Untangling the Controversy: Emergency Contraception for Adolescents Erica Monasterio, MN, FNP Division of Adolescent Medicine University of California, San Francisco

Emergency Contraception Definition: a device or drug used as an emergency procedure to prevent pregnancy following unprotected or under-protected intercourse.

Methods Currently Available in the U.S. Combined Oral Contraceptives Copper Intrauterine Devices Progestin-only Prepackaged ECPs (Plan B)

Copper Containing IUD Insertion Appropriate for low risk young women who have had a child and want to use an IUD as their method of contraception

Yuzpe Regimen: OC Formulations Adapted from ACOG Practice Bulletin. Int J Gynecol Obstet. 2002;78: Brand NamePills/Dose  g EE/ Dose mg levonorgestrel/ Dose Ovral2 white Alesse5 pink Levlite5 pink Nordette4 light orange Levlen4 light orange Levora4 white Lo/Ovral4 white Triphasil4 yellow Tri-Levlen4 yellow Trivora4 pink Slide Source:ContraceptionOnline

“Plan B” Brand name for progestin only emergency contraceptive pills Recently approved for over-the-counter purchase by women >18 years old

YRBS 2003 Trends in Sexual Activity

NSFG 2002 Significant Decline in year olds

More than half of youth <18 are sexually experienced Cumulative % of teens who have had sex before reaching selected ages % Abma JC et al., Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2002, Vital and Health Statistics, 2004, 23(24).

Young people are at high risk of unintended pregnancy for many years Menarche Spermarche First intercourse First marriage First birth Intend no more children First intercourse First marriage First birth Intend no more children AGE 14.0 MEN WOMEN The Alan Guttmacher Institute (AGI), In Their Own Right: Addressing the Sexual and Reproductive Health Needs of American Men, New York: AGI, 2002, p. 8.

Many teens use contraceptives The majority of teens (74% of females and 82% of males) used contraceptives the first time they had sex The majority of teens (83% of females and 91% of males) used contraceptives the last time they had sex A sexually active teen who does not use contraceptives has a 90% chance of becoming pregnant within a year Abma JC et al., Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2002, Vital and Health Statistics, 2004, 23(24).

Many young teens become pregnant each year 280,000 teens younger than 18 become pregnant annually 87% of these pregnancies are unintended Of pregnancies to 15–17-year-olds: –56% result in live births –30% result in abortions –14% end in miscarriage Guttmacher Institute, U.S. teenage pregnancy statistics: national and state trends and trends by race and ethnicity, New York: Guttmacher Institute, September 2006,, accessed October 9, 2006; and Finer LB et al., Disparities in unintended pregnancy in the United States, 1994 and 2001, Perspectives on Sexual and Reproductive Health, 2006, 38(2):90–96.

ECPs: Mechanism of Action ECPs act by preventing pregnancy and never by disrupting an implanted pregnancy, i.e. never as an abortifacient If taken before ovulation, ECPs disrupt normal follicular development and maturation, blocks LH surge, and inhibit ovulation; they may also create deficient luteal phase may have a contraceptive effect by thickening cervical mucus (theoretical: no clinical data)

ECPs: Mechanism of Action If taken after ovulation, ECPs have little effect on ovarian hormonal production and limited effect on endometrial maturation ECPs may affect tubal transport of sperm or ova

Indications After unprotected intercourse After under-protected intercourse –After barrier method “accidents” –After missed OCPs (>2) –After missed progestin-only pills (1) –>14 weeks since last Depo-Provera shot –Transdermal patch detached >24 hrs. –Vaginal ring expelled/removed >3 hours –Vaginal spermacide used alone

Contraindications to Progestin- Only ECP Pregnancy Hypersensitivity to any component Undiagnosed abnormal vaginal bleeding

Instruction for Use As soon as possible after unprotected or under- protected intercourse Effective up to 5 days (120 hours) after event Can take both pills at once (package instructions are 1 pill followed by 2nd pill 12 hours later) Next menses may be earlier, later, and/or heavier Return for pregnancy test if no menses in 3 weeks Discuss STI screening and effective contraceptive plan as appropriate

Levonorgestrel and Yuzpe Regimens: Delay of Treatment and Pregnancy Rates Piaggio G, et al. Lancet. 1999;353:721. Used with permission. Daily (hours) Women (N) Slide Source: ContraceptionOnline

Side Effects Nausea and vomiting (less with Plan B) Breast tenderness Menstrual disturbance in next menses (early, late, heavier) Headache, mood changes, fatigue

EC and Sexual Risk Behaviors EC use is not associated with increased risk taking behaviors among adolescent women. Expanding access to emergency contraception impacts women's ability to use the product – period. Gold, MA, Wolford JE, Smith KA, Parker Am. The effects of advance provision of emergency contraception on adolescent women’s sexual and contraceptive behaviors. Journal of Pediatric and Adolescent Gynecology Apr; 17(2):

Answering the Concerns: Will access increase risky behaviors? Studies show that increased access to emergency contraception among adolescents does NOT result in inappropriate use of Plan B as a routine form of contraception does NOT result in an increase in number of sexual partners, does NOT result in an increase in frequency of unprotected intercourse does NOT result in an increase in the frequency of sexually transmitted diseases Raine T. et al, Increased Access to Emergency Contraception and Impact on Pregnancy and STIs: A Randomized Controlled Trial, Journal of the American Medical Association, 2005; 293:54-62.

Answering the Concerns: Will access to EC interrupt regular care? Young women who have easier access to EC are also no more likely to use EC repeatedly, than women who obtain it from a clinic or healthcare provider Furthermore, research show that a request for emergency contraception may actually lead to initiation of routine gynecologic care, including counseling about sexual behaviors and prevention strategies Stewart, HE, Gold MA, Parker AM. The Impact of Using Emergency Contraception on Reproductive Health Outcomes: A Retrospective Review in an Urban Adolescent Clinic. Journal of Pediatric Adolescent Gynecology (2003) 16:313–318.

Answering the Concerns: Is it a contradictory message? 68% of adults and 77% of teens think making emergency contraception more widely and easily available is consistent with a strong message to teens that abstinence from sex is their best option by far National Campaign to Prevent Teen Pregnancy Website. Removing the barriers to access ensures that teens who have sex when they do not want or do not plan to – as well as those who experience a contraceptive accident – are able to avoid unintended pregnancy

Access to EC Individual providers have an essential role: –Counsel all youth, regardless of current sexual activity or current method of contraception –Assess for current risk –Provide on-site access when possible –Offer prescription along with a list of local pharmacies where EC can be obtained

Access to EC Clinics play a significant role –2.2 million sexually active minors need publicly supported contraceptive services and supplies* –Each year publicly funded family planning clinics provide services to roughly 900,000 minors –Therefore, clinics serve about 40% of minors in need of publicly supported contraceptive services Guttmacher Institute, Women in Need of Contraceptive Services and Supplies, 2004, New York: Guttmacher Institute, 2006

Advocacy Has an Impact

Access Issues to Consider State funding of EC Coverage by plans Pharmacy Access Pharmacy/pharmacist refusal to supply Unrestricted OTC status Protecting minor consent/confidentiality Educating and Engaging Parents