Contraception

Sexual and reproductive health decisions made during adolescence may have significant consequences, including transmission of sexually transmitted infections (STIs), pregnancy, or both. A trusted and informed health care provider is a pivotal source of information and support for sexual health and should be well-informed about adolescent contraceptive options.

In the 2019 Youth Risk Behavior Survey, 27% of U.S. students (grades 9-12) reported recent sexual activity and most reported using contraception; approximately half (54%) reported condom use, 23% used contraception pills, 5% use an IUD or implant, and 3% used intramuscular (IM) medroxyprogesterone, the combination patch, or the combination ring.

Assessment

Both the American Academy of Pediatrics (AAP) and the Society for Adolescent Health and Medicine (SAHM) promote policies that support adolescent consent and confidentiality. The following are general suggestions for a confidential sexual health assessment:

• Review nonconfidential information with the guardian(s) present.

• Give adolescents time alone to discuss sensitive topics, such as sexual health, with local consent and confidentiality laws kept in mind. Encourage adolescents to discuss these topics with their guardian(s).

• Use a trauma-informed care approach, which begins by asking permission to take a sexual history and helps frame a sensitive, patient-centered conversation.

• Have an open discussion about the five Ps of the sexual history — partners, practices, protection from STIs, past history of STIs, and pregnancy intention. This framework provides opportunities for patients to ask questions and for providers to promote health and overall well-being.

Counseling

The AAP, the SAHM, and the American College of Obstetrics and Gynecology (ACOG) provide guidance on sexual and reproductive health care. General contraceptive counseling principles include the following:

• Always review sexual consent and healthy sexual relationships (see Sex and Sexuality in this rotation guide).

• Provide counseling about both contraception and abstinence or postponement of sexual intercourse.

• Counsel sexually active adolescents to use the dual-use method — concomitant use of a female-dependent method and a condom.

• Continually reassess the need for contraception, even if patients have previously identified as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ). Sexual practices may change over time.

• Recognize that sexual orientation and sexual practices may be different (e.g., someone may identify as lesbian but have sex with males and females).

Adolescent and young adult males: Male adolescents often receive less sexual and reproductive health counseling than females. It is increasingly recognized that providers have an important role in initiating conversations with adolescent male patients about sexual and reproductive health, promoting positive masculinity that is not defined by sexual activity, and addressing risk behaviors. Male adolescents should be counseled about condom use as well as female-dependent contraceptive methods, including levonorgestrel as emergency contraception. This practice helps improve sexual health communication and prevent unplanned pregnancy.

Contraceptive options: Traditionally, health care providers have been advised to begin counseling adolescents and young adults with the most effective contraceptive method followed by less effective methods, as listed in the table below. However, the importance of honoring adolescents’ reproductive autonomy when providing contraception counseling is increasingly being recognized. A reproductive justice framework acknowledges reproductive mistreatment of marginalized individuals, recognizes that provider bias can affect care, works to minimize the effect of such bias, and prioritizes patients’ preferences, values, and lived experiences when discussing contraception options.

Anticipatory Guidance

Oral Contraceptive Pills

Combined oral contraceptive pills are the most commonly used hormonal contraception by adolescent and young adult sex assigned at birth females. It is important to review techniques to maximize adherence (e.g., setting a phone alarm reminder) and instructions for missed pills (see the AAP Technical Report on Contraception for Adolescents).

Adverse Effects:

Combined oral contraceptives are associated with several common side effects, listed below. Consistent medication use is important to reinforce to avoid spotting or breakthrough bleeding.

• nausea

• spotting

• breakthrough bleeding

• changes in acne (usually improvement)

• change in appetite that may lead to weight gain (may warrant a discussion of healthy nutrition and exercise habits)

• change in mood, particularly during the first 6 months of use (acknowledge and offer appropriate alternative methods if desired)

• increased blood pressure (document a baseline blood pressure and reassess at follow-up)

Estrogen-containing contraceptives are associated with an increased risk for clots and should be avoided in tobacco smokers and patients with co-occurring uncontrolled hypertension, migraines with aura, or known thrombotic disease (e.g., antiphospholipid syndrome). Be sure to ask about headaches, chest pain, shortness of breath, abdominal pain, and extremity pain/swelling both at baseline and follow-up visits. Progestin-only contraceptive pills do not increase risk for clots and may be an appropriate alternative for patients with contraindications to estrogen.

Progestin-only contraception pills are safe and typically effective but are not approved by the FDA for contraception. Adherence is even more important with progestin-only pills; missing a dose by even a couple of hours may lead to breakthrough bleeding.

Condoms

Information about male condoms, including appropriate use, where to purchase, and how to use them, maximizes their effectiveness.

Withdrawal

More than half of adolescent and young adult patients report using withdrawal for birth control. Therefore, it is important to inform patients that withdrawal is associated with a typical failure rate of 20% and does not protect against STIs.

Initiation of Contraception and Follow-Up

• Review medical history and family medical history before initiation of contraception to assess for medical eligibility and contraindications to any method (see the Contraception section in the Women’s Health rotation guide and the CDC Contraceptive Guidance for Health Care Providers).

• Document blood-pressure measurement before starting hormonal contraception.

• Neither pelvic nor breast exams are needed prior to initiation of contraception, except for IUDs.

• Consider Quick Start contraception (starting a hormonal contraception immediately, regardless of menstrual-cycle day) to reduce risk of unintended pregnancy if you are relatively certain that a patient is not currently at risk for pregnancy (e.g., negative pregnancy test, no intercourse since start of last menstrual period, or correct use of a contraceptive method since last menstrual period).

• Counsel to always use condoms as part of dual-method pregnancy prevention, particularly during the first 7 days following contraception initiation, and for STI prevention.

Surveillance of contraception: Patients should receive routine follow-up for surveillance of contraceptive use, review appropriate use, monitor and manage adverse effects, change methods as appropriate, and assess sexual health risk behaviors.

Emergency Contraception

Emergency contraception (EC) can be used after unprotected or underprotected intercourse (UPIC) to prevent unintended pregnancy. Options in the United States include:

• copper IUD (nonhormonal; e.g., the Paragard)

  • can be placed up to 7 days post-UPIC

  • most effective option (pregnancy rate is 0.09%)

• ulipristal acetate (selective progesterone-receptor modulator; e.g., Ella)

  • can be taken up to 5 days post-UPIC (as soon as possible)

  • prevents approximately 85%-98% of pregnancies.

• levonorgestrel (progestin; e.g., Plan B)*

  • can be taken 5 days post-UPIC (efficacy declines over time)

  • reduces risk of pregnancy by 49%

• Yuzpe method (combined oral contraceptive pills)

  • two doses of a combination estrogen-progestin oral contraceptive (taken 12 hours apart within 72 hours post-UPIC)

  • may use multiple oral contraception formulations

  • least effective

*Note: Although levonorgestrel is available without a prescription, it can be cost-prohibitive for some patients (approximately $50). The World Health Organization, the SAHM, the AAP, and the International Federation of Gynecology and Obstetrics recommend providing an advance prescription for EC to help maximize access, promote timely use, and reduce cost barriers. There is no evidence that having a prescription for EC increases the likelihood of unprotected intercourse among adolescent and young adult females.