Sexually active teens should get IUDs, doctors group says
With "Sesame Street" characters gracing the walls and building blocks on the floor, the pediatrician's office may seem like an unlikely place to discuss birth control.
But concerns about teething and toilet training quickly give way to discussions of other developmental milestones - such as a budding attraction to the opposite sex.
Without a lot of fanfare, the American Academy of Pediatrics recently issued new birth control recommendations for adolescents who are sexually active: long-acting reversible forms of contraception, such as intrauterine devices or hormonal implants, citing "efficacy, safety and ease of use."
The new policy is a shift for the nation's leading pediatrics organization, which last issued contraceptive guidelines in 2007 and did not recommend a specific contraceptive method.
"It's a change ... and one people might be surprised about," acknowledged Dr. Anita Chandra-Puri, a pediatrician in Chicago's Lincoln Park neighborhood. "But it's a change based on very careful research studies, which shows that this is a safe and very effective method of contraception."
According to the academy's policy statement, published in the October issue of Pediatrics, a decade of experience and data have demonstrated that IUDs and implants provide three to 10 years of contraception and are low risk and reliable. Only 1 in 2,000 women using implants get pregnant in a given year; for IUDs, the unintended pregnancy rate can be 1 in 500, depending on the type used. By contrast, the failure rate for condoms, the most popular form of contraception for teens, is 18 out of 100 times, the AAP reports.
The academy's guidelines support the 2012 findings of the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention, said Dr. Mary A. Ott, lead author of the update.
"We're really not a trailblazer ... we're just looking at the same evidence that IUDs are safe and effective," said Ott, who practices in Indianapolis. "We have a lot of work to do in pediatrics to expand our skills and our patients' comfort level ... but this policy statement is a step in the right direction."
The academy's endorsement comes on the heels of the controversial Supreme Court ruling in the Hobby Lobby case that closely held businesses can deny coverage for certain birth control methods - including IUDs - for religious objections. But opposition to the pediatric group's recommendation appeared to be muted, Ott said. "I'd say there was more surprise from the lay public than pushback."
While the academy still recommends that abstinence education be a part of any discussion about sexual health, clinicians are also realistic about their hormone-driven patients.
"Existing data suggest that over time, perfect adherence to abstinence is low," the academy said. "Therefore, pediatricians should not rely on abstinence counseling alone." On average, young people have sex for the first time at age 17, according to the Guttmacher Institute, a New York-based reproductive health and rights organization.
The academy stressed that condoms are still essential for preventing HIV and other sexually transmitted diseases.
"Adolescents are capable of understanding complex messages about sexual health ... they understand that their pediatricians can simultaneously encourage abstinence and provide nonjudgmental contraceptive information and care," explained Ott, adding that all methods of hormonal birth control are safer than pregnancy.
Although the U.S. teen birth rate remains the highest among industrialized nations, according to the Guttmacher Institute, it has been on a long downturn. In 2010, the teen birth rate was 34.4 births per 1,000 women - a significant decrease from the peak rate of 61.8 reached in 1991, reports the Guttmacher Institute. The decline was linked to greater access to birth control - specifically long-acting reversible contraceptives, such as IUDs and implants.
In Colorado, for example, the state's birth rate fell by 40 percent from 2009 to 2013, which officials attribute to dispensing IUDs, funded by an anonymous donor. With fewer unplanned pregnancies, the abortion rate dropped by 35 percent, the Colorado Department of Public Health and Environment reported.
The proportion of women using IUDs has steadily climbed to 7.7 percent in 2009, up from 2.0 percent in 2002, according to a 2012 Guttmacher Institute study. Last year, Bayer AG launched Skyla, the first IUD marketed to teens. Billed as "little sister" to Mirena - another Bayer IUD - it is smaller for younger bodies.
An IUD is a T-shaped device that a doctor inserts into a patient's uterus. The device contains hormones or copper, which keep sperm from reaching the cervix. Similarly, implants are tiny rods about the size of a matchstick that are inserted under the skin of the upper arm and also release hormones that block sperm from reaching an egg. Typically, a pediatrician would refer a patient to a gynecologist for these procedures.
Last month, the National Campaign to Prevent Teen and Unplanned Pregnancy launched a social media campaign - (hashtag) thnxbirthcontrol - to reach out to young people and take contraceptives out of the political arena and make them "a part of everyday life."
Even so, obstacles remain. Twenty states have limits on people younger than 18 consenting to using birth control, according to the Guttmacher Institute. In Illinois, minors can make their own decisions - another position endorsed by the academy, which stressed that pediatricians become "familiar" with laws regarding disclosure of confidential information.
There's also the cost, which is out of reach for the average high school student, who may not want her parents to see it on a bill. The cost of an IUD or implant can range from $750 to $1,000, which covers an exam, insertion and a follow-up visit, according to Planned Parenthood of Illinois.
In August, Medicaid came out with a family action plan that mandates that every Medicaid provider must provide the contraceptive method of choice to patients. "But regardless, we will work with teens because we know they'll need help with this, said Carole Brite, CEO of Planned Parenthood of Illinois.
Brite added that the agency encourages all clients to talk with their parents about these personal decisions - and even have parents accompany them to the clinic. "Parents may not like the idea of their kids being sexually active, but the alternative of an unintended pregnancy is even less desirable."
One Evanston mother, who brought her daughter to Planned Parenthood, recalled how the 17-year-old confided that she wanted to have sex with her boyfriend. The daughter started on the hormonal patch, but it would frequently peel off and when the family was on vacation, the daughter didn't have a replacement.
"It was just plain tough to keep up with it," said the mother, who asked that her name not be used to protect her daughter's privacy. "I wished she could have gone on Mirena, which was life-changing for me. I did a ton of research on IUDs, and I am absolutely convinced that this was the best way to go." Her daughter chose to have an IUD inserted when she was a senior in high school.
Across the Chicago area, those on the front lines of adolescent health have observed the increased popularity of IUDs.
"Girls are talking about it to their friends ... that once you have it, there's no daily pill, no remembering to go to the pharmacy and no coming back to the clinic for a shot every three months," said Yvonne Oldaker, a nurse at Aunt Martha's Community Health Center, which has eight family planning clinics throughout the suburbs. "Even the shortest (long-acting reversible contraceptive) promises three years - and that's long enough to get you through high school and get your diploma."
Still, peers can be a source of misinformation. Clinicians have heard just about everything from teens, they said, including that mustard can be used as natural birth control and that you can't get pregnant if you have sex standing up.
That's one reason Chandra-Puri, the Lincoln Park pediatrician, likes to take control of the discussion with her patients at an early age.
"Starting around 9 or 10, I explain that as they get older, more and more things are under their control - such as what they eat, when they go to sleep," the pediatrician said. "I start with nonsexual things, then around 11 or 12, I'll ask the parent to leave the room ... and that's when we get into more about sex. No one is surprised because they all know that it's coming."
Discussions about the HPV (human papillomavirus) vaccine also offer a segue into the conversation, since the virus - a principal cause of cervical cancer - is transmitted by sexual contact. The pediatric academy and the CDC recommend the vaccine for both boys and girls at 11 or 12 years old.
"It gives me an idea how shocked parents are going to be. ... If they are hesitant, I encourage them to talk to their kids about their values," Chandra-Puri said. "But I also tell them that it's my job to protect my patients, from a medical standpoint."
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