Contraception: A Primer for Pharmacists Materials

CONTRACEPTION: A PRIMER FOR PHARMACISTS

Liz Fredrickson, PharmD, BCPS

Liz Fredrickson is an Associate Professor of Pharmacy Practice and Pharmaceutical Sciences at the Northeast Ohio Medical University (NEOMED) College of Pharmacy. She completed a PGY1 residency and practiced as an Internal Medicine Clinical Pharmacy Specialist. She serves as Director of Instructional Labs and is course director for the Basic Pharmaceutics Lab and Parenteral Products and Parenteral Products Lab courses.

Topic Overview

Contraception is the use of methods or techniques to prevent pregnancy. Nearly all women who have ever had sexual intercourse have used some form of contraception, and 88% of women who seek pregnancy prevention report using contraception at any given time. Patients seeking contraception should be informed and supported through a shared decision-making model with their healthcare providers. Contraceptive counseling can be implemented to determine a patient’s preferences, values, and insights and ensure reproductive goals are being met. Additionally, providing evidence-based education on the use, efficacy, and side effects ensures that patients are well- informed and utilize contraception safely and effectively. This course will detail currently available nonhormonal and hormonal contraceptive options, with a review of appropriate use, failure rates, pertinent side effects, and contraindications. This course will also discuss strategies for selecting a contraceptive method and counseling patients on the selection and use of contraceptives.

Accreditation Statement:

RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.

Universal Activity Number: The ACPE Universal Activity Number assigned to this activity is 

Pharmacist  0669-0000-23-062-H99-P

Pharmacy Technician 0669-0000-23-063-H99-T

Credits: 1 hour of continuing education credit

Type of Activity: Continuing education

Media: Internet Fee Information: $4.99

Estimated time to complete activity: 1 hour, including Course Test and course evaluation

Release Date: March 28, 2023 Expiration Date: March 28, 2026

Target Audience: This educational activity is for pharmacists.

How to Earn Credit: From March 28, 2023, through March 28, 2026, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Study the section entitled “educational activity;” and

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

Credit for this course will be uploaded to CPE Monitor®.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Compare and contrast contraceptive methods

Recall indications, contraindications, side effect profiles, and monitoring parameters for contraceptives

Identify important considerations when selecting and counseling patients on contraceptives

Disclosures

The following individuals were involved in developing this activity: Liz Fredrickson, PharmD, BCPS, Pamela M. Sardo, PharmD, BS, and Susan DePasquale, MSN, PMHNP-BC. Pamela Sardo, PharmD, BS, was an employee of Rhythm Pharmaceuticals until March 2022, and has no conflicts of interest or relationships regarding the subject matter discussed. There are no financial relationships relevant to this activity to report or disclose by any of the individuals involved in developing this activity.

© RxCe.com LLC 2022: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.

Introduction

Contraception helps patients prevent pregnancy. Contraceptive methods may be hormonal or nonhormonal. Patients considering contraception have unique medical histories, preferences, and values that a clinician must review and consider when counseling them. Patients will also want to know how contraceptives are administered, failure rates, side effects, and contraindications. Strategies for selecting a contraceptive method are incorporated into patient counseling on the selection and use of contraceptives. Counseling is done through a shared decision-making process that involves the patient and the medical team. Once a method has been selected, adherence to the plan is crucial and correlates with patient satisfaction.

Overview of Contraception

Contraception is the use of methods or techniques to prevent pregnancy. Nearly all women who have ever had sexual intercourse have used some form of contraception, and 88% of women who seek pregnancy prevention report using contraception at any given time.1 In addition, rates of pregnancy are as high as 45% in the United States, and thus understanding available contraceptive options helps clinicians inform patients and promotes reproductive autonomy.2

Patients seeking contraception should be informed and supported through a shared decision-making model with their healthcare providers.3 To ensure reproductive goals are met, the choice of contraceptive method should depend not only on a patient’s medical history but their preferences, values, and insights.3 Additionally, providing evidence-based education on the appropriate use, efficacy, and side effects associated with contraceptives ensures patients are well-informed and utilize contraception safely and effectively.3

Contraceptive Options

Contraceptive methods prevent pregnancy through many mechanisms, including via barrier methods, by preventing ovulation, or by creating a hostile uterine environment that prevents a fertilized ovum from successfully implanting.4 They can be broadly classified as hormonal versus non-hormonal methods or long-acting versus short-acting methods.1 Despite commonalities in mechanisms of action, contraceptives can differ greatly in their efficacy, side effect profiles, and contraindications. Important considerations that influence the choice of contraception include failure rate, safety, and return to fertility.5

Contraceptive failure is an important consideration when counseling patients and is a means by which to assess the effectiveness of a contraceptive method.5 Failure is defined as the percent of women who will have an unintended pregnancy occur during the first year of contraceptive use and can be considered either perfect-use failure or typical-use (user) failure.4,5 Perfect- use failure occurs when the patient used the contraceptive properly, but the pregnancy still occurred.4 Typical-use failure accounts for both perfect-use failure and failure subsequent to a patient not following directions or staying adherent to therapy.4 Failure rates are generally reported as typical-use failures given these include both perfect-use and user-failure rates.4 Health care providers can assist women with preventing unintended pregnancies by providing education on the correct use of contraceptives, thereby lowering typical-use failure rates. Table 1 details failure rates associated with perfect use and typical use of various contraceptive methods.5

Table 1. Failure Rates of Birth Control Methods

Table 1 adapted from Britton, et al. (2020)5

Nonpharmacologic Therapies Fertility Awareness Methods

Fertility-awareness methods center on a couple avoiding sexual intercourse during times of the menstrual cycle when conception may occur.6 There are many available methods that fall under the term fertility-based methods, each with varying levels of effectiveness and user-friendliness.6 These methods include the use of physiological data, such as basal body temperature and cervical mucus changes, to determine a fertility window.6 While perfect adherence to these methods can lead to effectiveness, they require a strong understanding and commitment from both partners.6

Barrier Techniques

Like fertility-based methods, the success of barrier techniques lies in a patient’s ability to use them consistently and correctly.4 Because of this, they are associated with higher failure rates than other methods.4 Barrier techniques include the use of male condoms, which are also called rubbers, sheaths, prophylactics, and skins.7 Male condoms work by preventing semen from directly contacting the vagina.4 Condoms can be made from either latex, polyurethane, or lamb cecum and (aside from lamb cecum condoms) have the added benefit of preventing sexually transmitted infections (STIs) and sexually transmitted diseases (STDs).7 Latex condoms are available in numerous sizes, shapes, and thicknesses.7 Latex condoms should only be used with water-based lubricants, because oil-based formulations can degrade these condoms, making them less effective.4,7 Polyurethane condoms do not have this risk.7 Internal (female) condoms are available as well. These are polyurethane sheaths with a flexible ring at the bone ends.4 Internal condoms have higher failure rates than external condoms and should never be used in conjunction with external condoms.4 Patients should be counseled on the correct use of condoms, which includes placing the condom correctly and avoiding the reuse of a condom. Other barrier methods include diaphragms and cervical caps.

Pharmacologic Therapies

Spermicides

Spermicides are chemical surfactants (surface-active agents) that kill sperm by destroying their cell walls and preventing sperm from entering the cervix.4,7 They are available in many formulations, including creams, films, foams, gels, suppositories, sponges, and tablets.7 Over-the-counter spermicides contain an agent called nonoxynol-9.7 A prescription spermicide is also available that contains lactic acid, citric acid, and potassium bitartrate.4 It works by lowering pH and reducing sperm motility.1 Spermicides differ in their method of application, onset, and duration of action, and pharmacists should counsel patients on appropriate use.7

Nonhormonal Contraceptive Intravaginal Gel

Phexxi is an intravaginal, nonhormonal gel that provides a new barrier method option for patients.2,8 It includes lactic acid 1.8%, citric acid 1%, and potassium bitartrate 0.4%.2,8 Patients should be counseled to insert the gel within 1 hour before intercourse.2,8 By maintaining the acidic environment of the vagina, it is able to inhibit sperm motility while also acting as a barrier to sperm at the cervix via its viscous texture.2,8 In terms of typical use, intravaginal gel was shown to have an efficacy rate of 86.3% in the AMPOWER study.2 Common side effects include vaginal burning (18% of users) and itching (14.5% of users).8 Patients may possibly experience cystitis and urinary tract infections as well.2,8

Phexxi may benefit patients who desire a nonhormonal birth control option but do not wish to utilize the copper (nonhormonal) intrauterine device, those who prefer an on-demand option, and those who have allergies or do not wish to use condoms.2 The gel is also a reasonable option for women who are postpartum or breastfeeding, those who need a short-term alternative birth control method, and those approaching menopause.2 It should be noted this is not preferred for women who desire a highly efficacious form of birth control.2

Hormonal Contraception

Hormonal contraceptives are comprised of estrogen and progestin or a progestin alone.4 This type of birth control is available in many formulations, including oral contraceptives (OC), transdermal patches, vaginal rings, long- acting injections, subdermal implants, and intrauterine devices (IUD).4

Combined Hormonal Contraceptives

Combined hormonal contraceptives (CHCs) work to prevent conception before fertilization occurs by inhibiting the hypothalamic-pituitary axis.4,5 CHCs contain both progestin and estrogen.4,6 Progestins are synthetic forms of progesterone and there are many types available, with differences in their estrogenic, antiestrogenic, and androgenic effects.4 Progestins thicken cervical mucus, which prevents sperm penetration, delays sperm transport, and causes atrophy of the endometrium.4,5 Progestins also suppress ovulation by lowering LH levels.4,5 Estrogens suppress FSH release, preventing dominant follicle development, and play an important role in providing cycle control.4,5 Synthetic estrogens used within CHCs include ethinyl estradiol (EE). EE is the most utilized estrogen, with doses ranging from less than 20 mcg to 50 mcg.4 EE has a long half-life, which lends to its efficacy and effects on bleeding control.2 Some women may be intolerant to EE, and fortunately, there are other estrogens available, including estradiol valerate and estetrol.2 Esterol is a novel estrogen included in the product Nexstellis.2 Research has found it causes minimal impact on the synthesis of coagulation factors and hepatic metabolism, and studies have shown a decreased incidence of venous thromboembolism when compared to traditional combined oral contraceptives.2 Newer estrogens have demonstrated similar side effects as their traditional counterparts.2

Combined hormonal contraceptives are available in various forms, including oral pills, vaginal rings, and transdermal patches.5 They are moderately effective at preventing pregnancy.5

Combined Oral Contraceptives (COC)

Combined oral contraceptives are available in monophasic and multiphasic forms. Monophasic COCs contain equivalent amounts of estrogen and progestin and are taken for 21 days.4 The following seven days include a set of placebo pills.4 Multiphasic forms can be biphasic, triphasic, or quadriphasic, with varying amounts of estrogen and progestin.4 They also follow a 21-day estrogen and progestin phase followed by seven days of placebo pills.4 Natazia is an available quadriphasic regimen that includes estradiol valerate and dienogest as the progestin.2,9 It has been used to treat heavy menstrual bleeding.2,9 Data has not demonstrated a significant difference in either safety or efficacy for the multiphasic vs monophasic tablets.4 COCs can also be taken in an extended-use fashion.4 In these cases, the active tablets are taken continuously for at least 84 days and this is followed by seven days of inactive pills or pills that only contain estrogen.4

The choice of COC will depend on the hormonal content, dose, preferred formulation, and any existing medical conditions the patient may have.4 In general, a COC that has 35 mcg or less than EE is recommended, as it may be associated with less risk of thromboembolism, stroke, or myocardial infarction (MI).4 However, women may be at a greater risk of pregnancy when using COC that contain less than 35 mcg of EE.4 Compared to progestin-only contraceptives, COCs generally produce a more regular and consistent pattern of bleeding for patients.1

Initiating Combined Oral Contraceptives

Patients may choose from several methods when starting a COC regimen. These include taking the first pill on the first day of their menstrual cycle, taking the first pill on the first Sunday after their menstrual cycle begins, or using a quick start method (starting the day they receive the pills).4 When using the quick start method, the menstrual period will be delayed until the active tablets have been completed within the pack.4 Women should use a second method of contraception (such as condoms) or avoid sexual

intercourse for a minimum of seven days after starting any oral contraceptive.4

Side Effects of Combined Oral Contraceptives

Common side effects associated with COC include nausea, bloating, and breakthrough bleeding.4 These tend to improve over time as hormone levels adjust.4 Due to these hormonal changes, it is generally recommended not to switch formulations before a COC has been used for at least 2-3 months.4 Irregular bleeding can also occur with the use of COCs, and this commonly occurs during the first six months of therapy.1,4 The acronym ACHES is used to remember serious side effects of COCs that should be immediately discussed with a provider and will likely result in discontinuation of COC.4 These side effects include abdominal pain, chest pain, headaches, eye problems, and severe leg pain.4

Clinicians should be diligent in assessing potential drug-drug interactions with COCs. In general, women should be counseled to use a second form of birth control if there is a possibility for a drug interaction with their COC. Rifampin can decrease the effectiveness of birth control.10 Other antibiotics may as well, but these interactions are not as well documented.4 Women taking anticonvulsant medications such as phenobarbital, carbamazepine, or phenytoin should utilize a form of birth control other than COC.4 These anticonvulsants can metabolize estrogen and progestin, which reduces COC efficacy.4 Other potential drug interactions involve antiretroviral medications, which can decrease the effectiveness of COC; medications that increase potassium, which could result in hyperkalemia in women taking drospirenone; and St. John’s Wort, which may decrease COC effectiveness.4 In general, all of a patient’s medications should be reviewed to ensure no drug-drug interactions will affect the safety and efficacy of contraceptive therapy.

Counseling Patients on Combined Oral Contraceptives

Patients should be counseled on what to do if one or more doses of their COC are missed. If patients miss one dose of their medication, they should be told to take the tablet as soon as they remember and then take the remainder as prescribed.4 If two or more doses are missed, they should take one of the missed tablets and discard the rest.4 In this case, they should also use a second form of contraception until the active hormone tablets have been taken for at least seven days. They may also require counseling on the use of emergency contraception.

Transdermal Contraceptives

Two transdermal patches are available: Xulane, which contains 0.75 mg of EE and 6 mg of norelgestromin, and Twirla, which contains 30 mcg of EE and 120 mcg of levonorgestrel.11,12 To date, there is no head-to-head comparison of these two patches.2 Twirla offers the benefit of lower doses of hormones, lower detachment rates, and less site irritation compared to Xulane.2 Twirla users also experienced less nausea, headaches, and fatigue compared to COC users.2 The norelgestromin patch tends to cause less breakthrough bleeding and spotting compared to COC by cycle 13.2

In patients who weigh less than 90 kg, the patch is as effective as oral contraceptives.4 It is not recommended to be used first-line in patients weighing more than 90 kg, given the results of comparative trials.12 The patch can be applied to the abdomen, buttocks, upper torso, or upper arm at the start of a menstrual cycle, and it is removed and replaced weekly for 3 weeks.

11 The fourth week of the cycle is patch-free.11 Once the patch is applied, steady-state levels are reached within 48 hours and then maintained until the patch is removed.2

Patients should be counseled only to wear one patch at a time.11 If the patch is removed for less than 24 hours (for any reason), it can be replaced (or a new patch used), and no secondary birth control method is needed.11 If it is removed for more than 24 hours, a new patch should be applied, and a

secondary form of contraception used for at least 7 days.11 If the patch is removed during the third patch week, the hormone-free week should be skipped, and a new patch should be applied instead. 11

Side effects of the transdermal patch include application-site reactions (erythema, irritation) and effects like those of OCs, including headache and nausea.11,12 The patch does contain 60% more estrogen than OC, and thus may place patients at greater risk of thromboembolic events.11 The patch may benefit patients who have trouble with adherence, and the higher estrogen dose in norelgestromin can benefit those with acne.2 Women at higher risk of VTE should not use the patch.2

Vaginal Rings

Various vaginal rings are available for use, including NuvaRing, EluRyng, and Annovera.13-15 NuvaRing and EluRyng contain both EE and etonogestrel, while Annovera contains segesterone acetate and ethinyl estradiol.13-15 Nuvaring and EluRyng are placed for three weeks at a time, during which they release 15 mcg of EE per day and 120 mcg of etonogestrel per day.13-15 The ring is inserted on or before day 5 of the menstrual cycle.4 It is kept in place for 3 weeks, then removed for 1 week to allow for bleeding.13,14 The exact placement of the ring is not an issue because hormones are able to be absorbed anywhere in the vagina.13,14 There is also no risk of inserting the ring too far, as the cervix will block it.13,14

Rings should never be flushed down the toilet and instead placed into the foil patch and discarded in the trash.4 If either the Nuvaring or EluRyng is displaced for less than 3 hours, a new ring can be placed with no secondary form of birth control required.4 However, if it has been displaced for three or more hours, a new ring should be placed, and a secondary form of birth control used for at least seven consecutive days.4 If the ring should become displaced during the third week of use, a new ring should be placed and kept in place for 21 days.4 It is recommended to rinse the ring in lukewarm water prior to reinsertion.13,14

Annovera is a 13-cycle combined vaginal ring that offers patients a year of birth control while using the same ring.15 It is placed for 21 days and then removed for 7 days to allow for menses.15 The effectiveness of Annovera has been shown to be 97.3% when used as recommended.2 Expulsion of Annovera is more likely in the first cycle, and patients do not require a backup contraceptive method if the ring is reinserted within 2 hours.2

The side effects and warnings associated with vaginal ring use are like those associated with OCs. Patients may discontinue use due to vaginal symptoms or device expulsion.4 However, many patients experience better cycle control with the vaginal ring compared to the use of OC.4 In general, patients do not find the use of the ring to be uncomfortable.4 Vaginal rings may not be preferred by patients who find rings painful or uncomfortable, those with arthritis in the hands, those with pelvic floor dysfunction, and those with other conditions which may limit correct placement and use of vaginal rings.2 The ring is beneficial for patients seeking a reversible, longer-acting method that is not an injection and does not require the daily adherence of an oral method.2

Important Considerations of CHC Use

Armed with knowledge of the benefits and risks of CHCs, pharmacists can assist clinicians and their patients in making informed decisions regarding contraceptive therapy. The form of CHC chosen must be appropriate for the patient based on their medical history, lifestyle, ability to adhere to therapy and goals of therapy.1,4 Per the American College of Obstetricians and Gynecologists (ACOG), clinicians should complete a thorough medical history and obtain a blood pressure reading before prescribing OC.16,17,18 A discussion of the goals of therapy and risks/benefits should be had with the patient before determining the best choice of CHC. CHCs can provide patients with numerous non-contraceptive benefits such as decreased menstrual cramps, improved menstrual regularity, improved acne, and a decrease in iron deficiency anemia.4 Patients may prefer a certain type of CHC to assist with these benefits as well.

Patients should be counseled that CHCs do not protect against STDs and STIs, and patients should be counseled on the appropriate use of condoms to prevent these conditions.4 The following is a list of absolute and relative contraindications to the use of OC that should be reviewed by pharmacists.2

Women Older than 35 Years of Age: Women can remain fertile into their 40s, thus the use of contraception is important in this cohort. The benefit of using OC should be weighed against potential risks, which can include an increased risk of VTE in perimenopausal women older than 40.4 When low-dose formulations are used in healthy, non-obese women older than 40, there is not a significant risk of cardiovascular disease.4 If women older than 35 years of age have migraine disorders with aura, uncontrolled hypertension, smoke, or have diabetes with vascular disease, they should not be prescribed CHCs.17

Smoking: Women older than 35 years of age who smoke and use CHCs may have an increased risk of MI or stroke.4 Women who meet these criteria should only be prescribed CHCs cautiously, and other methods of birth control should be explored. If women smoke more than 15 cigarettes a day, CHC use is contraindicated.17 These women should consider the use of progestin-only or non-hormonal contraceptive options.4

Hypertension: CHC use can lead to small increases in blood pressure, regardless of the dose of estrogen prescribed.4 Some studies have demonstrated an increased risk of MI and stroke in patients with hypertension who use CHCs.4 Low-dose CHCs may be considered in women less than 35 years of age who have well-controlled blood pressure. If a woman has uncontrolled hypertension, with a systolic blood pressure greater than 160 mmHg or a diastolic blood pressure greater than 100 mmHg, CHCs should be avoided, and alternative methods sought.4

Dyslipidemia: There is the potential for progestins to decrease high- density lipoprotein (HDL) levels while increasing low-density lipoprotein

(LDL) levels.4 Conversely, estrogens may benefit patients by increasing the removal of HDL and increasing HDL levels.4 Overall, low-dose CHCs will not significantly impact lipid levels and, thus, women with dyslipidemia as a single risk factor can use CHCs.2 However, if they have multiple cardiovascular risk factors, alternative methods of contraception should be sought.4

Diabetes: Low-dose CHCs should not significantly impact women with diabetes in terms of either glucose or hemoglobin A1c levels.4 If a patient has diabetes and vascular disease, or has had diabetes for more than 20 years, they should not use CHCs.4

Migraine Headaches: CHC use has been shown to both increase or decrease the frequency with which women with migraines experience these types of headaches.4,18 Women who have migraines with aura may be at an increased risk of stroke if they use CHCs.4 CHCs can be used in women with migraines without aura who are otherwise healthy.4 Women with migraines with aura should not use CHCs regardless of age and should consider other contraceptive methods or a progestin-only OC.4,19

Breast Cancer: Women who use CHCs may be at a slightly increased risk of developing breast cancer compared to those who never used hormonal contraception.16 This risk is greater the longer CHCs are used and in women older than forty.2 The risk of breast cancer returns to levels of non-CHC users once CHC use is discontinued.2 Women older than 40 or those with an increased risk of breast cancer should not use CHCs.2

Thromboembolism: Women who use CHCs are at a three-fold higher risk for thromboembolic events than those who do not.4 This includes deep vein thrombosis (DVT) or pulmonary embolism (PE). The underlying mechanism is increased hepatic production of Factor VII, Factor X, and fibrinogen within the coagulation cascade via estrogen.4 New progestins used in OC (such as norgestimate and drospirenone) may incur a higher risk.4 Product labeling on the transdermal patch, as well as products

with drospirenone, now contain a warning regarding the risk of thromboembolism.20 Women with an increased baseline risk of thromboembolism should consider CHCs that contain either older progestins or other non-hormonal forms of birth control.4

Obesity: Obese women may be at an increased risk of birth control failure; however, the risk of CHCs and non-hormonal birth control failing is low.4,17 Additionally, use of progestin-only contraceptives are safe to use in obese women.4

Progestin-Only Contraceptives

Progestin-only contraceptives, as the name implies, contain progestin without estrogen.5 These contraceptives are available as pills, implants, injections, and intrauterine devices (IUDs).

Progestin-Only Pills (POPs)

POPs contain either norethindrone or drospirenone.1,5 Norethindrone is dosed at 0.35 mg daily and drospirenone at 4 mg daily.2 Drospirenone is a spironolactone derivative and has antiandrogenic properties; therefore, it may benefit patients through its effects on acne and fluid retention.2,21 POPs work by inhibiting ovulation in 50-70% of user cycles and can prevent pregnancy through mechanisms that impact cervical mucus.2 Patients can use POPs to bridge other forms of birth control (such as one requiring a future procedure).2 Benefits of use include quick return of fertility following cessation of therapy, minimal side effects, and safety for patients who may have contraindications to CHCs.4,5 Use of progestin-only pills requires strict adherence from patients. These pills are taken on a continual basis, with no interval of hormone-free pills.5 Missing a progestin-only OC is different from missing a combined hormonal OC. Norethindrone pills have a shorter half-life than CHC pills, and if a woman is only three hours late in taking the progestin-only tablet, a second form of birth control should be used for at least 48 hours.4,5

Common side effects of POP include prolonged or unscheduled bleeding that is more likely to occur during the first six months of therapy.2 Patients may eventually notice lighter or absent periods over time.2 Clinicians should counsel patients on what to expect regarding bleeding patterns during the first year of use to improve adherence rates.2 In a study with 700 participants, drospirenone was not found to increase the incidence of cardiovascular events or hyperkalemia.22

Injectable Progestin

Injectable progestin provides a long-term contraceptive option for women. This medication is injected into the skin and releases sustained levels of progestin that can inhibit ovulation.4,23 This option may benefit women who are breastfeeding, estrogen-intolerant, or women with a medical history that precludes the use of estrogens.4 This form of birth control also offers increased adherence, with lower failure rates than CHCs.4

Depo-Provera (DMPA), depot-medroxyprogesterone acetate, is an injectable progestin that is given via injection every 3 months either in the gluteal or deltoid muscle (intramuscular, IM) or in the abdomen or thigh (subcutaneous, SubQ).23 It is injected within five days of the first day of bleeding.22 Depo-Provera comes as a 150 mg/mL injection vial and is also available as a prefilled syringe that can be used for IM injections.23 Depo-SubQ Provera is also available as a prefilled syringe. These forms are traditionally administered within a medical office or clinic, but the Centers for Disease Control and Prevention has recommended the 104 mg SC DMPA but self- administered by patients at home.23 The ability to self-administer DMPA has led to increased adherence and higher rates of continuation. In one study, 97% of patients noted DMPA was easy to administer and had a satisfaction rate of 87%.2 It is important patients receive counseling on the appropriate administration and disposal of sharps.2

If Depo-Provera is administered at any time after day 7 of a cycle, a secondary form of contraception is needed for seven days.4 A confirmation that the patient is not pregnant is required prior to administration.4,23

Contraindications for use include a current diagnosis or history of breast cancer, thromboembolic disorders, cerebral vascular disease, or significant hepatic disease.23 DMPA is the only form of birth control that can delay a return to fertility.1 Thus, it is not a first-line option for women who want to be pregnant soon, as its effects can persist for up to 12 months following the final dose.1,4

Side effects include menstrual irregularities such as spotting and amenorrhea that may occur throughout the first year.4,23 The incidence of amenorrhea among women who use DMPA may be as high as 68% after 2 years.4 Other side effects in weight gain and breast tenderness.23 Some longitudinal studies have found effects on bone mineral density, and DMPA has a black box warning that it should not be continued for more than 2 years unless other means of contraception are inadequate. Bone density loss may not be reversible.23

Long-Acting Reversible Contraception (LARC)

Long-acting reversible contraception includes IUDs and implants that may be hormonal or non-hormonal. The benefit of LARC is their highly efficacious nature but a quick reversal of fertility once they are removed.4 Like the injection, they have excellent efficacy rates and adherence is not an issue as it is with CHCs.4 Nexplanon is an implant (small, polymer rod) that contains 68 mg of etonogestrel, which is released at a rate of 60 mcg daily for the first month of use and then 30 mcg daily until the end of three years.5,23 Some data suggest it can be used for up to 5 years, with efficacy rates higher at five years out than those of DMPA, pills, rings, or patches.2 Clinicians should discuss the options of keeping the implant in place for up to five years with their patients.2 Risks include the potential for irregular bleeding and the extended-use method may not be efficacious in patients with a BMI >/30 kg/m2.2

The implant is placed under the skin of the nondominant upper arm.24 Clinicians should ensure patients are not pregnant prior to insertion and need to be trained on proper insertion methods.4 Ideally, the implant should be

inserted between Day 1 and Day 5 of a cycle; if not, the woman should use a backup method of birth control for 7 days.4 Fertility should return within 30 days of implant removal.4

The implant is associated with irregular menstrual bleeding, which is a major counseling point to ensure women are comfortable with the use of the implant.24 It also may cause weight gain and patients to become emotionally labile.5 Nexplanon may interact with CYP450 inducers, such as rifampin and phenytoin.24 Contraindications include progestin-sensitive cancer, thrombosis, and undiagnosed abnormal bleeding.24

Another form of LARC is IUDs. To date, there are five types of IUDs available, including four hormonal versions that contain levonorgestrel (Mirena, Skyla, Liletta, and Kyleena) and one non-hormonal version made with copper (Paragard).25-29 IUDs exert their contraceptive effects through various mechanisms, including inhibition of sperm migration, disrupting ovum transport, and damaging a fertilized ovum.4 The hormonal versions may also thicken cervical mucus and cause endometrial suppression.4 Paragard can be left in place for up to 10 (and potentially 12) years; it may be associated with heavier periods and possible dysmenorrhea.25 Mirena can be left in place for eight years and Kyleena can be used for up to 5 years, Liletta for up to eight years, and Skyla can be used for up to 3 years.26-29 IUDs can be inserted on any day of the menstrual cycle. If it is not inserted between days 1 and 7, a backup method will be needed for 7 days.1 Insertion can be painful for patients, and counseling them to take an NSAID or acetaminophen prior may be helpful.4 Similar to the implant, the longer IUDs are kept in place, the more bleeding patterns may be impacted.4

Common side effects associated with the use of IUDs include irregular menstrual bleeding.25-29 Patients may also experience amenorrhea (absence of menses) when using the hormonal versions.5 Contraindications to use include pregnancy, pelvic inflammatory disease, presence of an STI or STD, post-abortion sepsis, purulent cervicitis, undiagnosed vaginal bleeding, uterine anomaly, allergy to an IUD component, or Wilson’s disease for the copper IUD. 25-29

Selecting a Contraceptive Method

Table 2 presents reasons for patients and clinicians to consider various contraceptive methods.

Table 2. Benefits of Contraceptive Methods for Suggested Patient Populations

Counseling Patients on Contraception

All members of the health care team, including physicians, pharmacists, and nurses, should work together collaboratively with the patient to 1) identify the patient’s goals related to family planning and reproductive outcomes,

2) assist the patient in making informed decisions, and 3) optimize health outcomes for the patient.3 This shared decision-making process involves the patient sharing their preferences and the medical team offering suggested methods that align with those preferences.3 The following steps can be utilized to provide patient-centered contraceptive counseling.3 At each step, healthcare team members can work inter-professionally, utilizing their specific skill sets to ensure the patient receives and is counseled on a preferred, safe, and effective contraceptive method.3 Steps in the contraceptive counseling process are outlined in Table 3 below.

Table 3. Steps in the Contraceptive Counseling Process

Adapted from Dehlendorf (2023), Contraceptive counseling and selection3

Emergency Contraception

Emergency contraception (EC) is used to prevent an unintended pregnancy following unprotected or inadequately protected sex, such as when no contraception is used, a condom breaks or a sexual assault occurs.4

Physicians may also choose to provide patients with an advanced prescription of EC when they use contraceptive methods with higher failure rates (such as the intravaginal gel).2 Options for EC include progestin-only (levonorgestrel) and progesterone receptor modulator (ulipristal) products.4 The Paragard IUD can also be inserted, or a high dose of an OC can be utilized.4 The mechanism of EC is via inhibiting or delaying ovulation.2 The levonorgestrel formulation should be taken within 72 hours of unprotected sex and the earlier this is taken the better the efficacy.30 It may be effective up to 5 days later.31 A second form, ulipristal acetate, delays ovulation.31 This EC must be taken within 5 days of unprotected intercourse.31 The overall effectiveness of EC has been found to range from 59% to 94%.2 Women who use EC may experience nausea, vomiting, and/or irregular bleeding.4

Summary

Choice of contraception should involve the clinician and patient using a shared decision-making model, given the personalized nature of each patient concerning goals, past medical history, and preferences. It is essential that every patient receives a safe, effective, and preferred choice of contraceptive agent, especially given that adherence correlates with patient satisfaction. Considerations for selection are numerous and include effectiveness, adherence, side effects, safety, return to fertility time, and preferred method. Clinicians should spend sufficient time counseling patients on side effects, ways to mitigate side effects, serious side effects that require medical attention, and proper methods of contraceptive use.

Course Test

Which phase of the menstrual cycle involves an increase in FSH levels and the development of follicles?

The follicular phase

The luteal phase

The ovulatory phase

The menstrual phase

Which of the following hormones is dominant during the luteal phase?

FSH

LH

Estradiol

Progesterone

Which of the following forms of contraception has the lowest failure rate with typical use?

Combined hormonal contraceptives

Progestin-only pills

Injectable progestin (DMPA)

Intrauterine device (IUD)

Which of the following is the most appropriate contraceptive for a 40-year-old woman who smokes 20 cigarettes a day?

Xulane

Paragard

Nuvaring

Loestrin

Which of the following forms of contraception can delay a patient’s return to fertility for up to twelve months?

Progestin-only pills

Hormonal intrauterine devices

Injectable progestin

Combined hormonal contraceptives

Which of the following is associated with an increased risk of thromboembolism?

Ethinyl Estradiol

Levonorgestrel

Drospirenone

Norethindrone

Which of the following intrauterine devices (IUDs) is nonhormonal?

Paragard

Sklya

Mirena

Liletta

Which of the following would be considered the best candidate for the use of a CHC?

A 40-year-old woman with a history of venous thromboembolism

A 35-year-old woman with migraines with aura

A 25-year-old woman who is obese

A 42-year-old woman with a family history of breast cancer

The risk of decreased bone mineral density is associated with which of the following types of contraception?

Combined hormonal contraceptives

Hormonal intrauterine devices

Injectable progestin (DMPA)

Progestin-only formulations

A patient requests a hormonal form of birth control that will not delay return to fertility and is not in a pill form. Which of the following is the best recommendation for this patient?

DMPA

Paragard

NuvaRing

Loestrin

References

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Fiffick A et al. Update on current contraceptive options: A case-based discussion of efficacy, eligibility, and use. CCJM. 2023;90(3)181-190.

Dehlendorf C. Contraceptive counseling and selection. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. 2023.

El-Ibiary SY, Shrader SP, Ragucci KR. Contraception. In: DiPiro JT, Yee GC, Posey L, Haines ST, Nolin TD, Ellingrod V. eds. Pharmacotherapy: A Pathophysiologic Approach, 11e. McGraw Hill; 2020.

Britton LE, Alspaugh A, Greene MZ, McLemore MR. An Evidence-Based Update on Contraception. Am J Nurs. 2020;120(2):22-33.

Simmons RG, Jennings V. Fertility awareness-based methods of family planning. Best Pract Res Clin Obstet Gynaecol. 2020;66:68-82.

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Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected practice recommendations for contraceptive use, 2016. MMWR Recomm Rep. 2016;65(No. RR-4):1–66.

Curtis KM, Tepper NK, Jatlaoui TC et al. U.S. Medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep. 2016;65(No. RR- 3):1–104.

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Bhupathiraju SN, Grodstein F, Stampfer MJ, et al. Exogenous hormone use: oral contraceptives, postmenopausal hormone therapy, and health outcomes in the Nurses’ health study. Am J Public Health. 2016;106(9):1631–1637.

Lexicomp Online. Drospirenone. Lexi-Drugs Online. Waltham, MA: UpToDate, Inc.; December 17, 2022. https://online.lexi.com. Accessed January 18, 2023.

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Lexicomp Online. Medroxyprogesterone. Lexi-Drugs Online. Waltham, MA: UpToDate, Inc.; January 1, 2023. https://online.lexi.com. Accessed January 18, 2023.

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