Nondaily Hormonal Contraception: Considerations in Contraceptive Choice and Patient Counseling

Family Nurse Practitioner Program, Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta, Georgia, USA.
Journal of the American Academy of Nurse Practitioners (Impact Factor: 1.02). 07/2004; 16(6):226-38. DOI: 10.1111/j.1745-7599.2004.tb00444.x
Source: PubMed


To review currently available choices for non-daily hormonal contraception, considering efficacy, safety, patient counseling issues, and appropriate patient selection.
Worldwide medical literature and the individual products' prescribing information.
Patients and clinicians have many nondaily hormonal contraceptive options available--from Depo-Provera quarterly injection, which has been available in the United States for over 10 years, to several new entries (Mirena 5-year intrauterine system, Lunelle monthly injection, NuvaRing monthly intravaginal ring, and Ortho Evra weekly transdermal patch). All these options offer high efficacy and enhanced convenience for many patients over daily oral contraceptives (OCs). Barriers to use of these agents may include patients' lack of information as well as fear or misconceptions regarding the hormones and methods. All of these can be addressed with adequate patient counseling and open dialogue. The clinician and patient need to be well-informed regarding these options so that they can work together and identify the best contraceptive fit for the patient---with the ultimate goal being to increase patient satisfaction and adherence and, thus, avoid unintended pregnancy.
Despite the efficacy of OCs, missed pills are quite common and contribute to unintended pregnancy. Many women in all population categories would benefit from the convenience and reliability of nondaily hormonal contraceptives. The highest efficacy rates with typical use are associated with agents that require minimal user participation (i.e., Depo-Provera, Mirena). Compared to daily regimens, all nondaily options offer increased convenience and may contribute to improved patient adherence. However, barriers to use may exist. Patient fears regarding use of hormones can be minimized by discussing the long-term safety of hormonal contraceptives. (The data are predominantly derived from Depo-Provera and OCs because these agents have been available in the United States and in the rest of the world for much longer than the newer nondaily options.) Patient counseling and appropriate expectations regarding changes in menstrual pattern have been demonstrated to further enhance patient adherence to therapy. Finally, patient lifestyle preferences must be considered. The finding that many women are comfortable with or even prefer amenorrhea, which is associated with options such as Depo-Provera, highlights how important it is for clinicians to avoid making assumptions about a patient's contraceptive preferences. Rather, clinicians and patients should exchange information through an open dialogue. For the majority of patients, nondaily hormonal contraceptives should be considered and offered as first-line options.

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    • "The country has continued to procure and support the availability of modern contraceptives methods including oral pills, injectables, implants, intrauterine devices (IUD), condoms, spermicides, and other vaginal barrier methods [10]. However, the effectiveness of contraceptives in preventing pregnancy varies from method to method, partly due to method use (adherence) and method efficacy [12] [13]. "
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    ABSTRACT: Poor adherence is one of the main causes of unintended pregnancies among women of reproductive age. The purpose of this study was to establish the predictors of contraceptive adherence. A total of 211 women were enrolled and interviewed while seeking family planning services at reproductive health Uganda facility. Binary logistic regression was used to analyze the association between adherence and the independent variables. Most of the respondents (83.4%) were currently using a hormonal contraceptive. Of the participants who were using contraceptives, 43% had discontinued use at some time for reasons other than pregnancy, 53.1% reported having short birth interval less than 2 years, and 7% reported having more children than desired. The predictors of poor contraceptive adherence included lower education level (OR 2.484, 95% CI 1.403-4.397) and lower self-efficacy (OR 1.698, 95% CI 1.959-3.004). Lack of male partner support (OR 2.014, 95% CI 1.140-3.557) and low education level (OR 2.103, 95% CI 1.196-3.699) were predictive of reporting short birth interval less than 2 years. The findings point to a number of predictors of contraceptive adherence that may have implications for designing and evaluating family planning programs. In the Ugandan context, studies to evaluate effective adherence improvement strategies are needed.
    Full-text · Article · Apr 2015
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    • "25 Our results also indicated that mean satisfaction scores of effects on lifestyle, confidence, side effects, concerns about future pregnancy and total satisfaction had no significant differences in the three groups. Freeman (2004) showed that many of women in demographic groups used non-daily hormonal contraceptives among which Depo-Provera shots had the highest efficiency rate. 26 Aktun et al. (2005) reported that the most common side effects in DMPA users were menstrual disorders, weight gain, and headache. "
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    ABSTRACT: Irregular population growth is considered as a serious threat to the international community and is also a major obstacle for nations' social and economic development. Thus, one of the ways to have a healthy community is to control the population and provide safe and effective contraceptive methods. Hormonal contraceptives are the most effective method of birth spacing. The present study aimed to determine and compare satisfaction from hormonal contraceptives including depot medroxyprogesterone acetate (DMPA), Cyclofem and LD in women referred to selected health care centers of Isfahan in 2010. This was a descriptive-comparative study with cross-sectional data collection method from 26 April 2010 to 28 October 2010. Simple non-probability sampling was used to select 150 individuals (divided into three groups of 50) among the females who referred to 8 selected health care centers in Isfahan to receive DMPA, Cyclofem, or LD for the first time, and/or those who had used contraceptives for three months. To assess satisfaction rate and its related factors, the standard ORTHO Birth Control Satisfaction Assessment Tool (BC-SAT) was completed three months after medicine consumption through interviewing. Data was analyzed using descriptive and inferential statistics (Fisher's exact, chi-square, ANOVA, and LSD tests). There were no significant differences in terms of mean score of satisfaction between the three groups. Cyclofem (192.2) and DMPA (188.1) gained the highest and lowest mean satisfaction scores, respectively. Although the mean satisfaction score in areas of ease of use/appropriateness, interference in menstruation pattern, acceptance and continuation of the method had significant differences in three groups, no statistically significant difference was observed in lifestyle, confidence to the method, side effects, concerns about future pregnancies and total satisfaction. Generally, there was no difference in satisfaction from the three studied hormonal contraceptives.
    Full-text · Article · Feb 2011 · Iranian journal of nursing and midwifery research
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    ABSTRACT: Many contraceptive methods have been developed for fertility regulation, either reversible or irreversible, in males and females. Oral contraceptives have been considered the most popular form of reversible contraception. However, they must be taken consistently, on a daily basis for 21 or 28 days of each menstrual cycle, in order to achieve the maximal outcomes of contraception. Moreover, their contraceptive efficacy has been reportedly affected by their interactions with many drug products taken concurrently for other conditions. To resolve the dilemma of daily compliance and the risk of potential interactions with drugs taken orally, several non-traditional delivery systems have been developed to permit contraceptive agents and their combinations to be administered via a non-oral route, and also at a lesser frequency of administration, so as to enhance treatment compliance, maximize therapeutic outcomes, and minimize adverse effects. One typical example is the successful development of the ethinylestradiol/norelgestromin patch for achieving contraception in females via transdermal delivery. With topical application on intact skin, each patch delivers a combination of norelgestromin and ethinylestradiol for a week. With a treatment schedule of 3 weeks with a patch on and 1 week without a patch for each menstrual cycle, the ethinylestradiol/norelgestromin patch has achieved a clinical efficacy that is considered bioequivalent to oral contraceptives (with an unintended pregnancy rate of 0.8% per woman-year for the patch versus 0.1% per woman-year for the combined oral contraceptive).Stimulated by the marketing success of the ethinylestradiol/norelgestromin transdermal contraceptive patch, and a growing recognition of the therapeutic benefits realized by delivering an orally inactive progestin via a transdermal route, other transdermal drug delivery systems (DDS), such as transdermal gels and a metered-dose transdermal spray system, have also been developed. Further transdermal contraceptive patches have also been developed. One of these is similar to the ethinylestradiol/norelgestromin patch, in that it is fabricated from an adhesive polymer matrix diffusion-controlled DDS; however, it has a two times smaller patch size (to minimize localized reactions at the application site). This was made possible by substituting norelgestromin with a more potent progestin called gestodene, that has a higher skin permeation rate. The other transdermal patch that has been developed employs a microreservoir partition-controlled delivery system, to provide dual-controlled delivery of estradiol (a natural estrogen) and levonorgestrel (another potent synthetic progestin) at constant rates (zero-order kinetics). Clinical studies have demonstrated that these two new patch systems may be attractive alternative forms of contraception, since ovulation inhibition has been achieved in all subjects who wear the transdermal patch for 3 weeks, replacing it on a weekly basis.A transdermal gel has been formulated to contain elcometrine, which has a progestational potency that is 100 times that of progesterone but is orally inactive, in an alcoholic solution. Preliminary clinical studies have indicated that suppression of ovulation was achieved in the majority of subjects receiving daily application of the transdermal gel. To address the problems associated with the dosing accuracy of the transdermal gel, due to difficulty controlling the area and size of the application site, the feasibility of delivering the transdermal gel from a metered-dose transdermal spray system is currently under evaluation by the Population Council.
    No preview · Article · Dec 2005 · American Journal of Drug Delivery
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