Recommended Birth Control Pill for an 18-Year-Old
Start with a low-dose combined oral contraceptive (COC) containing 30-35 μg ethinyl estradiol with either levonorgestrel or norgestimate as the progestin component. 1
First-Line Pill Selection
The American Academy of Pediatrics specifically recommends that adolescent medicine providers begin with a monophasic COC containing 30-35 μg ethinyl estradiol combined with levonorgestrel or norgestimate. 1 These formulations are considered first-line because:
- Low-dose pills (≤35 μg ethinyl estradiol) minimize thromboembolism risk while maintaining contraceptive efficacy 1
- Levonorgestrel and norethisterone-containing pills have the lowest venous thromboembolism risk among available progestins 2
- Monophasic regimens are simpler to manage and can be easily adjusted or extended based on patient needs 1
Among low-dose formulations, there are no clear data suggesting one is superior to another for adolescent use, so choosing one with the lowest copay on the patient's insurance formulary is appropriate. 1
Initiation Protocol
Use "quick start" or same-day initiation in healthy, non-pregnant adolescents:
- The patient can start the pill on the same day as the office visit 1
- No pelvic examination is required before initiating COCs 1
- Backup contraception (condoms or abstinence) must be used for the first 7 consecutive days 1
- Condoms should always be used for STI protection regardless of pill use 1
Safety Profile for Adolescents
The risks of COCs in healthy 18-year-olds are minimal:
- Baseline venous thromboembolism risk in adolescents is only 1 per 10,000 woman-years 1
- COCs increase this risk 3-4 fold to approximately 3-4 per 10,000 woman-years 1
- This is far lower than pregnancy-associated VTE risk of 10-20 per 10,000 woman-years 1
- The risk of death from COC use in teenagers is virtually nil 3
- Smoking is NOT a contraindication in women under 35 years old 1
Contraindications to Screen For
Do not prescribe COCs if the patient has: 1
- Severe uncontrolled hypertension (≥160/100 mmHg)
- Migraines with aura or focal neurologic symptoms
- Current or history of thromboembolism or known thrombophilia
- Complicated valvular heart disease
- Ongoing hepatic dysfunction
- Complications of diabetes (nephropathy, retinopathy, neuropathy)
Counseling Points
Address common transient side effects that typically resolve within 2-3 months: 1
- Irregular bleeding (most common)
- Headache
- Nausea
- Weight gain and mood changes have NOT been reliably linked to combined hormonal contraception 1
Schedule a follow-up visit 1-3 months after initiation to address persistent adverse effects or adherence issues. 1
Adherence Strategies
Promote consistent use with practical strategies: 1
- Cell phone alarms for daily reminders
- Support from family member or partner
- Prescribe up to 1 year of pills at a time to reduce barriers 1
If pills are missed: 1
- If 1 pill missed (24-48 hours): Take the missed pill immediately, continue as usual
- If ≥2 pills missed (>48 hours): Take the most recent missed pill, discard others, use backup contraception for 7 consecutive days
- If pills missed in week 3: Skip the hormone-free interval and start a new pack immediately
Non-Contraceptive Benefits
COCs provide significant health benefits beyond contraception: 1, 4
- Decreased menstrual cramping and blood loss
- Improvement in acne
- Protection against ovarian and endometrial cancers (with >3 years use)
- No negative effect on long-term fertility—completely reversible 1
- Reduced risk of pelvic inflammatory disease and ectopic pregnancy 4
Alternative Considerations
If the patient has difficulty with daily pill adherence, consider discussing long-acting reversible contraception (LARC) methods like IUDs or implants, which have higher typical-use effectiveness rates. 1 However, if a pill is preferred, the above recommendations provide the safest and most effective approach for an 18-year-old seeking contraception.