Medical Home Portal - Contraception

Introduction

Contraception Counseling for Adescents Including Those with Special Health Needs

The American Academy of Pediatrics (AAP) advises clinicians to counsel adolescent patients about contraception and ensure that they have access to a broad range of contraceptive services. [Division: 2017] [Martinez: 2015]

Rates of sexual activity are estimated to increase from 2% at age 12 to 61% by age 18. [Finer: 2013] Children with special health care needs and chronic illnesses have similar needs for sexual health and contraception. [Committee: 2014]

Most teen pregnancies are unintended and half result from contraception misuse. [Pritt: 2017] Only 4.3% of contraceptive users ages 15-19 use the most effective methods. [Kavanaugh: 2015] Long-acting reversible contraceptives (LARC), which include intrauterine devices (IUDs) and etonogestrel implants, are >20 times more effective than other reversible methods. [Birgisson: 2015] The low use of LARC is a major contributor to high teenage pregnancy rates in the United States. [Dalby: 2014]

Clinicians have a special role in preventing adolescent pregnancy and sexually transmitted diseases (STDs) and providing contraceptive counseling and access.

Other Names

Birth control
LARC (long-acting reversible contraceptives)
Oral contraceptive pill (OCP)
Pregnancy prevention
Sexual health

Billing and Coding for Contraception Services

ICD-10 Coding
Z11.3, Encounter for screening for infections with a predominantly sexual mode of transmission
Z30.0, Encounter for general counseling and advice on contraception
Z30.01, Encounter for initial prescription of contraceptives
Z30.4, Encounter for surveillance of contraceptives
Z70.8, Other sex counseling
Z70.9, Sex counseling, unspecified
Z72.5, High-risk sexual behavior

CPT and HCPCS Coding for Implants
CPT 11981, Insertion
CPT 11982, Removal
CPT11983, Removal with reinsertion
HCPCS J7307, Etonogestrel implant

CP and HCPCS Coding for IUD
CPT 58300, Insertion
CPT 58301, Removal
HCPCS J7298, Levonorgestrel IUD Mirena
HCPCS J7300, Copper IUD
HCPCS J7301, Levonorgestrel IUD Skyla

For further coding details, see the Quick Guide to Coding for Long-Acting Reversible Contraceptives (ACOG) ( PDF Document

187 KB).

Prognosis

Teen pregnancies are associated with adverse outcomes for the mother and baby. Teenage girls especially suffer socioeconomic consequences from pregnancy. One in three adolescent females who didn’t complete high school cite pregnancy or parenting as the reason. Adolescents who drop out are less likely to return to complete their high school diploma or GED, and they are more likely to be unemployed and have lower incomes than their peers who complete high school. [Raidoo: 2015] The Centers for Disease Control and Prevention (CDC) estimate that 20% of teen pregnancies are repeat pregnancies. [National: 2013] Because users of LARC methods are nearly twice as likely to be using their method of contraception at 2 years after initiation than users of alternative methods, providing LARC postpartum can help prevent subsequent teen pregnancies. [Birgisson: 2015]

Education and Access

Contraceptive counseling should occur before onset of sexual activity. The AAP recommends LARC as the first-line method to prevent pregnancy for sexually active teens. [Committee: 2014] To prevent STDs, LARC methods must be augmented by condom use.

Sexual Health Counseling at Well-Child Visits

Sex education is not associated with earlier onset of sexual activity or increased risk-taking behavior. [Lindberg: 2012] Clinicians can encourage abstinence while providing anticipatory guidance and contraceptive access to adolescents considering sexual activity.

Early Adolescence
Early adolescence (generally ages 11-14) begins with the onset of puberty and accompanying physical and emotional changes. Intercourse at this age is uncommon; sexual activity alerts the clinician to an unsafe situation. Introducing sexual health topics at well-child visits begins with the discussion of pubertal changes. To ensure children feel comfortable discussing reproductive health and sexuality, it is important to establish a rapport with the child and their caregivers to facilitate confidentiality (see Confidentiality, below). The clinician can help normalize pubertal changes, encourage abstinence, provide anticipatory guidance, and gauge the teen’s understanding of sex. [Richards: 2016] Involvement of trusted adults to discuss healthy behaviors and relationships with the adolescent is encouraged.

Middle Adolescence
Exploration of identity and independence begins in middle adolescence (generally ages 14-17). Teens typically do not seek sexual health care until after first intercourse, which increases their risk of sexually transmitted infections and unintended pregnancy. Offering teen-friendly resources, like pamphlets and websites written for teens, can encourage independence and help the teen to feel more involved in their care.

Late Adolescence
About 71% of adolescents have had sexual intercourse by age 19. [Richards: 2016] Older teens have likely been exposed to varied information concerning contraception and sexual health. This information can range from current and factual to objectively false. Discuss this with them. Correct any misinformation and reinforce evidence-based information. Ask about goals for the future, specifically plans for starting a family and if this is something they desire. Counsel sexually active teens to always use condoms as a dual method to prevent pregnancy and STDs.

Reproductive health information should be provided to all sexually active adolescents, including gay and lesbian adolescents. Research indicates that these sexual-minority adolescents are at higher risk for pregnancy than their peers due to earlier age of first sexual intercourse and more sexual partners. [Lindley: 2015] Similarly, adolescents with chronic medical conditions or developmental disabilities should receive similar sexual and reproductive health information, though it may need to be adapted to their developmental level. [Committee: 2014]

Access to Birth Control

Most contraceptives require initiation by a physician through prescription, administration, or insertion. This can be a barrier for adolescents who rely on guardians to access a clinician's care. Other barriers are costs, misconceptions about eligibility, and lack of insertion training. [Zieman: 2016] Barriers to costs are addressed below, barriers to lack of training can be addressed by seeking out evidence-based recommendations for providing contraception and attending LARC training.

Cost

The 2010 Affordable Care Act requires private insurers to cover FDA-approved contraceptive methods and contraceptive counseling at no cost to the patient when delivered by a network provider; however, states define family planning benefits and regulate payments made to providers and insurers. Low-cost and free contraception may be available at Title X family planning clinics, which can be found at Find a Family Planning Clinic (HHS).

Cost for Contraception as of March 2018

Confidentiality

Minors with private insurance coverage must abide by state laws, which may require parental consent. The Health Insurance Portability and Accountability Act (HIPAA) allows parents to access a child’s health records unless state law prohibits disclosure or the parent agrees to let their child receive confidential care. [Kumar: 2016]

Confidentiality may be breached when an explanation of benefits is sent to the insured. This breach can only be avoided by paying out of pocket, which may be impossible for adolescents given the high, up-front cost of LARC. [Kumar: 2016] Refer to a local Title X clinics, like Planned Parenthood, when privacy is a concern; federal regulations allow minors covered by Medicaid to consent for contraceptive services at these clinics.

The AAP recommends that pediatricians discuss confidentiality with patients and parents when appropriate. [Committee: 2014] Clinicians must be familiar with local laws regarding confidentiality for minors. [Society: 2016] The U.S. State Policies about Confidentiality for Individuals Insured as Dependents (Guttmacher Institute) is updated monthly. Clinicians may consider establishing clinic policies that are compliant with local regulations and protect an adolescent’s right to access confidential reproductive health care.

Assessment

Current & Past Medical History

It is important to ask adolescents directly about sexual activity. The CDC recommends using The Five P's (CDC) to take a thorough sexual history:

Partners: Ask about the number and gender of current and past sexual partner. Do not make assumptions based on sexual preference or gender identity.
Practices: Ask about sexual contact (anal, oral, vaginal).
Protection: Ask about condom use.
Past STDs: Ask about past diagnoses, treatments, and current symptoms for both the patient and partner.
Prevention: Ask about plans for pregnancy and use of contraception.

Comorbid Conditions

A detailed HEADSS Assessment ( PDF Document

72 KB) (Home, Education, Activities, Drugs, Sexuality, Suicide) can alert the clinician to risky behaviors and unsafe situations associated with sexual activity, such as abuse and substance use. [Zieman: 2016]

Sexually Transmitted Infections
Although adolescents and young adults (15-24 years of age) in the United States account for only 1/4 of the sexually active population they acquire 1/2 of new STDs. [Satterwhite: 2013]

Abuse
Children with a history of abuse or neglect are more likely to initiate sexual activity at a younger age and have more pregnancies than their peers. [Negriff: 2015] A history of abuse alerts the clinician to the possibility of risky sexual behavior. For children 14 years old and younger, intercourse is uncommon and alerts the clinician to the possibility of abuse. [Richards: 2016] Additionally, children of substance abusers are more likely to engage in risky sexual behavior. [Skinner: 2014] The Portal's Substance Use Disorders provides assessment and management information.

Physical Exam

Vital Signs
Do not use contraceptives containing estrogen in adolescents with a systolic pressure of ≥160 mmHg, diastolic pressure of ≥100 mm Hg, or vascular disease. [Curtis: 2016]

Weight
Screening for obesity is not necessary for the safe initiation of contraceptives. Calculating baseline BMI may be helpful for monitoring changes if the adolescent is concerned about weight change perceived to be associated with their contraceptive method. [Curtis: 2016] Obesity is not a contraindication to emergency contraceptive use, though some studies suggest a BMI >30 may increase the risk of pregnancy when taking levonorgestrel emergency contraceptive pills or ulipristal acetate. [Curtis: 2016]

Chest
Breast examination is not necessary for the safe initiation of contraceptives. [Curtis: 2016]

Genitalia
A pelvic exam is not indicated for initiation of contraception except in presence of abnormal discharge, bleeding, or pelvic pain. [Raidoo: 2015] A pelvic exam is necessary for IUD insertion to assess for uterine size, position, and any cervical or uterine abnormalities that may prevent insertion. [Curtis: 2016]

Testing

Pregnancy
Testing for pregnancy is not necessary before initiating contraception, but it is good practice, particularly for patients who may not be accurate historians. It is strongly recommended to perform a pregnancy test before inserting anything into the uterus.

The following considerations can help clinicians be reasonably certain a woman is not pregnant if she has no symptoms of pregnancy: [Curtis: 2016]

It has been <7 days after start of normal menses.
It has been <7 days after spontaneous or induced abortion.
The woman has not had sexual intercourse since start of last normal menses.
The woman has been correctly and consistently using a reliable method of contraception.
The woman is within 4 weeks postpartum.
The woman is fully or nearly fully breastfeeding and <6 months postpartum.

Sexually Transmitted Infections
Screen all sexually active adolescents annually for chlamydia and gonorrhea. If test results are positive, treatment with IUD in place is recommended. Do not insert IUDs in women with current purulent cervicitis or chlamydial infection or gonococcal infection. [Curtis: 2016]

Screening for syphilis, HIV, and hepatitis C is based on risk factors. [Zieman: 2016] In-depth screening guidelines can be found at Sexually Transmitted Diseases: Screening Recommendations and Considerations (CDC).

HPV and PAP testing are not recommended for women <21 years of age. [Saslow: 2012]

Contraindications and Drug Interactions

Most contraceptive methods are safe for use by all women. The Medical Eligibility Criteria for Contraceptive Use (CDC) ( PDF Document

170 KB) groups contraceptive methods into categories that indicate safety when used by women with specific health conditions. [Curtis: 2016] The categories are:

MEC 1: No restriction for the use of the contraceptive method
MEC 2: Advantages of using the method generally outweigh the risks
MEC 3: Risks usually outweigh the advantages of using the method
MEC 4: Unacceptable health risk if the contraceptive method is used

The MEC is accessible in a free app from the CDC and shows contraindications sorted by both method and medical condition. Links to download the app can be found in the Downloads and Resources section of Medical Eligibility Criteria for Contraceptive Use (CDC) ( PDF Document

170 KB). A summary of contraindications for contraception use is listed in the following table.

Contraindications

Oral Contraceptives and Antibiotics
With the exception of rifampin, previous concerns about concurrent use of contraceptives and antibiotics are not supported by recent evidence. [Simmons: 2018]

Oral Contraceptives and Rifampin
A clinically concerning drug interaction between oral contraceptive pills and rifampin and rifabutin has been found, though data are limited for other rifamycins. [Simmons: 2018] The CDC categorizes oral contraception interactions with rifampin and rifabutin as risks usually outweigh the advantages of using the method.

Interactions with Antiepileptic Drugs
Most drug-drug interactions are due to distinct mechanisms, making them predictable and avoidable. Antiepileptic drugs and most contraceptives, particularly oral and combined hormonal contraceptives, are metabolized by the liver, affecting effectiveness of both. Antiepileptic drugs regarded as compatible for use with oral contraception are valproate, gabapentin, levetiracetam, zonisamide, and lacosamide. [Reimers: 2015] Antiepileptic drugs that may increase the risk of unplanned pregnancy with oral contraception are carbamazepine, lamotrigine, phenobarbital, and phenytoin. [Reimers: 2015] These drugs, in addition to oxcarbazepine, topiramate, and primidone are rated as MEC 3 - risks usually outweigh the advantages of use. [Curtis: 2016]

Management

Initiating Contraception

Adolescents are eligible for all contraceptive methods, regardless of pregnancy history. [Zieman: 2016] All contraceptive methods can be started on the day of visit, regardless of menstrual cycle timing, if the clinician is reasonably sure the patient is not pregnant. If a patient desires LARC and is unable to receive it that day due to cost or privacy concerns, it is acceptable to use either combined hormonal contraceptives or depot medroxyprogesterone acetate injection (DMPA) until LARC can be inserted. Wait 5 days to start birth control methods containing progesterone for women who have used the emergency contraceptive ulipristal acetate. [Apter: 2017]

The following tables can be useful in educating the adolescent about birth control choices. Cost of contraception (listed above in the Access section) and privacy issues (discussed above in the Access section) may also be a consideration.

Considerations for the Initiation of Contraception

[Curtis: 2016] [Zieman: 2016]

Common Side Effects

[Curtis: 2016] [Zieman: 2016]

Contraception for Adolescents with Special Health Needs

Contraception for adolescents with special health needs requires consideration of physical and mental developmental status. Certain medical conditions or medications (including some over-the-counter and "natural" medicines) may be less compatible with certain types of contraception. See the Medical Eligibility Criteria for Contraceptive Use (CDC) ( PDF Document

170 KB) for details about medical conditions and medications that pose risks to contraceptive use.

Hormonal contraception may be used to help manage hygiene in adolescent girls. See Menstrual Management for Adolescents with Disabilities (AAP) for more discussion about menstrual management in adolescents with disabilities. [Quint: 2016]

The medical home clinician should be aware that surgical methods of contraception, such as sterilization through tubal ligation and hysterectomy, have significant ethical and legal considerations; relevant laws vary by state. Consider referral to a gynecologist with experience in this area. Recognize the increased risk of abuse in children and adolescents with special health care needs.

Changing Contraception Methods

For more details on switching between methods, initiating contraception postpartum, postabortion, or while breastfeeding, see U.S. Selected Practice Recommendations for Contraceptive Use (CDC).

Emergency Contraception

Levonorgestrel emergency contraceptive pills are available to all women of all ages without a prescription. When prescribing combined hormonal contraceptives, it is good practice to provide a prescription for ulipristal acetate or to encourage advance purchase of the levonorgestrel emergency contraceptive pill to ensure timely use, if needed.

Emergency Contraception Methods

[Curtis: 2016] [Zieman: 2016]

Pearls & Alerts

Adolescents with Special Health Care Needs
Adolescents with chronic illnesses and those with physical or mental disabilities have sexual health and contraceptive needs similar to their peers and require the same education and care in a developmentally appropriate context. These children are at increased risk of abuse.

At-Risk Youth
Stressful situations in childhood, such as being raised by a single parent and exposure to community or domestic violence, are associated with higher rates of sexual activity among minors. School attendance has been found to be protective. [Brahmbhatt: 2014]

HPV Vaccine
HPV vaccines are recommended for males and females from ages 9-26, regardless of sexual activity.

Bone Mineral Density
While there has been some concern in the past about the effect that depot medroxyprogesterone acetate (Depo-Provera) has on bone mineral density, the effect has been found to be reversible. [Committee: 2017]

Over-the-Counter Contraception
Emergency contraception, such as Plan B One-Step, is available without a prescription and do not require identification to purchase. Condoms may be obtained over the counter at any age.

Contraception to Treat Irregular Bleeding
To treat irregular bleeding, consider NSAIDs for 5-7 days during bleeding days and combined oral contraceptives or estrogen for 10-20 days.

Resources

Information & Support

For Professionals

Adolescent Reproductive and Sexual Health Education Program (PRH)
Education for professionals about best practices related to adolescent reproductive and sexual health; Physicians for Reproductive Health.

Center for Adolescent Health and Law
Promotes health care for adolescents, writes about the implications of the Affordable Care Act for adolescents and young adults, and publishes (for a fee) detailed information about state laws that allow minors to consent for their own health care.

Providing Quality Family Planning Services (CDC)
Recommendations for providers about what should be offered in a family planning visit, how these services should be provided, which services are available for special populations, and ways to use the family planning visit to provide selected preventive health measures; Centers for Disease Control and Prevention.

Quick Guide to Coding for Long-Acting Reversible Contraceptives (ACOG) ( PDF Document 187 KB)
CPT and ICD-10 coding details for reimbursement of contraceptive services; American Congress of Obstetricians and Gynecologists (updated August 2016).

Menstrual Management for Adolescents with Disabilities (AAP)
Information for clinicians in assisting with the pubertal transition and menstrual management; American Academy of Pediatrics / Pediatrics (July 2016).

U.S. Selected Practice Recommendations for Contraceptive Use (CDC)
Recommendations for health care providers from the July 29, 2016 / 65(4);1–66 Morbidity and Mortality Report from the Centers for Disease Control and Prevention.

For Parents and Patients

All about Birth Control (Planned Parenthood)
Information about the effectiveness, safety, and use of most birth control methods.

Sex, Health, and You (teensource.org) ( PDF Document 179 KB)
A 2-page handout about birth control, sexually transmitted diseases, relationships with family and peers, and teen rights surrounding reproductive care.

Talk With Your Kids Timeline (talkwithyourkids.org) ( PDF Document 73 KB)
A guide for parents about talking with your child at different ages about safety, relationships, puberty, and reproductive health.

Planned Parenthood for Teens (Planned Parenthood)
Information about relationships, your body, and sexual health.

Sex, etc.org
Information about sex by teens for teens.

Practice Guidelines

Committee on Adolescence.
Contraception for adolescents.
Pediatrics. 2014;134(4):e1244-56. PubMed abstract / Full Text

Patient Education

You and Your Sexuality (ACOG) ( PDF Document 82 KB)
Information that ranges from emotions and attraction to anal sex and rape; American College of Obstetricians and Gynecologists.

Your First Gynecologic Visit (ACOG) ( PDF Document 162 KB)
Learn about what to expect when getting a pelvic exam or Pap test; American College of Obstetricians and Gynecologists.

Tools

Find a Family Planning Clinic (HHS)
Search by city, state, or zip code to find a Title X family planning clinic; U.S. Health and Human Services.

Medical Eligibility Criteria for Contraceptive Use (CDC) ( PDF Document 170 KB)
A chart with potential restrictions for contraception use, which was last updated in 2017; Centers for Disease Control and Prevention.

Sexually Transmitted Diseases: Screening Recommendations and Considerations (CDC)
Recommended screening for ages 15-65 from the 2015 Sexually Transmitted Diseases Treatment Guidelines by the Centers for Disease Control and Prevention.

Services for Patients & Families Nationwide (NW)

Service Categories	NW		ID	MT	NM	NV	RI
Adolescent Medicine	1	1	8	1	2	6	2
Family Medicine		5	68	1	1	8	53
Gynecology: Pediatric/Adolescent; Special Needs		2	3			3	19
Obstetrics & Gynecology		4	13	74			50

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

Committee on Adolescent Health Care.
ACOG Committee Opinion no. 598: The initial reproductive health visit.
Obstet Gynecol. 2014;123(5):1143-7. PubMed abstract / Full Text

Curtis K, Jatlaoui T, Tepper N, et al.
Morbidity and Mortality Weekly Report (MMWR): U.S. Selected Practice Recommendations for Contraceptive Use.
Centers for Disease Control and Prevention. 65(4);1–66; July 29, 2016. / https://www.cdc.gov/mmwr/volumes/65/rr/rr6504a1.htm

Marcell AV, Burstein GR.
Sexual and Reproductive Health Care Services in the Pediatric Setting.
Pediatrics. 2017;140(5). PubMed abstract

Committee on Adolescent Health Care.
Committee Opinion No. 710: Counseling Adolescents About Contraception.
Obstet Gynecol. 2017;130(2):e74-e80. PubMed abstract

Raidoo S, Kaneshiro B.
Providing Contraception to Adolescents.
Obstet Gynecol Clin North Am. 2015;42(4):631-45. PubMed abstract

Authors & Reviewers

Initial publication: August 2018

Current Authors and Reviewers:

Author:	Rebekah Birdsall, DNP-WHNP
Contributing Author:	Jennifer Goldman-Luthy, MD, MRP, FAAP

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Contraception options: Aspects unique to adolescent and young adult.
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Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review.
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Brahmbhatt H, Kågesten A, Emerson M, Decker MR, Olumide AO, Ojengbede O, Lou C, Sonenstein FL, Blum RW, Delany-Moretlwe S.
Prevalence and determinants of adolescent pregnancy in urban disadvantaged settings across five cities.
J Adolesc Health. 2014;55(6 Suppl):S48-57. PubMed abstract / Full Text

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Contraception for adolescents.
Pediatrics. 2014;134(4):e1244-56. PubMed abstract / Full Text

Committee on Adolescent Health Care.
Committee Opinion No. 710: Counseling Adolescents About Contraception.
Obstet Gynecol. 2017;130(2):e74-e80. PubMed abstract

Curtis K, Jatlaoui T, Tepper N, et al.
Morbidity and Mortality Weekly Report (MMWR): U.S. Selected Practice Recommendations for Contraceptive Use.
Centers for Disease Control and Prevention. 65(4);1–66; July 29, 2016. / https://www.cdc.gov/mmwr/volumes/65/rr/rr6504a1.htm

Curtis KM, Jatlaoui TC, Tepper NK, Zapata LB, Horton LG, Jamieson DJ, Whiteman MK.
U.S. Selected Practice Recommendations for Contraceptive Use, 2016.
MMWR Recomm Rep. 2016;65(4):1-66. PubMed abstract

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Adolescent pregnancy and contraception.
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Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention.
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Changes in Use of Long-Acting Reversible Contraceptive Methods Among U.S. Women, 2009-2012.
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Kumar N, Brown JD.
Access Barriers to Long-Acting Reversible Contraceptives for Adolescents.
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Lindley LL, Walsemann KM.
Sexual Orientation and Risk of Pregnancy Among New York City High-School Students.
Am J Public Health. 2015;105(7):1379-86. PubMed abstract / Full Text

Martinez GM, Abma JC.
Sexual Activity, Contraceptive Use, and Childbearing of Teenagers Aged 15-19 in the United States.
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Providing Contraception to Adolescents.
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Update on Adolescent Contraception.
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