Contraceptives and teens: What are the options?
Consider these statistics: About one-fifth of female adolescents say they had sex before age 15. By age 17, 52% have had sex at least once.1 What methods of contraception do these young women use for protection against pregnancy?
According to information from the Alan Guttmacher Institute in New York City, 35% take oral contraceptives (OCs), 29% use condoms, 11% use injectables, and 5% choose other methods.2 Teen use of the injectable depot medroxyprogesterone acetate (Depo-Provera or DMPA, manufactured by Pharmacia & Upjohn of Bridgewater, NJ) is on the rise, say participants in Contraceptive Technology Update’s 2000 Contraceptive Survey. (See chart above.)
"We have many teens using DMPA," notes Barbara Kremer, CNM, MPH, a clinician at Planned Parenthood of Southern Arizona in Tucson. "Most like the convenience of it, as well as the high rate of efficacy."
DMPA is very popular among teens, agrees Diana Lithgow, RN, FNP, family nurse practitioner at Laguna Beach (CA) Community Clinic. It eliminates the telltale pill packs that signal use of contraception, and teens don’t have to worry about forgetting pills, she notes.
Research published in the early 1990s indicated that users of DMPA might develop decreased bone density.3 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.4
Providers say that despite any reservations concerning DMPA, they are willing to prescribe the injectable for young teens: 94.1% of participants in the 2000 Contraception Survey denoted such a preference.
"I try to use OCs first because I like the benefits, but if they cannot remember to take them on time and daily despite attempts at behaviors to help them remember, then Depo-Provera is definitely recommended," says Pamela Porter, PA-C, CRN, FNP, MSN, a clinician at Woodland (CA) Healthcare, a multispecialty clinic. "Pregnancy prevention is a far bigger concern than the osteoporosis concerns."
Half discuss bone mineral density
About half of survey respondents say they inform patients of DMPA’s potential effect on bone mineral density. Another 31.7% say they use other precautions, which include counseling on additional calcium supplementation. Nearly 14% say they take no precautions. (See chart on precautions to take in prescribing Depo-Provera, given the possibility that it might diminish bone mass, p. 111.)
All women are asked at their annual exam about diet and calcium intake, says Deborah Mathis, MSN, CRNP, women’s health coordinator at the University of Pennsylvania Student Health Service in Philadelphia. Informational handouts are available, and providers stress the need for 1,000 mg of daily calcium to all patients. (See resource box, p. 112, for calcium counseling information.) "We doubly stress it to our DMPA patients and do follow-up at most three-month visits," she adds.
Research is reassuring
Research now indicates that DMPA’s impact on bone density is a short-term or current-user effect, apparently without long-term implications, says Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/Jacksonville and director of menopause and gynecology services at the Medicus Women’s Diagnostic Center in Jacksonville.
He points to two studies:
• A New Zealand-based observation showed that menopausal former DMPA users had bone mineral density identical to that of age-matched never-users.5
• A recently published multicenter cross- sectional study performed in seven centers in three regions of the developing world indicates that former DMPA users had bone density similar to the bone density of never-users.6
In a long-term DMPA user, consider whether extra bone density concerns are present, such as with a slender, Caucasian, cigarette-smoking woman who started DMPA as an adolescent and is continuing injectable progestin-only contraception long-term, Kaunitz suggests. It is reasonable and easy to add "add-back" oral or transdermal estrogen, using menopausal or higher doses, he says. No published data, however, address the use of such add-back estrogen therapy, he adds.
How to treat cramps
What would you prescribe for an adolescent with severe dysmenorrhea who is not sexually active, has no plans to engage in such activity, and has found no relief from aspirin?
About 45% of participants in the 2000 survey say they would prescribe an oral contraceptive and a prostaglandin inhibitor. One-quarter say they would provide just a prostaglandin inhibitor, with an equal amount recommending just an OC. About 5% would use other methods. (See chart on an initial approach for a 17-year-old with severe dysmenorrhea, at left.)
Porter says she frequently offers OCs to teens and brings up the subject when their mothers accompany them. That approach allows Porter to discuss the benefits OCs can offer.
"I find that 99% of the time, it opens good communication between parent and child on a subject that neither knew how to approach," Porter says. "I recommend it for control of cycles, decreasing [their] length, acne reduction, less premenstrual syndrome, and, of course, if they do become sexually active, they are protected from pregnancy."
References
1. Terry E, Manlove J. Trends in Sexual Activity and Contraceptive Use. Washington, DC: National Campaign to Prevent Teen Pregnancy; 2000.
2. Alan Guttmacher Institute. Teenage Pregnancy: Overall Trends and State-by-State Information. New York City; April 1999.
3. Cundy T, Evans M, Roberts H, et al. Bone density in women receiving depot medroxyprogesterone acetate for contraception. BMJ 1991; 303:13-16.
4. Cundy T, Cornish J, Evans MC, et al. Recovery of bone density in women who stop using medroxyprogesterone acetate. BMJ 1994; 308:247-248.
5. Orr-Walker BJ, Evans MC, Ames RW, et al. The effect of past use of the injectable contraceptive depot medroxyprogesterone acetate on bone mineral density in normal post-menopausal women. Clin Endocrinol (Oxf) 1998; 49:615-618.
6. Petitti DB, Piaggio G, Mehta S, et al. Steroid hormone contraception and bone mineral density: A cross-sectional study in an international population. The WHO Study of Hormonal Contraception and Bone Health. Obstet Gynecol 2000; 95:736-744.
Resource
• The Web site for the National Dairy Council in Rosemont, IL, features a Calcium Counseling Resource with five reproducible handouts that providers can download to help patients meet their calcium needs and overcome barriers to improving their calcium status. Go to www. nationaldairycouncil.org, click on "Nutrition Clinic," then "Calcium Counseling Resource."
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