'But you can't reverse a hysterectomy!' Perceptions of long acting reversible contraception (LARC) among young women aged 16-24 years: a qualitative study.

OBJECTIVES: Long Acting Reversible Contraception (LARC) methods are highly effective in reducing the incidence of unwanted pregnancy. Recent data indicates that the rate of abortion in Grampian, North East of Scotland is above the Scottish average and LARC uptake among young women low. This study sought to explore young women's perceptions of LARC, with the aim of developing a strategy to increase LARC uptake. STUDY DESIGN: Qualitative study. METHODS: Sixty five women aged 16-24 were randomly recruited to this qualitative study from community centres and shopping areas. Recruitment and interviews were conducted in friendship pairs, triads or one-to-one basis. Participants were asked about current and past contraception use, views of contraception methods including LARC; and sources of information about contraception. Data were analysed using thematic content analysis. RESULTS: Women interviewed were aware of some of the delivery systems used for long acting contraception (intrauterine devices, implants and injections) but did not recognise them as 'LARC'. 'Long acting' was equated with permanency and the term 'reversible' appeared to have the opposite effect to its intention. Intrauterine devices were commonly referred to as 'coil'. The women often relied on verbal testimonies from those who had experienced using LARC, many of which were negative and inaccurate. A lack of in-depth knowledge about LARC and the opinion that LARC methods were for older women were also cited as barriers to use. CONCLUSIONS: This study shows that negative testimonies and the belief that LARC are not appropriate for young women may discourage LARC uptake.

Factors affecting adequacy of Pipelle and Tao Brush endometrial sampling.

OBJECTIVE: To compare factors influencing adequacy of endometrial samples obtained using two outpatient sampling devices--Pipelle and Tao Brush. DESIGN: Pragmatic unblinded trial with investigation schedule randomised separately within two groups according to endometrial cancer risk. SETTING: Gynaecology outpatient clinic of a large city hospital in Edinburgh, Scotland. POPULATION: All women referred to a gynaecology outpatient clinic during a 28-month period complaining of abnormal vaginal bleeding. METHODS: Women were assigned to two 'risk groups' for endometrial cancer ('high risk' for postmenopausal women and 'moderate risk' for premenopausal women aged over 40 years or with other risk factors). Women in each risk group had both types of biopsy and were randomised to two outpatient visualisations: hysteroscopy and/or transvaginal ultrasound scan. MAIN OUTCOME MEASURES: Completion of the investigation, adequacy of sample and acceptability of investigation to women. RESULTS: In 200 high-risk women, adequate samples were significantly more likely to be obtained by Tao Brush than Pipelle (P < 0.001). Nulliparity was strongly associated with failed insertion for both devices (P < 0.001). Inadequate samples were strongly associated with postmenopausal status only for Pipelle (P < 0.001), and among premenopausal women, for both samplers, with nulliparity (P < 0.001). A significantly greater proportion of women preferred the Tao Brush to the Pipelle endometrial sampler (P < 0.001). CONCLUSIONS: In postmenopausal women, Tao Brush sampling offers advantages over use of Pipelle, and the former should be considered as an alternative or additional sampling device in this group of women.

Evaluation of abnormal uterine bleeding: comparison of three outpatient procedures within cohorts defined by age and menopausal status.

OBJECTIVES: To compare three outpatient methods of endometrial evaluation in terms of performance, patient acceptability and cost-effectiveness. DESIGN: Pragmatic unblinded trial randomised separately within three groups determined by risk of endometrial cancer. SETTING: The gynaecology outpatient clinic of a large city hospital in Edinburgh, Scotland. PARTICIPANTS: Women referred for investigation and management of abnormal bleeding between January 1999 and May 2001. INTERVENTIONS: Investigations were: blind biopsy alone, hysteroscopy with biopsy, ultrasound evaluation including transvaginal ultrasound, and, in the low-risk group, the option of no investigation. Within this design, two devices for obtaining endometrial biopsy were compared, the Pipelle sampler and the Tao brush. MAIN OUTCOME MEASURES: Successful (informative) completion of the investigation, acceptability of the investigation method to women, women's satisfaction with clinic care in the short term and at 10 months and 2 years of follow-up, and cost-effectiveness to the end of investigation. RESULTS: Minor adverse events (e.g. shock, patient distress) did not occur for ultrasound, but occurred in 16% and 10% of women for hysteroscopy and biopsy procedures respectively. Pipelle biopsy provided an acceptable endometrial sample for 79% of moderate-risk women, but only 43% of high-risk women. The Tao brush gave similar performance in moderate-risk women (77%), but was more successful than the Pipelle sampler in postmenopausal (high-risk) women (72%). There were significantly more successful visualizations for ultrasound than for hysteroscopy in both the low-risk and the moderate-risk group, and a similar but non-significant trend in the high-risk group. Ultrasound was significantly better than hysteroscopy at detecting fibroids, but hysteroscopy significantly better for polyps. At the 10-month follow-up, high-risk women who had been investigated by hysteroscopy (with biopsy) had the most positive views of their clinic experience, but this effect had largely disappeared by 24 months. In the moderate-risk group, the subgroup randomised to biopsy alone gave the most negative responses about their clinic experience and health now. Women wishing they had more investigation comprised 22% of moderate-risk women and 38% of low-risk women, but only 14% of postmenopausal women. At follow-up the moderate-risk women (with menstrual bleeding problems), compared with postmenopausal women, had much worse ratings for clinic experience and health now. Resource use tended to be higher in the moderate- and low-risk women. There was minimal difference in cost-effectiveness between investigation options in the high-risk group, with the option involving hysteroscopy being marginally better than ultrasound. The most cost-effective investigation in the moderate-risk group was biopsy alone and in the low-risk group ultrasound. CONCLUSIONS: Decision-making about investigation would be clarified if postmenopausal women were studied separately from premenopausal women with menstrual bleeding problems. For postmenopausal women exclusion of cancer is a main objective, so once investigation has been completed discharge follows, but in the woman with abnormal menstrual bleeding, even if serious pathology is excluded, the original presenting symptoms require management. About 60% of premenopausal women with abnormal bleeding reported that their symptoms were not 'much improved' at 10 months. Research is needed to understand this phenomenon, and to explore ways to integrate patient factors into optimising evaluation and treatment. The significance of benign pathologies in this group also requires clarification. Given the relatively small differences observed in cost-effectiveness, there is justification for allowing other issues (such as clinician preferences and women's perspectives) to influence decisions as to the investigation method. There is scope to make better use of patient factors to inform decisions as to the most efficient and acceptable method of investigation for an individual woman. Additional analyses, using data available as a result of this study, will contribute to this agenda.

Use of a staff administered structured questionnaire to identify relevant life-style issues and social-health determinants in a sexual and reproductive health service.

OBJECTIVE: To evaluate a staff-administered questionnaire to identify life-style issues and social-health determinants. DESIGN: Structured questionnaire administered by a health professional after dealing with the primary reason for attendance. SETTING: Community-based UK sexual and reproductive health service. POPULATION: First 1329 selected clinic patients comprising 1018 women attending Family Planning and 161 women plus 150 men attending Genitourinary Medicine; 47% were aged under 25. MAIN OUTCOME MEASURES: Identification of relevant health-risk taking, life-style issues, and unaddressed health concerns. Participants were offered appropriate support, information and referrals. RESULTS: Two hundred and sixty-four (23%) of the Family Planning women and 83 (52%) of the Genitourinary Medicine women [plus 103 (69%) of the men] reported two or more sexual partners in the last year. A third of participants denied regular condom use. Six per cent of women and 5% of men questioned had previously been forced to have sex. Eleven per cent of men admitted to having paid for sex and 9% of women disclosed physical assault (one-quarter in the home). Eight per cent of women and 7% of men had unresolved issues relating to previous miscarriage, termination, or stillbirth. CONCLUSIONS: It is possible to identify relevant life-style issues and social determinants of health during routine practice using a staff-administered questionnaire. The resulting information may not otherwise have been disclosed and may impact significantly on health and care delivery. The information collected provides opportunities for both individuals and service planners to address wider health needs.

The future of protected areas in a crowded world.

PIP: Population-environment interactions date back to Malthus and even Confucius who viewed humans as a threat to the planet. In contrast, pronatalists regard the human mind the ultimate resource and think that there is no limit to the number of people the earth can support. There are a few countries whose population is projected to be lower in 2025 than it was in 1990: Belgium, Bulgaria, Denmark, Greece, Hungary, and Italy. The highest population growth rates (3% and above) are in Africa, the Gulf states, and some other Islamic countries. Rates of 1-3% are common everywhere outside Europe. Almost all of the wealthiest countries are growing at the rate of less than 1%, while the poorest countries, except for China and Sri Lanka, are growing at rates of 2% or more. The world's continuing population growth rides on the fact that in developing countries 40% of the population is under the age of 15. Relentless urbanization will eradicate 1.4 billion acres of arable land from 1980 to 2000. In 1950, 13 of the 25 most populous cities were in less developed countries; by 2000, 20 out of 25 will be. Migration, especially rural-urban migration, has an impact. "Economic refugees" from impoverished rural areas, "environmental refugees" from overworked lands or disaster-stricken areas, and political refugees from wars or persecution crowd around protected areas. Some examples of the population-protected area interactions include Kenya (the 3.56% growth rate threatens the world-renowned national parks), Tanzania (its 3.28% rate of growth causes encroachment into protected areas), Congo (natural rainforests are disturbed), Gabon (the rate of growth is 4.01%), and Zaire (an annual increment of over 1 million people). The threat to unexploited wildlife in the Ivory Coast, direct pressure on forested protected areas in Malaysia, deforestation in the Philippines, in-migration into the Pelen in Guatemala, the situation of the Shenandoah National Park in the United States, and pressures facing coastal areas of Mediterranean Europe are other situations that need stabilization, reduction, and restoration measures.^ieng

Integration of population, environment and development policies.

PIP: This paper examines the conceptual and practical issues involved in bringing the fields of population and environment closer together, and how these issues impact upon development planning. Although the international community's interest in environment and demography -- 2 areas closely intertwined -- continues to grow, they remain separated, viewed as distinct and specialized disciplines. The paper first discusses the separation between the 2 fields, explaining that it is the result of 3 types of imbalances: conceptual, organizational, and power. The essay then proposes 5 factors that can be used to develop population-environmental linkages. These include: developing conceptual models that reveal the interrelationships; taking an integrated approach for collecting environmental, population, and development data; encouraging local officials to monitor and act upon their findings of population and environmental situations; and garnering the political support needed to establish a decentralized, multi-sectoral development approach. The paper goes on to consider a conceptual framework for understanding the interrelated transitions between population and environment. These include demographic, epidemiologic, agricultural, forestry, toxicity, urbanization, and fossil fuel transitions. The paper points out the similarities of these transition -- among them, the fact during these periods society is especially vulnerable. Having considered the policy implications of a transition theory, the paper concludes by proposing a multi-method, decentralized, and comprehensive approach to development planning.^ieng

Intrauterine polyps--a cause of unscheduled bleeding in women using the levonorgestrel intrauterine system: case report.

The levonorgestrel intrauterine releasing system is a contraceptive that has been shown to reduce menstrual blood loss dramatically. Breakthrough bleeding, however, is a relatively common occurrence as with all methods of progestogen-only contraception and this limits its acceptability for women. Amenorrhoea can be achieved in the majority of women within 12 months of insertion. Any new pattern of bleeding after amenorrhoea or a persistence of heavy bleeding may be due to co-existing intrauterine pathology such as endometrial polyps. The use of out-patient techniques such as hysteroscopy and saline infusion sonography are indicated in these instances to exclude other intrauterine pathology.

Helping managers to manage: work schedules of field-workers in rural Bangladesh.

The Maternal-Child Health/Family Planning (MCH/FP) Extension Project in Bangladesh identifies and examines barriers to implementation of the national MCH/FP program, and determines strategies to overcome them. This study analyzes field-workers' ability to carry out more tasks than they do presently, and how their performance might be improved when additional field-workers are hired. In two experimental subdistricts, researchers observed the work of family welfare assistants (FWAs), the female family planning field-workers, to determine the duration and frequency of their home visits with village women and the content of their exchanges. While many factors influence the FWA's work, researchers found that the preplanned monthly work schedules could be manipulated relatively easily to improve duration and frequency of program contact with village women. With more time available to spend with women, the potential to improve the quality of services is enhanced.

Co-localization of matrix metalloproteinase-1 and mast cell tryptase in the human uterus.

The endometrium displays characteristic cyclical changes involving proliferation and differentiation. The differentiation that takes place requires major tissue remodelling involving the matrix metalloproteinase (MMP) family as key enzymes in this process. Mast cells, containing the tryptase and chymase enzymes that are capable of stimulating the MMP cascade, have been identified in the endometrium, but their role is still unclear. In this study, we observed that the majority of mast cells in the uterus reside in the myometrium and that they co-express mast cell tryptase and MMP-1 in the same intracellular granules. In endometrium exposed to synthetic progestogen via an intrauterine levonorgestrel system a significant increase in mast cells numbers was observed in women experiencing breakthrough bleeding compared to those in women with no reported bleeding. We conclude that mast cells contain MMP-1 and we postulate a potential role for mast cells in breakthrough bleeding.