Contraception

Aka: Contraception, Contraception Counseling, Birth Control, Provision of Contraception, Family Planning, Contraceptive Selection, Family Planning Counseling, Contraception Education, Contraceptive Services, Hormonal Contraception, Quick Start Algorithm for Non-IUD Hormonal Contraception, Long Acting Reversible Contraception

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II. Epidemiology

  1. Unintended Pregnancy rates
    1. United States: 45% in 2011 (had been >51% in 2008)
    2. Western Europe: 34%
    3. Eastern Europe: 54%
  2. References
    1. Finer (2016) N Engl J Med 374(9):843-52 +PMID:26962904 [PubMed]
    2. (2018) Hum Reprod 33(5):777-83 +PMID:29659848 [PubMed]

III. Efficacy: First year failure rates of Contraception

  1. Most effective methods: Permanent (<1 pregnancy per year in 100 women)
    1. Vasectomy: 0.15% failure rate
    2. Tubal Ligation: 0.5% failure rate
    3. Hysteroscopic Sterilization: 0.5% failure rate
  2. Most effective methods: Reversible (<1 pregnancy per year in 100 women)
    1. Implantable Contraception (e.g. Nexplanon): 0.05% failure rate
    2. Levonorgestrel IUD (e.g. Mirena): 0.2% failure rate
    3. Copper-T IUD: 0.8% failure rate
  3. Effective methods (6-12 pregnancies per year in 100 women)
    1. Depo Provera Injection: 6% failure rate
    2. Oral Contraceptives: 9% failure rate
    3. Contraceptive Patch (e.g. Ortho Evra): 9% failure rate
    4. Vaginal Contraceptive Ring (NuvaRing): 9% failure rate
    5. Contraceptive Diaphragm: 12% failure rate
  4. Least effective methods (>18 pregnancies per year in 100 women)
    1. Male Condom: 18%
    2. Female Condom: 21%
    3. Withdrawal Method: 22%
    4. Contraceptive Sponge: 12% (nullip) to 24% (parous) failure rate
    5. Natural Family Planning: 24% failure rate
    6. Vaginal Spermicide: 28% failure rate
  5. References
    1. (2013) MMWR Recomm Rep 62(RR-05):1-60 +PMID:23784109 [PubMed]
      1. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6205a1.htm

IV. Preparations: Non-Hormonal Options

  1. Male Condom
  2. Female Condom
  3. Contraceptive Diaphragm
  4. Contraceptive Sponge (no longer available in U.S.)
  5. Cervical Cap
  6. Vaginal Spermicide
  7. Natural Family Planning and Fertility awareness
  8. Contraceptive Sponge (returns to U.S. market in 2005)

V. Preparations: Hormonal Contraception

  1. Oral Agents (Daily)
    1. Oral Contraceptive (Combination OCP)
    2. Mini-Pill (Progesterone only)
      1. Norgestrel 75 mcg (Opill) is available OTC in 2024
  2. Injectable Options (Progesterone)
    1. Depo Provera Injectable (repeated every 3 months)
  3. Long Acting Reversible Contraception (LARC)
    1. Intrauterine Device
      1. Copper T-380A (Paragard) IUD: 10 years (studies support 12 years of use)
      2. Mirena: 7 year Levonorgestrel IUD (originally labelled for 5 years)
      3. Liletta: 6 year Levonorgestrel IUD
      4. Kyleena: 5 year Levonorgestrel IUD
      5. Skyla: 3 year device Levonorgestrel IUD
      6. Older devices included the one year Progestasert IUD (discontinued)
    2. Estrogen Containing Devices
      1. Vaginal Contraceptive Ring (NuvaRing)
      2. Contraceptive Patch (Ortho Evra)
    3. Implantable Progesterone Rods
      1. Nexplanon: Single Etonogestrel rod system approved for 3 years (studies support 5 years of use)
      2. Older devices no longer available included Implanon (lasted 2 years) and Norplant (lasted 5 years)

VI. History

  1. Confirmation of Non-Pregnant State
    1. Menstrual history
      1. Last Menstrual Period
      2. Menstrual period regularity
    2. Pregnancy history
    3. Lactation history
    4. Most recent intercourse
  2. Chronic medical problems (directs Contraceptive Selection as in management below)
    1. Diabetes Mellitus
    2. Cardiovascular Disease
    3. Seizure Disorders
    4. Bariatric Surgery
    5. Venous Thromboembolism or Thrombophilia
    6. Migraine Headache with aura
    7. Hypertension
    8. Tobacco Abuse
    9. Chronic Corticosteroid use
    10. Systemic Lupus Erythematosus
    11. Antiphospholipid Antibody Syndrome
  3. Sexual History (and risks for STI)
    1. Current and recent sexual partners
    2. Condom use
    3. Prior Sexually Transmitted Infection (STI)
  4. Other history related to Contraceptive Selection
    1. Contraceptive use in the past and preferences
    2. Intention for future pregnancy

VII. Exam

  1. Blood Pressure
    1. Avoid combination Oral Contraceptives in Uncontrolled Hypertension
  2. Body weight and BMI
    1. Consider avoiding Depo Provera in low BMI patients (increased Osteoporosis risk)
    2. Monitor weight for methods that may be associated with significant weight gain (e.g. Depo Provera)
  3. Pelvic Examination
    1. Not required for extra-pelvic forms of Contraception (e.g. OCP, Depo Provera, Nexplanon, Contraceptive Patch)
    2. Indicated when placing Intrauterine Device, Cervical Cap, Contraceptive Diaphragm
    3. STD Testing may be performed at time of IUD Placement in asymptomatic patients (to avoid delays)
    4. Avoid requiring Pap Smear or well woman physical exam prior to starting Contraception

VIII. Labs

  1. Pregnancy Test
    1. Confirmation of Non-Pregnant State by history may also suffice

IX. Management: General

  1. Initiation: Avoid barriers and delays
    1. Start Contraception at time of visit (unless not able to reliably confirm Non-Pregnant State)
    2. Hormonal contraceptives do not cause birth defects, pregnancy loss or IUGR
    3. Bridge to longterm method if unable to confirm Non-Pregnant State
      1. Use non-intrauterine Contraception until repeat Pregnancy Test in 2-4 weeks
    4. Backup methods for first week when starting Hormonal Contraception
      1. Use barrier methods for first week
      2. Emergency Contraception may be used after unprotected sex in first week
  2. Compliance
    1. Prescribe one year supply of Contraception
    2. Help facilitate compliance (reminder systems, longterm Contraception)
    3. Reassess Contraception compliance and method satisfaction at routine visits
    4. Discuss permanent methods (e.g. Vasectomy, Tubal Ligation) if completed intended child bearing
  3. Sexually Transmitted Infection prevention
    1. Make Condoms readily available as part of dual protection for those at risk of STI
  4. Specific cohorts
    1. Postpartum counseling on Contraception after delivery
    2. Perimenopause continuation of Contraception until Menopause or age 50 to 55 years old
    3. Adolescent Health counseling on Contraception and Sexually Transmitted Infection prevention
      1. Consider Long-Acting Reversible Contraception are preferred (e.g. IUD, dermal implants)
      2. Diedrich (2015) Am J Obstet Gynecol 213(5): 662 [PubMed]
      3. Schmidt (2015) J Adolesc Health 57(4): 381-6 [PubMed]

X. Management: Quick Start Algorithm for Non-IUD Hormonal Contraception (pill, patch, ring, injection, implant)

  1. See Quick Start Algorithm for Intrauterine Device
  2. Step 1: First Day of Last Menstrual Period (LMP)
    1. LMP >7 days ago: Go to Step 2
    2. LMP <7 days ago
      1. Start new Contraception today
      2. Backup Contraception indications
        1. Non-Injection Method (e.g. OCP, patch, ring, implant) AND
        2. LMP 5-7 days ago
  3. Step 2: LMP >7 days ago
    1. No unprotected sex since LMP
      1. Start new Contraception today
      2. Use backup Contraception for 7 days
    2. Unprotected sex since LMP and Urine Pregnancy Test negative
      1. Go to Step 3
  4. Step 3: Offer Contraception with discussion of pregnancy risk
    1. Informed Consent
      1. Early pregnancy is possible despite negative Pregnancy Test
      2. Hormonal contraceptives are considered safe when accidentally used in early pregnancy
      3. Benefits of starting Contraception outweigh risks of early pregnancy (CDC)
    2. Patient opts to start new Contraception
      1. Offer Emergency Contraception with Plan B (Levonorgestrel) if unprotected sex within last 5 days
      2. Start new Contraception today
      3. Use backup Contraception for first 7 days
      4. Repeat Pregnancy Test in 2-4 weeks (in home or office)
    3. Patient opts to delay start of new Contraception
      1. Go to Step 4
  5. Step 4: Delayed Contraception Start
    1. Offer Emergency Contraception (Levonorgestrel or Ulipristal) if unprotected sex within last 5 days
    2. Offer advanced prescription or future appointment for Contraception placement
    3. Discuss alternative Contraception methods until next menstrual period
    4. Start pill patch or ring within 5 days of next menstrual period
    5. Return for Contraceptive Implant within 5 days of next menstrual period
    6. Return for injection within 7 days of next menstrual period
  6. Resources
    1. Quick Start Algorithm (Reproductive Health Access Project)
      1. https://www.reproductiveaccess.org/wp-content/uploads/2014/12/QuickstartAlgorithm.pdf

XI. Management: Contraceptive Selection in comorbid conditions

  1. See Contraceptive Selection in Underlying Cardiovascular Disease
  2. See Contraceptive Selection in Seizure Disorder
  3. History of Diabetes Mellitus
    1. See Contraceptive Selection in Diabetes Mellitus
    2. Oral Contraceptives with low-dose Estrogen and less androgenic Progestin
      1. Avoid in vascular disease or microvascular disease, or in Diabetes Mellitus >20 years
    3. Intrauterine Device (Copper-T IUD or Levonorgestrel IUD)
    4. Progestin-Only Pill (lower efficacy)
    5. Avoid Depo Provera
  4. History of Bariatric Surgery (only roux-en-Y affected due to malabsorption)
    1. Avoid Oral Contraceptives and Progestin Only Pill
  5. Obesity (BMI >= 30 kg/m2)
    1. Avoid Contraceptive Patch in BMI >= 30 kg/m2
    2. Consider increased thrombosis risk with comorbid conditions (in which case avoid Estrogen products)
  6. History of Venous Thromboembolism
    1. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
    2. Preferred options include Intrauterine Device, Contraceptive Implant or Progestin-Only Pill
  7. Tobacco Abuse over age 35 years (CAD and VTE Risk)
    1. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
  8. History of Breast Cancer (current or prior)
    1. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
    2. Avoid all Progesterone products (Progestin-Only Pill, Depo Provera, Progestin IUD)
    3. Copper-T IUD is safe and preferred
  9. Migraine Headache with aura
    1. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
  10. Poorly controlled or Uncontrolled Hypertension
    1. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
    2. Intrauterine Device (Copper-T IUD or Levonorgestrel IUD), Contraceptive Implant or Progestin-Only Pill
  11. Heart or Cardiovascular Disease (Ischemic Heart Disease, Complicated Valvular Disease, Cerebrovascular Accident)
    1. See Contraceptive Selection in Underlying Cardiovascular Disease
    2. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
  12. Corticosteroids chronically
    1. Avoid Depo Provera (risk of Osteoporosis)
  13. Systemic Lupus Erythematosus, Antiphospholipid Antibodies
    1. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
  14. Significant Chronic Kidney Disease (e.g. Hemodialysis, Nephrotic Syndrome)
    1. Preferred options include IUDs, Progestin-Only Pills
    2. Avoid Drospirenone (Hyperkalemia risk)
  15. Severe liver disease (Cirrhosis, active liver cancer, active Viral Hepatitis)
    1. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
  16. Postpartum Contraception
    1. Early postpartum (first 3 weeks)
      1. Preferred: Intrauterine Device (Copper-T IUD or Levonorgestrel IUD) or Progestin-Only Pill
      2. Consider Intrauterine Device placement within 10 minutes of placental delivery
        1. Lopez (2015) Cochrane Database Syst Rev (6): CD003036 +PMID:26115018 [PubMed]
    2. In first 3 weeks, avoid all Estrogen products (Venous Thromboembolism Risk)
    3. In first 6 weeks AND Breast Feeding, avoid all Estrogen products (interferes with Lactation)
    4. After 6 weeks, any Contraception option may be used
  17. References
    1. (2024) Presc Lett 31(10): 57
    2. (2006) Obstet Gynecol 107(6): 1453-72 [PubMed]

XII. References

  1. Klein (2015) Am Fam Physician 91(9): 625-33 [PubMed]
  2. Lesnewski (2021) Am Fam Physician 103(5):291-300 [PubMed]
  3. Paradise (2022) Am Fam Physician 106(3):251-9 [PubMed]
  4. Tepper (2020) MMWR Morb Mortal Wkly Rep 69(14): 405-10 [PubMed]

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