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Review of ovulation return upon discontinuation of once-a-month injectable contraceptives.

Once-a-month combined injectable preparations draw their contraceptive efficacy from continuous ovulation suppression. When their use is discontinued, ovulation resumes within a few weeks or a few months, depending on the formulation. After use of the dihydroxyprogesterone acetophenide 150 mg/estradiol enanthate 5 mg combination for one to two years, ovulation returns in most subjects 3-4 months after discontinuation of treatment. Similarly, recent data show that after 2-year use of the depot-medroxyprogesterone acetate 25 mg/estradiol cypionate 5 mg or the norethisterone enanthate 50 mg/estradiol valerate 5 mg combination, approximately 70% women have resumed ovulation by the third month post-treatment. This is shorter than the time for return of ovulation experienced by ex-users of progestogen-only injectable contraceptives.

Contraceptive Agents, Female↗

Acceptability of the levonorgestrel-releasing intrauterine system after discontinuation of previous contraception: results of a French clinical study in women aged 35 to 45 years.

This open, noncomparative study evaluated the rate of premature removals of the levonorgestrel-releasing intrauterine system (LNG-IUS) Mirena because of adverse events. To take part in the study, women had to be aged between 35 years and 45 years, and had to change their contraception for poor compliance, poor tolerance, or unfavorable change in the benefit/risk ratio of their previous contraception (oral contraceptives or copper- or progestin-releasing intrauterine device). One removal of Mirena for a wish for pregnancy was excluded from analyses, so that there were 23 removals among 203 women included. The survival ratio was 88.7%, which corresponds to a 1-year rate of premature removals of 11.3%. No statistically significant difference was found between women switched from IUD and women switched from oral contraception regarding the continuation rate (p = 0.640, log-rank test) and the discontinuation rate (p = 0.430, chi(2) test). The main reasons for premature removal were bleeding problems (11 subjects including 2 amenorrhea, 5.4%), pain (5 subjects, 2.5%), and acne (2 subjects, 1%). Two premature discontinuations occurred after accidental removal. The number of bleeding or spotting days significantly decreased from baseline (p < 0.001), and gynecological symptoms were alleviated. Hematocrit, hemoglobin levels, and serum ferritin increased significantly. No pregnancies occurred. Acne and irregular bleedings were the most frequent adverse events. The results show the excellent acceptability as well as the favorable efficacy/safety ratio of the LNG-IUS Mirena in older reproductive age women whatever the primary method of contraception.

Adult↗

UNICEF supports birth control despite Holy See.

The Vatican has failed in its attempt to prevent the UN Children's Fund (UNICEF) from spreading the message of family planning in developing countries. Over the strong objections of the Holy See, the 41-member Executive Board of UNICEF has asked the agency to cooperate with the UN Population Fund (UNFPA) and the WHO "to support family planning in the context of sustainable national healthcare systems." A member of the Executive Board said the Vatican held the view that UNICEF had no legitimate right to be involved in family planning. "But the Holy See was in a minority of one," he said, adding that "the whole problem arises from the fact that the Vatican continues to equate birth control and abortion with family planning." A recently concluded board meeting unanimously adopted a resolution requesting UNICEF to "contribute substantively" to the UNFPA-sponsored International Conference on Population and Development (CPF) set to take place in 1994 in Cairo. The board also asked UNICEF Executive Director James Grant to submit a policy paper "on the involvement of UNICEF in family planning, taking into account the health of the child and the mother." The paper is to be presented for the consideration of the board at its regular session next year, with a view to approving it prior to the ICPD. Prior to the adoption of the resolution, J. Klink, a spokesman for the Holy See, told the Executive Board that there were "concerns" over calls for UNICEF to involve itself in family planning activities. He said UNICEF should not be concerned with family planning because there were other agencies entrusted with that mandate. Responding to the support given by Nordic countries to the UNICEF resolution, Klink said that wealthy nations must not impose dictates as to the "appropriate" size of poor families. "The Holy See would not propose that UNICEF halt its current balanced, informational approach to the spacing of births," he said. "Families must be free to decide their size." UNICEF, he pointed out, had clearly stated that it was not involved in abortion or sterilization and did not provide contraceptives. "UNICEF must continue to respect cultural and religious diversity," he said. At a meeting of the Preparatory Committee of the UN Conference on Environment and Development (UNCED) in April this year, the Vatican succeeded in striking a reference to family planning from a blueprint for development known as Agenda 21. Paragraph 99 of Agenda 21 had originally referred to the need for "integrated healthcare, including universal access to family planning services and the provision of safe contraceptives." But this paragraph was deleted in the final document adopted at UNCED in Rio de Janeiro in June. Given that family planning is the single most effective means with which to contain population growth, the UNFPA considered the omission a retrograde step in handling the dangers of overpopulation and environmental degradation. In Rio de Janeiro, Werner Fornos, president of the Washington-based Population Institute, criticized the Holy See "for interfering in the lives of people throughout the world because of religious dogmas." Grant told the board meeting last month that UNICEF would work with the UNFPA to spread knowledge and support program activities for successful family planning which he said was integral to safe motherhood. Birte Poulsen of Denmark told the meeting that reduced population growth was a prerequisite for sustainable development, and the UNICEF "must accord family planning issues top priority." And Inger Ann Ravum of Norway said the integration of family planning activities into UNICEF's program was welcome.

Behavior↗

[The effect of low dose gestagens on the hypothalamic-pituitary-ovarian axis].

The contraceptive effect of continuous treatment with low dose progestogens (minipill) has been attributed mainly to alterations of the cervical mucus and the endometrium. This study was undertaken to investigate the effect of low dose progestogens on hypothalamic-pituitary-ovarian function. Plasma concentrations of follicle stimulating hormone (FSH), luteininzing hormone (LH), estradiol-17 beta (E-2) and Progesterone were measured daily during apparently ovulatory menstrual cycles and during treatment cycles with different low dose progestogens. From the results obtained it was concluded that the minipill has a clear-cut effect on the LH/FSH peak at midcycle and on corpus luteum function. A cyclic secretion of E-2 is maintained in the majority of cases. In a few treatment cycles however, follicular maturation was suppressed as indicated by low E-2 concentrations. It was concluded that the minipill exerts a profound effect at the central and ovarian level which contributes to its satisfactory contraceptive efficacy.

Adult↗

Evaluation of Norplant use among Bangladeshi women.

Among 600 women in Bangladesh who initiated use of Norplant, 38% still had their implant at the end of its 5-year life span. To evaluate the contraceptive effectiveness, safety and acceptability of the implant, researchers recruited 200 women from each of 3 clinics in Dhaka who began using the method in 1985. Most of the participants were young (mean age 27), had had little or no formal education and had had an average of 3.4 live births. Participants were followed up at 1, 3, and 6 months after insertion, then every 6 months after insertion, then every 6 months until removal. The 5-year study was completed by 228 (38%) participants; 31 were lost to follow-up. 2 pregnancies were reported during the study; these were believed to have occurred prior to insertion of Norplant. Of the 340 removals during the course of the study, 45% were requested because of menstrual problems, 15% because of other side effects or medical reasons, 20% because the women desired the pregnancy and 20% for other personal reasons. Most of the women (86%) who completed the study planned to continue using a contraceptive method; of these, one-third planned to use Norplant again.

Asia↗

Experience of Thai women in Bangkok with Norplant-2 implants.

A prospective study of the Norplant-2 contraceptive subdermal implant system was conducted in Bangkok, Thailand. The objective of the study was to evaluate the efficacy, adverse effects, and overall acceptability of Norplant-2 implants. A total of 140 women were enrolled in a 3-year clinical trial. The mean age was 29 years. Of all the acceptors, 70% had completed primary school. The continuation rates at years 1, 2, and 3 were, respectively, 94%, 89%, and 83%. No accidental pregnancies occurred throughout the 3 years of use in this study. Personal reasons were the leading cause for termination of Norplant-2 implant use. The 3-year cumulative termination rate for personal reasons was 7.2%. These personal reasons were divorce, husband having vasectomy, and moving away from the study area. The other leading cause for termination was medical reasons; acne, headache, and pain at the implant site were the complaints. The termination rate for medical reasons in year 3 of the study was 4.6%. Prolonged menstrual flow was the other main reason for termination. The 3-year cumulative termination rate for menstrual irregularities was 3.8%. In this study, the cumulative termination for planned pregnancy at the end of the year 3 was only 1.6%. The incidence of difficult removals was 8%. Breakage of the rods on removal was encountered in the majority of these cases. The study findings presented suggest that the Norplant-2 implants are highly effective with high continuation rates. The Norplant-2 system could become another choice of long acting reversible contraception for Thai women.

Adolescent↗

Endometrial microstructure after long-term use of a 91-day extended-cycle oral contraceptive regimen.

OBJECTIVE: To assess the effect on the endometrial microstructure of an extended-cycle oral contraceptive (OC) regimen containing ethinyl estradiol (EE) and levonorgestrel (LNG). METHODOLOGY: Subjects received up to four cycles of a 91-day extended-cycle OC regimen (84 consecutive days of monophasic 30 microg EE/150 microg LNG followed by 7 days of placebo). Endometrial biopsies were performed prior to the initiation and at the completion of therapy. All endometrial samples were processed centrally and reviewed by three independent pathologists blinded to treatment groups. RESULTS: Endometrial biopsies were performed in 50 women. In general, samples taken after completion of therapy with no further hormonal exposure demonstrated rapid return to normal endometrial cycling. In contrast, the majority of subjects still on active extended hormonal OC therapy at the time of biopsy had inactive or atrophic endometrium. No intravascular blood clots were observed in any of the specimens. CONCLUSION: The endometrial findings observed in this cohort of women treated with a 91-day extended-cycle OC regimen for up to 1 year showed no significant pathology. Additionally, the endometrium reverted quickly to normal cyclic changes in those subjects who, after completing therapy, elected not to continue with hormonal contraception.

Adolescent↗

Male hormonal contraceptives.

As the world human population continues to explode, the need for effective, safe and convenient contraceptive methods escalates. Historically, women have borne the brunt of responsibility for contraception and family planning. Except for the condom, there are no easily reversible, male-based contraceptive options. Recent surveys have confirmed that the majority of men and women would consider using a hormonal male contraceptive if a safe, effective and convenient formulation were available. Investigators have sought to develop a male hormonal contraceptive based on the observation that spermatogenesis depends on stimulation by gonadotropins, follicle-stimulating hormone (FSH) and luteinising hormone (LH). Testosterone (T) and other hormones such as progestins suppress circulating gonadotropins and spermatogenesis and have been studied as potential male contraceptives. Results from two large, multi-centre trials demonstrated that high-dosage T conferred an overall contraceptive efficacy comparable to female oral contraceptives. This regimen was also fully reversible after discontinuation. However, this regimen was not universally effective and involved weekly im. injections that could be painful and inconvenient. In addition, the high dosage of T suppressed serum high-density lipoprotein (HDL) cholesterol levels, an effect that might increase atherogenesis. Investigators have attempted to develop a hormonal regimen that did not cause androgenic suppression of HDL cholesterol and that was uniformly effective by suppressing spermatogenesis to zero in all men. Studies of combination regimens of lower-dosage T and a progestin or a gonadotropin-releasing hormone analogue have demonstrated greater suppression of spermatogenesis than the WHO trials of high-dosage T but most of these regimens cause modest weight gain and suppression of serum HDL cholesterol levels. Overall, the data suggest that we are close to developing effective male hormonal contraceptives. The focus is now on developing effective oral regimens that could be safely taken daily or long-acting depot formulations of a male hormonal contraception that could be conveniently injected every 3 - 6 months. In this article, we shall review the exciting new developments in male hormonal contraception.

Contraceptive Agents, Male↗

Male involvement in reproductive health care.

The programme of action globally endorsed at the International Conference on Population and Development (ICPD) emphasised the need for equity in gender relations with a special focus on men's shared responsibility and active involvement to promote reproductive and sexual health. If men are brought into a wide range of reproductive health services in such a way that they are supported as equal partners and responsible parents, as well as clients in their own right, better outcomes are expected in reproductive health indicators such as contraception acceptance and continuation, safer sexual behaviours, use of reproductive health services, and reduction in reproductive morbidity and mortality. This paper focuses on these key questions. What does men's involvement mean and how should it be operationalised? What does shared responsibility mean for various reproductive health problems subsumed within the reproductive health framework? Programmes to involve men should be designed to address three major goals: (1) Improve sexual and reproductive health of men and women, (2) generate men's support for women's actions related to reproduction and respect for women's reproductive and sexual rights, and (3) promote responsible and healthy reproductive and sexual behaviour in young men and boys. Gender inequality is a major barrier that must be overcome if these goals are to be met. Improving the reproductive well-being of women and men requires freeing them both from restricted gender roles.

Contraception↗

Experience with side effects and health risks associated with Norplant implant use in adolescents.

Levonorgestrel implants (Norplant) have been recommended as a contraceptive method for teenage women. Our experience suggests that the use of Norplant implants in adolescents is associated with bleeding irregularities and modest weight gain. There is no effect on condom use or STD acquisition. Despite the bleeding irregularities, we documented high continuation rates, suggesting that with appropriate pre-insertion counseling, Norplant implants can be a successful contraceptive method for adolescent women.

Adolescent↗

Vasectomy and prostate cancer.

Numerous epidemiologic studies of vasectomized men have been conducted over the last decade. The majority of the reports have been reassuring with regard to possible long-term health consequences following male sterilization. In February 1993, two articles suggesting a relationship between vasectomy and prostate cancer appeared in the literature. Following publication of these studies, the United States National Institutes of Health (NIH) organized a meeting of experts to review the most recent literature on vasectomy and prostate cancer. After considering the evidence from the aforementioned studies and the preliminary findings of three unpublished studies, the NIH panel concluded that there was insufficient evidence of a real association between vasectomy and prostate cancer. This article reviews current information concerning the relationship, and recommends that providers continue to provide vasectomy as a contraceptive option. The research community should continue to investigate the possibility of a relationship between vasectomy and prostate cancer.

Case-Control Studies↗

Menstrual Migraine.

The initial treatment of menstrual migraine (MM) should be the same as that of migraine that occurs at any other time during the month and should include lifestyle modifications and the use of appropriate acute therapies aimed at decreasing attack symptoms, duration, and disability. If results of acute therapy are incomplete or unsatisfactory, then preventive strategies may be required. Comorbidities may, however, influence choice of preventive therapy or accelerate initiation of preventive therapy. Comorbid dysmenorrhea, menometrorrhagia, and endometriosis argue for early use of hormonal therapies. Hormonal strategies may be appropriate because the premenstrual decline in estradiol concentration predictably precipitates MM, and targeting and preventing this decline can decrease headache occurrence. Continuous combined hormonal contraceptives can reduce hormone fluctuations and, for some MM sufferers, can deliver more than contraceptive benefits. Nonsteroidal anti-inflammatory drugs are appropriate for treatment of co-occurring dysmenorrhea or when hormonal strategies are contraindicated; their efficacy may be caused partly by the role of prostaglandins in MM and dysmenorrhea. As with the use of hormonal therapy, use of nonsteroidal anti-inflammatory drugs allows for treatment of breakthrough headache with triptans. Results of clinical trials suggest that daily use of triptans in the menstrual window may bring about as much as 50% reduction in headache frequency, but such use still requires acute treatment of breakthrough headache and adherence to daily triptan limits. Use of this strategy requires that headache occurrence be highly predictable.

Journal Article↗

A survey of knowledge, attitudes and practices relating to emergency contraception among health workers in Manisa, Turkey.

OBJECTIVE: to determine knowledge, attitudes and practices relating to emergency contraception among health-care providers (general practitioners, nurses and midwives). DESIGN: a cross-sectional design using face-to-face interview methods plus questionnaire in the work setting. Researchers were able to maintain privacy by using priority strategies. SETTING: 18 primary health-care units in Manisa, western Turkey. SAMPLE: 182 health-care providers (general practitioners [n = 72]; nurses and midwives [n = 110] were invited to participate in the study, but 26 of them declined. PARTICIPANTS: 156 health-care providers. As 16 participants had not heard of emergency contraception, 140 health-care providers (general practitioners [n = 51] and nurses and midwives [n = 89]) were included. FINDINGS: of the health-care providers, almost one in 10 was unfamiliar with the term 'emergency contraception'. Only a few health-care providers knew how to use the intra-uterine contraceptive device (IUCD) for emergency contraception and the doses of emergency contraceptive pills. Some health-care providers included emergency contraception in routine consultations, but many did not support the use of emergency contraception in Turkey. Many of the providers thought that young people should not know about emergency contraception. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: knowledge among health-care providers about emergency contraception is inadequate. All health-care providers should know about emergency contraception and include it in routine contraceptive consultations. Thus, continuing education information programmes are required. Further research into the knowledge, practices and attitudes of health-care providers is needed to understand the underlying reasons for the hesitant attitudes among health professionals.

Adult↗

Menopause in Morocco: symptomatology and medical management.

OBJECTIVES: To assess the frequency of menopausal symptoms and patterns of recourse to medical care in Rabat, Morocco. METHODS: Face to face interviews with a representative sample of 300 women aged 45-55 years; information was collected on socio-demographic variables, reproductive history, use of health care, symptom checklist, and medical management of menopause. RESULTS: The most frequent complaints are fatigue and hot flashes, each reported by 61% of women, headaches (57%), joint pain (54%), anxiety (44%) and irritability (42%). Hot flashes, but not cardiovascular symptoms, are statistically associated with menopausal status. Only 5% of women in the sample take hormones, and 4% calcium; 13% continue to take contraceptives. The frequency of some symptoms and the use of health care for menopause are influenced by socio-economic factors. CONCLUSIONS: Reports of hot flashes and joint pains are relatively high, but the frequency of use of medical services for menopause is low.

Female↗

Pathophysiology of endometrial bleeding.

OBJECTIVES: To review the morphological and molecular events responsible for uterine bleeding in health and disease. METHODS: Review of pertinent literature focusing on the histology and pathophysiology of normal and abnormal uterine bleeding (AUB). RESULTS: The seat of normal menstrual bleeding is located in the upper two-thirds of the endometrial mucosa and is recognized by tissue necrosis, disruption of microvasculature, migratory leukocytes and platelet/fibrin thrombi in microvessels. The molecular events responsible for tissue and vascular breakdown are related to the release of proteolytic lysosomal enzymes of endometrial cell and inflammatory cell origin. In cases of AUB, tissue breakdown is located in the superficial layer (subsurface) of the endometrium. It is either focal (breakthrough bleeding) or diffuse (withdrawal bleeding). It is initiated by either chronic endometritis and/or microerosions or vascular fragility due to structural abnormalities of microvessels. Endometritis and microerosions occur in otherwise normal endometrium, polyps, submucosal leiomyomata, atrophy and cancer (organic causes). Primary vascular alterations are found in hyperestrogenic-type endometria, i.e. anovulatory dysfunctional uterine bleeding (DUB) and progestational-type endometrium, i.e. progestational contraceptives and combined, continuous hormonal replacement therapy (HRT) (non-organic causes). Ovulatory DUB and coagulation disorders are not appreciated histologically. These are related to impaired vasoconstriction and fibrinolysis and impaired coagulation factors, respectively. CONCLUSIONS: Histology may contribute to better understanding of the mechanisms of action that initiate, regulate and lead to AUB. Better insight may trigger in the development of therapeutic procedures that could either prevent or control vascular breakdown which results in unexpected uterine bleeding.

Endometrium↗

Differences in counseling men and women: family planning in Kenya.

A comparison of family planning sessions with male and female clients in Kenya found distinct gender differences. Most men came for information, while women wanted to adopt, continue, or change contraceptive methods. Consultations with men and couples were more than twice as long as consultations with women. Men communicated actively (for example, by volunteering extra information, asking questions, and expressing worries) during 66% of their turns to speak, compared with 27% for women. Providers offered men more detailed information than women, asked them fewer questions, issued fewer instructions, and responded more supportively. These communication patterns may be seen as a reflection of Kenyan gender roles and men's and women's different reasons for seeking family planning services. Kenyan providers need to improve the quality of their interactions with women. They also need to anticipate men's outspokenness and understand the male agenda if they are to counsel men effectively.

Adult↗

Altered prostate growth and daily sperm production in male mice exposed prenatally to subclinical doses of 17alpha-ethinyl oestradiol.

Approximately 2 million women in the USA and Europe continue taking oral contraceptives each year during undetected pregnancy due primarily to non-compliance and also to individual variation in sensitivity to hormones in the contraceptives. Prenatal exposure to oral contraceptives containing 17alpha-ethinyl oestradiol (EE) has generally not been associated with an increased incidence of externally observable malformations at birth. The purpose of this study was to assess effects on reproductive organs in adult male mice that had been exposed during gestation day 0 through 17 (equivalent to gestation week 16 in humans) to clinically relevant (approximately 0.5 microg/kg/day) and lower doses of EE. Doses used in this study ranged from 0.002 to 2 microg/kg/day. By 5 months of age, prostate weight was significantly (P < 0.05) higher than controls in most treatment groups of EE (0.02-2 microg/kg). Prostatic androgen receptor populations were significantly elevated only in the 0.02 microg/kg group, suggesting different mechanisms for the increase in prostate weight at different doses. Daily sperm production (DSP) and DSP per gramme of testis were reduced in all treatment groups during adolescence, but not later in adulthood. These findings are consistent with prior studies showing that prenatal exposure of mice to very low doses of a number of oestrogenic chemicals can alter the adult male reproductive system without causing gross external malformations.

Aging↗