Family Planning-Contraceptives Case File

Family Planning-Contraceptives Case File

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 28

A 38-year-old G3P3 divorced executive presents to your clinic for contraceptive advice. She has been in a monogamous relationship with her boyfriend for several months. She denies any drug allergies. She occasionally drinks alcohol and smokes half a pack of cigarettes a day. She mentions that she used to take birth control pills without any problems. All three of her children were born via vaginal delivery without complication. She and her partner are free of sexually transmitted diseases (STDs) based on their recent checkups. She reports that she is tired of using over-the-counter contraceptives because they are inconvenient. She said that her life is very busy because of work. She fears any form of surgery and has not excluded having another child. Her laboratory workup is normal. Her physical examination is normal. She is looking for the "best contraceptive method" for her situation.

⯈ What contraceptive options are available to this woman?

⯈ Which contraceptives are contraindicated for her?

ANSWER TO CASE 28:

Family Planning-Contraceptives

Summary: A 38-year-old parous woman presents for counseling regarding her contraceptive options. She is in a monogamous relationship. She reports that she is dissatisfied with using over-the-counter options and that she is not ready for permanent sterilization. She smokes a half-pack of cigarettes daily.

• • Available contraceptive options: Intrauterine devices (IUDs), progestin implants, injectable progestins, progestin-only oral contraceptives, barrier contraceptives, natural family planning
• • Contraindicated contraceptive options: Combined estrogen-progesterone contraceptives: oral contraceptive pills, patches, vaginal rings

ANALYSIS

Objectives

1. Know the available methods of contraception.
2. Be aware of contraindications for and of the side effects of contraceptives.

Considerations

Choosing a method of contraception is a personal decision, based on individual preferences, medical history, and lifestyle. In the United States, approximately 50% of pregnancies are unintended and approximately 50% of these pregnancies end in abortion. Approximately 80% of women having unprotected sex will become pregnant within a year. All methods of contraception have a number of risks and benefits of which the patient should be aware, as well as a failure rate, defined as inability to prevent pregnancy over a 1-year period. Sometimes the failure rate is a result of the method and sometimes it is a result of human error. Each method has possible side effects. Some methods require lifestyle modifications. Patients with certain medical conditions cannot use certain types of contraceptives.

There are numerous contraceptive options available and recommendations regarding contraceptive use must be individualized. In the case given, there are several important factors that must be considered. Combined hormonal contraceptives are to be used with caution in women who smoke cigarettes and are not recommended for smokers over the age of 35 because of increased risk of myocardial infarction and stroke. Given the patient's fear of surgery and because she is not certain whether she wants to have more children in the future, surgical sterilization via bilateral tubal ligation or hysteroscopic tubal occlusion or division is not a choice. A vasectomy for the partner, although potentially reversible, should be considered permanent sterilization and not ideal for this patient. Barrier methods are an inconvenience to the patient's busy lifestyle, but still a viable option. Given that both the patient and her boyfriend have no history of STDs and are in a long-term relationship, appropriate methods of contraception for them include IUDs or progestin implants. IUDs can last 3, 5, or 10 years before replacement, depending on the type used, and implants can last 3 years. Both reduce user error associated with pill and barrier contraception. Figure 28-1 is an algorithm that can be used as a guide to approaching family planning options.

Figure 28-1. Approach to family planning options.

Approach To:

Contraception

DEFINITIONS

INTRAUTERINE CONTRACEPTIVE DEVICE (IUD): Small T-shaped device placed in the endometrial cavity as a method of long-term contraception

TYPICAL USE EFFECTIVENESS: Efficacy of a method as it is actually used, when forgetfulness and improper use can occur

PERFECT USE EFFECTIVENESS: Efficacy of a method in perfect conditions, when consistent and reliable use occur

BARRIER CONTRACEPTIVE: Prevents sperm from entering upper female reproductive tract

STEROID HORMONE CONTRACEPTION: Estrogen plus progestin or progestin alone to provide contraception in various methods, including pills, patches, vaginal rings, injections, and implants

CLINICAL APPROACH

Choosing which contraception agent is best for a patient can be complex. Review of the patient's individual situation, medical problems, and ability to remember to take medication each day are important factors to consider. Table 28-1 summarizes some of the characteristics of various contraceptive agents.

FERTILITY AWARENESS AND OTHER METHODS

Fertility awareness (natural family planning or rhythm method) entails abstinence during the woman's fertile period, or using a barrier method during this time period. Fertility awareness has a failure rate of up to 25% with typical use and 3% to 5% with perfect use. Women with irregular cycles have the highest failure rates. This method is dependent on the ability to identify the approximately 10 days in each menstrual cycle that a woman is fertile, which can be accomplished using calendar calculation, basal body temperature charting, cervical mucus monitoring, or the symptothermal method. The calendar calculation uses the length of past reproductive cycles to predict fertile periods. The beginning of the fertile period is calculated by subtracting 18 days from the shortest of the previous 6 to 12 cycles. The end of the fertile period is calculated by subtracting 11 days from the longest cycle. For a consistent 28-day cycle, the fertile period would occur from days 10 through 17. The basal body temperature method is based on the knowledge that a woman's basal temperature increases during the luteal phase of the reproductive cycle. Temperature must be recorded early in the morning at the same time each day. An increase of 0.4°F from baseline indicates that ovulation has occurred. For this method to be most effective, a woman must either avoid intercourse or use barrier methods from the first day of menses to the third day

Abbreviations: OCP, oral contraceptive pill; PIO, pelvic inflammatory disease; STD, sexually transmitted disease; UTI,

urinary tract infection.

after the temperature increase. The cervical mucus method, also called the Billings ovulation method, depends on a woman recognizing the changes in cervical mucus that indicate ovulation is occurring or has occurred. The symptothermal method combines all three; calendar, basal body temperature, and cervical mucus methods.

Other methods include coitus interruptus, also known as the withdrawal method, postcoital douching, and lactational amenorrhea. Coitus interruptus involves withdrawing the penis before ejaculation and has a 27% typical use failure rate. Postcoital douching is used to flush semen out of the vagina, but sperm have been found within cervical mucus within 90 seconds of ejaculation, so this method is unreliable. Lactational amenorrhea occurs with suppression of ovulation due to breast-feeding. During the first 6 months following delivery, women who are exclusively breast-feeding have mostly anovulatory menstrual cycles, and pregnancy rates have been found to be approximately 1%.

BARRIER METHODS

There are five barrier methods of contraception: male condom, female condom, diaphragm, sponge, and cervical cap. In each, the method works by keeping the sperm and egg apart. The main possible side effect is an allergic reaction either to the material of the barrier or the spermicides that should be used with them.

Male Condom

Condoms on the market are made of latex rubber, polyurethane, or sheep intestine. Of these types, only latex and polyurethane condoms are effective in preventing STDs by providing a good barrier to viruses and bacteria. Polyurethane condoms have a higher rate of breaking or slipping than latex, and thus higher failure rates, but they can be used by patients with a latex allergy. Each condom can only be used once. Condoms have a typical use failure rate of approximately 15%, with most of the failures a result of improper use. Perfect use failure rate is about 2%. For maximal efficacy, a condom must be used with every coital act, should be in place before contact of the penis with the vagina, withdrawal must occur with the penis still erect, the base of the condom must be held during withdrawal, and an intravaginal spermicide or a condom lubricated with spermicide should be employed. Only water-based lubricants should be used with latex condoms as oil-based lubricants reduce efficacy.

Female Condom

The female condom consists of a lubricated polyurethane sheath with a flexible polyurethane ring on each end. One ring is inserted into the vagina much like a diaphragm, while the other remains outside, partially covering the labia. The female condom may offer some protection against STDs but are not as effective as male latex condoms. The estimated typical use failure rate is estimated at 21% and perfect use at 5%.

Sponge

The contraceptive sponge is made of white polyurethane foam. It is shaped like a small doughnut and contains spermicide. The sponge protects for 12 to 24 hours, regardless of how many times intercourse occurs. It is inserted into the vagina to cover the cervix during and after intercourse. After intercourse, the sponge must be left in place for over 6 hours before it is removed and discarded. It does not require fitting by a health professional and is available without prescription. It is to be used only once and then discarded. The typical use failure rate is 32% in parous women and 16% in nulliparous women, decreased to 20% and 9% in perfect use, respectively. An extremely rare side effect is toxic shock syndrome (TSS).

Diaphragm

The diaphragm is a flexible rubber disk with a rigid rim ranging in size from 2 to 4 inches in diameter. It is designed to cover the cervix during and after intercourse, so that sperm cannot reach the uterus. The diaphragm must be fitted by a health professional and the correct size prescribed to ensure a snug seal with the vaginal wall. Spermicidal jelly or cream must be placed on the cervical side of the diaphragm for it to be effective. If intercourse is repeated, additional spermicide should be added with the diaphragm still in place. A diaphragm may be placed up to 6 hours before intercourse, and should be left in place for 6 to 24 hours after intercourse. TSS has also been described with diaphragm use, so a diaphragm should not be left in place for longer than 24 hours. The diaphragm used with spermicide has a failure rate of 6% with perfect use and 18% with typical use.

Cervical Cap

The cervical cap is a dome-shaped silicone cap that fits snugly over the cervix. Like the diaphragm, it is used with a spermicide and must be fitted by a health professional. It is more difficult to insert than the diaphragm, but may be left in place for up to 48 hours. There also appears to be an increased incidence of irregular Papanicolaou (Pap) tests in the first 6 months of using the cap, and TSS is an extremely rare side effect. The cap has a failure rate of about 18%.

Spermicides Used Alone

Spermicides come in many forms (foams, films, creams, gels, suppositories, tablets) and work by forming a physical and chemical barrier to sperm. They should be inserted into the vagina within an hour before intercourse. If intercourse is repeated, more spermicide should be inserted. The only spermicidal agent in use in the United States is nonoxynol-9, which is a surfactant that destroys the sperm cell membrane. The failure rate for spermicides in preventing pregnancy when used alone is 29% with typical use and 18% with perfect use. Spermicides are available without a prescription. When spermicides are used with a condom, the failure rate is comparable to that of oral contraceptives and is much better than for either spermicides or condoms used alone.

HORMONAL CONTRACEPTION

Hormonal contraception involves ways of delivering estrogen and progesterone. Hormones temporarily interact with the body's reproductive cycle and have the potential for rare but serious side effects. When properly used, hormonal methods are extremely effective.

Oral Contraceptives

There are two types of oral contraceptive pills (OCPs): combination pills, which contain both estrogen and a progestin (a natural or synthetic progesterone), and progestin-only pills (POPs) (commonly known as the"minipill).

Combination pills are the most commonly used contraceptive method. The combination pill suppresses ovulation through inhibition of the hypothalamic pituitary- ovarian axis, alters the cervical mucus, retards sperm entry, and discourages ovum implantation by creating an unfavorable endometrium. Combination oral contraceptives offer significant protection against ovarian cancer, endometrial cancer, iron-deficiency anemia from menstrual blood loss, pelvic inflammatory disease (PID), and fibrocystic breast disease. Women who take combination pills have a lower risk of functional ovarian cysts. The POP reduces cervical mucus and causes it to thicken. The mucus thickening prevents the sperm from reaching the egg and keeps the uterine lining from thickening, which prevents the fertilized egg from implanting in the uterus. The POP is ideal for breast-feeding mothers because it does not interfere with milk production as combination OCPs do. When taken as directed, the failure rate for the POP is 1% to 3%; the failure rate of the combination pill is 1% to 2%. Typical use of OCPs has a failure rate of 8% to 10%.

Women over the age of 35 who smoke cigarettes and women with certain medical conditions should not take the combined OCP. Table 28-2 lists the absolute

and relative contraindications to taking the combined OCP. Minor side effects, which usually subside after a few months of usage, include nausea, headaches, breast swelling, fluid retention, weight gain, irregular bleeding, and depression.

When starting an OCP, ideally a patient should take the first pill on the first day of the start of menses. Women may also choose to start on the Sunday after the start of their menses for convenience. A quick-start method has also been proposed, in which patients start taking the pills as soon as they obtain the prescription (if pregnancy is unlikely), which improves compliance. Both Sunday-start and quick-start methods require an additional backup method to be used for the first week. Postpartum, non-breast-feeding women should start the OCP during the fourth week after delivery. Breast-feeding women should start the minipill during the sixth week after delivery. OCPs can be started the day after an induced or spontaneous abortion. If a pill is missed, it should be taken as soon as possible and the next dose should be taken as usual. If two or more pills are missed, the patient should be directed to the package insert for instructions and additional backup contraception should be used for at least 7 days following resumption.

The effectiveness of OCPs may be reduced by a few other medications, including some antibiotics, barbiturates, and antifungal medications.

Transdermal Contraceptive

A transdermal contraceptive patch (Ortho Evra and others) is a combined hormone patch containing norelgestromin and ethinyl estradiol. The treatment regimen for each cycle is three consecutive 7-day patches followed by one patch-free week, so that withdrawal bleeding can occur. It can be started in a similar fashion to combined OCPs: on the first day of the menstrual cycle, the first Sunday after the menstrual cycle, or the day the prescription is filled. If the Sunday-start or quick-start methods are used, a backup method of contraception is needed for 7 days. The patch may be placed on the buttocks, lower abdomen, upper outer arm, and upper torso, except for the breasts. If a patch becomes detached, it should be replaced as soon as possible. If the patch is detached for more than 24 hours, it should be replaced and a backup method of contraception used for the next 7 days. The patch's efficacy and side effects are comparable to that of combined OCPs, although there may be an increased risk of vascular thrombosis with use of the patch. Women who weigh more than 90 kg may be at increased risk of pregnancy with patch use.

lntravaginal Ring Contraceptive

NuvaRing is a flexible, transparent ring about 5 cm in diameter that delivers etonogestrel and ethinyl estradiol. A woman inserts the NuvaRing herself, wears it for 3 weeks, then removes and discards the device. After one ring-free week, during which withdrawal bleeding occurs, a new ring is inserted. It does not need to be fitted by a health professional, and does not need to be removed during intercourse. If a patient or her partner experience problems with the ring during intercourse, it may be removed, but should be replaced within 3 hours. If it is out for more than 3 hours, ovulation may occur. The manufacturer recommends using backup birth control for the first 7 days after placement if not switching from another hormonal contraceptive. Rarely, NuvaRing can slip out of the vagina, and it is recommended to check the position of the ring before and after intercourse. NuvaRing may not be appropriate for women with conditions that increase likelihood of ring expulsion, such as vaginal stenosis, cervical prolapse, cystocele, or rectocele. The efficacy and most side effects of NuvaRing are similar to those of combined OCPs, although vaginitis, discomfort, and foreign body sensation are also commonly reported.

Medroxyprogesterone Injection

Medroxyprogesterone acetate (Depo-Provera, Depo-subQ Provera 104) is an injectable form of a progestin. Medroxyprogesterone acetate has a failure rate of only 0.3% with perfect use, or 3% with typical use. Each injection provides contraceptive protection for 13 weeks, but can last for up to 4 months. It is injected every 3 months (90 days) into the gluteus or deltoid muscle. The first dose should be given within 5 days of the onset of menses, so that no backup contraception is needed. Its side effects include irregular menses, weight gain, and injection site reactions. Irregular bleeding and spotting is more significant during the first few months and then is followed by periods of amenorrhea. About half of women develop amenorrhea after a year of medroxyprogesterone acetate use. There may be a prolonged period of time prior to return of fertility after discontinuing Depo-Provera, up to 18 months in a small proportion of women.

Etonogestrel Implant

Contraceptive implants, Implanon and Nexplanon, are inserted subdermally in an in-office minor surgical procedure, and may be removed with another minor procedure. Placement should be timed during the menstrual cycle or during the hormonefree week if using a combined hormonal contraceptive method. The implant contains etonogestrel, the active metabolite of desogestrel, and is effective for 3 years. At the end of 3 years, when the device is removed, a new device may be placed in the same site. The failure rate is less than 1 % for women who weigh less than 70 kg.

The potential side effects of the implant include irregular menstrual bleeding, which is the most common reason for discontinuation, headaches, depression, acne, breast tenderness, abdominal pain, and weight gain.

INTRAUTERINE DEVICES

IUDs are small, plastic, flexible devices that are inserted into the uterus through the cervix by a trained physician. Three IUDs are presently marketed in the United States: ParaGard T380A, which is a T-shaped plastic device partially covered by copper that is effective for 10 years, Mirena, which is also a T-shaped plastic device, but contains levonorgestrel (a progestin) released over a 5-year period, and Skyla, which is essentially a smaller version of Mirena that releases slightly less levonorgestrel and lasts for 3 years. All are very effective; the copper-T IUD has a 0.6% to 0.8% failure rate, the Mirena has a failure rate of 0.2%, and Sklya has a failure rate of 0.9%. An IUD alters the uterine and tubal fluids, particularly in the case of copper- bearing IUDs, inhibiting the transport of sperm through the cervical mucus and uterus. Progesterone-containing IUDs also thin the uterine lining. Timing of placement should occur during the menstrual cycle and more specifically during the first 7 days of the menstrual cycle for levonorgestrel-containing IUDs.

Manufacturer contraindications for IUD include current or suspected pregnancy; current or recent acute PID or mucopurulent cervicitis; postpartum endometritis or infected abortion in the past 3 months; anatomically distorted uterine cavity, known or suspected uterine or cervical malignancy; unexplained uterine bleeding; and IUD already in place. Copper IUD is also contraindicated in Wilson disease. Levonorgestrel IUDs are also contraindicated in acute liver disease or liver tumor (benign or malignant); breast cancer; and prior ectopic pregnancy. A history of STDs is not a contraindication to IUD placement, but if a woman has a known STD, it is recommended to delay insertion for 3 months following resolution of the infection. Levonorgestrel IUDs may actually reduce the risk of PID by thickening cervical mucus and thinning the endometrium, but caution should be used in patients who are at high risk for PID, and women with multiple sex partners should be counseled to use condoms in conjunction with IUD to reduce risk of contracting an infection.

Side effects include irregular bleeding patterns during the first few months of use, headache, nausea, hair loss, acne, depression, decreased libido, ovarian cysts, and mastalgia. Many patients will become amenorrheic or oligomenorrheic with a levonorgestrel IUD in place, so it can be used to treat patients with menorrhagia. The copper IUD may actually cause heavy, irregular bleeding. Women may also experience some short-term side effects such as cramping and dizziness at the time of insertion; bleeding, cramps, and backache may continue for a few days after the insertion. Complications include expulsion, perforation of the uterus, and ectopic pregnancy. Approximately, 5% of women expel their IUD within the first year. The patient should check that the strings are palpable once a month, and if she cannot find the strings, she should see a health-care provider. The absolute rate of ectopic pregnancy is reduced with the IUD because of its high contraceptive efficacy. However, when accidental pregnancy does occur, there is increased likelihood of ectopic pregnancy. Adolescence and nulliparity are not contraindications.

SURGICAL S TERILIZATION

Tubal ligation seals a woman's fallopian tubes so that an egg cannot travel to the uterus. Hysteroscopic tubal obstruction through the placement of sterilization devices in the fallopian tubes is also available. Two types are Food and Drug Administration (FDA) approved: the micro-insert device (Essure) and the polymer matrix system (Adiana). Vasectomy involves closing off a man's vas deferens so that sperm will not be carried to the penis. Vasectomy is a minor surgical procedure, most often performed in a doctor's office under local anesthesia. Hysteroscopic tubal obstruction may be performed with local anesthesia or oral analgesics alone. Tubal ligation is an operating room procedure performed under general anesthesia. Major complications, which are rare in female sterilization, include infection, hemorrhage, and problems associated with the use of general anesthesia. The failure rate is less than 1%. Although there has been some success in reopening the fallopian tubes and the vas deferens, the success rate is low, and sterilization should be considered irreversible.

EMERGENCY CONTRACEPTION

All female patients of reproductive age should be made aware of postcoital contraception some of which are available over the counter for adolescent girls of 17 years and older. This knowledge does not increase the likelihood of high-risk behavior. The Yuzpe method consists of taking high-dose combined OCPs for emergency contraception, and can decrease the risk of pregnancy by about 75%. This method can be used up to 5 days after unprotected intercourse but is most effective when used within 72 hours. Consider prescribing an antiemetic to be used 1 hour before each dose, as nausea and vomiting are common side effects. Progestin-only emergency contraception is available without a prescription. One or two oral doses of levonorgestrel (Plan B) 0.75 mg, with 12 hours between doses, is more effective than the Yuzpe method, better-tolerated, and can be used up to 5 days after unprotected intercourse. Preven, a convenient emergency contraception kit, includes two doses of medication and a pregnancy test. A single dose of mifepristone (RU-486), a progesterone antagonist, is the most effective emergency contraceptive and has few side effects. A selective progesterone-receptor modulator, known as ulipristal acetate (Ella), is taken in a single dose up to 5 days after unprotected intercourse, and does require a prescription. Placing a copper-containing IUD within 5 days after unprotected sex is the most effective form of emergency contraception, and also provides another 10 years of birth control, but should be avoided in those at risk for STDs, ectopic pregnancy, or if long-term contraception is not desired.

CASE CORRELATION

• See also Cases 4 (Prenatal Care), 16 (Labor and Delivery), and 26 (Postpartum Care).

COMPREHENSION QUESTIONS

28.1 While working in the clinic of the county jail you see a G5P2032 for a wellwoman examination. She openly tells you that she was arrested for a history of prostitution. On arrest, she was found to be HIV positive. She is to be released next week and would like contraception. Which of the following agents is most appropriate for this patient?

A. Oral contraceptive agent

B. Depot medroxyprogesterone

C. Intrauterine contraceptive device

D. Condoms

E. Cervical cap

28.2 An 18-year-old woman reported having intercourse with her boyfriend 20 hours ago. She was concerned because the condom broke. She used no other form of contraception. The patient reported a history of regular periods since age 14 of heavy flow that usually lasts for longer than 7 days. She is 5 ft 8 in tall and weighs 165 lb. She plays as a forward on her high school basketball team and is worried about becoming pregnant. Which of the following is the most appropriate method of "emergency contraception"?

A. Yuzpe method

B. Plan B method

C. Insertion of a copper IUD

D. Intramuscular methotrexate

28.3 A 16-year-old adolescent girl presents to your clinic for a well-child check. She has been having regular periods for over 2 years, does not drink or smoke, gets straight As on her report cards, and is in the 75% for height and weight. She is Tanner Stage 5 for both breast and pubic hair development. During your interview, she reveals that she is sexually active and not using contraception. If she continues to have unprotected intercourse, what is the likelihood that she will become pregnant over the course of the next year?

A. 20%

B. 40%

C. 80%

D. 100%

28.4 A 36-year-old woman is seeking contraception. She has delivered her baby 8 weeks ago and is breast-feeding. She undergoes a history and physical examination, and is counseled regarding the various options. She is healthy, drinks an occasional glass of wine per month, does not smoke, and plans to have another child in a year or two. Her blood pressure is 114/70 mm Hg. The patient would like to initiate birth control at this visit. Which method is the most appropriate in her case?

A. Transcervical sterilization (Essure)

B. Natural family planning

C. The minipill

D. Combination oral contraception pills

E. Coitus interruptus

ANSWERS

28.1 D. Protection from STDs for this patient, and prevention from transmitting HIV to her future partners is of utmost concern. Condoms are the most effective agents to prevent the transmission of STD. Cervical cap although also a barrier method has high rates of STD transmission. IUDs can be used in selected nulliparous women and in women who desire future fertility. History of STD is not an absolute contraindication to IUD use, but with this patient's high-risk behavior, an IUD should probably be avoided. Oral contraceptives and depot medroxyprogesterone decrease the risk of PIO by thickening the cervical mucus but do not provide any protection from STDs.

28.2 B. Emergency contraception may include combination hormonal therapy, ideally used within 72 hours but can cause significant nausea and vomiting. Plan B is levonorgestrel and is more effective than the combined OCPs for postcoital contraception without the prominent side effect of nausea. Placing a copper IUD can cause heavy and irregular vaginal bleeding, and would not be a good choice for a patient who already experiences these symptoms. IM methotrexate is not used for emergency contraception.

28.3 C. Eighty percent of women having unprotected intercourse will be pregnant in 1 year.

28.4 C. The progestin-only pill "minipill" is the most effective form of birth control in the postpartum period for women desiring to breast-feed. Natural family planning and coitus interruptus (withdrawal method) have high rates of user error leading to failure. Essure is a permanent method of birth control that causes occlusion of the fallopian tubes. Combination OCPs can affect a woman's milk supply and have varying safety in lactation.

CLINICAL PEARLS

⯈ The male latex condom remains the best shield against HIV and other STDs .

⯈ Barrier methods, which work by keeping the sperm and egg apart, usually have only minor side effects.

⯈ Combination oral contraceptives offer protection against ovarian cancer, endometrial cancer, iron-deficiency anemia, PID, and fibrocystic breast disease.

⯈ Methods of hormonal contraception, when used properly, are extremely effective .

⯈ Noncontraceptive benefits of combination oral contraceptives include decreased incidence of benign breast disease, relief from menstrual disorders (dysmenorrhea and menorrhagia), reduced risk of uterine leiomyomata, protection against ovarian cysts, reduction of acne, improvement of bone mineral density, and a reduced risk of colorectal cancer.

⯈ Intrauterine and implantable contraceptives are also extremely effective and reduce the contribution of user error to the failure rate.

⯈ Surgical sterilization must be considered permanent. Vasectomy is considered safer than tubal ligation.

REFERENCES

Bonnema RA, McNamara MC, Spencer AL. Contraception choices in women with underlying medical conditions. Am Fam Physician. 2010;82(6):621-628. 

Brunsell SC. Contraception. In: South-PaulJE, Matheny SC, Lewis EL, eds. Current Diagnosis & Treatment: Family Medicine. 4th ed. New York, NY: McGraw-Hill; 2015. 

Burkman RT, Brzezinski A. Contraception and family planning. In: DeCherney AH, Nathan L, Laufer N, Roman AS, eds. Current Diagnosis & Treatment: Obstetrics & Gynecology. 11th ed. New York, NY: McGraw-Hill; 2013. 

Cunningham F, Leveno KJ, Bloom SL, et al. In: Cunningham F, Leveno KJ, Bloom SL, et al., eds. Williams Obstetrics. 24th ed. New York, NY : McGraw-Hill; 2013. 

Esherick JS, Clark DS, Slater ED. Disease management. In: Esherick JS, Clark DS, Slater ED, eds. Current Practice Guidelines in Primary Care 2015. New York, NY : McGraw-Hill; 2014. 

Hardeman], Weiss BD. Intrauterine devices: an update. Am Fam Physician. 2014 Mar 15;89(6): 445-450. 

Hoffinan BL, Schorge JO, Schaffer JI, et al. Contraception and sterilization. In: Hoffinan BL, Schorge JO, Schaffer JI, et al., eds. Williams Gynecology. 2nd ed. New York, NY: McGraw-Hill; 2012. 

Smoley BA, Robinson CM. Natural family planning. Am Fam Physician. 2012 Nov 15;86(10):924-928. 

Wieslander CK, Wong KS. Therapeutic gynecologic procedures. In: DeCherney AH, Nathan L, Laufer N, Roman AS, eds. Current Diagnosis & Treatment: Obstetrics & Gynecology. 11th ed. New York, NY : McGraw-Hill; 2013.

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