CONTRACEPTIVE SUCCESS

5 strategies to improve contraceptive success for your patients

Professor, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles

Chief, Women’s Health, Care Programs, Harbor-UCLA Medical Center, Los Angeles, California

Supported by an independent educational grant from Ortho Women’s Health and Urology and Schering-Plough.

Sponsored by the American Society for Reproductive Medicine.

Half of the annual population growth in the United States is due to unintended pregnancy.¹ Underestimation of fertility and pregnancy risks, discontinuation and noncompliance with a birth control method, as well as misinformation about mechanisms of action and ambivalence about pregnancy all contribute to this high rate of unintended pregnancy.^2,3

Planning a pregnancy can improve outcomes for the mother and child. Nevertheless, many women who do not want to become pregnant do not use birth control.² When a pregnancy is planned, women are less likely to smoke or drink alcohol and are more likely to take prenatal vitamins.⁴

FIGURE Comparing effectiveness of family planning methods LAM: Lactational amenorrhea method; IUD: Intrauterine device. Steiner MJ, et al. Am J Obstet Gynecol.2006;195:85-91. World Health Organization/Department of Reproductive Health and Research, Johns Hopkins Bloomberg School of Public Health/Center for Communications Program. Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva; 2007. Trussell J. In: Contraceptive Technology. 19th ed rev. New York, NY: Thomson Reuters;2008. Family Health International. Chart accessed online January 14, 2009. www.fhi.org/nr/shared/enFHI/EffectivenessChart.pdf

Contraceptive success depends on accommodating the individual patient’s lifestyle. Following are 5 strategies for a user-centric approach to family planning that gives patients more control, more choices, or more flexibility than they might have had previously.

Contraceptive methods that provide protection against pregnancy with a minimum of maintenance are in the top tier of efficacy, with rates near—or better than—sterilization.⁵ This group includes the intrauterine contraceptives (IUCs) and the etonogestrel implant. The two IUCs available in the United States, the copper T380A intrauterine device and the levonorgestrel-releasing intrauterine system, have comparable efficacy rates.⁶ Counseling about bleeding, pain, and amenorrhea can lower removal rates, and placing the devices during menses lowers the risk of expulsion.

Only 6 pregnancies in 20,648 cycles were reported with the etonogestrel implant.⁷ Because the FDA requires that any pregnancies within 2 weeks of discontinuation of a contraceptive method be reported in study data, these pregnancies may have occurred after the implant was removed and may provide evidence of a rapid return to fertility after using the etonogestrel implant. The implant works by releasing etonogestrel at levels high enough to inhibit ovulation, which can be reassuring to women who are concerned about the mechanism of action.⁸

Although not in the top tier of efficacy, the contraceptive patch and monthly vaginal ring also make use easier for patients. Contraceptive users, particularly women age 18 to 19 years, were more likely to comply perfectly with a weekly contraceptive patch than a daily oral contraceptive (OC).⁹

Annual visits and negative pregnancy tests are opportunities to stress the benefits of planning for pregnancy. When discussing any contraceptive method, clinicians can improve acceptance by emphasizing the noncontraceptive benefits of a given method. For example, OCs have been shown to reduce ovarian and endometrial cancer, benign breast disease, pelvic inflammatory disease, ectopic pregnancy, iron-deficiency anemia, menorrhagia, and dysmenorrhea.^10,11 Additionally, OCs have been associated with reduced incidence of endometriosis and rheumatoid arthritis.^10,11 Three OCs have been approved to treat acne and one has been approved for the treatment of premenstrual dysphoric disorder. Use of OCs can reduce menstrual blood loss, and extended regimens also reduce the frequency of withdrawal bleeding and associated symptoms.

Some women may be reluctant to begin an OC regimen because of side effects they have heard about, such as weight gain, headache, and breast tenderness. The results of one acne study are helpful in counseling such patients.¹² During 6 months of therapy, no statistically significant differences were found for any adverse event experienced by pill and placebo users. For example, as shown in the TABLE, 18.4% of women taking OCs got a headache, but 20.5% of placebo users did as well (P = .64).¹² Although there certainly are women who are sensitive to hormones, these data show that adverse effects do not usually increase when a new OC regimen is started.

Incidence of events commonly attributable to OC use

Patients in my public health clinic receive an abundant supply of free condoms, but one-third say they do not use them because they do not like condoms. To overcome this barrier, it may be useful to talk with couples about ways that their method of birth control can enhance sexual pleasure. For example, it was observed in clinical trials that the monthly vaginal ring also increases vaginal lubrication.¹³

Changes in the way condoms are made and marketed have enhanced their appeal. Condoms now come in a variety of sizes and with a variety of accessories for women, such as refreshing wipes, lubricants, and vibrating rings. Women are reported to purchase about 30% of condoms sold in stores, and some stores have moved condoms into the feminine hygiene section to increase the comfort of female shoppers.¹⁴

By recognizing the real-world barriers to use of contraceptives, clinicians can make it easier for patients to be successful. One-quarter of patients who leave with an OC prescription or sample do not start the OC because in the intervening time, they became pregnant, changed their mind, got confused about the instructions, or heard about adverse effects from another source.¹⁵ One way to address this gap is to use a Quick Start approach (Same Day Start), ie, starting a contraceptive method in the office that day, regardless of where the patient is in her cycle. When a patient begins her pill pack in the office, she is also counseled to use a backup method for the next 7 days. If she has had unprotected intercourse in the previous 5 days, she receives emergency contraception in the office and is told to wait 12 hours and then take the first OC pill. There is no increase in bleeding or spotting with Quick Start, and most women find this to be an acceptable option.¹⁵ This approach does increase the number of users who continued the OC into the next cycle, although the continuation rates at 3 and 6 months do not improve.¹⁶

Quick Start has also been used for depot medroxyprogesterone acetate (DMPA) injections and the vaginal ring.^17,18 At our institution, more than 80% of DMPA shots have been given outside the first 5 days of menses, when there was reasonable certainty that the patient was not pregnant. There have been no significant problems with this approach.¹⁷ The monthly vaginal ring provides excellent cycle control with Quick Start.¹⁸ By placing the vaginal ring that day in the office, the clinician can answer all the patient’s questions that might have kept a woman from considering ring use, such as how to place and remove the ring and whether it will interfere with intercourse.

Monthly trips to the pharmacy can be a barrier to women’s success; studies have shown that continuation rates improve when clinicians provide prescriptions for more than one cycle at a time.¹⁹ With special products, the patient receives 3 months of pills at once. These regimens reduce the frequency of withdrawal bleeds, although unscheduled bleeding and spotting is initially increased with extended regimens. An important counseling point for patients is that such bleeding problems decrease after the first cycle.

The vaginal ring has also been used off-label in an extended regimen.²⁰ There was an increase in unscheduled bleeding with a longer cycle that offset the decrease in scheduled withdrawal bleeds, but for women who can tolerate spotting, this is an option.

New users of hormonal contraceptive methods need as much education about how to use backup methods, such as condoms, as they do about their primary method of contraception.

Even though emergency contraception is available behind the counter for women age 18 years or older, advance prescriptions for emergency contraception should be provided routinely. This can be an important safety net for patients age 18 or older, because insurance does not cover behind-the-counter emergency contraception, and for younger women requiring prescriptions.

Lastly, it is necessary to explain mechanisms of action based on evidence, not theoretical conjectures. For example despite popular belief, the best scientific evidence has demonstrated that both IUDs and emergency contraception work only to prevent conception.^21,22

Correct use of medication for any asymptomatic condition is low. Clinicians can optimize contraceptive success by determining what patients will use, motivate them with information about noncontraceptive benefits, and provide backup methods. With ever more methods available to clinicians and patients, it is important to stay informed and be flexible as patients’ needs change.

Sexuality, Reproduction & Menopause ©2009 Lebhar-Friedman, Inc.