For more than two decades, contraceptive innovations have been at a virtual standstill, leaving American women dissatisfied with what they considered imperfect choices.
But a flurry of new contraceptives is finally arriving. The products--some already on the market and others still in development--are more convenient and, in some cases, as effective as sterilization (99%) at preventing pregnancy.
Two new hormonal contraceptives--a monthly shot and a new type of IUD--were designed to appeal to women who find birth control pills inconvenient. Women have long complained that it's hard to remember to swallow a pill at the same time each day, especially if they travel a lot.
New mechanical methods were developed to improve upon the cervical cap and diaphragm for women who can't or don't want to take hormones.
There is no single reason for the anticipated birth control bonanza. A marketplace long dominated by a few big companies has attracted smaller firms that see untapped potential to reach specific groups of women. They recognize that among women who don't like their contraceptive, compliance is poor. With half of all pregnancies in this country unplanned, it's not that the contraceptives are failing; it's that women fail to use them consistently and properly.
Another reason U.S. women will have expanded choice is that federal spending on barrier contraceptive research, which began in the mid-1990s, has begun to pay off. As a result, alternatives to the diaphragm and cervical cap are getting closer to FDA approval, although the researchers still haven't perfected spermicides effective against both pregnancy and sexually transmitted diseases.
That the new products are coming to fruition at the same time "is a matter of sheer chance," says James Trussell, a Princeton University economist who studies contraceptives. "You could call it a banner year for new methods," said Dr. Robert Rebar, former chairman of the ob-gyn department at the University of Cincinnati.
The two newest offerings, the Lunelle monthly shot and Mirena IUD, have been on the market for a few months. Anita Miyake, a married mother of three, is typical of their intended customer.
"I'm not one to remember to take the pill everyday," said Miyake, who participated in a research study of Lunelle at Harbor-UCLA Medical Center in Torrance. "I liked it. It's a nice method. It's convenient."
In November, she began using the Mirena IUD, which can be left in place five years: "It's wonderful," said Miyake, 31, who does outreach work in women's health at Harbor-UCLA. "I know I'm protected all the time and my periods are a lot lighter."
Many U.S. women are similarly eager to try reliable new methods.
"Women have clearly demonstrated they are amenable to looking at new methods of contraception other than oral contraceptives," said Rebar, now associate executive director of the American Society for Reproductive Medicine in Birmingham, Ala. They are especially receptive, he said, to hormonal methods that deliver more of the drug locally and less into the bloodstream.
Two promising hormonal alternatives awaiting marketing approval by the Food and Drug Administration also should appeal to women looking for reliable, longer-acting contraception that doesn't interfere with sexual spontaneity. They are a patch that delivers hormones through the skin and a plastic ring that releases hormones inside the vagina for 21 days.
Most of the new contraceptives have been in development 10 to 15 years, some tweaking technologies already in use. Hormone replacement patches, for example, were adapted to deliver contraceptives, and the maker of a three-month synthetic progesterone injection came up with the one-month estrogen and progesterone injection that restores fertility sooner after a woman stops it.
The U.S. contraceptive landscape has always been idiosyncratic. Unlike in other countries, the top choice of American women 18 to 45 is sterilization, followed by the birth control pill, a 1960 innovation that at today's lower doses has fewer side effects.
Part of the reliance on sterilization is driven by the limits of insurance and the way in which litigation has tainted methods popular overseas, such as the IUD.
"Contraceptive coverage almost always includes coverage for surgical sterilization of a woman but often has not covered other options," said Dr. Felicia Stewart, an ob-gyn with UC San Francisco's Center for Reproductive Health Research and Policy. "In the past, women have been financially biased toward having surgery. You might lose your coverage next week, so once your tubes are tied, you don't have to pay for anything anymore."
It remains unclear which of the new contraceptives will be covered by health insurers, which have been expanding coverage of contraceptives. Some insurers may be unlikely to cover the $350 to $395 upfront cost for a Mirena IUD, plus insertion fees, thinking a woman is unlikely to remain enrolled long enough for the plan to realize the benefit.