20 - Contraception For Medically Complex Teens

Dr. Susan Kaufman and  Dr. Bianca Allison take on contraception for teens whose chronic conditions and medications make standard options unsafe or ineffective. They discuss how we protect confidentiality, apply CDC guidance, and still center teen autonomy.

• assessing pregnancy-related risks tied to chronic disease and treatment
• protecting confidentiality with evolving minor consent laws and careful charting
• using the Guttmacher resource for state-by-state consent rules
• reviewing the full method range including IUDs and implants for adolescents
• counseling lupus patients with and without antiphospholipid syndrome
• addressing epilepsy pregnancy risks plus teratogenic anticonvulsants
• spotting anticonvulsant interactions that can reduce hormonal efficacy
• managing lamotrigine level changes with continuous combined regimens
• defining migraine with aura and why estrogen raises stroke risk
• framing VTE risk with estrogen and when progestin-only is preferred
• taking a family history for possible thrombophilias
• treating heavy menstrual bleeding with continuous regimens and LNG-IUD
• discussing BMI effects on the patch and emergency contraception choices
• counseling on depo-related weight gain and follow-up timing
• contraception considerations for cancer survivors and hormonally sensitive cancers
• managing hypertension categories with MEC-guided method selection
• weighing bone health with depo and combined hormonal contraception

What is PAG?
Pediatric and Adolescent Gynecology is a subspecialty of OBGYN (2 year fellowship) focusing on reproductive healthcare for children and young adults. It fills the overlap between general gynecologists and pediatricians. It is a multi-disciplinary field involving work with pediatric endocrinology, dermatology, hematology, surgery, ect. Go to NASPAG.org for more PAG educational resources.

Want to test your knowledge?
PAG WebEd cases are a great way to review our podcast content. 

Transcript

SPEAKER_01 0:00

A 17-year-old female presents to the office to discuss contraception. She has a history of migraines and she describes dark spots that happen about 30 minutes before her migraines begin. She has been taking topiramate with improvement in her migraines. So what contraceptives is she allowed to use? Hi everyone.

Case: Migraine Aura And Topiramate

SPEAKER_01 0:24

Welcome to Pagover Pastries, a 20 to 30 minute review podcast regarding often teenagers are surviving and living normal lives with their medical disorders. And so they're naturally going to be interested in contraception because they're going to become sexually active, and many of them are going to need contraception

Why Contraception Matters In Teens

SPEAKER_01 0:47

to treat a medical issue. Our reference today is chapter 22, Contraception for Adolescents with Medical Complexities, written by Drs. Ashley Ebersaw, Serena Margaret Liu, Elise Berlin, and Nicole Tyson. And you'll find this chapter in The Essentials of Pediatric and Adolescent Gynecology, a textbook released by NASBAG. So Bianca, what's your favorite pastry?

SPEAKER_00 1:16

Ooh, I think mine is a cream cheese Danish.

SPEAKER_01 1:20

Oh, okay. That's funny you say that. Because one of my favorite restaurants makes what I call cheese bread. It's really like a croissant type covering stuffed with cheese, and they are so good.

SPEAKER_00 1:33

That sounds up my alley. That's delicious.

SPEAKER_01 1:36

Okay, so let's get started. So if you have a young lady who's coming into your office with a medical disorder that is chronic and she's on chronic treatment, how do you assess her for the use of contraception?

SPEAKER_00 1:55

The first thing that I would do is to review potentially some of the pregnancy-related risks that might be associated with their medical condition, just in case that's new information to them that they haven't really learned before,

Confidentiality And Minor Consent Basics

SPEAKER_00 2:07

and also the risks of any of the medications that's outside the visit to really preserve confidentiality. There are, however, different state laws that can govern to what extent confidentiality might be allowed in contraceptive conversations and if a team can consent to their own contraceptive care. So I really encourage every clinician to make sure you know the laws in your state, especially as they may be evolving in the current socio-political climate.

SPEAKER_01 2:32

And there's a good resource for that. The Gutmacher website will list every state and it will tell us about contraception, about abortion care, about other reproductive health care, and what the laws are in terms of who can consent and who can't consent.

SPEAKER_00 2:49

Exactly. And one thing that I would also add is whether or not there are laws in your state governing kind of confidentiality or minor consent. Either way, it's really important as clinicians that we use discretion in our note-taking and the sharing of information after the visit and what's sent through patient portals to just really try to protect confidentiality as much as possible for a young person. And really, reproductive justice is just something I want to mention here as well, as sort of a framework that really by itself could be a whole podcast episode, how we sort of make sure we enact that in our clinical care. But basically, just want to highlight that we really have a responsibility to ensure that young people have equitable access to contraception and really respect their autonomy as they're making decisions around contraception and pregnancy.

SPEAKER_01 3:35

Absolutely. You know, we have we have contraceptive pills, patches, rings, the implant, depoprover injection, and IUDs. And what adolescents can use and what the medical field feels comfortable with providing has evolved over time. And now IUDs in particular are acceptable and often

Methods Overview And IUD Pain Prep

SPEAKER_01 4:00

first-line treatment for some of the things that we're going to go through. And that they can be put in women who have not had children.

SPEAKER_00 4:09

But there's also been much online recently and a lot more kind of scientific evidence as well about the pain that young people or niliparous individuals might experience with IUD placement. So just wanted to mention that there are some changing recommendations, both from the CDC and also from ACOG in this arena. And really, it's important for us to do anticipatory guidance about pain when we are placing IUDs, because that by itself can reduce pain experiences if someone is prepared and has expectations of that, and also break down some barriers for young people who might be hesitant about the IUD as a good option for them.

SPEAKER_01 4:44

Yeah, absolutely. All right. So let's touch on some medical conditions that impact contraceptives and vice versa. So for instance, teens with rheumatologic disorders, so how do we cancel them? With lupus, without the antiphospholipid syndrome, almost any contraceptive is acceptable. However, if someone has lupus with

Lupus And Estrogen Risk

SPEAKER_01 5:10

antiphospholipid syndrome, they are at increased risk for venous thrombosis so that certain contraceptives, particularly those with estrogen, may be contraindicated in this group.

SPEAKER_00 5:23

These recommendations are really based on just the increased baseline risk of folks who have lupus, especially with positive APLs regarding ischemic heart disease, stroke, venous thromboembolism. And therefore, it's really important to make sure that we're taking a very individualized approach as we're thinking about these larger guidelines that exist, but how they actually apply to our individual patient might really require us to think about that person's comorbidities, their medication exposures, the risk of pregnancy for them in particular. And so making sure we're really doing good shared decision making with a lot of young people in this space.

SPEAKER_01 5:58

Absolutely. It's our job to interpret all of these guidelines and then apply them individually. So, what about teens with neurologic conditions?

SPEAKER_00 6:08

So for a patient with epilepsy in particular, it's important to think about the pregnancy risk of someone who has seizures. So a systematic review and meta-analysis that was published in Jamma Neurology found that women with epilepsy have significantly increased odds of many different adverse maternal and fetal outcomes compared

Epilepsy Meds And Hormone Interactions

SPEAKER_00 6:28

to those who do not have a seizure disorder. And so this can include higher rates of miscarriage, preterm birth, maternal death, congenital conditions, and other adverse neonatal outcomes. The other consideration for folks with epilepsy is the use of teratogenic anticonvulsant medications. So for those who are on these anticonvulsant medications, that there are several and they interact with hormones in different ways, but those that are on anti-convulsant medications that we know to are teratogenic, it's really important to note that some of them should be avoided in adolescence or those who are at risk of pregnancy. And at least if someone is on those medicines, that we should be prompted to have a conversation about contraception so that they at least know that these are dangerous medications, potentially if they were to get pregnant. And so this can include alproic acid, um progablin, tapyrimate, phenobarbital, phenytoin, and carbamamazatine.

SPEAKER_01 7:24

We should encourage neurologists to send all of their teens that are on these medications for a gynecologic consult. And even if it's a special needs patient that's being treated, we should never assume that they are not sexually active.

SPEAKER_00 7:40

It is really important to also remember that um there are some medications that can that are used for anti-convulsant therapy that are may interact or decrease the effectiveness of hormonal contraception. So important to look through people's medication lists and see if they might be on venetoin, carbamazepine, barbituates, um, primodone, tapiramate or oxcarbamazepine, as those are the ones that we know are um definitely potentially going to interact with hormonal contraception.

SPEAKER_01 8:09

And combined oral contraceptives can affect blood levels of lamyctal. And this is really important if somebody is taking that for a seizure disorder, so that the level may go up or down depending on whether, or depending on when it's checked. And is it checked when they're taking the hormonal pill or is it checked during their placebo week? So a lot of people shy away from prescribing combined oral contraceptives to a teen who takes laminectol, no matter what she's taking it for. But I don't have any hesitancy to do that, and I work around it by putting them on a regimen that gives them continuous hormonal intake. And therefore, they I start them on their hormonal, on their hormonal medication. I get a ask the neurologist to do a lamictal level so we see where they're at on the medicine and whether that needs to be adjusted. And then if we keep their hormonal medication stable, that should keep their lamyctal level stable. And there is some good evidence that progesterone can increase the seizure threshold. There have been studies done with the natural progesterone, prometrium. I'm not aware of studies particularly done with other progestins, but just clinically and anecdotally, I've had plenty of patients with uh resistant seizures, and I have put them on whatever my favorite progesterone is at the moment, and it has definitely helped. So there is some benefit there both in contraception and in helping to treat their medical disorder. And this is really uh a thorn in my side, and I'll explain why in a moment, but I would like to hear your approach to girls with migraines.

SPEAKER_00 9:57

So migraines by themselves are not necessarily a contraindication or an issue when it comes to contraception. However, if they have migraines with aura, that's when the CDC and other guidelines that we have really indicate

Migraine With Aura Changes Everything

SPEAKER_00 10:12

that it needs to be a different conversation. So just to backtrack what is a migraine with aura. So this is a subtype of migraines that are characterized by having a transient, fully reversible focal neurologic symptom that precedes or accompanies the headache that shows up. So this could be visual disturbances, sensory symptoms like paresthesias or numbness, some sort of speech or language disturbance, motor symptoms, or like retinal symptoms, so other sort of visual phenomena. So they can usually happen about five to 60 minutes and kind of evolve before the headache onset. So that's a really concrete thing that everyone can scream for if someone indicates that they have chronic or recurrent headaches to just make sure that there aren't there isn't a truly an aura. And so the reason that we care about this is because people who have migraines with auras are at higher risk of stroke, up to six-fold, if they use combined hormonal contraceptives. So the combined oral contraceptive pill, the patches or the rings, compared to those who don't have migraines with auras.

SPEAKER_01 11:16

Because most people come in and say, I have migraines. But if you don't go into detail like you described about their symptoms with their migraines and really make a good determination of whether they have an aura or not, they may lose out on some potentially very helpful medications. What about hematologic disorders?

SPEAKER_00 11:36

We know that combined hormonal contraceptives can increase coagulation activity and are associated with like a two to four fold higher risk of VTE compared to non-use. And this is really driven by the estrogen component of those combined hormonal contraceptives, which can upregulate hepatic

VTE History And Thrombophilia Counseling

SPEAKER_00 11:54

production of pro-coagulant factors. For progestin-only methods, so we know from the literature and guidance from ACOG and the American College of Rheumatology that progestin-only methods really do have minimal effects on coagulation and are not usually associated with an increased risk of VTE, which is why a lot of rheumatologists, I think, do prefer this for a lot of their patients. But we also know that depo, madroxy progesterone acetate, and then also certain higher dose oral progestins might confer just a moderately increased VTE risk. But this is also, again, where she decision making can be really helpful for patients, just to understand what's important to them and how they use their methods and what their risk might be of VTE versus, of course, the in significantly increased risk of VTE once someone is pregnant or postpartum.

SPEAKER_01 12:41

Right. So, for instance, if you have an alder teen who previously had uh orthopedic surgery and was on an oral contraceptive at the time that contained estrogen and she developed a DVT. She she stopped her oral contraceptive, she was treated, she had a precipitating factor, it's now been a few years, and now she's back for contraception again. What would you tell her in terms of her choices?

SPEAKER_00 13:11

So, for those who have a provoked VTE event, I typically will contextualize the circumstances in which that happened and talk about how they might be at a slightly increased risk than the general population at having another event in the future. But that in the current moment, if as long as they're not experiencing anything else that puts them at higher risk of VTE. So again, have a different medical condition or have a surgery, a long plane flight, other things that might provoke a VTE, then it is probably safe for them to be on any method. But of course, if they were to be in a situation where they are going to potentially be experiencing something that might provoke a future VTE event, we would want to then maybe talk about a different method. So I usually do a lot of shared decision making also in those spaces and a lot of counseling about the fact that because it was provoked, it sort of puts them in a different category.

SPEAKER_01 14:04

Right. Absolutely. And it's important for us to know that that's not an absolute contraindication. There's another category of risk, and that's called thrombophilias. Anytime I'm counseling somebody about contraceptives for any reason, I take a good family history. And uh if there's a first degree relative who had an unprovoked thromboembolic event, I want to know if that person was tested so that I know how to cancel my patient and what I can prescribe for her. Interestingly, most of the studies done on thromboembolic disease were done with ethanol estradiol, because that's the primary estrogen in most of our combined or hormonal contraceptives. But we have a relatively new estrogen on the market called esterol, and it's an E4, and it's a natural estrogen that can be detected during pregnancy. And the pharmaceutical companies have made a synthetic version of that and combined it with trospirinone for a relatively new combined birth control pill. So theoretically, the risk of a thromboembolic event or stroke may be less with that estrogen, but I don't think we have enough evidence yet to say yay or nay. And again, in if we uh end up diagnosing the thrombophilia in our patient, then anything with estrogen would be a category four. But with shared decision making and counseling about the fact that it's there's no zero risk with progestins, we can put them on progesterone medication. So, how do you counsel young women who come in with heavy menstrual bleeding?

SPEAKER_00 15:49

For some people, their initial introduction to different contraceptive options, like you said, for non-pregnancy prevention purposes. So when it comes to options for reducing or suppressing menstrual flow, which is often the reason that we would be using these medications, I will often talk about using a combined hormonal contraceptive as a really wonderful

Heavy Bleeding And Period Suppression

SPEAKER_00 16:13

way to potentially suppress mencise. And so this would be the combined pills, the patches or the vaginal rings. And I'll often talk about using these continuously instead of using that placebo week or that week where they're not not using the ring or the patch. And that can often lead to lighter or more absent periods over time. And among especially those who use the pet pill and the ring, up to 90% of users will have no bleeding after about a year of continuous use. The progestin-only options can also be really helpful. So the DEPR Pavera shot can lead to amenorrhea in about 70% of folks who use it for up after about two years. And the implant, while it can cause some irregular bleeding at first, about 22% may have amenorrhea after a year. And then finally, just want to mention the leaving adjusteral IUD or the hormonal IUD. That can be one of the best tools that we have for heavy bleeding by really cutting menstrual blood loss by more than 90% and often leading to no periods in about half of folks after the first year.

SPEAKER_01 17:14

And these medications are definitely first-line treatments for bleeding disorders like Bon Willibrons and other platelet disorders. When you're talking about combined uh medications, the higher dose pills may work better than something like a 10 microgram pill. So I don't ever prescribe a 10 microgram pill. I often don't even prescribe the 20 microgram pills unless they really protest uh the amount of estrogen. Generally, I start with a 30 microgram pill.

SPEAKER_00 17:45

Absolutely. All pills are not exactly the same. And so if they are really unhappy with the bleeding profile of that particular pill, that we have options for ways to change that and hopefully manage their periods a little bit better.

SPEAKER_01 17:59

We all know that weight is a challenging topic because in most of the studies, young women with BMIs over 30 have been excluded from the studies. So there are some recommendations about what works and doesn't work in someone whose BMI is over 30.

SPEAKER_00 18:18

Yeah. But the encouraging thing is that most high-quality studies

Weight Considerations And Emergency Contraception

SPEAKER_00 18:30

don't show a significant difference in like oral contraceptive efficacy, for example, between those who are obese and non-obese. Long-acting reversible contraceptive options like the IEDs and implants do often, and we're seeing increasingly maintain higher efficacy regardless of weight, and sometimes could be preferred by that young person. And so it is a good one to make sure we mention. However, the two that I do want to point out that might have some different considerations for those who are in larger bodies might be the combined hormonal patch and then also the oral leave and agestural emergency contraception, since both of those might have reduced effectiveness in individuals at higher BMIs.

SPEAKER_01 19:10

Right. And again, we have to be mindful of the risk of thromboembolic phenomenon in somebody who has a larger body size. We should keep in mind that the risk of a thromboembolic phenomenon with pregnancy and postpartum is significantly higher than the risk with our combined oral contraceptives. Because the levo-norgestual emergency contraceptive pill may be a little less effective, we have olipristol, which has been shown to be more effective in teens with a BMI over 30. So I offer all methods to my patients. And if I'm using them uh using a hormonal method to treat a medical issue and it's not working, it's not working, and we're gonna change it. If we're using it for contraception and they're having breakthrough bleeding or some other indication to me that it may be less effective in pregnancy prevention and they're not using condoms, then of course I'm gonna counsel them about changing their method. So they're not excluded. We just have to keep all these factors in mind.

SPEAKER_00 20:19

I just want to flag that the depomadroxy progesterone acetate can be associated with weight gain from increases ranging from 0.6 to 8 kilograms over one to two years. And that can sometimes contribute to folks being less interested or discontinuing that method in particular. It's really hard, though, to predict which young people will experience substantial weight gain. But often earlier weight gain, like within about 5% of body weight within six months, can predict continued gain. And so it's really important for us as clinicians to counsel about expected weight changes and how that might feel to that young person to really reduce the chances of them discontinuing it if they're worried about perceived or feared weight gain. But we really don't see great evidence for any of the other methods being associated with weight gain. We'll see how things evolve over time. But as of now, hydroxy progesterone acetate is the only one that I really talk about in regards to weight gain.

SPEAKER_01 21:16

Okay. And I also reassure my patients that I'm not giving them a prescription or a device and telling them not to come back for a year. I'm gonna have them back in three months after they start something to reassess them and to look for weight gain. And if there's weight gain, we're gonna talk about it.

SPEAKER_00 21:34

Absolutely. I will often mention to patients that are on depot that it might make them hungrier. And so it might be a good opportunity for them to make sure they have healthier snacks on board or kind of talk about healthy nutrition.

SPEAKER_01 21:45

We are also seeing more survivors of cancer, which is really a wonderful thing. Some of these young ladies that are currently being treated are at increased risk for bleeding. Sometimes the oncologists ask. Ask for hormonal treatment up front to prevent periods, and sometimes we're called to consult on hormonal treatment if bleeding begins.

Cancer Hypertension And Other Conditions

SPEAKER_01 22:09

They can use any method of contraception, with the exception of if they have a hormonally sensitive cancer, such as a breast cancer that's ERPR positive. And the only other exclusion is in a person who's have who has cervical cancer or uterine cancer. So I won't say that the IUDs are absolutely in contraindicated, but generally not used in people with cervical cancer or uterine cancer.

SPEAKER_00 22:38

Sometimes, as a result of treatment, folks might actually have irregular mences or even amenorrhea, and that that doesn't guarantee any infertility necessarily unless further evaluation is done. And that those who are sexually active are still going to be at risk of pregnancy, even if they're not having regular mencies. And so just again, thinking about balancing for that young person who's in treatment, if you know their personal bleeding risk or VTE risk, maybe adverse effects like nausea vomiting, and then also what their goals might be around their reproductive health. So we can use all of these options potentially to manage a medical condition if it is related to heavy menses, but also those folks may still also want contraception for pregnancy prevention. So it's really important for us to think about all that together.

SPEAKER_01 23:23

And that's an excellent, excellent point. And then quickly, just to make some comments on kids with inflammatory bowel disease, hypertension.

SPEAKER_00 23:34

First, the definition of hypertension in adolescence would be anyone up to the age of 13, it's really about the percentile for age. So if it's above the 95th percentile for age, then that would be considered hypertension. If they're over 13, then we use the adult criteria. So stage one, stage two hypertension would be 130 over 80 to 139 over 89. And then stage two is over 140 over 90. And combined hormonal contraceptives might have a small but significant increase in blood pressure, but it's really rare for that to sort of create overt hypertension for an individual. So if we are seeing that someone has hypertension after starting combined oral contraceptives, it will probably change whether or not they're safe to be on those methods. But it would also mean that we do need to evaluate that underlying cause of hypertension potentially. I also will just bring this back quickly to the MEC and just mention that combined hormonal contraceptives are a category three if it's adequately controlled hypertension, but if a category four if it's really severe or uncontrolled hypertension. So the risk-benefit analysis and the shared decision making might be different for patients depending on how well treated their hypertension is. And progestin-only methods and copper IUDs are really category one or two, so fully safe with someone with hypertension.

SPEAKER_01 24:52

Absolutely. What about bone health? So there is a black box warning that there is not a loss of bone like we would see in a menopausal woman, but the slowdown of building bone by anywhere from 2 to 5% in the first couple of years of use of depot. And in fact, there was a recommendation among certain communities

Bone Health With Depo And CHC

SPEAKER_01 25:17

that Depo Provera could not be used for more than two years because of this. However, we do know that after stopping Depo Provera, the bone will catch up, assuming there's not another factor that's prohibiting that. We also know that teenagers notoriously are not engaged in bone healthy activities. They're not getting adequate calcium or vitamin D. They may not be physically active if they're not involved in sports. So when I have patients on Depo Provera and I reach that two-year mark, then again, we have a shared decision-making conversation, particularly if it's a medic, a medication that she and her mother absolutely positively want her to stay on.

SPEAKER_00 26:03

The combined hormonal contraceptives, though, are also have an interesting history, kind of as it relates to bone accrual, like you were saying, less so bone loss, but that there has been there was a systematic review actually in JPAG just this year that indicates that combined hormonal contraceptives in those young people who have already had menarchy, that it can maybe reduce some bone accrual compared to those who are non-users. And that's likely related maybe to the estrogen dose and the regimen and the duration of use. And so the lower dose preparations of ethylene estradiol, so the 20 microgram or less doses, but even standard doses like 30 micrograms have been associated with compromised bone mass acquisition. And so, and that of course can be more pronounced if you get to higher doses in some studies. So it is worth a conversation with a young person about the appropriateness of using combined hormonal contraceptives, especially for those who are already at higher risk of having poor bone health, as you mentioned. The most important takeaway from all of this is it's important to reference the medical eligibility criteria from the CDC and just noting that it did, it was updated about a year ago, but also that it's important to do shared decision making. So unless something is a category four, we need to sort of make sure we're approaching these conversations by asking them what's important to them in a method, how they might use the method, what they think of certain side effects, and aligning ourselves as a team player in their contraceptive journey and that anytime they have questions or concerns, or if as their health history evolves, that we're here to help support them.

SPEAKER_01 27:35

Absolutely. So let's go back to our case. So to pyramid decrease the effectiveness of hormonal contraception. And this patient has migraines with aura. So what would her options be for contraception? So we're left with all the progesterone pills. We do not have progesterone-only patches yet, but that would be very cool. But we have the implant and the progesterone-containing

Back To The Case: Safe Options

SPEAKER_01 28:00

IUD and depot provera.

SPEAKER_00 28:03

And just to briefly mention the progestin-only pills, just because some of that has changed so recently in the last few years that we have the option of the northindrone, which everyone is familiar with as sort of the mini pill. But in the last few years, now we have norgesterol or opill, which is available over the counter for patients, and then also just pferodone or slind, which is available by prescription, but actually can have a slightly longer missed window and can be really appealing for patients that want something that acts and looks a little bit more like a combined oral contraceptive.

SPEAKER_01 28:34

Yeah. Don't forget as well, just because a teenager has a complex medical problem or has a special need or a neurodivergence or a differing physical state, it does not mean that they're not interested in learning about contraception. It also does not mean that they won't need hormonal contraception to treat abnormalities or to prevent pregnancy. All right, so this has been so much fun. And thank you to everybody for listening to Pagover Pastry. For more information or our references, visit the Pagover Pastry page on the NASPAG website. If you have any questions for our speakers today or feedback, please email us at pagoverpastries at gmail.com. So, Bianca, thank you so, so much for

Resources And How To Reach Us

SPEAKER_01 29:26

recording this with me today.

SPEAKER_00 29:28

Thank you so much for having me.