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Prescribing Habits to Reduce the High Rate of Unintended Pregnancy
‘forgettable contraceptives.’ Once the IUD is in place, the only thing a woman
Table 1: Contraceptive Failure Rates with Correct and Consistent
is asked to do is to check its tailstrings once a month. Even though compliance
Use Compared with Rates Seen in Typical Use
with this requirement is questionable, the spontaneous expulsion rates of
IUDs are so very low that even non-compliance does not significantly raise
First-year Failure Rates (%)
pregnancy rates. The etonogestrel-releasing implant demands even less of the
Methods Correct and Consistent Use
a
Typical Use
b
Injectables 0.3 6.7
patient. In fact, the only thing that patients can do to compromise the efficacy
Oral contraceptives 0.3 8.7
of this implant is to use drugs that may increase hepatic clearance of
Male condoms 2.0 17.4
etonogestrel. The most common medication in this category is St John’s Wort,
Withdrawal 4.0 18.4
which the patient may not even consider to be a drug. Other agents that
Fertility awareness methods 5.0 25.3
could seriously reduce serum etonogestrel levels are some anticonvulsants
a. Trussel J. Choosing a Contraceptive: Efficacy, Safety and Personal Considerations. In: Hatcher RA, Trussell J,
(phenobarbital, dilantin) and some antiretroviral agents. Stewart F, et al. (eds), Contraceptive Technology, 19th edition, New York, Ardent Media, Inc., 2007. b. Kost K,
Singh S, Vaughan B, et al., Estimates of contraceptive failure from the 2002 National Survey of Family Growth.
Contraception, 2008;77(1):10–21.
Prescribing Practices to Reduce Access Barriers
Figure 1: Quick-start DMPA Protocol
‘Quick-start’ or ‘Same-day Start’ Protocols
‘Quick-start’ protocols have been developed and tested for virtually all Yes
LMP ≤5 days? No
hormonal methods of contraception, including for birth control pills,
20–22
contraceptive patches,
23
vaginal contraceptive rings,
24,25,13
and placement of Inject DMPA Unprotected IC since LMP?
the copper T-380A IUD. In these quick-start protocols, a woman starts using
Yes No
her new method on the day of her visit assuming that pregnancy has been
Negative Positive
UCG pregnancy test
ruled out (usually by history). With quick-start protocols for oral
Inject DMPA
Advise use of
contraceptives, patients take the first pill in the packet promptly. With
back-up method
patches, the first patch is applied immediately. The quick-start protocol
Unprotected IC <5 days?
for 7 days
No DMPA
with the vaginal contraceptive ring
24
has the advantage of providing the
Yes No
woman with a hands-on experience, with placement and removal of
Advise that UCG not conclusive,
the ring in the office. This reassures her that the ring will not cause her any
Offer EC
but DMPA should not affect fetus
discomfort or fall out. If the woman who wants to use quick-start hormonal
methods has had unprotected intercourse at any time during the previous
Yes
five days, she should be given two tablets of levonorgestrel EC pills. If a
Patient desires DMPA now?
Repeat UCG
woman uses EC, initiation of oral hormonal contraceptives can be delayed No
in 2–3 weeks
if IC <2 weeks
for 12 hours to avoid side effects that may attend simultaenous use of both
Offer barrier method for 14 days
hormonal methods. Women using EC can start DMPA, the ring, or the patch
immediately since systematic absorption of hormones from those methods
is slower and will not cause the same high peak levels of hormones seen
Menses <14 days?
with simultaneous use of oral contraceptives and EC. Of course, if the
Yes No
copper IUD is being placed following recent unprotected intercourse, no EC
Negative
tablets are needed, because placement of the copper IUD is the most
Inject DMPA Repeat UCG
effective post-coital method available.
26
Positive
The final consideration of quick-start protocols with the hormonal
No DMPA
method is that none of them works immediately. Each requires the use
of some other method (generally male condoms) until the cervical mucus their methods.
28,13,11
Women who were prescribed the three-month
is reliably thickened to prevent sperm entry into the upper genital tract.
27
extended-cycle product in the Verispan study automatically received a
Therefore, condom use is needed for seven days for all of the hormonal three-month supply of contraceptives and were more likely to have
methods except the patch, which may need nine days of back-up. One higher 12-month continuation rates.
11
Those who must return
further note is that patients who use EC with any of the non-injectable periodically to re-fill their prescriptions (often within a very inflexible and
methods should be advised to return for pregnancy testing only if they narrow window of time) were more likely to discontinue their method or
have symptoms of pregnancy or if they fail to have withdrawal to interrupt its use. One of the most common reasons for the non-
bleeding/menses at the expected time. As amenorrhea with DMPA is utilization of condoms is generally that couples do not have any
generally attributed to DMPA use, women should be advised to have available, again underscoring the need to supply generous quantities of
repeat pregnancy testing two to three weeks after EC/DMPA use to condoms whenever possible.
10
prevent significant delays in diagnosis of any pregnancy
13
(see Figure 1).
Provide Obvious, Desirable Non-contraceptive Benefits
Prescribe Large Numbers of Cycles The proliferation of US Food and Drug Administration (FDA)-approved
Studies have shown that women who are provided with large numbers non-contraceptive benefits demonstrates an attempt by the companies to
of cycles of hormonal contraceptives are more apt to continue to use add new broad-based appeal to their products. For example, three
US OBSTETRICS & GYNECOLOGY 15
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