If a pregnant adolescent chooses to terminate her pregnancy, she should be referred immediately to a nonjudgmental abortion service. The options for pregnancy termination depend on the gestational age. Surgical procedures include manual vacuum aspiration (<8 weeks’ gestational age), suction curettage (<12 to 14 weeks’ gestational age, depending on the provider), and dilation and evacuation (14 to 20 weeks’ gestational age). Early pregnancy (<8 weeks’ gestational age) can be terminated medically with oral mifepristone (RU-486) in combination with misoprostol, methotrexate with misoprostol, or misoprostol alone. Adolescents rarely present early enough to explore this option. In the second trimester (>12 weeks’ gestational age), labor induction and delivery can be effected by vaginal misoprostol or the intra-amniotic instillation of prostaglandins or hypertonic saline. Psychosocial support and subsequent contraceptive counseling and implementation should be available for adolescents who choose abortion.
Adolescents often begin intercourse without adequate birth control. Because unintended pregnancy can be associated with significant psychosocial morbidity for the mother, father, and child, prevention should be a primary goal. All methods of contraception significantly reduce the risk of pregnancy when used in a consistent and correct fashion. The best form of contraception is the one an individual will use. Contraceptives can be divided into user-based methods and LARCs. It is important to remind young women that steroidal contraception or LARCs do not provide any protection from STIs, and condoms should be used to reduce the risk of infection.
Abstaining from sexual intercourse is the most commonly used and most effective form of adolescent birth control. A degree of self-control, self-assuredness, and self-esteem is necessary. Adolescents who choose to be sexually active should be offered birth control, because there is a 70% chance of pregnancy in 1 year of regular, unprotected intercourse.
Combined oral contraceptives (COCs) contain a synthetic estrogen and progesterone that suppress gonadotropin secretion and ovarian follicle development and ovulation. COCs also produce an atrophic endometrium (inhospitable for blastocyst implantation) and thicken cervical mucus to inhibit sperm penetration. COCs are 99% effective if taken regularly and have numerous noncontraceptive benefits (decreased acne, less dysmenorrhea, and lighter menstrual flow). After a history and physical examination, COCs can be started on the first day of the next menstrual period or as a Quick Start. The Quick Start method refers to starting on any day of the cycle, usually on the day of the visit to the health care provider, as long as pregnancy has been ruled out. Contraindications and relative contraindications to COCs are listed in Tables 69-4 and 69-5. Blood pressure measurement to rule out preexisting hypertension should be obtained before prescribing a COC. Initially the adolescent should be seen monthly to reinforce good contraceptive use and safer sex. Unless adolescents show the ability to take a pill daily, contraception with COCs should be avoided. When COCs are prescribed, 28-day packets are recommended because they encourage a daily routine. One novel contraceptive regimen has packaged 84 active tablets to be taken sequentially followed by a 7-day hormone-free interval and the next package. Any COC can be used in such a fashion to induce long intervals between withdrawal bleeding.
Initial side effects, such as nausea (pills should be takenat night to reduce this), breast tenderness, and breakthroughbleeding (especially if pills are missed), are common andusually transient. COCs do not generally cause weight gain.Usually 3 to 4 months on one COC are needed to determineacceptability. If there is breakthrough bleeding, the physician