New AAP policy statement endorses use of emergency contraception for adolescents

Image: PD. Contraception use by geography. 

This is an advanced release statement provided to 2 Minute Medicine by the AAP/Pediatrics. 

Key points:

1. Lack of prescriber education and comfort is believed to be the source of low emergency contraception usage among American adolescents.

2. The American Academy of Pediatrics (AAP) encourages pediatricians to counsel and prescribe emergency contraception to teenage patients when appropriate.

Primer: While the rate of teen pregnancy in the United States is declining, it is still considered high when compared to other developed nations. Nearly half of U.S pregnancies overall, and fully 80% of adolescent pregnancies during adolescence, are unintended. There is hope that expansion of the use of emergency contraception will aid in preventing unwanted pregnancy after unprotected intercourse, sexual assault, or failed contraceptive measures for adolescents in particular. Emergency contraception is defined as any form of medical treatment that is effective in reducing the chance of a pregnancy after intercourse and includes both pharmacologic interventions and copper intrauterine device (IUD) placement. While rates of unplanned pregnancy remain high, only about 10% of women report using emergency contraception and only 52% of female teenagers report being aware of the correct time frame for its use. It is believed that a lack of physician education and a lack of comfort with prescribing these methods contribute to the low prescription rates among doctors, including pediatricians.  

Background reading:

1. Sexual experience and contraceptive use among female teens – United States, 1995, 2002, and 2006-2010 [CDC]

2. Emergency contraception: Separating fact from fiction [Cleveland Clinic Journal of Medicine]

This [policy statement]: reviews different methods of emergency contraception, makes recommendations for prescribers, and address ethical dilemmas in the use of these methods. Copper IUDs are only briefly addressed. Key statements are outlined below:

Methods of emergency contraception:

Levonorgestrel (Plan B, Plan B One Step, Next Choice): This is recommended as the first line method. It is not effective in pregnant individuals. Adverse effects: increased menstrual bleeding. Levonorgestrel works by disrupting ovulation, follicle development, and impairs maturation of the corpus luteum. There is no definitive effect on the endometrium.

Ulipristal acetate (ella): This progesterone agonist/antagonist is typically taken as a single dose up to 5 days after intercourse. Adverse effects: headache, nausea, and vomiting; may result in fetal loss if taken while pregnant. Works by delaying ovulation, may have effect on endometrium.

Combined oral contraceptives (Yuzpe Method): This method consist of 2 doses of medication containing ethinyl estradiol and levonorgestrel. Adverse effects: nausea and vomiting are relatively common. Individuals prone to clotting should not use this method. MEthod of action is similar to levonorgestrel

Advanced Prescribing:

With a 2010 review study as support, advanced prescribing is proposed as a way to improve access to emergency contraception for adolescent females. Through this method, teenagers would be able to stock either medication or a prescription for medication to be used or filled when needed. Advanced prescribing has not been found to increase adolescent sexual activity or reduce use of other contraceptives and also has not been found to reduce pregnancy rates.

Ethics:

– The AAP acknowledges the potential for personal beliefs to dissuade a physician from prescribing emergency contraception despite circumstances that might call for it.

– The AAP restates a previous policy recommendation that physicians are obligated to inform patients of legally available treatments even when these violate their personal beliefs, and in cases where they feel uncomfortable proceeding with care, they must refer patients to physicians who would be able to provide such care.

In sum: Emergency contraception is an important component of comprehensive reproductive counseling that includes unwanted pregnancy and sexually transmitted infection (STI) prevention. While other methods of contraception are effective when used properly, adolescents are at an increased risk for contraceptive failure. In addition, a portion of teenagers are victims of sexual assault. The statement encourages pediatricians to counsel male and female adolescents on emergency contraception whenever discussing sexual health and to supply those in need. Levonorgestrel is described as first line.

Click to read the release in Pediatrics 

Source: Upadhya KK, et al “Emergency contraception” Pediatrics 2012; DOI: 10.1542/peds.2012-2962.

By [LHC] and [DB]

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