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Adolescent pregnancy rates have been declining steadily since their peak in 1957, largely due to increased access to and use of effective forms of birth control.1,2 Long-acting reversible contraception (LARC) methods, such as hormonal and nonhormonal intrauterine devices (IUDs) and hormonal implants, have been proven safe and effective forms of birth control for adolescent patients and should be included among the full range of contraceptive options they are offered.3,4
LARC provides protection from pregnancy for 3 to 10 years depending on the method, offers noncontraceptive benefits, and may be preferred for adolescents with chronic conditions or with relative cautions or contraindications to estrogen-containing birth control options.5,6
Despite the wide acceptance of LARC methods, a number of barriers can impact its use: medical eligibility, adverse effects, access to methods, and the reluctance of some adolescents and families to consider these methods due to historical coercive uses of birth control among poor women and women of color.5-7 Effective counseling about contraception must take into account individual, sociocultural, and ethical-legal complexities, addressing the developmental needs and personal context of each adolescent patient.
LARC
Both the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend LARC methods as first-line options for adolescent patients.4,8 These recommendations are based on the proven safety record of LARC in young and nulliparous patients as well as its increased efficacy and greater continuation and satisfaction rates among adolescents compared with short-acting methods.3,9
Several LARC methods are available in the United States, including 1 progestin-containing subdermal implant (etonogestrel [ENG]), 4 progestin-containing (levonorgestrel [LNG]) IUDs, and 1 nonhormonal cooper IUD (Table 1).10-15
Rosenstock et al evaluated 7472 participants enrolled in the Contraceptive CHOICE Project, a prospective cohort study of women offered no-cost contraception.16 The study’s primary objective was to compare 12-month continuation rates among women of various ages. Among adolescents aged 14 to 19 years, method satisfaction rates 1 year after initiation were 54%, 56%, and 65.7% for the ENG implant, copper IUD, and LNG IUD, respectively, vs 33.1% for oral contraceptive pills.16 However, uptake and use of LARC is relatively lower than uptake and use of shorter-acting methods among adolescents.3,9
For many teens, the decision to start a LARC method may be made over several appointments and conversations with providers, possibly after trials of other methods. Clinicians need to be open to this process and assure that scheduling practices can accommodate their patients’ needs. It is important to respect the adolescent’s choice as well as the process and time it may take to make that choice.
Although a LARC method is not going to be the best fit for every adolescent, all patients should be informed about LARC options during comprehensive birth control counseling. This counseling should be patient-centered and not directive or coercive; the focus should be on the patient’s priorities and goals (Table 2).5
For more information about the current threats to adolescent confidentiality and contraceptive access, click here.
Contraindications
Outside of confirmed or suspected pregnancy and unexplained genital bleeding, there are few absolute contraindications to LARC for the majority of adolescents. In the case of LNG IUDs and the ENG implant, sensitivity to progestin is a contraindication, as is a history of breast cancer, hepatic tumors, or active liver disease.10-14
Contraindications for both LNG and copper IUDs include distortion of the uterine cavity, pelvic tuberculosis, systemic lupus erythematosus with positive or unknown antiphospholipid antibodies, cervical or endometrial cancer, and a history of complicated solid organ transplant with failure or rejection.17 Severe thrombocytopenia, Wilson disease, and an allergy to copper are additional contraindications for the copper IUD.17
In the setting of current pelvic inflammatory disease (PID), purulent cervicitis, or known gonorrheal or chlamydial infection, IUD insertion should be deferred until after successful treatment.18 Unknown gonorrhea or chlamydia status is not a reason to delay insertion, but adolescents should be screened at the time of insertion and treated appropriately if one of these infections is detected (a positive result does not require removal of the IUD).19
Drug Interactions
Both ENG and LNG are progestins, synthetic steroid hormones that activate the progesterone receptor. Progestins are metabolized via the cytochrome P450 (CYP) 3A4 pathway.10-14 Other medications, including many anti-inflammatory and anti-seizure medications, are CYP3A4 enzyme-inducing and can increase the metabolism of progestins; there have been documented contraceptive failures in patients taking CYP3A4 enzyme-inducing anti-seizure medications while using the ENG implant and other low-dose progestins. However, LNG’s primary action in IUDs is local and contributes to only part of the IUD’s efficacy, making it an available option for patients on these anti-seizure medications.19
The copper IUD has no drug interactions,15 which can be especially beneficial for individuals taking multiple medications.
Noncontraceptive Benefits
In addition to being effective, reversible contraception, LARC methods offer several potential noncontraceptive benefits, which may be the reason some adolescents are interested in a particular method.
One noncontraceptive use for LNG IUDs is treatment of heavy uterine bleeding and/or dysmenorrhea.20 This can be relevant for individuals with anemia and/or bleeding disorders (eg, von Willebrand disease), for whom hormonal therapy often is required as part of a regimen to limit heavy menstrual bleeding.4,5 The LNG IUD is also the most effective method of achieving amenorrhea in individuals who have difficulty managing menstrual flow or for whom menstrual flow is distressing (eg, adolescents with developmental delays and trans or nonbinary youth).20,21 The hormonal implant also can be beneficial for this indication but does not always lead to amenorrhea. For most teens, the implant is acne-neutral, or even beneficial in helping to clear acne.10
Both the implant and the LNG IUDs can be used in the treatment of endometrial hyperplasia, which is common in patients with polycystic ovarian syndrome.22
