Bone density in women receiving depot medroxyprogesterone acetate for contraception

OBJECTIVE

To determine if the use of the injectable contraceptive depot medroxyprogesterone (DMPA), which reduces ovarian oestrogen production, is associated with changes in bone density.

DESIGN

Population study. DMPA users were compared with two control groups selected from larger population studies and individually matched for several putative determinants of bone density (age, race, body mass index, and years of oestrogen deficiency). Controls and DMPA users were matched without prior knowledge of their bone density measurements.

SETTING

Teaching hospital and community family planning clinics.

SUBJECTS

30 current users of DMPA with a minimum five years' previous use, 30 premenopausal controls, and 30 postmenopausal controls.

MAIN OUTCOME MEASURE

Lumbar spine and femoral neck bone mineral density assessed by dual energy x ray absorptiometry.

RESULTS

Compared with premenopausal controls matched for age, race, and body mass index, DMPA users had significantly reduced bone density in the lumbar spine (mean difference 7.5% (95% confidence interval 1.9% to 13.1%), p = 0.002) and in the femoral neck (6.6%, (0.8% to 12.3%), p = 0.007). Compared with postmenopausal controls matched for body mass index and duration of oestrogen deficiency, DMPA users had greater bone density in the lumbar spine (8.9% (4.3% to 13.5%), p = 0.001), but in the femoral neck the difference in bone density was less (4.0% (-0.4% to 8.5%), p = 0.04).

CONCLUSIONS

Women using DMPA have bone density values intermediate between those of normal premenopausal and postmenopausal controls; thus, the degree of oestrogen deficiency induced by DMPA may have an adverse effect on bone density.

Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaican Study

There is little unequivocal evidence that nutritional supplementation of undernourished children has a beneficial effect on their mental development. The effects of nutritional supplementation, with or without psychosocial stimulation, of growth-retarded (stunted) children aged 9-24 months were assessed in a study in Kingston, Jamaica. 129 children from poor neighbourhoods were randomly assigned to four groups--control, supplemented only, stimulated only, and supplemented plus stimulated. A group of matched non-stunted children (n = 32) was also included. The supplement comprised 1 kg milk-based formula per week for 2 years, and the stimulation weekly play sessions at home with a community health aide. The children's development (DQ) was assessed on the Griffiths mental development scales. Initially the stunted groups' DQs were lower than those of the non-stunted group, and those of the control group declined during the study, increasing their deficit. Stimulation and supplementation had significant independent beneficial effects on the children's development. Estimates of the supplementation effect ranged from 2.2 (95% confidence limits-1.4, 5.7) for the hand and eye subscale to 12.4 (5.4, 19.5) for the locomotor subscale and those for the stimulation effect from 6.4 (2.8, 10.0) for hand and eye to 10.3 (3.3, 17.3) for locomotor. The treatment effects were additive, and combined interventions were significantly more effective than either alone. These findings suggest that poor mental development in stunted children is at least partly attributable to undernutrition.

An educational intervention on promotion of breast feeding

This study was designed to search for an effective method to promote exclusive breast feeding among Turkish city women delivering in hospitals. Four hundred and forty-two primiparae with uncomplicated deliveries and with healthy infants with birthweights of greater than 2500 g were exposed to a group educational session on breast feeding after birth, followed by one repeat session at home. Four hundred and ninety-nine women served as controls. All homes were visited monthly for 6 months by independent observers and data relevant to the feeding of the infants were collected. Weight measurements of 176 infants were taken at age 4 months. The study and control mothers were similar in sociodemographic characteristics which reflected a low socio-economic/educational background but relatively good housing conditions. Although significant differences in frequency of exclusive breast feeding were found between the study and control groups, the impact of the intervention was much lower than our expectations and short-lived. Type of feeding was not related to sex or birthweight of the infant, nor to maternal variables. Weight at age 4 months was within normal limits and similar in the study and control groups. It was concluded that lack of up-to-date information on infant feeding was the main obstacle to breast feeding in urban groups in Turkey, and that the impact of an educational intervention limited to the first week after delivery was lost within the first 2 months.

An educational intervention on promotion of breast feeding complemented by continuing support

The study, aiming to document the effect of continued support for mothers on frequency of exclusive breast feeding, was carried out by inclusion of breast feeding counselling in the context of well-baby care. One hundred and forty-six mothers who had been exposed to two educational sessions on breast feeding after delivery were given appointments to bring their baby to the paediatric hospital for well-baby care. The mother-infant pairs were followed by the same two residents for 4 months. Mean number of visits was six. A conscious effort was made during all visits to influence the mothers and their close relatives towards exclusive breast feeding. It was observed that in a large proportion of the infants, breast milk was being supplemented with water at the time of the first visit and no further effort was made to change this traditional behaviour. Comparison of the results with a group of mothers who had been exposed to similar educational sessions after delivery but without further support showed a striking increase in frequency of exclusive breast feeding (breast milk and water) in the supported group.

The effect of insecticide-treated bed nets on mortality of Gambian children

Insecticide treatment of bed nets ("mosquito nets") may be a cheap and acceptable method of reducing the morbidity and mortality caused by malaria. In a rural area of The Gambia, bed nets in villages participating in a primary health-care (PHC) scheme were treated with permethrin at the beginning of the malaria transmission season. Additionally, children aged 6 months to 5 years were randomised to receive weekly either chemoprophylaxis with maloprim or a placebo throughout the malaria transmission season. We measured mortality in children in PHC villages before and after the interventions described, and compared this with mortality in villages where no interventions occurred (non-PHC villages). About 92% of children in PHC villages slept under insecticide-treated bed nets. In the year before intervention, mortality in children aged 1-4 years was lower in non-PHC villages. After intervention, the overall mortality and mortality attributable to malaria of children aged 1-4 in the intervention villages was 37% and 30%, respectively, of that in the non-PHC villages. Among children who slept under treated nets, we found no evidence of an additional benefit of chemoprophylaxis in preventing deaths. Insecticide-treated bed nets are simple to introduce and can reduce mortality from malaria.

Impaired cell-mediated immunity in Papua New Guinean infants

Immune function was studied in Papua New Guinea highland infants with pneumonia, healthy highland controls and expatriate controls under the age of 15 months. Delayed-type hypersensitivity to tuberculin was depressed in highland pneumonia patients and highland controls as were CD4/CD8 T-lymphocyte ratios. The differences between highland and expatriate infants were more pronounced after 6 months of age, suggesting an environmental effect. Serum immunoglobulin and complement concentrations were higher in highland infants than in expatriate controls. Indices of nutritional status were similar in highland and expatriate infants but iron deficiency was more common in the highland infants in the study.

Long-term treatment of hirsutism: desogestrel compared with cyproterone acetate in oral contraceptives

OBJECTIVE

Effectiveness of 2-year treatment of hirsutism with low estrogen oral contraceptives (OCs) containing nonandrogenic or antiandrogenic progestogen. Evaluation of changes in plasma lipids.

DESIGN

Ten patients treated with desogestrel 150 micrograms + 30 micrograms ethinyl estradiol, 6 with desogestrel 150 micrograms + 50 micrograms ethinyl estradiol, 10 with cyproterone acetate 2 mg + 35 micrograms ethinyl estradiol. Random allocation. Paired comparisons.

CONTROL GROUP

19 normal women, not treated.

SETTING

Academic tertiary care.

PATIENTS

Women with hirsutism (idiopathic and/or polycystic ovary), 24 of 26 completed treatment.

INTERVENTION

Two-year treatment.

MAIN OUTCOME MEASURES

Hirsutism score, plasma testosterone, and lipids.

RESULTS

Initial hirsutism scores (11.8 +/- 0.6 SE) declined with treatment (-7.2 +/- 0.4, P less than 0.01) to 4.7 +/- 0.6, almost reaching control (3.6 +/- 0.3). Initial plasma cholesterol (4.33 mmol/L +/- 0.30 SE), similar to control (4.78 +/- 0.24), increased slowly over 2 years (+2.04 +/- 0.34, P less than 0.01). High-density lipoproteins cholesterol (1.05 mmol/L +/- 0.04 SE), similar to control (1.12 +/- 0.07), did not change the 1st year and increased at 2 years (+0.57 +/- 0.11, P less than 0.01). No differences appeared among treatment groups.

CONCLUSIONS

Treatment is very effective, 2 years for best results. The OCs tested are equally efficacious. Changes in plasma lipids are of some concern but of difficult interpretation.

Risk factors for ectopic pregnancy: a case-control study in France, with special focus on infectious factors

A case-control study was conducted in 1988 in seven Paris area maternity hospitals to evaluate the role of several risk factors, particularly infectious factors, in ectopic pregnancy. A total of 279 cases and 279 controls were compared for sociodemographic characteristics, cigarette smoking, sexual, reproductive and surgical histories, and conditions of conception. Pelvic inflammatory disease confirmed by celioscopy (odds ratio (OR) = 5.5, 95% confidence interval (CI) 2.1-13.9) and Chlamydia trachomatis seropositivity (OR = 3.9, 95% CI 2.3-6.7) appeared to be important risk factors for ectopic pregnancy. Other risk factors found to be associated with an increased risk of ectopic pregnancy were dose-related cigarette smoking at the time of conception (ORs 1.3 to 2.5), appendectomy (OR = 1.6, 95% CI 1.1-2.5), prior tubal surgery (OR = 5.1, 95% CI 1.7-15.4), induced conception cycle (OR = 3.2, 95% CI 1.1-9.3), and prior ectopic pregnancy (OR = 13.3, 95% CI 4.5-39.2). However, some of the latter risk factors, i.e., prior tubal surgery, prior ectopic pregnancy, and perhaps appendectomy, may be considered to be the results of pelvic inflammatory disease and sexually transmitted diseases. Maternal age, parity, prior induced abortion, and prior spontaneous abortion were not associated with ectopic pregnancy. Use of intrauterine device, progestagen micropill, and also combined estroprogestative pill at the time of conception were associated with a better prevention of intrauterine pregnancy than of ectopic pregnancy. These findings confirm the importance of several previously reported risk factors of ectopic pregnancy: sexually transmitted diseases, cigarette smoking, and prior ectopic pregnancy. They also identified new risk factors, appendectomy and induced conception cycle, and revealed that the combined estroprogestative pill does not prevent ectopic pregnancy as effectively as it does intrauterine pregnancy.

The long term benefits of a comprehensive teenage pregnancy program

A comprehensive program was founded in 1982 to provide adolescents with prenatal and family planning care. The program's impact through its first five years of operation on medical aspects of pregnancy course and fetal outcome will be the subject of a separate report. This study examines subsequent maternal and infant health of the patients attending the program compared to a control group. Four hundred ninety-eight adolescents and their newborns attending the program's mother-baby family planning clinic from 1982 to 1989 (subject group) were compared to ninety-one adolescents and their newborns receiving postpartum family planning and pediatrics clinics from 1980 through 1989 (control group). Seventy-five percent of the subject group regularly attended mother-baby clinic, compared to 18% of the control group attending family planning and pediatric clinics (P less than or equal to .0001). The subject group experienced less maternal and infant morbidity, greater school attendance, graduation, employment, and contraceptive use than the control group (P less than or equal to .0001). Many parameters improved with each program year indicating continued wide acceptance of our program by area adolescents.

Outpatient microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy

A prospective study of 17 cases of microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy was performed. Inclusion criteria included age less than 43; weight less than ideal body weight plus 20%; documentation of ovulation; 2 cm of proximal oviduct on hysterosalpingography; and a normal semen analysis or postcoital test. A comparison group of the 5 cases of sterilization reversal performed by a standard inpatient technique during the same period was analyzed. The study technique was performed on an outpatient basis in 15 of the 17 cases, 12 patients (71%) conceived 13 intrauterine pregnancies, one ectopic pregnancy occurred, and total patient costs and time until return to work were significantly less with the study versus standard technique.

Morphometric study of the human endometrium following continuous exposure to levonorgestrel released from vaginal rings during 90 days

The effects of vaginal devices releasing levonorgestrel (LNG) at a constant rate of approximately 20 micrograms/24 hrs on the human endometrium were studied in a group of 69 normally menstruating women during a period of 90 days of continuous use. Peripheral blood samples were withdrawn three times weekly starting at day 10 of a pretreatment (control) cycle and then three times weekly from day 60 to 90 of the treatment period. The levels of LNG, estradiol, progesterone and sex hormone binding globulin (SHBG) were analyzed by radioimmunoassay techniques. Endometrial biopsies were obtained in the luteal phase of the pretreatment cycle and on day 84-87 of the treatment period. Increased bleeding occurred in most subjects exposed to the LNG-releasing device; the mean number of bleeding and spotting days was 26.4 +/- 8.9 S.D. which exceeded that found in their control cycle. Morphometric analyses of the endometrial biopsies using 9 quantitative indices, revealed highly significant changes in glands and stroma following the use of the LNG-releasing vaginal device. Irrespective of the circulating steroid levels, the administration of LNG significantly diminished the glandular diameter (p less than 0.001), reduced the volume density of the glands (p less than 0.001) and of the glandular epithelium (p less than 0.001). and modified the ratio glandular epithelium: glands (p less than 0.001). It is concluded that levonorgestrel released at a rate of 20 micrograms/24 hrs, induces characteristic changes in the histologic structure of the human endometrium. Although no simple correlation has been found between any of the endometrial indices and the numbers of bleeding/spotting days or bleeding days, the changes as such may represent biochemical alterations which could be predisposing factors for intermenstrual bleeding and spotting. To prove a causal relationship between morphological and biochemical changes and changes in bleeding patterns, further in-depth studies may be required.

Relation of childhood malnutrition to parental education and mothers' nutrition related KAP

Severely malnourished children (26), weight for age 55.27 +/- 3.17, were identified in a colony of predominantly Muslim urban slum dwellers of low economic status. An equal number of normally nourished children matched for age, sex and per capita income were identified. A strong relation was found between nutritional status of the subjects and educational level of their mothers (P less than 0.025). Father's education was unrelated to childrens' nutritional status. A thirty seven point questionnaire was administered to the mothers to record their nutritional knowledge, attitudes and practices (KAP). Analysis revealed that better KAP in relation to 16 of these 37 questions was not associated with better nutritional status. Seven questions were found to have only a weak association. The remaining 14 questions were identified as important for a nutrition education programme. Comparison of nutritional KAP score based on these 14 questions in case of mothers of normal and severely malnourished children revealed a significantly higher score in the former. Questions related to growth monitoring and breast feeding were not found to be important. No significant association was found between mothers' KAP and educational level. It is concluded that (i) Maternal education and KAP are significantly and independently associated with childrens' nutritional status. (ii) The content areas of knowledge, attitudes and practices significantly associated with nutritional status pertain to nutritional requirements of children, nutritional value of foods, immunisation, hygiene, oral rehydration and diarrhea.

Seminal estrone, estrone sulfate, and estradiol-17 beta levels in fertile and infertile males

The seminal levels of estrone (E1), estrone sulphate (E1S), and estradiol-17 beta (E2) were measured simultaneously after a chromatographic step in the semen samples of 79 men, including fertile volunteers, vasectomized subjects, and patients with oligozoospermia and secretory azoospermia. E1S concentrations in seminal plasma were higher than in serum (with a semen/serum ratio of approximately 2). Seminal E1 and E1S levels in oligozoospermic subjects were significantly decreased compared to controls (p less than 0.02 and p less than 0.03, respectively). The seminal E1S concentration was significantly reduced in azoospermic patients (p less than 0.02) and to a greater extent in vasectomized subjects (p less than 0.001). As seminal E1S is likely to be mainly of testicular origin, the decreased seminal E1S levels in oligoazoospermia are an index of impaired testicular function.

Coronary heart disease risk markers in users of low-dose oral contraceptives

Seven combination oral contraceptives (OCs) were studied for their effects on glucose, insulin, triglyceride and lipoprotein concentrations. Subjects included 925 women using fixed-dose (monophasic) or variable-dose (triphasic) formulations and 418 premenopausal women not using OCs. The monophasics contained 150 or 250 micrograms of levonorgestrel, 500 or 1,000 micrograms of norethindrone or 150 micrograms of desogestrel as the progestin. Triphasic progestin doses were 50-125 micrograms of levonorgestrel or 500-1,000 micrograms of norethindrone. All the formulations increased the fasting serum triglycerides. No changes were seen in serum total cholesterol. The effects on serum lipoproteins depended on the progestin type and dose. Monophasics containing 500 micrograms of norethindrone or 150 micrograms of desogestrel lowered low density lipoprotein (LDL) cholesterol and increased high density lipoprotein (HDL) cholesterol. Monophasics containing levonorgestrel reduced HDL cholesterol. The triphasics did not affect LDL or HDL cholesterol but altered the balance of HDL subfractions. All the formulations caused a deterioration in glucose tolerance and insulin resistance and increased pancreatic insulin secretion. The greatest effects were seen with formulations containing levonorgestrel. The study showed that a reduction in the progestin dose and use of novel progestins can reduce the potentially adverse effects of OCs on metabolic risk markers for coronary heart disease.

Intrapartum and neonatal mortality in a traditional indigenous community in rural Guatemala

We identified high rates of intrapartum and neonatal mortality among children born in a traditional indigenous community in rural Guatemala. To examine the potential association of maternal characteristics and obstetric and newborn care practices with this mortality, we conducted a retrospective case-control study. Case were infants born in 1986 and 1987 who died during birth or in the first month of life, as identified by civil records; for each case, the next child born who survived the first month of life was selected as control. In interviews with mothers of cases and controls standardized data were collected on demographic and socioeconomic characteristics of the mother, her general obstetric history, history of the pregnancy, labor, and delivery, condition and care of the infant at birth, and morbidity and treatments of the infant after birth. Sixty-one cases and their controls were included in the study. Based on clinical condition at birth, we subcategorized cases into infants stillborn or dying in the first 24 hours of life (intrapartum cases) and those dying in the first month after day 1 (neonatal cases). Factors significantly associated with both subcategories of cases were maternal illiteracy, primagravity, failure to use "modern" prenatal care, and inter-birth interval less than 14 months. Intramuscular injection of oxytocin by the midwife during labor, and performance of greater than or equal to 3 vaginal examinations by the midwife were each significantly associated only with the intrapartum subcategory of cases. Mother's estimate of infant size as "smaller than normal" was associated with neonatal, but not with intrapartum, cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Uveal melanoma, hormonal and reproductive factors in women

In a case-control study, we explored a potential association between uveal melanoma and reproductive factors in women. Responses from telephone interviews of 186 women diagnosed with uveal melanoma were compared with responses of 423 women without this disease. All women resided in 11 U.S. western states. We observed a decreased risk of uveal melanoma for women who had ever been pregnant [relative risk (RR) = 0.60, 95% confidence interval (CI) = 0.37 -0.95], with an increase in this protective effect with more live births after adjustment for age, menopausal status, eye color, and skin sensitivity to the sun (1-2 births, RR = 0.47,95% CI 0.29-0.78; 3-4 births, RR = 0.38, 95% CI = 0.22-0.64; 5 or more births, RR = 0.33, 95% CI = 0.15-0.71). The largest effect was observed between nulliparous and parous women. No other reproductive factors, including use of oral contraceptives or postmenopausal estrogens, were shown to be related to risk for uveal melanoma. We conclude that most reproductive factors in this population play little or no role in the etiology of uveal melanoma. The association with number of live births must be confirmed in other studies to assure that it is unrelated to confounding factors not measured in this study.

Oral contraceptives and breast cancer: a French case-control study

The relationship between the risk of breast cancer and oral contraceptive use was investigated in a case-control study conducted in France between 1983 and 1987 in five public hospitals. Some 464 cases aged 25 to 56 years and 542 matched controls were interviewed about their history of the use of oral contraceptives (OC). Results are given for the entire population and for the subgroup of 358 and 379 premenopausal cases and controls. The multivariate relative risk estimate, for ever user, was 1.5 (p less than 0.01) in the whole group as well as in the premenopausal subgroup (p less than 0.02). However, there was no evidence that the effect varied appreciably according to duration of use, age at first use, use before first full-term pregnancy (FFTP) and time since first or last use. The risk was not altered for any particular brand of OC. We conclude that, because of the widespread attention given to the relationship between OC use and breast cancer, information bias might be responsible for part of the excess in risk observed among OC ever users.

Induced abortions, contraceptive practices, and tobacco smoking as risk factors for ectopic pregnancy in Athens, Greece

A case-control study of the role of induced abortion and other factors on the subsequent occurrence of ectopic pregnancy was undertaken in 1986-1987 in Athens, Greece, where a similar study 20 years ago found a tenfold risk of ectopic pregnancy among women with one or more illegal induced abortions. Seventy women residents of Athens, consecutively admitted to the major state maternity hospital with a diagnosis of ectopic pregnancy, were individually matched with women with a newly diagnosed pregnancy of the same order as the ectopic index pregnancy. Two control women were found for each of 63 cases, but only one control for each of the remaining seven cases. All cases and controls were interviewed by the same qualified obstetrician. Statistical analysis was undertaken with stratification of individual matched triplets and pairs, as well as through conditional multiple regression procedures. The relative risk of recurrence of an ectopic pregnancy was 6.39 with 95% confidence interval (CI) 1.96-21.04. Miscarriages did not increase the risk of ectopic pregnancy. The relative risk for subsequent ectopic pregnancy among women with one or more induced abortion, compared to women without such abortions, was 1.87 (CI 0.84-4.16) controlling only for the matching factors, and 1.71 (CI 0.69-4.27) when marital status (a possible selection factor) was also accounted for in the conditional logistic regression. There was no evidence for increasing risk with increasing number of induced abortions. Past use of an intrauterine device (IUCD) was associated with a relative risk of 3.89 (0.72-21.02); the relative risk increased with the duration of use of the IUCD.(ABSTRACT TRUNCATED AT 250 WORDS)

Lack of effect of oral contraceptive use on the pharmacokinetics of quinine

The pharmacokinetics of quinine after a single 600 mg oral dose of quinine sulphate were studied in seven female subjects who used oral contraceptives and in seven age-matched female controls who did not. There were no significant differences (P greater than 0.05) in the maximum plasma concentration (Cmax) and the time of peak concentration (tmax) between the subjects who used oral contraceptives (Cmax = 5.3 +/- 1.0 (s.d.) mg l-1; tmax = 1.4 +/- 0.7 h) and the control subjects (Cmax = 5.6 +/- 0.9 mg l-1; tmax = 2.1 +/- 0.9 h). The mean elimination half-life of quinine in the oral contraceptives user group (12.5 +/- 1.9 h) was similar (P greater than 0.05) to that in the control group (11.8 +/- 2.7 h). The oral clearance of quinine in the oral contraceptive user group was 0.133 +/- 0.055 l h-1 kg-1 (range 0.073-0.233) and was not significantly different (P greater than 0.05) from that observed in the control group (0.125 +/- 0.025 l h-1 kg-1, range 0.075-0.148).