New contraceptives widen choices, but the Pill still is a top selection

Interest in contraceptive patch and vaginal ring continues to grow

(Editor’s note: This issue of Contraceptive Technology Update contains results from the 2004 Contraception Survey, which provides an overview of current family planning methods. Look inside for information on the transdermal contraceptive, the contraceptive vaginal ring, the contraceptive injection, intrauterine contraception, and oral contraceptives, as well as other reproductive health issues. Check the December issue for information on emergency contraception.)

While the contraceptive transdermal patch (Ortho Evra, Ortho-McNeil Pharmaceutical, Raritan, NJ) and the contraceptive vaginal ring (NuvaRing, Organon, West Orange, NJ) are gaining increased use among women, many providers report that oral contraceptives (OCs) remain a popular form of birth control.

Responses to the 2004 Contraceptive Technology Update Contraception Survey reflect the Pill’s continued popularity; 39% of survey respondents say more than half of their patients use OCs (compared with 35% in 2003), and about 24% say 26%-50% of patients are pill users, which falls in line with responses from the 2003 survey.

"The number of clients leaving the clinic on pills has stayed stable over the months; however, the number of clients staying on pills seems to fluctuate with each new method that comes on the market," notes Judy Nicksich, women’s health care nurse practitioner at Western Wyoming Family Planning, a not-for-profit family planning agency in Rock Springs, WY. She estimates more than 50% of her female patients leave her office using pills each month.

Since its November 2001 approval by the Food and Drug Administration (FDA), the Ortho Evra patch has gained an increasing share of the contraception option mix offered by family planning providers, CTU survey results indicate. More than 90% of 2004 survey respondents say their facilities are now offering or plan to provide the Evra contraceptive patch, a slight increase from 2003’s 88% figure. It now is the No. 1 prescribed birth control brand in the United States.1

"Ortho Evra took off like crazy here," says Stephani Cox, APN, CNP, DPS, director of patient services at Planned Parenthood Springfield Area in Springfield, IL. "We could not keep it in stock."

Each transdermal patch contains 20 mcg of the estrogen ethinyl estradiol and 150 mcg of the progestin norelgestromin, the primary active metabolite of norgestimate. Designed to be changed once a week and worn for three weeks, it consists of an adhesive medicated layer worn against the skin, protected by a waterproof polyester layer. Just as pill users take placebos or no pills during the fourth week, patch users go patch-free that week. A placebo patch for the patch-free week would be a welcome addition, says Nicksich.

"The only complaint that I consistently hear is that a placebo patch would be useful so that one is not forced to remember to start patches over again in seven days," she observes. "This seems to be the biggest issue with use."

With growing popularity for the patch, clinics are looking for lower prices to cover the increased demand for the new method. Cost of one cycle of patches is slightly more expensive than one cycle of brand pills, according to A Pocket Guide to Managing Contraception.2

"Many of our patients love Ortho Evra," says JoElle Thomas, WHCNP, nurse practitioner at Custer Family Planning, a not-for-profit family planning agency in Bismarck, ND. "We need to be able to give a lower cost."

According to information recently presented at the annual congress of the Brussels, Belgium-based European Contraception Society, Evra is a cost-effective method in women who are likely to experience poor compliance with combination OCs.3 In similar research presented at the 2003 Advances for Reproductive Health forum presented by the Washington, DC-based Association of Reproductive Health Professionals, scientists estimated significant cost savings for the patch based on data showing improved compliance that resulted in increased rates of pregnancy prevention.4

Most female patients at the Men’s and Women’s Health Clinic at Wyoming County Public Health Department, a public health facility in Warsaw, NY, like the patch; however, some have problems with adhesion, says Donna Gray, CNM, NP, director of family planning.

In clinical trials, less than 2% of birth control patches had to be replaced because of complete detachment, and less than 3% had to be replaced because of partial detachment.5 If a patch seems loose, lifts partially up, or falls off, women should be instructed to try to reapply it or apply a new patch immediately if the original patch has been off for fewer than 24 hours.6 No backup contraception is needed, and the woman’s patch change day will remain the same. If the patch is no longer sticky, has been stuck to itself or another surface, has other material stuck to it, or has become loose or fallen off before, it should not be reapplied.6 Single replacement patches are available through pharmacists.

To apply the patch, women should press down firmly on the patch with the palm of the hand for 10 seconds, and make sure that the edges stick well. To make sure adhesion is secure, instruct patients to run their finger around the edge of the patch.6

"If we can convince the clients to spend the extra 10 seconds to put the patch on correctly, they are loving it," says Cox.

About 72% of respondents to the 2004 CTU Contraception Survey say their facility is now offering or planning to offer the NuvaRing, a ranking that moves down slightly from 2003’s 75% mark.

More women eye ring

"Our number of clients using NuvaRing has grown steadily over the last six months or so," says Cox.

NuvaRing releases a continuous low dose of the estrogen ethinyl estradiol and the progestin etonogestrel at an average rate of 0.120 mg etonogestrel and 0.015 mg ethinyl estradiol per day over a 21-day period of use. With vaginal drug administration, absorption is unaffected by gastrointestinal disturbances, and there is no first-pass hepatic effect.7

Women may not be familiar with the anatomy or the physiology of the vagina; they may ask if the ring will get "lost" inside them or if they will able to feel the ring.7 Encourage patients to insert the ring in the exam room so they see that the device is easy to insert and remove, as well as comfortable to wear.7

"Patients are reluctant to use an intravaginal means of contraception," says Joe Childress, MD, an obstetrician/gynecologist in private practice in San Antonio. "However, if a patient will allow the device to be inserted in the office, she usually will use the ring."

References

1. IMS Health. National Prescription Audit. Fairfield, CT; April 2004.

2. Hatcher RA, Zieman M, Cwiak C, et al. A Pocket Guide to Managing Contraception. Tiger, GA: Bridging the Gap Foundation, 2004.

3. Sonnenberg FA, Hagerty CG, Price MJ, et al. Is Evra, a transdermal, once-weekly, combined contraceptive patch cost-effective compared to combined oral contraceptives? Presented at the Eighth Congress of the European Contraception Society. Edinburgh, Scotland; June 2004.

4. Sonneberg FA. Cost-effectiveness and health outcomes of the transdermal contraceptive patch. Presented at the 2003 Advances for Reproductive Health forum of the Association of Reproductive Health Professionals. La Jolla, CA; September 2003.

5. Zacur HA, Hedon B, Mansour D, et al. Integrated summary of Ortho Evra/Evra contraceptive patch adhesion in varied climates and conditions. Fertil Steril 2002; 77(2 Suppl 2):S32-S35.

6. Moore A, Clark B. The transdermal contraceptive system: A unique look at patch users. Female Patient 2004; 29:7-11.

7. Alexander NJ, Baker E, Kaptein M, et al. Why consider vaginal drug administration? Fertil Steril 2004; 82:1-12.