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Contraception for teens

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					Contraception for teens:
     What’s new?
    Tony Ogburn MD
University of New Mexico
          Conflicts of interest
• Paragard IUDs for
  immediate PP insertion
  study
• “Consultant” for Organon
  to train providers on
  Implanon insertion
• Parent of two teens
                Objectives
At the completion of this presentation
 the learner will:
 - Be able to discuss the issues and barriers with
     teens and contraception
 - Understand the need for increased use of
     better contraceptive methods in teens
 - Be aware of several “new” contraceptive
     methods for use in teens
 What would you recommend?
• Carrie is a 17 yo G1P0 undergoing a D&C for a
  9 week anembryonic pregnancy. Two lifetime
  partners, current x 4 months. Uses condom
  “most of the time”.
  –   Pills
  –   Patch/Ring
  –   Implanon
  –   Depo-Provera
  –   IUD
  –   Condoms
                   The problem
• Teen pregnancy in the US
  – Highest of all industrialized nations
     • U.S                                     68/1000
     • England                                 44/1000
     • Healthy People 2010 goal                43/1000
  – Approximately one million teen pregnancies annually
     • 90% unplanned
  – Decrease by almost half in the past decade
     • Due to
         – Increased/improved use of contraceptives (75%)
         – Delay in onset of intercourse
     • Not due to an increase in abortions
      Why are we the worst?

Lack of access
  – Most other countries have universal health
    care – we don’t!!
  – Highest costs for teens among all nations
    (Darroch, 2001)
  – Even in populations with coverage (e.g. IHS)
    options are often limited
• We don’t use enough of the “best
  methods” - IUDs!!!!
       Why are we the worst?
• Abstinence until death
  education
  – Hundreds of millions of
    dollars spent to
    convince teens…
     • Sex before marriage
       will kill you or at least
       ruin your life
     • Contraception doesn’t
       work
     • STIs are deadly and
       can’t be prevented or
       treated
A better message?
      Why are we the worst?
• Perception that most teens don’t use
  contraception


• Wrong!
  – They don’t use contraception correctly!!
     Teens and contraception
• Over 50% report they were using
  contraception in the month they conceived
 (Moore 2002)
• Only 12% of sexually active teens report
  not using contraception (NSFG 2002)
• Teen pregnancy rates
  – 54% due to contraceptive “failure”
  – 46% due to non use of contraception
    (Santelli 2006)
                     Lack of use
• Privacy, fear of a lack
  of confidentiality
  (Reddy 2002, Guttmacher 2002)
• Fear of side effects
   – Weight gain, acne,
     bleeding, future infertility
    If many are contracepting…
          What’s wrong?
• Perfect use
  – How well the method prevents pregnancy if
    used as directed
• Typical use
  – How well the method prevents pregnancy
    when used in real life
 Common methods used by teens
• OCPs
  – 20-25% of teen
    contraceptors
  – Up to 50% report incorrect
    use
  – At least half discontinue
    within one year
  – Typical use efficacy 70-
    92%
 Common methods used by teens
• Condoms
  – Up to 60% of teen
    contraceptors (some dual
    users)
  – To be effective must …
     •   Use them every time
     •   Use a new one every time
     •   Put on correctly
     •   Hold base on withdrawal
  – Typical use efficacy 80% at
    best
Common methods used by teens
            • Depo Provera
              – Very high discontinuation
                rate in teens
                 • Side effects
                 • Repeated visits required
                 • Cost
              – Unwarranted concerns of
                providers and patients
                about bone health
        Methods to consider

• Implanon ®




• Nuvaring ®
         Methods to consider
• Intrauterine
  contraceptive devices
  – Mirena intrauterine
    system
     • Levonorgestrel
     • 5 years
  – Paragard
     • Copper containing
     • 10 years
                  Implanon ™
• FDA approved July 2006

• Available worldwide since 1997
  – Approximately 3 million implants inserted since 1998

• Single rod implant (As opposed to six for
  Norplant)
  – 68mg 3-keto-desogestrel (etonogestrel)
  – Achieve ovulatory inhibitory levels within 8 hours of
    insertion
                IMPLANON™
                          4 cm


                                  • IMPLANON™   is not radio-opaque
2 mm

              Core: 40% ethylene vinyl acetate (EVA)
                    60% etonogestrel (68 mg)

                Rate-controlling membrane: (0.06 mm)
                      100% EVA

Release Rate: 60 g/day to 70 g/d initially then decreases to
          25 g/d to 30 g/d by end of third year
                 Implanon ™
• Mechanism of action
  – Prevents ovulation
  – Alters cervical mucous
• Efficacy – Highly
  effective
  – .38 pregnancies/100
    women years
  – No data in women
    over 130% of ideal
    body weight
Implanon™ applicator
                   Implanon ™
• Easy to insert
  – >85% less than 1
    minute
• Easy to remove
  – One rod
  – Different material than
    Norplant - doesn’t
    stimulate fibrosis
  – 1.7% experience
    difficulty with removal
               Implanon ™
                  Side Effects
– Bleeding
  • Very common
       – 44% at 3 mo, 16% at 36 mo
  •   Irregular and unpredictable
  •   Variable throughout duration of use
  •   Total days of bleeding equal to non-users
  •   ~25% amenorrhea
  •   Most common cause of discontinuation
                        Implanon ™
• Side Effects
   – Weight gain
        • 3.7 lbs/2 years
   –   Emotional lability
   –   Acne
   –   Headache
   –   Depression
                Implanon ™
                  Acceptability

• Discontinuation rates
  – 12 months           22%
  – 24 months           32%
  – 36 months           39%
     • One fourth of discontinuations were because
       patients desired pregnancy
• Thorough pre-insertion counseling
  decreases discontinuation rates
               Implanon ™
                   Summary
• Advantages
  – Highly effective
  – Reasonably high acceptability and
    continuation
• Disadvantages
  – You must be trained by a certified trainer
  – It’s expensive
  – Bleeding is common
                  Nuvaring ®
• Combination of
  ethinyl estradiol and
  etonogestrel
• One size fits all
  – 2 x 1/8 inches –
    roughly equivalent to
    60mm diaphragm
• No specific placement
  requirements - just
  get it in the vagina!
                  Nuvaring ®
• Efficacy
  – Perfect use   99%
  – Typical use   92%
• Continuation – 1 year
  – 68%
• Usage
  – 3weeks in/ 1 week out
  – Consider continuous
    use
  – Out <3 hours OK
                     Nuvaring ®
• Side effects – similar to combination OCPs but
  less frequent/severe
  – Bleeding
       • 2-6%
• Acceptability     (Novak 2003)
  –   Baseline 66% preferred OCPs
  –   3 months 81% preferred ring
  –   97% would recommend to a friend
  –   Sex
       • 85% of women, 71% of men never felt it
       • Of those that felt it, 94% didn’t mind
                  Nuvaring ®
• Advantages
  – Better compliance,
    continuation than
    OCPs
  – Excellent cycle control,
    minimal abnormal
    bleeding
  – Easy to use
    continuously – avoid
    menses
  – Discrete!
 Intrauterine contraceptive devices
               IUCDs
• We know they are
  the best choice for
  most women

• What about teens?
             IUCDs
    The expanded patient profile
• Package labeling not
  updated in 20 years
• FDA approved new
  labeling in 2005 for
  Paragard
  – Evidence based
  – Changes can be
    considered
    appropriate for Mirena
    too
                Out with the old…
         Old Label                    New Label
Pregnancy or suspicion of pregnancy    No change


      Distorted uterine cavity         No change


       Current IUD in place            No change


Genital bleeding of unknown source     No change


         Wilson’s disease              No change
                  Out with the old…
               Old label                                  New label
     Acute PID or history of PID           Acute PID or current behavior suggesting
                                                       a high risk for PID
  Postpartum endometritis or infected      Postpartum or postabortal endometritis in
       abortion within last 3 months                    the past 3 months
Uterine or cervical cancer or unresolved    Known or suspected uterine or cervical
                 Pap smear                               malignancy
 Untreated acute cervicitis or vaginitis           Mucopurulent cervicitis
  Patient or partner with multiple                        Removed
                partners
  Increased susceptibility to infection                   Removed
          (AIDS, leukemia, etc.)
        Genital actinomycosis                             Removed
          IUCDs and Teens
• Concerns
  – STDs/PID
  – Future infertility
  – Insertion/Expulsion
  – Discontinuation
  – Non-compliance with regular health care
                       STIs/PID

• We still suffer from the Dalkon Shield debacle
• Attributable risk
   – Increases 6-fold in first 3 weeks post insertion
   – Decreases to baseline after 3 weeks (Mohllajee, 2006)
• Limited data suggest that no difference in
  severity of PID with an IUCD in place (Grimes 2000)
• No studies of PID risk in IUD users vs non-users
  with an STI
• Mirena may decrease risk of PID
                  Infertility
• GC/Chlamydia infections cause
  PID/infertility, NOT IUCDs
  – Case-control of 1895 women with infertility,
    with and without tubal occlusion, and currently
    pregnant women (Hubacher 2001)

    • IUD use         OR 0.9(0.5-1.6)

    • Chlamydia       OR 2.4(1.7-3.2)
                 Infertility

• Multiple studies
  – IUCD discontinued for desired pregnancy
  – Similar pregnancy rates to non users


• No difference in ectopic rate after IUCD
  use
Insertion/expulsion/continuation
• Not a lot of data
• Insertion – may be more painful/difficult
  – Premedication/ripening may help
• Expulsion
  – Two older studies reported 17-20%
  – More recent studies range from 2-10%
• Continuation
  – Similar to older, parous women
Non-compliance with regular health
             care
• Paternalism at it’s
  finest…
                    IUCDs
• Advantages
  – All the same reasons they are a great choice
    for most women!
  – Highly effective, discreet, long term method
  – High continuation and satisfaction rates
• Disadvantages
  – Slight increase in infection post insertion
  – Provider insertion
               Summary
• Teens are a high risk group for unintended
  pregnancy
• Most contracept, just not well
• Use of highly effective, less user
  dependent methods could have a dramatic
  impact on teen pregnancy rates
Now what would you recommend?
• Carrie is a 17 yo G1P0 undergoing a D&C for a
  9 week anembryonic pregnancy. Two lifetime
  partners, current x 4 months. Uses condom
  “most of the time”. What contraceptive would
  you recommend?
  –   Nothing – discuss abstinence
  –   Pills
  –   Patch/Ring
  –   Implanon
  –   Depo-Provera
  –   IUD
  –   Condoms
             Another teen
• Alissa is a 18 yo G3P2TAb1 who presents
  for an annual exam and refill on her OCPs.
  She recently had a medical abortion
  “because she ran out of pills”.
  – Any more information?
  – Issues?
  – What would you recommend?
           And one more…
• Tiffany is a 14 yo G0 who is brought in by
  her mother because she is concerned she
  may be having sex with her boyfriend.
  She says she has not but thinks she might
  soon.
  – Issues?
  – Recommendations?
Thanks!

				
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posted:3/29/2008
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