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This is an updated version of the article that appeared in print.

Am Fam Physician. 2022;106(3):251-259

Related editorial: Contraception Recommendations: Updates for the Busy Clinician

Published online May 27, 2022.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Primary care clinicians are uniquely situated to reduce unintended pregnancy in the context of a patient's medical comorbidities, social circumstance, and gender identity. New evidence regarding contraception use has emerged in recent years. The copper intrauterine device is the most effective option for emergency contraception, with similar effectiveness found for the levonorgestrel-releasing intrauterine system, 52 mg, and both offer extended future contraception. Ulipristal given within 120 hours after unprotected intercourse is the most effective oral emergency contraceptive. Oral levonorgestrel, 1.5 mg, is slightly less effective than ulipristal, and is less effective in patients with a body mass index of more than 30 kg per m2 and if administered after 72 hours. The Yuzpe method, which uses a combination of oral contraceptives, is less effective than ulipristal or oral levonorgestrel, 1.5 mg, and has high risk of nausea and vomiting. Contraception methods based on fertility awareness are safe and have similar effectiveness as condom use and the withdrawal method. Patients who have migraine with aura have a higher risk of ischemic stroke, and combined oral contraceptives appear to increase this risk. Therefore, the Centers for Disease Control and Prevention recommends avoiding their use in these patients. Studies support the extended use of the levonorgestrel-releasing intrauterine system, 52 mg, for eight years, the copper intrauterine device for 12 years, and the etonogestrel subdermal contraceptive implant for five years. One levonorgestrel-releasing intrauterine device, 52 mg, (Mirena) was recently approved by the U.S. Food and Drug Administration (FDA) for eight years of use to prevent pregnancy. However, the intervals for the copper intrauterine device and the etonogestrel subdermal contraceptive implant are longer than approved by the FDA, and patient-clinician shared decision-making should be used. Subcutaneous depot medroxyprogesterone acetate, 104 mg, a newer formulation with prefilled syringes, can be safely self-administered every 13 weeks. Because bone density loss appears to be reversible, the American College of Obstetricians and Gynecologists recommends considering use of depot medroxyprogesterone acetate beyond two years despite an FDA boxed warning about increased fracture risk. Testosterone does not prevent pregnancy but is safe to use with hormonal contraception; thus, transgender and gender-diverse patients with a uterus can be offered the full range of contraceptive options.

In the United States, 45% of pregnancies in 2011 were unintended.1 Primary care clinicians are uniquely situated to provide holistic contraceptive care in the context of a patient's medical comorbidities, social circumstance, and gender identity. This article addresses recent updates on the topic of contraception and answers common questions for clinicians. Table 1 includes comprehensive family planning resources provided by the Centers for Disease Control and Prevention (CDC).2

Clinical recommendations Evidence rating Comments
The copper IUD (Paragard) is the most effective form of emergency contraception, with the levonorgestrel-releasing intrauterine system, 52 mg, (Mirena, Liletta) found to be similarly effective,6,9 followed by oral ulipristal (Ella); oral levonorgestrel, 1.5 mg (Plan B One-Step); and the Yuzpe method.7 A Cochrane review of multiple RCTs, systematic review of RCTs and cohort studies, and an RCT
Fertility awareness methods of contraception are generally safe. They have varying effectiveness, depending on the method used, and are similarly effective as condom use and the withdrawal method.11 B Systematic review of observational studies
Combined hormonal contraceptives appear to increase the risk of ischemic stroke in patients who have migraine with aura and should be avoided in these patients.1921 B Expert opinion and patient-oriented data from two case-control studies
Pregnancy prevention persists with extended use of the levonorgestrel-releasing intrauterine system, 52 mg, for eight years; the copper IUD for 12 years; and the etonogestrel subdermal contraceptive implant (Nexplanon) for five years.25,26,33 B Patient-oriented outcomes from systematic reviews of six cohort studies of extended IUD use and five cohort studies of extended subdermal contraceptive implant use
Subcutaneous depot medroxyprogesterone acetate, 104 mg (Depo-SubQ Provera) can be self-administered safely and effectively.31,3943 A Systematic review and meta-analysis of RCTs and observational studies of patient-oriented outcomes
Use of testosterone is not sufficient for pregnancy prevention in transgender people with a uterus, regardless of the presence of amenorrhea.30 C Observational data (e.g., case series)
RecommendationSponsoring organization
Do not require a pelvic or other physical examination to prescribe oral contraceptives.American Academy of Family Physicians
ResourceExamples of content
Guidelines for providing family planning services: https://www.cdc.gov/reproductivehealth/contraception/qfp.htmHelping patients achieve pregnancy
Contraceptive services
Preconception counseling
Pregnancy testing and counseling
Sexually transmitted infection screening
Preventive health services
Screening for breast or cervical cancer
Conducting quality improvement of family planning metrics
Guidelines for initiating and managing specific contraceptionmethods: https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.htmlHow to be reasonably certain an individual is not pregnant (Table 5)
Contraceptive options
Examinations and testing
Follow-up planning
Managing common adverse effects of contraception
Initiating a contraception method
Switching to a different method
Postpartum and postabortion use
U.S. Medical Eligibility Criteria for Contraceptive Use, 2016: https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.htmlContraception options are evaluated based on common patient characteristics and medical conditions and are rated for safety according to an evidence review
Sexually transmitted infection treatment guidelines, 2021 (updated for drug resistance patterns): https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdfTreatment options for patients who have or are at risk of sexually transmitted infections
Patient resource on contraception: https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancyRisks and benefits of common contraceptives
Smartphone application summarizing contraception recommendations: https://www.cdc.gov/reproductivehealth/contraception/contraception-app.htmlSummary of U.S. Medical Eligibility Criteria for Contraceptive Use and selected U.S. practice recommendations

What Forms of Emergency Contraception Are Effective?

The copper intrauterine device (IUD; Paragard) is the most effective intervention for emergency contraception when placed within 120 hours of unprotected intercourse. A large single study suggests that the levonorgestrel-releasing intrauterine system, 52 mg, (Mirena, Liletta) is similarly effective. Oral ulipristal (Ella); oral levonorgestrel, 1.5 mg, (Plan B One-Step); and the Yuzpe method are also effective if started within 120 hours. Emergency contraception should be started as soon as possible.35 Oral emergency contraception may have decreased effectiveness with increasing body mass index. Table 2 summarizes emergency contraception options.58

MethodPrimary mechanismPregnancy rate after useCost*Considerations
Copper IUD (Paragard)Prevents fertilization0.1%VariesMost effective emergency contraception; not affected by BMI
Levonorgestrel-releasing intrauterine system, 52 mg (Mirena, Liletta)Unknown0.3%Varies
Oral levonorgestrel, 1.5 mg (Plan B One-Step)Delays or inhibits ovulation2.2%$10 ($40)Less effective with a BMI > 30 kg per m2
Ulipristal, 30 mg (Ella)Delays or inhibits ovulation1.3%— ($35)May be less effective with a BMI > 30 kg per m2
Hormonal contraception should be delayed for five days after ulipristal administration
Yuzpe method: combination of 0.1 to 0.12 mg of ethinyl estradiol and 0.5 to 0.6 mg of levonorgestrel, repeated after 12 hours (multiple brands available)Delays or inhibits ovulation2.5% to 2.9%$15 ($15)Significant risk of nausea and vomiting

EVIDENCE SUMMARY

When placed within 120 hours after unprotected intercourse, the copper IUD is 99.9% effective at preventing pregnancy.9 A recent study suggests that the levonorgestrel-releasing intrauterine system, 52 mg, is similarly effective.6 In 317 patients who received the levonorgestrel-releasing intrauterine system, 52 mg, within 120 hours of unprotected intercourse, only one pregnancy occurred. This was similar to the group using the copper IUD.6 Both methods offer reliable long-term contraception after placement, high continuation rates, high user satisfaction, and consistent effectiveness regardless of body mass index.46

Ulipristal is the most effective oral emergency contraceptive, with a 1.3% pregnancy rate when started within 120 hours. Oral levonorgestrel, 1.5 mg, is slightly less effective than ulipristal with a 2.5% pregnancy rate.7 Oral levonorgestrel, 1.5 mg, is approximately twice as effective if given within 72 hours than when given at 72 to 120 hours, and it is less effective for obese patients.7,8 Pregnancy rates may also increase for obese patients using ulipristal, but data are conflicting.8 The Yuzpe method uses a combination of oral contraceptives (0.1 to 0.12 mg of ethinyl estradiol and 0.5 to 0.6 mg of levonorgestrel) repeated after 12 hours. It is a low-cost, widely available method but is less effective than oral levonorgestrel, 1.5 mg, or ulipristal.7 The Yuzpe method is associated with high rates of nausea and vomiting.4,5,7

Oral emergency contraception does not affect an existing pregnancy, and a pregnancy test is unnecessary before use.3,5 Because ulipristal may interact with the progestin component of hormonal contraceptives, it is recommended to wait at least five days before starting hormonal contraception after using ulipristal to preserve emergency contraception effectiveness.4 Hormonal contraception may be started on the same day as oral levonorgestrel, 1.5 mg, administration.5 If a patient does not have a withdrawal bleed within three weeks of using oral emergency contraception, a pregnancy test should be performed.4

Are Fertility Awareness Methods of Contraception Effective?

Fertility awareness methods, which predict timing of ovulation so that intercourse can be avoided, have varying rates of effectiveness that are comparable to barrier and withdrawal methods.10 Smartphone-based applications that aid in fertility awareness are advertised as improving effectiveness but may not be subject to peer review.

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