Transcript Primary and Preventive Health Care for Female Adolescents

Primary and Preventive Health Care
for Female Adolescents
Jessica H. Pittman, MD
Assistant Professor, Obstetrics and Gynecology
University of Utah School of Medicine
Objectives
• Provide for the primary care needs of the adolescent,
demonstrating knowledge in areas such as health
guidance, screening and immunizations.
• Describe most common STIs including diagnosis,
treatment, and potential serious sequelae.
• Develop understanding and use of the Centers for
Disease Control and Prevention U.S. Medical
Eligibility Criteria for contraceptive use.
Health Guidance for adolescents
www.healthypeople.gov
Health Guidance Topics
• Homicide
• Suicide
• Motor vehicle crashes, including those caused by
drinking and driving
• Substance use and abuse
• Smoking
• Sexually transmitted infections, including human
immunodeficiency virus (HIV)
• Teen and unplanned pregnancies
• Homelessness
“Panel urges cholesterol screening for kids”
PEDIATRICS Vol. 128 No. Supplement 5 December 1, 2011 pp. S213 -S256
ADA Screening Guidelines for Pre-diabetes
and Diabetes in Medical Setting
Age
10-17yo
BMI
Risk factors
Screening tests
Frequency
Results
American Diabetes Association Clinical Practice Recommendations 2007 Diabetes Care January 2007
Who should be screened for diabetes?
Children/Adolescents 10-17
years old AND
Body Mass Index (BMI) is:
• >85TH percentile for age &
gender
• Or >85th percentile weight
for height
• Or weight is >120% of ideal
for height
• AND Two (2) Risk Factors…
Risk factors for Diabetes
• Family history of type
2 diabetes (1st/2nd degree)
• Race ethnicity
Native American, African
American, Hispanic American,
Asian/South Pacific Islander
• Signs of insulin
resistance
acanthosis nigricans,
hypertension, dyslipidemia,
polycystic ovary syndrome
Screening tests
The following results require additional testing*:
• Fasting plasma glucose
– Pre diabetes (100-125 mg/dL)
– Diabetes (≥ 126 mg/dL)
• Oral glucose tolerance test (2 hour, 75 gram)
– Pre diabetes (>140-199)
– Diabetes (>200)
*includes repeating testing to confirm diagnosis.
Abnormal test results
• Repeat test on subsequent day to confirm
results.
• Implement treatment plan including lifestyle
modification.
• Screen and treat for other Cardiovascular Risk
Factors:
• Hypertension
• Dyslipidemia
• Tobacco use
Initiate pap smear screening at age 21
– USPSTF (www.uspreventiveservicetaskforce.org)
– ASCCP (www. asccp.org/consensus.html)
– CDC (www.cdc.gov/cancer/cervical/basic_info/screening)
– ACOG (www.acog.org)
19 June 2012 Annals of Internal Medicine Volume 156 • Number 12, pages 880-891
Immunization
• Saves 33,000 lives.
• Prevents 14 million
cases of disease.
• Reduces direct health
care costs by $9.9
billion.
• Saves $33.4 billion in
indirect costs.
Despite progress, approximately 42,000 adults and 300 children in the
United States die each year from vaccine-preventable diseases.
www.healthypeople.gov
Immunizations
http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
HPV vaccination
• FDA approved for administration to females ages 9-26
• FDA 2009 approval for males 9-26yo
• Quadrivalent vaccine (types 6,11,16 and 18)
– HPV 6 and 11: 90% of genital wart cases
– HPV 16 and 18: 75% of cervical cancer cases
• Series of 3 injections: 0,2 and 6 months
• Can be administered with Hepatitis B
vaccine series, meningococcal vaccine
(Menactra) and Tdap (Adacel)
Reisinger KS et al. iPediatrics. 2010 Jun;125(6):1142-51.
Sexually transmitted infections:
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Human Immunodeficiency viruses (HIV 1/2)
Herpes Simplex viruses (HSV 1/2)
Human Papilloma Viruses (HPV)
Hepatitis B and C viruses
Gonorrhea
Chalmydia
Syphillis
Trichimoniasis
Drug resistant gonorrhea
• CDC no longer recommends the oral antibiotic
cefixime (Suprax) as a first-line treatment
option for gonorrhea in the U.S.
• Recommended drug proven effective for
treating gonorrhea = injectable ceftriaxone
• Close monitoring for treatment failures
– retesting with a culture-based gonorrhea test if
persistent symptoms after initial treatment
www.cdc.gov/std/treatment
Expedited Partner Treatment (EPT)
• Allows third-party prescription without prior
exam for STD treatment
• Prescription requirements vary by state
– In Utah, prescription order must include patient’s
name and address. Prescription label must bear
patient’s name. Utah Code Ann. 58-17b-602
• EPT is permissible in most states including:
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Utah
Idaho
Nevada
Wyoming
www.cdc.gov/std/ept/legal/utah/htm
CDC Guidance for use of EPT
• Support use of EPT for treatment of partners
of Gonorrhea and chlamydial infections in
women and men.
• Advise against use of EPT for:
– Gonorrhea and chlamydial infections in men
who have sex with men
– Women with trichomoniasis
– Syphilis
Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases.
Atlanta, GA: US Department of Health and Human Services, 2006.
Minor Consent Laws
• All 50 states specifically allow minors to consent
to testing and treatment for STDs, including HIV.
• 25 states have laws or policies that explicitly give
minors the authority to consent to contraceptive
services (in one or more circumstances):
– Utah state law confers the rights and responsibilities
of adulthood to minors who are married.
– Utah state funds may not be used to provide minors
with confidential contraceptive services.
http://le.utah.gov/~code/TITLE76/76_07.htm
www.guttmacher.org
Contraception
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Oral contraceptive pills
Combined contraceptive Patch
Intra-vaginal ring
Depo provera injection
Single implanted rod (Implanon/Nexplanon)
Intrauterine contraception (Mirena/Paragard)
Condoms
Quick start initiation method
• First pack in the office
– Supervised ingestion of first pill
– Improved compliance rate
– Refills on weekdays
vs. “Sunday Start”:
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Decrease breakthrough bleeding
May delay initiation or never start
Engage in unprotected sex one more cycle
Refills on weekends
Lara-Torre, E Contraception 2002;66:81
Westhoff C, Osborne LM, Schafer JE, Morroni C. Obstet Gynecol 2005;106:89-96.
Schafer JE, Osborne LM, Davis AR, Westhoff C. Contraception 2006;73:488-92.
Unintended Pregnancy
• 80 million unintended pregnancies occur
worldwide each year
• With typical use, the first year failure rate:
– copper T 380A (ParaGard®) is 1%
– LNG-IUS (Mirena®) is 0.1%
– Implant (Implanon/Nexplanon®) is 0.1%
• One-year continuation rates:
– 78% for the copper T 380A
– 80% for the LNG IUS
– 84% for Implanon®
Guttmacher Institute. Facts on contraceptive use. 2008. http://www.guttmacher.org
Trussell J. Contraceptive efficacy. Contraceptive technology 19th revised edition. New York: Ardent Media; 2007.
LARC methods
• Available LARC methods:
– Hormonal contraceptive IUD (Mirena)
– Nonhormonal contraceptive IUD with Copper
(ParaGard)
– Subdermal contraceptive implant
(Implanon/Nexplanon)
• Shorter-acting methods considered LARC:
– Depot medroxyprogestone acetate (Depo provera)
Depot Medroxyprogesterone Acetate
and Bone Mineral Density
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Decreased bone density noted in teenagers
No increased risk of fractures
Recovery of BMD following discontinuation
May consider supplement calcium and vit D
Consider alternative method if at risk
– Immobile, non-weight bearing, wheelchair bound
– Underweight
• Reassess after 2 years, continue DMPA if other
methods are inadequate
ACOG Committee Opinion No. 415. Obstet Gynecol 2008;112:727-30
Scholes D, et al. Arch Ped Adol Med 2005;159(2):139-144
Barriers to increased LARC use
• Providers may lack information or are misinformed.
– unsubstantiated risk related to STIs, ectopic pregnancy,
infertility, use postpartum, use postabortion, use by
nulliparous women, use by teens.
• Providers lack adequate training in IUC and implant
insertion
• Patients' fears, misinformation and lack of knowledge
have resulted in low demand.
• LARC is expensive and provider reimbursement low,
especially in the US.
Speidel et al. Contraception 78 (2008) 197–200
The Contraceptive CHOICE Project:
• 5086 women ages 14-20 enrolled
• Preferred LARC method by age:
– 18-20 years (61% chose LARC)
• Implant: 29%
• IUD: 71%
– 14-17 years (69% chose LARC)
• Implant: 63%
• IUD: 37%
Mestad R, et al. Contraception. 2011 Nov;84(5):493-8
U.S. Medical eligibility criteria (MEC)
http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf
U.S. Medical eligibility criteria (MEC)
• Comprehensive, evidence-based guidance on
contraceptive use
• Adapted from guidance previously developed
by the World Health Organization
• The U.S. MEC gives guidance to clinicians
providing family planning services to women,
especially women with medical conditions.
Increased VTE risk and contraception
• Communicating level of risk:
– OCP and VTE risk: 20-30/100,000
– Pregnancy VTE risk: 100/100,000
– Postpartum VTE risk: 500/100,000
• If increased VTE risk factors, Progestin only
methods preferred
– Pills
– Injectable
– Implant
– Intrauterine
James AH. Pregnancy-associated thrombosis. Hematol 2009; 277-85
Seeger JD, Loughlin J, Eng PM, Clifford CR, Cutone J, Walker AM. Risk of thromboembolism in women taking
ethinylestradiol/drospirenone and other oral contraceptives. Obstet Gynecol 2007; 110(3):587-93.
Drospirenone* and DVT risk
*Drospirenone containing birth control pills include: Beyaz, Gianvi, Loryna, Ocella,
Safyral, Syeda, Yasmin, Yaz, and Zarah.
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm257175.htm
Migraine Headaches
MacClellan LR et al. Stroke. 2007; 38: 2438-2445
Drug Interactions
Foldvary-Schaefer N et al. Neurology 2003;61:S2-15
Foldvary-Schaefer N, et al. Cleve Clin J Med 2004;71 Suppl 2:S11-8
Emergency Contraception
• ParaGard (copper) IUD
• Contraceptive pills (Yuzpe method)
– 19 pill brands available for use in U.S.
– Usually involves taking 4-5 pills, repeat in 12 hrs
• Plan B (Levonorgesterol)
• Next step
– Generic form of Plan B One step (July 2012)
• Ella (Ulipristal Acetate)
Fine P, Mathé H, Ginde S, Cullins V, Morfesis J, Gainer E..Obstet Gynecol. 2010;115:257-63
Plan B (Levonorgesterel)
• Single dose of levonorgesterol 1.5 mg
• Reduces pregnancy if taken within 72 hours of
unprotected intercourse
• FDA approved for OTC 2009 ( >17 yo)
• December 7, 2011 – Dept. of HHS overrules decision
of the Food and Drug Administration (FDA) to make
the emergency contraception method known as
Plan B One-Step available for
purchase without a prescription
or age restriction.
Emergency Contraceptive Pills
• Plan B One-Step and Next Choice
– Reduce the risk of pregnancy by 89% when started
within 72 hours after unprotected sex
– Continue to reduce the risk of pregnancy up to
120 hours after unprotected intercourse
– Inhibits or delays ovulation
– Less effective as time passes
– Does not interrupt established pregnancy
Rodrigues I, et al. Am J Obstet Gynecol. 2001;184:531‐7
Mikolajczyk RT, Stanford JB. Fertil Steril. 2007;88:565‐71
Ella (Ulipristal acetate)
• Use up to 120 hours after unprotected
intercourse
• Progesterone antagonist
• Delays ovulation
• Maybe more effective than levonorgestrel
• Especially 72-120 hour group
• Prescription only
I am every emotion times ten,
I conform yet I'm rebellious,
Always obeying but somehow still an outlaw,
Always talking but never heard,
I am a teenager.
-- Author Unknown
Additional resources
• American College of Obstetricians and Gynecologists
(www.acog.org)
• North American Society for Pediatric and Adolescent
Gynecology (www.naspag.org)
• Boston Children’s Hospital – Center for Young
Women’s Health (www.youngwomenshealth.org)
• Centers for Disease Control (www.cdc.gov)
• Planned Parenthood (www.plannedparenthood.org)