Family planning facilities embrace contraceptive patch, vaginal ring

Patch, ring offer convenience, but price may restrict access

Your patient is a young woman who says she needs reliable birth control, but states her busy schedule makes it hard to remember to take a daily pill. What are the options you offer?

If your list includes two new options, the contraceptive patch and the vaginal ring, you join the majority of respondents to the 2002 Contraceptive Technology Update Contraception Survey. About 58% said they already were offering the Evra patch (Ortho-McNeil Pharmaceutical, Raritan, NJ) and the NuvaRing vaginal ring (Organon, West Orange, NJ) or would be implementing their use by the end of the year.

Ortho Evra and NuvaRing use is just beginning in the practice of Carrie Hrubala, CNM, a certified nurse-midwife at Women’s Health Care of Trumbull, CT. She reports no initial problems with patients using the methods, and she soon will be seeing women for follow-up.

"We have both Evra and NuvaRing; young women are more interested in the patch," says Suzanne Schmidt, CRNP, a nurse practitioner at Pacific Coast Women’s Health in Encinitas, CA. "I’m disappointed that NuvaRing has not been as enthusiastically embraced."

Three-quarters of 2002 CTU survey respondents say their facilities are offering the contraceptive injectable Lunelle (Pharmacia Corp., Peapack, NJ), which entered the U.S. market in spring 2001. This figure represents a 15% jump from the some 60% of respondents who gave similar answers in the 2001 survey.

Lunelle has been a very popular option for patients seen by Kerry Raghib, CNM, MSN, a certified nurse-midwife at Trinity Medical Center, Medical Arts Clinic in Minot, ND. However, she is curious about its continued popularity following introduction of the contraceptive patch and vaginal ring, since the injectable method requires a monthly office visit.

Schmidt’s facility has very few Lunelle users. "It’s a pain for them to get in each month," she says. "Several have asked if they could get several [doses] and have their partners inject them."

Review of the methods

Who can use these new methods? Women who are candidates for the Pill also may be considered for the Evra patch, NuvaRing vaginal ring, and the Lunelle combined hormonal injectable contraceptive. (Click here to see the patient handout on Lunelle.) Those with contraindications should seek another method.

Each Ortho Evra patch contains 150 mcg of the progestin norelgestromin and 20 mcg of the estrogen ethinyl estradiol. In clinical trials, researchers found the contraceptive patch comparable to a combination pill in terms of contraceptive efficacy and cycle control.1 In the efficacy trial, the most common adverse events resulting in discontinuation were application site reactions, nausea, emotional lability, headache, and breast discomfort.2

A patch is worn for one week at a time and is replaced on the same day of the week for three consecutive weeks. The fourth week is "patch-free." Women can wear the patch on one of four areas of the body: the buttocks, abdomen, upper torso (front and back, excluding the breasts), or upper outer arm.

A flexible, transparent, colorless vaginal ring, the NuvaRing measures approximately 2 inches in diameter, with a cross-sectional diameter of about 1/8 inch. It releases a continuous low dose of the estrogen ethinyl estradiol and the progestin etonogestrel at an average rate of 0.120 mg of etonogestrel and 0.015 mg of ethinyl estradiol per day over a 21-day period of use.

Clinical trials have shown effectiveness rates for the ring to be similar to oral contraceptive pills.3 The most common side effects reported by NuvaRing users are vaginal infections and irritation, vaginal discharge (leukorrhea), headache, weight gain, and nausea.

Women begin using NuvaRing on or before the fifth day of their menstrual period. To use NuvaRing, a woman inserts the ring in the vagina, leaves it in for three weeks, and then removes the device for one week, during which she will have her menstrual period. Since the NuvaRing is not a barrier contraceptive, its exact positioning within the vagina is not critical for its effectiveness.

The Lunelle combined hormonal injectable method has contraceptive benefits similar to the Pill, yet offers women the convenience of once- a-month dosing. Each 0.5-cc aqueous solution of Lunelle contains 5 mg estradiol cypionate and 25 mg medroxyprogesterone acetate.

Clinical trials have shown effectiveness rates for the combined injectable contraceptive to be similar to oral contraceptive pills.4 Side effects include altered menstrual bleeding, weight change, and fluid retention.

The first injection of Lunelle is given within the first five days of the menstrual period, then is repeated monthly every 28-33 days, and no later than 33 days after the last injection. (Obtain in-depth coverage of these options in the Contraceptive Technology Reports supplements inserted in CTU; check the May 2002 issue for "A Trans-dermal Delivery System Examined: Ethinyl Estradiol and Norelgestromin for Contraception," the February 2002 issue for "The Vaginal Contraceptive Ring — Efficacy, Caution, and Instruct-ions," and the March 2001 issue for "Lunelle: Evaluation of a New Monthly Contraceptive Injection for U.S. Women.")

Price may be a problem

While family planning providers say they like the convenience afforded by the contraceptive patch and vaginal ring, they are concerned that price may prove to be a problem for some of their patients.

"We do not currently offer NuvaRing," notes Michele Van Vranken, MD, medical director of the Annex Teen Clinic and West Suburban Teen Clinic in Minneapolis. "We depend on discounted prices to provide options, and the company making NuvaRing is not offering one at this point."

The Washington, DC-based National Family Planning and Reproductive Health Association (NFPRHA) has launched a public campaign to seek increased funding for the federal Title X program, the only federal program that provides categorical funding for family planning. While NFPRHA has negotiated a reduced Title X price for Ortho Evra and is working on similar pricing for NuvaRing, more dollars will be needed to aid family planning clinics in adding these new methods. (See August 2002 CTU, p. 85, "Will rising prices limit the options for patients at family planning clinics?")

References

1. Audet MC, Moreau M, Koltun WD, et al. Evaluation of contraceptive efficacy and cycle control of a transdermal contraceptive patch vs. an oral contraceptive: A randomized controlled trial. JAMA 2001; 285:2,347-2,354.

2. Smallwood GH, Meador ML, Lenihan JP, et al. Efficacy and safety of a transdermal contraceptive system. Obstet Gynecol 2001; 98:799-805.

3. Roumen FJ, Apter D, Mulders TM, et al. Efficacy, tolerability, and acceptability of a novel contraceptive vaginal ring releasing etonogestrel and ethinyl oestradiol. Hum Reprod 2001; 16:469-475.

4. Kaunitz AM, Garceau RJ, Cromie MA. Comparative safety, efficacy, and cycle control of Lunelle monthly contraceptive injection (medroxyprogesterone acetate and estradiol cypionate injectable suspension) and Ortho-Novum 7/7/7 oral contraceptive (norethindrone/ethinyl estradiol triphasic). Lunelle Study Group. Contraception 1999; 60:179-187.

Survey Profile

A total of 374 providers participated in the 2002 Contraceptive Technology Update Contracep-tion Survey, which monitors contraceptive trends and family planning issues among readers. Results were tallied and analyzed by American Health Consultants in Atlanta, publisher of CTU and more than 100 other resources.

About 65% of responses came from nurse practitioners or registered nurses. Physicians represented 21% of the responses, with allied health professionals and health educators comprising about 3% of the response group. About 11% listed other professions. Some 86% of respondents identified themselves as care providers, with nearly 8% involved in administration.

More than one-third of the respondents said they were employed at public health facilities, with about 31% working in private practice settings. About 10% listed student health centers as their place of employment, with some 13% working in hospitals. The remaining 11% reported employment in other settings.

When it comes to location of their employment, 37% said they worked in an urban setting. About 31% said they were employed in a suburban facility, while 29% listed a rural location.