Microdose intravaginal levonorgestrel contraception: a multicentre clinical trial. II. Expulsions and removals. World Health Organization. Task Force on Long-Acting Systemic Agents for Fertility Regulation

This paper investigates the relationship between expulsions and removals, and demographic characteristics of 1005 women from 19 centres using a vaginal ring releasing 20 micrograms levonorgestrel per 24 hours. Emphasis is placed on discontinuations of method use due to expulsions, on the number and rate of expulsions, and the time at which the first expulsion occurred. The overall life-table discontinuation rate due to expulsion was 7.1% at one year. Life-table discontinuation rates increased with parity and were highest in Asian and lowest in European women. In respect to the number of expulsions experienced by women (expulsions did not necessarily lead to discontinuation), the women of high parity and those from Asia and Europe have the highest rates. The life-table first expulsion rate is 29% at one year. Such rates are highest in Chinese and Asian women. Following a first expulsion, the second expulsion rate is 45% by the end of the subsequent six months. The majority of first expulsions occur at defaecation (134 or 57% of 234 women), urination (12%) and during menstruation (17%). Rings were removed by 121 (12%) women on 201 occasions and for a variety of reasons. The main medical reasons were vaginal discharge and irritation, bleeding pain and dyspareunia. Others removed the ring during defaecation, intercourse or because the ring came out of place. Women also removed rings for curiosity, to show their husbands and to clean.

A study of the vaginal contraceptive sponge used with and without the fertility awareness method

The actual effectiveness rates of natural and barrier methods of family planning are lower than the theoretical ones. If couples accurately defined the limits of the fertile phase and used barriers at that time, then actual effectiveness might increase. A randomized, controlled clinical trial was initiated to determine the effectiveness of the contraceptive sponge used only during the fertile time and to compare this with sponge use at every intercourse. Recruitment problems and discontinuation forced the early termination of this study, but qualitative information about compliance and acceptability was collected. Common sponge problems were reported as were misuses of the sponge, but problems and misuse were not related. Determination of the fertile phase was reportedly easy, but complaints of and discontinuation for inconvenience occurred. For unplanned pregnancies, contraceptive behaviors around the time of conception are presented.

The in vivo release characteristics of a multi-compartment vaginal ring releasing 3-keto-desogestrel

The results of a stage I study of a new vaginal ring releasing 3-keto-Desogestrel [3kDOG] is reported. The study design consisted of one study cycle, where the ring was used continuously for 21 days and then removed. Twenty healthy volunteers were randomly allocated to each of two study groups. On day 5 of the menstrual cycle, group A used a vaginal ring releasing 30 micrograms 3kDOG per 24 hours and group B used a 15 micrograms 3kDOG per 24 hours ring. After initial absorption of the 3kDOG a plateau phase was reached in 46 hours [group A] and 49 hours [group B]. On reaching the plateau phase, the overall decline in plasma levels during the 21 days of use was 5.24% for group A and 5.27% for group B. This represents a daily decline in plasma levels of 0.27% and 0.28% for the 30 micrograms and 15 micrograms per 24 hours rings, respectively. The plasma levels achieved by the rings were significantly different throughout (p = 0.011). On removal after 21 days, the mean removal half-life for both ring types was similar at 20.9 hours for group A and 21.1 hours for group B. It is concluded that the characteristics of the delivery system are worthy of further study as a potential means of contraception using 3kDOG delivered from a vaginal ring.

Feminism and regulation collide: the Food and Drug Administration's approval of the cervical cap

In May 1988, the Prentif Cavity Rim cervical cap, a barrier method of contraception, was approved by the Food and Drug Administration (FDA) for contraceptive purposes in the United States. This paper describes some of the events leading to the approval of the cervical cap as a contraceptive. Of major interest is the unprecedented involvement of the feminist health movement in clinic-based research, policy making, and distribution of the cervical cap. The recall of the Vimule cervical cap, the use of lay health workers in fitting an experimental device, and the feminist providers' response to the FDA's regulation of the cervical cap are detailed.

Factors associated with use of the contraceptive sponge

A study of 264 current sponge users, 266 pill users and 45 diaphragm users shows that women who adopted the sponge were older, more educated and more likely to be married, to have higher incomes and to have had more pregnancies and children than were women who had used oral contraceptives. Compared with diaphragm users, sponge users were more likely to be never-married, had had fewer children and were more likely to be Protestant. Users of all three methods cited physicians as being the greatest source of influence in the decision to adopt their current method; however, sponge users were the least likely to cite physicians, and they were more likely to have been favorably influenced by the media than were pill or diaphragm users. Sponge users were more likely than pill users to have ever relied on other contraceptive methods and to have correctly answered more questions on contraceptive knowledge. Sponge users and diaphragm users were similar in the range of methods they had ever used and in contraceptive knowledge. However, sponge users reported more consistent use than did diaphragm users.

Reasons for non-use of family planning methods at Ilorin, Nigeria: male opposition and fear of methods

This study reports the main reasons given for non-use of contraception by non-pregnant women aged 15-44 years, who are at risk of unplanned pregnancy and living in the Ilorin Local Government Area of Kwara State, Nigeria. Six hundred and forty-six women were derived from a stratified cluster sample and interviewed using a questionnaire. Almost one-third (31.4%) of respondents gave male opposition to family planning as the reason for current non-use. Another 13.3% expressed fear of methods, 6.3% did not want to use contraception until the first child was born, and 13.6% until the desired number of children were born. Sociodemographic variables including age, educational level, religion, and residence as reasons for non-use were reported. Other important findings included a high awareness of, low availability of, or poor accessibility to contraceptive methods. Short and long term intervention strategies using information, education and communication materials are proposed to combat low levels of contraceptive use in this area.

Knowledge of reproductive physiology and modern contraceptives in rural Peru

This report is based on fieldwork conducted in a Peruvian community in 1986, which investigated Quechua-speaking Indians' knowledge of the female reproductive organs, perceptions of the way contraceptives work in the body, folk beliefs about conception and menstruation, and opinions about modern contraceptives. The findings reveal that the men have a more accurate knowledge of the female reproductive organs than the women do. However, the women are more knowledgeable about the action of modern contraceptives in the body. Most respondents perceived modern contraceptive methods as the best methods available, but the majority reported using the calendar rhythm method. This preference for rhythm is based on its economic advantage and on its adaptability to folk beliefs about physiology. The men's dominant role in reproductive behavior is related to cultural norms that emphasize traditional gender roles and that prohibit communication about sexual matters between men and women. Educational material, based on the respondents' knowledge of reproduction and taking into account their folk beliefs, might help to decrease the fear of contraceptive side effects and increase understanding of the function of contraceptives.

Adolescent contraception: nonhormonal methods

A comparison of the advantages, disadvantages, and costs of each method is presented in Table 1. Barrier methods of contraception offer adolescents protection against both pregnancy and STDs, but innovative approaches are needed to enhance availability and acceptability. Condom use in conjunction with a vaginal spermicide would provide optimal protection. The "female condom" may prove to be an effective alternative. Diaphragms and cervical caps can be prescribed for well-educated, highly motivated adolescents comfortable with insertion and removal. The vaginal contraceptive sponge provides many of the advantages of the diaphragm and cap without the need for an examination and fitting and also may be used as a backup method with the condom. Vaginal spermicides used alone are significantly less effective than in combination with a mechanical barrier. The IUD is not considered appropriate for most adolescents due to its association with an increased risk of pelvic infection. Periodic abstinence requires accurate identification of the fertile period, extensive education, and partner cooperation. Sterilization is rarely considered an option in adolescents. Alternate forms of sexual expression are available to adolescents who choose to abstain from intercourse.

Active surveillance for toxic shock syndrome in the United States, 1986

Active surveillance for toxic shock syndrome (TSS) was established in 1986 in Los Angeles County and in the states of Missouri, New Jersey, Oklahoma, Tennessee, and Washington. Case reports were solicited through biweekly contact with all acute-care hospitals. One hundred sixteen definite and 63 probable cases were reported; 85% of the cases occurred in female patients and 15% in male patients. Among cases in females, 83 (55%) were menstrual; the mean age of the patients with menstrual cases was 23 years (range, 12-46 years). The overall incidence of TSS was 0.53/100,000. The cumulative incidence varied significantly by region, ranging from 1.23/100,000 in Oklahoma to 0.22/100,000 in New Jersey (P = .0001); the incidence in all other areas ranged from 0.39/100,000 to 0.70/100,000. The incidence of menstrual TSS was 1.05/100,000 women 15-44 years of age and peaked in women between the ages of 15 and 19 years at 1.52/100,000. The incidence was higher in whites than in nonwhites for both menstrual TSS (1.21/100,000 vs. 0.34/100,000, P = .002) and nonmenstrual TSS (0.30/100,000 vs. 0.14/100,000, P = .031). Our data indicate that TSS continues to be a cause of morbidity. Although there is underreporting in national passive surveillance, the proportion of menstrual cases reported through active surveillance was similar to that reported to the passive system in 1986.

Risk factors for menstrual toxic shock syndrome: results of a multistate case-control study

For assessment of current risk factors for developing toxic shock syndrome (TSS) during menstruation, a case-control study was performed. Cases with onset between 1 January 1986 and 30 June 1987 were ascertained in six study areas with active surveillance for TSS. Age-matched controls were selected from among each patient's friends and women with the same telephone exchange. Of 118 eligible patients, 108 were enrolled, as were 185 "friend controls" and 187 telephone exchange-matched controls. Tampon use was a risk factor for developing TSS during menstruation (odds ratio = 29; 95% confidence interval = 7-120), and risk increased with increasing tampon absorbency (odds ratio = 1.34 per gram increase in absorbency; 95% confidence interval = 1.2-1.6). The role of tampon chemical composition could not be assessed because the number of cases was inadequate. Neither use of birth control pills for contraception nor use of medications for premenstrual or menstrual symptoms protected against or was a risk factor for the development of menstrual TSS.

Ecology of toxic shock syndrome: amplification of toxic shock syndrome toxin 1 by materials of medical interest

Historically, the literature suggests that staphylococcal exoproteins, including enterotoxins, are stimulated by various physicochemical ecologic factors, many of which have been shown to stimulate production of toxic shock syndrome toxin 1 (TSST-1). The propensity of different fibers and other substances to amplify TSST-1 production in toxic shock syndrome-associated strains of Staphylococcus aureus, as well as a comparative analysis of the underlying mechanisms of TSST-1 production, are reported. Two hundred twenty intravaginal devices or other products and materials and 60 experimental controls were examined for their propensity to induce TSST-1 production. Certain materials are superior to unaltered cotton in providing a more absorbent fiber--nutrients are efficiently drawn in, concentrating protein between fibers, and thereby creating an ideal physicochemical environment for the amplification of TSST-1 and other toxins. The greatest stimulation of TSST-1 was observed with (in decreasing order): polyester and carboxymethyl cellulose, polyacrylates, viscose rayon, gelatin foam, polyurethane, and cotton. No toxin was found with nasal tampons (polymer of polyvinyl acetal) or with vaginal cups (an elastomeric polymer). Results are discussed in terms of specific ecologic parameters from historical as well as recent perspectives.