Contraceptive choices vary by age

MOST ORAL CONTRACEPTIVE medications contain estrogen plus a progestin. They prevent pregnancy by inhibiting pituitary gland hormones that play key roles in egg development and preparing the uterus lining for implantation of the embryo. Over the years, the estrogen and progestin content of these pills has been reduced in an effort to decrease the incidence of common and serious adverse effects.

There are 62 million women aged 15 to 44 years in the United States, and about 62% of them currently use a contraceptive method.

"The choice of which contraceptive to use may vary from one stage of reproductive life to another," says Mark Abramowicz, MD, editor-in-chief of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs. "Intrauterine devices (IUDs), progestin implants and sterilization are the most effective contraceptive methods available to women. Hormonal contraceptives, when used correctly, are also highly effective in preventing pregnancy."

These medications have some secondary benefits. Women who take combination oral contraceptives have a reduced risk of both epithelial ovarian and endometrial cancer. They also experience a reduction in dysfunctional uterine bleeding and a lower incidence of ectopic pregnancy. However, estrogens can also lead to adverse effects such as nausea, breast tenderness and breast enlargement. Older formulations which contained more than 50 micrograms of ethinyl estradiol were associated with an increased risk of myocardial infarction and ischemic stroke, particularly in women who smoked or had uncontrolled hypertension.

"An oral combination contraceptive containing a low dose of estrogen-less than 35 micrograms-and a progestin is often prescribed for initial use," says Dr. Abramowicz. "Intrauterine devices and hormonal implants require no compliance on the part of the patient and are probably the most cost-effective of all reversible contraceptives. Barrier contraceptives have fewer adverse effects than oral or other hormonal contraceptives, but have much higher failure rates."

Over the years, insurance coverage for contraceptive medications has been a controversial topic.

In 2000, the Equal Employment Opportunity Commission (EEOC) ruled that an employer's failure to provide coverage for contraceptive drugs and services when it covers other preventive measures constitutes sex discrimination. Over the next few years, a series of rulings from the EEOC and federal courts found that health insurers and employers who exclude contraceptive coverage from comprehensive prescription plans are, as one decision put it, "leaving a fundamental and immediate healthcare need uncovered."

Nowadays, most workers in employer-sponsored plans do have coverage for contraceptives, according to the Kaiser Family Foundation. Twenty-eight states require insurers who cover prescription drugs to also cover all FDA-approved contraceptive drugs and devices, according to the Guttmacher Institute. Some of these states allow employers or insurers to refuse coverage on religious or moral grounds. In addition, several states have limited mandates for contraceptive coverage that apply only to certain insurers, such as HMOs, or to coverage written for specific markets.

Medicaid already requires states to cover family planning/contraceptives without cost-sharing. In addition, about half of the states currently have Medicaid programs that provide family planning services for women who don't qualify for full Medicaid coverage. In the past, these programs have required a special, time-consuming approval process. Under the reform law, states will be able to offer family planning services to those at 185% of poverty without needing additional federal approval.