It is becoming more and more important to discuss the issue of contraception for adolescents, as national and international data have highlighted:

  • The increasingly young age at which sexual intercourse begins

  • The frequent lack of contraception during sexual debut (Table 10.1)

  • The rise in the pregnancy rate [1]

  • Unchanged amount of abortions in adolescence [2]

  • Increased incidence of STI [3]

Table 10.1 Risk factors in unprotected sexual intercourse
Full size table

10.1 Counseling

Contraceptive counseling is essential, during which it is often necessary to overcome a more or less explicit resistance to the use of contraceptives (Table 10.2).

Table 10.2 Resistance to contraceptive use
Full size table

We need to ensure the appropriate timing and language when supplying information on all the available contraceptive methods, with regard to their use, their additional benefits, and any side effects.

It is necessary to arrive at a shared decision.

We need also to have partner agreement; in these cases, the compliance is longer.

The agreement of the mother (where involved) is also important.

The importance of double Dutch contraception (condom plus hormonal contraception) should be stressed in the context of the prevention of STI.

To give more information about emergency contraception.

10.2 First Prescription

It is essential to fully investigate both family and personal medical history.

Family history:

Investigate:

  • Cardiovascular disease: ischemic stroke, myocardial infarction (MI)

  • Previous venous thromboembolism (VTE) <45 years *

  • Hyperlipidemia

  • Hypertension

  • Autoimmune diseases

  • Migraine

*at least 2 first-degree family members with VTE is a contraindication to EP use; grandparents should be included in the family medical history.

Other papers have pointed out that a family history from a female patient (mother or sister), in which that patient has experienced a CHC or pregnancy-related VTE, may further increase VTE risk in her female relatives [4].

There is no indication to screen thrombophilia on the basis of a risks/benefits assessment [5].

10.3 Clinical Examination

10.3.1 Personal Pathological History

Investigate:

  • Current or previous illnesses *

  • Migraine

  • Autoimmune diseases (SLE, rheumatoid arthritis, thyroiditis, Sjogren syndrome, celiac disease) **

  • Raynaud syndrome

  • Drugs in use (exclusion of interactions)

  • Current or previous behavioral binge eating

  • Depression

  • Smoking (negotiate reduction in number of cigarettes)

  • Recreational drug use (alcohol, vasoactive substances)

  • Lifestyle (physical activity, sedentary, etc.)

*thrombophilic diathesis is an absolute contraindication for CHC use.

**in these cases it is useful to test for antiphospholipid antibodies.

10.3.2 Gynecological History

Investigate:

figure a

Clinical examination:

Always check

  • Blood pressure recording, Weight, Height, and BMI

  • Evaluate hyperandrogenic symptoms: acne, seborrhea, hirsutism

Not essential:

  • Gynecological examination

  • Pap Smear *

  • Breast examination

  • These can be carried out in a subsequent checkup

* <21 years: do not perform cytological screening independently of first sexual intercourse or risk behavior—ACOG 2012, US preventive services task force 2012, Canadian task force on preventive Health Care 2012.

All women who have been vaccinated against HPV should still follow the screening recommendations for their age groups (The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer 2016).

10.4 Routine Laboratory Tests?

These are not recommended routinely as they do not contribute substantially to CHC safety. If there is a family history of metabolic diseases, autoimmune diseases, diabetes or dyslipidemias, then these can be carried out.

The expected advantages of the elimination of prescription blood tests are:

  • To improve access to effective contraception for the adolescent population

  • To separate screening procedures and contraceptive prescription

  • To dispel the widespread belief that contraception is hazardous for female health

Recommendations at first control after 3 months use:

  • To note side effects and/or problems

  • Verify proper use end stress instructions of use.

  • Check blood pressure.

Annual follow-up

  • Blood pressure monitoring

  • Body weight and BMI evaluation

  • Pelvic examination

  • Screening for STI*

Stress the importance of checkups or telephone calls any time in order to discuss side effects or to change contraceptive method.

*Recommendations ACOG-4-2012: screening for STI every year or every new partner.

10.5 Choice of Contraceptive

The options regard composition, means of administration, and system of drug intake.

Composition:

It is possible to choose between combined contraceptive and progestin only. Use of long-acting reversible contraception (subcutaneous etonogestrel or IUS with levonorgestrel, DMPA depot medroxyprogesterone acetate injection) is strongly recommended in adolescence for less risk of failure and greater compliance [6, 7].

Today we have several CHC that differ in progestin* or estrogenic** composition and they also (all) have noncontraceptive benefits. It is therefore important to choose an individualized CHC, examining the blood loss and therapeutic effects or suspicious clinical elements (overweight, migraine).

Way of administration: oral, transdermal, transvaginal, subcutaneous, intrauterine.

System of drug intake: 21 days, 28 days, continuous. Association with placebo pills for continuous use is probably simpler to use and facilitate compliance.

It is very important to point out:

  • Instructions for the correct use.

  • What to do if you forget the pill.

  • Interactions with other drugs, diarrhea, vomiting.

  • It is not advisable to interrupt administration of OC because of greater risk of pregnancy, more side effects in the first months or after 1 month interruption [8].

*Desogestrel, gestodene, drospirenone, Chlormadinone acetate, dienogest, levonorgestrel, norelgestromin, etonogestrel.

**Ethinyl estradiol, estradiol valerate, estradiol hemihydrate.

At the first prescription of HC, further information may be given regarding noncontraceptive benefits.

Positive effects on:

  • Pelvic pain and dysmenorrhea

  • Spotting and/or heavy blood loss

  • Endometriosis

  • Premenstrual syndrome

  • Signs of hyperandrogenism (seborrhea, acne, hirsutism)

  • Functional ovarian cysts and benign ovarian tumors

  • Iron-deficiency anemia

  • Pelvic inflammatory disease

  • Ectopic pregnancies

Protective effects:

  • Epithelial ovarian cancer

  • Endometrial cancer

  • Colorectal cancer

… .. how can we enhance contraceptive compliance?

Discussing any doubts and describing possible side effects:

Spotting, oligomenorrhea, breast tension, weight gain….

On many occasions, the real reason for low compliance is a concern about health and fertility in the future.

Moreover, several authors have pointed out the close relationship between side effects and the nonrational perception of a major health risk [9].

Categories of medical eligibility criteria for oral contraceptive use

  1. 1.

    A condition for which there is no restriction for the use of the contraceptive method

  2. 2.

    A condition for which the advantages of using the method generally outweigh the theoretical or proven risks

  3. 3.

    A condition for which the theoretical or proven risks usually outweigh the advantages of using the method

  4. 4.

    A condition that represents an unacceptable health risk if the contraceptive method is used

Category 1: Unrestricted use

  • Age—from menarche *°

  • Postabortion—immediately first and second trimester, and post-septic

  • Non-migraine headaches—mild or severe

  • Minor surgery without immobilization

  • Severe dysmenorrhea

  • Endometriosis

  • Breast disease: benign breast disease or a family history of breast cancer**

  • Anemias—thalassemia, iron deficiency

  • Raynaud’s disease—primary without antiphospholipid antibodies

*we have no data on the effect of OC assumption and post-menarchal growth.

°data concerning effects on bone mass are not univocal (possible reduction effect on bone mass growth in very young people, but there is catchup with interruption of the treatment) [10].

WHO (2009) guidelines point out a relation between an estrogenic level (20 mcg) and BMD (bone mineral density) lower then controls; on the contrary, if you use higher EE levels, there are no differences.

**in hormonal contraceptive users with a family history of breast cancer, there is no higher risk of breast cancer [11].

In girls with known BRCA1/2 mutations, there is a risk of earlier breast cancer onset in the OC users but there is another positive effect in terms of reduced incidence of ovarian cancer, [12] so an individual evaluation end possible use of POP is advised.

Category 2: The benefits generally outweigh the risks

  • Smoking—aged <35 years

  • Obesity—BMI ≥30–34 kg/m2

  • Family history of VTE in a first-degree relative aged ≥45 years

  • Major surgery without prolonged immobilization

  • Superficial thrombophlebitis

  • Migraine headaches—without aura in women aged <35 years

  • Vaginal bleeding—suspicious for serious condition before evaluation

  • CIN

  • Raynaud’s disease—secondary without antiphospholipid antibodies

  • Non-liver enzyme-inducing antibiotics

Category 3: The risks generally outweigh the benefits

  • Obesity—BMI 35–39 kg/m2

  • Family history of VTE in a first-degree relative aged <45 years

  • Immobility (unrelated to surgery)—e.g., wheelchair use, debilitating illness

  • Known hyperlipidemias—e.g., family history of hypercholesterolemia

  • Symptomatic gallstones

  • Migraine headaches or a past history of migraine with aura at any age

Category 4: Unacceptable health risk and should not be used

  • Obesity—BMI ≥40 kg/m2

  • Migraine headaches—with aura at any age

  • Known thrombogenic mutations

  • Raynaud’s disease—secondary with antiphospholipid antibodies and thus a tendency to thrombosis

  • Hypertension—blood pressure ≥160 mmHg systolic and/or ≥95 mmHg diastolic; or vascular disease

  • VTE—current (on anticoagulants) or past history

  • Valvular and congenital heart disease—complicated by pulmonary hypertension, atrial fibrillation, history of subacute bacterial endocarditis

  • Hepatocellular adenoma

  • Angiopathic hereditary edema 3

Finally we must not forget adolescent girls with chronic diseases, which are nowadays increasingly frequent due to the better treatment of the underlying conditions; in these cases, the choice of contraceptive must consider the adolescents’ needs and their clinical situation, determined in collaboration with their specialist, following specific guidelines. In the presence of estrogen-dependent diseases or increased risk of venous thromboembolism, it must be considered the possibility of using POP.

The guidelines refer to the writing of this work are:

  • World Health Organization—Medical eligibility criteria for contraceptive use. Fifth edition 2015.

  • World Health Organization—Medical eligibility criteria for contraceptive use. Fourth edition 2009.

  • Royal College of Obstetricians and Gynecologists: Faculty of Sexual and Reproductive Healthcare Clinical Guidance; Contraceptive Choices for Young People Clinical Effectiveness Unit March 2010

  • Royal College of Obstetricians and Gynecologists: Faculty of Sexual and Reproductive Healthcare Combined Hormonal Contraception Clinical Effectiveness Unit October 2011 (Updated August 2012)

  • Royal College of Obstetricians and Gynecologists: Faculty of Sexual and Reproductive Healthcare. United Kingdom Medical Eligibility Criteria for Contraceptive Use (UKMEC) Update. London: FRSH; 2009.

  • Royal College of Obstetricians and Gynecologists: Faculty of Sexual and Reproductive Healthcare Clinical Guidance; First Prescription of Combined Oral Contraception Clinical Effectiveness Unit July 2006 (Updated January 2007)

  • Royal College of Obstetricians and Gynecologists: Venous Thromboembolism and Hormonal Contraception (Green-top Guideline N° 40, July 2010).

  • Haute Autorité de Santé, Rapport D’élaboration: Contraception chez l’homme et chez la femme, Avril 2013

  • American College of Obstetricians and Gynecologists: ACOG practice bulletin—Clinical management guidelines for obstetrician–gynecologists number 73, June 2006

  • Linee Guida italiane su l’efficacia e l’uso appropriato della contraccezione intrauterina. E. Arisi, V.Bruni, A. Di Spiezio Sardo, V. Dubini, G. Gubbini, F. Parazzini, Dicembre 2014