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Women’s Health- contraception

Primary Care Corner with Geoffrey Modest MD: Teens birthrate and sexual activity/contraception use

28 Jun, 17 | by

by Geoffrey Modest

2 related articles were recently published by the CDC.

1. In the United State from 1991 to 2014 the birth rate among teens age 15 to 19 hasdeclined by a dramatic 61%from 61.8 per 1000 to 24.2 per 1000, with larger % decreases in ethnic/racial minorities (see http://www.cdc.gov/mmwr/volumes/65/wr/mm6516a1.htm?s_cid=mm6516a1_w ). However the birth rate remained approximately twice as high for Hispanic and non-Hispanic black teens compared to non-Hispanic white teens. There are also significant geographic and socioeconomic disparities. See prior blog  for the full assessment . In brief:

— from 2006 to 2014, a 41% decline in birthrate overall, to 25.4 per 1000 female teens

— Hispanic: decreasing to 39.8 per 1000, a 51% decrease from 77.4 per 1000

— Black: decreasing to 37.0 per 1000, a 44% decrease, from 61.9 per 1000

— white: decreasing to 18.0 per 1000, a 35% decrease from 26.7 per 1000

— there is large geographic variability, for example the Hispanic birthrate in 2014 varied from 17.0 per 1000 in Maine to 58.0 per 1000 in Oklahoma; Black birthrate varied from 14.0 per thousand in New Hampshire to 54.6 per thousand in Arkansas; white birthrate varied from 4.8 per 1000 in New Jersey to 39.2 per 1000 in West Virginia. And, within states, sometimes the racial disparities remain very high: eg, in Nebraska the birth rate for whites was 16.2 (approx the national average) whereas the rates for black and Hispanic (42.6 and 53.9) were far above the national average for these groups.

–and, there was a higher birth rate in those who are unemployed, have lower levels of education and lower incomes.

Commentary:

–as a perspective, the overall US birth rate in 2011 for 15-19 years old females was 34.0 per 1000, vs 13 per 1000 the same year in Canada. And the rate in France was 7 per 1000 and in Germany 5 per 1000.

so,

–very dramatic changes in teen birth rate, with a narrowing of the gap for racial/ethnic minorities as compared to whites. However, as noted, the gap remains significantly discordant.

–And, I suspect, a large part of the geographic gap reflects access to and quality of care. And there are major concerns about the future: the trump administration etc are pushing for decreased Planned Parenthood (potentially leading to even less access to care/contraception for poor and minority patients, with anticipated increases in pregnancy rates, and likely maternal and fetal death rates) and even cutbacks in maternity care. For example, another blog showed that a restrictive abortion law in Texas led to an 18.2% decline in abortions; and there have been a plethora of studies linking lack of prenatal care to poorer outcomes.

–and, the overall social environment, getting worse in the trump era, no doubt will add to the problem: lower incomes, cutbacks in social programs (including perhaps health insurance), fewer safety net programs overall, and social upheaval in general (including targeting immigrants) will predictably lead to even less access to care, less sense of hope for the future, lower self-esteem, and poorer health outcomes, including pregnancy rates.

———————————————————

2. Another CDC article evaluated sexual activity and contraceptive use among teens aged 15-19 in the US from 2011-2015 (see https://www.cdc.gov/nchs/data/nhsr/nhsr104.pdf),finding:

 

–42.4% of never-married female teens (4.0 million) and 44.2% of never-married male teens (4.4 million) had sex at least once by the time of the interview; these numbers were similar to those from 2002 and 2006-2010, though looking back to 1988 there was a decline (downward trend, with p<0.05). By ethnicity/race, from 2002 to  2011-15:

–Hispanic female: 37.4% in 2002, 41.2% in 2011-15; Hispanic male: 54.8% to 45.7%

–non-Hispanic white female: 45.1% in 2002, 44.3% in 2011-15; non-Hispanic white male: 40.8% to 42.8%

–non-Hispanic black female: 56.9% in 2002, 45.7% in 2011-15; non-Hispanic black male: 63.3% to 58.6%

–of these, the differences in females in 2011-15 were not statistically significant; though the difference/decrease in non-Hispanic black males was significantly higher than the others

–assessing sexual activity by family structure at age 14: for females, a significantly lower % were sexually experienced if they lived with both parents (36.8% vs 50.8%) and for males (39.4% vs 51.9%); for males, if their mothers gave birth to first child by age >=20 (39.3% vs 56.7% if mothers younger). Also for males, less sexually experienced if mother had at least some college vs high school diploma or GED (41.0%​ vs 46.7%)

–by age: males more likely than females to have sex younger (age 15-16). Though probabilities were the same by age 17

–partners for first sexual experience: 74.1% of females but 51.1% of males were “going steady” with their partner; 13% of females and 27.3% of males with “just friends” (the latter especially true with younger teens)

–reasons for not having sex: most common: religion/morals (35.3% of females, 27.9% of males), then “not found right person yet” 21.7% females, 28.5% males; then “don’t want to get pregnant” 19.3% females, 21.2% males

–no change from 2002 in terms of % of teens who have had sex in past 3 months, though older teens (18-19 yo) were twice as likely as those 15-17.

 

–female teenager use of contraception at first sex:

–increased from 74.5% in 2002 to 81.0% in 2011-15, though lowest in non-Hispanic black teens at 62%, and higher in Hispanic (79%) and non-Hispanic white (87%) teens; overall, mostly using condoms (66.4% in 2002, increasing to 74.6% in 2011-15)

–dual protection (condom plus pill) also increased significantly from 13.1% in 2002 to 18.5% in 2011-15

–overall 5.8% of females had a long-acting reversible method (IUD in 2.8% or implant in 3.0%) in 2011-2015

–male teenager use of contraception at first sex:

–condom use increased from 70.9% in 2002 to 79.6% in 2006-10 and remained stable at 76.8% in 2011-2015

–emergency contraception use has increased significantly from 2002 (8% of female teens who ever used it) to 2011-15 (23%)

–no change in ever using condoms (97%), withdrawal (60%), pills (56%), depo-medroxyprogesterone (17%)

–feelings about hypothetical pregnancy (which does correlate with risk of teen birth, pregnancy risk behaviors): in 2011-15, more females would be very upset (60.5%) vs males (46.1%)

–teens who have sex at an earlier age are not only less likely to use contraceptives at time of first sex, but also at the last sex as well.

 

Commentary:

–although there are lots of statistics above, the report has even lots more….

–it is notable that 81% of females used contraception the first time they have sex, condoms were used by 77% of males the first time they have sex

–overall trends seem to confirm some decreases in sexual activity overall and increase in contraceptive usage since 1988, aligning with the observed decrease in teen pregnancy in the early 1990s (as above). though the contraceptive use largely plateaued or only decreased slightly since 2002, the types and effectiveness of contraceptives used has changed

–there is a general trend to promote long-acting reversible contraceptives (IUDs implants) in adolescents (eg, see https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Adolescents-and-Long-Acting-Reversible-Contraception ), and there is dramatically increasing use of emergency contraception

–one important potential utility of all of these statistics is to help us clinicians and public health people focus on teens where the statistical predictors point to those at highest risk of not using contraceptives or becoming pregnant (eg. family and social situation, education, age of first sex, ethnicity/race…)

 

–but, as noted in commentary after the first article, there are real concerns about the future, especially with access to high quality, affordable care (see above)

Primary Care Corner with Geoffrey Modest MD: New vs old OCPs and thromboembolism

23 Jun, 15 | by EBM

By: Dr. Geoffrey Modest

The BMJ just published a large analysis of the relationship between combined oral contraceptives OCPs and the risk of venous thromboembolism VTE (see BMJ 2015;350:h2135). They analyzed 2 nested case-control studies from 2 different UK databases, with a combined input from 1340 general practices, assessing the first diagnosis of VTE in women aged 15-49 from 2001-2013, and comparing this group to 5 controls matched for age, practice, and calendar year.

Results:

–10562 cases of VTE. mean age 38, 27% smokers in the VTE cases and 21% in controls, obesity in 27% vs 16% in controls. established risk factors for VTE were 47% vs 26% in controls

–odds ratio for incident VTE and use of OCPs in the previous year, adjusted for smoking, alcohol, ethnic group, BMI, comorbidities, and other contraceptives:

–current exposure to any OCP was associated with increased risk of VTE [odds ratio OR 2.97 (2.78-3.17)] vs no OCP exposure over the previous year, with breakdown as follows.

–newer OCPs:

–desogestrel         OR 4.28  (3.66-5.01)

–gestodene            OR 3.64  (3.00-4.43)  –not available in the US

–drospirenone      OR 4.12(3.43-4.96)

–cyproterone        OR 4.27  (3.57-5.11)  –not available in the US

–older OCPs (second generation)

–levonorgestrel     OR 2.38 (2.18-2.59)

​–norethisterone    OR 2.56 (2.15-3.06)    –not available in the US

–norgestimate       OR 2.53 ( 2.17-2.96)  –actually a third generation OCP which is partly metabolized to levonorgestrel, but is less androgenic than levonorgestrel and is actually considered a second generation one in Denmark.

–this translates to: the number of extra cases of VTE per year per women

        –levonorgestrel was lowest at 6 (5-7), along with norgestimate at 6 (5-8)

        ​–desogestrel was highest at 14 (11-17), along with cyproterone at 14 (11-17)

–overall, the risk associated with gestodene was 1.5x higher than levonorgestrel (the most commonly used in the UK), and those of desogestrel, drospirenone, and cyproterone was about 1.8x higher

–desogestrel had a slightly higher odds ratio for VTE with higher doses of estrogen. norethisterone and gestodene actually had slightly higher VTE rates at the lower estrogen dosages (these were not significant, which seems to support the primary association being with the progestin in these women already on lowish doses of estrogen)

So, most, but not all, studies over the past 2 decades have often shown increased VTE risk in the 3rd and 4th generation OCPs. The current very large UK groups, given the high quality of reporting, provides more information, though it is retrospective and observational. In terms of bias, one might think that since there have been older studies showing increased VTE risk with the newer agents, there might have been preselection bias to avoiding these agents in women surmised to be at somewhat increased risk, leading to understating the actual risk.  Although I do not prescribe OCPs so often these past years, I must admit that I have been largely avoiding the newer agents because of the issue of increased VTE found in several of the earlier studies, and now confirmed here.​

Primary Care Corner with Geoffrey Modest MD: Efavirenz and hormonal contraception

23 Feb, 14 | by EBM

recent report suggesting that efavirenz decreases the efficacy of intradermal Jadelle implant (this is the successor to Norplant, with 2 thin, flexible silicone rods, each containing 75 mg of the synthetic progestin levonorgestrel).

here is the abstract (that is all i could find), from PubMed:

Perry SH, Swamy P, Preidis GA, Mwanyumba A, Motsa N, Sarero HN. AIDS. 2014 Jan 2. [Epub ahead of print] Implementing the Jadelle implant for women living with HIV in a resource-limited setting in sub-Saharan Africa: concerns for drug interactions leading to unintended pregnancies.

“An analysis of 570 HIV-infected women in Swaziland using the Jadelle implant showed that age, condom use, which provider placed the implant, and CD4 cell count had no effect on unintentional pregnancy rates. However, antiretroviral regimen at the time of pregnancy correlated with pregnancy outcomes (P <0.001). None of the women on nevirapine or lopinavir/ritonavir-based regimens (n = 208 and 13, respectively) became pregnant, whereas 15 women on efavirenz (n = 121; 12.4%) became pregnant.”

so, this is a double hit for efavirenz. there are reports that HIV regimens with efavirenz lead to lower progestin blood levels on women on combination oral contraceptives (and recommendations that condoms still be used for contraception, as well as prevention of sexually-transmitted diseases).  this report adds significantly to the prior concerns.  in addition, efavirenz is probably the most teratogenic of the HIV antiretrovirals. so, bottom line, prob best not to choose efavirenz-based therapy on women of child-bearing age…

geoff

Primary Care Corner with Dr. Geoffrey Modest: Morning After Pill INEFFECTIVE in Overweight!?

27 Nov, 13 | by EBM

a disturbing story today that morning-after pills may not be as effective in overweight women (see http://in.reuters.com/article/2013/11/26/us-fda-morningafter-idINBRE9AP02B20131126 for story). basically, European health regulators found that a French morning after pill marketed as Norlevo had decreasing effectiveness in women over 165 pounds and was not effective at all in those over 176 pounds, prompting the Europeans to order a label change.  turns out that Plan B in the US is basically the same composition. there was a comment in Physician’s First Watch that “According to the CDC, the average American woman weighs 166.2 pounds, which may raise concern about the efficacy of this type of emergency contraception among many U.S. women. The battle to make emergency contraception available has been long and arduous. Hopefully, this recent information will not discourage users, as this may still be the best option available.”

a couple of comments:

1. it is pretty surprising to me that if the average US woman weighs in the “decreasing effectiveness” group, and that there are lots in the “not effective at all” group, that failure rates in the US would have been pretty apparent before this.

2. seems that BMI would be more useful than weight per se, since (i would assume) the issue is the amount of fat present, with its effects on hormone metabolism (ie and the amount of adipose tissue in a 6 foot tall woman weighing 176# is pretty different from a 5 footer of same weight)

2. there was a recent article in ObGyn journal (see  DOI: http://10.1097/AOG.0b013e31828317cc) which assessed efficacy of oral contraceptive pills, patches, and vaginal rings in 7500 women of varying BMIs followed 2-3 years.  no difference in failure rates in those with BMI <25 (8.5%), BMI 25-30 (11%), or BMI >30 (9%). this was an observational study with self-reported outcomes. dose of ethinyl estradiol in the pills ranged from 20-35 micrograms (though no information on whether the higher dose pills were taken more by the more overweight women). other observational studies have had mixed results.

so, quite concerning finding in Europe. i would assume that the Food and Drug Admin will assess this aggressively to see, for example, what the US experience is and if the morning after pill should have differing hormonal content based on BMI (or weight).

geoff

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