Barrier methods are particularly appropriate for young people. Compared to other methods, they are usually accessible, available and affordable. Youth can provide condoms directly to other youth, and condoms are readily available without prescription. They are effective immediately, are user-controlled and can be easily initiated and discontinued -- all advantages for youth.
Because barrier methods must be used correctly during every intercourse to be effective, counseling is needed for young adults to be successful users of these methods.
Using barrier methods also presents challenges for youth. Condoms in particular require partner participation and communication, difficult skills for most youth. Nevertheless, with counseling and training, condom use can encourage sexually active youth to talk about shared sexual responsibility, thus establishing patterns that may last into adulthood.
Barrier methods include the male condom and female-controlled methods -- spermicides, the female condom, diaphragm and cervical cap. The methods can be used alone, in combination, or with non-barrier types of contraception. All barrier methods are safe, have no systemic effects, and are relatively effective for preventing pregnancy. Some offer varying degrees of protection from STDs when used consistently and correctly. Only the diaphragm and cervical cap, which are not widely available in developing countries, require a clinic visit for proper fitting.
Latex condoms provide the best protection against STDs, including AIDS. Young people are particularly vulnerable to STDs because their sexual partners change more frequently than older adults, and some young adults have multiple partners. Also, young women are biologically more vulnerable to infections such as chlamydia because the exposed surface of the cervix is thinner than in older women.
Counseling about correct pill-taking is particularly important for young adults. The contraceptive effect of the pill wears off quickly once it is discontinued. This can be a problem for young women who may stop taking the pill when they break up with boyfriends, since they may resume the relationship or begin another and have intercourse before resuming pill use. Also, some youth may be less consistent pill users than older adults. Providers should encourage young women to link pill-taking to some daily routine to ensure correct use.
Pill use is independent of sexual intercourse and can be used without the male partner's knowledge or cooperation. Oral contraceptives (OCs) do not offer any protection against STDs, and thus providers should recommend that young adults at risk of STDs use condoms in addition to using the pill.
Young adults can safely use OCs containing both estrogen and progestin, which are very effective at preventing pregnancy when used consistently and correctly. OCs also provide non-contraceptive health benefits such as regular menses and protection against ectopic pregnancy, ovarian and endometrial cancer, and pelvic inflammatory disease (PID). Progestin-only pills, known as minipills or POPs, are slightly less effective at preventing pregnancy and more likely to cause breakthrough bleeding, compared with combined OCs. For minipills to be effective, they must be taken within three hours of the same time every day, a requirement that may be difficult for most young women.
Injectables are popular among many youth because they require only a periodic visit to a clinic or pharmacy. No supplies need to be kept at home, and a partner would not know a woman was using it. However, the difficulty of visiting the clinic or pharmacy may be a problem for young adults who want to use this method.
These hormonal contraceptives provide excellent protection against pregnancy but do not protect against STDs. They are safe for young people and, like the pill, have long-term, non-contraceptive benefits, including decreased risk of PID, ectopic pregnancy, and ovarian and endometrial cancers. Unlike pills, however, injectables and implants do not require a woman to take daily action, which make them easier to use for most young people. Two widely-used progestin-only injectables are available: DMPA (depot-medroxyprogesterone acetate), taken every three months; and NET-EN (norethisterone enanthate), taken every two months.
A progestin-only implant, Norplant, is effective for up to five years and is a good method for young women who know they do not want children for several years. Norplant requires a simple surgical procedure for insertion and removal.
These methods often result in irregular bleeding, spotting or amenorrhea, which may be of concern to some women. They often result in a delay in return to fertility, which could be important to young adults.
Theoretical concerns have been raised regarding use of progestin-only methods and bone density in women under age 16. Preliminary evidence suggests that long-term DMPA use may be associated with reduced bone density, but that this effect may be reversible after DMPA use is stopped.1 Adolescence is a time of rapid development in bone density and length. DMPA has been shown to lower estrogen levels, and estrogen is needed for developing and maintaining strong bones. Hence, using these methods could potentially predispose these women to osteoporosis in later life, but definitive studies have not been completed.
1. Cundy T, Evans M, Roberts H, et al. Bone density in women receiving depot medroxyprogesterone acetate for contraception. Br Med J 1991;303:13-16; Cundy T, Cornish J, Evans MC, et al. Recovery of bone density in women who stop using medroxyprogesterone acetate. Br Med J 1993;308:247-48.
Abstinence is the most certain way to prevent pregnancy and the transmission of STDs. It should be discussed as an option for young adults who have not initiated sexual intercourse and for those who have already begun sexual activity. Abstinence requires commitment, high motivation and self-control, making it difficult for many young adults to achieve.
Counseling should focus on gaining skills to cope with peer and partner pressure. Youth need to understand that sex is just one of many ways of expressing love and affection. Also, providers should ensure that youth have information and access to contraceptive options.
With careful screening, IUDs may be safely used by young women in stable, mutually monogamous relationships. For these women, it is important to counsel them to check for the IUD string regularly, to ensure the IUD has not been expelled. Women under age 20 who have not borne children may have an increased risk of expulsions and complications with IUD use.
Screening for STDs is particularly important. IUDs are not recommended for women at an increased risk of STDs. If a woman has had an STD in the last three months, she should not get an IUD until successfully treated. The insertion process can increase the risk of infection in the upper genital tract, leading to pelvic inflammatory disease. This in turn can lead to infertility. IUDs are very effective at preventing pregnancy, have few side effects, and are not expensive. IUDs do not protect against STDs.
For many youth, sex is largely unplanned and sporadic. Yet few youth know about the option of emergency contraception, which uses contraceptives after unprotected intercourse. Emergency contraception is an option when couples forget to use a barrier method or pill, use a method incorrectly, experience condom breakage or slippage, have unplanned sex with no contraceptives available, or if a woman is raped. It is not designed to be used as a regular method.
The most common approach to emergency contraception is to use a regimen of oral contraceptives. Higher doses of pills should be taken, the first within 72 hours after unprotected intercourse and the second dose 12 hours later. The dosage is achieved by taking multiple pills, typically four or two pills depending on the strength. Each dose should contain at least 100 mcg of ethinyl estradiol and 500 mcg of levonorgestrel. Used correctly, emergency contraception prevents about 75 percent of pregnancies that would otherwise occur.
Natural family planning methods may be the only options available for some young adults. However, to use periodic abstinence or withdrawal (coitus interruptus) successfully, couples must have a high motivation and self-control, characteristics that are especially difficult for young adults. Also, periodic abstinence requires a thorough knowledge of the menstrual cycle, which many young adults do not have.
In the months immediately after menarche, the menstrual cycle is not regular, making periodic abstinence difficult to practice. Also, periodic abstinence and withdrawal have very high pregnancy rates compared to other methods of contraception, and neither protects against STDs.
Sterilization is generally not an appropriate method for young adults since they are at the beginning of their reproductive years. Studies show that regret about having been sterilized is often associated with undergoing the procedure at a young age.1 Hence, it is extremely important for any young adult contemplating sterilization to know that this is a permanent procedure that should be considered irreversible. Reversibility is possible but is not always successful, and such services are not available in many locations.
There is a high probability that young adults, especially those without children, may experience changes in their lives and later desire to have children. Having received all of this information in counseling, a client also has the right to know there is no medical reason to deny this very effective method to a young adult based on age alone.
1. Wilcox LS, Chu SY, Eaker ED, et al. Risk factors for regret after sterilization: five years of follow-up in a prospective study. Fertil Steril 1991;55:927-33.
