Approximately 750,000 adolescents become pregnant each year in the United States and nearly half of high school students report having had sexual intercourse. More than 80% of teenage pregnancies are unplanned and result in substantial health care costs, reduced earning potential, and increased health risks to both the mother and newborn. The American Academy of Pediatrics has released an updated policy statement that endorses long-acting reversible contraception (LARC) as a first-line consideration for adolescent contraception.
Sexual history taking and counseling
The American Academy of Pediatrics (AAP) encourages the 5 P’s of sexual history taking: partners, prevention of pregnancy, protection from sexually transmitted infections (STIs), sexual practices, past history of STIs, and pregnancy. Confidentiality is advised for issues revolving around sexuality and sexually transmitted infections. Most states have legislation regarding minor consent for contraception, details of which can be found at the Guttmacher Institute. The adolescent should be encouraged to delay onset of sexual activity until they are ready, but abstinence should not be the only focus of contraception counseling, and adolescents should be supported in choosing, and adhering to, a method of contraception if they choose to be sexually active.
Methods of contraception
The updated AAP policy statement advises that physicians offer methods of contraception by discussing methods that are more effective preventing pregnancy as preferred over methods that are less effective. The effectiveness of all contraceptive methods is described by typical user rates and average user rates, expressed as the percent of women who become pregnant using the method for 1 year. The gap between perfect and typical user rates is explained by the amount of effort that is needed to reliably use the method. Typical user rates should guide decisions about contraceptive efficacy for adolescents. Long-acting reversible contraception (LARC), specifically implants and intrauterine devices, are the most effective methods and should be encouraged for adolescents who desire birth control.
Progestin implants: Implanon and Nexplanon (Merck) are both implants containing the active metabolite of desogestrel, a progestin. Failure rates are less than 1% for the 3-year duration of the implant. Unpredictable bleeding or spotting is common, but implants are ideal for patients who desire an extended length of pregnancy prevention, without any schedule of adherence.
IUDs: These LARCs include two levonorgestrel-releasing IUDs (Mirena, 52 mg levonorgestrel and Skyla, 13.5 mg levonorgestrel, Bayer HealthCare Pharmaceuticals) and a copper-containing IUD (ParaGard, Teva ). All remain in place for 3-10 years, depending on brand, and have less than 1% failure rates. Known to be safe for use in nulliparous adolescents and patients with a previous episode of pelvic inflammatory disease (PID), STI screening in the asymptomatic patient can be performed on the day of IUD insertion. Infection can be treated while the IUD remains in place. Contraindications to an IUD are current, symptomatic PID or current, purulent cervicitis.
Progestin-only injectable contraception: Depot medroxyprogesterone acetate (DMPA or Depo-Provera, Pfizer) is a long-acting progestin given as a single intramuscular injection every 13 weeks. DMPA has a typical use failure rate of 6% in the first year and can be initiated on the same day of the visit if the patient is not pregnant. Bone density reduction seems to recover once DMPA is discontinued and bone density does not need to be measured repeatedly. However, individual risk for osteoporosis must be assessed, and all patients need to be counseled on adequate calcium and vitamin D intake.
Combined oral contraceptives (COCs): COCs all contain an estrogen and a progestin. A follow-up visit is advised in 1-3 months after starting COCs, and no gynecologic examination is necessary prior to COC use. COC can be started on the same day as the office visit in nonpregnant adolescents. The typical use failure rates are 9%, and adolescents should be educated on what to do when pills are missed. A serious adverse event associated with COC is up to 4/10,000 risk of thromboembolism, but the risk is up to 20/10,000 during pregnancy. Rifampin and antiviral and antiepileptic medications can decrease efficacy. Contraindications to COCs should be reviewed prior to prescribing.
Contraceptive vaginal ring: The vaginal ring (NuvaRing, Merck) has similar efficacy and side effects as the COCs, since it releases a combination of estrogen and progestin. Inserted and left in place for 3 weeks, it is then removed for 1 week to induce withdrawal bleeding.
Transdermal contraceptive patch: The patch has similar a similar profile as COCs and the vaginal ring. It is placed on the upper arm, torso, or abdomen, left in place for 3 weeks, and removed for 1 week. Users have estrogen exposure of 1.6 times that of COC users, so there is a potential for increased thromboembolism with patch use. Obese patients have a higher risk of pregnancy with perfect use.
Progestin-only pills: Progestin only pills work by thickening cervical mucus. Failure rates are elevated, due to the need for strict, timed dosing schedule. They provide an option for the patient who has concerns with estrogen use.
Male condom use: Condoms remain a cheap, easily accessible form of contraception, used by 53% of female and 75% of male adolescents studied. With an 18% failure rate with typical use when used alone, condom use should be additional to another effective hormonal or long-acting contraceptive.
Emergency contraception: Various hormonal options can be used up to 5 days after unprotected intercourse. Plan B One-Step is a nonprescription form available for all women of childbearing potential.
Withdrawal: 57% of female adolescents report using this method. A 22% failure rate and lack of STI protection is important to relay to the patient and more effective contraception methods should be encouraged.
The Bottom Line
The IUD and implant should be considered safe, first-line contraceptive choices for adolescents. Physicians should counsel adolescent patients on all available methods of contraception in a developmentally appropriate, confidential manner that falls within the limits of state and federal law. Condoms should always be encouraged for STI protection.
Reference: Contraception for Adolescents. Pediatrics 2014;134:e1244-e56
Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Roesing is an assistant director in the Family Medicine Residency Program at Abington Memorial Hospital.
