Over the past decade, contraception options in the United States have expanded to include an over-the-counter progestin-only pill, a drospirenone progestin-only pill, a vaginal acidifying gel, a low-dose contraceptive patch, and a new vaginal contraceptive ring. Clinical evidence supports expanding the duration of use of the 52 mg progestin intrauterine device (IUD) and the copper IUD. Contraception counseling should center patient priorities and preferences rather than promoting methods based on the provider’s beliefs. To employ a reproductive justice lens when counseling patients about their contraception options, providers should remain up to date on all available methods.
Key points
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Clinicians should be well informed of all contraceptive methods to ensure noncoercive, person-centered contraceptive counseling.
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The levonorgestrel 52 mg intrauterine device (IUD) has recently been Food and Drug Administration (FDA) approved for use up to 8 years.
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The norgestrel progestin-only pill is the first contraceptive pill available over the counter.
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A vaginal acidifying gel that is placed precoitally named Phexxi was FDA approved in 2020.
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Introduction
Family planning, as defined by the World Health Organization, “allows people to attain their desired number of children, if any, and to determine the spacing of their pregnancies.” This article will focus on the use of contraception options in pregnancy prevention. However, it is important to acknowledge the plethora of indications for contraception outside of family planning. Hormonal contraception can be beneficial in treating conditions such as abnormal uterine bleeding, endometriosis, endometrial hyperplasia, adenomyosis, menopause, and gender dysphoria. The information presented in this article will provide an update on modern contraception in the United States.
In the past 20 years in North America, there has been increased acknowledgment of inequity and bias in reproductive health care spaces. Marginalized groups, including Black, indigenous and people of color, young, lower socioeconomic status (SES), disabled, and sexual and gender minority (SGM) individuals, bear the brunt of these inequities. Black and Latina women of lower SES are more likely to be counseled about sterilization and contraception, advised to restrict childbearing, and be recommended to use long-acting reversible contraceptives for contraception. A qualitative study found that young Black and Latina women receive implicit pressure to use contraception from providers which can negatively impact their willingness to engage with reproductive health care in the future. Regardless of race and ethnicity, younger women are more likely to receive provider-driven contraceptive counseling. Significant gaps exist in our knowledge of the contraceptive needs and experiences of SGM individuals who are assigned female at birth. One study showed that lesbian and bisexual cis-women are less likely to receive contraception counseling even though they may engage in sexual practices that could result in pregnancy. The experiences of transmasculine individuals in regard to contraception counseling is even less studied, but the need is great. One study showed that 17% of transmasculine individuals had been pregnant and 60% used contraception.
The Reproductive Justice (RJ) movement has helped to bring these inequities to the forefront. Sister Song, an early RJ organization, defines reproductive justice as “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.” Employing an RJ lens to reproductive health care includes honoring patient autonomy. This involves considering a patient’s contraception priorities and preferences rather than promoting methods based on the provider’s assumptions and beliefs. It empowers patients to have autonomy over their reproductive journey, which can sometimes include the choice not to use contraception. And lastly, it includes understanding the longstanding impact of systemic racism and eugenics, including forced sterilization of Black, Latina, poor, and disabled individuals, throughout the past century in North America. While much of the data cited in this article is US-based, discrimination based on race, gender, ethnicity, sexual orientation, ability, and age is not unique to the United States and exists across North America.
New contraceptive methods
Drospirenone Progestin-Only Pill
Slynd is a progestin-only pill (POP) that was Food and Drug Administration (FDA) approved for use in 2019. Previously, the only POP available was the norethindrone POP ( Table 1 ). Norethindrone POPs are packaged in a continuous use form, without a hormone-free interval. Slynd includes a 4-day hormone-free interval. This interval allows time for withdrawal bleeding and can improve the often-bothersome bleeding profile users experience with other progestin-only pills. Drospirenone is a fourth-generation progestin which has antiandrogenic properties and a longer half-life than norethindrone. The dose contained in Slynd is a relatively higher dose of progestin compared to other combined oral contraceptives or POPs. Users may experience less irregular bleeding and better efficacy compared to norethindrone-containing POPs. Where norethindrone POPs have a 3-hour missed pill interval, drospirenone POPs remain effective longer, with some studies suggesting up to 24 hours of continued protection after a missed pill. ,
| Hormone Type/Strength | Frequency/Duration of Use | Contraindications | |
|---|---|---|---|
| Norethindrone POP | 0.35 mg norethindrone | Once daily continuous, no hormone-free interval | Current breast cancer |
| Norgestrel POP | 0.075 mg of norgestrel | Once daily continuous, no hormone-free interval | |
| Drospirenone POP | 4 mg drospirenone | Once daily hormonal pills × 24, nonhormonal pills × 4 d | Current breast cancer Chronic kidney disease with known hyperkalemia |
| Combined oral contraceptive pills | 20–50 mcg of ethinyl estradiol Varying doses of progestins | Once daily hormonal pills followed by nonhormonal pills during time of withdrawal bleeding | Chronic kidney disease Current breast cancer Severe hypertension Vascular disease Complicated valvular heart disease Severe cardiomyopathy <3 wk postpartum Systemic lupus erythematosus with positive or unknown antiphospholipid antibodies Migraines with aura High risk for venous thromboembolism (VTE) Smoking 15 or more cigarettes per day + age 35 y or older |
Mechanism of action: ovulation suppression, cervical mucus thickening, and endometrial thinning.
Trouble shooting: If one pill is missed, take the next pill as soon as possible. Back up method is not indicated. If 2 or more pills are missed, take the next pill as soon as possible. Use back up method for the next 7 days.
Norgestrel, Progestin-Only Pill
On July 13, 2023, the FDA approved the first over-the-counter (OTC) hormonal contraceptive method, a norgestrel-containing progestin-only pill, brand name Opill. This POP contains 0.075 mg of norgestrel, a second-generation progestin. The short half-life of norgestrel requires daily administration at almost exactly the same time. In the United States, this has been a groundbreaking change to expand access to contraception especially in low-resource areas as individuals do not have to present personal identification or insurance to purchase the pill. Despite the improved access, cost remains a potential barrier to use. Without a prescription, the norgestrel pill costs $49.99 for a 3-month supply and $89.99 for a 6-month supply. Some insurance plans fully cover the cost of the OTC POP even without a prescription and some may allow use of flexible spending account funds to purchase the POPs.
Mechanism of action: Ovulation suppression, cervical mucus thickening, and endometrial thinning.
Troubleshooting: If a missed pill is less than 3 hours late, take the pill as soon as possible. Back up is not needed. If the pill is more than 3 hours late, take it as soon as remembered and continue the remainder of the pills at their regularly scheduled time. Use a backup method for 2 days (48 hours). The norgestrel pill will start working again after 2 days of continuous, on-time use.
Combined Contraceptive Rings: Annovera and NuvaRing
A new combined hormonal vaginal contraceptive ring was approved for use by the FDA in 2018. The segesterone acetate and ethinyl estradiol vaginal system, Annovera, is 97.5% effective in preventing pregnancy, similar in efficacy and mechanism of action as the NuvaRing but reusable up to 1 year. While NuvaRing requires placement of a new vaginal ring each month and multiple prescriptions or refills during a year of use, Annovera users require only 1 visit to the pharmacy for each year of use. Similar to the NuvaRing, Annovera should be used on a 28-day cycle with intravaginal placement for 3 weeks, followed by removal for 1 week. While not in use, Annovera ring should be washed with cold to lukewarm temperature water and will tolerate storage temperatures at 30°F or less. Hormonally, Annovera contains 17.4 mg of ethinyl estradiol (EE) and 103 mg of the progestin segesterone acetate. The average daily release of hormones is 13 mcg/day of EE and 150 mcg/day of segesterone acetate. Compared to Annovera, the NuvaRing intravaginal system contains 2.7 mg of EE and 11.7 mg of a different progestin, etonogestrel. The daily release rates are 15 mcg/d and 120 mcg/d, respectively. Extended cycling has not yet been studied in Annovera users. However, similar to other combined hormonal methods, it would be reasonable to discuss the benefits of extended cycling with a shared decision-making approach. Unscheduled bleeding was seen in 13% to 22% of Annovera users per cycle during 1 year of use. Whereas 7.2% to 11.7% of NuvaRing users may have unscheduled bleeding.
Mechanism of action: Ovulation suppression.
Contraindications: Severe hypertension, vascular disease, complicated valvular heart disease, severe cardiomyopathy, end-stage renal disease, nephrotic syndrome, less than 3 weeks postpartum, systemic lupus erythematosus with positive antiphospholipid antibodies, migraines with aura, current breast cancer, and those at high risk for venous thromboembolism (VTE).
Troubleshooting: Avoid removal of the vaginal ring for more than 2 hours during the 21-day period of active use.
Contraceptive Patches
| Hormone Dose per day | Size | Food and Drug Administration Approved | Efficacy | Special Considerations | |
|---|---|---|---|---|---|
| Twirla | 30 mcg of ethinyl estradiol and 120 mcg of levonorgestrel | 28 cm 2 | 2020 | 95% , | Higher risk of pregnancy in patients with body mass index (BMI) >30 kg/m 2 . |
| Zafemy | 35 mcg ethinyl estradiol, 150 mcg norelgestromin | 12.5 cm 2 | 2021 | 99% | FDA packaging lists concern for higher VTE risk in patients with BMI >30 kg/m 2, , ;however, this is not a true contraindication per Centers for Disease Control and Prevention Medical Eligibility Criteria and can be prescribed regardless of BMI. |
| Xulane | 35 mcg ethinyl estradiol, 150 mcg norelgestromin | 14 cm 2 | 2014 | 99% | |
| Mechanism of action: ovulation suppression Costs are similar Instructions: Place a new patch weekly × 3 wk, no patch × 1 wk. Troubleshooting: If <24 h without the patch, replace as soon as possible, back up method is not needed. If 24 h or greater without the patch, use a backup method for 7 d. | |||||
Vaginal Acidifying Gel
Vaginal pH regulating gel (commercially known as Phexxi) is an on-demand vaginal gel that contains lactic acid, citric acid, and potassium bitartrate. This formulation maintains the vagina at a pH of 3.5 to 4.5, despite the presence of alkaline semen, and immobilizes sperm from ascending into the upper reproductive tract. Recently approved in 2020, there are limited data on the efficacy of the product; however, initial clinical trials reported the 7-cycle typical use cumulative pregnancy rate of 13%. , Vaginal acidifying gel requires a prescription which will provide 1 box of 12 prefilled applicators. If not covered by insurance, the cost is about $285 per box. Each dose is inserted into the vagina up to an hour before coitus. If more than 1 act of vaginal intercourse occurs, additional doses must be applied. This gel can be used alongside other barrier methods of contraception; however, it is not recommended to be used with a hormonal vaginal ring. Some reported complications include vulvovaginal burning, itching, urinary tract infections (UTIs), bacterial vaginosis, and candidiasis. ,
Updates in duration of use
Progestin Intrauterine Devices
In North America, there are 4 different progestin intrauterine devices (IUDs) available. In the United States, this includes Mirena, Liletta, Kyleena, and Skyla. The Mirena IUD has been available since 2000 when it was first FDA approved for 5 years of use. Most recently in 2022 after a phase 3 trial showed Mirena remains up to 99% effective at preventing pregnancy after 6 to 8 years, it was approved by the FDA for 8 years of use. FDA approval of Liletta was updated and approved for use up to 8 years. If using the levonorgestrel 52 mg IUD for treatment of heavy menstrual bleeding, it is FDA approved for 5 years , ( Table 2 ).
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