Long-acting methods safe for teens — Include options in your counseling
Long-acting methods safe for teens — Include options in your counseling
Implants & IUDs should be offered as first-line contraceptive choices
When it comes to contraception, most teens choose contraceptive methods with relatively high typical use failure rates, such as withdrawal, condoms, and oral contraceptives (OCs). Such selections, coupled with inconsistent use or nonuse, play a large role in the high level of adolescent unintended pregnancies in the United States. Eighty-two percent of all teen pregnancies are unplanned, and they account for one-fifth of all unplanned pregnancies in the nation.1
It's time to meet the need for acceptable, reliable, and effective methods for adolescent contraception. The American College of Obstetricians and Gynecologists (ACOG) has moved toward that goal, with a committee opinion stating that long-acting reversible contraceptives such as the intrauterine device (IUD) and the contraceptive implant are safe, effective, and appropriate options for adolescents.2 With perfect and typical use pregnancy rates at less than 1% per year, such methods represent top-tier effectiveness for teens, the opinion states. [Download a PDF of the committee opinion at http://bit.ly/OJd2j1. Also, did you receive the Contraceptive Technology Update ebulletin sent Sept. 21 on this latest ACOG guidance? To receive breaking news as it occurs, provide your e-mail address to AHC Media customer service at (800) 688-2421 or [email protected].]
The implant and IUD also possess the highest rates of patient satisfaction and continuation of all available reversible contraceptives, the committee opinion notes. With their long-acting effectiveness, both methods eliminate the problem of inconsistent use seen with other forms of reversible birth control.
At long last, long-acting contraception (LARC) is being seen in a clear, evidence-based light, says Linda Dominguez, NP, nurse practitioner at Southwest Women's Health in Albuquerque and newly-elected chair of the Association of Reproductive Health Professionals in Washington, DC. "Young women at the highest risk of an unintended pregnancy should not be deliberately confined to the lowest effectiveness methods," notes Dominguez.
"[The] committee opinion will add muscle to the ongoing effort to push past the outdated practice habits and patterns that still permeate the field."
Time to change practice
Healthcare providers' concerns about LARC use in adolescents are a barrier to access, the committee opinion states. Intrauterine devices don't increase an adolescent's risk of infertility.3 Intrauterine devices also can be inserted without technical difficulty in most adolescents and nulliparous women.2
In the 1970s, IUDs were made in nulliparous sizes and routinely offered to adolescents as a contraception option, observes Susan Wysocki, WHNP-BC, FAANP, president & chief executive officer of Washington, DC-based iWomansHealth, which focuses on information on women's health issues for clinicians and consumers. However, safety concerns linked to one IUD, the Dalkon Shield, led to decreased use and reluctance by providers to offer the method to young women, she says.
"It is about time we put the past behind us and gathered what we have learned in the meantime to be able to offer a method of contraception to teens," says Wysocki.
Flaws in early research led to exaggerations in estimates of the risk of upper-genital tract infection associated with use of intrauterine contraception.4 Women ages 15-19 have the second highest rate of chlamydia and the highest rates for gonorrhea, so it is appropriate to screen for sexually transmitted infections (STIs) at the time or before IUD insertion, the committee opinion states.2 It is reasonable to screen for infections and place the IUD on the same day, and administer treatment if the test is positive, the opinion notes.2
Regarding the fear of pelvic inflammatory disease in young patients, Dominguez says providers need to educate that sexual infections stem from partners, not from devices. As with all nonbarrier forms of contraception, remember to counsel on dual use of condoms to protect against acquisition of STIs, the opinion notes.
Intrauterine contraception and the contraceptive implants are safe for use by adolescents, including immediately after giving birth or after an abortion, the opinion states. Complications from both methods are rare.
Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles, says, "Since many teens deliver by cesarean section, we should all learn how to place the IUD with lengthened tail strings through the uterine incision to avoid potential contamination from the vagina."
Plan for successful use
Counseling about LARC methods should occur at all health provider visits for sexually active adolescents, including preventive health, abortion, and prenatal and postpartum visits, the committee opinion states. Mothers of adolescents also need to be educated and reassured regarding the safety and wisdom of LARC methods, says Dominguez.
In talking about use of the intrauterine contraceptive or the contraceptive implant, discuss potential bleeding changes associated with either method. Adolescents using the copper T380 IUD or the levonorgestrel IUD can expect changes in their menstrual bleeding, particularly in the first few months of use. The copper T IUD might cause heavier bleeding that can be treated with nonsteriodal anti-inflammatory drugs. Women using the levonorgestrel IUD will have a decrease in bleeding over time that will lead to light bleeding, spotting, or amenorrhea.2
Teens who use the contraceptive implant should be counseled to expect changes in menstrual bleeding throughout use of the method. In an analysis of 11 studies, the most common bleeding pattern was infrequent bleeding in 33.3% of 90-day cycles, followed by amenorrhea in 21.4% of cycles.5
A change in bleeding pattern is the most common reason for discontinuation of use of the implant, so anticipatory guidance regarding such changes might improve satisfaction and continuation, the opinion advises. Tell patients that the bleeding pattern they experience in the first three months is broadly predictive of future bleeding patterns.6
In addition to high efficacy, the implant offers other benefits. High rates of infrequent bleeding or amenorrhea lead to higher hemoglobin levels in implant users.7 Other noncontraceptive benefits include reductions in dysmenorrhea and pelvic pain.8,9
Intrauterine devices and the contraceptive implant are the best reversible methods for preventing unplanned pregnancy, rapid repeat pregnancy, and abortions in adolescents, the opinion states. Complications from use are rare and differ little between teens and older women, it notes.
"It's encouraging that ACOG has taken such a positive action [in] strongly recommending increased access for adolescent women to implants and IUDs," says Nelson. "I think we should go further and say that implants and IUDs should be first-line options for all women at risk for pregnancy."
References
- Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011; 84(5):478-485.
- American College of Obstetricians and Gynecologists. Committee Opinion #539. Adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2012;120(4):983-988.
- Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet 2000; 356(9234):1,013-1,019.
- Dean G, Schwarz EB. Intrauterine contraceptives (IUCs). In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology. 20th revised ed. New York: Ardent Media; 2011.
- Darney P, Patel A, Rosen K, et al. Safety and efficacy of a single-rod etonogestrel implant (Implanon): results from 11 international clinical trials. Fertil Steril 2009; 91(5):1,646-1,653.
- Mansour D, Bahamondes L, Critchley H, et al. The management of unacceptable bleeding patterns in etonogestrel-releasing contraceptive implant users. Contraception 2011; 83(3):202-210.
- Dilbaz B, Ozdegirmenci O, Caliskan E, et al. Effect of etonogestrel implant on serum lipids, liver function tests and hemoglobin levels. Contraception 2010; 81(6):510-514.
- Shokeir T, Amr M, Abdelshaheed M. The efficacy of Implanon for the treatment of chronic pelvic pain associated with pelvic congestion: 1-year randomized controlled pilot study. Arch Gynecol Obstet 2009; 280(3):437-443.
- Walch K, Unfried G, Huber J, et al. Implanon versus medroxyprogesterone acetate: effects on pain scores in patients with symptomatic endometriosis — a pilot study. Contraception 2009; 79(1):29-34.
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