Starting Oral Contraceptives in Teenagers
First-Line Recommendation
Begin with monophasic combined oral contraceptives (COCs) containing 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate, as these formulations have the safest thrombotic profile and established effectiveness in adolescents. 1, 2, 3
Pre-Initiation Requirements
No pelvic examination is required before prescribing oral contraceptives to teenagers. 1 The only necessary assessments include:
- Blood pressure measurement to rule out severe uncontrolled hypertension (≥160/100 mm Hg) 1
- Pregnancy screening (urine or serum) 1
- Screening for absolute contraindications through history alone 1
Absolute Contraindications to COCs
Do not prescribe COCs to teenagers with: 1, 4
- Migraines with aura or focal neurologic symptoms
- History of thromboembolism or known thrombophilia
- Severe uncontrolled hypertension (≥160/100 mm Hg)
- Complicated valvular heart disease
- Active or chronic hepatic dysfunction
- Complications of diabetes (nephropathy, retinopathy, neuropathy, vascular disease)
Smoking is NOT a contraindication to COC use in teenagers under age 35. 1, 4
Quick Start Protocol
Initiate COCs the same day as the clinic visit in healthy, non-pregnant adolescents. 1, 2, 3 This "quick start" method removes barriers to contraceptive access and improves adherence. 1
Backup Contraception Requirements:
- Use condoms or abstinence for the first 7 consecutive days after starting COCs 1, 2, 3
- This 7-day window is critical because it takes this long to reliably suppress ovulation 4
Dual Protection Strategy
All sexually active teenagers must use condoms in addition to oral contraceptives, regardless of the contraceptive method chosen. 2, 3 This dual protection approach is essential because:
- COCs provide zero protection against sexually transmitted infections 2, 3
- Male latex condoms have an 18% typical-use failure rate but protect against STIs 2
- Routine STI screening should be performed in all sexually active adolescents 3
Prescribing Duration and Follow-Up
Prescribe up to 12 months of COCs at the initial visit. 1 This CDC recommendation reduces barriers to continuation and improves adherence. 1
Schedule a follow-up visit 1-3 months after initiation to address: 1
- Adverse effects (irregular bleeding, headache, nausea)
- Adherence challenges
- Questions or concerns
Formulation Selection Algorithm
Step 1: Standard Healthy Teenager
Prescribe monophasic COCs with 30-35 μg ethinyl estradiol + levonorgestrel or norgestimate. 1, 2, 3 Second-generation progestins like levonorgestrel have the safest coagulation profile with lower venous thromboembolism risk compared to newer progestins. 3, 4
Step 2: Heavy Menstrual Bleeding or Dysmenorrhea
Consider levonorgestrel IUD as first-line, or use low-dose COCs as an alternative. 2, 3 The levonorgestrel IUD provides superior menstrual suppression without estrogen exposure and has <1% failure rates. 2
Step 3: Acne or Hirsutism
Prescribe COCs with anti-androgenic progestins (norgestimate, desogestrel, or drospirenone). 4 Four FDA-approved formulations exist specifically for acne treatment in women desiring contraception. 4
Step 4: Premenstrual Dysphoric Disorder
Use drospirenone/ethinyl estradiol, which is FDA-approved for PMDD and has anti-mineralocorticoid effects that help with bloating and fluid retention. 3, 4
Critical Safety Counseling
Venous Thromboembolism Risk
The baseline VTE risk increases from 1 per 10,000 woman-years to 3-4 per 10,000 woman-years with COC use. 1, 3, 4 This is still significantly lower than pregnancy-related VTE risk of 10-20 per 10,000 woman-years. 1, 4
Typical vs. Perfect Use
COCs have a 9% typical-use failure rate in adults, which may be higher in adolescents due to adherence challenges. 1, 5 Counsel teenagers that:
- Perfect use requires taking the pill at the same time every day 1
- Missing pills significantly increases pregnancy risk 6
- Backup contraception is needed after missed pills 6
Missed Pill Instructions
One White (Active) Pill Missed:
Take the missed pill as soon as remembered; no backup needed. 6
Two Consecutive Pills Missed (Week 1 or 2):
Two Consecutive Pills Missed (Week 3) or Three or More Pills Missed:
- Continue taking 1 pill daily until Sunday (for Sunday start) 6
- Discard the rest of the pack and start a new pack 6
- Use backup contraception for 7 days 6
Drug Interactions
Certain medications reduce COC effectiveness and require alternative dosing or methods: 1, 4
- Anticonvulsants (except lamotrigine, levetiracetam, valproic acid) 1
- Ritonavir-boosted protease inhibitors, nevirapine, efavirenz 4
- Rifampin (but NOT other broad-spectrum antibiotics) 1
Non-Contraceptive Benefits
Long-term COC use (>3 years) provides significant health benefits: 2, 3, 4
- Protection against endometrial and ovarian cancers
- Decreased menstrual cramping and blood loss
- Reduced risk of iron-deficiency anemia
- Improvement in acne
- Treatment of dysmenorrhea and endometriosis
Common Pitfalls to Avoid
Do not require a pelvic exam before prescribing COCs - this creates an unnecessary barrier to contraceptive access. 1
Do not withhold COCs from smokers under age 35 - smoking is not a contraindication in this age group. 1, 4
Do not prescribe formulations with >35 μg ethinyl estradiol - higher doses increase VTE risk without improving efficacy. 4
Do not forget to prescribe condoms simultaneously - COCs provide zero STI protection. 2, 3
Do not prescribe third or fourth-generation progestins as first-line - second-generation progestins (levonorgestrel) have safer thrombotic profiles. 3, 4
Alternative to COCs: LARC Methods
Long-acting reversible contraception (LARC) methods should be discussed as first-line options before COCs due to superior effectiveness and continuation rates. 2 The levonorgestrel IUD and etonogestrel implant have:
- Failure rates <1% per year 2
- Continuation rates ≥75% at 1 year 2
- No daily adherence requirements 1
- Immediate postpartum insertion capability 1
However, if the teenager prefers oral contraceptives after counseling, the above COC initiation protocol should be followed.