Outwardly, this is manifested, first of all, by a jump in growth, a change in shape, and the appearance of secondary sexual characteristics.
Adolescence is a very responsible and difficult stage in the life of every person. During this period, changing ideas about themselves and the surrounding reality. Moving from child to adult world, a teenager does not fully belong to either one or the other, therefore his behavior is often unpredictable and inadequate. Emotional instability of the psyche is manifested by heightened shyness and at the same time aggressiveness, the tendency to take extreme positions and points of view quite often puts him in extremely difficult situations. This stage often determines the whole future life of a person.
The first menstruation (menarche) - the main sign of puberty of the female body, indicating the ability to conceive. For most girls, menarche occurs at 11-13 years. I
In Russia, traditionally pregnancy and the birth of children have been associated with marriage, sex before marriage is almost never discussed by society. However, in reality, about 60% of young people have sex experience up to 18 years. Some adolescents begin to have sex with 12-13 years.
In recent decades, a decrease in the age of onset of puberty and an increase in the age of marriage and the birth of the first child have been observed worldwide.
Thus, the “period of danger” (unwanted teenage pregnancy, the possibility of getting an STI) in adolescence increases significantly.
According to world statistics, the frequency of pregnancy among adolescents continues to grow. The share of young women in Russia accounts for about 6% of abortions. This indicator remains one of the highest among economically developed countries. In the age group up to 20 years, there is the highest frequency of abortions performed during pregnancy more than 12 weeks. It should be noted that the frequency of complications after abortion in adolescents is 2-2.5 times higher, and maternal mortality is 5-8 times higher than in women of reproductive age (Zakharov SV and others, 2000). According to the WHO, the highest incidence of STIs is observed among young people - in the age group 15-24 years old, and 2/3 of those who become ill with AIDS are infected before the age of 25 years.
It is very important to help adolescents get through this stage of their lives with the least loss. It is extremely important that every young man realizes that, while observing the rules of safe sexual behavior, he protects himself from STIs, including HIV infection.
Young people in adolescence should be informed about how to maintain their reproductive health. At the same time, some adolescents need individual work with them somewhat earlier.
The main task of contraception in adolescents is the prevention of first abortion, STIs and AIDS. Basic requirements for contraception:
• protection against STIs and AIDS.
A very important condition of contraception is the rapid restoration of the ability to conceive after the cessation of its use. Accessibility, confidentiality, economic benefits from the purchase of contraceptives and some other social and personal criteria are of particular importance.
According to WHO, “adolescence as such is not a basis for refusing any method of contraception. ".
The most suitable for sexually active adolescents who and the International Association of Pediatric and Adolescent Gynecologists recognized combined oral contraceptives (COCs), containing small doses of ethinyl estradiol (20-30 mcg) and third-generation progestogens
It should be noted that hormonal contraceptive pills are prescribed only by a doctor, who takes into account all the features of the girl's body, previous diseases, contraindications to this method of contraception, etc.
The characteristics of the body of adolescents are, as a rule, moderate estrogen saturation, high sensitivity of the receptor apparatus of target organs and the relative deficiency of progesterone. Therefore, drugs with a low content of estradiol and progestogens with pronounced hestagenic properties (Logest, Mersilon, Novinet, Lindi-no, Belara, etc.) are most often suitable for sexually active adolescents. These drugs are well tolerated, have few side effects, do not affect body weight, and therefore form a positive attitude towards contraceptives in general.
In hyperandrogenism, CEC with antiandrogenic progestogens should be preferred - Zanin, Yarin, Dia-non-35. For adolescent girls suffering from seborrhea (increased skin greasiness) and acne, a drug with a proven positive effect on Tri-Merci skin can be recommended.
The effectiveness of the COC, when properly administered, approaches 100%.
The advantages of using low and microdosing KOK in adolescents and young women are:
• high contraceptive efficacy,
• reducing the risk of estrogen-dependent side effects,
• lack of clinically significant effect on blood clotting,
• regulating effect on the menstrual cycle,
• therapeutic effect in dysmenorrhea, ovulatory pain, dysfunctional uterine bleeding, endometrium, acne, hirsutism.
Disadvantages. KOC needs to be taken regularly and daily, which requires a high motivation of behavior and causes problems for some young women. Despite the fact that COCs reduce the risk of inflammatory diseases of the pelvic organs, they do not protect against STIs.
Currently, due to the spread of STIs and AIDS, attitudes toward contraceptive methods are being revised in many countries. In case of promiscuous sexual relations with different partners, the “dual” method is most preferable (“belt and suspenders method”, “Dutch method”), i.e.
combination of KOC with a condom. This method allows you to combine high contraceptive efficacy with the protection of adolescents from STIs.
How long can you use hormonal contraception? Taking COCs is possible as long as there is a need for contraception. The beneficial effect of COC on the reproductive system increases with the duration of their use. It is proved that the frequency of subsequent infertility in women taking COC, was a hundred times less than that of peers who had childbirth and abortion without using contraception.
At present, experience is gained with the use of hormonal contraceptive methods alternative to pills (Novara ring vaginal ring, EVRA skin patch). The effectiveness of these contraceptives is not inferior to COC, for some women they are more preferable, especially for young women, for whom it is difficult to remember to take pills every day.
The use of barrier methods of contraception by adolescents is of great importance, primarily due to the fact that they can be used to prevent or significantly reduce the risk of contracting an STI.
It is proved that the use of barrier methods of contraception reduces the risk of STIs by more than 2-3 times. In recent years, the use of these contraceptives, especially condoms, has increased due to the danger of AIDS.
The effectiveness of the condom due to misuse directly at the time of sexual intercourse is low and ranges from 46 to 72%. Combined use of barrier methods of contraception (condom, especially with spermicide) increases the effectiveness of contraception up to 95-99% and contributes to protection against STIs, including HIV / AIDS.
The advantages of barrier methods. Condom is easy to use. In addition, barrier methods of contraception have proven to be an effective measure for preventing cervical cancer, in the development of which the role of viruses, such as human papilloma, has been proven.
Disadvantages: lower efficiency compared with COC. Allergic reactions to latex rubber or grease are possible.
Unacceptable and ineffective methods of contraception In adolescents: mini-drank, injectables, IUD, diaphragm, rhythmic methods.
With regard to the use of oral progestin contraception, the high incidence of ineffectiveness and the appearance of intermenstrual bleeding does not allow to consider this method as a method of first choice for teenage girls and young women. However, progestin
contraceptives can be successfully used by young nursing mothers.
For injectable progestogens and implants, an additional disadvantage limiting their use by young women is the delay in restoration of fertility (up to 9–10 months for injections and up to 12–18 months for implants). Prolonged drugs, despite the shortcomings described above, it makes sense to recommend to socially disadvantaged adolescent girls, including alcohol abusers, drugs that are in custody.
Despite the fact that, in accordance with the WHO eligibility criteria, the age of up to 20 years is assigned to the 2nd eligibility class, the use of intrauterine devices is not recommended by teenage girls. Anatomical and physiological features of the reproductive system in adolescence predispose to the development of complications associated with the use of IUDs (expulsion, bleeding, pain syndrome). In addition, with irregular sexual activity with frequent changes of sexual partners, the risk of STIs and inflammatory diseases of the pelvic organs, which can later lead to the development of infertility and / or ectopic pregnancy, significantly increases.
The use of diaphragms by adolescents is limited, mainly due to the inconvenience of their use and storage.
The rhythmic method of contraception is inappropriate because of the unsteady menstrual period in many girls.
Postcoital (emergency, urgent) contraception is of great importance for adolescents, since it is adolescents that often have "unplanned sex", without any contraceptive means.
Emergency contraception is used in situations where rape has occurred or when the use of a particular method of contraception was unsuccessful (for example, a condom broke).
The “progestogen attack” method with high doses of progestogens and the Yuzpe method using COC are currently used. Both methods are recommended to be used no later than 72 hours after “unprotected” sexual intercourse with an interval between receptions at 12 hours. The effectiveness of the method, taking into account compliance with all the rules described above, is 96-98%. In this case, it is preferable to use the drug Postinor (750 mcg of levonorgestrel) or Escapel (750 mcg of levonorge-boom) due to better tolerability and higher efficacy (see Chapter "Emergency contraception"). Teenagers
should be aware of the importance of a follow-up visit to the doctor to confirm that the pregnancy has not occurred. It should be emphasized that emergency contraception is a one-time contraception that should not be used continuously. Therefore, the method is absolutely unacceptable for regular use, as with the simultaneous taking of large doses of hormonal contraceptive pills, the endocrine system of a young woman is subjected to heavy loads. In this regard, after the use of emergency funds should be assigned to any other method of contraception.
Nevertheless, we believe that all adolescents should have information about the method of emergency contraception, but should be cautioned against frequent use.
In conclusion, I would like to emphasize that the versatility of the clinical effect of COC allows us to consider them the first choice drugs to protect adolescents from unwanted pregnancy. With simultaneous use of COCs and condoms, protection against STIs and HIV infection is enhanced.
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What are the features of contraception in adolescents?
Often the first sexual intercourse leads to the first abortion. And from the abortion department, not all women leave with the firm confidence that they can have children in the future. According to world statistics, the frequency of pregnancies among adolescents has increased significantly in recent years and continues to grow. Adolescence (15-18 years old) accounts for up to 4 million abortions carried out worldwide.
When choosing a contraceptive method, adolescents of both sexes rarely think about having any kind of infection through sexual contact, so the incidence of sexually transmitted diseases, including AIDS, is increasing. All this represents a great danger to the health of the younger generation and to the health of society as a whole. Contraception in adolescence pursues two main goals - to prevent abortion and infection with sexually transmitted diseases.
If you want to have sex during adolescence, first of all protect your health and the health of your future children.
Features of contraceptive behavior of adolescents
Contraceptive behavior of adolescent girls differs from the behavior of older age groups and has the following features:
- irregular sex life
- irregular menstruation,
- insufficient sex education,
- short-term use of contraception,
- the use of ineffective methods of contraception,
- fear of parents and doctor
- using the advice of friends in choosing a contraceptive method,
- high risk of STDs
- many sexual partners.
The main tasks of contraception in adolescence
Currently, doctors are particularly alarmed by the significant increase in the number of STDs among adolescents. According to modern literature data from sexually active adolescent girls, chlamydia are infected with 8-25%, gonorrhea - 0.4-12%, human papillomavirus (HPV) - 15-38%. Pathological results of PAP tests were found in 16%. More than 50% of those infected with HIV are young people under 25 years of age.
Thus, the main tasks of contraception in adolescents are:
- профилактика первого аборта и непланируемых первых родов,
- профилактика заболеваний, передающихся половым путем.
Contraceptives suitable for adolescence
Hormonal contraceptive method in adolescence
The hormonal method as the most reliable way to prevent pregnancy, which is extremely undesirable at this age period. But do not forget that this method does not prevent infection with sexually transmitted diseases. In adolescence, with a constant sexual partner, the hormonal contraceptive method is optimal.
Birth control pills for teens
Birth control pills for adolescents can only be taken if the following conditions are met: regular sex life, the onset of the first menstruation at least 2 years ago, at least 160 cm tall, no obesity, and serious heart and vascular diseases.
The World Health Organization recommends that teenagers take combined birth control pills. Best suited (Trikvilgr, Triregol, Triziston) and single-phase (Silest, Femoden, Mikroginon, Ripevidon, Marvelon) drugs. They provide the least intervention in the natural course of the processes occurring in the female body, and maintain the stability of the menstrual cycle.
Mini-drinking for teen contraception
The use of mini-pili (Atsetomepregeneol, Mikrolut, Exluton) is not recommended because their contraceptive efficacy is lower, and more often side effects develop (intermenstrual bleeding).
Emergency contraception in adolescence
Emergency contraception is an emergency measure of protection from unwanted pregnancy (although much more preferable than abortion). Sometimes in the literature it is called "emergency contraception" because it requires urgent and effective measures. Girls, if you doubt the integrity of a condom when using it or having unprotected sex, or if other methods of contraception cannot be used for one reason or another, do not let the matter take its course, do not wait for the next menstruation, because it may not to appear. Better use this method of protection from pregnancy, and you have 72 hours - three days (when using hormonal contraceptives) or 5-7 days if you decide to put an intrauterine device (which is not recommended during adolescence).
The use of combination pills for emergency contraception among adolescents should be most common. In Russia, Posinor is often used, containing 0.75 mg of levonorgestrel, however, note that the World Health Organization does not recommend it for use - contraceptive efficacy is too low and side effects often occur.
Introduction of intrauterine devices is made within 5-7 days after unprotected sex. As a means of emergency contraception, this method has a right to exist, but it is better for teenage girls not to use it, because there is a high risk of inflammation of the uterus and its appendages, especially if there are a large number of sexual partners or with casual sex.
Barrier methods of contraception adolescents
The use of barrier methods of contraception reduces the risk of sexually transmitted diseases by more than 2-3 times, especially when using a condom. However, the contraceptive effectiveness of a condom in young people due to improper use directly at the time of sexual intercourse is low and amounts to 50-75%. The simultaneous use of a condom and spermicides (pastes, creams, gels, etc.) is possible, which increases the effectiveness of the use of barrier methods of contraception. Use only spermicides in adolescence is impractical because their contraceptive effect is low.
In connection with the spread of AIDS and other sexually transmitted diseases, we recommend that adolescents combine birth control pills with condoms, which will protect both from unwanted pregnancy and sexually transmitted diseases (including AIDS).
Sexual and contraceptive behavior of adolescents
According to statistics, 35% of girls have first intimacy before the age of 16 years. Unwanted or unplanned pregnancies between the ages of 13-17 occur in 5-10% of sexually active girls. Negative factors and features of social behavior of adolescent girls are:
- casual and irregular intimate contacts with frequent changes of partners,
- the possibility of early infection with sexually transmitted infections,
- lack of knowledge about the consequences of unprotected sex and the ability to prevent unwanted pregnancies,
- incorrect or intermittent use of contraceptive methods
- closeness of adolescent environment for adults (unwillingness to follow the advice of parents and the recommendations of doctors),
- priority importance of advice of girlfriends and peers in matters of sex and contraception,
- the immaturity of the genital tract and the formation of the hormonal system, reducing the natural defenses of the female body.
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A good option for a girl is when her mother is the best friend, with whom you can talk in detail and without embarrassment about the relationship with the boy, about contraception and the risk of unwanted conception. However, it is optimal to solve all the problems and get answers to the questions from the pediatric gynecologist: the specialist of the Clinic will tactfully and professionally help the girl start an adult life without consequences and complications.
Requirements for protection methods
Contraception in adolescent girls should solve 2 main tasks:
- Preventing unplanned and unwanted pregnancy as a major factor in preventing abortion,
- Effective protection against viral and bacterial infections that threaten future women's health and childbearing ability.
The most important requirements for contraceptive methods include the following basic features of protective equipment:
- optimal contraceptive effectiveness,
- minimal negative impact on adolescent bodies,
- ease of use contraceptive,
- the ability to quickly restore reproductive function,
- availability of obtaining methods of protection.
Effective contraception in adolescents selected by an experienced physician will be the basis for preserving a girl’s health, preventing gynecological diseases and protecting against unwanted pregnancy.
All possible types of protection against unwanted pregnancy are divided into the following options:
- determination of dangerous days (natural methods),
- interrupted coitus
- barrier types of protection
- chemical spermicides,
- various types of hormonal contraception,
- intrauterine device,
Surgical sterilization is absolutely unacceptable, which irreversibly deprives the girl of the possibility of conceiving the desired baby in the future in a natural way. Introduction of an intrauterine contraceptive can cause unpleasant and dangerous consequences in the form of gynecological pathology (endometritis, cervicitis, cervical erosion, chronic adnexitis), which reduce reproductive capacity. Physiological methods (counting dangerous days, measuring basal temperature, cervical mucus test) are laborious, complex and ineffective. Interrupted sexual intercourse, which is used by most adolescents, practically does not protect against infections and unplanned pregnancy. The best options for contraception in adolescent girls are:
- combination of a condom with chemical spermicides,
- low-dose hormonal contraceptives.
Important conditions for the safety and success of contraception are the individual selection of the method by an experienced adolescent gynecologist and the strict implementation of the recommendations of a specialist.
Mechanical contraception includes the following options:
- male condom
- female condom
- vaginal diaphragm,
- cervical cap.
The male condom and female means of mechanical contraception prevent sperm from entering the vagina and uterus, which prevents the possibility of pregnancy. The main advantages of the method:
- absolute safety for the body of the girl,
- availability and ease of use
- protection against microbial infection.
The disadvantages of barrier protection options are:
- insufficient strength of latex, which leads to the possibility of breaking the condom with a high probability of unplanned conception,
- decrease in sexual sensations, which causes 70% of boys and 50% of girls to abandon this method,
- the complexity and inconvenience of using female types of barrier contraceptives.
The best way to increase the effectiveness of protection is the combined use of mechanical and chemical methods. Spermicides are special cream, gel or vaginal suppositories, which, if used properly, have a detrimental effect on the male sex cells that have entered the vagina of the girl. The most important advantages of spermicidal cream are:
- prevent conception,
- prevention of microbial infection due to the antiseptic properties of the contraceptive drug,
- moisturizing the vagina, reducing unpleasant feelings when using a condom.
The combined use of spermicides with barrier contraceptives significantly increases the effectiveness of protection, reduces the risk of inflammation in the genital tract of the girl and can be used for irregular sex life.
The emergence of low-dose and highly effective oral contraceptives has reduced the risk of side effects of hormonal agents on the body of a teenager and significantly increase protection against unwanted pregnancy. The most important benefits of any hormonal contraceptive options are:
- almost 100% protection from conception,
- regulation and restoration of cyclical periods,
- therapeutic effect on the skin with seborrhea and acne,
- the reversibility of the method (after the cancellation, the girl will be able to conceive, bear and give birth to a baby),
- safety of use (with proper selection of the drug and regular monitoring at the adolescent gynecologist),
- long-term use.
The disadvantages of hormonal contraception include:
- systemic effects on the body of a teenager (even minimal doses of hormones can have a negative impact on the formation of endocrine function),
- the presence of side effects and contraindications for use,
- high discipline necessary for taking daily pills,
- lack of protection against microbial infection with frequent changes of sexual partners,
- low availability of drugs due to the high cost of modern drugs.
The main options for hormonal drugs for pregnancy protection are:
- pills (oral contraceptives),
- vaginal ring (NovaRing),
- skin patch (Evra),
- intramuscular injections,
- subcutaneous implants
- hormonal intrauterine device.
The last three methods are practically not used in girls, which is explained by the pronounced systemic effects with a large number of adverse events. For adolescents, it is best to use oral contraceptives with low doses of hormones, modern methods of receiving contraceptives through the skin or the vaginal mucosa.
After a visit to the clinic to the pediatric gynecologist and a preliminary examination, the doctor will help you choose the optimal oral contraceptive. Possible options for tablets can be:
- monophasic drugs with the same hormone levels, which are used only for contraceptive purposes,
- two- or three-phase agents that provide therapeutic and protective effects,
- progestogenic drugs (mini-drank), in which there is no estrogen component.
Of great importance in the choice of contraceptive for adolescent girls is the dose of hormones. A pediatric gynecologist will give preference to microdosing (20 μg of estrogen) and low-dose (less than 35 μg) preparations with optimal efficacy and safety. It is important to carefully follow the advice of a specialist, taking pills in a disciplined manner every day and regularly visiting the doctor for preventive purposes. You cannot replace the oral contraceptive yourself or suddenly stop taking the pill: a violation of the contraceptive regimen can cause complications.
A modern and high-tech method of hormonal contraception involves the use of a special NovaraRing agent: a small soft-elastic ring is inserted into the vagina, low doses of hormonal agents are constantly released and penetrate through the mucosa into the blood. For a month, it is necessary 3 ringlet - the girl should change the contraceptive weekly, which will reliably protect against unplanned pregnancy. The undoubted advantages of the method:
- convenience of the contraceptive method,
- high efficiency and optimum protection
- safety for the girl's body,
- the reversibility of the method - after the cessation of the use of NovaRing, the reproductive function is immediately restored.
The only drawback of the vaginal ring is the high cost of the contraceptive.
At the core of the application of a highly efficient and safe method is the possibility of penetration of hormonal agents through the skin. Evra plaster should be glued weekly in one of the places determined by the doctor (stomach, shoulder, buttock). Excellent protection against unwanted pregnancy and the absence of pronounced side effects is one of the most important factors in choosing a contraceptive method, and the main disadvantage is the high price of the patch.
Postcoital or emergency contraceptive methods may be of major importance in preventing medical abortion in adolescents. The technique should be used in the following cases:
- any variant of unprotected intercourse,
- condom break
- missed tablet
Ordinary oral contraceptives or special medicines can be used for emergency protection against unwanted pregnancy. Before using this method, you must consult a teen gynecologist to know exactly how and what hormones to use. It is important to understand that post-coital contraceptive methods cannot be used frequently: the uncontrolled and repeated intake of pills using an emergency regimen may provoke gynecological diseases and dangerous complications.
Counseling adolescents on issues of contraception should be conducted by an experienced and qualified pediatric gynecologist with the gift of persuasion. It is necessary to explain to the girl all the advantages and disadvantages of each method, to help choose the option of protection, taking into account the hormonal background and the presence of associated diseases. Rational contraception in adolescents, selected by a specialist of the Clinic, is the most effective prevention of gynecological diseases, miscarriage and infertility
What method of contraception to choose?
Although Sarah is just starting to have sex, this does not mean that her young man did not do this before. Therefore, the doctor advised her to double the method of contraception, i.e. hormonal contraceptive use and condom use. This will provide the girl with effective protection.
For all sexually active young people, physicians should recommend a double contraceptive method, i.e. simultaneous use of hormonal contraceptives and condoms.
One would assume that Sarah would have enough condoms and emergency contraception just in case. However, even people with experience can condom tear or slip. As for inexperienced adolescents, who often do not use lubricants, this happens much more often. In addition, Sarah's young man may not want to use condoms. Sex can occur after drinking alcohol or drugs. For all these reasons, condoms combined with oral contraceptives will be much safer for Sarah. However, the doctor must tell about the existence of emergency contraception and how to use it if such a need arises.
Therefore, for Sarah, it is better to prescribe hormonal contraception, either in the form of COC, or prolonged contraceptives of reversible action, such as Implanon or Depo-Provera. In addition to contraceptive, COC has other positive effects, but prolonged contraceptives of reversible action are more effective, since exclude application errors. Nevertheless, it is important to offer Sarah a choice of contraception, and she should be informed enough to decide which method suits her best. Например, если она недостаточно организованна, забывчива или ей будет трудно принимать таблетки каждый день (особенно если ей придется хранить контрацептивы в тайном от родителей месте), то более подходящим выбором может быть Депо-Провера или Импланон.
Если девушка решила использовать КОК, какие лучше назначить?
The main rule in the appointment of hormonal contraceptives - choose oral contraceptives with the lowest dose of hormones, sufficient for contraception and control of the menstrual cycle. In the case of Sarah, monophasic (20 or 30 micrograms of ethinyl estradiol) or three-phase oral contraceptives with a low dose of hormones can be prescribed. These oral contraceptives contain a low dose of hormones, are affordable and convenient to use. In monophasic, the threshold for errors is higher than in three-phase ones. They are also more convenient to use if you want to postpone menstruation in connection with, for example, vacations or sporting events, and therefore they may be preferable. A good choice to start taking is monophasic with levonorgestrel, although you can prescribe other types of progesterone or prescribe them later if side effects occur.
The positive effects of COC
- High efficiency
- Normalization of the menstrual cycle:
- less heavy bleeding
- less common anemia
- regular bleeding with the ability to adjust the time of menstruation
- less pronounced PMS
- no ovulatory pain
- Less frequent inflammatory diseases of the uterus and appendages
- The risk of ectopic pregnancy is reduced
- Less common benign breast disease
- Less frequent functional ovarian cysts
- Reduces the risk of ovarian and endometrial cancer
- Improves sebaceous gland function
- Protection against osteoporosis and reduction of menopause symptoms in the older age group of women
- Reduced risk of endometriosis