(Published July 2013)
Using This Guide
Nearly half of all pregnancies in the United States are unintended—either mistimed or unwanted—even though most US women use some form of contraception.1 Experts estimate that at least half of all US women will experience an unintended pregnancy, and one in three will have an abortion by age 45.2
A wide array of highly effective hormonal and non-hormonal contraceptive methods are available to American women. Yet despite these options, many women prefer to use non-hormonal methods which, coupled with inconsistent, incorrect, and discontinued use, contribute to the prevalence of unintended pregnancy.
Why do women say they want to avoid hormones? They may be concerned about the safety of hormone use. They may fear side effects. They may perceive non-hormonal methods to be “more natural” and less disruptive of their body’s ecology and their libido.3
Avoidance of hormones is not always the issue when people choose methods that can be less reliable Cost also plays an important role. A recent study called the Contraceptive Choice Project was conducted by researchers at Washington University in St. Louis., This study found that when cost and knowledge barriers were removed to long-acting reversible contraceptive (LARC) methods such as intrauterine devices and implants, women were more likely to choose them.4 Sixty-seven percent of the 9,256 women ages 14 – 45 who were enrolled in the prospective study chose a long-acting method. Two-thirds of adolescents, who represented approximately 20 percent of the total study population, also chose a LARC method.5 LARC users were highly likely to continue with and be satisfied with their method. Among women who chose a LARC method, 86 percent were still using this method at one year. Only 55 percent of women who chose non – LARC methods were still using their method at one year. More over women using LARC methods had the highest satisfaction at one year follow-up.6
Knowledge is power, and it’s important for women and health care providers to be aware of the seven most effective contraceptive methods available in the US: tubal occlusion or ligation, vasectomy (for men), transcervical sterilization (Essure® micro-inserts), four reversible IUDs (Mirena® ,Skyla®, Paragard® “Copper-T”, and Liletta®) and a reversible implant (NEXPLANON). Most of these methods are hormone-free, although Mirena and Implanon do contain hormones. Other non-hormonal methods such as barrier and fertility-based awareness methods (Standard Days® and many others) also can be effective if they are used correctly and consistently, which often hinges on appropriate counseling and education. In the case of these less-effective methods, the guiding principle is that use of any method is better than use of no method at all, with its attendant 85 percent risk of unintended pregnancy.7
Interruptions in Contraceptive Use
The high risk of unintended pregnancy among Americans is often complicated by interruptions in contraceptive use. A number of factors cause these interruptions, including:
- misunderstanding of how to use the method;
- a change in health insurance status;
- challenges with accessing methods or contacting providers with questions about use or side effects;
- the effects of a significant life event;
- infrequent sexual activity; and
- misperceptions of risk of contraception as well as the risk of pregnancy.8
Interruptions in use also may be caused by providers’ misperceptions about the appropriateness or safety of specific contraceptive methods for women with underlying medical conditions (see box). However, highly effective and user-independent methods of contraception such as sterilization and IUDs are especially important among these women approximately one-fourth of deaths during pregnancy in the United States are among women with pre-existing medical conditions.9
Conditions associated with increased risk for adverse health events as a result of unintended pregnancy
- Breast cancer
- Complicated valvular heart disease
- Diabetes: insulin-dependent; with nephropathy/retinopathy/neuropathy or other vascular disease; or of >20 years’ duration
- Endometrial or ovarian cancer
- Hypertension (systolic >160 mm Hg or diastolic >100 mm Hg)
- History of bariatric surgery within the past 2 years
- Ischemic heart disease
- Malignant gestational trophoblastic disease
- Malignant liver tumors (hepatoma) and hepatocellular carcinoma of the liver
- Peripartum cardiomyopathy
- Schistosomiasis with fibrosis of the liver
- Severe (decompensated) cirrhosis
- Sickle cell disease
- Solid organ transplantation within the past 2 years
- Systemic lupus erythematosus
- Thrombogenic mutations
Source: Reference 10
Patient-provider discussions about contraceptive options are the strongest indicator of selection, adherence, and satisfaction with a method.11 Appropriate counseling allows patients to select the best contraceptive method, based on their lifestyle, desire for children, desired family size, and intended timing for pregnancy.
This concise reference guide for clinicians provides brief information about all non-hormonal contraceptive methods currently available in the United States. It is designed to help health care providers quickly counsel women about choosing the most appropriate and effective non-hormonal contraception for them. The goal is to find a method that a woman will use consistently and effectively, and for many women, LARC methods such as the IUDs are ideal in this regard.
In this guide, effectiveness for each non-hormonal contraceptive method is expressed as a failure rate, or the percentage of women who can be expected to become pregnant within the first year they use that method. Effectiveness rates are given for typical use (actual use, including occasional, inconsistent, or incorrect use) of the method. The guide is separated into two sections—highly effective methods and other non-hormonal methods—and the methods are presented in order of efficacy from highest to lowest. Separate chapters in this guide are devoted to each of the following methods:
Section 1. Highly Effective Non-hormonal Methods
Section 2. Other Non-hormonal Methods
Each section describes the method; presents information on its use, effectiveness, risks, and side effects; and concludes with a list of principal advantages and disadvantages of that method and counseling messages. Contraindications and precautions are listed for each method, based on information from the Medical Eligibility Criteria (MEC) for contraceptives from the Centers for Disease Control and Prevention (see box). Providers should carefully evaluate the risk/benefit ratio for use of the particular contraceptive by a woman with the relevant condition.
Medical Eligibility Criteria Categories
1 = A condition for which there is no restriction for the use of the contraceptive method.
2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks.
3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method.
4 = A condition that represents an unacceptable health risk if the contraceptive method is used.
Source: Reference 10
For a list of useful clinical resources on contraception, see ARHP’s Reproductive Health Topic Area on Contraception, located here. Providers can refer patients to the ARHP Method Match tool, available here.
Although office visits are time-limited, health care providers have a clear responsibility to counsel their patients who are of reproductive age on contraceptive options, focusing on the most appropriate and effective methods that meet each woman’s unique needs. Health care providers should factor in each patient’s personal and sexual situation when counseling about contraceptive methods. The cost and insurance or Medicaid coverage for contraceptive methods are variable and may influence the choice for some women.
Many contraceptive methods do not protect against sexually transmitted infections (STIs). If a woman is at risk for STIs, providers should recommend dual contraception use (condom plus an additional method). A discussion about having a backup method for situations such as missed pills or delayed access may help a patient avoid an unplanned pregnancy.12
The following abbreviations are used in this document:
BBT – basal body temperature
EC – emergency contraception
FAB – fertility awareness based
FC - female condom
HIV – human immunodeficiency virus
IUDs – intrauterine contraception
IUD – intrauterine device
IUS – intrauterine system
MEC – medical eligibility criteria
NNS – no-needle/no-scalpel vasectomy
NSV – no-scalpel vasectomy
PID – pelvic inflammatory disease
STIs – sexually transmitted infections (assumed to include HIV)
TSS – toxic shock syndrome