What does the US SPR mean for adolescents?
By Anita Brakman, MS
Director of Education, Research & Training
Physicians for Reproductive Health
New York City
Melanie Gold, DO, FAAP
Clinical Professor of Pediatrics
University of Pittsburgh School of Medicine
University of Pittsburgh Student Health Service
The Centers for Disease Control and Prevention (CDC) released its first U.S. Selected Practice Recommendations for Contraceptive Use (US SPR) in the June 21, 2013, Morbidity and Mortality Weekly Report. These practice recommendations address common, yet complex, issues surrounding initiating and using several contraceptive methods, and they serve as a resource for clinicians, including those who care for adolescents.
The US SPR is a useful companion to the CDC’s US Medical Eligibility Criteria for Contraceptive Use (US MEC), which provides detailed information on which types of contraception can be safely used by patients with a variety of medical conditions and other characteristics. The US MEC and the new US SPR are adaptations of similar documents published by the World Health Organization (WHO), but the U.S. versions are specific to patient populations in this country. For each method, the US SPR details appropriate timing of when to initiate the method and any necessary prerequisite examinations or testing, when and how long to use backup contraception, changes in practice when caring for women who are postpartum or postabortion, what follow-up care to offer, how to manage side effects, as well as guidance on switching between methods and how to address user errors such as missed pills or late injections.1
While the US SPR contains practical guidance on many areas of family planning, providers who care for teens might be especially interested two sections of the report: the recommendations on long-acting reversible contraception (LARC) and emergency contraception (EC).
Medical and public health organizations, including the American College of Obstetricians and Gynecologists, agree that long-acting methods should be considered a first-line choice of contraceptive method for healthy adolescents, regardless of parity.2-3 The US SPR states that implantable and intrauterine contraceptives are appropriate for teens and provides specific guidance on addressing side effects that might lead to method discontinuation, such as bleeding irregularities. With the high up-front cost of these methods and their potential for long-term protection against unintended pregnancy with immediate reversibility upon removal, helping young patients manage troublesome side effects is preferable to immediate discontinuation.
The report’s first recommendation in this area is to counsel all patients on potential changes in bleeding patterns so they will know what to expect and the possible duration of bleeding irregularities. Patients, including teens, using the copper intrauterine device (IUD) might find nonsteroidal anti-inflammatory drugs (NSAIDs) can provide short-term treatment for heavy or prolonged menstrual bleeding. The US SPR cautions, however, that while several studies show individual NSAIDs can be effective in reducing bleeding, there is not enough evidence to recommend one specific treatment regimen.
Bleeding changes are the primary complaint cited by patients who discontinue contraceptive implant use, especially teens.4,5 Again, NSAIDs are a recommended option for managing the light and unscheduled spotting associated with implant use. Another option for managing bleeding related to implant use is to prescribe a hormonal treatment, such as a low-dose combined oral contraceptive, as long as the patient has no medical contraindications to estrogen use. Evidence is weak and mixed regarding the possible benefits of vitamin E or ibuprofen in reducing implant-associated bleeding. If any patient desires removal of an implant, it is recommended to help her choose and initiate another method that she will tolerate more easily.
Use guidance on EC
The US SPR gives clinicians important direction for counseling teens about using emergency contraception, including levonorgestrel regimens, combined hormonal regimens, ulipristal acetate, and the copper IUD. The topic is timely, as EC and adolescents recently have been in the news as Plan B One-Step is set to move onto store shelves without any age restrictions. (Read the Contraceptive Technology Update article, "US drops age limits for Plan B One-Step," August 2013, p. 88.) The CDC report continues to recommend providing advance supplies or prescriptions for EC pills when possible and instructs clinicians on how to initiate ongoing contraception after a patient has taken EC pills. Any contraceptive method can be started immediately after using levonorgestrel or ulipristal acetate formulations of EC. However, patients will need to use a backup contraceptive method or abstain from intercourse for seven days after using levonorgestrel pills and 14 days after using ulipristal acetate. A pregnancy test is recommended if a patient does not have a withdrawal bleed within three weeks of taking EC. When the copper IUD is used for EC, no backup method is needed.
Clinicians who treat adolescents will find valuable guidance in the US SPR about many contraceptives including combined hormonal oral, vaginal, and transdermal methods; injections; LARC; EC; and fertility-awareness based methods. The full report, as well as related articles and resources from the CDC and the WHO, can be accessed easily at http://1.usa.gov/14vF2xf.
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. U.S. Selected Practice Recommendations for Contraceptive Use, 2013: adapted from the World Health Organization Selected Practice Recommendations for Contraceptive Use, second edition. MMWR Recomm Rep 2013; 62(RR-05):1-60.
- American Congress of Obstetricians and Gynecologists. Intrauterine device and adolescents. Obstet Gynecol 2007; 110(6):1,493-1,495.
- American Congress of Obstetricians and Gynecologists. Long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2011; 118(1):184-196.
- 4Raymond EG. Contraceptive implants. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
- Deokar AM, Jackson W, Omar HA. Menstrual bleeding patterns in adolescents using etonogestrel (ENG) implant. Int J Adolesc Med Health 2011; 23(1):75-77.