Adolescent Contraception

Adolescent Contraception
Overview of Issues Specific to Adolescents
Professor Mykhailo Medvediev
Evidence-Based Medicine
International Guidelines
Epidemiology: Declining Teen Pregnancy Rates
Teen pregnancy rates in the United States have declined dramatically. Among teens ages 15-19 years, the pregnancy rate peaked at 62 per 1000 in 1991 and declined 75% to 15 per 1000 in 2020.
Between 2010 and 2019, pregnancies declined by 9% overall, with a remarkable 52% decline among teens, followed by an additional 8% decline in 2020.
These declines are attributed to increased access to comprehensive sex education, improved contraceptive access, and shifting social norms around teenage sexual activity.
Reference: CDC Youth Risk Behavior Survey, 2021; Trends in teen pregnancy and childbearing, Office of Population Affairs, HHS
Current Contraceptive Use Patterns
47%
Condom Use
Among sexually active high school students
23%
Birth Control Pills
Oral contraceptive usage
10%
LARC Methods
IUD or contraceptive implant
15%
No Method
Did not use any contraception
Data from the 2021 Youth Risk Behavior Survey shows that approximately one-fifth of high school students are sexually active, with varied contraceptive method use.
Reference: MMWR Suppl 2023;72:55; Youth Risk Behavior Survey Data Summary & Trends Report 2011-2021
AAP Recommendation: Contraception in Medical Home
All adolescents should be able to receive contraception in their medical home. The AAP recommends that all clinicians who care for adolescents provide contraceptive care.
This 2025 policy update recognizes the unmet contraceptive needs of adolescents and positions primary care providers to meet these needs through knowledgeable, adolescent-centered counseling approaches.
Reference: Ott MA, Hoopes AJ, Sucato GS, et al. Contraception for Adolescents: Policy Statement. Pediatrics 2025;156
Developmental Considerations
Cognitive Development
Transition from concrete to abstract thinking impacts ability to plan ahead and problem-solve
Developmental Stage
Recognition of early, middle, or late adolescence guides contraceptive counseling
Method Selection
Understanding developmental stage assists with correct and consistent use
An understanding of adolescent development and behavior helps guide contraceptive counseling and ultimately optimizes an individualized plan.
Reference: Tyson NA, Labovsky MJ, Oizerovich SA, Liu SM. Adolescent contraception. In: Adolescent Gynecology, 2023
Noncontraceptive Benefits of Hormonal Contraception
Menstrual Symptoms
Reduction in dysmenorrhea severity, heavy menstrual bleeding, and premenstrual syndrome
Dermatologic Benefits
Treatment of acne and hirsutism
Disease Prevention
Protection against ectopic pregnancy, ovarian and endometrial cancer, benign breast disease
Therapeutic Uses
Treatment of endometriosis, reduction of ovarian cysts, management of menstrual migraines
Reference: Ott MA, Sucato GS, Leroy-Melamed M, et al. Contraceptive Counseling and Methods for Adolescents: Clinical Report. Pediatrics 2025;156
Addressing Adolescent Concerns: Weight Gain
Common Misconception
Many adolescents are concerned that hormonal contraceptives cause weight gain. However, a causal relationship has not been established.
DMPA Considerations
Some studies found association between DMPA use and weight gain, particularly in adolescents with baseline BMI ≥30 kg/m². In one study, those with BMI ≥30 gained 9.4 kg versus 4.0 kg in those with BMI <30 over 18 months.
Anticipatory guidance should be provided to patients with higher BMIs about potential weight gain with DMPA use.
Reference: Bonny AE, Ziegler J, Harvey R, et al. Arch Pediatr Adolesc Med 2006;160:40; Gallo MF, Lopez LM, Grimes DA, et al. Cochrane Database Syst Rev 2014:CD003987
Addressing Concerns: Fertility and Pregnancy Safety
Infertility Concerns
Longitudinal studies demonstrate return to baseline fecundity with cessation of all reversible contraceptive methods. Hormonal contraception does not cause future infertility.
Pregnancy Safety
Inadvertent use of contraceptives during early pregnancy is generally safe and does not increase risk for adverse pregnancy outcomes (except IUDs).
Height Impact
By menarche, most adolescents have achieved ≥95% of adult height. Hormonal contraception does not cause premature growth plate closure.
Reference: Yland JJ, Bresnick KA, Hatch EE, et al. BMJ 2020;371:m3966; Bracken MB. Obstet Gynecol 1990;76:552
Risk Perspective: VTE in Context
Combined oral contraceptive use is associated with 15-20 VTEs per 100,000 women per year, while pregnancy carries a three- to fourfold higher risk (60 per 100,000). The risk of VTE from estrogen-containing contraceptives must be balanced against the higher risk during pregnancy.
Reference: Farley TM, Collins J, Schlesselman JJ. Contraception 1998;57:211; Vandenbroucke JP, Rosing J, Bloemenkamp KW, et al. N Engl J Med 2001;344:1527
CDC Medical Eligibility Criteria
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.
The medical eligibility criteria for each method are available on the CDC website and the CDC contraception app, providing evidence-based guidance for contraceptive selection.
Key Resource: CDC contraception app provides quick access to medical eligibility criteria and practice recommendations
Reference: Nguyen AT, Curtis KM, Tepper NK, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep 2024;73(4):1-129
Motivating Factors for Contraceptive Use
01
Pregnancy Perception
Perceives pregnancy as a negative outcome
02
Educational Goals
Has long-term educational aspirations
03
Maturity Level
Demonstrates developmental maturity
04
Experience
Has experienced pregnancy scare or actual pregnancy
05
Support System
Has family, friends, or healthcare provider who sanction contraception use
Review of individual motivations to delay pregnancy helps with the decision to initiate a contraceptive method.
Reference: Nelson AI, Neinstein LS. Contraception. In: Handbook of Adolescent Health Care, 2009
Reproductive Justice Framework
Core Principles
Recognize mistreatment of marginalized groups
Acknowledge unconscious bias in counseling
Prioritize patient values and preferences
Support autonomy in method selection
Essential Elements
In-depth review of ALL reversible methods
Encouragement of healthy sexual experiences
STI prevention guidance
Attention to patient fears and concerns
Reference: ACOG Committee Statement Number 1. Patient-Centered Contraceptive Counseling. Obstet Gynecol 2022;139:350
Long-Acting Reversible Contraception (LARC)
85%
12-Month Continuation
LARC methods show highest continuation rates
40-50%
Non-LARC Continuation
Lower continuation with other methods
<1%
Pregnancy Rate
Highly effective contraception
LARC methods are considered first-line options for adolescents by AAP, NASPAG, and ACOG. Their efficacy does not require any action on the part of the adolescent.
Reference: Menon S, COMMITTEE ON ADOLESCENCE. Pediatrics 2020;146; Usinger KM, Gola SB, Weis M, Smaldone A. J Pediatr Adolesc Gynecol 2016;29:659
Intrauterine Devices: Key Features
Copper IUD
FDA approved for 10 years, evidence supports 12 years efficacy. Nonhormonal option with immediate effectiveness.
LNG IUD
Effective for 3-8 years depending on dose. Reduces heavy menstrual bleeding and dysmenorrhea.
IUDs are completely reversible contraceptive methods placed in the uterus. They can be removed at any time if pregnancy is desired or to switch methods. IUDs have the highest satisfaction and continuation rates of all contraceptive methods.
Reference: Heinemann K, Reed S, Moehner S, Minh TD. Contraception 2015;91:280; Dethier D, Qasba N, Kaneshiro B. Contraception 2022;113:13
IUD Safety in Adolescents
Evidence-Based Safety
IUDs can be used safely and effectively in adolescents. There is no difference in infection rates and little, if any, difference in complication rates between adolescents and older females.
Expulsion Rates
Data on adolescent expulsion rates are mixed, ranging from 5-9% compared with 4-5% in women >20 years old. Risk factors include heavy menstrual bleeding, anemia, bleeding disorders, previous expulsion, and elevated BMI.
Reference: Deans EI, Grimes DA. Contraception 2009;79:418; Fassett MJ, Reed SD, Rothman KJ, et al. Obstet Gynecol 2023;142:641
Contraceptive Implant: Etonogestrel
Size & Placement
Single flexible rod, matchstick size, placed under skin of inner upper arm
Duration
FDA approved for 3 years, evidence supports 5 years effectiveness
Efficacy
Pregnancy rate <1% per year, fertility returns quickly after removal
The contraceptive implant is an attractive option for adolescents desiring long-term, convenient, and reliable contraception. It is a progestin-only method that can be removed at any time.
Reference: Ali M, Akin A, Bahamondes L, et al. Hum Reprod 2016;31:2491; Teal S, Edelman A. JAMA 2021;326:2507
Managing Unfavorable Bleeding with LARC
1
Reassurance & Validation
Most LNG IUD users establish favorable bleeding pattern within one year. Provide validation of symptoms.
2
Treatment Options
NSAIDs (naproxen 500mg BID x 5 days), COCs (30-35mcg EE daily x 6 weeks), ulipristal acetate, or tamoxifen
3
Easy Access
Ensure adolescents have easy access to clinic staff for management advice to promote continuation
Unfavorable bleeding patterns are a major source of dissatisfaction. Short-term relief may promote continuation of LARC method.
Reference: Henkel A, Goldthwaite LM. Curr Opin Obstet Gynecol 2020;32:408; Madden T, Proehl S, Allsworth JE, et al. Am J Obstet Gynecol 2012;206:129.e1
Depot Medroxyprogesterone Acetate (DMPA)
Administration
Injectable progestin-only contraceptive providing effective, discrete contraception for 3 months. Administered intramuscularly every 12-13 weeks or subcutaneously with prefilled syringes for home use.
Efficacy & Return to Fertility
Pregnancy rate 4-7% per year. Return to fertility may take up to one year after discontinuation.
Special Benefits
Unique advantages for adolescents with seizure disorder - shown to decrease seizure frequency. May be administered every 8-10 weeks to optimize menstrual suppression and reduce catamenial seizures.
Reference: Sundaram A, Vaughan B, Kost K, et al. Perspect Sex Reprod Health 2017;49:7; Najafi M, Sadeghi MM, Mehvari J, et al. Adv Biomed Res 2013;2:8
DMPA and Bone Health
1
FDA Warning
Recommends against use >2 years due to bone mineral loss concerns
2
Evidence Review
Studies demonstrate bone loss is reversible once DMPA discontinued
3
ACOG & WHO Position
No limitations on DMPA use, including no restrictions on duration
4
Risk-Benefit Balance
Risk to bone health from unintended pregnancy greater than reversible risk from DMPA
Counsel patients about promoting bone health: adequate calcium and vitamin D intake, daily weight-bearing exercise, avoidance of cigarette smoking.
Reference: ACOG Committee Opinion: Depot Medroxyprogesterone Acetate and Bone Effects, 2014; WHO. Wkly Epidemiol Rec 2005;80:302
Progestin-Only Pills (POPs)
Safe & Effective
Provides oral contraceptive option without estrogen-associated risks. Taken continuously without placebo pills.
Over-the-Counter Access
Opill (norgestrel 0.075mg) available OTC in US, mitigating access barriers
Bleeding Pattern
May cause irregular and unpredictable menstrual bleeding due to continuous use
Lack of access is a well-known barrier to contraceptive use. OTC availability of progestin-only pills may help overcome this barrier.
Reference: Foster DG, Biggs MA, Phillips KA, et al. Contraception 2015;91:373; Wollum A, Trussell J, Grossman D, Grindlay K. Womens Health Issues 2020;30:153
Combined Oral Contraceptive Pills
1
Standard Regimen
21 days of active pills followed by 7 days placebo or no pill, during which menstrual bleeding occurs
2
Extended Cycle
84 days of monophasic pills followed by 4-7 hormone-free days for those wishing to avoid monthly periods
3
Continuous Use
No hormone-free days, safe and effective for menstrual suppression
Pregnancy rate 4-7% per year. Requires daily adherence and timely prescription refills. Extended and continuous regimens are safe and effective for adolescents.
Reference: Wright KP, Johnson JV. Ther Clin Risk Manag 2008;4:905; Li J, Panucci G, Moeny D, et al. JAMA Intern Med 2018;178:1482
Drug Interactions with COCs
Antiretroviral Therapy
Ritonavir-boosted protease inhibitors for HIV treatment may decrease COC efficacy
Anticonvulsants
Certain seizure medications can reduce contraceptive effectiveness
Antimicrobials
Rifampin and griseofulvin decrease efficacy (most other antimicrobials do not)
GLP-1 Agonists
May impact oral contraceptive absorption and effectiveness
Herbal Supplements
St. John's Wort reduces contraceptive hormone levels
Use UpToDate drug interactions program to check specific medication combinations.
Reference: Skelley JW, Swearengin K, York AL, Glover LH. J Am Pharm Assoc 2024;64:204; Curtis KM, Tepper NK, Jatlaoui TC, et al. MMWR Recomm Rep 2016;65:1
Transdermal Contraceptive Patch
Application & Formulations
Applied and replaced weekly at different sites for 3 weeks, followed by patch-free week. Two brands available in US:
Circular patch: 30mcg EE/120mcg LNG daily
Square patch: 35mcg EE/150mcg norelgestromin daily
Extended Cycles
Continuous weekly replacement for 12 weeks followed by 1 patch-free week is endorsed by ACOG, though theoretical VTE concerns exist.
Pregnancy rate 4-7% per year. Convenient option requiring only weekly adherence.
Reference: Nelson AL, Kaunitz AM, Kroll R, et al. Contraception 2021;103:137; Stanczyk FZ, Archer DF, Lohmer LRL, et al. PLoS One 2022;17:e0279640
Patch Use and BMI Considerations
5%
Pregnancy Rate (≥90kg)
Higher failure rate in patients weighing ≥90kg
0.3%
Pregnancy Rate (<90kg)
Standard efficacy in patients <90kg
FDA labels list BMI >30 kg/m² as contraindication due to theoretical VTE risk. However, US Medical Eligibility Criteria classifies patch as category 2 for BMI ≥30, indicating advantages generally outweigh risks.
Using shared decision-making, counsel patients with larger bodies about potential decreased effectiveness. Balance VTE risk discussion with higher VTE risk during pregnancy. Unless significant comorbidities exist, elevated BMI alone should not deny access to contraceptive patch.
Reference: Xulane FDA prescribing information, 2022; Curtis KM, Tepper NK, Jatlaoui TC, et al. MMWR Recomm Rep 2016;65:1
Vaginal Ring: Features & Use
Discrete & Convenient
One size, no fitting required. Monthly adherence only. Can be removed for 3 hours without reducing efficacy.
Two Formulations
EE-ENG ring (effective 1 month) or EE-SA ring (effective 1 year). Both release 15mcg EE daily.
Flexible Cycling
Standard: 3 weeks in, 1 week out. Extended: 12 weeks continuous, 1 week out. Continuous: no ring-free weeks.
Pregnancy rate 4-7% per year. Fertility returns within one month after discontinuation. Can be used concurrently with tampons.
Reference: Raine TR, Foster-Rosales A, Upadhyay UD, et al. Obstet Gynecol 2011;117:363
Vaginal Ring and Bone Health
Contraceptive rings contain less ethinyl estradiol (15mcg/day) than other combined hormonal contraceptives. Long-term effects on bone accrual during adolescence are not yet fully known.
Studies in premenopausal women showed no change in bone mineral density after 2 years of ring use compared to baseline. A 12-month study comparing ring, patch, and no hormonal contraception found no change in mean spinal BMD in any group.
While data are reassuring, studies did not include adolescents, and no long-term fracture risk studies exist.
Reference: Massai R, Mäkäräinen L, Kuukankorpi A, et al. Hum Reprod 2005;20:2764; Massaro M, Di Carlo C, Gargano V, et al. Contraception 2010;81:209
Estrogen-Specific Contraindications
Migraine with Aura
Absolute contraindication to estrogen-containing methods
Hypertension
Relative or absolute contraindication depending on severity
Thromboembolism Risk
Known thrombophilia, antiphospholipid syndrome, factor V Leiden, protein deficiencies
Postpartum Period
<21 days postpartum, 21-<30 days if breastfeeding, 30-42 days with other VTE risk factors
Bariatric Surgery
Malabsorption procedures (relative contraindication for COC pills only)
Acute Viral Hepatitis
Active liver disease contraindicates estrogen use
Reference: Nguyen AT, Curtis KM, Tepper NK, et al. MMWR Recomm Rep 2024;73(4):1-129
Copper IUD: Nonhormonal Option
Mechanism
Releases copper ions creating inhospitable environment for sperm, preventing fertilization
Duration
FDA approved for 10 years, highly effective throughout duration
Benefits
Hormone-free, immediately effective, does not suppress menstrual cycles, reduced cervical cancer risk
Well suited for individuals in whom hormones are contraindicated or those wanting long-lasting, hormone-free birth control. Most effective nonhormonal contraceptive option.
Reference: Teal S, Edelman A. JAMA 2021;326:2507; Long-term reversible contraception. Contraception 1997;56:341
Barrier Methods: External Condoms
Effectiveness
With consistent, correct use: 2% pregnancy rate. With typical use: 13% pregnancy rate.
Effectiveness depends on consistent and correct use at every act of sexual intercourse.
Dual Protection
Only method that provides both pregnancy prevention and STI protection, including HIV.
Essential for STI prevention even when using other contraceptive methods. Should be recommended for all sexually active adolescents.
Reference: Sundaram A, Vaughan B, Kost K, et al. Perspect Sex Reprod Health 2017;49:7; Contraceptive Technology Table 26-1, 2018
Abstinence and Contraceptive Counseling
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.
Even adolescents who intend to remain abstinent should receive comprehensive information about:
Pregnancy prevention methods
Emergency contraception availability and use
Condom use for STI prevention
Where to access contraceptive services if needed
Reference: Brückner H, Bearman P. J Adolesc Health 2005;36:271; Upadhya KK, COMMITTEE ON ADOLESCENCE. Pediatrics 2019;144
Emergency Contraception: Overview
Emergency contraception (EC) refers to methods that prevent pregnancy after underprotected or unprotected intercourse. EC can result from contraception nonuse, imperfect use, or nonconsensual sexual activity.
Mechanism of Action
Primarily delays or prevents ovulation. Less commonly prevents fertilization if ovulation occurred. Does NOT interrupt existing pregnancy.
Not Abortion
Hormonal EC does not interfere with implantation of fertilized egg. FDA label no longer includes this as mechanism for LNG EC.
Reference: Gemzell-Danielsson K, Berger C, Lalitkumar PG. Gynecol Endocrinol 2014;30:685; Plan B One-Step Information, FDA
Emergency Contraception Options
Levonorgestrel EC
Available OTC without prescription. Use within 72 hours (up to 120 hours). Pregnancy rate 1.8-2.6%. Efficacy decreases with BMI >26.
Ulipristal Acetate
Requires prescription. Use within 120 hours. Pregnancy rate 0.6-1.8%. More effective than LNG. Efficacy decreases with BMI >35.
Copper IUD
Most effective EC option (<0.1% failure). Insert within 120 hours. Provides ongoing contraception if left in place.
52mg LNG IUD
Effective alternative (0.3% failure). Insert within 120 hours. Provides ongoing hormonal contraception benefits.
Reference: Salcedo J, Cleland K, Bartz D, Thompson I. Contraception 2023;121:109958; Turok DK, Gero A, Simmons RG, et al. N Engl J Med 2021;384:335
EC Efficacy and BMI Considerations
BMI >26 kg/m² decreases efficacy of LNG EC pills. BMI >35 kg/m² decreases efficacy of ulipristal acetate. IUDs remain highly effective regardless of BMI and provide ongoing contraception.
Reference: Glasier AF, Cameron ST, Fine PM, et al. Lancet 2010;375:555; Salcedo J, Cleland K, Bartz D, Thompson I. Contraception 2023;121:109958
Contraceptive Initiation: Overcoming Barriers
Cost Barriers
Affordable Care Act requires coverage of FDA-approved contraceptives without out-of-pocket costs. Utilize Planned Parenthood, health departments, Title X clinics.
Access Barriers
Offer same-day appointments, after-school hours, weekends. Provide wide range of methods including quick-start and same-day LARC.
Confidentiality
Explicitly inform adolescents of their right to confidential services. Many states provide legal protections.
Reference: Patient Protection and Affordable Care Act, Public Law 111-148, 2010; Contraceptive and reproductive services for teens: Evidence-based clinical best practices, CDC
Impact of No-Cost Contraception
CHOICE Project Results
Prospective study of 1,404 urban female adolescents (ages 15-19) provided education about reversible contraceptive methods with emphasis on LARC benefits, and their choice of method at no cost.
Outcomes
Nearly 75% chose IUD or implant
Pregnancy rate: 34 vs 158 per 1000
Birth rate: 19 vs 94 per 1000
Abortion rate: 10 vs 42 per 1000
Compared to sexually active US teenagers in 2008, study participants had dramatically lower rates of pregnancy, birth, and abortion.
Reference: Secura GM, Madden T, McNicholas C, et al. N Engl J Med 2014;371:1316
Essential Counseling Points
Contact Information
Provide easy-to-read visit summary with clinic name, phone number, contact person, and instructions to reach provider with concerns.
STI Prevention
Counsel that nonbarrier methods do not prevent STIs. Recommend consistent condom use in addition to contraceptive method.
Emergency Contraception
Educate about EC availability and indications for use in event of gap in contraceptive use or method failure.
Online Resources
Provide reliable, accurate online resources for adolescents who turn to social media for information.
Reference: Ott MA, Sucato GS, Leroy-Melamed M, et al. Pediatrics 2025;156; Steiner RJ, Liddon N, Swartzendruber AL, et al. JAMA Pediatr 2016;170:428
Special Populations: Disabilities
Adolescents with physical or intellectual disabilities may have difficulty with menstrual hygiene. Hormonal contraception to suppress or reduce menstrual bleeding may be beneficial.
Method Options
LNG IUD, DMPA, ENG implant, contraceptive patch, continuous or extended cycle COC pills
Patient Involvement
Caregivers may drive request for menstrual suppression. Patient should be involved in discussion and decision-making as much as possible.
Reference: Quint EH, O'Brien RF, COMMITTEE ON ADOLESCENCE. Pediatrics 2016;138; ACOG Committee Opinion No. 448. Obstet Gynecol 2009;114:1428
Special Populations: Obesity
VTE Risk
Consider increased thromboembolism risk with estrogen-containing methods
Method Efficacy
Some methods may have decreased effectiveness at higher BMI
Weight Gain
Potential for additional weight gain with certain methods, particularly DMPA
Bariatric Surgery
Malabsorption procedures affect oral contraceptive absorption
Factors to consider include risk of thromboembolism, method efficacy, and potential weight gain. Detailed discussion in separate topic.
Reference: See "Contraception: Counseling for females with obesity" for comprehensive guidance
Follow-Up Care
01
Initial Follow-Up
Schedule appointment 2-4 months after initiating method to address questions, reinforce proper use, provide anticipatory guidance
02
Prescription Refills
Provide 12-month supply of pills, rings, or patches annually when possible (some insurers require shorter intervals)
03
As-Needed Visits
See patients with STI symptoms, side effect concerns, or requests for LARC removal
04
Annual Health Maintenance
All adolescents should have annual visit including STI screening per CDC recommendations
Close follow-up helps address side effects, optimize use, and promote continuation of method.
Reference: Curtis KM, Jatlaoui TC, Tepper NK, et al. MMWR Recomm Rep 2016;65:1
Key Resources & References
For Clinicians
CDC U.S. Medical Eligibility Criteria for Contraceptive Use, 2024
CDC U.S. Selected Practice Recommendations, 2024
CDC Contraceptive Guidance App
ACOG LARC Program
WHO Medical Eligibility Criteria
For Patients
bedsider.org - Method comparison
Planned Parenthood resources
Center for Young Women's Health
ACOG patient FAQs
Primary References
Ott MA, Hoopes AJ, Sucato GS, et al. Contraception for Adolescents: Policy Statement. Pediatrics 2025;156
Nguyen AT, Curtis KM, Tepper NK, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep 2024;73(4):1-129
Menon S, COMMITTEE ON ADOLESCENCE. Long-Acting Reversible Contraception: Specific Issues for Adolescents. Pediatrics 2020;146