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Unintended pregnancies are a worldwide problem but disproportionately impact developing countries. There were 121 million unintended pregnancies annually from 2015 to 2019, corresponding to a global rate of 64 per 1000 women aged 15–49; 61% of these cases resulted in an abortion. In middle- and high-income countries, the unintended pregnancy rate fell by 21% from 1990–1994 to 2015–2019, whereas it fell by 18% in low-income countries 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.

1. ORAL CONTRACEPTIVES

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 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, or norgestimate, since they are the least androgenic progestins. Pills are typically packaged in 21- or 28-day cyclic regimens but may be taken continuously to allow the user to decide if and when to have a withdrawal bleed. Studies have shown no significant risk from long-term amenorrhea in patients taking continuous oral contraceptives. ...

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