sign in sign up
<<
Home , Copper IUDs

THE JOURNAL OF FAMILY PRACTICE

Petra M. Casey, MD The latest contraceptive Sandhya Pruthi, MD Department of Obstetrics and Gynecology (P.M.C.), and options: What you must know the Breast Diagnostic Clinic, Division of General Internal Medicine (S.P.), Mayo Clinic, Proper counseling hinges on having the latest data at Rochester, Minn your fi ngertips. This review—and handy guide—will help [email protected]

as possible. In this review, we discuss se- Practice recommendations lect new options in a clinically relevant • Consider an oral contraceptive manner. Specifi cally, we explore the new- for women who would prefer less est oral contraceptives (OCs), including frequent menstrual periods (A). ® Dowdenextended-cycle, Health continuous, Media and short- ened hormone-free interval formulations. • An may be appropriate In addition, we review the latest data and for women with prior pelvicCopyright infl ammatoryFor personalupdated recommendations use only for the con- disease, ectopic , or an traceptive patch and ring, intrauterine abnormal Papanicolaou (Pap) smear devices (IUDs), implants, and emergency result, and for many adolescents (A). contraception (TABLE). We conclude by describing appropriate choices for the IN THIS ARTICLE • There are no medical patient described above. (See “So what ❚ At-a-glance contraindications to progestin-only do you recommend?” on page 803.) (A). contraceptive guide Strength of recommendation (SOR) ❚ Oral contraceptives Page 799 A Good-quality patient-oriented evidence Since OCs became available in the 1960s, B Inconsistent or limited-quality patient-oriented evidence C Consensus, usual practice, opinion, disease-oriented the standard regimen has been 21 active evidence, case series pills followed by 7 placebo pills, simu- lating the average unassisted monthly in which “menstrual” or 35-year-old woman with a family withdrawal bleeding occurs. Clinicians history of (mother have successfully lengthened intermen- Adiagnosed with breast cancer at strual intervals with OCs, without incur- age 55) requests your help in choosing ring additional risk, to control symptoms an appropriate method of contracep- of endometriosis, premenstrual syndrome, tion. She is a nonsmoker, has a body and menstrual-withdrawal headaches, or mass index of 25, and dislikes taking to satisfy many patients’ preference for pills. Which options would you recom- fewer menses per year.1,2 mend to her? Are there any that you Any monophasic active OC can be would rule out? used without a placebo interval to de- Helping your patient make the best lay menses for extended periods. Until choice requires that you be as up to date recently, such usage was off-label. Based

www.jfponline.com VOL 57, NO 12 / DECEMBER 2008 797

For mass reproduction, content licensing and permissions contact Dowden Health Media.

797_JFP1208 797 11/18/08 1:41:28 PM THE JOURNAL OF FAMILY PRACTICE

on extensive safety and effi cacy studies, reported ≥7 days of spotting and 6% re- however, the US Food and Drug Admin- ported ≥20 days of spotting during the istration (FDA) has now approved sev- fi rst cycle. Thirty-nine percent and 4%, eral formulations for extended-cycle and respectively, reported spotting during the continuous-cycle use. fourth cycle.3,4

Continuous OC: ❚ Extended-cycle OCs: Consistent hormonal milieu Fewer menses per year Lybrel, the only FDA-approved OC for Two FDA-approved extended-cycle OCs continuous use, contains are available: Seasonale and Seaso- 90 mcg and EE 20 mcg; pills are taken nique.3,4 Both products enable 4 sched- daily throughout the year.7 Progestin and uled menstrual intervals per year, as estrogen doses are lower than those found opposed to about 13 with 28-day cycles. in many monthly OCs and in all extended- Each regimen uses 84 consecutive pills of cycle formulations. A phase 3 trial of levonorgestrel 0.15 mg and ethinyl estra- 2134 women reported the safety and ef- diol (EE) 0.03 mg, followed by 7 placebo fi cacy of Lybrel to be comparable to cy- pills (Seasonale) or 7 pills of EE 0.01 mg clic OCs.8 Again, unscheduled bleeding (Seasonique). and spotting rates were relatively high Other potential advantages. With Sea- but decreased at pack 3 from 47% and sonique, the average length of menses is 26%, respectively, to 21% and 20%, re- 3 days, which is shorter than the average spectively, at pack 13. Predictably, amen- unassisted menstrual period. Seasonique’s orrhea rates increased from 27% to 59% 7 additional low-dose estrogen pills may between pack 3 and pack 13. help decrease estrogen withdrawal symp- toms, such as headaches in women with Shortened hormone-free interval menstrual migraine and vasomotor insta- OCs: Less breakthrough ovulation bility in perimenopausal women. Though The shortened hormone-free interval OC FAST TRACK this effect has also been reported with is an alternative for patients who want For patients other OCs containing low-dose estrogen regular, but shorter, menstrual intervals. during the traditional placebo week, spe- With 24 active and 4 placebo pills in unable to cifi c supportive evidence is not yet avail- each cycle, this regimen suppresses the swallow pills, able for these formulations.5,6 pituitary/ovarian axis to a greater extent a chewable OC Disadvantages to address. With than traditional 21/7-day regimens and is available Seasonale and Seasonique, unscheduled thus lowers the rate of breakthrough spotting or bleeding has been reported— ovulation.9 especially during initial use—at rates Loestrin 24 Fe contains norethin- considerably higher than those associ- drone 1 mg and EE 20 mcg; placebo pills ated with comparable traditional OCs.3,4 contain 75 mg of ferrous fumarate. Effective counseling will help ensure pa- Yaz contains the newer proges- tient compliance and satisfaction. tin drospirenone 3 mg and EE 20 mcg. During the fi rst cycle (days 1-91), Drospirenone, an analog of the antihy- about 65% of women taking either for- pertensive spironolactone, was intro- mulation reported ≥7 days of spotting, duced in a 21/7 formulation, Yasmin, and 29% to 35% reported ≥20 days of and proved to have benefi cial effects on spotting. By the 4th cycle (days 273-364), mood, water retention, and acne.10 Yaz, 39% to 42% of patients reported ≥7 days which contains a lower dose of EE than of spotting and 11% to 15% reported Yasmin, provides 3 additional days of ≥20 days of spotting. For patients tak- antimineralocorticoid and antiandrogen- ing comparable progestin and EE doses ic activity, and is indicated for the treat- in traditional monthly regimens, 38% ment of premenstrual dysphoric disorder,

798 VOL 57, NO 12 / DECEMBER 2008 THE JOURNAL OF FAMILY PRACTICE

798_JFP1208 798 11/18/08 8:22:01 AM The latest contraceptive options: What you must know ▼

TABLE How do these contraceptives compare?

ROUTE OF FREQUENCY OF FAILURES/YR WITH EXPECTED ADVERSE EFFECTS/ METHOD ADMINISTRATION ADMINISTRATION TYPICAL USE 33,35,51 MENSTRUAL PATTERN CONTRAINDICATIONS Cyclic OCs Oral Daily 8% Monthly menses, Hormonal adverse may have BTB initially effects Extended-cycle Oral Daily 8% Menses 4/yr, Hormonal adverse OCs (Seasonale, frequent BTB effects, unscheduled Seasonique) bleeding Continuous OCs Oral Daily 8% No scheduled menses, Hormonal adverse (Lybrel) frequent BTB effects, unscheduled bleeding Shortened hormone- Oral Daily 8% Shorter monthly Hormonal adverse free interval OCs menses effects, unscheduled (Loestrin 24 Fe, Yaz) bleeding

Transdermal patch Patch applied New patch applied 8% Monthly menses, Hormonal adverse (Evra) to skin weekly for 3 wk; may have BTB initially effects, increased risk off for 1 wk of VTE higher than OCs but lower than pregnancy; MI risk higher than comparable OCs, but use is reasonable if no cardiac risk factors Ring inserted in Ring inserted for 8% Monthly menses, Hormonal adverse (NuvaRing) vagina by patient 3 wk, removed for may have BTB initially effects 1 wk IUD IUD inserted Every 10 yr 0. 8% Heavier menses, Menorrhagia. (ParaGard T 380A) & removed may have BTB Contraindications: Acute by clinician PID or high risk for STI; postpartum endometritis within 3 mo; mucopuru- lent cervicitis; Wilson’s disease Levonorgestrel IUS IUS inserted Every 5 yr < 0.1% Lighter, shorter menses Minimal hormonal (LNG IUS, Mirena) & removed by or amenorrhea adverse effects. clinician Contraindications: Acute PID, history of or high risk for PID; postpartum endometritis within 3 mo; mucopurulent cervicitis Subdermal Inserted subder- Every 3 yr 0.3% Irregular, unpredictable Unscheduled bleeding, (Implanon) mally & removed bleeding mood symptoms, head- by clinician ache, weight gain, acne Depot medroxy- IM injection Every 3 mo 3% Irregular bleeding, Unscheduled bleeding, progesterone acetate amenorrhea reversible bone loss (Depo-Provera) BTB, breakthrough bleeding; IM, intramuscular; IUD, intrauterine device; IUS, intrauterine system; MI, myocardial infarction; OC, oral contraceptive; PID, pelvic infl ammatory disease; STI, sexually transmitted infection; VTE, venous thromboembolism.

a more severe form of premenstrual syn- An established OC with a twist: drome. Drospirenone-containing OCs Chewable pills are contraindicated for patients with re- For patients unable to swallow OCs, nal, adrenal, or hepatic impairment be- a chewable formulation, Femcon Fe, is cause of the progestin’s metabolism via available.11 It is hormonally identical these routes. to Ovcon 35, a well-established OC

www.jfponline.com VOL 57, NO 12 / DECEMBER 2008 799

799_JFP1208 799 11/18/08 1:41:32 PM THE JOURNAL OF FAMILY PRACTICE

containing norethindrone acetate 0.4 mg estrogen-dependent cancers as well as and EE 35 mcg. The 7 placebo pills con- liver disease preclude the use of OCs.16 tain ferrous fumarate 75 mg. The spear- Additional studies using the newer formu- mint-fl avored chewable pill (which can lations of OCs are needed to defi nitively also be swallowed) must be taken with 8 determine their long-term risk compared ounces of water. with traditional monthly formulations.

Noncontraceptive benefi ts of OCs—there are many ❚ : An extensive body of evidence supports Improving compliance the noncontraceptive health benefi ts of The contraceptive patch Evra is applied OCs. These include a decreased risk of: weekly and releases norelgestromin 150 • endometrial and mcg and EE 20 mcg each day, providing • bone loss an OC alternative that is less dependent • benign breast disease on compliance. However, in November • pelvic infl ammatory disease 2005, the FDA modifi ed product label- • ing to inform providers and the public • rheumatoid arthritis. that, based on pharmacokinetic studies, Women with symptoms of androgen patients using the patch were exposed to excess, premenstrual mood disorders, or hormone levels about 60% higher than endometriosis pain have long benefi ted with OCs of similar dosage.17 Another from treatment with OCs.10,12-14 Healthy FDA labeling change made in 2008 states perimenopausal women are excellent that “it is not known whether there are candidates for OCs to regulate menses changes in the risk of serious adverse and treat symptoms of estrogen defi - events based on the differences in phar- ciency. OCs with added estrogen during macokinetic profi les of EE in women us- the menstrual interval or shortened hor- ing [the patch] as compared with women mone-free interval may be more effective using oral contraceptives containing 35 FAST TRACK in moderating the perimenopausal tran- mcg of EE.” The absolute risk sition. However, specifi c evidence about What is the real risk of VTE? One case- these effects is not yet available for the control study reported that the rates of of VTE with the newest OC formulations. VTE events in patch users and OC users patch is lower were 52 per 100,000 woman-years and than that Risks of OCs have been reduced, 42 per 100,000 woman-years, respec- associated but some remain tively.18 Another large case-control study Many of the well-known risks and side showed the odds ratio (OR) of VTE to with pregnancy effects of OCs have been minimized over be 2.4 (95% confi dence interval [CI], the years as total doses of estrogen have 1.1-5.5) with the patch compared with decreased and less androgenic progestins OCs; data were corrected for high-risk have been incorporated into OC formu- factors.19 However, the absolute risks for lations. Nonetheless, OCs are contraindi- the patch and OCs were 40 and 18 per cated for women who have a history of 100,000 woman-years, respectively— venous thromboembolism (VTE) or coro- both lower than the risk of VTE associ- nary artery disease (or are at risk for these ated with pregnancy. complications), are over the age of 35 and The risk of myocardial infarction. The smoke, are pregnant or newly postpartum, OR for myocardial infarction among or are immobilized after surgery. patch users in the same population was OCs remain relatively contraindicat- 1.8 (95% CI, 0.5-6.8), and there was no ed for women with a history of migraines statistically signifi cant increase in the rate and focal auras, due to the increased risk of cerebrovascular accidents.19 Thus, it is for ischemic stroke.15 Breast and other reasonable to use the patch with caution

800 VOL 57, NO 12 / DECEMBER 2008 THE JOURNAL OF FAMILY PRACTICE

800_r1_JFP1208 800 11/19/08 12:15:23 PM The latest contraceptive options: What you must know ▼

in patients without cardiac risk factors years in women who are 16 years of age and to limit total hormone dosage by and older.24 This IUD’s active ingredient not using the patch in an extended-cycle is the spermicidal copper wire wound manner. Of note, the patch is reported to around the short arms of the device. A have decreased effi cacy in patients weigh- recent meta-analysis reported an asso- ing over 90 kg (198 lb).20 ciation between the use of a copper IUD and a decrease in the risk of endometrial cancer (OR=0.39; 95% CI, 0.29-0.51), ❚ Vaginal ring: though the mechanism for this associa- Fewer drug interactions tion is unclear.25 NuvaRing, the ethylene vinyl vaginal In late 2005, the FDA broadened ring, releases etonorgestrel (ENG) 120 the use of copper IUDs to include wom- mcg and EE 15 mcg each day (a lower en who are nulliparous; have a history estrogen dose than is contained in OCs of pelvic infl ammatory disease (PID), or the patch).21 The device is 5.4 cm in sexually transmitted disease, or ectopic diameter and 4 mm thick. Patients insert pregnancy; are in nonmonogamous rela- the ring intravaginally, remove it 3 weeks tionships; or have a history of premeno- later for menses, and insert a new ring pausal breast cancer. This method also 1 week later. may be used by women with asymptom- LNG-IUS (Mirena) Continuous use regimen. A ran- atic human immunodefi ciency virus in- domized controlled trial evaluating the fection, Actinomyces infection, abnormal frequency and management of break- Papanicolaou (Pap) test results, or vagi- through bleeding with continuous use nitis. Furthermore, data support its use in of the transvaginal contraceptive ring adolescents who are at particularly high reported a reduction in bleeding, fl ow, risk for unintended pregnancy.26 and pelvic pain, and a high continuation The copper IUD remains contra- rate. Most patients considered the bleed- indicated for patients with acute PID ing profi le with the continuous vaginal or current high-risk behavior for sexu- ring acceptable compared with the base- ally transmitted infections, as well as for FAST TRACK line 21/7 use.22 Each ring contains up to those who have mucopurulent cervicitis LNG IUS (Mirena) a 28-day supply of hormones. or have had postpartum endometritis Fewer interactions. Transvaginal ab- within the past 3 months.24 Wilson’s dis- has also been sorption of hormones with the vaginal ease is also a contraindication. used as a ring avoids a fi rst pass through the liver, Insertion tip. may be cost-effective thus decreasing many medication inter- used to soften the nulliparous for alternative to actions. Irregular bleeding experienced insertion.27 with OCs or the patch may be effectively hysterectomy reduced with the steadily released, rap- Levonorgestrel intrauterine system: and endometrial idly acting hormones in the ring.23 An alternative to the copper IUD ablation The levonorgestrel intrauterine system (LNG IUS), sold under the brand name ❚ Intrauterine contraception Mirena, is gaining tremendous popularity Intrauterine contraception is increasingly in the . Multiple mechanisms accepted by women who want long-term of action, including endometrial thinning, and effective contraception without hav- cervical mucus thickening, inhibition of ing to comply with a particular regimen. sperm function, and intermittent ovulation suppression are responsible for the >99% Copper IUD: effi cacy of this 5-year contraceptive. Many contraindications are lifted Irregular menses can be expected ini- The nonhormonal IUD ParaGard T 380A tially, and 20% of patients reported amen-

PHOTO: © 2008 BAYER HEALTHCARE PHARMACEUTICALS INC. HEALTHCARE PHOTO: © 2008 BAYER is indicated for contraception for up to 10 orrhea at 1 year of use. In the unlikely

www.jfponline.com VOL 57, NO 12 / DECEMBER 2008 801

801_JFP1208 801 11/18/08 1:41:36 PM THE JOURNAL OF FAMILY PRACTICE

event that a woman becomes pregnant not cause a hypoestrogenic state and ovu- while using Mirena, evaluate for ectopic lation suppression is rapidly reversible, pregnancy, which occurs in about half of with ENG levels undetectable within 10 in women using this system. days of implant removal.35 Furthermore, Noncontraceptive benefi ts. The sys- this method has no reported deleterious tem’s primary noncontraceptive benefi t effects on bone mineral density or lacta- is the dramatic reduction of menstrual tion.37,38 When counseling women about blood loss, reported to be up to 90%.28 the implant, emphasize its propensity to This contraceptive has been used as a result in “irregular and unpredictable” cost-effective alternative to hysterectomy bleeding. An average of 7 bleeding and and endometrial ablation.29,30 Mirena 10 spotting days within a 90-day period imparts a protective effect against PID, has been reported. Most women had likely secondary to progestin-mediated fewer bleeding/spotting days than they cervical mucus thickening.31 would without contraception, but un- It appears safe and expeditious to scheduled bleeding was the leading rea- provide both counseling and intrauterine son for method discontinuation (11%), contraception insertion in one visit, pro- followed by weight gain, emotional labil- vided pregnancy is excluded.32 Confi rm ity, acne, headache, and depression (each 35 Subdermal implant (Implanon) normalcy of cervical cytology and screen ≈1%-2%). for sexually transmitted disease, if indi- Implant insertion. The device is insert- cated. Prophylactic antibiotics are unnec- ed in the sulcus between the biceps and essary, as the risk of PID within 20 days triceps muscles of the nondominant arm. of insertion is only 9.7 per 1000 woman- It is crucial to place the implant subder- years.33 After 20 days, the risk declines to mally, tenting the skin during insertion to 1.4 per 1000 woman-years, the same as prevent deep insertion. High-frequency that of the general population.34 ultrasound can be used to detect nonpal- pable implants. The FDA has mandated 3 hours of training for clinicians before FAST TRACK ❚ Subdermal implant: they can obtain the device. The FDA requires Easily reversible In July 2006, the FDA approved Implanon, Depot medroxyprogesterone: clinicians to a subdermal .35 It Tried and true alternative undergo 3 hours has been available worldwide since 1998. The depot medroxyprogesterone acetate of training before The 40 × 2 mm single-rod implant con- (DMPA) injection has been a mainstay they can obtain the taining (ENG) 68 mg diffuses of contraception for decades. Available the hormone at a rate of 60 mcg/d imme- under the brand name Depo-Provera, it’s subdermal implant diately after insertion and then steadily at an option for women in whom estrogen- Implanon 30 mcg/d for up to 3 years. containing contraceptives are contrain- Its primary mechanism of action is dicated. Its convenience, reduced risk of ovulation suppression, with no ovulation anemia, and postpartum benefi ts are all detected for 30 months in a study group well known, and we have thus limited of more than 17,000 women.35 Increased our discussion of DMPA to the summary cervical mucus viscosity also contributes in the TABLE. to its effectiveness.35 In a large clinical trial, no pregnancies were reported in INC. more than 6100 cycles.36 However, this ❚ Emergency contraception: USA trial excluded women weighing more 2 pills, 12 hours apart

than 130% of their ideal body weight, so Plan B contains 2 tablets of levonorgestrel ORGANON

no data are available to support the effec- 0.75 mg, to be taken 12 hours apart as 2008 tiveness of Implanon in obese women.36 soon as possible after unprotected in- ©

Benefi ts and risks. This implant does tercourse. However, taking both doses PHOTO:

802 VOL 57, NO 12 / DECEMBER 2008 THE JOURNAL OF FAMILY PRACTICE

802_JFP1208 802 11/18/08 1:41:41 PM The latest contraceptive options: What you must know ▼

together is as effective as taking them sperm motility and integrity. With a separately, and doing so may improve copper IUD, additional primary contra- compliance.39 ception is unnecessary. The LNG IUS How it works. Emergency contracep- (Mirena) has not been studied as an al- tion (EC) works by inhibiting or delay- ternative EC. ing the surge of luteinizing hormone and follicular rupture before ovulation. It Some worry that EC’s availability does not affect implantation or corpus will encourage unprotected sex luteum function, and it poses no risk to Some authorities have wondered if in- an established pregnancy or embryo. EC creased access to EC might paradoxically is ineffective when administered after lead to more pregnancies by encouraging ovulation.40 unprotected sex. Researchers are explor- In a World Health Organization ing this issue. One study reported that (WHO) multicenter randomized trial, EC unfettered access to free EC resulted in prevented 79% to 84% of pregnancies if an increase in EC use, and another study taken 1 to 3 days after intercourse, and reported that patients with unrestricted 60% to 63% of pregnancies if taken 4 to EC access had inadequately protected 5 days after intercourse.41 Plan B is avail- sex more often than those in the control able without a prescription for women group.47,48 ages 18 and older. It is important to A systematic review of 23 articles screen for pregnancy before prescribing studying the effect of increased access to Plan B for younger patients. EC confi rmed an increase in EC use,49 Adverse effects include nausea and but no statistically signifi cant differences vomiting, occurring in 23% and 5% in pregnancy or rates. of patients, respectively. Intermenstrual bleeding occurs in 8% of patients taking So what do you recommend? progestin-only EC. Menses are expected For patients like the 35-year-old woman within 21 days of EC administration, and discussed earlier, who do not like taking the second cycle after EC should be of pills, there are many contraception op- FAST TRACK normal length.42 The authors of a WHO tions to choose from, including the patch, For emergency report concluded that “there are no med- vaginal ring, chewable OC, IUD, depot ical conditions wherein risks outweigh medroxyprogesterone injection, and sub- contraception, benefi ts of EC.”43 dermal implant. an estrogen- Combination estrogen/progestin for would not progestin EC is no more effective than progestin- be an issue for this patient—even though combination is only EC and results in higher rates of she has a family history of breast can- adverse effects, especially nausea and cer. Using hormonal contraception does no more effective vomiting.44 not increase the risk of breast cancer than progestin for individuals with a family history of alone and results IUD can also be used breast cancer in a fi rst- or second-degree in higher rates of in an emergency relative.50 ■ Insertion of a copper IUD provides EC adverse effects as well as ongoing contraception. It is hormone free and can be used effec- Correspondence tively for EC up to 5 days after sexual Petra M. Casey, MD, Department of Obstetrics and Gy- intercourse, then continued for primary necology, Mayo Clinic, 200 First Street SW, Rochester, contraception for up to 10 years.45 Its es- MN 55905; [email protected]. timated failure rate was less than 0.1% in 46 more than 8400 postcoital insertions. Disclosure The IUD works by impairing fertiliza- The authors reported no potential confl ict of interest rel- tion and implantation and by altering evant to this article.

CONTINUED

www.jfponline.com VOL 57, NO 12 / DECEMBER 2008 803

803_JFP1208 803 11/18/08 1:41:45 PM THE JOURNAL OF FAMILY PRACTICE

References of ethinyl estradiol. Contraception. 2006;73:223- 1. Andrist LC, Arias RD, Nucatola D, et al. Women’s 228. and providers’ attitudes toward menstrual sup- 19. Cole JA, Norman H, Doherty M, et al. Venous pression with extended use of oral contraceptives. thromboembolism, myocardial infarction, and Contraception. 2004;70:359-363. stroke among transdermal contraceptive system 2. Glasier AF, Smith KB, van der Spuy ZM, et al. users. Obstet Gynecol. 2007;109:339-346. Amenorrhea associated with contraception—an 20. American College of Obstetricians and Gynecolo- international study on acceptability. Contraception. gists. ACOG practice bulletin. Use of hormonal 2003;67:1-8. contraceptives in women with coexisting medical 3. Seasonale [package insert]. Pomona, NY: Duramed conditions. No. 73, June 2006. Obstet Gynecol. Pharmaceuticals, Inc; 2008. 2006;107:1453-1472. 4. Seasonique [package insert]. Pomona, NY: 21. Mulders TM, Dieben TO, Use of the novel com- Duramed Pharmaceuticals, Inc; 2006. bined contraceptive vaginal ring NuvaRing for ovu- lation inhibition. Fertil Steril. 2001;75:865-870. 5. Shortened pill-free interval delivered by new 20 mcg pill, Organon’s Mircette, schedule for US de- 22. Sulak PJ, Smith V, Coffee A, et al. Frequency and but this summer. Contraception Technol Update. management of breakthrough bleeding with con- 1998;19:85-87. tinuous use of the transvaginal contraceptive ring. Obstet Gynecol. 2008;112:563-571. 6. Casper RF, Dodin S, Reid RL, for the Study Investi- gators. The effect of 20 mcg ethinyl estradiol/1 mg 23. Bjarnadottir RI, Tuppurainen M, Killick SR. Com- norethindrone acetate (Minestrin), a low-dose oral parison of cycle control with a combined contra- contraceptive, on vaginal bleeding patterns, hot ceptive vaginal ring and oral levonorgestrel/ethinyl fl ashes and quality of life in symptomatic perimeno- estradiol. Am J Obstet Gynecol. 2002;186:389- pausal women. Menopause. 1997;4:139-147. 395. 7. Lybrel [package insert]. Philadelphia, Pa: Wyeth 24. ParaGard T 380A [prescribing information]. Pomo- Pharmaceuticals, Inc; 2007. na, NY: Duramed Pharmaceuticals, Inc; 2006. 8. Archer DF, Jensen JT, Johnson JV, et al. Evaluation 25. Beining RM, Dennis LK, Smith EM, et al. Meta- of a continuous regimen of levonorgestrel/ethinyl analysis of intrauterine device use and risk of en- estradiol: phase 3 study results. Contraception. dometrial cancer. Ann Epidem. 2008;18:492-499. 2006;74:439-445. 26. ACOG Committee Opinion. Intrauterine De- 9. Willis SA, Kuehl TJ, Spiekerman AM, et al. Greater vice and Adolescents No. 392. Obstet Gynecol. inhibition of the pituitary: ovarian axis in oral con- 2007;110:1493-1495. traceptive regimens with a shortened hormone-free 27. McNaught J. Adolescents and IUCDs—Not a con- interval. Contraception. 2006;74:100-103. traindication. J Ped Adolesc Gyn. 2006;19:303- 10. Parsey KS, Pong A. An open-label, multicenter 305. study to evaluate Yasmin, a low-dose combination 28. Lethaby AE, Cooke I, Rees M. Progesterone/pro- oral contraceptive containing drospirenone, a new FAST TRACK gestogen releasing intrauterine systems versus progestogen. Contraception. 2000;61:105-111. either placebo or any other medication for heavy Using hormonal 11. Femcon Fe [package insert]. Rockaway, NJ: War- menstrual bleeding. Cochrane Database Syst Rev. contraception ner Chilcott (US), Inc; 2007. 2005;(4):CD002126. 12. Burkman R. The evolution of oral contraceptives: 29. Hurskainen R, Teperi J, Rissanen P, et al. Quality does not increase 40 years of continuous improvement. Clinician. of life and cost-effectiveness of levonorgestrel-re- 2002;20:3-30. leasing intrauterine system versus hysterectomy the risk of breast 13. Vercellini P, Frontino G, De Giorgi O, et al. Continu- for treatment of menorrhagia: a randomised trial. cancer for ous use of an oral contraceptive for endometrio- Lancet. 2001;357:273-277. sis-associated recurrent dysmenorrhea that does 30. Römer T. Prospective comparison study of levo- individuals with not respond to a cyclic pill regimen. Fertil Steril. norgestrel IUD versus Roller-Ball endometrial abla- 2003;80:560-563. tion in the management of refractory recurrent hy- a family history 14. Guido M, Romualdi D, Giuliani M. Drospirenone for permenorrhea. Eur J Obstet Gynecol Reprod Biol. of it the treatment of hirsute women with PCOS; a clini- 2000;90:27-29. cal endocrinological, metabolic pilot study. J Clin 31. Toivonen J, Luukkainen T, Allonen H. Protective Endocrinol Metab. 2004;89:2817-2823. effect of intrauterine release of levonorgestrel on 15. Tzourio C, Tehindrazanarivelo A, Iglesias S, et pelvic infection: three years’ comparative experi- al. Case-control study of migraine and risk of ence of levonorgestrel- and copper-releasing in- ischaemic stroke in young women. Br Med J. trauterine devices. Obstet Gynecol. 1991;77:261- 1995;310:830-833. 264. 16. Steinauer J, Autry AM. Extended cycle combined 32. Ball CE. News and controversies in contracep- hormonal contraception. Obstet Gynecol Clin tion. AudioDigest Obstet Gynecol Clin Updates. North Am. 2007;34:43-55, viii. 2007;54:18. 17. Ortho Evra [prescribing information]. Raritan, NJ: 33. Grimes DA. Intrauterine device and upper genital Ortho-McNeil-Janssen Pharmaceuticals, Inc; 2001. tract infection. Lancet. 2000;356:1013-1019. 18. Jick SS, Kaye JA, Russmann S, et al. Risk of non- 34. Farley TM, Rosenberg MJ, Rowe PJ, et al. Intra- fatal venous thromboembolism in women using a uterine devices and pelvic infl ammatory disease: an contraceptive transdermal patch and oral contra- international perspective. Lancet. 1992;339:785- ceptives containing norgestimate and 35 microg/l 788.

804 VOL 57, NO 12 / DECEMBER 2008 THE JOURNAL OF FAMILY PRACTICE

804_JFP1208 804 11/18/08 8:22:28 AM Advertisement

IN THE UNITED STATES, 35. Implanon [package insert]. Roseland, NJ: Organon USA Inc; 2007. THE PRESS 36. Funk S, Miller MM, Mishell DR Jr, et al; The Implanon CANNOT US Study Group. Safety and effi cacy of Implanon, a single-rod implantable contraceptive containing BE CENSORED. etonogestrel. Contraception. 2005;71:319-326. 37. Beerthuizen R, van Beek A, Massai R, et al. Bone mineral density during long-term use of the proge- THE INTERNET stagen contraceptive implant Implanon compared to a non-hormonal method of contraception. Hum CANNOT Reprod. 2000;15:118-122. 38. Reinprayoon D, Taneepanichskul S, Bunyavejchev- BE CENSORED. in S, et al. Effects of the etonogestrel-releasing contraceptive implant (Implanon) on parameters of breastfeeding compared to those of an intrauterine POLITICAL device. Contraception. 2000;62:239-246. 39. Ngai SW, Fan S, Li S, et al. A randomized trial to ADVERTISING compare 24 h versus 12 h double dose regimen of CANNOT levonorgestrel for emergency contraception. Hum Reprod. 2005;20:307-311. BE CENSORED. 40. American College of Obstetricians and Gynecolo- gists. ACOG Practice Bulletin No. 69: emergency contraception. Obstet Gynecol. 2005;106:1443- WHY ARE 1452. 41. Von Hertzen H, Piaggio G, DingJ. Low dose mife- SOME MEMBERS pristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre OF CONGRESS & randomised trial. WHO Research Group on Post- Ovulatory Methods of Regulation. Lancet. ACADEMIA 2002;360:1803-1810. TRYING TO CENSOR 42. Raymond EG, Goldberg A, Trussell J, et al. Bleed- ing patterns after use of levonorgestrel emergency MEDICAL contraceptive pills. Contraception. 2006;73:376- 381. COMMUNICATIONS? 43. World Health Organization. Medical eligibility crite- ria for contraceptive use. 3rd ed. 2004. Available at: www.who.int/reproductive-health/publication/ med/mec.pdf. Accessed February 7, 2008. 44. Task Force on Postovulatory Methods of Fertility Diabetes. Cancer. Obesity. Respiratory Regulation. Randomised controlled trial of levo- disease. America’s medical professionals norgestrel versus the of combined are busier than ever. How can they stay oral contraceptives for emergency contraception. Lancet. 1998;352:428-433. current with medical advances and still improve their patients’ well-being? 45. American College of Obstetricians and Gynecolo- gists. ACOG Practice Bulletin No. 59. Intrauterine Information is part of quality care. Yet device. Obstet Gynecol. 2005;105:223-232. government controls threaten to keep 46. LaValleur J. Emergency contraception. Obstet Gy- doctors in the dark about current necol Clin North Am. 2000;27:817-839, vii. medical advances. 47. Raymond EG, Stewart F, Weaver M, et al. Impact of increased access to emergency contraceptive Restrictions on how much information pills: a randomized controlled trial. Obstet Gynecol. consumers and doctors can know about 2006;108:1098-1106. current and new treatments reduce 48. Raymond EG, Weaver MA. Effect of an emergency their ability to advocate for care. contraceptive pill intervention on pregnancy risk behavior. Contraception. 2008;77:333-336. Using censorship as a policy tool to 49. Raymond EG, Trussell J, Polis CB. Population ef- control healthcare costs is a bad idea! fect of increased access to emergency contracep- Yet that’s what vocal pockets of academic tive pills: a systematic review. Obstet Gynecol. 2007;109:181-188. medicine and Congress have in mind. 50. Casey PM, Cerhan JR, Pruthi S, Oral contraceptive We are concerned that some members use and risk of breast cancer. Mayo Clinic Proc. of Congress and Academia are seeking 2008;83:86-89. to restrict the content of CME and other 51. Trussell J. Contraceptive effi cacy. In: Hatcher RA, industry-sponsored communications Trussell J, Stewart FH, et al, eds. Contraceptive Technology, 18th ed. New York, NY: Ardent Media, without input from practicing physicians. Inc; 2004:773-845. Information is the fi rst step to care. To learn more, visit cohealthcom.org.

www.jfponline.com Th is message brought to you as a public service by the Coalition for Healthcare Communication.

805_JFP1208 805 11/18/08 8:22:32 AM