Sexual Health in Teens - Texas Children`s Hospital
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Transcript Sexual Health in Teens - Texas Children`s Hospital
Sexual Health in Teens
Jennifer Kurkowski, MSN, WHNP-BC
Jane Geyer, MSN, WHNP-BC
Division of Pediatric and Adolescent Gynecology at Texas Children’s Hospital
Baylor College of Medicine, Houston, Texas
Disclosures
We have no disclosures
Objectives
1) Discuss stages of adolescent development as it relates to sexuality
2) Identify sexual behavior risk factors in adolescents
3) Review birth control options including emergency contraception
4) Discuss sexually transmitted infections in adolescents including treatment
5) Describe how to obtain a proper sexual history in adolescents
Adolescent development
Development is divided into three states-early, middle, and late
One of the tasks for development is acquiring a mature sexual development
Early adolescence (10-14) is when sexual curiosity begins and may lead to
masturbation or early sexual activity
Middle adolescence (15-18) is when romantic relationships begin, serial
monogamy or having several partners
Late adolescence (18 +)- have more mature understanding of sexual
orientation, can participate in a variety of intimate relationships
Who is having sex?
Data from the 2013 Youth Risk Behavior Surveillance Survey
Nationwide 46.8% of students had ever had sexual intercourse
The incidence of ever having sexual intercourse was higher among Black and
Hispanic students
Among high school grades- 30% of 9th grade students reported having sexual
intercourse, 41.4% of 10th graders, 54.1% of 11th graders and 64.1% of 12th
graders
Nationwide 5.6% of students had had sexual intercourse for the first time
before age 13
7.3% of students reported they had been forced to have sexual intercourse
Lesbian, Gay, Bisexual
5% of teens identify as lesbian, gay, or bisexual
10% of females have participated in same gender sexual activity
2-6% of males have reported same gender sexual activity
Bisexual teens have higher rates of unprotected sex
Number of Partners and who is currently
sexually active
Nationwide 15% of students had had sexual intercourse with four or more
persons during their life
Higher among black and Hispanic males
From 1991-2013 significant linear decrease occurred overall in the prevalence
of having had sexual intercourse with four or more person (18.7-15.0%) as
well as the prevalence of being currently sexually active
34% of students had had sexual intercourse with at least one person during
the 3 months prior to the survey
Teen Pregnancy
Since 1990 the teen pregnancy rate has dropped by half
In 2010 there were approximately 614,000 pregnancies to women younger
than age 20 and the pregnancy rate was 57.4 per 1,000 women age 15-19
Majority of these pregnancies are unplanned
In 2010, 60% of pregnancies to girls age 15-19 resulted in a live birth, 15%
resulted in a miscarriage, and 26% resulted in an abortion
The children of teenage mothers are more likely to have lower school
achievement and drop out of high school, have more health problems, be
incarcerated at some time during adolescence, give birth as a teenager, and
face unemployment as a young adult
Teen Pregnancies in Texas
In Texas the teen pregnancy rate is 73 per 1000 women. Texas ranks 47th in
teen pregnancy rate. The lowest teen pregnancy rates are in New Hampshire
In 2014 there were 35,063 teen births
1.1 billion dollars were spent on teenage pregnancies
Who is using condoms/ birth control?
Among those who said they were currently sexually active 59.1% reported
they had used a condom during their last sexual encounter
From 1991-2013 a significant linear increase occurred in overall prevalence of
having used condoms during their last sexual encounter (46.2%-59.1%)
Overall 25.3% of currently sexually active students reported they had used
some type of birth control
19% reported using birth control pills to prevent pregnancy before their last
sexual intercourse
1.6% reported using the IUD or the birth control implant
4.7% reports using the patch, ring or shot
13.7% of student reported using no type of birth control
Birth control options
This discussion should include abstinence and contraceptive counseling
There are many forms of effective contraception
First line birth control methods for teens should be long acting reversible
contraceptives (LARCS). These include intrauterine devices and subdermal
implants
Other options include oral contraceptive pills, vaginal ring, skin patch, and
the injection
Who chooses birth control?
Teens are more likely to seek contraception if they:
Perceive pregnancy as a negative outcome
Have long-term educational goals
Are older in age
Experience a pregnancy scare or actual pregnancy
Have family, friends, and/or a clinician who sanction the use of contraception\
LARCS
The contraceptive choice study out of St Louis showed that :
Among women who chose a LARC method, 86% were still using the method at 1
year. For women who chose a non-long-acting method, only 55% were still using
their method at 1 year
Women using either LARC or the injection had the lowest unintended pregnancy
rates during year 1, year 2, and year 3 of their follow-up. Pill, patch and ring users
had much higher unintended pregnancy rates; they were 20 times more likely to
have an unintended pregnancy compared to LARC users in Year 1
The IUD and Implant should be discussed first when presenting options to
teens
Intrauterine Device (IUD)
Currently there are 3 IUDs available
They can last anywhere from 3-10 years
IUDs work by preventing sperm from fertilizing an egg as well as thickening
cervical mucus which blocks sperm from entering the uterine cavity
Birth control Implant
Small rod that is implanted under the skin in the upper arm
Currently one Implant is available
Works primarily by thickening cervical mucous and preventing ovulation
Biggest side effect is change in menstrual bleeding pattern
Colorado program
Colorado offered free LARCs to teenagers from 2009-2013
The birthrate among teenagers across the state dropped by 40% from 2009 to
2013, while their rate of abortions fell by 42%
Birth Control Pills
Combined oral contraceptive pills contain two hormones; estrogen and
progestin
One hormone pill is taken at the same time each day to prevent pregnancy
Encourage quick start method. If patients do this the pill will be effective in 1
week after starting it
Traditional cycles of BCP are 21 days of hormones followed by a 7 day
hormone free break
If used correctly can be 98% effective
Birth Control Patch
Hormonal contraceptive patch worn on the skin that contains two hormones;
estrogen and progestin
A patch is worn for one week at a time. A new patch is put on once per week
for three weeks. The fourth week is a hormone free break
There might be a higher risk of getting pregnant for women who weigh more
than 195 lbs
May cause skin irritation
Can be 98% effective if used perfectly
Birth Control Ring
Hormonal contraceptive ring is worn inside the woman’s vagina. It contains
two hormones; estrogen and progestin
A ring is worn for three weeks (21 days). The ring is removed for one week.
The fourth week is hormone free
May cause vaginal discharge or irritation
Can be 98% effective if used perfectly
Birth Control Injection
Progestin injection into arm or hip every 11-13 weeks
Is 99.7% effective
Stops body from releasing an egg each month
May cause irregular spotting/bleeding as well as amenorrhea
Can increase bone mineral loss. Getting regular weight bearing exercise and
Calcium+ and Vitamin D in your diet is important
Can cause weight gain by increasing patient’s appetite
Effectiveness of birth control Methods
Emergency Contraception
Emergency contraception is the use of drugs or a device after unprotected
intercourse to prevent pregnancy
Candidates include patients whose primary method failed or those who had
unprotected intercourse
Not intended to be a primary method of contraception
In April 2013 a federal judge in New York ordered the U.S. Food and Drug
Administration to make Plan B available to people of any age without a
prescription and available in the retail isle
Can help prevent up to 80% of expected pregnancies
Emergency Contraceptive Pill
If taken within 24 hours of unprotected sex prevents 95% of possible
pregnancies
Can be taken up to 120 hours (5 days) after unprotected sex preventing 58%
of possible pregnancies
Does not affect a pregnancy that has already implanted
Cost ranges from 28-40 dollars
Is available OTC at most pharmacies
How does Emergency contraception
work?
1)
Inhibition or delay in ovulation (primary way)
2)
Interference with fertilization or tubal transport
3)
Prevention of implantation by altering endometrial receptivity
4)
Causing Regression of the corpus luteum
5)
Thickening of cervical mucus resulting in trapping of sperm
Instead of causing an abortion Emergency contraception can help PREVENT a
patient from getting one
Legal issues with contraception
Minors right to contraception varies from state to state
In Texas you must have parental consent to start contraception unless you go
to a Title X program
Texas is one of two states that does not allow state funds to be used to
provide contraceptives to minors without parental consent
Teens do not need parental consent to obtain over the counter contraception
such as condoms or the emergency contraceptive pill
Sexually Transmitted Infections
CDC estimates that youth ages 15-24 make up just over one quarter of the sexually
active population, but account for half of the 20 million new sexually transmitted
infections that occur in the United States each year
Compared with older adults, sexually active young adults are at higher risk of acquiring
STIs
Risk factors include:
those who initiate sex at an earlier age,
residing in detention facilities
Drug use
Men having sex with men
Attending an STD clinic
Having multiple partners
increased biologic susceptibility- cervical ectropian
Screening for STIs
All 50 states allow adolescents to consent for their own STI care
There is no requirement in any state to notify parents except in limited or
unusual circumstances
This can become difficult if a patient has private health insurance and a
explanation of benefits is mailed to the parents
Despite high risk of STIs in adolescents many healthcare providers fail to
assess for risk factors or screen in asymptomatic patients
Who should be screened?
Routine screening for C. trachomatis on an annual basis is recommended for
all sexually active females aged <25 years
Routine screening for N. gonorrhoeae on an annual basis is recommended for
all sexually active females <25 years of age
No recommendation for screening males for C. trachomatis and N.
gonorrheoeae on a routine basis but a decision should be made based of
clinical judgement and risk factors
HIV screening should be discussed and offered to all adolescents
Screening for other STIs including syphilis, herpes, HPV, hepatitis is not
generally recommended in an asymptomatic patient
Cervical cancer screening is initiated at age 21
Chlamydia
Most common cause of bacterial sexually transmitted infections in both men and women
Nucleic acid amplification tests (NAATs)are more sensitive and specific than other diagnostic
test. Can be a urine test, self collected vaginal swabs or cervical swabs.
First line treatment: Azithromycin 1 gram in a single dose or Doxycycline 100 mg twice a day
X 7 days
Use Azithromycin when possible, better for patient compliance
Alternative therapies include: Ofloxacin 300 mg twice a day X 7 days, Levofloxacin 500 mg
twice a day X 7 days
Pt should abstain from for 1 week until after patient and partner have both been treated.
Can retest in 3 months if there is a concern about compliance
Can be asymptomatic but the most common symptom in women is cervicitis and in men is
urethritis.
Other symptoms include vaginal discharge, pelvic pain, burning with urination, irregular
bleeding, painful sex
Gonorrhea
Gonorrhea can be diagnosed through urethral gram stain, urine culture, DNA
probe, and DNA amplification techniques, and NAATs
CDC recommends when a patient is diagnosed with Gonorrhea they also be
concurrently treated for Chlamydia
Treatment: Ceftriaxone 250 mg IM in a single dose with either 1 g of Azithromycin
in a single dose or Doxycycline 100 MG BID X 7 days
The higher dose of Ceftriaxone is now recommended due to reports of treatment
failure
If a patient is allergic to cephalosporins they should be treated with Azithromycin
2 g in a single dose
Lots of drug resistance associated with gonorrhea
Can be asymptomatic but the most common symptoms in women include vaginal
discharge, pain with urination or irregular bleeding . Symptoms in men include
pain with urination and discharge from the penis.
Pelvic Inflammatory Disease
Acute infection of upper genital tract, involving uterus, fallopian tubes, and/or ovaries
Sexually transmitted pathogens
C. trachomatis- found in endocervix in 10-36%
N. gonorrhoeae-15-44%
Both in 5-12%
10-30% of untreated GC/Chl casesPID
Diagnosing PID
PID is a clinical diagnosis
Signs/Symptoms associated with PID
Abdominal pain ~90%
Abnormal vaginal discharge ~45-75%
Elevated ESR ~75-80%
Abnormal vaginal bleeding ~30-40%
Fever ~15-30%
Urinary frequency ~15-20%
Nausea/vomiting ~10-14%
Treatment for Pelvic inflammatory
Disease
Presumptive treatment for PID should be initiated in sexually active young
women and other women at risk for STIs if they are experiencing pelvic or
lower abdominal pain, if no cause for the illness other than PID can be
identified, and if one or more of the following minimum clinical criteria are
present on pelvic examination:
cervical motion tenderness
or
uterine tenderness
or
adnexal tenderness
Suspicion should be low for treatment do to risk of infertility in the future
Treatment
Specific Concerns
Compared to adult women, adolescents are at higher risk of cervical
infections (gonorrhea, chlamydia) due to the immaturity of the cervix leading
to larger surface area of cells unprotected by cervical mucous
An average of 10 days lapses before a symptomatic adolescent will seek care
25% of adolescents with an STI tried self treatment before seeking care
Single dose therapy is preferred when available, adolescents can be non
complaint with longer treatments
Strongly encourage patients to notify partners
Expedited Partner Therapy
EPT is the delivery of medications or prescriptions by patients diagnosed with
an STI to their sexual partners without clinical assessment of their partners.
The CDC concluded that EPT is a “useful option” to further partner
treatment, particularly for male partners of women with Chlamydia or
gonorrhea.
This is now legal in Texas. 31 states EPT is permissible, in 12 states EPT is
potentially allowable and EPT is prohibited in 7 states.
Human Papillomavirus (HPV)
The most common STI
More than 40 different types that can affect the genital tract
90% of the time the immune system with clear HPV
The CDC estimated that 20 million people in the US have HPV and 6 million new people are diagnosed each
year.
Can cause genital warts and cervical cancer. Can also lead to cancer in the anus, vagina, vulva, penis and
oropharynx
Genital warts can appear as a small bump or group of bumps in the genital area. May be small, large, flat
or in a cauliflower shape.
Genital warts can be diagnosed based on examination
Genital warts to not require treatment unless pt is symptomatic (puritis, discharge, burning, bleeding,
psychological distress etc). Treatment is not thought to decrease transmission rate to partner
Most patient respond well to medical therapy, surgical therapy should be reserved for patients who fail
medical therapy or those who have extensive lesions.
Medical therapies include Podofilox, Podophyllin, Trichloroacetic acid, and Imiquimod
Current Pap Guidelines: ASCCP
Current Pap guidelines recommend starting Paps at age 21 in healthy females
In Immunocompromised patients, pap tests can be initiated earlier at 18 or
onset of sexual activity due to higher risk of invasive cervical cancer
Healthy adolescent females (19 and younger) have a high incidence of HPV
with minor-grade cytological abnormalities but are at a very low risk for
invasive cervical cancer.
Most adolescents will clear HPV spontaneously within 2 years of exposure to
the virus without much long-term significance
HPV Vaccine Facts
Recommended for routine vaccination beginning in boys and girls at age 11 or
12. Can be given to females through age 26 and males through age 21.
3 shot series that protects against high risk strains of HPV known to cause
cervical, oropharyngeal, vulvar, penile and anal cancers. Also protects against
genital warts.
The annual number of HPV-positive oropharyngeal cancers is expected to
surpass the annual number of cervical cancers by the year 2020.
Lifetime risk of acquiring an HPV infection 74-70%
A study performed in girls ages 11-24 showed that the vaccine does not
increase sexual activity. Those who received the HPV vaccine were not more
likely to become sexually active than those who did not receive the vaccine.
Safe AND effective!!!
Estimated Vaccination Coverage of >= 1 HPV
Vaccine Dose Females ages 13-17
Estimated Vaccination Coverage of >= 1
HPV Vaccine Dose Males ages 13-17
Genital/Anal Ulcers: Herpes Simplex Virus
In United states, most adolescents presenting with genital ulcers are found to have
Herpes simplex virus (HSV) or Syphilis, genital herpes being most prevalent.
HSV typically presents with painful multiple vesicular or ulcerative lesions.
Both HSV-1 and HSV-2 can cause genital ulcers.
Approximately 50 million Americans are infected with HSV-2. Young women and
MSM more likely to be infected with genital HSV-1.
Cell culture and PCR testing are preferred testing methods in patients presenting
with possible outbreak. Accuracy declines as lesions begin to heal.
Type specific serologic testing may be performed. Most useful in following
scenarios:
Recurrent genital lesions with negative PCR or cell culture
Clinical diagnosis without laboratory confirmation
A patient whose partner has been diagnosed with genital herpes
HIV testing should be performed in all patients found to have HSV!!
HSV Treatment & Patient Education
Herpes outbreaks can be treated with antivirals including: Acyclovir,
Valacyclovir, or Famciclovir
Suppressive therapy should be considered in patients with recurrent
outbreaks. Daily suppressive therapy can decrease outbreaks by 70-80%. Is
also effective in those without recurrent symptomatic outbreaks.
Asymptomatic viral shedding can occur at any time, so infected individuals
should always notify partners of their condition and wear protection to
prevent transmission.
Male latex condoms can reduce, but not eliminate transmission
Patients must abstain from sexual activity when outbreaks are present
Herpes is a lifelong viral illness
Reportable STIs
All 50 states require Syphilis, gonorrhea and HIV to be reported. In Texas
reportable STIs include Chlamydia, gonorrhea, syphilis, HIV and Hepatitis. The
provider or lab can make the report
The age of sexual consent in Texas is 17
If a patient is younger than 17 and their partner is 3 or more years older than
them this is reportable. This is considered sexual assault/statutory rape
Any patient who is 13 years or younger and is sexually active this is reportable
in Texas
Obtaining a Sexual History
Routine assessment of risk factors and sexual activity is important
Many adolescents are not routinely evaluated for this during office visits
When discussing sexual activity with patients remain straight forward, non
judgmental and assure confidentiality
Let patients know a sexual history if an important part of regular medical
care
Ask to speak with adolescents in private, away from their parents
Sexual History Example Form
Partners
Do you have sex with men, women or both?
In the past two months, how many people have you had sex with?
In the past 12 months, how many people have you had sex with?
Prevention of Pregnancy
Are you and you partner trying to get pregnant? If no what are you doing to prevent
pregnancy?
Protection from STIs
What do you do to protect yourself from STIs and HIV?
Practices
Have you had vaginal sex?
Have you had anal sex?
Have you had oral sex?
Do you use condoms (never, sometimes, always)? If not why don’t you use
condoms?
Past history of STIs
Have you every had an STI?
Have any of your partners had an STI?
Who needs a Pelvic Exam?
Pelvic exams cause anxiety and discomfort in many adolescent patients.
Gonorrhea and Chlamydia can now be screened through the urine
Pelvic exams should be done on symptomatic adolescents or ones with
specific complaints
An external genital exam is appropriate for those patients complaining about
lesions
Questions???
References
1.
Legal Status of Expedited Partner Therapy (EPT).
www.cdc.gov/std/ept/legal.htm, accessed February, 2016.
2.
Notifiable Conditions
3.
Sexually Transmitted Diseases. www.cdc.gov/std/treatment/2010, accessed February, 2016
4.
United States National Immunization survey-Teen 2014. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6429a3.htm#fig3, accessed February, 2016
5.
Youth Risk Behavior Surveillance United States 2013, www.cdc.gov, accessed February, 2016
6.
Effectiveness of Family Planning Methods. http://www.cdc.gov/reproductivehealth/unintendedpregnancy/pdf/contraceptive_methods_508.pdf, accessed
February 2016
7.
The Guidelines for Comprehensive Sexuality Education: Grades K-12. Sexuality Information and Education Council of the United States.
www.siecus.org/_data/global/images/guidelines.pdf (Accessed February, 2016)
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Hatcher RA, Trussel J, Nelson AL, et al. Contraceptive Technology, 20th ed, Ardent Media, Inc, New York 2012.
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Nelson AI, Neinstein LS. Contraception. In: Handbook of Adolescent Health Care, Neinstein LS, Gordon CM, Katzman DK, et al. (Eds), Lippincott Williams &
Wilkins, 2009. p.389
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Diedrich JT, Zhao Q, Madden T, Secura GM, Peipert JF. Three-year continuation of reversible contraception,. Am J Obstet Gynecol. 2015 Aug 7
11.
Game Change in Colorado: Widespread Use Of Long-Acting Reversible Contraceptives and Rapid Decline in Births Among Young, Low-Income Women. Sue
Ricketts, Greta Klingler and Renee Schwalberg. Perspectives on Sexual and reproductive health. Volume 6, number 3. Septmeber 2014
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Wiesenfeld HC et. Al. Sex Transm Dis. 2005;32(7):400-5; Ness RB, et. al. Am J Obstet Gynecol 2002;186:929-37
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Bendnarczyk, R.A., Davis, R., Ault, K., Orenstein, W., Omer, S.B. (2012). Sexual activity related outcomes after human papilloma virus vaccination of 11 to
12 year olds. J Pediatr Adolesc Gtnecol, 27(2), 67-71.;
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Jemal A., Simard, E.P., Dorell C et al. Annual report to the nation on the status of cancer, 1975-2009, featuring the burden and trends in human papilloma
virus (HPV)-associated cancers and HPV vaccination coverage levels. J Natl Cancer Inst 2013 Feb 6:105(3):175-201.
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Trussell J., Raymond E. (2011). Emergency contraception: A last chance to prevent unintended pregnancy. 1-14
http://www.dshs.state.tx.us/idcu/investigation/conditions/, accessed February, 2016