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Abstract

There are many contraceptives in the world market today. Knowledge of the vast spectrum of contraceptive methods is essential to the everyday practice of healthcare personnel. Such knowledge translates to improved care and access for women so they can obtain and utilize the appropriate contraception for their individual needs. This is a review of non-oral and nonsurgical contraceptive methods.

Keywords

contraceptive patch hormonal injections intrauterine devices non-oral contraception progesterone implants vaginal ring women's health

Almost half of all pregnancies in the USA are unintended or unplanned [1,2]. In addition to the profound personal and societal impact of unintended pregnancy, cost analyses demonstrate a consistent cost saving of US$9000–14,000 per woman of childbearing age over a 5-year period if contraception is used, compared with pregnancy and abortion [3]. All methods of contraception have side effects and no one method is always effective in preventing pregnancy; nonetheless, morbidity and mortality rates are significantly higher for pregnancy and birth than for the use of any contraceptive method alone [4].

Oral contraceptive pills, male condoms and female sterilization are the contraceptive methods most commonly used in the USA [5]. However, approximately 3 million American women at risk of unintended pregnancy are using no form of contraception. Reasons frequently cited for discontinuing a method when contraception is still desired include side effects, difficulty of use, safety concerns and a lack of access to healthcare [6].

Considering the popularity of intrauterine methods among women in the USA prior to the publicity concerning the Dalkon Shield and the current popularity of the transdermal contraceptive patch, a considerable number of women who are seeking contraception desire either a nondaily or non-oral method. Encouraging and empowering a woman to choose a method of contraception that best suits her personal needs and lifestyle will considerably improve the likelihood that she will use that method consistently and correctly for as long as she chooses to not become pregnant [7]. Clinician knowledge of the wide variety of contraceptive methods and barriers to the use of some of these methods is therefore necessary and critical to help each woman with this important decision. An overview of non-oral and nonsurgical contraceptive methods will now follow.

Progesterone implants

Implanon®

Implanon® is currently available in The Netherlands, the UK, Sweden, Australia, Germany, Belgium, Finland, Switzerland, Denmark, Austria and Brazil, among other countries, and is likely to be available in the USA in the near future. It is a single-rod implant that is 4 cm long and 2 mm in diameter. It is approximately 5 mm longer than a single Norplant® rod. It has a membrane of ethylene vinyl acetate copolymer with a core impregnated with 68 mg of etonogestrel (3-ketodesogestrel). Etonogestrel is released at a rate of 60 μg/day and it is effective for 3 (probably up to 5) years. The single-rod implant is inserted into the subcutaneous tissue beneath the skin of the medial aspect of a woman's nondominant upper arm in the area between the biceps and triceps muscles.

The effectiveness of Implanon is similar to Norplant: there have been no pregnancies thus far in its testing [8 –10]. Within 24 h of insertion, the cervical mucus begins to thicken and ovulation inhibition appears to be more effective than Norplant (0% in the first 2 years). In addition to cervical mucus thickening and ovulation inhibition, the single-rod system creates an atrophic endometrium [11]. Although the cost of this method has not yet been determined in the USA, it is likely to be comparable to other long-term methods (e.g., intrauterine devices [IUDs]) and will thus be a cost-effective method for women seeking longer-term contraception.

Its advantages include decreased dysmenorrhea and overall increased amenorrhea and less bleeding than Norplant. It allows spontaneity, since no contraceptive action is required at the time of intercourse. In clinical trials, there has been a high continuation rate. It has been suggested that cyclic headaches may improve with Implanon due to the steady-state release of etonogestrel. In addition, a single implant is easier and faster to insert and remove than multiple implants and is usually accomplished with only a scalpel and gentle blunt pressure [12]. In some instances, a scalpel does not need to be used [13]. The copolymer used in this single-rod system may also create less of a fibrous sheath and, therefore, make it easier to remove. A return to baseline fertility is rapid and seemingly complete: 94% of women ovulate within 1 month of removal.

Disadvantages include initial irregular bleeding and an unpredictability of the time of bleeding. Although amenorrhea occurs in 20% of users, studies demonstrate that, despite an overall reduction in the amount and frequency of vaginal bleeding among Implanon users, short- and long-term use of this method does not provide users with a predictable bleeding pattern. Insertion and removal require an office procedure for which special training is needed and, as is the case for most nonbarrier methods, the single rod system provides no protection against sexually transmitted infections (STIs). Headache is the most common of the usual hormonal side effects reported by users. However, in a study by Croxatto, there was an average weight gain of approximately 10% or greater among one in five of those using the single-rod implant [14].

Norplant®

Norplant consists of six soft silastic implants, each 34 mm in length and 2.4 mm in diameter. They are inserted into the subcutaneous tissue beneath the skin of the medial aspect of a woman's nondominant upper arm. Each implant is filled with 36 mg of levonorgestrel powder, which is slowly released through micropores in the implant to achieve an average plasma concentration of 0.3 ng/ml over 5 years. The system is effective for up to 5 years. In women weighing less than 70.5 kg or over 35 years of age, it is effective for 7 years. As expected with a contraceptive method requiring no intervention after insertion, its perfect-use and typical-use failure rates in the first year are the same at 0.05%. The cumulative 7-year failure rate is 1.9% (this is higher for women >90 kg after 5 years of use). Norplant is not currently available in the USA. In August 2000, the manufacturer issued an advisory that the contraceptive efficacy of the implant could not be assured; however, lots that were suspect were eventually found to be effective [15].

Jadelle®

The Jadelle® system consists of two rods that are slightly larger than the six capsules of Norplant. Each rod is 0.25 cm in diameter, 4.3 cm long and contains 75 mg of levonorgestrel. Under local anesthesia, a #10 trocar is used to place the rods in a V configuration subdermally at the inner part of the nondominant upper arm. Insertion time is approximately 2 min and removal time is approximately 5 min. Levonorgestrel is released at 80 μg/day in the first months and decreases to 50 μg/day by 9 months. After 9 months, only 25–30 μg of progestin is released. Sivin and colleagues documented 5-year contraceptive effectiveness similar to Norplant and other long-term reversible contraceptive methods [16]. The major side effect is irregular bleeding [17] and there is a rapid return to fertility after removal of the rods. It has been approved for 3 years of contraception in the USA by the US Food and Drug Administration (FDA), but has not yet been marketed and is therefore not available in the USA.

Hormonal injections

Combined hormonal injections

LUNELLE® (Lunella™, Cyclo-Provera™, Cyclofem®, Ciclofemina™, Feminena™ and HRP 112) is not currently available in the USA because of a manufacturer recall in October 2002 for potential subpotency and contraceptive failure for injections administered since January 2002. It is a 0.5 cc suspension of 25 mg of medroxyprogesterone acetate (MPA) and 5 mg of estradiol cypionate (E₂C) and is injected into the deltoid or gluteus maximus every 28 ± 5 days. In places where this method is available, Lunelle provides women with the side-effect profile of oral contraceptive pills, with the advantage being that it is only administered once per month. As with other systemic hormonal contraceptives, it prevents pregnancy primarily by inhibiting ovulation [18]. Indeed, multicenter trials by the World Health Organization (WHO) revealed the contraceptive efficacy of Lunelle to be similar to long-term progestogen injections or IUDs, with first-year pregnancy rates reported to be 0–2/1000 women [19]. The most common side effects are changes in vaginal bleeding patterns but by approximately 6 months of use, most women report regular bleeding episodes [20].

Progestin-only injections

Depot medroxyprogesterone acetate (DMPA) injections (Depo-Provera®) consist of 1 cc of crystalline suspension of 150 mg DMPA injected intramuscularly into the deltoid or gluteus maximus every 11–13 weeks. A subcutaneous injection of 104 mg of DMPA was recently approved by the FDA and should be available in the near future. The perfect-use failure rate in the first year is 0.3%, whereas the typical-use failure rate in the first year is 3%. In the initial study of the subcutaneous 104 mg regimen, no pregnancies were reported in 16,023 woman-cycles of exposure [21,22]. Continuation of DMPA injections after 1 year is 42–56%.

As with other systemic progestin-only methods, DMPA inhibits ovulation by suppressing luteizing hormone (LH) and follicle-stimulating hormone (FSH) surges. It also thickens cervical mucus, which blocks sperm from entering the upper reproductive tract, and slows tubal and endometrial mobility. The lining of the endometrium also becomes thinner [23,24].

An advantage of DMPA is that it decreases blood loss, anemia and hemorrhagic corpus luteum cysts. After 1 year of use, 50% of women develop amenorrhea; 80% develop amenorrhea within 5 years. Therefore, in women with bleeding diatheses or who are receiving anticoagulants, this is a method of birth control that can provide important noncontraceptive benefits. It reduces sickle cell crises by approximately 70% [25]. DMPA does not interfere with anti-convulsants and there are reports of decreased dysmenorrhea and ovulation pain. For women with endometriosis, there is an improvement in pelvic pain; indeed, the new DMPA subcutaneous 104 mg regimen has been approved for the treatment of pain of endometriosis. It is convenient and permits sexual spontaneity, as it requires no action at the time of intercourse. There is a significant reduction in endometrial cancer, but surprisingly, no documented reduction in ovarian cancer as yet [26]. DMPA is convenient, since it provides 13 weeks of contraception, and is probably the most private method of contraception as it requires no pill packs, intravaginal strings, skin patches or sub-cuticular devices. It is also appropriate for women who are breastfeeding.

Disadvantages include irregular menses during the first several months. Many users experience unpredictable spotting and bleeding. However, after 6–12 months of use, amenorrhea is the more likely bleeding profile for users [27]. Breakthrough spotting and bleeding may interfere with sexual activity and other lifestyle considerations. The relative hypoestrogenic state in some women using DMPA may cause some dyspareunia, occasional hot flashes or decreased libido. There may also be an increase in depression, anxiety and other mood changes, although most studies show no overall adverse effect on mood. In addition, as with all methods described in this review, DMPA does not provide protection against STIs.

A woman must return to the clinic every 11–13 weeks to receive the next injection. DMPA is long acting and not reversible immediately, with a slow return to baseline fertility: an average of 10 months from the last injection. Due to the hypoestrogenic state, there is a potential for decreased bone mineral density if used for a prolonged period without opportunity for recovery prior to menopause. In a study by Cundy, women who received DMPA for 5 years or more had significantly reduced bone mineral density of the lumbar spine and femoral neck (especially after 15 years of use and if started before the age of 20 years) [28]. Although this effect was almost completely reversible, the FDA recently added language to the package insert warning against long-term use of DMPA due to concerns about reduced bone mineral density with prolonged use. Weight gain, headache, acne and hirsuitism may result from DMPA. Metabolic effects of DMPA may include a slight rise in glucose and low-density lipoprotein (LDL), and a decrease in high-density lipoprotein (HDL). Other side effects commonly include breast tenderness, bloating, transient hair loss and vasomotor symptoms. Severe depression is rare [29].

Candidates for use include women who desire long-term contraception and who can return for an office visit every 11–13 weeks. This is a good option for women who wish to have privacy with contraception and convenience and, for those women who cannot or should not use estrogen (i.e. those with a history of deep vein thrombosis [DVT], smokers over the age of 35 years, women who use medications that affect the clearance of the liver, women with sickle-cell disease, fibroids, anemia, seizure disorder, systemic lupus erythematosus [SLE] or endometriosis) [30]. This is also a good short-term method for women with disabilities, for whom vaginal bleeding is a hygienic and maintenance-of-care concern.

Other hormonal methods

Contraceptive patch

In 2002, the FDA approved the use of the combination contraceptive patch (Ortho Evra®) and it is currently the most widely used single-branded method of contraception in the USA. The patch is a 4.5 cm square that delivers a daily dose of 20 μg of ethinyl estradiol and 150 μg of norelgestromin (the active metabolite of norgestimate) [31]. One Ortho Evra patch is worn each week for 3 consecutive weeks and the fourth week is patch-free to permit withdrawal bleeding. It takes approximately 3 days to reach a steady-state of hormone levels after patch application. As with oral contraceptive pills and some other hormonal methods, the patch is amenable for use in an extended-use regimen, but no studies evaluating this use are currently available.

The patch may be worn on the lower abdomen, buttocks, upper outer arm or on the upper torso, except for the breasts, and is effective regardless of physical activity, including swimming and bathing. If the patch is detached partially or completely for less than 24 h, it should be reapplied to the same area or replaced with a new patch. If it is detached for longer than 24 h, a new patch should be applied (this day of the week becomes the new application day) and backup contraception should be used for 1 week. Three patches (a 1-month supply) cost about as much as a pack of oral contraceptive pills (maybe slightly higher). Women should be warned that there are counterfeit patches being sold over the internet that provide no contraceptive effect.

The patch prevents pregnancy in the same manner as the oral contraceptive pill by suppressing ovulation approximately 90–95% of the time. Moreover, as with any progestin-containing method, a thickening of cervical mucus results from patch use, which helps block sperm penetration into the upper reproductive tract. The lining of the endometrium becomes thin in response to the released hormones and tubal motility is slowed.

Among perfect users who do not miss an application and who maintain each patch for a full 7 days, only 3–6/1000 will become pregnant during the first year. In 2001, Zieman combined data from three efficacy studies (22,155 treatment cycles) using life-table analysis and found an overall failure rate of approximately 0.8% [32]. Of the 15 pregnancies in this review, five were in women who weighed over 90 kg. In a multicenter trial by Audet and colleagues, in 1417 women randomized to use the patch (n = 812) or the oral contraceptive pill, Triphasil® (n = 605), the pregnancy rate was approximately the same (it was lower with the patch than the pill but it was not statistically significant). There were five pregnancies among women using the patch (one user failure and four method failures) [33]. Furthermore, in this trial, compliance was significantly better among users of the patch than those taking the pill (88.2% of participants receiving the patch vs only 77.7% of participants receiving the pill).

Advantages of the patch mirror the menstrual benefits of the oral contraceptive pills, including decreased blood loss and anemia, decreased menstrual cramps/pain and more predictable menses. Its use considerably reduces the pain associated with ovulation. The transdermal patch can be used to manipulate the timing and frequency of menses, reduce the risk of internal hemorrhage from ovulation (which is important in women with bleeding diatheses) and to regulate menses and provide progestin for women with anovulation or polycystic ovary syndrome (PCOS), which reduces their risk of endometrial cancer [34]. Moreover, the patch is only applied on a weekly basis, which is a sound option for those women who forget to take their pills. There are, as yet, no data on the possible protective effects of the patch against ovarian, endometrial or colorectal cancer, nor are there data for a reduction in benign breast mass or ovarian cyst occurrence.

Disadvantages include breakthrough spotting, which is common in the first cycle among approximately 20% of users. However, this appears to be similar to the occurrence among users of oral contraceptive pills. Since the patch is more visible than pills, this may be considered as a disadvantage for some women. Just as with other nonbarrier methods, patch use affords no protection from STIs/HIV. In addition, the patch needs to be removed and reapplied weekly; accordingly, application-site problems include partial (2.8%) or complete (1.8%) detachment and skin irritation (1.1%). In a study of physical exertion and variable temperatures/humidity, less than 2% of patches were replaced for complete or partial detachment. In total, only 2.6% of women discontinued the patch because of application-site problems [35]. Nausea occurred in 20.4% of women on the patch versus 18.3% on the oral pill. Breast discomfort was greater in women using the patch than in women receiving the pill (15.4 vs 3.5% in cycle 1; 6.6 vs 1.5% in cycle 2); however, the difference was only significant in the first two cycles. Headaches were as likely in women using the patch (21.9%) as receiving the pill (22.1%) [36]. Allergic skin reactions can also occur with the patch. In a pooled analysis of clinical trial data, there was a suggestion that the patch could be less effective in women weighing 90 kg or more, leading the FDA to issue a precaution to clinicians who prescribe this method [37].

Other complications of patch use appear to be similar to combination oral contraceptive pill use, including risk of venous thromboembolism (VTE). Baseline risk of a VTE is 4–8/100,000 women/year. For a woman who takes contraceptive pills, the risk increases to 10–30/100,000/year. To place this in perspective, for a woman who is pregnant, this risk increases to 60/100,000/year. The risk of VTE is associated with the dose of estrogen; therefore, the risk is increased with 50 μg pills compared with 20–35 μg pills. In addition, the use of estrogen-containing hormonal contraceptives should be initiated with caution in women with known gallstones. There is no increased risk of myocardial infarction (MI) or stroke for women under the age of 35 years who neither smoke nor have hypertension and who are using hormonal contraceptives with an estrogen dose less than 50 μg. Women weighing over 90 kg should be warned that the patch may be less effective and that they should consider a backup method.

Vaginal contraceptive ring

The vaginal contraceptive ring (NuvaRing®) also has a unique and novel drug delivery system that permits effective contraception without the need for daily action by the woman who chooses this method. It is a 5.4 cm diameter, 4 mm thick flexible ring made out of ethylene vinylacetate polymer. The ring releases ethinyl estradiol at a rate of 15 μg/day and etonogestrel at a rate of 120 μg/day, and it is placed and left within the vagina for 3 weeks [38]. After 3 weeks, the ring is removed from the vagina for 1 week, allowing for a withdrawal bleed, and a new ring is then inserted at the completion of the ring-free interval. Like the transdermal patch, it is amenable for extended-use regimens, but this is an off-label use with no published information to support its safety or effectiveness. It is recommended strongly that it not be removed for intercourse. Douching is discouraged, but topical agents, such as antifungals, may be used simultaneously with the ring. A single vaginal ring maintains a steady, low release rate while in place and releases less estrogen daily than pills or the patch. In a 1-year study, the overall failure rate for the vaginal ring was 0.65 pregnancies/100 woman years [39].

The mechanism for ring contraception is, again, similar to the pills and the patch. In one study by Mulders, ovulation was suppressed for 35 days, thus providing a method that is forgiving for women who may be somewhat late to change their ring [40,41]. Each ring costs about the same as a pack of oral contraceptive pills or a month of transdermal patches. The overall pregnancy rate is 0.3–0.65/100 women/year for all first-time users [42].

Advantages of the ring include withdrawal bleeding in 98.5% of cycles, and bleeding at other times in only 5.5% of cycles [43]. Overall, there appears to be an improved withdrawal/spotting pattern than with oral pills. Like the transdermal patch, there are no published data on the effect of the ring on gynecologic cancers or masses. There are only two tasks for the ring user to remember: insertion and removal once a month, so compliance may be improved compared with pill use (92 vs 75% in one study) [44]. With regard to vaginal sensation, 85% of women and 71% of partners say they cannot feel it. The ring has the lowest serum levels of estrogen and progestin of any combined hormonal method, and there is a modicum of privacy with this method compared with the patch. In addition, like pills and the patch, return to ovulation after discontinuation is rapid.

The primary disadvantage of the ring method is a 3–5% reported frequency of vaginal discharge among women who use this method. Although the majority of these women appear to choose to continue using the ring method, such events can lead to the need for local or systemic therapies and increase the chance of early discontinuation. Other disadvantages of the ring include unscheduled bleeding that appears to be comparable to other lower-dose hormonal methods. This method should not be used for women who are uncomfortable placing or removing objects from their vaginas and, as with the diaphragm, women who have pronounced pelvic relaxation may not be good candidates for the ring. Finally, approximately 15–20% of partners of women using the ring reported that the ring was felt during intercourse; this could lead to problems during sex and create issues for couples who choose this method for contraception [45].

Intrauterine contraception systems

The only two IUDs available currently in the USA are the ParaGuard® T380A Intrauterine Copper IUD and the Mirena® levonorgestrel-releasing intrauterine system (LNG-IUS). The IUD may be used continuously for up to 5 (Mirena) or 10 (ParaGuard) years, although studies show that the effectiveness of both methods are 7 and 12 years, respectively [45,47]. Some side effects include increased menstrual bleeding and dysmenorrheal (ParaGuard) and irregular (Mirena) bleeding. Potential complications include an increased risk of pelvic inflammatory disease (PID) for the first 3 weeks following insertion and uterine perforation during insertion. Copper-containing IUDs provide protection against endometrial cancer, while progesterone-releasing IUDs decrease uterine bleeding/menorrhagia. In addition, IUDs have a 99% user satisfaction rate, which is the highest level of satisfaction for any contraceptive method currently being used by women [48].

Copper intrauterine device

This is a T-shaped intrauterine contraceptive made of radio-opaque polyethylene with a fine copper wire wrapped around the stem, providing a surface area of copper of 380 mm². A monofilament polyethylene tail of double strings protrudes through the cervix and into the vagina. It is approved for 10 years of use, but it is effective for at least 12 years. The perfect-use failure rate in the first year is 0.6%, and the typical-use failure rate in the first year is 0.8%; the cumulative 10-year failure rate is 2.1–2.8%. The copper IUD works primarily as a spermicide, although the exact mechanism has yet to be elucidated. Copper ions inhibit sperm motility and acrosomal enzyme activation so that sperm rarely reach the fallopian tube and are unable to fertilize the ovulated ovum. A sterile inflammatory reaction created in the endometrium also helps to phagocytoze the sperm. Experimental evidence suggests that the IUDs do not work routinely after fertilization and are therefore not considered to be abortifacients.

Advantages of the copper IUD include effective long-term contraception and convenient single insertion, which provides 10–12 years of protection against pregnancy. It also permits spontaneous sexual activity and requires no action at the time of use. It may provide protection against endometrial cancer (six of seven case–control studies) and 40% protection against cervical cancer. Upon removal, there is a rapid return to fertility. This method of contraception is also relatively private. It is highly cost effective, providing the greatest net benefits of any contraceptive method over a 5-year period. Indeed, every copper IUD inserted saves the healthcare system an estimated US$14,133 in its first 5 years of use [49]. This is also a good option for those who cannot or will not use hormonal methods. With the copper IUD, the risk of ectopic pregnancy is decreased to 10% of the baseline risk

The main disadvantage of the copper IUD is that it causes an increase in the average monthly blood loss by approximately 35% (which may be decreased by periodic use of nonsteroidal anti-inflammatory drugs). Due to the increase in menstrual-related bleeding, this IUD may increase dysmenorrhea. Indeed, the removal rate for pain and bleeding during the first year of use is 11.9%. Spotting and cramping are common with insertion and occur intermittently in the initial weeks following insertion. Some women are not at ease checking the strings, and the strings can sometimes cause partner discomfort.

An IUD requires an office procedure for insertion and removal, both of which can be uncomfortable. The risk of infection is increased in the first 20 days after insertion (1 in 1000 will acquire PID). This method offers no protection from STIs/HIV. An IUD may be expelled (either obviously or silently). The rate of expulsion declines with time: 11.3% being the cumulative expulsion rate over 5 years and 0.3% as the rate for the fifth year. Women who have expelled one IUD have about a 1:3 chance of expelling another [50]. In addition, it cannot be used by women who has an allergy to copper or who have Wilson's disease. Although women with HIV/AIDS may be at risk for other STIs, IUDs do not increase complications in women with HIV/AIDS [51].

A copper IUD can increase the risk of PID within the first 20 days of insertion (overall risk; 1/1000 insertions), especially if there is cervicitis, bacterial vaginosis or contamination with insertion. In addition, there is a 1/1000 risk of uterine perforation, especially in women who have a markedly verted uterus, breastfeeding women or with an inexperienced provider. Vasovagal episodes occur rarely with insertion. Expulsion can occur with insertion on menses, immediately postpartum or if it is not inserted high enough in the fundus or in a nulliparous woman. Pregnancy is rare and usually results from poor placement or expulsion.

Candidates include women who are currently in a mutually monogamous relationship and are at a low risk of STIs. Women with a history of PID may be candidates if they are currently in stable and mutually monogamous relationships with an uninfected partner and have had a pregnancy since the PID episode. An IUD is also a good option for women who do not want to or cannot use hormonal forms of contraception. A Pap smear is not a prerequisite for placement of an IUD in most parts of the world. However, if the result of a Pap is available, women who have known or suspected uterine or cervical cancer or an unresolved Pap smear should not receive an IUD. Severe anemia is a relative contraindication of the copper IUD, as can be the size of the uterus (the uterine cavity should be 6–9 cm for insertion).

Levonorgestrel intrauterine device

This is a T-shaped intrauterine contraceptive that initially releases approximately 20 μg of levonorgestrel/day; after 5 years, the release rate falls to 14 μg/day [52]. Its perfect-use and typical-use failure rates in the first year are 0.1% and its 5-year cumulative failure rate is 0.7% [53]. Since it is a progestin-releasing device, the LNG-IUS causes cervical mucus to become thicker, so sperm cannot enter the upper reproductive tract. It also causes changes in the uterine and tubal fluid that serve to impair sperm migration. Alteration of the endometrium also prevents implantation of a fertilized ovum [54]. This IUD also has some anovulatory effects in approximately 25–50% of users [55]. It costs approximately US$300–400 but is also highly cost effective for long-term contraception.

Its advantages include an improvement in menorrhagia. There is approximately 90% less blood loss with this IUD versus only 50% less with combined oral contraceptive pills. Monteiro found that, among 44 women with menorrhagia receiving the Mirena LNG-IUD, only two had persistent symptoms after 3 months of use. After 9 and 12 months of use, approximately half of the patients had amenorrhea [56]. Moreover, after 3–4 months of menstrual irregularities (mostly spotting), Mirena decreased menstrual blood loss by more than 70% – some estimates report up to 97% [57]. Amenorrhea results in approximately 20% of users after 1 year and in 60% by 5 years. The LNG-IUS also reduces the need for surgeries, such as hysterectomies or endometrial ablation for menorrhagia, fibroids or adenomeiosis.

Other advantages of the LNG-IUS include a protective effect against endometrial cancer. The LNG-IUS offers a decrease in pain scores in women with endometriosis [58,59]. With this IUD, as with the copper IUD, there is a rapid return to fertility once it is removed. Of the women who sought pregnancy after removal of the LNG-IUS, 79% conceived within the first year and 87% achieved pregnancy within 2 years following removal [60]. Similar to the copper IUD, LNG-IUS also decreases the risk of ectopic pregnancy [61]. LNG-IUS may also be used for progestational protection against endometrial hyperplasia in women using estrogen hormone therapies for the relief of menopausal symptoms and the prevention of osteoporosis (off-label use). Although the safety of this IUD is not documented in women with breast cancer, its use has been shown to considerably reduce the incidence of polyps and endometrial hyperplasia among women receiving tamoxifen [62].

Complications and disadvantages are similar for both IUDs, except for those related to the progestational nature of the LNG-IUS. Disadvantages of the LNG-IUS include a relatively high number of spotting and bleeding days in the first 6 months of use; this reduces precipitously to levels below nonusers after approximately 3–6 months of use. Amenorrhea occurs in approximately 20% of women in the first year of use. Expulsion occurs in approximately 2.9% of women using the LNG-IUS exclusively for contraception and in 8.9–13.6% of women who are using it for menorrhagia [63]. In addition, just as for the copper IUD, it offers no protection against STIs/HIV. There may be persistent, unruptured follicles, which may cause ovarian cysts, but most regress spontaneously and the rate of symptomatic ovarian cysts does not appear to be increased compared with nonusers [64]. Headaches, acne and mastalgia may occur within the first few months of use and are increased slightly in frequency compared with nonusers. Also, as with any IUD, there may be brief discomfort after insertion or removal.

Candidates for use include women who want effective, reversible, long-term contraception, including women who want to avoid surgical sterilization. Mirena can also be used in women with heavy menses, cramps and anemia. It is a good option for women who have an allergy to copper or Wilson's disease to consider. It may be used by women who have had an ectopic pregnancy, although current packaging instructions recommend avoidance in women with risk factors for ectopics.

Male methods

There are no hormonal contraceptives currently available for use by men seeking contraception. Male hormonal methods under development often use exogenous progestin or gonadotropin-releasing hormone (GnRH) antagonists to suppress FSH and LH, thereby decreasing spermatogenesis. However, such approaches have thus far led to methods with considerable side effects, including mood alterations and antiandrogenic effects, and have not been shown to be highly effective. Even when replacement testosterone has been provided for these users, effectiveness and acceptability of these methods have been poor. Injectable and implantable forms of progestin and testosterone or GnRH and androgen have also been evaluated with equally poor efficacy, side-effect profiles and acceptability. A somewhat more promising approach may be immunocontraception, which is based on interference of the male spermatogenesis process by products of an immune reaction. Such methods do not require hormonal manipulation and, therefore, do not incur the considerable adverse events observed with high-dose progestin or androgen regimens. However, such methods have not, as yet, been shown to be highly effective in preventing the production of mature sperm consistently and further work will be required before an acceptable and highly effective method of male contraception will be available for use.

Conclusion

There are numerous non-oral methods of contraception available for women seeking short-and long-term contraception, and more methods continue to evolve. It is clear that many women seek and will continue to seek effective contraception without needing to use a daily pill. However, the key issue for contraception is not whether a woman uses a particular method or regimen but, rather, whether she is allowed to choose the method that is best incorporated into her lifestyle and, thus, gain maximal contraceptive and noncontraceptive benefits for as long as she chooses not to become pregnant. Unfortunately, many barriers to this process exist, from economic to educational. Clinicians who care for reproductive-aged women must be knowledgeable regarding all barrier, daily and nondaily methods and, just as importantly, seek to exclude personal bias and misconception from their counseling of these patients. A large part of this knowledge must include, not only the instructions for proper use, but also the potential side effects (expected and unexpected), as well as benefits, of each method. In addition, a good understanding of the woman's personal life and sexual history and preferences is central to the ability to provide effective counseling and proper contraception.

With the veritable plethora of available contraceptive methods and the continuing development of new and different methods, women have and will continue to have contraceptive options to match their own personal needs and preferences. Limited market availability of these methods, lack of understanding by clinicians and patients, as well as economic and political barriers all still serve to limit or, in some cases, prevent the use of safe, reversible and highly effective contraception. The proper use of these methods by informed patients not only improves overall contraceptive use, but also serves to reduce the embarrassingly high numbers of unintended and unplanned pregnancies and the considerable concomitant morbidity associated with unintended pregnancy. With the support of informed clinicians and improved access to these methods, not only will unintended pregnancy rates continue to decline, but the health of reproductive-aged women will continue to improve. Proper access to these methods should not be a benefit of the wealthy, but rather a part of the medical care of all women, regardless of their geography or means to pay, as the impact of unintended pregnancy adversely affects all in society, regardless of who is at risk.

Future perspective

Over the next 5–10 years, contraceptive technology will continue to advance. Progesterone implants will be used more widely and a male contraception method may be available. Nevertheless, despite the fact that there are numerous methods of contraception, there are still millions of women worldwide who are using no form of contraception. An increase in different contraceptive methods and awareness, in conjunction with a decrease in economic and political barriers, will serve to help eliminate undue barriers to a woman's decision to plan a family.

Executive summary

Introduction

Almost half of all pregnancies in the USA are unintended or unplanned, which has a pervasive personal and societal impact.

Contraception, when compared with abortion, has repeatedly demonstrated cost savings.

Clinician knowledge of the wide variety of contraceptive methods is necessary in empowering each woman to make such an important decision for her reproductive health.

Progesterone implants

No progesterone implants are currently available in the USA.

Implanon® is a single-rod implant inserted subcutaneously in the upper arm, which lasts for 2 years.

Implanon is highly efficacious and its main disadvantage is irregular bleeding.

Norplant® (six rods) and Jadelle® (two rods) are other progesterone implant alternatives that last for 5 years. The side effects and efficacy are similar to Implanon.

Hormonal injections

Lunelle® is a combined hormonal monthly injection, which is not available in the USA.

Lunelle's side-effect profile is similar to oral contraceptives.

Depot medroxyprogesterone acetate (DMPA) (medroxyprogesterone depot) is administered conveniently every 11–13 weeks and decreases overall menstrual blood loss.

DMPAs main disadvantage is irregular menstrual bleeding.

A lower dose, subcutaneously administered DMPA is currently available and has an improved side-effect profile.

Other hormonal methods

A contraceptive patch is worn each week for 3 consecutive weeks and the fourth week is patch-free.

Advantages and disadvantages of the patch mirror those of the oral pill.

The vaginal contraceptive ring is worn conveniently for 3 consecutive weeks and removed for the last week of a woman's cycle.

The ring is highly effective and the primary disadvantage is vaginal discharge, as reported by 3–5% of users.

Intrauterine contraception systems

There are two intrauterine devices (IUDs) available currently in the USA.

The Mirena® or levonorgestrel-releasing intrauterine system (LNG-IUS) is used for up to 5 years.

The most common side effect of the LNG-IUS is irregular bleeding.

ParaGuard® is the copper-containing IUD that lasts for 10 years.

The copper IUD's most common side effect is increased menstrual bleeding.

IUDs have a 99% user satisfaction rate and are as effective, and sometimes more effective, than surgical methods.

Male methods

There are no hormonal contraceptives currently available for men.

They have had little success, since the rate of side effects is high and the efficacy is low.

Conclusions

With the plethora of available contraceptive methods, women have contraceptive options to match their own personal needs and preferences.

Lack of understanding by clinicians and patients, as well as economic and political barriers, still serve to severely limit or, in some cases, prevent the use of safe, reversible and highly effective contraception.

The proper use of these methods ultimately serves to reduce unintended and unplanned pregnancies, as well as the considerable concomitant morbidity associated with unintended pregnancy.

References

Papers of special note have been highlighted as either of interest (•) or of considerable interest (••) to readers.

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Good overview of unintended pregnancy in the USA.

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Compares multiple methods of contraception and discusses their economic value.

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10.

Another general overview of contraception.

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Overview of Implanon®.

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Good overview of implantable contraceptives.

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26.

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27.

Good review of advances in contraceptive technology.

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30.

Overview of depot medroxyprogesterone acetate (DMPA) subcutaneous formulation.

31.

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32.

DMPA overview.

33.

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34.

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35.

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36.

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37.

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38.

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39.

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41.

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42.

Oveview of the Ortho Evra® patch.

43.

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44.

Good randomized, controlled trial comparing the contraceptive patch and oral pill.

45.

Pierson

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46.

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47.

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48.

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49.

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50.

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51.

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53.

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54.

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55.

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56.

Good article on the vaginal ring.

57.

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58.

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59.

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60.

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61.

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62.

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63.

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64.

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65.

Curtis

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66.

Interesting review of contraception for women with certain medical conditions.

67.

Andersson

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68.

Levonorgestrel intrauterine system (Mirena®), package insert. Berlex Laboratories, Inc., Montvale, NJ, USA (2000).

69.

Critchley

Wang

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70.

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71.

Monteiro

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Diaz

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72.

Jensen

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73.

Lockhat

Emembolu

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74.

Petta

Ferriani

Abrao

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75.

Andersson

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76.

Luukainen

Allonen

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77.

Hubacher

Grimes

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78.

Good overview of the various noncontraceptive uses of intrauterine systems.

79.

Monteiro

Bahamondes

Diaz

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80.

Inki

Hurskainen

Palo

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Non-Oral Reversible Contraceptive Methods

Abstract

Keywords

Progesterone implants

Implanon®

Norplant®

Jadelle®

Hormonal injections

Combined hormonal injections

Progestin-only injections

Other hormonal methods

Contraceptive patch

Vaginal contraceptive ring

Intrauterine contraception systems

Copper intrauterine device

Levonorgestrel intrauterine device

Male methods

Conclusion

Future perspective

References