  All women with chlamydial infections should be rescreened 3-4 months after treatment is completed. Gonorrhea  Resistance to fluorquinolone antibiotics (ciprofloxacin, ofloxacin, levofloxacin) has been found on the West Coast. It is unknown how extensive this resistance will become or how quickly it may spread.  Cefixime and ceftriaxone are now considered the first line drugs to treat GC on the West Coast, but cefixime is no longer manufactured in the US. Expanded risk assessment for gay and bisexual men  Annual STD screening for chlamydia (anal, urethral), gonorrhea (anal, urethral, pharyngeal), HIV and syphilis.  Routine vaccination for hepatitis A and B. Use of Nonoxynol-9  Frequent use of the spermicide nonoxynol-9 has been shown to cause genital (vaginal, rectal) lesions that can increase the risk of HIV transmission.  Condoms lubricated with nonoxynol-9 are no longer recommended. (Previously purchased condoms with N-9 can however be used up until their expiration date.) To get a copy of the 2002 CDC STD Guidelines, call 1-888-232-3228 or visit =>


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