Combined hormonal contraceptive (CHC) use among obese women and contraceptive effectiveness: a systematic review.

OBJECTIVE: To evaluate from the literature whether combined hormonal contraception (CHC), including combined oral contraception pills (COCs), transdermal patch, vaginal ring or combined injectables, have different effectiveness or failure rates by body weight or body mass index (BMI). STUDY DESIGN: We searched PubMed and the Cochrane Library databases for all articles in all languages published between inception and February 2016, for evidence relevant to body weight or BMI, CHC use and contraceptive effectiveness. The quality of each individual study was assessed using the system for evaluating evidence developed by the United States Preventive Services Task Force. RESULTS: From 2874 articles, we identified 15 reports for inclusion, all of fair to poor quality. Fourteen studies measured the association of obesity status and contraceptive failure among COC users. Three fair quality and one poor quality study reported increased COC failure among a heterogeneous population of overweight and obese women compared with normal weight women, while eight fair quality and two poor quality studies did not find an association. Two fair quality studies reported on contraceptive transdermal patches. One pooled analysis described a higher proportion of pregnancies among women using the patch who weighed ≥90 kg; another secondary analysis suggested BMI>30 was associated with increased failure. No studies directly compared contraceptive effectiveness using the combined vaginal ring or combined injectable. CONCLUSION: Current available evidence addressing the risk of CHC failure in obese compared to normal weight women is limited to fair and poor quality studies. Studies of COCs show mixed results, though absolute differences in COC failure by body weight and BMI are small. Based on limited evidence, it appears that increasing body weight and BMI may contribute to decreasing contraceptive patch effectiveness.

Evaluating the Ozioma cancer news service: a community randomized trial in 24 U.S. cities.

OBJECTIVE: This community randomized trial evaluated effects of the Ozioma News Service on the amount and quality of cancer coverage in Black weekly newspapers in 24 U.S. cities. METHOD: We created and operated Ozioma, the first cancer information news service specifically for Black newspapers. Over 21 months, Ozioma developed community- and race-specific cancer news releases for each of 12 Black weekly newspapers in intervention communities. Cancer coverage in these papers was tracked before and during the intervention and compared to 12 Black newspapers in control communities. RESULTS: From 2004 to 2007, we coded 9257 health and cancer stories from 3178 newspaper issues. Intervention newspapers published approximately 4 times the expected number of cancer stories compared to control newspapers (p(12,21 mo)<.01), and also saw an increase in graphics (p(12,21 mo)<.01), local relevance (p(12 mo)=.01), and personal mobilization (p(12 mo)<.10). However, this increased coverage supplanted other health topics and had smaller graphics (NS), had less community mobilization (p(21 mo)=.01), and is less likely to be from a local source (NS). CONCLUSION: Providing news releases with localized and race-specific features to minority-serving media outlets can increase the quantity of cancer coverage. Results are mixed for the journalistic and public health quality of this increased cancer coverage in Black newspapers.

Safety of contraceptive methods for women with rheumatoid arthritis: a systematic review.

BACKGROUND: Women with rheumatoid arthritis (RA) and their clinicians may have unique concerns about certain methods of contraception. STUDY DESIGN: We conducted a systematic review of the literature in the MEDLINE database through February 2009 for peer-reviewed journal articles on use of any method of contraception, or progestins or estrogens, and progression of RA. RESULTS: We identified eight articles that met the inclusion criteria: six examined oral contraceptives (OCs), one progesterone, and one estrogen. We found no studies on other methods of contraception. For OCs, no consistent pattern of improvement or worsening of disease emerged and most patients showed little change in RA symptoms. We saw little improvement in the studies examining progesterone and estrogen. CONCLUSION: Although sparse and based primarily on older studies of poor quality, this information suggests that OC use is unlikely to affect RA disease progression. Research is needed on other forms of contraception, such as DMPA and IUD.

Contraceptive use among women with inflammatory bowel disease: A systematic review.

BACKGROUND: There are theoretical concerns that use of hormonal contraceptives by women with inflammatory bowel disease (IBD) might increase disease relapse and risk of other adverse health outcomes, including thrombosis. In addition, there are concerns that IBD-related malabsorption might decrease the effectiveness of orally ingested contraceptives. The objective of this systematic review was to evaluate the evidence on the safety and effectiveness of contraceptive use among women with IBD. STUDY DESIGN: We searched the PubMed database for peer-reviewed articles relevant to contraceptive use and IBD that were published in any language from inception of the database through February 2009. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. RESULTS: From 207 articles, we identified 10 studies that met our inclusion criteria. Evidence from five cohort studies (Level II-2, fair to good) suggests no increased risk of IBD relapse with use of oral contraceptives. Evidence from two pharmacokinetic studies (not graded) suggests that women with mild ulcerative colitis and those with an ileostomy following a proctocolectomy with small ileal resections have plasma concentrations of steroid hormones after oral ingestion of higher doses of combined oral contraceptives that are similar to the plasma concentrations among healthy volunteers. No studies were found that examined the risk of thrombosis among women with IBD who used hormonal contraceptives. CONCLUSIONS: Limited evidence suggests there is no increased risk of disease relapse among women with IBD who use oral contraceptives, and there seem to be no differences in the absorption of higher-dose combined oral contraceptives between women with mild ulcerative colitis and small ileal resections and healthy women.

Safety of contraceptive use among women with peripartum cardiomyopathy: a systematic review.

STUDY DESIGN: Women with peripartum cardiomyopathy (PPCM) have significant health risks during subsequent pregnancies and therefore have a critical need for safe and effective contraception. This systematic review examines evidence regarding the safety of contraceptive use among women with PPCM. METHODS: We searched the PubMed database for all primary research articles published through February 2009 that addressed the safety of any contraceptive method among women with PPCM or other cardiomyopathy of any type. RESULTS: Of 110 articles that addressed contraceptive safety among women with cardiac disease, three met our inclusion criteria. In these three studies, which included a total of five women with cardiomyopathy, though not specifically PPCM, cases of hypertension, transient ischemic attack (TIA), thromboembolism or heart failure were found among women with cardiac disease who used hormonal methods of contraception including combined oral contraceptives, progestin-only pills and depot medroxyprogesterone acetate. None of the studies reported any cases of cardiovascular complications or infective endocarditis among women with cardiac disease who used intrauterine devices (IUDs). CONCLUSIONS: We found no data concerning the safety of contraceptive use among women with PPCM, though we did find limited evidence of hypertension, TIA, thromboembolism and heart failure among women with cardiac disease who used hormonal methods of contraception. None of the studies reported any cases of cardiovascular complications or infective endocarditis among women with cardiac disease who used IUDs.

Contraceptive use among women with a history of bariatric surgery: a systematic review.

BACKGROUND: Weight loss after bariatric surgery often improves fertility but can pose substantial risks to maternal and fetal outcomes. Women who have undergone a bariatric surgical procedure are currently advised to delay conception for up to 2 years. STUDY DESIGN: We conducted a systematic review of the literature, from database (PubMed) inception through February 2009, to evaluate evidence on the safety and effectiveness of contraceptive use among women with a history of bariatric surgery. RESULTS: From 29 articles, five met review inclusion criteria. One prospective, noncomparative study reported 2 pregnancies among 9 (22%) oral contraceptive (OC) users following biliopancreatic diversion, and one descriptive study reported no pregnancies among an unidentified number of women taking OCs following laparoscopic adjustable gastric banding. Of two pharmacokinetic studies, one found lower plasma levels of norethisterone and levonorgestrel among women having had a jejunoileal bypass, as compared to nonoperated, normal-weight controls. The other study found no difference in plasma levels of D-norgestrel between women having a jejunoileal bypass of either 1:3 or 3:1 ratio between the length of jejunum and ileum left in continuity, but women with a 1:3 ratio had significantly higher plasma levels of D-norgestrel than extremely obese controls not operated upon. CONCLUSIONS: Evidence regarding OC effectiveness following a bariatric surgical procedure is quite limited, although no substantial decrease in effectiveness was identified from available studies. Evidence on failure rates for other contraceptive methods and evidence on safety for all contraceptive methods was not identified.

Contraceptive use among solid organ transplant patients: a systematic review.

BACKGROUND: Women undergoing solid organ transplantation are advised to avoid pregnancy for up to 24 months following transplant surgery. STUDY DESIGN: We conducted a systematic review of the literature, from database (PubMed) inception through February 2009, to evaluate evidence on the safety and effectiveness of contraceptive use among women having undergone solid organ transplantation. RESULTS: From 643 articles, eight articles from seven studies satisfied review inclusion criteria; six articles pertained to kidney transplant patients, and two reported on liver transplant patients. Two reports of one prospective cohort of 36 kidney transplant recipients taking combined oral contraceptives (COCs) or using the transdermal contraceptive patch reported no significant changes in biochemical measures after 18 months of use for either group, although 13 women modified antihypertensive medication, and two women discontinued the study because of serious medical complications. Four case reports of five kidney recipients using intrauterine devices reported inconsistent findings, including both beneficial health effects and contraceptive failures. One retrospective, noncomparative study of 15 liver transplant recipients using COCs or the transdermal contraceptive patch found no significant changes in any biochemical measures obtained, no discontinuations or severe complications and no pregnancies after a 12-month follow up. One case report of a liver transplant recipient on cyclosporine and prednisone documented the development of cholestasis associated with high-dose (50 mcg ethinyl estradiol) COC use as treatment for heavy uterine bleeding. CONCLUSIONS: Very limited evidence on COC and transdermal contraceptive patch use among kidney and liver transplant recipients indicated no pregnancies and no overall changes in biochemical measures. Excluding case reports, evidence on other contraceptive methods or contraception among other types of solid organ transplants was not identified.

When can a woman have repeat progestogen-only injectables--depot medroxyprogesterone acetate or norethisterone enantate?

BACKGROUND: Currently, there is a generally accepted 2-week grace period for women returning early/late for reinjection of either depot medroxyprogesterone acetate (DMPA) or norethisterone enantate (NET-EN). This systematic review evaluates the evidence regarding return to fertility and ovulation after injection of a progestogen-only contraceptive. STUDY DESIGN: We searched the PubMed database to identify all relevant evidence published in peer-reviewed journals from database inception through November 2008 regarding timing of fertility and return to ovulation after the last injection of DMPA or NET-EN. RESULTS: We identified 20 articles, 10 on DMPA use, eight on NET-EN use and two examining both types of injectables. Six studies examining time to pregnancy after discontinuing DMPA or NET-EN reported that pregnancy rates during the currently recommended 2-week grace period were zero or very low. Studies of return to ovulation indicated a wide variation in time to ovulation post-injection with the majority ranging from 15-49 weeks from the last injection (for DMPA) and 4.9-24.3 weeks from the last injection (for NET-EN). Limitations of this body of evidence include small sample sizes, lack of data on the main outcome of interest (time to pregnancy) and inconsistency in measurement of ovulation, a surrogate measurement for pregnancy risk. CONCLUSION: Studies evaluating time to pregnancy after last injection of DMPA or NET-EN reported extremely low pregnancy rates during the 2-week interval following the reinjection date; extremely low pregnancy rates for DMPA were also reported for 4 weeks following the reinjection date. Studies of return to ovulation after last injection of DMPA generally found that the earliest ovulation did not occur until several months after the last injection while studies of NET-EN reported ovulations around (or even before) the time for reinjection.