Providers share views on treatment of teens
Do teens represent a large portion of your family planning practice? If they do, join the majority of Contraceptive Technology Update readers who shared their viewpoints on adolescent care in our 1998 survey. From easing menstrual cramps to views on depot medroxyprogesterone (DMPA), providers offered a number of approaches to meeting the medical needs of adolescents in their survey responses.
While more than 90% of CTU readers say they are willing to prescribe DMPA to teens, at least 62% of them say they at least inform patients of the possible risk of diminished bone mass that may be encountered with the injectable method. (See CTU, January 1998, pp. 1-3, for more on this subject.)
Concern over bone density was sparked with the 1991 publication of a New Zealand cross- sectional study of 30 long-term DMPA users. This retrospective study found a difference of about 7% in bone density between DMPA users ages 25 and 51 and other premenopausal users.1 A subsequent study of some of the original DMPA users who discontinued the method found that bone density tended to increase after the method was stopped.2 Some providers are concerned about DMPA's effect during adolescence, a time of peak bone-building activity.
Iris Stendig-Raskin, CRNP, MSN, RNC, a nurse practitioner at Planned Parenthood Association of Bucks County in Bristol, PA, says her facility recommends calcium supplementation to all DMPA clients.
"We advise them to take four Tums [or whatever calcium equivalent they wish to use] per day, to minimize the bone demineralization that is known to occur with DMPA," she states. "The majority seem open to this suggestion."
At the Umatilla County Public Health Division in Pendleton, OR, the use of calcium supplements is reinforced if patients' intake is less than 1000 mg/day, say Shellie Johnson, BSN, RN, public health nursing supervisor, and Katrina Susi, BSN, RN, public health nurse III. The facility also offers several pamphlets and information sheets on calcium-rich foods.
"DMPA is an increasingly popular birth control method at our facility," comment the two clinicians in a written follow-up to their survey. "Convenience and efficacy are the most frequent reasons cited by our clients for their choice."
Challenges and solutions
DMPA is probably the No. 1 contraceptive choice at Clinic Services of Carlisle (PA) Hospital, says Rita Schlansky, RNC, MSN, CRNP, a nurse practitioner at the facility. Such popularity has led Schlansky to develop a DMPA counseling form for all nurses and nurse practitioners to use each time a patient comes in for an injection. (See p. 133 for a copy of the counseling form.)
During counseling sessions, providers discuss ways to increase calcium and vitamin D intake, Schlansky states. They also promote weight-bearing exercise, as well as ways to incorporate it into patients' lifestyles. If patients smoke, providers discuss smoking cessation methods and provide literature.
Prior to the initial DMPA injection, an intense one-on-one counseling session takes place, says Schlansky. At each visit for re-injection, the patient is sent home with a handout provided by DMPA manufacturers Pharmacia and Upjohn of Kalamazoo, MI. Patients are encouraged to call the clinic office between visits with any questions or concerns.
The top challenge with DMPA patients at Clinic Services is what staff members term DNKAs, which stands for "did not keep appointment, says Schlansky.
"We have wrung our hands over this problem," she explains. "We call the patient a day before the appointment as a reminder. We provide appointment cards. We now have a form that the patient signs, stating that if she misses three appointments, she needs another re-enrollment visit, which can be somewhat lengthy."
(Has your clinic found an effective way to deal with this problem? Please share it with other CTU readers by mailing it to Contraceptive Technology Update, P.O. Box 740056, Atlanta, GA 30374.)
Easing dysmenorrhea
What do providers recommend for those teens who are not sexually active, don't plan to be for the next year, yet report severe dysmenorrhea? CTU readers who participated in the annual pill survey are evenly distributed in their approach to this scenario. About 28% would recommend an oral contraceptive, some 32% would offer a prostaglandin inhibitor, and 35% would prescribe both.
Gail Lasher, ARNP, an OB/GYN nurse practitioner at the Everett (WA) Clinic, a multispecialty clinic, says even though she uses several different types of pills, no one formulation completely eradicates severe dysmenorrhea. She provides both OCs and anti-prostaglandins for her adolescent patients to ease such menstrual cramps.
An Alaskan nurse practitioner who asked not to be identified reports she regularly sees teens who are not currently sexually active, but who seek relief from menstrual cramps. She uses the same counseling strategies she would for someone desiring contraception.
"I talk about the benefits vs. risks, and with a low-dose pill, it's a great relief for many teens to have regular menses without pain and premenstrual symptoms," she notes.
References
1. Cundy T, Evans M, Roberts H, et al. Bone density in women receiving depot medroxyprogesterone acetate for contraception. BMJ 1991; 303:13-16.
2. Cundy T, Cornish J, Evans MC, et al. Recovery of bone density in women who stop using medroxyprogesterone acetate. BMJ 1994; 308:247-248.
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