what’s new in adolescent contraception? · what’s new in adolescent contraception? abby...

What’s New in Adolescent Contraception?Abby Furukawa, MD

Legacy Medical Group Portland Obstetrics and Gynecology

April 29, 2017

Objectives

• Provide an update on contraception options for the

adolescent female

• Discuss LARC methods and dispel common myths

• Review other contraceptive options

• Select an COCP and troubleshooting side effects

5/2/2017 LEGACY HEALTH 2

Financial Relationships

I, Dr. Abby Furukawa, have no relationship to any aspect

of private industry

Pediatricians and Adolescent Sexual Health

▪ Already a trusted source of

information for both patient and

her guardians

▪ Able to assess for STD risk,

screen for pregnancy, help

young women and their families

make healthy choices

▪ May be first point of information

regarding contraception options

May 2, 2017 LEGACY HEALTH 4

LARC = Long Acting Reversible Contraception

LEGACY HEALTH 5

Contraceptive CHOICE Project


LARC Advantages

▪ Highly efficacious

▪ Easy to use and forgettable

▪ Alternative to permanent sterilization methods

▪ Safe for most women (even teens and nullips)

▪ Long acting but rapidly reversible

▪ Private and doesn’t interfere with intercourse spontaneity

▪ Cost effective if planned use >1 year

▪ Few contraindications

▪ Non-contraceptive benefits


Levonorgestrel IUD – 52mg device

▪ 52mg Levonorgestrel device,

releases 18-20mcg/day

▪ Lasts up to 5-7 years

▪ 1st year pregnancy rate 0.1%

▪ Significant reduction in menstrual

bleeding (20% amenorrhea after 1st

year, 40-50% after 2nd year)

▪ Non-contraceptive benefits (anemia,

dysmenorrhea, heavy bleeding,

endometriosis)

▪ Side effects: prolonged bleeding,

persistent spotting, irregular bleeding


Levonorgestrel IUD – 13.5mg device

▪ 13.5mg Levonorgestrel device

releasing 14 mcg/day

▪ Lasts up to 3 years

▪ 3 year cumulative pregnancy

rate 0.9%

▪ Some reduction in menstrual

bleeding (6% amenorrhea at 1st

year, 12% at 2nd year)

▪ Side effects: irregular bleeding

▪ No non-contraceptive benefits

known


Copper (TCu380A) IUD


▪ 1st year pregnancy rate 0.5-0.8%

▪ Most effective form of Emergency

Contraception (and only IUD form)

▪ Completely non-hormonal

▪ Side effects – heavier, longer, more

painful cycles for some women (but

doesn’t increase discontinuation

rates)


IUD Contraindications

▪ Distorted uterine cavity

(bicornuate uterus, fibroids

distorting cavity, extremely large

or small cavity)

▪ Active pelvic infection (PID or after

septic abortion)

▪ Known or suspected pregnancy

▪ Wilson’s disease/Cu allergy

(Copper IUD)

▪ Current breast cancer, active liver

disease


IUD Complications

▪ Expulsion (2-5%)

▪ Perforation (1/1000)

▪ Intrauterine infection

▪ Irregular/abnormal bleeding

▪ Ectopic pregnancy

▪ Luteal phase pregnancy


IUD Myth #1: IUDs cause Infertility

▪ Infertility no more likely after

discontinuation of IUDs than

other reversible methods

▪ Large case-control study looking

at causes of tubal infertility

showed that the presence of

chlamydial antibodies, not prior

IUD use was associated with

infertility

▪ Baseline fertility returns rapidly

after IUD removal


IUD Myth #2: IUDs are Not Safe to Place in

Teens or Nulliparous Women

▪ Placement is not technically more

difficult in teens compared to older

women

▪ Discomfort from placement is

common, but anticipatory guidance

and analgesia during procedure is

helpful

▪ No definitive superior method for

lessened discomfort, but NSAIDs,

paracervical blocks, anxiolytics,

misoprostol are widely used


IUD Myths #3: IUDs cause infections

▪ Relative risk of pelvic inflammatory

disease (PID) is increased only in the

first 20 days after insertion, then

returns to baseline

▪ Same day chlamydia/gonorrhea

screening for teens/at risk populations

recommended, can be treated with

IUD in place

▪ Some evidence that LNG-IUDs

actually lower risk of PID secondary to

thickened cervical mucous


IUD Myths #4: IUDs cause Ectopic pregnancy

▪ Women using NO contraception have a 10-fold higher risk of

ectopic because their chance of pregnancy is higher

▪ Should pregnancy occur with IUD in place, however, ectopic risk

is 30%


Etonogestrel Implant▪ 68mg etonogestrel releasing

70 > 25 mcg/day


▪ Radio-opaque

▪ 3 year cumulative pregnancy

rate 0.38%

▪ Side effects: unpredictable

bleeding (33% infrequent

bleeding, 20% prolonged,

20% amenorrhea)

▪ Non-contraceptive benefits –

reduced dysmenorrhea, pelvic

pain, anemia


Depot Medroxyprogesterone Acetate (DMPA)▪ DMPA 150mg/1mL IM every 3 months (13w)

▪ Inhibits ovulation

▪ 0.7% 3 year failure rate

▪ Bleeding pattern:

> 1st 3 months irregular bleeding is common

> Nearly 50% amenorrhea by 1 year>75% with

prolonged use

▪ Other side effects: headaches, mood

changes, weight changes

▪ Non-contraceptive benefits – reduced

dysmenorrhea, pelvic pain, anemia, hygiene

easier, endometrial protection, lack of drug

interactions

▪ Delay in return to fertility


DMPA and Bone Density

▪ 2004 FDA Black Box warning

▪ 2005 WHO Technical Consult

> No restrictions on use (18-45yo) or time period of use

> Teens: advantages generally outweigh safety concerns

▪ Current evidence suggests that losses are substantially or fully

reversible

▪ Unclear whether DMPA affects fracture risk later in life

▪ Concerns about BMD effects should not reduce use past 2 year

mark

▪ Consider alternative methods (LARC) if long-term use is planned,

particularly in women with other risk factors for BMD loss

▪ Routine DEXA screening is not recommended for DMPA users


Combination Oral Contraceptive Pills▪ Estrogen + Progestin

> E2: Ethinyl estradiol, estradiol valerate

> P4: Norethindrone, Levonorgestrel,

Desogestrel, Drospirenone

▪ Monophasic vs multiphasic

▪ Continuous vs cyclic

▪ 92% typical use effectiveness

▪ Non-contraceptive benefits

> Dysmenorrhea, menorrhagia, cycle

regulation, anemia

> Reduced hair growth, acne

> May have benefits for moods, menstrual

migraines

> Reduced risk of endometrial, ovarian,

and colorectal cancers


Contraceptive Patch and Ring


How do I select a COCP for my patient?1. Offer LARC method

2. Rule out contraindications

> Smoker > 35 yo

> Prior DVT/VTE, hereditary thrombophilia

> Active hepatobiliary disease, severe inflammatory bowel disease,

SLE

> Migraine with focal neurologic symptoms

3. Is there an OCP that worked well for her in the past?

4. Periods or no periods?

> Regular cycles vs breakthrough bleeding

> Personal preference

5. Painful or heavy periods?

> Pick something with short placebo or no placebo

6. Trouble remembering the pill?

> Consider contraceptive ring or LARC method


How do I manage Breakthrough Bleeding?

▪ 30% of women will have this during the 1st 3 months of use –

counsel them!

▪ Most common reason for spotting: forgetting pills

▪ Options:

> Continue daily use, it’ll sort itself out

> Stop pill or ring x 3 days, then restart

▪ Consider switching to ring (more continuous application of

hormone)

▪ Consider switching to a cyclic regimen (21-day or 24-day rather

than 28)

▪ Norethindrone containing pills seem to be less likely to cause BTB


January 1, 2016 – Year-long OCP Prescriptions!


VTE and Drospirenone Containing COCs

▪ Biological plausibility

▪ Overall risk of VTE in all OCP users

is 3-9/10,000 woman-years

compared to non-users (1-5/10,000

woman-years)

▪ Risk of VTE in drosperinone

containing OCP users: 10.22/10,000

▪ Risk of VTE during pregnancy:

20/10,000

▪ Risk of VTE during 12 weeks

postpartum: 40-65/10,000


Progestin Only Pills

▪ Option for women with contraindications to estrogen use

▪ Only 90% effective in women with normal fertility

> Greater efficacy in women >40yo or lactating women

▪ Must be taken within 3 hour range every day

▪ Partial suppression of ovulation, but majority of efficacy from

thickening cervical mucous

▪ Cycle regulation unlikely, many women will have irregular periods

with this method


Selected References▪ Ott, Mary, Sucato G, and Committee on Adolescence. Contraception for

Adolescents. Pediatrics 2014; 134; e1257, October 2014

▪ Long-acting reversible contraception: implants and intrauterine devices. Practice

bulletin No. 121. American College of Obstetricians and Gynecologists. Obstetr

Gynecol 2011;118:184-96

▪ Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine

Devices. Committee Opinion 539. ACOG, October 2012

▪ Winner B, et al. Effectiveness of Long-Acting Reversible Contraception. N Engl J

Med 2012;366:1998-2007

▪ Secura G, et al. Provision of No-Cost, Long-Acting Contraception and Teenage

Pregnancy. N Engl J Med 2014;371:1316-23

▪ www.guttmacher.org/statecenter/adolescents.html

▪ Depo Medroxyprogesterone Acetate and Bone Effects. Committee Opinion 602.

ACOG, June 2014

▪ Risk of Venous Thromboembolism Among Users of Drospirenone-Containing Oral

Contraceptive Pills. ACOG Committee Opinion 540. ACOG, November 2012


http://www.guttmacher.org/statecenter/adolescents.html

Thank you!

Teens and Confidentiality in Oregon

▪ All minors may consent for any/all contraceptive services


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