Extended OC use, Quick Start has arrived
As a family planning provider, your focus is to remove barriers to contraceptive use. Responses to the 2013 Contraceptive Technology Update Contraception Survey indicate that many clinicians have moved to remove one hurdle by adopting the Quick Start method of method initiation. More than 75% of respondents say they use Quick Start to start patients on combined hormonal contraceptives.
"I have been using Quick Start for 10 years at least," says Caroline Strzesynski, WHNP-BC, a clinician at Wood County Community Health & Wellness Center in Bowling Green, OH. "It is an excellent option for pregnancy prevention; otherwise, women get pregnant waiting for a menstrual period to start their birth control method."
Such practice is upheld by the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 (U.S. SPR).1 The U.S. SPR clarifies that all methods may be initiated at any time in the menstrual cycle if the provider is reasonably certain that the woman is not pregnant.2
According to the U.S. SPR, a provider can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets any of the following criteria:
- has not had intercourse since last normal menses;
- or has been correctly and consistently using a reliable method of contraception;
- or is within seven days after normal menses;
- or is within four weeks postpartum (non-lactating);
- or is within the first seven days postabortion or miscarriage;
- or is fully or nearly fully breastfeeding, amenorrheic, and less than six months postpartum.1
Quick Start is preferred
When it comes to combined pills, Quick Start is preferred because other combined oral contraceptive initial protocols generally have a time gap between the time of prescription and the time the patient begins taking it. Research indicates as many as 25% of women who use other protocols fail to take the pills as instructed because they conceive in the interim, fail to fill the prescription, or worry about taking the Pill.3,4 (The New York City-based Reproductive Health Access Project, a reproductive health advocacy organization, has developed a Quick Start algorithm for different methods. Download a version of the tool at http://bit.ly/1fWSNH2.)
What's your practice when it comes to prescribing extended or continuous regimen pills? About 35% of 2013 survey respondents reported an uptick in use. About 55% of 2012 survey respondents saw increase in such regimens.
A new option in extended regimen pills came in April 2013 when the Food and Drug Administration approved Quartette (Teva Pharmaceuticals, North Wales, PA). Quartette incorporates an ascending-dose approach, with 20, 25 and 30 mcg of ethinyl estradiol, combined with 150 mcg of levonorgestrel over 84 days, followed by seven days of 10 mcg of ethinyl estradiol alone.
Current extended regimen pills include four brands of 30 mcg ethinyl estradiol/150 mcg levonorgestrel pills, packaged as 84 active pills and seven placebo pills: Seasonale and Jolessa (Teva Pharmaceuticals), Quasense (Actavis, Parsippany, NJ) and Introvale (Sandoz, Princeton, NJ). There are three brands of 30 mcg ethinyl estradiol/150 mcg levonorgestrel and 10 mcg ethinyl estradiol pills, packaged as 84 active pills and seven low-dose estrogen pills: Seasonique and Camrese (Teva Pharmaceuticals) and Amethia (Actavis). There are three brands of 20 mcg ethinyl estradiol/100 mcg levonorgestrel pills and 10 mcg pills, packaged as 84 active pills and seven low-dose estrogen pills: LoSeasonique and CamreseLo (Teva Pharmaceuticals) and Amethia Lo (Actavis).
There are two continuous regimen pills, containing 20 mcg ethinyl estradiol/90 mcg levonorgestrel, packed as 28-day packs with no hormone-free interval: Lybrel (Wyeth Pharmaceuticals, Philadelphia) and Amethyst (Actavis).5
Check pregnancy rates
While newer pill regimens potentially might improve efficacy and alter bleeding profiles compared to the standard 21/7 dosing strategy, few data on comparative pregnancy rates with these regimens are available, reports a new paper on the subject.6 In a retrospective analysis, real-world pregnancy rates were lower with 84/7 regimens versus 21/7 and 24/4 regimens.6 One-year pregnancy rates were significantly lower with 84/7 regimens than with 21/7 regimens (4.4% versus 7.3%; p less than .0001) and 24/4 (4.4% versus 6.9%, p less than .0001) regimens.
Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles, is "intrigued but not surprised" by the retrospective analysis's findings. "In one study of 1.7 million women filling their first pill prescription, we found that women using the three-month products were more likely to refill their prescriptions on time for a year than were women given monthly cycles of pills," says Nelson. "The convenience of getting supplies may add to the biological ovarian suppression to reduce pregnancy rates."7
Use counseling tips
What are some important talking points to use when discussing extended or continuous methods? According to information presented by Lee Shulman, MD, chief of the Division of Obstetrics and Gynecology-Clinical Genetics and Anna Lapham Professor of Obstetrics and Gynecology at the Northwestern University Feinberg School of Medicine in Chicago, such regimens offer the following advantages and benefits:
- Alleviate menstruation-related conditions.
- May reduce some side effects.
- Offer convenience.
- Require less need for hygiene products.
- Unscheduled breakthrough bleeding might occur, but should lessen over time.8
- Counsel women to contact you if they experience any of the following, advised Shulman:
- heavy bleeding;
- nausea with vomiting;
- severe headaches;
- mood changes;
- suspect pregnancy.8
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC). U.S. Selected Practice Recommendations for Contraceptive Use, 2013: adapted from the World Health Organization selected practice recommendations for contraceptive use, second edition. MMWR 2013; 62(RR-05):1-60.
- ACOG Committee Opinion No. 577: Understanding and using the U.S. Selected Practice Recommendations for Contraceptive Use, 2013. Obstet Gynecol 2013; 122(5):1132-1133.
- Westhoff C, Kerns J, Morroni C, et al. Quick start: novel oral contraceptive initiation method. Contraception 2002; 66(3):141-145.
- Nelson AL. Combined oral contraceptives: update 2012. Presented at the Contraceptive Technology: Quest for Excellence conference. Atlanta; November 2012.
- Jacobson JC, Likis FE, Murphy PA. Extended and continuous combined contraceptive regimens for menstrual suppression. J Midwifery Womens Health 2012; 57(6):585-592.
- Howard B, Trussell J, Grubb E, et al. Comparison of pregnancy rates in users of extended and cyclic combined oral contraceptive (COC) regimens in the United States: a brief report. Contraception 2014; 89(1):25-27.
- Nelson AL, Westhoff C, Schnare SM. Real-world patterns of prescription refills for branded hormonal contraceptives: a reflection of contraceptive discontinuation. Obstet Gynecol 2008; 112(4):782-787.
- Shulman LP. Extended- and continuous-cycle oral contraception: finding the right choice for the right patient. Presented at the Association of Reproductive Health Professionals Reproductive Health 2013 conference. Denver; September 2013.