Contraception
Introduction
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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. Photo, left: Jim Varney/Photo Science Library |
Other Names
LARC (long-acting reversible contraceptives)
Oral contraceptive pill (OCP)
Pregnancy prevention
Sexual health
Billing and Coding for Contraception Services
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 11981, Insertion
CPT 11982, Removal
CPT11983, Removal with reinsertion
HCPCS J7307, Etonogestrel implant
CPT 58300, Insertion
CPT 58301, Removal
HCPCS J7298, Levonorgestrel IUD Mirena
HCPCS J7300, Copper IUD
HCPCS J7301, Levonorgestrel IUD Skyla

Prognosis
Education and Access
Sexual Health Counseling at Well-Child Visits
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.
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.
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.
Access to Birth Control
Cost
Confidentiality
Assessment
Current & Past Medical 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

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]
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
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]
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]
Breast examination is not necessary for the safe initiation of contraceptives. [Curtis: 2016]
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
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.
- 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.
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]
Contraindications and Drug Interactions

- 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

With the exception of rifampin, previous concerns about concurrent use of contraceptives and antibiotics are not supported by recent evidence. [Simmons: 2018]
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.
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
Contraception for Adolescents with Special Health Needs

Changing Contraception Methods
Emergency Contraception
Pearls & Alerts
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.
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 vaccines are recommended for males and females from ages 9-26, regardless of sexual activity.
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]
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.
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) ( 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) ( 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) ( 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) ( 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) ( 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) ( 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 | # of providers* in: | NW | Partner states (6) (show) | | ID | MT | NM | NV | RI | UT | |
---|---|---|---|---|---|---|---|---|---|---|---|
Adolescent Medicine | 1 | 1 | 8 | 1 | 2 | 6 | 3 | ||||
Family Medicine | 3 | 68 | 1 | 1 | 7 | 50 | |||||
Gynecology: Pediatric/Adolescent; Special Needs | 2 | 3 | 1 | 21 | |||||||
Obstetrics & Gynecology | 4 | 11 | 78 | 65 |
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
Page Bibliography
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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
Committee on Adolescence.
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
Curtis KM, Tepper NK, Jatlaoui TC, Berry-Bibee E, Horton LG, Zapata LB, Simmons KB, Pagano HP, Jamieson DJ, Whiteman MK.
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Access Barriers to Long-Acting Reversible Contraceptives for Adolescents.
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Consequences of sex education on teen and young adult sexual behaviors and outcomes.
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Sexual Orientation and Risk of Pregnancy Among New York City High-School Students.
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Providing Contraception to Adolescents.
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