Concentration of depot medroxyprogesterone acetate and pain scores in adolescents: a randomized clinical trial

Hormonal and intrauterine methods for contraception for women aged 25 years and younger

BACKGROUND

Women between the ages of 15 and 24 years have high rates of unintended pregnancy; over half of women in this age group want to avoid pregnancy. However, women under age 25 years have higher typical contraceptive failure rates within the first 12 months of use than older women. High discontinuation rates may also be a problem in this population. Concern that adolescents and young women will not find hormonal or intrauterine contraceptives acceptable or effective might deter healthcare providers from recommending these contraceptive methods.

OBJECTIVES

To compare the contraceptive failure (pregnancy) rates and to examine the continuation rates for hormonal and intrauterine contraception among young women aged 25 years and younger.

SEARCH METHODS

We searched until 4 August 2015 for randomized controlled trials (RCTs) that compared hormonal or intrauterine methods of contraception in women aged 25 years and younger. Computerized databases included the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, CINAHL, and LILACS. We also searched for current trials via ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

We considered RCTs in any language that reported the contraceptive failure rates for hormonal or intrauterine contraceptive methods, when compared with another contraceptive method, for women aged 25 years and younger. The other contraceptive method could have been another intrauterine contraceptive, another hormonal contraceptive or different dose of the same method, or a non-hormonal contraceptive. Treatment duration must have been at least three months. Eligible trials had to include the primary outcome of contraceptive failure rate (pregnancy). The secondary outcome was contraceptive continuation rate.

DATA COLLECTION AND ANALYSIS

One author conducted the primary data extraction and entered the information into Review Manager. Another author performed an independent data extraction and verified the initial entry. For dichotomous outcomes, we computed the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). Because of disparate interventions and outcome measures, we did not conduct meta-analysis.

MAIN RESULTS

Five trials met the inclusion criteria. The studies included a total of 1503 women, with a mean of 301 participants. The trials compared the following contraceptives: combined oral contraceptive (COC) versus transdermal contraceptive patch, vaginal contraceptive ring, or levonorgestrel intrauterine system 20 µg/day (LNG-IUS 20); LNG-IUS 12 µg/day (LNG-IUS 12) versus LNG-IUS 16 µg/day (LNG-IUS 16); and LNG-IUS 20 versus the copper T380A intrauterine device (IUD). In the trials comparing two different types of methods, the study arms did not differ significantly for contraceptive efficacy or continuation. The sample sizes were small for two of those studies. The only significant outcome was that a COC group had a higher proportion of women who discontinued for 'other personal reasons' compared with the group assigned to the LNG-IUS 20 (OR 0.27, 95% CI 0.09 to 0.85), which may have little clinic relevance. The trial comparing LNG-IUS 12 versus LNG-IUS 16 showed similar efficacy over one and three years. In three trials that examined different LNG-IUS, continuation was at least 75% at 6 to 36 months.

AUTHORS' CONCLUSIONS

We considered the overall quality of evidence to be moderate to low. Limitations were due to trial design or limited reporting. Different doses in the LNG-IUS did not appear to influence efficacy over three years. In another study, continuation of the LNG-IUS appeared at least as high as that for the COC. The current evidence was insufficient to compare efficacy and continuation rates for hormonal and intrauterine contraceptive methods in women aged 25 years and younger.

Does research into contraceptive method discontinuation address women's own reasons? A critical review

OBJECTIVE

To examine the clinical and epidemiological literature addressing contraceptive method change or discontinuation and to assess whether the documented reasons reflected women's experiences.

METHODS

Major databases including Medline and PsycINFO were searched using keywords related to contraception and discontinuation, adherence and satisfaction, for articles published between January 2003 and February 2013. Studies in developed countries that focused on women of reproductive age and reasons for method change or discontinuation were included. Reasons reported were categorised and examined.

RESULTS

A total of 123 papers were reviewed in detail. Medical terminology was generally used to describe reasons for method discontinuation. The top two reported reasons were bleeding and pregnancy, but there was a lack of consensus about the categorisation of reasons. Broad categories that were not self-explanatory were included in more than half of the papers, often without further explanation. Only 12 studies expanded on categories containing 'other', 'non-medical' or 'personal' reasons. Eight papers included categories that attributed discontinuation to the participant, such as 'dissatisfied with method'.

CONCLUSIONS

Studies of reasons for discontinuation of contraceptives do not well describe women's specific reasons. Studies rely heavily on medical terms and often fail to document women's subjective experiences. Future studies should create an opportunity for women to articulate their non-medical reasons in their own words, including those related to their sexual lives. Furthermore, researchers should distinguish, if possible, between reasons for discontinuation of a method and reasons for ceasing participation in a research study.

Hormonal and intrauterine methods for contraception for women aged 25 years and younger

BACKGROUND

Women between the ages of 15 and 24 years have high rates of unintended pregnancy; over half of women in this age group want to avoid pregnancy. However, women under age 25 years have been found to have higher typical contraceptive failure rates within the first 12 months of use than older women. High discontinuation rates may also be a problem in this population. Concern that adolescents and young women will not find hormonal or intrauterine contraceptives acceptable or effective might deter healthcare providers from recommending these contraceptive methods. 

OBJECTIVES

This review examined randomized controlled trials of hormonal or intrauterine methods used for contraception in women aged 25 years and younger.

SEARCH METHODS

In February 2012, we searched the computerized databases Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, CINAHL, and LILACS for randomized controlled trials that compared hormonal or intrauterine methods used for contraception in women aged 25 years and younger. We also searched for current trials via ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

We considered all randomized controlled trials in any language that reported the contraceptive failure rates for hormonal or intrauterine contraceptive methods, when compared to another contraceptive method, for women aged 25 years and younger. The other contraceptive method could be another intrauterine method, another hormonal method, or a non-hormonal method. Treatment duration must have been at least three months.

DATA COLLECTION AND ANALYSIS

The first author extracted the data and entered the information into RevMan. Another author performed an independent data extraction and verified the initial entry. Because of disparate contraceptive exposures, we were not able to combine the studies in meta-analysis.

MAIN RESULTS

Four trials met the inclusion criteria. The trials compared the combined oral contraceptive versus the transdermal contraceptive patch, the combined oral contraceptive versus the vaginal contraceptive ring, the combined oral contraceptive versus the levonorgestrel intrauterine system, and the levonorgestrel intrauterine system versus the copper T380A intrauterine device. Because of small numbers of participants, the trials were not informative regarding contraceptive efficacy. Data on continuation rates were also limited. In one of these trials, the levonorgestrel intrauterine system was found to have a similar 12-month continuation rate as the combined oral contraceptive (odds ratio (OR) 1.48; 95% CI 0.76 to 2.89). In that trial, a higher proportion of women discontinued the levonorgestrel intrauterine system because of pain (OR 14.62; 95% CI 0.81 to 263.16), whereas a higher proportion of women discontinued the combined oral contraceptive for personal reasons (OR 0.27; 95% CI 0.09 to 0.85).

AUTHORS' CONCLUSIONS

Current evidence is insufficient to compare contraceptive efficacy and continuation rates for hormonal and intrauterine methods in women aged 25 years and younger. Limited data suggests that the levonorgestrel intrauterine system may be an acceptable alternative to the combined oral contraceptive in this population.

Contraception in Adolescence

Adolescents, due to the lack of knowledge, experience, and counseling, may confront serious social and health-related problems, such as out-of-wedlock pregnancies and sexually transmitted diseases (STDs). The age of the first sexual intercourse has declined recently. Unintended pregnancies often force adolescents into unwanted marriage or limit their opportunities to further education or employment while predisposing them to long-term welfare dependence. To be most effective, sex education programs should be developed through a process of collaboration between families, health care professionals, educators, government officials, and youth themselves. The contraceptive choices during adolescence are the male condom, the use of spermicides, combined oral contraceptives (COCs), the depomedroxyprogesterone acetate (DMPA), the female condom, the vaginal sponge, implants and patches, male hormonal contraception, and others. Issues of emergency contraception (EC) are also discussed.