While prenatal care is the province of the obstetrician, family planning and reproductive counseling can begin in the internist’s office. Sixty-five percent of American women between the ages of 15 and 44 use contraception: this chapter briefly reviews information about currently available contraceptive options. Efficacy is a prime concern, but convenience, cost, patient preference and side-effect profile should also be taken into account. Latex condoms are far more effective in preventing sexually transmitted diseases than other contraceptives.

TABLE 1: Contraceptive Efficacy

*For most women, the health benefits of contraception outweigh the health risks.

The advantage of these strategies is that there are no side effects. Unfortunately, an estimated 20 percent of women become pregnant in the first year of use. (While high, this is considerably lower than the 85 percent who will become pregnant using no contraception at all). Other disadvantages of calendar charting include complexity, lack of protection against sexually transmitted diseases, and inability to reliably predict ovulation in women with irregular menstrual cycles.

Calendar charting techniques are based on the facts that ovulation occurs on day 14 (+/- 2) before onset of the next menses, that sperm remain viable for two to three days and that the ovum survives for 24 hours. The calendar method involves keeping a menstrual calendar to determine the length of the patient’s longest and shortest cycle. The first day of menstruation is day 1, the first fertile day will be the number of days in the shortest cycle minus 10, and the last fertile day will be the number of days in the longest cycle minus 20. Patients are abstinent (or use other forms of birth control) during fertile days. Basal body charting takes advantage of the fact that a drop in basal body temperature (BBT) sometimes precedes ovulation by about 12 to 24 hours and a sustained rise (0.4 - 0.8 degrees F) follows ovulation for several days. Women using this technique measure their temperature daily and assume that they are fertile from the beginning of their cycle (or no later than day 4 if the cycle is greater than 25 days long) until the BBT has remained elevated for three consecutive days. It is safest to remain abstinent (or to use a back-up method of birth control) throughout the first half of the cycle.

Male condoms are easily accessible, inexpensive and provide protection against sexually transmitted disease as well as pregnancy. The failure rate (percentage of women experiencing an accidental pregnancy during the first year of use) is a low 3 percent with "perfect" or "theoretical" use and 14 percent with "typical" use. Perfect use is defined as correct and consistent use. With the addition of intravaginally applied spermicide, these numbers drop even further; the estimated failure rate with "perfect" use of condoms plus spermicide is 0.1 percent. Disadvantages of the male condom include decreased male sensation, lack of spontaneity, the potential for latex allergy and the risk of breakage. Natural membrane condoms have small pores that permit the passage of viruses, making latex condoms preferable. Patients using condoms should be counseled to use them for every act of intercourse, to use spermicide and to avoid the use of oil-based lubricants which reduce condom integrity. Specific lubricants to avoid include mineral oil, petroleum jelly and baby oils, as well as vaginal creams such as Monistat or Premarin. Condoms should be stored in a cool dry place, as heat may cause the latex to weaken.

Female condoms provide some protection against sexually transmitted disease, although they have not been as well studied as the male condom. Failure rates are somewhat higher than with male condoms, estimated at 5 percent with perfect use and 21 percent with typical use. The Reality female condom is a lubricated sheath with two flexible polyurethane rings - one lies inside the vagina and one remains outside the vagina. The condom can be inserted up to eight hours prior to intercourse and should be positioned so that the outer ring lies about one inch outside the vagina. It should be removed immediately after intercourse (before standing up) and a new condom must be used for each act of intercourse.

Diaphragms (plus spermicide) have a six percent failure rate with perfect use and a 20 percent failure rate with typical use. They require fitting by an experienced provider and should be refitted at each annual exam, after a weight change of 10 pounds or more, after abortions and after pregnancy. Like other female-controlled barrier methods, they can be placed up to six hours before intercourse; diaphragms should be left in place for at least six hours after intercourse. For repeated intercourse, fresh spermicide must be administered with an applicator. Diaphragms are associated with an increased risk of urinary tract infections but a decreased risk of cervical neoplasia; they should not be left in place for longer than 24 hours due to the risk of toxic shock syndrome.

Cervical caps (plus spermicide) have a nine percent failure rate with perfect use and a 20 percent failure rate with typical use in nulliparous women. They must be professionally fitted. The cap provides continuous protection for up to 48 hours and must be left in place at least eight hours after intercourse. For repeated intercourse, more spermicide is not necessary but the placement of the cap should be verified. The cervical cap should not be left in place longer than 48 hours because of the risk of toxic shock syndrome. They may be associated with an increased risk of pap smear abnormalities and users should therefore have a repeat Pap smear after three months of use. Contact with oil-based products can deteriorate the cap.

Used alone, spermicides have a failure rate of six percent with perfect use and 26 percent with typical use. They are accessible and convenient, but provide incomplete protection against sexually transmitted infections. (Most contain nonoxynol 9 as the active ingredient, which provides some protection against STIs). The onset of protection ranges from immediately after insertion (foam, jellies and creams) to 15 minutes later (suppositories, tablets and films). Each act of intercourse requires a new application of spermicide.

Oral contraceptives (OCs) are efficient and safe, with a 0.1 percent (typical) failure rate. Their primary mechanism of action is estrogenic inhibition of the mid-cycle surge of gonadotropin release, thereby preventing ovulation. Other advantages include reduced dysmenorrhea and menorrhagia, decreased ovarian cysts, protective effects against pelvic inflammatory disease, decreased ovarian and endometrial cancer rates and prevention of ectopic pregnancy. Oral contraceptives with a low androgenic progesterone may reduce acne. They do not provide protection against sexually transmitted disease, require daily administration and are associated with the side effects of estrogen and progesterone.

Before beginning oral contraceptives, patients should be evaluated for contraindications. History should rule out the presence of absolute contraindications (thromboembolic disease or inherited clotting defects, cerebrovascular disease, breast or endometrial cancer, hepatic adenoma or hepatocellular carcinoma, undiagnosed vaginal bleeding, pregnancy, breast feeding, severe hypertension or hyperlipidemia, and smoking in women over the age of 35). Relative contraindications include diabetes, migraine headaches, SLE, amenorrhea, depression, hypertension or heavy smoking in a woman of any age. Traditional recommendations are that physical exam should include weight, blood pressure, breast exam, liver palpation, pelvic examination and Pap smear, although some authors argue that blood pressure measurement is all that is needed. In women older than 40 who are at high risk for cardiovascular disease, it may be prudent to check a lipid profile and fasting blood sugar when OC’s are started and annually thereafter.

When choosing an oral contraceptive, low-dose formulations should be prescribed. Triphasic OCs minimize progestin dosing and may be beneficial in decreasing progestin-related side effects. Generally, the following OCs are among those that are effective and safe for long-term use: Ortho Cyclen, Ortho Tricyclen, Triphasil and Ortho-Novum 7/7/7. Patients should start the first pack of pills on the day menstruation begins (or on the subsequent Sunday) and should take the pills at the same time every day. It is important for patients to realize that other medications may decrease the efficacy of oral contraception - including ampicillin, rifampin, ritonavir, barbituates and phenytoin. OCs may decrease the activity of anticoagulants and methyldopa and can increase theophylline levels. A follow-up visit to check for adverse effects and to measure blood pressure should be scheduled within three months of initiating contraceptive use.

Depo-provera is a highly effective long-acting contraceptive that has no estrogen-related side-effects and can be given to lactating women. It is more effective than oral contraceptives, with a failure rate of 0.3 percent. Each 150mg IM injection provides three months (and usually 14 weeks) protection against pregnancy; there is no reduction in the risk of STDs. Disadvantages include the need for an injection every three months, irregular menstrual cycles, decreased bone density and the delay in return of fertility. Side effects include breakthrough bleeding (70 percent are amenorrheic by two years), weight gain and fluid retention.

Lunelle (medroxyprogesterone acetate/estradiol cypionate) is a new injectable long-acting contraceptive recently approved by the FDA. Its major advantages over Depo-Provera is that it causes less irregular bleeding and that there is only a three to four month delay in the return of fertility.

Norplant (levonorgestrel) is subdermally implanted in silicone rubber capsules and is effective for five years. With a failure rate of 0.09 percent, it is the most effective form of contraception available (as or more effective than surgical sterilization). Disadvantages include lack of protection against STDs, irregular bleeding, progesterone-related side effects including headache, and need for clinic visit for removal.

NuvaRing, another novel hormonal contraceptive, is a vaginal ring containing 15 ug of ethinyl estradiol and 120 ug of etononogestrel daily. Used monthly, it has recently been FDA approved and should shortly be available for use.

Ortho Evra is a weekly transdermal contraceptive patch designed to deliver 150 µg of norelgestromin and 20 µg of ethinyl estradiol daily to the systemic circulation. In a randomized trial, efficacy was found to be similar to that of oral contraceptives and adherence was significantly greater.

Intrauterine devices are extremely effective (0.1-2 percent failure rate), safe, long-acting contraceptives which are cheaper per year than most other methods. Disadvantages include menstrual irregularity, dysmenorrhea, and lack of STD protection. They are relatively contraindicated in women who are nulliparous, have a history of PID, abnormal uterine anatomy or uterine malignancy, history of ectopic pregnancy, genital bleeding of unknown etiology, multiple sexual partners or increased susceptibility to infection.

Emergency contraception used within 72 hours of intercourse can reduce the risk of pregnancy by approximately 75 percent. (The risk of pregnancy with one act of intercourse is estimated at 0-26 percent depending on where in the cycle it occurs). There are multiple regimens that can be used as emergency contraceptive pill treatment which contain high doses of both estrogen and a progestin (see Table 4). The first dose must be taken within 72 hours of intercourse and the second dose twelve hours later (see Figure 1). The PREVEN Emergency Kit is convenient and relatively inexpensive and includes the pills with a pregnancy test. Side effects of emergency contraception include nausea and vomiting, which can be decreased if pills are taken with a snack or milk.

The FDA has recently approved RU486 – mifeprostone in combination with misporostol – for medical abortion during the first nine weeks of pregnancy. Efficacy ranges from 92 to 96.9 percent. Common adverse effects include abdominal pain and cramping; other side effects include nausea, vomiting and diarrhea. Contraindications include confirmed or suspected ectopic pregnancy, undiagnosed adnexal mass, pregnancy of greater than 49 days duration, IUD in place, current long-term steroid use, allergy to either agent, adrenal insufficiency, hemorrhagic disorder, anticoagulant use or inherited porphyria. Compared to surgical abortion, medical abortion is available during early pregnancy, affords the patient control and is private. Disadvantages include increased time for completion, termination/expulsion of pregnancy at home, and the small risk that surgical abortion will still be required. Medicine residents should not prescribe RU486 at this time; patients should be referred to the Gynecology consult service.

Within 72 hours of unprotected or inadequately protected intercourse:

Consider testing for sexually transmitted diseases

Menstrual period within 21 days?