What are the effective options for birth control?

Birth Control Options

Long-acting reversible contraceptives (LARCs)—specifically intrauterine devices (IUDs) and subdermal implants—should be prioritized as first-line contraceptive options due to their superior effectiveness with typical use failure rates below 1%, compared to 6-28% for user-dependent methods. 1

Tier 1: Most Effective Methods (Failure Rate <1%)

Long-Acting Reversible Contraceptives (LARCs)

• Nexplanon (etonogestrel implant): 0.05% typical use failure rate with 84% continuation at one year 2

  • Ideal for patients who cannot use estrogen-containing methods 2
  • Lasts up to 3 years 3

• Mirena (levonorgestrel IUD): 0.2% typical use failure rate with 80% continuation at one year 2

  • Provides additional benefit of reduced menstrual bleeding 2
  • Effective for 5+ years 3

• Copper IUD (ParaGard): 0.6-0.8% failure rate with 78% continuation 1

  • Hormone-free option lasting up to 10 years 1

Permanent Sterilization

• Female sterilization: 0.5% failure rate 1
• Male sterilization (vasectomy): 0.1-0.15% failure rate 1
  • Requires additional contraception until procedure success is confirmed 1

Key advantage of LARCs: These methods eliminate user adherence issues, resulting in dramatically higher real-world effectiveness compared to user-dependent methods 2. They are appropriate for most women, including adolescents and nulliparous women 1.

Tier 2: Moderately Effective Methods (Failure Rate 6-12%)

Combined Hormonal Contraceptives

• Combined oral contraceptive pills: 9% typical use failure rate (0.3% perfect use) with 67% continuation 1
• Contraceptive patch (Evra): 9% typical use failure rate (0.3% perfect use) with 67% continuation 1
• Vaginal ring (NuvaRing): 9% typical use failure rate (0.3% perfect use) with 67% continuation 1, 2
  • Can be used for extended cycles up to 35 days for better menstrual control 4

Critical contraindications: Absolute contraindication with uncontrolled hypertension (BP >160/110 mmHg); use caution with BP ≥140/90 mmHg 1. Increased thromboembolism risk with tobacco use or age ≥35 years 1.

Progestin-Only Methods

• Depo-Provera (DMPA injection): 6% typical use failure rate (0.2% perfect use) with 56% continuation 1, 2

  • Requires quarterly injections; failure often due to missed appointments 2

• Progestin-only pills: 9% typical use failure rate (0.5% perfect use) 1

Barrier Methods

• Diaphragm: 12% typical use failure rate (6% perfect use) with 57% continuation 1

Tier 3: Less Effective Methods (Failure Rate 18-28%)

• Male condoms: 18% typical use failure rate (2% perfect use) with 43% continuation 1
• Female condoms: 21% typical use failure rate (5% perfect use) with 41% continuation 1
• Withdrawal: 22% typical use failure rate (4% perfect use) with 46% continuation 1
• Spermicides: 28% typical use failure rate (18% perfect use) with 42% continuation 1
• Fertility awareness methods: 24% typical use failure rate with 47% continuation 1

Critical counseling point: All patients, regardless of contraceptive choice, should be counseled about condom use for STD/HIV prevention, as hormonal contraceptives and IUDs do not protect against infections 1.

Emergency Contraception

• Emergency contraceptive pills (ECPs): Should be taken as soon as possible after unprotected intercourse 1, 5
• Copper IUD for emergency use: Can be inserted after unprotected intercourse and provides ongoing contraception 1

Clinical Implementation Principles

Counseling Approach

• Counsel patients about the most effective methods first, starting with LARCs 2
• All women should be counseled about the full range of contraceptive options for which they are medically eligible 1
• Use teach-back method to confirm patient understanding 1

Removing Barriers to Access

• Most women can start most contraceptive methods at any time with few or no examinations required 1
• Avoid unnecessary barriers such as mandatory pelvic exams before COC initiation or waiting for next menstrual period 1
• Provide same-day contraceptive access when possible 1

Special Considerations

• Postpartum patients: Long-acting reversible options carry lowest failure rate (<1%) and are strongly recommended for appropriate candidates 1
• Patients on teratogenic medications: Effective contraception is essential; LARCs are ideal 1
• Women aged ≥45 years: Can generally use combined hormonal contraceptives and DMPA, though individual risk factors must be assessed 1