Contraception early and late reproductive age group

DRHJZAINALABIDINHJHANAFIAH Consultant O&G, HRPZII

Teenage the reality

THE CURRENT SITUATION (Unesco report 2008) Half of the worlds population are under 25. Some 1.8 billion are aged 10-25, historys largest generation of adolescents, and about 85% live in the developing world. Most people become sexually active before their 20th birthday. 49% of girls in least developed countries marry before they turn 18. 10% 40% of young unmarried girls have had an unintended pregnancy according to community studies. Some 14 million children worldwide are born every year to young married and unmarried women aged 15 to 19.

The 2007 youth behavior surveillance U.S.

47.8% of students reported ever having had sexual intercourse (46.8% in 2005)
7.1% of students reported having had sex before the age of

13 years (6.2% in2005) 14.9% of students reported having had sex with four or more sexual partners (14.3% in 2005) 35.0% of students reported being currently sexually active, defined as having had sexual intercourse in the 3 months before the survey (33.9% in 2005) 61.5% of sexually active students reported that they or their partner had used a condom during last sex (62.8% in 2005)

TEEN PREGNANCY MEDICAL OUTCOMES

Less likely to receive prenatal care, often seeking it only in the third trimester, or none at all. As a result, the global incidence of premature births and low birth weight is higher amongst teenage mothers. Complications are greater for girls 14 years of age and younger, as an underdeveloped pelvis can lead to difficulties in childbirth.

 Obstructed labour which is common, which if

Caesarean section is not available can cause an obstetric fistula, a tear in the birth canal that creates leakage of urine and/or faeces. At least 2 million of the worlds poorest women live with fistulas. Complications during pregnancy and delivery are the leading causes of death for girls aged 15 to 19 in developing countries. They are twice as likely to die in childbirth as women in their 20s. Teenage girls account for 14% of the estimated 20 million unsafe abortions performed each year, which result in some 68,000 deaths.

Teenage pregnancy and adverse outcomes

How can this be avoided?

Specifically, effective approaches share three themes: Among adolescents who have not had sex, they encourage and reinforce these teens

decisions to be abstinent; Risky sexual activity among adolescents who have had sex by providing medically accurate information and access to preventive health care, including contraception. As a result, sexually active teens are more likely to use contraceptives consistently and correctly; and Effective programs such as: Using trained leaders who believe in the program; actively engaging youth in ways that personalize the information received; addressing peer pressure; teaching communication skills; and reflecting the age, sexual experience, and culture of the youth in the program.
Evaluations of comprehensive approaches that include all of these elements consistently show the following results: Decreases in rates of sexual activity; Fewer partners among sexually active teens; Decreases in unprotected sexual activity; and Decreases in rates of STDs Decreases teen pregnancy

Most of the decline in the teenage pregnancy rate over the past decade can be attributed to increased contraceptive use, with a small contribution from decreased sexual activity . To reduce the rates of teen pregnancy, programs must either improve teenage contraceptive behaviors, reduce teens sexual activity, or both.

CONTRACEPTION AND YOUNG PEOPLE: CHALLENGES

Many societies, including in Malaysia, disapprove of

premarital sex. As a result, young people have limited or no access to education and information on reproductive sexual health care. Modern contraceptive use among adolescents is generally low, and decreases with economic status. Fewer than 5% of the poorest young use modern contraception. Young women consistently report less contraceptive usage than men, evidence of their unequal power in negotiating safer sex or restrictions on their access to services (such as lack of information, shame, laws, health provider attitudes and practices, or social norms).

 Young people may hesitate to visit clinics because of lack

of privacy and confidentiality, inconvenient locations and hours, high costs, limited contraceptive choices and supplies, and perhaps most importantly, negative or judgmental provider attitudes. Laws and policies also may restrict adolescents access to information and services, for example, by limiting family planning to married people or requiring parental or spousal consent. A basic challenge in advocacy, especially in traditional societies, is the taboo on public discussion of sexual issues, including the fact that many young people are sexually active before marriage.

 The American College of Obstetricians and

Gynecologists (ACOG) has recently published recommendations for the first preventive visit with a gynecologist to be between the ages of 13 and 15 years. The time spent with their provider allows adolescents the opportunity to identify risk factors and challenges that can be overcome before the initiation of hormonal or non-hormonal contraception, in addition to encouraging abstinence.

Contraindications:
Absolute contraindications for contraception are

limited to only two conditions: thromboembolic mutations and the use of estrogencontaining methods and current pelvic inflammatory disease or mucopurulent cervicitis and initial placement of an intrauterine device (IUD).

 Abstinence: the most effective means of

birth control Unfortunately, recent data suggest that abstinence-only programs are not as effective as those in which other contraceptive options are offered at the same time.

 The male condom is the most commonly used

barrier method by adolescents. The efficacy in preventing STIs and the HIV epidemic increased their use during the 1990s. Despite their availability, however, the use of condoms is still not widespread reason; decreasing the spontaneity Practitioners should encourage the use of barrier methods, even when the teen is on another form of contraception.

 COC: best for efficacy and safety

Most effective and added non contraceptive benefits

High failure rate 15% (between age 15-17), up 28%

missed pills. Lower failure rate >18 years To prevent non compliant quick start vs traditional start. Other combined hormonal: transdermal patch and vaginal ring

 The progestin-only contraceptive pill and DMPA has been shown to

have similar efficacy to the OCP. Unfortunately, given its short half-life, failure rates may be increased because of patient noncompliance with the proper timing of the pill, which requires taking it around the same time of day (within 3 hours) each day. Extensive education regarding the irregular bleeding occurring in the first 3 months and need for compliance with pill dosing at a similar time each day is required to enhance adolescent compliance. Certain contraindications to these hormonal methods may include sensitivity to the agents, osteoporosis, undiagnosed vaginal bleeding, pregnancy, or severe liver disease.
Especially useful if teen mother is breastfeeding Other progestins like implanon subdermal implant.

 Traditionally, use of an IUCD or IUS has been avoided in

adolescents, because this population has the highest rates for STIs. Age alone is not an absolute contraindication to the use of these devices. WHO categorizes this forms of contraception as class 2 for individuals less than or equal to the age of 20 years. In recent studies, there has not been an increase in infertility or STI incidence with the use of these devices.

Emergency contraception
Emergency contraception (ECP), the use of non-

abortifacient hormonal medications within 72 to 120 hours after unprotected or underprotected coitus for the prevention of unintended pregnancy, is an important part of contraception counseling in adolescents. LNG 1.5 mg single dose or 0.75mg bd for 2 doses Copper IUCD Ulipristal 30mg single dose

In summary
Abstinence is best, study in US showed moral uplift, values and religion play a major role in the decision about sex. 2. Improve adolescent health access, access to comprehensive care, which includes counseling on abstinence and all contraceptive methods, and requiring pelvic examinations before the provision of services would be detrimental to the success of our prevention programs and should be discouraged.
1.

3. Fraser guidelines (gillick vs.west norfolk and wisbech health

authority) states its lawful to provide contraception without parental consent if health professional satisfied that:

The young person will understand the professionals advice The young person cannot be persuaded to inform their parents Likely to begin or to continue having SI with/without contraception Unless contraception is prescribed, their physical/mental or both likely to suffer For the young persons best interests require them to receive contraception with / without parental consent.

Note: although criteria apply to contraception, the principles are deemed to apply to others Rx, including abortion.

CONTRACEPTION for women over 40 years

 44 year old mrs wz a teacher with 3 children aged

between 11 to 19 years. Her 47 year old husband is also a teacher. She used DMPA for 4 years after her LCB, but discontinued after found herself gaining weight. The couple then has been relying on the method of safe period. Recently one of her colleague was pregnant despite practicing safe period which left her with much trepidation. They decided to consult the doctor regarding contraception as they wish to avoid unplanned pregnancy. How would you as the doctor advice and help them with their contraception requirement.

Special issues related to women >40years

Menstrual irregularities Concurrent medical conditions Increase risk of malignancies. Reduced fertility Altered frequency of intercourse Medical/social consequences of unplanned

pregnancy Issue of when to stop in women of perimenopause age.

OCP
Appropriate, provided specific risk factors

are excluded: - IHD, VTE, hypertension, stroke, migraine, complicated diabetes, breast CA, cervical CA, smoking are all risk factors for complication for OCP. Advantages are reduction in Endometrial, ovarian and colorectal CA, reduced menstrual irregularities, dysmenorrhoea, ovarian cyst, PID and endometriosis, possible
increase in BMD and decrease hot flushes

Progestogen only contraception (POC)

Limited data shows no associated risk of CVS disease

and breast CA. And not advisable in the presence of IHD, stroke, migraine, breast CA, hypertension and diabetes with complication. But, reduces BMD, caution in women with irregular bleeding (need to distinguish between side effects or underlying pathology). Prolonged amenorrhoea with POC is helpful in menorrhagia and endometriosis.

Sterilization

Globally, among the commonest method

among women >40 years. Benefits of a permanent method of last few years reproductive life against surgical consequences. Male sterilization should also be mentioned

IUCD/IUS
Copper IUD provide long term effective

contraception at least 10 years with minimal compliant and devoid of CVS risk or malignancy. IUS must be change every 5 years, advantageous for heavy bleeding.

What then is suitable for Mrs WZ?

She requires effective method for about 6 years
1st option: Cu IUD , minimal compliant, covers till

menopause (vaginal infection/uterine anomalies must be excluded) 2nd option: LNG IUS if heavy menstrual 3rd option: OCP may be offered. 4th option: consider sterilization.

When and how to stop at menopause

Advisable to stop when she ceases to ovulate! Generally accepted, a woman is unlikely to ovulate if

shes not on hormonal contraception: > 50 years of age after one year of amenorrhoea < 50 years of age after 2 years of amenorrhoea. If shes on hormonal (not OCP/DMPA): Can continue (POP/implants/IUS) till age of 55 after which unlikely to ovulate (POC often induces amenorrhoea
due to its action on endometrium not ovarian failure, OCP still cause withdrawal bleed even when ovaries failed)

summary

Most older women still can be offered a surprisingly

wide choice. A wider choice of progestogen only method for women where estrogen is contraindicated. Sterilization is more popular in this age group compared to younger group of women.