10/28/08njm

Q. Should I withhold contraception from a woman who is not 'current' on
her pap?

A. No, there should be no barriers to the use of FDA approved
contraception

With a 48% unintended pregnancy rate nationwide, the Indian Health
system adheres to the national benchmarks on this....namely that there
should be no obstacles placed in front of FDA approved birth control
methods.

Potential barriers could include....

[Real barriers:]{.underline} the legal standing of an adolescent in her
health care, having a 'current' pap smear, first pelvic exams performed
for 'baseline' data

[Perceived barriers]{.underline}: lack of confidentiality, fear of side
effects, sexual activity history documented in medical records

This is especially important now that cervical cancer screening has so
many permutations that aren't 'annual', but based on age, sexual debut,
and prior HPV status, etc....

...so while we encourage 'bundling' in some quality assurance issues
(induction of labor, etc...) the old bundling of cervical cancer
screening and birth control method is not recommended.

In the Indian Health system, the stated policy is that we support the
use of all FDA approved birth control methods, (see Chapter 13 below)

All of our recent meetings (the ACOG / IHS Postgraduate Course, our
biennial MCH/Women's Health meetings, etc...) have emphasized the Quick
Start system (see Westhoff below).

Questions about adolescent rights in your state?

Alan Guttmacher Institute:

Go to the **\"State Policies in Brief\"** links

[http://www.guttmacher.org/sections/adolescents.php?scope=U.S.%20specific](http://www.guttmacher.org/sections/adolescents.php?scope=U.S. specific)

See Meeting Lecture Notes - Authors: Ogburn, Espey

<http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm>

**Background:**

There is a 48% unintended pregnancy rate nationwide. Cervical cancer
rates in reproductive age women pale in comparison.

Let's look at adolescents as an example...

The pregnancy and abortion rates among adolescents in the United States
are higher than in other industrialized nations as a result of
intermittent, improper, and lack of use of contraception.

**INCREASING ACCESS TO CONTRACEPTION** --- Barriers that impede the
adolescent\'s access to contraception services should be recognized and
removed, when possible.

**Access to confidential services** --- The provider should recognize
and respect an adolescent\'s need for privacy as a basic premise for
providing confidential services. This goal can be achieved by
facilitating a relationship with an adolescent that is independent from
his or her parents.

The adolescent should be given an opportunity to provide her medical
history and to obtain gynecological and sexual information directly from
the clinician. Both the parents and the adolescent may need to be
educated regarding the new emphasis on direct interaction with the
adolescent, as this approach is different from the approach used when
children are younger and communication occurs primarily between the
clinician and the parents.

As an example, the following statement may be made to an accompanying
parent or guardian, \"I would like to make this visit a positive
experience for your daughter. It is important to respect an
adolescent\'s privacy as a normal part of her growing up. I would first
like to have the opportunity to review health information with you,
followed by reviewing health information with your daughter alone.
Usually, whatever is discussed between my teenage patients and me is
confidential, except in certain situations, such as if she has thoughts
of suicide, thoughts of physically harming someone, or reports she has
or is being physically or sexually abused. If you feel you need to know
more about what she and I have discussed, I strongly encourage you and
your daughter to talk to each other directly.\"

The age of the adolescent is a factor in whether she will choose the
option of complete confidentiality. A young teenager may express a
preference to have her mother present throughout the office visit,
particularly when the mother is aware of the teenager\'s sexual behavior
and is the one who desires the teenager to use a contraceptive method.
Despite such a situation, encouraging some independent time with the
adolescent is important to obtain a more detailed history about other
possible high-risk behaviors.

The provider who is not comfortable providing confidential contraceptive
services to a minor should provide names and phone numbers of other
clinicians or free clinics skilled in providing this care to
adolescents.

**Medical record** --- To keep certain portions of the sexual history in
the medical record private, all of this information should be contained
in a section identified as confidential. The confidential section may
then be released only with the adolescent\'s permission to a parent,
guardian, or other nonmedical party.

**Legal issues** --- A minor\'s right to access contraceptive services
in a health care setting without parental involvement varies from state
to state. Many states give adolescents the right to consent to
contraceptive services; no specific provisions have been found in
consent laws for minors in others. The need for parental consent also
may be related to state or federal funding for contraceptive services in
local clinics. Thus, a provider should become familiar with the rulings
in his or her own state and local clinic protocols.

**Deferring the pelvic examination** --- Many adolescents perceive the
pelvic examination to be a barrier to accessing contraceptive services.
A pelvic examination is necessary to obtain a Papanicalaou (Pap) smear
for cervical dysplasia and neoplasia and to test for sexually
transmitted infections (STIs), but is not required by the Food and Drug
for the initiation or reinstitution of oral contraceptives.

According to the American Cancer Society and American College of
Obstetricians and Gynecologists, cervical cancer screening by a Pap test
should begin approximately three years after first penile-vaginal sexual
intercourse or age 21 years, whichever comes first. If urine testing for
sexually transmitted infection (STI, gonorrhea and Chlamydia) is
available and a Pap test is not indicated, the speculum and bimanual
components of the pelvic examination may be deferred in an asymptomatic
adolescent. In all such cases, external genital inspection must be
performed. If urine testing is not available, swabs for gonorrhea and
chlamydia testing must be obtained directly from the endocervix via
speculum examination. A speculum and bimanual examination and microscopy
of vaginal secretions are necessary if the adolescent has gynecologic
and genital complaints such as an abnormal-looking discharge or
intermenstrual spotting. If urine testing is not available, swabs for
gonorrhea and chlamydia testing must be obtained directly from the
endocervix via speculum examination.

The first pelvic examination is a milestone for the adolescent and needs
to be a private and positive experience to foster communication on
sensitive topics between the adolescent and her healthcare providers.
Some clinicians offer their adolescent patients the option of having the
parent, partner, or a friend present for support during the examination.
If this option is offered, it is important to recognize the adolescent
may prefer to have the examination alone, but feels obligated to allow
her mother or partner to be present for the procedure. In any patient in
whom signs of physical trauma are noted, the adolescent should be
interviewed alone to elicit a history of possible physical or sexual
abuse.

Pelvic examination is not required by the Food and Drug Administration
(FDA) for the initiation or reinstitution of oral contraceptives. The
OCP package insert states: \"Physical examination may be deferred until
after initiation of oral contraceptives if requested by the woman and
judged appropriate by the clinician\". Thus, deferring the pelvic
examination may be considered at the first visit if the teenager has no
genital complaints (eg, abnormal vaginal discharge, pruritus, odor, etc)
and:

-   She has avoided going to a clinic or physician\'s office out of fear
    of a pelvic examination, or

-   She is having her menstrual period during the visit, or

-   Scheduling an appointment for initiating contraception involves a
    long delay because of the time allocated for complete physical and
    pelvic examination

-   

Teenagers appreciate that they have a choice in this matter. Subsequent
performance of the pelvic examination may be facilitated by making an
effort to alleviate fears related to the adolescent\'s perception of the
pain and embarrassment she thinks she will suffer from the procedure.
With appropriate education, one program found that among teenagers who
deferred the pelvic examination for the situations cited by the FDA, 69
percent returned for the pelvic examination at the three-month visit and
78 percent by the six-month visit.

**INCREASING CONTRACEPTIVE USE AND ADHERENCE** --- Oral contraceptive
pills (OCPs) are the most popular prescriptive contraceptive method used
by adolescents (44 percent), followed by condoms (37 percent), and depot
medroxyprogesterone acetate (DMPA) (10 percent).

Although a variety of hormonal contraceptive methods are available, this
discussion will focus on those commonly used by adolescents: OCPs and
DMPA. In addition, the transdermal patch will be discussed since it
appears to be increasing in popularity among adolescents. Use of the
vaginal ring is increasing among older adolescents who are comfortable
inserting it. There also is an emerging interest in the intrauterine
device. The approved progestin-only subdermal implant (single rod) is
effective for three years and is another viable option for adolescents
in the future.

Emergency contraception, which is discussed in detail separately, is
available by prescription and should be mentioned to all sexually active
adolescents.

**Motivating factors** --- The sexually active adolescent is more likely
to seek contraception in the following situations:

-   Perceiving pregnancy as a negative outcome

-   Having long-term educational goals

-   Being of older age

-   Experiencing a pregnancy scare or actual pregnancy

-   Having family, friends, and/or a clinician who sanction the use of
    contraception

Adolescents are more likely to use condoms if they understand condoms
can prevent HIV/AIDS, if they carry condoms and are not embarrassed to
use them, and if they are worried about getting AIDS.

**Initiating contraception** --- Adolescents vary in their readiness to
initiate contraception. From a developmental perspective, sexually
active girls in early adolescence have difficulty planning events and
activities; they often live for the moment. Therefore, implementing a
contraceptive method that requires planning and forethought is difficult
at this age without monitoring and adult support. Girls in middle and
late adolescence are more capable of higher-level planning, decision
making, and problem solving, skills essential to effective contraceptive
behavior.

**Education** --- Several points should be discussed at the time of
initiating a contraceptive:

-   Selecting the best method based on frequency of use and convenience

-   Risk of side effects

-   Tips on adherence

-   Use of condoms to protect against STIs

-   Practical suggestions to promote use, such as keeping condoms in a
    purse

-   The availability of and indications for emergency contraception

-   

Sometimes an adolescent is sexually active and does not desire a
pregnancy but is undecided about starting a method. In these cases, the
discussion should raise her awareness of her risk of pregnancy and STIs.
Reviewing stories of her sister(s), friends, or peers at school who are
teen mothers may be helpful. Girls who are not engaging in sexual
activity also should be educated about the use of condoms and emergency
contraception, in case their status changes.

In other cases, a nervous mother or grandmother may desire reliable
hormonal contraception for her daughter or granddaughter who is not yet
sexually active. The adolescent may have demonstrated an interest in
boys and/or may have an older sister who is a teenage mother. In these
cases, the clinician should have an open discussion with the adolescent
and the parent regarding parental fears, trust, and parent-monitoring
skills. Finally, the pros and cons of starting hormonal contraception in
an adolescent with growth potential should be considered against the
risk of pregnancy. Gaining the adolescent\'s trust, valuing her opinion,
and obtaining her consent for contraception in this case are important.

-   Selecting the best method --- A careful history should be obtained
    prior to beginning the counseling process. This step will help the
    clinician facilitate counseling regarding any possible absolute or
    relative contraindications to starting an estrogen-progesterone
    product.

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-   Anticipated adverse effects --- The anticipated side effects from
    hormonal contraception should be reviewed. Breakthrough bleeding or
    amenorrhea from OCPs, DMPA, and the transdermal patch can be very
    upsetting. These methods are likely to be discontinued unless the
    adolescent has been counseled about potential problems and their
    treatment. As an example, in one study of women treated with DMPA,
    women who were told about the possibility of amenorrhea were 2.5
    times more likely to continue DMPA than those not given this
    information.

-   

A rash and itching at the application site may be of concern to
adolescents using the transdermal patch. Partial or complete detachment
of the transdermal patch was reported in 35 percent of adolescents in
one study, compared with less than 5 percent in adults. Of note, no
detachments were reported when the patch was worn on the arm. The likely
explanation may be inadequate care in application and increased activity
among teenagers compared with adults.

-   Noncontraceptive benefits --- Reviewing the noncontraceptive
    benefits of OCPs, DMPA, and the transdermal patch with adolescents
    also is important. Benefits of OCPs and the transdermal patch
    include improved bone density and protection against ovarian cancer,
    endometrial cancer, salpingitis, ectopic pregnancy, benign breast
    disease, dysmenorrhea, and iron deficiency. The same benefits, with
    the exception of improved bone density, are provided by DMPA.

-   

**Informed consent** --- Although it is not necessary to obtain written
informed consent before the initiation of hormonal contraception in
adolescents, the use of a structured informed consent form can ensure
that the risks and benefits are adequately discussed. The form used by
Texas Children\'s Hospital for combination hormonal contraceptives is
provided as an example.

**Barriers to use and adherence** --- Barriers to the use of hormonal
contraception by adolescents include fear of side effects, some of which
are not substantiated by evidence.

**Fear of side effects** --- A fear of side effects from OCPs and DMPA
injections is a common barrier to the use of hormonal methods. As an
example, in one review, adolescents in a private practice setting were
overwhelmingly more concerned about weight gain from OCPs and those in
an urban hospital-based adolescent clinic were concerned about weight
gain, blood clots, birth defects, and infertility.

-   Weight gain --- Many adolescents are concerned that oral
    contraceptives cause weight gain. However, available data suggest
    this is not the case. In the review described above. adolescents who
    did not adhere to their OCPs were more likely to feel they had
    gained weight, although actual weight often was unchanged. Most
    young women did not gain more than 2.3 kg while using OCPs or 3.6 kg
    while using DMPA during a two-year period.

In another study, the effect of OCP use on body weight and fat
distribution was assessed in 49 healthy young women initiating treatment
with a low-dose OCPs (30 mcg ethinyl
[estradiol](http://www.uptodateonline.com/online/content/topic.do?topicKey=ped_drug/70684&drug=true)
plus 75 mcg gestodene); anthropometric measurements before and after the
initiation of OCP use were compared with those in 31 age-and-weight
matched women not using OCPs. Baseline body mass index (BMI), percent
fat, percent water, and waist-to-hip ratio (WHR) did not change
significantly after six cycles in the OCP users. A similar number of
women gained weight in both groups (30.6 percent of users, 35.4 percent
of controls); the typical weight gain in the OCP group was only 0.5 kg.
The weight gain in these women was caused by accumulation of fat, not
body water. Approximately 20 percent of women in both groups lost
weight. Thus, adolescents should be reassured that OCP use does not
result in an increase in body weight or percent body fat over that seen
in nonusers.

Adolescents also are increasingly concerned about weight gain from DMPA.
Although weight gain and DMPA use may be concomitant events, a causal
relationship has not been established. Factors other than DMPA may be
playing a role. As an example, in one study, after six months of DMPA
use, weight gain was greater among black than white subjects (4.2 versus
1.2 percent increase or mean weight gain of 2.9 versus 0.9 kg). A higher
baseline weight, eating restraint, eating disinhibition, and other
medications were predictive for weight gain in the black adolescents. In
contrast, the only predictive factor for weight gain in white
adolescents was a higher baseline weight. Thus, weight gain while using
DMPA appears to occur in adolescents with a propensity for weight gain.

-   Bone density --- DMPA and ultra low-dose estrogen (20 mcg) pills may
    interfere with achieving optimal peak bone mass in very young women
    by causing loss in bone density or interference with the increase
    during a time of expected bone accretion.

Rare cases of osteoporosis, including osteoporotic fractures, have been
reported postmarketing in patients taking DMPA. For this reason, the
United States Food and Drug Administration has a labeling change to
include a warning that DMPA be used as a long-term birth control method
(eg, longer than two years) only if other birth control methods are
inadequate.

It is important to review information regarding DMPA and bone density
with adolescents. The general opinion is that, if possible, DMPA should
be avoided in a girl during early adolescence. However, the data are not
sufficient to limit the use of the transdermal patch in adolescents; nor
are they sufficient to limit the use of DMPA in older adolescents. In
fact, some experts argue that for adolescents in whom DMPA is the only
acceptable contraceptive option, the benefit of pregnancy prevention
outweighs the potential risk to bone health. This conclusion is based
upon the following points:

-   Pregnancy also appears to decrease BMD

-   Most adolescents who use DMPA do so for less than two years

-   There is at least partial recovery of bone density after
    discontinuation of DMPA

-   The adolescent can modify other lifestyle factors to maximize bone
    health (ie, calcium intake, exercise, avoidance of tobacco use).

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-   Estrogen supplementation may provide additional bone protection and
    may be warranted for girls in whom BMD may already be decreased (eg,
    family history of osteoporosis, anorexia nervosa, chronic renal
    disease). The optimal dose and route for estrogen supplementation is
    not known; (0.625 mg equine estrogen per day is the only oral dose
    that has been tested).

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-   Spinal bone mineral density can be monitored with dual energy
    absorptiometry (DXA) and compared with normative data to determine
    whether DMPA should be continued or discontinued. DXA should be
    obtained in all young women who use DMPA continuously for two years.

-   

The Society for Adolescent Medicine has published a position paper
regarding the black box warning for DMPA. The position paper suggests
that:

-   With adequate explanation of benefits and potential risks, DMPA may
    continue to be prescribed to adolescent girls who need contraception

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-   Decisions regarding bone density monitoring of adolescents using
    DMPA for contraception should be individualized; the decisions
    should be made by the clinician in concert with the adolescent, and
    potentially the adolescent\'s guardian

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```
-   Duration of use of DMPA need not be restricted to two years

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```
-   Adolescents using DMPA should be encouraged to take 1300 mg and 400
    IU [[vitamin
    D]{.underline}](http://www.uptodateonline.com/online/content/topic.do?topicKey=ped_drug/27837&drug=true)
    and to exercise each day. Calcium and vitamin D supplements are
    available separately in tablet form or combined in a single tablet.

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```
-   Estrogen supplementation should be considered for girls who are
    doing well on DMPA and have osteopenia or are at risk for osteopenia
    and who have no contraindications to estrogen

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```
-   Pelvic inflammatory disease --- The relationship between OCPs pelvic
    inflammatory disease (PID) is complex. Whereas some studies indicate
    that the use of OCPs increases the risk of PID, others suggest that
    OCPs increase the risk for cervicitis and endometritis, but not
    salpingitis, thereby decreasing the severity of PID.

No association between DMPA and risk of PID has been reported. The
intrauterine device (IUD) itself does not increase the risk for PID.
However, the presence of the IUD may increase the severity of PID in an
adolescent due to their increased risk for STIs.

-   Venous thromboembolism --- The association between OCPs and risk of
    venous thromboembolism (VTE) appears to be related to estrogen dose
    and type of progestin. Even low-dose OCPs (30 to 50 mcg estrogen
    pills) can be associated with a modest increase (three- to sixfold)
    in the risk of VTE. OCPs containing third-generation progestins also
    may be associated with a slight increase in risk of VTE.

Many adolescents and their parents also have raised questions about the
reports of increased risk of VTE from the transdermal patch. The FDA has
required the label for the transdermal patch to contain a warning
regarding the possible increased risk of thrombotic events related to a
higher-than-average circulating estrogen level. This warning is
controversial because it is unclear whether the increased circulating
estrogen level will in fact be associated with a higher frequency of
adverse events.

The risk of VTE with OCPs or the transdermal patch should be considered
in relation to the risk of VTE during pregnancy. The risk of VTE may be
3- to 10-fold higher in pregnant than nonpregnant women.

Nonetheless, it is important to take a careful personal and family
history of deep venous thrombosis to identify those adolescent women who
might be at high risk before prescribing an OCP or the patch (eg, those
who have antiphospholipid antibodies or nephrotic syndrome).

-   Other effects --- Other side effects from OCPs of concern to
    adolescents include birth defects (11 percent) and infertility (10
    percent). Many adolescents hear about these effects from an adult
    who may have used higher-dose OCPs in the 1960s and 1970s or is
    otherwise misinformed. This situation underscores the importance of
    dispelling misconceptions about the adverse effects of OCPs, as well
    as DMPA, especially in adolescent women. There is no evidence to
    support an association between OCPs and either birth defects or
    infertility.

**Summary** --- The perceived adverse effects of hormonal contraception
is a real barrier to the use of this method among some adolescents.

-   Weight gain is a common concern. However, there is no evidence to
    suggest OCP use results in an increased body weight or percentage of
    body fat beyond that seen in nonusers. Among users of DMPA, weight
    gain appears to occur in those who have an underlying propensity for
    weight gain.

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```
-   DMPA and low-dose estrogen OCPs may interfere with the achievement
    of peak bone mass in very young adolescent women. The general
    opinion is that, if possible, DMPA should be avoided in girls during
    early adolescence. The data are not sufficient to limit the use of
    the transdermal patch in adolescents; nor are they sufficient to
    limit the use of DMPA in older adolescents.

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```
-   Low-dose OCPs are associated with a modest increase in the risk of
    venous thromboembolism.

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```
-   Inadvertent OCP administration during early pregnancy has not been
    associated with an increase in risk of congenital anomalies.

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-   OCPs do not increase the risk of infertility; in fact, the risk of
    primary infertility may be reduced in women who have taken an OCP.

**Choosing a method and promoting adherence**

**Here is just one example of a BCM to provoke thought...**

**OCPs** --- Common examples of adherence problems with OCPs include not
refilling OCP prescriptions, forgetting to take the pill, starting the
next pack late, using pills sporadically, and not using a backup method
when needed. In one study, 33 percent of adolescents missed a pill in
the previous three months. Therefore, the adolescent should be provided
clear verbal and written instructions. The clinician should ascertain
she has sufficient reading skills to interpret labels and instructions.
To optimize compliance with OCPs, an adolescent should be told only
three things to remember:

-   When to start the pill

-   Take the pill every day at the same time, especially when doing
    something else regularly like teeth brushing

-   Call the clinic/office if there are any questions

She should be asked to repeat these three instructions to assess and
promote her understanding of them. In addition, she should be given an
easy-to-read list stating the clinic\'s name, a contact person, phone
number, and instructions for when she misses pills. She should not rely
on her friends or family for information if she has a problem with her
medication.

-   When to start the pill --- OCPs can be started at any time. In
    adolescents, they are typically started on the first day of the next
    menstrual period or the Sunday after the onset of the menstrual
    period (\"Sunday start method\"). The rationale for this delayed
    start date is to make sure that the adolescent is not pregnant.
    However, as many as 25 percent of adolescents who seek OCPs from
    family planning clinics never take the first pill. Failure to begin
    the pill may occur due to ambivalence, confusion about starting
    instructions, or intervening pregnancy.

To address this issue, a \"same day\" or \"Quick start\" method is now
the preferred approach. The Quick start method requires increased
attention to the adolescent\'s self report of sexual activity since her
last menstrual period, the accuracy of the pregnancy test in the context
of her sexual history, and the use of emergency contraception when
applicable. (See Westhoff below)

-   Extended cycle pill or continuous pill use --- A schedule that
    involves continuous pill use for 84 days followed by a week of
    pill-free days may help to increase OCP adherence in adolescents who
    wish to avoid a monthly period. The desire to avoid monthly periods
    may be related to participation in athletic events or summer camps
    or to the general discomfort and \"hassle\" of monthly periods.

**Continuation rates** --- Continuation rates for OCPs in adolescents
vary based upon the location of services. In free urban community and
hospital-based clinics, rates after one year range from 9 to 40 percent.
By comparison, a 75 percent continuation rate was noted at one year in a
suburban practice. Intermittent use of contraception, method-switching,
and periodic abstinence appear to be common in African-American
adolescent females; in one series, one-third of such subjects on OCPs
reported frequent periodic abstinence in any month.

Intermediate continuation rates have been noted with DMPA. In a
retrospective chart review in an urban clinic, the one-year continuation
rates were 45 percent with DMPA and 12 percent with OCPs. Lower values
(32 percent at one year and 13 percent at two years) with DMPA were
noted among inner city, minority adolescents with high pregnancy rates.
Among those who discontinued therapy, 40 percent restarted the method at
a later time.

Data regarding adherence rates with the transdermal patch in adolescents
are limited. In one study of the feasibility and acceptability of the
patch in adolescents, 31 of 50 participants (62 percent) completed all
three-months of the study, and of these, 87 percent reported perfect
compliance and 77 percent planned to continue using the patch.

**SPECIAL CIRCUMSTANCES**

**The mentally handicapped adolescent** --- The mentally handicapped
adolescent has access to contraception under the supervision of a parent
or guardian. The availability of DMPA given every three months, the
transdermal patch, and continuous OCPs with withdrawal bleeding every
three months has significantly increased access to more convenient
hormonal contraception, improved adherence, and made menstrual hygiene
issues easier.

In most states, following an evaluation by three clinicians and
acquisition of parental consent, a mentally handicapped adolescent has
access to permanent sterilization after 21 years of age. In some states,
under special circumstances such as an ambulating, profoundly mentally
handicapped adolescent, sterilization of a mentally handicapped
adolescent younger than 21 years of age may be approved after a process
involving a review by an ethics committee and/or a court system.

**The chronically ill adolescent** --- Hormonal contraception for the
chronically ill adolescent can be a challenge. Estrogen-based hormonal
contraceptives, as an example, should not be offered to an adolescent
with significant valvular disease who is not being treated with an
anticoagulant. Although DMPA is useful in such cases, its effect on
fluid retention should be evaluated and monitored.

Similarly, estrogen-based hormonal contraceptives should not be offered
to an adolescent with antiphospholipid antibody abnormalities,
uncontrollable hypertension, and vascular involvement. DMPA is useful in
such cases; there have been no reports of SLE flares with long-term DMPA
use.

In addition, multiphasic or ultra-low OCPs are not recommended in
adolescents taking many anticonvulsants because anticonvulsants other
than [valproic
acid](http://www.uptodateonline.com/online/content/topic.do?topicKey=ped_drug/180190&drug=true)
increase the clearance of sex steroids. DMPA is a good alternative
because
[progesterone](http://www.uptodateonline.com/online/content/topic.do?topicKey=drug_l_z/212059&drug=true)
levels are high enough to be unaffected by increased P-450 activity.

Medications that alter the effectiveness of estrogen-based hormonal
contraceptives by increasing clearance of sex steroids include
[rifampin](http://www.uptodateonline.com/online/content/topic.do?topicKey=ped_drug/155269&drug=true),
[griseofulvin](http://www.uptodateonline.com/online/content/topic.do?topicKey=ped_drug/85209&drug=true),
and anticonvulsants. Herbal medication such as St. John\'s Wort also can
increase clearance of sex steroids. There are inadequate data to support
any significant drug interaction between common antibiotics and
estrogen-based hormonal contraceptives. Thus it is important the choice
of hormonal contraceptives be reviewed in the context of the chronic
illness, potential increase in estrogen-related complications, and drug
interactions during the counseling process. The risk of pregnancy needs
to be weighed against the risk of a medical complication from hormonal
contraception. In addition, emergency contraception should be discussed
with adolescents whose current treatment may be teratogenic to the fetus
or in whom pregnancy would severely compromise health.

**Resources:**

Westhoff C et al Initiation of Oral Contraceptives Using a Quick Start
Compared With a Conventional Start: A Randomized Controlled Trial.
Obstet Gynecol. 2007 Jun;109(6):1270-1276.

<http://www.ncbi.nlm.nih.gov/pubmed/17540797>

Chapter 13 - Maternal and Child Health

Section 3-13.12 F, IHS Manual, Part 3 - Professional Services,

Contraceptive Services - All available Food and Drug Administration
(FDA) approved types of contraceptive (mechanical, chemical and natural)
methods should be available to those clients requesting such services.
The choice of method will be that of the patient based on a careful
explanation of each method in accordance with the medical judgment of
the provider. Adequate follow-up should be available to respond promptly
to complications or side effects of the various methods as well as to
assure proper and effective use of the selected method.

<http://www.ihs.gov/PublicInfo/Publications/IHSManual/Part3/pt3chapt13/pt3chpt13.htm#12f>

Issues concerning the use of hormonal contraception by adolescents

<http://www.uptodateonline.com/online/content/topic.do?topicKey=adol_med/2363&selectedTitle=2~150&source=search_result#6>