Implanted Under the Skin, a New Contraceptive Protects Women Against Unwanted Pregnancies for Five Years
It has been 30 years since the Pill launched the "sexual revolution" in America, but women are still a long way from achieving perfect reproductive control. In the past decade there have been about 3.5 million unwanted pregnancies every year—nearly half of which ended in abortion. "Both as individuals and as a country, unintended pregnancy is one of America's biggest problems," says Jacqueline Darroch Forrest, vice president for research at the Alan Guttmacher Institute in New York City, a nonprofit reproductive health research organization.
America's dismal record is due in part to the limited number of contraceptive methods available here, far fewer than in much of Western Europe and even some Third World countries. Last month, however, the Food and Drug Administration took a major step by approving the first new type of contraceptive in the U.S. in nearly 30 years. It's called Norplant, and it can provide protection for up to five years with a single treatment. Norplant comes in the form of six silicone capsules the size of matchsticks. Inserted just beneath the skin on the inside of a woman's upper arm, the capsules slowly release the hormone progestin. The contraceptive will be marketed by Wyeth-Ayerst Laboratories in the U.S. next month, but it is hardly experimental. Developed over the past 24 years by the international nonprofit Population Council, it has already been approved in 16 countries.
"Norplant is not for everyone," says Forrest, "but it's an important step." Born in Jamestown, N. Y., the oldest of three children (before retirement, her father was an engineer, her mother a secretary), Forrest graduated from Barnard College in 1968 and eight years later got her Ph.D. from Princeton in sociology. She joined Guttmacher in 1978. Forrest lives in Chatham, N.J., with her husband, Michael Burnhill, a gynecologist, and their 16-year-old son, Chris. In her Manhattan office, crammed with books and statistical reports, Forrest spoke with senior writer Bonnie Johnson about both the benefits and the limitations of Norplant.
Norplant has been hailed as a breakthrough in contraception. Do you agree?
Yes, in that it is an important new method of delivering a proven contraceptive drug. Progestin, which inhibits ovulation and helps block the passage of sperm by thickening cervical mucus, is one of the hormones in oral contraceptives. And silicone has been used in surgical inserts for years. What is new is the format: silicone capsules that are placed under the skin.
What are the benefits of this new system?
Unlike the Pill, Norplant is not susceptible to user error. Once the capsules are implanted, the progestin is released continuously. Also, because it is released directly into the blood, you can give a lower dose and still have high effectiveness.
How effective is it?
The success rate is over 99 percent, about the same as that for sterilization, which is the most widespread method of contraception in the U.S. It is more effective than other reversible methods: Oral contraceptives are 94 percent effective; condoms, 86 percent; and the diaphragm, 84 percent. Of course, like the Pill, Norplant offers no protection against sexually transmitted diseases, such as AIDS. Only barrier or spermicide methods—like the condom or foam—provide that protection.
How are Norplant capsules inserted?
Under a local anesthetic, a 1/8-inch incision is made on the inside of the woman's upper arm. The implants are inserted in a fanlike formation, which makes them easier to remove. It's a minor procedure, which takes about 15 minutes, but it is surgery. There may be some bleeding and soreness.
How do you reverse the procedure?
The capsules are removed through another small incision, by maneuvering each implant so it can be pulled out. Removing them generally takes a little longer than putting them in.
Are there drawbacks to Norplant?
Irregular menstrual periods and spotting are common side effects. Some women stop having periods at all. A few Norplant users have experienced very heavy bleeding and have had the implants removed. As with oral contraceptives, weight gain, headaches and dizziness are also possible side effects.
Does it matter at what point in a woman's cycle Norplant is inserted or removed?
Wyeth-Ayerst recommends insertion during or just after menstruation—as a safeguard against implanting them in a pregnant woman. Fertility is restored within 48 hours of removal, so, unless you wish to conceive, you must immediately have a new Norplant inserted or resort to another form of contraception.
How much does Norplant cost?
Wyeth-Ayerst hasn't revealed the price yet, but my best guess is it will cost patients about $500 for the implants and doctor's fee combined. That's a concern. It's a lot of money to pay up front, and it will be out of the range of most public clinics. Since Norplant was developed in the public sector, one would hope that Wyeth-Ayerst in turn would make it affordable for all women who want to use it.
Who will benefit most from Norplant?
I think the group best served will be couples who have children and are considering sterilization. Norplant will give them a very effective method that will preserve their option to have children later.
Will it have any impact on the high number of unwanted pregnancies?
If it is primarily a replacement for sterilization—a method generally used by men and women over 30—then it will have very little effect. The greatest number of unplanned pregnancies are among teens and women in their 20s and they're especially high among the poor. Norplant is expensive. It requires forethought and access to a doctor for insertion and removal. For those reasons it's unlikely that a lot of young, low-income women will turn to it unless it becomes available at low cost through public clinics.
Do you fear women will be coerced into using Norplant by judges or employers?
The issue of other people telling women when or when not to have a child is an important one in our society. But the issue is not unique to Norplant, and I doubt there will be much coercive use of this contraceptive. At any rate there is no way Norplant could be implanted in a woman without her knowing about it.
If you had a daughter, would you recommend that she use Norplant?
If she were sexually active, I would recommend Norplant without hesitation for preventing pregnancy.
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