Primary and Preventive Health Care
for Female Adolescents
Jessica H. Pittman, MD
Assistant Professor, Obstetrics and Gynecology
University of Utah School of Medicine
Objectives
• Provide for the primary care needs of the adolescent,
demonstrating knowledge in areas such as health
guidance, screening and immunizations.
• Describe most common STIs including diagnosis,
treatment, and potential serious sequelae.
• Develop understanding and use of the Centers for
Disease Control and Prevention U.S. Medical
Eligibility Criteria for contraceptive use.
Health Guidance for adolescents
www.healthypeople.gov
Health Guidance Topics
• Homicide
• Suicide
• Motor vehicle crashes, including those caused by
drinking and driving
• Substance use and abuse
• Smoking
• Sexually transmitted infections, including human
immunodeficiency virus (HIV)
• Teen and unplanned pregnancies
• Homelessness
“Panel urges cholesterol screening for kids”
PEDIATRICS Vol. 128 No. Supplement 5 December 1, 2011 pp. S213 -S256
ADA Screening Guidelines for Pre-diabetes
and Diabetes in Medical Setting
Age
10-17yo
BMI
Risk factors
Screening tests
Frequency
Results
American Diabetes Association Clinical Practice Recommendations 2007 Diabetes Care January 2007
Who should be screened for diabetes?
Children/Adolescents 10-17
years old AND
Body Mass Index (BMI) is:
• >85TH percentile for age &
gender
• Or >85th percentile weight
for height
• Or weight is >120% of ideal
for height
• AND Two (2) Risk Factors…
Risk factors for Diabetes
• Family history of type
2 diabetes (1st/2nd degree)
• Race ethnicity
Native American, African
American, Hispanic American,
Asian/South Pacific Islander
• Signs of insulin
resistance
acanthosis nigricans,
hypertension, dyslipidemia,
polycystic ovary syndrome
Screening tests
The following results require additional testing*:
• Fasting plasma glucose
– Pre diabetes (100-125 mg/dL)
– Diabetes (≥ 126 mg/dL)
• Oral glucose tolerance test (2 hour, 75 gram)
– Pre diabetes (>140-199)
– Diabetes (>200)
*includes repeating testing to confirm diagnosis.
Abnormal test results
• Repeat test on subsequent day to confirm
results.
• Implement treatment plan including lifestyle
modification.
• Screen and treat for other Cardiovascular Risk
Factors:
• Hypertension
• Dyslipidemia
• Tobacco use
Initiate pap smear screening at age 21
– USPSTF (www.uspreventiveservicetaskforce.org)
– ASCCP (www. asccp.org/consensus.html)
– CDC (www.cdc.gov/cancer/cervical/basic_info/screening)
– ACOG (www.acog.org)
19 June 2012 Annals of Internal Medicine Volume 156 • Number 12, pages 880-891
Immunization
• Saves 33,000 lives.
• Prevents 14 million
cases of disease.
• Reduces direct health
care costs by $9.9
billion.
• Saves $33.4 billion in
indirect costs.
Despite progress, approximately 42,000 adults and 300 children in the
United States die each year from vaccine-preventable diseases.
www.healthypeople.gov
Immunizations
http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
HPV vaccination
• FDA approved for administration to females ages 9-26
• FDA 2009 approval for males 9-26yo
• Quadrivalent vaccine (types 6,11,16 and 18)
– HPV 6 and 11: 90% of genital wart cases
– HPV 16 and 18: 75% of cervical cancer cases
• Series of 3 injections: 0,2 and 6 months
• Can be administered with Hepatitis B
vaccine series, meningococcal vaccine
(Menactra) and Tdap (Adacel)
Reisinger KS et al. iPediatrics. 2010 Jun;125(6):1142-51.
Sexually transmitted infections:
•
•
•
•
•
•
•
•
Human Immunodeficiency viruses (HIV 1/2)
Herpes Simplex viruses (HSV 1/2)
Human Papilloma Viruses (HPV)
Hepatitis B and C viruses
Gonorrhea
Chalmydia
Syphillis
Trichimoniasis
Drug resistant gonorrhea
• CDC no longer recommends the oral antibiotic
cefixime (Suprax) as a first-line treatment
option for gonorrhea in the U.S.
• Recommended drug proven effective for
treating gonorrhea = injectable ceftriaxone
• Close monitoring for treatment failures
– retesting with a culture-based gonorrhea test if
persistent symptoms after initial treatment
www.cdc.gov/std/treatment
Expedited Partner Treatment (EPT)
• Allows third-party prescription without prior
exam for STD treatment
• Prescription requirements vary by state
– In Utah, prescription order must include patient’s
name and address. Prescription label must bear
patient’s name. Utah Code Ann. 58-17b-602
• EPT is permissible in most states including:
–
–
–
–
Utah
Idaho
Nevada
Wyoming
www.cdc.gov/std/ept/legal/utah/htm
CDC Guidance for use of EPT
• Support use of EPT for treatment of partners
of Gonorrhea and chlamydial infections in
women and men.
• Advise against use of EPT for:
– Gonorrhea and chlamydial infections in men
who have sex with men
– Women with trichomoniasis
– Syphilis
Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases.
Atlanta, GA: US Department of Health and Human Services, 2006.
Minor Consent Laws
• All 50 states specifically allow minors to consent
to testing and treatment for STDs, including HIV.
• 25 states have laws or policies that explicitly give
minors the authority to consent to contraceptive
services (in one or more circumstances):
– Utah state law confers the rights and responsibilities
of adulthood to minors who are married.
– Utah state funds may not be used to provide minors
with confidential contraceptive services.
http://le.utah.gov/~code/TITLE76/76_07.htm
www.guttmacher.org
Contraception
•
•
•
•
•
•
•
Oral contraceptive pills
Combined contraceptive Patch
Intra-vaginal ring
Depo provera injection
Single implanted rod (Implanon/Nexplanon)
Intrauterine contraception (Mirena/Paragard)
Condoms
Quick start initiation method
• First pack in the office
– Supervised ingestion of first pill
– Improved compliance rate
– Refills on weekdays
vs. “Sunday Start”:
–
–
–
–
Decrease breakthrough bleeding
May delay initiation or never start
Engage in unprotected sex one more cycle
Refills on weekends
Lara-Torre, E Contraception 2002;66:81
Westhoff C, Osborne LM, Schafer JE, Morroni C. Obstet Gynecol 2005;106:89-96.
Schafer JE, Osborne LM, Davis AR, Westhoff C. Contraception 2006;73:488-92.
Unintended Pregnancy
• 80 million unintended pregnancies occur
worldwide each year
• With typical use, the first year failure rate:
– copper T 380A (ParaGard®) is 1%
– LNG-IUS (Mirena®) is 0.1%
– Implant (Implanon/Nexplanon®) is 0.1%
• One-year continuation rates:
– 78% for the copper T 380A
– 80% for the LNG IUS
– 84% for Implanon®
Guttmacher Institute. Facts on contraceptive use. 2008. http://www.guttmacher.org
Trussell J. Contraceptive efficacy. Contraceptive technology 19th revised edition. New York: Ardent Media; 2007.
LARC methods
• Available LARC methods:
– Hormonal contraceptive IUD (Mirena)
– Nonhormonal contraceptive IUD with Copper
(ParaGard)
– Subdermal contraceptive implant
(Implanon/Nexplanon)
• Shorter-acting methods considered LARC:
– Depot medroxyprogestone acetate (Depo provera)
Depot Medroxyprogesterone Acetate
and Bone Mineral Density
•
•
•
•
•
Decreased bone density noted in teenagers
No increased risk of fractures
Recovery of BMD following discontinuation
May consider supplement calcium and vit D
Consider alternative method if at risk
– Immobile, non-weight bearing, wheelchair bound
– Underweight
• Reassess after 2 years, continue DMPA if other
methods are inadequate
ACOG Committee Opinion No. 415. Obstet Gynecol 2008;112:727-30
Scholes D, et al. Arch Ped Adol Med 2005;159(2):139-144
Barriers to increased LARC use
• Providers may lack information or are misinformed.
– unsubstantiated risk related to STIs, ectopic pregnancy,
infertility, use postpartum, use postabortion, use by
nulliparous women, use by teens.
• Providers lack adequate training in IUC and implant
insertion
• Patients' fears, misinformation and lack of knowledge
have resulted in low demand.
• LARC is expensive and provider reimbursement low,
especially in the US.
Speidel et al. Contraception 78 (2008) 197–200
The Contraceptive CHOICE Project:
• 5086 women ages 14-20 enrolled
• Preferred LARC method by age:
– 18-20 years (61% chose LARC)
• Implant: 29%
• IUD: 71%
– 14-17 years (69% chose LARC)
• Implant: 63%
• IUD: 37%
Mestad R, et al. Contraception. 2011 Nov;84(5):493-8
U.S. Medical eligibility criteria (MEC)
http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf
U.S. Medical eligibility criteria (MEC)
• Comprehensive, evidence-based guidance on
contraceptive use
• Adapted from guidance previously developed
by the World Health Organization
• The U.S. MEC gives guidance to clinicians
providing family planning services to women,
especially women with medical conditions.
Increased VTE risk and contraception
• Communicating level of risk:
– OCP and VTE risk: 20-30/100,000
– Pregnancy VTE risk: 100/100,000
– Postpartum VTE risk: 500/100,000
• If increased VTE risk factors, Progestin only
methods preferred
– Pills
– Injectable
– Implant
– Intrauterine
James AH. Pregnancy-associated thrombosis. Hematol 2009; 277-85
Seeger JD, Loughlin J, Eng PM, Clifford CR, Cutone J, Walker AM. Risk of thromboembolism in women taking
ethinylestradiol/drospirenone and other oral contraceptives. Obstet Gynecol 2007; 110(3):587-93.
Drospirenone* and DVT risk
*Drospirenone containing birth control pills include: Beyaz, Gianvi, Loryna, Ocella,
Safyral, Syeda, Yasmin, Yaz, and Zarah.
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm257175.htm
Migraine Headaches
MacClellan LR et al. Stroke. 2007; 38: 2438-2445
Drug Interactions
Foldvary-Schaefer N et al. Neurology 2003;61:S2-15
Foldvary-Schaefer N, et al. Cleve Clin J Med 2004;71 Suppl 2:S11-8
Emergency Contraception
• ParaGard (copper) IUD
• Contraceptive pills (Yuzpe method)
– 19 pill brands available for use in U.S.
– Usually involves taking 4-5 pills, repeat in 12 hrs
• Plan B (Levonorgesterol)
• Next step
– Generic form of Plan B One step (July 2012)
• Ella (Ulipristal Acetate)
Fine P, Mathé H, Ginde S, Cullins V, Morfesis J, Gainer E..Obstet Gynecol. 2010;115:257-63
Plan B (Levonorgesterel)
• Single dose of levonorgesterol 1.5 mg
• Reduces pregnancy if taken within 72 hours of
unprotected intercourse
• FDA approved for OTC 2009 ( >17 yo)
• December 7, 2011 – Dept. of HHS overrules decision
of the Food and Drug Administration (FDA) to make
the emergency contraception method known as
Plan B One-Step available for
purchase without a prescription
or age restriction.
Emergency Contraceptive Pills
• Plan B One-Step and Next Choice
– Reduce the risk of pregnancy by 89% when started
within 72 hours after unprotected sex
– Continue to reduce the risk of pregnancy up to
120 hours after unprotected intercourse
– Inhibits or delays ovulation
– Less effective as time passes
– Does not interrupt established pregnancy
Rodrigues I, et al. Am J Obstet Gynecol. 2001;184:531‐7
Mikolajczyk RT, Stanford JB. Fertil Steril. 2007;88:565‐71
Ella (Ulipristal acetate)
• Use up to 120 hours after unprotected
intercourse
• Progesterone antagonist
• Delays ovulation
• Maybe more effective than levonorgestrel
• Especially 72-120 hour group
• Prescription only
I am every emotion times ten,
I conform yet I'm rebellious,
Always obeying but somehow still an outlaw,
Always talking but never heard,
I am a teenager.
-- Author Unknown
Additional resources
• American College of Obstetricians and Gynecologists
(www.acog.org)
• North American Society for Pediatric and Adolescent
Gynecology (www.naspag.org)
• Boston Children’s Hospital – Center for Young
Women’s Health (www.youngwomenshealth.org)
• Centers for Disease Control (www.cdc.gov)
• Planned Parenthood (www.plannedparenthood.org)