Adolescents' reasons for and experience after discontinuation of the long-acting contraceptives Depo-Provera and Norplant.

PURPOSE: The objectives of this study were to examine the reasons for discontinuation of the long-acting contraceptives Depo-Provera and Norplant in adolescents, and to assess the adolescents' experience after discontinuation of the methods. METHODS: A total of 35 adolescents [gynecologic age 4.7 +/- 0.3 years, and body mass index (BMI) 24.2 +/- 0.6] who discontinued Depo-Provera, and 31 adolescents (gynecologic age 3.4 +/- 0.3 years, BMI 24.1 +/- 0.9) who discontinued Norplant were periodically assessed during use of the methods and up to 12 months after discontinuation. RESULTS: The most common reasons for discontinuation of both Norplant (after 21.8 +/- 1.6 months of use) and Depo-Provera (9.2 + 0.9 months of use) were irregular menstrual bleeding (64%), weight gain (41%), and increased headaches (30%). Resumption of menstrual regularity and dysmenorrhea was noted sooner after discontinuation of Norplant, compared with Depo-Provera. The increase in BMI noted at discontinuation of Depo-Provera (1.1, P = .0005) and Norplant (1.3, P = .03) persisted up to 6 months after discontinuation of either method (0.6, P = .01 post-Depo-Provera discontinuation; and 0.9, P = 0.02 post-Norplant discontinuation). Only 62% of the adolescents reported no break in contraceptive practice. The condom was the most popular method (37%) after discontinuation of Depo-Provera, and oral contraceptive (39%) after discontinuation of Norplant. The cumulative conception proportion reached 0.93 at 12 months after discontinuation of Norplant, and was significantly higher (P = .01) compared with the cumulative proportion of conception after discontinuation of Depo-Provera (P = .50). CONCLUSIONS: Health care providers should aggressively manage physical problems associated with Depo-Provera and Norplant use, and expedite the transition to a new contraceptive method to minimize the high pregnancy rate observed after discontinuation of these methods in adolescents.

PIP: The authors present their findings from the study of adolescents' reasons for discontinuing the use of Norplant and Depo-Provera. Their experiences after method discontinuation were also assessed. 35 adolescents of mean gynecologic age 4.7 years and body mass index (BMI) 24.2 who discontinued Depo-Provera, and 31 adolescents of mean gynecologic age 3.4 years and BMI 24.1 who discontinued Norplant were periodically assessed during use of the methods and up to 12 months after discontinuation. The most common reasons for discontinuation of both Norplant and Depo-Provera after mean periods of 21.8 and 9.2 months use, respectively, were irregular menstrual bleeding (64%), weight gain (41%), and increased headaches (30%). The resumption of menstrual regularity and dysmenorrhea was noted sooner after discontinuation of Norplant, compared to Depo-Provera. The increase in BMI noted at the discontinuation of Depo-Provera persisted up to 6 months after discontinuation of either method. 62% of adolescents reported no break in contraceptive practice. The condom was the most popular method (37%) after discontinuation of Depo-Provera, and oral contraceptives (39%) after discontinuation of Norplant. The authors conclude that health care providers should aggressively manage physical problems associated with Depo-Provera and Norplant use, and expedite the transition to new contraceptive methods in an effort to minimize the high pregnancy rates observed after discontinuation of these methods in adolescents.

Experience with side effects and health risks associated with Norplant implant use in adolescents.

Levonorgestrel implants (Norplant) have been recommended as a contraceptive method for teenage women. Our experience suggests that the use of Norplant implants in adolescents is associated with bleeding irregularities and modest weight gain. There is no effect on condom use or STD acquisition. Despite the bleeding irregularities, we documented high continuation rates, suggesting that with appropriate pre-insertion counseling, Norplant implants can be a successful contraceptive method for adolescent women.

PIP: An analysis of the experiences of 72 US adolescents (mean age, 15.5 years) suggests that Norplant implants are an appropriate contraceptive method for this population. All study participants had the implants inserted at a hospital-based adolescent clinic at least 1 year before chart review. The continuation rate was 97% at 12 months and 86% at 24 months. At insertion, 60 adolescents (83%) reported regular menstrual periods. At the various follow-up intervals (e.g., 3, 6, and 12 months), 12-18% had regular periods, 12-16% were amenorrheic, and the remainder had bleeding that was irregular in length and/or interval. Mean weight gains of 3, 4.5, and 5.8 pounds were recorded at 3, 6, and 12 months, respectively; however, there was no consistent trend and a substantial number of young women lost weight during the study period. Finally, there was no clear trend of increase or decrease after Norplant insertion in either condom use or rates of infection with sexually transmitted diseases (STDs). Pre-insertion counseling for adolescent Norplant acceptors should include preparation for menstrual irregularities and encouragement of condom use to prevent STD acquisition.

The pediatrician's role in assisting teenagers to avoid the consequences of adolescent pregnancy.

There are ways in which the practicing pediatrician can help adolescent prevent pregnancy or improve the outcome of pregnancy. Clearly, each practitioner will have to decide what services will work best within his or her practice as well as for the community.

PIP: The high rate of adolescent pregnancy remains one of the world's major medical/social problems. In the US, teens most at risk are young, Black or Hispanic, and poor. Serious medical and social sequelae may follow teen pregnancy. Comprehensive prenatal care provided by staff sensitive to the needs and concerns of adolescents; nutritional assessment and support services; schools for pregnant teens; and contraceptive and abortion services, however, reduce the seriousness of these sequelae and improve the quality of life for mothers and children over the long term. 4 realistic scenarios are offered in which practicing pediatricians have opportunities to help adolescents prevent pregnancy or improve its outcome. Ultimately, however, individual practitioners must decide which services will work best in the context of their practice and community.

Screening asymptomatic adolescent males for chlamydia.

Ninety-seven asymptomatic 16-21-year-old sexually active adolescent males were evaluated for gonorrhea and chlamydia by culture, chlamydia enzyme immunoassay, and an analysis of a random urine sample for pyuria using centrifuged urine and urine cytometer. The incidence of gonorrhea was 5.3% and chlamydia by culture 12.3%. Immunoassay was superior in sensitivity and specificity (75% and 99%, respectively) to centrifuged urine (sensitivity 58%, specificity 92%) or urine cytometer (58% and 91%) in identifying asymptomatic chlamydia urethritis. Chlamydia enzyme immunoassay is an acceptable, more rapid, and less expensive alternative to culture. The absence of pyuria in asymptomatic males cannot be assumed to indicate the absence of a sexually transmitted disease.

Survey of physician fellows in adolescent medicine, 1979-1984.

A national survey of physician fellows in adolescent medicine, a sequel to the 1974-1979 survey, was conducted in 1984. Fifty-one listed programs were identified; 48 directors responded. Two hundred twelve fellows were identified (111 one-year, 101 two-year); 151 (71%) returned the questionnaire. Eighty-six percent had a pediatric residency. Current or projected professional responsibilities were 36% full-time academic, 35% mixture of academic/private practice, and 29% private practice. Forty percent were spending 75-100% of their time in adolescent medicine. Recommended changes for their fellowship included more emphasis on research (34%), more inpatient care (18%), more experience in sports medicine/orthopedics (13%), more psychosocial training (12%), and more structured education (12%). Responses as to whether the objective was fully met in each of 18 different content areas showed 60-96% satisfaction in 12 areas but only 23-34% satisfaction in six (developing a research project, participating in a critical assessment of the literature, diagnosing/managing sports medicine, developmental disability, substance abuse problems, and managing pregnancy). Significant differences (p less than 0.05 or less than 0.01) between 1979-1984 fellows compared with the 1974-1979 group included more females, two-year fellows, and fellows in private practice and less fellows in full-time academic work or spending a majority of time in adolescent medicine. These results especially indicate that there are more programs and fellows, more two-year fellows, and suggest more satisfaction with the training experience.

Office microscopic examination for sexually transmitted diseases. A tool to lower costs.

Practical information is provided in the use of four office-oriented microscopic examinations--the Gram stain, the wet mount examination, the Tzanck test, and skin scraping techniques--to screen for the maximal number of sexually transmitted organisms at the least cost. Emphasis is placed on helping the primary care provider improve her or his technique.

Rubella control--1984.

The incidence of rubella and the congenital rubella syndrome has decreased dramatically in the United States since rubella vaccine became available in 1969. A marked shift in susceptibility rate has occurred so that 70% of current rubella cases involve teenagers and young adults. The history of rubella control is reviewed. Future research as well as altered public health strategies are suggested to optimize rubella control.

Chromosomally competent ovarian failure at adolescence.

Three female adolescents are presented with delayed or incomplete secondary sexual development due to primary ovarian failure. All three patients had normal blood leukocyte and ovarian tissue karyotypes. The importance of performing a diagnostic laparoscopy with ovarian biopsy in the setting of chromosome competent ovarian failure (CCOF) is emphasized.

PIP: The cases are described of 3 female adolescents evaluated at the Cincinnati Adolescent Clinic for delayed or incomplete secondary sexual development due to primary ovarian failure. All 3 patients had normal blood leukocyte and ovarian tissue karyotypes. The clinical, laboratory, and pathological findings are discussed with emphasis on distinguishing chromosome incompetent ovarian failure (CIOF-Turner's syndrome) from chromosome competent ovarian failure (CCOF). The patients included a 15 1/2 year old black female who sought evaluation of obesity and lethargy, a 17 1/2 year old white female with secondary amenorrhea in whom oral provera failed to induce menstrual flow, and a 17 1/2 year old black female with scanty, infrequent menses who achieved a normal amount and duration of menstrual flow with Norinyl 1 + 80. Hypoestrogenization should be suspected in cases of incomplete breast development for age, thin vaginal mucosa with a prepubertal pattern of the vaginal cytology, scant cervical mucus without ferning, and lack of withdrawal bleeding after progesterone administration. If any decrease in ovarian steroid production is clinically suspected in an adolescent with primary or secondary amenorrhea associated with delayed or incomplete puberty, serum gonadotropin levels should be measured. A single elevated follicle stimulating hormone (FSH) level in the menopausal range is diagnostic of primary ovarian failure in an adolescent. If the FSH is low or normal, hypothalamic or pituitary disease would be suspected. A blood leukocyte karyotype is the next diagnostic procedure for patients with primary ovarian failure to distinguish between CCOF and CIOF. If the blood karyotype is XO or a variant without a Y cell line, no further cytogenic workup or visualization of the gonads is needed, but girls with blood karyotype of XX or a mosaic pattern with 1 cell line with a Y chromosome should undergo laparoscopy and gonadal biopsy. A unilateral testis should be removed to avoid malignant changes in later years. Patients with CCOF may have other endocrine dysfunction, particularly autoimmune disease. Other possible diagnoses include resistant ovary syndrome, pure gonadal dysgenesis, premature menopause, or infectious, chemical, or other causes of ovarian failure. The incidence of CIOF is greater than that of CCOF among patients with primary ovarian failure. Optimal treatment requires medical and psychosocial intervention.

Areolar gland discharge in adolescent females.

Two Tanner stage IV adolescent females with secretion of material from the areolar glands of the breast are described. This report, as well as previous case reports, indicates that the condition is benign in the presence of an otherwise unremarkable physical examination. In contrast to galactorrhea, which must be evaluated completely, areolar gland discharge appears to be a curiosity that may be as rare as the number of case reports would suggest. It appears to warrant nothing more than careful observation.

The epidemiology of genital colonization with Staphylococcus aureus.

The prevalence of genital colonization with Staphylococcus aureus, including strains that have been associated with toxic shock syndrome, was studied in 600 women. Nine percent of these women were colonized with S. aureus, 5% of whom had positive vaginal cultures, and 1% were colonized with toxin-producing strains. Black women were colonized with S. aureus, including toxin-producing strains, as frequently or more frequently than white women. The highest colonization rates occurred in postpartum women. Trends toward increasing colonization occurred in relation to decreasing age and socioeconomic status. There were no statistically significant relationships between genital colonization with S. aureus and the use of tampons, oral contraceptives, or a variety of other personal habits and health problems. Genital cultures taken in consecutive menstrual cycles indicated that 35% of women with S. aureus were persistent carriers, and the rest either intermittent or transient carriers. Toxin-producing S. aureus was also identified in family members of women carrying the same organism. This report defines the prevalence of genital colonization in a large population of women, characterizes the women with S. aureus, and describes epidemiologic features of genital carriage.

Chlamydia trachomatis cervical infections in female adolescents.

To determine the prevalence of Chlamydia trachomatis cervical infection in an urban adolescent population, 100 sexually active female adolescents were screened with endocervical cultures for Chlamydia, in addition to bacterial cultures, Gram stains, wet mounts, and Papanicolau smears. C. trachomatis was isolated from 22% of these patients. Neisseria gonorrhoeae was isolated from only 3% of this population. No historical or clinical features were specific to those with positive chlamydial cultures, although cervical inflammations was noted more frequently. Treatment with tetracycline or erythromycin produced bacteriologic cure in 95% of culture-positive patients.

Mental health care in an adolescent medical setting.

Two hundred sixty-four troubled adolescents referred to a medical adolescent clinic were randomly assigned to one of three therapies and to one of four conditions defined by whether treatment was delayed for 6 weeks or not, and whether or not the case was presented to a psychiatrist. Patients were assessed by parents and self-reports at intake and at 6, 12, and 24 weeks, using the Adolescent Life Assessment Check List (ALAC). This 40-item instrument yielded a total and six subscores. Patients in all treatment conditions showed improvement across time as measured by the ALAC (patient or parent). Improvement was noted for each race--sex group, for each of the four conditions, and for patients assigned to each therapist. Differences in outcome were noted for immediate vs. delay groups and for groups given psychiatric consultation. By 6 months, scores on the adolescent ALAC approximated those of a matched normative sample tested. Although successful, the program should be replicated before its findings are generalized.

Parents view their adolescents' mental health.

A 40-item behavioral checklist was devised for use with adolescent patient and nonpatient samples. A comparable form is used to obtain information about the offspring from the parent or guardian. This report presents the responses of parents and compares them with those of their offspring in two samples. Parents of disturbed adolescents reported a significantly greater frequency of emotional-behavioral problems in their offspring than did parents of a medical sample, whereas the two samples of adolescents reported equivalent frequency of problems. Parental responses to items were clustered into six subscales. Effects of race and sex of the adolescent on subscale scores were investigated. Black parents in both samples reported fewer and less frequent problems than did white parents; in contrast, the black teenagers' reports were similar to the white except for the Affective Distress subscale. Parents and adolescents in both samples reported higher scores for girls than boys on this subscale.

Survey of physician fellows in adolescent medicine.

A national survey of physician fellows in adolescent medicine from 1974 to 1979 was made. One hundred forty-six fellows were identified; 107 responded to the questionnaire. Of the 40 listed programs for 1978-1979, 29 had at least one fellow during the survey period. Eleven filled every year. Eighty-three per cent of the respondents had taken a pediatric residency, 48% were in a full-time academic or institutional program, and 56% spent 75-100% of their professional time in adolescent health care. When asked to assess whether 15 different content areas were adequately covered in their fellowships, significant content deficiencies were identified. The most frequently recommended changes were for more inpatient care (30%), opportunity to do research (25%), and more involvement with psychosocial problems (22%). Two-year fellows indicated more satisfaction with the specific content areas. More attention should be given to two-year fellowships for those physicians with serious interest in academic or institutional careers.

Experience with the copper 7 intrauterine device in an adolescent population.

A retrospective study was conducted of 120 consecutive patients who received a Cu-7 IUD at the Cincinnati Adolescent Clinic during a four-year period from July, 1974, through June, 1978. Follow-up was obtained in 116 (97%) of the initial patient population. Mean age at initial Cu-7 insertion was 16.8 years; 81% of the patients were nulliparous. An experience of 149.7 women years was accumulated; the pregnancy rate at the conclusion of the study was 2.0/100 women years. Continuation rate was 83% at six months, 70% at 12 months, 49% at 24 months, and 39% at 36 months. Patient expulsion rate was 18% overall, with a total of 17 expulsion events/100 woman years. Subjective satisfaction with the IUD as a contraceptive method was expressed by 72% of these patients. The Cu-7 has proven to be a safe, effective, well-tolerated contraceptive method in the adolescent female.

PIP: Over the July 1974 through June 1978 period a retrospective study was conducted of 120 consecutive patients between the ages of 13 and 22 years who received a copper 7 IUD at the Cincinnatti Adolescent Clinic. The patient population was 58% black and 42% white, generally urban, and predominantly from lower socioeconomic areas. At the time of the initial Cu-7 insertion, 81% of the patients were nulliparous, 16% were primiparous, and 3% multiparous. Follow-up was obtained in 116 (97%) of the initial population. At the conclusion of the study the combined duration of Cu-7 retention was 149.7 woman years. The cumulative patient continuation rate was 96/116 or 83% at 6 months, 63/90 or 70% at 12 months, 27/55 or 49% at 24 months, and 12/31 or 39% at 36 months. 3 pregnancies occured, yielding a rate of 2.0/100 woman years of IUD retention. A survey of contraceptive methods used before Cu-7 insertion showed that 47% of the patients had used oral contraception, whereas 38% had no previous contraceptive experience. Partial spontaneous expulsion of the Cu-7 was noted in 18% of the patient population, with a total of 26 expulsions or 17/100 woman years. Most side-effects reported by patients were self-limited and resolved within 2-3 months following insertion. Documented episodes of sexually transmitted disease occurred in 60/116 (51%) of the patients during the period of IUD retention. The Cu-7 was removed from 64 patients (55%) at some point during the period studied. Subjective reasons for removal predominated. Almost 2/3 of the patients chose an alternative contraceptive following IUD removal.

Social alienation-personal disorganization assessment in disturbed and normal adolescents.

Two groups of adolescents seeking psychotherapy (N = 91 and N = 198) and a normative group (N = 112) provided 5-minute verbal behavior protocols which were content analyzed for social alienation-personal disorganization (SA-PD). The data supported the hypothesis that adolescents applying for help in 1974 to 1975 showed greater pathology than those seen in 1972 to 1973. The normative adolescents were significantly healthier than either of the two Adolescent Clinic groups. In the clinic samples, older adolescents were more disturbed than those in the younger ranges. The SA-PD scale is a useful addition to tools available for the assessment of emotional states of adolescents. The data support the idea that there appears to be an increasing severity in the problems presented by adolescents in very recent years.