1. Contraception in Adolescents Karen Soren, MD Director, Adolescent Medicine Associate Clinical Professor Pediatrics & Public Health Columbia University Medical Center

2. What are the barriers to teens using contraception? Developmental issues: –Early adolescence: present oriented, impulsive –Middle adolescence: omnipotent, invincible Teens are spontaneous Teens may be ambivalent about pregnancy Teens have inadequate access to information and confidential care; lack of awareness of NYS rights

3. The conversation: AAP recommends postponement of sexual activity, especially for young teens “But -if you are going to be sexually active, you need protection!” Condoms are the best method for protection against sexually transmitted Condoms are an imperfect method for pregnancy –prevention You need a back-up for your condom…

4. The contraceptive visit : What do you need to do? Reassure adolescents of confidentiality History –PMH- rule out conditions that would not allow safe use of estrogen-containing methods –Sexual history –History of previous contraceptive use –Current medications Physical (very basic!) –Weight, BP –Gyn exam NOT required

5. How Methods are Chosen Use by friends or relatives Accessibility Personal knowledge Media Fear of side effects Physician recommendation

6. SUMMARY TABLE OF CONTRACEPTIVE EFFICACY (In 100 women, # pregnancies in a year) MethodTypical UsePerfect Use No contraception85 Spermacides2918 Withdrawal274 Diaphragm166 Condom152 Birth control pills80.3 Ortho-Evra patch80.3 Nuvaring80.3 Depo Provera30.3 Mirena IUD0.2 Implanon0.05

7. Barrier and Non-hormonal Methods Male Condom Female Condom Diaphragm Cervical Cap IUD- Paragard (Copper)

8. Male Condom STI protection Over the counter Imperfect method of contraception –85% effective Possible latex allergy (my need to use polyurethane condoms) Many condoms now lubricated but do not contain spermicide - issues with nonoxynol nine – mucosal irritant Need a back-up method…

9. Plan B Large dose of levonorgestral Best taken as soon as possible after unprotected intercourse Can take up to 5 days after mess-up (package says 72 hours) Now Plan B One-Step – single pill 75-85% effective in reducing pregnancy if used within 72 hours, less so if used later No serious side effects Over the counter now - >17 yo

10. Female Condom This says it all…

11. Cervical Cap/Diaphragm

12. Hormonal Methods Combined hormonal methods (estrogen and progesterone): –Oral contraceptive pills Monophasic or multiphasic –Ortho Evra Patch –Nuvaring Progestin-only methods –Depo-Provera injection –Progestin-only pills (minipill) –Implanon –Mirena IUD

13. A little about estrogens… Older pill (1960’s) started with 150 mcg mestranol – eventually decreased to 50 mcg because of side effects Ethinyl estradiol introduced in 1970’s Dose varies from 50 mcg to 20 mcg, but most pills now used are between 20 and 30 mcg Lower dose → less side effects, but more break- through bleeding, and less room for non- compliance

14. What about the progesterone type? First generation: (norethindrone, norethindrone acetate)- medium androgenicity- in Loestrin Second generation: (levonorgestral) – higher androgenicity -in Alesse, Lo-ovral, Seasonalle, Seasonique, Lybrel, (norgestrel – Lo/Ovral) Third generation: (norgestimate, desogestrel) – low androgenicity but slight increase risk of clots – in Ortho tri-cyclin Lo (Acne), Desogen Drospirenone: (spironalactone analog)- helps contact hirsuitism – in Yasmin, Yaz (PMDD)

15. WHO Guidelines - medical eligibility for each contraceptive method- categories: 1 = a condition for which there is no restriction for the use of the contraceptive method 2 = a condition where the advantages of using the method generally outweigh the theoretical or proven risks 3 = a condition where the theoretical or proven risks usually outweigh the advantages of using the method 4 = a condition which represents an unacceptable health risk if the contraceptive method is used

16. Contraindications to Estrogen Active liver disease (4) Untreated gall bladder disease (asymptomatic -2, symptomatic -3) Hypertension (140/90 or greater – 3, 160/100 or greater - 4) Personal history of thrombosis (4) Known thrombogenic mutations (4) Family hx thrombosis (2)- investigate… Migraine with aura (4) Condition leading to venous stasis, immobilization (4) Lupus with positive (or unknown) anti-phospholipid antibody syndrome (4) Diabetes with vascular disease (3,4) Post- partum <21 days, +/- breastfeeding (4,3) Smokers >35 ( 15 cigs/day -4)

17. Evidence: Among women with migraine, women who also had aura had a higher risk of stroke than those without aura. Women with a history of migraine who use COCs are about 2 to 4 times as likely to have an ischemic stroke as non-users with a history of migraine. Migraines and estrogen-containing methods:

18. Conditions that have little or no contraindications to estrogen use: Depression (1) Irregular bleeding in teens -after evaluation (1) Dysmenorrhea (1) Abnormal Pap (2) Obesity (2 – some risks – but benefits outweigh risks) Diabetes without vascular disease (2) Sickle cell disease (2): However, as sicklers more at risk for strokes and acute chest and bone infections – prefer progestin- only methods

19. Medications Medications that decrease the effectiveness of combined oral contraceptives (and progestin-only pills, implant) –Anticonvulsants – phenytoin, phenobarbitol, topiramate, carbamazepine, lamotrigine (3) –Rifampin, rifabutin (3) However, little effect on pill metabolism in users of most antibiotics (1)

20. Combined OCP’s Mechanism of action –Progesterone inhibits LH, thickens cervical mucus, atrophies endometrium –Estrogen inhibits FSH Other actions of BCPs –Increase SHBG and decrease free testosterone –Inhibit 5-  reductase in skin, decreasing conversion of testosterone to DHT

21. Combined OCP’s PROS –Rapid return to fertility –No anticipation –Menstrual regularity –Decrease dysmenorrhea and anemia –Decrease ectopic pregnancy rate –Decrease PID –Decrease ovarian and endometrial cancer CONS –Daily medication –Regular supply needed –Multiple SEs –Multiple contraindications –CLOTS

22. Combined OCP Side Effects ESTROGEN –Nausea –Fluid retention –Breast tenderness –Increases clotting by decreasing protein C, S, antithrombin III –HTN PROGESTERONE –Increases appetite –Depression –Elevated lipids (TG)

23. How to prescribe OCP’s Become familiar with a few types of pills Rule out contraindications to estrogen Patient can start any day (but some prefer Sundays or first day of period) Can give up to 6 packs at a time Bring back after 3-4 weeks to determine: –If teen started pill and if it is taken correctly –Any side effects

24. So what pill do I prescribe? Can start with a low-dose pill (Alesse, Loestrin 1/20) If teen has acne or PCOS-type stigmata, consider Ortho tri-cyclin Lo If teen has hirsuitism / PCOS, can use Yaz or Yasmin instead For dysfunctional uterine bleeding, can use Lo/Ovral – longer half-life of progestin- stabilizes endometrium

25. Ortho Evra Patch Norelgestromin 6mg/ ethinyl estradiol 0.75mg in a transdermal delivery system 1 patch weekly for 3 weeks, then patch-free for 1 week Traditionally, Sunday or first day of menses start- however, can start anytime Menses usually 4 days after patch removal

26. Ortho Evra PROS –No need for daily med –Teens like ease of usage CONS –2-3% detach –Nausea/ vomiting –Less effective if >90kg –More complicated if forget to change or falls off –Breast pain, rash –CLOTS: 60% more estrogen than a 35 mcg pill (FDA alert)

27. NuvaRing Etonogestrel 120 mcg/d + ethinyl estradiol 15 mcg/d Silastic ring inserted intravaginally for 3 weeks with 1 week off Less estrogen because more bioavailable Does not need to be put around cervix, just in vaginal vault adjacent to mucosa

28. NuvaRing PROS –Less estrogen (15 mcg equivalent) –Protects for a full cycle CONS –No STI protection –18% of women, 30% of men feel ring –Most common SE is leukorrhea –Again - clots

29. Depo-Provera Medroxyprogesterone acetate –150 mg IM every 11-13 weeks (up to 14 weeks) Progesterone actions –Suppresses LH and prevents ovulation –Thickens cervical mucus –Atrophies endometrium –Decreases cilia motility in fallopian tubes 50% amenorrheic at 1 year

30. Depo-Provera, cont PROS –Highly effective –No anticipation –Can breast feed –Decrease endometrial ca, yeast infection, PID, fibroids –Increases seizure threshold CONS –SE can’t be immediately stopped –Delay in return to fertility –Irregular bleeding and amenorrhea –Hypo-estrogenic state OSTEOPOROSIS

31. Depo-Provera, side effects Headache Mood swings Weight gain Hair Loss Irregular bleeding One third discontinue use after one year as a result of side effects

32. POPs Progestin-only pills (Micronor, Nor-QD) Small dose of progestin – works primarily by increasing viscosity of cervical mucus Does not reliably inhibit ovulation Need to be taken carefully and consistently – if more than 3 hours late with pill, will not be effective Useful for teens with contraindications to estrogen who will not accept Depo or Mirena

33. Implanon Contains 68 mg etonogestrel Single rod implanted subdermally on day 1-5 of cycle Last for 3 years. Works by thickening cervical mucus and also inhibits ovulation No effects on bones or lipids Irregular bleeding common side effect

34. Mirena – progestin containing IUD IUD containing levonorgestral Helpful for menorrhagia and dysmenorrhea Effective for 5 years Previously discouraged in teens because teens more at risk for infection- liability concerns Movement to encourage IUD use in teens currently Infection probably most related to insertion Can be inserted in nulliparous young woman- slight risk that will be expelled – teens should check for the string

35. So- what contraceptive method would you recommend? 18 year old with no significant medical or family history going off to college 14 year old coming in after an abortion – does not want her mother to know she is sexually active Obese 17 year old with acne and irregular periods 15 year old with heavy bleeding for a month who comes to the emergency room and has a hemoglobin of 8 Amenorrheic 16 year old with facial hair 17 year old tampon user who cannot remember to take a pill, and wants to keep her sexual activity from her mother 15 year old with migraines, and some preceding blurry vision 18 year old with lupus who is non-compliant with her medications