EXECUTIVE SUMMARY

While more adolescents are choosing long-acting reversible contraceptive (LARC) methods, they may not be implementing dual use of condoms to protect themselves from sexually transmitted infections.

  • New research indicates that self-reported condom use was low overall among postpartum teenagers and lower among LARC users than those who used non-LARC hormonal methods.
  • While LARC methods are extremely effective at preventing pregnancy, they do not offer protection against sexually transmitted infections (STIs). This is of concern when it comes to adolescents, who represent nearly half of all diagnosed STIs annually.

While more adolescents are choosing long-acting reversible contraceptive (LARC) methods, they may not be implementing dual use of condoms to protect themselves from sexually transmitted infections (STIs). New research indicates that self-reported condom use was low overall among postpartum teenagers and lower among LARC users than those who used non-LARC hormonal methods.1

Researchers used a cross-sectional analysis, examining 2012-2015 data extracted from the Pregnancy Risk Assessment Monitoring System (PRAMS), a multisite surveillance system focused on maternal behaviors and experiences before, during, and shortly after pregnancy. Using data from 37 sites, the investigators assessed the association of condom use by contraceptive methods with a multivariable survey-weighted logistic regression. Included in the analysis were teenage mothers aged 19 with a recent live birth who were using LARC or non-LARC hormonal methods.1 Most of the postpartum teenage mothers were between ages 18 and 19 years, unmarried, first-time mothers who were experiencing an unintended pregnancy. Almost half were non-Hispanic white with current Medicaid coverage.

While condom use was reported by 28.8% of these sexually active teenagers overall, LARC users were half as likely to use condoms as non-LARC hormonal method users (17.8% versus 35.6%; adjusted prevalence ratio [aPR], 0.50; 95% confidence interval [CI], 0.41-0.60). Teens who used intrauterine devices (IUDs) (15.1%) were less likely to report condom use than those using an implant (21.5%; aPR, 0.70; 95% CI, 0.51-0.98); patch, ring, or injection users (24.9%; aPR, 0.61; 95% CI, 0.47-0.79); and pill users (47.2%; aPR, 0.32; 95% CI, 0.25-0.40).1

Counsel on Methods

Between 2006 and 2010, more than 80% of teens at risk of unintended pregnancy were using contraception, but just 59% used a highly effective method, including any hormonal method or IUD.2 Adolescents who use contraception most often use short-acting methods, such as condoms, notes Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine.

In a 2018 CDC analysis of the nearly 30% currently sexually active students nationwide, 53.8% reported that a condom was used during their last sexual intercourse. While the percentage of teens who used condoms fell from 61.5% in 2007, condoms remain the most-used contraceptive method by adolescents.3 Such methods have higher discontinuation and pregnancy rates compared with long-acting options such as the IUD and the implant. Long-acting methods offer extremely effective use; for example, the copper-T IUD reported failure rate at one year of 0.8 per 100 women, and a 10-year failure rate of 1.9 per 100 women over 10 years.4

Both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics recommend that clinicians inform pregnant teens about birth spacing and postpartum contraceptive use, including the safety and effectiveness of LARC methods that are safe to use immediately postpartum.5 Research indicates that teens who choose to initiate a LARC method shortly after pregnancy are at a lower risk of a short interpregnancy interval.6

When barriers to LARC use are removed, teens will choose long-acting methods. In the Colorado Family Planning Initiative, investigators provided free access to LARC methods to clients in Title X-funded clinics in 37 of Colorado’s 64 counties. Data indicate LARC use increased from 5% to 19% among low-income teenagers and young women. The increase in LARC use was accompanied by decreases in birth rates and abortion rates in both age brackets.7

While LARC methods are extremely effective at preventing pregnancy, they do not offer protection against sexually transmitted infections (STIs). This is of concern when it comes to adolescents, who represent nearly half of all diagnosed STIs annually.8 In 2017, more than 1.7 million cases of chlamydia were diagnosed, with 45% of cases found among young females ages 15 to 24.Previous cross-sectional data among teens indicate that using a LARC method is associated with lower condom use.10

Counsel on Dual Use

Since teens are at higher risk of STIs, providers should continue to follow standard guidelines for STI screening during the contraceptive counseling session, as well as advise adolescents to use male or female condoms consistently to decrease the risk of STIs, including HIV.4 (The CDC offers a free fact sheet on dual protection for adolescents, available at: https://bit.ly/2ospR3P.)

In an editorial accompanying the new study, the authors suggested one approach is to tell teens who choose LARC methods, “Now that you have a very effective method of preventing pregnancy on board, let’s talk about ways you can prevent STIs and stay healthy.”11

Remember that pre-exposure prophylaxis (PrEP) is available for adolescents at risk for HIV, says Anita Nelson, MD, professor and chair of the obstetrics and gynecology department at Western University of Health Sciences in Pomona, CA. PrEP consists of the anti-HIV drugs emtricitabine and tenofovir disoproxil fumarate. The FDA has approved its use for adolescents and adults who weigh at least 77 pounds. The indications for PrEP, initial and follow-up prescribing, and laboratory testing recommendations are the same for teens and adults.

REFERENCES

  1. Kortsmit K, Williams L, Pazol K, et al. Condom use with long-acting reversible contraception vs non-long-acting reversible contraception hormonal methods among postpartum adolescents. JAMA Pediatr 2019; doi: 10.1001/jamapediatrics.2019.1136.
  2. Branum AM, Jones J. Trends in long-acting reversible contraception use among U.S. women aged 15-44. NCHS Data Brief 2015; 188:1-8.
  3. Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance - United States, 2017. MMWR Surveill Summ 2018 Jun 15;67(8):1-114.doi:10.15585/mmwr.ss6708a1.
  4. ACOG committee opinion no. 735 summary: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2018 May;131(5):947-948.
  5. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines For Perinatal Care. 8th ed. Elk Grove Village (IL): AAP; Washington, DC: American College of Obstetricians and Gynecologists; 2017.
  6. White K, Teal SB, Potter JE. Contraception after delivery and short interpregnancy intervals among women in the United States. Obstet Gynecol 2015 Jun;125:1471-1477.
  7. Ricketts S, Klingler G, Schwalberg R. Game change in Colorado: widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspect Sex Reprod Health 2014 Sep;46(3):125-32. [Epub ahead of print.]
  8. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis 2013; 40(3):187-193.
  9. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2017. Sept. 25, 2018.
  10. Steiner RJ, Liddon N, Swartzendruber AL, et al. Long-acting reversible contraception and condom use among female US high school students: implications for sexually transmitted infection prevention. JAMA Pediatr 2016 May 1;170(5):428-34.
  11. Hoopes AJ, Sucato GS. Long-acting reversible contraceptive methods need a barrier to prevent sexually transmitted infections in adolescents. JAMA Pediatr 2019.