The prevalence of contraceptive use among postpartum women and its associated factors during the early phase of COVID-19 outbreak: a time series study.

BACKGROUND: Unintended pregnancies can adversely affect maternal health, preventable through timely postpartum contraception. During the COVID-19 pandemic, family planning services were constrained by policies that curtailed outpatient visits. We investigated the prevalence of postpartum contraceptive initiation at King Chulalongkorn Memorial Hospital (KCMH) during January to June 2020, comparing with the same period in 2019, and identified factors associated with such initiation. METHODS: We reviewed the medical records of 4506 postpartum women who delivered at KCMH during the study period. Logistic regression was conducted to test the association between early COVID-19 phase deliveries and post-partum long acting reversible contraception (LARC) initiation including copper intrauterine devices, levonorgestrel intrauterine systems, contraceptive implants, and progestogen-only injectable contraceptives. RESULTS: A total of 3765 women (83.6%), of whom 1821 delivered during the pandemic and 1944 during the historical cohort period, were included in this study. The proportion of women who initiated non-permanent modern contraceptives at six weeks postpartum was comparable between the COVID-19 (73.4%) and historical cohort (75.3%) (p = 0.27) periods. The proportion of women who initiated LARC at six weeks postpartumwas comparable between the historical cohort period (22.5%) and the COVID-19 (19.7%) (p = 0.05) period. Accessing a six-week postpartum check-up was independently associated with LARC initiation, of which the adjusted odds ratio (OR) (95% confidence interval) was 3.01 (2.26 to 4.02). CONCLUSIONS: Our findings demonstrated that accessing postpartum care significantly associate with the use of LARC. The data suggest the strong influence of postpartum check-ups in facilitating the adoption of effective contraception, emphasizing the need for accessible postpartum care to sustain maternal health during health crises.

Acceptability of telemedicine for follow up after contraceptive implant initiation at an obstetrics and gynecologic training center.

BACKGROUND: During the COVID-19 pandemic, telemedicine has become a popular adjunct to in-person visits, including for family planning services. This study determined the proportion of clients participated in telemedicine services and the association between sociodemographic factors and telemedicine participation during the COVID-19 pandemic. The adverse effects within the first seven days post-insertion were also reported. METHODS: This retrospective cohort study considered data from all women initiating contraceptive implantation between June 2020 and August 2021 at King Chulalongkorn Memorial Hospital. Clients were offered the following two options for follow-up visits: in-person or communication via an online LINE® Official Account (LINE® OA), a free chat application widely used among the Thais. Logistic regression analyses were used to assess the association between socio-demographic factors and telehealth usage. RESULTS: In total, 574 of 947 (60.6%) clients participated in telemedicine follow-up services during the period considered. A significant association between telemedicine usage and the following were observed: the peak of second wave COVID-19 outbreak in Thailand, using the period preceding the second wave as a reference [adjusted odds ratio (aOR) = 1.47 (95% confidence interval [CI]: 1.12-1.96)]; participants receiving governmental benefits for contraceptive implant payment (aOR: 3.23, 95% CI: 1.86-5.60), and timing of contraceptive implant(s) initiation, using interval insertion as a reference for which aORs of postpartum and immediate postpartum insertions were 0.62 (95% CI: 0.43-0.90) and 0.35 (95% CI: 0.24-0.52), respectively. Significant ecchymosis at the insertion site was observed in 13.1% of participants. CONCLUSION: This study emphasizes the significance of telemedicine during the COVID-19 epidemic, particularly in facilitating contraceptive implant initiation. Our data show a significant increase in the uptake and utilization of telemedicine during the pandemic's peak. The data also shows that during the period of Thailand's second COVID-19 epidemic, government benefits for contraceptive implant payment, and the timing of contraceptive implant initiation, are significantly associated with telemedicine use. This finding supports the continued use of telemedicine in healthcare, particularly for services like family planning, where remote follow-ups can provide safe, efficient, and timely care.

Does socioeconomic factors and healthcare coverage affect postpartum sterilization uptake in an urban, tertiary hospital?

BACKGROUND: Postpartum sterilization in Thailand has relatively few barriers compared to other countries. The procedure is covered by some healthcare plans, and paid out-of-pocket for others. We aim to determine if healthcare coverage and other socioeconomic factors affect the rate of postpartum sterilization in an urban, tertiary hospital. METHODS: We conducted a secondary analysis of data from a retrospective cohort of 4482 postpartum women who delivered at our hospital. Multivariable logistic regression was conducted to determine if sterilization reimbursement affects immediate postpartum sterilization rate. RESULTS: Overall immediate postpartum sterilization rate was 17.8%. Route of delivery and parity were similar in those who were reimbursed and those who were not. Women aged over 25 were more likely to have a healthcare plan that does not cover postpartum sterilization. Women whose healthcare plan reimbursed the procedure trended towards postpartum sterilization when compared to women who were not (aOR 1.05, 95% CI 0.86-1.28, p-value = 0.632). Women who delivered via cesarean section were more likely to undergo sterilization at the time of delivery (aOR = 5.87; 95% CI 4.77-7.24, p-value = < 0.001). Women aged 40-44 years were 2.70 times as likely to choose sterilization than those aged 20-24 years (aOR = 2.70; 95% CI 1.61-4.53, p-value < 0.001). CONCLUSIONS: Healthcare coverage of the procedure was not associated with increased postpartum sterilization in our setting.

Postpartum sterilization is an effective and popular method of contraception. In our hospital, postpartum sterilization is easily accessible compared to other countries where there are barriers such as mandatory waiting time, limited operating rooms and anesthesiologists. We examine factors that affect sterilization rates and found that older women and women with more children were more likely to choose postpartum sterilization. We also found that women who delivered by cesarean section were more likely to choose sterilization. Interestingly, whether the woman's healthcare plan covers postpartum sterilization does not affect the likelihood of sterilization.

Reproductive care in Thai women with diabetes mellitus: a descriptive cross-sectional study.

BACKGROUND: Pre-existing diabetes mellitus (DM) is a challenging pregnancy complication as poor glycemic control is associated with adverse maternal and fetal outcomes. In this study, we aimed to investigate DM-related knowledge, attitudes, preconception care practices, and contraceptive prevalence in women with DM. METHODS: This descriptive cross-sectional survey was conducted among reproductive-aged Thai women receiving DM treatment at King Chulalongkorn Memorial Hospital between August 1, 2021, and June 30, 2022. Patients with DM who were not pregnant or trying to conceive and could be contacted via the phone were included and a validated self-administered questionnaire was distributed electronically. RESULTS: A total of 238 participants were included in the final analysis, yielding 69.4% response rates. The mean (standard deviation) score for knowledge of pregnancy planning and pregnancy-related risks was 6.8 (3.5) out of 15. Only about half of the participants had discussed pregnancy planning with their physicians. Multivariable analysis showed that younger age at DM diagnosis, non-Buddhism, married, higher education, and medical personnel were significantly associated with higher knowledge scores. Women aged > 45 years and those with higher practice scores had significantly higher adjusted odds of using highly effective contraception; the most common methods included male condoms and combined oral contraceptive pills. There was an unmet need for contraception in 9.5% of women with DM. CONCLUSIONS: Although highly effective contraception is safe for patients with DM, only about half of our participants used tier one or two contraceptives or had received consultation regarding preconception planning. There was a notable gap in care coordination among specialists; integrating reproductive healthcare into DM therapy would improve access to preconception care.

We aimed to study the knowledge, attitudes, preconception care practices, and contraceptive usage among women with diabetes mellitus (DM) who were of reproductive age. A survey was conducted among Thai women receiving DM treatment at a university hospital. The results showed that participants had limited knowledge about pregnancy planning and diabetic-related risks. Only half of them had discussed pregnancy planning with their doctors. Factors such as younger age at DM diagnosis, being non-Buddhism, being married, having higher education, and being medical personnel were associated with higher knowledge scores. Older women and those with better practice scores were more likely to use highly effective contraception. However, there was still a need for contraception in some women with DM. We concluded that there was a lack of integration between specialists in reproductive healthcare and DM therapy, and improving this coordination would enhance access to preconception care for women with DM.

Knowledge, attitude, and intended practice of abortion among pharmacy students in Thailand after the amendment of the Thai Abortion Law.

BACKGROUND: The recently amended Thai abortion law allows pregnant women to undergo abortions up to the gestational age of 12 weeks. Medical abortion is significant because it has revolutionized access to safe abortion care-abortion medicine can now be safely and effectively administered outside of a healthcare facility to women in early pregnancy. This contribution supports the pharmacists' role in interprofessional safe abortion teamwork. Adequate knowledge of the current laws regarding safe abortion services will increase pharmacists' competence in providing services. However, safe abortions as a subject have not been formally incorporated into the curriculum for Thai pharmacy students. Therefore, this study aimed to evaluate the knowledge, attitude, and intended practice of fifth-year pharmacy students at Chulalongkorn University. METHODS: A cross-sectional study was conducted using an electronic self-administered questionnaire adapted from previously published studies to evaluate participants' knowledge of the recently amended Thai abortion law, attitude toward abortion, and intended practices. The invitations were sent to all fifth-year pharmacy students at Chulalongkorn University. RESULTS: Among all invitations sent, 104/150 (69.3%) participants responded to the survey. Only a third of the participants (31.7%) had good knowledge scores. Based on five questions regarding the gestational age limit for legal abortion, most participants (52.7%) answered questions incorrectly. Although more than half of the participants (52.5%) disagreed with two pro-choice statements, an overwhelming majority (87.5%) agreed that abortion was a woman's right. Safe abortion services were mostly agreed upon with serious fetal defects (91.9%), non-HIV maternal health conditions (82.2%), and sexual assaults (77.4%). A positive attitude toward abortion affects the intention to perform an abortion under socioeconomic conditions. CONCLUSION: Most participants lacked knowledge on the amended abortion law, especially on the gestational limits of abortion. Participants with favorable attitudes toward abortion tended to be more liberal regarding safe abortion services.

Survey of knowledge and attitude regarding induced abortion among nurses in a tertiary hospital in Thailand after amendment of the abortion act: a cross-sectional study.

BACKGROUND: The abortion act in Thailand is approximately 60 years old. However, because of increasing problems due to unsafe abortions, the act was recently amended to accord a legal status for abortions. In the southernmost provinces of Thailand, most people follow the Islamic faith, according to which induced abortion is a sin for both the providers and the pregnant women. This may affect the attitude of the medical staff, such as registered nurses, who play an important role in abortion services. Our study aims to evaluate the knowledge of the amended abortion act, attitude toward abortions and the intentions behind them, and willingness to perform abortions among registered nurses. METHODS: A cross-sectional study was conducted from January 2022 to February 2022 wherein a self-administrated questionnaire was electronically distributed to 450 registered nurses practicing at a tertiary hospital in the southernmost province of Thailand. Linear regression analysis and Fisher's exact test were conducted to evaluate the association between basic characteristics, knowledge scores, and attitudes toward induced abortion. RESULTS: A total of 375 nurses (83.3%) completed the survey. Most participants were Muslim (58.9%), and 18.7% of them correctly answered > 80% of the knowledge questions. Among all the participants, 41.4% had a favorable attitude toward induced abortion, of which 21.3% were willing to provide safe abortion services. Knowledge scores were independently associated with practicing in obstetrics-gynecology departments and a lower age. Participants practicing Buddhism and having good knowledge scores tended to have favorable attitudes toward abortion. CONCLUSIONS: Nurses in the southernmost province of Thailand lack knowledge regarding the amended abortion act and do not have a favorable moral attitude toward abortion. Favorable attitudes toward abortions, support toward intentions behind abortions, and a willingness to provide abortion services were all lesser among the Muslim participants than among the Buddhist participants. Compared with participants who scored lower, those with higher knowledge scores had a better moral attitude toward abortion and, in turn, demonstrated a greater intention to provide abortion services. Encouraging nurses to gain better knowledge may improve their attitude toward abortion, which may positively influence future medical practices.

Bone Densitometry in Transgender and Gender Non-Conforming (TGNC) Individuals: 2019 ISCD Official Position.

The indications for initial and follow-up bone mineral density (BMD) in transgender and gender nonconforming (TGNC) individuals are poorly defined, and the choice of which gender database to use to calculate Z-scores is unclear. Herein, the findings of the Task Force are presented after a detailed review of the literature. As long as a TGNC individual is on standard gender-affirming hormone treatment, BMD should remain stable to increasing, so there is no indication to monitor for bone loss or osteoporosis strictly on the basis of TGNC status. TGNC individuals who experience substantial periods of hypogonadism (>1 yr) might experience bone loss or failure of bone accrual during that time, and should be considered for baseline measurement of BMD. To the extent that this hypogonadism continues over time, follow-up measurements can be appropriate. TGNC individuals who have adequate levels of endogenous or exogenous sex steroids can, of course, suffer from other illnesses that can cause osteoporosis and bone loss, such as hyperparathyroidism and steroid use; they should have measurement of BMD as would be done in the cisgender population. There are no data that TGNC individuals have a fracture risk different from that of cisgender individuals, nor any data to suggest that BMD predicts their fracture risk less well than in the cisgender population. The Z-score in transgender individuals should be calculated using the reference data (mean and standard deviation) of the gender conforming with the individual's gender identity. In gender nonconforming individuals, the reference data for the sex recorded at birth should be used. If the referring provider or the individual requests, a set of "male" and "female" Z-scores can be provided, calculating the Z-score against male and female reference data, respectively.

Prior human papillomavirus-16/18 AS04-adjuvanted vaccination prevents recurrent high grade cervical intraepithelial neoplasia after definitive surgical therapy: Post-hoc analysis from a randomized controlled trial.

We evaluated the efficacy of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine in preventing HPV-related disease after surgery for cervical lesions in a post-hoc analysis of the PApilloma TRIal against Cancer In young Adults (PATRICIA; NCT00122681). Healthy women aged 15-25 years were randomized (1:1) to receive vaccine or control at months 0, 1 and 6 and followed for 4 years. Women were enrolled regardless of their baseline HPV DNA status, HPV-16/18 serostatus, or cytology, but excluded if they had previous or planned colposcopy. The primary and secondary endpoints of PATRICIA have been reported previously; the present post-hoc analysis evaluated efficacy in a subset of women who underwent an excisional procedure for cervical lesions after vaccination. The main outcome was the incidence of subsequent HPV-related cervical intraepithelial neoplasia grade 2 or greater (CIN2+) 60 days or more post-surgery. Other outcomes included the incidence of HPV-related CIN1+, and vulvar or vaginal intraepithelial neoplasia (VIN/VaIN) 60 days or more post-surgery. Of the total vaccinated cohort of 18,644 women (vaccine = 9,319; control = 9,325), 454 (vaccine = 190, control = 264) underwent an excisional procedure during the trial. Efficacy 60 days or more post-surgery for a first lesion, irrespective of HPV DNA results, was 88.2% (95% CI: 14.8, 99.7) against CIN2+ and 42.6% (-21.1, 74.1) against CIN1+. No VIN was reported and one woman in each group had VaIN2+ 60 days or more post-surgery. Women who undergo surgical therapy for cervical lesions after vaccination with the HPV-16/18 vaccine may continue to benefit from vaccination, with a reduced risk of developing subsequent CIN2+.

Effectiveness of a low dose testosterone undecanoate to improve sexual function in postmenopausal women.

BACKGROUND: Adding testosterone to hormonal therapy could improve sexual function and general well-being among women during climacteric. We evaluated the effectiveness of testosterone undecanoate on sexual function in postmenopausal women utilizing the standardized questionnaire FSFI score. METHODS: Postmenopausal women with sexual complaints and Female Sexual Function Index (FSFI) ≤ 26.5 were enrolled in to this randomized, double-blinded, placebo-controlled trial. Participants were randomly assigned to 8-week treatment with either oral testosterone undecanoate 40 mg or placebo twice weekly with daily oral estrogen. The FSFI scores before and after treatment were compared to assess any improvement of sexual function. RESULTS: Seventy women were recruited of which each group had 35 participants. The baseline characteristics and baseline FSFI scores were comparable between both groups. After 8 weeks of treatment, the FSFI scores significantly improved in both groups when compared to the baseline but the FSFI scores from the testosterone group were significantly higher than in the placebo group post-treatment (28.6 ± 3.6, 25.3 ± 6.7, respectively, p = 0.04). There was no difference in adverse effect between the two groups CONCLUSIONS: The twice weekly addition of testosterone undecanoate to daily oral estrogen was associated with a significant improvement in sexual function among postmenopausal women than the use of the estrogen alone. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01724658 (February 17, 2012).

The factors associated with mild cognitive impairment (MCI) in surgical menopause women.

BACKGROUND AND OBJECTIVE: As a sizeable proportion of persons with mild cognitive impairment will progress to frank dementia, early detection is an important strategy to prevent and decelerate the progression of cognitive decline. In Thailand, the prevalence of mild cognitive impairment in surgical menopause women has not been well established. The objectives of the present study were to determine the percentage and factors associated with mild cognitive impairment in women with surgical menopause. MATERIAL AND METHOD: Between October 2013 and July 2014, 200 eligible women at King Chulalongkorn Memorial Hospital were enrolled. The self-reported questionnaires were used to obtain the demographic data and the Thai version of the Montreal Cognitive Assessment (MoCA) was used to detect mild cognitive impairment (MCI). The MCI was diagnosed when the MoCA score was less than 25. The data were statistically analyzed using SPSS version 17 for student t-test, Chi-square test, and multiple regression analysis. RESULTS: The percentage of MCI in the present study was 43.5%. The univariate analysis showed that factors significantly related to MCI were marital status, educational levels, occupation, monthly income, and duration of hormone replacement therapy (HRT). Nevertheless, multiple regression analysis revealed that only older age at enrollment, marital status, low educational level, and low monthly income were significantly related to MCI. CONCLUSION: Almost half of the surgical menopause women in the present study had MCI. Older age at enrollment, marital status, low educational level, and low monthly income were significantly related to MCI. Age at surgical menopause and HRT were not found to be associated with MCI in this study.

Risk of newly detected infections and cervical abnormalities in women seropositive for naturally acquired human papillomavirus type 16/18 antibodies: analysis of the control arm of PATRICIA.

BACKGROUND: We examined risk of newly detected human papillomavirus (HPV) infection and cervical abnormalities in relation to HPV type 16/18 antibody levels at enrollment in PATRICIA (Papilloma Trial Against Cancer in Young Adults; NCT00122681). METHODS: Using Poisson regression, we compared risk of newly detected infection and cervical abnormalities associated with HPV-16/18 between seronegative vs seropositive women (15-25 years) in the control arm (DNA negative at baseline for the corresponding HPV type [HPV-16: n = 8193; HPV-18: n = 8463]). RESULTS: High titers of naturally acquired HPV-16 antibodies and/or linear trend for increasing antibody levels were significantly associated with lower risk of incident and persistent infection, atypical squamous cells of undetermined significance or greater (ASCUS+), and cervical intraepithelial neoplasia grades 1/2 or greater (CIN1+, CIN2+). For HPV-18, although seropositivity was associated with lower risk of ASCUS+ and CIN1+, no association between naturally acquired antibodies and infection was demonstrated. Naturally acquired HPV-16 antibody levels of 371 (95% confidence interval [CI], 242-794), 204 (95% CI, 129-480), and 480 (95% CI, 250-5756) EU/mL were associated with 90% reduction of incident infection, 6-month persistent infection, and ASCUS+, respectively. CONCLUSIONS: Naturally acquired antibodies to HPV-16, and to a lesser extent HPV-18, are associated with some reduced risk of subsequent infection and cervical abnormalities associated with the same HPV type.

Risk of first cervical HPV infection and pre-cancerous lesions after onset of sexual activity: analysis of women in the control arm of the randomized, controlled PATRICIA trial.

BACKGROUND: More information is needed about time between sexual initiation and human papillomavirus (HPV) infection and development of cervical precancer. METHODS: The objectives were to investigate the time between first sexual activity and detection of first cervical HPV infection or development of first cervical intraepithelial neoplasia (CIN), and associated factors in women from the double-blind, multinational, 4-year PATRICIA trial. PATRICIA enroled women aged 15-25 years with no more than 6 lifetime sexual partners. Women were randomized 1:1 to the HPV-16/18 AS04-adjuvanted vaccine or to control, but only women from the control arm who began sexual intercourse during the study or within 6 months before enrolment, and had no HPV infection detected before the recorded date of their first sexual intercourse, were included in the present analysis. The time between onset of sexual activity and detection of the first cervical HPV infection or development of the first CIN lesion was analyzed using Kaplan-Meier and univariate and multivariable Cox proportional-hazards models. RESULTS: A total of 9337 women were enroled in the control arm of PATRICIA of whom 982 fulfilled the required inclusion criteria for analysis. A cumulative total of 28%, 44%, and 62% of the subjects had HPV infection within 12, 24, and 48 months, respectively. The overall incidence rate was 27.08 per 100 person-years. The most common oncogenic types associated with 6-month persistent infection were HPV-16 (incidence rate: 2.74 per 100 person-years), HPV-51 (2.70), HPV-52 (1.66), HPV-66 (1.14), and HPV-18 (1.09). Increased infection risk was associated with more lifetime sexual partners, being single, Chlamydia trachomatis history, and duration of hormone use. CIN1+ and CIN2+ lesions were most commonly associated with HPV-16, with an overall incidence rate of 1.87 and 1.07 per 100 person-years, respectively. Previous cervical HPV infection was most strongly associated with CIN development. CONCLUSIONS: More than 25% of women were infected with HPV within 1 year of beginning sexual activity. Without underestimating the value of vaccination at older ages, our findings emphasize its importance before sexual initiation. TRIAL REGISTRATION: clinicaltrials.gov: NCT00122681 .

Inter-correlation of knowledge, attitude, and osteoporosis preventive behaviors in women around the age of peak bone mass.

BACKGROUND: As silent and preventable in nature, postmenopausal osteoporosis awareness should be raised among young women prior to an irreversible period of declining bone mass. We therefore decided to assess the inter-correlation of knowledge, attitude and osteoporosis preventive behaviors in women around the age of peak bone mass. METHODS: A cross-sectional study was conducted in 430 women aged 20-35 years. The participants' knowledge, attitude and behaviors concerning osteoporosis prevention were assessed along with demographic data using a four-part questionnaire. The items in this questionnaire were established by extensive literature review, including the Guideline for Management of Osteoporosis of the Thai Osteoporosis Foundation (TOPF) 2010. The content was validated by experts in osteoporosis and reliability was obtained with a Cronbach's alpha score of 0.83. RESULTS: The mean age of women in this study was 29.4 ± 4.6 years. Half of the participants (49.5%) had heard about osteoporosis, mostly from television (95.3%, n = 203/213) and the internet (72.8%, n = 155/213). Most women had certain knowledge (85.2%) and positive attitude towards osteoporosis (53.3%). Nevertheless, 80% of the studied population did not have appropriate osteoporosis behaviors. We found significant correlation between the level of attitudes and osteoporosis behaviors (adjusted odd ratio = 3.3 with 95% confidence interval of 1.9-5.7); attitude and educational level (adjusted odd ratio = 2.2 with 95% confidence interval of 1.4-3.4); and attitude and knowledge (adjusted odd ratio = 3.5 with 95% confidence interval of 1.8-6.8). CONCLUSION: Despite having certain knowledge about osteoporosis, the young women did not seem to have appropriate osteoporosis preventive behaviors. Developing a right attitude towards osteoporosis may be a key determinant to improving health practices in order to prevent osteoporosis.

Effect of a single dose of a combination injectable contraceptive for treatment of bothersome uterine bleeding in contraceptive implant(s) users: A randomized double-blind placebo-controlled trial.

OBJECTIVES: This study aimed to determine the proportion of participants whose uterine bleeding/spotting was interrupted for at least 7 days during the month after they received a combined hormonal injection. We also evaluated bleeding at 21 days and 12 weeks after the injection. STUDY DESIGN: We conducted a randomized, double-blind, placebo-controlled trial in 46 contraceptive implant users who presented with bothersome uterine bleeding/spotting. A single dose of a combination injectable contraceptive or placebo was administered intramuscularly at enrollment. RESULTS: The proportions of participants whose uterine bleeding/spotting was interrupted for at least 7 days the month after they received a combined hormonal injection were higher in the combination injectable contraception group than in the placebo group (87% vs 48%, p = 0.005). Participants who reported that they were bleeding free at 21 days after treatment were 52% and 35% in the combination injectable contraception group and placebo group, respectively (p = 0.24). At 12 weeks posttreatment, 17% of participants in the combination injectable contraception group and 4% in the placebo group reported cessation of bleeding with no recurrence (p = 0.34). The median days until the first bleeding interruption was shorter in the combination injectable contraception group compared with the placebo group (1 [interquartile range, 1-2] vs 8 [interquartile range, 1-28], p = 0.007). CONCLUSIONS: The combination injectable contraception interrupted bothersome uterine bleeding/spotting in contraceptive implant(s) users compared with placebo. However, this effect was limited only within the month when the treatment was administered. IMPLICATIONS: Bothersome uterine bleeding/spotting is a common side effect leading to contraceptive implant(s) discontinuation. In implant users experiencing these symptoms with no estrogen contraindications, a combined injectable contraception appears to rapidly improve bleeding for the duration of injectable exposure (1 month).

A randomized single-blind non-inferiority trial of delayed start with drospirenone-only and ethinyl estradiol-gestodene pills for ovulation inhibition.

We compared the efficacy of 4 mg drospirenone (DRSP) progestin-only pills (POPs) versus combined oral contraceptive pills (COCs) containing 0.02 mg of ethinyl estradiol (EE) and 0.075 mg of gestodene (GS) in ovulation inhibition and inducing unfavorable cervical mucus changes using a delayed-starting approach. This randomized controlled trial involved 36 participants aged 18-45 years. The major outcomes included ovulation inhibition assessed using the Hoogland and Skouby score, and cervical mucus permeability, assessed using the modified World Health Organization score. The results demonstrated ovulation inhibition rates of 77.8% for the EE/GS group and 88.9% for the DRSP group. The risk ratio and absolute risk reduction were 0.50 (95% confidence interval [CI]: 0.10, 2.40) and - 0.11 (95% CI: - 0.35, 0.13), respectively, satisfying the 20% non-inferiority margin threshold. The median time to achieve unfavorable cervical mucus changes was comparable between the DRSP (3 days, interquartile range [IQR]: 6 days) and EE/GS (3.5 days, IQR: 4 days) groups. However, the DRSP group had a higher incidence of unscheduled vaginal bleeding (55.56% vs. 11.11%; p = 0.005). DRSP-only pills, initiated on days 7-9 of the menstrual cycle, were non-inferior to EE/GS pills in ovulation inhibition. However, they exhibited delayed unfavorable cervical mucus changes compared to the standard two-day backup recommendation.Clinical trial registration: Thai Clinical Trials Registry (TCTR20220819001) https://www.thaiclinicaltrials.org/show/TCTR20220819001 .

Summary of the 2023 Thai Menopause Society Clinical Practice Guideline on Menopausal Hormone Therapy.

The Thai Menopause Society is an academic organization consisting of healthcare professionals engaged in menopause medicine. The position statement was first issued in 1994 and updated in 2003 and 2023. Herein, we reviewed the important updates of the 2023 position statement on menopausal hormone therapy (MHT) as an international reference for healthcare professionals in Thailand. An advisory panel of clinicians and research experts in the field of menopause reviewed the recommendation of published International Consensus Statements and updated the evidence using the MEDLINE database through PubMed. The evidence-based information and relevant publications were assessed, and a consensus on recommendations was subsequently achieved using the level of evidence to determine the recommendation strength and evidence quality. MHT remains the most effective treatment for vasomotor symptoms and genitourinary syndromes of menopause even after 20 years. Additionally, it is effective in preventing bone loss and fractures in postmenopausal women. The cardiovascular risk of MHT increased in women who initiated MHT after 60 years of age. Hormone therapy should be individualized following the hormone type, dose, administration route, use duration, and progestogen inclusion. The necessary pretreatment evaluation and appropriate follow-up recommendations were added for improved MHT standard care. The updated 2023 Clinical Practice Guideline on MHT is useful for gynecologists, general physicians, endocrinologists, and other healthcare professionals in treating menopausal women receiving hormone therapy in Thailand.

Recommended measurement instruments for genitourinary symptoms associated with menopause: the COMMA (Core outcomes in menopause) consortium.

OBJECTIVE: The aim of the study is to identify appropriate definitions and patient-reported outcome measures (PROMs) for each of the eight core outcomes previously selected for genitourinary symptoms associated with menopause: pain with sex, vulvovaginal dryness, vulvovaginal discomfort or irritation, discomfort or pain when urinating, change in most bothersome symptom, distress, bother or interference of genitourinary symptoms, satisfaction with treatment, and side effects. METHODS: We conducted a systematic review to identify possible definitions and PROMs, including their measurement properties. Identified definitions and relevant PROMs with acceptable measurement properties were entered into an international consensus process involving 28 participants from 10 countries to achieve final recommendations for each core outcome. RESULTS: A total of 87 publications reporting on 34 PROMs were identified from 21,207 publications screened. Of these 34 PROMs, 29 were not considered to sufficiently map onto the core outcomes, and 26 of these also had insufficient measurement properties. Therefore, only five PROMs corresponding to two core outcomes were considered for recommendation. We recommend the PROMIS Scale v2.0 - Sexual Function and Satisfaction: Vaginal Discomfort with Sexual Activity to measure the outcome of "pain with sexual activity" and the Day-to-Day Impact of Vaginal Aging (DIVA) Questionnaire to measure "distress, bother or interference" from genitourinary symptoms. Six definitions of "side effects" were identified and considered. We recommend that all trials report adverse events in study participants, which is a requirement of Good Clinical Practice. CONCLUSIONS: Suitable PROMs and definitions were identified to measure three of eight core outcomes. Because of the lack of existing measures, which align with the core outcomes and have evidence of high-quality measurement properties, future work will focus on developing or validating PROMs for the remaining five core outcomes.

Asia-Pacific consensus on long-term and sequential therapy for osteoporosis.

Objectives: This study aimed to present the Asia-Pacific consensus on long-term and sequential therapy for osteoporosis, offering evidence-based recommendations for the effective management of this chronic condition. The primary focus is on achieving optimal fracture prevention through a comprehensive, individualized approach. Methods: A panel of experts convened to develop consensus statements by synthesizing the current literature and leveraging clinical expertise. The review encompassed long-term anti-osteoporosis medication goals, first-line treatments for individuals at very high fracture risk, and the strategic integration of anabolic and antiresorptive agents in sequential therapy approaches. Results: The panelists reached a consensus on 12 statements. Key recommendations included advocating for anabolic agents as the first-line treatment for individuals at very high fracture risk and transitioning to antiresorptive agents following the completion of anabolic therapy. Anabolic therapy remains an option for individuals experiencing new fractures or persistent high fracture risk despite antiresorptive treatment. In cases of inadequate response, the consensus recommended considering a switch to more potent medications. The consensus also addressed the management of medication-related complications, proposing alternatives instead of discontinuation of treatment. Conclusions: This consensus provides a comprehensive, cost-effective strategy for fracture prevention with an emphasis on shared decision-making and the incorporation of country-specific case management systems, such as fracture liaison services. It serves as a valuable guide for healthcare professionals in the Asia-Pacific region, contributing to the ongoing evolution of osteoporosis management.

Recommended measurement instruments for menopausal vasomotor symptoms: the COMMA (Core Outcomes in Menopause) consortium.

OBJECTIVE: The aim of the study is to identify suitable definitions and patient-reported outcome measures (PROMs) to assess each of the six core outcomes previously identified through the COMMA (Core Outcomes in Menopause) global consensus process relating to vasomotor symptoms: frequency, severity, distress/bother/interference, impact on sleep, satisfaction with treatment, and side effects. METHODS: A systematic review was conducted to identify relevant definitions for the outcome of side-effects and PROMs with acceptable measurement properties for the remaining five core outcomes. The consensus process, involving 36 participants from 16 countries, was conducted to review definitions and PROMs and make final recommendations for the measurement of each core outcome. RESULTS: A total of 21,207 publications were screened from which 119 reporting on 40 PROMs were identified. Of these 40 PROMs, 36 either did not adequately map onto the core outcomes or lacked sufficient measurement properties. Therefore, only four PROMs corresponding to two of the six core outcomes were considered for recommendation. We recommend the Hot Flash Related Daily Interference Scale to measure the domain of distress, bother, or interference of vasomotor symptoms and to capture impact on sleep (one item in the Hot Flash Related Daily Interference Scale captures interference with sleep). Six definitions of "side effects" were identified and considered. We recommend that all trials report adverse events, which is a requirement of Good Clinical Practice. CONCLUSIONS: We identified suitable definitions and PROMs for only three of the six core outcomes. No suitable PROMs were found for the remaining three outcomes (frequency and severity of vasomotor symptoms and satisfaction with treatment). Future studies should develop and validate PROMs for these outcomes.

Cross-protective efficacy of HPV-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by non-vaccine oncogenic HPV types: 4-year end-of-study analysis of the randomised, double-blind PATRICIA trial.

BACKGROUND: We evaluated the efficacy of the human papillomavirus HPV-16/18 AS04-adjuvanted vaccine against non-vaccine oncogenic HPV types in the end-of-study analysis after 4 years of follow-up in PATRICIA (PApilloma TRIal against Cancer In young Adults). METHODS: Healthy women aged 15-25 years with no more than six lifetime sexual partners were included in PATRICIA irrespective of their baseline HPV DNA status, HPV-16 or HPV-18 serostatus, or cytology. Women were randomly assigned (1:1) to HPV-16/18 vaccine or a control hepatitis A vaccine, via an internet-based central randomisation system using a minimisation algorithm to account for age ranges and study sites. The study was double-blind. The primary endpoint of PATRICIA has been reported previously; the present analysis evaluates cross-protective vaccine efficacy against non-vaccine oncogenic HPV types in the end-of-study analysis. Analyses were done for three cohorts: the according-to-protocol cohort for efficacy (ATP-E; vaccine n=8067, control n=8047), total vaccinated HPV-naive cohort (TVC-naive; no evidence of infection with 14 oncogenic HPV types at baseline, approximating young adolescents before sexual debut; vaccine n=5824, control n=5820), and the total vaccinated cohort (TVC; all women who received at least one vaccine dose, approximating catch-up populations that include sexually active women; vaccine n=9319, control=9325). Vaccine efficacy was evaluated against 6-month persistent infection, cervical intraepithelial neoplasia grade 2 or greater (CIN2+) associated with 12 non-vaccine HPV types (individually or as composite endpoints), and CIN3+ associated with the composite of 12 non-vaccine HPV types. This study is registered with ClinicalTrials.gov, number NCT00122681. FINDINGS: Consistent vaccine efficacy against persistent infection and CIN2+ (with or without HPV-16/18 co-infection) was seen across cohorts for HPV-33, HPV-31, HPV-45, and HPV-51. In the most conservative analysis of vaccine efficacy against CIN2+, where all cases co-infected with HPV-16/18 were removed, vaccine efficacy was noted for HPV-33 in all cohorts, and for HPV-31 in the ATP-E and TVC-naive. Vaccine efficacy against CIN2+ associated with the composite of 12 non-vaccine HPV types (31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68), with or without HPV-16/18 co-infection, was 46·8% (95% CI 30·7-59·4) in the ATP-E, 56·2% (37·2-69·9) in the TVC-naive, and 34·2% (20·4-45·8) in the TVC. Corresponding values for CIN3+ were 73·8% (48·3-87·9), 91·4% (65·0-99·0), and 47·5% (22·8-64·8). INTERPRETATION: Data from the end-of-study analysis of PATRICIA show cross-protective efficacy of the HPV-16/18 vaccine against four oncogenic non-vaccine HPV types-HPV-33, HPV-31, HPV-45, and HPV-51-in different trial cohorts representing diverse groups of women. FUNDING: GlaxoSmithKline Biologicals.