Transcript Emergency Contraception for the Female Adolescent

Adolescent Contraception:
Pills, Shots, Patches and
Rings
John Kulig, MD, MPH
Laurie Hornberger, MD, MPH
Job Corps Regional Medical Consultants
Sexual risk behavior
ever had sexual intercourse
grade 9
grade 10
grade 11
grade 12
male
41%
42%
54%
61%
female
29%
39%
50%
60%
>4 lifetime sexual partners
grade 9
grade 12
male
14%
24%
female
6%
20%
Source: CDC 2001 Youth Risk Behavior Survey
Sexual risk behavior
initiation of sexual intercourse before age 13
male students
female students
white students
black students
Hispanic students
all students
9%
4%
5%
16%
8%
7%
Source: CDC 2001 Youth Risk Behavior Survey
Sexual risk behavior
condom use during last sexual intercourse
white students
black students
Hispanic students
57%
67%
54%
alcohol or drug use at last sexual intercourse
male students
31%
female students
21%
white students
28%
black students
18%
Hispanic students
24%
Source: CDC 2001 Youth Risk Behavior Survey
Adolescent Pregnancy
“Have been pregnant or gotten someone
pregnant.”
male
female
white
black
Hispanic
4%
5%
3%
11%
6%
Source: CDC 2001 Youth Risk Behavior Survey
Oral
Contraceptive
Pills
New progestins
1st generation:
norethindrone
2nd generation:
norgestrel
levonorgestrel
3rd generation:
desogestrel
norgestimate
new:
drospirenone
Noncontraceptive Benefits of OCs
decrease menstrual flow (lighter, shorter periods)
decrease menstrual cramps (no ovulation)
improve anemia (lighter, shorter periods)
improve acne (estrogen effect)
protect against ovarian and endometrial cancer
decrease benign breast disease
decrease ovarian cyst formation
prevent ectopic pregnancy
protect against some causes of PID
protect against osteoporosis
Oral Contraceptives and Risk
of Breast Cancer
study of 4575 women with breast cancer and
4682 controls - age 35 to 64 years at interview
relative risk 1.0 [0.8-1.3] for current OC users
relative risk 0.9 [0.8-1.0] for previous OC users
similar results in white and black women
relative risk did not increase with longer use or
with higher estrogen dose
no increased risk associated with initiation of OC
use in adolescence
NEJM 2002;346:2025-2032
Drug Interactions with OCs
most anticonvulsants
(except valproate)
rifampin
griseofulvin
St. John’s Wort
Seasonale®
extended regimen combined oral
contraceptive pills with ethinyl estradiol
and levonorgestrel
91 day cycles - 84 days on - 7 days off
4 menstrual cycles per year - one each
season
clinical trials underway
FDA approval anticipated in 2004
Emergency
Contraception
What is the best method of emergency
contraception (EC) for use by adolescents?
Options:
Yuzpe method (1982)
combination oral contraceptive pills
progestin-only pills
dedicated emergency contraceptive pill
products: Preven® and Plan B®
mifepristone (RU486)
insertion of intrauterine device
Ovral ®
Lo-Ovral ®
Ovrette ®
Mifepristone (RU486)
How does EC work?
mechanism of action of levonorgestrel +
ethinyl estradiol may depend upon timing
during the menstrual cycle
principal mechanism is prevention of
ovulation
may thicken cervical mucus
may interfere with transport of sperm, ova
or zygote
may inhibit implantation
How does EC work?
onset of pregnancy is medically defined as
implantation of a fertilized ovum in the wall
of the uterus (ACOG)
levonorgestrel + ethinyl estradiol is not
effective once implantation occurs
levonorgestrel + ethinyl estradiol does not
induce abortion
How effective is EC?
Pregnancy risk:
33% per cycle if sexually active qod
15% per cycle if sexually active once a week
condom failure reported by 4%-7% of
couples during a three-month interval
EC use could prevent 2 million unintended
births and 1 million induced abortions each
year in the US
How effective is EC?
Yutzpe regimen data:
EC efficacy 74% by meta analysis of ten
studies
0.5%-1.5% observed vs 4.7%-5.5% expected
pregnancy rate
no absolute contraindications except
pregnancy
no demonstrable teratogenicity
How effective is EC?
Importance of timing: combined pill data
77% effective if taken within 24 hours of
unprotected intercourse
efficacy declines to 36% if treatment is
delayed 25-48 hours
efficacy declines to 31% if treatment is
delayed beyond 48 hours
How effective is EC?
Importance of timing: Plan B® data
95% effective if taken within 24 hours of
unprotected intercourse – reduces crude
pregnancy rate from 8% to 0.4%
efficacy declines to 85% if treatment is
delayed 25-48 hours
efficacy declines to 58%-61% if treatment is
delayed beyond 48 hours
Are there medical
contraindications to EC use?
only absolute contraindication is
pregnancy (because EC will not work)
no evidence of harm to a developing fetus
no concern about estrogen-related
contraindications with progestin-only EC
potential drug interactions with certain
anticonvulsants, rifampin and griseofulvin
may reduce efficacy
Is pregnancy testing necessary
before using EC?
EC is ineffective if implantation has
occurred
no evidence of harm to developing fetus if
EC is taken inadvertently
routine pregnancy testing is not
recommended
consider pregnancy testing prior to EC use
if menses delayed
consider pregnancy testing after EC use if
menses does not occur within 3 weeks
Should an anti-emetic be
prescribed with EC?
Nausea:
Yuzpe regimen
Plan B®
Vomiting:
Yuzpe regimen
Plan B®
50.5%
23.1%
18.8%
5.6%
Data from a multi-center randomized clinical
trial of 1,998 women.
Should EC be prescribed in
advance of need?
women receiving EC in advance are two to
three times more likely to use them, but
not to use them repeatedly (US/Scotland)
80% of women who received EC in
advance began treatment within 24 hours
of intercourse vs 40% of women who
needed to fill an EC prescription
no more likely to engage in sexual activity
no more likely to use their regular
contraceptive less consistently
Should EC be prescribed in
advance of need?
fewer than one third of female adolescents
have heard of EC (1998 data)
17% of young women report no use of
contraception at most recent intercourse
20% of women report forced sexual
intercourse and 72% were under age 20 at
the time of the experience (NCHS)
lack of clinician availability on weekends
may disproportionately affect adolescents
Should EC be made available
without a clinician’s prescription?
Citizen’s Petition filed with the FDA in
February 2001 – 70 organizations
currently available over-the-counter in 13
industrialized nations
currently available from pharmacists in the
states of California and Washington
Ref: NEJM 2002;347:846-849
Should EC be made available
without a clinician’s prescription?
Arguments in favor of OTC availability:
improved public health
delays in treatment lead to more unintended
pregnancies
easier access to EC 24 hours a day
safe for self-medication
same dose for all women
same medications safely used for contraception
for decades
serious adverse effects do not occur, even with
inappropriate use
Should EC be made available
without a clinician’s prescription?
Arguments opposed to OTC availability:
no clinician contact to discuss potential side
effects
missed opportunity for contraceptive counseling
may make refusal of sexual intercourse more
difficult
EC is a euphemism for induced early abortion
EC might unintentionally be used in pregnancy
EC use might undermine use of non-emergency
contraception, including barrier methods
Does knowledge of EC alter
adolescent sexual behavior?
study of 916 male and 852 female
students age 14-15 in 12 schools in UK
single lesson on emergency contraception
improved knowledge persisted six months
later in comparison with controls
no difference in sexual activity, intent to
use EC or use of EC
Ref: BMJ 2002:324:1179-1183
Emergency Contraception
Resources
EC hotline 1.888.NOT.2.LATE
EC website http://not-2-late.com
Clinician’s guide to providing EC
http://www.piwh.org/publications.html
Consortium for Emergency Contraception
http://www.cecinfo.org/
Progestin-only
Injectable
Contraception
Depo Provera
depot medroxyprogesterone acetate
150 mg IM once every 12 weeks
irregular bleeding => amenorrhea
within 2 years (70%)
concerns:
weight gain
osteoporosis risk
Combined
Injectable
Contraception
Combined injectable
contraceptives
Lunelle:
– 25 mg depot-medroxyprogesterone acetate
and 5 mg estradiol cypionate injected (IM)
once a month
– 0.5 mL IM q 30 days + 3 days
– FDA approved in October 2000
– prefilled syringes withdrawn from the
market in October 2002 - potency concerns
Lunelle : Mechanisms of Action
Suppress ovulation
Reduce sperm transport in upper
genital tract (fallopian tubes)
Change endometrium making
implantation less likely
Thicken cervical mucus preventing
sperm penetration
Lunelle : Contraceptive Benefits
highly effective (0.1-0.4 pregnancies per
100 women during the first year of use)
effective immediately
does not interfere with intercourse
few side effects
can be provided by trained nonmedical
staff
no supplies needed by the patient

Lunelle
: When to Start
anytime you can be reasonably sure the
patient is not pregnant
days 1 to 7 of the menstrual cycle
postpartum:
– after 6 months if breastfeeding
– after 3 - 6 weeks if not breastfeeding
postabortion (immediately or within 7 days)
Contraceptive
Patch
Ortho Evra
seven day contraceptive patch
13/4 inch three layer adhesive patch
contains both estrogen and progestin
applied to the buttocks, lower abdomen or
upper body
newly applied weekly for three weeks, then
one week off for menses
less effective in women over 198 pounds
approved by the FDA in November 2001
Ortho Evra
Side effects leading to discontinuation:
nausea (2%)
moodiness (1.5%)
headache (1.1%)
breast discomfort (1%)
irritation at application site (1.9%)
Inadvertent detachment uncommon (1.9%),
even with exercise, humid climates,
saunas, hot tubs
Contraceptive
Vaginal Ring
NuvaRing
contraceptive vaginal ring - 2 inch diameter
worn for 21 days => removed for 7 days to
allow menses => replaced with new ring
releases 120 mcg of etonogestrel and 15
mcg of ethinyl estradiol daily
one size only - does not require fitting
cannot be inserted incorrectly
no increase in vaginal infections/discharge
3 hour window after inadvertent removal
Contraceptive
Implant
Implanon
progestin-only contraceptive implant
single flexible 4 cm rod inserted under the
skin of the upper arm
contains 68 mg etonogestrel - releases
40 mcg daily - 3 year efficacy
no pregnancies in 73,000 monthly cycles
irregular menstrual bleeding common
clinician visit for insertion and removal
Intrauterine
Contraceptive
System
Mirena
levonorgestrel-releasing intrauterine
system - 20 mcg daily - 5 year efficacy
highest risk of PID within 20 days of
insertion
irregular menstrual bleeding common in
first 3-6 months
clinician visit for insertion and removal
Condom Use and Hormonal
Contraception
Consistent condom use
OCs
21%
DMPA
18%
Norplant
9%
Condom use at last intercourse
hormonal contraception
no hormonal contraception
52%
69%

FemCap
silicone rubber cervical cap - less irritating than latex
used with microbicide/spermicide
worn for up to 48 hours
3 sizes:
– small (22 mm) - never pregnant
– medium (26 mm) - pregnant, no vaginal delivery
– large (30 mm) - vaginal delivery at term
can reuse for two years
FDA approved in March 2003
“The Contraceptive Report”
Quarterly update on advances in
contraceptive technology
Available online at:
www.contraceptiononline.org/contrareport/i
ssue.cfm
Subscribe for free at:
www.emron.com/TCR
Sexually Transmitted
Disease Guidelines
Centers for Disease Control
and Prevention
May 2002
Chlamydia
All sexually active adolescent and young
adult women should be screened annually,
regardless of the presence or absence of
symptoms.
All women with Chlamydia infections
should be rescreened 3-4 months after
treatment is completed.
Gonorrhea
Resistance to fluoroquinolone antibiotics
(ciprofloxacin,ofloxacin,levofloxacin) has
been found on the West Coast. It is
unknown how extensive this resistance will
become or how quickly it may spread.
Cefixime and ceftriaxone are now
considered first line drugs to treat GC on
the West Coast, but cefixime is no longer
manufactured in the US.
Gay and bisexual males
Expanded risk assessment - annual
screening:
– Chlamydia (anal, urethral)
– gonorrhea (anal, urethral, pharyngeal)
– HIV
– syphilis
Routine vaccination for hepatitis A and
hepatitis B
Use of Nonoxynol-9
Frequent use of the spermicide nonoxynol-9
has been shown to cause genital (vaginal,
rectal) lesions that can increase the risk of
HIV transmission
Condoms lubricated with nonoxynol-9 are
no longer recommended
Previously purchased condoms with N-9 can
be used up until their expiration date
2002 CDC STD Guidelines
Two copies mailed to each center by
Humanitas in February 2003 - one for
center physician - one for Wellness Center
reference
Order by phone: 1-888-232-3228
Order online: www.cdc.gov/std =>
www.cdc.gov/std/treatment/default.htm