Contraception PDF

c h a p t e r
134
Contraception
Anna Glasier
CHAPTER OUTLINE
CONTRACEPTIVE USE AND METHODS, 2297 HORMONAL CONTRACEPTION, 2304
Effectiveness and Efficacy, 2298 Combined Hormonal Contraceptives, 2304
Compliance and Adherence, 2300 Progestogen-Only Contraception, 2306
Discontinuation Rates, 2300 Initiation of Hormonal Contraception and
Contraindications,2301 Follow-up,2308
Health Benefits of Contraception, 2301 Emergency Contraception, 2308
NONHORMONAL METHODS, 2302 SUMMARY,2309
Natural Family Planning, 2302
Barrier Methods, 2302
Intrauterine Devices, 2303
KEY POINTS
C ontraception saves millions of lives.
The effectiveness of a contraceptive method depends on its mode of action and the need
for compliance: intrauterine and implantable are the most effective reversible method.
Discontinuation and switching of contraceptive methods is common and associated
with unintended pregnancy.
All contraceptive methods are extremely safe but assessment of medical eligibility is
essential for safe use, particularly by women with preexisting medical conditions.

Almost everyone in the developed world uses contracep- on health.1 Contraception has saved millions of lives.
tion at some time in his or her life. Most men will have It is estimated that increased contraceptive use has cut
used a condom, and the majority of women will have taken the number of maternal deaths in developing countries by
the oral contraceptive pill. All doctors should be aware about 40% since the mid-1990s. Preventing unintended
that most men and women have a sexual life and that, for pregnancy among women at risk of poor obstetric out-
women, it puts them at risk for pregnancy. Contracep- comethe very young, the very old, and the highly par-
tion is of particular relevance to endocrinologists, because ousprevents additional deaths. Prevention of induced
many endocrine diseases affect reproductive function and abortion is vital in reducing maternal mortality and mor-
vice versa. Endocrinologists, even if not infertility special- bidity in countries where abortion is illegal and/or unsafe.
ists, should have some knowledge of reproduction and the By increasing interpregnancy intervals, contraception
methods available to prevent it. also saves the lives of countless children and improves
their overall health. In the developed world, contracep-
tion has emancipated women, allowing them to choose
CONTRACEPTIVE USE AND METHODS whether and when to have children, and allowing them
In an article published in the Lancet in 2012, Cleland to play an equal role in society. The noncontraceptive
and colleagues wrote Contraception is unique among benefits of modern methods improve quality of life for
medical interventions in the breadth of its positive effect many individual women and contribute to improved
2297
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2298 PART 12 FEMALE REPRODUCTION
public health in, for example, cancer prevention. Disap- TABLE 134-1 Contraceptive Use by Age in the
pointingly, in many countries, including the United States United States, 2006 to 2010
and the United Kingdom, unintended pregnancy rates are
high despite good contraceptive prevalence. Female Male
Contraceptive prevalence has increased dramatically Age Sterilization Sterilization Pill Condom IUD
since the mid-1960s. In 2011, 63% of women aged 15 15-19 0 0 53.2 20.0 2.7
to 49 married or in a union were using contraception (all 20-24 2.6 0.9 47.1 25.5 5.6
methods) and 56% were using modern methods, result- 25-29 16.4 4.1 32.9 20.8 7.3
ing in a world total fertility rate (TFR) of 2.4 (TFR rep- 30-34 30.0 9.5 25.3 15.5 7.1
resents the number of children that would be born to a 35-39 37.3 16.6 17.0 12.1 6.5
40-44 50.6 20.0 9.8 1.9 3.2
woman if she were to live to the end of her childbearing
years and would bear children in accordance with cur- From Jones J, Mosher W, Daniels K. Current contraceptive use in
rent age-specific fertility rates).2 These impressive statis- the United States, 20062010, and changes in patterns of use since
1995. National Health Statistics Report No. 60. October 18, 2012.
tics, hide enormous variation between countries. In the
United Kingdom, 84% of married women use contracep-
tion, whereas in Chad only 3% are using any method.2 low risk of pregnancy (33%), had experienced problems
In the United States in 2009, the TFR was 1.9, which is with contraception in the past, or had concerns about side
well below the rate of 2.1 at which, without immigra- effects (32%).
tion, population growth stops.2 Demographic change has Currently available reversible methods of contracep-
an impact on contraceptive use. The average age of first tion fall into two broad categories: hormonal and non-
intercourse has fallen (in the United Kingdom, it has sta- hormonal. Certain issues are common to all methods.
bilized for both men and women at 16 years), and the
average age of first childbirth has risen to almost 30 in Effectiveness and Efficacy
many developed countries. Thus many women spend The effectiveness of a method of contraception is judged
years trying to avoid conception. by the failure rates associated with its use. Failure rates for
Patterns of contraceptive use vary across the world, currently available methods are shown in Table 134-2.7
and choice of contraceptive method depends on numer- The rates are estimated from U.S. studies and show the
ous factors. In the United States, the most common percentages of couples who experience an accidental preg-
methods used are the pill (28%) and female sterilization nancy during the first year of use for each method. The
(27%).3 Use of intrauterine devices (IUD) has increased effectiveness of a contraceptive depends on its mode of
since 1995 (from 0.8% in 1995 to 5.6% in 2006 through action and how easy it is to use. Pregnancy rates during
2010), probably as a result of the increased use of the the perfect use of a method reflect its efficacy. If a method
hormone-releasing IUD. On the other hand, fewer women prevents ovulation in every cycle in every woman, it should
report that their partners are using condoms as their cur- have an efficacy of 100%: if there is no egg, there can be
rent, most effective contraceptive method.3 In contrast, no conception. Only if a mistake is made or if the method
for example, sterilization is much less common and IUD is used inconsistently will a pregnancy occur. The con-
use much more common in France4 and Sweden,5 and traceptive implant called Implanon inhibits ovulation in
many more women in France use the pill compared with almost every woman for 3 years. There have been very few
women in either the United States or Sweden. Globally, pregnancies reported when Implanon has been correctly
the most common methods used are female sterilization inserted. Failures that have occurred are often associated
(38%), IUD (25%), and combined oral contraceptives with the user either being overweight or using concomitant
(COCs) (7.5%).2 medication (e.g., an anticonvulsant), which reduces the
Not only do patterns of contraceptive use vary among absorption of contraceptive steroids. The combined pill is
countries, but they also vary in the same country between similarly very effective at preventing ovulation but only if
different age groups and stages of life (Table 134-1). taken correctly. Pregnancy rates for perfect use are around
Contraceptive use also varies according to ethnicity and 1 in 1000; true failures are a result of incomplete inhibition
race, marital status and fertility intentions, education, and of ovulation, especially among women who metabolize the
income.3 Despite the high prevalence of the use of con- pill rapidly. Inhibition of ovulation, however, depends on
traception, unintended pregnancy is common and so is the pill being taken daily for 21 days followed by a pill-free
induced abortion. Although much of the decline in popula- interval (PFI) of only 7 days. If pills are missed or the PFI
tion growth has been achieved through contraceptive use, prolonged (imperfect use), ovulation can occur. Unless a
no country has achieved low fertility rates without access method is independent of compliance, such as Implanon,
to abortion. In the United States, the abortion rate in 2008 use is rarely perfect, and the effectiveness of a method (as
was 19.6/1000 women of reproductive age (compared opposed to efficacy) is reflected by pregnancy rates dur-
with around 15 in England and only 5 in the Netherlands), ing typical use (see Table 134-2). Pregnancy rates are still
despite apparently widespread use of contraception. In an often described by the Pearl Index, which is the number of
impressive national survey of 10,683 U.S. women having unintended pregnancies divided by the number of women
an abortion in 2000 and 2001, 54% claimed to be using years of exposure to the risk of pregnancy while using the
contraception in the month of conception: 28% condoms method. In trials, however, failure rates of most methods
and 14% the pill.6 Women who were not using a method decrease with time, because women most prone to failure
at the time of conception (46%) perceived themselves at become pregnant early after starting use of a method. With
134 CONTRACEPTION 2299
TABLE 134-2 Effectiveness and Failure Rates TABLE 134-3 WHO Medical Eligibility Criteria
of Contraception* Category 3 and 4 Conditions for COC, Combined
Contraceptive Patch, and Vaginal Ring
WOMEN EXPERIENCING AN UN-
INTENDED PREGNANCY WITHIN Category 3 Conditions
THE FIRST YR OF USE (%) Women
Continuing Breastfeeding, 6 weeks to 6 months postpartum
Typical Perfect Use at 1 Yrc Before 3 weeks after childbirth
Method Usea Useb (%) Smoking <15 cigarettes/day and older than age 35
Adequate controlled hypertension
No methodd 85 85 Blood pressure >140/90
Spermicidese 29 15 42 Severe hyperlipidemia
Withdrawal 27 4 43 Nonfocal migraine and older than age 35
Periodic abstinence 25 51 Past breast cancer; 5 yrs without recurrence
Ovulation method 3 Current or medically treated gallbladder disease
Sponge Past COC-related cholestasis
Parous women 32 20 46 Concomitant use of antiretroviral therapy with ritonavir-boosted
Nulliparous women 16 9 57 protease inhibitor
Diaphragmf 16 6 57 Concomitant use of some anticonvulsants. Concomitant use of
Condomg lamotrigine, rifampicin, or rifabutin
Female (Reality) 21 5 49
Male 15 2 53 Category 3/4 Conditions
Combined pill and minipill 8 0.3 68
Evra patch 8 0.3 68 Multiple risk factors for cardiovascular disease
NuvaRing 8 0.3 68 Diabetes with retinopathy, nephropathy, neuropathy, other
Depo-Provera 3 0.3 56 vascular disease or disease of more than 20 yrs duration. Acute
IUD viral hepatitis or flare of chronic disease
ParaGard (copper T) 0.8 0.6 78 Category 4 Conditions
Mirena (LNG-IUS) 0.1 0.1 81
Implanon 0.05 0.05 84 Breastfeeding <6 weeks postpartum
Female sterilization 0.5 0.5 100 Smoking >15 cigarettes/day and older than age 35. Blood pres-
Male sterilization 0.15 0.10 100 sure >160/100. Hypertension with vascular disease
Emergency Contraceptive Pills: Treatment initiated within 72 History of or current DVT/PE, even if established on anticoagu-
hours after unprotected intercourse reduces the risk of pregnancy lant therapy
by at least 75%. Major surgery with prolonged immobilization
Lactational Amenorrhea Method: LAM is a highly effective, Known thrombogenic mutations
temporary method of contraception.h History of or current ischemic heart disease
History of stroke
*Percentage of women experiencing an unintended pregnancy during Complicated valvular heart disease
the first year of typical use and first year of perfect use of contracep- Systemic lupus erythematosus (SLE) with positive antiphospho-
tion and the percentage continuing use at the end of the first year, lipid (aPL)
United States. Antibodies
aAmong typical couples who initiate use of a method (not necessar-
Migraine with aura (any age)
ily for the first time), the percentage who experience an accidental Current breast cancer
pregnancy during the first year if they do not stop use for any other Severe cirrhosis, hepatocellular adenoma, and malignant liver
reason. Estimates of the probability of pregnancy during the first tumors
year of typical use for spermicides, withdrawal, periodic abstinence,
the diaphragm, the male condom, the pill, and Depo-Provera are COC, Combined oral contraceptives; DVT, deep vein thrombosis; PE,
taken from the 1995 National Survey of Family Growth, corrected pulmonary embolism.
for underreporting of abortion. From the World Health Organization. Improving access to quality care
bAmong couples who initiate use of a method (not necessarily for the in family planning: medical eligibility criteria for contraceptive use.
first time) and who use it perfectly (both consistently and correctly), Geneva (Switzerland): WHO; 2008.
the percentage who experience an accidental pregnancy during the
first year if they do not stop use for any other reason. See the text
for the derivation of the estimate for each method. time, a cohort of couples still using a method increasingly
cAmong couples attempting to avoid pregnancy, the percentage who comprises couples unlikely to become pregnant (because
continue to use a method for 1 year. they are good at using the method, have infrequent sex,
dThe percentages becoming pregnant in columns 2 and 3 are based on
data from populations where contraception is not used and from

or are subfertile). So the longer the cohort is followed, the
women who cease using contraception so as to become pregnant. lower the pregnancy rate is likely to be. Furthermore, fail-
Among such populations, about 89% become pregnant within ure rates in most clinical trials are often underestimated
1 year. This estimate was lowered slightly (to 85%) to represent because all of the months of use of the method are taken
the percentage who would become pregnant within 1 year among into account when calculating failure rates, regardless of
women now relying on reversible methods of contraception if they
abandoned contraception altogether. whether or not intercourse has occurred during that cycle.
eFoams, creams, gels, vaginal suppositories, and vaginal film. For long-acting methods of contraception, such as IUDs
fWith spermicidal cream or jelly. and implants, the pregnancy rate with time (cumulative
gWithout spermicides.
hHowever, to maintain effective protection against pregnancy, another
pregnancy rate) is much more informative.
method of contraception must be used as soon as menstruation
There have been concerns throughout the years that
resumes, the frequency or duration of breastfeeds is reduced, bottle- the efficacy of hormonal contraceptives may be influ-
feeds are introduced, or the baby reaches 6 months of age. enced adversely by weight. In a retrospective cohort
From Trussell J: Contraceptive failure. In: Hatcher RA, Trussell J, Nel- analysis of 755 randomly selected women in Wash-
son A, etal. Contraceptive technology. 20th ed., New York (NY): ington State, women weighing more than 70.5 kg
Ardent Media; 2011, p. 50.
experienced a significantly increased risk of oral con- of intercourse (condoms, diaphragms, withdrawal, and
traceptive failure (RR1.6, 95% CI 1.1,2.4) compared natural family planning). The overestimate of the effec-
with women of lower weight. The risk of failure was tiveness of contraceptive methods tested in clinical trials
inversely related to the dose of estrogen in the pill. 8 A is compounded by the reality that trial participants tend
recent Cochrane review of the effectiveness of all hor- to use the methods more consistently and correctly than
monal contraceptives for overweight or obese women most users do in daily life when not participating in a trial.
concluded that the evidence did not generally show an
association of BMI with the effectiveness of hormonal Discontinuation Rates
contraceptives. 9 However the authors also stated that In an international review of discontinuation rates after
the evidence was limited and was of low quality. It 1 year of using hormonal contraception, rates varied from
does not help that many phase III trials of new contra- 19% (for Norplant) to 62% (the combined pill).13 Discon-
ceptive methods exclude obese women partly because tinuation rates are higher for methods that do not require
of concerns about possible increased failure rates, but removal by a health professional, as is clear from the data
also because of a fear of serious adverse events such in Table 134-2, which show the percentage of couples in
as VTE, which are more common in overweight women. the United States still using each method at the end of 1
Presently no authoritative guidelines recommend year. In the United States, 40% of married women and
changing contraceptive prescribing for overweight 61% of unmarried women using a reversible method of
women (e.g., doubling the dose), however, in the drug contraception change it during the course of 2 years.14
label one pharmaceutical company warns that for Someespecially those with more years of education
their levonorgestel emergency contraceptive (Norlevo change from a less effective method to a more effective
HRA-Pharma, Paris, France, which is not marketed method. But many change to less effective methods; in a
in the United States) in clinical trials,10 contracep- study of women in the United Kingdom who had Impla-
tive efficacy was reduced in women weighing 75 kg or non contraceptive implants removed, almost half changed
more and levonorgestrel was not effective in women to a less effective method.15 Adolescents are particularly
who weighed more than 80 kg. likely to discontinue their contraceptive methods. In
The effect of weight on contraceptive effectiveness is one study, 50% discontinued during the first 3 months
also seen with female sterilization. In a multicenter study of use. Reasons for discontinuation are often associated
of female sterilization using tubal rings, case control with perceived risks and real or perceived side effects.16
analysis showed three risk factors for technical failure: In the international review,13 the most common reason
obesity, previous use of an IUD, and previous abdominal for discontinuation was for bleeding dysfunction. In a
surgery.11 Swedish study following up 656 women for 10 years,17
between 28% and 35% of women (depending on age)
Compliance and Adherence stopped taking the oral contraceptive pill because of the
Many couples using contraception do so inconsistently fear of harmful side effects. Another 13% to 17% of them
and/or incorrectly. Inconsistent or incorrect use accounts stopped because of menstrual dysfunction, 15% to 20%
for the difference between perfect and typical-use fail- because of weight increase, and 14% to 21% because of
ure rates. Some methods are easier to use than others. side effects associated with mood change.17 Continuation
Because IUDs, the levonorgestrel intrauterine system rates are often regarded as a surrogate for acceptability
(IUS), and contraceptive implants are inserted and of a method, but this is simplistic. A multitude of factors
removed by a health professional and are entirely inde- determine acceptability, and continuation of a method
pendent of compliance for efficacy, their failure rates are may only reflect that method being the best of a bad lot.
accordingly very low (see Table 134-2). It is arguably the
provider who falls short of perfection and not the user for The Most Effective Reversible Methods of Contraception
these methods; typical and perfect use rates are almost It is clear from Table 134-2 that the most effective
the same. Imperfect use is rareundetected uterine perfo- reversible methods of contraception are intrauterine
ration during IUD insertion, for example. Depo-Provera and implantable contraceptives (copper IUDs, hormone-
lasts 12 weeks but demands the motivation and organi- releasing IUDs [Mirena], and implants including Impla-
zational skills required to attend to repeat doses. Compli- non, Norplant, and Jadelle). Their failure rates shown in
ance with oral contraception is not easy. In a U.S. study Table 134-2 are estimated from survey data. It is very dif-
using electronic pill dispensers, the average number of ficult to perform a randomized controlled trial compar-
pills missed each cycle was more than four.12 Adherence ing two different types of contraceptive method (because
recorded by the electronic monitoring device indicated most people are pretty clear about which one they prefer
much poorer adherence than that recorded by patient dia- to use), and it is unethical to perform one comparing a
ries, so women themselves are not aware of the number of method to placebo. However, in recent years there has
pills that they miss. Daily text-message reminders did not been a great deal of interest in looking at rates of repeat
improve oral contraceptive pill adherence. induced abortion as an index of contraceptive effective-
Together, poor compliance with, and discontinuation ness among women choosing to use different contracep-
of, oral contraceptives account for an estimated 700,000 tives. A number of studies in a range of countries have
unintended pregnancies in the United States each year. demonstrated that the rate of repeat abortion is signif-
Typical-use failure rates are even higher with methods icantly reduced among women who choose an IUD or
of contraception that rely on correct use with every act implant after induced abortion when compared with oral,
transdermal, or vaginal hormonal contraceptives or bar- updated document is available on the web, and a system
rier methods.18-21 In the one study, Depo Provera was is in place to incorporate new data into the guidelines
no better than the pill or condoms at preventing repeat as they become available. The CDC in 2010 created
abortion.22 A series of studies undertaken in St. Louis, the U.S. Medical Eligibility Criteria for Contraceptive
Mo., USA (CHOICE Project) has demonstrated a fall in Use.25 The majority of the U.S. guidance does not differ
abortion and teenage pregnancy rates in a setting where from that of WHO and covers more than 60 charac-
IUDs and implants are being enthusiastically promoted. teristics or medical conditions. However, some WHO
In a comparison of abortion and teenage pregnancy rates recommendations were modified for use in the United
in the region in which the intervention had been under- States, including recommendations about contraceptive
taken, with one nearby with no such intervention, there use for women with venous thromboembolism, valvu-
was a significant reduction in the percentage of abortions lar heart disease, ovarian cancer, and uterine fibroids
that were repeat abortions in the St. Louis region com- and for postpartum and breastfeeding women. Recom-
pared with Kansas City and nonmetropolitan Missouri mendations were added to the U.S. guidance for women
(P < .001).23 Abortion rates in the CHOICE cohort were with rheumatoid arthritis, history of bariatric surgery,
less than half the regional and national rates (P < .001). The peripartum cardiomyopathy, endometrial hyperplasia,
rate of teenage births within the CHOICE cohort was 6.3 inflammatory bowel disease, and solid organ transplan-
per 1000, compared with the U.S. rate of 34.3 per 1000. tation. Combined hormonal contraception, category
3 and 4 conditions for the IUD/IUS, and progestogen-
Contraindications only contraception according to the 2010 edition of the
Pharmaceutical companies list endless cautions, warn- USMEC are summarized in Tables 134-3, 134-4, and
ings, and contraindications in their contraceptive product 134-5, respectively.
labels. Most contraceptive users are young and medically
fit and can use any available method safely. A few medi- Health Benefits of Contraception
cal conditions, however, are associated with theoretical Most couples use contraception for more than 30 years.
increased risks if certain contraceptives are used, either Additional health benefits beyond pregnancy prevention
because the method adversely affects the condition (the
combined pill, for example, may increase the risk for a
woman with diabetes to develop cardiovascular compli- TABLE 134-4 WHO Medical Eligibility Criteria
cations) or because the condition or its treatment affects Category 3 and 4 Conditions for the Copper IUD
the contraceptive (some anticonvulsants interfere with and LNG-IUS
the efficacy of the combined pill). Because most trials of
new contraceptive methods deliberately exclude subjects Category 3 Conditions for Both Copper IUD and LNG-IUS*
with serious medical conditions, there is little direct evi- Within 48 hours and 4 weeks of childbirth
dence on which to base sound prescribing advice. In an Benign gestational trophoblastic disease with falling hCG
attempt to produce a set of international norms for pro- Initiation in the presence of ovarian cancer
viding contraception to women and men with a range of Initiation in someone with an increased risk of sexually transmit-
ted infections
medical conditions that may contraindicate one or more Initiation in someone with SLE and aPL antibodies
contraceptive methods, the World Health Organization Initiation in someone with AIDS
(WHO) has developed a system to advise on medical Continuation of use in the presence of pelvic tuberculosis
eligibility criteria (MEC) for contraceptive use.24 Using Category 4 Conditions for Both IUD and LNG-IUS
evidence-based systematic reviews, the document classi-
Puerperal sepsis
fies conditions into one of four categories (Box 134-1). Immediately postseptic abortion
For some conditions, a distinction is made between Anatomical abnormalities or fibroids that distort the uterine
starting the method and continuing its use. For example, cavity
a woman who is known to have ischemic heart disease Initiation of an IUD before evaluation of unexplained vaginal
(IHD) could start to use an LNG-IUS; it is a category-2 bleeding
Gestational trophoblastic disease with rising hCG levels
condition. However, if a woman already using an LNG- Initiation in the presence of cervical cancer
IUS develops IHD, then continued use of the contracep- Initiation in the presence of endometrial cancer
tive method is a category-3 condition. The regularly Initiation with current PID, purulent cervicitis, chlamydia, or
gonorrhea
Initiation with known pelvic tuberculosis
Box 134-1 Categories of Medical Eligibility Criteria AIDS, Acquired immunodeficiency syndrome; aPL, antiphospholipid;
for Contraceptive Use hCG, human chorionic gonadotropin; IUD, intrauterine device;
PID, pelvic inflammatory disease; SLE, systemic lupus erythematosus.
1. A condition for which there is no restriction for the use of the *There are a few conditions that are category 3 for the LNG-IUS only
contraceptive method. because of its hormone content: Acute DVT/PE; continuation of
2. A condition for which the advantages of using the method gen- LNG-IUS in a woman who develops ischemic heart disease, migraine
erally outweigh the theoretical or proven risks. with aura, ovarian cancer, AIDS or pelvic TB; SLE with APL
3. A condition for which the theoretical or proven risks usually antibodies; severe cirrhosis, hepatocellular adenoma, and malignant
outweigh the advantages of using the method. hepatoma.
4. A condition that represents an unacceptable health risk if the From the World Health Organization. Improving access to quality care
contraceptive method is used. in family planning: medical eligibility criteria for contraceptive use.
Geneva (Switzerland): WHO; 2008.
TABLE 134-5 Medical Eligibility Criteria

it can be used to deliver the progestogen component of
Category 3 and 4 Conditions for Progestogen-Only
HRT. Barrier methods, particularly condoms, protect
Contraception
against sexually transmitted infections (STIs), including
cervical cancer. When contraceptives are used for their
Condition POP DMPA Implants beneficial side effects or in the management of a medical
problem such as menorrhagia, the risk/benefit ratio (and
Breastfeeding <6 weeks 3 3 3
Multiple risk factors for cardio- 3
medical eligibility criteria) changes.
vascular disease
Blood pressure >160/100 3 NONHORMONAL METHODS
Hypertension with vascular 3
disease Natural Family Planning
Current DVT/PE 3 3 3
Current or history of IHD 3 Although few couples in the developed world use so-
initiation called natural methods of family planning (NFP), in some
Current or history of IHD 3 3 3 parts of the world these methods are common. All involve
continuation avoidance of intercourse during the fertile period of the
Stroke; initiation of method 3
Stroke; continuation of method 3 3 3
cycle (periodic abstinence). Methods differ regarding
Migraine with aura; continuation 3 3 3 the way in which the fertile period is recognized. The sim-
of method plest is the calendar or rhythm method in which the fertile
Unexplained unevaluated vaginal 3 3 period is calculated according to the length of the normal
bleeding menstrual cycle. The mucus or Billings method relies on
SLE with aLP antibodies 3 3 3
Initiation SLE with severe throm- 3 identifying changes in the quantity and quality of cervical
bocytopenia and vaginal mucus. As circulating estrogens increase with
Current breast cancer 4 4 4 follicle growth, the mucus becomes clear and stretchy,
Past breast cancer 3 3 3 allowing the passage of sperm. With ovulation and in the
High risk of or active HIV or
AIDS
presence of progesterone, mucus becomes opaque, sticky,
Complicated diabetes 3 and much less stretchy, or it disappears altogether, which
Severe cirrhosis 3 3 3 inhibits sperm transport. Intercourse must stop when fer-
Hepatocellular adenoma or malig- 3 3 3 tile-type mucus is identified, and it can start again when
nant hepatoma infertile-type mucus is recognized. Progesterone secretion
AIDS, Acquired immunodeficiency syndrome; aLP antiphospholipid; is also associated with a rise in basal body temperature
DMPA, Depo-Provera; DVT, deep-vein thrombosis; HIV, human (BBT) of about 0.5 C. The BBT method is thus able to
immunodeficiency virus; IHD, ischemic heart disease; PE, pulmo- identify the end of the fertile period. Other signs and
nary embolism; POP, progesterone-only pill; SLE, systemic lupus
erythematosus. symptoms such as ovulation pain, position of cervix, and
From the World Health Organization. Improving access to quality care degree of dilatation of the cervical os can be used to help
in family planning: medical eligibility criteria for contraceptive use. define the fertile period. (For a detailed review of NFP
Geneva (Switzerland): WHO; 2008. methods, see reference 30.)
Many couples find periodic abstinence difficult. Fail-
ure rates of natural methods are high (see Table 134-2),
offer significant advantages and influence acceptability. mostly because of rule-breaking. Perfect use of the mucus
In a nationwide sample of 943 U.S. women, satisfaction method is associated with a failure rate of only 3.4%.
with oral contraception was most likely among women There is no evidence that accidental pregnancies occur-
who were aware of the noncontraceptive benefits of the ring among NFP users, which are conceived with ageing
pill and who were experiencing few side effects.26 In a gametes, are associated with a higher risk of congenital
study of young women starting the combined pill, those malformations.
who benefitted from a reduction in preexisting trouble- The lactational amenorrhoea method (LAM) is used
some dysmenorrhea were eight times more likely to con- during breastfeeding. Amenorrhoea during breastfeed-
tinue using the pill than women who did not experience ing provides more than 98% protection from pregnancy
a similar benefit.27 COCs are commonly used by women during the first 6 months postpartum if the mother is
with hypothalamic amenorrhea for hormonal supplemen- fully or nearly fully breastfeeding and has not yet expe-
tation and by women with polycystic ovarian syndrome rienced vaginal bleeding after the 56th day postpartum.
(PCOS) for inducing cyclic endometrial shedding and Guidelines for LAM advise that as long as the baby is
minimizing acne in this population.28 less than 6 months old, a woman can rely on breastfeed-
Existing combined hormonal methods improve men- ing alone until she menstruates or until she starts to give
strual bleeding patterns and alleviate dysmenorrhea, acne, her baby significant amounts of food other than breast
and sometimes premenstrual syndrome.28 The combined milk.31 Prospective studies of LAM confirm the methods
pill significantly reduces the risk of ovarian29 and endo- effectiveness.32
metrial cancer.28 Increasing numbers of women choose
the levonorgestrel-releasing intrauterine system (LNG- Barrier Methods
IUS Mirena) and DMPA because of the amenorrhea they The male condom is inexpensive, is widely available with-
confer. Perimenopausal women appreciate the option of out involving health professionals, and, apart from occa-
continuing to use the LNG-IUS into menopause, when sional allergic reactions, is free from side effects. Although
the male condom is heavily promoted as the method of of the device and its insertion is high. The TCu 380A is
choice to reduce the risk of HIV and other sexually trans- licensed for 10 years but is effective for at least 12. The
mitted infections (STIs), it is less well regarded as a con- Mirena LNG-OUS system is discussed in detail in the sec-
traceptive method, being considerably less effective than tion that follows, entitled Progestin-Only Contraception.
so-called modern methods in the prevention of unintended
pregnancy (see Table 134-2). Condom failures follow Efficacy
mainly from improper use, inconsistent use, or lack of use, In a study involving 7159 women years of use of the TCu
rather than from condom breakage or slippage. Polyure- 380A, the cumulative pregnancy rate after 8 years was
thane condoms were developed to overcome the disad- 2.2 per 100 women years, not significantly different than
vantages of traditional latex condoms (allergic reactions, that of female sterilization.38
impaired sensation during intercourse, short shelf life in
certain storage conditions, and weakening with oil-based Mechanism of Action
lubricants). Although less effective for contraception, poly- The mechanism of action of the IUD has long been con-
urethane condoms offer an alternative for people with latex troversial. There is evidence that the copper ions are toxic
sensitivity. Condoms are effective in preventing STIs.33 to gametes and that the viability of both sperm and egg
Female barrier methods are much less popular. The are impaired, inhibiting fertilization. However, the pres-
diaphragm and cervical cap must be fitted by a health ence of an IUD is associated with a local inflammatory
professional and they do not confer the same degree of response in the endometrium that is sufficient to prevent
protection from STIs as condoms do. Recent innova- implantation if fertilization should occur. In reality, the
tions with the diaphragm include the Duet, which can IUD probably acts both before and after fertilization.
be loaded with spermicide or lubricant gel on both the
cervical and vaginal side of the device, and the one-size- Safety and Side Effects
fits-all SILCS diaphragm. There is little evidence to dem- The IUD is inserted using an aseptic technique, with or
onstrate that the concomitant use of spermicide increases without local anesthetic (in parous women, anesthesia is
the effectiveness of the diaphragm. The female condom rarely required).
covers the mucus membranes of the vagina and vulva and Perforation occurs in fewer than 1 in 1000 insertions.
is more effective in preventing STIs, but it has a high fail- If recognized within a few weeks, the IUD can usually be
ure rate and lower acceptability than the diaphragm. In retrieved laparoscopically before adhesions form around
a prospective study of the Reality polyurethane female it. For this reason, routine follow-up is recommended 4
condom among women from the United States and Latin to 6 weeks after insertion (which should be delayed in
America, the 6-month pregnancy rate was 15%.34 breastfeeding women until at least 4 weeks after delivery).
Spermicides used alone are classified with fertil- Expulsion occurs in approximately 1 in 20 women,
ity awareness methods as having the lowest contracep- most commonly within the first 3 months of use and usu-
tive effectiveness and are estimated to have a typical-use ally during menstruation. Women can be taught to feel
annual pregnancy rate of 28% and perfect use pregnancy for the tails of the device to check that it is still present
rate of 18% (see Table 134-2). Nonoxynol 9 (N-9) is a after menstruation.
spermicidal product sold as a gel, cream, foam, film, or Menorrhagia is the most common side effect associ-
pessary for use with diaphragms or caps. Because fre- ated with IUD use and the most common reason for dis-
quent use of N-9 might increase the risk of HIV transmis- continuation. Periods tend to last a couple of days more,
sion, women who have multiple daily acts of intercourse in addition to being heavier. Dysmenorrhea is also more
or who are at high risk of HIV infection should not use likely to occur among IUD users.
N-9.35 For women at low risk of HIV infection, N-9 is
probably safe. Ectopic Pregnancy
Because the IUD does not inhibit ovulation, it does not
Intrauterine Devices prevent ectopic pregnancy as effectively as methods that
The intrauterine device is a safe and effective long-acting do inhibit ovulation. Nonetheless, ectopic pregnancy is
method of contraception. In the United States in the 1970s, rare: 0.02/100 women years compared with 0.3 to 0.5 for
some 10% of couples used the IUD; in 2002 it accounted women not using contraception.39
for less than 2% of contraceptive use. The decline in use
resulted mainly from the reports of a number of deaths Pelvic Infection and Infertility
from sepsis among women using the Dalkon Shield.36 The Although a concern in the past, the balance of evidence
IUD has remained an important method in many other suggests that use of an IUD is not associated with infertil-
countries in the developed and developing world and has ity.40 Although there is an increased risk of pelvic infec-
undergone a revival since the introduction of the hormone- tion in the first 20 days after insertion, after 1 month, the
releasing LNG-IUS (Mirena). A useful review of the world risk of upper genital tract infection is small. Although
literature on all aspects of intrauterine contraception, STI is associated with an increased risk of tubal infer-
including both copper and progestogen-releasing devices, tility, previous IUD use is not.40 Many studies have
was published as a supplement to the journal Contracep- investigated pregnancy rates after IUD removal, and
tion in 2007.37 Because of its potential duration of use, the vast majority of them have demonstrated no impair-
the copper IUD is an extremely cost-effective method of ment of fertility.40 However, a sexual history should
contraception, even in countries where the up-front cost be obtained from every woman before IUD insertion.
Routine screening for Chlamydia trachomatis and Neis- contain only 15 g/day EE. Very low doses are associated
seria gonorrhea is only indicated in population groups with increased breakthrough bleeding. Most recently,
where prevalence of infection is high. Under these condi- the trend has been to change the type of estrogen using
tions, if screening is not readily available, prophylactic natural compounds such as estradiol (E2) and estradiol
antibiotics may be administered before insertion but are valerate (E2V) with the objective of overcoming the meta-
not recommended routinely because they have not been bolic effects and particularly decreasing the thrombotic
shown to be of benefit. risk of formulations with EE. A four-phasic pill approved
in Europe containing E2V and dienogest has shown
favorable results in hemostasis and metabolism studies41
HORMONAL CONTRACEPTION and is also approved for the treatment of heavy menstrual
There are two categories of hormonal contraception: bleeding.42 Similarly favorable metabolic profiles have
combined and progestogen only. Until fairly recently, been reported with a combination of E2 and nomegestrol
combined hormonal contraception was only available acetate approved in Europe.41,42 Large safety surveillance
as an oral preparationthe pill. Combined injectables, studies are ongoing to confirm whether the improved
the contraceptive patch, and the vaginal ring now offer metabolic profile will correlate with a decreased incidence
a variety of modes of administration. Progestogen-only of venous thromboembolism (VTE).
contraception (POC) is available through oral, injectable, Pills are available as monophasic, biphasic, triphasic,
implantable, and intrauterine delivery systems, the last and now quadriphasic preparations in which the dose of
three routes providing long-acting contraception. Long- both steroids stays the same throughout the 21 days of use
acting delivery systems have the theoretical advantage of (monophasic) or it changes. There is no evidence for any
providing very constant release rates of hormone (com- benefit of biphasic or triphasic pills, which tend to be more
pared with daily administration), and they also avoid the expensive. However, reducing the duration of the PFI to 4
first-pass effect through the liver, enabling lower doses of days has reduced the risk of breakthrough ovulation, and
steroids to be used. increasing the duration of uninterrupted pill use to 84 or
even 365 days confers amenorrhoea (which many women
Combined Hormonal Contraceptives
find desirable) and theoretically also reduces the risk of
Mode of Action failure as a result of missed pills.
Combined hormonal contraceptives (CHC) all inhibit
follicle development and ovulation. The 7-day break Transdermal. Although transdermal hormone replace-
between courses of pills, patches, and rings allows the ment therapy has been available for years, it was not un-
resumption of follicular growth, which may continue til 2003 that the first contraceptive patch was marketed.
to ovulation if the contraceptive method is restarted One preparation is available: a 20-cm2 patch deliver-
late. Endometrial atrophy and an alteration of cervical ing 20 g EE and 150 g norelgestromin (17-deacetyl
mucus characteristics impair implantation and sperm norgestimate) daily. Each patch lasts 7 days. Three
transport, respectively. patches are used consecutively, with a placebo patch or
a patch-free interval in week 4 when a withdrawal bleed
Delivery Systems occurs. Contraceptive protection lasts for up to 10 days,
Oral. The COC pill is by far the most popular method allowing for errors in changing the patch. In a random-
of hormonal contraception in the developed world. Clas- ized trial comparing the patch with a COC, effectiveness
sically taken for 21 days out of every 28, with a with- was not significantly different: the overall Pearl Index for
drawal bleed occurring during the 7-day pill-free interval the patch was 1.24/100 women years and for the COC
(PFI), most preparations contain the synthetic estrogen was 2.18.43 After the first few cycles of use, bleeding pat-
ethinyl estradiol (EE, commonly 30 to 35 g/day) in terns and side effects are similar to those associated with
combination with a synthetic progestogen. As natural the combined pill. Self-reported perfect use was sig-
progesterone is irregularly absorbed, the pharmaceuti- nificantly better with the patch (88%) than with the pill
cal industry has developed a variety of progestogens that (78%) in the randomized trial, although whether this is
differ mainly in their affinity for the androgen receptor. so with use outside a clinical trial remains to be seen.
Much has been written about the benefits of one pro-
gestogen over another in terms of androgenic side ef- Vaginal Ring. A combined contraceptive vaginal ring,
fects (acne, mood change, bloating) and cycle control. Nuvaring (Merck), releasing 15 g ethinyl estradiol and
In reality, there is little good evidence for any differential 120 g etonogestrel is made of soft ethylene-vinyl-acetate
effects, and cycle control (regular withdrawal bleeds at (EVA) copolymer, has an outer diameter of 54 mm, and
the scheduled time without any bleeding or spotting in a cross-sectional diameter of 4 mm. Designed to last for 3
between) is determined largely by the dose of estrogen. weeks, a 7-day ring-free interval is associated with bleed-
A few brands of COC contain an antiandrogen rather ing patterns that appear superior to those associated with
than a classical progestogen, and these pills better con- the OC. In a comparison with an oral COC containing 30
trol preexisting symptoms of hyperandrogenism, acne, g EE and levonorgestrel 150 g, the incidence of irregu-
and hirsutism. lar bleeding in the Nuvaring was significantly less (1.9%
In an attempt to reduce the cardiovascular risks of vs. 38.8%).44 In all other respects, including efficacy, the
the combined pill, the dose of estrogen has been reduced ring is no different from the pill, but there may be advan-
through the years, and pills are now available that tages in terms of demands on compliance.
Injectable. A once-monthly injectable contraceptive is some biological plausibility for this differential risk.52
contains 25 mg medroxyprogesterone acetate and 5 mg Whichever progestogen is used, the absolute risk of VTE
estradiol cypionate (Lunelle, Pharmacia).45 Injections is small (15/100,000 women years for pill users compared
are administered intramuscularly every 28 days. Bleed- with 5/100,000 for nonusers), and is much less than that
ing patterns and efficacy are comparable with the COC. associated with pregnancy (60/100,000 women years).
Bleeding episodes can be anticipated 18 to 22 days after The risk appears to be greatest during the first year of use
injection and are induced by a decline in estrogen con- of the COCperhaps because of the unmasking of in-
centrations to 50 pg/mL or less. Approximately 70% of herited thrombophilias such as Factor V Leidenand the
women experience one bleeding episode per month, with risk disappears within 3 months of stopping. Screening
only 4% experiencing amenorrhea over three treatment for known thrombophilias is not cost effective. Although
cycles. asking about a family history of VTE is routine when
prescribing the pill, this too fails to detect most women
Safety and Side Effects at risk of VTE. The risk of VTE among COC users is
There are very limited data on the long-term safety of the probably increased by obesity but not with smoking or
combined injectable contraceptives, patch, and vaginal hypertension.53
ring. In the Medical Eligibility Criteria,24,25 the patch and
ring are treated like the pill. However, because the estro- Myocardial Infarction. A meta-analysis of 23 studies of
gens in combined injectable contraceptives may be less COC use and myocardial infarction (MI) resulted in an
potent than ethinyl estradiol, the side effects may be dif- odds ratio (OR) of 2.5 (95% confidence interval [CI]:
ferent, and WHO positions the combined injectable con- 1.9-3.2) for current users compared with never users of
traceptive somewhere between POC and COC in terms of the COC.54 The risk was related to the dose of estrogen
safety. For example, smoking more than 15 cigarettes a but was nonetheless increased for users of low-dose pills.
day is a category 4 condition for the COC but a category Smoking and hypertension both substantially increase the
3 condition for a CIC. risk of MI among COC users, and there may be an in-
The combined pill is extremely safe. In a 39-year creased risk among women with diabetes, hypercholester-
follow-up of 46,000 women in the United Kingdom, olemia, or a history of pregnancy-induced hypertension
the overall risk of death from any condition was signif- or preeclampsia. The risk of MI appears to be indepen-
icantly lower for COC ever users compared with non- dent of past use.
users (adjusted relative risk 0.88, 95% CI 0.82-0.93).46
In the same cohort study, use ever of oral contraception Stroke. The risk of ischemic stroke increases among cur-
was associated with a 12% decrease in the relative risk rent users of the combined pill (OR 2.7; 95% CI: 2.2-
of diagnosis of any cancer compared with never users.47 3.3).55 Smoking and hypertension increase the risk of
ischemic stroke among pill users, and the risk also in-
Minor Side Effects. The combined pill is associated with creases among women who suffer from migraine with
a variety of minor side effects probably common to all aura.56 Most studies have shown no statistically signifi-
combined hormonal contraceptives regardless of deliv- cant increase in the risk of hemorrhagic stroke among
ery system. Nausea (rarely persistent), breakthrough COC users without other risk factors.
bleeding, chloasma, and breast tenderness are all at-
tributable to the steroid hormones. Mood change and Breast Cancer. COC use has long been considered as asso-
loss of libido are but two complaints in a list of very ciated with an increased risk of breast cancer, and a meta-
common concerns likely to be related to social circum- analysis57 of data from more than 53,000 women with
stances. Indeed, a recent U.S. study demonstrated a pro- breast cancer and 100,000 controls, published in 1995,
tective effect of the COC on mood swings.48 Although showed a relative risk of 1.24 (95% CI: 1.15-1.33). The
a very common reason for discontinuation, combined increased risk takes 10 years to decline to that of nonus-
hormonal contraception is not associated with signifi- ers. A more recent case-control study undertaken in the
cant weight gain.49 United States58 involving 8000 women suggested no in-
creased risk of breast cancer (RR 1.0; 95% CI: 0.8-1.3),
Hypertension. Pooled data50 from four large phase II clin- but the upper limit of the confidence interval was in keep-
ical trials suggest that the COC has a negligible effect on ing with the much larger meta-analysis. The risk of breast
blood pressure. cancer appears to be independent of the dose of EE and of
the duration of use and is not influenced by family history
Venous Thromboembolism. There is a three- to fivefold or age at first use. In the RCGP study, no increase in the
increase in the risk of venous thromboembolism (VTE) risk of death from breast cancer was detected.46,47
associated with COC use, which is apparently indepen-
dent of the dose of estrogen, certainly if below 50 g. The Ovarian Cancer. Use of the COC is associated with a re-
risk associated with the use of transdermal and vaginal duced risk of ovarian cancer.29 The longer the duration
CHC is probably similar to that of the pill. COCs con- of use, the lower the risk. The reduction persists for 30
taining the progestogens, gestodene, and desogestrel ap- years after stopping the pill, but the effect diminishes with
pear to be associated with an increased risk compared longer gaps since the last use. The effect does not seem to
with COCs containing levonorgestrel or norethisterone.51 be reduced by lower-dose pills and is independent of the
Although often attributed to confounding or bias, there histologic type of tumor, apart from mucinous tumors,
which are not affected (12% of malignant ovarian tu- in most parts of the world. POP offers a pill to women
mors). with contraindications to estrogen, such as breastfeed-
ing, diabetes with complications, and migraine with aura.
Endometrial Cancer. Although less robust than for ovar- Most POPs contain second-generation progestogens in
ian cancer, there are data to support a reduction in the doses that inhibit ovulation only inconsistently. In 2002, a
risk of endometrial cancer among women using the com- POP containing desogestrel 75 g/day, a dose sufficient to
bined oral contraceptive pill.47 inhibit ovulation in almost every cycle, was introduced in
Europe.60 All POPs are designed to be taken daily without
Cervical Cancer. The combined pill is associated with an a break. Bleeding patterns depend on the degree of sup-
increased risk of squamous carcinoma of the cervix, but pression of ovarian activity. If normal ovulation occurs
it is often suggested that the association may be a result consistently, a woman will experience menstrual bleeds at
of changes in the cervix (ectropion) or simply the result a frequency characteristic of her normal cycle. If both ovu-
of inadequate adjustment of variations in sexual behav- lation and follicle development are completely suppressed,
ior. Oncogenic human papilloma virus (HPV) is the cause amenorrhea will result. If ovulation or follicular develop-
of cervical cancer. COC use does not appear to increase ment (and therefore estrogen secretion sufficient to stimu-
the acquisition or persistence of HPV infection, but rather late endometrial growth) occurs irregularly, bleeding will
favor its progression to cervical cancer.59 Data from a be erratic and unpredictable.
number of studies have demonstrated that among current
users, the risk of invasive cervical cancer is increased with Injectable. Only one preparation has been available in
increasing duration of use. The relative risk for 5 years or the United States: depot medroxyprogesterone acetate
more of use is 1.90 (90% CI: 1.69-2.31). The increased (DMPA, Depo-Provera), administered intramuscularly
risk declines after cessation of use and, like breast cancer, every 12 weeks. The dose inhibits all ovarian activity.
is no different from that of never users by 10 years after Some 80% of women become amenorrheic after 1 year of
stopping.59 Women who use hormonal contraception and use, but a few will have persistent heavy and prolonged
have to attend a health professional for supplies are, how- bleeding. The recent development of a micronized subcu-
ever, a captive population for cervical screening. This con- taneous preparation, similar in all respects to the existing
tinues to be one of the arguments raised against making preparation, will allow self-injection, which may further
combined oral contraception available over the counter. increase acceptability for many women.
Liver Cancer. COC use is associated with an increased Implants. The first contraceptive implant to become avail-
risk of liver cancer but only in populations with a high able (in 1983 in Finland) was Norplant, which included six
rate of hepatitis B infection. Among others, the absolute Silastic capsules containing a total of 216 mg of levonorg-
risk of liver cancer is extremely small. estrel (LNG). Circulating levels of LNG are around 80 g/
day during the first 8 weeks and they decline slowly to 25
Progestogen-Only Contraception to 30 g/day at 60 months. Norplant is no longer avail-
POC is available in a variety of delivery systems. Up- able in the United States. Jadelle comprises two silicone
to-date guidance on their characteristics, efficacy, side rods releasing LNG at a similar rate. Jadelle and Norplant
effects, and clinical use are available on the U.K. Faculty are virtually identical in terms of efficacy, side effects, and
of Sexual and Reproductive Healthcare website (http:// duration of use. Implanon, a single rod containing 68 mg
www.fsrh.org/pages/Clinical_Guidance_2.asp). The 3-keto-desogestrel (a metabolite of desogestrel) provides
injectable preparations deliver a high dose of hormone; contraception for 3 years.61 The initial release rate of 60
the implant Implanon and the newest progestogen-only to 70 g/day falls gradually to around 25 to 30 g/day
pill, Cerazette, an intermediate dose; and the older oral at the end of 3 years. All contraceptive implants are in-
preparations and implants (levonorgestrel implants such serted subdermally on the inner aspect of the upper arm.
as Jadelle) and IUSs deliver much lower doses (Table Although easy to insert, removal can be troublesome, par-
134-6). ticularly if the implants are inserted subcutaneously rather
than subdermally. Implanon is a single rod preloaded into
Mode of Action a sterile disposable inserter, making insertion and removal
The mode of action depends on the dose of hormone. High much easier. The recent addition of 15 mg barium sulfate
doses (injectables) inhibit follicle development and ovula- to the implant core, making it detectable by x-ray, and the
tion completely, alter the characteristics of cervical mucus development of a preloaded inserter has led to a change of
(interfering with sperm transport), and cause endometrial name to either Nexplanon or Implanon NXT.
changes, including atrophy. Intermediate doses inhibit
ovulation but allow follicular development, whereas very Intrauterine System. The LNG-IUS (Mirena) has a T-
low doses inhibit ovulation only inconsistently, relying for shaped plastic frame with a reservoir on the vertical stem
efficacy mainly on their effect on cervical mucus, which containing 52 mg levonorgestrel releasing 20 g LNG/
inhibits the passage of sperm. day. Intrauterine concentrations of LNG are 1000 times
higher than those associated with subdermal implants.
Delivery Systems Marked endometrial atrophy occurs. The dose of LNG
Oral. The oral progestogen-only pill (POP or mini-pill) has a minimal effect on ovarian activity; most women
has been available for more than 40 years but is little used continue to ovulate. For a useful review of the world
literature on all aspects of intrauterine contraception, in- Ectopic pregnancy is listed in many older textbooks as
cluding progestogen-releasing devices, see the 2007 special a side effect of the POP because of the theoretical effect
supplement to the journal Contraception.37 In 2013, the of progestogens on tubal motility. The best data are for
FDA approved Skyla, which is a so-called mini Mirena Norplant and show no increased risk compared with
that has a smaller frame making it easier to insert. It has women not using contraception.
a lower dose of LNG (13.5 mg released at a rate of about
6 mcg/day) and lasts for 3 years. Unlike Mirena in the Ovarian Cysts. Incomplete suppression of ovarian activ-
United States, the label specifically states that it can be ity is a recipe not only for erratic bleeding but also for
used in nulliparous women. the development of ovarian follicular cysts. These occur
in 20% of women using the POP and Mirena. They are
Safety and Side Effects almost always asymptomatic.
Unpredictable unscheduled vaginal bleeding is the most
common side effect of all low-dose POC and the most Cancer. In the large meta-analysis reporting a rela-
common reason for discontinuation. Although incom- tive risk of 1.24 for use of the COC,57 an increased
plete suppression of ovarian activity is partly the cause, relative risk of breast cancer for both oral and injectable
a local effect on the endometrium of the continuous progestogen-only methods of contraception (RR 1.17
administration of progestogens also probably contrib- for both) was demonstrated, although for injectables
utes. Erratic bleeding occurs in around 70% of users of this was not statistically significant. There are much
progestogen-only implants and around 40% of classical fewer data for POP than for COC, and women with
POP users. In the first 3 to 6 months after insertion of risk factors for breast cancer may be preferentially pre-
Mirena, spotting is common and can be persistent. By the scribed POC. Recent anxieties about the contribution
end of 1 year, most women have very light, short, and of progestogens to the increased risk of breast cancer
infrequent bleeding episodes. Although the administra- associated with HRT have not yet spread to progesto-
tion of estrogens will usually stop the unscheduled bleed- gen-only contraceptives. There is no evidence for any
ing with POC, this is only a temporary solution and is not increased risk of other cancers.
one open to women with contraindications to estrogen. If
the bleeding pattern is unacceptablefor some women, Cardiovascular Disease and Venous Thromboembolism.
the advantages of the method outweigh the inconvenience There is no evidence for an increase in the risk of stroke
of unpredictable bleedinga different contraceptive or myocardial infarction in association with POC.63 Data
method must be sought. assessing the risk of venous thromboembolism in women
Amenorrhea occurs in up to 10% of women using the prescribed POC are limited. In a recent meta-analysis of
POP and LNG implants, 25% of Mirena users, and 80% eight observational studies, the use of POC was not asso-
of women using Depo-Provera. Most women consider ciated with an increased risk of venous thromboembolism
amenorrhea as a positive side effect, although for some compared with nonusers of hormonal contraception.64 A
it may prove unacceptable. Counseling before initiation potential association between injectable progestins and
about all bleeding disturbances, including amenorrhea, thrombosis, however, was identified as requiring further
improves continuation rates. study.
The metabolic side-effects of progestogens are said to
be associated with a range of common minor symptoms Gallbladder Disease. A weak association between use of
including acne, hirsutism, headache, mood change, and Norplant and gallbladder disease has been described, but
weight gain or bloating. Although collectively account- there is no evidence of any association with other POC.
ing for more than 10% of discontinuations of POC, all
are common complaints among women not using contra- Bone Mineral Density. The effects of hormonal contra-
ception. Depo-Provera use is associated with significant ception on bone mineral density (BMD) have received
weight increase62 in many women, but concerns about considerable attention during the past decade. A system-
an increased risk of depression are probably unfounded. atic review of the literature on BMD and POC conclud-
Low-dose POCs are not associated with weight gain. ed that limited evidence suggests that use of POC other
TABLE 134-6 Progestogen-Only Methods of Contraception
Method Type of Progestogen Dose Duration of Use Mode of Delivery

DMPA (Depo-Provera) Medroxyprogesterone acetate 150 mg 12 weeks IM injection
Net-en Norethisterone enanthate 200 mg 8 weeks IM injection
Norplant* Levonorgestrel 25-80 g/day 5 yrs Subdermal implant
Jadelle Levonorgestrel 25-80 g/day 5 yrs Subdermal implant
Implanon Etonogestrel 25-70 g/day 3 yrs Subdermal implant
Mirena Levonorgestrel 20 g/day 5 yrs Intrauterine
Progestasert Progesterone 65 g/day 1 yr Intrauterine
Cerazette Desogestrel 75 g/day Daily Oral
IM, Intramuscular.
*No longer available in the United States.
than DMPA does not affect BMD.65 However injectable (such as the measurement of serum cholesterol) have
methods deliver high doses of progestogen, suppress- become routine before starting a woman on a hormonal
ing ovarian activity and causing hypoestrogenism; there method of contraception. These tests and examinations
have been concerns that their use may increase the risk are often repeated annually. The contraceptive consulta-
of osteoporosis and fracture.66 Most studies demonstrate tion is often seen as an opportunity to undertake other
a reduction in BMD among current users of Depo-Pro- screening procedures, and there is a danger that these too
vera, but BMD is almost without exception within one become part of routine screening for hormonal contra-
standard deviation of the mean for nonusers (i.e., within ception. The WHO distinguishes between examinations
the normal range). Loss of BMD seems to stabilize after and investigations that are essential for safe prescribing of
4 years and is reversed after discontinuation of DMPA. contraception from those that are commonly performed
The data for most women then are reassuring. Concern but do not contribute substantially to safe and effective
remains about adolescents who use DMPA, because use use of the contraceptive method. WHO and the ACOG
of the method before peak bone mass is achieved may in their Selected Practice Recommendations on Contra-
jeopardize final bone mass. DMPA certainly is associated ceptive Use cover most of the common issues in managing
with BMD loss in teenagers compared with those using no the effective use of all methods of contraception.69,70
contraception, but further research on the clinical signifi-
cance of this observation is required.67 Few adolescents Emergency Contraception
use any method of contraception for long periods of time, Emergency contraception (EC) is defined as any drug or
so the concern may be more theoretical than practical. device that is used after intercourse to prevent pregnancy.
Moreover, the benefits in terms of pregnancy prevention It is used most commonly after unprotected intercourse
with this easy-to-use method outweigh any theoretical or following intercourse in which a condom has burst
concerns. The authors of the systematic review conclud- or slipped. Two preparations are available in the United
ed that BMD generally decreased more throughout time States and Europe: levonorgestrel 1.5 g, taken either as
among DMPA users, however, than among nonusers, a single dose or as two doses of 0.75 mg taken 12 hours
but women gained BMD on discontinuation of DMPA.65 apart within 72 hours of intercourse, and the progester-
Although there may be a case for caution in prescribing one receptor modulator ulipristal acetate (UPAella) 30
DMPA to women with known existing risk factors for mg as a single dose taken for up to 120 hours (5 days
osteoporosis, there is no evidence to support the use of after intercourse). In clinical trials, UPA appears to pre-
add-back estrogen, which makes it an expensive and com- vent more pregnancies than LNG (among women using
plicated method of contraception unsuitable for women UPA within 24 hours of intercourse the risk of pregnancy
with contraindications to estrogen. In the United States is reduced by almost two thirds compared with among
and the United Kingdom, health professionals are advised women taking LNG),71 probably because UPA continues
to use Depo-Provera with caution for adolescents. The to inhibit ovulation even after the LH surge has started,
WHO Medical Eligibility Criteria (2008) regard age less whereas LNG is no longer effective at that stage of the
than 18 and older than 45 as category 2 conditions for cycle (see later).72
use of Depo-Provera because of the theoretical effect on The International Consortium for Emergency Contra-
bone health (but age is outweighed by the benefits of us- ception (ICEC) and the Faculty of Sexual and Reproduc-
ing the method).24,25 tive Health (FSRH) in the United Kingdom have produced
clinical guidelines on emergency contraception.73,74 IUD
Return to Fertility insertion is sometimes used as an alternative to hormonal
Return to fertility occurs within days of cessation of all EC if a woman presents more than 72 hours after inter-
POC methods except injectables. The delay following dis- course but before 5 days after ovulation.74
continuation of DMPA is well recognized, but pregnancy
rates eventually reach those associated with cessation of Mode of Action
other methods.68 The mechanism of action of hormonal EC is not com-
pletely understood. There is good evidence that both
Initiation of Hormonal Contraception and Follow-up methods, LNG and UPA, inhibit or delay ovulation, but
The vast majority of women who use hormonal contra- ovulation is no longer inhibited by LNG after the LH
ception do not have any medical problems and are young. surge starts, whereas for UPA ovulation, inhibition per-
Providers need to recognize the very few who may be at sists until the LH peak is reached, after which time ovu-
risk of the rare but serious complications of hormonal lation is no longer inhibited.74 Evidence for an effect of
contraception. We primarily rely on identifying women LNG-EC on the endometrium that might inhibit implan-
who have other risk factors associated with the condi- tation is poor, and it is likely that it does not work if
tions of concern (e.g., cardiovascular disease or breast the woman has already ovulated. LNG-EC has no effect
cancer) and either informing them of the increased risks after implantation; it is not an abortifacient. Because UPA
or advising them not to use hormonal contraception. acts as an antiprogestogen, an affect on the endometrium
Taking a careful history (including family history) and cannot be ruled out. However, it may have some aborti-
observing obvious physical characteristics (such as obe- facient activity but not at the dose used for EC.73 In con-
sity) provides a lot of useful information. In the United trast, whereas the IUD diminishes the viability of gametes
States, detailed physical examination (including breast and the number of sperm reaching the fallopian tube,
and pelvic examination) and a variety of blood tests if it is inserted after fertilization has occurred, it works
by inhibiting implantation. The LNG-IUS is not recom- data for the safety of UPA if taken when pregnancy is
mended as an emergency contraceptive.74 already established and, although to date the evidence is
reassuring, the label advises against using UPA more than
Efficacy once in the same cycle in case it does not prevent concep-
The efficacy of emergency contraception is described in tion on the first occasion.74
terms of the number of potential pregnancies prevented
based on calculating the risk of pregnancy for the day of Advanced Provision of Emergency Contraception
the cycle on which intercourse occurred. This is difficult Most women who could use EC to try to prevent an
to calculate because many users are of unproven fertil- unwanted pregnancy do not do so. Whereas many sim-
ity, and the information about cycle length, date of last ply fail to recognize or acknowledge that they have put
period, and timing of intercourse is often vague or incor- themselves at risk of pregnancy, for others, failure to
rect, and it is impossible to know precisely when, in rela- use EC reflects difficulty with obtaining a supply within
tion to ovulation, treatment has been administered. Data the 72-hour time frame for use. A number of studies
suggesting that the LNG-EC prevents 75% to 85% of have demonstrated that EC is more likely to be used if
expected pregnancies is likely to be an overestimate. In a women have a supply ahead of needing to use it.75 This
direct comparison on LNG and UPA among 1899 women practice is encouraged by both the ACOG and the FSRH
seeking emergency contraception, the expected pregnancy and does not appear to be associated with any reduc-
rate was 5.5% for women randomized to UPA and 5.4% tion in the use of other more effective methods of con-
for those randomized to LNG-EC. The actual pregnancy traception after EC use or with any increase in unsafe
rate was 1.8% for UPA and 2.6% for LNG.71 In other sex. However, no one has been able to demonstrate a
words, LNG-EC prevented 55% of expected pregnancies reduction in unintended pregnancy rates associated with
whereas UPA prevented 67%. The IUD probably pre- advanced provision.75
vents more than 95% of pregnancies.74
Contraindications SUMMARY
There are no absolute contraindications to hormonal EC. A range of contraceptive methods is available. All are
For women at risk of STI, insertion of an IUD should be extremely safe; serious adverse events are uncommon.
covered with a broad-spectrum antibiotic.74 Effectiveness varies depending on both the mode of action
of the method and how easy it is to use. Incorrect and
Side Effects inconsistent use is common, and so contraceptives that
Side effects of LNG-EC and UPA are not different and are independent of compliance for their effectiveness and
are difficult to distinguish from anxiety associated with are long acting have the lowest failure rates. If contracep-
fear of pregnancy. Almost 30% of women will experi- tion has not been used or if an error in use is recognized,
ence a delay of more than 3 days in the onset of the next pregnancy may be prevented by emergency contracep-
menstrual period after using LNG, and slightly more after tion, which can be provided in advance.
UPA.73 Some will menstruate early. For most women,
however, menses will come at the expected time. For your free Expert Consult eBook with biblio-

There is no evidence that LNG-EC is teratogenic if graphic citations as well as the ability to take notes,
administered inadvertently to a woman who is already highlight important content, search the full text, and
pregnant or if pregnancy occurs.74 There are far fewer more, visit http://www.ExpertConsult.Inkling.com.
REFERENCES 24. World Health Organization. Improving access to quality care in fam-
ily planning: Medical eligibility criteria for contraceptive use. 4th ed
1. Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contra-
Geneva: Reproductive Health and Research, WHO; 2008. Accessed
ception and health. Lancet. 2012;380:149156.
at www.who.int/reproductive-health/publications/index.htm.
2. United Nations. World Contraceptive Use 2011. Accessed at http:/
25. Centers for Disease Control and Prevention. U.S. medical eligibility
/www.un.org/esa/population/publications/contraceptive2011/wallc
criteria for contraceptive use, 2010. Morbidity and Mortality Week-
hart_wcu2011.xls
ly Report. June 18, 2010;vol. 59. No. RR-4. Accessed at http://www.
3. Jones J, Mosher W, Daniels K. Current contraceptive use in the
cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm.
United States, 20062010, and changes in patterns of use since
26. Rosenburg MJ, Waugh MS, Meehan TE. Use and misuse of oral
1995. National Health Statistics Report No. 2012;60. October 18.
contraceptives: Risk indicators for poor pill taking and discontinu-
4. Bajos N, Leridon H, Gowlard H, the COCON Group, etal.
ation. Contraception. 1995;51:283288.
Contraception: From accessibility to efficiency. Hum Reprod.
27. Courtland Robinson J, Plichta S, Weisman CS, etal. Dysmenor-
2003;18:994999.
rhea and use of oral contraceptives in adolescent women attending
5. Oddens BJ, Milsom I. Contraceptive practice and attitudes in Swe-
a family planning clinic. Am J Obstet Gynecol. 1992;166:578583.
den 1994. Acta Obstet Gynecol Scand. 1996;75:932940.
28. ESHRE Capri Workshop Group. Non-contraceptive benefits of
6. Jones RK, Darroch JE, Henshaw SK. Contraceptive use among
combined oral contraception. Hum Reprod Update. 2005;11:
US women having abortions in 20002001. Perspect Sex Reprod
513525.
Health. 2002;34:294303.
29. Beral V, Doll R, Hermon C, etal. Collaborative Group on Epi-
7. Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J,
demiological Studies of Ovarian Cancer. Ovarian cancer and oral
Nelson A, etal., eds. Contraceptive technology. 20th ed. New
contraception: Collaborative reanalysis of data from 45 epidemio-
York: Ardent Media; 2011. 50.
logical studies including 23,257 women with ovarian cancer and
8. Holt VL, Cushing-Haugen KL, Daling J. Body weight and risk of
87,303 controls. Lancet. 2008;371:303314.
oral contraceptive failure. Obstet Gynecol. 2002;99:820827.
30. Flynn AM. Natural methods of contraception. Matern Child Health
9. Lopez LM, Grimes DA, Chen M, Otterness C, Westhoff C,
J. 1991;16:148153.
Edelman A, Helmerhorst FM. Hormonal contraceptives for con-
31. Labbok M, Koniz-Booher P, Cooney K, etal. Guidelines for breast-
traception in overweight or obese women. CD008452. Cochrane
feeding in family planning and child survival programs. Washing-
Database Syst Rev. 2013 Apr 30;4. Accessed at http://dx.doi.
ton, DC: Institute for Studies in Natural Family Planning; 1990.
org/10.1002/14651858. CD008452.pub3.
32. Perez A, Labbok M, Queenan J. Clinical study of the lactational amen-
10. Glasier A, Cameron ST, Blithe D, Scherrer B, Mathe H, Levy D,
orrhoea method for family planning. Lancet. 1992;339:968969.
Gainer E, Ulmann A. Can we identify women at risk of pregnan-
33. Weller SC, Davis-Beaty K. Condom effectiveness in reducing het-
cy despite using emergency contraception? Data from random-
erosexual HIV transmission. Cochrane Database of Systematic Re-
ized trials of ulipristal acetate and levonorgestrel. Contraception.
views. 2002;1. CD003255.
2011;84:363367.
34. Farr G, Gabelnick H, Sturgen K, Dorflinger L. Contraceptive ef-
11. Chi I-C, Mumford SD, Laufe LE. Technical failures in tubal ring
ficacy and acceptability of the female condom. American Journal of
sterilization: Incidence, perceived reasons, outcome, and risk fac-
Public Health. 1994;84(12):19601964.
tors. Am J Obstet Gynecol. 1980 Oct 1;138(3):307312.
35. World Health Organization. WHO/CONRAD technical consulta-
12. Hou MY, Hurwitz S, Kavanagh E, Fortin J, Goldberg AB. Us-
tion on Nonoxynol-9. Geneva: WHO; 2001. Accessed at http://ww
ing daily text-message reminders to improve adherence with oral
w.who.int/reproductivehealth/publications/nonoxyno19/nonoxyno
contraceptives: a randomized controlled trial. Obstet Gynecol.
19.pdf.
2010;116:633640. Erratum in: Obstet Gynecol. 2010;116:1224.
36. Hubacher D. The checkered history and bright future of intra-
13. DArcangues C, Odlind V, Frasier IS. Dysfunctional uterine bleeding
uterine contraception in the United States,. Perspect Sex Reprod
induced by exogenous hormones. In: Alexander MJ, DArcangues
Health. 2002;34:98103.
C, eds. Steroid hormones and uterine bleeding. Washington, DC:
37. Multi-authors. Special issue on intrauterine devices and systems.
AAAS Press; 1992:81105.
Contraception. 2007;75:S1S116.
14. Grady WR, Bill JOG, Klepinger DH. Contraceptive method switch-
38. United Nations Development Programme/United Nations Popula-
ing in the United States. Perspect Sex Reprod Health. 2002;34:135
tion Fund/World Health Organization/World Bank Special Pro-
145.
gramme of Research. Long-term reversible contraception. Twelve
15. Lakha F, Glasier A. Continuation rates of Implanon in the UK:
years of experience with the Tcu380A, and Tcu220C. Contracep-
Data from an observational study in a clinical setting. Contracep-
tion. 1997;56:341352.
tion. 2006;74:287289.
39. Sivin I. Dose and age-dependent ectopic pregnancy risks with intra-
16. Emans SJ, Grace E, Woods ER, etal. Adolescents compliance with
uterine contraception. Obstet Gynecol. 1991;78:291298.
the use of oral contraceptives. JAMA. 1987;257:33773381.
40. Grimes DA. Intrauterine devices and infertility: Sifting through the
17. Larsson G, Blohm F, Sundell G, etal. A longitudinal study of birth
evidence. Lancet. 2001;358:67.
control and pregnancy outcome among women in a Swedish popu-
41. Sitruk-Ware R, Nath A, Mishell Jr DR. Contraception technology:
lation,. Contraception. 1997;56:616.
Past, present and future. Contraception. 2013;87:319330.
18. Heikinheimo O, Gissler M, Suhonen S. Age, parity, history of re-
42. Fraser IS, Jensen J, Schaefers M, Mellinger U, Parke S, Serrani M.
peat abortion and contraceptive choices affect the risk of repeat
Normalization of blood loss in women with heavy menstrual bleed-
abortion. Contraception. 2008;78:149154.
ing treated with an oral contraceptive containing estradiol valerate/
19. Roberts H, Silva M, Xu S. Post abortion contraception and its ef-
dienogest. Contraception. 2012;86:96101.
fect on repeat abortions in Auckland, New Zealand. Contracep-
43. Audet MC, Morean M, Koltun WD, for the ORTHO/EVRA study
tion. 2010;82:260265.
group, etal. Evaluation of contraceptive efficacy and cycle control
20. Rose SB, Lawton BA. Impact of long-acting reversible contra-
of a transdermal contraceptive patch versus an oral contraceptive:
ception on return for repeat abortion. Am J Obstet Gynecol.
A randomized controlled trial,. JAMA. 2001;285:23472354.
2012;206:37.
44. Bjarnadottir RJ, Tuppurainen M, Killick SR. Comparison of cy-
21. Winner B, Piepert JF, Zhao Q, Buckel C, Madden T, Allsworth JE,
cle control with a combined contraceptive vaginal ring and oral
Secura GM. Effectiveness of long-acting reversible contraception. N
levonorgestrel/ethinyl estradiol. Am J Obstet Gynecol. 2002;186:
Engl J Med. 2012;366:19982007.
389395.
22. Cameron S, Glasier A, Chen Z, Johnstone A, Dunlop C, Heller
45. Kaunitz AM, Garceau RJ, Cromie MA. Lunelle Study Group:
R. Effect of contraception provided at termination of pregnancy
Comparative safety, efficacy and cycle control of Lunelle monthly
and incidence of subsequent termination of pregnancy. BJOG.
contraceptive injection (medroxyprogesterone acetate and estradiol
2012;119:10741080.
cypionate injectable suspension) and Ortho-Novum 7/7/7 oral con-
23. Piepert JF, Madden T, Allsworth JE, Secura GM. Preventing un-
traceptive (norethindrone/ethinyl estradiol triphasic). Contracep-
intended pregnancies by providing no-cost contraception. Obstet
tion. 1999;60:179187.
Gynecol. 2012;0:17.
2309.e1
2309.e2 REFERENCES
46. Hannaford PC, Iversen L, Macfarlane TV, etal. Mortality among con- 62. Clark MK, Dillon JS, Sowers M, Nichols S. Weight, fat mass
traceptive pill users: Cohort evidence from Royal College of General and central distribution of fat increase when women use depo-
Practitioners oral contraception study. Brit Med J. 2010;340:c972. medroxyprogesterone acetate for contraception. Int J Obesity.
47. Hannaford PC, Selvaraj S, Elliot AM, etal. Cancer risks among 2005;29:12521258.
users of oral contraceptives: Cohort data from the Royal Col- 63. World Health Organization Collaborative Study of Cardiovascular
lege of General Practitioners Oral Contraception Study. BMJ. Disease and Steroid Hormone Contraception. Cardiovascular dis-
2007;335:651659. ease and use of oral and injectable progestogen-only contraceptives
48. Berenson AB, Odom SD, Breitkopf CR, etal. Physiological and psy- and combined injectable contraceptives: Results of an international
chological symptoms associated with use of injectable contracep- multicentre case-control study. Contraception. 1998;57:315324.
tion and 20 g oral contraceptive pills. Am J Obstet Gynecol. 2008. 64. Mantha S, Karp R, Raghavan V, Terrin N, Bauer KA, Zwicker
[epub ahead of print]. JI. Assessing the risk of venous thromboembolic events in women
49. Gallo MF, Grimes DA, Schultz KF, etal. Combination estrogen- taking progestin-only contraception: A meta-analysis. BMJ. 2012;
progestin contraceptives and body weight. Systematic review of 345:e4944 (Published 7 August 2012).
randomized controlled trials. Obstet Gynecol. 2004;103:359373. 65. Curtis KM, Martins SL. Progestogen-only contraception and bone
50. Endrikat J, Gerlinger C, Cronin M, etal. Blood pressure stability in mineral density: A systematic review. Contraception. 2006;73:
a normotensive population during intake of monophasic oral contra- 470487.
ceptive pills containing 20 g ethinyl oestradiol and 75 g desogestrel. 66. Lopez LM, Chen M, Mullins S, Curtis KM, Helmerhorst FM. Ste-
Eur J Contracept Reprod Health Care. 2001;6:159166. roidal contraceptives and bone fractures in women: Evidence from
51. Skegg DCG. Third generation oral contraceptives. BMJ. 2000; observational studies. Cochrane Database Syst Rev. 2012 Aug
321:190191. 15;8. CD009849.
52. Rosing J, Middeldorp S, Curvers J, etal. Low-dose oral contracep- 67. Clark MK, Sowers M, Levy B, etal. Bone mineral density loss and
tives and acquired resistance to activated protein C: A randomised recovery during 48 months in first-time users of depot medroxypro-
cross-over study. Lancet. 1999;354:20362040. gesterone acetate. Fertil Steril. 2006;86:14661474.
53. Nightingale AL, Lawrenson RA, Simpson EL, etal. The effect of 68. Pardthaisong T, Gray RH, McDaniel EB. Return to fertility after
age, body mass index, smoking and general health on the risks of the discontinuation of depot medroxyprogesterone acetate and in-
venous thromboembolism in users of combined oral contraceptives. trauterine devices in Northern Thailand. Lancet. 1985;1:509512.
Eur J Contracept Reprod Health Care. 2000;5:265274. 69. World Health Organization. Improving access to quality care in
54. Khader YS, Rice J, John L, etal. Oral contraceptive use and family planning: Selected practice recommendations. Geneva:
risk of myocardial infarction: A meta-analysis. Contraception. WHO; 2002. Reproductive Health and Research. Accessed at, http
2003;68:1117. ://www.who.int/reproductivehealth/publications/index.htm.
55. Chan WS, Ray J, Wai EK, etal. Risk of stroke in women exposed to 70. American College of Obstetrics and Gynecologists. Emergency con-
low dose oral contraceptives: A critical evaluation of the evidence. traception: ACOG Practice Bulletin No. 69. Clinical Management
Arch Intern Med. 2004;164:741747. Guidelines for Obstetricians & Gynecologists. Obstet Gynecol.
56. Curtis KM, Mohllajee AP, Peterson HB. Use of combined oral con- 2005;106:14431452.
traceptives among women with migraine and nonmigrainous head- 71. Glasier AF, Cameron ST, Fine PM, etal. Ulipristal acetate versus
aches: A systematic review. Contraception. 2006;73:189194. levonorgestrel for emergency contraception: A randomised non-
57. The Collaborative Group on Hormonal Factors in Breast Cancer: inferiority trial and meta-analysis. Lancet. 2010;375:555562.
Breast cancer and hormonal contraceptives: A collaborative re- 72. Brache V, Cochon L, Deniaud M, Croxatto HB. Ulipristal acetate
analysis of individual data on 53,297 women with breast cancer prevents ovulation more effectively than levonorgestrel: Analysis of
and 100,239 women without breast cancer from 54 epidemiologi- pooled data from three randomized trials of emergency contracep-
cal studies. Lancet. 1996;347:17171727. tion regimens. Contraception. 2013 Nov;88:611618.
58. Marchbanks PA, McDonald JA, Wilson HG, etal. Oral contracep- 73. International Consortium for Emergency Contraception. Emergency
tives and the risk of breast cancer. New Engl J Med. 2002;346:2025 contraceptive pills medical and service delivery guidelines. Accessed at
2032. http://www.cecinfo.org/custom-content/uploads/2013/06/Medical-
59. International Collaboration of Epidemiological Studies on Cervical and-Service-Delivery-Guildelines-English-June-20131.pdf.
Cancer: Cervical cancer & hormonal contraceptives: Collabora- 74. Faculty of Family Planning and Reproductive Health Care Clini-
tive reanalysis of data from 16573 women with and 35509 women cal Effectiveness Unit. Emergency contraception 2012. Accessed at
without cervical cancer from 24 epidemiological studies. Lancet. http://www.fsrh.org/pdfs/CEUguidanceEmergencyContraception1
2007;370:16091621. 1.pdf.
60. Rice CF, Killick SR, Dieben T, etal. A comparison of the inhibition 75. Polis CB, Schaffer K, Blanchard K, etal. Advance provision of
of ovulation achieved by desogestrel 75 g and levonorgestrel 30 g emergency contraception for pregnancy prevention: A meta-analysis.
daily. Hum Reprod. 1999;14:982985. Obstet Gynecol. 2007;110:13791388.
61. Darney P, Patel A, Rosen K, Shapiro LS, Kaunitz AM. Safety and effi-
cacy of a single-rod etonogestrel implant (Implanon): Results from 11
international clinical trials. Fertil Steril. 2009 May;91(5):16461653.

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c h a p t e r

data from populations where contraception is not used and from

TABLE 134-5 Medical Eligibility Criteria

TABLE 134-6 Progestogen-Only Methods of Contraception

Method Type of Progestogen Dose Duration of Use Mode of Delivery

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