While use of new methods grows, OCs remain lead contraceptive choice

Ring, implant, and patch increase reversible options

While new methods are gaining favor with women, oral contraceptives (OCs) continue to be a popular method of birth control, say respondents to the 2008 Contraceptive Technology Update Contraception Survey. About 42% of survey participants report over half of their patients leave the office with an OC prescription in hand.

"We still have more than 50% combined oral contraceptive users; however, the NuvaRing and intrauterine contraception, especially Mirena, are being requested more often than last year," says Shirley LeBlanc, WHNP-BC, a women's health nurse practitioner at Planned Parenthood of Waco/Central Texas. NuvaRing, the contraceptive vaginal ring, is manufactured by Organon in West Orange, NJ. Mirena, the levonorgestrel intrauterine system, is manufactured by Bayer HealthCare Pharmaceuticals in Wayne, NJ.

About half (51%) of 2008 survey respondents said their facility now is offering or is planning to offer the contraceptive implant (Implanon, Organon; Roseland, NJ), which is slightly less than 2007's 53% statistic. A small, thin, hormonal contraceptive that is effective for up to three years, Implanon was approved in July 2006 by the Food and Drug Administration (FDA). The device, made of a soft medical polymer, contains 68 mg of the progestin etonogestrel. Implanted in the inner side of a woman's upper arm during an in-office procedure, the matchstick-sized device releases the drug in a low, steady dose. Its efficacy is comparable to sterilization.1

Implanon is in use at the Portales (NM) Public Health Office, reports Carol Morgan, RN, nurse manager; 10 devices had been inserted in 2008, with two more scheduled at press time, she says. "We have had to remove one Implanon due to excessive bleeding," says Morgan. "The others seem to be doing well."

While Implanon is available at the Knoxville (TN) Center for Reproductive Health, Corinne Rovetti, RNCS, FNP, family nurse practitioner and co-director, says little interest has been expressed for the method. "Our facility takes only limited insurances, and I believe that is the major obstacle to its use," says Rovetti. (Editor's note: Some insurance companies have yet to include coverage for Implanon. To determine coverage, go to www.implanon.com. Select "U.S. Consumers," then "Is Implanon right for me?" and then "Determining your health plan coverage.")

Why is implantable contraception a good choice for many women? Consider the following points listed by Lee Shulman, MD, professor in obstetrics and gynecology and chief of the Division of Reproductive Genetics in the Department of Obstetrics and Gynecology at the Feinberg School of Medicine of Northwestern University in Chicago, who presented at the 2008 annual meeting of the Association of Reproductive Health Professionals:

  • long duration of action;
  • not patient-dependent;
  • continuous steady-state steroid levels;
  • avoidance of first-pass effect from gastrointestinal absorption and hepatic metabolism;
  • high bioavailability.2

Potential candidates include women who desire long-term contraception, high effectiveness, rapid reversibility, and estrogen-free contraception, said Shulman. Contraindications include known or suspected pregnancy, current or past history of thrombosis or thromboembolic disorders, hepatic tumor or active liver disease, undiagnosed abnormal genital bleeding, known or suspected carcinoma of the breast or history of breast cancer, and hypersensitivity to the components of the implant.2

The contraceptive vaginal ring (NuvaRing, Organon; West Orange, NJ) continues to gain ground among women since its FDA approval in 2001. About 92% of 2008 survey participants say they now offer NuvaRing, similar to last year's figure.

NuvaRing remains quite popular with patients at the Family Planning of the Big Horns, a reproductive health care clinic in Sheridan, WY, states Ullainee Hartman, WHNP, a women's health nurse practitioner at the facility.

Women who have been satisfied with combined oral contraceptives and are interested in a nondaily method are more likely to continue using the contraceptive ring than the contraceptive patch (Ortho Evra, Ortho-McNeil Pharmaceutical; Raritan, NJ), results of a 2008 study indicate.3 To conduct the study, 500 women were randomly assigned to use the ring or the contraceptive patch for four consecutive menstrual cycles, starting with their next menses. Participants returned for a single follow-up visit during the fourth cycle for an evaluation, which included a questionnaire to assess acceptability and adverse effects.

Results suggest that women in the study were happier with the ring than the patch. Ring users reported fewer complications, and the majority preferred the ring to their pill.2 On the other hand, patch users were twice as likely to discontinue using the product by the end of the third cycle, and they were seven times more likely to say they had no wish to continue the method once the study was completed.3

Use of the contraceptive patch increased slightly in 2008. About 86% of survey participants said their facility offered the method, compared to about 84% in 2007. The patch is a popular choice among adolescents. An analysis of national surveys of trends in contraception prescriptions for 11- to 21-year-old females showed the patch and one oral contraceptive, Yasmin (Bayer HealthCare Pharmaceuticals; Wayne, NJ), accounting for a steadily increasing proportion of prescriptions.4

The FDA revised Ortho Evra's labeling in November 2005 with a bolded warning that the patch exposes women to higher total amounts of estrogen than a typical birth control pill containing 35 mcg estrogen. In September 2006, the drug's label was revised to include the results of two epidemiologic studies.5,6 One study found that the risk of nonfatal VTE events associated with use of the patch was similar to the risk associated with the use of OCs, while the other study showed an approximate twofold increase in the risk of VTE events in users of the patch compared to OC users.

The labeling was amended again in 2008 to include results of a third epidemiologic study, as well as additional information on the risk of VTE in patch users in one of the original studies.7,8 Results from the third study shows an increased risk for VTE among patch users compared to those taking OCs.7

References

  1. Raymond EG. "Contraceptive Implants." In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 19th revised edition. New York City: Ardent Media; 2007.
  2. Shulman L. New developments in contraception: The single-rod implant. Presented at the 2008 annual meeting of the Association of Reproductive Health Professionals. Washington, DC; September 2008.
  3. Creinin MD, Meyn LA, Borgatta L, et al. Multicenter comparison of the contraceptive ring and patch: A randomized controlled trial. Obstet Gynecol 2008; 111(2 Pt 1):267-277.
  4. O'Brien SH, Kaizar EE, Gold MA, et al. Trends in prescribing patterns of hormonal contraceptives for adolescents. Contraception 2008; 77:264-269.
  5. Jick SS, Kaye JA, Russmann S, et al. Risk of nonfatal venous thromboembolism in women using a contraceptive transdermal patch and oral contraceptives containing norgestimate and 35 mcg of ethinyl estradiol. Contraception 2006; 73:223-228.
  6. Cole JA, Norman H, Doherty M, et al. Venous thromboembolism, myocardial infarction, and stroke among transdermal contraceptive system users. Obstet Gynecol 2007; 109(2 Pt 1):339-346.
  7. Boston Collaborative Drug Surveillance Program. Postmarketing study of ORTHO EVRA and levonorgestrel oral contraceptives containing hormonal contraceptives with 30 mcg of EE in relation to nonfatal venous thromboembolism, ischemic stroke, and myocardial infarction. Accessed at www.clinicaltrials.gov/ct2/show/NCT00511784.
  8. Jick S, Kaye JA, Li L, et al. Further results on the risk of nonfatal venous thromboembolism in users of the contraceptive transdermal patch compared to users of oral contraceptives containing norgestimate and 35 microg of ethinyl estradiol. Contraception 2007; 76:4-7.