Review of postpartum contraceptive practices at Chiang Mai University Hospital: implications for improving quality of service.

OBJECTIVE: To evaluate the acceptance rate and patterns of contraceptive use among postpartum women. SUBJECTS AND METHODS: The records of 1,009 postpartum women attending the Family Planning Clinic at Chiang Mai University Hospital, Thailand, during January to December 2009 were reviewed. RESULTS: Mean age was 28.2 ± 5.7 years (range 15-48). Almost all 920 women (91.2%) practiced breastfeeding. The acceptance rate of contraception was 97.6%. The types of contraceptive used were: depot medroxyprogesterone acetate, 387 (38.4%); progestin-only pills, 262 (26.0%); tubal resection, 201 (19.9%); male condom, 78 (7.7%); oral combined pills, 49 (4.9%); intrauterine device, 5 (0.5%); implant, 3 (0.3%). Among women undergoing tubal resection, 29 (14.4%) were ≤24 years of age. Significant independent predictors for using long-acting reversible contraception were young age and little or no formal education. CONCLUSION: The acceptance rate of contraception in this study was high. However, the following issues need to be evaluated: compliance of women using progestin-only pills, awareness of long-acting reversible contraception as an alternative option in women considering sterilization, and interventions to promote the use of intrauterine devices and implants.

Sexual in menopausal women comparing perimenopausal and postmenopausal women.

OBJECTIVE: To compare aspects of sexual function between perimenopausal and postmenopausal women. MATERIAL AND METHOD: One hundred forty women, 70 perimenopausal women and 70 postmenopausal patients in the menopause clinic were interviewed at a first visit regarding aspects of sexual function compared between now and during the previous one-year period. All data were compared between perimenopausal and postmenopausal women. MAIN OUTCOME MEASURE: The following sexual function including sexual thoughts/fantasies, sexual desire, frequency of sexual intercourse, sexual excitement during sex, moisture in vagina during sex, amount of vaginal lubrication during sex, pain or discomfort during sex, vaginal stretching/flexibility during sex, intensity of orgasm during sex, sexual appeal in client's opinion, overall sexual satisfaction and sexually related anxiety were compared between groups. RESULTS: The mean age (+/- SD) of perimenopausal and postmenopausal women were 49.4 (+/- 3.0) years and 52.2 (+/- 2.8) years respectively in which there was no significant difference. Most women in both groups had sexual intercourse one to four times per month. There was statistically significant difference between groups in the following aspects, sexual thoughts/fantasies, sexual desire, frequency of sexual intercourse, sexual excitement during sex, moisture in vagina during sex, amount of vaginal lubrication during sex. All items had a negative impact on sexual function but a higher impact was found in postmenopausal women. However sexually related anxiety was unchanged in both and no significant difference was detected. CONCLUSION: Some sexual functions were significantly impaired in postmenopausal compared to perimenopausal women. However, the overall sexual satisfaction and sexually related anxiety were unchanged in postmenopausal women. So sexual problems are present but are not considered the most important problem among Thai women.

Clinical responses to the combination of estradiol and drospirenone in symptomatic postmenopausal Thai women.

OBJECTIVES: To investigate the efficacy and tolerability of the oral hormone replacement therapy (HRT) containing 1 mg estradiol (E2) plus 2 mg drospirenone (DRSP) in Thai women with postmenopausal symptoms. MATERIAL AND METHOD: Fifty-five Thai women with postmenopausal symptoms participated in this multicenter, open-label, non-comparative Phase IV study. The primary endpoint was the reduction of hot flushes after 12 weeks of treatment. Secondary endpoints included changes infrequency and intensity of menopausal symptoms as well as safety assessments after 4, 8, and 12 weeks of treatment. RESULTS: Treatment with 1 mg E2 plus 2 mg DRSP reduced the frequency of hot flushes in 94.6% of women at the end of the 12-week treatment period. In 60% of women, the frequency of hot flushes was reduced to 10% or less, compared to baseline findings and 49.1% of women had no remaining hot flushes. Other postmenopausal symptoms such as vaginal dryness, urinary incontinence, dysuria, and dyspareunia improved The most common adverse events were vaginal bleeding or spotting and breast tenderness. CONCLUSION: The oral HRT of 1 mg E2 plus 2 mg DRSP was effective and well tolerated by Thai women suffering from postmenopausal symptoms.

Patient satisfaction with the service at Menopause Clinic, Maharaj Nakorn Chiang Mai Hospital.

OBJECTIVE: To evaluate patient satisfaction of service at the Menopause Clinic and to identify factors affecting patient satisfaction. MATERIAL AND METHOD: Cross sectional descriptive study was conducted at the Menopause Clinic, Maharaj Nakorn Chiang Mai hospital. Three hundred twenty six subjects were included. The questionnaire consists of two parts, demographic and patient satisfaction. The patient satisfaction was evaluated in five aspects. RESULTS: The overall patient satisfaction level was good (mean 4.2 +/- 0.71). The satisfactions about service behavior quality of care and health information were in excellent level (mean 4.29 +/- 0.69, 4.25 +/- 0.65, and 4.26 +/- 0.69, respectively). The satisfaction about clinic facilities/conveniences and medical expense were in good level (mean 3.83 +/- 0.79 and 3.87 +/- 0.75). There are three variables that could affect patient satisfaction: Occupation and level of education affected satisfaction in medical expense aspect (p < 0.001 and p < 0.05) and number of visits affected the clinic facilities/convenience aspect (p < 0.05). CONCLUSION: Some patient characteristics affected the patient satisfaction. However, system and structure of service in different setting hospitals are of concerned.

Bone mineral density in women using depot medroxyprogesterone acetate (DMPA) for at least 2 years compared to a control group: a cross sectional study.

OBJECTIVE: To compare the effect of long-term use of depot medroxyprogesterone acetate (DMPA) on bone mineral density (BMD) in Thai women compared to the control. MATERIAL AND METHOD: A cross sectional study was conducted on Thai women of reproductive age who used DMPA (50 subjects) for contraception for at least 2 years and non-hormonal users (50 subjects). BMD was measured at the lumbar spine, femur and distal radius, and ulna. RESULTS: There was significantly lower BMD at the lumbar spines in the DMPA group but there was no significant difference in BMD between groups at the femur distal radius, and ulna. CONCLUSION: Long-term use of DMPA has a negative impact on lumbar spine BMD.

Comparison of osteoporosis self assessment tool for Asian (OSTA) and standard assessment in Menopause Clinic, Chiang Mai.

OBJECTIVE: To compare osteoporosis self assessment tool for Asian (OSTA) with the standard measurement of bone mineral density (BMD) by dual energy x-rays absorptiometry (DXA) in- identifying the prevalence of osteopenia and osteoporosis in Thai menopausal women who attended the Menopause Clinic, Faculty of Medicine, Chiang Mai University. MATERIAL AND METHOD: The data was retrospectively collected from the medical records of women who had lumbar femoral neck and radius BMD t-score measurement by DXA (Hologic, QDR-4500C) between January 2004 and December 2005. The body weight and age ofpatients were calculated for the OSTA index score. The women with OSTA score < -1 and > or = -1 were classified as "moderate to high risk" and "low risk" for fracture, respectively. The BMD T-scores of < -1 and > or = -1 were classified as "osteopenia to osteoporosis " and "normal" respectively. RESULTS: Three hundred and fifteen menopausal women of the age of 45-87 years were included. The BMD T-scores assessment revealed that more than half of the subjects had osteopenia to osteoporosis (T-score < or = -1), 196 women (62%) at lumbar spine, 133 women (42.2%) at femur and a third, 114 women (36.2%) at radius respectively. The OSTA index at the standard cut-point of < -1 had a sensitivity and specificity of 36.2% and 71.4% respectively for the lumbar spine and 40.6% and 72.0% respectively for the neck of the femur in predicting osteopenia to osteoporosis status. CONCLUSION: The OSTA index score had a low sensitivity (36-48%) but a high specificity (71-75%) for identifying osteopenic to osteoporotic women among population of menopausal period Nevertheless, it is a useful screening tool in old age women (> 65 years).

Impact of women's health initiative study on attitude and acceptance of hormone replacement therapy in Thai women attending menopause clinics.

OBJECTIVE: To assess the attitude and acceptance of Thai women attending menopause clinics on hormone replacement therapy (HRT) after the Women's Health Initiative (WHI) publication. MATERIAL AND METHOD: A standardized questionnaire was used to assess attitude and acceptance of HRT in 1,206 women who visited menopause clinics in six hospitals between September 2005 and February 2006. RESULTS: Of the total respondents, 92% were in the age of 40-70 years, 75% were in their peri- and post menopause, 25% were current users and the average duration of hormone use was 5.6 +/- 5.3 years. The women's perception of hormone benefits on osteoporosis prevention, skin improvement, and hot flashes treatment were 39.1%, 31.7%, and 28.9%, respectively. The most common concern of hormone use was malignancy. Hormone side effects were found to be the most common reason for switching hormone regimen. Of all the past users, 85% stopped HRT because they changed to another treatment regimen. Only 3.7% had been aware the WHI, of which 43.5% were influenced by its results. The most common source of HRT information was from doctors. For the ever users, 72.3% had some knowledge about HRT. CONCLUSION: The present survey revealed that very few women had been aware of the WHI study. Nevertheless, the prevalence of HRT current users was lower compared to a prior survey before the WHI publication. Doctors appeared to be the important source of HRT information, which may indirectly have an influence over women's attitude and acceptance on HRT.

The changes of sexuality in Thai women during pregnancy.

OBJECTIVE: To determine the changes of sexuality during pregnancy in Thai women and to explore their attitudes and sources of information concerning sexuality during pregnancy. MATERIAL AND METHOD: Three hundred and sixty pregnant women who met the study criteria were recruited. Women at each trimester (n = 120) were interviewed with a structured questionnaire whether their sex desire, coital frequency and orgasmic rate decreased, increased or remained unchanged as compared with the prepregnancy period. The change in their favorite sexual position, concerns about sexual intercourse during pregnancy, and their sources of information regarding sexuality were also determined. RESULTS: The pregnant women at each trimester reported a gradual and significant decrease in sexual desire (p < 0.05) and coital frequency (p < 0.05). The change in orgasmic rate was not statistically significant (p = 0.06). Generally the preferred sexual position was "man on top" however, this gradually and significantly changed to "rear position " in each trimester of pregnancy (p < 0.05). Fifty nine percent of the women thought they could have sexual intercourse; however 79.7% of them were concerned about sexual intercourse during pregnancy. The main concern was the potential harm to the fetus. Sixty two percent of pregnant women received information about sexuality during pregnancy from their health physicians. CONCLUSION: Sexuality decreased significantly throughout pregnancy in Thai women. The majority of pregnant women are concerned about the adverse effects of sexual intercourse on pregnancy outcomes. Therefore, sexuality during pregnancy should be clearly counseled to all couples to reassure that sexual intercourse in normal pregnancy is safe.

A successful strategy for Preimplantation Genetic Diagnosis of beta-thalassemia and simultaneous detection of Down's syndrome using multiplex fluorescent PCR.

OBJECTIVES: Preimplantation Genetic Diagnosis (PGD) is an alternative to prenatal diagnosis providing couples the chance to start a pregnancy with an unaffected fetus. The objective of the present study was to develop and apply quick, sensitive and accurate single cell PCR protocols for PGD of beta-thalassemia and Down's syndrome detection. MATERIAL AND METHOD: Two couples carrying beta-thalassemia codon41-42 mutation underwent routine IVF procedures. Embryo biopsy was performed on Day-3 post-fertilisation and single cell multiplex fluorescent PCR was employed for mutation analysis, contamination detection and diagnosis of trisomy 21 cases. RESULTS: Seventeen embryos were tested in two clinical PGD cycles. This resulted in the first birth following PGD for a single gene disorder in Thailand and South East Asia, confirmed by prenatal testing. Two embryos were shown to be affected by Down's syndrome. CONCLUSION: Successful strategy for PGD of beta-thalassemia and Down's syndrome detection using multiplex fluorescent PCR was introduced.

One year study of Implanon on the adverse events and discontinuation.

OBJECTIVE: To determine adverse events and discontinuation of Implanon in healthy Thai women between 16 and 45 years of age. DESIGN: Prospective descriptive study. SETTING: Family Planning Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University. SUBJECTS: Ninety-two female volunteers with eligible criteria, no contraindication for hormonal contraceptive and wished to have long-term contraception were recruited. MAIN OUTCOME MEASURES: Determination of adverse events was done three months after Implanon insertion. Discontinuation of Implanon use was reviewed during the study period of one year RESULTS: Amenorrhea (40.2%) and infrequent bleeding (39.1%) were the most menstrual adverse events. While most non-menstrual adverse events were headache/dizziness (27.2%) and lower abdominal pain (23.9%). Severe non-menstrual side effect was rare (1-2%). Seven subjects (7.6%) discontinued using Implanon during the one year period of study. CONCLUSION: Implanon demonstrated a high continue rate at the first year of insertion. It produced similar adverse events like other progestin-only contraceptives. Counseling before insertion is important for increased client satisfaction and a higher continuation rate.

Unintended pregnancy and associated risk factors among young pregnant women.

OBJECTIVE: To assess pregnancy intention and the associated risks among young pregnant women. METHODS: In a descriptive study, pregnant women aged 15-24 years were recruited at a prenatal clinic in Chiang Mai University Hospital, Thailand, between March 1, 2012, and February 28, 2013. Participants were interviewed by trained interviewers using a standardized questionnaire to elicit information about baseline characteristics, pregnancy intention, and contraception practice. RESULTS: Overall, 250 participants were recruited (mean age 20.7±2.4 years), and 163 (65.2%) declared that the pregnancy was unintended. The odds of the pregnancy being unintended were increased in students (P=0.006), women aged 20 years or younger (P=0.024), and women whose partner was a similar age (P=0.026). A higher percentage of women with unintended pregnancy than with intended pregnancy reported having no time to use contraception, a perceived difficulty of regular contraceptive use, fear of parents finding out about sexual activity, and embarrassment about using contraception. CONCLUSION: Pregnancy among young pregnant women in Thailand was often unintended. Educational status, age, and age difference between the couple were independently associated with unintended pregnancy.

Symptoms of estrogen deficiency in nursing personnel in Maharaj Nakorn Chiang Mai Hospital.

OBJECTIVE: To determine the self-reported prevalence and severity of climacteric symptoms of estrogen deficiency in nursing personnel working in Maharaj Nakorn Chiang Mai Hospital during the year 2002. DESIGN: Cross-sectional descriptive study. SETTING: Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University. SUBJECT: Six-hundred and eight nursing personnel, including professional nurses and practical nurses, aged 40-60 years, working in Maharaj Nakorn Chiang Mai Hospital. MATERIAL AND METHOD: The same sets of questionnaires were provided and distributed to each subject. Subjects had self assessment under individual decision with written consent and data was prospectively collected. The data were analyzed using software SPSS version 10 and presented in frequencies and percentage. MAIN OUTCOME MEASURE: The prevalence and severity of each climacteric symptoms. RESULTS: Five-hundred and seventy five of 608 subjects (94.6%) responded to the questionnaires, 62.6% of them were in normal reproductive period, while the remainder (37.4%) were in the menopausal period. The latter group was divided into 4 subgroups of pre/peri-menopause, post menopause, surgical menopause and premature ovarian failure. The prevalence of climacteric symptoms was systematically classified as follows, vasomotor instability 40.7% (severe cases, 5.4%), psychosomatic symptoms 50.9% (severe cases, 3.9%), lower urinary tract symptoms 29.1% (severe cases, 2.4%), lower genital tract symptoms 34.0% (severe cases, 2.7%), and other symptoms 50.7% (severe cases, 4.3%). The first five most common symptoms were as follows, forgetful 84.1% (severe cases, 7.9%), myalgia 74.3% (severe cases, 10.6%), anxious 71.0% (severe cases, 5.3%), tired 70.0% (severe cases, 4.1%), headache 68.3% (severe cases, 8.3%). The least common symptom was needle pain, the prevalence was 19.7% (severe cases, 1.3%). The overall prevalence of women using hormone replacement therapy was 13.1%, only 8.9% were current users. CONCLUSION: Focusing on each symptom of climacteric symptoms, the authors found high prevalence in psychosomatic symptoms and other symptoms such as forgetful, myalgia, anxious, tired and headache. While the classic symptom (vasomotor instability) was found to be low in the present study which was different from the previous reports. This may be due to the racial or cultural and educational factors among different populations.

Immediate complications of laparoscopic tubal sterilization: 11 years of experience.

OBJECTIVE: To evaluate the complications of laparoscopic tubal sterilization. METHOD: A retrospective study of laparoscopic tubal sterilization performed at Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine, Chiang Mai, Thailand was conducted. The details of the operation, including complications and operation time were collected from the operative and family planning registry. RESULTS: Between January 1987 and December 1997, 948 cases of laparoscopic tubal sterilization were performed as an outpatient setting. The combination of intravenous sedation and local anesthesia was employed in all cases. Minor intra-operative complications were found in 4.6% of cases. The most frequent complications were meso-salphingeal and meso-ovarian bleeding. No serious complication was found in this study. The mean operation time was 19.3 minutes (range 5-75 minutes). CONCLUSION: The present study suggested that out-patient laparoscopic tubal sterilization under the combination of intravenous sedation and local anesthesia is a convenient and relatively safe procedure.

Mammographic change in hysterectomized women on 0.625 mg/day of conjugated equine estrogen.

OBJECTIVE: To compare the mammographic change before and after conjugated equine estrogen (CEE) 0.625 mg/day in hysterectomized women. DESIGN: A retrospective descriptive study. SETTING: Menopause clinic, Maharaj Nakorn Chiang Mai Hospital. MATERIAL AND METHOD: Dedicated mammograms and demographic data of 66 women who had been hysterectomized were reviewed. Post surgical menopausal women were recruited for the study. CEE 0.625 mg/day was given just after the operation. The baseline mammography was done before the initiation of HRT and they were compared with the follow-up mammography performed 12-18 months after therapy. The degree of increase in mammographic density was classified as follows: minimal changes (10-25% increased density), moderated change (26-50% increased density), and marked change (> 50% increased density). RESULTS: The mean age +/- SD was 47 +/- 4.3 years old. The mean duration +/- SD of hormone used was 13.5 +/- 2.4 months. The most common indication for operation was myoma uteri (43.9%). On the baseline mammogram, 5 cases had cystic change and one case had a small circumscribed solid mass suspected to be fibroadenoma. On the follow-up mammograms, there were 2 cases (3.0%) detected to have significantly increased breast density. One was moderately increased and the other was markedly increased, but cystic changes and one fibroadenoma were not changed. CONCLUSION: CEE has little effect on increased mammographic density.

A comparison of multiphasic oral contraceptives containing norgestimate or desogestrel in acne treatment: a randomized trial.

OBJECTIVE: This study aimed to compare the effectiveness and safety of triphasic combined oral contraceptives (OCs) containing ethinyl estradiol (EE) and norgestimate (NGM) and biphasic combined OCs containing EE and desogestrel (DSG) in the treatment of mild to moderate acne. STUDY DESIGN: This was an investigator-blinded, randomized, parallel group trial conducted at 3 centers in Thailand. Female subjects 18-45 years old were assigned to one or the other OCs and evaluated for efficacy and safety parameters at the baseline visit and after 1, 3 and 6 months of treatment. RESULTS: Among 201 randomized subjects, data from 93 subjects in the EE/NGM group and 95 subjects in the EE/DSG group were analyzed. After 6 months of treatment with EE/NGM and EE/DSG, no differences between formulations were found for the decrease in total acne lesion counts (74.4% vs. 65.1%, respectively, p=.070) or facial improvement score. More women using EE/NGM showed a decrease in severity of facial seborrhea than those using EE/DSG (p=.005). No changes in weight were noted in either group as compared to baseline. CONCLUSION: Multiphasic OCs containing EE/NGM and EE/DSG provided comparable efficacy and tolerability in the treatment of acne. However, EE/NGM had a more beneficial effect on facial seborrhea reduction than EE/DSG. IMPLICATIONS: EE/NGM and EE/DSG are multiphasic OCs, which were shown to be clinically equally effective for mild to moderate facial acne, and the multiphasic combined OC with NGM was more effective for women with facial seborrhea. Clinicians may apply the results of this study when considering treatment options for facial acne and seborrhea.

Bone mineral density in women using the subdermal contraceptive implant Implanon for at least 2 years.

OBJECTIVE: To compare the effect of the long-term use of a subdermal single-rod contraceptive implant on bone mineral density (BMD) between users and a control group. METHODS: In this cross-sectional study, BMD was measured at the lumbar spine, femur, and distal radius and ulna in 100 Thai women of reproductive age, 50 who had used the Implanon implant for contraception for at least 2 years and 50 controls. RESULTS: Ethnicity, age, age at menarche, parity, menstrual pattern, and body mass index were similar in the 2 groups. The mean duration of Implanon use was 32.8+/-6.3 months. Although the prevalence of osteoporosis was rare at all sites in both groups, the Implanon users had a significantly lower BMD at the distal radius and ulna than the controls. CONCLUSION: The long-term use of Implanon seemed to have a negative impact on the mineral density of the distal radius and ulna.