Slide 27

Essentials of Contraception and Adolescents Objectives Review teen pregnancy trends, rates of sexual activity and contraceptive use Describe a comprehensive list of contraceptive methods and advantages/disadvantages of each option Discuss tips for initiation and use Dispel common myths Explain safety and risk in context Teen Pregnancy, Birth, and Abortion Rates Are Declining (15- to 19-year-olds)

Kost K and Henshaw S, U.S. Teenage Pregnancies, Births and Abortions, 2010: National and State Trends by Age, Race and Ethnicity. Contraceptive Use Rising at First Sex: 19822010 Guttmacher. September 2016. What are Teens Using for Contraception? Contraceptive Methods EVER Used by sexually active 15-19 year olds 97% 100%

80% 60% 60% 54% 40% 22% 20% 15% 5% 0% C om

d on W dr h it aw al Not so well P ill

EC o ep D Okay g in R 3% IU 2% D Im

t an l p 2% P ch t a Really, really well NCHS Data Brief #209, July 2015 (CDC NSFG 2011-2013)

Condom Use at Last Sex Percent 100 80 61.5 60 56.9 52.0 60.5 59.9 57.7 63.4 55.6 56.8

52.9 40 20 0 T F h 9t B H i

W National Youth Risk Behavior Survey, 2015 Case 1: Angela Angela is a 16-year-old young woman who makes an appointment to go on birth control. Her intake form indicates that she uses condoms most of the time. What additional information do you need from this patient?

Medical History Menstrual history Age at menarche Date of LMP Duration of menses Regularity/spotting Cycle length Cramps and impact on activities History of PE, DVT, MI,

migraine with aura or focal neurologic deficit Personal or family history of blood clots If affirmative, work-up for clotting disorder Prior experiences with contraception Case: Angela Angela is a little unsure of her medical history. She does not think anyone in her family has a history of blood clots. What questions do you ask before beginning

contraception counseling? Sexual Health History Sexual orientation and gender identity History of vaginal, oral, anal sex Age at coitarche Number and genders of partners Condom and contraception use Pregnancy history History of STIs Sexual satisfaction

History of survival, unwanted or coerced sex Childbearing plans Case: Angela Angela has had sex 3 times with her current boyfriend and used condoms during 2 of those three encounters. What did she do well? Affirmation And Education Used condoms at least 2 of 3 times! Came in to discuss birth control methods Give positive reinforcement whenever possible

IDEAL = DUAL USE Dual Use: Condom + LARC/Pill/Injectable/Patch/Ring Before Last Sex Percent 100 80 60 40 20 8.8 5.9 11.8

5.8 8.3 12.2 7.7 12.0 4.7 4.7 0 National Youth Risk Behavior Survey, 2015 Unprotected Sex in the Past Five Days?

No Urine pregnancy test if unprotected sex occurred more than 14 days prior Yes Branded EC products in the U.S. Plan B OneStep ella

Single dose - 1.5 mg levonorgestrel Label: Up to 72h after unprotected sex Recommend: Up to 120h OTC for men and women of all ages Single dose 30 mg Ulipristal acetate (UPA) Label: Up to 120h after unprotected sex Prescription Only Can order online at www.ella-kwikmed.com

Starting Contraception After LNG EC COCs/Progestinonly Pills Start immediately after LNG EC Vaginal Ring/Patch Start immediately after LNG EC DMPA/Implants/ IUCs Start immediately after LNG EC *With ALL methods: abstain/use back-up protection for first

7 days Starting Contraception After UPA EC U.S. Selected Practice Recommendations for Contraceptive Use, 2016 Start or resume hormonal contraception NO SOONER than 5 days after use of UPA Any nonhormonal contraceptive method can be started immediately after the use of UPA. For methods requiring a visit to a health care provider, such as Depo, implants, and IUDs, starting the method at the time of UPA use may be considered; the risk that the regular contraceptive method might decrease the effectiveness of UPA must be weighed against the risk of not starting a regular hormonal contraceptive method. Advise a pregnancy test if she does not have a withdrawal bleed within 3 weeks.

*With hormonal methods: abstain/use back-up protection for 7 days after restarting contraception Case: Angela Angela informs you that she last had unprotected sex two weeks ago. You do a urine pregnancy test. The result is negative. Do you need to perform a pelvic exam? Summary Guidelines WhenCervical to BeginCytology Pelvic and Pap Screening

smears Initial HPV Organization (Year Updated) American Congress of Obstetricians and Gynecologists (2016) United States Preventive Services Task Force (2012) American Cancer Society (2012) Screening

Interval for Under 30 vaccination Age 21, regardless of sexual initiation Every three years Same as unvaccinated women Age 21

Every three years Same as unvaccinated women Age 21 Every three years Same as unvaccinated women Case: Angela You tell Angela that there are many contraceptive options

available to her and you are confident that you can help her find one if she likes. Long-Acting Reversible Contraception Long-Acting Reversible Contraception (LARC) = IUDs and Implants Most effective methods: >99% Safest No estrogen Contraindications rare Highest patient satisfaction

(80% LARC vs 50% short acting) Highest continuation rates (86% LARC vs. 55% short acting) Long-term protectionlasts 3-12 years Rapid return of fertility Most cost effective Least likely to be used by teens Secura GM. The Contraceptive Choice Project. Am J Obstet Gyn. 2011. LARC Use at Last Sex: IUD/Implant 100

Percent 80 60 40 20 3.3 0 2.2 4.5 2.1 2.8 3.9

3.8 2.1 2.9 3.9 National Youth Risk Behavior Survey, 2015 Levonorgestrel IUD (Mirena) Extremely Effective

20 mcg levonorgestrel/day Progestin-only method 5-6 years use Cost : $50$700 Bleeding pattern: Light spotting initially: 25% at 6 months ~10% at 1 year Amenorrhea in: 44% by 6 months 50% by 12 months Trussel J. Contraceptive Technology. 2007; Hidalgo M. Contraception. 2002. Levonorgestrel IUD: (Liletta)

FDA approved 2015 for 3 years anticipate 7 year approval 19 mcg levonorgestrel/day similar to Mirena Progestin-only method Bleeding pattern: Light spotting initially: 25% at 6 months ~10% at 1 year Amenorrhea in: 44% by 6 months 50% by 12 months Levonorgestrel IUD (Skyla) Extremely Effective

14 mcg levonorgestrel/day Progestin-only method 3 years use Cost : ~$300$650 Smaller in size than Mirena 1.1 x 1.2 in. (vs. 1.3 x 1.3 in) Inserter tube 0.15 in. (vs. 0.19 in) More irregular bleeding than Mirena Only 6% have amenorrhea at 1 yr

Copper-T IUD: (Paragard) Extremely Effective Copper ions No hormones 12 years of use Cost: ~$150-$475 99% effective as EC Bleeding Pattern: Menses regular May be heavier, longer,

crampier for first 6 months Thonneau, PF. Am J Obstet Gynecol. 2008. Trussel J. Contraceptive Technology. 2007. Which IUD Is the Best Choice? Copper T IUD Want regular periods Want no hormones No h/o dysmenorrhea No h/o menorrhagia

LNG IUD OK w/irregular bleeding OK w/amenorrhea H/O dysmenorrhea H/O menorrhagia Implant: Nexplanon Extremely Effective Progesterone only (etonogestrel) Effective for 3-4 years Cost: ~$300$600 Mechanism: Inhibits ovulation

Bleeding pattern: Amenorrhea (22%) Infrequent (34%) 11% stop due to frequent bleeding Implanon insert: Diaz S., Contraception, 2002: Trussel J, Contraceptive Technology, 2007 Croxatto HB, Contraception, 1998; Diaz S, Contraception, 2002; Funk S, Contraception, 2005. Combined Hormonal Contraception Short-Acting Reversible Contraception Combined Hormonal Contraception (CHC)

Estrogen Inhibits FSH and LH Inhibits ovulation Progesterone Thickens cervical mucus to prevent sperm penetration Inhibits capacitation of sperm Includes oral contraceptive pills, contraceptive patch, intravaginal ring Birth Control Pill Use at Last Sex Percent 100 80 60

40 20 18.2 15.2 21.3 10.9 15.9 23.5 21.5 20.1 9.0 11.8 0 National Youth Risk Behavior Survey, 2015

Short-Acting Contraception Use: Injectable/Patch/Ring Before Last Sex Percent 100 80 60 40 20 5.3 0 2.7 7.9 3.3 5.8 5.5 5.7

4.9 3.1 6.0 National Youth Risk Behavior Survey, 2015 Very Effective Combined Oral Contraceptive Contain estrogen & progestin Most newer formulations contain 20 35 mcg of ethinyl estradiol 1 of 8 available progestins Mechanism: Inhibits ovulation

Effectiveness Perfect use: 0.3% Typical adult use: 8% Typical adolescent use: 5%-25%mainly due to poor adherence Non-Contraceptive Health Benefits Improves acne and hirsutism Menstrual-related health benefits: Decreased dysmenorrhea Decreased menstrual blood loss - decreased anemia May reduce menstrual-related PMS symptoms Reduces Endometrial and ovarian cancer risk

Benign breast conditions PID Estrogen-Related Side Effects Rare but serious health risks, including blood clots, heart attack, and stroke Patients should contact their medical provider immediately if they experience ACHES: Abdominal pain Chest pain Headaches Eye or visual changes

Severe leg pain or swelling Progestin-Related Side Effects Edema Abdominal bloating Anxiety Irritability Depression Myalgia Menstrual irregularities

Extended Cycling Decrease hormonal shifts and number of menses Convenience, treat dysmenorrhea, other cyclic symptoms Seasonalelevonorgestrel, 30 mcg EE for 84 days, 7 placebos Seasoniqueadded 10 mcg EE to placebos LoSeasonique20 mcg EE for 84 days Lybrel28 days 20 mcg EE, no placebos Do NOT need branded extended-cycling product! Improving Contraceptive Continuation Providing more than one cycle of birth control at initial visit increases

contraceptive continuation Women initiating OCP use at an urban familyplanning clinic who received 7 pill packs had a higher 6-month continuation rate than those getting 3 cycles (51% v. 35%) Greatest effect: teens younger than 18 years old White KO, Westhoff C. Obstet Gynecol 2011;118:61522 Prescribe or Dispense Multiple Cycles of Contraception Making contraceptives more accessible may reduce unintended pregnancy and abortion California women who received a 1-year supply were less likely to have a pregnancy compared with women who got 3 cycles or 1 month of pills Dispensing a 1-year supply: 30% reduction in odds of unplanned pregnancy

46% reduction in odds of an abortion Foster, Diana G. et al. Obstet Gynecol 2011;117:56672) Are COCs the best choice? Advantages: Effective Safe Quick return to fertility Health benefits Disadvantages: Requires daily adherence Semi-private Estrogen-related risks

& side-effects Progestin-Only Oral Contraceptives Called the mini-pill Two formulations: norethindrone and norgestrel No placebo week Mechanism of action: thickens cervical mucous Timing crucial ideally SAME TIME EVERY DAY If >3h late backup contraception for 48h Apgar BS. AFP. 2000; WHO MEC. 2004. Contraception Report. 1999. Apgar BS. AFP. 2000. et al.

Very Effective Transdermal Patch: Ortho Evra Estrogen and progestin Beige-colored patch changed once per w 3 weeks on/1 week off 9 days of medication in each patch Mechanism: Inhibits ovulation

Counseling Issues and Facilitating Use Application Place on clean, dry skin on arm, torso, buttocks, or stomach, NOT the breast Must stick directly to skin Reapplication No patch during the fourth week Missed or Late Patch

Use back-up method when: On for >9 days Apply a new patch after day 7 even if still bleeding Off for >7 days Falls off >24 hrs Is the Patch the Right Choice? Advantages Disadvantages Effective

60% more estrogen than COCs Safe Semi-private Weekly (not daily) adherence Estrogen-related risks and side effects Hyperpigmentation, irritation, and adhesive residue Possible same health benefits as COCs

Cost Very Effective Vaginal Ring Estrogen and progestin Flexible, unfitted ring placed in vagina In 3 weeks; out 1 week 4 weeks of medication in ring Continuous use: change first of each month Mechanism: inhibits ovulation

Counseling Issues and Facilitating Use Insertion Reinsertion Provider can Advise patients place the ring in to reinsert ring patients vagina on the same day in the every month to office/clinic and increase have patient compliance remove it and practice

inserting it again Ring can be removed safely for up to 3 herself hrs/day If Ring Falls Out During week 1 and 2, reinsert ring During week 3, insert NEW ring OR have withdrawal bleed and insert NEW ring after 7 days In all cases, use back-up method for 7 days Is the Ring the Best Choice?

Advantages Safe and effective Low dose Monthly adherence Same health benefits as COCs? May decrease BV risk Disadvantages Estrogen-related risks and side effects Discomfort with self insertion and removal

Increased vaginal wetness and discharge Patients and partners may feel it during sex Very Effective Injectable: Depo-Provera (DMPA) Progestin only IM or SQ injection every 3 months (14 weeks) Mechanism: Inhibits ovulation

Trussel J. Contraceptive Technology. 2007. Cromer BA. Am J Obstet Gynecol. 2005. Trussel J. Contraception. 2004.; Westhoff C. Contraception. 2003. et al. Injectable Contraception Perfect Use: 0.3% Typical Use: 3% Health Benefits Private Highly Effective Injected in deltoid or gluteus muscle every 3 months

LowMaintenanc e & LongActing No Estrogen Non-Contraceptive Benefits Decreases ovulation pain, mood changes, headaches, breast tenderness, and nausea Decreases risk of PID Decrease frequency of grand mal seizures Reduces frequency of sickle-cell crises Side Effects First several months: unpredictable or prolonged spotting After one year: 40%-50% have amenorrhea 20%25% of women discontinue use because

of menstrual issues Is DMPA the Best Choice? Advantages Disadvantages Highly effective Menstrual irregularities Safe and private Possible effects on weight and bones Injection every 12 weeks

Irreversible for three months Health benefits Office visit every three months Delayed return to fertility Dispel Common Myths Dispelling Myths When providers or patients hold

misperceptions about the risks associated with contraception Teens choices are unnecessarily limited DMPA and Bone: Much Ado about Nothing! Significant bone loss during pregnancy (3-5%) & breastfeeding (4-5%) Bone loss from DMPA similar. Most pronounced in first 1-2 years (3-5%) and then stabilizes (5% at 4.5 years). Bone loss is temporary and reversible.

Duration of use does not impact recovery. Bone loss associated with DMPA has never been shown to increase risk of fracture or any other clinical outcome. DMPA and Bone: Take Home Messages Women should be informed that the use of DMPA is associated with a slight decrease in BMD, which is reversible There should be no limit to the length of time that DMPA is used regardless of

a womans age Measuring BMD among DMPA users is not recommended Guilbert, E.R et al. Contraception 2009;79: 167-177 Contraception and Weight Gain Not all DMPA users gain weight 25% of users gain excessive weight Other users gain minimal weight Early weight gain at 6 months predicts excessive weight gain (avg. 15 lbs more over 3 years)

No association between caloric intake and weight gain Le Y.C. et al. Obstet Gynecol. 2009 Aug;114:279-84 Bahamondes L, et al. Contraception 2001;64:223-22 Contraception Efficacy and Weight: Evidence is Limited and Inconsistent Does obesity decrease efficacy? IUCs: No Implant: No effect Patch: data weak, no effect or weak effect COC: data weak, no effect or weak effect

Ring: No effect Xu et al. Obstetrics and Gynecology 2012 SFP: Contraceptive Considerations in Obese Women, Contraception 2009 Safety and Risk in Context Determining Safety of Contraception Methods The CDC developed the U.S. Medical Eligibility Criteria (MEC) for Contraceptive Use based on the World Health Organization Guidelines for Contraceptive Use There are 4 categories: 1 - No restriction (method can be used) 2 - Advantages generally outweigh risks

3 - Theoretical or proven risks usually outweigh the advantages 4 - Unacceptable health risk (method not to be used) CDC MMWR. 2016. U.S. Medical Eligibility Criteria (MEC) for CHC Use Category 4 = Absolute Contraindications Current breast cancer Severe cirrhosis, Hepatocellular adenoma, Malignant liver tumor, Acute/flare viral hepatitis Acute DVT/PE, History of DVT/PE with high risk for recurrence, Major surgery with prolonged immobilization Documented thrombogenic

mutations Migraine headaches with auras Diabetes >20 yrs or with vascular end-organ damage Hypertension: Sys >160, Dias >100 or with vascular disease Current or history of ischemic heart disease, complicated valvular heart disease, peripartum cardiomyopathy Postpartum <21days Age >35 and >15 cigarettes/day Complicated solid organ transplant History of stroke Lupus with positive or

unknown antiphospholipid antibody U.S. Medical Eligibility Criteria (MEC) for CHC Use Category 3 = Relative Contraindications Past Breast Cancer (>5 years) Breastfeeding <1m postpartum Postpartum 2142d with VTE risk History of DVT/PE with low risk for recurrence Symptomatic gallbladder disease Malabsorptive bariatric surgery (COCs)

Superficial venous Past OCP related cholestasis IBD with increased risk for VTE HTN: systolic <140159, diastolic <9099, controlled Age >35 and <15 cigarettes/ day Drugs: Rifampin, Rifabutin, Certain Anticonvulsants, Lamotrigine, Protease inhibitors Multiple sclerosis with prolonged immobility IUDs have Very Few Contraindications Current PID Current untreated mucopurulent cervicitis,

gonorrhea, or chlamydia Post abortion/partum infection in past 3 mo. Current or suspected pregnancy Anatomically distorted uterine cavity Wilsons disease (Paragard) Other: Uncommon issues for TEENS Known cervical or uterine cancer Known Breast Cancer (Mirena only) Genital bleeding of unknown etiology CDC US Medical Eligibility Criteria 2016 Implant: Only ONE Contraindication Current Breast Cancer Important to know about Class labeling of implant with CHC by FDA.

CDC US Medical Eligibility Criteria 2016 CDC US Medical Eligibility Criteria (USMEC) Nulliparit Breastfee y ding Adolesce Diabetes nce CIN Obesity Postpartu m

HIV Depression Stroke/DVT PID (continuation) STI (continuation) IUDs & Implants are a USMEC 1/2 for ALL of the following conditions CDC US Medical Eligibility Criteria MMWR 2016 VTE Risk in Context Risk in General Population 0.8 per 10,000 women per

year Risk in COC Users 3-4 per 10,000 women per year Pregnancy and Postpartum Period 6-12 per 10,000 women per year

The Patch Is Safe Failure rates similar to COCs Forgiving of delayed reapplication Higher detachment rate with teens (up to 35%) Higher failure rate among women who weigh 198 lbs Similar estrogen-related side effects and risks as COCs Increased amount of estrogen may increase clot risk, but risk still very low Few Contraindications for DMPA Use CDC/WHO Category 4: current breast cancer CDC/WHO Category 3: cirrhosis, diabetesrelated complications, history of breast cancer, current cardiovascular disease, liver tumors,

unexplained vaginal bleeding, poorly controlled hypertension or with vascular disease, multiple risk factors for cardiovascular disease, history of stroke, lupus with positive or unknown antiphospholipid antibodies Quick Start Improving Contraception Initiation with Quick Start for Hormonal Methods Patients are more likely to start method Improves continuation rates Offers earlier protection from pregnancy No significant difference in the bleeding patterns compared with menses start

Improving Contraception Initiation with Quick Start for Hormonal Methods Start the method THE DAY they fill the prescription for OCP, Ring, Patch, DMPA, Implant Ensure that: Negative pregnancy test that day Use condoms for first week Understands risks and benefits of method and when protected Discussion of EC Westoff C, Kerns J, Morroni C, et al. Contraception. 2002;66:1415. How to be Reasonably Certain that Your Patient is Not Pregnant (CDC SPR 2016)

If they have no symptoms or signs of pregnancy and meet any one of the following criteria: is 7 days after the start of normal menses has not had sexual intercourse since the start of last normal menses has been correctly and consistently using a reliable method of contraception is 7 days after spontaneous or induced abortion is within 4 weeks postpartum is fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority [85%] of feeds are breastfeeds), amenorrheic, and <6 months postpartum Making Contraception Affordable

www.contraceptionjournal.org/article/S0010-7824(14)00687-8/ pdf Wrap Up Take a full medical and sexual history Explore personal circumstances affecting method choice and compliance Discuss side effects candidly and validate concerns Encourage dual condom/contraception use Write an advanced prescription of EC or instruct on OTC access Provider Resources: Contraception www.cdc.gov/reproductivehealth/unintendedpregna ncy/usmec.htm United States Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2016

www.managingcontraception.com Managing Contraception store.managingcontraception.com/contraceptive-te chnology-20th-edition -Contraceptive Technology 20th Edition www.choiceproject.wustl.edu -Contraceptive Choice Project bedsider.org -Bedsider thenationalcampaign.org -The National Campaign to Prevent Teen and Unplanned Pregnancy www.reproductiveaccess.org/key-areas/contracepti on

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