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 serious 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 lack of protection against sexually transmitted diseases and the fact that an irregular menstrual cycle interferes with this type of calculation.

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 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 low - 3 percent with "perfect" 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 been less well studied than 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 failure rate of 6 percent (perfect) and 20 percent (typical). 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 because of the risk of toxic shock syndrome.

Cervical caps (plus spermicide) have a failure rate of 9 percent (perfect) and 20 percent (typical) in nulliparous women. In parous women, however, the failure rates are much higher – 26 percent (perfect) and 40 percent (typical). They must be professionally fitted. The cap provides continuous protection for up to 48 hours and must be left in place at least 8 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. Since there may be an increased incidence of pap smear abnormalities, users should have a repeat pap smear after 3 months of use. Contact with oil-based products can deteriorate the cap.

Used alone, spermicides have a failure rate of 6 percent (perfect use) and 26 percent (typical use). They provide some, but not complete, protection against sexually transmitted diseases and are accessible and convenient. The onset of protection ranges from immediately after insertion (foam, jellies and creams) to 15 minutes later (suppositories, tablets and films). Foam, jelly and cream are administered with a plastic applicator as close to the cervix as possible. Suppositories should be inserted to rest on or near the cervix. Film should be placed along the back wall of the vagina so that it rests on or near the cervix. Each repeated act of intercourse requires a new application of spermicide.

Oral contraceptives (OCs) are efficient and safe, with a 0.1 percent (typical) failure rate. Other advantages include reduced menstrual cycle symptoms, decreased ovarian cysts, protective effects against PID, decreased ovarian and endometrial cancer rates and prevention of ectopic pregnancy. 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. Physical exam should include weight, blood pressure, breast exam, liver palpation, pelvic examination and Pap smear. In women older than 40 at high risk for cardiovascular disease, a lipid profile and fasting blood sugar may be appropriate when OC’s are started and annually thereafter.

When prescribing an oral contraceptive, physicians should choose low-dose formulations. Triphasic OCs minimize progestin dosing and may be beneficial in decreasing progestin-related side effects. In general, 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.

Patients should follow up with their physician one to three months after starting oral contraception. Blood pressure should be measured and side effects assessed.

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.

Depo-provera is a highly effective long-acting contraceptive which 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.

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 sterilization). Disadvantages include lack of protection against STDs, irregular bleeding, progesterone-related side effects including headache, and need for clinic visit for removal.

Within 72 hours of unprotected or inadequately protected intercourse:

Counsel definitely to use a contraceptive until next period

Consider testing for sexually transmitted diseases

First, take anti-nausea medication:

25 mg meclizine has 24-hour duration

One hour later: first dose of combined pills (see Table 4 for doses)

12 hours later: second dose of combined pills

Menstrual period within 21 days?

YES: counsel to initiate a contraceptive she will use consistently and correctly

NO: advise physician visit and pregnancy test

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.