Contraception.

Contraception counseling and provision are vital components of comprehensive health care. Unplanned pregnancy can be devastating to any woman but is particularly dangerous for those with chronic illness. Internal medicine providers are in a unique position to provide contraception, as they often intersect with women at the moment of a new medical diagnosis or throughout care for a chronic problem. A shared decision-making approach can engage patients and ensure that they choose a contraceptive method that aligns with their reproductive plans and medical needs.

Achieving cost-neutrality with long-acting reversible contraceptive methods.

OBJECTIVES: This analysis aimed to estimate the average annual cost of available reversible contraceptive methods in the United States. In line with literature suggesting long-acting reversible contraceptive (LARC) methods become increasingly cost-saving with extended duration of use, it aimed to also quantify minimum duration of use required for LARC methods to achieve cost-neutrality relative to other reversible contraceptive methods while taking into consideration discontinuation. STUDY DESIGN: A three-state economic model was developed to estimate relative costs of no method (chance), four short-acting reversible (SARC) methods (oral contraceptive, ring, patch and injection) and three LARC methods [implant, copper intrauterine device (IUD) and levonorgestrel intrauterine system (LNG-IUS) 20 mcg/24 h (total content 52 mg)]. The analysis was conducted over a 5-year time horizon in 1000 women aged 20-29 years. Method-specific failure and discontinuation rates were based on published literature. Costs associated with drug acquisition, administration and failure (defined as an unintended pregnancy) were considered. Key model outputs were annual average cost per method and minimum duration of LARC method usage to achieve cost-savings compared to SARC methods. RESULTS: The two least expensive methods were copper IUD ($304 per women, per year) and LNG-IUS 20 mcg/24 h ($308). Cost of SARC methods ranged between $432 (injection) and $730 (patch), per women, per year. A minimum of 2.1 years of LARC usage would result in cost-savings compared to SARC usage. CONCLUSIONS: This analysis finds that even if LARC methods are not used for their full durations of efficacy, they become cost-saving relative to SARC methods within 3 years of use. IMPLICATIONS: Previous economic arguments in support of using LARC methods have been criticized for not considering that LARC methods are not always used for their full duration of efficacy. This study calculated that cost-savings from LARC methods relative to SARC methods, with discontinuation rates considered, can be realized within 3 years.

Does switching contraceptive from oral to a patch or vaginal ring change the likelihood of timely prescription refill?

OBJECTIVE: This study evaluated contraceptive refill patterns of women insured commercially in the US who switched from oral contraceptives (OCs) to the patch or vaginal ring and assessed if switching contraceptive methods changes refill patterns. STUDY DESIGN: Women aged 15-44 with ≥2 patch or ring prescriptions and ≥2 OC prescriptions before the first patch/ring prescription were identified from the MarketScan® Commercial database (1/1/2002-6/30/2011). Refill patterns 1-year pre- and postindex date (first patch/ring prescription) were evaluated, and women were categorized as timely or delayed refillers on OCs and patch/ring. Regression modeling was used to investigate the association between refill patterns and contraceptive methods and switching effects on refill patterns. RESULTS: Of 17,814 women identified, 7901 switched to the patch, and 9913 switched to the ring. Among timely OC refillers, the percentage of timely refills decreased (patch: 95.6% to 79.4%, p<.001; ring: 96.5% to 74.3%, p<.001). However, among delayed OC refillers, the percentage of timely refills improved (patch: 47.9% to 72.2%, p<.001; ring: 50.4% to 64.0%, p<.001) during patch/ring use. Nonetheless, compared to timely OC refillers, women who were delayed OC refillers had 1.68-fold [95% confidence interval (CI): 1.52-1.84, p<.001] and 1.85-fold greater odds (CI: 1.69-2.02, p<.001) of being a delayed refiller while on the patch and ring, respectively. CONCLUSION: Switching to the patch or ring may improve refill behavior for women who have problems refilling OCs timely; however, the magnitude of the improvement may fail to improve ultimate contraceptive efficacy by simply switching to the patch or ring. IMPLICATIONS: The impact on timely refills of switching from OCs to either the patch or ring is complex and varies depending on the pattern of timely refills on OCs.

Inappropriate use of combined hormonal contraceptives for birth control among women of reproductive age in the United States.

OBJECTIVE: To describe the extent of inappropriate use of combined hormonal contraceptives (CHC) according to the United States Medical Eligibility Criteria (U.S. MEC). METHODS: We analyzed Kantar Health's 2010 U.S. National Health and Wellness Survey data, which is an annual population-based survey of 75,000 U.S. adults via internet. A stratified random sampling framework was used to construct a sample that reflects the U.S. census by age, gender, and ethnicity. The analysis included nonpregnant females aged 18-44 years who used CHC, including oral, patch, or vaginal rings in the past 6 months. Women classified into category 3 (theoretical or proven risks usually outweigh the advantages of using the method) or 4 (unacceptable health risk) according to the U.S. MEC were defined as having high-risk conditions, or inappropriate CHC use. The proportions of women who had inappropriate CHC use were then projected to the U.S. population by diseases/conditions and demographic characteristics incorporating sampling weights. RESULTS: We identified 2963 adult females of reproductive age (mean 29.3±6.0) (i.e., 20.4% of all adult females of reproductive age in the database) as being CHC users. Among them, 23.7% (95% CI: 22.8%-24.5%) had at least one high-risk condition and 9.3% (95% CI: 9.2%-9.4%) had at least one condition of unacceptable risk. The three most common high-risk conditions were migraine (12.7%), multiple risk factors for arterial cardiovascular disease (9.3%), and hypertension (6.1%). Women with relatively higher proportions of inappropriate CHC use were age ≥35, not finished college, and Medicaid recipients. CONCLUSIONS: A large portion of women used CHC inappropriately. Hormone-free and progestin-only contraceptives are available options with potentially less risk for them.

Progesterone vaginal ring: introducing a contraceptive to meet the needs of breastfeeding women.

BACKGROUND: The 2012 London Summit on Family Planning called for innovative solutions for increasing contraceptive access for 120 million women and girls by 2020. One way of contributing to this goal is to address the contraceptive needs of postpartum women, who have considerable unmet need especially during lactation. The progesterone vaginal ring (PVR) has been shown to be effective and safe for breastfeeding women and has the potential to enhance contraceptive choice. This user-controlled method reduces dependence on health care providers and has the potential to reduce some access-related barriers that users face. Postpartum women who have used the method have found it easy to use and find it acceptable. A well-designed introductory approach is important to ensure that the PVR is integrated into health systems. CONCLUSION: The PVR is a new technology that increases contraceptive options for breastfeeding women and has the potential to improve the health of women and their infants. Careful planning with attention paid to numerous factors can result in its successful introduction.

Preference between precoital and daily use of Duet® and BufferGel in Zimbabwe.

Duet® is a microbicide-delivery system and cervical barrier for use daily or precoitally. We conducted a crossover study among 80 Zimbabwean women to explore factors associated with use-regimen preference. Women were assigned in random order to 14 days of precoital and 14 days of daily Duet and BufferGel use. About 51 % of women preferred precoital use, 39 % preferred daily use, and 10 % liked both equally. Overall product adherence during sex was similar for both use-regimens. In multivariable analysis, diaphragm experience was associated with preference for precoital use (AOR 2.80, 95 % CI 1.01-7.76). Reasons for preferring precoital use included use only when needed, cleanliness, and discomfort with daily use. Daily use preference included convenience, discreetness, and being prepared for "sex-on-demand." Different personal and life circumstances may result in varying use-regimen preferences. Methods that can accommodate both coitally-related and daily use may be advantageous by providing more choice to users.

New options for barrier contraception.

Barrier contraceptives are a safe alternative to hormonal methods of fertility management. Newer barrier method options include the Today Sponge, the FemCap, and the Lea's Shield. Understanding the use, benefits, and limitations of these barrier methods of birth control will assist women's health care providers to better meet the family planning needs of their patients.

Comparative analysis of the effectiveness of the diaphragm and birth control pill during the first year of use among suburban adolescents.

Little attention has been paid to the diaphragm as a contraceptive option for adolescents. To compare diaphragm and birth control pill use by adolescents, 124 females (aged 13-20 years) in a suburban-based adolescent health service were interviewed at least one year after receiving a contraceptive prescription. The 73 diaphragm choosers did not differ from the 51 pill choosers in age, race, or reason for their original visit to the health service. Diaphragm choosers, however, were better students, of higher socioeconomic status, and had had fewer prior pregnancies. In the year following prescription, continuous use for 12 months was reported by 43% of diaphragm choosers and 45% of pill choosers, with significantly more pill (26%) than diaphragm (8%) choosers reporting discontinued use for at least one month while remaining sexually active. Regular use (diaphragm every intercourse, missing less than or equal to 1 pill/month) was reported by 36% of diaphragm choosers compared to 88% of pill choosers; and at least one pregnancy during the year was reported by 15% of diaphragm choosers and 18% of pill choosers. At follow-up interviews, diaphragm subjects disliked the immediate annoyances of the diaphragm, and pill users expressed concern about the potential side effects of the pill. No single factor or set of factors correlated with continuous and regular use of either method. Because both methods present specific problems for certain patients, we suggest that in addition to the pill, the diaphragm should receive serious consideration as a contraceptive option for adolescents.

PIP: Little attention has been paid to the diaphragm as a contraceptive option for adolescents. To compare diaphragm and birth control pill use by adolescents, 124 females (aged 13-20 years) in a suburban-based US adolescent health service were interviewed at least 1 year after receiving a contraceptive prescription. The 73 diaphragm choosers did not differ from the 51 pill choosers in age, race, or reason for their original visit to the health service. Diaphragm choosers, however, were better students, of higher socioeconomic status, and had fewer prior pregnancies. In the year following prescription, continuous use for 12 months was reported by 43% of diaphragm choosers and 45% of pill choosers, with significantly more pill (26%) than diaphragm (8%) choosers reporting discontinued use for at least 1 month while remaining sexually active. Regular use (diaphragm every intercourse missing or=1 pill/month) was reported by 36% of diaphragm choosers compared to 88% of pill choosers; and at least 1 pregnancy during the year was reported by 15% of diaphragm choosers and 18% of pill choosers. At follow-up interviews, diaphragm subjects disliked the immediate annoyances of the diaphragm, and pill users expressed concern about the potential side effects of the pill. No single factor or set of factors correlated with continuous or regular use of either method. Because both methods present specific problems for certain patients, it is suggested that in addition to the pill, the diaphragm should receive serious consideration as a contraceptive option for adolescents.

Study of the intravaginal insert (IVI): acceptability, side effects, and post-coital spermicidal activity.

The authors describe their experience with a group of 49 sexually active, already protected women in order to evaluate the acceptability, side effects and post-coital spermicidal activity of a new vaginal contraceptive. The intravaginal insert (IVI) consists of a polyester resin plug (sponge) containing a 5% solution of nonoxynol-9 bound in a cold formation process, and having a cotton loop attached to the lower end. The results of this study indicate that this new vaginal contraceptive is free of major side effects, is well accepted by users, and has strong spermicidal and mechanical activity. Future clinical testing in order to try its anti-conceptive effectiveness is warranted.

PIP: To determine the safety, acceptability, and spermicidal effect of a new female barrier contraceptive sponge -- the intravaginal insert (IVI), 49 women, 18-35 years, who attended family planning clinics at the University of Texas Health Science Center at San Antonio and who were either IUD users or had had bilateral tubal sterilization at least 6 months earlier, were studied. The women had experienced regular menstrual cycles during the previous 3 months, had a normal reproductive history, and normal physical and pelvic examinations, including pap smear and gonorrhea culture, and were sexually active. Participants were active in the study for 6 weeks. Intravaginal inserts were used for a total of 30 days. Participants made at least 4 clinic visits during the study, and those who showed signs of irritation or had other complaints made additional visits as needed. During the initial visit, participants were instructed in the use of the IVI and were randomly assigned to 1 of 4 groups according to the frequency with which the IVI was changed. The IVI consists of a polyester resin plug containing a 5% solution of the spermicidal surfactant, nonoxynol-9 (N-9) bound in a cold formation process, with a cotton string loop attached to the lower end. The sponge is introduced into the vagina with a syringe-like applicator. Women assigned to the daily group (Group 1, n = 16) were to leave the inserts in place for 24 hours; those in the 2-day group (Group 2, n = 12) were to leave the insert in place for 48 hours; those in the 3-day group (Group 3, n = 16) were to leave the insert in place for 72 hours. The women in Groups 1, 2, and 3 were then to report to the clinic 1, 2, and 3 days after study admission, respectively, for their 1st follow-up visit. A control group (Group 4, n = 5) was given a non-medicated IVI, and followed the same protocol as group 3. All women returned to the clinic after 30 days of use. 2 weeks later, a final visit was scheduled. Previous contraceptive practice indicated that 42 women (85.7%) had prior experience with female barrier methods, with 31 (63%) having 6 months or more of extensive use of some type of female barrier contraceptive. 13 cases were classified as Class I -- negative with signs of inflammation. 2 cases were classified as Class II, showing minimal dysplasia associated with trichomoniasis; these patients were treated with a 7-day regimen of metronidazole and their repeat pap smears were normal. These 15 cases of abnormal pap smears were divided among the 4 groups as follows: Group 1, 3; Group 2, 4; Group 3, 6; and Group 4 (controls), 2. Women in the 72-hour group always complained of some degree of foul smell, which was detected by the investigator during the follow-up visits when the IVIs were removed. Results of the postcoital test suggest that the IVI works as a contraceptive by 2 mechanisms -- mechanical and chemical. The longer the period of use, the less residual N-9 concentration was detected in the sponge, showing the effective, slow, constant release of N-9 over time. This new vaginal contraceptive is free of major side effects.

The cervical cap: a retrospective study of an alternative contraceptive technique.

A follow-up study on 130 women fitted with a cervical cap over a 12-month period drew a response rate of 43% (56 respondents). The group was young, well educated, and highly motivated. The failure rate was 16.9 per 100 women years (Pearl method), with inconsistent use and dislodgement being of major importance. The continuation rate was 75% (minimum 3 months of use), and 84% expressed satisfaction with the method. No significant side effects or risks to health were encountered. The conclusion is that there is a significant demand for alternative contraceptive methods among a select group of women. However, in the present state of knowledge, use of the cap should probably not be encouraged as a primary means of contraception, but should be reserved for those women with multiple contraceptive problems or for highly motivated women who seek out this means, understand its limitations, and can accept the relative uncertainty of its effectiveness.