Contraception for teenagers

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					     Sex and the Teenager

         Dr. Helen Roberts
 Senior Lecturer Women’s Health
University of Auckland, New Zealand
Research Manager Family Planning
    What am I going to talk about?

•   Background abortion statistics for NZ
•   Results of our study at EDU
•   Review of some IUD/LARC information
•   What do we need to do now?
ASC report 2009
ASC report 2009

The general abortion rate is the number of abortions per 1,000
of the mean estimated population of women aged 15-44 years.
ASC report 2009

The abortion ratio is the number of abortions per 1,000 known pregnancies.
Known pregnancies include live births, stillbirths and induced abortions combined,
but do not include miscarriages
  Post abortion contraception and its effect on
  repeat abortions in Auckland, New Zealand
• Prospective cohort study at Epsom Day Unit (Auckland’s public
  abortion clinic)

• EDU is the largest abortion clinic in NZ providing approximately 30%
  of all abortions

• 1422 women who had a first trimester surgical abortion between
  November 2004 and January 2005

• Followed for 3 years

                   Roberts H, Silva M, Xu S. Contraception 2010;82:260-5
Sample description
      Descriptive variable   %      N

      Age                           1422
      <15                    0.7
      15-19                  21.6
      20-24                  26.6
      25-29                  20.6
      30-34                  15.1
      35-39                  11.1
      40-45                  4.3
      Ethnicity                     1422
      European               33.9
      Maori                  13.5
      European/Maori         6.8
      Pacific                20.5
      European/Pacific       2.3
      Asian                  11.8
      Asian Indian           8.9
      Other                  2.3
      Previous abortions            1421
      Yes                    40.3
      No                     59.7
Contraception at conception   %      N
Barrier                       43.2   1420
COC                           11.4
POP                           4.2
Depo Provera                  1.8
IUD                           1.3
ECP                           1.6
NFP                           5.3
Tubal ligation                0.1
No contraception              31.1
Reason for failure
Method failure                5.9    978
User failure                  48.7
No information available      45.4
Post abortion contraception
Barrier                       13.1   1416
COC                           27.8
POP                           8.7
Depo Provera                  18.0
IUD                           25.1
GP / FP                       6.1
No contraception              1.3
Only 14.5% of young women 19 years of age or less left using IUD
Relative odds of leaving the abortion clinic with IUD
among women with no previous abortions (n=428)
                               Odds ratio         p-value
                          (confidence interval)
      <19                     1.0
      20-24                   1.7 (0.8-3.5)
      25-29                   3.1 (1.3-7.6)
      30-34                   13.4 (4.5-39.6)
      35-39                   2.8 (0.9-9.1)
      40-45                   8.2 (0.8-83.4)

Relative odds of leaving the abortion clinic with IUD
among women with one or more previous abortions (n=307)
                               Odds ratio         p-value
                          (confidence interval)
      <19                      1.0
      20-24                    1.5 (0.5-4.2)
      25-29                    1.2 (0.4-3.7)       0.196
      30-34                    1.7 (0.5-6.0)
      35-39                    3.4 (0.9-12.8)
      40-45                    9.4 (0.9-96.2)
• Over the 3-year follow-up period, women using IUD
  were more than 70% less likely to return for a
  repeat abortion than those who left with a COC
  prescription (p<.001)
• All age groups were more likely than those 19 yrs
  or younger to leave the clinics with an IUD (p<.001)
• Nulliparous women were less likely to have an IUD
  inserted following abortion. With each added live
  birth, women were more than twice as likely to
  have left the clinic with an IUD versus COC
One year after study publication
• A recent 2011 EDU audit of 100 women who
  had an abortion showed an increase in IUD use.
• 49% left with an IUD insitu
• 45% of younger or nulliparous women had an
  IUD inserted
• An ongoing audit will determine whether this will
  translate into fewer repeat abortions for these
Why were young women not using IUD?

   Family Health International

 Underused Research Findings 2007
IUDs: information lags behind the evidence
 • British Survey (2006) reported that women lacked
   objective information about IUDs, not well informed by
   health professionals                       Asker 2006
 • Textbooks (both UK and US) lag behind the evidence
 • Advantages under-reported and disadvantages
 • Several texts listed qualities of women considered by the
   authors, but unsupported by the evidence, to be
   contraindications to IUD use eg nulliparity
                                             Espey 2002
Results from a questionnaire sent to US family physicians

                  Rubin S et al. Family Medicine Journal June 2010
       What do we know about the risk
             of PID with IUDs?
   IUD in situ           Don’t know                   No IUD
    get STI              diff PID risk                get STI

   Cx+STI                 Increased                 Cx+no STI
   IUD insert              PID risk                 IUD insert

So we know that if insert IUD with STI present small increase in PID compared
 to if no STI but do not know whether PID risk is any different when STI
 acquired with IUD in situ compared to women not using IUD
 Risk of PID if insertion with STI
• No RCTs insertion with STI v without STI
• But 6 prospective studies
• Included women who had inadvertently
  had IUD inserted with lab documented STI
• Risk of PID 0-5% v 0-2% without STI

          Mohllagee. Contraception 2006;73:145-53
  Risk of PID among IUD users
• Absolute rates of PID among IUD users
  are low.
• In a 5-year follow-up study in eight
  developing countries, the rate of acute PID
  among users of the copper IUD was
  0.6 per 1000 woman years

       Mohllajee et al. Contraception 2006;73: 145–153
   NICE Guidelines (UK) 2005
National Institute for Health+Clinical Excellence

• IUD may be used by adolescents but STI risk
  should be considered where relevant
• ie same advice as for other women
• IUD use is not contraindicated in nulliparous
  women of any age
Grimes D Contraception 2009
How can we improve the failure
      rate with pill use

  Although the practical failure rate of the
 combined pill is 5% –the adolescent
 failure rate is as high as 32%

 ........more “technical”problems

              Alan Guttemacher Institute 1994
     Continuous hormones

• Much less likely to have escape ovulation
  with missed pills
• Would need to miss 9 pills in a row to get
  possibility of escape ovulation
• Similar episodes of breakthough bleeding
• If breakthrough bleeding- take 3 day break
Continuous versus cyclic use of combined oral contraceptives for
   contraception: systematic Cochrane review of randomized
            controlled trials A. Edelman et al Human
•   METHODS: The review aimed to compare contraceptive efficacy,
    compliance, continuation, satisfaction, bleeding profiles, and menstrual
    symptoms of combined oral contraceptives with continuous dosing (>28
    days of active pills) versus traditional cyclic dosing (21 days of active pills
    and 7 days of placebo).
•   We searched five computerized databases as well as reference lists of
    relevant articles for randomized controlled trials (RCT) using continuous or
    extended combined oral contraceptives for contraception.
•    RESULTS: Six RCT met inclusion criteria and were of good quality.
    Discontinuation overall, and for bleeding problems, was not uniformly higher
    in either group. When studied, participants reported high satisfaction with
    both dosing regimens.
•    Five out of the six studies found that bleeding patterns were either
    equivalent or improved with continuous-dosing regimens.
•    The continuous-dosing group had greater improvement of menstrual-
    associated symptoms (headaches, genital irritation, tiredness,
    bloating, and menstrual pain).
  Improving compliance with
        Depo Provera
  Counselling women on expected bleeding
  patterns has been shown to improve
  continuation rates with methods such as
  Depo Provera

Cochrane Database of Systematic Reviews 2006,
Issue 1. Art. No.: CD004317
     Long Acting Reversible
      Contraception (LARC)
       IUDs and implants

Potential to….
Decrease unintended pregnancy
NICE guidelines on LARC
• LARC more cost effective (even at
  1 year ) than coc or injectables
     Another LARC
     Contraceptive Implants
                One rod implant- 3 years
                 Implanon (etonorgestrel)

Two rod implant –5 years
Jadelle (levonorgestrel)
Jadelle fully funded in NZ since 2010
    Bleeding and Continuation rates
             with Implants
•   Review of 11 clinical trials
•   Amenorrhea 22%
•   Infrequent bleeding 34%
•   Frequent bleeding 7%
•   Prolonged bleeding 18%
•   Discontinuation rate of 11% for bleeding
                                 Mansour 2008
   Summary and what needs to
        happen next?
• LARCs have a real potential to decrease
  unintended pregnancies
• IUDs are an appropriate method for adolescent
  and nulliparous women
• Clinics may need to consider increasing staff
  trained in LARC insertion
• Abortion hospitals need to have trained staff to
  offer immediate implant insertion post abortion
• We now have 3 trained nurses at EDU
Improving continuation rates
        with Jadelle
• There is almost no research regarding the
  adverse event rate post abortion insertion
  of Jadelle.
• A single study suggests that, for at least
  some women post abortion,
  discontinuation rates for irregular bleeding
  are less than when insertion takes place at
  other times
Improving continuation rates
        with Jadelle

• Recent Grant Application
• Adverse events following immediate
  insertion of Jadelle contraceptive implant
  post abortion and the effect on
  continuation rates.

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