Contraception

Descriptive text is not available for this imageBASICS

DESCRIPTION

  • Prevention of conception or pregnancy. Ideal contraceptive is 100% effective, has no side effects, is quickly reversed, and is readily accessible and easy to use by adolescents.
  • Management issues:
    • In practice, contraceptive efficacy is based on two core concepts:
      • Adherence or ability to “do” the method adequately
      • Continuation or length of time over which patient uses method
    • Long-acting reversible contraception (LARC) has failure rates of <1% and approximately 80% continuation rates contributing to superior effectiveness compared to other contraceptive methods.
    • The most effective methods should be offered as 1st-line contraceptive options for sexually active persons of all ages.
    • Body autonomy and the ability to control one’s reproductive decisions are at the heart of compassionate contraception. Clinician practice balances optimizing efficacy with the personal choice important to each patient.
  • Contraception concerns are applicable to all gender patients. As do their cisgender peers, reproductive-age transgender or gender-diverse male patients benefit from contraceptive information and choice.
  • Methods of contraception:
    • LARCs (see specific product information for detailed instructions on how to covert from other contraceptive methods; their respective onset of contraceptive effects; and drug interactions especially those that may reduce contraceptive effectiveness):
      • Etonogestrel implant
        • Single-rod subdermal implant containing 68 mg of progestin etonogestrel. Implant provides effective contraception for 3 years.
        • Benefits: easy to insert and remove device, insertion site easy to access (nondominant upper arm)
        • Can be placed in not yet sexually active patients considering future sexual activity or for heavy or painful menses
      • Levonorgestrel-releasing intrauterine devices (IUDs)
        • T-shaped polyethylene IUDs containing progestin hormones
        • Ovulation may be suppressed, but this is not the main mechanism of action (thickening of cervical mucus, inhibition of sperm survival, and alteration of the endometrium are the main mechanisms). Between 45% and 75% of persons ovulate on the 52-mg device, and almost all persons can ovulate on the lower dose levonorgestrel IUDs.
        • Ovulation on lower dose levonorgestrel IUDs may result in less amenorrhea and more regular menses, desired by some patients.
        • Mirena® and Liletta® contain 52 mg of levonorgestrel and a release rate of 20 mcg/24 h and are effective up to 8 years. These progestin IUDs also work as emergency contraceptives (ECs) if placed within 5 days of unprotected sex.
        • Kyleena® contains 19.5 mg of levonorgestrel and works up to 5 years.
        • Skyla® IUD is minimally smaller, 28 mm × 30 mm, contains 13.5 mg of levonorgestrel, releasing 5 to 14 mcg/24 h, with decline to 5 mcg/24 h after 3 years.
      • Copper T380 IUD
        • Contraceptive effect related to in utero oxidation with release of copper ions
        • U.S. Food and Drug Administration (FDA)-approved for use up to 10 years; may be effective for up to 12 years or even more
        • May also be placed as very effective EC and then retained for ongoing pregnancy prevention
    • Moderate-duration contraceptives:
      • Depot-medroxyprogesterone acetate (DMPA or Depo-Provera®)
        • IM injection administered every 3 months
        • Failure rates in real-world settings estimated as low as 6%, with 1-year continuation: 56% for users of all ages, likely lower for adolescents
        • Timing of administration may range from 10 to 15 weeks; effective up to 15 weeks; patients within the dosing window do not need additional pregnancy testing before re-administration.
        • Use for >2 year is not recommended due to the risk for decrease bone mineral density (BMD) with long-term use.
    • Short-acting estrogen-progestin contraceptives:
      • General issues:
        • Typically use both estrogen (to minimize breakthrough bleeding) and progestin (to block ovulation) in variety of delivery systems
        • Typical use failure rates at 9% but higher in adolescent populations. Continuation rates are 67%, likely lower in adolescents; 99.9% effective with perfect use, but in real-life use, difficulties with adherence and continuation significantly reduce effectiveness.
        • Some estrogen-progestin agents such as combined oral contraceptive pills (COCs) and vaginal rings may be used almost continuously for extended cycling. Such extended cycling may be useful for patients with dysmenorrhea, heavy periods, anemia, or times (life events) when delaying a period is desired.
      • COCs:
        • Monophasic COCs contain fixed doses of estrogens (ethinyl estradiol) and progestins. Phasic COCs vary doses of estrogens, progestins, or both; no practical difference between monophasic and phasic COCs
        • Benefits: reduce incidences of endometrial and ovarian cancers after as little as 3 months of use, protect against salpingitis (pelvic inflammatory disease [PID]) and subsequent ectopic pregnancies, and decrease incidences of benign breast disease and dysmenorrhea
        • Effective treatment for abnormal or heavy uterine bleeding (AUB), perimenstrual mood and physiologic symptoms, hygiene, and behavior changes around menses for some individuals with developmental delays, and sequelae of hyperandrogenism or polycystic ovary syndrome (AUB, hirsutism, acne)
      • Transdermal patch
        • Contains ethinyl estradiol and norelgestromin. Each patch left in place for 7 days, changed weekly the same day each week for 21 days (3 weeks), followed by 7 days (1 week) of a patch-free period (do not exceed 7 days of patch-free); convenient due to once-weekly change
        • Do not use in patients with body mass index (BMI) ≥30 kg/m2
        • Typically not recommended for extended cycling, as studies demonstrate 60% more circulating estrogen than with other estrogen-progestin methods, and this might increase vascular thrombotic event (VTE) risk.
      • Vaginal rings
        • NuvaRing® is a soft, flexible, polymer ring containing ethinyl estradiol and etonogestrel.
          • FDA-approved for vaginal insertion for 3 weeks and then removed for 1 week for menses
          • May be effective over a 4-week insertion and for extended cycling
          • Benefits: avoids 1st-pass liver effects and lower hormone doses
        • A single multiuse ring called Annovera® delivers 0.15-mg segesterone acetate and 0.013-mg ethinyl estradiol per day intravaginally and can be used over a year.
          • The ring contains two channels into which cores containing hormones are inserted, which are fixed to the device with silicone medical adhesives.
          • The ring may be placed intravaginally for 3 weeks and removed, cleaned, and stored in a refrigerated setting for up to 13 months.
          • Some providers recommend off-label continuous use, which may shorten its effectiveness to 12 months.
    • ECs: postcoital contraceptives, “morning-after” pills
      • General issues:
        • Safe but less effective (estimated 75%) than other hormonal/inserted contraceptives
        • Like other hormonal contraceptives, ECs block ovulation and do not act as an abortifacient.
        • Advance provision improves patient use but does not decrease overall pregnancy rates over time.
        • May be offered as a backup, additional contraceptive when using short- or moderate-acting contraceptives
      • Both the copper IUD and 52-mg progestin IUDs are the most effective ECs and effective up to 5 days postcoitus but require medical appointment and insertion. Once placed, they can be retained for ongoing effective contraception.
      • Ulipristal acetate (UPA) 30 mcg
        • Should be 1st-line option as efficacy seems less affected by timing and patient weight
        • Administered in a single oral dose up to 5 days post unprotected sex or contraceptive failure with equal effectiveness across time
        • More effective than progestin methods in overweight or obese persons
        • Not carried by all pharmacies
        • Often requires insurance preauthorization (unlike progestin-only methods), which may delay administration
      • Progesterone-only methods:
        • Most effective when used within 72 hours of intercourse or contraceptive failure; treatment less likely to be effective up to 5 days
        • Levonorgestrel administered one time at a dose of 1.5 mg PO available by prescription and over the counter in the United States
        • All gender patients should be educated about the use of ECs and may purchase this method over the counter as well.
      • Yuzpe method of emergency contraception with COCs
        • Consists of 100-mcg ethinyl estradiol + 0.5-mg levonorgestrel given with repeated second dose 12 hours later
        • This method has higher rates of nausea and vomiting.
        • Generally used as a matter of urgent timing, convenience, and expense if a patient has a COC pack of pills at home and prefers to use these for her emergency contraception method because other methods are more effective and have fewer side effects
    • Additional contraceptive methods:
      • General issues:
        • Well-known but with significantly lower efficacy
        • Include barrier methods to sperm entry (condoms, diaphragms)
      • External condoms (previously termed “male condoms”)
        • 88% effective with typical use; likely higher failure rates in adolescents
        • Correct condom use can prevent transmission of many sexually transmitted infections (STIs) including HIV, syphilis, Neisseria gonorrhoeae, Chlamydia trachomatis. Condoms offer some protection against herpes simplex virus (HSV) and human papillomavirus (HPV).
      • Internal condoms (previously termed “female condoms”): 79% effective
      • Diaphragm: 88% effective
      • Spermicidal agents
        • Include foam, film, vaginal inserts, as well as nonoxynol-9 as the active agent most widely used
        • Only 72% effective in preventing pregnancy with typical use; may reduce transmission of C. trachomatis and N. gonorrhoeae; when used with condoms, overall efficacy 93% with typical use
        • Irritant effect linked in some high-risk populations with increased risk of HIV transmission
        • Spermicides must be inserted with each intercourse, near the time of intercourse; some formulations require 10 to 15 minutes for activation. Most have an unpleasant taste.
      • Progestin-only pills (POPs) (“mini-pill”)
        • Much less effective than most other hormonal methods, as effectiveness is highly dependent on perfect use and timing
        • May offer some measure of benefit for persons who are immediately postpartum (up to 6 months) and breastfeeding on demand
        • Typically not a 1st-line method given break through ovulation and low efficacy
      • Abstinence
        • Sexual activity is a normal part of adolescent and adult human development.
        • Abstinence or refraining from vaginal-penile sexual intercourse is the most effective way to prevent unintended or unwanted pregnancy as well as transmission of STIs. Provider counseling and recommendations should promote a four-pronged approach to sexual decision making: personal maturity and readiness, thoughtful partner selection and communication, family planning and pregnancy prevention, as well as prevention of STIs.
  • Advising patients, including those in adolescence whose developmental milestones include reproductive maturity and developing intimate romantic and sexual relationships, to abstain from all forms of physical intimacy may be both unrealistic and counterproductive in the context of psychosocial development.
  • Providers should emphasize at every visit that only 100% use of condoms (or abstinence) protects against sexually transmitted diseases but is not the most effective form of birth control available.
  • All forms of birth control are not “equal”—long-acting reversible contraceptives are significantly more effective contraceptives than all other methods, even sterilization.
  • Long-acting reversible contraceptive implants are both highly desirable and well tolerated in all patients and should be offered as 1st-line contraceptives to all at risk for unintended pregnancy.
  • Include all gender patients in discussions about both condom use as well as contraceptive use.

GENERAL PREVENTION

  • Encourage consistent use of latex condoms.
  • Patients using oral contraceptive pills may be strongly encouraged to decrease or cease tobacco use, but tobacco use does not preclude estrogen-progestin methods in women <35 years of age.

PATHOPHYSIOLOGY

  • Combined estrogen-progestin hormonal therapy suppresses ovulation by directly decreasing release of hypothalamic gonadotropin-releasing hormone (GnRH) and pituitary follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
  • Progesterone thickens cervical mucus, thins the endometrium, and decreases tubal motility. Higher dose systemic progestins inhibit the hypothalamic-ovarian axis and halt ovulation.
  • Copper: Copper ions inhibit transtubal sperm migration and act in both an ovicidal and spermicidal way to prevent zygote formation.
  • Emergency contraception: Mechanisms of action include ovulation disruption, endometrial impairment to prevent implantation, and possibly sperm or ova transport alteration.
  • Spermicides (nonoxynol-9 and octoxynol-9) destroy sperm cell membranes. Most spermicidal preparations contain an inert base (foam, cream, or jelly) to support the spermicidal agent and provide a barrier to sperm entry.

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