METHOD SPECIFIC INFORMATION AND CONSIDERATIONS

POP Comparison Table
Medication	Norethindrone  (Micronor, 19 brands)	Norgestrel  (OPill)	Drospirenone  (Slynd)
Availability	By prescription (typically covered)	Over the counter ($15-20/mo) Cost-Assistance Program FSA/HSA eligible	By prescription (insurance coverage limited)
Mechanism	Thickens cervical mucus	Thickens cervical mucus	Ovulation suppression
Missed pill window	3 hour	3 hour	24 hour
Effects on acne	Increased	Increased	Decreased or less likely to worsen

Depot medroxyprogesterone acetate (DMPA, Depo-Provera®) Injection

• Typical use pregnancy rates: 4%
  • Pros: prevents pregnancy for 3 months at a time; decreased bleeding and pain with periods (amenorrhea 70% by 12 months), decreased risk of endometrial and ovarian cancer; can be injected in a health center or by the patient at home.
  • Cons: Slower return to fertility; weight gain (especially if rapid wt gain initially).
• Considerations:
  • Duration 13 weeks with flexible administration between 11 – 15 weeks (RHAP Injection Calendar)
  • Available in IM for administration by a healthcare professional or subcutaneous (SC) for self-administration.
  • DMPA-SC self-administration can be safely taught via telehealth (Burlando 2021), improving continuation, access, and autonomy (Kennedy 2019, Kohn 2017). Availability varies by state and pharmacy.
  • Despite concern for decreased bone density after 2 years of DMPA use (FDA label), bone density loss is reversible after discontinuation and limited studies of DMPA do not demonstrate an increased fracture risk (ACOG 2014)

Combined Hormonal Contraceptives (Pill, Patch, Ring)

• Mechanism: ovulation suppression; endometrial thinning, thickening of cervical mucus
  Typical use pregnancy rate: 7%
  • Pros: Decreased dysmenorrhea, PMS, menstrual migraines, acne, gynecologic cancers, ovarian cysts, PID, benign breast tumors, osteoporosis
  • Cons: Rare adverse health outcomes: VTE, heart attack, stroke for some risk categories
• Considerations:
  • Periods during CHC use is called ‘withdrawal bleeding’ when hormone levels drop during the hormone-free interval, and is usually lighter than regular menses. Hormone-free interval may be shortened (from 7 to 4 days) or removed (see Continuous Contraception below)

Combined Oral Contraceptives (COC)

• Pros: As above.
• Cons: Spotting first few months
• Considerations:
  • Most contain 20-35 mcg of ethinyl estradiol plus one of eight progestins
  • Recently FDA-approved pill Nextstellis® with novel estrogen (estetrol –E4).

Vaginal Ring:

• Flexible ring that the user places in the vagina; no fitting required.
• Pros: monthly use
• Cons: Can be inadvertently expelled, leading to failure if unnoticed.
• Considerations: 
• Annovera® Ring is FDA approved for 13 cycles
  • Use 3 weeks/1 cycle, wash, replace same ring next cycle
• NuvaRing / EluRing is FDA approved for 1 cycle
  • Use new ring for 3 weeks/1 cycle, discard, place new ring next cycle

Patch:

• Pros: weekly use; as above
• Cons: can cause allergic skin reactions; only available in one color.
• Considerations: 
  • Xulane® Patch is a smaller patch with higher dose (Xulane FDA label).
  • Twirla® Patch is larger patch with lower dose (Twirla FDA label)
  • Patch and Weight:
    • Both Xulane® and Twirla® are MEC 2 with higher weight due to increased VTE risk. There is also a concern for decreased efficacy (>198 lb; BMI ≥30).
    • However, the concern about patch VTE risk is based on four participants who experienced VTE during a Twirla® clinical trial (Twirla FDA label).
    • Use a harm reduction approach when considering this method: If a person favors the patch, consider that their risk of pregnancy is higher without contraception and VTE risk is higher in pregnancy.

Continuous CHC Contraception to Reduce / Eliminate Withdrawal Bleeding

• Defined as using CHCs in a continuous or extended fashion (skipping placebo weeks) to have longer intervals between bleeding.
• Fewer scheduled bleeds; less estrogen-withdrawal symptoms (Edelman 2014).
• Unscheduled bleeding decreases over time (often 6-12 months) with these regimens.
• Various monophasic OCP and vaginal ring (Annovera® or NuvaRing®) can be used.
• Continuous use of patch is controversial given theoretical increased VTE risk; only 1 study shows efficacy (Stewart 2005).

Long-Acting Reversible Contraception (LARC)

• Typical use pregnancy rates < 1%
• Pros: Highly effective, low-effort maintenance, long acting, improved continuation (Diedrich 2015)
• Cons: pain with insertion (IUD), requires removal sometimes by a healthcare professional. Health system and public health promotion has created incentivization and disproportionate coercion at expense of person-centered counseling (Boydell 2023, Higgins 2016).
• Recommendation:
  • Prioritize prompt LARC removal without delay or resistance, advising that removal is possible whenever it is desired and prior to discussing trial or awaiting symptom resolution (Amico 2018). Counsel about IUD self-removal.

Intrauterine Device (IUD)

• Pros: The copper IUDs available in the US (Copper 380 mm2, and new Copper T175 mm2) are both hormone-free. LNG 52 mg IUD provides symptom management for menorrhagia.
• Cons: Insertion pain is significant for many, and underestimated by providers. (See Appendix A: Pain Management for IUD Placement). Copper IUD can increase or prolong uterine bleeding and worsen dysmenorrhea, although the new Copper T175 mm2 improves bleeding profiles.
• Considerations:
  • No association of IUD with increased infertility risk (Hubacher 2001)
  • Cu T 380 and LNG 52 mg IUDs can be used as emergency contraception (EC), regardless of weight (Turok 2021, Wu 2010)
  • Self-removal is safe; 3 in 10 are successful (Petrie 2024). May improve satisfaction and autonomy (Foster 2014, Raifman 2018) (RHAP: IUD Self-Removal Fact Sheet)
  • Routine IUD string checks and follow-up visits are unnecessary and unsupported by evidence (Davies 2014)
  • Place any time in cycle if reasonably sure person is not pregnant (CDC SPR 2024)
    • Early evidence IUD can be placed any time in cycle with negative UPT (BakenRa 2021)
  • No routine antibiotic prophylaxis needed (CDC SPR 2024)
  • Back-up method 7 days (CDC SPR 2024), although early evidence suggests not required after LNG-52 mg or Cu IUD placement, more evidence needed (Fay 2021)
  • IUD Placement Videos (IERH): https://bit.ly/3O6gF1T
    • New Cu-T IUD (2024) placement video: https://bit.ly/4bvkxWt

Emergency Contraception

Emergency contraception (EC) refers to methods of contraception used post-coitally (after unprotected or underprotected sexual intercourse) to reduce the risk of pregnancy. May be used as needed or desired, including when other contraceptive methods fail (e.g. broken condom), or after non-consensual sex or assault. EC refers to both pill-based methods as well as IUD placement which requires seeing a healthcare provider.

• Pills work by preventing or delaying ovulation (Salcedo 2023). Levonorgestrel pills are available OTC, online, or with a prescription, increasing access for people of all ages and genders. Ulipristal Acetate pills require a prescription.
• The copper IUD interferes with sperm maturation and motility (Salcedo 2023, Wu 2010). More recently, the LNG IUD was found to be non-inferior to the copper IUD as a method of EC (Turok 2021). Both the copper and levonorgestrel IUDs are thought to create a foreign body reaction in the uterus that prevents pregnancy. Placement of an IUD requires an in-person visit with a provider.
• Typical use pregnancy rates: <1% to 2.1% (see table below)
  • Pros: As needed use
  • Cons: Requiries access in a specific time frame, pill options may create irregular bleeding/altered menstrual cycle, IUD can be difficult to access without insurance/trained providers, pills are less effective around time of ovulation (Glasier 2011).
• After UPA EC pills, consider delaying the initiation (not re-starting) of hormonal contraception by 5 days due to a risk of decreased prevention of ovulation (ASEC 2016, Salcedo 2023, CDC SPR 2024).

Weight and EC

• LNG ECP may be less effective with weight ≥ 165 lb / 75 kg (BMI ≥ 25).
• UPA may be less effective with weight ≥ 198 / 90 kg, BMI ≥ 30; thought to be more effective than LNG ECP across weight ranges.
• While efficacy of LNG EC pills and UPA EC pills is decreased in people with increased weight (Glasier 2011), it remains MEC 2. However, people over 198 lb / 90 kg made up less than 3% of the study population, so these data should be interpreted with caution (FDA Label). No one should be discouraged or restricted from using EC based on weight (Kardos 2019). After counseling, all options should be offered (Festin 2017).

Evidence that IUD and LNG EC Pills (ECPs) are not abortifacients

• Neither IUDs nor LNG ECPs will disrupt an implanted pregnancy or cause an abortion. IUD can prevent fertilization and implantation (Salcedo 2023, Turok 2021).
• Post-IUD tubal flush studies find no fertilized eggs (Ortiz 2007).
• Post-IUD transient hCG elevations not found (Wilcox 1987).
• LNG ECPs prevent ovulation by blocking LH surge, inhibiting follicular development and egg release. UPA delays ovulation, including after LH surge started. This extended activity likely explains UPA’s greater efficacy (Turok 2024).
• LNG EC taken after ovulation has similar conception rates vs. placebo. No effects on fetal development, miscarriage, stillbirth, or subsequent menses (Endler 2022).
• Although UPA (at higher dose) + Miso was found to be effective for abortion, when used alone, UPA does not affect an established pregnancy. Efforts to limit UPA as EC are detrimental, since it is effective up to 5 days after UPSIC, while LNG is effective up to 3 days. Additionally, UPA is more effective than LNG for people with larger bodies (Winikoff 2025).

Contraception After Abortion

All methods can be initiated at the time of procedural abortion.

Most methods can be initiated at any time of medication abortion, with the following considerations:

• Barrier methods: as soon as the patient resumes intercourse.
• Combined hormonal contraceptives: may start at any time (Tang 2002).
• DMPA Injection: may start at any time, may be provided IM in a health center or SQ for home use if available. Advise that injection at time of mifepristone is associated with a slightly increased rate of continuing pregnancy on the order of 1-3% (Raymond 2016).
• Implant: placement at time of mifepristone enhances patient satisfaction without increasing MAB failure rates (Raymond 2016).
• IUD: placement at follow-up visit after confirming MAB completion; may have slightly increased risk of expulsion (Sääv 2012).
• Permanent contraception: consents must be signed (30-180 days prior to procedure in the U.S. for patients with public insurance), refer and offer an acceptable bridge method.
• EC: offer and dispense or prescribe for future use.

^{DMPA with mife shows slight increase risk of continuing pregnancy risk (< 3%), without increased need of uterine aspiration or increased 6-month repeat pregnancy rate. Increased satisfaction”  (Raymond 2016).}

Contraception for People Who Create Sperm

Methods requiring cooperation of a sperm-producing partner are listed above and include external condoms, spermicides, and withdrawal. Additionally, vasectomy is an option for sperm producing individuals.

Vasectomy / Permanent Contraception

• Surgical procedure that involves separating and sealing both vas deferens, the tubes carrying sperm from the testes to the penis, as a means of permanent contraception, typically by cutting or cauterizing.
• Typical use pregnancy rate < 1%
• Pros: Highly effective, office-based procedure with no known impact on sexual performance. More effective and safer than tubal procedures. Can be done in an ambulatory care setting without general anesthesia.
• Cons: Surgical risks include infection, pain, and bleeding. Requires a backup method for 3 months before confirming success. Reversal is difficult and not always successful (Hollingsworth 2007).
• Considerations: Obtain a ѕеmеn analysis 3 months postoperatively (Sharlip 2012). The person should have had at least 20 ejaculates since the time of vаѕесtоmy

Additional Contraceptive Forms Under Investigation for People Who Produce Sperm

• Pills: typically focusing on blocking sperm production or reducing sperm motility.
• Contraceptive injections: injection of hormones to reduce sperm count.
• Contraceptive implants: typically releasing hormones to suppress sperm production.
• Reversible inhibition of sperm under guidance (RISUG): polymer gel injected into the vas deferens to block sperm flow.