Personal health and well-being are foundational to life, economic vitality, business competitiveness, personal achievement, and prosperity. Twenty years ago, this was a taboo subject, but contraception in adolescents has become a necessity due to the following reasons: the age of first sexual intercourse has changed significantly over the years, the fact that frequently adolescents have multiple sexual partners, and the presence of sexually transmitted diseases, such as the infection with human papillomavirus and Chlamydia among those between 15 and 20 years old.
“Carol Davila” University of Medicine and Pharmacy, Bucharest, has been involved in informational campaigns in high schools from Bucharest about contraception use among adolescents. The society, as well as the Romanian healthcare system, must pay special attention to contraception methods use in adolescents, because this age category is sexually active and has great fertility. Proper contraceptive education, starting from the adolescence, can help women avoid the risk of unwanted pregnancies for the rest of their lives. If pregnancy occurs at this age, besides the medical risk, the social risk is infinitely greater than the risk of using contraceptive methods(1). Healthy People 2020 defines the social determinants of health as “conditions in the environments in which people are born, live, learn, work, play, worship, and age, that affect a wide range of health, functioning, and quality-of-life outcomes and risks”(2).
Data from Eurostat from 2015 have reported that 12.3% of first children in Romania were born to teenage mothers. It is the highest proportion in the EU, followed by Bulgaria, where the rate is 11.9%, and Hungary (9%); at the opposite end are The Netherlands and Slovenia (both with 1.3%), Denmark and Sweden (both with 1.4%)(3). The higher pregnancy rate among teenagers is usually correlated with the rural environment, precarious socioeconomic status, family environment and in Roma community. A.D. Stănescu et al. have reported an incidence of pregnancies of 3.86% in girls aged between 12 and 18 years old(4).
Pregnancies in adolescents are considered to have a high risk; the risk of maternal mortality is two times higher for adolescent girls aged 15-19 years old than in pregnant women over 20 years old, four times higher in pregnant women under 15 years old, and five times higher for pregnant girls aged 10-14 years old(5). Studies demonstrated that maternal mortality and morbidity in adolescents are significantly higher compared with maternal morbidity and mortality in other age groups(6).
The social risks are when an unwanted child is born by a young mother, and the teenage mother does not have the financial resources to raise the child, nor the necessary experience or the desire to do so.
She usually keeps the pregnancy as hidden as she could from the family, and sometimes even from the father of the child. We must keep in mind that the psychological implications of an unwanted pregnancy at this age are also important, even though the pregnancy ends with abortion on request. Abortion on demand has medical risks, as well as important psychological implications(7). In Romania, teenagers have the right to get an abortion with parental consent(8).
Menstrual characteristics of adolescents
The median age at menarche is between 12 and 13 years old for the developed countries(9,10). Keep in mind that age is correlated with the development and maturation status of the genital tract, but also with the psychosomatic development in general. In the first two years after menarche, menstruations of the adolescents are irregular, both in rhythm and quantity, the cycles are anovulatory and the luteal phase is decreased. During this timeframe, cycle length should still be approximately 21-45 days, with menses lasting 2-7 days. Normal blood loss is 30 mL per cycle or three to six pads or tampons per day. Menstrual cycles become ovulatory in 70% of cases after 17-18 years old, and menstruation becomes regular at least two years after menarche.
It is particularly important to know that the central nervous system and adenohypophysis have not reached maturity at this stage, nor has the genital system, which means that the epithelium is fragile and the uterus is still infantile. The delay in growth is also usual. Abnormal uterine bleeding and menstrual irregularities are common during this period.
An important issue is the association between polycystic ovary syndrome (PCOS) and obesity, which has become common in adolescents and which must be taken into account when prescribing contraception. However, delineating appropriate diagnostic criteria for PCOS among adolescent girls is problematic because irregular menses, cystic acne, mild hyperandrogenism and multi follicular ovarian morphology occur during normal pubertal maturation.
Particularities of contraception in adolescents related to the development of sexuality
In developed countries, and especially in those with a liberal demand for abortions, the sexual life of young people starts rather early, having multiple sexual partners.
The sexual act is no longer censored, and the association with the consumption of alcohol, tobacco and illegal drugs raises numerous medical, social and family problems.
In socioeconomically developed countries, in the last century puberty starts earlier, so menarche appears in girls at 12-13 years old, compared with 14-15 years old in developing countries(9).
The first sexual contact in European countries is estimated around the age of 15-19 years old. Despite the rush of teenage girls into having sex life and having sexual intercourse with multiple partners, contraception has failed to be as easily accepted and used as expected. This has not been achieved due to poor education and information, even in the developed countries. Thus, adolescents begin their sexual life before having or even before being informed about contraceptive means(11).
The impact of contraception on adolescent development
The effect of contraception on stature growth represents a contradictory discussion among many studies. It is known that estrogen causes a decrease or sometimes a stop in the statural growth. This phenomenon occurs mainly by activating somatomedin, rather than by closing the epiphyseal cartilages. Some studies show that the dose of estrogen in pills is 10 times lower than the dose of estrogen that has been shown to stop growth. It is considered that at the age when adolescents begin their sexual activity, usually two years after the menarche, the statural growth has been completed or is in its last phase(12).
Studies have shown that contraceptives have no adverse effect on the functionality and maturation of the hypothalamo-pituitary-ovarian axis. The delayed anatomical maturation of the lower segment of the genital axis (vagina, uterus) sometimes makes it difficult to use local contraceptive methods, such as intrauterine device or other barrier methods.
A topic of interest among young girls using contraceptives is their effect on fertility rate. Although, in theory, research since the 70s has shown that, after the use of estrogens, the reproductive capacity returns to normal after one year, comparable to adult women, and within a few months after using the intrauterine device or immediately after using the contraceptive barrier(13), in practice stopping of contraception can be followed immediately by the occurrence of a pregnancy.
Sex education and choosing a suitable
Education and counseling about sexuality and contraception are very important. The family – and especially the mother – is the one who educates the teenage girl and answers questions related to the menstrual cycle, sexuality and contraception.
Usually, if the teenager tells her mother that she is about to start sex life, she calls her gynecologist for consultation and prescription. Problems arise in the disadvantaged environments and when preconceived ideas or local habits prohibit contraception or are ignorant, consequently exposing adolescents to the risks presented before.
The most important problem of adolescents is choosing a method of contraception, taking into account the particularities of the age: 1) personal, cultural, social and economic factors; 2) parity (history of fertility and abortion); 3) age; 4) pregnancy risk; 5) the frequency of sexual intercourse, as well as the number of sexual partners; 6) sexually transmitted diseases and her infectious risk; 7) medical contraindications to contraceptives; 8) access and desire to do abortion.
Non-medication, “natural” contraceptive methods should be limited to adolescents due to their high fertility and sometimes due to improper use.
The most frequently prescribed contraceptives for adolescents are:
estroprogestative contraceptive pill and subdermal implant (not available in Romania);
intrauterine devices (IUDs);
local contraception and the barrier methods.
Long-acting reversible contraceptives (LARC) include the subdermal implant (not available in our country) and IUDs, which are the first recommendation for adolescents by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists(15).
Oral contraceptive pills (OCPs)
Estroprogestative contraceptive pills are the first choice of contraception among adolescents. This method is preferred mainly from a subjective point of view: it is easy to obtain, it does not involve any gynecological manoeuvre, it does not require much consultation, and it does not interfere with the sexual act (which is important at this age).
The contraindications are the same as in adult women. Combined estrogen-progesteron pills contain estrogens 20-50 µg in an oral tablet associated with a progestative. They have a fixed composition for each single pill tablet, or various compositions – two-phase and three-phase pills that reproduce the menstrual cycle.
The pill has numerous benefits, including: high contraceptive safety, if used correctly, at this age category where fertility is also high, and reduced risks of ovarian and endometrial cancer. The estroprogestative pill has minimal side effects (metabolic risk, lower cardiovascular risk than in adult women) and consequently reduced contraindications and also rapid recovery after discontinuation of administration to a normal fertility level.
The disadvantages of the OCPs lie in the interpretation and understanding of this method by adolescents. The casual sex life, in addition to changing partners, makes the pill not accepted for continuous use. Adolescent using OCPs for contraception should also be advised to use condoms consistently for STD protection(16). Teenage girls are afraid of weight gain and of the negative effects on the development of the reproductive system, and do not accept the pills rapidly. If the pills are taken improperly, this method of contraception may not be effective. A major risk of using pills in adolescents is caused by current smoking habits, as smoking is a relative contraindication due to the risk of thrombophlebitis and embolism. A final risk involves increased lipid concentration due to the estrogen content of the pills(17).
Combined oral contraceptives are commonly used in adolescents. They are the most suitable because they provide good contraception and the risks are minimal at this age. We must keep in mind that pills with a low concentration of estrogen do not provide maximum contraception at this age, when fertility is increased. These oral contraceptives may be responsible for the occurrence of breast pain, mastopathy or polycystic ovarian syndrome(18).
The risks of thrombotic events are reduced when pills containing less than 50 µg ethinyl estradiol and levonorgestrel are used. Migraines with aura, familial thromboembolic accidents and uncontrolled high blood pressure, thrombophilia and certain diseases associated with ex-complicated valvular cardiac disease are contraindications for using contraceptive pills. However, the appearance of migraine under contraception requires the interruption of the treatment until the diagnosis is elucidated(19,20).
Regarding the interaction between the efficacy of the pill and antibiotics, it is known that antibiotics interfere with oral contraceptives at the level of the liver, decreasing the concentration of estrogen, but without altering the effectiveness of contraception. The effectiveness of oral contraceptives is only modified by rifampicin, some anticonvulsants (barbiturates, phenytoin) and retroviral medication for human immunodeficiency virus infection.
Progestive-only contraceptive pills and mini pills are not a safe method for adolescents, especially due to misuse. They are given continuously, at the same hour, and can have beneficial effects on dysmenorrhea. Long-acting progesterone-only injectable contraception (medroxyprogesterone acetate) may also be used in adolescents with poor intellectual status or where there are no other contraceptive possibilities as a form of long-acting birth control.
Intrauterine devices (IUDs)
Intrauterine devices are not an elective contraceptive method for adolescents recommended in our country. However, they should be considered, as this contraceptive method may be recommended by the doctor when adolescents have a relationship with a healthy partner, are married, had pregnancies or have a regular sex life. The acceptance of an intrauterine device by young girls is low when we talk about irregular or less intense sex life(21).
Data from the 2011-2015 National Health Statistics Report on contraceptive use among adolescents aged 15-19 years old revealed that 2.8% had used the IUDs compared to the 2006-2010 data which showed that 2.5% had ever used IUDs(22).
The uterine devices available in our country are the usual Cooper T 380 sterilizers and progesterone sterilizers – Mirena® (52 mg levonorgestrel [LNG]); Jaydess® (13.5 mg levonorgestrel). Each LNG-IUDs releases a different amount of levonorgestrel per day, with the dose decreasing over the life of the device.
IUDs are introduced by the doctor under strict conditions of asepsis during the menstrual cycle. The usual IUDs and Mirena® change at 5 years, while Jaydess®, at 3 years. Recent studies have shown that LNG-IUDs can be effective even for a longer period(22).
Expulsion of the intrauterine device is more common among adolescents, due to the size and the increased excitability of the uterus. The infectious risk is also increased in adolescents who are wearing sterilizers, not because of the presence of the device, but due to the increased risks at this age to contract a STD or other genital infections. Casual sex life at this age associated with several sexual partners make the risk of sexually transmitted infections higher. The American College of Obstetrics and Gynecology has recommended adolescent screening for gonorrhea and Chlamydia infection at the time of IUDs insertion in order to decrease the infectious risk(23). The consequence of the infectious risk is the occurrence of infertility or of an ectopic pregnancy(24). The risk of uterine perforation or extrauterine migration of the IUDs is very low. Similarly to adult women, IUDs in adolescents can cause changes in menstrual bleeding pattern and progesterone-related effects such as acne, seborrhea, breast tenderness and headaches.
The new devices that have appeared on the market, which have smaller sizes, make it easier to fix it inside the not yet fully developed uterine tract of the adolescent girls. We must keep in mind that sometimes the cost of an intrauterine device is a barrier in the choice of this method by the young girls(14).
Local contraception and barrier methods
These methods of contraception have less medical risks or side effects. Systematic condom use is associated with decreased risk of STD and unwanted pregnancies. However, an international study has shown that in recent years its use has decreased in adolescents(25). Teenagers rapidly accept this type of contraceptive method because they do not need to go to a doctor and do not need a prescription. It should be emphasized that this method offers lower contraceptive efficacy(17) when not used correctly.
The diaphragm is more difficult to accept because it interferes with sexual intercourse, being used by mature and highly motivated adolescents. However, it is not available in our country.
Several forms of spermicides are available in creams, vaginal suppositories and spray. Barrier-type contraceptives (diaphragm, cervical cap, sponges) are used by adolescents with accidental sex life(24). They can be purchased without a prescription. They are effective when used correctly; they must remain intravaginal for several hours after intercourse.
Contraception in adolescents has its particularities. Prescribing contraception, explaining the benefits and risks, establishing a follow-up plan, removing preconceived ideas, together with local or social measures of sexual education have informational and educational value for the future mature women. The future mothers, on their turn, will also need to provide contraceptive education.
A good sexual education should be initiated by the young woman’s family, more precisely by the mother and then at school, and by the providers of medical services who should offer specific individual counseling, usually anonymous.
National education policies and free distribution of contraceptives through family planning centers are very important in developing an informative network for young girls who are at the beginning of their sex life. There should also be services for teenagers that offer low-cost or free contraception, including male or female condoms, emergency contraception, as well as a full range of modern methods. These include reversible methods, together with the most recommended methods in the world: long-acting methods (LARS), that depend on the preferences and needs of adolescents.
Conflict of interests: The authors declare no conflict of interests.