Use and misuse of oral contraceptives: risk indicators for poor pill taking and discontinuation

Adolescents demanding a good contraceptive: a study with standardized patients in general practices

To assess how Flemish general practitioners (GPs) are handling the first contraception consultation, we used standardized patients (SPs) as the best method to assess the performance of GPs in daily practice. Thirty GPs got a visit from one of the three SPs. Based on a validated checklist, the SPs scored the performance of GPs and they registered the circumstances and the duration of the consultation. Twenty-eight consultations were analyzed. General practitioners scored moderately on the content level of the consultation. Rarely, GPs asked about attitude regarding safe sex, took gynecological history or discussed contraindications. None of the GPs took a personal history to exclude pregnancy. The SPs received enough information about correct pill use, but there was minimal discussion on factors associated with pill intake and interactions with other medications. Few GPs (6/28) gave a prescription corresponding to the Flemish guidelines. The others were influenced by the pharmaceutical representatives. The girls felt, however, very satisfied with the consultation with the GPs.

Factors influencing young women's decision making regarding hormonal contraceptives: a qualitative study

INTRODUCTION

Discontinuation of hormonal contraceptives is correlated with the experience of unwanted effects and is an important cause of unwanted pregnancy. Previous studies have not identified the factors that influence whether a woman will switch to another hormonal contraceptive, switch back to condom use or stop contraception altogether when side effects are experienced.

METHODS

This qualitative study used in-depth interviews to explore factors influencing young women's decision making regarding highly effective hormonal contraceptives in 51 women aged 16-25 years living in or just outside London, UK.

RESULTS

Young women's decision making regarding hormonal contraceptives is not simply determined by the experience of unwanted effects but reflects the meaning of unwanted effects in relation to underlying beliefs regarding the nature of hormones in contraceptives, 'natural' menses, menstrual control and the importance of avoiding pregnancy. When unwanted effects were experienced, women with no concerns about the nature of hormones tended to switch to other highly effective hormonal contraceptives. Those with underlying concerns regarding the nature of hormones returned to (inconsistent) condom use or stopped using contraception altogether. This was linked to experiencing unwanted pregnancy.

CONCLUSIONS

Eliciting attitudes regarding the nature of hormones in contraceptives, menstrual control and natural menses could enable health care practitioners to offer more tailored advice, interventions and contraceptives to women.

A Review of Transdermal Hormonal Contraception

Imperfect use of contraceptive methods notably increases the likelihood of pregnancy. One means of improving user adherence with hormonal contraception is to minimize the dosing schedule. Two forms of hormonal contraceptive have currently achieved this goal: the transdermal patch and the vaginal ring. The first and only transdermal contraceptive patch to receive worldwide regulatory approval (ethinylestradiol/norelgestromin) is a convenient approach to contraception that has a similar efficacy to oral contraceptives (OCs), but with the benefit of once-weekly administration. In addition, transdermal delivery of contraceptive hormones eliminates variability in gastrointestinal absorption, avoids hepatic first-pass metabolism, and prevents the peaks and troughs in serum concentrations that are seen with OCs. Norelgestromin, the progestin contained in the patch, is the active metabolite of norgestimate and is structurally related to 19-nortestosterone. Norgestimate and norelgestromin mimic the physiologic effects of progesterone at the progesterone receptor; however, norelgestromin has negligible direct or indirect androgenic activity, suggesting that it may be suitable for women with disorders related to androgen excess (such as hirsutism, acne, and lipid disorders).Contraceptive effectiveness is usually a function of the efficacy of a contraceptive in combination with compliance with its dosing regimen. The efficacy of the contraceptive patch has been clearly demonstrated in three phase III trials, two of which were randomized comparisons with an OC. The likelihood of pregnancy was similar between these contraceptive methods; however, compliance with the patch was notably better, particularly in younger women. The safety and tolerability profile of the patch was similar to that of the OC. A cost-effectiveness analysis has suggested that the contraceptive patch is more cost effective than the OC, due to decreased costs related to unwanted pregnancy.

The vaginal ring and transdermal patch: new methods of contraception

The most common method of reversible contraception used worldwide is the intrauterine device. However, in the Asia–Pacific the combined oral contraceptive pill and condoms, methods of contraception that require a high degree of day-to-day user compliance, are more popular. The combined vaginal ring and transdermal patch have been developed to overcome the need for daily compliance associated with combined pill use. They have the added advantages of non-oral delivery, thus avoiding gastro-intestinal interference with absorption, and in addition there is no hepatic first-pass effect. Both have been available internationally for some years and offer an alternative to the combined pill. This article reviews and summarises published data on these new methods.

Valuable safeguard or unnecessary burden? Characterization of physician consultations for oral contraceptive use in Mexico City

CONTEXT

Given the safety and efficacy of oral contraceptives (OCs), many health professionals believe that these should be widely available over-the-counter (OTC). Opponents of OTC availability argue that without a physician's consultation, women will not be properly screened and will not use OCs correctly, thereby compromising safety and efficacy. However, little is known about the content or quality of physicians' consultations.

METHODS

Trained simulated patients (SPs) attended 45 appointments with Mexico City public and private physicians to request a prescription for OCs. Immediately following each appointment, the SPs filled out a checklist regarding the information provided and examinations performed by physicians.

RESULTS

Both public and private physicians asked a few questions and provided little information regarding screening, pill-taking instructions, side effect information and warning sign information. Despite the fact that all SPs were appropriate OC candidates, women were denied a prescription in seven (15.6%) appointments mostly because of their age (regarded as either too old or too young).

CONCLUSION

In general, Mexican physicians are not providing women thorough information and screening in OC consultations, calling into question the assumption that a physician's appointment is necessary for or will ensure safe, proper OC use.

Advances in the management of endometriosis: an update for clinicians

Endometriosis is a chronic and recurrent disease characterized by the presence and proliferation of endometrial tissue outside the uterine cavity, which occurs in approximately 10% of women of reproductive age. In this estrogen-dependent disorder, lesions become inactive and gradually undergo regression during states of ovarian down-regulation, such as amenorrhoea or menopause. The impact of endometriosis includes impaired fertility potential, as well as symptoms of dysmenorrhoea, dyspareunia and chronic non-menstrual pain, all of which adversely affect quality of life. Management of endometriosis focuses on pain relief and includes medical and surgical treatment. Pharmacologic therapies currently in use include combination oral contraceptives (COCs), danazol, GnRH analogues and progestins. Although some agents show efficacy in relieving pain, all differ in their side effects, making it difficult to achieve a balance between efficacy and safety. Efficacy has been demonstrated with danazol or GnRH analogues; however, treatment is limited to 6 months because of significant metabolic side effects. Alternatives for longer-term management of symptoms include add-back therapy with GnRH analogues, COCs or progestins. Newer options for treatment of endometriosis include depot medroxyprogesterone acetate subcutaneous injection, as well as several agents under investigation that may prove to have therapeutic potential.

Measured and reported weight change for women using a vaginal contraceptive ring vs. a low-dose oral contraceptive

BACKGROUND

Women often stop hormonal contraception because of perceived weight change. We conducted a randomized trial comparing the contraceptive vaginal ring to a low-dose oral contraceptive (OC). We examined the difference between women's reported and measured baseline weights and looked at factors affecting perceived weight change.

METHODS

We randomized 201 participants to either the vaginal ring or an OC for three cycles. We weighed participants upon enrollment (n=194) and at exit (n=167), using the same instrument for all measurements. Participants also provided self-reported height and their reactions to perceived weight changes.

RESULTS

Baseline weight and body mass index were similar for both groups (mean weight=145.9 lb). Measured weight was, on average, 4.4 lb more than reported weight; this difference was greater in overweight and obese participants. Participants gained an average of 2.8 lb over 3 months; this gain did not differ between groups or by baseline weight. Subjects who reported a "bad change" in weight at exit (n=34) gained an average of 4.4 lb, whereas those who reported "no change" (n=112) gained 2.2 lb and those who reported a "good change" (n=14) gained 3.3 lb.

CONCLUSION

Participants underreported their weight, and this difference was greater for heavier women. There was little weight change for the women in our study. Participants' opinions about weight change were not correlated with measured weight changes.

Contraceptive behaviors in adolescents

A wide range of factors influence adolescents' contraceptive behaviors, from personal characteristics to family context to social support to knowledge about and access to contraception. Improving knowledge about contraception and counseling about successful contraceptive use can be helpful in decreasing the remarkably high US rates of adolescent pregnancy. Encouraging the postponement of sexual activity until an individual adolescent is developmentally capable of participating in a mature, healthy, mutually respectful relationship that incorporates effective contraception clearly is a goal that most clinicians, parents, teachers, and other responsible adults can support. Contraceptive technologies that incorporate delivery systems that are "user-friendly" and long-acting also will help to further lower US adolescent pregnancy rates that, while improving, are currently among the highest in the world.

The Role of Body Weight in Oral Contraceptive Failure: Results from the 1995 National Survey of Family Growth

PURPOSE

Many unintended pregnancies occur in women who use contraception. We conducted this study to determine if increasing body weight is associated with oral contraceptive (OC) failure.

METHODS

This retrospective cohort study consists of the 1916 women who reported using OCs in January 1993 and provided complete covariate information on the 1993 National Health Interview Survey and 1995 National Survey of Family Growth. Body weight and body mass index (BMI) were self-reported in 1993. The outcome was defined to be any conception occurring in women reporting OC use during the month of conception. Cox proportional hazards models were used to model the body weight/BMI-OC failure association.

RESULTS

Women with a BMI >/= 30 had a statistically significant increased risk of having an OC failure as compared to women with BMIs of 20 to 24.9 (HR=1.80, 95% CI, 1.01, 3.20). However, after adjustment for age, marital status, education, poverty, race/ethnicity, parity, and dual method use, this increased risk was attenuated and no longer statistically significant (HR=1.51, 95% CI, 0.81, 2.82). Increasing body weight was not associated with an increased risk of OC failure in the unadjusted or adjusted models.

CONCLUSIONS

We did not find a strong or statistically significant association between increasing body weight/BMI and OC failure among this population of women. Prospective studies specifically designed to examine this association are needed to determine if heavier women should be advised to use a contraceptive method other than OCs to prevent pregnancy.

The Coraliance study: non-compliant behavior. Results after a 6-month follow-up of patients on oral contraceptives

OBJECTIVES

This follow-up study was planned to establish the frequency with which women miss their contraceptive pill, and to observe their behavior when they forget it. In those women who changed from a continuous cycle to an interrupted type of cycle, or vice versa, the study also aimed to evaluate the impact of this change on the pattern of omission of pills.

METHODS

The longitudinal, prospective cohort study included healthy women of child-bearing age for whom a change of pill was being prescribed by their gynecologist. Data were recorded during the 6 months preceding inclusion in the study, and for the 6 months of follow-up; the women were asked to complete a diary in which they recorded the number and exact times of pill omission, and their behavior at each omission.

RESULTS

A total of 617 gynecologists included 3316 women into the study; of these, a group of 2418 (73%) revisited the same gynecologist at follow-up. The groups who either visited the same or a different gynecologist were similar with respect to age, oral contraception type, omission type and frequency. A large non-compliance rate and women's difficulties in maintaining safe contraception after missing a pill were observed in the group with follow-up. Women were never risk-free when they missed a pill; they turned to numerous sources for discordant or conflicting information; 15% of 'not-forgetting' women at the pre-inclusion cycle recorded at least one omission at the last cycle of the 6-month follow-up period. Omission fluctuations during the observational period make it difficult to designate 'forgetful' or 'non-forgetful' classes of women. Administration of the pill in a continuous cycle, and probably 'study' and 'auto-questionnaire' effects, contributed to an improvement in compliance. In the group taking the continuous cycle pill, the omission number slightly decreased, particularly on the first day and week of the cycle, irrespective of the initial cycle type.

CONCLUSIONS

The importance of the phenomenon of non-compliance rate is confirmed as well as women's difficulties in knowing how to maintain contraceptive safety. The continuous cycle regimen is likely to improve women's compliance during the critical period of the cycle.

Transdermal Drug Delivery: Clinical Considerations for the Obstetrician–Gynecologist

INTRODUCTION

The first transdermal drug delivery system was introduced in the United States over 20 years ago. Created as an alternative route of administration to improve patient compliance as well as to reduce side effects, the transdermal delivery of drugs now represents a $1.5 to $2 billion market and is growing rapidly.

DATA SOURCES

The medical literature from 1980 to 2005 was searched using the PubMed search engine. The search term was "transdermal," limited to human clinical trials. Abstracts were used to identify clinical trials that compared transdermal preparations and their oral counterparts in the same study.

TABULATION, INTEGRATION, AND RESULTS

In this article, we review the rationale for the transdermal administration of drugs; discuss aspects of the anatomy and physiology of the skin relevant to drug transport; examine the qualities required for a drug to be a good candidate for transdermal delivery; and consider key principles for the evaluation of the relative benefits of transdermal delivery, using studies of hormone replacement therapy and oral contraceptive as examples.

CONCLUSION

The data reviewed here suggest that certain clinical situations support the use of the transdermal administration of drugs over their oral counterparts.

Adolescents' experience with the combined estrogen and progestin transdermal contraceptive method Ortho Evra

BACKGROUND

The new combined estrogen & progestin contraceptive patch Ortho Evra was approved by the FDA in December 2001. To date, there is a paucity of data regarding its use in the adolescent age group. We examined adolescents' experience with this new contraceptive method.

METHODS

Using a questionnaire designed by the authors, care providers in a hospital based adolescent clinic interviewed and reviewed the charts of adolescent girls who had initiated Ortho Evra in 2002-2003.

RESULTS

Twenty-eight adolescent girls (age 18 +/- 1 years, gyn age 6 +/- 1 years, onset of sexual intercourse at 14 +/- 1 years, body mass index (BMI) 27.6 +/- 1.2, 57% Hispanic, 21% Caucasian, 11% African American, 7% biracial, 4% Indian American) who had used Ortho Evra for 7 +/- 1 months were enrolled. Half (50%) were adolescent mothers, and 57% had a history of irregular menstrual periods. All (100%) girls reported regular menstrual periods while using Ortho Evra, with only 14% experiencing occasional breakthrough bleeding. Half reported a shorter duration and 36% reported a lighter flow of their periods. About a third (39%) reported a decrease and 11% reported an increase in dysmenorrhea symptoms. About a third (29%) of those with a history of recurrent headaches at initiation reported decrease in headaches, and about a third (33%) of those with acne at initiation reported decrease in facial acne while on Ortho Evra. There were no significant BMI changes during Ortho Evra use. Although condom use while on Ortho Evra was poor (only 15% reporting consistent condom use), there were no pregnancies reported. A majority (93%) reported that they remembered to apply the patches on time, and 40% stated that Ortho Evra was easier than previous contraceptive methods. Two thirds (68%) were very satisfied and 29% were somewhat satisfied with the method, and 93% stated that they would recommend the method to a friend/relative. The preferred application site was the buttock (40%) followed by the lower abdomen (32%). About a fifth (21%) experienced at least one episode of complete patch detachment and 32% reported partial peeling of the patch corners. About a third (32%) would prefer another patch color, and 25% would like a fourth week placebo patch. The most common side effects were mild temporary application site reactions (64%), some discomfort on patch removal (32%), nausea (18%), and breast tenderness (18%). Eleven girls (39%) discontinued Ortho Evra (three lost health insurance, three because of application site reactions, two found patch application schedule difficult to remember, two desired pregnancy, two because of nausea, one because of perceived weight gain).

CONCLUSIONS

Ortho Evra provides excellent cycle control in adolescents. Most adolescents are satisfied with this method. Intensive efforts should be made to increase condom use by adolescents on Ortho Evra.

Hormonal Contraception and Physiology: A Research-based Theory of Discontinuation Due to Side Effects

Side effects influence the acceptability and continuation of hormonal contraceptives. Counseling the client about the management of side effects is a principal approach advocated for increasing continuation. Evidence of a biological basis for variation in women's tolerance of hormonal contraceptives argues, however, that greater attention should be given to altering the product rather than principally attempting to alter a woman's ability to deal with the product. Discontinuation rates for hormonal contraceptives, largely attributable to side effects and health concerns, are high in nearly all less-developed countries for which Demographic and Health Survey data are available. Oral contraceptives appear to be particularly problematic for Latin American women, most notably in Bolivia. Clinical trials suggest substantial variation in the physiological response to exogenous hormones, and new evidence confirms the hypothesis that the normal hormonal profiles of Bolivian women are significantly lower than those of women in the United States. These findings suggest a need for more population-specific physiological research linked to analyses of the possible association between endogenous hormone differences and contraceptive continuation. Appropriately adjusting the level of the steroid delivered may benefit women's health and improve the acceptability and continuation of hormonal contraceptives.

Concerns about contraceptive side effects among young Latinas: a focus-group approach

To identify perceptions and attitudes about contraceptive side effects in young, low-income Latina adolescents through focus-group conversations. We conducted seven focus-group discussions with Latino females in an outpatient clinic and community setting. Qualitative methodology was used to analyze data. Participants were recruited from the outpatient gynecology clinic at the University of Illinois at Chicago, and from the Easter Seals Day Care Center. Women were recruited if they were Latino and between the ages of 18 and 26 years (N = 40). Participants cited both perceptions of side effects as well as personal experience with side effects as reasons for not using or discontinuing the use of contraception. Women also demonstrated incorrect knowledge about contraception, and tended to value anecdotal information over information from health professionals. These factors led to reliance on less-effective methods of contraception, placing participants at risk for unintended pregnancy. Concern about side effects, fear of health consequences and misinformation were identified as barriers to effective contraceptive use in young, low-income Latinas. Providers caring for this population should address potential concerns about side effects of contraception as well as assess patients' understanding in light of cultural and language barriers.

Contraceptive efficacy and safety of DMPA-SC

DMPA-SC 104 mg/0.65 mL is a new, low-dose subcutaneous (SC) formulation of Depo-Provera contraceptive injection (150 mg/mL medroxyprogesterone acetate injectable suspension) that provides efficacy, safety and immediacy of onset equivalent to Depo-Provera intramuscular (IM) injection. Two large, open-label, Phase 3 studies assessed the 1-year contraceptive efficacy, safety and patient satisfaction with DMPA-SC administered every 3 months (12-13 weeks). Zero pregnancies were reported in both studies, which included a total of 16,023 woman-cycles of exposure to DMPA-SC and substantial numbers of overweight or obese women. DMPA-SC was well-tolerated and adverse events were similar to those reported previously with Depo-Provera IM. Thus, DMPA-SC offers women a new, highly effective and convenient long-acting contraceptive option.

Contraceptive risk and compensatory behaviour in young people in education post-16 years: a cross-sectional study

OBJECTIVES

To describe contraceptive risk and compensatory behaviour, using condoms or emergency contraception (EC), in young people in education aged 16-24 years.

DESIGN

Cross-sectional study.

SUBJECTS

A total of 1135 students aged 16-24 years.

SETTING

Educational establishments in and around London, UK.

RESULTS

Seventy-six percent of women and 55% of men reported having experienced sex either without contraception or when a condom split or came off. Most participants (or their sexual partners) who reported such risks had compensated by using EC at least once (72% women, 55% men) but only a minority had compensated on each occasion of risk (37% women and 22% men). Of the oral contraceptives users the majority (83%) had experienced a pill 'problem' and the majority of these participants had compensated for such problems by using condoms (79%). Fewer than half of the women who experienced pill problems (45%) compensated by using condoms on each occasion. Less than a quarter (23%) of those who experienced pill problems but did not compensate by using condoms ever compensated by using EC.

CONCLUSIONS

This study demonstrates high levels of primary contraceptive risk and low levels of consistent compensatory condom or EC use. The findings suggest that there would be large increases in EC use and repeated use if all primary contraceptive risks were followed by compensatory action. Interventions to increase contraceptive use should focus not only on initiation of contraception use but acknowledge that risks do happen and promote both continuing use and compensatory behaviour.

Why consider vaginal drug administration?

OBJECTIVE

To review the anatomy and physiology of the vagina, the merits of vaginal drug administration, and the currently available vaginal drug-administration systems.

DESIGN

Review of basic and clinical research.

RESULT(S)

Although clinicians commonly use topically administered drugs in the vagina, this route for systemic drug administration is somewhat novel. Experience with a variety of products demonstrates that the vagina is a highly effective site for drug delivery, particularly in women's health. The vagina is often an ideal route for drug administration because it allows for the administration of lower doses, steady drug levels, and less frequent administration than the oral route. With vaginal drug administration, absorption is unaffected by gastrointestinal disturbances, there is no first-pass effect, and use is discreet. Knowledge of anatomy, physiology, histology, and immunology of the vagina should allow clinicians to reassure their patients concerning this mode of delivery. Greater understanding and experience by clinicians should lead to increased use and acceptance of the vagina as a route for drug administration.

CONCLUSION(S)

The safety and efficacy of vaginal administration have been well established. The vaginal route of drug delivery is acceptable and may even be a preferable route of administration for many drugs, particularly hormones, whether for contraception or postmenopausal estrogen therapy.

Nondaily Hormonal Contraception: Considerations in Contraceptive Choice and Patient Counseling

PURPOSE

To review currently available choices for non-daily hormonal contraception, considering efficacy, safety, patient counseling issues, and appropriate patient selection.

DATA SOURCES

Worldwide medical literature and the individual products' prescribing information.

CONCLUSIONS

Patients and clinicians have many nondaily hormonal contraceptive options available--from Depo-Provera quarterly injection, which has been available in the United States for over 10 years, to several new entries (Mirena 5-year intrauterine system, Lunelle monthly injection, NuvaRing monthly intravaginal ring, and Ortho Evra weekly transdermal patch). All these options offer high efficacy and enhanced convenience for many patients over daily oral contraceptives (OCs). Barriers to use of these agents may include patients' lack of information as well as fear or misconceptions regarding the hormones and methods. All of these can be addressed with adequate patient counseling and open dialogue. The clinician and patient need to be well-informed regarding these options so that they can work together and identify the best contraceptive fit for the patient---with the ultimate goal being to increase patient satisfaction and adherence and, thus, avoid unintended pregnancy.

IMPLICATIONS FOR PRACTICE

Despite the efficacy of OCs, missed pills are quite common and contribute to unintended pregnancy. Many women in all population categories would benefit from the convenience and reliability of nondaily hormonal contraceptives. The highest efficacy rates with typical use are associated with agents that require minimal user participation (i.e., Depo-Provera, Mirena). Compared to daily regimens, all nondaily options offer increased convenience and may contribute to improved patient adherence. However, barriers to use may exist. Patient fears regarding use of hormones can be minimized by discussing the long-term safety of hormonal contraceptives. (The data are predominantly derived from Depo-Provera and OCs because these agents have been available in the United States and in the rest of the world for much longer than the newer nondaily options.) Patient counseling and appropriate expectations regarding changes in menstrual pattern have been demonstrated to further enhance patient adherence to therapy. Finally, patient lifestyle preferences must be considered. The finding that many women are comfortable with or even prefer amenorrhea, which is associated with options such as Depo-Provera, highlights how important it is for clinicians to avoid making assumptions about a patient's contraceptive preferences. Rather, clinicians and patients should exchange information through an open dialogue. For the majority of patients, nondaily hormonal contraceptives should be considered and offered as first-line options.

The impact of improved compliance with a weekly contraceptive transdermal system (Ortho Evra®) on contraceptive efficacy

OBJECTIVE

The contraceptive efficacy of perfect dosing cycles and imperfect dosing cycles has not been described previously. Method compliance determines the proportion of perfect and imperfect dosing cycles, and together can form the basis for evaluating differences in efficacy based on differences in compliance.

MATERIALS AND METHODS

The transdermal contraceptive delivery system (Ortho Evra) has been studied in a North American randomized trial vs. an oral contraceptive (OC) and in total has been evaluated in 3319 women in contraceptive clinical trials. This article explores the impact of perfect vs. imperfect compliance with the contraceptive method on contraceptive efficacy. Previously published data for a transdermal system (Patch, n = 812) and OC (Triphasil, n = 605) users from the North American comparative study were reanalyzed to determine the effect of imperfect use on the contraceptive efficacy of the different methods.

RESULTS

Contraceptive efficacy was significantly better (p = 0.007) in cycles with perfect dosing (Pearl Index = 0.83) compared to those with imperfect dosing (Pearl Index = 6.32) for both methods. This difference is homogeneous (p = 0.62) across the Patch and OC groups. Pooled data for all Patch users confirm that perfect dosing cycles are associated with significantly better efficacy than imperfect dosing cycles (p = 0.047). In addition, compliance did not vary by age in the pooled Patch data, which are in agreement with the previously published Patch data from the comparative study. In the comparative study, the percentage of cycles with perfect dosing was significantly higher with the Patch than with the OC (88.7% vs. 79.2%, p < 0.001), and was consistently high in all age groups (range, 89.6-91.8%). By contrast, among OC users, the percentage of cycles with perfect dosing increased with increasing age (p < 0.001) from 67.7% in users aged 18-20 years to more than 80% in those aged 30 years and older.

CONCLUSION

In conclusion, deviations from perfect use (whether corrected or not) of a transdermal contraceptive system and of an OC increase contraceptive failures by approximately 5-10-fold when compared to perfect use. The weekly change schedule of the transdermal contraceptive delivery system is associated with a significantly greater proportion of cycles in which there is perfect dosing compared to an OC.

The combined contraceptive vaginal ring, NuvaRing®, and tampon co-usage

We investigated the effect of tampon co-usage on systemic exposure to etonogestrel (ENG) and ethinylestradiol (EE) from the combined contraceptive vaginal ring, NuvaRing. One cycle of ring use consists of 3 weeks of ring use followed by a 1-week ring-free period. Fourteen healthy women were randomized to use both NuvaRing and tampons (Kotex( regular) or NuvaRing alone for one cycle; participants then switched to the alternate treatment regimen for a second cycle of ring use. The first tampon was self-administered on day 8 of the interaction cycle; 4 tampons a day were used for 3 consecutive days. Tampon co-usage did not result in any changes in serum ENG or EE concentrations and is thus not expected to compromise the ring's contraceptive efficacy.

Combination Estrogen–Progestin Contraceptives and Body Weight: Systematic Review of Randomized Controlled Trials

OBJECTIVE

Many women and clinicians believe that combination estrogen-progestin contraceptive use can lead to weight gain. This concern can deter women from starting hormonal contraception or lead to premature quitting. This review evaluated the association between combination contraceptive use and change in body weight.

DATA SOURCES

The computerized databases CENTRAL, MEDLINE, EMBASE, Popline, and LILACS (from their inception to 2002) were used to conduct this review. Known investigators and manufacturers were contacted for information about other trials not discovered in the database search.

METHODS OF STUDY SELECTION

All English-language, randomized controlled trials measuring weight change that were at least 3 treatment cycles in duration and that compared a combination contraceptive to a placebo or to a combination contraceptive that differed in drug, dosage, regimen, or study length were eligible for inclusion. Of the 570 reports of randomized controlled trials of eligible interventions that were identified, 42 trials were included in the systematic review.

TABULATION, INTEGRATION, AND RESULTS

Two reviewers independently abstracted data from the eligible trials using a standard form. Depending on the data available, the weighted mean difference using a fixed effect model with 95% confidence intervals was calculated for the mean change in weight between baseline and posttreatment measurements or the Peto odds ratio with 95% confidence intervals was calculated by using the proportion of women who gained or lost more than a specified amount of weight. The 3 placebo-controlled, randomized trials did not find evidence supporting a causal association between combination oral contraceptives or a combination skin patch and weight gain. Most comparisons from the 40 trials that compared 2 or more combination contraceptives showed no substantial difference in weight. In addition, discontinuation of combination contraceptives because of weight gain did not differ between groups when this factor was studied.

CONCLUSION

Available evidence is insufficient to determine the effect of combination contraceptives on weight, but no large effect is evident.

New Options for Teen Pregnancy Prevention

Teenage pregnancy rates remain unacceptably high in the United States, despite the availability of numerous contraceptive options. This article examines contraceptive methods currently available to adolescents and highlights newer products that may help meet some of the unique contraceptive needs of sexually active teens. The three newest agents (OrthoEvra trade mark, NuvaRing trade mark, and Seasonale) offer advantages such as higher contraceptive efficacy, increased privacy, ease of use, and low side effect profiles. A major advantage of each of these methods is that they eliminate the need for the teen to take daily action to prevent pregnancy. Nurses can be instrumental in helping teens to avoid unwanted pregnancy by assessing teens' contraceptive needs and educating them about contraceptive options. However, it is important to remember that because none of these new methods offer protection against sexually transmitted diseases, we should continue to educate adolescents about the need for condom use and provide them with instructions on using condoms correctly.

Obesity as a risk factor for antipsychotic noncompliance

OBJECTIVE

Weight gain is a common side effect of antipsychotic medications and is of particular concern with most of the newer "atypical" antipsychotics. It is, therefore, increasingly important to understand the impact of obesity and perceived weight problems on compliance with these medications.

METHODS

A survey of treatment and health issues was mailed to local chapters of the National Alliance for the Mentally Ill (NAMI) and National Mental Health Association (NMHA), who distributed them to people with schizophrenia. Noncompliance was defined as a self-report of missing any antipsychotic medication in the previous month. The primary independent variables were (1) body mass index (BMI; weight [kg]/height [m2])-categorized as normal (< 25, n = 73), overweight (25-30, n = 104), or obese (> 30, n = 100)-and (2) subjective distress over weight gain. Other independent variables included demographics, medication attitudes, and treatment satisfaction.

RESULT

BMI status and subjective distress from weight gain were predictors of noncompliance. Obese individuals were more than twice as likely as those with a normal BMI to report missing their medication (OR = 2.5; CI 1.1-5.5). A comprehensive model suggested that the primary mediator of noncompliance was distress over weight gain.

CONCLUSIONS

There appears to be a significant, positive association between obesity and subjective distress from weight gain and medication noncompliance, even when accounting for other possible confounding factors.

Feasibility study of the use of a daily electronic mail reminder to improve oral contraceptive compliance

Women who ingest their oral contraceptive pill (OCP) as part of a daily routine are more likely use their OCPs correctly. This trial examines the feasibility of an electronic-mail (e-mail) reminder system to improve OCP compliance. An e-mail reminder was sent to 50 new OCP users daily for 3 months. Subjects sent an e-mail reply to confirm receipt. OCP compliance was recorded on diaries. Four subjects were discontinued for not checking their e-mail. Active participants missed a median of 18% of the e-mail reminders (range: 0-65%). A follow-up visit was scheduled after completion of three OCP cycles. Of the 40 subjects returning completed diaries, 50% missed no active pills at all and 20% missed at least one in each cycle. Most found the daily e-mail somewhat (65%) or very helpful (19%) for OCP compliance. Of those continuing OCPs, 64% wanted to continue receiving e-mail reminders at the completion of the study. Because inconsistent OCP use is a significant cause of unplanned conception, the use of e-mail to improve OCP compliance has the potential to decrease unintended pregnancies.

Depot-medroxyprogesterone acetate injection (Depo-Provera): a highly effective contraceptive option with proven long-term safety

Depot-medroxyprogesterone acetate (Depo-Provera(R)) is a highly effective, nondaily hormonal contraceptive option that has been available in the United States for a decade, and worldwide for 40 years. Benefits and risks of hormonal therapy are often under scrutiny; however, long-term clinical experience has established the safety of this long-acting contraceptive. This article reviews the contraceptive efficacy, potential noncontraceptive health benefits and long-term safety of with regard to risk of cardiovascular events, breast and gynecologic malignancy and osteopenia. Comparisons with other hormonal contraceptives are made as clinically appropriate. Common patient management issues, including effects on menstrual cycle, body weight and mood, are also addressed. Finally, this review provides recommendations for appropriate patient selection.

Ortho Evra/Evra versus oral contraceptives: follicular development and ovulation in normal cycles and after an intentional dosing error

OBJECTIVE

To compare the effects of the contraceptive patch to oral contraceptives (OCs) on follicular size and incidence of ovulation in normal cycles and after dosing errors.

DESIGN

Randomized, open-label.

SETTING

Twelve centers.

PATIENT(S)

One hundred twenty-four ovulatory women.

INTERVENTION(S)

Subjects received either the patch (groups 1 and 2) or one of three OCs. Correct dosing occurred in cycles 1, 2, 3, and 5. The following dosing errors were planned during cycle 4, a shortened 10-day cycle: [1] patch group 1 subjects wore one patch for 10 consecutive days; [2] for patch group 2 and OC subjects, 7 dosing days were followed by 3 drug-free days.

MAIN OUTCOME MEASURE(S)

Follicular size, as determined at each cycle by the maximum mean follicular diameter.

RESULT(S)

After a 3-day dosing error, follicular size was significantly smaller in the patch group (mean, 7.0 mm) vs. each OC group (range of means, 11.8-17.1 mm). Similar results were seen after proper dosing. The incidence of ovulation was significantly lower for the patch users than for women using OCs.

CONCLUSION(S)

Follicular size and incidence of ovulation were significantly reduced among contraceptive patch users compared with women using OCs in normal cycles and after planned dosing errors.

Efficacy, safety and cycle control of five oral contraceptive regimens containing norgestimate and ethinyl estradiol

This randomized, multicenter, parallel group study evaluated four new oral contraceptive regimens of norgestimate (NGM) and ethinyl estradiol (EE) relative to ORTHO TRI-CYCLEN (NGM 180/215/250 microg/EE 35 microg). Healthy women (50/group) received three cycles of either ORTHO TRI-CYCLEN Lo (NGM 180/215/250 microg/EE 25 microg), one of three cyclophasic regimens (NGM cycling 180-250 microg/EE 35 microg or 25 microg) or ORTHO TRI-CYCLEN. Among all five regimens, ovulation suppression, cycle control and safety were generally comparable. Presumed ovulation (serum progesterone levels >or=3 ng/mL during Days 19-21 of Cycle 3), occurred in 0/41 (0%) subjects on ORTHO TRI-CYCLEN Lo and 3/43 (7%) subjects on ORTHO TRI-CYCLEN. Breakthrough bleeding and/or spotting (BBS; % total cycles) was 17.2% for ORTHO TRI-CYCLEN Lo and 14.4% for ORTHO TRI-CYCLEN. The mean number of days of BBS/cycle for ORTHO TRI-CYCLEN Lo and ORTHO TRI-CYCLEN was 3.7 and 3.1, respectively, for those subjects with such bleeding. Thus, ORTHO TRI-CYCLEN Lo appears similar to ORTHO TRI-CYCLEN in inhibiting ovulation and providing cycle control.

Controversies in adolescent hormonal contraception

Unintended pregnancy and abortion rates among US adolescents remain high although hormonal contraception is safe and effective in this population. Controversies affecting the provision of hormonal contraception for adolescents include the side effects of oral contraceptives, the possibility that progestin-only injectables lead to decreased bone health, and debate as to whether emergency contraception should be available to teens without a prescription. Each of these issues is addressed with a review of relevant literature.

The combined contraceptive vaginal ring, NuvaRing: an international study of user acceptability

The acceptability of the combined contraceptive vaginal ring, NuvaRing, was assessed during two trials conducted in North America and Europe. Women completed a questionnaire about the ring's clarity of instructions, ease of use, sexual comfort, cycle-related characteristics and satisfaction after 3, 6 and 13 cycles of use. A total of 1,950 women (82% of those recruited) completed a questionnaire at cycle 3. At baseline, 66% of participants preferred oral contraceptives, but after three cycles of ring use 81% preferred the ring. On study completion, 97% agreed that the instructions for use were clear; 85% of women and 71% of their partners never/rarely felt the ring during intercourse and 94% of partners never/rarely minded that the woman was using the ring. Overall acceptance was high, 96% were satisfied with the ring and 97% would recommend the ring. Similar responses were seen for women who prematurely discontinued from the studies, except that slightly fewer women were satisfied (60%) and would recommend the ring (75%). Reasons for liking the ring included 'not having to remember anything' (45%) and 'ease of use' (27%). In conclusion, there is a high level of user and partner acceptability for the contraceptive ring.

Official warnings on thromboembolism risk with oral contraceptives fail to inform users adequately

Following the 1995 "pill scare" relating to the risk of venous thrombosis from taking second- or third-generation oral contraceptives, the Committee on Safety of Medicines (CSM) withdrew their earlier recommended restrictions on the use of third-generation pills and published recommended wording to be used in patient information leaflets. However, the effectiveness of this wording has not been tested. An empirical study (with 186 pill users, past users, and non-users) was conducted to assess understanding, based on this wording, of the absolute and relative risk of thrombosis in pill users and in pregnancy. The results showed that less than 12% of women in the (higher education) group fully understood the absolute levels of risk from taking the pill and from being pregnant. Relative risk was also poorly understood, with less than 40% of participants showing full understanding, and 20% showing no understanding. We recommend that the CSM revisit the wording currently provided to millions of women in the UK.

Contraceptive Efficacy and Patient Acceptance of Lunelle

PURPOSE

To review the efficacy, safety, and patient acceptance of the Lunelle monthly contraceptive injection and to raise awareness of this new contraceptive in the United States.

DATA SOURCES

Worldwide scientific literature, reports of clinical trials, and manufacturers' product information and guidelines.

CONCLUSIONS

Lunelle is a combined hormonal method with a safety/tolerability profile comparable to that of oral contraceptives (OC) and a high efficacy rate and provides a rapid return of fertility after discontinuation. Moreover, Lunelle was well accepted in a large clinical trial, with satisfaction levels similar to those of new-start OC users.

IMPLICATIONS FOR PRACTICE

Oral contraceptives are the most popular hormonal birth control method in the United States; however, typical use is associated with higher failure rates than those observed with perfect use because of poor compliance. Poor compliance has been attributed in part to the need for daily administration. A new contraceptive method that does not require daily administration and is readily reversible may be suitable for many women, resulting in better overall efficacy.

Inconsistent use of oral contraceptives in rural Bangladesh

The purpose of this study is to explore predictors of inconsistent use of oral contraceptives (OCs) in rural Bangladesh. A total of 801 rural OC users were included in the study, about half of them (49%) missed one or more active pill(s) during the 6 months before the survey.Multivariate analysis revealed that Muslim women were 60% more likely to be inconsistent OC users compared to their non-Muslim counterparts. Women who lacked knowledge about contraindications were 60% more likely to take the pill inconsistently than were women who had the knowledge. Women who were not visited by family planning workers or did not have access to mass media were 40% more likely to be inconsistent OC users.OC users need increased information about correct OC use, which could be provided via improved access to mass media with specific messages on how to use OCs properly. Better access to the community clinics could improve the pill-taking behaviors of rural Bangladeshi women.

Acceptance of altering the standard 21-day/7-day oral contraceptive regimen to delay menses and reduce hormone withdrawal symptoms

OBJECTIVE

Measure acceptance and use of extending the number of active oral contraceptive (OC) pills beyond 21 days and/or shortening the hormone-free interval to reduce the frequency and severity of hormone withdrawal symptoms.

STUDY DESIGN

A retrospective review was performed of patients on OCs with unwanted hormone withdrawal symptoms who were counseled by one osbtetrician-gynecologist (P. J. S.) on altering their standard 21/7 regimen. All patients used a monophasic 30 to 35 microg pill and underwent an initial counseling visit between December 1993 and October 2000.

RESULTS

Of 318 patients counseled on "extending the number of active pills," 292 (92%) had documented follow-up after the initial counseling session. The primary reason for extending the number of active pills was to decrease symptoms of headache (35%), dysmenorrhea (21%), hypermenorrhea (19%), and premenstrual symptoms (13%). The remaining 12% of patients cited convenience, endometriosis, and other reasons such as menstrual-associated acne. Twenty-five (9%) of 292 chose not to extend, with a preference for monthly menses as the most common reason (40%) followed by a concern that symptoms were not severe enough to warrant extension (32%). Of 267 patients who initiated an extended regimen, 57 discontinued OCs, 38 returned to a standard regimen, and 172 were extending use at the time of last follow-up. Using survival analysis methods, at 5 years 46% +/- 5% (mean +/- SE) of patients continued an extended OC pattern. The regimen of OC use by patients continuing an extended pattern was 12 +/- 12 (mean +/- SD) weeks of active pills (median of 9 weeks and range to 104 weeks) with pill-free interval of 6 +/- 2 days (median of 5 days and range of 0-7 days).

CONCLUSION

The majority of patients with hormone withdrawal symptoms on OCs will initiate a regimen of extending active pills, often with a shortened hormone-free interval to reduce frequency and severity of associated symptoms.

Contraceptive applications of estrogen

Estrogens are a primary component of several contraceptive methods: combined oral contraceptive pills, a combined injectable contraceptive, the combined contraceptive vaginal ring, the combination transdermal contraceptive patch, and combined emergency contraceptive pills. Contraceptive formulations that contain estrogen are referred to as combined contraceptives because they also contain some form of progestin. This article reviews the contraceptive methods containing estrogen, beginning with a discussion of combined oral contraceptive pills. Formulations and clinical management, mechanisms of action, noncontraceptive benefits of use, therapeutic uses in addition to contraception, side effects, contraindications to use, and drug-drug interactions are described. Information follows about the newer combined contraceptive products including the injection, vaginal ring, and patch. Finally, combined emergency contraceptive pills are reviewed. Thorough knowledge of the contraceptive methods containing estrogen enables clinicians to provide expert care for women using these products.

Comparison of cycle control with a combined contraceptive vaginal ring and oral levonorgestrel/ethinyl estradiol

OBJECTIVE

The purpose of this study was to compare cycle control and tolerability of the NuvaRing (NV Organon, Oss, The Netherlands), a novel combined contraceptive vaginal ring, with a standard combined oral contraceptive pill.

STUDY DESIGN

Healthy women aged 18 to 40 years who requested contraception received either NuvaRing or a combined oral contraceptive containing 30 microg ethinyl estradiol and 150 microg levonorgestrel for 6 cycles in 3 similarly designed studies. Each cycle comprised 3 weeks of ring or pill use, followed by 1 ring- or pill-free week.

RESULTS

Two hundred forty-seven women began the studies, 121 women with NuvaRing and 126 women with the combined oral contraceptive. Withdrawal bleeding occurred in virtually all cycles in both groups. In the NuvaRing groups, the incidence of irregular bleeding was < or =5% in all cycles; this was lower than the combined oral contraceptive groups (5.4%-38.8%). Furthermore, the incidence of a normal intended bleeding pattern was significantly higher in the NuvaRing groups than in the combined oral contraceptive groups (P <.01). Both contraceptives were well tolerated.

CONCLUSION

NuvaRing has excellent cycle control and is well tolerated.

Assessment of compliance with a weekly contraceptive patch (Ortho Evra/Evra) among North American women

OBJECTIVE

To determine compliance with the contraceptive patch (Ortho Evra/Evra) overall and by age among women in North America and to compare rates of perfect use with those of an established oral contraceptive.

DESIGN

Data were pooled for three contraceptive studies in which women participated for up to 13 cycles; the subset of centers in North America was used in this analysis.

SETTING

76 North American centers.

PATIENT(S)

Healthy women 18-45 years of age.

INTERVENTION(S)

In all studies, the patch regimen was three consecutive 7-day patches (21 days) followed by 1 patch-free week per cycle.

MAIN OUTCOME MEASURE(S)

Perfect use for the patch or oral contraceptive, defined as 21 consecutive days of drug-taking followed by a 7-day drug-free period; for contraceptive patch users, no patch could be worn for more than 7 days. Oral contraceptives were used according to package labeling.

RESULTS

For all contraceptive patch users in North America (n = 1,785), perfect use was consistent across age groups. The percentage of cycles with perfect use of the patch ranged within age groups from 88.1% to 91.0%. In the comparative study conducted only in North America, perfect use was also consistent across age groups for the patch (n = 812), but rates of perfect use for the oral contraceptive (n = 605) differed significantly by age.

CONCLUSION(S)

Age did not affect compliance with the patch among all North American women studied. In a comparative study of women at North American centers, compliance with the weekly contraceptive patch was significantly better than with an established oral contraceptive. The contraceptive patch is uniformly easy to use across all ages.

A comparative and pooled analysis of the safety and tolerability of the contraceptive patch (Ortho Evra/Evra)

OBJECTIVE

To review the safety and tolerability of the contraceptive patch (Ortho Evra/Evra) versus a standard oral contraceptive (Triphasil) and to present the pooled safety and tolerability of the patch across three pivotal studies.

DESIGN

Three open-label, contraceptive studies of up to 13 treatment cycles.

SETTING

183 centers.

PATIENT(S)

Comparative study (812 patch, 605 oral contraceptive); pooled analysis (3,330 patch).

INTERVENTION(S)

The patch regimen was three consecutive 7-day patches (21 days) followed by 1 patch-free week per cycle; the oral contraceptive was dosed according to the U.S. physician package insert.

MAIN OUTCOME MEASURE(S)

Adverse events, laboratory tests, vital signs, and body weight.

RESULT(S)

The incidence of most events was similar between the patch and oral contraceptive groups, with the exception of a higher incidence of application site reactions, breast discomfort (cycles 1 and 2 only), and dysmenorrhea in the patch group. Pooled analysis demonstrated that most application site reactions (92%) and breast symptoms (86%) were mild or moderate in severity, and <2% of participants discontinued the patch because of either event. Only 7 (0.2%) participants experienced a serious adverse event classified as possibly, probably, or likely related to the patch. The mean change in body weight from baseline to the end of treatment was an increase of 0.3 kg.

CONCLUSION(S)

Overall, the contraceptive patch is well tolerated and has a side effect profile similar to an established oral contraceptive.

Pharmacokinetics of norelgestromin and ethinyl estradiol delivered by a contraceptive patch (Ortho Evra/Evra) under conditions of heat, humidity, and exercise

The objectives of this randomized, open-label, three-period, incomplete block design study were to evaluate the pharmacokinetics of norelgestromin (NGMN) and ethinyl estradiol (EE) delivered by the contraceptive patch, Ortho Evra/Evra, and to evaluate patch adhesion under conditions of heat, humidity, and exercise. During each treatment period, 30 healthy women wore Ortho Evra on the abdomen for 7 days under one of six conditions (normal activity, sauna, whirlpool, treadmill, cool water immersion, or a combination of activities). Blood samples were collected before and several times to 240 hours after patch application. Mean serum concentrations of NGMN and EE generally remained within the reference ranges, 0.6 to 1.2 ng/ml and 25 to 75 pg/ml, respectively, during the 7-day wearperiodfor all activities. Only 1 (1.1%) of 87 patches completely detached spontaneously. Peel force measurements were comparable for all activities. Ortho Evra was well tolerated. In conclusion, Ortho Evra delivers efficacious concentrations of NGMN and EE and maintains adhesive reliability through 7 days of wear even under conditions of heat, humidity, and exercise.

Noncompliance among a group of women using a novel method of contraception

OBJECTIVE

To compare the incidence of noncompliance measured objectively by a home use fertility monitor with the traditional self-reported incidence of compliance in a study of a new method of contraception.

DESIGN

Prospective cohort study.

SETTING

A large family planning clinic in Edinburgh.

PATIENT(S)

Thirty-two healthy women who took part in a trial assessing the efficacy of a novel method of contraception involving accurately timed administration of a single dose of mifepristone.

INTERVENTION(S)

Mifepristone was administered orally and a blood sample was collected on the same day.

MAIN OUTCOME MEASURE(S)

Percentage of missed tests detected by the monitor against the self-reported percentage during the critical period.

RESULT(S)

Women failed to perform 24.2% (95% confidence interval, 16.5-31.5) of the tests in the 162 cycles analyzed. They missed tests at an absolutely vital time for contraceptive efficacy in 42% of cycles according to the monitor while admitting to missing tests in 14.8%. Poor compliance was associated with younger women, those who discontinued the study before completion, and cycles in which women were not relying on the contraceptive method.

CONCLUSION(S)

The use of microelectronic monitoring systems may improve our understanding of the extent of patient noncompliance, providing objective information that no other monitoring technique can produce. This understanding provides the opportunity to make the optimum use of potentially effective treatments while validating research evidence.

Multiple-dose pharmacokinetics of a contraceptive patch in healthy women participants

This open-label, randomized study evaluated the pharmacokinetics of norelgestromin (NGMN) and ethinyl estradiol (EE) following the application of a contraceptive patch (1/week) for three cycles (3 weeks/cycle). Healthy women (n = 24) wore a 20-cm(2) patch (ORTHO EVRA/EVRA) on either their abdomen or buttock during blood sampling weeks and on any of four approved sites at other times. Serum was analyzed for NGMN and EE from samples taken during Week 1 of Cycle 1 and Weeks 1-3 of Cycle 3. Steady-state conditions were achieved during the three-cycle study. The patch delivered NGMN and EE at steady-state concentrations within their reference ranges throughout three cycles of treatment; reference ranges are based on studies with ORTHO-CYCLEN/Cilest. Steady-state serum concentrations and area under the curve from 0 to 168 h increased only slightly from Cycle 1, Week 1 to Cycle 3, Week 3 for NGMN and EE, indicating minimal accumulation. Treatment was well tolerated, and patch adhesion was excellent.

Pharmacokinetics of norelgestromin and ethinyl estradiol from two consecutive contraceptive patches

The primary objective of this open-label study was to determine the pharmacokinetics of norelgestromin (NGMN) and ethinyl estradiol (EE)following two consecutive applications of a contraceptive patch (ORTHO EVRA/EVRA). Twelve healthy women wore the first patch on their abdomen for 7 days and, after removal at 168 hours (day 7), wore a second patch for 10 days (i.e., 3 days beyond the intended 7-day wear period). Blood samples were collected before and at various times up to 456 hours (day 19) after application of the first patch for analysis of NGMN and EE. Mean serum concentrations of NGMN and EE remained within the reference ranges, 0.6 to 1.2 ng/ml and 25 to 75 pg/ml, respectively, during the entire 7-day wear period after application of the first patch and for 10 days after application of the second patch; reference ranges are based on studies with ORTHO-CYCLEN/ Cilest. No patch detached spontaneously. No subject discontinued or experienced a serious adverse event.

Will the pill make me sterile? Addressing reproductive health concerns and strategies to improve adherence to hormonal contraceptive regimens in adolescent girls

PAPER OBJECTIVE: This paper is designed to help clinicians understand the relationship between hormonal contraceptive side effects and the potential development of general and reproductive health concerns that can impact on adherence to hormonal contraception. By understanding the concerns raised by young women, we can then make our counseling more specific to the factors that affect compliance in this population.

DESIGN

Studies that specifically addressed hormonal contraceptive compliance, side effects, and method selection in adolescents and young women were chosen for this paper. All articles were from peer-reviewed journals. Medline-Ovid articles from 1980-2000 were used with the following search keywords: Contraception, Patient Compliance, Hormonal Contraception, Oral Contraceptive Pills, Norplant, Depo Provera, and Adolescents.

DATA SYNTHESIS

The general public has many concerns about the safety of hormonal contraception. The development of side effects, especially those that are menstrual-related, seem to cause adolescents and young women to feel that their general and reproductive health is being threatened.

CONCLUSIONS

Hormonal contraceptive counseling should include 1) explaining, in a nontechnical manner, how these methods work; 2) addressing negative information the patient has heard about the methods; 3) providing factual information about cancer risks, blood clots, and other general health concerns; 4) discussing the potential side effects and what each means to her health; 5) asking specifically about possible reproductive health worries, especially in light of the menstrual irregularities that may occur; and 6) assuring the patient that she should always feel free to share her concerns and worries with you, the provider.

Side effects and oral contraceptive discontinuation in rural Bangladesh

Using data from a survey on oral contraceptive (OC) compliance in rural Bangladesh, this study examines the role of side effects on OC discontinuation along with other potential predictors. A total of 1403 currently married women aged 15-49 years were interviewed; of these 43% discontinued OCs. Of the women who discontinued, 53% did so because of side effects, which was the main self-reported reason for OC discontinuation. Multivariate analysis revealed that after adjusting for duration of OC use, women who experienced side effects were 1.4 times more likely to discontinue OC use than their counterparts without such experience. Discontinued OC use was also associated with being Muslim, not being visited by field-workers, OC use as first method of contraception, lack of husband's support, and was inversely associated with duration of OC use. Adequate counseling about OC use, emphasizing the possibility of side effects, and better management of them, coupled with improved client-provider interaction and husband's supportive role could help in reducing OC discontinuation in rural Bangladesh.