Audit of condom issuing in eastbourne sexual health clinic

A perennial question at meetings of family planning practitioners concerns the numbers of condoms to give to patients. If the condom is to act as an effective contraceptive method, then there must be a condom available for every occasion of sexual intercourse. In recent years, the condom has been promoted as a means of protecting against sexually transmitted infections, including HIV. The 'Double Dutch' approach whereby the condom is used alongside other methods of contraception such as the Pill, has been advocated, particularly for younger people. The condom has consequently become a more commonly used method of contraception, particularly amongst the young and single. The family planning clinic in Eastbourne is now part of an integrated Sexual Health Clinic incorporating family planning (FPC), genito-urinary medicine (GUM), HIV and AIDS clinics. At the time of this audit, steps towards integration were already well advanced. We were keen to develop standards for issuing condoms which took account of identified need in target populations. At the same time clinicians were anxious to avoid waste given that the budget for condoms is finite. Often the idea of using a condom is introduced by clinicians rather than by clients, and this may lead to the issuing of condoms which the client is not motivated to use. We were also keen to eliminate any judgements about frequency of requests for supplies of condoms, and to this end the local Health Promotion Department ran training on sexual history taking which included approaches to asking about frequency of sexual intercourse.

Endometriosis in adolescents. Incidence, diagnosis and treatment

OBJECTIVE

To review the incidence and diagnosis of endometriosis in adolescents and to evaluate the surgical and medical treatment options for this special population.

STUDY DESIGN

Literature research.

RESULTS

Endometriosis is the most common cause of chronic pelvic pain in adolescents, affecting up to 70% of girls with chronic pelvic pain unresponsive to medical management. There may be a natural progression of endometriosis from atypical lesions in adolescents to classic lesions in adults.

CONCLUSION

Endometriosis should be strongly suspected in adolescent girls with chronic pelvic pain unresponsive to oral contraceptives and nonsteroidal antiinflammatory drugs. Initial management of endometriosis involves surgical resection or destruction at the time of diagnosis followed by medical management with continuous oral contraceptives. Gonadotropin-releasing hormone agonists should be considered for adolescents over 16 years of age who have completed pubertal maturation.

Compliance and other issues in contraception

About 5% of women in the United States (approximately three million) are not using contraception despite being at risk of unintended pregnancy. Teenagers have the highest rate of unintended pregnancy. Women 40 years and older most frequently terminate unintended pregnancy. Multiple theories and models, including the health belief model, the health decision model, the Prochaska change model, and the conviction-confidence model, have been developed to address choices and change in health behavior. Despite this information, current data on contraceptive compliance show considerable need for improvement. Side effects and patients' beliefs and preferences appear to influence strongly whether a method will be used appropriately. Systems improvements that address issues such as access and enhancement of provider-patient interaction appear to be areas of potential opportunity. Despite continued need for improvement, there is a paucity of information testing new approaches to improve contraceptive compliance.

Hormonal state rather than age influences cut-off values of protein S: reevaluation of the thrombotic risk associated with protein S deficiency

Of the well known risk factors for thrombosis protein S deficiency is one of the most difficult to diagnose with certainty. Reliable estimates for the prevalence of protein S deficiency in the general population are not available and the risk of thrombosis is a controversial issue. It has been shown that levels of protein S fluctuate over time. However the determinants of low levels of protein S in the healthy population are not clear. Therefore. we evaluated the influence of sex, age and hormonal state on the antigen levels of protein S in 474 healthy control subjects of the Leiden Thrombophilia Study (LETS). In univariate analysis, sex, age, oral contraceptive (OC) use and post-menopausal state all influenced protein S antigen levels. In a multivariate model for the whole sample only menopausal state and OC use had still an effect on the levels of total protein S and only menopausal state had an independent effect on the values of free protein S. On the basis of this analysis we established different cut-off levels for these subgroups and we re-evaluated in the Leiden Thrombophilia Study the risk of thrombosis for individuals with low protein S using these different reference ranges. With these specific cut-off points, we did not observe an increase in the risk of thrombosis in patients deficient of total protein S (OR 1.2, 95% CI 0.5-2.9) or free protein S (OR 1.3, 95% CI 0.5-3.5). When men and women were analyzed separately, the risk in women was 1.5 (95% CI 0.4-5.4) and 2.4 (95% CI 0.6-9.2) for total and free protein S deficiencies, respectively; and there was no increase in thrombotic risk for men. We conclude that it may be helpful to apply separate cut-off levels in the assessment of protein S levels. This does not, however explain the differences between our results and those of others in the estimate of thrombotic risk of protein S deficiency.

Evaluation of combined endoscopic and pharmaceutical management of endometriosis during adolescence

Laparoscopy is the most frequent surgical approach in gynecologic patients with acute or chronic pelvic pain. The symptomatology is frequently related to a specific gynecological pathology such as endometriosis or associated adhesive disease. During an eight year period, January 1990 to December 1997, 26 patients (aged 16-20 years) with endometriosis were diagnosed endoscopically and managed pharmaceutically in our clinic. The disease was evaluated and staged according to the American Society of Reproductive Medicine. The disease was evaluated as first stage in 16 patients (61.6%), as second stage in eight patients (30.8%), as third stage in one patient (3.8%) and as fourth stage in one patient (3.8%). Patients underwent adhesiolysis and management according to their laparoscopic findings. Postoperative pharmaceutical treatment (Danazol, GnRH analogues, Oral Contraceptives) was given. Patients were followed for the evaluation of the treatment. The efficacy of the combination of endoscopic and pharmaceutical management of the disease is discussed.

The oral contraceptive pill: a revolution for sportswomen?

OBJECTIVES

To determine the effects of the oral contraceptive pill (OCP) on skeletal health, soft tissue injury, and performance in female athletes.

METHODS

A literature review was performed using literature retrieval methods to locate relevant studies.

RESULTS

Most female athletes primarily choose to use the OCP for contraceptive purposes, but cycle manipulation and control of premenstrual symptoms are secondary advantages of its use. The effect of the OCP on bone density in normally menstruating women is unclear, with some studies reporting no effect, others a positive effect, and some even a negative effect. The OCP is often prescribed for the treatment of menstrual disturbances in female athletes, and improvements in bone density may result. Whether the OCP influences the risk of stress fracture and soft tissue injuries is not clear from research to date. Effects of the OCP on performance are particularly relevant for elite sportswomen. Although a reduction in Vo2MAX has been reported in some studies, this may not necessarily translate to impaired performance in the field. Moreover, some studies claim that the OCP may well enhance performance by reducing premenstrual symptoms and menstrual blood loss. A fear of weight gain with the use of the OCP is not well founded, as population studies report no effect on weight, particularly with the lower dose pills currently available.

CONCLUSIONS

Overall, the advantages of the pill for sportswomen would appear to outweigh any potential disadvantages. Nevertheless, there is individual variation in response to the OCP and these should be taken into account and monitored in the clinical situation. Women should be counselled as to the range of potential benefits and disadvantages in order to make an informed decision based on individual circumstances.

Recurrence rate of hirsutism after 3 different antiandrogen therapies

BACKGROUND

Although antiandrogens are frequently and successfully used to treat hirsutism, little attention has been paid to optimal duration of treatment and recurrence rate after cessation of therapy.

OBJECTIVE

Our purpose was to determine the recurrence rate of hirsutism after 3 different antiandrogen therapies.

METHODS

Eighty-one hirsute women referred to a tertiary hirsutism clinic were assigned to one of three regimens: spironolactone 100 mg/day with an oral contraceptive, cyproterone acetate 50 mg/day on days 1 to 10 with an oral contraceptive, or flutamide 250 mg twice a day. Hirsutism scores according to the Ferriman-Gallwey scoring system and endocrine parameters were evaluated before, during, and 1 year after withdrawal of treatment regimens.

RESULTS

Hirsutism scores decreased significantly and similarly in spironolactone, flutamide, and cyproterone acetate treatment groups. However, 1 year after withdrawal of treatment in all antiandrogen therapy groups, hirsutism returned.

CONCLUSION

Antiandrogens are effective in the treatment of hirsutism. However, cessation of antiandrogen therapy is followed by recurrence.

Conflicting advice? Australian adolescents' use of condoms or the pill

CONTEXT

Teenagers are exposed to two potentially conflicting sexual health messages, one emphasizing the prevention of sexually transmitted diseases (STDs) and the other stressing pregnancy prevention. To protect teenagers from both STDs and unwanted pregnancy, it is important to know what method choices they make and why.

METHODS

Data from a 1997 national survey of 3,550 Australian secondary school students were used to examine teenagers' method choice and patterns of advice-seeking about contraception and STD prevention. Logistic regression analyses were conducted to identify factors associated with the exclusive use of condoms or the pill.

RESULTS

Virtually all 961 currently sexually active students were using at least one contraceptive method--primarily condoms (78%) or the pill (45%). Some 31% were using condoms exclusively, and 10% were using the pill exclusively. Older students and those who had sought contraceptive advice had elevated odds of using the pill rather than condoms exclusively (odds ratios, 4.4 and 2.6, respectively), while those who had had only casual partners in the last year had a reduced likelihood of exclusive pill rather than condom use (0.1). Furthermore, the more students believed that their peers used condoms, the less likely they were to report exclusive pill use (0.4). Parents were the most frequent source of advice about contraception, followed by physicians and teachers. The most common sources of advice about HIV and other STDs were parents, teachers and then physicians.

CONCLUSIONS

Young people must be educated about the distinction between safer sex and contraception, and about how to prevent both STDs and pregnancy. Providing parents with current sexual health information may help to improve young people's sexual health.

A case of menstruation-associated asthma: treatment with oral contraceptives

A menstrual rhythm has been documented for exacerbations of asthma, which may have important clinical relevance to the patient with severe asthma. We report the case of a 26-year-old patient with menstruation-associated asthma who showed a dramatic response to oral contraceptives. It was noted that falls in peak respiratory flow rate coincided with ovulation. We concluded that oral contraceptive therapy is useful in this particular group of asthmatic patients.

Benefits and risks of oral contraceptives

The major benefits of modern low-dose oral contraceptives include relative safety and a high degree of efficacy, decreasing the need for abortion or surgical sterilization; reduced risks of bacterial (but not viral) pelvic inflammatory disease and of endometrial and ovarian cancer; improved menstrual regularity, with less dysmenorrhea and blood flow; and, when low-dose combination (not progestogen-only) oral contraceptives are used, reduced acne and hirsutism. Major risks are cardiovascular. Preliminary data from nonrandomized studies suggest that oral contraceptives containing third-generation progestogens are associated with increased risk of venous thromboembolism, particularly in carriers of the coagulation factor V Leiden mutation. The risk of arterial thrombosis, such as myocardial infarction or stroke, may be directly related to estrogen dose, particularly in women who have hypertension, smoke, or are >35 years old. Considering that only users aged >/=30 years who smoke >/=25 cigarettes/d have a higher estimated mortality rate than that of pregnant women, the benefits of oral contraceptives appear to outweigh their risks.

Preferred frequency and characteristics of menstrual bleeding in relation to reproductive status, oral contraceptive use, and hormone replacement therapy use

This study addresses attitudes towards changes in menstrual bleeding patterns caused by oral contraceptives (OC) or hormone replacement therapy (HRT) and preferred changes in bleeding pattern with and without use of OC or HRT in relation to reproductive age group. Data were collected by means of telephone interviews with 325 women in each of four age groups (15-19, 25-34, 45-49, and 52-57 years). In total, 80.5% of currently menstruating women preferred one or more changes in bleeding pattern such as less painful, shorter, or less heavy periods, or amenorrhea. The majority of the menstruating women in all age groups preferred to have a bleeding frequency of less than once a month or never, whether the bleeding was spontaneous or induced by OC. In the case of HRT, amenorrhea was most preferred. These findings with respect to preferred bleeding frequency and OC may have important implications for health care providers and for future contraception development.

An evidence-based guideline for the management of heavy menstrual bleeding. Working Party for Guidelines for the Management of Heavy Menstrual Bleeding

AIMS

The objective of this guideline is to provide evidence-based recommendations for the management of regular heavy menstrual bleeding in women with no detectable pathology.

METHODS

A multidisciplinary working party was formed which met on four occasions over a 12 month period. The evidence from randomised controlled trials was summarised into evidence tables and guidelines were developed. A draft report was circulated in November 1997 prior to the final report which was published in July 1998.

RESULTS

A diagnostic and treatment algorithm was produced (Figure 1) as well as a full text report. The cost of implementing the guideline was considered and overall net savings of $6 million were likely.

CONCLUSIONS

An explicit evidence-based guideline on the management of heavy menstrual bleeding was produced. Both the Royal New Zealand College of Obstetricians and Gynaecologists and the Royal New Zealand College of General Practitioners endorsed this guideline.

[Laparoscopic evaluation of adolescent girls suffering from algomenorrhea and acyclic pelvic pain]

120 adolescent girl suffered from acyclic pelvic pain and dysmenorrhoe (algomenorrhoee) was presented. They were treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and oral contraceptive pills (OCPs) and underwent a laparoscopy to determine the etiology of pelvic pain. Endometriosis was classified according to American Fertility Society classification. Adolescent with pelvic pain not responding to therapy with NSAIDs and OCPs have different rate of endometriosis.

Syndromes of hyperandrogenism in women

BACKGROUND

Although the actual incidence is not known, hyperandrogenism seems common among Australian women. Most women with syndromes of hyperandrogenism present with symptoms such as acne, hirsutism and androgenic alopecia, or menstrual irregularity.

OBJECTIVES

The aim of this overview is: to put in perspective the various causes of hyperandrogenism in women, provide a guide to evaluation of affected women; and briefly review current management strategies.

DISCUSSION

Hyperandrogenism in women is also associated with significant health problems including infertility, insulin resistance, gestational diabetes, type 2 diabetes mellitus and dyslipidaemia which may or may not be linked with obesity.

Oral-contraceptive use and risk of hip fracture: a case-control study

BACKGROUND

Epidemiological studies indicate a protective effect of postmenopausal oestrogen therapy on the risk of osteoporotic fractures. Whether premenopausal oestrogen exposure in the form of oral contraceptives also reduces the risk of osteoporotic fractures remains uncertain.

METHOD

We did a population-based case control study of hip fracture among Swedish postmenopausal women, 50-81 years of age, through mailed questionnaires and telephone interviews. Of those women who were eligible, 1327 (82.5%) cases and 3312 (81.6%) randomly selected controls responded.

FINDINGS

130 (11.6%) cases and 562 (19.1%) controls reported ever-use of oral contraceptives. Ever-use of oral contraceptives was associated with a 25% reduction in hip fracture risk (odds ratio 0.75 [95% CI 0.59-0.96]). Women who had ever used a high-dose pill (equivalent to > or = 50 microg ethinylestradiol per tablet) had a 44% lower risk for hip fracture than never-users (0.56 [0.42-0.75]). No overall trend was observed with duration of oral-contraceptive use, or time since last use. However, when making comparisons with women who have never used oral contraceptives, the odds ratios for hip-fracture were 0.69 (0.51-0.94) for use after age 40, 0.82 (0.57-1.16) for use at ages 30-39, and 1.26 (0.76-2.09) for use before age 30.

INTERPRETATION

Our results imply that in postmenopausal women, oral-contraceptive use late in reproductive life may reduce the risk of hip fracture, although we recognise the limitations of the case-control method.

A randomized double-blind placebo-controlled study to assess the effect of oral contraceptive pills on the outcome of medical abortion with mifepristone and misoprostol

This was a randomized double-blind placebo-controlled trial to determine the effect of oral contraceptive (OC) pills taken immediately after medical abortion on the duration of bleeding and complete abortion rate. Two hundred women in the first 49 days of pregnancy were given 200 mg mifepristone orally followed by 400 microg misoprostol vaginally 48 h later. One day later, they were randomized to receive either OC pills (30 microg of ethinyl oestradiol and 0.15 mg of levonorgestrel per tablet) or placebo for 21 days. The complete abortion rates were 98% in the OC group and 99% in the placebo group. The median duration of bleeding was similar: 17 (range: 5-57) days in the OC group and 16 (range: 6-55) days in the placebo group. In the OC group there was a small but significant fall in the haemoglobin concentration by 14 days (5.3 g/dl) after administration of mifepristone. The incidence of side-effects was similar in the two groups. We conclude that the use of OC pills does not decrease the duration of bleeding after medical abortion nor does it affect the abortion rate.

Cycle control with oral contraceptives: A review of the literature

Comparing the degree of cycle control provided by various oral contraceptives is problematic. The inherent limitations, small demonstrated differences, and differing methods of data presentation characteristic of these trials support the conclusion that it is almost impossible to compare the bleeding patterns of one preparation with those of another. Chlamydial infection, smoking, and inconsistency of use are factors that have significant effects on rates of spotting and breakthrough bleeding. Clinicians must alert patients to the possibility of intermenstrual bleeding and educate them with regard to the importance of continued, consistent oral contraceptive use to minimize those problems among pill users in their practices.

Moderate physical activity in relation to mammographic patterns

High-risk mammographic patterns may be used as a surrogate end point for breast cancer in etiologic research as well as in prevention studies. Physical activity may be one of the few modifiable risk factors for breast cancer. We examined the relationship between physical activity and mammographic patterns among 2720 Norwegian women, ages 40-56 years, who participated in both the Second and Third Tromsø studies. Epidemiologic data were obtained through questionnaires. Two questions from the Second Tromsø study and five questions from the Third elicited information on physical activity. The mammograms were categorized into five groups based on anatomical-mammographic correlations. For analysis, patterns I through III were combined into a low-risk group and patterns IV and V into a high-risk group. Odds ratios that were adjusted for age, education, menopausal status, body mass index, parity, age at menarche, oral contraceptive use, and alcohol intake, with 95% confidence intervals, were estimated using logistic regression. Women who reported moderate physical activity, i.e., more than 2 h/week, were 20% less likely (odds ratio, 0.8; 95% confidence interval, 0.6-1.1) to have high-risk mammographic patterns compared with those who reported being inactive. This relationship remains consistent when stratified by menopausal status, parity, and tertiles of body mass index. However, all of the associations between various measures of physical activity and high-risk patterns found in this study are weak with confidence intervals that include 1.0. Thus, chance is a reasonable explanation for the weak associations found. The relationship between physical activity and high-risk patterns should be examined further as a means to explore the biologic mechanisms relating physical activity to breast cancer risk.