Contraception

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
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
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
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
References
1. (2013) MMWR Recomm Rep 62(RR-05):1-60 +PMID:23784109 [PubMed]
  1. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6205a1.htm

Oral Contraceptive
Depo Provera Injectable (repeated every 3 months)
Intrauterine Device
1. Copper T-380A (Paragard) IUD: 10 years
2. Mirena (5 year device)
3. Skyla (3 year device)
4. Older devices included the one year Progestasert IUD (discontinued)
Vaginal Contraceptive Ring (NuvaRing)
Contraceptive Patch (Ortho Evra)
Implantable Progesterone Rods
1. Nexplanon (single rod system approved for 3 years of Contraception)
2. Older devices included Implanon (lasted 2 years) and Norplant (lasted 5 years)

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
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
Sexual History (and risks for STI)
1. Current and recent sexual partners
2. Condom use
3. Prior Sexually Transmitted Infection (STI)
Other history related to contraceptive selection
1. Contraceptive use in the past and preferences
2. Intention for future pregnancy

Blood Pressure
1. Avoid combination Oral Contraceptives in Uncontrolled Hypertension
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)
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

Initiation: Avoid barriers and delays
1. Start Contraception at time of visit (unless not able to reliably confirm Non-Pregnant State)
2. Bridge to longterm method if unable to confirm Non-Pregnant State
  1. Use non-intrauterine Contraception until repeat Pregnancy Test in 2-4 weeks
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
Sexually Transmitted Infection prevention
1. Make Condoms readily available as part of dual protection for those at risk of STI
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]