Rudolph's Pediatrics, 22nd Ed.

CHAPTER 78. Contraception

Erica B. Monasterio and Mary-Ann Shafer

Contraception is a health behavior that often begins during adolescence and evolves throughout reproductive life. On initiation of sexual activity, the majority of adolescents actually report contraceptive use, most typically a condom, but there is a significant difference between younger and older adolescents’ contraceptive use (35% of girls under 15 used no method at first intercourse compared to 17% of 17–19 year olds reporting no method use at first sex).1 Use of contraception at first sex is positively associated with higher continuation and consistency of method use over time.2 Discussions of sexual decision making, abstinence, sexual activity, reproduction, and contraception occur frequently as a normal part of the well-adolescent visit for female adolescents. In contrast, male adolescents, who are not at risk for pregnancy and do not require prescriptive contraceptives, may have clinician contact only during a sports physical or treatment of an injury or acute illness. Although sexuality and contraceptives are not traditionally discussed during “the sports check,” which often substitutes for the annual examination for male adolescents, clinicians should emphasize the need for such discussions because this visit may be the only contact between the male adolescent and a clinician.3

TYPE OF CONTRACEPTIVE

Common methods of contraception for male and female adolescents are reviewed in Table 78-1. Adolescents should be encouraged to choose a contraceptive method that they feel comfortable with, believe they can use successfully, and that meets their needs related to both pregnancy and sexually transmitted disease (STD) risk reduction. For some, using condoms, which are relatively inexpensive, easily obtained, and highly effective for protection from pregnancy and STDs, may be the best choice, but many adolescents have difficulty following through on consistent condom use. Heterosexual adolescents, like adults, tend to decrease their use of condoms over time in a relationship, and higher relationship quality and more frequent intercourse are associated with less condom use.4

ESTROGEN-PROGESTIN COMBINATION CONTRACEPTION

Combination hormonal methods, including oral contraceptive pills, the contraceptive patch, and the contraceptive ring are the contraceptive methods of choice for many adolescents soon after their sexual debut because using these methods is independent of sexual intercourse. The mechanism of action for combined hormonal contraception, regardless of the mode of delivery of the estrogen and progestin, includes the inhibition of ovulation through the hypothalamic and pituitary effects of the exogenous hormones. A reduction of gonadotropin-releasing hormone (GnRH) pulses as well as decreased pituitary responsiveness to GnRH results in the suppression of luteinizing hormone and follicle-stimulating hormone production, inhibiting ovulation. The thickening of cervical mucus, which inhibits sperm transport and decreased sperm capacitation (the ability of the sperm to enter the egg) are additional mechanisms of action primarily attributable to progestins. Such hormonal methods are generally safe and highly effective, but because they afford essentially no protection against sexually transmitted diseases including human immunodeficiency virus, the additional use of condoms is recommended. Dual method (hormonal contraception plus condom) use, however, is reported by less than a quarter of sexually active adolescents.1

Combined hormonal contraceptives are associated with a number of minor side effects, including nausea, breast tenderness, occasional weight gain, and breakthrough bleeding, especially within the first 3 months of use. There are also absolute and relative contraindications for use of hormonal contraception, which must be compared to the risk for pregnancy on an individual basis. Absolute contraindications include abnormal vaginal bleeding of unknown cause, estrogen-dependent tumor, liver disease, thromboembolic disease, and cerebrovascular disorders. Relative contraindications include metabolic diseases such as diabetes mellitus, current seizures, vascular headaches (migraine) with aura, and marked hypertension. Diseases of other organ systems that may be considered as contraindications to hormonal therapy include sickle cell disease, depression, and hepatic, pancreatic, cardiovascular, renal, and neurologic diseases. In addition, increased cardiovascular complications have been shown in older women of reproductive age who smoke, but for healthy young women, the absolute risk of cardiovascular disease is low, so use of combination hormonal contraception, even in the adolescent who smokes, is safer than the risks of pregnancy.5 Weight is also a factor to be considered when prescribing the contraceptive patch. A patient weight over 198 lbs. is associated with reduced contraceptive patch efficacy.

Table 78-1. Methods of Contraception

Constant advances are being made in combination hormonal contraception. New formulations, dosing regimens, and delivery methods have expanded the options for young women choosing these methods.

PROGESTIN-ONLY CONTRACEPTION

The options for use of progestin-only contraception have also expanded. The mechanisms of action for progestin-only contraceptives include the inhibition of luteinizing hormone production and thus the inhibition of ovulation, thickening of cervical mucus, an impact on sperm capacitation, and an alteration in the endometrium including reversible endometrial atrophy. Depot-medroxyprogesterone acetate (DMPA) is given in a 150-mg intramuscular dose every 11 to 12 weeks, providing reliable, highly effective injectable contraception. DMPA use has been widely initiated by adolescents and is prescribed for over 1 million adolescent girls in the United States annually. DMPA appeals to adolescents because it is comparably long lasting, easy to use, and invisible to parents and partners.6 However, there are some significant concerns for adolescents and physicians. Primary among these concerns are weight gain, irregular bleeding/amenorrhea, and a reduction in bone mineral density associated with DMPA use. Weight gain is a common side effect, with an average weight gain of 5.4 lbs in the first year and 16.5 lbs. after 5 years in adult women.7 For obese young women already struggling with their weight, this may be a significant deterrent to DMPA use. Irregular bleeding is a common reason for any method discontinuance among adolescents, and amenorrhea, while a potentially beneficial side effect for adults, is often poorly tolerated by adolescents, who equate lack of menses with pregnancy. Of greatest concern to physicians is the “black box” warning related to decreased bone mineral density in DMPA users. In response to this concern, the Society for Adolescent Medicine has issued a position paper on DMPA and bone density, recommending that providers continue to prescribe DMPA for patients who desire it, with an adequate explanation of benefits and potential risks. Bone density is most often regained after discontinuance of the method.6

Another advance in contraception is the single etonogestrel implant, an alternative delivery system for progestin-only contraception. Inserted under the skin in the upper arm, the implant is barely visible, long acting (3 years), and highly effective. As with DMPA, menstrual side effects may limit the appeal of this method to some adolescents, but unlike DMPA, concerns about weight gain and bone mineral density are not an issue with this method.8 Both depot-medroxyprogesterone and the etonogestrel implant may be excellent contraceptive methods for those adolescents who want long-term contraception not linked to coitus, are unable to use oral contraceptives, or cannot use estrogen-containing preparations. As with combined hormonal contraceptives, these methods do not protect against sexually transmitted infection (STIs), and the adolescent should be encouraged to use condoms if appropriate to reduce their risk of STIs.

INTRAUTERINE CONTRACEPTIVE DEVICES

Modern intrauterine contraceptive devices containing copper (which impairs sperm function and prevents fertilization) or progestin (which thickens cervical mucus, induces reversible endometrial atrophy, and may suppress ovulation) can be an excellent choice for the adolescent seeking reliable long-term contraception, particularly if she has had a child. Contraindications for intrauterine device insertion include current STI, history of an STI, or an increased risk for STI. The use of intrauterine contraceptives requires careful consideration of the patient’s history and current sexual risk. Although the risk of expulsion is slightly higher in women who have never had a child, nulliparity is not a contraindication to intrauterine contraceptive devices.7

EMERGENCY CONTRACEPTION

Regimens for emergency contraception (EC) utilizing combined oral contraceptive pills have been known and well accepted for years. The availability of a designated progestin-only product with increased efficacy, ease of dosing, and an improved side-effect profile has enhanced physicians’ ease in prescribing and patients’ acceptance of emergency contraception. Increased access to emergency contraception has been identified as a key factor in falling adolescent pregnancy rates, with an estimated 51,000 pregnancies averted among all women in the United States in 2000 attributed to the use of emergency contraception.9 Indicated for use after unprotected or underprotected intercourse, EC reduces the risk of pregnancy by 88%10 with a primary mechanism of action of delaying or inhibiting ovulation. Despite the safety and efficacy of this postcoital contraceptive method, physicians may create barriers to adolescents’ ability to use EC by limiting access based on timing in the menstrual cycle, requiring an office visit and a pregnancy test, and refusing to prescribe EC in advance due to concerns about “overuse” or that access to EC will discourage regular reproductive health care.11 EC efficacy is extremely time sensitive, with an increased risk of pregnancy as the time from unprotected intercourse to EC use increases. To facilitate quick and easy access to EC, physicians should educate all adolescents, male and female, sexually active and not, about EC and its use and consider providing a prescription for EC to female adolescents in advance so that it can be used as soon as possible when indicated.12

MEDICAL ASSESSMENT AT THE CONTRACEPTIVE VISIT

A complete medical and sexual history and limited physical assessment are recommended as a part of the first contraceptive visit to evaluate specific needs and eliminate serious contraindications to contraceptive use. Current recommendations to delay the first Pap smear until 3 years after sexual debut, combined with the ability to perform urine screening for chlamydia and gonorrhea have made it unnecessary to perform a pelvic examination in the asymptomatic adolescent requesting contraception. Follow-up may be individualized based on the adolescent’s needs. A discussion of any side effects and difficulties in using the method and the need for continued contraception should be reviewed briefly with the patient at each visit. For the male adolescent, a brief review of need and type of contraceptive should be done at each well visit.

METHOD INITIATION

Effective use of a hormonal method is enhanced if the adolescent can initiate the method right away rather than waiting for her next menses.13 In the interest of enhancing the adolescent patient’s ability to effectively prevent an unplanned pregnancy, the physician may opt for a “Quick Start” approach to initiating any hormonal contraceptive method. The principles of the Quick Start approach include (1) immediate initiation of method if 5 days or less since the onset of last menstrual period; (2) a negative urine pregnancy test if greater than 5 days since last menstrual period; (3) administration of emergency contraception if there has been unprotected sex in the prior 5 days, followed by initiation of the hormonal method the next day; (4) use of a backup method (condoms) for the next week if beyond day 6 of current cycle; and (5) a follow-up pregnancy test in 2 weeks if the method was initiated after day 5 of the current menstrual cycle.