What birth control methods are appropriate for a teenage patient, considering health, lifestyle, privacy, and the need for dual protection against sexually transmitted infections?

Teen Birth Control Options

Long-acting reversible contraception (LARC)—specifically the etonogestrel implant or levonorgestrel IUD—should be offered as the first-line contraceptive method for all sexually active teenagers, combined with mandatory condom use at every sexual encounter for STI protection. 1, 2

Dual Protection Strategy: The Non-Negotiable Foundation

All sexually active teenagers must use condoms regardless of their chosen contraceptive method, as no hormonal contraception or IUD protects against STIs including HIV, chlamydia, gonorrhea, HPV, and trichomoniasis. 1, 2

• Male latex condoms have an 18% typical-use failure rate for pregnancy prevention but remain essential for STI protection. 1
• Counsel teenagers on correct condom use including water-based lubricants only, and never recommend natural membrane condoms as they do not protect against STIs. 2
• The dual method approach (LARC + condoms) represents the gold standard for adolescent contraception. 3

First-Line Contraceptive Recommendations: LARC Methods

Etonogestrel Implant (Nexplanon)

The contraceptive implant should be your first recommendation for most teenagers seeking highly effective contraception. 1

• Failure rate of 0.05% with continuation rates of 84% at one year—the highest of any reversible method. 4
• Lasts 3 years and requires no daily adherence, making it ideal for adolescents who struggle with consistent pill-taking. 4
• Can be inserted same-day without pelvic examination; only pregnancy testing is required if sexually active. 2
• Use backup contraception (condoms) for the first 7 days after insertion. 4
• Common reason for discontinuation is unpredictable bleeding or spotting, which should be discussed upfront. 4

Levonorgestrel IUD (Mirena, Skyla)

The levonorgestrel IUD is particularly appropriate for teenagers with heavy menstrual bleeding or dysmenorrhea. 1, 5

• Failure rate of 0.2% with continuation rates ≥75% at one year. 4, 1
• Provides excellent menstrual suppression without estrogen exposure. 1
• Safe for nulliparous adolescents with no age-related restrictions. 2
• Mirena lasts 5-7 years; Skyla lasts 3 years. 4
• No pelvic examination required before insertion; can be placed same-day if reasonably certain patient is not pregnant. 2

Second-Line Option: Combined Oral Contraceptives (COCs)

When LARC methods are declined or medically inappropriate, prescribe monophasic COCs with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate as the initial choice. 5

Initiation Protocol

• Use the "quick start" method: begin COCs the same day as the visit in healthy, non-pregnant adolescents. 1, 5
• Counsel patients to use backup contraception (condoms) for the first 7 days. 1, 5
• No pelvic examination is required before initiating COCs. 5

Safety Considerations

• Second-generation progestins (levonorgestrel) have safer thrombotic profiles than third/fourth-generation progestins. 5
• Baseline VTE risk in adolescents is 1 per 10,000 woman-years; COC use increases this to 3-4 per 10,000 woman-years. 5
• Typical-use failure rate is 9%, significantly higher than LARC methods. 4, 2

Absolute Contraindications to COCs

• Severe uncontrolled hypertension 5
• Migraines with aura or focal neurologic symptoms 5
• Thromboembolism or thrombophilia 5
• Complicated valvular heart disease 5

Non-Contraceptive Benefits

COCs provide long-term protection against endometrial and ovarian cancers, decreased menstrual cramping and blood loss, improvement in acne, and reduced risk of iron-deficiency anemia. 1, 5

Third-Line Option: DMPA Injection (Depo-Provera)

DMPA should be used as a long-term birth control method (longer than 2 years) only if other birth control methods are inadequate due to significant bone mineral density loss. 6

• Failure rate of 6% with continuation rate of 56% at one year. 4
• Causes mean lumbar spine BMD decreases of 5.38% after 5 years of use in adults. 6
• BMD loss is of particular concern during adolescence and early adulthood, a critical period of bone accretion. 6
• BMD appears at least partially reversible after discontinuation, but longer treatment duration is associated with less complete recovery. 6
• All patients using DMPA should have adequate calcium and Vitamin D intake. 6

Emergency Contraception: Advance Prescription Required

Provide advance prescription for emergency contraception to all sexually active teenagers. 1

• Levonorgestrel 1.5 mg (Plan B One-Step) is available over-the-counter for all women of childbearing potential. 1
• Ulipristal acetate (ella) may have increased effectiveness over levonorgestrel at the end of the 5-day window and in heavier women, but is pregnancy category X. 1, 7
• Ulipristal acetate must be taken within 5 days (120 hours) of unprotected sex. 7
• After using ulipristal acetate, wait 5 days to start or resume hormonal birth control and use barrier contraception during this time. 7
• Do not use additional levonorgestrel emergency contraceptive pills within 5 days after taking ulipristal acetate. 7

Counseling Approach: Tiered Effectiveness Discussion

Present contraceptive options in order of effectiveness, starting with LARC methods first, then discussing less effective methods. 2

• Discuss typical-use versus perfect-use failure rates to set realistic expectations. 1
• Address confidentiality explicitly: explain how personal information will be protected and that most states support minor consent for contraception. 4
• Assess the "5 P's": practices, pregnancy prevention, partners, protection from STDs, and past STD history. 2
• Provide same-day contraception with a full year's supply when possible to reduce barriers to access. 2

Common Pitfalls to Avoid

• Do not assume LARC users will continue condom use—reinforce dual-method messaging at every encounter. 2
• Do not prescribe oral contraceptives as first-line when LARC is medically appropriate—LARC has superior effectiveness and continuation rates. 2
• Do not delay LARC insertion waiting for menses—insert at any time if reasonably certain patient is not pregnant. 2
• Do not omit discussion of emergency contraception—all teenagers should know about and have access to it. 1
• Do not forget STI screening—screen at least annually, more frequently if indicated, in all sexually active patients. 5, 2

Special Population: High STI Risk

For teenagers with multiple partners, history of STIs, or other high-risk factors, the combination of LARC plus mandatory condom use is even more critical. 2

• LARC methods do not depend on daily adherence, which is critical for adolescents with inconsistent use patterns. 2
• Obesity (BMI ≥30) is not a contraindication to any hormonal method or IUD. 2
• Reinforce that hormonal contraceptives and IUDs provide zero protection against STIs. 2