AAP Guidance on Emergency Contraception in teenagers

Paediatricians should be aware that sexual behaviour is prevalent among teenagers and that many sexually active teenagers may be the victims of sexual assault. Despite the availability of hormonal and long-acting contraceptives, the pregnancy prevention methods most commonly used by US teenagers are condoms and withdrawal. EC is an important back-up method to which all teenagers should have access.

Indications for use of EC include unprotected or under-protected intercourse, such as failure to use any form of contraception; sexual assault; and imperfect contraceptive use (eg, condom breakage or slippage and missed or late doses of oral contraceptive pills, contraceptive patch, contraceptive ring, or injectable contraception).

Paediatricians should provide ECPs (levonorgestrel or UPA) or Cu-IUD insertion to adolescents and young adults who are in immediate need of EC. In addition, the AAP recommends that paediatricians provide prescriptions and/or supply of ECPs (with refills and condoms) so adolescents have them on hand in case of future need (ie, advanced provision). When a visit is not possible, ECPs can safely be prescribed over the phone without requiring a pregnancy test.

ECPs are most effective in decreasing risk of pregnancy when used as soon as possible, but may be used up to 120 hours after unprotected or under-protected intercourse. Adolescents should be instructed to use EC as soon as possible after unprotected intercourse and to then schedule a follow-up appointment with their primary provider to address the need for STI testing and ongoing contraception.

Advanced provision of ECPs increases the likelihood that teenagers will use EC when needed, reduces the time to use, and does not decrease condom or other contraceptive use. Levonorgestrel ECPs are available to male and female patients regardless of age without a prescription but may be expensive when purchased over the counter and are often covered by insurance with a prescription. UPA is available by prescription only. Paediatricians should be aware that the stock of available ECPs, especially UPA, may vary by pharmacy and that local patterns of availability, cost, insurance coverage, and sources of low-cost EC in their practice area may affect the ability of their patients to obtain recommended services.

When a dedicated ECP product or Cu-IUD are not options, the use of combined oral contraceptive pills for EC (Yuzpe method) may be recommended. Adverse effects may include nausea, vomiting, and abdominal pain, and coadministration of an antiemetic may be considered with this method.

Meta-analyses have suggested that both levonorgestrel and UPA may be less effective in individuals who are overweight. Efficacy of the Cu-IUD is not affected by weight. Patients who do not wish to use a Cu-IUD or do not have access to IUD insertion should be offered EC pills regardless of their weight.

Repeat episodes of unprotected sex during the same cycle after the use of ECPs increase the risk of pregnancy because they work by delaying ovulation. Adolescents who use ECPs should be counselled to abstain or use another method to prevent pregnancy until their next period. Ongoing hormonal contraceptives may be initiated immediately after the use of levonorgestrel ECPs or the Yuzpe method. Ongoing hormonal contraceptives should not be initiated sooner than 5 days after the use of UPA to minimize the risk of interference with UPA activity. Nonhormonal methods (eg, condoms) may be initiated immediately after ECP use.

The AAP recommends that all adolescents receive counselling about EC as part of routine anticipatory guidance in the context of a discussion on sexual health and family planning regardless of current intentions for sexual behaviour. In addition, it is important that information about EC be included in all contraceptive and STI counselling for adolescents wherever these visits occur, including emergency departments, clinics, and hospitals. Information provided should include indications for use and options for access, including over-the-counter availability and advance prescription or supply if available in the clinic. It is important that paediatricians also provide this counselling to adolescents with physical and cognitive disabilities and their parents. At the policy level, paediatricians should advocate for low-cost or free, nonprescription access to ECPs for teenagers regardless of age and insurance coverage of EC without cost-sharing to further reduce cost barriers.