section name header

Basic Information ⬇

Author: Siri M. Holton, MD and Sneha Paranandi, MD

Definition

Contraception refers to the various modalities that a sexually active person uses to prevent pregnancy. These options can be either medical or nonmedical and used by all genders. There are numerous options, and this chapter should not be considered to be fully comprehensive of every option. The options are as follows:

  • •No contraception (unprotected intercourse); failure rate 85% both typical use and perfect use
  • •Abstinence: Failure rate 0%
  • •Withdrawal: Failure rate with perfect use, 4%; with typical use, 19%
  • •Rhythm method (natural family planning)
    1. 1.Failure rate with perfect use, 1% to 9%; with typical use, 20%
    2. 2.Lactation amenorrhea method (LAM): 0.5% to 2.0% failure rate in the first 6 mo after delivery when exclusively breastfeeding and amenorrheic
  • •Barriers
    1. 1.Male condom: Failure rate with perfect use, 3%; with typical use, 12%
    2. 2.Female condom: Failure rate with perfect use, 5.1%; with typical use, 12.4%; FDA labeling states 25% failure rate
    3. 3.Diaphragm and cervical cap: Failure rate 5% to 9% in nulliparous women, 20% in multiparous women
    4. 4.Spermicides (aerosols, foam, jellies, creams, tabs): Failure rate with perfect use, 3%; with typical use, 21%
    5. 5.Contraceptive gel (Phexxi): Failure rate with perfect use 7%, 14% with typical use
  • •Combined hormonal contraceptives
    1. 1.Oral pill (various estrogen/progestin combinations): Failure rate with perfect use, <1%; with typical use, 3%
    2. 2.Vaginal ring (NuvaRing): Failure rate Pearl index, 0.77
    3. 3.Contraceptive patch: Failure rate, 0.4% to 0.7%
  • •Progesterone only pill ("Mini pill")
    1. 1.Norethindrone: Failure rate with typical use, 1.1% to 13.2%. Requires precise timing of daily use for effectiveness
    2. 2.Drospirenone (Slynd): Failure rate of 4% based on one study
  • •Hormonal implants and injectables
    1. 1.Nexplanon (etonogestrel) single rod subdermal implant: Failure rate of 0.05%
    2. 2.Depo-Provera (medroxyprogesterone acetate): Failure rate, 0.3% in first year of use
  • •Emergency contraception (EC)
    1. 1.Combined estrogen-progesterone regimen: Decreases pregnancy rate by 74% or more with women treated within 72 h of coitus
    2. 2.Progestin-only method "Plan B": 2.2% pregnancy rate
    3. 3.Selective progesterone receptor modulator (ulipristal acetate): 1.4% pregnancy rate
    4. 4.Copper IUD: 0.1% pregnancy rate, most effective option
  • •Intrauterine device (IUD) or intrauterine system (IUS)
    1. 1.Copper T (380-A): Hormone Free. Failure rate with perfect use, 0.6%; with typical use, 0.8%
    2. 2.Levonorgestrel (LNG) IUD
      • •52 mg LNG IUD (Mirena and Liletta): 1-yr failure rate, 0.1% to 0.2%, 5-yr cumulative failure rate 0.5% to 1.1%
      • •19.5 LNG IUD (Kyleena): 5-yr cumulative failure rate, 0.6% to 1.6%
      • •13.5 LNG IUD (Skyla): First year Pearl index, 0.48
  • •Female sterilization (tubal ligation): Failure rate with perfect use, 0.2%; with typical use, 3%
  • •Male sterilization (vasectomy): Failure rate of 0.1% in first year
Synonyms

  • Birth control
  • Family planning
ICD-10CM CODES
Z30Encounter for contraceptive management
Z30.0Encounter for general counseling and advice on contraception
Z30.011Encounter for initial prescription of contraceptive pills
Z30.012Encounter for prescription of emergency contraception
Z30.013Encounter for initial prescription of injectable contraceptive
Z30.014Encounter for initial prescription of intrauterine contraceptive device
Z30.015Encounter for initial prescription of vaginal ring hormonal contraceptive
Z30.016Encounter for initial prescription of transdermal patch hormonal contraceptive device
Z30.017Encounter for initial prescription of implantable subdermal contraceptive
Z30.018Encounter for initial prescription of other contraceptives
Z30.09Encounter for other general counseling and advice on contraception
Z30.2Encounter for sterilization
Z30.4Encounter for surveillance of contraceptives
Z30.430Encounter for insertion of intrauterine contraceptive device

Diagnosis ⬆ ⬇

Workup

  • •To help facilitate method selection for the patient, we recommend obtaining the below information and consulting with Centers for Disease Control and Prevention Medical Eligibility Criteria (CDC MEC).
    1. 1.Thorough medical and surgical history
    2. 2.Obstetric history (was fertility desired with conception?)
    3. 3.Gynecologic history, including:
      1. a.History of previous sexually transmitted diseases
      2. b.Previous difficulties with contraception
      3. c.Frequency of intercourse
    4. 4.Family history
  • •Table E1 summarizes when to start using contraceptive methods. Categories of medical eligibility criteria for contraceptive use are described in Table E2. Conditions classified as category 3 and 4 for combined hormonal contraceptive use are summarized in Table E3.
  • •Examinations and tests needed before initiation of contraceptive methods described in Table 4.
  • •Recommendations for routine follow-up after contraceptive initiation summarized in Table E5.

TABLE E1 When to Start Using Specific Contraceptive Methods

Contraceptive MethodWhen to Start (if the provider is reasonably certain that the woman is not pregnant)Additional Contraception (i.e., backup) NeededExaminations or Tests Needed Before Initiationa
Copper-containing IUDAnytimeNot neededBimanual examination and cervical inspectionb
Levonorgestrel-releasing IUDAnytimeIf >7 days after menses started, use backup method or abstain for 7 days.Bimanual examination and cervical inspectionb
ImplantAnytimeIf >5 days after menses started, use backup method or abstain for 7 days.None
InjectableAnytimeIf >7 days after menses started, use backup method or abstain for 7 days.None
Combined hormonal contraceptiveAnytimeIf >5 days after menses started, use backup method or abstain for 7 days.Blood pressure measurement
Progestin-only pillAnytimeIf >5 days after menses started, use backup method or abstain for 2 days.None

BMI, Body mass index; CDC, Centers for Disease Control and Prevention; IUD, intrauterine device; STD, sexually transmitted disease; U.S. MEC, U.S. Medical Eligibility Criteria for Contraceptive Use.

a Weight (BMI) measurement is not needed to determine medical eligibility for any methods of contraception because all methods can be used (U.S. MEC 1) or generally can be used (U.S. MEC 2) among obese women. However, measuring weight and calculating BMI (weight [kg]/height [m]2) at baseline might be helpful for monitoring any changes and counseling women who might be concerned about weight change perceived to be associated with their contraceptive method.

b Most women do not require additional STD screening at the time of IUD insertion. If a woman with risk factors for STDs has not been screened for gonorrhea and chlamydia according to CDC’s STD Treatment Guidelines (http://www.cdc.gov/std/treatment), screening can be performed at the time of IUD insertion, and insertion should not be delayed. Women with current purulent cervicitis, chlamydial infection, or gonococcal infection should not undergo IUD insertion (U.S. MEC 4).

From Curtis KM et al: U.S. selected practice recommendations for contraceptive use, 2016, MMWR Recomm Rep 65(4):1-66, 2016.

TABLE E2 Categories of Medical Eligibility Criteria for Contraceptive Use

Category 1: A condition for which there is no restriction for the use of the contraceptive method
Category 2: A condition for which the advantages of using the method generally outweigh the theoretical or proven risks
Category 3: A condition for which the theoretical or proven risks usually outweigh the advantages of using the method
Category 4: A condition that represents an unacceptable health risk if the contraceptive method is used

From Kliegman, RM et al: Nelson textbook of pediatrics, ed 22, Philadelphia, 2025, Elsevier.

TABLE 4 Examinations and Tests Needed Before Initiation of Contraceptive Methods

CONTRACEPTIVE METHOD AND CLASS
Examination or TestCu-IUD and LNG-IUDImplantInjectableCHCPOPCondomDiaphragm or Cervical CapSpermicide
Examination
Blood pressureCCCAaCCCC
Weight (BMI) (weight [kg]/height [m]2)-b-b-b-b-bCCC
Clinical breast examinationCCCCCCCC
Bimanual examination and cervical inspectionACCCCCAcC
Laboratory Test
GlucoseCCCCCCCC
LipidsCCCCCCCC
Liver enzymesCCCCCCCC
HemoglobinCCCCCCCC
Thrombogenic mutationsCCCCCCCC
Cervical cytology (Papanicolaou test)CCCCCCCC
STD screening with laboratory tests-dCCCCCCC
HIV screening with laboratory testsCCCCCCCC

BMI, Body mass index; CDC, Centers for Disease Control and Prevention; CHC, combined hormonal contraceptive; Cu-IUD, copper-containing intrauterine device; HIV, human immunodeficiency virus; LNG-IUD, levonorgestrel-releasing intrauterine device; POP, progestin-only pill; STD, sexually transmitted disease; U.S. MEC, U.S. Medical Eligibility Criteria for Contraceptive Use.

a In instances in which blood pressure cannot be measured by a provider, blood pressure measured in other settings can be reported by the woman to her provider.

b Weight (BMI) measurement is not needed to determine medical eligibility for any methods of contraception because all methods can be used (U.S. MEC 1) or generally can be used (U.S. MEC 2) among obese women. However, measuring weight and calculating BMI at baseline might be helpful for monitoring any changes and counseling women who might be concerned about weight change perceived to be associated with their contraceptive method.

c A bimanual examination (not cervical inspection) is needed for diaphragm fitting.

d Most women do not require additional STD screening at the time of IUD insertion. If a woman with risk factors for STDs has not been screened for gonorrhea and chlamydia according to CDC’s STD Treatment Guidelines (https://www.cdc.gov/std/treatment), screening can be performed at the time of IUD insertion, and insertion should not be delayed. Women with current purulent cervicitis or chlamydial infection or gonococcal infection should not undergo IUD insertion (U.S. MEC 4).

From Curtis KM et al: U.S. selected practice recommendations for contraceptive use, 2016, MMWR Recomm Rep 65(4):1-66, 2016.

TABLE E5 Routine Follow-Up After Contraceptive Initiation

CONTRACEPTIVE METHOD
ActionCu-IUD or LNG-IUDImplantInjectableCHCPOP
General Follow-up
Advise women to return at any time to discuss side effects or other problems or if they want to change the method. Advise women using IUDs, implants, or injectables when the IUD or implant needs to be removed or when a reinjection is needed. No routine follow-up visit is required.XXXXX
Other Routine Visits
Assess the woman’s satisfaction with her current method and whether she has any concerns about method use.XXXXX
Assess any changes in health status, including medications, that would change the method’s appropriateness for safe and effective continued use based on U.S. MEC (i.e., Category 3 and 4 conditions and characteristics).XXXXX
Consider performing an examination to check for the presence of IUD strings.X----
Consider assessing weight changes and counseling women who are concerned about weight change perceived to be associated with their contraceptive method.XXXXX
Measure blood pressure.---X-

CHC, Combined hormonal contraceptives; Cu-IUD, copper-containing intrauterine device; IUD, intrauterine device; LNG-IUD, levonorgestrel-releasing intrauterine device; POP, progestin-only pills; U.S. MEC, U.S. Medical Eligibility Criteria for Contraceptive Use.

Laboratory Tests

  • •Pap smear should be done as routine and is not required before initiation of contraception
  • •Sexually transmitted infection screening, (e.g., chlamydia and gonorrhea) when appropriate
  • •Pregnancy test if suspected pregnancy

Treatment ⬆ ⬇

Nonpharmacologic Therapy

  • •Male condoms
    1. 1.95% latex (rubber), 5% polyurethane, or natural membrane (lamb’s intestine does not block transmission of sexually transmitted infections).
    2. 2.Proper use: Place on an erect penis and leave ½-inch empty space at the tip of the condom; use with non oil-based lubricants.
    3. 3.Effectiveness is increased when used with spermicides.
    4. 4.Main advantage: Condoms are the only method shown to reduce HIV transmission.
  • •Female condoms
    1. 1.Composed of polyurethane, with one end open and one end closed
    2. 2.Proper use: Place closed end over cervix, open end hanging out of vagina to cover penis and scrotum
    3. 3.Highly effective against HIV
  • •Spermicides
    1. 1.Types: Nonoxynol, octoxynol
    2. 2.Forms: Jellies, creams, foams, suppositories, tablets, soluble films
    3. 3.Proper use: Put in immediately before intercourse; may be used with other barrier methods
  • •Contraceptive gel
    1. 1.Phexxi: Nonhormonal and works by lowering pH of vagina
    2. 2.Proper use: Place in vagina up to 1 h before intercourse; may be used with other barrier methods
  • •Diaphragm and cervical cap
    1. 1.Must be fitted by practitioner, used with contraceptive gels, and refitted with weight gain or loss of 4.5 kg. Must also be refitted after pregnancy.
    2. 2.Diaphragm sizes: 50 to 105 mm; cervical cap sizes 26, 28, and 30 mm.
    3. 3.The correct fit allows the woman to remain ambulatory without feeling the device.
    4. 4.Proper use of diaphragm: Put in immediately before intercourse and keep in for 6 h after intercourse; must not remain in the vagina for longer than 24 h.
    5. 5.Proper use of cervical cap: Fit over the cervix exactly; must not remain in place for longer than 48 h.
  • •Lactation amenorrhea method (LAM)
    1. 1.Three criteria must be met for this method to be effective: Exclusive breastfeeding (∼ every 3 h), amenorrhea, and must be within 6 mo postpartum.
    2. 2.If patient begins supplementing with formula, pumping and feeding by bottle, has any vaginal bleeding, or once infant is 6 mo old, recommend alternative contraception.
    3. 3.Not a common practice in the U.S. but may be used with another method, such as the progesterone-only pill.
  • •Withdrawal
    1. 1.Withdrawal of the penis from the vagina before ejaculation
    2. 2.Depends on self-control, but there is a high typical use failure rate
  • •Rhythm method
    1. 1.Symptothermal type: Mucus method and ovulation pain combined with basal body temperature
    2. 2.Ovulation (Billings method): Takes into account mucus quality
    3. 3.Basal body temperature method: Uses biphasic temperature chart
    4. 4.Depends on awareness of physiology of male and female reproductive tracts
      1. a.Sperm viable in vagina for 2 to 7 days
      2. b.Ovum lifespan 24 h
  • •Sterilization
    1. 1.Male
      1. a.Vasectomy to interrupt vas deferens and block passage of sperm to seminal ejaculate
      2. b.Scalpel and nonscalpel techniques available
      3. c.More easily performed procedure than female sterilization and does not require general anesthesia
    2. 2.Female
      1. a.Leading method of birth control in U.S. in women older than 30 yr
      2. b.Interrupts fallopian tubes, blocking passage of ovum proximally and sperm distally through tube
      3. c.Methods: Bilateral salpingectomy, tubal ligation via removal of segment of fallopian tube, fulguration, application of clips (Filshie, Hulka) or band (Falope Ring)
      4. d.Essure: Tubal occlusion through hysteroscopic placement of microinserts into the fallopian tubes. Has been removed from the market
Acute General Rx

  • •Combination oral contraceptives
    1. 1.Standard administration: Taken daily for 21 to 24 days, placebo or pill-free interval of 4 to 7 days
    2. 2.Alternative regimen: Extended or continuous administration of active pills
    3. 3.Less than 50 mcg ethinyl estradiol in most common combination oral contraceptives; progestins most commonly used in combination pills are norethindrone, levonorgestrel, norgestrel, norethindrone acetate, ethynodiol diacetate, norgestimate, or desogestrel
    4. 4.Triphasic combination oral contraceptives (give varying doses of progestin and estrogens throughout cycle), monophasic oral contraceptives (offer same dose of progestin and estrogen throughout cycle), estrophasic pill (constant progesterone with variation of estrogen throughout the cycle)
    5. 5.If pill taken with antibiotics, efficacy is affected by inadequate GI absorption in most cases; only rifampin truly reduces pill’s effectiveness
    6. 6.Increased body weight decreases effectiveness
      1. a.Table E6 describes oral contraceptive formulations available in the U.S. Guidelines for use of combination estrogen-progestin contraceptives in women 35 yr of age and older are described in Table E7.
      2. b.Fig. E1 and Table E3 describes recommended actions after late or missed combined oral contraceptives.
      3. c.Recommended actions after vomiting or diarrhea while using combined oral contraceptives are described in Fig. E2.
      4. d.Medical disorders with contraindicated contraceptive options are described in Table E8.
      5. e.Table E9 summarizes absolute and relative contraindications to combined hormonal contraceptives.
  • •Mini pill
    1. 1.Progestin only; no placebo pills or pill-free intervals
    2. 2.May cause irregular bleeding because of the lack of estrogen effect on the lining of the uterus
    3. 3.Table E10 provides a summary and recommendations for progestin-only oral contraceptive use
  • •Hormonal implants and injectables
    1. 1.Nexplanon
      1. a.Single etonogestrel-secreting device that is inserted underneath the skin
      2. b.The most effective contraceptive available
      3. c.Approved by FDA in 2006 and effective over 3-yr period
    2. 2.Depo-Provera
      1. a.Medroxyprogesterone acetate given every 3 mo in IM injection form
      2. b.Major side effect: Irregular bleeding; can also affect bone density
      3. c.Fertility return possibly delayed up to 1 yr or longer after last injection
      4. d.Table E11 provides a summary and recommendations for depot medroxyprogesterone acetate (DMPA) use
  • •Emergency contraception (EC) (Table E12)
    1. 1.Done on emergency basis, if no contraceptive method used or failure of birth control (e.g., condom breakage or missed doses)
    2. 2.Methods:
      1. a.Hormonal methods:
        • (1)Levonorgestrel is available either as two 0.75-mg tablets taken 12 h apart (next choice) or as a 1.5-mg tablet taken once (Plan B, one step). It is indicated for emergency contraception to be used within 72 h after unexpected intercourse. It can be obtained OTC by women >15 yr of age and by prescription by younger patients. May be less effective in overweight and obese women.
        • (2)Ulipristal (Ella) is a progesterone-receptor agonist/antagonist available by prescription only. It is a 30-mg, single-dose tablet and can be taken up to 5 days after unexpected intercourse. More effective than Plan B. Requires a prescription.
        • (3)Combined estrogen-progesterone pills (Yuzpe regimen): In general, involves a first dose of 4 to 6 tablets (to achieve a dose of 100 to 120 mcg of ethinyl estradiol and 0.5 to 0.6 mg of levonorgestrel), followed by a second dose of 4 to 6 tablets 12 h later. Less effective option.
      2. b.Nonhormonal method: Copper IUD inserted within 5 days of coitus. Requires an office visit and insertion by trained provider.
  • •IUD
    1. 1.Device inserted into uterus to prevent sperm and ovum from uniting in fallopian tube, thickens cervical mucous
    2. 2.Types available in the U.S. (Table E13):
      1. a.ParaGard (Copper T/380-A): A polyethylene T wrapped with a fine copper wire effective for 10 yr
      2. b.Mirena LNG IUD: A T-shaped system with a chamber that contains levonorgestrel. Releases 20 mcg/day. Recently approved for 8 yr
      3. c.Liletta LNG IUD: Lower cost. Releases 18.6 mcg/day. Recently approved for 8 yr
      4. d.Kyleena LNG IUD: Releases 9.8 mcg/day. Approved for 5 yr
      5. e.Skyla LNG IUD: Slightly smaller device and lowest dose of levonorgestrel (may cause more irregular bleeding). Releases 8 mcg/day. Approved for 3 yr
  • •Vaginal ring
    1. 1.Types available in the U.S.:
      1. a.NuvaRing
        • (1)Provides daily dose of 120 mcg of etonogestrel and 15 mcg ethinyl estradiol
        • (2)Stays in vagina 3 wk and is removed the fourth for a contraceptive-free interval analogous to the placebo pills in combined oral contraceptive pills
        • (3)1 ring used per menstrual cycle
        • (4)Increased body weight decreases effectiveness/combination oral contraceptive, but may have higher risk of DVT
    2. 2.Recommended actions after delayed insertion or reinsertion with combined vaginal ring are described in Fig. E3
      1. a.Annovera
        • (1)Provides daily dose of 150 mcg segesterone acetate and 13 mcg ethinyl estradiol
        • (2)Stays in vagina 3 wk (21 days) and is removed the fourth for a contraceptive-free interval analogous to the placebo pills in combined oral contraceptive pills
        • (3)1 ring used for 13 menstrual cycles; on average, 1 yr per user
      2. b.Increased body weight decreases effectiveness/combination oral contraceptive, but may have higher risk of DVT
  • •Contraceptive patch
    1. 1.Each patch contains 6 mg norelgestromin and delivers an estimated continuous systemic dose of 150 mcg norelgestromin and 15 mcg of ethinyl estradiol daily
    2. 2.Worn 3 out of 4 wk
    3. 3.Increased body weight (specifically, weight >90 kg) associated with decreased effectiveness
    4. 4.Concern for increased risk of thromboembolic events
    5. 5.Ortho Evra brand discontinued; Xulane (generic) available in the U.S.
    6. 6.Recommended actions after delayed application or detachment with combined hormonal patch are described in Fig. E4

TABLE E6 Oral Contraceptive Formulations Available in the U.S.

NameEstrogenProgestinProgestin Dose (mg)
EE, 50 μg monophasicOvcon 50aEENorethindrone1.0
Ortho-Novum 1/50aMestranolNorethindrone1.0
Norinyl 1 + 50aMestranolNorethindrone1.0
EE, 35 μg monophasicFemcon FebEENorethindrone0.4
ModiconaEENorethindrone0.5
BreviconaEENorethindrone0.5
Ovcon 35aEENorethindrone0.4
Ortho-CyclenaEENorgestimate0.25
Demulen 1/35aEEEthynodiol diacetate1.0
Ortho-Novum 1/35aEENorethindrone1.0
Norinyl 1 + 35aEENorethindrone1.0
EE, 35 μg biphasicOrtho-Novum 10/11aEENorethindrone0.5/1.0
EE, 35 μg triphasicOrtho-Novum 7/7/7iEENorethindrone0.5/0.75/1.0
Ortho Tri-Cyclena,cEENorgestimate0.18/0.215/0.25
Tri-NorinylaEENorethindrone0.5/1.0/0.5
Estrostepa,cEE (20/30/35)Norethindrone acetate1.0
EE, 30 μg monophasicLoestrin 1.5/30aEENorethindrone acetate1.5
Ortho-CeptaEEDesogestrel0.15
DesogenaEEDesogestrel0.15
Lo-OvralaEENorgestrel0.3
NordetteaEELevonorgestrel0.15
LevlenaEELevonorgestrel0.15
YasminaEEDrospirenone3.0
EE, 30 μg triphasicTriphasilaEE (30/40/30)Levonorgestrel0.05/0.075/0.125
Tri-LevlenaEE (30/40/30)Levonorgestrel0.05/0.075/0.125
Extended cycle (84 active tablets)SeasonaleaEELevonorgestrel0.150
Extended cycle (84 estrogen/progestin tablets, 7 tablets 10 μg EE)SeasoniqueEELevonorgestrel0.150
EE, 25 μgCyclessaaEEDesogestrel0.10/0.125/0.150
Ortho Tri-Cyclen LoEENorgestimate0.18/0.215/0.25
EE, 20 μg monophasicLoestrin 1/20aEENorethindrone acetate1.0
LevliteaEELevonorgestrel0.1
AlesseaEELevonorgestrel0.1
21 Hormonally active tablets (2 inert tablets, 5 tablets 10 μg EE)MircetteaEEDesogestrel0.15
24 Hormonally active tabletsYazEEDrospirenone3.0
Loestrin 24FeEENorethindrone acetate1.0
Extended cycle (84 estrogen/progestin tablets, 7 tablets 10 μg EE)LoSeasoniqueEELevonorgestrel0.1
28 Hormonally active tabletsLybrelEELevonorgestrel0.09
Progestin-onlyMicronoraNorethindrone0.35

EE, Ethinyl estradiol.

a Generic versions available.

b Chewable tablets.

c Indicated for the treatment of acne in women desiring to use oral contraception.

From Melmed S et al: Williams textbook of endocrinology, ed 15, Philadelphia, 2025, Elsevier.

TABLE E7 World Health Organization (WHO) and American College of Obstetrics and Gynecology (ACOG) Guidelines Regarding Use of Combination Estrogen-Progestin Contraceptives (Oral Contraception, Ring, and Patch) in Women 35 Yr of Age and Older

VariableACOG GuidelinesWHO Guidelines
ObesityProgestin-only or intrauterine contraceptiona may be saferBenefit usually outweighs risksb
SmokerProgestin-only or intrauterine contraceptiona should be usedRisk unacceptable
HypertensionProgestin-only or intrauterine contraceptiona should be usedRisk unacceptable
DiabetesProgestin-only or intrauterine contraceptiona should be usedRisk unacceptable
MigraineProgestin-only or intrauterine contraceptiona should be usedRisk unacceptable
None of the above risk factorsHealthy, nonsmoking women doing well on a combination contraceptive can continue their method until age 50-55 yr after weighing the risks and benefits.For women ≥40 yr of age, the risk of cardiovascular disease increases with age and also may increase with use of combined hormonal contraceptives. In the absence of other adverse clinical conditions, combined hormonal contraceptives may be used until menopause.

a Generic versions available.

b Chewable tablets.

From Melmed S et al: Williams textbook of endocrinology, ed 15, Philadelphia, 2025, Elsevier.

TABLE E3 Conditions Classified as Category 3 and 4 for Combined Hormonal Contraceptive Use

Category 4 (a condition that represents an unacceptable health risk if the contraceptive method is used)
Complicated valvular heart disease
Current breast cancer
Severe decompensated cirrhosis
Deep venous thrombosis/pulmonary embolism (acute; history, not on anticoagulation or on established therapy for at least 3 mo with higher risk recurrence; major surgery with prolonged immobilization)
Complicated diabetes with nephropathy, retinopathy, neuropathy, or other vascular disease or duration of diabetes >20 yr
Migraine with aura
Poorly controlled hypertension (blood pressure >160/100 mm Hg) or hypertension with vascular disease
Ischemic heart disease (history of or current)
Hepatocellular adenoma
Malignant liver tumor
Peripartum cardiomyopathy (diagnosed <6 mo before or with moderately or severely impaired cardiac function)
Postpartum <21 days
History of cerebrovascular accident
Systemic lupus erythematosus with positive antiphospholipid antibodies
Thrombogenic pathogenic variants
Viral hepatitis (acute or flare)
Category 3 (a condition for which the theoretical or proven risks usually outweigh the advantages of using the method)
Past breast cancer with no evidence of disease for 5 yr
Breastfeeding and <1 mo postpartum
Deep venous thrombosis/pulmonary embolism (history of DVT/PE with lower risk recurrence)
Gallbladder disease (current, medically treated)
History of malabsorptive bariatric surgery
History of cholestasis and past combined oral contraceptive-related
Hypertension (adequately controlled or blood pressure <160/100 mm Hg)
Peripartum cardiomyopathy with mild impairment or >6 mo
Postpartum 21-42 days with other risk factors for venous thromboembolism
Drug interactions (ritonavir-boosted protease inhibitors; certain anticonvulsants; rifampin or rifabutin)
First-degree family member with a history of a blood clot/clotting disorder/thromboembolic event

From Curtis KM et al: U.S. medical eligibility criteria for contraceptive use, 2016, MMWR Recomm Rep 65(RR-3):1-104, 2016.

Figure E1 Recommended actions after late or missed combined oral contraceptives.

!!flowchart!!

(From Curtis KM et al: U.S. selected practice recommendations for contraceptive use, 2016, MMWR Recomm Rep 65[4]:1-66, 2016.)

Figure E2 Recommended Actions after Delayed Application or Detachment with Combined Hormonal Patch

!!flowchart!!

(From Curtis KM et al: U.S. selected practice recommendations for contraceptive use, 2016, MMWR Recomm Rep 65[4]:1-66, 2016.)

TABLE E8 Medical Disorders With Contraindicated Contraceptive Options

Medical DisorderContraindicated ContraceptionRationale/Complication
Systemic lupus erythematosus with antiphospholipid antibodies or thrombosisEstrogen-containing contraceptiona (ECC)Increased venous thrombosis (VTE) risk
Crohn diseaseAny oral contraceptionDecreased absorption
ECCbIncreased VTE risk
Severe dyslipidemiaECCIncreased VTE risk
Hypertension with risk factorscECCIncreased VTE, stroke, and myocardial infarction risk
Renal transplantECCIncreased VTE risk
Increased metabolism
ThrombophiliasECCIncreased VTE risk
Diabetes with risk factorsdECCIncreased VTE risk
Malabsorptive bariatric surgeryAny oral contraceptionDecreased absorption
Migraine with auraECCIncreased VTE
Epilepsy on enzyme-inducing antiepileptic drugs
  • Progesterone-only oral contraception
  • Progesterone implant
Increased metabolism

a Includes combined oral contraception, vaginal ring, and the transdermal patch.

b In cases of extensive or active disease, prior bowel resection, very active disease, corticosteroid use, or immobilization.

c Risk factors include poor control, tobacco use, age older than 35, other chronic medical condition leading to vascular degradation, end organ damage, use of antihypertensives.

d Risk factors include end organ damage, vascular disease, hyperlipidemia, poorly controlled disease.

Modified from Centers for Disease Control and Prevention: U S. medical eligibility criteria for contraceptive use, 2010, MMWR Recomm Rep 59 (RR-4):1-86, 2010.

TABLE E9 Absolute and Relative Contraindications to Combined Hormonal Contraceptives

Absolute Contraindications (Category 4)Relative Contraindications (Category 3)
Smoker age >35 yr and >15 cigarettes/daySmoker age >35 yr and <15 cigarettes/day
  • Hypertension:>160 systolic or >100 diastolic
  • Hypertension: Controlled or 140-159 systolic or 90-99 diastolic
  • Cardiac: Ischemic heart disease, complicated valvular heart disease, atrial fibrillation, peripartum cardiomyopathy <6 mo
  • Cardiac: Multiple risk factors for arterial cardiovascular disease, peripartum cardiomyopathy >6 mo with no/mild impaired function
  • Vascular: Vascular disease, venous thromboembolic (VTE) disease: Acute or high recurrence risk (e.g., thrombophilia), systemic lupus with antiphospholipid antibodies, complicated solid organ transplant
  • Vascular: VTE on treatment or past history and low recurrence risk, diabetes with end-organ damage (nephropathy, retinopathy, neuropathy)
  • Neurologic: Migraines with focal neurologic symptoms, stroke history
  • Neurologic: Migraine without neurologic symptoms and age >35 yr
  • Breast: Current cancer, postpartum <4 wk + breast-feeding (BF), postpartum <3 wk no BF
  • Breast: Cancer disease-free history >5 yr, postpartum 4-6 wk + BF + other VTE risks, postpartum 3-6 wk + no BF + other VTE risks
  • Gastrointestinal (GI): Liver failure, hepatocellular adenoma, malignant hepatoma, severe cirrhosis
  • GI: Acute viral hepatitis (oral contraceptive pill [OCP] only), symptomatic gallbladder disease, history of combined hormonal contraceptive (CHC)-related cholestasis, malabsorptive bariatric procedures (OCP only)
  • Immobilization (prolonged): Major surgery
  • Immobilization (prolonged): Multiple sclerosis
  • Drug interactions: Certain anticonvulsants, rifampicin, rifabutin, certain antiretroviral therapies

Modified from Centers for Disease Control and Prevention: Classifications for combined hormonal contraceptives. Available at https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/appendixd.html. Accessed July 26, 2021.

TABLE E10 Summary and Recommendations for Progestin-Only Oral Contraceptive Use

  1. 1.Progestin-only contraception is an option for women in whom an estrogen-containing contraceptive is either contraindicated or causes additional health. Ovulation is not consistently suppressed; the main contraceptive actions of progestin-only oral contraception are effects on cervical mucus and the endometrium.
  2. 2.The typical user failure rate with progestin-only oral contraception is estimated to be >8%. Women choosing progestin-only oral contraception are often subfertile as a result of breastfeeding or older reproductive age, so the failure rate in these populations may be lower than that in more fertile populations.
  3. 3.It is essential that the pill be taken at the same time each day to maximize contraceptive efficacy.
  4. 4.Menstrual irregularities are common in users of progestin-only oral contraception and represent the most frequent cause for contraceptive discontinuation.

From Melmed S et al: Williams textbook of endocrinology, ed 15, Philadelphia, 2025, Elsevier.

TABLE E11 Summary and Recommendations for Depot Medroxyprogesterone Acetate (DMPA) Use

  1. 1.DMPA is an excellent method for women who desire a long-term, reversible contraceptive.
  2. 2.DMPA primarily acts by inhibiting follicular maturation and ovulation through inhibition of gonadotropin secretion. It also affects cervical mucus.
  3. 3.DMPA is available in two formulations: 150 mg/1 ml for IM injection and 104 mg/0.65 ml for SC injection.
  4. 4.The ideal time to initiate DMPA is within 5 days of the onset of menses to ensure absence of pregnancy. The dose is repeated every 3 mo, with a 2-wk grace period.
  5. 5.Although DMPA does not permanently affect endocrine function, return of fertility may be delayed.
  6. 6.Thorough, candid counseling about side effects is important. Women who are well informed when they choose this method of contraception are much more likely to become highly satisfied users with high continuation rates.
  7. 7.Menstrual changes occur in all women using DMPA and are the most frequent cause for discontinuation.
  8. 8.Because DMPA induces amenorrhea, it can be used for managing a variety of gynecologic and nongynecologic disorders such as menorrhagia, dysmenorrhea, and iron-deficiency anemia.
  9. 9.There is no high-quality evidence that use of DMPA increases the risk of developing cancer, cardiovascular disease, or sexually transmitted infection. DMPA use significantly reduces the risk of developing endometrial cancer.
  10. 10.There is an association between current DMPA use and decreased bone mineral density; losses in bone mineral density are temporary, reverse after discontinuation of DMPA, and have not been linked to postmenopausal osteoporosis or fractures.

IM, Intramuscular; SC, subcutaneous.

From Melmed S et al: Williams textbook of endocrinology, ed 15, Philadelphia, 2025, Elsevier.

TABLE E12 Possible Indications for Emergency Contraception

SEXUAL ASSAULT
HIGH-RISK SEXUAL ACTIVITY
No contraception during intercourse
Intoxication (alcohol, drugs)
Coitus interruptus
CONTRACEPTION FAILURES
Condom breaking, spillage, leaks, intentional removal
Dislodgement and/or breaking of diaphragm, female condom, cervical cap
Expulsion of IUD
Spermicide failure to melt before coitus
DELAYED OR MISSED CONTRACEPTION
2 consecutive missed days of combined oral contraceptive
1 missed day of progestin-only oral contraceptives
>2-wk late injection of depot medroxyprogesterone
≥2 days late start of vaginal ring or patch cycle
Incorrect timing of spermicide/gel before sexual activity
OTHER
Exposure to teratogens in the absence of contraception

IUD, Intrauterine device.

From Kliegman, RM et al: Nelson textbook of pediatrics, ed 22, Philadelphia, 2025, Elsevier.

TABLE E13 Hormonal Intrauterine Devices

MirenaKyleenaLilettaSkyla
Duration of useFDA approved 8 yrFDA approved 5 yrFDA approved 8 yrFDA approved 3 yr
Daily hormone delivery over time20 mcg LNG/day → 9 mcg/day (52 mcg total)17.5 mcg LNG/day → 7.4 mcg/day (19.5 mcg total)19.5 mcg LNG/day → 9.8 mcg/day (52 mcg total)14 mcg LNG/day → 5 mcg/day (13.5 mcg total)
Device size32 mm × 32 mm28 mm × 30 mm32 mm × 32 mm28 mm × 30 mm
Diameter of insertion rod4.4 mm3.8 mm diameter4.4 mm diameter3.8 mm diameter

FDA, Food and Drug Administration; LNG, levonorgestrel.

From Kliegman, RM et al: Nelson textbook of pediatrics, ed 22, Philadelphia, 2025, Elsevier.

Figure E3 Recommended Actions after Delayed Insertion or Reinsertion with Combined Vaginal Ring

!!flowchart!!

(From Curtis KM et al: U.S. selected practice recommendations for contraceptive use, 2016, MMWR Recomm Rep 65[4]:1-66, 2016.)

Figure E4 Recommended Actions after Vomiting or Diarrhea While Using Combined Oral Contraceptives

!!flowchart!!

(From Curtis KM et al: U.S. selected practice recommendations for contraceptive use, 2016, MMWR Recomm Rep 65(4):1-66, 2016.)

Chronic Rx

  • •With all the previously mentioned types of birth control, annual follow-up visits are recommended, or as necessary, if problems arise.
  • •Pap smear should be completed per ASCCP guidelines.
  • •Sexually transmitted infection cultures should be performed as indicated.
  • •Patients with medical problems are followed up approximately every 6 mo when taking hormonal therapy.
Disposition

  • •Follow up yearly or more frequently according to patient’s side effects.
  • •Tailor birth control to patient according to different needs or side effects present at different times in life, notably bleeding profile, weight changes, and mood fluctuations. Effective counseling also requires an understanding of a woman’s preference and medical risks, benefits, side effects, and contraindications of each contraceptive method.
Referral

  • •If patient is medically complex, refer to a gynecologist for guidance on safe options.

Pearls & Considerations ⬆

Comments

  • •With hormonal contraception, if neurologic or cardiac symptoms arise, stop method immediately, evaluate, and refer to internist when appropriate.
  • •The effectiveness of long-acting reversible contraception (IUDs and implants) is superior to that of contraceptive pills, patch, or ring and is not altered in adolescents and young women.
  • •Management of women with bleeding irregularities while using contraception is described in Fig. E5.
  • •The FDA has approved Opill, a progestin-only oral contraceptive that contains norgestrel for sale over-the-counter without a prescription. Dosage is one 0.075-mg tablet taken at the same time each day. It is intended to provide an accessible option for prevention of pregnancy.

Figure E5 Management of women with bleeding irregularities while using contraception.

!!flowchart!!

(From Curtis KM et al: U.S. selected practice recommendations for contraceptive use, 2016, MMWR Recomm Rep 65[4]:1-66, 2016.)

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