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A different on-demand vaginal contraceptive, a vaginal pH regulator gel containing lactic acid-citric acid-potassium bitartrate (Phexxi), was FDA approved for use in the United States in 2020.

In a clinical study of the efficacy of Phexxi, the 7-cycle cumulative pregnancy risk was 7% when used as directed and 14% with typical use.

Unintended pregnancies are a worldwide problem but disproportionately impact developing countries. From 2010 to 2014, it is estimated that 44% of pregnancies worldwide were unintended and 56% of them resulted in an abortion. In developed regions, the unintended pregnancy rate fell by 30% compared to 1990–1994, whereas it fell by only 16% in developing regions over this time frame. It is important for primary care providers to educate their patients about the benefits of contraception and to provide options that are appropriate and desirable for the patient.


A. Combined Oral Contraceptives

1. Efficacy and methods of use

Combined oral contraceptives have a perfect use failure rate of 0.3% and a typical use failure rate of 8%. Their primary mode of action is suppression of ovulation. The pills can be initially started on the first day of the menstrual cycle, the first Sunday after the onset of the cycle, or on any day of the cycle. If started more than 5 days after the first day of the cycle, a backup method should be used for the first 7 days. 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 method should be used for 7 days. If intercourse occurred in the previous 5 days, emergency contraception should be offered. A backup method should be used for 7 days.

2. Benefits of oral contraceptives

Noncontraceptive benefits of oral contraceptives include lighter menses and improvement of dysmenorrhea, decreased risk of ovarian and endometrial cancer, and improvement in acne. Functional ovarian cysts are less likely with oral contraceptive use. There is also a beneficial effect on bone mass.

3. Selection of an oral contraceptive

Any of the 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 pills, but there are essentially no clinically significant differences for most women among the progestins in the low-dose pills. There is insufficient evidence that triphasic oral contraceptives provide any benefit compared to monophasic oral contraceptives in terms of effectiveness, bleeding patterns, or discontinuation rates. Therefore, monophasic pills are recommended as a first choice for women starting oral contraceptive use. Women who have acne or hirsutism may benefit from treatment with desogestrel, drospirenone, ...

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