REVIEW

CURRENT
OPINION Family planning in adolescents
Amitha K. Ganti and Paula J.A. Hillard

Purpose of review
As politics continue to shape contraception and abortion care, providers have a responsibility to address
the specific needs of the adolescent patient. Here we review the current literature on contraception and
abortion in adolescents.
Recent findings
Shared decision-making among patients, parents, and providers is the cornerstone of successful adolescent
family planning. Providers should be aware of local state regulations related to consent in minors. When
provided directive and noncoercive contraception counseling at no cost, adolescents are motivated and
effective decision-makers in their care. Long-acting reversible contraceptives should be offered as the first-
line method of contraception in adolescents.
Summary
Family planning in adolescents presents unique challenges to obstetrician-gynecologists. Improved access to
contraception and abortion services is significantly lowering unintended pregnancies rates in adolescents,
but more data assessing the effectiveness of interventions in marginalized communities are needed.
Keywords
abortion, adolescent, contraception, family planning, LARC

INTRODUCTION Yet, policy makers continue to push abstinence-

The United States has seen a steady decline in its
teenage pregnancy rates with an estimate of 18.8 per
&
1000 in 2017 [1 ]. Yet, the unintended pregnancy
rate remains the highest among any industrialized
nation and disproportionately involves low-income
and black adolescents [2]. This article reviews the
progress made thus far to address this critical
national health concern.
The medical literature has come to a resounding
conclusion that increasing access to contraception
and abortion is the most effective way to lower unin-
tended pregnancy among adolescents [3]. During one
high-impact study in which counseling was stan-
dardized and contraception was provided to nearly
10 000 study participants at no cost, the Contracep-
tive CHOICE Project in St Louis found no difference
based education, which has little evidence of efficacy
and some evidence of harm [8–10]. Contraception
counseling and provision has not been shown to
increase sexual activity among adolescents [11].
Sex education that incorporates topics on diversity
and consent is important and prevents crucial mis-
understandings around reproductive health and rela-
tionships [12,13]. Clinicians in all fields can provide
timely intervention and contraceptive education,
even in emergency rooms where resources may be
limited [14]. The issue of confidentiality has been
shown to be important to adolescent health care in
general, but the provision of confidential care is not
always straightforward [15]. Reduced public funding
for family planning services has been partially met by
increasing private insurance coverage that many ado-
&

in discontinuation rates between black and white
adolescents [4]. However, despite no-cost contracep-
tion, adolescents in the lower socioeconomic group
continued to have higher rates of unintended preg-
nancy – another reminder that access to family plan-
ning resources is a multifaceted issue [5]. The
Guttmacher Institute has observed that birth control
use has doubled in the United States after the passage
of the Affordable Care Act [6]. During the CHOICE
Project, St Louis saw significant Medicaid savings
with the introduction of no-cost contraception [7].
lescents gain through their parents [16 ]. The Centers
for Disease Control (CDC) surveyed the most
searched web sites for health information and found
Department of Obstetrics and Gynecology, Stanford University School of
Medicine, Stanford, California, USA
Correspondence to Amitha K. Ganti, MD, Department of Obstetrics and
Gynecology, 300 Pasteur Drive, G332, Stanford, CA 94305-5317, USA.
Tel: +1 9257192817; e-mail: aganti@stanford.edu
Curr Opin Obstet Gynecol 2019, 31:447–451
DOI:10.1097/GCO.0000000000000577

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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Family planning
KEY POINTS
 LARC can be considered first-line contraception
for adolescents.
 Adolescents make well informed decisions if provided
noncoercive counseling, the option of a first pelvic
examination, and same-day LARC insertion.
 Additional research and resources are needed to
address care for black, Hispanic, and low-
income adolescents.
only half warn about inadvertent breach of confi-
dentiality that can result from explanations of benefit
&
sent by insurers to parents [17 ]. Providers are there-
fore encouraged to be aware of state laws regarding
consent in minors to avoid this dilemma [18 ,19 ].
& &
CONTRACEPTIVE OPTIONS
With the advent of long-acting reversible contra-
ceptives (LARCs), adolescents, their parents, and
their providers have an armamentarium of options
to consider. Most adolescents can safely use LARCs,
&&
which are the most effective contraceptives [20 ].
Counseling should be noncoercive and directive, as
adolescents with their developing decision-making
capacity are particularly vulnerable to outside influ-
ences, such as parents, friends, providers, and the
media [21,22]. The CHOICE Project noted adoles-
cents with appropriate counseling express high rates
of satisfaction and continuation rates (>80%) [23]. A
unique aspect of counseling adolescents involves
addressing their sense of invincibility, which can
manifest with the idea that a pregnancy cannot
happen to them [24]. Common side effects of each
contraceptive option, such as irregular bleeding, can
be presented as expected eventualities; the clinician
can help prompt the individual teen to consider
how they might manage the side effect without
discontinuing the contraceptive method [25]. Stud-
ies suggest irregular bleeding can occur for a number
of months after an intrauterine device (IUD) inser-
tion, and 20–50% of users experience amenorrhea
by 1–2 years [26,27]. This information is important
to provide as preventive guidance. Adolescents are
particularly likely to raise concerns about weight
gain with oral contraceptives. However, a Cochrane
review found little evidence to support this claim,
and patients can be reminded that pregnancy nec-
essarily entails a weight gain of 15–30 pounds [28].
THE ADOLESCENT PELVIC EXAMINATION
The American College of Obstetricians and Gyne-
cologists states that a pelvic examination is not
448 www.co-obgyn.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
necessary to start contraception including an IUD
[29]. Perhaps, for this reason, Mestad et al. [30]
found the subdermal contraceptive implant more
popular with adolescents 14–17 years of age and the
IUD among those 17–18 years of age. The authors
believe adolescents benefit from having an initial
pelvic examination before making a decision about
an IUD, so they are fully informed and aware about
what this procedure entails. However, the authors
stress that requiring an initial pelvic examination
can become a barrier to care and should not be
required [31]. Ultimately, the patient’s choice
should be honored and same-day insertion should
be accommodated, which is especially feasible in an
adolescent medicine clinic [32]. There are many
excellent references for approaching the first pelvic
examination and same-day contraception initiation
&
in adolescents [33,34,35 ,36]. Adolescents will still
need reinforcement regarding sexually transmitted
infection (STI) prevention, as they may de-prioritize
barrier protection once they have effective birth
&
control [37,38 ].
INTRAUTERINE DEVICES
There are still many misconceptions among teens,
their parents, and clinicians regarding IUDs and
adolescents. IUDs can be inserted in adolescents
and nulliparous individuals, and also patients
who have never been sexually active, if medically
&& &
indicated or before coitarche [20 ,39,40 ]. They can
also be inserted immediately following delivery and
abortion [41]. The expulsion rate of IUDs is similar
between adolescents (6%) and adults (2–10%) [42].
Though IUD insertion is not recommended if frank
mucopurulent cervical discharge is noted, there is
no need to delay insertion to await STI testing
results, nor is there evidence to suggest IUDs cause
&&
STIs or PID [20 ]. There is, however, a transient
increase in the risk of infection during the immedi-
ate postinsertion time period [43]. If PID is detected
at a later time point, the CDC guidelines indicate
that an IUD does not have to be removed [44].
Finally, contraceptives including LARCs can be ini-
tiated at any time during the menstrual cycle, if the
clinician can be reasonably certain that the patient
is not pregnant [45].
The anticipation of pain is a major barrier to IUD
selection among adolescents and young adults. In a
study of IUD insertion in nulliparous women less
than 25 years of age, about 14% reported no pain,
66% had mild to moderate pain, and 21% had severe
pain [46–48]. Lidocaine gel reduces discomfort dur-
ing speculum placement, but studies conflict regard-
&
ing its effect thereafter [49,50 ]. Misoprostol may be
useful for insertions anticipated to be difficult, but
Volume 31  Number 6  December 2019

can cause significant cramps itself [51]. NSAIDs have
not been shown to reduce the pain of insertion, but
can help to alleviate postinsertion cramps [51]. Ran-
domized controlled trials indicate that a paracervi-
cal block can be successful in minimizing pain,
especially if performed by an experienced provider
[52,53]. The authors use a paracervical block rou-
tinely in adolescents, nulliparous patients, and anx-
ious individuals. Anecdotal experience notes that
patients are less anxious and uncomfortable during
the performance of the block when the action of
coughing allows passive impalement of the cervix
onto the needle. If feasible, frequent follow-up
appointments can address the adolescent’s postin-
sertion concerns proactively [25].
EMERGENCY CONTRACEPTION
An underutilized form of emergency contraception
that is also a highly effective LARC is the Copper
T380 IUD [54]. This use of the copper IUD argues for
wider availability of same-day IUD insertion. Ado-
lescents may worry about increased menstrual
bleeding and pain with the copper IUD, but newer
&
literature suggests this fear may be unfounded [55 ].
Policymakers and providers are working to remove
barriers to emergency contraceptive pills, but ado-
lescents continue to face pharmacies and clinics that
are unwilling to dispense medications, provide accu-
&
rate counseling, or refer to a specialty center [56 ].
MINIMIZING RAPID-REPEAT
PREGNANCIES AFTER ABORTION
In the United States, abortion rates have declined
the most among adolescents, though this trend is
again not consistent across all racial and socioeco-
nomic groups [57,58]. A study of rapid-repeat preg-
nancies in Colorado adolescents found a significant
reduction with the use of immediate postpregnancy
LARC insertion [59,60]. Similarly, a study of adoles-
cent patients at Planned Parenthoods in Austin,
Texas, found immediate postabortion LARC inser-
tion reduced rapid-repeat pregnancies in all income
brackets [61]. Pregnancy less than 6 months after an
abortion may carry an increased risk of preterm
&
delivery [62 ,63]. Thus, providers should incorpo-
rate contraception counseling into peripartum or
abortion care, because an adolescent may be more
receptive at this time [64]. However, providers
should take care not to coerce, stigmatize, or breach
the confidentiality of the adolescent [65,66]. A
meta-analysis by Maravilla et al. [67] found LARC
use, close follow-up visits, continued school atten-
dance, and education to be protective against rapid
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Family planning in adolescents Ganti and Hillard
repeat pregnancies, whereas depression, poor social
support, and history of abortion increased the risk.
NONCONTRACEPTIVE INDICATIONS
There are several noncontraceptive indications for
&
the use of hormonal birth control [68 ]. Menstrual
suppression may be a valuable component in the
care of patients who have heavy menstrual bleeding
(HMB), dysmenorrhea, symptomatic simple ovarian
cysts, developmental disabilities, or transgender
concerns [69–72]. Levonorgestrel-IUDs are now
approved for HMB and dysmenorrhea in adults
who also require contraception, but a growing body
of evidence suggests that the benefit extends to
adolescents, including in an off-label manner to
those who do not also require contraception [73].
Additionally, continuous extended cycle combined
oral contraceptive pills (COCs) and depo medrox-
yprogesterone acetate (DMPA) are good alternatives
for these indications, and an adolescent may find
these more acceptable first treatments [74]. The
clinical implications of decreases in bone mineral
density in adolescents as a result of DMPA use are
unclear [75]. Several societies agree that DMPA
should not be restricted in adolescents on this basis
[76–78]. COCs can also regulate cycles and treat
acne in patients with polycystic ovarian syndrome
(PCOS) [79]. Obese individuals can decrease their
long-term risk of endometrial cancer [80]. With
COCs, there is some concern regarding increased
risk of venous thromboembolism in the setting of
elevation of triglycerides and an often co-existing
metabolic syndrome [81]. However, the greater risk
factor for thromboembolic disease is pregnancy.
Unfortunately, some adolescents have the misun-
derstanding that they are unable to conceive due to
PCOS, so providers should pay close attention to
their counseling of these individuals [82].
CONCLUSION
When provided directive and noncoercive counsel-
ing, adolescents make well-informed decisions. In
the United States, the use of LARCs has led to a
discernible decrease in the rates of unintended preg-
nancy. A discussion of first-line options (LARCs),
expected side effects, and pain control can improve
patient satisfaction and adherence, as does no-cost
contraception. Providers should stay abreast of state
laws regarding adolescent consent for contraception
and strive to preserve confidentiality whenever pos-
sible. Additional research is needed to address the
gaps in care for black, Hispanic, and low-income
adolescents.
www.co-obgyn.com 449
Family planning
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
Dr Paula Hillard has been a consultant for Bayer phar-
maceuticals and is a Nexplanon trainer.
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