Details
The US has one of the highest rates of unintended pregnancy in the developed world. About half of all pregnancies in the US are unintended. Of these, approximately 40% end in abortion.[1][2]
The abortion rate in the US decreased by 21% between 2010 and 2019. In 2019, there were 11.4 abortions per 1000 women ages 15 to 44 years.[3] Although the overall abortion rate has declined, this is not seen across all population groups, with higher rates of unintended pregnancy and abortion in disadvantaged groups.[2][4] This disparity suggests there is limited access to contraception for some women and adolescents, and points to the importance of addressing birth control with all patients at risk for unintended pregnancy. To improve women's contraceptive options and their choices of place to access contraception, the World Health Organization recommends self-care interventions (e.g., self-injectable contraception and the over-the-counter availability of oral contraception).[5]
Contraceptive counseling should be patient-centered and aim to provide accurate information about all methods that the woman is medically eligible for, to help her choose which is best for her.[6] This should include information about the efficacy, risks, and side effects, as well as advantages, disadvantages, and noncontraceptive benefits of all methods that are available to her.[7][8]
Selecting an appropriate contraceptive method requires a complete medical history, with special focus on ruling out the most common contraindications. Several organizations provide guidance on the safety of different contraceptive methods in relation to health conditions and personal characteristics. These include the World Health Organization Medical Eligibility Criteria for contraceptive use (MEC), the Centers for Disease Control and Prevention (CDC) US Medical Eligibility Criteria (USMEC), the American College of Obstetricians and Gynecologists (ACOG), and the Faculty of Sexual and Reproductive Healthcare Medical Eligibility Criteria (UKMEC) in the UK.[8][9][10][11] Consult the relevant guidance for your area when providing contraception to women.
Initial counseling should include a general discussion about the risks and prevention of STIs.[12] A dual-protection strategy (i.e, condoms plus a second method) should be discussed with users of long-acting reversible contraceptive (LARC) methods because LARCs do not offer protection against STIs. The Contraceptive CHOICE cohort study reported a higher incidence of STIs in users of LARC methods.[13] Additionally, a study in postpartum teenage mothers found that condom use was lower among users of LARC, relative to non-LARC users.[14] These findings suggest a need for accurate and thorough counseling about STI risk and prevention alongside pregnancy prevention. However, it is important that this does not discourage providers from including LARC among methods offered, particularly given their efficacy in preventing pregnancy.
The ACOG recommends that pre-exposure prophylaxis should be discussed with all sexually active adolescent and adult patients for prevention of HIV.[15] See HIV infection (Prevention).
Patients can be reassured that a cervical cytology test and pelvic exam are not required before starting most contraceptives.[7][16]
Consider the patient's social context when discussing their contraceptive choices. For example:
A teenager whose parents disapprove of sexual activity may request a method that is easy to conceal
A working mother who travels often may be unable to remember a daily pill
An uninsured patient needs a method she can afford.
Adapt the approach to counseling for adolescents to ensure that information about contraceptive methods is given in a way that is developmentally appropriate and check their understanding. In addition, it is important to address any common misconceptions that adolescents may have concerning the different methods available.[17]
To maximize adherence, honor the patient's preferences, prescribing the particular method each patient chooses, unless a contraindication prevents this. However, it is also important to ensure that patients know their options, with special emphasis on awareness of the highest-efficacy methods. Patients who receive an ample initial supply of their contraceptive are more likely to adhere to treatment.[18]
The CDC's downloadable resources include a comparison of the effectiveness of different contraceptive methods, as well as other tools to use with patients.
CDC: reproductive health - contraception Opens in new window
Efficacy of contraception (defined as rates of unintended pregnancies per 100 women) is split into the following categories when comparing the effectiveness of different contraceptive methods:[19]
0 to 0.9: very effective
1-9: effective
10-19: moderately effective
20+: less effective.
Active military service generally reduces the adherence and effectiveness of contraception (50% to 65% of pregnancies are unintended in this population) and can therefore affect the suitability for some types of contraceptive (e.g., depot medroxyprogesterone acetate and the vaginal ring). Consequently, the ACOG recommends the use of long-acting reversible contraceptives (intrauterine devices or implant) for these women.[20]
Additionally, contraceptive measures should be discussed with women of child-bearing age who are taking potentially teratogenic medications.[21] Female patients should be enrolled in a pregnancy prevention programme, where there is one available, if they are taking sodium valproate.[22] This involves an annual assessment of the need for treatment with sodium valproate and a discussion of the risks of taking the drug during pregnancy. Patients should use a highly effective, user independent form of contraception such as a LARC.[22]
Barrier methods include:
Diaphragm and cervical cap
Female condom
Male condom
Spermicide (nonoxynol-9).
While barrier methods offer only moderate efficacy for prevention of unintended pregnancy, condoms and spermicide are available without a prescription, and latex/polyurethane condoms protect against HIV and other STIs.[12] Successful use of barrier methods requires consistency and discipline during intercourse. All barrier methods may be used safely during lactation.
The estimated pregnancy rate during typical and perfect use of the diaphragm is 17.4% and 16.3%, respectively.[1] The diaphragm and cervical cap must be fitted initially and prescribed by clinicians trained in their use. They must be filled and coated with spermicide and inserted before intercourse. Subsequent episodes of intercourse within 6 hours require vaginal insertion of more spermicide with an applicator. The diaphragm and cervical cap do not prevent HIV transmission. To use a cervical cap, the woman must be able to locate her cervix accurately.
Side effects and disadvantages include:
Skin irritation
Increased risk of bladder infection (diaphragm only)
Possible increase in risk of HIV transmission. There is evidence that frequent use of spermicide (the diaphragm or cap needs to be used with spermicide) does not decrease, and may actually increase, the risk of HIV transmission.[23][24]
The female condom is 79% to 95% effective for pregnancy prevention (typical to perfect use).[1] It consists of a lubricated polyurethane pouch that is inserted inside the vagina during sex. A new condom must be used each time a couple has intercourse. With proper use, the female condom can prevent transmission of HIV and other STIs.
Side effects and disadvantages include:
Friction/noise during intercourse
Loss of sensation
Inconvenience/interruption of sex
Slippage/breakage (has a higher risk of slippage than the male condom).
The male condom is 87% to 98% effective for pregnancy prevention (typical to perfect use).[1] A new condom must be used each time a couple has intercourse. With proper use, both latex and polyurethane condoms can prevent transmission of HIV and other STIs. Male condoms can also help to prevent early ejaculation.
Side effects and disadvantages include:
Latex allergy
Loss of sensation
Inconvenience/interruption of sexual intercourse
Slippage/breakage.
Spermicide comes in several forms, including gel, sponge, foam, and inserts. Gel, suppository, and film are 79% to 84% effective for pregnancy prevention (typical to perfect use), whereas the sponge is 83% to 88% effective. Some studies indicate a higher failure rate of the contraceptive sponge among parous users.[1] Spermicide must be inserted each time a couple has intercourse. It does not prevent HIV transmission.
Side effects/disadvantages include:
These methods include:
Lactational amenorrhea
Periodic abstinence (also known as rhythm- or fertility awareness-based methods)
Withdrawal.
They require no hormones or medications. Their moderate efficacy (on the World Health Organization contraceptive effectiveness scale) depends on consistent adherence.[19] The only risks associated with behavioral methods are inconvenience and failure.
To practice fertility awareness methods or withdrawal most effectively requires education and conscientious effort. A detailed explanation of these approaches (such as Billings method, cervical mucus method, two-day method, Standard Days Method™) is beyond the scope of this topic. Seek further information if counseling on these methods.
Lactational amenorrhea is 95% to 98% effective for pregnancy prevention (typical to perfect use).[1] To use this method, women must breast-feed exclusively, nursing at least every 4 hours during the day, and at least every 6 hours during the night. Women can continue using this method until one of the following events occurs:
They have their first menstrual period
They reach 6 months postpartum
Their infants nurse less often.
Periodic abstinence methods are also known as rhythm and fertility-awareness-based methods. Women predict ovulation by:
Tracking basal body temperature
Checking the consistency of cervical mucus
Charting menstrual cycles on a calendar
Monitoring urinary hormone levels
Symptothermal methods, monitoring several biomarkers, typically including cervical mucus and basal body temperature.[25]
Couples abstain from intercourse or use a barrier method from 5 days before the predicted day of ovulation to 2 days after ovulation. Some couples will require longer abstinence on either side of the predicted day of ovulation, given variability even in women with mostly regular menstrual cycles.
The effectiveness of periodic abstinence depends upon the particular method. In general, they are 85% effective with typical use, but effectiveness with perfect use can range from 95% to 99%.[1] However, one systematic review reported a lack of high quality studies examining their effectiveness in preventing pregnancy, suggesting that the efficacy of each method should be interpreted cautiously.[25] Combining more than one predictor increases efficacy.
In the US, the Food and Drug Administration approved a mobile app for marketing to premenopausal women aged ≥18 years. This app requires information from the woman on basal body temperature on a daily basis and uses an algorithm to calculate which days she is likely to be fertile. It provides information on which days she should abstain from sex or use protection.[26] One study reported that the Pearl Index, or failure rate, for the app was 6.9 pregnancies in 100 woman-years with typical use, and 1.0 pregnancies in 100 woman-years with perfect use.[27]
Withdrawal is 80% to 96% effective for pregnancy prevention (typical to perfect use).[1] This method requires a high level of trust and self-control. The man must be able to recognize the point at which ejaculation is inevitable, and he must withdraw his penis from the vagina before he ejaculates.
Even when performed perfectly, the withdrawal method may fail if there are live sperm in the man's pre-ejaculate.
Hormonal contraception includes:
Combined estrogen/progestogen contraception (pills, patch, or vaginal ring)
Progestogen-only contraception (pill, injection, implant, or progestogen intrauterine device).
Estrogen/progestogen contraceptives work primarily by suppressing ovulation. They are routinely available in three forms:
Pill
Patch
Vaginal ring.
Monthly injectables containing estrogen and progestogen are not discussed in this section and are not available in the US. More information about this method can be found in the World Health Organization Global Handbook on Family Planning: WHO: family planning - a global handbook for providers Opens in new window
While birth control pills must be taken daily, the patch is applied weekly and the vaginal ring is inserted monthly.
These contraceptives are moderately effective and well tolerated. Any formulation is likely to succeed. However, to promote adherence, clinicians should prescribe the type each patient chooses, unless there is a compelling reason to select a different one.
The hormones in combined hormonal contraceptives may interact with some other drugs. Women who take certain anticonvulsants (including phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine, lamotrigine) need to be advised that these medications can reduce the effectiveness of some hormonal contraceptives. This may mean considering alternate contraceptive options or, for the combined hormonal contraceptive, ensuring that a low dose of estrogen is not used.[10][11][28] Women who take most antibiotics may take estrogen/progestogen contraceptives without concern about decreased efficacy.[10][11] However, there are exceptions (e.g., rifamycins such as rifampin and rifabutin).
If it is reasonably certain that there is no risk of pregnancy, most women can begin combined hormonal contraceptives on the day they select the method, regardless of stage of menstrual cycle, and whether or not they have had a recent pelvic exam or cervical screening.[29] The Centers for Disease Control and Prevention recommends that if there are no symptoms or signs of pregnancy, and the woman meets any one of the following criteria, then a healthcare provider can be reasonably certain that the woman is not pregnant:[7]
Is ≤7 days after the start of normal menses
Has not had sexual intercourse since the start of last normal menses
Has been correctly and consistently using a reliable method of contraception
Is within 4 weeks postpartum
Is fully or nearly fully breast-feeding (exclusively breast-feeding or the vast majority [≥85%] of feeds are breast-feeds), amenorrheic, and <6 months postpartum.
Starting a contraceptive method at a time other than the start of the menstrual cycle is termed "quick starting." If a contraceptive method is started outside the first few days of the menstrual cycle it may not be immediately effective, which means that additional contraceptive precautions, such as condoms, may be needed for several days.[30] Quick start algorithms have been developed to guide the practitioner on which steps to take when a woman requests a new birth control method.
Reproductive Health Access Project: quick-start algorithm Opens in new window
CDC: when to start using specific contraceptive methods Opens in new window
For most women, the benefits of hormonal contraceptives exceed their potential risks.[31] Estrogen-containing contraceptives carry a small risk of thromboembolic complications (including myocardial infarction, stroke, and venous thrombosis).[32][33][34]
[ 
]
[ ]
Women with multiple cardiovascular risk factors (e.g., smoking, diabetes mellitus, and hypertension) should avoid estrogen-containing contraceptives, especially those with an estrogen dose over 35 micrograms/day.[10][11][33]
Several organizations provide guidance on the safety of different contraceptive methods in relation to health conditions and personal characteristics. These include the World Health Organization Medical Eligibility Criteria for contraceptive use (MEC), the Centers for Disease Control and Prevention US Medical Eligibility Criteria (USMEC), the American College of Obstetricians and Gynecologists (ACOG), and the Faculty of Sexual and Reproductive Healthcare Medical Eligibility Criteria (UKMEC) in the UK.[8][9][10][11] Consult the relevant guidance for your area when providing contraception to women.
Some of the most common absolute contraindications to estrogen-containing contraceptives in the USMEC guidance include:[10]
Migraine with aura
Smoking: in women aged <35 years who smoke >15 cigarettes/day
Ischemic heart disease, past or current
Stroke
Severe cirrhosis or liver tumor
Major surgery with prolonged immobilization (estrogen-containing contraceptives should be stopped 4-6 weeks before such surgery)
Deep venous thrombosis, past or current
Hypertension: poorly controlled (systolic ≥160 mmHg, or diastolic ≥100 mmHg)
Postpartum: less than 21 days
Breast cancer, current (diagnosis ≤5 years ago).
Please refer to your relevant local guidance for a full list of contraindications.
Some of the most common relative contraindications to estrogen-containing contraceptives include:[10]
Smoking: in women aged >35 years who smoke <15 cigarettes/day
Concurrent treatment with hepatic enzyme-inducing drugs, including certain anticonvulsants (e.g., phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine, lamotrigine) and antituberculosis drugs (e.g., rifampin, rifabutin). The combined oral contraceptive (COC) pill is not considered first-line in this group, because of higher failure rates due to increased metabolism of the COC pill. However, it can be considered if the dose and drug regimen are tailored to the patient. The dose and regimen of the COC will depend on whether the enzyme-inducing drug is being used short term (<2 months) or long term (>2 months); a higher dose of the estrogen component is required with long-term treatment. A long-acting contraceptive is preferred in these patients.[35]
Hypertension: well-controlled or moderately well-controlled (systolic 140-159 mmHg, or diastolic 90-99 mmHg)
Breast cancer, more than 5 years in the past.
Please refer to your relevant local guidance for a full list of contraindications.
Estrogen/progestogen pills come in many formulations, with varying doses of estrogen and varying types/doses of progestogen. Combined hormonal contraceptives are 93% to 99% effective for pregnancy prevention (typical to perfect use).[1]
Monophasic pills contain fixed doses of estrogen and progestogen. Multiphasic pills contain varying doses over the course of a 28-day pack. Most packs contain 21 active pills and 7 placebo pills. Withdrawal bleeding usually occurs while women are taking the placebo pills. Some newer products contain fewer placebo pills (e.g., 24 active pills and 4 placebo pills), with the goal of reducing the number of unintended pregnancies that occur when women miss one of the first few pills in a pack.
The most common side effects of combined hormonal contraceptive pills include irregular bleeding, nausea, headaches, and breast tenderness.[19]
Most side effects improve after the first 2 or 3 cycles, and persistent side effects often resolve when the woman changes to a different pill formulation. It can be challenging to prove whether the combined hormonal contraceptive pill is responsible for side effects, due to the difficulties in controlling other influential factors. There is evidence to support irregular bleeding and mood changes, but no consistent evidence to support depression or weight gain.[36] Some women can experience idiosyncratic side effects; if a woman wants to discontinue a method because of real or perceived side effects, her choices should ultimately be respected.
One systematic review found that the use of combined oral contraceptives containing other progestogens compared with the use of levonorgestrel-containing combined oral contraceptives may be associated with a small increased risk of venous thromboembolism.[37]
Fertility returns quickly when women stop taking estrogen/progestogen pills.[1]
The estrogen/progestogen patch contains hormones that are absorbed transdermally. The patch is 93% to 99% effective for pregnancy prevention (typical to perfect use).[1]
Each month’s supply of the norelgestromin/ethinyl estradiol patch contains three patches. Women apply a new patch each week for 3 weeks, and use no patch during week 4. Because each patch releases adequate hormone levels to last 9 days, women who change their patch 1-2 days late do not increase their risk of unintended pregnancy.
The most common side effects of the patch include irregular bleeding, skin irritation, headaches, and nausea.[19]
A Cochrane review noted that, compared with combined hormonal pill users, women using the norelgestromin-containing patch experienced more breast discomfort, dysmenorrhea, nausea, and vomiting.[38]
Most side effects improve after the first 2 or 3 cycles; persistent side effects often resolve when the woman changes to a different estrogen/progestogen formulation.
The patch has several noncontraceptive benefits. (See section on Noncontraceptive benefits for hormonal contraceptives.)
The efficacy of the norelgestromin/ethinyl estradiol patch may be decreased in women who weigh >90 kg. Additional precautions or an alternative method should be advised for women in this category.[36][39]
Because the norelgestromin/ethinyl estradiol patch causes higher serum estrogen levels than the low-dose pills or vaginal ring, it may be associated with a higher risk of thromboembolic complications. However, long-term data on venous thromboembolic risk with the patch are limited, and thromboembolism remains rare among patch users.[1] Fertility returns quickly when women stop using the patch.[1]
Another combined estrogen/progestogen transdermal patch is available which contains levonorgestrel and ethinyl estradiol. This is also a weekly patch. In a key clinical trial, the overall Pearl Index was 5.8, though that increased to 8.6 for those with BMI >30 kg/m². The side-effect profile was generally well-tolerated.
The vaginal ring contains estrogen/progestogen hormones that are absorbed through the vaginal mucosa. The ring is 93% to 99% effective for pregnancy prevention (typical to perfect use).[1]
There are now two vaginal rings approved for use in the US; etonogestrel/ethinylestradiol and segesterone/ethinylestradiol.
The etonogestrel/ethinylestradiol vaginal ring is approved for 21 days of use (with 1 week off), and is replaced with a new ring each month. Each package contains one ring. Women typically insert a new ring to remain in place for 3 weeks, and take out the ring for the fourth week. Because each ring releases adequate hormone levels to last 35 days, women who change their ring 10-15 days late do not increase their risk of unintended pregnancy. Its long duration of action makes the ring particularly amenable to continuous use (extended cycling; using the ring continuously, with no ring-free interval). This has several additional noncontraceptive benefits, including decreased blood loss and decrease in PMS symptoms. Women who choose extended cycling can insert a new ring on the same date of each month.
About 4% of women find that the ring is expelled spontaneously, which may occur with valsalva maneuvers.[40] Women can remove the ring (e.g., during intercourse) for up to 3 hours/day without losing contraceptive efficacy.
The segesterone/ethinyl estradiol vaginal system should also be placed in the vagina for 3 weeks followed by 1 week off. This cycle is repeated every 4 weeks. However, the same vaginal system may be used for 1 year (thirteen 28-day cycles), and should be cleaned and stored as per the manufacturer’s instructions after each use.
The most common side effects of the ring include irregular bleeding, increased vaginal discharge, low abdominal pain, and breast pain.[19] A systematic review and meta-analysis found that the vaginal ring is as effective and tolerable as the combined oral hormonal contraceptive but with a better bleeding profile.[41]
Most side effects improve after the first 2 or 3 cycles. One Cochrane review reported that users of the ring experienced less nausea, acne, irritability, and depression than pill users, but experienced more vaginal irritation and discharge.[38] The ring has several noncontraceptive benefits. (See section on Noncontraceptive benefits for hormonal contraceptives.) Fertility returns quickly when women stop using the ring.[1]
These methods work primarily by thickening cervical mucus. Some also suppress ovulation and make the endometrium less hospitable to implantation. Progestogen-only contraceptives are routinely available as:
Pill
Implant: a long-acting reversible contraceptive (LARC) method
Injection: a LARC method
Progestogen intrauterine device: a LARC method. Progestogen intrauterine device is covered in the section on Intrauterine devices.
Progestogen-only vaginal rings are not discussed in this section and are not available in the US. More information about this method can be found in the World Health Organization Global Handbook on Family Planning: WHO: family planning - a global handbook for providers Opens in new window
Once inserted, the implant and intrauterine device do not depend on their user for efficacy.
Progestogen-only methods are well suited to women who cannot take estrogen (e.g., women who have intolerable estrogen-related side effects or contraindications).[42] If it is reasonably certain that there is no risk of pregnancy, most women can begin the progestogen-only pill, injection, or implant on the day they select the method, whether or not they have had a recent pelvic exam/cervical screening.[43] The Centers for Disease Control and Prevention recommends that, if there are no symptoms or signs of pregnancy and the woman meets any one of the following criteria, then a healthcare provider can be reasonably certain that the woman is not pregnant:[7]
Is ≤7 days after the start of normal menses
Has not had sexual intercourse since the start of last normal menses
Has been correctly and consistently using a reliable method of contraception
Is within 4 weeks postpartum
Is fully or nearly fully breast-feeding (exclusively breast-feeding or the vast majority [≥85%] of feeds are breast feeds), amenorrheic, and <6 months postpartum.
CDC: when to start using specific contraceptive methods Opens in new window
The only absolute contraindication to progestogen-only contraception is current breast cancer.[10] Please refer to relevant Medical Eligibility Criteria for a full list of relative contraindications, which include positive antiphospholipid antibodies, severe liver cirrhosis, and a previous history of breast cancer.[10] Contraindications to progestogen-only methods are generally also contraindications to combined methods.
Norethindrone, drospirenone, and norgestrel are the only progestin-only pills currently available in the US and, of these, norgestrel is the first daily nonprescription oral birth control pill.[44] Norethindrone and norgestrel come in monophasic monthly packs without placebo pills. Drospirenone comes in monthly packs of 24 active tablets with 4 inactive tablets.
The progestogen-only pill is 93% to 99% effective for pregnancy prevention (typical to perfect use).[1] This method can be used safely during lactation. To maximize efficacy, women must take each pill at the same time daily.
Women who take norethindrone more than 3 hours late should use an additional method (e.g., any barrier method) for 2 days.[7] However, drospirenone allows for a 24-hour missed pill window which ensures contraceptive efficacy for up to 24 hours in the event of a missed (or delayed) dose.
Women may or may not have a monthly menstrual period while taking the progestogen-only pill. Commonly reported side effects include changes in bleeding patterns, headaches, mood changes, and breast tenderness.[19]
Fertility returns quickly when women stop taking the pill.[1]
The progestogen implant is a contraceptive device inserted subdermally in the upper arm. This is either a single rod or two rods. We have not included detail here on the two-rod implants, which are not available in the US. More information about two-rod implants can be found in the World Health Organization Global Handbook on Family Planning: WHO: family planning - a global handbook for providers Opens in new window
The single-rod contraceptive implant is 99% effective for pregnancy prevention.[1] It works primarily by preventing ovulation and also has additional contraceptive effect by thickening the cervical mucus and thinning the endometrial lining.[45][46] It releases etonogestrel, which has a contraceptive effect, for 3 years. It must be inserted and removed by a clinician trained in its use.[45] Complications relating to insertion or removal are uncommon, with risks of insertion that include pain, bleeding, hematoma, difficult insertion, and unrecognized non-insertion.[47] Rarely, nerve injuries have been reported.[48] However, the manufacturer has updated the instructions for administration to decrease this risk.
Many women become amenorrheic after a few months. However, many will experience irregular bleeding.
Commonly reported side effects include changes in bleeding patterns, headaches, abdominal pain, acne (can improve or worsen), weight changes, and mood changes.[19] Less than one quarter of women using the implant will have a regular bleeding pattern, with one third experiencing infrequent bleeding, one fifth no bleeding, and one quarter having prolonged or frequent bleeding. Dissatisfaction with bleeding is often a reason for discontinuing the implant.[46] In women with bothersome bleeding, short-term use (3 months) of additional combined hormonal oral contraceptives may be offered (off-label use), but it is important to exclude other causes of bleeding (such as STIs) first. Longer term use of the implant and combined hormonal oral contraceptives have not been studied.[46][49]
Fertility returns quickly when the implant is removed.[47]
Depot medroxyprogesterone acetate (DMPA) is an injectable contraception that can be given by intramuscular depot injection, or subcutaneously in a lower-dose formulation. Intramuscular DMPA is 96% to 99% effective for pregnancy prevention (typical to perfect use).[1] DMPA, given either subcutaneously or intramuscularly, appears to be equally efficacious with a similar safety profile when used by healthy women.[50] Women receive this injection either in a medical office, or for the subcutaneous formulation they may self-administer, every 12-13 weeks. Progestogen injection lowers the risk of ovarian and endometrial cancer. After two or more cycles, many women become amenorrheic.
Most commonly reported side effects include irregular bleeding, weight gain, headache, mood changes, abdominal pain, and decreased libido.[19]
DMPA is associated with a small loss of bone mineral density, which is largely recovered when it is discontinued.[51][52] Bone density stabilizes after 2 years of use and returns to baseline levels after the method is discontinued. Progestogen injection users should be counseled regarding diet and exercise to maintain bone health, although this has not been proven to affect rate of bone mineral density change, and they should not receive bone density monitoring. It is important to reassess the risks and benefits of this method every 2 years in women who wish to continue.[52][53]
Because progestogen levels decline gradually over many months, side effects may persist for months after women stop using this method. There can be a delay of up to 1 year in the return of fertility after discontinuing this method.[53]
The US FDA has approved a non-hormonal, on-demand, vaginal pH regulator contraceptive vaginal gel (lactic acid, citric acid, and potassium bitartrate) for the prevention of pregnancy in females of reproductive potential. The gel maintains vaginal pH within the normal range of 3.5 to 4.5 – an acidic environment that is inhospitable to sperm. The most common side-effects are vulvovaginal burning sensation and vulvovaginal pruritus.
IUDs work primarily through prevention of fertilization. The progestogen IUD (levonorgestrel intrauterine system [LNG-IUS]) also thickens cervical mucus and induces endometrial atrophy. Two types of IUD are available in the US:
Copper intrauterine device
Progestogen intrauterine device.
IUDs are very effective, well tolerated, long acting, and reversible. IUDs are well suited to women who cannot take estrogen (e.g., women who have intolerable estrogen-related side effects, or estrogen contraindications). They also do not require ongoing effort from the patient for effective use and are an effective reversible contraceptive method (with contraceptive implants being the most effective).[45] Because the copper IUD also has some post-fertilization effects, it can be used as emergency contraception up to 5 days after unprotected sexual intercourse. (The progestogen IUD is not recommended for emergency contraception.)[7] IUDs may be used by nulliparous women and those with a past history of STIs.[45][54][55] IUDs may be inserted at any point in the menstrual cycle when pregnancy can reasonably be excluded. The Centers for Disease Control and Prevention recommends that if there are no symptoms or signs of pregnancy, and the woman meets any one of the following criteria, then a healthcare provider can be reasonably certain that the woman is not pregnant:[7]
Is ≤7 days after the start of normal menses
Has not had sexual intercourse since the start of last normal menses
Has been correctly and consistently using a reliable method of contraception
Is within 4 weeks postpartum
Is fully or nearly fully breast-feeding (exclusively breast-feeding or the vast majority [≥85%] of feeds are breast-feeds), amenorrheic, and <6 months postpartum.
Before an IUD is inserted, there are a number of risks that should be discussed with all women:[56]
The overall risk of ectopic pregnancy is reduced with the use of IUD compared with no contraception. However, the few pregnancies that occur with an IUD in place are more likely to be ectopic.[9][57][58]
The risk of expulsion is around 5%, and is most common in the first year of use (particularly the first 3 months). Expulsion occurs more often in nulliparous women and in women who had the IUD inserted immediately postabortion or postpartum.[59][60]
The risk of uterine perforation is up to 2 in 1000 insertions. This is higher in breast-feeding women.[61] The risk of perforation decreases with inserter experience.[62]
Fertility returns quickly when the IUD is removed, and is not diminished by past IUD use.[63]
The copper IUD is a nonhormonal contraceptive. It is 99% effective for pregnancy prevention. It remains effective for 5-12 years, depending on the device used, and its use can be extended (off-label use) in women ages ≥40 years.[1][64] It is recommended to leave the IUD in situ until 1 year after the last menstrual period if this occurs at age ≥50 years.[45] It often causes heavier, more painful periods during the first few cycles. Less often, it causes irritation of the partner's penis during intercourse; this problem can be addressed by cutting the IUD's string shorter. It can be used as a postcoital method of contraception for up to 5 days after the earliest predicted date of ovulation (i.e., day 19 of a 28-day cycle).[7]
Theoretically, insertion of the IUD carries a small, transient risk of infection, which could lead to complications such as pelvic inflammatory disease (PID). However, one study found that IUD placement does not increase the risk of PID among individuals with asymptomatic cervical infection or at high risk for STIs.[65] Conclusions of older research studies may be less applicable in the setting of current IUDs and evidence-based STI screening practices. Prophylactic antibiotics are generally not recommended for insertion.[45][56] Women can be tested for STIs at the time of insertion, and as needed thereafter (e.g., for evaluation of symptoms or for screening). If a test is positive, clinicians can safely treat the patient and partner without removing the IUD.[7]
Online patient information is available that may help the patient decide which type of IUD is most suitable for them. Reproductive Health Access Project: IUD information Opens in new window CDC: when to start using specific contraceptive methods Opens in new window
The levonorgestrel intrauterine system (LNG-IUS) works primarily through prevention of fertilization, but also thickens cervical mucus and induces endometrial atrophy. It can prevent pregnancy for 3-6 years depending on the type selected. It is 99% effective for pregnancy prevention.[66] At 1 year, infrequent bleeding is common and some women will become amenorrheic.[56]
Commonly reported side effects include changes in bleeding patterns, acne, headaches, breast tenderness, and nausea.[19]
Similarly to copper IUDs, theoretically, insertion of the LNG-IUS carries a small, transient risk of infection that could lead to complications such as pelvic inflammatory disease (PID). However, one study found that IUD placement does not increase the risk of PID among individuals with asymptomatic cervical infection or at high risk for STIs. Conclusions of older research studies may be less applicable in the setting of current IUDs and evidence-based STI screening practices.[65] Prophylactic antibiotics are generally not recommended for insertion. Women can be tested for STIs at the time of insertion, and as needed thereafter (e.g., for evaluation of symptoms or for screening). If a test is positive, clinicians can safely treat the patient and partner without removing the IUD.[7]
Online patient information is available that may help the patient decide which type of IUD is most suitable for them. Reproductive Health Access Project: IUD information Opens in new window CDC: when to start using specific contraceptive methods Opens in new window
There are noncontraceptive benefits associated with levonorgestrel-containing IUDs, as they can also be used to treat menstrual disorders such as heavy menstrual bleeding, fibroids, and endometriosis.[67]
Sterilization provides very effective, permanent, nonreversible protection against pregnancy.[68] There are several procedures available for women and for men. Male sterilization procedures cost less and carry less risk than female sterilization procedures; however, in the US, female sterilization is performed more often than male sterilization.[69]
Female sterilization provides permanent, nonreversible protection against pregnancy. It is 99% effective for pregnancy prevention.[1] It involves cutting, banding, cauterizing, or removing the fallopian tubes.
[ ]
Tubal sterilization can be performed through a laparoscopic, abdominal, or transvaginal approach. A Cochrane review found that failure rates 12 months after sterilization and major morbidity were rare outcomes of any of the techniques in the review (partial salpingectomy, electrocoagulation, or using clips or rings). Minor complications and technical failures may be more common with rings than clips.[70]
Hysteroscopic sterilization is a form of tubal sterilization that involves insertion of implants into the fallopian tubes. However, the Essure hysteroscopic sterilization device is no longer sold or distributed in the US, and the Food and Drug Administration (FDA) has restricted its use. Additionally, the FDA has stipulated an extension of a postmarketing surveillance study, in order to gain further information about adverse events associated with the device and reasons for device removal.[71]
Risks of female sterilization relate to the surgical procedure and include infection, bleeding at the time of the procedure, and complications related to the anesthesia. There is also a small risk of failure of the procedure (less than 1 pregnancy in 100 women in the first year, and about 2 pregnancies in 100 women over 10 years).[19]
The risk of postprocedure regret is highest among young women under the age of 30 years.[72] Women who request sterilization should also be informed about long-acting reversible methods, such as IUDs and contraceptive implants. It should be explained to women who are considering sterilization that it is intended to provide permanent protection against pregnancy, and that reversal is usually not routinely available.[19][73][74]
Vasectomy provides permanent, nonreversible protection against pregnancy. It is 99% effective for pregnancy prevention.[1] Vasectomy is performed using local anesthesia with incision or no-incision ("no-scalpel") techniques.
Risks following the procedure include scrotal or testicular pain, infection at incision site, and hematoma.[19]
Vasectomy does not increase the risk of testicular or prostate cancer.[75][76][77]
Twelve weeks after vasectomy, men should have a semen analysis to assure the procedure's success.[7] Until a semen analysis demonstrates aspermia, men are advised to use a back-up method of contraception.
Vasectomy is intended to be a lifelong permanent method for protecting against pregnancy and reversal is not routinely available. Therefore, as part of the counseling process, couples should also be made aware of the long-acting reversible methods available to women.[73]
Medical conditions caused or exacerbated by menses: conditions in this group often improve with any hormonal contraceptive product (progestogen-only or combined estrogen/progestogen). However, for additional benefit and enhanced convenience, combined hormonal contraceptives can be used continuously. This means that women can skip the hormone-free interval of pills or vaginal ring. There is evidence that continuous extended cycling is effective and safe.[78] However, due to the variety of types of pill used in different trials, it is difficult to make direct comparisons between regimens.[79]
Continuous use of combined hormonal contraceptives benefit the conditions below by eliminating menses:
Heavy menstrual bleeding
Dysmenorrhea
Premenstrual syndrome
Endometriosis
Menstrual migraines
Irregular menses
Iron-deficiency anemia
Menstrual flares of rheumatoid arthritis
Coagulation defects (e.g., menstrual porphyria).
Non-menstrual conditions alleviated by combined hormonal contraceptives:
Acne
Hirsutism
Polycystic ovarian syndrome
Perimenopausal symptoms.
Risk reduction through use of combined hormonal contraceptives:
Ovarian cancer
Endometrial cancer
Osteoporosis
Colorectal cancer.[80]
Emergency post-coital contraception lowers the risk of pregnancy following unprotected sexual intercourse. Advance prescribing increases its use without increasing STIs or sexual risk-taking, even among adolescents.[81]
There are 4 types:[82]
Progestogen-only emergency contraception (levonorgestrel)
Selective progesterone-receptor modulator (ulipristal)
Copper IUD
Estrogen/progestogen emergency contraception (Yuzpe regimen).
There is online patient information about the different types of emergency contraception available in the US. Office on Women's Health: emergency contraception Opens in new window
There are no contraindications for use of emergency contraception in women with particular medical conditions or personal characteristics, but you should refer to relevant Medical Eligibility Criteria for further information.[10][82][83]
Reproductive and sexual coercion interferes with contraception use and pregnancy, and so women presenting for emergency contraception or unintended pregnancy should be screened and, if they answer affirmatively, offered long-acting methods of contraception (e.g., intrauterine devices, implant, or injection) that are less detectable to partners.[84]
Progestogen-only emergency contraception works primarily by preventing or delaying ovulation and is thought to reduce the chance of pregnancy by between 52% and 100%.[1] This method does not disrupt an implanted pregnancy. Women may take levonorgestrel orally as a single dose or as a split dose (one dose followed by a second dose 12 hours later).
[ ]
This medication is more effective the sooner it is taken, and evidence now suggests it may be ineffective if taken more than 96 hours after unprotected sexual intercourse (UPSI).[85] Efficacy may be lower for overweight women; however, a pooled analysis of three randomized controlled trials did not find evidence to support this.[86][87][88]
Commonly reported side effects include headache, nausea, and dysmenorrhea.[89]
Progestogen-only emergency contraception is available without a prescription in the US.[82]
Women who vomit less than 3 hours after taking emergency contraception may need to repeat the dose. The use of antiemetics can be considered.[7]
No particular follow-up arrangement is necessary, unless there is concern about possible pregnancy. If menses are delayed by more than 7 days after emergency contraception, a pregnancy test should be carried out.[89]
Any regular contraceptive can be started immediately after the progestogen-only emergency contraception (known as "quick-starting"), but the woman would need to abstain from sexual intercourse or use barrier contraception for 7 days. Centers for Disease Control and Prevention guidance advises a pregnancy test if there is no withdrawal bleed within 3 weeks.[7] However, UK guidance recommends that for women who quick start hormonal contraception, a pregnancy test would be advisable even if they have bleeding (as bleeding associated with contraception may not represent menstruation). A urine pregnancy test 21 days after the last episode of UPSI excludes pregnancy.[89]
Ulipristal is a selective progesterone-receptor modulator. It has agonist and antagonist effects on progesterone receptors. Although its mechanism of action is uncertain, it may work by delaying ovulation and through endometrial effects. Taken within 5 days of unprotected sexual intercourse (UPSI), it reduces the risk of pregnancy by about 90%.[90] Efficacy of ulipristal may be lower for obese women.[86][91] Guidance from the Centers for Disease Control and Prevention (CDC) advises that ulipristal and progestogen-only emergency contraception have similar efficacy when taken within 3 days of UPSI, but ulipristal is more effective 3-5 days after UPSI.[7] Meta-analysis data from two large randomized controlled trials suggest that ulipristal is significantly more effective than levonorgestrel emergency contraception at preventing pregnancy when taken from 0-120 hours after UPSI.[90]
Ulipristal is not recommended in patients who have severe asthma that is controlled by oral glucocorticoids. Side effects include headache, nausea, and dysmenorrhea.[89]
No particular follow-up arrangement is necessary, unless there is concern about possible pregnancy. If menses are delayed by more than 7 days after emergency contraception, a pregnancy test should be carried out.[89]
Women should be advised to wait 5 days after the use of ulipristal before starting hormonal contraception as it may decrease the effectiveness of ulipristal. The patient would need to abstain from sexual intercourse or use barrier contraception for 7 days after starting or resuming regular contraception. CDC guidance advises a pregnancy test if there is no withdrawal bleed within 3 weeks.[7] However, UK guidance recommends that in women who quick start hormonal contraception, a pregnancy test would be advisable even if they have bleeding (as bleeding associated with contraception may not represent menstruation). A urine pregnancy test 21 days after the last episode of UPSI excludes pregnancy.[89] There is a risk of pregnancy if further UPSI takes place before ongoing contraception is started, and the risk of decreasing the effectiveness of ulipristal needs to be weighed against the risk of not starting a regular hormonal contraceptive method.[7]
The copper IUD prevents fertilization and has some post-fertilization effects, with a local endometrial inflammatory reaction preventing implantation. It is nearly 100% effective up to 5 days after unprotected sexual intercourse.[1][82] It retains its high efficacy over the full 5-day window, and for obese patients.[82][92][93]
Side effects include changes in bleeding patterns; in particular, prolonged and heavy menstruation, irregular bleeding, and dysmenorrhea.[19]
This is the most effective emergency contraceptive and is the best method for women who desire an IUD for long-term contraception.[82][89] The World Health Organization Medical Eligibility Criteria for contraceptive use states that insertion of an IUD may increase the risk of pelvic inflammatory disease in women at increased risk of STIs; however, limited evidence suggests that this risk is low.[94]
Estrogen/progestogen emergency contraception works primarily by preventing or delaying ovulation. Taken within 72 hours of unprotected sexual intercourse (UPSI), this method reduces the risk of pregnancy by 75%, although some studies have reported lower effectiveness.[1] Combined estrogen and progestogen are taken in 2 doses in the Yuzpe regimen, which consists of one dose of ethinyl estradiol and levonorgestrel, followed by a repeated dose 12 hours later.[7][95] There is no specific combined emergency contraception product available in the US, so this method involves taking doses from a full packet of combined hormonal contraceptive pills.[89] Specific instructions depend on the brand of oral contraceptive used. This method does not disrupt an implanted pregnancy. It causes more nausea and vomiting than progestogen-only or ulipristal emergency contraception, and is less effective.[7][96]
Women who vomit less than 3 hours after taking emergency contraception may need to repeat the dose. Evidence suggests that antiemetics can reduce nausea and vomiting in women taking combined emergency contraception, so its use should be considered.[7]
No particular follow-up arrangement is necessary, unless there is concern about possible pregnancy. If menses are delayed by more than 7 days after emergency contraception, a pregnancy test should be carried out.[89]
Any regular contraceptive can be started immediately after the combined emergency contraception (known as "quick-starting"), but the woman would need to abstain from sexual intercourse or use barrier contraception for 7 days. Centers for Disease Control and Prevention guidance advises a pregnancy test if there is no withdrawal bleed within 3 weeks.[7] However, UK guidance recommends that for women who quick start hormonal contraception, a pregnancy test would be advisable even if they have bleeding (as bleeding associated with contraception may not represent menstruation). A urine pregnancy test 21 days after the last episode of UPSI excludes pregnancy.[89]
A number of organizations and professional societies have produced guidelines to assist healthcare providers in counseling users about safe and suitable contraceptive methods.
In the US, the Centers for Disease Control and Prevention (CDC) medical eligibility criteria (USMEC) for contraceptive use, contain recommendations to assist healthcare providers in counseling women, men, and couples about choice of contraceptive method. There is discussion of specific methods that are suitable for individuals with different requirements or certain medical conditions. These guidelines were developed following review of scientific evidence and consultation with national experts.[10] The American College of Obstetricians and Gynecologists (ACOG) guidelines on use of hormonal contraception in women with coexisting medical conditions explain how to use the USMEC criteria in practice.[11]
The ACOG guidelines on long-acting reversible contraceptive (LARC) methods, discuss the advantages and clinical challenges of LARCs, patient selection, and recommendations for initiation and ongoing management.[45][97] The ACOG also provide guidance on the use of LARCs in the postpartum period, advising that clinicians counsel patients about contraception during prenatal consultations. There is discussion of the advantages of immediate postpartum LARC methods, specific risks in this patient group (such as unrecognized expulsion), contraindications, and alternative options.[60]
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