Pediatricians accept an important role in boyish changeable bloom care. Their abiding relationships with patients and families acquiesce them to advice beforehand advantageous controlling about changeable and accommodate abnegation as a way to abjure the abrogating after-effects associated with chancy animal behaviors. As advocates for the bloom and abundance of boyish people, pediatricians acquaint their advocacy to boyish patients to adjourn animal action until they are ready, because any animal action for which the boyish is ill able may accept emotional, physical, and banking consequences. However, clinicians admit that some of their boyish patients are ually alive or will accept to become so. Contempo studies announce that, for some adolescents, alike accommodating in academic programs that apostle abnegation and signing abnegation pledges do not aftereffect in abstinent behavior.1,2 Pediatricians can accept an alive role in auspicious their boyish patients to use contraception to abate the accident of adventitious pregnancies and to anticipate ually transmitted infections (STIs). In antecedent publications, the American Academy of Pediatrics (AAP) has addressed issues of boyish uality, exceptionable pregnancy, STIs, and contraception.3 This action account provides the pediatrician with adapted advice on boyish animal behavior, which may beforehand to pregnancy, including guidelines for counseling adolescents about attainable methods of contraception. Current methods attainable are discussed, as are methods in development.
Reported contraceptive use by adolescents has added in contempo years. From 1991 to 2005, the allotment of ually alive aerial academy accepting who appear application a condom the aftermost time they had animal action added from 46.2% to 62.8% in 2005.4 Despite this increase, constant use of any contraceptive adjustment charcoal a claiming for best adolescents.
Levels of appear animal action by adolescents in the United States decreased during the 1990s for both es afterwards accretion for the antecedent 2 decades.4–6 The Centers for Ache Ascendancy and Prevention’s 2005 Boyhood Accident Behavior Surveillance Summary adumbrated that beneath than bisected (46.8%, bottomward from 49.9% in 1999) of all aerial academy accepting appear accepting had animal action in their lifetimes, and about one third (34.3%, bottomward from 37.5% in 1991 and 36.3% in 1999) of all accepting appear accepting animal action during the 3 months above-mentioned the assay and are advised currently ually active.4–6
Each year, about 850000 boyish girls become pregnant. The boyish abundance bulk has abandoned steadily over the accomplished decade. As of 2004, it was estimated that about 41.2% of all pregnancies are to adolescents 15 to 19 years of age.7 Back 1991, the boyish bearing bulk has beneath by 33%, the everyman bulk anytime appear for the nation. The abundance bulk for 15- to 17-year-olds has abandoned by 43% to 22.1% of all pregnancies.7 About 20% of abortions are in adolescents, although these ante abide to decrease.8,9 Decreases in abundance ante are anticipation to reflect a abatement in appear ante of animal action and an admission in appear use of longer-acting, added able contraceptive agents.10–12 Over the aftermost decade, evaluations of curricula beforehand that those with a absolute admission to changeable apprenticeship accept been able in convalescent animal behaviors and, thus, may additionally accord to this trend.13–15 Despite these crumbling ante of pregnancies and births, boyish bearing (22% of women abode giving bearing afore age 20) is still added accustomed in the United States than in added developed countries such as Great Britain (15%), Canada (11%), and France (6%).16
Providing advice to adolescents about contraception does not aftereffect in added ante of animal activity, beforehand age of aboriginal intercourse, or a greater cardinal of partners.15 In fact, if adolescents apperceive obstacles to accepting contraception and condoms, they are added adequate to acquaintance abrogating outcomes accompanying to animal activity.17 Two school-based studies that accustomed a adjournment of admission of animal action acclimated a absolute admission to changeable apprenticeship that included a altercation of contraception.18,19
Race, ethnicity, age, conjugal status, education, income, requirements for arcane care, and abundance intentions accept all been accustomed to affect contraceptive choice. Trends in methods of contraception acclimated by adolescents over the accomplished 2 decades actualization an admission in articulate contraceptive us (OCP) use and an admission in macho condom use.20 In contempo years, the cardinal of adolescents advertisement OCP use has remained abiding at about 18% to 20%.21 Use of injectable contraception by adolescents 15 to 19 years of age has added from 0% to 13% amid 1988 and 1995. A 9% abatement in contraceptive-failure–related pregnancies is attributed to the about-face to longer-acting bearing ascendancy methods.16
Factors that accord to abridgement of contraceptive use or inconsistent use accommodate issues accompanying to boyish development, such as abhorrence to accede one’s animal activity, accepting that one is allowed from the problems or after-effects surrounding animal action or pregnancy, and abnegation of the achievability of pregnancy. Added important factors are abridgement of apprenticeship and misconceptions apropos use or account of contraception. However, an adolescent’s akin of ability about how to use contraception finer does not necessarily associate with constant use. Adolescents may not use or may adjournment use of contraception for several affidavit including abridgement of affectionate monitoring, abhorrence that their parents will accretion out, ambivalence, and the acumen that bearing ascendancy is alarming or causes exceptionable adverse furnishings such as weight gain.22–25
Pediatricians should animate abnegation and accommodate adapted risk-reduction counseling apropos animal behaviors. Ideally, counseling should accommodate altercation about the blockage of STIs, apprenticeship on contraceptive methods, and ancestors planning casework for the ually alive patient. Such altercation necessarily takes abode aural the ambience of an abandoned patient’s accurate and affecting development as able-bodied as his or her amusing situation. Although pediatricians are optimally ill-fitted for such inquiry, we admit that not every arrangement will acquiesce the time required. The demands of absolute accommodating evaluation, counseling, and assay are daunting, indeed, but are allotment of the advancing apprenticeship of boyhood and about added ancestors members. This abode is advised as a adviser and, we hope, is attainable to alive clinicians.
When contraceptive casework are provided in the pediatrician’s office, behavior and procedures that abode the accouterment of such services, including confidentiality, should be developed and again explained to families afore the accouterment of such casework is anytime needed.26,27
Comprehensive bloom affliction of adolescents should accommodate a arcane animal history that should be acquired in a safe, nonthreatening ambiance through open, honest, and nonjudgmental advice with assurances of confidentiality. During the preadolescent years, the pediatrician can accommodate advanced advice by discussing boyhood and alms bloom apprenticeship abstracts to both the boyhood and his or her family. At the admission of puberty, the patient’s history should accommodate advice on both the family’s and the patient’s attitudes and ability about animal behaviors and the bulk of captivation in animal activity. Accustomed advice may be offered or attainable to both the ancestors and accommodating about methods of contraception and their uses. In addition, about this time, bloom aliment visits should activate to accommodate private, arcane time with the boyish to authorize affinity as able-bodied as appraise bulk of captivation in animal activity. For ually alive adolescents who use contraception, the role of the bloom affliction able is to brainwash and abutment compliance, to abetment in managing adverse furnishings or, alternatively, to admonition the accommodating apropos a new contraceptive adjustment as affairs require, and to accommodate referrals and aftereffect with alternate screening for STIs. Throughout adolescence, absolute changeable apprenticeship that includes altercation of abstinence, adapted contraceptive use, and aegis from STIs should be provided as allotment of advantageous animal development. Back initiating any hormonal contraceptive method, the charge for constant aegis adjoin STIs (either macho or changeable condoms) should be reinforced.
The primary acumen that adolescents may alternate or adjournment accepting ancestors planning or contraceptive casework is affair about abridgement of confidentiality.25,28 It is important for pediatricians to beforehand arrangement behavior that ensure accommodating confidentiality. Accompaniment requirements and standards of convenance should be reviewed, and the development of clear, concise, and connected arrangement protocols for acquaintance should be developed for staff, patients, and parents.29 These behavior should accommodate advice and apprenticeship apropos back acquaintance charge be waived, guidelines for agreement of services, medical blueprint access, arrangement scheduling, and advice disclosure.
For those patients whose parents are blind of their contraceptive use, it may be attainable to altercate with the boyish accommodating how the contraceptive adjustment will be consistently acclimated in all circumstances. Constant boyish contraceptive use is about batty during weekends away, ancestors vacations, adolescents’ trips to break with added relatives, and/or visits to noncustodial parents.
Pediatricians can advice adolescents analyze their own goals for safe and amenable animal behavior, including reinforcing and acknowledging abstinence. The beforehand of advantageous and amenable animal controlling is one of the goals of counseling adolescents about contraception. Successful counseling requires a admiring and nonjudgmental pediatrician who engages in able dialogue, which includes accomplished history taking, accurate listening, and alliteration of simple educational letters that accommodate capital information.26,30
Adolescents should be acerb encouraged to adjourn or adjournment the admission of animal activity. For patients who are already affianced in animal action or who are advertent accepting animal intercourse, a altercation of contraceptive methods and blockage of STIs (including HIV and AIDS) is essential. Condom use should consistently be reinforced, and boyhood charge be reminded that, for some STIs, condoms are not absolutely protective. Adolescents should be fabricated aware, in a nonthreatening and nonjudgmental manner, that although condom use is capital and may be life-saving, any abandoned who engages in animal acquaintance is at accident of application STIs that are transmitted through animal contact, such as canker canker and animal papillomaviruses, rather than body-fluid exchange, such as gonorrhea and tricniasis. Discussions should abode and analyze the adolescent’s affidavit for adequate ually alive and the aftereffect that animal action may accept on relationships with peers, parents, and cogent others. Clinicians may additionally accretion it advantageous to analyze with the boyish how he or she believes the animal adventures will change his or her own self-image. Boyish animal controlling has emerged in contempo studies as a circuitous coaction amid an adolescent’s acumen of peer-group expectations, claimed self-image, values, and desires and media influences.30–33 However, a caring, nonjudgmental yet informative, nonparental developed can apply abundant admission in teens’ animal decision-making; boyhood adduce abridgement of such a actuality as a missing key affection of changeable education.34 Pediatricians, therefore, may accept some admission in boyish animal controlling and are abnormally able-bodied positioned to appraise adventurousness behaviors in the breadth of uality.35
The affair of contraception for adolescents with abiding affliction or affliction is about forgotten. An estimated 10% to 20% of accouchement and adolescents acquaintance a affliction or abiding affliction by the age of 20 years.36 Contempo abstracts from the National Longitudinal Abstraction of Boyish Bloom has apparent that physically disabled adolescents are as ually accomplished as adolescents afterwards disabilities. Attitudes about contraceptives as able-bodied as changeable apprenticeship and counseling needs aural this citizenry should not be overlooked.37 A account of added assets for clinicians who admiration added advice about contraception for adolescents with abiding affliction and/or affliction is included at the end of this statement.
Numerous reviews and protocols for prescribing and managing contraception are available. The after breadth focuses on the account of assorted contraceptive methods attainable for adolescents. The pediatrician should accent the charge for STI blockage as able-bodied as contraception with anniversary accommodating at anniversary visit.17,38
Abstinence is the best able agency of bearing ascendancy and blockage of STIs and is a applicable action in the clinician’s toolkit for abbreviation adventitious abundance and accomplish abridgement in STI rates. Abnegation apprenticeship about focuses on dabbling the admission of boyish animal action until alliance or adulthood. Abounding schools accept adopted abstinence-dominant or abstinence-only apprenticeship programs for academy changeable curricula. To date, the affirmation apropos the ability of such interventions in the abridgement of chancy animal behaviors, including accident for STIs, has not been proven.14,39 No abstracts accept anon advised how able-bodied abnegation counseling works to abate an individual’s abundance and STI risk. In practice, abounding adolescents who intend to be abstinent about abort and accept . A longitudinal assay of boyhood and virginity pledges compared pledgers to nonpledgers and begin at a 6-year aftereffect that 88% of pledgers appear experiencing premarital and had STI ante that, statistically, were no altered from those of nonpledgers.2 A contempo commodity provides some activated tips for abnegation counseling aural an office-based ambience application a absolute angle including motivational interviewing.40
Several appear studies and evaluations accept adapted that absolute changeable apprenticeship is an able action for allowance boyish bodies adjournment admission of animal intercourse. In addition, analysis has apparent that these programs do not accelerate the admission or abundance of animal action and do not admission the cardinal of ally that ually alive boyhood have.15
There is some accord that changeable apprenticeship and interventions with some abstinence-based or “abstinence-plus” class apparatus are best able back targeted at boyish adolescents afore they become ually active.1,41 Some contempo studies accustomed the accent of youth, parent, physician, and apprenticeship partnerships for the blockage of bloom accident behaviors such as aboriginal admission of animal intercourse.13,42 One abstraction illustrated that an abstinence-only class had no cogent appulse on the admission of , the abundance of amid those accepting who had anytime had , or the cardinal of animal ally amid those who had anytime had . Two added studies produced agnate results.1 The AAP supports a absolute admission to changeable apprenticeship for adolescents. Abnegation should comedy a allotment in any absolute altercation of uality, and assets should be fabricated attainable for adolescents who feel pressured, but adopt not, to appoint in animal activity.
For some adolescents, abnegation may be a difficult choice. Adolescents who accept to abjure from animal action should be encouraged and accurate by their parents, peers, and association (including the media) and abnormally by their pediatricians. Adolescents charge to apperceive about added contraceptive options afore (or if) they adjudge to accept intercourse.
The macho condom is a automated barrier adjustment of contraception. The aborticide bulk at the end of first-year use for the macho acrylic condom is 3% with absolute use and as abundant as 14% with archetypal use.43 Acrylic condoms decidedly abate the manual of some STIs and, therefore, should be acclimated by all ually alive adolescents behindhand of whether an added adjustment of contraception is used. Macho condoms accept several added advantages for adolescents, including involving males in the albatross of contraception, accessible accessibility and availability to minors, use afterwards a prescription, and low cost.44 Polyurethane condoms can be acclimated by adolescents with a accurate acrylic allergy; however, acrylic condoms are preferred, because they accept a college ability bulk with archetypal use than polyurethane condoms.43 Some adolescents may accept bounded reactions to condoms that accept been pretreated with spermicide and should be counseled that condoms afterwards these agents are additionally available. Nonoxynol-9 is the abandoned actinic abettor in spermicidal articles attainable in the United States; there are nonspermicidal hypoallergenic lubricants attainable over the counter. Abandoned water-based lubricants may be acclimated with acrylic condoms, and both water- and oil-based articles may be acclimated with polyurethane condoms.44 Currently, there is a accustomed movement abroad from articles with nonoxynol-9 because of apropos that use increases accident of animal ulceration and irritation, which may facilitate the accretion of STIs.44 Condom use appear at best contempo action by females was 54% and by males was 71%, which is an admission in the aftermost decade.20 Surveys of aerial academy accepting over the aftermost decade announce that condom use has increased, with condom use at aftermost action accretion from 46.2% in 1991 to 62.8% in 2005.4
The changeable condom, accession barrier adjustment of contraception, provides contraceptive ability in the aforementioned ambit as added barrier methods, such as the diaphragm and cervical cap (with archetypal use).45 One balloon of the best broadly attainable changeable condom on the bazaar yielded a aborticide bulk of 0.8% with absolute use and amid 12% and 15% with archetypal use.46 The changeable condom additionally helps assure adjoin STIs. Adolescents’ apropos about application a changeable condom accommodate adversity of insertion, college bulk than macho condoms, and actualization and noisiness of the device. Changeable adolescents accept appear that the changeable condom could be advantageous if their macho ally did not appetite to use a condom. Further apprenticeship on application the changeable condom is bare for both genders. For adolescents who already use macho condoms, it is important to bazaar the changeable condom as an another contraceptive choice, because macho and changeable condoms should not be acclimated simultaneously.47 Macho condoms are adopted over changeable condoms because of college ability ante of preventing abundance and STIs and lower cost.
Vaginal spermicides are a actinic barrier adjustment of contraception activated intrally through a array of forms: gel, foam, suppository, or film. Spermicides abide of 2 components: a conception (the gel, foam, suppository, or film) and the actinic additive that kills the agent (eg, nonoxynol-9). As with any barrier method, the capability of spermicides depends on constant and absolute use. The aggregate of l spermicide and condoms is a absolute able agency of contraception for adolescents, because it provides able blockage of pregnancy, reduces the accident of application an STI, is attainable afterwards a prescription, and is inexpensive.48
There has been a catechism as to whether use of nonoxynol-9 abandoned provides able aegis adjoin STIs and HIV. In aerial doses, nonoxynol-9 can abrade the l lining, which makes boyish women added affected to HIV transmission. The Centers for Ache Ascendancy and Blockage accept assured that women should be beat from application nonoxynol-9 abandoned for STI and HIV protection, because 1 abstraction begin that a artefact absolute nonoxynol-9 did not assure adjoin HIV infection and may accept acquired an alike greater likelihood of manual as compared with a l lubricant.49,50 Use of spermicide abandoned is not advocated as a contraceptive method; condoms charge be acclimated in affiliation with l spermicides for aegis adjoin STIs
OCPs are a reliable, able adjustment for the blockage of pregnancy, are attainable abandoned by decree in the United States, and are the best accustomed adjustment of assigned contraceptive amid adolescents.21 Of the 2.7 actor boyish women who use contraceptives, 44% await on the pill.51 The Boyhood Accident Behavior Surveillance Summary appear that in both males and females who had animal action during the 3 months afore the survey, the allotment who acclimated bearing ascendancy pills to anticipate abundance during aftermost animal action was 17.6% in 2005, bottomward from 20.8% in 1991.4
Three forms of OCPs are currently available: the fixed-dose, monophasic aggregate (each book contains the aforementioned dosage of estrogen and progestin); the phasic dosage (the triphasic and biphasic packs that accommodate capricious doses of estrogen and progestin); and the minipill (which contains progestin only). Abounding of the newer forms of bearing ascendancy pills accept a low dosage of estrogen (20–35 μg) and accommodate new forms of progestin. These low-dose pills are about the “first-line” analysis for OCP initiation. There is academic abeyant for bargain ability of low-dose OCPs in patients who are demography some medications. Some accustomed medications that admission the metaism of constructed steroids by accretion alliance in the gut and agitator consecration in the alarmist are listed in Table 1. 52–54 In this analytic situation, decree of OCPs that accommodate 50 μg of ethinyl estradiol or switching to a hormonal adjustment that avoids first-pass metaism, such as injectable progestin, may be indicated; ability of transdermal or intral contraceptives with these medications are not known. Generally, the accustomed 28-day backpack of pills (21 canicule of hormone and 7 canicule of placebo) is assigned for teens, and circadian acquiescence is encouraged, decidedly over the 21 canicule of hormone-containing pills to aerate ability and abbreviate bleeding irregularities.55 The 21-day packs, if available, are bigger for adolescents who are demography OCPs in connected or continued cycles.
Medications That Abatement OCP Efficacy
The US Food and Biologic Administering (FDA) afresh accustomed a monophasic 30-μg ethinyl estradiol/0.15-mg levonorgestrel us for continued cycling alleged Seasonale (Barr Pharmaceuticals, Woodcliff Lake, NJ). This conception provides 84 canicule of connected hormonally alive pills followed by 7 canicule of placebo. This conception may be decidedly adapted for adolescents with medical altitude such as anemia, astringent dysmenorrhea, endometriosis, abortive uterine bleeding, or Von Willebrand and added bleeding diatheses and adolescents who adopt amenorrhea.56 In addition, adolescents who frequently absence OCPs may accept lower aborticide ante back application connected or continued regimens of OCPs with beneath or no placebo intervals.
The noncontraceptive allowances of OCP use accommodate beforehand in abscess and decreased menstrual cramping, pain, claret loss, and ovarian cysts. OCP use that exceeds 3 years provides cogent aegis adjoin endometrial and ovarian cancers. Overall, empiric abstracts announce that OCP use does not admission accident of cancer. Adverse furnishings accommodate nausea, tenderness, headaches, and beforehand bleeding. OCPs are one of the best-studied medications anytime assigned and are a safe advantage throughout a woman’s changeable years, because the adjustment is absolutely capricious and has no abrogating aftereffect on abiding fertility.57
OCPs accept a aborticide bulk of 0.1% back acclimated perfectly. However, aborticide ante ambit amid 5% and 8% with archetypal use and for adolescents may ability 15% to 26% because of noncompliance.58 Adolescents may accept adversity acknowledging with OCPs because of forgetfulness, attempts to adumbrate contraception from parents, and aberration of animal relations, amid added reasons. The National Assay on Ancestors Growth appear that as abounding as 42% of adolescents 15 to 19 years of age absent 2 or added pills in a 3-month period.57 Boyish acquiescence with OCP use may be added by adapted accommodating apprenticeship and analytic techniques, which includes accurate apprenticeship apropos the use of OCPs; advanced advice about adverse furnishings and their management; a altercation of absolute us accepting (including back the aboriginal us should be taken during the menstrual aeon or what to do if a us or pills are backward or missed); use of emergency contraception; and common aftereffect and monitoring. Patients should additionally be encouraged to use condoms in affiliation with OCPs to accommodate aegis adjoin STIs and added abundance prevention. In addition, back possible, involving the patient’s mother can abundantly enhance acquiescence with us taking.59
OCPs accept few contraindications in advantageous changeable adolescents. Estrogen-containing OCPs are contraindicated for those with a history of thromboemism or thrombophilia (ie, agency V Leiden alteration or protein C, protein S, or antithrombin III deficiencies); cyanotic affection ache or pulmonary avenue hypertension; systemic lupus erythematosus associated with antiphospholipid antibiotic affection or renal disease, decidedly associated with hypertension; or hepatic dysfunction. Patients who are demography anticonvulsant medications and HIV medications charge to be counseled anxiously and may be encouraged to use injectable progestins (Table 1).
Adolescents charge not accept a complete gynecologic assay by the pediatrician afore initiating OCPs or any added hormonal contraceptive method.60 In best circumstances, the pelvic assay may be deferred and OCPs may be assigned if the accommodating is healthy, is not pregnant, and has no contraindications to demography the pills. An analysis of the alien ballocks and either a urine awning or l besom for STIs may be commissioned for a pelvic assay as a screening for admission of contraceptive use. A pelvic assay is adumbrated for best situations in which belly affliction is allotment of the presenting complaint in a ually accomplished adolescent. Sexually alive changeable adolescents should be buried for STIs, abnormally chlamydia, at atomic annually and finer with anniversary new animal partner.61 Guidelines from the American Blight Association and the American College of Obstetricians and Gynecologists acclaim admission of Papanicolaou (Pap) analysis screening aural 3 years of aboriginal action (whether consensual or nonconsensual) or by 21 years of age.62
Depot medroxyprogesterone acetate (DMPA) bang is a long-acting progestin that is accustomed every 12 weeks (11–13 weeks) as a distinct 150-mg intramuscular dose. This adjustment of contraception, additionally accustomed by the cast name Depo-Provera (Pfizer, New York, NY), is awful able in preventing pregnancy. In the aboriginal year of use, the anticipation of adequate abundant is about 0.3%.63 Attainable back 1992 in the United States, some experts accept that the use of this adjustment back 1992 amid adolescents who are at aerial accident of adequate abundant is one agency amenable for the crumbling ante of boyish abundance in the United States.17 This adjustment is adequate for women who do not appetite to accept to bethink to booty their us anniversary day, cannot use the patch, or cannot use a contraceptive at the absolute time of intercourse.16 Added advantages accommodate abridgement of estrogen-related adverse furnishings and, agnate to OCPs, aegis adjoin endometrial blight and iron-deficiency anemia.64
The above disadvantage of this contraceptive adjustment for adolescents are menstrual aeon irregularities (present for about all patients initially), the charge for intramuscular administering every 11 to 13 weeks, and abeyant adverse furnishings including acne, weight gain, headaches, and bloating. A new formulation, which is administered subcutaneously, contains 104 mg of medroxyprogesterone acetate (Depo-Subq Provera 104 [Pfizer]), and is accustomed on the aforementioned dosing agenda as the intramuscular formulation, is now available. The subcutaneous avenue makes home administering of Depot-Provera possible, although there accept been no studies of home use in the boyish population. The lower dosage could abatement aishment of pituitary action and ovarian estradiol production, although no absolute abstracts are yet attainable to announce such an effect.65 Two ample open-label phase-3 studies accept begin subcutaneous DMPA to be appropriately able as intramuscular DMPA; however, the aberrant uterine bleeding that abounding patients accuse of afterwards initiating the biologic additionally accompanies subcutaneous use. As with the intramuscular route, this adverse aftereffect abundantly resolves over the aboriginal year of use: amenorrhea added from 26% of patients in ages 3 of use to 55% during ages 12.66
In accession to uterine bleeding irregularities, DMPA use over a abiding aeon is associated with a delayed acknowledgment to fertility, about 9 to 18 months, while the endometrial lining allotment to its pre-DMPA accompaniment and ovulatory action returns. Both subcutaneous and intramuscular DMPA actualization agnate delays to abundance afterwards injection.67 However, for boyish patients, such a adjournment does not usually affectation a above bridle to application this method. Both intramuscular and subcutaneous DMPA may be cautiously recommended for adolescents who accept abiding illnesses (eg, seizures, sickle corpuscle disease), are lactating, or are at accident of estrogen-related complications.64
Pediatricians should altercate abeyant adverse effects. Studies accept apparent that patients are added adequate to abide DMPA use if they are counseled about abeyant aberrant bleeding afore their aboriginal injection, but these studies did not ambition adolescents specifically.68 Clinicians charge additionally ensure that the accommodating is not abundant at the time of the antecedent bang and at anniversary bang that occurs at an breach greater than 12 weeks.
Because DMPA suppresses circulating estradiol concentrations, it causes reductions in cartilage mineral anatomy (BMD), which has generated some affair apropos the abiding effects. A -to-be accomplice abstraction of adolescents age-old 12 to 18 years begin that BMD decreased 3.1% afterwards 2 years of DMPA use, admitting BMD added 9.5% in the controls who were application no hormonal adjustment of contraception.69 Some added studies accept adumbrated an adverse appulse on biochemical markers of cartilage accumulation and absorption as able-bodied as the decreased BMD.70–72 In acknowledgment to these concerns, the FDA issued a “black-box” admonishing apropos the accident of decreased BMD amid DMPA users in November 2004.73 Currently, the admonishing recommends attached the use of DMPA to 2 years and application DMPA as abiding contraception abandoned if added methods are inadequate. The admonishing additionally emphasized the abridgement of authoritativeness apropos aiguille BMD accomplished afterwards in action amid users of DMPA, but experts anticipate such a brake may be unwarranted, abnormally for patients with no added alternatives for contraception. A afresh appear abstraction of boyhood and boyish developed women accurate complete accretion of BMD afterwards DMPA use, appropriately alms some bulk of beforehand about use not affecting abiding ashen bloom of boyish patients.74 In addition, an added accident of fractures has not been appear in adolescents application DMPA.
It is important to accede added accident factors for osteoporosis and to clothier counseling and recommendations to anniversary patient. Factors such as baby anatomy habitus, abiding booze or tobacco use, bistro disorders, or affliction that necessitates abiding use of corticosteroids may beforehand a analyst to acclaim adjoin DMPA use added strongly. All patients should be encouraged to accommodate foods and/or supplements to ensure assimilation of at atomic 1300 mg of calcium anniversary day forth with 400 IU of vitamin D, to participate in weight-bearing exercise regularly, and to stop smoker as important measures to beforehand ashen health. Application added estrogen has been empiric to anticipate accident of BMD in 1 abstraction of teens, admitting the use by boyhood of antiresorptive medications assigned for postmenopausal women is absolutely not recommended.75 As with all hormonal methods of contraception, condoms should be acclimated in affiliation with DMPA for aegis from STIs.
Another injectable hormonal contraceptive (known by the artefact name Lunelle [previously bogus by Pharmacia & Upjohn, Kalamazoo, MI]) accumulated estrogen and medroxyprogesterone acetate. Lunelle was fabricated attainable in the United States afterwards accepting of assurance in analytic trials in the United States and internationally. However, Lunelle was voluntarily aloof from the bazaar by its architect in September 2002 because some doses may not accept independent abundant hormone to anticipate pregnancy. Women who acclimated Lunelle adapted account dispensary visits for the bang of medications. Adverse furnishings were agnate to those of Depo-Provera and included weight gain, menstrual irregularity, headaches, and tenderness, although adverse furnishings were beneath than in trials with DMPA alone.76,77 A accustomed accepting of and all-embracing achievement with Lunelle by women in analytic trials adapted that this adjustment was broadly accepted, but its acknowledgment into the bazaar is not accepted in the future.
Levonorgestrel implants, additionally accustomed by the cast name Norplant (previously bogus by Wyeth-Ayerst Laboratories, St Davids, PA), were awful able long-acting progestin-only contraceptives that provided abundance blockage for up to 5 years. These implants adapted admittance of subcutaneous polymeric silicone capsules into the aerial arm by a accomplished bloom affliction professional. The 6-rod Norplant arrangement was the aboriginal progestin implant attainable in the United States but has been assuredly removed from the US market.78 Implanon (Organon USA, Roseland, NJ), a single-rod implant that contains etonogestrel, the alive metaite of desogestrel, has been acclimated in Europe back 1998 and is now attainable in some areas of the United States. Awful able (in analytic trials, no adventitious pregnancies were appear in ∼73000 cycles), Implanon may abide in abode for 3 years, but it is associated with aberrant bleeding in abounding users, abnormally during the aboriginal year of use.63
Levonorgestrel implants are ideal for adolescents who admiration an continued breadth of protection, feel clumsy to bethink to booty OCPs, or accept already had 1 pregnancy. It is additionally an accomplished contraceptive advantage for females who may accept adversity canonizing to use a contraceptive on a circadian base or at the time of intercourse. The above disadvantages for use in the boyish citizenry accommodate aerial antecedent bulk and abeyant adverse furnishings such as beforehand bleeding and headaches. The drugs listed in Table 1 additionally blemish the ability of levonorgestrel implants. The adversity of abatement of the implant, in aggregate with these added disadvantages, fabricated Norplant an abhorred anatomy of contraception for adolescents, and although Implanon is easier to remove, it shares abounding of Norplant’s adverse effects. In addition, condoms charge be acclimated in affiliation with progestin implants for aegis adjoin STIs.63
The l arena (NuvaRing [Organon USA]; 15 μg ethinyl estradiol/120 μg etonogestrel) is a round, adjustable accessory that measures 54 mm in alien bore and 4 mm cross-sectionally; it is amid in the and stays in abode for 3 weeks, with abatement for 1 anniversary to abet menstruation followed by admittance of a new ring. This bendable silicone l arena releases both estrogen and progestin hormones that assure adjoin abundance for 1 month. The arena has been apparent to accept greater than 99% ability back acclimated accurately by developed women. However, trials with boyish populations accept not been conducted. Acquiescence with the arena is high, and few adverse furnishings are experienced. Adverse furnishings would be the aforementioned as added accumulated hormonal methods, which accommodate tenderness, headaches, nausea, and some beforehand bleeding/spotting and an added accident of the added austere action of thrombotic events; bounded adverse furnishings may accommodate l affection of discharge, discomfort, and accessory problems.55
The aggregate hormonal transdermal adhering bark application (Ortho Evra [Ortho-McNeil Pharmaceutical, Raritan, NJ]) can be activated to the abdomen, aerial torso, aerial alien arm, or ocks account by application 1 application for anniversary of 3 weeks in a row, followed by 1 anniversary off the patch, during which a abandonment drain usually occurs. While in place, the 4.5-cm3 contraceptive application delivers 150 μg of norelgestromin and 20 μg of ethinyl estradiol daily. Ability ante from 1 abstraction adapted that the all-embracing anniversary anticipation of abundance was 0.8%, admitting the adjustment aborticide anticipation was 0.6%, agnate beyond age and ancestral groups.55
One abstraction appear that women who use the application are no added adequate to become abundant than women who use a aggregate OCP. At atomic 1 abstraction adumbrated a college bulk of bounded adverse furnishings with adolescents who use the application than with earlier patients; these furnishings accommodate patches dislodging as able-bodied as affliction and hyperpigmentation.79–81 Absolute accurate counseling apropos application adjustment with boyish patients, and conceivably alike affirmation of antecedent placement, is helpful.81
Although acquiescence with application the application is bigger compared with OCPs, the accident of abundance with absolute use of the application was college for women who counterbalance added than 198 pounds (0.9% in aboriginal 12 months of use) compared with women who counterbalance beneath (0.3%).82,83 Obviously, the risks of abundance charge be discussed as methods are considered; a abundance bulk of 1% at the end of 1 year in a accommodating who weighs added than 200 pounds, refuses added methods, and chooses to abide ually alive is a added adequate another than a abundance accident of 85% with no protection. For issues accompanying to compliance, the added bulk of the application should be considered. It has accustomed added compliance, which after-effects in beneath contraceptive failures. Added accessible adverse furnishings of accumulated hormone methods accommodate acting aberrant bleeding, acting discomfort, weight accretion or loss, and nausea.
The best apropos accessible adverse aftereffect of transdermal contraception or any accumulated hormone adjustment is accident of thrombotic events. In the ample analytic trials of the transdermal contraceptive patch, 1 case of nonfatal pulmonary array occurred during use of the patch, and 1 case of postoperative nonfatal pulmonary array was reported. Recently, the college bioavailability of estrogens delivered transdermally has prompted Ortho McNeil Pharmaceutical to affair a admonishing accurately accompanying to accident of thrombotic contest in Ortho Evra users.84 An added accident of venous thromboemic disorders has been associated with the use of aggregate hormonal articulate contraceptives compared with nonusers; generally, increases in ante by a agency of 3 to 6 accept been appear in studies that evaluated advantageous boyish women who had no added accident factors. A analysis of studies compared the accident of nonfatal venous thromboemism (VTE) amid altered OCPs. The authors begin that users of OCPs absolute desogestrel, a third-generation progestin, had an added accident compared with users of OCPs absolute levonorgestrel.85 Thus, a baseline accident for VTE of 1 per 10000 person-years is added to 3 to 4 per 10000 person-years during the time back articulate contraceptives are actuality used.85 The accident is abundant greater in those over age 35 and those who smoke, abnormally if cigarette use equals or exceeds 15 cigarettes daily. Although smoker should be beat for boyhood and boyish adults, smoker and use of accumulated hormone methods of contraception are not contraindicated in this age group.86 Whether the application places boyhood and women at added accident of VTEs compared with accumulated hormone OCPs is not known, because 2 altered studies with altered methodologies had altered outcomes.87 No studies to date accept anon advised whether the application increases the accident of thrombotic contest compared with added types of estrogen-containing methods. The accident of VTE is hardly animated but still absolutely low for anyone on an estrogen-containing adjustment compared with not actuality on a method. The accident of VTE associated with abundance should be advised adjoin the risks of the application or any accumulated hormone method. Compared with the accident of VTE during pregnancy, accident of VTE associated with accumulated hormone methods is advised lower in advantageous boyish women.55
As with articulate or transl accumulated contraceptives, condoms charge be acclimated in affiliation with anniversary adjustment for aegis adjoin STIs.
Intrauterine accessories (IUDs) are amid into the uterus and absolution hormones, ions, or enzymes that anticipate agent from agriculture the ova or anticipate implantation. The capability of IUDs is afflicted by several factors, including admeasurement of the IUD apparent breadth and the blazon of IUD used. Back acclimated appropriately, IUDs are about safe, able methods of contraception with a aborticide bulk of beneath than 1%. Condoms charge be acclimated in affiliation with IUDs for aegis adjoin STIs. IUDs accept ahead not been recommended for adolescents; accident of infection in boyhood (who about accept assorted ally or are serially monogamous) and accountability apropos (a accommodating who has not conceived afore application an IUD may aspect approaching infertility to IUD use) accept contributed to clinicians’ abhorrence to appoint this adjustment for boyish patients. IUDs accept not been apparent to affect abundance in the absence of infection; however, STI ante in boyish populations are absolutely cautionary. In some cases, however, an IUD may be adapted for an boyish who already has accouchement and is demography precautions to assure adjoin STIs. Mirena (Berlex, Montville, NJ), a anew developed IUD that contains the progestin levonorgestrel, gradually releases the progestin over an able aeon of 5 years and has a aborticide bulk of 0.3%. This IUD may be decidedly advantageous for adolescents with astringent menorrhagia and dysmenorrhea, as has been apparent in developed women. Additionally attainable is the nut IUD alleged ParaGard, which releases a baby bulk of nut that kills or immobilizes agent afore they can beget an egg. The ParaGard can be removed at any time but should be replaced afterwards 10 years.88
The diaphragm and cervical cap are barrier methods of contraception that additionally crave use of a spermicide. Diaphragms are adjustable acrylic cups that are amid into the afore action and charge abide in abode for 6 hours afterwards intercourse. Cervical caps are acrylic or silicone cups with a close rim that attach to the cervix and accommodate connected contraceptive aegis for up to 48 hours. Because of accident of baneful shock syndrome, caps should not abide for added than 48 hours.89 Consistent, absolute use of these methods is analytical for accomplishing a aerial bulk of effectiveness. The aborticide bulk of the diaphragm with absolute use is 6% and with archetypal use is 20%; for the cervical cap, the aborticide bulk is 26% with absolute use and 40% with archetypal use.89 These contraceptive methods may not be achievable for some adolescents, because they crave a decree and arrangement with a bloom affliction able for a fitting, because 1 admeasurement does not fit all. The boyish charge additionally be adequate and accomplished with insertion. Accident of urinary amplitude infection increases over baseline with both diaphragms and cervical caps; in addition, condoms charge be acclimated in affiliation with these accessories for aegis adjoin STIs.89
The abandonment method, which involves the macho partner’s attack to abjure the penis afore , is still broadly acclimated by adolescents in animal relationships. Adolescents should accept counseling that emphasizes the aerial aborticide bulk of abandonment for abundance prevention. On average, of every 100 women whose ally use withdrawal, 19 will become abundant during the aboriginal year of archetypal use. It is important to accent that preejaculatory aqueous can accommodate abundant agent to account pregnancy. Abundance is additionally accessible if berry or preejaculate leaks out assimilate the vulva. In addition, providers should accent that this contraceptive adjustment does not accommodate aegis adjoin STIs.90
Using fertility-awareness methods as a contraceptive advantage depends on several factors and requires a able ability of the menstrual aeon and changeable fertility. This adjustment involves the identification of abundant canicule aural anniversary menstrual aeon back action is best adequate to aftereffect in pregnancy. Couples can abjure during the abundant times of a woman’s aeon or use a aggregate of either barrier or abandonment methods. As abounding as 25% of users of these methods will acquaintance an adventitious abundance aural the aboriginal year of use, with some estimates of the abundance bulk alike higher.91 To optimize adjustment efficacy, users of this adjustment should clue their menses on a agenda for 3 months while additionally blockage and recording their basal anatomy temperature circadian and should analysis their cervical fungus bendability to clue back they ovulate. Pediatricians should be able to advise adolescents about the menstrual aeon but should accent that ovulation may not be anticipated in the aboriginal few year(s) afterwards menarche. Thus, abnegation or added reliable methods should be recommended for adolescents. In addition, bloom affliction professionals should accent that this contraceptive adjustment provides no aegis adjoin STIs if no barrier methods are acclimated during periods of animal activity.
Emergency contraception can be administered in 2 ways: by orally administering hormones or by inserting a copper-releasing IUD. An IUD can be amid to anticipate abundance up to 5 canicule afterwards caught action but is usually not recommended for adolescents (see IUD section).
The best frequently assigned and best-studied methods of emergency contraception are the accumulated estrogen-progestin (also alleged the Yuzpe regimen) and progestin-only regimens. There is now abandoned 1 committed artefact for emergency contraception: Plan B (DuraMed Pharmaceuticals, Pomona, NY). Plan B, a progestin-only dieting that contains levonorgestrel, is broadly attainable as 2 hormone pills that are taken aural 72 hours of caught intercourse. The best contempo abstracts abutment extending the time absolute of use to 120 hours afterwards caught intercourse; however, emergency contraception’s ability diminishes as hormonal administering becomes added alien from the caught action event.92–94 Boyish patients abnormally should be counseled that Plan B is 90% able if acclimated aural 24 hours, 75% able if acclimated aural 72 hours, and about 60% able if acclimated aural 120 hours. The Plan B dieting can now be simplified to accord both tablets at one time afterwards sacrificing ability or consistent in added adverse effects.94 Aggregate OCPs may be acclimated for emergency contraception back Plan B is not readily available; the dosage depends on the specific artefact chosen.95 A contempo abstraction begin that aggregate OCPs with progestin norethindrone can additionally be acclimated finer for emergency contraception. This abstraction begin that alike a distinct dosage of the articulate contraceptives or accumulated hormone adjustment was able for emergency contraception.96 Adverse furnishings may accommodate nausea, ing, and changes in the menstrual aeon during the ages of use. The progestin-only dieting is about preferred, because it is added able and causes beneath adverse effects.97,98 Overall, emergency contraceptives abate the accident of abundance afterwards caught by at atomic 74%.99,100
Most women who charge emergency contraception can use it safely. If the accommodating or practitioner suspects pregnancy, a abundance analysis can be administered; however, abundance testing afore emergency contraceptive use is not necessary. It is important to agenda that emergency contraception does not account aborticide and it is not teratogenic if taken in aboriginal pregnancy. Women who are already abundant should not use emergency contraceptives because they are abortive at absolute accustomed pregnancies; however, application them aback will not accept an adverse aftereffect on the fetus.99 Six studies accept begin that accouterment emergency contraception in beforehand increases the likelihood of women application it back it is bare and does not admission animal or contraceptive adventurousness behavior.101–106
As the AAP states in its action account on emergency contraception, abridgement of adventitious abundance is best accomplished by strategies that accommodate developing and implementing programs to advice adjournment and abate animal action and accretion the use of able contraceptives.95 However, the AAP continues to abutment bigger availability of emergency contraception to adolescents and advocates clinicians’ application of beforehand emergency contraception decree to ually alive adolescents, acquainted that in some cases, emergency contraception may be absolutely admired in preventing adventitious abundance and that emergency contraception is best able back acclimated anon afterwards caught intercourse.95 Recently, the FDA accustomed over-the-counter admission for Plan B for women 18 years and older, but Plan B still requires a decree for those boyish than 18 years.107 In appearance of the abeyant bulk of emergency contraception, pediatricians should acquaint adolescents about the availability of emergency contraception; however, it should not be advocated as a accepted adjustment of contraception.
The FDA afresh accustomed the aboriginal chewable OCP, Ovcon 35 (Bristol Myers Squibb Company, Princeton, NJ), a spearmint-flavored, 28-day dieting us that contains the aforementioned hormones acclimated in accustomed OCPs. Women who bite the pills instead of burning them should alcohol 8 oz of aqueous after to ensure that the abounding dosage alcove the stomach.108 Accession adjustment afresh accustomed by the FDA is the FemCap, a bendable silicone arch that covers the cervix. FemCap will be attainable by decree in 3 sizes and is advised to aftermost 48 hours per use.89,109 New forms of contraception for males are additionally actuality studied, including an article arrangement agnate to Norplant, account and account hormone injections, and a contraceptive patch.110 A progestin-only l arena is actuality developed, and Norplant II (a 2-rod arrangement as adjoin to the 6-rod arrangement in Norplant) is apprehension FDA approval. Condoms charge be acclimated in affiliation with these new forms of contraception for aegis adjoin STIs.
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