APGO Educational Series on

Women’s Health Issues

Contraception
Patient Counseling and Management

APGO Educational Series on Women’s Health Education

Introduction
 Most American women spend
approximately 36 years in the
reproductive stage of life (ages 15-44)1
– They try to avoid pregnancy at some
point in this interval
– ~30% of pregnancies are
unintended1
– 14% of births are unwanted1
– Annually, ~2% of women have an
induced abortion2
 Spacing children decreases infant
morbidity and mortality3,4 and the risk of
spontaneous abortion
 Successful family planning has a
positive impact on women, couples,
families, and society
1. Chandra A, et al. Vital Health Stat. 2005.
2. Jones RK, et al. Perspect Sex Reprod Health. 2008;40(1):6-16.
3. Klerman LV, et al. Am J Public Health. 1998;88:1182-1185.
4. McCalister DV, et al. Am J Obstet Gynecol. 1970;106(4):573-580.
Contraception
 Benefits often outweigh health risks
 Side effects can often be managed
or relieved
 Variety of options available to
US women:
– Combination hormonal or progestin
-only – pill, patch, vaginal ring
– Injectable – long-acting, depot, or
implant progestin
– IUD – copper or levonorgestrel
– Barrier methods – condom, diaphragm, vaginal
cap, spermicide
– Sterilization – female, male
– Fertility awareness; withdrawal
ACOG News Release: The ABCs of oral contraceptives. 2006Oct3
Health Benefits
 Barrier effect
– Condoms reduce transmission of infectious agents 1
 Endometrial cancer
– Risk significantly reduced with combination oral
contraceptives, depot medroxyprogesterone acetate
(DMPA) and non-medicated IUDs2, 3, 4
 Ovarian cancer
– Risk reduced by combination oral contraceptives 5, 6, 7
– Even in women with BRCA1 and BRCA2 mutations8
1. Grimes DA, et al. Am J Obstet Gynecol. 1995;172:227-235.
2. The Cancer and Steroid Hormone Study…. JAMA. 1987;257:796-800.
3. Burkman R, et al. Am J Obstet Gynecol. 2004;190:S5-S22.
4. Black A, et al. J Obstet Gynaecol Can. 2004;26(3):236-242.
5. Andersson K, et al. al. Contraception. 1994;49(1):56-72.
6. Ness RB, et al. Am J Epidemiol. 2000;152(3):233-241.
7. Westhoff C, et al. Am J Epidemiol. 2000;152(3):242-246.
8. ACOG Practice Bulletin No. 73. Obstet Gynecol. 2006;107(6): 1453-1472.
Other Benefits
 Withdrawal bleeding and dysmenorrhea
– Regulated and reduced with use of combination oral contraceptives 1,2,3
 Menstrual blood loss in menorrhagia
– Reduced with use of combination oral contraceptives, DMPA, or
levonorgestrel IUD4-9
 Acne
– Treated with combination oral contraceptives 10
 Perimenopause
– Lighter, predictable bleeding; vasomotor symptom relief; positive effect on
bone mineral density11-13

1. Kaunitz AM. 2007Feb7. 44 PowerPoint slides.
2. Davis AR, et al. Obstet Gynecol. 2005;106:97-104.
3. Edelman A. In: Practical gynecology: a guide for the
primary care physician; 2008.
4. Hatcher RA, et al. Contraceptive Technology; 2004.
5. Fedele L, et al. Fertil Steril. 1997;68(3):426-429.
6. Hubacher D, et al. Obstet Gynecol Surv.
2002;57(2):120-128.
7. Davis A, et al. Obstet Gynecol. 2000;96:913-920.
8. Marjoribanks J, et al. Cochrane Database Syst Rev.
2006;2.
9. Lethaby AE, et al. Cochrane Database Syst Rev.
2005;4.
10. Arowojolu AO, et al. Cochrane Database Syst Rev.
2004;3.
11. Best KA, et al. In: Gynecology for the primary care
physician; 2007.
12. Kaunitz AM. Am J Obstet Gynecol. 2001;
185:S32-S37.
13. Kaunitz AM. N Engl J Med. 2008;358:1262-1270.
Hormonal Contraceptives
 Combination hormonal – pill, patch, vaginal ring
– Oral contraceptives are the most commonly used
method in the US1
– Available in various dose and cycle combinations of
estrogen and progestin
 Progestin-only – pill, long-acting/depot injection,
implant, levonorgestrel IUD
– Candidates include women with cardiovascular risk
factors, diabetes, lipid disorders, estrogen-related
side effects, migraine headaches,2 are post-partum
or breastfeeding3

1. Chandra A, et al. Vital Health Stat . 2005.

2. Black A, et al. J Obstet Gynaecol Can. 2004;26(3):236-242.
3. McCann MF, et al. Contraception. 1994;50(6Suppl 1):S1-S195.
Combination Oral Contraceptives
 20-50 mcg of estrogen (ethinyl estradiol or
equivalent dose of mestranol) + a progestin
– Suppress pituitary gonadotropin secretion
– Progestin is the more effective
ovulation inhibitor
– Progestin causes changes in cervical mucus and
endometrium, hindering sperm transport and
embryo implantation (if ovulation occurs)1,2
 Monophasic (constant doses of hormones) or
multiphasic (varying doses of hormones)
+/- placebo phase

1. Hatcher RA, et al. Contraceptive Technology; 2004.

2. Best KA, et al. In: Gynecology for the primary care physician; 2007.
Combination Oral Contraceptives
 Relatively effective:
8% failure rate during
first year of use1, since
most women do not
take them perfectly2
 Fertility returns soon
after discontinuation

1. Hatcher RA, et al. Contraceptive Technology; 2004.

2. Trussell J. In: Contraceptive technology ; 2007.
Combination Oral Contraceptive
Health Risks
Today’s lower-dose OC
Formulations (< 50 mcg estrogen)
Are Safe for Most Healthy Women
and Have Been Extensively Studied1

 Breast Cancer
– Large British2, US2,3, and Canadian4
studies found no increased risk with
former or current use
– Results are inconsistent from
studies of OC use among
BRCA-positive women5,6
1. Hatcher RA, et al. Contraceptive Technology; 2004.
2. Hannaford PC, et al. Br Med J . 2007;335:651-660.
3. Marchbanks PA, et al. N Engl J Med. 2002;346(26):2025-2032.
4. Silvera SA, et al Cancer Causes Control. 2005;16(9):1059-1063.
5. Milne RL, et al. Cancer Epidemiol Biomarkers Prev. 2005;14(2):350-356.
6. Narod SA, et al. J Natl Cancer Inst. 2002;94(23):1773-1779.
Combination Oral Contraceptive
Health Risks
Cervical Neoplasia
 Data from 24 epidemiological studies involving
26 countries showed almost double the risk for
invasive cervical cancer in women taking OCs for
five or more years1
 After stopping OCs, at 10 years the risk declined to
same as never users1
 Reanalysis found other factors to be: younger age at
first intercourse, younger age at first full-term
pregnancy, increasing parity, increasing number of
sexual partners, and increasing duration of OC use2

1. International Collaboration of Epidemiological Studies of Cervical Cancer. Lancet. 2007;370:1609-1621.

2. International Collaboration of Epidemiological Studies of Cervical Cancer. Int J Cancer. 2007;120(4):885-891.
 Combination Oral Contraceptive
Health Risks
Venous Thromboembolism (VTE)
 Varying reports regarding risk associated with
estrogen dose or type of progestin1-7
 Pregnancy, childbirth and puerperium are
associated with risk of VTE higher than that
associated with the use of OCs:
Low-Dose Pregnant Postpartum
OC Users1 Women9 Women9

VTE Incidence
10 - 15 95 - 96 511
per 100,000 Woman-Years

 VTE risk is further increased with OCs if there are specific

thromboembolic risk factors or underlying diseases6

1. Westhoff CL. Am J Obstet Gynecol. 5. Sidney S, et al. Contraception. 2004;70(1):3-10.

1998;179(3Suppl1):S38-S42. 6. Suissa S, et al. Contraception. 1997;56(3):141-146.
2. Gallo MF, et al. Contraception. 2005;71(3):162-169. 7. Farmer RDT, et al. Contraception. 1998;57(2):67-70.
3. Lidegaard Ø, et al. Contraception. 1998;57(5):291- 8. Best KA, et al. In: Gynecology for the primary care
301. physician; 2007.
4. Lidegaard Ø, et al. Contraception. 2002;65(3):187- 9. Heit JA, et al. Ann Intern Med. 2005;143:697-706.
196.
Combination Oral Contraceptive
Health Risks
Stroke
 Low-dose formulations do not
increase risk of thrombotic or
hemorrhagic stroke in healthy,
nonsmoking women1-4
 Risk increased in women with
underlying predisposing diseases
or other risk factors
Myocardial Infarction
 Risk of MI substantially increased among OC users over 35 who smoke;
smoking and OCs act synergistically to increase risk 2,5,6
Metabolic Effects
 Oral estrogen increases triglyceride levels7

1. World Health Organization Collaborative. Lancet. 5. Best KA, et al. In: Gynecology for the primary care
1996;348:505-510. physician; 2007.
2. Lidegaard Ø, et al. Contraception. 2002;65(3):197- 6. World Health Organization Collaborative. Lancet.
205. 1996;348:498-505.
3. Siritho S, et al. Stroke. 2003;34(7):1575-1580. 7. Godsland IF, et al. N Engl J Med. 1990;323:1375-
4. Schwartz SM, et al. Stroke. 1998;29(11):2277-2284. 1381.
Contraceptive Patch and Ring
 Alternative combined
hormone delivery systems,
used on a 28-day cycle
– 1 patch applied
weekly x 3, then removed
for one patch-free week
– 1 ring inserted and left
for 3 weeks, then removed for one ring-free week
 Time to achieve steady state hormone levels - back-up
contraceptive may be needed1-3

1. Ortho Evra Label Information. Ortho-McNeil Pharmaceutical Inc; 2008Jan.

2. NuvaRing Label Information. Organon; 2007.
3. Kaunitz AM. In: Gynecology for the primary care physician; 2008.
Contraceptive Patch and Ring
 Transdermal patch produces
higher exposure to estrogen1
 Postmarketing surveillance
found two-fold increase in risk of
non-fatal VTE with the patch2,3
 Contraindications to use of
combination OCs should also be
considered to apply to the patch
and ring

1. Ortho Evra Label Information. Ortho-McNeil Pharmaceutical Inc; 2008Jan.

2. Boston Collaborative Drug Surveillance Program.
3. U.S. Food and Drug Administration. Questions and Answers. Ortho Evra (norelgestromin/ethinyl
estradiol); 2008Jan18.
Progestin-Only Contraceptives
 Candidates include women with
cardiovascular risk factors, diabetes, lipid
disorders, estrogen-related side effects or
contraindications, migraine headaches1, are
post-partum or breastfeeding2
 In lactating women, no decrease in milk
production has been shown with progestin-
only contraceptives1
 Irregular bleeding and spotting are the most
common side effects3,4

1. Black A, et al. J Obstet Gynaecol Can. 2004;26(3):236-242.

2. Ortho Micronor Prescribing Information. Ortho-McNeil Pharmaceutical Inc.; 2005Oct .
3. Westhoff C. Contraception. 2003;68(2):75-87.
4. IMPLANON™ Package Insert. Organon USA Inc. 2006Jul.
Progestin-Only Contraceptives
Pill – Norethindrone 0.35 mg
 Amount of progestin is less than in low-dose combination
OC formulations
 Taken continuously without hormone-free interval
 Need to be taken consistently:
– Delay of 3 or more hours requires back-up contraception
for 48 hours1,2
– If more than one pill is missed, emergency contraception
is advised (as well as continuing the pills with back-up
contraception until Day 8 of new pack)3
 Some clinicians prescribe 2 pills daily in women with normal
ovulatory function (ie, if not postpartum or lactating)4

1. Ortho Micronor Prescribing Information. Ortho-McNeil Pharmaceutical Inc.; 2005Oct .

2. Nor-QD facts and comparisons at Drugs.com. 2007Dec5.
3. Edelman A. In: Practical gynecology: a guide for the primary care physician; 2008.
4. Kaunitz AM. UpToDate; 2007.
Progestin-Only Contraceptives
Depot medroxyprogesterone actetate Injection
 Given every 3 months by injection: deep IM
(150 mg of Depo-Provera)1 or SC (104 mg of depo-
subQ provera 104)2
 3% first year failure rate with typical use; 0.3% first
year failure rate with consistent use
 Menses may not return for months after
discontinuation3
 Return to fertility may be delayed by 10-18 months
after discontinuation1,2

1. DEPO-PROVERA Contraceptive Injection. Pharmacia & Upjohn Company; 2004Nov.

2. depo-subQ provera 104™. Physician Information. Pfizer Inc.; 2007Oct .
3. Hatcher RA, et al. Contraceptive Technology; 2004.
 Progestin-Only Contraceptives
Depot medroxyprogesterone
actetate Injection
 Bone mineral density:
– Decreased with
current use1,2
– Not linked to fractures
or postmenopausal osteoporosis1
– Appears to fully recover
after discontinuation3,4-11
 DMPA appears to have no impact on risk for cervical, ovarian, or
breast cancer, but significantly reduces endometrial cancer risk3
1. DEPO-PROVERA Contraceptive Injection. Pharmacia 6. Kaunitz AM, et al. Contraception. 2006;74(2):90-99.
& Upjohn Company; 2004Nov. 7. Scholes D, et al. Arch Pediatr Adolesc Med.
2. depo-subQ provera 104™. Physician Information. 2005;159:139-144.
Pfizer Inc.; 2007Oct . 8. Scholes D, et al. Epidemiol. 2002;13:581-587.
3. Black A, et al. J Obstet Gynaecol Can. 2004;26(3): 9. Petitti DB, et al. Obstet Gynecol. 2000;95:736-744.
236-242. 10. Orr-Walker BJ, et al. Clin Endocrinol. 1998;49:615-618.
4. Kaunitz AM. UpToDate; 2007. 11. Cromer BA, et al. J Adolesc Health. 2006;39:296-301.
5. Rosenberg L, et al. Contraception. 2007;76(6):425-431.
Progestin-Only Contraceptives
Implant – Etonogestrel 68 mg
 Non-biodegradable rod implanted
subdermally; left in place for up to 3 years,
then removed (and replaced, if desired)1
 does not rely on user to remember taking or
using the product (except at the end of the
3-year term
 Overall 3-year failure rate is 0.38%1
 Return to fertility after removal is within days
to weeks1,2

1. IMPLANON™ Package Insert . Organon USA Inc. 2006Jul.

2. Hatcher RA, et al. Contraceptive Technology; 2004.
Counseling for Hormonal
Contraception
 Provide information
about all available products
 Long-term options (IUD,
depot injection, implant)
are most effective, especially
for women with difficulty
managing their contraception
(e.g., due to access,
privacy issues, lack of follow-up)
 OCs can be initiated in 3 ways:
– On first Sunday after menses begin
– On first day of period
– Immediately, regardless of timing of menses = “Quick Start” method 1

1. Westhoff C, et al. Contraception. 2002;66(3):141-145.

Counseling for Hormonal
Contraception
 OCs need to be taken consistently for contraceptive efficacy
and reduced side effects1
 If combined OC pills are missed, patient to take pills according
to the following schedule:2
– 1 tablet missed – take as soon as remembered and continue
taking remainder of tablets at the same time daily as before
– 2 tablets missed – take 2 tablets as soon as remembered,
then 2 on the following day, use back-up contraception for
7 days, take remainder of tablets at the same time daily
as before
– More than 2 consecutive tablets missed - continue taking
1 tab at the same time daily as before, use backup
contraception (e.g., condoms and spermicide) until current
pill pack is finished

1. Kaunitz AM. In:, Textbook of primary care medicine ; 2001.

2. Edelman A. In: Practical gynecology: a guide for the primary care physician,;2008.
Counseling for Hormonal
Contraception
OC Side Effects
 Commonly include nausea, breast
tenderness, menstrual changes
(e.g., amenorrhea, unscheduled
bleeding, and spotting)
 Breakthrough bleeding occurs in about
25% of women within the first three
months of use, becoming less
frequent with time1,2
 Advise patients that side effects are
most likely to occur during first three
months of use and that these symptoms are not dangerous;
with regular and consistent pill-taking, side effects should
abate

1. Best KA, et al. In: Gynecology for the primary care physician; 2007.
2. Black A, et al. J Obstet Gynaecol Can. 2004;26(3):220-236.
Counseling for Hormonal
Contraception
OC Side Effects
 Unscheduled bleeding continuing after 3 months of OC
use, should be evaluated for other potential causes,
including cervical or endometrial infection or neoplasia,
pregnancy, polyps, fibroids, or use of medications that
interfere with estrogen metabolism (e.g., smoking,
antiepileptics, rifampin, St. John’s Wort)1
 Chlamydial cervicitis has been reported as a cause of late-
onset unscheduled bleeding in OC users2
 If prolonged spotting/bleeding (ie, seven days or more) on
an extended use OC, take a 3-day pill holiday; this is more
effective than continuing the contraceptive3
1. Hatcher RA, et al. Contraceptive Technology; 2004.
2. Krettek JE, et al. Obstet Gynecol. 1993;81(5 Part 1):728-731.
3. Best KA, et al. In: Gynecology for the primary care physician; 2007.
Counseling for Hormonal
Contraception
OC Side Effects
 Some long-term OC users
may experience amenorrhea,
which is not medically
harmful
 Inadvertent use of OCs
during early pregnancy is
not associated with an
increased risk for fetal
anomalies or miscarriage
 There are no consistent data to suggest associations
between weight gain or headaches and OC use
 If problems or noncompliance due to side effects, a
formulation adjustment can be made
Barrier Methods
 Have assumed greater importance in recent
years due to their ability to reduce the risk of
sexually transmitted infections
 Are commonly used with other methods of
contraception, e.g., with OCs – the pill and
condom are the most common contraceptive
method combination1
 Particularly appropriate for women in stable
relationships who can predict when they will
have intercourse

1. Chandra A, et al. Vital Health Stat. 2005.

Barrier Methods
Male Condom
 Inexpensive, available without
prescription in various sizes
 Available as latex (natural rubber),
polyurethane, animal (lamb intestine),
lubricated with spermicide or not
 Do not use with latex condoms, to
avoid degradation of the rubber –
this is not a problem with synthetic condoms:
– Oil-based lubricants (e.g., petroleum jelly, baby or mineral oil)1
– Vaginal estrogen or antifungal creams1,2
 Failure rate is about 15% over the first year of typical use
 Dual protection (ie, condom + more effective long-term method) is more
likely to provide effective contraception

1. Hatcher RA, et al. Contraceptive Technology; 2004.

2. It’s Your Health—Condoms. Health Canada; 2005Aug.
Barrier Methods
Female Condom
 Much more expensive than the
male condom
 Acts as a vaginal liner, with end of
sheath remaining outside to cover
vulva
 Failure rate is about 21% over the
first year of typical use
 Should not be used with male
condom – possibility of adherence
and slippage
Barrier Methods
Diaphragm
 Available in several materials, styles
and sizes
 Prescription-only; fitted by a health
professional
 Positioned to completely cover the
cervix, fitting behind the pubic bone
and the posterior vaginal fornix;1,2
may be used with a male condom1
 First-year pregnancy rate for typical use is 16%
 UTIs can be a side effect of diaphragm use3 – could switch to a
smaller diaphragm or one with a different rim1
 Vaginal irritation, recurrent yeast infection, and bacterial vaginosis
may also be caused by use of a diaphragm1
1. Hatcher RA, et al. Contraceptive Technology; 2004.
2. Title 21 – Food and Drugs, U.S. Food and Drug Administration Center for Devices and Radiological
Health; April 1, 2007.
3. Hooton TM, et al. N Engl J Med. 1996;335:468-474.
Barrier Methods
Cervical Cap
 Prescription-only
 Deeper, smaller cup than diaphragm;
more difficult to fit and place
 First-year failure rate varies between
parous and nulliparous women:
32% vs. 16%, respectively
Sponge
 After wetting is placed high in vagina
 Can be inserted up to 24 hours before intercourse and needs to be
kept in place for 6 hours after last encounter1
 Associated with higher discontinuation and pregnancy rates than
diaphragm2

1. How Do You Use the Today® Sponge. Synova Healthcare Inc.; 2007.
2. Kuyoh MA, et al. Cochrane Database Syst Rev. 2002;3.
Barrier Methods
Spermicides
 Chemical contraceptive barrier:1 surfactants (nonoxynol-9,
octoxynol-9) that destroy sperm’s cell membrane
 Recommended to be inserted into the vagina no more than
1 hour before intercourse; should be kept in place at least
6-8 hours afterwards2
 Failure rate during the first year of typical use of
spermicides alone is approximately 29%
 Efficacy may be dose-related, based on concentration
of spermicide3
 Spermicides do not protect against STIs and HIV4
1. ACOG Education Pamphlet; 2003Feb.
2. Birth Control Guide. FDA Office of Public Affairs; 2003Dec.
3. Raymond EG, et al. Obstet Gynecol. 2004;103:430-439.
4. FDA News. U.S. Food and Drug Administration; 2007Dec18.
 Intrauterine Devices (IUDs)
 Highly effective; convenient;
have non-contraceptive benefits1,2
 Two IUDs are available
in the US:
– Copper T 380A – for up to
10 years of use; cumulative
ten-year pregnancy rate
is about 2%3

– Levonorgestrel-releasing IUD –
for up to 5 years of use;
cumulative five-year pregnancy rate is <1% 4
 Can be inserted at any time in the menstrual cycle, provided the
woman is not pregnant

1. Curtis KM, et al. Contraception. 2007;75(6Suppl):S60-S69 .

2. Varma R, et al. Eur J Obstet Gynecol Reprod Biol. 2006;125:9-28.
3. Sivin I. Contraception. 2007;75(6Suppl):S70-S75.
4. Andersson K, et al. Contraception. 1994;49(1):56-72.
Intrauterine Devices (IUDs)
 Earlier concerns about infection and infertility are no
longer appropriate:
– Cohort studies have identified rapid return to fertility
after IUD discontinuation1,2
– Prophylactic antibiotics at time of insertion appear
unwarranted except in populations of women with a
high prevalence of sexually transmitted diseases 3
– Case controlled studies revealed no increase risk of
upper genital tract infection in women who had
undetected chlamydial infections at the time of
IUD insertion4,5
1. Skjeldestad F, et al. Adv Contracept. 1988;4:179-184. V
2. Wilson JC. Am J Obstet Gynecol. 1989;160:391-396.
3. Grimes DA, et al. Contraception. 1999;60(2):57-63.
4. Faúndes A, et al. Contraception. 1998;58(2):105-109.
5. Skjeldestad FE, et al. Contraception. 1996;54(4):209-212.
Intrauterine Devices (IUDs)
Benefits
 Non-medicated and copper IUDs are associated with a 40%
reduction in the risk of endometrial cancer, prevention that is
statistically significant and clinically important 1
 The levonorgestrel device reduces measured blood loss by
about 90% in heavy menstrual bleeding, providing
comparable benefit to endometrial ablation techniques 2 and
superior benefit to oral medications, such as progestins and
NSAIDs3
 The levonorgestrel device can be used to prevent
endometrial hyperplasia during menopausal treatment with
estrogen

1. Andersson K, et al. Contraception. 1994;49(1):56-72.

2. Marjoribanks J, et al. Cochrane Database Syst Rev. 2006;2.
3. Milsom I, et al. Am J Obstet Gynecol. 1991;164:879-883.
Emergency Contraception
 Intended to prevent pregnancy after intercourse
 Prevent pregnancy by:1
– Inhibiting or delaying ovulation
– Hormones may alter sperm or ovum transport
– Hormones may alter the endometrium, making it
inhospitable to the implantation of an embryo
 Hormonal ECs do not affect an established pregnancy, nor
do they harm a fetus if taken inadvertently during early
gestation1
 Begin within 72 hours of unprotected sex to reduce risk of
pregnancy by at least 75%2

1. Food and Drug Administration. Federal Register. 1997;62(February 25):8609-8612.

2. Trussell J, et al. Contraception. 1998;57(6):363-369.
Emergency Contraception
 Emergency contraceptives (ECs) have included:
progestins only, combination estrogen-progestin
oral contraceptives, synthetic estrogens and
conjugated estrogens, antiprogestins, and insertion
of a copper-releasing intrauterine device1
 If menses are delayed more than a week, it may
indicate that the EC has failed
 Women using intermediate or high failure rate
contraception should be educated and encouraged
to keep an advance supply of EC, and given a
prescription for Plan B

1. ACOG Practice Bulletin No. 69. Obstet Gynecol. 2005;106:1443-1452.

Emergency Contraception
Plan B – levonorgestrel
0.75 mg x 2 Tablets
 Approved for over the counter
sale to women over age 17
 Instructions are to take 1 tablet
within 72 hours of unprotected
intercourse, and the second
12 hours later
 Clinical trial supports taking both tablets as soon as possible after
unprotected intercourse1
 ACOG suggests taking the two tablets as a single dose, or spacing them
12 to 24 hours apart2,3
 ACOG notes that pills should be taken within 3 days and no later than 5
days after unprotected sex2

1. Von Hertzen H, et al. Lancet. 2002;360:1803-1810.

2. ACOG Education Pamphlet AP114 ; 2007 May.
3. ACOG Practice Bulletin No. 69. Obstet Gynecol. 2005;106:1443-1452.
Emergency Contraception
Copper Intrauterine Device
 Another EC option, but not approved for this
indication in the US
 When inserted up to 7 days after unprotected
intercourse, or 5 days after ovulation, has a 1%
failure rate1
 Has additional advantage of providing continuing
method of contraception

1. Hatcher, et al. Contraceptive Technology; 2004.

Surgical Contraception
Sterilization
 The most common form of
contraception reported by US females
aged 35 to 44 years1
 The types of procedures, in order of
frequency: tubal sterilization,
vasectomy, hysterectomy benefits:
– Perceived permanence
– User controlled; confidential
– Avoidance of cumbersome options
(barrier) or those requiring consistent
use (barrier, OCs)
– Alternative to contraindicated
methods, e.g., estrogen-containing

1. Chandra A, et al. Vital Health Stat. 2005.

Surgical Contraception
Sterilization
Female - Tubal Sterilization
 Actions taken on the fallopian tubes:
 ligation with excision, occlusion with rings, clips or insertion of coils,
and electrocoagulation/cautery of a portion of the tubes1-4
 Does not cause changes in menstruation1,4
 As an ambulatory procedure, is performed in about 50% of cases,5
mostly laparoscopically6
 Done transcervically by tubal occlusion1,3,7 – as an office procedure,
without incisions or general anesthesia1,3
 Many observational studies have noted that tubal sterilization results
in a decreased risk of ovarian cancer5,7
1. Edelman A. In: Practical gynecology: a guide for the primary care physician; 2008.
2. Hatcher RA, et al. Contraceptive Technology; 2004.
3. Fortin CA, et al. J Obstet Gynaecol Can. 2004;26(4):368-376.
4. Peterson HB. Obstet Gynecol. 2008;111(1):189-203.
5. Westhoff C, et al. Fertil Steril. 2000;73(5):913-922.
6. Kulier R, et al. Cochrane Database Syst Rev. 2004;3.
7. ACOG Practice Bulletin No. 46. Obstet Gynecol. 2003;102:647-658.
Surgical Contraception
Sterilization
Male – Vasectomy
 Ligation of the vas deferens
under local anesthesia in the
office setting
 Does not provide immediate
contraception:
– There may be sperm
remaining in the vas up to
three months after the procedure 1,2
– Scheduled testing of ejaculate to determine when it becomes negative for
sperm
– Alternate contraceptive practices are required during this time
– Not using back-up contraception is often the reason for perceived
vasectomy failure1

1. Fortin CA, et al. J Obstet Gynaecol Can. 2004;26(4):368-376.

2. ACOG Education Pamphlet AP011; 2005.
Fertility Awareness-Based Methods
 Periodic abstinence
 Patients need to identify
potentially fertile days
and abstain from
intercourse or use barrier
methods
 Best in women with
regular cycles
 Vaginitis or cervicitis can affect signs of fertility
 Estimated to have a 25% failure rate during first
year of use
Contraception in
Women with Medical Problems
 WHO lists conditions where
pregnancy may exacerbate risk to
a woman’s health1
 Need to determine contraceptive
methods that are safest, given a
woman’s underlying diseases or
conditions
 ACOG Practice Bulletin
Number 73 provides a consolidated
summary of “clinical considerations
and recommendations”2

1. Medical eligibility criteria for contraceptive use. WHO; 2004.

2. ACOG Practice Bulletin No. 73. Obstet Gynecol. 2006;107(6):1453-1472.
Contraception in
Women with Medical Problems
Migraines
 Chinese review of 3901 stroke
patients reported that oral
contraceptives and migraine
were significant risk factors
for stroke1
 Studies have reported that
individuals experiencing
migraines with an aura are
more likely to have strokes2-7
 Some women experience migraines in relation to menses, associated
specifically with estrogen level fluctuations8
– Use of extended cycle or continuous combination OCs may control hormonal
fluctuations and be a treatment option for contraception and migraine control

1. Liu XF, et al. Chin Med Sci J. 2005;20(1):35-39
[abstract].
2. Stang PE, et al. Neurology. 2005;64:1573-1577.
3. Kurth T, et al. Neurology. 2005;64:1020-1026.
4. Etminan M, et al. Br Med J. 2004Dec13.
5. Carolei A, et al. Lancet. 1996;347:1503-1506.
6. Donaghy M, et al. J Neurol Neurosurg Psychiatry.
2002;73:747-750.
7. Tzourio C, et al. Br Med J. 1995;310:830-833.
8. MacGregor EA, et al. Neurology. 2006;67:2154-2158.
Contraception in
Women with Medical Problems
Migraines
 The WHO1:
– Advocates caution (category 2 or 3) in the use of hormonal
contraception in migraineurs
– Disapproves use (category 3 or 4) in women older than 35
– Classifies those with aura as having unacceptable health risk
(category 4) for this method of contraception
 In general, hormonal contraception is not contraindicated in
women with migraines, however need to review predisposing
factors and migraine patterns before prescribing
 Appropriate alternatives include progestin-only, intrauterine
and barrier methods2

1. Medical eligibility criteria for contraceptive use. WHO; 2004.

2. Teal SB, et al. Obstet Gynecol Clin N Am. 2007;34:113-126.
Contraception in
Women with Medical Problems
Obesity
 Combination oral and
transdermal contraceptives
may be less effective
in the obese woman1
 Obesity, combination OCs,
and age all represent
independent risk factors
for venous thromboembolism
(VTE)1,2
 Progestin-only contraception does not appear to increase VTE risk 2
 Contraceptives for obese women older than age 35 include
DMPA, progestin implant, IUD, vasectomy of the partner; 3
or barrier methods

1. ACOG Practice Bulletin No. 73. Obstet Gynecol. 2006;107(6):1453-1472.

2. Grimes DA, et al. Contraception. 2005;72(1):1-4.
3. Holt VL, et al.Obstet Gynecol. 2002;99:820-827.
Contraception in
Women with Medical Problems
Drug Interactions
Antiepileptic Drugs that
 Hepatic enzyme inducers (most May Reduce
commonly antiepileptic Contraceptive Efficacy
medications) decrease via Enzyme Induction
contraceptive blood levels, of
carbamazepine
estrogen and progestin1-3, in users
felbamate
of combined OC and patch,
oxcarbazepine
progestin-only pill and implant3
phenobarbital
 Simplest option may be to change phenytoin
to contraceptive where reduced primidone
efficacy has not been topiramate
demonstrated: DMPA or an IUD
(copper or levonorgestrel)1,3,4

1. ACOG Practice Bulletin No. 73. Obstet Gynecol. 2006;107(6):1453-1472.

2. Kaunitz AM; 2007Feb7. 39 PowerPoint slides.
3. O'Brien MD, et al. Epilepsia. 2006;47(9):1419-1422.
4. Teal SB, et al. Obstet Gynecol Clin N Am. 2007;34:113-126.
Contraception in
Women with Medical Problems
Drug Interactions
 Rifampin, a known enzyme inducer, reduces OC hormone levels1;
herbal medications can also have an effect on OC metabolism,
e.g., St. John’s Wort2,3
 Various antiviral agents (for treatment of HIV) can have different
hepatic enzyme effects, being substrates, inducers, or
inhibitors1,2,4, therefore contraceptive methods that bypass the
potential for drug interactions are recommended, ie., IUDs4
 OCs have been shown to increase drug levels of lamotrigine;5
with problems occurring during pill-free phases or when starting
or stopping OCs

1. Johns Cupp M, et al. Am Fam Phys . 1998;57(1).

2. ACOG Practice Bulletin No. 73. Obstet Gynecol. 2006;107(6):1453-1472.
3. Black A, et al. J Obstet Gynaecol Can. 2004;26(3):220-236.
4. Teal SB, et al. Obstet Gynecol Clin N Am. 2007;34:113-126.
5. Christensen J, et al. Epilepsia. 2007;48(3):484-489.
Contraception in
Women with Medical Problems
Systemic Lupus Erythematosus
 Reluctance to use combined OC contraception due to concerns of
causing disease flares and venous thromboses (related to
vasculitis and prothrombotic antibodies)1
 Two 2005 studies (randomized, controlled, in women under 40 with
stable disease and negative for antiphospholipid antibodies):2,3
– Rates of disease flare similar for combination OC, progestin-only pill,
and copper IUD; no differences in disease activity among the three
treatment groups over the one-year follow-up3
– Thromboses in Mexican trial - 2 with progestin-only pill, 2 with
combination OC3
– Rates of disease flare similar in combination OC and
placebo groups2

1. Teal SB, et al. Obstet Gynecol Clin N Am. 2007;34:113-126.

2. Petri M, et al. N Eng J Med. 2005;353:2550-2558.
3. Sánchez-Guerrero J, et al. N Engl J Med. 2005;353:2539-2549.
Contraception in
Women with Medical Problems
Systemic Lupus Erythematosus
 Combined OCs and progestin-only pills can be safe in the
woman with mild, stable lupus
 With history of vascular or renal disease, or
antiphospholipid antibodies present, combination estrogen-
progestin contraceptives should be avoided and progestin-
only contraceptives would represent prudent alternatives 1
 Note that the US Food and Drug Administration has
removed immunosuppression as a contraindication for the
copper IUD2

1. ACOG Practice Bulletin No. 73. Obstet Gynecol. 2006;107(6):1453-1472.

2. Teal SB, et al. Obstet Gynecol Clin N Am. 2007;34:113-126.
Contraindications to Contraceptives
(adapted from WHO1)
Contraindicated
Condition/Personal Characteristics
Contraceptive Methods
Breastfeeding < 6 weeks postpartum Combination OC, patch, ring
Smoker > 35 years old Combination OC, patch, ring
High blood pressure
Combination OC, patch, ring
(systolic >160 mm Hg; diastolic > 100 mm Hg)
Vascular disease Combination OC, patch, ring
Previous or current DVT or pulmonary embolism;
thrombogenic mutations; stroke or previous Combination OC, patch, ring
cerebrovascular accident
Major surgery with prolonged immobilization Combination OC, patch, ring
Previous or current ischaemic heart disease;
Combination OC, patch, ring
complicated valvular heart disease
Migraine with aura Combination OC, patch, ring
Distorted uterine cavity Copper and progestin IUD

1. Medical eligibility criteria for contraceptive use. WHO; 2004.

Contraindications to Contraceptives
(adapted from WHO1)
Contraindicated
Condition/Personal Characteristics
Contraceptive Methods
All combination estrogen-progestin
Breast cancer
and progestin-only methods
Active viral hepatitis;severe
Combination OC, patch, ring
decompensated cirrhosis;hepatoma
Malignant gestational trophoblastic
Copper and progestin IUD
disease

Puerperal sepsis; postseptic abortion; Copper and progestin IUD

Copper and progestin IUD

Pelvic infections - do not initiate; monitor devices
already in situ
Pregnancy All forms of contraception
To any component(s) in any form of
Allergies
contraception

1. Medical eligibility criteria for contraceptive use. WHO; 2004.

Patient-Centered
Contraceptive Decision Making
Appropriate Contraceptive Selection Should Take Several
Variables Into Account:
 Effectiveness (typical use failure rate); side effects
 Perceptions and misperceptions about risks and benefits of
contraceptive use and pregnancy
 Likelihood and ability to comply with the regimen
 Frequency of intercourse
 Age
 Cost of the method and ability to pay for it
 Concomitant drug use; health status and habits
 Desired duration of contraception; reversible vs. non-
reversible method
Counseling for
Contraceptive Success
 Inform the woman about all
available products, including
long-term options
 Educate post-partum
lactating women on the
limitations of the lactational
amenorrhea method
 Many post-partum women
experience unplanned
pregnancy due to false
perception of reduced fertility
Counseling for
Contraceptive Success
 Strategies that may
increase uptake and
continuation of
contraceptive use include:
 Counsel thoroughly on
all contraceptive options,
even if patient states a
preference for a particular
contraceptive1
 Encourage long-acting
reversible contraceptives having top tier effectiveness
 Avoid “bundling” of unrelated preventive care (e.g., Pap smear) with contraceptive
initiation
 Avoid unnecessary delays of waiting for a menstrual period or a follow-up exam after
a pregnancy event

1. Lamvu G, et al. Contraception. 2006;73(4):399-403.

 Counseling for
Contraceptive Success
Strategies That May Increase
Uptake and Continuation of
Contraceptive Use Include:

 Encourage dual protection,1

particularly in young women2
 Include male partner in counseling
when possible and appropriate3
 Dispense advance EC, if possible,
giving advance EC prescription to
all women under age 184,5

1. Berer M. Reprod Health Matters. 2006;14(28):162-170.

2. Department of Health and Human Services. Data from the National
Health and Nutritional Examination Survey (NHANES) 2003-2004.
3. Beenhakker B, et al. Contraception. 2004;69(5):419-423.
4. Raine T, et al. Obstet Gynecol. 2000;96(1):1-7.
5. Lo SS, et al. Hum Reprod. 2004;19(10):2404-2410.