Contraception

Contraceptive Use

Tara C. Jatlaoui

Yokabed Ermias

Lauren B. Zapata

Sexual Activity

According to the Youth Risk Behavior Surveillance System 2015, 41.2% of U.S. high school students had ever had sexual intercourse and approximately one-third reported being currently sexually active.

Although U.S. teens and European teens have similar levels of sexual activity and ages of sexual debut , U.S. teens are less likely to use contraception and less likely to use the most effective methods. Teen pregnancy rates have been declining worldwide as a result of delayed initiation of sexual activity and increased contraceptive use. Despite declines, the United States still had the highest 2013 teen birthrate in the Western industrialized world, with 26.5 live births per 1,000 females aged 15-19 yr ( Fig. 143.2 ). This is almost 1.5 times higher than the 2013 teen birthrate in the United Kingdom, which has the highest rate in Western Europe, and almost 8 times higher than the teen birthrate in Switzerland, which has the lowest rate in Western Europe. In 2011, of the 574,000 teen pregnancies in the United States, 75% were unintended, indicating an unmet need for reliable, effective contraception that teens will correctly and consistently use.

Contraceptive Counseling

Tara C. Jatlaoui

Yokabed Ermias

Lauren B. Zapata

The health screening interview during the adolescent preventive visit offers opportunities to identify and discuss unsafe sexual practices among all adolescents and to identify and reinforce safe sexual behaviors, including abstinence (see Chapter 137 ). Adolescents with medical conditions, either chronic or acute, are particularly vulnerable to having sexual and reproductive health omitted from their visits, although they have similar sexual health and contraceptive needs as healthy adolescents (see Chapter 734 ). Their comorbidities or concurrent medication use may make unintended pregnancy an increased health risk and may also reduce contraceptive options. The U.S. Medical Eligibility Criteria for Contraceptive Use outlines medical conditions associated with increased risk for adverse health events as a result of pregnancy and also provides recommendations for who can safely use specific contraceptive methods.

The goals of counseling with adolescents are to (1) understand adolescent experiences, preferences, perceptions, and misperceptions about pregnancy and use of contraceptives; (2) help adolescents put unprotected intercourse risk in a personal perspective; (3) educate adolescents about the various methods available using information that is medically accurate, balanced, and provided in a nonjudgmental manner; and (4) help adolescents choose a safe and effective method that can either be provided on site or be easily obtained through prescription or by referral. Counseling should include a review of all contraceptive methods available that the adolescent can use safely (see U.S. Medical Eligibility Criteria), starting with the most effective methods. Long-acting reversible contraception (IUDs and implants) is a safe and effective option for many adolescents, including those who have not been pregnant or given birth. The adolescent should be counseled about method effectiveness using typical-use failure rates. It is important to ask about use of withdrawal because 60% of female teens have used it for contraception and it has a typical-use failure rate of 20%. Abstinence should also be discussed as an option even if teens have engaged in sexual intercourse in the past. Situational abstinence may be the best option if they do not have another method available at a particular time.

Necessary concepts to address while discussing individual methods include how effective the method is, how long the method works, what behaviors are required for correct and consistent use, what side effects may be seen, any noncontraceptive benefits of the method (e.g., reduced menstrual bleeding, protection from STIs), and what signs or symptoms of complications should prompt a return visit. Reviewing common side effects allows teens to anticipate and cope with any changes with reassurance and may avoid method discontinuation. Weighing the possibility of certain side effects with the possibility of an unintended pregnancy may also help with the conversation. It is also important to address any specific misperceptions teens may have for certain contraceptives regarding side effects, effectiveness, or any other concept discussed.

Once an adolescent chooses a method, the provider and adolescent should discuss clear plans on correct and consistent use of the chosen method and strategies for appropriate follow-up ( Table 143.1 ). Providers should help the adolescent consider potential barriers to correct and consistent use (e.g., forgetting to take a pill daily) and develop strategies to deal with each barrier (e.g., use of reminder systems such as daily text messages or phone alarms). The provider should assess whether the teen understood the information discussed and may confirm by asking the teen to repeat back key concepts.

The U.S. Selected Practice Recommendations for Contraceptive Use provides guidance for providers regarding when to start contraception, how to be certain the woman is not pregnant at contraception initiation, and what examinations and tests are recommended before initiating contraception. Generally, women may start a contraceptive method other than an IUD at any time, and an IUD may be placed when a provider is reasonably certain that a woman is not pregnant. Most women do not require any exams or tests before initiating contraception. A pelvic examination is only required for placement of an IUD, unless otherwise indicated. STI screening is appropriate at IUD placement once sexual activity has begun, but most women do not require additional screening if they have been recently screened according to CDC sexually transmitted disease (STD) treatment guidelines. Gonorrhea and chlamydia screening using a self- or provider-collected vaginal swab or urine sample is recommended unless symptoms require a pelvic exam. IUD placement should not be delayed to receive screening results. ACOG guidelines recommend that the female teen should first visit a gynecologist between age 13 and 15 yr, unless necessary at an earlier age. This visit aims to establish rapport, educate the patient and parents or guardian on healthy sexual development, and provide routine preventive services. Cervical cancer screening is not recommended until age 21.

Providers should offer confidential services to adolescents and observe all relevant state laws and legal obligations (e.g., notification or reporting of sexual abuse). Chapter 137 discusses confidentiality and consent issues related to contraceptive management. Providers should also encourage adolescents to involve parents or guardians in their healthcare decisions, while giving parents clear information on their teen's right to confidentiality, privacy, and informed consent. All services should be provided in a youth-friendly manner, meaning that they are accessible, equitable, acceptable, appropriate, comprehensive, effective, and efficient. Resources are available that describe ways to ensure a teen-friendly reproductive health visit.

Long-Acting Reversible Contraception

Tara C. Jatlaoui

Yokabed Ermias

Lauren B. Zapata

Long-acting reversible contraception ( LARC ) includes 4 levonorgestrel (LNG) IUDs, the copper (Cu) IUD, and the etonogestrel subdermal implant. LARC methods are the only Tier 1 methods that are reversible (see Fig. 143.1 ). Considered “forgettable” contraception, LARC does not require frequent office or pharmacy visits and does not depend on user compliance for effectiveness. In the Contraceptive CHOICE Project in St. Louis, MO, >9,000 women were given the contraceptive method of their choice at no cost and were followed for 2-3 yr. The failure rates among women who used oral contraceptive pills, transdermal patch, or vaginal ring were >20 times higher than the failure rates for women using a LARC method. Acceptance, continuation, and satisfaction in this project were also higher among adolescents using LARC compared with adolescents using non-LARC methods. ACOG and AAP support the use of LARC methods for adolescents. The U.S. Medical Eligibility Criteria supports safe use of both IUDs and implants for adolescents and nulliparous women. Implants are considered category 1 for all ages, and IUDs are considered category 2 for women <20 yr old and for nulliparous women ( Table 143.2 ).

Other Progestin-Only Methods

Tara C. Jatlaoui

Yokabed Ermias

Lauren B. Zapata