Review Article

Journal of Pharmacy Practice

2017, Vol. 30(1) 130-135
Contraceptive Methods: A Review ª The Author(s) 2015
Reprints and permission:
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of Nonbarrier and Barrier Products DOI: 10.1177/0897190015585751
journals.sagepub.com/home/jpp

Charlie W. Colquitt, BS, PharmD, CPh1,

and Tonya S. Martin, PharmD, CGP, MAEd2

Abstract
The prevention of pregnancy remains an important part of the practice of medicine. Contraception can occur at a number of
points in the basic reproductive biological process and through a number of contraceptive product options. Pharmacists are
health care providers appropriately positioned to assist patients in suitable contraceptive product selection based on their
personal situations and lifestyles. This article provides an overview of available products for prevention of pregnancy and asso-
ciated risks and benefits. Contraceptive products are categorized by their hormonal content and method of action. Hormonal
options include oral contraceptive pills, contraceptive patch, implants, injection, intravaginal, and intrauterine devices. Barrier
products prevent pregnancy by creating a physical obstacle to the successful fertilization of an egg by sperm. All products and
methods are associated with benefits and potential complications that must be considered as patients, and health care providers
select the most satisfactory option.

Keywords
contraception, barrier methods, nonbarrier methods, hormonal, oral contraceptive pills (OCPs)

Introduction The Ovulation Cycle

The practice of birth control has been around for centuries
and people have relied upon their imaginations and ingenuity
to avoid pregnancy.1 Ancient writings dating back to 1850
BC refer to techniques using items placed in the vagina made
of crocodile dung, fermented dough, gum, honey, and acacia,
which most likely created a hostile environment for sperm.1
During the early second century in Rome, a highly acidic con-
coction of fruits, nuts, and wool was placed on the cervix as a
type of spermicidal barrier.1 Today’s options for contraception
have evolved considerably and include a variety of products
ranging in mechanism, efficacy, and accessibility.
There are over 15 unique types of prescription and nonpre-
scription and hormonal or nonhormonal contraceptive meth-
ods, with specific branded products numbering greater than
75. These numbers include permanent sterilization methods;
however, these techniques will not be discussed in this article.
The myriad of options allow people to prevent pregnancy by
selecting the available product that suits their personal situa-
tions and lifestyles. Contraceptive product selection can be
influenced by side effects experienced, ease of use, necessity
for personal protection from sexually transmitted infections
(STIs), and latex sensitivity. Other considerations include life-
style convenience, product accessibility, efficacy, and afford-
ability. Contraceptive product choices can be categorized in a
number of ways such as hormonal content, efficacy, or method
of action.
The endometrial or ovulation cycle, which consists of 3 phases,
is directly caused by fluctuating levels of the ovarian steroids,
estrogen, and progesterone. The 3 phases of the ovulation cycle
are the follicular phase, the ovulation phase, and the luteal
phase. The follicular phase is characterized by a rise in estrogen
levels that is parallel to the growth of a dominant follicle and
the conversion of andostenedione into estradiol. The increased
estrogen levels experienced during the follicular phase result in
a gonadotropin surge, which occurs predictably 34 to 36 hours
prior to the release of the ovum.2 During the ovulation phase,
progesterone levels increase in response to luteinizing hor-
mone. In the absence of pregnancy following ovulation during
the luteal phase, rupture of the follicle initiates a series of chem-
ical changes, including an immediate decrease then subsequent
rise in estrogen levels.2 Additionally during the luteal phase,
there is a dramatic drop in circulating estradiol and progesterone
1
College of Pharmacy, Florida A&M University, Tampa Bay Instructional Site,
Tampa, FL, USA
2
College of Pharmacy, Florida A&M University, Jacksonville Instructional Site,
Jacksonville, FL, USA
Corresponding Author:
Tonya S. Martin, Florida A&M University, College of Pharmacy, Jacksonville
Instructional Site, Jacksonville, FL, USA.
Email: tonya.martin@famu.edu
Colquitt and Martin
Table 1. Evaluating Birth Control Methods.2,3,19,20,24
Does it contain
Effectiveness Birth control method hormone?
>99% Copper IUD No
Other IUDs Yes
Implant Yes
91% to 94% Injectable Yes
Tablets Yes
Patch Yes
Ring Yes
78% to 88% Diaphragm/cervical cap/sponge No
Male condom No
Female condom No
Spermicide No
Abbreviation: IUD, intrauterine device.
levels. On average estradiol and progesterone levels, respec-
tively, peak at 250 pg/mL and 15 ng/mL then decline to less than
100 pg/mL and near negligible levels during the luteal phase.3
Pregnancy results from the successful completion of several
basic reproductive biological processes. Contraception can
occur at a number of these processes to prevent pregnancy.
Most women undergo continuous ovulation cycles at 25- to
35-day intervals during the approximately 40 years between
onset and cessation of menstruation. Without contraception,
pregnancy can occur on the day of ovulation or 2 days preced-
ing ovulation. To inhibit conception, products either block the
sperm from fertilizing the egg or exert their contraceptive
effects at the levels of ovarian-produced hormones.
Nonbarrier Methods
Several types of contraceptive products exert their effects at the
levels of the ovarian-produced hormones, estrogen and proges-
terone. These products include oral contraceptive pills (OCPs),
long-acting injections, implants, topical patches, intravaginal,
and intrauterine devices (IUDs).4 All of these products require
a prescription, and selection is based on the prescriber’s assess-
ment of the patient’s history, menstrual cycle, and adherence.4
Hormonal contraceptives consist of synthetic forms of estro-
gens and/or progestin at levels that suppress ovulation similar
to levels experienced during pregnancy.
Oral contraceptive pills. OCPs consist of synthetic forms of either
progestin only or estrogen and progestin in combination. OCPs
are the most frequently used in the United States. When used
correctly, they are considered to have greater than 99% effi-
cacy. Typically, combination OCPs are packaged as 21 active
tablets in monophasic, biphasic, or triphasic formulations fol-
lowed by 7 inert tablets for daily administration. The monopha-
sic agents consist of fixed amounts of the estrogen/progestin
ingredients in all 21 active tablets. The biphasic and triphasic
formulations have 2 or 3 different tablets, respectively, contain-
ing varying amounts of hormones, which more closely approxi-
mates levels experienced during a woman’s menstrual cycle.2,3
131
How it is used Made of latex
Lasts 10 years No
Lasts 3-5 years No
Lasts 3 years No
Lasts 3 months No
1 tablet every day No
Changed weekly No
Inserted monthly and left for 21 days No
Inserted before sex and left 6 hours after No
Worn every time before sex Yes, but nonlatex options available
Inserted every time before sex Yes
Applied every time before sex No
The estrogen content of the OCPs ranges from 20 to 50 mg per
active tablet. The progestin content varies considerably depen-
dent upon the potency differences in the compound used. OCPs
are also available in low doses of progestin-only formulations,
which commonly are referred to as the ‘‘minipill.’’ Progestin-
only OCPs are taken daily without interruption in active tablets
and considered compatible with breast feeding in the immediate
postpartum period (Tables 1 and 2).
There are a number of significant benefits for women taking
combination oral hormonal contraceptive medications. These
benefits should be weighed by the individual woman in consul-
tation with her health care provider and compared with all risks
that woman may have.
Ovarian cancer risk is reduced 40% in women who have
ever used oral hormonal contraception.5 The protection starts
within 3 to 6 months and increases with length of use; with
more than 10 years of use there is an 80% reduction in risk.5
Protection continues for at least 15 years after discontinuing
pills. Endometrial cancer risk is reduced by length of time tak-
ing combination oral hormonal contraception: 20% with
1 year use, 40% with 2 years of use, and 60% with 4 or more
years of use.6 Protection continues for 15 or more years after
discontinuation of therapy.6 Protection against benign breast
disease is also provided. There is a significant reduction
in fibrocystic changes and fibroadenoma development. This
protection against fibrocystic changes lasts up to 1 year after
discontinuation.6
The side effects of hormonal contraceptives have been
reduced since the introduction of lower dose formulations.
Still, approximately 40% of women who use hormonal birth
control have or perceive that they have side effects. Use of hor-
monal birth control places women at a higher risk of cardiovas-
cular system disorders, which includes myocardial infarction,
cerebrovascular accidents, venous thromboembolism, pulmon-
ary embolism, and hypertension. Cardiovascular risk is based
more on screening the women for risk factors than the hormo-
nal makeup of the pill when estrogen is less than 50 mg.7 The
risk of ischemic stroke increases in women who smoke and
have hypertension and decreases with low-dosed estrogen.7,8
132 Journal of Pharmacy Practice 30(1)

Table 2. Contraceptive Comparison Chart.

Contraceptive type % effectiveness Contains hormones Prescription required Protect against STIs Cost

IUD-levonorgestrel 99 Yes Yes No Up to US$927a

IUD-copper 99 No Yes No Up to US$927a
Subdermal implant 99 Yes Yes No Up to US$800a
Injection 94 Yes Yes No US$55b
Vaginal ring 91 Yes Yes No US$115c
Transdermal patch 91 Yes Yes No US$115c
OCP 91 Yes Yes No US$20-US$160c
Cervical cap with spermicide 77-87 No Yes No US$15-US$50c
Diaphragm with spermicide 86 No Yes No US$15-US$50c
Male condom 82 No No Yes 0.33-US$1/unit
Female condom 79 No No Yes US$1.40/unit

Abbreviations: IUD, intrauterine device; OCP, oral contraceptive pill; STI, sexually transmitted infection.
a
Includes the cost per unit for office examination, device, and insertion.
b
Cost of product per unit only. Office visit cost is not included.
c
Cost of product per month. Office visit cost is not included.

The risk of venous thromboembolic events are also reduced
when formulations are lower than 50 mg of estrogen. Migraines
without aura are not contraindicated in women taking oral con-
traceptives, but migraines with aura are. Persistent headaches
are often a precursor of cerebrovascular accidents. Women who
develop migraine headaches while on the pill or who experi-
ence increased severity or frequency should immediately stop
the pill and select another method of contraception.9 The inci-
dence of breast cancer may increase while taking combination
oral contraception or within the first 10 years after discontinua-
tion.10 After 10 years, there is no significant excess risk of hav-
ing a breast cancer diagnosis.11 Breast self-examination by
woman and annual breast examinations by health care provi-
ders are imperative.
Contraceptive injection. Medroxyprogesterone acetate is a deriva-
tive of progesterone, which has been formulated as an inject-
able agent indicated for the prevention of pregnancy.12 This
product is available as a prefilled syringe containing a single
150 mg dose.12 The dose is administered once every 3 months
by a trained health care professional.
The injection has the following 2 major side effects: men-
strual changes and delayed return to fertility. The menstrual
changes are irregular unpredictable episodes of bleeding and
spotting lasting as long as 7 days or more during the first few
months of use. These episodes become less frequent and
shorter until the woman has amenorrhea. The return of fertility
is delayed after discontinuation of the injection. The delay may
be as long as 18 to 24 months, but at least half of the women
conceive by the end of 1 year.2 Weight gain is the other promi-
nent side effect. Women may gain more than 5 pounds in the
first year and progressively increase thereafter.2
Transdermal patch. The synthetic hormones norelgestromin and
ethinyl estradiol are available in a transdermal patch formula-
tion. The transdermal system delivers 150 mg of norelgestromin
and 35 mg of ethinyl estradiol per day.13 One patch is applied
weekly for the first 3 weeks of the menstrual cycle followed
by 1 patch-free week. For application of the transdermal patch,
users should choose a clean, dry, intact, nonirritated location on
the abdomen, back, buttock, or upper outer arm that will not be
constricted or rubbed by clothing.13 Patients should be advised
not to use oils, powders, creams, lotions, or powders at the site
of application as this may cause the patch to fail to adhere prop-
erly.13 As long as the patch adheres appropriately to clean dry
skin, it is designed to permit normal activities such as bathing,
exercising, showering, swimming, and hot tubs.13 Additionally,
it should be advised to check daily to ensure the patch is main-
taining its position well.
The side effects are similar to those of combination oral
contraceptives with the addition of irritation at the site of
application. Other prevalent side effects include headache,
dysmenorrhea, and breast discomfort.12,13
Subdermal implant. Another option for long-term contraception
is a subdermal implantation of a rod that releases etonoges-
trel.14 This method is considered the most effective form of
contraception, with a reported 0.05% yearly failure rate.14 The
currently available etonogestrel-releasing subdermal implant is
a single rod that measures 4 cm in length and 2 mm in diameter
and is composed of an inner ethylene vinyl acetate core
embedded with crystals of the progestin active ingredient, eto-
nogestrel. The rate of release of the hormone is controlled by an
additional ethylene vinyl acetate layer that surrounds the inner
core. The implant contains a total of 68 mg of progestin. Ini-
tially upon implantation, the progestin is released at a rate of
60 to 70 mg/d. By the end of the first year of use, the rate is
decreased to 35 to 45 mg/d. At the end of years 2 and 3, the rate
is reduced to 30 to 40 mg/d, respectively.
While the device must be surgically inserted by a trained
health care professional, insertion of this form of contraceptive
is minimally invasive, requires only local anesthesia, and can
be completed in a physcian’s office within 5 minutes. Removal
of the implant is similarly simple and can occur at any time,
Colquitt and Martin
although, recommended at the end of 3 years of use with post-
removal return of ovulation resuming within 3 to 4 weeks.15,16
Insertion and removal complications are rare, reported in 0.3%
to 1% of insertions and 0.2% to 1.7% of removals. They include
local irritation, allergic reaction, infections, and hematoma
formation.15
Unlike estrogen-containing contraceptive methods, use of
the implant can safely be encouraged in patients with a history
of thromboembolic disease, hypertension, those who are over-
weight or obese, smoke, or are aged 35 and greater.14 There are
relatively few absolute contraindications to the use of this
method; they include current breast cancer, hypersensitivity
to any component of the implant, and pregnancy.14 Like the
progestin-only OCPs, the implant is safe for use in the imme-
diate postpartum period by lactating mothers.
Irregular bleeding is the most common side effect, espe-
cially in the first 6 to 12 months. For most women, periods
become fewer and lighter, but some will have longer heavier
periods with increased spotting.2 These side effects are com-
pletely normal. Less common side effects are changes in sex
drive, discoloration, or scarring of the skin over the implant,
pain or infection at the insertion site, and weight gain.16 Skin
irritation may occur at the site of placement of the contracep-
tive patch.16
Intravaginal ring. Intravaginal devices also provide safe options
of contraception for women. Etonogestrel/ethinyl estradiol
vaginal ring is a nonbiodegradable, flexible, transparent, com-
bination nonlatex contraceptive device. The ring is inserted in
the vagina and left in place for 3 weeks to release on average
0.120 mg/d of etonogestrel and 0.015 mg/d of ethinyl estradiol
hormones in the body for birth control.17 After 3 weeks, it is
removed for 1 ring-free week.17
The primary side effects are headaches occurring in 7% of
users.17 Other side effects include leucorrhea, nausea, weight
gain, coital problems, and device expulsion.17
Intrauterine devices. Inrauterine devices provide other safe
options of contraception for women. These agents may contain
hormones or be hormone free.
The levonorgestrel-releasing intrauterine system is an
option safe for latex-sensitive patients. The system consists
of a T-shaped polyethylene frame (T-body) with a steroid reser-
voir around the vertical stem.18,19 The reservoir consists of a
white cylinder, made of a mixture of levonorgestrel and silicon.
Two systems are available, one containing 13.5 mg of levonor-
gestrel, which provides contraception for 3 years, and the other
contains 52 mg of levonorgestrel and provides contraception
for up to 5 years.18,19 Like the other progestin-only methods,
the levonorgestrel-releasing intrauterine system is compatible
with breastfeeding in the immediate postpartum period.
The most common side effects are bleeding pattern altera-
tions, vulvovaginitis, abdominal/pelvic pain, acne, ovarian
cyst, and headache.20 Other less common concerns are ectopic
pregnancy, intrauterine pregnancy, sepsis, pelvic infection, and
perforation of the uterine wall or cervix.18,19
133
A nonhormonal IUD is available for women needing to
avoid the side effects of hormonal birth control. The intrauter-
ine copper contraceptive is a T-shaped IUD. The T-frame is
made of polyethylene with barium sulfate and contains cop-
per.21 The contraceptive effectiveness of this IUD is enhanced
by copper continuously being released into the uterine cavity.
Possible mechanisms of action include interference with sperm
transport or fertilization and prevention of implantation.21
The most common side effects are heavier and longer peri-
ods and spotting between periods. For most women, these typi-
cally subside in 2 to 3 months. Rare but more effects are pelvic
inflammatory disease (PID), device embedment, and perfora-
tion of the uterine wall or cervix.18,19,21
The increased cardiovascular risks encountered by women
using oral hormonal contraceptives are experienced by women
using other types of hormonal contraceptive methods, as well.
There are other risks associated with the use of non-oral hormonal
methods including placement-related complications, placement
site sensitivities, and infection. The levonorgestrel-releasing
intrauterine system and other IUDs may adhere to or perforate
the uterine wall and may be associated with increased
cramping.10-12 The risk of vaginal infection, including PID, is
increased by the use of contraceptive methods inserted into the
vagina by the consumer or health care provider, such as the intra-
vaginal ring and IUDs.9-12
Barrier Products
Male condoms. The male condom is one of the most popular and
affordable forms of birth control. Condoms made from latex
are the best at preventing pregnancy and also protect against
STIs such as HIV/AIDS and herpes if used properly.22 Today’s
male condom has evolved from being made of only latex to the
availability of various nonlatex condoms.23
Nonlatex condoms are made of polyisoprene, polyurethane,
or natural lamb. Polyisoprene is a type of natural rubber that is
stretchy and form fitting unlike polyurethane.24,25 Polyisoprene
is also cheaper than polyurethane. Polyisoprene is a synthetic
version of a material derived from the sap of the hevea tree and
contains no latex proteins but is strong and as safe as latex.25
There are advantages of using polyisoprene condoms when
compared to condoms made from polyurethane or latex. Poly-
isoprene condoms stretch and are less prone to slippage or
breakage. Polyisoprene condoms are Food and Drug Adminis-
tration (FDA) approved as an effective method of prevention of
pregnancy and reduction in the spread of STIs. A disadvantage
of polyisoprene condoms is thickness, which reduces heat
transfer between partners.
Polyurethane is a type of plastic that does not stretch like
latex or polyisoprene; therefore, slippage and breakage rates
are higher.26,27 It is thinner than most latex condoms, has little
or no smell, and is not damaged by oil-based products. The
effectiveness of polyurethane condoms in preventing preg-
nancy and the transmission of STIs has been FDA approved.
Polyurethane condoms also transmit heat better than latex, thus
enhancing sensitivity.
134
Lambskin condoms are made from the intestine of lamb.28
They are beneficial with respect to comfort and transmit heat very
well through a porous membrane. Some users may complain of a
distinct smell.28 The most important thing to note is lambskin con-
doms do not protect against the transmission of STIs or HIV. They
are only effective as a barrier method for contraception.28 These
condoms also have a Kling-Tite@ band, which is applied by the
hand to the base of the penis to hold the condom in place.
Female condom. The female condom is a soft, thin sheath of syn-
thetic latex fit loosely in the vagina. It is differently shaped than
the male condom and is inserted vaginally. The condom is
comprised of 2 flexible rings, one closed end inserted into the
vagina and the other open end remains outside of the vagina.29
The condom effectively protects against STI’s and HIV trans-
mission. The female condom can be inserted as early as 8 hours
before sexual intercourse. Disadvantages include both partners
experiencing uncomfortable sensations and feeling the inner
and outer ring during intercourse.29 Proper placement of prod-
uct may also be challenging for users.
Diaphragm. The diaphragm is a cup made of latex or silicone
with a flexible rim placed against the vaginal walls. The dia-
phragm completely covers the cervix.30 It is typically used with
a spermicide, therefore providing both a physical and a chem-
ical barrier to sperm. It is more effective than male condoms
and other female barrier methods.30 Male condoms can be used
at the same time a woman uses a diaphragm to enhance contra-
ception effectiveness. The diaphragm should remain in the
vagina for at least 6 hours after intercourse but no longer than
24 hours.30 Disadvantages of use are an increased risk of urin-
ary tract infections (UTIs) and incomplete bladder emptying.
A more serious condition is the risk of toxic shock syndrome
if the diaphragm is left in vagina for more than 24 hours.
Cervical cap. The cervical cap is dome shaped and made of sili-
cone material. The concave dome fits snuggly over the cervix
and held in place by the muscular walls of the vagina.31 The
cap has a strap that stretches over the length of the dome for
removal from vagina and it should be used with spermicide.
This device can be inserted up to 42 hours prior to intercourse
and should remain in vagina for at least 6 hours after inter-
course to ensure the sperm have died.31 The cap can be left
in for 48 hours but recommended to be removed before 24 hours
to avoid the development of a foul odor. To date, no incidence
of toxic shock syndrome have been reported but caution is indi-
cated. In comparison to the diaphragm, the cervical cap is asso-
ciated with a smaller incidence of UTIs. The cervical cap is
contraindicated in women with history of cervical cancer and
in women with an abnormally shaped cervix.
Spermicidal preparations. Spermicidal products are another form
of birth control. These chemical agents kill sperm. The active
ingredient is nonoxynol-9, which can be formulated as gels,
creams, aerosol foam, vaginal film, and sponges. Spermicidal pre-
parations are easy to use, but timing of initiating use is critical to
Journal of Pharmacy Practice 30(1)
effectiveness. Typically, the preparations need 10 to 15 minutes in
the vagina to become effective prior to being exposed to sperm.32
Disadvantages of spermicidal formulations are low effectiveness
rate and nonoxynol-9 causing irritation to the vagina or penis.
Emergency Contraception
Nearly, half of all pregnancies in the United States are unin-
tended.33 The use of emergency contraception pills can reduce
the risk of unintended pregnancy by 75%.33 Emergency contra-
ception has low toxicity, no potential for overdose, no terato-
genicity, no need for medical screening, self-identification of
the need, no important drug interactions, and uniform dosage
and thus meets the criteria for over-the-counter use.33 Two
emergency contraception products are available on the market.
The first contains 0.75 mg of levonorgestrel in each 2 tablets.
One tablet is taken within 72 hours of unprotected intercourse
and the other is taken 12 hours later. The second product con-
tains 1 tablet of 1.5 mg levonorgestrel. The single tablet is
taken within 72 hours of unprotected intercourse.
Conclusion
Pharmacists are in the prime setting to educate patients about dif-
ferent forms of contraception for both men and women. With the
numerous products on the market, pharmacists are the first line
of health care providers that patients can refer to for information
and guidance. Pharmacists can assist the patient by recommend-
ing the best product for the individual and advising the patient on
proper usage. They can also educate the patients on the risk of
latex exposure, alternative nonlatex products, HIV/AIDs, STIs,
and the possibility of pregnancy. With the emergence of Medi-
cation Therapy Management settings, pharmacists have the
opportunity to provide extensive education and counseling to
sexually active individuals, especially teenagers. Pharmacists
must avoid criticism and judgment and provide optimal care to
all patients. Pharmacists can also encourage behavioral interven-
tions to prevent STI transmission and unwanted pregnancies
through counseling, educating on proper use of contraceptives,
referring for STI screenings, and increasing awareness of com-
plications of STIs and unintended pregnancy.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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