What is the best contraceptive method for a healthy 14‑year‑old adolescent who wants menstrual suppression and has no contraindications to estrogen?

Best Birth Control for Menstrual Suppression in a 14-Year-Old

Start with a monophasic combined oral contraceptive (COC) containing 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate, prescribed in an extended or continuous cycle regimen to maximize menstrual suppression. 1, 2

Why COCs Are the Optimal First Choice

For a healthy 14-year-old without estrogen contraindications seeking menstrual suppression, COCs offer the best balance of effectiveness, safety, and menstrual control:

• Extended or continuous cycle regimens are particularly appropriate for adolescents desiring amenorrhea, eliminating the hormone-free interval to optimize menstrual suppression 1
• Low-dose pills (30-35 μg ethinyl estradiol) minimize thromboembolism risk while maintaining contraceptive efficacy 2
• Monophasic formulations are simpler to manage and can be easily adjusted based on patient response 1, 2

Specific Prescribing Protocol

Initial Prescription

• Prescribe a monophasic COC with 30-35 μg ethinyl estradiol combined with levonorgestrel or norgestimate 1, 2
• Use "quick start" initiation—begin the same day as the visit in this healthy, non-pregnant adolescent 1, 2
• Instruct continuous use (skipping placebo pills) to maximize menstrual suppression 1, 3

Patient Counseling Points

• Use backup contraception (condoms or abstinence) for the first 7 consecutive days 1, 2
• Expect unscheduled breakthrough bleeding, especially initially—this is the most common side effect of extended regimens but decreases over time 1, 3, 4
• If persistent bleeding occurs (>5 consecutive days), take a 4-day hormone-free interval, then resume continuous use 1, 4
• Common transient side effects (irregular bleeding, headache, nausea) typically resolve within 2-3 months 1, 2
• Weight gain and mood changes have NOT been reliably linked to COCs 1, 2

Adherence Strategies

• Set daily cell phone alarms as reminders 1, 2
• Involve family member or partner for support 1, 2
• Prescribe up to 1 year supply at once to reduce barriers 2

Safety Profile for This Age Group

The safety profile is excellent for healthy adolescents:

• Baseline VTE risk in adolescents is only 1 per 10,000 woman-years 1
• COCs increase this 3-4 fold to approximately 3-4 per 10,000 woman-years—far lower than pregnancy-associated VTE risk of 10-20 per 10,000 1
• No pelvic examination is required before initiating COCs 1, 2

Screen for These Contraindications

• Severe uncontrolled hypertension (≥160/100 mmHg) 1, 2
• Migraines with aura or focal neurologic symptoms 1, 2
• Complicated valvular heart disease 1
• Ongoing hepatic dysfunction 1
• Thromboembolism or thrombophilia 1

Why Not Other Options for This Patient?

Levonorgestrel IUD

While the levonorgestrel IUD provides excellent menstrual suppression and is first-line for many adolescents 5, 6, COCs are more appropriate for initial menstrual suppression in a 14-year-old because:

• COCs offer easier titration and immediate discontinuation if side effects occur 1
• Extended-cycle COCs provide predictable menstrual suppression with the option to induce withdrawal bleeding if desired 1
• IUD insertion may be more challenging in nulliparous young adolescents, though not contraindicated 5

Depot Medroxyprogesterone Acetate (DMPA)

DMPA should not be first-line for a 14-year-old despite providing menstrual suppression because:

• The FDA recommends use for longer than 2 years only if other methods are inadequate due to bone mineral density concerns 7
• Adolescents show significant BMD decline during critical bone-building years (mean decreases of 2.4-6% over treatment period) 7
• This is particularly concerning since adolescents should be increasing bone density during this developmental period 7

Non-Contraceptive Benefits

COCs provide significant additional health benefits beyond menstrual suppression:

• Decreased menstrual cramping and blood loss 1, 2
• Improvement in acne 1, 2
• Protection against endometrial and ovarian cancers with >3 years use 1, 2
• Completely reversible with no negative effect on long-term fertility 1, 2

Follow-Up Plan

• Schedule routine follow-up at 1-3 months to address persistent side effects or adherence issues 1
• If breakthrough bleeding persists, consider a 4-day hormone-free interval or brief estrogen supplementation 1, 4
• If significant side effects occur, adjust estrogen dose or progestin type rather than abandoning the method 1
• Always recommend condom use for STI protection regardless of pill use 2, 6