Chapters Transcript Updates in Outpatient Asthma Management & Implementation Of SMART Therapy in the ED Maria Liverpool, MD and Jessica Pittman, MD, MPH, review the current guidelines for asthma diagnosis and management, including SMART therapy. If it's my internet or what? Ok. Am I cutting out for everybody? I can hear you fine. I can hear you fine as well. Ok, great. Ok, that's good. Ok. It just must be on my end. We'll go ahead and get started. Um Should I just get started since we're now on time? Angie? Can you help me out if your internet is working? Well, I think I must be having bad internet. Mine's working just fine. I can hear her. Ok. Can you let her know to get started? Go ahead and get started. Doctor Dins. 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 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 per prescribing birth control for non birth control reasons, I think a lot about periods and what might be normal. So this is really just to review for you. But in 2015, the adolescent Committee of ACOG did practice this uh 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 mean age of onset of monarchy 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 nine or 10 can still be considered normal. And and in this regard, if we feel like breast development is normal two years before monarchy, then we've started also to tolerate breast development around age seven or eight. 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 seven or eight and periods can be normal starting around nine or 10. So within the first three years after monarchy, 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 one to cycle day one 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 45 days apart, it 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 two months here and there, I still don't get terribly terribly worried unless it's their normal. Um, that would require kind of a, a further work up. 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 three days, but anything lasting longer than seven days, I usually do a work up 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 as the general pads and tampons is like the general flow indicator. Um, up to eight regular pads or tampons actually can be pretty normal. Um As long as they can use it for at least two 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 vomited 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 three years of the Archy has not started by age 14 with signs of hers that I might be concerned about PC OS 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 seven 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 meeting 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. No. 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 that'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 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 It as far as estrogen goes, there are more contraindications, but that's when I use the CDC MEC. So the CDC MEC 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 and what you can see there on the far left, that's the conditions. And so it starts with age, then an atomic 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 subd condition. 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 will 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 considered it the next one on the arm. And then the um Leonore 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 two is maybe use some caution or think about it before prescribing it or make sure to like monitor these this thing. Or the next level three is really make sure the benefits are outweighing the risks of of the medication. And then level four 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 three for estrogen containing birth controls. And again, almost nothing is a category three or four 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 in a CG and the American Academy of Pediatrics, they do recommend that the lark 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, they're like, I want birth control, I want 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 and not have to be older. Um I do place Iu DS in some very young patients sometimes. Um So if you remember the contraceptive Choice project done here at wash U um at three years, they so they, they gave everybody free birth control is what they did. Uh And then they measured their continuation rates at 1234 and five years. And then they asked about why they changed methods or what their thoughts were. And so at the three year mark, any IUD users, so anyone who used the prog IUD, even the copper IUD continuation rates were 70%. So people were very, very happy with this method at the three year mark, the implant in the arm that continuation rate was second at 56%. Depot came in third at 33%. So while the continuation rates have gotten worse, um you could see any of those long acting methods were more patients were more likely to continue those methods. Um At three 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 a long acting methods and any IUD implant or shot, the adolescent was using 52% at three years. And in those who were not using a lark, 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. Let's 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. Um All right. So now I'm gonna just kind of move into uh one 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 five 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 hor combined hormonal contraceptive option like estrogen plus progesterone. That's the pills, patches in 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 two or three 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 four placebo pills and they're supposed to have a withdrawal period. However, what progesterone does is it causes endometrial atriss. So, actually not having the pill for four 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, sl 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 first six months, it's very, very common to have breakthrough bleeding. I would say almost everybody in the first three 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 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 three months. Um But I usually tell my patients that I would prefer every one 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 dr 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, nor acetate, which is a derivative of nor. Um and it's not a birth control. This one's sin is actually the most fantastic rates of amenorrhea. Um So in the patient population, it's 80 to 85% amenorrhea by three 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 condi conditions and does not interact with any other form or medicines in general. Um 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. Again, 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 next on, I will add nor acetate on top. So I can have menstrual suppression. Um The Libo nor IUD of the Mirena or the lile, those rates are technically only 20%. But if you kind of delve into it, uh the bleeding that there is is just light spotting every occasionally, only 20% of patients still have a regular period. Um and then anything that's lower in Levan Noge. So the Kyle or the Skyla, their rates of amen 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 four days. Um, bleeding is expected in those four 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 a s and then you can usually uh use as many as you want up to eight 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 four millimeters and that actually might be myometrium 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 in 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 eight 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 three times a day for seven days and then drop down to daily again by three days. Usually the bleeding is stopping with Provera, it's 20 mg three times a day. Again, three days, bleeding is stopping and then with the estin, it's 5 to 20 mg per day. So it's 1 to 4 pills at a time for seven days and 90% will stop bleeding within three days. So those are all really good oral methods. Within three days, the bleeding should stop and it gets lighter within 24 hours. Um Again, my preferred method is resin 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 Lysteda the tran acid. This can be IV or PO the bioavailability is the same. So if they're tolerating, po again, give it po um this decreases blood loss by 50% within eight hours. And usually by day three, again, people have stopped bleeding. These are kind of my go tos for acute bleeding. Um and then for dysmenorrhea, uh 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 prostate glands decreases the contractility of the uterus. It also decreases the effects on the rectum as well. For some people who have kind of bowel complaint, strain 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 damper. They're not, they do not treat periods like they have Tylenol which is 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 me to get my dog hamer 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 three months. But I tell them that first month you're not gonna notice a difference, give it three 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 the depression goes again, whatever they're wanting to do, they can do the continuous OCPs, the progesterone only pills, next plan, 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 action. 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 Yaz they have drain on which is the the least androgenic progestin as well. Um That one is also what's in SL and I don't know why this is doing that, that one's in SL 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 is 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 seven 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 sister. So, uh cousin, aunts, they 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 vomited a missing school. Um, the periods get worse and worse and then they start to have pain outside of their periods as well. So, a cyclic pain that's worsened with periods. A lot of times it'll have a 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 forward. That's why in its 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, Depol preve sin or an IUD and any of the, the above actually a next put on too as long as there is progesterone only pill. 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 six 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 sh 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 Lupron, that's the gold standard. Um This is a gene GNRH agonist antagonist, sorry. Uh So this will lower uh decreased ovulation at the level of the brain. This is a shot that's every three months and it has some pretty good side effects. So I do hesitate to use this if I don't have to or Alyssa 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 even somebody 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 or Alyssa 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 intervaginal uh therapy unless the patient feels comfortable with that. Ok. So some other considerations, um somebody who is at high risk for an ST I, so somebody who has a history of sex trafficking, homelessness, recurrent ST I si would be cautious using an IUD. Um There isn't proof that the IUD will increase the likelihood of an asinine infection. But if you put one in while they have an active infection, then there is a really good risk of P ID with that and maybe even a tubo ovarian abscess. So somebody could possibly have cervicitis 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 increasing to about four times higher than somebody who is not 100 and 30% of their ideal body weight. So this usually is about a BM I of 30 to 35. Um However, emergency contraception is also less effective at A BM I of 30 or above. Um this increases the risk of pregnancy by four 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 and 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 first six 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. But 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 Estin Noro acetate have been studied for somebody with seizures. And what they found is that depot will actually raise the threshold for seizures. Um And so 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 depot to see if we can help uh the s in the north end 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 thromboemboli estrogen is always contraindicated in those patients. Um So anybody who has thrombophilia, a family history of DVTs or PE during pregnancy or family OCP use, I would probably use caution and probably use a progesterone only method. Somebody who has migraine with aura is also contraindicated because of BTU risk. Um I would also, so the CDC MAC will also say the high doses of progestins. There's caution with initiation of those in somebody who has a high risk for A BT E um but continuation is usually pretty fine. So other considerations in breast cancer in breast cancer is controversial. Uh The best studies show 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 one 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, A actually recommends that we use birth control pills to decreased ovulation. So something that has estrogen in it is a little bit stronger at decreasing the ovulate ovulatory events. And so we say that by like monarchy, within two years of starting monarchy, we would recommend starting birth control for them because it lowers the risk of ovarian cancer. Right now, we have fabulous screening, very sensitive screen for breast cancer with the mammograms, we have zero screening for ovarian cancer. Somebody who has bracket is at significantly increased risk for ovarian cancer. And so using birth control pills to prevent o 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 that. 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 say their periods are still kind of out of whack then and they're on a triphasic, I'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 are 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 O pill. It was FDA approved last summer. Yay. Um And as of April 1st, it is available. So the Opill it's no gr so this is the progestin that is in your birth control pills like Christel L MS, those sorts of birth controls. Um So it's been around since the seventies and it was approved in the seventies 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 pills, the first generation. So this one metabolizes into Leon. Leon nor and so the thought is it should be more stabilizing to the endometrium because 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 is like nor 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 when 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 eight 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 4999 for three months. So this is kind of on par with some of the other birth control. The progesterone only birth control is like sl so it's this same cost as slimmed right now and right now you have to get slim 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 Opill 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, nine 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 gonna wrap up really fast. This is just to talk about what we did. Uh think about the menstrual cycle as 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 eight pads per day if they're a regular pad and then of course, like overnight pads would be maybe about five. 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 monarchy. 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 larks, consider the IUD or the or the next put on. Um And remember that there's no age cut off. So just use the Larks whenever you want. Uh keep in mind that anybody who has a BM I 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 two before it's uh considered dangerous. Um All right. So when in doubt, use the CDC Mec, 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 B 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 mo a once a month. We go to West County, of course, the central west end and Shiloh um and the telehealth too if that's what the patients want. So anyway, that is my presentation for today. Does anyone have any questions? Thank you so much. Yes, there are quite a few questions in the chat. You can see that. So you'll scroll to the top or put your mouse where the share button was and it should be near stop shared because I can't find it. I'll put up the QR code for everyone to scan as well. Y and sh there we go. OK. Chat. I can't. OK. How do I do this chat? Um OK. Did my screen sharing? Mess it up for you? OK. Yes. Yes. OK. So, oh I love this. This is in response to Elizabeth Harrison three 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 used 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 Zamy patch does not stick. It's just so terrible and that's the generic one. Zoo Lane does stick pretty well or I kind of like have mixed feelings about that one. The Tola 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 will be a generic Tola. So, yeah, I have like a handful who use the patch, but I'd 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 three 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 talk about bone health after three or four 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 AD VT 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 Five Liden is not a contraindication. If it's, if they're heterozygous, it is not a contraindication to estrogen. Um Oh, well, this is good to know. So Walmart in Colombia has over the counter birth control. Yay, it's annoying 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 four of us in the state of Missouri, two in Kansas City and two here in Saint 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 there, 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 noninvasive 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 just menorrhea. How comfortable from mc'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 three months if they wanted to start nsaids. Um Most patients though, from the get go, they're having an ovulatory 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 Depot? I try to, there is no good way of screening for bone health and somebody who um, is using Depo Provera. And so what we have seen in the adult population is that three 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 three 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 Dexa 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 bones and city is by age 19. And so if somebody's using it in their teen years, I would really probably try to use it for two years actually. Uh but whatever they want, as long as they understand their 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 or Alyssa, they still have endogenous estrogen production. So we never wiped 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 de are eliminated. And so they're still like obvious and making the estrogen that they normally would have depot 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 next one is Egin. My preference for suppressing bleeding for anybody is Egin. Um And it's very, very successful. So I did like a little teeny tiny clinical study and Nan on Plus Egin had 95% of the amenorrhea. So I would absolutely use Sin Norther and acetate. This is again, Walmart will cover this one if your other pharmacies won't, I don't know why. Ok. Anything else? I think that might be all the questions for today. Thank you so much. What great participation we had from everyone and a fantastic talk this morning. And um we thank you so much for taking your time to be here. Thank you. And like I said, this is a great topic. I love talking about it. I guess. Think about a Justin. It's my favorite pill, my favorite medicine. Um And let me know if you have any other questions. All right. Well, everyone have a great weekend and we'll, we'll see you next week for early bird. Rounds. Yeah. Ok. Created by Presenters Maria Liverpool, MD Emergency Medicine View full profile Jessica Pittman, MD, MPH Pediatric Lung Health View full profile
