Introduction
Contraception counseling is recommended to be a routine part of preventive health care visits. The American Academy of Pediatrics (AAP) recommends that pediatricians have a working knowledge of contraception to help adolescents reduce the risks and negative consequences of unintended pregnancy. Similarly, the American College of Obstetricians and Gynecologists (ACOG) recommends that all obstetrician-gynecologists routinely address the contraceptive needs of patients regardless of age. Contraception counseling should be nonjudgmental, comprehensive, and inclusive. This includes offering counseling to all adolescents regardless of medical conditions, including physical or intellectual disabilities. Adolescents and young adults with mild to moderate intellectual or developmental disability are just as likely to be sexually active as are their peers without disability. Most adolescents with disabilities do not receive the appropriate reproductive health counseling that they need.
The focus of this chapter is contraception provision for adolescents with medical complexities, as the benefits and risks of contraceptive use for adolescents with certain conditions may be different from those of healthy adolescents. Although the chapter is thorough, it is not comprehensive of all medical conditions. In addition to the standard elements of providing contraception care described in detail elsewhere, we recommend the reader adopt a standardized approach to assessing contraceptive needs for adolescents with medical complexity ( Box 22.1 ).
- 1.
Review the pregnancy-related risks associated with the medical condition and related medications.
- 2.
Review the contraindications to any contraceptive methods related to the medical condition.
- 3.
Consider the benefits of contraceptives for the underlying medical condition.
The US Medical Eligibility Criteria (US MEC) for Contraceptive Use from the Centers for Disease Control and Prevention (CDC) provide evidence-based guidance on medical eligibility for the initiation and continuation of contraceptive methods among people with various characteristics and medical conditions ( Box 22.2 ). This resource is also available for free online and in an app.
US MEC categorizes medical eligibility for contraceptive use into four categories:
- 1.
A condition for which there is no restriction for the use of the contraceptive method
- 2.
A condition for which the advantages of using the method generally outweigh the theoretical or proven risks
- 3.
A condition for which the theoretical or proven risks usually outweigh the advantages of using the method
- 4.
A condition that represents an unacceptable health risk if the contraceptive method is used
Categories are applied to method initiation and continuation, as the guidance may vary if the medical condition worsened while using the contraceptive method.
The World Health Organization (WHO) also provides an evidence-based guideline for the provision of contraception. When considering the CDC and WHO guidelines for contraceptive counseling, one must recognize that adolescents and teenagers are generally a healthier population than adults. There are limited available data on hormonal contraceptive effects in the teenage and adolescent population; however, the negative effects associated with hormonal contraception (i.e., risk of venous thromboembolism [VTE]) increase with increasing age.
Unique considerations for adolescents
The provision of contraception for adolescents requires unique considerations ( Box 22.3 ).
- 1.
Confidentiality
- 2.
State laws a
- 3.
Discretion
- 4.
Reproductive justice
https://www.guttmacher.org/state-policy/explore/minors-access-contraceptive-services
All efforts should be made to provide and maintain confidentiality to adolescents seeking contraception. The AAP states that protecting adolescent confidentiality during contraception care is in the best interest of the adolescent. Consider steps that may improve the discreetness of contraception when clinically appropriate. For example, adolescents needing to conceal the method from family or partners wanting a highly effective contraception may be interested in intrauterine devices (IUDs) or the implant, as those methods do not require trips to the pharmacy and require little maintenance. Additionally, cutting IUD strings flush to the level of the external os may provide privacy, as sexual partners cannot feel them.
When providing contraception counseling for adolescents, the provider is encouraged to use shared decision making to help the adolescent find the method that is right for them. In this approach, it is important to understand the patient’s preferences and priorities about contraception. Asking a question such as, “What are you looking for in a birth control method?” may help guide the conversation. Shared decision making should consider menstrual symptoms and methods, which may provide improvement in those symptoms in addition to contraception. If contraceptive effectiveness is the patient’s priority, tiered counseling or effectiveness counseling is appropriate. However, it is important to consider cultural and historical perspectives that may affect a person’s contraceptive choice. Historical and contemporary eugenic and racist practices may make people of color or in poverty wary of long-acting reversible contraceptives (LARCs). In addition, certain adolescents may prefer a method that they are more in control of that does not require a visit to their provider for discontinuation.
Ultimately, the provider’s role is to help the adolescent initiate the contraceptive method that best fits their preferences and priorities and is safe to use in the context of medical complexity ( Box 22.4 ). When considering medical comorbidities and their interaction with hormonal contraception, the provider must weigh these risks with the risk of pregnancy, which would expose the patient to higher levels of estrogen and progestogen than any available hormonal contraception
All patients should be counseled about:
- 1.
Abstinence as a method to prevent pregnancy.
- 2.
The importance of condom use for the prevention of sexually transmitted infections in addition to pregnancy prevention.
- 3.
Hormonal and nonhormonal use of contraception.
- 4.
Emergency contraception as safe with virtually no contraindications. (Consider provision at the initial visit or prescription for later use.)
Long-acting reversible contraceptives in adolescents
LARCs (IUD and subdermal implants) are safe and effective in the adolescent population. It should be noted that IUDs can be safely inserted in adolescents as both a form of contraception and emergency contraception (see section on “Use of Emergency Contraception” on page 238), contrary to some of the misconceptions associated with IUD insertion in this population ( Box 22.5 ).
- 1.
IUDs are safe and effective for adolescents and young adults.
- 2.
IUDs can be used as contraception and emergency contraception.
- 3.
Expulsion is more common in adolescents in comparison to the adult population; however, this should not deter placement.
- 4.
Anticipatory guidance can relieve pain experienced with IUD insertion and break down barriers to IUD placement.
- 5.
A paracervical block for IUD insertion is effective for reducing pain in adolescents.
Expulsion in adolescents and young adults may be more common in patients with abnormal uterine bleeding or heavy menstrual bleeding. Studies have demonstrated a range of expulsion rates in this population; however, a systematic review found a higher expulsion rate among adolescents and young adults in comparison with adults, with an expulsion rate of 8%. Despite the higher expulsion rate, it should be noted that postplacental IUD insertion has been found to have even higher expulsion rates, yet are cost-effective nonetheless ; therefore the 8% expulsion rate should not deter a provider from placing an IUD.
Despite its effectiveness, a barrier to IUD insertion in the adolescent population appears to be fear of pain with insertion. An association between anticipated pain and experienced pain has been demonstrated, which can be relieved with anticipatory counseling. Pain with IUD insertion in adolescents is similar to adults. , On the visual analogue scale, adolescents rate their pain from 30 to 70 mm, depending on whether a paracervical block is used. Pain reduction can be accomplished using a paracervical block in the adolescent population, similar to the adult population. ,
The frames of the IUD come in different sizes, with the copper IUD measuring 32 × 36 mm, levonorgestrel (LNG) 52 mg measuring 32 × 32 mm, and the LNG 19.5 and 13.5 measuring 30 × 28 mm. Although data are limited in adolescent populations, they suggest that people receiving smaller IUDs are more likely to report “no to mild pain” with insertion. Newer data suggest that smaller-framed IUDs may be associated with decreased expulsion in the nulliparous population. It should be noted that these data include two copper IUDs, one of which is not yet available on the market in the United States.
Medical complexities
Rheumatologic conditions
Pregnancy in patients with rheumatologic conditions, which can affect adolescents and young adults, may lead to serious maternal or fetal adverse outcomes. Adverse maternal events include worsening of preexisting proteinuria, increased thrombosis risk, and worsening of osteoporosis; fetal adverse outcomes may be fetal growth restriction or teratogenic effects resulting from medication. Reproductive health counseling is crucial for patients with rheumatologic diseases to optimize personal health. Shared decision making is a vital component of contraception counseling that considers the patient a unique individual with their own reproductive goals.
Both the CDC and the American College of Rheumatology (ACR) have evidence-based recommendations about best practices for contraception in patients with rheumatologic diseases but differ in a couple recommendations discussed further in Table 22.1 . ,
| CDC | ACR | Additional Information | |
|---|---|---|---|
| SLE With Negative aPL (Mild) |
|
| |
| SLE With Negative aPL (Moderate to Severe) |
|
| |
| SLE With Positive aPL |
|
|
|
Special considerations should be made for patients on mycophenolate mofetil/mycophenolic acid (MMF) taking contraception. MMF may reduce the serum concentrations of estrogen and progestins, rendering them less effective. IUDs, barrier methods paired with combined contraceptive pills, or the etonogestrel implant are preferred in patients with MMF.
Neurologic conditions
Epilepsy
Epilepsy is often diagnosed and managed during childhood, and so providers should be aware of how to counsel these patients on hormonal contraception and be familiar with hormonal interactions with antiepileptic medication. Patients with seizure disorders may experience a higher rate of anovulation, amenorrhea, and irregular menses. Although ACOG does not recommend initiating hormonal contraception before puberty, it recommends physicians discuss a plan for when menarche arrives.
For patients with epilepsy, pregnancy may increase their risk for seizure. Complications in the fetuses and children of mothers with epilepsy may include fetal loss and perinatal death, congenital malformations, neonatal hemorrhage, low birth weight, developmental delay, and childhood epilepsy. Additionally, certain anticonvulsant medications are known to be teratogenic ( Box 22.6 ).
- 1.
Valproic acid
- 2.
Pregabalin
- 3.
Topiramate
- 4.
Phenobarbital
- 5.
Phenytoin
- 6.
Carbamazepine
For people using hormonal contraception, the provider should consider their interactions with anticonvulsants. Certain anticonvulsants may decrease the effectiveness of hormonal contraception ( Box 22.7 ). If a combined estrogen-progestin oral contraceptive (COC) is used, the minimum suggested estrogen dose for adolescents and teenagers is 30 μg. Contrarily, serum levels of lamotrigine are decreased when used in combination with combined hormonal contraceptives (CHCs). For patients using lamotrigine for treatment of seizures, this may lower their seizure threshold and worsen control of their epilepsy (CDC US MEC category 3). Therefore when prescribing or changing contraceptive methods, care should be coordinated with the patient’s neurologist to adjust antiepileptic medication to ensure therapeutic levels.
- 1.
Phenytoin
- 2.
Carbamazepine
- 3.
Barbiturates
- 4.
Primidone
- 5.
Topiramate
- 6.
Oxcarbazepine
Finally, contraception may provide benefit to patients with epilepsy. There is a positive correlation between seizure frequency and mean estrogen/progesterone ratios, with fewer reported seizures when progesterone levels are elevated. Although the data are limited by small studies, depo medroxyprogesterone acetate (DMPA) has been shown to reduce seizure frequency. However, not all progestins have the same impact. A 2016 Cochrane review found very low-certainty evidence of no difference between norethindrone and placebo and moderate to low certainty evidence of no difference between progesterone and placebo for the treatment of catamenial epilepsy.
For patients who are using hormonal contraception to prevent pregnancy and who have refractory seizures on polytherapy with enzyme-inducing anticonvulsants, it is prudent to recommend barrier contraception in addition to their hormonal contraception because of the increased likelihood of drug-drug interactions. All forms of emergency contraception are safe in patients with seizure disorders who are on anticonvulsants.
Migraine with aura
People with a history of headaches should be evaluated for migraine with aura at the time of contraception counseling. Auras are complex neurologic symptoms, which most commonly manifest in visual symptoms but also include sensory, speech, language, motor, brainstem, or retinal symptoms. Patients with migraine with aura who use CHCs are at increased risk for stroke. If an adolescent is describing symptoms consistent with migraines with aura, a neurologic examination with a professional should be completed before making the formal diagnosis. CHCs should be avoided (CDC US MEC category 4); however, the absolute risk of stroke is low even in the presence of migraine with aura. Additionally, the risk of pregnancy particularly for the adolescent population, including the risk of stroke and the additional risks that come with pregnancy in this population, far outweigh the risk caused by hormonal contraception in the setting of migraines with aura. It is important to always individualize assessment of harms and benefits and practice shared decision making.
Hematologic conditions
Thromboembolism/stroke
Thromboembolisms and strokes are not common in the adolescent population, as the risk of VTE increases with age and comorbidities that come with aging. With that said, special consideration should be taken in patients with history of deep vein thrombosis (DVT), history of pulmonary embolism (PE), current DVT/PE, history of stroke, or otherwise at risk for thrombosis when prescribing hormonal contraception.
Estrogen in CHCs increases hepatic production of serum coagulation factors and fibrinogen, thereby increasing the risk of thromboembolism. The CDC MEC recommends that CHCs be avoided in all patients with acute DVT/PE or those with a history of DVT/PE (CDC US MEC category 3–4). According to a 2014 Cochrane review, the relative risk of VTE in women using COCs with ethinyl estradiol is 2.5 to 5.5 times the risk of VTE in women without COC use. Evidence suggests that hormonal contraception with <50 μg ethinyl estradiol has a reduced risk of VTE compared with pills containing 50 μg ethinyl estradiol, an elevated dose no longer prescribed in hormonal contraception available today. A novel oral contraceptive pill containing 14.2 mg of estetrol and 3 mg of drospirenone (Nextstellis in the United States and Drovelis or Lydisilka in the European Union) was recently developed. Whereas most COCs use ethinyl estradiol, the new pill contains estetrol, a naturally occurring estrogen. A phase 3 clinical trial containing 1674 women demonstrated that estetrol 14.2 mg/drospirenone 3 mg was efficacious, and no participants had a thrombotic event. The estetrol 14.2 mg/drospirenone 3 mg COC may have lower rates of thrombosis compared with traditional COCs, though commercial availability may be limited because of lack of insurance coverage.
Although the CDC considers the benefits of DMPA to outweigh the risks in someone with DVT/PE (CDC US MEC category 2), this risk is considered unacceptable in someone with a history of stroke (CDC US MEC category 3). The data are not strong, but there is some evidence for increased risk of VTE associated with the use of DMPA. , Data do not demonstrate similar effects with other progestin-only methods; however, the CDC also recommends against continuing progestin-only pills, LNG-IUDs, and the etonogestrel implant in those with a stroke (CDC US MEC category 3). It is acceptable to initiate a new, non-DMPA, progestin-only method (progestin-only pills, LNG-IUDs, and the etonogestrel implant) in patients with stroke history as long as the thrombotic event did not occur while using the method. Similar to DVT/PE, estrogen-based contraception should not be used in anyone with a history of stroke (CDC US MEC category 4).
Other risk factors for thrombosis
Thrombosis is rare, with a baseline risk of 1 to 5/10,000 women-years versus 3 to 15/10,000 women-years for users of hormonal contraception. In pregnancy, the risk increases fivefold, which is even higher than on hormonal contraception. These rates are based on the general population and are even lower in younger populations.
Although there are no contraindications for people with first-degree relatives with a history of DVT/PE, it is not recommended that a person with a known thrombogenic mutation (e.g., factor V Leiden mutation, prothrombin G20210A mutation, protein C, protein S, or antithrombin deficiency) use estrogen-based contraception (CDC US MEC category 4). Progestins are acceptable for patients with a history of thrombosis and outweigh the higher VTE risks associated with pregnancy. It should be noted that the majority of adolescents report engaging in sexual activity before completing high school with limited use of contraception. Routine thrombophilia testing is not recommended before initiating hormonal contraception, unless the patient has symptoms that would warrant thrombophilia testing.
There is increased risk for VTE among patients undergoing major surgery with prolonged immobilization; therefore CHCs should be avoided (CDC US MEC category 4). , All progestin-only methods are acceptable alternatives in this population (CDC US MEC category 2).
Heavy menstrual bleeding
Heavy menstrual bleeding (HMB) is defined qualitatively as “excessive menstrual blood loss which interferes with the woman’s physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms” and objectively as 80 mL or more of menstrual blood loss per month. LNG-IUD is considered a first-line treatment for people with nonacute HMB. The Mirena 52-mg LNG-IUD is Food and Drug Administration (FDA) approved for treatment of HMB. In fact, two recent studies of LNG use in adolescents found that 39.8% to 51% of users of an LNG-IUD reported amenorrhea. , Among adolescents with bleeding diatheses, use of the 52-mg LNG-IUD led to amenorrhea or spotting in approximately 60% of users. , Therefore in adolescents with HMB who desire contraception, LNG-IUD should be considered a first-line method given its contraceptive efficacy and benefits for the treatment of HMB.
CHCs are another contraceptive for adolescents with HMB that may provide the dual benefit of contraception and treatment of their HMB. CHCs with 30 to 35 μg of ethinyl estradiol are preferred in patients with HMB compared with COCs with ultralow-dose pills (10 μg ethinyl estradiol or less). Ultralow-dose pills may be less effective at controlling bleeding. , Triphasic pills have not been found to be more effective than monophasic pills in controlling vaginal bleeding. Additionally, extended cycling of COCs (skipping placebo pills) may also reduce the frequency of menstrual bleeding and thereby provide treatment for HMB. This may be done by counseling the patient about skipping placebo pills and by prescribing a prepackaged extended-cycle monophasic COC.
Finally, patients may also achieve a reduction in HMB with DMPA, with up to 46% of users experiencing amenorrhea at 1 year. ACOG offers clinical guidance of how to use hormonal contraception for menstrual suppression ( Table 22.2 ).
