美国儿科学会发布新的青少年避孕和性健康指南

美国儿科学会（AAP）最新发布的青少年避孕指南指出，儿科医生应重视青少年的避孕措施并充分考虑特殊人群的特殊情况，以便能够给予青少年充分合适的建议。

本次指南自2007年至今首次更新了一项新的青少年避孕措施，修订了现有的推荐措施，并提出了最佳的辅导青少年避孕方法（Pediatrics 2014 Sept. 29 [doi: 10.1542/peds.2014-2299]）。

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“青少年已有能力理解复杂的性健康知识，” 本次指南的第一作者、印第安纳大学儿科部门的Mary Ott医生认为， “青少年信任儿科医生，并希望医生在进行禁欲辅导时提供理性的避孕信息和方法，”。指南中最显著的变化是推荐长效可逆避孕（LARC）方法作为青少年的一线避孕选择，如植入式避孕与宫内节育器（IUDs）。

本次更新指南还强调了两个重点内容，一是需要特别关注肥胖、发育性残疾以及存在复杂疾病的青少年性生活和避孕需求，而事实上，所有激素节育方法均比怀孕安全。二则是强调了获得未成年人避孕同意和保密的重要性，并在青少年需要获得性健康援助时以“诚实、关爱、客观的态度，通过舒适、就事论事的方式进行交谈”。

HIPAA法案允许家长查看孩子的记录，但是某些州府则为未成年人设置了更高的保密权限，家长可选择允许自己的孩子得到隐私保护。由于较低的避孕措施采纳率和较高的青少年怀孕率与保密和知情同意的限制有关，AAP建议对青少年的性生活和性传播感染（STI）情况进行保密。指南还敦促制定专门的办公室守则确保医生与青少年及其父母讨论涉及解释相关情况时的保密性。

AAP建议采用5P原则询问了解青少年性行为，5P原则是指“性行为对象（partners）、怀孕的预防（prevention of pregnancy），STIs的预防（protection from STIs），性行为方式（sexual practices）以及既往性病和怀孕史（past history of STIs and pregnancy）”，之后医生应该采用激励式访谈，专注于青少年的未来目标以及生活中实现健康行为的方法。

指南还指出，每年75万怀孕青少年中大约有80%被确诊为意外怀孕，所有美国高中学生几乎一半报告曾有过性行为。但最有效的避孕措施——主要是激素避孕法——却最不被青少年亲睐。

虽然禁欲是避免意外怀孕的唯一100%有效的措施，但“儿科医生不应该只依赖禁欲辅导来预防危险的性行为，而应同时给所有青少年提供全面的性健康信息，”报告指出。不论是性行为活跃的青少年还是那些正考虑发生性行为的未成年人，都应接受安全、适当的避孕措施的教育，了解这些方法的风险和有效性，以及性传播疾病筛查的相关知识。

在推荐具体的避孕措施方面，儿科医生应该更关注常规措施的有效率。最有效的方法是那些要求较少依从性的方法，如植入式孕激素避孕和IUDs。 除了这些一线选择外，醋甲孕酮注射剂和避孕贴片也是非常有效的，且比怀孕更加安全。同时，儿科医生应仍然建议使用安全套，以防止性传播疾病的发生。

指南建议，青少年在接受避孕处方或放置宫内节育器之前，不需要进行妇科检查，且STI筛查可在处方同一天进行。

该指南内容还涉及了特殊人群的避孕建议和性健康咨询，包括肥胖青少年和16%～25%伴有发育性残疾或复杂疾病（慢性疾病或HIV）的青少年，以及器官移植接受者。尽管该类青少年的疾病史很特殊，但他们的性需求和行为与一般的青少年相似，同时也有特殊的需求，给予建议时需要考虑更多的安全性问题，如雌激素的使用、药物相互作用，以及基础疾病的潜在并发症等。

如服用的药物可能会导致胎儿畸形，则这类青少年需要绝对避孕，如罹患月经出血或出血性疾病，或正在接受化疗，则需要采用激素控制节育，以帮助抑制月经出血。报告建议儿科医生咨询疾病预防控制中心（CDC）的线上“避孕措施医疗标准”以了解各种激素避孕措施的相关知识，因为其对月经周期控制具有潜在的管理价值，如粉刺或痛经。

同时，激素避孕对肥胖青少年可能产生不同疗效和副作用，与非肥胖青少年相比，肥胖青少年可能会担心激素导致的发胖。 “有数据表明，与正常体重的未成年人相比，肥胖者不论采用复方口服避孕药、阴道环、宫内节育器还是植入剂都没有更易长胖的趋势，”指南指出，但肥胖者使用醋甲孕酮则更容易发胖。

该指南声明无资金赞助，作者无任何相关利益冲突。

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By: TARA HAELLE, Ob.Gyn. News Digital Network

FROM PEDIATRICS

Pediatricians should be aware of the most recent updates in contraception and considerations for special populations so they can appropriately counsel their adolescent patients, according to the new American Academy of Pediatrics policy statement on contraception for adolescents.

The statement, prepared by the AAP’s committee on adolescence, updates the one from 2007 with new contraceptive methods available to teens, revised recommendations regarding existing methods, and best practices in counseling teens on contraception (Pediatrics 2014 Sept. 29 [doi: 10.1542/peds.2014-2299]).

The most significant change in this policy statement is the recommendation for long-acting reversible contraceptive (LARC) methods, such as the implant and the intrauterine device (IUD), as first-line contraceptive choices for teens who choose not to remain abstinent.

“Adolescents are capable of understanding complex messages about sexual health,” said Dr. Mary Ott of the Indiana University department of pediatrics. “Adolescents trust pediatricians and understand that their pediatricians can simultaneously encourage abstinence and provide nonjudgmental contraceptive information and care,” said Dr. Ott, the study’s lead author.

Two other important points to emphasize in this updated statement are the special attention that should be paid to the sexual and contraceptive needs of obese, developmentally disabled, and medically complex adolescents, and the fact that all hormonal methods of birth control are safer than pregnancy, Dr. Ott said in an interview.

The report emphasizes the importance of confidentiality, minor consent for contraception, and an “honest, caring, nonjudgmental attitude and a comfortable, matter-of-fact approach to asking questions” when it comes to teens’ sexual health needs.

HIPAA allows parents access to their children’s records, but some states have laws affording greater confidentiality to minors that overrides that access, and parents can opt to allow their children confidential care.

Because lower contraceptive use and higher teen pregnancy rates are associated with limitations on confidentiality and consent, the AAP recommends confidentiality regarding teens’ sexuality and sexually transmitted infections (STIs). It also urges doctors to have an office policy that involves explaining and discussing confidentiality practices and options with patients and their parents.

Effective counseling starts with taking a sexual history with the five Ps, according to the AAP: “partners, prevention of pregnancy, protection from STIs, sexual practices, and past history of STIs and pregnancy.” From there, doctors should employ motivational interviewing, focusing on teens’ future goals and ways of incorporating healthy behaviors into their lives.

The report notes that approximately 80% of the 750,000 teen pregnancies each year are unplanned, and almost half of all U.S. high school students have reported having had intercourse at least once. Yet the most effective contraceptive methods – primarily hormonal ones – are the least utilized by teen girls.

Although abstinence is the only 100% effective way to avoid unplanned pregnancy, “pediatricians should not rely on abstinence counseling alone but should additionally provide access to comprehensive sexual health information to all adolescents,” the report states. Sexually active teens, or those considering sexual activity, should receive counseling on all safe and appropriate contraception options for their needs, on the methods’ risks and effectiveness, and on STI screening.

When advising teens on specific contraception methods, pediatricians should rely on efficacy rates based on typical use rather than perfect use. The most effective methods are those that require the least adherence of patients, such as progestin implants and IUDs.

After these recommended first-line contraceptive choices, Depo Provera injections and the contraceptive patch are very effective and safer than pregnancy. However, pediatricians should still recommend condom use with all sexual intercourse to protect against STIs.

Teens do not need a pelvic exam prior to receiving a contraception prescription or IUD placement referral, the statement recommends, and STI screenings can occur the same day as a prescription or IUD placement.

The report addressed contraception and sexual health counseling for special populations, including obese teens and the 16%-25% of teens with a physical or developmental disability or a complex illness – such as chronic disease or HIV – and organ transplant recipients.

Despite being historically overlooked, teens in these populations have sexual needs and outcomes similar to those of typical teens, the statement notes, but they have additional needs as well. “Issues that arise include safety concerns with estrogen use, medication interactions, and complications from the underlying disease,” the statement notes.

Those taking medications that can cause birth defects may need contraception, and others may need hormonal birth control to help suppress menstruation if they have heavy menstrual bleeding or a bleeding disorder or are undergoing chemotherapy. The report recommends that pediatricians consult the CDC’s online “U.S. Medical Eligibility Criteria for Contraceptive Use” and have a working knowledge of various hormonal contraceptive methods because of their potential value for menstrual cycle control and management of conditions such as acne or dysmenorrhea.

Meanwhile, hormonal birth control for obese teens may differ in efficacy and side effects, compared with nonobese teens, and obese teens may be concerned about gaining more weight with hormonal birth control. “Data suggest that women with obesity are no more likely to gain weight with combined oral contraceptives, the vaginal ring, IUDs, or implants than normal-weight peers,” the report notes, although obese teens using Depo Provera were more likely to gain weight than were normal-weight teens who used it.

No funding or disclosures were noted regarding the policy statement.