2024 contraceptive updates

Introduction

In the US, initiating access to moderately and highly effective contraceptive methods has historically required access to a health care provider. Systemic, institutional, and individual barriers impede access, such as lack of insurance coverage, transportation and appointment logistics, lack of providers, provider coercion, need for confidentiality, and legislative obstruction.

Since the 2022 Dobbs v Jackson Women’s Health Organization decision by the US Supreme Court, anti-choice groups have challenged mifepristone regulatory approval and distribution through multiple pathways, one of which uses the Comstock Act. This 1873 anti-vice law was originally intended to criminalize mailing of “obscene articles” including contraceptives and abortifacients.¹ Though the Supreme Court later removed Comstock’s contraceptive references in Griswold v Connecticut (1965), Justice Clarence Thomas argued in his Dobbs concurring opinion that the court should reconsider all its substantive due process precedents including Griswold and the rulings legalizing same-sex marriage.² The Republican Project 2025 platform outlines reinstitution of the most literal enforcement of the Comstock Act as critical for a future conservative presidential administration.³

With the criminalization of contraception looming now more than at any time during the past 5 decades, putting power back into the hands of our patients is more important than ever. Exciting efforts to improve access to self-directed initiation, administration, and removal of effective contraceptive methods have come to the forefront in the past year. In this 2024 contraceptive update, we review key publications related to patients’ options to engage with contraception outside of the formal health care system via over-the-counter (OTC) oral contraception and intra-uterine device (IUD) self-removal. Additionally, if patients are going to be managing moderately and highly effective contraceptive methods on their own, we must understand how information is accessed outside of typical health care settings.

OTC progestin-only pill demonstrates high rates of correct user self-selection

For decades the birth control pill has been widely accessible as an OTC medication in more than a hundred countries worldwide, but not the US.^4,5 In a 2011 nationally representative survey of adult women at risk of unintended pregnancy in the US, at least one-third reported difficulty obtaining a prescription for hormonal contraception.⁶

After decades of advocacy by reproductive justice organizations, community activists, researchers, and health care professionals, Opill (Perrigo) became the first OTC birth control pill to hit commercial shelves in the US in early 2024, nearly 50 years after initial regulatory approval of birth control pills. This product is a progestin-only pill (POP) containing norgestrel 75 mcg in a 28-day pack; users take 1 pill daily without any days off. The pill was marketed in the US as Ovrette years ago; it never had any regulatory issues but was simply no longer being sold in the US.

As part of the OTC Opill approval process, 2 studies were conducted to assess the ability of potential consumers to determine their own eligibility using only the OTC label without health care provider supervision.⁷ According to the US Medical Eligibility Criteria for Contraceptive Use, the only POP absolute contraindication is history of breast cancer.⁸ The draft OTC label includes this warning along with precautions for allergies, liver problems, unexplained abnormal uterine bleeding, and current pregnancy.

In this study, participants reviewed the label and completed a survey to assess if they could correctly self-select for OTC POP use. Investigators evaluated outcomes among 2 specific populations: 1772 all-comer participants who self-reported their medical conditions and 206 women with a known history of breast cancer. A panel of 3 obstetrician-gynecologists (ob-gyns) trained in family planning reviewed each participant and determined whether the use of Opill was clinically appropriate.⁷

Almost all individuals correctly self-selected POP use

Almost all (n=1670, 94%) all-comer participants met the label criteria for Opill use. Of the 102 (6%) who did not meet label criteria for use, 36 (35%) incorrectly selected to use it. However, after the ob-gyn panel reviewed the cases, 24 of these 36 participants were reclassified as clinically acceptable for POP use. Thus, 12 of 1772 (0.7%) participants incorrectly self-assessed that they could use the pill (Figure 1) of which only 1 had the absolute contraindication of breast cancer.⁷

Of the 206 participants with a history of breast cancer, 199 (97%) correctly selected not to use Opill. The ob-gyn panel determined that 1 of the 7 incorrect selectors was at low risk for harm because her breast cancer was not hormone-sensitive and was in remission.⁷

Implications for practice

Evidence confirms that most individuals are clinically eligible to use POPs such as Opill and can accurately determine contraindications without health care provider supervision. Given the safety of POPs, the benefits of improved access strongly outweigh potential risks. This evidence should encourage clinicians to continue to advocate for OTC status of other contraceptive methods.⁷

In these studies, participant inclusion criteria required the ability to read, speak, and understand English. Less than half of individuals in the all-comer population self-identified as having adequate health literacy (n=780, 44%), making the results generalizable. However, testing did not include participants whose primary language is not English. Future development of OTC contraceptive products should ensure equity in labeling, directions, and study design.⁷

Some patients are motivated to perform IUD self-removal outside of clinical settings

Long-acting reversible contraceptive methods (LARCs) such as the IUD and implant have continued to rise in popularity. LARCs typically require a health care provider for procedural insertion and removal, which introduces financial and logistical barriers. In addition, patients seeking early LARC removal may encounter some health care provider resistance or denial.^9,10 The option for LARC self-removal outside of the formal health care system can help maintain individuals’ reproductive autonomy. IUD self-removal has been previously evaluated in a clinical setting with 190 of 322 patients (59%) willing to try and 36 of 190 patients (19%) successful¹¹; no studies had previously investigated nonclinical settings.

In this study, the investigators designed an online resource guide for IUD self-removal and evaluated the likelihood of successful IUD self-removal with or without use of the guide. Secondary objectives were the determination of the acceptability of IUD removal and the characterization of successful attempts. Participants with an IUD in place desiring removal were recruited via social media and given a choice between a clinical or nonclinical setting for their planned self-removal attempt. Participants were then randomly assigned to either use the guide developed by the research team or not use it. Participants randomly assigned to use the guide were able to access it via cell phone or tablet. Participants randomly assigned to not use the guide were permitted to use any outside resources of their choosing. Using 19% as the anticipated incidence of successful IUD self-removal without the guide, the study was powered to detect an increase to 44% of successful self-removal with use of the guide.¹²

Participants who selected the clinical setting were given 15 minutes to attempt self-removal at the clinic site, after which they could either request more time or clinician removal. Participants who selected the nonclinical setting could select any location and had unlimited time for removal. They were required to submit a photo of their successfully removed IUD for confirmation.¹²

Thirty percent of all IUD self-removal attempts were successful

Of the 116 participants who attempted self-removal, most (n=93, 80%) participants chose to attempt their IUD self-removal in a nonclinical setting, citing convenience (82%), comfort (62%), and a desire to avoid a clinic visit (31%). Self-removal attempts were successful overall in 35 participants (30%) and were more likely to be successful in nonclinical settings (33/93 [35%]) than clinical settings (2/23 [9%]; P = 0.01) (Figure 2).¹²

The 81 participants who were unable to perform self-removal most commonly reported the primary reason as an inability to feel (n=27, 33%) or grasp (n=28, 35%) the strings. Thirty-one (38%) of these participants used a study clinician for removal, 10 (n=60, 17%) from the nonclinical setting and all 21 from the clinical setting. During these 31 removals, 5 (16%) were uncomplicated with 4 (13%) lacking visible IUD strings and 1 (3%) with IUD breakage during removal (copper IUD). There were no reported complications in any self-removal attempts regardless of whether the attempt was successful.¹²

Individuals seek information about IUD self-removal outside of the health care system

The study-provided IUD self-removal guide was used by 63 participants and almost all (n=61, 97%) found it helpful. However, successful removal did not differ between those with and those without the guide (20/63 [32%] vs 15/53 [28%], respectively; P = 0.7) (Figure 2). Some participants used additional outside resources (20/63 [32%] with the guide and 29/53 [55%] without it), most often online materials (85%) or a friend who had experience with IUD self-removal (17%); none sought provider advice.¹²

Overall, successful self-removal was associated with shorter mean duration in removal time (5 minutes vs 15 minutes; P < 0.001) and with the desire to not pay for a clinic visit (46% vs 22%; P = 0.01). Successful participants reported that self-removal was easy (60%) and comfortable (54%); they would try it again (97%); and they would recommend it to a friend (91%). Those who were unsuccessful also reported they would try it again (73%) and recommend it to a friend (54%).¹²

Implications for practice

IUD self-removal was more successful overall in this study than previously found; however, the success rate in the clinic was lower. These data provide more evidence that some individuals are highly motivated to remove their own IUDs, and that doing so in a nonclinical environment may improve their likelihood of success. An important limitation of this study is that it did not include outcome information for those who did not follow up after an unsuccessful attempt in a nonclinical setting. Uncomplicated patients can be encouraged by their health care providers to try IUD self-removal if it is something that they are interested in. In addition, self-removal success rates neared 40% for those with palpable IUD strings, highlighting the importance of not cutting IUD strings short. Package labeling recommends cutting threads to 3 cm in length. We encourage clinicians to measure threads to better understand just how long 3 cm really is to maximize the ability for interested patients to attempt self-removal.¹²

Social media is a powerful tool for contraceptive knowledge outside of the health care system

Most reproductive-age individuals do not first encounter reproductive health information from a health care provider, but, instead, by engaging with their communities.¹³ The experiences of family members, friends, coworkers, and social networks are valuable and influential. In the era of social media, this network extends to the online world. People are constantly online not only for personal entertainment but also to acquire information relevant to their lives and current events around the world.

TikTok is the newest short-form video platform to explode in popularity, with at least 2 billion users in 2024.14 Nearly 40% of Generation Z uses TikTok and Instagram to seek information rather than a traditional search engine.¹⁴ What makes TikTok unique compared with previous video platforms is that upon opening its app, users are automatically shown videos based on an algorithm, rather than content from creators to whom a user has subscribed. This means that TikTok users are constantly introduced to new content, information, and knowledge every time they open the app.

Most TikTok contraceptive content includes users’ personal experiences

Researchers have begun to characterize the contraception content available on TikTok. Two studies screened TikTok for English-language videos using search terms related to contraception and coded videos for type of content and whether their content creators were health care providers (HCP).^15,16

Stoddard et al. analyzed videos tagged with a variety of contraceptive terms (#iud, #nexplanon, #birthcontrolpills, #nuvaring, #birthcontrolpatch, #depo, #birthcontrol, #planb).15 Of 700 total videos, 365 (52.1%) included a patient’s personal experience and 351 (50.1%) discussed the logistics of obtaining a contraceptive method. Of 248 (35.4%) videos discussing contraceptive adverse effects, 194 (78.2%) involved an individual describing their personal experience.

Shackleford et al. analyzed videos specifically related to oral contraceptive pills (OCPs).¹⁵ Of 574 total videos, 205 (35.7%) were about combined OCPs, 176 (30.7%) were about POPs, 150 (26.1%) were about an unspecified type of pill, and the remainder discussed other contraceptive methods.¹⁶ The most common content included adverse effects (n=356, 62%) and pregnancy prevention (n=119, 20.7%). Most videos were considered educational (n=361, 62.9%) or patient testimonials (n=164, 28.6%).

Health care providers are more likely to create educational content

In both studies, content created by HCPs was more commonly educational compared with non-HCP videos. Stoddard et al. found that HCPs created 135 (19%) videos and 125 (92.6%) of these were considered educational. Of content made by non-HCP (n=565), only 127 (22.5%) were educational. Of the 43 most-viewed videos (more than 5 million views), 20 (46.5%) were created by HCPs and 26 (60.5%) were considered educational. The most viewed video overall was a plastic model demonstration of an IUD insertion.¹⁵

Shackleford et al. reported that HCPs were 86 times more likely to post educational content compared to non-HCP (aOR=86.31, 95% CI, 26.93-276.65). Videos by HCPs had significantly higher quality and reliability of information scores compared with non-HCP videos (P<0.001) but had significantly lower views, likes, and comments (P < 0.001).¹⁶

Implications for practices

TikTok has the power to create viral worldwide trends that consume the cultural zeitgeist and influence public opinion. Given that many individuals may understandably have inherent skepticism of the medical system, TikTok is a free and easily accessible resource. TikTok allows people to share and discuss personal experiences and seek validation from one another. Viewers are likely to trust the quality of information disseminated by content creators that they know, and this content is extremely likely to reach our patients and impact their perceptions of different contraceptive methods before they ever communicate with a health care provider. Knowing there is a significant amount of educational content or content by HCP on TikTok, clinicians should not immediately issue a blanket dismissal of online information. Instead, clinicians should be aware of what may be circulating and prepare to answer patients’ questions with thoughtfulness. As more patients are interested in taking their reproductive health into their own hands outside of the confines of the traditional health care system, health care providers should be prepared to adapt their own knowledge and practices to support patients and accommodate this shift. We suggest that HCPs embrace the current era of social media and familiarize themselves with TikTok content so they may use it as a tool to recommend accurate and high-quality videos to patients.

References

1. Felix M, Sobel L, Salganicoff A. The Comstock Act: implications for abortion care nationwide. KFF. April 15, 2024. Accessed August 6, 2024. https://www.kff.org/womens-health-policy/issue-brief/the-comstock-act-implications-for-abortion-care-nationwide/
2. Dobbs v Jackson Women’s Health Organization, 597 US ____ (2022).
3. Talukder S. Project 2025’s distortion of a Reconstruction-era law could enact a national abortion ban. Center for American Progress. June 13, 2024. Accessed August 6, 2024. https://www.americanprogress.org/article/project-2025s-distortion-of-a-reconstruction-era-law-could-enact-a-national-abortion-ban/
4. Grindlay K, Burns B, Grossman D. Prescription requirements and over-the-counter access to oral contraceptives: a global review. Contraception. 2013;88(1):91-96. doi:10.1016/j.contraception.2012.11.021
5. OTC birth control access world map. Free the Pill. Updated March 7, 2024. Accessed August 6, 2024. https://freethepill.org/otc-access-world-map
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7. Sober S, Bradford R, Henrie B, et al. Evaluation of consumer self-selection of a proposed over-the-counter, progestin-only daily oral contraceptive. Contraception. 2024;133:110401. doi:10.1016/j.contraception.2024.110401
8. Nguyen AT, Curtis KM, Tepper NK, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Reports. 2024;73(4):1-126. doi:10.15585/mmwr.rr7304a1
9. Senderowicz L. “I was obligated to accept”: a qualitative exploration of contraceptive coercion. Soc Sci Med. 2019;239:112531. doi:10.1016/j.socscimed.2019.112531
10. Kaneshiro B, Kon Z, Tschann M, Williams A, Kajiwara K, Soon R. Meeting women's requests for intrauterine device and contraceptive implant discontinuation: an exploratory survey of physicians. Hawaii J Health Soc Welf. 2020;79(10):296-301.
11. Foster DG, Grossman D, Turok DK, et al. Interest in and experience with IUD self-removal. Contraception. 2014;90(1):54-59. doi:10.1016/j.contraception.2014.01.025
12. Petrie KA, McCoy EE, Benson LS. IUD self-removal: a randomized controlled trial of a self-removal guide in clinical and nonclinical settings. Contraception. 2024;135:110421. doi:10.1016/j.contraception.2024.110421
13. Lim MS, Vella A, Sacks-Davis R, Hellard ME Young people’s comfort receiving sexual health information via social media and other sources. Int J STD AIDS. 2014;25(14):1003-1008. doi:10.1177/0956462414527264
14. GilPress. TikTok statistics for 2024: users, demographics, trends. What’s the Big Data. November 29, 2023. Accessed August 6, 2024. https://whatsthebigdata.com/tiktok-statistics
15. Stoddard RE, Pelletier A, Sundquist EN, et al. Popular contraception videos on TikTok: an assessment of content topics. Contraception. 2024;129:110300. doi:10.1016/j.contraception.2023.110300
16. Shackleford M, Horvath A, Repetto M, et al. An analysis of oral contraceptive related videos on TikTok. AJOG Glob Rep. 2024;4(3):100364. doi:10.1016/j.xagr.2024.100364