Contraception

Contraception is the prevention of pregnancy through the use of medications, medical devices, or behaviors. Many different contraceptive options (both hormonal and nonhormonal) exist, allowing individuals to choose a method suited to their medical needs and pregnancy prevention priorities; some methods offer additional noncontraceptive benefits. Hormonal contraceptives contain estrogen and/or progestins to prevent ovulation, fertilization, and/or implantation of an embryo. Nonhormonal contraceptives include sterilization, the copper IUD, barrier methods of contraception, and behavioral methods of contraception. The duration of contraception provided ranges from the length of intercourse (e.g., condoms) to years (long-acting reversible contraception such as IUDs and the progestin implant). The choice of contraception involves shared decision-making that balances the individual patient's preferences with the risks of contraceptive use. The US Medical Eligibility Criteria (USMEC) for contraceptive use are used to provide risk-based guidance for individuals with coexisting medical conditions. Although often neglected, easy access to contraception, including emergency contraception, is an important part of medical care for all individuals who require it. Some contraception is available without a prescription; most require a prescription or a health care professional to fit them.

Hormonal and nonhormonal contraception

• Hormonal contraception
  • Uses progestin with or without estrogen to prevent conception through one or a combination of the following:
    • Prevention of ovulation
    • Thickening of cervical mucus
    • Creation of an inhospitable intrauterine environment
  • Examples include the hormonal IUD, combined hormonal contraception, and progestin-only pill, implant, or injection.
• Nonhormonal contraception
  • Prevents conception without altering natural hormones
  • The mechanism of action depends on the method.
    • Copper IUD: creation of an inhospitable intrauterine environment
    • Barrier methods: prevention of sperm reaching the uterus
    • Behavioral methods: avoidance of sex during the fertile window
    • Sterilization: blockage of the passage of gametes

Overview of methods ^[1][2][3]

• All methods of contraception are reversible except sterilization.
• Choice of method is tailored to patient preference and comorbid medical conditions.
• For further information, see specific sections.

Contraceptive efficacy

The efficacy of contraceptive methods is reported as the contraceptive failure rate, i.e., the percentage of individuals who become pregnant within 12 months of initiating a contraceptive method. ^[11]

• Failure rate with typical use: includes all individuals using that method regardless of whether it is used correctly and/or consistently ^[11]
• Failure rate with perfect use, also called the Pearl index: includes only individuals who use the method correctly and consistently; mainly used in clinical studies ^[11]

85% of female individuals currently using a contraceptive method would become pregnant within 1 year if contraception were stopped. ^[4]

Selecting a method ^[12][13]

• Assess the individual's:
  • Future reproductive goals
  • Previous experience with contraception
  • Past medical history to determine USMEC for contraceptive use (may require a limited physical exam)
    • Some contraceptive methods are contraindicated for patients with select medical conditions.
    • Encourage patients with conditions that increase the risk of complications in pregnancy to use LARCs.
  • Individual contraceptive preferences
• Outline which methods an individual can safely use.
• Explain a combination of methods may be necessary to meet all of an individual's needs, e.g.:
  • Condoms for STI protection
  • AND LARC for highly effective contraception

Patient preference, comorbid medical conditions, and availability will affect the choice of contraception.

Prescribing contraception ^[12]

• Avoid barriers to contraceptive use.
  • Use a quick start approach rather than waiting until the next menstrual cycle.
  • Use patient history to reasonably exclude pregnancy rather than requiring a pregnancy test.
  • Offer STI testing, but do not require individuals to wait for results to initiate contraception. ^[8]
  • Do not require a routine pelvic examination and Pap smear.
  • Offer telehealth appointments for initiation of contraception and repeat prescriptions, when possible. ^[14]
• Prescribe a one-year supply of contraceptives. ^[6]
• Provide basic patient education (e.g., management of unscheduled bleeding, missed or delayed contraception).
• Advise patients to return at any point to discuss concerns or change contraceptive method.

All methods of contraception can be initiated at any time during the menstrual cycle. ^[6]

Patients do not require a pregnancy test prior to initiating contraception (including emergency contraception) if the following conditions are met. ^[8]

• No clinical features of pregnancy
• AND meets any of the following criteria
  • ≤ 7 days since menses began or the patient had a spontaneous or induced abortion
  • < 4 weeks postpartum
  • < 6 months postpartum and both:
    • Exclusively or almost exclusively (> 85% of feeds) breastfeeding
    • Amenorrheic
  • Since the beginning of prior menses has either:
    • Had no sexual intercourse
    • Been consistently using a dependable contraceptive method

The following information is used by health care providers for individuals with specific medical conditions or medically relevant factors (e.g., age) to estimate individualized levels of risk versus benefit when choosing a method of contraception.

Category definitions ^[6][15]

• USMEC category 1: no limitations on use
• USMEC category 2: benefits generally outweigh risks
• USMEC category 3: risks often outweigh benefits (