Pediatric Annals

Healthy Baby/Healthy Child 

Birth Control Management for the Primary Care Provider

Rachel S. Dawson, DO, MPH, FAAP

Abstract

Contraceptive management is occurring more frequently in the primary care setting. Pediatricians should be familiar with the most common methods of contraception due to the fact that families are comfortable seeking care for their adolescents at the primary care office for these types of concerns. Contraceptive methods are often used for noncontraceptive benefits as well, which makes it even more important to feel comfortable prescribing contraceptives at pediatricians' offices. [Pediatr Ann. 2019;48(2):e51–e55.]

Abstract

Contraceptive management is occurring more frequently in the primary care setting. Pediatricians should be familiar with the most common methods of contraception due to the fact that families are comfortable seeking care for their adolescents at the primary care office for these types of concerns. Contraceptive methods are often used for noncontraceptive benefits as well, which makes it even more important to feel comfortable prescribing contraceptives at pediatricians' offices. [Pediatr Ann. 2019;48(2):e51–e55.]

There are more than 1 million adolescent pregnancies annually in the United States.1,2 The US has the highest rate of teen pregnancy of any industrialized country, although pregnancy rates have dropped by 43% to 22% in the past several years.1,2 In general, sexual activity begins by mid- to late adolescence;3 therefore, discussions on this topic should begin in early adolescence.

It is important to communicate that abstinence is the only means of preventing pregnancy and sexually transmitted infections. It is also critical to interview adolescents privately during an office visit to obtain the most accurate information regarding their potential sexual activity status.4

Discussion in the Office Setting

It is important to understand that providing information about contraception does not increase rates of sexual activity, earlier age of first onset of intercourse, or greater number of partners.4 Abstinence should be discussed, but for sexually active teens comprehensive information is important, so it is essential to include private and confidential time during adolescent health care visits.4

Having discussions about contraception and sexually transmitted infections (STI) is essential. For some STIs, such as herpes simplex virus and human papilloma virus, condoms are not totally protective because these diseases can present in areas not covered by a condom. It is critical to explore with adolescents how they feel the sexual experience will change their own self-image.4

Why Discussions aAbout Contraceptives Are Important

The Youth Risk Behavior Surveillance System monitors priority health behaviors and experiences among high school students across the country. The most recent report stated that the percentage of high school students who have ever had sex declined from 48% in 2007 to 40% in 2017, and that the percentage of students who had four or more sexual partners also declined from 15% in 2007 to 10% in 2017.5 Even though this may seem reassuring, condom use among sexually active students decreased from 62% in 2007 to 54% in 2017.5 This decline comes after a period of increased condom use throughout the 1990s and early 2000s.

Approximately 35% of adolescents are not using contraception at time of first intercourse, and the approximate time between an adolescent female becoming sexually active and obtaining contraception is 12 months.2,4 About 20% of pregnancies occur within the first month of initiating sexual activity, with another 50% occurring within the first 6 months.2,4 In general, 85% of sexually active women become pregnant within 1 year if no method is used.2,4

Contraceptive methods have rates supplied by their manufacturer for lowest expected pregnancy rates when used as indicated, as well typical pregnancy rates for that particular method in a real-world setting. Using no contraception leads to an expected and typical outcome of 85% of women becoming pregnant within 1 year.2,4 For combined oral contraceptive pills, the expected rate is 0.1%, with a typical rate of 3% for most users.2,4 For the progestin-only pill, the expected rate is 0.5% with a typical rate of 3% for most users.4 Depo-medroxyprogesterone has the same typical and expected rates of 0.3%.4 A diaphragm with spermicide use has an expected rate of 6%, but it has only an actual 18% to 20% among those who use this method.4 Male condom use has an expected 2% to 3% rate with a 12% to 14% typical rate.4 Female condom use has a 5% expected rate with a 21% typical use rate.4 Vaginal spermicides show a 3% to 6% expected rate with an 18% to 26% typical rate.4 Finally, the intrauterine contraceptive devices boast a 0.1% to 2% expected pregnancy rate with a typical rate of 0.1% to 3%.4

As noted, methods that do not require frequent action on the part of patient have almost identical ideal and typical failure rates. For adolescents, typical failure for oral contraceptive pills is as high as 15% compared to 3% in all women.4 This is mostly due to adolescents forgetting to take the pill, with approximately 28% reporting missing two or more pills per cycle.4

Options Available to Adolescents

There are many options available for adolescents for contraceptive management. These include combined oral contraceptive pills, progestin-only pills, transdermal hormonal contraception, vaginal hormonal ring contraception, injectable hormonal contraception, implantable hormonal contraception, and intrauterine devices.6 It is also important to remember vaginal barrier contraception, as well as male condoms.6 Emergency contraceptive pills are an important method to also understand in the context of adolescent sexual behaviors.5

Oral contraceptive pills are generally synthetic estrogen and progestin. Estrogen is usually in the form of ethinyl estradiol ranging from 20 to 50 mcg/day. The progestin component is more variable containing ethynodiol diacetate, norethindrone acetate, norethindrone, norgestrel, levonorgestrel, desogestrel, norgestimate, and drospirenone to name a few. There are newer progestins, such as norgestimate, that have fewer androgenic effects. These pills may be monophasic with a constant amount of hormones released throughout the month or multiphasic with varying amounts of progestin and sometimes not as frequently, varying amounts of estrogen, throughout the month.

In general, the packs contain 21 days of active pills and 7 days of placebo pills. When choosing which type of birth control option to recommend for a particular patient, the following principles can be helpful. Lower estrogen (20 mcg) will cause more breakthrough bleeding but may be better to minimize side effects such as breast soreness, nausea, and headache. Progestin-dominant pills are helpful for dysmenorrhea, hypermenorrhea, previous breakthrough bleeding, or dysfunctional uterine bleeding. Higher-estrogen (50 mcg) pills are rarely used but beneficial for persistent intermenstrual bleeding and for patients who are on certain anticonvulsants.

Mechanism of Action

Birth control pills prevent pregnancy by suppressing the ovarian-hypothalamic axis, inhibiting gonadotropin-releasing hormone, and thus inhibiting ovulation.6 They also alter the endometrium and increase viscosity of endocervical mucus; these types may also have a direct effect on corpus luteum steroidogenesis.6

Safety of Oral Contraceptive Pills

It is safe for adolescents to take oral contraceptive pills containing 35 mcg or less of ethinyl estradiol. Some studies suggest that newer desogestrel-containing contraceptives increase the risk of venous thromboembolism.7 However, to put it into perspective, the estimated risk of death from oral contraceptive pill use is 1.3 per 100,000 compared to the risk of death in childbirth of 11.1 per 100,000 in adolescents.7

Other Available Options

Progestin-Only Pills

Progestin-only pills are available but less efficacious because they do not inhibit ovulation reliably. The mechanism of action is prevention of conception by thickening cervical mucus and inducing endometrial atrophy, as well as tubal mobility changes.6 If estrogen is contraindicated, this may be an option. However, skipping even one pill or delay of even a few hours in taking a pill can result in failure. If more than 3 hours late taking these pills, the person should use a back-up method for next 2 days to prevent pregnancy.

Transdermal Hormonal Contraceptives

Transdermal hormonal contraceptives are comprised of 20 mcg of ethinyl estradiol and 150 mcg of norelgestromin, which is the primary active metabolite of norgestimate. The patch is left in place for 7 days and replaced weekly for 3 weeks, with no patch needed during the fourth week. The efficacy is comparable to combined contraceptive pills, but compliance is usually better.6 Women who weigh more than 200 pounds have increased risk of pregnancy, and a small percentage discontinue due to local skin irritation.6

Vaginal Hormonal Ring

The vaginal hormonal ring was introduced in 2001, and it consists of ethinyl estradiol and etonogestrel. Etonogestrel is the biologically active metabolite of desogestrel. The ring is left in place for 3 weeks and then removed during the fourth week. Efficacy is also similar to oral combined contraceptive pills but compliance is better, with only a small number of users reporting leukorrhea and vaginal irritation.6

Implantable Hormonal Contraceptives

Implantable hormonal contraceptives have been available for many years, with the most common form consisting of a single rod-like implant that contains etonogestrel (the active metabolite of desogestrel). It is highly effective and remains in place for 3 years. This form of contraception is associated with irregular bleeding during the first year with another common side effect being headache.6 It is great for those who cannot reliably remember to take a pill daily. There is no concern with bone mineral density (BMD) problems associated with this form of contraception.6 The mode of action for this implantable contraceptive option includes inhibition of ovulation, thickening of the cervical mucus, and alterations in the lining of the uterus.6 In general, ovulation and fertility return within 3 months of discontinuation.

Injectable Hormonal Contraceptives

The most common injectable hormonal contraceptive is depo-medroxyprogesterone (DMPA). It is a highly effective progesterone-only contraceptive injected intramuscularly every 3 months. It inhibits ovulation by similar methods already discussed above. The first injection should be during menses; however, a pregnancy test may be obtained to avoid delaying use. The only contraindication is pregnancy. The most common adverse effect is menstrual changes, with amenorrhea being most common. Approximately 40% of patients become amenorrhoeic during the first 3 months of use and another 60% by 12 months.6 The average weight gain tends to be 4.4 pounds during the first year mostly due to increased caloric intake and not the shot itself.6

There is a black box warning regarding the use of DMPA and its possibly association with BMD.8 During adolescence, 60% of bone mass is acquired; therefore, if decreases in bone density occur during this time, this may increase risk of osteopenia and osteoporosis later in life.8 Studies showed a 1.5% decrease in BMD after 1 year of use with a 3.1% decrease in density over 2 years.8 This was in contrast to an increase in BMD in adolescent control patients. It is known that BMD increases after discontinuation of DMPA. This method should probably not be used in patients at risk for osteoporosis, such as those with chronic renal disease and anorexia nervosa. The following professional societies have made statements regarding use of this method in teens: the American College of Obstetrics and Gynecology guidelines state that the advantages outweigh the theoretical concerns,9 the Society for Adolescent Health and Medicine's position paper states that benefits outweigh the potential risks, and to continue without any restrictions on duration of use,10 and the World Health Organization's recommendations state that no restriction on use or duration of use is needed due to the fact that benefits outweigh theoretical concerns.11

Intrauterine Hormonal Contraceptives

Intrauterine hormonal contraceptives may also be used by adolescents. The failure rate is approximately 0.3%.6 This form of contraception contains levonorgestrel that gradually releases over a period of 3 to 5 years. It is useful for adolescents with severe menorrhagia and dysmenorrhea, and it is associated with reduction in blood loss. The mode of action for this form of contraception includes preventing sperm from fertilizing the ova and/or preventing implantation. Ovulation frequently occurs, but it does cause prevention of endometrial growth, thickening of cervical mucus, and inhibition of sperm mobility and function.8

Nonhormonal Contraceptive Options

Nonhormonal contraceptive options such as vaginal barriers and male condoms are also options.6 Vaginal barriers include diaphragm, cervical cap, and female condom, but many teens are uncomfortable about inserting them into their vagina. These methods do offer some protection against STIs, but adolescents should use spermicide with these methods.

The male condom provides protection against most STIs with latex options offering superior protection over natural condoms. These methods reduce STI rates more than diaphragms. Polyurethane condoms are available for those with latex allergy and are stronger and thinner but much more expensive.

Contraindications and Categories

There are four categories of patients to consider when prescribing contraceptives. Category one patients are those in whom oral contraceptive use is not restricted.6 Category two patients are those in whom oral contraceptives should be used with caution, but the advantages usually outweigh risks.6 Category three patients are those in whom contraceptive pills usually should be not used unless there are no other acceptable alternatives.6 Category four patients are those in whom oral contraceptive pills should not be used.6

Category one patients include those with a history of epilepsy, current antibiotic use (except rifampin), cervical ectropion, benign breast disease, thyroid disorder, pelvic inflammatory disease, mild headache, irregular menstrual bleeding, sexually transmitted infections, and those with a family history of breast cancer.6

Category two patients are defined as those with a history of sickle cell disease, moderate hypertension (<159/109 mm Hg), cervical cancer, undiagnosed breast mass, major surgery without prolonged immobilization, uncomplicated diabetes mellitus, severe headaches, mental retardation, severe psychiatric disorders, and drug or alcohol abuse.6

Category three patients are defined as those being fewer than 2 days postpartum, those with gallbladder disease, those who are lactating (>6 weeks to <6 months postpartum), those with undiagnosed vaginal bleeding, and anyone taking medications that decrease contraceptive efficacy such as griseofulvin, rifampin, barbiturates, hydantoins, carbamazepine, felbamate, topiramate, and St. John's wort.6

Category four patients are those in whom oral contraceptive pills should not be used due to the high risk of significant adverse events such as patients with history of deep vein thrombosis and/or pulmonary embolism, hypercoagulability disorders, lactation for less than 6 weeks postpartum, diabetes mellitus with complications, severe hypertension (>160/110 mm Hg), complicated congenital heart disease, breast cancer, surgery with prolonged immobilization, migraine with focal neurologic deficits, cerebrovascular disease, coronary artery disease, liver disease, and pregnancy.6

Noncontraceptive Benefits

It is important to emphasize the noncontraceptive benefits of contraceptive use such as lighter and more predictable menses, decreased dysmenorrhea, and improvement of acne due to decreased androgen production, reduced conversion of testosterone to dihydrotestosterone, and higher sex hormone-binding globulin levels.4 These benefits are important to emphasize so as to convince the adolescent to continue using it for the long term.

How to Start Adolescents on Contraceptives

First and foremost, adolescents do not need a pelvic examination to be started on a contraceptive method unless there is a medical reason to complete one. No laboratory tests are needed other than a pregnancy test to determine that the patient is not currently pregnant.

It is best to start on a Sunday after beginning of the next menses or the first day of next menses. However, they can be started at any time because adolescents are at high risk of becoming pregnant before the beginning of their next menses.

It is not cost effective to screen for prothrombotic mutations because one would have to screen more than 500,000 women to prevent one death.12 It is important to remind them that condoms must be used to prevent STIs.

Emergency Contraceptives

Emergency contraception can prevent pregnancy after unprotected intercourse or when regular contraceptive methods fail. Two major forms are available. The first option consists of four pills that each contain 0.25 mg of levonorgestrel and 50 mcg of ethinyl estradiol, a urine pregnancy test, and an information booklet.4,6 Instructions are for the patient to take the first two pills as soon as possible and then two pills again in 12 hours. The second option consists of two tablets each containing 0.75 mg of levonorgestrel.4,6 Instructions are to take the first tablet as soon as possible then the second tablet 12 hours later. Both tablets may also be taken at the same time without compromising efficacy. The mode of action of emergency contraception includes inhibition or delay in ovulation, interrupting follicular maturation, impairing sperm migration, fertilization, fallopian tube transport, endometrial receptivity, and finally, corpus luteum sufficiency.4,6

Emergency contraception does not interrupt an implanted pregnancy, and it does not cause an abortion.4,6 There is no evidence that it increases the risk of an ectopic pregnancy, and there are no adverse effects on an already existing fetus. Generally, it is not prescribed if more than 72 hours have elapsed; however, the progestin-only method may decrease risk of pregnancy if taken up to 5 days after unprotected intercourse.

Statistics on Emergency Contraception

The risk of pregnancy is reduced to 2% from 8%, which is the chance of getting pregnant from one episode of intercourse.6 The progestin-only method appears to be more efficacious, with 90% effectiveness if used within 24 hours, 75% if within 72 hours, and 60% if used within 120 hours.6 Nausea is the most common adverse event, but it is less likely with the progestin-only method. Some states allow pharmacies to dispense these pills without prescription if the person is older than age 18 years. It is important to follow up with these patients and recommend that the patient avoid having intercourse for the remainder of the cycle and return 2 to 3 weeks later to obtain a pregnancy test. It should be noted that the combined emergency contraception does not protect against tubal pregnancy, so there is need to be extra cautious in that situation.

Conclusion

It is important for pediatricians to offer contraceptives to adolescents. Pediatricians should discuss sexual abstinence as part of comprehensive sexuality education. Pediatricians should be prepared to offer confidential, nonjudgmental education, as well as risk-reduction counseling around issues of sexuality for adolescent patients. Pediatricians should update each patient's sexual history regularly to counsel and determine risk of STIs as well as need for contraceptive initiation and management. Enough time to counsel, educate, and solve problems regarding contraceptive needs or management needs to be a part of any given visit, and a separate visit for contraceptive follow-up should be arranged if not enough time is available for a comprehensive discussion. Pediatricians should encourage the consistent and correct use of latex condoms with every incidence of sexual intercourse. Pediatricians should know that it is appropriate to prescribe contraceptives without a pelvic examination; however, screenings for STIs should occur. Pediatricians should ensure access to basic contraceptive services for their adolescent patients either within their office setting or by referral to appropriate services. Pediatricians who offer contraceptive services to adolescents should provide appropriate follow-up to ensure compliance and monitor for potential side effects.

References

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  2. Guttmacher Institute. Adolescent sexual and reproductive health in the United States. https://www.guttmacher.org/sites/default/files/factsheet/adolescent-sexual-and-reproductive-health-in-united-states.pdf. Accessed January 14, 2019.
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  6. Klein DA, Arnold JJ, Reese ES. Provision of contraception: key recommendations from the CDC. Am Fam Physician. 2015;91(9):625–633.
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  8. [No authors listed]. Committee Opinion No. 602. Depot medroxyprogesterone acetate and bone effects. Obstet Gynecol.2014;123(6):1398–1402. doi:. doi:10.1097/01.AOG.0000450758.95422.c8 [CrossRef]
  9. American College of Obstetricians and GynecologistsCommittee on Adolescent Health Care, Committee on Gynecologic Practices. No. 602, June 2014 (reaffirmed 2019). Depot medroxyprogesterone acetate and bone effects. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Adolescent-Health-Care/co602.pdf?dmc=1. Accessed January 30, 2019.
  10. Cromer BA, Scholes D, Berenson A, Cundy T, Clark MK, Kaunitz AM. Depot medroxyprogesterone acetate and bone mineral density in adolescents—the black box warning: a position paper of the Society for Adolescent Medicine. J Adolesc Health. 2006;39(2):296–301. doi:. doi:10.1016/j.jadohealth.2006.03.011 [CrossRef]
  11. World Health Organization. Depot-medroxyprogesterone acetate (DMPA-SC) (Sayana Press): application for inclusion in the in the WHO Essential Medicines List. December2016. https://www.who.int/selection_medicines/committees/expert/21/applications/s18_medroxyprogesterone_acetate_form.pdf. Accessed January 30, 2019.
  12. Trenor CC, Chung RJ, Michelson AD, et al. Hormonal contraception and thrombotic risk: a multidisciplinary approach. Pediatrics.2011;127(2):347–357. doi:. doi:10.1542/peds.2010-2221 [CrossRef]
Authors

Rachel S. Dawson, DO, MPH, FAAP

Rachel S. Dawson, DO, MPH, FAAP, is the Regional Medical Director for Vaccines, South Central Region, Merck & Co., Inc.

Address correspondence to Rachel S. Dawson, DO, MPH, FAAP, via email: rachel.dawson@merck.com.

Disclosure: Rachel S. Dawson received grants from the Pfizer Independent Grants for Learning and Change (outside of the submitted work).

10.3928/19382359-20190111-01

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