Oral contraceptive pills (OCPs) continue to be the most commonly used form of prescription contraceptives used by adolescents in the United States. With proper use, oral contraceptives provide safe and effective birth control. Broad categories of OCPs include progestin-only pills (POPs) and combined oral contraceptive pills (COCs). Certain types of progestins have more potent antiandrogenic properties and are more effective in treating acne, hirsutism, and polycystic ovary syndrome. This article reviews types of OCPs, discusses risks and benefits of OCPs, and provides guidance for how to choose the most beneficial and appropriate OCP for individual adolescent patients.
Key points
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Oral contraceptive pills provide effective and safe contraception for adolescents when taken correctly.
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Oral contraceptive pills include 2 broad categories: progestin-only pills (POPs) and combined oral contraceptives (COCs).
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COCs lead to an increased risk of venous thromboembolism (VTE), so clinicians should perform a thorough assessment of any contraindications to estrogen before prescribing.
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COCs provide many noncontraceptive health benefits, including treatment of dysmenorrhea, excessive uterine bleeding, acne, and polycystic ovary syndrome.
Introduction
In 1960, the first oral contraceptive pill (OCP), Enovid, was approved by the US Food and Drug Administration. Since that time, OCPs available to US women have changed dramatically, with decreased hormone concentrations and increased variety in formulations. As detailed in other articles in this publication, the American Academy of Pediatrics and American College of Obstetricians and Gynecologists advocate that long-acting reversible contraceptives (LARCs) be recommended as first-line contraceptive options for sexually active adolescents (See Suzanne Allen and Erin Barlow’s article, “ LARC Methods ,” in this issue). Although trends are shifting in terms of increasing LARC use, OCPs continue to be the most common form of prescription contraception accessed by US adolescents.
Introduction
In 1960, the first oral contraceptive pill (OCP), Enovid, was approved by the US Food and Drug Administration. Since that time, OCPs available to US women have changed dramatically, with decreased hormone concentrations and increased variety in formulations. As detailed in other articles in this publication, the American Academy of Pediatrics and American College of Obstetricians and Gynecologists advocate that long-acting reversible contraceptives (LARCs) be recommended as first-line contraceptive options for sexually active adolescents (See Suzanne Allen and Erin Barlow’s article, “ LARC Methods ,” in this issue). Although trends are shifting in terms of increasing LARC use, OCPs continue to be the most common form of prescription contraception accessed by US adolescents.
Types of oral contraceptive pills, mechanism of action, and efficacy
There are 2 broad categories of OCPs: progestin-only pills (POPs) and combined oral contraceptives (COCs). POPs function primarily through thickening the cervical mucus and thereby preventing sperm penetration. In addition, POPs inhibit ovulation to variable degrees, reduce cilia activity in the fallopian tubes, and alter the endometrium. COCs, which contain both estrogen and progesterone, function primarily though inhibiting ovulation via feedback in the hypothalamic-pituitary-ovarian axis and thickening cervical mucus. When discussing efficacy of OCPs, it is crucial to distinguish perfect use from typical use. There is a significant discrepancy between these rates due to challenges with patient adherence to daily dosing. With perfect use, oral contraceptives have a 0.3% failure rate in the first year of use ; however, with typical use, oral contraceptives have a failure rate of 8% in the first year of use. Although OCPs offer excellent pregnancy protection with proper use, they do not offer protection from sexually transmitted infections (STIs). As such, all patients using OCPs for contraception should also be counseled to use condoms consistently for STI protection (See Zoon Wangu and Gale R. Burstein’s article, “ Adolescent Sexuality: Updates to the Sexually Transmitted Infection Guidelines ,” in this issue).
Both POPs and COCs require daily dosing; however, POPs require more exact dosing to maintain contraceptive efficacy. For adolescents, daily dosing in general can be problematic. When counseling an adolescent about OCPs for birth control, it is important for clinicians to speak openly with patients about the challenges of daily dosing and explore whether the adolescent feels that she is capable of adherence. Many adolescents find using an alarm in their cell phones to be a useful tool in helping them remember to take their pills. Because POPs require exact dosing in terms of the hour taken each day, most clinicians try to avoid this method as a primary form of birth control in adolescents. However, POPs may be the only option available for certain patients. With such patients, counseling must be very direct about the necessity of exact dosing, as well as the strong recommendation for consistent condom use, as both STI protection and back-up contraception.
Addressing common cultural myths about oral contraceptive pills
Many patients have preconceived notions about the efficacy, safety, and side effects of OCPs. It is very useful to explore a patient’s current understanding and knowledge of OCPs before prescribing so that common cultural “myths” can be dispelled. A common myth is that taking OCPs will impair a patient’s future fertility. Generally, OCPs do not adversely affect fertility. For most patients, menstrual cycles return promptly to the same pattern that existed before starting OCPs. Some women may experience some delay before menstrual cycles resume, but most do not.
Some patients may be concerned because menstrual flow is lighter than usual than what they experienced before starting OCPs. Some patients think that menstrual blood is “backing up” in their bodies. It is helpful to educate such patients about how OCPs prevent excessive build-up of the uterine lining, so infrequent menses, or light menses, while on OCPs does not pose a health risk.
Many patients believe that OCPs lead to significant weight gain. For some patients, this is a major reason to avoid OCPs, so it is important to address this concern in the early stages of contraceptive counseling. Patients will be reassured to know that multiple double-blind studies have shown no association between low-dose COC use and weight gain.
Patients may also hold the belief that birth control is “artificial” and unsafe, whereas pregnancy represents a natural, safe condition. It can be useful to educate such patients that negative health issues associated with being pregnant and postpartum are far more common than with OCPs.
Deciding between progestin-only pills and combined oral contraceptives
COCs are generally favored over POPs as a form of contraception because of the strict dosing schedule required by POPs. When deciding if an adolescent is an appropriate candidate for COCs, it is necessary to determine if the patient has a contraindication to estrogen-containing medications. The Centers for Disease Control and Prevention (CDC) recently published updated guidelines regarding medical eligibility for contraceptive use. This document, the US Medical Eligibility Criteria for Contraceptive Use (US MEC), is designed to assist clinicians to counsel patients about contraceptive method choice and was adapted from global guidance provided by the World Health Organization (WHO). The US MEC includes recommendations for using specific contraceptive methods in patients with specific medical conditions and can be accessed through the CDC Web site.
When assessing a patient’s safety profile regarding use of COCs, much of the decision-making revolves around the increased risk of venous thromboembolism (VTE) associated with estrogen. The relative risk of VTE in patients taking COCs is 3 to 5 times higher than in women who are not taking COCs. Certain patient characteristics, such as smoking and obesity, also contribute to increased VTE risk. Although the relative risk is increased, the absolute risk of VTE remains very low. Estimates regarding the prevalence of nonfatal VTE in the general population are highly variable. At baseline, a general estimate of a young, healthy woman’s risk of developing a VTE is 4 of 100,000 women per year. This risk increases to approximately 10 to 30 of 100,000 women per year when a patient is on a low-dose COC. However, when explaining this increased risk to patients, it is important to remind them that the risk of VTE when on a COC is still much lower than the risk of a VTE during pregnancy. During pregnancy, a woman’s risk of VTE increases to approximately 60 of 100,000 women per year.
As detailed in the US MEC, the WHO classifies medical eligibility criteria for contraception into 4 main categories, summarized in Table 1 .
| Category 1 | Condition for which there is no medical restriction to use method |
| Category 2 | Advantages of using contraceptive method generally outweigh the risks |
| Category 3 | Theoretic or proven risks usually outweigh advantages of contraceptive method |
| Category 4 | Unacceptable health risk if contraceptive method used |
When prescribing a COC, it is important to screen for common category 3 and 4 conditions that may pose contraindications to estrogen use. A clinician should inquire about personal and family history of VTE, history of migraine with aura, and history of hypertension. Patients who have underlying thrombophilias, such as Factor V Leiden deficiency, are not appropriate candidates for COC therapy. Common category 3 and 4 conditions are summarized in Table 2 . Please note that this list is not comprehensive; the US MEC has a more thorough description of medical contraindications to COC treatment.
| Category 3 conditions (use of method generally not recommended) |
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| Category 4 conditions (health risk associated with using method is unacceptable) |
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Smoking and combined oral contraceptive use
In adolescents, smoking does not represent an absolute contraindication to using COCs. Smoking alone increases the risk of VTE and this effect is compounded by COC use. Smoking itself causes 1.4 to 3.3 times risk increase in VTE. The combination of COC use and smoking compounds this risk further, leading to an 8.8 times risk increase in VTE. In patients younger than 35, smoking is classified as a category 2 condition. In patients ages 35 or older, smoking becomes a category 3 or 4 condition depending on the number of cigarettes smoked per day. Adolescent patients who smoke should be counseled about the increased risk of VTE and smoking cessation should be encouraged.
Prescribing the progestin-only pill
If a patient has a medical contraindication to estrogen or wishes to avoid estrogen for personal reasons, there are several nonhormonal methods and progestin-only methods available. As detailed in other articles of this issue, intrauterine devices are available in nonhormonal and progestin-only forms. Also, Nexplanon and Depo-Provera are highly effective contraceptive methods that contain progesterone only (See article, “ LARC Methods ,” in this issue). Patients who have medical contraindications to estrogen should be counseled about these other contraceptive methods. Alternatively, patients can be offered the POP.
Most clinicians try to avoid the use of the POP as a primary method of contraception due to difficulties many patients have with the exact daily dosing that this medication requires. POPs contain the active ingredient norethindrone at a concentration of 0.35 mg. The POP pack contains 28 days of active hormonal pills. Many patients are familiar with the traditional packaging of estrogen-containing COCs; most have 3 consecutive weeks of active hormonal pills followed by 7 days of placebo pills. Patients being prescribed a POP should be clearly counseled that these pills do not have a placebo week and it is crucial that they take every pill in a pack to maintain contraceptive efficacy. Common side effects of POPs include intermittent amenorrhea and irregular spotting. POPs also have several health benefits, including improved dysmenorrhea and possible protection against endometrial cancer.
Quick start method
The “traditional” way to initiate OCP use was to advise a patient to wait until her menstrual period and then start the OCP. This method is problematic in that many adolescents have irregular menses. Waiting for the onset of menses could result in significant delay in starting the OCP and could lead to an undesired “window of opportunity” for unintended pregnancy. Such reasoning supports the use of the “quick start method.” The quick start method applies to all types of OCPs, both POPs and COCs.
With the quick start method, the patient starts the OCP medication as soon as it is prescribed. In all sexually active patients, it is recommended to check a urine pregnancy test before giving an OCP prescription. If the pregnancy test is negative and the patient’s last menstrual period (LMP) was within the past 5 days, the patient may start the OCP on the day the script is provided. Back-up contraception is not necessary in this situation, although condoms are always recommended for STI protection.
If the patient’s LMP was more than 5 days ago, urine pregnancy test negative, and she has NOT had unprotected intercourse since LMP, the OCP can be started that day. In this situation, patients require back-up contraception for the first week of OCP use.
If the patient’s LMP was more than 5 days ago and she has had unprotected intercourse, then she should be counseled about the potential for an early pregnancy that would not necessarily be reflected in a urine pregnancy test. Use of a POP or COC is not associated with teratogenic effects or adverse pregnancy outcomes. Therefore, even if pregnancy cannot be definitively excluded, patients can be given the option to start an OCP and return for follow-up pregnancy testing within 2 to 3 weeks. If a patient has had unprotected intercourse within the past 5 days, she should be offered emergency contraception (EC) (See Ellen S. Rome and Veronica Issac’s article, “ Emergency Contraception ,” in this issue). If she chooses, the patient should take EC as soon as possible and then start the OCP that same day. The patient should be advised to use back-up contraception for 1 week and should return for follow-up pregnancy testing in 2 weeks.
Some patients may not be comfortable starting a contraceptive method when pregnancy cannot be definitively excluded and do not choose EC. Such patients can be provided with a script for the OCP and advised to use barrier contraception until their next menses. Patients should be advised to start the OCP on the first day of menses or the first Sunday following menses and should also be encouraged to return for pregnancy testing if menses is late.
Prescribing combined oral contraceptives
Just as with POPs, the quick start method is effective. COCs contain both estrogen and progesterone and function primarily through inhibiting ovulation and thickening cervical mucus. Benefits and risks associated with COCs and differences among COC formulations are discussed in the following sections.
Noncontraceptive health benefits of combined oral contraceptives
In addition to providing birth control, COCs offer several other health benefits noted in Table 3 . COCs can provide menstrual regulation, decreased menstrual flow, and improved dysmenorrhea. Many patients opt to use COCs for treatment of irregular, heavy, or painful menses (See Sheryl A. Ryan’s article, “ The Treatment of Dysmenorrhea and Excessive Uterine Bleeding ,” in this issue). COCs can help prevent and treat iron-deficiency anemia associated with menorrhagia. Long-term (>5 years) COC use offers some protective effects against endometrial and ovarian cancer. COC use can prevent ovarian cyst formation due to inhibition of ovulation. Certain formulations improve acne and hirsutism, which are discussed later.
| Menstrual-related |
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| Hematologic |
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| Cancer prevention |
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| Dermatologic |
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| Ovarian |
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