Sexual Health in Teens - Texas Children's Hospital
Sexual Health in Teens JANE GEYER, MSN, WHNP-BC DIVISION OF PEDIATRIC AND ADOLESCENT GYNECOLOGY AT TEXAS CHILDRENS HOSPITAL BAYLOR COLLEGE OF MEDICINE, HOUSTON, TEXAS Disclosures I have no disclosures Objectives 1) Discuss stages of adolescent development as it relates to sexuality 2) Identify sexual behavior risk factors in adolescents 2) Discuss sexually transmitted infections in adolescents including treatment and vaccination
3) Review birth control options including emergency contraception 5) Describe how to obtain a proper sexual history in adolescents Adolescent development Development is divided into three states- early, middle, and late One of the tasks for development is acquiring a mature sexual development Early adolescence (10-14) is when sexual curiosity begins and may lead to masturbation or early sexual activity
Middle adolescence (15-18) is when romantic relationships begin, serial monogamy or having several partners Late adolescence (18 +) more mature understanding of sexual orientation, can participate in a variety of intimate relationships Who is having sex? Data from the 2015 Youth Risk Behavior Surveillance Survey which includes data from youth in 9th through 12th grades Nationwide 41% of students had engaged in sexual intercourse at least once (down from 46.8% in 2013) 3.9% of youth had engaged in intercourse before the age of 13 (down from 5.6)
11.5% had had sex with 4 or more partners (down from 15%) 30% had sexual intercourse during previous 3 months and of these: 43% did not use a condom 14% did not use any method of pregnancy prevention 21% had used drugs or alcohol before sexual activity Sexual Behavior Trends in High School Students Lesbian, Gay, Bisexual (LGB)
In 2016, the CDC released the first nationally represented study of LBG high school students The study represents 1.3 million teens that identify as LBG. The study found these individuals are at much higher risk than heterosexual peers and were more likely to report: Being physically forced to have sex Experiencing dating sexual and physical violence Being bullied at school or online
Using illegal substances More than 40% have seriously considered suicide 60% have reported feeling sad or hopeless Sexually Transmitted Infections CDC estimates that youth ages 15-24 make up just over one quarter of the sexually active population, but account for half of the 20 million new sexually transmitted infections that occur in the United States each year Compared with older adults, sexually active young adults are at higher risk of acquiring STIs Risk factors include: Those who initiate sex at an earlier age, residing in detention facilities Drug use
Men having sex with men Attending an STD clinic Having multiple partners increased biologic susceptibility- cervical ectropian Screening for STIs All 50 states allow adolescents to consent for their own STI care There is no requirement in any state to notify parents except in limited or unusual circumstances This can become difficult if a patient has private health insurance and a explanation of benefits is mailed to the parents Despite high risk of STIs in adolescents many healthcare providers fail to assess for risk factors or screen in asymptomatic patients
Who should be screened? Routine screening for C. trachomatis on an annual basis is recommended for all sexually active females aged <25 years Routine screening for N. gonorrhoeae on an annual basis is recommended for all sexually active females <25 years of age No recommendation for screening males for C. trachomatis and N. gonorrheoeae on a routine basis but a decision should be made based of clinical judgement and risk factors HIV screening should be discussed and offered to all adolescents Screening for other STIs including syphilis, herpes, HPV, hepatitis is not generally recommended in an asymptomatic patient
Cervical cancer screening is initiated at age 21 Oral Sex Many STIs can be spread through oral sex CDC reports 33% of teenagers aged 15-17 engaged in oral sex between 2007-2010. It is possible to contract an STI in the mouth or throat from giving oral sex to an infected person It is also possible to get STDs on the penis from receiving oral sex from someone with a mouth or throat infection
STDs can be present in more than one area at the same time Several STDs that may be transmitted by oral sex can spread throughout the body of an infected person Chlamydia Most common reported bacterial sexually transmitted infections in both men and women. 1,598,394 cases reported to CDC in 2016. Nucleic acid amplification tests (NAATs)are more sensitive and specific than other diagnostic test. Can be a urine test, self collected vaginal swabs or cervical swabs. First line treatment: Azithromycin 1 gram in a single dose or Doxycycline 100 mg twice a day X 7 days
Use Azithromycin when possible, better for patient compliance Alternative therapies include: Ofloxacin 300 mg twice a day X 7 days, Levofloxacin 500 mg twice a day X 7 days Pt should abstain from for 1 week until after patient and partner have both been treated. Can retest in 3 months if there is a concern about compliance Can be asymptomatic but the most common symptom in women is cervicitis and in men is urethritis. Other symptoms include vaginal discharge, pelvic pain, burning with urination, irregular
bleeding, painful sex Gonorrhea Gonorrhea is the second most commonly reported STI in US. 350,062 cases were reported in 2014. Gonorrhea can be diagnosed through urethral gram stain, urine culture, DNA probe, and DNA amplification techniques, and NAATs CDC recommends when a patient is diagnosed with Gonorrhea they also be concurrently treated for Chlamydia Treatment: Ceftriaxone 250 mg IM in a single dose plus either 1 g of Azithromycin in a single dose or Doxycycline 100 MG BID X 7 days
The higher dose of Ceftriaxone is now recommended due to reports of treatment failure If a patient has a cephalosporin allergy, they should be treated with Azithromycin 2 g in a single dose CDC has reported emerging drug resistance associated with gonorrhea Can be asymptomatic but the most common symptoms in women include vaginal discharge, pain with urination or irregular bleeding . Symptoms in men include pain with urination and discharge from the penis. Trichomoniasis (T. vaginalis) Most prevalent non-viral STI in US, 13% of AA women and 1.8% non-hispanic white females. An estimated 3.1 million infections currently in US.
70-85% are asymptomatic Symptomatic women may have diffuse, malodorous, yellow/green discharge with vulvar itching/irritation Screening can be done in high risk patients, symptomatic patients Diagnosed via wet-mount microscopy (only 51-65% sensitivity) NAAT (highly sensitive) Vaginal culture is gold standard Treatment: metronidazole 2gm PO single dose or tinidazole 2gm PO single dose
Pelvic Inflammatory Disease Acute infection of upper genital tract, involving uterus, fallopian tubes, and/or ovaries Sexually transmitted pathogens C. trachomatis- found in endocervix in 10-36% N. gonorrhoeae-15-44% Both in 5-12% 10-30% of untreated G/C cases PID
Diagnosing PID PID is a clinical diagnosis Signs/Symptoms associated with PID: Abdominal pain ~90% Abnormal vaginal discharge ~45-75% Elevated ESR ~75-80% Abnormal vaginal bleeding ~30-40%
Fever ~15-30% Urinary frequency ~15-20% Nausea/vomiting ~10-14% Treatment for Pelvic inflammatory Disease Presumptive treatment for PID should be initiated in sexually active young women and other women at risk for STIs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum clinical criteria are present on pelvic examination: cervical motion tenderness or
uterine tenderness or adnexal tenderness Suspicion should be low for treatment do to risk of infertility in the future Treatment Syphilis (T. pallidum) 2014: 2,316 cases reported in Houston (including Woodlands and Sugarland) Much higher incidence in MSM population
No current screening recommendations in non-pregnant, non-HIV infected women. *Risk factor for HIV* Syphilis Primary Syphilis Single sore known as chancre, which is location where syphilis entered the body Round, firm, painless Lasts 3-6 weeks
Usually goes unnoticed Secondary Syphilis Skin rashes and/or mouth, vaginal or anal sores (mucous membrane lesions) Skin rash that typically looks rough, redidish/brown spots and does not itch. Usually on hands and soles of feet Other: hair loss, H/As, vision changes, fatigue, muscle aches, sore throat, swollen glands Latent and Latent Stages Latent stage begins when all previous symptoms disappear
Late Stage (tertiary) can occur 10-30 years after initial infection. Late stage symptoms: difficulty with coordination/concentration, numbness, paralysis, blindness, dementia, death If left untreated, pregnant women can spread the disease to the baby during pregnancy which can result in death of the baby, seizures, or developmental delay. Syphilis Diagnosis Presumptive diagnosis requires: RPR and a treponemal test (i.e., FTA-ABS, TP-PA assay, various enzyme immunoassays EIAs, Immunoblots, or rapid treponemal tests) Serum tests may be negative during early infection can repeat testing in 1-3 months in patients of concern
Use of only one serum test is insufficient for diagnosis. False positive RPR can be associated with HIV, immunodeficient patients, pregnancy, IV drug use, advanced age Nontreponemal test antibody titers (RPR or VDRL) useful at measuring disease activity and response to treatment Titers should be drawn at: 6, 12, and 24 months. Should decrease fourfold by 6 months to verify successful treatment Treatment Penicillin G 2.4 million units IM once
Treatment for latent or late stages may require longer duration of therapy If time of contraction is uncertain, must treat for latent or tertiary syphilis Jarisch-Herxheimer reaction acute, febrile reaction with/without H/A, myalgia and occurs within first 24 hours following treatment initiation. More common during treatment of early stages. Need antipyretics Genital/Anal Ulcers: Herpes Simplex Virus In United states, most adolescents presenting with genital ulcers are found to have Herpes simplex virus (HSV) or Syphilis, genital herpes being most prevalent.
HSV typically presents with painful multiple vesicular or ulcerative lesions. Both HSV-1 and HSV-2 can cause genital ulcers. Approximately 50 million Americans are infected with HSV-2. Young women and MSM more likely to be infected with genital HSV-1. Cell culture and PCR testing are preferred testing methods in patients presenting with possible outbreak. Accuracy declines as lesions begin to heal. Type specific serologic testing may be performed. Most useful in following scenarios:
Recurrent genital lesions with negative PCR or cell culture Clinical diagnosis without laboratory confirmation A patient whose partner has been diagnosed with genital herpes HIV testing should be performed in all patients found to have HSV!! HSV Treatment Herpes outbreaks can be treated with antivirals including: Acyclovir, Valacyclovir, or Famciclovir Acyclovir has the most data/studies supporting treatment outcomes. Treatment can reduce pain, length of healing process, and the viral shedding process.
Most common regimens for primary outbreaks: Acyclovir: 400mg TID x 7-10 days Valacyclovir: 1000mg BID x 7-10 days Most common regimens for recurrent outbreaks: Acyclovir: 400 mg TID x 5 days or 800mg BID x 5 days Valacyclovir: 1 G once daily x 5 days Suppressive therapy should be considered in patients with recurrent outbreaks. Daily suppressive therapy can decrease outbreaks by 70-80%. Is also effective
in those without recurrent symptomatic outbreaks. Herpes Patient Education Asymptomatic viral shedding can occur at any time, so infected individuals should always notify partners of their condition and wear protection to prevent transmission. Male latex condoms can reduce, but not eliminate transmission Patients must abstain from sexual activity when outbreaks are present Herpes is a lifelong viral illness Human Papillomavirus (HPV) The most common STI
More than 40 different types that can affect the genital tract 90% of the time the immune system with clear HPV The CDC estimated that 20 million people in the US have HPV and 6 million new people are diagnosed each year. Can cause genital warts and cervical cancer. Can also lead to cancer in the anus, vagina, vulva, penis and oropharynx Genital warts can appear as a small bump or group of bumps in the genital area. May be small, large, flat or in a cauliflower shape.
Genital warts can be diagnosed based on examination Genital warts to not require treatment unless pt is symptomatic (puritis, discharge, burning, bleeding, psychological distress etc). Treatment is not thought to decrease transmission rate to partner Most patient respond well to medical therapy, surgical therapy should be reserved for patients who fail medical therapy or those who have extensive lesions. Medical therapies include Podofilox, Podophyllin, Trichloroacetic acid, and Imiquimod Current Pap Guidelines: ASCCP Current Pap guidelines recommend starting Paps at age 21 in healthy females
In Immunocompromised patients, pap tests can be initiated earlier at 18 or onset of sexual activity due to higher risk of invasive cervical cancer Healthy adolescent females (19 and younger) have a high incidence of HPV with minor-grade cytological abnormalities but are at a very low risk for invasive cervical cancer. Most adolescents will clear HPV spontaneously within 2 years of exposure to the virus without much long-term significance HPV Vaccine Facts Recommended for routine vaccination beginning in boys and girls at age 11 or 12. Can be given to females through age 26 and males through age 21. New updates state males can be vaccinated until 26. Protects against high risk strains of HPV known to cause cervical,
oropharyngeal, vulvar, penile and anal cancers. Also protects against genital warts. The annual number of HPV-positive oropharyngeal cancers is expected to surpass the annual number of cervical cancers by the year 2020. Lifetime risk of acquiring an HPV infection 74-70% A study performed in girls ages 11-24 showed that the vaccine does not increase sexual activity. Those who received the HPV vaccine were not more likely to become sexually active than those who did not receive the vaccine. Safe AND effective!!! HPV Vaccine Guidelines with UPDATES
For those initiating the vaccine before their 15th Birthday, the 2 shot series is recommended with the second dose given at 6 12 months after first dose. For those initiating the vaccine on or after their 15th Birthday, the 3 shot series recommended with a second a third dose given at 2 and 6 months from the first injection. For interrupted vaccine schedules, ACIP still recommends continuing the series instead of restarting the series. Series completed based on initial age when 1st dose given. ACIP recommends vaccination with 3 doses of HPV vaccine (0, 12, 6 months) for females and males aged 9 through 26 years with primary or secondary immunocompromising conditions that might reduce cell-mediated or humoral immunity,*** such as B lymphocyte antibody deficiencies or defects, HIV infection, malignant neoplasms, transplant patients, autoimmune disease, or immunosuppressive therapy, because immune response to vaccination might be attenuated Estimated Vaccination Coverage of >= 1
HPV Vaccine Dose Females ages 13-17 Estimated Vaccination Coverage of >= 1 HPV Vaccine Dose Males ages 13-17 Specific Concerns Compared to adult women, adolescents are at higher risk of cervical infections (gonorrhea, chlamydia) due to the immaturity of the cervix leading to larger surface area of cells unprotected by cervical mucous An average of 10 days lapses before a symptomatic adolescent will seek care 25% of adolescents with an STI tried self treatment before seeking care
Single dose therapy is preferred when available, adolescents can be non complaint with longer treatments Strongly encourage patients to notify partners www.dontspreadit.org Expedited Partner Therapy (EPT) EPT is the delivery of medications or prescriptions by patients diagnosed with an STI to their sexual partner(s) without clinical assessment of their partner(s) The CDC concluded that EPT is a useful option to further partner treatment, particularly for male partners of women with Chlamydia or gonorrhea
This is now legal in Texas. 31 states EPT is permissible, in 12 states EPT is potentially allowable and EPT is prohibited in 7 states Reportable STIs All 50 states require Syphilis, gonorrhea and HIV to be reported. In Texas reportable STIs include Chlamydia, gonorrhea, syphilis, HIV and Hepatitis. The provider or lab can make the report The age of sexual consent in Texas is 17 If a patient is younger than 17 and their partner is 3 or more years older than their age, it must be reported. This is considered sexual assault/statutory rape In TX, any patient who is sexually active at 13 years or younger must be reported to CPS
Teen Pregnancy Since 1990 the teen pregnancy rate has dropped by half In 2015, 229,715 babies were born to girls 15-19 year This has dropped by 8% from 2014 The continued decline is thought to be due to more teens abstaining from sex and more sexually active teens using birth control The children of teenage mothers are more likely to have lower school achievement and drop out of high school, have more health problems, be incarcerated at some time during adolescence, give birth as a teenager, and face unemployment as a young adult
Disparities in Teen Pregnancies By race: 10% for Asian/Pacific Islanders 9% for non-Hispanic blacks 8% for Hispanics 8% for non-Hispanic whites 6% for American Indian/Alaska Natives (AI/AN)1
Risk factors: Low socioeconomic status (including lower education levels and low income) Teens in child welfare programs including foster care Teen Pregnancies in Texas In Texas the teen pregnancy rate is 73 per 1000 women. Texas ranks 47th in teen pregnancy rate. The lowest teen pregnancy rates are in New Hampshire In 2014 there were 35,063 teen births
1.1 billion dollars were spent on teenage pregnancies Who is using condoms/ birth control? Among those who said they were currently sexually active 59.1% reported they had used a condom during their last sexual encounter From 1991-2013 a significant linear increase occurred in overall prevalence of having used condoms during their last sexual encounter (46.2%-59.1%) Overall 25.3% of currently sexually active students reported they had used some type of birth control 19% reported using birth control pills to prevent pregnancy before their last sexual intercourse
1.6% reported using the IUD or the birth control implant 4.7% reports using the patch, ring or shot 13.7% of student reported using no type of birth control Birth control options This discussion should include abstinence and contraceptive counseling There are many forms of effective contraception First line birth control methods for teens should be long acting reversible contraceptives (LARCS). These include intrauterine devices and subdermal implants
Other options include oral contraceptive pills, vaginal ring, skin patch, and the injection Who chooses birth control? Teens are more likely to seek contraception if they: Perceive pregnancy as a negative outcome Have long-term educational goals Are older in age
Experience a pregnancy scare or actual pregnancy Have family, friends, and/or a clinician who sanction the use of contraception Have another medical reason to use birth control such as acne, menstrual cramps, etc. LARCS The contraceptive choice study out of St Louis showed that : Among women who chose a LARC method, 86% were still using the method at 1 year. For women who chose a non-long-acting method, only 55% were still using their method at 1 year
Women using either LARC or the injection had the lowest unintended pregnancy rates during year 1, year 2, and year 3 of their follow-up. Pill, patch and ring users had much higher unintended pregnancy rates; they were 20 times more likely to have an unintended pregnancy compared to LARC users in Year 1 The IUD and Implant should be discussed first when presenting options to teens Intrauterine Device (IUD) There are currently 3 IUDs available They can last anywhere from 3-10 years IUDs work by preventing sperm from fertilizing an egg as well as thickening cervical mucus which blocks sperm from entering the uterine cavity
Inserted by trained clinician in office Other uses: most common hormonal IUD is also recommended for patients with heavy menstrual bleeding. The copper IUD can be used as emergency contraception Birth control Implant Small rod that is implanted under the skin in the upper arm Currently one Implant is available. Lasts for 3 years Works primarily by thickening cervical mucous and preventing ovulation
Biggest side effect is change in menstrual bleeding pattern Colorado program Colorado offered free LARCs to teenagers from 2009-2013 The birthrate among teenagers across the state dropped by 40% from 2009 to 2013, while their rate of abortions fell by 42% Birth Control Injection Progestin injection into arm or hip every 11-13 weeks Is 99.7% effective
Stops body from releasing an egg each month May cause irregular spotting/bleeding as well as amenorrhea Can increase bone mineral loss. Regular weight bearing exercise and Calcium and Vitamin D intake is important Can cause weight gain by increasing patients appetite Birth Control Pills Combined oral contraceptive pills contain two hormones: estrogen and progestin One hormone pill is taken at the same time each day to prevent
pregnancy Encourage quick start method. If patients do this the pill will be effective in 1 week after starting it Traditional cycles of BCP are 21 days of hormones followed by a 7 day hormone free break If used correctly can be 98% effective Birth Control Patch Hormonal contraceptive patch worn on the skin that contains two hormones; estrogen and progestin A patch is worn for one week at a time. A new patch is put on
once per week for three weeks. The fourth week is a hormone free break There might be a higher risk of getting pregnant for women who weigh more than 195 lbs May cause skin irritation Can be 98% effective if used perfectly Avoid placement on breasts or legs Birth Control Ring Hormonal contraceptive ring is worn inside the womans vagina. It contains two hormones; estrogen and progestin
A ring is worn for three weeks (21 days). The ring is removed for one week. The fourth week is hormone free May cause vaginal discharge or irritation Can be 98% effective if used perfectly Contraindications to Estrogen: Migraines with aura Personal history of a stroke/blood clot
Known clotting disorders Hypertension Valvar heart disease Prolonged immobilization Watch out for those using certain anticonvulsants, antiretrovirals or rifampin Watch out for family history (first degree relatives) with history of blood clots or known clotting disorders
When in doubt, refer to CDC guidelines!!! Effectiveness of birth control Methods Emergency Contraception Emergency contraception is the use of drugs or a device after unprotected intercourse to prevent pregnancy Candidates include patients whose primary method failed or those who had unprotected intercourse Not intended to be a primary method of contraception In April 2013 a federal judge in New York ordered the U.S. Food and Drug Administration to make Plan B available to people of any age
without a prescription and available in the retail isle Can help prevent up to 80% of expected pregnancies Emergency Contraceptive Pill If taken within 24 hours of unprotected sex it can prevent 95% of possible pregnancies Can be taken up to 120 hours (5 days) after unprotected sex preventing 58% of possible pregnancies Does not affect a pregnancy that has already implanted Cost ranges from 28-50 dollars
Is available OTC at most pharmacies Coupons available online How does Emergency contraception work? 1) Inhibition or delay in ovulation (primary way) 2) Interference with fertilization or tubal transport 3) Prevention of implantation by altering endometrial receptivity
4) Causing Regression of the corpus luteum 5) Thickening of cervical mucus resulting in trapping of sperm Instead of causing an abortion Emergency contraception can help PREVENT a patient from getting one Legal issues with contraception Minors right to contraception varies from state to state In Texas you must have parental consent to start contraception unless you go to a Title X program Texas is one of two states that does not allow state funds to be used to
provide contraceptives to minors without parental consent Teens do not need parental consent to obtain over the counter contraception such as condoms or the emergency contraceptive pill Obtaining a Sexual History Routine assessment of risk factors and sexual activity is important Many adolescents are not routinely evaluated for this during office visits When discussing sexual activity with patients remain straight forward, non judgmental and assure confidentiality Let patients know a sexual history if an important part of regular
medical care Ask to speak with adolescents in private, away from their parents Sexual History Example Form Partners Do you have sex with men, women or both? In the past two months, how many people have you had sex with? In the past 12 months, how many people have you had sex with? Prevention of Pregnancy
Are you and you partner trying to get pregnant? If no what are you doing to prevent pregnancy? Protection from STIs What do you do to protect yourself from STIs and HIV? Practices Have you had vaginal sex? Have you had anal sex?
Have you had oral sex? Do you use condoms (never, sometimes, always)? If not why dont you use condoms? Past history of STIs Have you every had an STI? Have any of your partners had an STI? Who needs a Pelvic Exam? Pelvic exams cause anxiety and discomfort in many adolescent patients. Gonorrhea and Chlamydia can now be screened through the urine
Pelvic exams should be done on symptomatic adolescents or ones with specific complaints An external genital exam is appropriate for those patients complaining about lesions Questions??? References 1. Legal Status of Expedited Partner Therapy (EPT). www.cdc.gov/std/ept/legal.htm, accessed February, 2018 2. Notifiable Conditions 3.
Sexually Transmitted Diseases. www.cdc.gov/std/treatment/2010, accessed February, 2018 4. United States National Immunization survey-Teen 2014. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6429a3.htm#fig3, accessed February, 2016 5. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Decemeber 2016. 65(49);14051408. https://www.cdc.gov/mmwr/volumes/65/wr/mm6549a5.htm. Accessed February 2018. 6. Youth Risk Behavior Surveillance United States 2015, www.cdc.gov, accessed February, 2018 7. Effectiveness of Family Planning Methods. http://www.cdc.gov/reproductivehealth/unintendedpregnancy/pdf/contraceptive_methods_508.pdf, accessed February 2018 8. The Guidelines for Comprehensive Sexuality Education: Grades K-12. Sexuality Information and Education Council of the United States. www.siecus.org/_data/global/images/guidelines.pdf (Accessed February, 2018)
9. Hatcher RA, Trussel J, Nelson AL, et al. Contraceptive Technology, 20th ed, Ardent Media, Inc, New York 2012. 10. Nelson AI, Neinstein LS. Contraception. In: Handbook of Adolescent Health Care, Neinstein LS, Gordon CM, Katzman DK, et al. (Eds), Lippincott Williams & Wilkins, 2009. p.389 11. Diedrich JT, Zhao Q, Madden T, Secura GM, Peipert JF. Three-year continuation of reversible contraception,. Am J Obstet Gynecol. 2015 Aug 7 12. Game Change in Colorado: Widespread Use Of Long-Acting Reversible Contraceptives and Rapid Decline in Births Among Young, Low-Income Women. Sue Ricketts, Greta Klingler and Renee Schwalberg. Perspectives on Sexual and reproductive health. Volume 6, number 3. Septmeber 2014 13. Wiesenfeld HC et. Al. Sex Transm Dis. 2005;32(7):400-5; Ness RB, et. al. Am J Obstet Gynecol 2002;186:929-37 14. Bendnarczyk, R.A., Davis, R., Ault, K., Orenstein, W., Omer, S.B. (2012). Sexual activity related outcomes after human papilloma virus vaccination of 11 to
12 year olds. J Pediatr Adolesc Gtnecol, 27(2), 67-71.; 15. Jemal A., Simard, E.P., Dorell C et al. Annual report to the nation on the status of cancer, 1975-2009, featuring the burden and trends in human papilloma virus (HPV)-associated cancers and HPV vaccination coverage levels. J Natl Cancer Inst 2013 Feb 6:105(3):175-201. 16. Trussell J., Raymond E. (2011). Emergency contraception: A last chance to prevent unintended pregnancy. 1-14 http://www.dshs.state.tx.us/idcu/investigation/conditions/, accessed February, 2018
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