Which methods are winning in popularity?

More women may be moving toward use of the contraceptive vaginal ring, implant, and intrauterine device (IUD), but combined oral contraceptives (OCs) continue to lead as a top birth control choice. About 42% of respondents to the 2010 Contraceptive Technology Update Contraception Survey said more than half of their patients use OCs. While this number reflects a decrease from 2009's 57% level, clinicians say pills remain a popular choice with patients.

The numbers haven't changed much at the Family Planning Center of Ocean County in Lakewood, NJ, says Chris Ann Lemkan, APN-C, a nurse practitioner at the facility. If women can use it, the most popular method in still the birth control pill, Lemkan states.

While use of the contraceptive patch Evra (Ortho Evra, Ortho Women's Health & Urology, Raritan, NJ) and the vaginal ring NuvaRing (Merck & Co., Whitehouse Station, NJ) have increased in use in the last year at Casper-Natrona County Health Department in Casper, WY, about 70% of patients still use OCs, says Tia Hansuld, FNP, a nurse practitioner at the facility. Most patients choose the method because it is less expensive, she reports.

Check the options

More women are opting for the contraceptive vaginal ring, say survey respondents. About 92% offer or plan to offer the method, up from 2009's 88% figure.

The clients who like NuvaRing love it, observes Ingrid Silva, ANP, a nurse practitioner at El Paso County Department of Health and Environment in Colorado Springs, CO. It was a slower start as a method, but it has gained a positive response, she notes.

What is the best way to initiate contraceptive ring use? According to A Pocket Guide for Managing Contraception, teach the woman to insert and remove the ring in the office. Clinicians should ask women if they would like for the clinician to insert a ring following a pelvic exam to demonstrate just how little women will feel an inserted ring.1

Women also are choosing longer-acting methods, such as the contraceptive implant Implanon. (Merck & Co.) A single implant inserted under the skin of the upper arm, Implanon releases the progestin etonogestrel at an initial rate of 60 mcg per day, decreasing to 25-30 mcg per day by the end of year three. The method is effective for at least three years.1 It is considered a top-tier method in contraceptive effectiveness, along with the intrauterine device, female sterilization, and vasectomy.1 About 57% of survey respondents now offer the implant.

"So far this year, I have inserted 23 Implanons," says Marnie Schumacher, ARNP, a nurse practitioner at Grays Harbor County Public Health Department in Aberdeen, WA. "I actually have three clients that are on their second Implanon, the first one being in for three years, and they liked it so much they wanted a second one."

Clinicians at Thomas Jefferson Health District in Charlottesville, VA, also insert Implanons, but that number is not growing, says Leslie Steeves, CNM, a certified nurse midwife at the facility. The breakthrough bleeding experienced with the method is a still a significant issue for many women, says Steeves. "Although there are those that I am now taking out at three years and putting in another one, I wish I had a crystal ball to know who would do well on it and who wouldn't," she observes.

Counseling is an important point when it comes to successful use of the progestin-only contraceptive implant, according to Michael Policar, MD, MPH, associate clinical professor of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco (UCSF) School of Medicine and medical director of the UCSF Program Support and Evaluation for the California Family PACT (Planning, Access, Care, and Treatment) Program. Policar presented information on new contraceptive methods in a recent audio conference.2 Advise women that they will have fewer bleeding episodes, and that they will have the same or fewer bleeding days, said Policar. However, also tell them that their bleeding days/episodes will be unpredictable, and they might have more spotting days than before.2

Patch use drops

Use of the Evra contraceptive patch has dropped according to 2010 survey responses. Seventy-three percent say their facility now offers the option, down from 83% of 2009 survey respondents. This statistic continues a trend of decreased use. In 2005, 93% of respondents said their facility provided the method as a contraceptive option.

The Evra product label was revised in 2005, 2006, and 2008 due to the fact that the patch exposes women to higher levels of estrogen than most birth control pills. The 2008 labeling change included the results of an epidemiology study that found that users of the birth control patch were at higher risk of developing venous thromboembolism than women using birth control pills.3,4

The Evra patch might see competition. Agile Therapeutics of Princeton, NJ, has completed enrollment in its Phase III clinical trial of a transdermal contraceptive containing ethinyl estradiol (EE) and levonorgestrel (LNG). According to a pharmacokinetic study, the estrogen level in the AG200-15 patch EE dose is equivalent to an oral dose of about 30 mcg, while its LNG dose is comparable to approximately 100 mcg of an oral dose.5

The company also is developing a progestin-only transdermal contraceptive with an eye toward breastfeeding women who desire birth control, as well as for those women in which estrogen use is contraindicated. The patch under development is designed as a weekly patch using levonorgestrel as its progestin. Two formulations are being investigated: approximately 75 mcg/day and approximately 40 mcg/day.

References

  1. Zieman M, Hatcher RA, Cwiak C, et al. A Pocket Guide for Managing Contraception. Tiger, GA: Bridging the Gap Foundation. 2010.
  2. Policar M. Contraception 2009: new developments and applications. Accessed at http://www.training3info.org/admin/resources.
  3. Food and Drug Administration. FDA approves update to label on birth control patch. Press release. Accessed at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2008/ucm116842.htm.
  4. Boston Collaborative Drug Surveillance Program. Postmarketing study of ORTHO EVRA and levonorgestrel oral contraceptives containing hormonal contraceptives with 30 μg of EE in relation to non-fatal venous thromboembolism, ischemic stroke and myocardial infarction. Accessed at http://www.clinicaltrials.gov/ct2/show/NCT00511784.
  5. Archer DF, Stanczyk FZ, Rubin A, et al. Evaluation of exposure to ethinyl estradiol (EE) with a low dose combination transdermal contraceptive delivery system (AG200-15) compared to low-dose combination oral contraceptive. Fertil Steril 2010;94:S4-5.

Survey Profile

A total of 103 providers participated in the 2010 Contraceptive Technology Update (CTU) Contraception Survey, which monitors contraceptive trends and family planning issues among readers. A total of 767 surveys were mailed, with a response rate of 14.7%. Results were tallied and analyzed by AHC Media in Atlanta, publisher of CTU and more than 60 other medical newsletters and sourcebooks.

About 75% of responses came from nurse practitioners or registered nurses. Physicians represented about 12% of the responses, with health educators/counselors comprising less than 1% of the response group. About 12% listed other professions. About 82% of respondents identified themselves as care providers, with nearly 16% involved in administration and 2% in teaching.

More than half (62%) said they worked in public health facilities, with about 8% employed at private practice settings. About 9% listed student health centers as their place of employment, with about 5% working in hospitals. The remaining 16% reported employment in other settings.

When it comes to location of their employment, about 40% said they worked in an urban location. About 33% said they were employed in a rural area, while about 25% listed a suburban setting.