Abstinence is a wise and safe choice at any life stage, particularly for young patients who do not feel ready for a sexual relationship. However, abstinence-only programs are ineffective in delaying sexual debut or in reducing sexual risk behaviors among teens that are already sexually active [5]. Comprehensive sexual education has been shown to significantly decrease teen pregnancy rates, increase age at first intercourse, and significantly increase the likelihood of contraception use at first intercourse [5–7]. Furthermore, female participants in comprehensive sexual education programs were more likely to choose age-appropriate sexual partners, less likely to note first intercourse as an unwanted event, and more likely to express overall healthier partnerships associated with their first sexual encounter. Sexual education has not been shown to be associated with an earlier onset of sexual debut [5]. Therefore, although a patient who notes abstinence as their form of contraception should be encouraged to continue, sexual health should always be part of the discussion.

Noncoital sexual behavior includes mutual masturbation, oral sex, and anal sex and is a common expression of sexuality. The National Survey of Family Growth found that 45 % of females aged 15–19 years have had oral sex with an opposite-sex partner, but these numbers have remained stable over the past two decades. Compared with oral or vaginal sex, which are common in more than 90 % of males and females by age 25 years, anal sex is less common (10 % of female adolescents aged 15–19 years) and often is initiated later. Noncoital sexual behavior commonly coexists with coital behavior. The prevalence of oral sex among adolescents jumps dramatically in the first 6 months after initiation of vaginal intercourse, suggesting that both are often initiated around the same time and with the same partner. Although there is little risk of pregnancy with strictly noncoital activities, given this association, contraceptive discussion is warranted. Sexually transmitted infections, including HIV, HSV, HPV, hepatitis virus, syphilis, gonorrhea, and chlamydia, can be transmitted through noncoital sexual activity, and patients should be strongly counseled regarding safe sexual practices [8].

This method involves the withdrawing of the penis from the vagina and away from the external genitalia prior to ejaculation. It is mentioned here as a point of discussion, as it is practiced widely, with 55 % of adolescent women aged 15–19 years reporting having used the method before [9]. The failure rate of such technique is high (22 % with typical use) and it does not provide protection against sexually transmitted infections [9].

The male condom acts as a physical barrier, covering the penis and blocking the passage of sperm into the vagina. According to the 2013 YRBS, 41 % of US high school students did not use a condom during the last sexual intercourse [1]. All sexually active adolescents should be encouraged on regular condom use for the prevention of sexually transmitted infections including HIV, as well as increased contraceptive efficacy. In the general population, condom use has an overall reassuring failure rate of 2 %. However, in typical use, the male condom alone has a failure rate of 18 % [9]. For this reason, a more reliable form of contraception should be counseled as first line.

Female condom

Diaphragm

Spermicides

Combined oral contraceptive pills (COCs) are available in a wide variety of formulations. The choice of pill should be determined by the patient and physician based on clinical picture, medical history, and patient preference. The basic mechanisms of action are the same for all formulations and include both inhibition of ovulation and folliculogenesis and thickening of cervical mucus. COCs are taken daily and depending on the cycling pattern chosen can be given between 21 and 90 days with a 4–7-day pill-free interval for withdrawal bleeding. Use among adolescents is popular, with 19 % of sexually active US high school students endorsing use of COCs to prevent pregnancy prior to their last act of sexual intercourse [1]. However, compliance and continuation may prove challenging in this age group.

The contraceptive transdermal patch is a thin, flexible patch that contains 6 mg of norelgestromin (active metabolite of norgestimate) and 0.75 mg of ethinyl estradiol (EE). The patch releases 150 mcg of norelgestromin and 20 mcg of EE daily. The patch provides serum levels of EE that are higher than the common 35 mcg EE COC formulations; however, the VTE risk of the patch is equivalent to a 35EE/norgestimate oral contraceptive pill. The patch is applied to the buttocks, upper arm, lower abdomen, or upper torso and changed once weekly for 3 weeks. The fourth week is a hormone-free interval to allow for cycling. Its mechanism of action is the same as that of oral contraceptive pills. In some studies, the patch appears to enhance consistent and correct use as compared to COCs; however, their overall continuation rates and failure rates are the same. Patch users may note a transient skin reaction and more initial breakthrough bleeding than COCs users; the latter effect improves with use. Patients greater than 90 kg may have a higher risk of pregnancy when using the patch [9].

A soft, transparent flexible ring that releases 120 mcg of etonogestrel (major metabolite of desogestrel) and 15 mcg of EE daily. Although several cases of VTE have been reported in vaginal ring users, the serum EE levels are two and threefold lower than that found in 35EE COCs and the birth control patch. However, there have been studies linking the progesterone component of the ring to an increased risk of VTE. Possibly due to the lower estrogen output, studies have not shown improvement in bone mineral density using the ring, even after 24 months of use [9].

The ring is placed vaginally once every 28 days, with the last 7 days being a ring-free time frame to allow for withdrawal bleeding. The mechanism of action is mostly ovulation suppression, similar to oral contraceptive pills. In theory, the ease of once-monthly use should improve patient compliance and improve method success rates. However, in randomized comparative trials, the ring and COCs showed similar compliance and continuation rates. The vaginal ring has excellent cycle control, even in the first few cycles. It can be removed for up to 3 h without compromising effectiveness and is safe to use with tampons or during intercourse. The most commonly reported side effects are headache and vaginal wetness [9].