EVIDENCE-BASED CONTRACEPTIVE GUIDANCE
The rapidly growing body of evidence surrounding contraception is tremendously helpful to our patients. This chapter provides a brief update, with links to more in-depth resources. Keep in mind that the goal is to remove barriers to access for those patients desiring contraception, rather than to have every patient leave the abortion visit with a contraceptive method (Matulich 2015, Brandi 2018).
Visual Aids for Counseling
It helps to use visual aids so patients can explore their options. It is important to acknowledge the priorities inherent in the chart being used, and focus on methods that match the patient’s priorities. Some examples of visual aids:
- Your Birth Control Choices Factsheet (RHAP)
- Birth Control Method Options (FPNTC)
- Birth Control (Bedsider)
Simplified Screening (CDC SPR 2021)
Most methods can be safely initiated with few additional requirements. Prior to initiating a new method, the provider should:
- Review medical history to identify potential contraindications
- Consult the MEC. If patient desires MEC category 3 method:
- use shared-decision making to discuss risks
- Consider required exam components for specific methods:
- BP (self-report adequate): combined hormonal methods
- Pelvic exam: IUD and some diaphragms
- STI screening: IUD (same visit; only if risks & not yet screened; Sufrin 2015)
- Not required to initiate contraception:
- Heart, lung, breast or well-person exam, pap test, hemoglobin or “routine” labs
Quick Start – Initiation of Contraception (CDC QFP 2014)
- If desired, initiate method on day of patient’s visit in any part of the patient’s cycle (including same-day IUD / implant when feasible and desired by the patient).
- If unable, provide bridge method until the patient returns to start their desired method.
- Quick Start Algorithms (RHAP)
Post Abortion Initiation of Contraception
- Post aspiration, all methods can be started on day of procedure if desired
- Post medication abortion or miscarriage:
- Implant and DMPA can be placed or given day of mifepristone (Raymond 2016) Same day DMPA associated with increased ongoing pregnancy rate compared to initiation at follow-up (3.6% vs. 0.9%),but patient satisfaction is higher
- Pills, patch, and ring can be started after misoprostol administration
- IUD at follow-up visit and offer bridging method if unable to schedule follow-up within 7 days (CDC SPR 2021)
Evidence-based IUD and Implant Eligibility
- No association of IUD with increased infertility risk (Hubacher 2001)
- PID risk with IUD no greater than any other non-barrier contraceptive method
- No restriction for multiple partners
- Contraindications: pregnancy, cervicitis or PID, significant uterine cavity distortion
- LNG-IUD 52 mg minimizes blood loss with menorrhagia, endometriosis, fibroids
- IUD and implant are safe, effective, & have high satisfaction and continuation rates
- 3-year continuation ~ 70% LARCs vs. ~ 30% short-acting methods (Diedrich 2015)
- Assure removal upon request, for any reason, as part of informed consent process
IUD Selection for Individual Preferences
|Cu-T IUD||LNG 52 mcg IUD||LNG 13.5 – 19.5 mcg IUD|
|Paragard ®||Mirena ® / Liletta ®||Skyla ®/ Kyleena®|
|Wants regular menses||Wants light menstrual flow
Wants non-contraceptive benefits (for heavy menses or uterine protection)
|Wants less menstrual flow
|Doesn’t want hormones||Interested in benefits of hormones||Interested in benefits of hormones|
|Wants EC||Wants EC (Use with LNG ECP)||Needs/wants smaller IUD|
IUD & Implant Insertion Tips; Insertion and Removal Videos:
- IUD: place any time in cycle if reasonably sure patient is not pregnant (CDC SPR 2021)
- Consider IUD start with negative urine pregnancy test (UPT) at any time in the cycle. Research shows no pregnancies occurred with unprotected intercourse (UPI) episode 6-14 days before IUD placement, or with multiple UPI episodes (BakenRa 2021).
- Routine antibiotic prophylaxis unnecessary for IUD placement (US SPR 2016)
- Routine misoprostol is not evidence based (Pergialiotis, 2014).
- After an unsuccessful attempt, misoprostol 400 mcg vaginally or buccally 2 hrs prior improves subsequent placement (Bahamondes 2015)
- Routine IUD string checks not supported by evidence (Davies 2014)
- Back-up method is no longer required after 52 mg LNG-IUD placement (Fay 2021)
- Managing IUD insertion pain video (IERH): https://bit.ly/3KLucK2
- Most patients tolerate with PO Ibuprofen
- Paracervical block should be offered (if available), especially if there is history of painful insertion or nulliparous (Mody 2018)
- IUD Insertion Videos (IERH): https://bit.ly/3O6gF1T
- Cu-T using no touch technique: https://bit.ly/3O8nkIV
- Implant: https://bit.ly/3HCeFMi
- Pop out removal technique video: https://bit.ly/3GtSBCY
Ensuring IUD / Implant Removal
- Patients have a right to prompt LARC removal, without provider resistance
- Clinicians often prefer to await symptom resolution (Amico 2018)
- Resisting removal may jeopardize satisfaction & clinical relationship (Raifman 2018)
- Patients are more likely to consider IUD if aware of self-removal option (Foster 2014)
- Self-removal is safe; among those who try, 1 in 5 successful (Foster 2014)
- (RHAP): IUD Self-Removal Fact Sheet
Progesterone-only Methods (Implant, LNG-IUDs, DMPA, POP):
- Safe for most patients with estrogen contraindications (e.g. migraines with aura)
- Generally decrease bleeding & pain; possible amenorrhea (DMPA, LNG-IUD, Implant)
- Decreased risk of endometrial and ovarian cancer (DMPA, 52mg LNG-IUD)
- For metrorrhagia / menorrhagia & no contraindications, can add back estrogen
- DMPA-subcutaneous can be safely self-injected by patients (Burlando 2021)
- New POP (Slynd®) has a 24 hour missed-pill window, as compared to other POPs that must be taken within a 3 hour daily window.
Combined Hormonal Contraceptives (COC, Patches, Rings):
- Decreased dysmenorrhea, PMS & menstrual migraines, improved acne
- Decreased gyn cancers, ovarian cysts, PID, benign breast tumors, osteoporosis
- Rare adverse health outcomes: VTE, heart attack, stroke, for some risk categories.
- Annovera® Ring is FDA approved for 13 cycles as compared to NuvaRing® / EluRing® 1 month (may be used for 3 weeks/1 cycle, then replaced by a new ring a week later).
- Twirla® Patch is a slightly larger patch that is comparable to a low dose oral contraceptive, as opposed to Xulane® Patch which has a higher dose than an OCP. Twirla® is contraindicated with BMI >30 (increased VTE risk and less effective).
Peri-coital Methods (used at or around time of intercourse)
- Contraceptive gel (Phexxi®): acidifying vaginal gel that is hostile to sperm, placed into vagina up to 1 hour prior to intercourse
- Diaphragms (Caya®, Milex®)
- External / internal condoms, can protect against HIV and STIs
Extended / Continuous Contraception to Reduce / Eliminate Withdrawal Bleeding
- Safe, acceptable, and as efficacious as monthly cyclic regimens
- Fewer scheduled bleeds; less estrogen-withdrawal symptoms (Edelman 2014)
- Various monophasic OCP and vaginal ring (Annovera® or NuvaRing®) can be used
- Unscheduled bleeding decreases over time with these regimens
Contraceptive Care across the Gender Spectrum
- Transgender & gender diverse (TGD) patients (whose gender identity or expression is different from that assigned at birth) can be offered full range of contraceptive options.
- Testosterone does not serve as a contraceptive; its use is not a contraindication to hormonal contraception, though some prefer to avoid estrogens (Krempasky 2020, Bonnington 2020, ACOG 2021).
- TGD patients may want non-contraceptive menstrual suppression (Boudreau 2019)
- Include a discussion of future fertility goals with TGD patients when discussing contraception options
- See Birth Control across the Gender Spectrum (RHAP): https://bit.ly/3iczORk
Emergency contraception (EC):
- LNG EC pills (ECP) via US pharmacies / online without Rx for all ages / genders
- EC effectiveness:
- CuT or LNG 52 mg IUD equivalent; ~ 100% effective at any BMI or repeat intercourse; provides ongoing contraception (Turok 2021, Wu 2013)
- Offer IUD if increased risk ECP failure (Turok 2021, Glasier 2011, Shen 2017)
- UPA more effective than LNG ECP at any BMI. UPA less effective with BMI > 30, LNG ECP less effective with BMI > 25.
- After Ulipristal (UPA) EC pills, consider delaying Implant or DMPA until 5 days after UPA (ASEC 2016); theoretical decrease in efficacy, weighed again difficulty initiating method.
Evidence that IUD and EC Pills (ECPs) are not abortifacients
- Neither IUDs nor ECPs will disrupt an implanted pregnancy or cause an abortion.
- Post-IUD tubal flush studies find no fertilized eggs (Ortiz 2007)
- Post-IUD transient hCG elevations not found (Turok 2022)
- 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 2022).
- Neither LNG or UPA EC taken after ovulation affect implantation and LNG results in similar conception rates compared to placebo at that point. No evidence LNG exposure affects fetal development, miscarriage, stillbirth, or subsequent menses (Endler 2022).