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Quick Reference Guide for Clinicians
 
Choosing a Birth Control Method

(Updated June 2014)

Using This Guide

Contraceptive methods with high efficacy rates have been available for several decades. Still, nearly half of all pregnancies in the United States are unintended—either mistimed or unwanted.1 Experts estimate that at current rates, at least half of all women in the United States will experience an unintended pregnancy, and one in three will have had an abortion by age 45.2 Use of less effective methods, coupled with inconsistent, incorrect, and discontinued use, contributes to prevalence of unintended pregnancy.

The risk of unintended pregnancy is often further complicated by interruptions in contraceptive use. A number of factors cause these interruptions, including misunderstanding 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 pregnancy.3

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 contraception is especially important among these women; approximately one-fourth of deaths during pregnancy in the United States are among women with pre-existing medical conditions.4

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
  • Epilepsy
  • Hypertension (systolic >160 mm Hg or diastolic >100 mm Hg)
  • History of bariatric surgery within the past two years
  • HIV/AIDS
  • 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 two years
  • Stroke
  • Systemic lupus erythematosus
  • Thrombogenic mutations
  • Tuberculosis

Source: Reference 5

Health care providers need to counsel patients about each contraceptive option to allow them to select the best contraceptive method based on their lifestyle, desire for children, desired family size, and intended timing for pregnancy. Because patient-provider discussions about contraceptive options are the strongest indicator of selection, adherence, and satisfaction with a method, it is imperative that providers understand and are able to present patients with all available options.6

This concise reference guide for clinicians provides brief information about all 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 contraception for them.

In this guide, effectiveness for each 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 with both perfect use (correct and consistent use of the method with every act of intercourse) and typical use (actual use, including occasional, inconsistent, or incorrect use). Separate sections in this guide are devoted to each of the following methods:

  • Combined hormonal contraception (CHC), including the oral contraceptive pill, the contraceptive patch, and the vaginal ring
  • Progestin-only contraception, including the contraceptive implant, injectable contraception, and progestin-only oral contraceptives
  • Intrauterine contraception (IUC), including the copper intrauterine device (IUD) and the three levonorgestrel intrauterine systems (LNG 52 IUS, LNG 13.5 IUS, LNG 52 IUD)
  • Barrier methods, including the male condom, female condom, diaphragm, cervical cap, and sponge
  • Spermicides
  • Coitus interruptus (withdrawal)
  • Fertility awareness
  • Male sterilization (vasectomy)
  • Female sterilization (operative and non-operative surgical sterilization)
  • Emergency contraception

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 5

The last section of this reference guide includes several comparison charts to help make counseling more efficient.

For a list of useful clinical resources on contraception, see ARHP's Reproductive Health Topic Area on Contraception, located at www.arhp.org/topics/contraception. Providers can refer patients to the ARHP Method Match tool, available at methodmatch.

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 effective methods, including long-acting reversible contraception such as IUC and contraceptive implants. 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 back-up method for situations such as missed pills or delayed access may help a patient avoid an unplanned pregnancy.7

The following abbreviations are used throughout this document:

  • BMD – bone mineral density
  • CHCs – combined hormonal contraceptives
  • COCs – combined oral contraceptives
  • EC – emergency contraception
  • FC - female condom
  • FDA – Food and Drug Administration
  • HIV – human immunodeficiency virus
  • IUC – intrauterine contraception
  • IUD – intrauterine device
  • LNG IUS – levonorgestrel intrauterine system
  • MEC – medical eligibility criteria
  • NNS – no needle/no scalpel vasectomy
  • NSV – no scalpel vasectomy
  • OCs – oral contraceptives
  • PID – pelvic inflammatory disease
  • STI – sexually transmitted infection (assumed to include HIV)
  • TSS – toxic shock syndrome
  • UTI – urinary tract infection
  • VTE – venous thromboembolism