A working knowledge of contraception will assist the pediatrician in both sexual health promotion as well as treatment of common adolescent gynecologic problems. Best practices in adolescent anticipatory guidance and screening include a sexual health history, screening for pregnancy and sexually transmitted infections, counseling, and if indicated, providing access to contraceptives. Pediatricians’ long-term relationships with adolescents and families allow them to help promote healthy sexual decision-making, including abstinence and contraceptive use. Additionally, medical indications for contraception, such as acne, dysmenorrhea, and heavy menstrual bleeding, are frequently uncovered during adolescent visits. This technical report provides an evidence base for the accompanying policy statement and addresses key aspects of adolescent contraceptive use, including the following: (1) sexual history taking, confidentiality, and counseling; (2) adolescent data on the use and side effects of newer contraceptive methods; (3) new data on older contraceptive methods; and (4) evidence supporting the use of contraceptives in adolescent patients with complex medical conditions.

Pediatricians play a key role in adolescent sexual health and contraception. Sexual health is an important part of adolescent anticipatory guidance and screening, and pediatricians’ long-term relationships with adolescents and families allow them to help promote healthy sexual decision-making, including abstinence and contraceptive use. Additionally, medical indications for contraception, such as acne, dysmenorrhea, and heavy menstrual bleeding, are frequently uncovered during adolescent visits. A working knowledge of contraception will assist the pediatrician in both sexual health promotion as well as treatment of common adolescent gynecologic problems. This technical report provides the pediatrician with updated information on adolescent sexual behavior, guidelines for counseling adolescents, and an update on available methods of contraception. It is a companion to the policy statement “Contraception for Adolescents.”1 

Sexual intercourse is common among adolescents. In 2011, 47% of high school students reported ever having had sex, and 34% reported having had sex in the previous 3 months.2 For the pediatrician, this means that approximately half of their adolescent patients have engaged in sex, many without adequate protection against pregnancy and sexually transmitted infections (STIs).

Unintended pregnancy is a serious adolescent morbidity, and use of effective contraception is one of the pillars of adolescent pregnancy prevention. Each year, approximately 750 000 adolescent girls become pregnant, and 82% of these pregnancies are unplanned.3,4 More than half of these pregnancies (59%) end in births, 14% end in miscarriages, and 27% end in abortion.3 From 1990 to the early 2000s, adolescent pregnancy rates declined markedly, and 86% of this decline was attributable to increased consistent contraceptive use (the remainder was attributed to delay of sexual activity).5 By 20 years of age, 18% of young women will have given birth, and this number is largely unchanged from 2002.6 

The contraceptive method most commonly used by adolescents is the condom (96% of young women who have ever used a contraceptive reported previous condom use), followed by withdrawal (57%) (see Table 1). Among hormonal methods, experience with combined oral contraceptives (COCs) is most common (56%), followed by depot medroxyprogesterone acetate (DMPA) injection (20%), the transdermal patch (10%), and the vaginal ring (5%). More than 13% of adolescents have ever used emergency contraception (EC), and 15% have ever used periodic abstinence. However, ever having used a method does not necessarily translate into consistent or current use. When a nationally representative sample of all 15- to 19-year-old adolescent girls were asked about current use (past 3 months), 28% reported any contraceptive use. The pill was most commonly used (15%), followed by condoms (6%), DMPA (3%), and withdrawal, the contraceptive ring, and the intrauterine device (IUD) (all approximately 1%). The transdermal patch was less than 1% (see Table 2). Experience with long-acting reversible contraception (LARC), such as IUDs and implants, has increased markedly in 15- to 19-year-olds over the past decade, with the bulk of the increase in the 18- to 19-year age range. By 2009, it was estimated that 4.5% of contraceptive use was an IUD or implant.4 

TABLE 1

Lifetime Use (Ever-Use) of Contraception Among Sexually Experienced Women Aged 15 to 19 Years: United States, 2006 to 2010

Method% Distribution
Any method188  98.9 
Injectable 20.3 
Pill 55.6 
Contraceptive patch 10.3 
Contraceptive ring 5.2 
Emergency contraception 13.7 
Condom 95.8 
Female condom 1.5 
Periodic abstinence—calendar 15.0 
Withdrawal 57.3 
Other methods 7.1 
Long-acting reversible contraceptives (IUDs and implants)64  4.5 
Method% Distribution
Any method188  98.9 
Injectable 20.3 
Pill 55.6 
Contraceptive patch 10.3 
Contraceptive ring 5.2 
Emergency contraception 13.7 
Condom 95.8 
Female condom 1.5 
Periodic abstinence—calendar 15.0 
Withdrawal 57.3 
Other methods 7.1 
Long-acting reversible contraceptives (IUDs and implants)64  4.5 
TABLE 2

Current Contraceptive Use by Method of Women Aged 15 to 19 Years: United States, 2006 to 2008162 

Contraceptive Status and Method% Distribution
Using contraception 28.2 
 Pill 15.2 
 Implant, Lunelle, or patch 0.5 
 3-mo injectable (Depo-Provera) 2.6 
 Contraceptive ring 1.0 
 IUD 1.0 
 Condom 6.4 
 Withdrawal 1.1 
Not using contraception 71.8 
 Nonsurgically sterile—female or male 0.5 
 Pregnant or postpartum 3.9 
 Seeking pregnancy 0.9 
 Other nonuse:  
  Never had intercourse or no intercourse in 3 mo before interview 60.0 
  Had intercourse in 3 mo before interview 6.5 
Contraceptive Status and Method% Distribution
Using contraception 28.2 
 Pill 15.2 
 Implant, Lunelle, or patch 0.5 
 3-mo injectable (Depo-Provera) 2.6 
 Contraceptive ring 1.0 
 IUD 1.0 
 Condom 6.4 
 Withdrawal 1.1 
Not using contraception 71.8 
 Nonsurgically sterile—female or male 0.5 
 Pregnant or postpartum 3.9 
 Seeking pregnancy 0.9 
 Other nonuse:  
  Never had intercourse or no intercourse in 3 mo before interview 60.0 
  Had intercourse in 3 mo before interview 6.5 

Sexual history taking and counseling about pregnancy prevention, including contraceptive use, are key Bright Futures objectives for the adolescent visit.7 The demands of these tasks can be managed by situating them in an adolescent’s medical home. Because of pediatricians’ ongoing relationships with adolescents and families, they are optimally suited for this role.7 The following sections outline the evidence base for key elements relevant to contraceptive care, including confidentiality and consent, sexual history taking, and counseling.

In the setting of contraception and sexual health care, the American Academy of Pediatrics (AAP) believes that policies supporting adolescent consent and protecting adolescent confidentiality are in the best interests of adolescents. Most states have specific laws regarding minor consent to contraception (see “State Minor Consent Laws: A Summary”8 and the Guttmacher Institute’s State Center9 for regularly updated state-by-state summaries). For states without specific laws, best-practices guidelines, federal statutes, and federal case law may support minor confidentiality and consent.10 For example, family-planning clinics funded by Title X of the federal Public Health Services Act (42 USC §§300–300a-6 [1970]) are required to provide confidential services to adolescents.8 

The Health Insurance Portability and Accountability Act (HIPAA [Pub L No. 104-191, 1996]) specifically addresses minor confidentiality. Although HIPAA allows parents access to adolescents’ records as personal representatives of the minor, that access is denied when the minor can consent under state or other laws, or when the parent agrees that the minor may have confidential care.10 The AAP, therefore, recommends that pediatricians have an office policy that explicitly describes confidential services and that pediatricians discuss (and document) confidentiality with all parents and adolescents. As an additional protection for minors’ confidentiality, HIPAA states that if there is no applicable state law about the rights of parents to access the protected health information of their children, pediatricians (or other licensed health professionals) may exercise their professional judgment to provide or deny parental access to the records. This can be accomplished with careful documentation of their professional judgment.

Insurance billing, electronic health record systems, and patient portals create additional challenges to maintaining the confidentiality of visits, visit content, and associated laboratory testing that will need to be considered. The AAP policy statement on electronic health records supports privacy policies consistent with state health care consent laws and best practices around sensitive health topics such as sexual behavior and contraception.11 

Importance of Confidentiality and Consent

Careful attention to minor consent and confidentiality are important, because confidentiality is a major concern of adolescents12 and a reason for foregoing contraceptive care. In a nationally representative sample, adolescents most in need of confidential health services (eg, sexually active girls) were more likely to cite confidentiality as a reason for foregoing health care.13 Confidentiality concerns are heightened among adolescents from underrepresented minority groups14,15 and other groups at high risk of unintended pregnancy (eg, those involved with the juvenile justice system; lesbian, bisexual, and transgender; and lower-income youth).16,17 Many adolescents are unaware they can obtain confidential health care,18 presenting a potential barrier to access to contraceptive services.

Limitations on adolescents’ confidentiality and their ability to consent have been associated with lower use of contraceptive services and poor outcomes. Among minors attending family-planning clinics, young women reported that if parental notification were required for prescriptive contraceptives, only 1% would stop having vaginal sex, but 59% would stop using all clinic services.19 Among young African American women, fear of family finding out about sexual health services was a common reason to delay a first clinic visit for contraception.20 On a population level, minors’ capacity to consent to contraceptives has been associated with lower adolescent birth rates,21 and restrictions on minors’ capacity to consent to contraceptives have been associated with higher birth rates.22 

Parents

The relationship among parents, confidentiality, and access is complex. Many parents are supportive of minor consent and confidentiality for sexual health services. In a national Internet-based survey, 66% of parents agreed that it was important for adolescents to have private time with physicians, and more than half (54%) of parents did not want doctors to disclose confidential information obtained from adolescents to parents.23 Many parents are aware that their adolescents use confidential sexual health services. A national study of adolescent family-planning clinic clients revealed that 60% of adolescents reported that their parents were aware of their use of sexual health services.24 Among adolescents whose parents were aware of their sexual health service use, 79% would continue to use the services, even if parental notification were required; however, among adolescents whose parents were unaware of their sexual health services use, fewer than 30% would continue to use services.24 

Taking a Sexual History

Adolescents consider pediatricians and other health care providers a highly trusted source of sexual health and other confidential information.25,26 When pediatricians discuss sensitive topics with adolescents, instead of reporting discomfort, adolescents reported that the pediatrician understood their problems, eased their worries, and allowed them to make treatment decisions.27 Best-practices guidelines require that the sexual history be taken with the adolescent alone.7 Key to history taking is an honest, caring, nonjudgmental attitude and a comfortable, matter-of-fact approach to asking questions. This can be accomplished by using the “5 Ps” tool of the Centers for Disease Control and Prevention (CDC): partners, prevention of pregnancy, protection from STIs, sexual practices, and past history of STIs and pregnancy (see http://www.cdc.gov/std/treatment/SexualHistory.pdf).28 

Contraceptive counseling should be developmentally targeted, because the sexual health and contraceptive needs of early adolescents differ markedly from those of middle and late adolescents. Even among same-age adolescents, there is often a wide range in adolescents’ sense of themselves as a sexual being, their sexual experiences, and their interest and need for contraception. For example, a study of early adolescents described views and behaviors ranging from considering sex to be “nasty” and something best left to adults, to an intense curiosity about and initiation of sexual behaviors.29 Bright Futures provides sample questions and guidance for a developmentally tailored sexual history.7 

Counseling Using Motivational Interviewing

Increasing evidence from studies of adolescents suggests that individual counseling about contraception and sexual health topics is most effective using patient-centered approaches, such as motivational interviewing.30,31 Motivational interviewing can be used to address the ambivalence and discrepancies among adolescents’ sexual and contraceptive behaviors, their sexual and relationship values, and future life goals. Key elements are (1) an empathetic and nonjudgmental interviewer with unconditional positive regard for the adolescent in a safe, nonthreatening environment; (2) engaging adolescents in their own behavior change; (3) asking adolescents about their goals, and helping them identify inconsistencies between their goals and current behavior; (4) “rolling with resistance,” or avoiding direct confrontation when resistance is met, and waiting for adolescents to find their own answers rather than pointing them out; and (5) supporting adolescents’ capacity to change.32,33 Motivational interviewing is a natural extension of youth development principles in its focus on goals and future orientation, belief in adolescents’ capacity to change, and engagement of adolescents in the process of adopting health-promoting behaviors.34 

Motivational interviewing is accomplished through open-ended questions and careful listening.32,33 In the context of pregnancy prevention and sexual health promotion, discussions might explore the adolescent’s reasons for becoming sexually active and the effect that sexual intercourse and unintended pregnancy may have on relationships with peers, parents, and significant others.35 For example, does the adolescent believe that sex will deepen a relationship?36 Or is sexual behavior or pregnancy considered a marker for adulthood?37 A motivational interviewing approach to contraceptive counseling might also focus on adolescents’ goals (examples of goals linked to sexual decision-making include school completion, college, marriage, and childbearing37), and how contraception and the delay of pregnancy might affect those goals.35 An example of an inconsistency between goals and behaviors might be the adolescent who expresses a desire to graduate from high school and attend college but is frequently engaging in unprotected sex, putting her at risk for an unintended pregnancy.

A common concern of pediatricians is giving complex messages to adolescents: in the case of sexual behavior, the complex message is that a pediatrician would like to encourage abstinence but also is willing and able provide appropriate counseling regarding sexuality and contraception. With motivational interviewing approaches, it is possible and appropriate for pediatricians to provide this type of complex message, because the focus is on the adolescents’ values and relationships and related goals and discrepancies between goals and behaviors. Research suggests that adolescents are capable of understanding this type of complex message and, in fact, may disregard messages that they consider judgmental or overly simplified or that eliminate key health information.25,26 More detailed information on motivational interviewing with adolescents can be found in recent publications.35,38 

Abstinence Counseling in the Office Setting

Counseling about abstinence is an important component of sexual health care. When used consistently without exception, abstinence can be an effective means of contraception and STI prevention and is a viable strategy in the pediatrician’s toolkit for reducing unintended pregnancy and STIs. It has been estimated that approximately one-quarter of the decline in the adolescent pregnancy rates from 1995 to 2002 was attributable to the delayed initiation of sexual activity.5 Abstinence counseling should follow the motivational interviewing approaches described previously. A set of practical tips for abstinence counseling within an office-based setting has been published, and it uses a comprehensive motivational interviewing perspective.35 

When adhered to perfectly, sexual abstinence is 100% effective, making it an attractive choice for pregnancy prevention. However, many adolescents who practice abstinence do not adhere to the method 100% of the time (ie, they occasionally have vaginal-penile intercourse). Few data exist on actual effectiveness of abstinence (called “typical use,” see explanation in Methods of Contraception)39; however, existing data suggest that the effectiveness of abstinence for pregnancy and STI prevention over extended periods of time is likely low. For example, among adolescents reporting virginity pledges in the National Longitudinal Study of Adolescent Health, at 6-year follow-up (wave 3), 88% had engaged in sexual intercourse (most premarital), and 5% were infected with STIs.40 Because of concerns about a low typical-use effectiveness of abstinence as a contraceptive method, it is critical for pediatricians to reassess intentions to remain abstinent at every visit and additionally to provide access to comprehensive sexual health information, including information about EC and condom use. Comprehensive information, including pregnancy prevention, should be provided to all adolescents, including those who identify as lesbian and gay, because they may have opposite-sex partners as well.17 

Numerous reviews and recommendations for prescribing and managing contraception are available (see, for example, Contraceptive Technology41 and the CDC’s “US Selected Prescribing Recommendations for Contraceptive Use”42). Additionally, there are online resources for prescribing contraceptives geared toward clinicians (see Table 3). The following section focuses on the appropriateness of various methods available for adolescents.

TABLE 3

Online Contraceptive and Sexual Health Resources for Providers

Centers for Disease Control and Prevention  
 US Selected Practice Recommendations for Contraceptive Use, 2013 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6205a1.htm?s_cid=rr6205a1_w 
 Counseling Resources: Teen Pregnancy Prevention  http://www.cdc.gov/teenpregnancy/healthcareproviders.htm 
 US Medical Eligibility Criteria for Contraceptive Use, 2010 www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf 
Contraceptive Technology http://www.contraceptivetechnology.org/reproductive-health-resources/training-videos-slides/ 
Association of Reproductive Health Professionals Web site www.arph.org/ 
Managing Contraception www.managingcontraception.com/ga 
World Health Organization Medical Eligibility for Contraceptive Use http://whqlibdoc.who.int/publications/2010/9789241563888_eng.pdf 
Princeton University Emergency Contraception Web site ec.princeton.edu/ 
Centers for Disease Control and Prevention  
 US Selected Practice Recommendations for Contraceptive Use, 2013 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6205a1.htm?s_cid=rr6205a1_w 
 Counseling Resources: Teen Pregnancy Prevention  http://www.cdc.gov/teenpregnancy/healthcareproviders.htm 
 US Medical Eligibility Criteria for Contraceptive Use, 2010 www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf 
Contraceptive Technology http://www.contraceptivetechnology.org/reproductive-health-resources/training-videos-slides/ 
Association of Reproductive Health Professionals Web site www.arph.org/ 
Managing Contraception www.managingcontraception.com/ga 
World Health Organization Medical Eligibility for Contraceptive Use http://whqlibdoc.who.int/publications/2010/9789241563888_eng.pdf 
Princeton University Emergency Contraception Web site ec.princeton.edu/ 

When comparing the efficacy of different contraceptive methods, it is important to distinguish “perfect use” and “typical use.” Perfect-use efficacy refers to the probability of pregnancy if used consistently and correctly every time; data for perfect use come from clinical trials with very high levels of adherence.43 Typical-use efficacy refers to the probability of pregnancy during the first year of typical use; data for typical-use efficacy come from national surveys that include users with varying degrees of adherence.43 Thus, the typical-use efficacy rates reflect how well a contraceptive method works with an average user, factoring in mistakes, such as missed pills, forgotten condoms, or patches that are left on too long. Table 4 includes perfect- and typical-use data for all contraceptive methods. The individual methods appropriate for adolescents are addressed hereafter, discussed in order of effectiveness, starting with LARC. It is recommended that pediatricians use a “tiered” approach to contraceptive counseling, starting with the most effective methods.

TABLE 4

Contraceptive Method Efficacy

Method% of Women Experiencing an Unintended Pregnancy Within the First Year of Use% of Women Continuing Use at 1 Yearc
Typical UseaPerfect Useb
No method 85 85 — 
Spermicides (foams, creams, gels, suppositories, and film,) 28 18 42 
Fertility awareness-based methods 24 — 47 
Withdrawal 22 46 
Condom    
 Female 21 41 
 Male 18 43 
Diaphragm 12 57 
Combined pill and progestin-only pill 0.3 67 
Contraceptive patch 0.3 67 
Contraceptive ring 0.3 67 
DMPA injection 0.2 56 
IUD    
 Copper T 0.8 0.6 78 
 Levonorgestrel 0.2 0.2 80 
Single-rod contraceptive implant 0.05 0.05 84 
Female sterilization 0.5 0.5 100 
Male sterilization 0.15 0.10 100 
Method% of Women Experiencing an Unintended Pregnancy Within the First Year of Use% of Women Continuing Use at 1 Yearc
Typical UseaPerfect Useb
No method 85 85 — 
Spermicides (foams, creams, gels, suppositories, and film,) 28 18 42 
Fertility awareness-based methods 24 — 47 
Withdrawal 22 46 
Condom    
 Female 21 41 
 Male 18 43 
Diaphragm 12 57 
Combined pill and progestin-only pill 0.3 67 
Contraceptive patch 0.3 67 
Contraceptive ring 0.3 67 
DMPA injection 0.2 56 
IUD    
 Copper T 0.8 0.6 78 
 Levonorgestrel 0.2 0.2 80 
Single-rod contraceptive implant 0.05 0.05 84 
Female sterilization 0.5 0.5 100 
Male sterilization 0.15 0.10 100 

—, data not available.

Source: Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397–404.

a

Among typical couples who initiate use of a method (not necessarily for the first time), the percentage who experience an unintended pregnancy during the first year if they do not stop use for any other reason. Estimates of the probability of pregnancy during the first year of typical use for spermicides, withdrawal, periodic abstinence, the diaphragm, the male condom, the pill, and Depo-Provera are taken from the 1995 and 2002 National Survey of Family Growth, corrected for underreporting of abortion; see the text for the derivation of estimates for the other methods.

b

Among couples who initiate use of a method (not necessarily for the first time) and who use it perfectly (both consistently and correctly), the percentage who experience an unintended pregnancy during the first year if they do not stop use for any other reason.

c

Among couples attempting to avoid pregnancy, the percentage who continue to use a method for 1 year.

Currently available progestin implant LARC methods include Implanon and Nexplanon (Merck, Whitehouse Station, NJ). Both consist of a single-rod implant that contains etonogestrel, the active metabolite of desogestrel; Nexplanon also contains barium sulfate to render it visible on radiography. The implant, highly effective with a failure rate of less than 1%,43,44 may remain in place for 3 years. It is inserted into the inside of the nondominant upper arm, 6 to 8 cm above the elbow, by a medical professional who has completed the requisite training. Insertion takes approximately 1 minute, and removal can be accomplished in under 5 minutes.45 Complications are rare but include transient nerve injury and the need for removal under general anesthesia.44,46,47 

Implants are ideal for adolescents who prefer a method that does not require regularly scheduled adherence and who desire an extended length of protection. Authors in Brazil have identified it as a viable option for delaying second pregnancy in adolescent mothers.48 In Australia, a prospective study was conducted of 137 adolescent mothers, 18 years or younger.49 Participants selected their own method, with half choosing the implant and the remainder choosing COCs, DMPA, a barrier method, or nothing. Both method continuation and time to next pregnancy were significantly longer in implant users. It must be noted, however, that there were key differences between the users of the implant and users of other methods. For example, implant users were significantly more likely to be living with the birth father rather than one of their own parents. In addition, more than half of implant users discontinued their method earlier than 24 months, with the most common reason being abnormal uterine bleeding. This is consistent with observational studies (as opposed to clinical trials, which tend to enroll and retain more adherent contraception users) describing continuation rates and bleeding patterns in adult users.50,51 In a published summary of 11 clinical trials that included a total of 942 women within 80% to 130% of their ideal body weight, 64% reported amenorrhea or infrequent bleeding over the first 2 years, and 15% reported frequent or prolonged bleeding.52 This may differ from clinicians’ anecdotal experience in part because heavier women may have more bleeding than lighter women.53 Unlike most other continuous methods, it is not clear that implant users experience improved bleeding patterns over time.54 Experience in the first 3 months may help predict future bleeding patterns,53 but individual experience is highly variable. Although bleeding is frequent with all progestin-only methods, it is important to remember that unscheduled bleeding can also be a sign of an STI, and adolescents should be tested accordingly. Data are limited, but experts have recommended the use of nonsteroidal anti-inflammatory drugs and/or COCs as potentially helpful measures to manage implant-related bleeding.54 

Other than irregular bleeding, adverse effects are not common, but include emotional lability, weight gain, headache, and acne.52 Data are scant on the effect of the implant on bone mineral density (BMD).55,57 Given the higher estradiol level in implant users compared with DMPA users,54 it could be presumed that the implant has less effect on BMD, but this has not been adequately assessed in adolescent women. Similar to the combined hormonal methods, efficacy is impaired by hepatic enzyme-inducing drugs (see Table 5); however, implants are considered safe for women with estrogen contraindications.58 

TABLE 5

Medications That Decrease COC Efficacy

Antibiotics 
 Rifampin 
Anticonvulsants 
 Felbamate 
 Ethosuximide 
 Primidone 
 Phenobarbital 
 Phenytoin (Dilantin) 
 Carbamazepine 
 Oxcarbazepine 
 Lamotriginea 
 Rufinamidea 
 Topiramate 
Antidepressants 
 St. John’s wortb,c 
Antibiotics 
 Rifampin 
Anticonvulsants 
 Felbamate 
 Ethosuximide 
 Primidone 
 Phenobarbital 
 Phenytoin (Dilantin) 
 Carbamazepine 
 Oxcarbazepine 
 Lamotriginea 
 Rufinamidea 
 Topiramate 
Antidepressants 
 St. John’s wortb,c 

Source: World Health Organization. Medical Eligibility Criteria for Contraceptive Use. 4th ed. Geneva, Switzerland: World Health Organization; 2009.

a

Fewer data are available for these newer antiepileptic drugs, but available data suggest they can decrease COC effectiveness.

b

Advantages of COC use generally outweigh the risks.

c

Murphy PA, Kern SE, Stanczyk FZ, Westhoff CL. Interaction of St. John’s Wort with oral contraceptives: effects on the pharmacokinetics of norethindrone and ethinyl estradiol, ovarian activity and breakthrough bleeding. Contraception. 2005;71(6):402-408.

For adolescents who need highly effective contraception that is user- and coitus-independent, the implant is an outstanding choice. However, it is critical that the risk of persistent irregular bleeding is well understood; to date, this is the most common complaint resulting in premature removal. For adolescents seeking hormonal methods specifically to manage abnormal uterine bleeding and irregular cycles, a combined method or a levonorgestrel IUD may be more acceptable to the patient.

IUDs are inserted into the uterus to provide long-acting reversible contraception. Appropriate for adolescents, IUDs are generally safe, effective methods of contraception with a failure rate of less than 1% (see Table 4).43 Three IUDs currently are approved for the US market: a copper-containing T-shaped IUD (copper T380-A, ParaGard; Teva North America, North Wales, PA) and 2 levonorgestrel-releasing T-shaped IUDs (52-mg levonorgestrel, Mirena, and 13.5-mg levonorgestrel, Skyla; Bayer HealthCare Pharmaceuticals Inc, Wayne, NJ). The primary mechanism of action of both types of IUD is preventing fertilization by inhibiting sperm motility. The levonorgestrel IUDs also thicken cervical mucus. All mechanisms occur before implantation, when pregnancy begins, and inhibiting implantation is not believed to be a primary mechanism of action for either type of IUD.59 The 13.5-mg levonorgestrel IUD is approved for 3 years.60 The 52-mg levonorgestrel IUD is approved for 5 years,61 although data suggest that it is still effective at least up to 7 years; similarly, the copper T380-A IUD is approved for 10 years,62 but data support use for 12 years.63 Although IUDs have very low use in the United States, they are used extensively worldwide, and use is increasing in the United States, particularly among older adolescents.64 

Previous concerns about adolescents and IUDs have been addressed by more recent data demonstrating that IUDs are safe for nulliparous adolescents. For example, a case-control study demonstrated that past associations between infertility and IUD use among nulliparous women were attributable to STIs rather than IUDs.65 Other studies support a rapid return to fertility after IUD removal.66,67 Data also address concerns about pelvic infections. There is a small increase in infection risk around the time of IUD insertion as a result of the procedure. However, beyond the first 20 days after insertion, IUDs do not increase rates of pelvic inflammatory disease (PID) above baseline.68,69 Screening for gonorrhea and Chlamydia can be performed at the same time as insertion.59 Any necessary treatment can be subsequently provided without IUD removal, as international studies have demonstrated that STIs and PID can be treated with the IUD in place,70 as long as the patient improves with treatment. As a result, there are now more limited infectious contraindications to IUDs. These include current or recent (past 3 months) PID or current gonorrhea, Chlamydia, or purulent cervicitis. Additional contraindications include pregnancy and uterine anomalies that distort the uterine cavity in a manner incompatible with IUD insertion (see CDC recommendations for complete list58). HIV infection and immunosuppression are not contraindications to IUD use.

The one area with less clarity is that, for insertion of IUDs (but not continuation), “high risk of STIs” is considered by the CDC to be level 2 (benefits generally outweigh risks) or level 3 (risks generally outweigh benefits, but clinician may individualize). However, the data supporting the level 3 categorization are from a study of HIV-infected adult women in Africa.58 Beyond STI risk, existing concerns about IUD use in adolescents are that rates of expulsions and experiences of pain and discomfort are somewhat higher among nulliparous compared with parous young women. Nonetheless, current data suggest that IUDs are generally well tolerated in young women and that continuation and satisfaction rates are high.71,74 

Adolescent-specific data are limited on acceptability and use of IUDs for contraception; however, recent studies are promising, suggesting 1-year continuation rates of 75% or greater.75,78 The data on levonorgestrel IUD use for medical indications in adolescents reveal improvement in dysmenorrhea and heavy menses.76,79 The levonorgestrel IUD is also useful for adolescents with medical conditions that require long-term menstrual suppression in which estrogen is contraindicated or that present a serious risk to the fetus in the case of unintended pregnancy. For example, use of the levonorgestrel IUD with disabled nonambulatory adolescents allows effective menstrual suppression while avoiding both exogenous estrogen exposure and the bone-density effects of DMPA.78,80 Levonorgestrel IUDs also provide an important option for adolescent bariatric surgery patients, for whom experts recommend a delay of pregnancy of at least 12 to 18 months after surgery but who often experience a rapid return to fertility after surgery.81 Barriers to pediatricians inserting IUDs, such as lack of training, lack of office capacity, or not seeing enough patient volume to maintain skills, pose an access problem, which can be overcome by identifying specific providers in the community to whom these patients can be referred.

DMPA, also known by the brand name Depo-Provera (Pfizer, New York, NY) is a long-acting progestin that is given as a single injection every 13 weeks (up to 15 weeks) using a dose of either 150 mg delivered intramuscularly or 104 mg delivered subcutaneously; the feasibility of self-administration of the latter is currently under investigation. Both regimens have similar effectiveness and side effects.82 DMPA can be initiated on the same day as the visit (“mid-cycle” or “quick” start). The CDC states that even if pregnancy cannot be definitively ruled out, the benefits of initiating DMPA exceed the risks and that DMPA can be initiated at any time, with a follow-up pregnancy test in 2 to 4 weeks.42 

DMPA is highly effective in preventing pregnancy. In the first year of use, the probability of becoming pregnant by typical users is approximately 6% (perfect use is 0.2%; see Table 4).43 Some experts believe that the use of DMPA, which first became available in the United States in 1992, is one factor responsible for the declining rates of adolescent pregnancy in the United States.5,83 

DMPA is convenient for many adolescents because of its ease of use compared with coitus-dependent methods or those that require daily, weekly, or monthly adherence. Other advantages, similar to combined hormonal methods, include improvement in dysmenorrhea and protection against iron-deficiency anemia and endometrial cancer.84 DMPA may be safely recommended for adolescents who are lactating85 and most of those who have chronic illnesses.58 It may provide additional benefits in some circumstances, for example, by raising the seizure threshold85 and decreasing sickle cell crises.87,88 Despite recent work suggesting that DMPA may result in an increased risk of venous thrombosis,89 for patients at risk for estrogen-related complications, the advantages of DMPA are still believed to outweigh the risks.58 

The major disadvantages of DMPA for adolescents are menstrual cycle irregularities (present for nearly all patients initially), the need for an injection every 13 weeks, and potential adverse effects, including weight gain and interference with normal increases in bone density. Other adverse effects include headache, mastalgia, hair loss, and change in libido. Although rare, anaphylaxis to DMPA has been described.90 

The irregular bleeding associated with DMPA typically improves over time.91,92 Studies have demonstrated that patients are more likely to continue DMPA use if they are counseled about adverse effects before their first injection, but these studies did not target adolescents specifically.93,94 Long-term DMPA use is also associated with a delayed return to fertility, typically 9 to 18 months, while the endometrial lining returns to its pre-DMPA state and ovulatory function returns. Both subcutaneous and intramuscular DMPA show similar delays to fertility after injection.95 However, for adolescent patients, such a delay does not usually pose a major deterrent to using this method.

Although a number of observational studies have found an increased risk of weight gain among young women using DMPA,96,100 a recent Cochrane review101 evaluated this subject and identified only 2 high-quality and 2 moderate-quality studies, only one of which102 demonstrated that adolescents using DMPA had increased body fat percentage and decreased lean body mass. This finding, in contrast to widespread clinical observations about significant weight gain with DMPA, could be explained by significant variability in the trajectories of weight gain among women using DMPA. Bonny et al103 studied 97 adolescents and found that 21% experienced early weight gain, defined as an increase in weight of more than 5% at 6 months. Over 18 months, those early gainers experienced an increase in mean BMI of 7.6 compared with 2.3 for non-early weight gainers. Similar findings in adult patients104 suggest that weight-gain status at 6 months is a strong predictor of future excessive weight gain with ongoing DMPA use but that weight gain on DMPA is not a uniform finding for all patients.96,98 

Because DMPA suppresses circulating estradiol concentrations, it causes lack of BMD accrual105,107 and has an adverse effect on biochemical markers of bone formation and resorption.108 In response to these concerns, the Food and Drug Administration (FDA) issued a “black-box” warning regarding the risk of decreased BMD among DMPA users in November 2004.109 The warning recommended using DMPA for longer than 2 years only if other methods are inadequate, noting a lack of certainty regarding peak BMD attained later in life among users of DMPA. Since that time, 3 publications have described prospective studies of adolescent and young adult women during and after use of DMPA.110,112 All 3 documented substantial recovery of BMD after DMPA use, thus, offering reassurance about the long-term skeletal health of adolescent patients who use DMPA. The American College of Obstetricians and Gynecologists, recognizing the risk of unwanted pregnancy if adolescents’ contraceptive options are limited, does not advise limiting DMPA use to 2 years, nor does it recommend monitoring BMD after that time frame.83 In addition, some experts113 dispute the limited data that suggest a link between DMPA use and elevated risk of fractures in reproductive-age women114,115 and have called for removal of the black box warning.

Although recent studies are reassuring about the likelihood of bone recovery after DMPA cessation, it is important to consider other risk factors for osteoporosis and to tailor counseling and recommendations to each patient. Factors such as small body habitus, chronic alcohol or tobacco use, eating disorders, or illness that necessitates chronic use of corticosteroids may lead a clinician to more strongly encourage alternatives to DMPA. All patients should be encouraged to include foods and/or supplements to ensure intake of at least 1300 mg calcium each day along with 600 IU vitamin D,116 to participate in weight-bearing exercise regularly, and to stop smoking as important measures to promote skeletal health. Clinicians must remind patients that, as with all hormonal methods of contraception, condoms should be used in conjunction with DMPA for protection from STIs.

COCs have been available for more than 50 years. They are a reliable, effective method for the prevention of pregnancy, are available only by prescription in the United States, and are the most popular method of hormonal contraception among adolescents (see Tables 1 and 2). They are the prototype for other combined methods of birth control, including the vaginal ring and transdermal patch (discussed later), which have similar effectiveness, contraindications, medical benefits, and side-effect profiles.

COC Prescribing

COCs all contain an estrogen and a progestin. In almost every pill, the estrogen component is ethinyl estradiol, in amounts varying from 10 to 50 µg, with “low-dose” pills (35 µg or less) being first-line options for adolescents. An internal pelvic examination is not needed before initiation of this method nor any other method except an IUD. However, routine screening for STIs is recommended in all sexually active patients. (For a more complete discussion of gynecologic examinations of adolescents in the pediatric office setting, see the 2010 AAP clinical report on the subject.117) COCs can be started on the same day as the visit (“quick start”), or on the day following EC use (see section on EC) in healthy, nonpregnant adolescents. Patients should be counseled that a back-up method (ie, condoms or abstinence) should be used for at least the first 7 days for contraceptive efficacy, and a condom should be used at all times for protection against STIs. A routine follow-up visit 1 to 3 months after initiating COCs is useful for addressing persistent adverse effects or adherence issues.

There is no 1 pill formulation that is the best choice for every adolescent, and even within the “low-dose” range, changing the amount of estrogen or the type of progestin may be necessary to address adverse effects or optimize medical benefits. Patients also should be informed of common transient adverse effects, including irregular bleeding, headache, and nausea. Neither weight gain nor mood changes have been reliably linked to use of combined hormonal contraception.118,120 Recommendations for managing adverse effects have been published elsewhere121 or can be found online (http://www.managingcontraception.com/qa/index.php). COCs have few contraindications in healthy female adolescents. They should not be prescribed for patients with severe and uncontrolled hypertension (systolic pressure ≥160 mm Hg or diastolic pressure ≥100 mm Hg); ongoing hepatic dysfunction; complicated valvular heart disease; migraines with aura or focal neurologic symptoms; complications of diabetes (ie, nephropathy, retinopathy, neuropathy, or other vascular disease); complicated solid organ transplantation; or thromboembolism or thrombophilia (eg, factor V Leiden mutation; antiphospholipid antibody syndrome; or protein C, protein S, or antithrombin 3 deficiency).111 An excellent and up-to-date resource for prescribing hormonal contraceptives, the “US Medical Eligibility Criteria for Contraceptive Use,” is available on the CDC Web site (http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm) and in print.58 These recommendations weigh the risks and benefits of contraceptive methods against unwanted pregnancy. When hormonal methods are used for medical therapy, the risk/benefit ratio may differ, and treatment decisions should be considered on a case-by-case basis. Other useful resources include a 2004 detailed discussion of contraceptive choices for patients with congenital heart disease122 and a recent publication offering expert guidance on prescribing contraception to adolescents at increased risk of hypercoagulability.123 The most serious adverse event associated with COC use is the increased risk of blood clot, which is discussed in further detail in the following paragraphs.124 Although smoking should be discouraged, it is not a contraindication to COC use in teenagers and young adults.58 

New data have continued to emerge regarding the risks and benefits of different progestins. On April 10, 2012, the FDA posted a drug safety communication that resulted in revised drug labels for COCs containing the progestin drospirenone.125 These note that epidemiologic studies reported as high as a threefold increase in the risk of blood clots for drospirenone-containing products when compared with products containing levonorgestrel or some other progestins, whereas other epidemiologic studies found no additional risk of blood clots with drospirenone-containing products.

However, it is important to remember that most of the risk of blood clot is conferred from the estrogen component of the pill and that all COCs confer a lower risk of blood clot than pregnancy.126 The baseline incidence of venous thromboembolism in adolescents is up to 1 per 10 000 woman-years per year.127 Currently available COCs increase the risk of blood clot three- to fourfold, or up to 4 per 10 000123,124 woman-years. In comparison, the incidence of venous thromboembolism (VTE) associated with pregnancy and the postpartum period is 10 to 20 per 10 000 woman-years, of which 1% to 2% are fatal.128,129 

COCs decrease the effectiveness of some medications (eg, lamotrigine). Conversely, other medications, such as anticonvulsants and antiretroviral agents, decrease COC effectiveness to the extent patients may need to choose alternative methods130 (see Table 5 and Special Populations). With regard to antibiotics, neither a 2001 review of the literature131 nor a 2011 case-crossover study of 1330 COC failures132 found any definitive evidence of decreased COC effectiveness with the use of any antibiotic except rifampin.

Used perfectly, COCs are extremely effective, with a perfect-use failure rate for all users of 0.3%; however, the typical-use failure rate is 9%, suggesting that adherence is a key issue in COC use (see Table 4).43 Counseling should include strategies to promote adherence, such as cell phone alarms and support from a family member or partner. Patients should be instructed on what to do if pills are missed. A missed pill should be taken as soon as it is remembered. If more than 1 pill in a row is missed, only the most recently missed pill should be taken as soon as possible, and the remaining pills should be taken at the usual time, reminding patients that 7 consecutive hormone pills are required to prevent ovulation. Further instructions can be accessed online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6205a1.htm?s_cid=rr6205a1_w#Fig2.42 Patients should also be advised that EC may be needed if 2 or more pills are missed in the first week or if 1 or more pills were missed earlier in the same cycle or late in the previous cycle (see online instructions and Fig 1 for details).

FIGURE 1

Instructions for late and missed combined oral contraceptive pills.

FIGURE 1

Instructions for late and missed combined oral contraceptive pills.

COC Regimens

COCs are currently available in fixed-dose, monophasic regimens (each tablet contains the same dose of estrogen and progestin) or in phasic regimens (triphasic and biphasic packs that contain varying doses of estrogen and progestin). Standard pill packs include 28 pills total, with 21 to 24 hormone pills and 4 to 7 placebo (hormone-free) pills. Among low-dose pills, there are no clear data suggesting one formulation is superior to another for adolescent use, so it is appropriate to choose one with the lowest copay on a patient’s insurance formulary (if applicable). Many experts recommend starting adolescents on a monophasic pill with monthly bleeding and then changing regimens and/or extending cycles, as indicated, to address patient adverse effects or preference.121 Many adolescent medicine providers begin with a COC containing 30 to 35 µg of ethinyl estradiol and a progestin, such as levonorgestrel or norgestimate.

The benefits of decreasing or eliminating the placebo hormone-free interval (see section on COC benefits) have been increasingly recognized, and there are several regimens packaged with more than 21 active pills and fewer placebo pills. For example, some regimens (eg, Yaz [Bayer, Leverkusen, Germany], and Generess FE [Watson, Parsippany, NJ]) have 24 active pills and 4 pills without hormones. Several brands are available with 84 active pills and 7 placebos, or 84 active pills and 7 pills of low-dose estrogen (eg, Seasonique and LoSeasonique; Teva, Petah Tikva, Israel). In 2007, the FDA approved the first COC packaged with a year of continuous combined hormone pills, Lybrel (Pfizer, New York, NY).

COC Benefits

The noncontraceptive benefits of COC use include decreased menstrual cramping and blood loss and improvement in acne. Extended or continuous cycles may be particularly appropriate for adolescents with medical conditions, such as anemia, severe dysmenorrhea, endometriosis, abnormal uterine bleeding, and Von Willebrand and other bleeding diatheses and for adolescents who prefer amenorrhea.133 These regimens may also be useful for conditions that are known to be exacerbated cyclically, such as migraine (without aura), epilepsy, irritable bowel syndrome, some psychiatric symptoms,134 and behavioral problems (such as increased aggression or self-mutilation) that sometimes worsen cyclically in young women with profound cognitive impairment.135 The most common adverse effect of extended-cycle regimens is unscheduled bleeding. Eliminating the hormone-free interval will also minimize fluctuations in medications that interact with COCs (see section on Special Populations). In addition, ovarian suppression is optimized by COC regimens with shorter or no placebo (hormone-free) intervals, potentially increasing contraceptive effectiveness, especially among adolescents who frequently miss pills.136,138 

Families can be reassured that COC use has not been shown to increase the risk of breast cancer.139 Also, use of COCs for more than 3 years provides significant protection against endometrial and ovarian cancers.140 Overall, COCs are one of the best-studied medications ever prescribed. Completely reversible and with no negative effect on long-term fertility, COCs are a safe option throughout a woman’s reproductive years.

Contraceptive Vaginal Ring

The vaginal ring (NuvaRing; Merck) releases 15 µg ethinyl estradiol and 120 µg etonogestrel (the active metabolite of desogestrel) daily. It is a round, flexible device that measures 54 mm in outer diameter and 4 mm cross-sectionally. This soft silicone vaginal ring releases both estrogen and progestin hormones that protect against pregnancy for 1 month. It is inserted in the vagina and stays in place for 3 weeks, with removal for 1 week to induce menstruation followed by insertion of a new ring. Patients should be instructed to insert a new ring after 7 days even if bleeding has not ceased.

Because adolescents may be unfamiliar with their own reproductive anatomy, a pelvic model141 or other visual aid may be useful in explaining to patients where the ring will be. Patients should be reassured that the ring will not fall out. Eighty women (∼90% of them nulliparous) were examined with the ring in place and none were able to expel the ring by bearing down in a Valsalva maneuver.142 The ring typically sits with the superior-most portion of the ring lying posterior to the cervix.143 

Most patients will not have previous experience with intravaginal medication and may have questions about its use, such as whether tampons can be worn when the ring is in place. On the basis of evaluation of serum concentrations of ethinyl estradiol and etonogestrel, contraceptive efficacy should not be compromised by concomitant use of tampons,144 the spermicide nonoxynol-9,145 or intravaginal miconazole.146 Similarly, the ring is intended to stay in place during coitus but can be removed for up to 3 hours if desired. This is not typically recommended, and sexually active patients may be reassured to know that most men were not bothered by its presence, if it was noted at all.142,147 

The ring has comparable typical-use failure rate (9%), risks, and benefits as other combined hormonal methods43 but provides the simplest regimen.148,149 As with COCs, a same-day start can be used with the vaginal ring. Adverse effects are largely similar to other combined methods, including breast tenderness, headaches, nausea, and breakthrough bleeding or spotting, with the additional vaginal symptoms of discharge, discomfort, and problems related to the device (eg, expulsion).150 The limited investigation of bone health with the ring points to its bone neutrality, but these studies have not included adolescents younger than 18 years.151,152 Studies to date have yielded inconsistent results about how the risk of VTE with use of the ring compares with the risk with use of low-dose COCs.153,156 

Analogous to experience with the contraceptive patch, it has not been clearly demonstrated that the simplified regimen afforded by the ring results in improved medication adherence or continuation in young people.157 A trial of 237 college students randomized to use either the ring or COC found that perfect use was greater for the ring in the first 2 months but that this was no longer statistically significant in the third month of the study. Similarly, 6-month continuation rates were no different and were less than 30% for both groups.158 

The ring is an excellent method for extended use. The vaginal ring package insert states that 1 ring can be used for up to 28 days with no back-up method; however, the rings contain sufficient medication to be used for up to 35 days159 and, thus, can be replaced once every calendar month. This eliminates the need for additional refills potentially not covered by insurers, which sometimes poses barriers to continuous pill and patch regimens. As with COCs, the longer the duration of continuous hormones, the greater the number of unscheduled bleeding days; however, the difference between a 28-day and 49-day cycle is small.160 Similar to COCs, the decision about how often to allow uterine bleeding to occur can be individualized to the adolescent’s medical needs and preferences. Women who choose to use the ring continuously with no planned ring-free days can be advised to remove the ring for 4 days if they have more than 5 days of consecutive bleeding, as this has been found to result in fewer bleeding days overall.161 

The combination hormone transdermal contraceptive patch (Ortho Evra [Ortho-McNeil Pharmaceutical, Raritan, NJ]) contains 0.6 mg norelgestromin and 0.75 mg ethinyl estradiol and measures approximately 1.75 × 1.75 in. The patch can be placed on the abdomen, upper torso, upper outer arm, or buttocks, using 1 patch for each of 3 weeks in a row, followed by 1 week off the patch, during which a withdrawal bleed usually occurs. Current estimates of failure rates for typical use are 9% (<1% for perfect use).43 Approved by the FDA in November 2001, patch use rose in popularity until 2005, when use declined162 after publicity about increased estrogen exposure from the patch, which has been found to be 1.6 times higher than estrogen exposure with a COC.153 The patch has undergone multiple label revisions, most recently August 22, 2012. The 2012 package insert contains a black box warning citing 5 US studies163,170 (1 with statistically significant findings) that suggest a possible increased risk of VTE compared with a 20- to 35-µg COC, with odds ratios of 1.2 to 2.2. Although these potential health risks are concerning to some adolescents, the patch remains an important contraceptive alternative that may be the best option for some adolescents, especially in comparison with the many adverse consequences of unplanned pregnancy, which include an increased risk of VTE. Nonetheless, other methods may be safer first-line choices for patients interested in extended cycling.

The patch has comparable efficacy, benefits, and drug interactions as other combined methods, but provides a simpler regimen. Thus, it was initially assumed that the patch would promote improved contraceptive adherence in adolescents. Accordingly, early studies demonstrated better adherence to the patch than to COCs among adults,171,172 most notably among 18- and 19-year-olds,173,174 and 2 smaller studies of adolescents had high rates of self-reported short-term perfect patch use, 87% and 93%.175,176 However, contraceptive effectiveness requires that the method be sufficiently well accepted to be continued over time.

To our knowledge, there are no studies that have randomized adolescents to use either the patch or pills, and the observational studies that have compared these methods are plagued by possible selection bias; adolescents who choose a nondaily method may have behavioral characteristics that would interfere with continuation and perfect use of any method.177,179 For example, Bakhru and Stanwood177 prospectively followed 1230 women (416 of whom were 17 years or younger) who self-selected their method and found 57% continuation of the patch at 1 year compared with 76% continuation of the pill (P = .004). In contrast to their initial hypothesis, patch users were significantly less likely than pill users to continue their method and, thus, were more likely to experience pregnancy.177 Even lower rates of patch continuation, ranging from 25% to 50%, have been found in other longitudinal studies of adolescent patch users.179,181 

In addition, similar findings have been shown in randomized studies of adults. A 2010 Cochrane review182 (based on 4 such studies) concluded that patch users were more likely than pill users to discontinue study participation because of adverse effects. Similarly, in a study that randomized 500 women (average age, 25–26 years) to either the patch or the contraceptive vaginal ring, only 27% of patch users (versus 71% of ring users) planned to continue their assigned method after the 3-month study concluded.183 

Side effects of the patch are largely similar to other combined methods, with the addition of local adverse effects, such as dislodged patches and hyperpigmentation,175,176 contact dermatitis and other skin irritation,184 and concerns about the visibility and appearance of the patch.185,186 Investigations into the patch’s effect on bone health have yielded inconsistent results, with findings in adults150,151 more reassuring than those in adolescents.187 However, this limited work is far from conclusive.

Progestin-only pills (POPs, also known as “mini-pills”) work primarily by thickening cervical mucus, not by inhibiting ovulation. Because of the timing of this effect, it is generally recommended that pills be taken between 4 and 22 hours before coitus usually takes place. Perfect and typical-use failure rates for POPs are not calculated separately from those of combined hormonal contraceptives. Given the importance of even small variations in the timing of pill administration and the continued potential for ovulation, POPs are generally held to be less effective than combined hormonal methods.

Similar to other progestin-only methods, irregular bleeding is a common adverse effect. However, POPs are markedly less effective than other progestin-only methods, including the progestin-containing IUD, the progestin implant, and injectable progestin. Therefore, POPs are not typically recommended as a first-choice contraceptive in healthy adolescents. Nonetheless, they provide a progestin-only alternative for selected adolescent patients with demonstrated excellent medication adherence.

The male condom is a mechanical barrier method of contraception and STI prevention. In a recent nationally representative survey, condom use was reported at first intercourse by 68% of adolescent girls and 80% of adolescent boys and at most recent intercourse by 52% of adolescent girls and 75% of adolescent boys.188 Male condoms have several advantages for adolescents, including involving males in the responsibility of contraception, easy accessibility and availability to minors, use without a prescription, and low-cost STI protection.

Male condoms are most commonly made of latex. Lubricated condoms are used for vaginal and anal intercourse; unlubricated condoms are available for oral sex. Although many individuals will need additional lubrication with condoms, adolescents’ lubricant use is rarely assessed. Condoms should be used only with water-based lubricants (eg, K-Y Jelly [McNeil PPC Inc, Fort Washington, PA], Astroglide [Biofilm Inc, Vista, CA]), because oil-based lubricants (eg, petroleum jelly, massage oils, body lotions) can weaken latex and cause breakage. Male condoms also are available as polyurethrane (synthetic) for people with latex sensitivities and as natural membrane (eg, lamb cecum). Polyurethrane condoms have similar effectiveness to latex condoms but are more resistant to deterioration and are compatible with both oil- and water-based lubricants. Natural membrane condoms are porous and provide inadequate STI protection.

Condom effectiveness depends on consistent and correct use (see Table 6).189 For pregnancy prevention, the failure rate at the end of first-year use for the male latex condom is 2% with perfect use and 18% with typical use.43,190 Consistent evidence supports condoms as reducing the risk of disease transmitted to and from the penile urethra, including gonorrhea, Chlamydia, trichomoniasis, hepatitis B, and HIV.191,195 Emerging evidence also supports condoms as reducing the risk of acquiring diseases transmitted through skin or mucosal contact, including genital herpes simplex virus,196,197 human papillomavirus,198,199 and syphilis.200 Because condoms protect against STIs, all sexually active adolescents should be encouraged to use condoms, regardless of whether an additional contraceptive method is used. Instructions for condom use can be found in Table 6. Additional details on condoms and recommendations can be found in the AAP policy statement on condom use by adolescents.201 Despite increases in condom use, many adolescents do not use condoms effectively or at all. Condom use is influenced by individual, relationship, and broader social and structural factors,202,204 which should be addressed on multiple levels, including provider counseling, sex education, and interventions to improve access. Because condom use requires cooperation and communication between partners, condom use within relationships changes as relationships evolve205 and commonly declines in established relationships.206,207 

TABLE 6

How to Use a Condom Effectively

Before: Store condoms in a cool, dry place. Heat, including body heat from a pocket, can cause latex to degrade over time. Check the expiration date before use. 
1. Use a new condom for every act of vaginal, anal, and oral sex throughout the entire sex act (from start to finish). 
2. Before any genital contact, put the condom on the tip of the erect penis with the rolled side out. 
3. If the condom does not have a reservoir tip, pinch the tip enough to leave a half-inch space for semen to collect. Holding the tip, unroll the condom all the way to the base of the erect penis. 
4. After ejaculation and before the penis gets soft, grip the rim of the condom and carefully withdraw. Then gently pull the condom off the penis, making sure that semen does not spill out. 
5. Wrap the condom in a tissue and throw it in the trash where others will not handle it. 
6. If you feel the condom break at any point during sexual activity, stop immediately, withdraw, remove the broken condom, and put on a new condom. 
7. Ensure that adequate lubrication is used during vaginal and anal sex, which might require water-based lubricants. Oil-based lubricants (eg, petroleum jelly, shortening, mineral oil, massage oils, body lotions, and cooking oil) should not be used, because they can weaken latex, causing breakage. 
Before: Store condoms in a cool, dry place. Heat, including body heat from a pocket, can cause latex to degrade over time. Check the expiration date before use. 
1. Use a new condom for every act of vaginal, anal, and oral sex throughout the entire sex act (from start to finish). 
2. Before any genital contact, put the condom on the tip of the erect penis with the rolled side out. 
3. If the condom does not have a reservoir tip, pinch the tip enough to leave a half-inch space for semen to collect. Holding the tip, unroll the condom all the way to the base of the erect penis. 
4. After ejaculation and before the penis gets soft, grip the rim of the condom and carefully withdraw. Then gently pull the condom off the penis, making sure that semen does not spill out. 
5. Wrap the condom in a tissue and throw it in the trash where others will not handle it. 
6. If you feel the condom break at any point during sexual activity, stop immediately, withdraw, remove the broken condom, and put on a new condom. 
7. Ensure that adequate lubrication is used during vaginal and anal sex, which might require water-based lubricants. Oil-based lubricants (eg, petroleum jelly, shortening, mineral oil, massage oils, body lotions, and cooking oil) should not be used, because they can weaken latex, causing breakage. 

In the United States, the available methods of EC include orally administered hormones, either in a progestin-only dedicated EC product (levonorgestrel, 1.5 mg) or in high-dose combined estrogen and progestin oral contraceptive pills (the Yuzpe regimen); ulipristal acetate (a progesterone receptor modulator); and insertion of a copper IUD. These methods can prevent pregnancy when initiated up to 5 days after an act of underprotected sexual intercourse but are more effective the sooner they are used. Data suggest that ulipristal acetate, approved by the FDA in 2010, may have increased effectiveness over oral levonorgestrel at the end of the 5-day window of use and in heavier women.208,210 On the basis of data demonstrating that the levonorgestrel EC pill loses effectiveness in women who weigh more than 165 pounds and is ineffective in women who weigh more than 176 pounds, the levonorgestrel EC pill is undergoing revised labeling in Europe, and the FDA is considering whether to require similar revisions in the United States.211 

Unlike ulipristal, which is pregnancy category X, levonorgestrel does not have teratogenic or other adverse effects on the fetus,212 and a pregnancy test is not necessary before prescribing levonorgestrel EC.213 Levonorgestrel EC is estimated to be up to 85% effective.213,214 Additional details on prescribing EC can be found in the AAP policy statement on emergency contraception,213 and additional guidance can be found at http://ec.princeton.edu/questions/dose.html#dose.

Plan B One-Step (Teva Pharmaceuticals, Petah Tikva, Israel), a dedicated progestin-only method, is approved by the FDA as a nonprescription product for all women of childbearing potential. Generic versions are approved as nonprescription for women 17 years of age and older; however, proof of age is not required to purchase them.

Given the barriers to EC access and the importance of timely use, advance prescription for EC should be a part of routine adolescent care.213 There are no medical contraindications to this method, and multiple studies have found that providing EC in advance increases the likelihood of women using it when it is needed and does not increase sexual or contraceptive risk-taking behavior.215,216 Given the sometimes sporadic and unplanned nature of adolescent sexual behavior, counseling and advance provision of EC should be a part of anticipatory guidance.

Female Condoms

The female condom is a polyurethrane or synthetic nitrile pouch with 2 flexible rings, one fitting inside the vagina and the other on the perineum. Female condoms have a perfect-use failure rate of 5% and a typical-use failure rate of 21%.43 Among US adolescents and young adults, the female condom has had very low uptake,217 in part because of higher cost, less availability, lack of knowledge, and negative attitudes toward female condoms.

Vaginal Spermicides

Vaginal spermicides are a chemical barrier method (most commonly nonoxynol-9) applied intravaginally through a variety of forms: gel, foam, suppository, or film. Spermicides consist of 2 components: a formulation (the gel, foam, suppository, or film) and the chemical ingredient that kills the sperm. Table 4 describes typical- and perfect-use failure rates for vaginal spermicides. The CDC identifies being at high risk for HIV (eg, commercial sex workers) and HIV infection as contraindications for use of spermicides, as use can disrupt the cervical mucosa, potentially increasing risk of HIV acquisition or increased viral shedding and transmission of HIV.58,218 

Diaphragm, Cervical Cap, and Contraceptive Sponge

The diaphragm, cervical cap, and sponge are barrier methods of contraception. They are less commonly recommended for adolescents, because they do not provide STI protection and have lower effectiveness rates than other methods.43 Diaphragms are flexible latex cups used with spermicide that are inserted into the vagina before intercourse and must remain in place for 6 hours after intercourse. Cervical caps are latex or silicone cups with a firm rim that adhere to the cervix and provide continuous contraceptive protection for up to 48 hours. Sponges are polyurethane sponges that contain nonoxynol-9 spermicide. They are approximately 2 inches in diameter, can be inserted up to 24 hours in advance, and must be left in place for 6 hours after intercourse. Sponges are available over the counter. Diaphragms and caps require fitting by a health care professional. Table 4 provides typical- and perfect-use failure rates for the diaphragm, cervical cap, and contraceptive sponge. For the sponge, typical- and perfect-use failure rates are as much as 16% and 11%, respectively.219 These methods are contraindicated in women at high risk of HIV or women with HIV infection, because the concomitant spermicide use may increase risk of HIV acquisition or transmission.58 Detailed information can be found in Contraceptive Technology.41 

Periodic abstinence methods identify fertile days within each menstrual cycle, and the individual abstains during those fertile times. Fertile days can be determined using a menstrual calendar, basal body temperature, and cervical mucus consistency. In a recent national survey, 17% of adolescents report ever using periodic abstinence.6 Among both adults and adolescents, as many as 24% of individuals reporting periodic abstinence as their primary method of contraception will experience an unintended pregnancy within the first year of use. More concerning is the poor continuation rates for the method,220 even for individuals participating in clinical trials.221 An additional challenge with adolescents is that ovulation may not be predictable in the first few year(s) after menarche. If periodic abstinence is used, counseling on dual use of a condom and more reliable alternative methods should be offered. More detailed information can be found in Contraceptive Technology.41 

Withdrawal, or coitus interruptus, is a method in which the male partner attempts to “pull out” his penis before ejaculation. Although typically considered a “nonmethod,” withdrawal is commonly practiced by both adults and adolescents. In the National Survey of Family Growth 2006 to 2008, 8% to 11% of respondents reported using withdrawal at first sex,6 and in the 2006 to 2010 survey, 57% of adolescents reported ever using withdrawal as a contraceptive method.188 Adolescents’ reasons for using withdrawal include dissatisfaction with hormonal methods, and as a secondary or back-up method to condoms or hormonal contraception.222 Relationship development and the establishment of trust also were cited as reasons for use of withdrawal.222 The typical-use failure rate of withdrawal across all age groups is 22%43; however, unlike condoms, it provides no STI protection. Because of the common use of withdrawal, pediatricians should remember to ask about it; because of the limited effectiveness43 and lack of STI protection afforded by withdrawal, pediatricians should encourage adolescents to adopt more effective hormonal and/or barrier methods.

Pediatricians care for adolescents with a range of medical conditions that can affect sexuality, sexual behavior, and contraceptive needs. The CDC has recently addressed the contraceptive needs of young women with medical conditions in its publication “US Medical Eligibility Criteria for Contraceptive Use.”58 Available online, this document summarizes the literature on safety and efficacy of different contraceptive methods by medical condition. Populations of particular importance to pediatricians are summarized as follows.

Adolescents With Disabilities

An estimated 16% to 25% of adolescents are identified as having special health care needs, including physical disability, developmental disability, and chronic illness.223 Sexuality and sexual health care needs in this population are often overlooked, yet data reveal that adolescents with disabilities and chronic illnesses have similar levels of sexual behaviors and sexual health outcomes (eg, STIs).224,225 Adolescents with disabilities and chronic illnesses also have similar needs for counseling and support of healthy sexuality development.226,227 These data underscore the need for pediatricians to address sexuality and contraception as part of routine care and as a core function of a medical home, particularly for adolescents using teratogenic medications.

Adolescents with more severe physical disabilities or cognitive impairment may need hormonal contraceptives for menstrual control and hygiene. Adolescents with disabilities may have early or irregular menstrual cycles,228 and medications such as certain anticonvulsants and antipsychotics may influence the neuroendocrine system, leading to abnormal bleeding.229 Menstrual hygiene also may present a special problem for adolescents with motility and transfer difficulties, as well as for those with behavioral and developmental disabilities.230 Menstrual control and suppression is commonly achieved with COCs, transdermal patches, DMPA, and levonorgestrel IUDs.77,231,232 Continuous or extended cycles of COCs is a common approach,231,232 and there are reports of successful use of 52-mg levonorgestrel IUDs in adolescent patients.76,77,80 Surgical approaches (tubal ligation, endometrial ablation, or hysterectomy) are rarely necessary and present special ethical and legal issues. A detailed discussion of menstrual management for adolescents with disabilities can be found in recent review articles as well as professional consensus statements.231,233 

Adolescents With Obesity

Similar to adolescents with disabilities, sexuality and sexual health are often overlooked among adolescents with obesity. Although national data demonstrate some weight and BMI-related variation in body image and sexual behaviors, the sexual behaviors and sexual health needs of adolescents with obesity are substantially similar to those of their normal-weight peers.234,235 Obesity and related endocrine effects may influence the efficacy and adverse effect profiles of contraceptives, including EC (see previous section on EC). Excess pregnancies were found among transdermal contraceptive patch users weighing more than 90 kg (198 lb; 0.9% vs 0.3% among “perfect” users).236,237 Data are limited and inconsistent about whether hormonal contraceptive effectiveness varies by body weight or BMI.58 Systematic reviews and large cohort studies have revealed no or mixed effects for the effect of both body weight and BMI on COCs, IUDs, implants, and contraceptive injections.238,240 When examining complications, the World Health Organization and CDC found that among adult women, COC users with obesity are more likely than nonusers to experience thromboembolic complications.111 However, the absolute risk of thromboembolic complications among adolescent COC users is low.

Women with obesity, either with or without polycystic ovary syndrome, are often anovulatory and experience infrequent menses. Metformin is frequently used in the treatment of these women and can increase the frequency of ovulation, increasing their contraceptive needs. A frequent concern by both adolescents and providers is additional weight gain with hormonal contraceptive use among adolescents with obesity. Adult data suggest that women with obesity are not more likely to have significant weight gain with combined or progestin-only contraceptives.241,243 In contrast, adolescents with obesity who used DMPA were more likely than normal-weight nonusers, COC users with obesity, and normal-weight DMPA users to gain weight.96 

Increasing numbers of adolescents are having bariatric surgery performed, and these patients present special contraceptive needs. Presurgery data reveal a high prevalence of menstrual problems among adolescents with morbid obesity.81 Postsurgery data demonstrate an improvement in fertility, and professional consensus statements recommend delaying pregnancy for at least 12 to 18 months after bariatric surgery.244 Together, these suggest a need for highly effective contraceptives in such patients. The surgical procedures themselves may influence effectiveness of contraceptives. Postoperative complications, such as long-term diarrhea and/or vomiting, have the potential to decrease COC effectiveness.58 Additionally, surgical procedures involving a malabsorptive component have the potential to decrease COC effectiveness.58 Similar concerns about decreased COC effectiveness have not been described with laparoscopic placement of an adjustable gastric band. Given the challenges with oral, transdermal, and injectable contraceptives and the need for effective long-term postprocedure contraceptives, there is increasing use and success with levonorgestrel IUDs placed at the time of surgery.81 

Adolescents With HIV

The vast majority of adolescents with HIV acquire their infection during adolescence through sex, intravenous drug use, or other behavioral mechanisms. Only a small proportion of adolescents with HIV are infected perinatally. National data reveal that sexual behaviors of HIV-infected adolescents do not differ substantially from their uninfected peers, and therefore, these adolescents have similar contraceptive and sexual health needs. However, because of risks of transmission to partners and because of drug interactions with antiretroviral therapy (ART), adolescents with HIV infection present a challenge to prescribing contraception. Many antiretroviral agents have interactions with COCs, and a physician with expertise in HIV care should be consulted when prescribing hormonal contraception for an HIV-infected adolescent on ART.58,245 The CDC and the World Health Organization provide guidance on prescribing different contraceptives for patients with HIV infection receiving ART.246 Condoms are the preferred method of barrier contraception because of their demonstrated ability to decrease HIV transmission. Spermicides and diaphragms are contraindicated among HIV-positive women because of the potential for increased risk of genital lesions and potential increased risk of HIV transmission associated with nonoxynol-9. IUDs do not increase the risk of HIV acquisition or transmission and are safe and effective for HIV-infected individuals without increasing the risk of infections or complications in HIV-infected women. If COCs are used in HIV-infected adolescents receiving ART, a preparation containing ethinyl estradiol ≥30 µg should be prescribed.58 

Data on the interactions between ART and hormonal contraceptives (both combined and progestin only) are limited, but effects are known to include increased ART toxicity and, in the case of ritonavir-boosted protease inhibitors, decreased contraceptive steroid concentrations, potentially compromising contraceptive effectiveness. Other ART regimens (eg, etravirine-containing regimens) are teratogenic, necessitating highly effective contraceptives.246 

Adolescent Recipients of Solid Organ Transplantation

The improved survival of pediatric recipients of solid organ transplantation has prompted increased attention to quality-of-life issues, including involvement in romantic and sexual relationships, issues that are typically addressed by the patient’s pediatrician. Neither transplantation nor immunosuppressant medications decrease fertility, and conception can occur as early as 3 weeks after liver transplantation.247,248 Similar to other adolescents with chronic illnesses, transplant recipients are likely to be as sexually active as their peers.225,249,253 However, because these patients may underestimate their own fertility and because subspecialty physicians underestimate sexual activity and contraceptive needs in patients with chronic disease, it is imperative that primary care physicians assess these issues.254,256 

For transplant recipients who choose not to remain abstinent, a highly effective method is indicated. Patients who have established normal organ function and are stable at least 6 to 8 months after transplantation can use any of the currently available hormonal contraceptives, provided they do not have other contraindications to the estrogen component.58,254,257,258,260 Contraindications to estrogen, however, occur more commonly in transplant recipients. For example, COCs should not be prescribed to patients with active liver dysfunction or coronary artery disease.139 Also, deterioration of organ function or episodes of rejection would require reevaluation and consideration of substituting a nonhormonal method, at least temporarily. Given the excess risks associated with unplanned pregnancies in transplant recipients, knowledge about the availability of EC is especially important.

Potential drug interactions should be assessed, both to avoid drug toxicities and to maintain the effectiveness of all prescribed medications.261 For example, COCs can increase concentrations of immunosuppressive medications, such as cyclosporine, which has a narrow therapeutic window and significant toxicities (see Table 7). Patient care decisions may require consultation with a clinical pharmacologist. To avoid monthly fluctuations in drug concentrations, patients using combined methods should use them continuously, without a hormone-free interval. Although 1 study suggests that immunosuppressant concentrations remain stable with use of the contraceptive vaginal ring,259 both the ring and the patch are sufficiently similar to COCs that, until further data are available, they should be used with the same precautions that apply to COCs. Drug interactions with progestin-only methods are uncommon; however, monitoring cyclosporine concentrations is advisable.262 

TABLE 7

Immunosuppressant Adverse Effects and Interactions With Hormonal Contraception

Type of MedicationDrug InteractionsAdverse Effects Influencing ContraceptionContraceptive Considerations
Corticosteroids (prednisone) COCs may increase plasma concentrations of corticosteroids; monitor for increased corticosteroid effects Hypertension Severe and uncontrolled hypertension is a contraindication to COC use. 
Diabetes Low-dose pills have minimal impact on glucose metabolism. 
Weight gain, osteoporosis Monitor weight and BMD carefully if DMPA is used. 
Azathioprine (Imurana Liver toxicity Liver dysfunction interferes with estrogen metabolism. 
Mycophenolate mofetil (CellCeptb Diarrhea, vomiting Severe gastrointestinal disturbance could decrease COC absorption. 
Cyclosporine, tacrolimus (Prograf,c FK506) COCs may increase levels; monitor blood levels closely Hypertension Severe hypertension is a contraindication to COC use. 
Hyperlipidemia COCs have minimal effect on lipids. 
Hyperkalemia Drospirenone (a progestin with spironolactonelike activity) is contraindicated with hyperkalemia. 
Diabetes Low-dose pills have minimal impact on glucose metabolism. 
Headache Headache can be an adverse effect of steroid hormones: monitor headache frequency.d 
Sirolimus (RapamuneeCOCs may increase levels; monitor blood levels closely Hyperlipidemia COCs have minimal effect on lipids. 
Type of MedicationDrug InteractionsAdverse Effects Influencing ContraceptionContraceptive Considerations
Corticosteroids (prednisone) COCs may increase plasma concentrations of corticosteroids; monitor for increased corticosteroid effects Hypertension Severe and uncontrolled hypertension is a contraindication to COC use. 
Diabetes Low-dose pills have minimal impact on glucose metabolism. 
Weight gain, osteoporosis Monitor weight and BMD carefully if DMPA is used. 
Azathioprine (Imurana Liver toxicity Liver dysfunction interferes with estrogen metabolism. 
Mycophenolate mofetil (CellCeptb Diarrhea, vomiting Severe gastrointestinal disturbance could decrease COC absorption. 
Cyclosporine, tacrolimus (Prograf,c FK506) COCs may increase levels; monitor blood levels closely Hypertension Severe hypertension is a contraindication to COC use. 
Hyperlipidemia COCs have minimal effect on lipids. 
Hyperkalemia Drospirenone (a progestin with spironolactonelike activity) is contraindicated with hyperkalemia. 
Diabetes Low-dose pills have minimal impact on glucose metabolism. 
Headache Headache can be an adverse effect of steroid hormones: monitor headache frequency.d 
Sirolimus (RapamuneeCOCs may increase levels; monitor blood levels closely Hyperlipidemia COCs have minimal effect on lipids. 

Reproduced with permission from Sucato GS, Murray PJ. Gynecologic issues of the adolescent female solid organ transplant recipient. Pediatr Clin North Am. 2003;50(6):1521–1542.

a

Triton Pharma Inc, Concord, Ontario.

b

Genentech USA Inc, South San Francisco, CA.

c

Astellas Ireland Co Ltd, Kerry, Ireland.

d

If headaches increase after initiation of contraceptive method or neurologic symptoms accompany migraine headache, consider changing method.

e

Pfizer, Philadelphia, PA.

Historically, IUDs have been considered contraindicated in immunosuppressed patents because of theoretical risks of both decreased efficacy and increased risk of infection. However, more recent evidence argues against these theoretical risks,263 and the CDC does not consider IUDs contraindicated in patients with stable graft function.58 Although data are currently limited, anecdotal experience with adult transplant recipients suggests the levonorgestrel IUD can be an excellent choice because of the lack of drug interactions and outstanding contraceptive effectiveness.

Adolescent Oncology and Other Medically Complex Patients

Pediatricians may be called on to provide contraceptives for patients with cancer and other complex medical illnesses. In addition to pregnancy prevention, these adolescents may need menstrual suppression for heavy menstrual bleeding, bleeding disorders, or chemotherapy. Other medical conditions, such as rheumatologic illnesses, may present issues related to estrogen use, thromboembolism, or medication interactions. For these and other complex illnesses, the principles have been discussed in the previous sections, and consultation with appropriate adolescent medicine, adolescent gynecology, or family-planning specialists can be sought.

Frequent follow-up is important to maximize adherence for all methods of contraception, to promote and reinforce healthy decision-making, and to screen periodically for risk-taking behaviors and STIs. Follow-up visits should include routine examinations, reassessment for contraception method, STI surveillance, and other sexual health preventive measures, such as human papillomavirus immunization. The timing and frequency of reassessment will vary depending on the contraceptive method and the patient’s other health needs. An internal pelvic examination is not necessary for hormonal contraception (for a more complete discussion of gynecologic examinations of adolescents in the pediatric office setting, see the 2010 AAP clinical report on gynecologic examinations for adolescents).117 Regularly scheduled visits need to occur to assess contraceptive issues, such as use, adherence, adverse effects, and complications. Adolescents should receive ongoing support and reinforcement by using motivational interviewing approaches to enhance effective and consistent contraceptive use, including engaging parental support for contraceptive adherence, when possible. In addition, condom use at each sexual intercourse must be advised and reinforced at every visit. Individual factors, relationship factors, family support, knowledge and understanding of contraceptives, personal resources, access to confidential care, and fertility intentions have all been demonstrated to affect adolescent contraceptive choice. Adolescents rely on trusted health professionals, such as pediatricians, for accurate information, for individualized counseling and prescribing, and for support and problem-solving around continuation and adherence.

Mary A. Ott, MD, MA, FAAP

Gina S. Sucato, MD, MPH, FAAP

Paula K. Braverman, MD, Chairperson

William P. Adelman, MD, FAAP

Elizabeth M. Alderman, MD, FAAP, FSHAM

Cora C. Breuner, MD, MPH, FAAP

David A. Levine, MD, FAAP

Arik V. Marcell, MD, FAAP

Rebecca F. O’Brien, MD, FAAP

Pamela J. Murray, MD, MPH, FAAP

Loretta E. Gavin, PhD, MPH – Centers for Disease Control and Prevention

Margo Lane, MD, FRCPC – Canadian Pediatric Society

Rachel J. Miller, MD – American College of Obstetricians and Gynecologists

Benjamin Shain, MD, PhD – American Academy of Child and Adolescent Psychiatry

Karen S. Smith

James D. Baumberger, MPP

     
  • AAP

    American Academy of Pediatrics

  •  
  • ART

    antiretroviral therapy

  •  
  • BMD

    bone mineral density

  •  
  • CDC

    Centers for Disease Control and Prevention

  •  
  • COC

    combined oral contraceptive

  •  
  • DMPA

    depot medroxyprogesterone acetate

  •  
  • EC

    emergency contraception

  •  
  • FDA

    US Food and Drug Administration

  •  
  • HIPAA

    Health Insurance Portability and Accountability Act

  •  
  • IUD

    intrauterine device

  •  
  • LARC

    long-acting reversible contraception

  •  
  • POP

    progestin-only pill

  •  
  • STI

    sexually transmitted infection

  •  
  • VTE

    venous thromboembolism

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

1
American Academy of Pediatrics, Committee on Adolescence
.
Policy statement: contraception for adolescents.
Pediatrics
.
2014
, I
n press
2
Eaton
DK
,
Kann
L
,
Kinchen
S
, et al
Centers for Disease Control and Prevention (CDC)
.
Youth risk behavior surveillance - United States, 2011.
MMWR Surveill Summ
.
2012
;
61
(
4
):
1
162
[PubMed]
3
Kost K, Henshaw S, Carlin L. US Teenage Pregnancies, Births and Abortions: National and State Trends and Trends by Race and Ethnicity. New York, NY: Guttmacher Institute; 2010
4
Finer
LB
,
Zolna
MR
.
Unintended pregnancy in the United States: incidence and disparities, 2006.
Contraception
.
2011
;
84
(
5
):
478
485
[PubMed]
5
Santelli
JS
,
Lindberg
LD
,
Finer
LB
,
Singh
S
.
Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use.
Am J Public Health
.
2007
;
97
(
1
):
150
156
[PubMed]
6
Abma
JC
,
Martinez
GM
,
Copen
CE
.
Teenagers in the United States: sexual activity, contraceptive use, and childbearing, national survey of family growth 2006-2008.
Vital Health Stat 23
.
2010
; (
30
):
1
47
[PubMed]
7
Hagan
JF
,
Shaw
JS
,
Duncan
PM
.
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents
. 3rd ed.
Elk Grove Village, IL
:
American Academy of Pediatrics
;
2008
8
Center for Adolescent Health and the Law
.
State Minor Consent Laws: A Summary
. 3rd ed.
Chapel Hill, NC
:
Center for Adolescent Health and the Law
;
2010
9
Guttmacher Institute. An Overview of Minors' Consent Law as of January 1, 2014. State Policies in Brief as of June 1, 2014. Available at: www.guttmacher.org/statecenter/spibs/spib_MACS.pdf. Accessed June 20, 2014
10
English
A
,
Ford
CA
.
The HIPAA privacy rule and adolescents: legal questions and clinical challenges.
Perspect Sex Reprod Health
.
2004
;
36
(
2
):
80
86
[PubMed]
11
Spooner
SA
Council on Clinical Information Technology, American Academy of Pediatrics
.
Special requirements of electronic health record systems in pediatrics.
Pediatrics
.
2007
;
119
(
3
):
631
637
[PubMed]
12
Ford
CA
,
Millstein
SG
,
Halpern-Felsher
BL
,
Irwin
CE
 Jr
.
Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care. A randomized controlled trial.
JAMA
.
1997
;
278
(
12
):
1029
1034
[PubMed]
13
Lehrer
JA
,
Pantell
R
,
Tebb
K
,
Shafer
MA
.
Forgone health care among U.S. adolescents: associations between risk characteristics and confidentiality concern.
J Adolesc Health
.
2007
;
40
(
3
):
218
226
[PubMed]
14
Lyren
A
,
Kodish
E
,
Lazebnik
R
,
O’Riordan
MA
.
Understanding confidentiality: perspectives of African American adolescents and their parents.
J Adolesc Health
.
2006
;
39
(
2
):
261
265
[PubMed]
15
Vo
DX
,
Pate
OL
,
Zhao
H
,
Siu
P
,
Ginsburg
KR
.
Voices of Asian American youth: important characteristics of clinicians and clinical sites.
Pediatrics
.
2007
;
120
(
6
). Available at: www.pediatrics.org/cgi/content/full/120/6/e1481
[PubMed]
16
Blake
DR
,
Kearney
MH
,
Oakes
JM
,
Druker
SK
,
Bibace
R
.
Improving participation in Chlamydia screening programs: perspectives of high-risk youth.
Arch Pediatr Adolesc Med
.
2003
;
157
(
6
):
523
529
[PubMed]
17
Committee On Adolescence
.
Office-based care for lesbian, gay, bisexual, transgender, and questioning youth.
Pediatrics
.
2013
;
132
(
1
):
198
203
[PubMed]
18
Klein
JD
,
McNulty
M
,
Flatau
CN
.
Adolescents’ access to care: teenagers’ self-reported use of services and perceived access to confidential care.
Arch Pediatr Adolesc Med
.
1998
;
152
(
7
):
676
682
[PubMed]
19
Reddy
DM
,
Fleming
R
,
Swain
C
.
Effect of mandatory parental notification on adolescent girls’ use of sexual health care services.
JAMA
.
2002
;
288
(
6
):
710
714
[PubMed]
20
Zabin
LS
,
Stark
HA
,
Emerson
MR
.
Reasons for delay in contraceptive clinic utilization. Adolescent clinic and nonclinic populations compared.
J Adolesc Health
.
1991
;
12
(
3
):
225
232
[PubMed]
21
Guldi
M
.
Fertility effects of abortion and birth control pill access for minors.
Demography
.
2008
;
45
(
4
):
817
827
[PubMed]
22
Zavodny
M
.
Fertility and parental consent for minors to receive contraceptives.
Am J Public Health
.
2004
;
94
(
8
):
1347
1351
[PubMed]
23
Dempsey AF, Singer DD, Clark SJ, Davis MM. Adolescent preventive health care: what do parents want? J Pediatr. 2009;155(5):689.e1–694.e1
24
Jones
RK
,
Purcell
A
,
Singh
S
,
Finer
LB
.
Adolescents’ reports of parental knowledge of adolescents’ use of sexual health services and their reactions to mandated parental notification for prescription contraception.
JAMA
.
2005
;
293
(
3
):
340
348
[PubMed]
25
Ott
MA
,
Rosenberger
JG
,
McBride
KR
,
Woodcox
SG
.
How do adolescents view health? Implications for state health policy.
J Adolesc Health
.
2011
;
48
(
4
):
398
403
[PubMed]
26
Jones
RK
,
Biddlecom
AE
.
The more things change…: the relative importance of the Internet as a source of contraceptive information for teens.
Sexual Research and Social Policy
.
2011
;
8
(
1
):
27
37
27
Brown
JD
,
Wissow
LS
.
Discussion of sensitive health topics with youth during primary care visits: relationship to youth perceptions of care.
J Adolesc Health
.
2009
;
44
(
1
):
48
54
[PubMed]
28
Centers for Disease Control and Prevention
.
A Guide to Taking a Sexual History
.
Atlanta, GA
:
Centers for Disease Control and Prevention
;
2005
29
Ott
MA
,
Pfeiffer
EJ
.
“That’s nasty” to curiosity: early adolescent cognitions about sexual abstinence.
J Adolesc Health
.
2009
;
44
(
6
):
575
581
[PubMed]
30
Barnet
B
,
Rapp
T
,
DeVoe
M
,
Mullins
CD
.
Cost-effectiveness of a motivational intervention to reduce rapid repeated childbearing in high-risk adolescent mothers: a rebirth of economic and policy considerations.
Arch Pediatr Adolesc Med
.
2010
;
164
(
4
):
370
376
[PubMed]
31
Kamb
ML
,
Fishbein
M
,
Douglas
JM
 Jr
, et al
Project RESPECT Study Group
.
Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial.
JAMA
.
1998
;
280
(
13
):
1161
1167
[PubMed]
32
Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. Motivational interviewing. BMJ. 2010;340:c1900
33
Erickson
SJ
,
Gerstle
M
,
Feldstein
SW
.
Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings: a review.
Arch Pediatr Adolesc Med
.
2005
;
159
(
12
):
1173
1180
[PubMed]
34
Blum
RW
.
Healthy youth development as a model for youth health promotion. A review.
J Adolesc Health
.
1998
;
22
(
5
):
368
375
[PubMed]
35
Ott
MA
,
Labbett
RL
,
Gold
MA
.
Counseling adolescents about abstinence in the office setting.
J Pediatr Adolesc Gynecol
.
2007
;
20
(
1
):
39
44
[PubMed]
36
Ott
MA
,
Millstein
SG
,
Ofner
S
,
Halpern-Felsher
BL
.
Greater expectations: adolescents’ positive motivations for sex.
Perspect Sex Reprod Health
.
2006
;
38
(
2
):
84
89
[PubMed]
37
Ott
MA
,
Pfeiffer
EJ
,
Fortenberry
JD
.
Perceptions of sexual abstinence among high-risk early and middle adolescents.
J Adolesc Health
.
2006
;
39
(
2
):
192
198
[PubMed]
38
Naar-King
S
,
Suarez
M
.
Motivational Interviewing with Adolescents and Young Adults
.
New York, NY
:
Guilford Press
;
2010
39
Pinkerton
SD
.
A relative risk-based, disease-specific definition of sexual abstinence failure rates.
Health Educ Behav
.
2001
;
28
(
1
):
10
20
[PubMed]
40
Brückner
H
,
Bearman
P
.
After the promise: the STD consequences of adolescent virginity pledges.
J Adolesc Health
.
2005
;
36
(
4
):
271
278
[PubMed]
41
Hatcher
RA
,
Trussell
J
,
Nelson
AL
,
Cates
W
 Jr
,
Kowal
D
,
Policar
MS
.
Contraceptive Technology
. 20th rev ed.
Valley Stream, NY
:
Ardent Media
;
2011
42
Centers for Disease Control and Prevention
.
US selected practice recommendations for contraceptive use, 2013.
MMWR Recomm Rep
.
2013
;
62
(
RR-5
):
1
60
43
Trussell
J
.
Update on and correction to the cost-effectiveness of contraceptives in the United States.
Contraception
.
2012
;
85
(
6
):
611
[PubMed]
44
Graesslin
O
,
Korver
T
.
The contraceptive efficacy of Implanon: a review of clinical trials and marketing experience.
Eur J Contracept Reprod Health Care
.
2008
;
13
(
suppl 1
):
4
12
[PubMed]
45
Levine
JP
,
Sinofsky
FE
,
Christ
MF
;
Implanon US Study Group. Assessment of Implanon insertion and removal
.
Contraception
.
2008
;
78
(
5
):
409
417
46
Vidin
E
,
Garbin
O
,
Rodriguez
B
,
Favre
R
,
Bettahar-Lebugle
K
.
Removal of etonogestrel contraceptive implants in the operating theater: report on 28 cases.
Contraception
.
2007
;
76
(
1
):
35
39
[PubMed]
47
Wechselberger
G
,
Wolfram
D
,
Pülzl
P
,
Soelder
E
,
Schoeller
T
.
Nerve injury caused by removal of an implantable hormonal contraceptive.
Am J Obstet Gynecol
.
2006
;
195
(
1
):
323
326
[PubMed]
48
Guazzelli
CA
,
de Queiroz
FT
,
Barbieri
M
,
Torloni
MR
,
de Araujo
FF
.
Etonogestrel implant in postpartum adolescents: bleeding pattern, efficacy and discontinuation rate.
Contraception
.
2010
;
82
(
3
):
256
259
[PubMed]
49
Lewis
LN
,
Doherty
DA
,
Hickey
M
,
Skinner
SR
.
Implanon as a contraceptive choice for teenage mothers: a comparison of contraceptive choices, acceptability and repeat pregnancy.
Contraception
.
2010
;
81
(
5
):
421
426
[PubMed]
50
Lakha
F
,
Glasier
AF
.
Continuation rates of Implanon in the UK: data from an observational study in a clinical setting.
Contraception
.
2006
;
74
(
4
):
287
289
[PubMed]
51
Harvey
C
,
Seib
C
,
Lucke
J
.
Continuation rates and reasons for removal among Implanon users accessing two family planning clinics in Queensland, Australia.
Contraception
.
2009
;
80
(
6
):
527
532
[PubMed]
52
Darney
P
,
Patel
A
,
Rosen
K
,
Shapiro
LS
,
Kaunitz
AM
.
Safety and efficacy of a single-rod etonogestrel implant (Implanon): results from 11 international clinical trials.
Fertil Steril
.
2009
;
91
(
5
):
1646
1653
[PubMed]
53
Mansour
D
,
Korver
T
,
Marintcheva-Petrova
M
,
Fraser
IS
.
The effects of Implanon on menstrual bleeding patterns.
Eur J Contracept Reprod Health Care
.
2008
;
13
(
13
suppl 1
):
13
28
[PubMed]
54
Mansour
D
,
Bahamondes
L
,
Critchley
H
,
Darney
P
,
Fraser
IS
.
The management of unacceptable bleeding patterns in etonogestrel-releasing contraceptive implant users.
Contraception
.
2011
;
83
(
3
):
202
210
[PubMed]
55
Beerthuizen
R
,
van Beek
A
,
Massai
R
,
Mäkäräinen
L
,
Hout
J
,
Bennink
HC
.
Bone mineral density during long-term use of the progestagen contraceptive implant Implanon compared to a non-hormonal method of contraception.
Hum Reprod
.
2000
;
15
(
1
):
118
122
[PubMed]
56
Bahamondes
L
,
Monteiro-Dantas
C
,
Espejo-Arce
X
, et al
.
A prospective study of the forearm bone density of users of etonorgestrel- and levonorgestrel-releasing contraceptive implants.
Hum Reprod
.
2006
;
21
(
2
):
466
470
[PubMed]
57
Pongsatha
S
,
Ekmahachai
M
,
Suntornlimsiri
N
,
Morakote
N
,
Chaovisitsaree
S
.
Bone mineral density in women using the subdermal contraceptive implant Implanon for at least 2 years.
Int J Gynaecol Obstet
.
2010
;
109
(
3
):
223
225
[PubMed]
58
Centers for Disease Control and Prevention
.
US medical eligibility criteria for contraceptive use, 2010.
MMWR Recomm Rep
.
2010
;
59
(
RR-4
):
1
86
59
American College of Obstetricians and Gynecologists
.
ACOG Practice Bulletin No. 121: Long-acting reversible contraception: implants and intrauterine devices.
Obstet Gynecol
.
2011
;
118
(
1
):
184
196
[PubMed]
60
Skyla [package insert]. Wayne, NJ: Bayer HealthCare Pharmaceuticals; 2013. Available at: http://labeling.bayerhealthcare.com/html/products/pi/Skyla_PI.pdf. Accessed January 15, 2014
61
Mirena [package insert]. Wayne, NJ: Bayer HealthCare Pharmaceuticals; 2013. Available at: http://labeling.bayerhealthcare.com/html/products/pi/Mirena_PI.pdf. Accessed January 15, 2014
62
Paragard [package insert]. Sellersville, PA: Teva Woman’s Health Inc/Teva Pharmaceuticals; 2011. Available at: http://paragard.com/Pdf/ParaGard-PI.pdf. June 22, 2104
63
Long-term reversible contraception. Twelve years of experience with the TCu380A and TCu220C.
Contraception
.
1997
;
56
(
6
):
341
352
[PubMed]
64
Finer
LB
,
Jerman
J
,
Kavanaugh
ML
.
Changes in use of long-acting contraceptive methods in the United States, 2007–2009.
Fertil Steril
.
2012
;
98
(
4
):
893
897
[PubMed]
65
Hubacher
D
,
Lara-Ricalde
R
,
Taylor
DJ
,
Guerra-Infante
F
,
Guzmán-Rodríguez
R
.
Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women.
N Engl J Med
.
2001
;
345
(
8
):
561
567
[PubMed]
66
Hov
GG
,
Skjeldestad
FE
,
Hilstad
T
.
Use of IUD and subsequent fertility—follow-up after participation in a randomized clinical trial.
Contraception
.
2007
;
75
(
2
):
88
92
[PubMed]
67
Penney
G
,
Brechin
S
,
de Souza
A
, et al
Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit
.
FFPRHC Guidance (January 2004). The copper intrauterine device as long-term contraception.
J Fam Plann Reprod Health Care
.
2004
;
30
(
1
):
29
41, quiz 42
[PubMed]
68
Mohllajee
AP
,
Curtis
KM
,
Peterson
HB
.
Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review.
Contraception
.
2006
;
73
(
2
):
145
153
[PubMed]
69
Farley
TM
,
Rosenberg
MJ
,
Rowe
PJ
,
Chen
JH
,
Meirik
O
.
Intrauterine devices and pelvic inflammatory disease: an international perspective.
Lancet
.
1992
;
339
(
8796
):
785
788
[PubMed]
70
Grimes
DA
.
Intrauterine device and upper-genital-tract infection.
Lancet
.
2000
;
356
(
9234
):
1013
1019
[PubMed]
71
Hubacher
D
.
Copper intrauterine device use by nulliparous women: review of side effects.
Contraception
.
2007
;
75
(
suppl 6
):
S8
S11
[PubMed]
72
Brockmeyer
A
,
Kishen
M
,
Webb
A
.
Experience of IUD/IUS insertions and clinical performance in nulliparous women—a pilot study.
Eur J Contracept Reprod Health Care
.
2008
;
13
(
3
):
248
254
[PubMed]
73
Thonneau
P
,
Almont
T
,
de La Rochebrochard
E
,
Maria
B
.
Risk factors for IUD failure: results of a large multicentre case-control study.
Hum Reprod
.
2006
;
21
(
10
):
2612
2616
[PubMed]
74
Suhonen
S
,
Haukkamaa
M
,
Jakobsson
T
,
Rauramo
I
.
Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study.
Contraception
.
2004
;
69
(
5
):
407
412
[PubMed]
75
Godfrey
EM
,
Memmel
LM
,
Neustadt
A
, et al
.
Intrauterine contraception for adolescents aged 14-18 years: a multicenter randomized pilot study of levonorgestrel-releasing intrauterine system compared to the Copper T 380A.
Contraception
.
2010
;
81
(
2
):
123
127
[PubMed]
76
Paterson
H
,
Ashton
J
,
Harrison-Woolrych
M
.
A nationwide cohort study of the use of the levonorgestrel intrauterine device in New Zealand adolescents.
Contraception
.
2009
;
79
(
6
):
433
438
[PubMed]
77
Pillai
M
,
O’Brien
K
,
Hill
E
.
The levonorgestrel intrauterine system (Mirena) for the treatment of menstrual problems in adolescents with medical disorders, or physical or learning disabilities.
BJOG
.
2010
;
117
(
2
):
216
221
[PubMed]
78
Toma
A
,
Jamieson
MA
.
Revisiting the intrauterine contraceptive device in adolescents.
J Pediatr Adolesc Gynecol
.
2006
;
19
(
4
):
291
296
[PubMed]
79
Lara-Torre
E
,
Spotswood
L
,
Correia
N
,
Weiss
PM
.
Intrauterine contraception in adolescents and young women: a descriptive study of use, side effects, and compliance.
J Pediatr Adolesc Gynecol
.
2011
;
24
(
1
):
39
41
[PubMed]
80
Hillard
PJ
.
Menstrual suppression with the levonorgestrel intrauterine system in girls with developmental delay.
J Pediatr Adolesc Gynecol
.
2012
;
25
(
5
):
308
313
[PubMed]
81
Hillman
JB
,
Miller
RJ
,
Inge
TH
.
Menstrual concerns and intrauterine contraception among adolescent bariatric surgery patients.
J Womens Health (Larchmt)
.
2011
;
20
(
4
):
533
538
[PubMed]
82
Kaunitz
AM
,
Darney
PD
,
Ross
D
,
Wolter
KD
,
Speroff
L
.
Subcutaneous DMPA vs. intramuscular DMPA: a 2-year randomized study of contraceptive efficacy and bone mineral density.
Contraception
.
2009
;
80
(
1
):
7
17
[PubMed]
83
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice
.
ACOG Committee Opinion No. 415: Depot medroxyprogesterone acetate and bone effects.
Obstet Gynecol
.
2008
;
112
(
3
):
727
730
[PubMed]
84
Kaunitz
AM
.
Depot medroxyprogesterone acetate contraception and the risk of breast and gynecologic cancer.
J Reprod Med
.
1996
;
41
(
suppl 5
):
419
427
[PubMed]
85
Rodriguez
MI
,
Kaunitz
AM
.
An evidence-based approach to postpartum use of depot medroxyprogesterone acetate in breastfeeding women.
Contraception
.
2009
;
80
(
1
):
4
6
[PubMed]
86
Herzog
AG
.
Progesterone therapy in women with epilepsy: a 3-year follow-up.
Neurology
.
1999
;
52
(
9
):
1917
1918
[PubMed]
87
de Abood
M
,
de Castillo
Z
,
Guerrero
F
,
Espino
M
,
Austin
KL
.
Effect of Depo-Provera or Microgynon on the painful crises of sickle cell anemia patients.
Contraception
.
1997
;
56
(
5
):
313
316
[PubMed]
88
Manchikanti
A
,
Grimes
DA
,
Lopez
LM
,
Schulz
KF
.
Steroid hormones for contraception in women with sickle cell disease.
Cochrane Database Syst Rev
.
2007
;(
2
):
CD006261
[PubMed]
89
van Hylckama Vlieg
A
,
Helmerhorst
FM
,
Rosendaal
FR
.
The risk of deep venous thrombosis associated with injectable depot-medroxyprogesterone acetate contraceptives or a levonorgestrel intrauterine device.
Arterioscler Thromb Vasc Biol
.
2010
;
30
(
11
):
2297
2300
[PubMed]
90
Lestishock
L
,
Pariseau
C
,
Rooholamini
S
,
Ammerman
S
.
Anaphylaxis from depot medroxyprogesterone acetate in an adolescent girl.
Obstet Gynecol
.
2011
;
118
(
2 pt 2
):
443
445
[PubMed]
91
Hubacher
D
,
Lopez
L
,
Steiner
MJ
,
Dorflinger
L
.
Menstrual pattern changes from levonorgestrel subdermal implants and DMPA: systematic review and evidence-based comparisons.
Contraception
.
2009
;
80
(
2
):
113
118
[PubMed]
92
Arias
RD
,
Jain
JK
,
Brucker
C
,
Ross
D
,
Ray
A
.
Changes in bleeding patterns with depot medroxyprogesterone acetate subcutaneous injection 104 mg.
Contraception
.
2006
;
74
(
3
):
234
238
[PubMed]
93
Hubacher
D
,
Goco
N
,
Gonzalez
B
,
Taylor
D
.
Factors affecting continuation rates of DMPA.
Contraception
.
1999
;
60
(
6
):
345
351
[PubMed]
94
Canto De Cetina
TE
,
Canto
P
,
Ordoñez Luna
M
.
Effect of counseling to improve compliance in Mexican women receiving depot-medroxyprogesterone acetate.
Contraception
.
2001
;
63
(
3
):
143
146
[PubMed]
95
Jain
J
,
Jakimiuk
AJ
,
Bode
FR
,
Ross
D
,
Kaunitz
AM
.
Contraceptive efficacy and safety of DMPA-SC.
Contraception
.
2004
;
70
(
4
):
269
275
[PubMed]
96
Bonny
AE
,
Ziegler
J
,
Harvey
R
,
Debanne
SM
,
Secic
M
,
Cromer
BA
.
Weight gain in obese and nonobese adolescent girls initiating depot medroxyprogesterone, oral contraceptive pills, or no hormonal contraceptive method.
Arch Pediatr Adolesc Med
.
2006
;
160
(
1
):
40
45
[PubMed]
97
Espey
E
,
Steinhart
J
,
Ogburn
T
,
Qualls
C
.
Depo-provera associated with weight gain in Navajo women.
Contraception
.
2000
;
62
(
2
):
55
58
[PubMed]
98
Risser
WL
,
Gefter
LR
,
Barratt
MS
,
Risser
JM
.
Weight change in adolescents who used hormonal contraception.
J Adolesc Health
.
1999
;
24
(
6
):
433
436
[PubMed]
99
Berenson AB, Rahman M. Changes in weight, total fat, percent body fat, and central-to-peripheral fat ratio associated with injectable and oral contraceptive use. Am J Obstet Gynecol. 2009;200(3):329.e1–329.e8
100
Mangan
SA
,
Larsen
PG
,
Hudson
S
.
Overweight teens at increased risk for weight gain while using depot medroxyprogesterone acetate.
J Pediatr Adolesc Gynecol
.
2002
;
15
(
2
):
79
82
[PubMed]
101
Lopez
LM
,
Edelman
A
,
Chen-Mok
M
,
Trussell
J
,
Helmerhorst
FM
.
Progestin-only contraceptives: effects on weight.
Cochrane Database Syst Rev
.
2011
;(
4
):
CD008815
[PubMed]
102
Bonny
AE
,
Secic
M
,
Cromer
BA
.
A longitudinal comparison of body composition changes in adolescent girls receiving hormonal contraception.
J Adolesc Health
.
2009
;
45
(
4
):
423
425
[PubMed]
103
Bonny
AE
,
Secic
M
,
Cromer
B
.
Early weight gain related to later weight gain in adolescents on depot medroxyprogesterone acetate.
Obstet Gynecol
.
2011
;
117
(
4
):
793
797
[PubMed]
104
Le
YC
,
Rahman
M
,
Berenson
AB
.
Early weight gain predicting later weight gain among depot medroxyprogesterone acetate users.
Obstet Gynecol
.
2009
;
114
(
2 pt 1
):
279
284
[PubMed]
105
Cromer
BA
,
Blair
JM
,
Mahan
JD
,
Zibners
L
,
Naumovski
Z
.
A prospective comparison of bone density in adolescent girls receiving depot medroxyprogesterone acetate (Depo-Provera), levonorgestrel (Norplant), or oral contraceptives.
J Pediatr
.
1996
;
129
(
5
):
671
676
[PubMed]
106
Lara-Torre
E
,
Edwards
CP
,
Perlman
S
,
Hertweck
SP
.
Bone mineral density in adolescent females using depot medroxyprogesterone acetate.
J Pediatr Adolesc Gynecol
.
2004
;
17
(
1
):
17
21
[PubMed]
107
Cromer
BA
,
Stager
M
,
Bonny
A
, et al
.
Depot medroxyprogesterone acetate, oral contraceptives and bone mineral density in a cohort of adolescent girls.
J Adolesc Health
.
2004
;
35
(
6
):
434
441
[PubMed]
108
Rome
E
,
Ziegler
J
,
Secic
M
, et al
.
Bone biochemical markers in adolescent girls using either depot medroxyprogesterone acetate or an oral contraceptive.
J Pediatr Adolesc Gynecol
.
2004
;
17
(
6
):
373
377
[PubMed]
109
DepoProvera 150 mg and Depo SubQ Provera 104 [package inserts]
.
Cambridge, MA
:
Pfizer
;
2005
110
Scholes
D
,
LaCroix
AZ
,
Ichikawa
LE
,
Barlow
WE
,
Ott
SM
.
Change in bone mineral density among adolescent women using and discontinuing depot medroxyprogesterone acetate contraception.
Arch Pediatr Adolesc Med
.
2005
;
159
(
2
):
139
144
[PubMed]
111
Harel
Z
,
Johnson
CC
,
Gold
MA
, et al
.
Recovery of bone mineral density in adolescents following the use of depot medroxyprogesterone acetate contraceptive injections.
Contraception
.
2010
;
81
(
4
):
281
291
[PubMed]
112
Berenson
AB
,
Rahman
M
,
Breitkopf
CR
,
Bi
LX
.
Effects of depot medroxyprogesterone acetate and 20-microgram oral contraceptives on bone mineral density.
Obstet Gynecol
.
2008
;
112
(
4
):
788
799
[PubMed]
113
Kaunitz
AM
,
Grimes
DA
.
Removing the black box warning for depot medroxyprogesterone acetate.
Contraception
.
2011
;
84
(
3
):
212
213
[PubMed]
114
Vestergaard
P
,
Rejnmark
L
,
Mosekilde
L
.
The effects of depot medroxyprogesterone acetate and intrauterine device use on fracture risk in Danish women.
Contraception
.
2008
;
78
(
6
):
459
464
[PubMed]
115
Meier
C
,
Brauchli
YB
,
Jick
SS
,
Kraenzlin
ME
,
Meier
CR
.
Use of depot medroxyprogesterone acetate and fracture risk.
J Clin Endocrinol Metab
.
2010
;
95
(
11
):
4909
4916
[PubMed]
116
Institute of Medicine. Dietary reference intakes for calcium and vitamin D. Washington, DC: National Academies Press; 2010. Available at: www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-calcium-and-vitamin-D.aspx. Accessed January 15, 2014
117
Braverman
PK
,
Breech
L
Committee on Adolescence
.
American Academy of Pediatrics. Clinical report—gynecologic examination for adolescents in the pediatric office setting.
Pediatrics
.
2010
;
126
(
3
):
583
590
[PubMed]
118
Gallo
MF
,
Grimes
DA
,
Schulz
KF
,
Helmerhorst
FM
.
Combination estrogen-progestin contraceptives and body weight: systematic review of randomized controlled trials.
Obstet Gynecol
.
2004
;
103
(
2
):
359
373
[PubMed]
119
Böttcher
B
,
Radenbach
K
,
Wildt
L
,
Hinney
B
.
Hormonal contraception and depression: a survey of the present state of knowledge.
Arch Gynecol Obstet
.
2012
;
286
(
1
):
231
236
[PubMed]
120
Ott
MA
,
Shew
ML
,
Ofner
S
,
Tu
W
,
Fortenberry
JD
.
The influence of hormonal contraception on mood and sexual interest among adolescents.
Arch Sex Behav
.
2008
;
37
(
4
):
605
613
[PubMed]
121
Dickey
R
.
Managing Contraceptive Pill Patients
.
Fort Collins, CO
:
EMIS Inc Medical Publishers
;
2010
122
Canobbio
MM
.
Contraception for the adolescent and young adult with congenital heart disease.
Nurs Clin North Am
.
2004
;
39
(
4
):
769
785
[PubMed]
123
Trenor
CC
 III
,
Chung
RJ
,
Michelson
AD
, et al
.
Hormonal contraception and thrombotic risk: a multidisciplinary approach.
Pediatrics
.
2011
;
127
(
2
):
347
357
[PubMed]
124
Vandenbroucke
JP
,
Rosing
J
,
Bloemenkamp
KW
, et al
.
Oral contraceptives and the risk of venous thrombosis.
N Engl J Med
.
2001
;
344
(
20
):
1527
1535
[PubMed]
125
US Food and Drug Administration. Updated information about the risk of blood clots in women taking birth control pills containing drospirenone. Silver Spring, MD: US Food and Drug Administration; 2012. Available at: www.fda.gov/Drugs/DrugSafety/ucm299305.htm. Accessed January 15, 2014
126
van Hylckama Vlieg
A
,
Helmerhorst
FM
,
Vandenbroucke
JP
,
Doggen
CJ
,
Rosendaal
FR
.
The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study.
BMJ
.
2009
;
339
:
b2921
[PubMed]
127
Stein
PD
,
Kayali
F
,
Olson
RE
.
Incidence of venous thromboembolism in infants and children: data from the National Hospital Discharge Survey.
J Pediatr
.
2004
;
145
(
4
):
563
565
[PubMed]
128
Walker
ID
.
Venous and arterial thrombosis during pregnancy: epidemiology.
Semin Vasc Med
.
2003
;
3
(
1
):
25
32
[PubMed]
129
Heit
JA
,
Kobbervig
CE
,
James
AH
,
Petterson
TM
,
Bailey
KR
,
Melton
LJ
 III
.
Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study.
Ann Intern Med
.
2005
;
143
(
10
):
697
706
[PubMed]
130
Gaffield
ME
,
Culwell
KR
,
Lee
CR
.
The use of hormonal contraception among women taking anticonvulsant therapy.
Contraception
.
2011
;
83
(
1
):
16
29
[PubMed]
131
Dickinson
BD
,
Altman
RD
,
Nielsen
NH
,
Sterling
ML
;
Council on Scientific Affairs, American Medical Association. Drug interactions between oral contraceptives and antibiotics
.
Obstet Gynecol
.
2001
Nov;
98
(
5 Pt 1
):
853
60
132
Toh
S
,
Mitchell
AA
,
Anderka
M
,
de Jong-van den Berg
LT
,
Hernández-Díaz
S
National Birth Defects Prevention Study
.
Antibiotics and oral contraceptive failure—a case-crossover study.
Contraception
.
2011
;
83
(
5
):
418
425
[PubMed]
133
Sucato
GS
,
Gold
MA
.
Extended cycling of oral contraceptive pills for adolescents.
J Pediatr Adolesc Gynecol
.
2002
;
15
(
5
):
325
327
[PubMed]
134
Sucato
GS
,
Gerschultz
KL
.
Extended cycle hormonal contraception in adolescents.
Curr Opin Obstet Gynecol
.
2005
;
17
(
5
):
461
465
[PubMed]
135
Hamilton
A
,
Marshal
MP
,
Murray
PJ
.
Autism spectrum disorders and menstruation.
J Adolesc Health
.
2011
;
49
(
4
):
443
445
[PubMed]
136
Schlaff
WD
,
Lynch
AM
,
Hughes
HD
,
Cedars
MI
,
Smith
DL
.
Manipulation of the pill-free interval in oral contraceptive pill users: the effect on follicular suppression.
Am J Obstet Gynecol
.
2004
;
190
(
4
):
943
951
[PubMed]
137
Birtch
RL
,
Olatunbosun
OA
,
Pierson
RA
.
Ovarian follicular dynamics during conventional vs. continuous oral contraceptive use.
Contraception
.
2006
;
73
(
3
):
235
243
[PubMed]
138
Baerwald
AR
,
Olatunbosun
OA
,
Pierson
RA
.
Ovarian follicular development is initiated during the hormone-free interval of oral contraceptive use.
Contraception
.
2004
;
70
(
5
):
371
377
[PubMed]
139
ACOG Committee on Practice Bulletins-Gynecology
.
ACOG practice bulletin. No. 73: Use of hormonal contraception in women with coexisting medical conditions.
Obstet Gynecol
.
2006
;
107
(
6
):
1453
1472
[PubMed]
140
Vessey
M
,
Painter
R
.
Oral contraceptive use and cancer. Findings in a large cohort study, 1968-2004.
Br J Cancer
.
2006
;
95
(
3
):
385
389
[PubMed]
141
Carey
AS
,
Chiappetta
L
,
Tremont
K
,
Murray
PJ
,
Gold
MA
.
The contraceptive vaginal ring: female adolescents’ knowledge, attitudes and plans for use.
Contraception
.
2007
;
76
(
6
):
444
450
[PubMed]
142
Veres
S
,
Miller
L
,
Burington
B
.
A comparison between the vaginal ring and oral contraceptives.
Obstet Gynecol
.
2004
;
104
(
3
):
555
563
[PubMed]
143
Barnhart
KT
,
Timbers
K
,
Pretorius
ES
,
Lin
K
,
Shaunik
A
.
In vivo assessment of NuvaRing placement.
Contraception
.
2005
;
72
(
3
):
196
199
[PubMed]
144
Verhoeven
CH
,
Dieben
TO
.
The combined contraceptive vaginal ring, NuvaRing, and tampon co-usage.
Contraception
.
2004
;
69
(
3
):
197
199
[PubMed]
145
Haring
T
,
Mulders
TM
.
The combined contraceptive ring NuvaRing and spermicide co-medication.
Contraception
.
2003
;
67
(
4
):
271
272
[PubMed]
146
Verhoeven
CH
,
van den Heuvel
MW
,
Mulders
TM
,
Dieben
TO
.
The contraceptive vaginal ring, NuvaRing, and antimycotic co-medication.
Contraception
.
2004
;
69
(
2
):
129
132
[PubMed]
147
Guida
M
,
Di Spiezio Sardo
A
,
Bramante
S
, et al
.
Effects of two types of hormonal contraception—oral versus intravaginal—on the sexual life of women and their partners.
Hum Reprod
.
2005
;
20
(
4
):
1100
1106
[PubMed]
148
Roumen
FJ
,
Apter
D
,
Mulders
TM
,
Dieben
TO
.
Efficacy, tolerability and acceptability of a novel contraceptive vaginal ring releasing etonogestrel and ethinyl oestradiol.
Hum Reprod
.
2001
;
16
(
3
):
469
475
[PubMed]
149
Dieben
TO
,
Roumen
FJ
,
Apter
D
.
Efficacy, cycle control, and user acceptability of a novel combined contraceptive vaginal ring.
Obstet Gynecol
.
2002
;
100
(
3
):
585
593
[PubMed]
150
Edwardson
J
,
Jamshidi
R
.
The contraceptive vaginal ring.
Semin Reprod Med
.
2010
;
28
(
2
):
133
139
[PubMed]
151
Massai
R
,
Mäkäräinen
L
,
Kuukankorpi
A
,
Klipping
C
,
Duijkers
I
,
Dieben
T
.
The combined contraceptive vaginal ring and bone mineral density in healthy pre-menopausal women.
Hum Reprod
.
2005
;
20
(
10
):
2764
2768
[PubMed]
152
Massaro
M
,
Di Carlo
C
,
Gargano
V
,
Formisano
C
,
Bifulco
G
,
Nappi
C
.
Effects of the contraceptive patch and the vaginal ring on bone metabolism and bone mineral density: a prospective, controlled, randomized study.
Contraception
.
2010
;
81
(
3
):
209
214
[PubMed]
153
van den Heuvel
MW
,
van Bragt
AJ
,
Alnabawy
AK
,
Kaptein
MC
.
Comparison of ethinylestradiol pharmacokinetics in three hormonal contraceptive formulations: the vaginal ring, the transdermal patch and an oral contraceptive.
Contraception
.
2005
;
72
(
3
):
168
174
[PubMed]
154
Fleischer
K
,
van Vliet
HA
,
Rosendaal
FR
,
Rosing
J
,
Tchaikovski
S
,
Helmerhorst
FM
.
Effects of the contraceptive patch, the vaginal ring and an oral contraceptive on APC resistance and SHBG: a cross-over study.
Thromb Res
.
2009
;
123
(
3
):
429
435
[PubMed]
155
Jensen
JT
,
Burke
AE
,
Barnhart
KT
,
Tillotson
C
,
Messerle-Forbes
M
,
Peters
D
.
Effects of switching from oral to transdermal or transvaginal contraception on markers of thrombosis.
Contraception
.
2008
;
78
(
6
):
451
458
[PubMed]
156
van Vliet
HA
,
Rosendaal
FR
,
Fleischer
K
,
Rosing
J
,
Helmerhorst
FM
.
Effects of the contraceptive vaginal ring, the contraceptive transdermal patch and combined oral contraceptives on markers of hemostasis.
Contraception
.
2010
;
81
(
1
):
88
89, author reply 89–90
[PubMed]
157
Stewart
FH
,
Brown
BA
,
Raine
TR
,
Weitz
TA
,
Harper
CC
.
Adolescent and young women’s experience with the vaginal ring and oral contraceptive pills.
J Pediatr Adolesc Gynecol
.
2007
;
20
(
6
):
345
351
[PubMed]
158
Gilliam
ML
,
Neustadt
A
,
Kozloski
M
,
Mistretta
S
,
Tilmon
S
,
Godfrey
E
.
Adherence and acceptability of the contraceptive ring compared with the pill among students: a randomized controlled trial.
Obstet Gynecol
.
2010
;
115
(
3
):
503
510
[PubMed]
159
Timmer
CJ
,
Mulders
TM
.
Pharmacokinetics of etonogestrel and ethinylestradiol released from a combined contraceptive vaginal ring.
Clin Pharmacokinet
.
2000
;
39
(
3
):
233
242
[PubMed]
160
Miller
L
,
Verhoeven
CH
,
Hout
J
.
Extended regimens of the contraceptive vaginal ring: a randomized trial.
Obstet Gynecol
.
2005
;
106
(
3
):
473
482
[PubMed]
161
Sulak
PJ
,
Smith
V
,
Coffee
A
,
Witt
I
,
Kuehl
AL
,
Kuehl
TJ
.
Frequency and management of breakthrough bleeding with continuous use of the transvaginal contraceptive ring: a randomized controlled trial.
Obstet Gynecol
.
2008
;
112
(
3
):
563
571
[PubMed]
162
Mosher
WD
,
Jones
J
.
Use of contraception in the United States: 1982-2008.
Vital Health Stat 23
.
2010
;(
29
):
1
44
[PubMed]
163
Cole
JA
,
Norman
H
,
Doherty
M
,
Walker
AM
.
Venous thromboembolism, myocardial infarction, and stroke among transdermal contraceptive system users [published correction appears in
Obstet Gynecol
.
2008
;
111
(
6
):
1449]
. Obstet Gynecol. 2007;109(2 pt 1):339–346
[PubMed]
164
Dore
DD
,
Norman
H
,
Loughlin
J
,
Seeger
JD
.
Extended case-control study results on thromboembolic outcomes among transdermal contraceptive users.
Contraception
.
2010
;
81
(
5
):
408
413
[PubMed]
165
Dore
DD
,
Norman
H
,
Seeger
JD
.
Eligibility criteria in venous thromboembolism, myocardial infarction, and stroke among transdermal contraceptive system users.
Obstet Gynecol
.
2009
;
114
(
1
):
175
[PubMed]
166
Jick
S
,
Kaye
JA
,
Li
L
,
Jick
H
.
Further results on the risk of nonfatal venous thromboembolism in users of the contraceptive transdermal patch compared to users of oral contraceptives containing norgestimate and 35 microg of ethinyl estradiol.
Contraception
.
2007
;
76
(
1
):
4
7
[PubMed]
167
Jick
SS
,
Hagberg
KW
,
Hernandez
RK
,
Kaye
JA
.
Postmarketing study of ORTHO EVRA and levonorgestrel oral contraceptives containing hormonal contraceptives with 30 mcg of ethinyl estradiol in relation to nonfatal venous thromboembolism.
Contraception
.
2010
;
81
(
1
):
16
21
[PubMed]
168
Jick
SS
,
Hagberg
KW
,
Kaye
JA
.
ORTHO EVRA and venous thromboembolism: an update.
Contraception
.
2010
;
81
(
5
):
452
453
[PubMed]
169
Jick
SS
,
Kaye
JA
,
Russmann
S
,
Jick
H
.
Risk of nonfatal venous thromboembolism with oral contraceptives containing norgestimate or desogestrel compared with oral contraceptives containing levonorgestrel.
Contraception
.
2006
;
73
(
6
):
566
570
[PubMed]
170
Sidney
S
,
Cheetham
TC
,
Connell
FA
, et al
.
Recent combined hormonal contraceptives (CHCs) and the risk of thromboembolism and other cardiovascular events in new users.
Contraception
.
2013
;
87
(
1
):
93
100
[PubMed]
171
Urdl
W
,
Apter
D
,
Alperstein
A
, et al
ORTHO EVRA/EVRA 003 Study Group
.
Contraceptive efficacy, compliance and beyond: factors related to satisfaction with once-weekly transdermal compared with oral contraception.
Eur J Obstet Gynecol Reprod Biol
.
2005
;
121
(
2
):
202
210
[PubMed]
172
Weisberg
F
,
Bouchard
C
,
Moreau
M
, et al
NRGEEP-CON-401 Study Group
.
Preference for and satisfaction of Canadian women with the transdermal contraceptive patch versus previous contraceptive method: an open-label, multicentre study.
J Obstet Gynaecol Can
.
2005
;
27
(
4
):
350
359
[PubMed]
173
Archer
DF
,
Bigrigg
A
,
Smallwood
GH
,
Shangold
GA
,
Creasy
GW
,
Fisher
AC
.
Assessment of compliance with a weekly contraceptive patch (Ortho Evra/Evra) among North American women.
Fertil Steril
.
2002
;
77
(
2
suppl 2
):
S27
S31
[PubMed]
174
Archer
DF
,
Cullins
V
,
Creasy
GW
,
Fisher
AC
.
The impact of improved compliance with a weekly contraceptive transdermal system (Ortho Evra) on contraceptive efficacy.
Contraception
.
2004
;
69
(
3
):
189
195
[PubMed]
175
Harel
Z
,
Riggs
S
,
Vaz
R
,
Flanagan
P
,
Dunn
K
,
Harel
D
.
Adolescents’ experience with the combined estrogen and progestin transdermal contraceptive method Ortho Evra.
J Pediatr Adolesc Gynecol
.
2005
;
18
(
2
):
85
90
[PubMed]
176
Rubinstein
ML
,
Halpern-Felsher
BL
,
Irwin
CE
 Jr
.
An evaluation of the use of the transdermal contraceptive patch in adolescents.
J Adolesc Health
.
2004
;
34
(
5
):
395
401
[PubMed]
177
Bakhru
A
,
Stanwood
N
.
Performance of contraceptive patch compared with oral contraceptive pill in a high-risk population.
Obstet Gynecol
.
2006
;
108
(
2
):
378
386
[PubMed]
178
LaGuardia
KD
.
Performance of contraceptive patch compared with oral contraceptive pill in a high-risk population.
Obstet Gynecol
.
2006
;
108
(
6
):
1553
1554
[PubMed]
179
Sucato
GS
,
Land
SR
,
Murray
PJ
,
Cecchini
R
,
Gold
MA
.
Adolescents’ experiences using the contraceptive patch versus pills.
J Pediatr Adolesc Gynecol
.
2011
;
24
(
4
):
197
203
[PubMed]
180
Logsdon
S
,
Richards
J
,
Omar
HA
.
Long-term evaluation of the use of the transdermal contraceptive patch in adolescents.
ScientificWorldJournal
.
2004
;
4
:
512
516
[PubMed]
181
Thurman
AR
,
Hammond
N
,
Brown
HE
,
Roddy
ME
.
Preventing repeat teen pregnancy: postpartum depot medroxyprogesterone acetate, oral contraceptive pills, or the patch?
J Pediatr Adolesc Gynecol
.
2007
;
20
(
2
):
61
65
[PubMed]
182
Lopez
LM
,
Grimes
DA
,
Gallo
MF
,
Schulz
KF
.
Skin patch and vaginal ring versus combined oral contraceptives for contraception.
Cochrane Database Syst Rev
.
2010
;(
3
):
CD003552
[PubMed]
183
Creinin
MD
,
Meyn
LA
,
Borgatta
L
, et al
.
Multicenter comparison of the contraceptive ring and patch: a randomized controlled trial.
Obstet Gynecol
.
2008
;
111
(
2 pt 1
):
267
277
[PubMed]
184
Stricker
T
,
Sennhauser
FH
.
Allergic contact dermatitis due to transdermal contraception patch.
J Pediatr
.
2006
;
148
(
6
):
845
[PubMed]
185
Raine
TR
,
Epstein
LB
,
Harper
CC
,
Brown
BA
,
Boyer
CB
.
Attitudes toward the vaginal ring and transdermal patch among adolescents and young women.
J Adolesc Health
.
2009
;
45
(
3
):
262
267
[PubMed]
186
Sucato
GS
,
Bhatt
SK
,
Murray
PJ
,
Ott
MA
.
Transdermal contraception as a model for adolescent use of new methods.
J Adolesc Health
.
2011
;
49
(
4
):
357
362
[PubMed]
187
Harel
Z
,
Riggs
S
,
Vaz
R
,
Flanagan
P
,
Harel
D
,
Machan
JT
.
Bone accretion in adolescents using the combined estrogen and progestin transdermal contraceptive method Ortho Evra: a pilot study.
J Pediatr Adolesc Gynecol
.
2010
;
23
(
1
):
23
31
[PubMed]
188
Martinez
G
,
Copen
CE
,
Abma
JC
.
Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2006-2010 national survey of family growth.
Vital Health Stat 23
.
2011
;(
31
):
1
35
[PubMed]
189
Centers for Disease Control and Prevention. Male latex condoms and sexually transmitted diseases: condom fact sheet in brief. Atlanta, GA: Centers for Disease Control and Prevention. Available at: www.cdc.gov/condomeffectiveness/brief.html. Accessed January 15, 2014
190
Holmes
KK
,
Levine
R
,
Weaver
M
.
Effectiveness of condoms in preventing sexually transmitted infections.
Bull World Health Organ
.
2004
;
82
(
6
):
454
461
[PubMed]
191
Gallo
MF
,
Steiner
MJ
,
Warner
L
, et al
.
Self-reported condom use is associated with reduced risk of chlamydia, gonorrhea, and trichomoniasis.
Sex Transm Dis
.
2007
;
34
(
10
):
829
833
[PubMed]
192
Warner
L
,
Macaluso
M
,
Newman
D
, et al
.
Condom effectiveness for prevention of C trachomatis infection.
Sex Transm Infect
.
2006
;
82
(
3
):
265
[PubMed]
193
Paz-Bailey
G
,
Koumans
EH
,
Sternberg
M
, et al
.
The effect of correct and consistent condom use on chlamydial and gonococcal infection among urban adolescents.
Arch Pediatr Adolesc Med
.
2005
;
159
(
6
):
536
542
[PubMed]
194
Niccolai
LM
,
Rowhani-Rahbar
A
,
Jenkins
H
,
Green
S
,
Dunne
DW
.
Condom effectiveness for prevention of Chlamydia trachomatis infection.
Sex Transm Infect
.
2005
;
81
(
4
):
323
325
[PubMed]
195
Weller
S
,
Davis
K
.
Condom effectiveness in reducing heterosexual HIV transmission.
Cochrane Database Syst Rev
.
2002
;(
1
):
CD003255
[PubMed]
196
Martin
ET
,
Krantz
E
,
Gottlieb
SL
, et al
.
A pooled analysis of the effect of condoms in preventing HSV-2 acquisition.
Arch Intern Med
.
2009
;
169
(
13
):
1233
1240
[PubMed]
197
Stanaway
JD
,
Wald
A
,
Martin
ET
,
Gottlieb
SL
,
Magaret
AS
.
Case-crossover analysis of condom use and herpes simplex virus type 2 acquisition.
Sex Transm Dis
.
2012
;
39
(
5
):
388
393
[PubMed]
198
Winer
RL
,
Hughes
JP
,
Feng
Q
, et al
.
Condom use and the risk of genital human papillomavirus infection in young women.
N Engl J Med
.
2006
;
354
(
25
):
2645
2654
[PubMed]
199
Shew
ML
,
Fortenberry
JD
,
Tu
W
, et al
.
Association of condom use, sexual behaviors, and sexually transmitted infections with the duration of genital human papillomavirus infection among adolescent women.
Arch Pediatr Adolesc Med
.
2006
;
160
(
2
):
151
156
[PubMed]
200
Koss
CA
,
Dunne
EF
,
Warner
L
.
A systematic review of epidemiologic studies assessing condom use and risk of syphilis.
Sex Transm Dis
.
2009
;
36
(
7
):
401
405
[PubMed]
201
American Academy of Pediatrics, Committee on Adolescence
.
Policy statement: condom use by adolescents.
Pediatrics
.
2013
;
132
(
5
):
973
981
202
Matson
PA
,
Adler
NE
,
Millstein
SG
,
Tschann
JM
,
Ellen
JM
.
Developmental changes in condom use among urban adolescent females: influence of partner context.
J Adolesc Health
.
2011
;
48
(
4
):
386
390
[PubMed]
203
Bearinger
LH
,
Sieving
RE
,
Duke
NN
,
McMorris
BJ
,
Stoddard
S
,
Pettingell
SL
.
Adolescent condom use consistency over time: global versus partner-specific measures.
Nurs Res
.
2011
;
60
(
suppl 3
):
S68
S78
[PubMed]
204
Kenyon
DB
,
Sieving
RE
,
Jerstad
SJ
,
Pettingell
SL
,
Skay
CL
.
Individual, interpersonal, and relationship factors predicting hormonal and condom use consistency among adolescent girls.
J Pediatr Health Care
.
2010
;
24
(
4
):
241
249
[PubMed]
205
Manning
WD
,
Flanigan
CM
,
Giordano
PC
,
Longmore
MA
.
Relationship dynamics and consistency of condom use among adolescents.
Perspect Sex Reprod Health
.
2009
;
41
(
3
):
181
190
[PubMed]
206
Ku
L
,
Sonenstein
FL
,
Pleck
JH
.
The dynamics of young men’s condom use during and across relationships.
Fam Plann Perspect
.
1994
;
26
(
6
):
246
251
[PubMed]
207
Fortenberry
JD
,
Tu
W
,
Harezlak
J
,
Katz
BP
,
Orr
DP
.
Condom use as a function of time in new and established adolescent sexual relationships.
Am J Public Health
.
2002
;
92
(
2
):
211
213
[PubMed]
208
Fine
P
,
Mathé
H
,
Ginde
S
,
Cullins
V
,
Morfesis
J
,
Gainer
E
.
Ulipristal acetate taken 48-120 hours after intercourse for emergency contraception.
Obstet Gynecol
.
2010
;
115
(
2 pt 1
):
257
263
[PubMed]
209
Glasier
AF
,
Cameron
ST
,
Fine
PM
, et al
.
Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis.
Lancet
.
2010
;
375
(
9714
):
555
562
[PubMed]
210
Glasier
A
,
Cameron
ST
,
Blithe
D
, et al
.
Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel.
Contraception
.
2011
;
84
(
4
):
363
367
[PubMed]
211
Rockoff JD. FDA reviewing efficacy of Plan B contraception in women over 165 pounds. The Wall Street Journal. November 25, 2013. Available at: http://online.wsj.com/news/articles/SB10001424052702304011304579220533719517944. Accessed January 15, 2014
212
Grimes
DA
.
Switching emergency contraception to over-the-counter status.
N Engl J Med
.
2002
;
347
(
11
):
846
849
[PubMed]
213
Committee on Adolescence
.
Emergency contraception.
Pediatrics
.
2012
;
130
(
6
):
1174
1182
[PubMed]
214
Leung
VW
,
Soon
JA
,
Levine
M
.
Measuring and reporting of the treatment effect of hormonal emergency contraceptives.
Pharmacotherapy
.
2012
;
32
(
3
):
210
221
[PubMed]
215
Ellertson
C
,
Ambardekar
S
,
Hedley
A
,
Coyaji
K
,
Trussell
J
,
Blanchard
K
.
Emergency contraception: randomized comparison of advance provision and information only.
Obstet Gynecol
.
2001
;
98
(
4
):
570
575
[PubMed]
216
Meyer
JL
,
Gold
MA
,
Haggerty
CL
.
Advance provision of emergency contraception among adolescent and young adult women: a systematic review of literature.
J Pediatr Adolesc Gynecol
.
2011
;
24
(
1
):
2
9
[PubMed]
217
Bull
SS
,
Posner
SF
,
Ortiz
C
,
Evans
T
.
Knowledge of, attitudes toward, and stage of change for female and male condoms among Denver inner-city women.
J Urban Health
.
2003
;
80
(
4
):
658
666
[PubMed]
218
Wilkinson
D
,
Tholandi
M
,
Ramjee
G
,
Rutherford
GW
.
Nonoxynol-9 spermicide for prevention of vaginally acquired HIV and other sexually transmitted infections: systematic review and meta-analysis of randomised controlled trials including more than 5000 women.
Lancet Infect Dis
.
2002
;
2
(
10
):
613
617
[PubMed]
219
Today Sponge—Vaginal Contraceptive Sponge [consumer information leaflet]. Berkeley, CA: Myer Laboratories Inc; 2011. Available at: http://todaysponge.com/pdf/todaysponge-pi2.pdf. Accessed January 15, 2014
220
Vaughan
B
,
Trussell
J
,
Kost
K
,
Singh
S
,
Jones
R
.
Discontinuation and resumption of contraceptive use: results from the 2002 National Survey of Family Growth.
Contraception
.
2008
;
78
(
4
):
271
283
[PubMed]
221
Grimes
DA
,
Gallo
MF
,
Grigorieva
V
,
Nanda
K
,
Schulz
KF
.
Fertility awareness-based methods for contraception.
Cochrane Database Syst Rev
.
2004
;(
4
):
CD004860
[PubMed]
222
Whittaker
PG
,
Merkh
RD
,
Henry-Moss
D
,
Hock-Long
L
.
Withdrawal attitudes and experiences: a qualitative perspective among young urban adults.
Perspect Sex Reprod Health
.
2010
;
42
(
2
):
102
109
[PubMed]
223
Bethell
CD
,
Read
D
,
Blumberg
SJ
,
Newacheck
PW
.
What is the prevalence of children with special health care needs? Toward an understanding of variations in findings and methods across three national surveys.
Matern Child Health J
.
2008
;
12
(
1
):
1
14
[PubMed]
224
McRee
AL
,
Haydon
AA
,
Halpern
CT
.
Reproductive health of young adults with physical disabilities in the U.S.
Prev Med
.
2010
;
51
(
6
):
502
504
[PubMed]
225
Surís
JC
,
Resnick
MD
,
Cassuto
N
,
Blum
RW
.
Sexual behavior of adolescents with chronic disease and disability.
J Adolesc Health
.
1996
;
19
(
2
):
124
131
[PubMed]
226
Murphy
N
.
Sexuality in children and adolescents with disabilities.
Dev Med Child Neurol
.
2005
;
47
(
9
):
640
644
[PubMed]
227
Neufeld
JA
,
Klingbeil
F
,
Bryen
DN
,
Silverman
B
,
Thomas
A
.
Adolescent sexuality and disability.
Phys Med Rehabil Clin N Am
.
2002
;
13
(
4
):
857
873
[PubMed]
228
Worley
G
,
Houlihan
CM
,
Herman-Giddens
ME
, et al
.
Secondary sexual characteristics in children with cerebral palsy and moderate to severe motor impairment: a cross-sectional survey.
Pediatrics
.
2002
;
110
(
5
):
897
902
[PubMed]
229
Bauer
J
,
Isojärvi
JI
,
Herzog
AG
, et al
.
Reproductive dysfunction in women with epilepsy: recommendations for evaluation and management.
J Neurol Neurosurg Psychiatry
.
2002
;
73
(
2
):
121
125
[PubMed]
230
Dizon
CD
,
Allen
LM
,
Ornstein
MP
.
Menstrual and contraceptive issues among young women with developmental delay: a retrospective review of cases at the Hospital for Sick Children, Toronto.
J Pediatr Adolesc Gynecol
.
2005
;
18
(
3
):
157
162
[PubMed]
231
American College of Obstetricians and Gynecologists Committee on Adolescent Health Care
.
ACOG Committee Opinion No. 448: Menstrual manipulation for adolescents with disabilities.
Obstet Gynecol
.
2009
;
114
(
6
):
1428
1431
[PubMed]
232
Quint
EH
.
Menstrual issues in adolescents with physical and developmental disabilities.
Ann N Y Acad Sci
.
2008
;
1135
:
230
236
[PubMed]
233
Atkinson
E
,
Bennett
MJ
,
Dudley
J
, et al
Australian Society of Paediatric and Adolescent Gynaecology Working Party
.
Consensus statement: Menstrual and contraceptive management in women with an intellectual disability.
Aust N Z J Obstet Gynaecol
.
2003
;
43
(
2
):
109
110
[PubMed]
234
Akers
AY
,
Lynch
CP
,
Gold
MA
, et al
.
Exploring the relationship among weight, race, and sexual behaviors among girls.
Pediatrics
.
2009
;
124
(
5
). Available at: www.pediatrics.org/cgi/content/full/124/5/e913
[PubMed]
235
Mond
J
,
van den Berg
P
,
Boutelle
K
,
Hannan
P
,
Neumark-Sztainer
D
.
Obesity, body dissatisfaction, and emotional well-being in early and late adolescence: findings from the project EAT study.
J Adolesc Health
.
2011
;
48
(
4
):
373
378
[PubMed]
236
Audet
MC
,
Moreau
M
,
Koltun
WD
, et al
ORTHO EVRA/EVRA 004 Study Group
.
Evaluation of contraceptive efficacy and cycle control of a transdermal contraceptive patch vs an oral contraceptive: a randomized controlled trial.
JAMA
.
2001
;
285
(
18
):
2347
2354
[PubMed]
237
Zieman
M
,
Guillebaud
J
,
Weisberg
E
,
Shangold
GA
,
Fisher
AC
,
Creasy
GW
.
Contraceptive efficacy and cycle control with the Ortho Evra/Evra transdermal system: the analysis of pooled data.
Fertil Steril
.
2002
;
77
(
2
suppl 2
):
S13
S18
[PubMed]
238
Xu
H
,
Wade
JA
,
Peipert
JF
,
Zhao
Q
,
Madden
T
,
Secura
GM
.
Contraceptive failure rates of etonogestrel subdermal implants in overweight and obese women.
Obstet Gynecol
.
2012
;
120
(
1
):
21
26
[PubMed]
239
Brunner Huber
LR
,
Toth
JL
.
Obesity and oral contraceptive failure: findings from the 2002 National Survey of Family Growth.
Am J Epidemiol
.
2007
;
166
(
11
):
1306
1311
[PubMed]
240
Hormonal contraceptives for contraception in overweight or obese women.
Obstet Gynecol
.
2010
;
116
(
5
):
1206
1207
[PubMed]
241
Gallo
MF
,
Lopez
LM
,
Grimes
DA
,
Schulz
KF
,
Helmerhorst
FM
.
Combination contraceptives: effects on weight.
Cochrane Database Syst Rev
.
2008
;(
4
):
CD003987
[PubMed]
242
Lopez
LM
,
Edelman
A
,
Chen
M
,
Otterness
C
,
Trussell
J
,
Helmerhorst
FM
.
Progestin-only contraceptives: effects on weight.
Cochrane Database Syst Rev
.
2013
;(
7
):
CD008815
[PubMed]
243
Vickery
Z
,
Madden
T
,
Zhao
Q
,
Secura
GM
,
Allsworth
JE
,
Peipert
JF
.
Weight change at 12 months in users of three progestin-only contraceptive methods.
Contraception
.
2013
;
88
(
4
):
503
508
[PubMed]
244
American College of Obstetricians and Gynecologists
.
ACOG practice bulletin no. 105: Bariatric surgery and pregnancy.
Obstet Gynecol Clin North Am
.
2009
;
113
(
6
):
1306
1311
245
Tepper
NK
,
Curtis
KM
,
Jamieson
DJ
,
Marchbanks
PA
Centers for Disease Control and Prevention (CDC)
.
Update to CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: revised recommendations for the use of hormonal contraception among women at high risk for HIV infection or infected with HIV.
MMWR Morb Mortal Wkly Rep
.
2012
;
61
(
24
):
449
452
[PubMed]
246
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Washington, DC: Department of Health and Human Services; 2011. Updated February 2013. Available at: www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed January 15, 2014
247
Cupples
SA
.
Cardiac transplantation in women.
Crit Care Nurs Clin North Am
.
1997
;
9
(
4
):
521
533
[PubMed]
248
Laifer
SA
,
Darby
MJ
,
Scantlebury
VP
,
Harger
JH
,
Caritis
SN
.
Pregnancy and liver transplantation.
Obstet Gynecol
.
1990
;
76
(
6
):
1083
1088
[PubMed]
249
Shaben
TR
.
Psychosocial issues in kidney-transplanted children and adolescents: literature review.
ANNA J
.
1993
;
20
(
6
):
663
668
[PubMed]
250
Henning
P
,
Tomlinson
L
,
Rigden
SP
,
Haycock
GB
,
Chantler
C
.
Long term outcome of treatment of end stage renal failure.
Arch Dis Child
.
1988
;
63
(
1
):
35
40
[PubMed]
251
Melzer
SM
,
Leadbeater
B
,
Reisman
L
,
Jaffe
LR
,
Lieberman
KV
.
Characteristics of social networks in adolescents with end-stage renal disease treated with renal transplantation.
J Adolesc Health Care
.
1989
;
10
(
4
):
308
312
[PubMed]
252
Morel
P
,
Almond
PS
,
Matas
AJ
, et al
.
Long-term quality of life after kidney transplantation in childhood.
Transplantation
.
1991
;
52
(
1
):
47
53
[PubMed]
253
Ghahramani
N
,
Behzadi
A
,
Gholami
S
, et al
.
Postrenal transplant improvement of sexual function.
Transplant Proc
.
1999
;
31
(
8
):
3144
[PubMed]
254
O'Donnell
D
.
Contraception in the female transplant recipient.
Dial Transplant
.
1986
;
15
(
11
):
610
612
255
Kim
JH
,
Chun
CJ
,
Kang
CM
,
Kwak
JY
.
Kidney transplantation and menstrual changes.
Transplant Proc
.
1998
;
30
(
7
):
3057
3059
[PubMed]
256
Britto
MT
,
Rosenthal
SL
,
Taylor
J
,
Passo
MH
.
Improving rheumatologists’ screening for alcohol use and sexual activity.
Arch Pediatr Adolesc Med
.
2000
;
154
(
5
):
478
483
[PubMed]
257
Riely
CA
.
Contraception and pregnancy after liver transplantation.
Liver Transpl
.
2001
;
7
(
11
suppl 1
):
S74
S76
[PubMed]
258
Pietrzak
B
,
Bobrowska
K
,
Jabiry-Zieniewicz
Z
, et al
.
Oral and transdermal hormonal contraception in women after kidney transplantation.
Transplant Proc
.
2007
;
39
(
9
):
2759
2762
[PubMed]
259
Paternoster
DM
,
Riboni
F
,
Bertolino
M
, et al
.
The contraceptive vaginal ring in women with renal and liver transplantation: analysis of preliminary results.
Transplant Proc
.
2010
;
42
(
4
):
1162
1165
[PubMed]
260
Jabiry-Zieniewicz
Z
,
Bobrowska
K
,
Kaminski
P
,
Wielgos
M
,
Zieniewicz
K
,
Krawczyk
M
.
Low-dose hormonal contraception after liver transplantation.
Transplant Proc
.
2007
;
39
(
5
):
1530
1532
[PubMed]
261
Deray
G
,
le Hoang
P
,
Cacoub
P
,
Assogba
U
,
Grippon
P
,
Baumelou
A
.
Oral contraceptive interaction with cyclosporin.
Lancet
.
1987
;
1
(
8525
):
158
159
[PubMed]
262
Mastrobattista
JM
,
Katz
AR
.
Pregnancy after organ transplant.
Obstet Gynecol Clin North Am
.
2004
;
31
(
2
):
415
428, vii
[PubMed]
263
Estes
CM
,
Westhoff
C
.
Contraception for the transplant patient.
Semin Perinatol
.
2007
;
31
(
6
):
372
377
[PubMed]