Same-day initiation of the transdermal hormonal delivery system (contraceptive patch) versus traditional initiation methods

Hormonal Contraception: Systemic Estrogen and Progestin Preparations

Combined hormonal contraception (CHC) are short-acting, reversible methods containing both estrogen and progestin. Available CHC methods include combined oral contraceptives, transdermal patches, and vaginal rings. The combined oral contraceptive remains the most commonly used contraceptive method in the United States. The general principles of CHC will be reviewed, including mechanism of action and effectiveness. Unless otherwise stated, these principles apply to all CHCs. When discussing clinical studies and specific considerations related only to pills, patches, or rings, the method(s) will be specified. Words that specify sex are used when discussing studies in which sex was specified.

Risk of Pregnancy With Levonorgestrel-Releasing Intrauterine System Placement 6-14 Days After Unprotected Sexual Intercourse

Pregnancy is unlikely when a levonorgestrel-releasing intrauterine system (52 mg) is placed 6–14 days after unprotected intercourse.

Copper intrauterine device placement 6-14 days after unprotected sex

OBJECTIVE

To evaluate pregnancy risk following copper (CuT380A) intrauterine device (IUD) placement 6-14 days after unprotected intercourse.

STUDY DESIGN

We used a combined dataset from four protocols in which participants had received a CuT380A IUD regardless of recent unprotected intercourse. At entry, participants had negative point of care urine pregnancy testing and reported all acts of unprotected intercourse in the two weeks prior to IUD placement. We identified a subset of women who had placement 6-14 days after unprotected intercourse and provided follow-up information on pregnancy status 2-4 weeks after IUD insertion. This follow-up within the four protocols included self -administered home urine pregnancy test (UPT) results 2-4 weeks after IUD placement or continued contact for up to 6 months.

RESULTS

We identified 134 women who had a CuT380A IUD placed 6-14 days after unprotected intercourse and provided follow-up information on pregnancy status. Ninety-five (71%) participants reported UPT results 2-4 weeks after placement and the other 39 women were followed for 6 months after IUD placement to assess pregnancy status. Zero (97.5% CI 0-2.7%) participants reported a pregnancy within four weeks of CuT380A IUD placement.

CONCLUSION

In these collected data, no women with recent unprotected intercourse became pregnant within 1 month of CuT380A IUD placement.

IMPLICATION

These data indicate a low likelihood of pregnancy among women who reported unprotected intercourse 6-14 days preceding IUD insertion. For many women and their providers, these data may be sufficient to support same-day placement of a copper IUD rather than delaying IUD placement until the next menses.

Reproductive Health: Options, Strategies, and Empowerment of Women

Contraception is paramount to the overall health and longevity of women. Most women in the United States use birth control in their reproductive lifetimes. All options should be available and easily accessible to permit individualization and optimization of chosen methods. Current contraceptive methods available in the United States are reviewed. Emergency contraception, contraception in the postpartum period, and strategies to tailor methods to those affected by partner violence are also addressed. Tables and flow charts help providers and patients compare various contraceptive methods, optimize the start of a method, and identify resources for addressing safety in those with underlying medical conditions.

Quick starting hormonal contraception after using oral emergency contraception: a systematic review

INTRODUCTION

Unprotected intercourse after oral emergency contraception (EC) significantly increases pregnancy risk. This underlies the importance of promptly starting effective, ongoing contraception - known as 'quick starting'. However, theoretical concern exists that quick starting might interact with EC or hormonal contraception (HC) potentially causing adverse side effects.

METHOD

A systematic review was conducted, evaluating quick starting HC after oral EC [levonorgestrel 1.5 mg (LNG) or ulipristal acetate 30 mg (UPA)]. PubMed, EMBASE, The Cochrane Library, ICTRP, ClinicalTrials.gov and relevant reference lists were searched in February 2016. A lack of comparable studies prevented meta-analysis.

RESULTS

Three randomised controlled trials were identified. Two biomedical studies suggested HC action was unaffected by quick starting after UPA; one study examined ovarian quiescence (OR 1.27; 95% CI 0.51-3.18) while taking combined oral contraception (COC). Another assessed cervical mucus impenetrability (OR 0.76; 95% CI 0.27-2.13) while taking progestogen-only pills (POP). Quick starting POP reduced the ability of UPA to delay ovulation (OR 0.04; 95% CI 0.01-0.37). Side effects (OR 1.22; 95% CI 0.48-3.12) and unscheduled bleeding (OR 0.53; 95% CI 0.16-1.81) were unaffected by quick starting COC after UPA. Another study reported higher self-reported contraceptive use at 8 weeks among women quick starting POP after LNG, compared with women given LNG alone (OR 6.73; 95% CI 2.14-21.20).

Plan A: postabortion contraception

More than 1 million abortions are performed annually in the United States. Women presenting for abortion care are often motivated by the pregnancy to use effective contraception; they are also at high risk for repeat unintended pregnancy. For these reasons, abortion represents an optimal time to initiate effective contraception. There is strong evidence that most methods of contraception, including intrauterine devices and the contraceptive implant, should be initiated at the time of the abortion procedure. Most women ovulate within the first month after an abortion. If provision of contraception is delayed, women are less likely to use effective contraception and more likely to have a repeat unintended pregnancy. Although some methods of permanent contraception can be safely performed at the time of abortion, federal and state laws often restrict these procedures being performed concurrently. Contraceptive counseling and provision at the time of abortion are important strategies to decrease rates of unintended pregnancy.

Immediate versus delayed initiation of the contraceptive patch after abortion: a randomized trial

BACKGROUND

Immediate start of the contraceptive patch has not been studied in women after surgical abortion.

STUDY DESIGN

Women presenting for surgical abortion who had chosen the transdermal patch for contraception were randomized to either delayed start of the patch (beginning the Sunday after their abortion) or immediate start (directly observed application of the patch in the clinic). Subjects were contacted at 2 and 6 months to assess contraceptive use.

RESULTS

Two hundred ninety-eight women were randomized, and the follow-up rate was 71% at 2 months and 53% at 6 months. Method continuation did not differ by timing of initiation. At 2 months, 71% in the delayed-start group and 74% in the immediate-start group were using the patch [p=.6, with a difference of 3.1%, 95% confidence interval (CI)=-17.2% to +11.2%]. At 6 months, 55% in the delayed-start group and 43% in the immediate-start group were using the patch (p=.13, with a difference of 11.9%, 95% CI=-19.2% to +34%).

CONCLUSION

Immediate initiation of the contraceptive patch after surgical abortion was not associated with increased use of patch at 2 or 6 months.

Immediate start of hormonal contraceptives for contraception

BACKGROUND

Health care providers often tell women to wait until the next menses to begin hormonal contraception. The intent is to avoid contraceptive use during an undetected pregnancy. An alternative is to start hormonal contraception immediately with back-up birth control for the first seven days. Immediate initiation was introduced with combined oral contraceptives (COCs), and has expanded to other hormonal contraceptives. At the time of the initial review, how immediate start compared to conventional menses-dependent start was unclear regarding effectiveness, continuation, and acceptability. The immediate-start approach may improve women's access to, and continuation of, hormonal contraception.

OBJECTIVES

This review examined randomized controlled trials (RCTs) of immediate-start hormonal contraception for differences in effectiveness, continuation, and acceptability.

SEARCH METHODS

In August 2012, we searched MEDLINE, CENTRAL, POPLINE, LILACS, ClinicalTrials.gov, and ICTRP for trials of immediate-start hormonal contraceptives. We contacted researchers to find other studies. Earlier searches also included EMBASE.

SELECTION CRITERIA

We included RCTs that compared immediate start to conventional start of hormonal contraception. Also included were trials that compared immediate start of different hormonal contraceptive methods with each other.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors and entered into RevMan. The Peto odds ratio (OR) with 95% confidence interval (CI) was calculated.

MAIN RESULTS

Five studies were included. No new eligible studies have been found since the review was initially conducted. Method discontinuation was similar between groups in all trials. Bleeding patterns and side effects were similar in trials that compared immediate with conventional start. In a study of depot medroxyprogesterone acetate (DMPA), immediate start of DMPA showed fewer pregnancies than a 'bridge' method before DMPA (OR 0.36; 95% CI 0.16 to 0.84). Further, more women in the immediate-DMPA group were very satisfied versus those with a 'bridge' method (OR 1.99; 95% CI 1.05 to 3.77). A trial of two immediate-start methods showed the vaginal ring group had less prolonged bleeding (OR 0.42; 95% CI 0.20 to 0.89) and less frequent bleeding (OR 0.23; 95% CI 0.05 to 1.03) than COC users. The ring group also reported fewer side effects. Also, more immediate ring users were very satisfied than immediate COC users (OR 2.88; 95% CI 1.59 to 5.22).

AUTHORS' CONCLUSIONS

We found limited evidence that immediate start of hormonal contraception reduces unintended pregnancies or increases method continuation. However, the pregnancy rate was lower with immediate start of DMPA versus another method. Some differences were associated with contraceptive type rather than initiation method, i.e., immediate ring versus immediate COC. More studies are needed of immediate versus conventional start of the same hormonal contraceptive.

When can a woman start combined hormonal contraceptives (CHCs)? A systematic review

BACKGROUND

Conventional methods of initiating combined hormonal contraceptives (CHCs), specifically combined oral contraceptives (COCs), the contraceptive patch and the contraceptive ring, require that women delay starting CHCs until menses begin, during which time a woman may be at risk of unintended pregnancy. The objective of this systematic review is to examine the evidence on the risk of becoming pregnant after starting the method (contraceptive effectiveness including surrogate measures such as ovarian follicular development and hormone levels), risk of already being pregnant, side effects and continuation when starting CHCs on different days of the menstrual cycle.

STUDY DESIGN

We searched the MEDLINE database for all articles (in all languages) published in peer-reviewed journals from inception through March 2012 for evidence relevant to starting CHCs on different days of the menstrual cycle and the outcomes of contraceptive effectiveness (including ovarian follicular development and hormonal levels), side effects and continuation rates.

RESULTS

From 1635 reviewed articles, 18 studies met our inclusion criteria. Evidence from four studies suggests that neither the risk of inadvertently starting COCs in a woman who is pregnant nor the risk of pregnancy after COC initiation are affected by the cycle day on which COCs are started. While follicular activity increased as the cycle day on which COCs were initiated increased, no women ovulated when starting on Day 5. When starting on Day 7, there was no increase in ovulation for a 30-mcg pill but a significant increase in ovulation with a 20-mcg pill compared with starting on Day 1. Evidence from two small studies suggests that 7 days of pills leads to inhibition of ovulation. One small study suggests that only 3 days of ring use is needed to inhibit ovulation, but this was following one complete treatment cycle of ring use. Evidence also suggests that starting CHCs on any day of the cycle does not affect bleeding problems or other side effects for both COCs and the patch. While starting CHCs via Quick Start (starting on the day of the health care visit) may initially increase continuation compared with more conventional starting strategies, evidence suggests that this difference disappears over time.

CONCLUSION

The body of evidence suggested that (a) pregnancy rates did not differ by the timing of CHC initiation; (b) the more follicular activity that occurred prior to starting COCs, the more likely ovulation was to occur; however, no ovulations were seen when COCs were started at a follicle diameter of 10 mm (mean cycle day=7.6) or when the ring was started at follicle diameter of 13 mm (median cycle day=11); (c) bleeding patterns and other side effects did not vary with the timing of CHC initiation and (d) continuation rates of CHCs were initially improved by Quick Start, but differences between groups disappeared over time.

Adolescent contraception: review and guidance for pediatric clinicians

The objectives of this article are to review current contraceptive methods available to adolescents and to provide information, guidance, and encouragement to pediatric clinicians to enable them to engage in informed up-to-date interactions with their sexually active adolescent patients. Pregnancy prevention is a complex and dynamic process, and young people benefit from having a reliable authoritative source for information, counseling, and support. Clinicians who provide services for adolescents have a responsibility to develop their skills and knowledge base so that they can serve as that source. This review begins with a discussion about adolescent sexuality and pregnancy in the context of the adolescent developmental stages. We discuss approaches to introduce the topic of contraception during the clinic visit and contraceptive counseling techniques to assist with the discussion around this topic. In addition, information is included regarding confidential services, support of parental involvement, and the importance of male involvement in contraception. The specific contraceptive methods are reviewed in detail with the adolescent patient in mind. For each method, we discuss the mechanism of action, efficacy, contraindications, benefits and risks from the medical perspective, advantages and disadvantages from the patient's perspective, side effects, patient adherence, patient counseling, and any medication interactions. Furthermore, we have included a section that focuses on the contraceptive management for the adolescent patient with a disability and/or chronic illness. The article concludes with an approach to frequently asked or difficult questions. This section largely summarizes subsections on specific contraceptive methods and can be used as a quick reference on particularly challenging topics. Finally, a list of useful contraceptive management resources is provided for both clinicians and patients.

Effect of "observed start" vs. traditional "Sunday start" on hormonal contraceptive continuation rates after medical abortion

OBJECTIVE

This study was conducted to determine whether early initiation of combined hormonal contraception under direct clinical observation following successful medical abortion increases continuation rates with the method compared to traditional "Sunday start."

STUDY DESIGN

Women enrolled in a multicenter medical abortion trial with mifepristone and misoprostol who requested combined hormonal contraception (pill, ring or patch) following medical abortion were recruited. Women were randomized to initiate the method under supervision either at the 1-week medical abortion follow-up visit ("observed start") or at the first Sunday following this visit ("Sunday start"). Primary outcome was continuation of the chosen method at 6 weeks.

RESULTS

Of the 1128 women in the primary trial, 261 subjects enrolled in this substudy and 36/261 (13.8%) were lost to follow-up. There was no significant difference in method continuation at 6 weeks [observed start 108/114 (94.7%), Sunday start 101/111 (91.0%, p=.27].

CONCLUSION

Short-term continuation rates among those choosing hormonal contraception following medical abortion are high and are not significantly improved by initiating the method at the time of the first follow-up visit.

Immediate start of hormonal contraceptives for contraception

BACKGROUND

Health care providers often tell women to wait until the next menses to begin hormonal contraception. The main intent is to avoid contraceptive use during an undetected pregnancy. An alternative is to start hormonal contraception immediately with back-up birth control for the first seven days. Immediate initiation was first introduced with combined oral contraceptives (COCs), and has expanded to other hormonal contraceptives. How immediate start compares to conventional menses-dependent start is unclear regarding effectiveness, continuation, and acceptability. The immediate-start approach may improve women's access to, and continuation of, hormonal contraception.

OBJECTIVES

This review examined randomized controlled trials of immediate-start hormonal contraception for differences in effectiveness, continuation, and acceptability.

SEARCH STRATEGY

We searched MEDLINE, CENTRAL, POPLINE, EMBASE, and LILACS for trials of immediate-start hormonal contraceptives. We contacted researchers to find other studies.

SELECTION CRITERIA

We included randomized controlled trials that compared immediate start to conventional start of hormonal contraception. Also included were trials that compared immediate start of different hormonal contraceptive methods with each other.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors and entered into RevMan. The Peto odds ratio (OR) with 95% confidence interval (CI) was calculated.

MAIN RESULTS

Five studies were included. Method discontinuation was similar between groups in all trials. Bleeding patterns and side effects were similar in trials that compared immediate with conventional start. In a study of depot medroxyprogesterone acetate (DMPA), immediate start of DMPA showed fewer pregnancies than a 'bridge' method before DMPA (OR 0.36; 95% CI 0.16 to 0.84). Further, more women in the immediate-DMPA group were very satisfied versus those with a 'bridge' method (OR 1.99; 95% CI 1.05 to 3.77).A trial of two immediate-start methods showed the vaginal ring group had less prolonged bleeding (OR 0.42; 95% CI 0.20 to 0.89) and less frequent bleeding (OR 0.23; 95% CI 0.05 to 1.03) than COC users. The ring group also reported fewer side effects. For satisfaction, more immediate ring users were very satisfied than immediate COC users (OR 2.88; 95% CI 1.59 to 5.22).

AUTHORS' CONCLUSIONS

We found limited evidence that immediate start of hormonal contraception reduces unintended pregnancies or increases method continuation. However, the pregnancy rate was lower with immediate start of DMPA versus another method. Some differences were associated with contraceptive type rather than initiation method, that is, immediate ring versus immediate COC. More studies are needed of immediate versus conventional start of the same hormonal contraceptive.

Multicenter comparison of the contraceptive ring and patch: a randomized controlled trial

OBJECTIVE

To understand if the contraceptive ring or patch was more acceptable, as measured primarily by continuation, to women using an oral contraceptive and interested in a nondaily, combined hormonal contraceptive.

METHODS

Five hundred women were randomly assigned to use the contraceptive ring (n=249) or contraceptive patch (n=251) for four consecutive menstrual cycles, starting with their next menses. Participants returned for a single follow-up visit during the fourth cycle for an evaluation, which included a questionnaire to assess acceptability and adverse effects.

RESULTS

Rates of completion of three cycles were 94.6% (95% confidence interval [CI] 91.0-97.1%) and 88.2% (95% CI 83.4-92.0%) for ring and patch users, respectively (P=.03). Of these women, 71.0% (95% CI 64.8-76.6%) and 26.5% (95% CI 21.0-32.6%), respectively, planned to continue their method after the study (P<.001). Women switching to the patch were significantly more likely than women switching to the ring to experience longer periods (38% compared with 9%), increased dysmenorrhea (29% compared with 16%), frequent nausea (8% compared with 1%), frequent mood swings (14% compared with 8%), and frequent skin rash (12% compared with 2%) and were less likely to experience frequent vaginal discharge (8% compared with 17%). Ring users preferred the ring to the oral contraceptive (P<.001), and patch users preferred the oral contraceptive to the patch (P<.001). Nugent scores increased only in patch users (P=.01), although most of these women were asymptomatic.

CONCLUSION

Women satisfied with combined oral contraceptives and interested in a nondaily method are more likely to continue using the contraceptive ring than the contraceptive patch.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00269620.

LEVEL OF EVIDENCE

I.

The impact of programs to increase contraceptive use among adult women: a review of experimental and quasi-experimental studies

CONTEXT

Because rates of unintended pregnancy, abortion and unintended birth are very high among adult women in the United States, it is important to identify interventions that can increase contraceptive use in this population.

METHODS

PubMed, PsycINFO and POPLINE were searched for experimental or quasi-experimental studies published between 1990 and 2005 that evaluated policies or programs designed to increase contraceptive use or reduce pregnancy among adult women in the United States. In addition, relevant journals were searched, experts were asked to provide further citations and several subsequently published articles were included.

RESULTS

Only 11 studies that assessed programs, and none that assessed policies, were found. The evaluated interventions offered pregnancy and STD prevention counseling (one study); provided contraceptives in settings other than family planning clinics (two studies); had women initiate contraceptive use during the medical visit (two studies); provided advance supplies of emergency contraception (four studies); or implemented systems to remind injectable contraceptive users about their next injection (two studies). The interventions generally had positive, albeit short-term, effects on contraceptive use; none reduced pregnancy rates. Programs that gave women a contraceptive during the visit were the most effective at increasing method use. Advance provision of emergency contraception increased the likelihood of its use and did not affect regular contraceptive use.

CONCLUSIONS

Very few studies have evaluated interventions to increase contraceptive use among adult women. A research plan that rigorously assesses the impact of different approaches to increasing contraceptive use among adult women should be an integral part of any long-term effort to prevent unintended pregnancy in the United States.

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.

Medical Barriers to Effective Contraception

Medical barriers to contraception can prevent women from obtaining, initiating, and continuing their contraceptive method of choice. The barriers include lack of appropriate counseling, delaying initiation for menses or laboratory tests, inappropriate contraindications or mandated warnings, untrained clinicians, and financial or regulatory barriers preventing access by low-income, undocumented, or adolescent women. These barriers may partially explain why almost half of pregnancies in the United States are unintended and occur predominantly in the small proportion of sexually active women not using contraception.