Contraception:

INTRODUCTION The pregnancy and abortion rates among adolescents in the United
States are higher than in other industrialized nations as a result of intermittent, improper, and
lack of use of contraception [ 1,2 ].
This topic review will provide an overview of issues related to the provision of contraceptive
services to adolescent females. The various types of hormonal contraception and the risks and
benefits of these methods are discussed separately. (See "Overview of contraception" and
"Emergency contraception" and "Risks and side effects associated with estrogen-progestin
contraceptives" .)
NATIONAL DATA ON CONTRACEPTION IN TEENAGERS According to the National
Survey of Family Growth (2006-2008), among never-married teenagers, 79 percent of females
and 87 percent of males used a method of contraception at first sex, and 96 percent reported ever
using a contraceptive method [ 3 ]. With a few exceptions, teenagers' use of contraceptives has
changed little since 2002. The condom remained the most commonly used method (95 percent),
followed by the withdrawal method (58 percent) and the oral contraceptive pill (55 percent). The
use of highly effective hormonal injectables, mainly depot medroxyprogesterone, remained
stable (17 percent). One exception was an increase in the use of condoms and the use of a
condom combined with a hormonal contraceptive (dual method use) reported by males. Another
exception was an increase in the percent of female teenagers who had ever used periodic
abstinence, or the "calendar rhythm" method. In addition, female teenagers reported using a
wider array of hormonal methods than was reported in previous years (17 percent had ever used
emergency contraception, 11 percent the contraceptive patch, and 7 percent the vaginal ring).
DEVELOPMENTAL FACTORS Adolescents vary in their ability to implement various
types of contraception. From a developmental perspective, sexually active girls in early
adolescence have difficulty planning events and activities; they often have an idealistic point of
view, think about situations in a concrete or literal way, and live in the moment. Thus,
implementing a contraceptive method that requires planning and forethought to prevent the
possibility of pregnancy is difficult at this age without monitoring and adult support. Girls in
middle and late adolescence are more capable of higher-level planning, decision making, and
problem solving, skills essential to effective contraceptive behavior [ 4,5 ]. (See "Adolescent
sexuality", section on 'Adolescent development' and "Overview of contraception" .)
MOTIVATING FACTORS The sexually active adolescent is more likely to seek
contraception if she [ 2,5 ]:

Perceives pregnancy as a negative outcome

Has long-term educational goals
Is older
Experiences a pregnancy scare or actual pregnancy
Has family, friends, and/or a clinician who sanction the use of contraception

Adolescents are more likely to use condoms if they understand condoms can prevent HIV/AIDS,
if they carry condoms and are not embarrassed to use them, and if they are worried about getting
AIDS [ 6 ].
OVERCOMING BARRIERS Barriers that impede the adolescent's access to contraception
services should be recognized and removed when possible. Issues that adolescent females may
perceive as barriers to the initiation of contraception include the lack of access to confidential
services and the fear of undergoing a pelvic examination. They also may have concerns about
side effects of hormonal contraception. Ambivalence and indecision to take action despite
information can also be barriers in and of themselves.
Confidentiality The clinician should recognize and respect the adolescent's need for privacy
as a basic premise for providing confidential services. This goal can be achieved by facilitating a
relationship with the adolescent that is independent of the relationship with her parents.
The adolescent should be given an opportunity to provide her medical history and to obtain
gynecologic and sexual information directly from the clinician. The parents and the adolescent
may need education regarding the emphasis on direct interaction with the adolescent as part of
adolescent health care. This approach differs from that used when the child is younger and
communication occurs primarily between the clinician and the parents. (See "Confidentiality in
adolescent health care" .)
As an example, the following statement may be made to an accompanying parent or guardian: "I
would like to make this visit a positive experience for your daughter. It is important to respect an
adolescent's privacy as a normal part of her growing up. I would first like to have the opportunity
to review health information with you, followed by reviewing health information with your
daughter alone. Usually, whatever is discussed between my teenage patients and me is
confidential, except in certain situations, such as if she has thoughts of suicide, thoughts of
physically harming someone, or reports she has been or is being physically or sexually abused. If
you feel you need to know more about what she and I have discussed, I strongly encourage you
and your daughter to talk to each other directly."
The age of the adolescent is a factor in whether she will choose the option of complete
confidentiality. A young teenager may express a preference to have her mother present
throughout the office visit, particularly when the mother is aware of the teenager's sexual
behavior and is the one who desires the teenager to use a contraceptive method. Despite such a
situation, encouraging some independent time with the adolescent is important to obtain a more
detailed history about other possible high-risk behaviors. (See "Confidentiality in adolescent
health care" and "Adolescent sexuality", section on 'Confidentiality' and "Guidelines for
adolescent preventive services", section on 'Strategy for provision of adolescent preventive
services' .)
The clinician who is not comfortable providing confidential contraceptive services to a minor
should provide names and phone numbers of other clinicians or free clinics skilled in providing
this care to adolescents.

Legal issues A minor's right to access contraceptive services in a health care setting without
parental involvement varies from state to state. The need for parental consent also may be related
to state or federal funding for contraceptive services in local clinics. Thus, a clinician should
become familiar with the rulings in his or her own state and local clinic protocols. (See "Consent
in adolescent health care" and "Confidentiality in adolescent health care" .)
Pelvic examination Many adolescents perceive the pelvic examination to be a barrier to
accessing contraceptive services [ 6 ]. The first pelvic examination is a milestone for the
adolescent. It needs to be a positive experience to foster communication on sensitive topics
between the adolescent and her health care providers.
Pelvic examination is not required by the Food and Drug Administration (FDA) for the initiation
or reinstitution of oral contraceptives (OCs) [ 6,7 ]. The package insert for OCs states: "Physical
examination may be deferred until after initiation of oral contraceptives if requested by the
woman and judged appropriate by the clinician" [ 6 ].
Deferral of pelvic examination may be considered at the first visit if the teenager has no genital
complaints (eg, abnormal vaginal discharge, pruritus, odor, etc) and:

She has avoided going to a clinic or clinician's office out of fear of a pelvic examination,
or
She is having her menstrual period during the visit, or
Scheduling an appointment for initiating contraception involves a long delay because of
the time allocated for complete physical and pelvic examination

Teenagers appreciate that they have a choice in this matter. Subsequent performance of the
pelvic examination may be facilitated by making an effort to alleviate fears related to the
adolescent's perception of the pain and embarrassment she thinks she will suffer from the
procedure [ 7 ]. With appropriate education, one program found that among teenagers who
deferred the pelvic examination for the situations cited by the FDA, 69 percent returned for the
pelvic examination at the three-month visit and 78 percent by the six-month visit [ 6,8 ].
Although pelvic examination is not required for the initiation or reinstitution of oral
contraceptives, and initiation of cervical cancer screening has been postponed to age 21 years,
speculum and bimanual examination may be necessary to test for sexually transmitted infections
(STI) if urine tests are not available. (See "Screening for cervical cancer: Rationale and
recommendations", section on 'Starting age' and "Sexually transmitted diseases: Overview of
issues specific to adolescents", section on 'Evaluation' .)
Some clinicians offer their adolescent patients the option of having the parent, partner, or a
friend present for support during the examination. If this option is offered, it is important to
recognize the adolescent may prefer to have the examination alone but feels obligated to allow
her mother or partner to be present for the procedure. In any patient in whom signs of physical
trauma are noted, the adolescent should be interviewed alone to elicit a history of possible
physical or sexual abuse. (See "Evaluation of sexual abuse in children and adolescents" .)

Fear of side effects A fear of side effects is a common barrier to the use of hormonal
contraception. In one review, adolescents in a private practice setting were concerned about
weight gain, and those in an urban hospital-based adolescent clinic were concerned about weight
gain, blood clots, birth defects, and infertility [ 9 ].
Weight gain Many adolescents are concerned that oral estrogen-progestin contraceptives
cause weight gain. However, available data suggest this is not the case. Adolescents should be
reassured that oral contraceptive use does not result in an increase in body weight or percent
body fat over that seen in nonusers [ 9-11 ]. (See "Risks and side effects associated with
estrogen-progestin contraceptives", section on 'Weight' .)
Adolescents also are concerned about weight gain from depot medroxyprogesterone acetate
(DMPA). Although weight gain and DMPA use may be concomitant events, a causal
relationship has not been established; factors other than DMPA may contribute to weight gain [
12,13 ]. (See "Depot medroxyprogesterone acetate for contraception", section on 'Weight
changes' .)
Bone density DMPA and ultra-low-dose estrogen (20 mcg) pills may interfere with achieving
optimal peak bone mass in young adolescent women by causing loss in bone density or
interference with the increase in bone mass during a time of expected bone accretion [ 14-20 ].
(See "Normal puberty", section on 'Relation between pubertal events and bone growth' .)
Rare cases of osteoporosis, including osteoporotic fractures, have been reported in patients
taking DMPA, and the prescribing information for DMPA includes a warning that DMPA should
be used as a long-term birth control method (eg, longer than two years) only if other birth control
methods are inadequate [ 21 ]. (See "Depot medroxyprogesterone acetate for contraception" .)
It is important to review information regarding DMPA and bone density with adolescents. The
general opinion is that, if possible, DMPA should be avoided in a girl during early adolescence.
However, the data are not sufficient to limit the use of the transdermal patch in adolescents, nor
are they sufficient to limit the use of DMPA in older adolescents. In fact, some experts argue that
for adolescents in whom DMPA is the only acceptable contraceptive option, the benefit of
pregnancy prevention outweighs the potential risk to bone health [ 22-24 ]. A biological,
behavioral, and environmental risk assessment can facilitate optimal clinical decision-making to
prevent unintended pregnancy ( table 1 ). (See 'Clinician concerns' below.)
The Society for Adolescent Health and Medicine has published a position paper regarding the
black box warning for DMPA [ 25 ]. The position paper suggests that:

With adequate explanation of benefits and potential risks, DMPA may continue to be
prescribed to adolescent girls who need contraception.
Decisions regarding bone density monitoring of adolescents using DMPA for
contraception should be individualized; the decisions should be made by the clinician in
concert with the adolescent, and potentially the adolescent's guardian.
Duration of use of DMPA need not be restricted to two years.

Adolescents using DMPA should be encouraged to take 1300 mg of elemental calcium

and 400 international units vitamin D and to exercise each day. Calcium and vitamin D
supplements are available separately in tablet form or combined in a single tablet. (See
"Calcium requirements in adolescents" .)
Estrogen supplementation should be considered for girls who are doing well on DMPA
and have osteopenia or are at risk for osteopenia and who have no contraindications to
estrogen.

The effects of DMPA on bone density are discussed in greater detail separately. (See "Depot
medroxyprogesterone acetate for contraception" .)
Thromboembolism Low-dose estrogen-progestin contraceptives are associated with a modest
increase in the risk of venous thromboembolism (VTE). The association between estrogenprogestin contraceptives and risk of VTE appears to be related to the dose of estrogen and the
type of progestin. Even low-dose estrogen-progestin contraceptives (30 to 50 mcg estrogen) can
be associated with a modest increase (three- to sixfold) in the risk of VTE. Estrogen-progestin
contraceptives containing third-generation progestins also may be associated with a slight
increase in risk of VTE. (See "Risks and side effects associated with estrogen-progestin
contraceptives", section on 'Venous thromboembolic disease' .)
The prescribing information for the transdermal patch includes a warning regarding the possible
increased risk of thrombotic events related to a higher-than-average circulating estrogen level.
The risk of thromboembolism with the transdermal patch is discussed separately. (See
"Transdermal contraceptive patch", section on 'Major adverse events' .)
The risk of VTE with estrogen-progestin contraceptives should be considered in relation to the
risk of VTE during pregnancy. The risk of VTE may be 3- to 10-fold higher in pregnant than in
nonpregnant women. (See "Deep vein thrombosis and pulmonary embolism in pregnancy:
Epidemiology, pathogenesis, and diagnosis" and "Deep vein thrombosis and pulmonary
embolism in pregnancy: Prevention" .)
Nonetheless, it is important to take a careful personal and family history of deep venous
thrombosis to identify those adolescent women who might be at high risk before prescribing an
estrogen-progestin contraceptive (eg, those who have antiphospholipid antibodies or nephrotic
syndrome). (See "Contraception for women with inherited thrombophilias" .)
PID The relationship between oral contraceptives (OCs) and pelvic inflammatory disease
(PID) is complex. Whereas some studies indicate that the use of OCs increases the risk of PID,
others suggest that OCs increase the risk for cervicitis and endometritis, but not salpingitis,
thereby decreasing the severity of PID. (See "Pathogenesis of and risk factors for pelvic
inflammatory disease", section on 'Oral contraceptives' .)
No association between DMPA and increased risk of PID has been reported [ 26 ].
The intrauterine device (IUD) itself does not increase the risk for PID. However, the use of an
IUD may increase the risk of STIs, which secondarily increases the risk of PID [ 27,28 ]. (See

"Pathogenesis of and risk factors for pelvic inflammatory disease", section on 'Intrauterine
device and tubal ligation' and "Management of problems related to intrauterine contraception",
section on 'Infection' .)
Other effects Other side effects from estrogen-progestin contraceptives that may be of
concern to adolescents include birth defects and infertility. However, there is no evidence to
support these associations [ 9,29 ]. It is important to dispel such misconceptions when discussing
contraceptive methods with adolescent patients.
Clinician concerns Clinicians may be concerned about the long-term effects of initiating
hormonal contraception in adolescents who have recently achieved menarche. One concern is the
potential for decrease in bone density with DMPA or ultra-low-dose (20 mcg) combination OCs
because the accretion of bone mass during puberty serves as a bone bank for the remainder of
life. (See "Calcium requirements in adolescents", section on 'Bone growth during puberty' .) The
effects of DMPA on bone density are discussed separately. (See "Depot medroxyprogesterone
acetate for contraception" .)
Biological, behavioral, and environmental factors ( table 1 ) can assist with clinical decisionmaking when there is concern about the long-term effects of initiating hormonal contraception in
young adolescents. Biologic risks include baseline factors that may increase the risk for or
exacerbate potential adverse effects of hormonal contraception (eg, incomplete growth,
decreased bone density, etc) The behavioral and environmental risk assessment should include
psychologic and psychiatric factors that may influence the adolescents decision making and the
parents ability to monitor the adolescent (eg, learning disability, substance use, self-esteem, selfefficacy, living situation, lack of knowledge of teenagers whereabouts, etc). In general, the risks
of pregnancy in a young teenager with behavioral and environmental risk factors exceed the risks
of hormonal contraceptives, particularly when the parent is unable to monitor the adolescent.
INITIATION OF CONTRACEPTION It is important to gain the adolescent's trust, value her
opinion, and obtain her consent before initiating contraception.
History A careful history should be obtained before helping the adolescent to select a
contraceptive method. Information from the history will facilitate counseling regarding any
absolute or relative contraindications to starting an estrogen-progesterone product. (See "Risks
and side effects associated with estrogen-progestin contraceptives" and "Overview of
contraception" and "Counseling women considering combined hormonal contraception" .)
Counseling Several points should be discussed during contraceptive counseling:

Selecting the best method based on effectiveness, frequency of use, and convenience (
figure 1 ); the American College of Obstetricians and Gynecologists (ACOG)
recommends that long-acting reversible contraception (LARC), including the
etonogestrel implant and intrauterine devices (copper and levonorgestrel ) are the most
effective methods at preventing unintended pregnancy [ 30 ]
Risk of side effects
Tips on adherence (see 'Increasing adherence' below)

Use of condoms to protect against sexually transmitted infections (STIs)

Practical suggestions to promote use, such as keeping condoms in a purse
The availability of and indications for emergency contraception (see "Emergency
contraception" )

Sometimes an adolescent is sexually active and does not desire a pregnancy but is undecided
about starting a method. In these cases, the discussion should raise her awareness of her risk of
pregnancy and STIs. Reviewing stories of her sister(s), friends, or peers at school who are teen
mothers may be helpful. In addition, review of short-term educational goals may be helpful (eg,
preventing an unintended pregnancy over the next one year until she graduates from high
school). Girls who are not engaging in sexual activity also should be educated about the use of
condoms and emergency contraception, in case their status changes [ 31 ].
In other cases, a nervous mother or grandmother may desire reliable hormonal contraception for
her daughter or granddaughter who is not yet sexually active. The adolescent may have
demonstrated an interest in boys and/or may have an older sister who is a teenage mother. In
these cases, the clinician should have an open discussion with the adolescent and the parent
regarding parental fears, trust, and parent monitoring skills (See 'Clinician concerns' above.)
Finally, the pros and cons of starting hormonal contraception should be considered against the
risk of pregnancy. (See "Pregnancy in adolescents", section on 'Outcome' and "Sexually
transmitted diseases: Overview of issues specific to adolescents", section on 'Risk factors' .)
Adverse effects The anticipated side effects from hormonal contraception should be
reviewed. Breakthrough bleeding or amenorrhea from oral contraceptives (OCs), depot
medroxyprogesterone acetate (DMPA), and the transdermal patch can be upsetting. These
methods are likely to be discontinued unless the adolescent has been counseled about potential
problems and their treatment [ 32 ]. (See "Risks and side effects associated with estrogenprogestin contraceptives" .)
A rash and itching at the application site may be of concern to adolescents using the transdermal
patch. Partial or complete detachment of the transdermal patch was reported in 35 percent of
adolescents in one study [ 33 ], compared with <5 percent in adults [ 34,35 ]. No detachments
were reported when the patch was worn on the arm. The likely explanation may be inadequate
care in application and increased activity among teenagers compared with adults.
Benefits Reviewing the noncontraceptive benefits of OCs, DMPA, and the transdermal patch
with adolescents also is important. Benefits of OCs and the transdermal patch may include
improved bone density and protection against ovarian cancer, endometrial cancer, salpingitis,
ectopic pregnancy, benign breast disease, dysmenorrhea, and iron deficiency [ 2 ]. The same
benefits, with the exception of improved bone density, are provided by DMPA. (See "Overview
of the use of estrogen-progestin contraceptives", section on 'Noncontraceptive benefits' and
"Depot medroxyprogesterone acetate for contraception", section on 'Benefits' .)
Informed consent Although it is not necessary to obtain written informed consent before the
initiation of hormonal contraception in adolescents, the use of a structured informed consent

form can ensure that the risks and benefits are adequately discussed. The form used by Texas
Children's Hospital for combination hormonal contraceptives is provided as an example ( table 2
).
INCREASING ADHERENCE Adolescents who are initiating contraception should be given
an easy-to-read list that includes the clinic's name, a contact person, phone number, and
instructions about what to do if they miss a dose. They should not rely on their friends or family
for information if they have a problem with their medication. Strategies to increase contraceptive
adherence among adolescent females are summarized in the table ( table 3 ).
Hormonal contraception
Oral contraceptives Common examples of adherence problems with oral contraceptives
(OCs) include not refilling prescriptions, forgetting to take the pill, starting the next pack late,
using pills sporadically, and not using a backup method when needed. In one study, 33 percent of
adolescents missed a pill in the previous three months [ 9,36 ]. Therefore, the adolescent should
be provided clear verbal and written instructions. The clinician should ascertain that she has
sufficient reading skills to interpret labels and instructions. Demonstrating the instructions with
the actual pill pack (if possible) or a sample pack can also help with compliance.
To optimize adherence with OCs, an adolescent should be told only three things to remember:

When to start the pill

Take the pill every day at the same time, especially when doing something else regularly,
like teeth brushing
Call the clinic/office if there are any questions

She should be asked to repeat these three instructions to assess and promote her understanding of
them. In addition, she should be given an easy-to-read list stating the clinic's name, a contact
person, phone number, and instructions for when she misses pills.
OCs can be started at any time. In adolescents, they are typically started on the first day of the
next menstrual period or the Sunday after the onset of the menstrual period ("Sunday start
method"). The rationale for this delayed start date is to make sure that the adolescent is not
pregnant. However, as many as 25 percent of adolescents who seek OCs from family planning
clinics never take the first pill [ 37,38 ]. Failure to begin the pill may occur due to ambivalence,
confusion about starting instructions, or intervening pregnancy.
To address this issue, a "same day" or "Quick Start" method is now the preferred approach [ 39 ].
The Quick Start method requires increased attention to the adolescent's self-report of sexual
activity since her last menstrual period, the accuracy of the pregnancy test in the context of her
sexual history, and the use of emergency contraception when applicable ( algorithm 1 ). (See
"Overview of contraception", section on 'Initiation and administration of combined OCs' .)
Extended-cycle or continuous pill use The desire to avoid monthly periods may be related to
participation in athletic events or summer camps, or to the general discomfort and "hassle" of

monthly periods. A schedule that involves continuous pill use for 84 days followed by a week of
pill-free days may help to increase adherence in adolescents who wish to avoid a monthly period.
In addition, an oral contraceptive that provides continuous, year-round contraception has been
approved by the FDA. It contains levonorgestrel 90 mcg and ethinyl estradiol 20 mcg.
Until studies are conducted in adolescents, information on extended-cycle and continuous, yearround pills must be drawn from studies and clinical experience in adults. One-half to two-thirds
of adult women report a decrease in breakthrough spotting or bleeding (BTB) in the second half
compared with the first half of the extended or year-long regimen [ 40,41 ]. To manage BTB, a
three-day, hormone-free interval was more beneficial than continuous pills [ 40 ].
A systematic review of continuous use of oral contraceptives in adult women found that other
menstrual symptoms, including headaches, genital irritation, tiredness, bloating, and
dysmenorrhea also improved with extended-cycle pill use [ 42 ].
When extended-cycle pill use is prescribed, the adolescent should be warned that there may be
spotting and bleeding during the initial cycles, but this should decrease with prolonged use. If
marked BTB occurs, a three-day, hormone-free interval should be instituted and then one pill a
day resumed. (See "Overview of the use of estrogen-progestin contraceptives", section on
'Continuous pill' and "Hormonal contraception for suppression of menstruation" .)
DMPA The first shot of depot medroxyprogesterone acetate (DMPA) is typically given
during the menstrual period to ensure absence of pregnancy. Alternatively, DMPA can be
administered according to the Quick Start method ( algorithm 1 ) [ 43 ]. (See "Depot
medroxyprogesterone acetate for contraception", section on 'Timing of injections' .)
Adolescents taking DMPA should be given an appointment date for the next shot and, as for
adolescents taking oral contraceptives, an easy-to-read list stating the clinic's name, a contact
person, a phone number, and instructions if the scheduled dose is delayed.
Transdermal patch The fact that the transdermal patch does not require daily attention makes
it an attractive option for adolescents. However, the need for weekly change also may promote
decreased adherence.
The transdermal patch can be initiated according to the Quick Start method ( algorithm 1 ). (See
"Transdermal contraceptive patch", section on 'Initiation' .)
Strategies to promote weekly changes should be reviewed with adolescents using the transdermal
patch. These include using a wall, computer, or cell phone calendar; a cell phone weekly alarm;
or a sticker designating the change day on the bathroom mirror.
Vaginal ring The vaginal ring is an attractive option for some adolescents because it only
needs to be changed every three weeks. However, use of the vaginal ring requires that the
adolescent be comfortable inserting the ring in the vaginal canal; adolescents who use tampons
during menses may be more comfortable with this procedure. (See "Overview of contraception"
.)

For maximum effectiveness, the ring should not be removed from the vagina for more than three
hours during the three-week period. However, anecdotal evidence suggests that some adolescents
do not feel "clean" with the vaginal ring and have a need to wash it frequently. Frequent washing
decreases effectiveness and may cause intermittent bleeding or spotting.
Contraceptive implants The American College of Obstetricians and Gynecologists
recommends that the contraceptive implant be considered a first-line method (along with the
intrauterine device [IUD]) to prevent unintended pregnancy in adolescents [ 30 ]. Etonogestrel , a
single-rod implant containing the progestin etonogestrel, lasts three years and is available in the
United States. This contraceptive implant is potentially an attractive option for adolescents and
adolescent mothers who desire long-term, uninterrupted contraception. It provides pregnancy
protection within 24 hours, and fertility returns quickly after removal of the implant. (See
"Overview of contraception", section on 'Contraceptive implants' and "Etonogestrel
contraceptive implant" .)
Barrier contraception
Condoms Girls planning to use condoms should receive them before leaving the office or
clinic, if possible, to ensure availability and promote adherence [ 4 ].
Intrauterine device The American College of Obstetricians and Gynecologists recommends
that the IUD be considered a first-line method (along with the etonogestrel implant) to prevent
unintended pregnancy in adolescents [ 30 ]. Although a parous adolescent may be a better
candidate for the IUD than a nulliparous adolescent (because higher expulsion rates have been
reported in nulliparous adolescents), the risks and benefits of IUD for an adolescent must be
determined on a case-by-case basis (see "Overview of intrauterine contraception", section on
'Adolescents' ). The World Health Organization suggests [ 27,28,30 ]:

The IUD is an unacceptable risk in a woman with pelvic inflammatory disease (PID) or
purulent cervicitis currently or in the past three months.
The risks outweigh the advantages of inserting an IUD in a woman with multiple partners
or a partner with multiple partners.
There is no restriction on IUD placement when there is a past history of PID and no
current sexually transmitted infection.

Intrauterine contraception devices are discussed in detail separately. (See "Overview of

intrauterine contraception" .)
CONTINUATION RATES A systematic review of hormonal and intrauterine methods of
contraception in young women found limited data about continuation rates [ 44 ]. In a
prospective study that was not included in the systematic review, 12-month continuation rates
among 1099 urban adolescents (age 14 to 19 years of age) who were provided with contraception
at no cost were as follows [ 45 ]:

Levonorgestrel intrauterine system (n = 330) 81 percent

Copper intrauterine device (n = 55) 76 percent

Etonogestrel implant (n = 378) 82 percent

Depot medroxyprogesterone acetate (n = 112) 47 percent
Oral contraceptives (n = 146) 47 percent
Contraceptive patch (n = 21) 41 percent
Vaginal ring (n = 57) 31 percent

Continuation rates were greater among adolescents who used long-acting reversible
contraception (ie, levonorgestrel intrauterine system, copper intrauterine device, or etonogestrel
implant) than other methods (84.7 versus 44 percent).
SPECIAL CIRCUMSTANCES
The mentally handicapped adolescent The mentally handicapped adolescent has access to
contraception under the supervision of a parent or guardian. The availability of depot
medroxyprogesterone acetate (DMPA) given every three months, the transdermal patch, and
continuous oral contraceptives with withdrawal bleeding every three months has significantly
increased access to more convenient hormonal contraception, improved adherence, and made
menstrual hygiene issues easier.
In most states, following an evaluation by three clinicians and acquisition of parental consent, a
mentally handicapped adolescent has access to permanent sterilization after 21 years of age. In
some states, in special circumstances such as an ambulating, profoundly mentally handicapped
adolescent, sterilization of a mentally handicapped adolescent younger than 21 years of age may
be approved after a process involving a review by an ethics committee and/or a court system [ 46
].
The chronically ill adolescent Hormonal contraception for the chronically ill adolescent can
be a challenge. Estrogen-based hormonal contraceptives, as an example, should not be offered to
an adolescent with significant valvular disease who is not being treated with an anticoagulant.
Although DMPA is useful in such cases, its effect on fluid retention should be evaluated and
monitored. (See "Risks and side effects associated with estrogen-progestin contraceptives",
section on 'Cardiovascular disease' and "Depot medroxyprogesterone acetate for contraception"
.)
Similarly, estrogen-based hormonal contraceptives should not be offered to an adolescent with
antiphospholipid antibody abnormalities, uncontrollable hypertension, and vascular involvement.
DMPA is useful in such cases; there have been no reports of systemic lupus erythematosus flares
with long-term DMPA use. (See "Risks and side effects associated with estrogen-progestin
contraceptives", section on 'Venous thromboembolic disease' .)
In addition, multiphasic or ultra-low oral estrogen-progestin contraceptives are not recommended
in adolescents taking many anticonvulsants because anticonvulsants other than valproic acid
increase the clearance of sex steroids. DMPA is a good alternative because progesterone levels
are high enough to be unaffected by increased P-450 activity [ 47 ]. (See "Overview of the use of
estrogen-progestin contraceptives", section on 'Anticonvulsants' .)

Medications that alter the effectiveness of estrogen-based hormonal contraceptives by increasing

clearance of sex steroids include rifampin , griseofulvin , and anticonvulsants. Herbal medication
such as St. John's Wort also can increase clearance of sex steroids. There are inadequate data to
support any significant drug interaction between common antibiotics and estrogen-based
hormonal contraceptives. (See "Overview of the use of estrogen-progestin contraceptives",
section on 'Drug interactions' .)
It is important to review the choice of hormonal contraceptives in the context of the chronic
illness, potential increase in estrogen-related complications, and drug interactions during the
counseling process. The risk of pregnancy needs to be weighed against the risk of a medical
complication from hormonal contraception. In addition, emergency contraception should be
discussed with adolescents whose current treatment may be teratogenic to the fetus or in whom
pregnancy would severely compromise health [ 48 ]. (See "Emergency contraception" .)