Long-Acting Reversible Contraception for Adolescents: A Review of Practices to Support Better Communication, Counseling, and Adherence

Figures & data

Figure 1 Application of the Health Belief Model Constructs to LARC Use in Adolescents.

Table 1 How to Address LARC Myths and Barriers with Adolescents and Rationale for Response

LARC Myth	How to Address Myth	Rationale for Response
LARC methods can decrease my ability to get pregnant in the future (or reduce my future fertility).	The ability of the implant and IUD to prevent pregnancy is reversed as soon as the device is removed. There is no long-term reduction in your ability to get pregnant.	Many adolescents are concerned about returning to fertility after discontinuing a contraceptive method. The depot medroxyprogesterone acetate injection (Depo-Provera) is the only method associated with some delay in return to fertility; even this effect is not universal.
It is unsafe to skip or have no period, and I am worried that if LARC stops my periods, it could cause problems.	LARC methods stop the uterus lining from building up, so your period can be lighter or may stop altogether because there may not be much uterine lining to shed each month.	Setting expectations regarding changes to the menstrual cycle before initiating a LARC method will improve satisfaction and continuation. This is especially important for those whose goals include improving menstrual bleeding and decreased cramping.
LARC stops pregnancies by causing abortions.	Implantation of a fertilized egg is the definition of pregnancy. LARC prevents pregnancy before fertilization occurs, so no abortion is involved.	Implants and IUDs do not function by terminating pregnancies. Instead, they work to prevent ovulation (implant) or fertilization (IUD).
Having a device inserted increases my risk of infection (such as getting an STI or infection at the insertion site)	Increased infection risk is only present around the time of placement. Afterward, your chance of any infection is the same as anyone else.	While using a LARC does not make adolescents more likely to get an STI, providers should counsel that LARC does not prevent them from getting an STI either.
After the LARC device is placed, I cannot get it removed until a certain number of months or years have passed.	All LARCs can be removed at any time and do not have to stay in place for the entire duration of efficacy. The ability to get pregnant returns almost as soon as you get the device removed.	Adolescents have the right to refuse or discontinue a LARC method at any time. An adolescent-centered approach to counseling should include options for managing side effects and removal.
LARC methods are too expensive for me to afford.	Your health insurance should usually cover all contraceptive options at no cost.	Under the Affordable Care Act, insurance providers are required to cover all FDA-approved contraceptives, including LARCs. In certain states, state funds cannot be used to provide minors with confidential contraceptive services.
I need my parents’ permission and consent to get a LARC method.	In many states in the US, you can legally get a LARC without your parents’ consent or permission.	In many states in the US, adolescents can legally obtain contraception without parental consent or notification. Information regarding laws and restrictions in specific states is available at: www.guttmacher.org/statecenter/spibs/spib_MACS.pdf

Table 2 Communication Strategies When Considering LARC Placement with Adolescents

Areas of Focus	Consider Saying:	Avoid Saying:	Why This Matters
Introduction of contraceptive options	Long-acting reversible contraception (LARC) methods are the most reliable and effective methods for preventing pregnancy.	The best options for you are LARC methods. I recommend LARC methods above all others for all my adolescent patients.	Comprehensive contraceptive options should be discussed, and providers should avoid being coercive or overly directive. Providers should not assume LARCs are the best options for all their patients.
Adolescent-centered counseling	What is most important to you? (How well it prevents pregnancy, or something else?) How do you value other aspects such as ease of use, avoiding discomfort, side effects, or how long a method works?	We do not need to discuss other contraceptive options in detail or seriously consider them because LARCs are the most reliable and effective.	While LARCs offer the highest efficacy and reliability, providers should respect patients’ autonomy regarding selecting a contraceptive method based on whatever characteristics are most important to them.
Supporting autonomy	Contraception is a personal decision. The best choice will differ from person to person and at different stages in one’s life. All LARC methods can be stopped when you do not want them anymore.	A LARC method is meant to be kept in for the entire effective duration. You should not get a LARC method if you do not plan to keep it in place for the intended time.	Adolescents may be discouraged by the idea of committing to a method for a long duration. Counseling that a LARC can be discontinued at any time during use may enhance acceptability and willingness to initiate a LARC.
Anticipation of discomfort with LARC placement	Getting a LARC placed can be uncomfortable. At the same time, each person can have a different placement experience. Providers who place LARC have special training on how to place it and can offer you medications and other comfort measures before and after placement to make it easier for you.	Getting your LARC placed will not be painful. Even if some pain is involved, you should remember that any discomfort is worth the years of not having to think about your birth control.	Most women will experience discomfort with LARC placement. Providers should acknowledge this and recommend methods to help minimize it. Underrepresenting the potential for pain is dismissive of the patient’s concerns and the range of possible experiences.