Depot medroxyprogesterone acetate or oral contraception in postpartum adolescents.

OBJECTIVE: To compare rates of method continuation and repeat pregnancy among postpartum adolescents selecting depot medroxyprogesterone acetate or oral contraceptives (OCs). METHODS: A retrospective study of 161 adolescents aged 19 years and younger who gave birth at an urban teaching hospital between May 1, 1994, and April 30, 1995, returned to the hospital's family planning clinic within 14 weeks of delivery and chose depot medroxyprogesterone acetate (n=111, 69%), or OC (n=50, 31%) as their postpartum contraceptive method. Most subjects were black (99%), single (97%), and on medical assistance (85%). Data were gathered 12-18 months postpartum (mean+/-standard deviation [SD] 14.5+/-1.6 months) by telephone interview and medical record review. The main outcome measures were method continuation and repeat pregnancy. RESULTS: The mean (+/-SD) age at delivery was 17.8+/-1.4 years. Variables differentiating subjects selecting depot medroxyprogesterone acetate or OC included multiparity (34% versus 12%, P < .05), mean age at first pregnancy (15.9 versus 16.6 years, P < .05), and mean age at first delivery (16.1 versus 16.9 years, P < .05). The survival curves for depot medroxyprogesterone acetate and OC continuation differed significantly (median duration of use 8.1 versus 5.4 months, respectively), but the continuation rates at 12 months were similar (34% versus 32%). The survival curves for repeat pregnancy among subjects selecting depot medroxyprogesterone acetate differed significantly from curves of those choosing OC, with repeat pregnancy rates of 15% and 36% by 15 months. Postpartum selection of OC was the only variable entering a Cox regression model designed to predict repeat pregnancy (relative risk 3.0, 95% confidence interval 1.4, 6.7). CONCLUSION: Adolescent mothers choosing depot medroxyprogesterone acetate or OC immediately postpartum face similarly high rates of method discontinuation and repeat pregnancy within 1 year.

Recognition of tubo-ovarian abscess in adolescents with pelvic inflammatory disease.

PURPOSE: Ultrasonography of the pelvis is commonly used to diagnose tubo-ovarian abscess (TOA) in patients with pelvic inflammatory disease (PID). Our objective was to determine whether the clinical features of PID differ in adolescents with and without TOA. METHODS: A retrospective design was used to derive and validate a clinical model differentiating adolescents with PID who did and did not have TOA. The study population consisted of hospitalized adolescents with a discharge diagnosis of PID. Of the 208 patients discharged from January 1, 1990, to July 31, 1993, 87 (42%) met published criteria for PID and comprised the derivation set. Of the 63 patients from August 1, 1993, to June 24, 1994, 30 (48%) met criteria and comprised the validation set. All patients had pelvic ultrasonography performed during hospitalization. The ultrasonography records were reviewed retrospectively for TOA, ovarian and uterine size, clarity of tissue planes, and endometrial or cul-de-sac fluid. Medical records were reviewed for sociodemographic characteristics, medical and sexual history, physical examination, laboratory results, and hospital course. RESULTS: TOA was present in 17% of the derivation set and 20% of the validation set. A six-variable model developed on the derivation set performed best in differentiating the TOA and non-TOA groups: last menstrual period > 18 days prior to admission (60% and 17%), previous PID (53% and 22%), palpable adnexal mass (13% and 3%), white blood cell count > or = 10,500/microliters (33% and 64%), erythrocyte sedimentation rate > 15 mm/h (33% and 64%), and heart rate > 90/min (40% and 78%). In the derivation and validation sets, the model correctly identified 78 and 83% of the TOA groups and 88 and 77% of the non-TOA groups. The area under the receiver operating characteristic curve of the model was 0.92 in the derivation set and 0.87 in the validation set. CONCLUSIONS: We conclude that clinical characteristics help identify adolescents with acute PID who have TOA. These patients may have fewer signs of acute illness than those without TOA and may develop symptoms later in the menstrual cycle.

Adolescents' perceptions of factors affecting their decisions to seek health care.

OBJECTIVE: To have adolescents, rather than adults, identify characteristics of health care providers and sites that affect their decision to seek care. DESIGN: Five stages conducted over a 10-month period: (1) focus groups to frame the study questions; (2) nominal group technique to generate student responses; (3) three surveys to assess response importance; (4) one survey to link the most important responses with the decision to seek care; and (5) focus groups to explain the variables associated with the decision to seek care. SETTING: The Philadelphia (Pa) School District. PARTICIPANTS: The study population consisted of all ninth graders from 39 of Philadelphia's 42 public high schools. The 6821 students who returned the final survey comprised the study sample (69% of in-school youth). RESULTS: In the final survey, students used a Likert scale (1 to 5) to describe the impact of 31 ideas on their decision to seek care. The most important characteristics were provider hand washing, clean instruments, honesty, respect toward teens, cleanliness, know-how, carefulness, experience, seronegativity for the human immunodeficiency virus, equal treatment of all patients, and confidentiality. There was little variation in the order of the items by sex, race, or socioeconomic status. Factor analysis showed that the most important of four identified latent factors related to infection control and provider competency. CONCLUSION: Four of the top 10 characteristics that affect an adolescent's decision to seek care involve cleanliness and infection control. These findings offer providers and planners straightforward, modifiable factors that teens believe influence their decision to seek care.

Adolescent suicide attempters: do physicians recognize them?

The single most important risk factor for adolescent suicide is a previous attempt. It is unclear if physicians can identify adolescents who have attempted suicide. Our objectives were to determine the prevalence of previous attempts in an adolescent clinic population, if physicians identify attempters, and if attempters demonstrate persistent distress. Of 332 patients aged 12-19 years attending a medical clinic, 48 (14.5%) reported a previous attempt. The physician's visit note documented that only 8 (16.7%) of the 48 attempters were asked about suicidal behavior. Attempters were more likely than nonattempters (p less than 0.05) to be female; to come to clinic without a guardian; to give a chief complaint pertaining to sexually transmitted disease, obstetrics-gynecology, or mental health; and to report previous mental health care. Attempters had poorer mean scores (p less than 0.05) on validated subscales for family relationships, social competence, depression, unpopularity, somatic complaints, thought disorders, delinquency, aggression, and identity. We conclude that suicide attempts are common among adolescent clinic patients, that physicians may not recognize attempters, and that attempters remain distressed and in need of care. Physicians who see adolescents for routine medical problems must consider the potential for self-destructive behavior, regardless of the presenting complaint.

A human immunodeficiency virus peer education program for adolescent females.

Black adolescent females living in urban environments are at high risk for human immunodeficiency virus (HIV) infection. Our objectives were to develop an HIV peer education program and to pilot-test its effect on knowledge and sexual behavior. Between September 1989 and March 1990, all females aged 12-19 years attending an inner-city, hospital-based adolescent clinic were invited to meet individually with trained peer educators (10 females aged 16-19 years) to discuss acquired immunodeficiency syndrome (AIDS) and its prevention. Each participant completed a modified version of the AIDS Knowledge and Attitudes Survey immediately before and 2-6 weeks after the counseling session. Of the 283 counseled patients, 241 (85%) completed the follow-up questionnaire and comprised the study sample. Mean age was 15.6 years, mean Hollingshead (parental occupational) score was 3.4, and 216 (90%) patients were black. Baseline knowledge about routes of transmission was high and did not improve on follow-up. Comparison of individual baseline and follow-up responses revealed improvements (p less than 0.05) in routes by which HIV is not transmitted, methods of prevention, individuals at risk, and general information about AIDS. The improvement in total score between baseline and follow-up was 38% for patients with low baseline scores, 13% for middle scores, and 3% for high scores (p less than 0.05). At baseline, 50 (21%) patients reported sexual intercourse within the preceding 2 weeks, compared to 33 (14%) at follow-up (p less than 0.05). Of the sexually active patients, 22 (44%) reported no condom use at baseline, compared to 11 (33%) at follow-up (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)