Contraception - University of Washington



November 2016References:Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2013. MMWR. 2013;62: 1-64.Center for Disease Control Condom Fact Sheet. PK, Adelman WP, Alderman EM, Breuner CC, Levine DA, Marcell AV, O’Brien RF. Contraception for Adolescents. Pediatrics. 2014, 134 (4) e1244-e1256; DOI: 10.1542/peds.2014-2299. Ott MA and Sucato GS. Contraception for Adolescents. Pediatrics. 2014, 134 (4) e1257-e1281; DOI: 10.1542/peds.2014-2300. Providing Health Care to Minors Under Washington Law: A summary of health care services that can be provided to minors without parental consent. Available at Owner: Kristi Kiyonaga (kkiyonaga@)OBJECTIVES: Provide evidence-based recommendations for counseling and prescribing contraception for adolescentsHelp adolescents reduce risk of unintended pregnancyHelp adolescents reduce risk of sexually transmitted infectionsSUMMARY:Take a targeted medical and sexual historyEncourage abstinence Explore personal circumstances affecting method choice and complianceDiscuss side effects Encourage dual condom/contraception useDiscuss and write an advanced prescription of emergency contraceptionFollow-up periodically to address adherence, adverse effects, STI surveillanceEpidemiology47% of 9th-12th graders report having sex.59% of sexually active teens have used a condom before last sex, 19% using oral contraception, and 5% using other forms.Rates of teen pregnancy, birth and abortion have been declining in U.S.However, among 21 countries surveyed in 2011 teen pregnancy rates are highest in US.Confidentiality and ConsentAdolescent contraception should be provided as a confidential service.Encourage involvement of parents or trusted adults whenever possible.Washington State Law mandates that:Minors may obtain or refuse birth control services at any age without the consent of a parent or guardian.If they are 14 years or older minors may obtain tests and/or treatment for STDs (including HIV) without the consent of a parent or guardian.If adolescent is covered under a guardian’s insurance, prescriptions and STD testing will likely be visible by guardian.Washington State Take Charge Program provides confidential, free birth control to males and females for 1 year or 1-800-322-2588Gynecologic exam for females provided if necessaryObtain Medical HistoryAge at menarcheDate of last menstrual periodDuration of mensesRegularity of menstrual period/spottingCycle lengthCramps and impact on activitiesMood changes with mensesPrior experiences with contraceptionTobacco usePersonal or family history of endometriosis, clotting disorder, liver disease or tumor, breast cancerObtain Sexual History: The 5 PsPartnersPrevention of pregnancyProtection from STIssexual PracticesPast history of STIs and pregnancyCounseling ApproachesUse motivational interviewing with focus on future goals, belief in adolescents’ ability to change, engagement of adolescent in the process of adopting health-promoting behaviorsEncourage abstinence However, many adolescents planning on abstinence do not remain abstinentFor sexually active adolescents and those considering initiation of sexual activity, counseling includes:Initiating contraceptionSupporting adherence to the contraceptive methodManaging adverse effectsProviding periodic screening for STIsEncourage parents to talk with their kids about contraception. Parent-adolescent sexual communication is positively associated with adolescents’ use of contraceptives and condoms.Recommend dual contraception: condoms plus a long-acting method or hormonal contraceptiveEmergency ContraceptionProvide prescription in advance and counsel regarding use. Ella (ulipristal acetate; high-dose combined estrogen-progestin)Take as soon as possible after unprotected sexMost effective within 120 hours (5 days)Lower failure rate than Plan B for women over 165 poundsLess effective if over 195 pounds; consider Paragard IUDObtain pregnancy test prior to prescribing (insufficient data on embryotoxicity)Do not use a progesterone-containing contraceptive method for 5 days after taking Ella (decreases efficacy of Ella)Can get prescription online at ella-Plan B One-Step or generic (levonorgestrel)Take as soon as possible after unprotected sexMost effective within 72 hours, ok up to 120 hours (5 days)If over 72 hours consider EllaGive as a single dose: levonorgestrel 1.5 mg orallyLess effective if over 165 pounds; consider EllaPregnancy test not needed before use Over-the-counter for ages 17 and older, prescription required if youngerParagard Copper IUDMost effective emergency contraception, nearly 100%Place within 5 days of unprotected sexOnly approved for 16 years of age and olderStarting Contraception After Taking Emergency ContraceptionDo not use a progesterone-containing contraceptive method for 5 days after taking Ella After taking Plan B One-Step, start any contraceptive method immediatelyAfter taking Plan B One-Step: Abstinence or back-up protection required for the first 7 daysAfter taking Ella: Abstinence or back-up protection required until the next menstrual cycle Exam and monitoringReview weight, height, body mass index, and blood pressure at each visitPerform external genitourinary (GU) exam in sexually active patientsTestingObtain urine pregnancy test before initiating contraception If pregnancy status is uncertain, ok to proceed with contraception with the exception of IUDs.Recheck urine pregnancy test in 2-4 weeksIf unprotected sex has occurred in the last 5 days, consider emergency contraceptionSexually active patients:Perform an external genitalia examCollect vaginal swab (provider or patient-collected) or dirty urine to screen for gonorrhea and chlamydia. 2015 CDC STD treatment guidelines available here: HIV testingCervical cytology (pap smear) recommendations:Start at age 21, regardless of sexual initiation Adherence and Follow-upFollow-up in 1-3 months after initiation of contraception and annually thereafter Follow weight, blood pressureAddress use, adherence, adverse effects, and complicationsReassess relationships, sexual behaviors, contraceptive needs, STI surveillance and preventionAssess need for human papillomavirus immunizationCONTRACEPTIVE METHODSDiscuss in the order of most to least effective, as ordered below:Long-acting Reversible ContraceptionNexplanonSingle rod implant that inhibit ovulation. Contains ethonorgestrel, an active metabolite of progestin and desogestrelFailure rate less than 1%Effective for 3 yearsInserted into inside of upper arm by a clinician who has completed trainingTakes 1 week to become effective, need back-up method during this time15% amenorrheic at one yearSmall weight gain in clinical studies (3.7 pounds after 2 years), but few discontinue for this reasonCommon reason for discontinuation is unpredictable bleeding or spotting, up to 3 monthsRapid return to fertility after removal (1 week)Contraindications: thrombosis (legs, lungs, eyes, heart, brain), liver disease or liver tumor, unexplained vaginal bleeding, current or history of breast cancer, allergy to implanonBecause of similar side effect profile, consider trial of Depo-Provera prior to Nexplanon.Intrauterine Devices (IUDs)Mirena (52 mg levonorgestrel) Skyla (13.5 mg levonorgestrel, smaller diameter which may be easier for teens), Paragard (copper, associated with more bleeding and cramping, can be used as emergency contraception, can only be used for ages 16 and older)Failure rate less than 1%Mirena approved for 5 years, Skyla for 3 years, Paragard for 10 yearsNo estrogen, Paragard copper IUD contains no hormonesOk to use in adolescents with contraindications to estrogenMirena and Skyla suppress menstruationRapid return to fertility after IUD removal (1-2 months)Obtain pregnancy test, gonorrhea and chlamydia tests prior to insertionOk for adolescents with HIV, past PIDRisks:Nulliparous women can have moderate to severe pain with insertion. Consider insertion by experienced OB/GYN practitioner or under anesthesia (Seattle Children’s adolescent gynecology and some OB practices do this)Small increased risk of pelvic infection occurs only during insertion (first 21 days)Perforation risk 1:1000 or lessExpulsion of IUD If diagnosed with PID or exposed to gonorrhea or chlamydia post-insertion, treatment can occur without IUD removalContraindications: purulent cervicitis, PID, gonorrhea/chlamydia in past 3 months, uterine anomaly, Wilson’s disease (for copper IUD)Depo-Provera (Progestin-Only Injectable)Long-acting progestin that is given as an injection every 13 weeks (up to 15 weeks)150 mg intramuscularly or 104 mg subcutaneouslyFailure rate 6%Can be initiated on same day as visit at any time during menstrual cycle following negative pregnancy testTakes 1 week to become effective, need back-up method during this timeMost providers schedule visits every 12 weeks to allow for missed/late visits. There is variation in scheduling between clinics.If the adolescent is >15 weeks from last injection, she can have the injection following negative pregnancy test. Discuss back-up method for 7 daysConsider emergency contraception if pregnancy is possibleConsider repeat pregnancy test in 7-10 daysBenefits Improvement in dysmenorrheaProtective against iron-deficiency anemia, endometrial cancerSafe for most patients with chronic illnessAdverse effectsAlmost always causes initial menstrual irregularities, usually improves over timeWeight gainWeight gain status at 6 months is a strong predictor of future excessive weight gainObese adolescents more likely to gain weightReduction in bone mineral densityRecommend 1300 mg daily calcium, 600 IU daily vitamin D, weight-bearing exerciseOther: headache, mastalgia, hair loss, change in libidoCombined Hormonal Methods: oral contraceptive pills, vaginal ring, transdermal patchEach contain estrogen and progestinContraindications Systolic blood pressure ≥160 mm Hg or diastolic pressure ≥100 mmHgMigraines with aura or focal neurologic symptomsThromboembolism or thrombophiliaMost serious adverse event associated with combined oral contraceptionRisk of blood clots increases from 1 per 10,000 to 3-4 per 10,000 woman-yearsSmoking is not a contraindication to oral contraception use in adolescents, but can affect estrogen and have more irregular bleedingBreast cancerHepatic dysfunctionComplicated valvular heart diseaseComplications of diabetes (ie, nephropathy, retinopathy, neuropathy or other vascular disease)Solid organ transplantationBenefitsCan be helpful for dysmenorrhea, menorrhagia, hyperandrogenismAdverse effectsUsually transient: irregular bleeding, headache, nauseaAnticonvulsants and antiretroviral drugs decrease oral contraception efficacyWith the exception of rifampin, most broad-spectrum antibiotics do not affect the effectiveness of oral contraceptive pills Oral Contraceptive PillsContain an estrogen and a progestinFailure rates are 9% in adults, may be higher in adolescentsDiscuss daily adherence strategies such as cell phone alarms, support from family/partnerEstrogen is usually ethinyl estradiol 10 to 50 mcgMost adolescent medicine experts recommend 30-35 mcgBetter for bone densityLess breakthrough bleeding than lower dosesLess pill discontinuation than lower dosesLow-dose pill also okFewer estrogenic side effectsCan be initiated on same day as visit at any time during menstrual cycle following negative pregnancy testTakes 2 weeks to become effective, need back-up method during this time Efficacy is slightly lower for patients with BMI ≥ 35 kg/m?Use for more than 4 years protects against endometrial and ovarian cancersPrescribe up to 1 year of pills at a timeMissed pill scenariosMissed pill should be taken as soon as it is rememberedIf more than 1 pill in a row is missed, only the most recently missed pill should be taken as soon as possible, and the remaining pills should be taken at the usual timeSeven consecutive hormone pills are needed to prevent ovulationIf 2 or more pills are missed in the first week of the cycle, emergency contraception is indicatedIf 1 or more pills were missed earlier in the same cycle as a missed pill or late in the previous cycle, consider emergency contraceptionDiscuss continuous cyclingUse monophasic pills because brand names are more expensiveEliminate the hormone-free (placebo) intervalSpecifically indicate “skip placebos” on prescription for insurance coverageWrite prescription for 4 packs to cover every 3 monthsDecreases number of menses and hormonal shifts, helps with dysmenorrhea and other cyclic symptomsUseful for treating anemia, acne, severe dysmenorrhea, endometriosis, dysfunctional or heavy menstrual bleeding, Von Willebrand disease, and adolescents who prefer amenorrheaAlso useful for conditions that can be cyclic such as migraine (without aura), epilepsy, irritable bowel syndrome, inflammatory bowel disease, some behavioral symptoms.Contraceptive Vaginal RingReleases combination of estrogen and progestinFailure rate 9%Ring inserted in vagina by patient, stays in place for 3 weeksRemove for 1 week to induce withdrawal bleeding then new ring is inserted 7 days laterCan be initiated on same day as visit at any time during menstrual cycle following negative pregnancy testLabeled for 28 days of use, but can be used for up to 35 daysAdditional adverse effects: vaginal symptoms of discharge, discomfort, problems related to device (eg, expulsion)If ring comes out, ok to re-insert as long as this is done within 3 hoursMost male partners are not bothered by presence of vaginal ringTransdermal Contraceptive PatchReleases combination of estrogen and progestinFailure rate 9%Placed on abdomen, upper torso, upper outer arm, or buttocksAvoid placement on breast because estrogen in patch can cause breast tendernessOne new patch placed every week for 3 weeks, followed by 1 week off the patchWithdrawal bleeding usually occurs during the week off the patch Additional adverse skin effects (ie dislodged patches, hyperpigmentation, contact dermatitis)Risk of pregnancy slightly higher for women weighing > 198 poundsProgestin-Only Pills (mini pills)Thicken cervical mucus, but don’t inhibit ovulationStringent adherence is necessary, and therefore failure rate can be significantly higher than IUDs, contraceptive implants, and injectionsUsed most often for patients who have contraindication to estrogen use or safety concerns about estrogen useMale CondomsFailure rate is 18% for all users and can be higher in adolescentsAlways recommend dual contraception: condoms plus a highly effective hormonal or other long-acting methodReduces STI transmissionPromotes future fertility of female by protecting against asymptomatic chlamydial infections that can scar fallopian tubesAdvantages: male involvement, easy accessibility, low costRecommendations for use:Needs to be used every single time there is genital-to-genital or oral-to-genital contactUse a new condom each timeBefore contact, put the condom on the tip of erect penis with rolled side outIf condom doesn’t have a reservoir tip, pinch the tip to leave a half-inch space for semen to collectHolding the tip, unroll the condom all the way to the base of the penisAfter ejaculation and before the penis gets soft, grip the rip of the condom and carefully withdrawCarefully pull the condom off the penis, making sure semen doesn’t spill outWrap the condom in a tissue and throw in trash where others won’t handle itIf you feel the condom break, stop immediately, withdraw, remove broken condom, and put on a new condomUse adequate lubrication during vaginal and anal sex. Do not use oil-based lubricants (petroleum jelly, shortening, mineral oil, massage oils, body lotions, cooking oil) because they can weaken latexWithdrawalMale partner attempts to pull out penis before ejaculation57% of female adolescents report using this method22% failure rate among all usersOther methods less commonly used by adolescents: female condom, periodic abstinence (fertility awareness/rhythm method), vaginal spermicides, cervical cap, diaphragmOTHER CONSIDERATIONSComorbid conditionsSITUATIONHORMONE(S)SAMPLE BRANDS Thrombosis risk or estrogen sensitivity20 mcg estrogen Loestrin, Alesse, MircetteAcne or other androgenic excess3rd gen. progestin or norethindrone <1mg Ortho-Cyclen (35) or Ortho Cept (30)Hyperlipidemia or Diabetes Mellitus (DM)3rd gen. progestin or norethindrone <1mgOrtho-Cept, DesogenEndometriosisHigh progestin activity, continuous cycleLo-Ovral, Levora, SeasonaleFunctional ovarian cysts50 mcg ethinyl estradiolOvcon 50 or OvralPolycystic Ovarian Syndrome?Ortho Cyclen or Ortho CeptMigraine with auraProgestin onlyMirena, Nexplanon, Depo Provera, MicronorMigraines without auraLow dose estrogen Mircette, Alesse, LoestrinAdolescents with Disabilities, Chronic IllnessHave similar levels of sexual behaviors and sexual outcomes (eg, STIs)See CDC’s “US Medical Eligibility Criteria for Contraceptive use” available at: websites:For providers: Want to get LARC training? Resources here: institute website with evidence-based information: for parents to help them talk with their kids about sex: (Parent can text “TWYK” to 877877 to sign up for periodic tips)Teen and young adult patient info on choosing contraception: Also available en espa?ol!??Compártelo!Washington State Take Charge Program provides confidential, free birth control to males and females for 1 year :- or 1-800-322-2588-gynecologic exam for females provided if necessaryPlanned Parenthood app to track birth control and period: ................
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