The latest contraceptive options: What you must know
Proper counseling hinges on having the latest data at your fingertips. This review—and handy guide—will help.
Loestrin 24 Fe contains norethindrone 1 mg and EE 20 mcg; placebo pills contain 75 mg of ferrous fumarate.
Yaz contains the newer progestin drospirenone 3 mg and EE 20 mcg. Drospirenone, an analog of the antihypertensive spironolactone, was introduced in a 21/7 formulation, Yasmin, and proved to have beneficial effects on mood, water retention, and acne.10 Yaz, which contains a lower dose of EE than Yasmin, provides 3 additional days of antimineralocorticoid and antiandrogenic activity, and is indicated for the treatment of premenstrual dysphoric disorder, a more severe form of premenstrual syndrome. Drospirenone-containing OCs are contraindicated for patients with renal, adrenal, or hepatic impairment because of the progestin’s metabolism via these routes.
An established OC with a twist: Chewable pills
For patients unable to swallow OCs, a chewable formulation, Femcon Fe, is available.11 It is hormonally identical to Ovcon 35, a well-established OC containing norethindrone acetate 0.4 mg and EE 35 mcg. The 7 placebo pills contain ferrous fumarate 75 mg. The spearmint-flavored chewable pill (which can also be swallowed) must be taken with 8 ounces of water.
Noncontraceptive benefits of OCs—there are many
An extensive body of evidence supports the noncontraceptive health benefits of OCs. These include a decreased risk of:
- endometrial and ovarian cancer
- bone loss
- benign breast disease
- pelvic inflammatory disease
- ectopic pregnancy
- rheumatoid arthritis.
Women with symptoms of androgen excess, premenstrual mood disorders, or endometriosis pain have long benefited from treatment with OCs.10,12-14 Healthy perimenopausal women are excellent candidates for OCs to regulate menses and treat symptoms of estrogen deficiency. OCs with added estrogen during the menstrual interval or shortened hormone-free interval may be more effective in moderating the perimenopausal transition. However, specific evidence about these effects is not yet available for the newest OC formulations.
Risks of OCs have been reduced, but some remain
Many of the well-known risks and side effects of OCs have been minimized over the years as total doses of estrogen have decreased and less androgenic progestins have been incorporated into OC formulations. Nonetheless, OCs are contraindicated for women who have a history of venous thromboembolism (VTE) or coronary artery disease (or are at risk for these complications), are over the age of 35 and smoke, are pregnant or newly postpartum, or are immobilized after surgery.
OCs remain relatively contraindicated for women with a history of migraines and focal auras, due to the increased risk for ischemic stroke.15 Breast and other estrogen-dependent cancers as well as liver disease preclude the use of OCs.16 Additional studies using the newer formulations of OCs are needed to definitively determine their long-term risk compared with traditional monthly formulations.
Contraceptive patch: Improving compliance
The contraceptive patch Evra is applied weekly and releases norelgestromin 150 mcg and EE 20 mcg each day, providing an OC alternative that is less dependent on compliance. However, in November 2005, the FDA modified product labeling to inform providers and the public that, based on pharmacokinetic studies, patients using the patch were exposed to hormone levels about 60% higher than with OCs of similar dosage.17 Another FDA labeling change made in 2008 states that “it is not known whether there are changes in the risk of serious adverse events based on the differences in pharmacokinetic profiles of EE in women using [the patch] as compared with women using oral contraceptives containing 35 mcg of EE.”
What is the real risk of VTE? One case-control study reported that the rates of VTE events in patch users and OC users were 52 per 100,000 woman-years and 42 per 100,000 woman-years, respectively.18 Another large case-control study showed the odds ratio (OR) of VTE to be 2.4 (95% confidence interval [CI], 1.1-5.5) with the patch compared with OCs; data were corrected for high-risk factors.19 However, the absolute risks for the patch and OCs were 40 and 18 per 100,000 woman-years, respectively—both lower than the risk of VTE associated with pregnancy.
The risk of myocardial infarction. The OR for myocardial infarction among patch users in the same population was 1.8 (95% CI, 0.5-6.8), and there was no statistically significant increase in the rate of cerebrovascular accidents.19 Thus, it is reasonable to use the patch with caution in patients without cardiac risk factors and to limit total hormone dosage by not using the patch in an extended-cycle manner. Of note, the patch is reported to have decreased efficacy in patients weighing over 90 kg (198 lb).20
Vaginal ring: Fewer drug interactions
NuvaRing, the ethylene vinyl vaginal ring, releases etonorgestrel (ENG) 120 mcg and EE 15 mcg each day (a lower estrogen dose than is contained in OCs or the patch).21 The device is 5.4 cm in diameter and 4 mm thick. Patients insert the ring intravaginally, remove it 3 weeks later for menses, and insert a new ring 1 week later.
