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Contraception - Detailed Description

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Overview and Classification

1. Non-hormonal methods - barrier, spermicidal, natural, permanent
2. Hormonal methods - combined estrogen-progestin and progestin-only
3. Intrauterine contraception - copper and hormonal IUDs
4. Long-acting reversible contraceptives (LARCs)
5. Emergency contraception
6. Permanent/surgical methods - sterilization

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1. Non-Hormonal Methods

A. Coitus Interruptus (Withdrawal)

B. Breastfeeding / Lactational Amenorrhea Method (LAM)

• Fully breastfeeding (no supplemental feeds >5-10%)
• Feeding intervals do not exceed 4 hours (day) and 6 hours (night)
• Woman remains amenorrheic

C. Male Condom

• Latex condoms effectively prevent STDs (including HIV) and reduce cervical cancer risk
• Typical-use failure rate: 18%; perfect-use: 2%
• Efficacy increases substantially with experience
• Latex allergy risk: nonlatex (polyurethane, Tactylon) alternatives should be offered
• Oil-based lubricants degrade latex; water-based lubricants are recommended

D. Female Condom (FC2)

• Nitrile sheath with two flexible rings; FDA approved 2009
• Effective against pregnancy and STDs including HIV
• Slippage more common than with male condom; do NOT use concurrently with male condom
• Pregnancy rate: 15% in 6 months (initial trials); with perfect use, as low as 2.6%

E. Vaginal Spermicides

• Combine spermicidal agent (nonoxynol-9 [N-9] or octoxynol) with cream, jelly, foam, film, suppository, or sponge
• N-9 immobilizes sperm by detergent action
• Less effective alone than barriers; do not protect against HIV
• High-frequency use can cause vaginal lesions, increasing STD susceptibility
• N-9 is not absorbed systemically; no proven teratogenicity

F. Vaginal Barrier Methods

• Circular latex dome over cervix; used with spermicide
• Types: coil-spring, flat-spring, arcing (easiest insertion)
• Efficacy: 12% typical use, 6% perfect use per year
• Caya diaphragm (one-size-fits-most): FDA approved 2014; avoids fitting requirement

• Silicon cup fitting over cervix
• Three sizes (22, 26, 30 mm) based on obstetric history
• Less effective in parous women; approved for 48-hour use

• Polyurethane sponge impregnated with N-9
• Effective for multiple acts of intercourse over 24 hours
• Higher failure rate in parous women

G. Fertility Awareness-Based Methods (FABMs)

• Calendar/rhythm method, basal body temperature (BBT), cervical mucus (Billings method), Standard Days Method, TwoDay Method, Symptothermal method
• Typical-use failure: 24% (Standard Days) to 2-5% for newer digital methods
• Require regular cycles and motivated users

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2. Intrauterine Contraception (IUCs)

A. Copper IUD (Cu T380A - Paragard)

• T-shaped polyethylene device with copper wire on stem and arms
• Approved for 10 years (up to 12 years off-label)
• Mechanism: copper ions are spermicidal; prevent fertilization; alter endometrial environment
• Pearl index (first year): 0.5-0.8 per 100 women
• Rate of ectopic: 0.1 per 100 woman-years (much lower than unprotected women)
• Noncontraceptive benefit: most effective emergency contraceptive if placed within 5 days

B. Levonorgestrel-Releasing IUDs (LNG-IUS)

• Mechanism: thickens cervical mucus, suppresses endometrium, partially inhibits ovulation
• Failure rate: <0.1-0.2 per 100 woman-years (comparable to sterilization)
• Reduces menstrual blood loss by up to 90%; licensed for menorrhagia
• Benefits: treats dysmenorrhea, endometriosis, adenomyosis; reduces endometrial cancer risk; used as progestin in HRT

Risks of IUDs

Newer IUD Devices

• VeraCept: Nitinol-frame low-dose copper (175 mm²); smaller insertion tube; less insertion pain; being studied in Phase II trials
• IUB (OCON): Copper pearls on nitinol wire, spherical shape - preliminary data showed high expulsion rates
• FibroPlant LNG-IUS: Frameless, fundus-anchored; 14-20 mcg/day LNG; approved for 5 years; 5-year pregnancy rate 0.4%

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3. Hormonal Contraception

A. Combined Oral Contraceptives (COCs)

• Estrogen: Ethinyl estradiol (EE) 10-50 mcg (most modern pills: 20-35 mcg); estradiol valerate (Natazia/Qlaira); estetrol (new)
• Progestin: Multiple generations

• Monophasic: same dose daily × 21 days + 7 placebo, or 24 active + 4 placebo (24/4 regimen)
• Multiphasic (biphasic, triphasic): varying doses through cycle
• Extended cycle (Seasonale): active pills 84 days then 7 days placebo (4 periods/year)
• Continuous cycle (Seasonique, Amethyst): 365-day active pills; amenorrhea

• Primary: inhibition of ovulation via suppression of LH surge (estrogen) and FSH (progestin)
• Secondary: cervical mucus thickening (progestin), endometrial atrophy, altered tubal motility

B. Risks of Combined OCs

• VTE rate: 2.2/10,000 woman-years (no OC) → 9-12/10,000 woman-years (OC users) → 20/10,000 (pregnancy)
• Factor V Leiden mutation: risk rises to 27.7/10,000 in OC users vs. 2.2/10,000 without the mutation
• Third-generation progestins (desogestrel, gestodene) and drospirenone have 50-80% higher VTE risk vs. levonorgestrel-containing OCs, though absolute difference is ~3 cases/10,000 woman-years
• Women with diagnosed Factor V Leiden, antithrombin III deficiency, protein C or S deficiency, antiphospholipid syndrome should NOT use estrogen-containing contraceptives

• Current low-dose OCs do NOT increase myocardial infarction risk in nonsmoking women under 35 without vascular risk factors
• Smoking + OC use in women >35: substantially elevated stroke and MI risk (absolute contraindication)

• Small but clinically significant rise in BP in some users (3-5% develop hypertension)
• Reversible on discontinuation; monitor BP within 3 months of starting

• Association remains controversial; OCs do not substantially increase risk
• Benefits outweigh risks for the majority of women

• Slight increase with prolonged use (>5 years); HPV is the main causal factor

• Rare: benign hepatic adenoma (risk related to duration and dose)
• Absolute contraindication in active liver disease

C. Benefits of Combined OCs

• Reduced menstrual blood loss and dysmenorrhea
• Reduced premenstrual dysphoric disorder (PMDD) - especially EE/drospirenone (FDA-approved for PMDD)

• Reduced ovarian cysts
• Reduced ectopic pregnancies

• Ovarian cancer: 50% risk reduction, persisting 20+ years after stopping
• Endometrial cancer: 50% reduction; persisting years after stopping

• Reduced benign breast disease (fibroadenoma, fibrocystic changes)
• Reduced acute PID
• Reduced endometriosis severity
• Reduced uterine fibroids
• Reduced rheumatoid arthritis
• Acne treatment (norgestimate/EE, norethindrone/EE, drospirenone/EE are FDA-approved)
• Treatment of hyperandrogenic anovulation (PCOS)
• Increased bone mineral density

D. Drug Interactions

• Rifampicin significantly reduces OC efficacy (induces CYP3A4)
• Phenytoin, carbamazepine, phenobarbital, topiramate: reduce OC plasma levels
• St. John's Wort: reduces OC efficacy
• Antiretrovirals: complex interactions (see below under recent updates)
• Anticoagulants: separate category - see recent updates

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4. Progestin-Only Contraceptives

A. Progestin-Only Pill (POP / Mini-pill)

• Contains norethindrone 0.35 mg (traditional) or desogestrel 75 mcg (Cerazette - more ovulation inhibition)
• Taken daily without interruption, at the same time each day (3-hour window for norethindrone; 12-hour for desogestrel)
• Mechanism: cervical mucus thickening (primary), partial ovulation inhibition
• Efficacy: comparable to COC (0.3% perfect use, 9% typical use)
• Advantages: safe in breastfeeding, hypertension, smokers, vascular disease, migraine with aura, women >35

B. DMPA (Depot Medroxyprogesterone Acetate) - Depo-Provera

• DMPA-IM: 150 mg IM every 12-13 weeks
• DMPA-SQ (Depo-subQ Provera 104): 104 mg subcutaneously every 12-13 weeks (FDA approved 2005, 30% lower dose but equivalent ovulation suppression); also sold as Sayana Press (Uniject device for self-administration)

• Menstrual changes: irregular bleeding initially → amenorrhea with continued use
• Weight gain: ~1.6 kg/year (both DMPA-IM and SQ formulations)
• Bone density: Reversible decrease in bone mineral density; bone recovers after discontinuation; NOT recommended in adolescents unless no alternatives
• Delayed return of fertility: average 10 months after last injection

• Reduced anemia, PID, ectopic pregnancy, endometrial cancer risk
• Benefits patients with sickle cell disease (reduces crises)
• No increased risk of cervical, ovarian, or breast cancer

C. Subdermal Implants (LARCs)

• Single 4 cm × 2 mm radio-opaque rod placed in subdermal tissue of inner upper arm
• Releases 60-70 mcg/day initially, declining to ~25-30 mcg/day by end of 3 years
• Duration: 3 years (studies support efficacy up to 5 years off-label)
• Efficacy: lowest of all reversible methods - 0.05% failure rate; comparable to sterilization
• Mechanism: inhibits ovulation + cervical mucus thickening
• Side effects: irregular, unpredictable bleeding (most common reason for removal)
• Advantages: immediate reversibility (fertility returns within weeks of removal), no daily user action, safe in estrogen-contraindicated patients
• Insertion/removal: requires trained provider; rare complications include deep insertion or nerve injury

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5. Alternative Routes for Hormonal Contraception

A. Contraceptive Patch (Xulane / Zafemy)

• Transdermal patch delivering EE 20 mcg/day + norelgestromin 150 mcg/day
• Applied weekly for 3 weeks, then one patch-free week (induces withdrawal bleed)
• Efficacy comparable to COC
• Higher EE systemic exposure than 35-mcg COC (area under curve 60% higher)
• Higher VTE risk than equivalent oral COC
• Less effective in women >90 kg (obese)

B. Vaginal Ring (NuvaRing / Annovera)

• NuvaRing: EE 15 mcg/day + etonogestrel 120 mcg/day; placed vaginally for 3 weeks, removed for 1 week; monthly change
• Annovera: Segesterone acetate 0.15 mg/day + EE 0.013 mg/day; single ring used for 13 cycles (1 year); inserted 21 days, removed 7 days per cycle
• Efficacy comparable to COC
• Lower systemic estrogen exposure than patch; VTE risk similar to low-dose COC
• Advantages: user-controlled, weekly/annual replacement, reduced cycle-related symptoms

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6. Injectable Combined Contraceptives

• Cyclofem / Lunelle (formerly): 25 mg DMPA + 5 mg estradiol cypionate monthly injection
• Produces regular withdrawal bleeding; removed from US market due to packaging issues
• Available in other countries under names Cyclofem/CycloProvera

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7. Emergency Contraception (EC)

A. Levonorgestrel (Plan B, Take Action, etc.)

• 1.5 mg single dose (or two 0.75 mg doses 12 hours apart) up to 120 hours after intercourse
• Most effective within 24 hours (pregnancy rate 1.1%)
• Mechanism: delays/inhibits ovulation; does NOT work after ovulation (not abortifacient)
• Available without prescription in many countries
• Efficacy reduced in women with BMI >26 (particularly >30): 4.41× higher pregnancy risk

B. Ulipristal Acetate (Ella)

• Progesterone receptor modulator; 30 mg single tablet
• Approved up to 120 hours after intercourse
• More effective than levonorgestrel overall, especially when ovulation is imminent
• 42% lower odds of pregnancy at 72 hours; 65% lower at 24 hours
• Better efficacy in women with elevated BMI than levonorgestrel
• Prescription-only
• Interaction: Reduces efficacy if hormonal contraception started immediately after (recommend waiting 5 days)

C. Copper IUD (Cu T380A)

• Most effective EC: inserted within 5 days of unprotected intercourse
• Failure rate <0.1%
• Advantage: provides ongoing contraception for 10+ years
• Mechanism: spermicidal copper ions; prevents fertilization and implantation

D. Mifepristone (low dose)

• 10 mg mifepristone equally effective to levonorgestrel for EC (not abortifacient at this dose)
• Not commercially available for EC in most countries

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8. Sterilization

A. Female Sterilization

• Interval sterilization: 6+ weeks after delivery (most common: laparoscopic)
• Postpartum sterilization: Within 24-48 hours via mini-laparotomy (Pomeroy technique)
• Postabortal: Immediately following first or second trimester abortion

• Laparoscopy (most common in US for interval sterilization)
• Mini-laparotomy (common worldwide, especially postpartum)
• Colpotomy (posterior vaginal approach, less common)

• Unipolar coagulation: 0.75%
• Bipolar coagulation: 2.48%
• Filshie/Hulka clip: 1.77-3.65%
• Falope ring: 1.77%
• Postpartum partial salpingectomy: 0.75%

B. Vasectomy

• Outpatient procedure under local anesthesia
• Vas deferens occluded or excised through small scrotal incision or "no-scalpel" technique
• No-scalpel technique: less hematoma, faster recovery
• Failure rate: 0.1-0.15% (10-year cumulative)
• NOT associated with prostate cancer (large prospective studies)
• Lower cost, morbidity, and failure rate than female sterilization
• Confirmation of azoospermia required (semen analysis at 8-16 weeks post-procedure)

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9. Medical Eligibility Criteria (MEC)

• Breastfeeding <6 weeks postpartum
• Hypertension (systolic ≥160 or diastolic ≥100)
• Venous thromboembolism (current or history)
• Known thrombogenic mutations (Factor V Leiden, prothrombin G20210A, antithrombin III/protein C/S deficiency)
• Ischemic heart disease, stroke
• Valvular heart disease with complications
• Migraine with aura (any age)
• Breast cancer (current)
• Cirrhosis (severe), hepatic adenoma, liver tumors
• Smoking + age >35 years
• Diabetes with vascular complications

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10. Special Populations

Adolescents

• LARCs are recommended as first-line by most professional bodies
• DMPA used cautiously due to bone density effects; not first-line in adolescents
• Counseling on dual protection (condom + contraception) for STD prevention

Postpartum

• Barrier methods immediately; COC: wait 6 weeks (risk of VTE increased postpartum)
• Progestin-only methods (POP, DMPA, implant, LNG-IUS): safe within 6 weeks, even during breastfeeding
• Copper IUD: immediately postplacenta or after 6 weeks

Perimenopause

• Fertility decreases but remains possible until 1 full year of amenorrhea
• LNG-IUS preferred (manages perimenopausal bleeding + contraception)
• COC acceptable in nonsmoking, healthy women <50 without vascular risk factors

Breast Cancer Survivors

• All hormonal contraceptives Category 4; use copper IUD or barrier methods

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Recent Updates (2024-2026)

2024 US-MEC (CDC) Updates

• New recommendations for chronic kidney disease (CKD): Expanded guidance on contraceptive choice for women with CKD stages 3-5
• Revised DMPA risk categories: Updated for specific medical conditions
• Expanded pain management for IUD placement: Lidocaine (topical or paracervical block) now explicitly recommended to reduce insertion pain
• Bleeding with implant: Expanded management section

WHO MEC 6th Edition (November 2025)

• New comprehensive guidance updated with latest evidence for over 60 medical conditions
• Incorporates GRADE methodology throughout

Safety of Contraception with Anticoagulants (Systematic Review, 2026 - PMID 41177211)

• Updated review confirms copper IUD and progestin-only methods are safer options for women requiring anticoagulation
• Estrogen-containing methods remain Category 3-4 in anticoagulated women

Contraception in Liver Disease (Systematic Review, 2026 - PMID 40633896)

• Updated safety evidence for various contraceptive types in women with liver disease

Contraception After Organ Transplant (Systematic Review, 2026 - PMID 40930243)

• LARCs (copper IUD, LNG-IUS, implant) most suitable for transplant recipients
• Drug interactions between immunosuppressants (cyclosporine, tacrolimus) and hormonal methods require careful management

Antiretrovirals and Hormonal Contraception (Systematic Review, 2024 - PMID 38762199)

• Complex two-way interactions: many ARVs (efavirenz, ritonavir-boosted regimens) reduce contraceptive hormonal levels
• Copper IUD or progestin implant preferred in women on ART; avoid rifampicin-based regimens without backup

Salpingectomy for Sterilization

• Bilateral salpingectomy at the time of other gynecologic surgery (hysterectomy, cesarean delivery, laparoscopy) increasingly recommended as it effectively prevents ovarian cancer by removing the fallopian tube (site of origin for most high-grade serous ovarian cancers)
• ACOG and SOGC guidelines now recommend offering opportunistic salpingectomy

Novel Contraceptive Methods Under Development

• Nestorone/EE patch (Twirla): Approved 2020; lower EE dose (30 mcg/day total vs higher with Xulane)
• Annovera (segesterone + EE ring): 1-year vaginal ring; approved 2018, gaining uptake
• Estetrol (E4)/drospirenone (Nextstellis): Approved 2021; E4 is a natural estrogen with potentially lower VTE risk vs EE; lower hepatic effect
• Male hormonal contraception: Under investigation - testosterone + progestin combinations suppress spermatogenesis but development has been hampered by side effects (mood, acne, reduced libido)
• Non-hormonal female contraceptive (Phexxi - lactic acid gel): FDA-approved 2020; maintains vaginal pH to immobilize sperm; typical use ~14% failure rate

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Summary: Choosing a Contraceptive Method

1. Efficacy requirements
2. Estrogen contraindications
3. Desire for future fertility (reversibility)
4. STD protection needs
5. Medical comorbidities (using MEC categories)
6. Patient preference, cost, access
7. Breastfeeding status

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