What are the recommended contraceptive options for a 36-year-old female with no known medical contraindications?

Contraceptive Options for a 36-Year-Old Female

For a healthy 36-year-old woman with no medical contraindications, start with a combined oral contraceptive containing 20-30 μg ethinyl estradiol with levonorgestrel or norethisterone, or consider a long-acting reversible contraceptive (LARC) such as a levonorgestrel IUD or etonogestrel implant for superior effectiveness. 1

Primary Recommendations by Effectiveness

Tier 1: Long-Acting Reversible Contraceptives (Most Effective)

LARCs have failure rates of less than 1% per year and represent the most effective reversible options. 2

• Levonorgestrel IUD (LNG-IUD): Can be started anytime if reasonably certain the patient is not pregnant; requires backup contraception for 7 days if inserted >7 days after menses started 3

  • Requires bimanual examination and cervical inspection before insertion 3
  • Provides contraception for 3-7 years depending on formulation 2

• Etonogestrel Implant: Can be started anytime; requires backup contraception for 7 days if inserted >5 days after menses started 3

  • No examination needed before initiation 3
  • Provides contraception for 3 years 2

• Copper IUD (Cu-IUD): Can be started anytime with no backup contraception needed 3

  • Requires bimanual examination and cervical inspection before insertion 3
  • Provides non-hormonal contraception for up to 10 years 2

Tier 2: Combined Hormonal Contraceptives

Combined oral contraceptives are the most commonly used reversible method in the US (21.9% of all contraception) but have pregnancy rates of 4-7% per year due to typical use patterns. 2

• Combined Oral Contraceptive (COC): Recommended formulation is 20-30 μg ethinyl estradiol with levonorgestrel or norethisterone 1, 4

  • Can be started anytime; requires backup contraception for 7 days if started >5 days after menses 3
  • Blood pressure measurement required before initiation 3
  • Take daily for 21 days followed by 7 hormone-free days or 7 days of low-dose ethinyl estradiol (10 μg) 1

• Contraceptive Patch and Vaginal Ring: Alternative combined hormonal delivery systems with similar efficacy to COCs 5

  • Same backup contraception requirements as COCs (7 days if started >5 days after menses) 3

Tier 3: Progestin-Only Methods

Progestin-only methods avoid estrogen-related risks and are appropriate for women with contraindications to estrogen. 2

• Depot Medroxyprogesterone Acetate (DMPA): Can be started anytime; requires backup contraception for 7 days if started >7 days after menses 3

  • No examination needed before initiation 3
  • Consider potential for fluid retention 3

• Progestin-Only Pills (POPs):

  • Norethindrone/norgestrel: Requires backup contraception for 2 days if started >5 days after menses 3
  • Drospirenone: Requires backup contraception for 7 days if started >1 day after menses 3
  • No examination needed before initiation 3

Tier 4: Barrier Methods

Barrier methods have higher failure rates but no systemic side effects and provide STI protection. 3

• Male and female condoms, diaphragm with spermicide, cervical cap 3
• Should be used consistently and correctly; male latex condoms reduce STI risk including HIV 3

Critical Safety Considerations

Age-Related Factors at 36 Years

At age 36, this patient has no specific age-related contraindications to any contraceptive method, though cardiovascular risk assessment becomes increasingly important as women approach 40. 3

• Combined hormonal contraceptives increase venous thromboembolism risk from 2-10 events per 10,000 women-years to 7-10 events per 10,000 women-years 2
• This risk remains acceptable for healthy women under 35-40 years without additional risk factors 3

Absolute Contraindications to Estrogen-Containing Methods

Estrogen-containing contraceptives are potentially harmful for women with high thromboembolism risk. 3

• History of venous thromboembolism or pulmonary embolism 3
• Current or history of ischemic heart disease or stroke 3
• Migraine with aura 3
• Smoking ≥15 cigarettes/day (particularly relevant as patient approaches 35+ years) 3
• Uncontrolled hypertension 3

Practical Implementation

Missed Pill Management for COCs

Higher-dose pills (30 μg ethinyl estradiol) provide better ovulation suppression than lower-dose options (20 μg) when pills are missed. 1

• One pill late (<24 hours): Take immediately, continue regular schedule, no backup needed 1
• One pill missed (24-48 hours): Take most recent missed pill immediately, use backup contraception for 7 days 1
• Two or more pills missed (≥48 hours): Take most recent missed pill, discard others, use backup contraception for 7 days 1

Emergency Contraception Options

The copper IUD is the most effective emergency contraceptive and can be inserted within 5 days of unprotected intercourse. 3

• Cu-IUD: Most effective, can be continued as regular contraception 3
• Ulipristal acetate (30 mg): More effective than levonorgestrel 3-5 days after intercourse 3
• Levonorgestrel (1.5 mg): Effective within 5 days but less effective than ulipristal after 3 days 3
• Combined estrogen-progestin regimen: Less effective with more side effects 3

Common Pitfalls to Avoid

• Do not delay contraceptive initiation waiting for next menstrual period when switching methods—can start immediately if reasonably certain patient is not pregnant 3
• Do not prescribe combined hormonal contraceptives without blood pressure measurement 3
• Do not overlook LARC options—despite being most effective, use increased from only 6% in 2008 to 17.8% in 2016, indicating historical underutilization 2
• Do not assume all progestins are equivalent—levonorgestrel and norethisterone are first-line choices with established safety profiles 4