Contraception Guidelines

Introduction to Contraception

• Contraception should be maintained until menopause is confirmed (usually around 50-55 years old) or until the age of 51, as recommended by the American Academy of Family Physicians and the Centers for Disease Control and Prevention 1, 2
• The choice of contraceptive method should be based on factors such as desired contraceptive efficacy, tolerance to side effects, and coexisting medical conditions, as recommended by the American Academy of Pediatrics 3, 4

Estrogen Content and Breakthrough Bleeding

• Switching to a monophasic pill with higher estrogen content (30-35 μg ethinyl estradiol) is more effective at reducing breakthrough bleeding, as evidenced by studies, according to the American College of Obstetricians and Gynecologists 5
• Breakthrough bleeding is the most common issue when restarting oral contraceptives after discontinuation, and contraceptive protection is lost after missing pills for ≥48 hours, according to the Centers for Disease Control and Prevention and the American Academy of Pediatrics 2, 3
• Patients should be informed that irregular bleeding is common when restarting oral contraceptives and typically resolves within 2-3 cycles, as explained by the Centers for Disease Control and Prevention 2

Contraceptive Methods and Efficacy

• Long-acting reversible contraceptives (LARCs), such as IUDs and implants, have a typical failure rate of less than 1%, as reported by the American Academy of Family Physicians and the Centers for Disease Control and Prevention 1, 2, 6
• The following contraceptive methods have the corresponding typical failure rates:

Special Considerations

• Estrogen-containing contraceptives are potentially harmful for women with cardiovascular disease who are at high risk of thromboembolic events, as stated by the European Society of Cardiology and American College of Cardiology/American Heart Association guidelines 7, 8
• The levonorgestrel-releasing intrauterine device (LNG-IUD) is the safest and most effective contraceptive for women with cardiovascular disease, with no increased risk of thromboembolism, as recommended by the European Society of Cardiology guidelines 7, 8
• Estrogen-containing contraceptives should be avoided in women with Von Willebrand disease and those at high risk of thromboembolic events, as recommended by the American College of Cardiology 9, 8
• The levonorgestrel-releasing intrauterine device reduces menstrual blood loss by 40-50% and induces amenorrhea in many users, addressing complaints of heavy menses, and is recommended for women with Von Willebrand disease due to its better safety profile and reduced risk of bleeding complications 7, 10

Contraceptive Insertion and Maintenance

• No antibiotic prophylaxis is needed at insertion of the levonorgestrel-releasing intrauterine device, and the patient should be counseled about potential vasovagal reactions during insertion, which occurs in approximately 5% of patients 7
• The copper IUD placement procedure usually takes 5-10 minutes and can be done during any point in the menstrual cycle, and taking NSAIDs, such as naproxen 500-550mg, 1 hour before the procedure can help reduce discomfort, as recommended by the American College of Obstetricians and Gynecologists 11
• The levonorgestrel-releasing intrauterine device provides contraception for up to 5 years, requiring minimal maintenance, and the copper IUD is effective for up to 10 years and has typical and perfect use failure rates less than 1% 12

Emergency Contraception and Permanent Options

• The Centers for Disease Control and Prevention recommends that the copper IUD can also be used as emergency contraception up to 5 days after unprotected intercourse 12, 13
• If a pill is missed, the patient should follow a specific protocol: if less than 24 hours late, take the pill as soon as remembered; if 24-48 hours late, take the most recent missed pill and use a backup method for 7 days; if more than 48 hours late, take the most recent missed pill, use a backup method for 7 days, and consider emergency contraception if unprotected intercourse occurred, as recommended by the Centers for Disease Control and Prevention and the American Academy of Pediatrics 2, 3
• To restart oral contraceptives, it is recommended to start a new pack immediately, regardless of where the patient is in her menstrual cycle, and use backup contraception for 7 consecutive days, as advised by the Centers for Disease Control and Prevention 2, 3
• Tubal ligation (for women) or vasectomy (for partners) is a permanent option to consider when the family is complete, with an efficacy of >99%, as stated by the American Academy of Family Physicians 1