TOPIC 8: Contraception Methods – Understand and provide guidance to patients regarding methods of contraception
OFFICIAL ABP TOPIC:
Understand and provide guidance to patients regarding methods of contraception
- BACKGROUND
- CONTRACEPTIVE COUNSELING
- CONTRACEPTIVE METHODS
- KEY COUNSELING POINTS ABOUT CONTRACEPTIVE METHODS
- SPECIAL POPULATIONS
- CONTRAINDICATIONS
BACKGROUND
There are 750,000 adolescent pregnancies in the US each year, over 80% of which are unplanned. Pediatricians play a key role in adolescent pregnancy prevention and contraceptive counseling. A strong knowledge of contraceptive options enables pediatricians to both promote healthy sexual decision-making.
CONTRACEPTIVE COUNSELING
Counseling on both abstinence and contraception is important in caring for adolescents. Key aspects include:
- Promoting delayed sexual activity until the adolescent is ready
- Providing access to comprehensive sexual health information
- Supporting contraceptive initiation and adherence for those who are sexually active
- Offering STI screening and prevention measures
- Engaging in motivational interviewing to promote healthy behaviors, focusing on empowering adolescents to set goals and make autonomous, informed decisions about sexual health
- A detailed sexual history assessing the 5 Ps — partners, pregnancy prevention, STI protection, practices, and past history — guides contraceptive counseling. Confidentiality around sexuality and STI information and consent for contraceptive care should be maintained for adolescents to the extent the law allows. Pediatricians should discuss the benefits of sensitively involving trusted adults while respecting adolescent confidentiality.
CONTRACEPTIVE METHODS
Methods are listed in order from most to least effective, with long-acting reversible contraception being the most effective:
- Progestin implants: Highly effective, lasts 3 years
- Intrauterine devices: Copper IUD effective for 10 years, levonorgestrel IUD for 8 years, smaller levonorgestrel IUD for 3 years
- Depot medroxyprogesterone acetate (DMPA) injection: Given every 11-13 weeks
- Combined oral contraceptive pills (COCs): Contain estrogen and progestin, 9% failure rate with typical use
- Contraceptive vaginal ring: Releases estrogen and progestin, replaced monthly
- Transdermal contraceptive patch: Delivers estrogen and progestin, replaced weekly for 3 weeks, then 1 patch-free week
- Progestin-only pills (“mini pill”): Must be taken at the same time daily, thickens cervical mucus but may not inhibit ovulation
- Male condoms: Also protects against STIs, failure rate can be as high as 18% with typical use so dual contraception is recommended with condoms
Less commonly used methods that may be considered for those with non-hormonal preferences or other specific needs include spermicides, diaphragms, cervical caps, female condoms, and fertility awareness methods. However, these methods have higher typical use failure rates.
Emergency contraception options include levonorgestrel pills, ulipristal acetate pills, the Yuzpe method (higher dose COCs), and the copper IUD. The copper IUD is the most effective option. Ulipristal acetate may be more effective for higher body weight individuals.
KEY COUNSELING POINTS ABOUT CONTRACEPTIVE METHODS
- Counsel on the full range of contraceptive options, discussing the most effective methods first (implants and IUDs).
- Implants and IUDs have very low typical use failure rates (<1%) and are safe for nulliparous adolescents. IUDs do not increase infertility, ectopic pregnancy, or infection risk.
- DMPA injections and the patch are highly effective options that are much safer than pregnancy despite side effect profiles. Counsel on recommended DMPA scheduling every 11-12 weeks.
- Consistent and correct condom use should be encouraged with all methods to prevent STIs.
- Prescriptions can be provided without requiring a pelvic exam. STI screening can be done without a pelvic exam.
- Discuss strategies to promote contraceptive adherence, such as alarms and parental support. Emphasize daily adherence for COCs.
- Methods like COCs can be used continuously to suppress menses for medical conditions.
- Emergency contraception should be offered in advance to increase access.
SPECIAL POPULATIONS
- Adolescents with disabilities, chronic illness, and complex medical conditions have similar sexual health needs. Method choice may be influenced by:
- Patient use of teratogenic medications necessitating highly effective contraception methods
- Need for menstrual suppression (e.g., heavy bleeding, hygiene)
- Condition-specific safety concerns, drug interactions, and disease severity
- The CDC medical eligibility criteria for contraceptive use provides guidance on tailoring recommendations based on individual health profiles, particularly for adolescents with chronic illnesses, obesity, postpartum needs, or those on teratogenic medications. For example, it clarifies that IUDs and implants are appropriate for nulliparous adolescents and those with most chronic conditions.
- Some medications like anticonvulsants and antiretrovirals interact with COCs, lowering effectiveness. Alternative methods may be preferred.
- Obesity may impact contraceptive efficacy and side effects:
- DMPA is associated with more weight gain in obese adolescents than COCs, rings, implants, and IUDs
- Transdermal patch is less effective if weight >90kg
- Post-bariatric surgery, highly effective non-oral methods are recommended
- Postpartum adolescents can safely use implants and IUDs immediately after delivery to prevent rapid repeat pregnancy.
- Confidential, nonjudgmental care is critical for all adolescents, including those identifying as LGBTQ+.
CONTRAINDICATIONS
- IUDs are safe for adolescents and do not increase the risk of infertility or pelvic inflammatory disease. Contraindications include current untreated gonorrhea, chlamydia, or pelvic infection.
- Estrogen-containing methods like COCs, the patch, and ring are contraindicated in those with uncontrolled hypertension, migraines with aura, or a history of thromboembolism.
- DMPA may decrease bone mineral density. The FDA issued a black box warning, but no routine bone mineral density monitoring is recommended for adolescents. Tailor counseling based on other osteoporosis risk factors.
REFERENCES
https://publications.aap.org/pediatrics/article/134/4/e1244/32981/Contraception-for-Adolescents