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Published in final edited form as: Contraception. 2012 Jul 6;86(6):659–665. doi: 10.1016/j.contraception.2012.05.017

Types of combined oral contraceptives used by U.S. women

Kelli Stidham Hall 1,*, James Trussell 1,2
PMCID: PMC3469779  NIHMSID: NIHMS382411  PMID: 22770787

Abstract

Background

We sought to estimate the prevalence of types of combined oral contraceptives (COC) used among U.S. women.

Study Design

We analyzed interview-collected data from 12,279 women ages 15–44 years participating in the National Survey of Family Growth, 2006–2010. Analyses focused on COC use overall, by pill type, across sociodemographics and health factors.

Results

The prevalence of current COC use (88 different brands) was 17%. The majority of COC-users used earlier formulation COCs: ≥30 mcg (67%) versus <30 mcg estrogen (33%), monophasic (67%) versus multiphasic (33%) dosages, and traditional 21/7 (88%) versus extended/other cycle regimens (12%) regimens; Norgestimate (32%) and norethindrone (20%) were the most commonly used progestins. Sociodemographic, gynecological and health risk factors were associated with type of COC use.

Conclusion

Further investigation of specific COC use and of the factors associated with types of pills used among U.S. women at the population level is needed.

Keywords: combined oral contraceptives, estrogen dosage, progestin generation, formulation

1. Introduction

The oral contraceptive pill (OC) is among the most favored contraceptive methods, used by 9% of women aged 15–49 years worldwide and by over 18% of reproductive-aged women in developed regions [1]. More U.S. women use COCs than any other method [2,3].

Over the last five decades, COCs have undergone significant developments [3–9]. Lower estrogen doses, modified progestin components, multiphasic formulations, and extended cycle regimens and shortened hormone-free intervals have been attempts to improve safety and tolerability profiles while maintaining efficacy [3–14]. The wide range of COCs formulations currently available may have implications for unintended pregnancy and adverse event rates but also for other factors important to modern women’s lives such as non-contraceptive health conditions and reproductive health care access (e.g., contraceptive insurance coverage) [5–9,14–18]. However, the types of pills women are using at the population level have not been recently described.

We estimated the prevalence of COC use by type of COC and examined factors associated with type of COC use among women in the United States, 2006 to 2010.

2. Materials and methods

2.1 Study design

We used the most recent data from The National Survey of Family Growth (NSFG), a nationally representative survey conducted periodically by the National Center for Health Statistics since 1973. The population-based survey collects information on family life, marriage and divorce, pregnancy, infertility, use of contraception, and men and women’s health. Between 2006 and 2010 (continuous cycle), in-person interviews were conducted in the homes of 22,682 U.S. women and men ages 15 to 44 years. African Americans and Hispanics and adolescents and young adults aged 15 to 24 years were oversampled. The response rate was 77%. Further information about the design and sampling of the NSFG can be found at http://cdc.govnchs/nsfg.htm [19].

Our sample included all women ages 15 to 44 years (n=12,279). The Institutional Review Board of Princeton University approved this study.

NSFG questions assessed lifetime contraceptive use and the contraceptive method used in the month of the interview. Women who reported OC use in the last month identified their brand of pill from a chart of OCs available in the U.S. (trademarked or registered). If the pill was not on the chart, women were asked to specify the brand or present the actual pill pack.

We focused on COC use. We examined individual pill brands but also categorized COCs by: 1) ethinyl estradiol dosage (20 mcg, 25 mcg, 30 mcg, 35 mcg, or 50 mcg), 2) pill progestin component and the generation of progestin (1st generation = norethindrone and ethynodiol acetate pills; 2nd generation = levonorgestrel and norgestrel; 3rd generation = desogestrel, gestodene and norgestimate; 4th generation = drospirenone and dienogest), 3) monophasic or multiphasic (biphasic or triphasic) dosage; and 3) traditional 21/7 day supply versus extended or continuous cycle and shortened hormone free regimens (84/4, 24/4, 23/5, or 21/2/5 day supplies). Due to small numbers of women reporting the latter regimens, we combined them into a single category of extended/other cycle regimens. The NSFG did not assess off-label use.

2.2 Data analysis

We used descriptive statistics to describe the sample and provide weighted estimates of the proportion of women using COCs overall and by COC type. We provide a population estimate of the overall numbers of women in the United States using COCs based upon 2010 data from the U.S. Census Bureau’s estimate of the population of women ages 15–44 years (N=62,374,964) [20]. We also estimate the proportion of women using COCs who are at risk of an unintended pregnancy (sexually active women who are not trying to become pregnant, not pregnant or not sterile [3].

We use bivariate chi-square tests to compare the proportions of women using COCs across demographic and social groups and reproductive and health characteristics.

We performed multivariable logistic regression to estimate the likelihood of using types of COCs while adjusting for covariates. Covariates were considered for inclusion in regression models if their p-value in bivariate tests was ≤0.25. We present final reduced multivariate regression models in which we retained only those covariates that were significantly associated with the outcome (p<0.05).

We report unweighted frequencies (n) but weighted data were used to account for the complex, stratified sampling design of the survey; weighted proportions (%), chi-square tests and odds ratios (OR) with 95% confidence intervals (CI) were computed using the svy series of commands in Stata 11.0 (Stata Corporation, College Station, TX).

3. Results

3.1 Oral contraceptive use

Eighty-eight percent of all women aged 15–44 years (n=10,779/12,279) reported ever having used contraception; 73% had used OCs including 20% (n=2,032) in the month of the interview. Seventeen percent of all women were COC users (n=1,900); 0.4% were progestin-only pill users (n=57); 4% did not know (n=2) or report (n=73) their type of OC. Based upon the estimated 62,374,964 U.S. women ages 15–44 years, the number of current COC users is approximately 10,603,744 U.S. women. Excluding women in the survey who were pregnant (n=516), trying to become pregnant (n=395), with a history of surgical (n=1,857) or non-surgical (n=203) sterility, no sexual intercourse experience (n=1,674) or intercourse in the last 3 months (n=2,240), 25% of all women aged 15–44 at risk of unintended pregnancy were COC users (n=1,735/7,660).

3.2 Sociodemographic and health characteristics of oral contraceptive users

We describe characteristics of OC-using women (n=2,032) in Table 1. In brief, OC-users were on average 27 ± 7 SD years old, with adolescents and young adults (15–24 years) comprising 42% of the sample and women ages 35 years and older comprising 25%. The majority of OC-using women identified as white race/ethnicity (76%), followed by Hispanic (12%), Black (9%) and other (4%) race/ethnicity. Over half the sample reported any college education (65%) and 13% were still in high school. Nearly half resided in a suburban area (48%), followed by urban (30%) and rural (21%) residences. The majority were employed (76%) but 36% reported incomes below 200% of the federal poverty level. Twenty percent of OC-using women were uninsured at some point during the previous year. Over two-thirds were currently married or cohabitating with a non-marital partner (67%).

Table 1.

Sociodemographic, reproductive and health-related characteristics of the sample

U.S. women ages 15–44 years All women (n=12,279) % Oral contraceptive Users (n=2,032) %
Age group
 15–24 years 34 42
 25–34 years 32 37
 35–39 years 17 14
 ≥40 years 17 11
Race/ethnicity
 Hispanic 17 12
 White 62 76
 Black 15 9
 Other 6 4
Education level
 <High school diploma 13 6
 High school diploma or GED 21 15
 Any college 52 65
 Still in high school 14 13
Residence
 Urban 32 30
 Suburban 48 48
 Rural 20 21
Employment status
 Employed 66 76
 Unemployed 5 3
 In school 10 10
 At home/other 19 11
Poverty level
 <200% federal poverty level 46 36
 >200% federal poverty level 54 64
Insurance status
 Fully insured last year 73 80
 Uninsured during last year 27 20
Marital/cohabitation status
 Married or cohabitating 53 67
 Not married or cohabitating 47 33
Lifetime sexual intercourse experience
 Yes 86 93
 No 14 7
Sexually active in last 3 months
 Yes 82 88
 No 18 12
Age at menarche
 <11 years 8 8
 11–14 years 82 82
 >14 years 10 10
Parity
 0 childbirths 45 62
 1 childbirths 16 17
 >1 childbirths 39 21
Postpartum ≤3 months
 Yes 2 1
 No 98 99
Breastfeeding status
 Currently breastfeeding 2 1
 Not breastfeeding 98 99
History of gynecological problemsa
 Yes 29 27
 No 71 73
History of ovarian cysts
 Yes 16 14
 No 84 86
Gestational diabetes diagnosis
 Yes 4 3
 No 96 97
Non-gestational diabetes diagnosis
 Yes 2 1
 No 98 99
Body mass index
 Underweight BMI <18.5 3 3
 Normal weight BMI 18.5–24.9 46 53
 Overweight BMI 25–29.9 23 22
 Obese BMI ≥30 28 22
History of smoking in last year
 None 74 82
 < pack of cigarettes per day 18 15
 ≥ pack of cigarettes per day 8 4
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a

Gynecological problems may include ovulation problems, ovarian cysts, uterine fibroids or endometriosis. Results are presented as weighted percentages (%) of sociodemographic characteristics among all women and among oral contraceptive users.

For reproductive characteristics of OC users, the average age at menarche was 12.5 years, with 8% of women reporting early age at menarche <11 years. The majority reported sexual intercourse experience (93%), with 88% reporting sex within the last three months. Less than half reported a history of pregnancy (43%); 38% had given birth to one or more children. Only 1% of OC-using women were 3 months or less postpartum and 1% were breastfeeding. History of gynecological problems was reported by 27% of OC users; these included ovulation problems (18%), ovarian cysts (14%), uterine fibroids (3%) and endometriosis (4%).

For other health-related characteristics of OC users, 1% of women reported a history of non-gestational diabetes and 3% reported gestational diabetes. Nearly a quarter of OC-using women (22%) qualified as overweight with body mass indexes (BMIs) 25–29.9 kg/m2 and 22% obese with BMIs ≥ 30 kg/m2. Tobacco use was reported by 18% of women; 4% smoked a pack of cigarettes per day or more.

3.3 Characteristics of pills used among combined oral contraceptive users

Women reported using 88 different COC brands (Table 2). Among OC users (n=2,032), the five most commonly used COC brands were Ortho-Tricyclen Lo® (11%) followed by Yasmin® (11%), Yaz® (6%), and Ortho Tri-Cyclen® (5%) (Table 2). Use of COCs containing ≥30 mcg of ethinyl estradiol was more common (n=1,253, 67%) than use of <30 mcg formulations (n=643, 33%); 2% (n=46) used a 50 mcg pill. Forty-one percent of OC-using women used a 3rd generation progestin-containing COC (n=776), 22% used a 1st generation (n=425), 19% used a 2nd generation (n=382) and 17% used a 4th generation (n=317) progestin pill. Norgestimate (32%, n=622) and norethindrone (20%, n=394) were the most commonly used progestins. Two-thirds of OC-using women used monophasic (n=1,255, 67%) versus multiphasic (n=645, 33%) COC dosing. Of the multiphasic COC users, the majority used a norgestimate-containing pill (n=494, 78%); half used Ortho Tri-Cyclen® or Ortho Tri-Cyclen Lo® (n=332). The majority of OC users used the traditional 21/7 day regimen pills (n=1,675, 88%); 12% used extended or other cycle regimens (n=225).

Table 2.

Combined oral contraceptive use by brand among women ages 15–44 years in the United States

Combined oral contraceptives Progestin component Ethinyl estradiol dose (mcg) Monophasic (M) vs multiphasic (Ph) dosing Day supply n (n=2,032) % of all OC users
1900 94
Ortho Tri-Cyclen Lo® norgestimate 25 Ph 21/7 233 11
Yasmin® drospirenone 30 M 21/7 205 11
Yaz® drospirenone 20 M 24/4 107 6
Ortho Tri-Cyclen® noregestimate 35 Ph 21/7 99 5
Tri-Sprintec® noregestimate 35 Ph 21/7 87 5
Loestrin FE 1/20® noreth acetatea 20 M 21/7 90 4
Trinessa® noregestimate 35 Ph 21/7 73 3
Ortho-Cyclen® norgestimate 35 M 21/7 63 3
Microgestin 1.5/30® noreth acetatea 30 M 21/7 59 3
Aviane® levonorgestrel 20 M 21/7 56 2
Lutera™ levonorgestrel 20 M 21/7 48 2
Seasonale® levonorgestrel 30 M 84/7 47 2
Apri® desogestrel 30 M 21/7 46 3
Sprintec® norgestimate 35 M 21/7 44 2
Lo/Ovral® norgestrel 30 M 21/7 37 2
Kariva® desogestrel 20 M 23/5 32 2
Estrostep FE® noreth acetatea 20–35 Ph 21/7 32 1
Necon 1/35® norethindrone 35 M 21/7 31 2
Levora® levonorgestrel 30 M 21/7 29 2
Trivora® levonorgestrel 30–40 Ph 21/7 28 1
Ortho-Novum 7/7/7® norethindrone 35 Ph 21/7 25 1
Ortho-Novum 1/35® norethindrone 35 M 21/7 23 1
Alesse® levonorgestrel 20 M 21/7 21 1
Desogen® desogestrel 30 M 21/7 21 1
Ortho-Cept® desogestrel 30 M 21/7 21 1
Mononesessa® norgestimate 35 M 21/7 20 0.7
Seasonique® levonorgestrel 30 M 84/7 18 0.5
Zovia 1/50® ethy diacetateb 50 M 21/7 16 1
Junel FE 20™ norethindrone 20 M 21/7 15 1
Loestrin 21 1.5/30® noreth acetatea 30 M 21/7 15 0.6
Mircette® desogestrel 20 M 21/2/5 13 0.6
Cryselle® norgestrel 30 M 21/7 12 1
Ovcon 35® norethindrone 35 M 21/7 12 0.5
Levlen® levonorgestrel 30 M 21/7 11 0.5
Nortrel 28® norethindrone 35 M 21/7 11 0.5
Oegstrel® norgestrel 50 M 21/7 11 0.4
Triphasil® levonorgestrel 30–40 Ph 21/7 10 0.5
Tri-Levlen® levonorgestrel 30–40 Ph 21/7 10 0.4
Necon 7/7/7® norethindrone 35 Ph 21/7 9 0.7
Low-Ogestel® norgestrel 30 M 21/7 9 0.6
Cyclessa® desogestrel 25 Ph 21/7 9 0.4
Enpresse® levonorgestrel 30–40 Ph 21/7 9 0.4
Portia® levonorgestrel 30 M 21/7 9 0.4
Nortrel 7/7/7® norethindrone 35 Ph 21/7 7 0.5
Femcon FE™ norethindrone 35 M 21/7 7 0.2
Ortho-Novum 1/50® norethindrone 50c M 21/7 6 0.2
Zovia 1/35E® ethy diacetateb 35 M 21/7 6 0.2
Nordette® levonorgestrel 30 M 21/7 5 0.6
Norethin 1/35E norethindrone 35 M 21/7 5 0.3
Loestrin 24FE® noreth acetatea 20 M 24/4 5 0.2
Jenest® norethindrone 35 Ph 21/7 5 0.1
Ocella™ drospirenone 30 M 21/7 4 0.3
Levlite™ levonorgestrel 20 M 21/7 4 0.2
Nortrel 0.5/0.035® norethindrone 35 M 21/7 4 0.2
Ovcon 50® norethindrone 50 M 21/7 4 0.2
Reclipsen™ desogestrel 30 M 21/7 4 0.1
Necon 1/50® norethindrone 50c M 21/7 4 0.0006
Demulen 1/35® ethy diacetateb 35 M 21/7 3 0.3
Modicon® norethindrone 35 M 21/7 3 0.3
Ortho-Novumd® norethindrone NS M 21/7 3 0.3
Ortho-Novum 10/11® norithindrone 35 Ph 21/7 3 0.2
Kelnor™ ethy diacetateb 35 M 21/7 3 0.2
Velivet™ desogestrel 25 Ph 21/7 3 0.0009
Jolessa™ levonorgestrel 30 M 84/7 2 0.3
Demulen 1/50® ethy diacetateb 50 M 21/7 2 0.2
Junel 30™ norethindrone 30 M 21/7 2 0.2
Tri-Previfem™ noregestimate 35 Ph 21/7 2 0.2
Junel FE 30™ norethindrone 30 M 21/7 2 0.2
Norinyl 1+35® norethindrone 35 M 21/7 2 0.0007
Ovral® norgestrel 50 M 21/7 2 0.0006
Nortrel® norethindrone 35 M 21 2 0.0006
Lessina® levonorgestrel 20 M 21/7 2 0.0004
Zenchent® norethindrone 35 M 21/7 2 0.0004
Zovia®d ethy diacetateb NS M 21/7 1 0.0005
Microgestin FE 1/20® noreth acetatea 20 M 21/7 1 0.0003
Previfem™ norgestimate 35 M 21/7 1 0.0002
Necon 10/11® norithindrone 35 Ph 21/7 1 0.0002
Norinyl 1/50® norethindrone 50c M 21/7 1 0.0002
Junel 20™ norethindrone 20 M 21/7 1 0.0001
Balziva™ norethindrone 35 M 21 or 21/7 1 0.00009
Azurette™ desogestrel 20 M 21/7 1 0.00007
Mercilon® desogestrel 20 M 23/5 1 0.00007
Products not available in U.S.
Miranovae levonorgestrel 20 M 21/7 1 0.001
Nueva Perla (minulet) gestodene 30 M 21/7 2 0.0006
Microgynone levonorgestrel 30 M 21/7 1 0.0003
Valette dienogest 30 M 21/7 1 0.0003
Nocicline norethindrone 30 M 21/7 1 0.0001
Gynera gestogdene 30 M 21/7 1 0.00003
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Results are presented as frequencies (n) and weighted percentages (%) of women using each brand of combined oral contraceptive (COC) among all oral contraceptive (OC) users (n=2,032).

a

Norethindrone acetate.

b

Ethynodiol diacetate abbreviated as ethynodiol.

c

Estrogen component is mestranol.

d

Specific pill/dosage not specified (NS).

e

Equivalent formulations available in the United States.

3.4 Factors associated with types of combined oral contraceptive use

In unadjusted analyses, proportions of COC use by sociodemographic and reproductive factors varied by pill type characteristic and included age, race/ethnicity, education, marital/cohabitation status, parity, postpartum status, history of gynecological problems, non-gestational diabetes diagnosis, BMI, reason for COC use and type of medical practice where the pill was received.

In multivariable regression models, women aged 35–39 years (OR 1.9, CI 1.2–3.0, p=0.007) and those with a history of non-gestational diabetes (OR 11.0, CI 1.9–64.2, p=0.008) had greater odds of using a ≥30 mcg (versus <30 mcg) pill than younger women and those without a diabetes history. Women with an underweight BMI (OR 0.3, CI 0.1–0.7, p=0.006) had reduced odds of using a ≥30 mcg dose pill compared to those with a normal weight BMI.

For generation of progestin, women aged 35–39 years (OR 0.5, CI 0.3–0.8, p=0.007), with a history of gynecological problems (OR 0.7, CI 0.5–1.0, p=0.03) and an overweight BMI (OR 0.6, CI 0.4–0.8, p=0.001) had reduced odds of using 3rd or 4th generation progestin-containing pills (versus 1st or 2nd generation pills) than women aged 15–24 years, those without gynecological problems and those with normal weight BMIs. Women with a history of gestational diabetes had greater odds of using a 3rd or 4th generation pill (OR 3.8, CI 1.3–10.7, p=0.01).

Parous women (OR 1.7, CI 1.1–2.6, p=0.006 for parity=1 and OR 2.1, CI 1.3–3.3, p=0.002 for parity >1) and women who had received their COCs at a community (OR 1.6, CI 1.1–2.4, p=0.01) or family planning (OR 2.3, CI 1.5–3.6, p<0.001) clinic had greater odds of using multiphasic (versus monophasic) pills than nulliparous women and women who had received their COCs at private/HMO/employer-based practices. Women who had a history of non-gestational diabetes (OR 0.1, CI 0.1–0.5, p=0.005) and those using COCs for menstrual regulation (versus contraceptive reasons) had reduced odds of using multiphasic COCs (OR 0.6, CI 0.5–0.9, p=0.01).

Finally, women with a high school diploma/GED (OR 0.3, CI 0.1–0.7, p=0.009) had reduced odds of using extended cycle regimen pills (versus traditional 21/7 regimens) compared to those with less than a high school education. Women who used their COCs for “other” reasons (versus for contraceptive reasons) had greater odds of using an extended/other cycle regimens (OR 2.3, CI 1.1–4.7, p=0.03).

4. Discussion

Our finding on the prevalence of COC use among women in the U.S. is similar to national reports on contraceptive use from 1982 to 2008 [3]. Approximately 17% of our women aged 15–44 years surveyed between 2006 and 2010 were COC users (translating to a population estimate of 10,603,744 women in the United States); 25% of women at risk for an unintended pregnancy used COCs.

Women used 88 different COC brands, reflecting the evolution of available modern contraceptive pills. While data were limited to type of COC use in the month of the interview (and not reflective of pill types previously tried), findings suggest that women are using earlier pill formulations (≥30 mcg estrogen, 1st and 2nd generation progestins, monophasic dosages and traditional 21/7 regimens) which is a departure from trends in uptake of newer formulations noted in the 1980s [12,21]. Women’s positive experiences with COCs they were prescribed at initiation or younger ages may provide incentive for continuation despite availability of newer formulations. Cost may also be a driving force behind this trend, given lower prices and greater insurance coverage of older COCs compared to formulations with 3rd/4th generation progestins and extended or other cycle regimen pills. However, these potential determinants of types of COCs used cannot be determined from these data.

Reasons women did cite for current COC use were inconsistently associated with the types of pills used. Women taking COCs for acne were more likely to be using 3rd generation pills like Ortho Tri-Cyclen® [2,22] but not other FDA acne-approved COCs including Estrostep® (norethindrone-based 1st generation) or Yaz® (drospirinone-based 4th generation). Women using COCs for “other” non-contraceptive reasons were more likely to use extended cycle regimens, which have potential therapeutic effects on endometriosis and dysmenorrhea [7,13], though associations were not noted between pill type and specific endometriosis and gynecological problem reasons. The NSFG does not assess off-label pill use so we likely failed to capture women who are using extended cycle regimens or other pills types for non-contraceptive purposes. Moreover, given that any COC regardless of FDA-approved indication may exhibit therapeutic effects on acne, dysmenorrhea and other conditions, the lack of association found here is not surprising.

Differences in pill types across practice settings may be due to onsite availability of pharmaceutical samples, availability of inexpensive pill brands in clinic-based settings or prescription tailoring around clients’ drug prescription coverage [2,15,23]. Ortho-TriCyclen® and its equivalents (the most commonly used OCs) are widely available, commonly covered by prescription drug plans and affordable for clinic-based practices and their clientele [2]. Indeed, prescriber bias due to insurance types and formularies plays an important role in women’s use of particular pill types. We analyzed insurance status and other socioeconomic considerations potentially related to access including employment situation and income but these factors were not associated with types of COC used in multivariable models. Further evaluation of the influence of medical setting, provider prescribing patterns, and pharmaceutical access on specific COC use is warranted.

While our analysis has provided some foundation as to women’s characteristics related to types of pill use, the significance of cross-sectional associations are not apparent. Limited assessment of health-related factors including cardiovascular risks did not permit adequate examination of COC use among women with hormonal contraindications, and it remains unclear whether newer pill formulations are preferable to older ones in regards to safety [2,5,8,14,24,25–30]. We were unable to assess onset, duration or lifetime use of different COC types, which is pertinent to interpreting potential relationships found here. Finally, although attempts were made to ensure accurate identification of pill type, OC use measures were self-reported and recall bias is of concern. Examination of prospective and longitudinal data including pharmaceutical, insurance claims or marketing data may help further describe types and patterns of specific OCs used over time.

5. Conclusion

Our findings suggest that women in the United States favor COCs as their contraceptive method, with the majority relying upon pills with earlier hormonal formulations. Factors determining women’s use and nonuse of lower dose, newer progestin, multiphasic or extended cycle regimen pills are likely complex and require further investigation for their role in how and why women and health providers choose to initiate or switch to particular pills. Additional prospective research is warranted to determine relationships between COC formulations and adverse events, contraceptive use patterns and unintended pregnancy rates in current contexts and among women with cardiovascular and chronic disease risk factors. Of particular interest will be the impact of socioeconomic and political factors including the forthcoming U.S. health care reform on women’s access to and use of specific types of contraception in this country. Despite the high prevalence of OC use in the U.S., long-acting reversible contraceptive methods offer an ideal option for women at risk of pregnancy when cost barriers are removed [31].

Acknowledgments

Funding Source: This work was supported in part by a training fellowship (KSH) and by a Eunice Kennedy Shriver National Institute of Child Health and Human Development grant for Center Infrastructure #R24HD047879 (JT), both for the Office of Population Research at Princeton University.

Footnotes

Disclosure statement: None of the authors have a conflict of interest.

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