Building Strong Patient Relationships Begins in Adolescence

While many people are eager to leave their adolescence behind them, as ob-gyns, we know all too well that the development that occurs during these years lays the foundation for the rest of our lives. Not only are bodies and minds maturing, but adolescence is also defined by exposure to new ideas, experiences, and beliefs. Ideally, it is also the age where girls and young women begin to routinely visit the ob-gyn.

ACOG recommends that girls have an initial visit for screening and the provision of reproductive preventive health care services and counseling between the ages of 13 and 15 years. Caring for patients beginning in adolescence gives ob-gyns an important opportunity to focus on establishing a relationship of trust and ensuring young women are empowered with comprehensive knowledge about their reproductive health. Ensuring women get this knowledge helps them at every stage, not just adolescence. It informs all kinds of life decisions– from becoming sexually active to planning when and if to have a baby.

Of course, we cannot have these important conversations without acknowledging that while the United States has made progress reducing rates of unplanned pregnancy among teenagers, our rate remains among the highest in the developed world. Recent guidance, “Adolescent Pregnancy, Contraception, and Sexual Activity,” directly addresses the role ob-gyns can play to support adolescent girls in preventing unintended pregnancy. Contraceptive access to highly effective methods remains one of the most important factors, but comprehensive sexual education is also critical.

The success of this education relies on trust. In new guidance out this month, “Counseling Adolescents About Contraception,” ACOG highlights the importance of listening carefully to young patients concerns and priorities when discussing which contraceptive method choices are best for them. By the time they are teenagers, many young women have already been exposed to different ideas about contraception through friends, family, and pop culture. At the same time, they’re making decisions for themselves about their health care and what is important to them; physicians should be aware of these preferences and concerns and should partner with young women to assist them in making choices about their reproductive health.

Listening and respecting a patient’s perspectives and priorities truly should define the patient-provider relationship, not just one conversation. In many instances, ob-gyns may be the most trusted adult for teens who are ready to have essential conversations about their reproductive health, sexual activity, sexual orientation, gender identity, and/or mental health. We must be mindful of the sensitivities around these topics, and do our best to provide each patient with the care and knowledge she seeks. This also may include helping patients and parents navigate this new territory together; ob-gyns should encourage and support this communication when appropriate.

As late summer approaches, and more adolescents cross our paths, checking off annual doctor visits before the school year begins, we should each take time to reflect on our effort to have a lasting impact on patients’ reproductive health knowledge and relationship to their ob-gyn.

For a comprehensive overview of ACOG’s adolescent health care guidance, head to: https://www.acog.org/About-ACOG/ACOG-Departments/Adolescent-Health-Care

Guest Blog: Prevent Teen Pregnancy on a LARC

Elisabeth J. Woodhams, MD

In my Chicago clinic I see a lot of adolescents, and by extension, I prescribe a lot of contraception. Although, by “prescribe contraception” I actually mean “place IUDs and implants,” which, until recently, had been considered a fairly edgy clinical practice in some circles. Imagine my excitement, then, over ACOG’s latest recommendations from the Committee on Adolescent Health Care and the Long-Acting Contraception Work Group that encourage us to offer these two contraceptive methods as first-line options for sexually active teens.

Family planning specialists have long known that long-acting reversible contraception (LARC) devices are safe for adolescents and are significantly more effective at preventing pregnancy when compared with other forms of short-acting contraception, such as pills, patches, or vaginal rings. In fact, a recent study found that women using a LARC device were 20 times less likely to experience an unplanned pregnancy than women using short-acting methods. This is hugely important considering that:

  • 82% of adolescent pregnancies are unplanned
  • 20% of adolescent mothers will experience a second pregnancy within two years of their first pregnancy
  • Condoms are the most common method of contraception used by adolescents. While still important for preventing sexually transmitted infections (STIs), they are the least effective contraceptive method for preventing pregnancy.

LARC methods work better than short-acting ones because there’s no user error. As I tell my patients, a pack of pills only works if you’re actually taking them. Also, the continuation rates are better—in that same study, 86% of adolescents using a LARC device were still using it a year later, compared with 55% of those using a shorter-acting method.

And LARC methods are very safe for adolescents:

  •  IUD expulsion is uncommon in adolescents
  • There is no increased risk of infertility for IUD users
  • Any increased risk of pelvic inflammatory diseases (PID) is limited to the first 20 days after insertion of an IUD and is related to infection at the time of insertion rather than the IUD itself. This is another important reason ob-gyns should screen all their patients under 25 for chlamydia and gonorrhea annually.
  • IUDs and implants can be placed immediately post-delivery or post-abortion
  • IUDs and implants can decrease menstrual blood loss and decrease anemia, a plus for many teens

So make sure LARC methods are at the top of your list when you’re counseling adolescent patients. For many teens, LARC devices—combined with condoms for STI prevention—are the best way to ensure they get on the right reproductive track early.

Elisabeth J. Woodhams, MD, is a Family Planning Fellow at the University of Chicago in Illinois.

 

The Truth About Growing Up

The teenage years can be among the most challenging in the human experience. It’s a time of unparalleled physical and emotional growth when new, interesting, and sometimes frightening events happen in quick succession. Peer pressure to experiment with drugs and alcohol, have sex, be popular, figure out what to say and wear and do—the list goes on and on.

Today’s teens may have it harder than ever before. The new documentary “Bully” gives us a glimpse into what typical teens face at school every day—the content is so mature that it garnered an “R” rating, ironically prohibiting many of those who most need to see the movie from viewing it without an adult present.

In a perfect world, teens would consult their parents for advice on navigating the sometimes turbulent process of growing up. But we all know that’s not how it usually plays out. Many teens would rather avoid awkward conversations with their parents or other adults, instead turning to friends who are just as confused about the facts. The consequences of misinformation—such as teen pregnancy, substance abuse problems, or suffering in silence—are too steep.

As an ob-gyn, I remind my young patients that my door is always open if they need help working through difficult times. But, in case they’re not quite ready to have a conversation with me, their parents, or another trusted adult, there are some great online resources available:

  • www.girlsmarts.org: This website is devoted to helping teens work through tough scenarios such as meeting new friends in chat rooms; experimenting with smoking, alcohol, and drugs; and weight issues and eating disorders. Girlsmarts features polls, blog posts written by teens, and video content related to teen issues.
  • www.stopbullying.gov: The Centers for Disease Control and Prevention recently relaunched its anti-bullying website. The resources and information provided encourages teens, parents, schools, and communities to find solutions to prevent and respond to bullying and foster a safe environment for all members of the community.
  • Patient Fact Sheets: ACOG has developed a series of fact sheets for teens on a variety of topics such as body art and piercings, body image, stress and trauma, internet safety, plastic surgery, and pregnancy options. Corresponding fact sheets for parents are also available.

Share these resources with teens you know and see what happens. They just might spark a healthy conversation too important to miss.

Protecting Teen Girls from Violence

Approximately one out of every 10 high school teenage girls in the US reported experiencing physical violence from their dating partners in the previous year. This is not abstract—this could be happening to someone you know. A girl in your family or community may have recently been slapped, punched, kicked, pushed or grabbed, sexually coerced or raped, called names online, threatened, or screamed at in public—all by the person she is in an intimate relationship with.

Throughout February, ACOG and other organizations have been raising awareness as part of Teen Dating Violence Awareness Month. It’s important that we educate young girls—and women—that unsafe relationships are not only about physical violence. Those who monitor cell phone use, stalk or humiliate online, or control their partner’s wardrobe, choice of friends, or contraceptive use are abusive.

As a father and grandfather, I want to do everything in my power to make sure my children and grandchildren are safe. This feeling extends into my practice as well. As an ob-gyn, I am in a unique position to reach out to my patients, letting them know my office is a safe environment in which they can seek help. ACOG recommends that physicians screen all women for intimate partner violence at periodic intervals. Recognizing violence in a teenage girl’s relationship can be especially critical because adolescent violence can lead to intimate partner violence when she grows up.

To get help for yourself or someone you love, call the National Domestic Violence Hotline at 800-799-SAFE. Teens can also learn about healthy relationships at loveisrespect.org or get teen-specific help through the Dating Abuse Helpline at 866-331-9474.

Wrong-Headed Decision on Plan B One-Step

For a decade, ACOG has supported making emergency contraception (EC) available over the counter (OTC) without an age restriction. So it was deeply troubling and disappointing to see HHS Secretary Kathleen Sebelius overrule the US Food and Drug Administration’s decision to remove the age restriction and make Plan B® One-Step accessible to all females capable of becoming pregnant.

The argument that 11- and 12-year-olds are not capable of understanding how to use EC isn’t true, based on the data, and it misses the point. The majority of girls this young are not sexually active and do not represent the bulk of adolescents who are at risk of an unwanted pregnancy. According to the Guttmacher Institute, nearly half of all high school students in the US have had sex at least once, and 85% of adolescent pregnancies are unintended. These high school students are the adolescents who would most benefit from OTC access to EC.

The overwhelming scientific evidence shows that EC is safe for teens and women and is highly effective in preventing unintended pregnancy. Ideally, all sexually active teens and women would use effective contraception each and every time they engaged in sexual intercourse to avoid an unplanned pregnancy. But, we don’t live in a perfect world—a condom tears or you miss a pill, for instance. Rapid access to EC is especially important for women that have been raped.

EC products contain the same hormones as oral contraceptives, only in a higher dose. EC works primarily by preventing ovulation, but it can also prevent fertilization or implantation. However, timing is critical: EC is most effective when taken within 72 hours after unprotected intercourse. This is why OTC access is so important. There’s no need to wait for a doctors’ appointment to get a prescription, or to have the prescription filled.

While EC does not replace the consistent use of reliable birth control, making it available without a prescription to all provides an important safety net. For this reason, ACOG will continue to advocate for removing this unnecessary age restriction to OTC EC.

Drop in Cesareans, Teen Births, Premature Babies Welcome News

The CDC recently released preliminary 2010 data on births in the US and there’s good news. For starters, preterm births declined for the fourth straight year. Although the rate is still high, it’s clear that progress is being made in preventing premature births.

The other good news is that the cesarean delivery rate also decreased. I’d like to believe that ACOG’s concerted efforts to educate physicians and the public that there are increased risks associated with cesarean birth, as well as our efforts to encourage vaginal birth after cesarean (VBAC), has something to do with this. We’ve also educated doctors and patients about not inducing labor or scheduling a cesarean before 39 weeks of pregnancy without a pressing medical need to do so. A full term pregnancy is 40 weeks and babies need these last few weeks to gain weight and fully develop lung function.

Births to teens fell again for the third straight year, hitting a record low. Fewer teens are having sex and more of them are using contraception when they do.

This new data is encouraging, but we must keep the momentum up on driving these rates down further and in the process, improving maternal and infant health outcomes.