II. Epidemiology
-
Unintended Pregnancy rates
- United States: 45% in 2011 (had been >51% in 2008)
- Western Europe: 34%
- Eastern Europe: 54%
- References
III. Efficacy: First year failure rates of Contraception
- Most effective methods: Permanent (<1 pregnancy per year in 100 women)
- Vasectomy: 0.15% failure rate
- Tubal Ligation: 0.5% failure rate
- Hysteroscopic Sterilization: 0.5% failure rate
- Most effective methods: Reversible (<1 pregnancy per year in 100 women)
- Implantable Contraception (e.g. Nexplanon): 0.05% failure rate
- Levonorgestrel IUD (e.g. Mirena): 0.2% failure rate
- Copper-T IUD: 0.8% failure rate
- Effective methods (6-12 pregnancies per year in 100 women)
- Depo Provera Injection: 6% failure rate
- Oral Contraceptives: 9% failure rate
- Contraceptive Patch (e.g. Ortho Evra): 9% failure rate
- Vaginal Contraceptive Ring (NuvaRing): 9% failure rate
- Contraceptive Diaphragm: 12% failure rate
- Least effective methods (>18 pregnancies per year in 100 women)
- Male Condom: 18%
- Female Condom: 21%
- Withdrawal Method: 22%
- Contraceptive Sponge: 12% (nullip) to 24% (parous) failure rate
- Natural Family Planning: 24% failure rate
- Vaginal Spermicide: 28% failure rate
- References
IV. Preparations: Non-Hormonal Options
- Male Condom
- Female Condom
- Contraceptive Diaphragm
- Contraceptive Sponge (no longer available in U.S.)
- Cervical Cap
- Vaginal Spermicide
- Natural Family Planning and Fertility awareness
- Contraceptive Sponge (returns to U.S. market in 2005)
V. Preparations: Hormonal Contraception
- Oral Agents (Daily)
- Oral Contraceptive (Combination OCP)
- Mini-Pill (Progesterone only)
- Norgestrel 75 mcg (Opill) is available OTC in 2024
- Injectable Options (Progesterone)
- Depo Provera Injectable (repeated every 3 months)
- Long Acting Reversible Contraception (LARC)
- Intrauterine Device
- Copper T-380A (Paragard) IUD: 10 years (studies support 12 years of use)
- Mirena: 7 year Levonorgestrel IUD (originally labelled for 5 years)
- Liletta: 6 year Levonorgestrel IUD
- Kyleena: 5 year Levonorgestrel IUD
- Skyla: 3 year device Levonorgestrel IUD
- Older devices included the one year Progestasert IUD (discontinued)
- Estrogen Containing Devices
- Implantable Progesterone Rods
- Intrauterine Device
VI. History
-
Confirmation of Non-Pregnant State
- Menstrual history
- Last Menstrual Period
- Menstrual period regularity
- Pregnancy history
- Lactation history
- Most recent intercourse
- Menstrual history
- Chronic medical problems (directs contraceptive selection as in management below)
-
Sexual History (and risks for STI)
- Current and recent sexual partners
- Condom use
- Prior Sexually Transmitted Infection (STI)
- Other history related to contraceptive selection
- Contraceptive use in the past and preferences
- Intention for future pregnancy
VII. Exam
-
Blood Pressure
- Avoid combination Oral Contraceptives in Uncontrolled Hypertension
- Body weight and BMI
- Consider avoiding Depo Provera in low BMI patients (increased Osteoporosis risk)
- Monitor weight for methods that may be associated with significant weight gain (e.g. Depo Provera)
- Pelvic Examination
- Not required for extra-pelvic forms of Contraception (e.g. OCP, Depo Provera, Nexplanon, Contraceptive Patch)
- Indicated when placing Intrauterine Device, Cervical Cap, Contraceptive Diaphragm
- STD Testing may be performed at time of IUD Placement in asymptomatic patients (to avoid delays)
- Avoid requiring Pap Smear or well woman physical exam prior to starting Contraception
VIII. Labs
-
Pregnancy Test
- Confirmation of Non-Pregnant State by history may also suffice
IX. Management: General
- Initiation: Avoid barriers and delays
- Start Contraception at time of visit (unless not able to reliably confirm Non-Pregnant State)
- Hormonal contraceptives do not cause birth defects, pregnancy loss or IUGR
- Bridge to longterm method if unable to confirm Non-Pregnant State
- Use non-intrauterine Contraception until repeat Pregnancy Test in 2-4 weeks
- Backup methods for first week when starting Hormonal Contraception
- Use barrier methods for first week
- Emergency Contraception may be used after unprotected sex in first week
- Compliance
- Prescribe one year supply of Contraception
- Help facilitate compliance (reminder systems, longterm Contraception)
- Reassess Contraception compliance and method satisfaction at routine visits
- Discuss permanent methods (e.g. Vasectomy, Tubal Ligation) if completed intended child bearing
-
Sexually Transmitted Infection prevention
- Make Condoms readily available as part of dual protection for those at risk of STI
- Specific cohorts
- Postpartum counseling on Contraception after delivery
- Perimenopause continuation of Contraception until Menopause or age 50 to 55 years old
- Adolescent Health counseling on Contraception and Sexually Transmitted Infection prevention
- Consider Long-Acting Reversible Contraception are preferred (e.g. IUD, dermal implants)
- Diedrich (2015) Am J Obstet Gynecol 213(5): 662 [PubMed]
- 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)
- See Quick Start Algorithm for Intrauterine Device
- Step 1: First Day of Last Menstrual Period (LMP)
- LMP >7 days ago: Go to Step 2
- LMP <7 days ago
- Start new Contraception today
- Backup Contraception indications
- Non-Injection Method (e.g. OCP, patch, ring, implant) AND
- LMP 5-7 days ago
- Step 2: LMP >7 days ago
- No unprotected sex since LMP
- Start new Contraception today
- Use backup Contraception for 7 days
- Unprotected sex since LMP and Urine Pregnancy Test negative
- Go to Step 3
- No unprotected sex since LMP
- Step 3: Offer Contraception with discussion of pregnancy risk
- Informed Consent
- Early pregnancy is possible despite negative Pregnancy Test
- Hormonal contraceptives are considered safe when accidentally used in early pregnancy
- Benefits of starting Contraception outweigh risks of early pregnancy (CDC)
- Patient opts to start new Contraception
- Offer Emergency Contraception with Plan B (Levonorgestrel) if unprotected sex within last 5 days
- Start new Contraception today
- Use backup Contraception for first 7 days
- Repeat Pregnancy Test in 2-4 weeks (in home or office)
- Patient opts to delay start of new Contraception
- Go to Step 4
- Informed Consent
- Step 4: Delayed Contraception Start
- Offer Emergency Contraception (Levonorgestrel or Ulipristal) if unprotected sex within last 5 days
- Offer advanced prescription or future appointment for Contraception placement
- Discuss alternative Contraception methods until next menstrual period
- Start pill patch or ring within 5 days of next menstrual period
- Return for Contraceptive Implant within 5 days of next menstrual period
- Return for injection within 7 days of next menstrual period
- Resources
- Quick Start Algorithm (Reproductive Health Access Project)
XI. Management: Contraceptive Selection in comorbid conditions
- See Contraceptive Selection in Diabetes Mellitus
- See Contraceptive Selection in Underlying Cardiovascular Disease
- See Contraceptive Selection in Seizure Disorder
- History of Bariatric Surgery (only roux-en-Y affected due to malabsorption)
- Avoid Oral Contraceptives and Progestin Only Pill
- History of Venous Thromboembolism
- Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
- History of Breast Cancer (current or prior)
- Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
- Avoid all Progesterone products (Progestin-Only Pill, Depo Provera, Progestin IUD)
- Copper-T IUD is safe and preferred
-
Migraine Headache with aura
- Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
- Poorly controlled or Uncontrolled Hypertension
- Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
-
Ischemic Heart Disease
- Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
- Complicated Valvular Disease
- Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
-
Corticosteroids chronically
- Avoid Depo Provera (risk of Osteoporosis)
-
Tobacco Abuse over age 35 years
- Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
-
Cerebrovascular Accident
- Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
-
Systemic Lupus Erythematosus, Antiphospholipid Antibodies
- Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
- Severe liver disease (Cirrhosis, active liver cancer, active Viral Hepatitis)
- Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
- Postpartum Contraception
- Consider Intrauterine Device placement within 10 minutes of placental delivery
- In first 3 weeks, avoid all Estrogen products (Venous Thromboembolism Risk)
- In first 6 weeks AND Breast Feeding, avoid all Estrogen products
- References