1. S UCCESSES IN A DOLESCENT H EALTH : Improving Outcomes with Teens and LARC (Long-Acting Reversible Contraceptives) T HURSDAY, M AY 26, 2016

2. A forum to information-share about challenges faced and successful policies, programs, and practices in adolescent services. Listserv: Send an e-mail to LISTSERV@LIST.NIH.GOV with only this text in the message body:LISTSERV@LIST.NIH.GOV subscribe REGION-V-ADOLESCENTHEALTHNETWORK “your name” Contact Lesley.Craig@hhs.gov if you’d like to learn more.Lesley.Craig@hhs.gov The views expressed during today’s session are those of the presenters. They do not necessarily reflect the views of the Office of the Assistant Secretary for Health or the U.S. Department of Health and Human Services.

3. www.ohioadolescenthealth.org Twitter: @OhioAdolHealth

4. Hosted in recognition of National Teen Pregnancy Prevention Month

5. What Numbers Look Like for 2015 NCH 1140 Patients 309 LARC 27% LARC rate CPH 1248 Patients 189 LARC 15% LARC rate

6. Our Presenters Today Dr. Elise Berlan, Director, BC4Teens/Young Women’s Contraceptive Services Program, Columbus, Ohio Jo Taylor, CNP, Women’s Health Family Planning Center, Columbus Public Health, Columbus, Ohio

7. Elise D. Berlan, MD, MPH Associate Professor of Pediatrics The Ohio State University College of Medicine Director, BC4Teens/Young Women’s Contraception Program Nationwide Children’s Hospital

8. ………………..…………………………………………………………………………………………………………………………………….. Disclosure Merck Nexplanon® Clinical Trainer

9. ………………..…………………………………………………………………………………………………………………………………….. Roadmap Use of LARC in the US among adolescents Comparative effectiveness Describe IUDs and contraceptive implant Recommendations for use in adolescents Resources Next steps

10. ………………..…………………………………………………………………………………………………………………………………….. Long Acting Reversible Contraception = LARC = “Low Maintenance Contraception” Contraceptive implant IUD  Hormonal or copper https://thenationalcampaign.org/resource/whoops-proof-birth-control

11. ………………..…………………………………………………………………………………………………………………………………….. Teens and Sex in US? 47% CDC. Youth Risk Behavior Surveillance Survey— United States, 2013

12. ………………..…………………………………………………………………………………………………………………………………….. Teen Birth Characteristics (<18 years) US 2000-2005 79% pregnancy is unintended Of those not trying to become pregnant 48% were not using contraceptives at time of conception 52% were using contraceptives Coles et al. Contraception 2011 National Survey of Family Growth

13. ………………..…………………………………………………………………………………………………………………………………….. At last sex… 41% NO condom CDC. Youth Risk Behavior Surveillance Survey, Table 71— United States, 2013

14. ………………..…………………………………………………………………………………………………………………………………….. 41% NO condom 75% NO birth control pills, patch, shot, ring, implant or IUD CDC. Youth Risk Behavior Surveillance Survey, Table 71— United States, 2013 At last sex…

15. ………………..…………………………………………………………………………………………………………………………………….. 41% NO condom 75% NO birth control pills, patch, shot, ring, implant or IUD 91% NO dual method CDC. Youth Risk Behavior Surveillance Survey, Table 71— United States, 2013 At last sex…

16. ………………..…………………………………………………………………………………………………………………………………….. LARC use by teens seen in Title X clinics 7.1% Vital Signs: Trends in Use of Long-Acting Reversible Contraception Among Teens Aged 15–19 Years Seeking Contraceptive Services — United States, 2005–2013

17. ………………..…………………………………………………………………………………………………………………………………….. LARC use among contracepting US females ages 15-19 4.3% Kavanaugh et al. Obstetrics & Gynecology 2015

18. ………………..…………………………………………………………………………………………………………………………………….. Adolescent Girls/ Missed opportunities Adolescents experiencing a pregnancy with stable insurance coverage had an estimated average of 2.7 primary care visits in the 12 months prior to becoming pregnant Kharbanda et al. JAMA Pediatrics 2014

19. ………………..…………………………………………………………………………………………………………………………………….. % women experiencing unintended pregnancy during first year of use MethodTypical Use (%) Nexplanon®0.05 Hormonal IUD0.2-0.9 Copper IUD0.8 Depo Provera®/(DMPA)6 Pill/patch/ring9 Diaphragm12 Male condom18 Withdrawal22 Fertility awareness24 Trussell. Contraception. 2011 May ; 83(5): 397–404

20. ………………..…………………………………………………………………………………………………………………………………….. Non-LARC discontinuation Compared to IUD, all other methods are 6 to 12 times more likely to be discontinued 6 month discontinuation – DMPA 80% – Pill 57% – Patch and ring83% Maslyanskaya et al. JPAG 2015

21. Adolescent Contraceptive Use There are many missed opportunities. Birth control pills and/or condoms are most commonly used contraceptives. Pills have high failure rates Pills have high discontinuation rates. LARC use is low. WE CAN DO BETTER.

22. ………………..…………………………………………………………………………………………………………………………………….. LARC Access Opportunities Add value to interaction with patients Patient-centered Yen S, Saah T, Hillard PJ.Yen S, Saah T, Hillard PJ. J Pediatr Adolesc Gynecol. 2010 Jun;23(3):123-8.

23. Endorsements/ Practice recommendations 2010 United States Medical Eligibility Criteria for Contraceptive Use for women < 20 years Implant: No restrictions IUD: Advantages generally outweigh proven or theoretical risks http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm

24. Endorsements/ Practice Recommendations ACOG Committee Opinion (October 2012) LARC are safe and appropriate contraceptive methods for most women and adolescents ***Providers concerns about LARC use by adolescents are a barrier to access*** Committee Opinion No. 539. ACOG. Obstet Gynecol 2012; 120:983-8

25. Endorsements/ Practice Recommendations Society of Family Planning Clinical Guidelines (2010) “Use of the Mirena™ LNG-IUS and Paragard™ CuT380A intrauterine devices in nulliparous women” Adolescent women should be considered candidates for IUDs

26. Endorsements/ Practice Recommendations AAP Policy Statement (9/2014) LARC are recommended as first line options for teens Pediatrics Vol. 134 No. 4 Oct 1 2014

27. Winnable Battles Goal: reduce teen birth to less than 30.3 per 1,000 by 2015 Key action #4: Promote the use of effective contraceptive methods, including long-acting reversible contraception, by sexually active teens http://www.cdc.gov/winnablebattles/teenpregnancy/index.htm l

28. ………………..…………………………………………………………………………………………………………………………………….. Case 1. “Aisha, I’m so glad you are here to talk with me today about birth control. It sounds like you had a rough time with the pill. The good news is that there are some extremely effective options available to you. What I’d like to do would be to tell you a bit about your options, starting with the most effective. Okay?”

29. ………………..…………………………………………………………………………………………………………………………………….. Menu of Contraceptive Choice

30. ………………..…………………………………………………………………………………………………………………………………….. Etonogestrel Implant (Nexplanon®) A small, thin, implantable progestin-only hormonal contraceptive that is effective for at least 3 years 99.95% effective Primary Mechanism: suppression of ovulation Inserted under the skin in the inner arm using local anesthesia

31. ………………..…………………………………………………………………………………………………………………………………….. Etonogestrel Implant (Nexplanon®) Bleeding is unpredictable on this method Many women have fewer days of bleeding, but about 1/5 have more Primary reason for early discontinuation Does not appear to affect bone density None to minimal weight gain

32. ………………..…………………………………………………………………………………………………………………………………….. Etonogestrel Implant Discontinuation in Pediatric Setting Of 750 patients, 10.3% discontinued within one year. Bleeding problems were primary reason for early discontinuation. Berlan, Contraception 2016

33. ………………..…………………………………………………………………………………………………………………………………….. Informed Consent Etonogestrel Implant (Nexplanon®) Benefits: Highly effective, 3 years, reversible, safe Side effect: Unpredictable Bleeding (is NORMAL) Risks: doesn’t protect against STI Potential complications  Pain  Infection  Bleeding  Scar  Tissue damage  Migration

34. ………………..…………………………………………………………………………………………………………………………………….. 52 mg levonorgestrel (LNG) IUD A small flexible intrauterine device that releases 20 mcg/day LNG Primary Mechanism: thickens cervical mucus, inhibition of sperm motility and function

35. ………………..…………………………………………………………………………………………………………………………………….. 52 mg LNG IUD (Mirena®) 99.8% effective FDA-approved for heavy menstrual bleeding Reduces menstrual bleeding by 90% Effective for at least 5 years

36. ………………..…………………………………………………………………………………………………………………………………….. 52 mg LNG IUD (Mirena®) No effect on bone density or weight Women may have cramping and irregular bleeding ≤ 6 months Many women ovulate

37. ………………..…………………………………………………………………………………………………………………………………….. 52mg LNG IUD (Lilleta®) 99.4% effective Effective for 3 years* FDA approved Feb 2015 FDA approved for nulliparous LOW COST $$$$ From: Allergan and Medicines360 https://www.lilettahcp.com/

38. ………………..…………………………………………………………………………………………………………………………………….. 13.5 mg LNG IUD (Skyla®) 99.1% effective Effective for 3 years FDA approved for nulliparous More bleeding than Mirena®/lower dose

39. ………………..…………………………………………………………………………………………………………………………………….. Copper IUD (Paragard®) 99.2% effective Effective for at least 10 years FDA approved for nulliparous Emergency contraceptive Women may experience heavier menses and increased cramping Hormone-free

40. ………………..…………………………………………………………………………………………………………………………………….. Informed Consent ( 52 mg LNG IUD) Benefits: Highly effective, 5 years, reversible, safe, reduces menstrual bleeding Side effect: Cramps, bleeding/spotting X 3-6 mo. Risks: doesn’t protect against STI Potential complications – Infection – Bleeding – Pain – Perforation – Expulsion

41. ………………..…………………………………………………………………………………………………………………………………….. Case 1. Aisha is very interested in Nexplanon®. She reports her last intercourse was six months ago. Her insurance is Ohio Medicaid. Her urine pregnancy test is negative. Since you know many young women do not return for their LARC placement, you decide to quick start Nexplanon®.

42. ………………..…………………………………………………………………………………………………………………………………….. Case 1. Aisha tolerates the procedure well. She and her mother leave assured that an unintended pregnancy is extremely unlikely.

43. ………………..…………………………………………………………………………………………………………………………………….. What can you do? Patty Cason’s “3 Questions” 1.Do you think you would like to have (more) kids some day? 2.When do you think that might be? 3.How important is it to you to prevent pregnancy (until then)? From Medscape Education Ob/Gyn & Women's HealthMedscape Education Ob/Gyn & Women's Health “Speaking With Your Patients About Contraception” CME/CE Mark Hathaway, MD, MPH; Patty Cason, RN, MS, FNP-BC

44. ………………..…………………………………………………………………………………………………………………………………….. What can you do? Educate yourself! Train yourself! Provide accurate information to the teens and families you interact with. Encourage abstinence and condom use. Promote conversations with parents/guardians. Promote the use of contraception, including LARC, for sexually active teens

45. ………………..…………………………………………………………………………………………………………………………………….. Additional Resources http://www.nationwidechildrens.org/bc4teens CDC MEC and Selected Practice Recommendations for Contraceptive Use Association of Reproductive Health Professionals “You Decide Toolkit” http://www.arhp.org/Publications-and-Resources/Clinical-Practice-Tools/You-Decide Reproductive Health Access Project http://www.reproductiveaccess.org/ The Contraceptive Choice Project http://choiceproject.wustl.edu/ The National Campaign to Prevent Teen and Unplanned Pregnancy http://www.whoopsproof.org/ https://bedsider.org/ http://www.thenationalcampaign.org/ American Academy of Pediatrics Policy Statement on Contraception American Congress of Obstetricians and Gynecologists (ACOG) LARC Program Adolescent Health Working Group (CA) – Sexual Health Toolkit www.ahwg.net/resources/toolkit.htm

46. LARC Fact & Fiction : Dispelling 7 persistent IUD and Implant myths Practical tips to improve LARC use in your practice Jo Taylor, MSN, RN, CNP Columbus Public Health Women’s Health & Family Planning Center

47. Disclosures Merck Clinical Training Faculty

48. Myth #1: LARCs cause PID & Infertility History: The IUDs of the past, such as the Dalkon Shield, were associated with serious infections. Facts: The WHO looked at 23,000 IUD insertions and found the risk of PID was the same as a woman’s baseline risk. (Farley et al, Lancet, 1992) LARCs are reversible. Once removed, a woman’s fertility rapidly returns to her baseline. (ACOG Practice Bulletin 121, 2011)

49. Myth #2: LARCs cause Ectopic Pregnancies Facts: LARCs are exceptionally effective at preventing pregnancy and therefore reducing overall ectopic rates The evidence shows that IUDs reduce the risk of ectopic pregnancy to 1/10 th that of women not using any form of birth control. With the implant, ectopic pregnancies resulting from method failure were similar to that which occur in the general population (4.7%). (Russo et al, Journal of Adolescent Health, 2013)

50. Myth #3: IUDs are painful; Teens will not tolerate insertion Facts: Few studies exist that specifically look at adolescent pain with IUD insertion Brockmeyer et al (2008), reported 33% of nulliparous women found insertion to be “less painful” than expected, 45% the “expected level of pain,” and 19% found it to be “more painful than expected.” (Smith, Journal of Women’s Health Care, 2015) Implications for practice: Education is key, “Vocal Local”, Slow, deliberate actions, and support during initial period (Shore, Adolescent Medicine, 2014)

51. Myth #4: IUDs are only for women that have had a baby Facts: IUDs are USMEC Category 2 for nulliparous women (advantages outweigh the risk) According to ACOG, “Intrauterine devices may be inserted without technical difficulty in most adolescents and nulliparous women” (Committee Opinion, Number 539, October 2012)

52. Myth #5: LARCs can only be inserted during a menstrual period Facts: According to the CDC, an IUD or an implant may be inserted at any time if it is reasonably certain that the woman is not pregnant (CDC, SPR, 2013)

53. Myth #6: Serious side effects are common with LARCs Facts: With IUDs, perforation is rare, approximately 1 in 1000 IUD insertions. (ACOG Practice Bulletin 121, 2011) No significant differences in perforation rates between nulliparous and multiparous women (Lyus et al, Contraception, 2010) With implants, changes in menstrual bleeding patterns is the most common side effect.

54. Myth #7: Teens prefer pills More than 50% of young women thought positively about IUDs after being educated on them. When cost is removed as a barrier, adolescents are more likely to choose a LARC method over other methods (one study reported LARC usage as high as 61-69% in ages 14-17). (Russo et al, Journal of Adolescent Health, 2013)

55. Practical Tips for Incorporating LARCS into your practice Create a LARC friendly Culture “Speak LARC” All patients offered a LARC Evidence Based LARC first Counseling & Menu of Choice RLP – One Key Question Patient education materials Reduce barriers Follow up & Support

56. Promote a LARC friendly environment Anticipate billing/inventory issues Staff training Outreach, Social Media Patient Stories Strengthen Referral Network Use Resources Anticipate billing/inventory issues Staff training Outreach, Social Media Patient Stories Strengthen Referral Network Use Resources

57. Going Forward… The Key to our Success – Keep it Simple!

58. References Centers for Disease Control and Prevention. (2013). U.S. Selected Practice Recommendations for Contraceptive Use, 2013. Centers for Disease Control and Prevention. (2010). United States Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2010. The American College of Obstetricians and Gynecologists. (2012). Adolescents and Long-Acting Reversible Contraception: Implant and Intrauterine Devices. Committee Opinion, Number 539, October 2012. The American College of Obstetricians and Gynecologists. (2011). Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Committee Opinion, Number 121, July 2011. Farley, TM, Rosenberg, MJ, Rowe PJ et al. Intrauterine Devices and Pelvic Inflammatory Disease: An international perspective. Lancet 1992: 339: 785-8. Russo, J, Miller, E, Gold, M. Myths and Misconceptions About Long-Acting Reversible Contraception (LARC). Journal of Adolescent Health 52: S14-S21. Smith, S. (2015) The Use of Intrauterine Devices (IUDs) in Adolescents and Nulliparous Women: A Systematic Review. Journal of Women’s Health Care 4:277 Shore, W. (2014) Adolescent Medicine, An Issue of Primary Care: Clinics in Office Practice 41:3. Lyus, R, Lohr, P, Prager, S. (2010) Use of the Mirena™ LNG-IUS and Paragard™ CuT380A intrauterine devices in nulliparous women. Contraception 81: 5, 367-371. Min, J, Buckel, C, Secura, G, Peipert, J, Madden, T. (2015). Performance of a Checklist to Exclude Pregnancy at the Time of Contraceptive Initiation among Women with a Negative Urine Pregnancy Test. Contraception 91: 1, 80-84. Pace, L, Dolan, B, Tishler, L, Gooding, H, Bartz, D. (2016). Incorporating Long-acting Reversible Contraception Into Primary Care: A Training and Practice Innovation. Women’s Health Issues 26-2, 131-134. Retrieved from www.whijournal.com.

59. S UCCESSES IN A DOLESCENT H EALTH : Improving Outcomes with Teens and LARC (Long-Acting Reversible Contraceptives) QUESTIONS? Email: Lesley.Craig@hhs.gov

60. S UCCESSES IN A DOLESCENT H EALTH : Improving Outcomes with Teens and LARC (Long-Acting Reversible Contraceptives) THANK YOU