Women can now use several methods of hormonal birth control--not only pills but also the new vaginal ring and skin patch--without taking a break every fourth week to have a period, doctors say.
Experts speaking at the annual meeting of the American College of Obstetricians and Gynecologists, held last week in Los Angeles, said there is no harm in using the contraceptives for several months before allowing the shedding of the uterine lining.
Forty years after the launch of the birth control pill, "we've woken up and realized we don't need to have a monthly period," said Dr. Anita Nelson, professor of obstetrics and gynecology at UCLA School of Medicine.
Also discussed at the conference were the increasing demands for caesarean sections, the delivery risks of women in their 40s and the nation's high rate of preterm births. But it was the increasing number of options for skipping a monthly period that is likely to generate the most interest among women.
Women who want to use birth control pills continuously should select a brand that is monophasic, meaning that each pill in a 21-day package has an identical amount of hormones. Some birth control pills, called triphasic, have varying levels of birth controls for each week of the monthly cycle.
Two newer birth control options, the Evra hormonal skin patch, and the NuvaRing, a vaginal ring that releases hormones, can also be used continuously, although they are not labeled as such, Nelson says.
Evra recently became available, and NuvaRing, which was recently approved by the Food and Drug Administration, should be on the market this summer.
Many doctors, however, may resist endorsing continuous-use birth control until the FDA formally approves a product labeled for such use--and that product is on its way. Seasonale, a birth control pill marketed for 91 days of continued use, is currently in clinical testing and may reach the market in 2003. Dr. David M. Plourd, an assistant professor of obstetrics and gynecology at the Naval Medical Center in San Diego, said women's birth control options are increasing rapidly.
In addition to Evra and the NuvaRing, other newer methods are Lunelle, a monthly birth control shot, and Mirena, a progesterone-releasing intrauterine device that is approved for five years' use. On the horizon is a simpler, smaller version of Norplant, the hormone-releasing device that is implanted under the skin in the upper arm, and Essure, a permanent birth control method that could provide women with an alternative to tubal ligation.
Essure is a tiny coil that is inserted into the fallopian tube via a catheter deployed through the cervix. Once in place, tissue grows around the implant to block the tube. Unlike surgical tubal sterilization, Essure does not require an incision and can be performed without general anesthesia. If approved, Essure could become available early next year.
Other topics of discussion:
Caesarean sections. Is it reasonable for a woman having her first baby to opt for a planned, elective caesarean section instead of vaginal birth? That question continues to be hotly debated by obstetricians. At a forum on the issue, doctors could agree only that there is no scientific data showing the risks and benefits for an elective, first-birth C-section.
"I don't think we're yet in a position to be offering this as standard-of-care," said Dr. Robert Resnick, a professor of obstetrics and gynecology at UC San Diego. "We don't know enough to put this on the table as the No. 1 option."
Doctors are especially interested in determining just how much damage a vaginal birth does to the nerves and muscles in the pelvic floor. For example, many women suffer from incontinence after having a baby.
"We know there is short-term damage," said Dr. Joseph I. Schaffer, an associate professor of obstetrics and gynecology at the University of Texas Southwestern Medical Center in Dallas. "But the question we must address is what happens in the long term."
An increasing number of women are asking for C-sections, says Dr. Michael F. Greene, director of maternal-fetal medicine at Massachusetts General Hospital in Boston, but not because they worry about future pelvic-floor damage.
"Many women have a tremendous fear of labor," he said. "I think that may be more of a factor in requesting an elective C-section than we imagined."
Age differences: Women having babies in their 40s are not at greatly increased risk of complications compared to younger women, according to a study presented by Dr. Vivien L. Pan of USC's Keck School of Medicine.
Pan reported on 551 women ages 40 to 49 and 14,951 women in their 20s and 30s. Her analysis showed that older women were more likely to have existing disorders that can complicate pregnancy, such as diabetes and chronic hypertension, and were also more likely to acquire those conditions during pregnancy. Older women were also more likely to undergo a C-section.
However, there were no differences between the older and younger women for rates of preterm labor and birth, a complication called placenta previa, operative vaginal deliveries (such as use of forceps), use of epidurals, rates of vaginal birth after caesarean and the babies' overall health.
Preterm births: Rates of preterm birth in the United States remain stubbornly high--at about 10% of all births--despite several efforts over the past decade to address the problem. So far doctors have only been able to tell women when they are not likely to go into premature labor, said Dr. Michael L. Socol, a professor of obstetrics and gynecology at Northwestern University in Chicago.