Endometrial response to the use of a sequential oral contraceptive

Belgium is 1 of the few countries where sequential oral contraceptives are still commercially available. The authors investigated the endometrial effect of Ortho-Novum SQ (14 tablets of 100 mcg mestranol and 7 tablets of 100 mcg mestranol + 2 mg norethisterone) in 222 biopsy specimens obtained from 184 asymptomatic Caucasian women (mean +or- s.d, age and parity, 34.6 +or- 6.7 and 2.0 +or- 1.0, respectively) who had used this sequential OC during an average of 52.5 months. Notwithstanding predominantly longterm use of Ortho-Novum SQ, 43% of the tissue samples had normal proliferative or luteal endometrium. The data suggest a positive correlation between the endometrial response and the duration of pill use. No premalignant or malignant changes were found. In 15 of 24 subjects for whom multiple biopsy specimens were available, the histological picture was static; 7 showed regression and only in 2 were the changes progressive, although never more severe than minor 'class 2' lesions. These results, which are at variance with those reported for users of other sequential brands (mainly Oracon), suggest that prolonged use of Ortho-Novum SQ does not enhance the risk of endometrial cancer in premenopausal women having no additional risk factors for the development of this type of neoplasia.

Comparative study on the acceptability of two modern monophasic oral contraceptive preparations: 30 microgram ethinyl estradiol combined with 150 microgram desogestrel or 75 microgram gestodene

Cycle control and tolerability of two monophasic oral contraceptive pills containing 30 microg ethinyl estradiol (EE) with either 150 microg desogestrel (DSG) or 75 microg gestodene (GSD) were compared in women starting oral contraception. A minimum of 200 healthy women at risk for pregnancy were to be treated for a total of 6 cycles per patient in a prospective, randomized open parallel-group multicenter trial. Two hundred and forty-one subjects were randomized, 115 to DSG/EE and 126 to GSD/EE. Compliance to the study preparation was high (around 95%) in both groups and no pregnancies occurred during the study. Cycle control was excellent; there were no differences between the two groups with regard to incidence of spotting and breakthrough bleeding or duration and intensity of withdrawal bleeding. Side-effects were mild and in general comparable in the two groups. Both at baseline and during treatment, a higher proportion of women taking GSD/EE complained about breast tenderness. This resulted in more early withdrawals because of breast tenderness in the GSD/EE group. It was concluded that monophasic DSG/EE and GSD/EE are equally effective, have similar cycle control and both are generally well tolerated.

Consultation patterns and provision of contraception in general practice before teenage pregnancy: case-control study

OBJECTIVES

To determine patterns of consultation in general practice and provision of contraception before teenage pregnancy.

DESIGN

Case-control study, with retrospective analysis of case notes.

SETTING

14 general practices in Trent region.

SUBJECTS

240 registered patients (cases) with a recorded conception before the age of 20. Three controls per case were matched by age and practice.

MAIN OUTCOME MEASURES

Consultations in general practice and provision of contraception in the 12 months before conception and recorded provision of contraception at any time before conception.

RESULTS

Overall, 223 cases (93%) had consulted a health professional at least once in the year before conception, 171 (71%) had discussed contraception in this time, and 121 (50%) had been prescribed oral contraception. Cases were more likely to have consulted in the year before conception than controls (odds ratio 2. 70, 95% confidence interval 1.56 to 4.66). Most of the difference was owing to consultation for contraception. Overall, 53 cases (22%) resulted in a termination of pregnancy. Cases whose pregnancy ended in a termination were more likely to have received emergency contraception than either their controls (3.21, 1.32 to 7.79) or cases resulting in other outcomes (3.01, 1.06 to 8.51).

CONCLUSIONS

Most teenagers who became pregnant attended general practice in the year before pregnancy, and many had sought contraceptive advice. The reluctance of teenagers to attend general practice for contraception may be less than previously supposed. The association between provision of emergency contraception and pregnancy ending in termination emphasises the need for continuing follow up of teenagers consulting for this form of contraception.

Relationship of hormonal contraception and cervical ectopy as measured by computerized planimetry to chlamydial infection in adolescents

BACKGROUND

Adolescents are at increased risk for chlamydial infection and its sequelae. Hormonal contraception and cervical ectopy were previously suggested risk factors for chlamydia.

GOAL

To determine if chlamydia is more prevalent in female participants with greater ectopy and in hormonal contraceptive users.

STUDY DESIGN

Ninety-seven adolescent females aged 11 to 20 years were recruited from two Baltimore inner-city clinics. After administering a reproductive history questionnaire, endocervical specimens were tested for Chlamydia trachomatis by polymerase chain reaction. After acetic acid application to the cervix, cervical photographs were taken, the area of ectopy was quantified by computerized planimetry, and ectopy was categorized as none (0mm2), mild (< 22mm2), and moderate (> 22mm2). The likelihood of chlamydia by ectopy and type of hormonal contraceptive use was determined by logistic regression adjusted for age and sexual partners.

RESULTS

The odds of chlamydial infection was similar in persons with mild ectopy compared with no ectopy (adjusted odds ratio [OR], 0.76; 95% CI, 0.14-4.03), and in persons with moderate ectopy compared with no ectopy (adjusted OR, 1.94; 95% CI, 0.40-9.39). The likelihood of chlamydia was higher in depot-medroxyprogesterone acetate users compared with nonhormone users (adjusted OR, 5.44; 95% CI, 1.25-23.6). Oral contraceptive users did not have an increased likelihood of chlamydia (adjusted OR, 0.92; 95% CI, 0.10-8.78).

CONCLUSION

Using a new, reliable, and standardized technique to quantify cervical ectopy, the authors did not find an elevated prevalence of chlamydial infection in adolescents with cervical ectopy. Depot-medroxyprogesterone acetate use may increase the risk of chlamydial infection compared with combined estrogen-progestin oral contraceptives.

Acceptability of a novel vaginal microbicide during a safety trial among low-risk women

CONTEXT

The increasing recognition that women who are unable or unwilling to discuss or use condoms with their sexual partners need female-controlled methods for preventing sexually transmitted diseases (STDs), including HIV, has led to considerable focus on the development of vaginal microbicides. While many such products are being tested for safety and effectiveness, clinical trials generally overlook another key factor in a product's impact on infection rates-its acceptability to users.

METHODS

A Phase I clinical trial of a microbicidal gel included an assessment of the product's acceptability among 27 low-risk participants. Information on acceptability was gathered from structured interviews, participants' daily diaries and unstructured exit interviews.

RESULTS

Participants reported only minor side effects of product use, such as itching, burning and difficulty urinating; two women developed candida infections while participating in the study. None of the side effects could be conclusively linked to use of the gel. Some women noted product discharge and messiness as drawbacks of the method, but this experience varied according to how often the women applied the gel. For example, one-third of those who used it once daily said that at least some of the time, it was too "wet or drippy," compared with two-thirds of women who inserted the gel twice a day. However, participants considered these "nuisance factors" that could be outweighed by the potential protective characteristics of the product. The majority reported that they would use the product if it were available and proven efficacious, and if they perceived that they were at risk of STD infection.

CONCLUSIONS

Additional testing of this product is urgently needed. Furthermore, as other products approach Phase I testing, acceptability assessments should be a key component of clinical trials.

Depressive symptoms in users and non-users of depot medroxyprogesterone acetate

To evaluate the possible effects of depot medroxyprogesterone acetate (DMPA) injectable contraception on depressive symptoms, we conducted a population-based prospective study with women aged 18-39 years old enrolled at a health maintenance organization. At baseline, 183 women used DMPA and 274 were non-users. Data on depressive symptoms and on factors potentially related to DMPA use and depression were collected by questionnaire at 6-month intervals for up to 3 years. In multivariate longitudinal analysis, we found an increased likelihood of reporting depressive symptoms among continuous DMPA users (OR = 1.44; 95% CI = 1.00-2.07) and discontinuers (OR = 1.60; 95% CI = 1.03-2.48) when compared to non-users. Women who discontinued DMPA use had elevated depressive symptoms prior to discontinuation (OR = 2.30; 95% CI = 1.42-3.70) and immediately following discontinuation (OR = 2.46; 95% CI = 1. 46-4.14), and depressive symptoms subsided at subsequent visits relative to non-users. Our prospective analyses found an association between DMPA use and depressive symptoms but further research is needed to determine whether the relationship is causal.

The incidence of actinomyces-like organisms in Papanicolaou-stained smears of copper- and levonorgestrel-releasing intrauterine devices

Actinomyces-like organisms (ALOs) are a common finding in Papanicolaou-stained cervico-vaginal smears (PAP smears) of women using an intrauterine device (IUD). The incidence of ALOs positive PAP smears depends on the type of IUD. Pelvic actinomycosis is a severe disease that may require hysterectomy and salpingo-oophorectomy. In a retrospective study we compared the incidence of ALOs positive PAP smears in users of the new levonorgestrel-releasing intrauterine device (LNG-IUD) (n = 52) with the incidence in Multiload Copper IUD (ML375) users (n = 104). All IUDs had been inserted from 1996-1998. Women with a follow-up period of more than 9 months were included into the final analysis (LNG-IUD: n = 34; ML375: n = 65). The incidence of ALOs in LNG-IUD users (2.9%) was significantly lower than in ML375 users (20%). Clinical consequences of ALOs positive PAP smears are discussed controversially. The low incidence in the LNG-IUD users probably leads to less IUD-removals, reinsertions and less pelvic-inflammatory-diseases.

Knowledge and willingness to use emergency contraception among low-income post-partum women

We performed a multivariate analysis to determine factors associated with knowledge and willingness to use emergency contraception in a consecutive sample of 371 post-partum women from an inner-city public hospital. Women were queried about previous contraceptive use, pregnancy history including abortions and unplanned pregnancies, and demographic characteristics. Outcomes included knowledge of emergency contraception and willingness to use it. Questionnaires were conducted in person, in English or Spanish.Of 371 women, 3% had used emergency contraception, 36% had heard of it, and 7% knew the correct timing for use. Two-thirds of the population indicated a willingness to use emergency contraception in the future. Factors positively associated with knowledge included being a teenager or more than 30 years old, prior use of condoms, and history of an elective abortion. Being multiparous, monolingual Spanish-speaking, or Asian were negatively associated with knowledge. Willingness to use emergency contraception was positively associated with being multiparous and negatively associated with a higher income, moral or religious objections to the use of emergency contraception, a belief that it is unsafe or a perception that it is an abortificient. Knowledge about emergency contraception, especially correct timing, remains low. Multiparous women should receive increased education given their lack of knowledge but willingness to use emergency contraception. In order to increase the acceptability of emergency contraception, educational efforts must include accurate information about its mechanism of use and safety.

The case of Norplant as an example of media coverage over the life of a new health technology

BACKGROUND

The contraceptive implant Norplant (levonorgestrel) had a fairly short life in the UK. This made it a convenient subject for a case study of how media coverage alters over time. We set out to produce a critical description of national newspaper coverage of Norplant over the course of its use in the UK.

METHODS

We searched newspaper databases and press-clippings files for articles about Norplant printed between 1992 and 1996. For those that met our inclusion criteria, we extracted bibliographical data, made a standardised judgment about the "slant" of the article towards Norplant, and used qualitative techniques to analyse the content of the articles.

FINDINGS

101 national newspaper articles were included in the study. Norplant attracted media coverage over the course of its career, but the slant of articles shifted dramatically over time from a favourable to a negative presentation. This reflected the use of different story types over the course of time. Early reports presented Norplant very positively as either a clear improvement on existing contraceptive methods or a valuable addition to the range. Any disadvantages were down-played. The positive image of Norplant was reinforced immediately after its official launch by reports that it was in great demand but women might be denied access to it. Less than a year later, however, newspaper reports about Norplant were dominated by the stories of individual women who had had bad experiences with the product.

INTERPRETATION

Three main reporting themes were seen. At first, Norplant was presented as a positive new development, and one that might be denied to people. In later coverage it became a flawed and damaging product. These themes recur in media reporting of health technologies, and the fact that they occur at different stages in a product's career means that a balanced assessment of the technology is not usually feasible from media reporting at any one time. An appreciation of the forms and implications of these reporting frameworks could help health-care providers and users to appraise media reports more critically.

Mesigyna once-a-month combined injectable contraceptive: experience in Latin America

A phase III clinical study was carried out among 534 fertile Latin American women to evaluate cycle control, side effects, and contraceptive efficacy of a once-a-month combined injectable, Mesigyna, consisting of 50 mg norethisterone enanthate and 5 mg estradiol valerate. The pregnancy rate at 1 year was 0 per 100 woman-years for a total experience of 4688 woman-months. The overall discontinuation rate at one year was 17.9%. Discontinuation rate for bleeding problems was 5.1%. The Colombian women had a significant increase (p <0.001) in bleeding problems compared to other countries. The discontinuation rate for amenorrhea was 1.1%. There were no significant differences between the groups regarding discontinuation for other medical or non-medical reasons. Mean weight gain after one year of use was 1.02 kg. Mesigyna is an appropiate once-a-month injectable contraceptive for Latin American women since it is highly effective and its perception of normal menstrual bleeding is of importance in the Latin American population.