Contraception: Past, present, and future

In a recent interview, Michael L. Krychman, MD, a clinical health professor from the University of California, Irvine, in Orange County, discussed changes in the contraceptive landscape—from progesterone-only pills to intrauterine devices (IUDs). Krychman also dived into what contraceptive options physicians should be on the lookout for in 2023. This Q&A has been edited for brevity and clarity.

Contemporary OB/GYN®: What were some of the biggest approvals and milestones for contraception in 2022?

Michael L. Krychman, MD: The trend that we’re seeing for women’s health care is long-acting reversible contraception, which…has really moved into the forefront. I think a lot of women have been interested [in] contraception; they want safety and efficacy. There has been a trend I’ve seen in clinical practice of increasing [use of] IUDs.

Interestingly enough, the Mirena [levonorgestrel-releasing intrauterine system; Bayer] and Liletta [levonorgestrel-releasing intrauterine system; Allergan USA] [are] both approved for 8 years, [whereas] if you look in comparison with the copper IUD that we currently have, that is approved
for 10 years.

We are also seeing an increase in patient-directed contraception like Annovera (segesterone acetate and ethinyl estradiol vaginal system; Mayne Pharma). We are seeing an increased interest in this contraceptive method. The ring is self-directed, lasts 13 cycles, and doesn’t require refrigeration.

Contemporary OB/GYN®: We’ve talked about some of these trends, but are there any in contraception that are important for obstetrician-gynecologists to know?

Krychman: One of the trends that is increasing is this progesterone-only contraception for special populations, such as those who are breastfeeding, smokers, and women with obesity. There is now a new kid on the block for these special populations, Slynd (drospirenone; Exeltis USA), which has a dosing schedule of 24 plus 4 (24 active hormone pills + 4 placebo pills). But interestingly enough, it has a 24-hour miss pill window. Traditionally, when you’ve seen progesterone-only pills that we prescribed, they really needed to be taken tightly, meaning there was no window. And again, we all know we’re very busy. I personally can’t even remember to take vitamins on a regular basis. And I’m certainly missing some occasionally. As an added benefit, it is well tolerated and has an acceptable bleeding pattern in terms of [an adverse] effect profile.

I think there [are] other trends in what I would call the contraceptive realm that are hormonal. We saw a new patch, Twirla (levonorgestrel and ethinyl estradiol; Agile Therapeutics), which consists of 3 weeks on and
1 week off. We’re also seeing Nextstellis (drospirenone and estetrol tablets; Mayne Pharma), which has a half-life of 24 to 28 hours, minimal impact on hemostasis, and minimal first pass issues. Lastly, as a nonhormonal method, we are seeing the rise of Phexxi (lactic acid, citric acid, potassium bitartrate; Evofem), which is 1 dose, 1 hour before intercourse, and is patient-directed.

I think the trend for me is really looking at the woman in totality, and how we listen to our patients, recognize their lifestyle, recognize their preexisting conditions, and match and mirror that precision medicine request in terms of contraceptive choice. For me…that’s really important—to have a lot of different options available and really to marry the right contraception with the right patient as well.

Contemporary OB/GYN®: Are there any clinical studies going on right now that will add to the contraceptive options for the future? Does anything really stand out to you?

Krychman: I think there is some big interest in the low-dose copper IUD; I believe it’s in phase 3 clinical trials. And again, this will give us more options as well. So, we’d certainly have a lot of hormonal IUDs that are available and that have extended availability for the duration of use. But a lower dose of copper for a shorter duration may be very helpful, and it may be for certain patient populations as well.

I see a lot of women with hormone-sensitive malignancies. They still need contraception. Many of them are opting for extended nonhormonal treatments. And this may give them another option as well. I believe that there is a nonhormonal vaginal capsule that may function in terms of thickening the mucus and a nonhormonal copper coil that may be good for 5 years.

It’s nice to hear that there [are] still people and companies investing in women’s health. I take the philosophy that the more the merrier [when it comes to] this new trend in precision medicine, which is important because 1 size [does not] fit all; every woman’s contraceptive experience, every woman’s medical history, every woman’s birth spacing opportunities are very different. Someone may want extended periods, some may want shorter, and let’s not forget the noncontraceptive benefits of contraception as well.

Even though we’re talking about what’s new in contraception, these options may have far-reaching effects [and] more treatment opportunities off-label for abnormal bleeding or pelvic pain. So, a gamut of treatment opportunities is very helpful for women, and it’s helpful for clinicians to meet the needs of their patients.

Contemporary OB/GYN®: Is anything coming down the pike regarding FDA approvals for contraception in 2023 that you are looking forward to?

Krychman: We talked about this low-dose copper IUD, which is in clinical trials, but I’m not sure if it’s going to be getting to the US Food and Drug Administration for approval in 2023. But there’s a lot of buzz about male contraception, whether it’s a gel or a pill. I think the biggest thing to keep on the radar is this low-dose copper IUD and what those trials will demonstrate. It will give us another option—a nonhormonal IUD choice—which I think will be helpful.

Contemporary OB/GYN®: And is there anything else you would like to note?

Krychman: The most important thing to remember is to listen to your patients. When they come in, they have preconceived ideas about what is best for them. I think part of what we do as health care professionals is educate our patients, and we need to educate them on all the options. We also need to be very careful about what we’re referring and recommending to our patients. But I think the big issue is [adherence], and listen [to] and understand what their birth spacing is, what is their medical history, and impart that information. It’s also about shared decision-making. Choosing the right product for the right patient under the right circumstances, and at the right time of their lifecycle. It’s not uncommon that women will choose one product and then as they progress, or after they’ve had their children, they may choose another. And as they approach menopause, they may choose a different one. So again, keeping all these options [for] counseling open and unbiased, I think, is very important to ensure adequate treatment of both the contraceptive issues and any noncontraceptive issues as well.

Watch the full interview here: 2023 Contraceptive pipeline outlook