Contraception & Menopause
Match the method to the contraindication, then weigh the WHI risks of hormone therapy
Contraceptive efficacy and LARC
Typical use is what counts. Methods are ranked by typical-use failure per year, because real-world adherence—not perfect use—determines how many pregnancies occur.
| Method | Typical-use failure | Key points |
|---|---|---|
| Etonogestrel implant | <1% | 3 years; irregular bleeding is the main side effect |
| Levonorgestrel IUD | <1% | Up to 8 years; lightens periods, helps menorrhagia |
| Copper IUD | <1% | 10 years, hormone-free; can worsen bleeding and cramping |
| Sterilization | <1% | Permanent; vasectomy is simpler and safer than tubal surgery |
| DMPA injection | ~4% | Every 3 months; reversible bone-density loss, weight gain, delayed return of fertility (up to ~10 months) |
| Pill, patch, ring | ~7% | Depend on daily, weekly, or monthly adherence |
| Condoms, withdrawal, fertility awareness | ~13% (condoms) or more | Least effective; condoms alone prevent STIs |
Long-acting reversible contraception (LARC)—the etonogestrel implant, levonorgestrel IUDs, and the copper IUD—is first-line for most people, including adolescents and nulliparous patients, because efficacy does not depend on adherence. Nulliparity is not a contraindication to an IUD. The copper IUD works through a spermicidal foreign-body reaction and is the only highly effective hormone-free reversible method.
Combined vs progestin-only methods
Combined hormonal contraception (estrogen plus progestin as a pill, patch, or ring) works mainly by suppressing the LH surge and ovulation; the progestin also thickens cervical mucus and thins the endometrium. Its non-contraceptive benefits are cycle regulation, less menorrhagia and dysmenorrhea, improved acne, and a lower lifetime risk of ovarian and endometrial cancer—a durable effect that lasts years after stopping. Enzyme inducers such as rifampin and several anticonvulsants reduce its efficacy.
Estrogen contraindications (MEC category 4). Estrogen is prothrombotic, so combined methods are contraindicated with:
- Migraine with aura (ischemic stroke risk)
- Smoking at age ≥35 (≥15 cigarettes/day)
- Prior VTE or known thrombophilia
- Active breast cancer
- Hypertension with systolic ≥160 or diastolic ≥100 (140 to 159 or 90 to 99 is MEC 3)
- <21 days postpartum
- Active liver disease
- Prior stroke or coronary disease
Progestin-only options—the progestin-only pill, implant, DMPA injection, and levonorgestrel IUD—are safe when estrogen is out: VTE history, migraine with aura, a smoker ≥35, or immediately postpartum and breastfeeding (estrogen raises early postpartum VTE risk and can reduce milk supply). The copper IUD avoids hormones entirely and is the only choice with active breast cancer, which is MEC 4 for all hormonal methods. DMPA's bone-density loss and delayed fertility are both reversible.
A 38-year-old smoker with migraine with aura needs an estrogen-free method: an implant, an IUD, or DMPA.
Emergency contraception and STI protection
| Option | Window | Notes |
|---|---|---|
| Copper IUD | Up to 5 days | Most effective; also provides ongoing contraception |
| Levonorgestrel 52-mg IUD | Up to 5 days | Accepted IUD alternative (US SPR 2024); also provides ongoing contraception |
| Ulipristal acetate | Up to 5 days | Oral progesterone receptor modulator; prescription; wait 5 days before starting hormonal contraception (barrier backup meanwhile) |
| Levonorgestrel | Best within 72 hours | Over the counter; less effective at higher body weight |
Only barriers block STIs. No hormonal method or IUD protects against sexually transmitted infections; only condoms do. Counsel dual-method use: a hormonal or LARC method for pregnancy prevention plus condoms for STI protection.
Menopause and hormone therapy
Diagnosis. Menopause is 12 months of amenorrhea (mean age ~51), preceded by a perimenopausal transition with irregular cycles and rising FSH. The diagnosis is clinical; routine FSH testing is not required. Symptoms stem from falling estrogen.
Vasomotor symptoms (hot flashes, night sweats) respond best to systemic estrogen. Add a progestin if the uterus is intact to prevent endometrial hyperplasia and cancer; estrogen alone is used after hysterectomy. Nonhormonal options are SSRIs/SNRIs (low-dose paroxetine is FDA-approved; with tamoxifen, avoid paroxetine and fluoxetine, strong CYP2D6 inhibitors, and prefer venlafaxine), gabapentin, clonidine, fezolinetant, an NK3-receptor antagonist with a boxed warning for hepatotoxicity that needs baseline and periodic liver tests, and elinzanetant, an NK1 and NK3 receptor antagonist approved in 2025.
The WHI risk-benefit. Menopausal hormone therapy relieves vasomotor symptoms and prevents osteoporotic fracture, but the Women's Health Initiative showed that estrogen-progestin increases breast cancer, VTE, and stroke. Estrogen-only therapy (in women without a uterus) did not raise breast cancer risk. Use the lowest effective dose for the shortest necessary time, ideally starting before 60 or within 10 years of menopause (the timing hypothesis). Avoid hormone therapy with prior breast cancer, VTE, coronary disease or stroke, active liver disease, or undiagnosed vaginal bleeding.
Genitourinary syndrome and bone health
Genitourinary syndrome of menopause (vaginal dryness, dyspareunia, atrophy, recurrent UTIs) is treated with low-dose topical vaginal estrogen. Absorption is minimal, so no progestin is needed and it is generally safe even when systemic therapy is undesirable. Nonhormonal moisturizers and lubricants are alternatives.
Bone. Estrogen loss accelerates bone loss. Prevention is calcium ~1200 mg/day plus vitamin D, weight-bearing exercise, and smoking cessation.
- Screening: DEXA at 65 in average-risk women, earlier in postmenopausal women with risk factors (low weight, smoking, glucocorticoids, prior fracture).
- Definitions: osteoporosis is a T-score ≤−2.5 (or any fragility fracture); osteopenia is −1 to −2.5.
- Treatment: bisphosphonates are first-line; take them upright with water to avoid esophagitis, and watch for osteonecrosis of the jaw and atypical femur fractures. Alternatives include denosumab and raloxifene.