Tailoring Contraceptive Use to Patient Needs
Article Outline
The United States has a relatively high unintended pregnancy rate compared to other developed countries. About half of all pregnancies are unintended so, clearly, contraceptive use is not optimal for these women.1
Hormonal contraception will be used by more than 80% of U.S. women during their reproductive years. When taken properly, hormonal contraceptives are very effective. However, many methods are prone to inconsistent use and human error. Actual use rates often differ greatly from perfect use rates.1
A large variety of alternatives are available when choosing a hormonal contraceptive for a particular patient. There are different combined oral contraceptives (COCs) or progestin-only methods. There are pills, patches, injections, implants, and intrauterine devices.
Within the COC category there are many options: monophasic, biphasic, and triphasic pills. It is reasonable to prescribe a generic monophasic pill containing 30 to 35 mcg of estrogen for most patients.1 Multiphasic pills vary the amount of estrogen, progestin, or both over the active pill days in an attempt to mimic the normal menstrual cycle and minimize side effects. There are also 3 generations of progestins, plus the novel progestin drospirenone, which is not a testosterone derivative. The third-generation progestins have less androgenic activity.2
Newer to the market are extended cycle products, with an 84-day cycle. The longer cycle reduces the frequency of menstrual bleeding. These products elicit regular menstruation but with a higher rate of spotting. For long-term menstrual suppression, continuous COCs, depot medroxyprogesterone acetate (DMPA), or the levonorgestrel intrauterine system may be used.
The contraceptive patch contains estrogen and progestin. It is worn for a week at a time for 3 weeks, then no patch is worn for a week. If the patch is used continuously, the patient will become amenorrheic but may experience irregular bleeding.
The vaginal ring, with a combination of estrogen and progestin, is placed by users in the vagina and left for 3 weeks. It is then removed for a 1-week break prior to new ring insertion. The ring may also be used on a continuous basis. If used continuously, the patient will become amenorrheic but may experience irregular bleeding.1
Progestin-only options are progestin pills, DMPA (progestin injection), progestin contraceptive implants, and levonorgestrel intrauterine system. Progestin-only pills are used primarily in breast-feeding women and women with contraindications to estrogen. Benefits include immediate return to fertility on discontinuation, avoidance of estrogen-related side effects, decreased bleeding, decreased dysmenorrhea, and decreased risk of endometrial and ovarian cancer.2
DMPA is given by injection every 3 months. It causes decreased bleeding, and many patients become amenorrheic. It is useful in patients who have any condition that is worsened by the menstrual cycle, such as anemia, dysmenorrhea, or menstrual migraine. It also decreases the risk of endometrial cancer and ovarian cancer.
The etonogestrel implant, a single rod inserted under the skin, is effective for 3 years. It may cause irregular spotting that may last the entire 3 years. Bleeding is very light.
The levonorgestrel intrauterine system is effective for 5 years. It may cause irregular spotting during the first 1 to 3 months and then cause a decreased blood flow.1
One of the keys in prescribing an acceptable oral contraceptive is obtaining a detailed history that will help the clinician select a contraceptive that will either most closely mimic their normal menstrual patterns or reduce menstrual problems. Thus, the non-contraceptive effects of some hormones may actually motivate the patient to be more compliant in using the contraceptive method. For example, menstrual cycle regularity can be achieved by COCs. Patients must be taught that some unscheduled spotting is common in the first months with all COCs.
Almost all young women complain of dysmenorrhea, a leading cause of school and work absenteeism. About three-fourths of women with dysmenorrhea feel better with COCs. The patch or vaginal ring may be equally effective.
Menorrhagia, excessive menstrual bleeding, can lead to iron-deficiency anemia. COCs are effective in reducing blood flow. Extended cycle or continuous therapies will decrease the frequency of bleeding. Progestin-only contraceptives will also decrease blood flow.
For premenstrual dysphoric disorder (PDD) or premenstrual syndrome (PMS), COC with drospirenone has approval from the Federal Drug Administration (FDA). Other methods of avoiding menstruation-related symptoms are extended and continuous methods of contraception.
For menstrual migraines, extended cycle or continuous hormone contraceptives, including COCs, the patch, and DMPA, may be used. Progestin-only, intrauterine, or barrier contraceptives are effective for women who experience migraine with aura.
All COCs can theoretically improve hirsutism and acne. COCs with drospirenone have FDA approval for this, COCs containing levonorgestrel and desogestrel have been shown to be effective, but progestin-only contraceptives are not considered effective.
COCs and DMPA have been shown to be associated with a lower risk of endometrial cancer, an effect which lasts for up to 20 years. COCs also decrease the risk of ovarian cancer.3
All women of reproductive age should be asked about their need for contraception. Tailoring the contraceptive to the patient's individual condition and needs may help increase actual use rates and prevent unintended pregnancies.
References
Suggestions for topics are welcome.
PII: S1555-4155(10)00223-0
doi:10.1016/j.nurpra.2010.04.009
© 2010 American College of Nurse Practitioners. Published by Elsevier Inc. All rights reserved.
