Adolescents and Long-Acting Reversible Contraception

Educational Objectives

The goal of this program is to improve the use of long-acting reversible contraceptives in adolescents and young adults. After hearing and assimilating this program, the clinician will be better able to:

1. Identify the most effective contraceptive methods.
2. Consider drug-drug interactions with subdermal implants.
3. Compare the durations of efficacy of various available intrauterine devices.

Summary

Introduction: long-acting reversible contraception (LARC) is the most effective form of contraception available and has non-contraceptive benefits; intrauterine devices (IUDs) are currently the most effective hormonal method to treat heavy menstrual bleeding; barriers to use of LARCs are lack of patient knowledge and lack of availability of trained providers

Role of health care professionals: only 33% of adolescents report receiving information about contraceptives, sexually transmitted infections (STIs), or HIV prevention from their primary care providers (PCP); the American Academy of Pediatrics (AAP) recommends pediatric clinicians to provide confidential time during primary care visits for discussing sexuality, sexual health promotion, and risk reduction; clinicians can provide information about sexual health and development, healthy relationships, and prevention of unplanned pregnancies and STIs; the AAP recommends LARCs as the first-line choice, and pediatric providers should place them

Birth rates in adolescents: decreased ≈80% between 1991 and 2021 because more adolescents are abstaining from sexual activity, and more sexually active adolescents are using highly effective birth control methods; a youth risk behavior survey in 2023 reported only 33% of adolescents use effective hormonal birth control methods, and only 10% use condoms and effective hormonal birth control methods; continuance rate was only 30% for the pill, 30% for intravaginal ring, 11% for transdermal patch, 16% for intramuscular injection, 84% for implants, and 74% for IUD

Types of LARCs: include etonogestrel subdermal implant, copper IUD, and levonorgestrel-releasing IUD; the progestin subdermal implant suppresses ovulation; copper ions released by the copper IUD inhibit sperm function, which prevents fertilization; levonorgestrel-releasing IUDs thicken the cervical mucus (similar to pills, injections), preventing fertilization; <1% of LARC users unintentionally become pregnant in the first year of use vs 9% for the combined pill with typical use; Diedrich et al (2015) reported the continuance rates for levonorgestrel, copper IUDs, or the implant and overall LARC were 55% to 70% by year 3; the rate for non-LARC methods was only 31%; the study analyzed data from adult women and adolescent girls

Etonogestrel subdermal implant: was approved in 2006; the implant is currently a single rod implanted below the skin on the inner side of the upper arm; does not contain estrogen, so patients with migraine, headaches with aura, sickle cell anemia, and other conditions that increase clotting can use this dermal implant; it is effective for 3 yr; Planned Parenthood states its use for ≤5 yr; women have a rapid return of fertility after removal; drug-drug interactions are higher because of the continuous release of low-dose progestin; failure rate may increase to 17% in patients on antiepileptic drugs; rifampin, griseofulvin, aminoglutethimide, or St John’s wart may reduce its efficacy; ask women if they are using supplements

Intrauterine contraception: IUDs are the most effective form of reversible birth control; safety and efficacy in adolescents is well established; earlier concerns about risks for infection (eg, pelvic inflammatory disease [PID]) have been disproven; 5 IUDs are available for use; the expulsion rate in adolescents is 5% to 22%

Candidates for IUD: include nulliparous women, women not in monogamous relationships, women with a history of PID, and patients with immunosuppression (eg, solid organ transplant, treatment for autoimmune disease); the World Health Organization and Centers for Disease Control and Prevention (CDC) provide categories of medical eligibility criteria for contraceptive use, ie, category 1 (no contraindications to use the contraceptive method), category 2 (advantages of the methods outweigh risks), category 3 (the risks are greater than the benefits [proceed with extreme caution]), and category 4 (presence of unacceptable health risk that contraindicates its use); the CDC categorizes the implant as category 1; IUD use in younger and nulliparous women is category 2 because of concerns associated with higher expulsion risk and higher STI rates; new studies have reported no infertility risk with IUD use; absolute contraindications to IUDs are breast cancer, endometrial cancer, untreated cervical cancer, distorted uterine cavity, unexplained vaginal bleeding without evaluation, and acute pelvic infection (eg, PID, purulent cervicitis)

CDC guidance for nonpregnancy: there are no symptoms of pregnancy, ≤7 days after the start of normal menses, not engaged in sexual intercourse since the start of the last normal menses, correctly and consistently using a reliable method of birth control, <7 days after a spontaneous or induced abortion, or ≤4 wk postpartum

IUD and STIs: removal of an IUD is not required if the patient is diagnosed with chlamydia after placement; consider CDC-recommended treatments; IUD use is not associated with upper genital tract infection; STI screening before IUD placement is not required in women without risk factors; test STIs, if needed, before placing IUD in women with risk factors; IUD placement should be delayed if purulent cervicitis is noted on examination or if a known chlamydia or gonorrhea infection has not been treated

Types of IUDs: Skyla — designed for nulliparous women and adolescents; it is a smaller IUD and is effective for 3 yr; Liletta — contains only levonorgestrel and is effective for ≤6 yr; Kyleena — contains levonorgestrel and is effective for 5 yr; Mirena — can now be used for ≤7 yr; levonorgestrel thickens the cervical mucus and inhibits ovulation; Mirena is the only IUD approved to treat heavy menstrual bleeding; side effects include 3 to 6 mo of spotting or irregular menses, lighter menses, and stopping of menses after ≈1 yr; copper IUD — is nonhormonal and is effective for ≤10 yr; can also be used as emergency contraception if inserted ≤5 days of the last sexual intercourse; it may result in heavier and longer periods; speaker avoids its use in women already with heavy periods or with sickle cell anemia; it may also cause cramping; effectiveness is immediate for IUDs and 1 to 2 days for implants; return to fertility is immediate after removal

Factors influencing LARC use: include choice of LARC use by the adolescents themselves and recommendations from friends or family members; older adolescents and young adults are more likely to accept an IUD, while younger adolescents are more likely to accept implants; Black adolescents are more likely to choose a shorter-acting method

Unscheduled bleeding and LARC use: irregular bleeding is the only significant side effect of LARCs; it resolves over time; counsel women about this side effect; however, if the bleeding is worrisome, treat with a short course of nonsteroidal anti-inflammatory drugs (5-7 days) or add oral hormonal therapy (1 oral contraceptive pill daily for 10-20 days)

Counseling patients about LARCs: inform adolescents that LARCs are not the single solution to unintended pregnancy; focus on bodily autonomy; do not direct patients toward a specific contraceptive method

Readings

Diedrich JT, Zhao Q, Madden T, et al. Three-year continuation of reversible contraception. Am J Obstet Gynecol. 2015;213(5):662.e1-662.e6628. doi:10.1016/j.ajog.2015.08.001; Fanse S, Bao Q, Burgess DJ. Long-acting intrauterine systems: recent advances, current challenges, and future opportunities. Adv Drug Deliv Rev. 2022;191:114581. doi:10.1016/j.addr.2022.114581; Jatlaoui TC, Simmons KB, Curtis KM. The safety of intrauterine contraception initiation among women with current asymptomatic cervical infections or at increased risk of sexually transmitted infections. Contraception. 2016;94(6):701-712. doi:10.1016/j.contraception.2016.05.013; Maddox DD, Rahman Z. Etonogestrel (Implanon), another treatment option for contraception. P T. 2008;33(6):337-347; Paul R, Huysman BC, Maddipati R, et al. Familiarity and acceptability of long-acting reversible contraception and contraceptive choice. Am J Obstet Gynecol. 2020;222(4S):S884.e1-S884.e9. doi:10.1016/j.ajog.2019.11.1266.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Tanaka was recorded at Pediatrics in the Islands: Clinical Pearls 2024, held October 28, 2024, in Waikoloa, HI, and presented by Children’s Hospital Los Angeles Medical Group. For information on future CME activities from this presenter, please visit https://www.chla.org/chla-medical-group/cme-conferences. Audio Digest thanks the speakers and Children’s Hospital Los Angeles Medical Group for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.25 CE contact hours.

Lecture ID:

PD711502

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.