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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Related Studies

Ontology: Family Planning (C0009861)

Definition (OMS) Practices designed to plan and space pregnancy within the context of values, attitudes, and beliefs.
Definition (MSH) Health care programs or services designed to assist individuals in the planning of family size. Various methods of CONTRACEPTION can be used to control the number and timing of childbirths.
Definition (CSP) programs or services designed to assist the family in controlling reproduction by either improving or diminishing fertility; planning intended to determine the number and spacing of one's children through birth control or methods which promote reproduction.
Concepts Health Care Activity (T058)
MSH D005193
SnomedCT 73285008, 310031001
English Family Planning, FP - Family planning, Family planning, family planning, family planning services, family plan service, family planning service, Family Planning Services, Family Planning Service, Planning Service, Family, Service, Family Planning, Services, Family Planning, Planning Services, Family, Family planning service, Family planning service (qualifier value), Family planning and/or genetic counseling
Swedish Familjeplanering
Czech plánování rodičovství - služby
Finnish Perhesuunnittelupalvelut
Russian SEM'I PLANIROVANIE, SEM'I PLANIROVANIIA SLUZHBY, СЕМЬИ ПЛАНИРОВАНИЕ, СЕМЬИ ПЛАНИРОВАНИЯ СЛУЖБЫ
Japanese 産児制限, 家族計画, 計画出産
French Services de planification de la famille, Services de planification familiale, Services d'orthogénie, Planification familiale, Planning familial, Service de planning familial
Italian Pianificazione familiare, Servizi di pianificazione familiare
Croatian PLANIRANJE OBITELJI, SAVJETOVALIŠTA, PLANIRANJE OBITELJI
Polish Planowanie rodziny, Świadczenia związane z planowaniem rodziny, Usługi z zakresu planowania rodziny
Norwegian Familieplanlegging
Spanish Centros de Planificación Familiar, servicio de planificación familiar (calificador), servicio de planificación familiar, Servicios de Planificación Familiar
Portuguese Centros de Planejamento Familiar, Clínicas de Planejamento Familiar, Agências de Planejamento Familiar, Serviços de Planejamento Familiar
German Familienplanung
Dutch Gezinsplanning, Adviesbureau gezinsplanning
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Family planning counseling (C0199395)

Concepts Health Care Activity (T058)
MSH D012736
SnomedCT 397619005, 73285008, 306976002, 13197004, 389095005
English Education, Family Planning, FAMILY PLANNING EDUC, EDUC FAMILY PLANNING, Advice rel to pregn and fertil, Advice relating to pregnancy and fertility, education family planning, family planning education, family planning counseling, Family planning counseling (regime/therapy), Family planning counselling, Advice relating to pregnancy and fertility (regime/therapy), Family planning, FP - Family planning, Family planning treatments and procedures, Family planning counseling, Family planning counseling (regime/therapy)(procedure), Advice relating to pregnancy and fertility (regime/therapy)(procedure), Family Planning, Family Planning Education, Family planning education (procedure), Family planning education
Spanish educación sobre planificación familiar (procedimiento), educación sobre planificación familiar, asesoramiento sobre planificación familiar (régimen/tratamiento), consejo relacionado con embarazo y fertilidad (régimen/tratamiento), consejo relacionado con embarazo y fertilidad, asesoramiento sobre planificación familiar, asesoramiento sobre planificación familiar (procedimiento)
French Éducation en planification familiale, Éducation en matière de planification familiale
Czech výchova k plánování rodičovství
Norwegian Utdannelse i familieplanlegging
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Contraceptive methods (C0700589)

Definition (MEDLINEPLUS)

Birth control, also known as contraception, is designed to prevent pregnancy. Birth control methods may work in a number of different ways. These include

  • Preventing sperm from getting to the eggs - condoms, diaphragms and intrauterine devices (IUDs) work this way
  • Keeping the woman's ovaries from releasing eggs that could be fertilized - birth control pills work this way
  • Sterilization, which permanently prevents a woman from getting pregnant or a man from being able to get a woman pregnant

Your choice of birth control should depend on several factors. These include your health, frequency of sexual activity, number of sexual partners and desire to have children in the future. Your health care provider can help you select the best form of birth control for you.

NIH: National Institute of Child Health and Human Development
Definition (NCI) The prevention of conception or impregnation by the use of devices or drugs or surgery.
Definition (MSH) Prevention of CONCEPTION by blocking fertility temporarily, or permanently (STERILIZATION, REPRODUCTIVE). Common means of reversible contraception include NATURAL FAMILY PLANNING METHODS; CONTRACEPTIVE AGENTS; or CONTRACEPTIVE DEVICES.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D003267
SnomedCT 146680009, 146788008, 169558006, 13197004, 73285008
LNC MTHU024530
English Contraception, Contraceptive Method, Contraceptive Methods, Fertility Control, Fertilization Inhibition, Inhibition of Fertilization, Contraception NOS, INHIB OF FERTILIZATION, method birth control, contraceptive method, control fertility, birth control, contraceptives methods, birth control method, birth controls, contraception, fertility control, birth control methods, contraceptions, contraceptive methods, Contraception NOS (finding), Birth control method, Birth Control, Birth control, Contraception (finding), Contraceptive methods, Contraception, NOS, Birth control, NOS
Dutch geboorteregeling, contraceptie NAO, contraceptie, Anticonceptie, Contraceptie, Geboortebeperking
French Contraception SAI, Contrôle de la fécondité, Contrôle des naissances, Méthodes contraceptives, Contraception
German Geburtenkontrolle, Kontrazeption NNB, Verhuetung, Kontrazeption, Empfängnisverhütung, Schwangerschaftsverhütung
Italian Contraccezione NAS, Controllo della fertilità, Inibizione della fertilità, Controllo delle nascite, Metodi contraccettivi, Contraccezione
Portuguese Controlo dos nascimentos, Contracepção NE, Métodos Contraceptivos, Controle da Fecundidade, Limitação da Fecundidade, Contracepção, Controle da Natalidade, Métodos Anticoncepcionais, Anticoncepção, Controle de Natalidade
Spanish Control de la natalidad, Anticoncepción NEOM, anticoncepción, SAI, anticoncepción, SAI (hallazgo), Contraception NOS, Control de Natalidad, Métodos de Control de la Natalidad, Regulación de la Fecundidad, anticoncepción (hallazgo), anticoncepción, control de la natalidad, Control de la Natalidad, Anticoncepción
Japanese 避妊ＮＯＳ, ﾋﾆﾝ, ｼﾞｭﾀｲﾁｮｳｾﾂ, ﾋﾆﾝNOS, 避妊法, 避妊, 受胎調節
Swedish Födelsekontroll
Czech antikoncepce, Antikoncepce NOS, Prevence početí, Antikoncepce, antikoncepční metody, zamezení početí
Finnish Raskauden ehkäisy
Russian KONTRATSEPTSIIA, КОНТРАЦЕПЦИЯ
Croatian KONTRACEPCIJA
Polish Antykoncepcja
Hungarian Fogamzásgátlás, Fogamzásgátlás k.m.n.
Norwegian Befruktningshemming, Fertilitetskontroll, Fruktbarhetskontroll, Fødselskontroll, Prevensjon, Prevensjonsmetoder
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Contraception education (C1636201)

Concepts Health Care Activity (T058)
SnomedCT 398780007
Spanish educación para la salud - anticoncepción, educación sobre anticoncepción (procedimiento), educación sobre anticoncepción, educación para la salud - anticoncepción (régimen/tratamiento)
English Health education - contraception (regime/therapy), Health education - contraception, Contraception education (procedure), Contraception education
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Hormonal contraception (C2985296)

Definition (NCI) The birth control method that utilizes external source of sex hormones to prevent pregnancy by interfering with the ovulation, fertilization or implantation of the fertilized egg in the uterus.
Concepts Therapeutic or Preventive Procedure (T061)
English Hormonal Contraception, Hormonal contraception, Hormonal Birth Control, Hormonal Method
Czech Hormonální antikoncepce
Dutch hormonale anticonceptie
French Contraception hormonale
German Hormonelle Kontrazeption
Hungarian Hormonális fogamzásgátlás
Italian Contraccezione ormonale
Japanese ホルモン製剤による避妊, ﾎﾙﾓﾝｾｲｻﾞｲﾆﾖﾙﾋﾆﾝ
Portuguese Contracepção hormonal
Spanish Contracepción hormonal
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Contraception Management

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