Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

POLICY STATEMENT Contraception for Adolescents

COMMITTEE ON ADOLESCENCE abstract KEY WORDS Contraception is a pillar in reducing adolescent pregnancy rates. The contraception, adolescent, , , , oral contraceptive pills, contraceptive American Academy of Pediatrics recommends that pediatricians de- injection velop a working knowledge of contraception to help adolescents reduce ABBREVIATIONS risks of and negative health consequences related to unintended preg- AAP—American Academy of Pediatrics nancy. Over the past 10 years, a number of new contraceptive methods ACOG—American College of Obstetricians and Gynecologists have become available to adolescents, newer guidance has been issued BMD—bone mineral density CDC—Centers for Disease Control and Prevention on existing contraceptive methods, and the evidence base for contracep- COC—combined oral contraceptive tion for special populations (adolescents who have disabilities, are DMPA—depot medroxyprogesterone acetate obese, are recipients of solid organ transplants, or are HIV infected) EC— FDA—Food and Drug Administration has expanded. The Academy has addressed contraception since 1980, HIPAA—Health Insurance Portability and Accountability Act and this policy statement updates the 2007 statement on contraception IUD—intrauterine device and adolescents. It provides the pediatrician with a description and ra- LARC—long-acting reversible contraception — fl tionale for best practices in counseling and prescribing contraception PID pelvic in ammatory disease STI—sexually transmitted infection for adolescents. It is supported by an accompanying technical report. This document is copyrighted and is property of the American Pediatrics 2014;134:e1244–e1256 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 INTRODUCTION Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of Pediatricians play an important role in adolescent pregnancy pre- this publication. vention and contraception. Nearly half of US high school students The guidance in this statement does not indicate an exclusive report ever having had .1 Each year, approximately course of treatment or serve as a standard of medical care. 750 000 adolescents become pregnant, with more than 80% of these Variations, taking into account individual circumstances, may be pregnancies unplanned, indicating an unmet need for effective con- appropriate. traception in this population.2,3 Although are the most fre- All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, quently used form of contraception (52% of females reported revised, or retired at or before that time. use at last sex), use of more effective hormonal methods, including combined oral contraceptives (COCs) and other hormonal methods, was lower, at 31% and 12%, respectively, in 2011.1 Use of highly ef- fective long-acting reversible contraceptives, such as implants or in- trauterine devices (IUDs), was much lower.1 Adolescents consider pediatricians and other health care providers a highly trusted source of sexual health information.4,5 Pediatricians’ long-term relationships with adolescents and families allow them to ask about sensitive topics, such as sexuality and relationships, and to promote healthy sexual decision-making, including abstinence and www.pediatrics.org/cgi/doi/10.1542/peds.2014-2299 contraceptive use for teenagers who are sexually active. Additionally, doi:10.1542/peds.2014-2299 medical indications for , such as dysmenor- PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). rhea, heavy menstrual bleeding or other abnormal uterine bleeding, Copyright © 2014 by the American Academy of Pediatrics acne, and polycystic ovary syndrome, are often uncovered during adolescent visits. A working knowledge of contraception will assist the pediatrician in both sexual health promotion and treatment of common

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adolescent gynecologic problems. Contra- care.14 Therefore, the AAP recommends honest, caring, nonjudgmental attitude ception has been inconsistently covered that pediatricians have an office policy and a comfortable, matter-of-fact ap- as part of insurance plans. However, the that explicitly describes confidential proach to asking questions. This can Institute of Medicine has recommended services and that pediatricians discuss be accomplished by assessing the 5 Ps contraception as an essential component (and document) confidentiality with all of sexual history taking, as described of adolescent preventive care,6 and the parents and adolescents. As an addi- by the Centers for Disease Control and Patient Protection and Affordable Care tional protection for minors’ confiden- Prevention (CDC): partners, prevention Act of 2010 (Pub L No. 111–148) requires tiality, HIPAA states that if there is no of pregnancy, protection from STIs, sex- coverage of preventive services for applicable state law about the rights ual practices, and past history of STIs women, which includes contraception, of parents to access the protected and pregnancy.25 Counseling should draw without a copay.7,8 health information of their children, on motivational interviewing approaches, pediatricians (or other licensed health with the focus of the interview on future SETTING THE STAGE professionals) may exercise their pro- goals, belief in the adolescents’ capacity fessional judgment to provide or deny to change, and engagement of the Confidentiality and Consent parental access to the records.14 This adolescent in the process of adopting In the setting of contraception and sexual canbeaccomplishedwithcarefuldocu- health-promoting behaviors.26 For an health care, the American Academy of mentation of their professional judgment. example of motivational interviewing Pediatrics (AAP) believes that policies Insurance, billing, and electronic health for sexual health counseling, see Ott supporting adolescent consent and pro- 27 record systems create additional et al (2007), and for a more detailed tecting adolescent confidentiality are in challenges, including maintaining the discussion of counseling approaches, the best interests of adolescents. Ac- confidentiality of visits, visit content, see the accompanying technical re- cordingly, best practice guidelines rec- 28 associated laboratory test results, and port. ommend confidentiality around sexuality payment for the contraceptive method and sexually transmitted infections (STIs) Counseling About Abstinence and itself.15 For additional discussion of and minor consent for contraception.9–11 Contraception electronic health records, see the AAP The majority of states have specificlaws policy statement on health information Counseling about abstinence and regarding minor consent to contracep- technology.16 postponement of sexual intercourse tion (see State Minor Consent Laws: is an important aspect of adolescent Careful attention to minor consent and A Summary12 and the Guttmacher Insti- sexual health care. Abstinence is 100% confidentiality is important, because lim- tute’s State Center13 at http://www. effective in preventing pregnancy and itations on confidentiality and consent are guttmacher.org/statecenter/ for reg- STIs and is an important part of con- linked to lower use of contraceptives and ularly updated state-by-state summaries). traceptive counseling. Adolescents should higher adolescent pregnancy rates.17–21 For states without specific laws, best be encouraged to delay sexual onset until Parents need not be adversaries; in practice guidelines, federal statutes, and they are ready. However, existing data fact, many parents are supportive of federal case law may support minor suggest that, over time, perfect ad- minor consent and confidentiality for confidentiality and consent.12 For exam- herence to abstinence is low (ie, many sexual health services.22,23 As per- ple, clinics funded by adolescents planning on abstinence do mitted by law, adolescent contraception Title X of the federal Public Health Ser- not remain abstinent).29,30 Therefore, should be provided as a confidential vices Act (42 USC xx300–300a-6 [1970]) pediatricians should not rely on absti- service, with adolescents encouraged are required to provide confidential nence counseling alone but should to involve parents or trusted adults services to adolescents.12 additionally provide access to com- as they are able. The Health Insurance Portability and prehensive sexual health information Accountability Act (HIPAA [Pub L No. to all adolescents. For sexually active 104–191, 1996]) specifically addresses Sexual History Taking and adolescents, including gay and lesbian minor confidentiality. Although HIPAA Counseling adolescents,31 and those considering allows parents access to a minor’s Bright Futures recommends that pedia- initiation of sexual activity, counseling records as personal representatives, tricians take a developmentally targeted additionally includes initiating contra- that access is denied when the minor is sexual history, assess STI and pregnancy ception, supporting adherence to the provided with confidentiality under state risk, and provide appropriate screening, contraceptive method, managing ad- or other laws or when the parent agrees counseling, and, if needed, contra- verse effects, and providing periodic that the minor may have confidential ceptives.24 Key to history taking is an screening for STIs.24

PEDIATRICS Volume 134, Number 4, October 2014 e1245 Downloaded from www.aappublications.org/news by guest on September 29, 2021 METHODS OF CONTRACEPTION TABLE 1 Contraceptive Method Efficacy Method % of Women Experiencing an % of Women Continuing This section summarizes the contra- in the Use at 1 Yeara ceptive options for adolescents; the First Year of Use accompanying technical report pro- Typical Useb Perfect Usec vides more detailed information on No method 85 85 — each of the methods. When comparing (foams, creams, gels, 28 18 42 the efficacy of different methods, it is suppositories, and film) important to distinguish between typi- –based methods 24 — 47 Withdrawal 22 4 46 cal use and perfect use, and counseling Condom should be based on typical use. Typical Female 21 5 41 use efficacy refers to the probability Male 18 2 43 fi Diaphragm 12 6 57 of pregnancy during the rst year of Combined pill and progestin-only pill 9 0.3 67 typical use and includes users with 9 0.3 67 varying degrees of adherence; perfect Contraceptive ring 9 0.3 67 use efficacy is the probability of preg- DMPA contraceptive injection 6 0.2 56 IUD nancy if used consistently and correctly Copper T 0.8 0.6 78 every time.32 The most effective meth- 0.2 0.2 80 ods rely the least on individual adher- Single-rod contraceptive implant 0.05 0.05 84 Female 0.5 0.5 100 ence; for these methods, typical use Male sterilization 0.15 0.10 100 effectiveness approaches perfect use —, data not available. effectiveness. Contraceptive methods a Among couples attempting to avoid pregnancy, the percentage who continue to use a method for 1 y. b Among typical couples who initiate use of a method (not necessarily for the first time), the percentage who experience most commonly used by adolescents an accidental pregnancy during the first year if they do not stop use for any other reason. Estimates of the probability of are listed below, ordered from most to pregnancy during the first year of typical use for spermicides, withdrawal, periodic abstinence, the diaphragm, the male least effective, starting with long-acting condom, the pill, and Depo-Provera are taken from the 1995 and 2002 National Survey of Family Growth, corrected for underreporting of ; see the text for the derivation of estimates for the other methods. reversible contraception (LARC): implants c Among couples who initiate use of a method (not necessarily for the first time) and who use it perfectly (both and IUDs. Pediatricians are encouraged consistently and correctly), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason. to counsel adolescents in that order, discussing the most effective contracep- tive methods first (see Table 1 for con- Contraceptive implants can also be the first week for contraceptive effi- traceptive effectiveness). offered to pregnant adolescents and cacy and that a condom should be provided in the immediate postpartum used at all times for protection against Progestin Implants period, while the adolescent is still in STIs. Implanon and Nexplanon (Merck, White- the hospital. The American College of IUDs house Station, NJ) are both single-rod Obstetricians and Gynecologists (ACOG) implants that contain , and the CDC both support immediate IUDs inserted into the uterus also pro- the active metabolite of the progestin postpartum insertion of implants as a vide long-acting reversible contracep- desogestrel. Implants, a LARC method, safe and effective practice that removes tion. Three IUDs currently are approved are highly effective, with typical and barriers to care.36,37 The main theo- in the United States: 2 levonorgestrel- perfect use failure rates of less than retical concern about contraceptive releasing T-shaped IUDs (Mirena, 52 mg 1%32,33;theymayremaininplacefor implant use in the postpartum period levonorgestrel, and Skyla, 13.5 mg 3 years. The implant is inserted into is whether the progestin might have levonorgestrel; Bayer HealthCare Phar- the inside of the upper arm by a clini- some effect on breastfeeding; however, maceuticals Inc, Wayne, NJ) and a cian who has completed the requisite studies of contraceptive implant use copper-containing T-shaped IUD (Copper training. Implants are ideal for ado- among breastfeeding women have T380-A, ParaGard; Teva North America, lescents who prefer a method that does generally found no effects on breast- North Wales, PA). The 13.5-mg levonor- not require regularly scheduled ad- feeding performance or infant health gestrel IUD is approved for 3 years,40 the herence and who desire an extended and growth.38,39 When starting an im- 52-mg levonorgestrel IUD is approved length of protection. A common reason plant, patients should be counseled for 5 years,41 and the copper IUD is for discontinuation is unpredictable that a backup method (ie, condoms or approved for 10 years.42 Despite their bleeding or spotting.34,35 abstinence) should be used for at least low but increasing use in the United

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States, IUDs are used extensively world- that immediate insertion of IUDs pro- Use.”52 When starting DMPA, patients wide because they are safe and effective vides similar contraceptive coverage should be counseled that a backup methods of contraception with typical as delayed insertion, even with higher method (eg, condoms or abstinence) and perfect use failure rates of less than expulsion rates with immediate in- should be used for at least the first 1%.43 ThecopperIUDcanbeusedas sertion.56,57 week for contraceptive efficacy and emergency contraception (EC) within 5 The emerging adolescent-specific data that a condom should be used at all days of unprotected intercourse.43,44 on IUDs are promising. However, there times for protection against STIs. Despite past concerns, IUDs are now are some disadvantages. The limited DMPA is convenient for many adoles- known to be safe for nulliparous ado- data in adolescents suggest that ex- cents because of its ease of use. Other lescents. IUDs themselves do not cause pulsion, which occurs in fewer than advantages include improvement in tubal infertility in nulliparous women,45 5% of women using IUDs, may occur dysmenorrhea and protection against and studies support a rapid return to more frequently in younger women.58 iron deficiency anemia and endome- fertility after IUD removal.46,47 The risk Another concern is that more than half of trial cancer.69 DMPA is safe for most of pelvic infection with IUDs occurs young nulliparous women report mod- patients with chronic illness,37 is thought only during insertion. Beyond the first erate to severe pain with insertion.59,60 to raise the seizure threshold in ado- 21 days, IUDs do not increase rates of Nonetheless, studies demonstrate IUD lescents with epilepsy,70 and may de- STIs or pelvic inflammatory disease continuation rates in adolescents that crease sickle cell crises.71,72 (PID).48,49 Unless the adolescent is at exceed those with other hormonal The major disadvantages of DMPA in- very high risk for STIs (eg, had sex methods and effective use of the levo- clude the need for an injection every with a partner with known gonorrhea), norgestrel IUD for menstrual suppres- 13 weeks and the menstrual cycle screening for gonorrhea and chlamydia sion in adolescent patients with complex irregularities that are present for 61–67 can be performed on the day of in- medical conditions. nearly all patients initially. These men- sertion.50 Treatment, if needed, can strual irregularities typically improve be subsequently provided without IUD Progestin-Only Injectable over time73,74 and may be less likely to removal, because studies have dem- Contraception result in discontinuation if patients are onstrated that, provided the patient Depot medroxyprogesterone acetate counseled about these effects before improves with treatment, both STIs fi 75,76 (DMPA, also known by the brand name the rst injection. Other possible ad- and PID can be treated with the IUD Depo-Provera; Pfizer, New York, NY) is verse effects include headache, mastalgia, in place.51,52 Contraindications to IUD a long-acting progestin that is given as hair loss, change in libido, and weight placement are limited to current pu- 77 a single injection every 13 weeks (up gain. Studies in both adolescents and rulent cervicitis, gonorrhea, or chla- 78 to 15 weeks) using a dose of either adults suggest that weight gain status mydia, current PID and other current 150 mg delivered intramuscularly or at 6 months is a strong predictor of fu- pelvic infections (see “US Medical Eli- 104 mg delivered subcutaneously. Many ture excessive weight gain with ongoing gibility Criteria for Contraceptive Use” health care providers schedule visits DMPAuse,butthatweightgaindoesnot 37 79,80 for more extensive discussion). Past every 11 to 12 weeks for adolescents occur in all patients. PID is not a contraindication to IUD use. to allow for missed or delayed visits. DMPA causes reductions in bone min- HIV infection and immunosuppression Both regimens have similar effective- eral density (BMD),81–83 and in 2004 the are also not contraindications to IUD ness and side effects68 and are highly US Food and Drug Administration (FDA) use. effective in preventing pregnancy. In issued a black-box warning about the IUDs can also be offered to pregnant the first year of use, the probability of risk of decreased BMD among DMPA adolescents and provided in the im- becoming pregnant with typical use is users.84 Subsequent publications doc- mediate postpartum period, while the approximately 6%.32 DMPA can be ini- ument a substantial recovery of BMD adolescent is still in the hospital. Two tiated on the same day as the visit after the patient discontinues DMPA,85–87 systematic reviews concluded that im- (“mid-cycle” or “quick” start) as long and ACOG, recognizing the risk of un- mediate postpartum insertion of IUDs as the health care provider is reason- wanted pregnancy if women’scontra- is safe and effective,53,54 and both ACOG ably certain the adolescent is not ceptive options are limited, does not and the CDC support this practice.36,37,55 pregnant. For additional details, see advise limiting DMPA use to 2 years (in Studies have shown that many women the accompanying technical report and contrast to earlier concerns88)orrou- who desire an IUD at the time of delivery the CDC’s2013“US Selected Practice tinely monitoring bone density after that do not return for later insertion and Recommendations for Contraceptive time frame.89 Nonetheless, it remains

PEDIATRICS Volume 134, Number 4, October 2014 e1247 Downloaded from www.aappublications.org/news by guest on September 29, 2021 important to consider other risk factors diastolic pressure ≥100 mm Hg), ongo- on what to do if pills are missed. A for osteoporosis and to tailor counseling ing hepatic dysfunction, complicated missed pill should be taken as soon as and recommendations to each patient. valvular heart disease, migraines with it is remembered. If more than 1 pill in All patients should be counseled about aura or focal neurologic symptoms, a row is missed, only the most recently measures that promote skeletal health, thromboembolism or thrombophilia, missed pill should be taken as soon such as daily intake of 1300 mg of cal- complications of diabetes (ie, nephropathy, as possible, and the remaining pills cium and 600 IU of vitamin D and regular retinopathy, neuropathy, or other vas- should be taken at the usual time. weight-bearing exercise.90 cular disease), and complicated solid Patients should be reminded that 7 organ transplantation.37 The most se- consecutive hormone pills are needed Combined Oral Contraceptive Pills rious adverse event associated with COC to prevent ovulation. Additional instruc- use is the increased risk of blood clots, tions can be accessed online (http:// COCs are the most popular method which increases from 1 per 10 000 to www.cdc.gov/mmwr/preview/mmwrhtml/ of hormonal contraception for ado- 3 to 4 per 10 000 woman-years during rr6205a1.htm?s_cid=rr6205a1_w#Fig2).52 lescents. COCs all contain a progestin COC use.92,93 In comparison, the in- EC is indicated if 2 or more pills are and an estrogen. In almost every pill, the cidence of venous thromboembolism missed in the first week of the cycle.99,100 estrogen component is ethinyl estradiol associated with pregnancy and post- EC should also be considered if 1 or μ in amounts varying from 10 to 50 g. partum is 10 to 20 per 10 000 woman- more pills were missed earlier in the Many adolescent medicine experts be- years, of which 1% to 2% are fatal.94,95 same cycle as a missed pill or late in ginwithaCOCcontaining30to35μg Although smoking should be discouraged, the previous cycle (see online instruc- of ethinyl estradiol and a progestin it is not a contraindication to COC use tions provided earlier for details). such as levonorgestrel or norgestimate. in teenagers and adults younger than Many patients may benefit from de- However, any “low-dose” pill (ie, con- 35 years old.37 creasing or eliminating the hormone- taining ethinyl estradiol 35 μgorless) free (placebo) interval. Extended or can be used. Although inspection of the Patients should be informed that com- continuous cycles may be useful for external genitalia and a vaginal swab or mon transient adverse effects of COCs treating medical conditions such as urine screen for STIs are recommended include irregular bleeding, headache, anemia, acne, severe dysmenorrhea, practices in the care of sexually active and nausea. Recommendations for endometriosis, dysfunctional or heavy patients,91 no gynecologic examination managing adverse effects have been menstrual bleeding, Von Willebrand dis- is needed to determine eligibility for published elsewhere96 or can be found ease, and other bleeding diatheses and COC use. Like other combined methods online (http://www.managingcontraception. for adolescents who prefer amenor- including the contraceptive com/qa/index.php or http://www. rhea.101 These regimens may also be and transdermal patch, COCs can be cdc.gov/mmwr/preview/mmwrhtml/ useful for conditions that can be exac- started on the same day as the visit rr6205a1.htm?s_cid=rr6205a1_w).52 erbated cyclically, such as migraine (“quick start”) in healthy, nonpregnant Drug interactions should also be (without aura), epilepsy, irritable bowel adolescents. Patients should be coun- avoided. With medications that de- syndrome, inflammatory bowel disease, seled that a backup method (ie, con- crease COC effectiveness (eg, anti- and some psychiatric and behavioral doms or abstinence) should be used for convulsants and antiretroviral drugs), symptoms102; the most common adverse at least the first 7 days for contracep- patients may benefitfromchoosing effect of extended or continuous cycles tive efficacy and that a condom should an alternative method or dosing97 (see is unscheduled bleeding. Patients may be used at all times for protection the accompanying technical report for be reassured to know that observational against STIs. The CDC recommends pre- additional details). Most broad-spectrum data indicate that COC use does not in- scribing up to 1 year of COCs at a time.52 antibiotics (rifampin is an exception) do crease the risk of infertility or breast Additionally, a routine follow-up visit 1 to not affect the contraceptive effectiveness cancer103 and that use of COCs for more 3 months after initiating COCs is useful of COCs.37 than 4 years provides significant pro- for addressing adverse effects or ad- Typical use failure rates are 9% in tection against endometrial and ovarian herence issues. adults and may be higher in adoles- cancers.104 COCs have few contraindications in cents.32,98 Counseling should include healthy female adolescents. They should strategies to promote daily adher- Contraceptive Vaginal Ring not be prescribed for patients with ence, such as cell phone alarms and severe and uncontrolled hypertension support from a family member or The vaginal ring (NuvaRing; Merck, White- (systolic pressure ≥160 mm Hg or partner. Patients should be instructed house Station, NJ) releases a combination

e1248 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 29, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS of estrogen and progestin and thus has The patch has comparable efficacy, mitment at every sex act, tends to drop the same eligibility criteria for use as benefits, eligibility criteria for use, and off over time, and is influenced by in- COCs. As with COCs, a same-day start drug interactions as COCs; side effects dividual, relationship, and broader social (“quick start”) can also be used with are similar to those of other combined factors.130–133 Although the perfect use the vaginal ring. The ring is inserted in methods, with the addition of dislodged failure rate of condoms is 2%, the typical the and stays in place for 3 patches and skin effects, such as use failure rate is 18% for all users and weeks, with removal for 1 week to in- hyperpigmentation,114,115 contact der- can be higher among adolescents.32 The duce withdrawal bleeding, followed matitis, and other irritation.116 The risk high typical use failure rate, coupled by insertion of a new ring. Patients of pregnancy with correct (“perfect”) with the condom’s high STI protection, should be instructed to insert a new use of the patch is slightly higher for has led to the recommendation for dual ring after 7 days even if bleeding has women who weigh more than 198 contraception: condoms plus a highly not ceased. pounds than for women who weigh effective hormonal or other long-acting The ring has comparable efficacy, risks, less (0.9% vs 0.3% in first 12 months of method. Instructions for condom use and benefits as other combined hor- use).117,118 can be found in the accompanying monal methods but provides the sim- technical report, and additional details plest regimen.32,105,106 Adverse effects Progestin-Only Pills are provided in the AAP policy state- ment on condoms.133 are also similar, with the additional Progestin-only pills (also known as vaginal symptoms of discharge, dis- “mini-pills”) work primarily by thick- comfort, and problems related to the ening cervical mucus, not by inhibiting Emergency Contraception device (eg, expulsion).107 The ring is an ovulation. Because very stringent ad- In the United States, EC is available as excellent method for extended use herence is necessary, their failure oral levonorgestrel; an oral progesterone because, although labeled for 28 days fi rate can be signi cantly higher than receptor modulator, ; of use, the rings contain sufficient those of other combined hormonal high-dose combined estrogen–progestin medication to be used for up to 35 and progestin-only methods (IUDs and oral contraceptive pills (the Yuzpe regi- days108 and thus can be replaced contraceptive implants and injections). men); and placement of a copper IUD. once every calendar month. Sexually However, they provide an additional Levonorgestrel EC is preferred to the active patients may be reassured to option for patients who have safety because of the superior know that most men were not both- concerns about estrogen use (see adverse effect profile and effectiveness, ered by its presence, if it was noted accompanying technical report for whichisupto85%.44,134 Ulipristal acetate at all.109,110 additional details).37 may have greater effectiveness than oral levonorgestrel at the end of the 5-day Transdermal Contraceptive Patch Male Condoms window of use, and its remaining effec- The combination hormone (estrogen and The male condom is the most common tiveness and adverse effect profile are progestin) transdermal contraceptive contraceptive method used by ado- similar to those of levonorgestrel.135,136 In patch (Ortho Evra; Ortho-McNeil Phar- lescents, with up to 52% of female and addition, on the basis of recent data maceutical, Raritan, NJ) is placed on 75% of male adolescents reporting about lower efficacy of levonorgestrel EC, the abdomen, upper torso, upper outer condom use at last intercourse.1 Ad- ulipristalmaybemoreeffectiveinpeople arm, or buttocks using 1 patch for each vantages include male involvement in who weigh more than 165 pounds.137,138 of 3 weeks in a row, followed by 1 week the responsibility for contraception, Placement of a copper-bearing IUD is off the patch, during which a with- easy accessibility by minors without a less commonly used for EC in ado- drawal bleed usually occurs. Typical prescription, and low cost. Latex con- lescents but is the most effective EC use failure rates are similar to those doms also reduce STI transmission, method, with a failure rate of less of COCs at 9%.32 The FDA has identi- with consistent evidence for the than 1%.139 fied increased estrogen exposure (1.6 reduction of gonorrhea, chlamydia, The recommended dosage of levonor- times higher than with a low-dose trichomoniasis,119–123 and hepatitis B gestrel is a single 1.5-mg dose.134,140 It COC111) and a potential increased risk and HIV transmission124 and emerging is available either as 2 pills (0.75 mg of venous thromboembolism with the evidence for the reduction of herpes each) or as 1 pill (Plan B One-Step; patch112,113 (see accompanying tech- simplex virus,125,126 human papilloma- Teva Pharmaceuticals, Petah Tikva, nical report for more complete virus,127,128 and syphilis transmission.129 Israel). Levonorgestrel-based EC delays discussion). However, condom use requires com- or inhibits ovulation and does not

PEDIATRICS Volume 134, Number 4, October 2014 e1249 Downloaded from www.aappublications.org/news by guest on September 29, 2021 appear to be effective once ovulation SPECIAL POPULATIONS their normal-weight peers.148,149 In has occurred. If used inadvertently Adolescents With Disabilities and addressing contraception, it is impor- during early pregnancy, it is not ter- Medically Complex Illness tant to note that obesity and related atogenic, only ineffective.141 Thus, a endocrine effects can influence the pregnancy test is not mandatory before An estimated 16% to 25% of adoles- efficacy and adverse effects profiles of fi levonorgestrel EC is prescribed.44 cents are identi ed as having special contraceptives. For example, a small health care needs, including physical Plan B One-Step is approved by the number of excess pregnancies were disability, developmental disability, and FDA as a nonprescription product for found among transdermal contracep- medically complex illness.145 The im- all women of childbearing potential.142 tive patch users weighing more than proved survival of adolescents with Generic versions are approved as a 90 kg (198 lb).117,118 The World Health medically complex illnesses, such as nonprescription product for women Organization and CDC report that data disabilities, chronic disease, HIV, and 17 years of age and older; however, are limited and inconsistent about solid organ transplants, has prompted proof of age is not required to pur- whether COC effectiveness varies by greater attention to quality-of-life is- – chase them. Providing EC in advance body weight or BMI.37,150 152 Acommon sues. These issues, including adoles- increases the likelihood of use when concern of both adolescents and pro- cent interest in romantic and sexual it is needed without increasing sexual viders is additional weight gain among relationships, are typically addressed or contraceptive risk-taking behav- adolescents with obesity after they by a pediatrician. Sexuality and sexual ior.143,144 Therefore, EC should be pre- start contraception. Data suggest that health care needs in this population scribed or recommended in advance women with obesity are no more likely are often overlooked, yet data demon- for use for up to 5 days after an event to gain weight with COCs, the vaginal strate that, compared with healthy of unprotected intercourse.44 Addi- ring, IUDs, or implants than normal- adolescents, adolescents with chronic tional details on EC mechanisms and weight peers. In contrast, adolescents illness have similar levels of sexual use can be found in the AAP policy with obesity who used DMPA were behaviors and sexual health outcomes statement on emergency contracep- more likely than nonusers with obesity, (eg, STIs).146,147 In addition to pregnancy tion44 and the accompanying technical COC users with obesity, and normal- prevention, these adolescents may need report. weight DMPA users to gain weight.80 menstrual suppression for heavy men- Increasing numbers of adolescents are strual bleeding, bleeding disorders, or Withdrawal having bariatric surgery procedures chemotherapy. Other patients may be performed, and these patients need Withdrawal, or coitus interruptus, is using teratogenic medications and need highly effective contraception. Post- a method in which the male partner contraception for that reason. Issues surgery data reveal an improvement in attempts to pull out his before that arise include safety concerns with fertility coupled with the potential for . Because 57% of female estrogen use, medication interactions, decreased contraceptive effectiveness adolescents report using withdrawal,1 and complications from the underlying through malabsorption, vomiting, and pediatricians should ask about it. disease. The CDC has recently addressed diarrhea.86 Professional consensus However, because of its limited ef- the contraceptive needs of young women statements recommend delaying preg- fectiveness (22% failure rate among with medical conditions by publishing nancy for at least 12 months after the all users)32 and lack of STI pro- the “US Medical Eligibility Criteria for procedure.153 All contraceptive meth- tection, pediatricians should encour- Contraceptive Use.”37 Available online, ods are safe for women with a history age adolescents to adopt more effective this document summarizes the literature of bariatric surgery, with the exception methods. on safety and efficacy of different con- of oral contraceptives for women who traceptive methods by medical condition. have undergone malabsorptive proce- Other Methods Additional details on specific populations dures.37 There is increasing experience (eg, those with disabilities) are sum- The , periodic abstinence and success with the levonorgestrel marized in the accompanying technical (fertility awareness or “the rhythm IUD placed at the time of surgery.154 method”), vaginal spermicides, the report. , and the diaphragm are methods less commonly used by Adolescents With Obesity ADHERENCE AND FOLLOW-UP adolescents. Additional descriptions The sexual health needs and sexual Frequent follow-up is important to are available in the accompanying behaviors of adolescents with obesity maximize adherence for all methods technical report. are substantially similar to those of of contraception and to promote and

e1250 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 29, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS reinforce healthy decision-making. Ad- tricians should continue to make address needs for contraception, olescents count on trusted health pro- them available to their patients. STI screening, and sexual risk re- fessionals, such as pediatricians, for 4. Pediatricians should allow the ad- duction counseling for patients support and problem solving around olescent to consent to contraceptive who choose not to be abstinent. continuation and adherence. Regularly care and to control the disclosure 10. Pediatricians should allow suffi- scheduled contraceptive follow-up vis- of this information within the limits cient time with their adolescent its should address use, adherence, of state and federal laws. There are patients to address contraceptive adverse effects, and complications. a number of supports for protecting needs using a developmentally Pediatricians can use motivational inter- minor consent and confidentiality, appropriate, patient-centered ap- viewing approaches to increase effective including state law, federal statutes, proach, such as motivational inter- and consistent contraceptive use, in- and federal case law. Pediatricians viewing. If necessary, arrangements cluding engaging parental support for will need to be familiar with national should be made for a separate visit contraceptive adherence, when possi- best practice recommendations for for contraceptive follow-up to in- ble. Follow-up visits should additionally confidential care and with the rele- crease adherence and monitor for include reassessment of relationships, vant minor consent laws in their adverse effects and complications. sexual behaviors, contraceptive needs, states. 11. Pediatricians can complement the STI surveillance and prevention, and skills and resources of the pedi- other sexual health prevention mea- 5. Pediatricians should be aware atric office by being aware of sures, such as human papillomavirus that it is appropriate to prescribe state or federally subsidized in- immunization. contraceptives or refer for IUD placement without first conducting surance programs and clinics that provide con fidential and free RECOMMENDATIONS a pelvic examination. Screenings for STIs, especially chlamydia, can or low-cost 1. Pediatricians should counsel about be performed without a pelvic ex- care services and supplies, in- and ensure access to a broad amination and should not be cluding contraception. range of contraceptive services delayed. for their adolescent patients. This 6. Pediatricians should encourage LEAD AUTHORS includes educating patients about Mary A. Ott, MD, MA, FAAP the consistent and correct use of all contraceptive methods that are Gina S. Sucato, MD, MPH, FAAP condoms with every act of sexual safe and appropriate for them and intercourse. describing the most effective meth- COMMITTEE ON ADOLESCENCE, 2013–2014 ods first. 7. Pediatricians should have a work- ing knowledge of the different Paula K. Braverman, MD, Chairperson 2. Pediatricians should be able to William P. Adelman, MD, FAAP combined hormonal methods and educate adolescent patients about Elizabeth M. Alderman, MD, FAAP, FSHAM regimens, because these provide Cora C. Breuner, MD, MPH, FAAP LARC methods, including the pro- excellent cycle control both for David A. Levine, MD, FAAP gestin implant and IUDs. Given the Arik V. Marcell, MD, FAAP contraception and medical man- efficacy, safety, and ease of use, Rebecca F. O’Brien, MD, FAAP LARC methods should be consid- agement of common conditions, ered first-line contraceptive choices such as acne, dysmenorrhea, and PAST COMMITTEE MEMBER for adolescents. Some pediatricians heavy menstrual bleeding. Pamela J. Murray, MD, MPH, FAAP 8. Pediatricians should remember may choose to acquire the skills to LIAISONS provide these methods to adoles- that adolescents with chronic ill- Loretta E. Gavin, PhD, MPH – Centers for Disease cents. Those who do not should ness and disabilities have similar Control and Prevention identify health care providers in sexual health and contraceptive Margo Lane, MD, FRCPC – Canadian Pediatric their communities to whom patients needs to healthy adolescents while Society Rachel J. Miller, MD – American College of can be referred. recognizing that medical illness may Obstetricians and Gynecologists 3. Despite increased attention to ad- complicate contraceptive choices. Benjamin Shain, MD, PhD – American Academy verse effects, DMPA and the con- 9. Pediatricians should regularly update of Child and Adolescent Psychiatry ’ traceptive patch are highly effective their adolescent patients sexual his- STAFF methods of contraception that are tories and provide a confidential and Karen S. Smith much safer than pregnancy. Pedia- nonjudgmental setting in which to James D. Baumberger, MPP

PEDIATRICS Volume 134, Number 4, October 2014 e1251 Downloaded from www.aappublications.org/news by guest on September 29, 2021 REFERENCES

1. Martinez G, Copen CE, Abma JC. Teenagers 3rd ed. Chapel Hill, NC: Center for Ado- Academy of Pediatrics; 2008. Available at: in the United States: sexual activity, con- lescent Health and the Law; 2010 http://brightfutures.aap.org/pdfs/Guide- traceptive use, and childbearing, 2006– 13. Guttmacher Institute. An overview of minors’ lines_PDF/18-Adolescence.pdf. Accessed 2010 national survey of family growth. consent law. State policies in brief June 22, 2014 Vital Health Stat 23. 2011; (31):1–35 as of June 1, 2014. Available at: www. 25. Centers for Disease Control and Pre- 2. Kost K, Henshaw S, Carlin L. US Teenage guttmacher.org/statecenter/spibs/spib_MACS. vention. A Guide to Taking a Sexual History. Pregnancies, Births and : Na- pdf. Accessed June 20, 2014 Atlanta, GA: Centers for Disease Control tional and State Trends and Trends 14. English A, Ford CA. The HIPAA privacy rule and Prevention; 2005. Available at: www. by Race and Ethnicity.NewYork,NY: and adolescents: legal questions and clinical cdc.gov/std/treatment/SexualHistory.pdf. Guttmacher Institute; 2010 challenges. Perspect Sex Reprod Health. Accessed June 22, 2014 3. Finer LB, Zolna MR. Unintended pregnancy 2004;36(2):80–86 26. Blum RW. Healthy youth development as in the United States: incidence and dis- 15. Spooner SA; Council on Clinical In- a model for youth health promotion. A re- parities, 2006. Contraception. 2011;84(5): formation Technology, American Academy view. J Adolesc Health. 1998;22(5):368–375 478–485 of Pediatrics. Special requirements of 27. Ott MA, Labbett RL, Gold MA. Counseling 4. Ott MA, Rosenberger JG, McBride KR, electronic health record systems in pedi- adolescents about abstinence in the office Woodcox SG. How do adolescents view atrics. Pediatrics. 2007;119(3):631–637 http:// setting. J Pediatr Adolesc Gynecol. 2007;20 health? Implications for state health pol- pediatrics.aappublications.org/content/119/3/ (1):39–44 icy. J Adolesc Health. 2011;48(4):398–403 631.full.pdf+html. Accessed June 22, 2014 28. American Academy of Pediatrics, Com- 5. Jones RK, Biddlecom AE. The more things 16. Council on Clinical Information Technology. mittee on Adolescence. Technical report: change…: the relative importance of the Health information technology and the med- contraception for adolescents. Pediatrics. internet as a source of contraceptive in- ical home. Pediatrics. 2011;127(5):978–982. 2014; (in press) formation for teens. Sex Res Soc Policy. Available at: http://pediatrics.aappublications. 29. Brückner H, Bearman P. After the prom- 2011;8(1):27–37 org/content/127/5/978.full?sid=f3089a2a-b98c- ise: the STD consequences of adolescent 6. Institute of Medicine, Committee on Pre- 4046-99c3-4e5386ef6e20. Accessed June virginity pledges. J Adolesc Health. 2005; ventive Services for Women. Clinical Pre- 22, 2014 36(4):271–278 ventive Services for Women: Closing the 17. Reddy DM, Fleming R, Swain C. Effect of 30. Pinkerton SD. A relative risk-based, disease- Gaps. Washington, DC: National Acade- mandatory parental notification on ado- specificdefinition of mies Press; 2011 lescent girls’ use of sexual health care failure rates. Health Educ Behav. 2001; 7. Health Resources and Services Adminis- services. JAMA. 2002;288(6):710–714 28(1):10–20 tration. Women’s Preventive Services: Re- 18. Zabin LS, Stark HA, Emerson MR. Reasons 31. Committee on Adolescence. Office-based quired Health Plan Coverage Guidelines. for delay in contraceptive clinic utilization. care for lesbian, gay, bisexual, trans- Rockville, MD: Health Resources and Adolescent clinic and nonclinic populations gender, and questioning youth. Pediatrics. Services Administration; 2012 compared. JAdolescHealth. 1991;12(3): 2013;132(1):198–203. Available at: http:// 8. The Patient Protection and Affordable 225–232 pediatrics.aappublications.org/content/ Care Act. Pub L No. 111-148 (2010). Avail- 19. Guldi M. Fertility effects of abortion and 132/1/198.full.pdf. Accessed June 22, able at: www.dol.gov/ebsa/healthreform/. birth control pill access for minors. De- 2014 Accessed January 13, 2014 mography. 2008;45(4):817–827 32. Hatcher RA, Trussell J, Nelson AL, Cates W 9. Ford C, English A, Sigman G. Confidential 20. Zavodny M. Fertility and parental consent Jr, Kowal D, Policar MS. Contraceptive Health Care for Adolescents: position pa- for minors to receive contraceptives. Am Technology. 20th rev ed. Valley Stream, per for the society for adolescent medi- J Public Health. 2004;94(8):1347–1351 NY: Ardent Media; 2011 cine. J Adolesc Health. 2004;35(2):160–167. 21. Lehrer JA, Pantell R, Tebb K, Shafer MA. 33. Graesslin O, Korver T. The contraceptive Available at: www.adolescenthealth.org/ Forgone health care among U.S. adoles- efficacy of Implanon: a review of clinical SAHM_Main/media/Advocacy/Positions/ cents: associations between risk char- trials and marketing experience. Eur J Aug-04-Confidential_Health_Care_for_ acteristics and confidentiality concern. Contracept Reprod Health Care. 2008;13 Adolescents.pdf. Accessed June 22, 2014 J Adolesc Health. 2007;40(3):218–226 (suppl 1):4–12 10. American College of Obstetricians and 22. Dempsey AF, Singer DD, Clark SJ, Davis 34. Lakha F, Glasier AF. Continuation rates of Gynecologists. Guidelines for Adolescent MM. Adolescent preventive health care: Implanon in the UK: data from an obser- Health Care. Washington, DC: American what do parents want? J Pediatr. 2009;155 vational study in a clinical setting. Con- College of Obstetricians and Gynecolo- (5):689.e1–694.e1 traception. 2006;74(4):287–289 gists; 2011 23. Jones RK, Purcell A, Singh S, Finer LB. 35. Harvey C, Seib C, Lucke J. Continuation 11. American Academy of Pediatrics, Com- Adolescents’ reports of parental knowl- rates and reasons for removal among mittee on Adolescence. Policy statement: edge of adolescents’ use of sexual health Implanon users accessing two family achieving quality health services for services and their reactions to mandated planning clinics in Queensland, Australia. adolescents. Pediatrics. 2008;121(6):1263– parental notification for prescription con- Contraception. 2009;80(6):527–532 1270. Available at: http://pediatrics.aap- traception. JAMA. 2005;293(3):340–348 36. Committee on Adolescent Health Care Long- publications.org/content/121/6/1263.full. 24. Hagan JF, Shaw JS, Duncan PM, eds. Acting Reversible Contraception Working pdf+html. Accessed June 22, 2014 Bright Futures: Guidelines for Health Su- Group, The American College of Obstetri- 12. Center for Adolescent Health and the Law. pervision of Infants, Children, and Ado- cians and Gynecologists. Committee opinion State Minor Consent Laws: A Summary. lescents. Elk Grove Village, IL: American no. 539: adolescents and long-acting reversible

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contraception: implants and intrauterine device increase the risk of pelvic in- 61. Bayer LL, Jensen JT, Li H, Nichols MD, devices. Obstet Gynecol. 2012;120(4):983–988 flammatory disease among women with Bednarek PH. Adolescent experience with 37. Centers for Disease Control and Prevention. sexually transmitted infection? A system- intrauterine device insertion and use: US medical eligibility criteria for contra- atic review. Contraception. 2006;73(2): a retrospective cohort study. Contracep- ceptive use, 2010. MMWR Recomm Rep. 145–153 tion. 2012;86(5):443–451 2010;59(RR-4):1–6. Available at: www.cdc. 49. Farley TM, Rosenberg MJ, Rowe PJ, Chen 62. Alton TM, Brock GN, Yang D, Wilking DA, gov/mmwr/preview/mmwrhtml/rr5904a1. JH, Meirik O. Intrauterine devices and Hertweck SP, Loveless MB. Retrospective htm?s_cid=rr5904a1_e. Accessed June 22, pelvic inflammatory disease: an international review of intrauterine device in adoles- 2014 perspective. Lancet. 1992;339(8796):785–788 cent and young women. J Pediatr Adolesc 38. Gurtcheff SE, Turok DK, Stoddard G, Murphy 50. American College of Obstetricians and Gynecol. 2012;25(3):195–200 PA, Gibson M, Jones KP. Lactogenesis after Gynecologists. ACOG practice bulletin no. 63. Godfrey EM, Memmel LM, Neustadt A, et al. early postpartum use of the contraceptive 121: Long-acting reversible contraception: Intrauterine contraception for adoles- implant: a randomized controlled trial. implants and intrauterine devices. Obstet cents aged 14–18 years: a multicenter Obstet Gynecol. 2011;117(5):1114–1121 Gynecol. 2011;118(1):184–196 randomized pilot study of levonorgestrel- 39. Kapp N, Curtis K, Nanda K. Progestogen- 51. Grimes DA. Intrauterine device and releasing intrauterine system compared only contraceptive use among breast- upper-genital-tract infection. Lancet. 2000; to the Copper T 380A. Contraception. 2010; feeding women: a systematic review. 356(9234):1013–1019 81(2):123–127 Contraception. 2010;82(1):17–37 52. Centers for Disease Control and Pre- 64. Paterson H, Ashton J, Harrison-Woolrych 40. Bayer HealthCare Pharmaceuticals. Skyla vention. US selected practice recom- M. A nationwide cohort study of the use of package insert. Wayne, NJ: Bayer Health- mendations for contraceptive use, 2013: the levonorgestrel intrauterine device in Care Pharmaceuticals; 2013. Available at: adapted from the World Health Organiza- New Zealand adolescents. Contraception. http://labeling.bayerhealthcare.com/html/ tion Selected Practice Recommendations 2009;79(6):433–438 products/pi/Skyla_PI.pdf. Accessed Janu- for Contraceptive Use, 2nd Edition. MMWR 65. Pillai M, O’Brien K, Hill E. The levonorges- ary 13, 2014 Recomm Rep. 2013;62(RR-5):1–60 trel intrauterine system (Mirena) for the 41. Bayer HealthCare Pharmaceuticals. Mirena 53. Grimes DA, Lopez LM, Schulz KF, Van Vliet treatment of menstrual problems in ado- package insert. Wayne, NJ: Bayer Health- HA, Stanwood NL. Immediate post-partum lescents with medical disorders, or physi- Care Pharmaceuticals; 2013. Available at: insertion of intrauterine devices. Cochrane cal or learning disabilities. BJOG. 2010;117 http://labeling.bayerhealthcare.com/html/ Database Syst Rev. 2010; (5):CD003036 (2):216–221 products/pi/Mirena_PI.pdf. Accessed January 54. Kapp N, Curtis KM. Intrauterine device 66. Toma A, Jamieson MA. Revisiting the in- 13, 2014 insertion during the postpartum period: trauterine contraceptive device in ado- 42. Teva Women’s Health Inc/Teva Pharma- a systematic review. Contraception. 2009; lescents. J Pediatr Adolesc Gynecol. 2006; ceuticals. Paragard package insert. Sell- 80(4):327–336 19(4):291–296 ersville, PA: Teva Woman’s Health Inc/Teva 55. American College of Obstetricians and 67. Lara-Torre E, Spotswood L, Correia N, Pharmaceuticals; 2011. Available at: http:// Gynecologists. Increasing use of contra- Weiss PM. Intrauterine contraception in paragard.com/Pdf/ParaGard-PI.pdf. Accessed ceptive implants and intrauterine devices adolescents and young women: a de- June 22, 2014 to reduce unintended pregnancy. ACOG scriptive study of use, side effects, and 43. Trussell J. Update on and correction to committee opinion no. 450. Obstet Gynecol. compliance. J Pediatr Adolesc Gynecol. the cost-effectiveness of contraceptives in 2009;114(6):1434–1438 2011;24(1):39–41 the United States. Contraception. 2012;85 56. Chen BA, Reeves MF, Hayes JL, Hohmann 68. Kaunitz AM, Darney PD, Ross D, Wolter KD, (6):611 HL, Perriera LK, Creinin MD. Postplacental Speroff L. Subcutaneous DMPA vs. in- 44. Committee on Adolescence. Emergency con- or delayed insertion of the levonorgestrel tramuscular DMPA: a 2-year randomized traception. Pediatrics. 2012;130(6):1174–1182 intrauterine device after vaginal delivery: study of contraceptive efficacy and bone 45. Hubacher D, Lara-Ricalde R, Taylor DJ, a randomized controlled trial. Obstet Gynecol. mineral density. Contraception. 2009;80 Guerra-Infante F, Guzmán-Rodríguez R. Use 2010;116(5):1079–1087 (1):7–17 of copper intrauterine devices and the 57. Ogburn JA, Espey E, Stonehocker J. Barriers 69. Kaunitz AM. Depot medroxyprogesterone risk of tubal infertility among nulligravid to intrauterine device insertion in post- acetate contraception and the risk of women. N Engl J Med. 2001;345(8):561– partum women. Contraception.2005;72(6): breast and gynecologic cancer. J Reprod 567 426–429 Med. 1996;41(5 suppl):419–427 46. Hov GG, Skjeldestad FE, Hilstad T. Use of 58. Deans EI, Grimes DA. Intrauterine devices 70. Herzog AG. Progesterone therapy in IUD and subsequent fertility: follow-up for adolescents: a systematic review. women with epilepsy: a 3-year follow-up. after participation in a randomized clini- Contraception. 2009;79(6):418–423 Neurology. 1999;52(9):1917–1918 cal trial. Contraception. 2007;75(2):88–92 59. Thonneau P, Almont T, de La Rochebrochard 71. de Abood M, de Castillo Z, Guerrero F, 47. Penney G, Brechin S, de Souza A, et al; E, Maria B. Risk factors for IUD failure: Espino M, Austin KL. Effect of Depo- Faculty of Family Planning and Reproductive results of a large multicentre case–control Provera or Microgynon on the painful Health Care Clinical Effectiveness Unit. study. Hum Reprod. 2006;21(10):2612–2616 crises of sickle cell anemia patients. FFPRHC guidance (January 2004). The cop- 60. Suhonen S, Haukkamaa M, Jakobsson T, Contraception. 1997;56(5):313–316 per intrauterine device as long-term con- Rauramo I. Clinical performance of a 72. Manchikanti A, Grimes DA, Lopez LM, traception. J Fam Plann Reprod Health Care. levonorgestrel-releasing intrauterine Schulz KF. Steroid hormones for contra- 2004;30(1):29–41, quiz 42 system and oral contraceptives in young ception in women with sickle cell disease. 48. Mohllajee AP, Curtis KM, Peterson HB. nulliparous women: a comparative study. Cochrane Database Syst Rev. 2007; (2): Does insertion and use of an intrauterine Contraception. 2004;69(5):407–412 CD006261

PEDIATRICS Volume 134, Number 4, October 2014 e1253 Downloaded from www.aappublications.org/news by guest on September 29, 2021 73. Hubacher D, Lopez L, Steiner MJ, Dorflinger sity among adolescent women using and 97. Gaffield ME, Culwell KR, Lee CR. The use of L. Menstrual pattern changes from levo- discontinuing depot medroxyprogesterone hormonal contraception among women norgestrel subdermal implants and acetate contraception. Arch Pediatr Ado- taking anticonvulsant therapy. Contra- DMPA: systematic review and evidence- lesc Med. 2005;159(2):139–144 ception. 2011;83(1):16–29 based comparisons. Contraception. 2009; 86. Harel Z, Johnson CC, Gold MA, et al. Re- 98. Mosher WD, Jones J. Use of contraception 80(2):113–118 covery of bone mineral density in ado- in the United States: 1982–2008. Vital 74. Arias RD, Jain JK, Brucker C, Ross D, Ray lescents following the use of depot Health Stat 23. 2010; (29):1–44 A. Changes in bleeding patterns with de- medroxyprogesterone acetate contracep- 99. Faculty of Sexual and Reproductive pot medroxyprogesterone acetate sub- tive injections. Contraception. 2010;81(4): Healthcare, Royal College of Obstetricians cutaneous injection 104 mg. Contraception. 281–291 and Gynaecologists. Faculty of Sexual and 2006;74(3):234–238 87. Berenson AB, Rahman M, Breitkopf CR, Bi Reproductive Healthcare Clinical Guid- 75. Hubacher D, Goco N, Gonzalez B, Taylor D. LX. Effects of depot medroxyprogesterone ance: Combined Hormonal Contraception. Factors affecting continuation rates of acetate and 20-microgram oral contra- London, UK: Faculty of Sexual and Re- DMPA. Contraception. 1999;60(6):345–351 ceptives on bone mineral density. Obstet productive Healthcare, Royal College of 76. Canto De Cetina TE, Canto P, Ordoñez Luna Gynecol. 2008;112(4):788–799 Obstetricians and Gynaecologists; October M. Effect of counseling to improve com- 88. US Pharmaceuticals/Pfizer Inc. Letter to 2011. Updated August 2012. Available at: pliance in Mexican women receiving depot- health care professionals. November 18, www.fsrh.org/pdfs/CEUGuidanceCombined- medroxyprogesterone acetate. Contraception. 2004. Available at: www.fda.gov/downloads/ HormonalContraception.pdf. Accessed January 2001;63(3):143–146 Safety/MedWatch/SafetyInformation/Safe- 13, 2014 77. Bonny AE, Secic M, Cromer B. Early weight tyAlertsforHumanMedicalProducts/UCM1- 100. Mansour D. Revision of the “missed pill” gain related to later weight gain in ado- 66395.pdf. Accessed January 13, 2014 rules. J Fam Plann Reprod Health Care. lescents on depot medroxyprogesterone 89. American College of Obstetricians and 2011;37(3):128–131 acetate. Obstet Gynecol. 2011;117(4):793– Gynecologists Committee on Gynecologic 101. Sucato GS, Gold MA. Extended cycling of 797 Practice. ACOG committee opinion no. 415: oral contraceptive pills for adolescents. 78. Le YC, Rahman M, Berenson AB. Early depot medroxyprogesterone acetate and J Pediatr Adolesc Gynecol. 2002;15(5): weight gain predicting later weight gain bone effects. Obstet Gynecol. 2008;112(3): 325–327 among depot medroxyprogesterone ace- 727–730 102. Sucato GS, Gerschultz KL. Extended cycle tate users. Obstet Gynecol. 2009;114(2 pt 90. Institute of Medicine. Dietary reference hormonal contraception in adolescents. 1):279–284 intakes for calcium and vitamin D. Wash- Curr Opin Obstet Gynecol. 2005;17(5):461– 79. Risser WL, Gefter LR, Barratt MS, Risser ington, DC: National Academies Press; 2010. 465 JM. Weight change in adolescents who Available at: www.iom.edu/Reports/2010/ 103. ACOG Committee on Practice Bulletins– used hormonal contraception. J Adolesc Dietary-Reference-Intakes-for-calcium- Gynecology. ACOG practice bulletin no. 73: Health. 1999;24(6):433–436 and-vitamin-D.aspx Use of hormonal contraception in women 80. Bonny AE, Ziegler J, Harvey R, Debanne 91. Braverman PK, Breech L; Committee on with coexisting medical conditions. Obstet SM, Secic M, Cromer BA. Weight gain in Adolescence. American Academy of Pedi- Gynecol. 2006;107(6):1453–1472 obese and nonobese adolescent girls ini- atrics. Clinical report: gynecologic exam- 104. Vessey M, Painter R. Oral contraceptive tiating depot medroxyprogesterone, oral ination for adolescents in the pediatric use and cancer. Findings in a large cohort contraceptive pills, or no hormonal con- office setting. Pediatrics. 2010;126(3):583–590. study, 1968–2004. Br J Cancer. 2006;95(3): traceptive method. Arch Pediatr Adolesc Available at: http://pediatrics.aappublications. 385–389 Med. 2006;160(1):40–45 org/content/126/3/583.full.pdf+html. Accessed 105. Roumen FJ, Apter D, Mulders TM, Dieben 81. Cromer BA, Blair JM, Mahan JD, Zibners L, June 22, 2014 TO. Efficacy, tolerability and acceptability Naumovski Z. A prospective comparison of 92. Trenor CC III, Chung RJ, Michelson AD, of a novel contraceptive vaginal ring re- bone density in adolescent girls receiving et al. Hormonal contraception and throm- leasing etonogestrel and ethinyl oestr- depot medroxyprogesterone acetate (Depo- botic risk: a multidisciplinary approach. adiol. Hum Reprod. 2001;16(3):469–475 Provera), levonorgestrel (Norplant), or oral Pediatrics. 2011;127(2):347–357 106. Dieben TO, Roumen FJ, Apter D. Efficacy, contraceptives. JPediatr. 1996;129(5):671–676 93. Vandenbroucke JP, Rosing J, Bloemenkamp cycle control, and user acceptability of 82. Lara-Torre E, Edwards CP, Perlman S, KW, et al. Oral contraceptives and the risk a novel combined contraceptive vaginal Hertweck SP. Bone mineral density of venous thrombosis. N Engl J Med. 2001; ring. Obstet Gynecol. 2002;100(3):585–593 in adolescent females using depot 344(20):1527–1535 107. Edwardson J, Jamshidi R. The contracep- medroxyprogesterone acetate. J Pediatr 94. Walker ID. Venous and arterial thrombosis tive vaginal ring. Semin Reprod Med. 2010; Adolesc Gynecol. 2004;17(1):17–21 during pregnancy: epidemiology. Semin Vasc 28(2):133–139 83. Cromer BA, Stager M, Bonny A, et al. Depot Med. 2003;3(1):25–32 108. Timmer CJ, Mulders TM. Pharmacokinet- medroxyprogesterone acetate, oral con- 95. Heit JA, Kobbervig CE, James AH, Petterson ics of etonogestrel and ethinylestradiol traceptives and bone mineral density in TM, Bailey KR, Melton LJ III. Trends in the released from a combined contraceptive a cohort of adolescent girls. J Adolesc incidence of venous thromboembolism vaginal ring. Clin Pharmacokinet. 2000;39 Health. 2004;35(6):434–441 during pregnancy or postpartum: a 30-year (3):233–242 84. Pfizer. DepoProvera 150 mg and Depo population-based study. AnnInternMed. 109. Guida M, Di Spiezio Sardo A, Bramante S, SubQ Provera 104 package inserts. Cam- 2005;143(10):697–706 et al. Effects of two types of hormonal bridge, MA: Pfizer; 2005 96. Dickey R. Managing Contraceptive Pill contraception—oral versus intravaginal—on 85. Scholes D, LaCroix AZ, Ichikawa LE, Barlow Patients. Fort Collins, CO: EMIS Inc Medical the sexual life of women and their partners. WE, Ott SM. Change in bone mineral den- Publishers; 2010 Hum Reprod. 2005;20(4):1100–1106

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110. Veres S, Miller L, Burington B. A compar- condom use on chlamydial and gonococ- 134. Cheng L, Gülmezoglu AM, Piaggio G, ison between the vaginal ring and oral cal infection among urban adolescents. Ezcurra E, Van Look PF. Interventions for contraceptives. Obstet Gynecol. 2004;104 Arch Pediatr Adolesc Med. 2005;159(6): emergency contraception. Cochrane Da- (3):555–563 536–542 tabase Syst Rev. 2008; (2):CD001324 111. van den Heuvel MW, van Bragt AJ, Alnabawy 123. Niccolai LM, Rowhani-Rahbar A, Jenkins H, 135. Fine P, Mathé H, Ginde S, Cullins V, Morfesis AK, Kaptein MC. Comparison of ethinylestradiol Green S, Dunne DW. Condom effectiveness J, Gainer E. Ulipristal acetate taken 48–120 pharmacokinetics in three hormonal contra- for prevention of Chlamydia trachomatis hours after intercourse for emergency ceptive formulations: the vaginal ring, the infection. Sex Transm Infect. 2005;81(4): contraception. Obstet Gynecol. 2010;115(2 Pt transdermal patch and an oral contraceptive. 323–325 1):257–263 – Contraception. 2005;72(3):168 174 124. Weller S, Davis K. Condom effectiveness in 136. Glasier AF, Cameron ST, Fine PM, et al. 112. Cole JA, Norman H, Doherty M, Walker AM. reducing heterosexual HIV transmission. Ulipristal acetate versus levonorgestrel Venous thromboembolism, myocardial in- Cochrane Database Syst Rev. 2002; (1): for emergency contraception: a randomised farction, and stroke among transdermal CD003255 non-inferiority trial and meta-analysis. Lan- – contraceptive system users. Obstet Gynecol. 125. Martin ET, Krantz E, Gottlieb SL, et al. A cet. 2010;375(9714):555 562 – 2007;109(2 pt 1):339 346 pooled analysis of the effect of condoms 137. Rockoff JD. FDA reviewing efficacy of 113. Dore DD, Norman H, Loughlin J, Seeger JD. in preventing HSV-2 acquisition. Arch In- Plan B contraception in women over 165 – Extended case control study results on tern Med. 2009;169(13):1233–1240 pounds. The Wall Street Journal. Novem- thromboembolic outcomes among trans- 126. Stanaway JD, Wald A, Martin ET, Gottlieb ber 25, 2013. Available at: http://online. dermal contraceptive users. Contracep- SL, Magaret AS. Case-crossover analysis of wsj.com/news/articles/SB1000142405270- tion. 2010;81(5):408–413 2304011304579220533719517944. Accessed condom use and herpes simplex virus January 13, 2014 114. Harel Z, Riggs S, Vaz R, Flanagan P, Dunn K, type 2 acquisition. Sex Transm Dis. 2012; Harel D. Adolescents’ experience with the 39(5):388–393 138. Glasier A, Cameron ST, Blithe D, et al. Can combined estrogen and progestin trans- we identify women at risk of pregnancy 127. Winer RL, Hughes JP, Feng Q, et al. dermal contraceptive method Ortho Evra. despite using emergency contraception? Condom use and the risk of genital hu- J Pediatr Adolesc Gynecol. 2005;18(2):85–90 Data from randomized trials of ulipristal man papillomavirus infection in young 115. Rubinstein ML, Halpern-Felsher BL, Irwin acetate and levonorgestrel. Contracep- women. N Engl J Med. 2006;354(25): CE Jr. An evaluation of the use of the tion. 2011;84(4):363–367 2645–2654 transdermal contraceptive patch in ado- 139. Cleland K, Zhu H, Goldstuck N, Cheng L, 128. Shew ML, Fortenberry JD, Tu W, et al. As- lescents. JAdolescHealth. 2004;34(5): Trussell J. The efficacy of intrauterine sociation of condom use, sexual behav- 395–401 devices for emergency contraception: iors, and sexually transmitted infections 116. Stricker T, Sennhauser FH. Allergic contact a systematic review of 35 years of ex- with the duration of genital human pap- dermatitis due to transdermal contra- perience. Hum Reprod. 2012;27(7):1994– illomavirus infection among adolescent ception patch. J Pediatr. 2006;148(6):845 2000 women. Arch Pediatr Adolesc Med. 2006; 117. Audet MC, Moreau M, Koltun WD, et al; 140. von Hertzen H, Piaggio G, Ding J, et al; 160(2):151–156 ORTHO EVRA/EVRA 004 Study Group. Eval- WHO Research Group on Post-ovulatory uation of contraceptive efficacy and cycle 129. Koss CA, Dunne EF, Warner L. A systematic Methods of Fertility Regulation. Low dose control of a transdermal contraceptive review of epidemiologic studies assessing mifepristone and two regimens of levo- patch vs an oral contraceptive: a random- condom use and risk of syphilis. Sex norgestrel for emergency contraception: – ized controlled trial. JAMA. 2001;285(18): Transm Dis. 2009;36(7):401 405 a WHO multicentre randomised trial. Lan- 2347–2354 130. Matson PA, Adler NE, Millstein SG, cet. 2002;360(9348):1803–1810 118. Zieman M, Guillebaud J, Weisberg E, Tschann JM, Ellen JM. Developmental 141. Gallo MF, Grimes DA, Schulz KF, Helmerhorst Shangold GA, Fisher AC, Creasy GW. Con- changes in condom use among urban FM. Combination estrogen–progestin contra- fl traceptive efficacy and cycle control with adolescent females: in uence of part- ceptives and body weight: systematic review the Ortho Evra/Evra transdermal system: ner context. J Adolesc Health. 2011;48 of randomized controlled trials. Obstet Gynecol. the analysis of pooled data. Fertil Steril. (4):386–390 2004;103(2):359–373 2002;77(2 Suppl 2):S13–S18 131. Bearinger LH, Sieving RE, Duke NN, 142. US Food and Drug Administration. FDA 119. Holmes KK, Levine R, Weaver M. Effective- McMorris BJ, Stoddard S, Pettingell SL. approves Plan B One-Step emergency ness of condoms in preventing sexually Adolescent condom use consistency contraceptive for use without a pre- transmitted infections. Bull World Health over time: global versus partner- scription for all women of child-bearing Organ. 2004;82(6):454–461 specificmeasures.Nurs Res. 2011;60(3 potential. June 20, 2013. Available at: 120. Gallo MF, Steiner MJ, Warner L, et al. Self- suppl):S68–S78 www.fda.gov/NewsEvents/Newsroom/Press- reported condom use is associated with 132. Kenyon DB, Sieving RE, Jerstad SJ, Pettingell Announcements/ucm358082.htm. Accessed reduced risk of chlamydia, gonorrhea, SL, Skay CL. Individual, interpersonal, and January 13, 2014 and trichomoniasis. Sex Transm Dis. 2007; relationship factors predicting hormonal 143. Ellertson C, Ambardekar S, Hedley A, 34(10):829–833 and condom use consistency among ado- Coyaji K, Trussell J, Blanchard K. Emer- 121. Warner L, Macaluso M, Newman D, et al. lescent girls. J Pediatr Health Care. 2010;24 gency contraception: randomized com- Condom effectiveness for prevention of C (4):241–249 parison of advance provision and trachomatis infection. Sex Transm Infect. 133. American Academy of Pediatrics, Com- information only. Obstet Gynecol. 2001;98 2006;82(3):265 mittee on Adolescence. Policy statement: (4):570–575 122. Paz-Bailey G, Koumans EH, Sternberg M, condom use by adolescents. Pediatrics. 144. Meyer JL, Gold MA, Haggerty CL. Advance et al. The effect of correct and consistent 2013;132(5):973–981 provision of emergency contraception

PEDIATRICS Volume 134, Number 4, October 2014 e1255 Downloaded from www.aappublications.org/news by guest on September 29, 2021 among adolescent and young adult 148. Akers AY, Lynch CP, Gold MA, et al. Exploring 151. Hormonal contraceptives for contraception women: a systematic review of literature. the relationship among weight, race, and in overweight or obese women. Obstet J Pediatr Adolesc Gynecol. 2011;24(1):2–9 sexual behaviors among girls. Pediatrics. Gynecol. 2010;116(5):1206–1207 145. Bethell CD, Read D, Blumberg SJ, Newacheck 2009;124(5). Available at: www.pediatrics. 152. Brunner Huber LR, Toth JL. Obesity and oral PW. What is the prevalence of children with org/cgi/content/full/124/5/e913 contraceptive failure: findings from the special health care needs? Toward an un- 149. Mond J, van den Berg P, Boutelle K, Hannan 2002 National Survey of Family Growth. Am derstanding of variations in findings and P, Neumark-Sztainer D. Obesity, body dissat- J Epidemiol. 2007;166(11):1306–1311 methods across three national surveys. isfaction, and emotional well-being in early 153. American College of Obstetricians and Matern Child Health J. 2008;12(1):1–14 and late adolescence: findings from the Gynecologists. ACOG practice bulletin no. 146. McRee AL, Haydon AA, Halpern CT. Re- project EAT study. J Adolesc Health. 2011;48 105: bariatric surgery and pregnancy. Obstet productive health of young adults with – – physical disabilities in the U.S. Prev Med. (4):373 378 Gynecol. 2009;113(6):1306 1311 2010;51(6):502–504 150. Xu H, Wade JA, Peipert JF, Zhao Q, Madden 154. Hillman JB, Miller RJ, Inge TH. Menstrual 147. Surís JC, Resnick MD, Cassuto N, Blum RW. T, Secura GM. Contraceptive failure rates concerns and intrauterine contraception Sexual behavior of adolescents with chronic of etonogestrel subdermal implants in over- among adolescent bariatric surgery disease and disability. J Adolesc Health. weight and obese women. Obstet Gynecol. patients. JWomensHealth(Larchmt). 1996;19(2):124–131 2012;120(1):21–26 2011;20(4):533–538

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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/134/4/e1244 References This article cites 132 articles, 13 of which you can access for free at: http://pediatrics.aappublications.org/content/134/4/e1244#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Current Policy http://www.aappublications.org/cgi/collection/current_policy Committee on Adolescence http://www.aappublications.org/cgi/collection/committee_on_adoles cence Adolescent Health/Medicine http://www.aappublications.org/cgi/collection/adolescent_health:me dicine_sub Contraception http://www.aappublications.org/cgi/collection/contraception_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 29, 2021 Contraception for Adolescents COMMITTEE ON ADOLESCENCE Pediatrics 2014;134;e1244 DOI: 10.1542/peds.2014-2299 originally published online September 29, 2014;

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