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Can emergency contraception help to reduce teen pregnancy?The authors argue that PAs cannot provide optimal care to adolescents if they aren’t familiar with all pregnancy prevention options—including emergency contraception.Lisa Waller, PA-C, MMSc; William Bryson, PA-C, MMScLisa Waller practices at Georgia Pediatric Pulmonary Associates, Children’s Healthcare of Atlanta, Atlanta, Georgia. William Bryson is on the PA program faculty at Emory University School of Medicine. The authors have indicated no relationships to disclose relating to the content of this article.
Teen pregnancy rates in the United States have been declining since the early 1990s—a decline primarily attributable to more effective contraceptive practice, not to a decline in sexual activity. At the same time, however, US teen pregnancy rates remain persistently higher than those in most developed countries. According to 2006 data from the Guttmacher Institute, a nonprofit sexual health policy and research organization, approximately 750,000 teenagers annually still become pregnant, with 34% of these pregnancies ending in abortion.1 Most of the pregnancies are unplanned.2,3 By age 17, approximately half of adolescents are sexually active. Most teens are unlikely to use contraception regularly, and many do not use it at all. Statistics show that a sexually active teen has a 90% chance of becoming pregnant within a year if she is not using any form of contraception. While public education efforts have improved the rate of contraceptive use, 22% of teenage girls do not use any form of protection the first time they have intercourse.3 Only 35% of high school students report consistent use of contraception during every act of sexual intercourse.4 These behaviors put them at risk for sexually transmitted infections (STIs) and unintended pregnancy. Once teens become pregnant, only two thirds receive adequate prenatal care—a matter of great concern for several reasons. Young mothers have more low birth weight babies and more premature births. Children of young mothers have more childhood health problems and increased hospitalizations. These children are at higher risk for behavior and learning difficulties. Most research connects health and learning deficiencies to adolescent parents’ low economic and education levels.4 Health professionals agree that the numbers of teenage pregnancies and termination rates are too high, but reducing the high rates of adolescent pregnancy continues to be a challenge for clinicians. Emergency contraception (EC) has the potential to prevent 75% to 85% of unintended pregnancies and to eliminate approximately 50,000 elective abortions per year.2 In an adolescent patient population where contraception compliance is a serious issue, EC should be supported as an essential component to pregnancy prevention.
EMERGENCY CONTRACEPTIONPostcoital contraception has been used in humans since the 1960s, when a physician in the Netherlands provided high-dose estrogens to a 13-year-old rape victim.4 Since the 1970s, high-dose estrogen therapy has been combined with a progestin regimen and known as the Yuzpe method. Additionally, a progestin-only option (levonorgestrel) was created in an attempt to reduce the side effects associated with high-dose estrogen, most notably nausea and vomiting. What is EC? The same hormones found in oral contraceptives (OCs) are used for EC. When taken in a concentrated dose within 72 hours of unprotected intercourse, EC can prevent pregnancy. Studies have shown a potential benefit at more than 120 hours postintercourse, but FDA guidelines for approved use specify a maximum of 72 hours.1 The confirmed mechanisms of action for EC include delaying or hindering ovulation, disrupting follicular development, or interfering with the maturation of the corpus luteum.5 Additionally, several theories of action have not been clinically proven, such as inhibition of fertilization and alteration of cervical mucus.1 EC is ineffective if a fertilized egg has successfully implanted within the uterine wall. Safety The hormones in EC have been used in OCs taken by millions of women for decades. Serious complication rates, which are related to the estrogen component, have been proven to be extremely low. There is no associated toxicity with hormone use, so there is little danger in inadvertent overdose. There are no addictive properties to the hormones. In fact, the side effects—such as menstrual irregularities and nausea—may actually discourage women from using EC repeatedly. There have been no deaths or other serious consequences of an acute overdose of EC hormones. Decades of research show no risk or teratogenic ramifications of hormone exposure if a pregnancy has already been established.6 Patient screening The clinician should confirm that unprotected sexual intercourse occurred within the previous 72 hours before providing a prescription for EC. The focus should be on the exact number of hours since intercourse and on the date and normality of the last menstrual period. Clinicians should also ask about current or recent use of contraception and safe sex precautions to facilitate planning for future routine contraception. Neither a pelvic examination nor a pregnancy test is required before treatment, but these may be indicated if the patient may already be pregnant. Parental permission is not required for dispensing EC to an adolescent (see Table 1). 
Treatment options The Yuzpe regimen consists of the combination of 100 mcg of ethinyl estradiol (EE) and 0.5 mg levonorgestrel divided into two equal doses and taken 12 hours apart. Most combined OCs can be used as EC if dosed at the same hormone levels as the Yuzpe method. Nausea and vomiting, breast tenderness, fatigue, and headache are common with EC. However, use of an antiemetic 1 hour before dosing can reduce these effects. The majority of women taking EC will have a normal period on time, although irregular bleeding or spotting may occur, especially with repeated use. A meta-analysis of several clinical trials shows that EC has a 70% to 75% efficacy rate if used within the recommended time interval after unprotected intercourse.7 However, for pregnancy prevention, EC is not as effective as good compliance with most regular forms of contraception. Plan B is a prepackaged EC product containing two 0.75-mg levonorgestrel pills to be taken 12 hours apart. Recent studies have shown that taking both pills at the same time works just as well and may increase compliance.8 According to von Hertzen and colleagues, the progestin-based products are more effective than the combination pills, with pregnancy prevention rates of 88% and 75%, respectively.9 Because of the improved side-effect profile, better efficacy, and ease in dosing, progestin-only Plan B may be a better choice for an adolescent population. IMPACT OF EMERGENCY CONTRACEPTIONGold and colleagues conducted a randomized prospective study comparing a cohort of adolescents who received EC education and a single dose of EC to be used if needed to a group receiving EC education alone.10 Researchers told those provided with education alone that EC would be available to them through the clinic if needed. The aim of the study was to ascertain whether providing EC in advance would lead to higher sexual and contraceptive risk-taking. Subjects were predominately African-American, with a mean age of 17.1 years; nearly half were Medicaid recipients. A 6-month follow-up showed that providing EC in advance facilitates its earlier use and decreases overall pregnancy rates. Advance EC provision had no negative influence on the teenagers’ use of routine contraceptive methods. In addition, there were no more sexually transmitted infections or rates of unprotected intercourse among EC users as compared to controls.10 Raine and colleagues completed a controlled trial of female participants aged 16 to 24 years, 76% of whom were members of an ethnic minority, who attended a publicly-funded family planning clinic.11 About half had been pregnant before. As with the Gold study, patients were assigned to receive EC education and a single dose of EC in advance or education alone. Researchers found that advance provision of EC was the strongest predictor of EC use, after controlling for contraceptive method, pattern of contraceptive use, and frequency of unprotected sex. There was no significant increase in unprotected intercourse. Increased knowledge alone, without advance medication supply, did not increase requests for EC or promote behavior change.11 Stewart and colleagues performed a retrospective examination of the impact of using EC on reproductive health outcomes. Participants were aged 13 to 21 years, 63% African-American, in an urban, hospital-based adolescent clinic. This trial investigated whether prescribing EC affected pregnancy rates, STIs, number of sexual partners, age at first intercourse, and the scheduling of annual gynecologic examinations. Researchers found no associated poor reproductive health outcomes with the prescription of EC. Quite the opposite, their data showed that EC use may encourage the initiation of gynecologic care, thus providing an opportunity for STI testing and counseling.12 While limited original research exists on use of EC by adolescents, these studies demonstrate no behavioral or health consequences and validate EC use within pediatric practice. ACCESS TO EMERGENCY CONTRACEPTIONThe American Academy of Pediatrics, the Society for Adolescent Medicine, the AAPA, and the American Medical Association have issued position or policy statements in support of EC as an essential component of both primary and secondary pregnancy prevention efforts. However, despite established guidelines for its use, low levels of EC prescribing and discussion persist throughout the United States. In an attempt to understand the low utilization despite demonstrated safety and efficacy, we must address several real or perceived barriers. Adolescent barriers Reducing the high rates of adolescent pregnancy continues to be a challenge for clinicians. In 1996, the Kaiser Foundation in association with Princeton Survey Research Associates conducted telephone interviews on teenagers’ perceptions about sexual activity, pregnancy, contraception, and sources of information about sex and birth control. Of the 757 girls and 753 boys interviewed, less than 25% of either gender knew that “anything could be done” after unprotected sex to prevent pregnancy. Teenage females were slightly more aware than were males of the terms emergency contraception or morning-after pill (33% versus 24%). If they were aware, very few understood that a prescription is required or that there is a limited time in which to take EC. Knowledge was highest among older, white adolescents. Upon learning about EC, two thirds of the teenage girls reported they would be likely to use it. The reasons cited for not using EC were the lack of a regular medical provider and the need to share sensitive information with a provider.13 An interesting contrast is the higher knowledge level of EC among European youth: 75% to 95% in both males and females.2 Lack of a regular provider may pose a substantial barrier for many adolescents. As of 2001, 1.8 million American adolescents aged 16 to 18 years were uninsured, leaving many teenagers without any source of routine health care.14 An adolescent who is publicly insured is half as likely to have a regular provider as a publicly insured child younger than 5 years. Regardless of insurance status, 15- to 17-year-olds are the least likely to rely on an office-based clinician.15 With a 72-hour window for EC, this can severely limit access when needed. Adolescents may avoid seeking health care because of a perceived lack of confidentiality. Major pediatric/adolescent policy makers have made routine pleas to increase the availability of confidential services for teens. In a 2000 study, randomly selected public high school students in Massachusetts were surveyed regarding the relationship between perceived privacy and provider encounters for gynecologic care and health counseling. Results showed that while 76% wanted the opportunity to have confidential care, only 45% believed their regular provider would maintain privacy, and only about 25% had discussed their concerns with their providers. Initiation of gynecologic care and discussion of STIs, pregnancy prevention, and substance abuse were significantly higher if there was a perceived confidential relationship.16 Provider barriers In order for adolescents to obtain EC, they must have a relationship with a clinician that allows for knowledge of EC availability and how to obtain it. A telephone survey of 167 national adolescent health specialists revealed that most are prescribing EC, but only a few times a year or less. Twenty percent were unsure as to whether repeated use carried risks, and 25% thought EC would discourage routine contraceptive use. The likelihood of prescribing was related to various characteristics such as the specialty practiced (obstetrics and gynecology versus pediatrics), whether the specialist was in academic or private practice, and the length of time in practice.17 A comparable mail survey was completed by 233 practicing pediatricians in New York State. It found that only 16.7% of these pediatricians routinely counseled their adolescent patients about EC, and 72% were unable to identify any of the FDA-approved methods of EC. The reason for not prescribing was predominantly inexperience, regardless of gender, age, or practice type.18 In each survey, providers stated they were not comfortable prescribing EC because of insufficient training, experience, and information. Additionally, 5% to 35% of those surveyed had moral or religious concerns, but these were not cited as major factors in the decision-making process.17,18 The clinician becomes a barrier to adolescents knowing about and having access to EC if the clinician is misinformed regarding available prevention options. Additional avenues of access A global concern for increased access to EC has led to proposals for its OTC distribution. Several studies have asserted that providing patients with an advance supply of EC is an effective way to ensure prompt use. Nor has prospective provision of EC led to a decrease in condom use; many postulate that prospective provision of EC actually encourages teens to be more conscientious about contraception and that it is safe because of its low toxicity and nonaddictive, nonteratogenic profile.6 In August 2006, the FDA, after several denials, approved a proposal for OTC sales of Plan B to women aged 18 years and older.19 However, patients aged 17 years and younger still require a prescription—except in the handful of states where pharmacists can have a collaborative drug therapy agreement with a clinician who has independant prescriptive authority. In such states, adolescents can obtain Plan B simply by speaking with a pharmacist who has such an agreement. Historically, women in the United States have had fewer contraceptive options than women in most other developed countries. EC is widely available throughout Europe. Since 1999, France has made EC available without a prescription through pharmacists, with a large portion of the expense reimbursed through the national health plan. In 2000, the laws changed to allow high school nurses to distribute EC. French pharmacies now disperse EC at no cost, without parental approval, to adolescents. Pharmacists must counsel consumers about its use and give information about alternative forms of routine birth control. In this way pharmacists can serve as an entry-point into the health care system for adolescents. By having access to lists of referring primary care sites, they are able to link adolescents to reproductive health care services. France is a model worth studying, as their abortion rates are some of the lowest in the world.2 PAs can be advocates for their adolescent patients. Given the lack of routine health care for most adolescents, prescribing EC opens a door for establishment of regular care. While a pelvic examination is not a requirement for use, it may facilitate earlier initiation of women’s health services. Studies show that most adolescents get their primary sexual education from their peers, which likely perpetuates a cycle of misinformation. Provision of EC provides an opportunity for further discussion on healthy sexual behaviors and reducing the risk of STDs. Ideally, discussion should occur before the first sexual experience since up to 40% of adolescents use no contraception during first intercourse.4 Clinicians can increase the availability of materials such as brochures and wallet cards that include the toll-free telephone number for EC access (1-888-NOT-2-LATE). A written protocol regarding EC dispersal for all clinicians and staff can reduce delay. Female adolescents can be offered a prescription for EC that can be filled if needed. Progestin-only regimens are preferred for use in the adolescent population. Adjunctive counseling should include information about the mechanism of action, indications, efficacy, common side effects, and safety. PAs should take care to present EC as a true emergency method and not something to be used routinely. CONCLUSIONSWidespread availability of postcoital contraception remains one of the most promising ways to reduce this country’s high rates of unplanned pregnancies and abortions. In a population of patients for whom consistent contraceptive use is seemingly impossible, PAs should address pregnancy risk reduction as part of adolescent practice, regardless of the patient’s gender. PAs should familiarize themselves with EC in order to feel comfortable prescribing it and should be knowledgeable about EC availability and protocols for dispensing. Apart from confirmed pregnancy, when EC will be ineffective, or hypersensitivity to the product, there are no contraindications to use of EC in adolescents. While providers should ask about recent menstrual cycles and the true timing of last intercourse, requiring a pregnancy test, pelvic examination, or scheduled office visit can pose significant barriers for this population. Clinicians should consider advance provision of EC as a means to decrease access barriers. What happens to these adolescents when contraception failure occurs during nonclinic hours? Studies show that if adolescents have EC before they actually need it, they are more likely to use it. When giving EC in advance, the provider should discuss the importance of follow-up care after EC use to confirm that the patient is not pregnant, to offer STI testing, and to revisit and reinforce the need for routine nonemergent contraception use. To discuss any contraceptive method, providers must meet the confidentiality needs and concerns associated with an adolescent’s sexual health disclosure. Perceived confidentiality has been proven to open doors to discussions of STIs, sexuality, and substance abuse. It is crucial to reiterate messages regarding safe sexual practices and to reinforce condom usage, as the rates of STIs are still too high. Present EC as a true emergency method and not one to be used routinely. And no matter how sexually experienced the patient is, it is always worthwhile to suggest to adolescents the value of abstinence. REFERENCES
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