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Zimmerman LA, Sarnak DO, Karp C, Wood SN, Ahmed S, Makumbi F, Kibira SPS. Association between experience of specific side-effects and contraceptive switching and discontinuation in Uganda: results from a longitudinal study. Reprod Health 2021; 18:239. [PMID: 34838097 PMCID: PMC8627069 DOI: 10.1186/s12978-021-01287-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/06/2021] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND There is substantial evidence that contraceptive side-effects are a major deterrent to consistent use of contraception but few studies in low- or middle-income countries explore the role of specific side-effects on contraceptive use dynamics. This study used population-based, longitudinal data to explore the effect of specific side-effects on contraceptive continuation, discontinuation, and switching in Uganda. METHODS Data for this study come from two rounds of survey data collection in Uganda: PMA2020's sixth cross-sectional survey and a follow-up survey conducted 1 year later. The main outcomes of interest were discontinuation and switching among users of hormonal contraceptive methods (implants, injectables and oral pill) and the IUD at baseline (n = 560). Multivariable logistic regressions assessed the association of experiencing specific side-effects (more bleeding, less bleeding, irregular bleeding, increased dryness/reduced libido, and physical discomfort) with discontinuation and switching 1 year later, adjusting for socio-demographic characteristics, type of method, and length of use. We also examined the differential effects of side-effects between discontinuation and switching risks. RESULTS About 23% of hormonal and IUD contraceptive users reported experiencing side-effects at baseline survey. Overall, discontinuation and switching were higher among injectables and pill users, compared to IUD and implants users. Reporting more bleeding or less bleeding increased the odds of discontinuation and switching by 2.74 (95% CI 1.00-7.51) and 1.86 (1.04-3.34), respectively. There was no significant difference in discontinuation and switching by side-effects. CONCLUSIONS Greater attention should be paid to understanding the unique contributions of side-effects to contraceptive behavior using population-based data. While about a quarter of women reported experiencing side effects, those who experienced bleeding specific side effects were at higher risk of contraceptive discontinuation and switching. Providing greater individualized care that includes information and counseling about common side-effects, how they may impact daily life, and how tolerable these effects may be is necessary.
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Affiliation(s)
- Linnea A Zimmerman
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Dana O Sarnak
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Celia Karp
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Shannon N Wood
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Simon P S Kibira
- Department of Community Health and Behavioural Sciences, School of Public Health, Makerere University, Kampala, Uganda
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Wood SN, Karp C, Zimmerman L. Women's sexual experiences as a side effect of contraception in low- and middle-income countries: evidence from a systematic scoping review. Sex Reprod Health Matters 2021; 28:1763652. [PMID: 32530748 PMCID: PMC7888024 DOI: 10.1080/26410397.2020.1763652] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Contraception is essential to preventing unintended pregnancy. While contraceptive use has increased significantly over the past decade, discontinuation and gaps in use remain common. Although women cite side effects as the reason for discontinuing or stopping methods, little is known about the specific ways in which contraception affects women's sexual experiences. This systematic scoping review aimed to understand how contraceptive-induced side effects relating to women's sexual experiences have been measured, classified, and explored in the literature, specifically in low- and middle-income countries (LMICs). Studies were eligible for inclusion if they were peer-reviewed, English-language articles published between 2003 and 2018 that examined women's sexual experiences related to their use of modern contraception, including sexual satisfaction, arousal, sexual dysfunction, discomfort, vaginal dryness, sexual frequency, and relationship or partner dynamics. Study populations were restricted to women of reproductive age in LMICs. Twenty-two studies were deemed eligible for inclusion, comprising a range of methods and geographies. Emergent sexual experience themes included: menstrual issues impacting sexual experience; libido; lubrication; sexual pleasure; dyspareunia; and female sexual function. Results highlight the variability in measures used, lack of a women-centred perspective, and void in research outside of high-income countries to study the influence of contraception on women's sexual experiences. Very few studies focused on women's sexual experiences as the primary outcome or predictor. Providers should adopt woman-centred contraceptive counselling that considers women's relationships. Further research is needed to disentangle the nuanced effects of contraception on women's sex lives, contraceptive decision-making, and method continuation.
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Affiliation(s)
- Shannon N Wood
- Assistant Scientist, Department of Population, Family & Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Celia Karp
- Assistant Scientist, Department of Population, Family & Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Linnea Zimmerman
- Assistant Professor, Department of Population, Family & Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Hadji P, Neulen J, Schaudig K, Schwenkhagen A, Grimmbacher S, Wiegratz I. Extended-cycle versus conventional treatment with a combined oral contraceptive containing ethinylestradiol (30 μg) and levonorgestrel (150 μg) in a randomized controlled trial. Gynecol Endocrinol 2020; 36:513-520. [PMID: 32064971 DOI: 10.1080/09513590.2020.1725963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The objective was to assess efficacy and safety of a combined oral contraceptive containing ethinylestradiol (EE) and levonorgestrel (LNG) in an extended-cycle vs. a conventional-cycle regimen. This first European randomized, active controlled, open, prospective, parallel-group trial was conducted in 48 German gynecological centers. 1,314 healthy, sexually active women aged 18-35 years were randomized. With an unadjusted PI of 0.483 (upper 95% CI: 1.237), the extended-cycle regimen fulfilled the contraceptive efficacy of EE/LNG, the requirements of the European Medicines Agency. The mean total number of bleeding days per year was significantly lower in the extended-cycle vs. the conventional-cycle regimen. Analyses of bleeding patterns showed a reduced total number of bleeding/spotting days per year in the extended-cycle vs. the conventional-cycle regimen. Cycle-associated complaints and AE were comparable in both groups. Both regimens were very well accepted. The extended-cycle regimen of EE/LNG was effective and well tolerated resulting in a lower number of bleeding days and a favorable bleeding pattern compared to the conventional-cycle regimen.
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Affiliation(s)
- Peyman Hadji
- Frankfurter Hormon-und Osteoporosezentrum, Frankfurt am Main, Germany and Philipps-University of Marburg, Marburg, Germany
| | - Joseph Neulen
- Clinic for Gynaecological Endocrinology and Reproductive Medicine, University of Aachen, Aachen, Germany
| | - Katrin Schaudig
- Center of Gynaecological Endocrinology, Hormone Hamburg, Hamburg, Germany
| | | | - Stefanie Grimmbacher
- Clinical Science and Operations, Meda Pharma GmbH and Co. KG (A Mylan Company), Bad Homburg, Germany
| | - Inka Wiegratz
- VivaNeo Kinderwunschpraxis Frankfurt, Frankfurt am Main, Germany
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Black A, Guilbert E, Costescu D, Dunn S, Fisher W, Kives S, Mirosh M, Norman WV, Pymar H, Reid R, Roy G, Varto H, Waddington A, Wagner MS, Whelan AM. No. 329-Canadian Contraception Consensus Part 4 of 4 Chapter 9: Combined Hormonal Contraception. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 39:229-268.e5. [PMID: 28413042 DOI: 10.1016/j.jogc.2016.10.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. OUTCOMES Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the availability of cited contraceptive methods in Canada. EVIDENCE Medline and the Cochrane Database were searched for articles in English on subjects related to contraception, sexuality, and sexual health from January 1994 to December 2015 in order to update the Canadian Contraception Consensus published February-April 2004. Relevant Canadian government publications and position papers from appropriate health and family planning organizations were also reviewed. VALUES The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice are ranked according to the method described in this report. SUMMARY STATEMENTS RECOMMENDATIONS.
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FSRH Guideline (January 2019) Combined Hormonal Contraception (Revision due by January 2024). BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:1-93. [PMID: 30665985 DOI: 10.1136/bmjsrh-2018-chc] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Cho MK. Use of Combined Oral Contraceptives in Perimenopausal Women. Chonnam Med J 2018; 54:153-158. [PMID: 30288370 PMCID: PMC6165915 DOI: 10.4068/cmj.2018.54.3.153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/02/2018] [Accepted: 09/06/2018] [Indexed: 11/19/2022] Open
Abstract
While perimenopausal women have low fecundity, they are still capable of becoming pregnant and the majority of pregnancies occurring during perimenopause are unintended pregnancies. Therefore, even during perimenopause, contraception must be used if unintended pregnancies are to be avoided. However, many perimenopausal women and healthcare providers believe that older people should not take combined oral contraceptives (COC) because doing so may be dangerous. However, to date, there is no evidence that taking COC presents an increased risk of cardiovascular events or breast cancer for middle-aged women as compared to other age groups, and in their recommendations, the Centers for Disease Control and Prevention (CDC) also do not list age itself as a contraindication for COC. Perimenopausal women often experience menstrual irregularity, heavy menstrual bleeding, and vasomotor symptoms. Taking COCs can help control these symptoms and significantly reduce the risk of ovarian cancer, endometrial cancer, and colorectal cancer. The objective of the present review is to examine the usage methods of COC among perimenopausal women and the health issues that may arise from taking COC in perimenopausal women.
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Affiliation(s)
- Moon Kyoung Cho
- Department of Obstetrics and Gynecology, Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, Korea
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7
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MacGregor EA, Guillebaud J. The 7-day contraceptive hormone-free interval should be consigned to history. BMJ SEXUAL & REPRODUCTIVE HEALTH 2018; 44:bmjsrh-2017-200036. [PMID: 29945924 DOI: 10.1136/bmjsrh-2017-200036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 05/04/2018] [Accepted: 05/04/2018] [Indexed: 06/08/2023]
Abstract
AIM This review summarises the available data on the disadvantages of the 7-day contraceptive-free interval (CFI) of combined oral contraceptives (COCs), in contrast to shorter CFIs or continuous use - including flexible regimens - and provides recommendations for practice. METHODS Relevant papers were identified by Medline and PubMed. The final reference list was generated on the basis of relevance to the review, with priority given to systematic reviews and randomised controlled trials. RESULTS There is considerable inter- and intra-individual variation in the absorption and metabolism of COCs. Even with perfect use, the loss of endocrine suppression during the standard 7-day CFI allows follicular development with the risk of escape ovulation in a vulnerable minority. This risk increases in typical users whenever the CFI is prolonged: late restarts are a common reason for pill omissions. Shortening or eliminating the CFI improves contraceptive efficacy using the lowest doses available, without evidence to date of compromised safety. CONCLUSIONS There is no scientific evidence to support a 7-day CFI and it should be replaced either by a continuous flexible regimen, or extended regimens with a shortened CFI, prescribed first-line. In women preferring a monthly 'bleed', a 4-day CFI similarly provides a greater safety margin when pills are omitted.
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Affiliation(s)
- E Anne MacGregor
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, Centre for Neuroscience & Trauma, London, UK
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Polis CB, Hussain R, Berry A. There might be blood: a scoping review on women's responses to contraceptive-induced menstrual bleeding changes. Reprod Health 2018; 15:114. [PMID: 29940996 PMCID: PMC6020216 DOI: 10.1186/s12978-018-0561-0] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 06/15/2018] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Concern about side effects and health issues are common reasons for contraceptive non-use or discontinuation. Contraceptive-induced menstrual bleeding changes (CIMBCs) are linked to these concerns. Research on women's responses to CIMBCs has not been mapped or summarized in a systematic scoping review. METHODS We conducted a systematic scoping review of data on women's responses to CIMBCs in peer-reviewed, English-language publications in the last 15 years. Investigator dyads abstracted information from relevant studies on pre-specified and emergent themes using a standardized form. We held an expert consultation to obtain critical input. We provide recommendations for researchers, contraceptive counselors, and product developers. RESULTS We identified 100 relevant studies. All world regions were represented (except Antarctica), including Africa (11%), the Americas (32%), Asia (7%), Europe (20%), and Oceania (6%). We summarize findings pertinent to five thematic areas: women's responses to contraceptive-induced non-standard bleeding patterns; CIMBCs influence on non-use, dissatisfaction or discontinuation; conceptual linkages between CIMBCs and health; women's responses to menstrual suppression; and other emergent themes. Women's preferences for non-monthly bleeding patterns ranged widely, though amenorrhea appears most acceptable in the Americas and Europe. Multiple studies reported CIMBCs as top reasons for contraceptive dissatisfaction and discontinuation; others suggested disruption of regular bleeding patterns was associated with non-use. CIMBCs in some contexts were perceived as linked with a wide range of health concerns; e.g., some women perceived amenorrhea to cause a buildup of "dirty" or "blocked" blood, in turn perceived as causing blood clots, fibroids, emotional disturbances, weight gain, infertility, or death. Multiple studies addressed how CIMBCs (or menstruation) impacted daily activities, including participation in domestic, work, school, sports, or religious life; sexual or emotional relationships; and other domains. CONCLUSIONS Substantial variability exists around how women respond to CIMBCs; these responses are shaped by individual and social influences. Despite variation in responses across contexts and sub-populations, CIMBCs can impact multiple aspects of women's lives. Women's responses to CIMBCs should be recognized as a key issue in contraceptive research, counseling, and product development, but may be underappreciated, despite likely - and potentially substantial - impacts on contraceptive discontinuation and unmet need for modern contraception.
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Affiliation(s)
- Chelsea B. Polis
- Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY 10038 USA
| | - Rubina Hussain
- Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY 10038 USA
| | - Amanda Berry
- Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY 10038 USA
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Akintomide H, Rank KM, Brima N, McGregor F, Stephenson J. Counselling to include tailored use of combined oral contraception in clinical practice: an evaluation. BMJ SEXUAL & REPRODUCTIVE HEALTH 2018; 44:37-42. [PMID: 29103002 DOI: 10.1136/jfprhc-2017-101736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 06/20/2017] [Accepted: 07/11/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Combined oral contraception (COC, 'the pill') remains the most prescribed method of contraception in the UK. Although a variety of regimens for taking monophasic COC are held to be clinically safe, women are not routinely counselled about these choices and there is a lack of evidence on how to provide this information to women. AIM To assess the usefulness and feasibility of including tailored use of monophasic COC within routine COC counselling in a sexual and reproductive health (SRH) service using a structured format. METHOD Using a structured format, healthcare professionals (HCPs) counselled new and established COC users attending an SRH service about standard and tailored ways of taking the pill. Questionnaires were used to survey both the HCPs and patients immediately after the initial consultation, and then the patients again 8 weeks later. RESULTS Nearly all patients (98%, n=95) felt it was helpful to be informed of the different ways of using monophasic COC by the HCP, without giving too much information at one time (96%, n=108). The HCPs were confident of their COC counselling (99%, n=110) and did not think the consultations took significantly longer (88%, n=98). CONCLUSION This study demonstrates that information on different pill taking regimens is useful and acceptable to patients, and can improve contraceptive pill user choice. It is also feasible for HCPs to perform COC counselling to include tailored pill use during routine consultations in a clinical setting.
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Affiliation(s)
- Hannat Akintomide
- Sexual and Reproductive Health, Central and North West London NHS Trust, Margaret Pyke Centre, London, UK
| | - Katherine Margaret Rank
- Sexual and Reproductive Health, Central and North West London NHS Trust, Margaret Pyke Centre, London, UK
| | - Nataliya Brima
- Centre for Sexual Health & HIV Research, Infection & Population Health, University College London, London, UK
| | - Fiona McGregor
- Sexual and Reproductive Health, Central and North West London NHS Trust, Margaret Pyke Centre, London, UK
| | - Judith Stephenson
- Sexual & Reproductive Health, Institute for Women's Health, University College London, London, UK
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Black A, Guilbert E, Costescu D, Dunn S, Fisher W, Kives S, Mirosh M, Norman WV, Pymar H, Reid R, Roy G, Varto H, Waddington A, Wagner MS, Whelan AM. No 329-Consensus canadien sur la contraception (4e partie de 4) : chapitre 9 – contraception hormonale combinée. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:269-314.e5. [DOI: 10.1016/j.jogc.2017.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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11
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Estrogen-progestins and progestins for the management of endometriosis. Fertil Steril 2016; 106:1552-1571.e2. [DOI: 10.1016/j.fertnstert.2016.10.022] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/10/2016] [Accepted: 10/12/2016] [Indexed: 02/08/2023]
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Borgatta L, Buhling KJ, Rybowski S, Roth K, Rosen K. A multicentre, open-label, randomised phase III study comparing a new levonorgestrel intrauterine contraceptive system (LNG-IUS 8) with combined oral contraception in young women of reproductive age. EUR J CONTRACEP REPR 2016; 21:372-9. [PMID: 27494570 DOI: 10.1080/13625187.2016.1212987] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To compare user satisfaction and adverse events (AEs) with a levonorgestrel intrauterine system (LNG-IUS 8; average levonorgestrel release rate approximately 8 μg/24 h over the first year [total content 13.5 mg]) and a 30 μg ethinyl estradiol/3 mg drospirenone (EE/DRSP) combined oral contraceptive (COC) in a population of young women. METHODS Nulliparous and parous women (aged 18-29 years) with regular menstrual cycles (21-35 days) were randomised to LNG-IUS 8 or EE/DRSP for 18 months. The primary endpoint was the overall user satisfaction rate at month 18/end of study visit. RESULTS Overall, 279 women were randomised to LNG-IUS 8 with attempted placement and 281 women were randomised to EE/DRSP and took ≥1 pill; the mean age was 23.7 and 23.9 years, and 77.4% and 73.3% were nulliparous, respectively. At month 18/end of study, 82.1% and 81.9% of women, respectively, reported being 'very satisfied' or 'satisfied' with their treatment; however, significantly more LNG-IUS 8 users reported a preference to continue their treatment post-study (66.2% vs 48.8%; p = 0.0001). There were two pregnancies (one ectopic pregnancy, one spontaneous abortion) reported in the LNG-IUS 8 group and six (three live births, two spontaneous abortions, one induced abortion) in the EE/DRSP group. CONCLUSIONS LNG-IUS 8 and EE/DRSP were associated with similarly high user satisfaction rates. However, LNG-IUS 8 users were significantly more likely to prefer to continue their contraceptive method post-study, indicating that a levonorgestrel intrauterine system is an appealing contraceptive option for young women.
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Affiliation(s)
- Lynn Borgatta
- a Department of Obstetrics and Gynecology , Boston University School of Medicine , Boston , MA , USA
| | - Kai J Buhling
- b Department of Gynecological Endocrinology , University Hospital Hamburg-Eppendorf , Hamburg , Germany
| | - Sarah Rybowski
- c Bayer HealthCare Pharmaceuticals , Whippany , NJ , USA
| | | | - Kimberly Rosen
- c Bayer HealthCare Pharmaceuticals , Whippany , NJ , USA
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Nappi RE, Kaunitz AM, Bitzer J. Extended regimen combined oral contraception: A review of evolving concepts and acceptance by women and clinicians. EUR J CONTRACEP REPR 2015; 21:106-15. [PMID: 26572318 PMCID: PMC4841029 DOI: 10.3109/13625187.2015.1107894] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objectives: The clinical utility of extended regimen combined oral contraceptives (COCs) is increasingly being recognised. Our objective was to understand the attitudes of women and clinicians about the use of these regimens. We present the rationale for extended regimen COCs from a historical perspective, and trace their evolution and growing popularity in light of their clinical benefits. We conclude by offering potential strategies for counselling women about extended regimen COC options. Methods: We conducted a MEDLINE search to identify and summarise studies of extended regimen COCs, focusing on attitudes of women and clinicians regarding efficacy, safety/tolerability and fewer scheduled bleeding episodes and other potential benefits. Results: The body of contemporary literature on extended regimen COCs suggests that their contraceptive efficacy is comparable to that of conventional 28-day (i.e., 21/7) regimens. For women seeking contraception that allows infrequent scheduled bleeding episodes, particularly those who suffer from hormone withdrawal symptoms and cyclical symptoms (e.g., headache, mood changes, dysmenorrhoea, heavy menstrual bleeding), extended regimen COCs are an effective and safe option. Although satisfaction with extended regimen COCs in clinical trials is high, misperceptions about continuous hormone use may still limit the widespread acceptance of this approach. Conclusions: Despite the widespread acceptance among clinicians of extended regimen COCs as an effective and safe contraceptive option, these regimens are underused, likely due to a lack of awareness about their availability and utility among women. Improved patient education and counselling regarding the safety and benefits of extended regimen COCs may help women make more informed contraceptive choices.
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Affiliation(s)
- Rossella E Nappi
- a Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, Department of Obstetrics and Gynaecology , IRCCS San Matteo Foundation, University of Pavia , Pavia , Italy
| | - Andrew M Kaunitz
- b Department of Obstetrics and Gynecology , University of Florida College of Medicine-Jacksonville , Jacksonville , FL , USA
| | - Johannes Bitzer
- c Department of Obstetrics and Gynaecology , Basel University Hospital , Basel , Switzerland
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Krashin J, Tang JH, Mody S, Lopez LM. Hormonal and intrauterine methods for contraception for women aged 25 years and younger. Cochrane Database Syst Rev 2015; 2015:CD009805. [PMID: 26280888 PMCID: PMC9239531 DOI: 10.1002/14651858.cd009805.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Jamie Krashin
- University of North Carolina, School of MedicineObstetrics and Gynecology4012 Old Clinic BuildingCB 7570Chapel HillNorth CarolinaUSA27599
| | - Jennifer H Tang
- University of North Carolina, School of MedicineObstetrics and Gynecology4012 Old Clinic BuildingCB 7570Chapel HillNorth CarolinaUSA27599
| | - Sheila Mody
- University of California, San DiegoDepartment of Reproductive Medicine200 W. Arbor Drive 8433San DiegoCaliforniaUSA92103‐8433
| | - Laureen M Lopez
- FHI 360Clinical and Epidemiological Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
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Edelman A, Micks E, Gallo MF, Jensen JT, Grimes DA. Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception. Cochrane Database Syst Rev 2014; 2014:CD004695. [PMID: 25072731 PMCID: PMC6837850 DOI: 10.1002/14651858.cd004695.pub3] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The avoidance of menstruation through continuous or extended (greater than 28 days) administration of combination hormonal contraceptives (CHCs) has gained legitimacy through its use in treating endometriosis, dysmenorrhea, and menstruation-associated symptoms. Avoidance of menstruation through extended or continuous use of CHCs for reasons of personal preference may have additional advantages to women, including improved compliance, greater satisfaction, fewer menstrual symptoms, and less menstruation-related absenteeism from work or school. OBJECTIVES To determine the differences between continuous or extended-cycle CHCs (pills, patch, ring) in regimens of greater than 28 days of active hormone compared with traditional cyclic dosing (21 days of active hormone and 7 days of placebo, or 24 days of active hormones and 4 days of placebo). Our hypothesis was that continuous or extended-cycle CHCs have equivalent efficacy and safety but improved bleeding profiles, amenorrhea rates, adherence, continuation, participant satisfaction, and menstrual symptoms compared with standard cyclic CHCs. SEARCH METHODS We searched computerized databases (Cochrane Central Register of Controlled Trials, PUBMED, EMBASE, POPLINE, LILACS) for trials using continuous or extended CHCs (oral contraceptives, contraceptive ring and patch) during the years 1966 to 2013. We also searched the references in review articles and publications identified for inclusion in the protocol. Investigators were contacted regarding additional references. SELECTION CRITERIA All randomized controlled trials in any language comparing continuous or extended-cycle (greater than 28 days of active hormones) versus traditional cyclic administration (21 days of active hormones and 7 days of placebo, or 24 days of active hormones and 4 days of placebo) of CHCs for contraception. DATA COLLECTION AND ANALYSIS Titles and abstracts identified from the literature searches were assessed for potential inclusion. Data were extracted onto data collection forms and then entered into RevMan 5. Peto odds ratios with 95% confidence intervals were calculated for all outcomes for dichotomous outcomes. Weighted mean difference was calculated for continuous outcomes. The trials were critically appraised by examining the following factors: study design, blinding, randomization method, group allocation concealment, exclusions after randomization, loss to follow-up, and early discontinuation. Because the included trials did not have a standard treatment (type of CHC formulation, route of delivery, or time length for continuous dosing), we could not aggregate data into meta-analysis. MAIN RESULTS Twelve randomized controlled trials met our inclusion criteria. Study findings were similar between 28-day and extended or continuous regimens in regard to contraceptive efficacy (i.e., pregnancy rates) and safety profiles. When compliance was reported, no difference between 28-day and extended or continuous cycles was found. Participants reported high satisfaction with both dosing regimens, but this was not an outcome universally studied. Overall discontinuation and discontinuation for bleeding problems were not uniformly higher in either group. The studies that reported menstrual symptoms found that the extended or continuous group fared better in terms of headaches, genital irritation, tiredness, bloating, and menstrual pain. Eleven out of the twelve studies found that bleeding patterns were either equivalent between groups or improved with extended or continuous cycles over time. Endometrial lining assessments by ultrasound and/or endometrial biopsy were done in some participants and were all normal after cyclic or extended CHC use. AUTHORS' CONCLUSIONS The 2014 update yielded four additional trials but unchanged conclusions. Evidence from existing randomized control trials comparing continuous or extended-cycle CHCs (greater than 28 days of active combined hormones) to traditional cyclic dosing (21 days of active hormone and 7 days of placebo, or 24 days of active hormone and 4 days of placebo) is of good quality. However, the variations in type of hormones and time length for extended-cycle dosing make a formal meta-analysis impossible. Future studies should choose a previously described type of CHC and dosing regimen. More attention needs to be directed towards participant satisfaction, continuation, and menstruation-associated symptoms.
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Affiliation(s)
- Alison Edelman
- Dept. of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
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Dragoman MV. The combined oral contraceptive pill -- recent developments, risks and benefits. Best Pract Res Clin Obstet Gynaecol 2014; 28:825-34. [PMID: 25028259 DOI: 10.1016/j.bpobgyn.2014.06.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 06/18/2014] [Indexed: 11/15/2022]
Abstract
The introduction of the birth control pill as an effective, coitally-independent method of contraception was a public health milestone of the last century. Over time, combined oral contraception (COC) formulations and pill-taking regimens have evolved with improved safety and tolerability while maintaining contraceptive efficacy. In addition to protection against pregnancy, use of combined oral contraception confers a number of significant non-contraceptive benefits to users. COC use is also associated with well-studied risks. Common side effects are generally self-limiting and improve with increasing duration of use while serious adverse events, including venous thromboembolism, are rare among healthy COC users. Contraceptive decision-making should include consideration of both the risks and benefits of a given method versus the real consequences of unintended pregnancy.
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MESH Headings
- Bone Density/drug effects
- Colorectal Neoplasms/prevention & control
- Contraception/methods
- Contraception/trends
- Contraceptives, Oral/administration & dosage
- Contraceptives, Oral/adverse effects
- Contraceptives, Oral, Combined/administration & dosage
- Contraceptives, Oral, Combined/adverse effects
- Contraceptives, Oral, Hormonal/administration & dosage
- Contraceptives, Oral, Hormonal/adverse effects
- Dysmenorrhea/drug therapy
- Endometrial Neoplasms/prevention & control
- Evidence-Based Medicine
- Female
- Gynecology/trends
- Humans
- Menstrual Cycle/drug effects
- Ovarian Neoplasms/prevention & control
- Pregnancy
- Risk Assessment
- Risk Factors
- Venous Thromboembolism/chemically induced
- Venous Thromboembolism/prevention & control
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Affiliation(s)
- Monica V Dragoman
- Einstein College of Medicine, Montefiore Medical Center, Department of Obstetrics and Gynecology & Women's Health, 1695 Eastchester Road, Bronx, NY 10461, USA.
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Mendoza N, Lobo P, Lertxundi R, Correa M, Gonzalez E, Salamanca A, Sánchez-Borrego R. Extended regimens of combined hormonal contraception to reduce symptoms related to withdrawal bleeding and the hormone-free interval: a systematic review of randomised and observational studies. EUR J CONTRACEP REPR 2014; 19:321-39. [PMID: 24971489 DOI: 10.3109/13625187.2014.927423] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess whether continuous and extended regimens (CRs/ERs) of combined hormonal contraceptives (CHCs) improve symptoms related to withdrawal bleeding or the hormone-free interval and to compare the efficacy, safety, and cost of CRs/ERs to those of conventional 28-day regimens. STUDY DESIGN A literature search of the PubMed database was conducted for randomised clinical trials (RCTs) and observational studies published in any language between 2006 and 2013. RESULTS Sixteen RCTs and 14 observational studies evaluated issues related to our objectives. CRs/ERs, whose efficacy and safety were comparable to those described for conventional regimens, were preferred due to their improvement of symptoms related to withdrawal bleeding or the hormone-free interval and the lower costs resulting from the reduced incidence of these symptoms. CONCLUSION The contraceptive efficacy and safety of CR/ER use of CHCs is at least equal to that of 28-days conventional regimens, and this use may have some cost savings. CRs/ERs are recommended for women willing to take a CHC for treatment of symptoms related to withdrawal bleeding or the hormone-free interval.
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Affiliation(s)
- Nicolás Mendoza
- * Department of Obstetrics and Gynaecology, University of Granada , Spain
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Panicker S, Mann S, Shawe J, Stephenson J. Evolution of extended use of the combined oral contraceptive pill. ACTA ACUST UNITED AC 2014; 40:133-41. [PMID: 24648529 DOI: 10.1136/jfprhc-2013-100600] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Extended use of the combined oral contraceptive pill (COC), defined as taking active pills for at least 28 days, has been used in order to avoid bleeding at important times and to treat gynaecological conditions such as endometriosis. We examined the main issues involved in extended use of the COC and how it has evolved from being one of medicine's best-kept secrets to becoming more widely accepted by women and the medical community. STUDY DESIGN Literature review, using Medline, Embase, Pubmed, CINHAL Plus, the Cochrane Database of Systematic Reviews and the Ovid database for all relevant clinical trials, systematic reviews, meta-analyses, literature reviews, scientific papers and individual opinions between 1950 and October 2013. RESULTS Accumulating evidence supports various forms of extended pill use as suitable alternatives to the standard (21/7) regimen. In terms of user preference, much hinges on whether women wish to reduce the frequency or duration of scheduled bleeding on the combined pill. Available data on the safety of extended pill regimens do not give cause for concern, but longer term data should be collected. CONCLUSIONS Information for women considering extended COC regimens should keep pace with research findings to ensure that women and clinicians are better informed about the choices available.
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Affiliation(s)
- Sabeena Panicker
- Specialist Registrar in Obstetrics & Gynaecology, Sexual and Reproductive Health Research Group, Institute for Women's Health, University College London, London, UK
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Mendoza N, Sanchez-Borrego R. Classical and newly recognised non-contraceptive benefits of combined hormonal contraceptive use in women over 40. Maturitas 2014; 78:45-50. [PMID: 24656220 DOI: 10.1016/j.maturitas.2014.02.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 02/24/2014] [Accepted: 02/28/2014] [Indexed: 11/29/2022]
Abstract
Although age is the most crucial predictor of a woman's reproductive capacity, it is assumed that there is still a risk of pregnancy in menopause transition, as occasional spontaneous ovulation is possible. Moreover, age alone is not sufficient to contraindicate the use of any contraceptive method, whether hormonal or not. The use of new CHC in women over 40 has not only been associated with an improved safety profile but has also been associated with other non-contraceptive benefits or the consolidation of already-known benefits. The studies with new CHC have demonstrated that efficacy and safety do not differ from the corresponding parameters observed in younger women. Additionally, the new CHC offers specific and especially useful benefits for women over 40 in the treatment of menstrual disorders. Finally, interest is currently focused on the potential of early diagnosis and the prevention of cardiovascular disease and depression, both of which may be alleviated by the CHC.
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Affiliation(s)
- Nicolas Mendoza
- University of Granada, Obstetric and Gynecologic, Maestro Montero, 21, Granada, Spain.
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Sauer U, Mann S, Brima N, Stephenson J. Offering extended use of the combined contraceptive pill: a survey of specialist family planning services. Int J Womens Health 2013; 5:613-7. [PMID: 24109198 PMCID: PMC3792829 DOI: 10.2147/ijwh.s51329] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The purpose of this study was to determine attitudes to, and provision of, extended regimens for taking the combined oral contraceptive pill (COC) by specialist contraception practitioners from three contrasting specialist contraception services in London. METHODS An online cross-sectional survey was administered to all doctors and nurses, who counsel, provide, or prescribe the oral contraceptive pill at each clinic. RESULTS A total of 105 clinicians received the questionnaire and 67 (64%) responded. Only one of three clinics initiated and maintained guidelines for extended COC use. In that service, 60% of staff prescribing COC advised more than 50% of patients regarding alternative COC regimens. In the other two services, this was discussed with 20% and 6% of patients, respectively (P < 0.001). The reasons for prescribing extended use included cyclic headaches, menorrhagia, patient request, menstrual-related cramps, and endometriosis, and did not differ between the three different settings. The most common extended regimens were 63 pills or continuous use until bleeding occurs, followed by a hormone-free interval. Concerns highlighted by providers and patients were "unhealthy not to have a monthly bleed", "future fertility", and "breakthrough bleeding". Such comments highlight the need for further information for providers and patients. CONCLUSION There is growing evidence, backed by national guidance, about extended COC use, but routine provision of this information is patchy and varies ten-fold, even within specialist family planning services. Targeted training, use of service guidelines, and implementation research will be needed to extend patient choice of different COC regimens and change clinical practice.
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Affiliation(s)
- Ulrike Sauer
- Reproductive and Sexual Health, Enfield Community Service, Enfield
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Szarewski A. Randomized trial of the effect of tailored versus standard use of the combined oral contraceptive pill is not the second largest RCT. Contraception 2013; 88:758. [PMID: 23911097 DOI: 10.1016/j.contraception.2013.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 06/19/2013] [Indexed: 11/18/2022]
Affiliation(s)
- Anne Szarewski
- Wolfson Institute of Preventive Medicine Queen Mary, University of London, London, United Kingdom.
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