Contraception for young people

A contraception request is the second most common general practice presentation for females aged 14–17 years.

INTRODUCTION
CONTRACEPTIVE choices for younger women are in general no different to other age groups. The clinical issues are usually focused on establishing rapport, assessing maturity in decision making, capacity to consent to clinical management and child protection considerations.

Confidentiality is highly valued by young people and it is important to be explicit about rights. Other relevant issues include ability to pay for ongoing supplies, privacy of method, increased risk of sexually transmissible infections (STIs) and high fertility.

From a medical perspective there is no lower age limit for prescribing hormonal contraception if the young woman has started menstruating. The age of consent to medical treatment is 18.

However, the common law position in most states and territories is that a younger person can consent to their own treatment if they are judged as a mature minor.

A discussion about parental involvement should occur for those aged 16 or younger. Parental involvement removes the burden of keeping contraception secret, the surreptitious borrowing of Health Care or Medicare cards and it may assist with costs. In general, there are proven benefits of good parental communication.

CONDOMS
While effective as STI prevention, condoms are not a good choice as a sole method of contraception with a typical use efficacy rate of 82% per year. Dual protection with the addition of a long acting reversible method of contraception (LARC) or the combined oral contraceptive pill (COCP) can be encouraged.

EMERGENCY CONTRACEPTION
There is no legal lower age limit for dispensing of levonorgestrel emergency contraception (LNG-EC) for young women assessed as mature minors. Advance provision may be appropriate in some circumstances as young women may experience barriers to over the counter supply.

LONG-ACTING REVERSIBLE CONTRACEPTIVES (LARCS)
LARCs include contraceptive implants, injections and intrauterine methods and are highly effective, cost effective and underutilised in the Australian setting. Recently pregnant adolescents who chose a LARC substantially lower their risk of a rapid repeat pregnancy compared with those choosing the pill or condoms.

Etonogestrel implant
The etonogestrel implant (Imp­lanon NXT) is highly recommended as a first line choice for young women. It is more than 99.9% effective, cheap and lasts up to three years. Negative attitudes around bleeding patterns, weight gain and long term effects exist.

The implant is rapidly reversible and has no effect on future fertility. 25% of women will experience frequent and/or prolonged bleeding, 60% will have minimal or no bleeding. There is no proven effect on increase in weight gain,1 and acne and dysmenorrhoea often improve.

Depot medroxyprogesterone acetate injections (DMPA)
DMPA injections can be a good choice, although generally not first-line in women under 18 because of bone density concerns. Bone density decreases during use but is likely to recover after cessation. It is very effective, has a 50% chance of amenorrhoea, and is unaffected by liver-enzyme inducing medications including anti-epileptics. Its use can easily be concealed from other people.

Early weight gain is predictive of ongoing gain but only occurs in around 20% of users.

Intrauterine devices (IUDs)
IUDs are increasingly used worldwide in nulliparous as well as parous young women. The advantages outweigh the disadvantages in most circumstances. Nulliparity can be associated with an increased risk of expulsion as well as removal for bleeding and pain.

Young women are also at higher risk of chlamydia infection, so it is important to encourage the use of condoms, thus giving dual protection against unintended pregnancy and STIs.

COMBINED HORMONAL METHODS (COCP AND VAGINAL RING)
The COCP or vaginal ring can be a good choice for young women. While young women rarely have serious medical conditions that might contraindicate use, consideration needs to be given to issues such a BMI > 35kg/m² or migraine with aura or thrombophilia.

Benefits include improvement in dysmenorrhoea, heavy menstrual bleeding and acne as well as the ability to manipulate bleeding cycles. Disadvantages include a typical use failure rate of 9% per year.

PROGESTOGEN ONLY PILL (POP)
The POP is generally not recommended for young women, due to its strict timing regime and higher failure rates in this age group.      

Key points
There are a number of important requirements for contraception in younger women including:

• must be efficacious in this group due to the high fertility rate
• should be accessible as the young person may encounter difficulty obtaining items such as the postcoital pill
• must be easy to use to encourage commitment to use
• barrier methods such as condoms must be available to reduce the risk of sexually transmissible diseases
• affordability to young people to ensure continuity of supply
• privacy should be guaranteed
• any method should have an acceptable side effect profile (weight gain, acne, irregular bleeding).

Dr Kathleen McNamee MBBS, FRACGP, DipVen, GradDipEpiBio, MEpi
Senior Medical Officer, Family Planning Victoria

Co-author: Dr Deborah Bateson MA (Oxon), MSc, MBBS
Medical Director, Family Planning NSW

Co-author: Dr Caroline Harvey MBBS (Hons), FRACGP, DRANZCOG
Medical Director, Family Planning Qld

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