Nondaily hormonal contraceptives: Establishing a fit between product characteristics and patient preferences

,

Applied Evidence

Nondaily hormonal contraceptives: Establishing a fit between product characteristics and patient preferences

J Fam Pract. 2004 November;53(11):904-913

By

Jeffrey P. Levine, MD, MPH

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References

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Practice recommendations

Consider progestin-only DMPA-IM or L-IUS methods for women who want highly effective, nondaily, reversible contraception, and who regard amenorrhea as a desirable side effect; also suitable when estrogen therapy is contraindicated (SOR: C).
Consider the NE-patch or EE-ring, both containing estrogen and progestin, for women who are candidates for combined oral contraceptives, including those desiring shorter-term contraception and regular bleeding cycles (SOR:C).
To help women select the most appropriate and acceptable nondaily contraceptive option, review with patients each method’s route and schedule of administration, perfect vs typical use efficacy, potential noncontraceptive health benefits, reversibility, side effects, and long-term safety profile (SOR:C).

Oral contraceptives have made a major contribution to both women and society by substantially reducing the rate of unintended pregnancies. However, in actual clinical practice, contraceptive failures remain a problem. For example, the first-year pregnancy rate with oral contraceptives can be as high as 5% to 8%.¹ Experts agree that a leading reason for unintended pregnancy among oral contraceptive users is incorrect and inconsistent use. Women who do not use oral contraceptives consistently are nearly 3 times as likely to become pregnant as those who use them consistently.²

Today, women have alternatives to the daily regimen of oral contraceptives. Highly effective, convenient, nondaily contraceptive choices are available in injectable, intrauterine, intravaginal, and transdermal delivery systems, which may be administered weekly, monthly, every 3 months, or every 5 years, depending on a woman’s family planning needs and preferences.

This article compares the efficacy, non-contraceptive health benefits, side-effect profiles, and long-term safety of the available nondaily hormonal contraceptive options. It also reviews other factors to consider when selecting the most appropriate and acceptable option for women who are seeking nondaily contraception.

Options for nondaily contraception

The first available nondaily contraceptive, depot-medroxyprogesterone acetate (DMPA-IM; Depo-Provera), is a progestin-only injectable introduced in 1963 that has been used by more than 30 million women worldwide.³ Its efficacy, safety, and health benefits have been established through large-scale epidemiologic investigations, and it was approved for use in the United States in 1992.

In the past 2 years, other nondaily hormonal contraceptives with a variety of delivery systems have been introduced to the US market. The levonorgestrel-releasing intrauterine system (L-IUS; Mirena) is also a progestin-only method that has been in use worldwide for 10 years. Its health benefits and hormone-associated side-effect profile are similar to DMPA-IM (particularly bleeding patterns).

The etonogestrel/ethinyl estradiol vaginal ring (EE-ring; NuvaRing), and the norelgestromin/ethinyl estradiol transdermal system (NE-patch; Ortho Evra) will likely offer improved efficacy to oral contraceptives with a similar long-term safety profile.

Nondaily contraception potentially more convenient and effective

Unlike oral contraceptives, which must be taken every day, nondaily contraceptives offer dosing options ranging from weekly to every 5 years ( Table 1 ). These extended dosing intervals reduce the likelihood of missed doses and are more convenient for many women than daily dosing. These methods also provide greater privacy because there is no visible evidence of their use, with the exception of the patch, which can be worn on discreet locations under clothing.

Improved adherence associated with less frequent dosing of nondaily hormonal contraceptives appears to enhance contraceptive efficacy, an example of which is the similarity between first-year pregnancy rates during perfect and typical use of DMPA-IM ( Table 2 ). The antiovulatory concentrations of medroxyprogesterone acetate achieved within 24 hours of injection provide almost immediate protection against pregnancy and likely contribute to the high contraceptive efficacy seen with DMPA-IM.⁴ The lowest reported pregnancy rates with perfect and typical use of L-IUS are comparable, and there is no need for backup contraception following insertion.⁵ Furthermore, even with typical use, reported pregnancy rates for DMPA-IM and L-IUS (0.3% and 0.1%, respectively) are comparable to sterilization (0.5%).^1,5

Pregnancy rates during perfect use of the NE-patch and EE-ring also are low, but it is not yet possible to accurately estimate the failure rates of these methods during typical use due to limited US postmarketing experience.^6,7 A backup method is recommended for the first 7 days of EE-ring use if the patient has not previously taken hormonal contraception or is switching from a progestin-only method,⁷ and for the first 7 days of NE-patch use if the first patch is applied after Day 1 of menses.⁶

TABLE 1
Nondaily hormonal contraceptives (currently available in the US), compared with oral contraceptives

Method, Administration	Mechanism of action	Dosing schedule	Pregnancy first year (%)
Method, Administration	Mechanism of action	Dosing schedule	Perfect use	Typical use
DMPA-IM ¹ (Medroxyprogesterone acetate; Depo-Provera) Intramuscular injection, given by health provider	Inhibits secretion of gonadotropins, which prevents follicular maturation and ovulation and results in endometrial thinning	Every 3 mo	0.3	0.3
L-IUS ⁵ (Levonorgestrel; Mirena) Intrauterine system, placed by health provider	Effects morphological changes in the endometrium, including stromal pseudodecidualization, glandular atrophy, and leukocytic infiltration; inhibition of ovulation is observed in some women	Every 5 y	0.1	0.1
EE-Ring ⁷ (Etonogestrel/ethinyl estradiol; NuvaRing) Intravaginal ring, self-applied	Suppression of gonadotropins inhibits ovulation; other alterations include changes in cervical mucus and endometrium	Monthly (1 ring-free wk/mo)	1.0–2.0	Unknown*
NE-Patch ⁶ (Norelgestromin/ethinyl estradiol; Ortho Evra) Transdermal patch, self-applied	Suppression of gonadotropins inhibits ovulation; other alterations include changes in cervical mucus and endometrium	Weekly (1 patch-free wk/mo)	1.0	Unknown*
Oral contraceptives ¹ Combined or progestin-only Oral pills, self-administered	Suppression of gonadotropins inhibits ovulation; other alterations include changes in cervical mucus and endometrium	Daily (1 hormone-free wk/mo)	Combined: 0.1 Progestin: 0.5	Combined: 5.0 Progestin: 5.0
*Due to limited US postmarketing experience, a precise estimate of failure rate during typical use is not yet available.