Contraception: Issues specific to adolescents

INTRODUCTION — This topic review will provide an overview of issues related to the provision of contraceptive services to adolescent females. Emergency contraception, choosing a contraceptive method, and individual methods of contraception are discussed separately.

●(See "Emergency contraception".)

●(See "Contraception: Counseling and selection".)

●(See "Intrauterine contraception: Candidates and device selection".)

●(See "Contraception: Etonogestrel implant".)

●(See "Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration".)

●(See "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use".)

●(See "Contraception: Hormonal contraceptive vaginal rings".)

●(See "Contraception: Transdermal contraceptive patches".)

●(See "Contraception: Progestin-only pills (POPs)".)

●(See "Pericoital (on demand) contraception: Diaphragm, cervical cap, spermicides, and sponge".)

●(See "External (formerly male) condoms".)

●(See "Internal (formerly female) condoms".)

EPIDEMIOLOGY — In the United States, approximately 80 percent of pregnancies among adolescents age 15 to 19 years are unintended [1]. In national surveys, approximately one-fourth of high school students report that they are sexually active (defined by having sexual intercourse in the previous three months) [2]. Among sexually active students, only one-third used an effective method of contraception (ie, long-term reversible contraception or short-term hormonal contraception) and one-tenth did not use any method. The risk of pregnancy over the course of one year in couples who do not use any method of contraception is approximately 85 percent [3].

Among female high school students responding to the 2021 Youth Risk Behavior Surveys [2-4]:

●22 percent were currently sexually active and during their last sexual intercourse:

•47 percent used a condom

•23 percent used birth control pills

•5 percent used a shot, patch, or birth control ring

•10 percent used an intrauterine device (IUD) or contraceptive implant

•10 percent used a condom plus a highly effective/effective contraceptive method

•15 percent did not use any method to prevent pregnancy

Similarly, data from the 2011 to 2015 National Survey of Family Growth indicate that, among females age 15 to 19, condoms remained the most common method ever used (97 percent), followed by withdrawal (60 percent), oral contraceptive pills (56 percent), and depot medroxyprogesterone acetate (17 percent) [5]. Approximately 6 percent reported ever using long-acting reversible contraception (3 percent each for IUD and contraceptive implant). Compared with the previous survey (2006 to 2010), use of the contraceptive patch decreased (from 10 to 2 percent) and emergency contraception increased (from 14 to 23 percent). Among sexually experienced females, 16 percent reported using no method of contraception at first sexual intercourse. In an earlier survey (2011 to 2013) adolescents age 15 to 19 years who did not use any method of contraception at their first sexual intercourse were twice as likely to become mothers before age 19 years than those who used contraception at their first sexual intercourse (26 versus 10 percent) [6].

MOTIVATING FACTORS — The sexually active adolescent is more likely to seek contraception if they [7]:

●Perceive pregnancy as a negative outcome

●Have long-term educational goals

●Are more mature (see 'Developmental factors' below)

●Experience a pregnancy scare or actual pregnancy

●Have family, friends, and/or a clinician who sanction the use of contraception

Sexually active adolescents who do not desire pregnancy but are having difficulty choosing a method may be motivated to make a decision by raising their awareness of their risk of pregnancy (eg, by reviewing the stories of a sister, friend, or peer who is a teen mother) or reviewing their educational goals (eg, graduating from high school, going to college). (See 'Choosing a method' below and 'Resources for clinicians and patients' below.)

POTENTIAL BARRIERS — Barriers to use of contraceptives in adolescents may include [8-10]:

●Concerns about confidentiality and parental notification

●Cost

●Misperceptions about their risk of getting pregnant and the effectiveness of, contraindications to, preinitiation evaluation for, and adverse effects of contraception

●Knowledge deficits among adolescents and health care providers

●Difficulty accessing contraception

Removal of barriers appears to be associated with increased use of more effective methods of contraception and decreased rates of pregnancy, without increasing coital frequency or the number of male sexual partners [11-16]. In a prospective study, 1404 urban female adolescents (age 15 to 19 years) were educated about reversible contraception, with an emphasis on the benefits of long-acting reversible contraception (LARC); provided with their choice of reversible contraception at no cost; and followed for two to three years [11]. Nearly three-quarters of participants chose an intrauterine device (IUD) or contraceptive implant. Compared with sexually active United States teenagers in 2008, study participants had lower rates of pregnancy (34 versus 158.5 per 1000), birth (19.4 versus 94 per 1000), and abortion (9.7 versus 41.5 per 1000).

Confidentiality and parental consent

●Confidentiality – Assuring confidentiality is the first step in establishing basic trust and respect between the clinician and the adolescent patient. The adolescent should be given an opportunity to provide their medical history and to obtain gynecologic and sexual information directly from the clinician. The importance and the limits of confidentiality should be discussed with the adolescent and their parent or guardian at the initial visit. (See "Confidentiality in adolescent health care".)

The concept of conditional confidentiality can be introduced to the accompanying parent or guardian as follows:

"I would like to make this visit a positive experience for your child. It is important to respect an adolescent's privacy as a normal part of growing up. I would first like to have the opportunity to review health information with you, and then I would like to review health information with your child alone. Usually, whatever is discussed between my teenage patients and me is confidential, except in certain situations, such as if they have thoughts of suicide, thoughts of physically harming someone, or reports that they have been or are being physically or sexually abused. If you feel you need to know more about what they and I have discussed, I strongly encourage you and your child to talk to each other directly."

A young adolescent may prefer to have their parent or caregiver present throughout the office visit, particularly if the caregiver is aware of the teenager's sexual behavior and wants the teenager to use a contraceptive method. Even if this is the case, it is important to encourage independent time with the adolescent to obtain a more detailed history about other possible high-risk behaviors. (See "Guidelines for adolescent preventive services", section on 'Strategy for provision of adolescent preventive services'.)

The 21^st Century Cures Act was implemented in 2020 to improve medical care by increasing access, use, and exchange of electronic health information. However, the legal right of adolescent minors to receive confidential services in this context has been a challenge. The North American Society for Pediatric and Adolescent Gynecology and the Society for Adolescent Health and Medicine provide additional information about the 21st Century Cures Act and adolescent confidentiality, including recommendations for health care providers [17]. (See "Confidentiality in adolescent health care", section on 'Twenty-First Century Cures Act'.)

●Parental consent – Clinicians should be familiar with state regulations and local clinic protocols regarding a minor's right to access contraceptive services without parental involvement or notification. The need for parental consent also may be related to state or federal funding for hormonal contraception in local clinics. The Guttmacher Institute maintains a list of state policies regarding parental involvement and consent that are updated regularly. (See "Consent in adolescent health care".)

Cost — In the United States, the Patient Protection and Affordable Care Act of 2010 (public law No. 111-148) requires coverage of preventive services for females, including US Food and Drug Administration (FDA)-approved contraceptive methods, without out-of-pocket costs [18,19]. However, adolescents and young adult females who have health insurance through their parents may be reluctant to access such services unless their privacy can be assured [20]. In addition, challenges to this mandate may arise for adolescents in states that opted out of Medicaid Expansion or when adolescents with an insurance plan must seek an in-network provider experienced in offering highly effective contraceptive services [21]. We encourage providers to become familiar with local resources for provision of contraceptives at little or no cost (eg, by asking social workers for a local resource book or trustworthy online program). (See "Confidentiality in adolescent health care", section on 'Potential threats to confidentiality'.)

Misperceptions — Adolescent and clinician misperceptions are important barriers to effective adolescent contraception [22-25]. Adolescents may have misperceptions about their risk of getting pregnant (eg, if they have had unprotected sexual intercourse and did not get pregnant, they may believe that they are unable to become pregnant). Adolescents may mistakenly believe that they must have a pelvic examination and cervical inspection before initiation of any method of contraception; this evaluation is necessary only for intrauterine contraception. Both adolescents and clinicians may have misperceptions about the effectiveness of, contraindications to, preinitiation evaluation for, or adverse effects of various methods of contraception [26].

It is important to dispel misperceptions of adverse effects, particularly of hormonal methods (eg, the contraceptive implant, oral contraceptive pills, depot medroxyprogesterone acetate [DMPA]), when discussing contraceptive methods with adolescent patients. Examples of adolescent concerns include:

●Weight gain – Many adolescents are concerned that hormonal contraceptives cause weight gain. However, a causal relationship has not been established. The effects of hormonal contraception on weight are discussed in greater detail separately. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Weight changes' and "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Weight gain' and "Contraception: Etonogestrel implant", section on 'Counseling points'.)

●Effect on height – Adolescents may be concerned that hormonal contraception may cause premature closure of the growth plates, reducing their ultimate adult height. However, by the time of menarche, most female adolescents have already undergone their growth spurt and achieved approximately ≥95 percent of their adult height. (See "Normal puberty", section on 'Growth spurt'.)

●Congenital anomalies and infertility – Adolescents may be concerned that hormonal contraception may cause congenital anomalies or infertility. However, evidence to support these associations is lacking. (See "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Return of fertility'.)

●Overestimation of the magnitude of risk – In some cases, adolescents may be correct that a particular method of contraception is associated with an adverse effect, but may overestimate the magnitude of the risk (eg, decreased bone density with DMPA, venous thromboembolism [VTE] with hormonal contraception in the absence of underlying risk factors). (See "Contraception: Transdermal contraceptive patches", section on 'Risk of venous thrombotic events' and "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Venous thromboembolism' and "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Reduction in bone mineral density'.)

These side effects must be considered in relation to their risk during pregnancy [27]. As an example, the risk of VTE may be 3- to 10-fold higher in pregnant than in nonpregnant females. (See "Venous thromboembolism in pregnancy: Prevention".)

Clinician concerns — Clinicians may be concerned about contraindications and/or potential long-term effects (including FDA boxed warnings) of hormonal contraception in adolescents.

A comprehensive list of absolute (unacceptable health risks) and relative (theoretic or proven risks usually outweigh the advantages) contraindications to long-acting and hormonal contraceptive methods for females in the United States is available from the Centers for Disease Control and Prevention. An easy-to-use pocket-size wheel of the 2015 World Health Organization (WHO) medical eligibility for contraceptive use is available from the WHO [28].

Clinician concerns about the potential long-term effects of hormonal contraception (eg, decreased bone density with DMPA or ultra-low dose combination oral contraceptives) also may be a barrier to provision of contraception to adolescents. These concerns must be weighed against the risk of pregnancy in a young adolescent [27].

Biologic, behavioral/psychological, and environmental factors (table 1) can assist with clinical decision-making when there is concern about the long-term effects of initiating hormonal contraception in young adolescents. As a general rule, the risks of pregnancy in a young teenager with behavioral and environmental risk factors exceed the risks of hormonal contraceptives, particularly when the caregiver is unable to monitor the adolescent.

Difficulty accessing contraception — Many adolescents have difficulty accessing contraceptive services.

Evidence-based clinical best practices for adolescents to access contraceptive methods include [29]:

●Offering same-day appointments and appointments during after-school hours and on weekends

●Obtaining a sexual health history at every visit

●Offering a wide range of contraceptive methods

●Offering reliable contraception at every office visit to adolescents who are not on reliable contraception

●Prescribing hormonal contraception without prerequisite examinations or testing for sexually transmitted infections

●Offering contraception during an emergency department visit

In one study of 96 adolescents who received brief counseling (average of 12 minutes) during their emergency department visit, 33 percent either initiated a contraceptive method during the visit or at a follow-up referral visit ≤8 weeks later [30].

CHOOSING A METHOD — Developmental factors, patient factors (eg, medical history [31], sexual and reproductive history), and patient preferences (eg, convenience, tolerance of side effects) affect the choice of contraceptive method. Contraceptive counseling and selection are discussed in detail separately. Issues that are relatively more important for adolescents are described below. (See "Contraception: Counseling and selection".)

Developmental factors — Adolescent development affects the adolescent's ability to implement and adhere to a contraceptive regimen. From a developmental perspective, sexually active girls in early adolescence (10 through 14 years) have difficulty planning events and activities; they often have an idealistic point of view, think about situations in a concrete or literal way, and live in the moment. Implementing a contraceptive method that requires planning and forethought to prevent the "possibility" of pregnancy is difficult at this stage without monitoring and adult support. Girls in middle adolescence (15 through 18 years) and late adolescence (>18 years) are more capable of higher-level planning, decision making, and problem solving, skills essential to effective contraceptive behavior [32,33]. (See "Sexual development and sexuality in children and adolescents", section on 'Adolescent development' and "Contraception: Counseling and selection".)

Patient factors and preferences — A medical, reproductive/sexual, and social history will identify absolute (unacceptable health risks) or relative (theoretic or proven risks usually outweigh the advantages) contraindications and patient factors (eg, anemia, acne, dysmenorrhea) that may affect contraceptive choice (table 2). For most adolescents, the advantages of any method of reversible contraception outweigh the theoretic or proven risks [34].

Before discussing contraceptive options and possible contraindications, we evaluate patient preferences regarding childbearing (eg, do they want to prevent pregnancy now?), privacy, convenience, side effects, control or suppression of menstruation, spontaneity, social and cultural factors, etc [35,36]. Patient preferences are discussed in greater detail separately. (See "Contraception: Counseling and selection", section on 'The shared decision-making process'.)

In surveys or individual patient interviews, factors that are most important to adolescents include effectiveness, duration, convenience/ease of use, and side effects [37-39]. These factors are discussed below.

Abstinence — Complete abstinence from penile-vaginal intercourse is the most effective method of birth control. However, data suggest that adolescents who practice abstinence occasionally have penile-vaginal intercourse [40]. Thus, even adolescents who intend to remain abstinent should receive information about pregnancy prevention (including emergency contraception [EC]) and prevention of sexually transmitted infections [41]. (See "Emergency contraception" and "Prevention of sexually transmitted infections".)

Presenting options — When presenting options for contraception to sexually active adolescents, we describe them in order of effectiveness, starting with the most effective options (figure 1), as recommended by the American Academy of Pediatrics (AAP) [42] and the American College of Obstetricians and Gynecologists (ACOG) [24]. A summary of relevant information is provided in the table (table 2). More detailed information is available in individual topics related to the various methods.

Long-acting reversible methods — Intrauterine contraception and contraceptive implants are the two types of long-acting reversible contraception (LARC).

LARC methods are the most effective reversible methods of contraception; once they have been inserted they do not require regular action on the part of the adolescent. They are considered first-line options for adolescents by the AAP [42,43] and the ACOG [44-46].

In a systematic review of nine studies (26,907 participants) comparing intrauterine device (IUD) with other methods of contraception in females ≤25 years, the 12-month continuation rates were highest for LARC methods (approximately 85 percent compared with 40 to 50 percent for non-LARC methods) [47]. In a prospective cohort study, among 1099 urban adolescents (age 14 to 19 years) who were provided with contraception at no cost, 12-month continuation rates were greater for LARC than for other methods (81 versus 44 percent) [48]. Satisfaction was also greater with LARC than non-LARC methods (75 versus 42 percent).

●Intrauterine contraception – Intrauterine contraception with the copper or levonorgestrel-releasing (LNG) IUD is an attractive option for adolescents who desire long-term, uninterrupted contraception [49]. Noncontraceptive benefits of the LNG IUDs may include reduction in heavy menstrual bleeding, dysmenorrhea, and endometrial hyperplasia, as well as suppression of menses [43,50,51].

IUDs can be described to adolescent patients as follows [52]:

"IUDs are completely reversible contraceptive methods placed in the uterus. There are two types of IUDs. One is hormonal and lasts up to three or five years. The other is nonhormonal; it releases copper and can last up to 10 years. Either type can be removed at any time if you wish to become pregnant or want to switch to a new method. They are very safe and have the highest satisfaction and continuation rates of any contraception method."

The pregnancy rate is <1 percent per year in typical patients, and slightly higher in females younger than 25 years [53,54]. Fertility returns quickly after removal.

There are relatively few absolute (unacceptable health risks) or relative (theoretic or proven risks usually outweigh the advantages) contraindications to intrauterine contraception [55]. These include severe distortion of the uterine cavity, active pelvic infection, known or suspected pregnancy, Wilson disease (for the copper IUD), unexplained vaginal bleeding (for initiation of intrauterine contraception), breast cancer (for the LNG IUD), and hepatocellular adenoma or hepatoma (for the LNG IUD). (See "Intrauterine contraception: Candidates and device selection", section on 'Contraindications'.)

With adequate counseling regarding anticipated side effects and management of anticipated side effects, IUDs can be used safely and effectively in adolescents [43,56]. There is little difference in infection and complication rates between adolescents and older females [44,57-59]. Although some studies have reported an increased expulsion rate in young or nulliparous adolescents, the findings are inconsistent. (See "Intrauterine contraception: Background and device types" and "Intrauterine contraception: Candidates and device selection" and "Intrauterine contraception: Management of side effects and complications".)

●Contraceptive implant – The etonogestrel contraceptive implant is an attractive option for adolescents who desire long-term, uninterrupted contraception [43,49].

The contraceptive implant can be described to adolescent patients as follows [52]:

"The contraceptive implant is a single flexible plastic rod placed under the skin of your upper arm. It is hormonal and lasts up to three years. It can be removed if you wish to become pregnant or would like to switch to a different method."

The pregnancy rate is <1 percent per year in typical patients [54]. Fertility returns quickly after removal.

Absolute (unacceptable health risks) and relative (theoretic or proven risks usually outweigh the advantages) contraindications to the contraceptive implant include known or suspected pregnancy, severe (decompensated) cirrhosis, hepatocellular adenoma or hepatoma, undiagnosed abnormal vaginal bleeding, systemic lupus erythematosus with positive or unknown antiphospholipid antibodies, and known or suspected breast cancer or history of breast cancer [55]. (See "Contraception: Etonogestrel implant", section on 'Patient selection'.)

Unexpected and prolonged vaginal bleeding is a common side effect and can trigger request for premature removal. Easy access to clinic staff to provide management advice in such situations is critical. (See 'Whom to contact with questions' below and "Contraception: Etonogestrel implant", section on 'Counseling points' and "Evaluation and management of unscheduled bleeding in individuals using hormonal contraception", section on 'Progestin-releasing implants'.)

Depot medroxyprogesterone acetate — Depot medroxyprogesterone acetate (DMPA) is an injectable progestin-only contraceptive that provides effective, private, reversible contraception for three months. Noncontraceptive benefits of DMPA include protection against ovarian cancer, endometrial cancer, salpingitis, ectopic pregnancy, benign breast disease, acne, and iron deficiency.

The pregnancy rate is 4 to 7 percent per year in typical patients [60,61]. Return to fertility may be delayed for more than a year. (See "Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration", section on 'Return to fertility after discontinuation'.)

Absolute (unacceptable health risks) and relative contraindications (theoretic or proven risks usually outweigh the advantages) contraindications to DMPA, most of which are unlikely in adolescents, include [55]:

●Multiple risk factors for cardiovascular disease (eg, older age, smoking, diabetes, hypertension, low high-density-lipoprotein [HDL] cholesterol, high low-density-lipoprotein [LDL] cholesterol, high triglycerides)

●Vascular disease in patients with hypertension

●Systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥100 mmHg

●Ischemic heart disease or stroke

●Systemic lupus erythematosus with severe thrombocytopenia (relative contraindication to initiation of DMPA, but not continuation) or positive (or unknown) antiphospholipid antibodies

●Rheumatoid arthritis and receiving long-term corticosteroid therapy with a history of or risk factors for nontraumatic fractures

●Unexplained abnormal vaginal bleeding

●Breast cancer

●Diabetes with nephropathy, retinopathy, neuropathy, or other vascular disease or diabetes of >20 years' duration

●Severe (decompensated) cirrhosis, hepatocellular adenoma, hepatoma

(See "Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration", section on 'Patient selection'.)

Menstrual changes (eg, unscheduled bleeding, amenorrhea) are a common side effect of DMPA and a frequent reason for discontinuation. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Side effects'.)

DMPA is associated with decreased bone mineral density, which appears to be reversible [62], and it is important to discuss this possibility with the adolescent patient. However, the potential risk(s) of DMPA must be weighed against the potential benefit of pregnancy prevention [27]. Despite the boxed warning that DMPA should not be used for longer than two years unless other methods are inadequate [63], professional organizations suggest that with adequate explanation of potential risks and benefits, DMPA may be prescribed to adolescent girls who need contraception and may be used for more than two years [42,64]. In a multicenter observational study of adolescents with bone density loss during DMPA use, 14 of 15 subjects had vitamin D deficiency/insufficiency [65]. Thus, to mitigate the risk of decreased bone density, adolescents who choose DMPA are encouraged to take 1300 mg of elemental calcium and 600 to 1000 international units of vitamin D3 (calciferol) or D2 (ergocalciferol) per day and to exercise every day [42,64,65]. Decisions regarding monitoring of bone mineral density and estrogen supplementation should be made on a case-by-case basis. (See "Bone health and calcium requirements in adolescents" and "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Reduction in bone mineral density'.)

Pill, patch, or ring — Combined oral contraceptive pills, the contraceptive patch, and the vaginal ring are hormonal methods of contraception that contain both estrogen and progestin.

The pregnancy rate with these methods is 4 to 7 percent per year in typical patients [60,61]. Noncontraceptive benefits of combined hormonal contraception include improved bone density and protection against ovarian cancer, endometrial cancer, salpingitis, ectopic pregnancy, benign breast disease, acne, and iron deficiency. (See "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use", section on 'Counseling points'.)

Absolute (unacceptable health risks) and relative contraindications (theoretic or proven risks usually outweigh the advantages) contraindications to estrogen-progestin contraceptives include [55]:

●Multiple risk factors for arterial cardiovascular disease (eg, older age, smoking, diabetes, hypertension, low HDL cholesterol, high LDL cholesterol, high triglycerides)

●Vascular disease

●Hypertension

●Ischemic heart disease or stroke

●Known thrombophilia and thrombogenic mutations including antiphospholipid syndrome and factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies

●Deep vein thrombosis (DVT) and pulmonary embolism (PE) (past history of DVT/PE and not taking anticoagulant therapy or DVT/PE and taking anticoagulant therapy for ≥3 months)

●Superficial venous thrombosis (acute or history)

●Increased risk of thromboembolism (includes <21 days postpartum, whether breastfeeding or not)

●Complicated valvular heart disease

●Migraine with aura

●Breast cancer

●Diabetes with nephropathy, retinopathy, neuropathy, or other vascular disease or diabetes of >20 years' duration

●Medically treated gallbladder disease

●Acute viral hepatitis or flare of viral hepatitis (contraindication to initiation, but not continuation of combined hormonal contraception)

●Severe (decompensated) cirrhosis, hepatocellular adenoma, hepatoma

●History of surgery for obesity with a malabsorption procedure (eg, biliopancreatic diversion, jejunoileal bypass, Roux-en-Y bypass); this is a relative contraindication only for combined oral contraceptive pills, not for the contraceptive patch or the vaginal ring (see "Contraception: Counseling for females with obesity", section on 'Contraception pre- and post-bariatric surgery')

●Major surgery or multiple sclerosis with prolonged immobilization

●Drug interactions such as certain antiretroviral therapies, anticonvulsant medications, rifampin

Combined oral contraceptives — Combined oral contraceptive pills require the adolescent to take a pill daily and to remember to refill their prescription. Combination oral contraceptive pills usually are taken for 21 consecutive days followed by 7 days of no pill or placebo pills, during which menstrual bleeding occurs. (See "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use", section on 'Cyclic use'.)

Adolescents who wish to avoid monthly periods for medical or lifestyle reasons may choose to follow a schedule that involves continuous estrogen-progestin pills for 84 days followed by a week of pill-free days. In addition, a combination oral contraceptive that provides continuous, year-round contraception is available. Adolescents who choose to follow a continuous pill or extended cycle regimen should be advised that unscheduled bleeding may occur during the initial cycles but generally decreases with prolonged use. Continuous pill and extended cycle regimens are discussed separately. (See "Hormonal contraception for menstrual suppression" and "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use", section on 'Continuous or extended use'.)

In addition to the general contraindications for estrogen-progestin contraception described above, certain medications or herbal therapies may decrease the effectiveness of oral contraceptives. These include ritonavir-boosted protease inhibitors for the treatment of human immunodeficiency virus (HIV) infection, anticonvulsants, rifampin and griseofulvin (though not most other antimicrobials), and St. John's Wort. (See "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use", section on 'Drug interactions' and "HIV and women", section on 'Choice of contraception'.)

Specific interactions of combined oral contraceptive pills with other medications may be determined with the Lexicomp drug interactions tool included with UpToDate.

Transdermal patch — The transdermal is applied weekly (at a different site) for three weeks, followed by a patch-free week.

Nonhormonal side-effects of the contraceptive patch include application site reactions. Mild itching with irritation and redness can be managed by removing and discarding the patch and placing a new patch in another location. Severe itching with more severe redness and swelling may indicate an allergic reaction, in which case the patch should be removed and discarded and an alternative contraceptive method sought. (See "Contraception: Transdermal contraceptive patches", section on 'Side effects'.)

In addition to the general contraindications for estrogen-progestin contraception described above, obesity (body mass index >30 kg/m² or ≥95^th percentile for age (calculator 1)) is a contraindication for transdermal contraceptive patches [66,67]. (See "Contraception: Transdermal contraceptive patches", section on 'Contraindications'.)

Additional information about patch management, including what to do if the patch becomes detached, is provided separately. (See "Contraception: Transdermal contraceptive patches", section on 'Patch management'.)

Vaginal ring — The vaginal ring (figure 2) is inserted into the vagina by the patient. It is left in place for three weeks and then removed for a single ring-free week. The vaginal ring is available in one size – it does not need to be fitted. (See "Contraception: Hormonal contraceptive vaginal rings".)

Fertility returns within one month after discontinuation.

Adolescents who choose the vaginal ring must be comfortable inserting it into the vagina. Adolescents who use tampons during menses may be more comfortable with this procedure.

Anecdotal evidence suggests that some adolescents do not feel "clean" with the vaginal ring and remove it frequently for washing. Frequent washing decreases effectiveness and may cause intermittent bleeding or spotting.

Other methods — Barrier (condoms, diaphragms, cervical caps, sponges) and other methods of contraception (eg, spermicides, periodic abstinence [ie, the "calendar rhythm" method], withdrawal) are less effective because they require action on the part of the adolescent and/or partner at the time of sexual activity.

●External condoms – The effectiveness of external condoms (commonly called "condoms" [formerly "male condoms"]) for pregnancy prevention depends upon whether they are used consistently and correctly. With consistent, correct use, the pregnancy rate is 2 percent; with typical use it is 13 percent [60,61]. (See "External (formerly male) condoms".)

The effectiveness of external condoms for STI prevention is discussed separately. (See "Prevention of sexually transmitted infections", section on 'Male condom use'.)

●Other methods – Other methods of contraception are infrequently used by adolescents [6]. They are discussed separately:

•Diaphragm, cervical cap, and sponge (see "Pericoital (on demand) contraception: Diaphragm, cervical cap, spermicides, and sponge")

•Internal (formerly female) condom (see "Internal (formerly female) condoms")

•Fertility awareness-based methods (see "Fertility awareness-based methods of pregnancy prevention")

Special circumstances

Physical or intellectual disability — Adolescents with physical disability may have difficulty with menstrual hygiene. For such adolescents, hormonal contraception (eg, LNG IUD, DMPA, the contraceptive patch, or continuous or extended cycles of combined oral contraceptive pills) may be beneficial [43,68-73]. The intellectually disabled adolescent has access to contraception under the supervision of a parent or guardian. (See 'Choosing a method' above and "Hormonal contraception for menstrual suppression".)

Issues regarding sterilization among females with mental illness or disability are discussed separately. (See "Overview of female permanent contraception", section on 'Vulnerable populations'.)

Obesity — Contraception for obese females is discussed separately. (See "Contraception: Counseling for females with obesity".)

Postpartum or postabortion — Contraception for adolescents who are postpartum or postabortion is discussed separately. (See "Contraception: Postpartum counseling and methods".)

Chronic illness — For adolescents with chronic illness, it is important to consider the possibility of hormone-related complications and drug interactions, as well as the risk a pregnancy might pose to the adolescent's health. For some adolescents, progestin-only contraception (eg, DMPA, etonogestrel implant, LNG IUD) may be reasonable; for others, nonhormonal options are available; among these, the copper IUD is the most effective (table 2). The risks of the various contraceptive options must be weighed against the risk of pregnancy [27].

Specific recommendations for contraceptive methods in patients with medical or psychiatric issues are provided separately:

●Inherited thrombophilias (see "Contraception: Counseling for women with inherited thrombophilias")

●Systemic lupus erythematosus (see "Approach to contraception in women with systemic lupus erythematosus")

●HIV infection (see "HIV and women", section on 'Choice of contraception')

●Bipolar disorder (see "Bipolar disorder in women: Contraception and preconception assessment and counseling")

●Other conditions (see "Contraception: Counseling and selection", section on 'Special populations')

Specific interactions of combined oral contraceptive pills with other medications may be determined with the Lexicomp drug interactions tool included with UpToDate.

Options for emergency contraception — EC refers to methods that prevent pregnancy from occurring after an episode of unprotected intercourse. Unprotected intercourse can be a result of contraception nonuse or imperfect use, or can result from forced sexual activity. EC does not interrupt an existing pregnancy; thus, it does not cause abortion. EC options for adolescents are the same as for adults. (See "Emergency contraception", section on 'What are the emergency contraception methods?'.)

PREINITIATION COUNSELING

Whom to contact with questions — Adolescents who are initiating contraception should be given an easy-to-read list that includes:

●The name of the clinic

●The name or title (eg, charge nurse) of the appropriate contact person in the clinic

●The clinic phone number

●Instructions about what to do if they have any concerns about their contraceptive method

Easy access to clinic staff for counseling helps to ensure consistent and correct use of contraception. Adolescents should not rely on their friends or family for information if they have a problem with their contraceptive method.

STI prevention — Adolescents who choose effective methods of contraception (eg, long-acting reversible contraception, depot medroxyprogesterone acetate, combined hormonal contraception) must understand that these methods do not prevent sexually transmitted infections (STI) [74]. To prevent STI as well as pregnancy, consistent and correct use of a condom is necessary [42,75]. Consistent and correct use of male latex condoms reduces the risk STI, including HIV. (See "Prevention of sexually transmitted infections", section on 'Male condom use'.)

Other strategies to prevent STI include vaccines (eg, human papillomavirus, hepatitis B, hepatitis A) and antimicrobial prophylaxis. These strategies are discussed separately. (See "Prevention of sexually transmitted infections".)

Availability of emergency contraception — Adolescents who choose methods of contraception other than an intrauterine device or a contraceptive implant should be educated about the availability of and indications for emergency contraception in the event of a gap in contraceptive use or a method failure [41,76]. This is particularly true for adolescents who require medical treatments that may be teratogenic to the fetus (eg, isotretinoin) or in whom pregnancy would severely compromise health (eg, severe mitral stenosis, symptomatic aortic stenosis, Eisenmenger syndrome) [77,78]. (See "Pregnancy in women with congenital heart disease: General principles", section on 'Maternal risk stratification' and "Pulmonary hypertension with congenital heart disease: Pregnancy and contraception".)

Issues related to removal or discontinuation — Before initiation, we counsel adolescents about issues related to removal of long-acting reversible methods of contraception methods or discontinuation of hormonal contraceptive methods. We prioritize visits (by phone, video, or in-person) for adolescents who request removal of intrauterine devices and contraceptive implants to prevent self-removal. We counsel adolescents who are considering other methods about the risk of pregnancy, bleeding, and missed menstrual periods after discontinuation. These issues are discussed in detail separately:

●Intrauterine devices (see "Intrauterine contraception: Insertion and removal", section on 'IUD removal (with or without replacement)')

●Contraceptive implants (see "Contraception: Etonogestrel implant", section on 'Removal and return of ovulation')

●Depot medroxyprogesterone acetate (see "Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration", section on 'Discontinuation')

●Combined estrogen-progestin oral contraceptives (see "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use", section on 'Return of menses after stopping')

●Contraceptive patch (see "Contraception: Transdermal contraceptive patches", section on 'Return of fertility')

●Contraceptive vaginal ring (see "Contraception: Hormonal contraceptive vaginal rings", section on 'Return of fertility')

INITIATION AND INCREASING ADHERENCE — Most methods of contraception can be initiated without a pelvic examination [34,79]. Strategies to increase contraceptive adherence vary with the method of contraception (table 3). Increasing correct and consistent use of contraception is critical; contraceptive misuse (rather than lack of use) accounts for nearly one-half of unintended pregnancies [80].

Although it is generally not necessary to obtain written informed consent before initiation of contraception in adolescents (with the exception of the contraceptive implant), the use of a structured informed consent form can ensure that the risks, benefits, and anticipated side effects are adequately discussed. Benefits and risks, effectiveness, potential side effects including the boxed warnings for depot medroxyprogesterone acetate (DMPA), complications and danger signs of complications, and indications for discontinuation of the chosen contraceptive method must be included on the consent form. The consent forms must be written in a language understood by the adolescent or translated and witnessed by an interpreter.

LARC — Long-acting reversible methods of contraception (LARC) do not require strategies to increase adherence; their efficacy does not require any action on the part of the adolescent.

●Intrauterine contraception – Screening for sexually transmitted infections (STI) and a bimanual pelvic examination with cervical inspection are performed before insertion of an intrauterine device (IUD). Unless the adolescent is at very high risk for STI (eg, had sex with a partner with known gonorrhea), STI screening may take place at the time of IUD insertion [42]. If detected, STI can be treated with the IUD in place [34,81].

It is helpful for clinicians who are not trained to insert IUDs in nulliparous and parous teens to establish a relationship with a clinic or provider(s) who perform this procedure. We refer patients who require insertion under sedation (eg, some patients with cerebral palsy) to a trained provider, such as a pediatric or adolescent gynecologist or adolescent medicine specialist.

The insertion of intrauterine contraceptive devices and management of side effects are discussed separately. (See "Intrauterine contraception: Insertion and removal" and "Intrauterine contraception: Management of side effects and complications".)

●Contraceptive implants – Written informed consent is necessary before insertion of the contraceptive implant – the consent form is included in the box containing the implant. Pregnancy should be excluded before insertion of the etonogestrel contraceptive implant [34]. The implant is ideally inserted on the same day as the request, using the Quick Start method (algorithm 1). (See "Contraception: Etonogestrel implant".)

However, some practitioners are hesitant to insert the implant if they are not absolutely certain that pregnancy has been excluded or when emergency contraception cannot be taken (eg, the adolescent cannot recall the date of the last episode of protected or unprotected sexual activity). In this situation, the provider may prescribe a single injection of DMPA using the Quick Start method (algorithm 1). This approach provides immediate contraception and in the event the pregnancy test becomes positive, the implant does not need to be removed prematurely. Providing anticipatory guidance to caregivers and adolescents about this approach can minimize misunderstanding and expectations for Quick Start implant insertion in sexually active adolescents. (See 'DMPA' below.)

The insertion of the etonogestrel contraceptive implant and postinsertion counseling are discussed separately. (See "Contraception: Etonogestrel implant" and "Evaluation and management of unscheduled bleeding in individuals using hormonal contraception", section on 'Progestin-releasing implants'.)

DMPA — The first shot of DMPA is typically given during the menstrual period to ensure absence of pregnancy. Alternatively, DMPA can be administered according to the Quick Start method (algorithm 1) [82]. (See "Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration", section on 'Timing of injections'.)

Adolescents who choose DMPA may need support for continued use. Strategies to increase continuation of DMPA include:

●Scheduling the appointment for the next injection immediately after each shot

●Allowing for missed or delayed appointments by scheduling injections 11 to 12 weeks apart rather than 13 to 15 weeks [83,84]

●Instructing the adolescent to set a mobile phone reminder

●Using an automated text messaging reminder system [85,86]

●Self-administration of subcutaneous DMPA may be an option for select adolescents [87] (see "Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration", section on 'Injection techniques')

In a prospective study of urban adolescents who were provided contraception at no cost, the 12-month continuation rate for DMPA among adolescents 14 to 19 years was only 47 percent [48].

Pill, patch, or ring — Combined hormonal contraceptive methods include estrogen-progestin oral contraceptives, the contraceptive patch, and the vaginal ring.

●Estrogen-progestin oral contraceptives – Oral contraceptives can be started at any time. To ensure that the first pill is taken, a "same day" or Quick Start method is the preferred approach (algorithm 1) [88]. (See "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use", section on 'Initiation'.)

As an alternative to the Quick Start method, oral contraceptives can be started on the first day of the next menstrual period or the Sunday after the onset of the menstrual period ("Sunday start method"). Starting oral contraceptives during or soon after the next menstrual period helps make sure that the adolescent is not pregnant. However, when initiation of oral contraceptives is delayed, adolescents may never take the first pill. Failure to begin the pill may occur due to ambivalence, confusion about starting instructions, or intervening pregnancy.

Adolescents who choose oral contraceptive pills need support for continued and correct use, which entails:

•Refilling prescriptions

•Taking the pill every day

•Starting the subsequent pack on time

•Using a "back-up" method of contraception when necessary

Providing clear verbal and written instructions and reviewing the instructions with the actual pill pack (if possible) or a sample pack may increase continuation and adherence. If the adolescent does not have sufficient reading skills to interpret labels and instructions, instructions may be recorded on the adolescent's mobile phone or they may be referred to instructions at a reliable website (eg, "Birth Control Basics" available on the Center for Young Women's Health website).

To optimize adherence with oral contraceptives, we suggest giving an adolescent only three things to remember:

•When to start the pill

•Take the pill every day at the same time, especially when doing something else regularly, like teeth brushing

•Call the clinic/office if there are any questions (see 'Whom to contact with questions' above)

The adolescent should be asked to repeat these three instructions to assess and promote their understanding of them.

Additional strategies to increase continuation may include:

•Using an automated text messaging system to provide a daily reminder to take the pill [86,89,90]

•Prescribing or providing up to one year of oral contraceptive pills at a time (if insurance permits) [44]

In a prospective study of urban adolescents who were provided contraception at no cost, the 12-month continuation rate for oral contraceptives among adolescents 14 to 19 years was only 47 percent [48]. In other observational studies, missing pills was common in both adolescent and adult females [91,92]. In a study limited to adolescents aged 14 to 17 years, the average interval of consecutive pill use was only 32.5 days [91]

●Transdermal patch – The transdermal patch can be initiated according to the Quick Start method (algorithm 1). (See "Contraception: Transdermal contraceptive patches", section on 'Initiation'.)

Strategies to increase adherence to weekly changes include:

•Making a note or setting a reminder on a wall, computer, or cell phone calendar

•Using a weekly cell phone alarm

•Placing a sticker designating the change day on the bathroom mirror

In a prospective study of urban adolescents who were provided contraception at no cost, only 21 adolescents age 14 to 19 years chose the transdermal patch; of these, the 12-month continuation rate was only 41 percent [48].

●Vaginal ring – The vaginal ring can be initiated according to the Quick Start method (algorithm 1). (See "Contraception: Hormonal contraceptive vaginal rings".)

Strategies to increase adherence to the schedule of insertion for three weeks followed by a ring-free week include:

•Making a note or setting a reminder on a wall, computer, or cell phone calendar

•Using a cell phone alarm

•Placing a sticker designating the removal/reinsertion days on the bathroom mirror

Barrier methods — Strategies to increase the use of external (formerly male) condoms in sexually active adolescents include [32,93]:

●Provision of external condoms before the patient leaves the office or clinic

●Provision of practical suggestions to ensure availability (eg, keeping condoms in a purse)

Additional strategies to promote effective condom use are discussed separately. (See "External (formerly male) condoms", section on 'Strategies for promoting effective external condom use'.)

Barrier methods other than external condoms are infrequently used by adolescents [6]. They are discussed separately.

●Diaphragm, cervical cap and sponge (see "Pericoital (on demand) contraception: Diaphragm, cervical cap, spermicides, and sponge")

●Internal (formerly female) condom (see "Internal (formerly female) condoms")

FOLLOW-UP — Sexually active adolescent and young adult females should be seen whenever they have symptoms of sexually transmitted infection (STI) or require review of potential side effects of their contraceptive method (table 2) [34]. (See "Sexually transmitted infections: Issues specific to adolescents".)

Some methods of contraception require specific follow-up as indicated below:

●Depot medroxyprogesterone acetate – Every 13 weeks for repeat injection. When injection is necessary before 13 weeks, documentation of the rationale (eg, lack of transportation) may help with third party reimbursement. The Centers for Disease Control and Prevention practice recommendations indicate that early injection can be given when necessary with no time limit (eg, when the adolescent cannot return at the routine interval) [84].

●Combined oral contraceptive pills/vaginal ring/patch – The refill intervals for combined hormonal contraception may vary depending upon the payment method. If possible, a 12-month supply of pills, rings, or patches should be provided annually. However, some payment providers may require shorter refill intervals.

In addition to acute visits for symptoms of STI, side effects of contraception, or contraceptive refills, adolescents and young adult females should have an annual visit for health maintenance and preventive care. The components of this visit are discussed separately. (See "Guidelines for adolescent preventive services" and "Screening tests in children and adolescents" and "Sexually transmitted infections: Issues specific to adolescents", section on 'STI clinical patterns'.)

RESOURCES FOR CLINICIANS AND PATIENTS

For clinicians:

●ACOG LARC program – American College of Obstetricians and Gynecologists Long-Acting Reversible Contraception Program.

●CHOICE Project – A free website sponsored by the Washington University School of Medicine that provides resources on contraceptive options and training for clinicians.

●United States Medical Eligibility Criteria for Contraceptive Use (2016).

●United States Selected Practice Recommendations for Contraceptive Use (2016).

●World Health Organization Medical Eligibility Criteria for Contraceptive Use and 2015 Medical Eligibility Criteria Wheel for Contraceptive Use.

For patients:

●ACOG Frequently Asked Questions Especially for Teens – American College of Obstetricians and Gynecologists frequently asked questions about contraception.

●ACOG Expert View on long-acting birth control.

●bedsider.org – A free website developed by the private, nonprofit National Campaign to Prevent Teen and Unplanned Pregnancy; includes descriptions and a comparison of the various method and offers to set up automated email or text reminders for appointments, pills, injections, etc.

●Center for Young Women's Health – A free website run by Boston Children's Hospital that addresses reproductive health needs of teens and young adults.

●Planned Parenthood – A not-for-profit organization dedicated to reproductive health with resources for patients and clinicians.

●SexualityandU.ca – An educational site run by the Society of Obstetricians and Gynaecologists of Canada that includes descriptions of various methods and a tool to help with selection of birth control.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Contraception" and "Society guideline links: Adolescent sexual health and pregnancy".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

●Basics topics (see "Patient education: Teen sexuality (The Basics)" and "Patient education: Choosing birth control (The Basics)" and "Patient education: Hormonal birth control (The Basics)" and "Patient education: Long-acting methods of birth control (The Basics)")

●Beyond the Basics topics (see "Patient education: Adolescent sexuality (Beyond the Basics)" and "Patient education: Hormonal methods of birth control (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Motivating factors – Sexually active adolescents are more likely to seek contraception if they perceive pregnancy as a negative outcome, have long-term educational goals, are more mature, experience a pregnancy scare or actual pregnancy, or have family, friends, and/or a clinician who sanction the use of contraception. (See 'Motivating factors' above.)

●Potential barriers – Potential barriers to adolescent contraception include access to affordable contraception; concerns about confidentiality and parental notification; cost; misperceptions about the risk of unintended pregnancy; and misperceptions about the effectiveness of, contraindications to, preinitiation evaluation for, and adverse effects of various methods of contraception. (See 'Potential barriers' above.)

●Patient factors and preferences – A medical, reproductive/sexual, and social history will identify absolute (unacceptable health risks) or relative (theoretic or proven risks usually outweigh the advantages) contraindications, patient factors (eg, acne, dysmenorrhea), and individual patient preferences (eg, ease of use) that may affect contraceptive choice (table 2). (See 'Patient factors and preferences' above.)

●Presenting options – When presenting options for contraception to adolescents, we describe them in order of effectiveness, starting with the most effective methods (ie, intrauterine contraception and the contraceptive implant) (figure 1). We discuss effectiveness, contraindications, anticipated side effects (eg, unscheduled vaginal bleeding), adverse effects, and noncontraceptive benefits). (See 'Presenting options' above.)

●Preinitiation counseling – Before initiating contraception, we provide general information about whom to contact with questions, the need to use condoms to prevent sexually transmitted infections (STI), and the availability and indications for emergency contraception. (See 'Preinitiation counseling' above.)

●Initiation and increasing adherence – At the time of initiation of contraception, written informed consent can be obtained but is not required unless the chosen method is a contraceptive implant or intrauterine device or the contraception is provided in a federal or state-funded family planning clinic. A discussion about strategies to increase adherence (table 3) is also helpful. (See 'Initiation and increasing adherence' above.)

●Follow-up – Sexually active adolescent and young adult females should be seen whenever they have symptoms of STI, require review of potential side effects, or request removal of their contraceptive method (table 2). The frequency of contraception-related follow-up varies with the method (eg, repeat injection every 13 weeks for depot medroxyprogesterone acetate; annual or more frequent refills for contraceptive pills, patch, or vaginal ring). In addition to acute visits for symptoms of STI, side effects of contraception, or contraceptive refills/repeat injections, adolescents and young adult females should have an annual visit for health maintenance and preventive care. (See 'Follow-up' above.)