Nonoral Hormonal Contraceptives

^^ As an alternative to oral contraceptive pills, which must be taken daily in order to reliably prevent pregnancy, nonoral contraceptives in the form of transdermal, transvaginal, and injectable preparations are available and offer patients safe and effective alternatives to the pills for prevention of pregnancy. These formulations also do not require daily administration, making them more convenient than the pill formulations.

Ortho-Evra is a transdermal patch that contains both an estrogen (20 mcg of ethinyl estradiol) and a progestin (150 mcg of norelgestromin). A new patch is applied to the abdomen, buttocks, upper torso, or upper (outer) arm once weekly for 3 weeks, followed by seven patch-free days.8 Although some women have noted irregular bleeding during the first two cycles of patch use, the patch has been demonstrated to provide similar menstrual cycle control and contraceptive efficacy to that of COCs.34 It is important to note, however, that higher contraceptive failure rates are seen when the patch is used in women weighing more than 90 kg (about 200 lb).8,34 Further, the manufacturer prescriber information for the product indicates that women who take Ortho-Evra are exposed to approximately 60% more estrogen than women who take COCs with 35 mcg estrogen.3 While the clinical significance of this is not well defined, recent studies have suggested a link between the use of the patch and an in creased risk for venous thromboembolism. A slightly higher reported incidence of

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breast discomfort and local skin irritation has also been reported with the patch. '

NuvaRing is a unique transvaginal delivery system that provides 15 mcg ethinyl estradiol and 120 mcg etonogestrel for the prevention of ovulation. NuvaRing is inserted into the vagina on or before day 5 of the menstrual cycle and is removed from the vagina 3 weeks later.8 Seven days after the ring is removed, a new ring should be inserted. In clinical trials, NuvaRing demonstrated comparable efficacy and cycle control to that of COCs.8 Side effects seen with NuvaRing are similar to those observed

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in women taking COCs. NuvaRing should not be removed during intercourse. If the ring is dislodged or removed for more than 3 hours, efficacy could be compromised, and a backup method of contraception is recommended until a new ring has been in place for 7 days.

Depo-Provera is a progestin-only injectable contraceptive that contains depot medroxyprogesterone acetate. Depo-Provera is administered intramuscularly as a 150-mg injection once every 3 months. An advantage of Depo-Provera is that it provides an estrogen-free method of contraception either for women in whom estrogens are contraindicated or for women who cannot tolerate estrogen-containing preparations. Depo-Provera is extremely effective in preventing pregnancy. However, the incidence of menstrual irregularities (including amenorrhea) and weight gain appears to be much greater than that seen with COCs. The use of Depo-Provera also has been demonstrated to result in significant loss of bone mineral density (BMD).38 Although it is not known whether the use of Depo-Provera will increase the risk for osteo-porotic fracture, a black-box warning within the product labeling cautions against the risk of potentially irreversible BMD loss associated with long-term use (e.g., greater than 2 years) of the injectable product. While the extended duration of activity of this product may offer women the advantage of less frequent administration, it is important to note that on discontinuation of Depo-Provera, the return of fertility can be delayed by approximately 10 to 12 months (range 4-31 months).8

Depo-SubQ Provera 104 is also an injectable contraceptive product that contains only a progestin (depot medro-xyprogesterone acetate). This product, which was approved by the FDA in 2005, is different from Depo-Provera in that it is given subcu-taneously rather than intramuscularly, and it contains only 104 mg medroxyprogesterone acetate 9approximately 30% less hormone) every 3 months for the prevention of pregnancy.3 Clinical trials have demonstrated that the subcutaneous formulation of depot medroxyprogesterone acetate is as effective as the intramuscular formulation in the prevention of pregnancy.40 Although this product carries the same warning in its

package labeling regarding possible effects on BMD as DepoProvera, it is not yet known if the lower progestin dose will lessen the potential for long-term side effects.

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