Contraceptive choices: new options in the U.S. market.

Choice in contraceptive options was a static issue in the United States until recently.

It appeared that options were shrinking when Norplant was taken off the market last summer due to perceived negative side effects and when there was a delay in the arrival of the long-anticipated levonorgestrel-containing intrauterine system. Yet new methods are now here, offering greater variety among the old standards. At the same time, efficacy questions about tried and true methods have surfaced. (1)

This article will provide an overview of new methods currently available in the United States, focusing on the efficacy and safety of each choice. It will also highlight standard methods that have gained popularity, explore new problems with standard methods, and discuss other new products on the horizon.

TWO QUESTIONS

Before reviewing contraceptive methods, I feel it is important for readers to think of them in terms of two basic questions: "How well do they work?" and "Are they safe?" Although these are simple questions, the answers are far from easy.

Concerning how well contraceptives work, those who counsel individuals on their choice need to understand the concepts of perfect versus typical use. (2)

Perfect and typical use rates are used to help individuals make realistic personal decisions about the success of a contraceptive choice. For example, women who recognize they are not good at taking a pill on a daily basis would need to consider typical rather than perfect use statistics to determine if they could expect combined oral contraceptive pills to work for them.

Specifically:

Perfect use implies that an individual uses a contraceptive method "consistently according to a specified set of rules" (3)

Typical use reflects on "how effective methods are for the average person who does not always use methods correctly or consistently" (4)

The challenge is not to mix perfect use rates for one method with typical use rates for another.

Safety is also a complicated issue. Those who counsel individuals need to understand that some methods are risky for certain individuals and not for others. For example, women who smoke are at increased risk for cardiovascular disease when they use combined oral contraceptives.

NEW METHODS

The new contraceptive methods currently available in the U.S. market primarily involve hormones. They include Mirena, the progestin-releasing intrauterine system; Ortho Evera, the contraceptive patch; and NuvaRing, the contraceptive ring.

There are also a host of generic oral contraceptives currently available that are confusing clinicians and patients alike. (See box 2.) Many times clinicians may order a brand name with which a woman is familiar only to have the pharmacist substitute an appropriate generic brand from the woman's health insurance plan. The brand names, packaging, and pill colors often confuse users.

Mirena. This progestin--releasing intrauterine system (also known as LNg 20-IUD) releases 20 micrograms of levonorgestrel daily into the uterus. (5) It emits progestin that thickens the cervical mucus, making it impenetrable to sperm. It is reversible but is intended to last for five years.

The consistent release of progestin mitigates some complaints of heavy bleeding and painful periods common with non-hormonal IUDs. It is therefore recommended for perimenopausal women with complaints of heavy bleeding. (6) It is also ideal for many women not at risk for STDs.

In terms of safety, it reduces ectopic pregnancy risk, decreases menstrual bleeding by 70 percent (after initial irregular bleeding), and has a high continuation rate. It many also decrease the risk of Pelvic Inflammatory Disease (PID). (7)

Its availability is an issue for some clients. This is, however, improving. In terms of perfect use, it is 99.9 percent effective in preventing pregnancy. In terms of typical use, it is 99.9 percent effective in preventing pregnancy. In terms of typical use, it is 99.9…