Basics
Description
- Prevention of conception or pregnancy. Ideal contraceptive is 100% effective, has no side effects, is easily reversed, and is readily used by adolescents.
- Efficacy issues:
- In practice, contraceptive efficacy is based on two core concepts:
- Adherence or ability to adequately "do"¯ the method
- Continuation or length of time over which patient uses method
- Adherence and continuation improved by superior effectiveness of long-acting reversible contraceptives (LARCs), such as intrauterine devices (IUDs) or subdermal implants. LARCs have failure rates of less than 1% and approximately 80% continuation rates.
- The most effective methods should be offered as 1st-line contraceptive options for sexually active teens.
Methods of contraception:
- LARCs:
- Etonogestrel implant
- Single-rod subdermal implant containing 68 mg of progestin etonogestrel. Implant provides contraception for 3 years.
- Benefits: easy to insert and remove device, insertion site easy to access (nondominant upper arm)
- Can be placed in not yet sexually active patients considering future sexual activity or for heavy or painful menses
- Levonorgestrel-releasing (IUD)
- T-shaped polyethylene IUDs containing progestin hormones
- Ovulation may be suppressed in some women but is not the main mechanism of action, with between 45-75% of women ovulating on the 52 mg device, and almost all women ovulating on the lower dose LNG-IUD.
- Ovulation on the lower dose LNG-IUD may result in less amenorrhea and more regular menses which can be a desired effect for some women.
- Mirena ® contains 52 mg of levonorgestrel and a release rate of 20 mcg/day and is FDA-approved for use for up to 5 years but is effective up to 7 years. Significantly reduces menstrual bleeding and dysmenorrhea
- Skylar ® IUD is slightly smaller, 28 mm — 30 mm, and contains 13.5 mg levonorgestrel with a release rate of 5-14 mcg/day and decline to 5 mcg/day after 3 years.
- Copper T380 IUD
- Contraceptive effect related to in utero oxidation with release of copper ions.
- FDA-approved for use up to 10 years but may be effective for up to 12 years
- May also be placed as very effective emergency contraceptive and then retained for ongoing pregnancy prevention
- Moderate-duration contraceptives:
- Depot-medroxyprogesterone acetate (DMPA or Depo-Provera)
- IM injection administered every 12 weeks. Failure rates in real-world settings estimated as low as 6%, likely much higher for adolescents.
- 1-year continuation: 56% for users of all ages, likely lower for teens
- Effective up to 14 weeks, so patients within that dosing window do not need additional pregnancy testing before readministration
- Short-acting estrogen-progestin (EP) contraceptives:
- General issues:
- Typically use both estrogen (to minimize break-through bleeding) and progestin (to block ovulation) in variety of delivery systems
- Typical use failure rates at 9% but higher in adolescent populations. Continuation rates are 67%, likely lower in teens.
- Some EP agents such as combined oral contraceptive pills (COCs) and vaginal rings may be used almost continuously for extended cycling. Such extended cycling may be useful for patients with dysmenorrhea, heavy periods, anemia, or times (life events) when delaying a period desired.
- Combined oral contraceptive pills (COCs):
- Monophasic COCs contain fixed doses of estrogens (ethinyl estradiol [EE]) and progestins. Phasic COCs vary doses of estrogens, progestins, or both. No practical difference between monophasic and phasic COCs.
- 99.9% effective with perfect use but real-life use, difficulties with adherence, and continuation significantly reduce effectiveness.
- Benefits: reduce incidence of endometrial and ovarian cancers after as little as 3 months of use, protect against salpingitis (PID) and subsequent ectopic pregnancies, and decrease incidence of benign breast disease and dysmenorrhea
- Effective treatment for abnormal or heavy uterine bleeding (AUB), perimenstrual mood and physiologic symptoms, hygiene and behavior changes around menses for some developmentally delayed individuals, and sequelae of hyperandrogenism or polycystic ovary syndrome (AUB, hirsutism, acne)
- Transdermal patch
- Contains ethinyl estradiol and norelgestromin. Each patch left in place for 7 days, changed weekly, allowing 1 patch-free week per month for menses; convenient due to once-weekly change
- Typically not recommended for extended cycling, as studies demonstrate 60% more circulating estrogen than with other EP methods
- Unclear if this increases vascular thrombotic event (VTE) risk
- Vaginal ring
- Soft, flexible, polymer ring containing ethinyl estradiol and etonogestrel
- FDA-approved for vaginal insertion for 3 weeks then removed for 1 week for menses
- May be effective over a 4-week insertion and for extended cycling
- Benefits: avoidance of 1st-pass liver effects and lower hormone doses
- Emergency contraceptives (EC): postcoital contraceptives, "morning-after"¯ pills
- General issues:
- Safe but less effective (estimated 75%) than other hormonal/inserted contraceptives
- Not abortifacient but blocks ovulation, as do other hormonal methods of contraceptives
- Advance provision improves patient use but does not decrease overall pregnancy rates over time.
- May be offered to all women using short- or moderate-acting contraceptives
- Ulipristal acetate (UPA) 30 mcg
- Administered in a single oral dose up to 5 days post unprotected sex with equal effectiveness across time
- Is more effective in overweight or obese women than progestin methods
- Not carried by all pharmacies, both community and hospital based as of 2015
- Often requires insurance preauthorization (unlike progestin only methods) which may delay administration
- Progesterone-only methods:
- Most effective when used within 72 hours of intercourse; treatment less likely to be effective up to 5 days
- Levonorgestrel administered one time at a dose of 1.5 mg available by prescription and over the counter in the United States
- Male patients should be educated about the use of EC and may purchase this method over the counter as well.
- Yuzpe method of EC with COCs
- Consists of 100 mcg EE + 0.5 mg levonorgestrel given with repeated 2nd dose 12 hours later
- This method has higher rates of nausea and vomiting.
- Generally used as a matter of urgent timing, convenience and expense if a woman has a COC pack of pills at home and prefers to use these for her EC method because the other methods are more effective and have fewer side effects.
- Additional contraceptive methods:
- General issues:
- Well-known but with significantly lower efficacy
- Include barrier methods to sperm entry (male and female condoms, diaphragms)
- Male condoms
- 88% effective with typical use; likely higher failure rates in adolescents
- Female condom and diaphragm are 79% and 88% effective, respectively.
- Proper condom use can prevent transmission of sexually transmitted infections such as HIV, HPV, HSV, syphilis, Neisseria gonorrhoeae, and Chlamydia trachomatis.
- Important to inform teens that condoms are superior for STI prevention but inferior to other methods as a sole agent of contraception.
- Spermicidal agents
- Include: foam, film, vaginal inserts, as well as nonoxynal-9 as the active agent most widely used
- Only 72% effective in preventing pregnancy with typical use. May reduce transmission of C. trachomatis and N. gonorrhoeae. When used with condoms, overall efficacy 93% with typical use
- Irritant effect linked in some high-risk populations with increased risk of HIV transmission.
- Spermicides must be inserted with each intercourse, near the time of intercourse; some formulations require 10-15 minutes for activation. Most have an unpleasant taste.
- Progestin-only pills (POPs) ("mini-pill"¯)
- Much less effective than most other hormonal methods, as effectiveness is highly dependent on perfect use
- May offer some measure of benefit for women who are immediately postpartum (up to 6 months) and breastfeeding on demand
- Typically not a good method for most teens
- Abstinence
- Abstinence or refraining from vaginal-penile sexual intercourse is the most effective way to prevent unintended or unwanted pregnancy as well as transmission of STIs. However, gaining a mature understanding and experience of one's gender and sexual development is a necessary and desired component of adolescent development.
- Provider counseling and recommendations should promote a 4-pronged approach to sexual decision making: personal maturity and readiness, thoughtful partner selection and communication, family planning and pregnancy prevention, as well as prevention of STIs.
Alert
- Advising teenagers to abstain from all forms of physical intimacy may be both unrealistic and counterproductive in the context of their psychosocial development.
- Providers should emphasize at every visit that only 100% use of condoms (or abstinence) protects against sexually transmitted diseases but is not the most effective form of birth control available.
- All forms of birth control are not "equal"¯-long acting reversible contraceptives are significantly more effective contraceptives than all other methods, even sterilization.
- Long acting reversible contraceptive implants are both highly desirable and well tolerated in adolescents and should be offered as first line contraceptives to teens.
- Include male patients in discussions about both condom use as well as contraceptive use.
General Prevention
- Encourage consistent use of latex condoms.
- Patients using oral contraceptive pills may be strongly encouraged to cease tobacco use, but tobacco use does not preclude EP methods in women younger than 35 years.
Pathophysiology
- Combined EP hormonal therapy suppresses ovulation by directly decreasing release of hypothalamic gonadotropin-releasing hormone (GnRH) and pituitary follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
- Progesterone thickens cervical mucus, thins the endometrium, and decreases tubal motility. Higher dose systemic progestins inhibit the hypothalamic-ovarian axis and halt ovulation.
- Copper: Copper ions inhibit transtubal sperm migration and act in both an ovicidal and spermicidal way to prevent zygote formation.
- EC: Mechanisms of action include ovulation disruption, endometrial impairment to prevent implantation, and possibly sperm or ova transport alteration.
- Spermicides (nonoxynol-9 and octoxynol-9) destroy sperm cell membranes. Most spermicidal preparations contain an inert base (foam, cream, or jelly) to support the spermicidal agent and provide a barrier to sperm entry.
Diagnosis
History
General considerations in family planning interviews and methods counseling:
- Open queries about family planning intentions should be included in all reproductive age anticipatory guidance or reproductive health visits.
- One Key Question, "Do you want to be pregnant in the next 6 months or year?"¯ opens the conversation to all potential family planning intentions: intention to become pregnant, ambivalence about pregnancy, and desire for contraception and no immediate pregnancy plan.
- Method selection should consider and include the following: past use, failures, and side effects (both real and perceived) of contraceptives, priorities and goals for family planning.
- Does the patient want a pregnancy and parenting? Does his or her partner? Is the teen ambivalent about pregnancy and parenting?
- What is the teen's sexual history? Ask about sexual debut, recent partners, lifetime number of partners, gender and risk behaviors of partners, types of sexual behaviors (may be receptive or giving/insertive, penile-vaginal, penile-anal, oral, digital, dildos and other objects, other)
- Is sexual activity spontaneous or planned? Coerced or desired? Is the teen happy and confident about his or her sexual activity? Does sex give pleasure, feel uncomfortable, any other sexual concerns?
- What methods has the youth tried in the past? What worked, what did not work and why? Does the patient feel that she or he can be compliant with a daily pill or barrier methods? Can the teen demonstrate this ability with other medications or regimens?
- Does the patient require privacy and confidentiality? Does the teen have a parent or guardian's support regarding contraception and safer sex?
- Is the patient comfortable applying a condom or asking their partner to put on a condom?
- Does the patient have open communication with his or her partner? Does the partner respect the patient's decisions? Does the teen feel safe and respected by his or her partner?
- Are there any other barriers to adherence and continuation with the chosen contraceptive method? Is the patient comfortable with the level of efficacy and potential side effects with the current plan?
Physical Exam
- Is not essential for some patients who need to start contraception on an urgent or emergency basis. A thorough medical history that excludes current pregnancy, medical conditions that would be a contraindication to particular methods, and a plan for follow-up can allow some providers to begin a method without a physical exam at that time.
- Exams may be helpful in obtaining baseline weight, BP, and other physical stigmata (hirsutism, acne) that may benefit from hormones.
- It is not necessary to perform a pelvic exam on asymptomatic young women initiating hormonal contraception. It is not recommended to perform a pelvic exam (bimanual and speculum) for an adolescent who has never been sexually active but requests contraception.
- A pelvic exam to assess and diagnose an STI or to evaluate for pregnancy in a patient with amenorrhea may be indicated.
- The Centers for Disease Control and Prevention (CDC) recommends screening for STIs after sexual debut and at least annually until age 25 years.
- Papanicolaou cancer screening begins after sexual debut and by 21 years of age. Pap guidelines have been evolving and changing over recent years.
Diagnostic Tests & Interpretation
- Pregnancy test prior to initiating hormonal contraceptives:
- Urine pregnancy tests are typically adequate for diagnosing most pregnancies.
- Serum human choriogonadotropin hormone (B-hCG) is useful when trying to differentiate between normal and abnormal (miscarriage, ectopic) pregnancies.
- It is helpful to ask patients, "when was your last sexual activity without a condom and without birth control?"¯ in order to determine the accuracy of your current pregnancy test, not exclude very early pregnancy, and create a follow-up plan for possible future pregnancy testing in 2-4 weeks.
Treatment
General Measures
- Barrier methods: Trained personnel can teach the proper technique for application of condoms and spermicidal agents.
- Fertility (and ovulatory cycles) should return within 6 months of the last DMPA injection.
- Etonogestrel implant is a simple procedure easily done in outpatient settings but requires training and certification by the manufacturer.
- IUDs are also simple outpatient procedures for primary care providers with pelvic and uterine exam skills. Insertion of an IUD should be scheduled when one can be as certain as possible that the adolescent is not pregnant but should not be delayed in a manner that places teen at risk for unintended pregnancy.
- All methods offer contraceptive protection immediately if inserted days 0-5 of their menstrual cycle. Most teens return to ovulation soon after discontinuation of most contraceptives.
Alert
- Drugs that activate the cytochrome P-450 enzyme will diminish the efficacy of hormonal contraceptives and may include the following: phenobarbital, carbamazepine, primidone, rifampin, griseofulvin, HIV protease inhibitors, and tetracyclines (including doxycycline).
- Hormonal contraceptives can increase concentrations of phenytoin, benzodiazepines, antidepressants, corticosteroids, β-blockers, theophylline, and alcohol.
- Hormonal contraceptives can decrease the efficacy of acetaminophen, oral anticoagulants, hypoglycemics, and methyldopa.
Ongoing Care
Follow-up Recommendations
Patient Monitoring
- Patients using hormonal contraceptives should be seen within 6 weeks to 2 months of initiation, to evaluate adherence, continuation and help manage side effects.
- BP, weight, and STIs may continue to be monitored.
Prognosis
- Use of COCs declines over time:
- 45% in 3 months
- 33% at 1 year
Complications
Barrier methods
- Latex allergy: Patients may use polyurethane rather than latex condoms. Animal skin condoms are permeable to viral pathogens.
- Breakage or permeability: Oil-based lubricants and most intravaginal medications used with latex condoms will increase the risks of these complications.
Spermicides
- Local irritation or allergic reaction
- May increase the risk of HIV infection in adolescents with high-risk sexual partners
Hormonal EP contraceptives
- Contraindications to COC pills are uncommon in most teens and include the following: pregnancy, history of thromboembolic event, structural heart disease, breast cancer, active liver disease, migraine headaches with an aura, prolonged immobilization, or severe hypertension.
- Caution should be taken with women <6 weeks postpartum, with gallbladder disease, and those who use medications that affect liver enzymes.
- Minor, and usually self-limited, side effects of COCs may include intermenstrual spotting, nausea, breast changes, fluid retention, leukorrhea, minor headache, and depression.
- Thromboembolic events and liver disease are extremely rare in nonsmoking adolescents using estrogen-containing oral contraceptive pills. Placing risk in perspective is essential to adequate consent. Estimates of VTE may be communicated as follows:
- Baseline risk: 10 in 100,000 women-years
- COC user risk: 15 in 100,000 women-years
- 3rd generation COC (desogestrel) or patch risk: 30 in 100,000 women-years
- Pregnancy risk: 60 in 100,000 women-years
- Mortality from estradiol-containing methods is estimated at 1 in 1.5 million per year. Mortality from bike riding, motor vehicle crashes, and other causes is much higher. Death from gynecologic and related causes was 7/100,000 in 15-19-year-old adolescents per year. If no fertility control measures were used, the mortality is 0.3/100,000 per year in nonsmoking oral contraceptive pill users and 2.2/100,000 per year in smoking oral contraceptive pill users.
Progestin-only methods
- POPs' side effects include weight gain, rapid hair turnover, and menstrual irregularities.
- DMPA can reduce bone mineral density (BMD), which typically rebounds to normal after DMPA discontinuation. Because adolescence is the period of peak bone mass accretion, there is concern that DMPA use during adolescence may increase the risk for osteopenia or osteoporosis later in life. This has not been proven or validated at present. For adolescents with anorexia nervosa, chronic steroid use, chronic renal failure, there may be better LARCs available that have no BMD impact.
- Most common side effect reported with etonogestrel implant is abnormal bleeding. A wide range of bleeding patterns may be experienced, and it is not possible to predict the bleeding pattern for any individual.
- Overall, in the 90-day reference periods of clinical trial experience, 33.3% had infrequent bleeding, 21.4% had amenorrhea, 6.1% had frequent bleeding, and 16.9% had prolonged bleeding.
- The lower androgenic effect of etonogestrel may make side effects of acne and weight gain less frequent than with other progestins.
IUDs
- Contraindications to IUD placement are those who are pregnant or suspected to be pregnant, have active PID or puerperal or postabortion sepsis, malignancy of the genital tract, uterine abnormalities that distort the uterine cavity, an allergy to any component of IUDs, or Wilson disease (for the copper T IUD only).
- IUDs have been associated with a slightly higher risk of PID within the first 21 days after insertion, especially if cervical infection is present. IUDs do not increase risk of PID above baseline after this time.
- Younger age may confer an increased risk of IUD failure from expulsion because of smaller uterus and higher incidence of nulliparity.
- The copper T IUD has been associated with increased menstrual bleeding and spotting, especially in first 3-6 months after insertion. In addition, some women may experience menstrual pain and heavy bleeding throughout use.
Emergency contraception
- Nausea and/or vomiting occur in most patients using Yuzpe (EP) EC or "doubling up"¯ on oral contraceptive pills.
Additional Reading
- Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group, The American College of Obstetricians and Gynecologists. Committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol. 2012;120(4):983-988. [View Abstract]
- Bellanca HK, Hunter MS. ONE KEY QUESTION ®: preventive reproductive health is part of high quality primary care. Contraception. 2013;88(1):3-6. [View Abstract]
- Centers for Disease Control and Prevention. U.S. medical eligibility criteria for contraceptive use, 2010. MMWR Recomm Rep. 2010;59(RR-4):1-86. [View Abstract]
- Dean G, Schwarz EB. Intrauterine contraceptives (IUCs). In: Hatcher RA, Trussell J, Nelson AL, et al, eds. Contraceptive Technology. 20th ed. New York, NY: Ardent Media; 2011:147-191.
- Mestad R, Secura G, Allsworth JE, et al. Acceptance of long-acting reversible contraceptive methods by adolescent participants in the Contraceptive CHOICE Project. Contraception. 2011;84(5):493-498. [View Abstract]
- Sitruk-Ware R, Nath A, Mishell DR Jr. Contraception technology: past, present and future. Contraception. 2013;87(3):319-330. [View Abstract]
- Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Nelson AL, et al, eds. Contraceptive Technology. 20th ed. New York, NY: Ardent Media; 2011.
- Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998-2007. [View Abstract]
Codes
ICD09
- V25.9 Unspecified contraceptive management
- V25.02 General counseling on initiation of other contraceptive measures
- V25.8 Other specified contraceptive management
- V25.09 Other general counseling and advice on contraceptive management
- V25.01 General counseling on prescription of oral contraceptives
- V25.43 Surveillance of implantable subdermal contraceptive
- V25.42 Surveillance of intrauterine contraceptive device
ICD10
- Z30.9 Encounter for contraceptive management, unspecified
- Z30.09 Encounter for oth general cnsl and advice on contraception
- Z30.8 Encounter for other contraceptive management
- Z30.42 Encounter for surveillance of injectable contraceptive
- Z30.49 Encounter for surveillance of other contraceptives
- Z30.41 Encounter for surveillance of contraceptive pills
SNOMED
- 44651004 Contraceptive use education (procedure)
- 171027002 contraceptive implant education (procedure)
- 40176008 Diaphragm use education (procedure)
FAQ
- Q: My adolescent, minor patient asks for confidentiality regarding contraception. Can I comply?
- A: Yes. Teenagers benefit from private and confidential contraceptive services. Teens should have right to confidentiality regarding contraception and treatment of STIs, even though some states do not have specific laws protecting these rights. The benchmark of care supported by all professional medical societies supports private and confidential contraceptive care for teens. Do not assume, however, that a teen may not have or benefit from parental support in her efforts to prevent pregnancy. It may be in the patient's best interest to have a caring adult involved. Which adult and how he or she is involved should be negotiated with the adolescent.
- Q: My adolescent patient has been on and off short-acting birth control methods? I am worried about her risk of pregnancy? How might I better help her?
- A: There are several parts to managing this issue.
- First, in an open and supportive manner, ask her whether she wants to become pregnant and parent or would she like to delay pregnancy?
- Second, if she wishes to delay pregnancy over the next 6-12 months, offer her a LARC. Educate her on the superior efficacy and ease of use. Insert a LARC that day or facilitate an urgent referral to a teen-friendly provider if she continues to express an interest.
- While she waits for that appointment, offer to help her protect from unintended pregnancy with a single dose of DMPA providing coverage for the next 12 weeks. Offer her EC as well.
- Applaud efforts to be smart and safely sexually active.
- Engage her partner, if present and supportive, in contraceptive discussions and discussions about safe, satisfying, and responsible sexuality.
- Q: One of my patients has asked me to prescribe EC in advance for her. Is this something that I should do?
- A: Yes! EC is now over the counter, but if a patient is more likely to access using insurance coverage, this may increase use. Studies done clearly show that use of EC is safe. In fact, there are no absolute contraindications to using progestin-only EC. Because unprotected sexual encounters often take place at a time when adolescents do not have access to their health care providers (e.g., evenings or weekends), advanced prescription may be of benefit for many adolescents.
- Q: What should I tell my patient if she misses a dose of her oral contraceptive?
- A: If she has missed 1 pill, she should take it as soon as she remembers, then take the next pill at the regular time. If she has missed 2 doses, she should take 2 when she remembers, and then 2 the next day. She should use a back-up method during the cycle in which she had to "double up."¯ If she has missed 3 or more pills, she will probably menstruate. After discarding the last pack, she should start a new pack on the 1st Sunday after the start of her next period. She is not protected during the remainder of this cycle.