17.2 Contraception, Confidential Care & Pregnancy

This section is contraception, confidential adolescent care, and pregnancy — still clinical category #10, now Domain III as much as Domain II. AAP statements and CDC U.S. Medical Eligibility Criteria (MEC) are the method language. You match effectiveness, STI protection, medical eligibility, and the method she will actually use, not your personally favorite pill. You also practice confidentiality with named limits without inventing a state's minor-consent age.

Clinic opening. A 16-year-old, privately, wants contraception. She is nulliparous. A colleague says IUDs are for women who have had children and that a parent must sign because she is 16 "in every state." If you withhold the most effective reversible methods or invent a statute, you missed this section.

Quick Answer: LARC — levonorgestrel or copper IUD, and the etonogestrel implant — are first-line by effectiveness. CDC MEC does not forbid IUDs for age or nulliparity alone. Combined hormonal methods versus POP versus DMPA: the shot can delay return of fertility and decrease BMD while used — counsel calcium, vitamin D, and weight-bearing activity; do not withhold solely for bone if it is the method she will use. Condoms prevent STI. Emergency contraception is time-sensitive. Many states allow minors to consent to confidential contraceptive and STI care — know the principle and your jurisdiction; do not invent one state's age. Pregnancy: urine hCG, options counseling, refer; ectopic red flags to the ED. Prenatal vitamins with folic acid if continuing.

Effectiveness first: LARC is first-line counseling

Typical-use failure is why AAP puts long-acting reversible contraception at the front of the adolescent conversation. Perfect-use tables flatter daily pills. Adolescents miss pills.

CDC MEC assigns categories 1–4 (1 unrestricted, 2 advantages generally outweigh risks, 3 risks usually outweigh advantages, 4 unacceptable health risk). You are not memorizing every cell. You are expected to know: age under 20 and nulliparity are MEC 2 for IUDs — not a ban. Current PID, unexplained suspicious vaginal bleeding, pregnancy, and distorted uterine cavity are different problems. Quick start after a negative pregnancy test, with a backup method as indicated, beats a "come back on day 1 of your next period" ritual that loses the patient.

Screen for gonorrhea and chlamydia per CDC when indicated. You do not delay an IUD solely to wait for cultures in an asymptomatic adolescent if you can treat a later positive. The implant is a minor office procedure with device-specific training; if you do not insert, refer promptly. Do not default to a less effective method because your clinic lacks an inserter this week.

Same-day IUD insertion counseling includes peri-insertional cramping, a change in bleeding pattern (LNG often lighter; copper often heavier), and rare expulsion or perforation. Infection risk clusters around insertion when cervical infection is present — that is an argument for NAAT, not an argument that teenagers cannot have IUDs.

Combined hormonal, POP, and DMPA — the exam distinctions

Combined estrogen-progestin methods (combined oral contraceptives, transdermal patch, vaginal ring) prevent ovulation, stabilize bleeding, and treat dysmenorrhea and much of adolescent PCOS bleeding. Teach consistent use, quick start versus Sunday start, and ACHES warning symptoms (severe Abdominal pain, Chest pain, Headaches, Eye problems, Severe leg pain) as VTE and stroke red flags — rare in healthy teens, still taught. Migraine with aura is a standard reason to avoid combined estrogen. Uncontrolled hypertension and known thrombophilia are others. Smoking is a larger MEC issue at age 35 and older; do not pretend a 16-year-old smoker automatically has a 35-year-old's MEC 4, but do counsel tobacco and still consider progestin-only or LARC as cleaner choices. The patch can have higher estrogen exposure; follow current product and CDC language rather than improvising a BMI cutoff from memory if you are unsure.

Progestin-only pills avoid estrogen. Traditional norethindrone POPs are time-strict. They are an option when estrogen is contraindicated and in selected postpartum or breastfeeding contexts. They are not "the weak pill you give because she is young."

DMPA (medroxyprogesterone acetate), intramuscular or subcutaneous every 13 weeks, is highly effective when on time. Counsel two famous effects:

1. Delayed return of fertility — not sterilization. Median time to conception is many months after the last injection (often taught around 10 months from the last dose, with wide scatter). If she wants pregnancy in the next few months, DMPA is the wrong method.
2. Bone mineral density — DMPA is associated with reversible BMD decline during use. An FDA boxed warning exists. AAP and CDC do not restrict duration solely because of bone in adolescents when DMPA is otherwise the acceptable method. Counsel calcium, vitamin D, and weight-bearing activity. Do not order DEXA as a routine barrier to the shot. Do not scare her onto condoms-only because of the boxed warning if she will not use LARC or daily pills.

Amenorrhea on DMPA is common and can be a benefit. Early irregular bleeding is expected. Discuss weight change honestly without moralizing. Bring her back on time: a shot that drifts to 16 weeks is how typical-use failure appears.

Missed combined pills get a simple office script: take the most recent missed pill, use backup for 7 days if she missed enough consecutive active pills that ovulation risk returns, and offer EC if unprotected sex occurred in that window. You do not need a 40-row missed-pill appendix memorized; you need to not tell her to stop the pack and "wait for a period" after two missed pills.

Condoms, dual method, and emergency contraception

External or internal condoms are the method that reduces HIV and other STIs. LARC does not. The CPNP-PC script is dual method: highly effective pregnancy prevention plus condoms for infection, especially with new or multiple partners. Do not tell a 17-year-old on an implant that condoms are optional because "you're covered." Covered for pregnancy. Not for gonorrhea.

Emergency contraception (EC):

• Levonorgestrel 1.5 mg oral: sooner is better, labeled through 72 hours, with some efficacy through 120 hours. Counsel how to obtain it before she needs it (advance provision).
• Ulipristal acetate 30 mg: prescription, effective through 120 hours, generally more effective than LNG as BMI rises. Delay restarting hormonal contraception per current CDC timing because ulipristal is a progesterone-receptor modulator.
• Copper IUD: the most effective EC if inserted within 5 days, and it remains ongoing contraception.
• Do not require a pelvic exam, STI cultures, or a Pap to give oral EC. A pregnancy test is reasonable; do not delay EC for a next-week gynecology slot.
• EC does not interrupt an established pregnancy. Counsel that fact without a political speech. Repeat EC use is a cue to start ongoing contraception, not a reason to shame.

If she vomits soon after oral LNG, repeat per product guidance. The next menses may be early or late; a pregnancy test is due if she does not bleed. EC is not a reason to skip HIV and CT/GC screening when the encounter was otherwise unprotected.

Confidentiality versus mandatory reporting — principle, not a fake statute

AAP supports confidential sexual and reproductive health services for adolescents. Many U.S. states and jurisdictions allow minors to consent to contraception, STI testing and treatment, and pregnancy-related care without parental permission. The exact age, which services, and whether the clinician may inform a parent over the minor's objection vary by state. Do not invent a number ("in this country everyone 14 and older…") on the CPNP-PC. Teach the principle: know the law where you practice; many states allow confidential contraceptive and STI care; HIPAA treats 18-year-olds as adults; explain confidentiality and its limits in front of the caregiver at the start of adolescent visits so private time is not a surprise.

Limits that break confidentiality (safety, not a contraception technicality):

• Suicidal or homicidal ideation or plans
• Child abuse and sexual abuse, including a non-consensual encounter that meets your jurisdiction's reporting definition (age discordance, force, caregiver perpetration)
• Additional reportable conditions in some states — still do not fabricate a statute

You may encourage the adolescent to include a trusted adult. Encouraging is not forcing disclosure of consensual sexual activity when the law protects confidentiality. Billing statements and after-visit summaries that list "IUD insertion" can blow confidentiality at home — anticipate confidential communication, alternative contact numbers, and how the explanation of benefits will read.

If a parent demands to sit in for the entire visit, explain the clinic's adolescent-privacy routine as standard care, not as a secret. If the adolescent discloses a safety limit, you protect her and involve needed adults. Vaping, contraception, and STI testing are not in the same bucket as a suicide plan (well-child and mental-health chapters already drew that line).

Pregnancy: test, counsel options, catch ectopic

Urine hCG is the office test. Any adolescent with secondary amenorrhea, irregular bleeding, pelvic pain, breast tenderness plus a missed period, or "I need a checkup" after unprotected sex gets a test, not a lecture first. False reassurance from withdrawal is how you miss the diagnosis.

A positive test in primary care is three jobs:

1. Viability and location are not proven by urine hCG. If there is unilateral pelvic or abdominal pain, vaginal spotting, dizziness, shoulder-tip pain, syncope, or hemodynamic instability, this is ectopic until proven otherwise — ED now, not a prenatal-vitamin handout and a next-week obstetric slot. Prior PID, prior ectopic, and IUD in situ raise pretest probability; absence of those risks does not exclude ectopic.
2. Options counseling is non-directive: continue the pregnancy and parent, adoption, or abortion where legal and available. Provide accurate information and timely referral. Do not coerce, delay until a first-trimester window closes, or substitute your values for hers. Involve a parent when she agrees or when law requires; still treat her as the patient.
3. If continuing: start prenatal vitamins with folic acid 400 mcg daily (higher dose, commonly 4 mg, if a prior neural-tube-defect-affected pregnancy or selected high-risk conditions — look up rather than guessing every indication). Stop teratogens when you can (isotretinoin is the classic). Refer to obstetric or prenatal care. Screen for intimate-partner violence. Dating by last menstrual period is a start; ultrasound lives with prenatal care. Do not perform a Pap as the first pregnancy action in a 17-year-old. Do not prescribe combined estrogen for "cycle regulation" without a pregnancy test.

Exam traps. Withholding IUDs for nulliparity. Treating DMPA's BMD label as an absolute duration limit. Skipping condoms because she has an implant. Requiring a pelvic exam for oral EC. Inventing a state minor-consent age. Sending unilateral pain plus a positive hCG home on vitamins. Starting a combined pill without a pregnancy test.

Clinic close. Effectiveness first: implant and IUDs. MEC: adolescence is not an IUD ban. Combined versus POP versus DMPA — know bone and fertility delay for the shot. Condoms for STI. EC this visit, not next week. Confidential contraceptive and STI care is a many-states principle; reporting is for safety. Pregnancy test, options, refer; ectopic does not wait.