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For further information, see CMDT Part 18-12: Contraception

Key Features

General Considerations

  • Unintended pregnancies are a worldwide problem but disproportionately impact developing countries

  • Studies estimate that 40% of the 213 million pregnancies that occurred in 2012 were unintended

  • Globally, 50% ended in abortion, 13% ended in miscarriage, and 38% resulted in an unplanned birth

  • Primary care providers need to educate their patients about the benefits of contraception and to provide them options that are appropriate and desirable



Oral contraceptives

  • Combination pills

    • Have a theoretical failure rate of only 0.3% if taken absolutely on schedule but a typical use failure rate of 8%

    • Primary mode of action is suppression of ovulation

    • Pills can be started on the first day of the menstrual cycle, on the first Sunday after the onset of the cycle, or on any day of the cycle

      • If started on any day other than the first day of the cycle, a backup contraceptive method should be used

      • The combination pill is taken daily for 21 days, followed by 7 days of placebos or no medication, and this schedule is continued for each cycle

      • If an active pill is missed at any time, and no intercourse occurred in the past 5 days, two pills should be taken immediately and a backup contraceptive method should be used for 7 days

      • If an active pill is missed at any time, and intercourse occurred in the previous 5 days, emergency ("Plan B") contraception should be used immediately, and the combination pills restarted the following day; a backup contraceptive method should be used for 5 days

    • Another regimen involves taking a combination pill continuously with no regular menses; at the end of one years' use, 58% of the women had amenorrhea, and nearly 80% reported no bleeding requiring sanitary protection

    • Studies have not shown any significant risk from long-term amenorrhea for patients taking this continuous oral contraceptive regimen


  • There are many noncontraceptive advantages to oral contraceptives

    • Menstrual flow is lighter

    • Decreased risk of ovarian and endometrial cancer

    • Improvement in acne

    • Dysmenorrhea, pain with ovulation and postovulatory aching are relieved for most women

    • Functional ovarian cysts generally disappear with oral contraceptive use, and new cysts do not occur

    • Frequency of uterine myomas is lower in long-term users (> 4 years)

    • There is also a beneficial effect on bone mass

  • Selection

    • Any of the "low-dose" combination oral contraceptives (containing 35 mcg or less of ethinyl estradiol or 3 mg of estradiol valerate) are suitable for most women

    • There is some variation in potency of the various progestins in the low-dose pills, but this variation results in essentially no clinically significant differences for most women

    • Women who have acne or hirsutism may benefit from use of one of the pills containing the ...

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