January 1970

By: Robert A. Hatcher, MD, MPH
Professor Emeritus, Department of Gynecology and Obstetrics
Emory University School of Medicine

During the last week of September 2021, 500 participants in the Contraceptive Technology virtual conference learned about three new contraceptives that I want to tell you about.

• The Progestin-only Pill providing 4mg of Drospirenone
  • As of early October 2021, the most important change in oral contraception is the progestin-only pill providing 4 mg of drospirenone (DRSP) and marketed as Slynd. It is packaged to provide 24 active pills (DRSP 4 mg) and 4 inert pills. There is only one absolute contraindication (“4” in US Medical Eligibility Criteria or MEC) for the use of this pill—current breast cancer. Someone who currently has or is being treated for breast cancer should not be prescribed Slynd.
  • This progestin-only pill may be used during breastfeeding and immediately postpartum. It is extremely effective, and it is NOT contraindicated for persons at an elevated risk for blood clots (in contrast to estrogen-containing birth control pill).
  • The drospirenone-only pill Slynd is being called the first of the 4^th generation of birth control pills. It leads to a high likelihood of anovulation. Its suppression of ovulation and its pregnancy rates are equivalent to that associated with combined pills. It causes no increase in blood pressure and no increased risk of venous or arterial clots.
  • While users who take Slynd have more days of spotting in the first few cycles, only 3.3% discontinue use of this pill because of bleeding.
  • As with any new medication, its price will start out high, but most insurance plans do cover DRSP pills and persons covered by the Affordable Care Act will pay nothing for this new progestin-only pill.

• Self-administered Subcutaneous Depo Provera
  • Depo SQ is the way some users are now being taught to self-inject Depo Provera.
  • For years now it has been apparent that Depo Provera provided by deep IM injections every three months has the highest rates of discontinuation of any reversible contraceptive. One of the effects of the Covid-19 pandemic is that healthcare that can be self-administered at home has been encouraged. Depo SQ is a self-administered Depo Provera shot. A meta-analysis (combined data from multiple studies) by Kennedy, et al., analyzed rates of continuation and pregnancy among 4,000 users, some of whom were provided Depo IM and others taught to inject for themselves Depo SQ. Users Instructed to self-administer Depo Provera subcutaneously had higher continuation rates and lower pregnancy rates.
  • The US MEC guidance for Depo SQ and Depo IM are exactly the same.

• Levonorgestrel IUDs as Emergency Contraceptives
  • Clinicians have been reticent about providing a 52 mg levonorgestrel IUD (LNG IUD) for emergency contraception when a copper T 380A IUD, known to have an extremely low pregnancy rate, was available.
  • However, a recent study of IUDs for emergency contraception compared the 52 mg LNG IUD with the copper T 380A and found that the LNG IUD proved to be “noninferior” to the use of a copper IUD in pregnancy prevention. In the study, 706 women who had a negative pregnancy test and sought a morning-after contraceptive following unprotected intercourse were provided either the 52 mg LNG IUD or a copper T 380A IUD. After a month of IUD use, only 1 pregnancy was reported in users of an LNG IUD and 0 pregnancies among users of the copper IUD.
  • Users of the LNG IUD are likely to experience one of the non-contraceptive benefits attributed to the method, so it is likely that insertion of a 52 mg LNG IUD will become the preferred method of emergency contraception for many women in the future.
  • The non-contraceptive benefits associated with the LND IUD may include any of the following:
    • Decreased menstrual cramping, as much as a 95% reduction in menstrual blood loss
    • Protection against endometrial hyperplasia and endometrial cancer
    • Protection against the growth of uterine fibroids
    • Decreased endometriosis symptoms
    • Production of a thick mucus plug at the opening of the cervix preventing ascent into the uterus not only of sperm but also of a number of infectious agents.

BUT…innovation means nothing unless it leads to a change in practices. A continued focus is needed on the question “What is my (our) next right step?” The answer is in the hands of everyone providing contraceptives and of students of this field—offer your patients the option of any of these three exciting new methods: the drospirenone-containing progestin-only pill, the 52 mg LNG IUDs as emergency contraceptives, and Depo SQ for self-injection at home.