Sexuality and
Contraceptive Use
Among Adolescence
By: ROY Q. NALDO R.N., M.N.
Sexual Behaviour and
Unintended Pregnancy
One in ten young Filipino women age 15-
19 has begun childbearing: 8 percent are
already mothers and another 2 percent
are pregnant with their first child
according to the results of the 2013
National
Demographic and Health Survey (NDHS).
Among young adult women age 20 to 24,
43 percent are already mothers and 4
percent are pregnant with their first child.
By age 18, 60% of females will have had
sexual intercourse and by age 20 years
almost 80%. Many have had more than
one partner. Adolescents have the lowest
level of contraceptive knowledge and
use. Initiation of sexual activity while they
lack adequate knowledge and skills to
protect themselves places adolescents at
higher risk of unwanted pregnancy,
unsafe abortion, and STIs.
Although there appears to be an increase
in contraceptive use at first intercourse,
many adolescents still do not use any
method of contraception at first
intercourse or do not continue to use
contraception consistently.
The most commonly used method of
contraception at first intercourse is the
male condom, which is important from the
STI prevention perspective but is less
reliable as a contraceptive method due to
typical use failure rates that are
significantly higher than those seen with
other contraceptive methods.
Factors That Increase the Risk of Early Sexual
Activity in Adolescents
• Low socioeconomic status
• Living in a single-parent home
• Engaging in risk-taking behavior (e.g.
cigarette, alcohol, drug use)
• Having sexually active peers
• In some cases, early or rapid pubertal
development
Barriers to Contraceptive
Access and Use
Barriers to accessing contraceptive
information and methods include:
• social or culture taboos
• legal restrictions
• health care provider (HCP) attitudes
• healthcare systems
Adolescents may experience barriers
accessing contraception including
• inconvenient medical clinic hours
• financial restrictions
• lack of confidentiality
• lack of provider training.
Health Care Providers themselves may act as medical
barriers:
• By imposing their own personal values/moralistic
beliefs on the adolescent
• by applying inappropriate medical contraindications on
recommendations for contraceptive use
• by delaying initiation of contraception unnecessarily
(i.e. waiting until the next menses or until STI screening
results are available)
• by requiring unnecessary investigations prior to
contraceptive initiation (i.e. by erroneously insisting on
a Pap smear prior to starting contraception)
• by perpetuating unfounded myths about contraceptive
use.
HCPs should ensure that they have the necessary
skills and knowledge to provide
• unbiased
• non-judgemental
• evidenced-based
• adolescent-friendly sexual health and reproductive
health care and to be able to dispel common myths
and misperceptions about contraceptive use
Contraceptive Counselling
There should be no restrictions on the ability of adolescents to
receive complete and confidential contraceptive services.
An assurance of confidentiality will increase the willingness of
adolescents to disclose sensitive health information and seek
health care advice, while a loss of confidentiality can negatively
impact an adolescent’s participation in sexual health services.
The clinic should be welcoming to adolescents, ideally with
flexible scheduling, convenient times (timed around school),
and age appropriate visual aides.
Scheduled follow-up visits are important to ensure method
acceptability and ongoing contraceptive adherence.
There are many suggested approaches to contraception counselling.
1. The Centers for Disease Control suggest that sexual history taking should
include the “5Ps”:
• Partners
• Practices
• Protection from Sexually Transmitted Infections
• Past history of Sexually Transmitted Infections
• Pregnancy Prevention
2. Another approach to contraception counselling is the “GATHER” approach
where the HCP:
• Greets and builds rapport
• Asks questions and listens
• Tells her relevant information to help her make an informed choice
• Helps make a decision and provides other related information
• Explains the method in detail including its effectiveness, potential side
effects, and how to use it, and lastly has the patient
• Return for advice or further questions
Starting Contraception
Tier 1: LARC are methods that do not rely on the user.
(e.g. the non-hormonal copper coil (the IUD), the hormonal coil
(the IUS), the contraceptive injection (the Depo-Provera) and the
hormonal implant.)
Tier 2: Methods that rely on consistent use daily (pill), weekly
(patch), every three weeks (vaginal ring), every three months depo-
medroxyprogesterone acetate (DMPA).
Tier 3: Methods that rely on user during sexual activity (male and
female condom, spermicide, natural family planning), or immediately
after [emergency contraception (EC)].
Most contraceptive methods can be initiated at any time
during the menstrual cycle provided that pregnancy or
the possibility of pregnancy can be ruled out.
The “Quick Start” method refers to starting a method
immediately rather than waiting for the next menstrual
period.
• Starting contraception immediately/at the time of the
visit, has been associated with improved short-term
compliance and is not associated with an increased
incidence of breakthrough bleeding or other side
effects.
• When the possibility of pregnancy is uncertain, the
benefits of starting a combined hormonal
contraceptive (CHC) (CHC: COC, vaginal contraceptive
ring, contraceptive patch) likely exceed any risk.
Contraceptive Options
for Adolescents
Intrauterine Contraception (IUC)
Intrauterine contraceptives are Long-Acting Reversible
Contraception methods that are highly effective and can be used
by women of any age. Neither age nor nulliparity are
contraindications to their use although rates of IUC expulsion are
significantly higher in adolescents compared to older women
regardless of parity or Intrauterine Contraceptives type.
Many international societies have stated that Intrauterine
contraceptives are a safe first line choice for adolescents and
encourage HCPs to counsel all adolescents on their use for the
prevention of pregnancy due to their low typical use-failure rates
and high one-year continuation rates.
Progestin-only Contraceptive Options
Progestin-only contraceptives do not contain
estrogen and thus may be good options for young
women who cannot take estrogen.
There are few contraindications to progestin-only
methods:
• current breast cancer (Category 4)
• breast cancer remission within five years, severe
cirrhosis
• malignant liver tumour
• unexplained vaginal bleeding (Category 3)
A) Contraceptive Implant
The single rod implant containing etonogestrel, an
active metabolite of desogestrel, is the most effective
method of reversible contraception with an efficacy
of 99%. It is effective in situ for up to three years,
although it is likely effective for up to four years, and
high continuation rates are seen at one and two
years
B) DMPA
DMPA-IM is an intramuscular injection that is administered every 12 weeks by
a HCP. A lower dose subcutaneous version (DMPA-SC) that can be self-
administered is available in some countries. DMPA inhibits pituitary
gonadotropins, leading to anovulation and causes thickening of cervical
mucous.
Advantages of this method include discretion, infrequent dosing, and non-
contraceptive benefits such as reductions in dysmenorrhea, premenstrual
symptoms, HMB, fibroids, anemia, seizures, and sickle cell crises.
Disadvantages may include having to access a HCP for intramuscular injections,
unscheduled bleeding, delayed return to fertility, and weight gain. Adolescents
using DMPA appear to gain more weight than non-users or users of other
contraceptive methods
C) The Progestin-only Pill (POP)
The POP is taken every day, without a HFI. This
method works via thickening cervical mucous with
anovulation seen in only 50% of user. Adolescents
should be counselled that POP needs to be taken at
the same time every day to avoid pregnancy risk. It
is often used as post-partum contraception when
women are breastfeeding. Users may continue to
have regular cycles, however, unscheduled
bleeding is the most common reason for
discontinuation
Combined Hormonal Contraception
Combined Hormonal Contraception methods contain an
estrogen and a progestin. They include the pill, patch, and
vaginal ring. In the absence of medical contraindications
adolescents can safely use Combined Hormonal Contraception .
Absolute and relative contraindications should be reviewed
prior to initiation.
Common side effects including unscheduled bleeding, nausea,
and headaches, should be discussed with the adolescent prior to
initiation, as this improves continuation
Combined Hormonal Contraception
A. Combined Oral Contraceptive (COC) pills are the most
popular hormonal contraceptives among adolescents.
Typical use failure rate is 9% and is usually secondary to non-
adherence. Adolescents should be counselled on behaviours
to increase contraceptive adherence including: regular
schedule, phone alarm, and family member support.
Adolescents should be provided with resources (paper, app,
online) to assist when pills are missed.
B. The Contraceptive Patch
- should be placed on the buttocks, upper arm, upper
torso, or abdomen once weekly for three weeks. During
the Hormone-Free Interval in the fourth week, a
withdrawal bleed usually occurs. In obese adolescents,
there may be a slightly higher risk of failure with the patch
but obesity is not a contraindication to use of the
contraceptive patch. It can be used continuously for
menstrual suppression if desired.
C. The Vaginal Contraceptive Ring
- is inserted into the vagina by the adolescent and should remain in the
vagina for three weeks (21 days), although pharmacokinetic data indicate
that it is effective for at least 28 days.
- A vaginal ring is a type of hormonal contraception that works in a similar
way to the combined oral contraceptive pill to prevent pregnancy. I
When the ring is removed, the adolescent can choose to have a 4- to 7-day
Hormone-Free Interval or she can insert a new ring immediately to avoid
having a withdrawal bleed. At no time should the Hormone-Free Interval
exceed seven days. The ring can stay in the vagina during sexual intercourse
but if the adolescent does wish to remove it during intercourse, it should not
remain out of the vagina for more than three hours.
