Thomas Kimble, MD

In closing, any other thoughts that you have about particular unmet needs or challenges that are still existing for our patients who are looking for contraception?

: Yes, there are a couple. And one, I think we got a lot of valuable data out of the Contraception CHOICE Project. That was a large clinical trial done in St. Louis where women in the Greater St. Louis metropolitan area could go and get contraception at no cost. There were about 11 centers throughout the St. Louis area. And they could also switch to another method with no cost. One thing that was interesting that they did in the CHOICE Project was there a script that the providers had to use to counsel patients. And the biggest thing about the script at the time was that they switched the counseling from the order that most of us used to do years ago, where we would start talking about condoms and pills, and work our way up to IUDs, and implants, and the more safer, more effective forms of birth control, to they switched it to starting with the safest, most effective types. And they would start talking about LARCs first in the counseling and then go down in efficacy and safety. And what we saw was that by just switching the counseling order, that more people were interested in a LARC method. And the American College of Obstetrics and Gynecology recommends LARC first, and so it was right in line with that. I think we got great data from that. It helped us out with some provider bias, I call it sometimes. And there are still some gaps there, but another gap is in contraception coverage. We made leaps and bounds with the Affordable Care Act in that regard, but there's still a gap there. And there are still people, as you alluded to before, that they have state-sponsored coverage, but it's only temporarily. And maybe after 6-week postpartum, or a 3-month window, their insurance is going to end, and where are they? Unless they already have a LARC method, they're hung out there. And there are still gaps. And then the third one is getting to us. Again, we have a shortage of providers, and it's an access issue. We're making small steps. Having some pharmacists in certain states being able to prescribe is going to help us there. Having other types of healthcare- not necessarily providers, not necessarily a physician assistant, or a nurse practitioner, or a physician- but other providers who are well trained, working in conjunction with us, being able to discuss and then maybe initiate birth control, those are also things that can help narrow the gap.

And as you said, getting to us; and we're seeing this certainly, I think, in a lot of healthcare, but telemedicine, it's been a benefit. And a lot of patients, particularly during the pandemic, but even still now for busy lives, can access and obtain some methods of hormonal contraception through telemedicine without requiring them to travel or go to an in-person visit. And then the other thing, which again, we're also seeing some strides in that direction, but further evidence for extended duration of use for our LARC methods for those patients who are pleased with them and happy with them, and if they can keep them in for longer and longer, and there's evidence that it's safe and effective to do so. Each time one of the levonorgestrel IUDs is approved for extended use, a lot of my patients are like, "Amazing. Another year. So happy." I'm hoping we'll continue to see more data that supports that for some of our other LARC methods.

Well, thank you so much. Thank you for watching 

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Jenna Beckham, MD, MSPH, FACOG, and Thomas Kimble, MD, comment on unmet needs and challenges faced by patients looking for contraception.

Unmet Needs in Contraception

: With counseling about birth control, a lot of the manufacturers will provide anatomic models. They'll provide display samples of the products, like IUDs, or the vaginal ring, or the implant, so that you can show patients, and they get a better feeling, and they're more comfortable about it. And then there are some websites that are good and reliable. I always tell my patients, "Dr Google failed out of medical school, so don't go to Dr Google." But there are some reliable ones. You've got your major organizations, like the American College of Obstetrics and Gynecology, and the Society of Family Planning, the American Society for Reproductive Medicine, all have information that is more geared towards patients and women's health and reproductive health. And another really good website that I like to use all the time is Bedsider.org. That’s a source of reliable information for patients.

We're big fans of Bedsider.org around here. I think it's just an easier thing to remember than sending someone to ACOG or even Society for Family Planning.

It's an easier name to remember. And it has great visuals, great information, and different methods of patients who have different ways they like to learn, of either reading, looking at diagrams, watching little videos, so big fan of Bedsider.org. And for providers- and you mentioned having resident students, as do I- I love the CDC Medical Eligibility Criteria, the color chart. It's an easy thing to track. And that's a little bit more geared for providers in our counseling and thinking about medical conditions and risk factors. But the green, light red, dark red is an easy thing for our eyes to recognize in, deciding certain medical conditions when we take care of more complex patients and finding the right contraceptive method for them.

: I agree. And I use it on a regular basis.

Experts in gynecology share practical resources for patients and providers on the currently available contraceptive options.

Educational Resources on Contraceptive Options

We've already talked a little bit about the differences in these newer methods, but are there any other specific additional benefits that you think of that these specific newer methods or delivery systems might provide to patients?

: Yes. I think there are several benefits. One, we talked about the longer pill intake window with the 2 pills that are new that we discussed, the drospirenone-only pill and the drospirenone/estetrol pill. Now, again, comparing it to norethindrone, which is what's in the mini-pill, which has an 8- to 9-hour half-life, the progestin has a 30-hour half-life in the drospirenone-only pill. And then in the drospirenone and estetrol pill, the estetrol has a 28-hour half-life. That is great. Now, patients have a wider pill intake window if they happen to miss a pill. As you also mentioned, you can cycle patients now, whereas the mini-pill, they have to take it continuously because of the short half-life. Now, they can take it in an extended cycle regimen. And that provides our patients with a regular, scheduled period, which is convenient for more people. And then with the patch, we've got better adherence system; we've got lower hormone levels, and nowadays, less is more when it comes to the dosing of hormones; and other delivery methods, like the new vaginal gel.

In your practice and experience, how satisfied do you think patients are with currently what's available for contraceptive options?

: I do see a higher satisfaction. Historically, when we used to prescribe birth control pills for our patients, there was about a 50% continuation at 6 months. With increased tolerability, with lower hormones, people are having less adverse effects, they're having less risks and concerns, with the different options as well, that continuation rates have really increased.

: Like you said, the first pills which we've thought about for a long time as being, quote-unquote, "birth control," people think those are better tolerated. But as you said, and as we've discussed here today, there are more and more options available. We do still- I know you surely see them- there are those patients who have tried everything and have had an adverse reaction to pretty much everything that's available on the market, and those still are puzzling conundrums, and there are some patients who struggle still to find a satisfying option. But as you said, we've seen more and more satisfaction and people continuing to use their method, although still, some people do change. What do you see in your practice in terms of any kind of trend of when or how patients maybe switch from one method to another?

: Yes, I do, although again, I'm not seeing people switch as often as I used to years ago. And this is just anecdotally in my own clinical practice. But you've got the group who were prescribed birth control pills because, as you mentioned, that was just "birth control." And I still talk to other providers, my resident doctors, my medical students. Sometimes, when they want to say, "birth control," they say "OCPs." And I must correct them. "Well, let's get away from saying 'OCPs' when you really want to say 'contraception' because there are so many other options." We have that group that the person they saw, their prior provider, that's primarily what they prescribed. And they come to us, and then they hear about some of the other newer things, and I think we see a little bit more of that because of direct-to-consumer marketing. And they want to switch to this other thing that they've heard of or this other thing that their girlfriend or their sister is taking. We have some people who are on a LARC method, but again, they're reaching a milestone, and they want to either start or extend their family, and they know, maybe in 3, 4 months, they want to start trying for a pregnancy. And they want to get off their LARC method, use something temporary in the meantime, until they're ready to start. I see that group as well. But for the most part, I think people tend to be more satisfied than they were historically.

I agree. I think sometimes, for those patients who are using contraception not only for pregnancy prevention, but we talked about it earlier, about bleeding control, or if they have dysmenorrhea, some of those patients maybe struggle a little bit more to find just the right method because it's not just about preventing pregnancy, but it's controlling some of those other symptoms. And they may switch around a little bit more. We are still seeing, I think at least in our patient population, patients who have certain government insurances that only cover them through pregnancy, and then for a certain period of time after pregnancy, that may get a LARC, but then no longer have the coverage. And they are more expensive if you're paying out of pocket compared to buying birth control, OCPs, pills, over the counter- or not over the counter, but prescribed, buying them from a pharmacy, out-of-pocket cost. There are still some socioeconomic factors that may cause a shift or a change in method that perhaps might not be that patient's choice. But as you said, if it's just purely, I think, satisfaction with the method, it does seem that patients tend to find that and stick with it a little bit more, I think likely attributed to the fact that we have more options available, so they can find one that works better for them.

Drs Jenna Beckham and Thomas Kimble review the benefits of newly approved contraceptive systems, such as use in women with higher BMIs and ease of access.

Benefits of Recently Approved Contraceptives

Jenna Beckham, MD, MSPH, FACOG, and Thomas Kimble, MD, discuss patient misconceptions around contraceptive options and the impact on adherence.

Impact of Routes of Administration on Contraceptive Adherence

: There's a couple more that are still kind of new in the last few years. There's a new formulation of the contraceptive patch. What do you think about that one?

: That's a good one also. Transdermal birth control, the first one that was introduced, it was great. It was a game changer. It became extremely popular when it was first launched, but then there were some concerns. There were some concerns about increased cardiovascular risks with it. That is also an example of when statisticians went back and looked at the data, and they controlled for other risk factors. That risk was not as exaggerated as we initially thought. However, levonorgestrel is the progestin. That is a tried-and-true progestin. It's been around for decades. It's what we would consider a second-generation progestin. And then there's our ethinyl estradiol; we're also very familiar with that. That was one change. The other change is that the adherence system is a little different. When the initial contraceptive patch was launched, some people had issues with it coming off. Didn't like it. It got a little sticky. This one has an adherence system that is improved, and we think that increases the tolerability for patients more.

And although we said estrogen is relatively safe for most patients, this does have a slightly lower dose of that, so maybe if you have a patient who is sensitive to it, or particularly concerned about it, it's just another option for those patients.

: And that is absolutely a counseling point for me. This has a lower estrogen than the other patches on the market.

So those are all the hormonal methods that have been released recently. And then there's this new vaginal gel that does not have hormones but is another option for patients to use.

: That gel has been around for a while in development. My disclaimer for all the other 4- I was an investigator in their development. This one, on the very early phases, I was involved with it. It is great to have another option. Some of us get maybe a little too focused on, "Everybody needs a LARC." Well, they're not for everybody, and we need a variety of different types of birth control. It was great that we got this option. It is effective as a barrier method of birth control, as barriers are. One of the best things is the commercials, right?

: I really love some of the commercials for it. But it's a great option. It does require a prescription for use, as opposed to other spermicides. I've run into a barrier with getting coverage for it, and then we learned a little trick that when you're writing it for your patients, if you get any bounce back from their carrier, say that she's tried other spermicides and didn't tolerate them well. And if you can document that, then they do tend to cover it more often.

You're right. We, certainly, especially with our OB/GYN doctor hats on, are fans of LARCs. I tell all my patients it's my personal and professional favorite. But they're not for everyone, and the contraceptive method that works for a particular patient is the one that they like and that they're going to use. It is good to have those other options. The struggle with it- I always think about, as we already talked about, sometimes it's hard to remember to take a pill every single day. This has some of those similar adherence barriers or challenges, that you must use it with every act of sexual intercourse, and that may not always be either feasible or just something that patients may not remember to do. But for those who are motivated to use it, it is nice to have another non-hormonal option available.

: It is, and it's a great temporary option as well, I think. I had mentioned earlier, some people, they plan on getting that degree soon, or the promotion, and they are timing their pregnancies, and they know within a couple or a few months that they may want to attempt a pregnancy. And so LARCs aren't for everybody. I think they're great. That is what I try to encourage usually. But there is a need for some of these temporary and daily options.

Drs Jenna Beckham and Thomas Kimble comment on hormonal patch and vaginal gel contraceptives.

Hormonal Patch and Vaginal Gel Contraceptives

There's the new version of the contraceptive ring that you can use for up to a year. What do you think about that?

: The segesterone ethinyl estradiol vaginal ring was initially developed by the Population Council and that's exciting. It's the first new transvaginal ring that's been available and it's good for every year. Patients still remove it for a week every month so they still have planned scheduled periods just like they would with the initial atomic estriol ethinyl estradiol vaginal ring. That is not different. What is different though is the initial ring you used it for the 3 weeks and then you threw it away. This ring, it comes with a little retainer case and so you use the ring and then you place it in the case for the 7 days for the week. That's when most people will have a withdrawal period and then after 7 days out you take the same ring, you replace it, and you can use it for the next month. You can continue doing that for a total of 12 cycles or 13 cycles so it's great. You don't have to go back and forth to the pharmacy. For some people it's more cost effective as well.

Like you said it's nice to not have to worry about picking up a refill, going back to the pharmacy and also, it's maybe a little bit more earth friendly that we're not throwing things away every month.

: Now there's the newer combination pill that has a different formulation of estrogen.

: Estetrol, the drospirenone and estetrol tablets; that's a really fascinating new formulation and probably appeals to maybe your history buff interests.

: It's fascinating as well. We talked about all the benefits of drospirenone and it is having a longer half-life so just to go back to that; the mini pills' half-life is 9 hours, the half-life of the drospirenone is 30 hours, huge difference.

: Estetrol has a much longer half-life than ethinyl estradiol one. It is a natural or a native estrogen so there are 4 native estrogens. I'm going to take everybody back to that second-year physiology class, right? I love asking my medical students and residents this question; what are the 4 native estrogens? You have estrone, that is the one that we kind of think of more so with menopause. You have estradiol, that's the main estrogen that we refer to when we talk about the natural estrogen. That's what the ovary produces. You have estriol which is produced by the placenta in pregnancy and then you have estetrol. It all has to do with the number of books, carboxy groups and that's where you get the medroxy groups, that's where you get the estrone, estradiol 2 groups, estriol 3 groups and estetrol 4. It is very interesting. It is produced by the fetal liver and only in higher order primates. That is the only place we see this in nature. We don't know exactly why it exists, what its function is but it's very high in the fetal circulation. When a patient takes estetrol birth control, it is pretty much the same level as in pregnancy, and we think that lends to the safety. One of the great things about estetrol as an estrogen is it is not metabolized by the liver. Other estrogens are metabolized by the liver, so they activate the liver, and that's where you get the other issues that come in. That is where you get the clotting factors.

: That's where you get the lipid and the triglyceride production and some of the other concerns. that's also where you get stimulation of breast tissue. Well, estetrol is not metabolized by the liver. It is metabolized within cells, so that makes it a little different. But it's also what we call a NEST, a Native Estrogen with action in Selective Tissues, and that's interesting because it does not bind to estrogen receptors on cells. And that's where you have the issues with breast stimulation, which makes it a risk factor for breast cancer.

: Well, with estetrol, it binds to nuclear receptors, it's a whole entirely different mechanism on how it works, and you don't have some of those concerns. Well, you don't have the bad things. You do have the good things. Tissues that are stimulated by nuclear receptor, which is what estetrol does, would be the endometrium, the uterus, cardiovascular tissues, the vagina, and the brain. Those are things where you want somebody to take estrogen and have the positive effects, and you do get that. It also has a longer half-life; it's about 28 hours. They married it with drospirenone, with the 30-hour half-life I mentioned. Again, this is a pill that also has a lot of forgiveness.

Experts in gynecology review other contraception methods, including the contraceptive ring and drospirenone and estetrol tablets.