The latest on teenage contraceptive options

“The most used contraceptives among adolescents are condoms, withdrawal, and oral contraceptive pills. Although fewer teenagers use LARC methods, use of IUDs [intrauterine devices] and implants is increasing,” says Cara Clure, MD, a family planning fellow at the University of Colorado in Aurora. “LARC methods are safe, highly effective options for adolescents that have higher continuation and satisfaction rates compared with teenagers who use short-acting contraceptives.”

According to the American College of Obstetricians and Gynecologists (ACOG), about 19 of every 1000 teenaged girls became pregnant in 2017. Although this is a record for the United States—down from 117 per 1000 in 1990—teenager pregnancy rates in the United States are some of the highest among developed countries.¹ Although abstinence and sexual education have contributed to the decrease in adolescent pregnancy rates, the Centers for Disease Control and Prevention (CDC) reveals that increases in the use of contraceptives among these age groups are perhaps the biggest contributor to the decline.²

Furthermore, use of LARCs is gradually increasing. The CDC reports that, nationwide, LARC use among teenagers in 1 study increased from 0.4% in 2005 to 7.1% by 2013³ and about 20% by 2017^.4 Although these trends are promising, the reliance of teenagers in 65% of encounters to rely on the withdrawal method for birth control shows need for more education.

ACOG recommends discussing contraception options with patients between ages 13 and 15 years, regardless of previous sexual activity, clearing up misunderstandings; providing an overview of the most effective methods; and offering information on emergency contraception. “Because teenagers are at high risk of sexually transmitted infections (STIs), dual-method use—using condoms in addition to a more effective contraceptive method—is ideal,” Clure says.

Education on condom use seems to have taken hold, with about 97% of teenagers reporting condom use during sexual encounters, according to the CDC.² However, as a dual method, Clure says many adolescents choose oral contraceptive pills along with the use of technology like cell phone alarms or apps that can send re- minders and improve medication adherence. Clinicians can’t rely on technology alone to help adolescents figure out contraception, though.

“Teenagers should also be counseled about what to do if they miss a pill and about options for emergency contraception. Technology reminders can be helpful for those using the contraceptive patch, vaginal ring, or Depo-Provera [medroxyprogesterone acetate],” Clure says. LARCs, on the other hand, take a lot of guesswork out of the adherence equation. “Some adolescents may choose a LARC method because it does not require medication adherence.”

LARCs have become a favorite in this age group because of how effective these methods are, along with ease of use. Adherence is simpler than with oral contraceptives, so teenagers are more likely to be satisfied and continue with these forms of birth control. The safety and ease of LARCs make them an ideal choice to recommend to teenagers, ACOG reports.

The most popular types of LARCs include:

PROGESTIN IMPLANTS

These single-rod implants contain etonogestrel and are highly effective, with failure rates of less than 1%, according to the American Academy of Pediatrics (AAP). These implants are inserted into the inner part of the upper arm and can remain in place for up to 3 years. This option can be offered to pregnant teenagers or teenagers who have just given birth for immediate postpartum protection. No effects have been noted regarding breastfeeding, says AAP.⁵ Clinicians must warn patients about the need for a backup method of contraception for at least the first week after implantation, as well as the fact that implants may prevent pregnancy but do not prevent STIs.

IUDs

Inserted into the uterus, these devices are also highly successful and can provide long-term contraception. There are 2 types of IUDs approved in the United States. These include a T-shaped device that releases levonorgestrel and a T- shaped implant that contains copper. The latter may also be used as an emergency contraceptive method up to 5 days after unprotected intercourse. Like progestin implants, these LARCs have a less than 1% failure rate, but concerns have been raised about infection and infertility risks with these devices.

Although infertility has largely been disproved, there are other drawbacks to IUD insertion, according to AAP.⁵ These include pain with insertion and expulsion, which AAP says can occur more often in younger women. However, like implants, IUDs can be used as emergency contraception, can be placed in pregnant and immediately postpartum women, and have higher continuation rates than oral contraceptives. IUDs can- not be used in patients with purulent cervicitis, gonorrhea, chlamydia, and active pelvic inflammatory disease or certain other pelvic infections.

PROGESTIN-ONLY INJECTABLE CONTRACEPTION

These LARCs are not as long lasting as other methods but also do not re- quire removal to stop therapy. Long- acting progestin, also known as depot medroxyprogesterone (DMPA), is administered every 13 to 15 weeks as a single intramuscular or subcutaneous injection. Although backup contraception must be used for at least a week, and the injection cannot be used in pregnant women, this method is sometimes favored because it can usually be initiated on the same day as the decision is made to begin birth control.

A disadvantage to this method, outside of frequent injections, is more potential adverse effects (AEs) than from other LARCs.

Possible side effects include:

• menstrual irregularity
• headache
• mastalgia
• hair loss
• weight gain
• libido changes

Other options for contraceptives in teenagers include oral contraceptives, vaginal rings, contraceptive patches, and barrier methods like condoms, but adherence and proper use can be difficult for some younger patients—particularly those with special health care needs like developmental disability. Even if sexual activity is not the primary concern, contraceptives are sometimes used in these populations to help address other menstrual complications.

“Although there are few medical contraindications to contraceptives in healthy adolescents, a complete medical history, including a review of current medications, is important before contraceptive initiation. Adolescents with complex medical conditions may not be candidates for all contraceptive options,” Clure says. For example, estrogen-containing contraceptives or combined hormonal methods are contraindicated in adolescents with migraine with aura or a history of venous thromboembolism, she explains.

“If teenagers are not good candidates for estrogen-containing contraceptives, progestin-only options are preferred, including LARC methods,” Clure says. “Adolescents with intellectual or physical disabilities may benefit from contraceptive choices that reduce or suppress menstrual bleeding such as the levonorgestrel IUD, Depo-Provera, or combined hormonal methods like the pill and patch, because menstrual management may be difficult for these patients.”

Clure says all teenagers should be educated about possible AEs associated with different contraception methods. For example, combined hormonal methods such as pills, the patch, and the vaginal ring can cause irregular bleeding, breast tenderness, and nausea, especially with initiation. Irregular bleeding is common with the levonorgestrel IUD and contraceptive implant. Overall, the decision should rest solely with the patient after thorough education on all the options.

“The patient’s choice should be the guiding factor in prescribing one method of contraception over the other. When providing contraceptive counseling to adolescents, it is important to offer all contraceptive options that are appropriate for that patient, including LARC methods, and engage in shared decision-making with the adolescent,” Clure says. “Contraceptive counseling for teenagers should include anticipatory guidance about AEs, efficacy, and noncontraceptive benefits, such as improvement in dysmenorrhea and heavy menstrual bleeding, which may be a deciding factor for some patients. Adolescents should also be informed about how each method is initiated and discontinued.”

AEs, and the ease of use and adherence that LARCs offer, make them the first line of contraception for teenagers that AAP recommends.⁵ Pediatricians can receive training to offer LARCs to their patients but should also be prepared to make necessary referrals. Clure, however, cautions that there is no best method for everyone.

“Contraceptive counseling for adolescents should elicit and address concerns and misperceptions about contraception. Misinformation, particularly about the safety of LARC use in teenagers, can be a barrier, making it important to address the safety and benefits of LARC use in adolescents,” she adds. “No single contraceptive method is right for every teenager, and counseling should empower the teenager to make the decision that fits his/her needs and goals.”

References

1. Gerancher K; American College of Obstetricians and Gynecologists’ Committee on Adolescent Health Care. Counseling adolescents about contraception. American College of Obstetricians and Gynecologists. August 2017. Accessed May 15, 2021. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/counseling-adolescents-about-contraception

2. About teen pregnancy. Centers for Disease Control and Prevention. Updated March 1, 2019. Accessed April 24, 2021. https://www.cdc.gov/teenpregnancy/about/index.htm

3. Romero L, Pazol K, Warner L, et al; Centers for Disease Control and Prevention. Vital signs: trends in use of long-acting reversible contraception among teens aged 15-19 years seeking contraceptive services—United States, 2005-2013. MMWR Morb Mortal Wkly Rep. 2015;64(13):363-369.

4. Abma JC, Martinez GM. Sexual activity and contraceptive use among teenagers aged 15-19 in the United States, 2011-2015. National Health Statistics Report. 2017;104. https://www.cdc.gov/nchs/data/nhsr/nhsr104.pdf

5. Committee on Adolescence. Contraception for adolescents. Pediatrics. 2014;134(4):e1244-e1256. doi:10.1542/peds.2014-2299