Contraception in Adolescents

Karen Soren, MD

Director, Adolescent MedicineAssociate Clinical ProfessorPediatrics & Public HealthColumbia University Medical Center

What are the barriers to teens using contraception?

• Developmental issues:– Early adolescence: present oriented, impulsive– Middle adolescence: omnipotent, invincible

• Teens are spontaneous

• Teens may be ambivalent about pregnancy

• Teens have inadequate access to information and confidential care; lack of awareness of NYS rights

The conversation:

• AAP recommends postponement of sexual activity, especially for young teens

• “But -if you are going to be sexually active, you need protection!”

• Condoms are the best method for protection against sexually transmitted

• Condoms are an imperfect method for pregnancy –prevention

• You need a back-up for your condom…

The contraceptive visit : What do you need to do?

• Reassure adolescents of confidentiality• History

– PMH- rule out conditions that would not allow safe use of estrogen-containing methods

– Sexual history– History of previous contraceptive use– Current medications

• Physical (very basic!)– Weight, BP– Gyn exam NOT required

  

How Methods are Chosen

• Use by friends or relatives

• Accessibility

• Personal knowledge

• Media

• Fear of side effects

• Physician recommendation

SUMMARY TABLE OF CONTRACEPTIVE EFFICACY(In 100 women, # pregnancies in a year)

Method Typical Use Perfect Use

No contraception 85 85

Spermacides 29 18

Withdrawal 27 4

Diaphragm 16 6

Condom 15 2

Birth control pills 8 0.3

Ortho-Evra patch 8 0.3

Nuvaring 8 0.3

Depo Provera 3 0.3

Mirena IUD 0.2 0.2

Implanon 0.05 0.05

Barrier and Non-hormonal Methods

• Male Condom

• Female Condom

• Diaphragm

• Cervical Cap

• IUD- Paragard(Copper)

Male Condom

• STI protection• Over the counter• Imperfect method of contraception

– 85% effective

• Possible latex allergy (my need to use polyurethane condoms)

• Many condoms now lubricated but do not contain spermicide - issues with nonoxynol nine – mucosal irritant

• Need a back-up method…

Plan B• Large dose of levonorgestral• Best taken as soon as possible after

unprotected intercourse• Can take up to 5 days after mess-up (package

says 72 hours)• Now Plan B One-Step – single pill• 75-85% effective in reducing pregnancy if used

within 72 hours, less so if used later• No serious side effects• Over the counter now - >17 yo

Female Condom

This says it all…

Cervical Cap/Diaphragm

Hormonal Methods

• Combined hormonal methods (estrogen and progesterone):– Oral contraceptive pills

• Monophasic or multiphasic – Ortho Evra Patch– Nuvaring

• Progestin-only methods– Depo-Provera injection– Progestin-only pills (minipill)– Implanon– Mirena IUD

A little about estrogens…

• Older pill (1960’s) started with 150 mcg mestranol – eventually decreased to 50 mcg because of side effects

• Ethinyl estradiol introduced in 1970’s• Dose varies from 50 mcg to 20 mcg, but most

pills now used are between 20 and 30 mcg• Lower dose → less side effects, but more break-

through bleeding, and less room for non-compliance

What about the progesterone type?

• First generation: (norethindrone, norethindrone acetate)- medium androgenicity- in Loestrin

• Second generation: (levonorgestral) – higher androgenicity -in Alesse, Lo-ovral, Seasonalle, Seasonique, Lybrel, (norgestrel – Lo/Ovral)

• Third generation: (norgestimate, desogestrel) – low androgenicity but slight increase risk of clots – in Ortho tri-cyclin Lo (Acne), Desogen

• Drospirenone: (spironalactone analog)- helps contact hirsuitism – in Yasmin, Yaz (PMDD)

WHO Guidelines - medical eligibility for each contraceptive method- categories:

• 1 = a condition for which there is no restriction for the use of the contraceptive method

• 2 = a condition where the advantages of using the method generally outweigh the theoretical or proven risks

• 3 = a condition where the theoretical or proven risks usually outweigh the advantages of using the method

• 4 = a condition which represents an unacceptable health risk if the contraceptive method is used

Contraindications to Estrogen• Active liver disease (4)• Untreated gall bladder disease (asymptomatic -2, symptomatic -3)• Hypertension (140/90 or greater – 3, 160/100 or greater - 4)• Personal history of thrombosis (4)• Known thrombogenic mutations (4)• Family hx thrombosis (2)- investigate…• Migraine with aura (4)• Condition leading to venous stasis, immobilization (4)• Lupus with positive (or unknown) anti-phospholipid antibody

syndrome (4)• Diabetes with vascular disease (3,4)• Post- partum <21 days, +/- breastfeeding (4,3)• Smokers >35 (<15 cigs/day -3, >15 cigs/day -4)

Evidence: Among women with migraine,women who also had aura had a higher riskof stroke than those without aura.

Women with a history of migraine who useCOCs are about 2 to 4 times as likely to have an ischemic stroke as non-users with a history of migraine.

Migraines and estrogen-containing methods:

Conditions that have little or no contraindications to estrogen use:

• Depression (1)• Irregular bleeding in teens -after evaluation (1)• Dysmenorrhea (1)• Abnormal Pap (2)• Obesity (2 – some risks – but benefits outweigh

risks)• Diabetes without vascular disease (2)• Sickle cell disease (2): However, as sicklers

more at risk for strokes and acute chest and bone infections – prefer progestin- only methods

Medications

• Medications that decrease the effectiveness of combined oral contraceptives (and progestin-only pills, implant)– Anticonvulsants – phenytoin, phenobarbitol,

topiramate, carbamazepine, lamotrigine (3)– Rifampin, rifabutin (3)

• However, little effect on pill metabolism in users of most antibiotics (1)

Combined OCP’s

• Mechanism of action– Progesterone inhibits LH, thickens cervical

mucus, atrophies endometrium– Estrogen inhibits FSH

• Other actions of BCPs– Increase SHBG and decrease free testosterone– Inhibit 5- reductase in skin, decreasing

conversion of testosterone to DHT

Combined OCP’s

• PROS– Rapid return to fertility– No anticipation– Menstrual regularity– Decrease dysmenorrhea

and anemia– Decrease ectopic

pregnancy rate– Decrease PID– Decrease ovarian and

endometrial cancer

• CONS– Daily medication– Regular supply needed– Multiple SEs– Multiple

contraindications– CLOTS

Combined OCP Side Effects

• ESTROGEN– Nausea– Fluid retention– Breast tenderness– Increases clotting by

decreasing protein C, S, antithrombin III

– HTN

• PROGESTERONE– Increases appetite– Depression– Elevated lipids (TG)

How to prescribe OCP’s

• Become familiar with a few types of pills

• Rule out contraindications to estrogen

• Patient can start any day (but some prefer Sundays or first day of period)

• Can give up to 6 packs at a time

• Bring back after 3-4 weeks to determine:– If teen started pill and if it is taken correctly– Any side effects

So what pill do I prescribe?

• Can start with a low-dose pill (Alesse, Loestrin 1/20)

• If teen has acne or PCOS-type stigmata, consider Ortho tri-cyclin Lo

• If teen has hirsuitism / PCOS, can use Yaz or Yasmin instead

• For dysfunctional uterine bleeding, can use Lo/Ovral – longer half-life of progestin- stabilizes endometrium

Ortho Evra Patch

• Norelgestromin 6mg/ ethinyl estradiol 0.75mg in a transdermal delivery system

• 1 patch weekly for 3 weeks, then patch-free for 1 week

• Traditionally, Sunday or first day of menses start- however, can start anytime

• Menses usually 4 days after patch removal

Ortho Evra

• PROS– No need for daily med– Teens like ease of

usage

• CONS– 2-3% detach– Nausea/ vomiting – Less effective if >90kg– More complicated if

forget to change or falls off

– Breast pain, rash– CLOTS: 60% more

estrogen than a 35 mcg pill (FDA alert)

NuvaRing

• Etonogestrel 120 mcg/d + ethinyl estradiol 15 mcg/d

• Silastic ring inserted intravaginally for 3 weeks with 1 week off

• Less estrogen because more bioavailable• Does not need to be put around cervix,

just in vaginal vault adjacent to mucosa

NuvaRing

• PROS– Less estrogen

(15 mcg equivalent)

– Protects for a full cycle

• CONS– No STI protection

– 18% of women, 30% of men feel ring

– Most common SE is leukorrhea

– Again - clots

Depo-Provera• Medroxyprogesterone acetate

– 150 mg IM every 11-13 weeks (up to 14 weeks)

• Progesterone actions– Suppresses LH and prevents ovulation– Thickens cervical mucus– Atrophies endometrium– Decreases cilia motility in fallopian tubes

• 50% amenorrheic at 1 year

Depo-Provera, cont

• PROS– Highly effective– No anticipation– Can breast feed– Decrease endometrial

ca, yeast infection, PID, fibroids

– Increases seizure threshold

• CONS– SE can’t be

immediately stopped– Delay in return to

fertility– Irregular bleeding and

amenorrhea– Hypo-estrogenic state

OSTEOPOROSIS

Depo-Provera, side effects

• Headache

• Mood swings

• Weight gain

• Hair Loss

• Irregular bleeding

• One third discontinue use after one year as a result of side effects

POPs

• Progestin-only pills (Micronor, Nor-QD)• Small dose of progestin – works primarily by

increasing viscosity of cervical mucus• Does not reliably inhibit ovulation• Need to be taken carefully and consistently – if

more than 3 hours late with pill, will not be effective

• Useful for teens with contraindications to estrogen who will not accept Depo or Mirena

Implanon

• Contains 68 mg etonogestrel

• Single rod implanted subdermally on day 1-5 of cycle

• Last for 3 years.

• Works by thickening cervical mucus and also inhibits ovulation

• No effects on bones or lipids

• Irregular bleeding common side effect

Mirena – progestin containing IUD

• IUD containing levonorgestral• Helpful for menorrhagia and dysmenorrhea• Effective for 5 years• Previously discouraged in teens because teens

more at risk for infection- liability concerns• Movement to encourage IUD use in teens

currently• Infection probably most related to insertion• Can be inserted in nulliparous young woman-

slight risk that will be expelled – teens should check for the string

So- what contraceptive method would you recommend?

• 18 year old with no significant medical or family history going off to college

• 14 year old coming in after an abortion – does not want her mother to know she is sexually active

• Obese 17 year old with acne and irregular periods• 15 year old with heavy bleeding for a month who comes to

the emergency room and has a hemoglobin of 8• Amenorrheic 16 year old with facial hair• 17 year old tampon user who cannot remember to take a

pill, and wants to keep her sexual activity from her mother• 15 year old with migraines, and some preceding blurry

vision• 18 year old with lupus who is non-compliant with her

medications