Young women's knowledge, attitudes, and behaviors related to long-acting reversible contraceptives.

BACKGROUND: The present study explored 18- to 30-year-old women's knowledge and perceptions of the long-acting, reversible contraceptives (LARCs) Mirena and Implanon in a Midwestern state in the United States. METHODS: A telephone survey (n = 543) and 18 focus groups (n = 106) were conducted with women across a rural, Midwestern state. During the telephone survey, women answered questions related to their awareness and knowledge of two LARCs. During the focus groups, participants were asked to respond to questions related to their awareness, knowledge, behaviors, and perceptions of LARCs. RESULTS: In the telephone survey, half of the women reported hearing of Mirena. Only 8.0% of women had heard of Implanon. In the focus groups, most women reported knowing little about LARCs. Benefits associated with other contraceptives were not associated with LARCs. Women were concerned about potential side effects and problems stemming from using a contraceptive that is new to them. CONCLUSION: Increased use of LARCs would likely reduce the unintended pregnancy rate. As described, although some young women are aware of these long-term contraceptive options, there is still a need to educate women on their availability, use, and potential benefit.

Oral contraception and thrombophilia.

PURPOSE OF REVIEW: To describe current knowledge related to the association between oral contraception and the thrombophilias. RECENT FINDINGS: The use of oral contraception increases the risk of venous thromboembolism as well as arterial thrombosis. Third-generation pills seem to increase the risk of venous thromboembolism compared with second-generation pills. This effect seems to be reversed or absent for the risk of arterial thrombosis. The effect of oral contraception on the risk of venous thromboembolism is more pronounced during the first year of use. All these risks are further increased in patients with an inborn or acquired tendency for coagulation (thrombophilia). SUMMARY: Prospective users of oral contraception are potential candidates for screening/testing, because a positive screen may substantially decrease the risk of a thrombotic event. At present, the available testing methods are not cost effective, and the absolute risk is not defined for each thrombophilia. Until these shortcomings are solved, it is not recommended to test every woman who wishes to use oral contraception. Nevertheless, before starting on oral contraception, each patient should be carefully screened by a physician who should identify an increased risk of thrombophilia and tailor the laboratory testing.

Hormonal emergency contraception: a clinical primer.

Unintended and teenage pregnancies are major public health concerns in the United States. Emergency contraception is used to prevent pregnancy after failure of a contraceptive method or after unprotected intercourse. Expanded use of emergency contraception has the potential to reduce unintended pregnancy and induced abortions, while reducing state and federal healthcare expenditures. The recent approval of Plan B as an over-the-counter medication for individuals over 18 years of age should improve access to this medication. However, there are still widespread misconceptions about the mechanisms and implications of emergency contraception. Expanded access to emergency contraception is associated with increased use, but not associated with decreased efficacy, increased sexual risk-taking behavior, or less consistent use of traditional birth control methods. This review is designed to provide clinicians with information regarding the use of emergency contraception for reproductive age patients. It includes a brief description of methods of use, mechanisms of action, and side effect profiles of the most commonly used methods of emergency contraception, levonorgestrel and the Yuzpe method.

An assessment of the first 3 years' use of Implanon in Luton.

OBJECTIVES: Implanon was introduced in the UK in September 1999. We present here the results of our first 106 Implanon insertions, performed over a period of 18 months. The aims of the study were to study the clinical and demographic profile of Implanon users, to assess the continuation rates of Implanon in the local population, and to identify the reasons for removal. METHODS: This was a case note-based study in which the data were transferred to a standardised pre-tested proforma. RESULTS: The age range of the 106 Implanon users was 15-43 years. Eighty-six of these clients had their Implanon removed and the Implanon status of 20 clients is not known since they were lost to follow-up by our service. Of these 86 cases, 26 had completed the full 3-year period; therefore, the continuation rate at 3 years was 30.2%. The continuation rate at the end of 1 year was 69.8% and at 2 years was 44.1%. Of the 60 women who had their Implanon removed before the recommended 3-year period, the most common reason was for bleeding irregularity (24 cases, 40%). CONCLUSIONS: This is the first published study set in the UK within a real-life setting to follow up a cohort of Implanon users for the full 3-year period. No contraceptive failures were found, replicating previous clinical trials. The continuation rate in this real-life situation was quite low compared to clinical trials. This is frequently the case when comparing real-life situations with clinical trials and may be in part due to higher motivation on the part of clinical trial participants.

Introduction of the pill and its impact.

Introduction of the birth control pill in the United States in 1960 marked the end of a relatively short period of time (< 10 years) to intentionally produce an oral contraceptive, and the beginning of a relatively long period of controversy surrounding the use of the pill. Availability of the pill had an impact on various aspects of social life, including women's health, fertility trends, laws and policies, religion, interpersonal relationships and family roles, feminist issues, and gender relations, as well as sexual practices among both adults and adolescents. The pill proved to be highly effective from the outset. Although safety issues developed with the earlier formulations, continued evolution of pill hormones and doses has resulted in a greatly improved and safe oral contraceptive. A broad range of noncontraceptive health benefits also is associated with the pill. These health effects are significant, as they include protection against potentially fatal diseases, including ovarian and endometrial cancers, as well as against other conditions that are associated with substantial morbidity and potential hospitalization and associated costs. The popularity of the pill has remained high, with rates of use in the past 30 years in the United States ranging from one-quarter to almost one-third of women using contraception. Almost 40 years after its introduction, the pill's contraceptive efficacy is proven, its improved safety has been established, and the focus has shifted from supposed health risks to documented and real health benefits.

PIP: By the end of their reproductive years, more than 80% of US women will have used oral contraceptives (OCs), for an average of about 5 years. The pill has had a dramatic impact on social life in the US, affecting women's health, fertility trends, laws and policies, religion, interpersonal relations, family roles, women's careers, gender relations, and premarital sexual practices. The emergence of the women's rights movement of the 1960s and 1970s was significantly related to the availability of the pill and the control over fertility it enabled. This capability allowed women to make choices about other life arenas, especially work. Over the past 40 years, both the content and dose of the steroid components of OCs have changed significantly, with consequent reduced health effects. This improved safety profile has been further bolstered by the identification of women with risk factors such as smoking, high blood pressure, history of cardiovascular disease, and diabetes with vascular disease. In recent years, the emphasis has shifted from the health risks of OC use to the noncontraceptive health benefits.

Avaliação da tolerabilidade e do controle de ciclo de dois contraceptivos orais de baixa dose: estudo comparativo aberto / Assessment of the tolerability and cycle control of two low-dose oral contraceptives: an open-label study

Realizou-se um estudo aberto comparativo em nove centros brasileiros para avaliar a tolerabilidade e o controle de ciclo obtido com o uso de dois contraceptivos orais de baixa dose contendo 20 mg etinilestradiol/75 mg gestodeno e 20 mg etinilestradiol/150 mg desogestrel, durante seis ciclos de tratamento. Foram selecionadas 167 mulheres saudáveis com vida sexual ativa (77 no grupo do gestodeno e 90 no grupo do desogestrel), das quais 138 completaram os seis ciclos de tratamento. Em um subgrupo de novas usuárias realizou-se também perfil lipídico e hemostático. Foram avaliados 867 diclos no total. Ocorreu sangramento irregular em 4,6 por cento dos ciclos com gestodeno e em 8,1 por cento com desogestrel. A tolerabilidade a ambas preparações foi boa, mas houve significativamente mais náusea no grupo do desogestrel. O controle de ciclo foi bom com os dois contraceptivos, sendo que houve freqüência significativamente menor de sangramento irregular no grupo do gestodeno quando se leva em conta que todos os ciclos foram considerados. Não houve alterações clinicamente significativas no perfil hemostático. O perfil lipídico mostrou tendência a tornar-se mais favorável após seis ciclos de tratamento com as duas preparações. Não ocorreu alteração no peso médio das mulheres no grupo do gestodeno; no grupo do desogestrel houve aumento significativo no peso médio de aproximadamente 1 Kg após seis meses de tratamento. A adesão ao tratamento foi boa com as duas preparações. Os resultados deste estudo mostram que preparações contendo baixa dose de gestodeno ou desogestrel associados a 20 mg de etinilestradiol são contraceptivos bem tolerados que permitem bom controle de ciclo, sem efeitos colaterais significantes.

Increased number of induced abortions in Norway after media coverage of adverse vascular events from the use of third-generation oral contraceptives.

After the press release in Lancet (October 18, 1995) of increased risks for adverse vascular events in users of pills containing desogestrel and gestodene the total sales of oral contraceptives dropped over a two-month period by 17%, while sales of the only desogestrel brand available (Marvelon) dropped by over 70% in Norway. From sales, we can estimate that more than 45,000 women either changed from Marvelon to a second or first-generation brand or stopped using OCs. In total, more than 25,000 women discontinued OC use in Norway during November and December of 1995. Abortion data from one Norwegian county, representing 6-7% of the Norwegian population, show no statistically significant changes in the total number of induced abortions from the first quarter of 1996 as compared with that of the first quarter in preceding years. However, abortion rates that had been steadily decreasing from 1992 through 1995 in women 24 years old or younger, were promptly interrupted by a significant 36% increase during the first quarter of 1996. Most of the additional cases were found among single, childless students. The observed increased abortion rate among younger women is most probably linked to changes in contraceptive use during the pill scare of the late October through December of 1995, during which time these women conceived.

PIP: Reports appearing in the mass media in October 1995 citing a two-fold increase in the risk of venous thromboembolism in users of third-generation compared to second-generation oral contraceptives (OCs) were followed, in Norway, by a 17% drop in total OC sales and a 70% drop in sales of the only third-generation OC (Marvelon) on the market. More than 25,000 Norwegian women discontinued OC use in November-December 1995. Abortion data from one Norwegian county, representing 6-7% of the country's population, showed no significant changes in the total number of induced abortions in the first quarter of 1996 compared to the first quarter of preceding years. However, the steady decrease in the abortion rate for women 24 years of age or younger recorded in 1992-95 was interrupted by a 36% increase during the first quarter of 1996 (5.7/1000, compared with 4.2/1000 in the first quarter of 1995). Most of the growth in abortion cases occurred among single, childless students--a subgroup in which OC use tends to be high. Although this finding suggests that the mass media's "pill scare" may have led many young women to discontinue OC use or switch to less effective formulations, evaluation of the full effect of this event cannot be completed without national data on induced abortion and the completion of birth registration.

[Risk of thrombosis with oral contraceptives: value of a thrombophilia screening test]. / Thromboserisiko bei oralen Kontrazeptiva: Stellenwert eines Thrombophilie-Screenings.

Oral contraceptives increase the natural incidence of venous thrombosis of 1-2/10,000 women per year 3- to 4-fold. Recent studies have shown that desogestrel or gestodene containing formulations bear twice the risk of older low-dose ovulation inhibitors. During pregnancy, the incidence of thrombosis rises to 10/10,000 women-years and post partum up to 40/ 10,000. For 60% of thromboses no causal explanation can be found. In approximately 40% of the patients an inherited thrombophilia can be presumed. Among the hereditary types of thrombophilia, a resistance to activated protein C (APC-resistance) represents nearly 50%, while in 15 to 20% a deficiency of antithrombin III, protein C or protein S is found. APC-resistance, with a prevalence of 3-5% in the general population, increases the risk of thrombosis 8-fold and in users of oral contraceptives 35-fold. Antithrombin III-deficiency carries a comparable risk. Protein C-deficiency increases the risk of thrombosis 9-fold and in users of oral contraceptives 15-fold. Ovulation inhibitors do not influence the risk of thrombosis in women with protein S-deficiency. Anti-phospholipid-antibodies increase during treatment with oral contraceptives and represent a considerably enhanced risk of thrombosis. Inherent thrombophilia is suspected in a patient with a positive history or family history of thrombosis, especially with thrombosis before the age of 40 or with atypical localisation. Even in these risk groups, the cost-benefit ratio of selective screening is unfavorable, as today at most 70% of the hereditary thrombophilias can be diagnosed by laboratory analysis, and only very few of the patients will actually experience a thrombotic event: only 3 of 1000 carriers of APC-resistance will suffer from thrombosis during oral contraception. On the other hand, a negative result of laboratory tests does not exclude a hereditary thrombophilic disorder. At present, it is unclear whether a selective screening process is superior to a careful assessment of individual and family history. A general screening, however, cannot be justified because of the unfavorable cost/benefit ratio. If the individual or family history or pathological laboratory parameters indicate an increased risk of thrombosis, this risk has to be carefully weighed against the consequences of discontinuation of pill use. Those few individuals with risk factors who will experience a thrombo-embolic event, cannot be identified in advance. If oral contraceptives represent a particularly high risk in patients with thrombophilic disorders and/or other risk factors, other contraceptive methods should be considered. If a patient with risk factors decides on the use of oral contraceptives, she must be informed that in the case of symptoms indicating a thrombosis, a physician should be consulted immediately. The earlier an appropriate therapy is initiated, the more effectively pulmonary thrombo-embolism and permanent damage, such as the post-phlebitic syndrome, can be prevented.

Comparative assessment of two low-dose oral contraceptives, Lo-Femenal and Lo-Estrin, in Mexican women.

This trial was designed to determine the differences in effectiveness, clinical acceptability, and one-year discontinuation rates of two low-dose oral contraceptives: Lo-Estrin (norethindrone acetate 1.5 mg plus ethinyl estradiol 0.030 mg) and Lo-Femenal (norgestrel 0.30 mg plus ethinyl estradiol 0.030 mg) in 148 Mexican women. In addition, the effects of both oral contraceptive preparations on blood lipids were prospectively evaluated in a subgroup of 41 women. The results indicated that there were no differences in pregnancy rates, discontinuation or clinical acceptability between the two groups. The lipid changes observed were minimal for the Lo-Femenal subgroup and somewhat greater for the Lo-Estrin group, mainly an increase in serum triglycerides. These changes were interpreted as estrogen induced effects of norethindrone-containing oral contraceptives. Overall, the data indicate that both Lo-Femenal and Lo-Estrin are effective and safe combined oral contraceptives.

[Doctors and injectable contraception. Analysis of the logistics of prescribing in accordance with the views expressed by doctors]. / Médecins et contraception injectable. Analyse des logiques de prescription à partir des discours de médecins.

Injectable contraception (IC) using medroxyprogesterone acetate (Depoprovera) and norethisterone enanthate (Noristerat) has been discussed in numbers of publications since the Food and Drug Administration (FDA) of the USA have refused to authorize the use of Depoprovera as a contraceptive in America. This has provoked a large number of publications in the international literature. The refusal was based on the potential oncogenic risk of the molecule. The distribution of this product as a contraceptive in developing countries and its restricted authorisation in many industrialised countries including France has brought about contradictory debates about the assessment of this method (secondary effects, risks of developing cancer and teratogenesis). In 1986 we started a research using close collaboration between the health teams of Seine-Saint-Denis (which control clinics, family planning clinics and hospitals) in order to try to find some solution to this problem "for or against IC". The object of this research was to find out how acceptable this method was as compared with other contraceptive methods. The fact that many disciplines were involved (gynaecologists, sociologists, epidemiologists and pharmacologists) in this work made it possible first to find out the conditions under which IC was prescribed (by sociological analysis and discussions with doctors). And the socio-cultural features in which the doctors who prescribed this method of contraception were situated also came into play. The criteria under which ICs are prescribed are not mainly medical but are narrowly linked to socio-cultural factors and the socio-economic factors of the women for whom it is prescribed: and this is in comparison with other methods of contraception. Prescribing this substance has a degree of urgency about it.

Oral and intrauterine contraception: a 1978 risk assessment.

This report reviews the current literature on the various risks associated with the use of oral contraceptives and intrauterine contraceptive devices. Reports on oral contraceptives from large prospective studies are not beginning to supplement the detailed reports resulting from earlier case-control studies. These studies suggest that in Western societies there is an increase in the incidence of a variety of circulatory diseases, with an increased risk of death. With intrauterine contraceptive devices it now has been fairly well documented that there is an increased risk of pelvic inflammatory disease. After reviewing and assessing the risks of both methods in some detail and comparing these risks to the benefits, the resultant conclusion is that the benefits continue to outweigh the risks for both methods, except for older women who choose oral contraceptives and also are heavy smokers.

Selecting the optimum method of contraception for each patient.

The factors relating to the choice of the optimal method of contraception are discussed, indicating the wide range of variables which must be evaluated. Religious, cultural, educational and social factors are considered, as well as age and family size. Facts elicited through discussion of general medical, family, obstetric and menstrual histories help to indicate the advantages and disadvantages of available methods. The influences of the doctor, relatives, friends, and publicity are shown to affect the patient's choice and indicate that the theoretical effectiveness of a particular method forms only one part of a complex situation.

An assessment of the side effects of switching from one oral contraceptive to another.

Side effects associated with three oral contraceptives were evaluated in a study in which women were switched to Norlestrin 1 from either Ovral (64 subjects) or Norinyl 1/50 (26 subjects). In the cycle prior to crossover, breast discomfort was more frequent among Norinyl users than among Ovral users. The prevalence of all other reported side effects was not significantly different for Norinyl and Ovral. The crossover to Norlestrin did not significantly change the numbers of patients reporting side effects. By the end of third Norlestrin cycle, rates of all side effects were similar for women who were switched from either Ovral or Norinyl.

Effect of oral contraceptive agents on vitamin nutrition status.

Effects of low estrogen combination type oral contraceptives on some of the biochemical parameters used for assessing vitamin nutritional status were investigated in a group of women who had used the pill for 6 to 12 months. Another group of women was examined initially and then at one or more points of time within the first 6 months of treatment. Following changes were observed in women treated with oral contraceptives: 1) increased excretion of kynurenic acid and xanthurenic acid following tryptophan load; 2) increased EGOT activity and also an increase in vitro stimulation of EGOT with added PALP; 3) increased plasma vitamin A levels; 4) fall in erythrocyte folate levels; 5) fall in erythrocyte transketolase activity with no change in vitro stimulation with TPP; and 6) fall in erythrocyte riboflavin concentration associated with a decrease in erythrocyte glutathione reductase activity and increase in vitro stimulation with FAD. Most of these changes were observed during the first few cycles of oral contraceptive treatment.