THE USE OF NONHORMONAL METHODS OF CONTRACEPTION IN ADOLESCENTS

ADOLESCENT GYNECOLOGY, PART II: THE SEXUALLY ACTIVE ADOLESCENT

0031-3955/99 $8.00 4- .OO

THE USE OF NONHORMONAL METHODS OF CONTRACEPTION IN ADOLESCENTS Jessica Rieder, MD, and Susan M. Coupey, MD

Nonhormonal methods of contraception have been used for nearly 5000 years in an attempt to fend off unwanted pregnancies and sexually transmitted diseases (STDs).15Although current nonhormonal contraceptive technology has been dramatically transformed from the “chastity girdles” and “vaginal pessaries” of old, the popularity of these methods has undergone an evolution as well. Up until the first half of the twentieth century, nonhormonal contraception was the only form of birth control. With the development of antibiotic treatment of patients with gonorrhea and syphilis and the advent of oral contraceptive pills (OCPs), the popularity of nonhormonal contraception began to wane. In fact, in the mid-l950s, funding for public health programs aimed at STD prevention was reduced. With the increasing prevalence of penicillin-resistant strains of gonorrhea and viral STDs, including human papillomavirus and herpes simplex virus type 2 (HSV-2) in the 1970s and the identification of human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS) epidemic in the 1980s, the need for nonhormonal contraception once again rose to the forefront of public health concerns.15* 58 This article explores the role of nonhormonal methods of birth control in an era in which sophisticated hormonal contraceptives promise to be the most convenient and effective methods for pregnancy prevention. A comparison of nonhormonal contraceptive methods is outlined in terms of their mechanism of action, usage, effectiveness, advantages, and disadvantages in Table 1. Future nonhormonal contraceptive options are then reviewed. Finally, an approach for effective contraceptive counseling is discussed.

From the Division of Adolescent Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York PEDIATRIC CLINICS OF NORTH AMERICA ~

VOLUME 46 NUMBER 4 AUGUST 1999

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WHY NONHORMONAL METHODS OF CONTRACEPTION?

The staggering personal, social, and economic effects of early initiation of unprotected sexual intercourse continue to plague us as we approach the year 2000. More than 50% of all women and as many as 75% of all men in the United As many as 25% to States have had sexual intercourse by the age of 18 year~.~,'O 50% of sexually active adolescents do not use contraception at first intercourse.', Despite similar rates of sexual experience, the rates of adolescent pregnancy, childbirth, and abortion are higher in the United States than in any other developed country; approximately 1 million teenagers become pregnant each year.3,36, 62 In addition, approximately 3 million teenagers acquire STDs annuaccounting for approximately 25% of all STDS.~ Despite massive public awareness campaigns and school sexuality education programs, the negative health effects of teenage sexuality remain epidemic in proportion. In response to this problem, the Healthy People 2000 National Health Promotion and Disease Prevention Objectives set a goal for adolescents to "increase at least to 90 percent the proportion of ever sexually active adolescents aged 17 and younger who use contraception, especially combined method contraception, that both effectively prevents pregnancy and provides barrier protection against disease."% Even in this era of sophisticated hormonal contraceptive technology, then, the need for effective barrier contraception is of paramount importance. Besides their role in preventing STDs and pregnancy, nonhormonal methods of contraception play an important role in providing safe and effective birth control for adolescents with certain health conditions. For example, adolescents desiring effective contraception who present with a history of thrombosis or who suffer from migraines associated with focal neurologic symptoms should not use estrogen-containing contraceptives and are good candidates for nonhormonal contraception.6,27 Furthermore, young women who are on long-term medications, such as anticonvulsants or antituberculin medications, that could potentially interfere with the efficacy of hormonal contraceptives are also good candidates for nonhormonal contraception. TRENDS IN ADOLESCENT CONTRACEPTIVE USAGE RATES

In analyzing the data from the 1982, 1988, and 1995 National Survey of Family Growth (NSFG), several authors have examined trends in contraceptive usage rates for all sexually active women aged 15 to 44 years.', 49 Between 1988 and 1995, an increase in condom use occurred, most notably among women who were younger than age 25 years, black or Hispanic, or unmarried. A decrease in OCP and diaphragm use occurred coincidentally with an increase in condom and implantable and injectable hormone ~ s e . In 4 ~the mid-l980s, media emphasis on both the adverse effects of OCPs and the HIV epidemic resulted in a decrease in OCP use and a simultaneous increase in condom use.", 71 Using data from the NSFG, Abma et all found that, although female adolescents aged 15 to 19 years report higher rates of inconsistent use of coitus-dependent contraceptive methods (38%)than all women aged 15 to 44 years (33%), the use of these methods by adolescents is more consistent than that of young adult women aged 20 to 24 years (42%).Furthermore, data from the National Survey of Adolescent Males found that sexually active male adolescents aged 15 to 19 years reported higher rates of consistent condom use in 1995 (69%) than in 1988 (56%). Data from the Youth Risk Behavior Survey found that sexually active

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WHY NONHORMONAL METHODS OF CONTRACEPTION?

The staggering personal, social, and economic effects of early initiation of unprotected sexual intercourse continue to plague us as we approach the year 2000. More than 50% of all women and as many as 75% of all men in the United As many as 25% to States have had sexual intercourse by the age of 18 year~.~,'O 50% of sexually active adolescents do not use contraception at first intercourse.', Despite similar rates of sexual experience, the rates of adolescent pregnancy, childbirth, and abortion are higher in the United States than in any other developed country; approximately 1 million teenagers become pregnant each year.3,36, 62 In addition, approximately 3 million teenagers acquire STDs annuaccounting for approximately 25% of all STDS.~ Despite massive public awareness campaigns and school sexuality education programs, the negative health effects of teenage sexuality remain epidemic in proportion. In response to this problem, the Healthy People 2000 National Health Promotion and Disease Prevention Objectives set a goal for adolescents to "increase at least to 90 percent the proportion of ever sexually active adolescents aged 17 and younger who use contraception, especially combined method contraception, that both effectively prevents pregnancy and provides barrier protection against disease."% Even in this era of sophisticated hormonal contraceptive technology, then, the need for effective barrier contraception is of paramount importance. Besides their role in preventing STDs and pregnancy, nonhormonal methods of contraception play an important role in providing safe and effective birth control for adolescents with certain health conditions. For example, adolescents desiring effective contraception who present with a history of thrombosis or who suffer from migraines associated with focal neurologic symptoms should not use estrogen-containing contraceptives and are good candidates for nonhormonal contraception.6,27 Furthermore, young women who are on long-term medications, such as anticonvulsants or antituberculin medications, that could potentially interfere with the efficacy of hormonal contraceptives are also good candidates for nonhormonal contraception. TRENDS IN ADOLESCENT CONTRACEPTIVE USAGE RATES

In analyzing the data from the 1982, 1988, and 1995 National Survey of Family Growth (NSFG), several authors have examined trends in contraceptive usage rates for all sexually active women aged 15 to 44 years.', 49 Between 1988 and 1995, an increase in condom use occurred, most notably among women who were younger than age 25 years, black or Hispanic, or unmarried. A decrease in OCP and diaphragm use occurred coincidentally with an increase in condom and implantable and injectable hormone ~ s e . In 4 ~the mid-l980s, media emphasis on both the adverse effects of OCPs and the HIV epidemic resulted in a decrease in OCP use and a simultaneous increase in condom use.", 71 Using data from the NSFG, Abma et all found that, although female adolescents aged 15 to 19 years report higher rates of inconsistent use of coitus-dependent contraceptive methods (38%)than all women aged 15 to 44 years (33%), the use of these methods by adolescents is more consistent than that of young adult women aged 20 to 24 years (42%).Furthermore, data from the National Survey of Adolescent Males found that sexually active male adolescents aged 15 to 19 years reported higher rates of consistent condom use in 1995 (69%) than in 1988 (56%). Data from the Youth Risk Behavior Survey found that sexually active

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Figure 1. Data from the Youth Risk Behavior Surveys conducted by the Centers for Disease Control and Prevention of a representative sample of 9th-12th graders in the US. These data indicate a stabilization of sexual activity during the first half of the decade with just

over half of all high school students having had intercourse and a trend toward increased condom use at last intercourse with a significant increase from 46% in 1991 to 53% in 1995 having used condoms. Medium solid bars = ever had sex; solid bars = used condom at last sexual intercourse. (Dafa from Warren CW, Santelli JS, Everett SA, et al: Sexual behavior among US high school students, 1990-1995. Fam Plann Perspect 30:170-172, 200, 1998.)

high school students’ condom use at last intercourse increased from 46% in 1991 to 54% in 199561, (Fig. 1).Of unmarried women aged 15 to 24 years surveyed in the 1995 NSFG who had intercourse over the past 3 months, more than 80% used some form of contraception.’ Figure 2 depicts the percentage of distribution of contraceptives used by US adolescents aged 15 to 19 years in 1995. Furthermore, the 1995 NSFG data indicate that adolescents have the highest rates of dual method use of all sexually active women; the highest rates of combined OCP and condom use were in 15- to 19-year-old adolescents YO), followed by 20- to 24-year-old women (7”/0),with the lowest usage rates occurring in 25- to 44-year-old women (5%).The highest rates of combined condom and withdrawal use were in 15- to 19-year-old adolescents (So/,), with all women over age 20 years having much lower usage rates (< 3% for each of the groups aged 20-24, 25-29, 30-34, and 3544 years)j9 EFFICACY OF NONHORMONAL CONTRACEPTIVE METHODS IN ADOLESCENTS

The overall increased rates of contraceptive use by adolescents have resulted in a reduction in the rates of unintended pregnancy in 15- to 19-year-old women from 79 per 1000 women in 1987 to 71 per 1000 in 1994.32Despite this trend,

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Figure 2. Data from the 1995 National Survey of Family Growth was used to calculate the percentage distribution of 15-1 9-year-old nowHispanic white and non-Hispanic black contraceptive users by current method used. Up to 43% of. adolescent contraceptive use consists of nonhormonal methods (assuming that “other methods” are nonhormonal). Of note is the fact that in 1995, the proportion of 15-19 year olds using sterilization, IUD, or diaphragm as a contraceptive method was 0%. (Data from Piccinino LJ, Mosher WD: Trends in contraceptive use in the United States: 1982-1995. Fam Plann Perspect 30:4-10, 45, 1998.)

STD and pregnancy rates remain disproportionately elevated in teenagers. This brings into question the effectiveness of adolescent contraceptive practice. To properly assess contraceptive efficacy, physicians must understand the difference between perfect use and typical use of a contraceptive method. Perfect use of a method refers to use according to a specified set of rules at every act of intercourse. Typical use, however, includes both inconsistent and incorrect use.66 Contraceptive failure rates from typical use tend to be much higher than those of perfect use. In addition, contraceptive failure rates among adolescents tend to be higher than for the general population. This may be a result of the fact that adolescents are less experienced with birth control methods than are their older counterparts. Inexperience and incorrect use results in higher typical-use failure rates. Younger adolescents are less likely to have frequent sexual intercourse than are older teenagers and adult^.^ The infrequency of sexual intercourse and increased rates of contraceptive use, rather than contraceptive efficacy, are the factors that most likely account for the decreasing pregnancy rates among younger teem3 The ability to contracept more effectively, then, would further reduce pregnancy rates and serve to curtail the spread of STDs. MALE CONDOM Historical Perspective

Condoms, the oldest method of barrier contraception used by men, were initially developed during the Renaissance, with the primary purpose being

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protection from STDs. The earliest precursors of condoms were made from linen and animal bladders. The eighteenth century saw further construction improvementswith the use of sheep, lamb, and goat caeca that had been soaked, scraped, washed, dried, cut to 20 cm (8 in), and crowned with a decorative scarlet ribbon at the open end. By the late 1880s, the vulcanization of rubber resulted in mass production and widespread condom distributi~n.'~, ffi Modern condoms are made from latex rubber or lamb cecum, and in the 1990s, polyurethane condoms were introduced for individuals with latex sensitivity or allergy.9,46 More than 100 brands of condoms are available in the United States, with different sizes, shapes, thicknesses; with or without lubricants or spermicides; and with or without a reservoir tip. Tactylon condoms, made from nonallergenic plastic material, may soon become another nonlatex Mechanism of Action

Condoms, placed on an erect penis, serve as mechanical barriers that, for the wearer, decrease infection acquired through exposure to viral or bacterial particles from cervical, vaginal, vulvar, or rectal secretions or lesions. For partners of condom wearers, seminal fluid deposition, contact with infectious urethral discharge, or contact with infectious lesions on the head or shaft of the penis are prevented. Transmission of infectious particles from lesions on the areas of skin not covered by condoms still is possible, however. Latex condoms have been shown to be effective-barriers against HIV; HSV; cytomegalovirus; hepatitis B virus; and Treponema pallidurn, Chlamydia trachomatis, and Neisseria The small pores in lamb-cecum condoms, gonurrhoeae infection transmis~ion.~ however, allowed the passage of HIV and hepatitis B virus particles in laboratory studies? Although laboratory studies have shown that polyurethane condoms block the transmission of viral pathogens, proof of the prevention of HIV in vivo requires further human clinical Condom Failure and Testing

Condom failure to prevent pregnancy or STD transmission most often results from user failure, resulting in condom slippage and breakage, rather than product failure. Studies show that, if used correctly, condoms rarely slip off completely during intercourse or after withdrawal, although they may slip partially down the shaft of the penis.% Condoms have been shown to have breakage rates ranging from 0% to 6.7% and slippage rates during intercourse ranging from 0.6% to 6.4%.%Frezieres et aP1 recently found that polyurethane condoms have higher clinical breakage rates (7.2%) and slippage rates (3.6%) compared with latex condoms (1.1%and O.6%, respectively). Condom breakage may result from unrolling the condom fully before use, as well as from the use of oil-based lubricants, which reduce latex-condom integrity. Polyurethane condoms can be used with oil-based lubricants.26Product failure usually results from condom deterioration or poor manufacturing quality. To avoid condom breakage or deterioration, the Centers for Disease Control and Prevention have several recommendations, which are outlined in Table 2. In 1987, the US Food and Drug Administration (FDA) developed a program designed to inspect latex condom manufacturing, repackaging, and importing as a measure for evaluating quality control and testing procedures. The FDA method for testing condoms consists of a water-leak test, wherein a condom is

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Table 2. RECOMMENDATIONSFOR CORRECT MALE CONDOM USE 1. Use a new condom for each act of intercourse. 2. Store condoms in a cool, dry place and out of direct sunlight. 3. Do not use condoms that show evidence of damage or obvious signs of age (e.g., brittle, discolored). 4. Condom should be handled with care to prevent tearing or puncture. 5. Place the condom on before genital contact. 6. Hold the tip of the condom, unroll it onto the erect penis and leave space at the tip to collect semen-ensure that no air is trapped in the tip of the condom. 7. Ensure adequate lubrication-use only water-based lubricants with latex condoms. 8. If a condom breaks, it should be replaced immediately. If ejaculation occurs after breakage, the immediate use of spermicide may prevent pregnancy or STD transmission. 9. Following ejaculation, the base of the condom should be held and withdrawal should occur while the penis is still erect. 10. Never reuse a condom. From Centers for Disease Control and Prevention:Condoms for Prevention of Sexually Transmitted Diseases. MMWR Morb Mortal Wkly Rep 37(9):133-137,1988; with permission.

filled with 300 mL water and observed for leaks. In any given batch, the failure rate caused by water leaks cannot exceed 4 condoms per 1000 to meet the FDA’s acceptable-qualitylevel. Foreign-made and domestic-made condoms must undergo FDA testing to ensure the highest quality standards? Condom Usage Rates and Efficacy

The tripling of adolescent condom usage (reported by both male and female adolescents) during the 1980s accounts for current condom usage rates of more than 60% in male adolescents and almost 50% in female adolescents.’, lo, 49, 61 Santelli et a1%found that 25% of young men whose partners were taking OCPs were using condoms concurrently, and 21% of young women were using both OCPs and condoms. Condoms, if used consistently and correctly, can s i w c a n t l y reduce both pregnancy and STDs, including HIV. With perfect use, the condom failure rate for pregnancy prevention is 3% per year. Typical use, however, increases the failure rate to 12%. Spermicidally lubricated condoms are no more effective in pregnancy prevention than are nonlubricated condoms. This is because the dose of the active ingredient in spermicidally impregnated condoms is much lower than that found in intravaginally applied spermicide.30 The Benefits Associated with Condom Use

Using condoms provides many benefits. First, condom use does not require physician or parental involvement, allowing for enhanced confidentiality for adolescents. Condoms are readily accessible, easy to carry, and allow for male participation in contraceptive planning. Some couples enjoy using condoms to enhance foreplay. For some young women, they prevent bothersome postcoital seminal fluid leakage from the vagina. Furthermore, for women who develop antisperm antibodies, the use of condoms prevents the urticarial, even anaphylactic, response to sperm or semen. Perhaps the most attractive element of

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condom use is their affordability and their long-term cost efficacy when used by adolescents. Latex condoms cost approximately $1.50 to $3.00 per package of 46 To evaluate the overall cost-effectiveness of using various birth control three.30* methods, Trussell et aP7performed a study that estimated the cost of acquiring and using 11 contraceptive methods appropriate for adolescents. These costs were then compared with the long-term cost of using no contraceptive method. The study showed that condoms are overall the least costly contraceptive method for adolescents at both 1 and 5 years of use (Fig. 3). Moreover, combining male condoms with periodic abstinence or withdrawal further improved the cost savings. The polyurethane condom, Avanti, costs $9.00 to $10.50 per package of six; its long-term cost-effectiveness has not yet been estimated. The Disadvantages Associated with Condom Use

Perhaps the most frequently voiced complaint associated with condom use is the perception of reduced glans sensitivity in men. Some women also experience less satisfying intercourse when the man’s penis is covered with a condom. Because polyurethane is stronger than latex, polyurethane condoms are thinner, thus providing more comfort and sensitivity than do latex condoms. The transparent appearance, natural feel, ability to conduct warmth during intercourse, and lack of odor of polyurethane condoms are other reasons why these condoms

Figure 3.The cumulative costs of contraceptive use are calculated by considering costs of acquiring and using a contraceptive method, treating the side effects associated with contraceptive use or avoiding reproductive diseases, caring for an unintended pregnancy (including birth, miscarriage, induced abortion, or ectopic pregnancy), and treating STDs. Cumulative costs are compared at 1 and 5 years for nonhormonalmethods of contraception commonly used by adolescents. The male condom is the least costly method at both 1 and 5 years of use. Data for this analysis were obtained from a national private payer database. (Data fromTrussell J, Koenig J, Stewart F, et al: Medical care cost savings from adolescent contraceptive use. Fam Plann Perspect 29:248-255, 295, 1997.)

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may be preferred over latex condom^?^,^^ Some teenagers find that condoms are embarrassing to purchase or obtain from clinics, as well as embarrassing to use. Moreover, because their use is coitus dependent, many adolescents see them as inconvenient and a “mood spoiler.” Discreet modern condom packaging reduces embarrassment and facilitates the anonymous purchase of condoms. Condom placement during foreplay may be a method used to overcome embarrassment and the perception of inconvenience and may actually improve sexual pleasure. Another important disadvantage of latex condoms i s the propensity for some individuals to develop a latex allergy. An estimated 1%to 3% of the American population is latex sensitive.%Polyurethane and Tactylon condoms are nonlatex

FEMALE CONDOMS Historical Perspective

Spurred on by the STD and H N epidemic of the 1980s, research and development efforts have centered on providing contraceptive methods that could maximize STD protection. What followed was the FDA approval of polyurethane female condoms, Reality, in 1993. But not until August 1994 did Reality . female condoms reach widespread availability.%,44 Mechanism of Action

Female condoms are soft, polyurethane sheaths containing two flexible rings. They measure 7.8 cm in diameter and 17.0 cm in length.3O The inner ring at the closed end of these condoms is used to insert the device and, by anchoring behind the pubic bone, serves to hold the condom in place over the cervix. The outer ring at the open end remains about 2.5 cm outside the vagina and aids in the removal of the condom. These condoms are prelubricated with a siliconebased lubricant. During vaginal intercourse, the penis enters the vagina inside the condom, which serves as a barrier to impregnation and STD transmission, much as male condoms do. The only additional benefit of female condoms over male condoms, however, is that the external portion of female condoms adds further coverage of the labia and the base of the penis. Voeller et aP9 have performed laboratory tests using gaseous tracers and aqueous dyes to demonstrate the impermeability of the polyurethane pouch to small viral particles. Other in vitro studies have confirmed that polyurethane is impermeable to cytomegalovirus and HIV.13,3o Female Condom Failure

Similar to what is experienced with male condoms, female condom failure tends to result from user failure related to incorrect or inconsistent use rather than from product failure, such as breakage or tearing. Farr et all9found that as many as 60% of American women did not use the condom at every act of intercourse, and as many as two thirds failed to comply with product use instructions. Typical examples of incorrect use include inserting the condom after some penetration has occurred; allowing slippage of the outer ring into the vagina; penile misrouting, which occurs when the penis enters the vagina out-

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side (on either side of) the condom; failure to use adequate amounts of lubrication, resulting in a tendency for the condom to stick to and move with the penis rather than staying in place within the vagina; and using the condom for more than one act of intercourse. All of these mistakes may place the woman at risk for pregnancy and both partners at risk for STDs. To avoid these mistakes, couples need to be informed about the guidelines for proper female condom use that are outlined in Table 3. Female Condom Use Rates and Efficacy

Little statistical information is available on female condom use in adolescents. Furthermore, because of their relative newness, few studies exist regarding the efficacy of female condoms in preventing pregnancy or STDs. For typical use, however, contraceptive failure rates approach 21% and may be as low as 5% for perfect use.26During typical use, the efficacy of female condoms is not s i w c a n t l y different from that of diaphragms or cervical caps.14 In terms of STD prevention, Dominik et all4estimate that perfect use of female condoms by women having sexual intercourse twice weekly with an HN-infected partner may reduce the annual risk for acquiring H N by more than 90?'0.'~ Advantages Associated with Female Condom Use

Female polyurethane condoms have all of the advantages that male polyurethane condoms have over latex condoms-strength, durability, heat-conducting properties, and improved sensitivity. Many women find that female condoms are more natural, "cleaner," softer, and warmer than are male condoms. In addition, female condoms, as a female-dependent method, has features that may make it even more attractive than male condoms for many users. The use of female condoms without relying on male partners may make some women feel more protected, confident, and safe; however, men who are resistant to male condom use are commonly also resistant to female condom use. In a study conducted by Gollub et a1,= 73% of women and 44% of their partners preferred female condoms to male condoms." Women may also feel they are more protected with female condoms than with other female-dependentmethods because female condoms provide additional protection of the vaginal walls. Furthermore, female condoms do not interrupt sexual activity, and men may have more Table 3. RECOMMENDATIONS FOR CORRECT FEMALE CONDOM USE 1. Use a new female condom for every act of intercourse. 2. Position the female condom prior to every act of intercourse. 3. Do not tear the condom with fingernails or sharp objects. 4. Do not use male and female condoms at the same time. 5. Ensure adequate amounts of lubrication. 6 . Stabilize the female condom during penile insertion by holding onto the outer ring. 7. Following ejaculation, the penis is withdrawn and the condom remains inside the vagina. 8. To remove the condom, the outer ring is twisted to trap the semen inside the condom and the entire condom is gently pulled out and discarded. 9. Never re-use a female condom. Adapfedfrom Grimes D A Female condom becomes available nationwide. The Contraceptive Report 511-13, 1995; with permission.

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pleasure during intercourse because female condoms are looser fitting than are male condoms. One further advantage of female condoms has to do with their insertion. Female condoms, which are inserted in a similar fashion to diaphragms, conform to the shape of the vagina, but unlike diaphragms, they are available in only one size. Female condoms, therefore, do not need to be prescribed or fitted by physicians, which makes them much more accessible and convenient for adolescents to obtain. Many health care providers believe, however, that female-condom compliance and success rates might improve with the implementation of routine proper-use instruction. Disadvantages Associated with Female Condom Use

The lack of widespread popularity of female condoms among adolescents relates to their many perceived disadvantages. Many women object to the insertion or removal procedures, especially if they are uncomfortable with touching their genitals. Some adolescents also object to the noise that these condoms make during intercourse and to the aesthetically displeasing outer ring that protrudes from the vagina. Some men and women feel that they experience decreased sensitivity during interc~urse.~ Although many women feel safer with a female-dependent method of contraception that they can insert without their partners’ awareness, many female adolescents may fear that they are sending the message to their partners that they expect to have intercourse. These adolescents may have difficulty changing their minds about their desire to have intercourse and discuss this with their partners, who may have seen the condom in place. In addition, if an adolescent has intercourse three times a week, at a cost of $2.50 to $3.00 per female condom, the cost of contraception is $36.00 per month. Comparing this to the monthly cost of using male condoms, at $12.00 a month, or even OCPs, at $25.00 per month for unlimited episodes of intercourse, the cost of purchasing female condoms may be prohibitively expensive. Moreover, Trussell et aP7found that, for teenagers in the private sector, overall, female condoms are the second most costly contraceptive method at 1 year and the most costly at 5 years. The reason for this lies in the fact that, although female condoms reduce the incidence of STDs, they prevent fewer pregnancies than do hormonal methods during typical use, and they tend to be more expensive than other nonhormonal methods with similar contraceptive efficacy. This is not true when examining the cost-effectiveness of female condoms in the public sector, where female condoms tend to be less expensive than many other nonhormonal meth0ds.6~ DIAPHRAGM, CERVICAL CAP, AND CONTRACEPTIVE SPONGE Historical Background

The forerunners of modem diaphragms and cervical caps, initially developed in China, Europe, and Japan, consisted of oiled silk paper discs, linen cloths, and wax wafers placed against the cervix. The first contraceptive sponge, literally a sea sponge, was used centuries ago to ”soak up semen.”65With the vulcanization of rubber came the development of the diaphragm. In the 1880s, diaphragms became popular throughout Europe, and they were subsequently introduced in the United States in the 1920s. Modem contraceptive sponges

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were FDA approved in the mid-1980s and became available for use without a prescription. As of January 1995, sponges were no longer manufactured and distributed in the United States and therefore are not discussed further. Mechanism of Action

The diaphragm is a dome-shaped rubber cup with a flexible rim. It is inserted into the vagina, positioned to cover the cervix, and anchored in place behind the symphysis pubis, thus also covering the anterior vaginal wall. Diaphragms are available in a variety of sizes and different rim styles. They range in size from 50 mm to 95 mm in diameter. Most female adolescents require 65mm to 80-mm diameter diaphragm^.^^ A selection of rim styles are designed to accommodate the anatomic and vaginal muscle tone variances of different women. The Prentif Cavity Rim Cervical Cap is a soft rubber cup with a firm, round rim. The rim contains a groove that forms a seal with the cervix. Prentif Caps are available in different lengths and four different internal diameters. They are considerably smaller than are diaphragms and are made to fit over the cervix only. Placed in position before intercourse, diaphragms and cervical caps decrease access of sperm and infectious particles to the cervix. Diaphragms require proper fitting by clinicians, who must initially perform a pelvic examination to rule out the presence of a cfrstocele, rectocele, poor vaginal muscle tone, or other anatomic abnormalitiesthat make the diaphragm a poor choice. Cervical caps also require proper fitting by clinicians to ensure that the internal cap diameter fits the cervix. Fitting every woman properly is not possible because of the limited number of cap sizes and the wide normal variation in women’s cervical anatomy. A cap that is too small may cause cervical trauma, and a cap that is too large may easily dislodge. Fitting of either the diaphragm or cervical cap should be followed by proper use instruction to maximize user efficacy and method compliance. Diaphragms can be inserted immediately before or up to 6 hours before intercourse, and caps can be inserted immediately before or up to 30 minutes before intercourse. Diaphragms and cervical caps are effective only when used with spermicide. Spermicide, containing nonoxynol-9, should be placed in the dome of the diaphragm just before insertion, and additional spermicide should be inserted into the vagina before any subsequent acts of intercourse. In contrast, spermicide needs to be placed in the cervical cap before the first act of intercourse; subsequent acts do not require a reapplication of spermicide. Following intercourse, diaphragms and cervical caps must remain ~~,~ in place for at least 6 and 8 hours, respectively, before r e m ~ v a l .Diaphragms and cervical caps should not be worn for more than 24 hours and 48 hours, respectively, because of the risk for toxic shock syndrome. Usage, Efficacy, and Failure

The use of diaphragms and cervical caps traditionally has not been received with widespread acceptance by adolescents. Few studies, in fact, document adolescent use and contraceptive failure rates. In general, diaphragms and cervical caps, if used perfectly, have 1-year failure rates for pregnancy prevention of 6% and 9% (26% for parous women), respectively. For parous women, cervicalcap efficacy is substantially less than diaphragm efficacy. During typical use, however, both methods have a 1-year failure rate of 18%.4,68With regard to STD prevention, the estimated degree to which diaphragms or cervical caps reduce

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gonorrhea, chlamydia, and trichomonas transmission rates ranges from 50% to loo%, depending on which study is examined.%These methods have also been shown to reduce the risk for pelvic inflammatory disease (PID); diaphragm users decrease their risk for PID by half compared with nonusers.*z,37The efficacy of diaphragms or cervical caps in preventing HIV infection is not clear. Continuing the trend seen with previously discussed barrier methods of contraception, diaphragm or cervical-cap failure during actual use most often results from user failure. Inconsistent use is a major problem, and the discontinuation rate for diaphragm use after 1 year approaches 55% in teenagers.” Method failure may be associated with improperly fitted devices, frequent intercourse (three or more times a week), or enhanced fertility in women younger than 30 years of age. Variations in size and position of the cervix and limited device sizing may preclude perfect fitting in many women. The key to effective and consistent diaphragm or cervical-cap use is proper fitting and adequate instruction on insertion and removal, combined with high user motivation. Diaphragms and caps are to be cleaned with soap and water after each use. They should be routinely inspected for holes or other defects and stored in a cool, dry place to maximize longevity. Diaphragms must not be used with oil-based products, including medicated creams, such as Femstat, Monistat, and Vagisil, which destroy the latex. Female adolescents need to be reminded that diaphragm refitting should occur in association with major weight changes, after childbirth or abortion, and every 2 or 3 years. Cervical caps need to be replaced yearly. Benefits Associated with Diaphragm or Cervical Cap Use

Women using female-controlledbarrier methods have been shown, in actual use, to have more protection against STDs than women relying on male cond0ms.5~This may be the result of the fact that the use of female-controlled barrier methods avoids the need to negotiate condom use with male partners, and, consequently, female-controlled methods may be used more consistently. One attractive feature of such methods is that, for women who fear the use of hormones, no systemic or hormonal side effects occur from these barrier methods. For teenagers who have sexual intercourse only sporadically, a vaginal barrier may be effective for intermittent, yet immediate, pregnancy and STD protection. In addition, the ability to insert diaphragms or cervical caps in advance of intercourse allows for “planned spontaneity,” and intercourse need not be interrupted. Cervical caps can be left in longer than diaphragms and require less spermicide. This characteristic may make caps a more convenient, affordable, and less messy form of protection than diaphragms. Disadvantages Associated with Diaphragm or Cervical-Cap Use

Despite their many advantages, diaphragms and cervical caps have several disadvantages rendering them less popular methods of birth control among female adolescents. First of all, the requirement for clinician fitting of these methods may prevent many adolescents who seek confidentiality from even considering these methods. Moreover, many providers may require training to learn the proper fitting of these devices. If providers are unfamiliar with diaphragm or cap fitting, they may be reluctant to offer these methods. Difficulty with inserting or removing these devices and adolescents’ discomfort with

8

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touching their genitals may be prohibitive barriers for many patients. In addition, local skin irritation from spermicides or rubber may be experienced by certain individuals. Vaginal barriers also increase the risk for certain infections, including toxic shock syndrome, urinary tract infection, bacterial vaginosis, and vaginal candidiasis.3l The incidence of nomenstrual toxic shock syndrome during diaphragm and cervical-cap use has been shown to be 2.4 cases per 100,000 users per year.57For this reason, diaphragm and cervical-cap users need to be made aware of the signs and symptoms of toxic shock syndrome. The initial cost of diaphragms or cervical caps is $30 to $40, with the method-initiation cost ranging from $50 to $150, depending on the medical visit and device-fitting fee charged by physicians. These up-front costs may be prohibitive for some teens. Moreover, these methods are not very cost-effective if cumulative costs are examined at 1 and 5 ~ e a r s . 6Considering ~ the questionable efficacy of these methods in preventing M V transmission and the increased motivation required to use them properly, adolescents who are able to use condoms, which definitely reduces HIV transmission, probably have fewer reasons to use these barrier methods. SPERMICIDES Historical Perspective

Spermicides are perhaps the oldest form of contraception. In Egypt in 1850 the earliest spermicides took on the form of pessaries, made up of a mixture of honey and crocodile dung. During the second century, less-offensive spermicidal precursors, such as oil, honey, resin, and fresh acidic pomegranate pulp, were used to prevent ~regnancy.'~ Mercury and lead salts were used widely for many years, but their use was discontinued because of the potentially harmful effects to users and possibly fetuses. More modem spermicides include sulfhydryl-binding substances, bacteriocides, and surfactants (detergents).%Nonoxy1101-9 and octoxynol-9, two detergents, have been the only spermicides available in the United States for more than 30 years. BC,

Mechanism of Action

Spermicides consist of a base substance, such as foam, cream, jelly, film, suppository, or tablet, that serves to carry a spermicidal agent. They can be used alone or with diaphragms, cervical caps, sponges, and condoms and play an important role in both pregnancy and STD prevention. Spermicides act by destroying the cell membranes of sperm. In laboratory studies, nonoxynol-9 has also been shown to be lethal to Neisseria gonorrhoeae, Chlamydia trachomatis, HSV, hepatitis B virus, Trichomonas vaginalis, HIV, and Treponema pallidum.8~W S , 58~ , The in vivo microbicidal activity of nonoxynol-9, especially for intracellular 41 In fact, nonoxynol-9 vagiorganisms, such as HIV, however, is questionable.34, nal film, compared with placebo vaginal film, did not reduce the rates of new HIV, gonorrhea, or chlamydia1 infections in Cameroon sex workers concurrently using condoms.52Furthermore, the use of nonoxynol-9 with vaginal barriers or condoms may cause some degree of local irritation of vaginal and cervical tissues. Some physicians are concerned that nonoxynol-9, if applied in high concentrations or used frequently, may cause tissue ulceration and thus may increase an individual's susceptibility to acquiring H W Other evidence, how-

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ever, suggests that with normal concentrations and for appropriate durations, nonoxynol-9 does not cause vaginal irritation and, in fact, because of its activity against gonorrhea and chlamydia1 infections, provides some protection against HIV infection.54, Usage, Efficacy, and Failure Usage rates for spermicide alone have not been well studied in either the general or adolescent population. In addition, the lack of research documenting usage and efficacy rates of spermicide alone compared with spermicide in combination with other contraceptive methods makes the estimation of spermicidal efficacy nearly impossible. In general, however, 1-year contraceptive failure rates for pregnancy prevention during perfect use of spermicides alone is 6% and, for typical use, from 21% to 30%.2,4Failure rates for typical use are higher in spermicide-alone users than in most other nonhormonal contraceptive users. Used in combination with barrier methods, the efficacy rates of all methods improve. With perfect use, the combination of condoms and intravaginally applied spermicide may reduce failure rates to 0.1%. This is the same failure rate associated with OCPS.~~ Moreover, latex condoms used in combination with a spermicide, such as nonoxynol-9, are estimated to be 99.9% effective in preventing STD transmission during each act of intercourse.%Not surprisingly, then, spermicides also are an integral part of diaphragm'and cervical cap use. The successful use of spermicides requires an awareness of spermicide activation and duration times in relation to the method of spermicide application and timing of intercourse. For example, activation of the spermicide in foams, jellies, and creams occurs immediately upon insertion into the vagina; patients do not need to wait to initiate sexual intercourse. Spermicidal films, suppositories, and tablets, however, require 10 to 15 minutes for dissolution and dispersion in the vagina. This delay in protection necessitates a pause between spermicidal application and the initiation of sexual intercourse. Leakage of spermicide from the vagina is inevitable; thus, reliable protection lasts only 1 hour following insertion. Advantages Associated with Spermicide Use Spermicides are a valuable adjunct to the pregnancy and STD preventive function of condoms, diaphragms, caps, and fertility awareness methods. Like male and female condoms, they do not need to be prescribed by health care providers, which makes them much more accessible and convenient for teenagers to obtain. Furthermore, they are another female-dependent method that does not require partner involvement for implementation. Spermicides can be kept on hand for intermittent, yet immediate, use, with potentially no impact on efficacy. They can be used as a backup contraceptive measure when other barrier methods break or fail. Spermicides are relatively inexpensive, with typical initial purchase prices ranging from approximately $12 for a container of foam or tube of gel or cream, to $9.25 for 12 sheets of film, to $4 for a box of 12 suppositories.3 Disadvantages Associated with Spermicide Use The most common problem with spermicidal methods is vulvar, penile, or vaginal irritation resulting from the detergent action on cell membranes. To date,

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no other major systemic effects have been reported. Another common complaint of users is the "messiness" associated with the use of spermicides. Some studies in the early 1980s reported an association between intravaginal spermicides and congenital birth defects.%Subsequent studies, however, showed methodologic errors in these early studies and confirmed that no relationship exists between the use of spermicides and congenital anomalies.16,59, 7o Using spermicides in conjunction with other barrier methods to maximize pregnancy prevention may be an additional problem for many sexually active adolescents who find compliance with even one birth control method difficult. This fact becomes more poignant when considering the questionable efficacy that spermicides have in STD prevention. Spermicides alone should not be relied on as an effective method of birth control. INTRAUTERINE DEVICE Historical Perspective

Possibly the first intrauterine device (IUD), a hollow lead tube filled with fat that was inserted into the uterus, was developed by Hippocrates (460-377 BC).'~ Not until the twentieth century, however, were more sophisticated IUDs developed. IUDs are the most widely used reversible contraceptive throughout the world.41,53 In the United States, however, only 0.8% of contraceptive users use this safe and effective form of bikth c0ntrol.4~The low rates of IUD use in the United States may be directly attributed to the negative publicity that arose in connection with the association between the Dalkon Shield IUD and PID. The Dalkon Shield was manufactured with a multifilament tail that facilitated the ascent of bacteria into the uterine cavity, increasing the risk for PID. The major morbidity that ensued resulted in multiple lawsuits, and the Dalkon Shield was removed from the market in 1974. Although other IUDs available in the 1980s were considered safe, the manufacturers of these products voluntarily removed their products from the market because of the concern about high litigation costs. Today, only two IUDs are available in the United States. The Copper T 380A IUD became available in 1988. It is effective for up to 10 years. The progesterone-releasing IUD has been available since 1976. It is effective for 1 year only and must therefore be replaced annually. Both of these IUDs have monofilament tails. Despite evidence that, over the long term, the risk for PID associated with use of these IUDs is similar to the risk associated with the use of no contraception, physicians and patients continue to shy away from their use.39,40,45 Mechanism of Action

Intrauterine devices are an effective method for pregnancy prevention. They do not, however, prevent HIV or other STD transmission. IUDs are believed to serve as sterile foreign bodies that stimulate the release of macrophages and leukocytes into the uterine cavity. These cells, as well as the copper ions from the Copper T 380A IUD, are cytotoxic to sperm and egg cells, thereby incapacitating sperm and preventing fertilization. Progesterone-releasing IUDs, which release 65 pg/d progesterone into the uterine cavity, also thicken the cervical mucus and inhibit sperm transport. IUDs are not abortifacients because their primary mode of action lies in incapacitating sperm and preventing fertilization.

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In fact, studies have demonstrated that women using no contraception have higher embryonic loss rates, as measured by human chorionic gonadotropin levels, than women contracepting with IUDs.", 6o Usage, Efficacy, and Failure

Use of IUDs has generally been reserved for "women who are in the middle to late reproductive years, unable to take oral contraceptives, in a stable monogamous relationship, and not at risk for sexually transmitted diseases."" Most physicians rarely, if ever, recommend IUDs for adolescents and young adult women. The 1-year perfect-use (includes checking strings routinely to detect expulsion) failure rates of the Progesterone T IUD and the Copper T 380A IUD are 1.5% and 0.5%, respectively. Typical-use failure rates increase to 2.0% and O.8%, respectively.z,4*3 IUDs do not prevent STDs. The relative risk of developing PID is 15.6-fold for Dalkon Shield users compared with 1.5-fold for long-term users of other types of IUDS.~ Some risk for PID is related to IUD insertion. This risk has nothing to do with the IUD or the monfilament string and may be related to facilitation of ascent of sexually transmitted organisms already present on the cervix. A study conducted by the World Health Organization found that, although the risk for PID was increased during the first 20 days after insertion, the risk decreased markedly after 21 days and was similar to that of noncontraceptive users with long-term use.18 Furthermore, the risk for PID increases in users, as it does in nonusers, who are at risk for STDs. A history of multiple sexual partners and risk for STD exposure are relitive contraindications to the use of IUDs. Therefore, sexually active adolescents, who are at a high risk for STD exposure, tend not to be good IUD candidates. The risk for HN for IUD users is unknown. The effect of IUDs on creating a uterine environment that is favorable for HIV transmission is not well understood. In addition, the increased uterine bleeding that some IUD users experience may play a role in HIV transmission. Both of these areas require further study.3o Advantages of Intrauterine Device Use

Although initially expensive, IUDs, with a one-time total cost of insertion ranging from $150 to $300, is as economic over the long term as are most other commonly used contraceptives. In addition, IUDs can be used in women who have contraindications to hormonal contraception. Women who become pregnant while using IUDs have a greater likelihood of having ectopic pregnancies than do women using no method of birth control. The fact that IUD users are far less likely to get pregnant than are noncontraceptive users, however, results in IUDs having an overall protective effect on the development of ectopic pregnancy. Thus, the risk for ectopic pregnancy for IUD users is 60% less than that for noncontraceptive users.n Once inserted, little compliance on the part of users is required to ensure efficacy. This can be a very attractive characteristic for adolescents. Disadvantages of Intrauterine-Device Use

Many factors make IUDs an inappropriate contraceptive for adolescents. Once placed, IUDs require little effort on the part of adolescents. Initial place-

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ment requires referral to a clinician trained in IUD insertion. The inconvenience of this process may be prohibitive for adolescents. One of the most common reasons for discontinuing IUD use is the associated increased incidence of dysmenorrhea and heavy uterine bleeding. After 1 year of use, as many as 5% to 15% of patients stop using IUDs because of menorrhagia, intermenstrual spotting, or worsening menstrual cramping.24* 30, 45 An increased risk for IUD expulsion tends to occur in both young and nulliparous women, as well as in women with abnormal amounts of menstrual flow and severe dysmenorrhea. Placement of IUDs immediately postpartum and placement by poorly skilled clinicians also increase the risk for expulsion. Expulsion occurs in 2% to 10% of patients, and most expulsions occur in the first 3 months after insertion. Improperly skilled physicians also may have higher rates of uterine perforation during insertion. Perforation occurs in 0.6 per 1000 Copper T 380A insertions and 1.1 per 1000 Progesterone T insertions." Further complications associated with IUD use include pregnancy complications. If a woman using an IUD becomes pregnant and does not remove the IUD, she has a 10-fold increased risk for spontaneous abortion.R The absolute contraindication of active PID and the relative contraindications of multiple sexual partners, nulliparity, and current or recurrent lower genital tract infections renders IUDs unsuitable for most female adolescents. WITHDRAWAL, RHYTHM, AND STERILIZATION

Inappropriate though it may sePm, the withdrawal method continues to be a major method of contraception among teenagers, especially within the first year of becoming sexually active. Withdrawal, or coitus interruptus, involves removing the penis from the vagina before ejaculation. Although this method has the potential to be as effective for pregnancy prevention as other vaginal barrier methods, its effectiveness depends on men's ability to withdraw before ejaculation. Just before orgasm, many men, and more commonly male adolescents, may find that they lack the self-control to withdraw at the appropriate time. Furthermore, pre-ejaculatory fluid may escape before ejaculation, resulting in semen deposition in the vagina. First-year failure rates for perfect use of this method approach 4%, whereas typical use rates approach 24y0.~.Withdrawal provides no protection against skin lesions that may be actively infected with HSV or human papillomavirus. Both pre-ejaculation and unintentional ejaculation pose a risk for STD, including HIV, transmission. Although initially convenient, affordable, and easy to use, withdrawal alone should not be relied on as an effective method of birth control. Natural family planning, or periodic abstinence, relies on identifying the fertile period in a woman's menstrual cycle and abstaining from sexual intercourse during that time. If a couple uses a barrier method or withdrawal during the fertile period, they are practicing a fertility awareness-combined method. Periodic abstinence from 7 days before and 3 days after ovulation may prevent pregnancy in a woman with a regular cycle.%The fertile period can be identified by observing changes in cervical secretions, monitoring increases in basal body temperature, or using calendar calculations. Perfect-use failure rates range between 1%and 9%, whereas typical-use failure rates may be as high as 25%. Although this method is relatively inexpensive and without side effects, it has many disadvantages. First, it provides no protection against STDs, including HIV It requires a good understanding of ovulatory physiology and a great deal of time and motivation to follow calendars, monitor temperatures, observe

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cervical mucus changes, and remain abstinent during the fertile period, all of which are cumbersome for sexually active adolescents to accomplish. Furthermore, irregular cycles in many younger female adolescents make the determination of the fertility period an onerous task. Finally, the high failure rate makes this method unreliable. Sterilization is generally inappropriate as a method of contraception for female adolescents because it is essentially irreversible, and, thus, it is not usually discussed as a contraceptive option. The sole exception is with developmentally delayed adolescents, for whom some parents request sterilization.Even in such cases, to perform this procedure during the adolescent period is most often not appropriate. Adolescents with a developmental delay can effectively use injectable and implantable hormonal methods until they are older, when they may be able to participate in consenting to a sterilization procedure.

FUTURE NONHORMONAL CONTRACEPTIVESMlCROBlClDES AND NEW BARRIER METHODS

In response to the problem of the spread of HIV, the US government has increased funding for contraceptive research. To surpass the success that current nonhormonal methods have at preventing pregnancy and STDs, future methods need to be safer and more effective, offer more protection against STDs, be inexpensive, have fewer side effects, and be more-convenient and simple to use.& Nonhormonal contraceptive research is being conducted in two main areas, namely, chemical barriers or microbicides and mechanical barriers. In 1996, under the topical microbicide initiative, the National Institutes of Health and the Centers for Disease Control and Prevention planned to spend $100 million in microbicide research over the next 5 years.29Microbicides are chemical barriers designed to kill or inactivate STDs, including HIV. Some microbicides are designed to prevent infections only, and some have both microbicidal and spermicidal activity. Microbicides, like spermicides, consist of a vehicle compound and an active microbicidal agent. Current research involves the development of new microbicidal agents derived from detergents, chemicals, carbohydrates, proteins, and bacteria, as well as the enhancement of existing agents, such as nonoxynol-9, to produce more effective and less toxic microbi~ides.2~ Several new female-dependent vaginal barriers may soon be available for general use. The Femcap, which is not yet available, is a silicone, bowl-shaped device that covers the cervix. It will be available in two sizes, one size for nulliparous women and the other for parous women. The device will require a physician fitting and is to be used with spermicide. A 2-year to 3-year supply of two Femcaps costs approximately $75 to $80. Lea's Shield, which awaits FDA approval, is a silicone, bowl-shaped device that is placed over the cervix and anchored in the posterior vaginal fomix. It is unique in that it has two additional features: (1)a one-way valve that permits the passage of cervical secretions and (2) a loop at the front to aid in its removal. The device is available in one size, negating the need for physician fitting; costs $50; and needs to be replaced every 9 to 12 months. The Protectaid sponge, which is available in Canada and awaits FDA approval in the United States, consists of a polyurethane foam impregnated with a gel that contains three spermicidal agents and a dispersing agent. This sponge provides a physical and chemical barrier to sperm and infectious particles.

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CONTRACEPTIVE COUNSELING

Successful reduction in adolescent pregnancy and STD rates relies on the promotion and implementation of two behaviors, namely abstinence from sexual intercourse and effective contraception. Whereas awareness of the benefits of abstinence and effective contraception alone does not change behavior, comprehensive guidance that conveys knowledge, imparts motivation, and teaches specific method use and negotiation skills does.I7Maulden and Lukei2 demonstrated that the odds of an adolescent using a method of birth control at first intercourse increase by one third after contraceptive instruction. Furthermore, these odds increase to 70% to 80% if contraceptive education occurs within the same year that the adolescent becomes sexually active. Hingson et a133demonstrated that adolescents who have discussed HIV infection with their physicians are 1.7-fold more likely to use condoms than those who have not. Pediatricians interested in providing contraceptive counseling that provides the impetus for behavioral change must be aware that teenagers commonly hold often inaccurate attitudes toward contraception and that adolescents' decision-making abilities are influenced by their developmental stage. Furthermore, they must be aware that adolescents are responsive to open and nonjudgmental communication about sexuality and contraceptive issues. Bearing these facts in mind, physicians can act as facilitators as adolescents choose the most appropriate method of contraception. After all, the most effective form of birth control is the method that these adolescents will use. When the contraceptive decision is made, physicians should support effective use by seeing these adolescents frequently for follow-up and checking for consistent and correct method use. SUMMARY

Although the 1990s have seen a reduction in unintended pregnancy rates and improved contraceptive-use rates, the negative consequences of unintended pregnancy and STD acquisition continue to plague our youth. Primary health care providers, including pediatricians, play an essential role in further reducing unintended teen pregnancy and STD acquisition rates through the promotion of effective and consistent contraception. Pediatricians need to be aware that now, more than ever, nonhormonal contraceptive methods should be used by every sexually active youth, and counseling of both boys and girls should be routine. Although not as effective at preventing pregnancy as hormonal methods of contraception, many nonhormonal methods provide excellent STD protection. Condoms plus spermicide continue to be a very popular and effective method of pregnancy and STD prevention. The newer polyurethane male and female condoms provide alternative, safe barrier protection, although their efficacy at preventing HIV in vivo needs further study. Diaphragms and cervical caps, in conjunction with spermicide, also provide pregnancy and STD prevention, but not as effectively as male condoms plus spermicide. Although most likely to use condoms in association with another birth control method, adolescents often find dual-method use cumbersome and difficult to comply with. Finally, although IUDs and periodic abstinence are safe methods of birth control for older women in monogamous relationships, they are unlikely to be appropriate for most adolescents. In many respects, we have come full circle back to our "nonhormonal contraceptive roots." As we enter the twenty-first century, we have found that no single "miracle" approach can be used to reduce adolescent pregnancy and

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STD rates. Rather, pediatricians are obliged to offer nonhormonal methods of contraception, often in conjunction with other birth control methods, as a means of preventing unwanted STDs and pregnancy. Through a comprehensive community approach that uses sex education, abstinence programs, condom-availability programs, and contraceptive-skills training, however, pediatricians can play a central role in the promotion of effective and consistent contraception by adolescents. References 1. Abma JC, Chandra A, Mosher WD, et al: Fertility, family planning, and women’s health: New data from the 1995 national survey of family growth. Vital Health Stat 23(19):1-11, 1997 2. Abramowicz M Choice of contraceptives. The Medical Letter 379-12,1995 3. Alan Guttmacher Institute: Sex and America’s Teenagers. New York, Alan Guttmacher Institute, 1994 4. Alan Guttmacher Institute: Contraceptive Use. New York, Alan Guttmacher Institute, 1998 5. Beach RK: Contraception for adolescents: Part I. Adolescent Health Update 7143,1994 6. Bumhill M, Grimes DA, Hanson V, et a1 Clinical challenges in contraception: A program on women with special medical conditions. In The Association of Reproduction Health Professionals Clinical Proceedings 1-16, 1994 7. Cates W Jr, Stewart FH, Trussell J: Commentary: The quest for women’s prophylactic methods-hopes vs. science. Am J Public Health 829479-1482,1992 8. Celentano DD, Klassen AC, Weisman CS, et a1 The role of contraceptiveuse in cervical cancer: Maryland cervical cancer case-control study. Am J Epidemiol126592-604,1987 9. Centers for Disease Control and Prevention: Condoms for prevention of sexually transmitted diseases. MMWR Morb Mortal Wkly Rep 37:133-137,1988 10. Centers for Disease Control and Prevention: Youth Risk Behavior Surveillance-United States, 1995. MMWR CDC Surveil1 Summ 451, 1996 11. Cole HM: Diagnostic and therapeutic technology assessment (DATTA): Intrauterine devices. JAMA 261:2127-2130, 1989 12. Cramer DW, Goldman MB, Schiff I, et al: The relationship of tuba1 infertility to barrier method and oral contraceptive use.JAMA 2572446-2450,1987 13. Drew WL, Blair M, Miner RC, et al: Evaluation of the virus permeability of a new condom for women. Sex Transm Dis 17:llO-112, 1990 14. Dominik R, Strickler J, Sturgen K, et al: Comparative contraceptive efficacy of the female condom and other bamer methods. Fam Plann Perspect 266649,1994 15. Dyer KA: Curiosities of contraception: A historical perspective. JAMA 264:2818-2819, 1990 16. Einarson TR, Koren G, Mattice D, et a1 Maternal spermicide use and adverse reproductive outcome: A meta-analysis. Am J Obstet Gynecol 162655460, 1990 17. Elster AB, Kuznets NJ:American Medical Association Guidelines for Adolescent Preventative Services (GAPS): Recommendations and Rationale. Baltimore, Williams & Wilkins, 1994, p 78 18. Farley TMM, Rosenberg MJ, Rowe PJ, et a1 Intrauterine devices and pelvic inflammatory disease: An international perspective. Lancet 339:785-788, 1992 19. Farr G, Gabelnick H, Sturgen K, et a1 Contraceptive efficacy and acceptability of the female condom. Am J Public Health 8431960-1964,1994 20. Fisher M, Marks A, Trieller K Comparative analysis of the effectiveness of the diaphragm and birth control pill during the first year of use among suburban adolescents. J Adolesc Health Care 8395399,1987 21. Frezieres RG, Walsh TL, Nelson AL, et a1 Breakage and acceptability of a polyurethane condom: A randomized, controlled study. Fam Plann Perspect 3073-78,1998 22. Gollub EL, Stein Z, EL-Sadr W Short-term acceptability of the female condom among staff and patients at a New York City hospital. Fam Plann Perspect 27155-158, 1995

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23. Grimes DA Contraception & the STD epidemic: Contraceptive methods for disease prevention. The Contraception Report 3511,1992 24. Grimes DA Examining the IUD Highlights from a recent international conference. The Contraception Report 31-9,1992 25. Grimes DA Female condom becomes available nationwide. The Contraception Report. 5:11-13, 1995 26. Grimes DA: Future bamer methods. The Contraception Report 89-13,1997 27. Grimes DA Headache, migraine and oral contraceptives. The Contraception Report 812-14, 16, 1998 28. Grimes DA The polyurethane vaginal p o u h New barrier contraceptive may give women more control over STD prevention. The Contraception Report 3:12-14,1992 29. Grimes DA The search for microbicides to prevent STDs. The Contraception Report 84-8, 1997 30. Hatcher RA, Trussell J, Stewart F, et al: Contraceptive Technology, ed 17. New York, Irvington Publishers, 1998 31. Heaton CJ, Smith MA: The Diaphragm. Am Fam Physician 39231436,1989 32. Henshaw SK Unintended Pregnancy in the United States. Fam Plann Perspect 302429,46, 1998 33. Hingson RW, Strunin L, Berlin BM, et a1 Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. Am J Public Health 80295-299, 1990 34. Hira SK, Feldblum PJ, Kamanga J, et al: Condom and nonoxynol-9 use and the incidence of HIV infection in serodiscordant couples in Zambia. Int J STD AIDS 8243-250, 1997 35. Huggins G, Vessey M, Flavel R, et a1 Vaginal spermicides and outcome of pregnancy: Findings in a large cohort study. Contraception 25:219-230,1982 36. Jones EF, Forrest JD, Henshaw SK, et a1 Unintended pregnancy, contraceptivepractice and family planning services in developed countries. Fam Plann Perspect 20:53-67, 1988 37. Kelaghan J, Rubin GL, Ory HW, et a1 Barrier-method contraceptives and pelvic inflammatory disease. JAMA 248.184-187,1982 38. Kestelman P, Trussell J: Efficacy of the simultaneous use of condoms and spermicides. Fam Plann Perspect 23226227,232, 1991 39. Lee NC, Rubin GL, Borucki R The intrauterine device and pelvic inflammatory disease revisited New results from the women’s health study. Obstet Gynecol 721-6, 1988 40. Lee NC, Rubin GL, Ory HW, et al: Type of intrauterine device and the risk of pelvic inflammatory disease. Obstet Gynecol62:1-6, 1983 41. Levy JA The transmission of AIDS The case of the infected cell. JAMA 259:30373038, 1988 42. Mauldon J, Luker K The effects of contraceptive education on method use at first intercourse. Fam Plann Perspect 2819-24,41, 1996 Segal SJ: IUD use throughout the world: Past, present, and future. In 43. Maulden W, Bardin CW, Mishell DR Jr (eds): Proceedings from the Fourth International Conference on IUDs. Boston, MA, Butterworth-Heinem, 1994 44. McCabe E, Golub S, Lee AC: Making the female condom a “reality” for adolescents. J Pediatr Adolesc Gynecol 10115-123, 1997 45. Mishell Rd Jr, Sulak PJ: The IUD: Dispelling the myths and assessing the potential. Dialogues in Contraception 5 3 4 , 1 9 9 7 46. Neal W, Coupey S M New contraceptive options for adolescents. Compr Ther 23:439445,1997 47. Peipert JF, Gutmann J: Oral contraceptive risk assessment: A survey of 247 educated women. Obstet Gynecol82112-117, 1993 48. Peterson LS Contraceptive use in the United States: 1982-1990. In Advance Data from Vital and Health Statistics. Hyattsville, Md: US Dept of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics 260,1995 49. Piccinino LJ, Mosher WD: Trends in contraceptive use in the United States: 1982-1995. Fam Plann Perspect 304-10,45, 1998

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