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Overview of contraception
Author
Mimi Zieman, MD
Section
Robert L Barbieri, MD
Deputy
Kristen Eckler, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2015. &#124 This topic last updated: Jul 22, 2015.

Editor
Editor

INTRODUCTION Individuals choose to use contraception for many reasons:


All contraceptives provide control over the timing of pregnancy and avoidance of unintended pregnancy
Condoms provide protection from sexually transmitted infections
Hormonal contraceptives provide noncontraceptive health benefits (table 1)
A systematic review estimated contraceptive prevalence among women of reproductive age who were married or in a union was 63
percent worldwide and 77 percent in the United States [1]. Nevertheless, unintended pregnancy is a common problem. In a study
from the Guttmacher Institute using data from several sources, 49 percent of the 6.7 million pregnancies in the United States in
2006 were unintended [2]. About 5 percent of women of reproductive age had an unintended pregnancy that year, comprising 3.2
million pregnancies. The demographic characteristics of these women are shown in the table (table 2). Forty-three percent of the
unintended pregnancies were terminated. These alarmingly high statistics occurred even though most women reported using some
form of contraception [3]. The high rate of unintended pregnancy despite contraception highlights the importance of understanding
contraceptive efficacy in terms of typical, rather than perfect, use (see 'Effectiveness' below).
Some women choose to not use birth control. The reasons for nonuse were addressed in a report from the Pregnancy Risk
Assessment Monitoring System (PRAMS) which surveyed almost 8000 women with a recent unintended viable pregnancy who
stated they had not used birth control [4]. The women gave the following reasons for unprotected intercourse: 33 percent felt they
could not get pregnant at the time of conception, 30 percent did not really mind if they got pregnant, 22 percent stated their partner
did not want to use contraception, 16 percent cited side effects, 10 percent felt they or their partner were sterile, 10 percent cited
access problems, and 18 percent selected "other." That one-third of these women did not perceive themselves to be at risk of
becoming pregnant speaks to the need for more education.
Unintended pregnancy is associated with significant monetary costs. In 2010 in England, the National Health Service (NHS) provided
coverage for 218,100 unintended pregnancies (induced and spontaneous abortions, ectopic pregnancies, births) at a cost of
193,200,000 (USD$299,200,000) in direct medical costs [5]. Annual medical costs of unintended pregnancy in the United States
have been estimated to be $4.6 billion [6]. Contraception is a cost-effective approach for reducing these medical costs [7,8].
CHOOSING A METHOD OF CONTRACEPTION
Overview An understanding of the available contraceptive methods allows clinicians to counsel women about methods that are
most consistent with their lifestyle and beliefs, and therefore most likely to be successful. Factors to consider include:
Efficacy
Convenience
Duration of action
Reversibility and time to return of fertility

Effect on uterine bleeding


Type and frequency of side effects and adverse events
Cost
Accessibility
Protection against sexually transmitted diseases
Noncontraceptive benefits
Medical contraindications (see 'Women with medical issues and disabilities' below)
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and
decide which method she prefers (table 3). A list of questions that are useful for defining the patient's preferences are provided in
the table (table 4). Women should be counseled to choose the most effective method that they are likely to be able to use
successfully (figure 1). This means they will be able to comply with the requirements of using the method and they will likely adhere
to the method despite these requirements and the methods potential side effects. The best strategy for counseling women so they
will achieve this goal is unclear. (See "Counseling women considering combined hormonal contraception".)
Discontinuation of contraception for method-related reasons is common, and accounts for a significant proportion of unintended
pregnancies since many women switch to less effective methods or use no method at all. In the 2002 United States National Survey
of Family Growth (NSFG), 46 percent of women reported discontinuing at least one method because they were dissatisfied with it
[9]. Two-thirds of women discontinue hormonal methods because of side effects, while almost 40 percent of those who discontinue
the condom do so because of partner dissatisfaction. However, the discontinuation rate of long-acting reversible contraceptive
methods (intrauterine device [IUD], implant) appears to be lower, less than 10 percent at six months in one large study of young
women [10]. The higher continuation rates mirror higher satisfaction rates with these methods, but may also be due partly to the
need to see a clinician to discontinue, as well as the higher upfront costs.
Among couples attempting to avoid pregnancy, the percentage who continue to use a method for one year is approximately [11]:
Etonogestrel implant 84 percent
Levonorgestrel-releasing IUD 80 percent
Copper containing IUD 78 percent
Ring or patch or pill 67 percent
Diaphragm 57 percent
Depot Provera 56 percent
Fertility awareness based methods 47 percent
Male condom 43 percent
Female condom 41 percent
Effectiveness The effectiveness of a contraceptive method is expressed as both the theoretical (perfect use) efficacy and the
actual (typical use) effectiveness (table 5). The former refers to the pregnancy rate among those who use the method correctly on
every occasion (ie, inherent effectiveness); actual effectiveness is usually lower due to inconsistent or incorrect use. Actual
effectiveness is also influenced by frequency of intercourse, age, and regularity of menstrual cycles, as pregnancy is less likely in
women who are older, have infrequent sexual intercourse, and have irregular menstrual cycles.

In practice, contraceptive methods can be divided into three categories based upon their theoretical and actual effectiveness (figure
1) [3,12]. Women should be encouraged to first consider a method from the most effective options:
Most effective Long-acting reversible contraceptives (LARC; ie, intrauterine contraception, contraceptive implants) and
sterilization are associated with a low pregnancy rate regardless of the population studied, as the rate is minimally influenced by
adherence.
Effective Injectable contraceptives are the most effective in this tier of choices. Oral contraceptives, the transdermal
contraceptive system, and the vaginal ring are also associated with a very low pregnancy rate if they are used consistently and
correctly, but actual pregnancy rates are substantially higher because of inconsistent/incorrect use.
Least effective Other methods of contraception, including diaphragm, cervical caps, condoms, spermicides, withdrawal, and
periodic abstinence are associated with actual pregnancy rates that are much higher than perfect use rates. The overall pregnancy
rates associated with these methods have varied considerably among studies.
LARCs are the most effective reversible contraceptives [13]. They do not require ongoing effort on the part of the user for long-term
effective use, they are safe, they are economical when used over as little as a two-year period, and they provide prompt return of
fertility after removal. In addition, almost all women are eligible for use of one of the LARCs, including nulliparous women,
adolescents, and women who should avoid exogenous estrogen. For these reasons, LARCs should be discussed with all women
seeking contraception who are appropriate candidates for these methods. (See "Intrauterine contraception: Devices, candidates,
and selection", section on 'Candidates for intrauterine contraception' and "Etonogestrel contraceptive implant".)
The superior efficacy of LARCs has been illustrated by a study in the United States that enrolled 9256 women and provided free
contraceptives for three years [14]. The contraceptive failure rate among participants using pills, patch, or ring was significantly
higher than among participants using LARCs (4.55 versus 0.27 per 100 participant-years). Methods to improve LARC uptake,
including provision of LARC-specific education and access to LARC devices at an affordable cost (and without waiting), are also
associated with a reduction in unintended pregnancy. As an example, in a trial of 1500 women who were randomly assigned to
receive either standardized counseling for LARC or routine contraceptive counseling, standardized counseling for LARC resulted in
increased LARC use (28 versus 17 percent), and more importantly, a reduction in unintended pregnancies (8 versus 15 percent)
compared with routine counseling [15]. Similarly, when the state of Colorado offered affordable LARC methods from 2009 to 2013,
the teen birth rate decreased 40 percent and the abortion rate dropped by 42 percent compared with previous years [16].
Explanations for the apparent failure of other contraceptive methods when used by the typical patient include inconsistent
adherence to method requirements, incorrect use, gaps in use, discontinuation of the method, as well as failure of the method itself.
Cost and drug coverage issues also impact use of and adherence to contraception [17]. As an example, many insurance plans require
women to fill prescriptions for contraception on a monthly basis, which increases the chance of a delay in obtaining a needed
contraceptive refill. This is a common reason for contraceptive failure. The best way to address the problem of high failure with
typical use is by encouraging women to choose long-acting, highly effective reversible methods (LARCs) such as IUDs and implants,
which are underutilized in the United States, and providing them at low or no cost [18].
Effectiveness in studies is often assessed using the Pearl Index, which is defined as the number of unintended pregnancies per 100
women per year (ie, the number of pregnancies in 1200 observed months of use). One problem with this index is that it does not
account for the fact that contraceptive failure rates generally decline with continued use; therefore, a Pearl Index determined by a
study of new and short-term users of a method will likely be higher than that in a study including long-term users [19]. Demographic
factors are also not considered, although they influence method compliance and, in turn, efficacy. The effectiveness grouping listed
above is more clinically useful for informing patients about contraceptive effectiveness than the Pearl Index [20].
Noncontraceptive benefits Both hormonal and nonhormonal contraceptives have noncontraceptive benefits that should be
considered. The noncontraceptive benefits of estrogen-progestin contraceptives are listed in the table (table 1). Progestin-only
contraceptives also have some noncontraceptive benefits, such as lighter menstrual bleeding and reduced iron deficiency anemia
among long-term users, and protection against endometrial cancer. Condoms are the contraceptive method that provides the best
protection against acquisition or transmission of sexually transmitted infection; progestins may also provide some protection against
upper genital tract infection. (See "Counseling women considering combined hormonal contraception", section on 'Counseling about
noncontraceptive benefits' and "Prevention of sexually transmitted infections", section on 'Condom use' and "Depot
medroxyprogesterone acetate for contraception", section on 'Impact on cancer risk'.)

Cost An economic analysis of contraception for women constructed a Markov model to compare cost-effectiveness among the
most common contraceptive methods versus no contraception [7]. This model assumed users were not intending to have children
for five years and would not switch methods. It took into account factors such as costs of office visits, method failure, management
of side effects, andprescription/procedure/device costs, but did not account for noncontraceptive benefits. The major findings of the
analysis were:
The cost and effectiveness of any contraceptive method were superior to using no method
The most cost-effective methods were intrauterine contraception and vasectomy
Cost analysis was very sensitive to variations in the cost of contraceptive methods and unintended pregnancy, and the planned
duration of use
HORMONAL CONTRACEPTION Hormonal contraceptives may be taken orally, injected, or released from a subdermal implant,
transdermal patch, or intrauterine or intravaginal contraceptive device.
Issues to consider when beginning hormonal contraception The 2013 US Selected Practice Recommendations for Contraceptive
Use provide an overview of factors to consider when initiating contraception in healthy women, such as how to help a woman
initiate use of a contraceptive method, which examinations and tests are needed before initiating use (table 6), what regular followup is needed, and how to address problems that often arise during use [21].
The womans risk of acquiring a sexually transmitted infection should also be considered. Hormonal contraceptives are not
protective against sexually transmitted infections, including HIV infection [22]. Therefore, women at risk for acquiring a sexually
transmitted infection should be advised to use condoms (male or female) in addition to their hormonal method.
Additionally, concern has been raised that some types of hormonal contraceptive use may actually increase the risk of a woman
acquiring HIV infection. A meta-analysis of over 37,000 women reported that use of depot medroxyprogesterone acetate (DMPA)
may slightly increase rate of HIV acquisition whereas use of norethisterone enanthate (NET-EN) or combined hormonal
contraceptives [23] was not associated with increased risk. This is discussed in detail elsewhere. (See "Depot medroxyprogesterone
acetate for contraception", section on 'Effect on HIV acquisition and transmission'.)
Patient assessment Hormonal contraception can be safely provided after an appropriate medical history and blood pressure
measurement to exclude contraindications, such as hypertension (see 'Women with medical issues and disabilities' below) [21].
Screening for hypertension is recommended because it is a risk factor for development of cardiovascular disease, occurs in women
of childbearing age, and is asymptomatic and often unrecognized [24].
While breast and pelvic exams, cervical cancer screening, and screening for sexually transmitted diseases are important, most
groups, including the American College of Obstetricians and Gynecologists (ACOG), World Health Organization (WHO), the Royal
College of Obstetricians and Gynecologists (RCOG), and the Centers for Disease Control and Prevention (CDC) agree that these
procedures are not necessary before a first, or a renewed, prescription for hormonal contraception [21,25,26]. Chlamydia screening,
if indicated, can be performed on urine. Some groups recommend documentation ofweight/body mass index (BMI) when initially
prescribing hormonal contraceptives to monitor changes over time and counsel women who might incorrectly assume that weight
gain is associated with their contraceptive method [21,27]. (See "Clinical manifestations and diagnosis of Chlamydia trachomatis
infections".)
Excluding pregnancy Pregnancy can be reasonably excluded in women who meet any of the criteria in the table (table 7). For
women who do not meet any of these criteria, a pregnancy test can be performed, but should be obtained two or more weeks after
her last episode of unprotected intercourse. (See "Clinical manifestations and diagnosis of early pregnancy".) The benefits of starting
hormonal contraception immediately likely exceed any risk since these drugs are not teratogenic or abortifacient [28,29]; therefore,
same day start should be considered with a follow-up pregnancy test in two to four weeks [21].
Women with medical issues and disabilities Choosing a hormonal contraceptive method is more complicated for women with
certain medical disorders or personal characteristics, since physiologic changes and side effects associated with the method or with
pregnancy may increase the risk ofmorbidity/mortality in these women. Unintended pregnancy can be particularly serious for
women with certain medical conditions (table 8). (See "Counseling women considering combined hormonal contraception".)

One clinical scenario that has not been studied is the optimum hormonal method of contraception for women with limited mobility,
such as those in wheel chairs. Factors to consider include the negative effect of DMPA and immobility itself on bone mineral density,
as well as the increased risk of thrombosis associated with estrogen-progestin contraceptives and, possibly, third generation
progestins. A levonorgestrel-releasing intrauterine device (IUD) significantly reduces menstrual bleeding and requires little to no
attention while not carrying either of these risks appears to be a good option. The etonogestrel implant also contains no estrogen
and requires no attention, but is less likely to result in amenorrhea than the IUD. The IUD can be left in place for five years and the
implant for three years. Progestin-only pills are an alternative, but must be taken daily, have a higher failure rate, and provoke
irregular bleeding.
World Health Organization tables WHO has published comprehensive tables of medical conditions and personal characteristics
that may affect contraceptive choice [30]. These tables can be found online, and are summarized below.
Personal characteristics (table 9)
Cardiovascular disease (table 10)
Headache and epilepsy (table 11)
Depression (table 12)
Reproductive tract/breast abnormalities, cancer, infections (table 13)
Human immunodeficiency virus (HIV) (table 14)
Gastrointestinal disease (table 15)
Thalassemia and sickle cell anemia (table 16)
Diabetes and thyroid disease (table 17)
Drugs and drug interactions (table 18)
Rheumatological issues (table 19)
Initiation recommendations apply to women in whom the medical condition precedes initiation of the method; continuation
recommendations apply to women who develop the medical condition while using the method.
Centers for Disease Control and Prevention tables In 2010, the Centers for Disease Control and Prevention (CDC) modified the
WHO tables for medical eligibility criteria for contraceptive use [31]. Selected WHO recommendations were adapted for United
States clinicians and patients, the number of medical conditions was expanded and recommendations added, and contraceptive
methods not available in the United States were removed. The United States Medical Eligibility Criteria (USMEC) for Contraceptive
Use are available online and in the table (table 20).
Many of the absolute and relative contraindications to hormonal contraception listed in the CDC table described above are
discussed in detail in the following topics:
(See "Counseling women considering combined hormonal contraception".)
(See "Overview of the use of estrogen-progestin contraceptives".)
(See "Contraception counseling for obese women".)
(See "Risks and side effects associated with estrogen-progestin contraceptives".)
(See "Postpartum and postabortion contraception".)

(See "Contraceptive counseling for women with inherited thrombophilias".)


Women with a history of cancer The Society of Family Planning (SFP) provides clinical guidelines for contraception in women with
cancer [32]. These recommendations are similar to those published by the CDC, with some additional considerations. The SFP
recommends:
Women with active cancer or who have been treated for cancer within six months: avoid estrogen-progestin contraceptives
because both cancer and combined hormonal contraception are risk factors for venous thrombosis. (See "Risks and side effects
associated with estrogen-progestin contraceptives", section on 'Venous thromboembolic disease'.)
Women who have a history of chest wall irradiation for cancer: avoid systemic estrogen and/or progestin contraceptives because
these women are at increased risk of developing breast cancer and the risk may be greater in women who take exogenous
hormones.
Women with a history of breast cancer: use a copper-IUD unless they are taking tamoxifen. In the latter case, a levonorgestrelreleasing IUD is preferred to reduce the risk of tamoxifen-induced endometrial changes without increasing the risk of breast cancer
recurrence. (See "Approach to the patient following treatment for breast cancer", section on 'Contraception after breast cancer'.)
Women with anemia: use a levonorgestrel-releasing IUD to minimize menstrual blood loss. (See "Intrauterine contraception:
Devices, candidates, and selection", section on 'IUD selection'.)
Women with osteopenia or osteoporosis: avoid injectable progestin-only contraception (eg, DMPA). These women may benefit
from the effects of an estrogen-containing contraceptive on bone mineral density. (See "Depot medroxyprogesterone acetate for
contraception", section on 'Reduction in bone mineral density'.)
Women who are immunosuppressed: intrauterine contraception is not contraindicated.
Women at risk of breast cancer or recurrence: emergency contraceptive pills are not contraindicated.
Other guidelines Other national organizations have also published guidelines for contraceptive use in women with medical issues:
United Kingdom Medical Eligibility Criteria (UKMEC, available at www.fsrh.org/pdfs/UKMEC2009.pdf)
Estrogen-progestin versus progestin-only contraceptives Both the estrogen and progestin components of combined
contraceptives provide contraceptive actions, but the estrogen component also provides cycle control (ie, reduces the frequency
and duration of scheduled and unscheduled bleeding), which is beneficial. Another benefit is that estrogen maintains bone density
[33,34]. Disadvantages of combined contraceptives include estrogen-related side effects (eg, nausea, breast tenderness, bloating,
headache), estrogen-related risks (eg, venous thromboembolism), and the number of medical contraindications to use of exogenous
estrogen (see 'Women with medical issues and disabilities' above).
The various types of combined contraceptive products (pill, ring, patch) are similarly efficacious (table 5). The side effect profiles
differ and depend on the concentration of each hormone, the specific type of progestin, and local factors related to the application
site (skin, vagina). (See "Risks and side effects associated with estrogen-progestin contraceptives".) The pharmacokinetics varies by
delivery system. Oral estrogen administration is subject to a first-pass effect and enterohepatic recirculation leading to peaks and
troughs in serum estrogen concentrations, whereas the controlled release vaginal contraceptive ring and transdermal contraceptive
patch are associated with relatively constant serum estrogen levels [35]. Estrogen exposure is lowest with the vaginal ring and
highest with the patch.
Progestin-only contraceptives are an option for women who need to avoid estrogen (table 21). Progestin-only contraception is
associated with more unscheduled (breakthrough) bleeding. For progestin-only pills, ovulation is suppressed in 57 percent of cycles
compared with 95 to 99 percent of cycles with estrogen-progestin pills; however, the mechanism of action relies mostly on
thickening of cervical mucus, which inhibits sperm penetration [36].
A major advantage of progestin-only contraception is that it offers the option of long-term, forgettable contraception. All longacting hormonal contraceptives are progestin-only (levonorgestrel intrauterine system, DMPA injections, etonogestrel implant).

There are few contraindications to progestin use. Progestins should not be used in a woman with current breast cancer. Other
conditions where the CDC guidance states that risks outweigh benefits include severe decompensated cirrhosis, malignant liver
tumor, past breast cancer, systemic lupus erythematosus with antiphospholipid antibodies, and some other conditions where one
progestin-only method may be safer than another such method.
Initiation Hormonal contraception can be started anytime during the cycle (algorithm 1). We prefer the Quick Start method in
which the woman begins taking contraception on the same day that she is given the prescription/injection, as long as pregnancy is
reasonably excluded (see 'Patient assessment' above) [37].
Continuation of the contraceptive method is enhanced if the patient receives a prescription for a full year of contraception rather
than having to return for a new prescription every few months [37,38].
Follow-up A specific follow-up exam just to address contraception is not needed [21]. Women should be encouraged to return if
they have any concerns about their method, if they want to discontinue or switch methods, or if they have changes in health status
that could affect medical eligibility for continued use of the method.
Although a specific follow-up visit to measure blood pressure is not necessary in healthy users of estrogen-progestin contraceptives,
measurement of blood pressure is desirable at other routine visits, such as when the patient is seen for prescription refills or
noncontraceptive issues. Women can also be advised to obtain periodic blood pressure measurements where accessible, such as in a
pharmacy. The low risk of new hypertension in these patients was illustrated in a systematic review of five studies examining blood
pressure changes after initiation of oral estrogen-progestin contraceptives that found few women, at most 2 percent, developed
hypertension in the first year after initiating these drugs; however, methodological differences among the studies limited the
reliability of the findings [39]. (See "Risks and side effects associated with estrogen-progestin contraceptives", section on
'Hypertension'.)
Return to fertility after discontinuation Return to fertility after discontinuation of contraception is an important advantage of
reversible methods of contraception. Comprehensive reviews of studies that evaluated this issue found that in women who
discontinue contraception in order to conceive, the pregnancy rate in the 12 months following discontinuation of oral contraceptives
(cyclic combined or extended regimen) is similar to the pregnancy rate after discontinuation of other contraceptives, such as IUDs,
condoms, natural family planning, and progestin-only pills [40,41]. For all of these methods, 70 to 95 percent of women trying to
conceive became pregnant within 12 months. Prolonged use of combined hormonal contraception (eg, >5 years) does not decrease
the odds of conception within 12 months of discontinuation [42].
By comparison, the time to conception after discontinuing use of progestin-only injections is delayed; 50 percent of women conceive
six to seven months after the last shot, and greater than 90 percent after two years.
Counseling and strategies to enhance compliance Counseling about side effects and method convenience generally improves
compliance. Not requiring follow-up visits for prescription refills and monitoring is also effective. Strategies for counseling women
about choice of hormonal contraception and methods for enhancing compliance are discussed separately. (See "Counseling women
considering combined hormonal contraception", section on 'Strategies for enhancing compliance and continuation'.)
Switching from one hormonal method to another Depending on the contraceptive method, switching from one method to
another may require a period of back-up contraception if the new method is not begun within the first five days of onset of menses.
One expert groups recommendations for back-up contraception when switching between methods of contraception is illustrated in
the table (table 22). This is a reasonable approach, although others have recommended seven days back-up in all cases as a practical
clinical approach.
Switching from use of an IUD is a special case because there may be residual sperm in the reproductive tract, which theoretically
could result in fertilization and implantation. Management of women who are discontinuing the IUD and starting another method is
reviewed separately. (See "Intrauterine contraceptive device: Insertion and removal", section on 'Removal of IUD with or without
IUD replacement'.)
Does age matter? Although women of older reproductive age have lower fecundity and may have less frequent sexual intercourse
than younger women, they still need reliable contraception to avoid unintended pregnancy [43]. (See "Effect of advanced age on
fertility and pregnancy in women", section on 'Fertility'.)

No contraceptive method is contraindicated based on age alone (table 9 and table 20). Some women may no longer be good
candidates for combined hormonal contraception as they age because of acquired medical comorbidities. For these women, IUDs,
implants, and sterilization are preferred because of their high effectiveness and lack of association with cardiovascular events [43].
For women who remain candidates for combined hormonal contraception, these methods also provide noncontraceptive benefits,
such as reduction in hot flashes, regulated and/or reduced menstrual bleeding in the perimenopause, maintenance of bone
strength, and reduction in risk of some cancers (endometrial, ovarian, and possibly colorectal). Women who are not candidates for
combined hormonal contraception may still be good candidates for progestin-only contraception (see 'Estrogen-progestin versus
progestin-only contraceptives' above).
Contraception for women at the beginning of the reproductive age group is discussed separately. (See "Contraception: Overview of
issues specific to adolescents".)
Does weight matter? Some contraceptives may be less effective in obese women. Levonorgestrel and ulipristal emergency
contraception is less effective or not effective in obese women. (See "Contraception counseling for obese women" and "Emergency
contraception", section on 'Efficacy and risk factors for failure' and "Emergency contraception", section on 'Advance provision and
counseling'.)
When is it safe to stop using hormonal contraception? Contraception remains important during perimenopause, as women
cannot be certain of infertility until they reach menopause (ie, 12 months without menses). A false presumption of infertility is one
reason for the high rate of unintended pregnancy in perimenopausal women.
Determining when hormonal contraception can be safely discontinued is challenging because the effects of hormones on bleeding
patterns (eg, amenorrhea, regular withdrawal bleeding) make it difficult to diagnose menopause and there is no blood test that
reliably diagnoses menopause in women using hormonal contraception. One approach in healthy nonsmoking women is to
discontinue hormonal contraception when the risk of pregnancy is clearly remote based on age: ACOG and the North American
Menopause Society (NAMS) put this age between 50 and 55 years [44,45].
If a woman in the perimenopausal age group using hormonal contraceptive desires to stop, a reasonable approach is to choose the
median age of menopause, 51 years, and switch to a nonhormonal contraceptive. If over time she can be diagnosed as menopausal,
then the nonhormonal contraceptive can be discontinued, as well. Measurement of hormones, eg, follicle-stimulating hormone
(FSH), is not required to determine need for contraception.
Options for hormonal contraception
Estrogen-progestin pill, patch, or ring Combined estrogen-progestin contraceptives (pill (table 23), transdermal patch, vaginal
ring) inhibit the midcycle surge of gonadotropin secretion, so that ovulation is suppressed. They also alter endometrial receptivity
and inhibit the ability of sperm to access the upper genital tract. General principles of the use of combined estrogen-progestin
contraceptives, including pharmacology, mechanisms of action, indications, contraindications, efficacy, administration, different
preparations, and management of problems are reviewed separately:
(See "Overview of the use of estrogen-progestin contraceptives".)
(See "Risks and side effects associated with estrogen-progestin contraceptives".)
(See "Transdermal contraceptive patch".)
(See "Contraceptive vaginal ring".)
(See "Management of unscheduled bleeding in women using contraception".)
(See "Contraception counseling for obese women".)
(See "Contraception: Overview of issues specific to adolescents".)
When oral contraceptives are given on an extended rather than monthly cycle, the number of episodes of withdrawal bleeding per
year is reduced, and can be completely eliminated. In addition, shortening the hormone-free interval may reduce symptoms

associated with hormone withdrawal (eg, headache, pelvic pain). (See "Overview of the use of estrogen-progestin contraceptives",
section on 'Continuous pill' and "Hormonal contraception for suppression of menstruation".)
In contrast to oral contraceptive pills, which are taken daily, the contraceptive patch is applied weekly and the contraceptive vaginal
ring is applied monthly. The benefits, risks, and contraindications to use of all three methods are similar. The effects of combined
hormonal contraceptives on clotting factors, markers of coagulation and fibrinolysis, and lipids are largely independent of the route
of administration [46-48]. However, there are some differences among methods: the patch is associated with a higher frequency of
skin irritation and possibly venous thromboembolism, while the ring is associated with a higher frequency of vaginal discharge.
Progestin-only pill Progestin-only contraceptive pills are an option for women who need to avoid estrogen but want to take a
contraceptive pill. The "minipill" has a dose of progestin that is close to the threshold of contraceptive efficacy (norethindrone 0.35
mg); therefore, these pills should be taken at the same time each day and are taken every day without a pill-free interval. Variation
of only a few hours in administration can reduce contraceptive effectiveness so women should be prepared to use a back-up method
not only if one pill is missed, but also if there is a greater than three-hour delay in taking the pill. (See "Progestin-only pills (POPs) for
contraception".)
Progesterone-only ring Progesterone-only rings function primarily by thickening cervical mucus to prevent sperm penetration, but
also inhibit ovulation and endometrial receptivity. Progesterone-only rings may be less effective over the long-term than rings
containing both a progestin and an estrogen, but are still highly effective among breastfeeding women since breastfeeding provides
some protection from pregnancy. Unscheduled bleeding, which is a common side effect of all progestin-only methods, is less likely
to occur in breastfeeding women because of prolonged lactational amenorrhea [49]. A ring that releases a synthetic progestin
(Nestorone) is under development.
The progesterone vaginal ring contains 22.5 percent progesterone dispersed in silicone. The system delivers 10 mg/day of the
physiological hormone progesterone, but serum levels decline during its three-month duration of use [50]. It is available only in
South America. (See "Contraceptive vaginal ring", section on 'Progesterone-releasing vaginal ring'.)
Injectable contraceptives Injectable contraception is highly effective, reversible, and avoids the need for compliance daily or near
the time of sexual intercourse.
Progestin-only injection The only injectable contraceptive available in the United States is the progestin-only DMPA. DMPA (150
mg) is given by deep intramuscular injection and results in effective contraception for three months. Theoretical exceeds actual
effectiveness because some users do not return for their injections as scheduled (table 5). A lower-dose DMPA formulation (DMPASC, 104mg/0.65 mL), which is administered subcutaneously every three months, is also available [51]. The sub-Q formulation
provides slower and more sustained absorption of the progestin than conventional DMPA, which allows for a 30 percent lower dose
of progestin, but with the same duration of effect as conventional DMPA. Administration via the subcutaneous route is less painful
than intramuscular injection and potentially may allow patient self-administration. Intramuscular DMPA is available as a generic
formulation, which is less costly than DMPA-SC. Otherwise, the risks and benefits are similar to those with intramuscular
administration. Local reactions have been reported when DMPA is given subcutaneously. (See "Depot medroxyprogesterone acetate
for contraception".)
Estrogen-progestin injection In some other countries, combined estrogen-progestin injectables are available (eg, estradiol
cypionate-medroxyprogesterone acetate [Cyclofem], estradiol valerate-norethisterone enanthate [Mesigyna]). In a systematic
review of comparative trials of estrogen-progestin versus progestin-only injectable contraceptives, there were differences between
preparations in bleeding patterns and discontinuation rates, but the combined injectable drug was not clearly superior to or worse
than the progestin-only injectable drug [52].
Progestin-only implants A variety of contraceptive implants are available worldwide, but only Nexplanon is available in the United
States.
Etonogestrel implant (Nexplanon) A single-rod progestin implant (Implanon, Nexplanon) provides contraception for three years
by slow release of 68 mg of the progestin etonogestrel. Training sponsored by the manufacturer is required before the practitioner
can purchase and insert the implant. (See "Etonogestrel contraceptive implant".)
Levonorgestrel implant (Jadelle) A two-rod subdermal levonorgestrel implant (Jadelle) was approved by the United States Food
and Drug Administration (FDA) for five years of use, although it has not been marketed in the United States. It is available in most
other countries. The cumulative pregnancy rate in clinical trials was 0.3 at three years and 1.1 percent at five years [53], which is a

lower failure rate than that of oral contraceptives, and comparable to that of surgical sterilization. Efficacy may be reduced slightly
as body weight increases. In a multicenter study, there were no pregnancies in women weighing less than 50 kg or with
levonorgestrel serum concentrations greater than 180 pg/mL [54]. The major side effect is irregular bleeding [55].
Each rod is 0.25 cm in diameter, 4.3 cm long, and contains 75 mg of levonorgestrel. Under local anesthesia, a #10 trocar is used to
place the rods in a V configuration subdermally at the inner part of the nondominant upper arm (mean procedure time two
minutes). The progestin is released at 80 mcg per day in the first month, gradually decreasing to 50 mcg per day by nine months, and
then falling to 25 to 30 mcg per day thereafter. Removal is performed under local anesthesia by grasping the ends of the rods
through
a
3
to
4
mm
incision
at
the
apex
of
the
V
(mean
time
five
minutes).
Amenorrhea occurs, but is much less common than with DMPA injections. A systematic review determined the weighted prevalence
of amenorrhea over successive 90-day periods was 11, 13, 9 and 13 percent, respectively [56]. By comparison, approximately 50
percent of DMPA users are amenorrheic after one year.
Levonorgestrel-implant (Sino-implant) Sino-implant (II) is a two-rod contraceptive implant; each rod contains 75 mg
levonorgestrel. The main difference from Jadelle is that it can be left in place for up to four years (Jadelle can be left in place for up
to five years). Four randomized trials with a total of 15,943 women assigned to Sino-implant (II) had first-year probabilities of
pregnancy ranging from 0 to 0.1 percent and cumulative probabilities of pregnancy were 0.9 and 1.06 percent in the two trials that
presented data for four-year use [57].
Levonorgestrel-releasing IUD Several terms are used to describe intrauterine contraception, including IUD and intrauterine
contraceptive (IUC); the progestin-containing device is also referred to as an intrauterine system (IUS). In this topic, we use the term
IUD for all types of intrauterine contraception. Currently available IUDs release either a synthetic progestin or copper (see 'Copperreleasing IUD' below).
Levonorgestrel-releasing IUDs inhibit sperm transport and fertilization of ova, and partially inhibit ovulation. It is theoretically
possible that an additional mechanism is prevention of implantation. The higher dose levonorgestrel-releasing IUD (52 mg, initial
release rate 20 mcg/day [LNg20]) remains effective for at least five years [58]. A smaller and lower dose levonorgestrel-releasing IUD
(13.5 mg, initial release rate 14 mcg/day [LNg14]) remains effective for at least three years, thus it may be more appropriate for
women planning pregnancy in less than five years and women in whom insertion is difficult.
Current IUDs are not associated with the same problems (eg, increased risk of pelvic inflammatory disease [PID]) that caused
previous IUDs (eg, Dalkon shield) to acquire a poor reputation. Women who are at low risk for sexually transmitted diseases
do not have a higher incidence of PID with use of an IUD and well-designed studies have found that IUDs do not have adverse effects
upon fertility after removal.
IUDs decrease the overall risk of ectopic pregnancy compared with women who do not use contraceptives [59,60]. When pregnancy
does occur, the site of pregnancy should be immediately determined because the risk of ectopic pregnancy is increased (table 24).
A detailed discussion of the IUD can be found separately. (See "Intrauterine contraception: Devices, candidates, and selection".)
Intermittent hormonal contraception There is currently no hormonal contraceptive method approved for use only at the time of
intercourse. Two systematic reviews of observational studies of pericoital use of levonorgestrel as a method of contraception in
women having infrequent intercourse found that it was moderately efficacious and safe [61,62]. A commonly used regimen was 0.75
mg of levonorgestrel within one hour after coitus and a repeat dose if additional intercourse occurred more than three hours later.
For this dose, the pooled Pearl index was 5.4 pregnancies per 100 woman-years (95% CI 4.1-7.0) [62]. Limiting the analysis to three
high quality WHO-sponsored studies yielded a Pearl index of 8.9 pregnancies per 100 women years (95% CI 5.1-14.4). By
comparison, for sexually active women using no contraception, the estimated Pearl index is approximately 85 pregnancies per 100
women years. The studies were generally of low quality and further research is needed before this approach can be recommended
as a novel contraceptive method.
NONHORMONAL CONTRACEPTION
Tubal interruption or occlusion Tubal interruption and occlusion are surgical procedures that result in sterility. While these
procedures may be reversible, they should be considered permanent and therefore performed only after thorough patient
counseling. Detailed discussions of the various methods are available separately. (See "Surgical sterilization of women".)

Copper-releasing IUD Copper IUDs release copper continuously into the uterine cavity; this interferes with sperm transport and
prevents fertilization of ova [63]. It is theoretically possible that an additional mechanism is prevention of implantation. One type of
copper IUD, the TCu380A, remains effective for at least 10 years.
As discussed above, current IUDs are not associated with the same problems (eg, increased risk of pelvic inflammatory disease [PID])
that caused previous IUDs (eg, Dalkon shield) to acquire a poor reputation. Women who are at low risk for sexually transmitted
diseases do not have a higher incidence of PID with use of an IUD and well-designed studies have found that IUDs do not have
adverse effects upon fertility after removal. Consequently, the copper IUD revised its package label (September 2005) to remove the
prior section on "recommended patient profile" that included multiparity, mutually monogamous relationship and history of PID.
IUDs decrease the overall risk of ectopic pregnancy compared with women who do not use contraceptives [59,60]. When pregnancy
does occur, the site of pregnancy should be immediately determined because the risk of ectopic pregnancy is increased (table 24).
A detailed discussion of the IUD can be found separately. (See "Intrauterine contraception: Devices, candidates, and selection".)
Barrier methods Condoms (male and female), diaphragm, and cervical cap are the most common forms of barrier contraception.
Neither condoms nor the contraceptive sponge require a prescription, but a prescription is needed to purchase a diaphragm. The
effectiveness of all barrier methods of contraception is highly user-dependent (table 5 and figure 1). Male condoms provide better
protection againstacquisition/transmission of sexually transmitted infections, including human immunodeficiency virus (HIV), than
any other contraceptive method.
Condom Condoms are available for both men and women. (See "Male condoms" and "Female condoms".)
Diaphragm and cervical cap Diaphragms and cervical caps provide a barrier between sperm and the cervical canal and serve as a
reservoir for spermicide. They require fitting by a trained clinician and are only effective when used with a spermicide since the
barrier is not secure (see 'Spermicides' below). They must be left in the vagina for 6 to 8 hours after intercourse; the diaphragm
needs to be removed after this period of time, while the cervical cap can be left in place for up to 48 hours. These considerations
have caused them to be less desirable methods of contraception for many women. In addition, using a diaphragm can increase the
risk of urinary tract infections. (See "Barrier contraception: Diaphragm".)
The only cervical cap available in the United States is made of silicone rubber (FemCap). It has a strap to facilitate removal and
comes in three sizes; the appropriate size is based on the patients obstetric history. It does not require a custom fitting, but can only
be purchased with a prescription. In randomized trials, the FemCap was less effective in preventing pregnancy than the diaphragm
[64]. However, these trials were performed with the first generation FemCap, which was not approved by the United States Food
and Drug Administration (FDA); a second generation device has been approved by the FDA and is available for use in the United
States and Europe.
Sponge The Today sponge is a 2-inch wide circular disk, 3/4 of an inch thick, containing 1000 mg of nonoxynol-9 and attached to a
loop for removal. It is moistened with tap water before insertion deep in the vagina.
The sponge does not require fitting or a prescription and can be left in place and used repeatedly for up to 24 hours. When
compared to the diaphragm in randomized trials, the sponge was less effective and had a higher discontinuation rate [65]. Both the
contraceptive sponge and diaphragm may be linked to an increased risk of non-menstrual toxic shock syndrome, though rare [66].
Fertility awareness based methods Fertility awareness-based, or natural, methods are alternative methods of family planning for
women who prefer a nonhormonal, nonsurgical form of contraception for health or personal reasons. Fertility awareness-based
methods of contraception are discussed in detail separately. (See "Fertility awareness-based methods of pregnancy prevention".)
Other methods
Withdrawal The withdrawal method (coitus interruptus) requires men to withdraw from the vagina before ejaculation. Failure
occurs if withdrawal is not timed accurately or if the preejaculatory fluid contains sperm. Pregnancy rates of 18 to 28 percent per
year of use have been reported [3,67,68].
Lactation Women who breastfeed have a delay in resumption of ovulation postpartum due to prolactin-induced inhibition of
pulsatile gonadotropin-releasing hormone (GnRH) release from the hypothalamus. Breastfeeding can be relied upon to prevent
pregnancy only when the woman meets all three of the following conditions [69,70]:

She is less than six months postpartum


She is breastfeeding exclusively (ie, not providing food or other liquid to the infant)
She is amenorrheic.
If these conditions are not met, the risk of unintended pregnancy while breastfeeding is high, and women should add another
method of contraception [71]. (See "Postpartum and postabortion contraception", section on 'Lactation as a contraceptive
method'.)
Contraceptive choices during lactation Recommendations for nonhormonal and hormonal contraception use during lactation are
reviewed in detail elsewhere. (See "Postpartum and postabortion contraception", section on 'Contraceptive choices during
lactation'.)
Spermicides Spermicides are among the least effective methods of contraception (figure 1 and table 5) [72]. Spermicides
containing nonoxynol-9 are available without a prescription and in a variety of forms including gel, foam, cream, film, suppository,
and tablet. They are not a highly effective method of contraception when used alone (without a barrier method). This was illustrated
in a trial which randomly assigned 1536 women willingly to accept a moderate risk of pregnancy to use of one of five spermicides
[73]. The probability of pregnancy for each nonoxynol-9 preparation during six months of typical use was: 52.5 mg gel (22 percent),
100 mg gel (16 percent), 150 mg gel (14 percent), film (12 percent), and suppository (10 percent). Although the risk of pregnancy
was significantly higher with the 52.5 mg gel, none of the preparations reliably prevented pregnancy.
Effectiveness is reduced if the patient does not wait long enough for the spermicide to disperse before having intercourse, if
intercourse is delayed for more than one hour after administration, or if a repeat dose is not applied before each additional act of
intercourse.
Nonoxynol-9 preparations do not appear to significantly disturb the vaginal flora ecosystem, although a small increase in bacterial
vaginosis associated flora has been observed in the highest quartile of users [74].
Local irritation is not uncommon with spermicide use, and these agents tend to be messy. Spermicides do not protect
against acquisition/transmission of gonococcal or chlamydial infection [75] or HIV infection [76-79], and may cause vaginal irritation
thereby increasing susceptibility to HIV [76,80].
A meta-analysis concluded that maternal use of spermicides is not associated with adverse fetal outcomes, including congenital
malformations [81]. A subsequent analysis of data from the National Birth Defects Prevention Study (NBDPS) did not find significant
associations between reported first trimester spermicide use and any birth defect, except perimembranous ventricular septal
defects, which the authors noted may be a chance finding due to multiple comparisons [82].
Chemical methods Sclerosing chemicals have been used to occlude the fallopian tubes, but are not popular because they require
more than one application and because of safety concerns [83].
Quinacrine sterilization Quinacrine-induced tubal sclerosis is an alternative method of tubal sterilization which does not require
surgery [84,85]. It has not been assessed by the FDA for use in the United States, but is widely used in developing countries because
of its low cost and its ease of use. Contraceptive effectiveness is lower than with other sterilization techniques (see below) [83]. Over
100,000 procedures have been performed in over 30 countries [86].
The method involves transcervical insertion of seven 36-mg quinacrine pellets (252 mg total) into the uterine cavity on two
occasions one month apart under hysteroscopic guidance and using a modified IUD. Histopathological studies in pre-hysterectomy
volunteers showed that tubal occlusion occurred as a result of inflammation leading to fibrosis, which was limited to the cornual
area and the intramural portion of fallopian tubes [87]. Endometrial changes included atrophy, polypoid reactions, and fine
adhesions; long-term effects on the endometrium are not well-described, but available data are reassuring [88-90]. Cumulative
pregnancy rates at 1, 5, and 10 years postprocedure range from 0.3 to 3.3 percent, 1.1 to 10 percent, and 4.3 to 12.1 percent,
respectively [91].
Disadvantages of the technique include the need for multiple applications and the lack of a reliable method for confirming tubal
occlusion. Hysterosalpingography is not recommended because pressure from the dye may force open the scarred tube and allow

recanalization [92]. Although quinacrine appeared to be carcinogenic in rodents at doses higher than those used for human
sterilization [93], there is no evidence of an increased risk of cancer in human studies [90,94].
When is it safe to stop using nonhormonal contraception? In menstruating women, experts suggest that women age 50 years
continue to use contraception for one year after their last menstrual period (ie, menopause) and women <age 50 years continue to
use contraception for two years after their last menstrual period [95-97].
EMERGENCY CONTRACEPTION All couples using a barrier contraceptive (eg, condom, diaphragm, cervical cap), as well as women
using hormonal methods, should be informed about the use and nonprescription availability of emergency contraception for the
female partner. Emergency contraception is indicated if there is failure of the barrier contraceptive method (broken condom, failure
to use, etc). Emergency (postcoital) contraception is discussed separately. (See "Emergency contraception".)
CONTRACEPTION FOR MEN
Condoms The condom is the only reversible method of contraception available to men. (See "Male condoms".)
Vasectomy Vasectomy (ligation of the vas deferens) can be performed in a physician's office under local anesthesia. It is a safe,
highly effective sterilization procedure. Although men should be counseled before vasectomy that the procedure is permanent, the
procedure can often be reversed with a return of fertility. (See "Overview of vasectomy".)
INVESTIGATIONAL METHODS
Vaccines Contraceptive vaccines are under investigation; none are clinically available. These vaccines either target gamete
production (luteinizing hormone-releasing hormone [LHRH]/gonadotropin-releasinghormone [GnRH], follicle-stimulating hormone
[FSH]), gamete function (sperm antigens and oocyte zona pellucida [ZP]), or gamete outcome (HCG) [98].
Hormonal methods for men No male hormonal contraceptives are available for clinical use, although scientists have been
attempting to develop them for many years [99]. The current approach to male hormonal contraception is based on the ability of
exogenously administered sex steroids to suppress pituitary secretion of luteinizing hormone (LH) and FSH: spermatogenesis is
inhibited when the concentrations of these hormones are low. Endogenous testosterone production is also suppressed, so all of
these regimens involve administration of exogenous testosterone. A variety of androgen preparations are available; most involve
injections or implants, but a transdermal gel [100], a potent synthetic androgen (7a-methyl-19-nortestosterone [MENT]) [101,102],
and an oral formulation [103] are being investigated and appear promising.
Since testosterone alone does not completely suppress spermatogenesis in all men, most approaches to male hormonal
contraceptive involve a combination regimen, such as testosterone and a progestin or testosterone and a GnRH analog, which
synergistically suppress gonadotropins [100,104,105]. Combined regimens also enable use of lower doses of testosterone, although
androgen exposure is still above physiologic levels. The testosterone-progestin regimen parallels the estrogen-progestin regimen
that inhibits ovulation in hormonal contraceptives for women.
In addition to problems with variable suppression of spermatogenesis, efforts to develop an acceptable male hormonal
contraceptive regimen have also been hampered by the lack of long-acting, effective oral and transdermal testosterone preparations
and undesirable side effects [106]. The current transdermal testosterone patch has not resulted in reliable sperm suppression,
presumably due to suboptimal serum testosterone concentrations [107]. There is a theoretical concern that long-term
administration of supraphysiological quantities of testosterone might increase the risk of prostate disease.
An additional practical limitation of the use of male hormonal contraception is that it takes a few months to significantly reduce
sperm counts, thus there is a considerable delay before the contraceptive becomes effective.
Vas injection Vas occlusion methods, such as injectable silicone plugs, block the vas deferens without disrupting it, making
reversal easier. Reversible Inhibition of Sperm Under Guidance (RISUG) is another approach in which the vas is injected with a
polymer gel that kills sperm. If reversal is desired, the polymer can be flushed out with an injection of dimethyl sulfoxide.
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics.
th
th
The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or
five key questions a patient might have about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more

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detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information
and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your
patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of
interest.)
Basics topics (see "Patient information: Choosing birth control (The Basics)" and "Patient information: Vasectomy (The Basics)")
Beyond the Basics topics (see "Patient information: Birth control; which method is right for me? (Beyond the Basics)" and "Patient
information: Vasectomy (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS Choosing a contraceptive depends upon a number of factors, including efficacy,
reversibility, convenience, cost, availability (prescription versus nonprescription), and side effects. Thus, each patient's choice of
contraceptive method should reflect her opinion of the utility of each of these variables and where she is willing to make tradeoffs
between desirable and undesirable features of each method (table 3). Women should be counseled about the difference in typical
use effectiveness between the methods, and should be counseled to consider a highly effective method such as one of the longacting reversible contraceptives (LARCs) methods. Some generalizations can be made:
In addition to any method of contraception, we recommend use of condoms for individuals at risk of sexually transmitted
infections (Grade 1B). (See "Male condoms", section on 'Protection from STIs' and "Female condoms", section on 'Sexually
transmitted infections'.)
For couples who desire permanent contraception (sterilization), we suggest vasectomy. Vasectomy is as effective, but less morbid
and costly than tubal occlusion. (See "Overview of vasectomy" and "Surgical sterilization of women".)
Women who request sterilization should be counseled about availability of LARC methods, which are comparable to sterilization in
terms of efficacy (table 5), but are non-surgical and reversible. (See 'Effectiveness' above.)
For women who desire reversible contraception, we suggest LARC. Pregnancy rates are comparable to sterilization (table 5), and
they are more convenient than short-acting methods. (See 'Effectiveness' above.)
Combined estrogen-progesterone hormonal methods (pills, patch, vaginal ring) are rapidly reversible, but less effective than the
methods described above (although still highly effective when used properly) (table 5). Hormone-related side effects are common.
Convenience depends upon the specific method and varies from daily administration (oral contraceptive pills, standard or extended
cycle) to weekly (patch) to monthly (vaginal ring). Patients should not use these methods if they have a contraindication to taking
estrogen preparations. In particular, patch users may be at higher risk of thrombosis than pill users. (See 'Issues to consider when
beginning hormonal contraception' above and 'Estrogen-progestin pill, patch, or ring' above.)
Blood pressure should be measured prior to initiating estrogen-progestin contraception. (See 'Patient assessment' above.)
Estrogen-progestin contraception is generally avoided in hypertensive women because of an increased risk of cardiovascular disease,
including stroke. (See "Risks and side effects associated with estrogen-progestin contraceptives", section on 'Cardiovascular
disease'.)
The diaphragm and male condom are less effective and less convenient than hormonal methods (table 5). However, they are the
most readily reversible methods and not associated with systemic side effects (except for individuals who are sensitive to latex
products). Diaphragms are most effective when used with a spermicide. They are not recommended as the primary method for
women with serious medical conditions in whom pregnancy is life-threatening; these women require use of the most effective
methods of contraception. (See 'Barrier methods' above.)
Women using a barrier contraceptive (eg, condom, diaphragm, cervical cap) or who are at risk for pregnancy should be informed
about use of emergency contraception in case of failure of the barrier contraceptive method (broken condom, failure to use, etc).
Women prescribed hormonal contraceptives should also be informed about use of emergency contraception since they may miss
doses of their contraceptives and be at risk for unintended pregnancies. (See 'Emergency contraception' above.)
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