Chapters Transcript Video Updates in Family Planning for Adolescents and Medical Uses of Contraceptives Doctor Lea Brat is a primary care pediatrician practicing in Oakland with a focus on adolescent medicine. She currently serves as the adolescent health and school-based medicine medical director at the UCSF Benioff Children's Hospital at Oakland's FQHC. She completed her undergrad studies, as well as her medical education at UC Berkeley through the JMP program, and followed by her pediatric residency at UCSF. She continues to be involved in clinical work, where she precepts a variety of learners in our team clinics as well as our school-based clinics, and she is very passionate about the reproductive justice, uh, in adolescence and has continued to work on increasing access to. of family planning in this population as well. Um, she will be giving our lovely talk on updates in family planning for adolescents and medical uses of contraceptives. So without further ado, uh, please join me in welcoming Doctor Backer. All right, thank you. Good morning, everyone. We're gonna go ahead and dive in. Um, the only disclosure I have is that I became a trainer with Organon so that we could incorporate contraceptive implant training into our internal orientation. I also wanted to frame this discussion that um even though I will often use um girl and women, there's youth of all um gender that may come in seeking either help with family planning or period control. So definitely want us to be inclusive. Um, today we're gonna review person-centered contraceptive counseling. We'll go over the American Academy of Pediatrics practice guidelines regarding emergency contraceptives and long-acting reversible contraception. We will um review how to access and use the World Health Organization medical eligibility criteria and discuss some of the newer developments related to contraception. And I am excited that there are quite a few updates between when I last presented a similar talk in Monterey, um, and now, so. Glad to be able to share. Like Jay said, I do think having this talk rooted in reproductive justice is super important, and that is essentially the right for all individuals to build the families that they want to build. So if they opt to have children to be able to have um The resources they need, whether it be childcare, food security, a home to live in. And or for those who feel like it's not the right moment in time, um, the right to access family planning services and safe abortion services. Unfortunately, we still have a long way to go in the United States in making reproductive justice a reality. Um, this is the most recent data related to maternal mortality rates in so-called wealthy nations, and you can see that when we um, Zoom into maternal mortality rates, um, black women in America have a rate of 49.5 maternal deaths per 100,000 live births, and, um, women in general in the United States have the highest rates of maternal deaths per 100,000 live births compared to other developed nations. So that makes it even more important for people to decide if and when they would like to go forward with pregnancies because it can be um a life or death situation. 45% of pregnancies in the United States are unintended, and when we look at adolescence, it's an even higher percentage. Also wanted to point out that since Dobbs in June of 2022, um, making abortion laws vary state by state, there are many states where millions of women have lost access to abortion. Luckily, in California, we do have protective laws. But, um, You know, we have a duty to make sure that we are Using a reproductive justice framework. Fortunately, adolescent pregnancy rates have been um dropping in terms of unintended pregnancies, and that's largely due to increased access to contraceptive implants and IUDs, um, but there are still significant disparities and there is more work to be done. And in terms of why teen pregnancy is a cause for concern, Teen parents are less likely to graduate from high school, to receive adequate prenatal care, and more likely to have psychosocial complications afterwards. There are a lot of studies trying to tease apart to what extent it was pre-existing adverse childhood experiences that set up a kind of higher risk situation, um, but regardless of, you know, whether it is the ACEs or whether it is biological immaturity. Um, infants of teens are more likely to have complications such as being low birth weight, to be premature, and when we look at infant mortality, um, the highest rates of infant mortality occur, um, when the parent is young. So the 15 to 19 year olds, both in the, um, neonatal and post neonatal periods, can have significant infant mortality rates. So again, um, every person should be able to opt into when they would like to um take on the risks of pregnancy and parenting. Some of the factors that affect contraceptive use can be um at several different levels, like we think about the socio-ecological model in public health and um similarly in contraception at the patient level, they have perceived risks and benefits of contraception versus pregnancy, especially as it relates to possible side effects from contraceptives. And there are social influences, whether from friends, family members, and obviously their knowledge and attitudes about contraception or even aware of certain methods will influence their ability to use it. On the provider level, um, provider training. So again, thank you for being at this talk this morning. And even when there is knowledge, um, you know, being able to learn procedures for long acting reversible contraceptives, um, takes some doing to integrate into training, so shout out to our um residency and our System of care for making that possible. So again, we have a little work to do when it comes to training on IUD placement. And then there's a lot of structural issues, and that relates into some of the training things. So when our health care system, you know, rewards volume and quick visits over more detailed visit, that can be a barrier sometimes, um, reimbursement for methods that are more expensive can be a structural barrier, and so we'll dive into all of these things. We talk about shared decision making, where basically the patient um brings their goals and their preferences and values to which methods they might want to use, and our job as providers is to share our clinical knowledge, the risk. And benefits, medical contraindications and side effects. But at the end of the day, it is the patient who can decide um which method they want to use at this point in their life and that The decision making should be more on the patient side than on the provider side. Sometimes I joke that I'm gonna show you the menu of all these contraceptive options, tell you about them, but it's the patient's job to decide if there's anything on the menu that interests them today. And Sometimes we may not know the patient's priorities. Um, sometimes we think, oh, they're gonna obviously want the most effective method, but it may be that the patient wants to prioritize confidentiality, or maybe they hate having menstrual bleeding or spotting, or maybe they're really worried about weight gain. So by delving into what their priorities are, we can best serve them. There are some excellent resources from bedsider.org, and historically, We've tended to use the chart that talks about effectiveness. So the top tier here are the methods that are the most likely to prevent a pregnancy, and then so on down. But there's some newer resources from Bedside or this is their website where patients can kind of do compare and contrast of different methods. They also have some finder tools where depending on which method the patient wants, they can put in their zip code and it'll show some options of places to go to get the method they want. But the new resource that I want to highlight, which is really exciting, is a flip chart and a web resource where if the patient's priority is they want to minimize bleeding, or they want something that has a certain side effect profile, then you can turn the flip chart to the one that's their priority. So if they want to talk more about side effects, um, You know, there's a number of methods that have no hormones, and that's not to say that there won't be any method-related side effects. So, for example, with the copper IUD, there's no hormones, so there's no hormonal side effects, but in the first couple months of use, there can be heavier bleeding and cramping, so patients should be aware of that, um, if they start that method. Progestin methods can cause lighter, irregular periods. Um, some patients may have changes with mood or reduced libido. Um, all of these methods are reversible, and then, um, with the combined methods such as pill, patch and ring, periods tend to be more predictable, but initially there can be some breast tenderness, nausea, vomiting, and headaches. So these flip charts are super helpful. You can kind of go to the one that the patient says is their top priority. There's one that's around confidentiality, there's one around bleeding profile, and have a good discussion about what the options are. Um, wanted to review the pregnancy rates from the Choice study, which was one of the seminal studies of um using long acting reversible contraceptives in adolescence, and it found that when the barrier of cost and access was removed, um, there was significant benefit in terms of reducing unintended pregnancies in all patients that participated in the choice study. Um, not surprisingly, it can be hard to keep on top of taking a pill every day, changing a patch once a week, etc. So the patients that were using pill, patch and ring, um, were only successfully using it at the 1 or 2 year mark at around 40 to 50%. Whereas with IUDs and implants, which are more of our get it and forget it methods, um, at the end of the first year, 80 to 90% were still using their method, and at the end of 2 years, almost 80% were still using their method. And here we see a slide from the New England Journal of Medicine, um from 2012 about real world effectiveness and looking at rates of contraceptive failure, and we can see within the 1st 3 years, 9% of patients using pill patch and ring had had a pregnancy, whereas only um less than like 1% with long acting reversibles such as implant and IUD or Depo had had a pregnancy. So, um, AAP as well as ACOG says pediatricians should be able to educate patients about LARC methods, um, and ideally offer the ones they are able to offer. So, at the top of the list of the ones that we as pediatricians can certainly offer is Nexplanon. As my colleague says, it's easier than placing an IV you don't even need to get it in a vein, and in fact, ideally you do not get it in a blood vessel. So it is a subdermal implant. Um, the active hormone is eonogestral, which is a progestin-only method. There is no estrogen, which means there's no increased risk for thromboembolism. It is labeled for 3 years of use, but the latest studies have shown that it is effective for 5 years, and due to financial barriers and FDA approval hurdles, it is unlikely that they will go through the process to change the label, um, so it's important for us to educate patients that if they like their implant, they can use it for a full 5 years. Most patients with an implant do not need imaging, cause if the patient can feel it, and if we can feel it, then we know it's in the right place, but one of the differences between implanon, the prior generation of the contraceptive implant and explanon, is that it is radio opaque, so it can be seen on plain film, high frequency ultrasound, etc. Um, the most common reason for discontinuation is spotting, but it is possible to treat spotting with um NSAIDs or some estradiol or low dose OCP if they don't have a contraindication. I have a slide on that coming up. Um, for those who are interested in getting trained to insert implants, you can go to this website, nextpanontraining.com and sign up for an upcoming training, which is an FDA requirement. Um, to help patients access this method and um it's the only contraceptive that has an FDA requirement about training. It is important before a patient starts an implant to know that it can cause spotting, so about 20% of patients may have spotting every single day. The other patients are um May have irregular periods, so about 60% of patients using the implant have better cramps, lighter periods, but it may be unpredictable, and then 20% may have amenorrhea. And well, I often think of that as winning the lottery, there are some patients that find it reassuring to have some periods, and others who have family members monitoring their pad use and so not everybody is psyched for amenorrhea. If somebody is having bleeding on the implant at baseline, hopefully we have a hemoglobin as part of healthcare maintenance for all patients that get menses. Um, if they come in with spotting and their hemoglobin is normal, then we can just reassure them to, you know, that this is a side effect of Nexplanon. Ideally, they have a good iron intake, whereas if their hemoglobin is low, that's when we want to try to treat the spotting, um, presuming they have no contraindications to NSAIDs or estrogen, we can use ibuprofen, 600 mg, POQ8 hours for 5 days, ideally with food. We can use low dose estradiol or even a low dose birth control pill for a few cycles to settle down the spotting. Or if they don't like the method, you can take it out. Um, we would also ideally want them to increase their iron intake. If it turns out they are interested in an IUD, just comparing and contrasting copper IUDs and levonergestal IUDs such as the Mirena, copper IUDs are great for patients that want to have regular periods after the initial adjustment period of the 1st 3 months, the period pattern of somebody with a copper IUD is the same as it was at baseline. If they don't want any hormones, um, copper IUD is a good choice. Ideally, they would not have a history of dysmenorrhea or menorrhagia because those 1st 3 months, patients have um heavier bleeding and stronger cramps. With Leonner gestural IUDs such as Mirena, Lilata, Kylena, Skyla. Ideally, the patient would be OK with having initially some irregular bleeding, um, depending on which IUD patients may trend towards amenorrhea. So the higher the dose of the levo adjusterol such as Mirena or Lileta, the more likely that at the end of the first year, they will be taking a break from periods or having much lighter periods. Um, if they have a history of dysmenorrhea or heavy periods, Mirena IUD is one of our most effective methods to reduce those symptoms. So with um levonogest IUDs, it's a progestin only method. The levonerggesterol is released at about 20 mics per day. When we first started offering Mirena, they were initially thought to be good for only 5 years, but the latest science shows that if patients like the Mirena, they can use it for 8 years. A nice new development is that Mirena can be used as an emergency contraception, though sometimes accessing it within that 5 day window after unprotected sex can be a challenge. Um, but it's helpful if a patient comes in wanting a Mirena, and if they're in the window period. Um, before it had been studied as an emergency contraceptive, I would sometimes have a situation where a patient would come in wanting to run an IUD, but if they'd had recent unprotected sex, um, It was a little bit of a challenge to know if the right thing to do was to place it anyway when it had not yet been fully studied as an emergency contraceptive method, versus have them come back, running the risk of having them come back and be in the exact same scenario. Um, so it's nice now that both copper and Mirena IUDs can be used as emergency contraception. In terms of bleeding patterns, there's oftentimes spotting for the first um 6 months or so, and then by the end of the first year, about 20% are taking a break from periods. Um, by the end of 3 years, about half um are amenorrheic. Um, but once that IUD is removed, the cycles come back and are how they had been. The failure rate is really low at 0.1%, knock on wood, I've not had a patient to get pregnant on herrana in our setting yet. Um, Skyla is a slightly smaller device and it has a slightly lower dose of levooggesterol. So if a patient would like to have less menstrual suppression, then it can be a good choice. Um, it can only be used for 3 years, so sometimes if a patient doesn't anticipate wanting pregnancy for 5+ years, then it might make sense to try the Miranda. She can always remove it whenever she wants to, um. But some of the advantages of Skyla, slightly smaller and also less menstrual suppression for those that would like to have their periods still. In terms of how these IUDs work, the ones that have progestin in them, they thicken cervical mucus, the sperm motility and function is inhibited. There's a weak foreign body reaction, basically a signal to the brain that the uterus is occupied, and then ovulation is inhibited in 5 to 15% of cycles. The copper IUD on the other hand, um, can be used for up to 12 years if the patient wants it. It can be used as emergency contraceptives, and then, like I mentioned, the periods tend to stay how they had been, so if they have regular periods at baseline, they'll stay regular on the copper IUD um though they should be aware that there's an adjustment period with heavier cramps and periods for the 1st 3 to 6 months. In terms of the paraguard or copper IUD's mechanism of action, the copper ions can basically zap sperm, um, and it makes it an unfavorable environment for implantation. And patients often want to know how uncomfortable is it to get an IUD and basically, each person's body reacts a little bit differently, but with some of the distraction techniques that we use as well as some ibuprofen, um, and sometimes numbing agents on the cervix, many patients, even those who have not had sex in the past, have been able to tolerate IUDs using the small pediatric speculum. Um, we've had patients with gender dysphoria who are getting it for menstrual suppression, who've never had anything in there who can tolerate it in the office. Um, for special needs patients or those who don't think they can tolerate it in the office, our colleagues from gynecology can also, um, place IUDs in the OR with sedation. We are gonna do a little case. Um, you have an 18 year old young woman patient with type one diabetes and elevated hemoglobin A1C. She sends you a MyChart message early Sunday morning saying that she had sex on Saturday night and the condom broke. She's feeling really worried cause her app says she's at the time in her cycle where she's most likely to become pregnant. She wants to know if you can help her. So, some possible answers. You advise her pregnancy is unlikely given how high her hemoglobin A1C is. Tell her to do a home pregnancy test and call if it's positive. Advise her to take a plan B as soon as possible. Send a prescription for Ella to her pharmacy. Or tell her to come in to have an IUD placed. So, Some of the commentary about these, um, if she's interested in an IUD then certainly she could come in to have one placed when she calls, she should let the front desk know that she needs it urgently, um, and probably just chat with the doctor of the day to see how she can get that arranged, um, within that five-day window. If it turns out she does not want an IUD, then Ella, or ullarystal acetate can be sent to her pharmacy. Because that tends to be effective for the full 5 days of the window period. We'll have some slides coming up about Plan B versus Ella. Um, if Ella is not available, then Plan B or levonogeststerol can be used as emergency contraception, um, though it's most effective within the 1st 72 hours. Plan B is over the counter, um, and both Plan B and Ella can be provided under an advanced provision model. Um, so it's a good idea for folks of childbearing potential to have some emergency contraceptive pills at home in case it becomes necessary. In terms of the, um, if a home pregnancy test is positive, then it is not um a situation of emergency contraception, then we would be doing options counseling and we'll have some slides coming up about medication abortion and other options if she is not interested in being pregnant at this time. And then in terms of the elevated hemoglobin A1C, um, that can be a risk for teratogenicity and birth defects, but it is not um something that reduces fertility. OK, so this is the study from the New England Journal of Medicine, Dave Turrok et all looked at Mirena and copper IUDs for EC emergency contraception, and um the green box shows how many pregnancies would be expected after unprotected intercourse per 1000 women if nothing is used. The UTSB regimen is when you take a bunch of OCPs to um reduce. The chance of pregnancy, then you can see plan B had better efficacy than the UTB regimen. Ella even better, and then the copper and levodiestal IUDs um showed the lowest rate of pregnancy. When used as emergency contraception. Realistically though, a lot of adolescents are not interested in an IUD when they are young, and also it is logistically much more complicated than just taking a pill. Um, in terms of how Ella or ullarystal acetate works, it delays ovulation. It's basically an anti-progestant, and so, Um, if the ovulation does not occur within those 5 days, um, the sperm. Eventually Get flushed out and cannot cause a pregnancy. Um, if it turns out that the patient is already pregnant, as we had as one of the options in that case, Plan C is medication abortion, which is safe and legal in California, and so the regimen that's typically used is mifepristone, 200 mg PO and then followed by misoprostol. Um, there's a great brief online training abortion pills CME, which you have the link to the slides here, um, or if a patient would like to see options for getting abortion pills, um, the website Plancpills.org is a great resource. Some of the advantages of medication abortion are that it can be used up through 11 weeks of pregnancy, and internationally, there's countries that use it um a little further into the pregnancy than that. It does allow for greater autonomy and privacy. Um, some patients think of it as more natural, less invasive. Um, unlike a procedural abortion, medication abortion does take a day or two to complete the process, and bleeding and cramping can be heavier and more intense. Um, UCSF has Ruth Clinic, the reproductive Understanding Towards Health Clinic, um, and any patient who think they might be pregnant can be referred for options counseling and support. There's some phone numbers here, and currently there's some grant funding to help patients with transportation, childcare, um, coverage of missed wages, abortion doula, etc. Um, so feel free to refer patients that are pregnant and don't want to be, as well as patients that are pregnant and would like some help linking to prenatal care and resources for young parents. All right, we're gonna pivot to some of the medical uses of um hormonal contraceptive part of the talk. Um, here's a case of Anaya, a 14-year-old young woman who comes into a clinic with a history of irregular periods. She reports that she has had 3 weeks of vaginal bleeding and she came in because she was feeling really lightheaded during PE today. You do a point of care test and shows her hemoglobin is 8. So, obviously there's a lot of um History and other workup that we're going to want to do, but since this is kind of an overview, talk of a lot of topics when each of these things could be a full talk in and of themselves, we're gonna zoom into treatment. Um, if she is at all hemodynamically unstable, or if there's a social situation such that there's limited transportation or limited phone access, then it would certainly be reasonable to think about admission. Whereas if it turns out her vital signs are stable and the family feels comfortable. Doing a home regimen. Um, the traditional regimen that we've done for a long time. Involves using a regular OCP such as low overall, um, taking one birth control pill, PO 4 times a day for about 4 days with an antiemetic as needed. And then 1 pill 3 times a day for 3 days, 1 pill POBID for 2 days, and then an active pill PO daily for 6 months, then following her hemoglobin and arranging close follow up either in the teen clinic with us or in your practice. Um, there is a newer approach, and we have an exciting collaboration between PD Guy, uh, hematology, adolescent medicine, and the ED to kind of update and roll out, um. Some new treatment options, um, including tranexemic acid, which is an antifibrinolytic agent that prevents fibrine degradation and decreases menstrual blood loss. Um, interestingly, it's been over the counter in Europe, um, for almost 2 to 3 decades in Sweden and the UK. And in the United States, um, initially there is some labeling about it being contraindicated when using hormonal management, which when you're trying to treat irregular periods and period problems oftentimes the first thing we reach for are hormonal treatments. Um, but the latest studies have shown that being on hormonal treatment is not a contraindication to using tranixemic acid, and it's exciting that the North American Society for Pediatric and Adolescent Gynecology are working on a statement that will be Coming out this year, um, to update that labeling and will hopefully save us a lot of phone calls from the pharmacy because oftentimes we'll prescribe hormonal contraception and tranexemic acid, and then get a call saying, hey, you know, are you sure you want to do this? And to have say, yes, this is what we're trying to do. Um, we can also consider using norathyrone, a progestin-only method, um, at 5 to 10 mg orally, 3 times a day for 10 days. Progestin stabilizes the endometrial lining and reduces menstrual bleeding. Um, it is not a contraceptive regimen, so if your patient needs contraception, then once the menorrhagal situation has stabilized, then you can think about transitioning to a hormonal contraceptive regimen that is appropriate for preventing pregnancy. So in terms of sum and I know that's kind of a whirlwind tour of this topic, um, but you wanna make sure that any hemodynamic imbalances are corrected, prevent uncontrolled bleeding loss, correct anemia, replace iron stores, and there's many options for doing that. And like I said, if they need contraception, then figure out a plan to help prevent pregnancy. And just wanted to give a shout out to the abnormal uterine bleeding clinic, which is a wonderful collaboration between Doctor Burger Chen from gynecology, Doctor Matsunaga, Katrina Nino, um, from the hemophilia and Thrombosis Center. So the phone number is there if you have a patient that would benefit from their expertise, and these slides will be shared out after. And definitely shout out to Doctor Matsunaga and Doctor Burger Chen, who are working on um creating some streamlined protocols that we can use in the ED on the inpatient side, as well as some algorithms and order sets. So stay tuned for more on that. OK, so back to contraception, we have another case. Little Miss Independent, um, Brianna is a 16 year old young woman, and she has decided she would like to start birth control. She hasn't found the right time to bring it up with her primary care pediatrician cause her mom is always with her during her pediatric visits. She lives right near a pharmacy, and she has a history of migraines. True or false, she can go to the pharmacy and get birth control pills without a prescription. So, interestingly, as of 2016, women of any age in California could get birth control methods from the pharmacy without a prescription from a doctor, but it did involve um $40 pharmacy counseling fee, which ended up being a barrier for a lot of our patients. Um, some folks use some of the telemedicine ways to access contraception such as P Pandya Health, which can provide free delivery of pill patch or euvering with a 3 month supply at a time. But the exciting development from this year, or I guess last year technically, is that as of 2024, 0 pill um became our first over the counter birth control pill. And it is actually not a new medicine. Um, it is Norgestrel, and it had been marketed in the US for over 30 years. Um, sales had been discontinued for business reasons, not for safety or efficacy, but it is now back um on store shelves. And it is, um, has a similar effectiveness to combined oral contraceptives. Um, on average, you might see 2 pregnancies per 100 women years of use, but if when combined with the barrier methods such as condoms, then you won't see um that many pregnancies. The label suggests using a backup for the 1st 2 days, and if there is um delay in taking the dose, but some studies have shown that even delays of 6 hours didn't really affect um the thickening of the cervical mucus or the reduced ovarian activity. In terms of contraindications, if the patient has breast cancer, and particularly a progestin sensitive breast cancer, then that is a contraindication to use. Um, other scenarios to discuss with their clinician is if they have undiagnosed abnormal uterine bleeding, since progestin methods can cause irregular periods, might as well work that up in advance. Um, if they have active liver disease, or if they're taking a medication that has hepatic enzyme inducers. If they're using other hormonal contraception, then they wouldn't need to be taking another kind of birth control, and then there are some things to consider if they've recently used emergency contraceptions. Specifically, Ella, which is antiprogestant, can be undermined if somebody starts a progestin method right around the same time. So ideally they would wait 5 days after taking Ella to start their new hormonal contraception regimen. There is a wonderful app from the CDC called Contraception. It is free and happily it is still there, um, and it breaks down. Who can use what based on underlying medical conditions, based on method, and it has a pretty easy to follow green means go, um, there's no contraindications to the method. Um, if there's a 3, that's usually a shared decision making situation, and 4 means there's a contraindication. And I think it is super important for us to integrate contraceptive care within medical homes because back in the day when people would just go to Planned Parenthood and get birth control and not necessarily dive too deeply into their medical history, there were times when teenagers with migraine with aura would be put on regular birth control pills when that's actually a contraindication because of the increased risk of TIA and stroke. So important to just double check um which contraindications a patient might have. In terms of impact of the op pill and other progestin methods on menses, um, There can be breakthrough bleeding or spotting in about half of patients, not necessarily in every cycle, and only about 6% of patients will have amenorrhea within the first cycle, 28.7%, um. May, you know, go through. Less menstruation, but definitely it's not something that we can promise patients and it's pretty much a trial and error situation. Sometimes it can be a little bit overwhelming to know which pill to choose for patients, but in general, keeping it simple, choosing one that's on their formulary, um, monocyclic, there's no need for having different doses of hormones since um we are stabilizing the shifts of their menstrual hormones anyway. Um, some of the pills are fancy with added iron or folate, um, you know, if it's on their formulary, sure, but it's not necessary. In terms of if the patient would like to do extended menstrual cycling or um have a monthly period that's up to them, and basically, they can start on the day of the visit, they don't need to wait for Sunday start. Also, feel free to provide a one year supply. Studies have shown that those who get a full year's worth are 3 times as likely to avoid an unintended pregnancy. Um, and in California, we passed SB 999, which requires health plans to cover 12 months of hormonal contraception that's self-administered. Thanks to the Affordable Care Act, um, coverage without co-pay of contraceptives in each of the 17 categories identified by the FDA is required. And then we're just gonna talk briefly about some of the newer methods. Again, these slides will be shared, so no need to absorb all of this at once, but just some highlights. Subcutaneous depot, meaning self-administered depot, um, tends to be less painful, involve less weight gain, and can be um self-administered, which can sometimes lead to better adherence because there's less of a time investment coming into clinic. So definitely offer that to patients. We have a new vaginal ring called anovera, which can be used for up to 1 year, where basically, similar to the NuvaRing, it's inserted in the vagina for 3 weeks. Um, with the Nuvaring, patients toss it each month. With the anovera, they can remove it, wash it, and then reinsert it. With um nouverring, it needs to hang out in the fridge if they're storing it for a while, whereas with aloe vera, no refrigeration is needed. So for somebody who's trying to use it confidentially, it's kind of nice if you don't need to have a little baggie in the family's fridge, um, and then many health plans are covering aloe vera, so something to keep in mind. The newer contraceptive patch is called twirla, um, ortho Era is now being replaced by the generic zullain and zefey. So the main difference between twirla and zulain is that twirla has a slightly lower dose of the ethanol estradiol, and then the active progestin is levonergesterl. So with Torla, it is very similar to taking a regular low dose combined oral contraceptive pill. Um, whereas the Zulain has about 60% higher dose of estrogen than combined oral contraceptive pills. Both have pretty good efficacy um for patients with an elevated BMI. There may be decrease in efficacy, but um some method is better than no method, and if that's the method that the patient prefers, then um fine for her to try it. There has also been some studies looking at rates of blood clots in patients using the patch, and it is low, um, so it's kind of a shared decision making situation. As BMI goes up, the studies had showed slight increased risk of clots, but a low risk, um, When multiplied by large numbers, is still low overall. So it's pretty much up to the patient if she would like to try it or not. Um, So, twirla may be a better choice for a patient who wants lower hormonal levels and is less concerned about effectiveness of the method because she's also using a barrier method. Slind is the progesterone only estrogen-free pill that um works somewhat better than the traditional mini pill, Nothinrone um because even if somebody takes it a little bit late, it has a longer half life and so it's pretty much similar to other birth control pills, as long as she's taking it once a day, then the efficacy will be good. There can be some spotting on all the progestin-only methods, and there's overlap between drosperinone and um anti-mineralla corticoid activity. It's sort of similar to Spronolactone. So if the patient's taking a medicine that may increase potassium levels, let's say lisinopril or something like that, then the potassium levels should be monitored. And there's some thought that there's um some anti um Hyperandrogenism treatment from Slint. Finally, um, there is FEy, which is a vaginal gel that can help zap sperm. It can be used for up to one hour before sex, and it maintains an acidic environment in the vagina, which decreases sperm motility. So if you have a patient that does not want any hormonal treatments, but does not want to get pregnant, then they can think about FEI. All righty. So we're gonna transition to some Q&A just a reminder that this QR code can help you access um your evaluation and your ability to get your CME. So I will, um, oh, and then if you have a patient that would like anything related to family planning or an adolescent consult, here is the phone number for teen clinic. Um, we have clinical care available by phone, Zoom in the clinic, as well as at our school-based health centers in east and west Oakland. So I will Hand it over. Thank you so much. That was so much uh information. Um, I love that you went over just the uh the usual that we do, and then all the new things that have been added on. So it's very exciting to see all these things rolling out, um, and hopefully we can incorporate them into the practice. Um, we have a lot of questions, um, they're starting to blow up a little bit. Let me try to pull them up if possible. Uh, OK. First question we have is how often does an explan on training need to be repeated? Never. It's a once and done. But if somebody would like a refresher, let's say you did the training 3 years ago and you sort of didn't get a chance to place many, um, it's possible to do refreshers, and if you're a trainee here, you're welcome to rotate with us. We will coach you. They also now have reusable practice applicators. It used to be that the practice applicators were one time use, um, but now you can reload them and so you can place as many as you would like on a fake arm. Gotcha. That's super cool. I think uh we got to do that during our intern orientation. And then I have another question. Uh, there are several influencers online claiming of copper toxicity in regard to Paraguard, uh, lots of scientifically unbacked claims, it sounds like. Have you noticed patients inquiring, uh, about this or asking their devices to be removed because of this, and how do you, what's your counseling in that regard? So if the patient has Wilson's disease, they should avoid copper. If they do not have Wilson's disease, then we have lots of data showing that it's safe and effective. Most of my patients want to have lighter periods, better periods, so Mirena is much more popular amongst my patient population. I do have several patients on copper IUD, but so far I have not had anybody come in asking to have it out. Gotcha, gotcha. And then, um, what sort of your counseling just based in that regard of uh when folks want to get off of the IUD um what sort of like your counseling in terms of that aspect of switching over to a different uh contraceptive method and what that transition looks like? Yeah, so we try to be patient-centered and be pretty accommodating in terms of switching methods. And so I think once she's decided what her next step is, if she's trying to conceive, we'll do prenatal vitamins and talk about preparing for a healthy pregnancy. If she has decided she does not want to have an IUD then sometimes we can actually start the other method and once it's in place for 7 days, then You know, she can switch to the patch or whatever, and then take out her IUD. Also, going back to the question of reproductive justice and our history of reproductive coercion, patients should know that, um, studies show many times women can actually reach in, grab the strings and pull out the IUD themselves. It's kind of awkward and easier for us to help patients with that. But if they're worried about not being able to control their method, um, A significant chunk of the population has long enough fingers to self-re remove an IUD. But would it be something that you officially recommend, um, but something that can be brought up. Yeah, I think for the vast majority of patients, it's much more convenient to just come into clinic and that we can take them out. The other thing is, um, it's a lot easier for providers to learn how to remove an IUD than to insert them. And so, you know, if you have a patient that for whatever reason really hates her IUD, which is rare but it can happen, um, it's very easy to learn how to remove an IUD. Basically, there's a little string coming out of the cervix. We grab it with the ring forcep, have her cough, pull it out. So I bring that up because I think many people on this webinar today could learn how to remove IUDs. Is, is there like a website or anywhere that goes over that specifically, or is it as simple as that? There's a lot of um teaching resources. There's a UCSF group called Beyond the Pill, and they have a lot of teaching resources, um. And then we also have some kind of simulator models, um, so I know these days we're doing less Pap smears than we used to, which means folks have less experience finding the cervix and placing a speculum than we used to as pediatricians, um, but for those that feel comfortable finding a cervix, basically you just grab the strings and pull. Gotcha, gotcha. Um, going back to the emergency contraceptives, um, if a patient is unable to, uh, access Plan B or Ella, um, but they do have access to their own daily OCPs, should they be instructed to take a particular amount of their own pills, I think this was the Ua or the you may method that you were talking about. Yeah, the youth Bay regimen, Y U ZPE um and it is possible to like Google what is the recipe for youth bay with different brands of OCP. There's a lot more side effects cause it's kind of a higher estrogen load than you would get. With other approaches, but it kind of also highlights the benefits of advanced provision, and if many people have some emergency contraception available, um, then you won't be having to make yourself sick with the UB regimen. But anyways, in theory it is an option. Gotcha, gotcha. And then What is, what is the current uh patient weight restriction recommended uh when using Plan B versus LA? So if the BMI is greater than 30, then you wanna be a little careful and it's, it's all kind of relative to. So, you know, if you have nothing else, then go ahead and try it. um. But yeah, it's the BMI is above 30. And then, uh, this is an interesting question. Um, any male contraceptive options uh on the horizon, um, and if you could speak a little bit about what that sort of, um, Field looks like Well, given our investments in scientific research currently, we'll see how soon we'll, it's funny cause it's always my joke when I'm placing an implant or an IUD that, 01 day we'll have the young men stepping up and doing more than condoms. But anyways, I think there is research on that. Not ready for prime time yet, and maybe that can be a future grand rounds topics, somebody who's qualified to speak on that. Gotcha, gotcha. And then um I saw on the page where there was insurance coverage of specific contraceptive options or not, but it looked like uh the male options weren't covered for like a vasectomy or those were more limited. Um, I, I wasn't sure if there was like any specific reasoning for that or In California we are lucky in that medical and family pack do cover several of the male options, um, so. Again, yeah, it's awesome, OK. And then These questions are rolling in so quick. Um, There's a lot of uh this is along the lines of uh influencers and social media misinformation as well, but this might have maybe a little bit more weight that I'm not sure about. Um, there's a lot of commercials about Depot causing meningioma. Should we be hesitant about offering this to our patient, and is there any additional counseling that you do for this meningioma risk factor? Yes, that is one that patients have brought up a little bit. Um, my understanding is that it is rare and it has not changed how we counsel about Depot, um, but anyways, yes, I did. Hear about that on social media and did a literature search and did find a little bit on it, but it sounded like it was. Not something that It is a common thing, and we've had tons of patients on depot, knock on wood, have never had one that developed a meningioma. One thing that we didn't really have time to cover during this day are also the questions about bone mineral density with Depot, and that most studies have found that it's temporary demineralization, that it is not correlated with fractures clinically either in the moment or down the road. Um, so, you know, ACOG and others say that patients can use Depo as long as they want. They should try for some weight-bearing exercise, take calcium, vitamin D. And then the other question that comes about, up about Depot is weight gain. It is our only contraceptive method that has some association with weight gain. So just letting patients know we check your BMI every single time you come into the office, we'll keep track of it. If we find or if you notice that the depot is influencing your BMI, then we can always change methods. Um, but I think Weight concerns are more relevant than meningioma concerns. Gotcha, gotcha. Um, and then this kind of goes back to other uses of, uh, OCPs. We didn't get to talk about its use as much in acne. I, I, I assume that hasn't changed too much, um, but I was wondering if there were any changes. Thank you for bringing that up and yes, it was daunting to try to talk about all the medical uses of contraceptives and um pill patch and ring, the estrogen containing methods can be helpful for some patients with acne, especially those that have hormonally related acne, whereas the progestin-only methods are not thought to benefit acne and with some of the progestin-only methods, about 1 to 2% of patients may see a flare in their acne. Um, some studies have shown that the newer progestins such as rosperinone may have slightly more anti-angiogenic impact, but basically it's reasonable to consider pill patch or ring as part of acne treatment, especially if they also need contraception. Got you, but that's if it has like an estrogen component as well. Yeah, and that they can try it. There are many patients that find their acne clears quite nicely. Also for patients that have either dysmenorrhea or acne, and they're not sexually active, a lot of parents sometimes are a little surprised. What I suggest using hormonal treatments for those scenarios, and there's a nice handout from youngWommenshealth.org called Medical uses of oral contraceptives, and it sort of breaks it down for parents that There are times when we use this medicine for acne, or for dysmenorrhea, or for hirsutism, etc. and it doesn't mean that your young child is gonna be having sex just cause they're taking this method and sometimes just calling it hormonal medicine rather than birth control. I mean, obviously you're not trying to deceive a parent, but just letting them know that there are multiple uses for it. And also reassuring them that it does not reduce future fertility. A lot of parents are very concerned that if you start a young teenager on the pill that somehow it's going to influence their ability to have grandchildren, which it will not. Gotcha, gotcha. Um, OK. Could you, uh, just go back to the um abnormal uterine bleeding treatment page with the OCPs? Yeah. I just wanted to review just for uh our sake, and then um Oops, this one. Um, I wanted to ask about transitions after we complete this treatment, um, because we're gonna go back to the normal daily pill, uh, but if we have any breakthrough bleeding during that time, do we just try the OCP like the increased method QID? And start back from there again, or is that, is that a point for transition to a different uh alternative method, or is this like something that the AUB clinic would be handling and kind of out of our hands from the primary point. Oh, that's a great question, and I think some of it, or did I freeze? A little bit, it's intermittent, but OK, we can hear you. Cool. Um, so knowing the patient's hemoglobin is super helpful in figuring out how to guide them. So if it turns out their hemoglobin is pretty much normal, then we can recommend extended menstrual cycling, meaning they're just taking the active pill, they're staying on that, um, you know, for a couple of months while they build back up their stores. Um, whereas if it turns out they're quite anemic, then you might backtrack on the regimen, so meaning if they were taking one active pill daily to ramp it back up to BID, whereas if they're having a lot of trouble remembering to take their pill, then you might want to consider a method that has less user um involvement, so something like a patch or a ring. And then not to be shy about using the tranexemic acid as a way to further reduce bleeding. But it is pretty hard for folks to remember to take a pill every day, and if you're on again, off again with your OCP that is gonna cause some spotting. Gotcha. If you are I know we're out of time. Oh my gosh, there's so many questions, but if you are transitioning to like a patch method or um different form of a contraceptive method, um, are you increasing the dose for that as well if like the BID was working for them, are you doing a double dose of a patch or something else weird and unexpected that we're doing? I mean, I think oftentimes we'll sort of finish the taper and when things are at a relatively stable point, then to go ahead and just switch to the patch. I have not been doing like patch plus pill, not been doing ring plus pill, um. You know, so I think that. You would do your taper and then, you know, if you switch to something like Zula, which has a sort of higher dose of the hormones anyway, then that inherently has some higher doses of hormones. Um, but again, I am kind of excited to see how things go, um, with the tranexamic acid and noriendrone, um, because that may be even more effective. That sounds good. Thank you so much. It's 9:02. We still have a million questions coming in, which is great. Would it be OK if they reach out to you directly with any of these questions? Yeah, my email is on that last slide, Leila. Backra at UCSA, and I would be happy to chat some more. And um yeah, send your patients to us. We have lots of room, including for telehealth. Perfect. Thank you so much, Ira. Um, this was a great grand rounds, um, always a pleasure to have you here. Thanks so much. Have a great day. Created by
