by Janet P. Realini, MD, MPH
Rated among the 20th century’s top 10 public health achievements by the Centers for Disease Control and Prevention, family planning leads to healthier moms and babies, fewer abortions, healthier families, and lower health-care costs. Still, 49% of U.S. pregnancies are unintended. Although affluent women are having fewer unintended pregnancies, rates are going up for those with low income. Flat federal funding simply has not kept up with the growing need. Even with the planned Texas Medicaid women’s health expansion for preventive services, a need still exists for other funding sources (Titles V, X, and XX) to serve all the women in need.
No family planning method is perfect: abstinence and n-tural family planning, hormonal and barrier methods, and IUDs all have advantages and disadvantages. The update below also touches on some new developments that San Antonio physicians – and their patients – need to know.
Combination estrogen and progestin oral contraceptives, or COCs, help prevent ovarian and endometrial cancer, but not breast or cervical cancer. Rare cardiovascular adverse events include venous thromboembolism, or VTE; heart attack; or stroke. Because they contain estrogen, COCs are contraindicated for women who have had VTE, myocardial infarction, stroke, or migraine with aura.
Over the years, estrogen doses have come down, with correspondingly less risk of VTE. Progestin doses were minimized with cyclic pills, and newer progestins became available. The “third generation” progestin desogestrel (in Mircette®, Deso-gen®, and Ortho-Cept®) appears to have higher VTE risk, but norgestimate (in Ortho-Tricyclen®, Tricyclen-Lo®, and Ortho-Cyclen®) does not.
One newer progestin (droperinone, in Yasmin® and Yaz®) has anti-mineralocorticoid properties, and is marketed for its “anti-androgen” properties. However, it can cause hyperkalemia in susceptible women.
The current trend in pills is extended cycles, with fewer days off hormones and fewer withdrawal bleeds (e.g., Seasonale®). Some formulations reduce the number of medication-free days. Extending cycles may reduce nuisance symptoms (e.g., headache) and even accidental pregnancies. However, its long-term safety with regard to VTE and other rare problems has not been directly compared with older formulations.
The Ortho-Evra® patch, like COCs, contains an estrogen and a progestin. Each patch is worn for a week, with three weeks “on” and one week “off” for a withdrawal bleed. The patch may be easier than pills for some people to use perfectly, but it can cause skin irritation, as well as breast soreness and break-through bleeding.
With reports of VTE in young women, the safety of the patch has been questioned. Although pills have higher peak estrogen blood levels, the total estrogen dose appears to be higher with the patch. One study suggests similar VTE risks compared to pills, and one unpublished study suggests somewhat higher risks. To this author, it makes sense to reserve the patch for women for whom other options are not satisfactory.
The NuvaRing® is a flexible plastic ring worn in the vagina for three weeks, then taken out. After a week for withdrawal bleeding (“a period”), a new ring is inserted. Estrogen and progestin are absorbed through the vaginal lining. Some women – and men – dislike the feeling of the ring, and it occasionally causes vaginitis. However, even with its very low dose, the ring appears to have a low incidence of breakthrough bleeding.
Depo-Provera® and the new formulation, Depo SQ 104®, are high-dose, long-acting progestin-only methods given by injection once every three months. They are highly effective and are thought to be a safer method for women who have had VTE. However, Depo-Provera® can cause irregular bleeding and weight gain, and reduce bone density. While bone density probably recovers after discontinuation, an FDA “Black Box” warning about these injections suggests limiting their use to two years at a time, if possible.
The Copper T380A (ParaGard®) is highly effective and lasts up to 10 years. The Mirena® intrauterine system delivers a small dose of progestin, in addition to its physical contraceptive effect, and each device can be used for up to five years. Both devices appear to prevent fertilization as their primary mechanism of action.
In the U.S., intrauterine contraception is slowly gaining in popularity, and recently FDA recommendations for the Para-Gard® were expanded to include nulliparous women. In addition, the World Health Organization’s Medical Eligibility Criteria for IUD use now allow for continuation of IUD use with pelvic inflammatory disease and sexually transmitted infections — with patient informed consent and taking into consideration whether she is at continuing risk for STIs. However, this author feels that IUDs should not ordinarily be used in women at risk of STIs.
The FDA recently approved a single-rod subdermal implant, Implanon®, which is effective for up three years. Like its predecessor, Norplant®, this is a progestin-only method, with doses lower than in the injections. Because it is only one rod, Implanon® is expected to be easier to insert and remove than Norplant®. However, it may cause irregular bleeding and other nuisance side effects. It should not affect bone density or increase the risk of VTE, and weight gain should be less of a problem than with Depo-Provera®.
Male latex condoms work! When used correctly and consistently, condoms are highly effective in the prevention of HIV transmission. Condom use also reduces the risk of gonorrhea and chlamydia, trichomonas, syphilis, genital herpes, HPV infection, genital warts, and cervical cancer. And they prevent pregnancy, as well.
Unfortunately in today’s “culture wars,” condoms often are misrepresented as ineffective or defective. In reality, the main reason for condom failure is that people do not use them.
For people allergic to latex, there are several polyurethane condoms available (Avanti®, ez-on®). The female condom, also made of polyurethane but more expensive than male condoms, is an important option for some people. Studies of improved-design female condoms are under way.
Levonorgestrel (Plan B®) is a progestin-only product that reduces the chance of pregnancy by 89% if taken within 72 hours of unprotected sex. Plan B® works primarily by preventing ovulation. It does not affect an established, implanted pregnancy. (It is NOT the same as mifepristone, or RU-486). Plan B® is very safe – with no known serious adverse effects on health, nor any effects on sexual or contraceptive behavior.
Although fertilization does not occur at the time of coitus, some people assume that emergency contraception works after fertilization because it is used after sex. Since fertilization actually occurs at the time of ovulation – if sperm have been deposited through sex within the last five to six days – there is often time AFTER sex to interfere with ovulation and fertilization.
Vaginal spermicides, such as nonoxynol-9, act as detergents to kill sperm. In high doses, they can cause irritation of the vaginal mucosa, which may increase the risk of HIV transmission. For this reason, spermicides are NOT recommended for women at risk for STIs.
CycleBeads® is a simple device to assist women with cycles of 26 to 32 days to be aware of their fertile and infertile days. It can be used for deciding when to use barrier methods, or as a method of natural family planning.
Essure® is a coil device that is inserted hysteroscopically into the Fallopian tubes without a peritoneal incision. It requires a waiting period for effectiveness.
Dr. Realini is medical director of both the family planning program of the San Antonio Metropolitan Health District and Project WORTH, the City of San Antonio’s teen pregnancy prevention program. She is the author of BIG DECISIONSTM, a sexuality curriculum for 8th to 12th Grades.
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This “1115 waiver” will serve women age 18 to 44 who are at or below 185% of the federal poverty level (an annual income of $37,000 for a family of four).
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