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OCs offer effective, convenient, and accessible birth control
The advent of the new millennium brings along one constant from the past: Oral contraceptives (OCs) remain the leading choice of reversible contraception for American women. More than 60% of providers who participated in the 1999 Contraceptive Technology Update Contraception Survey say 50 or more women leave their offices each month with pill prescriptions in hand. (See chart, p. 98.)
"I think our number of OC patients has increased over the last few years, especially as more perimenopausal women are accepting them for relief of symptoms," notes Ann Tyree, FNP-C, family nurse practitioner at Beach Physicians and Surgeons in Huntington Beach, CA.
When it comes to prescribing pills for an older nonsmoking woman, survey respondents named Alesse, a 20 mcg pill manufactured by Wyeth-Ayerst Laboratories of Philadelphia, and Loestrin, offered in both 20 and 30 mcg strengths from Parke-Davis of Morris Plains, NJ, as top choices. (See chart, p. 99.)
And for young nonsmoking women, Ortho Tri-Cyclen, a 35 mcg tri phasic pill from Ortho-McNeil Pharmaceuticals of Raritan, NJ, continues its 1998 position as the leading choice for oral contraceptives. (See chart, p. 100.)
Why Ortho Tri-Cyclen? It offers efficacy, few complications, few side effects, and easy-to-use packaging, says Jonathan Weiner, MD, an OB/GYN in private practice in Fresno, CA.
Providers named Ortho Tri-Cyclen first whether or not they were bound by formulary constraints; 47% rated it as first choice in a nonformulary situation, and 32% named it No. 1 when prescribing under formulary restrictions. While nonformulary numbers rose from 44% in 1998, formulary numbers fell from the 41% reported last year.
Ortho Tri-Cyclen offers a graduated dose of the progestin norgestimate (180 mcg the first seven days, 215 mcg the next seven days, and 250 mcg the next seven days) and a constant 35 mcg dose of ethinyl estradiol.
Ortho-McNeil launched a powerful consumer advertising campaign for the OC following its 1997 federal Food and Drug Admin is tra tion (FDA) approval as an effective treatment for acne in women seeking contraception. (For additional information about the FDA approval, see CTU, March 1997, p. 25.) Providers say the marketing message is getting through to young women, who often request the pill by name. "Being advertised to improve acne has really increased the demand for this pill in our clinic," says Lorraine Charvet, NP, OB/GYN nurse practitioner at the Anchorage (AK) Health Depart ment’s family planning clinic.
Ortho-Cyclen, an Ortho-McNeil pill with 35 mcg ethinyl estradiol and 0.25 mg norgestimate, shared top second-choice pill selection standing with Ortho-Tri-Cyclen in the nonformulary category. It followed Ortho Tri-Cyclen in the second-choice formulary category.
OCs benefit aging women
More than 60% of survey respondents named a 20 mcg pill as their top choice for older nonsmoking women. Alesse and Loestrin maintained their leading positions as top pills in this category from the previous year’s survey.
"I have probably 10 or 12 women on Alesse," reports Judy Lee, ARNP, women’s health nurse practitioner at Gateway District Health Depart ment in Owingsville, KY. "It helps them through the perimenopausal stage."
Ortho Tri-Cyclen and newcomer Mircette, a 20 mcg pill with a shortened hormone-free interval from Organon of West Orange, NJ, also were listed as OC choices for older women. (Mircette entered the U.S. market in mid-1998, after results were tabulated for the 1998 CTU survey. For details, see CTU, July 1998, p. 85.)
Research has established that OCs protect women against dysmenorrhea and menorrhagia, menstrual cycle irregularities, iron deficiency anemia, ectopic pregnancy, pelvic inflammatory disease, ovarian cysts, benign breast disease, endometrial cancer, and ovarian cancer.1
In addition to these noncontraceptive health benefits, OCs have proven valuable in the management of a variety of gynecologic disorders, including dysfunctional uterine bleeding, persistent anovulation, premature ovarian failure, functional ovarian cysts, pelvic pain (including secondary dysmenorrhea), mittelschmerz (ovulatory pain), endometriosis, and the control of bleeding in women with blood dyscrasias.1
Providers are moving toward prescription of OCs specifically for noncontraceptive benefits. About one-third of providers participating in the 1999 CTU Contraception Survey say they or colleagues at their facility recommended pills in the last year to women specifically to decrease their risk of ovarian cancer. One-quarter of those responding to the 1998 survey indicated they would do so.
At Gateway District Health Department, providers present a "pro and con" approach to birth control, pointing out the risks and benefits of each method, says Lee. For women who have a family history of ovarian cancer, the role of OCs in reducing such risks represents a very appealing option, she notes.
"I find the fact that one-third of clinicians specifically prescribed pills in the past year to decrease women’s risk of ovarian cancer promising," comments Robert A. Hatcher, MD, MPH, professor of obstetrics and gynecology at Emory University in Atlanta and chairman of the CTU editorial advisory board. "Now if women knew enough about pills to request pills for the pre vention of ovarian cancer, this number would approach 100%."
No go for over-the-counter OCs
Despite their comfort level with the current formulations of combined OCs, the majority of survey respondents say they are yet unwilling to see OCs offered as an over-the-counter (OTC) drug. Nearly 30% of those participating in the 1999 survey say they would support the move, up from 22% in 1998. (See chart, p. 100.) Still, providers continue to hesitate to see women receive pills without medical assessment.
It is more complicated to take OCs for contraception than it is to take Tylenol for pain, and the contraindications for OCs are more serious, according to Grace Miyazaki, NP, family nurse practitioner at South Texas Family Planning and Health Corp. in Corpus Christi, TX. Many noncompliant women may cause themselves harm taking OCs without being medically evaluated, she says.
"There also is no solid standard system to deal with side effects and complications — i.e. who do you call if you experience a problem?" she asks. "Many people do not have a doctor to fall back on. Would companies dispensing OTC OCs have a hotline?"
By making OCs easily available for the patient, however, more women could protect themselves from the health risks associated with unintended pregnancies, says Amador Ramirez, MD, medical director of the Barren River District Health Department in Bowling Green, KY.
Some patients are afraid to come for an examination because they have misconceptions about Pap smears, states Ramirez, who sees a large number of patients of Vietnamese, Laotian, Cambodian, and Bosnian descent. By offering pills OTC, it would cover those women who do not use pills because they are afraid of the physician’s office, he says.
"It oversimplifies the arguments for and against putting the pill over-the-counter, but in one sense, the pro-OTC argument is a public health argument — for the general good, by increasing the number of women using the pill — whereas the argument for maintaining medical provision focuses on the good for the individual user," comments Linda Potter, DrPH, of Family Health Research in Princeton Junction, NJ. "At the same time, ignoring any other arguments, family planners have no data on the relative effectiveness of the two sources for protecting women against pregnancy."
1. Kaunitz AM. Oral contraceptive health benefits: Perception versus reality. Contraception 1999; 59 (1 Suppl):29S-33S.