Contraception for teenagers

Abstract

The majority of the UK population becomes sexually active in their teenage years. At that point, many present anxiously to their GP for advice, contraception or with an unplanned pregnancy. This article considers our legal and ethical responsibilities, special considerations in history taking, a young person’s health concerns and the declining, but still significant, incidence of teenage unplanned pregnancy.

The GP curriculum and contraception for teenagers

Clinical module 3.06: Women’s health requires GPs to:

Describe the legislation relevant to women’s health (e.g. abortion, contraception for minors)

Appreciate the definition of sexual health as being about the ‘enjoyment of the sexual activity you want without causing yourself or anyone else suffering or physical or mental harm’. It is also about contraception and avoiding infection

Know when urgent intervention is needed in sexual health and, if necessary, refer appropriately, e.g. in the provision of emergency contraception

Legal and ethical considerations

The age of consent to sexual activity in the UK is 16 years; however, around one-third of teenagers will already then be sexually active. Although unlawful, mutually agreed sexual activity between persons of similar age will not typically result in prosecution, unless there is evidence of abuse or exploitation. In England, Wales, and Northern Ireland, those under 13 years in age are considered unable to consent to sexual intercourse. In Scotland, sexual activity with a person under 13 years of age is regarded as ‘rape of a young child’ (Faculty of Sexual and Reproductive Healthcare (FSRH), 2010a).

Confidentiality

Respecting confidentiality is a cornerstone of good medical practice. Young people should be assured that the same duties of confidentiality apply to them. However, there are some exceptions. Information relating to sexual activity of under 13 year olds should usually be discussed with a designated doctor for child protection, and this must be documented. Where abusive or harmful sexual activity is suspected (Box 1), information can be disclosed to either the police or social services in order to safeguard the young person. Further guidance is available in the General Medical Council (GMC) publication, ‘0–18 years: Guidance for all doctors’ (GMC, 2007).

Box 1.

Examples and indicators of an abusive or harmful sexual activity.

• When a young person is too immature to understand or consent

• If there are significant differences in age, maturity or power between sexual partners

• If the young person’s sexual partner holds a position of trust or authority

• Use of force or the threat of force, emotional or psychological pressure

• Bribery or payment, either to engage in sexual activity or to keep it secret

• Drugs or alcohol used to influence a young person to engage in sexual activity

• Any involvement of someone known to the police or child protection agencies as having had abusive relationships with children or young people.

Reproduced from GMC (2007) . 0–18 years: Guidance for all doctors. Copyright GMC.

Consent

In UK law, any competent young person can consent to medical treatment. Young people over 16 years in age are presumed to be competent unless otherwise demonstrated. For those under 16 years in age, competence to consent must be demonstrated. The elements required to demonstrate capacity are summarised in Box 2 (British Medical Association (BMA), 2016).

Box 2.

Capacity.

Capacity is demonstrated if a young person can:

• Understand what the medical treatment is; the aim of treatment, why it is indicated and what the treatment involves

• Understand the potential risk/benefits and alternatives

• Understand the consequences of not receiving treatment

• Retain this information and evaluate it to make an informed decision

• Communicate this information

Source: BMA (2016) .

The GMC states (also known as the Fraser guidelines) that you can provide contraceptive, termination and sexually transmitted infection (STI) advice and treatment, without parental knowledge or consent, to young people under 16 years in age, provided that the criteria summarised in Box 3 are met (GMC, 2007). The Fraser guidelines were described by Lord Fraser in his judgement in the case of Mrs Victoria Gillick, who took her local health authority and Department of Health and Social Security to court in an attempt to prevent health professionals giving contraceptive advice or treatment to those under 16 years in age without parental consent. Meeting these criteria is often referred to as ‘Gillick competence’.

Box 3.

Fraser guidelines.

Apply when:

• The individual understands all aspects of the advice and its implications

• You cannot persuade the young person to tell their parents or to allow you to tell them

• In relation to contraception and STIs, the young person is very likely to have sex with or without such treatment

• Their physical or mental health is likely to suffer unless they receive such advice or treatment

• It is in the best interests of the young person to receive the advice and treatment without parental knowledge or consent.

In Scotland, the Fraser guidelines and ‘Gillick competence’ are often discussed; however, they have no authority in Scottish Law. Scottish legislation states the only criterion for consent is that the child understands the nature and consequence of treatment (BMA, 2016).

If you have concerns regarding a young person, advice should be sought from colleagues, local child protection leads and your medical defence organisation. It is good clinical practice to tell the young person that you are going to share information with another agency.

Availability

Contraception is available from a range of sources: specialist family planning clinics, GPs, specialist outreach clinics at young people’s centres (varies with geographic location). We should ensure services are convenient and accessible to young people in terms of timing and location (as they may wish to come alone after school). Approachable, friendly, non-judgemental staff are the key to providing effective contraception services. This positive approach to sexual health from health professionals improves patient self-esteem, motivation and achievement.

History taking

Presenting to the GP to discuss contraception can be a daunting experience for any young person. Often they may have never met the GP before, and be shy and embarrassed discussing sex. They may attend with a parent or alone. If accompanied it is good practice to ask if they would like to discuss anything alone. Open questions such as ‘Tell me about your partner?’ or ‘Tell me about your relationship?’ can enhance discussions and help establish the ideas, concerns and expectations of the young person. Closed questions can be used to clarify essential information, but avoid the consultation becoming an inquisition is crucial to establishing a therapeutic relationship and promoting a healthy sex life. Areas to cover in history-taking are covered in Box 4 (FSRH, 2010a). Open questions can be used to check understanding such as, ‘What would you do if you miss a pill?’; checking understanding is the key to promoting compliance and preventing unwanted pregnancies.

Box 4.

History taking.

• Sexually active?

• Using any contraception?

• Last menstrual period? Unprotected sexual intercourse since?

• In relationship? (Who with? How met? Age? Gender? How long?)

• Other partners?

If not sexually active already

• Do you feel ready? Do you feel you could say no if you wanted to?

• Have you discussed with partner (Ideas, concerns and expectations)

• Any discussions with friends/family/carer/teacher

Social history

• School/college/working

• Who lives at home? Who provides support/advice?

• Do your parents/carers know +/− will you tell them

Medical history

• Diabetes/epilepsy/inflammatory bowel disease

• Smoking/alcohol/non-prescription drugs/weight

• Prescribed medications (anti-epileptics, anti-migraine medications)

• Family history (VTE, heart disease, breast cancer)

• Human papillomavirus vaccine

Contraception

• Awareness of different options

• Will you remember to take a pill ever day?

• Know how to use/access condoms?

• Previous pregnancies/STIs

Sexual history

• Penetrative sites – condoms/screen STIs

• Ever been forced to have sex?

• Any partners ever rewarded you with clothes, food, money, alcohol, drugs for having sex?

Follow-up

• Repeat prescriptions

• Nexplanon/Intra-uterine system checks

• Accessing advice (e.g. missed pills)/emergency contraception

Adapted from FSRH (2010a) .

Contraceptive choices

In 2008–09, 43% of sexually active women aged between 16 and 19 years were not using any contraception. Of those that were, the most common choices were contraceptive pill (54%) and condoms (65%) (respondents were allowed more than one response) (Office for National Statistics, 2009).

Prior to menarche, condoms are the recommended contraceptive choice. Progestogen-only emergency contraception can be prescribed pre menarche if required (FSRH, 2010a). After menarche, young women can choose their preferred method of contraception provided there are no medical contraindications (United Kingdom Medical Eligibility Criteria (UKMEC), 2016).

Patients present with wide variation in contraceptive knowledge and preferences. Time should be spent establishing baseline information without presuming young people are aware of all contraception choices. Factors influencing contraceptive choices include effectiveness, anecdotal advice, safety, side-effect profile, discreetness, self-control, understanding of method, accessibility, ease of compliance. We should be mindful that our own assumptions on contraception or the views of practitioners providing specific services (such as implant or coil fitting) do not impede the consultation. For example, some practitioners prefer not to fit intrauterine devices in nulliparous women but there is no contraindication. Each individual woman should be given the full choice of contraceptive options unimpeded by false assumptions about what patients may or may not want.

Long-acting reversible contraception (LARC) options are less user-dependent and have lower failure rates. As such, these should be discussed and highlighted with young people. For example, with typical use oral contraceptives are associated with a 9% failure rate and condoms with an 18% failure rate compared with 0.05% for a progestogen-only implant (UKMEC, 2016). Real-size demonstration models of implants and coils may be useful to some patients during the consultation. Some patients may wish to take time to consider their options. These patients should be offered patient information leaflets or advised about online resources such as the Family Planning Association (www.fpa.org.uk/) or Brook (www.brook.org.uk/your-life/category/contraception). Patients may have individual preferences shaped by access to information. A review appointment to review choices, perhaps with partner or parent/carer may be appropriate. Where there are concerns that a patient may not re-present, consider ‘quick starting’ as discussed later in this article.

Young people’s health concerns and risks

Increasing use of social media by young people may bring heightened exposure to claims of side effects and risks associated with contraception use. We will discuss common health anxieties and current evidence to help us educate patients and facilitate decision-making.

Thrombosis

Recent publicity has again highlighted the venous thromboembolism (VTE) risk with combined hormonal contraception (CHC). Young people should be aware that there is a slightly increased risk, although absolute risk remains very small (5-12 per 10 000 women years). An individual may already be at an increased VTE risk, due to immobility, obesity, pre-existing medical conditions or family history and therefore CHC may be contraindicated. Specific guidelines are available in UKMEC (FSRH, 2010a; UKMEC, 2016)).

Weight gain

Patients can be reassured that some weight gain during reproductive years is normal, and is associated with eating and lifestyle changes. There is no clear evidence that CHC use promotes weight gain. Depot medroxyprogesterone acetate (DMPA) may be associated with a 2–3 kg weight gain over a 1-year period; the effect is greatest in those with a body mass index greater than 30 kg/m² pre-treatment. Other progestogen-only methods are not associated with weight gain (FRSH, 2010a).

Acne

Acne is common in the teenage population. CHC may improve acne. If there is no improvement consider switching to a less androgenic progestogen or a higher oestrogenic content. Co-cyprindiol combines a higher oestrogen component with less androgenic progestogen; it is licensed for severe acne that has not responded to antibiotics, it is not licensed for contraception alone. Patients prescribed co-cyprindiol should have clear documentation of discussion of higher VTE risk and should be reviewed regularly. Studies suggest the VTE risk is 1.5 to 2 times higher with co-cyprindiol than CHCs with levonorgestrel, but similar to the risks associated with third-generation progesterones (Medicines and Healthcare products Regulatory Agency, 2013). Treatment should be discontinued 3 to 4 months after the condition has resolved. The progestogen-only implant may be associated with an improvement, worsening or onset of acne. Acne is not associated with DMPA, but there is a slight increase in acne reported with the use of an intra-uterine system (IUS) (FSRH, 2010a).

Mood changes

Mood changes are subjective and individual. There is no evidence that hormonal contraception causes depression, however, in clinical practice, mood changes are associated with discontinuation of the CHC and progesterone-only pill (POP) (FSRH, 2010a).

Fertility

Only DMPA is associated with a delay in return of fertility for up to 1 year after discontinuation of DMPA. There is no delay in return of fertility with CHC, POP, progestogen-only implant and IUS methods (FSRH, 2010a).

Altered bleeding patterns

Pre-treatment counselling should involve discussion of menstrual changes. This can reduce patient distress and reduce subsequent consultations rates. Altered bleeding is common with progestogen-only methods and should be highlighted. CHC is beneficial in treating dysmenorrhoea and allows some control of bleeding by omitting the pill-free period. Altered bleeding on CHC may be more clinically significant, as it may be associated with missed pills, STIs and malabsorption (FRSH, 2010a). Guidance on unscheduled bleeding in women using hormonal contraception is available from FRSH (Royal College Obstetrics Gynaecology (RCOG), 2009).

Bone density

A Cochrane review concluded that CHC did not affect bone mineral density (BMD), but that DMPA may reduce BMD. This is of greatest concern in women under 18 years of age who may not have reached peak bone mineral mass. The small loss in BMD is usually recovered after discontinuation. The FRSH concludes that the DMPA may be considered for use by patients under the age of 18 years after all other options have been discussed or trialled and found to be unsuitable or unacceptable (FSRH, 2010a).

Cancer

CHC is not associated with an overall increased cancer risk. There may be a very small increased risk in cervical cancer with prolonged CHC use and a small increased risk of breast cancer, but the risk of breast cancer reduces after stopping treatment. The risk of ovarian and endometrial cancer is slightly reduced (FSRH, 2010a).

Follow-up

When initiating contraception, a 3-month review appointment should be offered. This gives an opportunity to address side effects, questions they have been too embarrassed to discuss and health promotion. Review may also improve compliance and reduce contraceptive failure rate. This is also an opportunity to discuss condoms and STI risk/screening.

Quick starting

Young people may be offered ‘quick starting’, which involves starting the oral contraceptive immediately instead of waiting until the start of their next menstrual period. This may be continued indefinitely or used as a bridging method until a LARC appointment can be scheduled. It may be used after emergency contraception. Patients should be counselled to use barrier methods until their contraceptive becomes active. Further detailed clinical information about quick starting and other contraceptive types is available from FRSH (FSRH, 2010b).

Emergency contraception

In 2008–09 17% of women aged between 16 and 19 years had used emergency contraception at least once in the preceding year (Office for National Statistics, 2009). Unfortunately, more recent figures are unavailable due a change in the way the information is recorded (general practice data is not included).

Education and accessibility are crucial. In 2008–09, 88% of respondents aged between 16 and 19 years were aware of emergency hormonal contraception, and 55% were aware of the IUD option (Office for National Statistics, 2009). We must aim to enhance patient awareness of the availability of emergency contraception, to promote early presentation and limit unwanted pregnancies. A summary of the key points about emergency contraception is shown in Box 5. All methods of emergency contraception, including the copper coil, should be made available to young people. Accessibility is crucial when designing contraception services, with consideration being given to removing barriers. Examples include: phone appointments, after-school appointments, pharmacy services and clinics on bus routes. Such initiatives ensure that those who need these services can access them.

Box 5.

Emergency contraception.

Copper IUD

• First line, prevents 99% expected pregnancies

• 120 hours after unprotected sexual intercourse or up to 5 days after earliest expected date of ovulation

• Preferred method for women on enzyme-inducing drugs

• May be access issues as needs trained fitter to insert

Levonorgestrel/Levonelle

• Available in pharmacies

• May be used more than once a cycle

• Licensed 72 hours (more effective sooner given)

Ulipristal acetate (ellaOne)

• Up to 120 hours

• Cannot give more than once/cycle

• Binds to progesterone receptors, so need barrier contraception for up to 16 days after

• Not effective if on proton pump inhibitors/enzyme inducers

Source: FSRH (2010a) .

Any women presenting after an episode of unprotected sexual intercourse should be advised to have STI tests at 2 and 12 weeks. Opportunistic discussion of condom use/accessibility and contraception can help prevent further presentations. Condoms can be offered during the consultation.

Teenage pregnancy

Enhanced sexual health education and improved access to services promoted by the Government’s Teenage Pregnancy Strategy are thought to have contributed to the reduction in teenage pregnancy rates. Societal changes with increased educational and working aspirations of young women and the stigma associated with teenage pregnancy have also provoked change. In England and Wales, in 1998 the conception rate in under 18 year olds was 46.6 per 1000, whereas in 2015, the estimated number of conceptions to women aged between15 and 17 years was 21 per 1000 women, a reduction of 55% (Office for National Statistics, 2017). The number of teenage mothers in education, employment or training has risen from 22% to 33% (Department of Health, 2010).

In Scotland, teenage pregnancy rates continue to reduce; from 7.8 per 1000 in 2007 to 4.2 in 2014 for under 16 year olds and from 41.9 per 1000 in 2007 to 22.1 in 2014 for under 18 year olds. Termination rates in the under-16-year age group remain higher than the delivery rate (Information Services Divisions, 2016). These figures remain higher than most of Western Europe.

Although the rate of teenage pregnancy is declining, many young people will present with an unplanned pregnancy. Risk factors for teenage pregnancy are included in Box 6, most are relatively unmodifiable for the individual.

Box 6.

Risk factors for teenage pregnancy.

• Teenage parent

• Social deprivation

• Homeless

• Been in care or currently in care

• School underachievers

• Crime involvement

Source: Department of Health (2010), Office for National Statistics (2017).

When a young person presents pregnant, a discussion of ideas, concerns and expectations, partner involvement, parent/carer involvement and their options is important. Although there are significant adverse events associated with teenage pregnancies (Table 1) avoid promoting the feeling that this is ‘the worst thing ever’; it does not have to to mean ‘game over’ for their own life and aspirations. This can be achieved with supportive, non-judgemental communication and understanding of the patient’s perspective.

When patients present after unprotected sexual intercourse, a negative pregnancy test or for contraception advice, the consultation is an important opportunity to discuss the risks of teenage pregnancy. For those who do present pregnant, positive support of patients’ decision-making is needed. If patients decide to continue with the pregnancy, positive, early engagement with health services can prevent or minimise many of the potential adverse effects of teenage pregnancy.

Table 1.

Adverse effects of teenage pregnancy.

Teenager	Child	Wider family
• Increased risk of anaemia, eclampsia • Increased risk of post-natal depression • Limits education/career prospects • Increased risk of poverty/social isolation	• Poor antenatal care (late bookers) • Low birth weight • Increased perinatal mortality • Sudden infant death syndrome • Increased risk of becoming a teenage parent • Increased risk of poverty	• Stigma • Financial implications • Impact of raising a grandchild

Source: Department of Health (2010), Office National Statistics (2015).

Key points

Presenting to the GP can be a daunting experience for any young person wanting to discuss contraception and requires the GP to have particular awareness, knowledge and skills

Contraceptive options for young people post menarche are the same as for all women, but careful attention is needed when gathering information and giving advice

Special vigilance is required to identify young people in need of advice on sexual health and contraception

Routine consultations about contraception provide an opportunity to promote a healthy sex life and to discuss STIs and the risks of teenage pregnancy

It is important not to assume prior knowledge of contraceptives when giving advice and to confirm knowledge and understanding

Young people may have particular worries about the specific side effects and risks of contraception that need to be explored and addressed

References

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Department of Health. (2010). Teenage pregnancy strategy: Beyond 2010. Retrieved from www.education.gov.uk/consultations/downloadableDocs/4287_Teenage%20pregnancy%20strategy_aw8.pdf.

FSRH. (2009). Management of unscheduled bleeding in woman using hormonal contraception. Retrieved from www.rcog.org.uk/globalassets/documents/guidelines/unscheduledbleeding23092009.pdf.

FSRH. (2010a). Contraceptive choices for young people. Retrieved from www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-young-people-mar-2010/.

FSRH. (2010b). Quick starting contraception. Retrieved from www.fsrh.org/standards-and-guidance/documents/ceuguidancequickstartingcontraception.

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