Analysis of uterine evacuation methods in postabortion care after implementation of a surveillance network (CLAP MUSA-Network) at a university hospital.

BACKGROUND: Management of uterine evacuation is essential for increasing safe abortion care. Monitoring through surveillance systems tracks changes in clinical practice and provides information to improve equity in abortion care quality. OBJECTIVE: This study aimed to evaluate the frequency of manual vacuum aspiration (MVA) and medical abortion (MA), and identify the factors associated with each uterine evacuation method after surveillance network installation at a Brazilian hospital. METHODS: This cross-sectional study included women admitted for abortion or miscarriage to the University of Campinas Women's Hospital, Brazil, between July 2017 and November 2020. The dependent variables were the use of MVA and MA with misoprostol. The independent variables were the patients' clinical and sociodemographic data. The Cochran-Armitage, chi-square, and Mann-Whitney U tests, as well as multiple logistic regression analysis, were used to compare uterine evacuation methods. RESULTS: We enrolled 474 women in the study, 91.35% of whom underwent uterine evacuation via uterine curettage (78.75%), MVA (9.46%), or MA (11.54%). MVA use increased during the study period (Z = 9.85, p < 0.001). Admission in 2020 (odds ratio [OR] 64.22; 95% confidence interval [CI] 3.79-1086.69) and lower gestational age (OR 0.837; 95% CI 0.724-0.967) were independently associated with MVA, whereas the only factor independently associated with MA was a higher education level (OR 2.66; 95% CI 1.30-5.46). CONCLUSION: MVA use increased following the installation of a surveillance network for good clinical practice. Being part of a network that encourages the use of evidence-based methods provides an opportunity for healthcare facilities to increase access to safe abortions.

Adaptation of a Brazilian university hospital to clinical treatment of ectopic pregnancy: Lessons learned over 17 years.

OBJECTIVE: To describe and compare the annual success rates of medical treatment in the analyzed period and to evaluate the associated factors. METHODS: Retrospective study with 158 women with tubal pregnancy followed up over 17 years. Statistical analysis was performed using the Cochran-Armitage test, the χ2 test, Mann-Whitney test, and multiple logistic regression. RESULTS: The success rate was 47.4%. There was a trend of significant change in the success rate of clinical treatment over time (Z = 2.01, P = 0.044); it was associated to undergoing treatment between 2012 and 2017 (P = 0.028), the absence of abdominal pain (P = 0.020), receiving a higher dose of methotrexate (P < 0.001), and less time hospitalized (P < 0.001). In the final statistical model, we observed that receiving a higher dose of methotrexate (P = 0.025, odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00-1.06), having a low serum ß-HCG concentration before treatment (P = 0.003, OR 0.87, 95% CI 0.79-0.95), and not having abdominal pain (P = 0.004, OR 4.26, 95% CI 1.61-11.28) were factors associated with a higher chance of successful clinical treatment for tubal pregnancy. CONCLUSION: A greater chance of success was observed among women undergoing clinical treatment from 2012 onwards, who used higher doses of methotrexate, were asymptomatic at admission, and had low concentrations of ß-hCG.

Effect of ulipristal acetate on gene expression profile in endometrial cells in culture and in vivo upon post-ovulatory administration in fertile women.

PURPOSE: To analyse the effect of ulipristal acetate (UPA) as emergency contraception (EC) on the gene expression of human endometrial cell line (HEC-1A) and endometrium from fertile women treated with UPA after ovulation. MATERIALS AND METHODS: HEC-1A cells were treated with UPA, and endometrial tissue from four healthy women was collected in cycles before, during and 2 months after post-ovulation pill intake. Ovulation and luteal phase were monitored, and endometrial biopsies were obtained at day LH + 7 in each cycle. In all cases, we analysed the expression profile of 192 genes associated to endometrial receptivity. RESULTS: We observed a significant change in total transcriptomic activity of UPA-treated HEC-1A cells compared to controls. In vivo, we also observed a trend to down-regulation of genes in the UPA-treated cycle that was partially restored in the post-treatment cycle. Altogether, our results supported a partially reversible effect of UPA in gene expression associated with uterine receptivity. CONCLUSIONS: When UPA was administered after ovulation, it seems to induce a down-regulation of the main genes involved in conditioning the endometrium for implantation. This effect is partially restored two months after pill intake. The action of UPA on the endometrium for users of EC should be further investigated.

Post-abortion contraception before hospital discharge after installation of a surveillance network in Brazil.

OBJECTIVE: To evaluate the use of contraception soon after abortion, ectopic, or molar pregnancy following the establishment of a surveillance network (MUSA). METHODS: A cross-sectional study of women admitted for abortion, or ectopic or molar pregnancy at UNICAMP Women's Hospital (part of the MUSA Network), Campinas, Brazil, between July 2017 and August 2019. Clinical and sociodemographic data were compared between women who initiated contraception before discharge and those who did not by using a Cochran-Armitage test and multiple logistic regression. RESULTS: Overall, 382 women were enrolled (mean ± SD age, 29.6 ± 7.4 years). Most women (287, 75.2%) had abortions, and 146 (38.2%) initiated contraception before hospital discharge. The most common contraceptives were injectables (75, 51.4%) followed by pills (65, 44.5%). Use of contraception increased during the study period (Z=3.69, P<0.01), mostly due to injectables (Z=3.84, P<0.01). Factors independently associated with contraceptive initiation were admission in 2019 (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.36-5.17) and not having an abortion for legal reasons (OR, 3.54; 95% CI, 1.30-9.62). CONCLUSION: Implementation of a surveillance network optimized the health service and quality of care. There was an increase in contraception use and a vulnerable population was identified.

A randomized controlled pilot study of ulipristal acetate for abnormal bleeding among women using the 52-mg levonorgestrel intrauterine system.

OBJECTIVE: To assess the efficacy of ulipristal acetate (UPA) for reducing abnormal bleeding among women using the 52-mg levonorgestrel intrauterine system (LNG-IUS). METHODS: A randomized, double-blind, placebo-controlled pilot study conducted from September 1, 2016 to September 30, 2018, at the University of Campinas, Brazil. LNG-IUS users reporting prolonged or frequent uterine bleeding for at least 1 year were randomized to receive 5 mg UPA per day for 5 days or placebo at an identical regimen. Bleeding was recorded for 90 days after treatment began and was compared between the groups. RESULTS: Of 94 eligible women, 64 with abnormal bleeding associated with LNG-IUS use declined treatment or device removal after counselling regarding anticipated bleeding patterns. For the 25 study participants, differences were nonsignificant between the UPA and placebo groups for number of days before bleeding stopped and days free of bleeding; however, UPA users displayed a trend for shorter duration before bleeding stopped and longer time free of bleeding. A similar trend for mean number of bleeding days at 30-, 60-, and 90-day follow-up was observed. CONCLUSION: A nonsignificant trend in reduction of abnormal bleeding was observed among LNG-IUS users taking 5 mg UPA per day for 5 days compared with placebo; however, further research is needed. CLINICALTRIALS.GOV: NCT03186586.

Fractional CO2 laser versus promestriene and lubricant in genitourinary syndrome of menopause: a randomized clinical trial.

OBJECTIVE: The aim of this study was to compare the effects of fractional CO2 laser therapy, promestriene, and vaginal lubricants on genitourinary syndrome treatment and sexual function in postmenopausal women. METHODS: We performed a randomized clinical trial including 72 postmenopausal women over the age of 50 years. The women were randomized into three intervention groups to receive one of the following treatments: three sessions of intravaginal fractional CO2 laser therapy; 10 mg of intravaginal promestriene cream 3 times a week; and vaginal lubricant application alone. Vaginal maturation, Vaginal Health Index (VHI) score, and Female Sexual Function Index (FSFI) were evaluated at baseline and after 14 weeks of therapy. RESULTS: We observed an improvement in the vaginal elasticity, volume, moisture, and pH in the CO2 laser and promestriene groups. The VHI score at 14 weeks was higher in the CO2 laser group (mean score 18.68) than in the promestriene (15.11) and lubricant (10.44) groups (P < 0.001). Regarding vaginal maturation, basal cells were reduced and superficial cells were increased after treatment. This improvement was more significant in the CO2 laser group (P <0.001). The FSFI score only showed improvement in the desire and lubrication domains in the CO2 laser group. There were no differences in total FSFI score among the three treatment groups. There were no adverse effects associated with any of the treatments. CONCLUSIONS: The use of fractional CO2 laser therapy to treat genitourinary syndrome resulted in better short-term effects than those of promestriene or lubricant with respect to improving the vaginal health in postmenopausal women.

Factors associated with knowledge about menopause and hormone therapy in middle-aged Brazilian women: a population-based household survey.

OBJECTIVES: The aim of the study was to evaluate knowledge about menopause and hormone therapy (HT) among middle-aged Brazilian women and identify the factors associated with the level of knowledge. METHODS: A cross-sectional study was conducted with 749 women aged 45 to 60 years, residing in the Metropolitan Region of Campinas, Brazil. The dependent variable was knowledge about menopause and HT evaluated using a numerical score based on the answers given to three questions that had several response options. The independent variables were sociodemographic characteristics, personal habits, and health conditions. Statistical analysis was carried out by Mann-Whitney, Kruskal-Wallis, and a generalized linear model. RESULTS: The mean age was 52.5 (±4.4) years. Most of the women were postmenopausal (68%) and 19.5% had a history of current or previous use of HT. The final score for knowledge about menopause ranged from +1 to +11, with a mean of 4.59 (±1.86) and a median of 4. Women with higher levels of schooling (coefficient = 0.64, P < 0.001); with higher socioeconomic status (coefficient = 0.47, P < 0.002); with vaginal dryness (coefficient = 0.47, P = 0.003); who consumed alcohol (coefficient = 0.61, P = 0.006); who use or had ever used any type of treatment to counteract menopausal symptoms (coefficient = 0.41, P = 0.008); with anxiety (coefficient = 0.35, P = 0.037); and with depression (coefficient = 0.31, P = 0.043) possessed greater knowledge about menopause and HT. Women with a higher number (≥3) of vaginal deliveries (coefficient = -0.61, P < 0.001) and a higher body mass index (coefficient = -0.02, P = 0.046) possessed less knowledge about menopause and HT. CONCLUSIONS: The knowledge about menopause and HT demonstrated by the interviewees was low and possibly related to the time of exposure to qualified information.

Hormonal, metabolic, and endometrial safety of testosterone vaginal cream versus estrogens for the treatment of vulvovaginal atrophy in postmenopausal women: a randomized, placebo-controlled study.

OBJECTIVE: The aim of the study was to evaluate the laboratory and endometrial safety of topical testosterone versus topical estrogen for the treatment of vaginal atrophy in postmenopausal women. METHODS: This was a randomized, placebo-controlled trial of 60 postmenopausal women aged 40 to 70 years at the Menopause Clinic of CAISM UNICAMP. Women were randomized into three vaginal treatment groups: estrogen, testosterone, or placebo. The treatment was applied 3 times a week for 12 weeks. Hormonal laboratory values of follicle-stimulating hormone, luteinizing hormone, estradiol, estrone, androstenedione, total testosterone, free testosterone, dehydroepiandrosterone, dehydroepiandrosterone sulfate, and sex hormone-binding globulin were assessed at baseline and at 6 and 12 weeks. Metabolic laboratory values of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and gamma-glutamyl transpeptidase were also assessed at baseline and at 6 and 12 weeks. Endometrial safety was assessed using ultrasonography at baseline and at 12 weeks. RESULTS: After 12 weeks of treatment, there were no significant differences in hormonal or metabolic laboratory values among all three groups. Two participants in the estrogen group had increased serum estradiol after 12 weeks of treatment. No change in endometrial thickening was reported in all three groups. CONCLUSIONS: Twelve weeks of treatment with topical testosterone or estrogen in postmenopausal women with symptoms of vaginal atrophy demonstrated laboratory and endometrial safety when compared with placebo.

Prevalence of hormone therapy, factors associated with its use, and knowledge about menopause: a population-based household survey.

OBJECTIVE: The aim of the study was to assess the prevalence of hormone therapy (HT), the factors associated with its use, and the importance of knowledge about menopause and HT. METHODS: A cross-sectional population-based study with 749 Brazilian women aged 45 to 60 years living in the Campinas Metropolitan Region was carried out between September 2012 and June 2013. The dependent variable was current or previous HT use. The independent variables were sociodemographic data, health-related problems, and knowledge about menopause assessed using a score that was obtained with a questionnaire on various aspects of menopause. RESULTS: The mean age of the women was 52.5 (±4.4) years. With regard to the menopause status, 16% were premenopausal, 16% were perimenopausal, and 68% were postmenopausal. Among all the women included, 19.5% reported current or previous HT use. In multiple regression analysis, being postmenopausal (prevalence ratio [PR] 2.76; 95% CI, 1.74-4.38), receiving information about menopause from physicians and health service workers (PR 2.73; 95% CI, 1.91-3.89), having bilateral oophorectomy (PR 2.18; 95% CI, 1.49-3.17), experiencing work interruption due to hot flashes (PR 1.44; 95% CI, 1.03-2.01), and having extensive knowledge about menopause (PR 1.12; 95% CI, 1.05-1.19) were associated with a higher prevalence of HT use. CONCLUSIONS: The prevalence of HT use was 19.5%. Menopause status, information source, surgical menopause, work interruption due to hot flashes, and knowledge about menopause were associated with HT use. Education promoted by healthcare systems can increase HT use in women who have indications for treatment.

Is the age at menopause a cause of sexual dysfunction? A Brazilian population-based study.

OBJECTIVES: The aim of the study was to evaluate the association between age at menopause and sexual dysfunction and the components of sexual function in postmenopausal women. METHODS: In this cross-sectional population-based study, data of 540 women aged 45 to 60 years regarding the age they were when they achieved menopause and its association with sexual dysfunction (evaluated using the Short Personal Experiences Questionnaire) were obtained through interviews. We assessed the data for associations between age at menopause and sexual dysfunction and demographic, behavioral, and clinical characteristics. RESULTS: Age at menopause was not associated with sexual dysfunction. Arousal (dysfunction) was the only component of sexual function that was associated with premature ovarian insufficiency (POI) and early menopause (P = 0.01). It was reported by 64.2% of women with POI (women <40 y), compared with sexual dysfunction rates of 50% and 45.6% of women aged 40 to 45 and >45 years, respectively (P = 0.04). In women with POI or early menopause, Poisson regression analysis showed that having a partner with sexual problems (prevalence ratio [PR] = 6.6; 95% CI: 3.3-13,2; P < 0.001) and dyspareunia (PR = 3.9; 95% CI: 1.8-8.2; P = 0.0005) were factors associated with arousal dysfunction. Satisfaction with the partner as a lover (PR = 0.4; 95% CI: 0.2-0.7; P = 0.002) was protective against arousal dysfunction. CONCLUSIONS: Arousal dysfunction was associated with early ovarian failure and POI. The major factors affecting this association were having a partner with sexual problems, dyspareunia, and no satisfaction with the partner as a lover. These findings highlight the importance of evaluating partner problems and improving lubrication in these groups of women.

Factors associated with urinary incontinence in middle-aged women: a population-based household survey.

INTRODUCTION AND HYPOTHESIS: The objective was to determine the prevalence of urinary incontinence (UI) and factors associated in a sample of Brazilian middle-aged women. METHODS: A cross-sectional study was conducted between September 2012 and June 2013 with 749 women. UI was defined as any complaint of involuntary loss of urine. The independent variables were sociodemographic data and health-related habits and problems. Statistical analysis was carried out using Chi-squared test and Poisson regression. RESULTS: The mean age was 52.5 (±4.4) years. The prevalence of UI was 23.6 %. Of these, 48 (6.4 %) had stress urinary incontinence, 59 (7.8 %) urinary urgency, and 70 (9.5 %) had mixed urinary incontinence. In the final statistical model, self-perception of health as fair/poor/very poor (PR: 1.90; 95 % CI, 1.45-2.49; P < 0.001), ≥1 vaginal deliveries (PR: 1.84; 95 % CI, 1.35-2.50; P < 0.001), higher body mass index (PR: 1.04; 95 % CI, 1.02-1.06; P = 0.001), vaginal dryness (PR: 1.60; 95 % CI, 1.23-2.08; P = 0.001), current or previous hormone therapy (PR: 1.38; 95 % CI, 1.06-1.81; P = 0.019), pre-/perimenopause (PR: 1.42; 95 % CI, 1.06-1.91; P = 0.021), and previous hysterectomy (PR: 1.41; 95 % CI, 1.03-1.92; P = 0.031) were associated with a greater prevalence of UI. Current or previous use of soy products to treat menopausal symptoms was associated with a lower prevalence of UI (PR: 0.43; 95 % CI, 0.24-0.78; P = 0.006). CONCLUSIONS: Several factors are associated with UI in middle-aged Brazilian women. The results highlight the importance of carrying out interventions aimed at reducing modifiable factors.