Contraception for Adolescents During the Coronavirus Disease 2019 Pandemic

In Reply Our publication, “Providing Contraception for Young People During a Pandemic is Essential Health Care,” was written in response to the sudden shift toward low-contact or no-contact medicine in the wake of the coronavirus disease 2019 pandemic.¹ Ensuring access to contraception is essential because every 6 months of lockdown can result in 47 million women losing access to contraception, resulting in an additional 7 million unintended pregnancies.² We welcome the letters submitted by Alouini and Venslauskaite and Uzoigwe and Ali because they exemplify common misperceptions within the medical community about contraception. The question of whether a physical examination is required prior to a contraception prescription, the safety of emergency contraception, and abstinence counseling are addressed here.

A physical examination is unnecessary prior to the initiation of almost all methods of contraception, the exceptions being a bimanual examination and cervical inspection prior to an intrauterine device insertion and a blood pressure determination (in person or in other settings) prior to initiation of combined hormonal contraceptives. According to the US Centers for Disease Control and Prevention, breast examination “does not contribute substantially to safe and effective use of [any] contraceptive method.”³ Worldwide, most countries do not require a prescription to obtain oral contraceptives. Alouini and Venslauskaite suggested that a breast examination is necessary to exclude breast cancer; however, contraindications to hormonal contraception only exist for those with active or recently treated breast cancer. To screen for that possibility, the question “Have you ever been told you have breast cancer or an undiagnosed breast lump?” is a part of our protocol screening questions.¹ Furthermore, there has not been any causal link between hormonal intrauterine contraception and increased breast cancer risks, as stated incorrectly by the authors. On the contrary, use of hormonal contraception has been linked to decreased risk of ovarian, endometrial, and colorectal cancers.⁴

The most common forms of emergency contraception (EC) include levonorgestrel (or Plan B) and ulipristal acetate (Ella) and are available in most countries over the counter or via pharmacist or clinician prescription. Given their favorable safety profile, medical experts have concluded that there are no situations where the risks of taking EC outweigh the benefits of pregnancy prevention. Many organizations, including the World Health Organization, have reaffirmed the importance of access to EC during this pandemic.⁵ The concern for hepatitis as the result of ulipristal acetate stems from daily use for the treatment of fibroids and is not relevant when considering its use as EC,⁶ as was suggested by Alouini and Venslauskaite.

This article was not written to undermine the value of abstinence as a valid choice; it was written to guide the provision of prescription contraceptives by health care professionals. Providing contraceptive counseling to young people at risk of unintended pregnancy is recommended by the World Health Organization, the US Centers for Disease Control and Prevention, and multiple medical organizations and does not increase unsafe behavior as suggested by the authors. Contraceptives are also used to manage medical conditions such as heavy menstrual bleeding, menstrual irregularity, and endometriosis. We believe that the coronavirus disease 2019 pandemic will exacerbate the challenges young people face in accessing medical care generally and contraceptives in particular. Discussing and ensuring access to contraception encourages healthy decisions when sexual activity occurs and equips adolescents and young adults to make those decisions with knowledge of all their options.

Corresponding Author: Tracey A. Wilkinson, MD, MPH, Indiana University School of Medicine, 410 W 10th St, Ste 2000, Indianapolis, IN 46202 (tracwilk@iu.edu).

Published Online: November 30, 2020. doi:10.1001/jamapediatrics.2020.5091

Conflict of Interest Disclosures: Dr Berlan is a consultant to Merck and Bayer and is a Nexplanon Clinical Trainer. No other disclosures were reported.