The Pill remains popular, despite newer options

You've discussed the latest birth control options with your female patient and touched on information on the contraceptive patch, vaginal ring, implant, and injection, as well as intrauterine contraception, barrier methods, and abstinence. The counseling also includes a discussion about oral contraceptives (OCs). Which method will your patient choose?

Look to the Pill, say respondents to the 2009 Contraceptive Technology Update Contraception Survey. More than half (57%) report more than 50% of their patients leave their office with OC prescriptions in hand, up from 2008's 42% figure.

"The NuvaRing [Merck & Co., Whitehouse Station, NJ] is well accepted, but the Pill is still by far the most often-used method," notes Mary Blasingame, RNP, APN, a nurse practitioner at Hot Spring County Health Department in Malvern, AR.

For women younger than 30, the Pill is the leading method of birth control, according to national data. By age 35, more women rely on sterilization.1

When it comes to new methods, many clinicians report the addition of the contraceptive implant Implanon (Merck & Co.) to their formularies. About 55% of survey respondents say their facilities were offering or planning to offer the contraceptive implant by the end of 2009, slightly up from 2008's 51% figure.

What are the features of Implanon? Highly effective and rapidly reversible, it requires no daily or coitus-related action. Implanon contains no estrogen, and it can be used during lactation.2 Its disadvantages include unscheduled vaginal bleeding, which clinicians might choose to describe as "irregularly irregular" cycles.2 To manage bleeding, consider such options as addition of oral estrogen or use of nonsteroidal anti-inflammatory drugs.2

Women do look hard at using Implanon because it is less to deal with, says Lenore Cappelluti, MSN, WHNP-BC, a nurse practitioner at Sheppard Air Force Base, Wichita Falls, TX. For success with the method, talk about the bleeding issues during the contraceptive counseling session, Cappelluti advises.

Even with careful counseling, some women might choose to forego the method due to bleeding issues. Many teens become disgusted with Implanon's breakthrough bleeding and ask for removal in six months, notes Sandra Ransom, RN, WHNP, a nurse practitioner at Planned Parenthood, Texas Central Region in Austin.

Few women at Wyoming County Health Department in Silver Springs, NY, are willing to use Implanon due to the irregularity and unpredictability of bleeding, and some don't like the idea of something in their arm, says Donna Gray, CNM, NP, a nurse practitioner and certified nurse midwife at the facility.

What about patch, ring?

Many family planning facilities now offer the vaginal ring and the contraceptive patch (Ortho Evra, Ortho Women's Health & Urology; Raritan, NJ). About 83% of 2009 survey respondents say their facilities are offering or plan to offer the Evra contraceptive patch (down slightly from 2008's 86%), with about 88% now offering or planning to offer the NuvaRing (down from 2008's 92% figure.)

The patch delivers 150 mcg of the progestin norelgestromin and 20 mcg of ethinyl estradiol per day. Pharmacokinetic data indicate that the release of ethinyl estradiol (EE) from this first-generation patch is associated with a substantially higher area under the curve for EE than low-dose oral contraceptives.3-6 Following the addition of this information to the Evra package insert, reports emerged that the method might be associated with a higher risk of thromboembolic disease than oral contraceptives.

Patients might mention hearing television reports about Evra's side effects, but after a discussion, these fears usually are relieved, says Blasingame.

NuvaRing releases 120 mcg of the progestin etonogestrel and 15 mcg of EE daily. NuvaRing may be purchased with a prescription at a drugstore or clinic. It costs about $15-$50 a month.

Deborah Mathis, MSN, CRNP, women's health administrative chief at the University of Pennsylvania Student Health Service in Philadelphia, says, "Our patients love the NuvaRing, they just do not like the price. The nurse practitioners in our practice are enthusiastic about NuvaRing and do much teaching, which encourages patients to try it. Once they try it, most are very happy with their choice."

The Pennsylvania student health center is facing the challenge of higher contraceptive costs following the 2005 federal Deficit Reduction Act, which tightened eligibility for nominally priced drugs. While 2009 federal legislation has restored the conditions enabling companies to offer deeply discounted contraception, many companies have not reinstituted nominal pricing.

Before the Pennsylvania student health center lost nominal pricing in December 2006, NuvaRing was its leading new start method, with more than 800 rings a month, reports Mathis. Since then, its numbers have significantly decreased, she states.

References

  1. Mosher WD, Martinez GM, Chandra A, et al. Use of contraception and use of family planning services in the United States: 1982-2002. Adv Data 2004; 350:1-36.
  2. Shulman LP. New developments in contraception: The single rod implant. Presented at the Contraceptive Technology conference. San Francisco; April 2008.
  3. 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.
  4. 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.
  5. 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 www.clinicaltrials.gov/ct2/show/NCT00511784.
  6. 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.