Long-acting reversible methods said superior in effectiveness

Family planners now have proof positive that the intrauterine device (IUD) and the contraceptive implant, two long-acting reversible contraceptives (LARC methods), are superior in their effectiveness, compared to the effectiveness of the contraceptive pill, patch, or ring.1

Women who used the pill, the patch or vaginal ring were 20 times more likely to have an unintended pregnancy than those who used an intrauterine device or implant, report researchers at Washington University School of Medicine in St. Louis.1 LARC methods were the most effective, and failure rates did not vary according to age, researchers note. Pill, patch, and ring methods were less effective, and failure rates in participants younger than age were twice as great as in women age 21 years, results indicate.1 Results of the large prospective cohort study, known as the Contraceptive CHOICE Project, were published in the May 24, 2012, issue of The New England Journal of Medicine.

"This study is the best evidence we have that long-acting reversible methods are far superior to the birth control pill, patch, and ring," says Jeffrey Peipert, MD, MPH, the Robert J. Terry Professor of Obstetrics and Gynecology at Washington University and co-author of the paper. "IUDs and implants are more effective because women can forget about them after clinicians put the devices in place."

More long-acting reversible contraceptives must be used if the United States is to decrease the number of unintended pregnancies, says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta. About 50% (3 million) of all U.S. pregnancies per year are unintended, a rate that is significantly higher than that in other developed countries.2

The effectiveness of IUDs and implants, also known as the "get-it-and-forget-it methods," is so high, and correct and consistent use is so nearly guaranteed, that extremely low pregnancy rates are found in all studies, says Hatcher, who presented on the subject at the 2012 Contraceptive Technology conferences.3

LARCs are best

Researchers enrolled 9,256 women; the first 7,486 women enrolled were included in the current paper. Of the women studied, 5,781 (77.2%) chose a LARC method. Participants were ages 14-45 and at high risk of unintended pregnancy. All women were sexually active or planned to become sexually active in the next six months, and they either were not using contraception or wanted to switch birth control methods. The women also said they did not want to become pregnant for the next 12 months.

Study participants could choose to use, at no cost, the IUD, implant, birth control pills, patch, ring, or contraceptive injection (depot medroxyprogesterone acetate [DMPA]). All women were counseled about the contraceptive methods, including their effectiveness, side effects, risks, and benefits. Participants were permitted to discontinue or switch methods as many times as desired during the study.

Researchers followed participants by telephone interviews at three and six months and every six months thereafter for the remainder of the study. During each interview, participants were asked about missed periods and possible pregnancy. Any participant who suspected pregnancy was asked to come in for a urine pregnancy test. Those with positive tests were asked if the pregnancy was intended and what contraceptive method, if any, was used at time of conception.

Researchers report 334 women became pregnant over the three-year study. A total of 156 pregnancies were due to contraceptive failure. The cumulative failure rates in the group of participants who used the pill, patch, or ring were 4.8%, 7.8%, and 9.4% at the end of years 1, 2, and 3, respectively; the corresponding rates in the group using IUDs or implants were 0.3%, 0.6%, and 0.9% (P<0.001). The failure rates among participants who used DMPA were similar to those among participants who used IUDs or implants (0.1%, 0.7%, and 0.7% for years 1, 2, and 3, respectively; P = 0.96), researchers note.1

Adolescents were at heightened risk for unintended pregnancy, data indicate. Participants under age 21 who used the pill, patch, or ring had almost twice the risk of unintended pregnancy as older women using the same methods, researchers note.

Check your counseling

Put the data from the CHOICE Project into your contraceptive counseling sessions so as to better inform women about the effectiveness of LARC methods. If more patients are counseled about these methods, a real impact can be made on unintended pregnancy rates, says Peipert.

"If there were a drug for cancer, heart disease, or diabetes that was 20 times more effective, we would recommend it first," Peipert notes. "Unintended pregnancies can have negative effects on women's health and education and the health of newborns."

References

  1. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. NEJM 2012; 366(21)40-49.
  2. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011; 84:478-485.
  3. Hatcher RA. Let's get serious about preventing unintended pregnancy. Presented at the 2012 Contraceptive Technology conferences. San Francisco and Boston; March 2012.