Quick Start’ approach eyed for DMPA and patch

Current package labeling for the contraceptive injection depot medroxyprogesterone acetate (DMPA) (Depo-Provera, Pfizer, New York City) calls for the method to be initiated within the first five days of a woman’s menstrual period.1 Oral contraceptives now are being started throughout the menstrual cycle in an approach known as "Quick Start," in which women take the first pill while in the clinician’s office. Quick Start is aimed at improving method acceptability and use by no longer forcing women to wait for their menstrual periods to begin their chosen method.2

Would a similar approach work when it comes to DMPA? Findings from a just-released study indicate that while immediate provision of DMPA did not affect patient satisfaction or continuation, it did reduce unintended pregnancies.3 In the study, only one pregnancy occurred among the women receiving DMPA immediately (Depo Now approach), whereas 18 pregnancies occurred among those who were provided a bridge method of contraception (pills, patches, or rings) and then offered DMPA after 21 days.3

Prescribers once instructed women to take one of two approaches when it came to oral contraceptive use: the "first-day start," which calls for pill use to begin the first day of the woman’s next period, or the "Sunday start," when pill use is initiated on the Sunday after the menstrual cycle begins.

Quick Start has gained favor since early research indicated that it improved pill continuation rates.1,4 Quick Start is now listed as the preferred method of pill initiation in Contraceptive Technology.5

Researchers at the Mailman School of Public Health at Columbia University in New York City have just presented their findings on the immediate administration of DMPA in a cohort of young women ages 14-26.3 In their study, they compared the immediate administration of DMPA ("Depo Now") to the immediate use of short-term hormonal methods that served as "bridge methods" until later DMPA initiation. They sought to determine whether Depo Now resulted in greater method continuation to DMPA across a six-month period as compared to other Quick Start bridge methods (pills, transdermal patch, or vaginal ring).

According to the researchers, findings support the use of immediate administration of DMPA with little adverse affect. While immediate administration does not appear to affect continuation or satisfaction, unintended pregnancy is substantially diminished during the first six months of DMPA use, the researchers state.

To perform the study, young women ages 14-26 seeking to use DMPA were randomized after meeting eligibility criteria to either the Depo Now group (n = 100) or an alternative Quick Start group (n = 250). Those assigned to the Depo Now group received their first injection of DMPA at the conclusion of their first visit, provided each was medically suitable for hormonal contraception and had a negative urine pregnancy test. Those randomized to the alternative Quick Start group were provided with their choice of pills, patch, or ring. Women were told to return to the clinic in 21 days to repeat the urine pregnancy test; those who were assigned to receive a bridge method then got their first injection of DMPA. Women were followed through two more DMPA cycles.3

To date, researchers have complete follow-up data on 231 women (Depo Now, 66; pills, 60; patch, 75; and ring, 30). According to the researchers, bivariate analyses revealed no difference in 21-day return rates between those who initiated DMPA immediately (64%) versus those who were randomized to use a bridge method (pills, 70%; patch, 79%; ring, 87%) to start DMPA. Among those who were randomized to the bridge method, 57% (n = 94) of those received their first DMPA injection, while 11% (17 out of 159) remained on their initial method or switched to a different method. Using an intention-to-treat analytic plan, continuation rates and satisfaction at the second (42% Depo Now, 35% pills, 35% patch, and 23% ring) and third (32% Depo Now, 22% pills, 27% patch, and 13% ring) injection visits were not significantly different between the groups. However, 19 unintended pregnancies did occur during the study period, with only one pregnancy occurring in the Depo Now group.3

One advantage of the Depo Now approach is that clinicians can provide same-day contraception to women, says Vaughn Rickert, PsyD, professor of clinical population and family health at the Mailman School. However, providers must be sure to complete the necessary prerequisites of checking for pregnancy and providing advance emergency contraception, with a second visit 21-28 days later to recheck for pregnancy.

"Returning to the clinic wasn’t a huge barrier for our patients," says Rickert. "It also provided an opportunity to check to see how each patient was doing with Depo."

How about patch use?

Researchers also are looking at a Quick Start approach when it comes to initiating use of the transdermal contraceptive (Ortho Evra, Ortho-McNeil Pharmaceutical, Raritan, NJ). Labeling for the patch calls for either "first-day" or "Sunday start" method initiation.6

Investigators at the University of Pittsburgh School of Medicine and Magee Womens Research Institute, both in Pittsburgh, conducted a study in which 60 women were randomized to initiate use of the contraceptive patch using Quick Start or on the first day of their next menses.7 Researchers 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.7 Reasons cited for not continuing with the patch were similar to those usually given for the Pill, including such side effects as breast tenderness and weight gain.7

Lead author Amitasrigowri Murthy, MD, MPH, director of the Division of Family Planning at Jacobi Medical Center, Bronx, NY, says one advantage of using the Quick Start approach with the patch lies in the ease of the counseling session. She says it is easier to have the patient apply the patch in the office, with a review of the calendar to explain the cycle of patch use.

Researchers found that about one-fourth of the women who discontinued patch use did so because they could not afford to pay for the contraceptive.

"Access to all methods of contraception by all women is still limited simply due to expense," say the researchers. "Those subjects who decided not to use the patch after the study proceeded to choose methods that were significantly less expensive and, unfortunately, possibly less effective."

References

  1. Pfizer. Depo-Provera Contraceptive Injection. Accessed at: www.pfizer.com/pfizer/do/medicines/mn_uspi.jsp#d.
  2. Westhoff C, Kerns J, Morroni C, et al. Quick Start. A novel oral contraceptive initiation method. Contraception 2002; 66:141.
  3. Rickert VI, Tiezzi L, Leon J, et al. Depo Now: Preventing unintended pregnancies among adolescents. Presented at the Society for Adolescent Medicine annual meeting. Boston; March 2006.
  4. Lara-Torre E, Schroeder B. Adolescent compliance and side effects with Quick Start initiation of oral contraceptive pills. Contraception 2002; 66:81-85.
  5. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 18th ed. New York: Ardent Media; 2004.
  6. Ortho-McNeil Pharmaceutical. Ortho Evra. Accessed at: www.orthoevra.com/html/pevr/full_prescribing.jsp.
  7. 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.