Noncompliance: How to improve method success
While women now have more contraceptive options, many still struggle with achieving success with their chosen contraceptive method. What can clinicians do to improve method success?
Researchers recently conducted a cross-sectional multicenter study to assess the self-described impact of noncompliant behavior among 26,250 typical users of three forms of combined hormonal contraception: the oral contraceptive (OC), the transdermal contraceptive [Ortho Evra, (Ortho-McNeil-Janssen Pharmaceuticals; Raritan, NJ], and the vaginal contraceptive ring (NuvaRing, Organon; West Orange, NJ).1
To assess method use, women completed a self-administered questionnaire; 65% of the women used OCs, 23% used the vaginal ring, and 12% used the transdermal patch. Researchers found noncompliant behavior, defined as missing/delaying in taking/applying, insertion, or removal of the pill/transdermal patch/vaginal ring, in 71% of pill users, 32% of patch users, and 21.6% of vaginal ring users. Emergency contraception was requested by 14% of pill users, 11% of patch users, and 6.3% of ring users.1
Noncompliant behavior negatively affected work activities and/or couple relationships in 10-20% of cases, researchers report. More than half of the women said they were worried, and about 20% stated they were scared due to inconsistent use of their contraceptive method.1
Daily dose a problem?
Iñaki Lete, MD, chief of the gynecology department at Hospital Santiago Apóstol, in Vitoria, Spain, says, "Based on our recent study where we have found noncompliant behavior in 71% of women using the pill, 32% of women using the patch, and 21% of women using the ring, we can conclude that when regarding the combined hormonal contraceptive methods, one of the most important factors in the noncompliance is the need of daily intake." Lete is the study's lead author. "When a woman takes a pill, she must to take it every day, 365 days in a year, so she has 365 opportunities to forget it," he says. "If the same woman uses the vaginal ring, she has only 12 or 13 opportunities to forget the ring."
Women participating in the study said they were tired of taking a pill every day for several years, says Lete. Women consider the new routes of administration of hormones more suitable and convenient, he states.
Research bears out Lete's observation. In studies comparing OC use against the transdermal patch, patch users reported more compliant cycles than pill users; odds ratios were 2.05 [95% confidence interval (CI)1.83 to 2.29] and 2.76 [95% CI 2.35 to 3.24] in two trials.2,3 In a multicenter trial in which women using OCs switched to the contraceptive patch or vaginal ring, researchers found that those women who were satisfied with combined oral contraceptives and interested in a nondaily method were more likely to continue using the contraceptive ring than the contraceptive patch.4
Educate for success
While the contraceptive patch and ring may offer more convenience, many women continue to choose oral contraceptives. How can you help them get on the right track when it comes to daily pill taking? Offer these tips from the Association of Reproductive Health Professionals (ARHP):
• Establish a routine that works for the patient.
Is your patient more likely to remember her pill in the morning or at night? How will she remind herself? Counsel women that it is best to take the Pill at the same time every day. To achieve, this goal, suggest making pill-taking part of something already in the daily routine, such as taking vitamins in the morning or brushing one's teeth before bed. If those don't work, how about right after dinner or with the first cup of coffee in the morning? Whether it's morning, noon, or night, counsel women that taking pills at a consistent time is the quickest way to develop a new routine.
• Try packing the pills.
Whether women decide to take their OC at home or at work, suggest that women carry their pills with them at all times. By doing this, they will have them on hand if they are suddenly called away or realize they forgot to take their daily dose.
• Mark the calendar.
Suggest that women try to pick up their pill packs on the same day every month and then mark their calendars accordingly. Many women pick up their packs every two months, on the first day of the month, says the ARHP.
• Implement the three-month rule for new users.
If women are new to OC use, counsel them to call or visit you for a quick checkup after three months of pill use. This follow-up contact gives women a great chance to discuss their experiences and review questions with you.5 (Editor's note: Get a free fact sheet for reproduction on the ARHP web site, www.arhp.org. Highlight "Patient Education," then "Health Matters Patient Education Fact Sheets," and then click on "Using Birth Control Pills Regularly For Success.")
Women may want to use their cell phones or personal digital assistants to set daily reminders for pill-taking, suggests Robert Hatcher, MD, MPH, professor of obstetrics and gynecology at Emory University in Atlanta.
Be sure that women leave the office with a prescription for emergency contraception, says Anita Nelson, MD, professor in the obstetrics and gynecology department at the University of California in Los Angeles (UCLA) and medical director of the women's health care programs at Harbor-UCLA Medical Center in Torrance. "Make sure that women have emergency contraception by prescription," she says. "Don't make them come into get it after the fact, because they don't come in on a timely basis."
References
- Lete I, Doval JL, Pérez-Campos E, et al. Self-described impact of noncompliance among users of a combined hormonal contraceptive method. Contraception 2008; 77:276-282.
- Audet MC, Moreau M, Koltun WD, et al. Evaluation of contraceptive efficacy and cycle control of a transdermal contraceptive patch vs. an oral contraceptive: A randomized controlled trial. JAMA 2001; 285:2,347-2,354.
- Urdl W, Apter D, Alperstein A, et al. Contraceptive efficacy, compliance and beyond: Factors related to satisfaction with once-weekly transdermal compared with oral contraception. Eur J Obstet Gynecol Reprod Biol 2005; 121:202-210.
- Creinin MD, Meyn LA, Borgatta L, et al. Multicenter comparison of the contraceptive ring and patch: A randomized controlled trial. Obstet Gynecol 2008; 111(2 Pt 1):267-277.
- Association of Reproductive Health Professionals. Using Birth Control Pills Regularly for Successful Contraception. Fact sheet. Accessed at www.arhp.org.
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