CDC Guidelines on How to Start Combined Hormonal Contraceptives

CLINICAL ACTIONS

Combined hormonal contraceptives contain both estrogen and a progestin. This contraceptive category includes combined oral contraceptives, transdermal patches and vaginal rings. They are effective when taken as directed, reversible and can be used by women of all ages.  It is important to alert women that they will not protect against STDs and other preventative measures will be required to protect against infections.  The following assumes there are no contraindications to estrogen component (e.g., breast cancer, hyperlipidemia, liver disease etc.). Only BP is “essential and mandatory” and when BP cannot be measured by a provider, a measurement obtained in other setting can be reported by the woman to her provider. The following are highlights from the CDC recommendations on initiation:  

Initiation – Criteria and Timing

Obesity

Patient with Amenorrhea (Not Postpartum)

Postpartum (Breastfeeding)

Postpartum (Not Breastfeeding)

Postabortion (Spontaneous or Induced)

Need for Follow-up

Switching from Another Contraceptive Method

Switching from an IUD

VTE WARNING Category 3 or 4

Initiation – Criteria and Timing  

CDC Criteria to determine with reasonable certainty that woman is not pregnant (≥1 of the following 

  • ≤7 days after the start of normal menses 
  • No sexual intercourse since the start of last normal menses 
  • Correctly and consistently using a reliable method of contraception 
  • ≤7 days after spontaneous or induced abortion 
  • Within 4 weeks postpartum 
  • Fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority [≥85%] of feeds are breastfeeds), amenorrheic, and <6 months postpartum  

Timing  

  • Start at any time if ‘reasonably certain’ not pregnant criteria are met  

Back-Up Contraception 

  • If combined hormonal contraception begun within the first 5 days since menstrual bleeding started 
    • No additional contraceptive protection is needed 
  • If combined hormonal contraception started >5 days since menstrual bleeding started 
    • Abstain from sexual intercourse or  
    • Use additional contraceptive protection for the next 7 days 

Obesity

  • Combined hormonal contraceptives are a category MEC 2 and therefore can be prescribe to women regardless of BMI
  • Obesity is a risk factor for VTE, but lower than risk from pregnancy

Patient with Amenorrhea (Not Postpartum) 

  • Timing 
    • Start at any time if ‘reasonably certain’ not pregnant criteria  
  • Back-up contraception 
    • Abstain from sexual intercourse or  
    • Use additional contraceptive protection for the next 7 days 

Postpartum (Breastfeeding) 

  • Timing 
    • Start when the woman is medically eligible (MEC guidance) and meets ‘reasonably certain’ not pregnant criteria  
  • US MEC postpartum guidance (combined hormonal contraceptives)  
    • Avoid combined hormonal contraceptives during the first 3 weeks (risk of VTE)  
    • Avoid combined hormonal contraceptives during the first 4 weeks (concerns regarding breastfeeding performance)  
    • Caution: Women who are postpartum with additional risk factors for VTE should not use combined hormonal contraceptives 4–6 weeks after delivery (please see ‘Primary Sources’ and ‘Related ObG Topics below for further guidance on medical eligibility)
  • Back-up contraception  
    • <6 months postpartum, amenorrheic, and fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority [≥85%] of feeds are breastfeeds)  
      • no back-up needed 
    • If not in the above category, and patient is ≥21 days postpartum and has not experienced return of her menstrual cycle  
      • Abstain from sexual intercourse or  
      • Use additional contraceptive protection for the next 7 days 
    • Menstrual cycles have returned and >5 days since menstrual bleeding started 
      • Abstain from sexual intercourse or  
      • Use additional contraceptive protection for the next 7 days 

Postpartum (Not Breastfeeding)

  • Timing 
    • Start when the woman is medically eligible (MEC guidance) and meets ‘reasonably certain’ not pregnant criteria  
  • US MEC postpartum guidance (combined hormonal contraceptives)  
    • Avoid combined hormonal contraceptives during the first 3 weeks (risk of VTE)  
    • Caution: Women who are postpartum with additional risk factors for VTE should not use combined hormonal contraceptives 4–6 weeks after delivery (Please see ‘Primary Sources’ and ‘Related ObG Topics’ for further guidance on medical eligibility)
  • Back-up contraception 
    • <21 days postpartum 
      • No additional contraceptive protection needed
    • ≥21 days postpartum and whose menstrual cycles have not returned  
      • Abstain from sexual intercourse or  
      • Use additional contraceptive protection for the next 7 days 
    • Menstrual cycles have returned and it has been >5 days since menstrual bleeding started 
      • Abstain from sexual intercourse or  
      • Use additional contraceptive protection for the next 7 days 

Postabortion (Spontaneous or Induced) 

  • Timing: 
    • Start combined hormonal contraception within the first 7 days following first-trimester or second-trimester abortion, including immediately postabortion  
  • Back-up contraception
    • If combined hormonal contraception not started at time of surgical abortion  
      • Abstain from sexual intercourse or  
      • Use additional contraceptive protection for the next 7 days

SYNOPSIS:

There may be times there is uncertainty whether a woman is pregnant. According to the CDC, “the benefits of starting combined hormonal contraceptives likely exceed any risk; therefore, starting combined hormonal contraceptives should be considered at any time, with a follow-up pregnancy test in 2–4 weeks.” In a situation where a woman needs to use additional contraceptive protection when making the switch to combined hormonal contraception, consider continuing previous contraceptive methods for 7 days after starting combined hormonal contraception

KEY POINTS

Need for Routine Follow-Up

  • The CDC states that if a patient is otherwise healthy, “No routine follow-up visit is required”
  • Women should be advised to return at any time to discuss
    • Side effects | Desire to change contraceptive method | Any other issues or concerns
  • At other routine visits, assess
    • Patient satisfaction | Concerns
    • Change in health status and medications that may impact use of combined hormonal contraceptives (e.g., move to MEC category 3 and 4 conditions)
    • Blood pressure
    • Weight changes, including if patients are concerned regarding perceived changes

Switching from Another Contraceptive Method 

  • Timing 
    • Start at any time if ‘reasonably certain’ not pregnant criteria are met  
    • Waiting for her next menstrual cycle is unnecessary
  • Back-up contraception  
    • If combined hormonal contraception started >5 days since menstrual bleeding started 
      • Abstain from sexual intercourse or  
      • Use additional contraceptive protection for the next 7 days 

Switching from an IUD

  • If the woman has had sexual intercourse since the start of her current menstrual cycle and it is >5 days since menstrual bleeding started, consider any of the following  
    • Retain the IUD for at least 7 days after combined hormonal contraception initiated and return for IUD removal or  
    • Abstain from sexual intercourse or use barrier contraception for 7 days before removing the IUD and switching 
  • If cannot return for IUD removal and has not abstained from sexual intercourse or used barrier contraception for 7 days 
    • Use emergency contraceptive pills at the time of IUD removal 
    • Combined hormonal contraceptives can be started immediately after use of emergency contraceptive pills (except for ulipristal acetate) 
    • Ulipristal acetate: Combined hormonal contraceptives can be started no sooner than 5 days after use  
  • Note: The CDC considers IUDs separately because in theory, if a woman has had sexual intercourse and it is >5 days from the time of her period, residual sperm could still potentially be active with a risk for fertilization

VTE WARNING Category 3 or 4 (risk outweigh benefits or unacceptable risk)

The following factors elevate risk of VTE sufficiently to classify as 3 or 4 and alternate methods should be used

  • Smoking ≥35 years of age
  • Postpartum <21 days
  • Postpartum 21-42 days with additional risk factors
    • ≥35 years of age | Previous VTE | Thrombophilia | Immobility | Transfusion at delivery | Peripartum Cardiomyopathy | BMI ≥30 | PPH | Postcesarean delivery | preeclampsia | smoking
  • Major surgery with immobilization
  • History of DVT or PE
  • Hereditary thrombophilia including antiphospholipid syndrome
  • Inflammatory Bowel Disease with
    • Active or extensive disease | Surgery | Immobilization | Steroid use | Vitamin deficiencies | Fluid depletion
  • SLE with positive or unknown antiphospholipid antibodies
  • Superficial DVT (acute or history)

Learn More – Primary Sources:

CDC: U.S. Selected Practice Recommendations for Contraceptive Use, 2016

CDC MEC: Classifications for Combined Hormonal Contraceptives

ACOG Practice Bulletin 206: Use of Hormonal Contraception in Women With Coexisting Medical Conditions

CDC: Effectiveness of Family Planning Methods

WHO: Family planning/contraception methods

Is Progestin-Based Contraception Linked to Depression?

BACKGROUND AND PURPOSE: 

  • Weight gain, acne, mood changes and depression have been listed as possible side effects of progestin-based contraceptive methods  
  • Worly et al. (Contraception, 2018) performed a systematic review to measure the association between progestin-only contraception and depression 

METHODS: 

  • Systematic Review 
  • Search included progestin-only contraception and depression, focusing on externally validated depression measures 
  • Study quality was evaluated using USPSTF and the Cochrane Risk of Bias Tools 
  • Study questions were as follows 
    • Is there an association or causative link between progestin-only hormonal contraception and depression? 
    • Does the type of progestin or route of administration influence such an association? 
    • Are there certain populations (e.g., adolescents, postpartum patients or women with a history of depression) in which this association exists?

RESULTS: 

  • 26 studies met inclusion criteria 
    • 5 randomized controlled trials 
    • 11 cohort studies 
    • 10 cross-sectional studies 
  • There was minimal association between progestin-only methods and depression 
  • Subdermal implants  
    • In five low-quality, high-risk-of-bias studies, there was no correlation between depression and subdermal implants  
  • Levonorgestrel IUD  
    • Four out of five varying-quality and medium-risk-of-bias studies there was no association  
    • One large population based study found an association, but was retrospective with a weak association and “evidence is unimpressive”  
  • Two progestin-only contraceptive pill studies with varying levels of quality and bias indicate no increase in depression scores 
    • One study demonstrated a lower depression scores but had a small sample size 
    • One larger population based study did find slight increased risk but retrospective and higher dose formulations   
  • Medroxyprogesterone acetate intramuscular injection  
    • Trials had varying levels of quality and bias, but overall show no difference in depression 

CONCLUSION: 

  • Difficult to derive definitive conclusions, but currently, there is no significant evidence to support an increased risk for increased depression with progestin contraception 
  • A minority of users may experience depression, but this effect was not seen in more robust studies  
  • Adolescents were likewise not found to have increased risk for depression  
  • It is important to continue to measure associations between progestin contraception and mental health 

Learn More – Primary Sources:  

The relationship between progestin hormonal contraception and depression: a systematic review 

Are Drug Interactions between Antibiotics and Hormonal Birth Control a Reality or Myth?

BACKGROUND AND PURPOSE: 

  • Limited data regarding hormonal contraception and antibiotics 
  • Rifamycin antibiotics (rifampin, rifabutin) induce key hepatic enzymes that are part of hormonal birth control pathway metabolism but this mechanism may not be generalizable to other more common antibiotics 
  • There is data that most pharmacists recommend backup contraception for women who use antibiotics with hormonal contraception due to concern for unintended pregnancy 
  • Simmons et al. (AJOG, 2018) sought to examine potential interactions between non-rifamycin antibiotics and hormonal contraceptives 

METHODS: 

  • Systematic review 
    • Search included trials, cohort, case-control, and pharmacokinetic studies when non-rifamycin antibiotics and hormonal contraceptive that addressed: 
    • pregnancy rates 
    • pharmacodynamics 
    • pharmacokinetic outcomes  
  • Reviews were independently assessed by two authors to avoid bias 
  • Risk of bias was assessed using the USPSTF evidence grading system 
  • Findings were tabulated by drug class 

RESULTS: 

  • Study quality ranged from good to poor and addressed only oral contraceptive pills, emergency contraception pills, and the combined vaginal ring 
  • Ethinyl estradiol was affected when administered with dirithromycin (a macrolide) and showed increased clearance but this effect was not seen with any other drug 
  • Two studies demonstrated no difference in pregnancy rates in women who used oral contraceptives with and without non-rifamycin antibiotics 
  • There was no observed differences in ovulation suppression or breakthrough bleeding in any study that combined hormonal contraceptives with any antibiotic 
  • No significant decreases in any progestin pharmacokinetic parameter occurred during co-administration with any antibiotic 

CONCLUSION: 

  • Clinical and pharmacokinetic outcome studies do not support the existence of a drug interaction between hormonal birth control and non-rifamycin antibiotics 
  • Authors do note that  
    • There may be individual differences in drug metabolism and they suggest a small subset of women (likely <1%) may be at risk for hormonal contraceptive failure when taking antibiotics  
    • Switching to another contraceptive or backup method if compliance is good and there is an unintended pregnancy 
    • Obesity may play a role in drug metabolism that could impact these study results 

Learn More – Primary Sources: 

Drug interactions between non-rifamycin antibiotics and hormonal contraception: a systematic review 

ACOG Practice Advisory: Counseling Patients About Breast Cancer Risk and Hormonal Contraception

SUMMARY:

ACOG has released a practice advisory in response to a recent prospective cohort study. The results from the paper by Mørch and colleagues (NEJM, 2017) was based on Danish nationwide registries (see ‘Related ObG Topics’ below) and identified the following

Overall risk of breast cancer in current or recent users compared to women who never used hormonal contraception

  • Increased Risk of breast cancer: Relative Risk (RR): 1.20 (95% CI, 1.14 to 1.26)
  • Risk increased with duration of use: RR 1.09 (95% CI, 0.96 to 1.23) at < 1 year vs 1.38 (95% CI, 1.26 to 1.51) after > 10 years (P=0.002)
  • Risk remains elevated after ≥5 years but not < 5 years

Oral Combined Contraceptives

  • Little evidence of major differences between various OCPs after statistical adjustments for multiple testing

Levonorgestrel-releasing intrauterine system (LNG-IUD)

  • No significant differences compared to OCPs
  • RR of breast cancer was 1.21 (95% CI, 1.11 to 1.33)

Contraceptive implants

  • Few breast-cancer events among users of the progestin-only implant and depot medroxyprogesterone acetate

KEY POINTS:

Relative vs Absolute Risk

Absolute risks remain low

  • Overall: 1 additional case of invasive breast cancer for every 7,690 women using hormonal contraception
  • Women <35 years: 1 additional case of invasive breast cancer for every 50,000 women using hormonal contraception

Benefits of Hormonal Contraceptives

ACOG addresses these benefits clearly in this Practice Advisory

  • Non-hormonal benefits (see ‘Related ObG Topics’ below)
    • Decreased risk of ovarian, endometrial, and colon cancer
    • Overall cancer risk may be lower in hormonal contraceptive users despite possibility of small increased breast cancer risk
  • Hormonal benefits
    • Maternal mortality rate in the US: 26.4 deaths per 100,000 women (2015)
    • The above risk is twice that of developing invasive breast cancer in the NEJM study

Study Limitations

ACOG highlights the following

  • Study confounders not assessed in this study
    • Breastfeeding | alcohol consumption |physical activity
  • Study may not be generalizable
    • Only a northern European population was included
  • More study required regarding relationship between progestin-only contraceptives and breast cancer risk
    • Study results were inconsistent regarding progestin-only formulations

Counseling recommendations

ACOG supports shared decision making and counseling should include the following

This recent study showed that women who use hormonal birth control methods may have a small increased risk of breast cancer, but the overall risk of breast cancer in hormonal birth control users remains very low

Hormonal birth control is very effective in preventing pregnancy and may lower a women’s overall risk of cancer by providing protection against other types of cancer

There are nonhormonal methods of birth control that are also good options

Women can do things to help lower their risk of breast cancer, like breastfeeding, getting more exercise, and limiting alcohol intake

Learn More – Primary Sources:

Practice Advisory: Hormonal Contraception and Risk of Breast Cancer

ACOG & SMFM Guidance on the Use of IUDs and Contraceptive Implants

SUMMARY:  

IUDs and etonogestrel single-rod contraceptive implants are categorized as Long-Acting Reversible Contraception (LARC).  ACOG and other professional and public health entities are calling for reduced barriers and improved access to LARC.  The latest ACOG practice bulletin reviews various LARC options, including clinical considerations such as use in the postpartum period and management in the setting of pelvic infections.  ACOG has also released an updated ‘Quick Coding Guide’ for LARC that can be found in ‘Learn More – Primary Sources’ section.

Available LARCs

Copper Intrauterine Device (T380A) 

  • FDA approval for 10 years  

Levonorgestrel-Releasing Intrauterine Devices (LNG-IUD) 

  • Total of 52 mg of levonorgestrel 
    • 20 micrograms released per day (Mirena) 
      • FDA approved for 7 years 
    • 18.6 micrograms released per day (Liletta)  
      • FDA approved for 6 years  
  • Total of 19.5 mg of levonorgestrel (Kyleena) 
    • 17.5 micrograms released per day  
      • FDA approved for 5 years 
  • Total of 13.5 mg of levonorgestrel (Skyla)   
    • 14 micrograms released per day
    • FDA approved for 3 years 

Contraceptive Implant

  • Subdermal implant with a core containing 68 mg of etonogestrel 
  • FDA approved for 3 years

Clinical Considerations

Nulliparous and Adolescents

  • LARCs should be offered routinely as safe and effective contraceptive options for nulliparous women and adolescents
  • Use of LARCs in adolescents supported by the AAP  
  • IUD  
    • MEC category 2 (advantages outweigh risks)
    • Risk of infection is low 
      • No evidence of association with infertility or tubal occlusion   
    • High satisfaction rate based on continuation rates  
    • Expulsion rates may be higher in adolescents vs older women and multiparous vs nulliparous  
    • Like the general population, nulliparous women and adolescents prefer LNG-IUD  
  • Implant 
    • MEC category 1 (no restrictions)  
    • Continuation rates higher in adolescents compared to OCPs  

SMFM Guidance on Women at High Risk for Medical Complications (2019)

  • Use of LARC is encouraged for women at highest risk for adverse health events as a result of a future pregnancy (GRADE 1B)
  • SMFM recommends discussion take place in the prenatal period regarding availability of immediate postpartum LARC and MEC guidelines should be used to determine best method for particular medical conditions (GRADE 1C)
  • Counseling should include discussion around expulsion rates but appear to be outweighed by benefit of higher continuation rates (GRADE 1C)
  • Providers who intend to utilize immediate postpartum LARC should obtain appropriate training (Best Practice)
  • SMFM recommends that for women who are eligible and desire LARC, following a high-risk pregnancy, immediate postpartum LARC should be used vs delayed placement due to overall superior efficacy and cost-effectiveness (GRADE 1B)
  • Encourage breastfeeding following immediate postpartum LARC based on current evidence (GRADE 1B)
  • SMFM suggests that if a women wishes and is eligible for LARC, but immediate postpartum is not feasible, consider early postpartum placement (GRADE 2C)
  • Contraceptive counseling should be (Best Practice)
    • Patient-centered
    • Within a shared decision-making framework 

Timing of Insertion  

  • Interval insertion 
    • Insertion may be performed at any time during menstrual cycle if patient is not pregnant  
    • No benefit to inserting during menses 
  •  Postabortion LARC Insertion  
    • Routinely offer immediate insertion following first trimester and second trimester abortion (induced or spontaneous)  
  • Postpartum LARC Insertion 
    • Offer immediate LARC insertion (IUD and implant) prior to hospital discharge 
    • Higher IUD expulsion rates (10-27%), but cost-benefit supports immediate insertion  
      • Considered ACOG ‘best practice’  
      • Waiting 4-6 weeks may result in barrier to access  
    • Contraindications to IUD placement include chorioamnionitis, endometritis, or puerperal sepsis or ongoing postpartum hemorrhage 

Effect on Breastfeeding  

  • Copper IUD: No hormonal concerns  
  • LNG-IUD and implant: Studies do not demonstrate a deleterious effect on breast feeding including milk volume/composition, newborn weight or exclusive breastfeeding rates  
  • ACOG recommends shared decision making regarding concerns  
    • Patients should be counseled regarding
      • Theoretical risk of reduced duration of breastfeeding
      • Lack of data supporting a negative association

Infection Risk and IUD  

  • Asymptomatic women who are at low risk of STDs and have undergone routine screening  
    • No additional screening required at the time of IUD insertion  
  • Women who have not been screened for STDs or at increased risk for STDs  
    • Requires CDC-recommended STD screening at the time of a single visit for IUD insertion 
    • Do not delay IUD placement while waiting on results  
    • Treat a positive test without removing the IUD  
  • Purulent cervicitis is a contraindication to IUD placement
  • If known chlamydia or gonorrhea infection, delay IUD insertion following infection treatment until  
    • Antibiotic course is complete 
    • Symptoms resolved 
    • Pelvic/cervical exam normal 
    • Repeat testing at 3 months for gonorrhea or chlamydia to rule out reinfection  
  • Routine antibiotic prophylaxis is not recommended prior to IUD insertion 
  • Actinomyces on cytology is an incidental finding 
    • No treatment or IUD removal required if patient is asymptomatic  

Pregnancy with IUD in situ 

  • Determine location of pregnancy to rule out ectopic pregnancy  
  • Remove IUD if strings visible as benefits outweigh risks  
  • If patient opts to retain IUD, counsel regarding risks (which are not totally eliminated by IUD removal) 
    • Abruption, placenta previa, preterm delivery, cesarean delivery, low-birth-weight infants, and chorioamnionitis  
    • Theoretical concerns regarding hormonal exposure with LNG-IUD  
  • If a patient opts for termination, remove at that time  

Ectopic pregnancy and IUDs 

  • IUDs do not increase the risk and therefore can be offered to women with history of ectopic pregnancy 
  • If pregnancy does occur with IUD in place, there is a small increased risk of ectopic pregnancy  

IUD Removal and Menopause 

  • Copper IUD: Wait for a year of amenorrhea before removal  
  • LNG-IUD: Continue until 50-55 years of age  (as amenorrhea may be related to LNG component)
    • Non-contraceptive benefit of protecting uterus in women using estrogen therapy 
  • IUDs do not need to be removed in menopausal women prior to expiration date 

Gyn Procedures with IUD in Place 

  • Endometrial biopsy, colposcopy, cervical ablation or excision, and endocervical sampling may all be performed with an IUD in place 

Backup Contraceptive Method  

  • Copper IUD 
    • No backup method required  
  • LNG-IUD & implant  
    • Backup required (e.g. condoms) for 7 days after insertion unless 
      • Immediately following surgical abortion  
      • 21 days from childbirth 
      • Transition from other reliable method 
      • Within 7 days of LMP for LNG-IUD 
      • Within 5 days of LMP for implant   

KEY POINTS:  

Underlying Mechanism

  • LARC devices do not disrupt pregnancy but rather disrupt fertilization  
  • Copper IUD 
    • Inhibits sperm migration/viability  
  • LNG-IUD 
    • Increased cervical mucus viscosity that prevents sperm entry  
  • Implant  
    • Suppresses ovulation 
    • Increased cervical mucus thickening  
    • Alters endometrial lining  

Adverse Events and Side Effects

IUDs 

  • Overall complications are uncommon and include expulsion (2 to 10%), method failure and rarely perforation (see ‘Related ObG Topics’ below)  
  • Copper IUDs 
    • Heavy Menses and pain  
      • LNG-IUD offers benefit of reduced menses, despite continued ovulation in majority of women  
  • LNG-IUD  
    • Minimal hormone released systemically 
    • Hormone related effects include headaches, nausea, breast tenderness, mood changes, acne and ovarian cyst formation  
    • No difference in weight gain compared to copper IUD  

Implants 

  • Amenorrhea or menstrual irregularity 
  • GI symptoms 
  • Hormonal effects: Headaches, breast pain and worsening acne (10-14%)  
  • Weight gain (reported in 12% of users) 
    • Literature shows no difference in weight gain at 1 year, after adjusting for confounders, between implant and IUD users 
  • Complications related to insertion (1%)  
    • Pain, bleeding, hematoma or incorrect insertion 
  • Complications related to removal (1.7%)  
    • Breakage or inability to palpate/locate the implant because of overly deep insertion 
    • Imaging techniques to identify location include high-frequency ultrasonography, MRI, X-ray, CT, or fluoroscopy 

Failure Rates (typical use)

  • Copper IUD  
    • 0.8 % (1 year)  
    • 10-year failure rate comparable with that of female sterilization (1.9 per 100 women) 
  • LNG-IUD  
    • 20 microgram release:  0.2% (1 year) 
  • Implant 
    • 0.05% (1 year)

Learn More – Primary Sources:

ACOG Practice Bulletin 186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices

SMFM Consult Series #48: Immediate postpartum long-acting reversible contraception for women at high-risk for medical complications

ACOG: Coding for the Contraceptive Implant and IUDs

Teenagers and Medical Care – When Is Parental Consent Not Required?

Adolescents are concerned about confidentiality and sometimes do not seek health care for this reason.  Myriad federal and state laws affect confidentiality of medical records in general.  However, it is the state that determines the statutes on the rights of minors to consent to healthcare services. Parents must generally consent before medical care is provided to their minor children; however, many states make important exceptions when it comes to sensitive services for which a parental consent requirement might deter an adolescent from obtaining needed care in a timely way. For example, all 50 states and the District of Columbia allow minors age 12 and older to access health care without parental consent for the treatment of STIs. Likewise, certain states and the District of Columbia allow minors to receive contraceptive services without notifying parents.  The access to these services helps reduce the transmission of STIs and prevent unplanned pregnancies. In most states, minors themselves may consent for substance abuse treatment, and in about half of the states, they are specifically authorized to consent to outpatient mental healthcare.

Furthermore, minors who may give consent can be divided into to two groups: mature minors and emancipated minors.

  • A mature minor is an adolescent younger than the age of majority. Such a minor can consent or refuse to consent to medical treatment if it is established that the minor is sufficiently mature to understand, discern and appreciate the benefits and risks of the proposed medical treatment. The age, ability, experience, education, training, and degree of maturity or judgment of the minor, as well as the conduct and demeanor of the minor at the time of the incident involved, all play a role.
  • To contrast, an emancipated minor is one who is legally free of parental control. A court ruling, marriage or enlistment in the U.S military for active duty are the most common scenarios. A minor who becomes a parent becomes the decision maker for the child.

Care of mature and emancipated minors is provided without parental consent or notification, although the physician will frequently work with the adolescent to involve parents in decision making, risk reduction, and ongoing health care. Of note, both mature and emancipated minors must still follow state laws on age-restricted activities such as voting and purchasing alcohol.

Health care providers should therefore be familiar with the regulations in their state of practice as minor consent laws vary between states. Institutions should be well-versed in state law to determine the degree of disclosure to parents/guardians that is permitted and/or required. If state law is not explicit, then institutions or individual providers should establish firm policies regarding the degree of confidentiality.

It is vital (and parents or guardians and adolescents should be informed, both separately and together) that the information each of them shares with the health care provider will be treated as confidential, and of any restrictions to the confidential nature of the relationship. Lastly, electronic health record systems need to be reviewed and possibly customized to accommodate the confidentiality needs related to minor adolescents and comply with the requirements of state and federal laws.

You can find a table with the state-by-state overview, broken down by contraceptive, STI, prenatal, adoption and abortion services at the Guttmacher Institute link below in ‘Learn More – Primary Sources’.

Learn More – Primary References:

ACOG Committee Opinion 803: Adolescent Confidentiality and Electronic Health Records

Guttmacher Institute: An Overview of Minors’ Consent Law

Confidentiality in Pediatric and Adolescent Gynecology: When We Can, When We Can’t, and When We’re Challenged

Adolescent and Caregiver use of a Tethered Personal Health Record System

LGBTQ Youth’s Perceptions of Primary Care

IUDs and Implants: How to Manage Potential LARC Complications

Use of long-acting reversible contraceptive (LARC) methods, both intrauterine devices and subdermal contraceptive implants, has increased dramatically in the past ten years.  Although the risk of complications is low, as use increases the absolute number of complications will increase.

CLINICAL ACTIONS:

Intrauterine device:

  • Pain
    • Lidocaine paracervical block reduces pain scores on insertion
    • Misoprostol does not improve pain scores and may be associated with nausea and vomiting
  • Strings not visualized
    • Rule out pregnancy and expulsion
    • Recommend backup contraception until IUD position can be verified
    • Recommend emergency oral contraceptives (if appropriate)
    • Ultrasound and X-ray of abdomen and pelvis can be used for localization
  • Possible expulsion
    • IUDs seen in the cervix are partially expelled and should be removed
      • Replacement or use of another method are both acceptable options
    • Low-lying IUDs (lower uterine segment) can be expectantly managed
  • Risk factors for expulsion include
    • Young age
    • Heavy menstrual bleeding and dysmenorrhea
    • Placement postpartum or post second trimester abortion
    • Presence of anatomic distortion of the uterine cavity
  • Uterine perforation
    • Is rare and generally asymptomatic
    • Usually occurs at the time of insertion
      • Do not use misoprostol routinely prior to insertion in nulliparous women but may be considered with difficult insertions
    • Rule out pregnancy and remove surgically unless the surgical risks of removal outweigh the benefits
  • PID
    • Can be treated with the IUD left in situ
    • Consider removal if no clinical improvement after 48-72 hours of antibiotics
  • Pregnancy with an IUD in place
    • Remove the IUD if the strings are visible or IUD within the cervix
    • IUD can be removed at time of procedure if patient elects termination
    • Evaluate for ectopic pregnancy

Implant:

  • Infection prevention
    • Use antiseptic technique and cover the insertion/removal site
    • Skin flora are the most common cause of infection
    • Remove implant if infection does not resolve
  • Bruising
    • Is common
    • Ice and anti-inflammatory medication can help
  • Nonpalpable implant
    • Locate with high frequency (>/= 10 MHz) ultrasound probe, two dimensional X-ray, or CT scan/fluoroscopy
    • Obtain a serum etonogestrel level if all studies are negative/equivocal
    • Refer to a surgeon with knowledge of the anatomy of the arm if implant is within muscle or neurovascular bundle
  • Pregnancy
    • Is rare
    • Remove the implant if the pregnancy is to be continued
    • Rule out ectopic pregnancy

SYNOPSIS:

LARCs are highly effective contraceptives with a low risk of complications.  Those mentioned above should be discussed with patients as part of informed consent.

KEY POINTS:

  • Recognition and prompt diagnosis/treatment of the untoward outcomes described above are important aspects of care
  • Overall, complication rates are low and LARCs remain a very effective mode of birth control

ICD-10 codes:

  • Z30.49 check/reinsertion/removal of implant
  • Z30.430 insertion of IUD
  • Z30.432 removal of IUD
  • Z30.433 removal and reinsertion of IUD

Learn More – Primary Sources:

ACOG Committee Opinion 672: Clinical challenges of long-acting reversible contraceptive methods

CDC Resources: Contraception in Women with Medical Conditions (US MEC)

The CDC US Medical Eligibility Criteria for Contraceptive Use (US MEC) is a major initiative that was created to guide “…the safe use of contraceptive methods among U.S. women with certain characteristics or medical conditions.” The guideline undergoes a major update every few years, with more targeted updates as needed based on new findings.

Open Access Resources

  • The CDC provides multiple resources to determine appropriate contraception in women with various medical issues
    • NOTE: The app has been updated so that healthcare professionals can now select up to 3 medical conditions or characteristics at once to view recommendations when counseling patients

US Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2016 | CDC
United States Medical Eligibility Criteria for Contraceptive Use