1. Adolescent Contraception Marcia J. Nackenson, M.D. Section of Adolescent Medicine Department of Pediatrics New York Medical College

2. Adolescent Contraception The Need Barriers to Adolescent Contraception Contraceptive Methods How to Provide Service

3. Adolescent Sexual Activity Ages 15 - 19 years Females:50% (1997) 55% (1990) Males:55% (1995) 60% (1988)

4. Adolescent Sexual Activity By School Grade (1996) Grade 9: 37% Grade 12:66%

5. Adolescent Sexual Activity By Race and Gender Males earlier than females Blacks earlier than Hispanics earlier than Whites Differences are lessening

6. Adolescent Contraceptive Behavior 25% use no contraception at 1st intercourse. 1 year intercourse before medical advice. 50% adol preg in 1st 6 months of sexual activity.

7. Adolescent Pregnancy 1 million pregnancies/year 85% unintended 50% live births 35% elective abortions 15% spontaneous abortions

8. But... Pregnancy Rates Decline 12% (1995) 103/1000 ages 15 - 19 yrs Abortion Rates Decline Birth Rates Decline 15% 57/1000

9. Recent Trends in Adolescent Sexuality Sexual Activity Down Condom Use Up Pill Use Down Pregnancy Rates Down Abortion Rates Down Birth Rates Down But…Condom & Pills 8%

10. Barriers to Adolescent Contraception Psychological Factors Availability Demographic Factors

11. Psychological Factors Immature cognitive functioning Dependency, passivity Difficulty in handling sexuality Risk-taking behavior Desire for pregnancy

12. Availability Cost Geographics Clinic hours Confidentiality issues

13. Demographic Factors Age Race Poverty Educational Plans Cultural Patterns

14. Legal Issues I. Consent A. Emancipated Minor B. Mature Minor C. Reproductive Matters II. Confidentiality III. Payment IV. Abortion

15. Issues in Selecting a Contraceptive Method Frequency of intercourse Tolerance of route of delivery Tolerance of side effects Nature of relationship ie, monogamous, long-standing

16. Recommended Methods for Adolescents CONDOMS PLUS: 1. Oral Contraceptives 2. Injectable Progestin (Depo-Provera) 3. Subdermal Implants (Norplant) 4. Spermicide

17. Limited Methods for Adolescents 1. Diaphragm 2. Female condom 3. Cervical cap

18. Methods Not Recommended for Adolescents 1. IUD 2. Tubal ligation/vasectomy

19. Contraceptive Effectiveness Most Effective Method Abstinence Implants Injectables Oral Contraceptives Vaginal Ring Patch IUD Pregnancy Rate % 0 0.09 0.3 0.1 1 1-2

20. Contraceptive Effectiveness Less Effective Method Condom plus foam Condom alone Female condom Diaphragm Withdrawal Rhythm No Method Pregnancy Rate % 2 - 10 2 - 20 5 - 20 2 - 18 20 20 - 30 90

21. History of Oral Contraceptives 2000 yrs ago - Arsenic, mercury, & strychnine 1920’s - Progesterone & estrogen isolated. 1935 - Progesterone synthesized. 1940’s - 50’s - Syntex: steroid synthesis 1950’s - Margaret Sanger - clinical trials 1960 - Enovid approved by FDA

22. Mechanisms of Oral Contraceptives Combination OCP: estrogen, progestin Inhibition of ovulation Thickened cervical mucous Endometrium less favorable for implantation Decreased tubal motility

23. Estrogen in OCP’s Ethinyl estradiol 20  30-35  - Most “low dose” OCP’s 50  Mestranol - converted to ethinyl estradiol 50 

24. Progestins in OCP’s Varying progestational & androgenic potency 6 different progestins available in U.S. Newer progestins less androgenic?

25. Newer Progestins (‘92-’93) Norgestimate - OrthoCyclen, Tricyclen Desogestrel - OrthoCept, Desogen ‘95 UK warning VTE FDA, ACOG - no changes needed Gestodene - Not available in US

26. Newer Progestins: Advantages Decreased androgenicity Increased SHBG Decreased free testosterone Improved LDL:HDL ratio Best for hirsutism, acne

27. Triphasics vs. Monophasics Less total hormone per month No clear clinical advantage

28. Minor Side Effects of OCP’s Breakthrough bleeding Nausea Breast soreness Headache Weight gain - NOT!

29. Major Side Effects Cardiovascular Related to high estrogen content, early pills Venous thromboemboli, MI, CVA Hypertension 1-5%, reversible with DC Esp. >35 yrs & smoker Post-op thromboemboli: DC pills 4 wks pre-op

30. Major Side Effects Cancer Dec. risk of endometrial & ovarian ca. Breast & cervical ca. - no definitive inc. JAMA ‘01: +FH breast ca. & OCP’s Ô inc. risk of breast ca. BUT: Based on early hi dose pills Hepatocellular adenoma - benign, 3-4/100,000

31. Other Side Effects Lipid level changes - screen if hi risk Carbohydrate metabolism - follow diabetics Post-pill amenorrhea or infertility - disproven Congenital anomalies - disproven

32. Beneficial Effects of OCP’s Dec. acne Dec. dysmenorrhea Dec. ovarian cysts Dec. fibrocystic disease of the breast Dec. PID Dec. endometrial and ovarian ca.

33. Absolute Contraindications Thromboembolic disorders Coronary artery disease Estrogen-dependent neoplasia Breast Cancer Pregnancy Active liver disease Undiagnosed abnormal vaginal bleeding

34. Oral Contraceptives Summary Safe and effective for healthy adol. Use low estrogen pill (20-35  g) 28 day pack and Sunday start method Judicious advice about side effects Frequent follow-ups.

35. Progestin Only Methods The Minipill - daily pill Depo-Provera - injectable Norplant - subdermal implant

36. Progestin Only Methods Mechanisms Blocks LH surge; inhibits ovulation Thickens cervical mucous Thin, atrophic endometrium

37. Progestin Only Pill Taken every day - no placebo pills Slightly less effective than combination pill; less forgiving of missed pill Indications - estrogen contraindication, lactation Disadvantages - unpredictable menses

38. Depo-Provera (Injectable Progestin) FDA approved 1992 Medroxyprogesterone acetate 150 mg. IM 1st injection within 1st 5 days of menses; neg Urine preg test Repeat q12 weeks ( up to 13.5 weeks) Cost: $50/dose

39. Depo-Provera Menstrual Changes Irregular menses Amenorrhea - 60% by 1 year Treatment of irregular bleeding: 1. Counseling 2. OCP 3. Ibuprofen 4. Estrogen

40. Depo-Provera Other Side Effects Weight gain - 2-5 lbs./yr. Delay to fertility - 9 mos. Depression Dec. libido Breast tenderness Decreased bone density - under study

41. NEW: Lunelle Combination injectable: Estrogen and progestin Given q28 days Advantage - regular menses Disadvantage - monthly visit

42. Subdermal Implants Norplant -FDA 1990, 6 levonorgestrel rods -Effective 5 years -Insertion and removal procedures -Bad publicity Implanon -Single rod, good for 3 years

43. Norplant Side Effects Irregular menses - greatest in 1st yr. Weight gain - less than Depo Headaches Acne Insertion site problems Depression Hair changes

44. Condoms Must always be recommended to prevent STD’s Latex or polyurethane only Reservoir-tipped, spermicide Effectiveness inc. with contraceptive foam Advantages: Safe, cheap, available Disadvantages: Coital dependent, male resistance

45. Condom Use 12-19 yr males 55% at first intercourse - Inc. from 20% in 1979 58% at last intercourse - Inc. from 21% in 1979 BUT - most teens use condoms sometimes

46. Spermicides Nonoxynol-9 Foam preferred When used with condoms, greatly inc. effectiveness.

47. Barrier Methods Diaphragm Sponge Cervical cap Lea’s shield

48. The Female Condom (1994) Polyurethane $3 each 5 - 25% failure Female controlled Cumbersome

49. Emergency Contraception Aka post-coital contraception, “morning after” pill Indications: Rape Contraceptive failure (condom broke) Unprotected intercourse 1997 FDA approved

50. Prescribing Emergency Contraception Plan B preferred - progestin only History, LMP,Urine preg test 2 tabs 50  pill ASAP (within 72 hrs), repeat in 12 hrs. Nausea (50%) and vomiting (20%), anti-emetics Mechanism - prevents implantation

51. Contraceptive Patch Ortho-Evra Available later 2002 Estrogen & progestin Apply new patch weekly x 3 4th week - withdrawal bleed

52. Vaginal Ring Nuvaring Estrogen & progestin Inserted for 3 weeks Ring-free week - withdrawal bleed

53. Ideal Contraceptive 100% effective Completely reversible No side effects Inexpensive Easy to use Accesible

54. Conclusions Encourage “adult attitudes” towards sexualtity. Any method is better than none. Compliance. Oral contraceptives vs. Depo-Provera Condoms must be used also.