In September, 500 people participated in a contraceptive technology virtual conference. The next day, 5,000 copies of the 16th edition of Managing Contraception were published. Below is some of the news from the new edition.
• The progestin-only pill providing 4 mg of drospirenone
As of early October, the most important change in oral contraception is Slynd, the progestin-only pill that provides 4 mg of drospirenone (DRSP). It is packaged with 24 active pills (DRSP 4 mg) and four inert pills. There is only one absolute contraindication (4 in U.S. Medical Eligibility Criteria [MEC]) for the use of this pill: It should not be prescribed to women with breast cancer. Breastfeeding women may use Slynd immediately postpartum. It is extremely effective, and it is not contraindicated for women at an elevated risk for blood clots (as are women using an estrogen-containing birth control pill).
Slynd is being called the first of the fourth generation of birth control pills. Its suppression of ovulation and its pregnancy rate are equivalent to combined pills. It does not cause increased blood pressure, and it carries no increased risk of venous or arterial clots.
While women who use Slynd experience more days of spotting in the first few cycles, only 3.3% discontinue this pill because of bleeding.
As with any new medication, the cost will be high to start with. But most insurance plans do cover DRSP, and women covered by the Affordable Care Act will not pay out of pocket.
• Self-administered subcutaneous Depo Provera (Depo-SubQ Provera)
Depo-SubQ is a way for women to inject Depo Provera themselves, eliminating the need for frequent office visits. This method has gained popularity during the COVID-19 pandemic, since any healthcare that can be administered at home is encouraged. The U.S. MEC numbers for Depo-SubQ and Depo intramuscular (IM) are exactly the same.
For years, it has been apparent that Depo Provera provided by deep IM injections every three months has the highest discontinuation of any reversible contraceptive. A meta-analysis covering 4,000 women provided Depo IM or taught to inject Depo-SubQ over 13-15 weeks revealed higher continuation rates and lower pregnancy rates in the women who used Depo-SubQ.1
• Levonorgestrel intrauterine devices (IUDs) as emergency contraceptives
David Turok, MD, MPH, FACOG, of the University of Utah, was one of the stars of the Contraceptive Technology Conference. He discussed the use of 52 mg levonorgestrel IUDs as emergency contraceptives.
In one study, 706 women who had a negative pregnancy test were provided either a 52 mg levonorgestrel IUD (Mirena or Liletta) or a copper T 380A IUD. Women were provided a urine pregnancy test to perform after a month of IUD use. One pregnancy occurred in users of the levonorgestrel IUD, and no pregnancies occurred among users of the copper IUD. Turok and colleagues concluded that use of a 52 mg levonorgestrel IUD was noninferior to the use of a copper IUD in pregnancy prevention.2
Before this study, clinicians were reticent about providing a levonorgestrel IUD instead of a copper IUD, known for its extremely low pregnancy rate. Women using a Liletta or Mirena IUD are so likely to experience one of the non-contraceptive benefits attributed to levonorgestrel IUDs that insertion of a 52 mg levonorgestrel IUD may become the preferred method of emergency contraception for many women in the future.
The non-contraceptive benefits for women who use a levonorgestrel IUD may include any of the following: decreased menstrual cramping; as much as a 95% reduction in menstrual blood loss; protection against endometrial hyperplasia and endometrial cancer; protection against the growth of uterine fibroids; decreased endometriosis symptoms; and production of a thick mucus plug at the opening of the cervix, preventing sperm and many infectious agents from entering the uterus. The widespread knowledge of these remarkable non-contraceptive benefits, in addition to the effectiveness of Mirena and Liletta as emergency contraceptives and ongoing contraceptives, has led to more and more women (and their clinicians) choosing these for emergency contraception and ongoing contraception.
Innovation means nothing unless it leads to a change in practices. A continued focus on the questions “Now what must I do?” “What must we do?” “What is our next right step?” is important.
The answer is in the hands of everyone providing contraceptives, and students of this field. Moreover, the answer is, of course, in the hands of the individuals choosing a contraceptive.
Provide the best progestin-only pill, use the 52mg levonorgestrel IUDs as emergency contraceptives, and provide the subcutaneous contraceptive injection for women to use at home.
Dr. Robert A. Hatcher is the chairman of the Contraceptive Technology Update editorial board. The 16th edition of Managing Contraception and the 21st edition of Contraceptive Technology can be ordered at: https://managingcontraception.com/.
REFERENCES
- Kennedy CE, Yeh PT, Gaffield ML, et al. Self-administration of injectable contraception: A systematic review and meta-analysis. BMJ Glob Health 2019;4:e001350.
- Turok DK, Gero A, Simmons RG, et al. Levonorgestrel vs. copper intrauterine devices for emergency contraception. N Engl J Med 2021;384:335-344.
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