Contraceptive compliance with a triphasic and a monophasic norethindrone-containing oral contraceptive pill in a private adolescent practice

Triphasic versus monophasic oral contraceptives for contraception

BACKGROUND

Side effects of oral contraceptive (OC) pills discourage adherence to and continuation of OC regimens. Strategies to decrease adverse effects led to the introduction of the triphasic OC in the 1980s. Whether triphasic OCs have higher accidental pregnancy rates than monophasic pills is unknown. Nor is it known if triphasic pills give better cycle control and fewer side effects than the monophasic pills.

OBJECTIVES

To compare triphasic OCs with monophasic OCs in terms of efficacy, cycle control, and discontinuation due to side effects.

SEARCH METHODS

We searched the computerized databases of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, POPLINE, EMBASE, and LILACS, as well as clinical trials databases (ClinicalTrials.gov and the World Health Organization Clinical Trials Registry Platform (ICTRP)) in May 2011. Additionally, we searched the reference lists of relevant articles. We also contacted researchers and pharmaceutical companies to identify other trials not found in our search.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing any triphasic OC with any monophasic pill used to prevent pregnancy. Interventions had to include at least three treatment cycles.

DATA COLLECTION AND ANALYSIS

We assessed the studies found in the literature searches for possible inclusion and for their methodological quality. We contacted the authors of all included studies and of possibly randomized trials for supplemental information about the methods used and outcomes studied. We entered the data into RevMan and calculated odds ratios for the outcome measures of efficacy, breakthrough bleeding, spotting, withdrawal bleeding and discontinuation.

MAIN RESULTS

Of 23 trials included, 19 examined contraceptive effectiveness. The triphasic and monophasic preparations did not differ significantly. Several trials reported favorable bleeding patterns, that is less spotting, breakthrough bleeding or amenorrhea, in triphasic versus monophasic OC users. However, meta-analysis was generally not possible due to differences in measuring and reporting the cycle disturbance data as well as differences in progestogen type and hormone dosages. No significant differences were found in the numbers of women who discontinued due to medical reasons, cycle disturbances, intermenstrual bleeding or adverse events.

AUTHORS' CONCLUSIONS

The available evidence is insufficient to determine whether triphasic OCs differ from monophasic OCs in effectiveness, bleeding patterns or discontinuation rates. Therefore, we recommend monophasic pills as a first choice for women starting OC use. Large, high-quality RCTs that compare triphasic and monophasic OCs with identical progestogens are needed to determine whether triphasic pills differ from monophasic OCs. Future studies should follow the recommendations of Belsey or Mishell on recording menstrual bleeding patterns and the CONSORT reporting guidelines.

Triphasic versus monophasic oral contraceptives for contraception

BACKGROUND

Side effects of oral contraceptive pills (OCs) discourage adherence to and continuation of OC regimens. Strategies to decrease adverse effects led to the introduction of the triphasic OC in the 1980s. Whether triphasic OCs have higher accidental pregnancy rates than monophasic pills is unknown. Nor is it known if triphasic pills give better cycle control and fewer side effects than the monophasic pills.

OBJECTIVES

To compare triphasic OCs with monophasic OCs in terms of efficacy, cycle control, and discontinuation due to side effects.

SEARCH STRATEGY

We searched the computerized databases of MEDLINE, EMBASE, POPLINE, LILACS and CENTRAL. Additionally, we searched the reference lists of relevant articles and book chapters. We also contacted researchers and pharmaceutical companies in Europe and the U.S. to identify other trials not found in our search.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing any triphasic OC with any monophasic pill used to prevent pregnancy. Interventions had to include at least three treatment cycles.

DATA COLLECTION AND ANALYSIS

We assessed the studies found in the literature searches for possible inclusion and for their methodological quality. We contacted the authors of all included studies and of possibly randomized trials for supplemental information about the methods and outcomes studied. We entered the data into RevMan 4.2 and calculated odds ratios for the outcome measures of efficacy, breakthrough bleeding, spotting, withdrawal bleeding and discontinuation.

MAIN RESULTS

Of 21 trials included, 18 examined contraceptive effectiveness: the triphasic and monophasic preparations did not differ significantly. Several trials reported favorable bleeding patterns, i.e. less spotting, breakthrough bleeding or amenorrhea, in triphasic versus monophasic OC users. However, meta-analysis was generally not possible due to differences in measuring and reporting the cycle disturbance data as well as differences in progestogen type and hormone dosages. No significant differences were found in the numbers of women who discontinued due to medical reasons, cycle disturbances, intermenstrual bleeding or adverse events.

AUTHORS' CONCLUSIONS

The available evidence is insufficient to determine whether triphasic OCs differ from monophasic OCs in effectiveness, bleeding patterns or discontinuation rates. Therefore, we recommend monophasic pills as a first choice for women starting OC use. Large, high-quality RCTs that compare triphasic and monophasic OCs with identical progestogens are needed to determine whether triphasic pills differ from monophasic OCs. Future studies should follow the WHO recommendations on recording menstrual bleeding patterns and the CONSORT reporting guidelines.

Assessment of oral contraceptive pill continuation in young women

STUDY OBJECTIVE

To assess oral contraceptive pill (OCP) continuation rates and factors associated with OCP continuation in young women.

DESIGN

A 12-month retrospective cohort study by chart review of 226 young women seen for an initial clinic visit.

SETTING

Urban hospital-based family planning clinic.

PARTICIPANTS

Predominantly African-American, sexually active young women, 12 to 21 years of age (median age, 17.2 years).

MAIN OUTCOME MEASURES

Scheduled OCP-appointment-keeping rates, pregnancy rates, and associated factors were compared between OCP-compliant and -noncompliant groups.

RESULTS

The OCP-appointment-keeping rate declined dramatically over 1 year, from 29% at the 3-month visit to 9% at the 12-month visit. Almost half seeking a postpartum visit checkup (PPVup) did not return after the initial clinic visit. Overall, a higher OCP-appointment-keeping rate was noted in those seeking OCPs vs. PPVup at the initial visit; P < .05 for 12-month visit. There was no difference in the pregnancy rates between OCP-compliant and -noncompliant groups. School enrollment and nulliparity was significantly associated with OCP compliance until the 6-month visit (P < .05).

CONCLUSION

In an urban hospital based clinic, the OCP continuation rate after the initial visit was poor. Continuation of OCPs may be anticipated by type of services sought at an initial visit. Methods to improve OCP continuation in this setting should be implemented.