Beyond “The Pill": Quick Guide to Non-COC Contraception for Primary Care NPs

Last week we covered combined oral contraception (COC). If you missed it, read it here:

https://www.nursepractitionermentor.com/blog/tips-for-prescribing-combined-oral-contraception 

This week, here’s a fast, clinic-friendly overview of other contraceptive options with how-to tips, who they’re great for, and counseling pearls. Share with a colleague who needs a quick refresher!

Progestin-Only Pill (POP)

Good for: Patients who can’t use estrogen (migraine with aura, postpartum, VTE risk, uncontrolled HTN) or prefer a pill.

How it works: Progestin thickens cervical mucus, thins the endometrium, and suppresses the LH surge (prevents ovulation).

How to use

• Start: Any time if pregnancy reasonably excluded. Consider a pregnancy test prior to starting.

• Backup: Use condoms/backup for 7 days unless started ≤5 days from menses onset.

• Missed pills (timing matters):

  • Norethindrone 0.35 mg (“Micronor,” generics): if >3 hours late, take 1 pill ASAP, continue daily, backup 48 hours.

  • Drospirenone 4 mg (“Slynd”): if >24 hours late, take 1 pill ASAP, continue daily, backup 7 days.

Pros/Cons

• ✔ Can be used by most women; helpful for PCOS/acne with drospirenone.

• ✖ Slynd has no generic (cost).

• Irregular bleeding is common early on—warn patients up front.

Depot Medroxyprogesterone Acetate (DMPA, “Depo”)

Good for: Patients who prefer a shot q3 months or want concealed contraception.

How to use

• Start: Any time; do a pregnancy test before first injection.

• Schedule: Every 3 months (IM or SC).

• If late: If outside the reinjection window, pregnancy test first.

• Backup: 7 days after the initial shot (unless started within 5 days of menses).

Pearls

• Fertility delay: return to ovulation may take 1–2 years—not ideal if pregnancy desired soon.

• Weight gain possible; counsel on diet/activity.

• Consider calcium/vitamin D and weight-bearing exercise; long-term use may reduce BMD (generally reversible).

Etonogestrel Implant (Nexplanon)

Good for: “Set-it-and-forget-it” highly effective contraception.

Key points

• In-office procedure; inserted in the upper arm.

• Duration: 3 years (FDA-approved).

• Backup: 7 days if not placed within 5 days of menses onset.

• Expect irregular bleeding patterns—most common reason for removal.

Transdermal Patch (Weekly)

Brands: Xulane® (EE 35 mcg/ norelgestromin 150 mcg), Twirla® (EE 30 mcg/ levonorgestrel 120 mcg)

How to use

• Apply 1 patch weekly for 3 weeks, then 1 patch-free week.

• Sites: abdomen, buttock, or upper torso (not the breasts).

Safety notes

• Same estrogen-related contraindications as COC.

• BMI ≥30 kg/m²: avoid/Category 3 (reduced efficacy and higher VTE risk).

• Possible less efficacy >90 kg—discuss alternatives.

Vaginal Ring (Monthly or Yearly)

Options

• NuvaRing®: Insert 3 weeks, remove 1 week; new ring each month.

• Annovera®: Reusable for 1 year; insert 3 weeks, remove 1 week, clean and reinsert.

Pearls

• Same contraindications as other estrogen-containing methods.

• Great option for malabsorption syndromes (bypasses GI tract).

• Teach patients to feel for ring placement if concerned.

Intrauterine Devices (IUDs)

Copper IUD (Paragard®)

• Non-hormonal; 10-year use.

• May cause heavier, more painful cycles in first 3–6 months.

• Excellent for patients wanting hormone-free contraception or emergency contraception (within 5 days of unprotected sex).

Levonorgestrel IUDs (Mirena®, Liletta®)

• Progestin-only; up to 8 years (brand-specific).

• Treats heavy menstrual bleeding; many users have lighter or absent menses.

• Backup: Not needed if inserted within 7 days of menses onset; otherwise 7 days of backup.

General Counseling & Safety Pearls

• No STI protection: Offer condoms and routine STI testing per risk.

• Blood pressure check is essential before any estrogen-containing method (patch/ring/COC).

• Red flags for estrogen methods: migraine with aura, smoking ≥15/day and age ≥35, uncontrolled HTN, VTE history, ischemic heart disease, severe liver disease, current breast cancer.

• Expect irregular bleeding with POPs, DMPA, and the implant—normalize this to reduce early discontinuation.

• Missed/late dose rules differ by method—save quick instructions in your EMR.

• Shared decision-making: Align the method with the patient’s goals (cycle control, acne, hormone-free, reversibility, cost).

Quick Comparison (at a glance)

• POPs: Daily pill; strict timing (especially norethindrone). Estrogen-free.

• Depo: q3-month injection; delayed fertility return, potential weight gain.

• Implant: 3-yr LARC; most effective; irregular bleeding common.

• Patch: Weekly; avoid BMI ≥30; estrogen risks apply.

• Ring: Monthly (NuvaRing) or yearly reusable (Annovera); estrogen risks apply.

• IUDs: Copper (10 yrs, heavier menses early) vs. LNG (up to 8 yrs, lighter menses).

References

• CDC U.S. Medical Eligibility Criteria (MEC), 2024 – Summary Chart: https://www.cdc.gov/contraception/media/pdfs/2024/07/us-mec-summary-chart-color-508.pdf 

• UpToDate. Combined estrogen-progestin oral contraceptives: patient selection, counseling, and use. (accessed Sept 2025)

• ACOG Practice Bulletin(s) on Long-Acting Reversible Contraception and Combined Hormonal Contraception.

• FDA Prescribing Information: Nexplanon®, Depo-Provera®, Xulane®, Twirla®, NuvaRing®, Annovera®, Paragard®, Mirena®, Liletta®.

Education only; not a substitute for medical advice. Use clinical judgment and local protocols.

👉 Questions or cases you want help with? Email me at [email protected]  or DM me on social.