Why is contraception important?

Contraception is the practice that allows a person to prevent pregnancy. Between 2015 and 2017, approximately 40% of never-married teenagers ages 15 to 19 years had had sexual intercourse. Although the percentage has trended slightly downward since 2002, the proportion is still significant.

In 2010, there were 57 pregnancies per 1000 females ages 15 to 19 years in the United States, which translates to 600,000 teen pregnancies annually. For those ages 10 to 14 years, there were 1.08 pregnancies per 1000 females in 2010. Despite the declining birth rate—17.4 births per 1000 adolescents in 2018 —teens ages 15 to 19 still have the highest rate of unintended pregnancy of all age groups.

Teens are at risk for sexually transmitted infections (STIs). The Centers for Disease Control and Prevention (CDC) data show that those ages 15 to 24 acquire half of all new STIs. In 2018, the rate of reported chlamydia was 3306 cases per 100,000 females ages 15 to 19, which was 1.3% higher than the 2017 reported rate. For this age group, reported gonorrhea cases in 2018 were 548.1 per 100,000 females—also higher than the 2017 rate (see Chapter 20 ). Dual contraceptive method use (barrier plus another contraceptive) is therefore especially important for adolescents.

According to the National Center for Health Statistics (NCHS) Data Brief in 2015, sexually active adolescent females most commonly choose external condoms, withdrawal, and oral contraceptive pills for contraception. These short-acting methods have more opportunity for human error, and therefore higher failure rates. Fewer teens choose long-acting reversible methods, which have lower failure rates (perfect and typical use rates are the same, with efficacy >99%). For those who choose short-acting methods, there are many apps and reminder alarms to help remember when the next dose is due or to trigger refill notifications.

The pearl index: What is it?

The Pearl Index (PI), expressed as number of contraceptive failures per 100 woman-years (HWY) of use, estimates contraceptive efficacy ( Table 21.1 ). The PI is calculated two ways: “actual” or “typical” use includes all pregnancies that occur in all months of exposure to the contraception method in a study, and “perfect” use includes only pregnancies in subjects who use the contraceptive method correctly and only during the period in which perfect use occurred. The PI is calculated by dividing the number of unintended pregnancies by the number of months the contraception was used.

If no contraception is used, the PI is 85 for both perfect and typical use. Counseling should be based on typical use. Life table methods are also used to calculate the probability of a contraceptive failure, but unlike PI, do not assume a constant failure over time, and thus attempt to eliminate the time-related bias of the PI calculation.

Contraception counseling

Contraception counseling is an important interaction between patient and health care provider. Care must be taken to avoid coercion and influence of personal or institutional bias and to intentionally keep in mind the patient’s values and background, as there is a long history of reproductive mistreatment, in particular for marginalized persons. Cost, time constraints or inability to go to a clinic, legal restrictions, lack of knowledge or misinformation, social or cultural concerns, and health care provider or parental attitudes are additional examples of barriers teens face when seeking contraception.

A Guttmacher report estimates that 21 million women were in need of publicly funded contraception supplies or services in 2016 because of being under the age of 20 or because of an income level below 250% of the poverty level. For the privately insured, the Affordable Care Act (outlined in the Health Resources and Services Administration Women’s Preventative Services Guidelines), as well as some state laws, require most private health plans to cover Food and Drug Administration (FDA)–approved contraceptive methods and counseling.

By removing financial and access barriers, the Contraceptive CHOICE Project promoted long-acting reversible contraceptives (LARCs) to reduce unintended pregnancy. Although both the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) recommend LARC (see Table 21.5 ) as safe and effective first-line contraception for teens, they are not often used. In the CHOICE study, 14- to 17-year-olds choosing LARC preferred the subdermal implant; 18- to 20-year-olds preferred the intrauterine device (IUD). Among the 14- to 19-year-olds, 82% of LARC users were still using their method at 12 months, compared with 49% of non-LARC contraceptive users. There was no significant change in number of sexual partners in any of the groups at 12 months. However, the overall numbers of pregnancy, birth, and abortion among CHOICE teen participants were significantly lower, illustrating that when comprehensive counseling is provided and barriers are removed, more teens choose LARC and continue to use it.

Consent and confidentiality for adolescents must be considered. Adolescents have the right to confidentiality; however, many factors, including electronic medical records and laws, pose challenges. The Guttmacher Institute has a chart that shows current state laws and policies that are helpful when navigating confidentiality and consent questions ( Table 21.2 ). (See Chapter 2 .) Education is also important. Comprehensive sex education (CSE) has been shown to increase communication between teens and parents or medical providers and improve media literacy, which is valuable as many adolescents use the Internet as a primary information source. The Title X family planning program is a federal grant program to provide comprehensive and confidential reproductive health counseling and services; in 2019, 17% of patients seen at a Title X clinic were younger than age 20. School-based health centers may also provide convenient services for teens, but unfortunately many do not provide contraception.

Shared decision making is a process to ensure teens pick a contraceptive option that works best for them ( Table 21.3 and Box 21.1 provide information on how to start a conversation about contraception). The ACOG recommends an initial reproductive health visit between the ages of 13 and 15, which is an opportunity to establish rapport, answer questions, and provide education. Of note, a pelvic examination is not required for initiation of contraception. To easily review contraceptive methods, medical conditions, side effects, and contraindications, the US Medical Eligibility Criteria (MEC) for Contraceptive Use has a free mobile application (see Table 21.2 ). It should be noted that none of the reversible contraceptive choices impair long-term fertility potential.

Adolescents may or may not choose to have relationships that include sexual activity. They may use terms like outercourse and abstinence, which have varied meanings to different people, but generally include sexual activities with the exception of penis-in-vagina intercourse. Providers can and should discuss healthy relationships and educate teens that oral sex, anal sex, and manual stimulation all carry a small risk of introducing semen into the vagina and could result in pregnancy and/or STI (see Table 21.3 ). Best practices for adolescent health care include taking a sexual health history, screening for STI, counseling, and providing contraception access. Medical offices can provide explicit descriptions of confidential services rendered. Sensitive topics are best discussed with the adolescent alone in an honest, nonjudgmental, supportive environment, keeping in mind the patient’s age.

The overall risk of developing cancer over a lifetime is similar among women who have used birth control and women who have not used birth control. In fact, newer studies are showing birth control users may have a lower chance of developing cancer. Using birth control pills may have an estimated net increase of life expectancy of 1 to 2 months, in addition to effects from preventing unwanted pregnancy.

What are the choices for contraception?

The choices are briefly outlined in Tables 21.4 and 21.5 . There are hormonal and nonhormonal as well as short- and long-acting options. Surgical sterilization and fertility awareness methods (charting temperature, ovulation, and cervical mucus) are not generally used by adolescents.

TABLE 21.4

What Are the Choices for Contraception?

Adapted from Nichole A. Tyson: Reproductive Health: Options, Strategies, and Empowerment of Women. Obstetrics and Gynecology Clinics of North America Volume 46, Issue 3, September 2019, Pages 409-430.

What Is the Name of the Contraception Method?	How Do You Use It?	Why Would You Pick This?	Myths and Common Concerns	Why Would You Avoid It (see US MEC for Comprehensive Information)?
The pill (combined oral contraceptive, or COC)	Take once daily at the same time; usually taking it after dinner is the easiest way to stay consistent and avoid nausea Choices for how to start taking pills? See Box 21.4	Easy to start, easy to stop Can help with heavy bleeding, cramps, acne, ovarian cysts, mood changes associated with cycles, and irregular periods	Does COC cause weight gain? There are no data to support that this is true. What if family members have breast cancer? COC users do not appear to have an increased risk for breast cancer. What if I cannot swallow pills? Chewable pills are available. Is a lighter period normal when taking COCs? Yes, because the lining of the uterus is less thick when on COC.	Side effects are usually mild: headaches, nausea, breast tenderness. If any history or increased risk for venous thromboembolism (VTE), you should not take COCs. If you cannot remember to take a pill every day. Will not protect against STI.
Progestin-only pills (POPs)	Same as COC (see above) Norethindrone pills: a 28-day pack without hormone-free pills Drospirenone: 28-day packs have four hormone-free pills	If estrogen is contraindicated	Backup contraception recommended if POPs are started more than 5 days from menses onset or if POP is taken more than 3 hours late.	Not as effective for acne. Increased chance of irregular bleeding versus COC. Will not protect against STI. More exact dosing than COC.
The patch There are two types: 1. Ethinyl estradiol 35 mcg and norelgestromin 150 mcg (EE/N) 2. Ethinyl estradiol 30 mcg and levonorgestrel 120 mcg (EE/LNG)	Apply and replace a patch once a week to a clean, dry area of skin on the abdomen, buttocks, or back EE/N patch can also be applied to the upper arm Do not put patch on the breast Rotate location to avoid skin irritation Patches are changed once a week for 3 weeks, followed by a patch-free week when menses occur If a patch is placed late (>48 h) or peels or falls off for more than 24 hours, a backup method is needed for 1 week	Only need to change the patch once a week Good option if ingesting oral medicine is difficult or causes side effects	Will it stick? The patch becoming unstuck and skin irritation are uncommon. Patch is good for up to 9 days even though instructions say to change it at 7 days of use. Can you see it? The patch is visible on the skin and only comes in one color. You can put the patch on your body in a place that is not visible to others.	Patches have similar systemic side effects, contraindications, and benefit profiles as COCs. The average serum EE concentration is higher with patch versus COC, and there may be a small increased risk for VTE ; overall risk is still low. There is a “black box warning” for EE/N patch: contraindicated if body mass index (BMI) ≥30 kg/m 2 (increased VTE risk). Patches may be less effective in obese users.
The vaginal ring There are two types: 1. ENG/EE: 120 mcg per day of etonogestrel (ENG) and 15 mcg/day of ethinyl estradiol 2. 150 mcg segesterone acetate and 13 mcg ethinyl estradiol (SA/EE)	1. ENG/EE ring is inserted into the vagina for 21 days, then removed for 7 days and discarded, during which time menstruation occurs, and then a new ring is inserted 2. SA/EE ring is inserted for 21 days and removed for 7 days, but you reinsert and use the same ring for thirteen 28-day cycles	Rings are more private than COC Nausea and breast tenderness are less common with rings, compared with COC Both rings are plastic and latex-free	Will it fall out? It generally does not, and if it does, push it back into the vagina. Can I put it in the wrong place? The ring releases hormone so it only needs to be in the vagina and feel comfortable.	Risks and contraindications similar to COC. Both contraceptive rings must be inserted into the vagina by the user. Local irritation is possible; toxic shock syndrome is possible but rare. SA/EE ring is slightly larger than the ENG/EE ring.
The shot (DMPA) There are two versions: 1. Intramuscular, 150 mg of depot medroxyprogesterone 2. Subcutaneous, 104 mg of depot medroxyprogesterone (DMPA-SC)	Start anytime it is reasonably certain that you are not pregnant Shots are given every 11–13 weeks	Privacy, high efficacy, and a convenient dose schedule Can self-inject DMPA-SC Tends to decrease incidence of seizures; helpful for those with epilepsy	What if I am late for my shot? Injections can be given up to 2 weeks late (15 weeks from previous shot) without a need for additional contraceptive backup.	Subcutaneous injections are often preferred over intramuscular injection in persons with bleeding disorders to avoid intramuscular hematoma. Irregular bleeding is common. Ovulation may not resume for up to a year after the last shot.
Cervical cap and diaphragm	Prescription only Both are silicone cups Both must be filled with spermicide and inserted into the vagina to cover the cervix Cervical cap is smaller Both must be left in for at least 6 hours after sex	No hormones Devices are reusable	Must use for every episode of sex. Cannot leave a cervical cap in for more than 2 days after sex. Cannot leave a diaphragm in for more than 24 hours after sex.	Cervical caps and diaphragms require advanced planning and can be challenging to insert, messy, and do not protect against STI. Toxic shock syndrome has not been reported with cervical cap use, but has been reported with the diaphragm.
External condom (formerly known as male condom )	Latex, plastic, or synthetic worn over the penis	No hormones Protects against sexually transmitted infection (STI) Easy to buy Do not need a prescription, sometimes can get them at school	Single use only. Be aware of latex allergy for condoms made with latex.	Must use correct technique. Check the expiration date. Recommended in addition to hormonal methods for protection against STI.
Internal condom (formerly known as female condom )	Sheath with a ring at each end—one ring is inserted into the vagina and the other ring hangs out about an inch from the vaginal opening	No hormones Protects against STI Do not need a prescription Easy to buy	Single use only. Be aware of latex allergy for condoms made with latex.	Must use correct technique. Check the expiration date. Recommended in addition to hormonal methods for protection against STI.
Spermicide	Can and should be used with condoms, diaphragms, and cervical caps Available over the counter as cream, gel, foam, suppository, or film Insert deep into vagina at least 10–15 minutes before intercourse	No hormones Do not need a prescription Easy to buy	Must be repeated if more than 1 hour passes before sex or if intercourse is going to happen again.	Higher failure rate compared with other methods if used alone. Must use for every episode of sex. Does not protect against STI. Can be messy or cause local irritation.
Withdrawal (“pulling out”)	The penis is withdrawn from the vagina before ejaculation			Higher failure rate compared with other methods. Does not provide STI protection. Widely practiced; providers should proactively ask adolescents about this behavior and encourage them to choose more effective contraception methods.
The sponge	A plastic spermicide-containing sponge Insert into vagina up to 24 hours before sex Works by physically blocking the cervix Sponge must be left in place for 6 hours after sex	No prescription needed	Single use only. Must insert into vagina every episode of sex.	Higher failure rate compared with other methods. Does not protect against STI. Can be messy or cause local irritation. Toxic shock has been reported.
Contraceptive gel	Prescription gel: lactic acid, citric acid, and potassium bitartrate Makes vaginal pH more acidic (inhospitable to sperm) 5 g vaginally via applicator up to 1 hour before sex	Not spermicide and not hormonal Can use with oral contraceptives	Single use only. Must insert into vagina every episode of sex.	Higher failure rate compared with other methods. Does not protect against STI. Cannot use with vaginal ring. Can be messy or cause local irritation.

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