Practice recommendations
- Consider an oral contraceptive for women who would prefer less frequent menstrual periods (A).
- An intrauterine device may be appropriate for women with prior pelvic inflammatory disease, ectopic pregnancy, or an abnormal Papanicolaou (Pap) smear result, and for many adolescents (A).
- There are no medical contraindications to progestin-only emergency contraception (A).
Strength of recommendation (SOR)
- Good-quality patient-oriented evidence
- Inconsistent or limited-quality patient-oriented evidence
- Consensus, usual practice, opinion, disease-oriented evidence, case series
A 35-year-old woman with a family history of breast cancer (mother diagnosed with breast cancer at age 55) requests your help in choosing an appropriate method of contraception. She is a nonsmoker, has a body mass index of 25, and dislikes taking pills. Which options would you recommend to her? Are there any that you would rule out?
Helping your patient make the best choice requires that you be as up to date as possible. In this review, we discuss select new options in a clinically relevant manner. Specifically, we explore the newest oral contraceptives (OCs), including extended-cycle, continuous, and shortened hormone-free interval formulations. In addition, we review the latest data and updated recommendations for the contraceptive patch and ring, intrauterine devices (IUDs), implants, and emergency contraception (TABLE). We conclude by describing appropriate choices for the patient described above. (See “So what do you recommend?” on page 803.)
Oral contraceptives
Since OCs became available in the 1960s, the standard regimen has been 21 active pills followed by 7 placebo pills, simulating the average unassisted monthly menstrual cycle in which “menstrual” or withdrawal bleeding occurs. Clinicians have successfully lengthened intermenstrual intervals with OCs, without incurring additional risk, to control symptoms of endometriosis, premenstrual syndrome, and menstrual-withdrawal headaches, or to satisfy many patients’ preference for fewer menses per year.1,2
Any monophasic active OC can be used without a placebo interval to delay menses for extended periods. Until recently, such usage was off-label. Based on extensive safety and efficacy studies, however, the US Food and Drug Administration (FDA) has now approved several formulations for extended-cycle and continuous-cycle use.
Extended-cycle OCs: Fewer menses per year
Two FDA-approved extended-cycle OCs are available: Seasonale and Seasonique.3,4 Both products enable 4 scheduled menstrual intervals per year, as opposed to about 13 with 28-day cycles. Each regimen uses 84 consecutive pills of levonorgestrel 0.15 mg and ethinyl estradiol (EE) 0.03 mg, followed by 7 placebo pills (Seasonale) or 7 pills of EE 0.01 mg (Seasonique).
Other potential advantages. With Seasonique, the average length of menses is 3 days, which is shorter than the average unassisted menstrual period. Seasonique’s 7 additional low-dose estrogen pills may help decrease estrogen withdrawal symptoms, such as headaches in women with menstrual migraine and vasomotor instability in perimenopausal women. Though this effect has also been reported with other OCs containing low-dose estrogen during the traditional placebo week, specific supportive evidence is not yet available for these formulations.5,6
Disadvantages to address. With Seasonale and Seasonique, unscheduled spotting or bleeding has been reported—especially during initial use—at rates considerably higher than those associated with comparable traditional OCs.3,4 Effective counseling will help ensure patient compliance and satisfaction.
During the first cycle (days 1-91), about 65% of women taking either formulation reported ≥7 days of spotting, and 29% to 35% reported ≥20 days of spotting. By the 4th cycle (days 273-364), 39% to 42% of patients reported ≥7 days of spotting and 11% to 15% reported ≥20 days of spotting. For patients taking comparable progestin and EE doses in traditional monthly regimens, 38% reported ≥7 days of spotting and 6% reported ≥20 days of spotting during the first cycle. Thirty-nine percent and 4%, respectively, reported spotting during the fourth cycle.3,4
Continuous OC: Consistent hormonal milieu
Lybrel, the only FDA-approved OC for continuous use, contains levonorgestrel 90 mcg and EE 20 mcg; pills are taken daily throughout the year.7 Progestin and estrogen doses are lower than those found in many monthly OCs and in all extended-cycle formulations. A phase 3 trial of 2134 women reported the safety and efficacy of Lybrel to be comparable to cyclic OCs.8 Again, unscheduled bleeding and spotting rates were relatively high but decreased at pack 3 from 47% and 26%, respectively, to 21% and 20%, respectively, at pack 13. Predictably, amenorrhea rates increased from 27% to 59% between pack 3 and pack 13.
Shortened hormone-free interval OCs: Less breakthrough ovulation
The shortened hormone-free interval OC is an alternative for patients who want regular, but shorter, menstrual intervals. With 24 active and 4 placebo pills in each cycle, this regimen suppresses the pituitary/ovarian axis to a greater extent than traditional 21/7-day regimens and thus lowers the rate of breakthrough ovulation.9