What are the recommended birth control options for pediatric patients?

Birth Control Recommendations for Pediatric Patients

Long-acting reversible contraceptives (LARCs) such as intrauterine devices (IUDs) and implants should be considered first-line contraceptive choices for adolescents due to their superior efficacy, safety, and ease of use. 1

Contraceptive Options for Adolescents

First-Line Options

• LARCs (Long-Acting Reversible Contraceptives)
  • Progestin implants and IUDs have the highest effectiveness with failure rates less than 1% per year 2
  • These methods require no daily adherence, making them ideal for adolescents 1
  • Pediatricians should be able to educate adolescents about these methods or refer to providers who can place them 1

Combined Hormonal Contraceptives

• Combined Oral Contraceptive Pills (COCs)

  • Most popular method among adolescents 1
  • Low-dose pills (35 μg ethinyl estradiol or less) are recommended as first-line options 1
  • Many experts recommend starting with a monophasic pill containing 30-35 μg ethinyl estradiol and a progestin such as levonorgestrel or norgestimate 1
  • No pelvic examination is required before initiating COCs 1
  • Can be started on the same day as the visit ("quick start") 1

• Contraceptive Vaginal Ring

  • Releases 15 μg ethinyl estradiol and 120 μg etonogestrel 1
  • Provides the simplest regimen with comparable effectiveness to COCs 1
  • Typical-use failure rate is approximately 9% 1

Progestin-Only Options

• Depot Medroxyprogesterone Acetate (DMPA)
  • Highly effective with a 0.3% failure rate when used correctly 3
  • Administered every 13 weeks 1
  • May cause menstrual irregularities, which typically improve over time 1
  • Associated with bone mineral density (BMD) reductions, but substantial recovery occurs after discontinuation 1

Management Considerations

Initiation and Follow-up

• Contraceptives can be started on the same day as the visit ("quick start") in healthy, non-pregnant adolescents 1
• Backup method (condoms or abstinence) should be used for at least the first 7 days after starting COCs or other hormonal methods 1
• A follow-up visit 1-3 months after initiating contraception is useful for addressing adverse effects or adherence issues 1

Managing Missed Pills

For combined oral contraceptives, if one pill is missed (<24 hours late):

• Take the missed pill as soon as possible
• Continue taking remaining pills at the usual time
• No additional contraceptive protection needed 1

If two or more consecutive pills are missed (≥48 hours late):

• Take the most recent missed pill as soon as possible (discard other missed pills)
• Continue taking remaining pills at the usual time
• Use backup contraception for 7 consecutive days
• Consider emergency contraception if pills were missed during the first week and unprotected sex occurred in the previous 5 days 1

Special Considerations

• Adolescents with chronic illnesses have similar contraceptive needs to healthy adolescents, but medical conditions may affect contraceptive choices 1
• For adolescents with sickle cell disease, levonorgestrel-releasing IUDs, DMPA, etonogestrel implants, and progestin-only pills are preferred due to increased thrombosis risk 1
• For adolescents who have undergone bariatric surgery, all contraceptive methods are safe except oral contraceptives after malabsorptive procedures 1

Noncontraceptive Benefits

• COCs can provide additional benefits including:
  • Decreased menstrual cramping and blood loss
  • Improvement in acne
  • Extended or continuous cycles for conditions like anemia, severe dysmenorrhea, endometriosis, and abnormal uterine bleeding 1
  • Protection against endometrial and ovarian cancers with use for more than 3 years 1

Important Counseling Points

• Pediatricians should counsel adolescents about all contraceptive methods, describing the most effective methods first 1
• Consistent and correct use of condoms should be encouraged with every act of sexual intercourse for STI protection 1
• Adolescents should be allowed to consent to contraceptive care and control disclosure of this information within limits of state and federal laws 1
• Screening for STIs is recommended in all sexually active patients but does not require a pelvic examination 1

Common Pitfalls to Avoid

• Failing to consider LARCs as first-line options despite their superior effectiveness 1
• Not providing adequate counseling about expected side effects, which can lead to discontinuation 1
• Requiring unnecessary examinations (like pelvic exams) before initiating contraception 1
• Neglecting to address bleeding irregularities, which are a common reason for discontinuation 1

By following these recommendations and considering each adolescent's specific needs, pediatricians can effectively provide contraceptive care that prioritizes both pregnancy prevention and overall health.