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Pearce-ings: IUDs, OCs, STDs ... OMG!!!

Let's face it, most of us when we entered into pediatrics envisioned bouncing babies, adorable toddlers, and snotty-nosed children drawing us pictures that adorned the walls of our office. Never did we imagine sitting in a room across from a stone-faced teenage girl to talk about birth control.

But, reality quickly sets in, and staying up to date with the latest recommendation on birth control is imperative or you need to make the proper referral. Knowing the laws of your state about birth control, which govern your ability to administer contraception without parental consent, is vital. The Guttmacher website gives you a concise list for each state (guttmacher.org/statecenter/adolescents.html). Parental involvement is always encouraged, but may be the obstacle that prevents the patient from having the discussion.

Abstinence is the only foolproof way to avoid pregnancy, yet many of us forget to discuss it during our conversation. With statistics like 40% of teens report to having engaged in some level of sexual activity by age 15, it is not far-fetched to believe that there are teens who just assume all of their peers are having sex (Hatcher, R.A., et al. Contraceptive Technology, 20th revised ed. New York: Ardent Media, 2011).

It is important that teens know that the majority of teens are not having sex, and saying "No" is an option. But teens will need support and help in developing the skills to incorporate abstinence into their relationships.

Discussing the health risk of sexually transmitted infections (STIs) and the possibility of infertility has a strong impact. Being clear on the risks of contracting human papillomavirus with the subsequent risk of cervical cancer associated with having multiple sexual partners, as well as the risk of contracting an incurable disease such as HIV, can be very persuasive.

Discussing condoms, how they protect against sexually transmitted diseases, and the value of dual protection is also important.

With pregnancy rates lower than 1% with perfect and typical use, long-acting reversible contraceptive (LARC) methods "are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women," according to the American College of Obstetricians and Gynecologists committee opinion No. 539, written by the Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group (Obstet. Gynecol. 2012;120:983-8). Complications of these methods--intrauterine devices (IUDs) and the contraceptive implant --are rare and are similar in adolescents and older women, yet LARCs are underused in the younger age group.

An IUD is a LARC that eliminates the need for the teen to remember to take an oral contraceptive. Mirena is one such IUD that has little to no side effects, and is easily placed and removed. It can be used to control dysmenorrhea and abnormal uterine bleeding/heavy menstrual bleeding as well.

Skyla is the newest intrauterine system on the market. Compared with Mirena, which has been available since 2000, the new system uses less levonorgestrel (14 vs. 20 mcg), has a smaller frame and inserter tube that have been shown to be less painful on insertion in nulliparous women, is associated with more abnormal bleeding, and is approved for 3 years (vs. 5 years) of use.

In the past, IUDs were discouraged because there was a fear that there was an increased risk of infection and pelvic inflammatory disease (PID) with their use. However, more recent research shows that there is only a slightly increased risk of PID at the time of insertion, and there is no increased risk of STIs or infertility associated with using IUDs. They have become increasingly popular for adolescents, and should be given as an option.

The contraceptive implant (Nexplanon), which is approved for 3 years of use, is another form of LARC.

The use of oral contraceptives is a common option, although challenging for the already-preoccupied teen. The birth control pill has a failure rate of 0.3% when used correctly, but that increases to 8% when used in its typical fashion, according to the U.S. Medical Eligibility Criteria for Contraceptive Use (MMWR 2010;59:188). Many parents express concerns regarding the safety of OCs because of all the media advertisements for lawsuits. The reality is they are safe. The risk of deep vein thrombosis is low in women younger than 35 years who are nonsmokers, without hypertension, and who are not obese. Starting with an ultralow dose of estrogen minimizes side effects. If a patient begins to have breakthrough bleeding, switching to a triphasic pill helps reduce those episodes.

The Minipill (a progestin-only contraceptive) and Depo-Provera (a progestogen-only injection) are options for women who cannot tolerate estrogen, but the downsides are that their use can increase acne and appetite (which can lead to weight gain). Depo-Provera use also has been shown to lead to significant bone density loss if used greater than 2 years. These contraceptives are all reasonable options for a teen who demonstrates a high level of responsibility.

A talk on contraception would not be complete without including information about emergency contraception. It is important to let teens know that if there is a risk of pregnancy, taking emergency contraception within 3-5 days can prevent them from becoming pregnant.

In June 2013, the Food and Drug Administration removed the requirement for minors to have a script to receive Plan B. My Way and Next Choice still require a prescription. Other options such as ella (ulipristal acetate, available by prescription) are hormone free, have fewer side effects, and have been shown to be more effective than hormones in preventing pregnancy.

In 2012, the American Academy of Pediatrics released a policy statement on emergency contraception, which stated: 'All adolescents, males and females.... should be counseled on emergency contraception as part of routine anticipatory guidance in the context of a discussion on sexual safety and family planning regardless of current intentions of sexual behavior" (Pediatrics 2012; 130:1174-82).

All of the oral emergency contraception methods are significantly less effective in obese women, and obese women are four times more likely to get pregnant despite using these methods. The copper IUD has been shown to be the most effective form of emergency contraception regardless of weight and offers continuous protection. But, it should be noted that using the copper IUD for this purpose is an off-label use in the United States.

Knowledge is power, and sharing this little bit of information can be life changing for a teen who is considering being sexually active.

BY FRANCINE PEARCE, M.D.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at pdnews@frontlinemedcom.com.
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Title Annotation:OPINION
Author:Pearce, Francine
Publication:Pediatric News
Date:Dec 1, 2013
Words:1091
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