What are the recommended first-line options for contraception medical treatment?

First-Line Contraception Options

Long-acting reversible contraception (LARC) with intrauterine devices (IUDs) or subdermal implants are the recommended first-line options for contraception, offering superior effectiveness with failure rates less than 1% per year compared to 4-7% for oral contraceptives. 1, 2

Primary Recommendations by Method Category

Long-Acting Reversible Contraception (LARC) - Highest Tier

IUDs and implantable contraceptives are more effective than short-term contraceptive methods and should be prioritized for most women. 1

• Levonorgestrel-releasing intrauterine device (LNG-IUD): Failure rate of 0.1% per year, with 81% continuation at one year 3
• Copper IUD (Cu-IUD): Failure rate of 0.6-0.8% per year, with 78% continuation at one year 3
• Subdermal implants: Failure rate of 0.05% per year, with 88% continuation at one year 3

LARC demonstrates 86% adherence at 12 months versus 55% for oral contraceptive pills, with contraceptive failure rates of 0.27 per 100 women-years compared to 4.55 for pills, patch, or ring. 1

Combined Hormonal Contraceptives (CHCs) - Second Tier

For women who prefer or are better suited to combined hormonal methods, low-dose formulations containing 20 μg ethinyl estradiol with 100 μg levonorgestrel are first-line. 4, 5

• Pills containing levonorgestrel or norethisterone combined with ethinyl estradiol ≤35 μg are considered first-line CHC options 5
• These formulations show a Pearl index of 0.88 and cumulative pregnancy rate of 1.9% over 3 years 4
• Typical use failure rate is approximately 5-9% per year 3, 2

CHCs can be initiated at any time if pregnancy is reasonably excluded; if started within the first 5 days of menstrual bleeding, no additional contraceptive protection is needed. 4

Progestin-Only Methods - Alternative Options

Progestin-only methods are valuable for women who cannot or choose not to use estrogen-containing methods. 4

• Injectable DMPA: Failure rate of 0.3% per year with perfect use, 70% continuation 3
• Progestin-only pills: Failure rate of 0.5% per year with perfect use 3

These methods avoid the venous thromboembolism risk associated with estrogen (2-10 events per 10,000 women-years baseline increased to 7-10 events with estrogen-containing methods). 2

Emergency Contraception Hierarchy

The copper IUD is the most effective emergency contraceptive, followed by ulipristal acetate, then levonorgestrel. 4, 6, 7

• Copper IUD: Most effective when inserted within 5 days of unprotected intercourse 4
• Ulipristal acetate (30 mg): Effective throughout the entire 120-hour window and may be more effective than levonorgestrel in overweight/obese women 1, 6
• Levonorgestrel: Effective but shows decreased effectiveness after 72 hours 6

After ulipristal acetate use, any regular contraceptive can be started immediately, but barrier contraception or abstinence is required for 14 days or until next menses. 6 After levonorgestrel, barrier contraception or abstinence is needed for only 7 days. 1

Special Population Considerations

Women with Cancer History

IUDs are the preferred first-line contraceptive option for women with a history of breast cancer. 1

• For women on tamoxifen, levonorgestrel-containing IUS may be preferable as it reduces tamoxifen-induced endometrial changes without increasing breast cancer recurrence risk 1
• Combined hormonal contraceptives should be avoided in women with active cancer or treated within the past 6 months due to VTE risk 1

Perimenopausal Women

Low-dose combined oral contraceptives (20 μg ethinyl estradiol with 100 μg levonorgestrel) are first-line for perimenopausal women with regular menses, providing both contraception and symptom management. 4

• No contraceptive method is contraindicated based on age alone 4
• Medical eligibility must confirm absence of cardiovascular risk factors, thromboembolism risk, and smoking status in women over 35 years 4

Critical Implementation Points

Medical eligibility screening is essential before initiating any hormonal contraceptive, particularly assessing cardiovascular and thromboembolism risk. 4

No routine follow-up visits are required for any method, but women should be advised when removal or reinjection is needed for IUDs, implants, or injectables. 4

No contraceptive method protects against sexually transmitted diseases; consistent and correct use of male latex condoms reduces STD risk including HIV. 4

Common Pitfall

The most significant pitfall is prescribing oral contraceptives as default first-line when LARC methods offer substantially higher effectiveness and continuation rates. Women younger than 21 years have twice the failure rate with pills, patch, or ring compared to women ≥21 years, making LARC particularly important for younger women. 1