What contraception method would you recommend for a 16-year-old female?

Contraception Recommendation for a 16-Year-Old Female

I strongly recommend long-acting reversible contraception (LARC)—specifically the etonogestrel subdermal implant or a levonorgestrel IUD—as the first-line contraceptive method for a 16-year-old, with counseling about dual protection using condoms for STI prevention. 1

Why LARC Methods Are Superior for Adolescents

The American Academy of Pediatrics explicitly recommends counseling adolescents about contraceptive methods in order from most to least effective, starting with LARC methods first 1. This approach prioritizes methods that reduce unintended pregnancy—the primary outcome affecting morbidity, mortality, and quality of life in this age group.

Efficacy Data That Matters

• Subdermal implant (Nexplanon): 0.05% failure rate with typical use, 84% continuation at 1 year 1
• Levonorgestrel IUD: 0.2% failure rate with typical use, 80% continuation at 1 year 1
• Combined oral contraceptive pills: 9% failure rate with typical use, only 67% continuation at 1 year 1

The failure rates for user-dependent methods like pills, patches, and rings are significantly magnified in young women compared to older adults 2. This makes LARC methods not just preferable but essential for preventing the substantial morbidity associated with adolescent pregnancy.

The Subdermal Implant: My Top Choice

The etonogestrel implant is ideal for a 16-year-old because it:

• Requires no adherence after insertion—eliminating the primary cause of contraceptive failure in adolescents 1
• Lasts 3 years with failure rates under 1% for both typical and perfect use 1
• Can be inserted in-office by trained clinicians 1
• Provides immediate contraception if inserted during the first 5 days of the menstrual cycle, or requires 7 days of backup contraception if inserted at other times 1

Common pitfall: The main reason for discontinuation is unpredictable bleeding or spotting 1. Counsel the patient upfront that irregular bleeding is common but does not indicate contraceptive failure, and this often improves over time.

Levonorgestrel IUD: Equally Excellent Alternative

The levonorgestrel IUD is another outstanding first-line option 1:

• Safety in nulliparous adolescents is well-established: IUDs do not cause tubal infertility in nulliparous women, and fertility returns rapidly after removal 1, 3
• Multiple formulations available: 52 mg (Mirena, approved 5 years but effective up to 7 years) or 13.5 mg (Skyla, approved 3 years) 1, 3
• The 13.5 mg formulation may be preferable for nulliparous teens due to smaller size 1
• Provides therapeutic benefits beyond contraception, including lighter periods or amenorrhea 3

Critical safety point: The risk of pelvic infection exists only during the first 21 days after insertion; beyond this window, IUDs do not increase rates of STIs or pelvic inflammatory disease 1, 3.

Addressing STI Risk: The Dual Method Approach

Adolescents are at higher risk for STIs, so LARC alone is insufficient 4. The patient must be counseled to:

• Use male latex condoms consistently with LARC to reduce risk of STIs including HIV 1
• Understand that LARC provides no STI protection despite excellent pregnancy prevention 1
• Follow standard STI screening guidelines for sexually active adolescents 4

When Short-Acting Methods Might Be Considered

If the patient declines LARC after thorough counseling, short-acting reversible contraception (SARC) options include 5:

• Combined oral contraceptive pills, patch, or vaginal ring: 9% typical use failure rate, but only 67% continuation at 1 year 1
• Depot medroxyprogesterone acetate (DMPA) injection: 6% typical use failure rate, 56% continuation at 1 year 1

However, these methods have substantially higher failure rates in adolescents due to adherence challenges 2, 5. The majority of adolescents continue to use SARC despite LARC being recommended 5, so if prescribing these methods, emphasize:

• Taking pills at the same time daily 6
• Using backup contraception for the first 7 days when starting 6
• What to do with missed pills (take as soon as remembered, use backup until 7 consecutive days of use) 1

Contraindications and Safety Screening

Before LARC insertion, assess for 1, 3:

• Current or recent (past 3 months) pelvic inflammatory disease—this is a contraindication 3
• Current pregnancy—perform pregnancy test before insertion 1
• Undiagnosed abnormal vaginal bleeding requiring evaluation 3

Important: Nulliparity and adolescent age are NOT contraindications to LARC 1, 3, 4. The American Academy of Pediatrics explicitly states that IUDs and implants are safe for nulliparous adolescents 1, 3.

Emergency Contraception Counseling

Provide information about emergency contraception options available if unprotected intercourse occurs 1:

• Copper IUD: Most effective emergency contraception, can be inserted within 5 days of unprotected intercourse 1
• Levonorgestrel: Available over-the-counter, single 1.5 mg dose 1
• Ulipristal acetate: 30 mg single dose, prescription required 1

Implementation Strategy

Counsel in this specific order 1:

1. First: Discuss LARC methods (implant and IUDs) emphasizing their superior efficacy and convenience
2. Second: Discuss DMPA injection if LARC declined
3. Third: Discuss combined hormonal methods (pills, patch, ring) only if all other options declined
4. Always: Emphasize condom use for STI protection regardless of contraceptive method chosen

This algorithmic approach, recommended by the American Academy of Pediatrics, ensures the most effective methods are presented first when the patient is most receptive to counseling 1.