Hormonal contraceptives

Last updated: March 1, 2022

Summarytoggle arrow icon

Hormonal contraceptives involve the use of estrogen and progestin analogs to prevent pregnancy. The contraceptive effect is mediated by negative feedback at the hypothalamus, ultimately leading to reduced pituitary follicle-stimulating hormone (FSH) and luteinizing hormone (LH) secretion. Without an LH surge, ovulation does not occur. Progestin also makes implantation less likely, as it causes a thickening of cervical mucus, a decrease in tubal motility, and the inhibition of endometrial proliferation. Oral contraceptives (OCs) are the most common form of hormonal contraception, but other forms of hormone delivery, including patches, injections, and implants, also exist. In combination monophasic OCs, the dose of estrogen and progestin remains constant, while in combination multiphasic OCs it varies over the course of one cycle. The decreased total hormone doses of multiphasic OCs mitigate certain associated side effects and risks. These include bothersome symptoms such as breast tenderness, nausea, bloating, and breakthrough bleeding as well as medical emergencies such as venous thromboembolism. Because of the complications associated with hormonal contraceptives, their use is contraindicated in patients with certain medical conditions and histories, e.g., significant hypertension, ischemic heart disease, venous thromboembolism, and stroke.

Types of hormonal contraceptives [1][2][3]

Overview of different types of hormonal contraceptives
Type Description Pregnancy rate in first year with typical use (with perfect use) [4] Indications
Oral contraceptive pill Combined oral contraceptive (COC)
  • 7% (< 1%)
Progestin-only contraceptive pills (minipill)
  • 7% (< 1%)
Contraceptive patch
  • 7% (< 1%)
  • Patches are considered as effective as COC pills
  • Only require application to the skin once a week
  • Similar indications as for COC
Vaginal ring
  • 7% (0.3%)
  • Similar indications as for COC
Injectable progestin
  • Depot medroxyprogesterone acetate (DMPA): long-acting progestin-only contraceptive
  • Intramuscular or subcutaneous injection administered every 3 months
  • 4% (0.2%)
  • Long-term and reversible
  • For women who have contraindications for estrogen-containing contraceptives
  • A good option for women who may not remember to use short-acting contraceptives consistently.
Progestin intrauterine device
  • Need to be replaced every 3 to 5 years (varies with type of device).
  • 0.7% (0.5%)
  • Long-term and reversible
Subdermal progestin implant
  • The device (flexible plastic rod) is usually inserted subdermally in the upper arm and lasts 3 years.
  • 0.1%

Intrauterine devices [5]

General

  • Small, t-shaped birth control devices inserted into a woman's uterus to prevent pregnancy
  • In the United States, they are available in two forms: nonhormonal copper-containing devices and plastic devices with progestogen hormones.
  • Inserted through a quick clinical procedure
  • Individuals must be tested for pregnancy and STIs before insertion.

Types

Adverse effects

Contraindications

Emergency contraception

Emergency contraception (EC) refers to measures taken to prevent pregnancy within 5 days of unprotected intercourse or contraception failure (e.g., condom breakage, missed oral contraceptives).

Approach

  • EC is recommended for individuals who have had unprotected intercourse or contraception failure and who do not wish to conceive. [8]
  • Health care providers should counsel and offer patients the best method according to their specific needs.
  • Eligibility and type of emergency contraceptive use are based on the following:
  • EC should be initiated as soon as possible to maximize efficacy.
Overview of emergency contraception methods [5]
Method Efficacy [8] Timing after unprotected intercourse
Intrauterine devices (IUDs) Copper IUD
  • Within 5 days
Progestin IUD
  • ≥ 99%
Oral emergency contraception medication Antiprogestins (Ulipristal acetate)
  • Approx. 99%
Progestins (Levonorgestrel)
  • Approx. 98%
  • Within 3 days
Combined oral contraceptives pills (Yuzpe regimen)
  • Approx. 86%

Oral emergency contraception medication [5][8][9]

General

  • Most effective when taken within 3 days of unprotected intercourse (ulipristal acetate can be taken within 5 days)
  • Does not disrupt embryo implantation or already established pregnancies
  • Significantly less effective in obese ; (BMI ≥ 30 kg/m2) or overweight ; (BMI 25–29.9 kg/m2) individuals [9][10]
  • For more information on the mechanisms of action, see “Pharmacodynamics” below.

Types

Adverse effects

Contraindications

The rate of pregnancy is ≤ 3.0% if emergency contraception is taken within 72 hours after unprotected sexual intercourse. The earlier it is taken, the lower the likelihood of pregnancy.

Mechanisms of action depend on the hormones used in the formulation.

Common side effects

Indications for immediate discontinuation [14]

Studies have shown that women taking estrogen-progestin combination OCPs before menopause have an increased risk of cervical carcinoma but a decreased risk of endometrial and ovarian carcinoma.

We list the most important adverse effects. The selection is not exhaustive.

Contraceptive indications

Non-contraceptive indications [5]

Absolute contraindications for estrogen-containing OCPs

Women who smoke and are > 35 years old should not be prescribed OCPs because of increased risk of cardiovascular side effects!

Relative contraindications for estrogen-containing OCPs

We list the most important contraindications. The selection is not exhaustive.

Minors

In the United States, laws allowing minors to consent to contraceptive health care are determined by individual states. Most states allow adolescents to receive medical care related to pregnancy prevention without parental consent.

  1. Cerel-Suhl SL, Yeager BF. Update on oral contraceptive pills. Am Fam Physician. 1999; 60 (7): p.2073-2084.
  2. Allen RH, Cwiak CA, Kaunitz AM. Contraception in women over 40 years of age. CMAJ. 2013; 185 (7): p.565-573. doi: 10.1503/cmaj.121280 . | Open in Read by QxMD
  3. Choosing a Birth Control Method. http://www.arhp.org/Publications-and-Resources/Quick-Reference-Guide-for-Clinicians/choosing/Progestin-Only-OCs. Updated: June 1, 2014. Accessed: June 17, 2017.
  4. World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), Knowledge for Health Project.. Family Planning - A global handbook for providers. WHO ; 2018
  5. Bosworth MC, Olusola PL, Low SB. An update on emergency contraception.. Am Fam Physician. 2014; 89 (7): p.545-50.
  6. Mahmood T, Saridogan E, Smutna S, Habib AM, Djahanbakhch O. The effect of ovarian steroids on epithelial ciliary beat frequency in the human Fallopian tube.. Hum Reprod. 1998; 13 (11): p.2991-4. doi: 10.1093/humrep/13.11.2991 . | Open in Read by QxMD
  7. Turok DK, Gero A, Simmons RG, et al. Levonorgestrel vs. Copper Intrauterine Devices for Emergency Contraception. N Engl J Med. 2021; 384 (4): p.335-344. doi: 10.1056/nejmoa2022141 . | Open in Read by QxMD
  8. American College of Obstetricians and Gynecologists. Emergency Contraception. Obstetrics & Gynecology. 2015; 126 (3): p.e1-e11. doi: 10.1097/aog.0000000000001047 . | Open in Read by QxMD
  9. American College of Obstetricians and Gynecologists. Access to Emergency Contraception. Obstetrics & Gynecology. 2017; 130 (1): p.251-252. doi: 10.1097/aog.0000000000002155 . | Open in Read by QxMD
  10. Kapp N, Abitbol JL, Mathé H, et al. Effect of body weight and BMI on the efficacy of levonorgestrel emergency contraception. Contraception. 2015; 91 (2): p.97-104. doi: 10.1016/j.contraception.2014.11.001 . | Open in Read by QxMD
  11. Snow SE, Melillo SN, Jarvis CI. Ulipristal Acetate for Emergency Contraception. Ann Pharmacother. 2011; 45 (6): p.780-786. doi: 10.1345/aph.1p704 . | Open in Read by QxMD
  12. Trenor CC, Chung RJ, Michelson AD et al. Hormonal contraception and thrombotic risk: a multidisciplinary approach. Pediatrics. 2011; 127 (2): p.347-357. doi: 10.1542/peds.2010-2221 . | Open in Read by QxMD
  13. Kang A, Khokale R, Awolumate OJ, Fayyaz H, Cancarevic I. Is Estrogen a Curse or a Blessing in Disguise? Role of Estrogen in Gastroesophageal Reflux Disease. Cureus. 2020 . doi: 10.7759/cureus.11180 . | Open in Read by QxMD
  14. Morbidity and Mortality Weekly Report (MMWR) - Appendix L - Summary of Classifications for Hormonal Contraceptive Methods and Intrauterine Devices. https://www.cdc.gov/Mmwr/preview/mmwrhtml/rr59e0528a13.htm. Updated: May 28, 2010. Accessed: June 17, 2017.

3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer