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

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

Adolescent Sexual Activity By School Grade (1996) • Grade 9: 37% • Grade 12: 66%

Adolescent Sexual Activity By Race and Gender • Males earlier than females • Blacks earlier than Hispanics earlier than Whites • Differences are lessening

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.

Adolescent Pregnancy

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

But...

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

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%

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

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

Availability

• Cost • Geographics • Clinic hours • Confidentiality issues

Demographic Factors

• Age • Race • Poverty • Educational Plans • Cultural Patterns

Legal Issues

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

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

Recommended Methods for Adolescents

CONDOMS PLUS:

1. Oral Contraceptives 2. Injectable Progestin (Depo-Provera) 3. Subdermal Implants (Norplant) 4. Spermicide

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

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

Contraceptive Effectiveness

Most Effective 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 Effectiveness

Less Effective 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

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

Mechanisms of Oral Contraceptives •

Combination

OCP: estrogen, progestin • Inhibition of ovulation • Thickened cervical mucous • Endometrium less favorable for implantation • Decreased tubal motility

Estrogen in OCP’s

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

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

• Newer progestins less androgenic?

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

Newer Progestins: Advantages

• Decreased androgenicity • Increased SHBG • Decreased free testosterone • Improved LDL:HDL ratio • Best for hirsutism, acne

Triphasics vs. Monophasics

• Less total hormone per month • No clear clinical advantage

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

Major Side Effects

Cardiovascular • 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

Major Side Effects

Cancer • Dec. risk of endometrial & ovarian ca.

• Breast & cervical ca. - no definitive inc.

JAMA ‘01: +FH breast ca. & OCP’s  inc. risk of breast ca.

BUT: Based on early hi dose pills • Hepatocellular adenoma - benign, 3-4/100,000

Other Side Effects

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

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.

Absolute Contraindications

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

Oral Contraceptives Summary • Safe and effective for healthy adol.

• Use low estrogen pill (20-35 m g) • 28 day pack and Sunday start method • Judicious advice about side effects • Frequent follow-ups.

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

Progestin Only Methods

Mechanisms • Blocks LH surge; inhibits ovulation • Thickens cervical mucous • Thin, atrophic endometrium

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

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

Depo-Provera Menstrual Changes

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

Depo-Provera Other Side Effects

• Weight gain - 2-5 lbs./yr.

• Delay to fertility - 9 mos.

• Depression • Dec. libido • Breast tenderness • Decreased bone density - under study

NEW: Lunelle

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

Subdermal Implants

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

Norplant Side Effects

• Irregular menses - greatest in 1st yr.

• Weight gain - less than Depo • Headaches • Acne • Insertion site problems • Depression • Hair changes

Condoms

• Must

always

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

Condom Use 12-19 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

Spermicides

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

Barrier Methods

• Diaphragm • Sponge • Cervical cap • Lea’s shield

The Female Condom (1994)

• Polyurethane • $3 each • 5 - 25% failure • Female controlled • Cumbersome

Emergency Contraception

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

Prescribing Emergency Contraception • Plan B preferred - progestin only • History, LMP,Urine preg test • 2 tabs 50 m pill ASAP (within 72 hrs), repeat in 12 hrs.

• Nausea (50%) and vomiting (20%), anti-emetics • Mechanism - prevents implantation

Contraceptive Patch

• Ortho-Evra • Available later 2002 • Estrogen & progestin • Apply new patch weekly x 3 • 4th week - withdrawal bleed

Vaginal Ring

• Nuvaring • Estrogen & progestin • Inserted for 3 weeks • Ring-free week withdrawal bleed

Ideal Contraceptive

• 100% effective • Completely reversible • No side effects • Inexpensive • Easy to use • Accesible

Conclusions

• Encourage “adult attitudes” towards sexualtity.

• Any method is better than none.

• Compliance.

• Oral contraceptives vs. Depo-Provera • Condoms must be used also.