The pill remains the default female contraceptive. Should it be?

Doug Hendrie

28/04/2020 4:27:54 PM

Newer contraceptives may be better options, but unfamiliarity may be preventing wider uptake.

Intrauterine devices
IUDs and implants may offer benefits over the pill.

The pill has been Australia’s default female contraceptive for decades.
But many other options have emerged since the first pill was released in Australia almost 60 years ago – and some can offer real benefits, according to Professor Danielle Mazza of the Monash University Department of General Practice.
So why, Professor Mazza asks, is the pill still the first choice of so many?
Implants or intrauterine devices (IUDs) – collectively known as long-acting reversible contraception (LARCs) – can now offer up to five years’ coverage with a higher effectiveness in typical-use scenarios, in which users may often forget to take the pill for a day or two.
By contrast, LARCs do not rely on users taking a pill every day. 
‘IUDs are suitable for use by young women and, in fact, recommended by peak bodies as one of the most effective ways methods of contraception,’ Professor Mazza told newsGP.
But like  the US, Australia has been slow to embrace the new contraception options. Rates of use for IUDs and implants combined are only around 11%, whereas around 25% of women choose IUDs for contraception in countries like Sweden.
‘For typical use, LARCs are 99% plus effective, whereas the pill is 91% effective,’ Professor Mazza said.
‘If you were to use the pill perfectly, then the effectiveness rate is higher. But typical use means it’s less effective.
‘Younger women are particularly vulnerable to the fact it requires a daily action.’
In part, the issue may be GP and patient unfamiliarity with LARCs or uncertainty about their safety and use. Young women may request the pill simply because it is the most well-known option.
‘If GPs don’t offer an implant or an IUD as an option, then women are unlikely to consider them,’ Professor Mazza said.
‘The pill is still the default. Many young women may not be aware of all their options or of how useful IUDs and implants could be for them.
‘Many GPs feel unfamiliar with IUDs. They may not have been trained in insertion.
‘There are also system barriers, such as the fact that insertion is poorly remunerated and very few GPs have the opportunity to train in family planning and contraception. That’s a real problem.’
The recent ACCORD trial by Professor Mazza and her colleagues found that uptake of LARCs could be boosted by delivering targeted education to GPs about effectiveness-based contraceptive counselling alongside a portal for rapid referral to get a LARC IUD inserted.
The randomised controlled trial involving 57 GPs and 740 women across Melbourne found that 46.6%of women attending trial-trained GPs opted for LARCs, compared with 32.8% who received usual care.
‘It demonstrates that if we invest in and around issues of contraceptive counselling and LARCs, we can increase rates of uptake, hopefully comparable to international levels,’ Professor Mazza said.
‘Some women many not be aware of the benefits of using something like an IUD, which markedly reduces bleeding.
‘Often women don’t have to suffer period pain, and a significant proportion don’t bleed at all, which some would really appreciate it. That means it can be a good treatment for endometriosis, too.’
Australia has one of the highest abortion rates in the developed world, indicating contraceptive options may not be in use or fully effective.
A 2018 survey published in the Medical Journal of Australia found the unplanned pregnancy rates at around 26% in Australia, with around 30% of the unplanned pregnancies terminated. About 50% of the unplanned pregnancies were to women who were not using any contraception.
In a 2017 Australian Journal of General Practice article, the authors note that Australia’s current approach to contraception could be improved.
‘[A]s high rates of unintended pregnancy, terminations and use of the “morning after pill” attest, many young women either use unreliable methods of contraception or are unreliable in their use of contraception,’ they state.

Correction: This article originally stated the first five-year LARC was listed on the Pharmaceutical Benefits Scheme (PBS) earlier this year.
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Dr Franziska Levin   29/04/2020 10:04:19 AM

We also have the copper IUD which can last up to 10 years and until the menopause if inserted after 40. This is a good option for women who want or have to avoid hormones and is also the gold standard for emergency contraception.
In the UK we routinely discuss LARC with oral contraceptive prescription and it is a national target to offer LARC with any emergency contraceptive prescription.
There is also a different POP containing desogestrel (eg Cerazette) which has a 12 hour window making it more user friendly.
If we had this POP and were using LARC more widely we could reduce the significant number of women with UKMEC 3 or 4 who are still using COC in a non safe way in Australia.