Through much of my career the standard approach to contraception for adolescents had been to offer birth control pills and barrier methods (condoms). Intrauterine devices (IUD) were avoided because of concerns about their potential impact on future fertility. In the last decade or so progesterone injections, which offer protection for 3 months at a time, and contraceptive patches have added important options for young women. In the 1990s an implantable form of contraception was introduced. It was highly effective but it consisted of 7 thin capsules and implanting and removing took some time and skill.
All of these options are highly effective when properly used, but notwithstanding that fact almost half of the 6.7 million pregnancies in the US are unplanned and unintended. That proportion is even higher among teens and young women (in their 20s), in minority groups and in women with less education. Of those unplanned pregnancies, fully half occur in women using contraception (but using it ineffectively).
The emotional, social and financial impact of an unplanned pregnancy can be devastating and enduring, so measures to improve contraceptive effectiveness and to allow for emotional maturation, social and financial stabilization and intentional family planning are very important. Long Acting Reversible Contraception (LARC) is an important new approach to this challenge. LARC methods include IUDs (copper IUD good for 10 years of contraception and hormonal IUDs good for 5 years of contraception) and a new hormonal implant (a single thin capsule the size of a matchstick implanted under the skin of the upper arm and good for 3 years of contraception). Well done studies have shown that LARC methods offer safe and more highly effective contraception for young women. Unplanned pregnancies are reduced by 40% compared to other contraceptive methods and by over 70% compared to the population of young women at large. In addition, when these methods are readily available and women understand all of their contraceptive options up to 75% will choose LARC.
There are two important barriers to the use of LARC:
- Many teens (and some providers) think that a pap smear and pelvic exam are required as part of contraceptive management and this can be a deterrent to a young woman seeking care. In fact, pap smears are not recommended until age 21 and the other testing necessary as part of this process does not require a pelvic exam. Specifically, testing for sexually transmitted illnesses, which is recommended for sexually active young women, can be done on urine samples or on self-collected swabs.
- Most primary care providers are not trained in the techniques for insertion of IUDs and implants and often, depending on insurance coverage, there can be delays in obtaining these devices. Providers and practices will need to commit to obtaining training and providing this service and payers will need to ensure ready access to the devices if we are to take advantage of these important benefits.
As with all forms of hormonal contraception, there is no protection from sexually transmitted illnesses so consistent use of condoms should still be recommended for young men and women.