1. What’s New in Adolescent Contraception? Rachel S-D Fortune, MD, FAAP Medical Director, Newport Academy

2. Pretest questions All of the following are ABSOLUTE contraindications to the use of combined hormonal contraceptives in adolescents, EXCEPT: a)Known thromboembolic mutation (i.e. factor V leiden, protein C, protein S, etc) b)Current cigarette smoker (<35 years of age) c)Family history of DVT/PE d)Personal medical history of stroke True or False: Intrauterine devices can be safely used in adolescent patients: a)True b)False

3. Rachel S-D Fortune, MD, FAAP Medical Director, Newport Academy

4. Disclosures “I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.” I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

5. Objectives Review current trends in adolescent sexual activity Explore eligibility criteria for various contraceptive methods Provide update on hormonal and non-hormonal methods of contraception Explore long acting reversible contraceptive (LARC) methods in depth

6. Youth Risk Behavior Surveillance Survey 2011 Trends in Adolescent Sexual Behaviors

7. Trends in Adolescent Pregnancy Rates Among 15-19 yo, pregnancy rates declined 27% from 1991  2000 117 68

8. Trends in Adolescent Pregnancy Rates Decreased pregnancy rate for 15- 19yo 86% attributable to changes in contraceptive prescribing 14% attributable to decreased sexual activity

9. Selecting a Contraceptive Eligibility Availability/Cost Mechanism of Action Feasibility Effectiveness Reversibility Side Effects

10. Contraceptive Eligibility Gordon and Pitts, 2012 Eligibility Availability/Cost Effectiveness Mechanism of Action Feasibility Reversibility Side Effects

11. Contraceptive Eligibility

14. Availability/Cost Medicaid covers: Long Acting Reversible Contraceptives (LARC) OCPs, NuvaRing, Ortho Evra patch Depo provera shots Private insurance companies cover*: Long Acting Reversible Contraceptives (LARC) OCPs, NuvaRing, Ortho Evra patch Depo provera shot For patients who cannot use their insurance: Planned Parenthood provides services at a cost Eligibility Availability/Cost Effectiveness Mechanism of Action Feasibility Reversibility Side Effects

15. Effectiveness Eligibility Availability/Cost Effectiveness Mechanism of Action Feasibility Reversibility Side Effects

16. The Basics Abstinence 100% effective Condoms Perfect use is only 85% effective Should be used in combination with all other methods Emergency Contraception (Plan B) Available to all No contraindications for anyone Very effective within 72 hours of unprotected sex Works by delaying ovulation; no effect on existing pregnancy

18. Combined Hormonal Contraceptives Oral contraceptive pills Vary in concentration of ethinyl estradiol Vary in type of progestin Mechanism of action: Ovulation inhibition Changes in cervical mucous (thickens) Needs high level of compliance Difficult for adolescent adherence Complex schedule for forgotten doses ~91% effective at preventing pregnancy Quick return to fertility

19. Combined Hormonal Contraceptives Side Effects 3-4x increase in risk of thromboembolic event Headaches Nausea Minor weight gain Contraindications Migraine with aura Past medical history of thromboembolism Untreated hypertension Lupus with vascular disease, nephritis or antiphospholipid Abs Less than 3 weeks post partum High triglycerides

20. Combined Hormonal Contraceptives Important points: Understand how/when to start OCPs* Counsel on minor side effects to avoid self discontinuation Low dose OCs may reduce bone mineral density Familiarize yourself with a couple of “go-to”, cheap pill options, such as Ortho Cyclen Follow up blood pressure and weight after 2-3 months Give plenty of refills! Be familiar with what is out there in the popular press!

21. Combined Hormonal Contraceptives OrthoEvra transdermal patch 150 mcg norelgestromin and 20 mcg ethinyl estradiol Mechanism of action: Ovulation inhibition Changes in cervical mucous (thickens) Needs a moderate level of compliance – once weekly ~91% effective at preventing pregnancy Quick return to fertility

22. Combined Hormonal Contraception Side Effects 3-4x increase in risk of thromboembolic event– may be higher Headaches Minor weight gain Site irritation Contraindications Migraine with aura Past medical history of thromboembolism Untreated hypertension Lupus with vascular disease, nephritis or antiphospholipid Abs Less than 3 weeks post partum High triglycerides Should not be used in patients >90kg (relative) Allergy to component of patch

23. Combined Hormonal Contraception NuvaRing intravaginal ring 120 mcg etonogestrel and 15 mcg ethinyl estradiol Mechanism of action: Ovulation inhibition Changes in cervical mucous (thickens) Needs a moderate level of compliance – once monthly Requires a high level of comfort with body ~91% effective at preventing pregnancy Quick return to fertility

24. Combined Hormonal Contraception Side Effects 3-4x increase in risk of thromboembolic event – may be higher Headaches Leukorrhea Contraindications Migraine with aura Past medical history of thromboembolism Untreated hypertension Lupus with vascular disease, nephritis or antiphospholipid Abs Less than 3 weeks post partum High triglycerides

25. Progestin-only pills (POPs) Progestin only pills 0.35 mg norethindrone Mechanism of action Ovulation suppression Changes in cervical mucous (thickening) Endometrial thinning Needs a HIGH level of compliance – very short half life Quick return to fertility Safe for patients with estrogen contraindication

26. Progestin-only pills (POPs) Side effects Headache Breast tenderness Acne/Hirsutism Nausea Spotting Contraindications Known or suspected pregnancy Genital bleeding of unknown etiology Liver tumors Acute liver disease

27. Depo Provera Depo Provera – “birth control shot”, DMPA 150 mg medroxyprogesterone acetate IM every 12 weeks Mechanism of Action Ovulation inhibition Changes in cervical mucous (thickens) Requires a lower level of compliance – every 12 weeks ~97% effective at preventing pregnancy Delayed return to fertility

28. Depo Provera Side Effects Irregular bleeding Weight gain (can be significant) Hair loss Bone loss Headaches Acne Contraindications Known or suspected pregnancy History of thromboembolic events Liver disease Genital bleeding of unknown etiology

29. The Land of LARC

30. Why LARC is BEST! Contraceptive Choice Project 9,256 adolescents and women (St Louis) 23% age 14-20 69% of 14-17 year olds chose LARC Implant>IUD 61% of 18-20 year olds chose LARC IUD>Implant Continuation rates better than non-LARC methods Copper IUD 75% Levonorgestrel IUD 81% Implant 82%

31. Why LARC is BEST!

32. Implanon/Nexplanon Etonogestrel implant Implanted in upper arm Placed by trained provider Simple office procedure Mechanism of action Ovulation inhibition Changes cervical mucous (thickens) Thins endometrium Prevents pregnancy at >99% for 3 years Rapid return to fertility after quick removal

33. Implanon/Nexplanon Side Effects: Irregular bleeding Headache Weight gain Acne Contraindications Known or suspected pregnancy PMH of deep vein thrombosis Liver tumors Genital bleeding of unknown etiology >130% IBW (relative)

34. Levonogestrel Intrauterine Device (Mirena IUD/Skyla IUD) Levonogestrel-releasing IUD (5 years and 3 years) Inserted into uterus Office procedure Tolerated by nulliparous women Mechanism of Action Changes cervical mucous (thickens) Inhibits sperm from reaching or fertilizing your egg Thins uterine lining >99% effective at preventing pregnancy Rapid return to fertility after removal of IUD

35. Levonogestrel Intrauterine Device (Mirena IUD/Skyla IUD) Side effects Expulsion Irregular bleeding Ovarian cyst Acne Contraindications Pregnancy or suspicion of pregnancy Uterine anomaly Acute pelvic inflammatory disease (PID) or high risk of developing PID Recent infected abortion in past 3 months Known or suspected uterine or cervical neoplasia or abnormal Pap smear Genital bleeding of unknown etiology Untreated cervicitis

36. Copper IUD (Paragard) Copper IUD (10 years) – continuous release of copper into uterus Inserted into uterus Office procedure Safe for nulliparous women Mechanism of Action Prevents sperm from reaching/fertilizing egg May prevent egg from attaching to the uterus >99% effective at preventing pregnancy Rapid return to fertility after removal of IUD

37. Copper IUD (Paragard) Side effects Expulsion Heavier, crampier periods Anemia Vaginitis and/or vaginal discharge Contraindications Pregnancy or suspicion of pregnancy Uterine anomaly Acute PID or high risk of developing PID Recent infected abortion in past 3 months Known or suspected uterine or cervical neoplasia or abnormal Pap smear Genital bleeding of unknown etiology Untreated cervicitis Wilson’s Disease

38. Quick Start Approach

39. Post-test questions All of the following are ABSOLUTE contraindications to the use of combined hormonal contraceptives in adolescents, EXCEPT: a)Known thromboembolic mutation (i.e. factor V leiden, protein C, protein S, etc) b)Current cigarette smoker (<35 years of age) c)Family history of DVT/PE d)Personal medical history of stroke True or False: Intrauterine devices can be safely used in adolescent patients: a)True b)False

40. Summary Contraception should be addressed with all adolescent patients in a primary care setting Knowledge of your patients current needs and medical history will guide your contraceptive decisions Being aware of emergency contraception and quick start contraceptive initiation WILL help prevent pregnancy in your patients

41. Thank You