Contraception in Adolescents

Adolescents (10 to 19 years) can safely use any contraceptive method for which they meet the medical eligibility criteria, and age alone is never a reason to withhold a method. Early pregnancy carries higher risks of obstructed labour, pre-eclampsia, preterm birth, unsafe abortion and school dropout, so the aim is to give access to the full method range, including long-acting reversible methods and emergency contraception, with condoms added for STI and HIV protection.

Consent and confidentiality. Patients under 18 years give assent, and consent is obtained in line with the law. Offer a private consultation, assure confidentiality within the limits of the law, and ask directly about coercion, transactional sex, sexual violence and age of partner.

Assessment. Take a menstrual history, date of last menstrual period, sexual history, prior pregnancy, STI and HIV risk, medicines, and medical conditions. Pregnancy is excluded by history when one of the usual criteria is met; otherwise a urine test is done. Blood pressure, weight and BMI are recorded but are not prerequisites for a progestin-only method. Pelvic examination, breast examination and cervical screening are not needed before starting a method.

Counselling. Explain side effects early, because adolescents are less tolerant of bleeding changes and discontinue sooner. Discuss missed-use plans, backup and the use of emergency contraception. Offer an HIV test in high-burden settings and PrEP where there is substantial risk. Assess for depression, substance use and safety at home.

Effectiveness. Typical-use failure in adolescents is higher than in older users for methods that need user action. Pregnancies in the first year of use per 100 women are about 0.05 for implants, about 0.2 for the levonorgestrel intrauterine device, about 0.8 for the copper device, about 3 for injectables and about 8 for combined pills.

Eligibility by method.

Method comparison. Implants and intrauterine devices have the highest continuation and the lowest failure and are first choices for most. Injectables suit patients who want a private method and accept bleeding change. Pills fit patients who can take a daily dose and want cycle control.

Interactions. Efavirenz, rifampicin and enzyme-inducing antiseizure medicines lower the effect of combined pills, progestin-only pills and implants. Advise condoms or choose DMPA or an intrauterine device.

Special groups.

• Adolescents living with HIV can use most methods; dolutegravir-based therapy has no interaction.

• Postpartum and postabortion adolescents have high rapid repeat pregnancy risk and should leave with a method.

• Survivors of sexual violence need emergency contraception, pregnancy and HIV post-exposure assessment, and a method of their choice.

• Adolescents with sickle cell disease can use progestin-only methods; combined pills are category 2.

Regimen lines.

• Etonogestrel 68 mg single rod, subdermal, inner non-dominant upper arm, once; replace at 3 years; backup 7 days if inserted after day 7 of bleeding.

• Levonorgestrel two 75 mg rods, subdermal; replace at 5 years (5-year system) or 3 years (3-year system); same backup rule.

• DMPA 150 mg intramuscularly every 13 weeks, repeat allowed up to 4 weeks late; DMPA 104 mg subcutaneously every 13 weeks, up to 4 weeks late, self-injection supported with up to 4 doses dispensed; backup 7 days if started after day 7 of bleeding.

• Norethisterone enanthate 200 mg intramuscularly every 8 weeks, up to 2 weeks late; not interchangeable with DMPA.

• Levonorgestrel 1.5 mg single dose (two 750 microgram tablets together), as soon as possible within 120 hours of unprotected intercourse.

• Copper T 380A: lifespan up to 12 years; levonorgestrel 52 mg device: 5 years.

Start rule for pills. Combined pills started within 5 days of the start of bleeding need no backup; later starts need backup 7 days. Progestin-only pills started within 5 days need no backup; later starts need backup 2 days.

Follow up. Offer a contact within 3 months for the first review, then at each visit with no appointment barrier. Address bleeding concerns promptly, review satisfaction, offer a switch rather than discontinuation, and repeat counselling on condoms and emergency contraception. After insertion of an intrauterine device, review at 3 to 6 weeks.

Adolescent-friendly delivery. Services should be private, non-judgemental, convenient in hours and free of requirements for parental presence beyond what the law requires.

Common problems. Bleeding change is the main reason for stopping; manage it with ibuprofen 800 mg three times daily for 5 days, or mefenamic acid 500 mg twice daily for 5 days, or one cycle of a combined pill with ethinylestradiol 30 micrograms and levonorgestrel 150 micrograms daily for 21 days where oestrogen is eligible. Remove the implant or device if bleeding remains unacceptable.

Red flags. Missed bleeding with pelvic pain, signs of pelvic infection, leg swelling or chest pain, severe headache, jaundice, and any disclosure of abuse.

Referral and escalation.

• Suspected ectopic pregnancy: urgent surgical referral.

• Sexual violence: emergency contraception within 120 hours, HIV post-exposure prophylaxis within 72 hours, STI treatment and safeguarding referral.

• Pregnancy: antenatal or postabortion care without delay.

• Persistent depression or substance use: refer for mental health care.