Non-oral hormone contraception

Luis Ignacio Leta Lasa followed on from Kristina’s presentation looking at the potential use of non-oral hormone contraception. Non-oral hormone contraceptives can be separated into two groups; combined hormonal contraceptives which are short acting reversible contraceptives (SARCs) such as the transdermal patch, vaginal ring and injectable and progestin only contraceptives which are long acting reversible contraceptives (LARCs) including the implant and LNG-IUS.

SARCs vs LARCs

SARCs can provide a number of advantages when used including; provision of good cycle control, cyclic bleeding that mimics natural menstruation, non-contraceptive benefits, protection against some forms of cancer, quick return to fertility and the avoidance of invasive intervention. However disadvantages include; the fact they need high compliance otherwise they are only minimally effective, they present hormonal dependent side effects, are linked to increased VTE risk, women may experience some withdrawal symptoms, they can interact with other drugs and can’t be used by a woman who is breast feeding.

The three different modalities of SARC (patch, ring and injectable) all contain estrogen and progestins but have different methods of administration and regimens. In Luis’ presentation he shared his experience of the vaginal ring in Spain. The TEAM’s study assessed the reasons for women choosing the pill, the patch or the ring. The study found the most popular method was the vaginal ring due its monthly regimen, convenience and lowered probability of non-compliance. The Remo study looked at non-compliance of different modalities, 61% of pill users reported forgetting to take pills, 32% of patch users forgot to take medication whilst only 22% of ring users reported compliance issues. Results suggest non-compliant behaviour is more frequent in users of daily contraceptive methods compared to users of monthly contraceptive methods. The HABITS study looked at the contraceptive modalities used in the general female population compared to HCPs in Spain. The vaginal ring was used by 3% of the general population and by 13% of the HCPs whilst the pill was used by 17% of the population compared to 13% of the HCPs. This study showed that HCPs opt for LARCs because of their effectiveness and safety whilst the general population rely more frequently on the condom and surgical methods.

The LARC methods have some important advantages; they are highly effective and don’t require compliance. They often limit or completely reducing bleeding, result in fewer side effects due to the absence of estrogens and have no increased risk of VTE. They also have positive effects on dysmenorrhea, endometriosis and heavy bleeding and have few contraindications. As with SARC methods, there are also disadvantages such as development of an unpredictable bleeding pattern which is the leading reason for leaving the method, androgenic effects, hypoestrogenic symptoms, reduced effect on PCOS, lower user control, requirement for long term family planning and dependency on a provider to stop the method.

Whilst they are all estrogen free the have different methods of administration and regimens either via intrauterine insertion or a subdermal implant. LARCs are also not equal in terms of effectiveness. The implant appears to be the most effective and has a much lower percentage of pregnancies when in use, only 5 pregnancies in every 10,000 women compared to 80 using the copper IUD and 20 using the coil. There are also concerns over ease of implementation, in a discussion between Spanish HCP, 93% said they had issues inserting and IUD and 27% said they had experienced difficulties inserting an implant.

Hormone contraception has more advantages than risks including important non-contraceptive benefits. Non-oral hormone contraception is usually associated with better compliance with LARC methods being the most effective as they are not dependent on the user, considerations such as unpredictable bleeding pattern and dependency on a HCP in order to stop are current barriers to further adoption of this effective method.