Women in search of stability.

This paper is based on a study of 97 recruits--50 sterilized and 47 non-sterilized--to a family planning programme in Kingston, Jamaica and tries to account for the reluctance of Jamaican women to accept contraceptive sterilization. The study demonstrates the association between mating patterns in the island and the acceptance of sterilization. This irreversible method was more likely to be chosen by women in more stable sexual unions.

A multicentred phase III comparative clinical trial of depot-medroxyprogesterone acetate given three-monthly at doses of 100 mg or 150 mg: 1. Contraceptive efficacy and side effects. World Health Organization Task Force on Long-Acting Systemic Agents for Fertility Regulation. Special Programme of Research, Development and Research Training in Human Reproduction.

Two dosages of depot-medroxyprogesterone acetate (DMPA), 100 mg and 150 mg given every 90 days, were compared in two groups of women with regard to effectiveness, reported complaints and reasons for discontinuation. A total of 1216 women were recruited into a seven-centre, multinational, randomized clinical trial. Follow-up was for a period of one year and resulted in a total of 5507 woman-months of experience of 100 mg DMPA and 5429 woman-months of experience of the 150 mg dose. The study showed little difference in efficacy and side effects between the two treatment groups. Two pregnancies occurred in women receiving 100 mg DMPA giving a Pearl Index of 0.44 per 100 woman-years. None occurred in the 150 mg group. There was no difference in the overall continuation rates between the two groups at one year, being 59.3% in the 100 mg group and 58.8% in the 150 mg group. Except for discontinuation of method use for amenorrhea, the rates of all medical and non-medical reasons given for discontinuation were comparable between the two treatment groups. Women's perception of lack of bleeding was reported as amenorrhea and resulted in discontinuation rates at 12 months for amenorrhea of 7.2% for women receiving 100 mg of DMPA and 12.5% for those receiving the 150 mg dose. Three centres, Alexandria, Karachi and Szeged, made the major contributions to this difference.

A multicentered phase III comparative clinical trial of depot-medroxyprogesterone acetate given three-monthly at doses of 100 mg or 150 mg: II. The comparison of bleeding patterns. World Health Organization. Task Force on Long-Acting Systemic Agents for Fertility Regulation Special Programme of Research, Development and Research Training in Human Reproduction.

A multicentered phase III clinical trial was conducted in seven countries to compare two dosages of depot-medroxyprogesterone acetate (DMPA), 100mg and 150mg, given every 90 days. Contraceptive efficacy and side-effects of both regimens were reported previously. Their effect on vaginal bleeding patterns is the object of this paper. A total of 1216 women were randomly assigned to a dose group and 1156 of them provided a menstrual diary. The comparison of the bleeding patterns is made using a 90-day reference period approach and following the guidelines published by WHO. In addition, the longest bleeding/spotting episode and the longest bleeding/spotting-free interval are calculated over the entire diary length. The only difference found between the two dose groups is a higher incidence of amenorrhea with the 150mg regimen. Overall, there is a high degree of consistency between the reasons given by individual women for discontinuing the contraceptive method and their vaginal bleeding pattern during the 90 days preceding discontinuation. However the data revealed large between-centre differences, both in the incidence of specific patterns, and in the identification by women of bleeding problems as reasons for discontinuation. This last point suggests that the life-table analysis underestimates the true incidence of menstrual irregularities. Comments on the reference period analysis method are made.

Myomectomy in infertile Jamaican women.

One hundred nineteen Jamaican women who underwent myomectomy from 1964 to 1969 were followed up for 5 to 9 years. Infertility was the most common presenting complaint. Preoperative hysterosalpingograms were performed on 61 patients and were abnormal for the majority of these patients. Surgery revealed submucous fibroids in 41 patients and pelvic inflammatory disease in 51 patients. The pregnancy rate following myomectomy was 18.5%, but successful outcomes occurred in only 9.2% of the cases. Pregnancy was unsuccessful for all patients who underwent both myomectomy and tuboplasty. Twenty-three patients had a recurrence of myoma, and 13 of these underwent subsequent hysterectomy.

Contractile responses of uterine smooth muscle to acetylcholine and marihuana extract.

Marihuana extract (ME) is known to influence smooth muscle activity. This study was designed to investigate the effect of crude ME on rat uterine muscle and to explain the mechanism of action using antagonists such as atropine, ergometrine and propranolol. The contractions and the electrical activity were recorded on isolated superfused rat uteri. It is speculated that ME by its uterine stimulatory action compromise uterine blood and may affect oxygen/nutrient transfer. The implication of this to the fetus is discussed.

Transdermal glyceryl trinitrate in the management of primary dysmenorrhea.

OBJECTIVE: Increased intra-uterine pressure due to exaggerated myometrial contractions is an important factor in the pathogenesis of dysmenorrhea, its treatment being associated with uterine muscle relaxation. Diminished synthesis of endogenous nitric oxide has been shown to induce myometrial contractions and, conversely, the administration of exogenous nitric oxide has successfully resulted in uterine relaxation in a variety of obstetrical/gynecological disorders. The objective of this study was to determine the role of transdermal glyceryl trinitrate, as a source of exogenous nitric oxide, in the management of primary dysmenorrhea. METHOD: This was a multi-national, double-blind, randomized and cross-over study in patients with primary dysmenorrhea. Eighty-eight patients from six countries were evaluated during three menstrual cycles while receiving glyceryl trinitrate patches, 0.1 mg/h (x) or matching placebo patches. Pain intensity scores assessed on a visual analog scale and the time-weighted sum of the pain intensity differences (SPID) were evaluated during days 1, 2 and 3 of each cycle using an analysis of variance (ANOVA) model. Overall assessment of efficacy and the incidence of adverse events were analyzed by the Stuart-Maxwell or the McNemar tests as appropriate. RESULTS: Efficacy was determined for the first day of each cycle, all days/all cycles and for patients who completed at least one cycle in each treatment modality. In all three analyses, SPIDs were statistically superior (P<0.01) for the glyceryl trinitrate patches. Pain intensity differences from hours 1 to 6 also showed statistically significant differences in favor of the active treatment. In the overall assessment of efficacy, glyceryl trinitrate patches were statistically superior as well. The incidence of headache was 26% for the active drug and 6.1% for placebo (P<0.01). CONCLUSIONS: The data indicate that transdermal glyceryl trinitrate, as a source of exogenous nitric oxide, is useful as a modulator of uterine contractility representing, therefore, a new and mechanistically different therapeutic alternative for the management of primary dysmenorrhea.

Testicular function in rats following immobilization stress.

Stress is believed to influence male reproductive activity. Male rats were subjected to immobilization stress for 2 h/day for 30 days to assess the effects of stress on testicular function. Net mass of the testes, epididymes and the seminal vesicles, sperm morphology, number of epididymal sperms and percent progressive motility of the sperms were determined. Adrenal weights were significantly increased (P less than 0.05) in the stressed animals. There was no significant difference between the control and the stressed animals with respect to testicular and epididymal weight, level of sperm production, progressive motility, seminal vesicular weight and abnormal forms. Histological examination also revealed a similarity in the structure of seminiferous tubules, adequacy of cell types of developing germ cells, structure of Leydig cells and epididymal lumina in both the groups. This study demonstrated a lack of significant effect of immobilization stress on testicular function in rats.

Prophylactic antibiotic in elective gynaecological and obstetrical major surgery.

A prospective controlled study of 580 patients who underwent non-radical major gynaecological or obstetrical surgery examined the use of prophylactic antibiotics. The test group of patients (290) showed a significantly lower (P=0.01) incidence of the total complications and the non-infective complication rate as against those among controls (290). The duration of hospitalisation was significantly reduced for both vaginal and abdominal surgery in the test group of patients as against those in the controls. There was no evidence of increased incidence of bacterial resistance or superinfection. The authors recommend the use of prophylactic antibiotic on a short term basis (for a total duration of 4 days), commencing preoperatively to achieve a significant reduction in the infective postoperative morbidity and a shorter stay by the patients.

Choriocarcinoma in Jamaica.

Fifty-two cases of choriocarcinoma were recorded in the Jamaica Cancer Registry for the parishes of Kingston and St. Andrew, giving an incidence of 1:7,384 live births. This is intermediate between figures reported for Western metropolitan populations and for Far Eastern countries. Clinicopathological studies on 26 cases treated at the University Hospital in Jamaica revealed that 65% followed either normal pregnancy or abortion. Choriocarcinoma following a normal pregnancy or occurring without a previous history of pregnancy carried a poorer prognosis than those with a preceding hydatidiform mole. Many patients had primary neurological manifestations. The overall prognosis was poor due to late presentation with disseminated metastases. Of the 26 patients, 15 died of the disease within two years and only six appeared for a six-year follow-up.

Psychosexual attitudes in the female following sterilization.

This study represents a three year follow-up, summarizing the psychosexual attitudes of 120 patients who were sterilized with tubal occlusion by one of three methods: culdoscopy, laparoscopy or postpartum laparotomy. The results indicate that most patients had a favorable impression of the procedure with little significant change in their sexual habits. Eight per cent of patients expressed regret at not being able to have more children. The frequency of coitus remained largely unchanged.

Diagnostic hysteroscopy.

Diagnostic hysteroscopy was performed on 100 patients. The most frequent indication was abnormal uterine bleeding. In premenopausal women, submucous fibroids were the main findings and in post-menopausal women, 59 per cent had an atrophic endometrium. Precise localization of the missing intrauterine contraceptive devices was achieved in all cases. Hysteroscopy improved diagnostic accuracy and reduced the need for blind curettage.

Hysteroscopic assessment of abnormal uterine bleeding in users of the intrauterine contraceptive device.

Sixty users of the IUD who complained of abnormal menstrual blood loss were evaluated by hysteroscopy, and the findings were compared with a matched group who had this investigation for "missing strings". Submucous fibroids and endometritis were more frequent in the study group whereas malposition of the IUD was commoner in the controls (p < 0.05).

PIP: Hysteroscopic findings in 60 Jamaican IUD users who complained of excessive bleeding revealed a high incidence of submucous fibroids and inflammatory lesions. Study subjects, recruited from the family planning clinic at the University of the West Indies, were using the Lippes Loop C or D; the average duration of use was 3.6 years. 60 matched controls undergoing hysteroscopic evaluation of missing IUD strings served as controls. Uterine abnormalities were detected in 42 of the 60 cases compared with only 26 of 60 controls (p 0.05). Submucous fibroids were identified in 16 cases and only 6 controls; endometriosis was present in 18 cases and 14 controls, while 4 cases and 2 controls had "suspicious" endometrium. Malposition of the IUD or penetration of the uterine wall was present in 14 cases compared to 36 controls. Until the levonorgestrel-releasing IUD (associated with reduced menstrual blood loss) becomes available in Jamaica, use of hysteroscopy is recommended to evaluate excessive bleeding in IUD users.

Radical vulvectomy--a 21-year review.

The factors surrounding patients subjected to radical vulvectomy were examined. Most patients were over the age of 40 years. The standard butterfly incision was used in all but 2 cases. The histology in all cases was invasive squamous cell carcinoma. The main complications were primary haemorrhage, urinary tract infection and wound dehiscence. The mean hospital stay was 50 days and the mortality rate was 4 per cent.

Chlamydial infections in selected populations in Jamaica.

The importance of Chlamydia trachomatis as a cause of genital tract infection in Caribbean countries is largely unknown. Two hundred and sixteen cervical and urethral specimens were collected from patients with cervicitis and urethritis attending a Sexually Transmitted Diseases (STD) Clinic, a Gynaecology Clinic and a Family Planning Clinic in Kingston. Specimens were tested for chlamydiae by direct immunofluorescence and cell culture methods. They were also investigated for N. gonorrhoeae infections. Seventy-two of 138 patients (52.2%) at the STD Clinic were positive for chlamydiae; 28 of 50 (56.0%) from the Gynaecology Clinic and 11 of 28 (39.3%) from the Family Planning Clinic were positive. The prevalence of C. trachomatis (52.3%) was higher than that of N. gonorrhoeae (11.1%) in all groups. The results indicate that C. trachomatis is a common cause of genital tract infections in Jamaica.

Large loop excision of the transformation zone (LLETZ)--an alternative treatment for cervical intraepithelial neoplasia.

The technique of large loop excision of the transformation zone (LLETZ) as an alternative to destructive/ablative methods of treatment of cervical intraepithelial neoplasia (CIN) such as cryotherapy, laser vaporization and cone biopsy of uterine cervix is assessed. Forty-five patients underwent this procedure for either diagnostic or therapeutic reasons. It was well-tolerated, and minor bleeding occurred in 4.4% of patients. The quality of the histological specimen was excellent in all cases, only two showing evidence of charring artefacts. In 11 patients (24.4%), a more serious lesion was detected than that found at punch biopsy of the cervix. This method offers a cheaper and more effective alternative to laser vaporization and combines the benefits of the gold standard cone biopsy of the cervix with that of local ablative techniques.

The effect of user fees on the utilization of family planning services. A clinical study.

A new fee structure was introduced to the Advanced Training and Research in Fertility Management Unit in 1992. The study looked at the effect of the new fees on attendance and the choice of contraceptive methods through an examination of clinical records and a questionnaire survey. There was a decline in attendance of roughly 28 per cent between 1992 and 1993. The decline affected mainly new clients and those who accepted injectables. A reduction in the price of injectables is suggested since the fee for this short-term method is more in line with those charged for long-term and permanent methods.

PIP: In order to foster the self-sustainability of its family planning (FP) program, Jamaica has introduced user fees for previously free FP services. In 1992, donations were solicited for injectables and sterilization. By January 1993, a fee of J $200 was set for sterilization, and fees for other services were introduced. A study was undertaken to 1) examine the effect of the new fee structure on clinic attendance; 2) determine the extent to which the fees might have encouraged a shift to other methods; and 3) establish a range of affordable prices for current users. Data were collected from clinic attendance records for January-April of 1990-1992 and compared to the same period in 1993. A 20% sample of clients (n = 1002) attending in January of each year was followed for 4 months to allow comparisons of method changes. Finally a questionnaire was administered to a 25% sample of daily users (n = 200) over 4 weeks in February 1993 to determine affordable fees. It was found that there was a 28% decline in attendance in 1993 over 1992 despite a temporary halt in sterilizations in early 1992. The number of new clients in 1993 increased but failed to reach the 1990 level. The number of old clients attending in 1993 was the lowest for the 4 years. In early 1992, there was a shortage of injectable contraceptives. Despite this, injectables were used 7% more in 1992 than in 1993 when a fee of J $100 was established. Almost a third of the sample of new clients accepted sterilization in 1993, and all of the women kept their appointments unlike previous experience (perhaps out of fear of a higher fee in the future). 1993 also saw the highest percentage of drop-outs of any year studied. Current prices charged by the clinic for oral contraceptives, injectables, and sterilization were acceptable to 85, 23, and 13% of the women, respectively. The substantial drop in clientele over a single year affected mainly clients using injectables. A reduction in the price of this method seems justified not only by the loss of clients but also because the fee for this method is higher than that for longterm or permanent methods. Costs could also be subsidized by other strategies, such as allowing higher income couples to pay a fee to secure an appointment instead of having to wait. Future price increases should be gradual, since increases of 10% a few times a year are less likely to result in patient loss.

Show, no show and sterilization.

The study investigates the factors involved in the decision of a sample of women to break appointments for sterilizations at the Fertility Management Unit of the University of the West Indies. A case control study involved 50 women who did not show up (no-shows) and an equal number who did show up (shows) over the same period. The no-shows had spent a shorter time in their current union than the shows, and some had no children for their partners at the time the appointments were made. Marriage was the single most important event that would encourage the no-shows to consider sterilization in the future. As long as poor women see child bearing as a precondition for financial assistance from spouses, they will hesitate to give up this capability.

PIP: As part of a research program to identify the barriers to increasing the acceptance of sterilization in the West Indies, a study was undertaken to determine why an estimated 16% of annual registrants for sterilization failed to keep their appointments (no-shows). From 300 no-shows, a random sample of 50 was interviewed and matched for year of registration, age, parity, marital and economic status, and geographic area with a control sample of 50 sterilized women. The most important reason for considering sterilization for all of the women was the desire to have no more children. The no-shows exhibited a lack of self-motivation, citing friends and medical personnel as motivators, and in no case did motivation come from the partner. The no-shows cited partner-related reasons and fear as causing them to break the appointments. Many women were ready for sterilization but were unable to discuss the topic with their partners. Among the sterilized women, 2 regretted the procedure. Among the no-shows, there had been 8 pregnancies, 3 of which were terminated, and 7 women were attempting to become pregnant. Recent research in the Caribbean suggests that improving women's status plays a more important role in reducing fertility than that played by family planning programs. As long as childbearing is seen as a precondition for receiving financial assistance from a man, it will continue.

Cervical pregnancy. Case report and literature review.

Cervical pregnancy is an uncommon life threatening form of ectopic pregnancy that is associated with the unexpected occurrence of uncontrollable haemorrhage from the cervix. To avoid hysterectomy and to maintain fertility, several conservative methods of termination have been used. We present herein, one such case which relates to a young woman who had successful conservative management of a cervical pregnancy using vasopressin infiltration of the cervix, a McDonald cerclage and cervical curettage followed by balloon tamponade. Subsequently, she became pregnant again with a normal intra-uterine pregnancy and had a successful vaginal delivery.

Successful pregnancy after hysteroscopic metroplasty.

Congenital anomalies of the uterus have been estimated to affect 0.06-10% of women. Uterine septae account for approximately 80% to 90% of these anomalies and is also associated with the poorest reproductive outcome. Pregnancy loss in patients with a septate uterus has been reported to be as high as 90% after other causes for miscarriages have been excluded. We present here the first experience in Jamaica, of a successful pregnancy outcome after hysteroscopic metroplasty in a woman with a septate uterus and three previous miscarriages.

Prevalence of viral and bacterial sexually transmitted pathogens in Jamaican pregnant women.

In this study we investigated the prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, human immunodeficiency virus type I (HIV-I), human T cell lymphotropic virus type 1 (HTLV-1) and hepatitis B virus (HBV) infections in 200 pregnant women attending antenatal clinics at the University Hospital of the West Indies. 19% of the women had at least one pathogen: C. trachomatis was found in 16%, HTLV-1 in 2%, HIV-1, HBV and N. gonorrhoeae each in 0.5% C. trachomatis infection was more prevalent in women less than 20 years of age (31%) than in those 20 years and older (16%; OR = 0.43; chi 2 = 5.66; p < 0.05). The study demonstrates the need for identification of sexually transmitted pathogens in antenatal women for syndromic management of genital infections as part of the strategy for prevention and control of HIV/AIDS (acquired immunodeficiency syndrome) in Jamaica.