A Guide to Selecting Safe Medical Contraception

Megan Cole and Morgan Wharton

updated July 2, 2012

In an effort to prevent unwanted pregnancies, many people use barrier contraceptives such as condoms or diaphragms. These methods are great because they also protect against sexually transmitted infections (STIs) and are generally safe and easy-to-use. However, for additional protection against pregnancy, many women use medical contraceptives as well, which reduce the risk of pregnancy. Deciding what type of medical contraceptive method to use is a difficult decision. Before making this decision with your doctor, there are many things to ask yourself:

  • How much personal responsibility do I want to have?
  • How important are ease of use and convenience?
  • How effective do I want my method to be?
  • Do I want to use this to treat other health conditions as well?
  • What are the side effects and do I have a medical condition that increases any of these risks?

Based on your health history, certain types of contraceptives may be safer or more effective than others. Use this guide to look up the conditions that apply to you. But first, read below for some important definitions.

Key definitions of different types of medical contraceptives

The Centers for Disease Control and Prevention (CDC) provide the following descriptions for the various types of medical birth control methods that are available to women. But first, one thing that is important to understand: hormone pills, patches, and injections interfere with your menstrual period.  Although you are likely to bleed in a way that is like your period, and in this article we refer to that as a “period,” it is not exactly the same as a menstrual period.

Combined pill-Also called “the pill,” it contains the female hormones estrogen and progestin. It is prescribed by a doctor. The pill should be taken at the same time each day. If you are older than 35 years and smoke, or have a history of blood clots or breast cancer, your doctor may advise you not to take the pill. The pill is 99% effective in preventing pregnancy if always used as directed and 92% effective if it is not always used as directed. Some of these pills are safer than others, so be sure to compare the risks. For example, see our article about Yaz, Yasmin, and similar types of pills containing the form of progestin known as drospirinone or DRSP:  Are Bayer’s Birth Control Pills too Risky?

Patch-This skin patch is prescribed by a doctor and worn on the lower abdomen, buttocks, or upper body (but not on the breasts). It releases the hormones progestin and estrogen into the bloodstream. You put on a new patch once a week for three weeks. During the fourth week, you do not wear a patch, and will have a “period.” The patch is 99% effective if always used as directed and 92% effective if it is not always used as directed. However, it has greater risks than most birth control pills and is less effective in women who weigh more than 198 pounds.

Hormonal vaginal contraceptive ring- The NuvaRing releases the hormones progestin and estrogen. You place the ring inside your vagina. You wear the ring for three weeks, take it out for the week to have a “period,” and then put in a new ring. It is 99% effective if always used as directed and 92% effective if it is not always used as directed. However, it has greater risks than most birth control pills.

Progestin-only pill-Unlike “the pill,” the progestin-only pill (known as the “mini-pill”) only has one hormone, progestin, instead of both estrogen and progestin. It is prescribed by a doctor. It should be taken at the same time each day. It is a good option for women who can’t take estrogen. They are 99% effective if used exactly as directed, and 92% effective for typical use.

Emergency Contraception- Emergency contraceptives (the “morning-after pill”) are used after intercourse has already taken place. They prevent pregnancy by delaying the release of an egg from the ovaries and, possibly, by thickening cervical mucus and making “swimming conditions” for sperm unfavorable.[1] [2] [3] Studies indicate that emergency contraception does not prevent implantation; it simply keeps the egg and sperm from ever meeting. When women took emergency contraception before they had ovulated, they became pregnant at a much lower rate. When women took emergency contraception after ovulating, they became pregnant at a rate comparable to women who had not taken emergency contraception. If emergency contraception prevented implantation, the women who took it after ovulating would have gotten pregnant at lower rates than women not taking emergency contraception.[1] [2] Plan B and ella are the two most common emergency contraceptives. Plan B can be taken up to 72 hours following intercourse and ella may be taken within 120 hours. [3] Estimated effectiveness in preventing pregnancy ranges from 52% to 94%.[3] Reported side effects include nausea, vomiting, headache, breast tenderness, cramps and fatigue[3] [4] For more information on emergency contraception visit our article on Morning After Pills.

Injection or “shot”- Women get shots of the hormone progestin in the buttocks or arm every three months from their doctor. This is commonly known by the brand name Depo-Provera. It is 97-99% effective at preventing pregnancy. However, it has greater risks than most birth control pills and since it lasts 3 months you can’t immediately stop using it if you have a negative reaction, as you could with most other contraceptives. The injectable form of progestin used in Depo-Provera has been linked to an increased risk of breast cancer in young women. When used a year or more, it doubles the risk of breast cancer, but for most young women that risk is very low. A woman is only at increased risk while she is using Depo-Provera; her risk returns to normal a year after she stops using it.

Implant-The implant is a single, thin rod that is inserted under the skin of a women’s upper arm. The rod contains progestin that is released into the body over 3 years. It is 99% effective at preventing pregnancy. However, it has greater risks than most birth control pills and there are surgical risks from implanting and removing it.

Copper IUD-A Copper IUD is a small device that is shaped in the form of a “T.” Your doctor places it inside the uterus to prevent pregnancy. It can stay in your uterus for up to 10 years. This IUD is more than 99% effective at preventing pregnancy.

LNg IUD-Also known as Mirena, this is a small T-shaped device that is placed inside the uterus by a doctor. It releases a small amount of progestin into the uterus each day to keep you from getting pregnant. It stays in your uterus for up to 5 years and is more than 99% effective at preventing pregnancy.

Other terms:


- No restrictions: there are no specific safety concerns associated with any health conditions. This does not mean that this method is entirely safe to use, and the side effects will be listed.  However, it does not pose serious known health risks that are predictable for certain kinds of women or women with certain health conditions.

- Benefits outweigh the risks: although there may be some health risks associated with using this method, the benefits of preventing pregnancy from using this method are greater than those risks. It may be more dangerous than not being pregnant, but pregnancy also has risks.  In general, this method is ok to use.

- Risks outweigh the benefits: there are both risks and benefits associated with using this method. However, the risks are greater than the benefits and could endanger your health. You should avoid using this method.

- Unacceptable risk: there are significant health risks associated with using this method. It must not be used.

Guide to selecting a medical contraceptive method based on current and past conditions

If you have or may have any of the following conditions, please read these warnings carefully so that you select a contraceptive method that is safe for you. These are listed in alphabetical order-search through the list and carefully read conditions that may apply to you.

Anatomic Abnormalities (body structure that is abnormal in size or location)

For those with a distorted uterine cavity, LNG-IUDs and copper-IUDs pose unacceptable health risks and are not to be used. Risks of other medical contraceptives for women with this condition are not known.

Breast cancer

- Current breast cancer: avoid all medical contraceptives except for Copper-IUD. – Past breast cancer (and no evidence of disease for 5+ years): for nearly all medical contraceptives, the risks usually outweigh the advantages. That’s because hormones increase the risk of breast cancer.  Copper-IUD is the only form of medical contraceptive that is recommended.

Cervical cancer

For those awaiting treatment for cervical cancer, you should not begin to use a LNG-IUD or a Copper-IUD, as the health risks of inserting it are unacceptable. However, if you are already using one of these devices, the benefits of keeping it in your body generally outweigh the health risks of removing it. For other types of medical contraceptives (combined pill, patch, or ring, progestin-only pill, injection, and implant), the benefits generally outweigh the risks, with the progestin-only pill being the safest method.

Cirrhosis (scarring of the liver)

If you have mild cirrhosis, then there are no restrictions on the above medical contraceptive methods and any of the above may be used. However, if you have severe (decomposed) cirrhosis, the risks of using a progestin-only pill, an injection, an implant, or a LNG-IUD outweigh the benefits. Using a combined pill, patch, or ring poses unacceptable health risks and must not be used. The only safe method with no restrictions is the Copper-IUD.

Deep venous thrombosis (DVT) /Pulmonary embolism (PE)( blood clots form deep in your vein (DVT)/one or more arteries in your lung are blocked (PE))

- History of DVT/PE, not on anticoagulant therapy: for those at higher risk for recurrent DVT/PE, the combined pill, patch, or ring poses unacceptable health risks and should not be used. For other methods (progestin-only pill, injection, implant, and IUDs), the benefits outweigh the risks. Using a Copper-IUD is the only method with no restrictions and is the safest method. For those with lower risk for recurrent DVT/PE, the risks generally outweigh the benefits for the combined pill, patch, or ring. For other methods (progestin-only pill, injection, implant, and IUDs), the benefits outweigh the risks. Again, using a Copper-IUD is the only method with no restrictions and therefore, is the safest method. – Acute DVT/PE: the combined pill, patch, or ring poses unacceptable health risks and should not be used. For other methods (progestin-only pill, injection, implant, and IUDs), the benefits generally outweigh the risks. – DVT/PE and established on anticoagulant therapy for at least 3 months: for those at high risk for recurrent DVT/PE, the combined pill, patch, or ring poses unacceptable health risks and should not be used. For other methods (progestin-only pill, injection, implant, and IUDs), the benefits generally outweigh the risks. For those at lower risk for recurrent DVT/PE, the risks outweigh the benefits for using the combined pill, patch, or ring, while the benefits generally outweigh the risks for all other methods (progestin-only pill, injection, implant, and IUDs). – Major surgery with prolonged immobilization (not being able to move around for three or more months): the combined pill, patch, or ring poses unacceptable health risks and should not be used. For other methods (progestin-only pill, injection, implant, and IUDs), the benefits outweigh the risks, although using a Copper-IUD is the only method with no restrictions and is the safest method.

Diabetes mellitus (DM)

Women need to be very careful about medical contraception if they have vascular disease, nephropathy/ retinopathy/ neuropathy (kidney disease or damage/eye damage/nerve damage), or diabetes that has lasted longer than 20 years. In general, the combined pill, patch, and ring should be avoided, because they pose unacceptable health risks. Also, the injection method has greater risks than benefits. Other methods (progestin-only pill, implant, and IUDs) have greater benefits than risks, but the Copper-IUD is the only method with no restrictions.

Endometrial cancer (cancer in the lining of the uterus)

Those with endometrial cancer should not begin to use a LNG-IUD or a Copper-IUD. If you are already using one of these devices, then the benefits of keeping it generally outweigh the risks of removing it. For all other methods of medical contraceptives (combined pill, patch, or ring, progestin-only pill, injection, and implant), there are no restrictions and they are acceptable to use.

Gall-bladder disease

For symptomatic individuals who currently have gall-bladder disease, or who have been medically treated, using the combined pill, patch, or ring poses more risks than benefits. For those treated with a cholecystectomy and for those who are asymptomatic, the benefits generally outweigh the risks for all types of contraceptives.

Gestational trophoblastic disease (group of rare tumors in the uterus during pregnancy)

For those with decreasing or undetectable “ß-hCG” levels (a hormone made by your body during pregnancy), the use of LNG-IUDs and Copper-IUDs has greater risks than benefits. All other contraceptive methods (combined pill, patch, or ring, progestin-only pill, injection, and implant) are acceptable and not restricted. For those with constantly high “ß-hCG” levels or worsening disease, use of LNG-IUDs and Copper-IUDs must be avoided, as these pose unacceptable health risks.

Headaches

- Migraine without aura (no visual disturbances such as flashing lights), if over 35: starting to use the combined pill, patch, or ring, pose unacceptable health risks and you should not do so. If you are already using the combined pill, patch, or ring, then the risks outweigh the benefits, and you should consider changing methods. – Migraine with aura (visual disturbance such as flashing lights), any age: the health risks for using the combined pill, patch, and ring are unacceptable and this method should not be used.  The risks outweigh the benefits of continued use of the progestin-only pill, an injection, an implant, or a LNG-IUD, so you should consider alternatives.  However, if you want to being using of one these mentioned methods, then the benefits generally outweigh the risks. The safest form of medical contraceptive for you is the IUD-Copper.

History of bariatric surgery (weight loss surgery)

- Restrictive procedures (procedures such as stomach stapling or banding): all methods may be used – Malabsorptive procedures (procedures that change digestion so that the body absorbs less food and energy): the risks outweigh the benefits for progestin-only pills, but all other methods (combined pill, patch, or ring, injection, implant, and IUDs) are safe to use.

History of cholestasis (the flow of bile from the liver is blocked)

For those with past cholestasis related to taking the combined pill, which is not pregnancy-related, the risks for taking the combined pill, patch, or ring outweigh the benefits. For other methods (progestin-only pill, injection, implant, and IUDs), the benefits outweigh the risks.

HIV

For those with AIDS, the risks outweigh the benefits for both LNG-IUDs and Copper-IUDs. All other methods (combined pill, patch, or ring, progestin-only pill, injection, and implant) are acceptable and without restriction.  However, none will protect against the spread of HIV/AIDS.

Hypertension

- Adequately controlled or low elevated blood pressure level (systolic 140-159 or diastolic 90-99): risks associated with using the combined pill, patch, and ring are greater than the benefits. Consider using any of the other methods of contraceptives (progestin-only pill, injection, implant, and IUDs) – High elevated blood pressure level (systolic ≥160 or diastolic ≥100) or vascular disease: do not use the combined pill, patch, or ring, as the health risks are unacceptable. Injections should also be avoided, because the risks outweigh the benefits.

Ischemic heart disease (coronary artery disease)

If you currently have ischemic heart disease or if you have a history of it, then you should not use the combined pill, patch, or ring. Continuing to use a progestin-only pill, injection, implant, or LNG-IUD poses greater risks than benefits, so you should find an alternative contraception. The only method without restriction is use of a Copper-IUD, and therefore, this is the safest method.

Liver tumors

The combined pill, patch, and ring should never be used for women with benign (non-cancerous) liver tumors with hepatocellular adenoma or for those with malignant (cancerous) liver tumors, because the health risks are unacceptable. Using a progestin-only pill, injection, implant, or LNG-IUD poses greater risks than benefits and should be avoided. The only method without restriction is use of a Copper-IUD, and it is the safest method for these women.

Multiple risk factors for arterial cardiovascular disease (heart disease)

Those with multiple risk factors for arterial cardiovascular disease, such as older age, smoking, diabetes and hypertension, should not use the combined pill, patch, or ring, as these methods have risks that outweigh benefits and often pose unacceptable health risks. Injection should also be avoided, as the risks outweigh the benefits.

Pelvic inflammatory disease (PID)

If you currently have PID, then you should not begin to use a LNG-IUD or a Copper-IUD, as the risks are unacceptable. However, the benefits of continuing to use one of these devices generally outweigh the risks of removing it.

Peripartum cardiomyopathy(weakened heart at the end of pregnancy, or after delivery)

Those with peripartum cardiomyopathy should not use the combined pill, patch, or ring, as the health risks are unacceptable. It is especially risky for those with “moderately or severely impaired cardiac (heart) function” and those who have had “normal or mildly impaired cardiac (heart) function” for less than six months.  The risks still outweigh the benefits even after six months.

Post-abortion

Immediately after a spontaneous miscarriage (also called a septic abortion), LNG-IUDs and Copper-IUD should not be used as a method of contraception, as the health risks are unacceptable.

Postpartum (in non-breastfeeding women)(having recently given birth)

For those who have given birth within the last 21 days, the combined pill, patch, and ring should be avoided, as the risks outweigh the benefits.

Postpartum (for breastfeeding or non-breastfeeding women, including post- caesarean section who have recently given birth)

Women with puerperal sepsis should not use LNG-IUDs or Copper-IUDs, as the health risks are unacceptable. Information on the safety of other methods is not available.

Sexually transmitted infections

- Women who currently have purulent cervicitis (swelling of the uterus, with discharge) or a chlamydial infection or gonorrhea should not begin to use LNG-IUDs or Copper-IUDs, as the health risks are unacceptable.

Smoking

- Over 35 years of age and not smoking: the benefits of using the combined pill, patch, or ring outweigh the risks, and therefore, may be used. For all other methods (progestin-only pill, injection, implant, and IUDs), there are no restrictions. – Over 35 and smoking fewer than 15 cigarettes/day: the risks of using the combined pill, patch, or ring outweigh the benefits, and therefore, this method should be avoided. For all other methods (progestin-only pill, injection, implant, and IUDs), there are no restrictions. – Over 35 and smoking more than 15 cigarettes/day: Do not use the combined pill, patch, or ring because they pose unacceptable risks. For all other methods (progestin-only pill, injection, implant, and IUDs), there are no restrictions.

Solid organ transplant

Women who have had a complicated solid organ transplant should not use the combined pill, patch, or ring, as the health risks are unacceptable. Beginning to use a LNG-IUD or Copper-IUD should also be avoided, as the health risks outweigh the benefits. For uncomplicated transplants, the benefits outweigh the risks for all methods.

Stroke

For women with a history of stroke, the combined pill, patch, and ring should not be used, as they pose unacceptable health risks. Risks outweigh benefits for injections, continued use of progestin-only pills, and continued use of implants. The safest method is a Copper-IUD.

Systemic lupus erythematosus (chronic, inflammatory autoimmune disorder that may affect the skin, joints, kidneys, and other organs)

- Positive (or unknown) antiphospholipid antibodies (disorder causing blood clots in arteries or veins): the combined pill, patch, and ring pose unacceptable health risks and should not be used. Using a progestin-only pill, injection, implant, or LNG-IUD poses greater risks than benefits and should be avoided. The only method without restriction is use of a Copper-IUD, and therefore, this is the safest method. – Severe thrombocytopenia (very low number of platelets in blood): do not start to use injections or starting to use a Copper-IUD as a contraceptive method because that poses greater risks than benefits.

Thrombogenic mutations (causing cogulating or clotting blood)

Women with thrombogenic mutations should not use the combined pill, patch, or ring, as the health risks are unacceptable.

Tuberculosis

- Non-pelvic: no restrictions on any method – Pelvic: for women with pelvic tuberculosis, starting to use a LNG-IUD or a Copper-IUD poses unacceptable health risks and should be avoided. For those continuing to use an IUD, the health risks outweigh the benefits and continued use should be avoided as well. For all other methods (combined pill, patch, and ring, progestin-only pill, injection, and implant), there are no restrictions.

Unexplained vaginal bleeding

For women with unexplained vaginal bleeding, the risks outweigh the benefits when using an injection or implant method. So, these methods should be avoided. Starting to use a LNG-IUD or a Copper-IUD poses unacceptable health risks and should also be avoided. For all other methods (combined pill, patch, or ring and progestin-only pill), the benefits outweigh the risks.

Valvular heart disease (disease involving one or more heart valves)

For women with complicated valvular heart disease, there are unacceptable health risks for using the combined pill, patch, or ring. There are no restrictions on other methods.

Viral hepatitis

For women with acute or flare viral hepatitis, the combined pill, patch, and ring pose  unacceptable health risks, and women should avoid starting to use these methods. For all other methods, there are no restrictions. This guide is based on the May 2010 “U.S. Medical Eligibility Criteria for Contraceptive Use,” released by the Centers for Disease Control and Prevention (CDC) and adapted from the “World Health Organization Eligibility Criteria for Contraceptive Use,” 4th edition. To view a full copy of the report, please visit http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf

[1] Trussell, James and Kelly Cleland. (2012). Emergency contraception: How it works (how it doesn’t). Science Friday. Retrieved from http://sciencefriday.com/blogs/06/15/2012/emergency-contraception-how-it-works-how-it-doesn-t.html
[2]        Lloyd, S. (2012). Controversy surrounding emergency contraception. EmpowHER. Retrieved from http://www.empowher.com/sexual-well-being/content/controversy-surrounding-emergency-contraception?page=0,0
[3]       clinical proceedings. (2011). Update on Emergency Contraception. In Association of Reproductive Health Professionals (Ed.).
[4]      Office of Women’s Health. (2012). Birth Control Guide. In U. S. Food and Drug Administration (Ed.).