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Counseling women considering combined hormonal contraception

Vanessa Cullins, MD, MPH, MBA
Section Editor
Mimi Zieman, MD
Deputy Editor
Kristen Eckler, MD, FACOG


Hormonal contraception methods are the most commonly used reversible methods in the United States; almost one-third of female contraceptors use oral contraceptive pills and many of the remainder use a hormonal injection, implant, transdermal patch, vaginal ring, or intrauterine system [1]. Most women can safely use many of the current hormonal contraceptive methods, with special consideration warranted for women with chronic medical disorders [2-5]. Nevertheless, many women and some clinicians avoid hormonal contraception because of misperceptions about the health risks and side effects [6].

This topic will review the issues related to counseling a woman who desires combined hormonal contraception. An overview of all contraceptive methods is presented separately. (See "Overview of contraception".)


Many unplanned pregnancies occur in women who are not using contraception because of barriers to access, concerns about adverse events, dissatisfaction with a method's side effects, lack of convenience, or other bothersome characteristics. Therefore, it is important for health care providers to appropriately counsel women about contraception, with attention to: the woman's values, preferences, and expectations [7-9]; both contraceptive and noncontraceptive benefits of the method; strategies for dealing with side effects; and strategies for a hassle-free switch to another method when desired by the woman. Women report that they want to be treated as equal partners during this dialogue [10].

Prior to making decisions about contraceptive methods that might work well for them, women usually want to understand the method's [7]:



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  1. Mosher WD, Martinez GM, Chandra A, et al. Use of contraception and use of family planning services in the United States: 1982-2002. Adv Data 2004; :1.
  2. Medical eligibility criteria for contraceptive use www.who.int/reproductivehealth/publications/family_planning/.../en/ (Accessed on July 10, 2012).
  3. Centers for Disease Control and Prevention (CDC). U S. Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR Recomm Rep 2010; 59:1.
  4. Centers for Disease Control and Prevention (CDC). Update to CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: revised recommendations for the use of contraceptive methods during the postpartum period. MMWR Morb Mortal Wkly Rep 2011; 60:878.
  5. Centers for Disease Control and Prevention (CDC). Update to CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: revised recommendations for the use of hormonal contraception among women at high risk for HIV infection or infected with HIV. MMWR Morb Mortal Wkly Rep 2012; 61:449.
  6. Shelton JD, Angle MA, Jacobstein RA. Medical barriers to access to family planning. Lancet 1992; 340:1334.
  7. Trussell J. Choosing a Contraceptive: efficacy, safety, and personal considerations. In: Contraceptive Technology, 19th ed, Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D (Eds), Ardent Media, Inc, New York 2007. p.19.
  8. World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communications Programs (CCP), INFO Project. Family Planning: a global handbook for providers, CCP and WHO, Baltimore and Geneva 2007.
  9. Reproductive Health Technologies Project and the Alan Guttmacher Institute. The Unfinished Revolution in Contraception: convenience, consumer access and choice. Conference Report. October, 2003. http://www.guttmacher.org/pubs/2004/09/20/UnfinRevInContra.pdf. (Accessed on July 09, 2012).
  10. The Pro-Choice Public Education Project. She Speaks: African American and Latino Young Women on Reproductive Health and Rights 2004. p.17. http://www.protectchoice.org/downloads/She%20Speaks%20Report%20Full. (Accessed on July 09, 2012).
  11. Frost JJ, Darroch JE. Factors associated with contraceptive choice and inconsistent method use, United States, 2004. Perspect Sex Reprod Health 2008; 40:94.
  12. Association of Reproductive Health Professionals: ARHP Clinical Proceedings, 2006. p.13.
  13. Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology, 20th ed, Ardent Media, Inc, New York 2011.
  14. Moreau C, Cleland K, Trussell J. Contraceptive discontinuation attributed to method dissatisfaction in the United States. Contraception 2007; 76:267.
  15. Potter L, Oakley D, de Leon-Wong E, Cañamar R. Measuring compliance among oral contraceptive users. Fam Plann Perspect 1996; 28:154.
  16. Trussell J, Jordan B. Reproductive health risks in perspective. Contraception 2006; 73:437.
  17. Gardner J, Miller L. Promoting the safety and use of hormonal contraceptives. J Womens Health (Larchmt) 2005; 14:53.
  18. World Health Organization (WHO). Improving access to quality care in family planning. In: Medical Eligibility criteria for contraceptive use. 3rd edition, Geneva, Switzerland, 2003.
  19. Hannaford PC, Kay CR, Vessey MP, et al. Combined oral contraceptives and liver disease. Contraception 1997; 55:145.
  20. Shortridge E, Miller K. Contraindications to oral contraceptive use among women in the United States, 1999-2001. Contraception 2007; 75:355.
  21. European Agency for the Evaluation of Medicinal Products Committee for Proprietary Medicinal Products CPMP Public Assessment Report: Combined oral contraceptives and venous thromboembolism. http://www.emea.europa.eu/pdfs/human/regaffair/0220101en.pdf. (Accessed on July 09, 2012).
  22. Prescriber Update Article: Venous thromboembolism with Diane 35™ and Estelle 35™. Prescriber Update 2002;23(1):2-3. http://www.medsafe.govt.nz/Profs/PUarticles/VTEwithCPA.htm (Accessed on July 09, 2012).
  23. Shulman LP, Goldzieher JW. The truth about oral contraceptives and venous thromboembolism. J Reprod Med 2003; 48:930.
  24. Mishell DR, Shulman LP: Venous thromboembolism and cardiovascular disease: hormonal contraception. Dialogues Contracept 2007; 11:5.
  25. van Hylckama Vlieg A, Helmerhorst FM, Vandenbroucke JP, et al. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. BMJ 2009; 339:b2921.
  26. Lidegaard Ø, Løkkegaard E, Svendsen AL, Agger C. Hormonal contraception and risk of venous thromboembolism: national follow-up study. BMJ 2009; 339:b2890.
  27. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of combined oral contraceptives and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ 2015; 350:h2135.
  28. Heit JA, Kobbervig CE, James AH, et al. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med 2005; 143:697.
  29. Heinemann LA, Dinger JC. Range of published estimates of venous thromboembolism incidence in young women. Contraception 2007; 75:328.
  30. Tepper NK, Boulet SL, Whiteman MK, et al. Postpartum venous thromboembolism: incidence and risk factors. Obstet Gynecol 2014; 123:987.
  31. Bitzer J, Amy JJ, Beerthuizen R, et al. Statement on combined hormonal contraceptives containing third- or fourth-generation progestogens or cyproterone acetate, and the associated risk of thromboembolism. J Fam Plann Reprod Health Care 2013; 39:156.
  32. Lidegaard Ø, Løkkegaard E, Jensen A, et al. Thrombotic stroke and myocardial infarction with hormonal contraception. N Engl J Med 2012; 366:2257.
  33. Mills A. Combined oral contraception and the risk of venous thromboembolism. Hum Reprod 1997; 12:2595.
  34. World Health Organization. Report of a WHO Scientific Group. WHO Technical Series - 877. Cardiovascular disease and steroid hormonal contraception 1998; 877:1.
  35. Rosenberg MJ, Waugh MS, Burnhill MS. Compliance, counseling and satisfaction with oral contraceptives: a prospective evaluation. Fam Plann Perspect 1998; 30:89.
  36. Rosenberg MJ, Waugh MS, Meehan TE. Use and misuse of oral contraceptives: risk indicators for poor pill taking and discontinuation. Contraception 1995; 51:283.
  37. Rosenberg MJ, Waugh MS. Oral contraceptive discontinuation: a prospective evaluation of frequency and reasons. Am J Obstet Gynecol 1998; 179:577.
  38. Improving Contraceptive Use in the United States. Guttmacher Institute. 2008. www.guttmacher.org/pubs/2008/05/09/ImprovingContraceptiveUse.pdf. (Accessed on July 09, 2012).
  39. Westhoff CL, Heartwell S, Edwards S, et al. Oral contraceptive discontinuation: do side effects matter? Am J Obstet Gynecol 2007; 196:412.e1.
  40. Bakhru A, Stanwood N. Performance of contraceptive patch compared with oral contraceptive pill in a high-risk population. Obstet Gynecol 2006; 108:378.
  41. Roumen FJ. The contraceptive vaginal ring compared with the combined oral contraceptive pill: a comprehensive review of randomized controlled trials. Contraception 2007; 75:420.
  42. Gallo MF, Nanda K, Grimes DA, Lopez LM, Schulz KF. 20 µg versus >20 µg estrogen combined oral contraceptives for contraception. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD003989.
  43. Cremer M, Phan-Weston S, Jacobs A. Recent innovations in oral contraception. Semin Reprod Med 2010; 28:140.
  44. Blumenthal PD, Edelman A. Hormonal contraception. Obstet Gynecol 2008; 112:670.
  45. Mansour D, Korver T, Marintcheva-Petrova M, Fraser IS. The effects of Implanon on menstrual bleeding patterns. Eur J Contracept Reprod Health Care 2008; 13 Suppl 1:13.
  46. Blumenthal PD, Gemzell-Danielsson K, Marintcheva-Petrova M. Tolerability and clinical safety of Implanon. Eur J Contracept Reprod Health Care 2008; 13 Suppl 1:29.
  47. Jensen JT. Contraceptive and therapeutic effects of the levonorgestrel intrauterine system: an overview. Obstet Gynecol Surv 2005; 60:604.
  48. Schaffir J. Hormonal contraception and sexual desire: a critical review. J Sex Marital Ther 2006; 32:305.
  49. Wiebe ER, Brotto LA, MacKay J. Characteristics of women who experience mood and sexual side effects with use of hormonal contraception. J Obstet Gynaecol Can 2011; 33:1234.
  50. Wiebe E, Kaczorowski J, Mackay J. Mood and sexual side effects of hormonal contraception: physicians' and residents' knowledge, attitudes, and practices. Can Fam Physician 2012; 58:e677.
  51. Harlow BL, Wise LA, Otto MW, et al. Depression and its influence on reproductive endocrine and menstrual cycle markers associated with perimenopause: the Harvard Study of Moods and Cycles. Arch Gen Psychiatry 2003; 60:29.
  52. Joffe H, Cohen LS, Harlow BL. Impact of oral contraceptive pill use on premenstrual mood: predictors of improvement and deterioration. Am J Obstet Gynecol 2003; 189:1523.
  53. Toffol E, Heikinheimo O, Koponen P, et al. Hormonal contraception and mental health: results of a population-based study. Hum Reprod 2011; 26:3085.
  54. Keyes KM, Cheslack-Postava K, Westhoff C, et al. Association of hormonal contraceptive use with reduced levels of depressive symptoms: a national study of sexually active women in the United States. Am J Epidemiol 2013; 178:1378.
  55. Gallo MF, Lopez LM, Grimes DA, et al. Combination contraceptives: effects on weight. Cochrane Database Syst Rev 2014; 1:CD003987.
  56. Lindh I, Ellström AA, Milsom I. The long-term influence of combined oral contraceptives on body weight. Hum Reprod 2011; 26:1917.
  57. Edelman A, Jensen JT, Bulechowsky M, Cameron J. Combined oral contraceptives and body weight: do oral contraceptives cause weight gain? A primate model. Hum Reprod 2011; 26:330.
  58. Lopez LM, Edelman A, Chen M, et al. Progestin-only contraceptives: effects on weight. Cochrane Database Syst Rev 2013; 7:CD008815.
  59. Bonny AE, Secic M, Cromer B. Early weight gain related to later weight gain in adolescents on depot medroxyprogesterone acetate. Obstet Gynecol 2011; 117:793.
  60. Mishell DR Jr. Noncontraceptive health benefits of oral steroidal contraceptives. Am J Obstet Gynecol 1982; 142:809.
  61. Kost K, Forrest JD, Harlap S. Comparing the health risks and benefits of contraceptive choices. Fam Plann Perspect 1991; 23:54.
  62. French L. Dysmenorrhea. Am Fam Physician 2005; 71:285.
  63. Yonkers KA, Brown C, Pearlstein TB, et al. Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. Obstet Gynecol 2005; 106:492.
  64. Dialogues in Contraception 3. Therapeutic uses of oral contraceptives 1991; 59:35.
  65. ESHRE Capri Workshop Group. Noncontraceptive health benefits of combined oral contraception. Hum Reprod Update 2005; 11:513.
  66. ACOG Practice Bulletin No. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol 2010; 115:206.
  67. Vessey M, Painter R. Oral contraceptive use and cancer. Findings in a large cohort study, 1968-2004. Br J Cancer 2006; 95:385.
  68. Hannaford PC, Selvaraj S, Elliott AM, et al. Cancer risk among users of oral contraceptives: cohort data from the Royal College of General Practitioner's oral contraception study. BMJ 2007; 335:651.
  69. Cullins VE. Noncontraceptive benefits and therapeutic uses of depot medroxyprogesterone acetate. J Reprod Med 1996; 41:428.
  70. Hubacher D, Grimes DA. Noncontraceptive health benefits of intrauterine devices: a systematic review. Obstet Gynecol Surv 2002; 57:120.
  71. Hall KS, Trussell J, Schwarz EB. Progestin-only contraceptive pill use among women in the United States. Contraception 2012; 86:653.
  72. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011; 84:478.
  73. Rosenberg MJ, Waugh MS, Long S. Unintended pregnancies and use, misuse and discontinuation of oral contraceptives. J Reprod Med 1995; 40:355.
  74. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006; 38:90.
  75. Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol 2011; 117:1105.
  76. Lewis LN, Doherty DA, Hickey M, Skinner SR. Implanon as a contraceptive choice for teenage mothers: a comparison of contraceptive choices, acceptability and repeat pregnancy. Contraception 2010; 81:421.
  77. Thurman AR, Hammond N, Brown HE, Roddy ME. Preventing repeat teen pregnancy: postpartum depot medroxyprogesterone acetate, oral contraceptive pills, or the patch? J Pediatr Adolesc Gynecol 2007; 20:61.
  78. Hou MY, Hurwitz S, Kavanagh E, et al. Using daily text-message reminders to improve adherence with oral contraceptives: a randomized controlled trial. Obstet Gynecol 2010; 116:633.
  79. Castaño PM, Bynum JY, Andrés R, et al. Effect of daily text messages on oral contraceptive continuation: a randomized controlled trial. Obstet Gynecol 2012; 119:14.
  80. Westhoff C, Heartwell S, Edwards S, et al. Initiation of oral contraceptives using a quick start compared with a conventional start: a randomized controlled trial. Obstet Gynecol 2007; 109:1270.
  81. Stewart FH, Harper CC, Ellertson CE, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA 2001; 285:2232.
  82. Foster DG, Parvataneni R, de Bocanegra HT, et al. Number of oral contraceptive pill packages dispensed, method continuation, and costs. Obstet Gynecol 2006; 108:1107.
  83. Foster DG, Hulett D, Bradsberry M, et al. Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies. Obstet Gynecol 2011; 117:566.
  84. US Selected Practice Recommendations for Contraceptive Use, 2013. http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. (Accessed on June 14, 2013).
  85. Steenland MW, Rodriguez MI, Marchbanks PA, Curtis KM. How does the number of oral contraceptive pill packs dispensed or prescribed affect continuation and other measures of consistent and correct use? A systematic review. Contraception 2013; 87:605.
  86. Upson K, Reed SD, Prager SW, Schiff MA. Factors associated with contraceptive nonuse among US women ages 35-44 years at risk of unwanted pregnancy. Contraception 2010; 81:427.
  87. Weisman CS, Maccannon DS, Henderson JT, et al. Contraceptive counseling in managed care: preventing unintended pregnancy in adults. Womens Health Issues 2002; 12:79.
  88. Lee JK, Parisi SM, Akers AY, et al. The impact of contraceptive counseling in primary care on contraceptive use. J Gen Intern Med 2011; 26:731.
  89. Halpern V, Lopez LM, Grimes DA, et al. Strategies to improve adherence and acceptability of hormonal methods of contraception. Cochrane Database Syst Rev 2013; 10:CD004317.