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AAP and ACOG recommend LARCs as the most effective in sexually active adolescents.
Contraception counseling should include anticipated adverse effects, need to use condoms for STD prevention, and indications for emergency contraception (including options and how to obtain).
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Pelvic exam, Pap smear, and STI testing per guidelines and routine follow-up 2 to 3 months postinitiation of all methods to assess tolerance
- Check for IUD strings 1 month after insertion; spontaneous expulsion rate highest in the first month.
- BP check within 3 months of initiation in patients on estrogen containing methods
DIET
St. John's wort may alter estrogen levels, reducing efficacy or causing breakthrough bleeding.
PATIENT EDUCATION
- Diaphragm: device inspected prior to each use, 1 tablespoon of spermicide in hollow of the dome, diaphragm is inserted into the vagina, additional applicator of spermicide placed in vagina. If placed >6 hours prior to intercourse need additional applicator of spermicide. Position needs to be checked post intercourse, and additional spermicide applied prior to each new episode of intercourse. Diaphragm should remain in place for at least 6 hours after the last episode of intercourse to maximize effectiveness.
- Male condoms: New condom is placed on the penis before genital contact, remains intact until the penis is withdrawn, new condom needs to be used with every act of intercourse.
- IUD: Patient should monitor presence of the string monthly following menses.
- OCP: Pill should be taken at approximately the same time each day. Back up birth control method is needed for the first 7 days with quick start and Sunday start methods.
COMPLICATIONS
- Estrogen-progestin contraceptives:
- Serious (requires discontinuation): stroke, thromboembolism, hypertension, myocardial infarction, and cholestatic jaundice
- Overall 5-fold increased risk of venous thrombosis compared to nonusers, comparable to the 4-fold increased risk of venous thrombosis during pregnancy (3)[B]
- Injectable contraceptive:
- Potential for decreased bone mineral density (BMD) if used for ≥2 years. Mostly recovers after discontinuation. Consider calcium/vitamin D supplementation if prolonged use.
- Nexplanon: insertion site reaction including pain, bleeding, paresthesias, and infection
- IUDs:
- Pelvic inflammatory disease (PID): Treat without removal unless serious infection or failure to respond to therapy.
- Uterine perforation
- Absolute risk of ectopic pregnancy is reduced with IUD, but if pregnancy does occur, there is a higher risk that it will be ectopic.
- Sponge and diaphragm: rarely associated with toxic shock syndrome
REFERENCES
11 Alkema L, Kantorova V, Menozzi C, et al. National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis. Lancet. 2013;381(9878):1642-1652.22 Cheng L, G źlmezoglu AM, Piaggio G, et al. Interventions for emergency contraception. Cochrane Database Syst Rev. 2008;(2):CD001324.33 van Hylckama Vlieg A, Helmerhorst FM, Vandenbroucke JP, et al. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. BMJ. 2009;339:b2921.
ADDITIONAL READING
- CDC Medical Eligibility Criteria for Contraceptive Use, 2010. Available as chart, app for smartphone ("CDC Contraception")
- Chart comparing contraceptive methods: ARHP Method Match at http://www.arhp.org/methodmatch/
CODES
ICD10
- Z30.9 Encounter for contraceptive management, unspecified
- Z30.41 Encounter for surveillance of contraceptive pills
- Z30.431 Encounter for routine checking of intrauterine contracep dev
- Z30.09 Encounter for oth general cnsl and advice on contraception
- Z97.5 Presence of (intrauterine) contraceptive device
- Z79.3 Long term (current) use of hormonal contraceptives
ICD9
- V25.09 Other general counseling and advice on contraceptive management
- V25.01 General counseling on prescription of oral contraceptives
- V25.42 Surveillance of intrauterine contraceptive device
- V25.40 Contraceptive surveillance, unspecified
- V25.43 Surveillance of implantable subdermal contraceptive
- V25.41 Surveillance of contraceptive pill
- V25.02 General counseling on initiation of other contraceptive measures
- V25.04 Counseling and instruction in natural family planning to avoid pregnancy
- V25.49 Surveillance of other contraceptive method
SNOMED
- 408968008 Contraception care education
- 5935008 oral contraception (finding)
- 312081001 IUD contraception
- 413116005 Transdermal contraceptive
- 225370004 Barrier contraception method
- 225371000 natural contraception (finding)
- 389095005 Contraception care (regime/therapy)
CLINICAL PEARLS
- Hormonal and IUD contraceptives may be initiated immediately if the likelihood of pre-existing pregnancy is low.
- Contraception method should be chosen based on individual patient needs.
- LARC methods provide high efficacy and convenience for patients.
- All patients should be counseled on emergency contraception options.