Prior to the initiation of any contraceptive method, it is essential to review the adolescent patient’s medical history to assess which contraceptive methods would carry unacceptable health risks. In particular, physicians should ask if there is a history of migraines with aura or clotting disorders to determine if the adolescent has an elevated thromboembolic risk. Other medical conditions that predispose a patient to thrombotic events, including cancer, systemic lupus erythematosus with positive antiphospholipid antibodies, and complicated valvular heart disease, should be elicited during the medical history. On physical examination, it is essential to obtain a blood pressure if considering estrogen-containing methods such as “the pill,” a common phrase referring to combined oral contraceptives (COCs) . In addition, if inserting an intrauterine device (IUD), a patient requires a bimanual examination and cervical inspection to ensure that she does not have cervicitis or pelvic inflammatory disease [1]. The Centers for Disease Control and Prevention (CDC) has published and periodically updates the US Medical Eligibility Criteria for Contraceptive Use, adapted from the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use [2]. This report provides evidence-based guidelines for the safe use of contraceptive methods for women with various medical conditions and characteristics, including venous thromboembolism and migraines with aura. An accompanying abbreviated decision-making tool “Summary Chart” is arranged by contraceptive method, including IUDs, implants, DMPA, progestin-only pills (POPs), and COCs, and provides clinical guidance for providers to help counsel women about contraceptive method choice and safety [2, 3].

Based on the US Medical Eligibility for Contraceptive Use, AB’s history of migraines with aura is a category “4” or unacceptable health risk for use of estrogen-containing contraceptives, including COCs [2]. Therefore, her provider must counsel AB that initiation of “the pill” has unacceptable health risks and is not an appropriate option for her. In general, adolescent girls have a very low incidence of thrombosis (1–10 per 100,000 per year) [4]. The thrombotic risk from COCs (reported relative risk of 3–5) is often weighed against the thrombotic risk of unplanned pregnancy (reported relative risk of 4.3–10) [4]. In the case of AB, however, migraines with aura is a risk factor for ischemic stroke [5], and this risk is further increased in conjunction with combined hormonal contraception use. After explaining the unacceptably high risks to AB, a non-estrogen-containing contraceptive alternative should be recommended for her.

In order to provide high-quality counseling to an adolescent requesting contraception, health-care practitioners must provide information about the relative effectiveness of the method, method use, health risks and medical contraindications, side effects, and non-contraceptive benefits of each available method, so that she can make an informed choice. After determining which contraceptive methods are safe for her to use, a menstrual history might aid in individualization of the best contraceptive method that has additional benefits of reduced menstrual bleeding or improvement in dysmenorrhea, if these are concerns for the adolescent.

It is also helpful to obtain insight into the adolescent’s reproductive life plan, including experiences with previous contraceptive methods, including the reasons for discontinuation, if applicable. Of note, the experiences of an adolescent’s friends and family members are important to ascertain, as they influence family planning decisions of adolescents. For example, AB does not want to continue using DMPA because of the associated unpredictable vaginal bleeding; therefore, etonogestrel implant may not be the method best suited for this adolescent, given its similar side effect of unpredictable vaginal bleeding. Further, since previous studies have demonstrated that DMPA is more likely to be associated with weight gain compared to other contraceptive methods such as COCs [6], discontinuation of DMPA is reasonable and respects the adolescent’s reproductive right to choose her contraceptive method. One important aspect of promoting adherence to contraceptive methods is investigation of which side effects are tolerable and which benefits are most desirable for each patient.

Counseling should start with most efficacious contraceptive methods, namely, long-acting reversible contraceptives (LARCs) , including copper and levonorgestrel IUDs and subdermal etonogestrel implants [7]. Studies have shown that with this tiered counseling approach, adolescents are more likely to choose a LARC method [8]. The American Academy of Pediatrics recommends LARC methods as first-line contraceptive options for adolescents given their efficacy, safety, and ease of use [9]. Previous studies involving adolescents have shown that LARC methods have higher continuation and satisfaction rates compared to COCs [10]. Further, the improved access to LARC methods and increased use in adolescents may decrease pregnancy, abortions, and birth rates in this age group [10]. During counseling, we recommend emphasizing the importance of dual methods using a condom at every sexual encounter to decrease the risk of STI acquisition . Finally, it is important to ask questions about the adolescent’s relationship and screen for intimate partner violence and reproductive coercion, as this may influence whether or not partner-independent methods are preferred [11, 12].

Prior to initiating contraception , it is important to check for any medication interactions. Specifically, there are medications that can decrease contraceptive effectiveness by inducing cytochrome P4503A (CYP3A), including rifampin and antiepileptic medications including topiramate, oxcarbazepine, and phenobarbital. Additionally, other medications have significant medication interactions with hormonal contraceptives, including the antiretroviral fosamprenavir and lamotrigine when used as monotherapy [2]. Many medications commonly prescribed to adolescents including selective serotonin reuptake inhibitors (SSRIs) and antifungals have no medication interactions with COC, DMPA, IUDs, or implants. See Table 18.1 for interactions between contraceptives and medications commonly prescribed to adolescents. For AB, there are no significant medication interactions with any contraceptive method.