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PubMed1996

The perimenopause and contraception.

OBJECTIVES: To review the implications of pregnancy in women in their forties and the contraceptive options open to them. METHOD: Medline and popline reviews of the literature. RESULTS: Women in their forties are still potentially fertile, and pregnancy in this age group is attended with increased maternal mortality, spontaneous abortion, fetal anomalies and perinatal mortality. In developing countries, these risks are compounded by high parity and poor medical care. Contraception for women in this age group has special risks and benefits, both should be balanced to choose between the different options available. Recent epidemiological and clinical pharmacology studies have indicated the safety of extending the use of combined oral contraceptives (COCs) beyond the age of 35 years and up to menopause. The improved picture of COCs has largely resulted from the use of low-dose-formulations, and avoidance of their use in women with risk factors for developing cardiovascular diseases. Besides their high reliability, which is desirable at this age, COCs will prevent the occurrence of climacteric symptoms and menstrual irregularities which are frequently complained of in the premenopausal years. Moreover, the use of COCs has a substantial protective effect against ovarian and endometrial cancers. Women who have reasons for avoiding COCs can use progestogen-only contraceptives like pills, depot injectables and implants. Norplant combines high efficacy and the long-term effect. Both copper-releasing and levonorgestrel-releasing IUDs (LNG-IUD) combine the advantages of high efficacy and long term effect. The reduced fecundity above the age of forty can allow extending the use beyond the accepted term, and up to one or two years beyond the menopause without the need for replacement. The levonorgestrel IUD has the advantage of reducing the amount of menstrual bleeding. The extent of use of barrier methods will depend upon the availability of a back-up by abortion service in case of failure. The condom has the added benefit of protection against STDs. Male or female sterilization is an excellent contraceptive option, provided that this approach is culturally acceptable and available at reasonable cost and low risk. CONCLUSION: Increasing the number of contraceptive options available to premenopausal women will improve proper counseling and enhance compliance.

Adult↗
PubMed2004

Participant characteristics associated with withdrawal from a large randomized trial of spermicide effectiveness.

BACKGROUND: In most recent large efficacy trials of barrier contraceptive methods, a high proportion of participants withdrew before the intended end of follow-up. The objective of this analysis was to explore characteristics of participants who failed to complete seven months of planned participation in a trial of spermicide efficacy. METHODS: Trial participants were expected to use the assigned spermicide for contraception for 7 months or until pregnancy occurred. In bivariable and multivariable analyses, we assessed the associations between failure to complete the trial and 17 pre-specified baseline characteristics. In addition, among women who participated for at least 6 weeks, we evaluated the relationships between failure to complete, various features of their first 6 weeks of experience with the spermicide, and characteristics of the study centers and population. RESULTS: Of the 1514 participants in this analysis, 635 (42%) failed to complete the study for reasons other than pregnancy. Women were significantly less likely to complete if they were younger or unmarried, had intercourse at least 8 times per month, or were enrolled at a university center or at a center that enrolled fewer than 4 participants per month. Noncompliance with study procedures in the first 6 weeks was also associated with subsequent early withdrawal, but dissatisfaction with the spermicide was not. However, many participants without these risk factors withdrew early. CONCLUSIONS: Failure to complete is a major problem in barrier method trials that seriously compromises the interpretation of results. Targeting retention efforts at women at high risk for early withdrawal is not likely to address the problem sufficiently.

Adult↗
PubMed2003

[A case of female alcoholic who developed liver cirrhosis with small amounts of alcohol by the common use of contraceptive agent].

A case of female alcoholic who developed liver cirrhosis with small amounts of alcohol by the common use of contraceptive agent was reported. A case was a 33-year-old female who had complained of systemic edema and jaundice. She had been drinking alcohol, while she had been taking the contraceptive agent from 20-year-old. On admission, she had a large amount of ascites with jaundice. She was diagnosed as liver cirrhosis and hepatic failure by CT scanning of abdomen and laboratory data. Her condition was temporarily improved by the abstinence and the treatment. Since she drank under hospitalization, she had to change the hospital and died after 2 months. She had been drinking for only 10 years. Her cumulative alcohol intake was also very small. She may have developed alcoholic cirrhosis with small amount of alcohol because of common use of contraceptive agent with drinking.

Adult↗
PubMed1999

Clinician/patient interaction: communicating the benefits and risks of oral contraceptives.

Myths and misperceptions continue to influence women's opinions about oral contraceptives (OC), despite the immense body of evidence regarding OC safety and efficacy. Patient opinions about OC failure rates and health risks are often far from proven fact, and the health benefits of OC are too often unrecognized. Because successful OC use requires an informed patient, effective communication between clinicians and their patients is needed to correct misinformation, relieve unnecessary fears, and increase OC use. A variety of interactive counseling skills and attitudes can improve the process of patient counseling; they are especially crucial for adolescents, who may be reluctant or unable to easily articulate their concerns. Counseling messages can be geared specifically to the interests and concerns of particular age groups: adolescents, young adults, and perimenopausal women. With thoughtful planning and involvement of all members of the healthcare team, clinicians can create time and opportunities for the provision of consistent, appropriate counseling to all candidates for OC use.

Adolescent↗
PubMed2003

The levonorgestrel intrauterine system: a clinical perspective from the UK.

The main contraceptive effects of this valuable product [the levonorgestrel intrauterine system (LNG-IUS)] are by endometrial suppression and changes to the cervical mucus and uterotubal fluid that impair sperm migration. The blood levels of LNG are very low, so progestogenic symptoms are uncommon. Most women still ovulate and in the remainder sufficient estrogen for health is produced from the ovary, even if they become amenorrhoeic, as many do; this is primarily a local end-organ effect and should be seen as a benefit. Although usable by selected nulliparae, it is ideal for the parous woman. It has unsurpassed efficacy, and return of fertility is rapid. Combining the best features of hormonal and intrauterine contraception, its gynecological benefits are impressive: the LNG-IUS user can expect a dramatic reduction in the amount and, after the first few occasionally troublesome months, in the duration of blood loss. Hemoglobin levels rise and dysmenorrhea is usually greatly benefited, unlike with current uterine ablation techniques. In perimenopausal women, it can protect the endometrium from overstimulation when estrogen replacement therapy (ERT) is added, by any chosen route. It thus provides a contraceptive modality of ERT with, usually, no bleeding and few progestogenic side effects-and is applicable before final ovarian failure. In summary, adverse side effects are few and in general they are not in the "hazardous" category. Regarding the admitted inconvenience of the first weeks of light postinsertion bleeding and the early phase low incidence of steroidal side effects: good counseling is paramount, since forewarned is forearmed!

Adult↗
PubMed2002

How safe is emergency contraception?

Emergency contraception is used to prevent pregnancy after unprotected sex but before pregnancy begins. Currently, women can use emergency contraception by taking higher doses of the active ingredients found in ordinary oral contraceptive pills [either combined estrogen-progestogen (progestin) or progestogen-only formulations], or by having providers insert copper-bearing intrauterine devices (IUDs). The antiprogestogen mifepristone also has an excellent efficacy and safety profile as emergency contraception, but it is currently available for this indication only in China. Many studies have documented providers' and women's fears about the individual and public health safety risks of emergency contraception. Some of these concerns include potentially increased risks of cardiovascular events (including arterial and venous disease), worries about possible effects on future fertility, feared teratogenic consequences following method failure or inadvertent use during pregnancy, exaggerated or extreme fears of adverse tolerability, and concerns about drug interactions with other medications. Wider public health questions include feared reductions in the use of ongoing, more effective contraception, possible 'abuse' of emergency contraception through overly frequent use, and potential increases in risky sexual encounters (owing to the existence of a back-up, postcoital method) and therefore in rates of sexually transmitted infections, including HIV/AIDS. These fears can each be generally allayed. Direct and indirect investigations of emergency contraception in the biomedical and social science literature, the extensively documented safety profile of ordinary oral contraceptives, and more than 30 years of clinical experience since hormonal emergency contraception was first described, give strong evidence for its safety. This review confirms declarations by the World Health Organization and the US Food and Drug Administration, and shows that emergency contraception has an excellent safety profile in nearly all women. Finally, emergency contraception allows women a second chance to avoid unwanted pregnancies. Whether pregnancy is carried to term or terminated, the condition has inherent risks that are greater than any posed by emergency contraception.

Congenital Abnormalities↗
PubMed2000

Access to emergency contraception.

OBJECTIVE: To evaluate access to emergency contraception among women seeking help from clinicians who registered to be listed on the Emergency Contraception Hotline (1-888-NOT-2-LATE, ie, 1-888-668-2528) and the Emergency Contraception Website (not-2-late.com). METHODS: Two college-educated investigators posing as women who had a condom break the previous night called 200 providers to seek help. RESULTS: Only 76% of attempts resulted in an appointment or telephone prescription from a hotline provider within 72 hours, 14% were failures, and 11% resulted in referrals to other providers not listed on the hotline or website. CONCLUSION: Even under ideal conditions, access to emergency contraception is currently constrained. Although emergency contraception could reduce significantly the incidence of unintended pregnancy and the consequent need for abortion, its potential will not be realized unless women have better access to clinicians who can prescribe emergency contraceptive pills.

Contraceptives, Oral, Combined↗
PubMed1998

Fertility and contraception in end-stage renal disease.

The hormonal aberrations that occur with end-stage renal disease (ESRD) are presented in this review in relation to fertility and conception among women on dialysis. The imbalance in gonadotropin production in dialysis-dependent men and women is characterized by elevations in luteinizing hormone (LH). In women dialysis patients, the normal estradiol-stimulated LH surge does not occur, resulting in anovulation. In men dialysis patients spermatogenesis is impaired, and low testosterone levels cause elevated LH. Infertility in those with ESRD is a culmination of many factors, including impotence and loss of libido, anovulation, and an altered hormonal milieu. Despite these inhibitors of conception, women on dialysis can conceive; pregnancy has been reported in 1% to 7% of women on dialysis in survey studies. The influence of dialysis mode (hemodialysis v peritoneal dialysis), recombinant human erythropoietin (EPO), and dialysis adequacy on the likelihood of conception among patients of either sex on dialysis is unknown. Reduced sexual activity and interest has consistently been reported in the ESRD population. The reasons for this are complex and likely involve the effects of comorbid illnesses, overall health status, body image factors, and hormonal alterations. Nephrologists rarely discuss conception and contraception with their women dialysis patients. Greater attention to these issues is needed.

Adult↗
PubMed1990

Clinical pharmacokinetics of prednisone and prednisolone.

The growth of knowledge in the field of the pharmacokinetics of prednisolone/prednisone has been slow for several reasons. First, convenient and specific methods for measuring these steroids only became available with the development of high performance liquid chromatographic methods. Secondly, prednisolone is nonlinearly bound to transcortin and albumin: since the unbound concentrations of prednisolone are biologically relevant, it was necessary to determine the free fraction in each plasma sample. Thirdly, due to the short half-life of prednisolone no steady-state is achieved, and therefore area under the concentration-time curve needed to be determined in all studies. Fourthly, prednisolone and prednisone are interconvertible and prednisolone is given intravenously as an ester prodrug, features which created controversies about the correct interpretation of pharmacokinetic results. Finally, the total body clearances of total and (to a lesser degree) of unbound prednisolone increase with increasing concentrations of prednisolone. Therefore, in order to compare pharmacokinetic results between different subjects, standardised doses had to be administered. The investigations performed so far have revealed that: (1) the dose-dependent pharmacokinetics partly explain the clinical observation that an alternate-day regimen with prednisone yields fewer biological effects; (2) the interconversion of prednisone into prednisolone is not a limiting factor, even in patients with severely impaired liver function; (3) hypoproteinaemia per se does not cause increased unbound concentrations of prednisolone in vivo; (4) patients with liver failure, renal failure or a renal transplant, subjects older than 65 years, women on estrogen-containing oral contraceptive steroids or subjects taking ketoconazole have increased unbound concentrations of prednisolone-whereas hyperthyroid patients, some patients with Crohn's disease, subjects taking microsomal liver enzyme-inducing agents or patients on intravenous prednisolone phthalate (instead of prednisolone phosphate) or on some brands of enteric coated prednisolone tablets have decreased concentrations of prednisolone. The biological relevance of the altered pharmacokinetics is supported in part by altered clinical effects and altered effects on cellular immunofunctions.

Animals↗
PubMed1999

Voluntary and involuntary sterilization: medical, ethical, legal and religious aspects.

Surgical voluntary sterilization has become one of the most widely used methods of contraception, with vasectomy and tubal sterilization being the most commonly employed techniques, associated with a low failure, morbidity, mortality, and long-term sequelae rate. As sterilization is related with the elimination of the possibility for procreation, a number of ethical, legal and religious issues have arisen, leading often to personal misjudgements, legal disputes, and failures in applying family planning. Involuntary sterilization is currently not practiced, except in cases of severely mentally retarded people, who are unable to appreciate the consequences of their acts or care for their children and who may have a high likelihood of propagating hereditary disease.

Ethics, Medical↗
PubMed1995

Vasectomy counseling.

The following recommendations for counseling patients about vasectomy may help to minimize the risk of litigation for family physicians who provide vasectomy services: (1) conduct a personal consultation with the patient; (2) discuss the impact of vasectomy on sexual function; (3) explain the procedure using diagrams during the office visit for the physical examination; (4) explain possible minor complications and risks, including the possibility of failure; (5) explain the need for a postoperative semen analysis and the need to use another contraceptive method for a while after vasectomy; (6) emphasize the permanence of the procedure; (7) have the patient read and sign an informed consent form; (8) provide preoperative and postoperative instructions; (9) answer questions and respond to concerns, and (10) telephone the patient the day after the surgery.

Humans↗