Eduovisual
Human Development
Adolescent sexual health and contraception counseling
— ~55% of US adolescents have had sexual intercourse by age 18; nearly half of new STIs annually occur in those aged 15–24
— US teen birth rate has declined but remains higher than peer nations; ~75% of adolescent pregnancies are unintended
— Confidentiality gaps, not lack of interest, are the dominant barrier to contraceptive uptake
— AAP, ACOG, and Bright Futures recommend confidential sexual health screening at every well visit starting at age 11–12, and at acute visits when relevant (dysuria, abdominal pain, mood, substance use, mental health crisis)
— Use HEEADSSS (Home, Education, Eating, Activities, Drugs, Sexuality, Suicide/safety) as the structured framework
— Always offer one-on-one time with the adolescent without the parent in the room from age 11 onward — frame this as routine, universal, not suspicion-based
— LGBTQ+ youth, youth in foster care, justice-involved youth, youth experiencing homelessness, youth with disabilities, survivors of trafficking or abuse
— Adolescents on teratogens (isotretinoin, valproate, mycophenolate, ACEi, warfarin, topiramate, methotrexate) — contraception is a medication safety issue, not optional
— Partner >3–5 years older, exchange of sex for money/food/shelter, coercion, injection drug use, multiple partners, prior STI, recurrent pregnancy testing
— Any disclosure of nonconsensual contact → shift to trauma-informed evaluation and mandatory reporting pathway
Step 3 management: At a routine 15-year-old's well visit, the first order is "ask parent to step out and discuss confidentiality limits with patient" — counseling and screening cannot proceed accurately until privacy is established. Document the confidentiality conversation explicitly in the chart.
— 16-year-old at well visit asking about "the shot," "the implant," or "the patch"
— 15-year-old with new boyfriend requesting STI testing, parents in waiting room
— 17-year-old starting isotretinoin and required to be on contraception
— 14-year-old with secondary amenorrhea after starting DMPA — pregnancy test still required
— 16-year-old on lamotrigine for epilepsy asking about combined oral contraceptives
— Partners: number, gender(s), age, new vs ongoing
— Practices: vaginal, anal, oral; receptive vs insertive
— Protection from STIs: condom use consistency
— Past history of STIs: including partner's history
— Pregnancy intention and prevention: desire to conceive now, in 1 year, in 5 years (reproductive life plan)
— Methods previously tried, reasons for discontinuation (bleeding, weight, mood, partner pressure)
— Adherence reality check: "How many pills did you miss last month?" rather than "Do you take it every day?"
— Emergency contraception use frequency — frequent use signals need for a more effective primary method
— Migraine with aura at any age → estrogen-containing methods are Category 4 (contraindicated)
— VTE history, known thrombophilia, SLE with antiphospholipid antibodies → avoid estrogen
— Uncontrolled HTN, smoker ≥35 (rare in teens but relevant in young adults), complicated valvular disease
— Hepatic adenoma, active liver disease, breast cancer
— Bariatric surgery with malabsorption → avoid oral methods
Board pearl: Migraine with aura + combined hormonal contraception = stroke risk multiplier. The question stem flags "visual zigzags before headache" — switch to progestin-only pill, implant, DMPA, or IUD. Migraine without aura in patients <35 is MEC Category 2 (generally use).
— Blood pressure is the only universally required exam element before combined hormonal contraception
— Pelvic exam is NOT required to initiate any contraceptive method, including IUDs in some protocols (though IUD insertion itself requires bimanual + speculum)
— Pap smear is NOT required — cervical cancer screening starts at age 21 regardless of sexual activity
— STI screening (urine NAAT for GC/CT) does not require a pelvic exam in asymptomatic patients
— BP <140/90 required for estrogen-containing methods
— BMI: obesity alone is not a contraindication to any method; the patch may have reduced efficacy at >90 kg
— Tanner staging documents pubertal development but does not gate contraceptive access — menarche is not required to start contraception if clinically indicated
— Acanthosis nigricans, hirsutism → PCOS workup; combined OCPs serve dual role
— Acne severity → may guide toward estrogen-containing method (improves acne) vs progestin-only (may worsen)
— Thyromegaly, galactorrhea → secondary amenorrhea workup before attributing to contraception
— Bruising, genital trauma, anogenital warts in a young child → abuse evaluation
— Speculum: mucopurulent cervicitis, friable cervix
— Bimanual: cervical motion tenderness, adnexal tenderness → PID
— External: vesicles (HSV), condylomata (HPV), chancre (syphilis), pubic lice
Step 3 management: A healthy 16-year-old requesting combined OCPs needs BP measurement and a confidential history — that's it. Ordering a pelvic exam, Pap, or "hormone panel" before initiation is wrong and creates an unnecessary barrier. Same-day start ("Quick Start") with a urine pregnancy test is best practice.
— Annual chlamydia and gonorrhea NAAT for all sexually active females ≤25 and all sexually active MSM (also pharyngeal and rectal sites by exposure)
— HIV screening at least once between ages 15–65; repeat annually if ongoing risk; opt-out approach
— Syphilis screening for MSM, pregnant adolescents, and based on local prevalence and behaviors
— Hepatitis B and C: universal HCV screening once in adults ≥18; HBV based on risk
— Trichomonas: screen women with HIV; symptomatic patients
— Urine NAAT or self-collected vaginal swab is equivalent or superior to clinician-collected for GC/CT — offer self-collection to reduce exam barrier
— Extragenital (pharyngeal, rectal) NAAT for MSM and based on exposure history — urine alone misses ~70% of extragenital infections
— Urine hCG before initiating any hormonal method if any chance of pregnancy
— CDC Quick Start: if patient is "reasonably certain not pregnant" (no unprotected sex since last menses, on reliable method, etc.), start same day and repeat hCG in 2–4 weeks
— Positive hCG → quantitative + transvaginal ultrasound if symptomatic, options counseling (continuation, adoption, abortion) in non-directive manner per AAP/ACOG
— HPV testing is not used for screening in adolescents — high transient infection rates
— Genital warts diagnosed clinically; biopsy only if atypical
Board pearl: A sexually active 19-year-old female presenting for any reason — well visit, sports physical, contraception, URI — should be offered annual chlamydia/gonorrhea screening. The right answer on Step 3 is often "urine NAAT for GC/CT" even when the stem seems unrelated.
— Positive GC or CT NAAT → treat presumptively, Expedited Partner Therapy (EPT) where legally permitted (legal in most US states for CT, fewer for GC)
— Test of cure NOT routinely needed for uncomplicated GC/CT in non-pregnant patients — retest in 3 months for reinfection
— Pregnancy + GC or CT → test of cure at 4 weeks
— Syphilis: nontreponemal (RPR/VDRL) titer + treponemal confirmation; follow titers post-treatment at 6 and 12 months
— HIV reactive screen → confirmatory HIV-1/2 Ab differentiation + HIV RNA; link to care within 7 days
— Clinical diagnosis: sexually active female + pelvic/lower abdominal pain + cervical motion, uterine, or adnexal tenderness with no other cause
— Treat empirically — low threshold, missed PID → infertility, ectopic, chronic pain
— TVUS if tubo-ovarian abscess suspected (severe pain, fever, palpable mass)
— Quantitative β-hCG + transvaginal US ≥6 weeks gestation
— Rh typing on every pregnant adolescent
— Prenatal labs if continuing pregnancy: CBC, blood type, HIV, syphilis, HBsAg, HCV, GC/CT, urine culture, rubella/varicella immunity
— STI screening at insertion is acceptable; do not delay IUD insertion to wait for results in low-risk patients
— If positive GC/CT discovered after insertion → treat with IUD in place (do not remove)
— Bimanual to assess uterine position and size; pregnancy test same day
CCS pearl: For suspected PID in a 17-year-old with bilateral lower quadrant pain and CMT, advance the clock with: urine hCG, urine NAAT GC/CT, CBC, HIV, RPR, start ceftriaxone 500 mg IM + doxycycline 100 mg PO BID × 14 days + metronidazole 500 mg PO BID × 14 days — don't wait for cultures.
— Tier 1 (<1% failure/year): LARCs — copper IUD, levonorgestrel IUDs (52, 19.5, 13.5 mg), etonogestrel implant (Nexplanon); also tubal/vasectomy (not relevant in adolescents)
— Tier 2 (6–9% typical use): DMPA injection, combined OCPs, progestin-only pill, patch, ring
— Tier 3 (12–28% typical use): condoms (male/female), diaphragm, sponge, fertility awareness
— Tier 4: spermicide alone, withdrawal
— Highest continuation rates, no daily adherence, rapid return to fertility
— Nexplanon: 3 years (FDA), effective up to 5; main side effect is unpredictable bleeding
— 52 mg LNG-IUD (Mirena, Liletta): 8 years, often induces amenorrhea, treats heavy menstrual bleeding
— Copper IUD: 10–12 years, hormone-free, can increase menstrual bleeding and cramping; also most effective emergency contraception
— Avoid "directive" counseling that steers all adolescents to LARCs regardless of preference — reproductive justice concern, particularly for marginalized youth
— Elicit priorities: bleeding pattern, weight, mood, acne, daily routine, partner awareness, cost, reversibility timeline
— Discuss dual method use: any non-barrier method + condom for STI prevention
Key distinction: "Most effective" ≠ "best for this patient." A teen who values monthly bleeding to reassure herself she isn't pregnant may prefer combined OCPs over an implant, even though efficacy is lower. Document preferences and counsel on the trade-off.
— Ethinyl estradiol (20–35 mcg) + progestin (norethindrone, levonorgestrel, drospirenone, desogestrel)
— Mechanism: suppress LH surge → no ovulation; thicken cervical mucus; thin endometrium
— Non-contraceptive benefits: ↓ dysmenorrhea, ↓ menorrhagia, ↓ acne, ↓ ovarian/endometrial cancer risk, regulates PCOS
— Contraindications (MEC 3/4): migraine with aura, <21 days postpartum, smoker ≥35, uncontrolled HTN, history of VTE/stroke/CAD, complicated DM, SLE with APLAs, breast cancer, severe liver disease
— Missed pill rules: 1 missed → take ASAP, continue; ≥2 missed → take latest, use backup × 7 days, consider EC if unprotected sex
— Norethindrone: strict 3-hour window; newer drospirenone POP: 24-hour window
— Safe in migraine with aura, postpartum, VTE history
— Black box: reversible bone mineral density loss — recovers after discontinuation; do not restrict use based on this alone (ACOG)
— Side effects: weight gain (~5 lb/year), irregular bleeding → amenorrhea, mood changes, delayed return to fertility (up to 10 months)
— Subdermal upper arm, in-office insertion
— Unpredictable bleeding most common reason for removal — pre-counsel heavily
— Enzyme inducers reduce efficacy: rifampin, phenytoin, carbamazepine, phenobarbital, topiramate >200 mg, lamotrigine (CHCs ↓ lamotrigine levels — bidirectional issue), St. John's wort, some HIV PIs
— Implant and IUDs NOT affected by most enzyme inducers (Cu-IUD and LNG-IUD have local action)
Board pearl: Teen on lamotrigine for epilepsy + wants contraception → choose LNG-IUD, Cu-IUD, or implant. CHCs lower lamotrigine, risking breakthrough seizures during pill-free week.
— Nulliparity is NOT a contraindication (AAP, ACOG)
— Timing: any day of cycle if reasonably certain not pregnant; immediate postpartum and post-abortion insertion are safe and increase continuation
— Pre-procedure: NSAID 30–60 min prior; counseling on cramping
— Pain management: paracervical block, naproxen; routine misoprostol pre-insertion not recommended (no efficacy benefit)
— Complications: expulsion (2–10%, higher in adolescents and immediate postpartum), perforation (<1/1000), PID risk elevated only in first 20 days post-insertion
— Subdermal medial upper arm, ~2 minutes; local anesthesia
— Palpate after insertion; if not palpable → US or MRI to localize before any removal attempt
— Copper IUD: most effective, >99%, within 5 days; bonus = ongoing contraception
— Ulipristal acetate (Ella) 30 mg PO: most effective oral option, within 120 hours, prescription only; more effective than LNG, especially BMI >25 and at 72–120 hours
— Levonorgestrel 1.5 mg (Plan B): OTC, no age restriction, within 72 hours; less effective at BMI >25–30
— Yuzpe regimen (high-dose OCPs): last resort
— Do not co-administer ulipristal with progestin contraceptives — delay starting/restarting progestin method × 5 days after ulipristal
— LNG-EC: can Quick Start hormonal method same day
— EC does not disrupt established pregnancy; not an abortifacient
— Repeat pregnancy test in 3 weeks if no menses
Step 3 management: 16-year-old presents 4 days after condom break. Best option = copper IUD same day (most effective + ongoing). If she declines, ulipristal 30 mg PO — not levonorgestrel, because it's been >72 hours and ulipristal retains efficacy out to 120 hours.
— Most methods retain efficacy; transdermal patch may have ↓ efficacy at >90 kg
— Levonorgestrel EC less effective at BMI >25–30 → prefer ulipristal or copper IUD
— Obesity itself ↑ VTE baseline; CHCs add further risk but are MEC 2 (generally use) unless additional risk factors
— Uncomplicated DM: CHCs MEC 2
— DM with nephropathy/retinopathy/neuropathy or >20 year duration: CHCs MEC 3/4 → use progestin-only or LARC
— Well-controlled HTN: CHCs MEC 3
— BP ≥160/100 or vascular disease: CHCs MEC 4 → LARC, POP, or DMPA (DMPA is MEC 2 for HTN)
— Enzyme-inducing AEDs (phenytoin, carbamazepine, oxcarbazepine, phenobarbital, topiramate >200 mg) → reduce hormonal efficacy → LARC preferred, especially LNG-IUD and Cu-IUD (no interaction)
— Lamotrigine: levels drop with CHCs → seizure risk; choose IUD/implant
— Valproate: teratogenic — contraception is mandatory
— All estrogen methods MEC 4
— Safe options: LNG-IUD, Cu-IUD, implant, POP, DMPA (DMPA MEC 2 in VTE history)
— With aura: CHCs MEC 4 at any age
— Without aura, age <35: CHCs MEC 2 (generally use); reassess if aura develops
— Severe cirrhosis, hepatocellular adenoma/carcinoma: CHCs MEC 4
— CKD on dialysis: LARCs preferred; estrogens raise VTE risk
Board pearl: A teen on isotretinoin must use two forms of contraception (iPLEDGE) or one highly effective method + abstinence documentation, with monthly pregnancy tests. Implant or IUD satisfies this best.
— Non-directive options counseling: continuation with parenting, adoption, abortion (state-law dependent)
— Prenatal care: initiate folic acid 0.4–0.8 mg, prenatal labs, social work, mental health screen, partner/intimate partner violence screen
— Higher risk of preeclampsia, preterm birth, anemia, postpartum depression, school dropout
— Immediate postpartum LARC (IUD or implant) is safe, recommended, reduces rapid repeat pregnancy
— CHCs: avoid first 21 days postpartum (VTE risk); avoid 21–42 days if additional VTE risk factors
— Breastfeeding: progestin-only methods preferred initially; CHCs MEC 2 after 30 days if breastfeeding well-established
— Initiate any method including IUD same-day after surgical or medical abortion
— Sexual orientation ≠ sexual behavior — ask about anatomy of partners, not labels
— Lesbian/bisexual teens still need pregnancy prevention if any sperm exposure
— Transgender male on testosterone: testosterone is NOT contraception — pregnancy still possible; LARCs preferred (no estrogen, no cycle attention required)
— Transgender female on estrogen: STI screening based on anatomy and behaviors
— Tenofovir/emtricitabine (Truvada or Descovy) approved for adolescents ≥35 kg
— Long-acting injectable cabotegravir every 8 weeks
— Screen HIV, renal function, HBV before initiation; repeat HIV q3 months
— Same right to confidential care, contraception, and STI screening
— Assess capacity individually; involve guardian only when capacity lacking — never reflexively
Key distinction: A transgender male with a uterus on testosterone who has receptive vaginal sex with a male partner needs pregnancy prevention AND STI screening — testosterone-induced amenorrhea does not equal infertility.
— VTE: absolute risk with CHCs ~3–9/10,000 woman-years (vs 1–5 baseline); higher with drospirenone and the patch
— Stroke and MI: rare in healthy young women without migraine with aura, smoking, or HTN
— DMPA: reversible BMD loss, weight gain, delayed fertility return
— IUD: expulsion, perforation (rare), malposition; pregnancy with IUD in place is more likely to be ectopic — but absolute ectopic risk is lower than no contraception
— Implant: bleeding irregularity (#1 reason for removal), insertion-site issues, deep/migrated implants
— Combined methods: nausea, breast tenderness, mood changes, breakthrough bleeding (improves by 3 months — counsel patience)
— Chlamydia/gonorrhea → PID → tubal-factor infertility (1 episode: ~12%, 3 episodes: ~50%), ectopic pregnancy, chronic pelvic pain
— HPV → cervical, anal, oropharyngeal cancers
— HIV → AIDS without treatment
— Syphilis → neurosyphilis, congenital syphilis
— HSV → neonatal HSV at delivery if primary infection in third trimester
— Preeclampsia (esp. <15 years), preterm birth, low birth weight, postpartum depression, anemia
— Social: school disruption, economic hardship, cycle of intergenerational early pregnancy
— Coerced sex, unrecognized intimate partner violence, reproductive coercion (partner sabotaging contraception)
— Mental health: depression, anxiety, suicidality higher in pregnant and parenting teens
CCS pearl: Pregnant adolescent with IUD in place → if strings visible and pregnancy <13 weeks, remove the IUD (reduces miscarriage, preterm birth, infection). If strings not visible, consult OB; do not blindly probe.
— Severe PID: high fever, vomiting, tubo-ovarian abscess, pregnancy, failed outpatient therapy → admit for IV cefotetan/cefoxitin + doxycycline, or clindamycin + gentamicin
— Ectopic pregnancy: positive hCG + adnexal mass/pain/bleeding + no IUP on TVUS → OB/GYN STAT, surgical vs methotrexate
— Acute VTE on CHCs: stop method, anticoagulate, evaluate thrombophilia after acute phase
— Disseminated gonococcal infection: arthritis-dermatitis syndrome → admit, IV ceftriaxone
— Severe pelvic pain post-IUD insertion: consider perforation, expulsion, ovarian torsion
— Adolescent medicine or gynecology for complex contraceptive counseling, recurrent EC use, complex bleeding
— Pediatric/adolescent gynecology for IUD insertion if primary care not credentialed
— Maternal-fetal medicine for high-risk adolescent pregnancy
— Mental health for depression, eating disorder, trauma — co-occurs frequently
— Child protective services and law enforcement for suspected abuse, trafficking, or statutory violations
— Refer to SANE (sexual assault nurse examiner) program or pediatric ED
— Evidence collection within 72–120 hours
— Empiric STI prophylaxis: ceftriaxone 500 mg IM + doxycycline 100 mg BID × 7 days + metronidazole 2 g PO; HBV vaccine ± HBIG; HIV PEP within 72 hours
— Emergency contraception
— Mandatory reporting in all states
— Partner hiding/destroying pills, sabotaging condoms, pressuring pregnancy
— Offer covert methods: IUD with trimmed strings, implant, DMPA
Step 3 management: Suspected ectopic in a sexually active 17-year-old with abdominal pain and amniorrhea: order urine hCG first, then quantitative β-hCG + transvaginal US, large-bore IV access, type and screen, OB/GYN consult before any pain medication delays diagnosis.
— Pregnancy is always #1 — urine hCG before any other workup
— Hypothalamic amenorrhea: anorexia, excessive exercise, stress (Female Athlete Triad/RED-S)
— PCOS: oligomenorrhea, hyperandrogenism, polycystic ovaries on US
— Hyperprolactinemia: galactorrhea, medication-induced (antipsychotics), prolactinoma
— Thyroid disease: hypo- or hyperthyroidism
— Premature ovarian insufficiency: elevated FSH, low estradiol
— Asherman syndrome: post-instrumentation scarring
— Contraception-related: DMPA, LNG-IUD, continuous CHCs commonly cause amenorrhea
— Anovulation: most common cause in adolescents (immature HPO axis, first 2–5 years post-menarche)
— Coagulopathy: von Willebrand disease in up to 20% of adolescents with heavy menstrual bleeding — screen with vWF antigen, ristocetin cofactor, factor VIII
— Endometritis/PID
— Pregnancy complications: threatened/missed/ectopic
— Contraceptive breakthrough bleeding (especially first 3 months)
— Trauma, abuse
— Thyroid disease, hyperprolactinemia
— Primary: most common; respond to NSAIDs + CHCs
— Secondary: endometriosis (consider if NSAID/OCP-refractory pain, family history, cyclic GI/GU symptoms), adenomyosis, obstructive Müllerian anomaly
Board pearl: A 15-year-old with menorrhagia since menarche soaking >1 pad/hour, family history of "easy bruising" → workup for von Willebrand disease before attributing to anovulation. Then treat with hormonal suppression (CHCs or LNG-IUD) + hematology co-management.
— Ectopic pregnancy (rule out first)
— Ovarian torsion: sudden unilateral pain, nausea, vomiting, mass on US with abnormal Doppler — surgical emergency, do not delay for confirmatory imaging if classic
— Ruptured ovarian cyst: mid-cycle, often self-limited
— Appendicitis: migratory RLQ pain, fever, leukocytosis — pelvic exam helps differentiate from PID
— PID/tubo-ovarian abscess
— Endometriosis
— Mittelschmerz
— Nephrolithiasis, UTI/pyelonephritis
— IBD flare, constipation
— Bacterial vaginosis: thin gray, fishy odor, clue cells, pH >4.5 — metronidazole
— Trichomoniasis: frothy yellow-green, strawberry cervix, motile trichomonads — metronidazole, treat partner
— Candidiasis: thick white "cottage cheese," pruritus — fluconazole
— Chlamydia/gonorrhea cervicitis: mucopurulent, friable cervix, often asymptomatic
— Physiologic leukorrhea: clear/white, no symptoms — reassurance
— Foreign body (retained tampon): foul odor, malodorous discharge
— HSV: clustered painful vesicles → ulcers; PCR confirms
— Syphilis: painless chancre, indurated; RPR + treponemal test
— Chancroid (rare in US): painful ulcer + tender lymphadenopathy
— Behçet, Crohn-related: noninfectious
— Functional ovarian cyst, dermoid (teratoma), endometrioma, hydrosalpinx, pregnancy (intrauterine or ectopic)
Key distinction: PID = bilateral pain, CMT, fever, mucopurulent discharge, often during/after menses. Appendicitis = anorexia, migratory pain, RLQ point tenderness without CMT. Get a urine hCG in both before imaging.
— Reinforce condom use for STI prevention even if using LARC (dual method)
— Vaccinations:
— HPV 9-valent: routine ages 11–12, catch-up through 26 (shared decision through 45)
— Meningococcal ACWY (11–12, booster 16), MenB (shared decision 16–23)
— HepB (complete series), HepA, Tdap (11–12), annual flu, COVID-19
— Mpox vaccine for at-risk MSM and others per CDC
— Tobacco, alcohol, cannabis, opioid screening (SBIRT) — substance use compounds risk-taking
— Mental health screening (PHQ-A, GAD-7) annually
— Revisit annually: "Do you want to be pregnant in the next year?" → guides counseling
— Preconception folic acid 0.4 mg for any teen who could become pregnant; 4 mg if on AEDs or family hx NTD
— Bleeding pattern counseling: first 3 months of any new hormonal method
— Quick refills, 12-month supply when allowed (improves continuation 30%)
— Texting/portal reminders for DMPA injections
— Offer PrEP to any adolescent with ongoing HIV exposure risk
— PEP for nonoccupational exposure: tenofovir/emtricitabine + dolutegravir × 28 days, start within 72 hours
— Begin Pap at age 21 regardless of sexual activity or vaccination status
— HPV co-testing or primary HPV testing at age 25–30+
Step 3 management: At a 17-year-old's annual visit, even if she's been on Nexplanon for a year without issues: rescreen GC/CT (urine NAAT), update HPV/Tdap/flu, screen depression/substance use, reaffirm reproductive life plan, and ask about partner safety. The implant doesn't make the rest of the visit go away.
— Phone/portal check-in at 3–6 weeks: tolerability, adherence, side effects
— In-person follow-up at 3 months for new method assessment
— No routine labs required for healthy adolescents on CHCs — BP check at 3 months, then annually
— DMPA: every 13 weeks (window up to 15 weeks); BMD monitoring not routinely indicated
— IUD: string check optional; routine annual visit, no specific IUD follow-up required after initial post-insertion check (4–6 weeks)
— Implant: palpate at insertion, no further routine monitoring
— Test of reinfection at 3 months for GC/CT (not test of cure)
— Test of cure at 4 weeks for pregnant patients
— Syphilis: RPR at 6 and 12 months; 4-fold decline = treatment success
— HIV: link to care, ART within days, CD4/viral load q3 months
— Contraception in place before discharge from L&D or abortion procedure
— Postpartum visit at 1–3 weeks and comprehensive at 4–12 weeks (ACOG "fourth trimester")
— Postpartum depression screen (EPDS or PHQ-9)
— Breastfeeding support, return-to-school plan, social work
— Trauma-informed: ask permission, give control, normalize
— Motivational interviewing for behavior change
— Cultural humility and language-concordant care
— Engage partner only with patient's explicit consent
— Confidentiality conversation, consent capacity, mandatory reporting decisions, EPT given
Board pearl: A teen on CHCs returning at 3 months with breakthrough bleeding: reassure (resolves by month 3–4 in most), reinforce daily adherence, do not switch methods prematurely unless persistent past 3 cycles or patient strongly prefers.
— All 50 states + DC allow minors to consent to STI testing/treatment without parental involvement
— Most states allow minor consent for contraception (varies — know your state's "minor consent" laws)
— Most states allow consent for prenatal care; abortion access varies dramatically post-Dobbs (parental involvement laws, gestational limits)
— HIPAA permits but does not require disclosure of confidential adolescent care to parents — clinician judgment within state law
— EHR safety: explanation of benefits (EOBs) sent to parent's address can break confidentiality — counsel about insurance billing risks; offer sliding scale, Title X clinics, Planned Parenthood
— Suspected child abuse, neglect, sexual abuse → report to child protective services
— Statutory rape laws vary by state (age of consent typically 16–18; age-gap exceptions in many states)
— Pregnancy in a 13-year-old by a 25-year-old → reportable; pregnancy in a 17-year-old by a 19-year-old often not, depending on state
— Suspected trafficking → law enforcement + specialized resources
— Adolescents generally have capacity for contraception decisions; document assent
— Emancipated minors and "mature minor" doctrine in many states
— Disability: assess decisional capacity individually
— Universal screening for intimate partner violence
— Safety planning, covert contraception when needed
— Avoid coercive LARC promotion to specific demographic groups
— Respect declination, support method removal whenever requested
— Language-concordant interpreter (not family member)
— Adolescent transitioning to adult care: explicit handoff, contraceptive method documentation, ensure no gap in supply
Step 3 management: A 15-year-old discloses sex with her 23-year-old "boyfriend" — this is statutory rape in most states regardless of stated consent. Provide medical care (STI screen, EC, contraception, pregnancy test) and make the mandatory CPS/law enforcement report per state law; explain to the patient with empathy.
— Migraine with aura + CHC = stroke risk; choose progestin-only or non-hormonal
— Most effective EC = copper IUD; most effective oral EC = ulipristal
— Levonorgestrel EC less effective at BMI >25–30
— No pelvic exam, Pap, or STI test required to start any contraceptive method
— Pap starts at 21 regardless of sexual debut or HPV vaccination
— Annual GC/CT NAAT for all sexually active women ≤25 and MSM
— HPV vaccine: 2 doses if started <15 (0, 6–12 months); 3 doses if started ≥15
— Quick Start: begin any method same day if reasonably certain not pregnant
— Nulliparity not a contraindication to IUD
— Pregnant with IUD + strings visible + <13 weeks → remove IUD
— DMPA: BMD loss reversible; do not restrict use
— Lamotrigine + CHC = lower lamotrigine = seizure risk
— Rifampin and most enzyme-inducing AEDs reduce hormonal contraceptive efficacy; IUDs and DMPA unaffected
— Postpartum CHC: wait ≥21 days (≥42 if VTE risk factors)
— Breastfeeding: progestin-only preferred initially
— Test of cure for GC/CT only in pregnancy; otherwise test of reinfection at 3 months
— Expedited partner therapy: CT yes, GC limited, syphilis/HIV no (require evaluation)
— Suspected PID: low threshold to treat empirically
— Plan B available OTC, no age restriction; Ella requires prescription
— Adolescent pregnancy: folic acid, prenatal labs, screen for IPV and depression
— Acne + need for contraception → CHC with antiandrogenic progestin (drospirenone, norgestimate)
— Heavy menses + contraception → LNG 52 mg IUD (also FDA-approved for HMB)
— Endometriosis pain + contraception → continuous CHC or LNG-IUD
— PCOS → CHC for menstrual regulation + endometrial protection
Key distinction: Plan B = OTC, no Rx, less effective if BMI >25 or >72 h. Ella = Rx, more effective at BMI >25 and out to 120 h. Cu-IUD = most effective EC, period.
Board pearl: When a stem mentions a sexually active adolescent and asks "next best step," the answer is almost always either confidential history, urine hCG, urine NAAT for GC/CT, or offer LARC — pick based on what's missing.
Adolescent sexual health care is universal, confidential, non-judgmental, and integrated into every visit — offer tiered-efficacy contraceptive counseling with LARCs as first-line, screen and treat STIs proactively, and navigate consent, mandatory reporting, and reproductive justice with equal rigor.
Step 3 management: Every adolescent visit = HEEADSSS + 5 Ps + reproductive life plan + immunizations + confidentiality protection — make this your reflex, and the questions answer themselves.