What are the available contraceptive options for a patient?

Contraceptive Options and Talking Points for Patient Appointment

Pre-Visit Preparation

Most women need minimal or no physical examination before starting contraception. 1 Blood pressure measurement is the only essential assessment before initiating combined hormonal contraception, and routine pelvic exams, cervical cytology, breast exams, HIV screening, or laboratory tests for lipids, glucose, liver enzymes, or thrombogenic mutations are not needed to safely provide contraception to healthy patients. 1

Contraceptive Options by Effectiveness

Tier 1: Highly Effective (Pregnancy Rate <1% per year)

Long-acting reversible contraceptives (LARCs) should be prioritized as first-line options because ideal use and real-world effectiveness are nearly identical. 1

Intrauterine Devices (IUDs)

• Levonorgestrel IUD (LNG-IUD): Pregnancy rate 0.1% per year, lasts up to 5+ years 1

  • Additional benefits: Reduces menstrual bleeding, may cause amenorrhea after prolonged use 1
  • Preferred option for patients with intimate partner violence (doesn't require partner participation) 1

• Copper IUD (Cu-IUD): Pregnancy rate 0.6-0.8% per year, lasts up to 10 years 1

  • Non-hormonal option for patients who cannot or prefer not to use hormones 2
  • May increase menstrual bleeding initially 1

Subdermal Implant

• Etonogestrel implant: Pregnancy rate 0.05% per year, lasts 3 years 1
• Single-rod system placed subdermally in upper arm 3
• May cause irregular bleeding patterns (manageable with NSAIDs 5-7 days or short-course hormonal treatment) 1

Tier 2: Effective (Pregnancy Rate 3-8% per year)

Combined Hormonal Contraceptives (CHCs)

Combined oral contraceptives containing 30-35 μg ethinyl estradiol are first-line for patients needing menstrual regulation or treatment of heavy menstrual bleeding. 4

• Combined Oral Contraceptives (COCs): Typical use pregnancy rate 5-7% per year 5

  • Monophasic pills with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate recommended 4
  • Additional benefits: Improves acne, reduces endometrial and ovarian cancer risk, treats dysmenorrhea 4, 6
  • Contraindication: Smoking in women >35 years, BMI ≥30 kg/m², history of VTE, thrombogenic mutations, uncontrolled hypertension 7
  • VTE risk increases from 2-10 per 10,000 woman-years to 7-10 per 10,000 woman-years 5
  • Blood pressure monitoring required at follow-up 4

• Contraceptive Vaginal Ring: Pregnancy rate similar to COCs 4

  • Releases 15 μg ethinyl estradiol and 120 μg etonogestrel daily 4
  • Simpler regimen (once monthly insertion) 4
  • May have reduced drug interaction risk with GLP-1 receptor agonists 8

• Transdermal Patch: Pregnancy rate similar to COCs 1

  • Avoid in SLE patients: Greater estrogen exposure than oral/vaginal methods raises concern for flare or thrombosis 1
  • Contraindicated in BMI ≥30 kg/m² 7

Progestin-Only Methods

• Depot Medroxyprogesterone Acetate (DMPA): Pregnancy rate 0.3% per year 1

  • Injection every 3 months 3
  • Amenorrhea common after ≥1 year of use 6
  • Second-line option for heavy menstrual bleeding or dysmenorrhea 4, 6
  • Breakthrough bleeding manageable with NSAIDs 5-7 days 6

• Progestin-Only Pills (POPs): Typical use pregnancy rate 5% per year 9

  • Perfect use pregnancy rate 0.5% per year 9
  • Requires strict daily timing (must be taken same time daily) 8
  • Preferred for breastfeeding women, can start immediately postpartum 1

Tier 3: Less Effective (Pregnancy Rate 18-28% per year)

Barrier Methods

• Male condoms: Typical use pregnancy rate 14% per year, perfect use 3% 1

  • Additional benefit: Protection against sexually transmitted infections 1
  • No physical examination needed before distribution 1

• Female condoms: Typical use pregnancy rate 21% per year, perfect use 5% 1

• Diaphragm with spermicide: Typical use pregnancy rate 20% per year, perfect use 6% 1

  • Requires pelvic exam for fitting 1

• Spermicides alone: Typical use pregnancy rate 26% per year 1

Fertility Awareness-Based Methods

• Pregnancy rate 25% per year with typical use 1
• Requires specific training and consistent monitoring 10
• High failure rate if not used appropriately 10

Special Populations and Considerations

Patients with SLE

• Stable/low disease activity without aPL: Effective contraceptives (hormonal or IUDs) strongly recommended; LARCs conditionally recommended as first choice 1
• Moderate/severe disease activity or nephritis: Progestin-only or IUD methods strongly recommended over combined estrogen-progestin contraception 1
• Positive antiphospholipid antibodies: Combined estrogen-progestin contraceptives contraindicated due to thrombosis risk 1

Patients on GLP-1 Receptor Agonists

• Use backup barrier contraception for at least first month of GLP-1 therapy when using oral contraceptives 8
• Monitor for breakthrough bleeding (signals reduced contraceptive effectiveness) 8
• Consider switching to LARC rather than managing bleeding if breakthrough occurs 8

Postpartum Contraception

• Estrogen-containing methods: Defer until 3-6 weeks postpartum due to VTE risk 1
• Progestin-only methods and IUDs: Can start immediately postpartum 1
• Start contraception no earlier than 4 weeks postpartum in non-breastfeeding women 7

Breastfeeding Women

• Progestin-only methods preferred: Can start immediately 1
• Combined hormonal contraceptives: Category 3 (risks usually outweigh benefits) if <1 month postpartum 1

Emergency Contraception

Discuss emergency contraception with all patients, including those with SLE or positive aPL, because risks are low compared to unplanned pregnancy. 1

• Levonorgestrel: Available over-the-counter, no medical contraindications including thrombophilia 1
• Must be initiated within 72-120 hours after unprotected intercourse 1
• Reduces pregnancy risk by at least 75% 1
• Any contraceptive method may be started after emergency contraceptive pills; use barrier method for 7 days (14 days after ulipristal) 1

Key Counseling Points

Barriers to Access

• Avoid unnecessary barriers: Routine pregnancy testing not necessary if detailed history suggests low pregnancy risk 1
• Weight measurement not needed for medical eligibility (all methods generally safe in obese women, though patch contraindicated if BMI ≥30) 1, 7
• Unnecessary procedures create logistical, emotional, and economic barriers, particularly for adolescents and low-income women 1

Factors Affecting Method Choice

• Intimate partner violence: Consider IUD (doesn't require partner participation) 1
• Mental health/substance use: May affect ability to consistently use contraception; refer for appropriate care if needed 1
• Medication interactions: Assess for drugs that may reduce contraceptive effectiveness 8

Managing Bleeding Irregularities

• Explore patient goals: Continue with/without treatment vs. discontinuation 1
• Treatment options by method:
  • Cu-IUD: NSAIDs 5-7 days 1
  • LNG-IUD: No specific interventions identified 1
  • Implant: NSAIDs 5-7 days for spotting; NSAIDs, hormonal treatment, or tranexamic acid for heavy bleeding 1
  • DMPA: NSAIDs 5-7 days 1
  • Extended/continuous CHC: Hormone-free interval 3-4 days (not during first 21 days, not more than once monthly) 1

Follow-Up

• No routine follow-up visit required 4, 6
• Patients should return if experiencing side effects or concerns 4, 6
• At follow-up: Assess satisfaction, health status changes, monitor blood pressure for hormonal methods 4, 6