New methods make inroads on Pill's position, but OCs remain popular

Patch use edges down, ring use increases, and over half offer implant

As 2007 draws to a close, review the changes at your family planning facility. How has the mix of contraceptive options changed throughout the year?

For more than half (53%) of the 2007 Contraceptive Technology Update Contraception Survey respondents, 2007 marked the first year of availability of the contraceptive implant (Implanon, Organon; Roseland, NJ).

A small, thin, hormonal contraceptive that is effective for up to three years, Implanon was approved in July 2006 by the Food and Drug Administration (FDA). The device, made of a soft medical polymer, contains 68 mg of the progestin etonogestrel. Implanted in the inner side of a woman's upper arm during an in-office procedure, the matchstick-sized device releases the drug in a low, steady dose.

Implanon represents an extremely effective, convenient, and safe method of contraception, observes Andrew Kaunitz, MD, professor and associate chair in the Obstetrics and Gynecology Department at the University of Florida College of Medicine — Jacksonville. "The insertions I have performed have proceeded quickly and smoothly, and all recipients are continuing to use their implants," he notes. "Unfortunately, few women seem to be aware of this method currently, and insurance coverage is iffy."

Kaunitz says he is looking forward to the manufacturer sponsoring direct-to-consumer (DTC) advertising regarding implantable contraception to increase awareness among women. Organon is now evaluating a DTC campaign for Implanon, but has not yet set a timeline for implementation, says Jake Knorr, company spokesman. Kaunitz also looks to more health plans to cover the birth control method. (Implanon training will be offered at the 2008 Contraceptive Technology conference in Boston March 6-8 and in San Francisco April 3-5. Registration information is available at the Contemporary Forums web site, www.contemporaryforums.com.)

More women select ring

The contraceptive vaginal ring (NuvaRing, Organon; West Orange, NJ) continues to gain ground among women since its FDA approval in 2001. More than 90% of 2007 survey participants say they now offer NuvaRing, up from 80% in 2005.

The NuvaRing is popular with college-age and older women, reports Lynn Fair, WHNP, a nurse practitioner at Columbia/Boone (MO) County Health Department.

Some survey participants say the need for vaginal insertion makes some women shy away from NuvaRing use. Reassurance is needed to help women understand the ease of NuvaRing, says Bryna Harwood, MD, assistant professor of obstetrics and gynecology and director of family planning at the University of Illinois at Chicago. Harwood reviewed patient guidelines for use of the contraceptive ring and patch at the 2007 Contraceptive Technology conference in Washington, DC.1

When counseling women, instruct women to insert the ring into the vagina as far as possible, she says. Reassure women that the ring can't get lost or "misplaced," Harwood notes.

Patch use declines

Use of the contraceptive patch (Ortho Evra, Ortho-McNeil Pharmaceutical; Raritan, NJ) dropped in 2007. About 84% of survey participants said their facility offered the method, compared to about 88% in 2006. About 93% of participants indicated the method was in use in 2005. What has led to the decrease?

The FDA revised Ortho Evra's labeling in November 2005 with a bolded warning that the patch exposes women to higher total amounts of estrogen than a typical birth control pill containing 35 mcg estrogen.

While there has been positive response to the patch and ring, neither method is used as much as pills. Cost is an important factor, says Tia Hansuld, clinic director and nurse practitioner at the Casper-Natrona County Health Department in Casper, WY.

Quick Start an option?

How do you initiate use of the contraceptive ring and patch? Research has looked at immediate initiation of combined hormonal methods.

For the vaginal ring, researchers looked at 201 women who used immediate start of the ring or low-dose oral contraceptives. Researchers charted user satisfaction and method continuation three months after ring or pill initiation. Among the study participants with follow-up data, 61% of ring users and 34% of pill users were very satisfied with their methods. About 80% of women using the ring chose to continue with the ring following the trial, while 59% of pill users chose to continue with the Pill.2

In a different study with the contraceptive patch, 60 women were evenly randomized to initiate use of the method by Quick Start (Group 1) or on the first day of their next menses (Group 2). Investigators used telephone contact at six weeks to ensure that the second cycle had been initiated. A single follow-up visit was scheduled after completion of the third patch cycle. Continuation rates for Groups 1 and 2 were 97% and 93%, respectively, into the second cycle, and 93% and 90%, respectively, into the third cycle. About half of the subjects planned to continue using the patch after the study.3

Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the University of California in Los Angeles (UCLA) and medical director of the women's health care programs at Harbor — UCLA Medical Center in Torrance, describes the Quick Start method for pill initiation in Contraceptive Technology.4 She also is an advocate of the approach for initiating the contraceptive ring, patch, and injection. Nelson advises nine days of backup contraception when the Quick Start method is used for the patch, and seven days of backup contraception for the ring.

References

  1. Harwood B. Rings and patches: Clinical considerations & protocols for prescribing. Presented at the Contraceptive Technology conference. Washington, DC; March 2007.
  2. Schafer JE, Osborne LM, Davis AR, et al. Acceptability and satisfaction using Quick Start with the contraceptive vaginal ring versus an oral contraceptive. Contraception 2006; 73:488-492.
  3. Murthy AS, Creinin MD, Harwood B, et al. Same-day initiation of the transdermal hormonal delivery system (contraceptive patch) versus traditional initiation methods. Contraception 2005; 72:333-336.
  4. Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 18th revised edition. New York City: Ardent Media; 2004.