1. Preventive Care and Sexual Health Information for Tweens and Teens Developed by: ACOG District XII Health Care for Underserved Women Committee

2. Lindsey M. McAlpin, MS,MD Resident Physician, Florida State University College of Medicine, Department of Obstetrics and Gynecology, Sacred Heart Hospital System, Pensacola, FL o ACOG District XII Junior Fellow Vice Chair University of Texas Health Science Center Medical School, Class of 2013 Tulane University, Masters of Science, Department of Neuroscience, 2009 Tulane University, Bachelor of Science, Department of Psychology and Neuroscience, 2008 Tulane University, Bachelor of Arts, Department of Art History, 2008

3. General Risk Factors for Tweens and Teens Poor Diet Lack of Exercise Smoking/Drugs/Alcohol Early initiations of Sexual Activity

4. When Should You See an Ob/Gyn? Ideally BEFORE there is a problem The American College of Obstetricians Gynecologists (ACOG) recommends young women see a obstetrician/gynecologist (Ob/Gyn) between the ages of 13-15 years

5. Sexual Debut 62% 12 th graders sexually active… ½ their mothers are unaware

6. Just the Facts…….. 2002 Center for Disease Control (CDC) National Survey of Family Growth 11% of girls sexually active by age 13 24% of girls sexually active by age 15 40% of girls sexually active by age 16 70% of girls sexually active by age 18 Every 10 seconds, a teen becomes sexually active

7. CDC Trends in Sexual Début Girls, Ages 15-19

8. In Florida 2012 CDC 1991-2011 High School Youth Risk Behavior Survey Data In the US, 6% of girls are sexually active by age 13, in Florida 8% of girls report sexually activity by 13 Overall, 15% of US high students report having sexual intercourse with 4 or more partners In Florida, 16% of high school students will have 4 or more partners by graduation 13% of high school students report that they did not use any method to prevent pregnancy or transmission of STIs during their last episode of sexual intercourse 12% of sexually active teens age 15-19 report not using contraception

9. More facts……. 12 million NEW Sexually Transmitted Infections (STIs) cases per YEAR 3 million of them are in TEENS 9,000 teen STIs per DAY

10. STI Facts Herpes Simplex Virus (HSV)-  20 million active cases Human Papilloma Virus (HPV)-  24 million active cases Human Immunodeficiency Virus (HIV)  More than 1 million active cases

11. HIV in Florida Florida is #3 nationwide for HIV infections 1999: 5,424 new cases 22% of new cases are female 12 % age 15-24

12. Gonorrhea in Florida (2000 Data) Total new cases per year: 25,000 people 127.8 cases/100,000 people

13. Chlamydia in Florida (2008 Data) Total new cases per year= 75,000 people 389.1 cases/100,000 people

14. Teen Pregnancy 1997-183,324 births to 15-17 year olds in USA 1997-305,886 births to 18-19 year olds in USA 35% of all teen pregnancies are aborted The teen pregnancy rates have started to decrease In 2011, there were 333, 746 births to adolescents age 15-19  5.1% of these were in Florida-ranked 25 out of 51 states and territories Improved from 15 out of 51 in 2008 18% of these births were repeat births in females under age 20 92% of these births occurred outside of marriage

15. Teen Pregnancy 8 out of 10 teen moms live below the poverty level for 10 years 9 out of 10 teen moms never finish college

16. Pregnancy Prevention Communication between teens and parents, counselors, trusted adults, and partner is KEY Commit to your decision Date those that share your views and values Avoid alcohol, tobacco, and drug use Safe sex-if your going to do it, be SMART Think of YOUR future

17. Consequences of Our Choices…… Emotional effects Physical effects Future Fertility Possibility of Cancer Consequences and effects on loved ones

18. When Should My Daughter see a Ob/Gyn? Recommended first visit age 13-15 Annually thereafter: o To discuss problems with menstrual cycles o To check for STIs if sexually active o To discuss/answer questions about sexual activity

19. What to Expect from an Initial Visit? History and Physical o History on menstrual cycle (period) o Examination to assess physical development o Screen for emotional and behavioral conditions/problems o Discuss/obtain immunizations Generally does not involve a Pelvic Exam All females aged 13-18 should receive annual OBGYN visit Annual visit should focus on: o Healthy eating habits o Regular exercise o Avoiding tobacco/alcohol/drug use o Sexual activity

20. Consequences of Our Choices…… Emotional effects Physical effects Future Fertility Possibility of Cancer Consequences and effects on loved ones

21. HPV Infections can cause CANCER Cervical Cancer Vaginal Cancer Vulvar Cancer Anal Cancer Penile Cancer Mouth and Throat Cancers

22. What, How, Where, and Why of HPV Human papilloma virus o More than 150 strains of the virus, 40 of these infect the human genital tract o Can cause warts on both the skin and genital tract Contracted by skin-to-skin contact o Genital strains of HPV are contracted by engaging in sexual activity with a person who is already infected with the virus Infection in the female genital tract, especially the cervix can lead to the development of cancer

23. Prevalence of HPV Sexually active female college students were found to have a baseline HPV infection rate of 26% When these women were rechecked every 6 months, 60% were eventually found to be HPV POSITIVE at least once over 3 year period. 80% of sexually active women will contract HPV at some point in their lifetime

24. Risk Factors for Developing Cervical Cancer #1 Risk Factor=HPV Number of partners Age of first sexual contact Smoking HIV infection

25. Invasive Cervical Cancer 12,360 cases in the USA/year 4,020 deaths in the USA/year 16% of reproductive tract cancers

26. Role of the Pap Smear in Cervical Cancer Prevention OBGYNs perform Pap smears to to screen for pre-cancer and cancer cells in the cervix Start screening at age 21, then every 3 years or more frequently if abnormal Responsible for 70% decrease in cervical cancer deaths.

27. Pap Smears What It ISWhat It ISNT Use of a speculum to look at the cervix Collecting cells on the surface of the cervix with a special tool and looking at them under a microscope to observe for pre- cancerous and cancerous changes A routine pelvic exam An STD screening for other infections (chlamydia, gonorrhea, etc.)

29. We do Pap smears to try to prevent cervical cancer after women are already infected with HPV. But can we prevent HPV infections before they occur?

30. What is the HPV Vacccine?

31. Quadrivalent HPV Vaccine-Gardasil Produces immunity against the four HPV strains that most commonly cause pre-cancerous cervical changes and cervical cancer o 6,11,16,18 Approved by CDC in 2006 Recommended for females ages 11-26 o Vaccine may be given to females as young as 9 years old

32. How Do I Get the Vaccine? Vaccine is dispensed in 3 doses o 1 st -dose at visit, o 2 nd dose at two months o 3 rd dose at six months Through the Florida Department of Health- Vaccine for Children (VFC) Program

33. How Safe is the HPV vaccine? Vaccine was studied for a period of over 10 years Included 25,000 people 1,124 adolescent girls age 9-14 Vaccine works against the virus particle, not live virus vaccine Rare complications noted from 5 year Scandinavian study

34. Is the Vaccine Effective? HPV 16 and 18 responsible for 70% of cervical cancers HPV 6 and 11 cause 90% of genital warts cases The vaccine is almost 100% effective Since introduction of the vaccine in 2006, there has been a 56% reduction in HPV infections in US adolescent girls, even with low vaccination rates o Research has also shown fewer cases of genital warts

35. New Developments Gardasil was FDA approved for young men ages 9-26 in October 2009 Cervarix is an additional FDA approved HPV vaccine FDA approved for ages 9-25 o Only covers HPV strains 16 and 18 o Does NOT prevent HPV associated warts (strains 6 and 11)

36. New Developments New vaccine in development that covers 9 different HPV types

37. What we have done.. With only a 33% vaccination in US girls, and 10% vaccination rate in US boys, rate we have decreased the incidence of HPV by 56% in girls ages14-19!!!

38. BUT we can do better… Only 25.3% of eligible Florida adolescent girls are getting vaccinated VS. 80% adolescent girls vaccinated in Rwanda

39. We can prevent close to 33,000 cases of HPV linked cancer cases annually with the HPV vaccine

40. QUESTIONS?

41. Resources ACOG Pamphlet AP073 Human Papillomavirus (HPV) Infection Jan 13 ACOG Pamphlet AP167 Human Papillomavirus Vaccines Feb 2014 cdc.gov/vaccines/teens cancer.gov/cancertopics/factsheet/Prevention/HPV-vaccine The initial reproductive health visit. Committee Opinion No. 598. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:1143–7. Human papillomavirus vaccination. Committee Opinion No. 588. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:712–8 www.ImmunizationforWomen.org/HPV

42. References CDC. Human papillomavirus vaccination coverage among adolescent girls, 2007–2012, and postlicensure vaccine safety monitoring, 2006–2013—United States. MMWR 2013;62:591–5. CDC. Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices. MMWR 2007;56(No. RR-2):1–24. Markowitz, L. Hariri,S.Lin.C.,Dunnel,E. Steinau,E. McQuillan,G and Unge,E. Education in Human Papillomavirus (HPV) Prevalence Among Young Women Following HPV Vaccine Introduction in the United States, National Health and Nutrition Examination Surveys, 2006–2010J Infect Dis. June 2013. ACOG pratice Bulleton Number 131, November 2012 Screening for Cervical Cancer. US Department of Health and Human Services, Office of Adolescent Health