Materials for next week:
- Case and discussion and the UW Division of Gen Peds Clinical Guidelines on Contraception
- Update on Adolescent Contraception. Advances in Pediatrics 2016
- Essentials for Contraception Powerpoint from Physicians for Reproductive Health (an amazing repository of educational materials is available on their website)
- Teen and young adult patient info on choosing contraception: www.bedsider.org
- Epidemiology: Whereas rates of teen sexual activity between ages of 15-19 have been relatively stable, the rates of teen pregnancy, birth, and abortion have all been declining thanks to more appropriate condom and birth control use. About 47% of 9-12 graders report having had sex in national surveys, with 59% having used a condom before last sex, 19% having used birth control pills, and 5% using other forms. Even with decreasing rates, rates of teen pregnancy in the US are about twice rates in Europe, with the CDC reporting 1 in 4 adolescent girls will become pregnant by age 20.
- What’s the most common birth control among adolescents? Condoms are the most commonly used form by teens, with 90% reporting using at least once. Condoms have a failure rate up to 25%. Next most common are combined oral contraceptive pills (COCs); the failure rate is 8-9% for typical use and up to 25% for teens. Other combined hormonal forms including the transdermal patch and vaginal ring, which may be more effective among teens as they don’t require daily dosing. Injectable progestin-only hormonal method (Depo-provera) lasts for 12 weeks and is more effective, but is associated with weight gain and some bone density loss with longer term use.
- What’s the most effective birth control? Remember, IDEAL is DUAL USE: CONDOMS + another form. The long-acting reversible contraceptives (LARCs) including implantable (e.g., Nexplanon) and intrauterine devices (IUDs) are most effective pregnancy prevention (less than 1% failure rate), and are now recommended as first-line for adolescents. Nexplanon is inserted into the subcutaneous tissue of the upper arm and lasts 3 years; the main side effect is irregular menstrual bleeding, and 15% of individuals amenorrheic at one year. IUDs last longest, but require a pelvic exam to insert. The hormonal IUDs (Mirena-up to 7 years, Kyleena- up to 5 years, Liletta -up to 7, Skyla – up to 3 years) are better for decreasing bleeding overall. The copper IUD (ParaGard) has no hormones, lasts up to 12 years, can be inserted as emergency contraception, yet is associated with more bleeding and cramping.
- What myths about IUDs do we need to dispel? 1) IUDs do not increase a woman’s risk of pelvic inflammatory disease (PID), as long as she’s not infected at time of insertion. 2) If exposed to gonorrhea or chlamydia post-insertion, treatment can occur without IUD removal. 3) IUDs can be used in females who have not yet conceived and do not increase the risk of infertility; fertility returns to baseline within 1-2 months post-removal.
- What needs to happen in a visit to start COCs?
- Brief medical and sexual hx, including date of last unprotected sex and current meds.
- Rule out absolute contraindications like migraines with aura, history of DVT/PE, or personal or family history of clotting disorder (see the US Medical Eligibillity Criteria for Contraceptive Use -USMEC)
- Blood pressure and weight. Pelvic exams are no longer needed
- Negative pregnancy test
- Provide affirmation and education, as well as condoms and advance emergency contraception