Births among adolescents account for 13 percent of all births in the United States. Adolescents most commonly use contraception at the time of first intercourse but then often do not use contraception as sexual activity increases. Davtyan reviews contraception issues in adolescents and discusses some of the misconceptions adolescents may have about contraception.

The author performed a MEDLINE search of the literature from 1980 to 1999 to gather information on contraception. The author notes that misconceptions about the risks of contraception, fear of the pelvic examination and concerns about confidentiality keep many teenagers from seeking advice from their physicians. Better communication with adolescents can help overcome some of these barriers. Most teens would like to discuss contraception and sexually transmitted diseases with their physicians, but most clinicians do not bring up these topics. Physicians are legally protected when providing diagnosis and treatment of sexually transmitted diseases, contraception, pregnancy testing and substance-abuse counseling to minors. Fear of parental discovery can deter teenagers from seeking advice and help.

A 1995 survey revealed that condoms were used for contraception by 37 percent of teenagers 15 to 19 years of age. Condom failure is higher among adolescents, mainly because of incorrect and inconsistent use. Failure is less likely with latex condoms than with polyurethane condoms or female condoms. A discussion of condom use should include how and when to place the condom, how and when to remove it and how to safely carry a condom in a pocket, wallet or purse. The advantage of condoms is that they protect against sexually transmitted diseases, indirectly preventing infertility and cervical cancer. Spermicides can increase the contraceptive efficacy of condoms.

Many adolescents are not aware of the availability of emergency contraception, which can be effective for up to 72 hours after unprotected intercourse and works by interfering with ovulation, fertilization and implantation. The two most commonly used regimens in the United States are (1) two doses of 100 μg of ethinyl estradiol and 0.5 mg of levonorgestrel (or 1.0 mg of norgestrel) administered 12 hours apart or (2) two doses of 0.75 mg of levonorgestrel administered 12 hours apart. Side effects of emergency contraception are nausea, vomiting and irregular bleeding.

Oral contraceptives are the most common method of contraception among adolescents. The concern about weight gain while taking oral contraceptives should be countered by reassuring the patient that weight gain rarely results from such low doses of hormones. The patient should also be reassured that fertility is not affected by the use of oral contraceptives, although pregnancy might be delayed for several months following cessation of oral contraceptive use. Side effects of oral contraceptives include nausea, breast tenderness and irregular bleeding. These effects are usually self-limited and tend to disappear after three cycles. Taking the oral contraceptive at night with a meal may minimize nausea. The advantages, disadvantages and side effects of oral contraceptives should be discussed with the patient (see the accompanying table).

Long-term hormonal contraceptives, such as depot medroxyprogesterone acetate and subdermal implants of levonorgestrel, are useful in adolescents because they make minimal demands on the patient. An injection of depot medroxyprogesterone acetate, 150 mg, is administered every three months, and the levonorgestrel implant can last up to five years. These long-acting progestins can cause irregular bleeding, amenorrhea, weight gain, nausea and depression. The adolescent needs to know that the menstrual changes are not harmful.

The intrauterine device may not be suitable for use in teenagers, who may be at increased risk of contracting a sexually transmitted disease.

The author concludes that adolescents need to be educated about sexually transmitted diseases, contraception and emergency contraception after unprotected intercourse. The combined goals of preventing sexually transmitted diseases and unwanted pregnancy should be considerations when choosing a contraceptive method.

editor's note: Cultural values regarding sexuality, pressure from peers and the media, and socioeconomic conditions all play a role in the decisions that adolescents make regarding sexual activity. Decisions to engage in unsafe sex may also be based on inadequate knowledge about the risks of pregnancy and sexually transmitted infections. In some teenagers, nondecision-making actually occurs. Parent-teenager discussions about sexual activity, especially when the parent is comfortable and skillful in talking about sex, seem to be associated with an increased likelihood of communication between sexual partners about the risks and the use of condoms. Parent-teenager discussions about sex should be encouraged if the parents know what to say and how to say it.—r.s.