- Update on contraception
Rachel B. Rapkin, MD; Mitchell D. Creinin, MD (August 2011)
- An appeal to the FDA: Remove the black-box warning for depot medroxyprogesterone acetate!
Andrew M. Kaunitz, MD; David A. Grimes, MD (August 2011)
- Levonorgestrel or ulipristal: Is one a better emergency contraceptive than the other?
Robert L. Barbieri, MD (Editorial; March 2011)
- IUD use in nulliparous and adolescent women
Jennefer A. Russo, MD; Mitchell D. Creinin, MD (Update on Contraception, August 2010)
EDITOR’S NOTE: Brand names are given parenthetically in some places in the text solely to provide better recognition of methods discussed.
As other articles in this issue of OBG Management attest, medical science continues to focus attention on improving methods of family planning. That emphasis has meant a regular flow of new reports, studies, and guidelines for you to absorb and translate into better practice—no easy task.
Here is help: 10 (+ 1) practical, sensible recommendations for improving contraceptive care that have emerged from recent evidence and that are reasonably easy to incorporate into the care you provide. As with previous installments of this occasional “recommendations” series, we include a brief discussion and pertinent references for each tip.
1. Pelvic exam? It isn’t mandatory.
Do not require pelvic examination before you prescribe an oral contraceptive.
Henderson JT, Sawaya GF, Blum M, Stratton L, Harper CC. Pelvic examinations and access to oral hormonal contraception. Obstet Gynecol. 2010;116(6):1257–1264.
The World Health Organization and ACOG recommend that you consider pelvic examination optional before prescribing an oral contraceptive (OC). Recent evidence indicates, however, that many health-care providers don’t follow that recommendation. Avoiding an unnecessary pelvic exam is a plus for a patient who may fear the procedure; following this guidance therefore removes a potential barrier to care and saves time in a busy practice.
2. Provide more, not less
Prescribe (when possible, dispense) 6 to 12 months of an OC at office visits.
Potter JE, McKinnon S, Hopkins K, et al. Continuation of prescribed compared with over-the-counter oral contraceptives. Obstet Gynecol. 2011;117(3):551–557.
Foster DG, Hulett D, Bradsberry M, Darney P, Policar M. Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies. Obstet Gynecol. 2011;117(3):566–572.
Studies show that 1) women who are given six or more pill packages at a clinic visit have a lower discontinuation rate than women given one to five packs and 2) prescribing a 1-year supply of OC pill packages (as opposed to one to three packs) is associated with a 30% reduction in the odds of conceiving an unplanned pregnancy and a 46% reduction in the odds of having an abortion.
Use intrauterine devices and subdermal implants as first-line contraception more often.
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 59: Intrauterine device. Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol. 2005;105(1):223–232.
Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105–1113.
Long-acting methods such as the copper intrauterine device (IUD) (Paragard) and the levonorgestrel intrauterine system (LNG-IUS) (Mirena) are the most effective reversible contraceptives because they eliminate the difference between perfect and typical use. A woman at low risk does not need to have a negative cervical culture before having an IUD or the LNG-IUS inserted, and a woman does not need to be on her menses at the time of insertion. In addition, antibiotic prophylaxis is not recommended before or at the time of insertion.
IUDs—and this applies to the subdermal contraceptive implant (Implanon), too—also have the highest rates of satisfaction and 12-month continuation.
4. Take advantage of broader benefits
Use hormonal contraceptives for noncontraceptive indications.
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 110: Noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(6):206–218.
Jensen JT, Parke S, Mellinger U, Machlitt A, Fraser IS. Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial. Obstet Gynecol. 2011;117(4):777–787.
Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, Muysers C, Jensen JT. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116:625-632.
Hormonal contraceptives have long been used for such indications as cycle control and treatment of acne. The LNG-IUS and OCs are highly effective, compared with placebo, for treating heavy menstrual bleeding in the absence of organic pathology.* As a potential alternative to surgical treatment of menorrhagia, OCs offer even broader benefit for many women.
*Mirena is approved by the Food and Drug Administration for treating heavy menstrual bleeding.
5. To encourage continuation, begin now