What are the recommended birth control options?

Recommended Birth Control Options

Long-acting reversible contraceptives (LARCs) such as intrauterine devices (IUDs) and implants are the most effective birth control options with failure rates less than 1% per year and should be considered first-line choices for most women seeking contraception. 1

Contraceptive Options by Effectiveness

Most Effective Options (Failure Rate <1%)

• Long-Acting Reversible Contraceptives (LARCs)
  • Levonorgestrel IUDs: 0.1% failure rate, effective for 3-7 years 1, 2
  • Copper T380A IUD: 0.6-0.8% failure rate, effective for up to 10 years 1, 2
  • Subdermal implants: 0.05% failure rate, effective for 3-5 years 1, 2

Moderately Effective Options (Failure Rate 3-9%)

• Hormonal Methods
  • Combined hormonal contraceptives (pills, patches, rings): 5-9% typical failure rate 1, 3
  • Progestin-only pills: 5-9% typical failure rate 1
  • Injectable contraception (Depo-Provera): 0.3% perfect use, 3-6% typical use 1, 2

Less Effective Options (Failure Rate >10%)

• Barrier Methods
  • Male condoms: 14% typical failure rate 1, 3, 2
  • Female condoms: 21% typical failure rate 1, 2
  • Diaphragm with spermicide: 20% typical failure rate 1, 3, 2
• Other Methods
  • Fertility awareness methods: 25% typical failure rate 1
  • Withdrawal method: 19% typical failure rate 1, 2
  • Spermicides alone: 26% typical failure rate 3, 2

Decision Algorithm for Contraceptive Selection

1. Assess need for STI protection:

   • If STI protection needed: Recommend condoms plus another more effective method
   • If STI protection not needed: Proceed to step 2

2. Assess desire for long-term vs. short-term contraception:

   • For long-term (>1 year): Consider LARCs (IUDs or implants)
   • For short-term (<1 year): Consider hormonal methods or barrier methods

3. Assess medical contraindications:

   • History of thrombosis or cardiovascular risk factors: Avoid combined hormonal methods 1
   • Smoker over age 35: Avoid combined hormonal methods 1
   • History of breast cancer: Avoid hormonal methods
   • Current or history of liver disease: Avoid or use caution with hormonal methods

4. Consider non-contraceptive benefits needed:

   • Heavy menstrual bleeding: Consider levonorgestrel IUD (71-95% reduction in blood loss) 1
   • Dysmenorrhea: Consider hormonal methods 1
   • Acne/hirsutism: Consider combined hormonal contraceptives 4

Specific Method Considerations

Combined Hormonal Contraceptives

• Pills containing levonorgestrel or norethisterone with ≤35 μg ethinyl estradiol are considered first-line oral options 5
• Low-dose ethinyl estradiol/levonorgestrel (20 μg/100 μg) provides effective contraception with Pearl index of 0.84-0.88 6, 7
• Increased risk of venous thrombosis from 2-3 to 7-10 events per 10,000 women-years 8, 4
• Can improve acne, endometriosis, and premenstrual dysphoric disorder 8

Progestin-Only Methods

• Good option for women with contraindications to estrogen
• Levonorgestrel IUD is particularly beneficial for women with heavy menstrual bleeding 1
• Safer than combined hormonal contraceptives for women with thrombosis risk factors 1

Barrier Methods

• Require consistent and correct use for maximum effectiveness
• Provide STI protection (male and female condoms)
• Can be used as backup with other methods

Common Pitfalls and Caveats

• Inconsistent use: User-dependent methods like pills have significantly higher failure rates with typical use compared to perfect use 1, 8
• Ignoring medical contraindications: Failure to screen for risk factors for thrombosis before prescribing combined hormonal methods 1
• Inadequate counseling about side effects: Irregular bleeding is common in the first 3-6 months of hormonal contraceptive use 1
• Not providing advance emergency contraception: Consider providing advance supply of emergency contraception for women using less effective methods 9
• Overlooking non-contraceptive benefits: Hormonal methods can provide significant quality of life improvements for conditions like dysmenorrhea and heavy menstrual bleeding 4

For women seeking the most effective protection against unintended pregnancy with minimal user intervention, LARCs (IUDs and implants) should be recommended as first-line options due to their superior effectiveness, long duration of action, and favorable side effect profile.