Contraception

PDF Reference Guides

• CDC Contraception Guidelines

• Patient Education Chart

Contraindications to starting long-acting reversible contraception (LARC)

• Contraindications to starting an IUD

  • Levonorgestrel and copper

    • Pregnancy or elevated beta-hCG (e.g. gestational trophoblastic disease)

    • Distorted uterine cavity and/or unexplained uterine bleeding

    • Pelvic infection and/or active sepsis

    • Active cervical and/or endometrial cancer

  • Levonorgestrel: Also applies to medroxyprogesterone implant and injections (see below)

    • Breast cancer within the past 5 years

    • Ischemic heart disease

    • Liver tumors and/or severe cirrhosis

    • Systemic lupus erythematosus with positive or unknown antiphospholipid antibodies

  • Copper: History of severe anemia or bleeding disorders (e.g. thrombocytopenia)

• Contraindications to starting medroxyprogesterone

  • Implant (Nexplanon) and injection (Depo-Provera):

    • History of cerebrovascular disease

    • Morbid obesity (Nexplanon contraindicated if > 90 kg and Depo-Provera can result in weight gain)

    • All contraindications levonorgestrel IUD apply (see above)

  • Injection (Depo-Provera) only

    • Hypertension: Systolic > 160 mmHg and/or diastolic > 110 mmHg

    • Diabetes with vascular complications (retinopathy/nephropathy/neuropathy)

    • Severe thrombocytopenia

Note: The copper IUD is the only approved form of birth control for women with a history of breast cancer within the past 5 years and/or antiphospholipid antibody positive systemic lupus erythematosus.

Combined Oral Contraception (Estrogen + Progesterone)

Contraindications

• Common

  • Hypertension: Systolic > 160 and/or diastolic > 110

  • Current medications: Rifampin, anticonvulsants, antiretrovirals

  • Actively breastfeeding and less than 42 days postpartum

  • Thrombosis risk:

    • Age > 35 years and an active smoker

    • History of superficial venous thrombosis

    • History of DVT/PE and not currently on anticoagulation

    • Systemic lupus erythematosus with positive or unknown antiphospholipid antibodies

  • Neurovascular: History of ischemic stroke, migraine with aura

• Additional considerations

  • Breast cancer within the previous 5 years

  • Cardiovascular: Ischemic and/or valvular heart disease, diabetes with vascular complications (retinopathy/nephropathy/neuropathy)

  • Gastrointestinal/Hepatobiliary: History of bariatric surgery, active gallbladder disease, acute viral hepatitis, liver tumors and/or severe cirrhosis

Prescription Options

• Ethinyl estradiol 0.03 mg and drospirenone 3 mg (Yasmin): Also used for acne, breast soreness, severe menstrual cramps, breakthrough bleeding

• Ethinyl estradiol 0.035 mg and norgestimate 0.25 mg (Ortho-Cyclen)

  • May reduce depression, moodiness, irritability

  • Phasic version (Ortho Tri-Cyclen) increases progesterone dose every 7 days, i.e. 0.18 mg days 1-7, 0.215 mg days 8-14, 0.25 mg days 15-21

• Ethinyl estradiol 0.03 mg and norethindrone acetate 1.5 mg (Loestrin): Also used for reduction of endometriosis symptoms

Counseling

• Start first dose on the first Sunday following menstruation (if menstruation begins on Sunday, use an additional form of birth control x 1 week)

• Missed doses

  • One missed dose (< 48 hours late): Take missed dose and resume dosing at normal time

  • Two or more missed doses (≥ 48 hours late)

    • Take most recently missed dose and discard previous doses

    • Use additional form of birth control x 1 week