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Adolescent Gyn Series

Update on Adolescent Contraception

Eduardo Lara-Torre, MD; Jennifer E. Dietrich, MD

The United States continues to have one of the highest adolescent pregnancy rates among developed countries—up to 90 per 1,000 women aged 15 to 19 years. Some 49% of these pregnancies are unintended (45 per 1,000 women).1 Currently, many adolescents do not seek contraceptive advice until 12 months after their first sexual encounter, when pregnancy and sexually transmitted infection (STI) may have already occurred. An estimated 61% of unintended pregnancies occur prior to receiving counseling, and approximately 47% of unintended pregnancies and 23% of all pregnancies end in elective abortion.2

ADOLESCENT CONTRACEPTIVE CONCERNS

Adolescents represent a diverse segment of the population, involving patients from age 13 to 19 years. Although the needs of a single, 15-year-old may not be the same as those of a married 18-year-old woman with two deliveries, key contraceptive characteristics are shared within the group. Adolescents have many contraceptive choices, and many try more than one method. Contraceptive methods attractive to the teenaged population should be safe and free of unpleasant or irreversible side effects. They should also be effective, with data available on failure rates with perfect and imperfect use. A method should also be convenient, with a long duration of action; some teenagers can reliably take pills every day, while others prefer to use a method once per week or once every 3 months. In addition, some adolescents may require discretion in contraception, so packaging and labeling may be an issue. The need for noncontraceptive benefits such as suppression of ovarian cysts, dysmenorrhea, and menorrhagia may influence a patient¡s choice. Finally, because parents may or may not be a part of an adolescent¡s decision to begin using birth control, accessibility and confidentiality are critical.3 Teenaged access to care for pregnancy, contraception, and STIs do not require parental consent or notification. By contrast, abortion laws are different in each state, and some may require prior parental authorization or notification. When possible, parents should be involved in discussions about contraception and confidentiality.4

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ABSTINENCE-ONLY EDUCATION

A subject of much controversy, abstinence has become the focus of the federal government¡s teenaged pregnancy prevention campaign, with more than $50 million invested. A review by Thomas5 of abstinence-only education programs showed that teenagers were positively influenced in their attitudes toward sex, but that their overall sexual behavior did not change. Such findings suggest that while abstinence-only programs are an important part of adolescent counseling, they have little overall effect on teenaged pregnancy rates and STI incidence.5

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ORAL CONTRACEPTIVES

Extended Cycles

Continuous combined oral contraceptives (OCs) are popular because women of all ages prefer fewer periods, and the side effects are minimal.6-8 Premenstrual symptoms, dysmenorrhea, pad usage, and disruption of daily activities are all reduced in users. Increased breakthrough bleeding is the most common side effect, which improves with repeated cycles. Other common side effects such as headache, nausea, and emesis are the same as for a 28-day OC regimen. Girls should understand that side effects are likely to decrease with continued use.9 Common indications for extended cycling are shown in the Table, but patient choice remains paramount.

ÀQuick Start” Initiation

This method provides an alternative to the traditional ÀSunday start” protocol. Most adolescents who seek contraceptive advice want immediate results and want to receive a contraceptive the same day. With this method, patients present for a routine visit that may include STI screening, pregnancy testing, a pelvic examination, and contraceptive counseling. If they choose OCs and have negative urine pregnancy findings, they can be started immediately on a combination OC, with the first active pill taken during the visit under practitioner supervision. Patients are generally given a sample pack to continue the first cycle and a prescription.10

The side effect profile, efficacy, and safety are similar to the Sunday-start method, while the compliance is better.11 Immediate dosing after a negative pregnancy test and a midweek refill schedule enhance reliability. The fear of pregnancy is not applicable, as this is a nonteratogenic medication and pregnancy can be diagnosed at the end of the first pack if menses does not occur.12 However, the use of backup contraception is required for the first 1 to 3 weeks.

Noncontraceptive Benefits

Noncontraceptive OC benefits important to this age group include the alleviation of acne, symptom relief for teenagers with polycystic ovary syndrome (PCOS), and weight loss. Data have shown the benefit of combined OCs, especially those containing the progestin drospirenone, in the treatment of acne due to an increase in sex hormone-binding globulin.13,14 This topic is of extreme importance to teenagers, as many who desire contraception also need treatment for this prevalent condition.

Regarding PCOS, data show that OCs containing drospirenone can decrease abnormal adipocytokine and adiposity levels, leading to a decrease in weight when compared with other formulations.15 Adding an insulin modulator (eg, metformin) seems to provide better results than OCs alone.16

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CONTRACEPTIVE PATCH

The transdermal contraceptive patch has an active surface of 20 cm2, releasing 150 mcg of norelgestromin and 20 mcg of ethinyl estradiol (EE) in a 24-hour period. The middle adhesive layer contains the hormonal dosage, achieving a drug plateau by 48 hours after placement regardless of site or environmental conditions. The patch has gained popularity for its weekly dosing schedule and ease with discretionary use. Although improved pregnancy rates have not been shown in randomized clinical trials when compared with OCs, increased compliance because of its ease of use may play a role in decreasing contraceptive failure.17 Furthermore, this method provides a 2-day Àforgiveness” period in the event of a delay in the change of the patch. Adolescents should be cautioned that in patients weighing > 80 kg, pregnancy rates have been shown to increase.17 Currently, only cyclic use of the patch has been approved by the US Food and Drug Administration (FDA), but continuous use is now under study. Upcoming designs include a clear outer layer and a tattoo-image, which should increase demand among teenagers.

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INTRAVAGINAL RING

This method was designed for ease of application and to increase compliance. The ring is 5.4 cm in diameter, inert, and flexible, and delivers continuous daily doses of 15 mcg of EE and 120 mcg of the progestin etonogestrel over 3 weeks, with a 1-week ring-free period for menses. This is an ideal method for the ad-olescent who is already comfortable using tampons and has no contraindications to combined hormonal contraception. Benefits include discretion in use and decreased frequency of dosing. Common concerns are pain during insertion and partner discomfort. Further reassurance and counseling may be needed to address these concerns, as studies demonstrate that the majority of women and their partners do not notice the ring when correctly placed in the posterior fornix.18 The side-effect profile is similar to that of other combined hormonal methods. Finally, adolescents should be counseled that a back-up method is recommended for at least 7 days if the ring is removed for more than 3 hours at a time. While only cyclic use of the intravaginal ring is FDA-approved, continuous use is under investigation.

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INTRAUTERINE CONTRACEPTION

The intrauterine device (IUD) has not been historically popular for use in the adolescent population. Because of the tendency toward multiple sexual partners and high STI rates among teenagers, there may be an undue risk of pelvic inflammatory disease (PID). Although patients should be counseled about these risks, the levo-norgestrel-releasing intrauterine system (LNG-IUS) has been associated with fewer cases of PID than the copper IUD, decreasing the concern in selected populations, including those in teenage family planning clinics with proper counseling and screening.19 Placement of an IUD in a nulliparous teenager can be facilitated by proper patient positioning and the use of non-steroidal anti-inflammatory drugs. Furthermore, the pain and bleeding experienced by women with a copper IUD are less likely with the LNG-IUS. The LNG-IUS users achieve an amenorrhea rate of up to 44% after 6 months, which may be attractive to some teenagers.20 More research in this area is needed prior to recommending this method in the adolescent population.

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DEPOT MEDROXYPROGESTERONE ACETATE

Characterized by a failure rate of less than 0.3% and infrequent 3-month dosing, depot medroxy-progesterone acetate (DMPA) injection is an attractive option for teenagers. The high likelihood of amenorrhea and discretion of use are further inducements, but common side effects such as irregular bleeding and hair loss may discourage patients. Concern has also been expressed about reduced bone mineral density (BMD) among long-term users. Data have shown a decrease in BMD among adolescents that seems to develop over 2 years of use, and it is unclear whether this loss is reversible on discontinuation.21 The FDA has recently issued a Àblack-box” warning suggesting a 2-year limit for use, especially in young patients. There are no data on the use of supplemental calcium and exercise in DMPA users, but this is recommended regardless of contraceptive method as part of general health counseling. Further investigation on the long-term effects of this method is needed before final recommendation can be made, as pregnancy itself may carry a more detrimental effect in BMD than this contraceptive method.

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EMERGENCY CONTRACEPTION

Emergency contraception (EC) in the form of a two-dose, levo-norgestrel (LNG)-only pill is now available in the United States by prescription. Initial trials showed a reduction in pregnancy rates of up to 85% when started before 72 hours after unprotected intercourse, although it is effective even if used later. A single-dose protocol has produced similar pregnancy rates and side-effect profiles,22 and could improve adolescent compliance. While the Yuzpe regimen using combined OCs can have severe side effects (eg, nausea, emesis), it is an effective alternative, but the LNG-only tablets seem to be more effective with fewer side effects.22 Adolescents using LNG show no significant disruption of menstrual onset or severe side effects, making this a safe method for teenagers.23 There has been some concern about the future sexual and contraceptive behavior of adolescents utilizing EC, but providing advance prescriptions appeared to improve use of the method, and did not cause an increase in unprotected intercourse or a decrease in use of condoms or hormonal contraception. In fact, teenagers were twice as likely to use the method earlier when it is more effective compared with counseled peers who did not receive a prescription.24,25

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SUBDERMAL IMPLANTS

After the six-rod LNG implant system was removed from the market, a single-rod system was developed with current extensive experience in Europe and Mexico. This 4-cm implant contains a core of etonogestrel surrounded by an ethinyl-vinyl acetate membrane. Maximum levels of the progestin are achieved approximately 4 days postinsertion, and continue for up to 3 years (Pearl index = 0).26

Compared with the LNG implant system, insertion and removal times are decreased significantly at 0.61 versus 3.90 minutes and 2.18 versus 11.25 minutes, respectively.27 There are also fewer bleeding episodes and an increase in the amenorrhea rate. Although pregnancy rates associated with this method seem to be as good as with the LNG system, the improved acceptability and decreased discontinuation because of ease of use may improve these rates by increasing compliance.27 This is an important factor for adolescent mothers requiring long-term, reversible contraception; compared with their peers using OCs, the continuation rate was much higher at 15 months postpartum (95% versus 33%), decreasing the risk of another pregnancy during the teenaged years.28 This method has recently been given Àapprovable” status by the FDA and should be available in the United States soon.

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CONCLUSION

Adolescents have unique contraceptive needs. Physicians need to consider these requirements to improve efficacy and compliance both short- and long-term. The benefits far outweigh the risks of unintended pregnancy, allowing adolescents to remain in school and decreasing abortion rates within this group. The array of available methods allows physicians to provide tailored, individual care to these patients while keeping them safe.

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Eduardo Lara-Torre, MD, is chair, Department of Obstetrics and Gynecology, Bay Health Medical Center, Milford Campus; and practicing Pediatric and Adolescent Gynecologist, Milford, Del. Jennifer E. Dietrich, MD, is fellow, Division of Pediatric and Adolescent Gynecology, Department of Obstetrics, Gynecology and Women¡s Health, University of Louisville School of Medicine, Louisville, Ky.

References

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