Birth control resident survival guide
Synonyms and keywords: Contraception options, Birth control options, Planned parenthood, Birth prevention, Family planning, Conception prevention

# Overview
Contraception or birth control is mainly used for the prevention of unwanted pregnancy intentionally by using one of many different methods including  devices, sexual practices, chemicals, drugs or surgical procedures. Contraception methods can also be used for other purposes such as prevention of sexual transmitted infection, treatment of different conditions such as acne, polycystic ovary syndrome, endometriosis, amenorrhea, dysmenorrhea, premenstrual syndrome, primary ovarian insufficiency, and heavy menstrual periods. Health care providers should consider the important elements when choosing the most appropriate contraceptive method for women, men, or couples such as safety, effectiveness, availability (including accessibility and affordability), and acceptability. CDC has created recommendations and categories for the use of birth control based on the element of safety.

# Birth Control Options

## Female birth control options
Long-acting reversible contraception (LARC): is 99% effective, has a high rate of satisfaction, long-term use, quick return to fertility when discontinued and includes the following:
- Intrauterine device (IUDs)  (> 99% effective)
Copper IUD: Effective for up to 10 years, used for patients with light menstrual periods, patients who desire long-term contraception without using hormonal contraception
Progestin-releasing IUD: Effective for up to 5 years, used for patients with heavy menstrual bleeding and dysmenorrhea
- Copper IUD: Effective for up to 10 years, used for patients with light menstrual periods, patients who desire long-term contraception without using hormonal contraception
- Progestin-releasing IUD: Effective for up to 5 years, used for patients with heavy menstrual bleeding and dysmenorrhea
- Subdermal implant (> 99% effective): Effective for up to 3 years
Injectable contraception
- Depot-Medroxyprogesterone: (94% effective), IM injection is given every 3 months
Combined hormonal contraceptives
- Oral contraceptive (estrogen/progestin pills) (OCPs)  (91% effective)
- Contraceptive patch  (91% effective)
- Vaginal Ring  (91% effective)
Barrier and chemical methods
- Female Condom
- Diaphragm
- Cervical Cap
- Sponge
- Spermicide (80% failure rate if used alone). Should be used with cervical cap or diaphragm, may damage the genital epithelium and increase risk of acquiring SDIs
Traditional options/Natural contraception
- Fertility awareness
- Lactational Amenorrhea Method (LAM) (Breastfeeding can help with child spacing)
- Abstinence or withdrawal
- Rhythm Method
Surgical options
- Permanent Sterilization (Tubectomy/tubal ligation)
Emergency contraception
- Copper IUD
- Emergency contraceptive pills

## Male birth control options
Male contraception includes the following:
Barrier contraception
- Condoms (80% effective), the only type of contraception that prevent sexually transmitted infections
Male Sterilization
- Vasectomy
Coitus Interruptus or Withdrawal (75% effective)
Hormonal Contraception
- Testosterone in combination with other hormones under research and development
- Testosterone enanthate: intramuscular short-acting testosterone formulations suppresses sperm concentration to very low levels
- Long-acting intramuscular testosterone undecanoate
Hormonal contraceptive injectable regimes using testosterone combined with other molecules
- Testosterone plus progestin
- Testosterone plus Gonadotropin Releasing Hormone (GnRH) antagonists
- Hormonal contraceptive transdermal regimes using testosterone and Nestorone: gel-gel combination
- Oral formulations: the male pill 

# Indications
- Contraceptive use: Prevention of unwanted pregnancy
- Non-contraceptive use: Treatment of different conditions such as:
Acne
Amenorrhea
Dysmenorrhea
Endometriosis
Heavy menstrual periods
Premenstrual syndrome (PMS)
Primary ovarian insufficiency (POI)
Polycystic ovary syndrome (PCOS): OCPs are used for menstrual regulation
- Acne
- Amenorrhea
- Dysmenorrhea
- Endometriosis
- Heavy menstrual periods
- Premenstrual syndrome (PMS)
- Primary ovarian insufficiency (POI)
- Polycystic ovary syndrome (PCOS): OCPs are used for menstrual regulation

# Contraindications

## Combined hormonal contraceptives
- Pregnancy
- Less than 6 wks postpartum
- Smoking (age  35, and 15 cigarettes per day)
- Hypertension (systolic  160mmHg or diastolic 100mmHg)
- Venous thromboembolism (VTE) (current of past history)
- Prior history of throboembolic event or stroke
- Thrombophilia (factor V Leiden, APLS)
- Ischemic heart disease
- Cerebrovascular accident history
- Complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, history of subacute bacterial endocarditis)
- Migraine headache with aura or focal neurological symptoms
- Breast cancer (Active)
- History of an estrogen-dependent tumor
- Diabetes with retinopathy/nephropathy/neuropathy
- Severe cirrhosis (active or severe decompensated liver disease) (impair steroid metabolism)
- Liver tumor (adenoma or hepatoma)
- Hypertriglyceridemia
- Age  35 and smoking < 15 cigarettes per day
- Adequately controlled mild hypertension
- Hypertension (systolic 140 - 159mmHg or diastolic 90 - 99mmHg)
- Migraine headache over the age of 35
- Currently symptomatic gallbladder disease
- Mild cirrhosis
- History of combined OCP-related cholestasis
- Medications that interfere with OCPs: Lamotrigine, Rifampin
- Inherited thrombophilia carrier and family member with thrombophilia plus thromboembolism

## IUDs
- Uterine anomalies or severe distortion
- Active pelvic infection
- Wilson disease
- Complicated organ transplant failure

## Subdermal implant
- Progesterone receptor-positive breast cancer

# Emergency Contraception

# Side Effects

# U.S. Medical Eligibility Criteria for Contraceptive Use (MEC), 2016
Abbreviations: BMI: body mass index; CHC: combined hormonal contraceptive; COC: combined oral contraceptive; Cu-IUD: copper-containing intrauterine device; ECP: emergency contraceptive pill; IUD: intrauterine device; LNG: levonorgestrel; POC: progestin-only contraceptive;  STD: sexually transmitted disease;  UPA: ulipristal acetate
Women, men, or couples should consider the following elements when choosing the most appropriate contraceptive method:
- Safety
- Effectiveness
- Availability (including accessibility and affordability)
- Acceptability
- Categories of medical eligibility criteria for contraceptive use
The following table focuses on the safety of the use of the contraceptive method for a person with a particular characteristic based on CDC guidelines and recommendations:

# Dos
- Increase the levothyroxine dose in patients with hypothyroidism who started taking OCPs.  Oral contraceptives (estrogen) alter the transport and tissue delivery of thyroid hormone by increasing the synthesis of  throxine-binding globulin which can lead to a relative hypothyroid state in patients with hypothyroidism.
- Consider increasing the dose of warfarin when the patient uses OCPs
- Give two forms of contraceptives and take monthly pregnancy tests for sexually active women who use Isotretinoin for acne
- Give non-oral form of contraception (IUD, implant) for one year to patients who underwent bariatric surgery to achieve weight loss goals and stabilize nutritional status
- You can use IUD in a nulliparous female who has no contraindications

# Don'ts
- Don't give CHC to a patient of  age  35 who smokes 15 cigarettes per day
- Don't give CHC for a patient  with history of Migraine headache with aura or focal neurological symptoms