CONTRACEPTIVE METHODS
Cathryn B. Heath, MD, Clinical Associate Professor of Family Medicine,
University of Medicine & Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick
Sandra M. Sulik, MD, Associate Professor, Department of Family Medicine, State University of New York,
Upstate Medical University, Syracuse
| Introduction: >50% of pregnancies in United States unintended; elective abortion rate 23%; poll found women want
easy-to-use and more adaptable options that do not require daily attention and are easy to remember; target all reproductive-aged
women, new users, and women switching methods; 60% of unintended pregnancies occur in
women who use contraception; ≈1 million American women become pregnant due to improper use of oral contraceptive
pills (OCPs); ≤40% of women miss taking ≤3 pills per month
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| Choosing contraceptives for individual patients: not all women want OCPs; listen to patient; allow patient to ask
questions; make sure patient knows how to start and continue contraceptive use; keep messages simple; give printed
handout
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| Improving contraceptive use: address patient’s fears; Papanicolaou (Pap) test not necessary before dispensing contraception;
help patient choose method
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| Contraception in older (≥35 yr of age) women: sterilization group ≈25%; 60% to 70% of women use no or intermittent
contraception
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| Norelgestromin and ethinyl estradiol transdermal system (Ortho Evra): convenient for patients who have difficulty
remembering contraception; transcutaneous system with 20 µg of ethinyl estradiol and 150 µg of norelgestromin;
suppresses ovulation and increases cervical mucus; applied to arms or buttocks; advise patients against
cutting patches; users should not apply powder, lotion, or other substances under patch; effective; 5 of 15 pregnancies
occurred in women who weighed >198 lb; adverse effects include breast tenderness, headache, application reactions,
nausea, and menstrual cramping; trials showed higher or similar discontinuance rate to OCPs; compliance
and breast tenderness higher than with OCPs; pros—compliance; less estrogen delivery; ease of use; fairly accessible;
cons—expensive ($40/mo); application site problems; same hormonal side effects as OCPs; may be less effective
in women who weigh >198 lb
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| Vaginal ring: etonogestrel and ethinyl estradiol vaginal ring (NuvaRing); woman must be comfortable with touching
own body in order to insert ring; round flexible silicone ring; suppresses ovulation and increases cervical mucus;
targeted for women who forget contraception; separate timer rings after 3 wk to remind user to remove ring and
rings again after 7 days to remind user to insert new ring; study saw 6 pregnancies in 1145 women during 1 yr of
use; forgetting to insert new ring most common reason for failure; ring can be removed for 3 hr and remain effective;
survey found that men did not care about presence of ring during sexual intercourse; 97% of cycles have withdrawal
bleeding; 6.5% of cycles have irregular spotting (most commonly occurs within first few days of inserting
new ring); ≈13% of women experience vaginitis; 6% of women had increase in vaginal discharge;
contraindications—same as those for combined estrogen and progesterone OCPs; silicone allergy; pros—ease of
use; discrete; delivers low dose of estrogen; spotting and breakthrough bleeding uncommon; cons—$40 per ring;
patient must be willing to insert and remove ring herself; side effects similar to those of OCPs
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| Progesterone intrauterine device (IUD): may improve menorrhagia but not approved by Food and Drug Administration
(FDA) for menorrhagia
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| Quick-start method: screen for pregnancy; if patient not pregnant, start OCP while in office, regardless of where she
is on cycle; effective; may increase spotting; counsel patient to return for second pregnancy test if period does not
come
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| Levonorgestrel and ethinyl estradiol (Seasonale): used for 84 days followed by 7 days of inactive pills; 4 menses
per year; may be useful for patients with menorrhagia; consider cost
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| Levonorgestrel intrauterine system (IUS): releases ≈20 µg of levonorgestrel daily; 5-yr method; must be inserted in
physician’s office; thickens cervical mucus, inhibiting sperm motility and function in uterus and fallopian tubes;
prevents endometrial growth and inhibits ovulation; Pearl index 0.14 (tested per 12,000 women-years of use); first-
year pregnancy rate 0.20%; 5-yr cumulative rate 0.50% to 0.70%; unnoticed expulsion uncommon; side effects—
spotting (improves with time); amenorrhea in 20% of women within first year; headache; breast tenderness; edema;
acne; pelvic inflammatory disease (PID) <1.00 case per 100 women-years; ectopic pregnancy rate 0.02 per 100
women-years (lower than copper IUDs); antibiotic prophylaxis for women at risk; contraindications—uterine
anomaly; acute (within 3 mo) PID; postpartum endometritis; wait 3 mo after infected abortion before considering
IUS; multiple sex partners; positive history of ectopic pregnancy; IUS vs IUD—pregnancy rates equivalent; higher
likelihood of expulsion and amenorrhea with IUS (may contribute to higher discontinuance rate); ARCH Foundation
provides IUS at no cost if patient’s insurance does not provide coverage; pros—reversible; decrease in
menses; effective for 5 yr; low failure rate; low PID rate; return to fertility high; easy procedure for physicians to
perform; cons—uterine insertion requires office visit; spotting common; initial up-front cost high; variable health
insurance coverage; physicians require training to perform procedure
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| OCPs and inherited hypercoagulable states: in OCP users, risk for venous thromboembolism increases 35- to 99-fold
in carriers of factor V Leiden; risk higher during first year of OCP use; more common in users of desogestrel or
gestodene OCPs; medroxyprogesterone (Depo-Provera) contraindicated for patients with history of venous thromboembolism
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| Polyurethane condoms: less vaginal irritation reported than with latex condoms; men reported same amount of skin
irritation; higher likelihood for breakage and slippage (8.4% vs 5.4%) than with latex condoms; latex condoms recommended
unless patients have latex allergy
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| OCPs and acne: ethinyl estradiol and norgestimate (Ortho Tri-Cyclen) or drospirenone and ethinyl estradiol (Yasmin)
approved by FDA for acne; newer progestin-containing OCPs effective; ultra low-dose (25 µg) OCPs include
Ortho Tri-Cyclen Lo and ethinyl estradiol and desogestrel (Cyclessa); effective; increased discontinuance rate due
to irregular bleeding with ultra low-dose OCPs; 59% to 81% of users discontinue because of side effects; Yasmin—
spironolactone analogue; antimineralocorticoid and antiandrogenic effects; shown beneficial for acne and hirsutism;
contraindicated in women with renal insufficiency, hepatic dysfunction, or adrenal insufficiency; warning for patients
on long-term nonsteroidal anti-inflammatory drugs (NSAIDs), potassium supplements, potassium-sparing diuretics,
angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and heparin;
check serum potassium level during first month of use, and educate women about NSAID use; as effective as other
low-dose OCPs; associated with small amount of temporary weight loss; pros—good cycle control; useful for
women sensitive to estrogenic side effects; may control acne and hirsutism; cons—increased rate of venous thromboembolic
events; contraindications; warning about NSAID use
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| OCPs and weight gain: poll found 53% of women 35 to 45 yr of age believe OCPs caused weight gain; trial found
weight gain identical between placebo and OCP groups
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| Women with migraine headaches: risk for stroke increases in women >45 yr of age with migraine (migraine with
aura associated with greater risk); greater risk for ischemic stroke in OCP users with migraine, particularly those
with focal symptoms; OCPs not recommended for women with focal neurologic symptoms with migraine headache;
OCPs can be used on women <35 yr of age who have no focal findings; OCPs not recommended for women
>35 yr of age with migraine
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| Permanent sterilization: tubal ligation; Essure procedure—minimally invasive; microinsert placed transcervically
through fallopian tubes to cause scarring; irreversible; performed in office; 99.8% effective in preventing pregnancy;
requires back-up method of contraception for 3 mo after insert placed; hysterosalpingography required after
3 mo to confirm scarring; side effects—cramping in ≈30%; pain; nausea; vomiting; dizziness; bleeding; at 15 mo,
≈9% of women complain of back pain or abdominal pain; 3% have dyspareunia; complications include 2.0% rate
of expulsion, 1.0% rate of perforation, and ≈0.5% unsatisfactory device location; pros—permanent; no incision required;
performed under local anesthesia; cons—requires alternative contraception for 3 mo after procedure; requires
hysterosalpingography; requires hysteroscopy for insertion
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| Contraception and health care coverage: consider cheap reversible choices; uncertain whether fertility-based methods
effective for families
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| Emergency contraception: used to prevent pregnancy after known or suspected failure of birth control or after unprotected
intercourse; inhibits ovulation; no direct evidence of inhibition of sperm migration to prevent fertilization
or implantation; no effect after implantation of fertilized egg has occurred; levonorgestrel (Plan B)—two 0.75-mg
doses taken 12 hr apart; approved by FDA for emergency contraception; both doses can be given at same time; can
be prescribed with antiemetic to decrease nausea and vomiting; efficacy 49% to 85%; give doses as soon as possible;
can be taken up to 72 hr after intercourse; copper IUD—not approved by FDA for emergency contraception;
99% effective; problems—emergency contraception requires prescription in most states; behind-the-counter distribution
available in Washington, California, Alaska, and New Mexico; drugs unavailable in 25% of pharmacies;
only 1 in 4 obstetricians discussed emergency contraception during routine contraceptive counseling; improving
access vital to giving women choices and decreasing abortion rate; consider increasing accessibility by offering
drugs to women in advance (overuse not shown in small studies); patient-directed questionnaires about contraindications,
cost concerns, and hormonal side effects useful for counseling
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| Newer methods: Depo-subQ Provera—same side-effect profile as Depo-Provera; etonogestrel (Implanon)—single-
rod implantable method under development; male contraception under development
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| Questions and answers: vaginal ring as extended-use contraceptive—use for 7 wk followed by withdrawal bleeding;
not approved; insurance-based decision; may be beneficial for vaginal atrophy; nulliparous status—not contraindication
for placement of IUD or IUS; use of norethindrone-only OCP in patients with thrombotic disease and
migraines—progestrogerone-only pills have same contraindications; not recommended; pregnancy screening for
quick-start method—urine pregnancy test if urine concentrated; if urine not concentrated, use quantitative β-human
chorionic gonadotropin (hCG); discuss time of last unprotected intercourse and counsel patients; start if urine pregnancy
test negative; Plan B after 72 hr—decrease in efficacy <1%; bone mineral loss—black-box recommendation
on intramuscular (IM) medroxyprogesterone; should not be used for >2 yr because bone mineral density after discontinuance
may not revert; discuss with patient and consider checking bone mineral density; no data on concern
about progestin-only pills; Depo-subQ Provera—used in Indiana; well-received; more comfortable than IM injections;
small quantity (0.65 mL) injected; approved to dose every 14 wk instead of every 12 wk; some studies suggest
less osteoporotic effect than IM form; venous thromboembolism and Ortho Evra—Associated Press reported 3
to 6 times higher risk for venous thromboembolism with patch than with pill but not medically studied; from medical
viewpoint, cases of venous thromboembolism fewer than would be expected from risk for venous thromboembolism
during pregnancy; Pap screening—recommended to start 3 yr after onset of sexual activity; discuss
contraception and risk for human papilloma virus (HPV) and sexually transmitted diseases (STDs); contraception
can be given without screening; etonogestrel (Implanon)—injectable; can be inserted in 15 sec; effective for 3 yr;
side effects include weight gain, hair loss, and bleeding; well accepted in Europe; choosing right patient key; Plan
B and refills—may provide extra coverage
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Educational Objectives
| The goal of this program is to educate the listener about choosing effective forms of contraception. After hearing and
assimilating this program, the participant will be better able to:
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 | 1. Explain how to use contraceptive methods that do not require daily attention, such as the transdermal patch and
vaginal ring.
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| 2. List contraindications and side effects of the levonorgestrel intrauterine system (IUS).
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| 3. Choose an oral contraceptive pill (OCP) for patients with acne.
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| 4. Describe the Essure procedure.
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| 5. Counsel patients about emergency contraception.
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Discussed on This Program
Drospirenone and ethinyl estradiol [Yasmin]
Ethinyl estradiol and desogestrel [Cyclessa, Desogen, Kariva, Mircette, Velivet]
Ethinyl estradiol and levonorgestrel [Alesse, Aviane, Empressa, Lessina, Levite, Levlen, Levlite, Levora, Nordette,
Portia, Preven, Seasonale, Triphasil, Tri-Levlen, Trivora]
Ethinyl estradiol and norgestimate [Mononessa, Ortho-Cyclen, Ortho Tri-Cyclen, Ortho Tri-Cyclen Lo, Sprintec,
TriNessa, TriSprintec]
Etonogestrel [Implanon]
Etonogestrel and ethinyl estradiol vaginal ring [NuvaRing]
Gestodene
Heparin sodium injection
Levonorgestrel [Plan B]
Levonorgestrel-releasing intrauterine system [Mirena]
Medroxyprogesterone acetate [Amen, Curretab, Cycrin, Depo–Provera, Depo-subQ Provera, Hematrol, Provera]
Norelgestromin/ethinyl estradiol transdermal system [Ortho Evra]
Progestasert (intrauterine progesterone contraceptive system)
Suggested Reading
Akerlund M et al: Comparative profiles of reliability, cycle control and side effects of two oral contraceptive formulations
containing 150 micrograms desogestrel and either 30 micrograms or 20 micrograms ethinyl oestradiol. Br J
Obstet Gynaecol 100:832, 1993; Archer DF et al: The impact of improved compliance with a weekly contraceptive
transdermal system (Ortho Evra) on contraceptive efficacy. Contraception 69:189, 2004; Audet MC et al: Evaluation
of contraceptive efficacy and cycle control of a transdermal contraceptive patch vs an oral contraceptive: a randomized
controlled trial. JAMA 285:2347, 2001; Chacko MR et al: Assessment of oral contraceptive pill continuation in
young women. J Pediatr Adolesc Gynecol 12:143, 1999; Gallo MF et al: Skin patch and vaginal ring versus combined
oral contraceptives for contraception. Cochrane Database Syst Review CD003552, 2003; Gonzalo IT et al: Levonorgestrel
implants (Norplant II) for male contraception clinical trials: combination with transdermal and injectable testosterone.
J Clin Endocrinol Metab 87:3562, 2002; Loder EW et al: Headache and combination estrogen-progestin
oral contraceptives: integrating evidence, guidelines, and clinical practice. Headache 45:224, 2005; Murthy AS et al:
Same-day initiation of the transdermal hormonal delivery system (contraceptive patch) versus traditional initiation
methods. Contraception 72:333, 2005; Sarkar NN: The combined contraceptive vaginal device (NuvaRing): a comprehensive
review. Eur J Contracept Reprod Health Care 10:73, 2005; Smith LF et al: Women's knowledge of taking
oral contraceptive pills correctly and of emergency contraception: effect of providing information leaflets in general
practice. Br J Gen Pract 45:409, 1995; Stewart FH et al: Extended use of transdermal norelgestromin/ethinyl estradiol:
a randomized trial. Obstet Gynecol 105:1389, 2005; Ubeda A et al: Essure: a new device for hysteroscopic tubal
sterilization in an outpatient setting. Fertil Steril 82:196, 2004; Westhoff C et al: Bleeding patterns after immediate
initiation of an oral compared with a vaginal hormonal contraceptive. Obstet Gynecol 106:89, 2005; Westhoff C et al:
Quick start: novel oral contraceptive initiation method. Contraception 66:141, 2002.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Drs. Heath and Sulik spoke in San Francisco at the American Academy of Family Physicians’ (AAFP) 2005 Scientific
Assembly, presented September 28 to October 2, 2005. The Audio-Digest Foundation thanks the speakers and the
AAFP for their cooperation in the production of this program.
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