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1.
Artigo em Inglês | MEDLINE | ID: mdl-33179265

RESUMO

INTRODUCTION: We aimed to give a global overview of trends in access to sexual and reproductive health and rights (SRHR) during the coronavirus disease 2019 (COVID-19) pandemic and what is being done to mitigate its impact. MATERIAL AND METHODS: We performed a descriptive analysis and content analysis based on an online survey among clinicians, researchers, and organizations. Our data were extracted from multiple-choice questions on access to SRHR services and risk of SRHR violations, and written responses to open-ended questions on threats to access and required response. RESULTS: The survey was answered by 51 people representing 29 countries. Eighty-six percent reported that access to contraceptive services was less or much less because of COVID-19, corresponding figures for surgical and medical abortion were 62% and 46%. The increased risk of gender-based and sexual violence was assessed as moderate or severe by 79%. Among countries with mildly restrictive abortion policies, 69% had implemented changes to facilitate access to abortion during the pandemic, compared with none among countries with severe restrictions (P < .001), 87.5% compared with 46% had implemented changes to facilitate access to contraception (P = .023). The content analysis showed that (a) prioritizations in health service delivery at the expense of SRHR, (b) lack of political will, (c) the detrimental effect of lockdown, and (d) the suspension of sexual education, were threats to SRHR access (theme 1). Requirements to mitigate these threats (theme 2) were (a) political will and support of universal access to SRH services, (b) the sensitization of providers, (c) free public transport, and (d) physical protective equipment. A contrasting third theme was the state of exception of the COVID-19 pandemic as a window of opportunity to push forward women's health and rights. CONCLUSIONS: Many countries have seen decreased access to and increased violations of SRHR during the COVID-19 pandemic. Countries with severe restrictions on abortion seem less likely to have implemented changes to SRHR delivery to mitigate this impact. Political will to support the advancement of SRHR is often lacking, which is fundamental to ensuring both continued access and, in a minority of cases, the solidification of gains made to SRHR during the pandemic.

2.
Obstet Gynecol ; 132(4): 888-894, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30130351

RESUMO

OBJECTIVE: To evaluate whether ulipristal acetate reduces the number of bleeding days in etonogestrel implant users in a 30-day period as compared with placebo. METHODS: We performed a single-center, randomized, double-blind, placebo-controlled trial. Eligible participants were women aged 18-45 years with an etonogestrel implant in place for greater than 90 days and less than 3 years who reported greater than one bleeding episode in a 24-day period. Enrolled participants were randomized to receive 15 mg ulipristal acetate compared with an identical-appearing placebo daily for 7 days. Participants completed daily bleeding diaries using automated text messaging to evaluate whether ulipristal acetate reduces the number of bleeding days as compared with placebo. Secondary outcomes included participant satisfaction with bleeding and the effect of ulipristal acetate on ovulation status. A sample size of 52 per group (n=104) was planned, calculated with an effect size of a 30% reduction in bleeding days, SD of 10 days, and dropout of 15%. Our study was terminated early (N=65) as a result of a U.S. Food and Drug Administration hold, but power was sufficient for analysis. The effect of ulipristal acetate on ovulatory potential was evaluated in a subset with weekly serum progesterone. RESULTS: From May 2017 to January 2018, 65 women were allocated to receive 15 mg ulipristal acetate (n=32) or placebo (n=33) daily for 7 days. Demographic characteristics were similar between groups. Women randomized to ulipristal acetate reported 5 fewer days of bleeding over a 30-day reference period after treatment (P=.002). At the conclusion of the 30-day follow-up period, women in the ulipristal acetate group were more satisfied with their bleeding profile than the placebo group (87.5% vs 60%, respectively; P<.001). Serum progesterone levels were nonovulatory in a subset of each group (placebo group range: less than 0.2-1.3 ng/mL; ulipristal acetate group range: less than 0.2-4.4 ng/mL). CONCLUSION: Ulipristal acetate is well-tolerated and reduced the number of bleeding days in etonogestrel implant users in our study. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03118297.


Assuntos
Anticoncepcionais Femininos/efeitos adversos , Desogestrel/efeitos adversos , Norpregnadienos/uso terapêutico , Hemorragia Uterina/tratamento farmacológico , Adulto , Anticoncepcionais Femininos/administração & dosagem , Desogestrel/administração & dosagem , Feminino , Humanos , Hemorragia Uterina/induzido quimicamente , Adulto Jovem
3.
Am J Obstet Gynecol ; 217(6): 672.e1-672.e6, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28919400

RESUMO

BACKGROUND: Use of more effective contraception may lead to less condom use and increased incidence of sexually transmitted infection. OBJECTIVE: The objective of this study was to compare changes in condom use and incidence of sexually transmitted infection acquisition among new initiators of long-acting reversible contraceptives to those initiating non-long-acting reversible contraceptive methods. STUDY DESIGN: This is a secondary analysis of the Contraceptive CHOICE Project. We included 2 sample populations of 12-month continuous contraceptive users. The first included users with complete condom data (baseline, and 3, 6, and 12 months) (long-acting reversible contraceptive users: N = 2371; other methods: N = 575). The second included users with 12-month sexually transmitted infection data (long-acting reversible contraceptive users: N = 2102; other methods: N = 592). Self-reported condom use was assessed at baseline and at 3, 6, and 12 months following enrollment. Changes in condom use and incident sexually transmitted infection rates were compared using χ2 tests. Risk factors for sexually transmitted infection acquisition were identified using multivariable logistic regression. RESULTS: Few participants in either group reported consistent condom use across all survey time points and with all partners (long-acting reversible contraceptive users: 5.2%; other methods: 11.3%; P < .001). There was no difference in change of condom use at 3, 6, and 12 months compared to baseline condom use regardless of method type (P = .65). A total of 94 incident sexually transmitted infections were documented, with long-acting reversible contraceptive users accounting for a higher proportion (3.9% vs 2.0%; P = .03). Initiation of a long-acting reversible contraceptive method was associated with increased sexually transmitted infection incidence (odds ratio, 2.0; 95% confidence ratio, 1.07-3.72). CONCLUSION: Long-acting reversible contraceptive initiators reported lower rates of consistent condom use, but did not demonstrate a change in condom use when compared to preinitiation behaviors. Long-acting reversible contraceptive users were more likely to acquire a sexually transmitted infection in the 12 months following initiation.


Assuntos
Infecções por Chlamydia/epidemiologia , Preservativos/estatística & dados numéricos , Gonorreia/epidemiologia , Contracepção Reversível de Longo Prazo , Doenças Sexualmente Transmissíveis/epidemiologia , Tricomoníase/epidemiologia , Adolescente , Adulto , Estudos de Casos e Controles , Infecções por Chlamydia/prevenção & controle , Estudos de Coortes , Anticoncepção/métodos , Feminino , Gonorreia/prevenção & controle , Humanos , Incidência , Modelos Logísticos , Análise Multivariada , Estudos Prospectivos , Doenças Sexualmente Transmissíveis/prevenção & controle , Tricomoníase/prevenção & controle , Adulto Jovem
4.
Obstet Gynecol ; 130(3): 609-615, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28796678

RESUMO

OBJECTIVE: To evaluate the association of low socioeconomic status as an independent risk factor for unintended pregnancy. METHODS: We performed a secondary analysis of data from the Contraceptive CHOICE project. Between 2007 and 2011, 9,256 participants were recruited and followed for up to 3 years. The primary outcome of interest was unintended pregnancy; the primary exposure variable was low socioeconomic status, defined as self-report of either receiving public assistance or having difficulty paying for basic necessities. Four contraceptive groups were evaluated: 1) long-acting reversible contraceptive method (hormonal or copper intrauterine device or subdermal implant); 2) depot medroxyprogesterone acetate injection; 3) oral contraceptive pills, a transdermal patch, or a vaginal ring; or 4) other or no method. Confounders were adjusted for in the multivariable Cox proportional hazard model to estimate the effect of socioeconomic status on risk of unintended pregnancy. RESULTS: Participants with low socioeconomic status experienced 515 unintended pregnancies during 14,001 women-years of follow-up (3.68/100 women-years; 95% CI 3.37-4.01) compared with 200 unintended pregnancies during 10,296 women-years (1.94/100 women-years; 95% CI 1.68-2.23) among participants without low socioeconomic status. Women with low socioeconomic status were more likely to have an unintended pregnancy (unadjusted hazard ratio [HR] 1.8, 95% CI 1.5-2.2). After adjusting for age, education level, insurance status, and history of unintended pregnancy, low socioeconomic status was associated with an increased risk of unintended pregnancy (adjusted HR 1.4, 95% CI 1.1-1.7). CONCLUSION: Despite the removal of cost barriers, low socioeconomic status is associated with a higher incidence of unintended pregnancy.


Assuntos
Anticoncepção/métodos , Tomada de Decisões , Gravidez não Planejada , Adulto , Anticoncepção/economia , Grupos Étnicos , Feminino , Humanos , Indiana/epidemiologia , Serviços de Saúde Materna , Gravidez , Fatores de Risco , Fatores Socioeconômicos , Adulto Jovem
6.
Am J Obstet Gynecol ; 216(6): 586.e1-586.e6, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28147241

RESUMO

BACKGROUND: The subdermal contraceptive implant and the 52-mg levonorgestrel intrauterine device are currently Food and Drug Administration approved for 3 and 5 years of use, respectively. Limited available data suggested both of these methods are effective beyond that time. Demonstration of prolonged effectiveness will improve the cost-effectiveness of the device, and potentially patient continuation and satisfaction. OBJECTIVE: We sought to evaluate the effectiveness of the contraceptive implant and the 52-mg hormonal intrauterine device in women using the method for 2 years beyond the current Food and Drug Administration-approved duration. STUDY DESIGN: We initiated this ongoing prospective cohort study in January 2012. We are enrolling women using the contraceptive implant or 52-mg levonorgestrel intrauterine device for a minimum of 3 and 5 years, respectively (started intrauterine device in ≥2007 or implant in ≥2009). Demographic and reproductive health histories, as well as objective body mass index, were collected. Implant users were offered periodic venipuncture for analysis of serum etonogestrel levels. The primary outcome, unintended pregnancy rate, was calculated per 100 woman-years. We analyzed baseline demographic characteristics using χ2 test and Fisher exact test, and compared serum etonogestrel levels stratified by body mass index using the Kruskal-Wallis test. RESULTS: Implant users (n = 291) have contributed 444.0 woman-years of follow-up. There have been no documented pregnancies in implant users during the 2 years of postexpiration follow-up. Calculated failure rates in the fourth and fifth years for the implant are calculated as 0 (1-sided 97.5% confidence interval, 0-1.48) per 100 woman-years at 4 years and 0 (1-sided 97.5% confidence interval, 0-2.65) per 100 woman-years at 5 years. Among 496 levonorgestrel intrauterine device users, 696.9 woman-years of follow-up have been completed. Two pregnancies have been reported. The failure rate in the sixth year of use of the levonorgestrel intrauterine device is calculated as 0.25 (95% confidence interval, 0.04-1.42) per 100 woman-years; failure rate during the seventh year is 0.43 (95% confidence interval, 0.08-2.39) per 100 woman-years. Among implant users with serum etonogestrel results, the median etonogestrel level was 207.7 pg/mL (range 63.8-802.6 pg/mL) at the time of method expiration, 166.1 pg/mL (range 67.9 25.0-470.5 pg/mL) at the end of the fourth year, and 153.0 pg/mL (range 72.1-538.8 pg/mL) at the end of the fifth year. Median etonogestrel levels were compared by body mass index at each time point and a statistical difference was noted at the end of 4 years of use with overweight women having the highest serum etonogestrel (195.9; range 25.0-450.5 pg/mL) when compared to normal (178.9; range 87.0-463.7 pg/mL) and obese (137.9; range 66.0-470.5 pg/mL) women (P = .04). CONCLUSION: This study indicates that the contraceptive implant and 52-mg hormonal intrauterine device continue to be highly effective for at least 2 additional years of use. Serum etonogestrel evaluation demonstrates median levels remain above the ovulation threshold of 90 pg/mL for women in all body mass index classes.


Assuntos
Anticoncepcionais Femininos , Desogestrel/administração & dosagem , Implantes de Medicamento , Dispositivos Intrauterinos Medicados , Levanogestrel/administração & dosagem , Adolescente , Adulto , Índice de Massa Corporal , Estudos de Coortes , Desogestrel/efeitos adversos , Feminino , Humanos , Levanogestrel/efeitos adversos , Pessoa de Meia-Idade , Gravidez , Gravidez não Planejada , Estudos Prospectivos , Fatores de Tempo , Estados Unidos , United States Food and Drug Administration , Adulto Jovem
7.
Am J Obstet Gynecol ; 216(5): 443-450, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-27988268

RESUMO

Nearly 20% of women using contraception are using progestin-only contraception, including progestin-only pills, depot-medroxyprogesterone acetate, subdermal etonogestrel implants, and levonorgestrel intrauterine devices. This number will continue to grow with the increased provision of long-acting reversible contraception. Although overall satisfaction among women using progestin-only contraception is high, dissatisfaction and discontinuation may be associated with unscheduled bleeding and spotting. The exact etiology of irregular bleeding associated with progestin-containing contraceptives is not completely understood, yet several mechanisms have been suggested. Several therapies targeting these mechanisms have been evaluated with mixed results. This paper will review the physiology and management of unscheduled bleeding with progestin-containing contraceptives.


Assuntos
Metrorragia/prevenção & controle , Antibacterianos/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Antifibrinolíticos/uso terapêutico , Anticoncepcionais Femininos/uso terapêutico , Anticoncepcionais Orais Hormonais/uso terapêutico , Desogestrel/uso terapêutico , Doxiciclina/uso terapêutico , Estrogênios/uso terapêutico , Feminino , Antagonistas de Hormônios/uso terapêutico , Humanos , Dispositivos Intrauterinos Medicados , Acetato de Medroxiprogesterona/uso terapêutico , Mifepristona/uso terapêutico , Progestinas/uso terapêutico , Tamoxifeno/uso terapêutico , Ácido Tranexâmico/uso terapêutico
8.
Artigo em Inglês | MEDLINE | ID: mdl-29386949

RESUMO

Background: The objective of the study was to estimate the personal usage of long-acting reversible contraception (LARC) among obstetrics and gynecology (Ob/Gyn) residents in the United States and compare usage between programs with and without a Ryan Residency Training Program (Ryan Program), an educational program implemented to enhance resident training in family planning. Materials and methods: We performed a web-based, cross-sectional survey to explore contraceptive use among Ob/Gyn residents between November and December 2014. Thirty-two Ob/Gyn programs were invited to participate, and 24 programs (75%) agreed to participate. We divided respondents into two groups based on whether or not their program had a Ryan Program. We excluded male residents without a current female partner as well as residents who were currently pregnant or trying to conceive. We evaluated predictors of LARC use using bivariate analysis and multivariable Poisson regression. Results: Of the 638 residents surveyed, 384 (60.2%) responded to our survey and 351 were eligible for analysis. Of those analyzed, 49.3% (95% confidence interval [CI]: 44.1%, 54.5%) reported current LARC use: 70.0% of residents in Ryan Programs compared to 26.8% in non-Ryan Programs (RRadj 2.14, 95% CI 1.63-2.80). Residents reporting a religious affiliation were less likely to use LARC than those who described themselves as non-religious (RRadj 0.76, 95% CI 0.64-0.92). Of residents reporting LARC use, 91% were using the levonorgestrel intrauterine device. Conclusion: LARC use in this population of women's health specialists is substantially higher than in the general population (49% vs. 12%). Ob/Gyn residents in programs affiliated with the Ryan Program were more likely to use LARC.

9.
Mo Med ; 114(3): 163-167, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-30228573

RESUMO

To control their reproductive lives, women must have access to all contraceptive methods including the most effective reversible methods, intrauterine devices, and implants. The Contraceptive CHOICE Project, a study of 9,256 women in St. Louis, showed that when barriers to contraception are removed, many women choose intrauterine devices and implants, substantially reducing rates of unintended pregnancy and abortion. This article discusses strategies we learned from the CHOICE Project to improve uptake of the most effective contraceptive methods.


Assuntos
Anticoncepção/métodos , Dispositivos Intrauterinos/estatística & dados numéricos , Contracepção Reversível de Longo Prazo/métodos , Aborto Induzido/estatística & dados numéricos , Anticoncepção/estatística & dados numéricos , Anticoncepcionais/provisão & distribução , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Dispositivos Intrauterinos/economia , Dispositivos Intrauterinos/provisão & distribução , Contracepção Reversível de Longo Prazo/estatística & dados numéricos , Gravidez , Gravidez não Planejada , Estudos Prospectivos , Estados Unidos/epidemiologia
10.
Contraception ; 94(5): 556-560, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27364099

RESUMO

OBJECTIVE: This study aims to evaluate the effect of baseline bleeding patterns on rates of amenorrhea reported at 12 months in levonorgestrel (LNG) 52 mg intrauterine system (IUS) users. We also assessed the effect of baseline bleeding patterns at 3 and 6 months postinsertion. STUDY DESIGN: In this secondary analysis of the Contraceptive CHOICE Project, we included participants who had an LNG-IUS inserted within 1 month of enrollment and continued use for 12 months. Using 12-month telephone survey data, we defined amenorrhea at 12 months of use as no bleeding or spotting during the previous 6 months. We used chi-square and multivariable logistic regression to assess the association of baseline bleeding pattern with amenorrhea while controlling for confounding variables. RESULTS: Of 1802 continuous 12-month LNG-IUS users, amenorrhea was reported by 4.9%, 14.8% and 15.4% of participants at 3, 6 and 12 months, receptively. Participants with light baseline bleeding or short duration of flow reported higher rates of amenorrhea at 3 and 6 months postinsertion (p<.03), while LNG-IUS users with heavy or prolonged flow were less likely to report amenorrhea at 3 and 6 months (p<.03). In a multivariable analysis, participants with self-reported heavy bleeding at baseline were less likely to report amenorrhea at 12 months than those who reported moderate bleeding (ORadj, 0.36; 95% CI, 0.16-0.69). CONCLUSION: Women with heavier menstrual bleeding are less likely than women with moderate flow to report amenorrhea following 12 months of LNG-IUS use. IMPLICATIONS: Baseline heavy menstrual flow reduces the likelihood of amenorrhea with LNG-IUS use, information that could impact contraceptive counseling. Anticipatory counseling can improve method satisfaction and continuation, an important strategy to continue to reduce unintended pregnancy and abortion rates.


Assuntos
Amenorreia/epidemiologia , Anticoncepcionais Femininos/administração & dosagem , Dispositivos Intrauterinos Medicados/efeitos adversos , Levanogestrel/administração & dosagem , Menorragia/epidemiologia , Aborto Induzido , Adolescente , Adulto , Anticoncepcionais Femininos/efeitos adversos , Feminino , Humanos , Levanogestrel/efeitos adversos , Modelos Logísticos , Análise Multivariada , Gravidez , Gravidez não Planejada , Estudos Prospectivos , Estados Unidos , Adulto Jovem
11.
Eur J Contracept Reprod Health Care ; 21(5): 361-6, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27419258

RESUMO

OBJECTIVE: Estimate symptom improvement rate of women with bleeding complaints using the etonogestrel contraceptive implant when started on continuous combined oral contraceptives (COC). METHODS: We conducted a double-blinded randomised controlled trial of women reporting troublesome bleeding related to their etonogestrel contraceptive implant and desiring intervention. Participants received continuous COCs or placebo for four weeks to evaluate self-reported bleeding improvement at four weeks. Participants could continue study treatment or prescribed COCs for another eight weeks if desired. We planned to enroll 130 participants between two sites (80% power to detect a 20% effect size at a 0.05 significance level, with 10% loss to follow up). RESULTS: We closed the study after enrolling 26 participants due to recruitment futility. All women on COCs and 75% of placebo users reported bleeding improvement at four weeks (p = 0.09), with 92% and 42%, respectively, reporting significant improvement (p = 0.03). The median number of days until bleeding stopped for at least four days in COC and placebo users was 1 day (range 1-9) and 4.5 days (range 1-28), respectively (p = 0.63). Eight (75%) COC and five (42%) placebo users opted to continue study treatment (p = 0.41). Despite bleeding improvement, women who desired implant removal at enrollment were more likely to re-request removal than those who initially considered other interventions (3 of 5 [60%] vs 1 of 17 [6%], p = 0.03). CONCLUSION: Although women who have troublesome bleeding while using the contraceptive implant may experience improvement with no treatment over 4 weeks, women using COCs are more likely to report significant improvement. Clinicaltrials.gov registration number: NCT01963403.


Assuntos
Anticoncepcionais Femininos/efeitos adversos , Anticoncepcionais Orais Combinados/uso terapêutico , Desogestrel/efeitos adversos , Menorragia/tratamento farmacológico , Metrorragia/tratamento farmacológico , Adolescente , Adulto , Método Duplo-Cego , Implantes de Medicamento , Feminino , Humanos , Menorragia/induzido quimicamente , Metrorragia/induzido quimicamente , Adulto Jovem
12.
Contraception ; 92(4): 313-8, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26093189

RESUMO

OBJECTIVE: The objective was to compare three strategies for Chlamydia trachomatis and Neisseria gonorrhoeae screening prior to intrauterine device (IUD) insertion. STUDY DESIGN: This was a secondary analysis of the Contraceptive CHOICE Project. We measured the prevalence of C. trachomatis and/or N. gonorrhoeae at the time of IUD insertion. We then compared sensitivity, specificity, negative and positive predictive values, and likelihood ratios for three screening strategies for C. trachomatis and N. gonorrhoeae prior to IUD insertion: (a) "age-based" ­ age ≤25 years alone; (b) "age/partner-based" ­ age ≤25 and/or multiple sexual partners; and (c) "risk-based" ­ age ≤25, multiple sexual partners, inconsistent condom use and/or history of prior sexually transmitted infection (STI). RESULTS: Among 5087 IUD users, 140 (2.8%) tested positive for C. trachomatis, 16 (0.3%) tested positive for N. gonorrhoeae, and 6 (0.1%) were positive for both at the time of IUD insertion. The "risk-based" screening strategy had the highest sensitivity (99.3%) compared to "age-based" and "age/partner-based" screening (80.7% and 84.7%, respectively.) Only one (0.7%) woman with a chlamydia or gonorrhea infection would not have been screened using "risk-based" screening. CONCLUSION: A risk-based strategy to screen for C. trachomatis and N. gonorrhoeae prior to IUD insertion has higher sensitivity than screening based on age alone or age and multiple sexual partners. IMPLICATIONS: Using a risk-based screening strategy (age≤25, multiple sexual partners, inconsistent condom use and/or history of an STI) to determine who should be screened for C. trachomatis and N. gonorrhoeae prior to IUD insertion will miss very few cases of infection and obviates the need for universal screening.


Assuntos
Infecções por Chlamydia/diagnóstico , Gonorreia/diagnóstico , Programas de Rastreamento/métodos , Adolescente , Adulto , Infecções por Chlamydia/epidemiologia , Infecções por Chlamydia/microbiologia , Chlamydia trachomatis/isolamento & purificação , Feminino , Gonorreia/epidemiologia , Gonorreia/microbiologia , Humanos , Dispositivos Intrauterinos Medicados , Modelos Logísticos , Pessoa de Meia-Idade , Missouri/epidemiologia , Neisseria gonorrhoeae/isolamento & purificação , Estudos Prospectivos , Fatores de Risco , Adulto Jovem
13.
Obstet Gynecol ; 125(3): 599-604, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25730221

RESUMO

OBJECTIVE: To evaluate the effectiveness of the contraceptive implant and the 52-mg hormonal intrauterine device (IUD) in women using the method beyond the current U.S. Food and Drug Administration (FDA)-approved duration of 3 and 5 years, respectively. METHODS: Women willing to continue using their implant or 52-mg levonorgestrel IUD beyond the FDA-approved duration were followed prospectively for contraceptive effectiveness. Unintended pregnancy rate per 100 women-years was calculated. Implant users are offered periodic venipuncture for analysis of serum etonogestrel levels. The Kruskal-Wallis test was used to compare the etonogestrel levels across body mass index (BMI) groups. RESULTS: Implant users (n=237) have contributed 229.4 women-years of follow-up, with 123 using the etonogestrel implant for 4 years and 34 using it for 5 years. Zero pregnancies have been documented, for a failure rate of 0 (one-sided 97.5% confidence interval [CI] 0-1.61) per 100 women-years. Among 263 levonorgestrel IUD users, 197.7 women-years of follow-up have been completed. One pregnancy was confirmed, for a failure rate of 0.51 (95% CI 0.01-2.82) per 100 women-years. Among implant users with serum etonogestrel results, the median and range of etonogestrel level at 3 years of use was 188.8 pg/mL (range 63.8-802.6 pg/mL) and 177.0 pg/mL (67.9-470.5 pg/mL) at 4 years of use. Etonogestrel levels did not differ by BMI at either time point (3 years: P=.79; 4 years: P=.47). CONCLUSION: Preliminary findings indicate the contraceptive implant and 52-mg hormonal IUD continue to be highly effective for an additional year beyond the FDA-approved 3 and 5 years. Serum etonogestrel levels indicate the implant contains adequate hormone for ovulation suppression at the end of both 3 and 4 years of use. LEVEL OF EVIDENCE: II.


Assuntos
Anticoncepcionais Femininos/administração & dosagem , Desogestrel/administração & dosagem , Dispositivos Intrauterinos Medicados , Levanogestrel/administração & dosagem , Adolescente , Adulto , Feminino , Humanos , Estudos Prospectivos , Fatores de Tempo , Estados Unidos , United States Food and Drug Administration , Adulto Jovem
14.
Clin Obstet Gynecol ; 57(4): 635-43, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25286295

RESUMO

The Contraceptive CHOICE Project was a prospective cohort study of 9256 women in the St Louis area. The project provided no-cost reversible contraception to participants for 2 to 3 years with the goal of increasing uptake of long-acting reversible contraception and decreasing unintended pregnancy in the area. This manuscript will provide a brief summation of the major findings to date including the dramatic effect the project had on unintended pregnancy and abortion rates.


Assuntos
Aborto Induzido/estatística & dados numéricos , Anticoncepcionais Femininos/uso terapêutico , Aconselhamento/métodos , Serviços de Planejamento Familiar/métodos , Acesso aos Serviços de Saúde , Dispositivos Intrauterinos , Gravidez não Planejada , Adolescente , Adulto , Estudos de Coortes , Dispositivos Anticoncepcionais Femininos , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Gravidez , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
15.
N Engl J Med ; 371(14): 1316-23, 2014 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-25271604

RESUMO

BACKGROUND: The rate of teenage pregnancy in the United States is higher than in other developed nations. Teenage births result in substantial costs, including public assistance, health care costs, and income losses due to lower educational attainment and reduced earning potential. METHODS: The Contraceptive CHOICE Project was a large prospective cohort study designed to promote the use of long-acting, reversible contraceptive (LARC) methods to reduce unintended pregnancy in the St. Louis region. Participants were educated about reversible contraception, with an emphasis on the benefits of LARC methods, were provided with their choice of reversible contraception at no cost, and were followed for 2 to 3 years. We analyzed pregnancy, birth, and induced-abortion rates among teenage girls and women 15 to 19 years of age in this cohort and compared them with those observed nationally among U.S. teens in the same age group. RESULTS: Of the 1404 teenage girls and women enrolled in CHOICE, 72% chose an intrauterine device or implant (LARC methods); the remaining 28% chose another method. During the 2008-2013 period, the mean annual rates of pregnancy, birth, and abortion among CHOICE participants were 34.0, 19.4, and 9.7 per 1000 teens, respectively. In comparison, rates of pregnancy, birth, and abortion among sexually experienced U.S. teens in 2008 were 158.5, 94.0, and 41.5 per 1000, respectively. CONCLUSIONS: Teenage girls and women who were provided contraception at no cost and educated about reversible contraception and the benefits of LARC methods had rates of pregnancy, birth, and abortion that were much lower than the national rates for sexually experienced teens. (Funded by the Susan Thompson Buffett Foundation and others.).


Assuntos
Aborto Induzido/estatística & dados numéricos , Coeficiente de Natalidade , Anticoncepcionais Femininos , Dispositivos Intrauterinos , Gravidez na Adolescência/estatística & dados numéricos , Adolescente , Coeficiente de Natalidade/etnologia , Anticoncepcionais Femininos/administração & dosagem , Anticoncepcionais Femininos/economia , Desogestrel , Feminino , Humanos , Dispositivos Intrauterinos/economia , Levanogestrel , Gravidez , Gravidez na Adolescência/prevenção & controle , Estudos Prospectivos , Estados Unidos , Adulto Jovem
16.
Obstet Gynecol ; 124(4): 718-26, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25198262

RESUMO

OBJECTIVE: To investigate whether age 14 to 19 years and nulliparity are associated with expulsion of levonorgestrel and copper intrauterine devices (IUDs). METHODS: This was a planned secondary analysis of the Contraceptive CHOICE Project. We used Kaplan-Meier survival analysis to estimate expulsion rates for the first levonorgestrel or copper IUD received during study participation. Cox proportional hazards regression models were used to investigate baseline characteristics associated with expulsion. RESULTS: A total of 5,403 females were included; 4,219 (78%) used the levonorgestrel IUD and 1,184 (22%) used the copper IUD. There were 432 initial expulsions reported. The 36-month cumulative expulsion rate was 10.2 per 100 IUD users and did not vary by IUD type (levonorgestrel IUD 10.1 compared with copper IUD 10.7, P=.99). In the bivariate analysis, multiple characteristics including age, nulliparity, immediate postabortion insertion, and heavy menses were associated with expulsion. The cumulative rate of expulsion was lower in nulliparous women compared with parous women (8.4 compared with 11.4; P<.001) and higher in females aged 14 to 19 compared with older women (18.8 compared with 9.3; P<.001). After adjusting for confounders and stratifying by IUD type, the hazard ratio of expulsion for females aged 14 to 19 years was 2.26 (95% confidence interval [CI] 1.68-3.06) for the levonorgestrel IUD and 3.06 (95% CI 1.75-5.33) for the copper IUD. Compared to parous levonorgestrel IUD users, expulsion was lower for nulliparous levonorgestrel IUD users (adjusted hazard ratio 0.59, 95% CI 0.44-0.78). CONCLUSION: IUD expulsions were not increased in nulliparous females. More expulsions were observed in females aged 14 to 19 compared with older women regardless of parity or IUD type. LEVEL OF EVIDENCE: : II.


Assuntos
Expulsão de Dispositivo Intrauterino/efeitos adversos , Dispositivos Intrauterinos Medicados/efeitos adversos , Levanogestrel/farmacologia , Paridade , Taxa de Gravidez/tendências , Adolescente , Adulto , Fatores Etários , Análise de Variância , Distribuição de Qui-Quadrado , Estudos de Coortes , Feminino , Seguimentos , Humanos , Dispositivos Intrauterinos de Cobre/efeitos adversos , Estimativa de Kaplan-Meier , Pessoa de Meia-Idade , Análise Multivariada , Gravidez , Modelos de Riscos Proporcionais , Estudos Prospectivos , Medição de Risco , Fatores de Tempo , Adulto Jovem
17.
Hum Pathol ; 44(12): 2861-4, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24134929

RESUMO

Ectopic complete molar pregnancy in the ovary is an exceptionally rare event. Here we present a case of ovarian complete hydatidiform mole in a 20-year-old gravida 2 para 1 woman. At presentation, the patient underwent excision of a hemorrhagic left ovarian cyst, with routine sections demonstrating a hemorrhagic corpus luteum with a single microscopic focus of detached atypical trophoblast, without chorionic villi. Subsequent left salpingo-oophorectomy for persistently elevated human chorionic gonadotropin led to a final diagnosis of complete hydatidiform mole arising in the ovary. The fallopian tube was unremarkable. Zygosity was determined using short tandem repeat analysis, confirming the diagnosis of monospermic complete mole. In the clinical setting of a markedly elevated human chorionic gonadotropin level and an ovarian mass, histopathologic examination is critical in distinguishing ectopic pregnancy from choriocarcinoma. Short tandem repeat analysis can be a useful adjunct to histologic diagnosis in challenging cases.


Assuntos
Mola Hidatiforme/patologia , Neoplasias Ovarianas/patologia , Neoplasias Uterinas/patologia , Adulto , Feminino , Loci Gênicos , Humanos , Mola Hidatiforme/genética , Mola Hidatiforme/cirurgia , Repetições de Microssatélites , Neoplasias Ovarianas/genética , Neoplasias Ovarianas/cirurgia , Ovariectomia , Gravidez , Neoplasias Uterinas/genética , Neoplasias Uterinas/cirurgia
19.
Sex Transm Dis ; 40(7): 546-51, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-23965768

RESUMO

BACKGROUND: We used universal screening to determine the prevalence rates of Neisseria gonorrhoeae (GC), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) in 9256 women enrolling into a contraceptive study. METHODS: We offered screening using nucleic acid amplification or culture to all participants enrolling into the Contraceptive CHOICE Project. Demographic characteristics were collected through staff-administered questionnaires. Univariate and multivariable analyses were performed to assess the risk of sexually transmitted infection at baseline and to compare risk profiles of CT and TV. RESULTS: Results were available for 8347 consenting women with satisfactory results; 656 (7.9%) were tested positive for 1 or more infections. Approximately one third of participants were older than 26 years, and half were identified as African American. There were 35 cases of GC for a prevalence of 0.4% (95% confidence interval [CI], 0.3-0.6), 260 cases of CT for a prevalence of 3.1% (95% CI, 2.8-3.5), and 410 cases of TV for a prevalence of 4.9% (95% CI, 4.4-5.4). Black women were more likely to be tested positive (odds ratio, 3.95; 95% CI, 3.08-5.06) compared with white women and accounted for 81.3% of cases. T. vaginalis was more prevalent in black women (8.9%) compared with white women (0.9%). Older age was a risk factor for TV, whereas younger age was associated with CT. Of the 656 positive cases, 106 (16%) were diagnosed in women older than 25 years, falling outside traditional screening guidelines. CONCLUSION: We found GC, CT, and TV to be more prevalent than current national statistics, with TV being the most prevalent. Current screening recommendations would have missed 16% of infected women.


Assuntos
Infecções por Chlamydia/epidemiologia , Chlamydia trachomatis/isolamento & purificação , Anticoncepção/economia , Gonorreia/epidemiologia , Doenças Sexualmente Transmissíveis/epidemiologia , Vaginite por Trichomonas/epidemiologia , Adolescente , Adulto , Afro-Americanos/estatística & dados numéricos , Chlamydia trachomatis/genética , Estudos de Coortes , Demografia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Humanos , Pessoa de Meia-Idade , Missouri/epidemiologia , Neisseria gonorrhoeae/genética , Neisseria gonorrhoeae/isolamento & purificação , Técnicas de Amplificação de Ácido Nucleico , Prevalência , Risco , Trichomonas vaginalis/genética , Trichomonas vaginalis/isolamento & purificação , Adulto Jovem
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