Adolescent Contraception

Marcia J. Nackenson, M.D.

Section of Adolescent Medicine

Department of Pediatrics

New York Medical College

Adolescent Contraception

• The Need

• Barriers to Adolescent Contraception

• Contraceptive Methods

• How to Provide Service

Adolescent Sexual ActivityAges 15 - 19 years

• Females: 50% (1997)55% (1990)

• Males: 55% (1995)60% (1988)

Adolescent Sexual ActivityBy School Grade (1996)

• Grade 9: 37%

• Grade 12:66%

Adolescent Sexual ActivityBy Race and Gender

• Males earlier than females

• Blacks earlier than Hispanics earlier than Whites

• Differences are lessening

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.

Adolescent Pregnancy

• 1 million pregnancies/year

• 85% unintended

• 50% live births

• 35% elective abortions

• 15% spontaneous abortions

But...

• Pregnancy Rates Decline 12% (1995)103/1000 ages 15 - 19 yrs

• Abortion Rates Decline

• Birth Rates Decline 15%57/1000

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%

Barriers to Adolescent Contraception

• Psychological Factors

• Availability

• Demographic Factors

Psychological Factors

• Immature cognitive functioning

• Dependency, passivity

• Difficulty in handling sexuality

• Risk-taking behavior

• Desire for pregnancy

Availability

• Cost

• Geographics

• Clinic hours

• Confidentiality issues

Demographic Factors

• Age

• Race

• Poverty

• Educational Plans

• Cultural Patterns

Legal Issues

I. Consent

A. Emancipated Minor

B. Mature Minor

C. Reproductive Matters

II. Confidentiality

III. Payment

IV. Abortion

Issues in Selecting a Contraceptive Method

• Frequency of intercourse

• Tolerance of route of delivery

• Tolerance of side effects

• Nature of relationshipie, monogamous, long-

standing

Recommended Methods for Adolescents

CONDOMS PLUS:1. Oral Contraceptives

2. Injectable Progestin (Depo-Provera)

3. Subdermal Implants (Norplant)

4. Spermicide

Limited Methods for Adolescents

1. Diaphragm

2. Female condom

3. Cervical cap

Methods Not Recommended for Adolescents

1. IUD

2. Tubal ligation/vasectomy

Contraceptive EffectivenessMost Effective

Method

Abstinence

Implants

Injectables

Oral Contraceptives

Vaginal Ring

Patch

IUD

Pregnancy Rate %

0

0.090.3

0.1

0.1

1

1-2

Contraceptive EffectivenessLess Effective

Method

Condom plus foam

Condom alone

Female condom

Diaphragm

Withdrawal

Rhythm

No Method

Pregnancy Rate %

2 - 10

2 - 20

5 - 20

2 - 18

2020 - 3090

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

Mechanisms of Oral Contraceptives

• Combination OCP: estrogen, progestin

• Inhibition of ovulation

• Thickened cervical mucous

• Endometrium less favorable for implantation

• Decreased tubal motility

Estrogen in OCP’s

• Ethinyl estradiol20

30-35 - Most “low dose” OCP’s 50

• Mestranol - converted to ethinyl estradiol

50

Progestins in OCP’s

• Varying progestational & androgenic potency

• 6 different progestins available in U.S.

• Newer progestins less androgenic?

Newer Progestins (‘92-’93)

• Norgestimate - OrthoCyclen, Tricyclen

• Desogestrel - OrthoCept, Desogen

‘95 UK warning VTE

FDA, ACOG - no changes needed

• Gestodene - Not available in US

Newer Progestins: Advantages

• Decreased androgenicity

• Increased SHBG

• Decreased free testosterone

• Improved LDL:HDL ratio

• Best for hirsutism, acne

Triphasics vs. Monophasics

• Less total hormone per month

• No clear clinical advantage

Minor Side Effects of OCP’s

• Breakthrough bleeding

• Nausea

• Breast soreness

• Headache

• Weight gain - NOT!

Major Side EffectsCardiovascular

• 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

Major Side EffectsCancer

• Dec. risk of endometrial & ovarian ca.• Breast & cervical ca. - no definitive inc.

JAMA ‘01: +FH breast ca. & OCP’s inc. risk of breast ca.

BUT: Based on early hi dose pills• Hepatocellular adenoma - benign,

3-4/100,000

Other Side Effects

• Lipid level changes - screen if hi risk

• Carbohydrate metabolism - follow diabetics

• Post-pill amenorrhea or infertility -

disproven

• Congenital anomalies -

disproven

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.

Absolute Contraindications

• Thromboembolic disorders

• Coronary artery disease

• Estrogen-dependent neoplasia

• Breast Cancer

• Pregnancy

• Active liver disease

• Undiagnosed abnormal vaginal bleeding

Oral ContraceptivesSummary

• 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.

Progestin Only Methods

• The Minipill - daily pill

• Depo-Provera - injectable

• Norplant - subdermal implant

Progestin Only MethodsMechanisms

• Blocks LH surge; inhibits ovulation

• Thickens cervical mucous

• Thin, atrophic endometrium

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

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

Depo-ProveraMenstrual Changes

• Irregular menses

• Amenorrhea - 60% by 1 year

• Treatment of irregular bleeding:

1. Counseling

2. OCP

3. Ibuprofen

4. Estrogen

Depo-ProveraOther Side Effects

• Weight gain - 2-5 lbs./yr.

• Delay to fertility - 9 mos.

• Depression

• Dec. libido

• Breast tenderness

• Decreased bone density - under study

NEW: Lunelle

• Combination injectable:

Estrogen and progestin

• Given q28 days

• Advantage - regular menses

• Disadvantage - monthly visit

Subdermal Implants

• Norplant

-FDA 1990, 6 levonorgestrel rods

-Effective 5 years

-Insertion and removal procedures

-Bad publicity• Implanon

-Single rod, good for 3 years

Norplant Side Effects

• Irregular menses - greatest in 1st yr.

• Weight gain - less than Depo

• Headaches

• Acne

• Insertion site problems

• Depression

• Hair changes

Condoms

• Must always be recommended to prevent STD’s

• Latex or polyurethane onlyReservoir-tipped, spermicide

• Effectiveness inc. with contraceptive foam

• Advantages: Safe, cheap, available

• Disadvantages: Coital dependent, male resistance

Condom Use12-19 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

Spermicides

• Nonoxynol-9

• Foam preferred

• When used with condoms, greatly inc. effectiveness.

Barrier Methods

• Diaphragm

• Sponge

• Cervical cap

• Lea’s shield

The Female Condom(1994)

• Polyurethane

• $3 each

• 5 - 25% failure

• Female controlled

• Cumbersome

Emergency Contraception

• Aka post-coital contraception,“morning after” pill

• Indications:Rape

Contraceptive failure (condom broke) Unprotected intercourse

• 1997 FDA approved

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

Contraceptive Patch

• Ortho-Evra• Available later 2002• Estrogen & progestin• Apply new patch

weekly x 3• 4th week - withdrawal

bleed

Vaginal Ring

• Nuvaring• Estrogen & progestin• Inserted for 3 weeks• Ring-free week -

withdrawal bleed

Ideal Contraceptive

• 100% effective

• Completely reversible

• No side effects

• Inexpensive

• Easy to use

• Accesible

Conclusions

• Encourage “adult attitudes” towards sexualtity.

• Any method is better than none.

• Compliance.

• Oral contraceptives vs. Depo-Provera

• Condoms must be used also.