Overview
Definition:
Contraception counseling for adolescents involves providing comprehensive, age-appropriate information and support to enable informed decision-making regarding pregnancy prevention
Emphasis on Long-Acting Reversible Contraception (LARC) is crucial due to their high efficacy, low user-dependency, and reversibility, making them ideal for this population.
Epidemiology:
Adolescent pregnancy remains a significant public health concern globally and in India, with varying rates by region and socioeconomic status
Early sexual debut, inconsistent contraceptive use, and barriers to access contribute to unintended pregnancies
LARC methods have lower failure rates compared to user-dependent methods.
Clinical Significance:
Effective contraception counseling for adolescents is vital for reducing unintended pregnancies, sexually transmitted infections (STIs), and associated negative health, social, and economic outcomes
Promoting LARC empowers adolescents with highly effective, long-term pregnancy prevention, supporting their educational and life goals
It is a key component of comprehensive adolescent healthcare and sexual health education, directly impacting future health trajectories and public health outcomes.
Counseling Principles
Patient Centered Approach:
Emphasize respect, non-judgment, and confidentiality
Use open-ended questions to understand their needs, concerns, and readiness for different methods
Ensure clear, jargon-free language.
Comprehensive Information:
Discuss all available contraceptive methods, including their benefits, risks, failure rates, side effects, and reversibility
Specifically highlight LARC methods (IUDs, implants) as highly effective, long-acting options.
Shared Decision Making:
Guide adolescents through the decision-making process, empowering them to choose a method that aligns with their lifestyle, health status, and personal preferences
Address any misconceptions or fears they may have.
Addressing Barriers:
Identify and address potential barriers to access, such as cost, parental consent laws (where applicable), provider bias, and transportation
Advocate for adolescent-friendly healthcare services.
Contraceptive Method Selection:
Explain the mechanism of action, typical and perfect use failure rates, duration of effectiveness, side effects, and contraindications for each method
Focus on LARC methods (hormonal and non-hormonal IUDs, etonogestrel implant) due to their superior efficacy and reduced user dependency.
Emergency Contraception:
Provide information on emergency contraception (EC) as a backup method, explaining its use and limitations
Stress that EC is not a regular contraceptive method.
Larc Emphasis
Why Larc For Adolescents:
High efficacy and low failure rates reduce unintended pregnancies
Reduced user dependency means consistent protection regardless of adolescent adherence
Long duration of action (3-12 years) provides extended coverage
Reversible, allowing for future fertility.
Types Of Larc Available:
Intrauterine Devices (IUDs): Hormonal (levonorgestrel-releasing IUDs like Mirena, Kyleena, Skyla, Liletta) and Copper IUDs (ParaGard)
Contraceptive Implants: Etonogestrel implant (Nexplanon).
Hormonal Iuds Details:
Levonorgestrel-releasing IUDs: Typically last 3-8 years depending on device
Mechanism: Thicken cervical mucus, thin endometrium, reduce sperm motility
Side effects: Irregular bleeding, amenorrhea, potential dysmenorrhea initially
Effectiveness: >99%.
Copper Iuds Details:
Non-hormonal IUD: Typically lasts up to 10-12 years
Mechanism: Copper ions are spermicidal and inflammatory, preventing fertilization and implantation
Side effects: Heavier, longer, or more painful periods
increased risk of pelvic inflammatory disease (PID) during insertion
Effectiveness: >99%.
Contraceptive Implants Details:
Etonogestrel implant: Single rod, lasts up to 3 years
Mechanism: Releases etonogestrel, suppressing ovulation and thickening cervical mucus
Side effects: Irregular bleeding patterns (most common), weight changes, mood changes, acne
Effectiveness: >99%.
Contraindications To Larc:
Absolute contraindications are few but critical: pregnancy, unexplained vaginal bleeding, known or suspected cervical/endometrial cancer, active pelvic infection or PID for IUDs, current breast cancer (for hormonal methods)
Relative contraindications and counseling points are important for each method.
Diagnostic Approach To Contraceptive Needs
History Taking:
Sexual history: age of onset, number of partners, condom use, prior STIs
Menstrual history: regularity, duration, flow, dysmenorrhea
Medical history: chronic illnesses, allergies, medications, psychiatric conditions, history of VTE or breast cancer
Social history: support systems, substance use, future plans
Review of systems focusing on gynecological and general health
Assess for signs of pregnancy.
Physical Examination:
General physical examination
Vital signs
Abdominal examination
Pelvic examination (if indicated and adolescent is comfortable): external genitalia, speculum examination, bidentate palpation to assess uterus and adnexa for masses, tenderness, or malposition.
Pregnancy Testing:
Urine or serum human chorionic gonadotropin (hCG) is essential for any adolescent presenting with amenorrhea or irregular bleeding, or initiating hormonal contraception
A negative pregnancy test is required before IUD or implant insertion.
Sti Screening:
Screen for STIs based on risk factors, including Chlamydia and Gonorrhea testing
Offer HIV testing
Discuss barrier methods (condoms) for STI prevention alongside LARC for pregnancy prevention.
Management Of Adolescent Contraception Larc Focus
Initial Counseling And Selection:
Thorough discussion of all methods, emphasizing LARC
Address fears and myths regarding LARC (e.g., pain of insertion, permanent damage)
Explore personal preferences and potential side effects
Shared decision-making is paramount.
Larc Insertion Procedure:
For IUDs: sterile technique, informed consent, cervical preparation (if needed), proper insertion technique
For implants: sterile technique, local anesthesia, subcutaneous insertion in the upper arm
Provide clear post-procedure instructions and warning signs.
Follow Up Care For Larc:
Schedule follow-up 4-6 weeks post-insertion to assess for pain, bleeding changes, expulsion (IUDs), or other side effects
Teach self-monitoring skills
Provide readily available contact information for concerns.
Management Of Side Effects:
Address side effects promptly
For irregular bleeding with hormonal LARC, consider NSAIDs or continuous hormonal suppression for short periods
For pain during menstruation, NSAIDs are effective
For IUD expulsion or displacement, repositioning or removal may be necessary.
Alternative Contraceptive Methods:
If LARC is not chosen or suitable, counsel on other methods including combined oral contraceptives, progestin-only pills, patch, ring, and depot injections, discussing their adherence requirements and typical use failure rates in adolescents.
Complications And Prevention
Iud Related Complications:
Expulsion: Higher risk in the first year, especially after menses
Perforation: Rare, risk higher with postpartum or breastfeeding insertion
Pelvic Inflammatory Disease (PID): Increased risk during insertion, typically from pre-existing asymptomatic infection
Prevention: Careful insertion technique, screening for STIs, patient education on warning signs.
Implant Related Complications:
Insertion site pain, bruising, or infection
Malposition or migration of the implant
Irregular bleeding patterns are common but usually manageable
Ovarian cysts: Functional ovarian cysts can occur and typically resolve spontaneously
Prevention: Sterile technique, careful insertion, patient education on bleeding management.
Systemic Side Effects:
Hormonal methods (hormonal IUDs, implant) can cause mood changes, headaches, acne, or weight changes in some individuals
These are often mild and transient
Prevention: Careful patient selection, counseling on potential side effects, and managing them if they occur.
Contraceptive Failure And Pregnancy:
While LARC has extremely low failure rates, pregnancy can still occur
Management of contraceptive failure involves pregnancy testing, discussion of options (continuation, termination, adoption), and management of any complications
Emphasize STI testing if a pregnancy with LARC is diagnosed.
Key Points
Exam Focus:
LARC methods (IUDs, implants) are the most effective reversible contraceptive options for adolescents due to high efficacy and low user dependency
Understanding indications, contraindications, insertion/removal procedures, and management of side effects for IUDs and implants is critical for DNB/NEET SS.
Clinical Pearls:
Always ensure confidentiality and a non-judgmental approach
Assess for pregnancy before initiating any hormonal contraception or inserting an IUD/implant
Teach adolescents to recognize warning signs for complications and when to seek immediate medical attention
Offer condoms for STI protection even when LARC is used for pregnancy prevention.
Common Mistakes:
Underestimating adolescent capacity for informed consent
Failing to offer LARC as a primary option
Not performing pregnancy tests before initiating hormonal methods or LARC
Inadequate counseling on side effects and follow-up care
Stigmatizing attitudes towards adolescent sexual health
Overlooking STI screening.