Latex allergy and contraception.

PIP: Latex, a material derived from the rubber tree, can cause an allergic reaction in the form of contact dermatitis. This allergy can manifest in a rash, swelling, and itching, and symptoms can be mild or severe. Individuals who come into frequent contact with latex are at risk of developing an allergy. Latex allergy should be suspected in cases of swelling or itching after a medical examination, contact with rubber gloves, swelling or itching of the mouth and lips after blowing up a balloon or having a dental examination, or oral itching after eating bananas, chestnuts, or avocados. Latex sensitivity can cause penile, vaginal, or rectal itching or swelling after using male condoms or a vaginal diaphragm. People with latex allergies can use lambskin condoms (which protect against pregnancy but not against sexually transmitted diseases [STDs]) or polyurethane condoms. The female condom, Reality, is made of polyurethane and protects against pregnancy, STDs, and HIV/AIDS. The male polyurethane condom, Avanti, will be available nationwide in the US in 1997. Additional research is required to determine if the male polyurethane condom protects against STDs as well as pregnancy.^ieng

Contraception and the prevention of sexually transmitted diseases.

Sexually transmitted diseases (STDs) are a major cause of ill health in women and their sexual partners and children. Contraceptive methods alter in various ways the risk of acquiring STD but assessment of the odds ratio is difficult due to the many confounding factors. Spermicides have been reported to kill a wide range of bacteria and viruses including HIV in vitro and to protect in vivo from infection by gonorrhoea, chlamydia and pelvic inflammatory disease (organisms unspecified). Spermicides will not cure pre-existing infections. Condoms and diaphragms will give some protection from bacterial and viral infections in all parts of the genital tract. Hormonal contraception and tubal ligation give protection to the upper genital tract but not the cervix. Carcinoma of the cervix follows the same pattern as STDs. The risk of pelvic infection in intrauterine device users is discussed in the chapter by Bromham (pp 100-123, this issue).

PIP: Spermicides kill a wide range of bacteria and viruses causing sexually transmitted diseases (STDs), including the human immunodeficiency virus (HIV) in vitro, and protect in vivo from infection by gonorrhoea, chlamydia, and pelvic inflammatory disease (PID). In the UK and the US, the most commonly used compound in spermicidal agents is the neutral surfactant nonoxynol-9. Although spermicides reduce the incidence of reinfection by some STDs, an in vivo virucidal action is not supported by convincing data. Among barrier methods, latex condoms provide an impervious barrier in vitro to most STD pathogens, including HIV. Natural condoms made of sheep intestinal membrane can allow passage of hepatitis B viral particles but not HIV in vitro. Several studies have shown protection against cervical gonorrhoea and PID among diaphragm users; however, diaphragm use has been associated with an increased rate of urinary infection and also bacterial vaginosis. It is conceivable that women using oral contraceptives (OCs) do not develop as much tubal damage as women not using OCs because of a modified immunological reaction. A study carried out in Europe showed a statistically significant protective effect against PID of the levonorgestrel-containing IUD as compared with the copper-containing Nova-T. A case/control study of 1028 women in Chicago in 1970 noted admission for PID during the following 7 years of only 1 woman who had been sterilized compared to 9 controls. A case/control study examining risk factors for cervical intraepithelial neoplasia (CIN) in 103 women with biopsy-confirmed CIN II or III did not find an increased risk with either OC or IUD use after adjusting for other known risk factors. After adjustment for age and education, the odds ratio for diaphragm use was .3 and the odds ratio for condom use was .5. Thus, hormonal contraception and tubal ligation give protection to the upper genital tract but not to the cervix.

[The hormone diaphragm affords safe contraception and relief from menstrual pain]. / Hormonikierukka antaa varman ehkäisysuojan ja vapauttaa kuukautisvaivoista.

PIP: In Finland, the hormonal diaphragm Levonova was put on the market in the fall of 1990. Since that time, more than 20,000 Finnish women have been using them. The hormonal diaphragm is most suitable for women who want long-term contraception. It has a 5-year duration, and its contraceptive effectiveness equals that of sterilization. Levonova releases levonorgestrel directly into the uterus, thus its effect is local, and therefore, women who cannot take other hormonal preparations can use it. Thus, there is no upper age limit for using Levonova in contrast to oral contraceptive use. Nevertheless, hormonal diaphragms are not recommended for nulliparous women 25 years of age. This preparation is mainly recommended for women who no longer wish to have a child, yet who do not want to undergo sterilization in cases they change their mind. The hormonal diaphragm is fitted during menstruation, or at the latest on the 7th day after the beginning of menstruation. This is a simple procedure, and a follow-up examination 3 months later is recommended. In rare instances, side effects such as headache, lower abdominal tumescence, lack of appetite, and depression can occur, but these are transitory. In general it has been observed that in women who have had heavy bleeding or painful menstruation, these symptoms become ameliorated after the insertion of the hormonal diaphragm. Levonova has been tested during 10,000-use years with the participation of 3500 women using it from 1-5 years. These investigations are currently proceeding, and 50% of women are kept under observation during normal use in order to get Levonova registered in the countries of the European Common Market, the manufacturer, Leiras Pharmaceutical co., has disclosed.^ieng

Choice of contraceptives.

PIP: A table lists the commonly used methods of reversible contraception, their mechanism of action, and some adverse effects -- oral contraceptives (OCs), combined and progestin only; IUDs; the condom; diaphragm with spermicide; cervical cap with spermicide; sponge with spermicide; spermicide; periodic abstinence; and medroxyprogesterone acetate. The progestin-only OCs have a higher failure rate than the combined OCs and may cause irregular bleeding. Their principal indication is for nursing mothers who want to use an OC. To minimize the risk of cardiovascular adverse effects, OCs containing 35 mcg of estrogen or less and a low dose of a progestin are preferred. Most studies have found no overall increase in the incidence of breast cancer in women using OCs, but the possibility remains that the incidence may be increased in some subgroups. The 2 IUDs now marketed in the US -- the Progestasert and the Copper T380A both have a T shape and are medicated. The increased risk of pelvic inflammatory disease associated with IUDs was limited to the 1st few months after insertion in 1 study of 472 women using IUDs other than the Dalkon Shield. The increased risk of ectopic pregnancy appears to be lower with copper-containing devices than with the Progestasert. The advantages of condom use include safety and protection against sexually transmitted diseases, including Acquired Immune Deficiency Syndrome (AIDS). Diaphragms, which also offer some increased protection against sexually transmitted diseases, have been associated with an increased risk of urinary tract infection. The cervical cap, a smaller device than the diaphragm, can be left in place for 48 hours without adding more spermicide and is less messy to use than the diaphragm. The vaginal contraceptive sponge can protect during multiple acts of coitus over a 24-hour period. Nonoxynol-9, the most common spermicide used in the US, is a chemical surfactant that destroys the cell walls of sperm and offers some protection against sexually transmitted diseases. Women with irregular menstrual periods have the greatest risk of failure with periodic abstinence. Medroxyprogesterone acetate is not approved by the US Food and Drug Administration for contraceptive use.^ieng

Effect of contraceptives on the skin.

PIP: Combined oral contraceptives (COCs) affect the skin 3 different ways. They decrease the amount of androgenic hormones produced in the ovaries and adrenal gland. They also limit the quantity of biologically active circulating testosterone. Finally, estrogen markedly decreases oil production in the sebaceous glands. Physicians should prescribe to women with acne a COC that is low in progestogen and high in estrogen. A biphasic pill with no more than 500 mcg norethisterone/day meets these requirements. If a woman is taking systemic antibiotics to treat acne, however, the physician should prescribe a biphasic pill containing 50 mcg ethinyl estradiol. Even though many believe that using COCs causes hair loss, there is little evidence to support it. Nevertheless, if a woman has indeed experienced hair loss, she should take a COC with a high estrogen to progestogen ratio. As in some pregnant women, cholasma may occur in women taking COCs when not protected from sunlight. Physicians need to prescribe the lowest possible dose of hormones in these women and counsel them to shield their face from sunlight. To err on the side of safety, women who have had a malignant melanoma should not use a hormonal contraceptive. In addition, women who have experienced many bouts of skin candidiasis should use an alternative contraceptive. Other skin disorders that they have been found to be more prevalent in women taking COCs include erythema nodosum, accelerated systemic lupus erythematosus, porphyria cutanea tarda, herpes gestationis, spider naevus, and telangiectasia. There also exists an association between dermatitis and barrier methods and spermicides. Some articles have suggested that copper containing IUDs have also cause a variety of skin disorders.^ieng

Risk factors for urinary tract infection.

The authors carried out a case-control study in 1982-1983 to investigate the possible influence of behavioral factors on the risk of urinary tract infection. Study participants were college women attending a student health service. Cases were 43 women with culture-confirmed urinary tract infection. There were two control groups: 149 women with upper respiratory infection and 227 women visiting the gynecology clinic. Using each set of controls, the study confirmed that sexual intercourse is a risk factor and that there is a dose-response effect for increasing levels of coital frequency. The study also found that use of the diaphragm was significantly associated with urinary tract infection (odds ratios 3.0, 2.3), an association which remained significant even after controlling for possible confounding by coital frequency. The findings did not show an association with many of the factors commonly believed to be important such as type of clothing worn and volume of fluids consumed.

PIP: A case study was conducted among college women using a student health service at a university in southern Michigan to identify and evaluate behavioral factors which may be determinants of urinary tract infection. Women who presented to the student health service with symptoms suggestive of urinary tract infection and found to have pyuria on urinalysis were offered the opportunity to participate in a clinical trial comparing antibiotic regimens in the treatment of their urinary infection. Women with identified structural abnormalities of the urinary tract were not admitted to the study. On their 1st visit, women enrolled in the antibiotic study were asked to complete a questionnaire for the epidemiologic study described here. Midstream specimens were obtained during the 1st visit prior to therapy and were cultured quantitatively using standard methods. A patient with symptoms of acute urinary tract infection was included as a case if the urine culture was positive or probable. 2 different control groups were used to assess risk factors for urinary tract infection. For the 1st control group, women presenting to the student health service with coryza and/or sore throat, an oral temperature of less than 38.9 degrees Centigrade, and a clinical diagnosis of uncomplicated viral upper respiratory infection were asked to complete the same questionnaire as cases. For the 2nd control group, women attending the gynecology clinic at the same student health service for routine scheduled pelvic examinations and/or contraceptive services were asked to complete the same questionnaire. Cases were entered into the study from March through December 1982. The students used as controls participated from March 1982 through March 1983. The subjects completed a standard self-administered multiple-choice questionnaire, asking primarily about activities during the 3 weeks prior to completion of the questionnaire. 47 women with presumptive urinary tract infection participated in the clinical trial. 43 cases of confirmed urinary tract infection were identified, 38 with a positive and 5 with a probable urine culture result. In all, 149 upper respiratory infection controls and 227 gynecology controls participated. The history of previous urinary tract infection was significantly greater in cases than in either of the control groups. 4 variables were included in the final logistic model: coital frequency within 3 weeks, use of the diaphragm within 3 weeks, history of previous urinary tract infection, and age. Coital frequency during the previous 3 weeks was associated strongly with illness, with generally higher risk at higher frequencies. A significant association with the diaphragm was observed in comparison with both control groups. The findings failed to show an association with many of the factors commonly believed to be important such as type of clothing worn and volume of fluids consumed.

Urinary tract infection in relation to diaphragm use and obesity.

We have examined factors influencing the rate of first referral to hospital for urinary tract infection among the 17,032 women taking part in the Oxford Family Planning Association contraceptive study. The risk of first referral declined with age, was higher in nulliparous women than in parous women, was higher in non-obese than in obese women and was higher in current users of the diaphragm than in current users of other methods or no method of contraception. The main increase in the risk of referral in current diaphragm users occurred during the first 24 months when overall rates were 2-3 times higher in users than in non-users or ex-users of the diaphragm. The negative association between hospital referral for urinary tract infection and obesity was unexpected. It was not explicable in terms of age, parity or diaphragm use. It may be that obese women are less likely to receive trauma to the genital area during sexual intercourse than non-obese women because adipose tissue offers them some protection. Another possibility is that increased oestrogenization in obese women, resulting from peripheral conversion of androstenedione to oestrone, has a beneficial effect on the bladder and urethra, thus reducing the liability to infection.

PIP: Throughout England and Scotland from 1968-74, 17,032 white, married women whose ages ranged from 25-39 years were studied in an attempt to observe the correlation of urinary tract infection to diaphragm use and obesity. The risk of urinary tract infection was not found to be linked to social class and cigarette smoking. Infection was, however, found to be connected to age, parity, obesity and contraceptive use. The risk of urinary tract infection was shown to decrease with age. The risk of UTI (urinary tract infection) was found to be more prevalent among nulliparous than parous women. Women who were non-obese and women who currently used the diaphragm were at greater risk than women who were obese and women who used other/none methods of birth control. The current study along with other studies confirm that a connection exists between the use of a diaphragm and an increased risk of urinary tract infection.

[Relationships between contraception and gynecologic infections]. / Relazioni tra contraccezione e flogosi genitali nella donna.

PIP: Infections of the upper genital tract are commonly referred to as pelvic inflammatory disease (PID) and are often accompanied by fever, leucocytosis, and adnexal tumefaction. Risk factors are sexual activity at an early age, types of microbes, number of partners, and frequent sexual intercourse. Some studies found more incidence of mycotic vaginitis in women using oral contraceptives (OC) with a high estrogen content. It was also suggested that OC use reduced gonococcal pelvic infections by 50% by means of reducing menstrual flow and by modifying cervical mucus, making it impenetrable to bacteria. Nevertheless, OCs protect only in severe cases of PID. OC users appear to have a higher rate of chlamydial infections of the lower genital tract. IUD users have a 1.6 to 9.3 times higher risk of getting pelvic infections depending on age, number of partners, and frequency of intercourse. The risk is highest in the first 30 days after receiving the IUD, and long use (2 years) augments the risk of severe PID. There is increased risk of gonococcal infection in IUD users. Significantly increased numbers of anaerobic bacteria are present in cervical cultures of IUD users. Longterm IUD use is linked to a higher prevalence of actinomycetes. Among barrier methods, the use of the condom reduces the risk of infection with gonorrhea or chlamydia eightfold. The diaphragm provides effective protection against gonococcal and chlamydial infections, although its incorrect size and prolonged contact with spermicide can produce microlesions. Sterilization is associated with the reduction of genital infections; however, these are low-risk women aged 30 who are married. The spread of sexually transmitted diseases is an important factor to consider when choosing a contraceptive.^ieng

Association between diaphragm use and asymptomatic bacteriuria.

The prevalence of asymptomatic bacteriuria was assessed in women using different contraceptive methods. Three hundred and twenty women attending a family planning centre were studied, 80 in each of the following groups: diaphragms, intrauterine contraceptive devices (IUCDs), oral contraceptives (OCs) and no contraception. The numbers with asymptomatic bacteriuria in the 4 groups were as follows: diaphragm - 12 (all E coli); IUCD - 3 (E coli; P mirabilis; S saprophyticus); OC - 5 (all E coli); no contraception - 4 (3 E coli; 1 S saprophyticus). The prevalence of Gram-negative bacteriuria in women using diaphragms was significantly higher than for women in the other groups (chi 2 = 8.98; p less than 0.05). Factors such as parity, numbers of sexual partners and frequency of sexual intercourse had no apparent effect. The use of diaphragms may contribute to the risk of Gram-negative urinary tract infections in sexually active women.

PIP: A prospective study was carried out to determine whether the prevalence of asymptomatic bacteriuria in women is affected by contraceptive method. Study subjects included 320 women attending a family planning center who were divided into 4 groups according to contraceptive method: diaphragm (80 women), IUD (80 women), oral contraceptives (80 women), and no contraceptive method (80 women). Diaphragm users were found to have a significantly higher incidence of bacteriuria (p 0.05) than women in the other 3 contraceptive groups. Escherichia coli was the organism isolated from all of the women using diaphragms who had asymptomatic infection. 3 of these 12 women reported having had urinary tract symptoms in the preceding year. Parity, number of sexual partners, and frequency of intercourse did not have an effect on the prevalence rate of asymptomatic urinary tract infection in the different contraceptive groups. The 15% prevalence rate of asymptomatic bacteriuria found in this study among diaphragm users is 3 times the rate found in pregnancy or among sexually active nonpregnant women. Overall, these findings support the view that diaphragm use contributes to the risk of urinary tract infections with Gram-negative organisms.

Toxic shock syndrome associated with diaphragm use.

PIP: This article presents a case of toxic shock syndrome associated with the use of a diaphragm. The patient, a 31-year-old white female, presented with symptoms of shock and bilateral lower quadrant pain. A diagnosis of toxic shock syndrome was made on the basis of the patient's fever, rash, desquamation, and involvement of the gastrointestinal, muscular, mucous membrane, renal, and hematologic organ systems. The patient had discontinued oral contraceptive use 3 weeks earlier and had used a diaphragm for birth control the day before the onset of illness. The device was in place for 10 hours. She was not a tampon user. The diaphragm is considered to be the most likely etiologic agent in this case of toxic shock syndrome, although a specific pathophysiologic mechanism has not been identified. Caution should be exerted in prescribing the diaphragm to patients with a prior history of this syndrome.^ieng

Oral contraception and serious psychiatric illness: absence of an association.

The incidence of serious psychiatric illness, as measured by first referral to hospital for specialist advice and treatment, has been investigated among 16,746 women taking part in the Oxford Family Planning Association contraceptive study. Of these women, 9,504 were recruited while using oral contraceptives, 4,144 while using a diaphragm and 3,098 while using an intrauterine device. The results are reassuring with respect to oral contraceptive use. First referral rates per 1000 woman-years of observation in the oral contraceptive, diaphragm, and intrauterine device entry groups were 3.0, 2.6, and 2.8 respectively for non-psychotic psychiatric disorders and 0.46, 0.43 and 0.53 respectively for psychotic disorders. Attempted suicide occurred only 40% as often amongst diaphragm users as amongst users of oral contraceptives or intrauterine devices; this finding presumably reflects the characteristics of women who choose the diaphragm as their birth control method.

Relationship between contraceptive method and vaginal flora.

This study was undertaken to assess whether the vaginal flora was affected by the method of contraception, and in particular as to whether the incidence of vaginal candidiasis increased when oral contraceptives were used. One thousand and two consecutive vaginal or cervical swabs from women attending a family planning centre were cultured. Candida albicans was isolated from 13% of women using no contraception, 16% using oral contraceptives, and from 9%, 19% and 18% of those using diaphragms, intrauterine contraceptive devices (IUCD) and condoms respectively. These differences were not statistically significant. Women using an IUCD had significantly more Gram-positive cocci cultured than women in any other group, while those using diaphragms had significantly more Gram-negative bacilli. Our clinical impression that the use of oral contraceptives led to an increase in vaginal candidiasis, was not confirmed by this study.

PIP: Increase in the number of positive cultures for fungi of bacteria taken from vaginal or cervical swabs, in oral contraceptive (OC) users was assessed. Women attending a family planning center in Christchurch, New Zealand, had a vaginal or cervical swab taken prior to a cervical smear. The swabs were placed in transport media and then cultured on brain-heart infusion agar with added chloramphenicol for Candida albicans isolation and modified Thayer-Martin agar and blood agar for Neisseria gonorrhoea. The presence of Trichomonas vaginalis was ascertained by examining a wet preparation and by culture onto Trichomonas medium. Other aerobic bacteria were isolated from the blood agar plates and identified using standard techniques. The culture results from 1002 consecutive swabs were assessed. There was no difference in the rates of infection with C. albicans between the different contraceptive groups. Similarly, there were no differences when the OC group was subdivided into those with either standard dose, low dose, or no estrogen content. When a similar analysis was carried out for the isolation of Gram positive cocci, the groups differed significantly due largely to the high rate of isolation of Gram positive cocci from women using IUDs. The patients also differed signifficantly in the rate of infection with Gram negative bacilli. To limit the number of multiple comparisons, the diaphragm and IUD groups were compared; the isolation rate of Gram negative bacilli was significantly higher in the diaphragm group. The isolation rate of Gram negative bacilli from women using IUDs or condoms was significantly higher than in those women using OCs. T. vaginalis was isolated from 1 woman who had never used contraceptives, 2 who were not using them at the time the swabs were taken, 7 taking OCs, and 1 using condoms. N. gonorrhoea was isolated from 3 women using 3Cs and 1 using an IUD. OC use was not associated with an increased incidence of cervical or vaginal infection by C. albicans, T. Vaginalis, N. gonorrhoea, or by any bacterial species. The highest rate of isolation of Gram-positive cocci was seen in women using IUDs.

Toxic shock syndrome and diaphragm use.

A case of toxic shock syndrome (TSS) associated with diaphragm use is presented. Adolescents who use a diaphragm should be informed of the symptoms of TSS, and those with the syndrome should be questioned about diaphragm use.

PIP: A case of toxic shock syndrome (TSS) associated with diaphragm use is presented. A 15-year-old female was admitted to the hospital. 36 hours prior to the onset of her symptoms she had been fitted with a diaphragm. The diaphragm was in place for 12 hours, removed for 17 hours, and then replaced 7 hours prior to the onset of illness. Pelvic exam revealed copious vaginal discharge and a diaphragm still in place. When previously questioned however, the patient had reported she had removed the diaphragm. After 12 months, during which time the patient did not use tampons or a diaphragm, there was no recurrence of symptoms. The role of a diaphragm in the etiology of TSS is unclear. Some authors say that the blockage of the normal clearance of vaginal secretions by intravaginal devices may lead to the overgowth of staphylococcus and its enterotoxin. Others have suggested that vaginal ulcerations or trauma may enable the staph toxin to be absorbed. Neither hypothesis has been proved. TSS may also occur in women who use the cervical cap which remains in place for 4-7 days, but this has not yet been reported. It may be important for physicians to educate their patients as to the possibility of TSS, its early signs and symptoms. Since many adolescent girls use diaphragms, a teen with TSS should be questioned about diaphragm use.

Toxic shock syndrome associated with diaphragm use.

PIP: A case report is presented of toxic shock syndrome associated wtih diaphragm use. The patient, an 18-year old white woman, gravida 1, para 1, was in good health prior to the reported episode. She had a low transverse cesarean section for fetal distress 3 months prior to admission and had not yet resumed menstruation. 48 hours prior to admission, after unprotected intercourse, she developed a vaginal discharge requiring the use of a pad. 12 hours later she used a diaphragm, left it in place overnight, and failed to remove it the next morning. During the day pelvic and lumbar pain developed, followed by vomiting and a fever as high as 103 degrees Farenheit. That evening, 12 hours before admission, the diaphragm was removed with drainage of copious purulent discharge. The edges of the diaphragm and the discharge were blood streaked. She also developed a diffuse macular blanching rash, sparing only the circumoral region. At the time of admission the following morning her blood pressure was 60/0mmHg; pulse, 180 beats/minute; and temperature, 102 degrees Farenheit. Significant physical findings included the rash, conjunctivitis, a pharyngeal infection, and a lack of adenopathy. Pelvic examination showed a vaginal discharge, a very tender, slightly enlarged warm uterus, and normal adnexa. Cultures of the vaginal discharge were positive for Staphylococcus aureus, resistant to penicillin and ampicillin, and sensitive to methicillin, cephalothin, erythromycin, colistin, chloramphenicol, tetracycline, sulfisoxazole, and aminoglycoside antibiotics. The white blood count rose from 11,000/mm on admission to a high of 13,000/mm with a left shift the next day. The patient received 1.2 million units of intravenous penicillin every 4 hours, 80 mg of gentamicin every 8 hours, and 300 mg of clindamycin every 6 hours, as well as fluid replacement of 2 g of methylprednisolone followed by 1 g every 6 hours. The shock, fever, and rash resolved in the following 48 hours. 2 days after admission there was circumoral exfoliation. The discharge and electrolyte and renal abnormalities cleared in 3 days. Laboratory abnormalities corrected in 24-48 hours except for liver function tests. After 8 days in the hospital, the patient was discharged on 500 mg of cloxacillin every 6 hours. This particular case is unusual because it began with development of a vaginal discharge without vaginal obstruction, developed during a 24-hour period when a diaphragm was in place, and was not associated with menstruation. Whether the discharge represented staphylococcal infection is unknown, but the diaphragm certainly seems to have contributed to the course of events.^ieng

The effects of prolonged retention of diaphragms on colonization by Staphylococcus aureus of the lower genital tract.

To determine whether prolonged retention of diaphragms alters Staphylococcus aureus colonization of the lower genital tract, 183 nonpregnant, asymptomatic women were screened for the presence of this pathogen in the cervix and upper vagina. Nineteen (10.4%) had positive cultures: 5 from the vagina, 8 from the cervix, and 6 from both sites. A second examination with quantitation revealed the presence of S. aureus in 7 of the 19 patients. In five of the six available patients, the number of staphylococci increased significantly after prolonged (24 hour) retention of diaphragms and decreased in one subject only. In two additional patients S. aureus was recovered after, but not before, the use of diaphragms. An increase in the number of other microorganisms also was noted after prolonged retention of diaphragms. In vitro study of the spermicide nonoxynol-9 revealed that it had no inhibitory activity on staphylococci or group B streptococci but was highly effective against Streptococcus pneumoniae.

Contraception.

PIP: An article written for the layman presents information on oral contraception, the IUD, the vaginal diaphragm, the condom, and foam. Oral contraception is discussed in terms of effectiveness, cost, how it works, complications, and contraindications. The 7 major types of IUDs and the complications are listed after a discussion of what the device is, how it works, and its' cost. 8 contraindications are given. The structure of the diaphragm, the cost, and how to use it are discussed. The complications and contraindications are listed. The section on the condom includes a description, its' use, cost, and disadvantages. Foam is briefly mentioned in terms of its' effectiveness, cost, and advantage and disadvantage. 5 alternatives are listed for women who find all of the methods are contraindicated, undesirable, or both.^ieng

Letter: PGE2 as a vaginal abortifacient - diaphragm effect.

PIP: Schulman et al reported reduction in interval-abortion time and decreased side effects when prostaglandin (PG) E2 vaginal suppositories were administered within a contraceptive diaphragm. The authors conducted a study to confirm Schulman et al' finding. 2 groups of 20 patients with gestational ages ranging from 13 to 20 weeks were matched. 1 group (non-diaphragm) had a 20 mg. suppository inserted every 4 hours high in the vaginal fornix. The other group (diaphragm) had a contraceptive diaphragm containing the suppository inserted at 4-hour intervals. The authors' protocol differed from that of Schulman's in that oxytocin sensitivity was not sought and PGE2 alone was used. Oxytocin, however, was used to promote placental expulsion following fetal delivery in 4 cases. There were no statistically significant differences observed between the groups with respect to total drug dose (84 mg. for diaphragm group and 80 mg. for non-diaphragm), abortion-interval time (15.2 hours vs. 14.3 respectively), or frequency of side effects (vomiting, diarrhea). Schulman's reduced side effects may have followed the decreased absorption rate of PGE2 and avoidance of plasma peaks secondary to reduction in drug-mucosal interface. Schulman also reported onset of uterine activity in the diaphragm group (mean, 41 minutes) versus the control group's mean of 79.4 minutes. There is no known physiologic explanation for such findings.^ieng