Contraception

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Updated by: Dr. Seema Menon
Updated on: 4/2017

Abstinence

• Effectiveness:
  • If ALL sexual activity is avoided (including skin to skin contact) 100% effective at preventing pregnancy and STDs
• Pros:
  • No side effects
  • Free
• Cons:
  • No protection if sexual activity is forced
• Contraindications:
  • None

Combined oral contraceptive pills

• Effectiveness:
  • Perfect use: 99% effective
  • Actual use: 92-95% effective
• Pros:
  • Menstrual cycles become lighter and are regular
  • Can be used for extended cycling
  • Can help with dysmenorrheal and other symptoms of PMS
  • Decreases incidence of physiologic ovarian cysts, ovarian cancer, and endometrial cancer
  • Does not interrupt sexual activity
  • Protects against pregnancy if sexual activity is forced
• Cons:
  • Needs to be taken every day at the same time
  • Does not protect against STDs
  • Certain medications may interact with the pill:
    • Decrease the efficacy of the OCP: carbamazepine, Phenobarbital, phenytoin, rifampin, griseofulvin, barbiturates, felbamate, topiramate, ethosuximide
    • Decrease the efficacy of the medication: warfarin, lorazepam, salicylates
    • Decreases clearance of medication: cyclosporine, dantrolene
    • Drugs potentiated by OCP: benzodiazepines, beta blockers, caffeine, corticosteroids, TCA
      • Increases the risk of thrombotic events
      • Potential side effects include nausea and headaches
• Contraindications:
  • Absolute: Pregnancy, hypercoagulable states, history of DVT/PE/stroke, active liver disease, vaginal bleeding of unknown etiology, estrogen-dependent malignancy (breast cancer), prolonged immobilization, complicated congenital heart disease, severe hypertension, migraine with aura or focal neurological defects
  • Relative: high blood pressure, gall bladder disease, smoking, hyperlipidemia

Condoms

• Effectiveness:
  • Perfect use: 97% effective
  • Actual use: 86% effective
• Pros:
  • Protects against STDs
  • Inexpensive
  • No hormones involved
• Cons:
  • Need to interrupt sexual activity to use
  • Possibility that condom can break
  • Must be placed correctly
  • Need to use a new one with each episode of intercourse
  • Latex can be weakened by oil based lubricants (always use water based), extreme heat or cold, humidity, sunlight, age (always check the expiration date)
• Contraindications:
  • Latex allergy (instruct patients to use polyurethane condoms instead)

Depo-Provera

• Effectiveness:
  • Perfect use: 99.7% effective
  • Actual use: 97% effective
• Pros:
  • Each injection prevents pregnancy for 3 months (12 weeks)
  • Does not contain estrogen, so appropriate to use in those with contraindications to estrogen
  • Protection even if sexual activity is forced
  • Many girls stop getting their periods while receiving injections
    • Periods return on average 6-12 months after discontinuation of injections
• Cons:
  • Does not protect against STDs
  • Need to see health care provider every 3 months for the injection
  • Common to see irregular bleeding during the first 3 months after initiating injections
  • Side effects include weight gain, depression, hair loss
  • May see decrease in bone density
    • This decrease has not been shown to cause increase in fractures
    • Decreased bone density has been shown to reverse on discontinuation of injections
• Contraindications:
  • Caution in girls with history of/high risk of bone fractures

Emergency contraception

(Note: Emergency contraception (EC) does not work if a woman is already pregnant. EC will NOT cause an abortion.)

• Effectiveness:
  • Perfect use: lowers risk of pregnancy 75-89%
• Pros:
  • Can be taken 5 days (120 hours) after unprotected sex
  • Girls 17 and over can get over the counter (do not need a prescription)
  • Can be taken if sexual activity is forced
• Cons:
  • Does not protect against STDs
  • Girls 16 and under need a prescription
    • Side effects include nausea, headache

Hormonal implants (Implanon)

• Effectiveness:
  • Perfect use: 99.95%
  • Actual use: 99.95%
• Pros:
  • Prevents pregnancy for 3 years
  • Can have it removed at any time
  • Pregnancy protection even if sexual activity is forced
  • Does not contain estrogen, so appropriate to use in those with contraindications to estrogen
• Cons:
  • No protection against STDs
  • Requires minor procedure for both insertion and removal of the rod
  • Need to have a health care provider trained in insertion/removal
  • Side effects including irregular bleeding, depression, hair loss, weight gain
• Contraindications:
  • Pregnancy, active liver disease, vaginal bleeding of unknown etiology
• Lactational:
  • Effectiveness

Amenorrhea Method (LAM)

• Effectiveness:
  • Perfect use: 98% effective
  • Actual use: 98% effective
• Pros:
  • Does not interrupt sexual activity
  • Can prevent pregnancy in forced sexual activity
• Cons:
  • Only can be used within 6 months of delivery in a woman who has not had menstrual period since delivery and is breast feeding baby at least 6-10 times per day
  • Does not protect against STDs
• Contraindications:
  • Not breast feeding

Levonorgestrel IUD (Mirena)

• Effectiveness:
  • Perfect use: 99.8%
  • Actual use: 99.8%
• Pros:
  • Prevents pregnancy for up to 5 years
  • Does not need daily attention - just need to check the strings once a month
  • Will likely have much lighter periods or none at all (Also a treatment for menorrhagia)
  • Pregnancy protection even if sexual activity is forced
  • Does not contain estrogen, so appropriate to use in those with contraindications to estrogen
• Cons:
  • Does not protect against STDs
  • Need to have health care provider trained in insertion/removal
  • Increased risk of PID during the first few weeks after insertion in patients with STDs
  • Small risk of spontaneous expelling
  • Small risk of uterine perforation during placement
  • Moderate to severe uterine cramping during placement
  • Irregular, light bleeding for approximately 2 months after placement
• Contraindications:
  • Pregnancy, abnormal uterus (mullerian anomaly), recent PID, cervical/endometrial/ovarian cancer

Ortho-evra patch, Nuva Ring

• Effectiveness:
  • Perfect use: 99.7% (patch and ring)
  • Actual use: 99% (patch); 95% (ring)
• Pros:
  • Does not need to be taken every day (the patch lasts 1 week and the ring lasts 3 weeks)
  • Makes menstrual periods more regular and lighter
  • Can use extended cycling
  • Can help with dysmenorrhea and other PMS symptoms
  • Decreases incidence of ovarian cysts, ovarian cancer and endometrial cancer
  • Does not interrupt sexual activity
  • The ring can be left in during sex or removed for maximum of 3 hours
  • Protection from pregnancy even if sexual activity is forced
• Cons:
  • Does not protect against STDs
  • The patch may not be as effective in people over 200 lbs
  • Potential side effects include irregular bleeding, breast tenderness, nausea, headaches
  • Patch is associated with slightly higher risk of thrombotic event (but lower than thrombotic risk associated with pregnancy).
  • Patch may cause skin irritation or change in skin pigment
  • Vaginal ring may cause leukorrhea, foreign body sensation
• Contraindications:
  • Absolute: Pregnancy, hypercoagulable states, history of DVT/PE/stroke, active liver disease, vaginal bleeding of unknown etiology, estrogen-dependent malignancy (breast cancer), prolonged immobilization, complicated congenital heart disease, severe hypertension, migraine with aura or focal neurological defects
  • Relative: high blood pressure, gall bladder disease, smoking, hyperlipidemia

Progestin-only pills

• Effectiveness:
  • Perfect use: 98% effective
  • Actual use: 95% effective
• Pros:
  • Does not contain estrogen, so appropriate to use in those with contraindications to estrogen
  • Protection even if sexual activity is forced
• Cons:
  • Needs to be taken every day at the same time
  • Does not protect against STDs
  • Associated with breakthrough bleeding

Rhythm method

• Effectiveness:
  • Perfect use: 91-98% (average 94%) effective
  • Actual use: 76% effective
• Pros:
  • Free
  • Do not need to interrupt sexual activity
• Cons:
  • Woman needs to know when she is ovulating and avoid sex few days before and few days after
  • Does not protect against STDs
  • Does not protect against forced sexual activity
• Contraindications:
  • Irregular periods

Withdrawal

• Effectiveness:
  • Perfect use: 96% effective
  • Actual use: 77-81% effective
• Pros:
  • Free
  • No hormones needed
• Cons:
  • Perfect use rarely happens: Pre-ejaculate may contain sperm
  • Does not prevent STDs