Hormonal Contraceptive Options
There are now three hormonal, long-term, reversible
contraception methods: hormone implants (Norplant) and hormone injections (Depo-Provera
or Lunelle). They're all highly effective, but they can cause side effects some
women find unacceptable. This category now includes the latest FDA-approved
contraceptive, NuvaRing, a vaginal ring that releases hormones daily and is
changed once a month.
Commonly referred to as "the implants" or "the rods", Norplant is an excellent
contraceptive option for many women. It has been plagued since its launch
by lawsuits, predominantly because of the very small amount of medical
grade silicone contained in the rods and the fear that silicone may be associated
with systemic illnesses (this has essentially been disproved, however, by several
medical studies). Other lawsuits were initiated by women whose physicians
had difficulty removing the rods when they no longer wished to use them.
Norplant consists of six timed-release capsules slightly smaller than matchbook
matches, implanted in a fan-shape just under the skin of the upper arm. The
capsules contain levonorgestrel, a synthetic female hormone similar to the progestin
used in birth control pills. The implants provide protection against unwanted
pregnancy for 5 years by slowly releasing a hormone, which interferes with pregnancy
by blocking ovulation, by thickening the cervical mucus and by thinning the
lining of the uterus. The insertion is generally a 10-15 minute outpatient
surgical procedure under local anesthetic, using a small incision, less than
an eighth of an inch long. The physician places the six capsules just under
the skin then covers it with gauze and a small bandage; stitches are not required.
When the anesthetic wears off, there may be some tenderness or itching, and
perhaps some temporary discoloration, bruising and swelling. Infection at the
site of insertion has also been reported.
Removal takes longer than insertion, usually from 15 to 30 minutes. As
with insertion, a small incision is made under local anesthesia. Sometimes,
capsules are more difficult to remove than others. When this happens, the woman
may have to return a second time, after the area has healed, for removal of
the remaining capsules. If desired, a new set of implants can be inserted at
the same time the old set is removed, either in the same arm and through the
same incision, or in the other arm.
The price for a single Norplant system, including all the necessary apparatus
for insertion and removal as well as the set of six capsules, has been set at
$350. Fees for insertion and related costs, such as counseling and removal,
vary, depending on the physician. There is a group called the Norplant
Foundation (1-800-760-9030) that provides financial assistance to women without
insurance who would like to use this contraceptive method.
Norplant provides an effective contraceptive benefit within 24 hours after
insertion. If at any time the woman experiences unpleasant side effects
or if she wants to become pregnant, the implants can be removed. Because
of the confusion about insertion and removal complications, Norplant's manufacturer,
Wyeth Ayerst Laboratories, has established a toll-free telephone number (1-800-934-5556)
where patients can obtain information about Norplant and the names of providers
in their area who are experienced in Norplant insertion and removal.
Like any medication, Norplant has side effects. The more serious side
effects are uncommon but include changes in menstrual bleeding (including stopping
it altogether), release of breast milk, depression, skin rash, speech or visual
changes, severe and sudden shortness of breath. The more common side effects
include stomach pain; swelling of the face, ankles or feet; mild headache; mood
changes; fatigue; weight gain; and pain or irritation at the implant site. Other
less common side effects include: acne, breast pain; hot flashes; insomnia;
decreased libido; hair loss; and skin pigment changes. Removal may cause
some scarring and women must be aware of this before choosing this option.
Depo-Provera (medroxyprogesterone acetate):
- The hormone in Norplant does pass into breast milk, but has not been shown
to cause any problems for the nursing child. Norplant is considered
a safe and effective contraceptive for nursing mothers. Norplant is
completely reversible upon removal, usually restoring fertility within 2 months.
- Norplant cannot be used by women with breast cancer, liver disease or a
history of blood clots.
- Because Norplant's effectiveness does not depend on patient compliance,
its effectiveness is close to of sterilization in the first year. Pregnancy
rates are slightly higher in heavier women, increasing after the third
year of use in those who weighed more than 153 pounds. Because Norplant
is not a barrier contraceptive, however, it offers no protection against STDs.
Commonly referred to as "the shot", Depo-Provera, approved by FDA in 1992,
is injected by a health professional into the buttocks or arm muscle once every
three months. Depo-Provera prevents pregnancy in three ways, essentially the
same way that Norplant works: it inhibits ovulation, changes the cervical mucus
to help prevent sperm from reaching the egg, and changes the uterine lining
to prevent the fertilized egg from implanting in the uterus. This progestin
injection is highly effective in preventing pregnancy, in large part because
it requires minimal effort for the woman to comply -- she simply has to show
up for her injection once every three months. Protection against pregnancy can
begin immediately if injection is given within 5 days of the menstrual period.
- The benefits and side effects are Depo-Provera are similar to those of
the mini-pill (progestin only pill) and Norplant. The most common complaints
about side effects are also similar and can include irregular or missed periods,
weight gain, and breast tenderness.
- Delayed fertility for up to 18 months is one of the side effects that may
occur after Depo-Provera is discontinued. More than 80 percent of women become
pregnant within one year of discontinuing Depo, and 90 percent will become
pregnant within two years. Pregnancy may occur anytime after 12 weeks
following the last injection. But the average time between the last Depo injection
and pregnancy is about nine months, including the three months during which
the injection is effective. This is why Depo is not usually prescribed for
women who are planning to have a child in the near future.
- As with Norplant, injections often cause menstrual irregularities. After
one year of use, up to 45 percent of Depo-Provera users will experience amenorrhea
(no periods). It may also cause an increase in blood pressure and some weight
gain. Abnormal menstrual bleeding; unexpected breast milk production; depression;
skin rash; changes in speech, coordination, or vision; severe and sudden shortness
of breath; stomach pain; swelling of face, ankles, or feet; mild headache;
mood changes; unusual fatigue; hair loss; and acne.
This is the newest contraceptive option, approved by the FDA in late 2000.
It is a once-a-month intramuscular injection of progestin (25 mg) and estradiol
(5 mg). For women with regular menstrual periods, the shot should be given within
5 days of menses in order to block ovulation. A recent study of 1,103 women
compared the effectiveness of Lunelle versus a commonly used oral contraceptive
pill: there were no unintended pregnancies among the women who received the
injection, whereas there were 2 unintended pregnancies in the Pill takers. As
this study showed, compliance problems are reduced in women taking a monthly
injection compared to women taking a daily Pill.
As with the Pill, Lunelle is not recommended for women who are heavy smokers,
or who are at risk for blood clots, coronary artery disease or stroke. It is
also not recommended for women with uncontrolled diabetes or high blood pressure.
NuvaRing is the newest birth control option to be approved by the Food and
Drug Administration (10/01). NuvaRing is a small, flexible vaginal ring coated
with hormones. Like birth control pills, NuvaRing releases estrogen and progestin
to provide contraception. The difference from the pill lies in the delivery
-- whereas birth control pills must be taken orally every day, NuvaRing is inserted
like a diaphragm and releases its hormones continuously and in a lower dose
than the pill. NuvaRing is inserted once a month and removed after 21 days,
after which a normal period begins. A visit to the gynecologist is necessary
for a prescription, but it is not needed for insertion or removal.
Click here for more information on birth control.
Created: 10/31/2001  - Donnica Moore, M.D.