08. Contraception

Resident Editor: Anne Montgomery, MD

Faculty Editors: Meg Autry, MD, and Miranda Dunlop, MD

BOTTOM LINE

✔ Most effective: intrauterine device (IUD), implant, injectables, sterilization (permanent)

✔ Least effective: condoms, diaphragm, withdrawal, sponge, rhythm method

Background

  • Almost half of the pregnancies in the US are unintended.
    • Unintended pregnancies occur equally among women who were not using any contraception and among women using contraception incorrectly or inconsistently.
  • Preventing unintended pregnancy involves helping each woman, man, or couple choose the most appropriate form of contraception for her/his/their reproductive goals and providing education on appropriate use.  

Choosing a contraceptive method

  • Each woman must weigh the advantages of each method against the disadvantages and side effects in order to select a preferred method that she is most likely to use. Factors to consider include:
    • Safety
    • Efficacy
    • Availability (accessibility, cost)
    • Convenience
    • Reversibility
  • Remember that hormonal contraception methods DO NOT protect against STIs. 

Intrauterine Devices (IUDs)

  • Extremely effective methods of contraception (approx. 20x as effective as pills, patch, ring) that are completely reversible; efficacy does not vary with BMI.
  • Underutilized in the U.S.; appropriate for almost all women, including adolescents, nulliparas, and women in the postpartum and postabortion periods. 
  • 5 IUDs currently approved in the US:
    • ParaGard: Copper IUD; lasts up to 10 yrs; associated with heavier, more painful periods in some women; can also be used as emergency contraception.
    • Mirena: Levonorgestrel-releasing (20mcg/day); lasts up to 5 yrs, often used for non-contraceptive benefits including less menstrual bleeding
    • Liletta: Lower-cost alternative to Mirena (19mcg/day); approved for 3 yrs.
    • Kyleena: Levonorgestrel-releasing (17.5mcg/day); smaller than Mirena; lasts up to 5 yrs; targeted toward nulliparous women; may have less effect on bleeding but also less systemic effects; only recently became available so not enough evidence yet. 
    • Skyla: Levonorgestrel-releasing (14mcg/day); smaller than Mirena; lasts up to 3 yrs; targeted toward nulliparous women.
      • All hormonal IUDs are associated with irregular bleeding initially.
  • Must be inserted and removed by a trained provider. 
  • STI screening is not required before insertion as long as there are not any current symptoms and up-to-date on recommended age-appropriate screening.
    • The risk of PID associated with insertion and use of IUDs is very low. 

Implant - Nexplanon

  • Subdermal etonogestrel implant (progestin-only); extremely effective method of contraception, providing up to 4 years of continuous contraception.
  • Rapid return to fertility (94% ovulating within 3-6 wks after removal); good for women seeking long-term contraception and those with contraindications to estrogen.
  • Inhibits ovulation and thickens cervical mucus; most women experience some irregular bleeding which may last for the entire duration of the implant
  • The efficacy of Nexplanon does not seem to vary with BMI. 

Injectable - Depo-Provera (DMPA)

  • Progestin injection (150mg DMPA) providing 12 weeks of continuous contraception; injected IM into deltoid or gluteus maximus muscle.
  • Beneficial for women on anti-coagulation or with bleeding diathesis (decreases anemia, acute sickle cell crises); an excellent choice for those on anti-convulsants and those who cannot take estrogen.
  • Lasts irreversibly for 3 months, which can be problematic if the patient experiences side effects (irregular bleeding, amenorrhea, weight gain, acne). 
  • Longer return to fertility (up to 10 months from the last injection).

Patch – Ortho Evra

  • Releases 20 mcg of Ethinyl estradiol & 150 mcg of norelgestromin per 24 hours.
  • Each patch lasts 1 week, so 3 patches provide a month’s contraception with 1 patch-free week; rapid return to baseline fertility.
  • Contraindications/side effects are similar to those of combination OCPs.
    • Due to higher circulating estrogen levels, the Patch carries a higher risk of VTE than the pill and is not recommended to be used continuously.
    • Avoid in women >90 kg (198 lbs) as may not be as effective.

Ring - NuvaRing

  • Small, flexible ring inserted vaginally once a month; releases about 15 mcg Ethinyl estradiol and 120 mcg etonogestrel daily. 
  • Left in place for three weeks, removed for the remaining week each month (allowing breakthrough bleeding) or exchanged for a new ring if using continuously; rapid return to baseline fertility.
  • Contraindications/side effects are similar to those of combination OCP and Patch.
    • Higher risk of VTE than the pill; similar to the patch above. 

Pill – Combined OCPs

  • Prevent pregnancy primarily by suppressing ovulation by suppression of LH and FSH surges and alteration of cervical mucus/endometrium. All are formulations of synthetic estrogen and synthetic progesterone. 
  • Reduces risk of ovarian and endometrial cancer; this protection is increased with a longer duration of use. Conflicting studies have shown an increase in breast cancer risk, especially with a longer duration of use, but the absolute risk increase is small. 
  • Remember that although estrogen is associated with DVT risk, pregnancy itself doubles the risk of DVT (compared with COC use: 200 vs. 100/100,000 per year, respectively)!
  • Monophasic vs. multiphasic pills: the same dose of estrogen with either the same dose (monophasic) or an escalating dose of progesterone (multiphasic) for 21 days; last 7 days are placebo. Monophasics are preferred if continuous COC use planned (see below), 
  • Most practitioners start with a monophasic pill with 20-35 mcg of Ethinyl estradiol and progesterone with low androgenic activity (e.g. Desogen, Alesse, Ortho-Cyclen). If a pill was well tolerated in past, it is likely to be well tolerated again.

BOTTOM LINE

✔ Combination OCPs have the same type of estrogen with variation in the progesterone

✔ OCPs are either monophasic or multiphasic

✔ Consider back-up contraception when starting, depending on start date

Directions/timing for starting combination Oral Contraceptive Pills (OCPs)

  • In asymptomatic women, a pelvic examination is not necessary before starting OCPs.
  • “First Day Start”: Start on 1st day of the next period. No backup contraception is needed.
  • “Sunday Start”: Starting the Sunday after the next period. Recommend backup contraception for 7 days.  Has the benefit of no periods on weekends.
  • “Quick Start”: Starting the same day of the visit after the urine pregnancy test. Must use 7 days of backup contraception. 

Continuous use of combination OCPs

  • Can control the timing of cycles by eliminating some or all pill-free intervals (placebo pills), either for medical (dysmenorrhea, anemia) or personal reasons (sports, travel).  Monophasic formulations are preferable.
  • Periods 4 times/year: Seasonale, Seasonique marketed specifically for this purpose but any monophasic can be tailored to this schedule. May have breakthrough bleeding.
  • Ring users can also take advantage of continuous use. 

Troubleshooting problems with OCP use

A. Breakthrough bleeding

  • Spotting can occur in the first few cycles; usually resolves. Advise patient to take the pill at the same time every day.  
  • If persistent may be due to a low dose of estrogen. If increasing the estrogen dose does not change the irregular bleeding, switch to another category of progestin.
  • If there is still breakthrough bleeding, choose another method or consider a pill holiday for up to 6 months to regenerate the endometrium as well as a pelvic ultrasound to evaluate for structural causes of bleeding. 

B. Nausea

  • Rule out pregnancy. Often secondary to estrogen dose and resolves after the first 3 months. If intolerable, switch to a lower estrogen dose pill (e.g. 20 mcg).

C. Headache:

  • Women with classic migraine headaches should discontinue OCPs because of the increased risk of stroke. A lower dose of progesterone may help.  If headaches occur consistently during the placebo week, they may be secondary to estrogen withdrawal.  May benefit from continuous OCPs. 

D. Weight gain:

  • The average weight gain with new progesterones is 0.5-1 lbs.  Can switch to lower dose progesterone pill if not already on one.

E. Missing a pill

  • 1 missed pill – take the missed pill when remembered; take the next pill at the scheduled time.
  • 2 missed pills, week 1 or 2 of cycle – take 2 missed pills when remembered, then 2 pills next day, then resume regular schedule and use a backup method for 7 days.
  • 2 missed pills, week 3 of cycle – start a new pack and use a backup method for 7 days.
  • 3 missed pills – start a new pack and use the backup method for 7 days.

F. Medication Interactions

  • Reduced OCP efficacy with certain anti-convulsants, protease inhibitors, and griseofulvin. With these medications consider a higher dose OCP or progestin-only method.   Rifampin is the only antibiotic that reduces the effectiveness of OCPs. If these meds are prescribed, use a backup method for the duration of the medication and 7 days afterward (controversial).

Mini-pill - Progestin-only OCP

  • A good option for women who are intolerant to estrogen or who are breastfeeding. 
  • No apparent increased risk of venous thromboembolism (VTE). 
  • Slightly higher failure rate than combination pills; changes the cervical mucus, impedes ovum transport and inhibits implantation.
  • Must be taken at the same time every day to improve efficacy and lessen irregular bleeding (backup method necessary if >27 hours between pills).
  • Side effects: spotting or irregular periods.

Contraindications to estrogen-containing methods

  • Thromboembolic disease (current or remote) or clotting disorder
  • Cerebrovascular or CAD (current or remote)
  • Poorly-controlled hypertension (avoid if BP >160/90)
  • Known or suspected breast cancer or other estrogen-dependent neoplasms
  • Heavy smoking (>15 cigs/day) if >35 years old (increased risk of MI, DVT)
  • Undiagnosed abnormal uterine bleeding
  • Cholestatic jaundice of pregnancy or jaundice with prior OCP use, liver failure
  • Current breastfeeding in the first 6 months postpartum
  • Obesity (avoid if BMI >39, maybe less effective and increase DVT risk at lower BMI) 
  • Classic migraines (classic aura, >72h duration, treated with ergot derivatives, increased risk of CVA)

General considerations for oral progestin-only methods:

  • Avoid in women with breast cancer currently or h/o breast cancer within previous 5 years; active hepatitis, jaundice, or liver failure; on medications that increase hepatic clearance (rifampin, carbamazepine, phenytoin, topiramate, St John’s Wort, griseofulvin).
  • Consider in women with contraindications to or side effects from estrogen: a personal history of thrombosis, exclusive breastfeeding, smokers >35 yrs, HTN, CAD/CVA, lupus, those who fear worsening migraine headaches or other estrogen-related side effects such as nausea.

References for patients:

References:

Curtis KM and JF Peipert. Long-acting reversible contraception. N Engl J Med 2017;376(5):461-8. 

Curtis KM, TC Jatlaoui, NK Tepper, et al. U.S. selected practice recommendations for contraceptive use, 2016. MMWR Recomm Rep 2015;65(4):1-66.

Kaunitz AM. Contraceptive counseling and selection. UpToDate Online, updated January 8, 2018. Accessed April 15, 2018.

Lesnewski R, Prine L. Initiating Hormonal Contraception. Am Fam Physician 2006;74:105-12.