FAMILY PLANNING · METHOD REVIEW · TOPIC: CONTRACEPTION · REF: ACOG / CDC / FDA
The Method Selector Contraception reference · U.S. edition
Reproductive health · Patient guide

Contraception is not one decision. It is a series of them.

Roughly 90% of American women who are sexually active use contraception at some point, yet fewer than half feel they have enough information to choose between methods. The differences in effectiveness, side effects, reversibility, and cost vary enormously — and the right answer depends on what matters most to each person.

15 min read
ACOG-aligned
18 methods · 4 classes
90%
U.S. women who are sexually active have used at least one contraceptive method.
18
FDA-approved method categories — the ACA requires plans to cover at least one from each.
< 1%
Typical-use failure rate of LARC methods (IUD and implant) — the most effective reversible options.
40%
Of pregnancies in the U.S. are unintended — a rate higher than most developed countries.
Section 01 · How contraception works

Four mechanisms — and most methods use more than one.

Contraceptive methods interrupt the reproductive process at different points. Understanding which mechanism a method uses is what makes side effects and effectiveness predictable.

Preventing ovulation

The primary mechanism of combined hormonal methods (pill, patch, ring) and progestin-only methods (pill, implant, hormonal IUD). They suppress the LH surge needed to release an egg.

Thickening cervical mucus

Progestin thickens cervical mucus, creating a barrier that prevents sperm from reaching the egg. This is a secondary mechanism in most hormonal methods and the primary mechanism of the implant.

Thinning the uterine lining

Hormonal methods also thin the endometrium, which makes implantation less likely if fertilization does occur. This is a contributing mechanism, not the primary one.

Blocking sperm directly

Condoms, diaphragms, cervical caps, and spermicides work by physically blocking or neutralizing sperm at the point of entry. Condoms also protect against STIs — no hormonal method does.

One clarification that matters in clinical conversations: emergency contraception is not an abortifacient. Levonorgestrel and ulipristal work primarily by preventing or delaying ovulation — if ovulation has already occurred, they do not interrupt an established pregnancy. The copper IUD works by creating a sterile inflammatory environment that is toxic to sperm and eggs before fertilization. None of these are the same as medication abortion (mifepristone + misoprostol), which is a distinct treatment for an established pregnancy.

Section 02 · Effectiveness

Typical-use effectiveness — which is what actually matters.

Clinical trials often report "perfect use" failure rates, which assume flawless adherence. Real-world effectiveness — "typical use" — is what most people actually experience.

Typical-use effectiveness · first year of use
Higher bar = more effective
Implant (Nexplanon)3 years · subdermal
99.9%
Hormonal IUD3–8 years · intrauterine
99.8%
Copper IUDup to 10 years · intrauterine
99.2%
Sterilizationtubal / vasectomy · permanent
99.5%
The pill · patch · ringdaily / weekly / monthly
91%
Depo-Provera shotevery 3 months
94%
Male condomevery act
87%
Female condom · diaphragmevery act
79–83%
Withdrawal · fertility awarenessbehavioral
78–80%
Spermicide aloneevery act
72%
The gap between LARC and everything else is enormous. A hormonal IUD is roughly 20 times more effective in typical use than the pill. The reason is not pharmacology — it is that LARC methods do not depend on the user remembering to do anything. This is why ACOG and AAP recommend LARC as first-line for adolescents and young adults.
Section 03 · The full field

Eighteen categories — one comparison.

Method Typical use Duration Notes
LARCImplant 99.9% 3 years Single rod in upper arm. Lowest failure rate of any reversible method. Irregular bleeding is common early.
LARCHormonal IUD 99.8% 3–8 years Liletta, Mirena, Kyleena, Skyla. Lighter periods; often improves cramps. Insertion can be uncomfortable.
LARCCopper IUD 99.2% up to 10 years Hormone-free. Heavier, longer periods initially. Can also be used as emergency contraception up to 5 days.
HormonalCombined pill 91% Daily Estrogen + progestin. Regulates cycles, reduces acne and cramping. Avoid if migraines with aura or high clot risk.
HormonalProgestin-only pill 91% Daily No estrogen — safe for those who cannot take combined pills. Must be taken within a 3-hour window (except Slynd).
HormonalPatch 91% Weekly Applied weekly for 3 weeks, then off 1 week. May not be as effective in people over 90 kg.
HormonalVaginal ring 91% Monthly NuvaRing or Annovera (year-long reusable). Insert for 3 weeks, remove for 1. No daily action.
HormonalDepo-Provera 94% 3 months Injection. No daily action. Delayed return to fertility after stopping; long-term use reduces bone density.
BarrierMale condom 87% Per act Only method that also protects against STIs. Latex, polyurethane, or lambskin (lambskin does not block viruses).
BarrierFemale condom 79% Per act Less effective than male condoms in typical use. Also provides STI protection.
BarrierDiaphragm 83% Per act Used with spermicide. Can be placed up to 2 hours before sex. Refitting needed after weight change or childbirth.
BarrierCervical cap 71–86% Per act Used with spermicide. Less effective in people who have given birth.
EmergencyLevonorgestrel Not a routine method Per event Plan B and generics. Best within 72 hours; less effective for people over 165 lbs.
EmergencyUlipristal (ella) Not a routine method Per event Prescription only. Effective up to 120 hours. More effective than levonorgestrel, including at higher body weights.
EmergencyCopper IUD > 99% Up to 10 years Most effective emergency method. Placed up to 5 days after unprotected sex and continues as routine contraception.
Sterilization 99.5% Permanent Tubal ligation or vasectomy. Considered irreversible; regret rates are highest in people under 30.
Withdrawal 78% Per act No protection against STIs. Failure rate depends entirely on timing and control.
Fertility awareness 76–88% Behavioral Tracking cycles to identify fertile days. Effectiveness depends on method and consistency.
Section 04 · Long-acting reversible

LARC — the methods that do not depend on remembering.

LARC stands for long-acting reversible contraception — the hormonal IUD, copper IUD, and subdermal implant. These are the most effective reversible methods available, and they require nothing more than a single placement procedure.

Hormonal IUD — levonorgestrel-releasing
3 to 8 years depending on device

Releases a small amount of levonorgestrel directly into the uterus, which thickens cervical mucus, thins the uterine lining, and suppresses sperm motility. The progestin dose is much lower than the pill and mostly local — which is why systemic hormonal side effects are usually mild.

Common benefits: dramatically lighter periods, reduced cramps, and — for many users — periods that stop entirely after a year. Insertion takes about 5 minutes and can be performed in an office setting. Cramping and spotting are common in the first 3 to 6 months, then usually improve.

DevicesMirena (8 yr) · Liletta (8 yr) · Kyleena (5 yr) · Skyla (3 yr)
Copper IUD — hormone-free
Up to 10 years

Contains no hormones. The copper creates an inflammatory environment that is toxic to sperm and interferes with egg viability — preventing fertilization before it can occur. This is the same mechanism that makes it the most effective form of emergency contraception.

Because there are no hormones, it does not affect mood, weight, or acne. Periods are typically heavier and cramping is more intense in the first 3 to 6 months, then gradually normalize. First choice for people who cannot or prefer not to use hormonal methods.

DeviceParaGard (10-year) · others in development
Subdermal implant — the most effective reversible method
3 years · Nexplanon

A single rod — about the size of a matchstick — placed under the skin of the upper inner arm. Releases etonogestrel continuously for 3 years with a typical-use failure rate of 0.1%. It is the most effective reversible contraceptive in existence, ahead of IUDs.

Placement takes 1 minute in an office with local anesthetic. Irregular bleeding is the most common side effect and the most common reason for removal. Some users bleed frequently, others rarely or not at all — there is no way to predict which pattern you will have.

DeviceNexplanon
Facts worth knowing
Counselling and access

Any LARC can be removed at any time for any reason — no waiting period, no clinician permission needed. Removal takes about 5 minutes and fertility returns to baseline immediately.

LARC does not cause infertility, ectopic pregnancy, or weight gain at greater rates than other methods — these concerns are common but not supported by the evidence. Initial cramping and bleeding changes are the effects most users actually experience.

Under the ACA, all FDA-approved LARC methods are covered without cost-sharing by most private insurance plans in the U.S.

Section 05 · Hormonal methods

Daily and cyclical options — with benefits beyond contraception.

Hormonal methods other than LARC require action from the user — daily, weekly, or monthly. In exchange, they offer predictable cycles, and many users choose them for their non-contraceptive effects.

Combined pill — estrogen + progestin
Daily

The most-used hormonal method worldwide. Prevents ovulation, thickens cervical mucus, and thins the endometrium. Typical-use effectiveness is about 91%, because missing pills is common.

Non-contraceptive benefits: regular, lighter periods; less cramping; improvement in acne and PMS symptoms; reduced risk of ovarian and endometrial cancer with long-term use. Several formulations are available, and finding the right one sometimes takes a trial or two.

Examplesethinyl estradiol + various progestins · extended-cycle (Seasonale) · estradiol valerate (Natazia)
Progestin-only pill — the mini-pill
Daily · narrow window

Contains no estrogen. Safe for people who cannot take combined hormonal methods — including those with migraine with aura, hypertension, smoking over age 35, or a history of blood clots. The primary mechanism is thickening cervical mucus.

Traditional progestin-only pills (norethindrone) must be taken within the same 3-hour window every day — a stricter requirement than combined pills. Slynd (drospirenone) has a 24-hour window and works more like a combined pill in that respect. Irregular bleeding is common.

Examplesnorethindrone (Micronor, Camila) · drospirenone (Slynd)
Patch and ring — less frequent action
Weekly / monthly

The patch (Xulane, Twirla) is applied to the skin and changed weekly for 3 weeks, then off for 1 week. Effectiveness may be reduced in users over 90 kg (198 lbs), which is why it is not always first choice for higher weights.

The vaginal ring (NuvaRing, Annovera) is inserted for 3 weeks and removed for 1. Annovera is reusable for a full year. Both require no daily action, which improves typical-use effectiveness compared with the pill in some patients.

ExamplesXulane · Twirla · NuvaRing · Annovera
Depo-Provera — the injection
Every 3 months

An intramuscular or subcutaneous injection of medroxyprogesterone acetate, given every 3 months. Typical-use effectiveness is about 94% — higher than the pill, because there is nothing to remember between visits.

Delayed return to fertility is the main caveat: after the last injection, ovulation may not resume for 6 to 9 months, longer than for any other reversible method. Long-term use is associated with reversible decrease in bone mineral density, which is why continuous use beyond 2 years is sometimes discouraged in adolescents.

ExamplesDepo-Provera IM · Depo-SubQ Provera 104
Section 06 · Emergency contraception

Three options — and the clock matters.

Emergency contraception is a backup, not a routine method. The three options differ in how long they work, how effective they are, and whether a prescription is needed.

Levonorgestrel — Plan B and generics

Available over the counter, no age restriction. Best within 72 hours; can be used up to 120. Works by delaying or preventing ovulation. Less effective for people over 165 lbs — ulipristal or a copper IUD is a better choice in that case. Does not work if ovulation has already occurred.

Ulipristal — ella

Prescription only. Effective up to 120 hours (5 days). More effective than levonorgestrel, particularly for people at higher body weights. Works by delaying ovulation. May be less effective if taken with certain medications that induce liver enzymes.

Copper IUD — the most effective

Placed within 5 days of unprotected sex. Failure rate under 0.1%. Continues working as routine contraception for up to 10 years. Requires an office visit for placement. The single most effective emergency option available.

Two clarifications that come up often. Emergency contraception is not a medication abortion. Levonorgestrel, ulipristal, and the copper IUD all work before fertilization — they prevent ovulation, block sperm, or prevent the egg and sperm from meeting. None of them interrupt an established pregnancy. Weight matters for levonorgestrel — the FDA notes reduced effectiveness in people with BMI over 30, and both ACOG and the manufacturer recommend ulipristal or a copper IUD in this situation.

Section 07 · Choosing

Four questions that narrow the field quickly.

There is no universally "best" contraceptive method. The right one depends on what matters most to the person using it. Four questions do most of the work.

A quick decision aid · four questions
Not a prescription · a conversation starter
1

How important is effectiveness?

If pregnancy must be avoided with near certainty, LARC or sterilization is the answer. If a 5–10% annual failure rate is acceptable, pills, patch, ring, and condoms are reasonable.

2

How much action do you want to take?

If remembering a daily pill is a barrier — for any reason — the implant, IUD, shot, or ring removes that variable. If a daily routine is fine, more methods are available.

3

Do you need STI protection?

Only external and internal condoms reduce STI transmission. Hormonal methods and IUDs do not. Many people use a condom alongside another method for this reason.

4

What about side effects?

If hormonal side effects are a concern, the copper IUD is hormone-free. If cycle control matters, combined pills and hormonal IUDs often improve periods. If bleeding changes are unacceptable, some options should be avoided.

Section 08 · Access & affordability

Cost is the single biggest barrier — and it is not supposed to be.

ACA — no cost-sharing

Under the Affordable Care Act, most private insurance plans must cover all FDA-approved contraceptive methods without cost-sharing, including at least one option in each of the 18 method categories. This means no copay for the pill, patch, ring, IUD, implant, shot, or emergency contraception with a prescription.

Medicaid & Title X

Medicaid covers contraception in all states, but specific method coverage varies. Title X clinics provide free or low-cost contraception to anyone regardless of insurance or immigration status. Find them at opa.hhs.gov or by calling 1-800-230-PLAN.

Over-the-counter and telehealth

Some states allow pharmacists to prescribe hormonal contraception directly. Telehealth platforms provide prescriptions with mail-order delivery. Emergency contraception pills are OTC with no age restriction. Opill (norgestrel) is the first OTC daily contraceptive pill in the U.S.

Where the pharmacy price still varies substantially: if you use a non-LARC method — particularly the pill — the same generic tablet can cost several times more at one pharmacy than another. Under the ACA, the cost should be zero with insurance, but the insurance must be active and the specific formulation must be covered. A live prescription price comparison shows the current range in about two minutes, and the same logic applies to every generic on a patient's list. If you are filling an online refill for the first time, the process is documented step by step in this how to order prescriptions online guide — prescription first, licensed seller second, small first order third.

Before filling from any seller — online or local — verify them. A working VIPPS seal that resolves to a live NABP record, a real U.S. street address, and a prescription requirement that cannot be waived. A transparency page like this one about Metformin4You is a reasonable example of the standard to expect.

Section 09 · What to watch for

Side effects and warning signs that matter more than average.

Seek prompt evaluation

If any of these appear while using contraception, contact a clinician rather than waiting.

Severe calf pain, leg swelling, or one-sided leg pain. Suggests deep vein thrombosis — a rare but serious complication of combined hormonal contraception, especially in the first months of use or after a long flight.
Sudden shortness of breath, chest pain, or rapid heart rate. Could indicate pulmonary embolism — a medical emergency. Call emergency services.
New severe headache with visual changes, weakness, or difficulty speaking. Aura-type migraines are a contraindication to combined hormonal contraception; any new focal neurological symptom warrants urgent evaluation.
Severe abdominal pain during IUD use. If it is one-sided and sharp, ectopic pregnancy must be excluded — the IUD prevents most pregnancies but does not eliminate the risk entirely. Rare but important.
Heavy bleeding with a foul-smelling discharge and fever after IUD or implant placement. Suggests pelvic infection — treatable but requires prompt care.
Missed period with any symptoms of pregnancy. No method except sterilization is 100% effective. A pregnancy test is the correct next step before continuing the method.
Section 10 · Questions

Five asked most often at the clinic.

Q·01 What is the most effective form of reversible contraception? +
Long-acting reversible contraceptives (LARCs) — the copper IUD, hormonal IUDs, and the subdermal implant — are the most effective reversible methods, with failure rates under 1% per year. They do not depend on user action and remain effective for 3 to 10 years depending on the device. Sterilization is more effective still but is generally considered permanent.
Q·02 How effective are birth control pills in real-world use? +
With perfect use, combined oral contraceptives are over 99% effective. With typical use — including missed pills, late starts, and drug interactions — effectiveness drops to about 91%. This gap between perfect and typical use is why long-acting methods have higher real-world effectiveness than pills.
Q·03 What is emergency contraception and how long does it work? +
There are three main options. Levonorgestrel pills (Plan B One-Step and generics) work best within 72 hours but can be used up to 120 hours. Ulipristal acetate (ella) is more effective and works up to 120 hours. The copper IUD is the most effective form of emergency contraception and can be placed up to 5 days after unprotected sex. None of these are abortion pills — they work by delaying or preventing ovulation.
Q·04 Does insurance cover birth control in the U.S.? +
Under the Affordable Care Act, most private insurance plans must cover FDA-approved contraceptive methods without cost-sharing, including at least one option in each of the 18 method categories. This includes the pill, patch, ring, IUDs, implant, shot, and emergency contraception with a prescription. Coverage for over-the-counter emergency contraception varies. Medicaid coverage varies by state.
Q·05 Can I get pregnant while on birth control? +
Yes — no method except sterilization is 100% effective. However, the failure rates of LARC methods are under 1% per year, which is lower than almost any other medication class in medicine. The most common cause of unintended pregnancy on hormonal contraception is missed or late pills, not method failure.
◆ Sources & Verification
This reference is aligned with public clinical guidance from the American College of Obstetricians and Gynecologists (ACOG), the CDC Division of Reproductive Health — U.S. Medical Eligibility Criteria for Contraceptive Use, and the U.S. Food and Drug Administration's Birth Control resources. Drug-label information draws on the National Library of Medicine's DailyMed database and MedlinePlus. Pharmacy verification follows the NABP VIPPS program. Sliding-scale and free services are available through the Title X Family Planning Program.
◆ Before the next refill

Most contraception is covered fully. When it is not, price still matters.

Under the ACA, most private insurance covers contraception without cost-sharing — but not every formulation is on every plan's list, and out-of-pocket prices vary. A two-minute comparison across licensed U.S. sellers is a useful habit to build. Begin with the current Metformin price comparison as a live demonstration of how wide the spread runs.

Open the price comparison