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Contraception: Treat it With Options

By Susan Peterman

PHILADELPHIA, P.A. -- April 10, 2006 -- Contraception will be increasingly managed by internists through emergency contraception (EC), stated Anne M. Eacker, MD, and Eliza L. Sutton, FACP, both of the University of Washington, at an opening session of the American College of Physicians - American Society of Internal Medicine annual meeting (ACP-ASIM) held here April 6-8.

The use of EC, combined oral contraceptives (COCs), and newer delivery systems for contraception, such as the Ortho Evra Birth Control Patch and the NuvaRing were surveyed, with particular concern for the internist who prescribes contraceptives to women of various ages and risk factors.

While EC is underused in internal medicine practices, these methods are responsible for over a 40% decline in abortions,, notes Drs. Eacker and Sutton. While the copper IUD is the most effective method of EC, hormonal methods such as levonorgestrel, or the Yuzpe Method, which uses ethinyl estradiol, are best used within 24 hours of unprotected intercourse and carry lower risk of complications than the intrauterine device (IUD).

Careful evaluation of risk factors, Dr. Eacker noted, is necessary before prescribing COCs. The risk of breast cancer, scientific studies show, is only slightly higher in current users of COCs versus ever-users, and dissipates 10 years after discontinuing them.

Studies have demonstrated the protective effects of COC use in endometrial and ovarian cancers. Women who present with concerns of weight gain when considering use of COCs can be presented with the evidence which indicates that weight gain in COC users may not be significantly different from those who use non-hormonal methods.

Increased risk of venous thromboembolic events (VTEs) has been shown to occur in the first year of use. Patients who use transdermal patches show no greater incidence of VTEs as compared to patients on low doses of estrogen. Which estrogen estradiol to use should take into account risk of VTE, Drs. Eacker and Sutton noted.

Which COCs should an internist prescribe? Reasonable first-choice pills would be second-generation progestin, all of which are available in generic form. (estrogen, norethindrone, levonorgestrel). Dr. Eacker insists "The time to start using them is today. Self-reported compliance far exceeds that indicated in a study in which a device recorded compliance. Only 19% to 33% of patients missed not one pill."

Completion of Papanicolao and pelvic exams should not delay or be required for prescribing COCs, although many physicians continue to wait for these results, Dr. Eacker notes. However, the patient's blood pressure should be checked before prescribing and intermittently thereafter.

Dr. Sutton noted the American College of Gynecology (ACOG) recommends that smokers who are >35 years of age consider methods of contraception other than COCs. Dr. Sutton recommends, as does ACOG and the World Health Organization, that women who experience migraines or are at risk of stroke consider other methods of contraception since the risk of COC use in these women outweighs the benefits.

Depo-medroxyprogesterone (DMPA), such as Depo Provera, administered in a transdermal patch to be placed on the upper arm or buttock, is the most cost effective contraceptive, especially with generic availability. However, an FDA "black box" warning noted that fertility can be delayed up to 22 months after use is stopped, and the product has been linked to decreased bone mineral density.

New to the market is a lower-dose DMPA, Depo-Subq. While more expensive, Depo-Subq can be self-administered, and is easier to remove than its DMPA predecessor.

These newer methods of administration, such as the patch, have been shown to have increased efficacy in preventing pregnancy as compared to COCs, and improved compliance, especially in adolescents. However, increased exposure to ethinyl estradiol with the patch was noted, but whether this poses a risk is not yet clear, according to the presenters.


[Presentation title: Contraception: What the Internist Should Know]

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