What are the recommended contraceptive options for family planning?

Recommended Contraceptive Options for Family Planning

For healthy women seeking contraception, start with a combined oral contraceptive containing 20-30 μg ethinyl estradiol with levonorgestrel or norethisterone, or consider long-acting reversible contraceptives (LARCs) such as copper or levonorgestrel IUDs and subdermal implants, which have failure rates of less than 1% per year compared to 4-7% for oral contraceptives. 1, 2

Tiered Approach by Effectiveness

Most Effective Methods (Failure Rate <1% per year)

Long-Acting Reversible Contraceptives (LARCs):

• Copper IUD (Cu-IUD): Failure rate 0.6-0.8% with typical use, can remain in place for extended periods and requires no daily adherence 3, 2
• Levonorgestrel IUD (LNG-IUD): Failure rate 0.1% with typical use, provides additional benefits of reduced menstrual bleeding 3, 2
• Subdermal implants: Failure rate 0.05% with typical use, effective for 2-3 years depending on formulation 3, 4
• Female sterilization: Failure rate 0.5%, permanent option for those who have completed childbearing 3
• Male sterilization (vasectomy): Failure rate 0.10-0.15%, requires additional contraception until procedure success is confirmed 3

Highly Effective Methods (Failure Rate 5-9% with typical use)

Combined Oral Contraceptives (COCs):

• First-line recommendation: Pills containing 20-30 μg ethinyl estradiol with levonorgestrel or norethisterone provide effective contraception with relatively low venous thromboembolism risk 1, 5
• Typical use failure rate: 4-7% per year, though perfect use approaches 0.1% 6, 2
• Mechanism: Primarily inhibits ovulation through suppression of gonadotropins, with secondary effects on cervical mucus and endometrium 6

Progestin-Only Pills (POPs):

• Failure rate approximately 0.5% with perfect use, 7-9% with typical use 3, 7
• Appropriate for women with contraindications to estrogen, including those with cardiovascular risk factors 7
• Require strict adherence to timing (must be taken at same time daily) 4

Injectable Contraception (DMPA):

• Failure rate 0.3% with typical use 3
• Administered every 3 months, reducing adherence burden 4

Moderately Effective Methods (Failure Rate 12-28% with typical use)

Barrier Methods:

• Male condoms: 14% failure rate with typical use, 3% with perfect use; provide STD protection 3
• Female condoms: 21% failure rate with typical use, 5% with perfect use 3
• Diaphragm with spermicide: 20% failure rate with typical use, 6% with perfect use 3

Fertility Awareness Methods:

• Standard Days Method (SDM): Most appropriate for women with regular cycles of 26-32 days 3
• Women with two or more cycles <26 or >32 days within one year should be advised that SDM may not be appropriate due to higher pregnancy risk 3
• Does not protect against STDs; barrier methods should be used on days 8-19 for dual protection 3

Special Considerations for Method Selection

Cardiovascular Risk Assessment

Estrogen-containing methods increase venous thromboembolism risk:

• Baseline risk: 2-10 events per 10,000 women-years 2
• With COCs: 7-10 events per 10,000 women-years 2
• Contraindications to COCs: Current or history of venous thromboembolism, cardiovascular disease, uncontrolled hypertension, smoking in women ≥35 years, breast cancer 6, 7

Blood pressure monitoring is required for COC users 1

Age-Specific Guidance

Women ≥45 years:

• Can generally use implants, LNG-IUD, or Cu-IUD without restrictions 3
• May use COCs and DMPA with careful consideration of cardiovascular risk factors 3
• Increased relative risk for venous thromboembolism and myocardial infarction with COC use, though absolute risk remains low in healthy non-smokers 3

Non-Hormonal Options

For women preferring or requiring non-hormonal contraception:

• Copper IUD: Most effective non-hormonal reversible option with <1% failure rate 2, 8
• Barrier methods: Condoms, diaphragms, spermicides provide hormone-free options but require consistent use 8
• Permanent sterilization: For those certain about not desiring future fertility 8

Emergency Contraception

Four options available in order of effectiveness:

1. Copper IUD (most effective): Can be inserted within 5 days of unprotected intercourse, or up to 5 days after ovulation if timing can be estimated 3

2. Ulipristal acetate (UPA): Single 30 mg dose, more effective than levonorgestrel 3-5 days after intercourse 3

3. Levonorgestrel: Single 1.5 mg dose or split dose (0.75 mg × 2), similar effectiveness to UPA within first 3 days but less effective days 3-5 3

   • May be less effective in obese women 3

4. Combined estrogen-progestin regimen: Less effective than UPA or levonorgestrel and associated with more side effects (nausea, vomiting) 3

All ECPs should be taken as soon as possible within 5 days of unprotected intercourse 3

Missed Pill Management for COC Users

One pill late (<24 hours):

• Take missed pill immediately, continue regular schedule
• No backup contraception needed 1

One pill missed (24-48 hours late):

• Take most recent missed pill immediately
• Use backup contraception (condoms) or avoid intercourse for 7 consecutive days 1

Two or more consecutive pills missed (≥48 hours late):

• Take most recent missed pill immediately, discard other missed pills
• Continue remaining pills at usual time
• Use backup contraception for 7 consecutive days 1
• Consider emergency contraception if unprotected intercourse occurred 1

Non-Contraceptive Benefits

COCs provide additional health benefits:

• Reduced risk of ovarian and endometrial cancers 2, 7
• Improvement in acne, endometriosis, and premenstrual dysphoric disorder 2, 7
• More predictable bleeding patterns 2, 7
• Reduction in menstruation-related symptoms including migraine headaches 7

Common Pitfalls to Avoid

Do not require unnecessary barriers to contraceptive access:

• Pelvic examination is not required before initiating COCs 3
• Most women can start most methods at any time if reasonably certain they are not pregnant 3
• Provide same-day contraceptive initiation when possible 3
• Consider dispensing multiple pill packs at once to improve continuation 3

Do not overlook STD protection:

• Hormonal and intrauterine methods do not protect against sexually transmitted diseases 3
• Consistent and correct use of male latex condoms reduces STD risk including HIV 3
• Consider dual method use (hormonal contraception plus condoms) for STD prevention 3

Recognize hepatitis C treatment interactions:

• Discontinue ethinyl estradiol-containing contraceptives before starting ombitasvir/paritaprevir/ritonavir with or without dasabuvir due to risk of ALT elevations 6
• Can restart approximately 2 weeks after completing hepatitis C treatment 6