Contraceptive methods that may be available in the United States in the near future are described in Table 4. These include a monthly injection containing medroxyprogesterone acetate/estradiol cypionate (MPA/E2C, Lunelle, a two-rod levonorgestrel subdermal implant (Norplant-II), a one-rod etonorgestrel implant (Implanon), an IUD that releases levonorgestrel 20 μg/day for up to 7 years (LNG-20 IUD, Mirena), a vaginal ring that releases etonorgestrel and ethinyl estradiol (NuvaRing) and is discarded after 3 weeks to allow menses, and a 1-week transdermal patch that releases 17-desacetylnorgestimate and ethinyl estradiol (EVRA). A US company has also announced its intentions to reintroduce the Today contraceptive sponge impregnated with 1-g nonoxynol-9.
Data from clinical trials indicate that the monthly combination injection, the new implants, and the levonorgestrel IUD are highly effective contraceptive methods.1, 13 In an open-label, nonrandomized, parallel, controlled study of the MPA/E2C contraceptive injection, no pregnancies occurred among 782 women during the first year of use (13 cycles of 28 days).13 With the two-rod implant, 5-year failure rates of 0.7% were reported in a large clinical trial,28 and the one-rod implant has been shown to be effective for 3 years with no pregnancies in a large number of women.29 A 7-year cumulative failure rate of 1.1% has been reported with the LNG-20 IUD.1 The vaginal ring appears to have contraceptive effectiveness considerably higher than the diaphragm, approaching that of OCs.30 However, no published data addressing the contraceptive efficacy of the estrogen-progestin vaginal ring or the transdermal patch are currently available.
Table 4. Comparison of available and prospective contraceptive methods
| Parameter | Monthly Injection | Implants | LNG-20 IUD | Vaginal Rings | Transdermal Patch | Sponge |
| Efficacy | High | High | High | Intermediate, some user dependence | Intermediate, some user dependence | Similar to other barrier methods |
| Length of protection | 1 mo | 3–5 yr | 5–7 yr | 1 mo | 7 days | Single use with coitus |
| Rapid return of fertility | Yes | Yes | Yes | Yes | Yes | Yes |
| Regular cycles | Yes | Variable | Yes, most users | Yes, user controlled | Yes | Yes |
| Amenorrhea | Uncommon | Variable | Variable | No | No | No |
| Appropriate in nursing mothers | Unknown | Yes | Yes | No | No | Yes |
| Procoagulant | No | No | No | May be less so than oral contraceptive | Unknown | No |
| Noncontraceptive benefits | Unknown | Unknown | Reduces menorrhagia | Unknown | Unknown | May reduce risk of STDs |
| Provider required to initiate | Yes | Yes | Yes | Yes (Rx) | Yes (Rx) | No |
| Provider required to discontinue | No | Yes | Yes | No | No | No |
| Privacy | Yes | Seen or felt by some users | Usually (string may be felt by partner) | Yes, can be removed before intercourse | No | No |
LNG, levonorgestrel; IUD, intrauterine device, STD, sexually transmitted disease.
(Adapted
from Mishell DR, Arias RD, Darney PD et al: Contraception in the US:
New methods = wider choices. Contemp Obstet Gynecol Suppl:1–26, 2000.)
These new contraceptive options will be valuable additions to the menu of contraceptive choices that clinicians can offer their patients. With the monthly combination injection, US women will have a shorter-acting alternative to DMPA. Although monthly injections are required, menstrual cycles are regular and there is a rapid return to fertility following cessation of use. Moreover, because estradiol cypionate does not increase hepatic globulin synthesis, no significant procoagulant effects have been seen in users of the monthly combination injection.16 The new second generation implants are much simpler to insert and remove than the first generation six-rod system, and their initial acceptance by patients and clinicians in many European countries has been excellent.30 Amenorrhea rather than irregular bleeding is generally seen with these products, which is acceptable to an increasing number of US women.30 These improvements may lead to a renaissance of interest in contraceptive implants among US clinicians and patients.
With the LNG-20 IUD, progestin is released more slowly and acts locally on the endometrium.30 Thus, there is less bleeding and indeed often amenorrhea occurs, making this a useful contraceptive option to reduce menstrual blood loss in women with menorrhagia, including those with bleeding dyscrasias. This progestin-releasing IUD also provides endometrial protection in menopausal women using estrogen, with few of the side effects related to systemic progestin use. The vaginal ring releases a low dose of hormones continuously when in place. Although designed to be removed for 7 days after 3 weeks of use, it can remain in place for longer periods, enabling a woman to control the timing of menses. The device is smaller than the diaphragm; because it is a one-size-fits-all product, no fitting is required. The ring should be an attractive contraceptive option for a substantial number of women. Like the vaginal ring, the new estrogen/progestin transdermal patch provides efficacy and cycle control similar to that of OCs without the need for daily pill-taking.30
A dedicated formulation became available in the United States in 1998 for emergency contraception. With Preven, the marketed version of the Yuzpe regimen, two tablets of a 50 μg-estrogen/progestin OC are taken 12 hours apart. Recently, a progestin-only method—Plan B—was approved. With Plan B, two 750-mg tablets of levonorgestrel are taken 12 hours apart. Plan B is reported to be 85% effective with a pregnancy rate of less than 2%.30 An advantage of the progestin-only method is that it causes fewer gastrointestinal side effects than the older method. Today, some clinicians provide every patient at risk for pregnancy with an advance prescription for emergency contraception. This strategy increases the likelihood that women will use emergency contraception when they need it and represents an important tool for reducing unintended pregnancies.
CONCLUSIONS
Effective contraception benefits both mothers and children by decreasing morbidity and mortality, improving the social and economic status of women, and improving the relationship of the mother with all her children. Despite the availability of effective, reversible methods of contraception, the United States has rates of unintended pregnancy and abortion more resembling those of a developing country than other industrialized nations. Among US couples, 40% choose male or female sterilization as their method of contraception, whereas in developing nations where access to female sterilization is limited, the IUD is the most popular method. In more developed countries, the OC is the most popular method of birth control, followed by the condom and the IUD.
Heavy reliance on sterilization by US couples reflects the lack of contraceptive choices and the mistaken belief that this surgical method is 'foolproof'. In fact, failure rates with various methods of tubal sterilization have been underestimated; this method is no more effective than injections, IUDs, or implants. The negative media attention focused on problems with reversible methods has also contributed to overuse of sterilization. An additional factor is that most health-care plans cover sterilization whereas only 49% of typical indemnity plans cover the cost of OCs, IUDs, diaphragms, or contraceptive implants and injections. Plans that provide coverage of prescription drugs often do not cover OCs.
New contraceptive methods likely to become available in the US soon will increase the number of effective, reversible contraceptive choices for US couples. Greater access to a wider variety of methods will increase contraceptive use. Much as a good cafeteria offers a wide selection of foods to accommodate a variety of tastes, so too must clinicians be able to offer women safe, effective, convenient options that meet their individual needs and preferences. The availability of a greater number of contraceptive choices will increase the use of more effective methods and thus has the potential to reduce unintended pregnancies and abortions in US women of all ages.
With the LNG-20 IUD, progestin is released more slowly and acts locally on the endometrium.30 Thus, there is less bleeding and indeed often amenorrhea occurs, making this a useful contraceptive option to reduce menstrual blood loss in women with menorrhagia, including those with bleeding dyscrasias. This progestin-releasing IUD also provides endometrial protection in menopausal women using estrogen, with few of the side effects related to systemic progestin use. The vaginal ring releases a low dose of hormones continuously when in place. Although designed to be removed for 7 days after 3 weeks of use, it can remain in place for longer periods, enabling a woman to control the timing of menses. The device is smaller than the diaphragm; because it is a one-size-fits-all product, no fitting is required. The ring should be an attractive contraceptive option for a substantial number of women. Like the vaginal ring, the new estrogen/progestin transdermal patch provides efficacy and cycle control similar to that of OCs without the need for daily pill-taking.30
A dedicated formulation became available in the United States in 1998 for emergency contraception. With Preven, the marketed version of the Yuzpe regimen, two tablets of a 50 μg-estrogen/progestin OC are taken 12 hours apart. Recently, a progestin-only method—Plan B—was approved. With Plan B, two 750-mg tablets of levonorgestrel are taken 12 hours apart. Plan B is reported to be 85% effective with a pregnancy rate of less than 2%.30 An advantage of the progestin-only method is that it causes fewer gastrointestinal side effects than the older method. Today, some clinicians provide every patient at risk for pregnancy with an advance prescription for emergency contraception. This strategy increases the likelihood that women will use emergency contraception when they need it and represents an important tool for reducing unintended pregnancies.
CONCLUSIONS
Effective contraception benefits both mothers and children by decreasing morbidity and mortality, improving the social and economic status of women, and improving the relationship of the mother with all her children. Despite the availability of effective, reversible methods of contraception, the United States has rates of unintended pregnancy and abortion more resembling those of a developing country than other industrialized nations. Among US couples, 40% choose male or female sterilization as their method of contraception, whereas in developing nations where access to female sterilization is limited, the IUD is the most popular method. In more developed countries, the OC is the most popular method of birth control, followed by the condom and the IUD.
Heavy reliance on sterilization by US couples reflects the lack of contraceptive choices and the mistaken belief that this surgical method is 'foolproof'. In fact, failure rates with various methods of tubal sterilization have been underestimated; this method is no more effective than injections, IUDs, or implants. The negative media attention focused on problems with reversible methods has also contributed to overuse of sterilization. An additional factor is that most health-care plans cover sterilization whereas only 49% of typical indemnity plans cover the cost of OCs, IUDs, diaphragms, or contraceptive implants and injections. Plans that provide coverage of prescription drugs often do not cover OCs.
New contraceptive methods likely to become available in the US soon will increase the number of effective, reversible contraceptive choices for US couples. Greater access to a wider variety of methods will increase contraceptive use. Much as a good cafeteria offers a wide selection of foods to accommodate a variety of tastes, so too must clinicians be able to offer women safe, effective, convenient options that meet their individual needs and preferences. The availability of a greater number of contraceptive choices will increase the use of more effective methods and thus has the potential to reduce unintended pregnancies and abortions in US women of all ages.
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| Davis A, Lippman J, Godwin A et al: Triphasic norgestimate/ethinyl estradiol oral contraceptive for the treatment of dysfunctional uterine bleeding. Obstet Gynecol 95 (Suppl 1): S84, 2000 | |||
| Cates W Jr, Sulak PJ: Contraceptives and STDs: Alternative approaches to providing dual protection. Dialog Contracept 6: 1, 2000 | |||
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| Darney PD, Callegari LS, Swift A et al: Condom practices of urban teens using Norplant contraceptive implants, oral contraceptives, and condoms for contraception. Am J Obstet Gynecol 180: 929– 937, 1999 | |||
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| Zheng S-R, Zheng H-M, Qian S-Z et al: A randomized multicenter study comparing the efficacy and bleeding pattern of a single-rod (Implanon) and a six-capsule (Norplant) hormonal contraceptive implant. Contraception 60: 1– 8, 1999 | |||
| Mishell
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= wider choice. Contemp Obstet Gynecol Suppl:1–26, 2000
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