First-Line Oral Contraceptive for a Healthy 16-Year-Old
Start with a low-dose monophasic combined oral contraceptive containing 30-35 μg ethinyl estradiol combined with either levonorgestrel or norgestimate. 1, 2
Recommended Formulation
Low-dose COCs containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate are the first-line options for adolescents due to their established safety profile, effectiveness, and lower thrombotic risk compared to newer progestins. 1, 2
Second-generation progestins like levonorgestrel demonstrate a safer coagulation profile compared to third and fourth-generation progestins (desogestrel, drospirenone), making them preferable for initial prescribing. 2
Among low-dose formulations, there are no clear data suggesting one is superior to another for most users, so choosing the lowest copay option on the patient's insurance formulary is appropriate. 2
Initiation Protocol
Use the "quick start" method: COCs can be started on the same day as the visit in healthy, non-pregnant adolescents. 1, 2
Counsel the patient to use a backup method (condoms or abstinence) for at least the first 7 days for contraceptive efficacy. 1, 2
Emphasize that condoms should be used at all times for STI protection, regardless of contraceptive method. 1
No internal pelvic examination is needed before initiating COCs, though routine STI screening is recommended in all sexually active patients. 1
Safety Considerations
Critical contraindications to screen for before prescribing: 1, 2, 3
Severe uncontrolled hypertension (≥160/100 mm Hg)
Migraines with aura or focal neurologic symptoms
Current or history of thromboembolism or thrombophilia
Complicated valvular heart disease
Ongoing hepatic dysfunction
Complications of diabetes
The risk of venous thromboembolism increases from 1 per 10,000 to 3-4 per 10,000 woman-years with COC use, which is still significantly lower than the 10-20 per 10,000 risk during pregnancy. 2, 3
Smoking is not a contraindication to COC use in individuals younger than 35 years old, though it should be discouraged. 2
Non-Contraceptive Benefits
Low-dose COCs provide multiple health benefits beyond contraception: 1, 2
- Decreased menstrual cramping and blood loss (protecting against iron-deficiency anemia)
- Improvement in acne through anti-androgenic properties
- Long-term use (>3 years) provides significant protection against endometrial and ovarian cancers
Follow-Up and Adherence
Schedule a routine follow-up visit 1-3 months after initiating COCs to address persistent adverse effects or adherence issues. 1
Counsel about common transient adverse effects including irregular bleeding, headache, and nausea—these typically resolve within the first few cycles. 1
Important reassurance: Neither weight gain nor mood changes have been reliably linked to combined hormonal contraception use. 1
Recommend cell phone alarms for daily pill reminders and support from family members to improve adherence. 3
Prescribe up to 1 year of COCs at a time to reduce barriers to continuation. 2
Common Pitfalls to Avoid
Do not require a pelvic exam before prescribing—this is an unnecessary barrier to contraceptive access in healthy adolescents. 1
Do not prescribe higher-dose formulations (>35 μg ethinyl estradiol) as first-line—these have higher VTE risk without improved efficacy. 2
Do not start with third or fourth-generation progestins (desogestrel, drospirenone) as first-line—reserve these for specific indications like acne or if first-line options are not tolerated. 2
Rifampin is the only antibiotic that definitively reduces COC effectiveness; routine antibiotics do not require backup contraception. 1, 2