What to tell your patients

Pill, patch or injectable?

New birth control methods have women flocking to
practitioners for advice on what's best for them

By Julia Cyboran

Caroline Ouellet has been using birth control for over six years. She used to have reminders posted on her bathroom mirror so that she wouldn't forget to take the pill every evening before hitting the sack. Two years ago she had a close call after forgetting to take the pill three days in a row. "I was getting home late and not bothering to go through with my routine, so I forgot," Ms Ouellet explains. "I hesitated to change contraception methods but after that I took the initiative to ask my doctor about other options He recommended an injectable contraceptive once every three months. I haven't looked back since." Be that as a it may, the advent of the oral contraceptive pill in the 1960s put women in control of their reproductive health. Today, over 1.3 million women use the pill and 46 different OC products are available, as well as Medroxyprogesterone (the injection) and most recently Norelgestromin-ethinylestrdrol (the patch). The variety of choices has never been greater.But with choice, comes the question, "what product is best for me?" "Prescribing the pill is the first step, the second is to make sure that your patient is happy with it," says Dr Sheila Dunn. "Things that doctors feel aren't a big issue are a big issue for the woman, such as side effects like weight gain and nausea." Although statistics show a relatively low proportion of patients actually experience side effects, it's still the major reason why women hesitate to use hormonal methods of BC, or are reluctant to change products. "Choosing a birth control method is an informed decision," explains Dr Stephanie Palerme, recipient of the Queen's University Contraception Advice Research and Education Fellowship.Patients need to be aware of the pros and cons of the available products before picking what method is right for them.

• The Pill
  There are a variety of pills on the market mainly available in three different doses, 20, 30, and 35µg of estrogen. "Once you get below 35µg there have not been any decent studies that show an actual difference between pills," explains Dr Dunn. If a woman is looking for better cycle control, a higher dose of estrogen will better suit her needs (between 30 and 35µg). Pill side effects do vary, so if one formula isn't working for your patient after an adequate trial period another one with a slightly different hormonal composition might be better.

• The injection
  The medroxyprogesterone injection is taken every 11-13 weeks. It's convenient for women who tend to forget to take the pill everyday. It's also an ideal method for women who don't tolerate OCs that contain high levels of estrogen. It's important for patients to know that they may experience breakthrough bleeding at the beginning of therapy. With regular use of the injection, a woman will eventually stop having menstrual bleeding. Because of the absence of estrogen, there's no added cancer risk to women who smoke (unlike the pill or the patch). Women should be aware that the injection does reduce bone density. "Because we don't have great studies for bone density, I try to use alternate methods for teens or peri-menopausal women," says Dr Dunn. Women who have two or more risk factors for osteoporosis should also be made aware of the increased likelihood of this disease. Patients who are concerned about weight gain should also know that Medroxyprogesterone might cause an annual weight gain of 2 to 2.5kg.

• The patch
  The latest method to hit pharmacy shelves is the Norelgestromin-ethinylestrdrol patch. Dr Palerme explains that the patch's main advantage is that it improves patient compliance. "The patch (like the injection) is ideally suited for women who have difficulty remembering to take the pill." It has the same overall hormone composition as the average pill, so the side effects are similar. Some women may be concerned that the patch will fall off. Not to worry, the adhesive quality of the patch has been rigorously tested on women who do intense exercise and even swim while wearing the patch. Though 5% actually come off, the patch also allows for a two-day grace period, its efficacy lasts up to nine days, unlike the pill that must be taken every day.