Tahshann S. Richards, DO, MPH Attending Physician Department of Family Medicine Union Community Health Center October 18, 2012

 National Youth Risk Behavior Study  47.4% of students had ever had sexual intercourse  33.7% of students had sexual intercourse with at least one person during the 3 mo before the survey (currently sexually active)  6.2% of he students had sexual intercourse for the first time before 13 years old  15.3% had sexual intercourse with ≥4 persons during their life

 National Youth Risk Behavior Study  Among 33.7% sexually active students reported that during their last sexual encounter they or their partner had used the following:  Condom (60%)  Birth control pills (18%)  Injectable birth control, birth control ring, or intrauterine device (IUD) (5.3%)  Condom plus any of the above (9.5%)

 82% of adolescent pregnancies are unplanned  Accounts for 1/5 of all unintended pregnancies in the US  106 Bronx teens / 1,000 get pregnant  30% more than the national rate  about 2x frequency in Staten Island  Teen births -4 per 1,000 in the Bronx  2x rates in Queens and Manhattan

 Start the talk early!!  Preadolescence  Puberty  Provide health info to preteens and family  Adolescence  Attitudes/knowledge about sex  Sexual activity  Use of contraception

Talking about contraceptive DOES NOT:  Increase rate of sexual activity  Reduce the age of coitarche  Increase number of sexual partners  Increase sexual experimentation

 Promote healthy and responsible sexual decision making (including abstinence)  Be supportive and non-judgmental  Good history taking  Careful listening  KISS (Keep it Simple Silly) method

Know Teens Rights  When is confidentiality waived?  Guidelines for reimbursement for services  Medical record access  Appointment scheduling  Office policy regarding information disclosure

For sexually active teens using contraceptives  Support compliance  Manage side effects  Change method of contraception accordingly  Provide referral and frequent follow up  Counsel and screen periodically for STIs

 Abstinence  Most effective  Delay initiation of sexual activity until adulthood  Efficacy of abstinence based education controversial

 Condoms  Mechanical barrier method  Reduce transmission of STDs; therefore NOT optional  Pros  Easily accessible  No Rx required  Inexpensive  Legally purchased by minors  Young men share responsibility for contraception

 Female condoms  Barrier method  Effective in prevention of STDs  Cons  Costly  Limited accessibility  Difficult to insert  Squeaks 

 Spermicides  Contains nonoxynol 9 and octoxynol 9  High contraceptive failure rate when used alone  Effective in reducing pregnancy and STDs when used with condoms  Efficacy comparative to OCPS if used with condoms  Pros  No Rx required  Inexpensive

 Oral Contraceptive Pills (“The Pill” or OCPs)  Monophasic (Ortho Cyclen), Multiphasic (Ortho TriCyclen, Loestrin)  Best for teens who:  Desire regular menses  Motivated and organized to take pill every day  Condom must be used to protect against STI

 OCPs  Pros  Helps dysmenorrhea  Regulates menses  Treat DUB  Decrease risk of osteoporosis  Treat Acne  Protection against:  Ovarian and endometrial CA  Ectopic pregnancy  Ovarian Cysts  Iron deficiency anemia  Benign breast disease

 OCPs  Quick start  Gyn exam and PAP (if indicated ) within next 3 mo  Frequent follow up and monitoring

 Enhance compliance with patient education and problem solving  If teens miss 1–2 pills:  Take a pill as soon as pt remembers  Take the next pill at the usual time  If teens miss 3 or more pills:  Do not finish pack  Throw away remaining pills  Start next pack

 Depo Provera (“The Shot”)  Medroxyprogesterone Acetate)  Long acting progestin  Suppresses ovulation  Thickens cervical mucus  Creates a thin, atrophic endometrium  Given 150 mg IM dose every 12 weeks  Best for teens who:  Chronic illness (sickle cell, seizures, MR)  Are lactating  At risk for complication with estrogen  Pts who do not remember to take pills

 Depo Provera  Pros  Protection against endometrial cancer and iron deficiency anemia  Convenient  Effective pregnancy prevention  Cons  Irregular menses  Need for injection  Side effects- weight gain, headaches, bloating, depression and mood changes  Associated with delayed return to fertility  Possibly reversible osteopenia

 Nuvaring (“The Ring”)  Combined hormonal ring  Etonogestrel and Ethinyl estradiol  Inserted once a month  Stays in vagina for 3 weeks  Must be removed 21 d after insertion  New ring is inserted 7 d later

 Ortho Evra Patch (“The Patch)  Norelgestramin/ethinyl estradial  Transdermal  Change once a wk  Avoid placing on breast  Pros  Easy to remember  Effective  Cons  Increased risk of thromboembolic events  Not flesh colored

 Long Acting Reversible Contraception (LARC)  Pros  Safe, Effective  Higher continuation rate (LARC 86% vs short acting 55%)  Decrease unintended pregnancy rate (22x higher for short acting contraceptives vs LARC)  Barriers  Inaccessible  The provider!

 Intrauterine Device (IUD)  Mirena (Levonorgestrol)  Reversible  Protection up to 5 years  Expulsion rate range from 5-22 %  Changes in menstrual bleeding esp. in 1 st month

 Implant (Implanon, Etonogestrel)  Reversible, up to 3 years  High rates of infrequent bleeding or amenorrhea  Higher hemoglobin levels  Reduction in dysmenorrhea and pelvic pain  Minimal or no weight gain

 Emergency Contraceptive Pills (Plan B)  Levonorgestrel  Progestin only pill  Effective up to 72 hrs after sex  Pregnancy test done before administration of pills and 3 weeks after administration to detect  Rx required for <18 yrs old  Provide refill for future use

 Follow Up  Annual Pap  Screen for STIs every 6 mo-1 yr  Follow up Quarterly (sooner when initiating contraceptives)  CONDOMS, CONDOMS, CONDOMS…

References  ACOG. Adolescents and Long-Acting Reversible Contracpetion: Implants and Intrauterine Devices. Number 539. October 2012 ACOG. Adolescents and Long-Acting Reversible Contracpetion: Implants and Intrauterine Devices. Number 539. October 2012  CDC. Youth Risk Behavior Surveillance Unite dstates MMWR vol 62. no 4 June 2012 CDC. Youth Risk Behavior Surveillance Unite dstates MMWR vol 62. no 4 June 2012  AAFP. Managing Adverse Effects of Hormonal Contraceptiin Am Fam Physician 15:82 (12) December 2010 AAFP. Managing Adverse Effects of Hormonal Contraceptiin Am Fam Physician 15:82 (12) December 2010  AAP. Contrapception and Adolescents. Pediatrics Vol 104 No. 5 November 1999 AAP. Contrapception and Adolescents. Pediatrics Vol 104 No. 5 November 1999  teen-pregnancy-rate-cries-action-article #ixzz29dxRv5B8 teen-pregnancy-rate-cries-action-article #ixzz29dxRv5B8