1. Adolescent Contraception
Kristin M. Rager, MD, MPH
Assistant Professor
UK Department of Pediatrics
Section on Adolescent Medicine

2. Unintended Pregnancy Among 15-17 yo - 83% of pregnancies
By age y, only about 30% of pregnancies are unplanned

3. Unintended pregnancies

4. Most Common Causes of Unintended Pregnancy
Contraceptive nonuse
Contraceptive user failure
Contraceptive method failure

5. Effectiveness of Methods
Perfect Use
Typical Use
OCP
>99%
95%
Evra
98-99%
Nuva
DMPA
99.7%
Mirena
99.9%
Condoms
97%
86%
Birth control methods are very effective-

6. Discontinuation - 1 Yr of Use
Method
% Who Discontinued Use
OCP
29%
Evra
Nuva
DMPA
30%
Mirena
Condoms
39%
One reason is that people often want to be on contraception, and start it, yet then discontinue use. A means of decreasing these discontinuation rates, and therefore, unplanned pregnancies, is to properly educate patients about the contraceptive methods and help them to chose what is best and most realistic for them…..

7. So Many Options…
With adolescents, you want to make sure that you are able to counsel them about all the options, - this includes how to use each method, what the sides are, what the benefits are, who shouldn’t use them…
Today we will review ocp, ec, evra, nuva, depo, and mirena

8. Oral Contraceptives (OCP)
Combination
Monophasics
Triphasics
Ethinyl estradiol content – 20 mcg-35mcg
Progestin only
Not a good choice for teens b/c <3hour window
But may need pop’s in those with contras to estrogen

9. Combined OCP - How They Work
Suppress HPO axis
Inhibit ovulation
↑ viscosity of cervical mucus
Alter endometrium
Alter endometrium to make implantation less likely

10. Combined OCP - Benefits
Dysmenorrhea, menorrhagia
Ovarian cyst suppression
Anemia, osteoporosis prevention
Risk of ovarian and uterine CA, PID, ectopics
Benign breast disease
Acne
First and Formost, pregnancy prevention (duh), also

11. Combined OCP - Sides GI symptoms (nausea) Headaches
Breakthrough bleeding
Libido changes
HTN - <2%
Weight change – NOT A SIDE EFFECT

12. Absolute Contraindications
Thromboembolic disease
Cerebrovascular or Coronary disease
Breast cancer
Estrogen –dependent neoplasia
Liver tumors
Pregnancy
Undiagnosed vaginal bleeding
Contras with combined ocp or any other estrogen containing method
Undiagnosed vaginal bleeding in adults primarily

13. Newer OCP Seasonale 30 mcg EE/levonorgestrel
84 days hormones, 7 days placebo
Therefore only 4 periods per year. Great for people who want/need infrequent menses – or anyone who just doesn’t feel like having a period every month!

14. Newer OCP Yasmin 30 mcg EE Drosperinone – spironolactone derivative
Anti-androgenic effects
Possibility of increased K

15. Must take a pill every day!!

16. Emergency Contraception
Inhibits ovulation
Changes cervical mucus
Alters transport of sperm
Interference with corpus luteum
NOT medical abortion
Cannot interrupt an established pregnancy
Within 72 hours of unprotected sex; repeat exactly 12 hours later (consider timing of 1st OC
Abstain until menses
Initiate contraceptive method

17. Emergency Contraception
Methods
Yuzpe method
High dose estrogen (100mcg) and progesterone
Major nausea
Plan B
0.75 mcg levonorgestrel x2
No nausea
Menses may be early or late
Yuzpe method is good when you don’t have access to plan b, can just give 2 doses of 100mcg ee (with phenergan)

18. EC -Plan B
% Pregnancies Prevented
Treatment Delay

19. Ortho Evra - “The Patch”
Suggested Core Slide

20. Composition of Transdermal System
Backing layer
Middle layer
Release liner
The patch is comprised of three layers – a backing layer, a middle layer, and a release liner – this is referred to as a matrix system
In this system, the hormones are actually in the middle layer with the adhesive (ie, the drugs are in the glue)

21. Estrogen and Progestin Delivery
Delivers continuous systemic doses of hormones
150 µg norelgestromin (NGMN) +
20 µg ethinyl estradiol (EE)
Per day
Due to its unique delivery mechanism, each patch worn delivers continuous doses of estrogen and progestin into the bloodstream
The progestin is norelgestromin – the active metabolite of norgestimate, commonly found in popular OCs
The estrogen is ethinyl estradiol, which is used in all OC formulations
4. 20 mcg continuous ee .
Suggested Core Slide

22. Where to Apply the Patch
Clean, dry, intact healthy skin
In a place where it won’t be rubbed by tight clothing
Should not be placed on skin that is red, irritated, or cut
Apply on first day of menses for “instant” protection
No makeup, creams, lotions, powders or other topical products should be applied to the skin area where the patch is or will be placed
If start on other day, like Sunday start, must use condoms for 7 days!!
2-4% of patches partially or completely detach

23. Partial or Complete Detachment
Contraceptive Patch
Partial or Complete Detachment
<24 hours
>24 hours
or uncertain
Attempt Reattachment
Stop current cycle. Start new cycle by applying new patch
Successful
Unsuccessful
I’m not going to go over this, but it is important to let pts know it might happen, and to write for a “spare” and give them handouts on what to do when /if it happens…..
Use backup contraception for one week
Continue method as usual
Apply new patch. Change day remains the same
Suggested Core Slide

24. Forgot to Apply/Change
Week 1
Week 2 or Week 3
Week 4
<48 hours
>48 hours
Apply patch as soon as remembered
Must use backup contraception for 1st week of new cycle
Remove patch when remembered
No backup contraception required
Remove current patch
Apply new Patch immediately
No backup contraception needed
Remove current patch
Apply new Patch immediately
Must use backup contraception for one week
If a patient forgets to change her patch, management is relatively simple
At the start of any patch cycle: (Week 1/Day 1): May not be protected from pregnancy; should apply the first patch of her new cycle as soon as remembered; new “Patch Change Day” and a new “Day 1”. Patient must use back-up contraception for the first week of new cycle
In the middle of the patch cycle (Week Two/Day 8 or Week Three/Day 15) one or two days (up to 48 hours): Should apply a new patch immediately; next patch applied on usual “Patch Change Day”; no back-up contraception is needed
More than two days (48 hours or more): May not be protected from pregnancy; should stop the current contraceptive cycle and start new four-week cycle immediately by putting on a new patch; new “Patch Change Day” and new “Day 1”; patient must use back-up contraception for one week
4. At the end of the patch cycle (Week 4/Day22): Remove patch when remembered; next patch applied on usual “Patch Change Day”, which is day after Day 28. Under no circumstances should there be more than a 7-day patch- free interval between dosing cycles. If so, patient may not be protected from pregnancy; backup contraception must be used for 7 days; risk of ovulation increases each day beyond recommended contraceptive-free period; if coital exposure has occurred during extended patch-free interval, possibility of fertilization should be considered
Suggested Core Slide

25. Evra Side Effects breast symptoms headache application site reaction
nausea
menstrual cramps
abdominal pain
In decreasing frequency of occurrence.
The most common things I have noted are breast tenderness and application site reaction

26. Precautions Body weight 198 lbs. (90 kg)
Results of clinical trials suggest that the contraceptive patch may be less effective in women with body weight >198 lbs (90 kg) than in women with lower body weights
3330 women were studied and there were 15 pregnancies on evra. 5 of the 15 were in women who weighed >198 pounds (these were only 3% of the participants) – still 95% effective in these women

27. Must change patch once a week!

28. NuvaRing Nuva ring is a flexible, transparent vaginal ring
Suggested Core Slide

29. NuvaRing Release EE: 15 µg/day + etonorgestrel
Insert ring on day 1-5 of cycle- remains in vagina for 21 days
Remove day 22-27–New ring inserted day 28
When first starting, should use condoms first 7 days
Menses occur 2-3 days after removing ring
Suggested Core Slide

30. NuvaRing Exact position not important Put where it is comfortable
Remove by putting finger in vagina and pulling it out
If removed or slips out of place for >3 hrs, back-up contraception is necessary for 7 days
Vaginal muscles hold it in place
should be noted that the ring can be expelled from the vagina while removing a tampon, moving the bowels, straining, or with severe constipation
If the ring slips out and it has been out less than three hours, you should still be protected from pregnancy. The ring should be re-inserted as soon as possible. If it has been out of the vagina for more than three hours, you may not be protected from pregnancy. You must use an additional method of birth control, such as male condoms or spermicide, until the ring has been in place for seven days in a row
Of note, must be refridgerated until dispensing. Pt may keep at room temp for up to 4 months.

31. Nuva - Sides Vaginitis Headache Leukorrhea Weight gain Nausea
Foreign body sensation
Coital problems
Device expulsion
90% of couples didn’t report fb sensation by man or woman during coitus

32. Must change Nuva once a month!

33. Depo-Provera (DMPA) Inhibits ovulation
After 150 mg im, ovulation suppressed for up to 14 weeks
Produces thinning of the endometrium
Increases viscosity of cervical mucous
By suppressing hpo axis

34. DMPA - Sides Menstrual irregularity Weight gain
60% amenorrhea at 1 year
Weight gain
5#/year for first 3 years
Bone density – teens should be increasing bone density not losing
Pts often have irregular spotting and even heavy bleeding

35. Must get DMPA every 12 weeks!

36. Mirena IUD Releases 20 mcg levonorgestrel/day Lasts at least 5 years
Thickens cervical mucus and inhibits sperm motility and function
The LNG IUS does not usually inhibit ovulation, but the pregnancy rate and the ectopic rate are extremely low, suggesting that a primary endometrial effect as the mechanism of action is unlikely. The endometrial atrophy, which is a consequence of the high endometrial levels of LNG, leads to the substantial decrease in menstrual flow and absence of bleeding in some women noted in users of this form of intrauterine contraception. A weak foreign-body effect is also noted
It is important to some patients that the LNG IUS mechanisms of action are all preconception. They prevent fertilization rather than disrupt implantation (a common misconception)

37. Mirena IUD Good Candidates:
Patients in a long term, monogamous relationship
Not at risk for an STI
No uterine anomalies
Suggested Core Slide

38. Important Points!!
None of the hormonal methods protect against sti’s and hiv, therefore is important to encourage condom use
Talk about contraception with all teens – not just those who are already having sex
There is no evidence that talking about or providing b.c. to teen increases sexual activity, number of partners or causes earlier sex

39. Important Points!!
Don’t have to have a pelvic exam to start contraception!
Don’t have to have parent’s consent to start contraception!

40. Thanks! Questions??