Use of long-acting reversible contraceptives to reduce the rate of teen pregnancy

CASE 2: TEEN REQUESTS RELIABLE CONTRACEPTION

Danielle is a 16-year-old nulliparous female currently using condoms for contraception but wants a more reliable method. Her options include an IUD/IUS (MEC 2 for women younger than 18 years), a contraceptive implant (MEC 1 for all ages), DMPA (MEC 2 for women younger than 18 years), and combined oral contraceptives (MEC 1 for all ages).

The use of DMPA by teenagers is worrisome because users experience a loss of 1% to 3% of bone mineral density (BMD) over 1 year, although BMD is regained after discontinuation.¹⁹ Whether BMD relates to fracture risk in adolescents is unclear, but there is no evidence that DMPA increases the risk. Nevertheless, a baseline BMD measurement repeated every other year is recommended for thin females taking DMPA. To slow potential bone loss, daily exercise and age-appropriate calcium and vitamin D intake should be encouraged in teens, who often do not get enough calcium.

Obese adolescents who use DMPA are more likely to gain weight than nonobese DMPA users and obese users of other contraceptive methods.²⁰ Obese adolescents who use DMPA can gain as much as 10 kg.²¹

Any of the methods mentioned are options for contraception for Danielle, with continued use of condoms and counseling about dual protection. Compliance with the method chosen should be assessed at every visit.

Case conclusion

Danielle chooses DMPA, and in the first 6 months, she gains 20 pounds. She is frustrated by the weight gain and chooses to change to the contraceptive implant. She continues to use condoms always and remains satisfied with her choice 1 year later.

CASE 3: TEEN WITH HISTORY OF MULTIPLE SEXUAL PARTNERS

Yolanda is a 17-year-old female with a history of multiple sexual partners who lives in an area of high human immunodeficiency virus (HIV) presence. In addition to strong and supportive counseling about risk reduction and condom use, she also needs a highly effective contraceptive method. Available options include progestin-only implants, progestin-only injectables, and combined hormonal methods.

In 2010, the CDC and WHO stated that women at high risk of HIV and those already positive for HIV or acquired immunodeficiency syndrome (AIDS) are eligible for LARC use (MEC category 1).¹⁶ In January/February 2012, the recommendations were updated to address several key questions about hormonal contraception and HIV, including the risk of HIV acquisition in noninfected women, the risk of HIV disease and progression among HIV-positive women, the risk of transmission from infected to noninfected male partners, and the potential for interactions between hormonal contraception and antiretrovirals.

The revisions declared that contraceptive implants, injectables, pills, and IUDs/IUSs were still usable with HIV risk, HIV positivity, and AIDS, but that women using progestin-only injectable contraception should be strongly advised to also always use condoms (male or female) and other HIV preventive measures.²²

Case conclusion

Yolanda chooses an IUS, which she uses successfully for the next few years. She uses condoms sporadically, but has fewer partners per year than in prior years. At last screening, she was HIV negative. Motivational interviewing and counseling are used to increase her condom usage and to decrease the number of partners with whom she has sexual activity. Her knowledge of sexually transmitted infections and contraceptive efficacy has increased, and she is less ambivalent about navigating condom use with her current partner. She is scheduled for monthly visits to continue to work on motivation to use condoms consistently in order to remain HIV negative.

DISCUSSION

Where LARC access is widespread and sex education is comprehensive, teen pregnancy rates and abortion rates tend to decline. An initiative to increase LARC use in 13 countries with significant need for contraceptives but with low IUD use resulted in significant increase in their use.²³ Initiatives were tailored to each of the countries using a variety of models and means of distribution to provide LARCs. The data suggest that creating demand and linking it with delivery can significantly increase LARC use.

Prevention of disease, teen pregnancy, and sequelae of disease are goals of enhancing adolescent access to LARCs. To achieve this, LARCs should be prescribed before patients need them. Teachable moments, such as patients presenting with potential pelvic inflammatory disease or asking for a pregnancy test, should be recognized. Discussions with these patients should present the pros and cons of LARCs along with addressing any barriers they have to their use.

Educate not just colleagues but pharmacists, parents, patients, schools, and communities. Employ and engage social media tools to remind adolescents to be safer. Do not allow barriers to prevent LARC usage, and train residents and students to do the same.

SUMMARY

Adolescents who are at risk of unintended pregnancy need access to highly effective contraceptive methods. For adolescents eligible to use all methods of contraception, LARCs are safe and may be particularly suitable for this population. Dual protection should be encouraged for adolescents.

Myths and misconceptions about all contraceptives, including LARCS, remain barriers to effective use. Health care providers are in a unique position to provide confidential care to adolescents and to educate youth about the various contraceptive options while separating myth from fact. Use of LARCs requires the patient’s consent, access to care, and affordable options. This requires clinicians to be knowledgeable about the most recent data on contraceptive efficacy and side effect profiles.