An update on long-term contraception methods
An update on long-term contraception methods
This activity is provided by Haymarket Medical Education (HME) in collaboration with Medical Education Resources (MER).
Release Date: August 15, 2014
Expiration Date: August 14, 2015
Estimated time to complete the educational activity: 30 minutes
Statement of Need: With the advent of the Patient Protection and Affordable Care Act, insurance will cover more contraceptive options for more women. Health-care providers of all types need to be familiar with these options so that they can help patients of varying ages, medical risk factors, and childbearing plans choose the most appropriate method of long-term birth control.
Target Audience: This activity has been designed to meet the educational needs of primary-care health-care professionals who treat women using or seeking to use long-term contraception.
Learning Objectives: After completing the activity, the participant should be better able to:
- Compare several long-acting reversible contraceptive methods available in the United States
- Discuss synthetic hormones used in oral contraception
- Analyze risks associated with the use of specific long-term contraceptive methods
- Interpret case-based scenarios for application in everyday practice
Deanna Bridge Najera, MPAS, MS, PA-C, family-practice provider
Keystone Health Farmworker Program, Gettysburg, Pa.
Physician Credit: HME is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Credit Designation: HME designates this enduring material for a maximum of 0.5 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Nursing Credit: MER is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Credit Designation: This CE activity provides 0.5 contact hour of continuing nursing education.
MER is a provider of continuing nursing education by the California Board of Nursing Registered Nursing, Provider #CEP 12299, for 0.5 contact hour.
American Academy of Physician Assistants (AAPA)
The AAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 0.5 hour of Category I credit for completing this program.
In accordance with the ACCME Standards for Commercial Support, HME requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any commercial interest. HME resolves all conflicts of interest in an effort to ensure independence, objectivity, balance, and scientific rigor in all its educational programs. Furthermore, HME seeks to verify that all scientific research referred to, reported, or used in a CME/CE activity conforms to the generally accepted standards of experimental design, data collection, and analysis. HME is committed to providing its learners with high-quality CME/CE activities that promote improvements in health care and not those of a commercial interest.
The faculty reported the following financial relationships with commercial interests whose products or services may be related to the content of this CME activity:
|Name of faculty||Reported Financial Relationship|
|Deanna Bridge Najera, MPAS, MS, PA-C||No relevant financial relationship|
The planners and managers for this program reported the following financial relationships with commercial interests whose products or services may be related to the content of this CME activity:
HME planners and managers have no relevant financial relationships to disclose.
MER planners and managers have no relevant financial relationships to disclose.
Disclosure of Unlabeled Use:This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. HME and MER do not recommend the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Method of Participation:There are no fees for participating in and receiving CME/CE credit for this activity. During the period of August 2014 through August 2015, participants must:
- Read the learning objectives and faculty disclosures;
- Study the educational activity;
- Submit the post-test online (clinicians may register at www.mycme.com)
- Complete the evaluation form online
A statement of credit will be issued only upon receipt of a completed activity evaluation form and a completed posttest with a score of 70% or better.
Disclaimer: The content and views presented in this educational activity are those of the authors and do not necessarily reflect those of HME or MER. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient's conditions and possible contraindications on dangers in use, review of any applicable manufacturer's product information, and comparison with recommendations of other authorities. The information presented in this activity is not meant to serve as a guideline for patient management.
HOW TO TAKE THE POST-TEST: Click here after reading the article to take the post-test on myCME.com.
By Deanna Bridge Najera, MPAS, MS, PA-C
Since the first hormonal contraceptive was introduced in 1961,1 a plethora of brands in 14 broad categories have been developed.2 Despite all these options, it is estimated that half of all pregnancies in the United States are unintended, 3 with approximately 40% of those unintended pregnancies ending in abortion.4
With the advent of the Patient Protection and Affordable Care Act, contraception will be covered without a co-pay by in-network providers, as defined in this excerpt from a list of preventive health services for women covered by plans participating in the U.S. government's Health Insurance Marketplace:
“(Food and Drug Administration [FDA])-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt ‘religious employers.'”5
Contraception is often considered the purview of the women's-health provider. However, with more individuals now having access to a greater number of contraceptive options, a broader array of clinicians may be involved in prescribing or at least answering questions and guiding patient choices.
From a brief interaction in an emergency setting, to the pediatric patient making adult choices, to the hematologist diagnosing a hypercoagulable state, all providers benefit from knowing what method of contraception their patients are using or should be using.
Basics of contraception
In the United States, the most common methods of contraception are combined oral contraception, containing the hormones progestin and estrogen (usually referred to as birth-control pills or simply “the Pill”), followed by female sterilization and then the male condom.2
Hormonal methods rely at least on progestin, which uses a negative feedback loop to inhibit ovulation. Progestin inhibits luteinizing hormone, which prevents the release of the follicle, makes the uterine lining thin and less likely to support implantation, and thickens cervical mucus to slow sperm.6
Estrogen is used in combined oral contraceptives to help prevent ovulation by targeting follicle-stimulating hormone and luteinizing hormone and also to stabilize the endometrium and reduce breakthrough bleeding.
The progestins used thus far in contraception fall into four basic groups (Table 1). Norethindrone, the first to be developed, is generally well tolerated, but users are prone to breakthrough bleeding.
Table 1. Progestins by category7
|First generation||Well-tolerated, but lower doses associated with breakthrough bleeding||Norethindrone|
|Second generation||Long half-life, more androgenic activity (better for libido, worse for hirsutism/acne/lipids)||Levonorgestrel|
|Third generation||Same progestational activity with decreased androgenic activity||Desogestrel|
|Fourth generation||Anti-androgenic properties||Drospirenone|
In order to try to reduce the bleeding, a second-generation progestin, levonorgestrel, was developed. Its additional androgenic properties improve libido but worsen hirsutism, acne, and dyslipidemia.
Desogestrel and other third-generation progestins have the same effectiveness as previous progestins but with less androgenic activity, and therefore, less effect on skin and hair. The fourth-generation progestin drospirenone has anti-androgenic properties.7
Other contraceptive methods utilize spermicidal agents with or without a barrier. In addition to the male condom, contraceptive products in this category include the female condom, the diaphragm, and the vaginal contraceptive sponge.
These devices are all used only during intercourse and are removed afterward; this article will focus on longer-term contraceptive methods.
Patient scenario #1: A 16-year-old is referred to your clinic after requesting emergency contraception from the local pharmacy. She has never had a gynecologic exam before.
According to the American Congress of Obstetricians and Gynecologists (ACOG), long-acting reversible contraception (LARC) is the first-line treatment for all women and adolescents.8 This includes intrauterine devices (IUDs)—also referred to as an intrauterine system (IUS) or intrauterine contraceptives (IUCs)—and the subdermal implant. IUDs and implants are considered extremely effective, with less than 1 pregnancy per 100 women using these methods for one year.9
Three IUDs are currently available in the United States, two hormonal and one hormone-free. The hormonal systems contain levonorgestrel in two strengths (13.5 mg or 14 mcg/day, known as levonorgestrel-14, and 52 mg or 20 mcg/day, known as levonorgestrel-20).These devices are FDA-approved for use for 3 years and for 5 years, respectively.10
The hormonal IUDs have been shown to reduce menstrual bleeding and will often result in secondary amenorrhea, making them an excellent option for women who suffer from menorrhagia.11,12
IUD insertion is contraindicated in women with known uterine defect, but post-licensure studies have shown that the hormonal IUD can be used in the presence of uterine fibroids, albeit with the possibility of higher expulsion rates.13
Other FDA-listed contraindications for hormonal IUDs are similar to those for other hormonal agents and include cervical or uterine cancer or current infection.14
The copper IUD has been available in some form for more than 20 years. It is FDA-approved for 10 years of use, although it is likely effective for 12 years and possibly up to 20 years.15,16
Copper, a known natural spermicide, is used in various devices internationally for prolonged contraception. The copper IUD can be used off-label for emergency contraception because it is immediately effective, although access to this method of emergency contraception has previously been very limited.10
Because the copper IUD is hormone-free, it is safe for use in women who suffer from migraines with aura, uncontrolled hypertension, hypercoagulable states, or other conditions that make hormonal methods ill-advised.
The only conditions that are contraindications for the copper IUD are an abnormally shaped uterus, active cervical cancer, and thrombocytopenia associated with systemic lupus erythematosus. Theoretically, Wilson's disease would also be a contraindication to a copper IUD, although studies have not been done to prove this.17
Women who already suffer from menorrhagia usually have only minor, if any, improvement in their symptoms and some women will complain of increased bleeding and irregular menses with the copper IUD.18
Contrary to popular belief, IUDs do not increase the risk of pelvic inflammatory disease (PID) as long as there are no overt signs of infection at time of insertion and particular care is taken in the first month of use when infection risk is highest, such as adding a barrier method (preferably condoms, but a cervical cap or diaphragm can also be used).15
In addition, IUDs can be used by women who have a history of PID or ectopic pregnancy or who are not in a monogamous relationship.6 If PID does develop, the IUD does not necessarily need to be removed, although close follow-up is necessary.
IUDs can be placed immediately postpartum or post-abortion, or at a 6-week follow-up appointment. Moreover, there is no increased risk of ectopic pregnancy with IUD placement.19
The following methods and procedures have been studied to reduce pain with IUD insertion, although a Cochrane review showed no significant improvement associated with them: insertion during menstruation, administration of 800 mg of ibuprofen 30 minutes before procedure, off-label use of 400 mcg of misoprostol buccally 2 hours before procedure, and/or use of a paracervical block.20
Simple measures such as playing music of a patient's choice or having a friend or loved one in the room to comfort her can be of benefit without any side effects. Pain with insertion can also be related to the size of the IUD itself, which is especially important for nulliparous patients or those with a stenosed cervix due to surgery or other procedures (Table 2).
Table 2. Comparison of long-acting reversible contraception (larc) methods
|Type||Size||FDA-approved length of use||Contraindications|
|Levonorgestrel-14 IUD||28 mm x 30 mm; insertion tube 3.8 mm in diameter||3 years||Abnormally shaped uterus, acute cervicitis/pid, hepatic disease, progestin-dependent cancer, lupus with apla, unexplained vaginal bleeding, headache with aura|
|Levonorgestrel-20 IUD||32 mm x 32 mm; insertion tube 4.4 mm in diameter||5 years||Abnormally shaped uterus, acute cervicitis/pid, hepatic disease, progestin-dependent cancer, lupus with apla, unexplained vaginal bleeding, headache with aura|
|Copper IUD||32 mm x 36 mm||10 years||Abnormally shaped uterus, acute cervicitis/pid, lupus with severe thrombocytopenia, unexplained vaginal bleeding|
|Subdermal implant||40 mm x 2 mm||3 years40 mm x 2 mm||Hepatic disease, progestin-dependent cancer, unexplained vaginal bleeding, headache with aura|
For the patient in scenario #1, the first step would be to assess her pregnancy plans. It is important to remember that it is the job of the provider to respect the patient's autonomy,21 and if she is trying to become pregnant (as long as no laws are being broken and safety is not an issue), she should be started on prenatal vitamins and encouraged to undergo testing for sexually transmitted infections (STIs).
If she does not want to get pregnant, then LARC is the first-line option, and questions regarding her menstrual cycle should follow. If this patient suffers from menorrhagia or dysmenorrhea, a hormone-bearing IUD or contraceptive injection has been shown to be best for suppressing heavy bleeding.11,12,16
Although IUDs should not be inserted in women who have overt signs of cervicitis, testing prior to insertion is not required, meaning that vaginal exams are also not needed.Whereas all sexually active individuals should be tested for STIs, requiring an exam before the initiation of any type of contraception is not required.22
The new recommendations regarding cervical cancer screening have pushed the age of the first Pap smear to 21, regardless of the age of sexual debut.23 This is yet another reason to delay forcing patients to have what can be viewed as an invasive procedure.
Although guidelines for cervical cancer screening have extended the interval for Pap smear testing to once every 3 years (or 5 years with co-testing for human papillomavirus),23 annual exams should still be encouraged so that contraception and STI testing can be reviewed.
For those patients who are not getting an IUD but should still be screened for STIs, self-collected vaginal swabs are just as accurate, if not more so, for chlamydia and gonorrhea.24
Even female, first-morning-void urine samples can be submitted for polymerase chain reaction (PCR) for these two infections.24 Patients should also be reminded that oral HIV testing is available over-the-counter; cheek swabs produce results within 20 minutes.
The subdermal implant used in the United States contains 68 mg of etonogestrel. After the device has been placed in the upper arm, the average release rate is 40 mcg/day by the end of the first year and gradually drops over the 3 years of use for which the device is FDA-approved. The latest version of the implant contains barium to make it easier to visualize on a variety of imaging modalities.10
Before inserting the implant into or removing it from a patient, the provider must have attended an approved training course
Insertion is done with a preloaded device that places the 40-mm x 2-mm rod subdermally; removal consists of a single stab incision at one end of the rod. Both procedures are performed using local anesthesia. A topical anesthetic such as lidocaine plus epinephrine also can be used prior to insertion or removal.
Because the rod contains hormones, the same contraindications exist for the implant as for other methods of hormonal contraception. Subdermal implants have been shown to result in some weight gain, another consideration for patients.25.
Most women using this method report abnormal menstrual patterns with variable amounts of bleeding. Patients who suffer from keloid scarring may not be ideal candidates for subdermal implant because keloids occur whenever there is damage to the skin; inserting an implant could cause a keloid to form, although no specific contraindications regarding keloids exist.
Patient scenario #2: A 42-year-old woman comes in wondering what form of contraception she should be using. She has been receiving progestin injections but is worried about the effect they may have on her bones.
Depot medroxyprogesterone acetate (DMPA) comes in two forms: 150 mg for intramuscular injection and 104 mg for subcutaneous injection. DMPA is considered a LARC and is considered to be very effective, demonstrating effectiveness >92% of the time.6
Regardless of which dosage is used, injections are given every 3 months and result in decreased menstrual flow and often complete cessation of menses as well as reduction in sickle cell crises.16
DMPA is the only contraceptive method of those discussed here that can result in delayed return to fertility after discontinuation. That can be ameliorated by switching to a more easily reversible agent (oral contraceptive pills, transdermal patch, or vaginal ring) in order to try to induce regular cycles more rapidly when pregnancy is desired.
The subcutaneous DMPA injection can be administered by the patient herself, if desired.26 Some women report that the injection site becomes thickened and fibrous,27 which again calls into question use of this method in women with keloids.
Weight gain is the biggest concern for women who receive the injection. While studies have only shown an average weight gain of 5 lb in the first year, the more overweight a woman is before starting DMPA, the more likely she is to gain more weight.25
FDA labeling includes a “black box” warning regarding loss of bone mineral density (BMD) with prolonged use of DMPA; the FDA recommends limiting its use to 2 years but both the World Health Organization and ACOG support the long-term use of this method.16,28
The amount of bone loss seen with DMPA is similar to that seen during pregnancy and lactation, and BMD returns to baseline after cessation.6
The only time to be cautious regarding the use of DMPA is when a patient is approaching menopause; supplementation with calcium and vitamin D can be done at any age and, of course, exercise is always recommended to improve bone health,16 but it may be in the patient's best interest to change to another method.
Discussing the risk of continuing contraception versus the risk of pregnancy with patients is important, particularly as they approach menopause. Progestin-only methods can be safely used up to age 55 years, at which point a non-hormonal method should be implemented. Estrogen-containing products should be used only by women who have no cardiovascular risk factors.29as been amenorrheic for 1 year, it is safe to assume that she is postmenopausal and thus can discontinue contraception. Be sure to remind these patients that even though contraception is no longer required, they remain at risk of contracting STIs, and barrier methods and testing are still recommended.
For the patient in scenario #2, a discussion of her family history and personal risk factors for osteoporosis would be prudent. If she has risk factors and/or is still concerned, changing to a different progestin-only method, such as an IUD implant or a progestin-only pill, would be advisable.
Contraindications to hormonal contraception
Patient scenario #3. A 27-year-old woman comes in wanting to discuss changing her contraceptive. She made the appointment after she saw advertisements indicating that her current brand of pills is associated with an increased risk of clot or stroke.
The risk of venous thromboembolism (VTE) is one of the primary concerns that both patients and providers have regarding hormonal contraception. Traditionally, this risk has been linked to the estrogen content, which has been reduced over time to a range of 20–30 mcg for the vast majority of combined oral contraceptives.30
However, studies also have shown that the type of progestin in oral contraceptives pills also contributes to the VTE risk, with levonorgestrel associated with the lowest risk, followed by gestodene, drospirenone, and desogestrel, in ascending order of risk.30
Nevertheless, VTE risk must be viewed and explained in relation to the risk associated with pregnancy and postpartum states. This can also be related to patients using the “You Decide” toolkit, which can be accessed through the Association of Reproductive Health Professionals' website (bit.ly/1vaFOIy).
Any condition that results in a hypercoagulable state is considered a contraindication to hormonal contraception, although the relative risk may differ based on the condition and the method. The World Health Organization and Centers for Disease Control and Prevention have each developed medical eligibility criteria for contraceptive use that include specific health conditions and the risk per broad categories (combined oral contraceptives, injectable progestin, progestin-only implant/IUD, and hormone-free IUD). 14,16
In general, if a patient has any of the following conditions, a hormonal contraceptive is contraindicated: active breast cancer, cirrhosis, liver tumors, ischemic heart disease, migraines with aura, and systemic lupus erythematosus with antiphospholipid antibodies (or unknown antibody status).
Choosing an oral contraceptive pill
A multitude of brands of oral contraceptive pills with a variety of hormone combinations and strengths are available. Providers often prefer brands with which they have the most experience. In general, the product chosen should minimize the risk of side effects for the patient while remaining affordable.
To reduce risks of thrombosis, nausea, breast tenderness, and headache, a lower-dose estrogen or estrogen-free pill should be selected. To reduce breakthrough bleeding, pills containing a higher level of estrogen or a more potent progestin can be prescribed. To minimize androgenic effects and avoid dyslipidemia, a third-generation progestin or low-dose norethindrone or ethynodiol diacetate can be used.31
Patients should be instructed on the importance of taking the pill at the same time every day; this practice is even more vital with the very-low-dose pills and progestin-only pills.
Having a full week of placebo pills for a withdrawal bleed has been shown to be too long for some women who have shortened menstrual cycles resulting in early follicle development and an increased risk of pregnancy.32
Owing to this, many brands are now available with only 4 days of hormone-free interval (placebo pills) or none at all. Any brand of oral contraceptive pills can be “strung together” (off-label) to accomplish this, although brands with extended regimens are available to improve compliance.
An increasing number of patients are undergoing gastric bypass surgery and the efficacy of oral contraceptive pills in this population has been called into question due to decreased gastric absorption, but the limited studies available have shown no significant difference in serum hormone levels between oral-contraceptive users who have and have not undergone gastric bypass surgery.33
However, patients with gallbladder disease and inflammatory bowel disease should be encouraged to avoid oral contraceptive pills.
The vaginal contraceptive ring is a flexible, clear band that is FDA-approved to be worn intravaginally for 3 weeks and then removed for 1 week to allow for withdrawal bleeding. Each ring contains 35 days of hormone, meaning that it can be used off-label for a full month and removed and replaced on the same day, improving compliance.6
The device should be inserted behind the pubic bone as deep in the vaginal cavity as possible but it does not have to go around the cervix. It can be worn during sex and usually stays in place, although the woman or her partner should check to make sure it is still in the vaginal vault after sexual activity.
If the ring does comes out, advise the patient to simply rinse it with warm, not hot, water and to reinsert it immediately, despite the fact that it can be out for 3 hours before hormone levels start to drop.6
Some women express concern about placement of the vaginal ring; it helps to point out that it sits in the same place as a tampon. In fact, a tampon applicator with the tampon removed can be used to assist with insertion of the vaginal ring.
Having an intact hymen is the only additional contraindication to vaginal-ring use beyond the risks associated with any hormonal option.
A single brand of contraceptive transdermal patch currently is available in the United States. It is FDA-approved for 1 week of continuous wear, after which it is removed and replaced. That is repeated for a total of three cycles; the patch is then left off for the menstrual week.
Each patch contains 9 days of active medication but that can be hard to “track” through the month.6 Patients need to be reminded to shift the location of the patch over their body—torso, upper arms, abdomen, and buttocks (the breasts should be avoided)—in order to minimize skin irritation.
Those with eczema or other skin conditions may find the patch too irritating to use. In addition, patients should be cautioned about placing the patch where clothing may rub, such as the bra-strap area and the panty line.
It is safe to shower and swim with the patch on but women who are involved in activities that require prolonged contact with water, such as participation on swim teams or in triathlons, may find that the patch does not work for them.
Some of the biggest complaints regarding the patch are the “gummy” adhesive residue and the lack of color options to match skin tones. Although there is an additional warning about increased risk of thrombosis with the use of the patch,10 compared with the thrombosis risk during pregnancy the transdermal patch remains a safe option for many women.
In patient scenario #3, it would be appropriate for the clinician to review all the woman's VTE risk factors and answer her questions in-depth, documenting the visit in detail.
The clinician also should be sure to compare VTE risks between methods and overall compared with pregnancy and postpartum status. (See the “You Decide” information mentioned previously.)
In general, as discussed, the lower the estrogen rate, the lower the VTE risk, whereas for progestin, the type used confers more VTE risk than does actual dosage. If a patient is highly concerned or has significant risk factors, the hormone-free IUD would most likely be the safest method.
Selecting the best method for the patient
Patient scenario #4. A 22-year-old woman comes in wondering what method of birth control she should choose. She has had 1 child and may want to have another, but not within the next year.
Although LARCs are recommended as first-line contraception, not every patient has access to a practitioner who is comfortable with providing or certified to provide the most effective methods (IUD, subdermal implant). Therefore, once contraindicated methods are eliminated, a provider should discuss the pros and cons of the remaining options.
It is important that patients understand that they can change their method at any time. While waiting for LARC placement, patients can still start another method in order to prevent pregnancy until their longer-term choice takes effect.15
Providers are often reluctant to give contraception without a negative pregnancy test, but they must remember that easily reversible contraception does not induce abortions nor is it associated with any birth defects.34
If desired, a urine-based pregnancy test can be done in the office to ease the minds of both provider and patient. If a patient has had unprotected intercourse in the 2 weeks preceding the visit, contraception can still be initiated on the day of the visit, and a repeat urine pregnancy test can be done 2 weeks later to confirm negative results.
When discussing LARC or the extended use of reversible contraceptives, patients often express discomfort with the idea of not having a monthly cycle. It may be helpful for the clinician to explain that taking hormonal contraception inhibits the growth of the endometrium, and that the number of cycles the average woman experiences in her lifetime is markedly higher now than in previous generations, when women started puberty later and were pregnant more often with prolonged breastfeeding, thus having fewer cycles than today.35
Highlighting the beneficial “side effects” of contraception may assist patients in deciding what method would most benefit them. These benefits include regulated menstrual cycles, reduced dysmenorrhea and menstrual blood loss, and reduced risks of ectopic pregnancies, endometrial and ovarian cancers, PID, and acne.2,15
If the patient in scenario #4 believes that she wants to have a child in the next 2 years, then an easily reversible agent (oral contraceptive pills, transdermal patch, vaginal contraceptive ring) would most likely be best, but the shorter-use IUD may also be an option.
If she wants longer-term contraception, a first step would be searching for a provider who offers LARC on Bedsider.org, a website operated by the nonprofit organization The National Campaign to Prevent Teen and Unplanned Pregnancy.
If such a practitioner cannot be found, the injection would be the next most effective method.
On the horizon
Several clinical trials involving oral contraceptives are under way, focusing on different estrogen and progestin products in an effort to reduce VTE risk and improve side-effect profiles.10,36
A new transdermal patch that is now in phase 3 clinical trials delivers levonorgestrel and ethinyl estradiol. This hormone combination differs from that contained in the current transdermal patch, which combines norelgestromin and ethinyl estradiol, and from the patch newly approved in Europe that combines gestodene with ethinyl estradiol.
The levonorgestrel patch has been associated with decreased side effects (nausea, headache, skin residue) compared with the currently available transdermal patch.36 The levonorgestrel patch and the norelgestromin patch are also being tested in overweight and obese women.10
A progestin-releasing vaginal ring currently on the market in other parts of the world is safe for women who are breastfeeding or otherwise need to avoid estrogen products.10
A newer ring in development is designed to be used for 13, 3-week cycles (and removed for 1 week at the end of every 3-week cycle), thus requiring only a single ring for an entire year.10,36 Vaginal rings with different hormones and dosages are also currently undergoing testing.
A monthly injectable is probably going to be reintroduced to the U.S. market within the next year as well.10,36
Optimize a short appointment
Covering everything of importance regarding contraception during a time-limited appointment can be difficult. The contraception algorithm presented in Figure 1 can help to pinpoint quickly the best fit for a patient.
The appointment could be made even more efficient by having the woman fill out a pre-visit questionnaire in which she provides information on her personal and family history that could be used to identify risk factors and subsequently help to rule out various contraceptive methods in conjunction with World Health Organization and/or Centers for Disease Control and Prevention medical eligibility criteria mentioned previously.
If a clinician cannot personally offer the contraception option that the patient desires, then starting the patient on another method and referring her to a reproductive-health provider is ideal.
Practitioners in family practice, pediatrics, and internal medicine can all benefit from advanced training in reproductive-health methods, allowing them to provide more comprehensive care for their patients as well as cultivating another source of revenue for their practice.
To help clinicians better serve their patients with regard to contraception, Table 3 list contraception-related resources for providers and patients, respectively.
TABLE 3. Online resources for contraception
HOW TO TAKE THE POST-TEST: Click here after reading the article to take the post-test on myCME.com.
Deanna Bridge Najera, MPAS, MS, PA-C, provides comprehensive care at a seasonal migrant clinic through Keystone Health in Gettysburg, Pennsylvania, and recently began a full-time position in emergency medicine.
- Junod SW, Marks L. Women's trials: the approval of the first oral contraceptive pill in the United States. J Hist Med Allied Sci. 2002;57(2):117-160. Available at www.jfponline.com/articles/editor-s-pick/article/abnormal-bleeding-in-your-female-patient-consider-a-progestin-iud/a9664434dd51b2ed51766ef21a78302e.html.
- Guttmacher Institute. Contraceptive use in the United States. Fact Sheet. 2014. Available at www.guttmacher.org/pubs/fb_contr_use.html.
- Sitruk-Ware R, Nath A, Mishell DR. Contraception technology: past, present and future. Contraception . 2013;87(3):319-330. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3530627/.
- Guttmacher Institute. Unintended pregnancy in the United States. Fact Sheet. 2013. Available at www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html.
- Centers for Medicare & Medicaid Services. What are my preventative care benefits? Part 2: Preventative health services for women. Available at www.healthcare.gov/what-are-my-preventive-care-benefits/#part=2.
- ARHP Clinical Advisory Committee. Choosing a birth control method. Powerpoint. 2009. Washington, D.C.; Association of Reproductive Health Professionals (ARHP). Available at www.arhp.org/core.
- Nelson AL. Combined oral contraceptives. In Hatcher RA, Trussell J, Nelson AL, et al, eds. Contraceptive Technology . 19th ed. New York, N.Y.: Ardent Media, Inc.: 2007:195-197.
- Committee on Gynecologic Practice. ACOG Committee Opinion: Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Long-Acting Reversible Contraception Working Group, The American Congress of Obstetricians and Gynecologists. 2009 (reaffirmed 2011);Number 450. Available at www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Gynecologic_Practice/Increasing_Use_of_Contraceptive_Implants_and_Intrauterine_Devices_To_Reduce_Unintended_Pregnancy.
- Centers for Disease Control and Prevention. Effectiveness of family planning methods. 2011. Available at www.cdc.gov/reproductivehealth/UnintendedPregnancy/PDF/Contraceptive_methods_508.pdf.
- Bahamondes L, Bahamondes MV. New and emerging contraceptives: a state-of-the-art review. Int J Womens Health. 2014;6:221-234. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3933723/
- Hendriks E, Rubin SE, Prine L. Abnormal bleeding in your female patient? Consider a progestin IUD. J Fam Pract. 2014;63(1):17-21. Available at www.jfponline.com/articles/editor-s-pick/article/abnormal-bleeding-in-your-female-patient-consider-a-progestin-iud/a9664434dd51b2ed51766ef21a78302e.html
- Marret H, Fauconnier A, Chabert-Buffet N, et al. Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. Eur J Obstet Gynecol Reprod Biol . 2010;152(2);133-137.
- Zapata LB, Whiteman MK, Tepper NK, et al. Intrauterine device use among women with uterine fibroids: a systematic review. Contraception . 2010;82(1):41-55.
- Centers for Disease Control and Prevention. United States Medical Eligibility Criteria (US MEC) for Contraceptive Use. 2010. Available at www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm.
- Association of Reproductive Health Professionals. Quick reference guide for clinicians: choosing a birth control method. September 2011. Available at arhp.org/publications-and-resources/quick-reference-guide-for-clinicians/choosing.
- World Health Organization Department of Reproductive Health and Research (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Coummunication Programs (CCP). Knowledge for Health Project. Family Planning: A Global Handbook for Providers. 2011 update. Baltimore, Maryland, and Geneva, Switzerland: CCP and WHO; 2011. Available at whqlibdoc.who.int/publications/2011/9780978856373_eng.pdf.
- The Wilson Disease Association. Wilson disease frequently asked questions. 2009. Available at www.wilsonsdisease.org/wilson-disease/wilsondisease-faqs.php.
- Hubacher D, Chen PL, Park S. Side effects from the copper IUD: do they decrease over time? Contraception . 2009;79(5):356-362. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2702765/.
- Berenson AB, Tan A, Hirth JM, Wilkinson GS. Complications and continuation of intrauterine device use among commercially insured teenagers. Obstet Gynecol . 2013;121(5):951-958. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC4028832/.
- Allen RH, Bartz D, Grimes DA, et al. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev . 2009;(3):CD007373.
- Higgins JA. Celebration meets caution: LARC's boon, potential busts, and the benefits of reproductive justice approach. Contraception Journal. April 2014. Available at www.arhp.org/publications-and-resources/contraception-journal/april-2014
- Henderson JT, Sawaya GF, Blum M, et al. Pelvic examinations and access to oral hormonal contraception.
2010;116(6):1257-1264. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3745305/.
- Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. J Low Genit Tract Dis .2012;16(3):175-204. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3915715/.
- Fang J, Husman C, DeSilva L, et al. Evaluation of self-collected vaginal swab, first void urine, and endocervical swab specimens for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae in adolescent females. J Pediatr Adolesc Gynecol. 2008; 21(6):355-360.
- Lopez LM, Edelman A, Chen M, et al. Progestin-only contraceptives: effects on weight. Cochrane Database Syst Rev . 2013;7:CD008815. Available at onlinelibrary.wiley.com/doi/10.1002/14651858.CD008815.pub3/full.
- Beasley A, White KO, Cremers S, Westhoff C. Randomized clinical trial of self versus clinical administration of subcutaneous depot medroxyprogesterone acetate. Contraception . 2014;89(5):352-356.
- Pharmacia & Upjohn Company, Division of Pfizer Inc. Depo-SubQ Provera 104 – medroxyprogesterone acetate injection, suspension, 104 mg/0.65 mL. Physician Information. August 2013; LAB-0295-11.0. Available at >http://labeling.pfizer.com/ShowLabeling.aspx?id=549.
- Committee on Adolescent Health Care, Committee on Gynecologic Practice. ACOG Committee Opinion: Depot medroxyprogesterone acetate and bone effects. The American Congress of Obstetricians and Gynecologists. June 2014;Number 602. Available at www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Depot-Medroxyprogesterone- Acetate-and-Bone-Effects.
- Allen RH, Cwiak CA, Kaunitz AM. Contraception in women over 40 years of age. CMAJ . 2013;185(7):565-573. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3626808/.
- van Hylckama Vlieg A, Helmerhorst FM, Vandenbroucke JP, et al. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. BMJ . 2009;339:b2921. Available at www.bmj.com/content/339/bmj.b2921.
- Cerel-Suhl SL, Yeager BF. Update on contraceptive pills. Am Fam Physician . 1999;60(7):2073-2084. Available at www.aafp.org/afp/1999/1101/p2073.html
- Baerwald AR, Pierson RA. Ovarian follicular development during the use of oral contraception: a review. J Obstet Gynaecol Can. 2004;26(1):19-24. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2891973/.
- Paulen ME, Zapata LB, Cansino C, et al. Contraceptive use among women with a history of bariatric surgery: a systematic review. Contraception . 2010;82(1):86-94.
- Phillips O, Simpson J. Contraception and congenital malformations. The Global Library of Women's Medicine. 2008. DOI 10.3843/GLOWM.10398. Available at www.glowm.com/section_view/heading/Contraception%20and%20Congenital%20Malformations/item/397.
- ARHP Clinical Advisory Committee. Choosing when to menstruate: the role of extended contraception [PowerPoint lecture]. Association of Reproductive Health Professionals (ARHP). May 2006.
- ARHP Clinical Advisory Committee. New developments in contraception [PowerPoint]. Association of Reproductive Health Professionals (ARHP). September 2012.
All electronic documents accessed August 4, 2014