Adolescent
Contraception:
An Update
John W. Kulig, MD
From the Department of Pediatrics, Tufts University School of Medicine and New England Medical Center, Boston
ABSTRACT. Increased adolescent sexual activity in the
past decade has resulted in corresponding increases in pregnancy, childbirth, and abortion, as well as a changing spectrum of sexually transmitted diseases. Contraceptive use in this age group remains limited and is subject to developmental, peer, family, and cultural influences. The
most appropriate contraceptive methods may differ
among adolescents when compared with older parous women based upon such factors as efficacy, availability, cost, side effects, reversibility, and the need for preplan-ning. This review updates changes in patterns of contra-ceptive use among adolescents, presents recent data on both the benefits and the potential risks of the oral contraceptive pill, and addresses the risk of complications with the intrauterine device. The possible teratogenicity of spermicides, the risk of toxic shock syndrome with barrier methods of contraception, and controversy about the use of depot medroxyprogesterone acetate are ex-plored. Newly introduced methods such as the triphasic pill, vaginal sponge, cervical cap, spermicidal condom, and a simplified approach to postcoital contraception are discussed. Finally, recent compliance studies conducted among adolescents are reviewed.
A recent national survey of metropolitan youth
indicated that 69% of females and 78% of males
had experienced premarital sexual intercourse by age 19 years.’ The mean age at first intercourse for females was 16.2 years, and their partners’ mean
age was 19.0 years. For males, the mean age at first
intercourse was 15.7 years with a partner whose mean age was 16.4 years.2 The proportion of all unmarried female teenagers who had ever experi-enced a pregnancy increased from 9% in 1971 to
16% in 1979.’
Among premaritally sexually active young
women aged 15 to 19 years, 34% reported always
using contraception and 27% reported never using
contraception, with the remaining 39% reporting
Reprint requests to (J.W.K.) Department of Pediatrics, New England Medical Center, 171 Harrison Av, Box 479, Boston, MA 02111.
PEDIATRICS (ISSN 0031 4005). Copyright © 1985 by the American Academy of Pediatrics.
inconsistent use. Among teenagers who had ever
practiced contraception, use of the pill and
intra-uterine device (IUD) as a first method declined by
41% during the period from 1976 to 1979, whereas
use of withdrawal and the rhythm method increased by 86%. Use of a contraceptive method at first
intercourse was age dependent. Only 31% of fe-males younger than age 15 years used any method, whereas 62% of those 18 years and older reported
contraceptive use at first intercourse. For males, 34% of those younger than age 15 years and 59% of those 18 years and older used a method of
con-traception at first intercourse. Approximately half
of those using contraception at first intercourse used a prescription method. Among the reasons
reported by young women for not having used con-traception were lack of preplanning for intercourse, lack of thought about contraception, unavailability
of contraception, lack of knowledge about
contra-ception, refusal to use contraception, the thought
that pregnancy was impossible, and the desire for pregnancy or lack of concern about the possibility ofpregnancy. Among young men, the major reasons
were lack of preplanning, unavailability of
contra-ception, lack of knowledge, and refusal to use
con-traception.2
Several recent reviews have outlined the
ap-proach to the adolescent patient requesting
contra-ception including details of the medical evaluation
and follow-up and an extensive discussion of oral
contraceptive choices, contraindications, and side effects.35 Oral contraceptives remain the method of choice for the majority of young women and can be safely prescribed once an ovulatory menstrual cycle has been established, often heralded by the
onset of primary dysmenorrhea. IUDs have been
advocated for adolescents who have had a child and who are at low risk for pelvic infection. Barrier
methods are recommended for highly motivated adolescents, as a back-up method when the pill or
IUD use is started, and for those who have
prescrip-tion methods of contraception compared with ap-proximately $40 for condoms and foam.6 Although parental involvement is encouraged, the courts have recently ruled that family planning counseling and services for teenagers may remain confidential;
thus, health care providers are not obligated to
inform parents when contraceptives are prescribed.
METHODS OF CONTRACEPTION
Oral Contraception
Adverse publicity in the lay press has contributed
to the decline in use of prescriptive methods of
contraception by adolescents in the past decade. In the 15- to 19-year age group, mortality attributable
to pregnancy and childbirth is 12.9 deaths per
100,000 live births, whereas mortality rates attrib-utable to contraception include 0.3 deaths in
non-smokers on the pill, 2.2 deaths in smokers on the
pill, and 0.8 deaths in IUD users per 100,000 users
per year.7 Recent studies have emphasized the non-contraceptive health benefits of oral contraceptives
and concluded that young women who are in good
health and do not smoke can use oral contraceptives with minimal risk of adverse effects.” Potential
health benefits are listed in the Table, with an
estimate of relative risk included where available. Two recent reports have raised concern about the association between pill use and risk of breast
can-cer in young women. Pike et al’2 reported that
women who used high progesterone combination-type oral contraceptives for 5 years or more before
25 years of age had a fourfold increased risk of
developing breast cancer before age 37 years.
McPherson et al’3 reported that women who used
oral contraceptives before their first term preg-nancy had an increased risk of developing breast
TABLE. Noncontraceptive Benefits of Oral
Contracep-tive Pills”
Benefit Relative Risk
Iron deficiency anemia 0.57
Menorrhagia 0.52
Irregular menses 0.65
Intermenstrual bleeding 0.72
Endometrial cancer 0.50
Ovarian cancer 0.60
Breast cancer 0.96
Fibroadenoma 0.50
Fibrocystic breast disease 0.40
Functional ovarian cysts 0.07
Rheumatoid arthritis 0.49
Salpingitis (pelvic inflammatory disease) 0.50
Duodenal ulcer *
Ectopic pregnancy *
Premenstrual syndrome *
Dysmenorrhea *
* Relative risk not estimated.
cancer before age 45 years, which was related to
duration of use. These findings were recently
re-futed by the Cancer and Steroid Hormone Study
which found that neither the duration of oral con-traceptive use nor time since first use altered the
risk of breast cancer.’4’6 Women whose first use
was more than 15 years prior to the study and who
used oral contraceptives for 1 1 years or more had a
relative risk of 0.8.’ Differences in methodology were said to account for contrasting results with the previous studies.15
The Steroid Hormone Study also demonstrated a reduced risk of endometrial cancer developing in women who used oral contraceptives. The protec-tive effect was most notable for nulliparous women and persisted for at least 10 years after cessation of all contraceptive use.’7 The same multicenter study
demonstrated that the risk of ovarian cancer
de-creased with increasing duration of oral contracep-tive use and remained low long after cessation of
use, independent of other confounding variables.’8
The Centers for Disease Control estimated that
2,000 cases of endometrial cancer and 1,700 cases
of ovarian cancer are prevented each year by past
and current oral contraceptive use among women
in the United States.’7”8
An additional concern was raised by a British
study that suggested that long-term oral
contracep-tive use may increase the risk of cervical neoplasia. Cervical dysplasia, carcinoma in situ, and invasive cancer occurred twice as frequently in long-term
users of oral contraception than in a control group using IUDs. No association was found with the
particular formulation of oral contraceptive used.
The mechanism by which oral contraceptives
ad-versely influenced the risk of cervical neoplasia was
also unclear. Although unable to rule out the
influ-ence of confounding variables, the authors
recom-mend that women who have accumulated more than
4 years of oral contraceptive use should regularly
have cervical cytologic evaluation in order to detect
disease when it is still curable.’9 Previous studies
have suggested that oral contraceptive use does not appear to influence the risk of cervical cancer.”
Cardiovascular complications of oral contracep-tive use include venous thromboembolism (five- to sixfold increased risk), hypertension (threefold in-creased risk), thrombotic stroke (fivefold increased
risk), subarachnoid hemorrhage, and myocardial
infarction. Mortality is attributable to cerebral vas-cular accidents and myocardial infarctions.10’2#{176} Dif-fering conclusions reached in retrospective studies
of these complications may be attributed to changes in oral contraceptive formulation during the past 20 years.’#{176} No deaths from cardiovascular
18 years.5 Most of these deaths occur in women older than 35 years or who smoke or are hyperten-sive. The risk of venous thromboembolism could be reduced if the pill was not used by women who are predisposed because of heart disease, other chronic disease leading to immobility, or obesity. Oral con-traceptive use should be discontinued prior to elec-tive surgery and in the event of significant trauma,
and the lowest dosage of estrogen should be
pre-scribed. The incidence of thrombotic stroke could be decreased if the pill was not used by women with hypertension or a history of migraine. A strong
family history of hypertension has also been con-sidered a relative contraindication. Finally, the
in-cidence of myocardial infarction in oral contracep-tive users could be reduced if they were not pre-scribed for women at increased risk of premature
coronary artery disease, including smokers and
women with hypertension, diabetes, hypercholes-terolemia, or a family history ofpremature coronary artery disease.2#{176}
In a report from the Lipid Research Clinic Prey-alence Study2’ about 5% of adolescent girls reported oral contraceptive use. They had significantly higher levels of total cholesterol, triglycerides, and
high density lipoprotein cholesterol (HDL) than
did nonusers. In addition, 58% of the oral contra-ceptive users were classified as smokers compared
with 23% of the non-oral contraceptive users. No
significant difference in blood pressure was noted.
The finding of elevated HDL was unexpected
be-cause cigarette smoking and oral contraceptive use are strongly associated with reduced levels of HDL
in adult women.2’ Subsequent studies have
sug-gested that pills with a high estrogen to progester-one ratio are likely to have a positive effect on HDL cholesterol and, conversely, that
progesterone-dom-inant pills are associated with higher levels of low density lipoprotein cholesterol.22’23 Progestin-dom-inant pills should be avoided by women at risk for
cardiovascular disease.23
Barrier methods and oral contraception may
ac-tually protect future fertility by reducing the risk
of sexually transmitted infection, including pelvic
inflammatory disease (PID).24 The protective effect
of oral contraceptives may be due to thickening of
cervical mucus.25 Prior use of oral contraception
may possibly result in a delay in conception when
pregnancy is planned. Lynn et al26 reported that the interval from cessation of contraception to con-ception was 13 months or greater in 25% of prior
pill users vs 11% for former users of all other
methods of contraception.
New compounds and delivery systems are
cur-rently being developed for steroidal contraception.
A number of long-acting, alternative systems are
likely to become available, including injectables and
implants in biodegradable vehicles and vaginal
rings.27 In addition to the fixed-dose combination oral contraceptive pill, pharmaceutical manufac-turers have recently introduced both biphasic and triphasic oral contraceptive preparations.28’29 Two of the new triphasic pills contain a fixed amount of estrogen with a variable amount of progestin which either increases in increments during the cycle (Or-tho-Novum 7/7/7) or increases then decreases (Tn-Noninyl) in an attempt to produce a more
physio-logic response with the lowest dose of steroidal
hormone possible. The third formulation
(Tn-phasil) varies both the estrogen and progestin
doses. Two European studies of a similar
prepara-tion conclude that the tniphasic pill provides
effec-tive contraception with good cycle control and a
low incidence of side effects.30’3’ A recent study of
Ortho-Novum 7/7/7 demonstrated a reduction in
midcycle breakthrough bleeding when compared
with the biphasic Ortho-Novum 10/11. The daily
incidence of bleeding was comparable with that of the fixed-dose Ortho-Novum 1/35 and yet provided a 25% reduction in progestin content per cycle.29
Although packaging is designed to minimize
con-fusion, proper use among adolescents may be com-promised by the presence of several different color pills in a single package.
Intrauterine Contraception
Intrauterine contraception offers several
advan-tages for the female teenager. Once inserted, the
IUD requires only self-examination for partial ex-pulsion and return for follow-up clinic visits. Cost
is comparable to other prescriptive methods of
con-traception and use of the device requires no pre-planning for intercourse. This method is
immedi-ately reversible by means of removal and its
use-effectiveness may actually exceed that of other
methods due to poor contraceptive compliance in
this population. In a study of 120 consecutive
ado-lescents who received a Cu-7 IUD, Kulig et al32
reported a pregnancy rate of 2.0/100 women years, a continuation rate of 83% at 6 months and 70% at
12 months, and an expulsion rate of 18% overall; they also found that 72% of the patients were satisfied with the IUD as a method of
contracep-tion. Mean age at Cu-7 insertion was 16.8 years, and 81 % of the patients were nulliparous. Common
side effects included increased cramping, heavier
and longer menstrual flow, and intermenstrual
spotting with no significant change in hematocnit value. Acute salpingitis was documented in 8% of
the adolescents with the Cu-7.32 Kaufman et al33
of PID and demonstrated that the risk was greatest in users of the Dalkon Shield and lowest in users
of copper-containing IUDs. The risk of PID was
unrelated to the duration of use of the device, and
the data may be confounded by recent evidence that use of oral contraceptives and barrier methods of
contraception may confer protection against
PID.24’33 Although not advocated as a first choice
method, the IUD may be particularly useful in
adolescents who have been noncompliant with
other methods of contraception or in whom oral contraceptives are contraindicated. Mildly men-tally retarded female teenagers may particularly
benefit from this method provided they have no
prior history of salpingitis or involvement with
multiple partners.
Barrier Methods
Recent reviews of barrier methods of
contracep-tion have focused on new developments and protec-tion against sexually transmitted disease.3436 Lane et al37 documented successful use of the diaphragm by young women among whom only 2% became
pregnant and more than 80% continued to use the
method after the first year. Diaphragms are most useful in older adolescents who are comfortable with insertion and know their own anatomy, as
evidenced by past use of tampons rather than pads.
Diaphragms are fitted by the health care provider
who checks the position after a practice insertion. The adolescent is then asked to return in 1 week
with the diaphragm in place for a final recheck.
Toxic shock syndrome has recently been reported in association with diaphragm use; however, in each
of the recent cases, the diaphragm was left in po-sition for at least 36 hours prior to the onset of symptoms.3839
A disposable synthetic vaginal contraceptive
sponge has recently been marketed which acts as a
barrier and an absorbent and releases a spermicide.
Initial studies suggest that the efficacy, side effects,
and acceptability of this method are similar to that
of the diaphragm, but with all of the advantages of
a nonprescriptive method.4#{176}The sponge is inserted
by the patient into the vagina, covers the cervix,
and may be left in place for as many as 24 hours
but should be removed no sooner than six hours
after intercourse. A retrieval loop is incorporated
into the sponge in order to facilitate removal.34’35
Several cases of toxic shock syndrome have recently
been reported in association with use of the sponge;
however, the sponge itself does not support the
growth of Staphylococcus aureus and spermicide-containing contraceptives may actually afford some protection against the risk of toxic shock
syn-drome.41’42
The cervical cap is not currently approved for
general use as a contraceptive method by the Food
and Drug Administration (FDA). Preliminary
re-sults reveal a relatively high failure rate of 16.9
pregnancies per 100 women years due to inconsist-ent use and dislodgement.43 Difficulty in fitting the
device may also be encountered among young
women and prolonged use would raise the question of a potential association with toxic shock
syn-drome as noted with the diaphragm and sponge.34
Condoms remain the only method of contracep-tion widely available to the male adolescent. The
condom provides both effective contraception and
protection against sexually transmitted disease,
may be purchased over-the-counter at low cost, is unassociated with significant side effects, and al-lows the male partner to share in the responsibility for birth control.44 A recent study provides indirect
evidence that condoms block the transmission of
herpes simplex virus.45 Condom use has been pre-scnibed in the conservative management of squa-mous cell cervical intraepithelial neoplasia. In a
recent study, 136 of 139 women showed complete
regression of biopsy-proven disease when treated
only with condom use during intercourse.46 Con-doms are now available with a spermicidal lubricant
which provides an additional advantage to this
bar-nier method; however, the use of such condoms should not be considered a substitute for the use of a spermicide by the female partner.
Recent studies have refuted alleged links between
oral contraceptive or spermicide use and the
occur-rence of congenital malformations. Jick et al47
mi-tially reported an excess of limb reduction deform-ities, neoplasms, syndromes associated with chro-mosomal abnormalities, and hypospadias in infants
whose mothers filled a prescription for a vaginal
spermicide prescription. A higher incidence of spontaneous abortion was also noted in these preg-nancies.47 Three subsequent studies failed to
con-firm this association.485#{176} Linn et al5#{176}concluded that
prior contraceptive method seems unrelated to the risk of congenital malformations.
Alternative Methods
Yuzpe et al5’ recently reported on the efficacy of Ovral (ethinyl estradiol combined with
dl-norges-trel) as a postcoital oral contraceptive. Women were
treated with Ovral, two tablets given within 72
hours of intercourse, followed by two additional tablets 12 hours later. This combination reduced the number of pregnancies by 84% and offered
Despite extensive clinical experience and an ex-cellent safety record, medroxyprogesterone acetate
injection (Depo-Provera) continues to lack FDA
approval for use as a contraceptive method in the United States. Liang et al52 recently found no evi-dence of an increased risk of cancer of the breast,
uterine corpus, or ovary in more than 40,000 women years of observation. Rosenfield et a153 recently
reviewed the arguments for and against Depo-Prov-era and could find no reason to deny FDA approval.
The Committee on Drugs ofthe American Academy
of Pediatrics54 has endorsed the use of
Depo-Prov-era for a small well-defined group of adolescents who need effective contraception and are unable to
benefit from other methods. Since prolonged use of this drug often results in a reversible amenorrhea,
Depo-Provera is particularly useful in severely re-tarded adolescent girls who are unable to manage
menstrual hygiene. This drug may also be useful in patients with chronic illness such as sickle cell
disease or congenital heart disease in whom oral
contraceptives and IUDs may be contraindicated. Periodic abstinence based upon fertility
aware-ness is of limited usefulness in adolescents due to
poor compliance and a greater likelihood of irregu-lan menstrual cycles. Abstinence remains a positive
choice for many adolescents and should be
rein-forced and encouraged when chosen. Alternate
methods of sexual expression without intercourse may adequately meet their evolving developmental
needs. Sterilization is an option unavailable to most minors with the exception oflife-threatening illness or severe developmental delay, in which case a court order may be required.
COMPLIANCE
Recent studies of adolescent compliance with
contraceptive therapy have provided clues to
en-hancing the likelihood of success.55 Litt et al56 found that compliance correlated positively with post-menarchal age, frequency of intercourse, autonomy in making and paying for a clinic appointment for the purpose of contraception, and acceptance of a method at the time of the initial clinic visit. In a
study of factors associated with oral contraceptive
compliance in adolescents, Scher et a157 determined
that the most important factors associated with
noncompliance were an age of 15 to 16 years at
initiation of oral contraception use, no plans to
attend college, dissatisfaction with the clinic visit, the occurrence of side effects, and lack of parental involvement with the clinic visit. Compliance was
not associated with prior pregnancy or parental knowlege of pill use. In a similar study, Durant et
al58 found noncompliance to be associated with
multiple sexual partners during the previous 3
months, appointment made by the adolescent, a
low evaluation of personal health, feelings of
hope-lessness, worry about becoming pregnant, and
his-tory of a prior abortion. Finally, Jay et a159
dem-onstrated that incorporating a peer counselor into
the health care team may be effective in enhancing adolescent compliance.
Efforts are underway to encourage media adver-tising of contraceptives in order to reach a wide
adolescent audience.#{176} Although nonprescription vaginal contraceptives are now advertised on cable
television, there is currently no such advertising
during national network programming.
CONCLUSION
Although the past decade has witnessed major
advances in the technology of contraception, the
use of effective methods by sexually active
adoles-cents remains suboptimal and inconsistent.
Cur-rent efforts should be directed toward education, improved availability of services, and further un-derstanding of the adolescent’s decision-making process regarding sexual activity and contraceptive
use.
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