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Providing More Contraceptive Packs Improves Continuation Rate

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Penny Murata, MD
  • CME Released: 8/30/2011
  • Valid for credit through: 8/30/2012, 11:59 PM EST
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Target Audience and Goal Statement

This article is intended for primary care clinicians and specialists who provide oral contraceptives to women.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Report whether providing 3 vs 7 cycles of oral contraceptive pills affects the 6-month continuation rate.
  2. Describe whether providing oral contraceptive pills as packs or by prescription affects the 6-month continuation rate.


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  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.


  • Brande Nicole Martin

    CME Clinical Editor, Medscape, LLC


    Disclosure: Brande Nicole Martin has disclosed no relevant financial relationships.

CME Author(s)

  • Penny Murata, MD

    Clinical Professor, Pediatrics, University of California, Irvine, California
    Pediatric Clerkship Director, University of California, Irvine, California


    Disclosure: Penny Murata, MD, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

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Providing More Contraceptive Packs Improves Continuation Rate

Authors: News Author: Laurie Barclay, MD CME Author: Penny Murata, MDFaculty and Disclosures

CME Released: 8/30/2011

Valid for credit through: 8/30/2012, 11:59 PM EST


Clinical Context

According to an article by Mosher and Jones published in the August 2010 issue of Vital and Health Statistics, 82% of women of reproductive age in the United States have used oral contraceptive pills (OCPs). However, one of the primary reasons that women discontinue OCPs is running out of pills, in addition to difficulty in accessing pills, as reported by Smith and Oakley in the September-October 2005 issue of the Journal of Midwifery & Women's Health and by Kerns and colleagues in the November-December 2003 issue of Perspectives on Sexual and Reproductive Health. In the June 2007 issue of Obstetrics & Gynecology, Westhoff and colleagues noted that OCPs are often provided as a 3-month supply by packs in hand or by prescription. In the March 2011 issue of Obstetrics & Gynecology, Foster and colleagues found that women who received a greater supply of OCPs were more likely to continue OCP use.

This randomized study by O'Connell White and Westhoff assesses whether providing a 3- or 7-cycle supply of OCPs affects the continuation of OCP use at 6 months, with subgroup analysis by age and pill supply as packs or prescription.

Study Synopsis and Perspective

Providing a greater supply of OCP packs when they are initiated may improve continuation rates, according to the results of a randomized, controlled trial reported in the September issue of Obstetrics & Gynecology.

"The often small number of [OCP] cycles provided may contribute to high rates of discontinuation," write Katharine O'Connell White, MD, MPH, and Carolyn Westhoff, MD, MSc. "We examined the effect of an increased OCP supply on 6-month continuation rates."

At an urban family-planning clinic, 700 women starting OCP use were randomly assigned to receive either 3 or 7 cycles of OCPs. Participants younger than 18 years and those who were uninsured received their entire OCP supply as packs, whereas those older than 18 years and who had insurance were further assigned to receive either OCP packs or a prescription for refills. At 6 months after enrollment, participants were telephoned to determine rates of OCP continuation and adverse events.

More than three quarters (76%) of participants had available follow-up data (260/342 participants in the 3-pack group; 244/319 participants in the 7-pack group). Rates of continuation at 6 months were higher in the 7-pack group than in the 3-pack group (51% vs 35%; P < .001). Among women younger than 18 years, the treatment effect was more pronounced (49% vs 12%; P < .001) than among women aged 18 years and older (52% vs 40%; P =.018).

Compared with women who received packs, those who received a prescription had lower OCP continuation rates (42% vs 21%; P = .027). Adverse events were infrequent and were not associated with receiving more OCP packs.

"A greater OCP supply at the time of initiation can improve continuation rates, especially among women younger than 18 years of age," the study authors write.

Limitations of this study include a smaller than anticipated insured subgroup, and a largely Hispanic, urban, and poor study population with low generalizability to all groups of women.

"Many medications need to be taken regularly to prevent disease progression and disability," the study authors conclude. "Drug-dispensing limits — 30-day supplies when filled at community pharmacies — are used to control prescription drug costs but may result in overall higher costs as a result of worsening disease. Medication continuation could be greatly enhanced by simply allowing patients to have a greater supply of pills on hand."

A grant from the Office of Population Affairs, Department of Health and Human Services, supported this study. Some of the study authors report various financial relationships with the Department of Health and Human Services, Duramed/Teva, Merck, Bayer, and/or Pfizer.

Obstet Gynecol. 2011;118:615-622. Abstract

Study Highlights

  • 700 women aged 35 years or younger seeking OCP use at an urban family planning clinic were randomly assigned to receive either 3 or 7 cycles of OCPs.
  • Exclusion criteria were contraindications to hormonal contraceptives, hormonal contraceptive use in the past 7 days, desiring pregnancy in the next 6 months, not sexually active, not English- or Spanish-speaking, and plans to leave the area within 6 months.
  • 359 women were randomly assigned to receive 3 cycles.
  • 341 women were randomly assigned to receive 7 cycles.
  • 661 women participated.
  • Women were assigned to groups by age and insurance status.
  • 19% of participants were younger than 18 years and received OCPs as packs: 42 received 3 cycles, and 43 received 7 cycles.
  • 64% of participants were aged 18 years and older without insurance and received OCPs as packs: 165 received 3 cycles, and 159 received 7 cycles.
  • 17% of participants were aged 18 years and older with insurance and were randomly assigned to receive packs or prescription for refills: 25 received packs and 28 received prescriptions in the 3-cycle group; 16 received packs and 26 received prescriptions in the 7-cycle group.
  • All women received 1 free pack of OCPs for initial use and a supply of condoms.
  • All women received routine care, including emergency contraception during the visit, if indicated.
  • The healthcare provider selected the OCP from the 2 available types: 35 µg ethinyl estradiol and 0.18/0.215/0.25 mg norgestimate, or 25 µg ethinyl estradiol and 0.18/0.215/0.25 mg norgestimate.
  • Patients who received 3 cycles were scheduled for a routine 3-month follow-up visit.
  • Patients who received 7 cycles did not have a scheduled follow-up.
  • The 7-cycle vs 3-cycle group was more likely to have given birth and to have at least 2 children.
  • Most participants were Hispanic.
  • 504 of 661 participants were interviewed by telephone 6 or more months after enrollment: 260 in the 3-cycle group and 244 in the 7-cycle group.
  • OCP continuation was defined as OCP use in the past 7 days or by number of packs started and completed.
  • The primary outcome measure was 6-month OCP continuation within each group.
  • Follow-up data were obtained from 76% of participants (260/342 in the 3-cycle group, and 244/319 in the 7-cycle group).
  • The 6-month OCP continuation rate was higher for the 7-cycle vs the 3-cycle group (51% vs 35%; P < .001).
  • The effect of 7-cycle vs 3-cycle OCP use on 6-month continuation rates was greater for participants younger than 18 years (49% vs 12%; P < .001) vs for those 18 years of age or older (52% vs 40%; P = .018).
  • Receiving prescription vs packs was linked with a lower rate of 6-month continuation overall (21% vs 42%; P = .027) in both the 3-cycle group (21.4% vs 56.0%) and the 7-cycle group (42.3% vs 50.0%), based on limited data and small sample size.
  • 6 adverse events occurred in the 3-cycle group: ectopic pregnancy, syncope, upper respiratory infection, asthma exacerbation, gastroenteritis, and ulcerative colitis flare-up.
  • 3 adverse events occurred in the 7-cycle group: cholecystectomy, hemiplegic migraine, and gastroenteritis.
  • Pregnancies occurred in 25 (9.9%) of 260 women in the 3-cycle group and 22 (9.0%) of 244 women in the 7-cycle group.
  • The most common reasons for discontinuation of OCPs were adverse effects, ran out of pills, not sexually active, missed pills, and seeking pregnancy.
  • Discontinuation of OCP as a result of running out of pills was more common in the 3-cycle vs the 7-cycle group (42/168 vs 16/119 women who discontinued use; P = .02).
  • Study limitations included lack of generalizability to other populations and limited power to compare effects of pack vs prescription supply because of the small subgroup size.

Clinical Implications

  • Women who receive 7 vs 3 cycles of OCPs have a higher 6-month continuation rate (51% vs 35%), especially those younger than 18 years (36.9% vs 11.8%).
  • Providing OCPs as packs vs by prescription appears to be linked with greater 6-month continuation rate, according to limited data. Providing 7 cycles vs 3 cycles of OCPs does not result in more adverse events or pregnancies.

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