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Contraception

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  • See also

    Engaging with and assessing the adolescent patient
    Sexual health history taking in the adolescent
    Sexually transmitted infections

    Key Points

    1. Adolescents are at increased risk of unintended pregnancy compared to older age groups
    2. Education and advice on contraception is part of comprehensive care for sexually active adolescents
    3. Long-acting reversible contraceptives are the contraception of choice for young people
    4. Barrier contraceptives (eg condoms) should be used in addition to more reliable forms of contraception to reduce the risk of sexually transmitted infections

    Background

    • In Australia, almost 75% of people aged 14-18 years report having had an intimate relationship. Almost 50% of students aged 16-18 years report having engaged in sexual intercourse
    • Adolescents are the age group least likely to use the most reliable forms of contraception
    • Discussing contraception does not increase the likelihood of sexual activity
    • Empowering young people to have control over their reproduction is paramount and has successfully lowered Australia’s teenage pregnancy rate
    • Long-acting reversible contraceptives (LARCs) are the most effective forms of contraception, have the highest continuation rate, most cost effectiveness and higher satisfaction rates compared to shorter acting reversible contraception. They are considered the best contraception choice in young people as they are safe, reversible and they do not rely on regular user administration

    Assessment

    Principles of engaging with and assessing the adolescent patient should be considered

    • Assess and document whether the adolescent fulfills the criteria of a ‘mature minor’ and has capacity to consent to treatment
    • Discuss confidentiality. Adolescents have a legal right to confidential health care unless
      • they cannot be considered a mature minor and/or
      • there is significant concern regarding risk (ie harm to self or others, physical or sexual abuse)

    History

    Sexual health history

    • Current sexual behaviour, including risk of sexual abuse
    • Current and past contraceptive use (type, frequency)
    • Past history and current risk of STIs
    • Symptoms of STIs

    Menstrual history

    • Assess for dysmenorrhoea, heavy or irregular menstrual bleeding, which may be improved or worsened by certain contraception methods

    Medications

    • Prescribed and complementary medications can interact with hormonal contraceptive methods

    Assess for contraindications to specific contraceptive options. These may include:

    • Risk of thromboembolism
    • Malabsorption
    • Liver disease
    • Medications that may interact with hormonal contraception eg enzyme inducing anti-epileptic medication

    Assess attitudes, barriers and access to contraception including religious, cultural, financial and geographical factors

    Examination

    • Blood pressure
    • Body mass index (BMI)
    • Further examination is usually not required, unless there are symptoms warranting assessment and investigation for STIs

    Management

    Investigations

    • Baseline investigations are not usually required
    • Consider STI screen if sexually active and not performed in the preceding 12 months

    Treatment

    • Each contraception option has advantages and disadvantages; the best method for each person may be different. The efficacy, benefits, risks, side effects and contraindications of each should be considered
    • For detailed information regarding medical contraindications see US Medical Eligibility for Contraception (US-MEC)
    • Cost may need to be considered. See ReachOut - Contraception
    • Discuss correct use, anticipated side effects and time to efficacy, provide written patient information
    • Arrange review at least 3 months post commencement of contraception to assess adherence, side effects and satisfaction with chosen method

    Long-acting reversible contraception

    Most reliable: Less than 1 pregnancy per 100 women per year with typical use

    Method

    What is it and how it works

    Benefits

    Side effects and risks

    Etonogestrel implant (Implanon™)

    • Subdermal implant inserted into inner, upper arm
    • Releases progestogen
    • Prevents ovulation, thickens cervical mucus
    • Insertion and removal with local anaesthetic
    • Effective for up to 3 years
    • Over 99% effective
    • Highly effective
    • Minimal user involvement
    • Cost-effective
    • 20% of users become amenorrheic
    • 1 in 3 have lighter and less painful periods
    • Acne may improve
    • Rapid return to normal periods post-removal
    • 20% have frequent or prolonged bleeding
    • Headaches, acne, tender breasts and mood changes possible
    • Side effects may improve with time, irregular menstrual bleeding usually resolves in 3 months
    • Efficacy reduced by some enzyme inducing drugs

    Intrauterine devices (IUD)

    • Levonorgestrel IUD
    • Copper IUD
    • Impair sperm motility, fertilisation and implantation
    • Commonly inserted under general anaesthetic, though possible awake
    • Highly effective
    • Minimal user involvement
    • Cost-effective
    • No drug interactions
    • Rapid return to normal periods after removal
    • Insertion risks: Discomfort and cramping, usually transient. 1 in 500 risk of uterine perforation, 1 in 300 risk of infection, small risk of expulsion
    • Irregular menstrual bleeding common in first 3-6 months
    • Contraindicated in patients with pelvic inflammatory disease and some STIs

    Levonorgestrel IUD
    (Mirena™)

    • Releases small amount of progestogen, that in addition to the above, thickens cervical mucus
    • Effective for up to 5 years
    • Over 99% effective
    • Periods become lighter and shorter
    • 20% amenorrhoeic at 1 year
    • Hormonal side effects possible eg headaches, skin changes, tender breasts, mood changes - usually resolve after 3 months

    Levonorgestrel IUD
    (Kyleena™)

    • Releases small amount of progestogen, that in addition to the above, thickens cervical mucus
    • Effective for up to 5 years
    • Over 99% effective
    • Periods become lighter and shorter
    • 12% amenorrhoeic at 1 year
    • More likely to have irregular menstrual bleeding compared to Mirena™ or Copper IUD. Bleeding is usually light

     

    Copper IUD

    • Releases small amount of copper continuously
    • Effective for 5-10 years depending on type
    • Over 99% effective
    • No hormonal side effects
    • Periods may be heavier and more painful

    Shorter acting reversible contraception

    Medium reliability: 3-7 pregnancies per 100 women per year with typical use


    Method

    What is it and how it works

    Benefits

    Side effects and risks

    Combined oral contraceptive pill (“the pill”)

     

    • Daily tablet containing oestrogen and progestogen
    • Prevents ovulation, thickens cervical mucus 
    • With typical use, 93% effective. If used perfectly, up to 99% effective

     

    • Periods usually lighter, less painful, more regular
    • No period if hormone free tablets are skipped
    • Acne can improve
    • Reduction in risk of endometrial cancer

     

    • Not reliable contraception if dose missed or taken >24 hrs late
    • Vomiting, severe diarrhoea, certain medications or malabsorption reduce efficacy
    • Use is contraindicated in malabsorption and severe liver disease
    • Side effects not common, may include irregular menstrual bleeding, nausea, headaches, tender breasts, bloating, skin changes, mood changes
    • Return of periods may be delayed up to 3 months after cessation
    • Very small increased risk of developing deep vein thrombosis (7-10 per 10 000 woman years), acute myocardial infarction or stroke
    • Slight increase in risk of breast and cervical cancer - reduces with time after stopping

    Prescribing information
    A low-dose pill containing ≤35 micrograms ethinyloestradiol (EE), and either levonorgestrel or norethisterone is the recommended first choice in Australia. This combination is considered to have the ‘gold standard’ safety profile, with a low risk of VTE. Most low-dose pills are listed on the PBS and are cost-effective options.

    Risk factors for venous or arterial thrombosis include smoking, increased BMI, immobilisation, personal or family history of thromboembolism or thrombogenic mutations, migraine with aura, diabetes with vascular complications or uncontrolled hypertension. In patients with these conditions, alternative contraception methods are preferrable.

    Source: NPS Combined oral contraceptive pills

    Combined contraceptive ring (Nuvaring™

    • Soft plastic ring containing oestrogen and progestogen, inserted into vagina for 3 weeks every month
    • Prevents ovulation, thickens cervical mucus
    • With typical use, 93% effective. If used perfectly, up to 99% effective
    • Periods usually lighter, less painful and more regular
    • Acne can improve
    • Reduction in risk of endometrial cancer
    • Periods return to normal quickly after stopping
    • May be less effective if ring is removed and not reinserted within 24 hours
    • Risks and side effects as per combined oral contraceptive pill

    Progestogen only pill (POP)

     

    • Daily tablet
    • Thickens cervical mucus, may inhibit ovulation
    • With typical use, 93% effective. If used perfectly, up to 99% effective
    • Contraceptive option if oestrogen is contraindicated or not tolerated
    • Periods return to normal quickly after stopping
    • No increased risk of venous thromboembolism
    • Not reliable contraception if dose missed or taken ≥3 hours late (levonorgesterel/ northisterone POPs) or ≥24 hours late (drospirenone POP)
    • Side effects include irregular menstrual bleeding, tender breasts, headaches, skin changes and mood changes

    Prescribing information
    POPs containing either levongesterel or northisterone are available on the PBS. A drospirenone POP is also available, not listed on PBS.

    Contraceptive injections (“depo”)

    • Injection of progestogen, administered every 12 weeks
    • Thickens cervical mucus and prevents ovulation
    • With typical use, 96% effective. If used perfectly, up to 99% effective 
    • 50-60% have no period or light bleeding
    • Periods less painful

     

    • Frequent or prolonged menstrual bleeding can occur but usually transient
    • Weight gain
    • Small decrease in bone density, usually returns to normal after cessation
    • Mood change, tender breasts, headaches, skin changes
    • Return of periods may be delayed up to 6-12 months after cessation

    Barrier contraception, withdrawal and fertility awareness methods

    Least reliable: 12-20 pregnancies per 100 women per year with typical use


    Method

    What is it and how it works

    Benefits

    Side effects and risks

    Condoms

    Condoms are not reliable for contraception, however effective at reducing the risk of STIs

    • Thin pouch that prevents ejaculate from penis entering vagina or anus
    • Internal condom is a soft pouch inserted into vagina or anus before sex
    • With typical use, 88% effective. If used perfectly, up to 98% effective
    • Excellent at preventing STIs
    • Easy to use, low cost, minimal side effects
    • Non-latex condoms available if latex allergy
    • May be less effective if incorrectly applied, breaks or slips, past expiry date, used with oil-based lubricant, left in hot places for a long time (eg glove box of car)

    Diaphragm

    • Shallow silicone cup inserted into vagina. Must be used with Caya™ gel placed into diaphragm before insertion
    • With typical use, 82% effective. If used perfectly, up to 86% effective
    • Few side effects
    • Does not require prescription
    • May be less effective if not inserted properly, if inserted >2 hours before sex or if removed <6 hours after sex
    • May cause irritation to vagina or penis
    • Increased risk of UTI

     

    Withdrawal, fertility awareness methods

    • Not recommended in adolescents
    • Unreliable form of contraception and does not protect against STIs

    Consider consultation with local paediatric team when

    • You suspect non-consensual relationship or abuse. If sexual assault is suspected, refer to local guidelines. Early consultation with specialist services is vital

    Consider consultation with Adolescent Gynaecology when

    • Significant medical factors may impact on contraceptive eligibility or adherence
    • Significant menstrual symptoms are not improved with first line contraception

    Consider transfer when

    Care required beyond comfort level of local services

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Parent information

    ReachOut

    Sexual Health Victoria: Emergency contraception
    Raising Children: Teens sexual health: services, resources and links
    Health direct: Unplanned pregnancy
    Kids Health Info: Skipping periods when taking the pill

    Additional information

    NPS: Combined oral contraceptive pills
    CDC: U.S. Medical Eligibility Criteria for Contraceptive Use
    FSRH: UK Contraceptive Choices for Young People

    Last updated October 2023

  • Reference List

    1. European Medicines Agency. Press Release. Benefits of combined hormonal contraceptives (CHCs) continue to outweigh risks. 2014. Retrieved from https://www.ema.europa.eu/en/documents/referral/benefits-combined-hormonal-contraceptives-chcs-continue-outweigh-risks_en.pdf (viewed March 2023)
    2. Faculty of sexual & reproductive healthcare. Clinical guideline: Contraceptive choices for young people. 2019. Retrieved from https://www.fsrh.org/standards-and-guidance/fsrh-guidelines-and-statements/contraception-for-specific-populations/young-people/ (viewed September 2022)
    3. Faculty of sexual & reproductive healthcare. Clinical guideline: Combined hormonal contraception. 2020. Retrieved from https://www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception/ (viewed March 2023)
    4. Fisher, CM, Waling, A, Kerr, L, Bellamy, R, Ezer, P, Mikolajczak, G, Brown, G, Carman, M. & Lucke, J. 2019. 6th National Survey of Australian Secondary Students and Sexual Health. 2018, (ARCSHS Monograph Series No. 113), Bundoora: Australian Research Centre in Sex, Health & Society, La Trobe University
    5. Kauer, S, Fisher, C. Victorian Young People and Sexual Health. 2018, Bundoora: Australian Research Centre in Sex, Health & Society, La Trobe University
    6. NPS MedicineWise. Combined oral contraceptive pills: supporting an informed choice. 2017. Sydney: NPS MedicineWise. Retrieved from https://www.nps.org.au/news/combined-oral-contraceptive-pills-supporting-an-informed-choice (viewed May 2023)
    7. Stewart, M, Black, K. Choosing a combined oral contraceptive pill. Australian Prescriber. 2015; Feb;38(1): 6-11
    8. Therapeutic Goods Administration. Update – Dienogest and risk of venous thromboembolism. Australian Government. 2021. Retrieved from https://www.tga.gov.au/news/safety-updates/update-dienogest-and-risk-venous-thromboembolism (viewed March 2023)
    9. Therapeutic Guidelines. Progestogen-only oral contraception. 2020. Melbourne: Therapeutic Guidelines Limited. Retrieved from https://www.tg.org.au (viewed May 2023)
    10. World Health Organisation. Family Planning/Contraception Methods. Retrieved from https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception (viewed May 2023)