1. Adolescent Contraception Kristin M. Rager, MD, MPH Assistant Professor UK Department of Pediatrics Section on Adolescent Medicine

2. Unintended Pregnancy • Among 15-17 yo - 83% of pregnancies • Among 18-19 yo - 75% of pregnancies

3. Unintended pregnancies

4. Most Common Causes of Unintended Pregnancy • Contraceptive nonuse • Contraceptive user failure • Contraceptive method failure

5. Effectiveness of Methods

6. Discontinuation - 1 Yr of Use

7. So Many Options…

8. Oral Contraceptives (OCP) • Combination • Monophasics • Triphasics • Ethinyl estradiol content – 20 mcg-35mcg • Progestin only • Not a good choice for teens b/c <3hour window

9. Combined OCP - How They Work • Suppress HPO axis • Inhibit ovulation • ↑ viscosity of cervical mucus • Alter endometrium

10. Combined OCP - Benefits • Dysmenorrhea, menorrhagia • Ovarian cyst suppression • Anemia, osteoporosis prevention • Risk of ovarian and uterine CA, PID, ectopics • Benign breast disease • Acne

11. Combined OCP - Sides • GI symptoms (nausea) • Headaches • Breakthrough bleeding • Libido changes • HTN - <2% • Weight change – NOT A SIDE EFFECT

12. Absolute Contraindications • Thromboembolic disease • Cerebrovascular or Coronary disease • Breast cancer • Estrogen –dependent neoplasia • Liver tumors • Pregnancy • Undiagnosed vaginal bleeding

13. Newer OCP • Seasonale • 30 mcg EE/levonorgestrel • 84 days hormones, 7 days placebo

14. Newer OCP • Yasmin • 30 mcg EE • Drosperinone – spironolactone derivative • Anti-androgenic effects • Possibility of increased K

15. Must take a pill every day!!

16. Emergency Contraception • Inhibits ovulation • Changes cervical mucus • Alters transport of sperm • Interference with corpus luteum • NOT medical abortion • Cannot interrupt an established pregnancy

17. Emergency Contraception • Methods • Yuzpe method • High dose estrogen (100mcg) and progesterone • Major nausea • Plan B • 0.75 mcg levonorgestrel x2 • No nausea • Menses may be early or late

18. EC -Plan B % Pregnancies Prevented Treatment Delay

19. Ortho Evra - “The Patch”

20. Backing layer Middle layer Release liner Composition of Transdermal System

21. Estrogen and Progestin Delivery • Delivers continuous systemic doses of hormones • 150 µg norelgestromin (NGMN) • + • 20 µg ethinyl estradiol (EE) Per day .

22. Where to Apply the Patch • Clean, dry, intact healthy skin • In a place where it won’t be rubbed by tight clothing • Should not be placed on skin that is red, irritated, or cut • Apply on first day of menses for “instant” protection

23. Contraceptive Patch Partial or Complete Detachment <24 hours >24 hours or uncertain Attempt Reattachment Stop current cycle. Start new cycle by applying new patch Successful Unsuccessful Use backup contraception for one week Continue method as usual Apply new patch. Change day remains the same

24. Forgot to Apply/Change Week 1 Week 2 or Week 3 Week 4 <48 hours >48 hours • Apply patch as soon as remembered • Must use backup contraception for 1st week of new cycle • Remove patch when remembered • No backup contraception required • Remove current patch • Apply new Patch immediately • No backup contraception needed • Remove current patch • Apply new Patch immediately • Must use backup contraception for one week

25. Evra Side Effects • breast symptoms • headache • application site reaction • nausea • menstrual cramps • abdominal pain

26. Precautions • Body weight 198 lbs. (90 kg) • Results of clinical trials suggest that the contraceptive patch may be less effective in women with body weight >198 lbs (90 kg) than in women with lower body weights

27. Must change patch once a week!

28. NuvaRing

29. NuvaRing • Release EE: 15 µg/day + etonorgestrel • Insert ring on day 1-5 of cycle- remains in vagina for 21 days • Remove day 22-27–New ring inserted day 28 • When first starting, should use condoms first 7 days

30. NuvaRing • Exact position not important • Put where it is comfortable • Remove by putting finger in vagina and pulling it out • If removed or slips out of place for >3 hrs, back-up contraception is necessary for 7 days

31. Nuva - Sides • Vaginitis • Headache • Leukorrhea • Weight gain • Nausea • Foreign body sensation • Coital problems • Device expulsion

32. Must change Nuva once a month!

33. Depo-Provera (DMPA) • Inhibits ovulation • After 150 mg im, ovulation suppressed for up to 14 weeks • Produces thinning of the endometrium • Increases viscosity of cervical mucous

34. DMPA - Sides • Menstrual irregularity • 60% amenorrhea at 1 year • Weight gain • 5#/year for first 3 years • Bone density – teens should be increasing bone density not losing

35. Must get DMPA every 12 weeks!

36. Mirena IUD • Releases 20 mcg levonorgestrel/day • Lasts at least 5 years • Thickens cervical mucus and inhibits sperm motility and function

37. Mirena IUD • Good Candidates: • Patients in a long term, monogamous relationship • Not at risk for an STI • No uterine anomalies

38. Important Points!! • None of the hormonal methods protect against sti’s and hiv, therefore is important to encourage condom use • Talk about contraception with all teens – not just those who are already having sex

39. Important Points!! • Don’t have to have a pelvic exam to start contraception! • Don’t have to have parent’s consent to start contraception!

40. Thanks! Questions??