Chapters Transcript Contraception In The adolescent: Prescription and OTC Maggie Dwiggins, MD, presents on how to understand safety and efficacy of contraception for adolescents. OK, well, um, sorry for all the challenges this morning, but it looks like hopefully we are up and running. Um, somebody stopped me if the internet, or if I'm starting to lag or anything like that. Um, but thank you so much for having me. I really enjoy talking about this topic, contraception. Um, and there are some I've had a few people recently ask me kind of the difference between birth controls and what the safety and all that stuff, uh, so I just wanted to give a really brief overview and You don't have to, you know, I talk about this all the time. You don't have to prescribe birth control if you don't feel like that's what's right for you. That's kind of what we're here for. But sometimes it's nice to have just one or two options to bridge patients or sometimes they're just thinking about it and they don't want to go to the gynecologist or, you know, those sorts of things. So hopefully this will give you just kind of a brief understanding and um some really exciting news about the over the counter birth control, so. I will get started. I have no disclosures today. And as you can see, these are the objectives. Really, I just want um you to have kind of an understanding of how to decide when one birth control is safe or when another one might not be quite as safe. And then review how kind of I use contraceptives in a non-contraceptive manner, because I think we did a recent poll and it was about 80% of my users are not using birth control for contraception, but for other complaints. And then just to kind of acknowledge some con some common special considerations, you know, when one thing might be contraindicated or kind of other things to think about when prescribing. So, as an introduction, uh, because most of the time, I am prescribing birth control for non-birth control reasons. I think a lot about periods and what might be normal. So this is really just a review for you, but in 2015, the adolescent Committee of ACOG did practice this practice bulletin, and it was entitled Menstruation in Girls and Adolescents Using the menstrual Cycle as a vital sign. So this was really supposed to raise awareness that yes, while we do tolerate some menstrual cycle abnormalities, we really do think that somebody within a year of monarchy should be having some pretty regular-ish type of periods. So the main aim. The age of onset of menarchy is still stable. So the mean age is still 12 to 13. However, this is trending earlier. So in the past several years, we have started to see periods like 2 to 3 years before that. So really starting around age 9 or 10 can still be considered normal. And, and In this regard, if we feel like breast development is normal 2 years before menarchy, then we've started also to tolerate breast development around age 7 or 8. Again, this is still, you know, each patient is different, so we need to, to think about them as a whole, but a lot of times now, the archy can be normal starting around 7 or 8, and periods can be normal starting around 9 or 10. So within the 1st 3 years after menarchy, about 90% of the adolescent population will have a period, at least every 21 to 45 days. So no sooner than every 21 days from cycle day 1 to cycle day 1 and no later than 45 days. That can be this month it was 21 days and next month it's 45 days. So it's not very, very normal or regular, but within 21 to 40, 5 days apart. Still within one standard deviation to have a period as infrequently as every 90 days though. And so somebody who is having, you know, skipping 2 months here and there, I still don't get terribly, terribly worried unless it's their normal. Um. That would require a kind of a further workup. And then the typical length of a period is about 5 to 7 days. Um, this can change as the patient ages. Usually, it should be about at least 3 days, but anything lasting longer than 7 days, I usually do a workup. And then the flow can be difficult to quantify, especially because, uh, these adolescents use various methods for their periods, but we usually use like pads, the general. Pads and tampons is like the general flow indicator. Um, up to 8 regular pads or tampons actually can be pretty normal, um, as long as they can use it for at least 2 hours. And then last pain and cramping pain, about 90% of patients will have pain with periods, but they should be able to go to school without vomiting. Um, and that's kind of the red flag. If they're missing school or having vomiting because of the pain, that's kind of a lot, so. OK. That did not work. There we go. And when I see menstrual abnormalities, this is again just from that practice bulletin, um, this is usually what I would, would evaluate. Um this is kind of what I talked about. So I'm not sort of within 3 years of the larky, has not started by age 14 with signs of hirsutism, then I might be concerned about PCOS, has not started by 14 with signs of um Excess exercising or eating disorders are very, very thin. No period by 15, more frequently than every 21 days, less frequently than every 90 days, or lasting more than 7 days. So, this question too, it seems kind of silly, but how does birth control work? So the birth control part of birth control really is the progesterone. The estrogen does not do very much at all. So the progestin is what's providing the contraception, and the way that it works is it thickens cervical mucus, as well as mucus in the fallopian tubes. So at the level of the cervix, it's inhibiting sperm. Penetration into the uterus and so it's preventing egg and sperm from meeting. It also slows the movement of the egg through the fallopian tube. So it's delaying again when the sperm is feeding the egg, and we know that there's only a 24 hour window of fertilization, and so that's kind of how it works. Um. Progestins also can prevent ovulation as well by inhibiting the HPO. Again, just as a reminder, progesterone is only made after ovulation, and so the presence of progesterone in the serum tells the brain that uh ovulation has occurred and it's this negative feedback. Um, estradiol, what it does is it kind of stabilizes the endometrium just a little bit more, so breakthrough bleeding is less common, but it gives additional HPO feedback to further prevent ovulation. And birth control is also really, really safe too. There are no reports of serious illnesses by overdose, including when children's overdose, um, on them. You can take a whole entire pack at once, and in fact, that's some formulations of kind of plan plan B um emergency contraception can use like a whole pack of birth control. Um, for the progesterones, there's only one contraindication. So you can use progesterone only methods very, very, very safely. The only contraindication is active breast cancer. So that person themselves has active breast cancer. They're the only ones that cannot use it. Um, as far as estrogen goes, there are more contraindications, but that's when I use the CDCEC. So the CDCEC is the medical eligibility criteria. It is an app, you can also get it on your browser, um, but download it is free. So it's, and it's not very big, um, and it's been very, very helpful, especially for some things that I don't encounter very much. Uh, and then what it does, so I'll kind of show you. This is what it looks like if you open it in the browser. Um, when you use the app, it's a little bit more user friendly because you just kind of search for the condition, and then you open it up and you like kind of go through it like that. Um, when you open it in the browser, what you get is this table. It's what you can see there on the far left, that's the conditions, and so it starts with age, then anatomic abnormalities, you know, and then the subconditions. Of them. And so if you look down to breast disease, the subconditions are undiagnosed mass, benign breast disease, family history of cancer, and active current or past breast cancer. And so condition subcondition, and then you go over and what you can see in those boxes are all the different types of birth control that you can have. So first it's the combined hormonal contraceptives and that would be the pill patches and rings. And then second would be the progesterone only pills, then the injection, the Depo-Provera injection, the implant, they're considering it the next one on in the arm, and then the, um, levo estal IUD followed by the copper IUD. So those are kind of all the, all the methods that we can offer. And then it gives it a rating from 123 or 41 is there, there's nothing to be concerned about. You can use this willy-nilly if you wanted. A level 2 is maybe use some caution or think about it. Before prescribing it and or make sure to like monitor these this thing or the next. Level 3 is really make sure the benefits are outweighing the risks of, of the medication, and then level 4 is really we need to use something different here. But, but one thing to keep in mind is that these risks of the birth control must always be compared to the risk of pregnancy in these individuals. So as a reminder again, adverse events in pregnancy are common. It is pregnancy is one of the leading killers of young women in the United States, and as we know that mortality is about 40. In some populations even as high as 45% here in the United States, so. You know, conditions that are associated with increased risk, if you have a pregnancy, are again kind of all of those things that are category 3 for estrogen containing birth controls, and again, almost nothing is a category 3 or 4 for progesterone. And so even in these conditions, the risk of morbidity and mortality in pregnancy significantly outweighs the risks of using progesterone. So, to get kind of started into the meat of it, um, I get this question a lot. What is the best contraception for an adolescent, and the best one is the one that the patient will use. Um, so, ACOG and the American Academy of Pediatrics, they do recommend that the LARC methods, and that would be your injections, the implant in the arm, or an IUD, um. So this should be the first line of the, if the adolescent comes to you and they're like, I want birth control on the best birth control, then this should be the first line that we offer them. Um, the safety of these methods has been reiterated in various publications as well as in the CDC MC, and you no longer have to have a pregnancy, you no longer have to be older. Um, I do place IUDs in some very young patients sometimes. Um, so, if you remember the contraceptive choice project done here at Wash U. Um, at 3 years, they, so they, they gave everybody free birth controls what they did, and then they measured their continuation rates at 1234, and 5 years, and then they asked about why they changed methods or what their thoughts were. And so at the 3 year mark, any IUD users, so anyone who used the progestin IUD, even the copper IUD, continuation rates were 70%. So people were very, very happy. With this method at the 3-year mark. The implant in the arm, that continuation rate was 2nd at 56%. Depo came in 3rd at 33%. So while the continuation rates have gotten worse, um, you can see any of those long-acting methods were more patients were more likely to continue those methods. Um, at 3 years. OCP users, the continuation rate was only 30%. The ring was 29%, and the patch is 28%. So those methods people weren't using, and they don't always come back to us, they just kind of run out of their refill and they don't come back. Um, so just keep that in mind. Uh, they further broke it down into the adolescent population. They didn't have enough initially to do a big Evaluation, um, but they just broke it up into the long-acting methods versus the non-acting methods, and any IUD implant or shot, the adolescent was using 52% at 3 years, and in those who were not using a LARC, it was only 21%. So, So always keep that in mind. Um, however, Just about this study too, long-term use may not always be the patient's goal because we are looking at um reproductive age women and so sometimes they discontinue for pregnancy too. Just keep that in mind. Um, All right, so contraception and pregnancy. So unintended pregnancies, um, It's a serious side effect of sexual activity. So in the US, only 50% of teenagers who have a pregnancy while in high school will actually graduate from high school, and of those, 50% still live in poverty for the rest of their lives. So unintended pregnancies is big. Um, and even when we're using contraception, unintended pregnancies is still possible. So somebody who consistently uses any form of birth control, unintended pregnancy rates are only 5%. With inconsistent use, it's pretty high, it's 41%, and that is compared to 54% in somebody who is not using a hormonal contraception and might only be using uh fertility timing or condoms. Um, But again, like I said, in my patient population, we really do see that the majority are using birth control for non-birth control reasons. Um, so, um, this is a study for like across the country, how are adolescents using birth control. Again, in my population, I would say that the vast majority are using it for not just birth control, but for something else. A lot of it is dysmenorrhea, a lot of it is endometriosis, actually a lot of it is acne as well. So All right. So now I'm gonna just kind of move into Uh, 01 more slide. So about menstrual regulation, because I get this one a lot too. So some of my patients still want to have periods. It's fine to not have a period. Uh, in fact, not having periods lowers the risk of cancer of the uterus and the ovaries significantly. And so if you're not having to grow cells and then shed them and grow them again, that lowers the risk of an abnormal cell forming inside the uterus. If you're not ovulating, you don't have to burst and then heal. So again, you're not putting new cells in. And any time you can stay kind of static and not add cells, that lowers the risk of an abnormal cell forming. So over the course of 5 years of a progesterone user, the risk of cancer that um uterus and the ovaries goes down by 50%. If somebody uses progesterone for 10 years, that cancer risk goes down by 80%, and the risk of colon cancer is decreased by 50%. So again, no reason to actually have periods. However, I have some people who do still want to have a regular period, and if that's the case, really the only thing that they can use is a combined hormonal contraceptive option like estrogen plus progesterone, that's the pills, patches, and the rings, or they can try slint if they have an estrogen contradiction. Um, for the birth control pills, I've put OCPs, but really it's pills, patches, and rings. Those periods are very, very predictable, lighter, shorter, and less painful, can be used to have a period every 2 or 3 months if they wanted to. Um, with somebody who uses estrogen, most of them will need to bleed occasionally, and so I say that menstrual suppression overall is not terribly, terribly effective with estrogen use. Um, the slimmed version, there are 4 placebo pills and they're supposed to have a withdrawal period. However, what progesterone does is it causes endometrial action. So actually not having the pill for 4 days is just kind of like, oh, the body can start growing endometrium again and that's why it starts to bleed, but a lot of patients will have missed periods, light spotting, continuous unpredictable bleeding. So Slin is still not very good at causing menstrual regulation. But again, these are kind of the only options that they have, they still want to have a regular period. All right. So now, some non-contraceptive uses. These are kind of the most common ones that I use. So we just talked about menstrual regulation. Um, I also get a lot for menstrual suppression, acute bleeding, or irregular bleeding, as well as dysmenorrhea, acne, and then endometriosis. So for menstrual suppression, no method is 100% effective, and I always have to remind my patients of this. Um, but we can get pretty, pretty close. We can get like 80%. And so, this table just kind of shows what the rates of amenorrhea are at 12 months, and this is based on manufacturer labeling, but I kind of see some different numbers in my practice, kind of anecdotally. So, at the one year mark, anyone who's using a combined hormonal contraception like the patches, or sorry, the rings or the pills should have about an 80% chance of amenorrhea. I don't find that it's that high. I would say more like 60 to 70%, and it does take a full year. So in the 1st 6 months, it's very, very common to have breakthrough bleeding. I would say almost everybody in the 1st 3 months, but at 12 months, it's supposedly 80%. So the transdermal patch, we do not recommend it for menstrual suppression, and that's because hormones build up in the adipose tissue. And so if you put on the patch, it goes directly into the adipose tissue and the patch itself is already about a 50 mcg estrogen daily is what they're um seeing and so if you start to. Build up in adipose tissue and really slowly over time and those levels get higher than 50 mcg. So we do recommend at least a patch-free interval every 3 months, um, but I usually tell my patients that I would prefer every 1 month, um, unless they're kind of a really, really low risk candidate. Um, the mini pill, Micronor, the one that is just north and drum birth control pill, the rates of amenorrhea are terrible. They, they should not be used for menstrual suppression. Uh, only 10% of patients have amenorrhea with this method, and you'll have some patients that do super well for 6 to 8 months and then all of a sudden they start bleeding, and when they start bleeding, there's almost nothing that you can do. Um, so I would not use that traditional progesterone only pill for menstrual suppression. Now noendro acetate, which is a derivative of noendrone, um, and it's not a birth control. This one's aestin. It's actually the most fantastic rates of amenorrhea. Um, so in the patient population it's 80 to 85% amenorrhea by 3 months, and so it's the fastest acting one overall as well. And I love this method if they don't need birth control because again it's not providing contraception, but it is so well tolerated, so few side effects, very easy to use, and does not interact with any other medical conditions and does not interact with any other form or medicines in general. So this is probably my favorite method of menstrual suppression if we need it. Uh, Depo-Provera injections, again, amenorrhea only 70%. With the, uh, next one on implant, I get terrible rates of amenorrhea, it's only 20%. Patients usually have more than 14 days of bleeding per month with this one. So a lot of times if I have a Nexon, I will add norendro and acetate on top so I can have menstrual suppression. Um, the levo noestal IUDs of the Mirena or the Lileta, those rates are technically only 20%, but if you kind of delve into it. Uh, the bleeding that there is, it's just light spotting every occasionally. Only 20% of patients still have a regular period. Um, and then anything that's lower in Lebonogesterol, so the Kylena or the skyla, their rates of amenorr are only 12%, so pretty, pretty bad. So breakthrough bleeding is very, very common. Somebody who has estradiol, again, the endometrium is still building, so it does need to be shed. Um, if you're taking an estrogen version for menstrual suppression, the only way to kind of get rid of the bleeding is to stop taking the estrogen and let that shed. So these patients do need a hormone break for about 4 days. Um, bleeding is expected in those 4 days to become heavier and more painful because it is a, a regular period. Those who are using progesterone only methods, what they do is they cause atrophy of the endometrium or very thinning of the endometrium, so really they need to increase the dose of the hormone to achieve suppression. Um, so this could be increased the number of pills. If it's a birth control insurance does not like to do that, but if it's HS and then you can usually uh use as many as you want, up to 8 is safe in a day, um, or if it's depot, I would give an early depot injection. It's safe every month. Uh, but somebody who's using progesterone, if they have bleeding, that's kind of unresponsive, I'll do an ultrasound and if the endometrial thickness is less than 4 millimeters, then that actually might be myometrial bleeding. So they need to thicken up the lining just a little bit. So I would either decrease the dose of the progestin or add something that has estrogen to thicken that lining. All right, on to the next one. Acute uterine bleeding. So this is a lot what we see in kind of an emergency setting. There are very, very, very few studies about hormones and stopping bleeding and what is the best method. Um, but I would say that really IV versus oral, if they can tolerate oral, there's no reason to do IV. Um, you can see within 8 hours IV estrogen has about a 72% chance of stopping the bleeding, but this study that did this uses the estrogen in a way that we don't use anymore because we don't find it to be safe. So really, it's within 24 hours now. Um, combined pills, you would do 3 times a day for 7 days, then drop down to daily. Again, by 3 days, usually the bleeding is stopping. With Provera, it's 20 mg 3 times a day, again, 3 days bleeding is stopping, and then with the Aegestin, it's 5 to 20 mg. Per day, so it's 1 to 4 pills at a time for 7 days, and 90% will stop bleeding within 3 days. So those are all really good oral methods. Within 3 days, the bleeding should stop and it gets lighter within 24 hours. Um, again, my preferred method is ASin because if we need, because it's just easier to get insurance to pay for it, and I find that the bleeding stops initially, but then it usually comes back. Um, we can also consider the Lieta, the trimic acid. This can be IV or PO. The bioavailability is the same, so if they're tolerating PO again get a PO. Um, this decreases blood loss by 50% within 8 hours, and usually by day 3 again, people have stopped bleeding. These are kind of my go to's for acute bleeding. Um, and then for dysmenorrhea, um, this one kind of, it's whatever the patients want. So if they still want to have regular periods, that's fine, and they want menstrual suppression, that's fine too. It's really whatever they want. I will talk about NSAIDs as first line, um, because again, this might work for some patients. And so, um, what NSAIDs do, I prefer Aleve to ibuprofen because Aleve is kind of a twice a day dosing. Uh, but everybody seems to have ibuprofen around as well. And what it does is these are non-steroidal anti-inflammatories, and they actually decrease prostaglandin that is being released from the uterus, and that is how it how it decreases pain. So it does need to be taken scheduled. Starting a day or two before the period starts, because that will lower the amount of prostaglandins. The lower the prostaglandins decreases the contractility of the uterus. It also decreases the effects on the rectum as well for some people who have kind of bowel complaints during periods. Um, with not as much contractions, you actually don't have as much bleeding, and so blood loss can be improved by a small amount as well. That only, the improvement in amount of blood loss is only seen by about 40% of patients though, so it's, I don't usually say that everybody can can notice this, but usually people will notice a really improvement of their dysmenorrhea. Um, and again. You all know this, but I have to remind my patients that if we're using ibuprofen, it is weight-based, and so somebody who is 60 kg and is only using 200 mg probably is not gonna see that big of an effect. Uh, so, so remind them that it's weight-based. My alpanprin, they're not, they do not treat periods. Like they have Tylenol, which does not helped very much. They have aspirin, which is hard on the stomach and is not as good of an NSAID as Aleve is, and it also just has caffeine. So I like, if I could do one thing with my career, I would like need to get my dog hampering off the shelves because they're just like, should not be targeted for periods. But anyway, that's again, neither here nor there. Um, So, birth control, OCPs patches, rates. So 90% of users will see improvement in their periods by 3 months, but I tell them that first month you're not gonna notice a difference. Give it 3 months because that's how long it takes. Uh, periods are very, very Predictable. And so because they could be like, Wednesday afternoon, I'm gonna start my period, they could start taking their NSAIDs Tuesday, oops, sorry. They could start taking them Tuesday in preparation for Wednesday. Um All right. And then as far as depression goes, again, whatever they're wanting to do, they can do the continuous OCPs, the progesterone only pills, Nexlo plus the progesterone only always or the IUD. So really whatever their goal is, is fine with me. All right, so for acne, um, the goal Of the treatment is to minimize acne by reducing androgen actions. So the estrogen component of birth control pills is what inhibits the ovarian androgen production, but also increases sex hormone binding globulin. What that does is it results in reduction of the serum free androgen levels, which is kind of like blinds the effect of the skin to these androgens. Um, it also has an inhibitory effect of androgens in the sebaceous glands as well, and so that's how estrogen itself is helping with acne. Um, any OCP will have this side effect, but Yasmin and Y, they have drospirinone, which is the the least androgenic progestin as well. Um, that one is also what's in Slind, and I don't know why this is doing that. That one's in Slind as well, uh, but the progestin itself is not gonna be as good as the estrogen at helping with acne. Um, OK. So this one. It's usually the only indication that I use estrogen for aside from patient preference and still having periods, um, especially if they don't need birth control. Uh, so again, it's really whatever the patient wants, but I always tell them that acne is a pretty nice side effect. Helping with acne is a nice side effect. And now with endometriosis, we get a lot of consults regarding possible endometriosis in girls who have dysmenorrhea. And in those, so, my screening for those who I think are at high risk for endometriosis are those who have a family history. So, somebody who has a family history is about 7 times more likely to have endometriosis than somebody who does not have a family history of it. And it's usually within mom or grandma or a sister, so, uh, cousin, aunts, they're kind of farther removed, but still, it would be um something that I think about. These patients also typically start out with periods that are manageable, and the periods themselves get less and less manageable. A lot of the times they're missing school or vomiting, kind of like what I said in our little, we had a little study, uh, that we've now opened up to kind of nationally to just kind of look at what the red flags are for endometriosis, and we did see that vomiting and we see in school were about 80% predictive of endometriosis. Um. So those are the three big ones. So family history, vomiting and missing school, um, the periods get worse and worse, and then they start to have pain outside of their periods as well. So acyclic pain that's worsened with periods. A lot of times it'll have uh pain with penetration or with use of tampons as well. Um, NSAIDs might not be that helpful for these patients. I can't, I don't know why my slides are just going important. That's. NSAIDs might not be that helpful, uh, but medical management with hormones is successful in 90% of patients with endometriosis as a first line. So for these, we might be able to avoid surgery or avoid more aggressive medications. Um, first line would be menstrual suppression, and so that would be with again, whatever they want, continuous OCPs, Depo-Provera, Aegestin, or an IUD. And any of the above actually a next put on too, as long as there is progesterone only pills. So the IUD will stop periods, but it's not gonna treat endometriosis. Nexon will treat endometriosis, but it's not gonna stop periods. So that's just the the way that we're thinking. Um, if the symptoms fail to improve within about 6 months, that's when I'll usually move to surgery because right now that's the only way that we have to diagnose endometriosis is with pathology and biopsy, um. We are doing a study right now that I might start soliciting you guys for patients, we'll see, uh, but it's, can we predict endometriosis based on uterine contractility. It's shown to be hopeful in the adult population, so now we're opening this study to the adolescent as well. But right now, surgery is the only way to diagnose it, and then with surgery, we can be more aggressive with medical management. Right now, the first line is loprom, that's the gold standard. Um, this is a GNRH agonist, antagonist, sorry. Uh, so this will lower, uh, decrease ovulation at the level of the brain. This is a shot that's every 3 months and it has some pretty good side effects. So I do hesitate to use this if I don't have to. Orlia is a GNRH agonist, and so this is the newer version, this is the pill version. It has fewer side effects, but it's only been studied in some of the 18. Or older and so I don't use it in somebody younger because they're no longer giving us samples of it. So really we have to start at age 18. Uh, they have a really good program too for prior off and coverage of it, and so I have been pretty successful at uh at having our lists available. Um, narcotics are never used ever to treat endometriosis pain. It's just a slippery slope. We don't wanna start with that and it also just does not help that much. But another adjuvant that is really successful is pelvic floor physical therapy, um. That can be, you know, a lot of people hesitate to start out with that, but really the physical therapists are so, so good at meeting the patient where they are and what they're comfortable with. So they might, might just start out with some pelvic floor muscle relaxation, hip relaxation, some strengthening techniques. They don't have to do intravaginal uh therapy unless the patient feels comfortable with that. OK, so some other considerations. Um, somebody who is at high risk for an STI, so somebody who has a history of sex trafficking, homelessness, recurrent STIs, I would be cautious using an IUD, um. There isn't proof that the IUD will increase the likelihood of an ascending infection, but if you put one in while they have an active infection, then there is a really good risk of PID with that, maybe even a tubal ovarian abscess. So if somebody Could possibly have cervixitis at the time of insertion, and I don't think they're going to be able to follow up and complete their medication. I might hesitate to use an IUD and I might use like a nexton instead for this patient. Um. Obesity. So this is a hotly debated topic. Um, of all of the contraceptives, the patch is the only one that has been shown to have decreased efficacy in somebody who has obesity. And again, this is because adipose tissue kind of sucks up all these hormones and so not as much is noted. Uh, the failure rate is about is increased to about 4 times higher than somebody who is not 130% of their ideal body weight. So this usually is about a BMI of 30 to 35. Um However, emergency contraception is also less effective at a BMI of 30 or above. Um, this increases the risk of pregnancy by 4 times. So again, if the, if this patient is like the patch is literally the only method that I'm going to use, I will still use it for them, because emergency contraception is not as effective and I still pregnancy is also still highly risky in somebody who has obesity. Um, I would also probably hesitate for somebody who's obese to use the Depo-Provera. Uh, because 50% of users will have weight gain, and it's about 10 pounds per year. So again, I don't want to do any harm, but again, if this is the only method that the patient is going to use, and we talk about it, we measure their weight at every single injection because they will start to gain weight within the 1st 6 months, then I'm like, well, if that's what you wanna use, I guess this is what you can use. Um, somebody who has seizures. So they have a contraindication, but not like it's a relative contraindication for the use of estrogen. What estrogen does is it lowers the threshold for a seizure and so it makes the seizure more likely. So if there's a progesterone version that I can use, I would rather use that because again, I don't want to do any harm. Uh, in the studies of the progesterone-only methods, only the Depo-Provera and Ajuin Northender acetate have been studied for somebody with seizures, and what they found is that Depo will actually raise the threshold for seizures. Um, and so it makes seizures overall less likely. Again, I'm not that sure how it works, but as somebody who has poorly controlled seizures, I sometimes will just use Depo to see if we can help. Uh, the AS and the north in acetate, it improves seizures because with periods there tends to be an increase in seizure activity, and so it decreases that increase if that makes sense. Um, but I think that any of the progesterone methods should also be quite effective at or could be safe. Um, and then the last one is the increased risk of, uh, thromboembolus. Estrogen is always contraindicated in those patients. Um, so anybody who has thrombophilia, a family history of DVT or PE during pregnancy, or family. OCP use, I'd probably use caution and probably use the progesterone only method. Somebody who has migraine with aura is also contraindicated because of a BTE risk. Um, I would also, so the CDC map will also say the high doses of progestins, there's caution with initiation of those in somebody who has a high risk for a BTE, um, but continuation is usually pretty fine. So other considerations in breast cancer in breast cancer is controversial. Uh, the best study showed that in somebody who Has no other risk for breast cancer if they use something that has estrogen and progesterone, their risk can be increased by 1 in a million. And so very, very slim chances of breast cancer and actually in somebody who has BRCA or a family history of BRCA, ACCC actually recommends that we use birth control pills to. Decrease ovulation. So something that has estrogen in it is a little bit stronger at decreasing the ovul ovulatory events. And so we say that by like menarchy within 2 years of starting menarchy, we would recommend starting birth control for them because it lowers the risk of ovarian cancer. Right now we have fabulous screening, very sensitive screening. For breast cancer with the mammograms, we have 0 screening for ovarian cancer. Somebody who has BRCA is at significantly increased risk for ovarian cancer, and so using birth control pills to prevent ovarian cancer is what we recommend. So I feel very comfortable using birth control pills in somebody with a family history of BRCA or with a family history of breast cancer. Um, So triphasics, this would be like your ortho tricycline and those sorts of things. I don't actually like them kind of at all. So the, the thought by the old drug companies were that it was going to mimic the natural cycle of the body, and this is not what happens. There's really no proven benefit of doing it that way because it's still exogenous hormones. It doesn't like matter. You don't feel any different. And there's a lot more breakthrough bleeding. So you're going from like low dose to high dose to medium dose to none, and a lot of the adolescents will have breakthrough bleeding when you go from that high to the medium dose. Um, if they forget a pill, it's like over, you know, they're going to have all kinds of breakthrough bleeding. Um, so I don't, I don't tend to use, you also can't use this one continuously because it's just like. The breakthrough bleeding is just all over the place. Um, so I've kind of stopped using that and then if somebody comes to me and they said their periods are still kind of out of whack then and they're on a triphasic that'll always just switch them to a monophasic. Um, And then a lot of questions about age. Again, all contraceptives are safe after the patient has their first period. There are some nuances, there's some some thought about estrogen will decrease your overall height potential, and the studies that decrease in height is only a quarter of an inch, if any, um, so I do find that it's pretty safe in anybody. OK. So last, I just wanna say, yay, we now have an over the counter birth control. This is so exciting. This is the pill. It was FDA approved last summer. Yay! Um, and as of April 1st. It is available. So the O pill, it's Norgestol. So this is the progestin that is in your birth control pills like Crisel, Eins, those sorts of birth controls. Um so it's been around since the 70s. It was approved in the 70s as a progesterone only birth control, but because there were other things going on, they didn't pur pursue final approval and production because they already had the mini pill. They didn't think they needed another progesterone pill. Um, but this is a second generation progestin. As opposed to the mini pill, it's a first generation. So this one metabolizes into levonergestral and so the thought is it should be more stabilizing to the endometrium cause that's what's in the IUD and we see that it's pretty good at stopping periods, um. But we'll see. Not a whole lot of people have used it yet. Um, it is like the mini pill, it was like Noendrone, so it only has active pills. There are no placebo pills at all, but the bleeding profile for this one is still like TBD. We're not that sure what the bleeding is gonna look like. Um, again, the only contraindication for this one is somebody who themselves has active breast cancer, so there's no really no contraindication. It's very safe, no age restrictions. It was studied in the adolescent, unlike almost every single other birth control. So I just said it was only age 15, but I think it, it would be absolutely safe in somebody younger than 15. And again, it was available starting in in April. Um, I had some concerns about it, and so these are kind of Me talking to myself about my concerns. So, insurance coverage. Only 8 states have mandated over the counter coverage for birth control, but what the company did was they actually made it pretty affordable. So the out of pocket cost is only 1999 per month or 49 dollars.99 for three months. So this is kind of on par with some of the other birth control, the progesterone only birth controls like slim. So this Same cost is slimmed right now, and right now you have to get slimmed through a specialty pharmacy. The Opill is going to be more available, so while pharmacies can choose to stock it or not, not all pharmacies have to have it. I don't know which ones in the area will cover it, but it is available on Amazon. So you can buy O pill on Amazon currently if you wanted to. There are other online retail pharmacies too that will cover it. Um, the other limitation to this one though is that historically somebody using a progesterone only pill is, is not very satisfied with it because of the terrible bleeding profile. Like I said, only 20% have amenorrhea. Um, so we'll see if people like it, but it is such a safe and good option. There's also this stigma against progesterone only pills, so people fear that they are inferior to an estrogen containing pill, but that's also not true. The efficacy is the same. So it's still with typical use 9 per 100 will become pregnant with birth control pills that have estrogen versus those who don't. Um, so I think this is a fabulous option. I'm so excited, and I think that we should all feel very comfortable that this is a safe thing that our patients can get and they can just get it off of Amazon or like go into the pharmacy and buy it themselves. So again, no age restriction, you can just go in and buy it if the pharmacy is covering it. You don't have to have a parent with you. All right. So I'm just going to wrap up really fast. This is just to Talk about what we did, uh, think about the menstrual cycle as a vital sign, and the adolescent. 21 to 90 days really is pretty normal as long as 90 days is not the average, um, but every 21 to 45 days, I would think that that's pretty appropriate. Um, like my kind of cut off for flow would be no more than 8 pads per day if they're a regular pad, and then of course, like overnight pads would be maybe about 5. let's see, uh. Too much or too frequent bleeding can indicate a bleeding disorder. So again, just like thinking about how long the periods are and how frequent they are. And then contraception, it is safe after menarchy, so anybody who has a period can safely start a birth control in the adolescent. No method is better than the other. Consider if their main goal is to prevent a pregnancy. Consider the LARCs, consider the IUD or the or the next one on, um. And remember that there's no age cutoff, so just use the LARCs whenever you want. Uh, keep in mind that anybody who has a BMI of greater than 30 will have decreased efficacy of the emergency contraception. So again, like still keep, you know, birth control in mind for these patients as well. Um, usually if it's just their, if their obesity is their only red flag for use, and that's usually 2 before it's uh considered dangerous. Um, All right. So, when in doubt, use the CDC Mac, the app, the, the website, whatever you want, and that'll just kind of help ease your mind about the safety of these medications, so. Um, do you have any questions? There's our book, which is a great protocol book for adolescent gynecology, kind of whatever you want. And then again, here's our little team. Our nurse is on maternity leave. She may not come back, but we'll see. Um, but we, we have offices. Kind of all over. We have South County, Moab, once a month we go to West County, of course, the Central West and then Shiloh, um, and then telehealth too, that's what the patients want. So, anyway. That is my presentation for today. Does anyone have any questions? So, oh, I love this. This is in response to Elizabeth Harrison. 3 questions, I love that. So, do you have many patients who use the patch? No. I have more patients who use the patch than who use the ring, um, but I don't have that many. Um, it is a good option though, you know, it's It's something that they don't have to take every single day. I always tell them about it, but I don't know why. I think they're so afraid that it won't stick, and I would say the fay patch does not stick. It's just so terrible, and that's the generic one. Zoo Lane does stick pretty well, although I, I kind of like have mixed feelings about that one. The twirla patch also really sticks quite well. It's a different formulation. It's a lower estrogen one and so insurances, of course, aren't covering it yet. Um, but hopefully in the next year or so there'll be a generic tourla. So yeah, I have like a handful who use the patch, but I would say like not very many. Um, do I discourage Depot? I don't discourage Depot, but when I am talking about all the options, I say, like, very frankly that I have a love-hate relationship with Depot. It's great because it's every 3 months, your periods will usually become less frequent, but the kind of part of it is the weight gain. It's the only method that makes them gain weight. And I also talked about bone health after 3 or 4 years of use. Um, so I don't like discourage it, but I just say like, this is something that I fear might happen to you. So if you're OK with that, that's fine. But like, again, pregnancy is so much more risky than the depot that I let the patient do whatever they feel the most comfortable with. Um, And then I cut out a bit. So a family history of a DVT during pregnancy or while taking an OCP is not a contraindication. To me that's a red flag though, so I would, if they are willing to use a progesterone only method, I would prefer to use that method, um, but they can still use estrogen as well. It's not contraindicated. Um, factor 5 lien is not a contraindication if it's, if they're heterozygous, it's not a contraindication to estrogen. Um, Um, well, this is good to know. So Walmart in Colombia has over the counter birth control, yay! It's knowing that it's in a locked case at the pharmacy, but that's fine, you know, like do whatever they need to do. It's available at Walmart. I actually really like Walmart for prescribing medications. It's it's quickly becoming my favorite pharmacy, so yay for Walmart. Uh, incidence of endometriosis in the adolescent. So I don't actually know the true incidence because it's underdiagnosed, but what we're finding is that 75% of adolescents who continue to have painful periods despite hormonal birth control will end up having endometriosis. So it's a pretty high number of them, um, but it's still like Just the diagnosis of it is so tricky right now because you have to have a surgeon trained to operate on a smaller body. And again, like there's only 4 of us in the state of Missouri, 2 in Kansas City and 2 here in St. Louis, who will operate on somebody who's like less than 40 kg. Um, and that's not everybody who has endometriosis, but again, like if they're younger than 16, a lot of adult gynecologists also won't see them and so it's hard to capture the true incidence because Of the barriers for diagnosis, and that's why I'm super excited about this research study, because if we can have like a more equitable non-invasive method of diagnosing endometriosis, I think we will better understand the incidence. Um, OK. Any other questions? Wait, there are more. I see them now. Um, more moms advocate for birth control for dysmenorrhea. How comfortable from Min's onset would you start? Oh, I would start right away if they have dysmenorrhea. I don't like. I find birth control to be so safe in most patients that I don't have a whole lot of problems starting it right away, um. If, if it's for painful periods, like you could always start with the NSAIDs just to see, but I wouldn't, I would probably not make them wait more than 3 months if they wanted to start NSAIDs. Um, most patients, though, from the get-go, they're having anovulatory cycles, and so an ovulation often is less painful. Ovulatory cycles are usually when it becomes more painful, and so you could give it a year, but I would, I would start it right away if that's what they wanted. Um, should we discontinue Depo? I try to. There is no good way of screening for bone health in somebody who is using Depo-Provera. And so what we have seen in the adult population is that 3 years of use significantly lowers bone mineral density, and that does resolve after discontinuation. DEXA is not as sensitive for these nuanced decreases in density. So we can screen with DEXA, but I'm like, I don't know if that's actually helpful or if this means anything. Um, so I try to, I really try to change them after probably the 3 year mark. I try to get them to do something different, but again, if that's all that they want to do. And they know the risks of it, then I'll probably offer a screening dexXA every year just for fun, but I, I do try to. Not, especially somebody who's accruing their bone mass, you know, like the, the peak accrual for bone density is by age 19, and so if somebody's using it in their teen years, I would really probably try to use it for 2 years actually, uh, but whatever they want, as long as they understand the risks and they have like Good, like they show that they understand these risks. Um, With progesterone only pills, do they still have endogenous estrogen production? Yes, so with all of these methods except for like the treatments for endometriosis, the lupron and oralli said, they still have endogenous estrogen production, so we never wipe that out completely. Um, with the estrogen pills, ovulation is decreased a little higher frequency, and so those really high levels of estrogen are probably decreased more with progesterone only pills, only 40% of ovulatory events are are eliminated and so they're still like. and making the estrogen that they normally would have. Depo is a little bit stronger at suppressing the ovaries, but still, like, the ovaries are always making estrogen. It just might not get up to like 200, it might just stay around like 30 to 50 nanograms per deciliter. My preference for bleeding with somebody who has an expo, I'd say a Justin. My preference for suppressing bleeding for anybody is Ajuin. Um, and it's very, very successful. So I did like a little teeny tiny clinical study and Nexplanon plus Ain had 95% of the amenorrhea. So I would absolutely use ASin, Northiner acetate. This is again, Walmart will cover this one if your other pharmacies won't. I don't know why. Created by Presenters Maggie Dwiggins, MD, MS Pediatric & Adolescent Gynecology, LGBTQIA+ Health Obstetrics & Gynecology, Washington University Transgender Center View full profile
