Expert’s Corner: Teens and long-acting contraception

Teens adolescents long acting reversible contraception birth control implant IUD

The use of long-acting reversible contraceptive (LARC) methods among teens is on the rise. LARC use among 15- to 19-year-olds increased from 1 to 4.5 percent between 2007 and 2009. Both the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics recommend LARC—specifically, intrauterine devices (IUDs) or implants—as a first-line contraceptive option for teens.

Some leaders in pediatric medicine are calling for increased access to LARC for teens. S. Jean Emans, MD, chief of Adolescent Medicine at Boston Children’s Hospital, and her colleague Amy DiVasta, MD, offer some insights into LARC and teens.

LARC: Advantages and challenges

Teens do need better access to LARC; however, a deliberate and thoughtful approach to LARC, specifically, intrauterine devices (IUDs) or implants, is warranted.

LARCs are effective for teens because they don’t have to think about birth control after the initial insertion. And for some young women, there are clinical advantages. For instance, an IUD can help manage heavy or uncontrolled vaginal bleeding.

Despite the advantages, pediatricians need to consider practical and educational issues associated with offering these methods. Many pediatricians may feel most comfortable counseling the teen patient about all options, and risks and benefits, rather than providing the actual office procedures for LARC.

DiVasta and Emans detail several issues related to IUDs for their colleagues:

  • Level of procedural experience in the pediatric office. “A physician needs to be quite facile with pelvic exams and anatomy to insert an IUD safely,” says Emans. A provider who performs only a few pelvic exams each year may not have the training or skills for successful IUD insertions and the management of complications. The office facilities may not be designed to implement IUD protocols.
  • Cost. The price of an IUD is in the range of $700. “A lot of practices don’t want to undertake the procedure and charge it to the insurance because they are at-risk for the insurer saying no or covering a small fraction of the cost,” says Emans.
  • Informed decision-making. “LARC is an important decision for these patients. If a young woman has the IUD removed before five years expires, she may not be eligible for another IUD until the end of that original five years,” explains DiVasta. If a young woman has not thought through the implications of her choice, she may limit her birth control options for several years. “Inserting an IUD as soon as the patient hears about it may not allow adequate time for the teen to think through all options and truly consent to the method,” says Emans.

Birth control implants do not bring the same educational and training challenges as IUDs but come with other possible issues.

While implant placements are easier to perform than IUD insertions, initial training still takes three hours; more time with supervised insertions and removals is necessary to truly master the procedure. Also, the cost issues are similar, and unlike an IUD, an implant is not completely confidential. There may be a bump or scar on the arm with an implant. In addition, menstrual bleeding may be less predictable with an implant.

Making the right referral

If a pediatrician does not offer LARC and refers a patient to another provider, DiVasta suggests referring to a specific clinician, preferably one she knows, or a specific family-planning service. The reason: most teens do not have optimal follow-up with referring providers, and specific information could help ensure proper follow-up by the patient.

“LARC methods should be first-line options,” sums DiVasta. “Pediatricians and adolescent medicine specialists should be prepared to counsel patients about these options, know where they’re available and help direct patients to the resources regardless of whether or not they can personally provide these methods.”

Boston Children’s Division of Adolescent Medicine provides contraceptive consultation for both healthy and medically complex teens and young adults, as well as LARC insertions. Contact them to learn more. The website (directed by the divisions of Adolescent Medicine and Gynecology) also has health information for teens and parents on LARC.