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ACOG Encourages Long-Acting Contraceptives for Sexually Active Teens

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Evidence Supports LARC Use in Teens

This committee opinion is an excellent resource for clinicians taking care of adolescents. It succinctly and comprehensively provides the evidence to show that long acting reversible contraceptives (IUD and implant) should be offered as first line methods to adolescents.

In 2008, twice as many teenagers in the United States became pregnant, compared with Sweden. Birth control pills and condoms are the most popular forms of contraceptives used by teens in the United States, and have higher failure rates compared with LARC methods and high discontinuation rates. While the uptake of LARC nationally has been low in the adolescent population, data from the contraceptive CHOICE study found that with appropriate counseling, and no financial, logistical, provider or other barriers to use, over 40% of females aged 14-17 years chose the implant and over 40% of those aged 18-20 years chose an IUD. The study is a prospective cohort of more than 9,000 women aged 14-45 years who desired contraception, and after enrolling in the study were given comprehensive contraceptive counseling and their choice of contraception free of cost for a specified duration, after enrollment.

Another study of teens attending a family planning clinic showed that more than half had not heard of intrauterine contraceptives and when counseled appropriately by health care providers, they were three times more likely to be interested in using it.

LARC methods have both contraceptive and noncontraceptive benefits. There are few absolute contraindications to using LARC methods, and increasing their use has the potential to reduce unintended pregnancy in the U.S. adolescent population with appropriate counseling and in the absence of financial, logistical, provider or other barriers.

Dr. Rameet H. Singh, assistant professor of obstetrics and gynecology at the University of New Mexico, Albuquerque. Dr. Singh said she had no relevant financial disclosures.


 

FROM OBSTETRICS & GYNECOLOGY

Health care professionals should encourage sexually active adolescents to consider long-acting reversible contraceptive methods when counseling them about contraceptive choices, according to an American College of Obstetricians and Gynecologists’ committee opinion.

With pregnancy rates less than 1% with perfect and typical use, long-acting reversible contraception (LARC) methods "are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women," the opinion states. Although the complications of these methods – intrauterine devices and the contraceptive implant – are rare and are similar in adolescents and older women, they are underused in the younger age group, according to ACOG committee opinion No. 539, written by the Committee on Adolescent Health Care’s Long-Acting Reversible Contraception Working Group. The opinion was published in the October issue of Obstetrics & Gynecology (2012;120:983-8).

"Increasing adolescent access to LARC is a clinical and public health opportunity for obstetrician-gynecologists," the opinion says, adding: "With top-tier effectiveness, high rates of satisfaction and continuation, and no need for daily adherence, LARC methods should be first-line recommendations for all women and adolescents," combined with the use of consistent use of condoms to reduce the risk of sexually transmitted infections.

Dr. Melissa Kottke

The new opinion is a reaffirmation of the committee opinion issued in 2007. "We’ve had the support to offer these top-tier methods as first line for adolescents for years ... and yet teens are largely using condoms, oral contraceptive pills, and withdrawal – methods with much, much higher failure rates – for contraception, if they are using anything at all," said Dr. Melissa Kottke, a member of the committee and medical director of the Jane Fonda Center for Adolescent Reproductive Health at Emory University in Atlanta.

Health care providers are not routinely offering these methods to teens, possibly because they mistakenly think that teens will not choose these methods, which data indicate is not the case; and they may not have the training or comfort level to provide them, she said in an interview. Clinicians may also believe that LARCs are only appropriate for parous teens and there is a "lingering fear of infection," but there are data that support the safe use of IUDs and the implant in both parous and nulligravid teens, she said, adding that all women, including adolescents, should be counseled on condom use and other approaches to decrease their risk of sexually transmitted infections.

The opinion recommends that adolescents should be routinely screened for sexually transmitted infections when or before an IUD is inserted.

Among the statistics cited in the ACOG opinion is that 42% of all adolescents aged 15-19 years have had intercourse and 82% of adolescent pregnancies are not planned.

The opinion refers to depot medroxyprogesterone acetate (DMPA) injection, the contraceptive patch, vaginal ring, and OCs, as well as condoms and other short-acting methods, as adolescent contraceptive "mainstays," but points out that these methods are associated with lower continuation rates and higher pregnancy rates among adolescents than LARC methods. For example, a study published in 2011 found that 1 year after starting a short-acting contraceptive, continuation rates among women 15-24 were as low as 11% for the contraceptive patch, 16% for DMPA, and about 30% for OCs and the vaginal ring. But in another study, continuation rates for the levonorgestrel intrauterine system and contraceptive implant among women under aged 20 at 1 year were 85%, and copper IUD continuation rates at 1 year among adolescents were 72%.

The use of LARC methods have increased in the United States, from 22.4% in 2002 and 8.5% in 2009. But among teenagers, about 4.5% of adolescents use LARC, mostly IUDs. Use of the contraceptive implant, the etonogestrel single-rod contraceptive approved in 2006, is low in all age groups (less than 1% of the women in the United States using contraception and 0.5% of those aged 15-19 years), according to the opinion.

The committee cites barriers to use of LARCs by adolescents – including cost, lack of access, and concerns among health care providers about their safety in younger patients – and note that training and education programs "should address common misconceptions and review the key evidence and benefits of adolescent LARC use."

In the interview, Dr. Kottke, also with the department of gynecology and obstetrics at Emory, said that she believed that many of these barriers "can be overcome with clinician support, education and training ... and the impact on the health and wellness of our adolescent patients and our communities will be substantial."

She disclosed that she has been an Implanon trainer in the past. (Nexplanon, the etonogestrel implant, is the only contraceptive implant currently on the market; it is a radiopaque version of Implanon, which is no longer available.)

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