What s New in Adolescent Contraception?

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 May 2, 2017 LEGACY HEALTH 6

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 May 2, 2017 LEGACY HEALTH 7

Levonorgestrel IUD 52mg device 52mg Levonorgestrel device, releases 18-20mcg/day Lasts up to 5-7 years 1 st year pregnancy rate 0.1% Significant reduction in menstrual bleeding (20% amenorrhea after 1 st year, 40-50% after 2 nd year) Non-contraceptive benefits (anemia, dysmenorrhea, heavy bleeding, endometriosis) Side effects: prolonged bleeding, persistent spotting, irregular bleeding May 2, 2017 LEGACY HEALTH 8

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 1 st year, 12% at 2 nd year) Side effects: irregular bleeding No non-contraceptive benefits known May 2, 2017 LEGACY HEALTH 9

Copper (TCu380A) IUD Lasts up to 10 years 1 st 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) May 2, 2017 LEGACY HEALTH 10

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 May 2, 2017 LEGACY HEALTH 11

IUD Complications Expulsion (2-5%) Perforation (1/1000) Intrauterine infection Irregular/abnormal bleeding Ectopic pregnancy Luteal phase pregnancy May 2, 2017 LEGACY HEALTH 12

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 May 2, 2017 LEGACY HEALTH 13

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 May 2, 2017 LEGACY HEALTH 14

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 May 2, 2017 LEGACY HEALTH 15

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% May 2, 2017 LEGACY HEALTH 16

Etonogestrel Implant 68mg etonogestrel releasing 70 > 25 mcg/day Lasts up to 3 years 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 5/2/2017 LEGACY HEALTH 17

Depot Medroxyprogesterone Acetate (DMPA) DMPA 150mg/1mL IM every 3 months (13w) Inhibits ovulation 0.7% 3 year failure rate Bleeding pattern: > 1 st 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 5/2/2017 LEGACY HEALTH 18

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 5/2/2017 LEGACY HEALTH 19

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 5/2/2017 LEGACY HEALTH 20

Contraceptive Patch and Ring 5/2/2017 LEGACY HEALTH 21

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 5/2/2017 LEGACY HEALTH 22

How do I manage Breakthrough Bleeding? 30% of women will have this during the 1 st 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 5/2/2017 LEGACY HEALTH 23

January 1, 2016 Year-long OCP Prescriptions! 5/2/2017 LEGACY HEALTH 24

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 5/2/2017 LEGACY HEALTH 25

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 5/2/2017 LEGACY HEALTH 26

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 May 2, 2017 LEGACY HEALTH 27

Thank you!

Teens and Confidentiality in Oregon All minors may consent for any/all contraceptive services 5/2/2017 LEGACY HEALTH 29