Symposium on Adolescent Medicine
Contraception for the Teenager Joseph L. Rauh, M.D.,* Robert L. Burket, M.D.,** and Richard R. Brookman, M.D.***
Family planning services have developed and expanded rapidly in the United States during the last decade. When family planning and adolescent health services have interacted, the result frequently has been an increased awareness of the need for contraceptive services for adolescents and the initiation of teenage family planning programs. When this interaction has not taken place, either adolescents have not been served at all or they have been served in adult programs without consideration of their special needs. In this article we will briefly describe current adolescent sexual development and behavior and review attitudes and laws which are in force in the United States to deal with the special problems and needs of the sexually active teenager. Finally, we will describe the application of contraceptive methods to young people.
SEXUAL DEVELOPMENT AND BEHAVIOR Any discussion of contraception for the teenager must recognize the secular acceleration of puberty and the societal prolongation of adolescence long past biologic maturation. In addition one must consider that today reproduction is no longer necessary at an early age in order to sustain the family group. Thus we now find adolescents fecund at an earlier age but not ready for parenthood financially, educationally, or socially until a much later time. Zacharias37 established a mean menarchal age of 12.5 years for 6217 healthy student nurses who were retrospectively surveyed from ':'Director, Division of Adolescent Medicine, University of Cincinnati and Children's Hospital Medical Centers; Associate Professor of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio ':"'Consultant in Obstetrics-Gynecology, Cincinnati Adolescent Clinic; Associate Clinical Professor of Obstetrics and Gynecology, University of Cincinnati College of Medicine *':
'Staff Physician, Cincinnati Adolescent Clinic; Instructor in Pediatrics, University of Cincinnati College of Medicine
Medical Clinics of North America- Vol. 59, No. 6, November 1975
1407
1408
JOSEPH
L.
RAUH, ROBERT
L.
BURKET, AND RICHARD
R.
BROOKMAN
throughout the United States in the mid 1960's, Since ovulation usually occurs 12 to 24 months following menarche, the average American girl today can conceive by age 14. The average male can ejaculate and produce sperm by 15.5 years. A major question logically follows-can the current increase in incidence of early pregnancy and venereal disease be explained largely on biologic grounds rather than as a result of a "sexual revolution" as documented by current surveys26 indicating earlier coital experience? Cutrighfl argues that the increase in adolescent pregnancy can be explained by earlier fecundity as well as a significant decrease in the incidence of spontaneous abortion. For instance, he states that the present mean age at menarche (12.5 years) implies that 94 per cent of girls aged 17.5 are fully fecund. When the mean age at menarche was about 16.5, 100 years ago, only 13 per cent of girls were fully fecund at age 17.5. Two recent American studies provide a reasonably accurate picture of adolescent sexual behavior-the Zelnik and Kantner study 13. 14 and the Sorensen report. 32 Zelnik and Kantner interviewed over 4000 nevermarried adolescent females (67 per cent white, 33 per cent black) ages 15 through 19. They found that by age 15, 32 per cent of the black females and 11 per cent of the white girls had experienced intercourse. By age 19 the percentages were 81 per cent and 40 per cent respectively. It was also significant that by age 19, among the sexually active females, 51 per cent of the black and 41 per cent of the white girls had experienced at least one pregnancy. Sorensen reported on interviews from a carefully designed national sample of 393 adolescents 13 to 19 years of age. This sample included both sexes; 86 per cent were white, 14 per cent black. Sorensen's findings were similar to those of Zelnik and Kantner. Forty-five per cent of the girls and 59 per cent of the boys had experienced intercourse by age 19. From an analysis of these studies and Cutright's data it is probable that one can account for roughly half of the observed increase in teenage illegitimacy on the basis of earlier fecundity, with the other half attributable to earlier sexual experience. Without question, earlier adolescent biologic development and earlier coitus are closely interrelated. Both trends are cogent arguments for providing contraceptive services to adolescents.
ATTITUDES AND LAWS In the past 5 years the American Academy of Pediatrics, the American Medical Association, the American College of Obstetrics and Gynecology, the Society for Adolescent Medicine, the American Academy of Family Practice, Planned Parenthood, and others have recommended that physicians be free to provide birth control services to sexually active minors, if necessary without parental consent.lO When parental consent is given, there is rarely any legal difficulty in providing such services. Communication, however, between teenager and parent about sexual matters may be difficult, even where a good
CONTRACEPTION
1409
relationship otherwise exists; therefore, more and more physicians and lEigal experts feel that the teenage patient should also give consent. The physician is not so limited legally as he may think. At least 23 states and the District of Columbia specifically permit minors to consent for their own contraceptive needs. 21 In states where the statutes are ambiguous or restrictive, organizations and individual doctors are openly providing contraceptive services to minors without legal prosecution. This liberalizing trend with reference to medical treatment of minors without parental consent also finds expression in a mature minor rule 21 which permits medical care to be given to unemancipated minors of sufficient intelligence to understand the nature and consequence of the treatment to which they are consenting, where the treatment is for the minor's benefit. No physician or clinic anywhere in the United States is known to have been "prosecuted criminally or sued for damages for having examined or treated a minor in connection with contraception. "36 The legal risk at present is best summarized in Hofmann's words as "minimal and unprecedented."9 There are, however, physicians, attorneys, legislators, and parents who continue to subscribe to the "parent's rights" view; i.e., until a teenager is legally adult, age 18, he or she should not be permitted to give self-consent for medical treatment. They point out that the physician is not an alternate parent and should not initiate a discussion about sexual behavior or the need for contraception. The argument logically ensues that to provide an adolescent with a contraceptive program encourages sexual activity that can be promiscuous. We feel the "parent's rights" view is not realistic or sensitive to the basic rights and health needs of American youth. Health providers are responsible for meeting health needs. Fortunately today a majority of Americans feel youth should have access to family planning services. 23
RISKS AND NON-USE OF CONTRACEPTION The physician must carefully assess the adolescent's sexuality, including current sexual activity, as part of a comprehensive health profile. How frequently and with how many partners has intercourse occurred? What is the biologic stage of development (Tanner rating)? Does it correlate with social and emotional maturity? What is the probability of fecundity? What are the teenager's values and how do they parallel those of his or her family? What has been the experience of the parents, siblings, grandparents, and other relatives with early or unplanned pregnancy? How sophisticated and knowledgeable is the adolescent about coital risk, reproduction, contraception, etc.? Data comparing the relative morbidity and mortality risks of pregnancy with the risks of the use of a major contraceptive method in adolescents are not available. Our Clinic continues to utilize national Planned Parenthood data for adult women followed during the late 1960s. Table J24 provides comparative estimates of the risk of death from complications of pregnancy and from contraceptive methods for
1410
JOSEPH
L.
RAUH, ROBERT
L.
BURKET, AND RICHARD
R.
BROOKMAN
Table 1. Comparative Estimates" of Risk of Death from Complications of Pregnancy, Thromboembolic Disease, and Contraception for 100,000 Adult Women for One Year METHOD
Virgins Foam and condom Pills Intrauterine device Diaphragm or foam Condom None - sexually active (coitus 2.6 times per week)
NO. OF PREGNANCIES
DEATHS PER
1,000 100 5,000 10,000 15,000
o
1.7 2.0 3.3 4.1 4.6 6.0
83,000
25.7
100,000
"'These estimates are calculated from death rates of 29/1 00,000 adult women per year for all complications of pregnancy, 1. 7 for thromboembolic disease among women of childbearing age, 1.6 for complications for oral contraception, and 1.0 for complications of IUDs. For example, it is estimated that if 100,000 adult women all used IUDs for one year, there would be 5000 pregnancies, resulting in 1.5 deaths. There would also be 1.0 deaths from all complications of IUDs and 1.6 deaths from thromboembolic disease among the 95,000 women who did not get pregnant. The cumulative death rate for the IUD method is then estimated at 4.1/100,000. From Rauh, J. L., Johnson, L. B., and Burket, R. L. The reproductive adolescent. Pediat. Clin. N. Amer., 20:1005,1973.
adult women. Clearly sexual activity without contraception has the highest morbidity rate. All contraceptive methods have markedly lower mortality rates. The Zelnik and Kantner study carefully assessed attitudes, knowledge, and use or non-use of the contraceptive methods. Four-fifths of the sexually experienced never-married young women ages 15 to 19 studied indicated that they had engaged in sexual intercourse without using contraception. More specifically, only 19 per cent said they used it all the time. Of those who had become pregnant, the overwhelming majority indicated that the pregnancy had been unintended and of these only 13 per cent had used any kind of contraception to prevent it. Table 2 provides some explanation and insight into why teenagers run the risk of pregnancy by having sexual intercourse without contraceptive protection. 29 One should not assume that older adolescents or adolescents attending college are more knowledgeable or disciplined contraceptors. Crist2 reported on the types of birth control methods used by 393 sexually active women at a major state university in the southeastern United States. The average age of the students was 19.6 years. Of the 393 sexuallyactive women 65 per cent used high risk methods (withdrawal, rhythm, douche, or nothing) while only 35 per cent used low risk methods (condom, diaphragm, jelly, foam, pill, or intrauterine device).
1411
CONTRACEPTION
Table 2. Per Cent'~ of Never-Married Sexually Experienced Women 15 to 19 Years of Age, According to Reasons They Reported for Not Using Contraception: by Race, 1971 PER CENT BY RACE
REASON':'*
Time of month Low risk N ona vailability Hedonistic objection Want pregnancy Moral/medical objection
Total (N = 976)
White (N = 454)
Black (N = 522)
39.7 30.9 30.5 23.7 15.8 12.5
45.2 26.4 32.1 23.9 12.5 10.8
24.3 43.0 26.3 23.2 24.7 17.2
"Base includes all respondents who gave reason for nonuse of contraception. Per cents in each category add to more than 100 because 36.1 per cent of respondents (34.5 per cent of blacks and 36.8 per cent of whites) gave multiple reasons which fell in more than one category. "'"Nearly two thirds of the respondents gave reasons which fall in only one of the six major categories. (Blacks and whites are similar in this respect). The categories and their constituent items are as follows: 1. Time of Month: "Time of the month when couldn't become pregnant." 2. Low Risk: "Too young to become pregnant;" "Didn't have intercourse often enough to become pregnant;" "Didn't think could become pregnant." 3. Nonavailability: "Didn't have contraception available;" believed "it was too expensive;" "didn't know about contraception;" "didn't know where to get contraception." 4. Hedonistic Objections: "Partner objected;" "sex isn't as much fun if contraception is used;" "too inconvenient;" "didn't want to use." 5. Want Pregnancy: "Trying to have a baby;" "didn't mind if became pregnant." 6. Moral/Medical Objection: Believed it was "wrong" or "dangerous" to use contraception; medical reasons. From Shah, F., Zelnik, M., and Kantner, M.: Unprotected intercourse among unwed teenagers. Family Planning Perspectives, 7:39,1975, with permission.
CONTRACEPTION General Considerations Family planning programs for adolescents have been established in a variety of settings-Planned Parenthood clinics, adolescent medical clinics, postpartum maternity and infant care programs, free clinics, neighborhood health centers, and private practices. In general, the more comprehensive the general medical care provided in these settings, the more comfortable, interested, and compliant the teen-ager will be with the method used. 34 Careful follow-up, with appointments more frequent than those for adult women, is essential. A system should be developed to call back patients who have missed appointments. Girls using oral contraceptive agents should be seen at least every 3 months during the first year for follow-up examination (questions about headache, leg swelling, determination of blood pressure) and more importantly to reinforce the necessity of day-to-day adherence to pill taking. This adherence
1412
JOSEPH
L.
RAUH, ROBERT
L.
BURKET, AND RICHARD
R.
BROOKMAN
is best explained with visual aids-calendars and pictures or samples of the contraceptive prescribed. Girls using intrauterine devices require extensive counseling and reassurance before, during, and after insertion. In our Clinic such patients are seen at least 6 times during the first year. The first post-insertion visit should be within 3 weeks. Patients should be able to call at any time regardless of the method used. The entire staff should understand and enthusiastically endorse the philosophy of the program and assist in reinforcing the value and use of the methods. Marinoff17 showed a significant difference in IUD usage among high risk adolescents coming to two different family planning clinics-where the staff was enthusiastic about IUDs they were the first-choice method; in contrast, when the staff felt they were not appropriate for the patients served, they were much less used. Oral Contraceptive Agents There are now at least 25 different types of oral contraceptives packaged in 40 different ways (basically as a 20 or 21 day pill or as a 28 day pill with 21 active tablets and 7 inert or iron-containing tablets). Only the combined tablets containing estrogen and progesterone-like compounds will be discussed. We feel that neither the "sequentials" nor the "mini-pill" have any general use for the teenager. Risks of "patient failure" from missing one or more pills as well as break-through menstrual bleeding problems are frequent enough with both these latter types to make them contraindicated in adolescents. The primary effect of the combined oral contraceptive is inhibition of ovulation by blockage of gonadotrophic hormone released from the pituitary. In addition, the endometrium of the uterus and the cervical mucosa are also altered. The theoretical effectiveness of these agents approaches 100 per cent, undoubtedly the highest of any method presently available. Experience has taught us, however, that the actual effectiveness of this method in adolescents falls far below the theoretical figures. In our clinic, which serves a low income urban population, use of the pill among younger adolescents (12 to 16 years) resulted in a failure rate at least double that seen when the IUD is the primary method. 25 Other authors confirm this problem with oral therapy in similar populations. 7 ,8 The need to follow precise instructions for the daily intake of tablets, always difficult for adolescents, necessitates continued motivation. Intensive sex education does not necessarily insure motivation. Oral contraceptives have been more successful in older and more sophisticated adolescents who function more like adults emotionally. ESTROGENIC VERSUS PROGESTATIONAL ACTIVITY. When oral contraceptives are used, the physician should try to select a pill which best meets the needs of the individual patient. 5 ,18 He should consider the biologic and psychosocial maturation of the patient, the menstrual history, body build, the endocrine profile, presence or absence of hirsutism, acne, etc. Table 3 lists most of the combined agents available in the United States, and their contents. They are grouped according to their estrogen potency. All have either ethinyl estradiol or mestranol as the
1413
CONTRACEPTION
Table 3. Relative Estrogenic Activity of the Combined Oral Contraceptive Agents ESTROGEN
PROGESTOGEN
(mg/tab)
(mg/tab) Cl)
e ~
'0
gen ~
Cl)
DRUG
~
Strongly Estrogenic Enovid 5 Enovid E
.075 .1
Moderately Estrogenic Norinyl1 + 50-0rtho-Novum 1/50 NOrinyl1 + 80-0rtho-Novum 1/80 NOrinyI2-0rtho-Novum 2 Ovulen
.05 .08 .1 .1
Minimally Estrogenic Brevicon - Modicon .:. Demulen Loestrin - Zorane .:' Lo/Ovrai* Norlestrin 2.5 mgm Ortho-Novum 2 Ortho-Novum 10 Ovral
.1 .06
'0
~;a
... ..c:: ... ... en ~ (1$
.~
~~
Ol
'0
tlen
;gO;
'0"
..c::~
Cl) bI)
Z
Cl)
0'" ~ Cl)
~iS
"0 ~
]~
... (1$
Cl) ...
'" Cl) 0 "
z
Contraception for the Teenager Joseph L. Rauh, M.D.,* Robert L. Burket, M.D.,** and Richard R. Brookman, M.D.***
Family planning services have developed and expanded rapidly in the United States during the last decade. When family planning and adolescent health services have interacted, the result frequently has been an increased awareness of the need for contraceptive services for adolescents and the initiation of teenage family planning programs. When this interaction has not taken place, either adolescents have not been served at all or they have been served in adult programs without consideration of their special needs. In this article we will briefly describe current adolescent sexual development and behavior and review attitudes and laws which are in force in the United States to deal with the special problems and needs of the sexually active teenager. Finally, we will describe the application of contraceptive methods to young people.
SEXUAL DEVELOPMENT AND BEHAVIOR Any discussion of contraception for the teenager must recognize the secular acceleration of puberty and the societal prolongation of adolescence long past biologic maturation. In addition one must consider that today reproduction is no longer necessary at an early age in order to sustain the family group. Thus we now find adolescents fecund at an earlier age but not ready for parenthood financially, educationally, or socially until a much later time. Zacharias37 established a mean menarchal age of 12.5 years for 6217 healthy student nurses who were retrospectively surveyed from ':'Director, Division of Adolescent Medicine, University of Cincinnati and Children's Hospital Medical Centers; Associate Professor of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio ':"'Consultant in Obstetrics-Gynecology, Cincinnati Adolescent Clinic; Associate Clinical Professor of Obstetrics and Gynecology, University of Cincinnati College of Medicine *':
'Staff Physician, Cincinnati Adolescent Clinic; Instructor in Pediatrics, University of Cincinnati College of Medicine
Medical Clinics of North America- Vol. 59, No. 6, November 1975
1407
1408
JOSEPH
L.
RAUH, ROBERT
L.
BURKET, AND RICHARD
R.
BROOKMAN
throughout the United States in the mid 1960's, Since ovulation usually occurs 12 to 24 months following menarche, the average American girl today can conceive by age 14. The average male can ejaculate and produce sperm by 15.5 years. A major question logically follows-can the current increase in incidence of early pregnancy and venereal disease be explained largely on biologic grounds rather than as a result of a "sexual revolution" as documented by current surveys26 indicating earlier coital experience? Cutrighfl argues that the increase in adolescent pregnancy can be explained by earlier fecundity as well as a significant decrease in the incidence of spontaneous abortion. For instance, he states that the present mean age at menarche (12.5 years) implies that 94 per cent of girls aged 17.5 are fully fecund. When the mean age at menarche was about 16.5, 100 years ago, only 13 per cent of girls were fully fecund at age 17.5. Two recent American studies provide a reasonably accurate picture of adolescent sexual behavior-the Zelnik and Kantner study 13. 14 and the Sorensen report. 32 Zelnik and Kantner interviewed over 4000 nevermarried adolescent females (67 per cent white, 33 per cent black) ages 15 through 19. They found that by age 15, 32 per cent of the black females and 11 per cent of the white girls had experienced intercourse. By age 19 the percentages were 81 per cent and 40 per cent respectively. It was also significant that by age 19, among the sexually active females, 51 per cent of the black and 41 per cent of the white girls had experienced at least one pregnancy. Sorensen reported on interviews from a carefully designed national sample of 393 adolescents 13 to 19 years of age. This sample included both sexes; 86 per cent were white, 14 per cent black. Sorensen's findings were similar to those of Zelnik and Kantner. Forty-five per cent of the girls and 59 per cent of the boys had experienced intercourse by age 19. From an analysis of these studies and Cutright's data it is probable that one can account for roughly half of the observed increase in teenage illegitimacy on the basis of earlier fecundity, with the other half attributable to earlier sexual experience. Without question, earlier adolescent biologic development and earlier coitus are closely interrelated. Both trends are cogent arguments for providing contraceptive services to adolescents.
ATTITUDES AND LAWS In the past 5 years the American Academy of Pediatrics, the American Medical Association, the American College of Obstetrics and Gynecology, the Society for Adolescent Medicine, the American Academy of Family Practice, Planned Parenthood, and others have recommended that physicians be free to provide birth control services to sexually active minors, if necessary without parental consent.lO When parental consent is given, there is rarely any legal difficulty in providing such services. Communication, however, between teenager and parent about sexual matters may be difficult, even where a good
CONTRACEPTION
1409
relationship otherwise exists; therefore, more and more physicians and lEigal experts feel that the teenage patient should also give consent. The physician is not so limited legally as he may think. At least 23 states and the District of Columbia specifically permit minors to consent for their own contraceptive needs. 21 In states where the statutes are ambiguous or restrictive, organizations and individual doctors are openly providing contraceptive services to minors without legal prosecution. This liberalizing trend with reference to medical treatment of minors without parental consent also finds expression in a mature minor rule 21 which permits medical care to be given to unemancipated minors of sufficient intelligence to understand the nature and consequence of the treatment to which they are consenting, where the treatment is for the minor's benefit. No physician or clinic anywhere in the United States is known to have been "prosecuted criminally or sued for damages for having examined or treated a minor in connection with contraception. "36 The legal risk at present is best summarized in Hofmann's words as "minimal and unprecedented."9 There are, however, physicians, attorneys, legislators, and parents who continue to subscribe to the "parent's rights" view; i.e., until a teenager is legally adult, age 18, he or she should not be permitted to give self-consent for medical treatment. They point out that the physician is not an alternate parent and should not initiate a discussion about sexual behavior or the need for contraception. The argument logically ensues that to provide an adolescent with a contraceptive program encourages sexual activity that can be promiscuous. We feel the "parent's rights" view is not realistic or sensitive to the basic rights and health needs of American youth. Health providers are responsible for meeting health needs. Fortunately today a majority of Americans feel youth should have access to family planning services. 23
RISKS AND NON-USE OF CONTRACEPTION The physician must carefully assess the adolescent's sexuality, including current sexual activity, as part of a comprehensive health profile. How frequently and with how many partners has intercourse occurred? What is the biologic stage of development (Tanner rating)? Does it correlate with social and emotional maturity? What is the probability of fecundity? What are the teenager's values and how do they parallel those of his or her family? What has been the experience of the parents, siblings, grandparents, and other relatives with early or unplanned pregnancy? How sophisticated and knowledgeable is the adolescent about coital risk, reproduction, contraception, etc.? Data comparing the relative morbidity and mortality risks of pregnancy with the risks of the use of a major contraceptive method in adolescents are not available. Our Clinic continues to utilize national Planned Parenthood data for adult women followed during the late 1960s. Table J24 provides comparative estimates of the risk of death from complications of pregnancy and from contraceptive methods for
1410
JOSEPH
L.
RAUH, ROBERT
L.
BURKET, AND RICHARD
R.
BROOKMAN
Table 1. Comparative Estimates" of Risk of Death from Complications of Pregnancy, Thromboembolic Disease, and Contraception for 100,000 Adult Women for One Year METHOD
Virgins Foam and condom Pills Intrauterine device Diaphragm or foam Condom None - sexually active (coitus 2.6 times per week)
NO. OF PREGNANCIES
DEATHS PER
1,000 100 5,000 10,000 15,000
o
1.7 2.0 3.3 4.1 4.6 6.0
83,000
25.7
100,000
"'These estimates are calculated from death rates of 29/1 00,000 adult women per year for all complications of pregnancy, 1. 7 for thromboembolic disease among women of childbearing age, 1.6 for complications for oral contraception, and 1.0 for complications of IUDs. For example, it is estimated that if 100,000 adult women all used IUDs for one year, there would be 5000 pregnancies, resulting in 1.5 deaths. There would also be 1.0 deaths from all complications of IUDs and 1.6 deaths from thromboembolic disease among the 95,000 women who did not get pregnant. The cumulative death rate for the IUD method is then estimated at 4.1/100,000. From Rauh, J. L., Johnson, L. B., and Burket, R. L. The reproductive adolescent. Pediat. Clin. N. Amer., 20:1005,1973.
adult women. Clearly sexual activity without contraception has the highest morbidity rate. All contraceptive methods have markedly lower mortality rates. The Zelnik and Kantner study carefully assessed attitudes, knowledge, and use or non-use of the contraceptive methods. Four-fifths of the sexually experienced never-married young women ages 15 to 19 studied indicated that they had engaged in sexual intercourse without using contraception. More specifically, only 19 per cent said they used it all the time. Of those who had become pregnant, the overwhelming majority indicated that the pregnancy had been unintended and of these only 13 per cent had used any kind of contraception to prevent it. Table 2 provides some explanation and insight into why teenagers run the risk of pregnancy by having sexual intercourse without contraceptive protection. 29 One should not assume that older adolescents or adolescents attending college are more knowledgeable or disciplined contraceptors. Crist2 reported on the types of birth control methods used by 393 sexually active women at a major state university in the southeastern United States. The average age of the students was 19.6 years. Of the 393 sexuallyactive women 65 per cent used high risk methods (withdrawal, rhythm, douche, or nothing) while only 35 per cent used low risk methods (condom, diaphragm, jelly, foam, pill, or intrauterine device).
1411
CONTRACEPTION
Table 2. Per Cent'~ of Never-Married Sexually Experienced Women 15 to 19 Years of Age, According to Reasons They Reported for Not Using Contraception: by Race, 1971 PER CENT BY RACE
REASON':'*
Time of month Low risk N ona vailability Hedonistic objection Want pregnancy Moral/medical objection
Total (N = 976)
White (N = 454)
Black (N = 522)
39.7 30.9 30.5 23.7 15.8 12.5
45.2 26.4 32.1 23.9 12.5 10.8
24.3 43.0 26.3 23.2 24.7 17.2
"Base includes all respondents who gave reason for nonuse of contraception. Per cents in each category add to more than 100 because 36.1 per cent of respondents (34.5 per cent of blacks and 36.8 per cent of whites) gave multiple reasons which fell in more than one category. "'"Nearly two thirds of the respondents gave reasons which fall in only one of the six major categories. (Blacks and whites are similar in this respect). The categories and their constituent items are as follows: 1. Time of Month: "Time of the month when couldn't become pregnant." 2. Low Risk: "Too young to become pregnant;" "Didn't have intercourse often enough to become pregnant;" "Didn't think could become pregnant." 3. Nonavailability: "Didn't have contraception available;" believed "it was too expensive;" "didn't know about contraception;" "didn't know where to get contraception." 4. Hedonistic Objections: "Partner objected;" "sex isn't as much fun if contraception is used;" "too inconvenient;" "didn't want to use." 5. Want Pregnancy: "Trying to have a baby;" "didn't mind if became pregnant." 6. Moral/Medical Objection: Believed it was "wrong" or "dangerous" to use contraception; medical reasons. From Shah, F., Zelnik, M., and Kantner, M.: Unprotected intercourse among unwed teenagers. Family Planning Perspectives, 7:39,1975, with permission.
CONTRACEPTION General Considerations Family planning programs for adolescents have been established in a variety of settings-Planned Parenthood clinics, adolescent medical clinics, postpartum maternity and infant care programs, free clinics, neighborhood health centers, and private practices. In general, the more comprehensive the general medical care provided in these settings, the more comfortable, interested, and compliant the teen-ager will be with the method used. 34 Careful follow-up, with appointments more frequent than those for adult women, is essential. A system should be developed to call back patients who have missed appointments. Girls using oral contraceptive agents should be seen at least every 3 months during the first year for follow-up examination (questions about headache, leg swelling, determination of blood pressure) and more importantly to reinforce the necessity of day-to-day adherence to pill taking. This adherence
1412
JOSEPH
L.
RAUH, ROBERT
L.
BURKET, AND RICHARD
R.
BROOKMAN
is best explained with visual aids-calendars and pictures or samples of the contraceptive prescribed. Girls using intrauterine devices require extensive counseling and reassurance before, during, and after insertion. In our Clinic such patients are seen at least 6 times during the first year. The first post-insertion visit should be within 3 weeks. Patients should be able to call at any time regardless of the method used. The entire staff should understand and enthusiastically endorse the philosophy of the program and assist in reinforcing the value and use of the methods. Marinoff17 showed a significant difference in IUD usage among high risk adolescents coming to two different family planning clinics-where the staff was enthusiastic about IUDs they were the first-choice method; in contrast, when the staff felt they were not appropriate for the patients served, they were much less used. Oral Contraceptive Agents There are now at least 25 different types of oral contraceptives packaged in 40 different ways (basically as a 20 or 21 day pill or as a 28 day pill with 21 active tablets and 7 inert or iron-containing tablets). Only the combined tablets containing estrogen and progesterone-like compounds will be discussed. We feel that neither the "sequentials" nor the "mini-pill" have any general use for the teenager. Risks of "patient failure" from missing one or more pills as well as break-through menstrual bleeding problems are frequent enough with both these latter types to make them contraindicated in adolescents. The primary effect of the combined oral contraceptive is inhibition of ovulation by blockage of gonadotrophic hormone released from the pituitary. In addition, the endometrium of the uterus and the cervical mucosa are also altered. The theoretical effectiveness of these agents approaches 100 per cent, undoubtedly the highest of any method presently available. Experience has taught us, however, that the actual effectiveness of this method in adolescents falls far below the theoretical figures. In our clinic, which serves a low income urban population, use of the pill among younger adolescents (12 to 16 years) resulted in a failure rate at least double that seen when the IUD is the primary method. 25 Other authors confirm this problem with oral therapy in similar populations. 7 ,8 The need to follow precise instructions for the daily intake of tablets, always difficult for adolescents, necessitates continued motivation. Intensive sex education does not necessarily insure motivation. Oral contraceptives have been more successful in older and more sophisticated adolescents who function more like adults emotionally. ESTROGENIC VERSUS PROGESTATIONAL ACTIVITY. When oral contraceptives are used, the physician should try to select a pill which best meets the needs of the individual patient. 5 ,18 He should consider the biologic and psychosocial maturation of the patient, the menstrual history, body build, the endocrine profile, presence or absence of hirsutism, acne, etc. Table 3 lists most of the combined agents available in the United States, and their contents. They are grouped according to their estrogen potency. All have either ethinyl estradiol or mestranol as the
1413
CONTRACEPTION
Table 3. Relative Estrogenic Activity of the Combined Oral Contraceptive Agents ESTROGEN
PROGESTOGEN
(mg/tab)
(mg/tab) Cl)
e ~
'0
gen ~
Cl)
DRUG
~
Strongly Estrogenic Enovid 5 Enovid E
.075 .1
Moderately Estrogenic Norinyl1 + 50-0rtho-Novum 1/50 NOrinyl1 + 80-0rtho-Novum 1/80 NOrinyI2-0rtho-Novum 2 Ovulen
.05 .08 .1 .1
Minimally Estrogenic Brevicon - Modicon .:. Demulen Loestrin - Zorane .:' Lo/Ovrai* Norlestrin 2.5 mgm Ortho-Novum 2 Ortho-Novum 10 Ovral
.1 .06
'0
~;a
... ..c:: ... ... en ~ (1$
.~
~~
Ol
'0
tlen
;gO;
'0"
..c::~
Cl) bI)
Z
Cl)
0'" ~ Cl)
~iS
"0 ~
]~
... (1$
Cl) ...
'" Cl) 0 "
z
