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Contraception Corner

Guiding Adolescent Contraceptive Choices

Barbara Clark, RN, MSN, MPH; Barbara Malat, CNP, PA-C; Melanie A. Gold, DO

Discussing contraceptive use with the adolescent girl provides an opportunity to encourage both sexual responsibility and the exploration of her individual health care needs as she begins to make her own decisions.

Despite recent declines, the birth rate for US girls aged 15 to 17 years is twice that of those in Canada and England, and 10 times higher than the rates in France and Sweden.1 Indeed, the probability of a US teenager giving birth before age 20 years is 13%.2

Of teenagers who become pregnant, approximately 35% undergo abortion, 14% have miscarriages, and 51% give birth.3 Those who do give birth are less likely to graduate from high school, and are more likely to experience low self-esteem and depression.4-6 Children of adolescent mothers are at greater risk of preterm birth, low birthweight, child abuse, neglect, poverty, and death.7-10 Consequently, teenaged girls need to know about their contraceptive choices, and clinicians must learn how to best communicate with them.

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POPULAR CONTRACEPTIVE OPTIONS


In 2002, the most common contraceptive methods used by teenagers were condoms (94%), combination estrogen/progestin oral contraceptives (COCs) (61%), and depot medroxyprogesterone acetate (DMPA) (21%).2 Only 8% of teenagers had ever used emergency contraception (EC).2

While teenagers should not solely rely on condoms for birth control, they are essential to protect against sexually transmitted infections (STIs). Therefore, education in condom use is critical: Condom failure is generally due to improper or inconsistent use, not defects and breakage.11

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Combination Oral Contraceptives

In addition to contraception, COCs can help to alleviate adolescent dysmenorrhea and acne.12 However, many teenagers do not use COCs properly; 20% to 30% report missing a pill every month, with many missing three pills per cycle.13 In addition, only 34% of adolescent women continue using COCs 1 year after starting.14

Prompt initiation of COCs and quicker protection can be promoted with the "quick-start" method, whereby women start COCs the same day as their office visit, while the directions are fresh in their minds. A study comparing the traditional Sunday start to a same-day start approach found that quick-start adolescent users were more likely to remain compliant at 3 months (72% versus 56%, P = .059).15 Side effects (eg, breakthrough bleeding, nausea, vomiting) were similar for both groups. Regardless of the start method, teenagers must be reminded to use "back-up" contraception for the first 14 days.

As many teenagers prefer less frequent menstruation,16 they may be receptive to the extended 84/7-day COC or prolonging the use of monophasic COCs by eliminating the pill-free week. Depending on the regimen chosen, the number of transitions and restarts can be reduced from 13 to four or fewer per year.

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Combination Oral Contraceptives

Depot medroxyprogesterone acetate is convenient, reversible, and highly effective. While those who use DMPA can lose significant bone mineral density, this effect is reversed after therapy is stopped.17,18 Current evidence suggests that DMPA may not affect skeletal health in later years.18

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OTHER CONTRACEPTIVE CHOICES

Other choices include the contraceptive patch, vaginal ring, copper-containing intrauterine device, and the levonorgestrel-releasing intrauterine system. Research shows 87.1% of teenaged users reported perfect compliance with the patch, and 77% intended to continue use.19 Some evidence suggested that the patch may increase the risk of venous thromboembolism compared with COCs,19 but another study showed no difference in risk.20 Data are conflicting regarding continuous use of the patch, and the vaginal ring has not been approved for continuous contraception. Overall, teenagers may adhere better to contraceptive regimens that do not require daily use, treat menstrual disorders, and reduce the frequency of menses.

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Emergency Contraception

In the United States, EC is administered via the prepackaged Plan B pills or the off-label use of COCs.21 When used within 72 hours after unprotected intercourse, EC prevents approximately 80% of pregnancies.22-24 Prevention may be provided up to 120 hours postintercourse, although efficacy probably decreases somewhat.25

Teenagers who receive an advance provision of EC (AEC) are three times more likely to use it after unprotected sex than those who do not have EC on hand (P = .006).26 There were no differences between the groups regarding unprotected sex, but the treatment group reported using less effective contraception at follow-up. A study of minority teenagers found that the AEC group reported nearly twice as much EC use as the control group (15% versus 8%, P = .05) at 1-month follow-up, but not at 6 months (8% versus 6%, P = .54).27 The AEC group also began EC significantly sooner (11.4 hours versus 21.8 hours, P = .005). There were no differences between groups regarding unprotected sex, but more AEC participants reported condom use in the past month at 6-months follow-up (77% versus 62%, P = .02).

Other researchers compared the effect of providing young women with AEC, direct access to EC through pharmacies, and access to EC through a clinic (control group).28 Women with pharmacy access were just as unlikely to use EC as those in the control group, whereas women who received AEC were twice as likely to use EC. The frequency of unprotected intercourse and STI rates were similar for all groups.

Citing inadequate data of EC effects in young teenagers, the US Food and Drug Administration has delayed approval of over-the-counter availability. However, a large, randomized, controlled trial has shown that both girls aged < 16 years and adults who had AEC behaved similarly in terms of unprotected sex, condom use, STIs, and pregnancy.29 Use was greater among teenagers with AEC (44% versus 29%, P .001), and risky sexual behavior was comparable.

Many teenagers are not aware of EC. For example, of 197 inner-city adolescents surveyed, 71% were sexually experienced. Of those, only 30% had heard about EC, although more than 87% said they would use it if needed.30

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TALKING TO TEENAGERS

Engaging teenagers in confidential, open, and nonthreatening dialogue early—before they initiate intercourse—is preferable (Table 1).31 Clinicians should stress abstinence to prevent pregnancy and STIs with an emphasis on delaying sexual activity and resisting peer pressure and coercion. Table 2 lists Internet resources for information about teenaged contraception for providers, parents, and adolescents.

Table not available online

Table 1. Counseling Teenagers About Contraception31

Table not available online

Table 2. Resources for Information on Contraception for Teenagers

As most teenagers become sexually active, however, clinicians should encourage condom use, discuss high-risk behaviors and STIs, and promote suitable contraceptive choices. In addition to contraceptive considerations, selection should also depend on the noncontraceptive advantages and disadvantages of the various methods (Table 3). Other important points include ways to maintain consistent use and how to handle missed/delayed doses. For many teenagers, setting an alarm on their cellular phones may be helpful.

Table not available online

Table 3. Noncontraceptive Considerations of Contraceptives for Adolescent Women

Adolescents should be encouraged to talk to their parents and guardians about their health care decisions, but clinicians must also inform teenagers and their parents about the requirements and limits of confidentiality.6,32 Each state has different laws about confidentiality and consent for adolescent health care, so it is essential to check local regulations.

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CONCLUSION

Unintended pregnancy continues to be a significant problem in the Unites States. Teenagers need counseling on the correct use, side effects, and efficacy of contraceptives. Higher adherence may be achieved with contraceptive methods that do not require daily use and with those initiated by the quick-start method. Emergency contraception should be routinely discussed and provided in advance as a back-up for contraceptive failure. Through nonjudgmental and nonthreatening communication, clinicians can guide teenagers toward sensible sexual decisions and responsible contraceptive use.

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Barbara Clark, RN, MSN, MPH, is a freelance writer in Arlington, Va. Barbara Malat, CNP, PA-C, is family nurse practitioner, Family Practice Department, Rural Satellite of the Olmsted Medical Center, Chatfield, Minn. Melanie A. Gold, DO, is associate professor of pediatrics, Division of Adolescent Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Childrenês Hospital of Pittsburgh, Pa.

References

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