Young women under the age of 16 years require special consideration when requesting contraception. Such young women can give voluntary consent, which enables prescription and supply providing that the practitioner has determined that the minor is sufficiently mature to understand the details of the method and its use. All reversible methods may be appropriate but it is necessary to provide information in a form that is fully understood.
For women with pre-existing medical conditions including obesity, the benefits and risks of the use of individual methods needs to be weighed against the risks of pregnancy for that woman.
In developed countries, the median age of young women at their first intercourse is 16 years with 20–30% reporting sexual intercourse before the age of 15 years. Early age at first intercourse is significantly associated with pregnancy under 18 years. Comprehensive sex education, which includes information about all contraceptive options and their optimal use is essential. Services for young adolescents need to be confidential, youth friendly and culturally appropriate with time allocated for development of rapport and to address contraceptive, sexuality and broader health issues.
Consent
Any competent young person, regardless of age, can give voluntary consent to medical treatment. Young people under the age of 16 years must have sufficient understanding and maturity to fully comprehend the contraceptive options available and the benefits, risks and consequences of using the proposed method. Ideally, young women should be encouraged to inform parents or allow the clinician to do so. If this is not possible, then the clinician must assess the competency of the young woman to make the decision, the likelihood of intercourse continuing with or without contraception, whether her physical or mental health could suffer if contraception was withheld and if it is in her best interests to provide contraception without parental consent.
In recent years, the number of contraceptive options available has increased but very young women are not being given the option of choosing methods other than condoms or the combined oral contraceptive pill. Both the World Health Organization Medical Eligibility Criteria (WHO MEC) 2009 and guidelines from the Faculty of Family Planning and Reproductive Health Care (FFPRHC) 2009 state that age should not act as a barrier to any reversible contraceptive method for young adolescents. Individual health factors, contraceptive needs and wishes as well as lifestyle, pregnancy and sexually transmitted infection (STI) risk need to be taken into account when assisting young people in choosing a method. Insistence on intrusive examinations that is, breast, pelvic examination or Pap smear can be a barrier to young women accessing contraception. Careful history taking to exclude contraindications is sufficient to ensure safe provision.
Condoms
Condoms protect against pregnancy and STIs, require no medical or parental involvement, are readily available, relatively inexpensive, safe, easy to use and have no systemic effects. Contrary to prevailing beliefs, condoms have low breakage and slippage rates estimated to occur in 1.6–3.6% of coital acts and a pregnancy rate of 2% for perfect use and 15% for typical use. Although an ideal method for adolescents, who are more likely to have short serially monogamous relationships, very young adolescents are less likely to use condoms consistently. Most failures occur from inconsistent use.
Polyurethane condoms are thinner, looser, conduct body heat better and can be used with oil-based lubricants. A Cochrane review (2006) concluded that although they were associated with a higher rate of clinical breakage, they were still a feasible alternative for people with a latex allergy, although contraceptive efficacy required more research.
Both sexes should receive counselling about condoms, prevention of pregnancy, STIs and negotiating condom purchase and use. Instruction in correct condom use is essential as failure rates are highest in the first months of use.
Adolescents who choose to use hormonal contraceptives should be aware that these methods do not protect against STIs and are encouraged to use condoms as well if they change partners or have multiple partners.
Condoms
Condoms protect against pregnancy and STIs, require no medical or parental involvement, are readily available, relatively inexpensive, safe, easy to use and have no systemic effects. Contrary to prevailing beliefs, condoms have low breakage and slippage rates estimated to occur in 1.6–3.6% of coital acts and a pregnancy rate of 2% for perfect use and 15% for typical use. Although an ideal method for adolescents, who are more likely to have short serially monogamous relationships, very young adolescents are less likely to use condoms consistently. Most failures occur from inconsistent use.
Polyurethane condoms are thinner, looser, conduct body heat better and can be used with oil-based lubricants. A Cochrane review (2006) concluded that although they were associated with a higher rate of clinical breakage, they were still a feasible alternative for people with a latex allergy, although contraceptive efficacy required more research.
Both sexes should receive counselling about condoms, prevention of pregnancy, STIs and negotiating condom purchase and use. Instruction in correct condom use is essential as failure rates are highest in the first months of use.
Adolescents who choose to use hormonal contraceptives should be aware that these methods do not protect against STIs and are encouraged to use condoms as well if they change partners or have multiple partners.
Combined oral contraceptives
Combined oral contraceptives (COCs) should not be prescribed prior to menarche. Smoking is not a contraindication in young women. There has been concern about a possible increased risk of breast cancer in women starting COCs before age 20 and continuing for more than 8 years. A large population-based study recently demonstrated no overall relationship between COC use and breast cancer, including starting before age 20, duration of use, hormonal dose and positive family history.
Acne is a major problem for many young women. A Cochrane review found that COCs reduced acne count lesions, severity grades and self-assessed acne compared with placebo. However, differences in the comparative effectiveness of COCs containing different progestogens were less clear. For women with mild-to-moderate seborrhoea or acne, any low-dose oestrogen-dominant COC can be used. Monophasic preparations of EE 30 μg plus norgestimate, desogestrel or gestodene are preferable for the 10% of women in whom acne deteriorates with levonorgestrel combinations. In recalcitrant or severe acne, preparations containing an anti-androgenic progestogen are indicated.
Since only 26% of adolescents 14 years and under take their pill daily compared to 40% in other age groups, they require careful counselling about starting their pill, taking it regularly, how to ensure they do not forget and how to deal with missed pills. They should understand that nausea, breast tenderness and breakthrough bleeding (especially if they miss pills) are common in the first few cycles and encouraged to persist for 3 months until their pill use is reviewed.
Combined oestrogen/progestogen contraceptive patch
There are no large studies of adolescent experience of the Evra ® patch. A 3-month study found that of 62% still using the patch, 87% reported perfect compliance and 77% were planning to continue patch use. The rate of partial and complete patch detachment was 35.5%, higher than in adults. The most common side effects were breast tenderness and site skin reactions. A study of adolescents who had used the patch for 5–8 months found that all had regular withdrawal bleeds with 14% reporting occasional breakthrough bleeding, half reporting shorter bleeds, a third lighter bleeding and no significant weight gain. A third with recurrent headaches and a third with acne reported improvement. A third experienced peeling of the patch at the edges and 21% at least one episode of complete detachment. The major side effects reported were mild temporary site reactions (64%), some discomfort on patch detachment (32%), nausea (18%) and breast tenderness (18%). Satisfaction level was high and 94% would recommend the method to a friend but a third would have preferred another patch colour and a quarter would like a placebo patch for the patch-free week.
Contraindications to patch use are the same as for COCs. Young women with a known skin reaction to adhesive plasters are likely to develop a skin reaction to the patch. In view of the high partial detachment rate in adolescents, it is imperative that instructions for management of detachments are carefully explained and reinforced with clear written instructions.
Controversy has arisen over the dose of oestrogen delivered by the patch, suggesting an increased incidence of venous thrombo-embolic (VTE) disease due to consistently higher serum levels, compared to a 35 μg pill, although the peak daily oestradiol level is 35% higher for the 35 μg pill. However, when comparing claims paid by managed-care companies for VTE in users of the Evra patch and norgestimate containing pills, no difference was found in the incidence of VTE.
NuvaRing
Studies of adolescents’ knowledge about the contraceptive ring indicate that few adolescents have heard about the ring but, when given detailed information and demonstrations of ring use with a pelvic mode, a substantial proportion of women as young as 14 years indicated an interest in using the method. Initial insertion of the ring by a health professional or encouraging insertion and removal practice under supervision at the time of prescription increases confidence. Reasons for liking the ring included no requirement for daily action, effectiveness equivalent to the pill, good cycle control, low incidence of side effects and ease and convenience of use. Disincentives were the possibility of the ring being felt by the partner during intercourse and the need for inserting fingers into the vagina. In many countries, it is possible for adolescents to register online for an automatic short message service (SMS) reminder to remove or insert a new ring.
The side effects are similar to other combined hormonal methods (CHM). Specific device-related side effects are vaginitis or increased vaginal discharge (5%) and an occasional woman with difficulty in removing or inserting the ring and slippage or expulsion, mainly on defecation. A few women have difficulty with remembering to remove or reinsert the ring as they are unaware of its presence and a small percentage remove the ring during intercourse as either they or their partner find it uncomfortable.
Initiation of combined hormonal contraceptives (CHC)
Although combined hormonal contraceptives (CHCs) are generally started in the first 7 days of the menstrual cycle, a useful option is to start them at the time a young woman visits the clinic, no matter where she is in her cycle and advise condom use for the next 7 days. A pregnancy test 3 weeks later is advisable. Waiting for the next period to start the method may result in a pregnancy in the intervening time.
CHCs can be started up to 7 days after an abortion <24 weeks gestation, 21 days post-partum if not breastfeeding and 6 weeks post-partum if partially breastfeeding. Continuous rather than cyclical use of CHCs may improve compliance and efficacy but adolescents’ acceptance of irregular bleeding associated with these regimens needs to be assessed.
Progestogen-only pill (POP)
The POP is not an ideal method for young adolescents as it requires meticulous pill taking and produces unpredictable bleeding patterns. Since inhibition of ovulation is the primary mode of action of the DSG POP, this is preferable for young girls as it provides a slightly longer window (12 h) for delayed pill taking.
DMPA and NET-EN
DMPA is given every 12 ± 2 weeks as a 150 mg 1 ml −1 intramuscular injection or as a subcutaneous injection of 104 mg 0.65 ml −1 . NET-EN is given intramuscularly every 8 ± 2 weeks. There are no data on use of NETA in young adolescents. A randomised controlled trial (RCT) comparing pregnancy rates for DMPA and NET-EN found 1-year cumulative pregnancy rates of 0.1% and 0.4%, respectively, and 2-year cumulative pregnancy rates of 0.4% (4/1000) for both.
DMPA is a suitable contraceptive for young women with few absolute contraindications. The major concern about long-term use of DMPA in women under the age of 16 is its possible effect on peak bone mass. A longitudinal study by Theintz et al. indicated that maximum increase in bone mass occurs between the ages of 11 and 14 years and the rate of accumulation decreases from 16 years with statistically non-significant gains between 17 and 20 years. A number of studies in women aged 12–18 years using DMPA have shown decreases in bone mineral density (BMD) ranging from 1.34% to 1.53% at the femoral neck and lumbar spine, greatest in the first year of use. However, a systematic review showed that after ceasing DMPA use, BMD consistently returned to near or baseline in women of all ages. Although the WHO MEC for DMPA indicate the benefits of use outweigh the risks in women from menarche to 18 years, in women under 16 years, it is wise to recommend combined hormonal methods first and use DMPA if these are unsuitable.
It is a suitable method for young women with known thrombogenic mutations, hyperlipidaemia, migraine with aura, diabetes and mild cirrhosis and who cannot tolerate oestrogens or are inconsistent pill takers.
The return of fertility is delayed following discontinuation of DMPA and NET-EN with median time to pregnancy with DMPA 5.5 months but can be as long as 12 months. With NET-EN, the return to fertility is shorter with over 50% women pregnant by 6 months.
Before deciding on DMPA use, adolescents need to be counselled about the unpredictable bleeding patterns, irregular bleeding/spotting and an increasing incidence of amenorrhoea with increasing duration of use. Rates of amenorrhoea at 12 months range from 52% to 64% and 71% at 2 years for DMPA-subcutaneous (SC) and 34–35% at 3 months and 71% at 12 months for DMPA-intramuscular (IM).
The major reasons for discontinuation of DMPA are bleeding changes and weight gain, approximately 3 kg at 2 years. Adolescent girls with a body mass index (BMI) ≥ 30 appear to have a significantly higher weight gain than women with a BMI <25 with both preparations. Other reported side effects are headaches, acne and mood changes. There is no evidence for a causal relationship between DMPA use and mood swings.
Longer duration of use makes DMPA preferable to NET-EN for adolescents. Its main advantages are improvement in adherence, no oestrogenic side effects, reduced menstrual flow preventing iron-deficiency anaemia, safe for breastfeeding adolescents, reduced frequency of epileptic seizures, a favourable effect on sickle cell disease and coagulopathy, reduced dysmenorrhoea and premenstrual symptoms and reduced risk of pelvic inflammatory disease (PID). The efficiency is not reduced with use of enzyme-inducing drugs or antibiotics.
Initiation of progestogen-only injectables
The first injection should be given within the first 5 days of a menstrual period to provide immediate contraceptive cover. If pregnancy can be ruled out with certainty, it can be given at any time of the cycle with condoms used for 7 days. It can be given immediately after an abortion and anytime post-partum, even if breastfeeding, provided menstruation has not returned. If changing from a combined hormonal contraceptive, it can be given at any time if the method has been used correctly. If more than 14 weeks have elapsed since the last injection, the possibility of pregnancy must be ruled out before the next injection is given and alternate contraception used for the following 7 days. There is no evidence of any adverse effects on the foetus, should a pregnancy occur during DMPA use.
Combined oestrogen/progestogen monthly injections (CICs)
There are two very effective combined oestrogen/progestogen monthly CICs available with a failure rate of 0.3 per HWY. CICs have better cycle control than the POIs and there are no restrictions on the basis of age. Contraindications and side effects are the same as for COCs. There is a rapid return of fertility with 65–75% of women ovulating within 2 months of ceasing use. A study of CIC use in adolescents reported a continuation rate of 41% at the end of 12 months. The major problem for adolescents is their ability to schedule regular clinic visits for follow-up injections or adherence to a self-injection schedule.
Progestogen-only subdermal implants
Three implants are available: Norplant and Jadelle with 5-year life span and Implanon with a 3-year life span. A Cochrane review found that there was no difference between Implanon and Norplant in continuation rates or contraceptive effectiveness, with no pregnancies reported.
Implantable methods of contraception offer long-acting highly effective reversible contraception for adolescents but few data exist on use by very young women. One study of 13 adolescent users of Norplant showed continuation rates of 100% at 6 months, 92.5% (12/13) at 12 months and 53.8% (7/13) at 24 months. No pregnancies occurred. The reasons for Norplant selection were its convenience (86%) and problems tolerating the pill (14%). A US retrospective study of 144 Norplant users aged 14–21 years analysed the factors associated with duration of use. Of the 130 Norplant users with follow-up data, 60% reported side effects such as breakthrough bleeding, headache, depression or mood swings. The removal rate was 49% with median duration of use being 29 months. Multivariate analysis indicated that women with at least one prior pregnancy had a twofold increased risk of Norplant removal compared to those who had never been pregnant. Larger studies are needed to identify additional factors associated with long-term use of implantable contraception among young women and to suggest interventions that would improve compliance such as routine follow-up. Counselling adolescents explicitly about side effects will help but adolescents may be less tolerant of frequent or prolonged bleeding.
Implants should be inserted in the first 5 days of menses, immediately post-abortion, any time from 4 weeks post-partum even if breastfeeding. As fertility returns rapidly after removal, if contraception is required, another hormonal method should be started prior to the removal of an implant.
The intrauterine device (IUD)
The IUD provides highly effective low-maintenance long-acting contraception. The copper T 380A has a life span of 10–12 years and the levonorgestrel intrauterine system (LNG IUS) for 5–7 years. Until recently, IUDs have not been advised for adolescents. As increasing data have accumulated about the minimal PID risk of IUDs, both the MEC and the American College of Obstetricians and Gynecologists (ACOG) have approved the use of IUDs from menarche to 20 years. ACOG suggests active encouragement of IUD use as first-line choices for both nulliparous and parous adolescents.
A systematic review of the few studies of IUD use in adolescents concluded that published reports were generally reassuring. Continuation rates at 12 months ranged from 48% to 88% decreasing over time and were similar or better than COC rates but were generally slightly lower than in adult women. Cumulative pregnancy rates increased from 2% at 6 months to 11% at 48 months.
The main concern for IUD use in young women is the risk of PID and subsequent infertility. The risk of PID is greatest in the first 3 weeks after insertion (9.7/1000 WYs). After this, it is 1.4/1000WYs, similar to the rate in non-IUD users and related to presence of an STI, not IUD use. Even when a documented infection is present, the PID rate is 0–5 %. The LNG IUS may provide some protection against PID. Infertility rates are no different in former IUD users than users of other methods.
Contraindications are current pregnancy, active PID or puerperal or post-abortion sepsis within the last 3 months, current STI, purulent cervicitis, undiagnosed abnormal vaginal bleeding, known distortions of the uterine cavity, allergy to any IUD components or Wilson’s disease (copper IUDs).
Insertion of copper devices should be carried out in the first 12 days of the cycle, and LNG IUS in the first 7 days of the cycle or at any time if pregnancy can be reliably excluded. Copper IUDs can be inserted immediately post-abortion or post-delivery or 4–6 weeks later. The LNG IUS can be inserted 4–6 weeks after delivery.
Adolescents should be screened for chlamydia and gonorrhoea and if positive, treated prior to insertion. Screening at the time of insertion expedites use and, if positive, treating the STI with the IUD in situ is effective. Discomfort with IUD insertion is common. In one study, 86% of adolescents reported mild to severe pain but there is no evidence that IUD insertion is technically more difficult in adolescents. Non-steroidal anti-inflammatory drugs (NSAIDs) administration or misoprostol to soften the cervix or use of a paracervical block may lessen discomfort. Perforation rates in all IUD insertions are rare at 0–2.3/1000 insertions and are usually asymptomatic. There are no specific data for adolescent insertions but there is no reason to believe that the rate would be any higher.
IUD expulsion rates in adolescents vary from 5% to 22% over 6–48 months, inversely related to age but not parity. Copper devices increase menstrual flow, duration and cramping, the commonest reasons for discontinuation. Tranexamic acid or NSAIDS are useful in IUD-induced heavy bleeding. The LNG IUS decreases menstrual flow, duration and cramps but causes irregular bleeding and spotting initially and amenorrhoea in at least 25% by 12 months. It is particularly useful in young adolescents with menorrhagia or severe dysmenorrhoea associated with endometriosis.
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