Khalida Itriyeva, MD, FAAP
(Dr. Khalida Itriyeva, MD, FAAP is adolescent specialist at Cohen Children’s Medical Center. She is a NYS AAP Chapter 2 Youth and Adolescence Committee Member.)
Use of Long-Acting Reversible Contraceptives (LARC) in Adolescents
The American Academy of Pediatrics (AAP) encourages pediatricians to familiarize themselves with, and to counsel adolescent patients on, all methods of contraception including LARCs. LARCs represent the most effective methods of birth control, with efficacy rates greater than 99 percent. As they are not user dependent and do not require patients to remember to take them, they are more effective than short-acting contraceptive methods, such as the oral contraceptive pill, transdermal patch, and vaginal ring.
LARCs include two types of contraceptives: the subdermal implant, which is placed under the skin of the non-dominant upper inner arm, and the intrauterine device (IUD). The subdermal implant currently available in the United States is the Nexplanon®, containing the progestin etonogestrel. Pediatric providers may learn to insert and remove the device by completing the mandatory training course offered by the manufacturer. Insertion of the implantis a 5-10 minute outpatient office procedure performed under local anesthesia. The implant is approved by the Food and Drug Administration (FDA) for 3 years of use, although recent studies have demonstrated extended use efficacy (off-label) for up to 5 years of use. The most common side effect of the subdermal implant is irregular menstrual bleeding, which is also the most common reason for discontinuation of the implant among users.
The second LARC method is the IUD. There are two types of IUDs currently available: the copper IUD (Paragard®) and 4 hormonal IUDs containing varying amounts of the progestin levonorgestrel (Mirena®, Liletta®, Kyleena®, and Skyla®). IUD insertions require provider training and are performed in the outpatient office setting. Duration of use varies among the different types of IUDs, from 3 years (Skyla®) to 10 years (Paragard®). Common side effects of the IUD include irregular bleeding and cramping during the first several months after insertion. Paragard may also result in heavier, longer, and more painful menses. Menstrual bleeding with Mirena and Lilettatypically decreases over time, and many women will ultimately experience amenorrhea. Women who choose the Kyleena and Skyla IUDs may continue to experience monthly periods or irregular spotting, as they contain smaller amounts of levonorgestrel. An added benefit of the copper IUD is that it can be used as emergency contraception for up to 5 days after unprotected sex, and it is the only non-hormonal IUD available, for women who would prefer a hormone-free birth control method.
Despite the myths surrounding the safety of IUDs for adolescents, studies have shown that IUDs are safe, highly effective methods of contraception for teenagers. IUDs may be inserted without technical difficulty in most nulliparous women and adolescents. Adolescents may be screened for sexually transmitted infections (STIs) at the time of IUD insertion and are not required to have a separate visit for STI screening or a pelvic exam prior to their IUD insertion. IUDs can be placed at any time during the menstrual cycle as long as pregnancy can be reasonably excluded. Modern IUDs do not cause ectopic pregnancy, pelvic inflammatory disease (PID), or infertility. The risk of PID is only increased during the first 3 weeks after IUD insertion, and is likely due to the insertion procedure and not the device itself. As pregnancy is a very rare occurrence with IUDs, in the unlikely event that a woman becomes pregnant with an IUD in place, there may be a greater likelihood of ectopic pregnancy.
There are few conditions that are contraindications to the use of LARCs in adolescents. These conditions are summarized in the U.S Medical Eligibility for Contraceptive Use, referenced below. Most adolescents can safely use the LARC methods and pediatric providers should familiarize themselves with these methods in order to provide comprehensive, objective, fact-based, patient-centered contraceptive counseling to their patients.
References:
- Committee on Adolescence. Contraception for adolescents. Pediatrics. 2014 Oct;134(4):e1244-56. doi: 10.1542/peds.2014-2299.
- Curtis KM et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep. 2016 Jul 29;65(3):1-103. doi: 10.15585/mmwr.rr6503a1.