Contraception: Overview of issues specific to adolescents

INTRODUCTION — 

This topic will provide an overview of issues related to the provision of contraceptive services to adolescents with female reproductive systems.

The following issues are discussed in more detail 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 — 

The estimated number of pregnancies in the United States declined by 9 percent between 2010 and 2019. Among teens ages 15 through 19 years, the decline was 52 percent, followed by a further decline of 8 percent in 2020 [1,2]. Furthermore, teen pregnancy rates have declined considerably compared with peak rates [1]. Among teens ages 15 through 19 years, the pregnancy rate peaked at 62 per 1000 in 1991 and was down 75 percent to a rate of 15 per 1000 in 2020. In addition to declining pregnancy rates, birth rates are declining among teens ages 15 through 19 years [1,3-6].

These declines are attributed to several factors, including increased access to comprehensive sex education, improved access to contraception, and a shift in social norms around teenage sexual activity.

In the 2021 Youth Risk Behavior Survey, approximately one-fifth of high school students reported that they are sexually active (defined by having sexual intercourse in the previous three months) [7]. Among sexually active students, only one-third report using hormonal contraception, and only a small percentage of those report the use of long-acting reversible contraception (LARC) [8-10]:

●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 or contraceptive implant

●10 percent used a condom plus an effective or highly effective contraceptive method

●15 percent did not use any contraceptive method

Similarly, the National Survey of Family Growth found that from 2015 to 2019, condoms were the most commonly used contraceptive method and that LARC use, although increasing, was used by a minority of adolescents [11]. In addition, 65 percent reported using withdrawal, 22 percent reported using emergency contraception, and, at first sexual intercourse, 23 percent reported using no method of contraception.

The risk of pregnancy over the course of one year in couples who do not use any method of contraception is approximately 85 percent [9].

FACTORS TO CONSIDER — 

Developmental factors, medical history, patient's sexuality, sexual behaviors, and gender identity, as well as patient values and preferences, all impact the choice of contraceptive method [12]. Adolescent concerns about contraception can also impact use. Concerns most relevant to adolescents are described below. General contraceptive counseling and method selection are discussed in more detail separately. (See "Contraception: Counseling and selection".)

Developmental factors — An understanding of adolescent development and behavior will help guide the provider's contraceptive counseling and ultimately optimize an individualized plan. The transition from concrete to abstract thinking during adolescence can have a profound impact on a teen's ability to plan ahead, problem solve, and use a contraceptive method correctly [13]. Recognition of the patient's developmental stage (ie, early, middle, or late) will assist with helping the patient to navigate correct and consistent method use and appropriate follow-up care [14].

Noncontraceptive benefits — Noncontraceptive benefits of hormonal contraception include reduction in the severity of dysmenorrhea and pelvic pain; treatment of acne, hirsutism, and endometriosis; and protection against ectopic pregnancy, benign breast disease, iron deficiency, and ovarian and endometrial cancer.

Some hormonal contraceptives will reduce menstrual blood flow, which is beneficial for teens with heavy menstrual bleeding or those desiring a reduction in blood flow. Additionally, hormonal birth control reduces ovarian cysts, severity of premenstrual syndrome, premenstrual dysphoric disorder, and menstrual migraines. However, estrogen-containing contraception should not be used if the migraine is associated with an aura. (See "Estrogen-associated migraine headache, including menstrual migraine", section on 'Common clinical questions about estrogen and migraine'.)

Depot-medroxyprogesterone acetate (DMPA) may reduce the frequency of seizures in adolescents with epilepsy. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Beneficial effects on comorbid conditions'.)

Adolescent concerns — Adolescent concerns about hormonal method adverse effects include:

●Weight gain – Many adolescents are concerned that hormonal contraceptives cause weight gain. However, a causal relationship has not been established [15,16]. While some studies have found an association between DMPA use and weight gain compared with no method [17] and with combined hormonal methods [18,19], other studies have not [20-22].

Baseline body mass index (BMI) may play a role in weight gain with DMPA use. In a prospective study (450 girls aged 12 to 18 years) assessing weight gain over the 18 months following initiation of DMPA, adolescents who had a BMI ≥30 kg/m² at baseline gained more weight than those with a BMI <30 kg/m² (9.4 versus 4.0 kg) [17]. Among all participants with a BMI ≥30 kg/m², weight gain was greater among those using DMPA (9.4 kg) than those using an oral contraceptive pill (0.2 kg) or using no method (3.1 kg). Thus, it is advisable to provide anticipatory guidance to patients with higher BMIs that they may gain weight while using DMPA.

The effects of hormonal contraception on weight are discussed in greater detail elsewhere. (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'.)

●Reduction in final height – Adolescents may be concerned that hormonal contraception will cause premature closure of their growth plates, impacting their final adult height. However, by the time of menarche, most adolescents have already undergone their growth spurt and achieved ≥95 percent of their adult height. (See "Normal puberty", section on 'Linear growth spurt'.)

●Harmful to pregnancy – Adolescents may be concerned that initiating a contraceptive method while unknowingly pregnant will cause harm. However, with the exception of intrauterine devices (IUDs), inadvertent use of contraceptives during early pregnancy is generally safe and does not increase the risk for adverse pregnancy outcomes [23-27]. By contrast, placing an IUD if a person is unknowingly pregnant does increase the risk for miscarriage, infection, and preterm delivery [28].

Adolescents should be counseled that if they wait to start contraception until they are certain they are not pregnant, it is possible that they will become pregnant in the interim. However, if they do decide to wait, emergency contraception (EC) should be discussed, pointing out that the copper and levonorgestrel (LNG) IUDs are also considered appropriate for EC.

●Infertility – Adolescents may be concerned that use of hormonal contraception will lead to future infertility. Longitudinal studies of all reversible contraceptive methods demonstrate return to baseline (and sometimes improved) fecundity with cessation of the contraceptive [29]. (See "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Return of fertility'.)

●Overestimates of adverse event magnitude – In many cases, adolescents overestimate the level of risk associated with contraceptive use, including decreased bone density with DMPA and venous thromboembolism (VTE) with estrogen-containing methods. Yet, in the absence of underlying risk factors, the added risk attributed to hormonal contraception is small. (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'.)

Additionally, the risk of VTE attributable to estrogen-containing contraceptive methods must be balanced against the risk of VTE during pregnancy [30]. Combined oral contraceptive (COC) use is associated with 15 to 20 VTEs per 100,000 women per year, while pregnancy is associated with a three- to fourfold higher risk (60 per 100,000 women per year) [31-33]. (See "Venous thromboembolism in pregnancy: Prevention".)

Contraindications to use — Providers may be concerned about contraindications and/or potential long-term effects of hormonal contraception. Contraindications are often divided into absolute (unacceptable health risks) and relative (theoretical or proven risks usually outweigh the advantages).

A comprehensive list of absolute and relative contraindications to long-acting and hormonal contraceptive methods is available from the Centers for Disease Control and Prevention (CDC) [34]. The medical eligibility criteria for each method are available on the CDC website and the CDC contraception app [35].

Concerns about potential long-term adverse effects of hormonal contraception (eg, decreased bone density with DMPA or ultra-low-dose combination oral contraceptives) should be weighed against the risks of pregnancy and postpartum in a young adolescent [30]. For most adolescents, the advantages of any method of reversible contraception outweigh the theoretical or proven risks [36].

Motivating factors — The sexually active adolescent is more likely to use contraception if they [37]:

●Perceive pregnancy as a negative outcome

●Have long-term educational goals

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

●Experience a pregnancy scare or actual pregnancy

●Have family, friends, and/or a health care provider who sanction the use of contraception

Review of the individual's motivations to delay pregnancy may help with the decision to initiate a contraceptive method.

Patient values and preferences — Evaluation of patient values and preferences is an important part of the shared decision-making process when determining an appropriate method. Before discussing contraceptive options and possible contraindications, we evaluate patient preferences regarding [38,39]:

●Childbearing (eg, do they want to prevent pregnancy now)

●Privacy

●Convenience

●Side effects

●Control or suppression of menstruation

●Spontaneity

●Social and cultural factors

The patient's sexuality, sexual behaviors, and gender identity may also impact their contraceptive preferences.

In surveys and individual patient interviews, issues that are most important to adolescents include contraceptive effectiveness, method duration of action, convenience/ease of use, and side effects [40-42]. Patient preferences are discussed in greater detail separately. (See "Contraception: Counseling and selection", section on 'The shared decision-making process'.)

Special circumstances

Physical or intellectual differences in ability — Adolescents with physical or intellectual disability may have difficulty with menstrual hygiene. For such adolescents, hormonal contraception to suppress or reduce menstrual bleeding may be beneficial. Examples of methods include LNG IUD, DMPA, etonogestrel (ENG) implant, contraceptive patch, and continuous or extended cycles of COC pills [43-49]. The caregivers of adolescents with intellectual disabilities may be the drivers of a request for menstrual suppression. It is important that the patient be as involved in the discussion and decision-making as possible. (See "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 — Factors to consider when prescribing contraception for an obese adolescent include risk of thromboembolism, method efficacy, and further weight gain. These are discussed in more detail separately. (See "Contraception: Counseling for females with obesity".)

Postpartum or postabortion — Contraceptive issues relevant to adolescents who are postpartum or postabortion are discussed separately. (See "Contraception: Postpartum counseling and methods".)

Chronic illness — Chronic illness may present additional risks to the adolescent's use of contraceptives or limit contraceptive options because of drug interactions. These need to be weighed against the risk that a pregnancy might pose to the adolescent's health. For some adolescents, progestin-only contraception (eg, progestin-only pills, DMPA, ENG implant, LNG IUD) may be preferable. Others may prefer nonhormonal options; among these, the copper IUD is the most effective (table 1).

Specific recommendations for contraceptive methods in patients with chronic conditions are provided separately:

●Inherited thrombophilias (see "Contraception: Counseling regarding inherited thrombophilias")

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

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

●Migraines with aura (see "Types of migraine and related syndromes in children", section on 'Migraine with aura')

●Seizure disorder (see "Seizures and epilepsy in children: Initial treatment and monitoring", section on 'Additional considerations in adolescent girls')

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

For specific drug interactions with COC pills, refer to the drug interactions program included within UpToDate.

REPRODUCTIVE JUSTICE FRAMEWORK — 

The approach to contraceptive options counseling has primarily focused on efficacy, with the long-acting reversible contraception methods favored over other options. However, a reproductive justice framework has been proposed that instead emphasizes sensitivity to the patient's cultural and social context [50].

Incorporating a reproductive justice framework involves recognizing:

●The mistreatment experienced by marginalized groups and how it can impact their reproductive choices

●The potential presence of unconscious bias that might affect the way patient counseling is conducted

●The importance of prioritizing patient values, preferences, fears, and experiences when assisting with selection of an appropriate contraceptive method

It is essential to include the following:

●An in-depth review of all reversible contraceptive methods (table 1)

●Encouragement and support for healthy and satisfying sexual experiences

●Guidance on practices to prevent sexually transmitted infections, including HIV

●Attention to patient fears and concerns

●Review of the potential noncontraceptive benefits of hormonal contraception

CONTRACEPTIVE OPTIONS

Progestin-only methods

Long-acting reversible methods — Long-acting reversible contraception (LARC) methods include intrauterine devices (IUDs) and contraceptive implants. LARCs are the most effective reversible methods of contraception because their efficacy does not require any action on the part of the adolescent. They are considered first-line options for adolescents by the American Academy of Pediatrics [49,51], the North American Society for Pediatric and Adolescent Gynecology, and the American College of Obstetricians and Gynecologists (ACOG) [52-56].

In a systematic review of nine studies (26,907 participants ≤25 years) comparing methods of contraception, the 12-month continuation rates were highest for LARC methods (approximately 85 percent compared with 40 to 50 percent for non-LARC methods) [57]. Satisfaction may also be greater with LARC than non-LARC methods (75 versus 42 percent in one study) [58].

However, it is important that a traditional "LARC-first" counseling approach also provide room for patients to have autonomy to choose their preferred method, which may include a non-LARC method, and to empower patients to request LARC removal whenever they wish. Without this focus, "LARC-first" counseling could be considered reproductive coercion, working against the principles of reproductive justice by overemphasizing LARC methods at the expense of other options [59].

●Intrauterine contraception – Intrauterine contraception with the copper or levonorgestrel-releasing (LNG) IUD is an attractive option for adolescents who desire long-term, uninterrupted contraception [60]. Noncontraceptive benefits of the LNG IUD include reduction of heavy menstrual bleeding, dysmenorrhea, and endometrial hyperplasia [49,61-63]. The pregnancy rate is <1 percent per year [64,65], and fertility returns quickly after removal.

IUDs can be presented to adolescent patients as follows [66]:

"IUDs are completely reversible contraceptive methods that are placed in the uterus. There are two types of IUDs. One is hormonal and works for three to eight years depending on the dose of the hormone. The other type is nonhormonal and releases copper; it is US Food and Drug Administration (FDA) approved for up to 10 years of use, but further evidence supports efficacy for 12 years [67-70]. Either type of IUD can be removed at any time if you wish to become pregnant or want to switch to a different method or no method. IUDs are quite safe and among the most effective methods available. They also have the highest satisfaction and continuation rates of all contraceptive methods."

There are relatively few absolute or relative contraindications to intrauterine contraception [71]. Contraindications include 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'.)

IUDs can be used safely and effectively in adolescents [49,72]. There is no difference in infection rates and little, if any, difference in complication rates between adolescents and older females [52,73-75].

Data on whether adolescent patients have an increased frequency of IUD expulsion are mixed [76-78]. Expulsion rates among adolescents ranged from 5 to 9 percent compared with 4 to 5 percent in women >20 years old. Risk factors for expulsion include a history of heavy menstrual bleeding, anemia, bleeding disorders, previous IUD expulsion, and elevated body mass index (BMI) [77-79].

We suggest that providers who are not trained to insert IUDs establish a relationship with a clinic or provider(s) who performs this procedure. Patients may prefer or need sedation to have the IUD inserted. IUDs can also be placed synchronously with other procedures requiring anesthesia, such as dental procedures. Patients with special needs should be referred to a trained provider, such as a pediatric and adolescent gynecologist or adolescent medicine specialist, to discuss options.

The insertion of IUDs, management of side effects, and more details about IUDs are discussed separately. (See "Intrauterine contraception: Insertion and removal" and "Intrauterine contraception: Management of side effects and complications" and "Intrauterine contraception: Background and device types" and "Intrauterine contraception: Candidates and device selection".)

●Contraceptive implant – The etonogestrel (ENG) contraceptive implant is an attractive option for adolescents who desire long-term, convenient, and reliable contraception [49,60]. The pregnancy rate is <1 percent per year in typical patients [65], and fertility returns quickly after removal. It can be described to adolescent patients as follows [66]:

"The contraceptive implant is a single flexible plastic rod, the size of a matchstick, which will be discreetly placed just under the skin of the inner part of your upper arm. It is a progestin-only method that is effective for five years and can be removed at any time."

Although the FDA has approved the contraceptive implant for up to three years of use, there is evidence that supports effectiveness for up to five years [60,80].

Most of the absolute and relative contraindications to the contraceptive implant are uncommon in adolescents. Conditions 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 [71]. (See "Contraception: Etonogestrel implant", section on 'Patient selection'.)

●Unfavorable bleeding patterns associated with LARCs – Unfavorable bleeding patterns are a major source of dissatisfaction and requests for removal of progestin-only LARC methods. Adolescents should have easy access to management advice from clinic staff when this occurs. Reassurance, validation of symptoms, and provision of treatment for short-term relief may promote continuation of the LARC method.

Most LNG IUD users will establish a favorable bleeding pattern within a year of IUD insertion. However, the ENG implant is associated with more persistent unpredictable bleeding [81]. A course of nonsteroidal anti-inflammatory drugs (NSAIDs), combined oral contraceptives (COCs), ulipristal acetate, or tamoxifen may provide relief when LARC bleeding is problematic [81-86] (see "Evaluation and management of unscheduled bleeding in individuals using hormonal contraception", section on 'Progestin-releasing implants' and "Intrauterine contraception: Management of side effects and complications", section on 'Continued bleeding and cramping'):

•NSAIDs – Naproxen 500 mg orally twice a day for five days every four weeks

•Oral contraceptives – A COC pill containing 30 to 35 mcg of ethinyl estradiol (EE) daily for six weeks

Patients who develop new unscheduled bleeding or whose unfavorable bleeding pattern worsens should be evaluated for pregnancy, sexually transmitted infections (STIs), and, if using an IUD, location of IUD.

Other progestin-only methods

●Depot medroxyprogesterone acetate (DMPA) – DMPA is an injectable progestin-only contraceptive that provides effective, discrete contraception for three months. The pregnancy rate is 4 to 7 percent per year [87,88]. Return to fertility may take up to a year. (See "Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration", section on 'Return to fertility after discontinuation'.)

DMPA is administered intramuscularly every 12 to 13 weeks. The dose is generally administered in the office, and we prefer scheduling injections 12 weeks apart so that there is time remaining in the window if the visit needs to be rescheduled. Additionally, the Centers for Disease Control and Prevention (CDC) practice recommendations indicate that early injection can be given when necessary with no minimum interval [89]. Subcutaneous medroxyprogesterone acetate is another option for administration. It is available in prefilled syringes that can be administered at home. (See "Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration", section on 'Administration'.)

Medroxyprogesterone acetate has unique advantages for adolescents with seizure disorder as it has been shown to decrease seizure frequency. For some adolescents with a seizure disorder, it may be beneficial to administer DMPA in shorter intervals (eg, every 8 to 10 weeks) to optimize menstrual suppression and reduce catamenial seizures [90,91].

Menstrual changes (eg, unscheduled bleeding, amenorrhea) are a common side effect of DMPA and a frequent reason for discontinuation. Methods to manage unscheduled bleeding associated with LARCs may also provide relief when DMPA bleeding is problematic. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Side effects' and 'Long-acting reversible methods' above.)

Most of the absolute and relative contraindications to DMPA are uncommon in adolescents. The most frequent contraindications to initiation of DMPA in adolescents include [71] (see "Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration", section on 'Patient selection'):

•Unexplained abnormal vaginal bleeding

•Systemic lupus erythematosus with severe thrombocytopenia or positive (or unknown) antiphospholipid antibodies

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

Although the FDA recommends against using DMPA for longer than two years out of concern about bone mineral loss and increased fracture risk, studies demonstrate that bone loss is reversible once DMPA is discontinued [92,93]. ACOG and the World Health Organization have reviewed the data and have concluded that there should be no limitations on the use of DMPA, including no restrictions on the duration of use [93,94]. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Reduction in bone mineral density'.)

An additional consideration is that the risk to bone health from an unintended adolescent pregnancy is even greater than the reversible risk from DMPA. We counsel patients about other ways to promote good bone health. These include adequate calcium and vitamin D intake, daily weight bearing exercise, and avoidance of cigarette smoking. (See "Bone health and calcium requirements in adolescents".)

●Progestin-only pill – Progestin-only pills (POPs), also referred to as mini-pills, are a safe and effective form of contraception for adolescents. These provide an oral contraceptive option without the risks associated with the estrogen component of COCs. POPs are taken continuously without any placebo pills, which may cause irregular and unpredictable menstrual bleeding.

Lack of access is a well-known barrier to contraceptive use [95]. A progestin-only over-the-counter oral contraceptive, Opill (brand name; norgestrel 0.075 mg), is available in the United States and may mitigate this barrier [96,97].

Most of the absolute and relative contraindications to the POP are uncommon in adolescents. Conditions include severe (decompensated) cirrhosis, history of bariatric surgery, hepatocellular adenoma or hepatoma, systemic lupus erythematosus with positive or unknown antiphospholipid antibodies, known or suspected breast cancer or history of breast cancer, anticonvulsant therapy, rifampin therapy, and development of ischemic heart disease or stroke after initiating the POP [71].

Combined estrogen-progestin methods — COC 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 [87,88]. (See "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use", section on 'Counseling points'.)

Combined oral contraceptive pills — COC pills require the adolescent to take a pill daily and to remember to refill their prescription on time. COC pills usually are taken for 21 consecutive days followed by 7 days of placebo pills or no pill, during which menstrual bleeding usually 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 other reasons may choose to follow an extended contraceptive schedule that involves taking monophasic hormone pills (ie, every pill has the same dose of estradiol and progestin) for 84 days followed by 4 to 7 hormone-free days. Alternatively, continuous (ie, no hormone-free days) monophasic COC pills are also safe and effective [98,99]. Adolescents who choose to follow an extended cycle regimen or a continuous COC regimen should be advised that unscheduled bleeding may occur but generally decreases over time with consistent use. Extended cycle and continuous COC 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'.)

Certain medications or herbal therapies may decrease the effectiveness of oral contraceptives. These include ritonavir-boosted protease inhibitors for the treatment of HIV infection, anticonvulsants, glucagon-like peptide-1 (GLP-1) agonists [100], 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 COC pills with other medications may be determined using the drug interactions program included in UpToDate.

Transdermal patch — The transdermal patch is applied and replaced weekly at different sites for three weeks, followed by a patch-free week. There are two available brands of contraceptive patches in the United States. One is a circular patch containing 30 mcg EE/day and 120 mcg LNG/day (ie, EE-LNG patch). The other is a square patch containing 35 mcg EE/day and 150 mcg norelgestromin/day (ie, EE-NGMN patch).

While there are theoretical concerns about an increased risk of venous thromboembolism (VTE) associated with continuous weekly replacement of the contraceptive patch, existing data have not demonstrated an actual association, and ACOG endorses this practice [101,102]. In one study that evaluated the EE pharmacokinetics of 12 weeks of continuous contraceptive EE-NGMN patch use, the EE levels varied widely from day to day, but the mean absolute values remained below 100 pg/mL and few side effects were noted [103]. Patients who choose extended cycles with 12 weeks of continuous weekly patch replacement should be counseled about the advantages and potential risks associated with continuous patch use.

The FDA labels list BMI >30 kg/m² as a contraindication to patch use due to a theoretical concern for increased risk of VTE events.

The FDA labels also include a warning that the patch provides decreased contraceptive efficacy for patients with larger bodies. These warnings are based on a small subsample of approximately 100 participants weighing ≥90 kg from an efficacy trial of the EE-NGMN patch, who had a pregnancy rate of 5 percent [104]. The pregnancy rate in the remaining 3230 participants weighing <90 kg was 0.3 percent. Phase 3 clinical trials of the EE-LNG patch included more patients with elevated BMIs, and the efficacy of the patch also decreased with increasing BMI [105].

We acknowledge the contraceptive efficacy and risk of adverse effects of contraceptive patch use associated with elevated BMI. We also consider that the United States Medical Eligibility Criteria for Contraceptive Use classifies the contraceptive patch as category 2 for BMI ≥30 kg/m², which indicates that the advantages generally outweigh the risks [71].

Using shared decision-making, we counsel patients with larger bodies about the potential for decreased patch effectiveness so that they can weigh this possibility together with their personal preferences, experiences, and unique circumstances. When we counsel about the risk of VTE, we also counsel about the even higher risk for VTE during pregnancy. Unless there are other significant medical comorbidities, we do not use elevated BMI alone as a basis for denying a patient access to the contraceptive patch.

Dermatitis at the application site is a nonhormonal side effect of the contraceptive patch. Mild itching with irritation and redness can be managed by removing and discarding the patch and placing a new patch in another location. Alternatively, fluticasone spray (eg, brand name Flonase) can be applied to the site and allowed to dry prior to placing the patch [106]. (See "Contraception: Transdermal contraceptive patches", section on 'Side effects'.)

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 is a discrete and convenient option for adolescents and only requires monthly adherence. It is available in only one size and does not need to be fitted. It can be used concurrently with tampons if there is spotting or bleeding, and it can be removed for three hours at a time without reducing efficacy. Fertility returns within one month after discontinuation.

There are two brands of vaginal ring available. One releases 15 mcg EE and 120 mcg of ENG daily, and the other releases 15 mcg EE and 150 mg segesterone acetate (SA) daily. Both are inserted into the vagina by the patient (figure 1) and are left in place for three weeks, followed by a single ring-free week. The EE-ENG ring is effective for one month, while the EE-SA ring is effective for one year.

If patients desire extended cycles, a new EE-ENG ring may be inserted every 3 weeks for 12 weeks, followed by 1 ring-free week; the EE-SA ring can be left in place for 12 weeks, followed by 1 ring-free week. For continuous use, the ring-free week can be eliminated for either brand. Although data supporting the effectiveness of extended and continuous cycling are only available for the EE-ENG ring, these findings should theoretically also apply to the EE-SA ring. If the EE-ENG ring is used continuously, it can be left in place for one month (instead of three weeks) before replacing. If used continuously, the EE-SA ring should be removed, cleaned, and reinserted periodically. Of note, continuous use of the EE-SA ring may not be effective for a full year, so a new prescription should be considered after nine months of continuous use. (See "Contraception: Hormonal contraceptive vaginal rings".)

Acceptability studies found similar continuation rates of the vaginal ring and the oral contraceptive pill in adolescents and young adults [107]. However, the vaginal ring is not a commonly used contraceptive among adolescents. We present the vaginal ring to patients as an option that is discrete, convenient, reliable, and can be left in place for three to four weeks at a time. We work with adolescents to increase comfort with their anatomy and to ensure understanding about how to insert and remove the ring. We also dispel common myths (eg, the ring can get lost inside of the vagina).

Contraceptive rings contain less EE (15 mcg/day) than other combined hormonal contraceptives. Thus, it is not yet known whether use of a contraceptive ring adversely impacts bone accrual during adolescence and young adulthood, which could have long-term adverse effects on peak bone mass. In one study evaluating bone density in premenopausal females, there was no demonstrated change after two years of contraceptive ring use compared with baseline [108]. Another study of adult women compared baseline bone mineral density (BMD) to BMD after 12 months of using the vaginal ring (15 mcg EE), the transdermal patch (20 mcg EE), or no hormonal contraception. The mean spinal BMD values did not change in any of the three groups [109]. While these data are reassuring, the study did not include adolescents. Additionally, no long-term study has evaluated fracture risk.

Estrogen-specific contraindications — Many of the absolute and relative contraindications to estrogen are uncommon in adolescents. The more frequent contraindications in adolescents include [71]:

●Migraine with aura

●Hypertension

●Increased risk for thromboembolism

•Systemic lupus erythematosus with positive (or unknown) antiphospholipid antibodies

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

•Major surgery with prolonged immobilization

•<21 days postpartum (whether breastfeeding or not), 21 to <30 days postpartum and breastfeeding, and 30 to 42 days postpartum with other risk factors for VTE not mentioned above

●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 COC 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')

●Drug interactions that may decrease efficacy of method, such as certain antiretroviral therapies, anticonvulsant medications, rifampin, and GLP-1 agonists

●Acute viral hepatitis

Nonhormonal methods

Copper intrauterine device — The copper IUD is a nonhormonal option that releases copper ions to create an inhospitable environment for sperm, preventing fertilization. Copper IUDs can last up to 10 years and are highly effective.

The copper IUD is well suited for individuals in whom the use of hormones is contraindicated or those who want a long-lasting, hormone-free birth control option that does not suppress menstrual cycles. Additionally, it is effective immediately and has been associated with a reduced risk of cervical cancer in some studies.

Barrier and other methods — Barrier (eg, condoms, diaphragms, cervical caps, sponges) and other nonhormonal contraceptive methods (eg, spermicides, periodic abstinence [ie, the "calendar rhythm" method], withdrawal) are often less effective because they require action on the part of the adolescent and/or their 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 [87,88]. (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 nonhormonal contraception are infrequently used by adolescents [110]. They are discussed separately:

•Phexx: Nonhormonal contraceptive gel used immediately prior to sex; approximately 86.3 percent effective with typical use (see "Pericoital (on demand) contraception: Diaphragm, cervical cap, spermicides, and sponge", section on 'Pericoital versus other contraceptive methods' and "Pericoital (on demand) contraception: Diaphragm, cervical cap, spermicides, and sponge", section on 'Formulations')

•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")

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 vaginal intercourse [111]. Thus, even adolescents who intend to remain abstinent should receive information about pregnancy prevention (including emergency contraception and condom use) [112]. (See "Emergency contraception" and "Prevention of sexually transmitted infections".)

EMERGENCY CONTRACEPTIVE METHODS — 

Emergency contraception (EC) refers to methods that prevent pregnancy from occurring after an episode of underprotected or unprotected intercourse (UPI). UPI can be the result of contraception nonuse, imperfect use, or nonconsensual sexual activity. EC options for adolescents are the same as for adults. (See "Emergency contraception", section on 'What are the emergency contraception methods?'.)

Hormonal EC does not interrupt an existing pregnancy; thus, it does not cause abortion. EC pills primarily function by delaying or preventing ovulation. Less commonly, they prevent fertilization by sperm if ovulation has already occurred [113,114].

Hormonal EC does not interfere with implantation of a fertilized egg, and the US Food and Drug Administration (FDA) label no longer includes this as a possible mechanism of action for levonorgestrel (LNG) EC pills [115]. However, FDA labeling for ulipristal acetate EC pills states that "it may also work by preventing implantation to the uterus" [116,117]. Nevertheless, data from two systematic reviews fail to support this statement [113,118].

Pregnancy rates following EC pill use within 120 hours of intercourse range from 0.6 to 2.6 percent [119-123], with lower rates following ulipristal acetate than LNG use. In one trial, 1696 patients seeking EC were randomly assigned to receive either ulipristal acetate or LNG EC pills within 72 hours of intercourse. The pregnancy rate was lower in the ulipristal group than the LNG group, although the difference was not statistically significant (1.8 versus 2.6 percent, odds ratio 0.68, 95% CI 0.35-1.31) [121].

A body mass index (BMI) >26 kg/m² decreases the efficacy of LNG EC pills, and a BMI >35 kg/m² decreases the efficacy of ulipristal acetate [124]. These effects should be taken into consideration when deciding which oral EC method is most appropriate for the patient. The efficacy of ulipristal acetate is also decreased if hormonal contraception is started concurrently [124]. We advise patients to delay the initiation of hormonal contraception for five days after use of ulipristal acetate EC and then use a second method (eg, a condom) for an additional seven days. Shared decision-making is important here, weighing the risks and benefits of delaying the initiation of contraception.

The copper intrauterine device (IUD) is the most effective EC option because it can prevent fertilization and implantation. Its failure rate is less than 0.1 percent, and it has the added benefit of providing long-term contraception if left in place. The copper IUD can be inserted up to 120 hours after UPI.

The 52 mg LNG IUD is an effective alternative for those seeking EC who prefer the benefits of a hormonal IUD and is recommended by the Society of Family Planning [124]. In one trial, 639 women ages 18 to 35 years seeking EC and desiring an IUD for ongoing contraception were randomly assigned to receive either a copper IUD or an LNG IUD within five days of UPI [125]. At one month following insertion, no participants in the copper IUD group were pregnant, compared with one participant in the LNG IUD group (0 versus 0.3 percent, difference -0.3 percent, 95% CI -1.8 to 0.9 percent).

LNG EC is available without a prescription in retail pharmacies and online, while ulipristal acetate requires a prescription. Neither provides ongoing contraception. The copper and LNG IUDs may be preferable if time elapsed since UPI is greater than 72 hours, EC effectiveness is the priority, and/or a highly effective, long-lasting method is desired. Additional details are discussed in a separate topic. (See "Emergency contraception", section on 'What are the emergency contraception methods?'.)

CONTRACEPTIVE INITIATION COUNSELING — 

Contraceptive initiation counseling should include anticipatory guidance and strategies to manage side effects and optimize method use.

Overcoming potential challenges to use

Cost of contraceptive — In the United States, the Patient Protection and Affordable Care Act of 2010 (public law No. 111-148) requires coverage of preventive services for individuals with female reproductive systems, including US Food and Drug Administration-approved contraceptive methods, without out-of-pocket costs [126,127]. However, challenges to this mandate may arise for adolescents living in states that opted out of Medicaid Expansion. We encourage providers to become familiar with local resources for provision of contraceptives at little or no cost, including Planned Parenthood, the local department of health, or a local Title X family planning clinic. Additionally, social workers may be able to provide a local resource book or trustworthy online program.

Insurance plans that require use of in-network providers may create a financial barrier to access of providers with experience offering highly effective contraceptive services [128]. Adolescents and young adults who have commercial health insurance through their parents may be reluctant to access such services unless their privacy can be assured [129]. (See "Confidentiality in adolescent health care", section on 'Potential threats to confidentiality'.)

The impact of contraceptive cost on contraceptive use was evaluated in a prospective study that included 1404 urban female-identifying adolescents (age 15 to 19 years) [130]. Participants were educated about reversible contraceptive methods, 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. Nearly three-quarters of participants chose an intrauterine device (IUD) or contraceptive implant. Compared with sexually active teenagers in the United States in 2008, study participants had lower rates of pregnancy (34 versus 158 per 1000), birth (19 versus 94 per 1000), and abortion (10 versus 42 per 1000).

Access to contraceptive — Many adolescents face barriers to contraceptive services. An important barrier is lack of or perceived lack of access to confidential care [131,132]. Many states provide legal protections for an adolescent's right to confidential services, and it is important for providers to be aware of their states' relevant statutes. When confidential services are available, adolescents should be explicitly informed of this right. This increases the likelihood that they will disclose sexual activity and engage in a discussion about contraception.

Evidence-based best practices for adolescent access to contraceptive methods include [133]:

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

●Offering a wide range of contraceptive methods, including quick-start and same-day LARC

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

●Offering contraception during emergency department visits

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 [134].

Whom to contact with questions — Easy access to clinic or office staff helps to ensure consistent and correct use of contraception. Adolescents who are initiating contraception should be given an easy-to-read visit summary that includes:

●The name of the clinic or private office

●The clinic or office phone number

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

●Instructions to contact their provider or clinic if they have any concerns about their contraceptive method

●Reliable and accurate online resources for the many adolescents who turn to social media for their information

●Information about emergency contraception (EC) and how to access EC services if needed

Sexually transmitted infection prevention — We counsel adolescents who choose a nonbarrier contraceptive method that these methods alone do not prevent STIs [135]. To prevent STIs, including HIV, consistent and correct use of a condom in addition to their contraceptive is recommended [51,136]. Routine STI and HIV screening are also advised. (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, such as HIV pre-exposure 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 IUD or a contraceptive implant should be educated about the availability of and indications for EC in the event of a gap in contraceptive use or a method failure [112,137]. (See 'Emergency contraceptive methods' above.)

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) [138,139]. (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".)

Discontinuation of method — At the time of contraceptive method initiation, we talk with adolescents about issues related to removal of long-acting reversible methods or discontinuation of other hormonal methods. We always prioritize timely visits for those who request removal of IUDs and contraceptive implants.

We counsel adolescents about delayed or missed menstrual periods after discontinuation of a method, the anticipated time to return of fertility, and for those who are considering other contraceptive methods, we review the risk of pregnancy associated with the option they choose.

These issues are discussed in detail separately:

●IUDs (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')

FOLLOW-UP — 

Close follow-up can help address side effects, optimize use, and promote continuation of the method. We schedule a follow-up appointment two to four months after initiating the method to address patient questions and concerns, reinforce proper use, and provide additional anticipatory guidance. Refills need not align with follow-up appointments. If possible, a 12-month supply of pills, rings, or patches should be provided annually, but some insurers may require shorter refill intervals.

We also meet with sexually active adolescent and young adult females whenever they have symptoms of sexually transmitted infection (STI) or require review of potential side effects of their contraceptive method (table 1) [36].

All adolescents and young adults should have an annual visit for health maintenance and preventive care, including STI screening as recommended by the Centers for Disease Control and Prevention (CDC). 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.

●The Pleasur – A sex-positive website that promotes fulfilling sex focusing on sexual health and pleasure. It aims to destigmatize the negativity and shame surrounding sex.

●United States Medical Eligibility Criteria for Contraceptive Use (2024).

●United States Selected Practice Recommendations for Contraceptive Use (2024).

●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 messaging 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.

●SexandU.ca – An educational website 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

●Factors to consider

•Developmental – Recognition of the patient's developmental stage (ie, early, middle, or late) assists with helping the patient to navigate correct and consistent use of a contraceptive method as well as appropriate follow-up care. (See 'Developmental factors' above.)

•Noncontraceptive benefits – Hormonal contraception has many noncontraceptive benefits, including treatment of acne and reduction in the severity of dysmenorrhea and premenstrual syndrome. Some methods may also reduce heavy menstrual blood flow. (See 'Noncontraceptive benefits' above.)

•Adolescent concerns – Adolescent concerns about initiating a hormonal contraceptive often include weight gain and infertility. They may also overestimate the known risks of various methods. (See 'Adolescent concerns' above.)

•Contraindications to use – A comprehensive list of absolute and relative contraindications to long-acting and hormonal contraceptive methods is available from the Centers for Disease Control and Prevention (CDC). (See 'Contraindications to use' above.)

•Motivating factors – A review of the individual's motivations to delay pregnancy may help with the decision to initiate a contraceptive method. (See 'Motivating factors' above.)

•Patient values and preferences – Within the framework of reproductive justice, we evaluate patient preferences regarding childbearing, privacy, convenience, side effects, control or suppression of menstruation, and spontaneity. We also ask about social and cultural issues that may impact their decision.

●Contraceptive options – Contraceptive options include progestin-only methods, combined estrogen-progestin methods, nonhormonal methods, and abstinence (table 1). The routes of administering hormonal methods include pill, patch, vaginal ring, implant, and intrauterine device. (See 'Contraceptive options' above.)

●Emergency contraception – Hormonal emergency contraception (EC) does not interrupt an existing pregnancy. It works primarily by delaying or preventing ovulation. Less commonly, it stops fertilization by sperm if ovulation has already occurred. Depending on the method, it can be used up to five days following unprotected intercourse (UPI). (See 'Emergency contraceptive methods' above.)

●Contraceptive initiation counseling – Contraceptive initiation counseling should include anticipatory guidance and strategies to manage side effects and optimize method use. We provide general information about whom to contact with questions, the need to use condoms to prevent sexually transmitted infections (STIs), and the availability and indications for EC. We also discuss noncontraceptive benefits of hormonal contraception and issues related to discontinuation of a method. (See 'Contraceptive initiation counseling' above.)

●Follow-up – Close follow-up is important to address side effects, optimize use, and promote continuation of the method. We schedule follow-up for two to four months after initiation of the method to discuss concerns and address questions. 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 long-acting reversible contraceptive method (table 1). Adolescent and young adult females should also have an annual visit for health maintenance and preventive care that includes STI screening as recommended by the CDC. (See 'Follow-up' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Mariam R Chacko, MD, who contributed to earlier versions of this topic review.