Contraception in the under-16s

Introduction
The teenage pregnancy rate in Britain remains
alarmingly high (Table 1).1 It is the highest in
Europe: six times higher than the Netherlands and
twice as high as France or Germany.2 However,
whilst about one third of under-16s admit to being
sexually active,3 the same as in the Netherlands,
Dutch teenagers are far more likely to use reliable
contraception at the beginning of their sexual lives.
British teenagers have sex and relationship
education at school4 but many young people report
that they are already sexually active.Teenagers often
seem unprepared for the first time they have sex
and give various reasons for not using condoms as
protection; for instance,‘We did not have a
condom’,‘We were not expecting to do it that night’
or ‘I did not know him well enough to ask him if he
had a condom’.
There is also a high level of sexually transmitted
infections (STIs) in the teenage population in
Britain: currently, the highest number of positive
tests for Chlamydia trachomatis is found in women
under the age of 20 and men in the 20–25 age
group.5 Doctors should exercise the opportunities
in their role to raise awareness in young people
about the risks of unprotected sex, to educate and,
of course, to protect them. A teenager will
sometimes visit their general practitioner (GP) to
consult about a sports injury, a sore throat, acne or
other ailments unrelated to sex but this does give
the GP an opportunity to discuss lifestyle choices
with the young person and, of course, these will
include their views on sexual activity.Young
women often attend a gynaecological consultation
with their mother: there may be an opportunity to
see the young woman alone for at least part of the
consultation to discuss with her whether or not she
is sexually active, as she may not always give a true
account with her mother present.
The contraceptive consultation
Young women do, of course, specifically seek help
with contraception but this is often a crisis
situation, for instance, if they need a pregnancy test
or emergency contraception. They will make a
choice as to where to attend depending upon their
knowledge of services. This is often gained from
asking friends or looking on the internet. If the
young woman has a good relationship with her GP
she will usually seek help at the surgery in the first
instance, but in the case of an emergency this can
sometimes be difficult as there may be no
appointments available.
In some areas the emergency contraceptive or
‘morning-after’pill is available free of charge to under-
16s from the local pharmacist.In this case,the
pharmacist is trained to hold the necessary consultation
and give advice about ongoing contraception but the
latter does still require a prescription.
Some young women seek help at young persons’
clinics run by local family planning services, or at
specialist young peoples’ services, such as the Brook
Centres. It is vital that the clinician who sees the
young woman is well trained in carrying out this
sensitive type of consultation. Clinicians should
introduce themselves by name and explain their
role, for example, medical or nursing.The views of
young people about their ideas for a good
consultation have been sought and their first
requirement is the assurance of confidentiality by
the health professional.6 All health professionals
who see young women under the age of 16 without
parental consent must adhere to the Fraser
guidelines,which emanated from the Gillick vWest
Norfolk and Wisbech AHA case of 1986 (Box 1).7
It is important to ascertain the nature of the sexual
activity and whether this was consensual between
two young people. Although sex under the age of 16
is not deemed legal in the UK, this occurs
sufficiently often at the experimental and risktaking
stage of young peoples’ lives for the law to be
unenforceable. Sometimes, the young woman will
not have indulged in activity that we would
consider has put them at risk, for example, close
genital contact while fully clothed, but this is a good
opportunity for education. On the other hand, the
clinician must be alert to any abusive or coercive
sexual activity and take necessary action.8 If a
clinician is concerned about a case of underage
sexual activity he should discuss the case with the
child protection lead for his organisation or place of
work. In a consensual situation, it is important to
ascertain whether this incident was an isolated
Year Number Rate/1000 %TOP
Under-16s
1998 7855 8.8 52.9
1999 7408 8.2 53.0
2000 7620 8.3 54.5
2001 7407 8.0 56.0
2002 7395 7.9 55.7
2003 7558 7.9 57.6
2004 7181 7.5 57.6
2005 7462 7.8 57.4
Under-18s
1998 41 089 46.6 42.4
1999 39 247 44.8 43.5
2000 38 699 43.6 44.8
2001 38 461 42.5 46.1
2002 39 350 42.6 45.8
2003 39 553 42.1 46.1
2004 39 593 41.5 46.0
2005 39 683 41.1 46.9
TOPtermination of pregnancy
Table 1
Teenage pregnancy rates in
Britain.1 (Crown copyright material
is reproduced with the permission
of the controller of HMSO.)
Box 1
Assessment of Fraser competence
• The value of parental support must be discussed.
• Is the young woman in, or about to begin, a sexual
relationship?
• Will the physical or mental health of the young woman suffer
if she is not given advice or contraception?
• Is it in the young woman’s best interests to be given advice or
contraception without parental consent?
• Is the young woman mature enough to understand the
advice that is given to her?
occurrence or whether the sexual activity is
continuing and ongoing contraception is required.
The clinician should assess whether it is in the
young woman’s best interests to be prescribed
contraception and whether she is mature enough to
comprehend the advice given. They will then be
able to discuss contraceptive choices.
The contraceptive pill
The contraceptive pill (‘the pill’) is the method
most commonly known to young women and the
first choice of contraceptive prescribed by the
majority of doctors.However, long-acting
reversible contraception (LARC) methods9 may
actually be more appropriate for teenagers.
Young women will have some degree of knowledge
of contraception and, inevitably,preconceived ideas
about certain methods: the clinician needs to explore
these and find out what the young woman wants.
They may have a rather contrary view about the use
of a method such as the pill and feel that it has a role
in long-term relationships, not as protection against
pregnancy in casual relationships. There is a feeling
amongst some young women that starting the pill
means making a commitment to a partner that they
are not ready to give. It should also be remembered
that their information about a method might have
come mainly from friends and relatives, not health
professionals or through sex and relationship
education at school.They may well focus on negative
views of the method, such as fear of weight gain,
irregular bleeding or fertility problems, maintaining
that they know someone who took it and was unable
to become pregnant later in life, yet at the same time
talking about a friend who became pregnant while
taking the pill.
The role of the doctor is to explain the mode of
action of the method and to help weigh up the
benefits and side-effects. The main benefit to a
young woman is, of course, reliability, but the
noncontraceptive benefits, such as a reduction in
menstrual loss, dysmenorrhoea and the incidence of
ovarian cancer,may also be important, although
they can seem rather remote issues to a teenager. It is
wise to cover potential minor side-effects in this first
consultation, for example, breast discomfort or mild
headaches, but also to emphasise that these are
temporary and will diminish after the first pack or
two.Young women seem relatively unconcerned
about more serious potential risks such as venous
thromboembolism; even so, the relative risk should
be put into proportion for them.10
In spite of all the care and attention given in a good
and informative consultation, some young women
are poor pill users who often forget to take them.11
Older women are able to keep them on display, such
as on their bedside table or with their make-up or
toothbrush, where they will see them and not forget
to take them.However, young women are often
unable to do this, as they may be hiding them from
their parents. It is helpful to give these women
strategies to remember to take the pill daily. The
most useful tool is their mobile phone: they should
be advised to set a reminder alarm on the phone, as
it is generally at their side day and night.
The actual combined oral contraceptive failure rate
in the first year of use is 6–8 pregnancies per 100
women.A retrospective study12 of young women in
Nottingham who had become pregnant in one year
showed that 50% of them had been prescribed the
pill by their GP in the year leading up to the
pregnancy.The question remains as to why they had
not complied with the medication. The conclusion
was that the consultations had been shorter than the
average GP consultation time, possibly because of
embarrassment and discomfort on the part of the
young woman and/or doctor.Young women tended
to seek out the female partner in the practice for the
contraceptive consultation.
The contraceptive consultation with a young
woman takes time, as the doctor has to listen to her
needs and explain the method in detail. It is
advisable to give back-up literature, as the young
woman may only remember a small fraction of the
discussion. They will have further queries after the
consultation to feel secure in their decision to use
this method and they should be given a telephone
contact number or address of a website (see
Websites).Brook has a manned telephone helpline
for young people .
The contraceptive patch
Containing ethinylestradiol and norelgestromin,
this is marketed as EVRA and has a place amongst
contraceptive choices for young women. It is a
means of delivering estrogen and progestogen
contraception via the transdermal route. The
activity profile is very similar to oral contraception
but the advantage to the adolescent is that she only
needs to remember to change the patch once a
week:However, in the 4-weekly cycle there is one
patch-free week: she still has to remember to restart
her patches after this.
Long-acting reversible
contraception
Bearing in mind the difficulties some young women
have with compliance, it is advisable to consider
longer-acting contraceptive methods (Box 2). Since
the subdermal implant, Implanon (etonogestrel
implant), was licensed in 1999, it has grown in
popularity with young women. The National
Institute of Health and Clinical Excellence (NICE)
produced guidelines in October 2005, Long-acting
Reversible Contraception,9 emphasising the role of
these methods in young women.
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Review 2008;10:22–26 The Obstetrician & Gynaecologist
2008 Royal College of Obstetricians and Gynaecologists
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The Obstetrician & Gynaecologist 2008;10:22–26 Review
2008 Royal College of Obstetricians and Gynaecologists
The implant is described in the literature as a
contraceptive rod about the size of a hairgrip.Young
women do not like this description, as they have a
perception of something hard, large and sharp being
inserted into their arm. I describe Implanon as a
soft, flexible tube and show them the demonstration
implant, allowing them to feel and hold it: this
makes the method far more acceptable to them.
Implanon contains 68 mg etonorgestrel and, in the
initial phase, 60–70 micrograms is the daily
measurable blood level, falling to 30–40 micrograms
after a few weeks. The insertion technique is simple
and acceptable to young women, being virtually
pain free after local anaesthetic injection.
The main advantage of the method is its high level
of efficacy,with a failure rate of 0.1% over 3 years.
Minor side-effects, such as occasional skin
problems and weight gain, occur in 10% of users.
However, irregular bleeding is more common and it
is important to counsel the young woman about
this problem, which is common with most forms of
progestogenic contraception.About 33% of users
discontinue the method in less than 3 years because
of irregular bleeding.9 The NICE guidance was
updated in June 2006 to advise that irregular
bleeding is best treated with mefenamic acid or
ethinyloestradiol. This method has become more
popular with young women in the first 5 years of
availability in the UK: in our young peoples’ service
at the London Brook Centres we inserted 350%
more implants in 2005–06 than in 2000–01.
Implants may only be inserted by doctors or nurses
who have completed the accredited training of the
Faculty of Sexual & Reproductive Healthcare
(FSRH) of the RCOG or the Royal College of
Nursing and it is important that more clinicians
complete the training to increase availability of the
method to young women.
Injectable contraception
The most commonly used injectable contraceptive
in the UK is medroxyprogesterone acetate (DMPA,
marketed as Depo-Provera).Young women often
choose this method as it has the advantage of
12 weeks’ contraceptive protection without the
need to remember to take pills daily.While irregular
bleeding can occur with the implant, after two to
three injections of Depo-Provera amenorrhoea
usually develops. Initial counselling about the
method needs to cover this side-effect, as young
women will become anxious about amenorrhoea
and suspect that they are pregnant unless they have
been warned to expect this.
There has been evidence of possible reduced bone
mineral density with Depo-Provera use in excess of
2 years13 and the ChiefMedical Officer issued an
urgent communication in November 2004 about
the prescription of this method to young women
under the age of 19.14 In this case, Depo-Provera
should be used only where no other method is
suitable or acceptable to the young woman, as per
the NICE guideline on LARC.9
Intrauterine devices and
systems
The NICE guidance9 emphasises that younger
women should not be considered unsuitable for
these methods: they can be used in nulliparous
young women and there are no restrictions to the
use of intrauterine devices (IUDs) or intrauterine
systems (IUSs) in adolescents. The slimline IUD
already exists for the smaller uterine cavity. In my
own experience,working in a young persons’
specialist service with very young women, the main
use of the IUD is as an emergency contraceptive,
where a young woman has had unprotected sex at a
fertile time of the cycle and does not present until
more than 3 days after the event, or where there
have been multiple episodes of unprotected sex
since the previous period.
Young women can be anxious about the procedure
and a careful explanation of the method, its mode
of delivery and the benefits and side-effects usually
alleviates this.As the rate of C. trachomatis
infection is high in this age group, it is essential to
take an endocervical chlamydia swab and to give
antibiotic cover for the fitting of the IUD or IUS, as
stated in the FSRH guidance on IUDs.15
Some practitioners are concerned about the ethical
issue of using an invasive method in a young
woman.However, all young women are able to give
their consent to the procedure provided that they
understand what is to be undertaken, believe in it
and retain the information long enough to give
informed consent.
Barrier methods
The condom is the contraceptive method most
commonly used by young people and this is to be
encouraged.The methods previously described do
not protect the user from STIs: ‘double Dutch’, the
use of a contraceptive method and a barrier
method, should be encouraged in this age group.
Box 2
Use of long-acting reversible
methods of contraception
in teenagers
These are suitable for:
• young, nulliparous women
• administration immediately following termination of
pregnancy
• young women with diabetes
• young women with a body mass index 30
• migraine aura sufferers
• young women with contraindications to estrogens
Choices for adolescents include:
• IUDs, IUSs, implants: no specific restrictions to their use
• DMPA: care is needed—use only if other methods
unacceptable or unsuitable