Abstract Study Objective Physiological states of estrogen deficiency can lead to bone demineralization. Lead is stored in bone and may be released into blood during demineralization. The ...contraceptive injection depomedroxyprogesterone acetate (DMPA) is associated with estrogen deficiency and bone demineralization and, we hypothesized, may be associated with toxic blood lead levels in adolescents at high risk for lead exposure. We sought to compare blood lead levels in inner-city adolescent girls using DMPA with levels in those using oral contraceptive pills (OCP) and those taking no hormones and to examine the influence of lead exposure and reproductive history on blood lead levels in the total sample. Design Cross-sectional survey of a clinical convenience sample. Setting Inner-city adolescent clinic in an academic medical center. Participants 174 females aged 13–21 years; 86% minority ethnicity. Interventions None Main Outcome Measures Measurement of blood lead levels and an 82-item questionnaire examining lead exposure and reproductive history. Results 28 subjects were using DMPA, 25 used OCPs, and 121 used no hormones. Mean blood lead level in the total sample of 174 was 1.6 μg/dL, SD = 1.1. Many subjects had environmental risk factors for lead exposure and 15% reported one or more past pregnancies. Mean blood lead levels for subjects with the various environmental and reproductive risk factors ranged from 1.2 μg/dL to 2.0 μg/dL and were not different from levels for subjects without such risk factors. Mean blood lead levels for subjects in the 3 hormonal groups were significantly different (2.1 vs. 1.2 vs.1.5 μg/dL in DMPA, OCP, and no hormone groups respectively, P = 0.007). We dichotomized the blood lead levels into “High” ≥4 μg/dL, or “Low” <4 μg/dL. We found that a significantly higher proportion of girls using DMPA (4/28) than those not using any hormone (2/121) had “High” levels ( P = 0.012). Conclusions Despite reported high-risk exposure to lead and the possibility of long-term accumulation of lead in bone, we did not find elevated blood levels in our sample. However, DMPA-treated girls were significantly more likely to have higher mean blood lead levels than OCP users and non-hormone users. In addition, DMPA users were more likely to have blood lead levels more than two standard deviations above the mean for the sample as a whole than untreated girls. Further studies are needed to examine low-level lead poisoning in adolescents and the consequences of contraceptive choices on bone health.
Abstract Background In 1998, the Centers for Disease Control and Prevention (CDC) changed their guidelines for treatment of adolescents with pelvic inflammatory disease (PID), no longer recommending ...hospitalization of all teenagers. Study Objectives (1) To determine the proportion of adolescents with PID who were admitted for failed outpatient treatment after the CDC guideline change. (2) To determine if adolescents admitted for PID after the guideline change needed longer hospital stays and/or were more likely to be “very ill” as measured by inflammation markers, e.g. fever or to have tubo-ovarian abscess (TOA) than those admitted before the change. Design Retrospective chart review Setting/Participants All 12-21-year-old females with the diagnosis of PID admitted to an adolescent inpatient unit in an inner-city teaching hospital during a two-year period before T1=1995-1997 (54 cases) and after T2=1998-2000 (91 cases) the CDC guideline change. Interventions None Main Outcome measures Reason for admission (failed outpatient treatment; TOA; or admission at the time of diagnosis of PID); clinical toxicity at admission, and length of hospital stay (LOS). Results During T2, 22% of PID admissions were for failure of outpatient therapy. However, those admitted after failure of outpatient therapy (n=20) in T2 were less likely to be “very ill” than those who were admitted at the time of PID diagnosis in either T1 or T2 (n=123) RR:0.30; 95% CI:0.09-0.94. Mean LOS for females admitted to the adolescent unit with all diagnoses other than PID did not change between T1 and T2 but mean LOS for those diagnosed with PID decreased significantly from 6.3 ± 3.7 days to 4.7 ± 2.7 days, respectively ( P = 0.002). LOS for PID was longer for younger (<16 years; 8.20 ± 4.5 days) than older (≥16 years; 5.0 ± 2.8 days) girls ( P = 0.02) and for adolescents with TOA (7.9 ± 5.0 days) than for those without (5.3 ± 2.9 days) ( P = 0.05). Conclusion At our medical center, after the CDC guideline change many adolescents with PID were admitted because of failure of outpatient therapy but they were not sicker than those admitted at the time of diagnosis and overall LOS for PID was shorter. These findings are reassuring because they suggest that an initial trial of outpatient therapy for PID is unlikely to harm adolescents and may lead to significant cost savings.
We agree with the recent AJPH Perspectives piece by Gubrium et al.1 in response to Northridge and Coupey's column2 on long-acting reversible contraception (LARC) and reproductive health equity. ...Northridge and Coupey's recent response3 acknowledges that they see LARC as one component of a larger social justice agenda. However, both the initial piece2 and the response to Gubrium et al.3 fail to locate LARC within the context of sexual and reproductive justice.
Access to reproductive healthcare for adolescent girls with medical conditions requiring use of mycophenolate mofetil or sodium (MMF), a teratogenic immunosuppressant, is important to prevent ...unintended pregnancy and birth defects in offspring. Highly effective long acting reversible contraception (LARC), intrauterine devices (IUDs) and contraceptive implants, is recommended for this population. The aim of this study is to describe the girls prescribed MMF at a children's hospital and the reproductive healthcare they received.
We searched electronic health records (EHR) to identify females aged 10 through 20 years prescribed MMF at our children's hospital from January 2010 through December 2019. Of the 225 patients identified, we excluded 64 who initiated MMF before January 2010. We reviewed the EHRs of 161 subjects starting with the first visit, either inpatient or outpatient, when the MMF was prescribed and prospectively reviewed all subspecialty, and reproductive health visit notes thereafter. We entered the date and type of each health visit as well as EHR documentation of menarche, coitarche, sexual activity, pregnancies, and contraceptive use into an online database, REDCap.
Of the 161 subjects: 50% had systemic lupus erythematosus (SLE), 25% solid organ or bone marrow transplant, 25% other disease; 39% were Hispanic, 32% Black. At MMF initiation, mean age was 15.2 ± 3.9 years; 89% were post-menarchal; 19% had coitarche. We recorded subjects’ EHR data for a mean of 5 ± 3 years after MMF initiation. 42% ever had sex, with mean time to EHR documentation of sexual activity of -0.7 ± 2.4 years since MMF initiation. Of the 68 subjects who ever had sex, a higher proportion had SLE v. transplant v. other disease, 66% v. 19% v. 15%, p<0.001. Of all 161 subjects, 68(42%) attended a reproductive health visit (49/68(72%) with adolescent medicine) a mean of 1.7 ± 1.8 years after MMF initiation. Within 3 months of the first reproductive health visit, 37/68(54%) were using an effective contraceptive method: 24(35%) IUD; 7(10%) contraceptive implant; 5(7%) combined oral contraceptive pill; 1(2%) progestin only pill. Of the 22 subjects who had a pregnancy, 14 were unplanned, 6 were using MMF at the time of diagnosis of pregnancy.
We found that adolescent girls prescribed the teratogenic immunosuppressant mycophenolate need reproductive health care; a majority were post-menarchal and more than 40% were sexually active, especially those with SLE. We also found a high uptake of LARC methods of contraception in those who attended a reproductive health visit suggesting that increasing access to contraceptive services for these high-risk adolescent girls may reduce their risk of adverse pregnancy outcomes.
Summary Background African American and Hispanic adolescents have disproportionately higher rates of obesity compared to white adolescents. In adults, modest weight loss of five percent improves CVD ...risk marker levels. Less is known about the effects of modest changes in BMI on CVD risk markers in adolescents, particularly newer markers such as C reactive protein (CRP), lipoprotein (a) and homocysteine. Objective To examine the effect of modest BMI change on CVD risk marker levels in a group of severely obese, African American and Hispanic adolescents. Study design A six-month longitudinal analysis. Subjects Eighty-three African American and Hispanic adolescents were recruited (mean age ± sd: 15.1 ± 2.0 years); 50 (60%) were reevaluated at 6 ± 2 months. Results At baseline, mean BMI was 42.3 ± 7.8 kg/m2 . BMI directly correlated with CRP ( p = < 0.001); homocysteine ( p = 0.02); insulin ( p = 0.05); and systolic and diastolic blood pressures (both p = <0.001). BMI remained significantly associated with CRP and insulin after adjusting for age, sex and ethnicity ( p = 0.001). At six-month follow up, there was a significant p for trend between the three groups of BMI change (those with a ≥5% BMI decrease, those who maintained BMI within 5% and those with ≥5% BMI increase) and CRP ( p = 0.05) and insulin ( p = 0.04). Conclusions A modest decrease in BMI is associated with improvement in CRP and insulin levels. Obese adolescents should be encouraged to continue with modest weight loss goals as they result in improvement in cardiovascular disease risk markers.
