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

Recent progress in advanced biomaterials for long-acting reversible contraception

Unintended pregnancy is a global issue with serious ramifications for women, their families, and society, including abortion, infertility, and maternal death. Although existing contraceptive strategies have been widely used in people's lives, there have not been satisfactory feedbacks due to low contraceptive efficacy and related side effects (e.g., decreased sexuality, menstrual cycle disorder, and even lifelong infertility). In recent years, biomaterials-based long-acting reversible contraception has received increasing attention from the viewpoint of fundamental research and practical applications mainly owing to improved delivery routes and controlled drug delivery. This review summarizes recent progress in advanced biomaterials for long-acting reversible contraception via various delivery routes, including subcutaneous implant, transdermal patch, oral administration, vaginal ring, intrauterine device, fallopian tube occlusion, vas deferens contraception, and Intravenous administration. In addition, biomaterials, especially nanomaterials, still need to be improved and prospects for the future in contraception are mentioned.

Randomized, double-blind, two-way crossover bioequivalence and adhesion study, in healthy women, of a transdermal contraceptive patch with a newly sourced adhesive component at the end of shelf life vs. the EVRA patch at the beginning of shelf life

OBJECTIVE

Evaluate bioequivalence, based on norelgestromin (NGMN) and ethinyl estradiol (EE) plasma concentrations, and adhesion of a transdermal contraceptive patch containing a newly sourced adhesive component (test) at end of shelf life (EOSL) vs. the marketed EVRA patch (reference) at beginning of shelf life (BOSL).

MATERIALS AND METHODS

In this randomized, double-blind, two-way crossover study, healthy women received a single, 7-day application of test and reference patches in 4 sequences: two 11-day treatment periods separated by a 21-day washout. Assessments included NGMN and EE pharmacokinetics (PK), adhesion (per European Medicines Agency (EMA) 5-point scale), irritation potential and application-site reactions, and tolerability. Patches were bioequivalent if 90% CIs of geometric mean ratios (GMRs) of test/reference for Cmax, AUC168h, AUC0-tlast, and AUC∞ were 80 - 125%. Patch adhesion was comparable if ratios of geometric mean cumulative adhesion percentages were ≥ 90%.

RESULTS

68 women were randomized, and 62 completed both treatments. 55 and 59 participants in the reference and test group, respectively, had patch adhesion ≥ 80% (EMA score 0 - 1) at end of treatment. Bioequivalence was demonstrated: GMRs for pharmacokinetic (PK) parameters ranged from 102.76 - 105.57% for NGMN and 93.78 - 94.80% for EE, and associated 90% CIs were fully within the bioequivalence acceptance range (80 - 125%) for both. The patches had comparable adhesion properties (GMR, 101.4% (90% CI: 99.2 - 103.6)) and incidences of treatment-emergent adverse events.

CONCLUSION

NGMN-EE transdermal test patch at EOSL was bioequivalent to the marketed patch at BOSL, supporting widening the product's shelf-life specification. Adhesive properties and safety profiles were comparable between patches.

The new low-dose transdermal contraceptive system (Twirla®): results from preclinical and Phase III trials

A new low-dose, once-a-week contraceptive transdermal delivery system (TDS) with 2.3-mg ethinyl estradiol (EE) and 2.6-mg levonorgestrel (LNG; Twirla^®) has recently been approved by the US FDA for contraception of women with BMI <30 kg/m². The rationale for developing this new patch, the preclinical study results and the results from two innovative Phase III clinical trials demonstrate that this patch has an acceptable Pearl index (4.3%) for its indicated users and has safety and tolerability comparable to other similar dose oral combined hormonal contraceptives. This new TDS provides an improvement over the existing TDS products, with significantly lower steady-state estrogen exposure, a level equal to that with 30-µg EE containing oral contraceptives.

Comparison of a transdermal contraceptive patch with a newly sourced adhesive component versus EVRA patch: A double-blind, randomized, bioequivalence and adhesion study in healthy women

OBJECTIVE

To evaluate the bioequivalence of norelgestromin and ethinyl estradiol (NGMN-EE) and adhesion of a transdermal contraceptive patch containing a newly sourced adhesive component (test) compared with the marketed (reference) patch.

STUDY DESIGN

In this randomized, double-blind, 2-way crossover study, healthy women received single 7-day application of both test and reference patches. Treatment phase included two treatment periods of 11 days each separated by a 21-day washout period starting from day of patch removal (day 8) of treatment period 1. Assessments included NGMN and EE pharmacokinetics (PK), adhesion using European Medicines Agency (EMA) 5-point scale, irritation potential and application-site reactions, and safety. Patches were bioequivalent if 90% CIs of ratios of means of test/reference for AUC_168h, AUC_inf, and C_ss fell within 80-125%. Patch adhesion was comparable if ratios of mean cumulative adhesion percentage values of test/reference were ≥90.0%.

RESULTS

Seventy women were randomized; 57 completed both treatments with ≥80% adhesion (score 0-1). Bioequivalence of test and reference patches was demonstrated as 90% CI of ratio of geometric means for AUC_168h, AUC_inf, and C_ss for NGMN and EE fell within 80-125%. Both patches had similar adhesion properties (geometric mean ratio was 100.3% [90% CI, 93.2-107.9]). Similar rates of mild-to-moderate itching (11% vs 10%) and erythema events (79% vs 74%) were reported for test and reference patches, respectively, on day 8.

CONCLUSIONS

The test patch with the newly sourced adhesive component is bioequivalent to the currently marketed NGMN-EE transdermal patch and has similar adhesion and irritation potential.

IMPLICATIONS STATEMENT

The norelgestromin and ethinyl estradiol transdermal patch containing a newly sourced adhesive component is bioequivalent to the currently marketed patch for both active moieties. Both patches had similar adhesion, irritation potential, and safety profiles.

Delivery Strategies for Skin: Comparison of Nanoliter Jets, Needles and Topical Solutions

Drug diffusion within the skin with a needle-free micro-jet injection (NFI) device was compared with two well-established delivery methods: topical application and solid needle injection. A permanent make-up (PMU) machine, normally used for dermal pigmentation, was utilized as a solid needle injection method. For NFIs a continuous wave (CW) laser diode was used to create a bubble inside a microfluidic device containing a light absorbing solution. Each method delivered two different solutions into ex vivo porcine skin. The first solution consisted of a red dye (direct red 81) and rhodamine B in water. The second solution was direct red 81 and rhodamine B in water and glycerol. We measured the diffusion depth, width and surface area of the solutions in all the injected skin samples. The NFI has a higher vertical dispersion velocity of 3 × 10⁵μm/s compared to topical (0.1 μm/s) and needle injection (53 μm/s). The limitations and advantages of each method are discussed, and we conclude that the micro-jet injector represents a fast and minimally invasive injection method, while the solid needle injector causes notable tissue damage. In contrast, the topical method had the slowest diffusion rate but causes no visible damage to the skin.

Transdermal delivery of combined hormonal contraception: a review of the current literature

The transdermal patch provides an effective and convenient option for hormonal contraception. The patch currently on the US market contains 150 µg norelgestromin and 35 µg ethinylestradiol (EE). The 20 cm² patch is applied once weekly for 3 weeks, followed by a patch-free week, for a 21–7 cycle. Typical failure rates are similar to that of combined oral contraceptives (COCs). Transdermal delivery results in less peaks and troughs of estrogen, but a higher total estrogen exposure compared with COCs. Though studies show mixed results, the risk of developing venous thromboembolism (VTE) is about twice as high with the patch as with COCs; however, the absolute risk of VTE remains low. The side effect profile is similar to that of COCs, with slightly higher rates of breast tenderness plus a unique adverse effect of application site reactions. Two new patches have been developed, one containing gestodene and EE in Europe and another containing levonorgestrel and EE. Overall, the patch provides an alternative to COCs for women who want autonomy and the benefit of not needing to take a pill daily, with similar efficacy and tolerability.

Predictors of unintended pregnancy in women with epilepsy

Objective:

To determine whether rates of unintended pregnancy in women with epilepsy (WWE) vary by contraceptive category and when stratified by antiepileptic drug (AED) category.

Methods:

These retrospective data come from the Epilepsy Birth Control Registry (EBCR) web-based survey of 1,144 WWE in the community, 18–47 years of age, who provided demographic, epilepsy, AED, contraceptive, and pregnancy data. Participants indicated whether pregnancies were intended or unintended, as well as the type of contraceptive and AED used at conception. We report failure rates relative to the frequency of use of each contraceptive category in the EBCR.

Results:

Most WWE (78.9%) reported having at least one unintended pregnancy; 65.0% of their pregnancies were unintended. Unintended pregnancy was more common among younger, racial minority, and Hispanic WWE. Among reversible contraceptive categories, the intrauterine device had the lowest failure rate. Failure rates varied greatly on systemic hormonal contraception (HC), depending on whether oral or nonoral forms were used and especially in relation to the category of AED with which HC was combined. Oral forms had greater failure rate than nonoral forms. HC combined with enzyme-inducing AEDs had a substantially greater failure rate than HC combined with no AED or any other AED category and in comparison to barrier plus any AED category. Other AED–HC combinations, in contrast, carried lower risks than barrier.

Conclusions:

Unintended pregnancy is common among WWE and may vary by contraceptive category and AED stratification. In view of the important consequences of unintended pregnancy on pregnancy outcomes, these retrospective findings warrant further prospective investigation.

Oral contraception

Oral contraception (OC) remains a popular noninvasive, readily reversible approach for pregnancy prevention and, largely off label, for control of acne, hirsutism, dysmenorrhea, irregular menstruation, menorrhagia, and other menstrual-related symptoms. Many OC formulations exist, with generics offering lower cost and comparable efficacy. Certain medical conditions, including hypertension, migraine, breast cancer, and risk of venous thromboembolism (VTE), present contraindications. Blood pressure measurement is the only physical examination or testing needed before prescription. Although no OC is clearly superior to others, OCs containing the second-generation progestin levonorgestrel have been associated with lower VTE risk than those containing other progestins.

Safety and tolerability of a new low-dose contraceptive patch in obese and nonobese women

OBJECTIVE

The safety and tolerability of a new low-dose levonorgestrel/ethinyl estradiol (LNG/EE) contraceptive patch was compared with 2 combination oral contraceptives in 2 clinical studies in which approximately 30% of enrolled participants were obese.

STUDY DESIGN

Two phase 3, open-label, randomized, parallel-group, multicenter trials compared the LNG/EE contraceptive patch (n = 1579) with combination oral contraceptives (n = 581) in healthy women 17-40 years of age. Combination oral contraceptives were LNG 100 μg per EE 20 μg (combination oral contraceptive 20; n = 375) or LNG 150 μg per EE 30 μg (combination oral contraceptive 30; n = 206). Safety and tolerability data from the 2 trials were evaluated in integrated safety analyses.

RESULTS

Treatment-emergent adverse events of 2% or greater in the LNG/EE contraceptive patch were nasopharyngitis (5.2%), nausea (4.1%), upper respiratory infection (3.5%), headache (3.4%), sinusitis (2.9%), cervical dysplasia (2.3%), and urinary tract infection (2.1%). Including skin reaction-related treatment-emergent adverse events, the proportion of women who experienced any treatment-emergent adverse event was similar among women randomized to the contraceptive patch (47.5%), the combination oral contraceptive 20 (47.4%), or the combination oral contraceptive 30 (46.8%). The incidence of treatment-emergent adverse events was similar in obese vs nonobese participants in all groups. Serious adverse events occurred in less than 1% of participants in any of the treatment groups.

CONCLUSION

The LNG/EE contraceptive patch and combination oral contraceptives were well tolerated and associated with similar treatment-emergent adverse event incidences in obese and nonobese women.

Permeation measurement of gestodene for some biodegradable materials using Franz diffusion cells

Biodegradable poly(d,l-lactide) (PDLLA), Poly(trimethylene carbonate) (PTMC), polycaprolactone (PCL), poly(caprolactone-co-d,l-lactide) (PCDLLA) and poly(trimethylene carbonate-co-caprolactone) (PTCL) are recently used for clinical drug delivery system such as subcutaneous contraceptive implant capsule due to their biodegradable properties that they could possess long-term stable performance in vivo without removal, however their permeation rate is unknown. In the work, biodegradable material membranes were prepared by solvent evaporation using chloroform, and commercial silicone rubber membrane served as a control. Gestodene was used as a model drug. Gestodene has high biologic progestational activity which allows for high contraceptive reliability at very low-dose levels. The permeation rate of gestodene for several biodegradable materials was evaluated. In vitro diffusion studies were done using Franz diffusion cells with a diffusion area of 1.33 cm². Phosphate buffer solution (PBS, pH 7.4), 10% methanol solution and distilled water were taken in donor and receiver chambers at temperature of 37 °C respectively. The in vitro experiments were conducted over a period of 24 h during which samples were collected at regular intervals. The withdrawn samples were appropriately diluted and measured on UV–vis spectrophotometer at 247 nm. Conclusion data from our study showed that permeation rate of PCDLLA with CL ratio more than 70% could be more excellent than commercial silicone rubber membrane. They may be suitable as a candidate carrier for gestodene subcutaneous contraceptive implants in contraceptive fields.

Self-reported and verified compliance in a phase 3 clinical trial of a novel low-dose contraceptive patch and pill

OBJECTIVE

Pregnancy rates in US contraceptive clinical trials are increasing due to decreased treatment compliance. This study compared compliance with a new low-dose levonorgestrel (LNG) and ethinyl estradiol (EE) contraceptive patch (CP, Twirla™) with that of a low-dose combination oral contraceptive (COC) in a demographically diverse population.

STUDY DESIGN

This analysis was part of an open-label, parallel-group, multicenter phase 3 study that randomized healthy sexually active women (17-40years) to 13cycles of LNG/EE CP or 6cycles of COC, then 7cycles of LNG/EE CP. We defined self-reported compliance as cycles that, according to diaries, show 21days of patch wear without missed days or any patch worn >7days or 21days of pill-taking without missed pill days. We verified compliance by detectable plasma presence of LNG and EE at cycles 2, 6, and 13.

RESULTS

Of the intention-to-treat population with diary information (N=1328, mean age 26.4years, 46% minorities, 33% obese), 10.0% of the CP (n=998) versus 21.2% of the COC group (n=330) self-reported noncompliance after 6cycles (p<.001). Laboratory assessments verified 10-14% of participants in both groups as noncompliant. Self-reported perfect use did not vary between obese [body mass index (BMI) ≥30kg/m(2)] versus nonobese (BMI <30kg/m(2)) participants in both groups or when stratified by age, education, or race/ethnicity in the CP group.

CONCLUSIONS

Self-reported compliance was significantly greater in the CP than COC group and did not vary by obesity status. Discrepancies between self-reported and verified compliance question reliability of patient diaries.

IMPLICATIONS STATEMENT

This paper, based on an analysis of a phase 3 trial, shows that compliance was significantly greater with a new weekly transdermal CP than with a once-daily COC in obese as well as nonobese participants. Discrepancies between self-reported compliance and laboratory-verified compliance raise questions regarding the reliability of patient diaries.

Risk drinking and contraception effectiveness among college women

Risk drinking, especially binge drinking, and unprotected sex may co-occur in college women and increase the risks of STI exposure and pregnancy, but the relationships among these behaviors are incompletely understood. A survey was administered to 2012 women of ages 18-24 enrolled in a public urban university. One-quarter of the college women (23%) drank eight or more drinks per week on average, and 63% binged in the past 90 days, with 64% meeting criteria for risk drinking. Nearly all sexually active women used some form of contraception (94%), but 18% used their method ineffectively and were potentially at risk for pregnancy. Forty-four percent were potentially at risk for STIs due to ineffective or absent condom usage. Ineffective contraception odds were increased by the use of barrier methods of contraception, reliance on a partner's decision to use contraception, and risk drinking, but were decreased by the use of barrier with hormonal contraception, being White, and later age to initiate contraception. In contrast, ineffective condom use was increased by reliance on a partner's decision to use condoms, the use of condoms for STI prevention only, and by risk drinking. Thirteen percent of university women were risk drinkers and using ineffective contraception, and 31% were risk drinkers and failing to use condoms consistently. Risk drinking is related to ineffective contraception and condom use. Colleges should promote effective contraception and condom use for STI prevention and consider coordinating their programs to reduce drinking with programs for reproductive health. Emphasizing the use of condoms for both pregnancy prevention and STI prevention may maximize women's interest in using them.

Contraception for adolescents

A working knowledge of contraception will assist the pediatrician in both sexual health promotion as well as treatment of common adolescent gynecologic problems. Best practices in adolescent anticipatory guidance and screening include a sexual health history, screening for pregnancy and sexually transmitted infections, counseling, and if indicated, providing access to contraceptives. Pediatricians' long-term relationships with adolescents and families allow them to help promote healthy sexual decision-making, including abstinence and contraceptive use. Additionally, medical indications for contraception, such as acne, dysmenorrhea, and heavy menstrual bleeding, are frequently uncovered during adolescent visits. This technical report provides an evidence base for the accompanying policy statement and addresses key aspects of adolescent contraceptive use, including the following: (1) sexual history taking, confidentiality, and counseling; (2) adolescent data on the use and side effects of newer contraceptive methods; (3) new data on older contraceptive methods; and (4) evidence supporting the use of contraceptives in adolescent patients with complex medical conditions.

Influence of structured counseling on women's selection of hormonal contraception in Israel: results of the CHOICE study

Background

The multinational CHOICE (Contraceptive Health Research Of Informed Choice Experience) study evaluated the effects of structured counseling on women’s contraceptive decisions, their reasons for making those decisions, and their perceptions of combined hormonal contraceptive (CHC) methods in eleven countries. The aim of this paper to present data from the 1,802 women participating in Israel’s CHOICE program.

Methods

Women (aged 17–40 years) who consulted their health care providers about contraception and who would consider a CHC method qualified to participate. After indicating their intended CHC method, the women received counseling about the daily pill, weekly patch, and monthly vaginal ring. After counseling, the women completed a questionnaire about their contraceptive decisions.

Results

Before counseling, 67%, 6%, and 5% of women (mean age 27 years) intended to use the pill, patch, or ring, respectively. Counseling significantly influenced the women’s CHC choice, with 56%, 12%, and 23% of women selecting the pill, patch, or ring (P<0.0001 for all contraceptive methods versus before counseling). Logistic regression analysis suggested that age significantly increased the probability of switching from the pill to the ring.

Conclusion

Although the pill was the most popular choice overall, counseling appeared to influence Israeli women’s contraceptive decisions, with significantly more women selecting the patch. More than four times as many women selected the ring after counseling than before counseling.

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.

Skin patch and vaginal ring versus combined oral contraceptives for contraception

BACKGROUND

The delivery of combination contraceptive steroids from a transdermal contraceptive patch or a contraceptive vaginal ring offers potential advantages over the traditional oral route. The transdermal patch and vaginal ring could require a lower dose due to increased bioavailability and improved user compliance.

OBJECTIVES

To compare the contraceptive effectiveness, cycle control, compliance (adherence), and safety of the contraceptive patch or the vaginal ring versus combination oral contraceptives (COCs).

SEARCH METHODS

Through February 2013, we searched MEDLINE, POPLINE, CENTRAL, LILACS, ClinicalTrials.gov, and ICTRP for trials of the contraceptive patch or the vaginal ring. Earlier searches also included EMBASE. For the initial review, we contacted known researchers and manufacturers to identify other trials.

SELECTION CRITERIA

We considered randomized controlled trials comparing a transdermal contraceptive patch or a contraceptive vaginal ring with a COC.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors and entered into RevMan. For dichotomous variables, the Peto odds ratio (OR) with 95% confidence intervals (CI) was calculated. For continuous variables, the mean difference was computed. We also assessed the quality of evidence for this review.

MAIN RESULTS

We found 18 trials that met our inclusion criteria. Of six patch studies, five examined the marketed patch containing norelgestromin plus ethinyl estradiol (EE); one studied a patch in development that contains levonorgestrel (LNG) plus EE. Of 12 vaginal ring trials, 11 examined the same marketing ring containing etonogestrel plus EE; one studied a ring being developed that contains nesterone plus EE.Contraceptive effectiveness was not significantly different for the patch or ring versus the comparison COC. Compliance data were limited. Patch users showed better compliance than COC users in three trials. For the norelgestromin plus EE patch, ORs were 2.05 (95% CI 1.83 to 2.29) and 2.76 (95% CI 2.35 to 3.24). In the levonorgestrel plus EE patch report, patch users were less likely to have missed days of therapy (OR 0.36; 95% CI 0.25 to 0.51). Of four vaginal ring trials, one found ring users had more noncompliance (OR 3.99; 95% CI 1.87 to 8.52), while another showed more compliance with the regimen (OR 1.67; 95% CI 1.04 to 2.68).More patch users discontinued early than COC users. ORs from two meta-analyses were 1.59 (95% CI 1.26 to 2.00) and 1.56 (95% CI 1.18 to 2.06) and another trial showed OR 2.57 (95% CI 0.99 to 6.64). Patch users also had more discontinuation due to adverse events than COC users. Users of the norelgestromin-containing patch reported more breast discomfort, dysmenorrhea, nausea, and vomiting. In the levonorgestrel-containing patch trial, patch users reported less vomiting, headaches, and fatigue.Of 11 ring trials with discontinuation data, two showed the ring group discontinued less than the COC group: OR 0.32 (95% CI 0.16 to 0.66) and OR 0.52 (95% CI 0.31 to 0.88). Ring users were less likely to discontinue due to adverse events in one study (OR 0.32; 95% CI 0.15 to 0.70). Compared to the COC users, ring users had more vaginitis and leukorrhea but less vaginal dryness. Ring users also reported less nausea, acne, irritability, depression, and emotional lability than COC users.For cycle control, only one trial study showed a significant difference. Women in the patch group were less likely to have breakthrough bleeding and spotting. Seven ring studies had bleeding data; four trials showed the ring group generally had better cycle control than the COC group.

AUTHORS' CONCLUSIONS

Effectiveness was not significantly different for the methods compared. Pregnancy data were available from half of the patch trials but two-thirds of ring trials. The patch could lead to more discontinuation than the COC. The patch group had better compliance than the COC group. Compliance data came from half of the patch studies and one-third of the ring trials. Patch users had more side effects than the COC group. Ring users generally had fewer adverse events than COC users but more vaginal irritation and discharge.The quality of the evidence for this review was considered low for the patch and moderate for the ring. The main reasons for downgrading were lack of information on the randomization sequence generation or allocation concealment, the outcome assessment methods, high losses to follow up, and exclusions after randomization.

Contraception technology: past, present and future

Steady progress in contraception research has been achieved over the past 50 years. Hormonal and nonhormonal modern contraceptives have improved women's lives by reducing different health conditions that contributed to considerable morbidity. However, the contraceptives available today are not suitable to all users, and the need to expand contraceptive choices still exists. Novel products such as new implants, contraceptive vaginal rings, transdermal patches and newer combinations of oral contraceptives have recently been introduced in family planning programs, and hormonal contraception is widely used for spacing and limiting births. Concerns over the adverse effects of hormonal contraceptives have led to research and development of new combinations with improved metabolic profile. Recent developments include use of natural compounds such as estradiol and estradiol valerate with the hope to decrease thrombotic risk, in combination with newer progestins derived from the progesterone structure or from spirolactone, in order to avoid the androgenic effects. Progesterone antagonists and progesterone receptor modulators are highly effective in blocking ovulation and preventing follicular rupture and are undergoing investigations in the form of oral pills and in semi-long-acting delivery systems. Future developments also include the combination of a contraceptive with an antiretroviral agent for dual contraception and protection against sexually transmitted diseases, to be used before intercourse or on demand, as well as for continuous use in dual-protection rings. Although clinical trials of male contraception have reflected promising results, limited involvement of industry in that area of research has decreased the likelihood of having a male method available in the current decade. Development of nonhormonal methods is still at an early stage of research, with the identification of specific targets within the reproductive system in ovaries and testes, as well as interactions between spermatozoa and ova. It is hoped that the introduction of new methods with additional health benefits would help women and couples with unmet needs to obtain access to a wider range of contraceptives with improved acceptability.

Ovarian activity in obese and nonobese women treated with three transdermal contraceptive patches delivering three different doses of ethinyl estradiol and levonorgestrel

BACKGROUND

The effect of obesity on ovarian follicular suppression in women using low-estrogen dose contraceptive patches has not been determined.

STUDY DESIGN

A Phase II, parallel-group, multicenter, three-cycle study evaluated three patches containing different ethinyl estradiol (EE) and levonorgestrel (LNG) doses. Serum levels of EE, LNG, sex hormone-binding globulin and progesterone were compared in 41 obese [body mass index (BMI) ≥30] and 75 nonobese (BMI <30) women.

RESULTS

Suppression of ovulation during the luteal phase was dose dependent, with the highest dose (AG200-15) preventing progesterone increases in all women (cycles 2-3). In the follicular phase, the lowest-dose patch had the highest rate of increased progesterone in nonobese subjects. Progesterone levels ≥3.0 ng/mL in the follicular phase were more common in obese than nonobese women.

CONCLUSIONS

AG200-15 suppresses ovulation in obese and nonobese women. All three patches found increased progesterone in the follicular phase, albeit more in obese versus nonobese women.

Acceptability of PrEP for HIV prevention among women at high risk for HIV

OBJECTIVE

To assess the acceptability of a daily pill for prevention of HIV acquisition among 400 Ghanaian women in the oral tenofovir disoproxil fumarate (TDF) clinical trial.

METHODS

Structured questionnaires were conducted with women enrolled in the trial at enrollment and at each of the 12 monthly follow-up visits. Growth curve analysis was used to examine adherence patterns over time. Qualitative interviews were carried out with a subsample of the clinical trial population, and thematic analysis was applied to these data.

RESULTS

Overall, acceptability of the pill was good. Adherence remained > 82% throughout the 12-month trial. Consistent access to the pill and study assignment were both associated with adherence. Most reported problems diminished over time as women became accustomed to the pill and developed strategies to incorporate pill taking into their daily routines.

CONCLUSIONS

If daily preexposure prophylaxis (PrEP) for HIV is found to be efficacious and has as few physical side effects as TDF, acceptability of this method among women in the study population may not be problematic. However, future studies must develop better acceptability measures, in order to more fully address the relationship among adherence, safety, and effectiveness.

High levels of women's satisfaction and compliance with transdermal contraception: results from a European multinational, 6-month study

OBJECTIVE

To investigate compliance, satisfaction, and preference in women using a transdermal contraceptive patch.

METHODS

Women (18-46 years) from eight European countries used contraceptive patches (norelgestromin 6 mg, ethinylestradiol 600 μg) for six, 4-week treatment cycles. Compliance, satisfaction, and preference were assessed after 3 and 6 cycles and study completion using self-report methods.

RESULTS

Of the 778 participants, 36.8% (n = 287) used no contraception at baseline. The most common methods were oral contraceptives (67.9%, n = 334) and barrier methods (21.5%, n = 106). Of oral contraception users, 63.5% (n = 212) were satisfied or very satisfied with their previous method, but compliance was poor with 77.8% (n = 260) reporting missed doses. After 3 and 6 cycles, >80% of all included women were satisfied or very satisfied with the patch. At study completion, most participants (73.7%) reported a preference for the patch compared to their previous method. Of 4107 cycles, 3718 (90.5%) were completed with perfect compliance. Two pregnancies occurred during this study, representing a Pearl Index of 0.63. No new safety issues were identified and the patch was well tolerated.

CONCLUSION

Women were highly satisfied with transdermal contraception and preferred this form of family planning over their previous method. Transdermal contraception represents a valuable addition to contraceptive options with potential to offer high compliance and efficacy.

Adolescents' experiences using the contraceptive patch versus pills

STUDY OBJECTIVE

To compare use of the weekly transdermal contraceptive patch (patch) with daily combined hormonal contraceptive pills (pills) in adolescents.

DESIGN

Prospective longitudinal study of adolescents' self-selected (non-randomized) use of the patch or pills.

SETTING

Urban, university hospital-affiliated, adolescent outpatient clinic.

PARTICIPANTS

13-22-year-old female adolescents seeking hormonal contraception, 40 who chose the patch and 40 who chose pills.

INTERVENTIONS

Data were collected via self-report on paper questionnaires at three-cycle intervals for a total of up to nine cycles.

MAIN OUTCOME MEASURES

Method continuation, perfect use, method satisfaction, quality of life, and side effects, including menstrual changes and perceived mood changes.

RESULTS

After nine cycles, 38% of patch users and 60% of pill users were still using the method they had chosen at enrollment. There were no significant differences between the groups in self-reported perfect use. No differences were found in quality of life or side effects. Both patch and pill users noted menses became lighter and more predictable and reported decreased depression prior to their menses; only the pill group reported improvement in premenstrual anger. Method satisfaction was similar in both groups except patch users were more likely to report that their contraceptive method improved normal daily activities.

CONCLUSIONS

Despite apparent advantages of the patch over the pill, adolescents using both methods continue to face challenges achieving perfect and sustained contraceptive use.

Pharmacokinetics, tolerability and cycle control of three transdermal contraceptive delivery systems containing different doses of ethinylestradiol and levonorgestrel

BACKGROUND

The only available contraceptive patch, Ortho Evra®, delivers a relatively high dose of estrogen.

MATERIALS AND METHODS

Three transdermal contraceptive delivery systems (TCDS) containing low doses of ethinylestradiol (EE) and levonorgestrel (LNG) were evaluated in two open-label randomized trials. In a phase 1, two-period, cross-over trial, AG200-12.5 and AG200LE were compared with a 150 μg LNG/30 μg EE oral contraceptive (OC) (Levlen®) in 39 women. In a phase 2, parallel-group, multicenter, three-cycle study, AG200LE, AG200-12.5 and a higher-dose formulation, AG200-15, were evaluated in 123 women.

RESULTS

In Study 1, mean steady-state plasma concentrations (Css, pg/mL) for the TCDS were 17 pg/mL to 26 pg/mL for EE and 1117 pg/mL to 1505 pg/mL for LNG (for AG200LE and AG200-12.5 respectively). Maximum concentration (Cmax) and Css for both analytes were significantly lower than for Levlen. In both studies, the Css levels for EE and LNG in all groups were within the ranges reported for low-dose OCs. Cycle control for AG200-15, assessed by breakthrough bleeding and spotting episodes as well as number of days of unscheduled bleeding and/or spotting, was similar to that reported for low-dose OCs. Most adverse events were considered mild to moderate in intensity. The incidence of patches falling off was <2%.

CONCLUSIONS

All three patches exhibited excellent safety and wearability profiles while maintaining plasma drug levels required for ovulation suppression and adequate cycle control. A slight increase in the EE dose in AG200-15 still places this TCDS within the range of low-dose OCs, with EE exposure much lower than reported for Ortho Evra. AG200-15 was selected for further testing in phase 3 studies.

Three-dimensional skin models as tools for transdermal drug delivery: challenges and limitations

INTRODUCTION

Transdermal drug delivery has several known advantages over the oral route and hypodermic injections. The number of drugs that can be taken up transdermally is, however, limited owing to the innate barrier function of the skin. New transdermal drug candidates need to be tested extensively before being used on humans. In this regard, in vitro permeation methods are highly important to predict in vivo permeation of drugs.

AREAS COVERED

This review illustrates how different types of reconstructed skin models are being used as alternatives to human and pig skin for in vitro permeation testing of drugs. Insights into how various factors (including the physicochemical nature of molecules and formulations) or skin properties might affect the permeability of drugs in reconstructed skin models are provided. Also, opportunities and pitfalls of reconstructed skin models are highlighted.

EXPERT OPINION

Many studies have revealed that the permeability of reconstructed skin models is much higher compared with human excised skin. This is in accordance with the incomplete barrier found in these models. Nevertheless, the reconstructed skin models available today are useful tools for estimating the rank order of percutaneous absorption of a series of compounds with different physicochemical properties. A major challenge in the further development of reconstructed skin models for drug delivery studies is to obtain a barrier function similar to in vivo skin. Whether this goal will be achieved in the near future is uncertain and will be, in the authors' opinion, a very difficult task.

Contraceptive failure in the United States

This review provides an update of previous estimates of first-year probabilities of contraceptive failure for all methods of contraception available in the United States. Estimates are provided of probabilities of failure during typical use (which includes both incorrect and inconsistent use) and during perfect use (correct and consistent use). The difference between these two probabilities reveals the consequences of imperfect use; it depends both on how unforgiving of imperfect use a method is and on how hard it is to use that method perfectly. These revisions reflect new research on contraceptive failure both during perfect use and during typical use.

Why do women experience untimed pregnancies? A review of contraceptive failure rates

Contraceptive failure contributes to a substantial proportion of unintended pregnancy, particularly in the developed world. A number of socio-demographic factors seem to impact on the risk of a woman experiencing contraceptive failure. Many of the issues exist across cultural boundaries and are complex to address. In discussing the failure rates for individual contraceptive methods, this article will highlight the advantage of improving uptake of long-acting reversible methods of contraception which have a high efficacy and are less user-dependent than many of the other available methods.

Skin patch and vaginal ring versus combined oral contraceptives for contraception

BACKGROUND

The delivery of combination contraceptive steroids from a skin patch or vaginal ring offers potential advantages over the traditional oral route. The skin patch and vaginal ring could require a lower dose due to increased bioavailability and improved user compliance.

OBJECTIVES

To compare the contraceptive effectiveness, cycle control, adherence (compliance), and safety of the skin patch or the vaginal ring versus combination oral contraceptives (COCs).

SEARCH STRATEGY

For trials of the contraceptive patch or the vaginal ring, we searched MEDLINE, POPLINE, CENTRAL, EMBASE, LILACS, ClinicalTrials.gov, and ICTRP. We contacted manufacturers and researchers to identify other trials.

SELECTION CRITERIA

All randomized controlled trials comparing the skin patch or vaginal ring with a COC.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors and entered into RevMan. For dichotomous variables, the Peto odds ratio (OR) with 95% confidence intervals (CI) was calculated. For continuous variables, the mean difference was computed.

MAIN RESULTS

We found 5 trials of the skin patch and 10 of the vaginal ring. Contraceptive effectiveness was similar for the patch or ring versus the comparison COC. More patch users discontinued early than COC users: ORs were 1.59 (95% CI 1.26 to 2.00), 1.56 (95% CI 1.18 to 2.06), and 2.57 (95% CI 0.99 to 6.64). Patch users also had more discontinuation due to adverse events. Compared to COC users, patch users reported more breast discomfort, dysmenorrhea, nausea, and vomiting. Patch users reported more compliant cycles than the COC users in two trials: ORs were 2.05 (95% CI 1.83 to 2.29) and 2.76 (95% CI 2.35 to 3.24). The ring trials generally showed similar discontinuation for ring and COC users. Ring users reported less nausea, acne, irritability, and depression than COC users. Ring users had more vaginitis and leukorrhea but less vaginal dryness. Ring users had similar adherence to COC users in two trials but less adherence in one. Cycle control was generally similar for the patch and COC, and was similar or better for the ring versus COC.

AUTHORS' CONCLUSIONS

Effectiveness was similar for the methods compared. The patch could lead to more discontinuation while the vaginal ring showed little difference. The patch group had better compliance than the COC group but more side effects. Ring users generally had fewer adverse events than COC users but more vaginal irritation and discharge. High losses to follow up can affect the validity of the results.

Evaluation of menstrual bleeding patterns: a new proposal for a universal guideline based on the analysis of more than 4500 bleeding diaries

OBJECTIVE

To develop a universal guideline allowing the comparison of interventions like oral contraceptives and hormone replacement therapy with an impact on menstrual bleeding pattern.

METHODS

Literature analysis and cluster analysis of 4612 bleeding diaries.

RESULTS

We summarized key definitions needed for the evaluation of menstrual bleeding patterns from the literature. We developed a methodology to systematically evaluate menstrual bleeding patterns that distinguishes between cyclical and continuous hormonal regimens.

CONCLUSION

This universal guideline can be applied to all prospective clinical studies that affect menstrual bleeding patterns. It allows regulatory agencies and prescribing physicians to make meaningful comparisons of different products.

Satisfaction and compliance in hormonal contraception: the result of a multicentre clinical study on women's experience with the ethinylestradiol/norelgestromin contraceptive patch in Italy

Background

For many women finding the right contraceptive method can be challenging and consistent and correct use over a lifetime is difficult. Even remembering to take a birth control pill every day can be a challenge. The primary objective of this study was to evaluate women's experience with a weekly ethinylestradiol/norelgestromin contraceptive patch (EE/NGMN patch), given new technologies recently developed in hormonal contraception to increase women's options in avoiding daily dosing.

Methods

In 24 Italian sites, 207 women received the EE/NGMN patch for up to 6 cycles. At study end, overall satisfaction and preference, as well as compliance, efficacy and safety, were evaluated.

Results

175 women (84.5%) completed the study. The overall satisfaction rate was 88%; convenience and once-a-week frequency of the patch were especially appreciated. At baseline, 82 women (39.4%) were using a contraceptive method, mainly oral contraceptives and barrier methods, but only 45.1% were very satisfied/satisfied; after 6 months with the patch, 86.3% of this subset was very satisfied/satisfied. Considering the method used in the 3 months before the study entry, 78.1% strongly preferred/preferred the patch, for convenience (53.9%), ease of use/simplicity (28.9%), fewer (9.2%) and less severe (2.6%) side effects. Compliance was very high: 1034/1110 cycles (93.2%) were completed with perfect compliance and the mean subject's compliance score was 90%. One on-therapy pregnancy occurred. The patch was safe and well tolerated: adverse events frequency was low, with predominantly single reports of each event. Most of them started and subsided during cycle 1.

Conclusion

This study demonstrated that the EE/NGMN patch is associated with high satisfaction levels and excellent compliance. At study end, the majority of women indicated that they would continue using the patch.

Understanding contraceptive failure

Contraceptive failure is a major source of unintended pregnancy. This chapter will review sources of data and measurement of contraceptive failure, summarize results from the literature on the risks of contraceptive failure during typical and perfect use for available methods of contraception, provide a tool for communicating risks of contraceptive failure to clients, examine determinants of contraceptive failure, and identify methodological pitfalls in the published literature.

Dermal and Transdermal Drug Delivery Systems: Current and Future Prospects

The protective function of human skin imposes physicochemical limitations to the type of permeant that can traverse the barrier. For a drug to be delivered passively via the skin it needs to have adequate lipophilicity and also a molecular weight <500 Da. These requirements have limited the number of commercially available products based on transdermal or dermal delivery. Various strategies have emerged over recent years to optimize delivery and these can be categorized into passive and active methods. The passive approach entails the optimization of formulation or drug carrying vehicle to increase skin permeability. Passive methods, however do not greatly improve the permeation of drugs with molecular weights >500 Da. In contrast active methods that normally involve physical or mechanical methods of enhancing delivery have been shown to be generally superior. Improved delivery has been shown for drugs of differing lipophilicity and molecular weight including proteins, peptides, and oligonucletides using electrical methods (iontophoresis, electroporation), mechanical (abrasion, ablation, perforation), and other energy-related techniques such as ultrasound and needless injection. However, for these novel delivery methods to succeed and compete with those already on the market, the prime issues that require consideration include device design and safety, efficacy, ease of handling, and cost-effectiveness. This article provides a detailed review of the next generation of active delivery technologies.

Cost savings from the provision of specific methods of contraception in a publicly funded program

OBJECTIVES

We examined the cost-effectiveness of contraceptive methods dispensed in 2003 to 955,000 women in Family PACT (Planning, Access, Care and Treatment), California's publicly funded family planning program.

METHODS

We estimated the number of pregnancies averted by each contraceptive method and compared the cost of providing each method with the savings from averted pregnancies.

RESULTS

More than half of the 178,000 averted pregnancies were attributable to oral contraceptives, one fifth to injectable methods, and one tenth each to the patch and barrier methods. The implant and intrauterine contraceptives were the most cost-effective, with cost savings of more than $7.00 for every $1.00 spent in services and supplies. Per $1.00 spent, injectable contraceptives yielded savings of $5.60; oral contraceptives, $4.07; the patch, $2.99; the vaginal ring, $2.55; barrier methods, $1.34; and emergency contraceptives, $1.43.

CONCLUSIONS

All contraceptive methods were cost-effective-they saved more in public expenditures for unintended pregnancies than they cost to provide. Because no single method is clinically recommended to every woman, it is medically and fiscally advisable for public health programs to offer all contraceptive methods.

Safety, efficacy and patient acceptability of the combined estrogen and progestin transdermal contraceptive patch: a review

The worldwide introduction of the first, unique patch for hormonal contraception (ethinyl estradiol/norelgestromin, EE/NGMN patch) was widely recognized as a significant event in the development of drug delivery systems. This innovation offers a number of advantages over the oral route, and extensive clinical trials have proved its safety, efficacy, effectiveness, and tolerability. The weekly administration and ease of use/simplicity of the EE/NGMN patch contribute to its acceptability, and help to resolve the two main problems of non-adherence, namely early discontinuation and inconsistent use. The patch offers additional benefits to adolescents (improvement of dysmenorrhea and acne), adults (improvement in emotional and physical well-being, premenstrual syndrome, and menstrual irregularities), and perimenopausal women (correction of hormonal imbalance, modulation of premenopausal symptoms), thus providing high satisfaction rates (in nearly 90% of users). Since its introduction, the transdermal contraceptive patch has proved to be a useful choice for women who seek a convenient formulation which is easy to use, with additional, non-contraceptive tailored benefits for all the ages.

Skin patch and vaginal ring versus combined oral contraceptives for contraception

BACKGROUND

The delivery of combination contraceptive steroids from a skin patch or vaginal ring offers potential advantages over the traditional oral route. The skin patch and vaginal ring could require a lower dose due to increased bioavailability and improved user compliance.

OBJECTIVES

To compare the contraceptive effectiveness, cycle control, compliance, and safety of the skin patch or the vaginal ring versus combination oral contraceptives (COCs).

SEARCH STRATEGY

We searched MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS for trials of the contraceptive patch or the vaginal ring. We contacted manufacturers and researchers to identify other trials.

SELECTION CRITERIA

All randomized controlled trials comparing the skin patch or vaginal ring with a COC.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors and entered into RevMan. For dichotomous variables, the Peto odds ratio (OR) with 95% confidence intervals (CI) was calculated. For continuous variables, the weighted mean difference was computed.

MAIN RESULTS

We found three trials of the skin patch and eight of the vaginal ring. Contraceptive effectiveness was similar for the patch or ring and the comparison COC. Patch users reported more compliant cycles than COC users; ORs were 2.05 (95% CI 1.83 to 2.29) and 2.76 (95% CI 2.35 to 3.24) in two trials. One crossover ring trial had more noncompliance for the ring users. Satisfaction with method was higher for ring users than COC users in two studies. More patch users discontinued early than COC users: OR 1.58 (95% CI 1.25 to 1.99) and 1.45 (95% CI 1.11 to 1.90) in two trials. Patch users also had more discontinuation due to adverse events (AEs). The ring trials generally showed similar discontinuation for ring and COC users. Compared to COC users, patch users were more likely to report breast discomfort, dysmenorrhea, nausea, and vomiting. Ring users reported less nausea, irritability, and depression than COC users in single trials. However, ring users had more vaginitis and leukorrhea. Bleeding problems were generally similar or less common for the ring versus COC.

AUTHORS' CONCLUSIONS

Effectiveness rates were similar for the methods compared. The patch group had better compliance than the COC group. Compared to COC users, patch users had more side effects. Ring users generally had fewer adverse events than COC users but more vaginal irritation and discharge. The patch could lead to more discontinuation while the vaginal ring showed little difference. High losses to follow up can affect the validity of the results.

Transdermal drug delivery systems: skin perturbation devices

Human skin serves a protective function by imposing physicochemical limitations to the type of permeant that can traverse the barrier. For a drug to be delivered passively via the skin it needs to have a suitable lipophilicity and a molecular weight < 500 Da. The number of commercially available products based on transdermal or dermal delivery has been limited by these requirements. In recent years various passive and active strategies have emerged to optimize delivery. The passive approach entails the optimization of formulation or drug carrying vehicle to increase skin permeability. However, passive methods do not greatly improve the permeation of drugs with molecular weights >500 Da. In contrast, active methods, normally involving physical or mechanical methods of enhancing delivery, have been shown to be generally superior. The delivery of drugs of differing lipophilicity and molecular weight, including proteins, peptides and oligonucletides, has been shown to be improved by active methods such as iontophoresis, electroporation, mechanical perturbation and other energy-related techniques such as ultrasound and needleless injection. This chapter details one practical example of an active skin abrasion device to demonstrate the success of such active methods. The in vitro permeation of acyclovir through human epidermal membrane using a rotating brush abrasion device was compared with acyclovir delivery using iontophoresis. It was found that application of brush treatment for 10 s at a pressure of 300 N m(-2) was comparable to 10 min of iontophoresis. The observed enhancement of permeability observed using the rotating brush was a result of disruption of the cells of the stratum corneum, causing a reduction of the barrier function of the skin. However, for these novel delivery methods to succeed and compete with those already on the market, the prime issues that require consideration include device design and safety, efficacy, ease of handling, and cost-effectiveness. This chapter provides a detailed review of the next generation of active delivery technologies.

Transdermal hormonal contraception: benefits and risks

Transdermal drug delivery systems have been available in the United States for >20 years. Since the introduction of the first transdermal patch (scopolamine) for the treatment of motion sickness, >35 transdermal patch products have been approved by the US Food and Drug Administration for a variety of indications that include hormone replacement therapy, nicotine replacement therapy, chronic pain (fentanyl), angina (nitroglycerin), hypertension (clonidine), and more recently, overactive bladder (oxybutynin), and contraception (ethinyl estradiol/norelgestromin). Clinical data demonstrated the efficacy and safety of the contraceptive patch; however, concerns regarding estrogen levels and reports of venous thromboembolism led to the development of 2 epidemiologic studies and, subsequently, revised product labeling. Despite this, the contraceptive patch may be an appropriate option for some patients.