Progestin-only contraceptive pill use among women in the United States

BackgroundProgestin-only contraceptive pills (POPs) offer a safe and effective contraceptive option, particularly for women at increased risk of venous thromboembolism. However, the prevalence of POP use among women in the United States is unknown.Study DesignWe analyzed population-based data from 12,279 women aged 15–44 years in the National Survey of Family Growth. Data were collected continuously from 2006 to 2010 by in-person, computerized household interviews. Analyses describe POP use across sociodemographic and reproductive characteristics and thromboembolic risk profiles.ResultsOverall, 0.4% of all reproductive-aged women in the United States currently use POPs. POP use was higher among parous, postpartum and breastfeeding women than their counterparts (all p values<.001). Women at higher risk of thromboembolism (older, obese, diabetic or smoking women) had similar proportions of POP use as women without those risks.ConclusionPOPs are rarely used by US women. While data on chronic disease were limited, our results suggest that relatively few women with increased risk of thromboembolism are considering POPs when choosing an oral contraceptive.     

Women's out-of-pocket expenditures and dispensing patterns for oral contraceptive pills between 1996 and 2006

Background

Little is known about the out-of-pocket expenditures and dispensing patterns for oral contraceptive pills (OCPs), factors associated with these outcomes and whether they change over time.

Study Design

Observational cohort using 1996–2006 Medical Expenditure Panel Surveys.

Results

Women spent $16 out-of-pocket per pack, on average (median=$10.41). Of the OCP users, 38% paid $15 or more per pack and 44% obtained one pack per purchase. Over time, fewer women paid $15 or more (52% in 1996–1998 vs. 34% in 1999–2006, p<.001) and fewer obtained one pack per purchase (76% in 1996–1998 vs. 35% in 1999–2006, p<.001). Age and insurance were associated with out-of-pocket expenditures and dispensing patterns.

Conclusion

Women paid a substantial amount out-of-pocket for OCPs and dispensing limits remained, although these improved over time. Better insurance coverage of contraception and policies targeting younger women and the uninsured in particular would help overcome barriers to OCP access.     

Both a combined oral contraceptive and depot medroxyprogesterone acetate impair endothelial function in young women

Background

The study was conducted to determine whether the use of a combined oral contraceptive (COC) or depot medroxyprogesterone acetate (DMPA) interferes with endothelial function.

Study Design

The study was conducted on 100 women between the ages of 18 and 30 years. Fifty women had not used hormonal contraception (control group) for at least 12 months, 25 were current users of a COC (ethinylestradiol 30 mcg+levonorgestrel 150 mcg) and 25 were current users of DMPA (150 mg) for at least a 6-month period. All women were evaluated for brachial flow-mediated dilation (FMD), intima-media thickness, carotid distensibility and stiffness index, arterial pressure, body mass index, waist circumference, heart rate and lipid profile.

Results

A significant difference in FMD was observed between the COC and control groups (6.4±2.2% vs. 8.7±3.4%, p<.01) and between the DMPA and control groups (6.2±2.1% vs. 8.7±3.4%, p<.01). The DMPA group had lower values of total cholesterol (TC) and low-density lipoprotein (LDL-C) than COC users and the control group (TC: DMPA=139.9±21.5 mg/dL vs. controls=167.1±29.2 mg/dL vs. COC=168.2±37.5, p=.001; LDL-C: DMPA=85.3±20.1 mg/dL vs. controls=102±24.5 mg/dL vs. COC=106.7±33.3 mg/dL, p=.01). The control group had higher levels of high-density lipoprotein (HDL-C) than the DMPA and COC groups (controls=52.4±14.1 mg/dL vs. DMPA=42.2±7.2 mg/dL vs. COC=45.4±9.1 mg/dL, p=.001). No significant differences were observed regarding the other variables.

Conclusions

FMD was lower among COC and DMPA users, suggesting that these hormonal contraceptives may promote endothelial dysfunction.     

Using changes in binding globulins to assess oral contraceptive compliance

BackgroundValidity of oral contraceptive pill (OCP) clinical trial results depends on participant compliance. Ethinyl estradiol (EE2) induces increases in hepatic binding globulin (BG) levels. Measuring these BG increases may provide an effective and convenient approach to distinguish noncompliant from compliant OCP users in research settings. This analysis evaluated the usefulness of measuring increases in corticosteroid-, sex-hormone- and thyroxine-binding globulins (CBG, SHBG and TBG, respectively) as measures of OCP compliance.MethodsWe used frozen serum from a trial that compared ovarian suppression between normal-weight and obese women randomized to one of two OCPs containing EE2 and levonorgestrel (LNG). Based on serial LNG measurements during the trial, 17% of participants were noncompliant. We matched noncompliant participants with compliant participants by age, body mass index, ethnicity and OCP formulation. We measured CBG, SHBG and TBG levels and compared change from baseline to 3-month follow-up between the noncompliant and compliant participants. Construction of receiver operator characteristic (ROC) curves allowed comparison of various BG measures.ResultsChanges in CBG and TBG distinguished OCP noncompliant users from compliant users [area under the ROC curve (AUROC), 0.86 and 0.89, p<.01]. Changes in SHBG were less discriminating (AUROC 0.69)ConclusionsEE2-induced increases in CBG and TBG provide a sensitive integrated marker of compliance with an LNG-containing OCP.     

Effects of combined oral contraceptives containing levonorgestrel or chlormadinone on the endothelium

BackgroundAlthough the use of combined oral contraceptives (COCs) is associated with an increased risk of arterial and venous thromboembolic events, less is known about the impact of COCs on endothelial function. The present study evaluated the effects on the endothelium of healthy women of combinations of 30 mcg ethinylestradiol (EE)/2 mg chlormadinone acetate (CMA) and 30 mcg EE/150 mcg levonorgestrel (LNG).Study DesignSixty-four healthy women were evaluated, 21 using a nonhormonal contraceptive method (control) and 43 using COCs, randomized to EE 30 mcg /CMA 2 mg or to EE 30 mcg/LNG 150 mcg. Anthropometric parameters, systolic arterial pressure (SAP), diastolic arterial pressure (DAP), ultrasound markers of endothelial function, flow-mediated dilation (FMD) of the brachial artery, intima–media thickness (IMT) and common carotid artery stiffness were measured at randomization and 6 months later.ResultsRelative to baseline, EE/CMA users showed a significant reduction in mean DAP at 6 months (p=.02), and EE/LNG users showed a significant increase in mean IMT (p=.02) and a significant reduction in mean FMD (p=.01) at 6 months. DAP at 6 months was significantly lower in COC users than in controls (p=.01). Intergroup evaluations showed that, at 6 months, mean SAP (p=.02) was significantly lower in EE/LNG users than in controls (p=.02) and that mean DAP was significantly lower in EE/CMA (p<.01) and EE/LNG (p=.01) users than in controls. EE/LNG users experienced a mean FMD reduction almost threefold greater than that of EE/CMA users. Compared to controls, EE/LNG users experienced a 7.5-fold greater reduction in mean FMD.ConclusionsCOC containing LNG is associated with more pronounced changes in the FMD and IMT of healthy women than a COC containing CMA and nonhormonal contraception. Further studies are needed to determine whether these differences may lead to higher risk of arterial thromboembolic events.     

Contraceptive use and pregnancy outcome in three generations of Swedish female teenagers from the same urban population

Background

The primary objective of the study was to describe contraceptive use, reasons for discontinuation of contraception and pregnancy outcome in three generations of female teenagers over a period of 20 years. The secondary objective was to describe the relationship between contraception, smoking, body mass index (BMI) and socioeconomic status (SES).

Study Design

A cross-sectional comparison of 19-year-old women born in 1962, 1972 and 1982 and living in the city of Gothenburg, Sweden, in 1981, 1991 and 2001 was conducted. Contraceptive use, pregnancy outcome, smoking and weight/height were assessed by a postal questionnaire.

Results

Current contraceptive use was unchanged between the 62 (60%) and 72 cohorts (62%) but had increased (p<.01) in the 82 cohort (78%); there was no difference in contraceptive use between SES groups at any time. Condom use alone increased over time (p<.01), and the use of oral contraception and a condom together had increased in the 72 and 82 cohorts compared to the 62 cohort (p<.01). Reasons given for using and discontinuing oral contraceptives in three generations of teenagers were studied over 20 years. In addition to contraception, oral contraception was used to reduce dysmenorrhea and heavy bleeding. Discontinuation due to bleeding disturbances decreased (p<.01) over time, whereas discontinuation due to mental side effects increased (p<.01). The percentage of women who had been pregnant at ≤19 years of age in the 82 cohort (7%) was lower (p<.01) than in the 1962 (11%) and 1972 (13%) cohorts. However, there was a successive increase (p<.001) in the percentage of women who had been pregnant more than once at ≤19 years of age (1962/1972/1982: pregnant more than once, 8%/21%/31%). Smoking decreased over time (p<.01) and was no longer related to SES in the 82 cohort. BMI increased (p<.01) over time. There was no difference in BMI between SES groups in the 62 and 72 cohorts but was higher in the low-SES group in the 82 cohort compared to the middle (p<.01) and high (p<.05) SES groups.

Conclusions

Contraceptive use was higher in the 82 cohort where there was a corresponding reduction in the percentage of women who had been pregnant at ≤19 years of age compared with the 62 and 72 cohorts. Discontinuation of oral contraception due to mental side effects increased over time. The prevalence of smoking decreased and BMI increased, and there were changes in smoking prevalence and BMI in the different SES groups over time.     

Estrogen-free oral hormonal contraception: benefits of the progestin-only pill

Although combined oral contraceptives (COCs) are commonly used and highly effective in preventing pregnancy, they may not be suitable for some women. COC use is associated with increased rates of cardiovascular events and is not recommended in nonbreastfeeding women in the immediate postpartum period or in breastfeeding women during the initial 6 months of breastfeeding. Moreover, estrogen-related adverse effects, such as headache, are common. Estrogen-free progestin-only pills (POPs) are a valuable option in women who prefer to take an oral hormonal contraceptive, but are ineligible for, or choose not to use, COCs. Although some POPs have been associated with lower contraceptive effectiveness than COCs, the POP containing desogestrel has shown similar contraceptive effectiveness to COCs. The most commonly reported complaints in women using all POPs are bleeding problems. Counseling women interested in using POPs about the variable bleeding patterns associated with this method may improve compliance and acceptance.     

Effects of an estrogen-free, desogestrel-containing oral contraceptive in women with migraine with aura: a prospective diary-based pilot study

Background

Migraine with aura (MA) is a contraindication to the use of combined oral contraceptives (COCs) because of the increased risk of ischemic stroke. Progestogen-only contraceptive pill (POP) is a safe alternative to COCs and it is preferable in women with cerebrovascular diseases or risk factors for stroke.

Study Design

Prospective diary-based pilot study. Thirty women with MA (n=15 who have never used COCs and n=15 who had previously used COCs were diagnosed according to the International Headache Society criteria. The observational period lasted 9 months during which women filled in a diary with the clinical characteristics of headache attacks. After a 3-month run-in period, each subject received an estrogen-free desogestrel (DSG) (75 mcg/day)-containing OC (Cerazette®; Schering-Plough, formerly NV Organon, Oss, The Netherlands). Follow-up evaluations were planned at the end of the third and sixth month of treatment.

Results

The number (mean±S.D.) of migraine attacks was significantly reduced both in previous COCs users (from 3.9±1.0 to 2.9±0.8; p<.001) and nonusers (from 3.2±0.9 to 2.6±1.3; p<.02) following 6 months of POP use in comparison with the run-in period. Duration of headache pain did not differ significantly in both groups throughout the study. Interestingly enough, a beneficial POP effect on the duration (mean±S.D.) of visual aura (from 16.3±9.5 to 11.4±5.6 min) and on the total duration (mean±S.D.) of neurological symptoms (from 33.6±23.3 to 18.6±18.0 min) was only significantly reported by previous COCs users (p<.001, for both) by the end of the study period. The POP was well tolerated by each woman and the bleeding pattern was variable with a tendency towards infrequent bleeding.

Conclusions

The present study supports the use of the POP containing desogestrel in a population of women with MA and underlines a positive effect on symptoms of aura, especially in MA sensitive to previous use of COCs.     

Effects of oral contraception with ethinylestradiol and drospirenone on oxidative stress in women 18-35 years old

Background

Oral contraceptives (OCs) with estrogens and progestins may affect oxidative stress (OS) status.

Study design

A group of 32 women using oral contraceptives (OCU) containing 0.03 mg ethinylestradiol and 3 mg drospirenone have been compared to a matched control group of 30 noncontraception users (NCU). Blood levels of antioxidants, trace elements and markers of lipid peroxidation were assessed by biochemical methods. A microarray analysis of whole blood mRNA levels of 200 genes involved in OS-dependant pathway was also performed.

Results

Levels of zinc, vitamin E and antibodies to oxidized low-density lipoproteins (LDLs) were not significantly different between the two groups. On the other hand, significant increases in the mean levels of lipid peroxides (+176%, p<.001), oxidized LDLs (+145%, p<.002), copper (+103%, p<.001), Cu/Zn ratio (+100%, p<.001) and a significant decrease in the mean level of β-carotene (−41%, p<.01) were observed in the OCU compared to NCU. There was a highly significant positive correlation between the lipid peroxide levels and the copper-to-zinc ratio. From the 200 genes tested by microarray, one coding for HSP70 was significantly up-regulated (log² fold change=+ 0.45, p<.02) and one coding for inducible nitric oxide synthase significantly down-regulated (log² fold change=−0.24, p<.05) in the OCU compared to the NCU.

Conclusions

The recently introduced combination of ethinylestradiol and drospirenone induced the heightening of lipid peroxidation correlated with high levels of copper, a situation that could be associated with increased cardiovascular risk.     

Effect of a contraceptive pill containing estradiol valerate and dienogest (E2V/DNG) in women with menstrually-related migraine (MRM)

Background

Combined hormonal contraception might worsen migraine in sensitive women, especially during the free-hormone interval, and raise concerns about the vascular risk. The characteristics of a contraceptive pill containing estradiol valerate/dienogest (E2V/DNG) might be of potential benefit in women with menstrually related migraine (MRM) who choose to use oral contraception for birth control.

Study design

This was a prospective diary-based pilot study. Thirty-two women (age > 35 years) [n= 18 who had never used combined oral contraceptives (COCs) and n= 14 who had previously used COCs] diagnosed with MRMs according to the International Headache Society criteria were included. During the observational period, women filled in a diary with the clinical characteristics of migraine attacks. After a three-cycle run-in period, each subject received a COC containing E2V/DNG (Qlaira®/Natazia®; Bayer HealthCare, Berlin, Germany) administered using an estrogen step-down and progestogen step-up approach. Follow-up evaluations were scheduled at the last cycle of run-in and at the third and sixth cycles of treatment.

Results

The number of migraine attacks was significantly reduced at the third (p<.001) and sixth cycles (p<.001) in comparison with the run-in period. A similar result was evident for the duration (p<.001 at the third and p<.001 at the sixth cycle) as well as for the severity of head pain (p<.001 at the third and p<.001 at the sixth month). Indeed, a significantly lower number of analgesics were used at the third cycle (p<.001) in comparison with baseline, and a further decrease was evident at the sixth cycle (p<.001) in comparison with the third cycle of E2V/DNG use. Interestingly, duration and severity of head pain were significantly correlated with the number of days of dysmenorrhea at the third cycle (r= .89, p=.000 and r= .67, p=.02; respectively) and at the sixth cycle (r= .76, p=.000 and r= .62, p=.04; respectively) in women without complete remission of menstrual cramps during the study period.

Conclusions

The present diary-based pilot study indicates that the use of a pill containing EV2/DNG for six cycles has a positive effect in women with MRM and suggests an association between dysmenorrhea with COCs use as a potential feature of refractory head pain.     

The Association Between Postpartum Insurance Instability and Access to Postpartum Mental Health Services: Evidence From Colorado

IntroductionThe objective of this study was to assess the association between postpartum insurance instability and access to postpartum mental health services.MethodsWe used 2018–2019 Colorado Health eMoms survey data, which sampled mothers from the 2018 birth certificate files at 3–6 months and 12–14 months postpartum. Respondents were classified as stably insured or unstably insured based on postpartum insurance status at each time point. We examined postpartum insurance patterns and used logistic regression to assess the association between postpartum insurance instability and mental health care access.ResultsInsurance changes primarily occurred by 3–6 months postpartum. Of respondents with public coverage at childbirth, 33.2% experienced postpartum insurance changes compared with 9.5% with private coverage (p < .001). Respondents who were younger, had incomes of less than $50,000, and were of Hispanic ethnicity were more likely to experience unstable postpartum insurance. Respondents who experienced postpartum insurance instability had a lower odds of reporting that they discussed mental health at a postpartum check-up (adjusted odds ratio, 0.4; 95% confidence interval, 0.2–0.7; p < .01) and received postpartum mental health services (adjusted odds ratio, 0.4; 95% confidence interval, 0.2–0.9; p < .05).ConclusionsThe majority of postpartum insurance disruptions occurred among respondents with public coverage at childbirth and by 3–6 months postpartum. Respondents who experienced unstable coverage were more likely to have less access to postpartum mental health care. Policies that increase postpartum insurance stability, such as postpartum Medicaid extensions beyond 60 days, are needed to improve access to postpartum mental health services.     

Choice of the levonorgestrel intrauterine device,etonogestrel implant or depot medroxyprogesterone acetate for contraception after aspiration abortion

ObjectiveWomen who have abortions are at high risk of contraception discontinuation and subsequent unintended pregnancy. The objective of this analysis was to identify factors associated with choice of highly effective, long-acting, progestin-only contraceptive methods after abortion.Study designWomen presenting for surgical abortion who selected the levonorgestrel intrauterine device (IUD), the progestin implant or the progestin injection (depot medroxyprogesterone acetate or DMPA) as their postabortion contraceptives were recruited to participate in a 1-year prospective cohort study. We used multivariable multinomial logistic regression to identify factors associated with choosing long-acting reversible contraceptives (IUD or implant) compared to DMPA.ResultsA total of 260 women, aged 18–45 years, enrolled in the study, 100 of whom chose the IUD, 63 the implant and 97 the DMPA. The women were 24.9 years old on average; 36% were black, and 29% were Latina. Fifty-nine percent had had a previous abortion, 66% a prior birth, and 55% were undergoing a second-trimester abortion. In multivariable analyses, compared with DMPA users, women who chose the IUD or the implant were less likely to be currently experiencing intimate partner violence (IPV); reported higher stress levels; weighed more; and were more likely to have finished high school, to have used the pill before and to report that counselors or doctors were helpful in making the decision (all significant at p<.05, see text for relative risk ratios and confidence intervals.) In addition, women who chose the IUD were less likely to be black (p<.01), and women who chose the implant were more likely to report that they would be unhappy to become pregnant within 6 months (p<.05) than DMPA users.ConclusionA variety of factors including race/ethnicity, past contraceptive use, feelings towards pregnancy, stress and weight were different between LARC and DMPA users. Notably, current IPV was associated with choice of DMPA over the IUD or implant, implying that a desire to choose a hidden method may be important to some women and should be included in counseling.ImplicationsIn contraceptive counseling, after screening for IPV, assessing patient’s stress and taking a history about past contraceptive use, clinicians should discuss whether these factors might affect a patient’s choice of method.     

Prevalence and Predictors of Prenatal and Postpartum Contraceptive Counseling in Two Texas Cities

ObjectivesWe investigated the prevalence of and sociodemographic associations with receiving prenatal and postpartum contraceptive counseling, including counseling on intrauterine devices (IUDs) and implants.MethodsWe used data from a prospective cohort study of 803 postpartum women in El Paso and Austin, Texas. We examined the prevalence of prenatal and postpartum counseling, provider discouragement of IUDs and implants, and associated sociodemographic characteristics using χ² tests and logistic regression.ResultsOne-half of participants had received any prenatal contraceptive counseling, and 13% and 37% received counseling on both IUDs and implants prenatally and postpartum, respectively. Women with more children were more likely to receive any contraceptive counseling prenatally (odds ratio [OR], 1.99; p < .01). Privately insured women (OR, 0.53; p < .05) had a lower odds of receiving prenatal counseling on IUDs and implants than publicly insured women. Higher education (OR, 2.16; p < .05) and attending a private practice (OR, 2.16; p < .05) were associated with receiving any postpartum counseling. Older age (OR, 0.61; p < .05) was negatively associated with receiving postpartum counseling about IUDs and implants and a family income of $10,000 to $19,000 (OR, 2.21; p < .01) was positively associated. Approximately 20% of women receiving prenatal counseling and 10% receiving postpartum counseling on IUDs and implants were discouraged from using them. The most common reason providers restricted use of these methods was inaccurate medical advice.ConclusionsPrenatal and postpartum counseling, particularly about IUDs and implants, was infrequent and varied by sociodemographics. Providers should implement evidence-based prenatal and postpartum contraceptive counseling to ensure women can make informed choices and access their preferred method of postpartum contraception.     

Impact of different contraceptive methods on quality of life in rural women of the Jiangsu province in China

Background

The combined oral contraceptives (COCs) and intrauterine devices (IUDs) are the most common contraceptive methods used by women. Women's choices of contraceptive method are largely affected by the safety and efficacy of contraceptive methods as well as by change in women's quality of life. However, there are still scanty data focusing on the impact of COC or IUD on quality of life in women, especially in China. The aim of this study was to evaluate the impact of desogestrel and ethinyl estradiol tablets (Marvelon) and Yuangong-Cu220 IUD (YCu220 IUD) on quality of life in rural women of the Jiangsu province in China.

Study Design

In this prospective cohort study, 784 COC users and 910 YCu220 IUD users were included. The women filled up quality-of-life questionnaires (Quality of Life Enjoyment and Satisfaction Questionnaire) before and after use of contraceptive methods.

Results

Significant score changes in physical health, mood, work/school/labor, living situation, vision, general well-being and overall satisfaction were noted as significant improvements after COC use in women (p<.05), and the largest improvements were in physical health and living situation; all item scores except for work/school/labor, household activities and leisure time activities had improved statistically from baseline in YCu220 IUD users (p<.05). For COC users, the proportions of women with total quality-of-life scores ≥57 before and after COC use were 11.50% and 11.79%, respectively; but the proportion of YCu220 IUD users with total quality-of-life scores ≥57 increased from 4.40% to 12.04%. Compared to women without contraceptive use history, women with past OC and/or IUD use had a significantly higher difference in the total quality-of-life scores.

Conclusions

COC and YCu220 IUD could significantly improve overall quality of life in rural women of the Jiangsu province.     

A pilot study of the Copper T380A IUD and oral levonorgestrel for emergency contraception

BackgroundThis study evaluates the willingness of women presenting for emergency contraception (EC) to enroll in a study offering the copper intrauterine device (IUD) or oral levonorgestrel (LNG) and follows up the two groups for 6 months after EC administration to compare use of an effective method of contraception.Study DesignThis prospective observational study offered these two methods to women presenting for EC. The primary outcome was use of an effective method of contraception 6 months after presenting for EC.ResultsThirty-four women (60%) chose oral LNG and 23 (40%) chose the copper IUD. One month after presenting for EC, 21 (96%) of 22 in the IUD group were still using the IUD and all 22 were using an effective method of contraception (efficacy ≥92%). In the LNG group, 13 (52%) of 25 were using an effective method of contraception (p<.001). At 6 months, 9 (69%) of 13 IUD users and 11 (52%) of 21 oral LNG EC users were using an effective method (p=NS).ConclusionWomen presenting for EC were willing to enroll in a study offering the copper IUD or oral LNG.