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Contraception in Adolescents
Symposium on Pediatric and Adolescent Gynecology
Contraception in Adolescents
Stanley C. Marinoff, M.D., MP.H.*
Major changes with regard to the provision of contraceptive services for teenagers have occurred over the past few years. The end of the 1960's saw physicians struggling with the moral and ethical problems they faced. 6 However, as it soon became obvious that something must be done to stem the rise of teenage pregnancies, most of which in the earlier ages were out-of-wedlock, the trend went from whether to provide birth control to how. The American Academy of Pediatrics, in April, 1971, recommended that "the teenage girl whose sexual behavior exposes her to possible conception should have access to medical consultation and the most effective contraceptive advice and methods consistent with her physical and emotional needs; the physician so consulted should be free to prescribe or withhold contraceptive advice in accordance with his best medical judgment in the best interests of his patient." The American College of Obstetricians and Gynecologists in May of 1971 made the following statement on contraceptive services to minors: The never-married, never-pregnant, sexually involved female has not yet been reached with effective contraception. The laws of some states indirectly prohibit this service for minors and thereby prevent the gynecologist from serving them or place the physician in legal jeopardy if he does so. The American College of Obstetricians and Gynecologists believes that: The unmarried female of any age whose sexual behavior exposes her to possible conception should have access to the most effective methods of contraception. In order to accomplish this, the individual physician, whether working alone, in a group or in a clinic, should be free to exercise his best judgment in prescribing contraception and, therefore, the legal barriers which restrict his freedom should be removed. These restricting legal barriers should be removed even in the case of an unemancipated minor who refuses to involve her parents. A pregnancy should not be the price she has to pay for contraception. On the other hand, in counseling the patient, all possible efforts should be made to involve her parents. The contraceptive services should be offered whenever possible in a broad spectrum counseling context which would include mental health and venereal disease.
*Assistant Professor, Departments of Obstetrics and Gynecology and Community Medicine, The Mount Sinai School of Medicine; Director, Adolescent Guidance Clinic, Mount Sinai Hospital, New York, New York Supported in part by Grant RF 71-002 from the Rockefeller Foundation.
Pediatric Clinics of North America- Vol. 19, No.3, August 1972
811
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Every effort should be made to include male partners in such services and counseling.
Legal Status As far as contraceptive services are concerned, one is not a minor after age 18, with few exceptions. Married teenagers and those of majority age may give their own consent. The provision of contraceptive services to teenage minors without parental consent has now become the major question that faces the practicing physician. Seven states, Colorado, Illinois, Oregon, Tennessee, Virginia, West Virginia, and Wyoming, have passed laws allowing minors to give their own informed consent for contraception. Many other states have approved legislation to allow minors to consent to medical examinations and treatment for venereal disease. The trend seems to be in the direction of allowing young adults to make decisions concerning their own health care and, furthermore, to allow the physician to provide medical services including contraception to those classified by law as minors. "Birth Control, Teenagers and the Law: A New Look, 1971" by Pilpel and Wechsler gives an astute review of the subject as well as a state by state description of the pertinent laws. Medical Status While the legal status is in a state of flux, the medical status of teenage contraception is undergoing constant change also. The use of oral hormonal compounds to "regulate" periods is undergoing scrutiny. The attitude toward the use of intrauterine devices (IUD) in the nulliparous is changing. The concept of motivation for pregnancy as well as for contraception is becoming more important. The availability of safe, legal abortion in some states has changed medical concepts of what is the safest form of birth control. On the following pages, these topics will be discussed on the basis of an approach to the teenage contraceptor that has been developed. This approach is aimed primarily at the high school teenager rather than the potentially more sophisticated high school graduate, college student, or working girl. Byage 17 most females will have reached biologic maturity. However, chronologic age does not necessarily assure emotional maturity, so each patient must be treated individually. The discussion of specific contraceptive methods will be limited to their advantages and disadvantages in reference to the adolescent population.
DELIVERY OF SERVICE To successfully deliver family planning services to adolescents, one must first reach sexually active teenagers with information about services; secondly, one must create an atmosphere in which the delivery of these services is conducive to their acceptance and use. This relates to the private practitioner's office as well as the clinic. The most promising means of reaching the teenage population is by word of mouth. Direct communication allows the teenager to provide more than just the infor-
CONTRACEPTION IN ADOLESCENTS
813
mation as to where and when services are offered. Flyers per se have not been useful in reaching target populations. The flyer just informs; the milieu of the clinic or office is transmitted by the face to face communication. And it is this milieu that is most important. How the teenager is treated on entrance to the facility lays the groundwork for all that follows. There is immediate nonverbal as well as verbal communication. The teenager dislikes the hospital setting and especially the rigors of the medical "system." Attempts should be made to dispense with as much of the formalities as possible. Some clinics have developed a drop-in situation where no appointments are needed. Others have made their contraceptive programs separate from the general medical setting; some have felt that it should be part of comprehensive medical care. One program uses teenagers as receptionists and counselors. Another has set up a teen advisory council to help with the running of the clinic. Each system has its advantages and disadvantages. However, whichever is used, the nonjudgmental attitude of the staff and the proper counseling. set-up are essential. Lack of availability of contraceptives will force adolescents into using improvised methods. A survey in one southern city found the most common contraceptive methods among the teenagers were douching with a popular brand of soda and Saran-Wrap condoms. Because of the lack of knowledge of reproductive processes and of the availability of contraceptives, teenagers will continue to use these methods, erroneously thinking that they are effective and the only means available. Educational programs will correct these fallacies. However, the provision of contraceptive services and pure sex education are not enough. The teenager is searching for answers to questions that are not being supplied by the school system, church, or parents. What teenagers are seeking is their identity in relation to human sexuality. For this reason informal rap sessions have become an integral part of contraceptive counseling. It is through this approach that the teenager is not only given the information needed to help make the decisions involved in a mature outlook towards sex, but is also provided with a channel for expressing his own feelings in a peer group setting.
METHOD COUNSELING Individualization is the key word in the approach to the teenage contraceptor. There is no one best method for all patients. Some of the factors which must be considered are: (1) frequency of sexual relations; (2) development of the individual- both physically and emotionally, and (3) motivation for contraception. Frequency of sexual intercourse plays a major role in the type of contraceptive that the physician will prescribe. Among 583 predominantly white female teenagers requesting contraception at a Planned Parenthood facility, over 50 per cent of those answering the question had coitus more than once a week. 4 In a survey of low income, pregnant adolescents, 40 per cent had intercourse more than four times before becoming pregnant. 3 It is unsound to place the female who has only sporadic relations
814
STANLEY
C.
MARINOFF
on long term hormonal contraceptives. This patient needs knowledge of sexual function and the availability of a convenient method. Moreover, the efficacy of any method, no matter how sound medically, still lies in the motivation for its use. Among a group of abortion repeaters it was found that the motivation for pregnancy was so great that no amount of education or availability of contraceptives would be successful. The use of paramedical personnel or teenagers has been useful in helping the patient make the choice of method. The advantages and disadvantages of each method are openly discussed in relation to the factors outlined. Once a method is chosen, the physician must approve of it medically taking into consideration all the contraindications for each method. Freedom for change of method is always left open. The patient is seen at regular intervals and the use of the method checked for accuracy of use as well as undesirable side-effects. If there has been a change in the status of the individual, the method may be changed to reflect this new status. By laying a groundwork in education and knowledge about the patient, her life patterns, her emotional and physical development and motivation for contraception, the patient can be started toward a life of sensible and effective contraception.
METHODS
Condoms For the teenager, the condom is the most easily available and cheapest form of contraception. Also, it is the only form of contraception that protects against venereal disease. It is available without a prescription and can be purchased from vending machines as well as in drug stores. The quality is controlled by the Federal Drug Administration and one brand is as effective as another. The acceptance of such a method when made available to adolescent males was demonstrated by a study in an inner city area of North Carolina. This study sponsored distribution of free condoms through commercial outlets such as grocery stores, barber shops, and pool halls. Results showed an increase in the use of the condom from 19 to 68 per cent and an increase of those who used it with their last coital exposure from 20 to 91 per cent. The conclusions drawn from this study were: "(1) Condoms are acceptable to adolescents in a magnitude not previously appreciated; (2) adolescent males will accept a sizable share of the burden in pregnancy prevention if given the opportunity; and (3) small neighborhood commercial outlets have a potentially important role in nonclinical contraceptive distribution programs."l Spermicidal Creams, Jellies, and Foams Creams, jellies, and foams are also available over the counter without . a prescription. They work by producing a spermicidal environment in the vagina. Because of this, they must be inserted no more than 60 minutes before intercourse and a repeat application must be used if relations are repeated. Better dispersion makes the foam much more effective than
CONTRACEPTION IN ADOLESCENTS
815
creams or jellies alone. Recent advances in the field of foams have brought forth pre-filled applicators. This allows filling of the inserter up to seven days prior to use so it then can be carried with an individual until used. Two hundred and ninety-six patients ages 15 to 20 who used this method for an average length of 270 days had a pregnancy rate of 6.4 per cent. However, the combination of an aerosol contraceptive foam and a condom brings to the less sexually active teenager a method that is cheap, easily available without a prescription, and effective if used properly.
Diaphragm A method that has a high use effectiveness rate with extremely few side-effects is the diaphragm. It should never be used alone as it is not as exact a barrier as is the condom. It is used with a spermicidal jelly or cream that provides the extra protection needed. The disadvantages in the adolescent population are (1) it must be fitted by a physician, (2) it needs a prescription to be purchased, and, most important, (3) it needs motivation and some skill to be used effectively. However, for the young adult with good motivation and an ongoing relationship, it represents a reasonable approach to contraception. The fitting should be by a trained individual who will instruct the patient in its use. The main advantage of the diaphragm is its lack of immediate side-effects and potential for long range deleterious effects.
Rhythm Method The rhythm system at its most effective use will produce about 14 pregnancies per 100 women-years. The term women-years is based on 13 cycles per year for 1 woman, or 1 cycle for 13 women or any combination thereof. Therefore, in 100 women-years we are discussing 1300 cycles in any combination. This method depends on the regularity of the cycle and on an understanding of the concept of ovulation. To be most effective, the cycle length for at least a year should be charted with the aid of a daily basal body temperature. The irregularity of the adolescent cycle, especially in the first years following menarche, and the lack of knowledge about ovulation exhibited by most adolescents preclude this as an effective measure in this population. In a study of pregnant adolescents misconceptions about the "safe period" was found to be one of the most striking examples of lack of sexual knowledge.
Douching Douching has no place in the armamentarium of contraceptive techniques. On ejaculation, the male releases millions of sperm directly into the cervical canal. By the time the female douches, these are already well into the canal and perhaps the uterus-well out of reach of any douche solution.
Oral Contraceptives The "pill" has become synonymous with a variety of oral contraceptives, all combining a synthetic progesterone known as a progestin and an
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estrogen. Table 1 lists the currently available combination type pills. Oral contraceptives act primarily by inhibiting ovulation. The administration of estrogen and progestin replaces the cyclic hormonal production of the body. It seems the primary effect of the sustained estrogen level is to block the release of luteinizing hormone (LH) from the pituitary. There may also be some blockage of follicle-stimulating hormone (FSH). In addition, the pill inhibits the normal maturation of the endometrium and produces a cervical mucus hostile to sperm penetration. The combination of these three actions makes it 100 per cent effective if taken properly. To decrease the chance of error in taking oral contraceptives, most manufacturers now package the pill in 21 or 28 day cycle kits. With the 21 day package, the patient has only to remember to start one week after stopping, on the same day. The 28 day package has 7 inert pills so the patient takes one pill a day continually once she has started. The first cycle is best started on the fifth day of menstruation, counting the first day of bleeding as day one. A complete history and physical is necessary before prescription of the pill. The history should be detailed enough to rule out hepatic disease, a tendency toward or previous thromboembolic phenomena, and a family history of mammary or endometrial cancer. A Papanicolaou smear is done and repeated annually. In the sexually active adolescent, a culture from the endocervix for gonococcus is also taken. Absolute contraindications to prescribing the oral contraceptives are the same in adolescents as in the adult. They are: (1) thrombophlebitis, thromboembolic disorders, cerebral apoplexy or a past history of these conditions; (2) markedly impaired liver function; (3) known or suspected carcinoma of the breast; (4) known or suspected estrogen-dependent neoplasia; (5) undiagnosed abnormal genital bleeding.
Table 1.
Commonly Available Combination Oral Contraceptives
AGENT
Demulen Enovid E Enovid 5 Norinyl1 Norinyl2 Norlestrin 1 mg. or Norlestrin Fe 1 mg. Norlestrin 2.5 mg. or Norlestrin Fe 2.5 mg. Provest Ortho-Novum 1/50 Ortho-Novum 1/80 Ortho-Novum 2 Ovral Ovulen Ovulen-21 Ovulen-28
ESTROGEN
Ethinyl estradiol 0.05 mg. Mestranol 0.10 mg. Mestranol 0.075 mg. Mestranol 0.05 mg. Mestranol 0.10 mg. Ethinyl estradiol 0.05 mg. (F e = inert tablets Fe) Ethinyl estradiol 0.05 mg. (Fe = inert tablets Fe) Ethinyl estradiol 0.05 mg. Mestranol 0.05 mg. Mestranol 0.08 mg. Mestranol 0.10 mg. E thinyl es tradiol 0.05 mg. Mestranol 0.1 mg.
PROGESTIN
MANUFACTURER
E thynodiol diacetate 1 mg. Norethynodrel 2.5 mg. Norethynodrel 5.0 mg. Norethindrone 1 mg. Norethindrone 2 mg. Norethindrone acetate 1 mg.
Searle
Norethindrone acetate 2.5 mg.
Parke-Davis
Medroxyprogesterone acetate 10 mg. Norethindrone 1 mg. Norethindrone 1 mg. Norethindrone 2 mg. Norgestrel 0.5 mg.
Upjohn
Ethynodiol diacetate 1 mg.
Searle Searle Syntex Syntex Parke-Davis
Ortho Ortho Ortho Wyeth Searle
CONTRACEPTION IN ADOLESCENTS
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In adolescence, those contraindications concerning liver function and undiagnosed abnormal genital bleeding are the most pertinent. Abnormal bleeding in the adolescent cannot be automatically attributed to its most common cause, dysfunctional bleeding associated with anovulation. Recent reports of adenocarcinoma of the vagina in young women whose mothers had taken estrogens during pregnancy makes it imperative that a pelvic examination be done on all patients with abnormal bleeding. The use of a proper speculum combined with a rectal exam and abdominal palpation permits this exam, in a majority of cases, to be performed without undue discomfort even in the virginal female. Of the other possible contraindications, failure of epiphyseal closure, and failure to establish regular menses must especially be considered in the adolescent. Most females will have completed their bone growth by age 14 or 15. The introduction of estrogens in the dosage employed in the low dose oral contraceptives most likely will have little influence on the normal teenager's growth pattern. The problem of failure to establish menses is more important. About 2 to 3 per cent of patients receiving oral contraceptives have amenorrhea and anovulation post treatment. Most of these patients have a history of irregular periods prior to the start of treatment. For this reason, it is recommended that teenagers be allowed to establish a normal menstrual pattern prior to use of hormonal therapy for contraception. The use of oral contraceptives to regulate cycles for the convenience of the patient carries with it a risk of anovulatory problems post treatment. The long-range effects of the oral contraceptives on metabolic effects such as protein changes and glucose tolerance abnormalities have not been resolved. One major problem in the use of oral contraceptives in adolescents is the associated high failure and discontinuance rate. Even with intensive counseling and educational programs this rate is still higher than in the older age groups. In one study, the failure rate of those taking oral contraceptives was over 30 per cent.7 One reason for this may be in the life style patterns of the teenager which is apt to preclude the regimen of daily pill taking. Another explanation is the lack of motivation seen in certain populations. Even those well motivated may have difficulties hiding the oral contraceptives from uninformed parents and develop anxiety and guilt feelings. These emotional aspects add to any side-effect symptoms and increase the discontinuance rate. And all too often, discontinuance is not associated with alternate contraception and pregnancy occurs. Intrauterine Devices (IUD) While no one is certain as to its mode of action, the intrauterine device has been demonstrated to be a highly effective method of contraception. It is not perfect-pregnancies occur with it in situ and after unnoticed expulsion. Medical removals are necessary for excessive bleeding and pain. Expulsions occur spontaneously and are higher in the nulliparous young patient. However, for the adolescent it provides a method that once established has definite advantages from the viewpoint of the physician. One, the concerns over the long-range effects of exogenous hormones are rendered irrelevant; and two, it affords as high or
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higher an amount of protection against pregnancy than the pill if discontinuance and failure rates are taken into consideration. The more liberal attitude toward abortion in many states is making available one possible solution to contraceptive failures from any method. The IUD must be inserted by a physician or other trained personnel such as a certified nurse-midwife. Insertion techniques, problems of management, etc., are discussed well by Sobrero.8 In many adolescent programs the IUD has become a major contraceptive method. It can be used in those patients with a medical contraindication to oral contraceptives, or those who have not been able to use the pill because of lack of motivation or inability to follow instructions. More and more it is becoming the method of choice. In one study where there was a very high expulsion rate of IUDs, more girls still became pregnant using oral contraceptives than those using IUDs." This is also true in our post-partum clinic where over 80 per cent of our patients are given IUDs. Our pregnancy rate in the IUD patients was 3 per cent and of those on oral contraceptives, 7 per cent. Moreover, the experience with nulliparous patients is similar to that with the parous ones. Modifications of the size and shape of the intrauterine device have decreased the expulsion rate and increased the efficacy. In the nulliparous the newer Dalkon shield and Cu-T device are showing promising results. Insertion is usually innocuous; however, in the nulliparous woman, it may be necessary to use a para-cervical local anesthetic with the Dalkon shield. The Cu-T has not yet been released for use in the United States. The Federal Drug Administration is conducting extensive studies to determine the fate of the copper ion. Results from other countries seem to indicate that this small device will be highly effective and easily inserted in the nulliparous. Many studies confirm our belief that there is no contraindication to using the IUD in the nulliparous patient.
SUMMARY Major changes with regard to the provision of contraceptive services for adolescents are occurring. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have endorsed the position of supplying contraceptive services to those who need them regardless of age. The provision of services to teenage minors without parental consent remains a legal question. The trend seems to be toward allowing this type of care. Delivery of service models are being developed throughout the nation. Contraceptive counseling must take into consideration factors other than the choice of method. Educational programs concerning sexuality should be included. The various contraceptive methods and their applicability in the adolescent population are discussed. The intrauterine device is becoming the method of choice in both nulliparous and parous teenage patients.
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REFERENCES 1. Arnold, C. B., and Cogswell, B. E.: A condom distribution program for adolescents. The findings of a feasibility study. Amer. J. Publ. Health, 61 :739,1971. 2. Johnson, L. B., et al.: Problems with contraception in adolescents. Clin. Pediat., 10:315, 1971. 3. Marinoff, S. C., et al.: Sexuality of adolescent unwed mothers. Med. Aspects Human Sexuality, in press. 4. OIds, S.: Instituting and operating a teen birth control clinic in Grand Rapids, Michigan. Unpublished communication. 5. Pilpel, H. F., and Wechsler, N. F.: Birth control, teenagers and the law: A new look, 1971, Family Planning Perspectives, 3:37 (July) 1971. 6. Pion, R. J.: Prescribing contraception for teenagers-a moral compromise. Obstet. Gynec., 30:752, 1967. 7. Rauh, J. L., et al.: The management of adolescent pregnancy and prevention of repeat pregnancies. HSMHA Health Reports, 86:66, 1971. 8. Sobrero, A. J.: Intrauterine devices in clinical practice. Family Planning Perspectives, 3: 16 (Jan) 1971. The Mount Sinai School of Medicine Fifth Avenue and lOOth Street N ew York, N ew York 10029
Contraception in Adolescents
Stanley C. Marinoff, M.D., MP.H.*
Major changes with regard to the provision of contraceptive services for teenagers have occurred over the past few years. The end of the 1960's saw physicians struggling with the moral and ethical problems they faced. 6 However, as it soon became obvious that something must be done to stem the rise of teenage pregnancies, most of which in the earlier ages were out-of-wedlock, the trend went from whether to provide birth control to how. The American Academy of Pediatrics, in April, 1971, recommended that "the teenage girl whose sexual behavior exposes her to possible conception should have access to medical consultation and the most effective contraceptive advice and methods consistent with her physical and emotional needs; the physician so consulted should be free to prescribe or withhold contraceptive advice in accordance with his best medical judgment in the best interests of his patient." The American College of Obstetricians and Gynecologists in May of 1971 made the following statement on contraceptive services to minors: The never-married, never-pregnant, sexually involved female has not yet been reached with effective contraception. The laws of some states indirectly prohibit this service for minors and thereby prevent the gynecologist from serving them or place the physician in legal jeopardy if he does so. The American College of Obstetricians and Gynecologists believes that: The unmarried female of any age whose sexual behavior exposes her to possible conception should have access to the most effective methods of contraception. In order to accomplish this, the individual physician, whether working alone, in a group or in a clinic, should be free to exercise his best judgment in prescribing contraception and, therefore, the legal barriers which restrict his freedom should be removed. These restricting legal barriers should be removed even in the case of an unemancipated minor who refuses to involve her parents. A pregnancy should not be the price she has to pay for contraception. On the other hand, in counseling the patient, all possible efforts should be made to involve her parents. The contraceptive services should be offered whenever possible in a broad spectrum counseling context which would include mental health and venereal disease.
*Assistant Professor, Departments of Obstetrics and Gynecology and Community Medicine, The Mount Sinai School of Medicine; Director, Adolescent Guidance Clinic, Mount Sinai Hospital, New York, New York Supported in part by Grant RF 71-002 from the Rockefeller Foundation.
Pediatric Clinics of North America- Vol. 19, No.3, August 1972
811
812
STANLEY
C.
MARINOFF
Every effort should be made to include male partners in such services and counseling.
Legal Status As far as contraceptive services are concerned, one is not a minor after age 18, with few exceptions. Married teenagers and those of majority age may give their own consent. The provision of contraceptive services to teenage minors without parental consent has now become the major question that faces the practicing physician. Seven states, Colorado, Illinois, Oregon, Tennessee, Virginia, West Virginia, and Wyoming, have passed laws allowing minors to give their own informed consent for contraception. Many other states have approved legislation to allow minors to consent to medical examinations and treatment for venereal disease. The trend seems to be in the direction of allowing young adults to make decisions concerning their own health care and, furthermore, to allow the physician to provide medical services including contraception to those classified by law as minors. "Birth Control, Teenagers and the Law: A New Look, 1971" by Pilpel and Wechsler gives an astute review of the subject as well as a state by state description of the pertinent laws. Medical Status While the legal status is in a state of flux, the medical status of teenage contraception is undergoing constant change also. The use of oral hormonal compounds to "regulate" periods is undergoing scrutiny. The attitude toward the use of intrauterine devices (IUD) in the nulliparous is changing. The concept of motivation for pregnancy as well as for contraception is becoming more important. The availability of safe, legal abortion in some states has changed medical concepts of what is the safest form of birth control. On the following pages, these topics will be discussed on the basis of an approach to the teenage contraceptor that has been developed. This approach is aimed primarily at the high school teenager rather than the potentially more sophisticated high school graduate, college student, or working girl. Byage 17 most females will have reached biologic maturity. However, chronologic age does not necessarily assure emotional maturity, so each patient must be treated individually. The discussion of specific contraceptive methods will be limited to their advantages and disadvantages in reference to the adolescent population.
DELIVERY OF SERVICE To successfully deliver family planning services to adolescents, one must first reach sexually active teenagers with information about services; secondly, one must create an atmosphere in which the delivery of these services is conducive to their acceptance and use. This relates to the private practitioner's office as well as the clinic. The most promising means of reaching the teenage population is by word of mouth. Direct communication allows the teenager to provide more than just the infor-
CONTRACEPTION IN ADOLESCENTS
813
mation as to where and when services are offered. Flyers per se have not been useful in reaching target populations. The flyer just informs; the milieu of the clinic or office is transmitted by the face to face communication. And it is this milieu that is most important. How the teenager is treated on entrance to the facility lays the groundwork for all that follows. There is immediate nonverbal as well as verbal communication. The teenager dislikes the hospital setting and especially the rigors of the medical "system." Attempts should be made to dispense with as much of the formalities as possible. Some clinics have developed a drop-in situation where no appointments are needed. Others have made their contraceptive programs separate from the general medical setting; some have felt that it should be part of comprehensive medical care. One program uses teenagers as receptionists and counselors. Another has set up a teen advisory council to help with the running of the clinic. Each system has its advantages and disadvantages. However, whichever is used, the nonjudgmental attitude of the staff and the proper counseling. set-up are essential. Lack of availability of contraceptives will force adolescents into using improvised methods. A survey in one southern city found the most common contraceptive methods among the teenagers were douching with a popular brand of soda and Saran-Wrap condoms. Because of the lack of knowledge of reproductive processes and of the availability of contraceptives, teenagers will continue to use these methods, erroneously thinking that they are effective and the only means available. Educational programs will correct these fallacies. However, the provision of contraceptive services and pure sex education are not enough. The teenager is searching for answers to questions that are not being supplied by the school system, church, or parents. What teenagers are seeking is their identity in relation to human sexuality. For this reason informal rap sessions have become an integral part of contraceptive counseling. It is through this approach that the teenager is not only given the information needed to help make the decisions involved in a mature outlook towards sex, but is also provided with a channel for expressing his own feelings in a peer group setting.
METHOD COUNSELING Individualization is the key word in the approach to the teenage contraceptor. There is no one best method for all patients. Some of the factors which must be considered are: (1) frequency of sexual relations; (2) development of the individual- both physically and emotionally, and (3) motivation for contraception. Frequency of sexual intercourse plays a major role in the type of contraceptive that the physician will prescribe. Among 583 predominantly white female teenagers requesting contraception at a Planned Parenthood facility, over 50 per cent of those answering the question had coitus more than once a week. 4 In a survey of low income, pregnant adolescents, 40 per cent had intercourse more than four times before becoming pregnant. 3 It is unsound to place the female who has only sporadic relations
814
STANLEY
C.
MARINOFF
on long term hormonal contraceptives. This patient needs knowledge of sexual function and the availability of a convenient method. Moreover, the efficacy of any method, no matter how sound medically, still lies in the motivation for its use. Among a group of abortion repeaters it was found that the motivation for pregnancy was so great that no amount of education or availability of contraceptives would be successful. The use of paramedical personnel or teenagers has been useful in helping the patient make the choice of method. The advantages and disadvantages of each method are openly discussed in relation to the factors outlined. Once a method is chosen, the physician must approve of it medically taking into consideration all the contraindications for each method. Freedom for change of method is always left open. The patient is seen at regular intervals and the use of the method checked for accuracy of use as well as undesirable side-effects. If there has been a change in the status of the individual, the method may be changed to reflect this new status. By laying a groundwork in education and knowledge about the patient, her life patterns, her emotional and physical development and motivation for contraception, the patient can be started toward a life of sensible and effective contraception.
METHODS
Condoms For the teenager, the condom is the most easily available and cheapest form of contraception. Also, it is the only form of contraception that protects against venereal disease. It is available without a prescription and can be purchased from vending machines as well as in drug stores. The quality is controlled by the Federal Drug Administration and one brand is as effective as another. The acceptance of such a method when made available to adolescent males was demonstrated by a study in an inner city area of North Carolina. This study sponsored distribution of free condoms through commercial outlets such as grocery stores, barber shops, and pool halls. Results showed an increase in the use of the condom from 19 to 68 per cent and an increase of those who used it with their last coital exposure from 20 to 91 per cent. The conclusions drawn from this study were: "(1) Condoms are acceptable to adolescents in a magnitude not previously appreciated; (2) adolescent males will accept a sizable share of the burden in pregnancy prevention if given the opportunity; and (3) small neighborhood commercial outlets have a potentially important role in nonclinical contraceptive distribution programs."l Spermicidal Creams, Jellies, and Foams Creams, jellies, and foams are also available over the counter without . a prescription. They work by producing a spermicidal environment in the vagina. Because of this, they must be inserted no more than 60 minutes before intercourse and a repeat application must be used if relations are repeated. Better dispersion makes the foam much more effective than
CONTRACEPTION IN ADOLESCENTS
815
creams or jellies alone. Recent advances in the field of foams have brought forth pre-filled applicators. This allows filling of the inserter up to seven days prior to use so it then can be carried with an individual until used. Two hundred and ninety-six patients ages 15 to 20 who used this method for an average length of 270 days had a pregnancy rate of 6.4 per cent. However, the combination of an aerosol contraceptive foam and a condom brings to the less sexually active teenager a method that is cheap, easily available without a prescription, and effective if used properly.
Diaphragm A method that has a high use effectiveness rate with extremely few side-effects is the diaphragm. It should never be used alone as it is not as exact a barrier as is the condom. It is used with a spermicidal jelly or cream that provides the extra protection needed. The disadvantages in the adolescent population are (1) it must be fitted by a physician, (2) it needs a prescription to be purchased, and, most important, (3) it needs motivation and some skill to be used effectively. However, for the young adult with good motivation and an ongoing relationship, it represents a reasonable approach to contraception. The fitting should be by a trained individual who will instruct the patient in its use. The main advantage of the diaphragm is its lack of immediate side-effects and potential for long range deleterious effects.
Rhythm Method The rhythm system at its most effective use will produce about 14 pregnancies per 100 women-years. The term women-years is based on 13 cycles per year for 1 woman, or 1 cycle for 13 women or any combination thereof. Therefore, in 100 women-years we are discussing 1300 cycles in any combination. This method depends on the regularity of the cycle and on an understanding of the concept of ovulation. To be most effective, the cycle length for at least a year should be charted with the aid of a daily basal body temperature. The irregularity of the adolescent cycle, especially in the first years following menarche, and the lack of knowledge about ovulation exhibited by most adolescents preclude this as an effective measure in this population. In a study of pregnant adolescents misconceptions about the "safe period" was found to be one of the most striking examples of lack of sexual knowledge.
Douching Douching has no place in the armamentarium of contraceptive techniques. On ejaculation, the male releases millions of sperm directly into the cervical canal. By the time the female douches, these are already well into the canal and perhaps the uterus-well out of reach of any douche solution.
Oral Contraceptives The "pill" has become synonymous with a variety of oral contraceptives, all combining a synthetic progesterone known as a progestin and an
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estrogen. Table 1 lists the currently available combination type pills. Oral contraceptives act primarily by inhibiting ovulation. The administration of estrogen and progestin replaces the cyclic hormonal production of the body. It seems the primary effect of the sustained estrogen level is to block the release of luteinizing hormone (LH) from the pituitary. There may also be some blockage of follicle-stimulating hormone (FSH). In addition, the pill inhibits the normal maturation of the endometrium and produces a cervical mucus hostile to sperm penetration. The combination of these three actions makes it 100 per cent effective if taken properly. To decrease the chance of error in taking oral contraceptives, most manufacturers now package the pill in 21 or 28 day cycle kits. With the 21 day package, the patient has only to remember to start one week after stopping, on the same day. The 28 day package has 7 inert pills so the patient takes one pill a day continually once she has started. The first cycle is best started on the fifth day of menstruation, counting the first day of bleeding as day one. A complete history and physical is necessary before prescription of the pill. The history should be detailed enough to rule out hepatic disease, a tendency toward or previous thromboembolic phenomena, and a family history of mammary or endometrial cancer. A Papanicolaou smear is done and repeated annually. In the sexually active adolescent, a culture from the endocervix for gonococcus is also taken. Absolute contraindications to prescribing the oral contraceptives are the same in adolescents as in the adult. They are: (1) thrombophlebitis, thromboembolic disorders, cerebral apoplexy or a past history of these conditions; (2) markedly impaired liver function; (3) known or suspected carcinoma of the breast; (4) known or suspected estrogen-dependent neoplasia; (5) undiagnosed abnormal genital bleeding.
Table 1.
Commonly Available Combination Oral Contraceptives
AGENT
Demulen Enovid E Enovid 5 Norinyl1 Norinyl2 Norlestrin 1 mg. or Norlestrin Fe 1 mg. Norlestrin 2.5 mg. or Norlestrin Fe 2.5 mg. Provest Ortho-Novum 1/50 Ortho-Novum 1/80 Ortho-Novum 2 Ovral Ovulen Ovulen-21 Ovulen-28
ESTROGEN
Ethinyl estradiol 0.05 mg. Mestranol 0.10 mg. Mestranol 0.075 mg. Mestranol 0.05 mg. Mestranol 0.10 mg. Ethinyl estradiol 0.05 mg. (F e = inert tablets Fe) Ethinyl estradiol 0.05 mg. (Fe = inert tablets Fe) Ethinyl estradiol 0.05 mg. Mestranol 0.05 mg. Mestranol 0.08 mg. Mestranol 0.10 mg. E thinyl es tradiol 0.05 mg. Mestranol 0.1 mg.
PROGESTIN
MANUFACTURER
E thynodiol diacetate 1 mg. Norethynodrel 2.5 mg. Norethynodrel 5.0 mg. Norethindrone 1 mg. Norethindrone 2 mg. Norethindrone acetate 1 mg.
Searle
Norethindrone acetate 2.5 mg.
Parke-Davis
Medroxyprogesterone acetate 10 mg. Norethindrone 1 mg. Norethindrone 1 mg. Norethindrone 2 mg. Norgestrel 0.5 mg.
Upjohn
Ethynodiol diacetate 1 mg.
Searle Searle Syntex Syntex Parke-Davis
Ortho Ortho Ortho Wyeth Searle
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In adolescence, those contraindications concerning liver function and undiagnosed abnormal genital bleeding are the most pertinent. Abnormal bleeding in the adolescent cannot be automatically attributed to its most common cause, dysfunctional bleeding associated with anovulation. Recent reports of adenocarcinoma of the vagina in young women whose mothers had taken estrogens during pregnancy makes it imperative that a pelvic examination be done on all patients with abnormal bleeding. The use of a proper speculum combined with a rectal exam and abdominal palpation permits this exam, in a majority of cases, to be performed without undue discomfort even in the virginal female. Of the other possible contraindications, failure of epiphyseal closure, and failure to establish regular menses must especially be considered in the adolescent. Most females will have completed their bone growth by age 14 or 15. The introduction of estrogens in the dosage employed in the low dose oral contraceptives most likely will have little influence on the normal teenager's growth pattern. The problem of failure to establish menses is more important. About 2 to 3 per cent of patients receiving oral contraceptives have amenorrhea and anovulation post treatment. Most of these patients have a history of irregular periods prior to the start of treatment. For this reason, it is recommended that teenagers be allowed to establish a normal menstrual pattern prior to use of hormonal therapy for contraception. The use of oral contraceptives to regulate cycles for the convenience of the patient carries with it a risk of anovulatory problems post treatment. The long-range effects of the oral contraceptives on metabolic effects such as protein changes and glucose tolerance abnormalities have not been resolved. One major problem in the use of oral contraceptives in adolescents is the associated high failure and discontinuance rate. Even with intensive counseling and educational programs this rate is still higher than in the older age groups. In one study, the failure rate of those taking oral contraceptives was over 30 per cent.7 One reason for this may be in the life style patterns of the teenager which is apt to preclude the regimen of daily pill taking. Another explanation is the lack of motivation seen in certain populations. Even those well motivated may have difficulties hiding the oral contraceptives from uninformed parents and develop anxiety and guilt feelings. These emotional aspects add to any side-effect symptoms and increase the discontinuance rate. And all too often, discontinuance is not associated with alternate contraception and pregnancy occurs. Intrauterine Devices (IUD) While no one is certain as to its mode of action, the intrauterine device has been demonstrated to be a highly effective method of contraception. It is not perfect-pregnancies occur with it in situ and after unnoticed expulsion. Medical removals are necessary for excessive bleeding and pain. Expulsions occur spontaneously and are higher in the nulliparous young patient. However, for the adolescent it provides a method that once established has definite advantages from the viewpoint of the physician. One, the concerns over the long-range effects of exogenous hormones are rendered irrelevant; and two, it affords as high or
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higher an amount of protection against pregnancy than the pill if discontinuance and failure rates are taken into consideration. The more liberal attitude toward abortion in many states is making available one possible solution to contraceptive failures from any method. The IUD must be inserted by a physician or other trained personnel such as a certified nurse-midwife. Insertion techniques, problems of management, etc., are discussed well by Sobrero.8 In many adolescent programs the IUD has become a major contraceptive method. It can be used in those patients with a medical contraindication to oral contraceptives, or those who have not been able to use the pill because of lack of motivation or inability to follow instructions. More and more it is becoming the method of choice. In one study where there was a very high expulsion rate of IUDs, more girls still became pregnant using oral contraceptives than those using IUDs." This is also true in our post-partum clinic where over 80 per cent of our patients are given IUDs. Our pregnancy rate in the IUD patients was 3 per cent and of those on oral contraceptives, 7 per cent. Moreover, the experience with nulliparous patients is similar to that with the parous ones. Modifications of the size and shape of the intrauterine device have decreased the expulsion rate and increased the efficacy. In the nulliparous the newer Dalkon shield and Cu-T device are showing promising results. Insertion is usually innocuous; however, in the nulliparous woman, it may be necessary to use a para-cervical local anesthetic with the Dalkon shield. The Cu-T has not yet been released for use in the United States. The Federal Drug Administration is conducting extensive studies to determine the fate of the copper ion. Results from other countries seem to indicate that this small device will be highly effective and easily inserted in the nulliparous. Many studies confirm our belief that there is no contraindication to using the IUD in the nulliparous patient.
SUMMARY Major changes with regard to the provision of contraceptive services for adolescents are occurring. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have endorsed the position of supplying contraceptive services to those who need them regardless of age. The provision of services to teenage minors without parental consent remains a legal question. The trend seems to be toward allowing this type of care. Delivery of service models are being developed throughout the nation. Contraceptive counseling must take into consideration factors other than the choice of method. Educational programs concerning sexuality should be included. The various contraceptive methods and their applicability in the adolescent population are discussed. The intrauterine device is becoming the method of choice in both nulliparous and parous teenage patients.
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REFERENCES 1. Arnold, C. B., and Cogswell, B. E.: A condom distribution program for adolescents. The findings of a feasibility study. Amer. J. Publ. Health, 61 :739,1971. 2. Johnson, L. B., et al.: Problems with contraception in adolescents. Clin. Pediat., 10:315, 1971. 3. Marinoff, S. C., et al.: Sexuality of adolescent unwed mothers. Med. Aspects Human Sexuality, in press. 4. OIds, S.: Instituting and operating a teen birth control clinic in Grand Rapids, Michigan. Unpublished communication. 5. Pilpel, H. F., and Wechsler, N. F.: Birth control, teenagers and the law: A new look, 1971, Family Planning Perspectives, 3:37 (July) 1971. 6. Pion, R. J.: Prescribing contraception for teenagers-a moral compromise. Obstet. Gynec., 30:752, 1967. 7. Rauh, J. L., et al.: The management of adolescent pregnancy and prevention of repeat pregnancies. HSMHA Health Reports, 86:66, 1971. 8. Sobrero, A. J.: Intrauterine devices in clinical practice. Family Planning Perspectives, 3: 16 (Jan) 1971. The Mount Sinai School of Medicine Fifth Avenue and lOOth Street N ew York, N ew York 10029