The availability of effective contraception is a significant factor in the decreasing rate of unplanned pregnancy among adolescents. Long-acting reversible contraception (LARC) methods — the most effective form of contraception — have been confirmed to be safe and effective when used by adolescents.
A new AAP clinical report can help pediatricians navigate issues surrounding use of LARCs.
Long-Acting Reversible Contraception: Specific Issues for Adolescents from the Committee on Adolescence is available at https://pediatrics.aappublications.org/content/early/2020/07/16/peds.2020-007252 and will be published in the August issue of Pediatrics.
Indications, barriers
LARCs include one progestin subdermal implant and five intrauterine devices (IUDs). The progestin subdermal implant suppresses ovulation. The copper IUD and the progestin-releasing levonorgestrel IUDs (LNG-IUDs) prevent fertilization. The progesterone-containing LARCs also reduce the amount of blood loss and cramping during a menstrual cycle. Despite the well-established contraceptive and noncontraceptive benefits, rates of LARC use in teens remain at 2% to 3%.
Gaps in both patient and provider knowledge, availability of trained providers, and concerns about cost and confidentiality are key barriers to LARC availability. Multiple resources are accessible and detail the safety and efficacy of LARC use by adolescents (see resources). Formal training sessions, including those at professional society meetings, can improve clinicians’ ability to perform LARC counseling, placement and removal.
Concerns over cost and confidentiality often present a challenge to the pediatrician when providing reproductive health care. Particularly challenging is ensuring confidential care of patients in the justice and welfare systems. Resources from the AAP, American College of Obstetricians and Gynecologists, and Guttmacher Institute are available to guide providers when confidentiality questions surface (see resources).
Importance of education
While LARCs have garnered much attention from various professional societies including the AAP, it is essential that these methods are not seen as a panacea for all reproductive health concerns. Providing clear education on sexually transmitted infection (STI) prevention remains important, as gonorrhea and chlamydia rates among adolescents using LARCs are higher due to less frequent condom use. Similarly, an assessment of personal safety, including intimate partner violence, remains an essential part of reproductive care regardless of the contraceptive method chosen.
When providing contraceptive services to patients, providers should focus on increasing the availability of LARCs and not on the uptake of LARCs. Counseling should be based on principles of reproductive justice. While it is important for providers to understand the well-established safety and efficacy of LARC use in the adolescent population, contraceptive counseling should be done in a nondirective manner. Keeping the conversation focused on what contraceptive benefits a patient most values and what side effects she finds unacceptable can help keep the counseling session patient-focused rather than LARC-focused.
Recommendations
The report includes the following suggested guidance:
- Recognize LARCs as safe options for adolescents.
- Seek and obtain the required training for placement and removal of LARCs.
- Focus on improving availability of LARC services to adolescents and not on increasing teen use of LARC methods.
- Discuss side effects, including expected changes in bleeding patterns.
- Recognize LNG-IUD as a promising option for reducing menses, particularly in those with cognitive or physical disabilities or those diagnosed with anemia attributable to heavy menstrual bleeding.
- Understand that LARC placement need not be delayed for screening of STIs. IUD placement should be delayed, however, if purulent cervicitis is noted or if an untreated gonorrhea or chlamydia infection is present.
- Emphasize dual therapy with barrier protection in LARC users to prevent STIs (see related article at http://www.aappublications.org/news/2020/07/20/barrierprotection072020).
- Know that confidentiality can be compromised when delivering LARC services during the consent process and by insurance billing and various automated features of the electronic health record. Understand state laws on reproductive health and financial operations to cover LARC services.
- Provide in-depth counseling on all available contraception methods, their side effects, review of medical eligibility and assessment of personal safety when providing LARC services.
Dr. Menon, lead author of the clinical report, is the liaison from the North American Society of Pediatric and Adolescent Gynecology to the AAP Committee on Adolescence.
