1. Sexual Health in Teens Jennifer Kurkowski, MSN, WHNP-BC Jane Geyer, MSN, WHNP-BC Division of Pediatric and Adolescent Gynecology at Texas Children’s Hospital Baylor College of Medicine, Houston, Texas

2. Disclosures  We have no disclosures

3. Objectives  1) Discuss stages of adolescent development as it relates to sexuality  2) Identify sexual behavior risk factors in adolescents  3) Review birth control options including emergency contraception  4) Discuss sexually transmitted infections in adolescents including treatment  5) Describe how to obtain a proper sexual history in adolescents

4. Adolescent development  Development is divided into three states-early, middle, and late  One of the tasks for development is acquiring a mature sexual development  Early adolescence (10-14) is when sexual curiosity begins and may lead to masturbation or early sexual activity  Middle adolescence (15-18) is when romantic relationships begin, serial monogamy or having several partners  Late adolescence (18 +)- have more mature understanding of sexual orientation, can participate in a variety of intimate relationships

5. Who is having sex?  Data from the 2013 Youth Risk Behavior Surveillance Survey  Nationwide 46.8% of students had ever had sexual intercourse  The incidence of ever having sexual intercourse was higher among Black and Hispanic students  Among high school grades- 30% of 9 th grade students reported having sexual intercourse, 41.4% of 10 th graders, 54.1% of 11 th graders and 64.1% of 12 th graders  Nationwide 5.6% of students had had sexual intercourse for the first time before age 13  7.3% of students reported they had been forced to have sexual intercourse

6. Lesbian, Gay, Bisexual  5% of teens identify as lesbian, gay, or bisexual  10% of females have participated in same gender sexual activity  2-6% of males have reported same gender sexual activity  Bisexual teens have higher rates of unprotected sex

7. Number of Partners and who is currently sexually active  Nationwide 15% of students had had sexual intercourse with four or more persons during their life  Higher among black and Hispanic males  From 1991-2013 significant linear decrease occurred overall in the prevalence of having had sexual intercourse with four or more person (18.7-15.0%) as well as the prevalence of being currently sexually active  34% of students had had sexual intercourse with at least one person during the 3 months prior to the survey

8. Teen Pregnancy  Since 1990 the teen pregnancy rate has dropped by half  In 2010 there were approximately 614,000 pregnancies to women younger than age 20 and the pregnancy rate was 57.4 per 1,000 women age 15-19  Majority of these pregnancies are unplanned  In 2010, 60% of pregnancies to girls age 15-19 resulted in a live birth, 15% resulted in a miscarriage, and 26% resulted in an abortion  The children of teenage mothers are more likely to have lower school achievement and drop out of high school, have more health problems, be incarcerated at some time during adolescence, give birth as a teenager, and face unemployment as a young adult

9. Teen Pregnancies in Texas  In Texas the teen pregnancy rate is 73 per 1000 women. Texas ranks 47 th in teen pregnancy rate. The lowest teen pregnancy rates are in New Hampshire  In 2014 there were 35,063 teen births  1.1 billion dollars were spent on teenage pregnancies

10. Who is using condoms/ birth control?  Among those who said they were currently sexually active 59.1% reported they had used a condom during their last sexual encounter  From 1991-2013 a significant linear increase occurred in overall prevalence of having used condoms during their last sexual encounter (46.2%-59.1%)  Overall 25.3% of currently sexually active students reported they had used some type of birth control  19% reported using birth control pills to prevent pregnancy before their last sexual intercourse  1.6% reported using the IUD or the birth control implant  4.7% reports using the patch, ring or shot  13.7% of student reported using no type of birth control

11. Birth control options  This discussion should include abstinence and contraceptive counseling  There are many forms of effective contraception  First line birth control methods for teens should be long acting reversible contraceptives (LARCS). These include intrauterine devices and subdermal implants  Other options include oral contraceptive pills, vaginal ring, skin patch, and the injection

12. Who chooses birth control?  Teens are more likely to seek contraception if they:  Perceive pregnancy as a negative outcome  Have long-term educational goals  Are older in age  Experience a pregnancy scare or actual pregnancy  Have family, friends, and/or a clinician who sanction the use of contraception\

13. LARCS  The contraceptive choice study out of St Louis showed that :  Among women who chose a LARC method, 86% were still using the method at 1 year. For women who chose a non-long-acting method, only 55% were still using their method at 1 year  Women using either LARC or the injection had the lowest unintended pregnancy rates during year 1, year 2, and year 3 of their follow-up. Pill, patch and ring users had much higher unintended pregnancy rates; they were 20 times more likely to have an unintended pregnancy compared to LARC users in Year 1  The IUD and Implant should be discussed first when presenting options to teens

14. Intrauterine Device (IUD)  Currently there are 3 IUDs available  They can last anywhere from 3-10 years  IUDs work by preventing sperm from fertilizing an egg as well as thickening cervical mucus which blocks sperm from entering the uterine cavity

15. Birth control Implant  Small rod that is implanted under the skin in the upper arm  Currently one Implant is available  Works primarily by thickening cervical mucous and preventing ovulation  Biggest side effect is change in menstrual bleeding pattern

16. Colorado program  Colorado offered free LARCs to teenagers from 2009-2013  The birthrate among teenagers across the state dropped by 40% from 2009 to 2013, while their rate of abortions fell by 42%

17. Birth Control Pills  Combined oral contraceptive pills contain two hormones; estrogen and progestin  One hormone pill is taken at the same time each day to prevent pregnancy  Encourage quick start method. If patients do this the pill will be effective in 1 week after starting it  Traditional cycles of BCP are 21 days of hormones followed by a 7 day hormone free break  If used correctly can be 98% effective

18. Birth Control Patch  Hormonal contraceptive patch worn on the skin that contains two hormones; estrogen and progestin  A patch is worn for one week at a time. A new patch is put on once per week for three weeks. The fourth week is a hormone free break  There might be a higher risk of getting pregnant for women who weigh more than 195 lbs  May cause skin irritation  Can be 98% effective if used perfectly

19. Birth Control Ring  Hormonal contraceptive ring is worn inside the woman’s vagina. It contains two hormones; estrogen and progestin  A ring is worn for three weeks (21 days). The ring is removed for one week. The fourth week is hormone free  May cause vaginal discharge or irritation  Can be 98% effective if used perfectly

20. Birth Control Injection  Progestin injection into arm or hip every 11-13 weeks  Is 99.7% effective  Stops body from releasing an egg each month  May cause irregular spotting/bleeding as well as amenorrhea  Can increase bone mineral loss. Getting regular weight bearing exercise and Calcium+ and Vitamin D in your diet is important  Can cause weight gain by increasing patient’s appetite

21. Effectiveness of birth control Methods

22. Emergency Contraception  Emergency contraception is the use of drugs or a device after unprotected intercourse to prevent pregnancy  Candidates include patients whose primary method failed or those who had unprotected intercourse  Not intended to be a primary method of contraception  In April 2013 a federal judge in New York ordered the U.S. Food and Drug Administration to make Plan B available to people of any age without a prescription and available in the retail isle  Can help prevent up to 80% of expected pregnancies

23. Emergency Contraceptive Pill  If taken within 24 hours of unprotected sex prevents 95% of possible pregnancies  Can be taken up to 120 hours (5 days) after unprotected sex preventing 58% of possible pregnancies  Does not affect a pregnancy that has already implanted  Cost ranges from 28-40 dollars  Is available OTC at most pharmacies

24. How does Emergency contraception work? 1) Inhibition or delay in ovulation (primary way) 2) Interference with fertilization or tubal transport 3) Prevention of implantation by altering endometrial receptivity 4) Causing Regression of the corpus luteum 5) Thickening of cervical mucus resulting in trapping of sperm  Instead of causing an abortion Emergency contraception can help PREVENT a patient from getting one

25. Legal issues with contraception  Minors right to contraception varies from state to state  In Texas you must have parental consent to start contraception unless you go to a Title X program  Texas is one of two states that does not allow state funds to be used to provide contraceptives to minors without parental consent  Teens do not need parental consent to obtain over the counter contraception such as condoms or the emergency contraceptive pill

26. Sexually Transmitted Infections  CDC estimates that youth ages 15-24 make up just over one quarter of the sexually active population, but account for half of the 20 million new sexually transmitted infections that occur in the United States each year  Compared with older adults, sexually active young adults are at higher risk of acquiring STIs  Risk factors include:  those who initiate sex at an earlier age,  residing in detention facilities  Drug use  Men having sex with men  Attending an STD clinic  Having multiple partners  increased biologic susceptibility- cervical ectropian

27. Screening for STIs  All 50 states allow adolescents to consent for their own STI care  There is no requirement in any state to notify parents except in limited or unusual circumstances  This can become difficult if a patient has private health insurance and a explanation of benefits is mailed to the parents  Despite high risk of STIs in adolescents many healthcare providers fail to assess for risk factors or screen in asymptomatic patients

28. Who should be screened?  Routine screening for C. trachomatis on an annual basis is recommended for all sexually active females aged <25 years  Routine screening for N. gonorrhoeae on an annual basis is recommended for all sexually active females <25 years of age  No recommendation for screening males for C. trachomatis and N. gonorrheoeae on a routine basis but a decision should be made based of clinical judgement and risk factors  HIV screening should be discussed and offered to all adolescents  Screening for other STIs including syphilis, herpes, HPV, hepatitis is not generally recommended in an asymptomatic patient  Cervical cancer screening is initiated at age 21

29. Chlamydia  Most common cause of bacterial sexually transmitted infections in both men and women  Nucleic acid amplification tests (NAATs)are more sensitive and specific than other diagnostic test. Can be a urine test, self collected vaginal swabs or cervical swabs.  First line treatment: Azithromycin 1 gram in a single dose or Doxycycline 100 mg twice a day X 7 days  Use Azithromycin when possible, better for patient compliance  Alternative therapies include: Ofloxacin 300 mg twice a day X 7 days, Levofloxacin 500 mg twice a day X 7 days  Pt should abstain from for 1 week until after patient and partner have both been treated.  Can retest in 3 months if there is a concern about compliance  Can be asymptomatic but the most common symptom in women is cervicitis and in men is urethritis.  Other symptoms include vaginal discharge, pelvic pain, burning with urination, irregular bleeding, painful sex

30. Gonorrhea  Gonorrhea can be diagnosed through urethral gram stain, urine culture, DNA probe, and DNA amplification techniques, and NAATs  CDC recommends when a patient is diagnosed with Gonorrhea they also be concurrently treated for Chlamydia  Treatment: Ceftriaxone 250 mg IM in a single dose with either 1 g of Azithromycin in a single dose or Doxycycline 100 MG BID X 7 days  The higher dose of Ceftriaxone is now recommended due to reports of treatment failure  If a patient is allergic to cephalosporins they should be treated with Azithromycin 2 g in a single dose  Lots of drug resistance associated with gonorrhea  Can be asymptomatic but the most common symptoms in women include vaginal discharge, pain with urination or irregular bleeding. Symptoms in men include pain with urination and discharge from the penis.

31. Pelvic Inflammatory Disease  Acute infection of upper genital tract, involving uterus, fallopian tubes, and/or ovaries  Sexually transmitted pathogens  C. trachomatis- found in endocervix in 10-36%  N. gonorrhoeae-15-44%  Both in 5-12%  10-30% of untreated GC/Chl cases  PID

32. Diagnosing PID  PID is a clinical diagnosis  Signs/Symptoms associated with PID  Abdominal pain ~90%  Abnormal vaginal discharge ~45-75%  Elevated ESR ~75-80%  Abnormal vaginal bleeding ~30-40%  Fever ~15-30%  Urinary frequency ~15-20%  Nausea/vomiting ~10-14%

33. Treatment for Pelvic inflammatory Disease  Presumptive treatment for PID should be initiated in sexually active young women and other women at risk for STIs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum clinical criteria are present on pelvic examination:  cervical motion tenderness or  uterine tenderness or  adnexal tenderness  Suspicion should be low for treatment do to risk of infertility in the future

34. Treatment

35. Specific Concerns  Compared to adult women, adolescents are at higher risk of cervical infections (gonorrhea, chlamydia) due to the immaturity of the cervix leading to larger surface area of cells unprotected by cervical mucous  An average of 10 days lapses before a symptomatic adolescent will seek care  25% of adolescents with an STI tried self treatment before seeking care  Single dose therapy is preferred when available, adolescents can be non complaint with longer treatments  Strongly encourage patients to notify partners

36. Expedited Partner Therapy  EPT is the delivery of medications or prescriptions by patients diagnosed with an STI to their sexual partners without clinical assessment of their partners.  The CDC concluded that EPT is a “useful option” to further partner treatment, particularly for male partners of women with Chlamydia or gonorrhea.  This is now legal in Texas. 31 states EPT is permissible, in 12 states EPT is potentially allowable and EPT is prohibited in 7 states.

37. Human Papillomavirus (HPV)  The most common STI  More than 40 different types that can affect the genital tract  90% of the time the immune system with clear HPV  The CDC estimated that 20 million people in the US have HPV and 6 million new people are diagnosed each year.  Can cause genital warts and cervical cancer. Can also lead to cancer in the anus, vagina, vulva, penis and oropharynx  Genital warts can appear as a small bump or group of bumps in the genital area. May be small, large, flat or in a cauliflower shape.  Genital warts can be diagnosed based on examination  Genital warts to not require treatment unless pt is symptomatic (puritis, discharge, burning, bleeding, psychological distress etc). Treatment is not thought to decrease transmission rate to partner  Most patient respond well to medical therapy, surgical therapy should be reserved for patients who fail medical therapy or those who have extensive lesions.  Medical therapies include Podofilox, Podophyllin, Trichloroacetic acid, and Imiquimod

38. Current Pap Guidelines: ASCCP  Current Pap guidelines recommend starting Paps at age 21 in healthy females  In Immunocompromised patients, pap tests can be initiated earlier at 18 or onset of sexual activity due to higher risk of invasive cervical cancer  Healthy adolescent females (19 and younger) have a high incidence of HPV with minor-grade cytological abnormalities but are at a very low risk for invasive cervical cancer.  Most adolescents will clear HPV spontaneously within 2 years of exposure to the virus without much long-term significance

39. HPV Vaccine Facts  Recommended for routine vaccination beginning in boys and girls at age 11 or 12. Can be given to females through age 26 and males through age 21.  3 shot series that protects against high risk strains of HPV known to cause cervical, oropharyngeal, vulvar, penile and anal cancers. Also protects against genital warts.  The annual number of HPV-positive oropharyngeal cancers is expected to surpass the annual number of cervical cancers by the year 2020.  Lifetime risk of acquiring an HPV infection 74-70%  A study performed in girls ages 11-24 showed that the vaccine does not increase sexual activity. Those who received the HPV vaccine were not more likely to become sexually active than those who did not receive the vaccine.  Safe AND effective!!!

40. Estimated Vaccination Coverage of >= 1 HPV Vaccine Dose Females ages 13-17

41. Estimated Vaccination Coverage of >= 1 HPV Vaccine Dose Males ages 13-17

42. Genital/Anal Ulcers: Herpes Simplex Virus  In United states, most adolescents presenting with genital ulcers are found to have Herpes simplex virus (HSV) or Syphilis, genital herpes being most prevalent.  HSV typically presents with painful multiple vesicular or ulcerative lesions.  Both HSV-1 and HSV-2 can cause genital ulcers.  Approximately 50 million Americans are infected with HSV-2. Young women and MSM more likely to be infected with genital HSV-1.  Cell culture and PCR testing are preferred testing methods in patients presenting with possible outbreak. Accuracy declines as lesions begin to heal.  Type specific serologic testing may be performed. Most useful in following scenarios:  Recurrent genital lesions with negative PCR or cell culture  Clinical diagnosis without laboratory confirmation  A patient whose partner has been diagnosed with genital herpes  HIV testing should be performed in all patients found to have HSV!!

43. HSV Treatment & Patient Education  Herpes outbreaks can be treated with antivirals including: Acyclovir, Valacyclovir, or Famciclovir  Suppressive therapy should be considered in patients with recurrent outbreaks. Daily suppressive therapy can decrease outbreaks by 70-80%. Is also effective in those without recurrent symptomatic outbreaks.  Asymptomatic viral shedding can occur at any time, so infected individuals should always notify partners of their condition and wear protection to prevent transmission.  Male latex condoms can reduce, but not eliminate transmission  Patients must abstain from sexual activity when outbreaks are present  Herpes is a lifelong viral illness

44. Reportable STIs  All 50 states require Syphilis, gonorrhea and HIV to be reported. In Texas reportable STIs include Chlamydia, gonorrhea, syphilis, HIV and Hepatitis. The provider or lab can make the report  The age of sexual consent in Texas is 17  If a patient is younger than 17 and their partner is 3 or more years older than them this is reportable. This is considered sexual assault/statutory rape  Any patient who is 13 years or younger and is sexually active this is reportable in Texas

45. Obtaining a Sexual History  Routine assessment of risk factors and sexual activity is important  Many adolescents are not routinely evaluated for this during office visits  When discussing sexual activity with patients remain straight forward, non judgmental and assure confidentiality  Let patients know a sexual history if an important part of regular medical care  Ask to speak with adolescents in private, away from their parents

46. Sexual History Example Form  Partners  Do you have sex with men, women or both?  In the past two months, how many people have you had sex with?  In the past 12 months, how many people have you had sex with?  Prevention of Pregnancy  Are you and you partner trying to get pregnant? If no what are you doing to prevent pregnancy?

47.  Protection from STIs  What do you do to protect yourself from STIs and HIV?  Practices  Have you had vaginal sex?  Have you had anal sex?  Have you had oral sex?  Do you use condoms (never, sometimes, always)? If not why don’t you use condoms?  Past history of STIs  Have you every had an STI?  Have any of your partners had an STI?

48. Who needs a Pelvic Exam?  Pelvic exams cause anxiety and discomfort in many adolescent patients. Gonorrhea and Chlamydia can now be screened through the urine  Pelvic exams should be done on symptomatic adolescents or ones with specific complaints  An external genital exam is appropriate for those patients complaining about lesions

49. Questions???

50. References 1. Legal Status of Expedited Partner Therapy (EPT). www.cdc.gov/std/ept/legal.htm, accessed February, 2016.www.cdc.gov/std/ept/legal.htm 2. Notifiable Conditions http://www.dshs.state.tx.us/idcu/investigation/conditions/, accessed February, 2016http://www.dshs.state.tx.us/idcu/investigation/conditions/ 3. Sexually Transmitted Diseases. www.cdc.gov/std/treatment/2010, accessed February, 2016www.cdc.gov/std/treatment/2010 4. United States National Immunization survey-Teen 2014. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6429a3.htm#fig3, accessed February, 2016http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6429a3.htm#fig3 5. Youth Risk Behavior Surveillance United States 2013, www.cdc.gov, accessed February, 2016www.cdc.gov 6. Effectiveness of Family Planning Methods. http://www.cdc.gov/reproductivehealth/unintendedpregnancy/pdf/contraceptive_methods_508.pdf, accessed February 2016http://www.cdc.gov/reproductivehealth/unintendedpregnancy/pdf/contraceptive_methods_508.pdf 7. The Guidelines for Comprehensive Sexuality Education: Grades K-12. Sexuality Information and Education Council of the United States. www.siecus.org/_data/global/images/guidelines.pdf (Accessed February, 2016) 8. Hatcher RA, Trussel J, Nelson AL, et al. Contraceptive Technology, 20th ed, Ardent Media, Inc, New York 2012. 9. Nelson AI, Neinstein LS. Contraception. In: Handbook of Adolescent Health Care, Neinstein LS, Gordon CM, Katzman DK, et al. (Eds), Lippincott Williams & Wilkins, 2009. p.389 10. Diedrich JT, Zhao Q, Madden T, Secura GM, Peipert JF. Three-year continuation of reversible contraception,. Am J Obstet Gynecol. 2015 Aug 7 11. Game Change in Colorado: Widespread Use Of Long-Acting Reversible Contraceptives and Rapid Decline in Births Among Young, Low-Income Women. Sue Ricketts, Greta Klingler and Renee Schwalberg. Perspectives on Sexual and reproductive health. Volume 6, number 3. Septmeber 2014 12. Wiesenfeld HC et. Al. Sex Transm Dis. 2005;32(7):400-5; Ness RB, et. al. Am J Obstet Gynecol 2002;186:929-37 13. Bendnarczyk, R.A., Davis, R., Ault, K., Orenstein, W., Omer, S.B. (2012). Sexual activity related outcomes after human papilloma virus vaccination of 11 to 12 year olds. J Pediatr Adolesc Gtnecol, 27(2), 67-71.; 14. Jemal A., Simard, E.P., Dorell C et al. Annual report to the nation on the status of cancer, 1975-2009, featuring the burden and trends in human papilloma virus (HPV)-associated cancers and HPV vaccination coverage levels. J Natl Cancer Inst 2013 Feb 6:105(3):175-201. 15. Trussell J., Raymond E. (2011). Emergency contraception: A last chance to prevent unintended pregnancy. 1-14