# Presentation: 099278

## Family Planning

- Helping students successfully plan and prepare for their futures

- Sara Mackenzie, MD, MPH
- Region 6 Medical Consultant

## Objectives 

- Review factors impacting adolescent pregnancy
- Review currently available contraceptives
- Discuss goals for upcoming year

## Adolescent Pregnancy 

- Motivation to avoid pregnancy governed in part by a woman’s perception of the benefits of deferring parenthood.  Perception strongly influenced by:
-  present circumstance
-  belief in her future life chances
- Ref: Hatcher RA et al.  Contraceptive technology 18th Revised Ed.

## Sexual Risk Behavior

- Source: CDC 2001 Youth Risk Behavior Survey

| Ever had sexual intercourse | Male | Female |
| --- | --- | --- |
| Grade 9 | 41% | 29% |
| Grade 10 | 42% | 39% |
| Grade 11 | 54% | 50% |
| Grade 12 | 61% | 60% |
| 4 or more lifetime sexual partners | Male | Female |
| Grade 9 | 14% | 6% |
| Grade 10 | 24% | 20% |

## Slide 5

## Challenges to Effective Contraceptive Practice 

- All methods require abstract thinking about the future – many youth have not developed this skill yet
- The most effective contraceptive methods for preventing pregnancy, do not reduce risk of STI

## Components of Effective Contraceptive Practice Program 

- Focus on reducing one or more sexual behaviors that lead to risk of unplanned pregnancy or STI
- Deliver and consistently reinforce clear message
- Provide basic information
- Address social pressures and develop communication skills

## Slide 8

## Current Contraceptive Options 

- Abstinence
- Barrier
- Hormonal
- Emergency contraceptive
- IUDs
- Sterilization

## Current Contraceptives 

- Abstinence
- Only 100% effective way to prevent pregnancy
- Only 100% effective way to prevent STI transmission
- Requires control, interrupts sexual expression
- Ensure have access if change the plan

## Barrier: Failure Rates 

|  | Perfect Use | Actual |
| --- | --- | --- |
| Male condom | 2% | 15% |
| Female condom | 5% | 21% |
| Diaphragm | 6% | 16% |
| Cervical cap | 4% | 14% |

## Barrier

- Require planning at time of intercourse
- Male condoms readily available
- Male and female condoms reduce risk STI transmission
- Possible breakage, embarrassment, require male involvement for male condom

## Hormonal Contraceptives:Failure Rates 

|  | Perfect Use | Actual |
| --- | --- | --- |
| OCPs | 0.3% | 8% |
| Patch | 0.3% | 8% |
| Vaginal Ring | 0.3% | 8% |
| Injectables | 0.3% | 3% |

## Oral contraceptive pills

- Lo-Ovral (biphasic)

- Seasonale

## Contraceptive Technology 

- Contraceptive Technology
- 18th Revised Edition
- Robert A Hatcher, et al

## Noncontraceptive Benefits 

- decrease menstrual flow (lighter, shorter periods)
- decrease menstrual cramps (no ovulation)
- improve anemia (lighter, shorter periods)
- improve acne (estrogen effect)
- protect against ovarian and endometrial cancer
- decrease benign breast disease
- decrease ovarian cyst formation
- prevent ectopic pregnancy
- protect against some causes of PID
- protect against osteoporosis

## Medical Conditions Precluding Use

- Thromboembolic disorder
- Past history deep venous thrombosis
- Cerebrovascular or coronary artery disease
- Valvular heart disease with thrombogenic complication
- Uncontrolled hypertension
- Diabetes with vascular involvement
- Migraine with focal neurologic symptoms
- Prolonged immobilization
- Breast cancer
- Active liver disease

## Hormonal Contraceptives: Patch

- Each patch lasts 7 days
- Replace each week for 3 week cycle, 1 week patch-free
- 20% complain of reaction at site
- less effective in women over 198 pounds

## Hormonal Contraceptives: Patch

- Higher risk of blood clots with patch than in women using 35 ug OCP
- Risk is still low and should be discussed, weighed against risk of pregnancy if unlikely to take pill daily

## Hormonal Contraceptives: Vaginal Ring

- Flexible, soft, transparent ring
- Ethinyl estradiol and etonorgestrel released in steady, low dose – serum levels lower than with patch or pill
- Place every 28 days
- Remove after 21 days for 7 day ring-free period

## Hormonal Contraceptives: Injectable

- Depot medroxyprogesterone acetate
- 150 mg IM once every 12 weeks
- irregular bleeding => amenorrhea within 2 years  (70%)
- concerns:
- weight gain
- osteoporosis risk

## Hormonal Contraceptives: Implants

- progestin-only contraceptive implant
- single flexible 4 cm rod
- inserted under the skin f the upper arm
- Lasts 3 years
- contains 68 mg etonogestrel - releases
- 	40 mcg daily - 3 year efficacy
- irregular menstrual bleeding common
- clinician visit for insertion and removal

## Current Contraceptives 

- Emergency contraceptive
- Plan B (or other)
- Use within 72 hours of unprotected sex (up to 5 days)
- Not abortogenic- will not cause established pregnancy to abort!
- Can take both pills (two 0.75mg tablets) at same time to increase compliance
- Plan B available over the counter since August 2006 for women 18 and older; rx required under 18

## Emergency Contraceptive: Importance of Timing 

- Plan B® data 95% effective if taken within 24 hours of unprotected intercourse - reduces crude pregnancy rate from 8% to 0.4%
- Efficacy declines to 85% if treatment is delayed 25-48 hours
- Efficacy declines to 58%-61% if treatment is delayed beyond 48 hours

## Emergency Contraceptive 

- EC is ineffective if implantation has occurred
- No evidence of harm to developing fetus if EC is taken inadvertently
- Routine pregnancy testing is not recommended
- Consider pregnancy testing _prior_ to EC use if menses delayed
- Consider pregnancy testing _after_ EC use if menses does not occur within 3 weeks

## Emergency Contraceptive

- Women receiving EC in advance are two to three times more likely to use them, but not to use them repeatedly (US/Scotland)
- 80% of women who received EC in advance began treatment within 24 hours of intercourse vs 40% of women who needed to fill an EC prescription
- No more likely to engage in sexual activity
- No more likely to use their regular contraceptive less consistently

## Current Contraceptives 

- Intrauterine device
- Usually used in woman with prior pregnancy but can be used in nulliparous woman
- 2 options- mirena and copper
- Monogamous committed relationship and no STIs

## Slide 28

## Mirena IUD

- Levonorgestrel-releasing intrauterine system - 20 mcg daily
- 5 year efficacy
- Highest risk of PID within 20 days of insertion
- Irregular menstrual bleeding common in first 3-6 months
- Clinician visit for insertion and removal

## Current Contraceptives 

- Surgical sterilization
- Vasectomy
- Tubal ligation

## Job Corps Goals 

- Reduce rate of pregnancy on center
- Target:
-   # on center pregnancy/female OBS <5%
- Track MSWR for pregnancy and encourage return after delivery