Check methods with combined hormones

The contraceptive vaginal ring (NuvaRing, Merck & Co., Whitehouse Station, NJ) and patch (Ortho Evra, Ortho Women’s Health & Urology, Raritan, NJ). are two effective options for women who choose combined hormonal methods.

Use of the ring continues to climb, as more than 95% of respondents to the 2012 Contraceptive Technology Update Contraception Survey report availability now or soon at their clinics, a slight rise over 2011’s 91% figure.

NuvaRing is “pretty popular” at the University of Wisconsin — Eau Claire Student Health Center, notes Debbie Wright, MSN, OGNP, nurse practitioner at the facility. National sales figures for 2011 compiled by IMS Health, a Danbury, CT-based healthcare technology and information company, point to such popularity. In the category of hormonal contraceptives excluding the Pill, NuvaRing captured a little more than 63% of U.S. market share in 2011, with Evra sales at about 17%. Sales for the contraception injection depot medroxyprogesterone acetate (DMPA, Depo-Provera, Pfizer, New York City; Medroxyprogesterone Acetate Injectable Suspension USP, Teva Pharmaceuticals USA, North Wales, PA) registered about 19%.1

Conventional use of the ring follows a 28-day cycle. A woman inserts a new ring and keeps it in for three weeks, with one week in which the ring is removed, which allows for a withdrawal bleed. A new ring is inserted after the ring-free week.2

As with any birth control method, good counseling regarding potential problems can help women achieve success with the contraceptive vaginal ring. If a woman accidentally removes or expels her ring while removing a tampon, engaging in intercourse, or having a bowel movement, counsel that if less than three hours have passed, the ring should be rinsed with lukewarm water and re-inserted as soon as possible. If more than three hours have passed or there is uncertainty about the time period that it has been out, women should rinse and re-insert the ring, resuming the cycle. However, advise the patient to use back-up contraception for seven days and take emergency contraception as needed.3

How about the patch?

Each Ortho Evra patch contains 6 mg of norelgestromin, and 0.75 mg of ethinyl estradiol. It releases 150 mcg of norelgestromin and 20 mcg of ethinyl estradiol on a daily basis. It is designed to mimic the 28-day dosing regimen of oral contraceptives; women use three seven-day patches for one week each, then have a seven-day patch-free interval.2

The patch offers convenience, with the weekly patch regimen easier for some women to remember than the daily dosing of a combined oral contraceptive.2 The patch can be worn on the buttocks, upper arm, lower abdomen, or upper torso, excluding the breasts.2 Be sure patients will be comfortable wearing the patch, says Wright. “We have found that this younger generation does not like wearing the patch on the body,” observes Wright. “While they may shave their head, have tattoos, and do body modification, wearing the patch is not desirable.”

New patch in wings?

Use of the contraceptive patch declined in 2012, according to survey responses. A total of 70% of respondents said their facility provided the method, compared to 78% in 2011. While patch use continues to decline, the potential advent of a new transdermal contraceptive option might change usage.

Developed by Agile Therapeutics of Princeton, NJ, AG200-15 is an investigational combination hormonal contraceptive patch designed to deliver a low dose of ethinyl estradiol and levonorgestrel comparable to low-dose combination oral contraceptives. Agile has filed a New Drug Application with the Food and Drug Administration for AG200-15 and has registered the trademarked name Twirla.

In a phase III pivotal trial of AG200-15, results suggest the study drug had significantly greater compliance (defined as no missed days of contraception in the cycle) than an oral contraceptive.4 The data were presented at Association of Reproductive Health Professionals’ 2012 Annual Meeting.

Of 1,328 women (mean age, 26.4 years; 60% new hormonal contraceptives users; 46% non-Caucasian; 33% obese), 998 received the patch and 330 received an oral contraceptive for the first six study cycles. Women in the study were treated for one year (13 cycles) with the patch or for six cycles with the Pill, followed by seven cycles of patch use. Subjects recorded patch application and pill-taking on diary cards. Cycles with perfect compliance were defined as cycles with 21 days of patch wear without missed days or any patch worn for more than seven days or cycles with 21 days of pill-taking without days of missed pills.

Over the first six cycles, the percentage of cycles with perfect compliance was significantly higher in the patch versus the pill group (90.5% vs. 78.8%, P less than .001). Compliance with the patch improved over the six treatment cycles, while compliance with the Pill worsened over the six cycles.4

Research presented at the 2012 American College of Obstetricians and Gynecologists Annual Meeting indicates the investigational low-estrogen patch is as effective as conventional oral contraceptives. An additional finding of the trial is that the efficacy of the investigational patch did not decline in obese women.5


  1. IMS Health. Contraceptive Market Top 5 Products. Danbury, CT; August 2012.
  2. Nanda K. Contraceptive patch and vaginal contraceptive ring. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
  3. Cwiak C. In defense of the follow-up visit: missed pills, loose patches, slippery rings, and bleeding changes. Presented at the Contraceptive Technology Quest for Excellence conference. Atlanta; November 2012.
  4. Kaunitz A, Archer DF, Foegh M. Increased compliance with a low-dose combination contraceptive patch (AG200-15) compared with a low-dose combination oral contraceptive (COC) in a phase 3 clinical trial. Contraception 2012; 86(2):178.
  5. Kaunitz AM, Mishell DR, Foegh ML. Comparative Phase 3 Study of AG200-15, a Low-Dose Estrogen and Levonorgestrel Contraceptive Patch. Presented at the 60th Annual Clinical Meeting of the American College of Obstetricians and Gynecologists. San Diego; May 2012.