Combination hormonal methods, including oral contraceptive pills,
the contraceptive patch, and the contraceptive ring are the contraceptive methods
of choice for many adolescents soon after their sexual debut because
using these methods is independent of sexual intercourse. The mechanism
of action for combined hormonal contraception, regardless of the
mode of delivery of the estrogen and progestin, includes the inhibition
of ovulation through the hypothalamic and pituitary effects of the
exogenous hormones. A reduction of gonadotropin-releasing hormone
(GnRH) pulses as well as decreased pituitary responsiveness to GnRH results
in the suppression of luteinizing hormone and follicle-stimulating
hormone production, inhibiting ovulation. The thickening of cervical
mucus, which inhibits sperm transport and decreased sperm capacitation
(the ability of the sperm to enter the egg) are additional mechanisms
of action primarily attributable to progestins. Such hormonal methods
are generally safe and highly effective, but because they afford
essentially no protection against sexually transmitted diseases
including human immunodeficiency virus, the additional use of condoms is
recommended. Dual method (hormonal contraception plus condom) use,
however, is reported by less than a quarter of sexually active adolescents.1
Combined hormonal contraceptives are associated with a number
of minor side effects, including nausea, breast tenderness, occasional
weight gain, and breakthrough bleeding, especially within the first
3 months of use. There are also absolute and relative contraindications
for use of hormonal contraception, which must be compared to the
risk for pregnancy on an individual basis. Absolute contraindications
include abnormal vaginal bleeding of unknown cause, estrogen-dependent
tumor, liver disease, thromboembolic disease, and cerebrovascular
disorders. Relative contraindications include metabolic diseases
such as diabetes mellitus, current seizures, vascular headaches
(migraine) with aura, and marked hypertension. Diseases of other
organ systems that may be considered as contraindications to hormonal
therapy include sickle cell disease, depression, and hepatic, pancreatic,
cardiovascular, renal, and neurologic diseases. In addition, increased
cardiovascular complications have been shown in older women of reproductive
age who smoke, but for healthy young women, the absolute risk of
cardiovascular disease is low, so use of combination hormonal contraception,
even in the adolescent who smokes, is safer than the risks of pregnancy.5 Weight
is also a factor to be considered when prescribing the contraceptive
patch. A patient weight over 198 lbs. is associated with reduced
contraceptive patch efficacy.
Constant advances are being made in combination hormonal contraception.
New formulations, dosing regimens, and delivery methods have expanded
the options for young women choosing these methods.