What are the recommended contraception options for a healthy adult female?

Contraception Options for Healthy Adult Females

For a healthy adult female seeking contraception, long-acting reversible contraceptives (LARCs)—specifically the levonorgestrel intrauterine device (LNG-IUD) or subdermal implant—are the most effective reversible options with failure rates less than 1% per year, and should be considered first-line choices. 1, 2, 3

Most Effective Methods: Long-Acting Reversible Contraceptives (LARCs)

Subdermal Implant

• Highest effectiveness with a failure rate of only 0.05%, making it the most effective reversible contraceptive available 3, 4
• Can be inserted at any time during the menstrual cycle if reasonably certain the patient is not pregnant 1
• No examination required before insertion 1, 2
• Requires backup contraception (abstinence or barrier methods) for 7 days if inserted more than 5 days after menses started 1
• Effective for multiple years with minimal to no bone loss 3
• All patients with obesity (BMI ≥30 kg/m²) can use implants without restriction 1, 3

Levonorgestrel Intrauterine Device (LNG-IUD)

• Failure rate less than 1% per year 3, 4
• Additional benefit of reducing menstrual bleeding 3
• Can be inserted at any time during the menstrual cycle 1, 3
• Requires bimanual examination and cervical inspection before insertion 1, 2
• Backup contraception needed for 7 days if inserted more than 7 days after menses started 1
• STI screening should be performed if risk factors present, but should not delay IUD placement 1, 2

Copper Intrauterine Device (Cu-IUD)

• Non-hormonal option with no systemic effects 2
• Can be inserted at any time 1
• No backup contraception needed regardless of cycle timing 1
• Requires bimanual examination and cervical inspection before insertion 1, 2

Highly Effective Short-Acting Methods

Combined Hormonal Contraceptives (CHCs)

• Includes oral contraceptive pills, patch, and vaginal ring 5, 6
• Oral contraceptive pills are the most commonly used reversible method in the US, comprising 21.9% of all contraception 4
• Typical use failure rate: 4-7% per year (perfect use: 0.1%) 7, 4
• Blood pressure measurement is mandatory before initiation 1, 2
• No other systematic examination required if medical history is negative 2
• Can be started at any time; backup contraception needed for 7 days if started more than 5 days after menses 1
• New users should start with formulations containing ≤0.035 mg estrogen to minimize exposure 7

Key contraindications for CHCs:

• History of deep vein thrombosis or pulmonary embolism (absolute contraindication, Category 4) 2, 8
• Age over 35 with smoking 7, 8
• Current or history of breast cancer 7
• Active hepatitis C treatment with ombitasvir/paritaprevir/ritonavir regimens 7

Important consideration: CHCs increase venous thrombosis risk from 2-10 events per 10,000 women-years to 7-10 events per 10,000 women-years 4

Progestin-Only Pills (POPs)

• Safer alternative for patients with thromboembolic risk factors (Category 1 or 2) 2, 8
• No examination required before initiation 1
• Norethindrone or norgestrel POP: Backup contraception needed for 2 days if started more than 5 days after menses 1
• Drospirenone POP: Backup contraception needed for 7 days if started more than 1 day after menses 1

Depot Medroxyprogesterone Acetate (DMPA) Injection

• No examination required before initiation 1
• Can be started at any time 1
• Backup contraception needed for 7 days if started more than 7 days after menses 1
• Caution: Effects are irreversible for 11-13 weeks after administration 9

Barrier Methods

Male Condoms

• Typical use failure rate: 14% per year (perfect use: 3%) 7
• No medical contraindications 5
• Provides STI protection 5

Female Condoms and Diaphragms

• Female condom typical use failure rate: 21% per year 7
• Diaphragm typical use failure rate: 20% per year 7

Emergency Contraception

• Ulipristal acetate may be more effective than levonorgestrel in women who are overweight or obese 3
• Should be taken as soon as possible after unprotected intercourse 6

Critical Clinical Pearls

Pre-Initiation Requirements Summary

• Blood pressure: Required only for CHCs 1, 2
• Pelvic exam: Required only for IUDs 1, 2
• No exam needed: Implant, DMPA, POPs 1
• BMI measurement: Not required for medical eligibility but may be helpful for baseline monitoring 1

Common Pitfalls to Avoid

• Never delay IUD placement to await STI screening results unless purulent cervicitis is visible 1, 2
• Do not refuse contraception even with contraindications to certain methods—alternatives always exist 2
• The risk of unintended pregnancy often exceeds the risks of contraception itself 2
• Failing to counsel about expected bleeding pattern changes with hormonal methods leads to non-adherence 9

Special Populations

• Obesity (BMI ≥30): All contraceptive methods can be used without restriction 1, 3
• Postpartum breastfeeding: Implant can be inserted anytime (Category 2 if <1 month, Category 1 if ≥1 month) 1
• Postpartum non-breastfeeding: All methods can be inserted immediately, including LARCs 1