REVIEW

Helping Women Choose Appropriate Hormonal Contraception: Update on Risks, Benefits, and Indications
Abby L. Spencer, MD, MS,a Rachel Bonnema, MD, MS,b Megan C. McNamara, MD, MScc
a

Department of Medicine, Section of General Internal Medicine, Allegheny General Hospital, Pittsburgh, Pa; bDepartment of Medicine, Section of General Internal Medicine, University of Nebraska Medical Center, Omaha; and cDepartment of Medicine, Section of General Internal Medicine, Case Western Reserve University, Cleveland, Ohio.

ABSTRACT Primary care physicians frequently provide contraceptive counseling to women who are interested in family planning, have medical conditions that may be worsened by pregnancy, or have medical conditions that necessitate the use of potentially teratogenic medications. Effective counseling requires up-to-date knowledge about hormonal contraceptive methods that differ in hormone dosage, cycle length, and hormone-free intervals and are delivered by oral, transdermal, transvaginal, injectable, or implantable routes. Effective counseling also requires an understanding of a woman’s preferences and medical history as well as the risks, benefits, side effects, and contraindications of each contraceptive method. This article is designed to update physicians on this information. © 2009 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2009) 122, 497-506 KEYWORDS: Contraception; Contraception counseling; Contraceptive choice; Women’s health

The rate of unintended pregnancies in the United States is nearly 1 in 5 for women of all ages and 1 in 10 for women aged 18-24 years.1 Because primary care physicians routinely provide treatment for a variety of medical conditions, including conditions that may be adversely affected by pregnancy and conditions that necessitate the use of potentially teratogenic drugs,2 it is important for them to have a thorough knowledge of contraceptive methods. Women today have the option of using new types of oral contraceptives that differ from traditional types in terms of hormone dosages, cycle length, and hormone-free intervals. They also have the option of using contraceptives with a variety of hormone delivery systems, including transdermal, transvaginal, injectable, and implantable devices. In this review, we discuss newer contraceptives and give special consideration to their use by women with medical disorders.
Funding: None. Conflict of Interest: None. Authorship: Each author was involved in the conception, design, and the writing of the manuscript, and approved the submitted version of the manuscript. Requests for reprints should be addressed to Abby L. Spencer, MD, MS, Department of Medicine, Division of General Internal Medicine, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212. E-mail address: aspence1@wpahs.org

Intrauterine devices or systems may be appropriate for many women seeking effective long-term contraception but are beyond the scope of this article which focuses primarily on newer hormonal methods. We present 3 clinical vignettes and use the vignettes to discuss controversies about benefits and risks associated with different contraceptive methods.

CASE 1
A 27-year-old woman presents to you for advice about contraception. She says she would be willing to take oral contraceptive pills on a daily basis. She typically experiences bloating and pain for 3 days before her menses and reports that her menstrual flow is heavy and lasts for 6 days. She smokes a pack of cigarettes a week, and her mother had breast cancer at the age of 65 years.

How Do Oral Contraceptive Pills Work?
Oral contraceptive pills are agents that contain estrogen (ethinyl estradiol) and a progestin. They work primarily by preventing the surge of luteinizing hormone and thereby preventing ovulation, but they also thicken the cervical mucus and alter the endometrial lining to help prevent fertilization or implantation. Failure rates of oral contraceptive pills vary from 0.3% with perfect use to 8%

0002-9343/$ -see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2009.01.016

Seasonique [Duperform liver function tests before initiating oral contraramed Pharmaceuticals]. A types. have a diastolic blood presIndividual oral contraceptive pills differ in terms of their sure above 90 mm Hg. On the and ameliorates many androgenic other hand. and Lybrel [Wyeth Pharmaceuticeptive pill use.15 They of venous thromboembolism astraception for women with medical coalso might improve acne. Penn]).14. dysphoric disorder.6. and venous thromboembolism. taken in cycles ranging from 21-84 cysts. highly effective immone-binding globulin.10 Active liver disLoestrin 24 [Warner Chilcott. Women with hormone withcontraindication for prescribing oral contraceptive pills11 drawal symptoms or severe dysmenorrhea may benefit from to the patient in case 1.7. . premenstrual side effect is venous thromboemment of cycles/side effects.13 and ovarian bolism. side effects. a synthetic progestin that is chemically related to spironolactone. pressure above 160 mm Hg. such as Extended-cycle or Conventional Oral desogestrel and gestodene.13. stroke. NJ]. and according to the American the fewer periods per year and shorter hormone-free interCollege of Obstetricians and Gynecologists (ACOG) vals provided by extended-cycle regimens as outlined in Practice Bulletin. ovulatory pain. but it is not necessary to [Duramed Pharmaceuticals. Indeed. der. and hormoneand are therefore at increased risk of an adverse cardiofree interval. Montville. Family history of breast cancer is not a cals. new forpills provide several noncontraThe most common side effects of ceptive benefits. although it may result in a pill use is lower than the risk of cystic ovary syndrome. which is unique for its novel progestin. In case 1. offer her improved cycle of and Contraindications control and regularity.6. the risk ● Depo-Provera is a safe method of conand endometrial cancer. contraindicated in women who have a systolic blood and contraindications. sociated with oral contraceptive and other manifestations of polymorbidities. mulations (transdermal patch and intraoral contraceptive pills are nauthey reduce the risks for endomesea.3 It is important to counsel patients about failure rates and to remind them that oral contraceptive pills do not offer protection against sexually transmitted diseases. oral contraceptive Pills? able in low estrogen dosages. thromboembolism is 4 times as 4 high in oral contraceptive pill users as in nonusers. contraindication). delivery systems.9 Other contraindications to oral conconsist of a 21-day course of hormones followed by a 7-day traceptive pill use include diabetes with end-organ damhormone-free interval. Vol 122. vaginal ring). venous thromboem4 for Her Based on Her Symptoms and bolism risk is higher in women who are obese and in women who use oral contraceptive pill formulas that Contraceptive Needs? Would You Choose an contain specific third-generation progestins. costs. hirsutism. On the one hand. The antiandrogen pills. or smoke after the age of 35 years estrogen dosage. premore serious but less common days for improved efficacy and managemenstrual syndrome. known thromboembolic disorintervals (Yaz [Bayer Healthcare Pharmaceuticals]. benign breast disease. The American Journal of Medicine. an estrogen-dependent tumor. Newer oral contraceptive pills inage. What are Appropriate Contraceptive Options Among oral contraceptive pill users. and thereby CLINICAL SIGNIFICANCE for Oral Contraceptive reduce the risk of iron-deficiency ● Combination contraceptives are availanemia. Seasonale ease is a contraindication. and the density. oral contraceptive pill use may minimize the patient’s dysmenorrhea and menorWhat Are the Side Effects rhagia. headache. Pomona. breastfeeding within 6 weeks of delivery (relative clude Yasmin (Bayer Healthcare Pharmaceuticals. increase in the level of sex-horabsolute risk of venous thrombo● Implanon is a new. unexplained extended-cycle regimens that offer shorter hormone-free vaginal bleeding. Philadelphia. No 6.12 For example. which reembolism among oral contracepplantable progestin-only contraceptive.6 family history of BRCA 1 or 2 mutaTable 1. The imvenous thromboembolism assoreversible decrease in bone mineral provement occurs secondary to an ciated with pregnancy.498 with typical use. breast tenderness. failure rates. the risk of venous effects. and with new progestin triosis. ovarian and breakthrough bleeding. and several breast cancer.6-8 It is contents. June 2009 What Are the Noncontraceptive Benefits of Oral Contraceptive Pills? Oral contraceptive pills are often considered the first-line treatment for women with dysfunctional uterine bleeding. and a personal history of the following: NJ).5 Contraceptive Pill? Oral contraceptive pill use is contraindicated in Table 1 describes numerous oral contraceptive pill and women who have a history of migraine headache with nonoral contraceptive pill options and compares hormone aura and are therefore at increased risk of stroke.16-19 tions should not preclude provision of oral contraceptive Yasmin contains drospirenone. Rockaway. progestin type and dosage. NY]. duces circulating free testosterone tive pill users is small. Traditional oral contraceptive pill regimens vascular event.

499 . Traditional oral contraceptive pills (OCPs) Update on Contraception Extended-cycle OCPs Yasmin Packet of 28 tabs containing ethinyl estradiol (20 ␮g) and drospirenone (3 mg). 4 placebo tabs. and evidence of PCOS. breastfeeding within 6 weeks of delivery. headache. myocardial infarction (MI). nausea. 4 placebo tabs. Average Cost per Month $20-$60 Failure Rate 0. Might offer particular benefit to women with acne. 7 placebo tabs. Spotting. stroke. diastolic BP Ͼ90 mm Hg. hepatic. nausea. menorrhagia. nausea. or history of the following: migraine headache with aura. Special Considerations Consider for women with dysmenorrhea. Spotting. active liver disease. stroke. 3%-8% with typical use. contraindication to estrogen. Loestrin 24 Packet of 24 tabs containing ethinyl estradiol (20 ␮g) and norethindrone (1 mg). MI. smoking after the age of 35 years. hirsutism. Same as traditional OCPs. or polycystic ovary syndrome (PCOS). breakthrough bleeding. Yaz Packet of 24 tabs containing ethinyl estradiol (20 ␮g) and drospirenone (3 mg). breast tenderness. Shorter HFI may offer particular benefit for women with estrogen withdrawal symptoms. VTE. Same as Yasmin. VTE. Side Effects and Drawbacks Spotting. stroke. and known thromboembolic disorder. acne. Same as above but also renal. irregular menstrual periods. Women can expect rapid resolution of fertility after stopping OCPs. nausea. Might be safer for women with mild hypertension given modest reductions in SBP seen with drospirenone. Same as traditional OCPs. unexplained vaginal bleeding. VTE. Shorter HFI may offer particular benefit for women with estrogen withdrawal symptoms.3% with perfect use. 7 placebo tabs.Spencer et al Table 1 Method Characteristics of Contraceptive Methods Description Packet of 21 tabs containing ethinyl estradiol (20-50 ␮g) and progestin. venous thromboembolism (VTE). estrogen-dependent tumor. or adrenal insufficiency. breast cancer. Same as traditional OCPs. VTE. Contraindications Systolic blood pressure (SBP) Ͼ160 mmHg. diabetes with end-organ damage. MI. hirsutism. $ϳ60 Similar to rates of traditional OCPs. MI. stroke. Same as Yasmin. stroke. Spotting. $ϳ60 Similar to rates of traditional OCPs. $ϳ60 Similar to rates of traditional OCPs. Particular benefit in women with premenstrual dysphoric disorder.

$50-$60 0. Same as traditional OCPs. No 6. shorter HFI than Seasonale. 7 placebo tabs. VTE. 0 placebo tabs.3% with perfect use. . Same as traditional OCPs. Efficacy may be reduced in obese women. Might have increased risk of VTE as compared with OCPs. 7 tabs containing ethinyl estradiol (10 ␮g). 0 placebo tabs. $ϳ60 Similar to rates of traditional OCPs. or endometriosis. The American Journal of Medicine. stroke. Special Considerations Same as traditional OCPs. Contraindications Same as traditional OCPs.15 mg). stroke. Ortho Evra Transdermal patch that is applied once a week and releases ethinyl estradiol (75 ␮g) and norelgestromin (6 mg) during the week. dysmenorrhea or endometriosis. Consider for women who are unable to take pills on a daily basis but would benefit from combined estrogen and progestin contraceptive. nausea. Withdrawal bleed is once every 3 months or once/season. Seasonale Seasonique Packet of 84 tabs containing ethinyl estradiol (30 ␮g) and levonorgestrel (0. Unknown if additional days of estrogen exposure increases risk.500 Table 1 Method Continued Description Packet of 84 tabs containing ethinyl estradiol (30 ␮g) and levonorgestrel (0. nausea. reaction at site of application. Same as Seasonale. VTE. Spotting. stroke. Option for women who do not desire monthly periods. June 2009 Lybrel Packet of 28 tabs containing ethinyl estradiol (20 ␮g) and levonorgestrel (0. MI. MI. Same as traditional OCPs. Withdrawal bleed is once every 3 months or once/season. $ϳ60 Similar to rates of traditional OCPs. nausea. Side Effects and Drawbacks Spotting. VTE. dysmenorrhea. Unknown if additional days of estrogen exposure increases risk. Vol 122. Shorter HFI can offer particular benefit for women with estrogen withdrawal symptoms. Has decreased effectiveness and should not be used by women weighing Ͼ90 kg. 8% with typical use. Might be more helpful for women with dysmenorrhea or endometriosis. MI.15 mg). stroke. VTE. Fewer withdrawal bleeds per year and shorter HFI may offer particular benefit for women with estrogen withdrawal symptoms. Average Cost per Month $ϳ60 Failure Rate Similar to rates of traditional OCPs. MI.09 mg). Spotting. Same as traditional OCPs.

seizure disorder. MI.Spencer et al Table 1 Method NuvaRing Continued Description Soft plastic ring that is inserted vaginally and releases ethinyl estradiol (15 ␮g) and etonogestrel (0. Injectable formula of medroxyprogesterone acetate that is administered intramuscularly (150 mg) or subcutaneously (104 mg) every 12 weeks. Consider for women who are unable to use products containing estrogen or have a desire for longterm contraception. Side Effects and Drawbacks Leukorrhea. Consider for women who have dysmenorrhea. vaginal discomfort. Rare risk of ring falling out.12 mg) each day for at least 3 weeks. active for 3 years. may decrease effectiveness. stroke.3% with perfect use. phenytoin. releases etonogestrel. migraine headache with aura. VTE. Consider for women who have dysmenorrhea. Implanon Single-rod device that is implanted subdermally in the upper arm. transient decrease in bone mineral density. John’s wort. stroke. thromboembolism. Update on Contraception Depo-Provera $16-$20 ($50$90 per injection) 0. rifampin and St. 8% with typical use. stroke. Is safe for women who are breastfeeding. None. or a history of cardiovascular disease. 3% with typical use. MI. Does not increase the risk of VTE. or peripheral vascular disorder. may have delayed reversibility. are unable to use products containing estrogen. Average Cost per Month $50-$60 Failure Rate 0. Use of CYP3A inducers. Special Considerations Consider for women who would benefit from a combined estrogen and progestin contraceptive but who are either obese or unable to take pills on a daily basis. Contraindications Same as traditional OCPs. such as carbamazepine.05% with perfect or typical use. breast cancer. Irregular bleeding. Irregular bleeding. $15 ($500-$750 per implant) 0. or bone fracture. active liver disease.3% with perfect use. 501 . phenobarbital. or have a desire for long-term contraception. hemoglobinopathies.

She has been using this injectable contraceptive for 2 years. the first Food and Drug Administration (FDA)-approved oral contraceptive pill taken 365 days per year. and altering the endometrial lining. Yasmin can lower systolic and diastolic blood pressure up to 4 mm Hg. is an option for women with hormone withdrawal symptoms who do not desire scheduled monthly periods.20 Additionally. . Although the patch is generally as effective as oral contraceptive pills (Table 1). Common side effects of OCPs include nausea.5% of women per year).31 NuvaRing has been associated with an increase in leukorrhea. uncontrolled hypertension. and contraindications are similar to those of other combinedhormone contraceptives. its side effects.27 Discussing a patient’s preferences for menstrual frequency and tolerance for scheduled and unscheduled bleeding will be important in deciding which contraceptive will best fit her needs. and then removed for 1 week (the hormone-free interval). Unlike the patch. These risks are increased in women with migraines with aura. and resolution of fertility are similar to other oral contraceptive pills.502 and antimineralocorticoid activity of Yasmin causes less weight gain and water retention and may offer a greater reduction in acne and hirsutism than that offered by traditional oral contraceptive pills. and myocardial infarction.23-27 Fluctuating hormone levels allow endometrial buildup and can exacerbate premenstrual symptoms and menstrual headaches by creating hormone excess and withdrawal states. this problem has not been found in clinical trials.24-27 The newer extended-cycle oral contraceptive pills with a shorter or eliminated hormone-free interval reduce the risk of these unwanted effects by preventing endogenous estradiol production while still providing highly effective and safe contraception. and in women aged Ͼ35 years who smoke. hepatic. The ring releases 15 ␮g of ethinyl The American Journal of Medicine. which prevent pregnancy by inhibiting ovulation. New York. efficacy.22 During the standard 7-day hormone-free interval that occurs with use of low-dose estrogen formulations. studies have shown that it has decreased efficacy in women who are obese (Ͼ90 kg). The Ortho Evra patch is a thin transdermal patch containing 75 ␮g of ethinyl estradiol and 6 mg of norelgestromin. and contraindications are similar to those of other combined-hormone contraceptives (Table 2). Otherwise. However. as there is no hormone-free interval. Extended-cycle OCPs may reduce unwanted menstrual symptoms by preventing endogenous estradiol production with shorter hormone-free intervals. If the ring falls out (as occurs in 2. and increased spotting due to endogenous estradiol production. breast tenderness. Vol 122.12 mg of etonogestrel daily for 3-5 weeks. For example. Lybrel. OCPs ϭ oral contraceptive pills. Discussing your patients’ preferences for menstrual frequency and tolerance for scheduled and unscheduled bleeding will be important in deciding whether a traditional or extended-cycle OCP will best fit her needs. While one study showed no difference in the risk of venous thromboembolism with use of the patch versus oral contraceptive pills. Ortho Evra patch and NuvaRing are combined-hormonal options if a woman can not take a daily pill. ovulation with unintended pregnancy. cardiovascular risks. She likes not having to take a daily pill and is pleased that her menstrual cycles have lightened substantially. and breakthrough bleeding. Each ring releases about half the level of hormones as the average oral contraceptive pill without affecting efficacy. so it can be kept in longer than 3 weeks. thickening cervical mucus.20. OCPs are not associated with an increased risk of breast cancer in non-mutation carriers. No 6.29 These studies were the basis for updating the Ortho Evra label to indicate a higher risk of venous thromboembolism. she read some recent reports about the effects of Depo-Provera on “bone strength” and wonders if it is still safe for her to use. stroke.28 Most of the side effects. the function of the hypothalamic-pituitary-ovarian axis recovers rapidly. the venous thromboembolism risk associated with patch use is lower than the venous thromboembolism risk associated with pregnancy.18. NY). diabetes with complications.13. VTE ϭ venous thromboembolism. cardiovascular risks. OrthoEvra may be less effective in obese women (Ͼ90 kg). there are two options available: the Ortho Evra patch and the NuvaRing. June 2009 estradiol and 0. More rare but serious side effects include VTE. and this increases the risk of ovarian follicle development. other studies showed that the risk was twice as high with the patch as compared with oral contraceptive pills containing norgestimate or levonorgestrel. it can be rinsed and reinserted without a change in efficacy.29 Of note. CASE 2 A 31-year-old woman with a history of seizure disorder presents to your office to discuss Depo-Provera (Pfizer.21 Although potassium retention is a potential side effect of Yasmin use. Yasmin is contraindicated in patients with renal. the ring is not affected by excess weight. Nevertheless. Most women find the ring easy to insert and remove and comfortable to retain during intercourse. headaches.19 If a woman is having difficulty remembering to take a daily pill but would like to have the benefits of a combined estrogen-progestin contraceptive.16-18.32 Depo-Provera can be given intramuscularly (150-mg dose) or subcutaneously (104-mg Table 2 Take-Home Points: Case 1 Oral contraceptive pills (OCPs) are comprised of varying doses of estrogen and progesterone. Safety. or adrenal insufficiency. usually for 3 weeks.30 NuvaRing is a soft plastic ring that is inserted vaginally. How Does Depo-Provera Work? Depo-Provera (depot medroxyprogesterone acetate) is a progestin-only contraceptive that was approved by the FDA more than 15 years ago. Drosperinone-containing OCPs or progestin-only contraceptives may be safer options for women with mild hypertension.

She previously tried Norplant. such as sickle cell disease. matched cohort study among young women showed that Depo-Provera users had substantial bone mineral density loss but that the loss was reversible with discontinuation of use. which best controlled her symptoms but is no longer available. . She also tried Depo-Provera. dose).33 this may be considered a desirable side effect for many users. Roseland. Implanon has been available for more than 10 years but has been widely marketed in the United States only since 2007.38 In 2006.44 Implanon is extremely effective in preventing pregnancy and has an efficacy rate similar to that associated with sterilization or use of an intrauterine device.40) and there was no increased risk with longer durations of use. and this can adversely affect bone health.43. the FDA issued a black box warning that women who use Depo-Provera may lose significant bone mineral density and recommended that use be limited to Ͻ2 years. You counsel her about various methods of contraception. stroke. weight gain.1 (confidence interval 0. and mood changes. She is currently using an extended-cycle oral contraceptive pill but has severe symptoms every 3 months with menses. which is the same progestin used in the NuvaRing.33 Who Are Good Candidates for Depo-Provera? Depo-Provera is safe for women with a history of cardiovascular disease.35 CASE 3 A 31-year-old woman presents to your office to establish care. multicenter. and altering the endometrial lining. She underwent 2 laparoscopies to treat severe endometriosis more than 10 years ago. preventing ovulation through suppression of the luteinizing hormone surge.43. case-control study published by the World Health Organization (WHO).33 However.40.33 Approximately 40% of women receiving Depo-Provera will experience amenorrhea within the first 3 months of use. Depo-Provera is effective in women taking these medications.40 The WHO has recommended that there be no restriction on the use of Depo-Provera. DepoProvera can decrease the frequency of seizures. systematic reviews of How Does Implanon Work? Implanon is a contraceptive device that is implanted subdermally in the upper arm and remains active for 3 years. She is currently sexually active and in a monogamous relationship.33. VTE.39 In 2006 and again in 2008. Unlike other progestinonly methods.41 The authors of the 2006 review identified only one study that evaluated the risk of fracture among Depo-Provera users. Implanon causes estradiol to gradually increase to normal endogenous levels after an initial decrease. myocardial infarction. a 7-year. although women are instructed to return in 12 weeks to ensure timely administration.Spencer et al Update on Contraception 503 various studies reached the same conclusion about reversibility of bone mineral density loss. although studies are conflicting about whether there is a true causal relationship. NJ).45 Table 3 Take-Home Points: Case 2 Depo-Provera is a progesterone-only contraceptive method that is safe in women with a variety of medical conditions Depo-Provera does not increase the risk of stroke.. Anticonvulsants can increase hepatic metabolism of estrogen and progesterone in oral contraceptive pills. It is highly effective and works by thickening the cervical mucus. In 2004.32. What Are the Side Effects of and Contraindications for Depo-Provera? Commonly reported side effects associated with DepoProvera include menstrual irregularities.36 Depo-Provera users were not more likely than nonusers to experience stroke. or venous thromboembolism.34 Women with seizure disorder are especially good candidates for DepoProvera. Results of her annual Pap smears have been normal. thromboembolism.32 Several studies also have examined the risk of more serious health consequences associated with Depo-Provera use.6.32 About 2% of women will discontinue Depo-Provera within the first 2 years due to weight gain. which she did not tolerate well.97-1.35 moreover. and the overall combined risk for cardiovascular disease was similar in users and nonusers. and this study suggested no association between stress fracture occurrence and Depo-Provera use. Like other progestin-only contraceptives. Implanon works by blocking the luteinizing hormone surge and thereby preventing ovulation. or peripheral vascular disease. It also thickens the cervical mucus and thins the endometrial lining. thereby lowering contraceptive efficacy.32. It consists of a single rod that contains etonogestrel.37 Depo-Provera reduces serum estradiol levels.6 It is ideal for women with hemoglobinopathies. because these women will likely notice a decrease in painful hemolytic crises. presumably secondary to its high progesterone levels.42 Practitioners should advise patients about the risk of bone mineral density loss but reassure them about reversibility with discontinuation. prospective. According to the findings of an international. or breast cancer Users of Depo-Provera may experience a decrease in bone mineral density that is reversible with discontinuation and is not associated with increased fracture risk VTE ϭ venous thromboembolism. They also should recommend that Depo-Provera users exercise regularly and increase their intake of calcium and vitamin D (Table 3).33 Its slow absorption through the subcutaneous tissues provides adequate systemic levels of progesterone for at least 14 weeks. including Implanon (Organon USA Inc. acute myocardial infarction. Pooled results from the WHO trial and a similar trial conducted in New Zealand indicated that the relative risk for breast cancer among women who used Depo-Provera sometime during their life was 1.

The correct placement is confirmed by palpation. If a woman’s medical condition requires treatment with a potentially teratogenic drug. Difficulty with removal is experienced in only 2%-3% of patients. partial prothrombin time. or bone mineral density. long-term contraceptive using a single rod subdermal implant containing the progestin etonogestrel. In this open-label study. and only one small study has examined the effect of Implanon on hemostatic elements. Norplant production was halted in the United States after clinicians and patients complained about difficulty in removing the device and after the manufacturer found it necessary to recall a single lot of the implant devices because they released lower-than-expected levels of hormone. . However.53 Therefore.46 The cost of implantation is typically $500-$750 and is often covered by health insurance.45 What Are the Side Effects and Beneficial Noncontraceptive Effects of Implanon? Like other progestin-only contraceptives. June 2009 What Are the Contraindications for Implanon? Implanon is contraindicated in women being treated with CYP3A-inducing or CYP3A-inhibiting medications.50 There have been no long-term studies about Implanon.43 How Does Implanon Differ from Norplant? Norplant was a highly effective implant system that consisted of 6 rods containing levonorgestrel. the increase with Implanon is relatively low (about 0. active venous thromboembolic disease is listed as a contraindication in the packaging information for several progestin-only methods. there was no change in prothrombin time. disposable applicator supplied by the manufacturer to insert the rod about 3 fingerbreadths above the medial epicondyle of the humerus. but these contraindications are controversial.44 SUMMARY Physicians need up-do-date information to help each patient choose a contraceptive that is appropriate based on her medical history and preferences for a pill.7 kg/m2) and only about 3%-7% of Implanon users have their implant removed because of weight gain. including Implanon. or levels of fibrinogen or other coagulation variables over a 6-month period. inhibitors of CYP3A might increase serum etonogestrel levels and cause toxicity. For implantation. there are no data available on the association between Implanon use and venous thromboembolism. At 6 months. The newer formulations and extended-cycle regimens reviewed Table 4 Take-Home Points: Case 3 Implanon is a highly effective. 80% of women with dysmenorrhea at baseline will have an improvement in symptoms with no major effects on weight. Within a week. 30% have infrequent bleeding. While inducers of CYP3A might decrease the efficacy of Implanon and lead to unintended pregnancy. bone mineral density. women who smoke or have hypertension. most experts consider Implanon to be an acceptable choice for women who have venous thromboembolism and cannot use contraceptives that contain estrogen (Table 4). and the remainder experience frequent or prolonged bleeding.43 In 2002. but about 70% of women with acne experience no change in their condition. the clinician gives the patient a local anesthetic and then uses a preloaded. it is imperative that her physician counsel her about the wide range of contraceptive methods that are available.48 After removal of the etonogestrel implant. migraine headaches. quickly reversible. acne.43.49 Discontinuation of use usually occurs during the first 8-9 months and is generally due to frequent or prolonged bleeding.6. progestin-only methods can be used in most cases. implant. about 30%-40% have amenorrhea. about 50% of women experience infrequent bleeding. During the first 3 months of use. If estrogen is contraindicated.43 Implanon has mixed effects on acne.52 However. or a history of venous thromboembolism). Vol 122. and fractures. One study indicated that its use was associated with a decrease in symptoms of dysmenorrhea in 80% of women with a history of this disorder. Most important preimplantation counseling point is the possibility of irregularly irregular bleeding patterns. Some studies indicate that etonogestrel causes mild abnormalities in results of liver function tests. Implanon may cause irregular bleeding. a study that followed Implanon users and nonhormonal intrauterine device users for 2 years showed no clinically significant difference in the bone mineral density levels of these 2 groups.47 The American Journal of Medicine. Implantation and removal of Implanon require training but can be performed as simple office procedures. or other method.51.49 Progestin-only methods of contraception have long been considered safe to use in women with an increased risk of venous thromboembolism (eg. etonogestrel becomes undetectable and ovulation quickly follows.504 Women experience a quick return to normal cycles after implant removal. No 6. diabetes mellitus. Implanon is an alternative for women who cannot use estrogenbased contraceptives and is safe to use during breastfeeding. although many women experience infrequent bleeding or amenorrhea. Unfortunately. and the usual cause is that the implant was placed too deep in the arm.49 Implanon has other effects to consider. etonogestrel levels fall quickly. Although many progestin-only contraceptives are associated with an increase in weight.6 Implanon is contraindicated in women with active liver disease or active venous thromboembolism. and there have been no reports of infertility after removal. but the abnormalities are thought to be of minimal clinical significance. Serum etonogestrel levels in Implanon users have been shown to have less variability than levonorgestrel levels in Norplant users.

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