Pregnancy and Contraception :Pregnancy and Contraception 0r, Keeping the Ovens Bunless


Adolescent sexual activity :Adolescent sexual activity Nearly half of American teenagers between the ages of 15 and 19 has had sex at least once Average age of sexual debut is 17 At age 15, only 13% of American teens report sexual activity 7 in 10 by age 19 Most use contraceptive of some sort Excellent information at: http://www.guttmacher.org/pubs/fb_ATSRH.html (but the webpage wouldn’t let me steal their graphs)


Teen pregnancy (nationwide) :Teen pregnancy (nationwide) About 40 pregnancies per 1,000 girls between the ages of 15 and 19 Slight uptick in rates in 2006 (most recent stats available) since steady decline beginning in 1991 About a third end in abortion, most (about 60%) with at least one parent’s consent/support Less than 1% choose adoption (ChildTrends, 1995.)


Adolescent sexual activity (Maine) :Adolescent sexual activity (Maine) 45% of Maine high school students report having had sex at least once 34% report having had sex within the past three months 60% report condom use at most recent intercourse 40% report some form of hormonal contraception


Teen pregnancy (Maine) :Teen pregnancy (Maine) Fifth lowest rate of teen pregnancy in the nation Steadily declining over the past two decades (45%) Most pregnancies are in older adolescents (18-19 years of age) Vast majority (88%) unintended


Basic contraceptive physiology :Basic contraceptive physiology


Basic contraceptive physiology :Basic contraceptive physiology Primary mechanism is by inhibition of the pituitary release of gonadotropins Primarily progesterone-mediated Also thickens cervical mucus and creates uterine environment “hostile to implantation” Estrogen stabilizes endometrium and enhances efficacy


Barrier contraception :Barrier contraception Condoms (male and female) Diaphragms Provide “barrier” to sperm entering vaginal vault or cervix You probably already knew that, though Condoms most accessible and commonly-used form of contraception and STI prevention


Female condom :Female condom


Oral contraceptive pills :Oral contraceptive pills Most have a combination of estrogen and progesterone Can be mono-, bi- or tri-phasic Newer formulations often have lower doses of estrogen to minimize side effects Progestin-only pills (“mini pills”) also available Not commonly used, due to side effects and “fastidious” nature


Yaz :Yaz Contains drospirenone instead of testosterone-derived progestin More closely mimics physiological progesterone 24/4 cycle, instead of usual 21/7 Related to spironolactone, and causes slight increase in potassium Should be used with caution in patients with liver, kidney or adrenal disease


Common side effects :Common side effects Weight gain Break-through bleeding Nausea Headaches


Contraindications :Contraindications Migraine with aura Increased risk of stroke Prothrombotic medical condition Use with caution in patients with a family history of clotting disorders, early stroke, MI or deep vein thrombosis Patients with this family history should have coagulation work-up before considering estrogen-containing OCPs


DepoProvera :DepoProvera Medroxyprogesterone acetate 150 mg, delivered IM or 104 mg delivered sub-Q 3-month dosing cycle Irregular bleeding after the first shot, followed by amenorrhea for the remainder of use


DepoProvera :DepoProvera Common side effects including break-through bleeding, weight gain, moodiness; some experience hair loss Causes demineralization of bone Current recommendation is to switch methods after 24 months of continuous use Can be used by patients with coagulopathy In consultation with hematologist


Mirena :Mirena IUD impregnated with levonorgestrel, a progestin Provides 5-year contraceptive efficacy Has to be placed and removed by a medical provider Not widely used in nulliparous women Varies by provider


OrthoEvra (aka “the patch”) :OrthoEvra (aka “the patch”) Once weekly transdermal patch Combination of norelgestromin (progestin) and ethinyl estradiol (EE) Delivers more “steady state” hormonal contraception Similar side effects to low-dose combination OCPs, as well as some skin irritation By-passes first-pass metabolism Prescribing information describes 60% more steady-state EE than 35 mcg OCP VTE comparative odds ratio between 0.9 and 2.4


NuvaRing :NuvaRing Vaginal ring impregnated with enorgestrel (progestin) and EE Inserted vaginally once every three weeks, with one-week withdrawal bleed phase Also bypasses first-pass metabolism, but unclear comparative risk profile with OCPs (progestin may be prothrombotic) Common side effects include sensation of foreign body, vaginal irritation, and expulsion Adolescent girls may lack enthusiasm for inserting or retaining a vaginal foreign body


Extended cycling :Extended cycling Marketed under different brand names Can be done safely with regular OCPs (assuming no other contraindications) Some may have initial increase in break-through bleeding Often self-limited


Emergency Contraception :Emergency Contraception Aka “the morning-after pill,” Plan B Higher dose of progestin Exact mechanism not clear May impede fallopian motility, thicken cervical mucus or prevent implantation Does NOT abort an existing pregnancy Available without prescription to adult women Can also use certain combination OCPs, but dose of estrogen is nauseating Anti-emetics must also be prescribed


Questions? :Questions?