Contraceptive Counseling and Methods for Adolescents: Clinical Report Free

It is important for pediatricians to be knowledgeable about basic contraceptive counseling and the range of contraceptive methods. Adolescents have an unmet need for contraception. In 2021, 30% of all high school students reported ever having sex.¹ Among sexually active students in 2021, 52% reported using a condom at last sexual intercourse and 33% reported that they or a partner used an effective form of contraception (either long acting reversible method [LARC] or hormonal method) at last sexual intercourse; of those, 10% reported dual use of condom and a more effective hormonal or LARC method together.¹ Almost 14% of sexually active youth used no method of contraception at last sexual intercourse.² 

Contraception is an important tool in optimizing adolescent reproductive health, and the majority of the declines in adolescent pregnancy since the 1990s are attributable to increased use of contraception.³ However, many adolescents continue to face barriers to accessing effective, equitable contraceptive care.⁴ As trusted health care professionals, many with long-term relationships with adolescents, pediatricians are often the first health care provider that adolescents speak to about sexual and reproductive health concerns^5,6 and pediatricians are well-positioned to meet adolescents’ contraceptive needs with patient-centered, evidence-informed, developmentally tailored, equity-focused counseling. In addition to using contraception for pregnancy prevention, many adolescents, particularly adolescents with medical complexity, use hormonal contraception for menstrual regulation and other medical indications.

This clinical report is a companion to the revised policy statement “Contraception for Adolescents,”⁷ provides an overview of contraceptive methods available to adolescents in the United States, and expands on counseling guidance in the policy statement. This report builds on the series of method-specific statements and clinical reports from the American Academy of Pediatrics (AAP) on LARCs,⁸ barrier methods,⁹ and emergency contraception (EC).¹⁰ It also includes new information on progestin-only pills (POPs) as well as combined hormonal, barrier, and other methods not included in the method-specific statements. Together, this family of documents supports the pediatrician in providing evidence-informed and equity-informed practices in counseling and prescribing contraception for adolescents. Table 1 lists contraceptive methods and the effectiveness of each. Other sources of information on contraception that may be useful to the pediatrician are listed in Table 2, including the contraceptive guidance documents from the Centers for Disease Control and Prevention (CDC), the US Medical Eligibility Criteria (US MEC)¹¹ and its companion document, the US Selected Practice Recommendations (US SPR).¹² Both are available online and as free applications for mobile devices. The US-MEC reviews data on medical conditions and contraceptives and categorizes methods as 1 – no restrictions; 2 – advantages generally outweigh theoretical or proven risks; 3 – theoretical or proven risks usually outweigh advantages, but may be used with a specific patient using a shared decision making approach; and 4 – unacceptable health risk.¹¹ The most recent version of the US-MEC, released in August 2024, includes many important updates. Even experienced clinicians are advised to consult this reference when prescribing for adolescents with ongoing medical conditions, using it in conjunction with shared decision making and consideration of an adolescent’s preferences and circumstances to make an individualized treatment plan.

Effective contraceptive counseling with adolescents applies principles of shared decision making and person-centered care within a sexual and reproductive health equity framework.^13–15 The pediatrician provides medical knowledge about contraception, while the adolescent offers perspective on their goals, preferences and life circumstances, and together they make a collaborative decision about contraception initiation, continuation, or discontinuation.¹⁴ Shared decision-making may involve a parent/caregiver or trusted adult as preferred by the adolescent, as adolescents frequently identify family as sources of sexual health values, information, and support for method choice.¹⁶ Additionally, peers and partners can be sources of influence or support for contraceptive choice and continuation.^6,17–20 If the adolescent chooses, a partner can be included in contraceptive visits and decision making.²¹ 

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th edition, recommends that pediatricians obtain a developmentally tailored sexual history from the adolescent alone, assess STI and pregnancy risk, and provide appropriate screening, counseling, and, when needed, contraception.²² Taking a sexual history is facilitated by an honest, caring, nonjudgmental attitude and a comfortable, matter-of-fact approach to asking questions. Tools for sexual history taking include the “5 Ps” of sexual history: partners, practices, protection from STIs, past history of STIs, and pregnancy intention²³ and motivational interviewing focused on future goals, validating adolescents’ capacity to reach those goals, and engaging adolescents in adoption of health-promoting behaviors.^23–25 

Gender-inclusive language ensures that adolescents maintain trust and confidence with their care team.²⁶ Providers may introduce themselves with their personal pronouns and inquire about the adolescent’s gender identity, pronouns, and sexual identity as part of the confidential interview. Pediatricians may consider using terms like “a person who can become pregnant” or “someone with a uterus” rather than “women” to include those individuals who identify as transmasculine or nonbinary and have contraceptive needs. Beyond pregnancy-capable individuals, pediatricians can ensure that contraceptive information and counseling is available to all individuals who can contribute to a pregnancy, including those who make sperm, such as birth-assigned males (ie, cisgender males, transgender females, and gender diverse youth with testicles).²¹ 

If adolescents have experienced prior sexual abuse, sexual assault, human trafficking, and other forms of trauma, a healing-centered approach may be necessary.²⁷ Of particular importance, adolescents involved in the child welfare and juvenile justice systems have high rates of sexual trauma and high rates adverse sexual health outcomes; many have also experienced biases from providers.^28–30 A healing-centered approach includes using language and skills to promote trust building, as well as screening for trauma, and referring to trauma-specific health care services as indicated.^31,32 

For adolescents and young adults with diminished decision-making capacity due to cognitive impairment or intellectual disability, the pediatrician can involve a parent/caregiver to partner in decision-making that centers the best interests of the adolescent. An alternative framework is supported decision-making, in which the adolescent or young adult with cognitive impairment identifies a trusted adult (frequently a parent) to help communicate their preferences to the clinician.^33,34 

Research suggests that adolescents make decisions differently than adults—for example, adolescents may be less risk averse, have more challenges considering multiple perspectives, and make different decisions in “hot” (high emotion and distraction) decision-making scenarios.^35–37 Nonetheless, studies of overall capacity for health decisions demonstrate that adolescents have adult-type capacity to understand health information, weigh risks and benefits, and make rational, voluntary choices.^35,38–41 In a study of contraceptive decision making, by 14 years of age, participants demonstrated the capacity to self-screen for medical contraindications, understand contraceptive information, appreciate how it affects them personally, balance risks and benefits, and make voluntary decisions.^41,42 

An adolescent-centered counseling approach within a sexual and reproductive health equity framework starts with a pediatrician reflecting on their own biases and assumptions about an adolescent’s contraceptive needs. Pediatricians who choose not to provide contraceptive care because of claims of conscience are directed to the AAP policy statement, “Physician Refusal to Provide Information or Treatment on the Basis of Claims of Conscience.”⁴³ Referrals need to be time-sensitive, respectful, nonjudgmental and done with an awareness of the power differential between adolescents and providers.

Self-reflection is followed by assessing the adolescent’s stated goals and preferences, (independent of the preferences of interested family members, partners, or friends), developmental needs and contextual factors. Stated preferences might include how a method is used (and whether it requires a prescription or procedure) or method efficacy at preventing pregnancy. Developmental needs and contextual factors might include an adolescent’s prior (or lack of) contraceptive experiences, need for more interactive counseling, school and family characteristics, social norms, and relevant cultural perspectives.^44–46 

After this assessment, the pediatrician can then present method options based on the adolescent’s stated preferences, developmental needs, and context. Ideally, a pediatrician will be able to provide a range of methods based on access, from over-the-counter (OTC) options like emergency contraception, condoms, and progestin-only contraceptive pills, which do not require a prescription and are not disclosed to guardians through the EHR or EOB, to prescription-based options such as combined hormonal contraceptive methods, the contraceptive injection, and long-acting reversible contraceptive (LARC) devices such as implants and intrauterine devices (IUDs). Important guidance on counseling about LARC methods using sexual and reproductive equity principles can be found in the Patient-Centered LARC Counseling Section of the AAP Clinical Report on Long-Acting Reversible Contraception.⁸ Pediatricians additionally need to take into account and educate adolescents about access to contraception and abortion services based on state law, which may limit options an adolescent might have if they become pregnant.⁴⁷ 

Pediatricians may use contraceptive decision aids to improve knowledge and provide additional support to adolescents making contraception decisions.⁴⁸ (See Table 3 for examples of decision aids.) For many adolescents seeking contraception, pregnancy prevention is a key priority, and counseling should proceed from most effective to least effective methods.⁴⁶ Other adolescents may prioritize menstrual control, not taking a daily pill, or privacy; for these adolescents, method preferences will be different.

Table 3 provides a step-by-step summary of this sexual and reproductive equity-informed counseling framework. Shared contraception decision-making with adolescents is often an iterative process. Adolescents may need to try more than one method, working together with their pediatrician to address barriers and facilitators to effective use, including access, payment, transportation for continuity of care, burden of use, and side effects. It may be helpful to schedule a follow-up visit 1 to 3 months after starting a contraceptive method to check in on this process.

For the pediatrician, comprehensive contraceptive counseling relies on familiarity with the full range of contraceptive methods. The purpose of this clinical report is to provide pediatricians with an updated review of effectiveness and method characteristics to help inform shared decision making with their patients.

LARCs (ie, intrauterine devices [IUDs] and contraceptive implants) are safe and provide the most effective pregnancy prevention for adolescents. Although only one aspect of an adolescent-centered approach to contraceptive decision making, effectiveness has become particularly salient given recent restrictions on access to safe abortion care.⁴⁷ Compared with other methods, LARCs have both higher effectiveness and higher continuation. In the CHOICE study, the 14- to 19-year-old participants (who had parental permission to participate and a higher rate of prior pregnancy than teens in the general population) had a 12-month continuation rate of LARCs of 81%, compared with 44% for non-LARC methods.⁴⁹ Also from the CHOICE study, the contraceptive failure rate was 20 times higher in women 14 to 45 years of age who used combined hormonal pills, patches, or rings than in those using LARC methods.⁵⁰ This was an especially notable finding in those women younger than 21 years in whom the pill, patch, and ring contraceptive failure rates were twice as high as in women 21 years or older.⁵⁰ Permanent contraception (eg, tubal ligation, hysterectomy, vasectomy), although listed in many adult-oriented resources, raises legal, ethical, and medical concerns for adolescents and is addressed in a separate AAP policy statement.⁵¹ 

Shorter-acting contraceptives include combined hormonal contraceptive (CHC) methods and progestin-only methods. CHC methods contain a combination of progestin and estrogen and include pills, vaginal rings, and transdermal patches. All progestin-only methods, including levonorgestrel IUDs, implants, injections, and pills, are safer for health conditions in which estrogen use is contraindicated. Shorter-acting hormonal contraceptives (pills, patches, rings) are highly effective but are often discontinued after less than 6 months of use, most commonly because of reported side effects.⁵² Emergency contraception (EC [eg, designated oral products, IUDs, pills]) are important tools and account for a significant part of the decrease in adolescent pregnancy rates. Pediatricians should be aware of any restrictions on contraceptive methods for minors in their states. With states considering legislation restricting EC, IUDs, and other methods, the AAP State Advocacy team can provide pediatricians with an update on their state’s legal landscape and opportunities for advocacy by pediatricians at the state level ([email protected]).

Contraception should always be started on the day of visit (“quick start”) if the health care provider is reasonably certain the adolescent is not pregnant, remembering that menstrual periods can be irregular in adolescents and the urine pregnancy tests may not detect a very early pregnancy, especially prior to missed menses. (See the CDC algorithm in the US selected Practice Recommendations for Contraceptive Use, 2024¹²). However, even when the health care provider is not reasonably certain the adolescent is not pregnant, the benefit of starting almost all contraceptive methods may outweigh the risks of delaying contraceptive initiation, and shared decision making with the adolescent is recommended. To prevent pregnancy as soon as possible after unprotected intercourse, EC is indicated and can be provided with oral levonorgestrel, oral ulipristal acetate or an IUD (see EC and IUD method sections below).¹⁰ 

If a pediatrician is unable to provide a specific method, the pediatrician should be knowledgeable about adolescent-friendly locations where patients can access the full range of methods.⁴³ A “bridge method” that is easily accessed can be useful for any patients experiencing a delay in obtaining their preferred method of ongoing contraception—for example, prescribing oral contraceptive pills that can be procured at a local pharmacy and used until a patient can obtain a clinician-placed LARC method. Online resources exist to help identify the nearest health center offering LARCs—for example, https://www.bedsider.org/find-health-care/clinics.

Providers should counsel adolescents to use a backup method (ie, condom or other barrier method) for 7 days after initiation of a hormonal contraceptive method and encourage adolescents to use a condom and/or latex sheet for all sexual encounters to protect against sexually transmitted infections (STIs).⁹ Contraception should be provided within the context of routine sexual health care, and pediatricians should address topics such as human papillomavirus (HPV) vaccination and routine screening for STIs.²² Except for IUD placement, a pelvic examination is not necessary to start contraception. Following contraception initiation, patients should be provided with clear instructions on how to contact the office with problems or questions and with additional sources of information about their method, including how to manage missed doses, in the format (eg, online links, QR codes, or taking a photo of the instructions) preferred by the patient. Some adolescents do not want to receive paper copies of instructions that may be discovered by others. Contraception counseling can be an iterative process, and some patients may need to try multiple contraceptive methods to find the one that best fits their needs. Scheduling a routine follow-up visit can help address the management of side effects or minimize a gap prior to changing to a different method if necessary or desired. Virtual visits (telehealth or telephonic) are well-suited to these types of visits.

Nexplanon (Organon, Whitehouse Station, New Jersey) is a single-rod implant that contains 68 mg of etonogestrel, the active metabolite of the progestin desogestrel, that provides highly effective pregnancy prevention for up to 2 years beyond the US Food and Drug Administration (FDA)-approved 3 years (5 years total).^53–55 Nexplanon is currently the only available subdermal contraceptive implant in the United States. Implants are suitable for adolescents who prefer a method that does not require regularly scheduled adherence and who desire an extended length of protection.^8,56 Training is widely available at no cost through the manufacturer, and increasing numbers of general pediatricians are learning to place and remove implants.⁵⁷ Additional information can be found in the AAP clinical report on LARC methods.⁸ 

The IUD is a LARC medical device inserted into the uterus. There are 6 FDA-approved IUDs (Table 4). IUDs are safe for nulliparous individuals, do not cause infertility, and provide rapid return to fertility after removal.^58,59 The copper T380-A IUD has been shown to be effective emergency contraception within 5 days of unprotected intercourse,¹⁰ and a study of adult patients showed similar effectiveness of the 52-mg levonorgestrel IUD as emergency contraception.⁶⁰ Patients desiring an IUD after the EC window but before pregnancy can be reliably ruled out may choose to quick start another contraceptive method that can be more easily discontinued as a bridge method until pregnancy can be reliably excluded and an IUD can be safely placed. If an IUD is placed, providers may recommend another pregnancy test 2 weeks after the last episode of unprotected intercourse. If an IUD user is found to be pregnant, the increased risks of spontaneous abortion and preterm delivery can be decreased by IUD removal.¹² Menstrual cups have been shown to increase the risk of IUD expulsion, whereas tampons have not been shown to do so.^61–63 The AAP clinical report on LARC methods and the ACOG provide additional information on risks, benefits, and counseling for implants and IUDs.^8,64 Because IUD insertion can cause severe cramping, pain management options, including insertion under sedation for select patients, should be included in counseling. There is no consensus on a single, evidence-informed, best practice. However, options for pain management are presented in the SPR.¹² 

Depo medroxyprogesterone acetate (DMPA, Depo-Provera [Pfizer, New York, New York]) is a long-acting progestin that is injected every 3 months, using a dose of either 150 mg intramuscularly or 104 mg subcutaneously.¹² As an off-label use, patients can self-inject the subcutaneous formulation after instruction, which has demonstrated improved contraceptive continuation rates.^12,65 Both regimens have similar side effects and are highly effective in preventing pregnancy.^65,66 DMPA may be administered up to 2 weeks late (15 weeks after last injection) without requiring backup contraception, and there is no time limit for early injections.¹² 

DMPA advantages include easy use, reduction of uterine bleeding, and improvement in dysmenorrhea. Disadvantages include the need for regular injections and menstrual cycle irregularities that occur in nearly all patients initially but typically improve over time.⁶⁶ Other potential side effects include headache, mastalgia, hair loss, change in libido, and weight gain. Studies in both adolescents and adults suggest that DMPA-related weight gain occurs in a minority of users and that weight gain status at 6 months after initiation is a strong predictor of future excessive weight gain with ongoing DMPA use.^67,68 

In 2004, the FDA issued a “boxed warning” (the highest safety-related warning that medications can have) regarding the risk of decreased bone mineral density (BMD) among DMPA users. The ACOG, citing substantial recovery of BMD after discontinuing DMPA, does not advise limiting the duration of DMPA use nor routinely monitoring bone density but does recommend a shared decision-making approach.⁶⁹ With the emergence of limited data linking bone fracture to more than 2 years of DMPA use, the risk-benefit discussion for hormonal contraception may be more challenging when prescribing DMPA for teens for medical uses rather for contraception.^70,71 It is good practice to include counseling to promote skeletal health, including meeting recommended daily intake of 1300 mg of calcium and 600 IU of vitamin D, and regular weight-bearing exercise.⁷² 

There are 3 progestin-only oral contraceptives (sometimes called “mini-pill”) currently available in the United States. Norethindrone 0.35 mg has been available since the late 1960s. In July 2023, norgestrel 0.75 mg (brand name Opill, Perrigo, Dublin, Ireland) became the first oral birth control pill approved by the FDA to be available in the US without a prescription and without age restrictions.⁷³ Both of these POPs have no placebo interval. They prevent pregnancy by thickening cervical mucus and do not reliably inhibit ovulation.⁷⁴ It is recommended they are taken within the same 3-hour window each day to maintain efficacy. Adolescents’ access to over-the-counter contraceptive options will be affected by retail pricing and insurance coverage which warrant ongoing attention, particularly as more options become available.⁷⁵ 

A newer POP containing the progestin drospirenone (brand name Slynd, Exeltis USA Inc, Florham Park, New Jersey) provides another POP alternative for individuals with estrogen contraindications (eg, migraine headaches with aura, severe and uncontrolled hypertension) who struggle with traditional POPs because of breakthrough bleeding or adherence issues. Similar to the mechanism of action of CHC, Slynd suppresses ovulation, including even when a pill is delayed by 24 hours, and has a built in 4-day placebo interval intended to create more predictable monthly bleeding.⁷⁶ Slynd contains an analog of spironolactone and, thus, has the potential to cause hyperkalemia in those at risk, for example patients with renal disorders or using medications with elevated potassium as a potential side effect.⁷⁷ 

CHC methods (pills, transdermal patches, and vaginal rings) are the most used methods of hormonal contraception for adolescents. Although more data are available from studies of combined oral contraceptive (COC) pills than the other modalities, all have the same mechanism of action and similar contraindications to use, which are minimal in healthy adolescents. CHCs are identified as an unacceptable health risk (MEC category 4) for adolescents with severe and uncontrolled hypertension (systolic pressure ≥160 mm Hg or diastolic pressure ≥100 mm Hg), <21 days postpartum, peripartum cardiomyopathy (with normal or mildly impaired cardiac function <6 months postpartum or with moderately or severely impaired cardiac function) liver tumors (hepatocellular adenoma or malignant hepatoma), severe (decompensated) cirrhosis, acute viral hepatitis, nephrotic syndrome, dialysis, major surgery with prolonged immobilization, current history of thromboembolism or thrombophilia, sickle cell disease, lupus (with positive or unknown antiphospholipid antibodies), history of and current ischemic heart disease, history of cerebrovascular accident (stroke), complications of diabetes (eg, nephropathy, retinopathy, neuropathy, or other vascular disease), migraines with aura or focal neurologic symptoms, and continuation in a patient with multiple risk factors for atherosclerotic cardiovascular disease.^11,78,79 Given the frequency of headache symptoms, careful attention to headache classification⁸⁰ will prevent unnecessarily limiting access to CHC. Complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation or history of subacute bacterial endocarditis), and complicated solid organ transplant are additionally identified as an unacceptable health risk (MEC category 4),¹¹ and collaboration with the patient’s specialty team is prudent. Smoking, although discouraged, is not a contraindication for adolescents or adults younger than 35 years of age (MEC category 2).¹¹ 

Venous thromboembolism (VTE) is the most serious adverse event associated with CHC, which increases from a baseline risk of 1 per 10 000 to 3 to 4 per 10 000 person-years during CHC use.^81–83 In comparison, the incidence of venous thromboembolism during pregnancy and postpartum is 10 to 20 per 10 000 person-years, of which 1% to 2% are fatal.⁸⁴ Although there are some conflicting data suggesting higher VTE risk using the patch⁸⁵ and other data showing small differences in VTE risk with different progestins, the absolute VTE risk for CHC is low and similar across CHC methods.⁸⁶ 

Numerous studies have investigated the risk of breast cancer associated with use of hormonal contraception with inconsistent findings, but overall, the additional risk of premenopausal breast cancer conferred by hormonal contraception is generally thought to be low and a family history of breast cancer is not considered a contraindication to any hormonal contraceptive method.^11,87 In contrast, there is a demonstrated decrease in the risk of ovarian and endometrial and possibly colon cancer with the use of COC pills.⁸⁸ 

CHCs have similar common side effects including transient irregular bleeding, headache, and nausea. Recommendations for managing adverse effects are available elsewhere and online.^12,89–91 Pediatricians are advised to use caution to avoid drug interactions with CHCs, particularly with medications that decrease contraceptive effectiveness (eg, some anticonvulsants and rare antiretroviral drugs).^12,92,93 Antibiotics, except for rifamycin antibiotics such as rifampin, are unlikely to affect the contraceptive effectiveness.⁹⁴ 

All CHC methods can be started on the day of visit (quick start as described above) in healthy, nonpregnant adolescents with advice to use a back-up method (eg, condoms) for at least the first 7 days if sexually active. The US SPR has clear and comprehensive guidance on managing late or missed doses of pills, patches, and rings.¹² 

Providers may authorize sufficient refills for a full year (13 four-week cycles). Method continuation is higher when patients receive a full-year prescription at one time, a practice recommended by the CDC¹² and legally required in some states when requested by patients (see, for example, the state of Washington⁹⁵). A routine follow-up visit at 1 to 3 months may be useful for addressing adverse effects or adherence issues but is not necessary.

In most COC pills, the estrogen component is ethinyl estradiol in amounts varying from 10 to 50 μg. A common approach is to begin with a COC containing 30 to 35 μg of ethinyl estradiol (EE). Lower doses of EE are available and not contraindicated but may have an adverse impact on bone mineral density acquisition⁷² and be associated with more irregular bleeding compared with higher doses of estrogen.⁹⁶ Higher doses (ie, 50 μg EE) increase thrombotic risk.⁸⁶ In addition, one pill (Nextstellis, Mayne Pharma LLC, Raleigh, North Carolina) combines a plant-synthesized version of the naturally occurring estrogen, estetrol, with drospirenone. Although theoretically it has the potential for an improved safety profile, based on the currently available data, prescribing considerations are the same as for all other COC pills.^97,98 

Pill packs typically include a combination of hormone-containing pills and hormone-free or “reminder” pills. While taking reminder pills, uterine bleeding occurs because of the absence of hormones. Pills are packaged to support a variety of regimens, from monthly cycling (4–7 hormone-free days per month) to extended cycling to continuous active pills with zero hormone-free pills per year.⁹⁹ For example, a commonly used extended cycling regimen includes 12 weeks of hormone pills and 7 hormone-free pills. Any commonly prescribed brands of monophasic COC pills can be used in any of the aforementioned regimens. Comprehensive counseling includes strategies to promote daily adherence, such as mobile device alarms, tracker mobile applications, and support from a family member or partner.

There are 2 vaginal rings. NuvaRing (Merck, Whitehouse Station, NJ) requires insertion of a new ring each month. Patients insert the contraceptive ring into the vagina and leave it in place for 3 weeks, with removal for 1 week to induce withdrawal bleeding. A new ring is inserted after 7 days even if bleeding continues. Annovera, a ring that can be used for up to a year, is a similar diameter (2.25” vs 2.13”) to the Nuvaring but twice as thick (0.33” vs 0.16”). It is removed after 21 days of use and stored unrefrigerated for 7 days to allow a withdrawal bleed, and then reinserted each month. In addition to other CHC side effects, ring users may experience vaginal discharge or discomfort and problems related to the device (eg, expulsion or inability to locate).¹⁰⁰ The NuvaRing contains sufficient medication for use up to 35 days¹⁰¹ and, thus, can be used continuously and replaced without a period of removal to skip menses.⁹⁹ There are no data on continuous use of Annovera. Patients do not need to remove rings for tampon use, menstrual cup use, or intercourse, but if the adolescent chooses, they can remove them for up to 2 hours for Annovera and 3 hours for NuvaRing without diminished efficacy for pregnancy prevention.¹⁰² 

There are 2 types of transdermal patches available in the United States; beige/peach is the only color available. The square patch (Xulane, Viatris Pharmaceuticals, Inc, Canonsburg, Pennsylvania, and Zafemy, Amneal, Bridgewater, New Jersey) delivers 150 μg/d norelgestromin and 35 μg/d ethinyl estradiol, but its labeling notes that overall estrogen exposure is about 60% higher than with an oral birth control pill containing 35 μg of ethinyl estradiol. The larger (28 cm² vs 14 cm²) circular patch (Twirla, Agile Therapeutics, Princeton, New Jersey) delivers 120 μg/d levonorgestrel and 30 μg/d ethinyl estradiol. Both patches are labeled for use only by individuals with a body mass index (BMI) <30 kg/m². Patches are placed on the abdomen, upper torso, or buttocks (and also upper outer arm for Xulane), using 1 patch per week for 3 weeks in a row, followed by 1 week off the patch, during which time a withdrawal bleed usually occurs. Similarly to the pill and ring, the patch-off week can be eliminated for continuous use to reduce bleeding.^99,103 In addition to other CHC side effects, users may also experience dislodged patches and skin effects (hyperpigmentation, contact dermatitis, and other irritation).^104,105 

Barrier methods include the external (formerly called “male”) condom, internal (formerly “female”) condom, latex sheets (dental dams), diaphragms, cervical caps, sponges, spermicides, and vaginal pH modulators. A recent AAP policy statement and technical report on barrier methods provides detailed information for the pediatrician on external and internal condoms and dental dams.⁹ 

Diaphragms are shallow, dome-shaped silicone cups used with spermicide and placed inside the vagina prior to intercourse. The Milex diaphragm (Cooper Surgical, Trumbull, Connecticut) requires fitting by a provider. A newer contoured diaphragm (Caya, HPSRx Enterprises, Salem, Virginia) is one-size-fits-most and does not require fitting. Both can remain in the vagina for up to 24 hours. Cervical caps are 1.5 × 1 inch silicone cups that fit over the cervix with spermicide inside. Contraceptive sponges are 2-inch pieces of plastic foam impregnated with spermicide. The single-use sponge is wetted to activate the spermicide, can be placed up to 24 hours prior to sex, and remains in for up to 30 hours. All 3 methods (diaphragm, cervical cap, sponge) require remaining in for at least 6 hours after intercourse. The typical use failure rates for diaphragms and sponges are high (see Table 1), and they do not protect from STIs. Younger adolescents use these methods less frequently, but older adolescents may desire these event-specific and hormone-free methods.¹⁰⁶ 

Two contraceptive vaginal gels are available. Nonoxynol-9 spermicide is available OTC as gel, cream, foam, film, or suppository. Nonoxynol-9 gels are used with diaphragms and cervical caps, and nonoxynol-9 is impregnated in sponges. The typical use failure rate of nonoxynol-9 alone is 21%.⁹⁰ Nonoxynol-9 does not protect against STIs. Because repeated and high-dose use may cause vaginal or anal lesions that may increase HIV transmission, the CDC considers its use an unacceptable health risk (MEC category 4) for individuals at risk for HIV.¹¹ For individuals living with HIV, use of nonoxynol-9 is usually not recommended unless other more appropriate methods are not available or acceptable (MEC category 3).¹¹ A newer vaginal pH modulator (Phexxi, Evofem Biosciences, San Diego, California) is a prescription contraceptive acidifying gel with active ingredients lactic acid 1.8%, citric acid 1%, and sodium bitartrate 0.4%. It prevents pregnancy by modulating vaginal pH and impairing sperm motility. It is applied immediately before or up to an hour before sexual intercourse and reapplied every hour thereafter. Population-based effectiveness data are not available; clinical trials from the manufacturer reported a typical use failure rate of 14%.^76,107 A new applicator should be used for each vaginal sexual act,⁷⁶ and the vaginal pH modulator may be used with other methods except the vaginal ring.

When used within 120 hours after unprotected intercourse, EC reduces the risk of pregnancy, and the sooner EC is initiated, the more effective it is. ECs include FDA-indicated oral EC products, levonorgestrel and ulipristal acetate (a progesterone receptor modulator), and IUDs. Oral levonorgestrel and ulipristal acetate are more effective the sooner they are taken after unprotected intercourse and may be less effective in individuals with higher BMI.¹⁰⁸ While individuals may start another hormonal contraceptive method immediately after taking oral levonorgestrel EC, starting another hormonal method within 5 days of using ulipristal acetate may decrease the effectiveness of ulipristal.¹² Shared decision-making is recommended to weigh this risk against potentially delaying care for patients who choose an ongoing contraceptive method that requires an office visit (LARC or DMPA) to start. A recent study demonstrated that the levonorgestrel IUD was noninferior to the copper IUD for use as EC,⁶⁰ an off-label use for both. Body weight and timing (≤5 days) do not affect the effectiveness of the IUD as EC. The AAP policy statements on LARC methods⁸ and emergency contraception¹⁰ provide additional detailed information.

Withdrawal, abstinence, and fertility awareness-based methods are less effective methods but are practiced by many adolescents.² Withdrawal, or coitus interruptus, is a method in which the penis is pulled out of the vagina before ejaculation. Withdrawal has limited effectiveness, with a 20% overall failure rate (adolescent data not available).¹⁰⁹ Although less than 4% of individuals report currently using withdrawal,¹¹⁰ lifetime use is common, and 65% of sexually active 15- to 19-year-old adolescents reported ever using withdrawal.¹¹¹ In fertility awareness-based methods, individuals abstain during fertile days of their menstrual cycle, identified via menstrual calendar, basal body temperature, observations of cervical mucus, or a combination of these three. Fertility awareness places a high responsibility on users, and it may be less effective for adolescents, as ovulation is often not predictable in the first few years after menarche. Fertility awareness-based mobile applications are available but have not been tested in people younger than 18 years and are not indicated for persons with irregular periods.¹¹² 

As a contraceptive method, abstinence has a perfect use efficacy of 100%; however, in nationally representative surveys, many adolescents who plan to be abstinent become sexually active,^113,114 making the typical use effectiveness much lower. These data suggest that pediatricians should not rely on abstinence counseling alone and need to provide comprehensive sexual health information including when and how to access to EC.

An estimated 16% to 25% of adolescents have special health care needs, including physical disability, intellectual disability, and medically complex conditions.¹¹⁵ Sexuality and sexual health care needs in this population are often overlooked, yet compared with healthy adolescents, adolescents with chronic medical conditions have similar levels of sexual behaviors and STIs.¹¹⁶ In addition to pregnancy prevention, medically complex adolescents may have medical indications for contraceptives. For example, patients with intellectual disability or mobility limitations may benefit from menstrual suppression.¹¹⁷ Collaboration with a patient’s managing subspecialist about contraception can enhance a pediatrician’s knowledge of the underlying condition, how that may impact contraceptive effectiveness, and side effects (such as hypertension with renal disease, low bone density with celiac disease, or seizure management).^79,81,118 When applicable, adolescents with medical complexity should be made aware of the additional risks that an unplanned pregnancy could pose to their health.

Medications that are teratogenic are commonly prescribed for adolescents, and many teenagers are not counseled about contraceptives.^119,120 Pediatricians prescribing teratogens or caring for adolescents who are prescribed teratogenic medications, such as isotretinoin, spironolactone, or mycophenolate, should discuss pregnancy prevention with patients^120–122 For example, anticonvulsants are widely prescribed for both seizure disorder and behavioral indications and interact with many contraceptives.^79,120 The CDC addresses contraception considerations for certain medical conditions and medication interactions in the US MEC (see Table 2),¹¹ and the ACOG provides guidance on the hormonal contraception use for adolescents and adults with coexisting medical conditions as well as medical management of menstrual suppression.^{81,99,120,123} 

Contraceptive care in adolescents with a uterus who are transgender and gender diverse (TGD) includes pregnancy prevention and menstrual regulation as desired by the patient. For both these indications, all hormonal methods, including those including estrogen, can be used by patients also taking testosterone. Testosterone may or may not provide amenorrhea and is not to be used as a contraceptive method. Ideally, communication around amenorrhea, anatomy, and physical examinations will be healing centered and consider individual dysphoria.¹²⁴ The Society for Family Planning published clinical recommendations for contraceptive counseling with individuals who are TGD.²⁶ 

Many adolescents need or desire menstrual regulation or suppression, and contraceptives can treat medical conditions such as anemia, acne, severe dysmenorrhea, endometriosis, bleeding disorders, abnormal or heavy menstrual bleeding, and thrombocytopenia related to chemotherapy.^{81,118,125–127} Given the relative safety of hormonal contraceptives, adolescents may use them to reduce bleeding or move toward amenorrhea. Contraceptives may be useful for ovarian suppression for conditions with catamenial exacerbation, such as migraines, epilepsy, irritable bowel syndrome, inflammatory bowel disease, and some psychiatric and behavioral symptoms.^{79,118,120,123} 

Menstrual management involves a variety of methods, and providers can use shared decision-making approaches in counseling. CHC methods offer patients some control over when withdrawal bleeding occurs. When using continuously or with extended cycling, there is the “tailored approach” of taking active pills until bleeding reoccurs, and the “scheduled approach” of a break every 3 to 4 months to reduce unscheduled breakthrough bleeding.^103,128,129 In the tailored approach, patients stop pills for 3 to 5 days when they begin spotting and then reinitiate active pills. Some pills are packaged and marketed for 3-month cycles or continuously. The most common adverse effect of extended/continuous cycles is unscheduled bleeding.¹³⁰ A common approach to continuous and extended cycling with COC pills is to use monophasic, 30-μg or 35-μg ethinyl estradiol pills and a second- (levonorgestrel or norgestrel) or third-generation (desogestrel or norgestimate) progestin.¹⁰³ Prescribers can indicate extended cycling to help the pharmacy and insurance dispense refills earlier. See Table 5 for rates of amenorrhea and anovulation for contraceptive methods.

For those with contraindications to estrogens or who wish to avoid estrogen, progestin-only options can be used for menstrual suppression and extended cycling. Users can start and stop POPs more quickly than progestin-only shots, implants, or IUDs; however, adolescents using POPs may experience more breakthrough bleeding. DMPA effectively suppresses ovulation and menstruation, is safe for most patients with chronic illness,¹¹ and is used for medical conditions such as anemia¹²⁶ and seizure disorders,^79,120 as described above. The 19.5-mg and 52-mg levonorgestrel IUDs can reduce uterine bleeding with minimal hormonal exposure but do not reliably suppress ovulation; in contrast, the implant suppresses ovulation but has higher rates of breakthrough bleeding.^8,131,132 

Access to a full range of contraceptive methods is an important component of safe, equitable, and adolescent-centered health care, and pediatricians are well-placed to address contraceptive needs. Together with the companion policy statement, “Contraception for Adolescents,” and the family of policy statements and clinical reports on contraception and sexual health, the AAP provides guidance for a comprehensive, equity-informed approach to contraception for adolescents.

Mary A. Ott, MD, MA, FAAP

Gina S. Sucato, MD, MPH, FSAHM, FAAP

Maayan Leroy-Melamed, MD, MPH, FAAP

Andrea J. Hoopes MD, MPH, FAAP

Elizabeth M. Alderman, MD, FSAHM, FAAP, Chairperson

Elise Berlan, MD, MPH, FAAP

Richard J. Chung, MD, FAAP

Michael Colburn, MD, MEd, FAAP

Laura K. Grubb, MD, MPH, FAAP

Janet Lee, MD, FAAP

Stephenie B. Wallace, MD, MSPH, FAAP

Anne-Marie Amies, MD – American College of Obstetricians and Gynecologists

Liwei L. Hua, MD, PhD – American Academy of Child and Adolescent Psychiatry

Seema Menon, MD – North American Society of Pediatric and Adolescent Gynecology

Maria H. Rahmandar, MD, FAAP – AAP Section on Adolescent Health

Ellie Vyver, MD – Canadian Pediatric Society

Karen Smith

James Baumberger, MPP

AAP

American Academy of Pediatrics

ACOG

American College of Obstetricians and Gynecologists

BMD

bone mineral density

BMI

body mass index

CDC

Centers for Disease Control and Prevention

CHC

combined hormonal contraceptive

COC

combined oral contraceptive

IUD

intrauterine device

DMPA

depot medroxyprogesterone acetate

EC

emergency contraception

LARC

long-acting reversible contraceptive

MEC

Medical Eligibility Criteria

POP

progestin-only pill

SPR

Selected Practice Recommendations

STI

sexually transmitted infection

VTE

venous thromboembolism