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

Evaluation of adherence to a daily progestin-only pill in a simulated over-the-counter setting

OBJECTIVE

The Adherence with Continuous Dose Oral Contraceptive: Evaluation of Self-Selection and Use (ACCESS) study assessed whether consumers can adhere to the regimen for a progestin-only pill (norgestrel 0.075 mg) in an over-the-counter (OTC) setting.

STUDY DESIGN

An actual use study in a simulated OTC environment assessed adherence to directions to take norgestrel 0.075 mg every day at the same time in 883 participants for up to 24 weeks.

RESULTS

Eighty-five percent (747/883) of participants reported ≥85% adherence to taking norgestrel 0.075 mg every day and reported taking their dose within three hours of their scheduled dosing time on 96% of days. When accounting for use of a condom for 48 hours if a pill was missed, participants reported correctly following the label's directed use for 97% of doses overall, with 95% of participants following label directions for ≥85% of doses. The main limitations were related to finding a balance between intensely collecting data to ensure accurate assessment of adherence and leaving users to behave as they would in a real OTC situation without healthcare practitioner intervention. We observed that some participants reported taking more doses than they could have based on the supply of medication given to them. To fully examine the situation, and the impact on the conclusions, additional post hoc sensitivity analyses were performed, and showed remarkably consistent results.

CONCLUSIONS

Consumers were highly adherent to taking norgestrel 0.075 mg when using only the information provided by the proposed OTC label.

IMPLICATIONS

Adherence to a daily oral contraceptive pill was high when obtained OTC. This suggests that effectiveness of an OTC pill is likely to be like that of a prescribed pill and easier access to this effective contraceptive should allow more opportunity to prevent pregnancy.

Adherence among a cohort taking progestin-only pills prescribed by a healthcare provider: Results of the BENCHMARK study

OBJECTIVES

To measure adherence over 6 months of progestin-only pill (POP) use.

STUDY DESIGN

Prospective observational cohort study measuring adherence to daily dosing and timing of dose in patients prescribed a POP, with up to six months of follow-up, conducted from January to October 2020. A pharmacy benefit manager identified potential participants with a newly prescribed POP and extended an invitation to participate. We enrolled qualified respondents by telephone, trained them to use an electronic diary to report daily whether they had taken their POP and at what time. We followed participants for up to six months. We calculated adherence to daily pill taking as the proportion of evaluable days in which a participant took a POP, and the proportion of participants reporting ≥85% adherence. We calculated adherence to same time each day as the proportion of doses taken no later than three hours after the previous dose time of day.

RESULTS

The user population comprised 199 participants, 154 (77.4%) of whom completed six months of follow-up. The majority (n=170, 85.4%) were taking norethindrone. Norethindrone users reported POP intake on 22,327 (96.4%) of 23,156 evaluable days, with 155 (91.2%) participants reporting ≥85% adherence; less than half (n=73, 42.9%) reported 100% adherence. Participants reported adherence to same time each day on 21,698 of 22,157 (97.9%) evaluable days.

CONCLUSIONS

Among participants taking a prescribed POP, participants demonstrated high adherence for daily pill taking and the same time of day, though the majority were not 100% adherent.

IMPLICATIONS

This study reports data specific to adherence among those taking a progestin-only pill (POP) in the prescription setting. Clinicians who counsel patients about POP use should be aware that majority of patients were not 100% adherent, although most report ≥ 85% adherence.

The 7-day contraceptive hormone-free interval should be consigned to history

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.

An open-label, two-period comparative study on pharmacokinetics and safety of a combined ethinylestradiol/gestodene transdermal contraceptive patch

We investigated the pharmacokinetics and safety profiles of a newly developed combined ethinylestradiol (EE)/gestodene (GSD) transdermal contraceptive patch after a single-dose administration and compared with the market available tablet formulation in healthy adult subjects. An open-label, two-period comparative study was conducted in 12 healthy women volunteers. A single dose of the study combined EE/GE transdermal contraceptive patch and oral tablet (Milunet^®) were administered. Blood samples at different time points after dose were collected, and concentrations were analyzed. A reliable, highly sensitive and accurate high-performance liquid chromatography coupled with tandem mass spectrometry (HPLC/MS/MS) assay method was developed in this study to determine the plasma concentrations of EE and GSD. Compared to the tablet, the study patch had a significantly decreased maximum plasma concentration (C_max), extended time to reach the C_max and half-life, as well as increased clearance and apparent volume of distribution. The half-lives of EE and GSD of the patch were 3.3 and 2.2 times, respectively, than the half-life of the tablet. The areas under the plasma concentration–time curve (AUCs) of EE and GSD of the patch were 8.0 and 16.2 times, respectively, than the AUC of the tablet. No severe adverse event was observed during the whole study, and the general safety was acceptable. In conclusion, compared to the oral tablet Milunet, the study contraceptive patch was well tolerated and showed potent drug exposure, significant extended half-life and stable drug concentrations.

Understanding the use of contextual cues: design implications for medication adherence technologies that support remembering

Objective

Forgetfulness is one of the main reasons of unintentional medication non-adherence. Adherence technologies that help people remember to take their medications on time often do not take into account the context of people’s everyday lives. Existing evidence that highlights the effectiveness of remembering strategies that rely on contextual cues is largely based on research with older adults, and thus it is not clear whether it can be generalized to other populations or used to inform the design of wider adherence technologies that support medication self-management. Understanding how younger populations currently remember medications can inform the design of future adherence technologies that take advantage of existing contextual cues to support remembering.

Methods

We conducted three surveys with a total of over a thousand participants to investigate remembering strategies used by different populations: women who take oral contraception, parents and carers who give antibiotics to their children, and older adults who take medications for chronic conditions.

Results

Regardless of the population or the type of regimen, relying on contextual cues—routine events, locations, and meaningful objects—is a common and often effective strategy; combinations of two or more types of cues are more effective than relying on a single cue.

Conclusions

To effectively support remembering, adherence technologies should help users recognize contextual cues they already have at their disposal and reinforce relevant cues available in their environment. We show that, given the latest developments in technology, such support is already feasible.

Trends in the use of oral contraceptives among adolescents and young women in Spain

Background

We aimed to determine the prevalence of consumption of oral contraceptives (OCs) among adolescents and young women living in Spain and to identify the factors associated with this consumption.

Methods

We performed a cross-sectional study on the consumption of OCs by women aged 15–30 years residing in Spain. We used secondary individualized data from the 2006 (n = 2513) and 2012 (n = 1530) Spanish National Health Surveys. The dependent variable was the use of OCs in the previous 2 weeks. Independent variables included sociodemographic characteristics, comorbidity, lifestyle, and healthcare resource utilization.

The prevalence of OC consumption was analysed by investigating the changes observed between 2006 and 2012. We used multivariate logistic regression to identify the independent factors associated with OC use in each year.

Results

In 2006, 14.42 % of women reported using OCs; this percentage dropped to 10.21 % in 2012 (p < 0.05). Multivariate analysis revealed an association between OC use and visits to the gynaecologist (AOR, 5.60 [95 % CI, 2.93–10.73] in 2006; and AOR, 3.55 [95 % CI, 1.30–9.73] in 2012), Pap smear tests (AOR, 1.8 [95 % CI, 1.23–2.87] in 2006; and AOR, 2.42 [95 % CI, 1.30–4.51] in 2012), and smoking in 2006 (AOR, 1.42 [95 % CI, 1.04–1.93]).

Conclusions

There was a significant decrease in OC use from 2006 to 2012 among adolescents and young women living in Spain. In the present study, consumers of OCs were women who visited a gynaecologist more often and complied more with preventive measures such as Pap smear testing. Also, women who reported having used OCs were more likely to smoke than the rest of the study population, although the smoking habit is a risk factor for thrombotic events in women who take OCs.

Pharmacokinetic overview of ethinyl estradiol dose and bioavailability using two transdermal contraceptive systems and a standard combined oral contraceptive

Objective: To determine the relative bioavailability of ethinyl estradiol (EE) and gestodene (GSD) after application of a novel transdermal contraceptive patch vs. a standard combined oral contraceptive (COC) pill (study 1), and to evaluate the pharmacokinetics (PK) of EE after application of the EE/GSD patch compared with an EE/norelgestromin (NGMN) patch (study 2). Materials: Participants were healthy, non-obese women aged 18 – 45 years (study 1) or 18 – 35 years (study 2). Compositions of study treatments were as follows: 0.55 mg EE/2.1 mg GSD (EE/GSD patch); 0.02 mg EE/0.075 mg GSD (standard COC); 0.6 mg EE/6 mg NGMN (EE/NGMN patch). Methods: In study 1, which consisted of 3 treatment periods (each followed by 7 patch- or pill-free days), treatments were administered in one of two randomized orders: either P–M–E (EE/GSD patch (P) every 7 days for 28 days → COC (M) once-daily for 21 days → two 7-day patch-wearing periods followed by one 10-day patch-wearing phase (E)), or the same treatments administered in sequence M–P–E. For study 2, participants received either the EE/GSD patch or EE/NGMN patch for seven treatment cycles (one patch per week for 3 weeks followed by a 7-day patch-free interval). Results: In study 1, average daily exposure to EE was similar for treatments P and M; the mean daily area under the concentration-time curve (AUC) ratio of treatment P vs. treatment M for EE was 1.06 (90% confidence interval (CI): 0.964 – 1.16), indicating average daily delivery similar to oral administration of 0.019 – 0.023 mg EE. For unbound GSD, average daily exposure was lower for treatment P vs. treatment M. The mean AUC ratio of treatment P vs. treatment M for unbound GSD was 0.820 (90% CI: 0.760 – 0.885), indicating average daily delivery from the patch of 0.057 – 0.066 mg GSD. Prolonged patch wearing did not result in a distinct decline in GSD and EE serum concentrations. In study 2, AUC at steady state (AUC_0–168,ss), average steady-state serum concentration, and maximum steady-state serum concentration for EE was 2.0 – 2.7-fold higher for the EE/NGMN patch vs. the EE/GSD patch. The EE/GSD patch was well tolerated in both studies. Conclusions: Based on the 90% CI of the AUC ratio of oral treatment vs. patch application for unbound GSD and EE, the daily doses of GSD and EE released from the EE/GSD patch over the 7-day application period provided the same systemic exposure as those recorded after daily oral administration of a COC containing 0.02 mg EE and 0.06 mg GSD. The EE/GSD patch showed reduced EE exposure compared with the EE/NGMN patch. Together with its good tolerability, these properties support the EE/GSD patch as an effective and well-tolerated alternative to available transdermal and oral contraceptives.

Pharmacokinetics and adhesion of a transdermal patch containing ethinyl estradiol and gestodene under conditions of heat, humidity, and exercise: A single-center, open-label, randomized, crossover study

In this open-label, randomized study, 36 women (18-45 years) applied an ethinyl estradiol/gestodene contraceptive patch once-weekly for 3 weeks followed by a 1-week, patch-free interval, in 3 treatment periods. The primary objective was to evaluate the pharmacokinetics of ethinyl estradiol and gestodene under conditions of heat, humidity, and exercise. The secondary objective was to evaluate patch adhesion under the same conditions. Weeks 1 and 2 of each period comprised "standardized normal activity" (SNA); in week 3, SNA continued or women used a sauna, whirlpool, swimming pool, or performed an exercise combination. Thirty-one women completed the study; 23 yielded evaluable pharmacokinetic data. Analyses were exploratory and conducted using an analysis of variance. Area under the concentration-time curve from 0 to 168 hours (AUC0-168 ) for gestodene and ethinyl estradiol during sauna, swimming, and whirlpool was equivalent to previous SNA recordings. For exercise combination, the gestodene AUC0-168 was 12% lower compared with SNA, albeit not considered clinically relevant. Two women lost a total of 3 patches during sporting activities; other detachments during this week were not correlated with sporting activity. Overall, hormone delivery using the ethinyl estradiol/gestodene patch under conditions of heat, humidity, and exercise corresponded to delivery under normal conditions.

A phase 1, multicentre, open-label study to evaluate ovarian follicular activity and hormone levels with an extended-regimen combined oral contraceptive with low-dose ethinyl estradiol supplementation

OBJECTIVES

To evaluate the effect on ovarian follicular activity of the 91-day extended-regimen combined oral contraceptive (COC), consisting of 84 days of levonorgestrel (LNG)/ethinylestradiol (EE) 150 μg/30 μg tablets plus seven days of EE 10 μg tablets in place of placebo.

METHODS

This was a phase 1, open-label study. Ovarian follicular activity was classified via the Hoogland and Skouby method. Safety and tolerability as well as return to ovulation were assessed.

RESULTS

Of the 35 subjects included in the efficacy analysis, luteinized, unruptured follicles, or ovulation were detected in 0 of 35 cycles during the first 28-day interval; 1 of 35 cycles (2.9%) in the second 28-day interval; and 2 of 35 cycles (5.7%) in the final 35-day interval. The ovarian activity rate over the entire 91-day treatment period was 2.9%. There was a low incidence of treatment-emergent adverse events. Ovulation returned in most subjects (77.1%, 27/35) within 32 days following the last dose of COC.

CONCLUSIONS

The 91-day extended-regimen COC with low-dose EE supplementation was found to be effective in suppressing ovarian activity and inhibiting ovulation and was well tolerated. Return to ovulation was rapid, occurring within approximately one month after discontinuation of COC.

Bleeding pattern and cycle control of a low-dose transdermal contraceptive patch compared with a combined oral contraceptive: a randomized study

OBJECTIVE(S)

The aim of this study was to investigate the bleeding pattern and cycle control of a contraceptive patch containing 0.55 mg ethinyl estradiol (EE) and 2.1 mg gestodene (GSD) compared with a combined oral contraceptive (COC) containing 0.02 mg EE and 0.1 mg levonorgestrel (LNG).

STUDY DESIGN

In this phase III, randomized, controlled, double-blind, double-dummy, multicenter trial, healthy women aged 18-45 years (smokers aged 18-35 years) received either the EE/GSD patch and a placebo tablet (n=171), or a placebo patch and the COC (n=175) for seven 28-day cycles. Bleeding control was assessed in two 90-day reference periods.

RESULTS

Mean number of bleeding/spotting days was comparable across treatment groups in both reference periods (p>.05). Mean number of bleeding/spotting episodes was also comparable in reference period 1; however, there were fewer bleeding/spotting episodes for COC in reference period 2 (3.4 versus 3.1; p=.01). Mean length of bleeding/spotting episodes was comparable across treatment groups for both reference periods (p>.05). Withdrawal bleeding occurred consistently in both groups over the entire treatment period, but its absence was more common in the COC group in cycles 4 and 6 of reference period 2 (p<.01). Intracyclic bleeding was comparable between groups.

CONCLUSION(S)

Bleeding pattern and cycle control with the EE/GSD patch was comparable to an EE/LNG-containing COC.

IMPLICATIONS STATEMENT

The findings suggest that bleeding patterns with the EE/GSD patch are similar to an EE/LNG-containing COC, except for absence of withdrawal bleeding, which was less common in patch users. The EE/GSD patch may constitute an additional contraceptive option for women.

A comparison of bleeding patterns and cycle control using two transdermal contraceptive systems: a multicenter, open-label, randomized study

OBJECTIVE(S)

To investigate the bleeding pattern and cycle control parameters of a contraceptive patch containing 0.55 mg ethinyl estradiol (EE) and 2.1 mg gestodene (GSD) compared with a patch containing 0.6 mg EE and 6 mg norelgestromin (NGMN).

STUDY DESIGN

In this phase III, open-label, randomized, parallel-group trial, healthy women aged 18-35 years (smokers aged 18-30 years) received either the EE/GSD patch (n=200) or the EE/NGMN patch (n=198). Treatment consisted of one patch per week for 3 weeks followed by a 7-day, patch-free interval for seven cycles. Bleeding control was assessed in two 90-day reference periods.

RESULTS

In reference period 1, mean number of bleeding/spotting days was comparable across treatment groups (p>0.05). However, in reference period 2, there were fewer bleeding/spotting days in the EE/GSD patch group (15.7 versus 18.4; p<0.0001). Mean number of bleeding/spotting episodes was comparable across groups for both reference periods, but bleeding/spotting episodes were shorter for the EE/GSD patch than the EE/NGMN patch during reference period 1 (5.13 days versus 5.53 days, respectively; p<0.05) and reference period 2 (5.07 versus 5.66; p=0.0001). Both treatment groups showed a similar frequency of withdrawal bleeding episodes; however, across all seven cycles, the length of these episodes was consistently shorter with the EE/GSD patch (p<0.01). There were no notable treatment differences in intracyclic bleeding.

CONCLUSION(S)

Bleeding pattern and cycle control achieved with the EE/GSD patch was similar to that of the EE/NGMN patch.

IMPLICATIONS STATEMENT

The paper presents data on the bleeding pattern and cycle control parameters of an investigational transdermal contraceptive patch containing EE and GSD compared with an approved contraceptive patch containing EE and NGMN. This descriptive study found that bleeding patterns associated with the EE/GSD patch were similar to those of an EE/NGMN patch providing higher EE exposure.

Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception

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.

Effect of a low-dose contraceptive patch on efficacy, bleeding pattern, and safety: a 1-year, multicenter, open-label, uncontrolled study

This Phase III, uncontrolled, open-label, multicenter study was conducted to investigate the contraceptive efficacy, bleeding pattern, and cycle control of a novel once-a-week contraceptive patch, delivering low-dose ethinyl estradiol (EE) and gestodene (GSD) at the same systemic exposure seen after oral administration of a combined oral contraceptive containing 0.02 mg EE/0.06 mg GSD. Participants were women aged 18 to 35 years, all of whom received the EE/GSD patch for 13 cycles each of 21 treatment days (one patch per week for 3 weeks) followed by a 7-day, patch-free interval. The primary efficacy variable was the occurrence of unintended pregnancies during the study period as assessed by life table analysis and the Pearl Index. Secondary efficacy variables were days with bleeding during four 90-day reference periods and during 1 treatment year, bleeding pattern, and cycle control. The Kaplan-Meier probability of contraceptive protection after 364 treatment days was 98.8% and the adjusted Pearl Index was 0.81. The percentage of participants with intracyclic bleeding/spotting decreased over time, from 11.4% to 6.8% in cycles 1 and 12, respectively. Almost all participants (range: 90.8%-97.6%) experienced withdrawal bleeding across the study period. Compliance was very high (mean: 97.9%; median: 100%). The most frequent adverse events were headache (9.5%) and application site reaction (8.5%); no clinically significant safety concerns were observed. Results suggest the EE/GSD patch is highly effective in preventing pregnancy. Menstrual bleeding pattern was favorable and within the ranges expected of a healthy female population. The patch was well tolerated and treatment compliance was high.

Investigation of the hemostatic effect of a transdermal patch containing 0.55 mg ethinyl estradiol and 2.1 mg gestodene compared with a monophasic oral contraceptive containing 0.03 mg ethinyl estradiol and 0.15 mg levonorgestrel: an open-label, randomized, crossover study

Background

Transdermal delivery of contraceptives offers several advantages over combined oral contraceptives (COCs), including effective absorption and the provision of relatively constant serum concentrations. Ethinyl estradiol (EE) and the progestin gestodene are well-absorbed through the skin and, therefore, well-suited for use in a transdermal contraceptive patch.

Objective

The objective of this study was to investigate the impact of a once-weekly transparent, transdermal patch delivering low doses of EE and gestodene equivalent to a COC containing 0.02 mg EE and 0.06 mg gestodene on hemostasis parameters compared with a monophasic COC containing 0.03 mg EE and 0.15 mg levonorgestrel.

Methods

In this single-center, open-label, randomized, crossover study, 30 women (aged 18–35 years) received three cycles of each treatment, separated by a two-cycle washout period. The primary outcome measure was the absolute change from baseline in prothrombin fragments 1 + 2 and d-dimer.

Results

For both treatments, prothrombin fragments 1 + 2 remained stable during the first treatment period, and increased only slightly in the second period (mean absolute change 0.025 and 0.028 nmol/L in the novel Bayer patch and COC groups, respectively). Increases in d-dimer were observed in both periods (mean absolute change 107.0 ± 147.2 ng/L for the novel Bayer patch and 113.7 ± 159.0 ng/L for the COC). There were no statistically significant treatment differences in prothrombin 1 + 2 or d-dimer (p = 0.667 and p = 0.884, respectively) and no statistically significant treatment sequence or period effects.

Conclusion

A COC containing 0.03 mg EE and 0.15 mg levonorgestrel and the novel Bayer patch have comparable influence on hemostatic endpoints. Both treatments were well-tolerated by subjects.

Effects of an ethinyl estradiol/gestodene transdermal contraceptive patch on the endometrium: a single-center, uncontrolled study

AIM

This study aims to investigate the effect of a transdermal contraceptive patch containing ethinyl estradiol and gestodene on endometrial proliferation over 1 year.

MATERIALS & METHODS

In this open-label, uncontrolled, Phase IIb study, women (aged 18-35 years) used the patch for 13 cycles of 28 days. The primary variable was histologic endometrial effects at cycle 13. Secondary objectives included contraceptive efficacy and safety.

RESULTS

Overall, 89 women were treated. At all visits, endometrial biopsies were devoid of any abnormalities. One woman became pregnant. The patch was well tolerated, with no safety concerns.

CONCLUSION

The ethinyl estradiol and gestodene patch had an endometrial effect consistent with suppression of endometrial proliferation in most patients. No endometrial abnormalities or other concerns were reported; compliance was good.

Evaluation of factors associated with noncompliance in users of combined hormonal contraceptive methods: a cross-sectional study: results from the MIA study

Background

Understanding contraception from the perspective of the user may help to improve compliance. The aim of this project was to determine the factors that influence the noncompliance in young women that use combined hormonal contraceptives (pill, patch or vaginal ring).

Methods

A nationwide cross-sectional multicenter epidemiology study. Physicians [obstetricians/gynecologists]) recorded socio-demographic, clinical and current contraception data of 8,762 women. Women completed a self-administered questionnaire on compliance. After the assessment of self-administrated questionnaire, the physicians reported on their recommendations on the possibility of changing the contraceptive.

Results

Fifty-two percent of women were noncompliant, mainly because of simple forgetfulness (pill, 74.9%; patch, 47.8%; vaginal ring, 69.1%). The percentage of noncompliant women was lower in vaginal ring users (26.6%) than in patch users (42.4%) or pill users (65.1%) (p < 0.0001). The most common course of action after noncompliance was to take/use the contraceptive as soon as possible. In the multiple logistic regression analysis, the use of the pill increased the probability of noncompliance compared with the patch and the vaginal ring (odds ratio [IC95%]: 2.53 (2.13-3.02) and 4.17 (3.68-4.73, respectively), and using the patch compared with the vaginal ring (1.65 (1.36-1.99)). Others factors associated with noncompliance were: high treatment duration, low degree of information on the contraceptive method, understanding of instructions on the contraceptive method, indifference to becoming pregnant, lack of partner support, not participation in selecting the method, not having a routine for taking treatment and difficulties remembering use the contraceptive method. Switching contraceptive method was proposed by the physicians to 43.2% of women (51.8% of pill users, 58.2% of patch users and 19.4% of vaginal ring users).

Conclusions

More than 50% of combined hormonal contraceptive users did not comply with the treatment regimen. The percentage of noncompliant women was lower between vaginal ring users. Understanding user’s reasons for noncompliance by the clinician and encouraging a collaborative approach can go a long way to improving compliance.

[General practitioners' (GPs) practice regarding the line to take in case of missed pill]

OBJECTIVE

To explore general practitioners' (GPs) practice face of missed pill and prevention of such missings.

MATERIAL AND METHOD

Twenty-five GPs from Sarthe Department (Western France) took part in semistructured interview during which they expressed themselves on the prevention of missed pill and its consequences.

RESULTS

Twelve out of 20 physicians stated positively that their female patients often forget their pill. However, they noted that missed pill was seldom a reason for phone call or consultation. During the initial pill prescription, GPs insisted on how to take the pill (14/25) as well as advice in case of a missed pill (22/25), their availability (12/25) and the instruction leaflet (16/25). But only five quoted the importance of involving women in the choice of contraception. On prescription renewal, only nine out of 25 ask their patients about observance defect and eight out of 25 repeated the information. If patients asked for further explanation, only two doctors out of 25 had practices in line with the French National Authority for Health's (HAS) recommandation guidelines.

CONCLUSION

GPs' attitudes are partly due to a lack of practice's knowledge in primary and emergency contraception methods. It seems essential to promote GPs' training and to take into account their expectations and needs. Furthermore, female patient must be actor of the choice of her contraceptive method in order to improve compliance and, therefore, effectiveness.

The combined oral contraceptive pill and the assumed 28-day cycle

Some studies involving women taking the combined oral contraceptive pill (COCP) have on occasion assumed the COCP group to have a rigid 28-day pharmaceutically driven cycle. Anecdotal evidence suggests otherwise, with many women adjusting their COCP usage to alter the time between break-through bleeds for sporting and social reasons. A prospective field study involving 533 scuba diving females allowed all menstrual cycle lengths (COCP and non-COCP) to be observed for up to three consecutive years (St Leger Dowse et al. 2006). A total of 29% of women were COCP users who reported 3,241 cycles. Of these cycles, only 42% had a rigid 28-day cycle, with the remainder varying in length from 21 to 60 days. When performing studies involving the menstrual cycle, it should not be assumed that COCP users have a rigid confirmed 28-day cycle and careful consideration should be given to data collection and analysis. The effects of differing data interpretations are shown.

Missed hormonal contraceptives: new recommendations

OBJECTIVE

To provide evidence-based guidance for women and their health care providers on the management of missed or delayed hormonal contraceptive doses in order to prevent unintended pregnancy.

EVIDENCE

Medline, PubMed, and the Cochrane Database were searched for articles published in English, from 1974 to 2007, about hormonal contraceptive methods that are available in Canada and that may be missed or delayed. Relevant publications and position papers from appropriate reproductive health and family planning organizations were also reviewed. The quality of evidence is rated using the criteria developed by the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

This committee opinion will help health care providers offer clear information to women who have not been adherent in using hormonal contraception with the purpose of preventing unintended pregnancy.

SPONSORS

The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS: 1. Instructions for what women should do when they miss hormonal contraception have been complex and women do not understand them correctly. (I) 2. The highest risk of ovulation occurs when the hormone-free interval is prolonged for more than seven days, either by delaying the start of combined hormonal contraceptives or by missing active hormone doses during the first or third weeks of combined oral contraceptives. (II) Ovulation rarely occurs after seven consecutive days of combined oral contraceptive use. (II) RECOMMENDATIONS: 1. Health care providers should give clear, simple instructions, both written and oral, on missed hormonal contraceptive pills as part of contraceptive counselling. (III-A) 2. Health care providers should provide women with telephone/electronic resources for reference in the event of missed or delayed hormonal contraceptives. (III-A) 3. In order to avoid an increased risk of unintended pregnancy, the hormone-free interval should not exceed seven days in combined hormonal contraceptive users. (II-A) 4. Back-up contraception should be used after one missed dose in the first week of hormones until seven consecutive days of correct hormone use are established. In the case of missed combined hormonal contraceptives in the second or third week of hormones, the hormone-free interval should be eliminated for that cycle. (III-A) 5. Emergency contraception and back-up contraception may be required in some instances of missed hormonal contraceptives, in particular when the hormone-free interval has been extended for more than seven days. (III-A) 6. Back-up contraception should be used when three or more consecutive doses/days of combined hormonal contraceptives are missed in the second and third week until seven consecutive days of correct hormone use are established. For practical reasons, the scheduled hormone-free interval should be eliminated in these cases. (II-A) 7. Emergency contraception is rarely indicated for missed combined hormonal contraceptives in the second or third week of the cycle unless there are repeated omissions or failure to institute back-up contraception after the missed doses. In cases of repeated omissions of combined hormonal contraceptives, emergency contraception may be required, and back-up contraception should be used. Health care professionals should counsel women in these situations on alternative methods of contraception that do not demand such stringent compliance. (III-A).

La contraception des adolescentes en France en 2007

The two main objectives of adolescence contraception are the eviction of involuntary pregnancies and the prevention of sexually transmitted infections. In France, in spite of our rich contraceptive arsenal and a widely spread information, the rate of voluntary termination of pregnancy keeps growing among the teenagers population--and this, probably because the gap between theoretical effectiveness and practice of contraception is particularly wide among the young people. Every contraceptive means can be used by teenagers; the best option being, it seems, the "double DUTCH", which consists of concomitant use of condoms and hormonal contraception. Most often, the consultation for contraception is the first gynaecological consultation. That is the reason why it is usually stressful for teenagers who dread undergoing a gynaecological examination. If this examination is not necessary for most of young patients, it is essential to create a trustful relationship and to make explicit the several contraceptive methods. During this consultation it is interesting to look for common teenage troubles like addiction to smoking and eating disorders. For any prescription of hormonal contraception, it is important to explain the benefits and the possible side effects, to stress the observance and to tell the teenager about the recommendations in case of forgetting. Concerning condom - the only efficient way of preventing sexually transmitted infections--, it is useful to talk about it in concrete and straightforward terms, to show its handling and to inform about risks of tearing. With this state of mind, an emergency contraception can be prescribed straightaway in order to make its use easier. Also, without any moralizing speech, the need for maturity must be emphasized as well as taking care of one's body with the aim of avoiding a premature pregnancy or any sexually transmitted infection. This consultation must be coupled with a close follow-up, availability and mutual confidence which are the main elements vouching for a good observance and consequently an efficient contraception.

[Emergency contraception: evaluation of women's understanding of it, a requisite for the effectiveness of the treatment]

OBJECTIVE

To evaluate how much women who attend primary care consultations understand about the correct use of emergency ("morning after") contraception (EC), their information requirements and their views about free EC prescription.

DESIGN

Cross-sectional study, using a questionnaire.

SETTING

Les Corts Primary Care Centre, Barcelona, Spain.

PARTICIPANTS

A total of 130 women aged 15 to 45 years old who attended primary care consultations in May and June, 2005, were included. One-hundred and twenty-four of them (95.4%) agreed to the questionnaire.

MAIN MEASUREMENTS

We tested knowledge of EC, and we drew up a questionnaire to evaluate understanding. This had 4 multiple-choice questions, as well as socio-demographic data, contraception background, how they preferred to obtain EC, and their information requirements.

RESULTS

We found a lack of knowledge about several aspects of EC use: in particular, 33% of the women thought that EC eliminated completely the risk of pregnancy. We only found differences for better knowledge of EC in women who had used it before (3.03; 95% CI, 2.29-3.77) versus those who had never used it (2.47; 95% CI, 1.54-3.4; P=.028. Free prescription of EC in health centres was approved of by 75.8%, while 83.1% said they needed more information. Their preferred method to obtain this information was by leaflet.

CONCLUSIONS

Women who attend primary health care clinics have a need for information on EC. Their lack of knowledge could limit the effectiveness of treatment. A brief explanation and handing out a leaflet could solve this problem.

The Transdermal Patch and the Vaginal Ring: Two Novel Methods of Combined Hormonal Contraception

This article reviews two novel contraceptive methods that have become recently available in the United States: the transdermal patch and the vaginal ring. In general, newer methods of contraception are designed to make adherence easier for patients. The two contraceptive methods discussed in this article may help patients achieve this goal.

Menstrual-cycle-related symptoms: a review of the rationale for continuous use of oral contraceptives

As many as 80% of reproductive-aged women experience physical changes associated with menstruation, and 20% to 40% experience menstrual-cycle-related symptoms. Decades of research in women with menstrual disorders, such as dysmenorrhea and menorrhagia, have shown that continuous use of oral contraceptives (OCs), without the hormone-free interval, is a safe and effective method to relieve these symptoms and ultimately induce amenorrhea in many women. If given the opportunity, a majority of women would opt for extended-cycle or continuous regimens, and numerous clinical trials have shown that continuous OC regimens induce amenorrhea in 80% to 100% of women by 10 to 12 months of use. For women who do not wish to become pregnant, a continuous OC regimen should be an available option.

Extended cycle hormonal contraception in adolescents

PURPOSE OF REVIEW

There is increasing interest in the use of extended cycles of hormonal contraception to manage menstrual cycle-related complaints in adolescents and to accommodate the menstrual preferences of patients using hormonal contraception. This review summarizes recent findings related to the use of extended cycles and highlights their relevance to adolescents.

RECENT FINDINGS

Many adolescents would prefer to menstruate less frequently. Among health care providers who prescribe hormonal contraceptives, the majority believe suppressing withdrawal bleeding is well tolerated and prescribe extended cycling regimens to their patients. Shortening or eliminating the hormone-free interval results in greater ovarian suppression and thus may increase contraceptive efficacy. Studies in adult women have not identified changes in metabolic parameters beyond what would be expected from traditional cyclic use. New endometrial biopsy data have found no pathologic changes; most women using an extended cycle had atrophic endometriums. Extended cycling is frequently associated with breakthrough bleeding. In some women, this can be managed with a brief hormone-free interval.

SUMMARY

Recent findings demonstrate high levels of interest in extended cycling among adolescents and providers, and continue to add to the growing body of literature supporting the safety and improved contraceptive efficacy of extended regimens. Further research is warranted to focus on issues including cancer, thrombotic disease and fertility, and should enroll a sufficient adolescent sample.

Continuous or extended cycle vs. cyclic use of combined oral contraceptives for contraception

BACKGROUND

The avoidance of menstruation through extended or continuous administration (greater than 28 days of active pills) of combination oral contraceptives (COCs) has gained legitimacy through its use in treating endometriosis, dysmenorrhea, and menstruation-associated symptoms. Avoidance of menstruation through continuous use of COCs 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 COCs dosed continuously (greater than 28 days of active pills) compared with traditional cyclic dosing (21 days of active pills and 7 days of placebo). Our hypothesis was that continuously administered COCs have equivalent efficacy and safety but improved bleeding profiles, amenorrhea rates, adherence, continuation, participant satisfaction, and menstrual symptoms compared with cyclic COCs.

SEARCH STRATEGY

We searched computerized databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, POPLINE, LILACS) for trials using continuous or extended COCs during the years 1966 to 2005. 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 (greater than 28 days of active pills) versus traditional cyclic administration (21 days of active pills and 7 days of placebo) of COCs 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 4.2. 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 pill and time length for continuous dosing), we could not aggregate data into meta-analysis.

MAIN RESULTS

Six randomized controlled trials met our inclusion criteria. Study findings were similar between 28-day and extended cycles in regard to contraceptive efficacy (i.e., pregnancy rates) and safety profiles. When compliance was reported, no difference between 28-day and extended 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 in most studies. The few studies that reported menstrual symptoms found that the extended cycle group fared better in terms of headaches, genital irritation, tiredness, bloating, and menstrual pain. Five out of the six studies found that bleeding patterns were either equivalent between groups or improved with continuous-dosing regimens. Endometrial lining assessments by ultrasound were done in a small number of participants but all endometrial stripe measurements were less than 5 mm.

AUTHORS' CONCLUSIONS

Evidence from existing randomized control trials comparing COCs given continuously (greater than 28 days of active pills) to traditional monthly cyclic dosing (21 days of active pills and 7 days of placebo) is of good quality. However, the variations in type of pill and time length for continuous dosing make direct comparisons between regimens impossible. Future studies should choose a previously described type of pill and dosing regimen. More attention needs to be directed towards participant satisfaction and menstruation-associated symptoms.