Continuation and compliance of contraceptive use

Comparison of Combined Parenteral and Oral Hormonal Contraceptives: A Systematic Review and Meta-Analysis of Randomized Trials

BACKGROUND

Delivering contraceptive hormones through a transdermal patch or a vaginal ring might have advantages over the traditional oral route.

OBJECTIVES

To compare the effectiveness, compliance, and side effect profile of oral and parenteral drug administration methods.

METHODS

We performed a systematic literature search in four medical databases-MEDLINE (via PubMed), Cochrane Library (CENTRAL), Embase, and Scopus-from inception to 20 November 2022. Randomized controlled trials assessing the efficacy, compliance, and adverse event profile of combined parenteral and oral hormonal contraceptives were included.

RESULTS

Our systematic search provided 3952 records; after duplicate removal, we screened 2707 duplicate-free records. A total of 13 eligible studies were identified after title, abstract, and full-text selection. We observed no significant difference in contraceptive efficacy (Pearl Index) between oral and parenteral drug administration (MD = -0.06, CI: -0.66-0.53; I2 = 0%). We found significant subgroup differences between parenteral methods in terms of compliance (χ2 = 4.32, p =0.038, I2 = 80%) and certain adverse events: breast discomfort (χ2 = 19.04, p =0.001, I2 = 80%), nausea (χ2 = 8.04, p =0.005, I2 = 75%), and vomiting (χ2 = 9.30, p =0.002; I2 = 72%).

CONCLUSION

Both parenteral and oral contraceptives can be used as an effective contraceptive method, and the route of administration should be tailored to patient needs and adverse event occurrence.

Method of Hormonal Contraception and Protective Effects Against Ectopic Pregnancy

The risk of ectopic pregnancy was higher in women using low-dose hormonal intrauterine devices (13.5 mg levonorgestrel) than in women using other types of hormonal contraception

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Contraception: what is the resistance all about?

PURPOSE

The aim of this study is to identify the aspects associated with resistance to contraception, providing healthcare workers with the necessary tools to increase compliance with contraception and, ultimately, reduce the rate of voluntary abortions.

MATERIAL AND METHODS

We performed a review of the literature published in Medline between 1st January 2000 and 31st July 2020. We included studies based on qualitative analyses, describing women's perception and attitudes towards contraception, including a population aged 15 years or older and conducted in either Europe or North America.

RESULTS

A total of 23 articles were included in the study. Resistance to contraceptive uptake was most frequently due to ambivalence about pregnancy, with up to 54% of ambivalent women reporting not using any means of contraception, and communication issues with the partner and/or health care provider, with a positive association found between communication with the partner and contraceptive use (OR 1.07; p < .050). Additional barriers to contraceptive use were the quality of the relationship with the partner, the perception of the risk of becoming pregnant after unprotected sexual intercourse, and unfamiliarity with contraception.

CONCLUSIONS

Family planning consultations should acknowledge the aspects that influence contraceptive uptake and address them as part of their consultations.

Correcting oral contraceptive pharmacokinetic alterations due to obesity: a randomized controlled trial

OBJECTIVE

To determine if increasing the hormone dose or eliminating the hormone-free interval improves key pharmacokinetic (PK) alterations caused by obesity during oral contraceptive (OC) use.

STUDY DESIGN

Obese [body mass index (BMI)≥30 kg/m(2)], ovulatory, otherwise healthy, women received an OC containing 20 mcg ethinyl estradiol (EE)/100 mcg levonorgestrel (LNG) dosed cyclically (21 days active pills with 7-day placebo week) for two cycles and then were randomized for two additional cycles to the following: continuous cycling (CC, a dose neutral arm using the same OC with no hormone-free interval) or increased dose (ID, a dose escalation arm using an OC containing 30 mcg EE/150 mcg LNG cyclically). During Cycles 2, 3 and 4, outpatient visits were performed to assess maximum serum concentration (Cmax), area under the curve (AUC0-∞) and time to steady state as well as pharmacodynamics. These key PK parameters were calculated and compared within groups between baseline and treatment cycles.

RESULTS

A total of 31 women enrolled and completed the study (CC group, n=16; ID group, n=15). Demographics were similar between groups [mean BMI: CC, 38 kg/m(2) (S.D. 5.1); ID, 41 kg/m(2) (S.D. 7.6)]. At baseline, the key LNG PK parameters were no different between groups; average time to reach steady state was 12 days in both groups; Cmax were CC: 3.82±1.28 ng/mL and ID: 3.13±0.87 ng/mL; and AUC0-∞ were CC: 267±115 h ng/mL and ID: 199±75 h ng/mL. Following randomization, the CC group maintained steady-state serum levels whereas the ID group had a significantly higher Cmax (p<.001) but again required 12 days to achieve steady state. However, AUC was not significantly different between CC (412±255 h ng/mL) and ID (283±130 h ng/mL). Forty-five percent (14/31) of the study population had evidence of an active follicle-like structure prior to randomization and afterwards this decreased to 9% (3/31).

CONCLUSION

Both increasing the OC dose and continuous dosing appear to counteract the impact of obesity on key OC PK parameters.

IMPLICATIONS

Obesity adversely affects the pharmacokinetics of very low dose OC pills. Although the impact of these changes on OC efficacy is still under debate, PK parameters can be normalized in obese users by continuous dosing or increasing to a low-dose pill.

Unintended pregnancy among HIV positive couples receiving integrated HIV counseling, testing, and family planning services in Zambia

Objective

We describe rates of unintended pregnancy among HIV positive couples in Lusaka, Zambia. We also identify factors associated with unintended pregnancy among oral contraceptive pill (OCP) using couples in this cohort.

Design

Data were analyzed from couples randomized in a factorial design to two family planning intervention videos.

Methods

Rates of unintended pregnancy were stratified by contraceptive method used at time of pregnancy. Predictors of time to unintended pregnancy among OCP users were determined via multivariate Cox modeling.

Results

The highest rates of unintended pregnancy were observed among couples requesting condoms only (26.4/100CY) or OCPs (20.7/100CY); these rates were not significantly different. OCP users accounted for 37% of the couple-years (CY) observed and 87% of unintended pregnancies. Rates of unintended pregnancy for injectable (0.7/100CY) and intrauterine device (1.6/100CY) users were significantly lower relative to condom only users. No pregnancies occurred among contraceptive implant users or after tubal ligation. Factors associated (p<0.05) with time to unintended pregnancy among OCP users in multivariate analysis included the man wanting more children, the woman being HIV negative versus having stage IV HIV disease, and the woman reporting: younger age, no previous OCP use, missed OCPs, or sex without a condom.

Conclusions

Long-acting reversible contraceptive methods were effective in the context of integrated couples HIV prevention and contraceptive services. Injectable methods were also effective in this context. Given the high user failure rate of OCPs, family planning efforts should promote longer-acting methods among OCP users wishing to avoid pregnancy. Where other methods are not available or acceptable, OCP adherence counseling is needed, especially among younger and new OCP users.

Trial registration

ClinicalTrials.gov NCT00067522

Unscheduled bleeding with continuous oral contraceptive pills: a comparison of progestin dose

BACKGROUND

Although the use of continuous oral contraceptive pills (OCPs) eliminates scheduled uterine bleeding, unscheduled bleeding is common. The objective of this study was to determine whether progestin dose influences bleeding with use of continuous OCPs.

STUDY DESIGN

This was a secondary data analysis of two other studies of continuous OCPs. Women were eligible if they were switching from a cyclic hormonal contraceptive to a continuous OCP. Women took a 20-mcg ethinyl estradiol (EE)/100-mcg levonorgestrel (LNG) pill or a 20-mcg EE/90-mcg LNG pill for 112 days. The number of bleeding/spotting days was compared between groups using a t test. Sample size was adequate to detect a difference of 8 days of bleeding/spotting over the 112 day study period (β=0.80, α=0.05).

RESULTS

Sixty-six subjects were enrolled, 33 in each group. There were no differences in baseline characteristic, missed OCPs or side effects. There were no differences in the mean number of bleeding/spotting days in the first 84 days of the study (90 mcg LNG mean 20.8 (SE 3.6) days versus 100 mcg LNG 17.8 (SE 2.3) days, p=.48), nor was there a difference in the time to amenorrhea (p=.35).

CONCLUSION

Our results do not support the use of one LNG dose over another to decrease the amount of unscheduled bleeding women experience when initiating a continuous OCP.

Studying the use of oral contraception: a review of measurement approaches

BACKGROUND

Although oral contraception (OC) misuse is presumed to play an important role in unwanted pregnancy, research findings have often been equivocal, perhaps reflecting unaddressed inconsistencies in methodological approaches.

METHODS

Using established databases, we performed a systematic review of measurement methods for OC use using primary research reports published from January 1965 to December 2009.

RESULTS

Terminology used to describe OC use, which included "continuation," "compliance," and "adherence," differed across studies and was rarely defined. The majority of studies (n = 27 of 38, 71%) relied solely on self-report measures of OC use. Only two reports described survey or interview questions, and reliability and validity data were seldom described. More rigorous measurement methods, such as pill counts (electronic or manual), serum and urinary biomarkers, and pharmacy records, were infrequently employed. Nineteen studies simultaneously used more than one method, but only three studies compared direct and indirect methods.

CONCLUSIONS

The lack of a consistent, well-defined measurement of OC use limits our understanding of contraceptive misuse and related negative outcomes. Future research should clarify terminology, develop standardized measures, incorporate multimethod approaches with innovative methods, and publish details of measurement methods.

Profile of long-acting reversible contraception users in Europe

OBJECTIVES

To assess the profile of long-acting reversible contraceptives (LARCs) users in Europe.

METHODS

A random sample of women aged 15-49 years in 14 European countries (Germany, France, UK, Spain, Italy, Russian Federation, Estonia, Latvia, Lithuania, Austria, Czech Republic, Denmark, Norway, and Sweden) underwent web-based or computer-aided face-to-face interviews in June 2006. In this paper data pertaining to a subgroup of women using LARCs are presented.

RESULTS

A total of 11,490 women participated in the full study. Of these, 1,188 (10%) women were LARC (hormonal implant, injectables, levonorgestrel-releasing intrauterine system [LNG-IUS], copper intrauterine device [Cu-IUD]) users. The age of the LARC users exceeded 30 years for 57-91% of them. Furthermore, more than half of them found convenience an extremely important factor when selecting the LARC as a contraceptive method. As compared to those wearing a Cu-IUD, women using hormonal LARCs experienced fewer physical and emotional symptoms that appeared or worsened during menstruation.

CONCLUSIONS

LARCs have their place in the contraceptive market in Europe. The most popular LARCs among European women were the LNG-IUS and the Cu-IUD; both were mainly used by women who had children and had no wish to have more in the future.

The structure of contraceptive education and instruction within nurse led family planning clinics: a grounded theory study

AIMS

This study aimed to explore and analyse how nurses instruct women in contraceptive use during consultations in family planning clinics to produce a grounded theory of contraceptive education.

BACKGROUND

Nurses play a key role in instructing women how to use contraception in family planning clinic consultations. These one-to-one situations are encounters where women are taught how to use contraceptive methods effectively. However, very little is known about the nature of these consultations.

DESIGN

A qualitative study using a grounded theory approach was used.

RESULTS

Three linked 'core categories' emerged from the data analysis. Firstly, women are educated about their body and how it responds to contraception: 'reproductive education'. This core category is closely linked to 'surveillance' where women are taught to monitor their reproductive health and to 'contraceptive regimen' where women are instructed in techniques to successfully use a contraceptive method. Together these three core categories present a grounded theory of 'contraceptive education'.

CONCLUSIONS

Nursing practice in this important area of women's health care is complex and requires skilled practitioners. This study presents unique empirical data into how nurses conduct one-to-one consultations with women - providing a novel insight into how contraception is explained in clinical situations. Key issues for practice from the data were the lack of a balance when discussing side effects, the rigidity of some instructions and the lack of recognition of risk from sexually transmitted infection.

RELEVANCE TO CLINICAL PRACTICE

Nurses working in sexual health need to ensure that women understand the often complex instructions they provide and that rigid instruction be occasionally amended to enable some flexibility. The manner in which side-effects are discussed should also be balanced. Nurses need to address the risk of sexually transmitted infections more substantially in contraceptive discussions.

The impact of medication regimen factors on adherence to chronic treatment: a review of literature

This article reviews recent literature in chronic illness or long-term health management including asthma, contraception, diabetes, HIV disease, and hypertension/cardiovascular disease, mental disorders, pain, and other diseases to determine the relationship between regimen factors and adherence to medications. The authors conducted an electronic literature search to detect articles published between 1998 and 2007. Articles were included if they pertained to a chronic illness or to contraception, included a clear definition of how adherence was measured, and included regimen factors as primary or secondary explanatory variables. Methodology of the studies varied greatly, as did methods of measuring adherence and regimen factors. Surprisingly few of these articles concerned (1) chronic treatment, (2) regimen factors such as dosing, pill burden, and regimen complexity, and (3) adherence measured in a clear manner. Most studies failed to use state-of-the-art methods of measuring adherence. Despite these flaws, a suggestive pattern of the importance of regimen factors, specifically dose frequency and regimen complexity, emerged from this review.

Nurses' discourse in contraceptive prescribing: an analysis using Foucault's 'procedures of exclusion'

AIM

This paper is a report of an analysis of the discourse about contraceptive efficacy and side effects used by nurses when prescribing contraception.

BACKGROUND

All women seeking contraception should be informed of the efficacy and potential adverse effects of the particular method they are considering. This information facilitates an informed choice. Women also require this information in order to monitor for any side effects. Paradoxically, side effects are also a key factor in reducing adherence with contraceptive regimens. However, there is no literature that explores specifically how this issue is addressed in clinical consultations, or places these practices in a theoretical context.

METHOD

Forty-nine consultations between nurses and women in sexual health clinics were audio-recorded during 2002. Data were subject to a discourse analysis using Foucault's 'procedures of exclusion' to explore the discursive construction of contraceptive efficacy and side effects

FINDINGS

The nurses employed specific discursive strategies when discussing contraception. When addressing efficacy, discourse centred on medico-statistical facts, but side effects were described in lay terms that minimized their severity. Nurses contextualized contraceptive side effects within potential problems that women might experience in pregnancy, and also attempted to 'normalize' contraceptive-related problems.

CONCLUSION

Discourse and its deployment play a key role in practitioner-client relationships that sexual health nurses need to become more aware of how they discuss clinical issues about contraception with women. Clinical data on contraceptive side-effects are present in the literature, and it is important that sexual health nurses use this to help women make truly informed decisions.

Satisfaction among women: differences between current users of barrier (male condom) and non-barrier methods

OBJECTIVES

To determine the differences in and factors related to satisfaction between barrier (male condom) and non-barrier method users.

METHODS

A semi-structured questionnaire was used for collecting data for this cross-sectional survey. The questionnaires were completed via one-on-one interviews by the researchers. The study group was selected using stratified random sampling. Exclusion criteria were, being unmarried, pregnant, in postmenopausal status and using traditional methods. A total of 434 currently married women using modern contraceptive methods participated in the study. Contraceptive users were dichotomized into two groups as non-barrier method users and barrier method users.

RESULTS

About half of the participants (n = 191, 44%) were barrier method users. Their mean age was 33.7 +/- 7.3 years, 66.6% (n = 131) were well educated and reported significantly less pregnancies, given births, living children and abortions (reproductive history events) than non-barrier users. Barrier method users were significantly more likely to be satisfied with their contraceptive method of choice (OR: 2.4; 95% CI 1.2-5.2). Among barrier method users, deciding the type of the contraceptive method themselves had significant effect on satisfaction.

CONCLUSION

In our study, satisfaction was mostly affected by heavy side effects and health risks of the methods resulting in less satisfaction with the contraceptive method among non-barrier method users. Other factors which may influence satisfaction deserve further investigation.

Doppler color flow analysis of the uterine arteries before and after intrauterine device insertion: a prospective study

OBJECTIVE

An intrauterine device (IUD) is one of the most frequently used methods of birth control around the world. Although a relationship between its use and menstrual disorders has been well documented, only a few studies have tried to show whether there are any vascular modifications. The aim of our study was to evaluate the influence of an IUD on uterine artery blood flow using Doppler assessment.

METHODS

A total of 100 patients selected for IUD use were prospectively evaluated with Doppler analysis before and 30 days after insertion. The resistive index (RI) and pulsatility index (PI) were used to evaluate uterine artery vascular resistance. Patients were allocated in 2 groups according to whether they were (group 2) or were not (group 1) lactating.

RESULTS

The PI and RI of the patients in groups 1 and 2 before and after IUD insertion were not statistically significantly different (P = .298 and .23). When we compared uterine artery blood flow indices before and after IUD insertion for groups 1 and 2 separately, we observed in group 1 that the mean +/- SD PI values were 2.45 +/- 0.62 and 2.55 +/- 0.55 (P = .38) and the RI values were 0.87 +/- 0.08 and 0.87 +/- 0.06 (P = .88) before and after IUD insertion, respectively. In group 2, the PI values were 2.31 +/- 0.55 and 2.37 +/- 0.69 (P = .68) and the RI values were 0.85 +/- 0.07 and 0.86 +/- 0.07 (P = .44) before and after IUD insertion. Finally, we used the mean blood flow indices of the uterine arteries of all patients to compare the effect of IUD insertion. Results were also not statistically significant when we compared PI and RI before and after IUD insertion.

CONCLUSIONS

The presence of an IUD does not interfere with the vascular resistance of the uterine arteries that can be shown by Doppler flow assessments 1 month after insertion.

The 2002 Canadian Contraception Study: Part I

OBJECTIVES

To investigate the contraception and sexual health-related awareness, attitudes, and practices of a representative sample of Canadian women of childbearing age.

METHODS

A self-report survey was mailed to a national sample of 3345 women, aged 15 to 44 years, who were members of a pre-recruited market research panel. Survey questions and methodology were similar to 3 previous Canadian Contraception Studies, allowing for description of current patterns of behaviours and beliefs and comparison of trends over time.

RESULTS

Of 3345 women contacted, 1582 returned completed surveys, for a response rate of 47.3%. Responses were weighted to represent Canadian women by region, age, and marital status on the basis of current census data. Eighty-six percent of women sampled had ever had sexual intercourse and 78% were currently sexually active. Women's familiarity with oral contraceptives and condoms as methods of contraception was high (96% and 93%, respectively), but familiarity with other methods was much lower (sterilization, 62%; withdrawal, 59%; the morning-after pill, 57%; intrauterine devices, 50%; depot [injectable] medroxyprogesterone acetate, 38%). A very favourable opinion was held by 63% of respondents concerning oral contraceptives, by 38% concerning condoms, and by 39% and 28% concerning male and female sterilization, respectively. Among respondents who have ever had sexual intercourse, the most frequently used current methods were oral contraceptives (32%), condoms (21%), male sterilization (15%), female sterilization (8%), and withdrawal (6%). Nine percent of these respondents reported using no method of contraception at all. The currently reported rate of female sterilization is the lowest ever recorded in Canada. Survey results show that adherence to contraceptive methods is a challenge for many women and their partners, and that risk of sexually transmitted disease is an ongoing concern.

CONCLUSION

This study provides a wide-ranging examination of contraception awareness, beliefs, and use among Canadian women that may provide guidance for clinical and public health practice. Part 1 of this report describes the methodology of the 2002 Canadian Contraception Study and the overall results of this study; Part 2 considers results pertaining specifically to adolescent women and women in their later reproductive years, reports on indicators of women's sexual function and reproductive health history, describes approaches to addressing challenges in contraception counselling, and presents data concerning trends in Canadian women's awareness and use of contraception over the past 2 decades.