Contraception Options

Introduction to Contraception

• The American College of Obstetricians and Gynecologists and other authorities provide guidelines for various contraception methods, including intrauterine devices, barrier methods, and injectable contraceptives 1, 2, 3

Intrauterine Devices

• The American Academy of Allergy, Asthma, and Immunology suggests that copper IUDs are well-tolerated in women with hereditary angioedema, with an 83.3% tolerance rate 1

Barrier Methods

• The American College of Obstetricians and Gynecologists indicates that barrier methods are not associated with problems for women in this age group 1

Injectable Contraceptives

• The Centers for Disease Control and Prevention recommends considering self-administered subcutaneous DMPA-SC (104 mg) as an alternative to provider-administered injections if the patient prefers this approach, with the standard dose of Depo-Provera being 150 mg administered by deep intramuscular (IM) injection in the gluteal or deltoid muscle, or 104 mg subcutaneously every 13 weeks 3, 2
• Depo-Provera injections should be administered every 3 months (13 weeks), with a grace period allowing administration up to 15 weeks from the previous injection without requiring additional contraceptive protection, as recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC) 2, 3, 4, 5, 6
• The typical use failure rate of Medroxyprogesterone acetate (MPA) injection is approximately 6%, and the perfect use failure rate is less than 1% 4, 3, 5
• Menstrual irregularities are common initially but typically improve over time, with amenorrhea developing in many long-term users, and weight gain is a common side effect, with studies suggesting that weight gain at 6 months is a strong predictor of future excessive weight gain 2, 4

Benefits and Risks

• Depo-Provera is associated with decreased bone mineral density, and regular monitoring is recommended to assess bone health, with the American College of Obstetricians and Gynecologists recommending daily intake of 1300 mg calcium and 600 IU vitamin D, regular weight-bearing exercise, and smoking cessation to mitigate reductions in BMD associated with MPA use 4, 3
• Progestin-only methods, including the Mirena IUD, are appropriate for women with contraindications to estrogen-containing contraceptives, including those with rheumatic diseases or antiphospholipid antibodies, and are classified as Category 1 (no restrictions for use) by the CDC's Medical Eligibility Criteria for Contraceptive Use for women at high risk for HIV and other conditions 7, 8
• Depo-Provera is safe for use in women with HIV, with no evidence of increased infectious complications or significant interactions with antiretroviral medications, and can be used in women with hereditary angioedema caused by C1 inhibitor deficiency 9, 1, 6, 10, 11, 12

Special Considerations

Follow-up and Counseling

• Regular follow-up every 3 months is recommended to assess side effects management, bone health considerations, and weight changes, with patients instructed to contact healthcare providers if they experience side effects or have questions 3, 4
• Thorough counseling about expected menstrual changes, such as menstrual irregularities and amenorrhea, reduces discontinuation rates, and patients should be aware that Depo-Provera provides contraception but not STI protection 3, 4, 5, 2
• A backup method (condoms or abstinence) should be used for at least the first week after starting MPA, as it provides no protection against STIs 4
• The median time for return to ovulation after discontinuation is approximately 30 weeks, with a 97.4% cumulative rate of return to ovulation at 12 months 4