Screening and brief intervention with adolescents with risky alcohol use in school-based health centers: A randomized clinical trial of the Check Yourself tool

Background: This study aimed to compare care delivery and alcohol and marijuana use for adolescents with risky alcohol use who received a school-based health center (SBHC) visit with and without the Check Yourself tool, an electronic tool that gives motivational feedback on substance use and summarizes results for providers. Methods: We conducted a randomized controlled trial with 148 adolescents aged 13-18 who met criteria for moderate- to high- risk alcohol use, recruited from urban SBHCs. Participants were randomized to receive their SBHC visit with (n = 73) or without (n = 75) the Check Yourself screening and feedback tool. All SBHC providers received a brief training on motivational interviewing. Results: Adolescents who received the Check Yourself tool + SBHC visit reported higher levels of alcohol (67%) and marijuana (73%) counseling from the provider during their visit, compared with those who received a SBHC visit without the tool (40% and 45%, respectively, Ps < .005), and had higher motivation to decrease marijuana use relative to those who did not (P = .02). Relative to baseline, adolescents in both groups reduced their typical number of drinks of alcohol, maximum number of drinks of alcohol, and hours high on marijuana over time (Ps < .02) at 2-month follow-up. Conclusion: When adolescent patients are given an electronic screening and feedback tool, it can prompt providers to increase counseling of adolescents with substance use risk. Overall, participants who had a visit with a trained provider reported high satisfaction with care and decreased the amount of alcohol use over 2 months, suggesting that SBHCs are an excellent venue for delivery of brief substance use interventions.

Reviewing Manuscripts: A Systematic Approach

Peer-review of manuscripts submitted for publication in a scholarly journal is a cornerstone of the scientific process. Most scholars receive little or no training on how to conduct this key component of academic citizenship. This article provides guidance on a systematic approach to performing peer-review.

Video Intervention to Increase Perceived Self-Efficacy for Condom Use in a Randomized Controlled Trial of Female Adolescents

STUDY OBJECTIVE

To assess the effects of the Seventeen Days interactive video on young women's perceived self-efficacy for using condoms 6 months after being offered the intervention, relative to a control.

DESIGN

Multisite randomized controlled trial.

SETTING

Twenty participating health clinics and county health departments in Ohio, Pennsylvania, and West Virginia.

PARTICIPANTS

Sexually active female adolescents ages 14 to 19 years.

INTERVENTIONS

Seventeen Days (treatment intervention; sex education) vs Driving Skills for Life (control intervention; driving education).

MAIN OUTCOME MEASURES

Perceived self-efficacy for condom use.

RESULTS

Participants in the Seventeen Days group reported higher perceived condom acquisition self-efficacy after 6 months than those in the driving group. This finding held after controlling for baseline self-efficacy scores and other covariates.

CONCLUSION

The Seventeen Days program shows promise to improve perceived self-efficacy to acquire condoms among sexually active female adolescents-an important precursor to behavior change.

Contraceptive counseling among pediatric primary care providers in Western Pennsylvania: A survey-based study

OBJECTIVES

Data suggest that adolescents in the United States receive inadequate contraceptive counseling. This study sought to determine factors affecting pediatricians' discussion of contraception with adolescent patients, with a specific focus on long-acting reversible contraception-implantable contraception and intrauterine devices.

METHODS

A cross-sectional survey was sent via email to a convenience sample of pediatric residents and pediatric primary care providers in Western Pennsylvania. Self-reported contraceptive counseling and prescribing practices in response to clinical vignettes were assessed.

RESULTS

Of potential participants (287), 88 (31%) responded. Younger providers and providers who had received contraceptive training were significantly more likely to discuss long-acting reversible contraception methods. Discussion of contraceptive methods also varied by both the age and the sexual history of the patient.

CONCLUSION

Variation in contraceptive counseling potentially results in missed opportunities to counsel about and provide the most effective contraceptive methods. More uniform, universal provider training might alleviate some of these inconsistencies.

2016 Updates to US Medical Eligibility Criteria for Contraceptive Use and Selected Practice Recommendations for Contraceptive Use: Highlights for Adolescent Patients

The US Medical Eligibility Criteria for Contraceptive Use (MEC) and US Selected Practice Recommendations for Contraceptive Use (SPR) provide evidence-based guidance to safely provide contraception counseling and services. Both documents were updated in 2016 and are endorsed by the North American Society for Pediatric and Adolescent Gynecology. The purpose of this mini-review is to highlight updates to the US MEC and US SPR that are most relevant to health care providers of adolescents to support dissemination and implementation of these evidence-based best practices. This document is intended to highlight these changes and to complement, not replace, the detailed practice guidance within the US MEC and US SPR.

Barriers to Long-Acting Reversible Contraceptive Uptake Among Homeless Young Women

STUDY OBJECTIVE

To identify barriers to long-acting reversible contraception (LARC) uptake among homeless young women.

DESIGN

In this mixed methods study surveys and guided interviews were used to explore women's contraceptive and reproductive experiences, interactions with the health care system, and their histories of homelessness.

SETTING

All surveys and interviews were conducted at a homeless drop-in center or shelter.

PARTICIPANTS

Fifteen women between 18 and 24 years of age with a past year history of homelessness.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Perceived barriers to contraceptive use, including knowledge and access barriers and interactions with the health care system around reproductive health.

RESULTS

Confusion about the possibility of early termination of LARC, and the perception that providers deliberately withhold selective information about contraceptive options to bias contraceptive decision-making, were 2 key new findings. Women also reported interest in visual aids accompanying verbal contraceptive counseling. Pregnancy attitudes and history of reproductive and sexual coercion also influenced contraceptive decision-making and reported interest in LARC methods.

CONCLUSION

Comprehensive counseling about all contraceptive options, including LARC, are important for targeting the perceived gaps in contraceptive education and care among homeless young women.

Racial and/or Ethnic Differences in Formal Sex Education and Sex Education by Parents among Young Women in the United States

STUDY OBJECTIVE

We sought to investigate the associations between race and/or ethnicity and young women's formal sex education and sex education by parents.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis of a nationally representative sample of 1768 women aged 15-24 years who participated in the 2011-2013 National Survey of Family Growth.

INTERVENTIONS AND MAIN OUTCOME MEASURES

We assessed 6 main outcomes: participants' report of: (1) any formal sex education; (2) formal contraceptive education; (3) formal sexually transmitted infection (STI) education; (4) any sex education by parents; (5) contraceptive education by parents; and (6) STI education by parents. The primary independent variable was self-reported race and/or ethnicity.

RESULTS

Nearly all of participants (95%) reported any formal sex education, 68% reported formal contraceptive education, and 92% reported formal STI education. Seventy-five percent of participants reported not having any sex education by parents and only 61% and 56% reported contraceptive and STI education by parents, respectively. US-born Hispanic women were more likely than white women to report STI education by parents (adjusted odds ratio = 1.87; 95% confidence interval, 1.17-2.99). No other significant racial and/or ethnic differences in sex education were found.

CONCLUSION

There are few racial and/or ethnic differences in formal sex education and sex education by parents among young women.

Parents' Role in Adolescent Depression Care: Primary Care Provider Perspectives

OBJECTIVE

To understand how primary care providers (PCPs) perceive barriers to adolescent depression care to inform strategies to increase treatment engagement.

STUDY DESIGN

We conducted semistructured interviews with 15 PCPs recruited from community pediatric offices with access to integrated behavioral health services (ie, low system-level barriers to care) who participated in a larger study on treating adolescent depression. Interviews addressed PCP perceptions of barriers to adolescents' uptake of care for depression. Interviews were audiorecorded, transcribed, and coded for key themes.

RESULTS

Although PCPs mentioned several adolescent barriers to care, they thought parents played a critical role in assisting adolescents in accessing mental health services. Important aspects of the parental role in accessing treatment included transportation, financial support, and social support. PCPs perceived that parental unwillingness to accept the depression diagnosis, family dysfunction, and trauma were common barriers. PCPs contrasted this with examples of good family support they believed would enable adolescents to attend follow-up appointments and have a "life coach" at home to help monitor for side effects and watch for increased suicidality when starting antidepressants.

CONCLUSIONS

In this PCP population, which had enhanced access to mental health specialists, PCPs primarily reported attitudinal barriers to adolescent depression treatment, focusing mainly on perceived parent barriers. The results of these qualitative interviews provide a framework for understanding PCP perceptions of parental barriers to care, identifying that addressing complex parental barriers to care may be important for future interventions.

Racial and ethnic differences in young men's sex and contraceptive education

PURPOSE

Racial/ethnic disparities exist in young men's contraceptive knowledge. This study examines whether the likelihood of receiving sexual health education varies by race/ethnicity.

METHODS

We examined racial/ethnic differences in sex and contraceptive education both in school and from parents with multivariable logistic regression models among 4,104 men aged 15-24 years using data from the 2006-2010 National Survey of Family Growth.

RESULTS

Nearly all respondents (96.6%) reported formal sex education. Fewer reported formal birth control education (66.6%), parental sex discussions (66.8%), and parental discussions specifically about birth control (49.2%). In multivariable analysis, black men were less likely than white men to report receiving formal contraceptive education (adjusted odds ratio [aOR], .70; 95% CI, .51-.96). Both black and U.S.-born Hispanic men reported more parental sex discussions than white men (aOR, 1.44; 95% CI, 1.07-1.94, aOR, 1.47; 95% CI, 1.09-1.99, respectively).

CONCLUSIONS

Nearly all respondents reported having received formal sexual health education. Fewer reported receiving education about birth control either at school or at home. Black men were less likely to report receiving formal contraceptive education.

Contraception for adolescents

A working knowledge of contraception will assist the pediatrician in both sexual health promotion as well as treatment of common adolescent gynecologic problems. Best practices in adolescent anticipatory guidance and screening include a sexual health history, screening for pregnancy and sexually transmitted infections, counseling, and if indicated, providing access to contraceptives. Pediatricians' long-term relationships with adolescents and families allow them to help promote healthy sexual decision-making, including abstinence and contraceptive use. Additionally, medical indications for contraception, such as acne, dysmenorrhea, and heavy menstrual bleeding, are frequently uncovered during adolescent visits. This technical report provides an evidence base for the accompanying policy statement and addresses key aspects of adolescent contraceptive use, including the following: (1) sexual history taking, confidentiality, and counseling; (2) adolescent data on the use and side effects of newer contraceptive methods; (3) new data on older contraceptive methods; and (4) evidence supporting the use of contraceptives in adolescent patients with complex medical conditions.

Frequency of Chlamydia trachomatis-specific T cell interferon-γ and interleukin-17 responses in CD4-enriched peripheral blood mononuclear cells of sexually active adolescent females

An evaluation of CD4 T cell responses to candidate Chlamydia trachomatis vaccine antigens was conducted in an adolescent female cohort exposed through natural infection to explore antigen immunogenicity and correlation with protection from reinfection. The frequency of peripheral blood CD4 T cell IFN-γ and IL-17 responses to three candidate vaccine antigens, polymorphic membrane protein G (PmpG), F (PmpF), and major outer membrane protein (MOMP), were determined by ELISPOT; responses to chlamydial heat shock protein 60 (HSP60) and to elementary bodies (EB) were included for comparison. Responses of Infected (n=8), Seropositive/Uninfected (n=13), and Seronegative/Uninfected (n=18) participants were compared. The median CD4 IFN-γ response to EB was significantly increased in Infected (P=0.003) and Seropositive/Uninfected (P=0.002) versus Seronegative/Uninfected female subjects. Higher rates of positive IFN-γ responders to EB, PmpF, and MOMP were detected in Seropositive/Uninfected versus Seronegative/Uninfected participants (P=0.021). IL-17 responses were generally low. A positive IFN-γ response to any of the antigens tested was associated with a trend toward a reduced risk of reinfection, although not statistically significant. Among this adolescent cohort, chlamydial-specific CD4 IFN-γ but not IL-17 responses were detected in acutely and previously infected participants and a positive CD4 IFN-γ response was associated with a non-significant reduced risk of reinfection.

Mental health and substance use disparities among urban adolescent lesbian and bisexual girls

BACKGROUND

Sexual minority girls (SMGs) report large substance use disparities and victimization experiences, yet there is a dearth of research that focuses exclusively on SMGs.

OBJECTIVE

To examine substance use and mental health disparities among SMGs and to determine whether disparities were larger for African American compared with European American girls.

METHOD

Data were used from Wave 11 of the Pittsburgh Girls Study, a multiple-cohort, prospective study of urban girls. Girls for the current analysis were aged 16 to 19 years. Fifty-five percent were African American. One hundred and seventy-three (8.3%) identified as SMGs, and 1,891 identified as heterosexual. Multiple regression analyses controlling for age, race, and parent education were conducted.

RESULTS

SMGs reported a robust pattern of large disparities in externalizing, internalizing, and borderline personality disorder symptoms. There was little evidence to suggest disparities were moderated by race.

CONCLUSION

SMGs and their families would benefit from intervention and prevention programs to reduce disparities among this highly vulnerable population.

Cross-sectional evidence for a stress-negative affect pathway to substance use among sexual minority girls

Sexual minority girls (SMGs) are four times more likely to engage in substance use than are heterosexual girls. A better understanding of the explanatory mechanisms of this disparity is needed to inform prevention and intervention programs. The goal of this study was to conduct a preliminary test of a "stress-negative affect" pathway by examining gay-related victimization and depression as mediators of substance use among SMGs. Adolescent girls (N = 156, 41% SMGs) were recruited from two urban adolescent medicine clinics to participate in an NIH-funded study of adolescent substance use. The average age was 17.0 years old and 57% were nonwhite. Mediation analyses were conducted in a multiple regression framework using SPSS and a mediation macro utilizing bias-corrected bootstrapping. Four models were estimated to test mediated pathways from sexual orientation to gay-related victimization (Mediator 1), to depression symptoms (Mediator 2), and then to each of four substance use variables: cigarettes, marijuana, alcohol, and heavy alcohol use. Significant mediated pathways (mediation tests with 95% CIs) were found for cigarette, alcohol and heavy alcohol use outcome variables. Results provide preliminary support for the minority stress hypothesis and the stress-negative affect pathway, and may inform the development of future prevention and intervention programs.

Sexual minority-related victimization as a mediator of mental health disparities in sexual minority youth: a longitudinal analysis

Sexual minority youth (youth who are attracted to the same sex or endorse a gay/lesbian/bisexual identity) report significantly higher rates of depression and suicidality than heterosexual youth. The minority stress hypothesis contends that the stigma and discrimination experienced by sexual minority youth create a hostile social environment that can lead to chronic stress and mental health problems. The present study used longitudinal mediation models to directly test sexual minority-specific victimization as a potential explanatory mechanism of the mental health disparities of sexual minority youth. One hundred ninety-seven adolescents (14-19 years old; 70 % female; 29 % sexual minority) completed measures of sexual minority-specific victimization, depressive symptoms, and suicidality at two time points 6 months apart. Compared to heterosexual youth, sexual minority youth reported higher levels of sexual minority-specific victimization, depressive symptoms, and suicidality. Sexual minority-specific victimization significantly mediated the effect of sexual minority status on depressive symptoms and suicidality. The results support the minority stress hypothesis that targeted harassment and victimization are partly responsible for the higher levels of depressive symptoms and suicidality found in sexual minority youth. This research lends support to public policy initiatives that reduce bullying and hate crimes because reducing victimization can have a significant impact on the health and well-being of sexual minority youth.

The management of menstrual suppression and uterine bleeding: a survey of current practices in the Pediatric Blood and Marrow Transplant Consortium

BACKGROUND

Current guidelines recommend the use of combined hormonal contraceptive pills for menstrual suppression in pediatric blood and marrow transplant (BMT) recipients but recent research reveals that provider practice varies. This study was designed to describe the current practice for managing menstrual issues, that is, menstrual suppression and uterine bleeding, in pediatric BMT patients and to better understand health care providers' practices in the use of gonadotropin-releasing hormone agonists (GnRHa).

PROCEDURE

A cross sectional survey consisting of 53 questions was distributed via email to principal investigators in the Pediatric Blood and Marrow Transplant Consortium (PBMTC). Responses were collected using www.surveymonkey.com.

RESULTS

Menstrual suppression and uterine bleeding in pediatric BMT patients are primarily managed by pediatric oncologists (97%). The most frequently reported hormonal method used for induction of therapeutic amenorrhea was GnRHa (41%). The top three reasons for choosing a method were greater likelihood of amenorrhea, concerns about side effects, and possible gonadal protection. Continuous combined hormonal contraceptive pills were the most commonly used method for the management of clinically significant uterine bleeding regardless of primary method used for menstrual suppression.

CONCLUSION

Despite the 2002 PBMTC guidelines, wide variation in menstrual suppression management practices still exists. Our data show that use of GnRHa is more common than previously reported. Additional research is needed to develop evidence-based practice guidelines in pediatric BMT patients.

Rett syndrome and menstruation

OBJECTIVE

Describe the experience that girls with Rett syndrome have with menstruation including menstrual hygiene, dysmenorrhea, premenstrual syndrome (PMS), and attempts at treatment.

DESIGN

Anonymous web-based survey.

SETTING

Convenience sample recruited from Rett syndrome LISTSERV in July of 2009.

PARTICIPANTS

Mothers of girls with Rett syndrome between the ages of 10-25 who have had at least one menses.

MAIN OUTCOME MEASURES

Prevalence, frequency, and severity of dysmenorrhea and PMS; hygiene concerns; and treatments attempts and perceived effectiveness.

RESULTS

Dysmenorrhea and PMS are common problems among young women with Rett syndrome. Despite their frequency and severity they do not routinely limit activities. Multiple treatment attempts are common. Hormonal contraception is used mostly for menstrual cycle control with oral contraceptive pills the most commonly used method.

CONCLUSIONS

Young women with Rett syndrome have standard symptoms of dysmenorrhea and PMS as well as autism spectrum specific PMS symptoms. Hormonal contraception is commonly used for menstrual management.

Transdermal contraception as a model for adolescent use of new methods

PURPOSE

To examine the factors related to adolescents' decisions to use the transdermal contraceptive patch (patch) so as to develop a model for understanding how adolescents decide to use new contraceptive methods.

METHODS

We conducted in-depth semi-structured interviews with 18 young women aged 15-21 years who had experience using the patch. Data were analyzed using a two-stage method informed by grounded theory.

RESULTS

We constructed a two-level model, encompassing individual, social, and environmental factors, to explain adolescents' decisions to use a new method of hormonal contraception. Social and environmental influences on the decision-making process included media, social network experiences and opinions, healthcare providers, and partner relationships. These in turn affected the following individual factors in the decision to use the patch: individual characteristics, method knowledge and beliefs, method support, and past contraceptive experience. The newness of the patch permeated all levels of the decision-making process.

CONCLUSIONS

This model provides a framework for understanding the use of new contraceptive methods and can inform clinical strategies for contraceptive counseling with adolescents.

Adolescents' experiences using the contraceptive patch versus pills

STUDY OBJECTIVE

To compare use of the weekly transdermal contraceptive patch (patch) with daily combined hormonal contraceptive pills (pills) in adolescents.

DESIGN

Prospective longitudinal study of adolescents' self-selected (non-randomized) use of the patch or pills.

SETTING

Urban, university hospital-affiliated, adolescent outpatient clinic.

PARTICIPANTS

13-22-year-old female adolescents seeking hormonal contraception, 40 who chose the patch and 40 who chose pills.

INTERVENTIONS

Data were collected via self-report on paper questionnaires at three-cycle intervals for a total of up to nine cycles.

MAIN OUTCOME MEASURES

Method continuation, perfect use, method satisfaction, quality of life, and side effects, including menstrual changes and perceived mood changes.

RESULTS

After nine cycles, 38% of patch users and 60% of pill users were still using the method they had chosen at enrollment. There were no significant differences between the groups in self-reported perfect use. No differences were found in quality of life or side effects. Both patch and pill users noted menses became lighter and more predictable and reported decreased depression prior to their menses; only the pill group reported improvement in premenstrual anger. Method satisfaction was similar in both groups except patch users were more likely to report that their contraceptive method improved normal daily activities.

CONCLUSIONS

Despite apparent advantages of the patch over the pill, adolescents using both methods continue to face challenges achieving perfect and sustained contraceptive use.

Eliminating monthly periods with combined hormonal contraception

Combined hormonal contraceptives have been increasingly marketed and prescribed in extended regimens to manage menstrual-cycle-related complaints and accommodate patients' preferences. Extended regimens provide less frequent menstruation and may confer better ovarian follicular suppression and, thus, more effective pregnancy prevention. Most healthcare providers prescribe extended regimens and believe that menstrual suppression is safe; many women, when given the choice, would prefer to menstruate less frequently. However, most women will experience breakthrough bleeding, which may limit patient acceptance of an extended regimen. Recent studies have addressed strategies for minimizing unscheduled bleeding, but further research is needed to identify how best to tailor regimens to the medical needs and preferences of individual women.

Extended cycling of combined hormonal contraceptives in adolescents: physician views and prescribing practices

PURPOSE

We sought to determine the practices of physicians who prescribe for adolescents extended cycles of combined hormonal contraception, in which hormones are taken for longer than 21 days and menstruation is delayed.

METHODS

Five hundred physicians from the membership rosters of the Society for Adolescent Medicine and the North American Society for Pediatric and Adolescent Gynecology were asked to complete an online 39-question survey.

RESULTS

The 222 respondents (44% of those contacted) were mostly pediatricians (55%) and gynecologists (34%). Ninety percent reported having ever prescribed extended cycles of hormonal contraception to adolescents, and 33% said extended cycles make up more than 10% of their total combined hormonal contraceptive prescriptions. Respondents most commonly prescribed extended cycles to accommodate patients' requests to induce amenorrhea for specific events (82%) or for fewer menses per year (72%), and to treat menorrhagia (68%), dysmenorrhea (65%), and endometriosis (62%). The most commonly prescribed extended regimen was 84 continuous hormone days followed by 7 hormone-free days (46%), most often with an oral contraceptive containing 30 mug of ethinyl estradiol. Gynecologists were more likely than other physicians to prescribe extended cycles frequently, to prescribe hormone-free intervals shorter than 7 days, and to prescribe continuous regimens that eliminate the hormone-free interval completely.

CONCLUSIONS

Physicians prescribe extended cycles of combined hormonal contraceptives to adolescents to accommodate patient requests and to treat common gynecologic conditions. Currently, a variety of extended cycling regimens are prescribed, suggesting that further study is needed to determine the optimal regimen for this subset of patients and their individual needs.

Developmental and reproductive health issues in adolescent solid organ transplant recipients

The improved survival of pediatric recipients of solid organ transplants has prompted increased attention to quality of life issues. In adolescents these include attainment of normal growth and development, and involvement in romantic and sexual relationships. This review focuses on the reproductive health care needs of adolescent solid organ transplant recipients, including issues related to puberty, menstruation, and fertility. Contraceptive options, and the implications of their use by transplant recipients, are described. With close clinical follow up, most currently available hormonal contraceptive methods can be considered, and the impact of drug interactions with immunosuppressants can be minimized by eliminating hormone-free intervals. Monitoring for sexually transmitted infections, including oncogenic Human Papilloma Virus and its sequelae, is especially important for transplant recipients. Comprehensive reproductive health care visits are recommended for all sexually active adolescent solid organ transplant recipients.

Extended cycle hormonal contraception in adolescents

PURPOSE OF REVIEW

There is increasing interest in the use of extended cycles of hormonal contraception to manage menstrual cycle-related complaints in adolescents and to accommodate the menstrual preferences of patients using hormonal contraception. This review summarizes recent findings related to the use of extended cycles and highlights their relevance to adolescents.

RECENT FINDINGS

Many adolescents would prefer to menstruate less frequently. Among health care providers who prescribe hormonal contraceptives, the majority believe suppressing withdrawal bleeding is well tolerated and prescribe extended cycling regimens to their patients. Shortening or eliminating the hormone-free interval results in greater ovarian suppression and thus may increase contraceptive efficacy. Studies in adult women have not identified changes in metabolic parameters beyond what would be expected from traditional cyclic use. New endometrial biopsy data have found no pathologic changes; most women using an extended cycle had atrophic endometriums. Extended cycling is frequently associated with breakthrough bleeding. In some women, this can be managed with a brief hormone-free interval.

SUMMARY

Recent findings demonstrate high levels of interest in extended cycling among adolescents and providers, and continue to add to the growing body of literature supporting the safety and improved contraceptive efficacy of extended regimens. Further research is warranted to focus on issues including cancer, thrombotic disease and fertility, and should enroll a sufficient adolescent sample.

Gynecologic health care for the adolescent solid organ transplant recipient

The improved survival of pediatric recipients of solid organ transplants has prompted increased attention to quality of life issues. These include attainment of normal growth, involvement in romantic relationships, and the desire to control fertility. As an increasing number of adolescent transplant recipients are involved in normal social and sexual relationships, they require careful attention to their gynecologic and reproductive health care needs. Anticipating the onset of sexual activity before it occurs may help to prevent a mistimed pregnancy by providing or prescribing condoms and emergency contraception in advance. In addition, many transplant recipients can safely use the currently available methods of hormonal contraception provided there is careful attention to organ function, other medical problems, and concurrently prescribed medications. In adolescent patients, issues such as pubertal development and menstruation, contraception, and routine gynecologic health care are typically addressed by the patient's primary care provider. However, the complexity of the adolescent transplant recipient's medical care necessitates close collaboration among all health care providers caring for the patient. This review is intended to help the transplant team better understand the gynecologic health care needs and treatment options of their adolescent patients.

Gynecologic issues of the adolescent female solid organ transplant recipient

Advances in the field of transplant medicine are providing adolescent recipients with continual improvements in health and quality of life. With expanding opportunities for normal social and sexual relationships, adolescents require careful attention to their gynecologic and reproductive health (Box 1). Medical considerations vary depending on the type of organ transplanted, underlying and comorbid conditions, and current medication use. Most adolescent girls achieve menarche, however, and irregular cycles should be evaluated and managed with the same considerations applied to healthy young women. The management of menstrual disorders frequently uses hormonal contraceptive methods. Many transplant recipients also are sexually active and require a contraceptive method to prevent a mistimed pregnancy. With careful attention to organ function, other medical problems, and concurrently prescribed medications, many transplant recipients can use safely the currently available methods of hormonal contraception.

Adolescents' use of emergency contraception provided by Washington State pharmacists

STUDY OBJECTIVE

To increase knowledge about adolescents who obtained emergency contraceptive pills (ECP) directly from a pharmacist without first contacting a physician.

DESIGN

Cross-sectional self-administered survey.

SETTING

Fifteen randomly selected pharmacies providing ECP in western Washington State.

PARTICIPANTS

Adolescents 15-21 years old (n = 126) who obtained ECP directly from a pharmacist.

OUTCOME MEASURES

Responses to a 20-item questionnaire examining adolescents' reasons for seeking care from a pharmacist, need for additional medical evaluation, risk for not receiving additional medical care, and satisfaction with care provided by the pharmacist.

RESULTS

The most common reasons for using the pharmacy were convenience (44%), lack of knowledge about alternatives (38%), and privacy (31%). If the pharmacy service were not available, 58% said they would see a doctor, 22% said they would wait to see if they got pregnant, and 20% did not know. Based on self-report, 81% of adolescents needed a new method of ongoing contraception, an evaluation for sexually transmitted disease, or both. Among these adolescents, 36% had risk factors for not receiving this care. Adolescents were satisfied with the pharmacy service; 94% said they would recommend the service to a friend.

CONCLUSIONS

ECP provision by pharmacists is a useful way to increase access to emergency contraception. However, many adolescents using ECP need additional medical care. Programs designed to increase ECP access should use these opportunities to link adolescents with more comprehensive reproductive health care services.