A Tireless Advocate for Adolescent Girls’ Health

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Adolescent gynecologist Aletha Y. Akers, MD, MPH, is a busy woman. Still relatively new to The Children’s Hospital of Philadelphia, 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), which was approved by the FDA in late 2013. Her second study, meanwhile, is supported by a four-year R01 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. Her move to CHOP constitutes a homecoming of sorts, as she attended medical school at Johns Hopkins University, did her undergraduate work at Byrn Mawr College, and grew up in Philadelphia.

“What was really attractive to me about this job is in addition to being trained as an OB/GYN I trained as a health services researcher,” said Dr. Akers. “Therefore the idea of coming to a place where I can interface with multiple different subspecialties and ask, ‘What are the needs of your patients? and ‘How can we optimize care?’ is exactly what I love doing.”

A big part of Dr. Akers’ job is 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.

The Division of Adolescent Medicine has provided non-surgical gynecologic services to adolescent girls for many years. However, historically the Division has had to partner with the CHOP Pediatric Surgery Department and HUP OB/GYN department to make sure the needs of adolescent patients are met. Dr. Akers was brought on, in part, to centralize and optimize surgical and non-surgical gynecologic services at CHOP.

Her first task has been to build a LARC (long-acting reversible contraceptives) clinic at 3550 Market Street, within the Adolescent Medicine Specialty Clinic. Her next tasks are to develop CHOP’s capacity to provide outpatient surgical services and to establish an inpatient GYN consult service. Going forward, she plans to make meet with other CHOP subspecialties to understand the gynecological needs of the patients they serve, she added.

IUS Trial to Investigate Paracervical Nerve Blocks

Dr. Akers’ 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.

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

While many 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 IUS to hit the market, the Skyla.

Manufactured by Bayer Healthcare, Skyla is the smallest IUS currently on the market. Skyla’s smaller size could mean its insertion is less painful than other, larger IUS devices. In fact, “in clinical testing it was demonstrated to be slightly less uncomfortable compared to Mirena,” Dr. Akers said.

The next question is whether medication can further mitigate pain during IUS insertion. Although many pain medications have been studied, almost none have been shown to be effective at reducing IUS insertional pain. However, Dr. Akers pointed out, recent literature shows that paracervical nerve blocks — medication injected into sites around the cervix — show promise in adult women.

With this trial Dr. Akers hopes to answer the question of how effective paracervical nerve blocks 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.

There are “a lot of potential reasons adolescents may benefit more from pain control during IUS insertion,” Dr. Akers said. 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, Dr. Akers noted.

Obesity, Relationships, and Sexual Behavior

Where her Skyla investigation is clinical and patient-based, Dr. Akers’ second project, funded by an R01 from the NICHD, is data-based and behavioral. Over the course of the investigation, she will be leading a study 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 previous 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.

Dr. Akers’ NICHD R01 follows an R21 from the same agency, which was designed to explore the relationship among obesity, obesity and weight perception. This work resulted in three papers currently under review that show among adolescent girls, obesity is linked with greater sexual risk behaviors regardless of age at sexual initiation.

In their current investigation, the researchers will be making use of two datasets: the Pittsburgh Girls Study (PGS) which completed 14 years of data collection in 2013 and the National Longitudinal Study of Adolescent Health (Add Health), which started in 1994 and is currently collecting its fifth wave of data. Both are large datasets, and compliment each other; because Add Health is national and the PGS is local and population-based, data seen in each can be confirmed in the 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 Craig-Dalsimer Division of Adolescent Medicine.

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