Birth Control Options
Birth control options for women include:
The condom is the only form of birth control that protects against sexually transmitted diseases.
Women of all ages can now get the levonorgestrel emergency contraceptive pill Plan B One-Step without a prescription. Generic versions, such as Next Choice One Dose, are currently available without a prescription only for women age 17 years and older. The other type of “morning-after pill”, ulipristal (ella), requires a prescription for all women regardless of age.
Birth Control Pills and Blood Clots
All birth control pills can increase the risk for blood clots. For this reason, they are not recommended for women who have high blood pressure, a history of heart disease, are over age 35 and smoke, or who have other risk factors. According to the Food and Drug Administration (FDA), birth control pills that contain drospirenone have a much higher risk for causing blood clots than levonorgestrel or other types of progestin. Drospirenone is the progestin used in the Yaz and Beyaz brand birth control pills.
IUDs and Implants for Adolescents
The American College of Obstetricians and Gynecologists (ACOG) recommends intrauterine devices (IUDs) and contraceptive implants (Implanon, Nexplaon) as first-line contraceptive options for sexually active teens based on the effectiveness of these contraceptives and high rates of patient satisfaction.
A New England Journal of Medicine study found that long-acting contraceptives such as IUDs and implants are 20 times more effective at preventing pregnancy than short-acting birth control pills, patches, or rings.
Contraceptives are devices, drugs, or methods for preventing pregnancy either by preventing the fertilization of the female egg by the male sperm or by preventing implantation of the fertilized egg.
Choosing the appropriate contraceptive is a personal decision. Contraceptive options include:
The condom is the only birth control method that provides protection against sexually transmitted diseases (STDs).
Emergency contraception is also included in this report. It is an option for situations when other birth control methods were not available or failed. It should not be used or substituted for regular birth control.
Contraceptive effectiveness is characterized by "typical use" and "perfect use":
The most effective standard female contraceptives have a failure rate of less than 1% with typical (normal) use. They are:
By comparison, failure rates for the male latex condom are about 18% with typical use and 2% with perfect use. Failure rates for hormonal contraception are about 9% for the first year of typical use. To put these rates into perspective, a sexually active woman of reproductive age who does not use contraception faces an 85% likelihood of becoming pregnant in the course of a year.
Oral contraceptives (OCs, birth control pills, or “the Pill,”) are available by prescription and come in either a combination of estrogen and progestin or progestin alone. Most women use the combination hormone pill. Women who experience severe headaches or high blood pressure from the estrogen in the combined pill can take the progestin-only pill.
The birth control pill is the most popular form of contraception in the United States, used by more than 10 million American women.
Birth control pills work by:
When a woman stops taking the pill, she usually regains fertility within 3 - 6 months.
Most birth control pills contain a combination of an estrogen and a progesterone (in a synthetic form called progestin). The estrogen compound used in most combination OCs is estradiol. There are many different progestins, but common types include levonorgestrol, drospirenone, norgestrol, norethindrone, and desogestrel.
These hormones can cause temporary side effects especially during the first 2 - 3 months of birth control use. Common side effects of oral contraceptives include:
Although women are often concerned about weight gain, most studies have not found this to be a side effect associated with oral contraceptives. The estrogen in combination birth control pills may cause some fluid retention.
Women who take birth control pills need to be sure to take the pills every day. It’s best to get in the habit of taking the pill at the same time every day. Your risk for becoming pregnant if you miss a dose depends on the type of pill you are taking. Progestin-only pills have a stricter schedule than combination hormone pills.
For 28-day or 21-day combination OCs, catch-up doses depend on when in the cycle you forgot to take the pill. Read the directions that come with your pills and check with your doctor or pharmacist if you have any questions. It is a good idea to keep on hand a back-up form of barrier birth control (condom, spermicide, sponge). Emergency (“morning after”) contraception is another option.
Standard OCs. Traditional combination birth control pills come in either a:
Continuous-Dosing OCs. Extended-cycle (also called “continuous-use” or “continuous-dosing”) oral contraceptives aim to reduce -- or even eliminate -- monthly menstrual periods. These OCs contain a combination of estradiol and the progestin levonorgestrel, but they use extending dosing of active pills:
Progestin-Only Pills. Progestin-only pills come in 28-pill pack that contains all active pills. Progestin-only pills, also called “mini-pills,” must be taken at precisely the same time each day. You can become pregnant if you delay taking a pill by even 3 hours.
Oral contraceptives are the choice of most American women who use birth control, making them the most popular reversible contraceptives in the U.S. Oral contraceptives are among the most effective contraceptives. With perfect use (taking the pill every day), fewer than 1 in 100 women become pregnant each year while on birth control pills. With typical use (sometimes missing a dose), about 9 in 100 women become pregnant.
Advantages and Benefits of OCs. In addition to preventing pregnancy, oral contraceptives may also have the following advantages:
Disadvantages and Serious Risks of OCs. Combination birth control pills can increase the risk of developing or worsening certain serious medical conditions. The risks depend in part on a woman’s medical history. Deep vein thrombosis, heart attack, and stroke are some of the major risks associated with combination birth control pills.
Birth control pills are not recommended for women who:
Serious risks of birth control pills may include:
The skin patch and vaginal ring are other hormonal contraceptive methods of administering the combination of progestin and estrogen.
Skin Patch. Ortho Evra is a birth control skin patch. It contains a progestin (norelgestromin) and estrogen. The patch is placed on the lower abdomen, buttocks, or upper body (but not on the breasts). Each patch is worn continuously for a week and reapplied on the same day of each week. After three weekly patches, the fourth week is patch-free, which allows menstruation. (The patch remains effective for 9 days, so being slightly late in changing it does not increase the risk for pregnancy.)
The Ortho patch exposes women to higher levels of estrogen than most birth control pills, and therefore increases the risk for blood clots in the veins (venous thromboembolism). Venous thromboembolism can cause blockage in lung arteries and other serious side effects. Older women (over age 40) and women with risk factors for blood clots (such as cigarette smoking or a family history of blood clots) may find other birth control products to be a safer choice. Discuss with your doctor whether the patch is appropriate for you.
Vaginal Ring. NuvaRing is a 2-inch flexible ring that contains both estrogen and progestin (etonogestrel). It is inserted into the vagina. Women can insert the ring by themselves once a month and take it out at the end of the third week to allow menstruation. It works well and may cause less irregular bleeding than oral contraceptives. Side effects include vaginal infections, irritation, and discharge. As with the patch, NuvaRing may pose a higher risk for blood clots than oral contraceptives.
Implant contraception involves inserting a rod under the skin. The rod releases tiny amounts of the hormone progestin into the bloodstream.
The first implant was the Norplant system, which used six rods that contained levonorgestrel. Due in part to serious complications, Norplant was withdrawn from the U.S. market in 2002. The main complication was difficulty inserting and, in particular, removing the rods. (Many women experienced scarring.) In addition, some women who used Norplant experienced heavy irregular bleeding. A two-rod implant called Jadelle is sold in other countries, but not the United States.
In 2006, the FDA approved Implanon, a new implant contraceptive. A new version of Implanon, called Nexplanon, was approved in 2011. In contrast to Norplant:
Implant insertion takes about a minute and is performed with a local anesthetic in a doctor’s office. The rod remains in place for 3 years, although it can be removed at any time. (The removal procedure takes a few minutes longer than insertion.) After the rod is removed, a new one can be inserted.
Implant contraception is very effective with failure rates of less than 1%. It is 20 times more effective than short-acting contraceptives like birth control pills. The American College of Obstetricians and Gynecologists recommends implant contraception or intrauterine devices (IUDs) as first-line contraceptive options for adolescents.
Studies indicate that Implanon/Nexplanon is safe. Irregular bleeding and headaches are the main side effects. Although the risk for pregnancy is very low (fewer than 1 of 100 women), if conception does occur there is an increased risk for ectopic pregnancy, which is a dangerous condition. Implants can also increase the risks for ovarian cysts, and for blood clots.
Injected contraceptives are given once every 3 months. Most injectables are progestin-only. In the United States, depo-medroxyprogesterone acetate (Depo-Provera) is the only approved injected contraceptive. Depo-Provera (also called Depo, or DMPA) uses a progestin called medroxyprogesterone.
Depo-Provera is very effective in preventing pregnancies. About 3 in 100 women who use it become pregnant. However, Depo also carries the risk for many mild and serious side effects including the loss of bone density (see "Disadvantages"). Because of this complication, Depo-Provera should not be used for longer than 2 years.
Because Depo-Provera does not contain estrogen, it is safe for many women who may be at risk for complications from combination oral contraceptive use, such as women over age 35, women with high blood pressure, obese women, and smokers.
Depo-Provera should not be given to women who have a history of:
Because of the long lag time between ending treatments and restoration of fertility, Depo-Provera is not recommended for women who are thinking of becoming pregnant within 2 years.
The intrauterine device (IUD) is a small plastic T-shaped device that is inserted into the uterus. An IUD's contraceptive action begins as soon as the device is placed in the uterus and stops as soon as it is removed. IUDs have an effectiveness rate of close to 100%. They are also a reversible form of contraception. Once the device is removed, a woman regains her fertility.
Two types of intrauterine devices (IUDs) are available in the United States:
With some exceptions, an intrauterine device (IUD) can be inserted at any time, except during pregnancy or when an infection is present. It may be inserted immediately after a woman gives birth or after elective or spontaneous miscarriage. It is typically inserted in the following manner by a trained health professional:
The strings have two purposes:
The insertion procedure can be painful and sometimes causes cramps, but for many women it is painless or only slightly uncomfortable. Patients are often advised to take an over-the-counter painkiller ahead of time. They can also ask for a local anesthetic to be applied to the cervix if they are sensitive to pain in that area. Occasionally a woman will feel dizzy or light-headed during insertion. Some women may have cramps and backaches for 1 - 2 days after insertion, and others may suffer cramps and backaches for weeks or months. Over-the-counter painkillers can usually moderate this discomfort.
Intrauterine devices are an excellent choice of contraception for women who are seeking a long-term and effective birth control method, particularly those wishing to avoid risks and side effects of contraceptive hormones. The LNG-IUS may be better suited for women with heavy or regular menstrual flow.
Around the time of insertion and shortly afterwards, women should be considered at low risk for sexually transmitted disease (mutually monogamous relationship, using condoms, or not currently sexually active).
Women with risk factors that preclude hormonal contraceptives should probably avoid progestin-releasing IUDs, although the progestin doses are much lower with LNG-IUS and probably do not pose the same risks.
Women with the following history or conditions may be poor candidates for IUDs:
IUDs have the following advantages:
Additional advantages, depending on the specific IUD, include:
Menstrual Bleeding. Both types of IUDs affect menstruation:
Expulsion. About 2 - 8% of IUDs are expelled from the uterus within the first year. Expulsion is most likely to occur:
Other Safety Concerns. Studies indicate that:
Barrier contraceptives provide a physical or chemical barrier to block sperm from passing through the cervix into the uterus and fertilizing the egg. Examples of barrier contraceptives include:
Spermicides are sperm-killing substances available as foams, creams, gels, films, or suppositories. They are typically used along with another barrier device. Diaphragms and cervical caps require the application of a spermicide to be effective. The sponge comes pre-applied with a spermicide. Some condoms come pre-lubricated with spermicide.
When used alone, the spermicide is inserted into the vagina within 30 minutes of sexual intercourse and must be reapplied every time you have sex.
Spermicides are relatively inexpensive and can be purchased at a drugstore without a prescription. In general, spermicides may be an appropriate choice for women who have intercourse only once in a while, or need backup protection against pregnancy (for instance, if they forget to take their birth control pills). They are not recommended as a primary form of birth control.
Spermicides have several drawbacks:
The condom is the only type of birth control that protects against sexually transmitted diseases (STDs) including HIV, the virus that causes AIDS.
Male Condom. The male condom is a thin sheath that is rolled onto an erect penis. If used perfectly each time, the annual risk for pregnancy is about 2%. With typical use, the average annual rate of pregnancy is about 17%.
Male condoms are available in different materials:
Latex condoms are the most common. They are less likely to slip or break than those made of polyurethane. Polyurethane condoms are recommended for people who are allergic to latex or who find the smell of latex unpleasant. Condoms made from animal membrane (such as lambskin) can prevent pregnancy, but they are permeable and do not protect against sexually transmitted infections.
Most condoms come pre-lubricated. Lubricants can also be purchased and applied separately.
Female Condom. The female condom is a thin 7 inch lubricated pouch made of polyurethane. It comes with a ring at both ends:
The female condom offers effective protection against pregnancy and STDs. It can be inserted up to 8 hours before sex, but is visible outside of the vagina. Some women have difficulty with the insertion. Female condoms are more expensive than male condoms and (like male condoms) can only be used once.
The diaphragm is a small dome-shaped latex cup with a flexible ring that fits over the cervix. The cup acts as a physical barrier against the entry of sperm into the uterus. A diaphragm is usually used along with a spermicide, although whether spermicide is necessary is an issue of some debate.
Diaphragms come in different sizes and require a fitting by a trained health care provider. Some women will need to be refitted with a different-sized diaphragm after pregnancy, abdominal or pelvic surgery, or weight loss or gain of 10 pounds or more. As a general rule, diaphragms should be replaced every 1 - 2 years.
Using and Inserting the Diaphragm. The diaphragm can be placed in the vagina up to 1 hour before intercourse. The following are general guidelines for insertion:
Advantages of the Diaphragm. The diaphragm can be carried in a purse, can be inserted up to an hour before intercourse begins, and usually (although not always) cannot be felt by either partner. It does not interfere with a woman’s hormones.
Disadvantages and Complications of the Diaphragm. Some disadvantages or complications are as follows:
The cervical cap (FemCap) is a thimble-shaped latex cup that fits over the cervix. It is always used with a spermicidal cream or gel. It is similar to a diaphragm, but smaller, and is available in only four sizes. The cap is sold by prescription and requires a pelvic examination, Pap test, and fitting by a health care provider.
Insertion and Use of the Cervical Cap. After a small amount of spermicide is placed in the cap, the device is inserted by hand. As in diaphragm use, instruction and practice is required. The cap must be kept in the vagina for 8 hours after the final act of intercourse. Caps wear out and should be replaced every 1 - 2 years. A refitting may also be needed when a woman experiences certain changes in her health or physical status.
Advantages and Disadvantages of the Cervical Cap. The cervical cap is similar to the diaphragm in terms of most advantages and disadvantages. Unlike the diaphragm, the cervical cap can safely remain in the vagina for up to 48 hours (twice the time limit for a diaphragm).
The sponge is a disposable form of barrier contraception. It is made of soft polyurethane foam coated with spermicide, is round in shape, and fits over the cervix like a diaphragm, but is smaller and easily portable. The Today sponge is the only brand of contraceptive sponge available in the United States.
Use and Insertion. To use the sponge, the woman first wets it with water, then inserts it into the vagina with a finger, using a nylon cord loop attachment. It can be inserted up to 6 hours before intercourse and should be left in place for at least 6 hours following intercourse. The sponge provides protection for up to 12 hours. It should not be left in for more than 30 hours from time of insertion.
The sponge should not be used during menstruation, after childbirth, miscarriage, or termination of pregnancy, or by women with a history of toxic shock syndrome.
Advantages and Disadvantages. The sponge is easy to use, is not felt during intercourse, and can be inserted up to 6 hours before intercourse. However, because it contains the spermicide nonoxynol-9, it does not protect against sexually transmitted diseases and may increase the risk for vaginal irritation and transmission of HIV. [See Spermicides section.]
Fertility awareness methods, also called natural family planning, are cycle-based methods that rely on tracking the changes in the body that signal fertility. A woman is only fertile during part of her menstrual cycle. By monitoring certain changes in her body, a woman can more or less predict the fertile phase and abstain from sexual intercourse during that time. She can also use barrier methods if they are not prohibited by religious beliefs.
Fertility awareness methods include:
Temperature Method. To determine the most likely time of ovulation and therefore the time of fertility, a woman is instructed to take her body temperature, called her basal body temperature. This is the body's temperature as it rises and falls in accord with hormonal fluctuations.
By studying the temperature patterns over a few months, couples can begin to anticipate ovulation and plan their sexual activity accordingly. To avoid losing spontaneity, couples should try to avoid becoming fixated on the chart in scheduling their sexual activity.
Cervical Mucus Method. The cervical mucus method (also called the ovulation method) requires a woman to take a sample (by hand) of her cervical mucus every day for a least a month and to record its quantity, appearance, feel, and to note other physical signs connected with the reproductive system. Cervical mucus changes in predictable ways over the course of each menstrual cycle:
Once a woman's individual pattern is understood, analyzing cervical mucus can provide a highly accurate guide to fertility.
Calendar Method. The calendar (rhythm method) is considered the least reliable of fertility awareness methods. Women who have very irregular periods may have even less success with this method. In the calendar method, the woman first keeps a record of her menstrual periods for about 6 - 12 months. She then subtracts 18 days from the shortest and 11 days from the longest of the previous menstrual cycles. For example, if a woman's shortest cycle was 26 days and her longest cycle was 30 days, she must abstain from intercourse from day 8 through day 19 of each cycle.
Symptothermal Method. This method combines the temperature, cervical mucus, and calendar methods and is considered the most effective fertility awareness method. In addition, the woman tracks symptoms that may identify her fertile period. These symptoms include changes in the shape of the cervix, breast tenderness, and cramping pain.
Because of the high risk for pregnancy, fertility awareness methods are recommended only for those whose strong religious beliefs prohibit standard contraceptive methods. Couples who are not guided by religious authority, but who simply want a more natural sexual life, may use a barrier contraceptive during the fertile phase and no contraception during the rest of the cycle. However, they should understand the risk of pregnancy will be higher with this method. To be effective against pregnancy, cycle-based methods require not only training, commitment, discipline, and perseverance, but also the cooperation of the male partner. Cycle-based methods are not recommended for women unless they are in a stable, monogamous relationship, and can count on their partner's willing participation.
Fertility-based awareness methods do not protect against sexually transmitted diseases.
Emergency contraception is available to prevent pregnancy in situations such as:
Emergency contraception is administered as a pill or, less commonly, as an IUD. Emergency contraception should not be used as a substitute for regular routine contraception.
Emergency contraception most likely works by preventing or delaying the release of an egg from a woman's ovaries. This method prevents pregnancy in the same way as regular birth control pills.
The emergency contraceptive pill is also known as the “morning-after” pill. There are two types of emergency contraceptive pills:
Levonorgestrel. Levonorgestrel is a progestin that is used in many birth control pills. Levonorgestrel emergency contraceptive pills include:
Ulipristal. Ulipristal acetate (ella) is a newer type of emergency contraception pill that requires a prescription from a health care provider:
Ulipristal can make birth control pills less effective. To help prevent pregnancy, you will need to use a barrier form of of birth control (condom, diagphram, spermicide) for a short time after using ulipristal.
Other Emergency Contraceptive Methods. Two other methods that may be used to prevent pregnancy after unprotected sex are:
Emergency contraception may cause side effects. Most are mild. They may include:
After you use emergency contraception, your next menstrual cycle may start earlier or later than usual. Your menstrual flow may be lighter or heavier than usual:
Sometime, emergency contraception does not work. However, research suggests that emergency contraceptives have no long-term effects on the pregnancy or developing baby.
You should not use emergency contraception if:
You may be able to use emergency contraception even if you cannot regularly take birth control pills. Talk to your health care provider about your options.
The FDA is currently reviewing whether levonorgestrel emergency contraception is less likely to work in women who are above a certain weight. Some research suggests that ulipristal or the copper-releasing IUD may be more effective options for women who are overweight or obese.
Emergency contraception should not be used as a routine birth control method. It is less effective at preventing pregnancies than most types of birth control.
Female surgical sterilization (also called tubal sterilization, tubal ligation, and tubal occlusion) is a permanent method of contraception. It offers lifelong protection against pregnancy.
Female surgical sterilization procedures block the fallopian tubes and thereby prevent sperm from reaching and fertilizing the eggs. The ovaries continue to function normally, but the eggs they release break up and are harmlessly absorbed by the body. Tubal sterilization is performed in a hospital or outpatient clinic under local or general anesthesia.
Sterilization does not cause menopause. Menstruation continues as before, with usually very little difference in length, regularity, flow, or cramping. Sterilization does not offer protection against sexually transmitted diseases.
Laparoscopy. Laparoscopy is the most common surgical approach for tubal sterilization:
Minilaparotomy. Minilaparotomy does not use a viewing instrument and requires an abdominal incision, but it is small -- about 2 inches long. The tubes are tied and cut. Generally speaking, minilaparotomy is preferred for women who choose to be sterilized right after childbirth, while laparoscopy is preferred at other times. Minilaparotomy usually takes about 30 minutes to perform. Women who undergo minilaparotomy typically need a few days to recover and can resume intercourse after consulting their doctor.
Essure. The Essure method uses a small spiral-like device to block the fallopian tube. Unlike tubal ligation, the Essure procedure does not require incisions or general anesthesia. It can be performed in a doctor’s office and takes about 45 minutes. A specially trained doctor uses a viewing instrument called a hysteroscope to insert the device through the vagina and into the uterus, and then up into the fallopian tube. Once the device is in place, it expands inside the fallopian tubes. During the next 3 months, scar tissue forms around the device and blocks the tubes. This results in permanent sterilization.
Before undergoing sterilization, a woman must be sure that she no longer wants to bear children and will not want to bear children in the future, even if the circumstances of her life change drastically. She must also be aware of the many effective contraceptive choices available. Possible reasons for choosing female sterilization procedures over reversible forms of contraception include:
If married, both partners should completely agree that they no longer want to have children and should also have ruled out vasectomy for the man. Vasectomy is a simple procedure that has a lower failure rate than female surgical sterilization, carries fewer risks, and is less expensive.
Even if all these factors are present, a woman must consider her options carefully before proceeding. Women at highest risk for regretting sterilization include:
If a woman changes her mind and wants to become pregnant, a reversal procedure is available, but it is very difficult to perform and requires an experienced surgeon. Subsequent pregnancy rates after reversal depend on the surgeon’s skill, the age of the woman, and, to a lesser degree, her weight and the length of time between the tubal ligation and the reversal procedure. Not all insurance carriers cover the cost of reversal.
Women who choose sterilization no longer need to worry about pregnancy or cope with the distractions and possible side effects of contraceptives. Sterilization does not impair sexual desire or pleasure, and many people say that it actually enhances sex by removing the fear of unwanted pregnancy.
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