hormonal contraception adolescent vietnam - en

Half of women with an unintended pregnancy report using a contraceptive method in the month that they conceivedHenshaw et al.. Starting a Teen on Hormonal ContraceptivesTake a medical hi

Hormonal Contraception in Adolescents

Rebecca Jackson, MD

Associate Professor Obstetrics, Gynecology &

Reproductive Sciences and Epidemiology & Biostatistics San Francisco General Hospital

Why contraception in teens is important Hormonal methods and issues specific to adolescents

Acknowledgement

Slides adapted with permission from presentations by Jody Steinauer, MD and Tina Raine, MD

Sex* by Age (US)

Mosher WD, Chandra A, Jones J Sexual behavior and selected health measures: Men and women 15–44 years of age, United States, 2002 Advance data from vital and health statistics; no 362 Hyattsville, MD: National Center for Health Statistics 2005

*Heterosexual vaginal intercourse

6.3 Million U.S Pregnancies

52 % Intended

abortion

Half of women with an unintended pregnancy report using a contraceptive method in the month that they conceived

Henshaw et al Unintended Pregnancy in the United Sates Fam Plann Perspect 1998; 30:4-29.

Poverty Unable to complete education

26% of females used no contraception

Teen Contraceptive Use – First Sex

Abma et al Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2002 National Center for Health Statistics Vital Health Stat 23(24) 2004.

Teens - Contraception Used

At Last Sex

Source: 1995 National Survey of

Family Growth

Contraception for teens

Can safely use all methods (except sterilization)

Need to make choice themselves Side effects more problematic to teens Often don’t initiate or fill the prescription (consider quick start)

Starting a Teen on Hormonal Contraceptives

Take a medical history (Illnesses, Migraines ) Assess weight and blood pressure

Pelvic exam not necessary:

Screen for STIs… using urine if no problems Determine when a Pap test is needed

Provide education, counseling, and support Patient preference

Past method use and problems

Effectiveness of Methods

Failures per 100 women in first year of use

Method Typical Use Correct &

Consistent Use

Always Very Effective

Implants 0.1 0.1 Injectables 0.3 0.3 IUD 0.8 0.6

Very effective with

Only somewhat effective as

commonly used Effective when used correctly

Male Condoms 14 3 Diaphram 20 6 Spermicides 26 6 Fertility awareness 20 1-9 Withdrawal 19 4

No method 85 85

WHO Medical Eligibility

Guidelines

Classification

1 Use method in any circumstances, no

restriction

2 Generally use the method,

advantages outweigh risks

3 Use only if no other method available,

risks outweigh advantages

4 Method not to be used, unacceptable

health risk

Improving access to quality care in family planning Medical eligibility criteria for initiating and continuing use of contraceptive methods Second Edition WHO, 2000.

Combined Hormonal Contraception

Category 4 Contraindications

Vascular or heart disease - stroke, MI, diabetic, severe HTN (>160/100) or Multiple CVD RF

Smoking (>15 cigarettes/day) and Age >35

Migraine with Aura or Age>35 and migraines

Active liver disease or tumor

History of DVT/PE or known thrombogenic mutation

Major surgery with prolonged immobilization

Breast feeding < 6 weeks postpartum

Current breast cancer

http://www.who.int/reproductive-health/publications/RHR_00_2_medical_eligibility_criteria_3rd/

(Teens may have these)

Breast feeding: 6 wks-6 months; past breast cancer Postpartum <21 days

Smoking (<15 cigarettes/day) and Age >35 Elevated BP (140-159/90-99) or controlled HTN History of HTN where BP can’t be evaluated

Multiple risk factors for CVD Liver or gall bladder disease or OCP-related cholestasis Drugs that affect liver enzymes (Rifampin, seizure meds)

Combined Hormonal Contraception Category 3 Contraindications

http://www.who.int/reproductive-health/publications/RHR_00_2_medical_eligibility_criteria_3rd/

(Teens may have these)

OCP “Pros” for Teens

Temporally unrelated to intercourse!

Regulates periodsDecreases menstrual cramping and flowImproves acne

Improves hirsutismReduces risk of ovarian and endometrial cancer

Decreases benign breast neoplasms

OCP “Cons” for Teens

Temporally unrelated to intercourse!

Requires a daily regimen

No place to keep them

No STD protectionFear of side effects or “danger”:

“Will I be able to have children later?”

“Will it make me gain weight?”

Daily: Extended Use Pills

May increase efficacy and

adherence

Up to 25% of women have follicle ready to ovulate by day 7 of

placebo week!

So if the start of the new pack

is delayed, they are at high risk of pregnancy!

Continuous use

2 months/3 months, then a week off

Weekly: Transdermal Contraceptive System “Patch”

Women are more

compliant than with pill!

(88% v 78%)

Audet, JAMA, 2001

“Patch” Issues for teens

Easily placed and removed but hard

to hide Few side effects – comparable to pills except

20% skin irritation – 2% stopped method

More breast discomfort in first 2 cycles (19%) than pills (6%)

More spotting (20%) than pills in first

2 cycles3% detached

“Patch” and thrombosis

Increased risk thrombosis?

Numerator and denominator are unclear New user bias

Serum levels slightly higher than 35 mcg pill

Increase with each week, reaches steady state

Case-control study – VTE patch v 35 mcg pill

OR 1.1 (95% CI 0.7-1.8) Risk of thrombosis may or may not be higher than other combined methods

Jick et al Contraception 2006.

Monthly: Contraceptive

Vaginal Ring

Nuvaring™

15 mcg EE & 120mcg desogestrel daily

One ring each month Ring in vagina for 3 weeks Ring removed for one week Constant, low hormone

levels Very effective!

Failure rate 1.2%

Miller, Ob Gyn, 2005

“Ring” Issues for teens

Easily placed and removed (and hidden) but need to be comfortable placing in vagina

Most women and men don’t notice during sex High acceptability and compliance

Few side effects – comparable to pills except

Less spotting 5% (significantly less in first month)

1% stop method because of discharge 2.5% stop method because of discomfort

Dieben, Ob Gyn, 2002

Headaches and

Combined Hormonal Contraception

Initiate Continue

Non migrainous (mild/severe) 1 1 2 2

Migraine

(i) no focal neurologic symptoms

Age < 35 2 2 3 3

Age > 35 3 3 4

(ii) focal neurologic symptoms 4 4

(at any age)

http://www.who.int/reproductive-health/publications/RHR_00_2_medical_eligibility_criteria_3rd/

Prescribing combined methods

in Women with Migraines

Lower & consistent estrogen levels with ring

Consider 20 or 25 mcg pillsConsider eliminating the placebo week

in women who have migraines triggered by withdrawal of estrogenRegular follow-up in 1-3 months after initial Rx

Need to discontinue method if headaches worsen

Migraine with Aura: Use Progestin-Only Methods

Depot medroxyprogesterone acetate

(DMPA)

Category 4 Contraindications

Current breast cancer

http://www.who.int/reproductive-health/publications/RHR_00_2_medical_eligibility_criteria_3rd/

Current liver disease or tumor Multiple risk factors for Arterial vascular disease (age over 35, smoking, hypertension, diabetes)

Current DVT/PE Current ischemic heart disease Worsening Migraine with aura on DMPA Past breast cancer

Depot medroxyprogesterone acetate

Polaneczky M, Liblanc M J Adolesc Health 1998 Aug;23(2):81-8

Other side effects:

Transient bone mineral density lossWeight gain

Mood changesDelayed return to fertility

Depo-Medroxyprogesterone

(DMPA)

The Etonogestrel Subdermal

Implant

Why a New Implant?

Most effective contraceptives Low-dose progestin is safest method

No impact on bone density Single implant is more acceptable

Easier to insert and removeLess visible

Better bleeding pattern

Lasts 3 years

Mirena Intrauterine

Contraceptive

Mirena levonorgestrel IUS

Releases 20 mcg/day

Effective for 5 (7) years

0.1% failure in one year

1.1% failure in seven years

Compare with tubal ligation failure rate of 1.9% in ten years

Sivin, et al Contraception 1991.

IUC: Dispelling Common Myths

In fact:

DO NOT cause pelvic infection

DO NOT decrease the chance of future pregnancies

DO NOT cause ectopic pregnanciesCAN be used for women who have not been pregnant

Disruptive to menstrual cycles

No evidence of decreased use of other contraception when given access to EC

Emergency Contraception Efficacy

(use after one act of unprotected intercourse)

If 100 women have unprotected sex 100

in the 2 nd or 3 rd week of their cycle…

Male Condoms

Don’t forget them!

Only method with STD protection Used by growing numbers of teens Adolescents more likely to rely on condoms for BC than older women Efficacy dependent on consistent use Myth: condoms break a lot

Side effects are more important reason for discontinuation

Encourage more effective methods

Thank you! Questions? jacksonr@obgyn.ucsf.edu