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AJN  February 2020  Vol. 120, No. 2
ajnonline.com
Continuing Education
CE
HOURS

1.5
An Evidence-
Based Update on
Contraception
A detailed review of hormonal and nonhormonal methods.
ABSTRACT: Contraception is widely used in the United States, and nurses in all settings may encounter
patients who are using or want to use contraceptives. Nurses may be called on to anticipate how family
planning intersects with other health care services and provide patients with information based on the
most current evidence. This article describes key characteristics of nonpermanent contraceptive methods,
including mechanism of action, correct use, failure rates with perfect and typical use, contraindications,
benefits, side effects, discontinuation procedures, and innovations in the field. We also discuss how con
traceptive care is related to nursing ethics and health inequities.
Keywords: birth control, contraception, family planning, reproductive health
C
ontraception is widely used in the United States,
with an estimated 88.2% of all women ages 15
to 44 years using at least one form of contra
ception during their lifetime.1 Among women who
could become pregnant but don't wish to do so, 90%
use some form of contraception.2 Thus, nurses in var
ious settings are likely to encounter patients who are
using contraception while presenting for a vast range of
health care needs. Nurses will have many opportuni
ties to support such patients by coordinating contra
ceptive use with other treatments, such as by identifying
medications that interact with contraceptives or are
teratogenic. Some patients, meeting with a nurse on
an unrelated matter, may even seize the moment to
ask questions about contraception.
Patients are best prepared to make informed
decisions about contraceptive use when they have
evidence-based information; nurses can better sup
port patients' reproductive goals by cultivating their
own knowledge base. This article will prepare nurses
at various practice levels and practice settings to
meet the needs of patients who are current or
potential contraceptive users. It describes the major
categories of nonpermanent contraceptive methods
and provides evidence-based updates. We also dis
cuss inequities in contraceptive care that nurses can
address using their current clinical knowledge and a
reproductive justice approach.
Contraception in context. In its position statement
on reproductive health, the American Nurses Associa
tion (ANA) has asserted that clients have the right to
make reproductive health decisions "based on full
information and without coercion," and that nursing
professionals must be prepared to discuss "all relevant
information about health choices that are legal."3 Simi
larly, the American Academy of Nursing has issued
policy recommendations that support "access to safe,
quality sexual and reproductive health care and repro
ductive health care providers."4 Aligning with these
policies means that, across settings and in accordance
with their scope of practice, nurses should be prepared
to provide contraceptive counseling, services, and referrals.

Page 2
By Laura E. Britton, PhD, RN, Amy Alspaugh, MSN, RN, CNM, Madelyne Z. Greene, PhD, RN,
and Monica R. McLemore, PhD, MPH, RN, FAAN
Figure 1. The Hormonal Regulation of Ovulation
(c) 2013 Encyclopdia Britannica, Inc.
hypothalamus
gonadotropin
fallopian tube
releasing
hormone
(GnRH)
developing
pituitary
fmbriae follicles
ovary
luteinizing
hormone
(LH)
follicle-
estrogen
stimulating
estrogen
hormone
uterus
(FSH)
progesterone
corpus
luteum
cervix
endometrium
ovulation
ovum
vagina
At left: the hypothalamus secretes gonadotropin-releasing hormone (GnRH), which stimulates the pituitary gland to secrete the gonadotropins
luteinizing hormone (LH) and follicle-stimulating hormone (FSH). LH and FSH stimulate the growth and maturation of the ovarian follicles. The
mature follicle secretes estrogen, inhibiting the hypothalamus from further GnRH production (until the next reproductive cycle). At right: after
ovulation, blood levels of LH and FSH fall, and the ruptured follicle, now a corpus luteum, secretes estrogen and progesterone to prepare the
uterine lining for fertilization and implantation. Adapted with permission from Encyclopdia Britannica, (c) 2013 by Encyclopdia Britannica, Inc.
Moreover, adopting a reproductive justice
approach to care delivery can potentially improve
the quality and equity of reproductive health care
and outcomes significantly.5 Reproductive justice is
a human rights framework that aligns with the
ANA's Code of Ethics for Nurses with Interpretive
Statements,6, 7 and functions simultaneously as a the
ory, a practice, and a strategy. For more details, see
Reproductive Justice.5, 7 Understanding contraception
and contraceptive care in the context of both nurs
ing ethics and reproductive justice will help nurses
be best prepared for providing optimal care.
CONTRACEPTIVE METHODS: KEY CONSIDERATIONS
Three main considerations commonly arise in discus
sions of contraceptive methods: method safety and
contraindications, failure rates, and return to fertility.
An important source for data about method
safety comes from the Centers for Disease Control
and Prevention (CDC): the U.S. Medical Eligibility
Criteria for Contraceptive Use (U.S. MEC),8 which
categorizes the safety of contraceptive methods in
accordance with the specific health concerns of
patients (see Table 18). In this article we'll highlight
the common contraindications and drug interac
tions categorized as U.S. MEC 4: "A condition that
represents an unacceptable health risk if the contra
ceptive method is used."8 We recommend that read
ers familiarize themselves with the U.S. MEC,
which includes a comprehensive list of such condi
tions; it's available free online (www.cdc.gov/mmwr/
volumes/65/rr/pdfs/rr6503.pdf) and as an app.
Failure rates represent a way to assess the efficacy
of various contraceptive methods. For a given method,
the failure rate is the percentage of users who have an
unintended pregnancy during the first year of use; a
lower failure rate indicates higher efficacy. For context,
consider that up to 85% of women who have unpro
tected intercourse will experience an unintended
pregnancy within a year.9 Failure rates for perfect and
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typical use of a given contraceptive method are also
distinguished. Perfect use reflects method use when
instructions are followed exactly and consistently; typi
cal use reflects real-life use, when the method may not
be used consistently or perfectly.
Many people have questions about the timing of
return to fertility after stopping contraceptive use.
The return to fertility is relatively rapid after cessa
tion of almost all hormonal and nonhormonal
methods, with the exception of depot medroxypro
gesterone acetate (DMPA). For example, in one
study among women who discontinued combined
hormonal contraception, pregnancy rates were
57% at three months and 81% at 12 months after
cessation.10 Conversely, ovulation may not resume
for 15 to 49 weeks after one's last DMPA injection,
according to one systematic review.10
Method safety, efficacy, and return to fertility are
not the only considerations that influence contracep
tive choice. It's important for nurses and other provid
ers to understand that individuals will value different
features of various contraceptive methods. Personal
preferences (such as for a hormonal or nonhormonal
method, ease and comfort with mode of use, partner
acceptance, effects on the sexual experience, strength
of desire to avoid pregnancy, and religious or spiritual
beliefs and practices), medical considerations (such as
whether the method protects against sexually trans
mitted infections [STIs], potential side effects), and
structural factors (such as immediate and ongoing
costs, ability to begin or stop use without needing
access to health care)-all of these elements play a
role.11-14 Seeing the whole picture will better equip
nurses to help patients choose a method most aligned
with their preferences and needs.
In this article, we describe the most common non-
permanent contraceptive methods; summarize their
efficacy, mechanisms of action, uses, common adverse
effects, and contraindications; and review the modes
of administration of each type. Emergency contracep
tion lies beyond the scope of this article and is not
addressed.
HORMONAL CONTRACEPTIVES
Combined hormonal contraceptives (CHCs) are
among the most commonly prescribed and well-
researched types of medication in use.1, 15 Synthetic
estrogen and progestin revolutionized modern fam
ily planning when this combination first came on
the market in pill form in 1960. Today CHCs can
be delivered through a pill, patch, or vaginal ring
with similar failure rates: less than 1% with perfect
use and 7% to 9% with typical use.9, 16, 17
In CHCs, both progestins and estrogen inhibit the
hypothalamic-pituitary-ovarian axis, which controls
the reproductive cycle (see Figure 1).18 Progestins pre
vent pregnancy by inhibiting the luteinizing hormone
(LH) surge, thus suppressing ovulation, thickening
the cervical mucus, lowering fallopian tube motility,
and causing the endometrium to become atrophic.18
Estrogens prevent pregnancy by suppressing follicle-
stimulating hormone (FSH) production, which prevents
the development of a dominant follicle.18 Progestin is
responsible for the majority of both contraceptive
action and side effects; the addition of estrogen helps
prevent irregular or unscheduled bleeding.9
Traditionally, users take CHCs for three weeks,
then placebo pills or nothing for one week. The
hormone-free week prompts "withdrawal bleeding,"
caused by withdrawal from active CHC ingredients,
that mimics the menstrual cycle and may provide
assurance that the user isn't pregnant.18 Nurses can
educate their patients that withdrawal bleeding is not
actual menses and isn't clinically necessary.18, 19
Common side effects of CHCs include lighter,
shorter periods (40% to 50% reduction in menstrual
flow); irregular bleeding (breakthrough bleeding or
spotting); amenorrhea; nausea; breast tenderness;
emotional lability; headaches; and reduced premen
strual syndrome symptoms (such as bloating, cramp
ing, and acne).18 CHCs are also associated with
reduced risk of ovarian, endometrial, and colon can
cer, and are essential in treating polycystic ovarian
syndrome.18 As with other methods, it's difficult to
predict which individuals will experience which side
Reproductive Justice
Reproductive justice is grounded in the following four principles, which posit that it's a human right5, 7
-  to become pregnant and have children, and to determine how one wishes to give birth and create families.
-  to choose not to become pregnant or have children, and to have access to options for preventing or
ending pregnancy.
-  to parent one's children with dignity-including by having access to essential social supports, safe envi
ronments, and healthy communities-without fear of violence from individuals or the government.
-  to disassociate sex from reproduction, as healthy sexuality and pleasure are essential components of a
full human life.
While the goal of reproductive justice is to address the systems and structures that create reproductive
health inequities, making sure that people who need contraceptive services receive high-quality care is a
crucial step toward that goal.
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Table 1. U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC): Categorization of Safety for Specific
Health Conditions8
Category
Condition
Safety Recommendation
U.S. MEC 1
A condition for which there is no restriction for the use of the
contraceptive method.
Can use the method.
U.S. MEC 2
A condition for which the advantages of the contraceptive
method generally outweigh the theoretical or proven risks.
Can use the method.
U.S. MEC 3
A condition for which the theoretical or proven risks of the
contraceptive method generally outweigh its advantages.
Should not use the method
unless no other method is
appropriate and acceptable.
U.S. MEC 4
A condition for which the contraceptive method poses an
unacceptable health risk.
Should not use the method.
effects and how severe these will be. Certain side
effects, particularly amenorrhea, may be considered
beneficial by some people but unacceptable by others.20
These may be referred to as "noncontraceptive bene
fits" of these methods.
CHC contraindications (U.S. MEC 4-category
conditions) include being age 35 years or older and
smoking 15 or more cigarettes per day; being less than
21 days postpartum; having a systolic blood pressure
of 160 mmHg or greater, or a diastolic blood pressure
of 100 mmHg or greater; having had major surgery
with prolonged immobilization; experiencing migraine
with aura; and being at elevated risk for recurrent
deep vein thrombosis or pulmonary embolism.8
CHCs are still effective when taken concurrently
with many medications, including most commonly
used antibiotics. But concurrent use of certain medi
cations-including rifampin (Rifadin) or rifabutin
(Mycobutin) therapy, the antiretroviral drug fosampre
navir (Lexiva), and certain anticonvulsants-can reduce
CHC effectiveness.8 In such cases, use of a nonhor
monal backup contraceptive method is recommended.
CHC pills. Numerous CHC pills are currently
available on the market. Typically, pills contain a
combination of 10 to 35 mcg ethinyl estradiol and
one of the four generations of progestins. Different
formulations have different side effect profiles, so
patients may need to try another formulation if an
undesirable side effect occurs.
Pills should be taken at about the same time every
day to maintain ovulation suppression. This frequent
dosing is one of the major drawbacks of pill use, and
missing a pill is common, regardless of age.16 In gen
eral, nurses should counsel patients that a missed pill
should be taken as soon as it is remembered. Ovula
tion suppression is not guaranteed if more than 48
hours have elapsed since the last pill was taken. Miss
ing a single pill will have little effect on effectiveness,
but if two pills are missed, the most recent pill should
be taken as soon as possible, and a backup method
(such as condoms) should be used for seven days.18
Pills can be initiated at any time. A "Sunday
start" has been popular in the past because it typi
cally ensures that the withdrawal bleed does not
occur on weekend days. Recently, a "quick start,"
starting the pill on the day of visit, has become
more popular because, at least initially, it's associ
ated with better adherence, and there is no increase
in the incidence of irregular bleeding.21
Extended and continuous use are increasingly pop
ular dosing regimens. Extended use involves using the
CHC for longer than the typical month-long cycle,
thereby giving the user an extended time between
withdrawal bleeds. This can be achieved by taking
pills specifically designed for such regimens or by sim
ply skipping the placebo pills in a 28-day pill pack
(though users will run out of pills more quickly). Con
tinuous use involves taking CHCs without interrup
tion for an indefinite time. Extended and continuous
use regimens have been associated with improved ovu
lation suppression, increased medication adherence,
high user acceptability, decreases in scheduled bleed
ing, and less breakthrough bleeding over time.19, 22
Moreover, decreasing or eliminating periods can be
preferable for patients who have period-related mood
changes, headaches, painful cramping, heavy menses,
or other estrogen-related changes. While extended and
continuous use regimens have primarily been studied
regarding CHC pills, there is evidence of similar effi
cacy among CHC patch and vaginal ring users.23
CHC transdermal patch. The CHC transdermal
patch (Xulane), a thin square about two inches
across, contains 150 mcg norelgestromin and 35 mcg
ethinyl estradiol (see Figure 2). It can be placed on
the stomach, upper arm, buttock, or back, and
must be completely attached to the skin to be effec
tive. The patch is replaced every week for three
weeks; during the fourth week no patch is worn
and a withdrawal bleed occurs. Weekly application
is appealing for those who don't want the burden of
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Photo (c) Alamy.
Figure 2. The Transdermal Patch
daily pill taking. In 2014, the patch became avail
able as a generic product.
While contraindications for CHCs apply to all deliv
ery methods, there are some additional concerns with
the patch. Findings from early research suggested there
was an increased risk of venous thromboembolism
(VTE) with the patch compared to CHC pills, but later
research has yielded conflicting results.24, 25 The U.S.
Food and Drug Administration (FDA) recommends
that the same guidelines regarding VTE be applied to
both methods: CHC pills and the patch should be
avoided in patients at high risk for clots, such as those
who have a history of or current VTE or surgery
requiring immobilization.24, 26 The patch also causes
skin irritation in about 20% of users, though only
about 3% discontinue the method for this reason.17
CHC vaginal ring. The ring (NuvaRing) is a clear,
flexible ring about two inches in diameter that is
placed in the vagina for 21 days and removed for
seven days to allow for withdrawal bleeding; it's
replaced monthly (see Figure 3). It releases 15 mcg/
day of ethinyl estradiol and 120 mcg/day of etonoges
trel. Users can simply place the ring in the vaginal
canal themselves. As with the patch, the less frequent
applications can be appealing and can lead to
increased adherence.17 The ring's internal placement
ensures the steady delivery of hormones, which
allows for lower serum concentrations than occur
with either the patch or pills. As a result, the ring gen
erally has milder side effects than are seen with other
CHC delivery methods.17 Some users may experience
increased vaginal irritation and discharge.17 There is
also some evidence of reduced vaginal dryness, which
may appeal to perimenopausal women and others
who tend to experience such dryness.
Ring users may have concerns about their risk for
pregnancy if the ring is removed intentionally or acci
dentally. The ring can be removed for up to three
hours without diminishing its contraceptive effect.
This gives users the option of removing it during sex
if they prefer. The manufacturer recommends rinsing
the device in cool or lukewarm water prior to rein
sertion.27 If the ring is out for more than three hours,
users should take extra steps to protect against preg
nancy. As with any device, users should consult the
package insert for more specific instructions.
Progestin-only methods include pills, injections,
implants, and intrauterine devices (IUDs). Without
concomitant estrogen, progestin-only methods pose
less risk of VTE than CHCs.28 While the safety of the
CHC pill, patch, and ring are addressed collectively
in the U.S. MEC, the progestin-only methods are given
separate safety profiles. Like CHCs, progestin-only
methods require a prescription.
Progestin-only pills (POPs). POPs are generally
made withfirst-generation progestins, and dosage
amounts are substantially lower than those found in
any CHC. Like CHCs, POPs should be taken at the
same time of day. They are used continuously, with
no hormone-free interval. Despite their pharmaco
kinetic differences, failure rates are often reported
together: Hatcher and colleagues report that for
both types of pills, the failure rate is less than 1%
with perfect use and 7% with typical use.9 That
said, POPs have a higher failure rate when not
taken at the same time every day, because effective
drug levels are maintained in the bloodstream for
only 22 hours.9 Nurses should caution patients that
Figure 3. The Vaginal Ring
Photo (c) Shutterstock.
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they must be vigilant about adhering to the dosing
schedule. The most common side effects of POPs
are unscheduled bleeding and spotting, likely due to
the shorter daily window of efficacy and the
absence of estrogen.18
POPs are considered safe in many clinical scenar
ios wherein CHCs are contraindicated (as noted
above). As with CHCs, patients should use a non-
hormonal backup method when taking certain
medications, including rifampin or rifabutin ther
apy, the antiretroviral drug fosamprenavir, and cer
tain anticonvulsants.8
DMPA injection. DMPA (Depo-Provera) is avail
able as a 150 mg/mL intramuscular injection or a
104 mg/mL subcutaneous injection given every 12 to
13 weeks.18, 29 Injections must be administered by a
provider. The failure rate is less than 1% with perfect
use and 4% with typical use.9 In addition to the afore
mentioned progestin mechanisms of action, DMPA
also affects the hypothalamic-pituitary-ovarian axis
at the hypothalamus, inhibiting ovulation through
suppression of gonadotropin-releasing hormone.18
Irregular periods are a common side effect. One
systematic review found that, after a year of regular
use, only 12% of DMPA users had regular periods
and 46% had amenorrhea.30 Although personal
preferences vary, amenorrhea may be seen as bene
ficial by patients with anemia, endometriosis,
fibroids, dysmenorrhea, or menorrhagia.9 Other
potential side effects include weight gain, impaired
glucose metabolism, bone mineral density loss,
headache, and mood changes (specifically depres
sion).18 Because DMPA is one of the more discrete
methods available, it may appeal to people wishing
to keep their contraception private.
DMPA has few contraindications and almost no
drug interactions. Additional benefits include
decreased risk of endometrial cancer and pelvic
inflammatory disease, reduced incidence of epileptic
seizures, and reduced frequency of sickle cell crises.9, 29
Implants. Implants and IUDs containing progestin,
as well as IUDs without hormones, are collectively
referred to as long-acting reversible contraception
(LARC). LARC insertions and removals are within
the scope of practice of advanced practice clinicians,
including NPs and certified nurse midwives. Once
inserted, LARCs involve little user effort to main
tain contraceptive efficacy.
The single-rod implant (Implanon, Nexplanon),
which is about the size of a matchstick, is inserted in
the upper arm and can remain in place for up to three
years (see Figure 4). The implant contains 68 mg of
etonogestrel that is released incrementally at slowly
diminishing rates, from 60 to 70 mcg/day initially to
25 to 30 mcg/day by the end of the third year.31 Fail
ure rates with both typical and perfect use are below
1%.9 The most commonly reported reasons for dis
continuation include irregular bleeding (10%), emo-
Figure 4. The Single-Rod Implant
tional lability (2%), and weight gain (2%).32 The
implant method can appeal to people who want a
long-term, reversible, highly effective method but are
uncomfortable with having devices in the vagina or
uterus or with insertion procedures at those sites.18
The implant is safe for the vast majority of people,
though there are contraindications for some specific
conditions, such as active breast cancer.8
IUDs with progestin (also called intrauterine sys
tems [IUSs]). With both typical and perfect use,
IUDs have failure rates below 1%.9 Those with pro
gestin alter the cervical mucus such that sperm can
not pass through the cervix to access the upper
reproductive tract.
Four levonorgestrel (LNG) IUDs are available on
the U.S. market, with similar effectiveness but vary
ing doses, duration, and side effects.33 The naming
convention uses a number to indicate the average
number of micrograms of LNG released per day.
The LNG-IUS 20 (Mirena) and LNG-IUS 12
(Kyleena) can be used up to five years. The LNG
IUS 20 (Liletta, designed as a lower-cost version of
Mirena) can be used up to four years, and the LNG
IUS 8 (Skyla) up to three years. The LNG-IUS 12
and LNG-IUS 8 are smaller in size, which makes
insertion easier. Amenorrhea occurs in 20% of LNG
IUS 20 users after one year, in 12% of LNG-IUS 12
users after one year, and in 12% of LNG-IUS 8 users
after three years.
Contraindications to IUD use include current
purulent cervicitis, chlamydia infection, gonorrhea
infection, or pelvic inflammatory disease at the time
of insertion.21 If pelvic inflammatory disease devel
ops after insertion, a course of antibiotics may be
prescribed, and removal may be warranted.
Photo (c) Alamy.
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Despite their safety and efficacy, IUD use in the
United States is lower than in other parts of the
industrialized world.34 IUDs have a fraught history,
the legacy of which may affect patient and provider
attitudes (see Are IUDs Safe?8, 9, 35-40). This is slowly
starting to change, and recent substantial declines in
unintended pregnancies are attributed, in part, to
an increase in the use of LARCs.41
NONHORMONAL METHODS
Nonhormonal methods include the copper IUD, bar
rier methods with and without spermicides, and
behavioral methods. Nonhormonal methods gener
ally have fewer risks and side effects because, by defi
nition, they don't involve exposure to exogenous or
synthetic hormones. As with hormonal methods, the
effectiveness, safety, and ease of use of various non-
hormonal methods are important user considerations
and will strongly influence individual choices.
Copper IUD. The most effective reversible non-
hormonal method is the copper IUD (Paragard),
which has a failure rate below 1% with both typical
and perfect use; the device can be used for up to 10
years, and must be inserted by a skilled provider.9, 42
Copper ions are spermicidal. The copper IUD does
not affect ovulation or timing of the menstrual
cycle, but it is associated with heavier menstrual
bleeding and cramping.43 In a three-year Australian
study among 211 users, of the 59 women who dis
continued use though still requiring contraception,
28 did so because of heavy bleeding.44 This side
effect may be felt more acutely by users switching
from a hormonal method that lessened their normal
flow; anticipatory guidance from nurses can help
prepare such users for this possibility.
The copper IUD may be an appealing option for
those who are limited by contraindications to CHCs
or progestin-only methods. In addition to the afore
mentioned contraindications for progestin-containing
IUDs, copper IUDs are contraindicated for women
with copper allergies, uterine infections, or uterine
8
cancer.
Barrier methods (with or without spermicides)
include condoms and diaphragms used at the time of
intercourse. Efficacy is highly dependent on user
behavior, and failure rates with typical and perfect use
vary widely. For the male condom, failure rates with
typical and perfect use are 13% and 2%, respectively;
for the female condom, 21% and 5%, respectively;
and for the diaphragm, 17% and 16%, respectively.9
Condoms are available over the counter. Those
made from polyurethane or latex prevent the transmis
sion of STIs, including HIV infection. Nonlatex con
doms made of lambskin are available for individuals
with latex sensitivity, but don't protect against STIs.
Diaphragms are inserted into the vaginal canal
such that they block the cervical os and can be
placed up to an hour before intercourse. They
Are IUDs Safe?
Current intrauterine devices (IUDs) are among the most effective, safe, and convenient contraceptive
methods available.8, 9 But there was a time when this was not the case. It's important for nurses to
understand why, as lingering fears and reservations about IUDs are incongruent with current recom
mendations.
In 1971, a new IUD called the Dalkon Shield was introduced and was on the market for three years. Its
use was soon associated with increased risk of pelvic inflammatory disease, spontaneous abortion (often
late in pregnancy), ectopic pregnancy, and infertility. But it took 10 years for the magnitude of the prob
lem to fully emerge. Many factors caused these adverse events, some specific to the device and others
specific to the state of the medical field. One of the biggest design flaws of the Dalkon Shield was its multi-
filament tail string. IUDs typically have monofilament tail strings that help providers to remove the device.
But because removal of the Dalkon Shield required additional force, a cable-style, multifilament string was
used. In contrast to monofilament strings, the multifilament string served as an easy vector for bacteria-
such as those that cause chlamydia or gonorrhea-to move quickly from the vagina to the uterus. This led
to a fivefold increase in pelvic inflammatory disease among women using the Dalkon Shield compared
with those using other IUDs and a sevenfold increase in pelvic inflammatory disease among Dalkon Shield
users compared with women using no contraception.35 Poor screening for and identification of sexually
transmitted infections exacerbated the problem. Moreover, the manufacturer initially claimed it was safe
to leave the Dalkon Shield in place when pregnancy did occur; this practice resulted in miscarriage, septic
abortion, and several deaths.36
For a time, virtually all IUDs disappeared from the U.S. market, and fears about their use have persisted.37
Yet all current IUDs are approved for use in nulliparous women, adolescents and teenagers, and women at
increased risk for pelvic inflammatory disease. Notably, the American Academy of Pediatrics recommends
IUDs as a first-line contraceptive method for adolescents.38 The use of current IUDs is not associated with
infertility, and fertility returns very rapidly upon removal.39, 40
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require a prescription, and have traditionally come
in multiple sizes, thus requiring fitting by a provider.
Diaphragms are used with a spermicide to increase
their effectiveness. In the United States, all commer
cially available spermicides contain nononoyl-9
(N-9) and are sold over the counter. N-9 may cause
irritation or allergic reactions, and increases the risk
of urinary tract infections.8 The irritation can cause
genital lesions, which may increase the risk of HIV
acquisition. For women with HIV, N-9 irritation is
suspected of increasing viral shedding, which
increases the likelihood of transmission to partners.
Thus, spermicide use is contraindicated in people
at high risk for contracting HIV and is not recom
mended for people who have HIV.8
Behavioral methods include withdrawal, lacta
tional amenorrhea (LAM), and fertility awareness-
based methods (FABMs). Withdrawal (often called
"pulling out") involves removal of the penis from
the vaginal canal during intercourse but before ejac
ulation. The failure rates are 20% with typical use
and 4% with perfect use.9 Withdrawal requires
good communication and mutual agreement, as
well as adequate physical control by the ejaculating
partner. Research indicates that only a very small
proportion of individuals use withdrawal as their
primary contraceptive method; but because it's also
commonly used in conjunction with other methods
and might not be considered a "real" method, its
use may be underreported.45 Withdrawal may be an
option for people who don't want to use other con
traceptive methods for religious or cultural reasons.
LAM relies on the natural suppression of the LH
surge that occurs during exclusive breastfeeding. It's
highly effective when infants are exclusively fed
breast milk on demand, when infants are under six
months of age, and when the woman has not yet
resumed menses.18 If breastfeeding is nonexclusive or
the infant is older than six months, efficacy drops.
FABMs involve avoiding unprotected intercourse
during an estimated fertile window, which is deter
mined through a variety of strategies of varying effec
tiveness. There are limited data about failure rates for
each approach46; but collectively, the FABMs appear
to have failure rates of 15% with typical use and from
0.4% to 5% with perfect use.9 These methods may
involve tracking the menstrual cycle, basal body tem
perature, cervical mucus, or LH levels in order to cal
culate the likely fertile period. Midcycle, the LH surge
preceding ovulation is followed by an increase in pro
gesterone, causing a small but measurable increase in
basal body temperature. The timing of ovulation var
ies, even among women with similar cycle lengths.47
Some FABM users might not fully comprehend how
the method works,48 and nurses can help them reach a
better understanding of their menstrual cycle.
Although FABMs have traditionally been a low-
tech contraceptive method, several mobile apps that
support FABMs are now available. An app user
inputs the relevant data, and the app uses an algo
rithm to generate fertility window predictions. Apps
algorithms vary, as does the accuracy of their pre
dictions.49, 50 Nurses should explain to patients that
most health apps aren't regulated by the FDA, and
very few have been evaluated in peer-reviewed sci
entific studies.51 In one study, nearly 20% of FABM
apps contained erroneous medical information.50
Moreover, there is evidence that some app compa
nies' advertising overstates their product's efficacy.52
For recent developments in contraception, see
53-62
Innovations in Hormonal and Nonhormonal Methods.
DISPARITIES IN ACCESS AND USE
Because of economic hardship and institutionalized
racism, homophobia, and transphobia, many people
have compromised access to the full spectrum of con
traceptive options. Studies indicate that such socio
economic factors play a role in the higher rates of
unintended and unwanted pregnancies observed
among Black and Latina women compared with
white women in the United States, as well as influenc
ing user preferences.14, 63 Black and Latina women
tend to report lower rates of overall contraceptive use
and prescription contraceptive use, but higher rates of
condom use and tubal ligation or sterilization.64, 65
Three main considerations commonly arise
in discussions of contraceptive methods:
method safety and contraindications,
failure rates, and return to fertility.
Disparate patterns of contraceptive use and
options are also related to bias and discrimination
within the health care system. Barriers to high-
quality contraceptive care may emerge in the forms
of limited knowledge about contraceptive options,
limited access to health care generally, receiving
biased care from providers, and reproductive coer
cion. For example, there is evidence to suggest
that providers are more likely to recommend IUDs
to Black and Latina women with low socioeco
nomic status than to white women with such sta
tus.66 Explanations for this pattern include that
some providers subconsciously see certain women
(that is, women of color or low socioeconomic
status) as "not needing" more children, needing a
lower-maintenance method, or needing more help
to effectively prevent pregnancy.67 But pressuring
certain patients into using LARCs undermines
their reproductive autonomy and risks continuing
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historically coercive and racist U.S. contraception
policies. As frontline providers, nurses can address
these disparities by engaging in reflexive nursing
practices and working to undo institutionalized
racism.68
Members of sexual and gender minorities-includ
ing those who identify as lesbian, gay, bisexual, queer,
transgender, or gender nonbinary-also require access
to contraceptive services. But they often have limited
access to safe, affirming health care of all types.
Members of these minorities have pregnancy and
childbearing histories, plans, and desires as diverse as
those of any other population. Many nonheterosex
ual women have been pregnant and given birth, and
many have a desire to do so.69 Others regularly have
sex that could lead to pregnancy, and need and want
reliable and consistent contraception.70, 71 Still others
may rarely or never have penile-vaginal intercourse,
and use contraception mainly for its noncontraceptive
benefits, such as menstrual regulation, or acne or
endometriosis treatment.72
Many transgender or nonbinary individuals who
have a uterus and ovaries are capable of becoming
pregnant through penile-vaginal intercourse.73 Tes
tosterone therapy in transgender men is not a reliable
contraceptive method, though this misconception is
common.74 Access to effective contraception may
be especially critical for transgender men or trans-
masculine people, since many desire menses suppres
sion.75, 76 Clinical and anecdotal evidence also
suggest that menstruation and pregnancy may trig
ger or heighten feelings of gender dysphoria or may
put safety at risk by "outing" one as transgender or
transmasculine.77, 78 Some members of these minori
ties may achieve amenorrhea and pregnancy preven
tion with sterilization. Others may want to stop
Innovations in Hormonal and Nonhormonal Methods
Hormonal contraceptives.
Combined hormonal contraceptives. In 2018, the U.S. Food and Drug Administration (FDA) approved a
new progestin-estrogen combined hormonal contraceptive, segesterone acetate plus ethinyl estra
diol (Annovera). This is a vaginal ring that is placed for 21 days; removed, cleaned, and stored for seven
days; and then reinserted for the start of a new cycle.53 The ring, which is slightly larger and thicker
than the ethinyl estradiol-etonogestrel monthly ring (NuvaRing) and can be used for up to 13 cycles
(one year), might be a good option for women who have difficulty picking up birth control at a phar
macy on a regular basis, are at risk for losing insurance coverage, or travel frequently. Unlike the
NuvaRing, which requires refrigeration prior to dispensing, Annovera does not require refrigeration
for long-term storage.
Progestin-only contraceptives. The possibility of self-administration of depot medroxyprogesterone ace
tate (DMPA) by subcutaneous injection is being explored. There is evidence that self-administration
improves method continuation.54 Interest has been documented among current DMPA users, who may
encounter barriers obtaining or refilling their usual prescription.55
Nonhormonal contraceptives.
Single-size diaphragm. In 2014, the FDA approved a single-size silicone diaphragm (Caya).56 This single-
size option means that users no longer have to be fitted by a provider, although like other diaphragms it
requires a prescription. In one study, 76% of users could correctly position this diaphragm with written
instructions, and 94% could do so with coaching.57 The single-size diaphragm is described as fitting
"most women," though it will not fit those who previously used a diaphragm sized 50 to 60 mm or 85 to
90 mm.58 According to the manufacturers, contraindications include having a current vaginal infection,
severe pelvic floor or uterine descent, small or absent retropubic recess, acute or frequent bladder infec
tions, and being within the first six weeks postpartum.58 Users are instructed to insert the diaphragm
before intercourse and to use it in combination with a water-based spermicidal gel. Several compatible
gels are available. One study of a newer, lactic acid-based gel found its effectiveness comparable to that
of gels containing nonoxynol-9.59
FDA-approved, fertility awareness-based method (FABM) mobile app. In 2018, the FDA approved the mar
keting of the Natural Cycles FABM mobile app through the de novo premarket review pathway, which is
used for low-to-moderate-risk devices.60 The manufacturers claimed failure rates of 6.5% with typical use
and 1.8% with perfect use, indicating much higher effectiveness than generally observed with other
FABMs. The app's algorithm calculates fertile days for menstruating women ages 18 and older, based on
basal body temperature readings and menstrual cycle information. The product's marketing has been
sharply criticized in the media,61 and debates continue regarding the best methodological approach to
measuring the efficacy of FABMs.62
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Resources for Nurses
U.S. Medical Eligibility Criteria for Contraceptive Use
www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html
A detailed document, a summary chart, a digital app, a slide set and more are available for reference
regarding contraceptive safety for patients with specific health concerns.
U.S. Selected Practice Recommendations for Contraceptive Use
http://dx.doi.org/10.15585/mmwr.rr6504a1
These recommendations address common, often controversial or complex issues regarding initiation and
use of specific contraceptive methods with an eye toward application in the clinical setting. The site
includes helpful charts and algorithms.
Centers for Disease Control and Prevention: Reproductive Health: Contraception
www.cdc.gov/reproductivehealth/contraception/index.htm#Contraceptive-Effectiveness
The site includes a link to a chart showing the comparative effectiveness of contraceptive methods and
abbreviated instructions for use.
Bedsider
www.bedsider.org
Consumer-oriented, evidence-based decision aids about contraceptives are featured, including an
interactive "method explorer" and numerous topic-specific articles and videos.
menstruating but retain the possibility of becoming
pregnant later in life. Nurses can let such patients
know that this may be possible with progestin-only
IUDs. Estrogen-containing contraceptives may cause
amenorrhea but are contraindicated in people on
masculinizing hormone therapy.
An essential component of patient-centered nursing
practice is the delivery of individualized care; this
includes avoiding assumptions about a patient's repro
ductive health priorities and needs based on member
ship in a particular group. Individuals from any mar
ginalized or stigmatized group who have experienced
bias and discrimination in health care might have
learned to expect the same from future encounters. It's
important for nurses in all clinical settings to under
stand how such history can affect patients' current
experiences and the nurse-patient relationship. By
applying nursing skills such as taking thorough health
histories, listening actively to patients' reproductive
health priorities, and referring patients to appropriate
health care services, nurses may be able to improve
these relationships and clinical outcomes.
CONCLUSION
It's vital that nurses in all settings and specialties stay
current on the latest evidence regarding contraception.
First, this is essential to fulfilling the World Health
Organization's recommendation to provide compre
hensive contraceptive patient education79 and the
ANA's ethical mandate to support the reproductive
self-determination of all patients.6 Second, nurses can
provide better patient-centered care if they can compe
tently address patients' family planning concerns and
questions with current and evidence-based knowledge.
We recognize that this is challenging, as new types of
contraception, hormonal formulations, delivery sys
tems, and indications for use are always being devel
oped. For a list of resources that will help nurses stay
up to date, see Resources for Nurses. Lastly, actively
addressing the concerns of patients from stigmatized
groups will ultimately contribute to efforts to resolve
disparities in contraceptive care and work toward
reproductive justice for all. 
For four additional continuing nursing educa-
tion activities on the topic of contraception, go
to www.nursingcenter.com/ce.
Laura E. Britton is a postdoctoral fellow at the Columbia Uni
versity School of Nursing in New York City. Amy Alspaugh is a
doctoral student at the Medical University of South Carolina
College of Nursing in Charleston, as well as a clinical instructor
in the Schools of Nursing at the University of North Carolina at
Chapel Hill and Duke University in Durham, NC. Madelyne Z.
Greene is an  at the University of Wisconsin-
Madison School of Nursing. Monica R. McLemore is an associ
ate professor in the Department of Family Health Care Nursing
at the University of California San Francisco School of Nursing.
Contact author: Laura E. Britton, leb2216@cumc.columbia.edu.
The authors and planners have disclosed no potential conflicts
of interest, financial or otherwise. A podcast with the authors is
available at www.ajnonline.com.
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