Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs
   

 

 

Sexuality - Contraception (B3)

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Adolescent sexual activity rates increased steadily over the last century, reflecting earlier onset of menarche as well as changing social conditions, although in recent years those rates appear to have plateaued. In 1995, it was reported that 51% of women aged 15-19 had ever had sexual intercourse since menarche. While the sexual activity of American adolescents reflects that of adolescents in most developed countries, the pregnancy rates of teens in these countries differ significantly. For example, the unintended pregnancy rates in developed European countries are 50-85% lower than in the United States . On the positive side, U.S. teen pregnancy rates have decreased 17% from 1990 to 1997, however, still almost 10% of U.S women aged 15-19 become pregnant and 85% of all adolescent pregnancies were unplanned, unintended or mistimed.

Contraceptive use among adolescents has increased dramatically since the mid-1980s in response to concerns about sexually transmitted diseases (STDs). On the positive side, the vast majority of adolescents now report using some form of birth control at the time of first intercourse (76% of teenage girls and 72% of teenage boys). However, condom use at last intercourse declines with increasing grade level from 66.6% in 9 th graders to 47.9% in 12 th graders (and 37.7% of 18-24 year old college students). There are also still significant delays in obtaining contraception and most young women are sexually active for months before they seek medical attention.

The ideal contraceptive method for adolescents would be safe, effective, reversible, inexpensive, convenient, private, and have few side effects. Several generalizations may be helpful:

  • Every method of contraception for adolescents is safer than pregnancy.
  • There is no ideal contraceptive method and thus, health-care providers must help provide the adolescent with an array of contraceptive choices to meet the teen's individual needs, respecting religious and cultural beliefs, and medical conditions.
  • Sexually active adolescents often face the risk of both STDs and unintended pregnancy and are thus candidates for two interventions - one method for STD risk reduction (condoms, safer sex practices) and another to effectively reduce pregnancy risk (usually hormonal contraception).
  • Compliance depends heavily on motivation which may depend on appropriate patient education and understanding.
  • Noncontraceptive benefits offered by birth control methods should be considered when selecting methods and counseling patients.
  • Adolescents with chronic medical problems have more complex decisions to make when determining a balance between risk and benefits.
CONTRACEPTIVE EFFICACY

Effectiveness is measured by a contraceptive method failure rate. This can represent either:

    • Typical use failure rate - this number best reflects the pregnancy rate in actual use by the average patient.
    • Correct and consistent use (perfect use or method) failure rate - this number reflects perfect use but is not a realistic number and should not be routinely quoted to adolescents.

Examples include:

Women experiencing pregnancy
Method
Typical use
Perfect Use

Implant
0.09
0.09
Injections
0.1
0.1
IUD - copper T380A
0.7
0.6
Oral contraceptives
Combined
2.6-6.0
0.1
Progestin only
3.0-10.0
0.5
Male condom
12.0
3.0
Withdrawal
19.0
4.0
Spermicides
40.0
6.0
Female condom
21.0-26.0
5.0
No method
85.0
85.0

CONTRACEPTIVE SAFETY

All methods of birth control are safer for a young woman's health than pregnancy. Despite the safety of contraception, surveys show that patients grossly overestimate contraceptive risks. Adolescents are particularly vulnerable to misinformation.

GENERAL CONSIDERATIONS IN METHOD SELECTION

Helpful to consider:

    • A teen's knowledge base regarding STD and pregnancy risks
    • Motivation for contraception including relationship with their partner
    • Frequency of intercourse
    • What teen would do if they were pregnant

RECOMMENDED CONTRACEPTIVE METHODS FOR TEENS

The most frequently recommended methods of contraception for adolescents include condoms, oral contraceptives and hormonal injections. Emergency (postcoital) contraception (EC) is underutilized by all age groups, but is particularly important for teens. EC should be more widely available for teens, both by advance prescription and after-the-fact to prevent many unwanted pregnancies.

The reader is directed to detailed articles on contraceptives in reference section below for further information on particular contraceptive methods.

HORMONAL CONTRACEPTIVE DEVICES/ORAL CONTRACEPTIVES

Mechanisms of Action

Combination oral contraceptives seem to work through one or more of the following mechanisms:

    • Thickening of cervical mucus
    • Inhibition of ovulation
    • Endometrial changes - thin endometrium induced by progestins.
    • Slowed tubal motility

Advantages for Adolescents

    • Safe, effective contraception
    • Relatively easy method (once a day)
    • Taken at time independent of coitus
    • Rapidly reversible method
    • Many noncontraceptive health benefits

Disadvantages

    • Requires daily administration
    • Potential side effects
    • Requires counseling on safer sex practices
    • Post-pill amenorrhea

Increasing Adolescent OCP Compliance

Suggestions include:

      • Emphasize the noncontraceptive benefits of oral contraceptives
      • Demonstrate concretely how to use pills.
      • Have teens explicitly discuss their concerns about pill use so that they can be addressed.
      • Help the teen plan for crucial logistics such as pill storage and how to remember to take the pills each day
      • Start pills on the first day of bleeding (no back-up method is needed) or consider starting pills immediately if pregnancy can be ruled out to simplify instructions and use barrier method as back-up for first cycle.
      • Shorten the pill free interval. Start each new pack of pills on the first day of menses. Or eliminate the pill free interval for several packs, e.g “bicycling”, “recycling” or “combination continuous use”.

Special considerations in adolescents:

  • When to start:
    • Young users : Ideally a teen would have at least three to six regular periods after menarche before starting the pill. However, if a young menarchal teen is sexually active, the risks of pregnancy exceed those of the risks of taking hormonal contraceptives. There is no evidence that the early use of OCPs leads to premature epiphyseal closure or to any disruption in the maturation of hypothalamic-pituitary-ovarian axis.
    • Following pregnancy : After a first-trimester therapeutic abortion or miscarriage, the pill should be started immediately to prevent ovulation. After a pregnancy, a 3 - 4 week delay should be allowed before starting OCPs, due to the risk of thromboembolism. However, progestin-only methods can be initiated immediately.
  • If the teen has very irregular cycles, she should be informed that her cycles are likely to be regular while she is using the pills, but will return to their usual, irregular intervals when the pills are stopped, and that her menses may not return for some time after discontinuation.
  • Initial examination
    • History: Menstrual history, past history and risk factors for sexually transmitted diseases (STDs), history of problems that suggest any contraindications for use of the pill, and sexual and family histories
    • Physical examination: The optimal exam would include: weight and blood pressure measurements, thyroid examination, breast examination, abdominal examination, and pelvic examination. However, only a blood pressure and, perhaps, a breast exam are required to start pills. The pelvic exam may be deferred for 3-6 months at a minimum. This is particularly the case for women who are being prescribed OCPs for noncontraceptive benefits and who may not be sexually active.
    • Laboratory tests : Pap smear and screening for Chlamydia are recommended for every sexually active teen. However, each of these tests is recommended for well woman care; they are not required for pill prescription.
    • Education: Counseling is the most critical component of the visit.
  • Follow-up
    • It is preferable to see the teenager at 1 month and again at 3 months after starting the pill and then every 6 months. The visit after 1 month is important, especially in younger teens, as more than 10% of women discontinue the pill during the first month due to minor side effects.
    • Check blood pressure at 3 months and then as indicated for well woman care.
    • Perform breast and pelvic examination every 12 months for routine care. Annual screening for chlamydia is required for sexually active women under age 25.

Other hormonal contraceptives include:

  • Injectables both combination and progestin only
  • Progestin only oral contraceptives
  • Implantable contraceptives
  • Vaginal ring: combination estrogen and progestin (nuvaring)
  • Transdermal patch (Evra patch)
  • Intrauterine system
  • Emergency contraceptive pills

EMERGENCY CONTRACEPTION

Emergency contraception has a tremendous potential to reduce the numbers of unplanned pregnancies and to decrease the need for abortion for women of all ages. It has been estimated that proper use of EC could prevent 1.5 million unplanned pregnancies and 0.7 million abortions each year.

The three available methods include a short course of combination oral contraceptive medication, short course of progestin only or the insertion of a IUD. The literature suggests that the progestin only method has the advantages of higher efficacy and lower side effects. While it is approved for us up to 72 hours after unprotected coitus, there is evidence that it is effective longer than this.

Pregnancy rates after unprotected sexual intercourse

 
Combination EC
Progestin-only

Pregnancy rate
3.2%
1.1%
Up to 24 hours
2.0%
0.4%
25-48 hours
4.1%
1.2%
49-72 hours
4.6%
2.7%

Emergency contraception is the only approved contraception available after intercourse. The mechanism of action are similar to oral contraceptives in that they delay or inhibit ovulation, alter tubal motility, and they can alter the composition of the endometrium to block implantation.

More information is available at: http://www.NOT-2-LATE.com/

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Cases

A 16-year-old adolescent female comes into the health facility and you are seeing her for a routine annual examination. The teen's mother is in the waiting room. During your history with the teen you find out that she has a boyfriend and that she started becoming sexually active with her boyfriend two months ago. She is occasionally using condoms.

Question:
What would be important on her history?

Answer

  • Menstrual history - She was menarchal at age 12, her periods have been regular and her last menstrual period was normal and was two weeks ago.
  • Sexual history - She has only had one sexual partner for the past two months. This is consensual sexual relationship.
  • Past history for sexually transmitted diseases (STDs) - She has had no history of STDs and has no vaginal symptoms.
  • Contraceptive history - She has only used condoms and these about 60% of the time.
  • Review of systems for any contraindications to hormonal contraceptives. She has no history of any chronic diseases but has mild acne.
  • Her thoughts on contraceptives - She has discussed oral contraceptives with a girlfriend who uses them and would really like to start them.
  • How she would handle the discussion of sexual activity and contraception with her mother . She has thought about this and decided that although she has good relationship with her parents, at this point in time she would not like them to know that she is sexually active and that she is using contraception. She might involve them later but not now. You discuss what concerns she might have with them being involved and she is very clear that she does not want them to be involved at this time.

Question
What would you need to check on her physical examination?

Answer

  • Weight and blood pressure measurements : Weight and height 45 th percentile, BP 116/76
  • Thyroid examination : Normal
  • Breast examination : No masses
  • Abdominal examination : No masses or tenderness
  • Skin examination : Normal except for mild comedonal acne on face
  • Pelvic examination : You discuss the need for a pelvic examination now that she is sexually active and the importance of current and future screening for sexually transmitted infections and for detection of abnormalities of the cervix by Pap smear and checking for cervical pre cancer and cancer. She refuses an examination at this point because she is concerned that her mother is at the office. She states that she is ok with getting an examination at a future time.

Question
How would you proceed with a prescription of oral contraceptives at this point?
Should you prescribe the pill without a pelvic examination?
Do you need the parents involvement or consent?

Answer
While a pelvic examination is an important health screening examination in sexually active females, it is not a mandatory precursor to prescribing oral contraceptives. There is nothing in her history that would contraindicate the prescribing of oral contraceptives. The American Cancer Society is suggesting in their new guidelines that a Pap smear can be performed three years after a teen starts sexual activity. In terms of screening for STDs, you have two choices in this teen. She has no symptoms and one partner, so you could wait to screen her at another visit in the near future or you could order a urine DNA amplification test for chlamydia and gonorrhea.

Prescribing of contraception to a 16 year old without parental consent depends heavily on the local laws in ones state or country. Most states in the U.S. allow for prescribing of medications to prevent pregnancy without parental consent and with the consent of the teen. Most states also allow or require this information to be confidential.


Question
Are there any tests you need to order before filling a prescription with this teen for OCPs?

Answer
There are no specific lab tests that would be needed in this teen to prescribe oral contraceptives. STD screening is important for all sexually active adolescents, but should not be a barrier in prescribing OCPs to this teen.


Question
Which pill would you chose and when would you choose to start her on the pill?

Answer

  • While there is no best pill, a second or third generation pill that contains 35 ug or less of estradiol and contains a progestin other than norgestrel would be fine. Since her menses is likely to start in the next 1-2 weeks, one could start with the first day of her next menses.
  • She should be counseled to use condoms each time she is sexually active until then. She should be advised to use condoms for 7 days after she starts the pill.
  • She should also be advised to return, if her menses do not start on time, as she could potentially be pregnant from a recent contact with her boyfriend.

You prescribe her the medication and ask her make an appointment in 2-3 months to see how she is doing with the pill and to perform a pelvic examination. She is in a health care system that allows for return appointments without parental involvement so that turns out not to be an issue with this teen. You have her mother come in and review the teen's normal findings on examination and check if she has any questions.


Question
The teen calls you up in a month. She states that the pills have been fine but that she forgot three pills the past three days and she had sex last night. What would you advise her?

Answer
First, to prevent pregnancy, emergency contraception might be helpful as she missed three pills. She is prescribed emergency contraception to take this evening and in the morning. She is then instructed on some methods to enhance compliance. These include:

  • Emphasizing the noncontraceptive benefits of oral contraceptives - particularly the possible improvement in acne for this teen.
  • Having the teen chose a best time and place to take the pill each day - usually best to keep same time and place.
  • Shortening the pill free interval. Start each new pack of pills on the first day of menses. One could also eliminate the pill free interval for several packs, e.g. “bicycling”, “recycling” or “combination continuous use”.

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Web Sites

http://www.teenwire.com/
This teen site from the Planned Parenthood Federation of America provides information and news about teen sexuality, sexual health, and relationships.

http://www.youngwomenshealth.org/
The Center for Young Women's Health site, sponsored by Children's Hospital in Boston , provides information on health issues that affect teenage girls and young women

http://www.guttmacher.org/
Information and resources from the Alan Guttmacher Institute, a nonprofit organization focused on reproductive health research, policy analysis, and public education.

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References

Emans SJH, Laufer MR, Goldstein DP. Pediatric and adolescent gynecology, 4 th ed. Philadelphia : Lippincott Williams and Wilkins

Hatcher RA, Guest F, Stewart et al. Contraceptive Technology 17 th edition, 1998.

Neinstein LS: Adolescent health Care: A Practical Guide, Philadelphia , Lippincott Williams and Wilkins, 2002

Chapter 42: Contraception: Neinstein LS and Nelson AL

Chapter 43: Combined Hormonal Contraception: - Nelson AL and Neinstein LS

Chapter 44: Intrauterine Devices - Nelson AL and Neinstein LS

Chapter 45: Barrier Contraceptives - Nelson AL and Neinstein LS

Chapter 46: Emergency Contraception - Nelson AL and Neinstein LS

Chapter 47: Long-Acting Progestins - Nelson AL and Neinstein LS

Glasier A. Emergency postcoital contraception. N Engl J Med. 1997;337:1058.

Glasier A, Baird D. The effects of self-administering emergency contraception. N Engl J Med. 1998;339:1.

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Copyright (©) 2004-2013 Lawrence S. Neinstein, University of Southern California . All rights reserved. Republication or redistribution of the text, table, graphs and photos is expressly prohibited. The University of Southern California shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.