Aetna considers Depo-Provera (medroxyprogesterone acetate injectable suspension) medically necessary for any of the following indications:
Cystic ovaries
Dysfunctional uterine bleeding
Dysmenorrhea
Endometriosis
Menorrhagia
Oligomenorrhea
Renal cancer
Endometrial cancer
Breast cancer.
Aetna considers Depo-Provera experimental and investigational for prevention of pregnancy and for all other indications. Note: Many plans exclude coverage of contraceptives. Please check benefit plan descriptions for details.
Lunelle (Combination Estrogen and Medroxyprogesterone Injection):
Aetna considers Lunelle (combination of estrogen and medroxyprogesterone in a monthly contraceptive injection) medically necessary for prevention of pregnancy.
Aetna considers Lunelle experimental and investigational for all other indications. Note: Many plans exclude coverage of contraceptives. Please check benefit plan descriptions for details.
Progesterone or Hydroxyprogesterone Injection:
Aetna considers progesterone or hydroxyprogesterone injection medically necessary for any of the following indications:
Menstrual disorders including secondary amenorrhea and dysfunctional uterine bleeding; or
Corpus luteum insufficiency (Note: Coverage is limited to persons with Advanced Reproductive Technology benefits covering injectable medications for infertility); or
Diagnosis of endogenous estrogen production (as in diagnosis of menopause); or
Prevention of preterm labor in women who are at high risk (e.g., prior history of preterm labor).
Aetna considers injectable progesterone or hydroxyprogesterone experimental and investigational for all other indications, including any of the the following, because it has not been shown to be effective for these indications:
Treatment of premenstrual syndrome; or
Prevention of pregnancy; or
Treatment of endometrial hyperplasia.
Etonogestrel Subdermal Implant:
Aetna considers etonogestrel subdermal implant (Implanon) medically necessary for the prevention of pregnancy.
Aetna considers etonogestrel subdermal implant experimental and investigational for all other indications. Note: Many plans exclude coverage of contraceptives. Please check benefit plan descriptions for details.
Progestin-releasing Intrauterine Devices:
Aetna considers progestin-releasing intrauterine devices (IUDs) (e.g., Mirena levonorgestrel-releasing intrauterine device; Progestasert progesterone-releasing intrauterine device) medically necessary for contraception and for treatment of heavy menstrual bleeding.
Aetna considers progestin-releasing IUDs experimental and investigational for all other indications. Note: Many plans exclude coverage of contraceptives. Please check benefit plan descriptions for details.
Progesterone Vaginal Suppositories:
Aetna considers progesterone vaginal suppositories medically necessary for infertility associated with documented ovarian failure and to supplement endogenous progesterone in women at high risk of spontaneous abortion due to documented luteal phase deficiency.
Aetna considers progesterone vaginal suppositories experimental and investigational for the treatment of premenstrual syndrome (PMS), for the prevention of preterm birth, and for all other indications because its effectiveness for these indications has not been established.
Depo-Provera is an injectable formulation of medroxyprogesterone acetate, a derivative of progesterone. Depo-Provera has shown efficacy for the adjunctive and palliative treatment of advanced, inoperable endometrial or renal carcinoma. Additionally, as an intramuscular injection administered every 3 months, Depo-Provera has been shown to be highly effective in the prevention of pregnancy (less than 1% failure rate in the first year). It is also effective in treating other various progesterone-mediated conditions.
When being used as a contraceptive, Depo-Provera is only covered under plans that specifically cover contraceptive drugs (without specifying oral contraceptives), contraceptive devices, or contraceptive drug implants.
Intramuscular medroxyprogesterone has been used for the treatment of menorrhagia/abnormal uterine bleeding, as an alternative to oral progestogen therapy. However, since progestogen therapy for menorrhagia/abnormal uterine bleeding must be cyclical in nature, experts usually prescribe oral, rather than intramuscular, medroxyprogesterone for these indications.
Parenteral medroxyprogesterone has been used as an alternative to oral forms of medroxyprogesterone when indicated to treat breast carcinoma in postmenopausal women; however, recognized drug compendia note that only parenteral medroxyprogesterone is indicated for adjunct treatment of metastatic renal or endometrial carcinoma and endometriosis.
Parenteral medroxyprogesterone was used in the past as a treatment for precocious puberty, but has been replaced by other modalities.
The U.S. Pharmacopoeia (2002) states that, although oral medroxyprogesterone is preferred, parenteral medroxyprogesterone has been used for secondary amenorrhea, dysmenorrhea, menorrhagia, oligomenorrhea, dysfunctional uterine bleeding, endometriosis, and endometrial hyperplasia accompanying polycystic ovary syndrome.
According to recognized drug compendia, oral therapy is preferred for female hormone replacement in menopause and for testing for endogenous estrogen production.
Lunelle (combination estrogen and medroxyprogesterone injection) approved by the FDA as a once per month injectable contraceptive in October 1999. Lunelle was not approved by the FDA for any indication other than the prevention of pregnancy.
Norplant (levonorgestrel) is an implantable, combined drug and delivery system that continuously releases a low dose of the progestin levonorgestrel. Norplant is FDA approved for contraception and is surgically implanted in the physicians' office or clinic. A single implant provides contraception for up to 5 years. Norplant is especially useful for patients for whom compliance is an issue, and for patients for whom pregnancy poses an unacceptable medical risk. It is recommended that a trial of a progestin-only oral contraceptive be carried out prior to implantation, to assess patient tolerance to drug side effects. Norplant (levonorgestrel subdermal implant) is no longer available in the United States.
On July 17, 2006, Implanon (Organon USA, Inc., Roseland, NJ), a single-rod progestogen-only (etonogestrel) contraceptive implant, received FDA approval. Implanon is the only implantable contraceptive device currently available in the United States. The distribution of Norplant was stopped in 2000 after questions surfaced about the strength of certain lots of the drug. In 2002, Wyeth Pharmaceuticals (Madison, NJ), the manufacture of Norplant, decided not to re-introduce Norplant to the U.S. market.
Implanon is a long-acting (up to 3 years), reversible, contraceptive method. It must be removed by the end of the 3rd year and may be replaced by a new Implanon at the time of removal if continued contraceptive protection is desired. Implanon is contraindicated in women who have (i) known or suspected pregnancy, (ii) current or past history of thrombosis or thromboembolic disorders, (iii) hepatic tumors (benign or malignant), active liver disease, (iv) undiagnosed abnormal genital bleeding, (v) known or suspected carcinoma of the breast or personal history of breast cancer, and (vi) hypersensitivity to any of the components of Implanon.
In a multi-center clinical study, Funk and colleagues (2005) evaluated the safety and effectiveness of Implanon. Sexually active American women (n = 330) with apparently normal menstrual cycles used the implant for up to 2 years. All subjects recorded bleeding and/or spotting daily in a diary. Safety was assessed through adverse experiences (AE), laboratory tests and physical and gynecological examinations. Total exposure was 474 woman-years (6186 cycles), and 68 % of subjects had at least 1 year of exposure. No pregnancies occurred. The most common bleeding pattern observed throughout the study was infrequent bleeding, defined as less than 3 episodes of bleeding in a reference period (excluding amenorrhea). The least common pattern was frequent bleeding, defined as more than 5 episodes of bleeding in a reference period. Infrequent, prolonged and frequent bleeding patterns were most common early in the study and declined thereafter. During the 3-month reference periods 2 to 8 (months 4 to 24), the incidence of amenorrhea ranged from 14 to 20 %. A total of 43 subjects (13 %) withdrew from the study because of bleeding pattern changes and 76 subjects (23 %) discontinued because of other AE. Other common AE leading to discontinuation, besides bleeding irregularities, were emotional lability (6.1 %), weight increase (3.3 %), depression (2.4 %) and acne (1.5 %). Use of Implanon for up to 2 years had no clinically significant effects on laboratory parameters, physical and pelvic examinations, vital signs or body mass index. The average length of time required for Implanon insertion and that for removal were 0.5 and 3.5 mins, respectively, and all the procedures were uncomplicated. The return to normal menstrual cycles and fertility was rapid after removal. The authors concluded that Implanon is a safe, highly effective and rapidly reversible new method of contraception. This finding is in agreement with that of Croxatto (2000) as well as that of Zheng, et al. (1999).
According to the U.S. Pharmacopoeial Convention (2002), accepted indications for injectable progesterone and hydroxyprogesterone include: 1) treatment of menstrual disorders including secondary amenorrhea and dysfunctional uterine bleeding; 2) corpus luteum insufficiency treatment; and 3) diagnosis of endogenous estrogen production. The U.S. Pharmacopoeia states that progesterone or hydroxyprogesterone injection can be used to test for endogenous estrogen production and can be used to determine whether low levels of estrogen are present if withdrawal bleeding does not occur after a progestin challenge in menopausal women before estrogen-progestin ovarian hormone therapy is considered. The U.S. Pharmacopoeia notes, however, that determination that serum gonadotropins are elevated is the standard way to confirm menopause. The U.S. Pharmacopoeial Convention has concluded that injectable progesterone and hydroxyprogesterone has not been shown to be an effective treatment for premenstrual syndrome. Injectable progesterone or hydroxyprogesterone is not indicated for prevention of pregnancy.
de Fonseca, et al. (2003) reported on the results of a randomized, placebo-controlled trial of progestin vaginal suppositories in high-risk women, and found that the incidence of preterm birth was significantly reduced, from 28.5% to 13.8% for births before 37 weeks, and from 18.6% to 2.8% for births before 34 weeks in the placebo versus the progesterone groups, respectively. More recently, Meis et al. (2003) reported the results of a multicenter randomized clinical study, involving over 450 high risk women, showed that weekly injections of 17-alpha-hydroxyprogesterone resulted in a significant reduction in recurrent preterm birth.
In a randomized, double-blind, placebo-controlled trial, Rouse et al (2007) examined if 17 alpha-hydroxyprogesterone caproate (17P) would reduce the rate of preterm birth in twin gestations. Healthy women with twin gestations were assigned to weekly intramuscular injections of 250 mg of 17P or matching placebo, starting at 16 to 20 weeks of gestation and ending at 35 weeks. The primary study outcome was delivery or fetal death before 35 weeks of gestation. A total of 661 women were randomly assigned to treatment. Baseline demographic data were similar in the two study groups. Six women were lost to follow-up; data from 655 were analyzed (325 in the 17P group and 330 in the placebo group). Delivery or fetal death before 35 weeks occurred in 41.5 % of pregnancies in the 17P group and 37.3 % of those in the placebo group (relative risk, 1.1; 95 % confidence interval [CI], 0.9 to 1.3). The rate of the pre-specified composite outcome of serious adverse fetal or neonatal events was 20.2 % in the 17P group and 18.0 % in the placebo group (relative risk, 1.1; 95 % CI, 0.9 to 1.5). Side effects of the injections were frequent in both groups, occurring in 65.9 % and 64.4 % of subjects, respectively (p = 0.69), but were generally mild and limited to the injection site. The authors concluded that treatment with 17P did not reduce the rate of preterm birth in women with twin gestations.
In a randomized study, Abu-Musa et al (2008) examined the effect of 17-alpha-hydroxyprogesterone caproate (HPC) before embryo transfer on the outcome of in-vitro fertilization and embryo transfer (IVF-ET). A total of 125 patients undergoing IVF-ET were randomly assigned into treatment and control groups. In the treatment group, 63 patients received 17-HPC (250 mg, i.m.), 1 day before ET. The control group consisted of 62 patients who did not receive any injections. Main outcome measures were pregnancy and multiple-pregnancy rates. The two groups were similar with respect to the age of patients, total dose of follicle-stimulating hormone, number of oocytes and embryos obtained, and number and quality of embryos transferred. There was no significant difference in the pregnancy rate (34.9 % versus 38.7 %) or in the rate of multiple gestation (15.9 % versus 9.7 %) between cases and controls, respectively. The authors concluded that the use of 17-HPC before ET does not appear to affect the outcome of IVF-ET.
Fonesca and colleagues (2007) noted that previous randomized trials have shown that progesterone administration in women who previously delivered prematurely reduces the risk of recurrent premature delivery. Asymptomatic women found at mid-gestation to have a short cervix are at greatly increased risk for spontaneous early preterm delivery. These investigators examined if progesterone reduces this risk in such women. Cervical length was measured by transvaginal ultrasonography at a median of 22 weeks of gestation (range of 20 to 25 weeks) in 24,620 pregnant women seen for routine prenatal care. Cervical length was 15 mm or less in 413 of the women (1.7 %), and 250 (60.5 %) of these 413 women were randomly assigned to receive vaginal progesterone (200 mg each night) or placebo from 24 to 34 weeks of gestation. The primary outcome was spontaneous delivery before 34 weeks. Spontaneous delivery before 34 weeks of gestation was less frequent in the progesterone group than in the placebo group (19.2 % versus 34.4 %; relative risk, 0.56; 95 % CI, 0.36 to 0.86). Progesterone was associated with a non-significant reduction in neonatal morbidity (8.1 % versus 13.8 %; relative risk, 0.59; 95 % CI, 0.26 to 1.25; p = 0.17). There were no serious adverse events associated with the use of progesterone. The authors concluded that in women with a short cervix, treatment with progesterone reduces the rate of spontaneous early preterm delivery.
Simhan and Caritis (2007) stated that although the use of progestational agents to prevent preterm birth among high-risk women is promising, the results of afore-mentioned trials highlight the gaps in the current knowledge of the biologic contribution of various risk factors to preterm birth. Unanswered questions regarding the possible mechanisms of action of the various progestins in preventing preterm birth have led to uncertainty with respect to choice of agent, route of administration, dose regimen, and clinical indication. The authors stated that further research on progestational agents is needed.
In an editorial that accompanied the studies by Rouse et al and Fonesca et al, Thornton (2007) stated that there are at least 14 ongoing trials involving women with high-risk pregnancies (both singleton and twin) that aim to recruit a total of more than 5000 women and the author was aware of at least 2 more currently awaiting funding decisions. These studies should have ample power to test the effect of progesterone on important fetal outcomes as well as any differential effect in twin gestations, and long-term follow-up of the surviving children will provide important additional information. In the meantime, the remaining uncertainties about both efficacy and fetal safety mean that even women at high-risk for preterm delivery should join one of the ongoing randomized trials, rather than take a treatment for which the efficacy and safety have not been proved.
Progestin-releasing intrauterine systems (e.g., Mirena levonorgestrel-releasing intrauterine system; Progestasert progesterone-releasing intrauterine device) are safe, effective, long-term contraceptive devices. Progestasert offers pregnancy prevention for one year, and Mirena offers pregnancy prevention for 5 years. Progestin-releasing intrauterine systems have also been shown to decrease the volume of menstrual blood loss in women with normal periods and those with menorrhagia. Heavy menstrual bleeding markedly impairs the quality of life in many healthy women. Management of the condition usually depends on the degree of bleeding and discomfort found acceptable by the individual woman. Medical treatments include oral medications and a hormone-releasing intrauterine system (e.g., Mirena, Progestasert). Surgical options include conservative surgery (e.g., uterine resection or ablation) and hysterectomy. A Cochrane review (Marjoribanks, et al., 2003) compared the safety, effectiveness, and acceptability of surgery versus medical therapy for heavy menstrual bleeding. The authors concluded that surgery reduces menstrual bleeding at one year more than medical treatments, but a hormone-releasing intrauterine system appears equally beneficial in improving quality of life and may control bleeding as effectively as conservative surgery over the long term.
Kuanitz et al (2009) compared the effects of the levonorgestrel intrauterine system and endometrial ablation in reducing heavy menstrual bleeding. This systematic review and meta-analysis was restricted to randomized controlled trials in which menstrual blood loss was reported using pictorial blood loss assessment chart scores. A total of 6 randomized controlled trials that included 390 women (levonorgestrel intrauterine system, n = 196; endometrial ablation, n = 194) were retrieved. Three studies pertained to 1st-generation endometrial ablation (manual hysteroscopy) and 3 to 2nd-generation endometrial ablation (thermal balloon). Study characteristics and quality were recorded for each study. Data on the effect of treatment on pictorial blood loss assessment chart scores were abstracted, integrated with meta-analysis techniques, and presented as weighted mean differences. Both treatment modalities were associated with similar reductions in menstrual blood loss after 6 months (weighted mean difference, -31.96 pictorial blood loss assessment chart score [95 % confidence interval (CI), -65.96 to 2.04]), 12 months (weighted mean difference, 7.45 pictorial blood loss assessment chart score [95 % CI, -12.37 to 27.26]), and 24 months (weighted mean difference, -26.70 pictorial blood loss assessment chart score [95 % CI, -78.54 to 25.15]). In addition, both treatments were generally associated with similar improvements in quality of life in 5 studies that reported this as an outcome. No major complications occurred with either treatment modality in these small trials. The author concluded that based on the meta-analysis of 6 randomized clinical trials, the efficacy of the levonorgestrel intrauterine system in the management of heavy menstrual bleeding appears to have similar therapeutic effects to that of endometrial ablation up to 2 years after treatment.
A number of double-blind clinical trials have failed to show that progesterone suppositories are more effective than placebo in treating premenstrual syndrome. Although proponents of progesterone therapy for PMS have agreed that many of the clinical trials have been done inappropriately with respect to selection criteria, study size, treatment duration and/or blinding method, at least one study has controlled these variables quite well (Maddocks, 1986). This study indicated that the response to progesterone vaginal suppositories is, at best, marginal and not significantly different from response to placebo. Freeman (2004) stated that progesterone has consistently failed to show efficacy for severe PMS/premenstrual dysphoric disorder in large, randomized, placebo-controlled trials.
Although not proven effective, progesterone has also been used during first few months of pregnancy to prevent habitual or threatened abortion due to hormonal imbalance but may also delay expulsion of a defective ovum. Potter and Scott (2005) stated that inadequate progesterone production has been proposed a cause of recurrent pregnancy loss and progesterone is given to prevent miscarriage, despite a lack of supportive evidence.
In a Cochrane review on prenatal administration of progesterone for preventing preterm birth, Dodd et al (2006) noted that intramuscular progesterone is associated with a reduction in the risk of preterm birth of less than 37 weeks' gestation, and infant birth weight of less than 2500 grams. However, other important maternal and infant outcomes have been poorly reported to date, with most outcomes reported from a single trial only. It is unclear if the prolongation of gestation translates into improved maternal and longer-term infant health outcomes. Similarly, information regarding the potential harms of progesterone therapy to prevent preterm birth is limited. The authors concluded that further information is needed to ascertain the clinical value of the use of vaginal progesterone in the prevention of preterm birth. Guidelines from the American College of Obstetricians and Gynecologists (2003) have stated that whether vaginal progestins are as effective as intramuscular progestins in preventing preterm birth “remains to be proved in a larger population.”
Insertion of levonorgestrel-releasing intrauterine system [Mirena]
S4989
Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies
ICD-9 codes covered if selection criteria are met:
626.2
Excessive or frequent menstruation
V25.1
Insertion of intrauterine contraceptive device
V25.42
Surveillance of intrauterine contraceptive device
Progesterone vaginal suppositories:
ICD-9 codes covered if selection criteria are met:
256.2
Postablative ovarian failure
256.31 - 256.39
Other ovarian failure
628.0 - 628.9
Infertility, female
ICD-9 codes not covered for indications listed in the CPB:
625.4
Premenstrual tension syndromes
The above policy is based on the following references:
No authors listed. Drugs used for gynecologic indications. In: Drug Evaluations Subscription. DR Bennett, ed. Chicago, IL: American Medical Association; 1993; II Endo: 6:7 - 6:12.
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Weiss RM. The management of abnormal uterine bleeding. Hosp Practice. 1992;27(10A):55-78.
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Maddocks S, Hahn P, Moller F, Reid RL. A double-blind placebo-controlled trial of progesterone vaginal suppositories in the treatment of premenstrual syndrome. Am J Obstet Gynecol. 1986;154(3):573-581.
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Warren MP, Shantha S. Uses of progesterone in clinical practice. Int J Fertil Womens Med. 1999;44(2):96-103.
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Cicinelli E, de Ziegler D. Transvaginal progesterone: Evidence for a new functional 'portal system' flowing from the vagina to the uterus. Hum Reprod Update. 1999;5(4):365-372.
Warren MP, Biller BMK, Shangold MM. A new clinical option for hormone replacement therapy in women with secondary amenorrhea: Effects of cyclic administration of progesterone from the sustained-release vaginal gel Crinone (4% and 8%) on endometrial morphologic features and withdrawal bleeding. Am J Obstet Gynecol. 1999;180(1 Pt 1):42-48.
Ludwig M, Diedrich K. Evaluation of an optimal luteal phase support protocol in IVF. Acta Obstet Gynecol Scand. 2001;80(5):452-466.
Wyatt K, Dimmock P, Jones P, et al. Efficacy of progesterone and progestogens in management of premenstrual syndrome: Systematic review. BMJ. 2001;323(7316):776-780.
Stewart A, Cummins C, Gold L, et al. The effectiveness of the mirena coil (levonorgestrel-releasing intrauterine system) in menorrhagia. Birmingham, UK: West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham (WMHTAC); 1999.
Setala M, Hurskainen R, Kauko M, et al. Treatment of pain caused by endometriosis. Helsinki, Finland: Finnish Office for Health Care Technology Assessment (FinOHTA); 2001.
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Haas DM, Ramsey PS. Progestogen for preventing miscarriage. Cochrane Database Syst Rev. 2008;(2):CD003511.
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Rauramo I, Elo I, Istre O. Long-term treatment of menorrhagia with levonorgestrel intrauterine system versus endometrial resection. Obstet Gynecol. 2004;104(6):1314-1321.
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Crosignani P, Olive D, Bergqvist A, Luciano A. Advances in the management of endometriosis: An update for clinicians. Hum Reprod Update. 2006;12(2):179-189.
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da Fonseca EB, Bittar RE, Carvalho MH, Zugaib M. Prophylactic administration of progesterone by vaginal suppository to reduce the incidence of spontaneous preterm birth in women at increased risk: A randomized placebo-controlled double-blind study. Am J Obstet Gynecol. 2003;188(2):419-424.
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Check JH. Pharmacological options in resistent ovary syndrome and premature ovarian failure. Clin Exp Obstet Gynecol. 2006;33(2):71-77.
Singh M, Mansour D, Richardson D. Location and removal of non-palpable Implanon implants with the aid of ultrasound guidance. J Fam Plann Reprod Health Care. 2006;32(3):153-156.
Wahabi HA, Abed Althagafi NF, Elawad M. Progestogen for treating threatened miscarriage. Cochrane Database Syst Rev. 2007:(3):CD005943.
Rouse DJ, Caritis SN, Peaceman AM, et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. A trial of 17 alpha-hydroxyprogesterone caproate to prevent prematurity in twins. N Engl J Med. 2007;357(5):454-461.
Fonseca EB, Celik E, Parra M, et al; Fetal Medicine Foundation Second Trimester Screening Group. Progesterone and the risk of preterm birth among women with a short cervix. N Engl J Med. 2007;357(5):462-469.
Simhan HN, Caritis SN. Prevention of preterm delivery. N Engl J Med. 2007;357(5):477-487.
Thornton JG. Progesterone and preterm labor -- Still no definite answers. N Engl J Med 2007; 357(5):499-501.
Lopez L, Newmann S, Grimes D, et al. Immediate start of hormonal contraceptives for contraception. Cochrane Database Syst Rev. 2008;(2):CD006260.
Manchikanti A, Grimes DA, Lopez LM, Schulz KF. Steroid hormones for contraception in women with sickle cell disease. Cochrane Database Syst Rev. 2007:(2):CD006261.
Grimes DA, Lopez LM, Gallo MF, et al. Steroid hormones for contraception in men. Cochrane Database Syst Rev. 2007;(2):CD004316.
Mavranezouli I; LARC Guideline Development Group. The cost-effectiveness of long-acting reversible contraceptive methods in the UK: Analysis based on a decision-analytic model developed for a National Institute for Health and Clinical Excellence (NICE) clinical practice guideline. Hum Reprod. 2008;23(6):1338-1345.
Kaunitz AM, Meredith S, Inki P, et al. Levonorgestrel-releasing intrauterine system and endometrial ablation in heavy menstrual bleeding: A systematic review and meta-analysis. Obstet Gynecol. 2009;113(5):1104-1116.
Abu-Musa A, Usta I, Nassar A, et al. Effect of 17alpha-hydroxyprogesterone caproate before embryo transfer on the outcome of in vitro fertilization and embryo transfer: A randomized trial. Fertil Steril. 2008;89(5):1098-1102.
Guay DR. Drug treatment of paraphilic and nonparaphilic sexual disorders. Clin Ther. 2009;31(1):1-31.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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