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Valerie Tarico

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Picture a Technology Revolution. In Contraception. It's Here.

Posted: 01/26/2012 3:11 pm

Imagine a future in which we can simply toggle the default on human fertility, so that accidental pregnancy is a thing of the past and women become fertile only when they want to become pregnant. By nature, adolescence switches our fertility default to "on" and it is stuck there for the next 40 years. Globally, 100 million women want to delay, space or limit child bearing but have no control over their fertility. Even women who are lucky enough to have contraceptives like Pills or patches or injections have to keep switching fertility back off.

The latest generation of long acting reversible contraceptives (LARCs) are game-changers. On the Pill --1960s technology with minor tweaks -- one in 12 women gets pregnant each year! With condoms, it's one in eight. (No contraception would be eight out of ten.) With the most effective hormonal IUD available, that number is one in 700. That's the same as sterilization, and yet fertility can be restored by a five-minute procedure and returns within a few cycles.

Fit and Forget.
The primary reason LARC's are so much more effective than older contraceptive technologies is the default factor. Manufacturers like to talk about "perfect use" -- but are you perfect? Do you know anyone who is? Next to nobody remembers to take the pill at the same time every day. And next to nobody uses the condom "perfectly" for years on end. The average woman on birth control pills misses multiple pills per month; and this remains true of women even when they are trying really hard, even when they send themselves text message reminders.[1] Pills and condoms have a 100 percent predictable, baked-in failure rate, because real live human beings are part of the equation. What's painful is that most people don't know that. So when contraceptives fail, they think it's just them.

LARC's by contrast are "fit and forget." The implant Implanon or Nexplanon is good for three years. The Mirena IUD, which releases a micro-dose of progestin, is good for five to seven. A copper Paragard IUD is good for at least 12. Even the Ring is headed in this direction. A one-year ring should be available in the U.S. in 2014. Getting a LARC is more hassle and expense than getting a pill pack or box of condoms. It requires a medical procedure; no one technology works for everyone; and sometimes the first one isn't a fit. But once a LARC is settled in, the expense and hassle of monthly or daily or every-time-you-have-sex contraception is over.

Choose your period.
If that wasn't enough, some LARCs have a side benefit (formerly thought of as a side effect) that radically improves the lives of many women: They reduce menstruation. Hormonal IUDs, which release a micro-dose of progestin, reduce bleeding by on average 90 percent, completely eliminating periods (and cramps, bloating, anemia and related menstrual morbidity) in most users by the second year. In 2009, the FDA approved the Mirena IUD to regulate menstrual bleeding. Implants and injections also can be "bleed free." One Seattle family planning provider asks every woman who comes through her door: "How often do you want to have your period? Once a month, once every few months, or never?"

For women who are plagued monthly with cramps, nausea and worse, being able to reduce symptoms is a godsend. American women miss over 100 million hours of work annually because of menstrual symptoms. But even for women with milder periods, less may be better. Growing evidence suggests that Western women overall experience more menstrual bleeding than is optimal from a health standpoint. We have four times as many periods as our hunter gatherer ancestors. What has been called the "incessant ovulation" of modern women causes chronic anemia and may have more severe lifetime effects including increased risk of cervical, uterine and breast cancers, and osteoporosis. More and more women are opting for menstrual regulation by using continuous birth control pills, but this requires that they keep their entire bodies flooded with hormones, in contrast to the micro-dose released locally by an IUD.

Jump the Information Gap.
In the U.S., young women who have not yet started families are only beginning to use IUD contraception thanks in part to an information gap. FDA approval lags behind international trends and U.S. research. The agency removed restrictive language limiting the copper ParaGard IUD to women with children only in 2005, and the agency has not yet signed off on the use of a hormonal IUD for childless women. By contrast, the World Health Organization, Center for Disease Control, and American College of Obstetricians and Gynecologists have endorsed the use of both IUDs in young women including adolescents and childless women. In other words, the safety of this technology has been established to the satisfaction of international and professional bodies but regulations still restrict promotion of LARCs directly to young women.

In addition, while family planning specialists are rapidly shifting their clients to LARCs, other medical gatekeepers often remain mired in old habit patterns and in anxieties that were relevant to 1970s technology. Misinformation in the medical community translates into misinformation or more often a simple absence of information among members of the public. Men and women blame themselves for failures of more traditional contraceptives, not knowing that a large human error factor is built in. Similarly, women rarely have any idea how many of their peers experience debilitating menstrual symptoms like their own. Most have not even heard that a LARC can reduce their risk of pregnancy by an order of magnitude or that menstrual regulation is a healthy option.

Demand Better.
Room for improvement in contraception is dramatic. In the U.S. the percent of pregnancies that are unintended has been stable between 45 and 50 percent for almost a generation. In almost half of these cases, the woman was using contraception in the month she got pregnant. Contraception failed. Unmarried women between the ages of 18 and 29 describe 70 percent of their pregnancies as unintended! Live births to U.S. teens are higher than any other country with similar economic development, and roughly half of girls who give birth as teens drop out of school. It doesn't have to be this way. In a study of 100 post-partum teens, half were given a LARC and half the pill. At the end of a year, one in the LARC group was pregnant again; 20 were pregnant again in the Pill group.

The U.S. population includes 65 million women of reproductive age. Most of these women either aren't ready to start families or already have as many children as they desire. And yet they continue ovulating and then bleeding each month, paying a price in health and lifestyle for close to 40 years. Young millennials vent their annoyance via wry commentary, "Why Periods Suck" for example at Tumblr or Twinklex or Facebook. Hundreds of older women have posted more painful tales of woe at the online Museum of Menstruation (mum.org). To the question, "Would you stop menstruating if you could?" responses fall two to one on the yes side. In an international study of over 4,000 women who had a hormonal IUD, 55 percent stated that preference for shorter, lighter periods was a factor in their contraceptive choice.

American women are ready for change. IUD use in the United States is dramatically low compared to other developed countries. Currently 26 percent of Norwegian female contraceptive users have an IUD, but less than 6 percent of Americans do. And yet, the U.S is showing a rapid shift in recent years. From a low of 1.3 percent of U.S. women using any kind of IUD in 1993, prevalence jumped to 2 percent by 2002 and then to 5.5 percent between 2006 and 2008. With FDA approval of bleed-free Implanon in 2006, approval of the Mirena for menstrual symptoms in 2009, and a long-acting ring in the pipeline, we are on the cusp of a contraceptive revolution that has the potential to revolutionize our lives.

[1] Hou MY, Hurwitz S, Kavanagh E, Fortin J, Goldberg AB. "Using daily text-message reminders to improve adherence with oral contraceptives: a randomized controlled trial." Obstet Gynecol 2010 Sep, 116(3): 633-40.

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