Gynecologist's Studies Aim to Improve Adolescent Girls' Health

Adolescent gynecologist Aletha Y. Akers, MD, MPH, is a busy woman. Still relatively new to CHOP, Dr. Akers has already tackled her many responsibilities with aplomb: launching Children’s Hospital’s new adolescent gynecological consult service; seeing patients in the clinic; and leading two studies: a clinical trial, and an analysis of data from two large datasets of adolescent health in the U.S.

Dr. Akers’ clinical trial, funded by a grant from Bayer Healthcare is an investigation of the new Skyla intrauterine system (IUS, also known as an IUD), which was approved by the FDA in late 2013. Her second study is supported by an award from the NIH Dr. Akers received to study the role romantic and peer relationships play in the sexual behavior of obese and non-obese adolescent girls.

After spending eight years at the University of Pittsburgh Medical Center’s Magee-Womens Research Institute, Dr. Akers came to Children’s Hospital in August 2014. In addition to being a practicing gynecologist, Dr. Akers — who is also a faculty member at PolicyLab — conducts research focused on adolescent sexual behavior and reproductive health services. She is also director of the Division of Adolescent Medicine’s new Adolescent Gynecology Consultative Services, which she will be developing in conjunction with Hospital of the University of Pennsylvania (HUP) gynecologists.

Investigating Contraceptive Pain

Dr. Akers’ Skyla IUS trial is rooted in the fact that adolescents experience the highest rates of unintended pregnancy among women of all reproductive age groups, she said. Indeed, according to CDC data, the birth rate for teens aged 15 to 19 years old outpaces that of the general population, at 26.5 live births per 1,000 versus 12.4 births per 1,000.

Long-acting reversible contraceptives like IUDs are considered first-line options for pregnancy prevention in adolescents, and are very effective at treating menstrual disorders, but their uptake remains low among adolescents, Dr. Akers noted. Many adolescents cite the fear of pain during insertion of these devices as a major barrier to adoption.

While a number of studies have examined pain control options among adult women, few have been focused on adolescent women under age 21, who are unlikely to have ever had a pelvic exam or gynecologic procedure. To that end, Dr. Akers has been leading a study of pain associated with the latest intrauterine system (IUS) to hit the market, the Skyla. Manufactured by Bayer Healthcare, the Skyla IUS is the smallest IUS currently on the market. Skyla’s smaller size could mean its insertion is less painful than other, larger IUS devices.

With this trial Dr. Akers hopes to answer the question of how effective paracervical nerve blocks, in which pain medication is injected into sites around the cervix, are at reducing IUS pain in women aged 14 to 22 years. Subjects will be randomized to receive an anesthetic versus those who will receive a “sham” paracervical block, meaning they will be touched with the end of a Q-tip rather than injected.

Because adolescents often have less experience with gynecological procedures, they have less experience with discomfort in that part of the body, and can be more wary of vaginal examinations or procedures, Dr. Akers noted. And because Skyla doesn’t carry the same minimum uterus size restrictions as other IUS devices, it could be used in adolescents who need menstrual cycle control or help with family planning, she said.

Obesity and Sexual Behavior

Where her Skyla investigation is clinical, Dr. Akers’ second project, funded by the NICHD, is data-based. Over the course of the investigation, she will be examining the role social relationships play in the sexual behavior of obese and non-obese girls. By studying large datasets, Dr. Akers and her team hope to determine whether body mass index accounts for differences in how girls develop relationships, and whether that has an impact on their sexual practices.

“There is previous literature that shows that there is a relationship between obesity and reproductive health and relationship formation for women,” noted Dr. Akers.

Adolescent obesity is associated with higher rates of sexual risk-taking and drug use. For example, a 2014 Journal of Obesity study showed obese, sexually active adolescent girls were more likely to have multiple sex partners and engage in unprotected intercourse. And work by Dr. Akers, published in Pediatrics in 2009, showed girls who perceive themselves to be overweight may be less likely to negotiate condom use and more likely to initiate sex early. Moreover, the relationship between obesity and sexual behaviors varied significantly by race.

In their current investigation, the researchers will be making use of two datasets: the Pittsburgh Girls Study which completed 14 years of data collection in 2013 and the National Longitudinal Study of Adolescent Health, which started in 1994 and is currently collecting its fifth wave of data. Both are large datasets and compliment each other.

The overall point of the work, Dr. Akers said, is to ask, “if we look at how peer relationships develop for children, and if we look more at how romantic relationships develop ... is there a relationship between the two, and can we identify some key factors that begin to help us to think about how we may want to structure prevention efforts, educational efforts for these girls?”

To learn more about Dr. Akers’ work and adolescent medicine at CHOP, see the April edition of Bench to Bedside.