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In addition to oral contraceptives, other hormonal contraceptives can
be used to reduce bleeding. Some of these approaches reduce the frequency
of bleeding on a cyclical basis, whereas others (such as Depo-Provera®,
Mirena®, and Implanon™)
are continuous and reduce or eliminate bleeding. See Table 2 for a list
of these latter methods.
Two newer, longer-acting, combination hormonal contraceptives represent
potential methods for suppressing menstruation.1
Contraceptive Vaginal Ring
Extended use of the NuvaRing®,
a combination estrogen-progestin method approved for contraception in
October 2001,2 presents an appealing
concept. This ring is approved for 3-weeks-in, 1-week-out use. In a
small pharmacokinetic study on the effects of the vaginal ring after
extended use (worn in the vagina for 5 weeks rather than the conventional
3 weeks), investigators determined that ovulation continued to be inhibited,
and there were no unfavorable safety observations.3
Because these results may not be found in a larger population of women
of different body weights, ages, and other characteristics, the authors
did not recommend the use of the ring beyond 3 weeks.
Transdermal Contraceptive Patch
Ortho Evra®, a combination hormonal
method, approved as a contraceptive in November 2001,4
also has appeal to women and clinicians for extended use. Conventionally,
the patch is worn for 3 of 4 weeks each month, on a traditional oral
contraceptive 21/7-day schedule. For extended use, it could be replaced
every week for 4 weeks without a patch-free interval.
Although clinical trials on the extended use of NuvaRing and Ortho
Evra have been conducted, these data have not been published to date.
| “I started using
an extended oral contraceptive regimen in my residency so I would
have one less thing to deal with. Initially, after 2–3 months
of continuous oral contraceptives, I had some breast tenderness
and some breakthrough bleeding. At that point, I started a pill-free
week. On those placebo days, my mood dropped. I am now using the
NuvaRing and use it continuously. I have had spotting only once
in the last 7 months.”
—Patricia, ob/gyn physician,
age 30 |
| TABLE 2. Other
Therapeutic Options for Suppressing Menses5-10 |
| Methods |
Injectable progestin-only contraceptives
(Depo-Provera®) |
Levonorgestrel intrauterine system (Mirena®) |
Norethindroneacetate tablets (Aygestin)a |
Danocrine (Danazol®) |
GnRH, leuprolide acetate (Lupron Depot®)c |
Etonogestrel implantable contraceptive (Implanon™;
FDA approval pending as of July 2004) |
| Description and Dosage |
Injectable progestin-only contraceptive: 150 mg every 3 months.
A subcutaneous injection is pending FDA approval as of July 2004.
|
Progestin-releasing IUD: releases 20 mg of LNG daily; effective
for 5 years |
Oral progestins: 5 mg, 1–3 tablets daily |
Gonadotropin inhibitor with progestational and androgenic properties:
Danazol, 100–200 mg twice daily (optional titration to lowest
dose sufficient to maintain amenorrhea) |
Delivery methods and dosages vary |
Single-rod implantable contraceptive containing 68 mg of etonogestrel;
effective for 3 years |
| Contraception Provided |
Yes |
Yes |
Yes (but not FDA approved for contraception) |
No |
No |
Yes |
Medical Usesb
Effects on Menstrual |
Menorrhagia, dysmenorrhea, endometriosis, anemia, PMS, menstrual
migraines
|
Menorrhagia |
Menorrhagia, dysmenorrhea, endometriosis, anemia, PMS, menstrual
migraines |
Endometriosis, fibrocystic breast changes, menorrhagia |
Menorrhagia, dysmenorrhea, endometriosis, anemia, PMS, menstrual
migraines |
Insufficient experience to draw from as yet |
| Blood Loss |
Amenorrhea common with long-term use—50% with 1 year of
use, 90% with 2 years
|
80–90% decrease in blood loss; ~20% of users are amenorrheic
by 1 year |
Reduces bleeding by 87% after 3 months of use |
Produces amenorrhea |
Produces amenorrhea |
21% of users are amenorrheic in any 90-day reference period |
| Adverse Effects |
Irregular bleeding or spotting, possible weight gain, transient
loss in bone mineral density, delayed return to fertility
|
Intermenstrual bleeding, ovarian cysts, acne |
Mood changes, bloating, weight gain |
Androgenic effects, such
as weight gain and acne; hypoestrogenic reactions, such as flushing,
sweating, vaginal dryness and irritation |
Hypoestrogenic effects; these may be counteracted with add-back
progestin and/or estrogen/progestin |
Breakthrough bleeding/spotting, acne, headache, breast pain |
| Cost |
Cost-effective; less expensive than alternatives
|
Initial high cost, but becomes cost-effective with extended use |
More costly than extended OC regimen |
Expensive |
Very expensive |
Cost not yet known |
FDA = Food and Drug Administration
GnRH = gonadotropin-releasing hormone
IUD = intrauterine device
LNG = levonorgestrel
OC = oral contraceptive
PMS = premenstrual syndrome.
a. Approved for the treatment of endometriosis.
b. None of the medical noncontraceptive uses listed are FDA-approved
indications, except as noted.
c. Approved for the treatment of endometriosis and menorrhagia-induced
anemia in women with fibroids.
Other GnRH agonists approved for the treatment of endometriosis
include Synarel® and Zoladex®. |
References
1. Kaunitz AM. Menstruation: choosing whether…and when. Contraception
2002;62:277-284.
2. Bjarnadóttir RI, Tuppurainen M, Killick SR. Comparison of
cycle control with a combined contraceptive vaginal ring and oral levonorgestrel/ethinyl
estradiol. Am J Obstet Gynecol 2002;186:389-395.
3. Mulders TMT, Dieben TOM. Use of the novel combined contraceptive
vaginal ring NuvaRing® for ovulation
inhibition. Fertil Steril 2001;75:865-870.
4. Zieman M, Guillebaud J, Weisberg E, et al. Contraceptive efficacy
and cycle control with Ortho Evra™/Evra™
transdermal system: the analysis of pooled data. Fertil Steril
2002;77(Suppl 2):S13-S18.
5. Kaunitz AM. Choosing to menstruate or not. Contemporary OB/GYN
2001;46:73-91.
6. Kaunitz AM. Extended Regimen Contraceptive Choices for Less Frequent
Menstruation. Presentation at 2002 Annual Meeting of the Association
of Reproductive Health Professionals, Denver, Colorado, September 2002.
7. Nilsson C, Allonen H, Diaz J, Luukkainen T. Two years’ experience
with two levonorgestrel-releasing intrauterine devices and one copper-releasing
intrauterine device: a randomized comparative performance study. Fertil
Steril 1983;39:187-192.
8. Hidalgo M, Bahamondes L, Perrotti M, Diaz J, Dantas-Monteiro C,
Petta C. Bleeding patterns and clinical performance of the levonorgestrel-releasing
intrauterine system (Mirena) up to two years. Contraception
2002;65:129-132.
9. Affandi B. An integrated analysis of vaginal bleeding patterns in
clinical trials of Implanon. Contraception. 1998;58(6 suppl):99S-107S.
10. Urbancsek J. An integrated analysis of nonmenstrual adverse events
with Implanon. Contraception. 1998;58(6 suppl):109S-115S.
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