Latest Recommendations in Contraceptive Forms

Dr. Margaret Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP

What are the different forms of contraception?  

There are three different tiers of contraception sorted based on effectiveness. Tier One options allow for less than one pregnancy per 100 females in a year. Tier Two contraception has been shown to lead to 6-12 pregnancies per 100 females in a year, and Tier Three contraception has an effectiveness of 18 or more pregnancies per 100 females in a year. Specific contraceptive options grouped by tiers are: 

Tier 1:  

  • Reversible:
    • Implant
    • Intrauterine device (IUD)
  • Permanent:
    • Male sterilization (vasectomy)
    • Female sterilization (tubal ligation)

Tier 2:  

  • Injection 
  • Pill (Combined oral contraception) 
  • Patch 
  • Ring 
  • Diaphragm 

Tier 3:  

  • Male condoms 
  • Female condoms 
  • Withdrawal method 
  • Birth-control sponge  

What are Tier 2 contraceptive methods? 

Tier 2 contraception is the most popular as it is easy to start and more effective than tier 3 contraceptives. Most of these methods contain either ethinyl estradiol (EE) or progestin, which is a synthetic form of progesterone that allows once daily dosage.  

The ways that these hormonal methods work to prevent pregnancy are through ovarian and pituitary inhibition and the thickening of the cervical mucus. In the case of progestin, the endometrial lining may atrophy, and in the case of EE, it sees proliferation. One added benefit of both methods is cycle control, which may help women who experience spotting or heavy flows. 

What are the four ways to start Tier 2 contraception? 

  • The traditional “Sunday start” method calls for contraception to begin on the first Sunday after menses. This requires a backup method needed in the interim week.
  • The more modern version calls for starting on the first day of menses and requires no backup method. 
  • The “Quickstart” method allows patients to start on the same day of their appointment. With this method, it is important to make sure the patient is not already pregnant and use a backup method for 7 days. 
  • The “Jumpstart” method, for patients who recently had unprotected coitus, has patients start contraception the day of their appointment, take oral emergency contraception (e.g. Plan B), and use backup contraception for 7 days. 

What are some other benefits of Tier 2 contraception? 

  • Management of irregular cycles
  • Management of dysmenorrhea
  • Management of menorrhagia and anemia 
  • Reduction of cancer risks: the risk of ovarian, endometrial, and colorectal cancer goes down due to the suppression of ovulation. This benefit may take up to a couple of years of hormonal contraceptive use to come to fruition. 
  • Reduction of changes of developing ovarian cysts 
  • Prevention of bone loss
  • Prevention of PID and ectopic pregnancyRelated: Contraception Updated Recommendations 

What methods do not require daily patient action? 

These Tier 2 contraceptive methods are effective, easy to start, and can be initiated on the same day of a patient’s appointment. However, these do require daily patient action to be effective. There are other options that have a higher adherence rate because they require less patient action. These include: 

Tier 2: 

  • Non-oral forms of estrogen/progestin (patch and ring):
    • The NuvaRing provides for self-insertion for 3 weeks of continuous use and then being removed for one week.
    • The Ortho Evra patch delivers a continuous dose of hormones throughout the day and lasts for a week. There is a higher adherence rate in young women as opposed to the pill since this only requires once-a-week action to replace the patch.

Tier 1:  

Long-acting reversible contraception (LARC) includes: 

  • Levonorgestrel-releasing intrauterine system (LNG-IUS): Mirena or Skyla
    • Effective for 3-5 years
    • Reduces dysmenorrhea and blood loss
  • Copper IUD ParaGard
    • Approved in the US for 10 years
    • No alteration in menstrual flow (not a great option for women with cramps or heavy flow)
    • This is the single most effective form of emergency contraception.
  • Implantable progestin: Implanon, Nexplanon
    • Effective for at least three years
    • May cause irregular bleeding
    • Can augment with an oral contraceptive for 3 months or timed NSAID use for 2 weeks

How can NPs help with hormonal contraceptive success? 

In order for patients to have the most success with starting contraception, it is important for nurse practitioners to remove barriers to starting. This can include having a conversation about different methods, especially for long-active methods if the patient is younger and not looking to have children for years. It likely involves asking the parent of a minor to step out of the room so you can have an open conversation with your patient about their sexual practices. 

It may also mean avoiding unnecessary tests. Women may not be comfortable with a pelvic exam or the requirement to come back for STI testing or a second visit. These extra steps can be a barrier to starting contraception, so it is important to know the required testing (if any) before beginning contraception and not ask for more.  

Finally, it is important for nurse practitioners to make sure patients who schedule an IUD insertion have short-term birth control in the interim. 

Do any of these contraceptive methods protect against STIs? 

No! Condoms are the only contraceptive method that protect against STIs, and they are only effective when used properly. It is important patients are educated properly about the difference between pregnancy prevention and STI protection so they can act accordingly. 

Related: Contraception Updated Recommendations  

What are the options for emergency contraception? 

With hormonal emergency contraception, an established pregnancy will not be affected, and nor is there a greater risk of birth defects if a woman does become pregnant. 

  • The Copper IUD is the single most effective method. It has a pregnancy rate of 0.09%.
  • Emergency contraceptive pills
    • Ulipristal acetate as a single dose. This is more effective than Plan B outside of 3 days post-coitus.
    • Levonorgestrel in a single dose (“Plan B”)
    • Combined estrogen/progestin in two doses is no longer the recommended option

What are the best contraceptive options for women with hypertension or a high risk of cardiovascular disease? 

The best conceptive options for women with well-controlled hypertension are progestin-only pills or implants or Levonorgestrel IUS. If the woman’s hypertension is poorly controlled, the Copper IUD is the best option because it is non-systemic.  

This is also true if the woman has multiple risk factors for cardiovascular diseases, such as older age, smoking, diabetes, and hypertension. In this case, a Copper IUD is the best option, with the progestin-only pill, implant, and Levonorgestrel IUS being the Category 2 options. 

What is the connection between acne and hormones? 

Acne is caused by high androgen levels, which increase sebum levels and lead to more blocked pores. Hormonal contraception methods help because estrogen supplementation ties up some of the androgens.  

The evidence for how helpful this is, however, is not particularly strong. Therefore, nurse practitioners should evaluate additional solutions with their patients in order to develop a well-rounded plan for acne management. 

Are there issues for women with increased BMI and hormonal contraception? 

There is a higher rate of contraceptive failure in women with BMIs higher than 35. This applies to the pill, the patch, and the NuvaRing. In such cases, nurse practitioners should recommend patients consider an implant, IUD, or IUS. 

What are special considerations for women on antiepileptic medications? 

Certain antiepileptic medications can interact with oral contraception and cause an increased contraceptive failure rate. In this case, the best contraceptive options for women on antiepileptic medications are the copper IUD, Levonorgestrel IUS, and a progestin-based injection. 

How do antibiotics and oral contraceptions interact? 

The alteration of gut flora caused by antibiotics can reduce the circulation of hormone levels. This is unlikely to reduce the contraceptive benefit, however, it may cause spotting. This is important information for a nurse practitioner to pass along to patients who need to go on antibiotics. 

What can NPs suggest to women on oral contraception who report persistent spotting? 

One downside of the very low dosage of oral contraception is that the pills must be taken within one or two hours of the same time each day to be most effective. Otherwise, it is very easy for a woman to experience spotting. One way to prevent this is with a hormone-free interval of 3-4 days once a month. This would allow for a normal period that will make it less likely to experience spotting in the future.  

Earn CE hours by watching the Contraception Updated Recommendations online course (free with Passport Membership).