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Contraception

Basics

  • Definition: Medications or procedures to control pregnancy timing and prevent unintended pregnancies.
  • Categories: Hormonal and nonhormonal.
  • Incidence: 45% of U.S. pregnancies are unintended, associated with adverse outcomes.
  • Risk factors for unintended pregnancy: Women 18–24 years, >40 years, unmarried, less education, minorities.

Diagnosis

  • Review medical, family, social, obstetric, gynecologic, menstrual, prior contraceptive, and STI history.
  • Screen hypertension.
  • Evaluate contraindications using CDC Medical Eligibility Criteria (MEC).
  • Absolute and relative contraindications exist for estrogen-progestin, progestin-only, levonorgestrel IUD, and copper IUD (detailed in source).

Diagnostic Tests

  • Pregnancy test.
  • Screen for gonorrhea and chlamydia prior to IUD insertion.
  • Pap smear if indicated, but contraception should not be delayed.

Treatment

General Measures

  • Select method based on patient preference, effectiveness, STI prevention need, side effects, contraindications.

Hormonal Contraceptives

  • Estrogen-progestin contraceptives: suppress ovulation, thicken cervical mucus, alter endometrium. Failure rate ~9% typical use, 0.3% perfect use.
  • Combined Oral Contraceptives (COCs):
  • Mostly ethinyl estradiol (10–50 µg) + various progestins.
  • 21 active + 7 placebo days or continuous use.
  • "Quick start" recommended or first day of menses.
  • Weekly patch (Ortho Evra/Xulane, Twirla) and vaginal ring (NuvaRing, Annovera) alternatives available.
  • Patches have higher estrogen exposure; Twirla contraindicated if BMI ≥30.

  • Vaginal rings have similar VTE risk as COCs.

  • Progestin-only contraceptives:

  • Pills: Norethindrone 0.35 mg (Micronor), Drospirenone (Slynd), Norgestrel (Opill OTC).
  • Injectable (Depo-Provera): every 3 months, side effects include irregular bleeding, weight gain, depression.
  • LARCs:
    • Levonorgestrel IUDs (Mirena, Kyleena, Skyla) with varying hormone doses and durations (3–8 years).
    • Copper IUD (ParaGard) effective for 10+ years, increases bleeding and cramps.
    • Nexplanon implant releases etonogestrel, lasts 3–5 years, common menstrual irregularities.

Emergency Contraception

  • Copper and levonorgestrel IUDs most effective (within 5 days of intercourse).
  • Ulipristal acetate (Ella), levonorgestrel pills (Plan B), and Yuzpe regimen available.
  • Efficacy may decrease with BMI >30.

Additional Nonhormonal Methods

  • Male condoms, spermicides, sponge, diaphragm, Phexxi (prescription vaginal contraceptive gel).
  • Failure rates vary; condoms ~2% perfect, 18% typical use; spermicides and sponges higher failure.

Permanent Sterilization

  • Female: tubal ligation (0.5% failure at 1 year).
  • Male: vasectomy (0.15% failure at 1 year).

Complementary & Alternative Methods

  • Fertility awareness (24% failure).
  • Withdrawal (22% failure).
  • Lactational amenorrhea (7% failure if criteria met).

Pediatric Considerations

  • LARCs recommended first-line by AAP and ACOG.

Ongoing Care

  • Follow-up at 1–3 months for tolerance and complications.
  • IUD string check 1 month post-insertion.
  • BP check within 3 months for estrogen-containing methods.

Diet & Drug Interactions

  • St. John's wort may reduce estrogen effectiveness.

Patient Education

  • Proper diaphragm use with spermicide.
  • Correct condom use.
  • Monthly IUD string checks.
  • Emphasize STI prevention.
  • Useful resources:
  • https://www.reproductiveaccess.org/contraception/
  • https://www.cdc.gov/reproductivehealth/contraception/

Complications

  • Estrogen-progestin: risk of stroke, thromboembolism, hypertension, MI, cholestatic jaundice (discontinue if serious).
  • Injectable DMPA: decreased bone mineral density with ≥2 years use; calcium/vitamin D advised.
  • Nexplanon: insertion site pain, bleeding, paresthesias, infection.
  • IUDs: uterine perforation risk; ectopic pregnancy risk increased if pregnancy occurs.
  • Sponge and diaphragm: risk of toxic shock syndrome.

Clinical Pearls

  • LARCs provide high efficacy and convenience.
  • Use CDC MEC to guide contraception in complex cases.

ICD10: - Z30.9 Encounter for contraceptive management, unspecified
- Z30.41 Encounter for surveillance of contraceptive pills
- Z30.431 Encounter for routine checking of intrauterine contraceptive device