Adolescent Contraception

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Introduction

The Centers for Disease Control and Prevention's 2005 Youth Risk Behavior Surveillance Summary reported 34.3% of all students being currently sexually active. 850,000 adolescent girls become pregnant each year.  It is important to note that 35% of teenagers do not use contraception during their first sexual encounter. 20% of teenage pregnancies occur within the first month of beginning sexual activity and 50% within 6 months.  Follow-up data from 2010 showed that 18.3% of babies born to teenagers were repeat births. It is thus essential to initiate discussions about contraception prior to the beginning of sexual activity. 

Talks with the adolescent must be both private and confidential. The overall goals of discussing the various methods of contraception with the adolescent are to prevent sexually transmitted diseases (STDs), prevent unintended pregnancies, and promote sexual education and healthy choices. There are serious consequences when an adolescent is not adequately informed about contraception methods. They may feel embarrassed about asking a physician for guidance on contraception or have fear that their parents will find out, feel they are invincible, and lack the knowledge of how to get access to care. 

 

Methods of Contraception

Abstinence

Abstinence education focuses on the delay of initiation of adolescent sexual activity until marriage or adulthood.

Pros

Cons

  • 100% effective method of birth control and prevention of STDs
  • No data on whether abstinence education reduces pregnancy or STD risk
  • Many adolescents who intend on being abstinent fail and have sex

 

Male Condoms

The male condom serves as a mechanical barrier method of contraception.

Pros

Cons

  • Latex condoms significantly reduce the transmission of some STDs
  • Should be used by all sexually active adolescents regardless of additional method of contraception
  • Involves males in the responsibility of contraception
  • Easy accessibility – available to minors, use without prescription, low cost, easy to transport
  • Can be coated with nonoxynol-9, a spermicidal product
  • Failure rate at the end of first-year use is 3% for perfect use and 14% for typical use
  • Polyurethane condoms can be used for those with a latex allergy, but they are less efficacious
  • Nonoxynol-9 use increases risk of genital ulceration and irritation thus increasing the likelihood of STD transmission
  • Adolescents may not use condoms every time they have sex (54% use by females and 71% use by males at most recent intercourse)

 

Female Condoms

The female condom also works by a barrier method of contraception. Its efficacy is similar to other barrier methods such as the diaphragm and cervical cap.

Pros

Cons

  • Helps protect against STDs
  • Very useful for females with male partners who do not want to use a condom
  • Can be inserted 8 hours prior to having sex
  • Can be used with spermicide
  • Failure rate of 0.8% with perfect use and 12%-15% with typical use
  • Adolescents have concerns about difficulty of insertion and appearance and noisiness of the device
  • Male condoms are cheaper and have higher efficacy rates of preventing pregnancy and STDs

 

Diaphragm and Cervical Cap

These are barrier methods which have higher efficacy when used with spermicide. The diaphragm is a flexible latex cup that is inserted into the vagina and must remain there for 6 hours after having sex. Cervical caps are latex or silicone cups that have a firm rim that suctions to the cervix preventing sperm from entering the uterus for up to 48 hours.

Pros

Cons

 

  • Failure rate of diaphragm with perfect use is 6% and 20% with typical use
  • Failure rate of cervical cap is 26% with perfect use and 40% with typical use
  • Require prescription and doctor's visit for fitting
  • Increased incidence of urinary tract infection
  • Does not prevent transmission of STDs
  • Requires some skill for use
  • Unpopular with teenagers

 

Vaginal Spermicides

Vaginal spermicides are applied intravaginally and serve as a chemical barrier method of contraception. They come as a gel, foam, suppository, or film. Nonoxynol-9 is the chemical compound that kills the sperm.

Pros

Cons

  • Very effective for adolescents when used in conjunction with condoms – prevents pregnancies, decreases risk of STDs, available without prescription, cheap

 

  • Women should not use nonoxynol-9 alone for STD and HIV protection – they may have an even higher rate of transmission when compared to lubricant alone
  • Not advocated as a contraception method when used alone

 

Oral Contraceptives (OCPs)

There are currently three formulations of OCPs including the fixed-dose in which each tablet contains the same dose of estrogen and progestin, the phasic dose which contain varying doses of estrogen and progestin, and the minipill which only contains progestin. OCPs are the most popular method of prescribed contraceptive among adolescents. Absolute contraindications include history of DVT, CVA, known Factor V Leiden mutation or other thrombophilic risk factors. 

Pros

Cons

  • Reliable and effective for the prevention of pregnancy
  • Improves acne, decreases menstrual cramping, pain, blood loss, and ovarian cysts
  • Protection against endometrial and ovarian cancers
  • Pelvic exam is unnecessary prior to initiation
  • Rx only
  • Potential of lower efficacy with the use of other medications
  • Adverse effects directly related to estrogen dose: nausea, breast tenderness, headaches, and breakthrough bleeding
  • Failure rate of 0.1% when used perfectly and 5%-8% with typical use
  • Adolescents are often noncompliant – failure rates may reach 15%-26%
  • Does not prevent transmission of STDs

 

Injectable Hormonal Contraception

A long-acting progestin-only formulation, depot medroxyprogesterone acetate (DMPA), can be injected every 12 weeks as a single 150-mg intramuscular dose to serve as an effective method of contraception.

Pros

Cons

  • Highly effective in preventing pregnancy (pregnancy rate in first year of use is 0.3%)
  • Convenient and less dependent on compliance vs. the pill
  • Lack of estrogen-related adverse effects
  • Protection against endometrial cancer and iron-deficiency anemia
  • Menstrual cycle irregularities
  • High discontinuation rate amongst adolescents (33% choosing to discontinue after first shot)
  • Adverse effects include acne, weight gain, headaches, and bloating
  • Delayed return to fertility (9-18 months) with prolonged use
  • Reduction in bone mineral density – unknown effects on long-term skeletal health
  • Does not prevent transmission of STDs

 

Progestin Implants

Norplant-2 and Implanon are levonorgestrel implants that are inserted subcutaneously into the upper arm in the doctor's office. It is a highly effective progestin-only contraceptive that works for up to 5 years.

Pros

Cons

  • Good for adolescents who want an extended length of protection
  • Convenient – do not need to remember to take a pill every day or bring a barrier
  • High initial cost
  • Adverse effects include breakthrough bleeding and headaches
  • Some medications may decrease its efficacy
  • Difficult to remove
  • Does not prevent transmission of STDs

 

NuvaRing

NuvaRing is a round and flexible vaginal ring that is inserted in the vagina and stays in place for three weeks, subsequently removed for one week to induce menstruation, and inserted again. The ring is made of silicone and releases estrogen and progestin.

Pros

Cons

  • 99% efficacy when used correctly
  • High compliance
  • Few adverse effects
  • Adverse effects include irregular bleading, vaginitis, headache, leukorrhea, nausea, and vaginal discomfort.
  • Expulsion a common reason for discontinuation
  • Does not prevent transmission of STDs

 

Ortho Evra

Orthro Evra is a transdermal adhesive skin path that contains norelgestromin and ethinyl estradiol. It can be applied to the abdomen, upper torso, upper outer arm or buttocks weekly. One patch lasts for one week and three patches are used for three weeks in a row followed by one week without the patch to induce withdrawal bleeding.

Pros

Cons

  • Same efficacy as OCPs
  • Higher compliance than with OCPs
  • Adolescent girls are more likely to dislodge the patch and experience irritation and hyperpigmentation than adult women
  • Does not prevent transmission of STDs
  • Adverse effects include skin irritation at placement site, temporary irregular bleeding, temporary breast discomfort, weight gain or loss, and nausea
  • 2005 FDA warning: patch may be associated with increased estrogen exposure, though this may be based on difference in pharmacokinetic profiles of various patients. 

 

Intrauterine Devices (IUDs)

IUDs are inserted into the uterus where they release hormones, ions or enzymes that prevent sperm from fertilizing the ova or prevent implantation. Mirena releases the progestin levonorgestrel and is effective for 5 years and ParaGard releases copper that kills or immobilizes sperm and is effective for 10 years. Absolute contraindications include a past history or continuing risk for ectopic pregnancy.

Pros

Cons

  • Safe and effective method of contraception (fail rate <1%)
  • Does not affect fertility in the absence of infection
  • Useful for adolescents with severe menorrhagia and dysmenorrhea, as amenorrhea can occur in 1 year in 20-50% of patients.
  • Does not prevent transmission of STDs
  • Usually nor recommended for nullparous women

 

Withdrawal

The withdrawal method is when the male partner withdraws his penis from the vagina before ejaculation.  It is very commonly used by adolescents.

Pros

Cons

 

  • Failure rate of 19% within the first year
  • Does not prevent transmission of STDs

 

Periodic Abstinence Methods

This requires the female partner to have a strong awareness of her menstrual cycle and reproductive fertility. In this method, the partners abstain from having sex on the days when sex is most likely to result in pregnancy.

Pros

Cons

 

  • Failure rate of >25% in the first year
  • Particularly ineffective for adolescents because ovulation may not be predictable in the first few years after menarche
  • Does not prevent transmission of STDs

 

Emergency Contraception

Emergency contraception can be administered either by ingesting oral hormones or inserting a copper-releasing IUD. An IUD can be inserted to prevent pregnancy for up to 5 days after having unprotected sex. The oral preparation of the progestin-only regimen, known as Plan B, is the much more popular method of emergency contraception. The two pills in Plan B should be taken within 72 hours of having unprotected sex.  Absolute contraindications include known pregnancy due to its lack of efficacy in such an instance, but a pregnancy test should be administered only if pregnancy is suspected.

On a policy level, providers should advocate for increased non-prescription access to emergency contraception for teenagers to reduce cost-barriers. 

Pros

Cons

  • Reduces the risk of pregnancy after unprotected sex by at least 74%
  • Does not cause abortion and is not teratogenic
  • No increased amount of adverse effects with repeated use
  • 90% effective within 24 hours, 75% effective within 72 hours, 60% effective within 120 hours
  • Adverse effects include nausea, vomiting, and changes in the menstrual cycle
  • Requires prescription for those under 17 years of age

 

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References

  1. AAP Committee on Adolescence. (2007). Policy statement: contraception and adolescents. Pediatrics, 120(5), 1135-1148.
  2. AAP Committee on Adolescence. (2012). Policy statement: emergency contraceptionPediatrics, 130(6), 1174-1182.
  3. Gupta, N., et. al. (2008). Hormonal contraception for the adolescent. Pediatrics in Review, 29(11), 386-397. 
  4. Kennedy K. (2007). Frankly speaking: how to talk to teens about sexuality, abstinence, appropriate contraceptive use and protection from sexually transmitted infections. AAP News, 28(11), 1-9.
  5. O'Connell, P.M. (2013). CDC: repeat births among teens remains high. AAP News, published online April 4, 2013.
  6. Rimsza, M. (2003). Counseling the adolescent about contraception. Pediatrics in Review, 24(5): 162-170.
  7. Tulloch, T. and Kaufman, M. (2013). Adolescent sexuality. Pediatrics in Review, 34(1), 29-38.

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