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Adolescent Contraception

Adolescent Contraception. Marcia J. Nackenson, M.D. Section of Adolescent Medicine Department of Pediatrics New York Medical College. Adolescent Contraception. The Need Barriers to Adolescent Contraception Contraceptive Methods How to Provide Service.

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Adolescent Contraception

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  1. Adolescent Contraception Marcia J. Nackenson, M.D. Section of Adolescent Medicine Department of Pediatrics New York Medical College

  2. Adolescent Contraception • The Need • Barriers to Adolescent Contraception • Contraceptive Methods • How to Provide Service

  3. Adolescent Sexual ActivityAges 15 - 19 years • Females: 50% (1997) 55% (1990) • Males: 55% (1995) 60% (1988)

  4. Adolescent Sexual ActivityBy School Grade (1996) • Grade 9: 37% • Grade 12: 66%

  5. Adolescent Sexual ActivityBy Race and Gender • Males earlier than females • Blacks earlier than Hispanics earlier than Whites • Differences are lessening

  6. Adolescent Contraceptive Behavior • 25% use no contraception at 1st intercourse. • 1 year intercourse before medical advice. • 50% adol preg in 1st 6 months of sexual activity.

  7. Adolescent Pregnancy • 1 million pregnancies/year • 85% unintended • 50% live births • 35% elective abortions • 15% spontaneous abortions

  8. But... • Pregnancy Rates Decline 12% (1995) 103/1000 ages 15 - 19 yrs • Abortion Rates Decline • Birth Rates Decline 15% 57/1000

  9. Recent Trends in Adolescent Sexuality • Sexual Activity Down • Condom Use Up • Pill Use Down • Pregnancy Rates Down • Abortion Rates Down • Birth Rates Down • But…Condom & Pills 8%

  10. Barriers to Adolescent Contraception • Psychological Factors • Availability • Demographic Factors

  11. Psychological Factors • Immature cognitive functioning • Dependency, passivity • Difficulty in handling sexuality • Risk-taking behavior • Desire for pregnancy

  12. Availability • Cost • Geographics • Clinic hours • Confidentiality issues

  13. Demographic Factors • Age • Race • Poverty • Educational Plans • Cultural Patterns

  14. Legal Issues I. Consent A. Emancipated Minor B. Mature Minor C. Reproductive Matters II. Confidentiality III. Payment IV. Abortion

  15. Issues in Selecting a Contraceptive Method • Frequency of intercourse • Tolerance of route of delivery • Tolerance of side effects • Nature of relationship ie, monogamous, long-standing

  16. Recommended Methods for Adolescents CONDOMS PLUS: 1. Oral Contraceptives 2. Injectable Progestin (Depo-Provera) 3. Subdermal Implants (Norplant) 4. Spermicide

  17. Limited Methods for Adolescents 1. Diaphragm 2. Female condom 3. Cervical cap

  18. Methods Not Recommended for Adolescents 1. IUD 2. Tubal ligation/vasectomy

  19. Method Abstinence Implants Injectables Oral Contraceptives Vaginal Ring Patch IUD Pregnancy Rate % 0 0.09 0.3 0.1 0.1 1 1-2 Contraceptive EffectivenessMost Effective

  20. Method Condom plus foam Condom alone Female condom Diaphragm Withdrawal Rhythm No Method Pregnancy Rate % 2 - 10 2 - 20 5 - 20 2 - 18 20 20 - 30 90 Contraceptive EffectivenessLess Effective

  21. History of Oral Contraceptives 2000 yrs ago - Arsenic, mercury, & strychnine 1920’s - Progesterone & estrogen isolated. 1935 - Progesterone synthesized. 1940’s - 50’s - Syntex: steroid synthesis 1950’s - Margaret Sanger - clinical trials 1960 - Enovid approved by FDA

  22. Mechanisms of Oral Contraceptives • CombinationOCP: estrogen, progestin • Inhibition of ovulation • Thickened cervical mucous • Endometrium less favorable for implantation • Decreased tubal motility

  23. Estrogen in OCP’s • Ethinyl estradiol 20m 30-35m - Most “low dose” OCP’s 50m • Mestranol - converted to ethinyl estradiol 50m

  24. Progestins in OCP’s • Varying progestational & androgenic potency • 6 different progestins available in U.S. • Newer progestins less androgenic?

  25. Newer Progestins (‘92-’93) • Norgestimate - OrthoCyclen, Tricyclen • Desogestrel - OrthoCept, Desogen ‘95 UK warning VTE FDA, ACOG - no changes needed • Gestodene - Not available in US

  26. Newer Progestins: Advantages • Decreased androgenicity • Increased SHBG • Decreased free testosterone • Improved LDL:HDL ratio • Best for hirsutism, acne

  27. Triphasics vs. Monophasics • Less total hormone per month • No clear clinical advantage

  28. Minor Side Effects of OCP’s • Breakthrough bleeding • Nausea • Breast soreness • Headache • Weight gain - NOT!

  29. Major Side EffectsCardiovascular • Related to high estrogen content, early pills • Venous thromboemboli, MI, CVA • Hypertension 1-5%, reversible with DC • Esp. >35 yrs & smoker • Post-op thromboemboli: DC pills 4 wks pre-op

  30. Major Side EffectsCancer • Dec. risk of endometrial & ovarian ca. • Breast & cervical ca. - no definitive inc. JAMA ‘01: +FH breast ca. & OCP’s Ô inc. risk of breast ca. BUT: Based on early hi dose pills • Hepatocellular adenoma - benign, 3-4/100,000

  31. Other Side Effects • Lipid level changes - screen if hi risk • Carbohydrate metabolism - follow diabetics • Post-pill amenorrhea or infertility - disproven • Congenital anomalies - disproven

  32. Beneficial Effects of OCP’s • Dec. acne • Dec. dysmenorrhea • Dec. ovarian cysts • Dec. fibrocystic disease of the breast • Dec. PID • Dec. endometrial and ovarian ca.

  33. Absolute Contraindications • Thromboembolic disorders • Coronary artery disease • Estrogen-dependent neoplasia • Breast Cancer • Pregnancy • Active liver disease • Undiagnosed abnormal vaginal bleeding

  34. Oral ContraceptivesSummary • Safe and effective for healthy adol. • Use low estrogen pill (20-35 mg) • 28 day pack and Sunday start method • Judicious advice about side effects • Frequent follow-ups.

  35. Progestin Only Methods • The Minipill - daily pill • Depo-Provera - injectable • Norplant - subdermal implant

  36. Progestin Only MethodsMechanisms • Blocks LH surge; inhibits ovulation • Thickens cervical mucous • Thin, atrophic endometrium

  37. Progestin Only Pill • Taken every day - no placebo pills • Slightly less effective than combination pill; less forgiving of missed pill • Indications - estrogen contraindication, lactation • Disadvantages - unpredictable menses

  38. Depo-Provera (Injectable Progestin) • FDA approved 1992 • Medroxyprogesterone acetate 150 mg. IM • 1st injection within 1st 5 days of menses; neg Urine preg test • Repeat q12 weeks ( up to 13.5 weeks) • Cost: $50/dose

  39. Depo-ProveraMenstrual Changes • Irregular menses • Amenorrhea - 60% by 1 year • Treatment of irregular bleeding: 1. Counseling 2. OCP 3. Ibuprofen 4. Estrogen

  40. Depo-ProveraOther Side Effects • Weight gain - 2-5 lbs./yr. • Delay to fertility - 9 mos. • Depression • Dec. libido • Breast tenderness • Decreased bone density - under study

  41. NEW: Lunelle • Combination injectable: Estrogen and progestin • Given q28 days • Advantage - regular menses • Disadvantage - monthly visit

  42. Subdermal Implants • Norplant -FDA 1990, 6 levonorgestrel rods -Effective 5 years -Insertion and removal procedures -Bad publicity • Implanon -Single rod, good for 3 years

  43. Norplant Side Effects • Irregular menses - greatest in 1st yr. • Weight gain - less than Depo • Headaches • Acne • Insertion site problems • Depression • Hair changes

  44. Condoms • Must always be recommended to prevent STD’s • Latex or polyurethane only Reservoir-tipped, spermicide • Effectiveness inc. with contraceptive foam • Advantages: Safe, cheap, available • Disadvantages: Coital dependent, male resistance

  45. Condom Use12-19 yr males • 55% at first intercourse - Inc. from 20% in 1979 • 58% at last intercourse - Inc. from 21% in 1979 • BUT - most teens use condoms sometimes

  46. Spermicides • Nonoxynol-9 • Foam preferred • When used with condoms, greatly inc. effectiveness.

  47. Barrier Methods • Diaphragm • Sponge • Cervical cap • Lea’s shield

  48. The Female Condom(1994) • Polyurethane • $3 each • 5 - 25% failure • Female controlled • Cumbersome

  49. Emergency Contraception • Aka post-coital contraception, “morning after” pill • Indications: Rape Contraceptive failure (condom broke) Unprotected intercourse • 1997 FDA approved

  50. Prescribing Emergency Contraception • Plan B preferred - progestin only • History, LMP,Urine preg test • 2 tabs 50m pill ASAP (within 72 hrs), repeat in 12 hrs. • Nausea (50%) and vomiting (20%), anti-emetics • Mechanism - prevents implantation

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