Teens and Contraception:
New Approaches for Improved
Compliance and
Decreasing Teen Pregnancy
Jennie Yoost MD, MSc
Assistant Professor
Pediatric and Adolescent Gynecology
Marshall University Department of OBGYN
LEARNING OBJECTIVES
 Understand the mechanism of action and safety
profile of different long acting reversible
contraceptives including the subdermal implant
and levonorgestrel intrauterine devices.
 Understand the spectrum of contraceptives
available and continuation rates of different
methods among teenage users.
 Understand the noncontraceptive benefits to using
different methods of contraception.
 Understand use, access, and mechanism of action
of Emergency Contraception.
Case #1
14 year old female presents with her mom.
She started menses age 11. Mom is
interested in discussing birth control. The
girl is not sexually active. Mom feels she
“has a good head on her shoulders” and
makes good decisions. She worries about
some of her friends, and wants her started
on birth control “just in case”.
Case #2
 15 year old female presents for vaginal discharge.
She has been sexually active since age 12, and has
had a total of 6 partners since that time. She took
birth control pills for a few months, but not using
anything at this time. Pregnancy test is negative in
the office. You ask if she is interested in birth
control. She reports that she is, but “just has a hard
time remembering it.”
What do you offer her?
WHAT ARE OPTIONS FOR TEENS?
SAME OPTIONS AS ADULTS!
Pills
Patch
Ring
Injection
Intrauterine Device
Subdermal Implant
Abstinence:
It is important.
It is encouraged.
It can be secondary.
It only works if you are abstinent
Are teens really “doin’ it”?
Youth Risk Behavioral Survey 2011
45.6% sexually active
4% report sexual debut before age of 13.
(7% among AA)
13% > 4 sexual partners
53% report condom use
22.6% OCP use
7.5% other methods
The problem of unintended pregnancy
 6.7 million pregnancies per year in the US
50% are unintended
Among 15-19 year olds: 82% unintended
 2010 US adolescent birth rate
34.2/1000
 2007 US adolescent birth rate
42.5/1000
How do we compare to the rest of the world?
Variations within the US: among states (2010)
GOOD:
New Hamp 15.7
Massachusetts 17.2
Vermont 17.9
BAD:
Texas 52.2
Arkansas 52.5
New Mexico 53
Mississippi 55
WV (44.8) #43
Teens and birth control compliance:
METHOD
USE
FAILURE:
Perfect
Use
FAILURE:
Typical
Use
Continuation
at 12 months
Pills
Take one pill
daily
0.3%
9%
33-52%
Patch
Place one
patch weekly
0.3%
9%
25-50%
Ring
Place one ring 0.3%
monthly
9%
31%*
Injection by
0.2%
health
provider
Pills are
overall the
every 3
teens.months
6%
27-55%
Injection
•
most common choice for
• 50% of adolescents report missed pills
during a given cycle
What is a LARC?
Long Acting Reversible Contraception
Intrauterine Device
Progesterone containing (Mirena®, Skyla®)
Copper T (Paragard®)
Subdermal Implant
Nexplanon®
LARCs- a good option for teens!
Copper IUD
 Paragard®
 No hormones
 Effective for up to 10 years
 Placed by a simple procedure
 Can be done under sedation
 Mechanism of Action
 Copper ions inhibit sperm motility
 Inhibition of sperm capacitation (ability of sperm to
fertilize an ovum)
 Sterile inflammatory reaction of endometrium
(phagocytosis of sperm)
 May cause increased menstrual bleeding
LARCs- a good option for teens!
Levonorgestrel IUDs
 Mirena®
 20mcg/day
levonorgestrel
 Lasts 5 years
 Skyla®
 14mcg/day
levonorgestrel
 Lasts 3 years
 Smaller dimensions
 Placed by a simple
procedure
 Can be done under
sedation
 Mechanism of Action
 Increased cervical mucous
 Decreased tubal motility/
change in tubal fluid
 Alteration of endometrium
 Ovulatory inhibition
Levonorgestrel IUDs
Noncontraceptive
Benefits
Contraindications
Decreased menstrual
bleeding
Active PID or puerperal or
postabortion sepsis
Amenorrhea
Current STDs
Improved dysmenorrhea
Undiagnosed vaginal
bleeding
Malignancy of genital
tract
Known uterine anomaly
or distortion of uterine
cavity
Local action
No medication interaction
Use in girls with medical
comorbidities
Pregnant (too late!)
LARCS- a good option for teens!
Subdermal Implant
 Nexplanon™
 68mg etonogestrel
 Single rod
 Effective for at least 3 years
 Procedure
 Inserted subdermally in
groove just below biceps
 Can be placed at initial visit
 Mechanism of Action
 Ovulation inhibition
 Increased cervical mucous
 Endometrial atrophy
Nexplanon®
LARCs- a good option for teens!
METHOD
Levonorgestrel
IUD
Subdermal
Implant
FAILURE:
Perfect Use
0.2%
FAILURE:
Typical Use
0.2%
0.05%
0.05%
Don’t Believe Me?
ACOG: “top tier methods of contraception
including IUDs and implants should be
considered as first line choices for adolescents”
CDC/WHO:
• Subdermal implants=
Category I “no restriction”
• IUD=Category II “advantages
outweigh theoretically or
proven risk”
“But my friend’s
sister’s friend told
me that…….”
Lets Look at the Data:
Pregnancy
Compliance/ Continuation
Satisfaction
Bleeding patterns
Risks
 CHOICE study- prospective cohort
 (St. Louis, Aug 2007-Sept 2011)
 9256 patients
 Risk of pregnancy:
Pill/patch/ring= 4.55/100 pt years
LARC= 0.27/ 100 pt years
Efficacy not altered when stratified for
age <21
CHOICE Study Results:
LARCs had
81%
continuation
at 1 year--Better than
any other
non-LARC
method!!
LARC- Satisfaction
 CHOICE study:
 75% of patients chose a LARC method
 69% of adolescents chose a LARC method
 Women using LARC methods had highest satisfaction at
1 year follow up
Method
% Satisfied at 1 year
Levonorgestrel IUD
86%
Copper IUD
80%
Subdermal Implant
78%
Injection
54%
Pills
54%
Ring
52%
Patch
42%
Subdermal Implant: What are
the risks?
Complications are rare (<1%)
Infection
Hematoma formation
Local irritation
Expulsion- rare case reports
occurring in setting of infection
Subdermal Implant: Bleeding
patterns
 Unscheduled bleeding
 Can not predict bleeding pattern
 Abnormal bleeding can lead to discontinuation in 10-14%
of patients
 Meta-analysis (780 women)
 Evaluated bleeding patterns in first 2 years of use
 22% amenorrhea
 34% infrequent bleeding (<3 episodes of bleeding)
 7% frequent bleeding (>5 episodes of bleeding)
 18% prolonged bleeding (≥1 episode lasting >14 consecutive
days)
IUD Risks:
“This ain’t your Mama’s IUD”
Infection:
 Monofilament string- does not increase
risk of pelvic infection
 WHO clinical trial (23,000 IUD insertions)
Risk of PID was same as baseline risk in
population without an IUD
Increased in first 20 days after insertion
(9.7/1000 women-years)
From 21 days- 8 years risk 1.4/1000
women years (same as general
population)
IUDs and Infection
 Screen for Gonorrhea and Chlamydia
before or at the time of insertion
 What if GC/CT test comes up positive?
 TREAT---Do NOT REMOVE IUD
 Absolute risk of PID is low
0-5% among women with a positive
GC/CT test at time of insertion
IUD Risks: Expulsion
 Partial or complete expulsion from the
uterus
 Skyla: 3.2% (clinical trial- 54 out of
1665)
 Mirena/Paragard- between 2-10% in first
year
 What to do:
Can replace it with another IUD
Can change methods
IUD Risks: Perforation
 Skyla clinical trial: incidence of <0.1%
 Mirena/Paragard:
 WHO: <1 per 1000
 Dependent on experience of practitioner
 Insufficient data to demonstate a difference in
perforation risk between parous and
nulliparous women
 Only case series exist of difficult removals and
laparoscopic removals
IUD: Bleeding patterns
Mirena®
 Most common change is decreased
bleeding
 Average monthly blood loss drops by 90%
 At 1 year 20-40% amenorrhea
 Best bleeding profile among all options
FDA approved for treatment of heavy
menstrual bleeding
IUD Bleeding patterns: Skyla™
First 90
days
Second
90 days
1 year
3 years
Amenorrhea
<1%
3%
6%
12%
Infrequent bleeding
8%
19%
20%
22%
Frequent bleeding
31%
12%
8%
4%
Prolonged bleeding
59%
17%
9%
3%
Treatment days
1-28
Treatment days
337-365
Mean # bleeding days
7.3 (±5.6)
2.1 (±2.7)
Mean # spotting days
9.2 (±6.1)
3.3 (±3.1)
IUD: Other Myths and Misconceptions
MYTH: IUD causes infertility
 Fertility returns
immediately with removal
 Prior studies among infertile
women showed no
correlation with previous
IUD use
MYTH: IUD causes ectopic
pregnancy
Misconception: IUD insertion is
painful/difficult in nulliparous
 Insertion not technically difficult
 Risk of discomfort (86% report
discomfort with insertion)
 Pre-procedure misoprostol gives
no improvement
 Overall well tolerated
 Lowers risk just as overall
risk of pregnancy decreased Misconception: IUDs must be inserted
 0-0.5per 1000 womenyears (compared to 3.25-5
in women without)
 If pregnancy occurs,
proportion is higher
during menses
 Can be inserted at any time
 Menses may make insertion easier
 Must exclude pregnancy
Levonorgestrel IUD: Don’t
Forget the Benefits!!
 Treatment of heavy
menstrual bleeding
 Treatment of
dysmenorrhea (“bad
cramps”)
 Treatment of pelvic pain
and endometriosis
 Use in those with medical
contraindications to
estrogen
 Menstrual suppression for
physical and
developmental disabilities
Contraception in Teens:
Some final thoughts
A pelvic exam is not required for
giving an adolescent birth control
(IUD is exception)
Quick Start is preferred for all
methods
Discuss concerns/misperceptions at
the onset
Case #3
 16 year old female presents for routine
gyn exam on Monday morning. Sexual
history reveals that she is currently not
using any hormonal contraceptive
method. Had unprotected sex on
Saturday night and concerned about her
chance of pregnancy. Wants to know
what she should do.
Emergency Contraception
Plan B One-Step™ - Levonorgestrel 1.5mg
 FDA approved in 1999
 Available over the counter for age ≥17
 2011- Dept HHS overturned FDA decision to make OTC without
age restriction
4/5/13: Federal court rules emergency
contraceptives needs to be sold over
the counter
4/30/13: FDA approves morning-after
pill without prescription for girls 15 and
older
Response to court ruling:
American Academy of Pediatrics:
“While pediatricians recommend that teens delay
sexual activity until they fully understand its
consequences, we strongly encourage the use of
Society
contraception,
of Adolescent
including Health
emergency
andcontraception
Medicine:
“Today’s
to protect
ruling
theacknowledges
health of our adolescent
clear evidence
patients
that
EC is a safe and
whoeffective
are sexually
method
active.”
of backup birth
control for all women of reproductive age”
American College of Obstetricians and Gynecologists:
“EC is a safe, effective way to help prevent unintended
pregnancy after a contraceptive failure, unprotected sex, or
sexual assault. We believe all EC products should be
available over the counter.”
Emergency Contraception:
What is it?
Levonorgestrel 1.5mg
• Progesterone only medication taken in
one dose
• Decreases risk of pregnancy from 8%
to 1-2% after single episode of
unprotected sex
• Can be taken up to 5 days after
unprotected intercourse
Emergency Contraception:
How does it work?
Progesterone
Inhibits or delays
ovulation
May interfere with
sperm transport or
tubal motility
Does not disrupt a
pregnancy!!!!
X
X
Let me repeat…..
If you’re already pregnant, it won’t
do anything to the existing
pregnancy
Will not cause an abortion
Will not harm a developing embryo.
Emergency Contraception:
Who can take it?
World Health Organization: Category 1
No restrictions to use
Okay for females with contraindications to
birth control pills
Cardiovascular disease, liver disease,
migraines, etc…
Emergency Contraception:
When do you take it?
 No clinical exam or pregnancy test
necessary before use
 Any time unprotected or inadequately
protected intercourse occurs
 Take as soon as possible after event
 Efficacy decreases with time
 Still moderately effective when taken up
to 5 days after intercourse
Emergency Contraception:
What are the side effects?
 Nausea (18%)
 Vomiting (4%)
Repeat dose if vomiting occurs <2
hours from initial dose
 Irregular bleeding
Menses occurs usually within 1 week
before or after expected
Emergency Contraception:
Costs approximately $50
Does not protect against subsequent
intercourse
Does not protect against STDs
Need to discuss more effective
forms of contraception
References:

ACOG Practice Bulletin No. 121: Long-acting reversible contraception:
Implants and intrauterine devices. Obstet Gynecol 2011;118:184-96.

Committee opinion no. 539: adolescents and long-acting reversible
contraception: implants and intrauterine devices. Obstet Gynecol
2012;120:983-8.

FINER LB, ZOLNA MR. Unintended pregnancy in the United States:
incidence and disparities, 2006. Contraception 2011;84:478-85.

KEARNEY MS, LEVINE PB. Why is the teen birth rate in the United States
so high and why does it matter? The journal of economic perspectives : a
journal of the American Economic Association 2012;26:141-66.

YANG Z, GAYDOS LM. Reasons for and challenges of recent increases in
teen birth rates: a study of family planning service policies and
demographic changes at the state level. J Adolesc Health 2010;46:51724.

MARTIN JA, HAMILTON BE, VENTURA SJ, et al. Births: final data for
2010. National vital statistics reports : from the Centers for Disease
Control and Prevention, National Center for Health Statistics, National
Vital Statistics System 2012;60:1-70.

EDWARDS SM, ZIEMAN M, JONES K, DIAZ A, ROBILOTTO C, WESTHOFF
C. Initiation of oral contraceptives--start now! J Adolesc Health
2008;43:432-6.

EATON DK, KANN L, KINCHEN S, et al. Youth risk behavior surveillance United States, 2011. MMWR Surveill Summ 2012;61:1-162.
References:

THURMAN AR, HAMMOND N, BROWN HE, RODDY ME. Preventing repeat
teen pregnancy: postpartum depot medroxyprogesterone acetate, oral
contraceptive pills, or the patch? J Pediatr Adolesc Gynecol 2007;20:615.

SUCATO GS, LAND SR, MURRAY PJ, CECCHINI R, GOLD MA. Adolescents'
experiences using the contraceptive patch versus pills. J Pediatr Adolesc
Gynecol 2011;24:197-203.

ZIBNERS A, CROMER BA, HAYES J. Comparison of continuation rates for
hormonal contraception among adolescents. J Pediatr Adolesc Gynecol
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RUSSO JA, MILLER E, GOLD MA. Myths and misconceptions about longacting reversible contraception (LARC). J Adolesc Health 2013;52:S1421.

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among adolescents. J Adolesc Health 2013;52:S22-8.

ROSENSTOCK JR, PEIPERT JF, MADDEN T, ZHAO Q, SECURA GM.
Continuation of reversible contraception in teenagers and young women.
Obstet Gynecol 2012;120:1298-305.

WINNER B, PEIPERT JF, ZHAO Q, et al. Effectiveness of long-acting
reversible contraception. N Engl J Med 2012;366:1998-2007.

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Gynecol 2010;115:1100-9.
Thank You!