Contraception Guidelines

Introduction to Contraception

• The American Academy of Pediatrics recommends that contraception be 91% effective with typical use, resulting in a 9% failure rate 1

Patient Considerations

• Patients with contraindications to estrogen use should be considered for progestin-only methods, which have lower efficacy than combined oral contraceptives (COCs) due to stricter adherence requirements 1
• Progestin-only pills require very stringent adherence and have a higher typical-use failure rate than COCs 1
• The American Academy of Pediatrics suggests that progestin-only pills be prescribed if contraindications to estrogen exist, with consideration of other progestin-only methods (implants, injections) for better efficacy 1

Special Populations

• Patients with sickle cell disease are preferred to use progestin-only methods (implants, injections, progestin-only pills) due to increased thrombosis risk 2
• The American Academy of Pediatrics recommends Long-Acting Reversible Contraception (LARC) methods, including IUDs and implants, as first-line contraceptive choices for adolescents due to their superior efficacy, safety, and ease of use 1
• All contraceptive methods are appropriate for adolescents with obesity, except DMPA, which may cause additional weight gain in this population 1
• The CDC suggests caution when prescribing injectable contraception (DMPA) to adolescents due to potential weight gain 3

Contraceptive Methods

• LARC methods have an effectiveness of 97% with typical use, and options include Depot medroxyprogesterone acetate (DMPA), which has advantages such as no daily adherence required and is a private method 1
• Combined Oral Contraceptives (COCs) have a typical use failure rate of 9% and require daily adherence 1
• The transdermal contraceptive patch (Ortho Evra) and the vaginal ring (NuvaRing) are other options for adolescents, with typical use failure rates similar to COCs 1, 3
• The following table illustrates the stroke risk associated with different doses of ethinyl estradiol:

4

• Lower-dose estrogen formulations (<50 μg) have significantly lower stroke risk compared to higher-dose formulations, with COCs containing ≤20 μg ethinyl estradiol having the lowest stroke risk among combined hormonal methods 4

Contraindications and Precautions

• COCs should not be prescribed for adolescents with severe uncontrolled hypertension (≥160/100 mmHg), ongoing hepatic dysfunction, complicated valvular heart disease, migraines with aura or focal neurologic symptoms, thromboembolism or thrombophilia, or complications of diabetes 1, 3
• The American Academy of Pediatrics recommends choosing a low-dose combined oral contraceptive (COC) with ≤35 μg ethinyl estradiol for adolescents, as it provides excellent contraceptive efficacy and a favorable safety profile 3

Initiation and Management

• No pelvic examination is required before starting COCs, according to the American Academy of Pediatrics 3
• The CDC recommends advising patients to use backup contraception (condoms) for the first 7 days after starting COCs 5, 6
• The American Academy of Pediatrics suggests prescribing up to 1 year of COCs at the initial visit and scheduling a follow-up visit 1-3 months after initiation to address any side effects or adherence issues 3
• The American Academy of Pediatrics recommends explaining common transient side effects (irregular bleeding, headache, nausea) that typically resolve within 3 months and emphasizing the importance of taking pills at the same time each day 3

Emergency Contraception and STI Prevention

• Emergency contraception, such as levonorgestrel EC (Plan B), can be taken up to 72 hours after unprotected sex and is most effective when taken immediately after unprotected intercourse 7
• Condoms should be used in addition to hormonal contraception to protect against STIs, and a backup method (condoms or abstinence) should be used for the first 7 days after starting a new contraceptive method 1, 3
• Be aware of medications that may decrease COC effectiveness, including rifampin, certain anticonvulsants (e.g., carbamazepine, phenytoin), and some antiretroviral drugs, as reported by the American Academy of Pediatrics 1
• Most broad-spectrum antibiotics do not affect COC effectiveness, according to the American Academy of Pediatrics 1