Dr Rob Steele (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy, Kansas City. Before we introduce our guest, I wanted to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/cmepodcast and click the Claim CME button that's there on the page.

Today, we are joined by Dr. Ashli Lawson to talk about contraception updates and reviews. Dr. Lawson is a physician of Gynecology at Children's Mercy Kansas City, a Texas native, we won't hold that against her. No, I'm just kidding with you. She received her MD from UT Southwestern and completed her OB-GYN residency at Parkland Memorial Hospital. She then moved to Kansas City where she trained in pediatric and adolescent gynecology.

She loved the city and institution so much that she and her husband made Kansas City home. Her special interests include Müllerian anomalies, a fancy word for differences in the gynecologic anatomy; transitioning the medically complex patient; and medical education. And Dr. Lawson has presented at the national level on multidisciplinary care of teens with endometriosis and long-term management, neovaginas, and she has authored textbook chapters on neonatal ovarian masses. Thank you for joining us today, Dr. Lawson.

Dr Ashli Lawson: My pleasure to be here, and great job tackling those new words.

Host: I'll tell you, I feel like those will roll off the tongue. But you know, when you have to do the introduction, sometimes it's a little more difficult. Let's jump right into it. Let's talk about contraception and the types of contraception. Can you go over for the primary care physician the differences in them, and what do they offer, and how do they vary?

Dr Ashli Lawson: So, I'm going to start with even taking one step back before that, in the patient in front of you who's coming in for contraception. I think it's really important, especially now too, that we're checking our own bias as we're counseling patients. And so, before we get into the medicine of contraception, ask that patient, what are their goals for building a family or preventing pregnancy? And that's a really good place to start before you get into all the nuts and bolts of the different contraceptions. So if they're saying, "Yes, I want to prevent pregnancy," great. This podcast is all about that. We're going to talk about the different forms of contraception. But if they're either ambivalent or seeking pregnancy, that's a great time to pause and really pivot the conversation and see how do you get them the resources they need and make sure that they're safe in the moment.

So once you've confirmed that indeed this patient is looking to try and prevent pregnancy, we got to check and see what do they want out of something for contraception. Some different things that teens have told me are that they're looking for something that's in their control, that they can start and stop quickly, or things that they don't have to remember, just depending on the patient. Or maybe they're looking for something that's not associated with weight gain, or maybe they've had a friend who had a good or bad experience with one thing, so they're looking to either not experience that or experience that.

So, I like to start by gauging what their familiarity is with birth control, and what they want out of it. The CDC gives us a few different ways to categorize birth control. They do three different categories. So, the first one is we can talk about birth control in a reversible versus an irreversible. So, irreversible is not really what we're talking about for teens. Like a tubal ligation, vasectomy, that's not really what we're talking about. So, most of the things we discuss are going to be the reversible kind.

The next category that CDC uses is hormonal versus non-hormonal. So, non-hormonal would be things like the condom, the diaphragm, the sponge, spermicide withdrawal method. Those aren't usually things I talk about in clinic, because I prescribe medicines and do procedures. And so if a patient wants more information, I can point them the right way, but I really focus on what they need a prescription for.

And then, the last category CDC talks about are the tiers of effectiveness, and this is where I'm going to focus now. So, there's the least effective methods, which prevent about 80% of pregnancy. And then, there's kind of this medium effectiveness that prevents 90-95% of pregnancy. And then, there's the most effective forms of contraception, which prevent more than 99% of pregnancies. So, the least effective things are going to be your condom, withdrawal methods, spermicides. The medium effectiveness, preventing 90-95% are going to be the things that most people are familiar with: the pill, the patch, the vaginal ring, the shot. And then, the most effective things are going to be those long-acting reversible contraceptives, or LARCs as you'll hear them called; things like the Nexplanon, that's the subdermal implant in your arm, or an IUD, an intrauterine device.

All of these different methods, the pill, the patch, the ring,, the shot, the IUD, the implant, they all have progesterone in them, so that's great. Some of them also have estrogen in there, and that's the one that you always read about and learned about in med school, making sure that your patient doesn't have a contraindication to estrogen. So, things that contain estrogen are going to be the pill, the patch, and the ring. There are progesterone-only pills, which we'll talk about a little bit more later, but I tend to clump the pill, patch, and ring all together as kind of having similar formulations. I like the pill, patch, and the ring, because I can also control periods with that and a lot of patients are coming to me for period problems. So, I like the pill, the patch, the ring because I've got some manipulation with that.

But if we're really focusing on contraception, it's what does the patient want. So, a pill is going to be oral that you have to take every 24 hours. The patch is going to be transdermal, that you take every seven days. The ring is going to be transvaginal that you leave inside the vagina for three weeks. The shot is going to be either subcutaneous or intramuscular that you get every three months. The Nexplanon is going to be subdermal, it's a procedure to implant a device that lasts for at least three years. And the IUD is going to be intrauterine, that also requires a procedure, and the one we typically use lasts up to 8 years.

So, as you can see, there's lots of variation both in how we give it to them, how frequently we give it, kind of some of the other effects that they have, like whether or not we can manipulate periods, and how effective they are at preventing pregnancy.

Host: I really appreciate that. You went back on me to say, "Hey, let's find out what the patient really wants out of this". I think that's really important. It's easy in a busy practice to just think, "Okay, here are my three go-tos. Let's give those options and move forward. I think that's super important to really understand both the desires, wants, lifestyles, all those things that get put into the equation of which contraceptive method to choose. So, I think that's really fantastic. I'll be honest, it's dizzying, as a primary care physician, all the options as you went through very, very eloquently. I think that can be some of the hardest challenges I think in practice, is to think through all those possibilities.

Dr Ashli Lawson: Yeah. I find that pulling up that CDC Family Planning Effectiveness Chart online and in the room in front of me helps me stay organized, and it also is a visual cue for the patients. So, we have some of them printed off in our clinic and laminated and I bring them in multiple times a day, but you can also pull it up on your computer too, CDC Family Planning Effectiveness Chart. And it has things color coded, it has the percentages up, it's got visual cues of when periods are going to occur or how long each method lasts. So, it's a nice way to stay organized because it can be dizzying.

Host: That's a great pearl of wisdom right there to pull that up online. Speaking of online, do you find that adolescents come in more armed with information these days? Or are they, for the most part, just waiting to hear from you about what those options are?

Dr Ashli Lawson: I usually ask them at the beginning, because I can usually save some time if I learn where they get their information and what information they have. I do find that a good amount of my patients are coming in with an open mind, but there are a lot that have taken to social media, and gathered information there.

There was a recent study published in the Journal of Pediatric and Adolescent Gynecology about preconceived notions about an IUD. And so, it looked at the top IUD hashtags and said, if you're in the top 10% of viewed, what kind of information is being given. And more than 90% of them both had negative information, so they weren't looking favorably upon an IUD, and it was false information, or at least skewed misinformation.

So, I try to acknowledge that, yes, that's where my teens are getting it, but it might not be the most accurate. And so, I have to find a way to meet them in the middle and say, "I hear you and I understand you that that's something that one person went through on TikTok. I'm also here to tell you that I place IUDs every week and over 90% of my patients are happy."

Host: Yeah, very good. That's good perspective. So, not to totally continue to expand the options here, but can you give a flavor of just the newer products that are either on the market or coming on the market that you could anticipate?

Dr Ashli Lawson: So going back to the pill, the birth control pill is standardly given with estrogen and progesterone. There is a progesterone-only pill, it's called Micronor, and it has norethindrone in it. But that progesterone-only pill just hasn't been that great at preventing pregnancy, and it's also got horrible breakthrough bleeding. And so, it's really been a bummer to some of us who have patients who can't use estrogen, like some of my lupus patients, or my patients with clots, but they want something that's within their control, they want a pill. And that Micronor just wasn't really cutting it for most of them.

So, there's a new progesterone-only pill on the market called Slynd, S-L-Y-N-D. It's progesterone-only called drosperinone, and we've seen comparable rates of pregnancy prevention to the estrogen-progesterone combined birth control. So, that's great. It's circumventing that need for estrogen, but we're also seeing the same pregnancy prevention rates. It has not been studied as well at menstrual control. But anecdotally, those of us who use it in the adolescent population are seeing similar rates of good period control, not these high rates of breakthrough bleeding. In the adult world, it's also looked at in patients who have endometriosis, which might cause more pelvic pain or pain with intercourse. And we're seeing some early subgroup analysis showing improvement in those things. So, it's great for my older teens transitioning to adulthood who might have endometriosis and have those other secondary things they need a birth control pill for. So, Slynd is one that is newly on the market that I've liked and use in an appropriate patient.

Another one that recently came to the market is a patch called Twirla, T-W-I-R-L-A. The current patch that we have is called Xulane, that's the generic. And one of the problems with Xulane is that it has a contraindication on it saying that if you have a BMI over 30, you are at risk for a blood clot with this, so don't take it. Also, if you're over 90 kilograms, it might not be as good at pregnancy prevention, so don't take it. And that's been kind of prohibitive.

So, Twirla came out and said, "Let's decrease how much estrogen is in our patch." So, they decreased it by a little bit. Big hopes, little adjustment. And they didn't see great results. That's okay. That's how we make progress in medicine. So, they don't have quite the same contraindication that Xulane still has, but there is a little asterisk that says pause when you start getting to higher BMIs and weights. We did see though that there's better wearability of this, so it wasn't falling off as much as the Xulane patch or causing as much skin irritation. So for my patient who's on the patch and that's really what they want, but man, they're calling me every week saying their patch is falling off and their skin is red, I can now say, "Hey, I've got another one that's almost the same formulation, same effectiveness, but it has better wearability. So, let's switch to that."

I'm also hopeful that there's been kind of chatter in these markets about making more racially diverse patches. Right now, our patches are all ivory, and they're pretty obvious. Even though you can put them in other places, it would be nice to see some multicultural patches. So, that is something to look forward to on the market.

Host: Oh, that's great call out. That's wonderful. Tell me, you know, there are the successes and failure rates with any of those methods, but they're also dependent on the user, right? And there's different levels of sort of remembering regarding the types. How do you assess that with the adolescents about what their lifestyle and, quite honestly, just their ability to remember whether it's a pill or whether to go with something that is a little more longstanding.

Dr Ashli Lawson: Parents are really helpful. Even though these are usually some confidential discussions, I'm bringing the parents back into the room too when we're making that final decision. And I can kind of give them the eyes back and forth, like, "Your daughter wants the pill, but does she take a pill daily? Has she ever taken a pill daily? Does she brush her teeth daily?" I don't know. And so, you can give the parents the eye to see what their understanding of this situation is. On each medicine that you prescribe for birth control, there is something called perfect use. And there's the in-practice failure rate. And so, those are the two things that I usually remind the patients of.

So, things like the birth control pill, needing a daily compliance, it prevents pregnancy 90-95% of the time. In adolescents, we see that they are not good at that every single day at roughly the same time, and we see that their actual use, or their actual failure rate, is probably closer to preventing 80% of pregnancies, but with closer to a 10-20% failure rate. And so, that's when I've got my CDC chart up in the room. I'm saying, "These numbers right here are the perfect use." Preventing 5% of pregnancy, yes, it can if you get it in every day at the same time, or if you change your patch every week at the same time. But It starts to go down when you start missing a pill, and we can get close to 25% failure rate.

Host: Well, Dr. Lawson, I want to thank you again for your time. One quick last question. My understanding is that you are a Girl Scout Gold Award recipient and lifetime member.

Dr Ashli Lawson: I am.

Host: What is a Gold Award recipient?

Dr Ashli Lawson: It's the equivalent of an Eagle Scout in Girl Scouts. So, you have to go through the whole program and you have to do a long-acting service project. So, I made incubator isolette covers and swaddles and nursing-friendly material for a NICU in Austin when I was a little 17-year-old.

Host: Very good. Well, I'm embarrassed that I didn't know that. That's fantastic that you're a recipient of that. So, let me ask you this. Do you know what the most popular Girl Scout cookie is, the one that sells the most?

Dr Ashli Lawson: I would guess Thin Mints.

Host: Yeah, you got it. You nailed it. That's pretty much everyone's favorite. Actually, it's not my favorite. I personally like the shortbread, the Trefoils, which by ingredient is the healthiest. So, I'm going with that one. I'm going to go ahead and put that one in my back pocket to say I eat the healthiest Girl Scout cookies because they're my favorite.

Well, thank you again, Dr. Lawson for joining us today. As a reminder, claim your CME credit for listening to today's show. Visit cmkc.link/cmepodcast and click the Claim CME button. This has been another episode of Pediatrics in Practice, a CME podcast. See you next time!