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Emphasize long-acting reversible methods
Despite the safety and efficacy of the Copper T intrauterine device (ParaGard IUD, Barr Pharmaceuticals; Pomona, NY), the levonorgestrel intrauterine system (Mirena IUS, Bayer HealthCare Pharmaceuticals; Wayne, NJ), and the single-rod contraceptive implant (Implanon, Organon; Roseland, NJ), the most popular methods in the United States are oral contraceptives (OCs) and sterilization.1 How can clinicians counsel more effectively on these long-acting methods to increase their use?
Research now under way by Jeffrey Peipert, MD, MPH, MHA, professor of obstetrics and gynecology at the Washington University School of Medicine in St. Louis, might yield answers to this question. Peipert is leading a cohort study of 10,000 women in the St. Louis region, looking at use of such reversible long-term methods of birth control as subdermal implants and intrauterine contraception (IUC). Implemented in 2007, the Contraceptive Choice Project is providing birth control at no cost to all participants for three years, reports Peipert. So far, researchers have recruited approximately 2,800 women; more than half (55%) are choosing IUC, and another 10% are selecting Implanon.
"We hope to reduce the rate of unintended pregnancy and teen pregnancy in our region," he says. "We are also studying continuation rates and satisfaction with current reversible contraceptive methods."
To determine how often patients switched from combined hormonal methods or depot medroxy-progesterone (DMPA) at initial screening for the project, researchers looked at the first 500 women enrolled.2 They evaluated the contraceptive method used at screening, then the method chosen at enrollment following contraceptive counseling.
At screening, half of the women were not using contraception, 12% used barrier methods, 36% used combined hormonal methods or DMPA, and less than 1% used long-acting reversible methods. At enrollment, 66% of patients initiated long-acting methods, and 32% initiated combined hormonal contraception or DMPA. Of the 181 patients using a combined hormonal method or DMPA at screening, 59% of patients switched to long-acting reversible methods at enrollment (39% levonorgestrel intrauterine contraception, 6% copper intrauterine contraception, 14% subdermal implant). A small percentage (10%) of those participants requested long-acting methods but used a shorter-acting contraceptive method to "bridge" until insertion could be performed.
Findings indicate that once financial barriers are removed and appropriate contraceptive counseling provided, a significant number of women, including those currently using shorter-acting hormonal contraceptive methods, ultimately will choose long-acting methods, researchers note.
In 2002, the leading method of contraception in the United States was the oral contraceptive pill, used by 11.6 million women, followed by female sterilization, used by 10.3 million women.1 Clinicians' mindset must change when it comes to offering long-acting reversible contraception, says Peipert. Intrauterine contraception and the contraceptive implant should be considered first-line options for almost all women, he maintains.
These methods are forgettable; they are not dependent on remembering to take a pill, put in a ring, put on a patch, or get an injection, Peipert states. They are the most effective reversible methods available; all, or at least most, women interested in avoiding pregnancy should be offered these methods, he says.
Women with histories of myocardial infarction, stroke, deep vein thrombosis, systemic lupus erythematosus, hypertension, and even older smokers can use each of these top-tier methods.3
No longer should clinicians reserve intrauterine contraception for parous women, says Peipert says. It is perfectly fine to use intrauterine contraception in women who have not had children, he says. The World Health Organization eligibility criteria classes use of IUDs in young women ages 20 and younger, as well as for nulliparous women, as a "2," which means the advantages of using the method generally outweigh the theoretical or proven risks.4
The ParaGard IUD is approved for use for nulliparous women in stable relationships from ages 16 through menopause. In recent Food and Drug Administration-approved labeling changes for the levonorgestrel intrauterine system, neither nulliparity nor nulligravity is listed as a contraindication.5
Clinicians do not need to avoid use of intrauterine contraception in women with a past history of a sexually transmitted infection (STI), advises Peipert. However, providers should avoid insertion in women who have an active STI or current cervicitis, or who are at high risk for STIs, he notes. "Bottom line: IUCs are not just for married, monogamous, parous women," says Peipert. "They should be offered to all women as an excellent and highly effective contraceptive option."
Clinicians also should counsel on use of Implanon, which Peipert sees as a very effective, "forgettable" method. All women should be counseled regarding the unpredictable bleeding associated with this method for successful use, he notes.
For intrauterine contraception and the implant, financial barriers continue to represent a major obstacle to use of long-acting methods, even among otherwise well-insured women, observes Andrew Kaunitz, MD, professor and associate chair in the obstetrics and gynecology department at the University of Florida College of Medicine — Jacksonville. Although the IUD and the IUS have upfront costs of about $500 each in product and medical costs, they are the most cost-effective contraception over a five-year period, when the financial price of a possible unwanted pregnancy is considered.6 If existing long-acting contraceptives were used by more patients, rates of unintended pregnancy and abortion would fall substantially, Kaunitz states.
"I look forward to a time when long-acting methods are universally accessible to U.S. women," he says. "More educational outreach to women about long-acting methods, including direct-to-consumer advertising, would also be desirable and welcome."