From the Journals

AAP advises pediatricians to support emergency contraception for all teenagers

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Pediatricians often omit counseling on EC

Despite declining teen birth rates, the United States has the highest rate of teen pregnancy among developed nations outside the former Soviet Bloc, according to the Guttmacher Institute. This high rate remains in part because of the significant barriers that prevent access to reproductive health services for adolescents. Teen pregnancy prevention remains an important adolescent health issue because of the high risk of poor health outcomes facing teen parents and their children. As advocates for children, pediatricians should educate, advocate for, and provide contraception to their patients. To this end, the AAP’s policy statement on emergency contraception (EC) provides practical guidance to increase access for EC for adolescents.

Simply put, EC provides contraception for “emergencies” such as unprotected sex, sexual assault, missed birth control pills, and condom failure. While EC is not meant to be the sole form of contraception used by adolescents, it is an important stop-gap measure – and the only one that can be used after sex. The “gold standard” for contraception in teens remains long-acting reversible contraception (LARC) methods such as the intrauterine device and the hormonal implant. These methods are recommended first line by the AAP because of their high efficacy.

Despite these recommendations, LARC use remains low, with only 6% of sexually active U.S. teens using these methods. While pediatricians should continue to encourage LARC methods, they should not neglect counseling on other contraceptive methods, including on EC.

In fact, studies demonstrate that pediatricians often omit counseling about EC, and most do not prescribe these medications routinely. Despite several available over-the-counter formulations, there still are significant barriers to teens in accessing these medications. In my practice, I have experienced teens who miss the opportunity to use this medication because of its cost and nonavailability when it is needed – from either inadequate stock at the pharmacy or from pharmacists’ conscientious objections. Ideally, counseling on EC should be part of the routine anticipatory guidance provided to all adolescents, and routine prescriptions should be given to adolescent women. When I prescribe EC to teens preventively, I tell them to fill the prescription and have it “on hand” at home in case it is ever needed, given the time-sensitive nature of most formulations. This policy also saliently addresses counseling for adolescent men – who often are overlooked in conversations about EC as they cannot use these methods. However, increasing their awareness and knowledge of this method can increase its use in their partners.

This policy provides excellent technical information on different formulations of EC, side effects, contraindications, and anticipatory guidance to give patients about the use of these medications. Additionally, it highlights the copper IUD – the often forgotten, but most effective form of EC that provides lasting pregnancy prevention. Overall, this policy provides great information to “demystify” EC and encourages pediatricians to engage in improving reproductive health access for adolescents.*

Kelly Curran, MD, specializes in adolescent medicine at the University of Oklahoma Health Sciences Center, Oklahoma City. She was asked to comment on the AAP policy statement on emergency contraception. Dr. Curran is a member of the Pediatric News Editorial Advisory Board. Email her at [email protected].



Educating pediatricians to inform their teenage patients about emergency contraception is an important step toward reducing adolescent pregnancy in the United States, according to a policy statement issued by the American Academy of Pediatrics.

“Improved use of contraception, not declines in sexual activity, has been the most significant contributor to the decline in pregnancy risk among U.S. teenagers over the past decade,” wrote Krishna K. Upadhya, MD, MPH, and colleagues on the AAP’s Committee on Adolescence.

Data suggest that adolescents are more likely to use emergency contraception when it has been prescribed or given before they need it; however, many pediatricians do not routinely counsel adolescents about emergency contraception, they noted.

In the statement published Nov. 18 in Pediatrics, the committee listed indications for emergency contraception as unprotected or underprotected intercourse for reasons including sexual assault, lack of contraception use, or ineffective contraception use. The committee recommended that pediatricians provide emergency contraception in the form of oral pills (levonorgestrel or ulipristal acetate) or copper IUDs to adolescents in immediate need of emergency contraception, and ideally, to make those products available in advance so teens have them on hand.

The committee recommended the use of combined contraceptive pills known as the Yuzpe method, if dedicated emergency contraceptive pills or IUDs are not available, and emphasized the possible impact of overweight and obesity on the effectiveness of emergency contraceptive pills.

The recommendations also include advising adolescents about proper use of emergency contraception, and the need for follow-up visits to address ongoing contraception and testing for sexually transmitted diseases. The committee noted that adolescents using emergency contraceptive pills must be counseled to abstain or use additional contraception (such as condoms) because of the delay in ovulation associated with these products.

The committee recommended that all adolescents receive counseling on emergency contraception as part of a general discussion on sexual health, regardless of current sexual activity or lack of it. “In addition, it is important that information about EC be included in all contraceptive and STI counseling for adolescents wherever these visits occur, including emergency departments, clinics, and hospitals,” and that pediatricians provide this information to teens with physical and cognitive disabilities and their parents as well, they wrote.

The committee concluded the recommendations by asking clinicians to advocate for free or inexpensive nonprescription access to emergency contraceptive pills for adolescents regardless of age and insurance status.

M. Susan Jay, MD, program director of adolescent health and medicine at the Children’s Hospital of Wisconsin, Milwaukee, commented in an interview, “Forty years ago, as I completed my training, I don’t believe it would have been possible to contemplate the growth of adolescent health care, including reproductive health care that current pediatric practitioners are asked to provide to the adolescents under their care.”

“Today we are asked to be a resource from topics related to vaping and trafficking as well as psychosocial concerns from anxiety to eating disorders. This policy statement from the AAP addresses how best to approach and counsel both young women and young men as they traverse the issues of sexual engagement and responsibility. I have been privileged to work with pediatric residents who are far more sophisticated and knowledgeable than I have ever been, but they call and ask the very questions so adroitly presented in this policy statement. Most of my pediatric colleagues have had a limited adolescent medicine experience, and yet they are asked to care for youth in sensitive situations and want the tools necessary to provide the very best and safest care to their patients. Most of us will not be skilled in the placement of copper IUDs as outlined as an option for emergency contraception, but knowledge of the medications reviewed is of importance and relevant to everyday practice.

"This policy statement is a resource and educational update rolled into one, and Dr. Upadhya and her colleagues on the AAP’s Committee on Adolescence should be commended for assisting providers to offer the best and safest care,” said Dr. Jay, who was not involved in writing the AAP policy statement, and is a member of the Pediatric News Editorial Advisory Board who was asked to comment on the new policy statement.

The American College of Pediatricians (ACPeds), a conservative-leaning pediatric organization opposes the AAP’s recent opinion and the provision of emergency contraception to youth, Michelle Cretella, MD, executive director for the group, said in an interview. In its own position statement, ACPeds wrote that preprescribing EC to adolescent patients, or making them available without prescription, “carries significant medical risk and is counterproductive to the parent-adolescent and patient-physician relationships.”

“Increased access to [EC] does not result in lower pregnancy rates among adolescents and young adults,” said Dr. Cretella, a board-certified pediatrician who is not currently in practice. The ACPeds position statement cites a 2012 study that examined a Washington state program that allowed patients to access EC through pharmacies without a prescription. The analysis found the increased access to EC resulted in a statistically significant rise in gonorrhea for women and overall for both genders. The increased access to EC did not impact birth rates or abortion rates, according to the study (Economic Inquiry. 2013 Jul;51[3]:1682-95).

The ACPeds statement also notes a report by the Heritage Foundation that found sexually active teenagers were less likely to be happy and more likely to be depressed than were youth who were not having sex. The 2003 report, which examined responses from 6,500 adolescents through the 1996 National Longitudinal Survey of Adolescent Health, also found that sexually active teenagers were significantly more likely to attempt suicide, compared with teens who were not sexually active.

Dr. Upadhya disclosed having no financial conflicts.

SOURCE: Upadhya KK et al. Pediatrics. 2019 Nov 18. doi: 10.1542/peds.2019-3149.

This article was updated on 11/19/19 and 12/16/19.

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