The US has the highest pregnancy rate of any industrialized nation, approximately twice that of Canada, four times that of France, and eight times that of Japan or Italy.1 In recent years, the rate has declined, partially due to delayed coitarche (age of onset of vaginal sexual intercourse) but mainly due to greater use of contraception.2 Per the 2011 Youth Risk Behavior Survey (a national survey of about 15,000 youth in schools), 33% of high school freshmen, 44% of sophomores, 53% of juniors, and 63% of seniors have had vaginal sexual intercourse. To prevent unplanned and unwanted teenage pregnancies, which have negative consequences on a teenager’s health and future, pediatricians must be able to provide birth control or at least know where to refer their patients in need.
To know whether an adolescent needs birth control, the pediatrician needs to ask, without the parent(s) in the room, if the patient has ever had vaginal sex. Other standard questions in a sexual history include: are you interested in men, women or both? Have you had oral, vaginal, or anal sex? How many sexual partners have you had in your life? In the past 2 months?
Minors’ access to contraception varies by state: 21 states and the District of Colombia allow adolescents to consent to contraceptive care, four states have no explicit policy and 25 states only allow permission in certain circumstances. It is important to know the law in your state.
According to Jones and colleagues,3 one in five adolescents would use no contraception or resort to the withdrawal method if there were mandated parental notification of contraception services.
Each year, about 10% of teenagers in high school lose their virginity.4 Some of these students may not show up for years between visits to their physicians, missing opportunities to learn about the risks of being sexually active.
Regardless of their sexual history, all teenagers should be educated about their rights to confidential reproductive health care and about emergency contraception (EC). These methods should be discussed not only with any young woman, regardless of her sexual orientation (because she could be raped and need EC), but also with any heterosexual young man of reproductive age. EC is one of the few methods in which men can take responsibility by carrying EC with them in case a condom fails.
Indications for EC
The main indications to prescribe EC are unprotected intercourse, sexual assault, or failure of a contraceptive method such as a broken condom or missed doses of oral/vaginal/injection contraceptives. We recommend that every teenager has an advance provision of EC, either as a prescription kept on hand or the actual EC package kept at home. EC should be provided in advance so that the medication is immediately available should first-line prophylactic methods fail. Otherwise, the teenager must locate a provider, connect with the provider, and find a pharmacy to fill the prescription while the window of opportunity to prevent a pregnancy is closing. Some might fear that EC could be viewed as sufficient contraception in itself by young adults and that their interest in regular contraceptive methods would decline. However, research has shown that when adolescents are provided with EC in advance, they do not forsake their current form of birth control for EC. Providers can counsel teens about EC with the emphasis that having both a primary contraceptive method and EC offers the best protection. EC can be thought of as a “fire extinguisher” that is readily available for an emergency; but it has a much lower efficacy than regular birth control, and so should be excluded from non-emergent use.
Any young woman presenting for a pregnancy test who has had unprotected vaginal sex in the past 120 hours (5 days) is a candidate for EC. In addition, the provider should always ask as part of their sexual history: “When was the last vaginal intercourse and was it protected?” If unprotected and within the past 120 hours, consider providing EC (see Sidebar 1).
Overview of Contraception
Emergency contraception (in increasing order of efficacy)
Regular contraceptive options (in increasing order of efficacy)
- Yuzpe method (100 mcg ethinyl estradiol and 1 g of norgestrel every 12 hr)
- Progesterone-only (1.5 mg levonorgestrel orally x 1)
- Ulipristal acetate (30 mg orally x1)
- Copper IUD
- Abstinence or Masturbation
- Combined hormonal methods
- Depot medroxyprogesterone injection
- Contraceptive implant
- Intrauterine device (Copper IUD)
- Intrauterine systems (IUD with levonorgestrel)
Emergency Contraception Treatment Regimens
EC originated as high doses of combination estrogen/progesterone pills (the Yuzpe regimen per the Canadian professor Albert Yuzpe, MD). The Yuzpe regimen has a much lower efficacy compared with other EC options, preventing only 57% of pregnancies versus 85% with levonorgestrel-only (LNG-only) pills. The Yuzpe regimen also has double the incidence of nausea and vomiting compared with LNG-only EC.
If no other EC options are available, then one could utilize the Yuzpe method. Many brands of regular oral contraceptive pills can be used as EC as long as the dose equals at least 100 mg ethinyl estradiol and 1 gm of norgestrel taken as soon as possible and again in 12 hours. For a complete list of US Food an Drug Administration (FDA)-approved pills for use as EC, see Sidebar 2.
Minors’ access to contraception:
Approved pills for emergency contraception:
Reviews of condoms by users:
Patient information about IUDs:
LNG-only EC (Plan B, Plan B One-Step, Teva; Next Choice, Duramed) is FDA approved for use within 72 hours of unprotected sex, although World Health Organization (WHO) studies have shown efficacy up to 120 hours.5 The WHO suggested regimen is 1.5 mg LNG as soon as possible after unprotected sex, sexual assault, or contraceptive failure.
FDA-approved in 2010, ulipristal acetate (UPA; ella, Watson) is a progesterone receptor agonist and antagonist. Its efficacy is proven up to 120 hours after unprotected sex, taken in a single 30-mg dose. If taken within 24 hours, UPA had a 65% lower pregnancy rate than LNG. If taken within 72 hours, UPA had a 42% lower pregnancy rate.6 However, providers must keep in mind that UPA may not be widely available in US pharmacies. They should ensure that the patient will be able to obtain the medication if not provided in the office.
The copper IUD is the most effective EC, preventing 99.9% of pregnancies.7 The copper IUD may be inserted up to 5 days after unprotected intercourse or contraceptive failure.
Counsel for the Adolescent Patient on EC
When discussing EC with patients, providers should cover the following issues: the possibility of EC failure; future contraceptive plans; and follow-up care. Teens may ask the provider if EC will terminate an existing pregnancy — they should be educated that LNG EC is not an abortifacent. LNG works mainly by delaying ovulation and will not disrupt an already fertilized and implanted pregnancy. Possible side effects to communicate to the patient for oral EC regimens include nausea, vomiting, headaches, and menstrual-like cramping.
Return to Other Contraception Methods
The patient can start oral contraceptive pills (OCP), the patch, or the vaginal ring the day after she finishes taking EC; there is no need to wait for her next monthly bleeding. A new OCP user should begin a new pill pack. A continuing user who needed EC due to pill-taking errors can continue where she left off with her current pack. All women will need to use a backup method for the first 7 days after EC use.
Contraindications to Use of EC
Per the WHO guidelines in 2009,8 there are no level 3 nor 4 contraindications to Yuzpe or LNG-only EC. Patients with known allergies to LNG or OCPs should not receive LNG-only EC. Patients with a known pregnancy should not receive EC, as the medication will not be effective.
Legal and Confidentiality Considerations
In 17 states, health care facilities are legally required to provide EC to sexual assault patients.9 As of 2009, LNG-only EC pills are available “behind the counter” at pharmacies and require identification for men and women aged 17 and older. Patients 16 years of age and younger require a prescription from the physician. In nine states, a pharmacist may prescribe EC directly without a physician’s prescription if they work in collaboration with a physician or have undergone specialized training.8
Research has shown that as many as one in three women have trouble reaching climax when having sex, and as many as 80% of women have difficulty with orgasm from vaginal intercourse alone. It is important to counsel adolescents that there are other ways to explore intimacy with a partner, such as mutual masturbation. Other options are secondary abstinence, which refers to people who are sexually experienced (not virgins) but choose to become abstinent (no longer sexually active). Some common reasons people choose to become abstinent following initiation of sex include contracting an STD, fear of unintended pregnancy, and moral or faith-related reasons.
Most youth have been educated about condoms, in part because of sexual education programs offered in schools. A clinical pearl about condoms for providers to know is that there are different thicknesses. Thinner condoms may have better sensation, without increased breakage. For information about which condoms to offer in your clinic, see Sidebar 2. Besides abstinence and masturbation, condoms are the only proven method for the prevention of STDs.
Combined Hormonal Methods
The contraceptive patch, OCPs, and contraceptive vaginal ring all contain estrogen and progesterone, and share many of the same side effects and contraindications.
Their benefits include lighter menses; regulation of menses; improved acne; and decreased risk of ovarian, endometrial, and colorectal cancer. The primary difference between the methods is how often a patient has to think about the medication — once a day, once a week, or once a month. Also, the contraceptive patch has a greater total estrogen exposure over time when compared to the pill and, thus, a slightly higher thromboembolic risk.10 The patch essentially is equivalent to a 50-mcg pill and is indicated in patients who take medications that speed up the metabolism of estrogen, or who require higher estrogen levels.
The pill causes hormone levels to peak and drop each day. Each weekly contraceptive patch takes 3 days after application to reach a steady hormone level of 20 mcg ethinyl estradiol. The ring releases 15 mcg of ethinyl estradiol locally at a steady dose every day, which may explain why the ring is less likely to cause headaches and nausea than either the pill or patch.
The most common side effects of the pill are lighter menstrual bleeding and spotting (which should stop after 3 to 4 months). The patch may cause skin irritation at the site. The vaginal ring may cause discharge and/or irritation.
Less common side effects for OCP include nausea and vomiting, especially during the first month of use; frequent or more severe headaches; breast tenderness for the first few months; depression or mood changes; chloasma; and change in libido. Venous thromboembolisms are rare but adolescents should seek emergent/urgent care if they experience one of the symptoms listed in Sidebar 3 (ACHES mnemonic). We suggest reviewing these symptoms with patients, although the risk is very low in someone who is younger than 35 years of age and a nonsmoker:
ACHES Mnemonic for Venous Thromboembolism
bdominal pain that is severe or persistsC
hest pain may be a sign of pulmonary embolismH
eadaches that are severe may be a sign of stroke, migraine, or high blood pressure (hypertension)E
ye problems, such as blurred vision or loss of visionS
evere leg pain or sudden swelling of one leg
Patients may skip the placebo pills in the OCP packs or the withdrawal weeks for the patch/ring, thus “continuously” staying on active hormones. Many patients may feel uncomfortable about not having a period each month, although data indicate that it is not abnormal for a woman not to have monthly periods.11Anecdotally, many young women enjoy that the pill/patch/ring gives them control over the timing of their periods. A 2005 survey from the Association of Reproductive Health Professionals found that 72% of women said they did not like having a period and 40% would prefer no periods ever.
Depot Medroxy Progesterone Acetate Injection
Injections of depot medroxy progesterone acetate (DMPA) are indicated for any young woman who needs pregnancy prevention, especially if she is unable to use an estrogen-containing form of birth control (see Sidebar 4).
Contraindications for Combined Hormonal Methods
- Migraine with aura
- Complicated diabetes
- Severe HTN (BP ≥ 160/100 mm Hg)
- Active liver disease or tumor
- Personal (not family) history of DVT/PE or known thrombogenic mutation
- Major surgery with prolonged immobilization
- Breast-feeding < 6 weeks postpartum
- Current breast cancer
- Elevated BP (140-159/90-99 mm Hg) or controlled HTN
- History of HTN where BP cannot be evaluated
- Breast-feeding: 6 weeks to 6 months
- Past breast cancer
- Postpartum < 21 days non–breast-feeding
- Liver or gall bladder disease or OCP-related cholestasis
- Drugs that affect liver enzymes (rifampin, seizure meds)
BP = blood pressure; DVT = deep vein thrombosis; HTN = hypertension; OCP = obstructive cholestasis during pregnancy; PE = pulmonary embolism.
The benefits of this method are a decrease in menstrual-associated symptoms such as dysmenorrhea, headaches, and breast tenderness; minimal drug interactions; fewer grand mal seizures; fewer sickle cell crises; decreased incidence of PID and endometrial cancer. Relative contraindications include a history of depression, obesity, and low bone mineral density.
The possible side effects/disadvantages of DMPA are irregular menses (approximately 40% achieve amenorrhea by the 4th shot); a decrease in bone mineral density (reversible after stopping the medication12); exacerbation of depression; weight gain in overweight or obese patients; once it has been administered, there is no reversing it; a delay in return in fertility (9 to 10 months is the median). Additionally, visits are required every 3 months for the injection, since it is dosed every 12 weeks, although it can be given up to 16 weeks after the last shot.3
Contraceptive Progesterone Releasing Implant
The contraceptive progesterone releasing implant (Nexplanon, Merck & Co.) is indicated for any young woman who needs pregnancy prevention, especially if she is unable to use an estrogen-containing form of birth control (see Sidebar 4). The benefits of this method include lighter menses; ease of use/adherence; reduced ectopic pregnancy; no estrogen; and high acceptability and continuation rates.
The WHO states that contraindications for this method are14: breast-feeding less than 6 weeks postpartum; current deep vein thrombosis or pulmonary embolism; unexplained vaginal bleeding; systemic lupus erythematosus (SLE) with positive or unknown antiphospholipid antibodies; severe cirrhosis; liver tumor; current or past breast cancer; use of ritonavir-boosted protease inhibitors; and specific anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine), rifampin, or rifabutin.
Possible side effects/disadvantages of the implant are an irregular menses; an ovarian cyst-suppression rate that is lower than that of OCPs; possible decreased efficacy when used with antiretroviral agents, antiepileptics, and rifampin.13
The implant lasts for 3 years, although one study had no pregnancies in 275 women at year 4.13
A clinical pearl for any progesterone-only method-related irregular bleeding, is that providers can treat with prostaglandin inhibitors such as nonsteroidal anti-inflammatory drugs, such as ibuprofen 800 mg three times a day for 5 days. Failing that, supplemental estrogen has also been effective.
Intrauterine Device/System (IUD or IUS)
In October 2012, ACOG issued a statement that IUDs should be offered as first-line contraception for adolescents.15 IUDs are considered low risk for nulliparous young women and adolescents. They also do not increase risk of PID outside of the month after insertion, and can be left in during treatment of PID.16 IUDs are also not associated with an increased risk of ectopic pregnancy.13
Intrauterine Device (Copper IUD)
The primary benefit of this method of contraception is that it is a non-hormonal option, with high efficacy, rapid reversibility, cost-effectiveness, reduced endometrial cancer, and high adherence rates. It is also administered as a private method. However, copper IUDs are associated with heavier menstrual bleeding, and increased dysmenorrhea. The FDA has approved IUDs to be dosed for 10 years; they have been known to be effective for up to 12 years.13
Intrauterine Systems (IUD with LNG)
The benefits of using an IUD with LNG are that the patient tends to have lighter menses; the efficacy rate is as good as tubal ligation; and there is a decreased rate of PID because of LNG’s effects on cervical mucus. There is also rapid reversibility with the IUD with LNG; it is cost-effective, associated with reduced endometrial cancer, has high adherence rates, and is a private method.
The primary side effect for IUDs with LNG is irregular menses (at 2 years, there is 50% amenorrhea and 25% oligomenorrhea.)17 The FDA has approved dosing of this method for 5 years, though it has been shown to be effective for up to 7 years.
Special Populations and IUD/IUS
The IUD/IUS is safe in women who are immunosuppressed due to organ transplantation, autoimmune disease, or infection with HIV. IUD/IUS may be safely used in women with cardiac disease and structural abnormalities (eg, heart valve abnormalities or shunts). Antibiotic prophylaxis for IUD placement is not warranted, although antibiotic prophylaxis for removal may be.
A clinical pearl for IUD use includes knowing that unpublished qualitative research has shown that young women who use the IUD found it encouraging when their provider disclosed whether she herself used the IUD. The same effect could probably be accomplished by explaining to patients that many MDs use the IUD. For more information, see Sidebar 2.