Oral Contraceptive Options for a 14-Year-Old
For a 14-year-old adolescent requiring oral contraception, a low-dose combined oral contraceptive (COC) containing 30-35 μg of ethinyl estradiol with levonorgestrel or norgestimate is the most appropriate first-line option. 1
First-Line Recommendation
Combined Oral Contraceptives (COCs)
- Start with a COC containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate
- These provide reliable contraception while minimizing risks
- No pelvic examination is required before starting COCs
- Can be started on the same day as the visit ("quick start")
Rationale for COCs in Adolescents
Efficacy and Safety
- Perfect-use failure rate of 0.3%, typical-use failure rate of 9% 1
- Low-dose COCs (≤35 μg ethinyl estradiol) minimize estrogen-related risks
- The risk of venous thromboembolism increases from 1 per 10,000 to 3-4 per 10,000 woman-years during COC use 1
- This risk is significantly lower than the thromboembolism risk associated with pregnancy (10-20 per 10,000 woman-years) 1
Non-Contraceptive Benefits
- Decreased menstrual cramping and blood loss
- Improvement in acne
- More regular cycles
- Protection against endometrial and ovarian cancers with long-term use 1
Important Counseling Points
Starting COCs
- Use backup method (condoms or abstinence) for at least the first 7 days
- Condoms should be used at all times for protection against STIs 1
- Schedule follow-up visit 1-3 months after initiation to address adverse effects or adherence issues
Common Side Effects
- Irregular bleeding (especially in first few cycles)
- Headache
- Nausea
- These side effects are typically transient 1
Adherence Strategies
- Set daily reminders (cell phone alarms)
- Take pill at the same time each day
- Discuss what to do if pills are missed:
- If <24 hours late: Take pill as soon as remembered
- If 24-48 hours late: Take most recent missed pill and continue pack
- If >48 hours late: Take most recent missed pill, continue pack, and use backup method for 7 days 1
Alternative Options
Progestin-Only Pills
- Option for patients with contraindications to estrogen
- Work primarily by thickening cervical mucus
- Require very stringent adherence (must be taken at same time daily)
- Higher typical-use failure rate than COCs 1
Emergency Contraception
- Should be discussed as a backup option
- Levonorgestrel EC (Plan B) can be taken up to 72 hours after unprotected sex
- Most effective when taken immediately after unprotected intercourse 2
- Can be provided in advance
Special Considerations for Adolescents
Medical Contraindications
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
- Complications of diabetes 1
Stroke Risk Considerations
- Lower-dose estrogen formulations (<50 μg) have significantly lower stroke risk compared to higher-dose formulations 1
- Table 14 from the American Heart Association/American Stroke Association guidelines shows that COCs with ≤20 μg ethinyl estradiol have the lowest stroke risk among combined hormonal methods 1
Follow-up Care
- Schedule follow-up 1-3 months after initiation
- Assess for side effects, adherence issues, and proper use
- Annual follow-up thereafter if no issues arise
- Counsel about importance of consistent use and what to do if pills are missed
By following these guidelines, you can provide effective contraception for a 14-year-old while minimizing risks and maximizing benefits.