EXECUTIVE SUMMARY

To help prevent unplanned pregnancy among adolescents, the American Academy of Pediatrics has issued an updated policy statement on emergency contraception (EC) to educate providers on use of EC in adolescents, and advocate for expanded access for teens.

Insertion of a copper intrauterine device within five days of unprotected or underprotected intercourse is the most effective method of EC, and has the additional benefit of providing ongoing contraception when left in place.

Ulipristal acetate and mifepristone are the most effective oral forms of EC, with failure rates ranging from 0.9% to 2.1%. While levonorgestrel EC pills are less effective than ulipristal acetate and mifepristone, which are prescription-only, they are available over the counter.


Although teen pregnancy and birth rates have been declining since the early 1990s, reaching historic lows at 22.3 per 1,000 females ages 15-19 years in 2015, U.S. rates still are higher than those in other developed countries.1 Figures show that in 2011, the U.S. rate (52 per 1,000 females, ages 15-19 years) was more than six times as high as Switzerland (eight per 1,000), more than twice as high as France (25 per 1,000), and slightly higher than England (47 per 1,000).2

Among the 2.5 million sexually active female adolescents ages 15-19 years who reported current birth control use, 55% relied on the condom, and 20% used withdrawal.3 The American Academy of Pediatrics has issued an updated policy statement on emergency contraception (EC) to educate providers on use of EC in adolescents, and advocate for expanded access for teens.4

Providers who offer care to adolescents in any setting, including primary care, EDs, and hospitals, can play a “crucial role” in promoting positive sexual and reproductive health outcomes,” policy statement lead author Krishna Upadhya, MD, MPH, an adolescent medicine specialist in Washington, DC, said in a statement. “EC is one tool available to prevent pregnancy, and information about EC should be included as a part of counseling about pregnancy and sexually transmitted infection prevention in all settings.”5

What Are the EC Options?

Insertion of a copper intrauterine device (IUD) within five days of unprotected or underprotected intercourse is the most effective method of EC, and provides ongoing contraception when left in place, according to the updated policy statement.6-8

Failure rates for EC methods vary. The copper IUD has a failure rate of 0.09% after insertion.6 Ulipristal acetate and mifepristone are the most effective oral forms of EC, with failure rates ranging from 0.9% to 2.1%.9 Although levonorgestrel EC pills are less effective than ulipristal acetate and mifepristone, which are prescription-only, they are available over the counter. Failure rates for levonorgestrel pills range from 0.6% to 3.1%. All EC methods should be ingested (or placed) as soon as possible after unprotected intercourse.10

What Can You Do?

Make EC counseling a regular part of anticipatory guidance regarding sexual health discussions with patients and parents, regardless of current sexual activity or gender, says Brooke Bokor, MD, MPH, an adolescent medicine specialist in the division of adolescent and young adult medicine at Children’s National Hospital in Washington, DC. Adolescent males need to be counseled about EC as well. Explain that a person of any gender or age can buy it over the counter, she states.

Prescribe and encourage peer providers to prescribe EC with refills to all sexually active females at routine visits in advance to facilitate quick access, says Bokor. Encourage teens to fill the prescription and keep it in a drawer, she explains.

Educate members of the practice staff about EC options, including timing, options for access, the fact that any age or gender can access, and make a protocol to facilitate easy access to a prescription by the advice of a nurse or doctor on call, says Bokor. Even members of the front desk staff need to have fingertip access to information to ensure ease of access, she says.

REFERENCES

  1. Abma JC, Martinez GM. Sexual activity and contraceptive use among teenagers in the United States, 2011-2015. Natl Health Stat Report 2017;104:1-22.
  2. Sedgh G, Finer LB, Bankole A, et al. Adolescent pregnancy, birth, and abortion rates across countries: Levels and recent trends. J Adolesc Health 2015;56:223-230.
  3. Lindberg L, Santelli J, Desai S. Understanding the decline in adolescent fertility in the United States, 2007-2012. J Adolesc Health 2016;59:577-583.
  4. Upadhya KK; Committee On Adolescence. Emergency contraception. Pediatrics 2019; doi:10.1542/peds.2019-3149.
  5. Upadhya KK. Policy updates guidance on emergency contraception, advocates for access. Nov. 18, 2019. Available at: https://bit.ly/2P9Mfj4.
  6. Cleland K, Zhu H, Goldstuck N, Cheng L, et al. The efficacy of intrauterine devices for emergency contraception: A systematic review of 35 years of experience. Hum Reprod 2012;27:1994-2000.
  7. Wu S, Godfrey EM, Wojdyla D, et al. Copper T380A intrauterine device for emergency contraception: A prospective, multicentre, cohort clinical trial. BJOG 2010;117:1205-1210.
  8. Turok DK, Godfrey EM, Wojdyla D, et al. Copper T380 intrauterine device for emergency contraception: Highly effective at any time in the menstrual cycle. Hum Reprod 2013;28:2672-2676.
  9. International Consortium for Emergency Contraception (ICEC). Emergency contraceptive pills: Medical and service delivery guidelines. 3rd edition. 2012.
  10. Society for Adolescent Health and Medicine. Emergency contraception for adolescents and young adults: Guidance for health care professionals. J Adolesc Health 2016;58:245-248.