Choice of Contraceptives
Choice of Contraceptives
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Med Lett Drugs Ther. 2015 Sep 14;57(1477):127-32
 Select a term to see related articles  Beyaz   cervical cap   Condom   Contraceptives   Depo-Provera   Diaphragm   Drospirenone   Ella   Emergency contraception   Essure   Estrogens   IUD   Levonorgestrel   Liletta   Mirena   Nexplanon   Next Choice One Dose   NuvaRing   Oral contraceptives   Ortho Evra   ParaGard   Plan B One Step   Progestins   Skyla   Spermicides   Ulipristal acetate   Xulane   Yasmin   Yaz 

Implants, intrauterine devices (IUDs), and sterilization are the most effective contraceptive methods available. Pills, patches, rings, and injectables, when used correctly, are also highly effective in preventing pregnancy. Barrier and fertility-based methods have the highest rates of failure.1,2

AN IMPLANT — Nexplanon, a single-rod implant containing the progestin etonogestrel, is placed under the skin on the inside of the non-dominant upper arm and is effective for up to 3 years. As with other progestin-based methods, bleeding irregularities are common. Implants, once placed, require no adherence and provide long-term protection against pregnancy. Fertility returns rapidly after removal.3

INTRAUTERINE DEVICES — The 4 IUDs currently available in the US are all highly effective in preventing pregnancy. IUDs have high satisfaction and continuation rates and may be the most cost-effective of all reversible methods of contraception.

ParaGard T 380A, a copper-containing IUD, is FDA-approved for up to 10 years of use. It has been shown to be effective for up to 20 years in some women.4

Mirena is FDA-approved for up to 5 years of use, but it has been shown to be effective for up to 7 years. It releases 20 mcg/day of levonorgestrel initially, which decreases gradually to 10 mcg/day over 5 years. Mirena has an approved secondary indication for heavy menstrual bleeding.

Skyla is FDA-approved for up to 3 years of use. It releases 14 mcg/day of levonorgestrel initially, which decreases gradually to 5 mcg/day over 3 years. Skyla is slightly smaller than Mirena, which might be advantageous in nulliparous women. One study comparing Mirena with 2 smaller devices, including one similar to Skyla, found that women receiving the smaller devices were more likely to report little or no pain than those undergoing Mirena placement.5

Liletta, which is the same size as Mirena, releases 18.6 mcg/day of levonorgestrel initially, which decreases gradually to 12.6 mcg over 3 years. It is FDA-approved for up to 3 years of use.6

Benefits – IUDs, once inserted, require no adherence and provide long-term protection against pregnancy; fertility is restored upon removal. All of the levonorgestrel-releasing IUDs can reduce dysmenorrhea.

Adverse Effects – Uterine perforation can occur during IUD placement. The copper IUD may cause heavy bleeding and cramping. All of the IUDs can cause irregular or heavy bleeding in the first 3-6 months after placement. IUD-associated infection is mainly related to insertion; women who have a low risk of acquiring a sexually transmitted infection are unlikely to develop an IUD-associated infection. Ovarian cysts have been reported with all levonorgestrel-releasing IUDs.

STERILIZATION — Tubal sterilization procedures can be done abdominally or hysteroscopically. Abdominal procedures are performed using various techniques to cut, cauterize, or clip the fallopian tubes via laparoscopy or minilaparotomy. Hysteroscopic methods involve placing devices into the fallopian tubes that cause (after several months) tubal occlusion. Essure is the only such device currently approved in the US.7 Its labeling states that tubal occlusion should be confirmed three months post-operatively; an alternate form of birth control should be used until the confirmatory test.

ORAL CONTRACEPTIVES — Most oral contraceptives available in the US are a combination of the estrogen ethinyl estradiol and a progestin. The estrogen and progestin content of these pills has been reduced over the years to decrease the incidence of adverse effects. The lower-dose formulations (≤20 mcg of ethinyl estradiol) are effective, but they may have a higher risk of failure and can cause changes in bleeding patterns (irregular, frequent, or prolonged). Table 2 lists some common oral hormonal contraceptives.

Monophasic vs Multiphasic – Monophasic oral contraceptives contain fixed doses of estrogen and progestin in each active pill. Multiphasic oral contraceptives vary the dose of one or both hormones during the pill cycle. Many multiphasic pills have a lower total hormone dose per cycle; there is no convincing evidence that they cause fewer adverse effects or improve bleeding patterns compared to monophasic pills.

Shorter or Fewer Hormone-Free Intervals – Most traditional oral contraceptives are packaged as a 21/7 cycle (21 days of active tablets and 7 days of placebo), resulting in 13 scheduled bleeding episodes each year. Newer regimens include fewer hormone-free days per 28-day cycle (2-4 placebo tablets) or extended cycles with fewer withdrawal bleeds per year. Most studies found that use of extended-cycle contraceptives results in fewer menstrual symptoms such as headache, bloating, and menstrual pain.8 Several products are designed and packaged for extended cycles, but any traditional 21/7 oral contraceptive can be used continuously by skipping some or all of the placebo pills.

Non-Contraceptive Benefits – Women who take combination oral contraceptives have a reduced risk of both epithelial ovarian and endometrial cancer. This benefit is detectable within one year of use and appears to persist for years after discontinuation. Other benefits include a reduction in dysfunctional uterine bleeding and dysmenorrhea, a lower incidence of ectopic pregnancy and benign breast disease, and an increase in hemoglobin concentrations. Many women also benefit from the convenience of menstrual regularity. All combination oral contraceptives increase sex hormone binding globulin and decrease free testosterone concentrations, which can lead to improvements in hirsutism and acne. Combination oral contraceptives are also often used off-label to treat polycystic ovary syndrome.

Choice of a Progestin – Progestins such as desogestrel and norgestimate have less androgenic activity and are claimed to improve acne more than older progestins, but these claims have not been substantiated by controlled trials. Combination oral contraceptives containing drospirenone, a synthetic progestin with antiandrogenic and antimineralocorticoid activity, have been shown to improve symptoms associated with premenstrual dysphoric disorder (PMDD), hirsutism, and acne, but whether they are more effective than other combination oral contraceptives for these indications is not known.9

Adverse Effects – Estrogens can cause nausea and breast tenderness and enlargement. Oral contraceptives with lower doses of ethinyl estradiol have a higher incidence of bleeding disturbances. Unexpected bleeding or spotting is common with all extended-cycle or continuous regimens, particularly during the initial cycles.

Other Risks – Older formulations of combination oral contraceptives containing ≥50 mcg of ethinyl estradiol were associated with an increased risk of myocardial infarction and ischemic stroke, particularly in women who smoked or had uncontrolled hypertension; these risks are decreased with formulations that have lower doses of ethinyl estradiol. Users of contraceptives with lower estrogen doses have a risk of venous thromboembolism (VTE) that is 2-3 times higher than that of non-users; this risk is lower, however, than the risk of VTE associated with pregnancy.

A case-control study in over 10,000 women with VTE found that current exposure to any combination contraceptive was associated with an increased risk of VTE (adjusted odds ratio 2.97) compared to no exposure in the previous year. Exposure to certain progestins (desogestrel, gestodene, drospirenone, and cyproterone) was associated with a higher risk of VTE (odds ratios ranged from 1.52 to 1.80) compared to levonorgestrel.10

Estrogen-containing contraceptives are not recommended for smokers (≥15 cigarettes/day) who are ≥35 years old or for women who have hypertension, coronary artery disease, heart failure, cerebrovascular disease, diabetes with end-organ damage, or migraine headaches with focal neurological symptoms, or for those who are at risk for VTE. Their use is also contraindicated in women with a history of breast cancer, a thromboembolic disorder, or liver disease. Progestin-only or nonhormonal methods are preferred in women at increased risk of cardiovascular or thromboembolic events.

Progestin-Only – "Minipills," which are taken daily without a hormone-free interval, are predominantly used by breastfeeding women and those in whom estrogen is poorly tolerated or contraindicated, such as women ≥35 years old who smoke. Irregular bleeding is common with progestin-only pills; taking the pill at the same time each day is crucial in preventing breakthrough bleeding and pregnancy.

Drug Interactions – Some drugs taken concurrently, including rifampin (Rifadin, and others), several anti-HIV drugs, anticonvulsants, and St. John's wort, can induce the metabolism of oral contraceptives and decrease their effectiveness. Contraceptive failure has also been reported with concurrent use of some antibiotics, including penicillins and tetracyclines; a cause-and-effect relationship has not been established.

OTHER HORMONAL CONTRACEPTIVES — Injectable Contraceptives – Injectable contraceptives containing medroxyprogesterone are effective and eliminate the need for daily adherence. Medroxyprogesterone acetate is injected intramuscularly (Depo-Provera, and generics) or subcutaneously (Depo-SubQ Provera 104) once every 3 months. Amenorrhea is common and irregular bleeding can occur. Weight gain, headache, and decreases in bone mineral density have been reported. Because of the risk of loss of bone mineral density, labeling for both injectable products recommends discontinuing their use after 2 years unless no acceptable alternative is available, but the American College of Obstetricians and Gynecologists has urged practitioners to continue the injections after 2 years when their clinical judgement is that such use is appropriate.11 The return of fertility can be delayed for 6-12 months (median 10 months) after the last injection.

Transdermal Patch – Xulane, a generic version of the (no longer marketed) Ortho Evra patch, delivers an average daily dose of 20 mcg of ethinyl estradiol and 0.15 mg of norelgestromin. A new patch is applied to the buttock, lower abdomen, back, or upper outer arm each week for 3 weeks, followed by one patch-free week. Its efficacy is similar to that of combination oral contraceptives, although it may be less effective in women who weigh ≥90 kg. The adverse effects and risks of the patch are similar to those of combination oral contraceptives, but patch users are exposed to higher average levels of estrogen than users of combination oral contraceptives containing 30-35 mcg of ethinyl estradiol. Compliance may be improved compared to oral contraceptives, but breakthrough bleeding is more common in the first 2 cycles. Skin irritation at the application site can occur and may lead to discontinuation.

Vaginal Contraceptive Ring – NuvaRing is inserted intravaginally by the patient (no fitting is necessary) and left in place for 3 weeks, followed by one ring-free week. It can be left in place for up to 4 weeks and the number of ring-free days can be reduced. It delivers a daily dose of 15 mcg of ethinyl estradiol and 0.12 mg of etonogestrel, the active metabolite of desogestrel. If the ring is removed for more than 3 hours, backup contraception should be used until the ring has been in place for 7 consecutive days. The ring offers excellent cycle control and a rapid return to fertility after removal. Reasons for discontinuation have included device-related discomfort, headaches, and vaginal discharge. Its efficacy is similar to that of combination oral contraceptives, but users report less nausea, acne, irritability, and depression.

EMERGENCY CONTRACEPTION — Hormonal methods of emergency contraception, which apparently prevent or delay ovulation, can prevent 50-80% of pregnancies.12

Progestin-Only ECPs – Progestin-only emergency contraception pills (ECPs) available in the US include Plan B One-Step, Next Choice One Dose, and several generic formulations of these. Since 2013, progestin-only ECPs have been available over the counter with no age restrictions. All progestin-only ECPs use levonorgestrel, either as a single dose of 1.5 mg or as two doses of 0.75 mg taken 12 hours apart. Progestin-only ECPs should be started as soon as possible within 72 hours after unprotected intercourse, although some studies indicate that they may be effective if taken within 5 days.13 Side effects include headache, abdominal pain, and breast tenderness. Nausea and vomiting occur less frequently with levonorgestrel alone than with estrogen-progestin combinations. Progestin-only ECPs decrease in efficacy with increasing body mass index (BMI).14

Antiprogestin ECPs – Ulipristal acetate (Ella), an antiprogestin, is FDA-approved for emergency contraception.15 It is only available by prescription and is approved for use up to 5 days after unprotected intercourse. Ulipristal acetate is the most effective hormonal option for emergency contraception. A meta-analysis found that women who took ulipristal acetate for emergency contraception within 120 hours after unprotected intercourse were less likely to become pregnant than those who took progestin-only ECPs.16 Its adverse effects are similar to those of levonorgestrel. Ulipristal acetate should be considered a first-line hormonal option for emergency contraception, especially for overweight or obese women.17

Copper IUD – A copper IUD inserted within 5 days after intercourse is the most effective method of emergency contraception.14 Pregnancy rates as low as 0.1% have been reported with use of the copper IUD.18 It may cause heavy bleeding and cramping. IUD-associated infection is mainly related to insertion; women who are at low risk of acquiring a sexually transmitted infection have a minimal risk of an IUD-associated infection.

Combined ECPs – Many oral contraceptives can also be used in doses suitable for emergency contraception; 26 combined estrogen and progestin (usually ethinyl estradiol and levonorgestrel) oral contraceptives are available in the US for this indication. All are recommended for use in 2 doses 12 hours apart. They are somewhat less effective than other hormonal methods. Doses should be taken as soon as possible within 72 hours after unprotected intercourse. Patients who vomit within 1 hour of administration should repeat the dose.

Adverse Effects – Nausea and vomiting occur less frequently with levonorgestrel alone than with estrogen-progestin combinations. Headache, abdominal pain, and breast tenderness have been reported with both progestin-only and combination oral contraceptives. No fetal malformations caused by unsuccessful use of hormones for emergency contraception have been reported.

BARRIER CONTRACEPTIVES — The effectiveness of barrier contraceptives is highly user-dependent. These methods have much higher failure rates than hormonal contraceptives, IUDs, or sterilization.

Diaphragms and Cervical Caps – Diaphragms and cervical caps are used with spermicide and placed over the cervix. Diaphragms can be inserted up to 6 hours before intercourse and should not be removed for 6 hours afterward; they should not be left in place for more than 24 hours because of the danger of toxic shock syndrome. Spermicide must be reapplied for each act of intercourse. Cervical caps can be left in place for up to 48 hours, and do not require additional spermicide with repeated intercourse. Whether these devices have protective effects against HIV or other sexually transmitted infections is unclear. Diaphragms and cervical caps are not routinely stocked in pharmacies and may be difficult to obtain.

Condoms – Only condoms prevent both pregnancy and sexually transmitted infections, including HIV infection. Both male and female condoms are available. Most male condoms in the US are latex; they are effective when used correctly, but can break when stored improperly or used with oil-based lubricants. Alternatives for patients with latex sensitivity include lamb intestine and synthetic polyurethane condoms. Lamb condoms do not protect against viral infections. Synthetic polyurethane male condoms are more likely to break than latex condoms, and may be less effective in preventing pregnancy. Female condoms have the advantage of improved coverage of the external genitalia, possibly offering better protection against STIs. They can be used with either an oil- or water-based lubricant.

Sponge – The Today sponge is an over-the-counter barrier contraceptive containing the spermicide nonoxynol-9. It is moistened in water and placed over the cervix. The sponge is effective immediately after insertion and, if left in place, intercourse may be repeated for up to 24 hours. The sponge should remain in place for 6 hours after the last act of intercourse. It should be removed after 24-30 hours because of the risk of toxic shock syndrome. Sponges have been inferior to diaphragms in both effectiveness and continuation rates. The availability of the sponge is inconsistent.

Spermicides – Nonoxynol-9 is available as a foam, film, gel, cream, suppository, and tablet. It must be placed in the vagina no more than 1 hour before intercourse and reapplied before each act of intercourse. The spermicide should be in contact with the cervix; suppositories, films, and tablets need to dissolve in order to be effective.

FERTILITY AWARENESS-BASED METHODS — Fertility awareness-based methods of contraception involve avoidance of intercourse or use of barrier methods during the presumed fertile days of the menstrual cycle. The approaches now recommended rely on observation of changes in cervical mucus (ovulation), changes in body temperature (symptothermal), and estimation of the range of fertile days in the woman's usual menstrual cycle (Calendar Rhythm, TwoDay, and Standard Days methods). Relatively long periods of abstinence are necessary with all of these methods, and failure rates are high.

CONCLUSION — Intrauterine devices (IUDs) and hormonal implants require no compliance on the part of the woman and are probably the most cost-effective of all reversible contraceptives. Oral contraceptives containing a low dose of estrogen (≤35 mcg) and a progestin are highly effective and have non-contraceptive benefits. Barrier contraceptives have fewer systemic adverse effects than hormonal contraceptives, but have much higher failure rates. For emergency contraception, ulipristal acetate (Ella) is the most effective hormonal option, but the copper IUD (ParaGard T 380A) is the most effective method overall.

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