No-daily hormonal contraception today: general overview and application in specific clinical settings

Figures & data

Figure 1. Flow chart regarding the selection process of the studies used in the review.

Table 1. No daily hormonal contraceptives. SARC: short-acting reversible contraceptives; LARC: long-acting reversible contraceptives; LNG-IUD: levonorgestrel-releasing intrauterine system; ETN etonogestrel; EE: ethinylestradiol; LNG: levonorgestrel.

No-daily contraceptives
Category	Type of Hormones	Contraceptive option
No-daily SARC	Progestins + estrogens	Vaginal ring	ETN + EE
		Transdermal patch	Norelgestromin + EE
LARC	Progestins	LNG-IUD	LNG
		ETN subdermal implant	ETN

Table 2. Pros and cons of no-daily SARC. SARC: short-acting reversible contraceptives; EE: ethinylestradiol.

No-daily SARC
PROS	Avoidance of the first hepatic passage → low and constant blood levels of EE → fewer side effects and excellent cycle control
	Effective also in intestinal malabsorption
	Monthly menstrual flow
	Rapid return to fertility
	Non-invasiveness with good acceptability
	Containing EE
CONS	User-dependent contraceptives
	Monthly menstrual flow
	EE → not for use if contraindications are present (i.e. breastfeeding)
	EE → increased risk of thromboembolism

Table 3. Pros and cons of LARC hormonal contraceptives.

No-daily LARC
PROS	Maximum contraceptive efficacy
	Do not require any user action after insertion
	The user cannot alter the method’s efficacy
	Ideal for patients with low compliance (adolescents or patients with disabilities) or to avoid forgetfulness (‘forgettable contraception’)
	Long-term but reversible contraception
	Progestin-only → if estrogens are contraindicated and in perimenopause
	Possible use during breastfeeding
	Do not increase thromboembolic risk
	Effective for dysmenorrhea and endometriosis
CONS	High upfront cost
	Dependent on the correct placement
	Possible menstrual irregularities

Table 4. Recommendations and use of no-daily contraception in specific settings LARC: long-acting reversible contraceptives; LNG-IUD: levonorgestrel-releasing intrauterine system; ETN etonogestrel; EE: ethinylestradiol; IUC: Intrauterine contraception.

Recommendations and use of no-daily hormonal contraception in specific settings
Adolescents	LARC use is recommended to decrease the rates of unintended pregnancy and abortion → they require no action after placement.
Perimenopause	Above 40 years of age, careful assessment of cardiovascular, metabolic, medical history and lifestyle risks is essential. The LNG-IUD with additional estrogen and vaginal ring is effective for perimenopausal symptoms.
Obesity	LNG-IUD safe and effective contraceptive method for obese women without contraindications. LNG-IUD is not associated with an increased risk of VTE and exerts only minimal effects on plasma lipids and glucose metabolism. ETN subdermal implant has a nonrelevant impact on fasting glucose and insulin in obese women. Earlier replacement of the ETN subdermal implant after 24 months may be considered.
Eating disorders or intestinal malabsorption	No-daily contraceptive methods avoid the oral route.
Breastfeeding	Progestin-only contraceptives do not adversely affect a woman’s ability to initiate and continue breastfeeding or an infant’s growth and development. ETN subdermal implant and LNG-IUD can be used 6 weeks after delivery.
Post-voluntary interruption of pregnancy	LARC: a good option for women who have a higher risk of forgetfulness or repeated voluntary interruption of pregnancy. IUC and the ETN subdermal implant can be inserted concurrently with surgery or at the time of the follow-up visit. For medical abortion: IUC can be inserted from the time that abortion has been established. ETN subdermal implant can be inserted at the time of mifepristone administration. Contraceptive patch, contraceptive ring, and ETN subdermal implant should be given immediately after the first pill of the medical abortion regimen.