In this lecture, we will discuss contraception, a critical part of adolescent medicine. Why is this so critical in adolescent medicine? It’s because 46% of US high school students report having had sex. There are more than 700,000 US teen pregnancies each year. This rate of teen pregnancy has come down but that’s because of increased use of contraceptives in these kids. There are two main types of contraception. We have hormonal methods and barrier methods. Among hormonal methods, oral contraceptive pills are the most commonly used in the United States. These generally either are alone or combined estrogen and progesterone. Hormonal methods can exist which contain progesterone alone and this may have a different or improved side effect profile. Likewise, there are barrier methods and condoms are the most frequently used. So, let’s go through the methods of standard adolescent birth control in terms of what these methods are and how we use them. So, oral contraceptive pills are generally estrogen or estrogen and progesterone combined. Usually, this is a daily pill. There’s also the opportunity for providing a transdermal patch. Again, estrogen and progesterone and this time, it’s an adhesive patch that’s left on the skin. We also can provide adolescents with vaginal rings. These may have estrogen and progesterone. It’s a flexible ring that’s inserted and left in the vagina. Also, we can recommend condom use which obviously does not involve hormones but it has to be used every time you have sex. There are also long acting varieties of birth control where patients do not have to intervene on a regular basis like a daily pill or remembering to change their vaginal ring. This cheap one is the intrauterine device. This is inserted by a healthcare professional into the uterus. We can leave it there as long as five years or we can do an etonogestrel implant. This is an implant usually in the upper arm on the inside, so it’s subtle, by a health professional. This slowly secretes hormones and can be left in the arm for up to three years. Likewise, we can inject progesterone, we call these Depo-shots, into the arm every three months as an effective method of birth control. When we go to an adolescent and we discuss birth control, it’s important to have them help make the decision as to what type of birth control is best for them. Minors can consent to healthcare related to sexual health and birth control. They do not need parental approval. There are certain consideration of factors here. One, privacy. Second, will they adhere to this regimen? If it’s someone who’s irresponsible, is the daily pill really the best option? Will they be able to tolerate the side effects? What side effects seem intolerable or tolerable to them? Also, are there any contraindications? Do they have a clotting disorder, so they really shouldn’t be on estrogens? Are there any noncontraceptive benefits to these medications? For example, a patient with severe acne may prefer the birth control because of its benefits regarding acne. We have to determine the patient’s understanding of what they want and their decision. Because of all these things, long-acting, reversible contraceptive is becoming increasingly popular in the United States. The IUD is rapidly becoming our first choice for effective contraception in teenage girls. Let’s talk about disadvantages and advantages of all these methods. Let’s start with condoms. Condoms, advantages: Well, you only need to use it when it’s needed. It has minimal side effects. It prevents many STDs which some of the other methods do not. On the other hand, it does interfere with spontaneity. The adolescent needs to remember. As you can imagine, an adolescent often forgets. It may break or tear rendering it less effective. And in patients with latex allergies, it can be hard to find a non-latex condom. Let’s talk about oral contraceptive pills, advantages and disadvantages. The advantages of an OCP is that it can make menses shorter, lighter, and much more predictable. This is a great opportunity for someone with say, dysfunctional uterine bleeding. It does decrease acne which is viewed as a benefit among many of our female patients. It can sometimes suppress ovarian cysts which may cause pain in adolescents. So, it may help with a painful period. On the downside, it does not prevent sexually transmitted diseases. Daily adherence is difficult for some teenagers. The estrogen can cause some side effects such as nausea, breast tenderness, headache, and the risk of thrombosis. What are the advantages and disadvantages of the transdermal patch? This is a patch that’s placed on the skin. Well, the advantages, again, it makes these menses shorter, lighter, and more predictable. It will decrease acne. It will suppress ovarian cysts. What’s great about this is it’s only once a week as opposed to everyday. On the downside, there’s no STD prevention. It does lack some privacy in that in the locker room or whatever, other kids can see that you have a patch on. It can cause skin irritation at the site of the patch application. The patients have all those estrogen related side effects that we discussed in oral contraceptive pills. What about the vaginal ring? This is inserted by the girl up into her vagina. So, there are some advantage to this. Again, shorter or lighter predictable menses, decreased acne, ovarian cyst suppression. This is very private. No one can tell it’s in there. You only have to do it once a month. On the downside, again, no STD prevention. It may require a patient to be comfortable with actually a self insertion of this device. So, the girl has to be pretty comfortable with herself and her body. It sometimes causes vaginal discharge or yeast infections or other problems in the vagina. Again, we still have those estrogen related side effects like nausea. What about the Depo-shot? This is an intramuscular injection of progesterone every three months. It can cause amenorrhea. It’s very private but this infrequent dosing is sometimes annoying. Every three months, the patient has to remember to go back to the office to get another shot. Also, it can cause spotting of the menses which sometimes girls find annoying when they can’t predict when they’re going to spot. On the downside, again, there’s no STD prevention. They may suffer some weight gain. They may have irregular periods for a few months before they develop their amenorrhea. You can have decreased bone mineral density which is bad for them long term. So, we have to be thinking about optimizing calcium intake. What about the IUD? The IUD is rapidly becoming a very positive option in adolescent girls in the United States. The huge advantage here is there is no maintenance. You go to the doctor. They put it in. You’re done for five years. It does last up to five years. You can remove it when childbearing is wanted. So, if a girl at the age of 17 doesn’t want to have a child but at the age of 22 does, she simply has it taken out. This is the most effective form of birth control. However, just like in the oral contraceptive pills, this does not prevent STDs. There is a rare risk of intrauterine infection. Patients may develop cramping or bleeding with the presence of that IUD. So, what are the advantages and disadvantages of the etonogestrel implant, NEXPLANON for example? It goes right up in that arm. There’s no maintenance. Once it’s in, it’s good. It’s got a reasonably low risk. It’s a pretty safe thing to put in. It’s very effective. It’s reasonably private because most people can’t see it because it’s placed on the inner part of the arm. On the downside, again, it does not prevent STDs. There is a minor surgery needed both to implant it and even more perhaps surgery to remove it. Cramping and bleeding can absolutely happen.