Hormonal Contraception and the Adolescent Patient

Educational Objectives

The goal of this program is to improve adolescent health through therapeutic use of hormonal contraceptives. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate normal from abnormally heavy menstrual bleeding.
2. Evaluate the advantages and disadvantages of various contraceptive options.
3. Counsel patients about risks associated with different types of contraceptives.

Summary

Oral contraceptives (OCs): used for many medical indications; hormonal intrauterine devices (IUDs; eg, Mirena) are used for heavy, irregular periods, as well as birth control; OCs are typically supplied in 28-day packs including 21 active pills and 7 placebos (withdrawal bleed occurs during the placebo week); pills are also available in 24-day packs, which may be used for premenstrual dysphoric disorder (PMDD) or acne; extended-cycle OCs are available but associated with high likelihood of breakthrough bleeding (may be used to protect the uterus in patients with secondary amenorrhea)

Normal menstruation: bleeding is irregular during the first few years after menarche; normal periods occur every 3 to 5 wk; the interval between periods is calculated using the first day of consecutive periods; periods normalize after 2 yr, with duration of ≈5 days; 3 to 6 pads per day is normal

Medical indications for contraceptive medications: include cramping, functional cysts (overly large follicular cysts), heavy menses, irregular menses, contraception, endometriosis, and reducing cancer risk (ie, protecting the endometrial lining in patients with, eg, polycystic ovary syndrome)

Heavy bleeding: indicated by bleeding for >7 days, using >6 fully soaked pads per day, need for doubling of pads, “flooding,” and/or needing to change pads at night; consider evaluating von Willebrand factor, with repeat testing to confirm suspicious findings

Abnormal uterine bleeding (AUB): encompasses the previously used terms “dysfunctional uterine bleeding” and “menorrhagia”; in patients presenting with, eg, an anovulatory phase with bleeding lasting 8 wk and low hemoglobin level (eg, 7 g/dL), norethindrone (eg, Aygestin, Norlutate) 5 mg once daily may be used to suppress bleeding and stabilize and thin the uterine lining; prescribe for 30 days initially and refer to a gynecologist if long-term use is needed

Options for contraception: long-acting, reversible contraception (LARC) is recommended as the first-line option for adolescents by the American Academy of Pediatrics (nearly 100% effective); hormonal IUDs

Mechanism of OCs: prevention of ovulation; thickening of mucus in the cervix deters fertilization of an egg that has been released (eg, if the pill pack is started late); adherence is crucial; clinicians should counsel women to take the pills at approximately the same time every day (recommend setting an alarm or having a parent remind the patient)

Efficacy of contraceptive methods: IUDs are highly effective (hormonal IUDs for ≤7 yr, nonhormonal IUDs for ≤10 yr); contraceptive pills, patches, and rings have similar efficacies (all contain estrogen and progestin); contraceptive injections (eg, Depo-Provera [medroxyprogesterone acetate]) are effective, but patients often fail to return for repeat injections; withdrawal and rhythm have low efficacies

Combined (progestin and estrogen) hormonal methods: contraindications — can be checked via a mobile application; include migraine with aura, blood clots, and hypertension; having a parent with a blood clot is not an absolute contraindication, but the risk of developing clots is increased 2-fold in such patients, even in the absence of a clotting disorder; advantages — provides predictable bleeding; may improve acne; disadvantages — pills require adherence; patches may cause hypopigmented areas and are associated with nausea due to inconsistent absorption (clotting studies have been inconclusive); regimens for nonoral options — rings are placed for 3 wk, removed for 1 wk to allow withdrawal bleeding, then replaced; patches are replaced weekly for 3 wk, followed by a 1-wk break

Bleeding profiles of progestin-only options: useful for patients with a contraindication to estrogen products but associated with unpredictable bleeding; medroxyprogesterone acetateinjections — have a good bleeding profile; 75% to 80% of patients are amenorrheic at 1 yr; bleeding improves with each injection; etonogestrel implant (Nexplanon) — associated with significant irregular bleeding; only 20% of patients achieve amenorrhea at 1 yr; not suitable for those with irregular bleeding and heavy periods; norethindrone — may be used as a bridge to stop bleeding; progestin IUDs — the bleeding profile is similar to that of contraceptive injections; ≈98% of patients report lighter, less painful periods

Estrogen doses and effects: doses in combined OCs range from 10 to 50 μg (10-35-μg doses are most commonly used); associated with improvements in acne and hirsutism secondary to decreased testosterone; adverse effects include headache, breast tenderness, increased blood pressure (uncommon), and clot risk (low)

Combined OCs: first generation — acne may worsen with combinations of norethindrone and ethinyl estradiol (eg, Junel, LoEstrin, Microgestin); a low-dose (20-μg) option may be considered when parents have reservations about hormonal therapy (can be uptitrated to 30 μg, if necessary); helpful for cramping; second generation — combination of norgestrel and ethinyl estradiol (eg, Alesse, Lo-Ogestrel, Ogestrel); more antiandrogenic; effective for treating heavy menses; third generation — combination of norgestimate and ethinyl estradiol (eg, Ortho-Cyclen, Sprintec); reduces acne; fourth generation — combination of drospirenone and ethinyl estradiol (eg, Yaz, Yazmin); risk for clots is somewhat higher than with other options; effective for treating PMDD and acne (the most highly antiandrogenic OC)

Risk for venous thromboembolism: low overall; occurs in 1 in 10,000 women at baseline; with combined OCs, 4 to 6 in 10,000 women; risk is greater during pregnancy or after delivery

Antiandrogenic benefits: a trial of drospirenone-ethinyl estradiol OCs is often initiated before patients begin treatment of acne with isotretinoin (eg, Accutane); excellent results are typically achieved in 3 mo; adding spironolactone 100 mg increases efficacy (200 mg if treating hirsutism)

Other concerns: the discontinuation rate is 11% in first month and 50% in the first year; breakthrough bleeding (ask about skipped doses); mood changes; significant weight gain is not often observed; interaction with other medications (eg, carbamazepine [Tegretol], higher doses of topiramate [Topamax]) lower the effectiveness of OCs); additional contraindications — include smoking, hypertension, liver disease, breast cancer, and complicated irritable bowel syndrome; risk for breast cancer — increases with OCs, but overall risk is not high (≈1 extra case for every 7600 women using OCs for 1 yr)

Additional considerations: OCs are best started on the first Sunday after menses have ended; instruct patients to take a missed pill as soon as it is remembered (and to take 2 pills if a full day is missed); estrogen-progestin patches — have the same adverse effects as combined OCs; less effective in patients weighing >198 lb; emergency contraception — levonorgestrel (eg, Next Choice, Plan B) is available over the counter and is >90% effective if taken within the first 24 hr (less effective in women weighing >165 lb); ulipristal (eg, Ella, Logilia) is available by prescription only and is effective for 3 to 5 days

Readings

Calhoun AH, Batur P. Combined hormonal contraceptives and migraine: an update on the evidence. Cleve Clin J Med. 2017; 84(8):631-638. doi:10.3949/ccjm.84a.16033; Edelman AB, Cherala G, Blue SW, et al. Impact of obesity on the pharmacokinetics of levonorgestrel-based emergency contraception: single and double dosing. Contraception. 2016; 94(1):52-57. doi:10.1016/j.contraception.2016.03.006; Hillard PA. Menstrual suppression: current perspectives. Int J Womens Health. 2014; 6:631-637. Published 2014 Jun 23. doi:10.2147/IJWH.S46680; Lavin M, Aguila S, Dalton N, et al. Significant gynecological bleeding in women with low von Willebrand factor levels. Blood Adv. 2018;2(14):1784-1791. doi:10.1182/bloodadvances.2018017418; Mathur R, Levin O, Azziz R. Use of ethinylestradiol/drospirenone combination in patients with the polycystic ovary syndrome. Ther Clin Risk Manag. 2008;4(2):487-492. doi:10.2147/tcrm.s6864; Mayeda ER, Torgal AH, Westhoff CL. Weight and body composition changes during oral contraceptive use in obese and normal weight women. J Womens Health (Larchmt). 2014;23(1):38-43. doi:10.1089/jwh.2012.4241; Rajashekar S, Giri Ravindran S, Kakarla M, et al. Spironolactone versus oral contraceptive pills in the treatment of adolescent polycystic ovarian syndrome: a systematic review. Cureus. 2022;14(5):e25340. Published 2022 May 25. doi:10.7759/cureus.25340; Shoupe D. LARC methods: entering a new age of contraception and reproductive health [published correction appears in Contracept Reprod Med. 2016 Apr 14;1:6]. Contracept Reprod Med. 2016;1:4. Published 2016 Feb 23. doi:10.1186/s40834-016-0011-8; Zöller B, Ohlsson H, Sundquist J, Sundquist K. Family history of venous thromboembolism is a risk factor for venous thromboembolism in combined oral contraceptive users: a nationwide case-control study. Thromb J. 2015;13:34. Published 2015 Oct 21. doi:10.1186/s12959-015-0065-x.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. DiPaolo was recorded at Hot Topics in Pediatrics, held July 21-23, 2022, at Lake Buena Vista, FL, and presented by Nemours Children's Health, Jacksonville, FL. For information on future CME activities from this presenter, please visit https://www.nemours.org/education/cme. Audio Digest thanks the speakers and Nemours Children's Health for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

PD684201

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.