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Increasing numbers of females born with congenital heart disease are reaching childbearing age. Practitioners involved in the management of the adolescents or adults must be aware not only of the risks of pregnancy associated with varying types of CHD but with other issues involving the reproductive cycle to provide appropriate care, counseling, and education.
OBJECTIVE: The objective of this short communication is to measure and compare the force needed to remove the implanted "0-suture" GyneFix intrauterine contraceptive device (IUD) and the "0-suture" FibroPlant trade mark -LNG intrauterine system (IUS) from the uterus of pre- and postmenopausal women. STUDY DESIGN: A nonrandomized comparative study in 119 pre- and postmenopausal women. A dynamometer (Pesola) was used to measure the removal force in newtons. RESULTS: The results of this study show a mean removal force of 8.5 and 9.5 newtons, respectively (range, 3-11 and 4.5-11), in pre- and postmenopausal women, which is significantly different (p = 0.003). CONCLUSIONS: The force needed to remove the IUD/IUS anchored in the myometrium of the uterine fundus of pre- and postmenopausal women is higher than the removal force found in previous studies in which the IUD consisted of a slightly thinner anchoring thread (00 instead of 0 suture). The statistically significantly different removal force between the two groups has no clinical implications. The difference may reflect the increased compactness of the uterine tissue in the postmenopausal uterus.
OBJECTIVE: The objective of the present study is to report on the force needed to remove the implanted GyneFix intrauterine contraceptive device (IUD) from the uterine cavity. This study is the first long-term study on the retrieval of the anchored IUD. STUDY DESIGN: A two-center, noncomparative study to measure the force needed to remove the IUD in 251 women. A dynamometer (Pesola, Switzerland) was used to measure the removal force in newtons. RESULTS: The results of this study show a mean removal force of 6.2 and 6.1 newtons, respectively (range, 0-10), in parous and nulligravid or nulliparous women (p = 0.62). There was no difference in removal force for those women with a duration of use either less than 60 months or longer than 60 months (median of 6 newtons in both groups; p = 0.22). CONCLUSIONS: The force needed to remove the GyneFix IUD suggests that the implantation technology used in the insertion of the device is reliable, provided the anchoring knot is properly inserted in the fundal myometrium. The results of this study indicate that early expulsion of the device could be explained by failure to implant the knot adequately (no implantation or partial implantation), which requires a degree of skill. The present study does not provide an explanation for the occurrence of late expulsion, although some speculations can be made.
OBJECTIVES: Our objective was to compare data on contraceptive use in relation to reported sexual activity in women from different minority ethnic groups. DESIGN: We analyzed the National Survey of Sexual Attitudes and Lifestyles 2000. SUBJECTS: Women aged 16-44 years, numbering 6932 and residing in Britain, participated in this study. MAIN OUTCOME MEASURES: Our main outcome measures are as follows: percentage of women reporting sexual activity, use of contraception and type of contraception (hormonal, barrier or permanent methods). RESULTS: Overall, fewer women from the UK's four main ethnic minority groups reported recent sexual activity, compared with white women. Among sexually active women, contraceptive use was significantly lower in all ethnic minority groups than in white women, but this pattern differed according to marital status. In ever-married or cohabiting women, lower contraceptive use was reported by Indian (78%) and Pakistani women (74%) than by other groups. Among single women, black Caribbean (88%) and black African (82%) women reported using less contraception compared with white (95%) and Indian (100%) women. Women from all ethnic minority groups were less likely than white women to report using hormonal contraception and permanent methods and were more likely to use barrier methods. The differences between ethnic groups remained significant after adjusting for educational achievement and parity. Deprivation and acculturation did not account for the use of contraception or the type of contraceptive method used. CONCLUSION: Sexually active married Pakistani and Indian women reported the lowest overall use of contraception. Among sexually active single women, black African and black Caribbean women reported levels of contraceptive use that were lower than those reported by white women. Sexually active women from all four minority ethnic groups were less likely than white women to use reliable methods of contraception.
Women with epilepsy face unique challenges in maintaining steroidal contraceptive efficacy because some antiepileptic drugs (AEDs) increase the rate of hepatic metabolism of contraceptive steroids, leading to higher potential for contraceptive failure in this population. Planned pregnancy is of great clinical and social importance for women with epilepsy because of the increased risk of birth defects from fetal exposure to AEDs. Current clinical guidelines for contraceptive management in women with epilepsy provide misleading information by focusing on the estrogen content of the formulation, which regulates the menstrual cycle, rather than on the progestin content of the formulation, which provides contraceptive efficacy. This article reviews studies of AED-contraceptive interaction and misconceptions about maintaining contraceptive efficacy and makes recommendations for contraceptive management in women with epilepsy who receive concomitant AED therapy.
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Endocervical Chlamydia trachomatis infection was found in 13 of 162 volunteer female university students (8%). Infection was correlated with younger age (p less than 0.05), less than or equal to 4 years of intercourse (p less than 0.05), a history of gonorrhea (p less than 0.01), and exposure to a partner with urethritis (p less than 0.01). Women who used intrauterine or barrier contraception had less infection (2%) than did women who used oral contraception (14.3%, p less than 0.05) or none at all (10.7%, p less than 0.05). Infection was strongly associated with a cervicitis score calculated from erythema, ectopy, discharge, and secretions that contained white blood cells (p less than 0.0001). By multivariate analysis, a proposed clinical approach was arrived at for testing for chlamydial organisms all women with cervicitis who were not using barrier contraception. The positive predictive value of this approach for chlamydial infection was 28%, and the negative predictive value 98.4%. Cervical ectopy was increased in women who used oral contraception (p less than 0.01), and infection was increased in women with ectopy, regardless of their contraceptive method (p less than 0.001). These results will aid in more rapid diagnosis of endocervical chlamydial infection and in the choice of contraception in young women and high-prevalence groups.
The causes of abnormal uterine bleeding include a wide spectrum of diseases of the reproductive system and nongynecologic causes as well. The differential diagnosis of abnormal excessive uterine bleeding includes organic causes that may be subdivided into reproductive tract disease, iatrogenic causes, and systemic disease. Reproductive tract disease that may result in abnormal uterine bleeding comprises the complications of pregnancy (threatened, incomplete, or missed abortion, ectopic pregnancy, trophoblastic disease, placental polyp, and subinvolution of the placental site), malignant tumors (endometrial, cervical, vaginal, vulvar, and oviduct malignancies and granulosa theca cell ovarian tumors), infection (endometritis, salpingitis), and other benign pelvic disorders (traumatic lesions of the vagina, severe vaginal infections, foreign bodies, cervical polyps, cervical erosion, cervicitis, submucous uterine leiomyomas, adenomyosis, endometriosis, and endometrial polyps). Iatrogenic causes of abnormal uterine bleeding include sex steroids, hypothalamic depressants, digitalis, phenytoin, anticoagulants, and intrauterine contraceptive devices. Systemic diseases that may cause abnormal uterine bleeding include hypothyroidism, cirrhosis, and coagulation disorders. Abnormal uterine bleeding that occurs in a woman of reproductive age should be considered the result of complication of pregnancy until proved otherwise. Abnormal uterine bleeding occurring in a woman of perimenopausal or postmenopausal age should be considered the result of a malignancy until proved otherwise. Menorrhagia occurring in an adolescent should be attributed to a coagulopathy until proved otherwise. When an organic cause of abnormal uterine bleeding cannot be found, then by exclusion the diagnosis of dysfunctional uterine bleeding is assumed. Coagulation disorders, particularly von Willebrand disease, are more common than many physicians realize. Women with a history of high-risk factors, all adolescents with menorrhagia, women with anovulatory dysfunctional uterine bleeding who fail medical or surgical therapy, and women with ovulatory dysfunctional uterine bleeding without an anatomic uterine lesion should be screened for a coagulopathy.
A review of the literature on pelvic actinomycosis reveals that actinomycetes normally reside in the female genital tract. Therefore the identification of actinomycetes in the vagina or cervix by any laboratory technique, including Papanicolaou smears with specific immunofluorescence or culture, is not diagnostic of any disease and is not predictive of any disease. The evidence strongly suggests that removal of the intrauterine contraceptive device of a patient with a positive culture is not necessary and that, in the absence of evidence for pelvic infection, antibiotics are not required. Pelvic actinomycosis is a rare disease whose pathogenesis is poorly understood.
Women who seek an abortion are motivated to use contraceptive methods afterwards. Because the return of fertility after abortion is immediate, there is a need for effective and safe contraception promptly after the termination of pregnancy. A randomized trial of Mirena and NovaT intrauterine contraceptive devices inserted at the time of elective termination of pregnancy, duration no more than 12 weeks, is reported here. Women were randomized 2:1 resulting in 305 subjects with Mirena and 133 with NovaT as a segment of a larger study of 3000 women. In the Mirena group, two pregnancies at year 4 resulted in a final gross rate of 0.8 at 5 years, which was significantly (p < 0.0004) lower than the corresponding rate of 9.5 with NovaT. Terminations because of expulsion, bleeding problems, pain, pelvic inflammatory disease and other medical reasons were less common in the Mirena group, but not significantly different. The cumulative expulsion gross rate for NovaT at 5 years was 15.4 and for Mirena it was 10.5. Termination rates because of amenorrhea were low in both groups. It is concluded that both devices were well tolerated. Mirena was more effective and the rate of adverse events was lower than with NovaT. Special attention should be paid to the insertion procedure when carried out at the time of abortion.
The objective of this study is to evaluate whether regular follow-up after insertion of an IUD protects against the risk and side effects of this contraceptive device. To study the effectiveness of the follow-up visits done after IUD insertion, we compared a group of women with regular follow-up visits (group A: after 6 weeks, 3, 6 and 12 months) with women who had non-regular follow-up visits (group B: after 6 weeks and annually) for pregnancy, expulsion rates and discontinuation. A total of 280 women were included (group A: 199, group B: 81). Three pregnancies and 2 unnoticed expulsions were observed. The detection rate of an unnoticed expulsion is 0.35 and 0.11 per 100 visits for, respectively, the visit 6 weeks after insertion and all successive visits. Women in group A came significantly more frequently for unscheduled visits [relative risk (RR): 1.6; 95% confidence interval (CI): 1.03-2.4]. The number of discontinuations, pregnancies and expulsions did not differ between groups, but women in group B had their IUD removed earlier (p < 0.01). We conclude that regular follow-up after the insertion of an IUD is not effective.
An improved long-acting Norgestrel-T contraceptive device has been developed. The effects of different release levels of levonorgestrel on the endometrium were studied in a selected group of 42 subjects. A randomized comparative study of the clinical performance of Cu-T 200 and Ng-T devices was undertaken in 200 fertile women for 15 months. Quantitation of the menstrual blood loss was performed on a selected group of 20 users. This new Ng-T device proved highly effective in fertility control. It was associated with a significant reduction in the amount of menstrual blood loss and incidence of termination probabilities due to bleeding and pain.
The anatomic sizes of 210 vas segments from 107 volunteers of vasectomy were measured by computerized image graphic technique with microphotography. The mean equivalent-round, outer and inner diameters of the vas were 2.17 +/- 0.20 mm and 0.56 +/- 0.08 mm, respectively. The calculated thickness of vas wall was 0.81 +/- 0.21 mm. The maximal volumes of 124 vas segments (1 cm in length) were tested by injecting colored solution into vas lumen until vas rupture. The mean rupture volume of 1 cm vas lumen was 0.05 +/- 0.007 mL. A significant influence of the thickness of vas wall (p < 0.05) and body height (p < 0.05) on the rupture volume was noticed in stepwise regression analysis. A tunnel-like rupturing pattern was observed in morphological observation. The obtained rupture volume provides a security line in determining the injection volume of occlusive material or the size of the implanted contraceptive device.
Although medical history has documented the desire to control fertility since ancient times, safe and effective contraception did not exist until this century and has not been equally available to all people. Strong moral sentiments, economic and social class factors, religious beliefs, familial and gender relations, and political as well as legal constraints have often limited the ability of physicians in favor of contraception to provide advice and methods of birth control to their patients. By the early 1900s, a constellation of factors--in particular, the large influx of poor immigrants, and feminist groups advocating women's rights--helped to move forward a birth-control movement in this country and abroad. In the early 20th century, Margaret Sanger became one of the most avid proponents of contraception in the United States. By 1950, she and Katharine McCormick had contracted with biologist Gregory Pincus to develop an effective birth control pill. A collaborative effort by Pincus and other researchers led to trials of the pill in Puerto Rico, Haiti, and Mexico between 1956 and 1957, which provided the basis for an application to the Food and Drug Administration for approval of the first oral contraceptive.
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Twelve human uteri containing intrauterine contraceptive devices (IUDs) and ten uteri without IUDs were obtained at hysterectomy. Samples of fluid were collected from the uterine lumina by absorbing the fluid in small pieces of lens paper. In the samples of luminal fluid we measured the concentration of beta-galactosidase, an enzyme which is present in human neutrophilic leukocytes and whose concentration in luminal fluid should correlate with the local inflammatory response to the intrauterine foreign body. In the samples of fluid from IUD-bearing uteri, the concentration of beta-galactosidase was significantly (P less than 0.0005) greater than that in luminal fluid from control uteri, the averages of the two groups differing by 3.8 units. To determine whether a foreign-body response of this magnitude could have any effect on preimplantation embryos, we cultured mouse embryos from day 4 to day 7 of development in culture media to which extracts of human leukocytes were added. All mouse embryos were killed when the culture media contained enough leukocyte extract to give beta-galactosidase concentrations of 0.5 unit or higher. Thus mouse embryos were killed by leukocyte extracts whose beta-galactosidase concentrations were actually less than the concentration of this marker enzyme measured in IUD uterine fluid. This comparison indicates that the luminal fluid in IUD-bearing uteri contains leukocyte break-down products in sufficient concentration to be lethal for preimplantation embryos.
Thirty-eight infertile women conceived 43 times following treatment for intrauterine adhesions (IUA). Adhesions were classified as being minimal in 7 women, moderate in 20 others, and extensive in 11. All women underwent hysteroscopy with division of all adhesions utilizing miniature scissors and high-dose estrogen treatment for 2 months. In addition 35 of the 38 women had either an intrauterine contraceptive device or a Foley catheter placed to prevent readherence of the walls, and 31 women had the uterine cavity investigated again prior to attempting a pregnancy. Prior to treatment for IUA only 16.7% of all pregnancies in those women with no other cause for pregnancy loss resulted in the delivery of a living infant. However, following treatment 87.2% of these pregnancies resulted in the delivery of a viable infant (P less than 0.001). No instances of placenta accreta occurred, and manual removal of the placenta was not required. Division of adhesions under hysteroscopic control together with the adjunctive measures utilized is superior to all other methods of therapy for IUA and should replace them.