EXPERT ANALYSIS FROM AAP 2017
CHICAGO (FRONTLINE MEDICAL NEWS) – The steady drop in teen pregnancy rates over the past 25 years – more than a 75% decline – is directly attributed to more effective use of contraception, but it only will continue if teens use the most effective forms of contraception, explained Rachael Phelps, MD, medical director of Planned Parenthood of Central and Western New York.
Teen birth rates in the United States already remain much higher than those in other high-income countries. In fact, the 2015 U.S. rate of 22 births per 1,000 teens ages 15-19 years is barely below that of India and Rwanda – and more than triple the rates in France, Germany, Italy, and other Western European countries.
It is therefore the responsibility of pediatricians to know and recommend the most effective forms of contraception to their teen patients, Dr. Phelps told attendees at the annual meeting of the American Academy of Pediatrics. Of the approximately half of all pregnancies that are unintended in the United States, the largest proportion occur among women in their early 20s, followed by women in their late 20s, and then by teens.
“A lot of what you’re doing for adolescents in primary care is transitioning them from being a child to being an adult,” Dr. Phelps said. “Once they’re in their 20s, they may not see a primary care doctor, so you have the opportunity to give them the skills and the knowledge they need with contraception to protect themselves not only through their teens, but through their 20s.”
Contraceptive methods’ effectiveness
The most effective forms of birth control, with a less than 1% chance of pregnancy, are long-acting reversible contraceptives (LARCs), including the implant (Nexplanon) and an intrauterine device (IUD), such as Skyla, Mirena, Liletta, and Kyleena, and the hormone-free Paragard. Sterilization also is highly effective, but is permanent and rarely an ideal option for the average teen.
Other hormonal options are second best, with 94%-99% effectiveness, but require more frequent replacement. Whereas the implant lasts 3 years and the IUDs last anywhere from 3 to 12 years depending on the type, the pill must be taken daily. The patch is replaced each week, the ring is replaced each month, and Depo-Provera shots are required every 3 months.
The least effective methods of birth control include withdrawal, natural family planning (fertility planning), and barrier methods such as condoms and diaphragms. Depending on the method, 12-24 women out of 100 will get pregnant each year using these methods, although that’s better than the 90% or more of women who get pregnant each year when using no contraception.
Most teens (69%) use less effective short-acting contraception. Despite the superior effectiveness of LARC methods, only 4% of teens ages 15-19 years are using them. “If we could increase that number, we could make some real strides in [reducing] our teen pregnancy rates,” Dr. Phelps said, highlighting the problem with starting on the pill.
“The problem is, if you try pills first and see how that goes, the way you’re going to find out it didn’t go so well is she’s going to be pregnant,” Dr. Phelps said. “When you think about an IUD or an implant being invasive, you need to think about the alternative, which is pregnancy.”
Just over half of teens using contraception use oral contraceptives (54%), according to the Centers for Disease Control and Prevention, yet research shows only a third of women remember to take their pill every day in their first month. By their third month, just one in five women have remembered the pill every day, and more than half (51%) have forgotten three or more pills ( Fam Plann Perspect. 1996 Jul-Aug;28[4]:154-8 ).
“When we talk about risk, we often think about the risk of the method versus not using the method,” Dr. Phelps said. “But what we should be thinking about is the risk of the method versus the risk of pregnancy. That’s the true comparison because they’re not going to stop having sex.”
After oral contraception, condoms are most popular (23%), followed by 9% using Depo-Provera, and the remaining 10% split across withdrawal, the ring, and the patch, she said.
LARCs preferred by teens and organizations
The AAP, the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP) all recommend LARCs as first-line contraceptive choices.
Teens also prefer LARCs to the short-term, less effective methods as well, found the Contraceptive Choice Project study. Given a choice of any birth control method without cost or other access barriers, 72% of teens would choose a LARC, compared with 28% of teens who would choose a short-acting method, Dr. Phelps said.
Satisfaction rates with LARCs, ranging from 78% with the implant to 86% with a hormonal IUD, also far exceeded satisfaction with other hormonal contraception, ranging from 42% for the patch to 54% for Depo-Provera and oral contraceptives, the study found. And LARCs are among the safest contraceptive choices because they contain no estrogen and have few contraindications.
Understanding LARC and hormonal options
The two types of IUDs are an levonorgestrel IUD and a copper-T IUD. The levonorgestrel IUD contains progestin only, released at 20 mcg per day, and is effective up to 3-7 years. Most patients have light spotting initially, lasting 6 months in about 25% of patients and up to a year in 10%. By 6 months, 44% don’t have periods, which increases to 50% by 1 year (“ Contraceptive Technology ,” 19ed. [London: Ardent Media, 2007]).
The copper-T IUD contains copper ions but no hormones and is effective up to 12 years, starting immediately. Women have regular periods, but they may be heavier, longer, or with more cramps for the first 6 months.
Both IUDs and implants are safe in nulliparous, postpartum, and breastfeeding teens as well as those with obesity, cervical intraepithelial neoplasia, diabetes, HIV, depression, stroke/myocardial infarction/deep vein thrombosis/pulmonary embolism, pelvic inflammatory disease, and sexually transmitted infections.
Dr. Phelps reviewed insertion for both IUDs and the implant, but also said providers can refer teens for LARCs using http://larc.arhp.org to find someone. She also recommended the Managing Contraception pocket-sized book, available at www.managingcontraception.com and free for medical students and residents. Further, the U.S. Medical Eligibility Criteria provides all necessary information on contraindications and is available as a mobile app.
All the hormonal options, including the levonorgestrel IUD, become effective 1 week after starting. The implant, costing $300-$600, contains only progesterone, is effective up to 4 years and works by inhibiting ovulation. Just over one in five girls (22%) have no period, 34% have infrequent light bleeding, and 11% discontinue it because of frequent bleeding.
Depo-Provera contains progestin only and involves an injection every 12-14 weeks; irregular bleeding is initially common, after which most patients experience amenorrhea.
Patients using the patch, containing both estrogen and progestin, should change it once a week for 3 weeks and then take 1 week off for their period. Providers should advise teens to stick the patch directly on clean, dry skin of the arm, torso, buttocks, or stomach, but not to their breasts.
The ring similarly contains estrogen and progestin and has 1 off week after 3 weeks of use, but it is changed out monthly. Patients pinch the ring and place it into the vagina in any location, going deeper if it is uncomfortable.
Emergency contraception
Of the two emergency contraception options, ulipristal acetate – prescription only as 30 mg used up to 120 hours after unprotected sex – is always more effective than levonorgestrel – over-the-counter as 1.5 mg used up to 72 hours after unprotected sex. Both, however, are less effective in those with obesity (ulipristal acetate if BMI great than 30 and levonorgestrel if BMI greater than 25), Dr. Phelps said. If the patient had unprotected sex 3-5 days earlier and/or has a higher BMI, ulipristal acetate is preferred. Ideally, teens should be provided emergency contraception ahead of time, thereby increasing earlier use and use overall when it’s needed without increasing risk-taking behavior.
Common misconceptions
Dr. Phelps also reviewed some of the key myths that providers and teens often believe about LARCs and other contraceptive methods.
“When providers or patients hold misperceptions about the risks associated with contraception, teens’ choices are unnecessarily limited,” she said.
Key facts to know about IUDs are that even nulliparous teens can use them, teens can tolerate IUD placement, and IUDs do not increase the risk of pelvic inflammatory disease or infertility. Even teens with multiple partners and/or a history of sexually transmitted infections, pelvic inflammatory disease, or ectopic pregnancy can use IUDs, Dr. Phelps emphasized.
Although Depo-Provera can lead to 3%-5% bone loss, similar to pregnancy and breastfeeding, in the first 1-2 years, the loss is temporary and reversible. No research has shown Depo-Provera to increase risk of fracture or other negative clinical outcomes, no limits to its duration of use exist, and measuring bone mass density is not recommended.
Although Depo-Provera does cause excessive weight gain in 25% of users – an average 15 pounds over 3 years – the risk of increase is evident at 6 months. All other hormonal options – IUDs, the implant, pill, patch, or ring – do not cause weight gain. Finally, obesity does not decrease the effectiveness of IUDs, the implant, patch, pill, or ring.
No funding was used for this presentation. Dr. Phelps reported having done clinical training and speaking for Merck.
