Benefits and risks. This implant does not cause a hypoestrogenic state and ovulation suppression is rapidly reversible, with ENG levels undetectable within 10 days of implant removal.35 Furthermore, this method has no reported deleterious effects on bone mineral density or lactation.37,38 When counseling women about the implant, emphasize its propensity to result in “irregular and unpredictable” bleeding. An average of 7 bleeding and 10 spotting days within a 90-day period has been reported. Most women had fewer bleeding/spotting days than they would without contraception, but unscheduled bleeding was the leading reason for method discontinuation (11%), followed by weight gain, emotional lability, acne, headache, and depression (each ≈1%-2%).35
Implant insertion. The device is inserted in the sulcus between the biceps and triceps muscles of the nondominant arm. It is crucial to place the implant subdermally, tenting the skin during insertion to prevent deep insertion. High-frequency ultrasound can be used to detect nonpalpable implants. The FDA has mandated 3 hours of training for clinicians before they can obtain the device.
Depot medroxyprogesterone: Tried and true alternative
The depot medroxyprogesterone acetate (DMPA) injection has been a mainstay of contraception for decades. Available under the brand name Depo-Provera, it’s an option for women in whom estrogen-containing contraceptives are contraindicated. Its convenience, reduced risk of anemia, and postpartum benefits are all well known, and we have thus limited our discussion of DMPA to the summary in the TABLE.
TABLE
How do these contraceptives compare?
| METHOD | ROUTE OF ADMINISTRATION | FREQUENCY OF ADMINISTRATION | FAILURES/YR WITH TYPICAL USE 33,35,51 | EXPECTED MENSTRUAL PATTERN | ADVERSE EFFECTS/CONTRAINDICATIONS |
|---|---|---|---|---|---|
| Cyclic OCs | Oral | Daily | 8% | Monthly menses, may have BTB initially | Hormonal adverse effects |
| Extended-cycle OCs (Seasonale, Seasonique) | Oral | Daily | 8% | Menses 4/yr, frequent BTB | Hormonal adverse effects, unscheduled bleeding |
| Continuous OCs (Lybrel) | Oral | Daily | 8% | No scheduled menses, frequent BTB | Hormonal adverse effects, unscheduled bleeding |
| Shortened hormone-free interval OCs (Loestrin 24 Fe, Yaz) | Oral | Daily | 8% | Shorter monthly menses | Hormonal adverse effects, unscheduled bleeding |
| Transdermal patch (Evra) | Patch applied to skin | New patch applied weekly for 3 wk; off for 1 wk | 8% | Monthly menses, may have BTB initially | Hormonal adverse effects, increased risk of VTE higher than OCs but lower than pregnancy; MI risk higher than comparable OCs, but use is reasonable if no cardiac risk factors |
| Vaginal ring (NuvaRing) | Ring inserted in vagina by patient | Ring inserted for 3 wk, removed for 1 wk | 8% | Monthly menses, may have BTB initially | Hormonal adverse effects |
| Copper IUD (ParaGard T 380A) | IUD inserted & removed by clinician | Every 10 yr | 0. 8% | Heavier menses, may have BTB | Menorrhagia. Contraindications: Acute PID or high risk for STI; postpartum endometritis within 3 mo; mucopurulent cervicitis; Wilson’s disease |
| Levonorgestrel IUS (LNG IUS, Mirena) | IUS inserted & removed by clinician | Every 5 yr | < 0.1% | Lighter, shorter menses or amenorrhea | Minimal hormonal adverse effects. Contraindications: Acute PID, history of or high risk for PID; postpartum endometritis within 3 mo; mucopurulent cervicitis |
| Subdermal implant (Implanon) | Inserted subdermally & removed by clinician | Every 3 yr | 0.3% | Irregular, unpredictable bleeding | Unscheduled bleeding, mood symptoms, headache, weight gain, acne |
| Depot medroxyprogesterone acetate (Depo-Provera) | IM injection | Every 3 mo | 3% | Irregular bleeding, amenorrhea | Unscheduled bleeding, reversible bone loss |
| BTB, breakthrough bleeding; IM, intramuscular; IUD, intrauterine device; IUS, intrauterine system; MI, myocardial infarction; OC, oral contraceptive; PID, pelvic inflammatory disease; STI, sexually transmitted infection; VTE, venous thromboembolism. | |||||
Emergency contraception: 2 pills, 12 hours apart
Plan B contains 2 tablets of levonorgestrel 0.75 mg, to be taken 12 hours apart as soon as possible after unprotected intercourse. However, taking both doses together is as effective as taking them separately, and doing so may improve compliance.39
How it works. Emergency contraception (EC) works by inhibiting or delaying the surge of luteinizing hormone and follicular rupture before ovulation. It does not affect implantation or corpus luteum function, and it poses no risk to an established pregnancy or embryo. EC is ineffective when administered after ovulation.40
In a World Health Organization (WHO) multicenter randomized trial, EC prevented 79% to 84% of pregnancies if taken 1 to 3 days after intercourse, and 60% to 63% of pregnancies if taken 4 to 5 days after intercourse.41 Plan B is available without a prescription for women ages 18 and older. It is important to screen for pregnancy before prescribing Plan B for younger patients.
Adverse effects include nausea and vomiting, occurring in 23% and 5% of patients, respectively. Intermenstrual bleeding occurs in 8% of patients taking progestin-only EC. Menses are expected within 21 days of EC administration, and the second cycle after EC should be of normal length.42 The authors of a WHO report concluded that “there are no medical conditions wherein risks outweigh benefits of EC.”43
Combination estrogen/progestin for EC is no more effective than progestin-only EC and results in higher rates of adverse effects, especially nausea and vomiting.44