Evolution of Contraception Options


Kate White, MD, MPH, reviews the current contraceptive landscape and highlights the benefits of progestin-only contraception options, especially in women with higher BMIs or those concerned about missed pill windows.

Kate White, MD, MPH: Patients are constantly asking me about their birth control choices. Why don’t they have more choices? I talked to them about how even in the course of my own career, I have seen the number of choices people have relatively explode. There are so many more choices available today than there were 20 years ago. One of my favorite new methods to talk about with patients is a new progestin-only pill that’s on the market. It contains drospirenone, which is one of the more popular progestins to use in oral contraception these days. It’s a pill combination that is what’s called 24/4 dosing. There’s 24 days of active pills and four days of placebo. Not only do people get to stay on the method with this formulation, patients have a longer missed pill window than with other progestin-only pills. In the past, we used to have to counsel patients that if they took their progestin-only pill any more than 3 hours late, it was like they didn’t take the pill at all and they needed to use backup contraception for a few days. With this pill, people can miss the pill for up to 24 hours, which is much easier by having a longer window of time that patients can take the pill and have it remain effective. It’s more aligned with how people live their lives these days. It is very hard to take a pill at the same time every day for an indefinite period of time. A pill like this is much more user-friendly. Plus, because it doesn’t have estrogen in it, the number of people who can use it safely, is even wider than typical birth control pills. Another new innovation and contraception has been a new vaginal ring that has progesterone and ethinyl estradiol in it. We talk about this as being the 1-year ring that instead of having to go back to the pharmacy every month for a refill, you can use the same ring for an entire year. You use it in a similar way that you use other birth control methods with hormones, where you’re taking it for 3 weeks and then it’s out for 1 week. But the fact is that you can just store it on your bedside table and don’t need to go back to the pharmacy, which makes it incredibly convenient. This method does contain estrogen and has a contraindication for people with a BMI over 30. It is safer for youth and for people who are not obese.

The theory behind this one is that estradiol may have a lower clotting risk, but the company has not proven this yet. It is still theoretical. The risk profile is still the same.

There’s also a new combined hormonal contraceptive on the market. This one has drospirenone, one of everyone’s favorite new progestins instead of ethinyl estradiol, which is the estrogen found in every other combined hormonal contraception. This one uses a novel estrogen called estradiol. The hope is that this form of estrogen may be less likely to cause blood clots, which of course, is one of the things that people who use estrogen-containing birth control are worried about. We don’t know yet and we’ll have to see how patients experience this method over time, but it is very exciting that the idea of possibly having a method that has a lower risk profile than other methods on the market.

A lot of patients don’t realize that it is normal to use more than one contraceptive and a lot of patients don’t realize how common it is to switch birth control methods. When I ask patients about their past history of birth control use, some of them are almost embarrassed when they tell me that they’ve used a few different kinds and then they’re shocked when I tell them that the average pregnancy capable person uses 3 to 4 methods of birth control over the course of their life. People can change their methods for all kinds of reasons. They have relationship changes that change what they want to use. They want reversibility to be different. Let’s say that they want to conceive in the near future so they want a method that they can stop whenever they want to. Or conversely, they don’t want to get pregnant for a while and want a long-acting method that they don’t need to think about. Also, they may have different goals for their birth control methods at different ages in life. For instance, when you’re younger, you may want acne control and control of menstrual cramps. As you’re getting older, maybe more towards perimenopause, you either want control over the menopausal symptoms or even cancer prevention. It’s important to let patients know that contraception use is a journey and that their needs may change over time and that changing is totally normal, and that, as your provider, you’re going to be with them every step of the way.

There are many places where both providers and patients can find out information about the array of available contraceptive options. There are nonprofit organizations like the Reproductive Health Access Project, Bedsider.org [Bedsider Birth Control Support Network], and picck.org [Partners in Contraceptive Choice and Knowledge] that have a lot of good information including things like decision aids and method information sheets that are helpful for both providers and patients. When it comes to thinking about the safety of various methods, our go-to is the medical eligibility criteria published by the Centers for Disease Control and Prevention (CDC). The CDC publishes a handy full-color chart as well as a guide to all kinds of medical conditions, and then, how safe it would be to use a contraceptive method with any of these conditions. There’s also a handy smartphone app that may be the easiest way to access this information. When a provider is seeing a patient, and if they have any medical conditions, you can easily plug those into the app and then get recommendations on what methods for this patient may be safe to use. The CDC rates all methods as 1 through 4, where 1 is that there are no restrictions in using the method and a 4 is where there are absolute contraindications to using that method. A 2, which is where the benefits outweigh the risks of use. And a 3, where in general the risks outweigh the benefits. But there are some subtleties and nuances in that system. It’s a simple system for use, but a lot of providers can bring a lot of knowledge and education to those conversations. It’s a great conversation starter with patients about methods that they want to think about using or methods they want to think about avoiding.

Transcript Edited for Clarity

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