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Women’s Health - Contraception - Fast Facts | NEJM Resident 360

An estimated 45% of pregnancies in the United States are unplanned. Numerous methods of contraception are available, but many are underutilized or used incorrectly or inconsistently. Many patients will visit the primary care office and ask to begin a new method of contraception or switch to a different method. However, many others appreciate when clinicians initiate a conversation about contraceptive options. Consider starting the conversation by asking patients one key question:

Would you like to become pregnant in the next year?

Evaluation

The Centers for Disease Control and Prevention (CDC) recommends that a medical history for helping women select a contraception method should include the following information:

• prior contraceptive experience (including history of contraceptive failure, unintended pregnancy, abortion)

• desire for future pregnancy and contraceptive preferences (including religious and cultural beliefs)

• risk factors for thromboembolic disease when considering use of an estrogen-based contraceptive agent (personal or family history of venous thromboembolism, recurrent miscarriages, smoking status, history of migraines with aura)

• age and menstrual, pregnancy, and breastfeeding history

• sexual practices, condom use, previous sexually transmitted infections (STIs)

• blood pressure measurement (if estrogen-containing contraceptives are being considered)

• complete medication list (to identify medications that reduce effectiveness of hormonal contraceptives)

Methods of Contraception

(Source: Effects of Two Educational Posters on Contraceptive Knowledge and Intentions: A Randomized Controlled Trial. Obstet Gynecol 2019.)

Additional Notes:

• A new formulation of the vaginal contraceptive ring (Annovera) provides protection for up to one year from a single reusable device.

• The CDC also provides a Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use that provides guidelines on the safety of specific contraceptives for a wide range of medical conditions.

Subdermal Arm Implants

• The hormonal implant is a small rod that is placed subdermally in the arm and releases progestin hormone. Current models of the subdermal implant include single- or double-rod systems. The single-rod system (Nexplanon) is used in the United States while the two-rod system (Jadelle) is available internationally.

• • Subdermal contraceptive implants (Nexplanon) are effective for 5 years, although the manufacturer’s instructions still recommend replacement after 3 years.

• Primary care providers (including residents) can receive training on implant placement and removal.

• Implant placement and removal can be done easily in the primary care office.

• The implant has the lowest failure rate of any contraceptive method (including surgical sterilization), making it a particularly good option for the most fertile women (i.e., those younger than 20 years). It requires no action from the patient after placement and cannot be expelled like an IUD.

• As with hormonal IUDs, implants are progestin-only and are therefore safe in women with contraindications to estrogen (including hypertension, history of venous thromboembolism, and migraine with aura).

• As with other forms of progestin-only contraception, irregular bleeding is common, but most women have fewer and lighter periods.

Intrauterine Contraceptives

IUDs in the United States: Five IUDs are currently available in the United States. Four contain levonorgestrel (Liletta, Mirena, Skyla, and Kyleena), and one nonhormonal IUD that contains copper (ParaGard).

• Duration of efficacy: 

  • ParaGard: 12−20 years

  • Mirena and Liletta: 7 years

  • Kyleena: 5 years

  • Skyla: 3 years

• Recent studies have demonstrated evidence that the intrauterine devices with 52 mg of levonorgestrel are effective for 7 years

• IUDs are placed in office settings by trained clinicians (e.g., gynecologist, primary care provider, nurse practitioner).

• IUDs can safely be placed for nulliparous women, virgins, and adolescents.

• IUDs are among the most effective contraceptives available.

• Women promptly return to normal fertility after discontinuation of IUDs.

• Many women with progesterone IUDs have lighter or absent withdrawal bleeding and less severe dysmenorrhea; many women with copper IUDs experience no change or an increase in menstrual bleeding and cramping.

• IUDs may be inserted any time in the menstrual cycle, once pregnancy has been ruled out.

• About 2%–10% of women expel an IUD; if this occurs, an IUD can be replaced.

  • Rates of expulsion are higher in women younger than 20 years and when IUDs are placed within 4 weeks of delivery.

  • Both copper and hormonal IUDs can be placed immediately after vaginal or cesarean delivery (except in the presence of iosisitis or chorioamnionitis).

• Women with risk factors should be tested for STIs at the time of IUD placement but are not required to have negative test results available at the time of IUD placement.

• • If the patient has or develops an STI while an IUD is in place, the IUD does not need to be removed — treat the infection with antibiotics as you ordinarily would.

• Copper and hormonal IUDs are equally effective for emergency contraception (see Emergency Contraception below).

• The Dalkon Shield, an IUD available from 1970–1974, was linked to increased risks of complications such as pelvic inflammatory disease. The Dalkon Shield has been off the market since the mid-1980s. The safety of modern IUDs, both copper and hormone-containing, is well established. They are not linked to increased risks of septic abortions or pelvic inflammatory disease.

Oral Contraceptives, Patches, and Rings

• Efficacy: These contraceptives must be used as directed (daily pills, weekly patches, monthly rings, or yearly ring) to achieve maximum effectiveness.

• • Typical use during the first year results in an undesired pregnancy in one out of eight women.

  • Progestin-only “mini” pills offer an alternative to estrogen-containing pills for women who are unable or do not want to take estrogen. The newest version (Slynd) has extended the window for taking a missed pill to 24 hours.  

• Safety: A thorough history, including patient report of prior normal blood pressure measurements, are adequate for safe prescribing.

• • Neither a pelvic exam nor any other physical exam is needed to prescribe or renew oral contraceptive medications.

• Contraindications: Estrogen-containing pills, patches, and rings are considered contraindicated in women with the following conditions:

• • migraine headache with aura

  • active smoking and age ≥35 years

  • history of deep vein thrombosis and pulmonary embolism (DVT/PE)

  • uncontrolled hypertension

  • ischemic heart disease

  • stroke

  • systemic lupus erythematosus with antiphospholipid antibodies

• **Missed doses:**Specific instructions about missed doses should be provided to any patient with a prescription for a pill, patch, or ring.

• Risk of postpartum venous thromboembolism (VTE): Women who are within 3 weeks of delivery should not use estrogen-containing pills, patches, or rings because of an increased risk of postpartum VTE.

• Women with active breast cancer are generally counselled to avoid estrogen- or progesterone-containing contraceptive, including patches, pills, rings, the injection, or implant. 

• • A CDC app can help you make decisions about safe contraception for women with complicated medical histories.

• Vaginal rings can remain in place during intercourse (or can be removed for up to 3 hours).

Emergency Contraception

Options for emergency contraception:

• single-dose levonorgestrel (Plan B One-Step), available without a prescription

• • some efficacy up to 5 days, but efficacy declines each day and with increasing body-mass index (BMI)

• ulipristal (Ella), available by prescription only

• • typically twice as effective as levonorgestrel

  • approved for use up to 120 hours after unprotected sex

  • less effective in obese women

• copper IUD

• • for use within 120 hours (5 days) after unprotected sex

  • offers long-term contraception, with efficacy up to 10 years

• mifepristone (not available in the United States in emergency contraception formulation)

  • as effective as levonorgestrel

Copper and hormonal IUDs are equally effective and considered the most effective for emergency contraception. All women requesting emergency contraception should be counseled about other more effective contraceptives and the availability of mifepristone for medication abortion (learn more about providing medical abortion in a primary care practice). Repeated use of emergency contraception pills is not associated with adverse effects on a woman’s health. Women experiencing reproductive coercion may find repeated use of emergency contraception their best option.

The Bedsider website can be used to help patients find a local health center or clinic that offers emergency contraception. Patients can also call their local pharmacy to ensure availability.

See the guideline and review sections in this rotation guide for more details on prescribing and choosing contraceptive methods.

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