Telemedicine for adolescent and young adult long-acting reversible contraception post-insertion visits: outcomes over 1 year.

OBJECTIVES: Telemedicine for long-acting reversible contraception (LARC) care is understudied given the rapid implementation of these services in response to the COVID-19 pandemic. We compared outcomes over 1 year of adolescents and young adults (AYAs) attending a LARC post-insertion visit via telemedicine versus in person. STUDY DESIGN: We included AYAs (ages 13-26 years) who received LARC between 4/1/20-3/1/21 and attended a post-insertion visit within 12 weeks. Outcomes over 1 year were compared between AYAs who completed this visit via telemedicine versus in person. We analyzed the data using descriptive statistics, bivariate analyses, and regression models. RESULTS: Of 194 AYAs (ages 13.9-25.7 years) attending a post-insertion visit, 40.2% utilized telemedicine. Menstrual management (OR = 1.02, CI: 0.40-2.60), acne management (p = .28), number of visits attended (RR = 1.08, CI: 0.99-1.19), and LARC removal (p = .95) were similar between groups. AYAs attending via telemedicine were less likely than those attending in person to have STI testing (p = .001). Intrauterine device expulsion or malposition and arm symptoms with implant in situ were rare outcomes in both groups. CONCLUSION: Roughly 40% of AYAs attended a post-insertion visit via telemedicine during the first year of the COVID-19 pandemic and had similar 1-year outcomes as those attending in person. The decreased likelihood of STI testing for those using telemedicine highlights the need to provide alternative options, when indicated, such as asynchronous or home testing. IMPLICATIONS: Our results support the use of telemedicine for AYA LARC post-insertion care given similar clinical outcomes and healthcare utilization for LARC-related concerns over 1 year as in-person visits. Furthermore, our results identify STI testing as a potential gap in telemedicine care which can help inform and improve clinic protocols.

Relationship between long-acting reversible contraception and acne in a cohort of adolescents and young adults.

BACKGROUND: The use of progestin-only long-acting reversible contraception (LARC) may be a risk factor for acne. Few studies have focused primarily on the effects of hormonal LARC on the development or exacerbation of acne in adolescents and young adults. We sought to understand the incidence and management of acne following hormonal LARC insertion in this adolescent/young adult population. METHODS: A secondary data analysis was conducted of prospectively collected quality improvement (QI) data from the Adolescent Medicine LARC Collaborative. Subjects were evaluated by clinicians in adolescent medicine clinics at participating study sites, and acne severity was documented using a standardized recording instrument and scale. Descriptive statistics were reported as frequencies and percentages for categorical variables or mean and standard deviation (SD) for continuous variables. We compared demographic and clinical characteristics by those who had worsening acne, accounting for site inter-correlation using Cochran-Mantel-Haenszel chi-square tests for categorical variables and linear generalized estimating equation (GEE) regression for continuous variables. RESULTS: Of 1319 subjects who completed LARC insertion, 28.5% (376/1319) experienced worsening acne following use of progestin-only LARC. Acne was a contributing factor to LARC removal in only 3% (40/1319), and the sole reason for removal in 0.4% (5/1319) of all subjects. As this was a secondary analysis of prospectively collected QI data, limitations of this study include incomplete or inaccurate documentation of acne severity. Moreover, LARC insertions without follow-up/removal visits or with only follow-up/removal within 8 weeks of insertion were excluded from our study, which may also bias results. CONCLUSIONS: Adolescents and young adults seeking progestin-only LARC should be counseled about the potential for developing acne or experiencing a worsening of existing acne during LARC use. However, acne was not a common reason for LARC discontinuation.

Continuation rates of hormonal intrauterine devices in adolescents and young adults when placed for contraceptive and non-contraceptive indications.

OBJECTIVE: This study aimed to estimate and compare continuation rates of hormonal intrauterine devices (IUDs) when placed for contraceptive or menstrual management indications in adolescents and young adults. STUDY DESIGN: We conducted a secondary analysis of a prospectively collected database of all hormonal IUD insertions from January 1, 2017 through December 31, 2020, with at least 1-year follow-up, across four Adolescent Medicine practices. IUD insertions without known indication were excluded. RESULTS: A total of 936 IUD insertions were attempted, 45% for contraception only, 18% for menstrual management only, and 37% for both indications. Insertion was successful in 868 (93%) attempts, and success did not differ by indication (p = 0.74). The mean age at insertion was 18.9 years (SD = 2.4 years), with no difference by indication. Of the completed insertions, 650 (75%) had at least one follow-up during the data analysis period. Excluding those without follow-up, the overall continuation rates were 77% at 1 year, 66% at 2 years, and 54% at 3 years. While continuation rates did not differ by indication at 1 year, at 3 years, continuation was highest among those who sought the device for menstrual management only (contraception = 53%, menstrual = 57%, both = 53%, p < 0.01) Malposition was rare (4.0%), as was device expulsion (2.5%), and these did not differ by indication. CONCLUSION: IUD continuation rates were high among adolescents and young adults and did not significantly differ when placed for contraceptive or non-contraceptive indication in the first year of use. IMPLICATIONS: Adolescents and young adults may seek the hormonal IUD for contraception and/or menstrual management. Our study found that IUD continuation rates were high at 1 year regardless of the indication for utilization.

Long-acting reversible contraception in gender-diverse adolescents and young adults: Outcomes from a multisite collaborative.

OBJECTIVES: This study aimed to describe the clinical experience of gender-diverse adolescents and young adults receiving long-acting reversible contraception (LARC). STUDY DESIGN: This was a secondary analysis of prospectively collected quality improvement data among gender-diverse adolescents and young adults receiving LARC in four adolescent medicine clinics. RESULTS: Most attempted insertions (59/63) were successful. A majority (54%) chose LARC for both contraception and menstrual management. Pelvic pain/cramping and unsatisfactory bleeding were reported side effects. One known expulsion and six known LARC removals occurred. CONCLUSIONS: Gender-diverse adolescents and young adults had high rates of successful LARC insertion and demonstrated a side effect profile similar to a broader adolescent and young adult population seeking LARC care. IMPLICATIONS: LARC is an important and well-tolerated method of menstrual management and contracention in gender-diverse adolescents and young adults, although more investigation is needed to understand how gender-affirming testosterone therapy may impact the LARC experience in this population.

Contraceptive Implant-Associated Bleeding in Adolescent/Young Adult Clinical Practice: Associated Factors, Management, and Rates of Discontinuation.

PURPOSE: To identify factors associated with bothersome implant-associated uterine bleeding, and to evaluate the impact of bleeding management on implant discontinuation. METHODS: We analyzed a quality improvement database of implant insertions (n = 825) at three adolescent/young adult programs and described individuals with and without reported bothersome bleeding. We utilized logistic regression to assess for factors associated with bleeding. RESULTS: Implant recipient mean age was 18.9 ± 2.6 years, and 27% reported having subsequent bothersome uterine bleeding. Recipients had increased odds of reporting such bleeding if they had previously irregular menses (odds ratio [OR] = 1.36; 95% confidence interval [CI]: 1.11-1.68 irregular and infrequent, OR = 1.41; 95% CI: 1.07-1.86 irregular and frequent) or sought the implant for menstrual management purposes exclusively (OR = 1.67; 95% CI 1.42-1.96) or in combination with contraceptive need (OR 1.65; 95%: CI 1.57-1.72). Prior use of the progestin injection or implant was associated with lower odds of subsequent bleeding report (OR = 0.63; 95% CI: 0.54-0.73; OR = 0.54; 95% CI: 0.39-0.75, respectively). Medication management of bleeding was associated with the likelihood of implant discontinuation at 1 year compared to those with untreated bleeding (hazard ratio 1.98 times, 95% CI: 1.39-2.81). The implant was continued for 3 years in over 50% of recipients with ever-managed bothersome bleeding. DISCUSSION: Individuals with historically irregular menses and those seeking the implant for menstrual management more often reported bothersome bleeding. Treating such bleeding with medication was associated with higher 1-year discontinuation rates, although many continued implant use for 3 years. Such findings may influence implant preinsertion counseling and/or postinsertion bleeding management.

Reproductive Health Care for Female Adolescents Prescribed Mycophenolate at a Children's Hospital: A 10-Year Retrospective Cohort Study.

OBJECTIVES: To describe female adolescents' reproductive health needs and subspecialists' teratogenic counseling at initiation of mycophenolate as well as use of reproductive health care and contraception after mycophenolate initiation. STUDY DESIGN: We searched health records for female patients aged 12-20 years prescribed mycophenolate from 2010 to 2019. We included 125 subjects, 72 with systemic lupus erythematosus, 27 with transplants, and 26 with other conditions. We reviewed all encounters with pediatric subspecialists and reproductive clinicians. We recorded counseling by subspecialists at mycophenolate initiation and compared rates pre- and post-Risk Evaluation and Mitigation Strategy (REMS). We recorded subjects' menstrual, sexual and pregnancy history, type of first highly effective contraceptive method used, and duration of use over the decade. RESULTS: At mycophenolate initiation, mean age was 16.8 ± 2.6 years; 72% Hispanic/Latina or Black. In total, 80% were postmenarchal, 28% ever had sex, 18% ever had a reproductive health care visit, 14% used highly effective contraception, and 7% were ever pregnant. Post-REMS vs pre-REMS, we found greater rates of counseling for teratogenicity (68% vs 32%, P < .001) and contraception (62% vs 32%, P < .001) and pregnancy testing (51% vs 24%, P < .01). Over the mean 4.9 ± 3.3 years' follow-up, 56% ever had sex; 59% ever attended a reproductive health care visit; 38% used highly effective contraception; and 10% had a pregnancy. CONCLUSIONS: Adolescents prescribed mycophenolate have ongoing unmet reproductive health care needs. Although many are sexually active, fewer use effective contraception. Teratogenicity counseling rates improved over the decade but not rates of referral for reproductive health care.

Adolescent/Young Adult Long-Acting Reversible Contraception: Experience from a Multisite Adolescent Medicine Collaborative.

OBJECTIVE: To report on long-acting reversible contraception (LARC) experience and continuation rates in the Adolescent Medicine LARC Collaborative. STUDY DESIGN: LARC insertion data (682 implants and 681 intrauterine devices [IUDs]) were prospectively collected from January 1, 2017, through December 31, 2019, across 3 Adolescent Medicine practices. Follow-up data through December 31, 2020, were included to ensure at least 1 year of follow-up of this cohort. Continuation rates were calculated at 1, 2, and 3 years, overall and by Adolescent Medicine site, as were descriptive statistics for LARC procedural complications and patient experience. RESULTS: Implant and IUD insertion complications were uncommon and largely self-limited, with no IUD-related uterine perforations. Uterine bleeding was the most frequently reported concern at follow-up (35% implant, 25% IUD), and a common reason for early device removal (45% of implant removals, 32% of IUD removals). IUD malposition or expulsion occurred following 6% of all insertions. The pooled implant continuation rate at 1 year was 87% (range, 86%-91% across sites; P = .63), 66% at 2 years (range, 62%-84%; P = .01), and 42% at 3 years (range, 36%-60%; P = .004). The pooled IUD continuation rate at 1 year was 88% (range, 87%-90% across sites; P = .82), 77% at 2 years (range, 76%-78%; P = .94), and 60% at 3 years (range, 57%-62%; P = .88). CONCLUSIONS: LARC is successfully provided in Adolescent Medicine clinical settings, with continuation rates analogous to those of well-resourced clinical trials. Uterine bleeding after LARC insertion is common, making counselling imperative. Future analyses will assess whether the medical management of LARC-related nuisance bleeding improves continuation rates in our Adolescent Medicine patient population.

Sexting and Young Adolescents: Associations with Sexual Abuse and Intimate Partner Violence.

STUDY OBJECTIVE: To explore whether sexting by young adolescent girls and boys is associated with adverse life experiences including exploitative or violent sexual relationships. DESIGN AND SETTING: Cross-sectional, anonymous survey of a convenience sample of minor adolescents younger than age 18 years recruited while waiting for care in clinics affiliated with a children's hospital in a low-resource, high-poverty, urban community. PARTICIPANTS: Five hundred fifty-five adolescents aged 14-17 years, 63% girls and 37% boys. MAIN OUTCOME MEASURES: We measured sexting by asking, "Have you ever sent a sexually suggestive or naked picture of yourself to another person through text or e-mail?" The survey also measured risk behaviors, sexual abuse, intimate partner violence (IPV), and arrest and included a validated depression scale. RESULTS: Mean age was 15.6 ± 1.1 years; 59% were Hispanic, 28% were black; 44% of girls and 46% of boys ever had sex; 24% of girls and 20% of boys ever sent a sext. More girls than boys reported sexual abuse (16% vs 3%; P < .01), IPV victimization (15% vs 7%; P < .01), and depression (33% vs 17%; P < .01). More boys than girls reported arrest (15% vs 7%; P < .01). Independent associations with sexting for girls were: ever had sex (odds ratio [OR], 4.59; 95% confidence interval [CI], 2.29-9.19; P < .001); sexual abuse (OR, 3.81; 95% CI, 1.80-8.05; P < .001); IPV victim (OR, 2.72; 95% CI, 1.11-6.62; P < .05), and for boys: ever had sex (OR, 4.26; 95% CI, 1.47-12.32; P < .01); sexual abuse (OR, 38.48; 95% CI, 1.48-999.46; P < .05); IPV perpetration (OR, 16.73; 95% CI, 1.64-170.75; 95% CI, P < .05), as well as cannabis use, older age, other race, and arrest. CONCLUSION: For young adolescents, sexting is independently associated with exploitative and abusive sexual relationships including sexual abuse and IPV with similarities and differences in predictors of sexting for girls and boys.

Improving Tracking of Postdischarge Results of Sexually Transmitted Infection Screening Tests in Hospitalized Adolescents and Young Adults: A Quality Improvement Initiative.

Hospitalizations offer chlamydia and gonorrhea screening opportunities for youth who may not seek preventive care. Tracking of screening test results still pending after hospital discharge is an important component of clinical care. This process can be improved by protocol use and enhanced by effective, automated electronic health record tools.

Contraceptive Needs of Adolescents with Chronic Illness.

Contraception and sexual health form a key part of comprehensive health care for all adolescents, including those who suffer from chronic illness. Multiple studies have shown that adolescents with chronic illness have rates of sexual activity equal to or greater than their healthy counterparts. Primary care pediatricians have the most comprehensive view of the health of their medically complex patients and the benefit of a longstanding relationship. The Centers for Disease Control and Prevention have created a comprehensive guide that provides advice on safe contraceptive options for patients with complex medical conditions. Here we review three cases of adolescents with common chronic medical conditions: von Willebrand disease, systemic lupus erythematosus, and sickle cell disease. [Pediatr Ann. 2019;48(2):e78-e85.].

The Female Athlete Triad: A Comparison of Knowledge and Risk in Adolescent and Young Adult Figure Skaters, Dancers, and Runners.

STUDY OBJECTIVE: The female athlete triad is often found in sports that value leanness and aesthetics and can lead to adverse health effects. We aimed to compare knowledge and risk of the triad among adolescent figure skaters, dancers, and runners. DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOME MEASURES: We advertised our survey on social media platforms: sports-specific forums; Facebook; and Instagram. We received 928 responses. We included female figure skaters, dancers, and runners aged 25 years or younger (N = 712). We asked participants to name the triad components and dichotomized knowledge scores as high or low. We developed a 6-question triad risk scale and defined "at risk" if participants endorsed 3 or more questions. RESULTS: Of 712 participants: 60% were figure skaters; 28% dancers; 12% runners; 78% were adolescents (≤17 years of age); 22% young adults (18-25 years); 12% had heard of the triad. A higher proportion of runners than figure skaters and dancers had high knowledge of the triad (16% vs 6% vs 5%, P < .01). Overall 60% of athletes were "at risk" of the triad, 25% skipped a period for 3 or more months, and 34% had a history of stress fractures or shin splints. Young adults vs adolescents and dancers vs figure skaters and runners had nearly twice the odds of triad risk. CONCLUSION: Most athletes were at risk of the triad but few knew about it. Dancers were at higher risk compared with figure skaters and runners. Efforts should be made to raise awareness of the triad among athletes, parents, and coaches, with special attention paid to the dance community.

Pediatricians' Knowledge and Practices Related to Long-Acting Reversible Contraceptives for Adolescent Girls.

STUDY OBJECTIVE: A 2014 American Academy of Pediatrics (AAP) policy statement identified long-acting reversible contraceptives (LARCs) as first-line choices for adolescents, but pediatricians' current knowledge and practices about intrauterine devices (IUDs) and subdermal contraceptive implants (Implants) is unknown. We aimed to characterize pediatricians' knowledge and practices about LARCs for adolescents. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional online survey emailed to a convenience sample of AAP member pediatricians in New York, Utah, Illinois, and Kansas in 2015 and 2016. The study included 561 practicing pediatricians. MAIN OUTCOME MEASURES: We measured knowledge about the suitability of IUDs and Implants for adolescents using two 7-item scales; a score of 7 indicates all correct. We dichotomized participants' scores as high and low knowledge if they scored ≥85% correct or <85%, respectively. RESULTS: Mean age was 47.4 (±11) years; 73% were female; and 72% general pediatricians. Almost all, 88%, counsel about contraception; 64% counsel about IUDs, and Implants, but only 4.1% insert them; 72% prescribe short-acting hormonal contraceptives; 44% had read the AAP policy statement. Mean score on the knowledge scale was lower for IUDs than for Implants (4.2 vs 5.1, respectively; P < .001). Multivariable regression analysis indicated that female pediatricians, adolescent medicine subspecialists, agreeing that pregnancy is a serious problem for adolescents in their practice, and having read the AAP policy statement predicted high knowledge about IUDs as well as Implants for adolescents. CONCLUSION: Most pediatrician respondents provided reproductive health care for adolescents and counseled about LARCs, but few inserted the devices. We identified knowledge deficits about suitability of IUDs for adolescents.

Polycystic Ovary Syndrome: An Under-recognized Cause of Abnormal Uterine Bleeding in Adolescents Admitted to a Children's Hospital.

STUDY OBJECTIVE: To evaluate whether ovulatory dysfunction due to polycystic ovary syndrome (PCOS) is a common underlying etiology of abnormal uterine bleeding (AUB) in adolescents who require hospitalization and to explore etiology, treatment, and complications of AUB with severe anemia in adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We identified female patients aged 8-20 years admitted to a children's hospital for treatment of AUB from January 2000 to December 2014. Our hospital protocol advises hormonal testing for PCOS and other disorders before treatment for AUB. We reviewed medical records and recorded laboratory evaluations, treatments, and final underlying diagnoses as well as recurrences of AUB and readmissions in the subsequent year. RESULTS: Of the 125 subjects, the mean age was 16.5 ± 2.9 years; mean hemoglobin level was 7.0 ± 1.8 g/dL; 54% were overweight/obese; and 41% sexually active. PCOS accounted for 33% of admissions; hypothalamic pituitary ovarian axis immaturity 31%; endometritis 13%; bleeding disorders 10%. Girls with PCOS were more likely to be overweight/obese (74% vs 46%; P < .01) and girls with hypothalamic pituitary ovarian axis immaturity had lower hemoglobin levels (6.4 g/dL vs 7.4 g/dL; P < .05), than girls with all other etiologies of AUB. Treating physicians failed to diagnose endometritis as the etiology for AUB in 4 of 8 girls with positive tests for sexually transmitted infection and no other etiology. CONCLUSION: PCOS was the most common underlying etiology in adolescents hospitalized with AUB. Screening for hyperandrogenemia is important for early diagnosis of PCOS to allow ongoing management and prevention of comorbidities. Endometritis was frequently underestimated as an etiology for AUB.

Predictors of Early Discontinuation of Effective Contraception by Teens at High Risk of Pregnancy.

STUDY OBJECTIVE: In the United States, teen pregnancy rates are declining. However, the United States still has the highest teen pregnancy rate among high-income countries. Understanding factors that predict discontinuation of effective contraception might help to further decrease teen pregnancy. We aimed to assess predictors of early discontinuation of effective contraception during typical use by high-risk teens. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We recruited 145 women aged 13-20 years (mean, 17.7 ± 1.8 years); 68% (99/145) Hispanic; 26% (38/145) black; 14% (20/145) ever pregnant; and 4% (6/145) high school dropouts who chose an effective contraceptive method during a health care visit and we prospectively assessed use of the method after 6 months. Contraceptive choices of the 130 participants who were reassessed at 6 months (90% retention) were: intrauterine device (IUD), 26% (34/130); depot medroxyprogesterone acetate (DMPA), 8% (10/130); combined oral contraceptives (COCs), 48% (62/130); transdermal patch (Patch), 13% (17/130); and intravaginal ring (Ring), 5% (7/130). RESULTS: After 6 months, only 49 of 130 (38%) continued their chosen method; 28 of 130 (22%) never initiated the method; and 53 of 130 (40%) discontinued. Users and nonusers at 6 months did not differ according to cultural and/or social characteristics (age, ethnicity, acculturation, education, health literacy) but differed according to contraceptive method type. For the 102 of 130 who initiated a method, 88% continued use of the IUD, 20% DMPA, 43% COC, 17% Patch and Ring (P < .001). Using Cox proportional hazards multivariable analysis, compared with IUDs, all other methods predicted discontinuation: DMPA (hazard ratio [HR], 5.6; 95% confidence interval [CI], 1.2-26.7; P < .05); COCs (HR, 6.6; 95% CI, 1.8-25; P < .01); Patch and Ring (HR, 12; 95% CI, 3.0-48; P < .001). Discontinuation was also predicted by past use of hormonal contraceptives (HR, 1.9; 95% CI, 1.0-3.6; P < .05) and high school dropout (HR, 8.2; 95% CI, 1.6-41; P < .01). CONCLUSION: Contraceptive method type is the strongest predictor of early discontinuation; compared with IUDs, all other methods are 6-12 times more likely to be discontinued. Cultural and/or social characteristics, with the exception of school dropout, are of little predictive value. Increasing the use of IUDs by high-risk teens could decrease discontinuation rates and possibly teen pregnancy rates.