hormonal contraception adolescent vietnam - en

Hormonal Contraception in Adolescents
Hormonal Contraception in Adolescents
Rebecca Jackson, MD
Associate Professor
Obstetrics, Gynecology &
Reproductive Sciences and
Epidemiology & Biostatistics
San Francisco General Hospital

Preview

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
25 % Unintended

Despite method use
23 % Unintended
No method used
Henshaw, Family Planning Perspectives, 1998
Half of
unintended
pregnancies
end in
abortion

Teen Pregnancy

The majority (78%) of teen pregnancies
are unintended.

About 45% of teen pregnancies end in
abortions; roughly 250,000 abortions per
year.

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.

Consequences of adolescent
pregnancy

Increased morbidity/mortality during
pregnancy


Unsafe abortion

Sexually transmitted infections

Social and personal consequences of
early pregnancy

Poverty

Unable to complete education


26% of females used no contraception
at first sex

Contraceptive use at first sex is more
likely for teens who are older at first sex

Teens who do not use contraception at
first sex are much more likely to have a
birth before reaching age 20
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

Hormonal Methods

Combined Estrogen & Progesterone

OCPs

Skin patch, Vaginal Ring,
Injectables

Progesterone-only

Injectable (DMPA)

Implant (Implanon)

IUD (Mirena)

Emergency contraception

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

Offer condoms

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
consistent use
Combined OCPs 6-8 0.1
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

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
/>(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
/>(Teens may have these)

OCP “Pros” for Teens

Temporally unrelated to intercourse!

Regulates periods

Decreases menstrual cramping and flow

Improves acne

Improves hirsutism

Reduces 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 protection

Fear 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”

Ortho Evra
™

20mcg EE & 150mcg
norelgestomin daily

One patch each week
for 3 weeks

Very effective! Failure
rate 0.9%

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 cycles

3% 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
Age < 35
2
2
3

3

Age > 35
Age > 35
3
3
4
4
(ii) focal neurologic symptoms
(ii) focal neurologic symptoms


4
4




4
4


(at any age)
(at any age)
/>
Prescribing combined methods
in Women with Migraines

Lower & consistent estrogen levels with
ring


Consider 20 or 25 mcg pills

Consider eliminating the placebo week
in women who have migraines
triggered by withdrawal of estrogen

Regular follow-up in 1-3 months after
initial Rx

Need to discontinue method if
headaches worsen