1. Teens and Contraception: New Approaches for Improved Compliance and Decreasing Teen Pregnancy
Jennie Yoost MD, MSc
Assistant Professor
Pediatric and Adolescent Gynecology
Marshall University Department of OBGYN

2. LEARNING OBJECTIVES
Understand the mechanism of action and safety profile of different long acting reversible contraceptives including the subdermal implant and levonorgestrel intrauterine devices.
Understand the spectrum of contraceptives available and continuation rates of different methods among teenage users.
Understand the noncontraceptive benefits to using different methods of contraception.
Understand use, access, and mechanism of action of Emergency Contraception.

3. Case #1
14 year old female presents with her mom. She started menses age 11. Mom is interested in discussing birth control. The girl is not sexually active. Mom feels she “has a good head on her shoulders” and makes good decisions. She worries about some of her friends, and wants her started on birth control “just in case”.

4. Case #2
15 year old female presents for vaginal discharge. She has been sexually active since age 12, and has had a total of 6 partners since that time. She took birth control pills for a few months, but not using anything at this time. Pregnancy test is negative in the office. You ask if she is interested in birth control. She reports that she is, but “just has a hard time remembering it.”
What do you offer her?

5. WHAT ARE OPTIONS FOR TEENS?
SAME OPTIONS AS ADULTS!
Pills
Patch
Ring
Injection
Intrauterine Device
Subdermal Implant

6. Abstinence: It is important. It is encouraged. It can be secondary.
It only works if you are abstinent

7. Are teens really “doin’ it”?
Youth Risk Behavioral Survey 2011
45.6% sexually active
4% report sexual debut before age of (7% among AA)
13% > 4 sexual partners
53% report condom use
22.6% OCP use
7.5% other methods

8. The problem of unintended pregnancy
6.7 million pregnancies per year in the US
50% are unintended
Among year olds: 82% unintended
2010 US adolescent birth rate
34.2/1000
2007 US adolescent birth rate
42.5/1000

9. How do we compare to the rest of the world?

10. Variations within the US: among states (2010)
GOOD:
New Hamp 15.7
Massachusetts 17.2
Vermont 17.9
BAD:
Texas 52.2
Arkansas 52.5
New Mexico 53
Mississippi 55
WV (44.8) #43

11. Teens and birth control compliance:
METHOD
USE
FAILURE: Perfect Use
FAILURE:
Typical Use
Continuation at 12 months
Pills
Take one pill daily
0.3% 9%
33-52%
Patch
Place one patch weekly
25-50%
Ring
Place one ring monthly
31%*
Injection
Injection by health provider every 3 months
0.2% 6%
27-55%
Pills are overall the most common choice for teens.
50% of adolescents report missed pills during a given cycle

12. What is a LARC? Long Acting Reversible Contraception
Intrauterine Device
Progesterone containing (Mirena®, Skyla®)
Copper T (Paragard®)
Subdermal Implant
Nexplanon®

13. LARCs- a good option for teens! Copper IUD
Paragard®
No hormones
Effective for up to 10 years
Placed by a simple procedure
Can be done under sedation
Mechanism of Action
Copper ions inhibit sperm motility
Inhibition of sperm capacitation (ability of sperm to fertilize an ovum)
Sterile inflammatory reaction of endometrium (phagocytosis of sperm)
May cause increased menstrual bleeding

14. LARCs- a good option for teens! Levonorgestrel IUDs
Mechanism of Action
Increased cervical mucous
Decreased tubal motility/ change in tubal fluid
Alteration of endometrium
Ovulatory inhibition
Mirena®
20mcg/day levonorgestrel
Lasts 5 years
Skyla®
14mcg/day levonorgestrel
Lasts 3 years
Smaller dimensions
Placed by a simple procedure
Can be done under sedation

15. Levonorgestrel IUDs Noncontraceptive Benefits Contraindications
Decreased menstrual bleeding
Amenorrhea
Improved dysmenorrhea
Local action
No medication interaction
Use in girls with medical comorbidities
Contraindications
Pregnant (too late!)
Active PID or puerperal or postabortion sepsis
Current STDs
Undiagnosed vaginal bleeding
Malignancy of genital tract
Known uterine anomaly or distortion of uterine cavity

16. LARCS- a good option for teens! Subdermal Implant
Nexplanon™
68mg etonogestrel
Single rod
Effective for at least 3 years
Procedure
Inserted subdermally in groove just below biceps
Can be placed at initial visit
Mechanism of Action
Ovulation inhibition
Increased cervical mucous
Endometrial atrophy

17. Nexplanon®

18. LARCs- a good option for teens!
METHOD
FAILURE:
Perfect Use
Typical Use
Levonorgestrel IUD
0.2%
Subdermal Implant
0.05%

19. Don’t Believe Me?
ACOG: “top tier methods of contraception including IUDs and implants should be considered as first line choices for adolescents”
CDC/WHO:
Subdermal implants=
Category I “no restriction”
IUD=Category II “advantages outweigh theoretically or proven risk”

20. “But my friend’s sister’s friend told me that…….”

21. Lets Look at the Data: Pregnancy Compliance/ Continuation Satisfaction
Bleeding patterns
Risks

22. CHOICE study- prospective cohort
(St. Louis, Aug 2007-Sept 2011)
9256 patients
Risk of pregnancy:
Pill/patch/ring= 4.55/100 pt years
LARC= 0.27/ 100 pt years
Efficacy not altered when stratified for age <21

23. CHOICE Study Results:

25. LARCs had 81% continuation at 1 year---
Better than any other
non-LARC method!!

26. LARC- Satisfaction CHOICE study:
75% of patients chose a LARC method
69% of adolescents chose a LARC method
Women using LARC methods had highest satisfaction at 1 year follow up
Method
% Satisfied at 1 year
Levonorgestrel IUD
86%
Copper IUD
80%
Subdermal Implant
78%
Injection
54%
Pills
Ring
52%
Patch
42%

27. Subdermal Implant: What are the risks?
Complications are rare (<1%)
Infection
Hematoma formation
Local irritation
Expulsion- rare case reports occurring in setting of infection

28. Subdermal Implant: Bleeding patterns
Unscheduled bleeding
Can not predict bleeding pattern
Abnormal bleeding can lead to discontinuation in 10-14% of patients
Meta-analysis (780 women)
Evaluated bleeding patterns in first 2 years of use
22% amenorrhea
34% infrequent bleeding (<3 episodes of bleeding)
7% frequent bleeding (>5 episodes of bleeding)
18% prolonged bleeding (≥1 episode lasting >14 consecutive days)

29. IUD Risks: “This ain’t your Mama’s IUD”
Infection:
Monofilament string- does not increase risk of pelvic infection
WHO clinical trial (23,000 IUD insertions)
Risk of PID was same as baseline risk in population without an IUD
Increased in first 20 days after insertion (9.7/1000 women-years)
From 21 days- 8 years risk 1.4/1000 women years (same as general population)

30. IUDs and Infection
Screen for Gonorrhea and Chlamydia before or at the time of insertion
What if GC/CT test comes up positive?
TREAT---Do NOT REMOVE IUD
Absolute risk of PID is low
0-5% among women with a positive GC/CT test at time of insertion

31. IUD Risks: Expulsion Partial or complete expulsion from the uterus
Skyla: 3.2% (clinical trial- 54 out of 1665)
Mirena/Paragard- between 2-10% in first year
What to do:
Can replace it with another IUD
Can change methods

32. IUD Risks: Perforation
Skyla clinical trial: incidence of <0.1%
Mirena/Paragard:
WHO: <1 per 1000
Dependent on experience of practitioner
Insufficient data to demonstate a difference in perforation risk between parous and nulliparous women
Only case series exist of difficult removals and laparoscopic removals

33. IUD: Bleeding patterns
Mirena®
Most common change is decreased bleeding
Average monthly blood loss drops by 90%
At 1 year 20-40% amenorrhea
Best bleeding profile among all options
FDA approved for treatment of heavy menstrual bleeding

34. IUD Bleeding patterns: Skyla™
First 90 days
Second 90 days
1 year
3 years
Amenorrhea
<1% 3% 6%
12%
Infrequent bleeding 8%
19%
20%
22%
Frequent bleeding
31% 4%
Prolonged bleeding
59%
17% 9%
Treatment days 1-28
Treatment days
Mean # bleeding days
7.3 (±5.6)
2.1 (±2.7)
Mean # spotting days
9.2 (±6.1)
3.3 (±3.1)

35. IUD: Other Myths and Misconceptions
Misconception: IUD insertion is painful/difficult in nulliparous
Insertion not technically difficult
Risk of discomfort (86% report discomfort with insertion)
Pre-procedure misoprostol gives no improvement
Overall well tolerated
Misconception: IUDs must be inserted during menses
Can be inserted at any time
Menses may make insertion easier
Must exclude pregnancy
MYTH: IUD causes infertility
Fertility returns immediately with removal
Prior studies among infertile women showed no correlation with previous IUD use
MYTH: IUD causes ectopic pregnancy
Lowers risk just as overall risk of pregnancy decreased
0-0.5per 1000 women- years (compared to in women without)
If pregnancy occurs, proportion is higher

36. Levonorgestrel IUD: Don’t Forget the Benefits!!
Use in those with medical contraindications to estrogen
Menstrual suppression for physical and developmental disabilities
Treatment of heavy menstrual bleeding
Treatment of dysmenorrhea (“bad cramps”)
Treatment of pelvic pain and endometriosis
Dysmenorrhea is leading cause of short-term recurrent school absenteeism

37. Contraception in Teens: Some final thoughts
A pelvic exam is not required for giving an adolescent birth control (IUD is exception)
Quick Start is preferred for all methods
Discuss concerns/misperceptions at the onset

38. Case #3
16 year old female presents for routine gyn exam on Monday morning. Sexual history reveals that she is currently not using any hormonal contraceptive method. Had unprotected sex on Saturday night and concerned about her chance of pregnancy. Wants to know what she should do.

39. Emergency Contraception
Plan B One-Step™ - Levonorgestrel 1.5mg
FDA approved in 1999
Available over the counter for age ≥17
2011- Dept HHS overturned FDA decision to make OTC without age restriction
4/5/13: Federal court rules emergency contraceptives needs to be sold over the counter
4/30/13: FDA approves morning-after pill without prescription for girls 15 and older

40. Response to court ruling:
American Academy of Pediatrics:
“While pediatricians recommend that teens delay sexual activity until they fully understand its consequences, we strongly encourage the use of contraception, including emergency contraception to protect the health of our adolescent patients who are sexually active.”
Society of Adolescent Health and Medicine:
“Today’s ruling acknowledges clear evidence that EC is a safe and effective method of backup birth control for all women of reproductive age”
American College of Obstetricians and Gynecologists:
“EC is a safe, effective way to help prevent unintended pregnancy after a contraceptive failure, unprotected sex, or sexual assault. We believe all EC products should be available over the counter.”

41. Emergency Contraception: What is it?
Levonorgestrel 1.5mg
Progesterone only medication taken in one dose
Decreases risk of pregnancy from 8% to 1-2% after single episode of unprotected sex
Can be taken up to 5 days after unprotected intercourse

42. Emergency Contraception: How does it work?
Progesterone
Inhibits or delays ovulation
May interfere with sperm transport or tubal motility
Does not disrupt a pregnancy!!!! X X

43. Let me repeat…..
If you’re already pregnant, it won’t do anything to the existing pregnancy
Will not cause an abortion
Will not harm a developing embryo.

44. Emergency Contraception: Who can take it?
World Health Organization: Category 1
No restrictions to use
Okay for females with contraindications to birth control pills
Cardiovascular disease, liver disease, migraines, etc…

45. Emergency Contraception: When do you take it?
No clinical exam or pregnancy test necessary before use
Any time unprotected or inadequately protected intercourse occurs
Take as soon as possible after event
Efficacy decreases with time
Still moderately effective when taken up to 5 days after intercourse

46. Emergency Contraception: What are the side effects?
Nausea (18%)
Vomiting (4%)
Repeat dose if vomiting occurs <2 hours from initial dose
Irregular bleeding
Menses occurs usually within 1 week before or after expected

47. Emergency Contraception:
Costs approximately $50
Does not protect against subsequent intercourse
Does not protect against STDs
Need to discuss more effective forms of contraception

48. References:
ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2011;118:
Committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2012;120:983-8.
FINER LB, ZOLNA MR. Unintended pregnancy in the United States: incidence and disparities, Contraception 2011;84:
KEARNEY MS, LEVINE PB. Why is the teen birth rate in the United States so high and why does it matter? The journal of economic perspectives : a journal of the American Economic Association 2012;26:
YANG Z, GAYDOS LM. Reasons for and challenges of recent increases in teen birth rates: a study of family planning service policies and demographic changes at the state level. J Adolesc Health 2010;46:
MARTIN JA, HAMILTON BE, VENTURA SJ, et al. Births: final data for National vital statistics reports : from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 2012;60:1-70.
EDWARDS SM, ZIEMAN M, JONES K, DIAZ A, ROBILOTTO C, WESTHOFF C. Initiation of oral contraceptives--start now! J Adolesc Health 2008;43:432-6.
EATON DK, KANN L, KINCHEN S, et al. Youth risk behavior surveillance - United States, MMWR Surveill Summ 2012;61:1-162.

49. References:
THURMAN AR, HAMMOND N, BROWN HE, RODDY ME. Preventing repeat teen pregnancy: postpartum depot medroxyprogesterone acetate, oral contraceptive pills, or the patch? J Pediatr Adolesc Gynecol 2007;20:61- 5.
SUCATO GS, LAND SR, MURRAY PJ, CECCHINI R, GOLD MA. Adolescents' experiences using the contraceptive patch versus pills. J Pediatr Adolesc Gynecol 2011;24:
ZIBNERS A, CROMER BA, HAYES J. Comparison of continuation rates for hormonal contraception among adolescents. J Pediatr Adolesc Gynecol 1999;12:90-4.
RUSSO JA, MILLER E, GOLD MA. Myths and misconceptions about long- acting reversible contraception (LARC). J Adolesc Health 2013;52:S
CARR S, ESPEY E. Intrauterine devices and pelvic inflammatory disease among adolescents. J Adolesc Health 2013;52:S22-8.
ROSENSTOCK JR, PEIPERT JF, MADDEN T, ZHAO Q, SECURA GM. Continuation of reversible contraception in teenagers and young women. Obstet Gynecol 2012;120:
WINNER B, PEIPERT JF, ZHAO Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012;366:
ACOG Practice Bulletin No. 112: Emergency contraception. Obstet Gynecol 2010;115:

50. Thank You!