A 16-year-old girl comes to the office with her mother for a contraception consultation. The patient recently became sexually active with her boyfriend of 6 months, and they use condoms for contraception. She has regular monthly menses, with 4 days of vaginal bleeding. On the first day of her menstrual period she often has heavier bleeding and mild cramping relieved by nonsteroidal anti-inflammatory drugs. Her last menstrual period was 2 weeks ago. The patient has no chronic medical conditions or previous surgeries. Family history is significant for osteoporosis in her maternal grandmother and an aunt, but is otherwise noncontributory. She does not use tobacco, alcohol, or illicit drugs. She has no known drug allergies. Blood pressure is 118/68 mm Hg and pulse is 72/min. BMI is 23 kg/m². Physical examination is unremarkable. Urine pregnancy test is negative. Chlamydia and gonorrhea nucleic acid amplification testing are collected. The patient asks about the side effects of different contraception methods. Which of the following is the most appropriate response to the patient?

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Explanation: 11ec2b69_c143_5b5a_8f63_17a940e6d790_MD0005_00 Combined estrogen/progestin contraception is a common contraceptive method used by adolescents. Contraception is achieved due to the action of progestin, which suppresses GnRH pulses, thereby reducing FSH and LH secretion and inhibiting ovulation. Breakthrough bleeding is a common side effect, particularly with low-dose and continuous pills, and can lead to discontinuation of oral contraceptive use. Breakthrough bleeding occurs due to a thin, atrophic endometrium that sheds erratically when oral contraceptives do not contain enough estrogen. Breakthrough bleeding may be treated by prescribing a contraceptive pill with higher estrogen dose to thicken and stabilize the endometrium. Even if irregular bleeding occurs, combined oral contraceptives are still effective in preventing pregnancy and should be continued on schedule. Other common side effects of combined oral contraceptives include breast tenderness, nausea, headaches, and moodiness; these are most common at the time of initiation. Noncontraceptive benefits include treatment of dysmenorrhea and abnormal uterine bleeding (eg, anovulation, leiomyoma), reduction of acne and hirsutism (eg, polycystic ovary syndrome), and decrease in ovarian and endometrial cancer risk. (Choice B) Weight gain does not occur with combined oral contraceptive use; however, bloating is a common side effect. (Choice C) Copper and progestin intrauterine devices are long-acting, reversible contraceptive methods and are first-line contraception for adolescents due to ease of use and effectiveness after placement. Nulliparity is not a contraindication to use. (Choice D) Depot medroxyprogesterone acetate is a safe method of contraception and can temporarily decrease bone mineral density during use. This bone density loss is reversible and not associated with an increased risk of future osteoporosis. (Choice E) Combined hormonal contraceptives prevent pregnancy by suppressing ovulation. Ovulation resumes within 30 days of discontinuation of combined hormonal contraceptives, but may take up to 12 months with depot medroxyprogesterone acetate. There is no long-term effect on fertility with either of these methods. Educational objective: Unscheduled bleeding is the most common side effect of the combined oral contraceptive pill and occurs due to a thin atrophic unstable endometrium that sheds erratically. Oral contraceptives do not cause weight gain or impaired fertility. References: Committee opinion no 699: adolescent pregnancy, contraception, and sexual activity. (http://www.ncbi.nlm.nih.gov/pubmed/28426620) Committee opinion no. 602: depot medroxyprogesterone acetate and bone effects. (http://www.ncbi.nlm.nih.gov/pubmed/24848921) Treatment of unscheduled bleeding in women using extended- or continuous-use combined hormonal contraception: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/23044386)

A 16-Year-Old Girl Comes to the Office with Her Mother