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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.

Norplant:

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.

  • 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.
Depo-Provera (medroxyprogesterone acetate):

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.
Lunelle:

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:

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.


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