What oral contraceptive medications are recommended for teenagers and for what indications?

Selecting Oral Contraceptives for Teenagers

For healthy adolescents seeking contraception, start with a low-dose monophasic combined oral contraceptive containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate, as these formulations have the most established safety profile and lowest thrombotic risk. 1, 2

First-Line Selection Algorithm

For Standard Contraception

• Prescribe monophasic COCs with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate as the initial choice for most healthy teenagers 1, 2
• Second-generation progestins (levonorgestrel) demonstrate a safer coagulation profile compared to newer progestins, with lower odds ratios for venous thromboembolism 2
• Among low-dose pills, no clear data suggest one formulation is superior for most users, so the lowest copay option on the patient's insurance formulary is often appropriate 2

Initiation Protocol

• Use "quick start" method—begin COCs the same day as the visit in healthy, non-pregnant adolescents 1
• Counsel patients to use backup contraception (condoms or abstinence) for the first 7 days 1
• No pelvic examination is required before initiating COCs 1
• Prescribe up to 1 year of COCs at a time to improve access 2

Indication-Specific Selection

For Acne Treatment

Choose one of four FDA-approved formulations for moderate acne in females ≥14 years who desire contraception: 3

• Norgestimate/ethinyl estradiol 2, 3
• Norethindrone acetate/ethinyl estradiol/ferrous fumarate 2, 3
• Drospirenone/ethinyl estradiol 2, 3
• Drospirenone/ethinyl estradiol/levomefolate 2, 3

These work through anti-androgenic properties by decreasing ovarian androgen production, increasing sex hormone-binding globulin, and reducing free testosterone 2

For Heavy Menstrual Bleeding or Dysmenorrhea

• First choice: Consider levonorgestrel IUD for most effective menstrual suppression without estrogen exposure 4
• Alternative: Low-dose COCs (30-35 μg ethinyl estradiol) provide decreased menstrual cramping and blood loss 1, 4
• Use extended or continuous cycle regimens for teens with heavy bleeding or anemia—eliminate or reduce the hormone-free interval 1, 4
• COCs reduce risk of iron deficiency anemia by decreasing menstrual blood loss 4

For Premenstrual Dysphoric Disorder (PMDD)

• Drospirenone/ethinyl estradiol is FDA-approved for PMDD treatment in females who choose oral contraception 3
• The anti-mineralocorticoid effects of drospirenone may help with bloating and fluid retention symptoms 2, 3
• Effectiveness for PMDD beyond three menstrual cycles has not been formally evaluated 3

For Conditions Exacerbated Cyclically

Extended or continuous cycle regimens are particularly useful for: 1

• Migraine without aura 1
• Epilepsy 1
• Irritable bowel syndrome 1
• Inflammatory bowel disease 1
• Endometriosis 1
• Von Willebrand disease or other bleeding disorders 1, 4

Critical Contraindications

Absolute contraindications—do NOT prescribe COCs if patient has: 1, 2

• Severe uncontrolled hypertension (≥160/100 mm Hg) 1
• Migraines with aura or focal neurologic symptoms 1, 2
• Thromboembolism or thrombophilia (Factor V Leiden, antiphospholipid antibody syndrome, protein C/S/antithrombin deficiency) 1, 2
• Complicated valvular heart disease 1, 2
• Ongoing hepatic dysfunction 1
• Complications of diabetes (nephropathy, retinopathy, neuropathy, vascular disease) 1
• Complicated solid organ transplantation 1
• Age >35 years AND smoking 3

Important caveat: Smoking in adolescents <35 years is NOT a contraindication to COC use, though smoking cessation should be encouraged 2

Safety Considerations by Formulation

Thrombotic Risk Stratification

• Baseline VTE risk in adolescents: 1 per 10,000 woman-years 1
• VTE risk with COCs: 3-4 per 10,000 woman-years 1, 2
• VTE risk in pregnancy: 10-20 per 10,000 woman-years (significantly higher than COCs) 1
• COCs containing ≥35 μg ethinyl estradiol show statistically higher VTE odds ratios than lower doses 2
• Second-generation progestins (levonorgestrel) have safer thrombotic profiles than third/fourth-generation progestins 2

For Patients with Hypertension Concerns

• Drospirenone-containing pills have anti-mineralocorticoid effects that may help mitigate blood pressure increases 2
• Lower doses of ethinyl estradiol minimize potential stroke risk 2
• For patients with specific stroke risk factors, consider progestin-only contraception instead 2

Common Pitfalls and Management

Adherence Optimization

• Seven consecutive hormone pills are required to reliably prevent ovulation—this is critical counseling 1, 2
• Recommend cell phone alarms and support from family members or partners 1
• Schedule follow-up at 1-3 months after initiation to address persistent adverse effects or adherence issues 1

Managing Missed Pills

• Take one missed pill as soon as remembered 1
• If >1 pill missed consecutively, take only the most recently missed pill immediately and continue the rest at usual time 1
• Emergency contraception is indicated if ≥2 pills missed in the first week of the cycle 1

Expected Transient Side Effects

• Counsel patients about common transient effects: irregular bleeding, headache, nausea 1
• Weight gain and mood changes have NOT been reliably linked to combined hormonal contraception 1
• Unscheduled bleeding is the most common adverse effect of extended-cycle regimens but improves over time 1

Drug Interactions

• Rifampin definitively decreases COC effectiveness—use backup contraception 1
• Other antibiotics have NOT been shown to decrease COC effectiveness 1
• COCs decrease effectiveness of lamotrigine 1
• Certain antiretroviral agents (ritonavir-boosted protease inhibitors, nevirapine, efavirenz) can reduce hormonal levels 1, 2

Long-Term Benefits

Prescribing COCs provides significant non-contraceptive health benefits: 1, 2

• Long-term use (>3-4 years) provides significant protection against endometrial and ovarian cancers 1, 2
• COC use does not increase risk of infertility or breast cancer 1
• Decreased menstrual cramping and blood loss 1, 4
• Improvement in acne 1
• Treatment of anemia, endometriosis, and bleeding disorders 1, 4

Essential Counseling Points

• Always emphasize condom use for STI protection regardless of contraceptive method chosen 1, 4
• Routine STI screening is recommended in all sexually active patients 1
• Perfect-use failure rate is 0.3%, but typical-use failure rate is 9% due to adherence issues 1
• COCs are completely reversible with no negative effect on long-term fertility 2