Contraceptive features preferred by women at high risk of unintended pregnancy.

CONTEXT: Available contraceptives are not meeting many women's needs, as is evident by high levels of typical-use failure, method switching and discontinuation. To improve women's satisfaction with contraceptive methods, determining what features they prefer and how these preferences are satisfied by available methods and methods under development is crucial. METHODS: The importance of 18 contraceptive method features was rated by 574 women seeking abortions--a group at high risk of having unprotected intercourse and unintended pregnancies--at six clinics across the United States in 2010. For each available and potential method, the number of features present was assessed, and the percentage of these that were "extremely important" to women was calculated. RESULTS: The three contraceptive features deemed extremely important by the largest proportions of women were effectiveness (84%), lack of side effects (78%) and affordability (76%). For 91% of women, no method had all of the features they thought were extremely important. The ring and the sponge had the highest percentage of features that women deemed extremely important (67% each). Some streamlined modes of access and new contraceptive technologies have the potential to satisfy women's preferences. For example, an over-the-counter pill would have 71% of extremely important features, and an over-the-counter pericoital pill, 68%; currently available prescription pills have 60%. CONCLUSION: The contraceptive features women want are largely absent from currently available methods. Developing and promoting methods that are more aligned with women's preferences presumably could help increase satisfaction and thereby encourage consistent and effective use.

Attitudes toward unprotected intercourse and risk of pregnancy among women seeking abortion.

BACKGROUND: Despite the high prevalence of unintended pregnancies caused by lack of contraceptive use, little is known about women's reasons for or attitudes toward unprotected intercourse (UI). METHODS: We included 562 women seeking pregnancy termination at six U.S. abortion clinics who completed surveys on their experiences and attitudes about UI, knowledge of the risk of conception, and willingness to engage in UI in the future. RESULTS: Respondents reported an average of 18 acts of UI leading up to conception. The most commonly reported reasons for UI were thinking one could not get pregnant (42%), difficulties procuring a contraceptive method (40%), and not planning to have sex (38%). When asked about attitudes toward UI, 48% reported that UI feels better or more natural, 36% said it is okay to have UI once in a while or at certain times of the month, and 28% cited partner or relationship benefits as a reason to engage in UI. In addition, 23% said they were somewhat or extremely likely to engage in UI in the next 3 months. Younger women (<20 years), women who named partner or relationship benefits to UI, and women who underestimated the risk of conception were significantly more willing to engage in UI in the next 3 months. CONCLUSIONS: Given the prevalence of risk taking and the perceived benefits of UI, contraceptives, particularly long-acting methods, need to be made easy to procure and use. The success of coital specific methods may be limited by women underestimating the risk of conception.

Predictors of long-term outcome after laparoscopic esophagomyotomy and Dor fundoplication for achalasia.

OBJECTIVE: To identify predictors of long-term outcome of laparoscopic Heller myotomy for achalasia, including predictors of heartburn and recurrent dysphagia, which occasionally develop postoperatively. DESIGN: Retrospective review using interviews of patients. SETTING: Academic university hospital. PATIENTS: One hundred sixty-five patients with achalasia who underwent a laparoscopic esophagomyotomy and Dor fundoplication. MAIN OUTCOME MEASURES: Dysphagia and heartburn before and after the operation were assessed on a 4-point Likert scale, as were postoperative dilations, reoperations, and antacid use. Potential predictors were age, race, sex, body mass index, weight loss, duration of symptoms, manometry findings, esophageal diameter, previous treatment, and operative technique. RESULTS: Follow-up averaged 62 (range, 1-174) months. Dysphagia frequency was once a week or less in 128 patients (78%), several times per week in 25 (15%), and daily in 12 (7%). Satisfaction scores averaged 3.7 on a 4-point scale. Thirty patients (18%) required a postoperative dilation, and 6 (4%) underwent another operation. The only predictor of postoperative dysphagia was duration of symptoms longer than 10 years (odds ratio, 0.2; P = .03). Preoperative dilations predicted the need for postoperative dilations (odds ratio, 2.4; P = .03). Only 20 patients (12%) reported heartburn more than once weekly, although 75 (45%) reported taking antacids. No variable predicted postoperative heartburn or antacid use. CONCLUSIONS: Long-term outcomes after laparoscopic esophagomyotomy were excellent across a wide spectrum of disease severity and presentations. Previous treatments, such as balloon dilation or botulinum toxin (Botox) injection, did not portend worse outcomes. When the myotomy was extended 2 cm onto the stomach and a Dor fundoplication was performed, severe heartburn was rare.

Excellent outcomes of laparoscopic esophagomyotomy for achalasia in patients older than 60 years of age.

BACKGROUND: The effectiveness of an esophagomyotomy for dysphagia in elderly patients with achalasia has been questioned. This study was designed to provide an answer. METHODS: A total of 162 consecutive patients with achalasia who had a laparoscopic myotomy and Dor fundoplication and who were available for follow-up interview were divided by age: < 60 years (range, 14-59; 118 patients), and ≥ 60 years (range, 60-93; 44 patients). Primary outcome measures were severity of dysphagia, regurgitation, heartburn, and chest pain before and after the operation as assessed on a four-point Likert scale, and the need for postoperative dilatation or revisional surgery. RESULTS: Follow-up averaged 64 months. Older patients had less dysphagia (mean score 3.6 vs. 3.9; P < 0.01) and less chest pain (1.0 vs. 1.8; P < 0.01). Regurgitation (3.0 vs. 3.2; P = not significant (NS)) and heartburn (1.6 vs. 2.0, P = NS) were similar. Older patients were no different in degree of esophageal dilation, manometric findings, number of previous pneumatic dilatations, or previous botulinum toxin therapy. None of the older patients had previously had an esophagomyotomy, whereas 14% of younger patients had (P < 0.01). After laparoscopic myotomy, older patients had better relief of dysphagia (mean score 1.0 vs 1.6; P < 0.01), less heartburn (0.8 vs. 1.1; P = 0.03), and less chest pain (0.2 vs. 0.8, P < 0.01). Complication rates were similar. Older patients did not require more postoperative dilatations (22 patients vs. 10 patients; P = 0.7) or revisional surgery for recurrent or persistent symptoms (3 vs. 1 patients; P = 0.6). Satisfaction scores did not differ, and more than 90% of patients in both groups said in retrospect they would have undergone the procedure if they had known beforehand how it would turn out. CONCLUSIONS: This retrospective review with long follow-up supports laparoscopic esophagomyotomy as first-line therapy in older patients with achalasia. They appeared to benefit even more than younger patients.