1. Adolescent Contraception: Pills, Shots, Patches and Rings John Kulig, MD, MPH Laurie Hornberger, MD, MPH Job Corps Regional Medical Consultants

3. Sexual risk behavior ever had sexual intercoursemalefemale grade 9 41%29% grade 1042%39% grade 1154%50% grade 1261%60% >4 lifetime sexual partnersmalefemale grade 914% 6% grade 1224%20% Source: CDC 2001 Youth Risk Behavior Survey

4. Sexual risk behavior initiation of sexual intercourse before age 13 male students 9% female students 4% white students 5% black students 16% Hispanic students 8% all students 7% Source: CDC 2001 Youth Risk Behavior Survey

5. Sexual risk behavior condom use during last sexual intercourse white students 57% black students 67% Hispanic students54% alcohol or drug use at last sexual intercourse male students 31% female students21% white students 28% black students 18% Hispanic students24% Source: CDC 2001 Youth Risk Behavior Survey

7. Adolescent Pregnancy “Have been pregnant or gotten someone pregnant.” “Have been pregnant or gotten someone pregnant.” male 4% female 5% white 3% black11% Hispanic 6% Source: CDC 2001 Youth Risk Behavior Survey Source: CDC 2001 Youth Risk Behavior Survey

10. Oral Contraceptive Pills

11. New progestins 1st generation: norethindrone 2nd generation: norgestrellevonorgestrel 3rd generation: desogestrelnorgestimatenew:drospirenone

12. Noncontraceptive Benefits of OCs decrease menstrual flow (lighter, shorter periods) decrease menstrual cramps (no ovulation) improve anemia (lighter, shorter periods) improve acne (estrogen effect) protect against ovarian and endometrial cancer decrease benign breast disease decrease ovarian cyst formation prevent ectopic pregnancy protect against some causes of PID protect against osteoporosis

13. Oral Contraceptives and Risk of Breast Cancer study of 4575 women with breast cancer and 4682 controls - age 35 to 64 years at interview relative risk 1.0 [0.8-1.3] for current OC users relative risk 0.9 [0.8-1.0] for previous OC users similar results in white and black women relative risk did not increase with longer use or with higher estrogen dose no increased risk associated with initiation of OC use in adolescence NEJM 2002;346:2025-2032 NEJM 2002;346:2025-2032

14. Drug Interactions with OCs most anticonvulsants most anticonvulsants (except valproate) (except valproate) rifampin rifampin griseofulvin griseofulvin St. John’s Wort St. John’s Wort

15. Seasonale ® extended regimen combined oral contraceptive pills with ethinyl estradiol and levonorgestrel 91 day cycles - 84 days on - 7 days off 4 menstrual cycles per year - one each season clinical trials underway FDA approval anticipated in 2004

16. Emergency Contraception

17. What is the best method of emergency contraception (EC) for use by adolescents? Options: Yuzpe method (1982) combination oral contraceptive pills progestin-only pills dedicated emergency contraceptive pill products: Preven and Plan B dedicated emergency contraceptive pill products: Preven ® and Plan B ® mifepristone (RU486) insertion of intrauterine device

18. Ovral ® Lo-Ovral ®

20. Ovrette ®

23. Mifepristone (RU486)

25. How does EC work? mechanism of action of levonorgestrel + ethinyl estradiol may depend upon timing during the menstrual cycle principal mechanism is prevention of ovulation may thicken cervical mucus may interfere with transport of sperm, ova or zygote may inhibit implantation

26. How does EC work? onset of pregnancy is medically defined as implantation of a fertilized ovum in the wall of the uterus (ACOG) levonorgestrel + ethinyl estradiol is not effective once implantation occurs levonorgestrel + ethinyl estradiol does not induce abortion

27. How effective is EC? Pregnancy risk: 33% per cycle if sexually active qod 15% per cycle if sexually active once a week condom failure reported by 4%-7% of couples during a three-month interval EC use could prevent 2 million unintended births and 1 million induced abortions each year in the US

28. How effective is EC? Yutzpe regimen data: EC efficacy 74% by meta analysis of ten studies 0.5%-1.5% observed vs 4.7%-5.5% expected pregnancy rate no absolute contraindications except pregnancy no demonstrable teratogenicity

29. How effective is EC? Importance of timing: combined pill data 77% effective if taken within 24 hours of unprotected intercourse efficacy declines to 36% if treatment is delayed 25-48 hours efficacy declines to 31% if treatment is delayed beyond 48 hours

30. How effective is EC? Importance of timing: Plan B data Importance of timing: Plan B ® data 95% effective if taken within 24 hours of unprotected intercourse – reduces crude pregnancy rate from 8% to 0.4% efficacy declines to 85% if treatment is delayed 25-48 hours efficacy declines to 58%-61% if treatment is delayed beyond 48 hours

31. Are there medical contraindications to EC use? only absolute contraindication is pregnancy (because EC will not work) no evidence of harm to a developing fetus no concern about estrogen-related contraindications with progestin-only EC potential drug interactions with certain anticonvulsants, rifampin and griseofulvin may reduce efficacy

32. Is pregnancy testing necessary before using EC? EC is ineffective if implantation has occurred no evidence of harm to developing fetus if EC is taken inadvertently routine pregnancy testing is not recommended consider pregnancy testing prior to EC use if menses delayed consider pregnancy testing after EC use if menses does not occur within 3 weeks

33. Should an anti-emetic be prescribed with EC? Nausea: Yuzpe regimen50.5% Plan B Plan B ® 23.1%Vomiting: Yuzpe regimen18.8% Plan B Plan B ® 5.6% Data from a multi-center randomized clinical trial of 1,998 women.

34. Should EC be prescribed in advance of need? women receiving EC in advance are two to three times more likely to use them, but not to use them repeatedly (US/Scotland) 80% of women who received EC in advance began treatment within 24 hours of intercourse vs 40% of women who needed to fill an EC prescription no more likely to engage in sexual activity no more likely to use their regular contraceptive less consistently

35. Should EC be prescribed in advance of need? fewer than one third of female adolescents have heard of EC (1998 data) 17% of young women report no use of contraception at most recent intercourse 20% of women report forced sexual intercourse and 72% were under age 20 at the time of the experience (NCHS) lack of clinician availability on weekends may disproportionately affect adolescents

36. Should EC be made available without a clinician’s prescription? Citizen’s Petition filed with the FDA in February 2001 – 70 organizations currently available over-the-counter in 13 industrialized nations currently available from pharmacists in the states of California and Washington Ref: NEJM 2002;347:846-849

37. Should EC be made available without a clinician’s prescription? Arguments in favor of OTC availability: improved public health delays in treatment lead to more unintended pregnancies easier access to EC 24 hours a day safe for self-medication same dose for all women same medications safely used for contraception for decades serious adverse effects do not occur, even with inappropriate use

38. Should EC be made available without a clinician’s prescription? Arguments opposed to OTC availability: no clinician contact to discuss potential side effects missed opportunity for contraceptive counseling may make refusal of sexual intercourse more difficult EC is a euphemism for induced early abortion EC might unintentionally be used in pregnancy EC use might undermine use of non-emergency contraception, including barrier methods

39. Does knowledge of EC alter adolescent sexual behavior? study of 916 male and 852 female students age 14-15 in 12 schools in UK single lesson on emergency contraception improved knowledge persisted six months later in comparison with controls no difference in sexual activity, intent to use EC or use of EC Ref: BMJ 2002:324:1179-1183

40. Emergency Contraception Resources EC hotline1.888.NOT.2.LATE EC websitehttp://not-2-late.com http://not-2-late.com Clinician’s guide to providing EC http://www.piwh.org/publications.html http://www.piwh.org/publications.html Consortium for Emergency Contraception http://www.cecinfo.org/ http://www.cecinfo.org/

41. Progestin-only Injectable Contraception

43. Depo Provera  depot medroxyprogesterone acetate depot medroxyprogesterone acetate 150 mg IM once every 12 weeks 150 mg IM once every 12 weeks irregular bleeding => amenorrhea irregular bleeding => amenorrhea within 2 years (70%) within 2 years (70%) concerns: concerns: weight gain osteoporosis risk

44. Combined Injectable Contraception

45. Combined injectable contraceptives Lunelle  : –25 mg depot-medroxyprogesterone acetate and 5 mg estradiol cypionate injected (IM) once a month –0.5 mL IM q 30 days + 3 days –FDA approved in October 2000 –prefilled syringes withdrawn from the market in October 2002 - potency concerns

47. Lunelle  : Mechanisms of Action Suppress ovulation Change endometrium making implantation less likely Thicken cervical mucus preventing sperm penetration Reduce sperm transport in upper genital tract (fallopian tubes)

48. Lunelle  : Contraceptive Benefits highly effective (0.1-0.4 pregnancies per 100 women during the first year of use) effective immediately does not interfere with intercourse few side effects can be provided by trained nonmedical staff no supplies needed by the patient

49. Lunelle  : When to Start anytime you can be reasonably sure the patient is not pregnant days 1 to 7 of the menstrual cycle postpartum: –after 6 months if breastfeeding –after 3 - 6 weeks if not breastfeeding postabortion (immediately or within 7 days)

50. Contraceptive Patch

51. Ortho Evra  seven day contraceptive patch 1 3/4 inch three layer adhesive patch contains both estrogen and progestin applied to the buttocks, lower abdomen or upper body newly applied weekly for three weeks, then one week off for menses less effective in women over 198 pounds approved by the FDA in November 2001

53. Ortho Evra  Side effects leading to discontinuation: nausea (2%) moodiness (1.5%) headache (1.1%) breast discomfort (1%) irritation at application site (1.9%) Inadvertent detachment uncommon (1.9%), even with exercise, humid climates, saunas, hot tubs

54. Contraceptive Vaginal Ring

55. NuvaRing  contraceptive vaginal ring - 2 inch diameter worn for 21 days => removed for 7 days to allow menses => replaced with new ring releases 120 mcg of etonogestrel and 15 mcg of ethinyl estradiol daily one size only - does not require fitting cannot be inserted incorrectly no increase in vaginal infections/discharge 3 hour window after inadvertent removal

57. Contraceptive Implant

59. Implanon  progestin-only contraceptive implant single flexible 4 cm rod inserted under the skin of the upper arm contains 68 mg etonogestrel - releases 40 mcg daily - 3 year efficacy no pregnancies in 73,000 monthly cycles irregular menstrual bleeding common clinician visit for insertion and removal

61. Intrauterine Contraceptive System

62. Mirena  levonorgestrel-releasing intrauterine system - 20 mcg daily - 5 year efficacy highest risk of PID within 20 days of insertion irregular menstrual bleeding common in first 3-6 months clinician visit for insertion and removal

64. Condom Use and Hormonal Contraception Consistent condom use OCs21% DMPA18% Norplant 9% Condom use at last intercourse hormonal contraception52% no hormonal contraception69%

65. FemCap  silicone rubber cervical cap - less irritating than latex used with microbicide/spermicide worn for up to 48 hours 3 sizes: –small (22 mm) - never pregnant –medium (26 mm) - pregnant, no vaginal delivery –large (30 mm) - vaginal delivery at term can reuse for two years FDA approved in March 2003

67. “The Contraceptive Report” Quarterly update on advances in contraceptive technology Available online at: www.contraceptiononline.org/contrareport/ issue.cfm Subscribe for free at: www.emron.com/TCR www.emron.com/TCR

68. Sexually Transmitted Disease Guidelines Centers for Disease Control and Prevention May 2002

69. Chlamydia All sexually active adolescent and young adult women should be screened annually, regardless of the presence or absence of symptoms. All women with Chlamydia infections should be rescreened 3-4 months after treatment is completed.

70. Gonorrhea Resistance to fluoroquinolone antibiotics (ciprofloxacin,ofloxacin,levofloxacin) has been found on the West Coast. It is unknown how extensive this resistance will become or how quickly it may spread. Cefixime and ceftriaxone are now considered first line drugs to treat GC on the West Coast, but cefixime is no longer manufactured in the US.

71. Gay and bisexual males Expanded risk assessment - annual screening: –Chlamydia (anal, urethral) –gonorrhea (anal, urethral, pharyngeal) –HIV –syphilis Routine vaccination for hepatitis A and hepatitis B

72. Use of Nonoxynol-9 Frequent use of the spermicide nonoxynol-9 has been shown to cause genital (vaginal, rectal) lesions that can increase the risk of HIV transmission Condoms lubricated with nonoxynol-9 are no longer recommended Previously purchased condoms with N-9 can be used up until their expiration date

73. 2002 CDC STD Guidelines Two copies mailed to each center by Humanitas in February 2003 - one for center physician - one for Wellness Center reference Order by phone: 1-888-232-3228 Order online: www.cdc.gov/std => www.cdc.gov/std/treatment/default.htm