What contraception options are recommended for a teenager?

Contraception for Teenagers

Primary Recommendation

All sexually active adolescents should use condoms for STI protection, and for pregnancy prevention, recommend long-acting reversible contraception (LARC) methods—specifically the levonorgestrel IUD or etonogestrel implant—as first-line options due to their superior effectiveness and high continuation rates, with combined oral contraceptives containing 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate as an alternative for those who prefer or require non-LARC methods. 1, 2, 3

Dual Protection Strategy

• Condoms must be recommended to all sexually active teenagers regardless of other contraceptive methods chosen, as they provide essential protection against gonorrhea, Chlamydia, trichomoniasis, hepatitis B, HIV, herpes simplex virus, human papillomavirus, and syphilis 3, 1
• Male latex condoms have a 2% failure rate with perfect use but 18% with typical use, highlighting the importance of counseling on correct and consistent use 3
• Water-based lubricants (K-Y Jelly, Astroglide) should be used with latex condoms, never oil-based products like petroleum jelly, which weaken latex and cause breakage 3

First-Line Contraceptive Options

Long-Acting Reversible Contraception (LARC)

The levonorgestrel IUD is the most effective option for adolescents, with failure rates less than 1% per year and continuation rates ≥75% at 1 year 2, 4, 5

• Provides excellent menstrual suppression without estrogen exposure, making it ideal for teens with heavy menstrual bleeding, dysmenorrhea, or contraindications to estrogen 2
• No negative effect on long-term fertility 2
• Does not require daily adherence, eliminating user-dependent failure 5

The etonogestrel implant offers similar high effectiveness (failure rate <1% per year) and lasts up to 3-5 years depending on the system 4, 5

Combined Oral Contraceptives (COCs)

For teens who prefer or require oral contraceptives, prescribe monophasic COCs containing 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 1, 2

• Second-generation progestins (levonorgestrel) have safer coagulation profiles with lower venous thromboembolism (VTE) risk compared to third/fourth-generation progestins 1
• Baseline VTE risk in adolescents is 1 per 10,000 woman-years; COC use increases this to 3-4 per 10,000 woman-years 1
• Typical-use failure rates for COCs are 4-7% per year, significantly higher than LARC methods 4

Initiation Protocol

• Use the "quick start" method: begin COCs the same day as the visit in healthy, non-pregnant adolescents 1
• Counsel patients to use backup contraception (condoms) for the first 7 days 1
• No pelvic examination is required before initiating contraception 1
• Obtain baseline urine pregnancy test before starting any hormonal method 3

Indication-Specific Selection

Heavy Menstrual Bleeding or Dysmenorrhea

• First choice: levonorgestrel IUD for significant improvement in bleeding and cramping 2
• Alternative: low-dose COCs (30-35 μg ethinyl estradiol with levonorgestrel or norgestimate), particularly extended or continuous cycle regimens 2
• Depot medroxyprogesterone acetate (DMPA) provides improvement in dysmenorrhea and protection against iron-deficiency anemia with convenient 13-week injections 2

DMPA Considerations

• May cause reductions in bone mineral density (BMD), though substantial recovery occurs after discontinuation 2
• Requires counseling about menstrual irregularities to improve continuation rates 2
• Recommend calcium 1300 mg and vitamin D 600 IU daily for teens using DMPA 2

Premenstrual Dysphoric Disorder

• Drospirenone/ethinyl estradiol is FDA-approved for this indication, with anti-mineralocorticoid effects helping with bloating and fluid retention 1

Acne

• COCs provide improvement in acne as a non-contraceptive benefit 1

Absolute Contraindications to COCs

Do not prescribe combined hormonal contraceptives to teens with: 1

• Severe uncontrolled hypertension
• Migraines with aura or focal neurologic symptoms
• History of thromboembolism or thrombophilia
• Complicated valvular heart disease

Progestin-Only Pills (POPs)

• Not typically recommended as first-choice contraceptive in healthy adolescents due to markedly lower effectiveness compared to other progestin-only methods (IUD, implant, DMPA) 3
• Work primarily by thickening cervical mucus, not by inhibiting ovulation 3
• Require strict timing (taken 4-22 hours before coitus) and excellent medication adherence 3
• May be considered for selected adolescent patients with demonstrated excellent adherence who have contraindications to estrogen 3

Emergency Contraception

Advance prescription for emergency contraception should be part of routine adolescent care 3

• Levonorgestrel 1.5 mg (Plan B One-Step) is available over-the-counter for all women of childbearing potential 3
• Take both 0.75 mg tablets at once (easier regimen, equally effective as split dosing) 3
• Estimated 85% effective when used within 5 days of unprotected intercourse, but more effective the sooner it's used 3
• Loses effectiveness in women weighing >165 pounds and is ineffective in women >176 pounds 3
• No teratogenic effects; pregnancy test not necessary before prescribing 3

Ulipristal acetate may have increased effectiveness over levonorgestrel at the end of the 5-day window and in heavier women, but is pregnancy category X 3

Copper IUD insertion within 5 days of unprotected intercourse is also highly effective emergency contraception 3

Non-Contraceptive Health Benefits

COCs provide significant long-term benefits including: 1

• Long-term protection against endometrial and ovarian cancers
• Decreased menstrual cramping and blood loss
• Improvement in acne
• Reduced risk of iron-deficiency anemia 2

Critical Counseling Points

• Emphasize that no contraceptive method except condoms protects against STIs 1
• Discuss typical-use versus perfect-use failure rates to set realistic expectations 3
• Address barriers to access and adherence through provider counseling, sex education, and interventions to improve access 3
• Routine STI screening is recommended for all sexually active adolescents 1
• Hepatitis B and HPV immunization should be offered if not previously completed 3

Common Pitfalls to Avoid

• Do not require pelvic examination before contraceptive initiation—this creates unnecessary barriers to access 1
• Do not prescribe progestin-only pills as first-line when more effective progestin-only methods (IUD, implant, DMPA) are available 3
• Do not overlook weight considerations when prescribing levonorgestrel emergency contraception 3
• Do not forget to counsel about condom use even when highly effective contraception is prescribed 3, 1
• Do not prescribe third or fourth-generation progestins when second-generation options (levonorgestrel) have safer thrombotic profiles 1