Contraception in Adolescents

Karen Soren, MD

Director, Adolescent Medicine

Associate Clinical Professor
Pediatrics & Public Health
Columbia University Medical Center
 What are the barriers to teens
using contraception?
• Developmental issues:
– Early adolescence: present oriented, impulsive
– Middle adolescence: omnipotent, invincible
• Teens are spontaneous
• Teens may be ambivalent about pregnancy
• Teens have inadequate access to information
and confidential care; lack of awareness of
NYS rights
 The conversation:
• AAP recommends postponement of sexual
activity, especially for young teens
• “But -if you are going to be sexually active,
you need protection!”
• Condoms are the best method for
protection against sexually transmitted
• Condoms are an imperfect method for
pregnancy –prevention
• You need a back-up for your condom…
 
The contraceptive visit : What do
you need to do?
• Reassure adolescents of confidentiality
• History
– PMH- rule out conditions that would not allow
safe use of estrogen-containing methods
– Sexual history
– History of previous contraceptive use
– Current medications
• Physical (very basic!)
– Weight, BP
– Gyn exam NOT required
 How Methods are Chosen

• Use by friends or relatives

• Accessibility
• Personal knowledge
• Media
• Fear of side effects
• Physician recommendation
 SUMMARY TABLE OF CONTRACEPTIVE EFFICACY
(In 100 women, # pregnancies in a year)

Method Typical Use Perfect Use

No contraception 85 85
Spermacides 29 18
Withdrawal 27 4
Diaphragm 16 6
Condom 15 2
Birth control pills 8 0.3
Ortho-Evra patch 8 0.3
Nuvaring 8 0.3
Depo Provera 3 0.3
Mirena IUD 0.2 0.2
Implanon 0.05 0.05
 Barrier and Non-hormonal Methods

• Male Condom
• Female Condom
• Diaphragm
• Cervical Cap
• IUD- Paragard
(Copper)
 Male Condom
• STI protection
• Over the counter
• Imperfect method of contraception
– 85% effective
• Possible latex allergy (my need to use
polyurethane condoms)
• Many condoms now lubricated but do not
contain spermicide - issues with nonoxynol nine
– mucosal irritant
• Need a back-up method…
 Plan B
• Large dose of levonorgestral
• Best taken as soon as possible after
unprotected intercourse
• Can take up to 5 days after mess-up (package
says 72 hours)
• Now Plan B One-Step – single pill
• 75-85% effective in reducing pregnancy if used
within 72 hours, less so if used later
• No serious side effects
• Over the counter now - >17 yo
Female Condom

This says it all…

Cervical Cap/Diaphragm
 Hormonal Methods
• Combined hormonal methods (estrogen and
progesterone):
– Oral contraceptive pills
• Monophasic or multiphasic
– Ortho Evra Patch
– Nuvaring
• Progestin-only methods
– Depo-Provera injection
– Progestin-only pills (minipill)
– Implanon
– Mirena IUD
 A little about estrogens…
• Older pill (1960’s) started with 150 mcg
mestranol – eventually decreased to 50 mcg
because of side effects
• Ethinyl estradiol introduced in 1970’s
• Dose varies from 50 mcg to 20 mcg, but most
pills now used are between 20 and 30 mcg
• Lower dose → less side effects, but more break-
through bleeding, and less room for non-
compliance
 What about the progesterone type?
• First generation: (norethindrone, norethindrone
acetate)- medium androgenicity- in Loestrin
• Second generation: (levonorgestral) – higher
androgenicity -in Alesse, Lo-ovral, Seasonalle,
Seasonique, Lybrel, (norgestrel – Lo/Ovral)
• Third generation: (norgestimate, desogestrel) –
low androgenicity but slight increase risk of clots
– in Ortho tri-cyclin Lo (Acne), Desogen
• Drospirenone: (spironalactone analog)- helps
contact hirsuitism – in Yasmin, Yaz (PMDD)
 WHO Guidelines - medical eligibility for each
contraceptive method- categories:

• 1 = a condition for which there is no restriction for

the use of the contraceptive method
• 2 = a condition where the advantages of using
the method generally outweigh the theoretical or
proven risks
• 3 = a condition where the theoretical or proven
risks usually outweigh the advantages of using
the method
• 4 = a condition which represents an
unacceptable health risk if the contraceptive
method is used
 Contraindications to Estrogen
• Active liver disease (4)
• Untreated gall bladder disease (asymptomatic -2, symptomatic -3)
• Hypertension (140/90 or greater – 3, 160/100 or greater - 4)
• Personal history of thrombosis (4)
• Known thrombogenic mutations (4)
• Family hx thrombosis (2)- investigate…
• Migraine with aura (4)
• Condition leading to venous stasis, immobilization (4)
• Lupus with positive (or unknown) anti-phospholipid antibody
syndrome (4)
• Diabetes with vascular disease (3,4)
• Post- partum <21 days, +/- breastfeeding (4,3)
• Smokers >35 (<15 cigs/day -3, >15 cigs/day -4)
Migraines and estrogen-containing
methods:

Evidence: Among women with migraine,

women who also had aura had a higher risk
of stroke than those without aura.

Women with a history of migraine who use

COCs are about 2 to 4 times as likely to
have an ischemic stroke as non-users with
a history of migraine.
Conditions that have little or no
contraindications to estrogen use:
• Depression (1)
• Irregular bleeding in teens -after evaluation (1)
• Dysmenorrhea (1)
• Abnormal Pap (2)
• Obesity (2 – some risks – but benefits outweigh
risks)
• Diabetes without vascular disease (2)
• Sickle cell disease (2): However, as sicklers
more at risk for strokes and acute chest and
bone infections – prefer progestin- only
methods
 Medications
• Medications that decrease the
effectiveness of combined oral
contraceptives (and progestin-only pills,
implant)
– Anticonvulsants – phenytoin, phenobarbitol,
topiramate, carbamazepine, lamotrigine (3)
– Rifampin, rifabutin (3)
• However, little effect on pill metabolism in
users of most antibiotics (1)
 Combined OCP’s
• Mechanism of action
– Progesterone inhibits LH, thickens cervical
mucus, atrophies endometrium
– Estrogen inhibits FSH

• Other actions of BCPs

– Increase SHBG and decrease free testosterone
– Inhibit 5- reductase in skin, decreasing
conversion of testosterone to DHT
 Combined OCP’s
• PROS • CONS
– Rapid return to fertility – Daily medication
– No anticipation – Regular supply
– Menstrual regularity needed
– Decrease – Multiple SEs
dysmenorrhea and – Multiple
anemia contraindications
– Decrease ectopic – CLOTS
pregnancy rate
– Decrease PID
– Decrease ovarian and
 Combined OCP Side Effects
• ESTROGEN • PROGESTERONE
– Nausea – Increases appetite
– Fluid retention – Depression
– Breast tenderness – Elevated lipids (TG)
– Increases clotting by
decreasing protein C,
S, antithrombin III
– HTN
 How to prescribe OCP’s
• Become familiar with a few types of pills
• Rule out contraindications to estrogen
• Patient can start any day (but some prefer
Sundays or first day of period)
• Can give up to 6 packs at a time
• Bring back after 3-4 weeks to determine:
– If teen started pill and if it is taken correctly
– Any side effects
 So what pill do I prescribe?

• Can start with a low-dose pill (Alesse,

Loestrin 1/20)
• If teen has acne or PCOS-type stigmata,
consider Ortho tri-cyclin Lo
• If teen has hirsuitism / PCOS, can use Yaz
or Yasmin instead
• For dysfunctional uterine bleeding, can
use Lo/Ovral – longer half-life of progestin-
stabilizes endometrium
 Ortho Evra Patch

• Norelgestromin 6mg/ ethinyl estradiol

0.75mg in a transdermal delivery
system
• 1 patch weekly for 3 weeks, then
patch-free for 1 week
• Traditionally, Sunday or first day of
menses start- however, can start
anytime
• Menses usually 4 days after patch
removal
 Ortho Evra
• PROS • CONS
– No need for daily med – 2-3% detach
– Teens like ease of – Nausea/ vomiting
usage – Less effective if >90kg
– More complicated if
forget to change or falls
off
– Breast pain, rash
– CLOTS: 60% more
estrogen than a 35 mcg
pill (FDA alert)
 NuvaRing

• Etonogestrel 120 mcg/d + ethinyl

estradiol 15 mcg/d
• Silastic ring inserted intravaginally for 3
weeks with 1 week off
• Less estrogen because more bioavailable
• Does not need to be put around cervix,
just in vaginal vault adjacent to mucosa
 NuvaRing

• PROS • CONS
– Less estrogen – No STI protection
(15 mcg – 18% of women,
equivalent) 30% of men feel
– Protects for a full ring
cycle – Most common
SE is leukorrhea
– Again - clots
 Depo-Provera
• Medroxyprogesterone acetate
– 150 mg IM every 11-13 weeks (up to 14 weeks)
• Progesterone actions
– Suppresses LH and prevents ovulation
– Thickens cervical mucus
– Atrophies endometrium
– Decreases cilia motility in fallopian tubes

• 50% amenorrheic at 1 year

 Depo-Provera, cont
• CONS
• PROS
– SE can’t be
– Highly effective
immediately stopped
– No anticipation
– Delay in return to
– Can breast feed fertility
– Decrease endometrial – Irregular bleeding and
ca, yeast infection, amenorrhea
PID, fibroids – Hypo-estrogenic state
– Increases seizure OSTEOPOROSIS
threshold
 Depo-Provera, side effects
• Headache
• Mood swings
• Weight gain
• Hair Loss
• Irregular bleeding
• One third discontinue use after one year
as a result of side effects
 POPs
• Progestin-only pills (Micronor, Nor-QD)
• Small dose of progestin – works primarily by
increasing viscosity of cervical mucus
• Does not reliably inhibit ovulation
• Need to be taken carefully and consistently – if
more than 3 hours late with pill, will not be
effective
• Useful for teens with contraindications to
estrogen who will not accept Depo or Mirena
 Implanon
• Contains 68 mg etonogestrel
• Single rod implanted subdermally on day
1-5 of cycle
• Last for 3 years.
• Works by thickening cervical mucus and
also inhibits ovulation
• No effects on bones or lipids
• Irregular bleeding common side effect
 Mirena – progestin containing IUD
• IUD containing levonorgestral
• Helpful for menorrhagia and dysmenorrhea
• Effective for 5 years
• Previously discouraged in teens because teens
more at risk for infection- liability concerns
• Movement to encourage IUD use in teens
currently
• Infection probably most related to insertion
• Can be inserted in nulliparous young woman-
slight risk that will be expelled – teens should
check for the string
 So- what contraceptive method would you
recommend?
• 18 year old with no significant medical or family history
going off to college
• 14 year old coming in after an abortion – does not want
her mother to know she is sexually active
• Obese 17 year old with acne and irregular periods
• 15 year old with heavy bleeding for a month who comes to
the emergency room and has a hemoglobin of 8
• Amenorrheic 16 year old with facial hair
• 17 year old tampon user who cannot remember to take a
pill, and wants to keep her sexual activity from her mother
• 15 year old with migraines, and some preceding blurry
vision
• 18 year old with lupus who is non-compliant with her
medications