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HORMONAL CONTRACEPTION FOR ADOLE

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HORMONAL CONTRACEPTION FOR ADOLE Powered By Docstoc
					 Adolescents and Emergency
     Contraception (EC):
    Debunking the Myths

            Melanie A. Gold, D.O.
     Associate Professor of Pediatrics
University of Pittsburgh School of Medicine
Objectives for EC Presentation
 Understand adolescents knowledge, attitudes
  and perceived barriers to using EC
 Describe   adolescents use of EC
  – Advance Provision Studies
  – Pharmacy Access Studies
         and address potential concerns about
 Identify
  adolescents and EC
 Describe   resources and supporting references
Concerns about Teens and EC
If EC was more easily available………..
 Adolescents   might have more unprotected sex
 Adolescents   might use EC repeatedly and
 “abuse EC”
 Adolescentsmight stop using condoms and other
 ongoing, more effective methods of contraception
 Adolescentsmight get more STIs and have more
 unintended pregnancies
        That was then, this is now…
          Changes in Knowledge,
         Attitudes, and Barriers to
       Emergency Contraception Use
1996
                Allison M. Aiken, M.D.
                Melanie A. Gold, D.O.
        2002   Andrew M. Parker, Ph.D.
Awareness of EC Among U.S. Adolescents
                    Heard of Used   Would    Correct
                      EC      EC    Use EC   Timing

 Cohall
 N=197 inner city
 teens
                     25%      -       87%       -
 Delbanco            28%      -       67%     9%
 N=1510 teens

 Gold                44%      3%      67%     20%
 N=133 inner city
 adolescent women
Study Design
 Females,  13-21 years, recruited from hospital-based
  adolescent clinic in Pittsburgh in 1996 (n=95) and
  2002 (n=100)
 Could be sexually active, virginal, or abstinent
 Pre-intervention interview
  – Sexual and contraceptive history
  – Knowledge and experiences with EC
 Educational   intervention
 Post-intervention   interview
  – EC knowledge re-test
  – Attitudes and perceived barriers
Demographics by Year
                            1996       2002        p-value
                            (n=95)     (n=100)
 Mean Age + SD in yrs       16.1±1.6   16.9 +2.0   0.004

 Ethnicity (%)
    Black                   64%        77%
    White                   27%        15%         0.106
    Other                   9%          8%

 Ever sexually active (%)   79%        80%         0.856
 Mean Coitarche + SD        14.0+1.9   14.6+1.6    0.030
 Ever pregnant (%)          17 %       14 %        0.793
                                           1996

Heard of and Ever Used EC
                                                     2002



                1996 (N=95) 2002 (N=100)   p-value
                n (%)       n (%)


 Heard of EC    48 (50)    74 (74)          .001

 Ever used EC    3 (3)     13 (13)          .012
                                                                             1996

Pre-Intervention Knowledge of EC
                                                                                         2002
                                1996 (N=48) 2002 (N=74) p-value
                                n (%)       n (%)

 Know where to get               39 (81)          71 (96)           .008
 Know time limits               10 (21)           39 (53)           <.001

 EC is not abortion              33 (69)          43 (58)           .236

 Parental permission 28 (58)                      52 (70)           .175
 -------------------------------------------------------------------------------------
 Side effects < 24 hrs               ---          55 (74)             ---

 Not hurt future fertility ---                    68 (92)             ---
Post-Intervention Knowledge of EC
                                1996 (N=93)       2002 (N=100) p-value
                                n (%)             n (%)

 Know where to get 93 (100)                       97 (97)           .092

 Know time limits               84 (90)           94 (94)           .167

 EC is not abortion             76 (83)           96 (96)           .002

 Parental permission 56 (62)                      97 (97)           <.001
 -----------------------------------------------------------------------------------
 Side effects < 24 hrs               ---          92 (92)             ---

 Not hurt future fertility           ---          97 (97)             ---
Post-Intervention Attitudes Toward Using EC

                            1996 (N=95)         2002 (N=100)       p-value
                              n (%)               n (%)

  Like EC                      68 (74%)            98 (98%)         <.001

  --------------------------------------------------------------------------

  OTC Availability             ---                 46 (46%)           ---

  Advance EC                   ---                 84 (84%)           ---
                                                  1996


Perceived Barriers to EC Use
                                                         2002

                          1996 (N=92) 2002 (N=100) p-value
                           n (%)       n (%)

 Make me very sick        64 (70)     31 (31)    <.001

 Decrease fertility       61 (66)     20 (20)    <.001

 Cost of medication       42 (46)     37 (37)     .224

 Not know where to call   40 (44)     28 (28)     .025

 Afraid parents know       36 (39)    34 (34)     .461

 Against beliefs          23 (25)     23 (23)     .746
Conclusions
Between 2002 and 1996 ..…

 EC   knowledge and use increased
 Positive   attitudes towards using EC increased
 Cost   became the #1 perceived barrier
Does EC Promote Risk-Taking?
 Shouldadolescents be given prescriptions for
 EC in advance of need?
 Should  adolescents be allowed access to EC
 directly from a pharmacy?


 What impact will having easier access to EC
 have on adolescents’ sexual and
 contraceptive behaviors?
Impact of Providing Advance EC
8   studies found that providing EC in advance
  resulted in women being 2 to 4 times more
  likely to use EC when needed
 No  study found higher rates of unprotected
  intercourse among the advance groups
 Three    studied adolescents   (Raine, 2000; Gold, 2004,
  Raine, 2005)

 One  study found a decrease in use of more
  effective contraceptive methods (Raine, 2000)
Advance Provision EC: San Francisco
 Publicly   funded family planning clinic, 1998
 Women  16-24 years of age, mostly Hispanic
 and black
 Randomized:     Advance EC or education-only
 Assessed contraceptive practices at
 enrollment and at 4-month follow-up
 Advance group 3x more EC use than
 education-only group (20% vs 7%, P = .006)
                                Raine, Obstet Gynecol 2000
Advance Provision EC: San Francisco
 No difference by group in frequency of
  unprotected sex or consistency of condom
  use at 4-month follow-up
 More  in advance-EC group switched to
  less effective contraceptive method at 4-
  month follow-up compared with education-
  only group (28% vs 17%, P = .05)
 Limitation:   only 1 follow-up (at 4 months)
                                         Raine, 2000
Advance Provision EC: Pittsburgh
 Urban   family planning clinic, 1997-2002
 Female   adolescents 15-20 years old (n=301)
 Randomized   to advance EC (1 course) or
 information-only group (followed for 6 months)
 Advance  EC group used EC nearly 2x more
 than information-only group (15% vs. 8%)
 Nodifference by group in rates of
 unprotected sex at 1 or 6 months
                    Gold, Wolford, Smith & Parker, JPAG 2004
 Advance Provision EC: Pittsburgh
 Advance EC group reported higher condom
 use as compared to information-only group
 (77% vs. 62%, p=0.02 )
 Advance  EC group reported no significant
 difference in hormonal contraception use
 Advance  EC group started EC sooner after
 unprotected sex (mean 11.4 hrs) compared to
 the information-only group (mean 21.8 hrs)
                   Gold, Wolford, Smith & Parker, JPAG 2004
Advance Provision EC: San Francisco
 Randomized  controlled trial, July 2001 to June
 2003, 4 family planning clinics
  – n=2117, 15-24 yrs
 Three   groups
  – Advance provision group (3 packs of Lng EC)
  – Pharmacy Access Group
  – Clinic Access group (control)
 Main outcomes: EC use, pregnancies and STIs
 at 6 months, changes in contraceptive and
 condoms use, sexual behavior           Raine 2005
Advance Provision EC: San Francisco
 Advance     provision group vs. clinic group
  – More likely to use EC (37% vs. 21%, p<.001)
  – Similar frequency unprotected sex (40% vs. 41%, p=.46)
 Pharmacy      Access group vs. Clinic group
  – No more likely to use EC (24% vs. 21%, p=.25)
 8%   got pregnant and 12% acquired an STI over 6 months
  – No difference in pregnancies or related behaviors by group
       » no change in contraceptive method
  – No difference in STI acquisition or related behaviors by group
       » unprotected intercourse
       » number of sexual partners
                                                       Raine 2005
Provision of EC by Pharmacists
  Pharmacist-Prescriber   voluntary collaborative
  agreements
  Pharmacist prescribes directly to patient
  using clearly defined written protocols
  Currently allowed in 35 states (degree of
  authority varies greatly by state)
  Allows easier access to certain prescription
  drugs, such as influenza vaccinations
States Pharmacists Dispensing EC
 States with Collaborative Practice Agreements

 Washington   State
 California
 Alaska
 Hawaii
 Massachusetts
 New   Hampshire
States Pharmacists Dispensing EC
  States with Independent Prescribing Authority

 California
 Maine
 New   Mexico
Adolescents’ Use of Emergency
Contraceptive Services in Washington
State
                  Gina Sucato, MD, MPH1
                 Jacqueline Gardner, PhD2
               Thomas Koepsell, MD, MPH3

            University of Pittsburgh School of Medicine1
University of Washington, School of Pharmacy2 and Epidemiology3
Access to EC
 Demonstration   project
  – Western Washington State
  – Program for Appropriate Technology in Health
  – Packard Foundation

           delegate authority to prescribe ECP to
 Physicians
 pharmacists

 Women  got EC at a pharmacy without first
 contacting a physician
 Objective
To increase knowledge about adolescents who obtain
 EC directly from pharmacists

 Reasons    for seeking care in the pharmacy

 Satisfaction   receiving care from the pharmacist

 Need    for additional medical evaluation

 Risk   for not receiving additional medical care
Design
 Cross-sectional   survey
  – 20 item
  – self-administered
  – multiple choice

 Participants
  – All women who obtained EC in a participating
    pharmacy
  – Responses from adolescents < 21 years old were
    analyzed
Survey Questions
1) Why are you coming to the pharmacist for emergency
     contraception?

3) Do you intend to see a doctor some time in the next
     month to discuss birth control or related issues?

17) How clear was the information the pharmacist provided
     about emergency contraception?

18) How satisfied are you with the amount of privacy you
     had?

19) How satisfied are you with the amount of time you had
     to ask the pharmacist questions?
Sample
 49   pharmacies averaged >3 EC / month

 Stratified   by volume of EC prescriptions
  – “high volume” stores > 10 / month


 15   randomly selected
  – 13/29 high volume pharmacies
  – 2/20 low volume pharmacies
  Analysis
 838   EC prescriptions during 4 month study period
  – < 630 surveys distributed
  – 305 surveys completed
  – 36% response rate
  – 126 adolescents 15-21 years old

 Surveys   weighted
  – pharmacy’s probability of selection
  – pharmacy’s response rate

 Results   for an estimated 1109 adolescent EC users
        Characteristics of Adolescent
               Respondents

Characteristic                   Adolescent ECP users*
                                    [estimated n=1109]
                                Percent (95% confidence interval)
White race                              71 (56 - 87)

Had health insurance                    81 (73 – 90)

Intended to pay cash                    98 (94 – 100)

Used EC >1 prior times                  28 (13 – 43)

Used EC >3 prior times                    4 (1 – 11)

*Based on sampling design and weights
                  Reasons for Using the Pharmacy
                  50


                  40    44%
                                   38%
% with response




                  30
                                              32%

                  20


                  10


                   0
                        Easy    Only place   Privacy
“If you couldn’t get emergency contraception from
       the pharmacist, what would you do?”


                                   See Doctor

        20%
                                   See if get
                 58%               pregnant
       22%
                                   Don't know
“If you couldn’t get emergency contraception from
      the pharmacist, what would you do?”*

                                                     See Doctor

             16%
                                                     See if get
       13%                                           pregnant
                       71%
                                                     Don't know



* Among adolescents with a source for routine medical
care and using a prescription method of birth control.
Satisfaction with Pharmacy Visit
                                100
                                      99%                 95%
                                                 94%             94%
% satisfied or very satisfied




                                80

                                60

                                40

                                20

                                 0
                                      Clarity   Privacy   Time   Friend
                      Additional Medical Needs
                100

                80
                                                      81%
% of EC users




                60
                          61%
                40
                                       41%
                20

                 0
                        Need birth   Need STD       Need birth
                         control     evaluation   control or STD
                                                    evaluation
Risk of not getting follow-up medical care
           3%              No source for
                           medical care

                     31%   No intention to
                           seek medical care


64%
                           Both



                2%         Neither risk
                           reported
Results
Many adolescents unlikely to receive EC
 elsewhere

 95%   - had source for routine medical care

 38%   - pharmacy only place they knew to go

 58%- would seek care from a physician if
 pharmacy service was not available

 41%   - obtained EC evening or weekend
 Conclusions
 Pharmacistsincreased access to EC for
 adolescents who were unlikely to obtain it
 elsewhere
            were satisfied with the care provided
 Adolescents
 by pharmacists
            have additional medical needs that
 Adolescents
 cannot be met in the pharmacy
 Implications
 Expansion   of the pharmacist’s role in providing
 EC
  – increase timely access
  – facilitate referral to more comprehensive reproductive
    health care services

 Future   studies
  – programs to improve access to EC
  – link young women with the rest of the health care
    system
Data on Repeat Use of EC
 Noadvance provision or pharmacy access
 studies demonstrate excessive use among
 adults or adolescents
 No studies report increase risks of serious side
 effects with increase use
 Repeated    use of levonorgestrel (Plan B) will
 result in irregular break vaginal bleeding which
 is more a nuisance than a medical problem
Concerns about Teens and EC
 Adolescents might have more unprotected sex:
  No evidence to date that this is true
 Adolescents might use EC repeatedly - “abuse
  EC”: No evidence to date that this is true
 Adolescents  might discontinue using condoms
  and other methods of contraception: Most
  studies show no difference, 1 study showed
  higher condom use, 1 study showed less
  effective contraception use
Concerns about Teens and EC
 Adolescents    might get more STIs and have
  more unintended pregnancies: No studies
  showed higher pregnancy rates or higher STI
  rates with advance provision or pharmacy
  access to EC (but no lowering of pregnancy
  rates either!)
More Concerns about Teens and EC
 Liability   Issues for Pharmacists
 Standing orders might exclude or limit access
  to adolescents
 Pharmacists     might “conscientiously object”
 Concerns about parental involvement / anger if
  adolescents are provided with EC without their
  permission
 How should patients start
new contraceptive methods
     after EC use?
Starting Contraception After EC

 Recommend     abstinence for 2 weeks
 Offercondoms and spermicide if choose
 not to stay abstinent
 Newer   methods to consider starting:
  – Patch, Vaginal Ring
Starting Contraception After EC
 ECs          COCs, Patch or Vaginal Ring:
  – Can start the day after taking EC or wait until
    onset of next menses or start 10-14 after EC if
    uHCG (-) with no unprotected intercourse in
    between; not effective until 7-10 days of use
 ECs         Depo-Provera:
  – Give 10-14 days after EC if uHCG (-) with no
    unprotected intercourse in between; not effective
    until 10-14 days after injection (could wait until
    menses)
    EC Advance Provision References
        A, Baird D. The Effects of Self-Administering
 Glasier
  Emergency Contraception. NEJM. 1998; 339 (1):1-4.
 Lovvorn   A, et. al. Provision of emergency contraceptive
  pills to spermicide users in Ghana. Contraception.
  2000; 61: 287-93.
 Raine  T, et. al. Emergency contraception: Advance
  provision in a young, high-risk clinic population. Obstet
  Gynecol. 2000; 96: 1-7.
 EllertsonC, et. al. Emergency Contraception:
  Randomized Comparison of Advance Provision and
  Information Only. Obstet Gynecol. 2001; 98(4): 570-5.
   EC Advance Provision References
 JacksonRA, et. al.. Advance supply of emergency
 contraception: effect on use and usual contraception – a
 randomized trial. Obstetrics Gynecol. 2003;102(1):8-16.
 GoldMA, Wolford JE, Smith KA, Parker AM. The Effects
 of Advance Provision of Emergency Contraception on
 Adolescent Women's Sexual and Contraceptive
 Behaviors. J Ped Adolesc Gyn. 2004; 17:87-96.
 LoSST, Fan SYS, Ho PC, et al: Effect of advanced
 provision of emergency contraception on women’s
 contraceptive behaviour: A randomized controlled trial.
 Hum Reprod. 2004; 19: 2404.
   EC Pharmacists Access References
 Raine   TR, Harper CC, Rocca CH, et al: Direct access to
  emergency contraception through pharmacies and effect
  on contraception and STIs: A randomized controlled
  trial. JAMA 2005; 293:54.
 Sucato GS, Gardner JS, Koepsell TD. Adolescents’ use
  of emergency contraception provided by Washington
  State Pharmacists. J Ped Adolesc Gyn 2001; 14 (4):
  163-9.
 Conard LE, Fortenberry JD, Blythe MJ, Orr DP.
  Pharmacists’ attitudes toward and practices with
  adolescents. Arch Pediatr Adolesc Med. 2003;157:361-
  365.
             Other EC References
 StewartHE, Gold MA, Parker AM. The impact of using
 emergency contraception on reproductive health outcomes:
 a retrospective review in an urban adolescent clinic. J Ped
 Adolesc Gyn, 2003;16(5):313-8.
 GoldMA, Sucato G, Conard LE, Hillard P. Provision of
 Emergency Contraception to Adolescents: Position Paper of
 the Society for Adolescent Medicine. Journal of Adolescent
 Health 2004;35:66-70.
 AikenAM, Gold MA, Parker AM. Changes in Young
 Women’s Awareness, Attitudes, and Perceived Barriers to
 Using Emergency Contraception. J Ped Adolesc Gyn,
 2005;18(1):25-32.
 Emergency Contraception References
 Committee   on Adolescence. Policy Statement: Emergency
  Contraception. Pediatrics 2005;116:1038.
 American Academy of Pediatrics’ policy statement on EC,
  fact sheet for parents and adolescents, and speaking
  points for pediatricians can be found at ww.aap.org
 American  College of Obstetricians and Gynecologists
  ACOG Practice Bulletin: Clinical Management Guidelines
  for Obstetricians-Gynecologists: Emergency Contraception.
  No. 69, December 2005. Obstetrics and Gynecology
  2005;106 (6):1443
  Emergency Contraception References
 Conard LE and Gold MA. Emergency contraceptive pills:
 a review of the recent literature. Current Opinions in
 Obstetrics and Gynecology. 2004;16:389-395.
 ConardLA and Gold MA. Emergency Contraception.
 Adolesc Med Clin. 2005 Oct;16(3):585-602.
 Conard LE and Gold MA. What You Need to Know About
 Providing Emergency Contraception. Contemporary
 Pediatrics. 2006; 3(2): 49-70.

				
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