Pill power: Oral contraceptives hold top spot in family planning arsenal
Ease of use, accessibility make pill first choice for birth control
The benefits of the birth control pill, combined with its ease of use and accessibility, keep it as a top choice for women, according to results from the 1998 Contraceptive Technology Update Pill Survey. More than 70% of providers who responded to the annual survey said 50 or more women leave their offices with pill prescriptions each month.
For the first time, the 1998 CTU survey allowed readers to list their first and second choices for both formulary and nonformulary pills when choosing contraceptives for both 21-year-old and 42-year-old nonsmoking women. Prescribing restrictions or none, providers were quick to name Ortho Tri-Cyclen (Ortho-McNeil Pharmaceuticals, Raritan, NJ) as the leading choice for young women. (See chart, p. 126.)
"Because 55% to 60% of the women I see are ages 18 to 24, I have found Ortho Tri-Cyclen a good choice both for cycle control and because it is indicated for acne," notes Reina Favors, NP, quality assurance director for Planned Parenthood of Greater Iowa in Des Moines. "I would say that a majority of the patients I see do well with this pill."
Ortho-McNeil, which received approval from the Food and Drug Administration for Ortho Tri-Cyclen as the first hormonal treatment for moderate acne, has been effective in marketing the new indication. (See CTU, March 1997, pp. 25-27, for details on the approval.) Many patients come to providers' offices seeking the "acne pill," says Mary Anne Baker, CNM, a clinician at Health Quarters Reproductive Health Care Services in Beverly, MA. "Many teens come in asking for it because it helps acne. It is the only oral contraceptive pill requested by those who have a preference."
With a graduated dose of the progestin norgestimate (180 mcg the first seven days, 215 mcg the next seven days, and 250 mcg the next seven days) and a constant dose of 35 mcg of ethinyl estradiol, Tri-Cyclen offers good cycle control and tolerability by patients. This ease of use has led Theresa Rundell, ARNP, family planning/STD program lead staff person at the Klickitat County Health Department in White Salmon, WA, to name it as the "start pill" for any age group when clinic RNs need to do delayed exams in her absence.
Pricing and the availability of samples also play a large part in clinicians' choices, especially as patient numbers swell and operating dollars decrease.
"Ortho Tri-Cyclen is provided on contract from the state of Kansas; thus it becomes a matter of economics for our facility in order to provide low-cost contraceptive methods," states Jan Noyes, RNC, ARNP, a women's health nurse practitioner at Lyon County Health Department/Flint Hills Community Health Center in Emporia, KS. "Also, we have had extremely good results with Ortho Tri-Cyclen with compliance, few side effects, and, of course, improved acne."
CTU readers named Triphasil, a 30/40/30 mcg pill from Wyeth-Ayerst of Philadelphia as the No. 2 nonformulary pill choice. Ortho-Cyclen, a 35 mcg Ortho-McNeil product, was selected as the No. 2 formulary pill choice. (See chart at left for category choices.)
Lower dose as age rises
When it comes to older women and the pill, low-dose oral contraceptives play a pivotal role in birth control. CTU readers named Alesse, manufactured by Wyeth-Ayerst, and Loestrin from Parke-Davis of Morris Plains, NJ, as top choices for 42-year-old nonsmoking patients.
Alesse, a 20 mcg pill, has made inroads since its 1997 U.S. debut (see CTU, August 1997, pp. 93-95, for more details), with more than 26% of readers citing it as the first choice in the older patient category. Loestrin, which is offered in both 20 and 30 mcg strengths, also continues to hold a leading spot. (See chart, p. 127.)
Charles Harper, MD, coordinator of ambulatory care/OB/GYN at Women's Hospital of Greensboro (NC), says he likes to use Alesse or Loestrin 1/20 for women ages 35 to 50 who are nonsmokers. "With the lowering of estrogen, you can have fewer problems with estrogen that you might with that age range and still provide just as good contraception," he notes.
Look for more 20 mcg pills to join the 1999 CTU pill survey. Berlex Laboratories of Wayne, NJ, says its new pill, Levlite, will be available to physicians and pharmacists before the end of this year. The new pill relies on 0.100 mg of levonorgestrel and 20 mcg of ethinyl estradiol for its contraceptive efficacy. (The November 1998 CTU will include more information on this new pill.)
Pill offers protection
Oral contraceptives' (OCs) protective effects against ovarian and endometrial cancers are leading more clinicians to evaluate use. One-fourth of CTU survey respondents said they had recommended pills to patients specifically to decrease ovarian cancer risks. (The November 1998 CTU will feature coverage of a just-released study that indicates OCs cut the chances of ovarian cancer in half among women who inherit a faulty gene that puts them at risk for the disease.1)
One in five Americans think the pill is somewhat unsafe, while more than one in 10 think it is "very unsafe."2 The Birmingham, AL-based American Society for Reproductive Medicine (ASRM), joined by a host of women's health organizations, is taking steps to dispel such myths with an upcoming public awareness campaign. Television advertisements with actress Jacklyn Zeman (nurse Bobbie Spencer on ABC's General Hospital) will caution women not to be a "statistic" when it comes to unintended pregnancy. The spots also will note the pill's other health benefits besides pregnancy prevention.
The society recently hosted a scientific conference on oral contraceptives, which reviewed some 40 years of research on the drug. After evaluating the evidence, experts agreed that pills containing less than 50 mcg of estrogen - the dosage taken by more than 95% of pill users - are extremely safe and can be taken by the majority of women throughout their reproductive years.
Examine your patients' needs and offer information on how OCs might benefit them, suggests Carolyn Westhoff, MD, DSc, medical director of family planning at Columbia Presbyterian Medical Center and associate professor of clinical OB/GYN and public health at Columbia University, both in New York City. She co-chaired the ASRM conference. If the patient is an adolescent, acne may be a hot topic, she notes. For a young, nulliparous woman, the pill's effect on dysmenorrhea may be of interest. Women in their 30s and 40s will want to hear more about oral contraceptives' protective effect against ovarian and endometrial cancers.
"Listen to when the patient is discussing a problem," says Westhoff. "For example, if she is in her 40s and talks about irregular periods, perhaps the pill could be an option for her."
References
1. Narod SA, Risch H, Moslehi R, et al. Oral contraceptives and the risk of hereditary ovarian cancer. N Engl J Med 1998; 339:424-428.
2. Henry J. Kaiser Family Foundation. National Survey on Public Perceptions about Contraception. Menlo Park, CA; Jan. 31, 1996.
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