Contraception Key Features

1 Offer opportunistic contraceptive advice -

adolescents, young men, postpartum & perimenopausal women
2 Advise of specific factors that may reduce efficacy
3 Aid decision-making to ensure adequate contraception:
a) identify risks (relative and absolute contraindications).
b) sexually transmitted disease exposure.
c) Identify barriers to specific methods
d) advise of efficacy and side effects
4 hormonal contraceptives, manage side effects appropriately
5 All (barrier methods, decreased hormonal methods efficacy) post-coital contraception.
6 Unprotected sex or failure contraceptive method, time limits in post-coital contraception

SOGC Contraception Guidelines 2015-2017 (9 Chapters): Typical Failure Rate Chart

Assisting women to explore their plans for childbearing - family planning and contraceptive care

6 Cs- Contraceptives used in the past

pre-Conceived ideas
Contraindications
non-Contraceptive benefits
drug Coverage
Capability to adhere

Fertility Decreases with age

STI, Condoms, dual protection, post exposure prophylaxis, Hep B & HPV vaccination

Opportunity - BMI, BP, smoking cessation, Sexual function, IPV

Barriers of cost, immigration status, language, lack of knowledge of options, partner or peer
pressures/coercion, or lack of understanding of the health care system.

Health care provider barriers - lack of appropriate counselling, inappropriate contraindications,

delaying initiation for menses or investigations, selective prescribing practices (lack of training or
comfort in contraceptive provision (including IUD insertion), applying their own personal beliefs and
values to their patients

Slow regulatory approval, lack of profitability

Permanent Contraception (Chapter 6)

10-year cumulative failure rate of female permanent contraceptive procedures < 2%.
Proxy decision-maker cannot consent to non-therapeutic sterilization of mentally incompetent person
Tubal sterilization- no age restrictions
Ectopic pregnancy-substantial risk if pregnancy occurs after tubal ligation
Decreased ovarian cancer risk
Regret most common complication 6-20%
(Increased- young age, childlessness, unstable relationships, tubal at delivery)
(Decreased- Maternal (disease), complex child, TL in family)

Tubal occlusion may not be complete for several months after the hysteroscopic procedure
 Effectiveness of Family Planning Methods
Most Reversible Permanent How to make your method
Effective Implant Intrauterine Device Male Sterilization Female Sterilization most effective
(IUD) (Vasectomy) (Abdominal, Laparoscopic, Hysteroscopic)
After procedure, little or
nothing to do or remember.
Less than 1 pregnancy Vasectomy and
per 100 women in a year hysteroscopic sterilization:
Use another method for
0.05 %* LNG - 0.2 % Copper T - 0.8 % 0.15 % 0.5 % first 3 months.

Injectable Pill Patch Ring Diaphragm Injectable: Get repeat

injections on time.
SUN MON TUES WED THUR FRI SAT

1
Pills: Take a pill each day.
6-12 pregnancies per 2 Patch, Ring: Keep in place,
100 women in a year 3
change on time.
4

Diaphragm: Use correctly

6% 9% 9% 9% 12 % every time you have sex.

Male Condom Female Condom Withdrawal Sponge Condoms, sponge,

withdrawal, spermicides:
Use correctly every time
you have sex.
Fertility awareness-based
18 or more pregnancies methods: Abstain or
per 100 women in a year 18 % 21 % 22 % 24 % parous women use condoms on fertile
12 % nulliparous women days. Newest methods
Fertility-Awareness Spermicide (Standard Days Method
Based Methods and TwoDay Method)
JANUARY may be the easiest to use
Sp
1
8
2
9
3
10
4
11
5
12
6
13
7
14
erm and consequently more
icid effective.
15
22
16
23
17
24
18
25
19
26
20
27
21
28 e
29 30 31 1 2 3 4

24 % 28 %
Least * The percentages indicate the number out of every 100 women who experienced an unintended pregnancy
Effective within the first year of typical use of each contraceptive method.
CS 242797 CONDOMS SHOULD ALWAYS BE USED TO REDUCE THE RISK OF SEXUALLY TRANSMITTED INFECTIONS.
Other Methods of Contraception
Lactational Amenorrhea Method: LAM is a highly effective, temporary method of contraception.
Emergency Contraception: Emergency contraceptive pills or a copper IUD after unprotected
intercourse substantially reduces risk of pregnancy.
Adapted from World Health Organization (WHO) Department of Reproductive Health and Research, Johns Hopkins Bloomberg
School of Public Health/Center for Communication Programs (CCP). Knowledge for health project. Family planning: a global
handbook for providers (2011 update). Baltimore, MD; Geneva, Switzerland: CCP and WHO; 2011; and Trussell J. Contraceptive
failure in the United States. Contraception 2011;83:397–404.
Natural Family Planning (Chapter 4)

FERTILITY AWARENESS-BASED METHODS (FAB)

Perfect use, 1-year pregnancy rates 0.4% for symptothermal method
4% and 5% for standard days and two-day methods, (typical use 24%)

Standard Days Method - avoid intercourse on days 8 to 19 (menstrual cycle 26 to 32 days in length)

Calendar Days Method - track cycle length 6-12 months

Start of fertile window, subtract 20 days from shortest cycle length
End of fertile window, subtract 10 days from longest cycle length

Symptothermal Method- evaluates cervical mucus for first fertile day

Cervical mucus & temperature for last fertile day

Cervical Mucus- as ovulation approaches, mucus becomes abundant, clearer, more elastic
Fecundability is decreased 3 days after clearest & most elastic mucus produced
After ovulation, mucus first becomes thick, opaque & reduces in volume significantly

Basal Body Temperature - Wake-up, special BBT thermometer, after at least 6 hours of sleep
Rises at least 0.5ºC (post-ovulatory elevation of progesterone)
No unprotected intercourse- beginning of cycle until after 3 consecutive days of temperature elevation

Two Day Method- no cervical mucus “today” or “yesterday” a woman’s fertility is low

Coitus interruptus (“withdrawal”) risk reduction strategy

Abstinence - be respectful
Discuss emergency contraception & STI screening

Lactational amenorrhea - <6 months postpartum, fully or nearly fully breastfeeding, no menses All
pregnant or postpartum women should receive clear instructions

Barrier methods (Chapter 5)

Latex condoms protection against pregnancy, STIs, including HIV, if used consistently & correctly
Lubricants & products use with latex condoms

Safe
Water & silicone-based lubricants (check package insert)
Contraceptive foam and film, Glycerin USP, Egg white, Saliva, Water, Vaginal moisturizers

Unsafe
Baby oil, mineral oil, suntan oil, fish oil, coconut oil/butter, palm oil
Olive oil, peanut oil, or vegetable oil, Margarine, butter
Hemorrhoid or burn ointments, Petroleum jelly, Rubbing alcohol
Vaginal creams (Monistat, Estrace, Femstat, Vagisil, Premarin)
Some sexual lubricants (Elbow Grease, Hot Elbow Grease, Shaft)

Non-latex condoms (polyisoprene, polyurethane, silicone, & lambskin)- an increased incidence of

breakage & slippage, use when latex allergies
Lambskin condoms do not protect against HIV
BARRIER METHODS For Women
Diaphragm or
cap needs acid-
buffering
lubricant

Can insert up to
2 hours before
intercourse

Reapply lubricant
prior to each
Cervical Cap - 3 sizes intercourse
(pregnancy history) Milex Wide-Seal Silicone Omniflex Diaphragm
Leave in place at
least 6 hours
after intercourse.

Diaphragms
should not be left
in longer than 24
hours after
insertion (TTS)

Cervical cap can

remain for up to
48 hours. Caya SILCS Diaphram - Fits 65 to 80 mm
Inserting Cervical Cap
Contraceptive
sponge &
spermicides

Used alone are

not highly
effective
contraceptive
methods

Nonoxynol-9

May cause
vaginal epithelial
damage and
increase the risk
of HIV infection.
Vaginal Contraceptive
Female Condom - Insert up to 8 Spermicidal Foam Film (2x2 inches) -
hours before intercourse insert 15 minutes
before intercourse
 Using a condom
• Put a drop or two of water-based lubricant or saliva inside the condom.
• Place the rolled condom over the tip of the erect penis.
• Leave a half-inch space at the tip to collect semen.
• If not circumcised, pull back the foreskin before rolling on the condom.
• Pinch the air out of the tip with one hand (friction against air bubbles causes most condom
breaks).
• Unroll the condom over the penis with the other hand.
• Roll it all the way down to the base of the penis.
• Smooth out any air bubbles.
• After ejaculation and while the penis is still erect, hold onto the rim of the condom at the base of
the penis so that the condom does not slip off.
• Do not spill the semen.
• Throw the condom away (do not flush down the toilet).
• Wash the penis with soap and water before any further contact.

Intrauterine Contraception - IUC (Chapter 7)

As effective as permanent contraception methods
Condom use recommended for STI & HIV protection

IUC -change in cervical mucus (+ endometrial atrophy)

Contraindications- Category 4
Pregnancy
Current pelvic inflammatory disease or purulent cervicitis
Puerperal sepsis
Immediately post-septic abortion
Known distorted uterine cavity
Abnormal vaginal bleeding not adequately evaluated
Cervical or endometrial cancer awaiting treatment
Malignant trophoblastic disease & persistently elevated BHCG levels & active intrauterine disease
Current progestin receptor+ breast cancer (for LNG-IUS)
Pelvic tuberculosis
Category 3 (consultation prior to advising against)
Past history progestin receptor-positive breast cancer >5 years ago (LNG-IUS)
Severe decompensated cirrhosis, hepatocellular adenoma, or malignant hepatoma (LNG-IUS)
Complicated solid organ transplantation (graft failure, rejection, cardiac allograft vasculopathy)
Postpartum >/= 48 hours to < 4 weeks

Levonorgestrel releasing-decrease menstrual blood loss & dysmenorrhea

Copper & LNG-IUS decrease endometrial cancer risk

Menstrual blood loss Cu-IUD increases up to 65%, Use of NSAIDs or tranexamic acid may help
Average number of bleeding days decreases over time

Unscheduled bleeding, persistent or with pelvic pain

Investigate for infection, pregnancy, uterine or cervical pathology, expulsion, or malposition of IUD

BTB on IUD- 2 weeks of estrogen can stabilize

Nulliparous women report more pain at insertion - less pain LNG-IUS 13.5 mg compared with 52 mg
Cu-IUDs - slight increase in dysmenorrhea; LNG-IUS 52 mg may reduce dysmenorrhea

LNG-IUS 52 mg (150-200 pg/mL)- acne, breast tenderness, headaches, altered mood

Uterine perforation risk decreases with inserter experience, higher in postpartum & breastfeeding
Bimanual examination, tenaculum & sounding may decrease perforation risk

PID increased slightly in first month

Expulsion risk factors- heavy menstrual bleeding, dysmenorrhea, young age, atypical uterine
shape, leiomyoma, and previous expulsion. Not nulliparity.

Ectopic pregnancy lower in IUC users; 15-50% of pregnancies with IUC use are ectopic pregnancies

Potential pregnancy complications-increased risks of spontaneous abortion, septic abortion,

preterm delivery, and preterm premature rupture of membranes;
Early IUC removal improves outcomes but does not entirely eliminate risks

IUD do not increase the risk of infertility

STI- IUC can remain in place treat with appropriate antibiotics; PID, not necessary to remove IUC
unless no clinical improvement after 48-72 hours of appropriate antibiotic treatment.

IUC can be inserted at any time during menstrual cycle if reasonably certain not pregnant
No signs/symptoms of pregnancy & any of:
1. Is </= 7 days after start of a normal menses
2. Not been sexually active since last normal menses
3. Consistently & correctly using an effective method
4. Is </= 7 days of a spontaneous or induced first or second trimester abortion
5. Within 4 weeks postpartum
6. Fully/nearly fully breastfeeding & amenorrheic & < 6 months postpartum
If any of the above criteria are met, a pregnancy test is not required.
In most other cases, a negative high sensitivity urine pregnancy test will reasonably exclude
pregnancy.

Postpartum - immediate IUC insertion (within 10-15 minutes of placental delivery) regardless of mode
of delivery. A higher risk of expulsion & perforation.

Bimanual examination, cervical inspection for uterine position & size, uterine or cervical
abnormalities

STI screening on the day of insertion is a reasonable strategy, mucopurulent discharge or pelvic
tenderness, insertion should be delayed until treated, Routine antibiotic prophylaxis for IUC insertion
not indicated

“no-touch” technique, cervix may be cleansed with iodine or chlorhexidine

Tenaculum applied to the cervix, gentle traction applied, uterus should be sounded.
Once IUC has been inserted to level of fundus, allow arms to expand
Strings trimmed 2 to 3 cm beyond cervical os

NSAIDs, misoprostol? No evidence (option if difficulty)

Misoprostol pre- insertion didn't help, more side effects
No backup needed after copper IUC
Backup for 7 days post LNG-IUS. Follow-up 4-12 weeks.

Lost strings, exclude pregnancy, explore cervical canal, ultrasound, not found (plain abd xray).
Jaydess 13.5 mg silver ring detectable by US

BTB on IUC - 2 weeks of estrogen can stabilize

Copper IUC until menopause if >/= 35 yrs @ insertion

LNG-IUS 52 mg inserted at >/= 45 years for 7 years

Progestin Only Contraception (Chapter 8)

Menstrual cycle disturbances-most common side effect

Contraceptive doses, do not increase risk of venous thromboembolism, myocardial infarction, stroke

Depot Medroxyprogesterone acetate DMPA

Category 4 - Current diagnosis of breast cancer

Category 3 (consultation before advising against)
History of breast cancer & no current disease for 5 years
Unexplained vaginal bleeding (before evaluation)
Severe decompensated cirrhosis
Benign hepatocellular adenoma or malignant hepatoma

150 mg IM every 12-13 weeks (<14 weeks) ovulation unlikely within 14 weeks (WHO 16 weeks)
If within 5 days of menses, effective within 24 hours, after 5 days use backup for 7 days

Efficacy not decreased in overweight & obese

Weight gain early predicts more weight gain, more common in adolescents

Headache, acne, decreased libido, nausea, breast tenderness, abdominal pain or discomfort,
nervousness, dizziness, asthenia

Delay in resumption of ovulation

Decrease BMD, largely reversible (greatest loss in first 1-2 years) (like pregnancy, breast-feeding)
No osteoporosis or increased fracture - advise "bone health"

Does not decrease breast milk production

Decreased risk of endometrial and ovarian cancer

Irregular bleeding after 3-6 months - R/O infection, pregnancy, pathology

Conjugated equine estrogen 0.625-1.25 mg/day, Estradiol 1-2 mg/day for 28 days
Estrogen transdermal 50-100 mg/day for 25 days
COC for 1 to 3 months
NSAIDs- Mefenamic acid 500 mg BID, Ibuprofen 800 mg BID, or celecoxib 200 mg daily for 5 days
Tranexamic acid 500 mg BID for 5 days

>14 weeks, R/O pregnancy, then depends if UPI in last 5-14 days
Progestin Only Pill POP

Additional Category 3
Malabsorptive bariatric surgery procedures
Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate,
oxcarbazepine)
Rifampicin/rifabutin

Patients avoiding estrogen - mechanism is altered cervical mucus

Norethindrone 35 mcg QD - 2 hours onset, lasts 22 hours; No hormone free break

Take same time daily within 3 hours (depends upon last UPI if misses, or vomiting/diarrhea)

Combined Hormonal Contraception CHC (Chapter 9)

Combined Oral Contraceptives COC, Transdermal Contraceptive Patch, Vaginal Contraceptive Ring

Typical use failure rates up to 9% (BMI >30 small increase in failure possible) - See Chart

Careful history includes assessment of patient's health - see contraindications

BP only examination needed - if healthy history (consider baseline weight, BMI)

Pelvic examination, Pap test, STI or thrombophilia screening, are not required prior to initiating CHC

Combined oral contraceptive pills - COCs -

Non-contraceptive benefits - decreased menstrual bleeding, decreased acne, fewer endometriosis
symptoms, decreased ovarian & endometrial cancer risk

COCs increased risk of venous thromboembolism

Periodic "pill breaks" unnecessary and increased risk VTE during first month on re-start
Hormone Holidays - increased VTE, Risk Unintended Pregnancies, Duration of Side Effects

Counselling - when to start & importance of never having > 7-day HFI
Non-contraceptive benefits, Potential side effects & risks, Common myths & misconceptions,
Risks & danger signs, when/where to seek medical care,
What to do if pills are missed, when to consider EC,
Emphasize dual protection (COC with condoms to protect against STIs and HIV)

Start COC at any time during the menstrual cycle, if possibility of pregnancy can be reasonably
ruled out (or check for pregnancy in 2-4 weeks if uncertain)
Immediate (Quick Start) - improve short-term compliance, no increase bleeding or other side effects

Back-up contraception (barrier method) or abstinence for the first 7 consecutive days unless
CHC begun on first day of menses

Switching from another method of contraception - see Table 3

Women may switch from one method to another during the first 5 days of their menses

Continuous or Extended Use of COC

To avoid HFI & withdrawal bleed - skip placebo pills immediately start active hormone-containing pills
84/7 Most efficacious, less escape ovulations, 24/4 (drospirone more effective), 21/7
CHC Contraindications
Category 4
<4 weeks postpartum (breastfeeding)
<21 days postpartum (not breastfeeding)
Smoker >35 years (>15 cigarettes/day)
Vascular disease
Hypertension (systolic >160 mmHg or diastolic >100 mmHg)
Acute DVT/PE
History of DVT/PE not receiving anticoagulant therapy or higher risk for recurrent VTE (history of
estrogen-associated DVT/PE, pregnancy-associated DVT/PE, idiopathic DVT/PE, known thrombophilia
(antiphospholipid syndrome, active cancer except non-melanoma skin cancer, history of recurrent DVT/PE)
Major surgery with prolonged immobilization
Known thrombophilia
Current and/or history of ischemic heart disease
History of stroke
Complicated valvular heart disease (pulmonary hypertension, risk of atrial fibrillation, history of subacute
bacterial endocarditis)
Systemic lupus erythematosus with positive (or unknown) antiphospholipid antibodies
Migraine with aura
Peripartum cardiomyopathy with moderately/severely impaired cardiac function
Peripartum cardiomyopathy with normal/mildly impaired cardiac function <6 months
Current breast cancer
Severe decompensated cirrhosis
Hepatocellular adenoma
Malignant hepatoma
Complicated solid organ transplantation (graft failure, cardiac allograft vasculopathy)

Category 3 (May benefit from expert consultation prior to advising against the method)
4 to 6 weeks postpartum (breastfeeding with other risk factors for VTE such as aged >35, previous VTE,
immobility, transfusion at delivery, peripartum cardiomyopathy, BMI >30 kg/m2, postpartum hemorrhage,
Cesarean delivery, preeclampsia, or smoking)
3 to 6 weeks postpartum (not breastfeeding with other risk factors for VTE)
DVT/PE on established anticoagulation therapy with no other risk factors for VTE (history of estrogen-
associated DVT/PE, pregnancy-associated DVT/PE, idiopathic DVT/PE, known thrombophilia including
antiphospholipid syndrome, active cancer excluding non-melanoma skin cancer, history of recurrent
DVT/PE)
History of DVT/PE with lower risk of recurrent DVT/PE (no other risk factors for VTE)
Multiple sclerosis with prolonged immobility
Smoker aged >35 (<15 cigarettes per day)
Multiple risk factors for arterial cardiovascular disease (older age, smoking, diabetes, hypertension, low
HDL, high LDL, or high triglyceride levels (according to severity of conditions)
Adequately controlled hypertension (blood pressure can be evaluated)
Hypertension (systolic 140 to 159 mmHg or diastolic 90 to 99 mmHg)
Peripartum cardiomyopathy with normal/mildly impaired cardiac function >6 months
History of breast cancer and no evidence of disease for 5 years
Symptomatic gallbladder disease (current or medically treated)
Acute or flare of viral hepatitis (for COC initiation only; assess according to severity of condition)
Diabetes with nephropathy/retinopathy/neuropathy, other vascular disease, or diabetes of >20 years
duration (assess according to severity of condition)
Past COC-related cholestasis
History of malabsorptive bariatric procedures (Roux-en-Y gastric bypass, biliopancreatic diversion)
Certain anticonvulsant use (phenytoin, oxcarbamazepine, barbiturates, primidone, topiramate,
oxcarbazepine, lamotrigine)
Rifampicin or rifabutin therapy
FPV ART therapy
Switching from one method of contraception to another

Table 3 Switching from one method of contraception to another

Switching to
Initial
method Contraceptive Contraceptive Injectable
COC POP Implant LNG-IUS Cu-IUD
patch vaginal ring Progestin
No interruption.Take
Apply the patch for No Take 1 tablet Inject Insert and Insert up to
the first tablet of the
1 week and take 1 interruption.Insert of POP and DMPA and take 1 Insert and take 1 5 days
new pack of COC
COC COC tablet the same the day after taking COC for 2 take 1 COC COC tablet COC tablet daily after taking
the day after taking
day and 1 the next any tablet of the days at the tablet daily daily for 7 for 7 days the last
any tablet of the
day initial COC same time for 7 days more days COC tablet
initial COC
Inject
No Insert 7
Take the first tablet
DMPA at Insert 7 days Insert up to 5
Take the first tablet 1 interruption.Insert days
Contraceptive of POP 2 days least 7 days before days after
day before taking the the ring and remove before
patch before taking the before removing removing the
patch off. the patch the same removing
patch off removing the patch patch
day the patch
the patch
Inject Insert 7
Insert 7 days May insert up to
Take the first COC Apply the patch 2 Take the first POP DMPA 7 days
Contraceptive before 5 days after
tablet 1 day before days before tablet 2 days before days before before
vaginal ring removing removing the
removing the ring removing the ring removing the ring removing removing
the ring ring
the ring the ring
Inject
DMPA and
Insert and Insert and
Take 1 COC tablet Apply the patch and Insert the ring and take 1 POP Insert up to 5
take 1 POP take 1 POP
POP and 1 POP tablet take 1 POP daily for take 1 POP tablet tablet daily days after taking
tablet daily tablet daily
daily for 7 days 7 days daily for 7 days for 7 a POP tablet
for 7 days for 7 days
additional
days
Take the Insert no
Insert no
Take the first COC Apply the patch no Insert the ring no first POP later than Insert no later
later than 13
Progestin tablet no later than later than 13 weeks later than 13 weeks tablet no 13 weeks than 14 weeks
weeks after
injectable 13 weeks after the after the last after the last later than 13 after the and 5 days after
the last
last injection injection injection weeks and 5 last the last injection
injection
days after injection
 the last
injection
Take 1 POP Inject Insert at
The patch should be
Take 1 COC tablet Insert the ring for at tablet daily DMPA at least 7 Insert up to 5
applied for at least 7
per day for 7 days least 7 days before for 2 days least 7 days days days after
Implant consecutive days
before removing the removing the before prior to before removing the
prior to removing
implant implant removing removing removing implant
the implant
the implant the implant the implant
Take 1 POP Inject Insert at Insert the
The patch should be tablet daily DMPA at least 7 Insert the new Cu-IUD on
Take 1 COC tablet Insert the ring for at
LNG applied for at least 7 for 2 days least 7 days days LNG-IUS on the the same
daily for 7 days least 7 days before
intrauterine consecutive days before before before same day that the day that
before removing the removing the LNG-
system prior to removing removing removing removing previous LNG- the LNG-
LNG-IUS IUS
the LNG-IUS the LNG- the LNG- the LNG- IUS is removed IUS is
IUS IUS IUS removed
Remove the Cu-
IUD and insert
the LNG-IUS on
Insert the
Insert at the same day.
Take 1 POP Inject new Cu-
Take 1 COC tablet The patch should be The ring should be least 7 Condoms should
tablet daily DMPA at IUD on the
daily for at least 7 applied for at least 7 inserted at least 7 days be used for at
for at least 2 least 7 days same day
Cu-IUD consecutive days consecutive days days before before least 7 days
days before before that the
before removing the prior to removing removing the Cu- removing before the Cu-
removing removing initial Cu-
Cu-IUD the Cu-IUD IUD the Cu- IUD is removed
the Cu-IUD the Cu-IUD IUD is
IUD and for another 7
removed
days after the
LNG-IUS is
inserted

DMPA: depot medroxyprogesterone acetate; IUS: intrauterine system.

Note. The delay between the initial method and Cu-IUD insertion takes into account the post-coital effect of the Cu-IUD.
 CHC - Discussion points with patients Choosing between CHC options

Effectiveness for Pregnancy Prevention Monophasic recommended over multiphasic

Risk of pregnancy with 1 year of typical use 9%
LARC more effective than pill, patch, or ring 30 mg EE versus 20 mg EE
-less unscheduled bleeding &
Noncontraceptive Benefits -lower discontinuation rates
Decrease risk of endometrial, ovarian, colorectal
cancer Lowest VTE risk: LNG plus 20/30 mg EE
Improve acne
Improve primary dysmenorrhea Nonoral options avoid first-pass hepatic
metabolism
Common adverse effects -theoretically avoid some drug interactions
Bleeding irregularity (12%) -theoretically not as effective against acne
Nausea (7%)
Weight gain (5%); not linked to CHC (rigorous Patch users versus pill & ring users
study) -more breast discomfort, painful menses,
Headache (4%); improves or disappear over nausea, vomiting
months
Breast tenderness (4%) Ring users versus pill
Mood changes (5%) -fewer bleeding problems, less nausea &
emotional changes
Major adverse effects -more vaginal irritation & discharge
VTE; absolute risk attributable 0.56/ 1000
person–years
CVD; absolute risk 18.9/ 100,000 person–years
for MI 28.3/ 100,000 person–years for stroke
Increased risk breast cancer (OR 1.08; CI,1.00–
1.17) & cervical cancer

Breakthrough bleeding - 15 - 30%, often improves with time, higher rate <20 mcg EE
>3 cycles consider - irregular pill taking; smoking; uterine or cervical pathology; malabsorption;
pregnancy; medications (anticonvulsants, rifampin, St. John’s Wort or other herbal meds); infection
New onset of irregular bleeding in long-term COC users - chlamydia infection (up to 29%)

Limited evidence for switch to COC with higher dose of estrogen, or higher estrogen:progestin
ratio, different type of progestin (gonane to estrane progestin or vice versa), or longer half-life
progestin (drospirenone, dienogest, desogestrel)

Short course of oral estrogen with COC (1.25 mg conjugated estrogen or 2 mg E2 daily for 7 days)
Consistent pill use and smoking cessation should be emphasized
If bleeding problematic for the woman, discuss alternative methods of contraception

Amenorrhea - COCs progestin-dominant, some women have no withdrawal bleeding during HFI
(<20 mg EE & shorter HFI regimes) - amenorrhea not dangerous
Consistent pill taking & no symptoms of pregnancy - pregnancy unlikely
Rule out pregnancy if new onset of amenorrhea.

Lo-Lo amenorrhea 50% by one year - Failure first week- inadequate follicular suppression
Breast pain (mastalgia) - resolves after several COC cycles, decreasing COC estrogen content may
help; decreasing caffeine does not help

Galactorrhea during COC use is rare - other possible causes should be investigated

Nausea - commonly reported side effect during first COC cycles, decreases with time
(Placebo-controlled studies - no increase in nausea in COC users compared with placebo)
Lower estrogen COC may be helpful or taking COC at bedtime
If new onset nausea occurs in long-time pill user, pregnancy must be ruled out

Diarrhea or vomiting - limited evidence but reasonable to used missed dose recommendations

Missed pills “late” (<24 hours since a pill should have been taken), “missed” (>24 hours since last pill
was taken), how many pills were missed, timing in the pill pack, and whether UPI has occurred

Highest risk of ovulation when hormone-free interval HFI >7 days (delaying CHC start or missing
hormone doses during first or third weeks of cycle) unless repeated omissions or failure

Use back-up contraception after missed doses

1 COC or other (CHC) method missed in first week of use -

Back-up contraception or abstinence until CHC method in use for 7 consecutive days

Missed CHC in second or third week of hormones - Hormone-free interval eliminated for that cycle

3 consecutive doses/days missed CHC in 2nd or 3rd week hormone -

Back-up contraception 7 days
Scheduled HFI should be eliminated in these cycles

LNG-EC when EC required for missed CHC - potential drug interaction UPA-EC & CHC
CHC restarted same day or day after LNG-EC taken

HRU. Hormonal contraceptives: pharmacology tailored to women’s health. 2016

Adolescents - Wait 1–2 years after menarche

(immaturity HPO axis - secondary sexual characteristics & bone development) - adequate estrogen
5–7 years after menarche critical for good peak bone mass (COC-stable circulating concentrations
estrogens below typical physiologic cyclic variability)
Prefer estrogen 30 μg, especially if will be used for a long period

Perimenopausal women - if non-smokers, contraceptive safety, fewer vasomotor symptoms,

Prevention of osteoporosis, regularization of menstrual cycle &
Prevention of endometrial, ovarian, colorectal cancer

Menstrual irregularity (rhythm, quantity and pain) - low-estrogen - no menstruation between packs;
Spontaneous cycle may not occur 25–50d after stop, flexibly modify cycles (take continuously for
months or years), reduce menstrual flow, reduction or elimination dysmenorrhea, (especially
uterotropic progestins) (reduce thickness & maturation of endometrium, decreasing menstrual flow,
inhibiting prostaglandin production & interfering with cyclo-oxygenase 2 enzyme action)
[Best - estradiol valerate (E2V) + dienogest (DNG), quadriphasic regime, 26+2d]
Premenstrual syndrome and premenstrual dysphoric disorder - estrogen deficit during 7 days off
(pelvic pain, headache, bloating, breast tension) - continuous, 24/4;
DRSP anti-mineralcorticoid properties inhibit water retention, reduces PM ,
3 mg DRSP & 20 μg EE-PMDD (Cochrane)

PCOS - COCs reduce acne & hirsutism, restores cyclic regularity, improve bone density
(inhibition of folliculogenesis, suppression pituitary gonadotrophins)
EE 30 μg & DRSP most effective (inhibition of adrenal androgens)
CPA, DNG, DRSP, CMA - progestins with anti-androgenic activity
COCs increase TG, total cholesterol, aggravate insulin resistance, cause weight gain
Metformin + COC - sharper androgen reduction, no aggravation insulin resistance

Side effects of oral contraceptives - Reducing EE - less breast tension, headache, nausea; DRSP
reduced total & extracellular water retention
Progestin only (MPA) - weight increase 3–6 kg in 36 months, 5% in 6 months
Acne and Hirsutism

Obese - BMI > 30 kg/m2, half-life LNG longer, lower serum peak & slower steady state
than BMI < 25 kg/m2 (20 μg EE & 100 μg LNG)

Drug Interactions - EE sulphated in intestinal wall, hydroxylated in cytochrome P450-3A4

(CYP3A4) pathway of liver, conjugated with glucuronides and passes into enterohepatic circulation
COC is a moderate inhibitor of CYP1A2 and a weak inhibitor of CYP3A4, CYP2D6, and CYP219.

AEDs - phenytoin, phenobarbital, carbamazepine, felbamate, topiramate, oxcarbazepine, primidone -

induce CYP3A4 - enhanced metabolism either/both estrogenic & progestogenic - reducing efficacy

Valproic acid inhibits CYP3A4 and thus does not affect COC efficacy
COCs reduce lamotrigine levels 50% - monitor lamotrigine levels when initiate or discontinue COC

Most broad-spectrum antibiotics do not affect COC effectiveness (except rifampicin and griseofulvin)

Grapefruit inhibits CYP450 - Increased BTB, no contraception change (transient EE increase)

 CHAPTER 9: Combined Hormonal Contraceptives

Table 4. Drug interactions with COCs

Medications whose interaction may cause Medications that may increase COC Medications whose effect may be altered
contraceptive failure activity by COCs
Antiepileptic drugs (AEDs) Acetaminophen Anastrozole
(e.g. barbiturates, carbamazepine, Amiodarone Anticoagulants
clobazam, fosphenytoin, phenytoin, Estrogenic herbs (alfalfa, black cohosh, Benzodiazepines (alprazolam,
oxcarbazepine, perampanel, primidone, bloodroot, ginseng, hops, kudzu, licorice, chlordiazepoxide, diazepam, midazolam,
rufinamide, topiramate) red clover, saw palmetto, soybean, triazolam)
Bile acid sequestrants (cholestyramine, thyme, wild yam, yucca) Beta-blockers (acebutolol, propranolol)
colestipol, colesevelam) Antifungals (fluconazole, voriconazole) Caffeine
Bosentan Erythromycin Corticosteroids
Dabrafenib Grapefruit juice Cyclosporine
Deferasirox Progestogenic herbs (bloodroot, Fosamprenavir (FPV)46
Exenatide chasteberry, Lamotrigine265
Fosaprepitant damiana, oregano, yucca) Mifepristone
Hepatitis C protease inhibitors Rosuvastatin Phenytoin
(boceprevir, telaprevir) Serotonin reuptake inhibitors (fluoxetine, Ropinirole
HIV protease inhibitors (atazanavir, fluvoxamine, sertraline) Selegiline
darunavir, FPV, lopinavir/ritonavir, Vitamin C Theophylline
nelfinavir, ritonavir, darunavir, tipranavir) Thyroid products
Modafinil Tizanidine
Mycophenolic acid Tranexamic acid
Purcalopride Tricyclic antidepressants (amitriptyline,
Rifampin clomipramine, desipramine, doxepin,
St. John’s Wort268 imipramine, nortriptyline)
Ulipristal acetate Ursodiol
Ulipristal Acetate (UPA)
Voriconazole
Zolmitriptan

Transdermal Contraceptive
TRANSDERMAL CONTRACEPTIVEPatch - 20-cm2 patch - Clinical
PATCH Daily 35 mg EE
studies & 200
found that mg
the norelgestromin
PI with perfect use of the
(norgestimate primary active metabolite) - serum hormone levels patch
contraceptive increase gradually
was 0.7 (95% CI, over 48-72
0.31 to 1.10), hrs,
whereas
Introduction
reach a plateau, remain constant - One patch appliedwith
weekly for 3useweeks,
typical the PIthen
was1 0.88
patch-free week
(95% CI, 0.44 to
The
Place contraceptive
on buttocks, patchupper
was approved
outer arm, for use
lowerin Canada
abdomen, in upper
1.33). torso, A
231,280,282 excluding
subgroup ofbreast
women weighing more than 90
2002
History andofbecame available for
malabsorptive use in procedures
bariatric January 2004. isThe not a kg
contraindication to contraceptive
may have an increased risk of pregnancy patch useusing the
while
2
contraceptive patch is a 20-cm square
May be less effective in women with body weight of >90 matrix system that kg
patch. 280,282,283
In one study, 4 of 6 pregnancies that occurred
delivers 200 mg of with
Likely associated norelgestromin
improvements (the primary active
in hyperandrogenic symptoms
were in women weighing(acne,athirsutism)
least 90 kg280; in a pooled analysis,
metabolite of norgestimate) and 35 g of EE
Less breakthrough bleeding/spotting; more breast discomfort/pain,
m daily to the dysmenorrhea,
5 of the 15 pregnancies that occurred nausea/vomiting
in patch users were in
systemic circulation.277 Following
Patch detachments are rare the first application
if cannot re-attach of the
- replace
women weighing more than 90 kg. 282
patch, serum hormone levels increase gradually over the first
48 to 72 hours, reach a plateau, and then remain constant Compliance affects contraceptive effectiveness, and patch
278
during
Vaginal theContraceptive
remainder of theRing 21-day-15 ug EE Compared
period. & 120 ug progestinusers mayENG be more compliant than
(desogesterol of COCs.251,282,284
usersmetabolite)
active
with
dailythe forCOC, plasma(up
3 weeks hormone levels remain
to 28 days) constant and
of continuous Compared
use then with COC,
1 ring-free weekthe odds of perfect compliance with
the
Less peak levels are lower because first-pass
compliance-demanding method hepatic meta-
of contraception, the patch are 2.05 swallowing
difficulty to 2.76 times higher (95% CI 1.83with
pills, conditions to 2.29
231,251,281
bolism and gastrointestinal enzyme degradation are avoided.
decreased gastrointestinal absorption (IBD), non-contraceptive effects and 2.35 to 3.24, respectively). However, early
Although
Reducedpeak levels areblood
menstrual lower,loss,
the area under the
improved discontinuation
curve, of menses,
duration rates mayferritin
hemoglobin, be higher
levelscompared
after 3 with the
cycles
278,279
which represents overall EE exposure, is higher. COC,
Reduced dysmenorrhea, premenstrual syndrome, menstrual headaches & migraines, hirsutism, and patch users are more likely to discontinue due to
231,251,285
hyperandrogenemia, endometriotic nodule volume adverse events than are COC users.
One
Morepatch is applied
vaginal weekly for(vaginitis,
symptoms 3 consecutive weeks, fol-ring problems); Less nausea, acne, emotional lability
leukorrhea,
lowed by 1 patch-free
Malabsorptive week.procedures
bariatric The patch is not placed on 1 of 4
a contraindication Summary
to vaginalStatement
contraceptive ring use
sites: the buttocks, upper outer arm, lower
Not good ring candidates: Significant pelvic relaxation, abdomen, or vaginal stenosis, obstruction (if prevent ring
15. The contraceptive patch may be less effective in
upper torso, excluding the breast.
retention); if vagina more susceptible to irritation or ulceration; inability/unwillingness
women with a body weight !90tokgtouch (II-2). genitals
Women with a history of genital herpes (herpes simplex virus) may still use the ring
Effectiveness
If ring interferes with intercourse - remove it before & reinsert it ASAP after intercourse within 3 hours
The
Rinse patch has a perfectwater
in lukewarm use failure
beforerate of 0.3% and a typical
reinsertion Mechanism of Action
16 231,251,280,281
use failure rate of 9%. It is as effective as COCs.
No interaction - ring & antimycotics (miconazole), amoxicillin, The mechanism of actionspermicides,
doxycycline, is similar to that of the COC.
tampons
 Side effects related to hormone dose of OCs. (A) Side effects related to estrogen dose.

Vincenzo De Leo et al. Hum. Reprod. Update 2016;22:634-

646

© The Author 2016. Published by Oxford University Press on behalf of the European Society of
Human Reproduction and Embryology. All rights reserved. For Permissions, please email:
journals.permissions@oup.com
Emergency contraception EC (Chapter 3)

Back-up method when regular contraception not used, used improperly, or contraceptive accident
Post-coital insertion of copper IUD or hormonal contraception - initiate as soon as possible after UPI

2 tablets of Levonorgestrel LNG 750 mcg to be taken together as a single 1.5 mg dose [OTC]
Yuzpe method - COC for 2 doses of ethinyl estradiol (100 mcg) and LNG (500 mcg) 12 hours apart
[Rx, less effective, more side effects]
Ulipristal acetate UPA 30 mg [Rx] selective progesterone receptor modulator

Combined oral contraceptive pills for use as EC

Pills per dose Ethinyl estradiol (mcg/dose) Levonorgestrel (mcg/dose)

Alesse 5 100 500

Triquilar 4 yellow 120 500

Min-Ovral 4 120 600

Summary table of risks of pregnancy with different methods of EC according to timing since UPI

Day since UPI ≤1 2 3 4 5 6 7

Methods, % Risk of pregnancy

Yuzpe EC2 3.2 3.2 3.2 >3.2 >3.2 NA NA

LNG EC 9., 10. 2.3 1.6 2.7 2.8 3.0 NA NA

UPA EC 9., 10. 0.9 2.2 0.9 0** 0** NA NA

Emergency, %

Cu-IUD6 0.01 0.01 0.01 0.01 0.01 0.01 0.01

Copper IUD most effective emergency contraception, up to 7 days.

Levonorgestrel effective up to 5 days (120 hours), decreases with time
Ulipristal acetate is more effective up to 5 days, especially after 72 hours

Hormonal emergency contraception not effective if taken on day of ovulation or after ovulation

Levonorgestrel may be less effective BMI > 25 kg/m2 and ulipristal acetate ≥ 35, still some efficacy
Copper IUD recommended for BMI > 30 kg/m2, ulipristal acetate first choice BMI ≥ 25 kg/m2

Discuss plan for ongoing contraception

Hormonal contraception can begin the day of or the day following use of levonorgestrel, back-up
contraception for first 7 days,
Initiate 5 days following ulipristal acetate, with back-up contraception for first 14 days (III)
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use
Condition Sub-Condition Cu-IUD LNG-IUD Implant DMPA POP CHC Condition Sub-Condition Cu-IUD LNG-IUD Implant DMPA POP CHC
I C I C I C I C I C I C I C I C I C I C I C I C
Age Menarche Menarche Menarche Menarche Menarche Menarche Diabetes a) History of gestational disease 1 1 1 1 1 1
to to to to to to b) Nonvascular disease
<20 yrs:2 <20 yrs:2 <18 yrs:1 <18 yrs:2 <18 yrs:1 <40 yrs:1 i) Non-insulin dependent 1 2 2 2 2 2
≥20 yrs:1 ≥20 yrs:1 18-45 yrs:1 18-45 yrs:1 18-45 yrs:1 ≥40 yrs:2 ii) Insulin dependent 1 2 2 2 2 2
>45 yrs:1 >45 yrs:2 >45 yrs:1 c) Nephropathy/retinopathy/neuropathy‡ 1 2 2 3 2   3/4*
Anatomical d) Other vascular disease or diabetes
a) Distorted uterine cavity 4 4 of >20 years’ duration‡ 1 2 2 3 2   3/4*
abnormalities
b) Other abnormalities 2 2 Dysmenorrhea Severe 2 1 1 1 1 1
Anemias a) Thalassemia 2 1 1 1 1 1 Endometrial cancer‡ 4 2 4 2 1 1 1 1
b) Sickle cell disease‡ 2 1 1 1 1 2 Endometrial hyperplasia 1 1 1 1 1 1
c) Iron-deficiency anemia 2 1 1 1 1 1 Endometriosis 2 1 1 1 1 1
Benign ovarian tumors (including cysts) 1 1 1 1 1 1 Epilepsy‡ (see also Drug Interactions) 1 1   1*   1*   1*   1*
Breast disease a) Undiagnosed mass 1 2   2*   2*   2*   2* Gallbladder disease a) Symptomatic
b) Benign breast disease 1 1 1 1 1 1 i) Treated by cholecystectomy 1 2 2 2 2 2
c) Family history of cancer 1 1 1 1 1 1 ii) Medically treated 1 2 2 2 2 3
d) Breast cancer‡ iii) Current 1 2 2 2 2 3
i) Current 1 4 4 4 4 4 b) Asymptomatic 1 2 2 2 2 2
ii) Past and no evidence of current Gestational trophoblastic a) Suspected GTD (immediate
disease for 5 years 1 3 3 3 3 3 disease‡ postevacuation)
Breastfeeding a) <21 days postpartum   2*   2*   2*   4* i) Uterine size first trimester   1*   1*   1*   1*   1*   1*
b) 21 to <30 days postpartum ii) Uterine size second trimester   2*   2*   1*   1*   1*   1*
i) With other risk factors for VTE   2*   2*   2*   3* b) Confirmed GTD
ii) Without other risk factors for VTE   2*   2*   2*   3* i) Undetectable/non-pregnant
  1*   1*   1*   1*   1*   1*   1*   1*
c) 30-42 days postpartum ß-hCG levels
i) With other risk factors for VTE   1*   1*   1*   3* ii) Decreasing ß-hCG levels   2*   1*   2*   1*   1*   1*   1*   1*
ii) Without other risk factors for VTE   1*   1*   1*   2* iii) Persistently elevated ß-hCG levels
or malignant disease, with no
d) >42 days postpartum   1*   1*   1*   2* evidence or suspicion of intrauterine   2*   1*   2*   1*   1*   1*   1*   1*
Cervical cancer Awaiting treatment 4 2 4 2 2 2 1 2 disease
Cervical ectropion 1 1 1 1 1 1 iv) Persistently elevated ß-hCG levels
Cervical intraepithelial or malignant disease, with evidence   4*   2*   4*   2*   1*   1*   1*   1*
neoplasia 1 2 2 2 1 2 or suspicion of intrauterine disease
Cirrhosis a) Mild (compensated) 1 1 1 1 1 1 Headaches a) Nonmigraine (mild or severe) 1 1 1 1 1   1*
b) Severe‡ (decompensated) 1 3 3 3 3 4 b) Migraine
Cystic fibrosis‡   1*   1*   1*   2*   1*   1* i) Without aura (includes menstrual
migraine) 1 1 1 1 1   2*
Deep venous thrombosis a) History of DVT/PE, not receiving
(DVT)/Pulmonary anticoagulant therapy ii) With aura 1 1 1 1 1   4*
embolism (PE) i) Higher risk for recurrent DVT/PE 1 2 2 2 2 4 History of bariatric a) Restrictive procedures 1 1 1 1 1 1
ii) Lower risk for recurrent DVT/PE 1 2 2 2 2 3 surgery‡ COCs: 3
b) Malabsorptive procedures 1 1 1 1 3
b) Acute DVT/PE 2 2 2 2 2 4 P/R: 1
c) DVT/PE and established anticoagulant History of cholestasis a) Pregnancy related 1 1 1 1 1 2
therapy for at least 3 months b) Past COC related 1 2 2 2 2 3
i) Higher risk for recurrent DVT/PE 2 2 2 2 2   4* History of high blood
ii) Lower risk for recurrent DVT/PE 2 2 2 2 2   3* pressure during 1 1 1 1 1 2
d) Family history (first-degree relatives) 1 1 1 1 1 2 pregnancy
e) Major surgery History of Pelvic surgery 1 1 1 1 1 1
i) With prolonged immobilization 1 2 2 2 2 4 HIV a) High risk for HIV 2 2 2 2 1   1* 1 1
ii) Without prolonged immobilization 1 1 1 1 1 2 b) HIV infection   1*   1*   1*   1*
f ) Minor surgery without immobilization 1 1 1 1 1 1 i) Clinically well receiving ARV therapy 1 1 1 1 If on treatment, see Drug Interactions
Depressive disorders   1*   1*   1*   1*   1*   1* ii) Not clinically well or not receiving ARV
therapy‡ 2 1 2 1 If on treatment, see Drug Interactions

Abbreviations: C=continuation of contraceptive method; CHC=combined hormonal contraception (pill, patch, and, ring); COC=combined oral contraceptive; Cu-IUD=copper-containing
Key: intrauterine device; DMPA = depot medroxyprogesterone acetate; I=initiation of contraceptive method; LNG-IUD=levonorgestrel-releasing intrauterine device; NA=not applicable;
1 No restriction (method can be used) 3 Theoretical or proven risks usually outweigh the advantages POP=progestin-only pill; P/R=patch/ring ‡ Condition that exposes a woman to increased risk as a result of pregnancy. *Please see the complete guidance for a clarification to this classification:
2 Advantages generally outweigh theoretical or proven risks 4 Unacceptable health risk (method not to be used) www.cdc.gov/reproductivehealth/unintendedpregnancy/USMEC.htm.
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use
Condition Sub-Condition Cu-IUD LNG-IUD Implant DMPA POP CHC Condition Sub-Condition Cu-IUD LNG-IUD Implant DMPA POP CHC
I C I C I C I C I C I C I C I C I C I C I C I C
Hypertension a) Adequately controlled hypertension 1* 1* 1* 2* 1* 3* Pregnancy 4* 4* NA* NA* NA* NA*
b) Elevated blood pressure levels Rheumatoid a) On immunosuppressive therapy 2 1 2 1 1 2/3* 1 2
(properly taken measurements) arthritis
b) Not on immunosuppressive therapy 1 1 1 2 1 2
i) Systolic 140-159 or diastolic 90-99 1* 1* 1* 2* 1* 3* Schistosomiasis a) Uncomplicated 1 1 1 1 1 1
ii) Systolic ≥160 or diastolic ≥100‡ 1* 2* 2* 3* 2* 4*
b) Fibrosis of the liver‡ 1 1 1 1 1 1
c) Vascular disease 1* 2* 2* 3* 2* 4* Sexually transmitted a) Current purulent cervicitis or chlamydial
Inflammatory bowel diseases (STDs) infection or gonococcal infection 4 2* 4 2* 1 1 1 1
disease
(Ulcerative colitis, Crohn’s disease) 1 1 1 2 2 2/3*
b) Vaginitis (including trichomonas vaginalis
Ischemic heart disease‡ Current and history of 1 2 3 2 3 3 2 3 4 and bacterial vaginosis) 2 2 2 2 1 1 1 1
Known thrombogenic
1* 2* 2* 2* 2* 4*
c) Other factors relating to STDs 2* 2 2* 2 1 1 1 1
mutations‡ Smoking a) Age <35 1 1 1 1 1 2
Liver tumors a) Benign b) Age ≥35, <15 cigarettes/day 1 1 1 1 1 3
i) Focal nodular hyperplasia 1 2 2 2 2 2 c) Age ≥35, ≥15 cigarettes/day 1 1 1 1 1 4
ii) Hepatocellular adenoma‡ 1 3 3 3 3 4 Solid organ a) Complicated 3 2 3 2 2 2 2 4
b) Malignant‡ (hepatoma) 1 3 3 3 3 4 transplantation‡ b) Uncomplicated 2 2 2 2 2 2*
Malaria 1 1 1 1 1 1 Stroke‡ History of cerebrovascular accident 1 2 2 3 3 2 3 4
Multiple risk factors (e.g., older age, smoking, diabetes, Superficial venous a) Varicose veins 1 1 1 1 1 1
for atherosclerotic hypertension, low HDL, high LDL, or high 1 2 2* 3* 2* 3/4* disorders b) Superficial venous thrombosis
cardiovascular disease triglyceride levels)
(acute or history) 1 1 1 1 1 3*
Multiple sclerosis a) With prolonged immobility 1 1 1 2 1 3 Systemic lupus a) Positive (or unknown) antiphospholipid
b) Without prolonged immobility 1 1 1 2 1 1 erythematosus‡ antibodies 1* 1* 3* 3* 3* 3* 3* 4*
Obesity a) Body mass index (BMI) ≥30 kg/m2 1 1 1 1 1 2 b) Severe thrombocytopenia 3* 2* 2* 2* 3* 2* 2* 2*
b) Menarche to <18 years and BMI ≥ 30 c) Immunosuppressive therapy 2* 1* 2* 2* 2* 2* 2* 2*
kg/m2 1 1 1 2 1 2
d) None of the above 1* 1* 2* 2* 2* 2* 2* 2*
Ovarian cancer‡ 1 1 1 1 1 1 Thyroid disorders Simple goiter/ hyperthyroid/hypothyroid 1 1 1 1 1 1
Parity a) Nulliparous 2 2 1 1 1 1 Tuberculosis‡ a) Nonpelvic 1 1 1 1 1* 1* 1* 1*
b) Parous 1 1 1 1 1 1 (see also Drug Interactions) b) Pelvic 4 3 4 3 1* 1* 1* 1*
Past ectopic pregnancy 1 1 1 1 2 1 Unexplained vaginal (suspicious for serious condition) before
Pelvic inflammatory a) Past bleeding evaluation 4* 2* 4* 2* 3* 3* 2* 2*
disease i) With subsequent pregnancy 1 1 1 1 1 1 1 1 Uterine fibroids 2 2 1 1 1 1
ii) Without subsequent pregnancy 2 2 2 2 1 1 1 1 Valvular heart a) Uncomplicated 1 1 1 1 1 2
b) Current 4 2* 4 2* 1 1 1 1 disease b) Complicated‡ 1 1 1 1 1 4
Peripartum a) Normal or mildly impaired cardiac Vaginal bleeding patterns a) Irregular pattern without heavy bleeding 1 1 1 2 2 2 1
cardiomyopathy‡ function b) Heavy or prolonged bleeding 2* 1* 2* 2* 2* 2* 1*
i) <6 months 2 2 1 1 1 4 Viral hepatitis a) Acute or flare 1 1 1 1 1 3/4* 2
ii) ≥6 months 2 2 1 1 1 3 b) Carrier/Chronic 1 1 1 1 1 1 1
b) Moderately or severely impaired cardiac
function 2 2 2 2 2 4 Drug Interactions
Antiretroviral therapy Fosamprenavir (FPV)
Postabortion a) First trimester 1* 1* 1* 1* 1* 1* All other ARV’s are 1/2* 1* 1/2* 1* 2* 2* 2* 3*
b) Second trimester 2* 2* 1* 1* 1* 1* 1 or 2 for all methods.
c) Immediate postseptic abortion 4 4 1* 1* 1* 1* Anticonvulsant therapy a) Certain anticonvulsants (phenytoin,
Postpartum a) <21 days 1 1 1 4 carbamazepine, barbiturates, primidone, 1 1 2* 1* 3* 3*
(nonbreastfeeding b) 21 days to 42 days topiramate, oxcarbazepine)
women) b) Lamotrigine 1 1 1 1 1 3*
i) With other risk factors for VTE 1 1 1 3*
ii) Without other risk factors for VTE 1 1 1 2 Antimicrobial a) Broad spectrum antibiotics 1 1 1 1 1 1
therapy b) Antifungals 1 1 1 1 1 1
c) >42 days 1 1 1 1
Postpartum a) <10 minutes after delivery of the placenta c) Antiparasitics 1 1 1 1 1 1
(in breastfeeding or non- i) Breastfeeding 1* 2* d) Rifampin or rifabutin therapy 1 1 2* 1* 3* 3*
breastfeeding women, SSRIs 1 1 1 1 1 1
including cesarean
ii) Nonbreastfeeding 1* 1*
b) 10 minutes after delivery of the placenta St. John’s wort 1 1 2 1 2 2
delivery) 2* 2*
to <4 weeks
c) ≥4 weeks 1* 1* Updated July 2016. This summary sheet only contains a subset of the recommendations from the U.S. MEC. For complete guidance, see: http://www.cdc.gov/reproductivehealth/
unintendedpregnancy/USMEC.htm. Most contraceptive methods do not protect against sexually transmitted diseases (STDs). Consistent and correct use of the male latex condom
d) Postpartum sepsis 4 4 CS266008-A
reduces the risk of STDs and HIV.