Clinical Review

UPDATE: contraception

OBG Manag. 2008 August;20(8):46-55

Lisa K. Perriera, MD

Mitchell D. Creinin, MD

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IN THIS ARTICLE

The patch and thromboembolism
Is the patch less effective in over-weight women?
Why not long-acting reversible contraception?

References

1. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect. 1998;30:24-29, 46.

2. Rosenberg MJ, Waugh MS, Long S. Unintended pregnancies and use, misuse and discontinuation of oral contraceptives. J Reprod Med. 1995;40:355-360.

3. Sibai BM, Odlind V, Meador ML, Shangold GA, Fisher AC, Creasy GW. A comparative and pooled analysis of the safety and tolerability of the contraceptive patch (Ortho Evra/Evra). Fertil Steril. 2002;77(2 Suppl 2):S19-S26.

4. Arhendt HJ, Nisand I, Bastianelli C, et al. Efficacy, acceptability and tolerability of the combined contraceptive ring, NuvaRing, compared with an oral contraceptive containing 30 microg of ethinyl estradiol and 3 mg of drospirenone. Contraception. 2006;74:451-457.

5. Oddson K, Leifels-Fischer B, de Melo NR, et al. Efficacy and safety of a contraceptive vaginal ring (NuvaRing) compared with a combined oral contraceptive:a 1-year randomized trial. Contraception. 2005;71:176-182.

6. van den Heuvel MW, van Bragt AJ, Alnabawy AK, Kaptein MC. Comparison of ethinylestradiol pharmacokinetics in three hormonal contraceptive formulations: The vaginal ring, the transdermal patch and an oral contraceptive. Contraception. 2005;72:168-174.

7. Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton LJ, 3rd. Trends in the incidence of venous thromboembolism during pregnancy or postpartum:a 30-year population-based study. Ann Intern Med. 2005;143:697-706.

8. d’Arcangues C. Worldwide use of intrauterine devices for contraception. Contraception. 2007;75(6 Suppl):S2-S7.

9. Long-term reversible contraception. Twelve years of experience with TCu380A and TCu220C. Contraception. 1997;56:341-352.

10. Sivin I, Schmidt F. Effectiveness of IUDs: a review. Contraception. 1987;36:55-84.

11. Rivera R, Chen-Mok M, McMullen S. Analysis of client characteristics that may affect early discontinuation of the TCu-380A IUD. Contraception. 1999;60:155-160.

12. Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra Infante F, Guzmán-Rodríguez R. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med. 2001;345:561-567.

13. Grimes DA. Intrauterine devices (IUDs). In:Hatcher RA, ed. Contraceptive Technology. 18th ed. New York: Ardent Media, Inc.;2004:495-530.

14. Sivin I, Stern J. Healthduring prolonged use of levonorgestrel 20 micrograms/d and the copper TCu 380Ag intrauterine contraceptive devices: a multicenter study. International Committee for Contraception Research (ICCR). Fertil Steril. 1994;61:70-77.

15. Kadir RA, Chi C. Levonorgestrel intrauterine system: bleeding disorders and anticoagulant therapy. Contraception. 2007;75(6 Suppl):S123-S129.

16. Wildemeersch D, Dhont M. Treatment of non-atypical and atypical endometrial hyperplasia with a levonorgestrel-releasing intrauterine system. Am J Obstet Gynecol. 2003;188:1297-1298.

17. Dhar KK, NeedhiRajan T, Koslowski M, Woolas RP. Is levonorgestrel intrauterine system effective for treatment of early endometrial cancer? Report of four cases and review of the literature. Gynecol Oncol. 2005;97:924-927.

18. Gardner FJ, Konje JC, Abrams KR, et al. Endometrial protection from tamoxifen-stimulated changes by a levonorgestrel-releasing intrauterine system:a randomised controlled trial. Lancet. 2000;356:1711-1717.

19. Lockhat FB, Emembolu JO, Konje JC. The efficacy, side-effects and continuation rates of women with symptomatic endometriosis undergoing treatment with an intra-uterine administered progestogen (levonorgestrel):a 3 year follow-up. Hum Reprod. 2005;20:789-793.

20. Toivonen J, Luukkainen T, Allonen H. Protective effect of intrauterine release of levonorgestrel on pelvic infection: three years’comparative experience of levonorgestrel-and copper-releasing intrauterine devices. Obstet Gynecol. 1991;77:261-264.

21. Backman T, Huhtala S, Blom T, Luoto R, Rauramo I, Koskenvuo M. Length of use and symptoms associated with premature removal of the levonorgestrel intrauterine system:a nationwide study of 17,360 users. BJOG. 2000;107:335-339.

22. Croxatto HB. Clinical profile of Implanon:a single-rod etonorgestrel contraceptive implant. Eur J Contracept Reprod Health Care. 2000;5(Suppl 2):21-28.

23. Chiou CF, Trussell J, Reyes E, et al. Economic analysis of contraceptives for women. Contraception. 2003;68:3-10.

Fast Track

Women who used the ring were happier with the ring than with the pill. Women who used the patch, however, were happier with the pill than with the patch.

Women randomized to the patch had a serum ethinyl estradiol level 1.6 times higher than women randomized to an OC and 3.4 times higher than women randomized to the ring

The copper IUD is FDA-approved for use in nulliparous patients

The authors report no financial relationships relevant to this article.

We’ve heard that troubling statistic: Approximately 50% of pregnancies in the United States are unintended. But did you know that one half of those unintended pregnancies occur in women who were using some form of birth control at the time of conception?¹ Such pregnancies are due to discontinuation of the method, incorrect use, or method failure.² The focus of this article is contraceptive counseling, with special attention to:

which methods of combination hormonal contraception women prefer
the controversy surrounding the contraceptive patch in regard to thromboembolic disease
long-acting reversible contraception (LARC), such as the intrauterine device (IUD) and the contraceptive implant, with an emphasis on how LARC is of benefit to both the patient and society.

The ultimate goal of good contraceptive counseling? To help women choose the easiest and most effective method with the fewest side effects.

In head-to-head comparison, women preferred the ring to the patch

Creinin MD, Meyn LA, Borgatta L, et al. Multicenter comparison of the contraceptive ring and patch. Obstet Gynecol. 2008;111:267–277.

The ethinyl estradiol/etonogestril vaginal ring (NuvaRing) and the ethinyl estradiol/norelgestromin patch (OrthoEvra)—both approved by the Food and Drug Administration (FDA) in 2001—are the only nonoral forms of combined hormonal contraception on the market. These methods are said to increase patient compliance and, potentially, efficacy, because they are nondaily forms of contraception.

Until recently, these methods had been compared only with the combination oral contraceptive (OC), but a recent trial compared them directly to each other. At the conclusion of the study, 71% of ring users and 26.5% of patch users planned to continue using the assigned method (P<.001).

This information should aid clinicians in counseling women about which combination hormonal method to choose.

Participants started out using the OC

The multicenter, randomized, controlled clinical trial comparing the patch and ring included 479 women who were using, and happy with, the combination OC. After rating their satisfaction with the OC, women were randomized to the patch or ring and given 3 months’ worth of product. Follow-up involved only two telephone calls and one visit at the end of the third cycle, because this degree of monitoring was thought to mimic clinical practice.

The percentages of women who completed three cycles of their assigned product were 94.6% and 88.2% in the ring and patch groups, respectively (P=.03). The most common reasons for early discontinuation in the ring group were discomfort and adverse effects. In the patch group, the most common reasons were adverse effects, skin irritation, and adherence problems.

Even after adjusting for age, education, and whether an OC was actively being used at the time the study began, patch users were twice as likely to discontinue the patch at the end of three cycles and seven times more likely to state that they did not want to continue the patch.

Adverse effects were greater than with the pill

Women switching from pill to patch were significantly more likely to report breast pain, nausea, skin rash, longer menstrual bleeding, and menstrual pain than women who switched from the pill to the ring (P<.001).

Women who switched from the pill to the ring were more likely to experience vaginal discharge (P=.003) and a larger amount of vaginal discharge than patch users (P<.001).

These findings are similar to those of previous studies that compared the patch with the pill, noting that breast discomfort, application-site reaction, and dysmenorrhea were more common in patch than pill users.³ Earlier studies also found the ring to be associated with complaints of vaginal discharge.^4,5

Findings may not be generalizable

The most important finding from this direct comparison is the difference in patient satisfaction between groups. Visual analog scales showed that women using the ring were happier with the ring than with the pill, whereas women using the patch were happier with the pill than with the patch (P<.001). Questionnaires revealed that women were more satisfied with the ring than they were with the patch, and were more likely to recommend the ring than the patch to a friend (P<.001).

Based on continuation rates, patient satisfaction, and adverse-effect profiles, women in this study clearly preferred the ring to the pill, and the pill to the patch. When using this information to counsel patients, however, it is important to recall that this population was specific. The women had been using an OC, with which they were happy. This study cannot necessarily be generalized to women who are just initiating combination hormonal contraception, but it can be helpful in counseling a patient who may want to switch from an OC to a method that involves nondaily dosing.