EXECUTIVE SUMMARY

Progestin-only contraceptives are safe and offer women flexible, non-estrogenic birth control options. However, their use lags behind that of other methods.

  • The only U.S. Medical Eligibility Criteria for Contraceptive Use Category 4 (condition represents unacceptable health risk if method is used) rating for progestin-only contraception is current breast cancer.
  • Data indicate no increase in cardiovascular events with use of progestin-only methods. For example, studies suggest no increase in venous thromboembolism with injection or pills. Data from observational studies show that progestin-only use is not associated with an increased risk of stroke or myocardial infarction.

Progestin-only contraceptives are safe
and offer women flexible, non-estrogenic birth control options. However, use lags behind that of other methods. Although more than 10 million U.S. women use oral contraceptives, just 0.4% currently use progestin-only pills (POPs).1

In 2012, it was estimated 1.3% of American women of reproductive age used the etonogestrel implant (Nexplanon, Merck, Whitehouse Station, NJ), and 4.5% used the contraceptive injection depot medroxyprogesterone acetate (DMPA).2 Although most U.S. women who use intrauterine contraception select a levonorgestrel device, use of both hormonal and nonhormonal IUDs is reported by just 10.3% of U.S. women.3

Possible Option for Some Women

Progestin-only methods represent an excellent option for women with common medical conditions that preclude estrogen use, says Melissa Kottke, MD, MPH, MBA, director of the Jane Fonda Center and associate professor in the Department of Gynecology and Obstetrics at Emory University School of Medicine. The only U.S. Medical Eligibility Criteria for Contraceptive Use Category 4 (condition represents unacceptable health risk if method is used) rating for progestin-only contraception is current breast cancer, Kottke notes. Category 3 (usually not recommended; clinical judgment and continuing access to clinical services are required for use) conditions vary somewhat by method, says Kottke, who spoke about progestin-only methods at the 2017 Contraceptive Technology conference in Atlanta.4 For example, for breast cancer, past history and no evidence of current disease for five years is considered a Category 3.

Research indicates no increase in cardiovascular events with use of progestin-only methods, says Kottke. Findings suggest no increase in venous thromboembolism with injection or pills.5 Data from observational studies show that progestin-only use is not associated with an increased risk of stroke or myocardial infarction.6,7

Hone Counseling Skills

Bleeding irregularities may occur in many women who use progestin-only methods. According to information from clinical trials, at one year of use, less than 10% of DMPA and levonorgestrel IUD users, and 25% of implant users, have regular monthly bleeding, while others experience various patterns from infrequent bleeding and amenorrhea to bleeding that is irregular, frequent, or prolonged.8-10 Use a handy infographic developed by the Centers for Disease Control and Prevention to help women successfully handle bleeding irregularities encountered with use of progestin-only methods, notes Kottke. (Get the chart at http://bit.ly/2AsYbqt.)

Overall, women indicate high satisfaction with using progestin-only contraception, but dissatisfaction and discontinuation of use may be associated with spotting or unscheduled bleeding.11 While researchers do not completely understand the exact causes of irregular bleeding with progestin-containing contraceptives, some have conducted studies to find effective therapies to manage such unscheduled bleeding. Researchers at the Washington University School of Medicine in St. Louis now are enrolling women using the contraceptive implant in a double-blind, randomized, placebo-controlled trial evaluating ulipristal acetate, a selective progesterone receptor modulator, as a potential treatment.

In the study, women will be randomized to receive either 15 mg of ulipristal acetate daily for seven days or placebo for the same duration. The investigators hope to show that the drug will decrease bleeding and spotting days in implant users with unscheduled bleeding when compared to placebo as assessed by daily bleeding diaries.

Concerns about weight gain can keep some women from initiating progestin-only contraceptives and can lead to early discontinuation among users. However, a 2016 review of 22 studies found limited evidence of body weight or body composition change with the use of progestin-only methods.12 The mean weight gain at six or 12 months was less than 4.4 lbs. for most studies.

By providing appropriate counseling about typical weight gain, clinicians may help reduce contraceptive discontinuation resulting from perceptions about weight gain.

REFERENCES

  1. Hall KS, Trussell J, Schwarz EB. Progestin-only contraceptive pill use among women in the United States. Contraception 2012;86:653-658.
  2. Daniels K, Daugherty J, Jones J, Mosher W. Current contraceptive use and variation by selected characteristics among women aged 15-44: United States, 2011-2013. Nat Health Stat Rep 2015;86:1-14.
  3. Kaiser Family Foundation. Intrauterine Devices (IUDs): Access for Women in the U.S. Fact sheet. Available at: http://kaiserf.am/2z1ICUo. Accessed Dec. 20, 2017.
  4. Kottke M. All by myself: The unassuming story of progestin only contraception. Presented at the 2017 Contraceptive Technology conference. Atlanta; November 2017.
  5. Lidegaard Ø, Milsom I, Geirsson RT, Skjeldestad FE. Hormonal contraception and venous thromboembolism. Acta Obstet Gynecol Scand 2012;91:769-778.
  6. Chakhtoura Z, Canonico M, Gompel A, et al. Progestogen-only contraceptives and the risk of stroke: A meta-analysis. Stroke 2009;40:1059-1062.
  7. Chakhtoura Z, Canonico M, Gompel A, et al. Progestogen-only contraceptives and the risk of acute myocardial infarction: A meta-analysis. J Clin Endocrinol Metab 2011;96:1169-1174.
  8. Fraser IS, Tiitinen A, Affandi B, et al. Norplant consensus statement and background review. Contraception 1998;57:1-9.
  9. Newton JR, D’arcangues C, Hall PE. A review of “once-a-month” combined injectable contraceptives. J Obstet Gynaecol (Lahore) 1994;4 Suppl 1:S1-34.
  10. Suvisaari J, Lähteenmäki P. Detailed analysis of menstrual bleeding patterns after postmenstrual and postabortal insertion of a copper IUD or a levonorgestrel-releasing intrauterine system. Contraception 1996;54:201-208.
  11. Zigler RE, McNicholas C. Un-scheduled vaginal bleeding with progestin-only contraceptive use. Am J Obstet Gynecol 2017;216:443-450.
  12. Lopez LM, Ramesh S, Chen M, et al. Progestin-only contraceptives: Effects on weight. Cochrane Database Syst Rev 2016;(8):CD008815.