Teenagers and the Morning-After Pill

Now the nation’s leading pediatrics organization is encouraging doctors to also talk to teenagers about the morning-after pill — and to send girls home with prescriptions for emergency contraception, just in case.

The recommendation, announced last week by the American Academy of Pediatrics, is the latest salvo in the contentious debate over access to emergency contraception. Ever since the Food and Drug Administration approved levonorgestrel (now sold under the brand name Plan B One Step, and generically as Next Choice), advocates have pushed to make it more easily accessible.

Several medical societies, including those representing gynecologists and pediatricians, favor making emergency contraceptives available over the counter, since the drugs are supposed to be taken within five days of unprotected sex in order to be effective. In 2006, levonorgestrel was made available over-the-counter for women age 18 and older. In 2009, after a legal fight, the age was lowered to 17.

EMERGENCY CONTRACEPTION

1999 F.D.A. approves Plan B as a prescription drug for emergency contraception.

2003 Advocates apply for over-the-counter status, saying women cannot obtain a doctor’s prescription quickly when needed.

2006 The Bush administration allows over-the-counter sales to women 18 and older.

2009 The F.D.A. lowers the age limit for over-the-counter sales to 17.

2011 The F.D.A. recommends making Plan B available over-the-counter for all ages.  Kathleen Sebelius, secretary of health and human services, overrules the agency’s recommendation, saying the drug may not be safe for younger girls.

2012  The American Academy of Pediatrics encourages doctors to provide counseling and “advance emergency contraception prescriptions” to curb teenage pregnancies.                                   

The academy’s policy revision was prompted in part by new research showing that young women provided with advance prescriptions for the morning-after pill were more likely to use the drug after unprotected sex than those without a prescription, and were more likely to use it in a timely manner.

“If you’ve got a teen in the clinic, you ought to be talking to them about sexual activity, even if that’s not necessarily why they’re coming in,” said Dr. Cora Breuner, a pediatrician and a member of the academy’s committee on adolescence. “Not enough people know about emergency contraception, not even 30- and 40-year-old women.”

A recent study of college students, for example, found that only 16 percent knew that emergency contraception was available at college health centers.

Compared to years past, American teenagers have actually been postponing sexual activity. The average age of initiation is 17; by age 19, about 70 percent of teenagers are sexually active. Still, though teenage childbearing rates have dropped sharply in the last 50 years, the teenage birthrate in America is one of the highest in the developed world, according to the Centers for Disease Control and Prevention.

Many teenagers use condoms for birth control, but while they also protect against sexually transmitted diseases, they may break or slip. Teenagers may forget a birth control pill on occasion, and a significant number of young girls are sexually assaulted.

Just last month, the American College of Obstetricians and Gynecologists also called for making oral contraceptives available without a prescription; it recently endorsed teenage use of long-acting reversible birth control methods, like intrauterine devices and implants. In some states, a parent’s permission may be needed for a doctor to prescribe emergency contraceptives to a minor.

Emergency contraceptives prevent fertilization of an egg by delaying or inhibiting ovulation and thickening cervical mucus, obstructing the progress of sperm. Though some critics have suggested these are abortion pills, in fact they are distinct drugs with different modes of action.

Curiously, however, no studies have found significantly lower pregnancy rates among young women who received advance emergency contraceptive prescriptions.

Some of the studies may have been too small to detect a statistically significant reduction, said Catherine L. Haggerty, an associate professor of reproductive epidemiology at the University of Pittsburgh and one of the authors of a recent review of the literature.

One 2006 study found that even when young women have emergency contraceptives on hand, many didn’t use them.

Emergency contraception may also be less effective than believed, according to an updated review of studies published last year. Researchers often depend on study subjects to estimate their pregnancy risk at the time of unprotected sex themselves, but many do not accurately date their menstrual cycles, skewing the results, the review noted.

Plan B One Step and Next Choice are effective in at least half of the instances they are used, according to the review. But some studies have found that the drugs are just as effective two to four days after unprotected sex as they are when taken the morning after.

Objections to increasing availability come from many quarters. Advocates of abstinence education say doctors should encourage teenagers to delay sexual activity.

“Why not write a policy that encourages physicians to use their influence to guide teens to avoid all the risks related to sex?” said Valerie Huber, president of the National Abstinence Education Association.

John B. Jemmott III, a professor at the University of Pennsylvania who developed an abstinence-only sex education program, said, “The problem is that this doesn’t do anything about sexually transmitted diseases and H.I.V.” If teenagers have sex, “we want them using condoms.”

Researchers have found that having a prescription for emergency contraception does not lead to more risky sexual behavior among young women. But many of those studies included few girls younger than 18.

Two studies that did include younger girls — a 2000 report that included many high-risk adolescent girls in San Francisco and a 2005 study of teenage mothers — found that those given advance prescriptions said they had been more careless about birth control and more likely to have had unprotected sex.

Dr. Elizabeth Miller, at Children’s Hospital of Pittsburgh of UPMC, said she routinely provides teenagers with an advance prescription for emergency contraceptives, but she takes her cues from the patient and does not force a prescription on anyone.

She said she recently saw a 16-year-old girl who told her that she planned to wait until marriage to have sex, but was confused about her nascent sexual feelings. “We had a wonderful conversation about emerging sexual drive and about masturbation and orgasm, and I absolutely supported her wanting to wait to be intimate with someone until after marriage,” Dr. Miller recalled.

At the same time, she emphasized that the morning-after pill could also be used after contraception failure, or after sexual assault.

To those who worry that talking about sex and contraception with youngsters is tantamount to condoning sexual activity, advocates say research shows the opposite.

“Good information, in fact, has a protective effect,” said Sarah Brown, of the nonprofit National Campaign to Prevent Teen and Unplanned Pregnancy. “What we’ve learned from good research is that talking about these issues helps young people have a plan, understand it, and know what they would do.”

Robert A. Hatcher MD, MPH

Professor of Gynecology and Obstetrics

Emory University School of Medicine

Atlanta, GA

December 5, 2012