Overview of Contraceptive Methods

Educational Objectives

The goal of this program is to improve the use of contraception. After hearing and assimilating this program, the clinician will be better able to:

1. Compare the advantages and disadvantages of various contraceptive methods.
2. Counsel sexually active patients on the forms of emergency contraception that are most effective for preventing pregnancy.

Summary

Prescribing birth control (BC): patients who prefer a regular cycle can be prescribed pills, patches, or ring; patients who prefer ease of use and are comfortable with breakthrough bleeding or spotting can be prescribed a hormone intrauterine device (IUD) or etonogestrel (Implanon, Nexplanon); if the patient does not want any hormones, copper IUD or sterility can be recommended

Combined oral contraceptive pill (OCP): a combination of estrogen and progestin in various forms, the majority of which contain ethinyl estradiol (EE); formulations of progesterone include drospirenone, levonorgestrel (LNG), norethindrone, desogestrel, norgestrel, ethynodiol diacetate, and norgestimate; mechanism of action — EE suppresses follicle stimulation; progesterone suppresses the surge of luteinizing hormone (LH; ovulation) and thickens the cervical mucus, preventing sperm to eggs; formulations are monophasic and multiphasic, which have a similar contraceptive effect, however, the dose of the multiphasic OCP decreases throughout the month and results in an overall lower dose of hormones; continuous hormone is commonly used to support conditions, eg, endometriosis, premenstrual dysphoric disorder (PMDD), hyperandrogenism, menopausal symptoms, and dysmenorrhea, and prevents monthly withdrawal bleed but causes a small amount of breakthrough bleeding; patients must be informed; missed pills — if a pill is missed, it can be taken as soon as the patient remembers it; if a pill is missed for 2 day, the patient should resume BC pack and use a backup method for 1 wk to prevent pregnancy; if >2 day missed, use of a backup contraception and an emergency contraception (EC) is recommended; failure rate of combined OCP is 6% to 9%, likely because of inconsistent use or increased body mass index (BMI) ≥35 kg/m²

Variations of combined hormones:intravaginal ring — eg, NuvaRing (hormone-impregnated; 21 day on and 7 day off; contains etonogestrel and EE) and Annovera (also 21 day on, 7 day off; replaceable for 13 cycles; contains segesterone and EE); favorable because it has lower levels of EE compared with other combined methods, inhibits ovulation, and thickens cervical mucus; has not been studied in women with BMI >29 kg/m²; not preferred by some women because of risk for increased leucorrhea and vaginitis; hormone patch — eg, Xulane (contains 35 μg/day EE and 150 μg/day norelgestromin) and Twirla (contains 30 μg/day EE and 120 μg/day LNG; approved in 2020); placed once weekly for 3 wk on a nonhormonal tissue (not the breast); contraindicated in patients with BMI >30 kg/m² because of risk for venous thromboembolism (VTE); has the highest dose of EE

Complications of combined OCPs: include VTE, cardiovascular (CV) disease, and liver and gallbladder disease; minor side effects include bloating, weight gain, breast tenderness, nausea, fatigue, and headache; in ≈3% of patients, onset of ovulation is delayed after prolonged use; contraindicated in smokers >35 yr of age, those with history of VTE or bleeding disorder, transplantation, uncontrolled hypertension, history of coronary artery disease, gallbladder and liver disease, and those with aural migraine, BMI >30 kg/m², or history of gastric bypass, specifically Roux-en-Y; consider an alternative method; when prescribing, providers should refer to the medical eligibility criteria chart from the Centers for Disease Control and Prevention

Progestin-only pill (POP): also known as the “mini pill”; most frequently prescribed in patients who prefer to avoid estrogen; does not interfere with lactation; the 2 formulations are norethindrone (0.35- or ≤1-mg dose in a 28-day pack) and drospirenone (3–4-mg dose in a 24-day pack); must be taken at the same time every day to maintain efficacy; increases rate of follicular cysts but has no effect on weight gain, bone density, CV risk, or lipid profile; fast return to ovulation after use; drospirenone can cause hyperkalemia because of receptor use

Medroxyprogesterone acetate (Depo-Provera): a 150-mg intramuscular injection given every 12 wk; acts on glucocorticoid receptors, thickens cervical mucus, blocks LH surge, and inhibits ovulation; most notable side effect is weight gain; ≈50% of women use it for amenorrhea side effect, and the remaining 50% have unscheduled bleeding; contributes to insulin resistance and causes slight increase in blood glucose for diabetic patients; 0.5% to 3.5% reversible bone density loss occurs after 1 yr of use, and ≤5% loss after 5 yr; there is slower return to ovulation compared with combined OCPs; benefits include ease of use, decreased bleeding risk, and inhibition of endometrial growth in endometriosis; for women on chronic anticoagulation, it may prevent hemorrhagic cysts and also provides endometrial protection, which reduces risk for endometrial and ovarian cancer

Long-acting reversible contraceptives (LARCs): nonhormonal copper IUD — approved for 10-yr use, with low failure rate of 0.5% to 0.8%; can be used for EC within 120 hr of intercourse; there is a slightly increased risk of bleeding (may improve after ≈6 mo) and pelvic inflammatory disease (PID; if exposed to sexually transmitted infection [STI] during use); benefits include regular cyclicity, avoidance of exogenous hormones, safe usage for patients treated for PID ≥3 mo prior, and patients with HIV and/or history of VTE; LNG-IUD — eg, Mirena and Liletta (52 mg LNG), Kyleena (19.5 mg), and Skyla (13.5 mg); results in a high, effective endometrial concentration of LNG, but a low plasma concentration; Mirena and Liletta are approved for 6-yr use, Skyla for 3 yr, and Kyleena for 5 yr; decreases overall bleeding, however, it does not consistently inhibit ovulation; there is some benefit for dysmenorrhea, endometriosis-related pain, and hyperplasia; contraindications — current or history of breast cancer or active liver disease; rare risk for uterine perforation upon placement; IUD may be removed if the strings are visible (without removal, there is increased risk for chorioamnionitis and second-trimester spontaneous abortion)

Subdermal contraception: consists of 68 mg of etonogestrel; implanted in the subdermal space, usually in the nondominant arm; approved for 3 yr; follow-up studies show efficacy for ≤5 yr; most common side effects include bruising at the site, unscheduled bleeding; there are no significant changes in bone density or lipid profiles and no CV events; associated with minimal weight gain; safe for use in women with HIV and those with history of VTE; has potential side effects when mixed with antiseizure drugs

Emergency contraception: copper IUDs (use within 5 day of intercourse); 1.5 mg or 0.75 mg (taken 12 hr apart) of LNG (eg, Next Choice One-Dose, Plan B One-Step) should be used within 72 to 120 hr of intercourse; a 30-mg tablet of ulipristal (Ella) should be taken within 5 day; all of these methods prevent pregnancy by inhibiting ovulation, fertilization, and implantation, but do not terminate an already established pregnancy

Readings

Bigrigg A, Evans M, Gbolade B, et al. Depo Provera. Position paper on clinical use, effectiveness and side effects [published correction appears in Br J Fam Plann 2000 Jan; 26(1):52-3]. Br J Fam Plann. 1999; 25(2):69-76; Britton LE, Alspaugh A, Greene MZ, et al. CE: An evidence-based update on contraception. Am J Nurs. 2020; 120(2):22-33. doi:10.1097/01.NAJ.0000654304.29632.a7; Chabbert-Buffet N, Jamin C, Lete I, et al. Missed pills: frequency, reasons, consequences and solutions. Eur J Contracept Reprod Health Care. 2017; 22(3):165-169. doi:10.1080/13625187.2017.1295437; Khialani D, Rosendaal F, Vlieg AVH. Hormonal contraceptives and the risk of venous thrombosis. Semin Thromb Hemost. 2020; 46(8):865-871. doi:10.1055/s-0040-1715793; Lopez LM, Grimes DA, Gallo MF, et al. Skin patch and vaginal ring versus combined oral contraceptives for contraception. Cochrane Database Syst Rev. 2013; 2013 Apr 30(4):CD003552. doi:10.1002/14651858.CD003552.pub4; Rott H. Thrombotic risks of oral contraceptives. Curr Opin Obstet Gynecol. 2012; 24(4):235-240. doi:10.1097/GCO.0b013e328355871d; Tyson N, Lopez M, Merchant M, et al. Subdermal contraceptive implant insertion trends and retention in adolescents. J Pediatr Adolesc Gynecol. 2021; 34(3):348-354. doi:10.1016/j.jpag.2020.12.019; Zapata LB, Steenland MW, Brahmi D, et al. Effect of missed combined hormonal contraceptives on contraceptive effectiveness: a systematic review. Contraception. 2013; 87(5):685-700. doi:10.1016/j.contraception.2012.08.035.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Gunn was recorded exclusively for Audio Digest on September 3, and September 17, 2021, respectively, using virtual teleconference software, in compliance with social-distancing guidelines during the COVID-19 pandemic. Audio Digest thanks the speakers and Cedars-Sinai Medical Center for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

FP694501

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.