Use of levonorgestrel implants versus oral contraceptives in adolescence: a case-control study

Long-Acting Reversible Contraception, Condom Use, and Sexually Transmitted Infections: A Systematic Review and Meta-analysis

INTRODUCTION

Given mixed findings regarding the relationship between long-acting reversible contraception and condom use, this systematic review and meta-analysis synthesizes studies comparing sexually transmitted infection‒related outcomes between users of long-acting reversible contraception (intrauterine devices, implants) and users of moderately effective contraceptive methods (oral contraceptives, injectables, patches, rings).

METHODS

MEDLINE, Embase, PsycINFO, Global Health, CINAHL, Cochrane Library, and Scopus were searched for articles published between January 1990 and July 2018. Eligible studies included those that (1) were published in the English language, (2) were published in a peer-reviewed journal, (3) reported empirical, quantitative analyses, and (4) compared at least 1 outcome of interest (condom use, sexual behaviors other than condom use, sexually transmitted infection‒related service receipt, or sexually transmitted infections/HIV) between users of long-acting reversible contraception and users of moderately effective methods. In 2020, pooled ORs were calculated for condom use, chlamydia/gonorrhea infection, and trichomoniasis infection; findings for other outcomes were synthesized qualitatively. The protocol is registered on the International Prospective Register of Systematic Reviews (CRD42018109489).

RESULTS

A total of 33 studies were included. Long-acting reversible contraception users had decreased odds of using condoms compared with oral contraceptive users (OR=0.43, 95% CI=0.30, 0.63) and injectable, patch, or ring users (OR=0.58, 95% CI=0.48, 0.71); this association remained when limited to adolescents and young adults only. Findings related to multiple sex partners were mixed, and only 2 studies examined sexually transmitted infection testing, reporting mainly null findings. Pooled estimates for chlamydia and/or gonorrhea were null, but long-acting reversible contraception users had increased odds of trichomoniasis infection compared with oral contraceptive users (OR=2.01, 95% CI=1.11, 3.62).

DISCUSSION

Promoting condom use specifically for sexually transmitted infection prevention may be particularly important among long-acting reversible contraception users at risk for sexually transmitted infections, including adolescents and young adults.

Drug eluting implants in pharmaceutical development and clinical practice

Introduction: Drug eluting implants offer patient convenience and improved compliance through less frequent dosing, eliminating repeated, painful injections and providing localized, site specific delivery with applications in contraception, ophthalmology, and oncology.Areas covered: This review provides an overview of available implant products, design approaches, biodegradable and non-biodegradable polymeric materials, and fabrication techniques with a focus on commercial applications and industrial drug product development. Developing trends in the field, including expanded availability of suitable excipients, development of novel materials, scaled down manufacturing process, and a wider understanding of the implant development process are discussed and point to opportunities for differentiated drug eluting implant products.Expert opinion: In the future, long-acting implants will be important clinical tools for prophylaxis and treatment of global health challenges, especially for infectious diseases, to reduce the cost and difficulty of treating chronic indications, and to prolong local delivery in difficult to administer parts of the body. These products will help improve patient safety, adherence, and comfort.

Chlamydia Infection Among Adolescent Long-Acting Reversible Contraceptive and Shorter-Acting Hormonal Contraceptive Users Receiving Services at New York City School-Based Health Centers

STUDY OBJECTIVE

One concern regarding long-acting reversible contraceptive (LARC) use among female adolescents is the potential for sexually transmitted infection acquisition. Few studies investigate chlamydia infection among adolescent LARC users compared with other hormonal contraceptive method (non-LARC) users. We hypothesized that incident chlamydia infection would be similar in these 2 groups and that it would not be associated with adolescent LARC use.

DESIGN, SETTING, AND PARTICIPANTS

Secondary data analysis of electronic health records of adolescents who started using LARC (n = 152) and non-LARC methods (n = 297) at 6 New York City school-based health centers between March 2015 and March 2017.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Demographic characteristics, sexual risk factors, and occurrence of chlamydia infection over a period of 1 year were compared in the 2 groups using χ² tests and t tests. Multivariable logistic regression was used to test the association between LARC use and chlamydia infection adjusting for relevant covariates.

RESULTS

Among 422 adolescent patients tested the year after method initiation, 48 (11.4%) had at least 1 positive chlamydia test. The proportions of LARC users and non-LARC users with chlamydia infection were not statistically significantly different (10.9% vs 11.6%; P = .82). Multivariable analysis showed that LARC use was not associated with greater chlamydia risk (adjusted odds ratio, 0.84; 95% confidence interval, 0.41-1.43).

CONCLUSION

Adolescent LARC users did not have significantly higher chlamydia infection occurrence compared with non-LARC users the year after method initiation. Concern for chlamydial infection should prompt recommending condom use but should not be a barrier to recommending adolescent LARC use.

Effects of initiating a contraceptive implant on subsequent condom use: A randomized controlled trial

OBJECTIVE

To evaluate whether initiation of a contraceptive implant, a method of long-acting reversible contraception, reduces condom use, as measured by a biomarker of recent semen exposure [prostate-specific antigen (PSA)].

STUDY DESIGN

We conducted a randomized controlled clinical trial in which 414 Jamaican women at high risk for sexually transmitted infections (STIs) attending family planning clinics received the contraceptive implant at baseline ("immediate" insertion arm, N=208) or at the end ("delayed" insertion arm, N=206) of a 3-month study period. Participants were tested for PSA at baseline and two follow-up study visits and were asked about their sexual activity and condom use.

RESULTS

At baseline, 24.9% of women tested positive for PSA. At both follow-up visits, the prevalence of PSA detection did not significantly differ between the immediate versus delayed insertion arm [1-month: 26.1% vs. 20.2%, prevalence ratio (PR)=1.3, 95% confidence interval (CI)=0.9-1.9; 3-month: 25.6% vs. 23.1%, PR= 1.1, 95% CI=0.8-1.6]. The change in PSA positivity over the three study visits was not significantly larger in the immediate arm compared to the delayed arm (1-sided p-value of .15).

CONCLUSIONS

Contraceptive implants can be successfully introduced into a population at high risk of unintended pregnancy and STIs without a biologically detectable difference in unprotected sex in the short term. This information strengthens the evidence to support promotion of implants in such populations and can help refine counseling for promoting and maintaining use of condoms among women who choose to use implants.

IMPLICATIONS

Sex unprotected by a condom was not higher over 3 months in women receiving a contraceptive implant, compared with those not receiving the implant.

The impact of oral contraceptive initiation on young women's condom use in 3 American cities: missed opportunities for intervention

PURPOSE

To describe women's condom use and assess predictors of consistent condom use and dual method use in the 6 months after the initiation of oral contraception (OC).

METHODS

We conducted a planned secondary cohort analysis among women less than 25 years of age initiating oral contraceptives at public family planning clinics in Atlanta, Dallas and New York City, USA, as part of a randomized trial. These clinics provide care to predominantly African American or Hispanic women of low socioeconomic status. Participants completed interviews at enrollment and at 6 months after OC start. We used multivariate logistic regression to assess factors associated with consistent condom and dual method use at 6 months.

RESULTS

1281 participants met the inclusion criteria for this analysis. At enrollment prior to OC start, 28% were consistent condom users. In the six months after initiation of oral contraception, only 14% always used a condom and 4% always used dual methods. In multivariate analysis, receiving basic advice to always use a condom after OC initiation from a provider during the baseline clinic consultation was associated with a 50% increase in the odds of using condoms consistently. Only 28% of participants were given this condom use advice.

CONCLUSIONS

This study documents a decline in women's condom consistent use subsequent to initiation of the oral contraceptive and suggests that opportunities for positive intervention around condom use among women starting hormonal methods are being missed. Basic condom use advice, which is neither time consuming nor resource dependent, was associated with increased consistent use and should be immediately implemented in all family planning services.

Combined oral contraceptives' influence on weight, body composition, height, and bone mineral density in girls younger than 18 years: a systematic review

OBJECTIVE

Combined oral contraceptives (COCs) are increasingly used by adolescents. The aim of this review is to investigate the evidence regarding COCs' influence on weight, height and bone mineral density (BMD) in girls younger than 18 years.

METHOD

Systematic literature search using PubMed/Medline and Scopus (January 1990-February 2012) on COCs for girls under 18 years of age and the possible influence on body parameters. MeSH terms: Oral contraception; Adolescent; Weight; Body composition; Height; Bone mineral density.

RESULTS

There is no evidence that COCs induce weight gain in girls younger than 18 years. Obese girls are not at higher risk of gaining weight. COCs do not cause changes in body fat and lean mass beyond the changes caused by natural development. Moreover, growth and stature are unaffected. Few studies indicate that COCs have a negative impact on BMD, but the evidence is presently too limited for definite conclusions.

CONCLUSION

Studies in young users are few. Presently, there are no indications of a negative impact of COCs on weight, body composition or height. Lesser increases in BMD cannot be excluded. As the demand for COCs is increasing among the youngest girls, there is a need for prospective studies addressing this issue.

Dual use of condoms and contraceptives in the USA

Background Use of condoms in conjunction with other contraceptive methods has multiple benefits: prevention of unintended pregnancy, protection against sexually transmissible infections (STI), and sequentially, defence against the threat of infertility. However, few reviews compare dual method use prevalence or trends or systematically review the facilitators and barriers of dual method use across multiple studies. Methods: The authors review the literature on trends and covariates of dual method use in the USA among both nationally representative and smaller samples. Results: Although dual method use prevalence estimates vary widely across study populations, nationally representative estimates are consistently lower than Western European countries, who in turn report lower rates of unintended pregnancies and STI. The majority of published work on dual method use focuses on adolescents. Prior studies have associated dual method use with a range of individual-level factors: socio-demographic variables, such as younger age; STI risk behaviours and risk perception; relationship variables, such as number of partners, relationship length, and partner support of condoms; and educational factors, such as prior exposure to HIV prevention messages. Conclusions: Although dual method use appears to be on the rise, especially among adolescents and young adults, US rates are comparatively low and leave much room for improvement. This review identifies several populations most in need of intervention. However, we encourage public health practitioners to evolve beyond individual-level studies and interventions to focus on the relational, socio-cultural, and structural influences on dual method use. Dual use promotion programs and policies should also equally target men and women, adolescents and adults.

Do women using long-acting reversible contraception reduce condom use? A novel study design incorporating semen biomarkers

Long-acting reversible contraceptive (LARC) methods are highly effective against pregnancy. A barrier to their widespread promotion can include the concern they will lead reduced condom use and, thus, will put couples at higher risk for sexually transmitted infections (STIs). We review evidence from previous studies of condom "migration" associated with the use of LARC and propose a novel study design to address the two main methodological issues that have limited these earlier studies. Namely, we propose to use a randomized controlled trial design and to use a biological marker of semen exposure for measuring changes in condom use.

Condoms for dual protection: patterns of use with highly effective contraceptive methods

OBJECTIVES

U.S. women experience high rates of unplanned pregnancy and sexually transmitted infections (STIs), yet they seldom combine condoms with highly effective contraceptives for optimal protection. Because oral contracep tives (OCs) have been the predominant form of highly effective contraceptio in the U.S., it is unknown whether condom use is similarly low with increasingly promoted user-independent methods.

METHODS

We used weighted data from the National Survey of Family Growth to assess condom use odds among women relying on OCs vs. user-independent methods (i.e., injectibles, intrauterine devices, and implants). We also estimated the expected reduction in unplanned pregnancies and abortions if half or all of the women currently using a single highly effective method also used condoms.

RESULTS

Across every demographic subgroup based on age, partner status, race/ethnicity, household income, and education, condom use prevalence was lower for women relying on user-independent methods vs. OCs. Multivariable models for adult women also revealed a significant reduction within most demographic subgroups in the odds of condom use among women relying on user-independent methods vs. OCs. Population estimates suggested that if half of all women using highly effective methods alone also used condoms, approximately 40% of unplanned pregnancies and abortions among these women could be prevented, for an annual reduction of 393,000 unplanned pregnancies and nearly 76,000 abortions. If all highly effective method users also used condoms, approximately 80% of unplanned pregnancies and abortions among these women could be prevented, for an annual reduction of 786,000 unplanned pregnancies and nearly 152,000 abortions.

CONCLUSIONS

Adding condoms to other methods should be considered seriously as the first line of defense against unplanned pregnancy and STls. This analysis can serve to target interventions where dual-method promotion is needed most.

A brief, low-cost, theory-based intervention to promote dual method use by black and Latina female adolescents: a randomized clinical trial

HIV/AIDS disproportionately affects young women of color. Young women who use hormonal contraception are less likely to use condoms. Brief, inexpensive HIV-prevention interventions are needed for high-volume clinics. This study was a randomized clinical trial of two interventions: (a) a video made for this study and (b) an adaptation of Project RESPECT counseling. Four hundred Black and Latina teenage women completed a questionnaire about their sexual behaviors and were randomly assigned to (a) see the video, (b) get counseling, (c) see the video and get counseling, or (d) receive usual care. At 3-month follow-up, those who saw the video and received counseling were 2.5 times more likely to have used a condom at last intercourse with their main partner than teens in the usual care group. These differences did not persist at 12-month follow-up. This suggests that a brief intervention can positively affect condom use in the short term.

Contraception for teenagers and young adults with cancer

Adolescence can be an extremely stressful time for all concerned. When this period is then compounded by the development of cancer, formidable and seemingly insurmountable problems may be perceived. Cancer in adolescence is relatively uncommon, with an annual incidence rate in western populations of approximately 150-200 per million. Five-year survival of patients diagnosed around 1990 exceeded 70% in the United Kingdom (UK) and United States of America (USA), and adolescents with cancer are likely to remain fertile. Further advances in therapeutic modalities are creating a generation of adolescents and young adults with cancer who can now aspire to the same sexual and reproductive activities as their healthy peers. This then raises the issue of avoidance of undesired pregnancy during and after treatment. This article aims to address the contraceptive needs of adolescents and young adults undergoing treatment for cancer.

High-risk teen compliance with prescription contraception: an analysis of Ohio Medicaid claims

STUDY OBJECTIVE

This study examines utilization of and compliance with prescription contraception by adolescents.

DESIGN

Retrospective cohort analysis of billing and pharmacy claims.

SETTING

Ohio Medicaid fee-for-service enrollees.

PARTICIPANTS

Claims data of 12- to 19-year-olds identified at high risk for pregnancy by sexually related service billing or procedure code.

MAIN OUTCOME MEASURE

Prescription contraception use and compliance patterns were examined over a 12-month study period.

RESULTS

During a 6-month enrollment period, 3338 females were identified at risk for pregnancy. Over one-fourth (920) became pregnant. Across the 12-month follow-up, 40% (1328) used no prescription contraception and 33% (1090) used some prescribed contraceptive. Most teens used injectable medroxyprogesterone (517) or oral contraceptive pills (492). About 20% of those using any type of prescribed contraceptive were compliant for the full year; less than 30% used a method for 3 months or less. Whites were more compliant with contraception than nonwhites. Younger age and concurrent mental health condition were also predictors of noncompliance.

CONCLUSIONS

Teens at risk for pregnancy demonstrated poor compliance with prescribed contraceptives. Billing/pharmacy claims analysis is a useful tool for identifying teens at risk for pregnancy in order to target and evaluate interventions or to benchmark care provided to adolescents.

Will the pill make me sterile? Addressing reproductive health concerns and strategies to improve adherence to hormonal contraceptive regimens in adolescent girls

PAPER OBJECTIVE: This paper is designed to help clinicians understand the relationship between hormonal contraceptive side effects and the potential development of general and reproductive health concerns that can impact on adherence to hormonal contraception. By understanding the concerns raised by young women, we can then make our counseling more specific to the factors that affect compliance in this population.

DESIGN

Studies that specifically addressed hormonal contraceptive compliance, side effects, and method selection in adolescents and young women were chosen for this paper. All articles were from peer-reviewed journals. Medline-Ovid articles from 1980-2000 were used with the following search keywords: Contraception, Patient Compliance, Hormonal Contraception, Oral Contraceptive Pills, Norplant, Depo Provera, and Adolescents.

DATA SYNTHESIS

The general public has many concerns about the safety of hormonal contraception. The development of side effects, especially those that are menstrual-related, seem to cause adolescents and young women to feel that their general and reproductive health is being threatened.

CONCLUSIONS

Hormonal contraceptive counseling should include 1) explaining, in a nontechnical manner, how these methods work; 2) addressing negative information the patient has heard about the methods; 3) providing factual information about cancer risks, blood clots, and other general health concerns; 4) discussing the potential side effects and what each means to her health; 5) asking specifically about possible reproductive health worries, especially in light of the menstrual irregularities that may occur; and 6) assuring the patient that she should always feel free to share her concerns and worries with you, the provider.

A qualitative assessment of condom use decisions by female adolescents who use hormonal contraception

Young women who use hormonal contraception are at increased risk of HIV. This study, based on the Health Belief Model, was designed to understand how adolescent women who use hormonal contraceptives make decisions about condom use. Thirty-nine young, minority women participated in open-ended interviews. The interviews were transcribed and analyzed by both authors separately. The results suggest that barriers to condom use include use of a hormonal method of contraception, perceived trust in a partner, and a perception of the condom as "irritating." Facilitators for condom use included not being with a steady partner and fear of pregnancy and infection. The young women also suggested that being able to talk to their parents about condom use, having condoms widely available, and seeing HIV-prevention messages in many venues would increase their use of condoms. They noted that seeing young, HIV-positive women demographically similar to themselves would also prompt them to use condoms. Nurses should incorporate these factors into HIV-prevention interventions for adolescents.

Short-term effects of a progestational contraceptive drug on food intake, resting energy expenditure, and body weight in young women

BACKGROUND

Studies showed that hormonal fluctuations that occur over the human menstrual cycle affect energy intake and expenditure. However, little is known about the possible effects on body weight regulation that may arise when these cyclic changes are suppressed with hormonal contraceptives.

OBJECTIVE

The aim of this study was to examine how a progestational contraceptive drug (depot medroxyprogesterone acetate) affects food intake, resting energy expenditure (REE), and body weight in young women.

DESIGN

Twenty normal-weight women were tested in a single-blind, placebo-controlled experiment. Body weight, REE, and 3-d food intake (food provided) were measured in the follicular and luteal phases of 2 menstrual cycles before a single injection of depot medroxyprogesterone or saline solution was administered. Measurements were also taken 4 times after injection: in the luteal and follicular phases of 2 cycles in the placebo group and 2 wk apart (to mimic timing of the menstrual phases) in the drug group.

RESULTS

Before injection, the phase of the menstrual cycle affected both energy intake and REE. The study participants consumed more energy (4.3%; P = 0.02) and expended more energy at rest (4.3%; P = 0.0002) in the luteal phase than in the follicular phase. Comparison of pre- and postinjection means showed that treatment with the contraceptive drug had no significant effects on energy intake, REE, or body weight.

CONCLUSIONS

This study showed that, although phases of the menstrual cycle affected energy intake and REE, depot medroxyprogesterone acetate did not alter energy intake or expenditure or cause weight gain in young women.

Assessment of oral contraceptive pill continuation in young women

STUDY OBJECTIVE

To assess oral contraceptive pill (OCP) continuation rates and factors associated with OCP continuation in young women.

DESIGN

A 12-month retrospective cohort study by chart review of 226 young women seen for an initial clinic visit.

SETTING

Urban hospital-based family planning clinic.

PARTICIPANTS

Predominantly African-American, sexually active young women, 12 to 21 years of age (median age, 17.2 years).

MAIN OUTCOME MEASURES

Scheduled OCP-appointment-keeping rates, pregnancy rates, and associated factors were compared between OCP-compliant and -noncompliant groups.

RESULTS

The OCP-appointment-keeping rate declined dramatically over 1 year, from 29% at the 3-month visit to 9% at the 12-month visit. Almost half seeking a postpartum visit checkup (PPVup) did not return after the initial clinic visit. Overall, a higher OCP-appointment-keeping rate was noted in those seeking OCPs vs. PPVup at the initial visit; P < .05 for 12-month visit. There was no difference in the pregnancy rates between OCP-compliant and -noncompliant groups. School enrollment and nulliparity was significantly associated with OCP compliance until the 6-month visit (P < .05).

CONCLUSION

In an urban hospital based clinic, the OCP continuation rate after the initial visit was poor. Continuation of OCPs may be anticipated by type of services sought at an initial visit. Methods to improve OCP continuation in this setting should be implemented.

Condom practices of urban teens using Norplant contraceptive implants, oral contraceptives, and condoms for contraception

OBJECTIVES

The availability of long-acting hormonal birth control methods has created new contraceptive options for adolescents. The purpose of this study was to determine whether teens initiating these methods use condoms less frequently than teens using oral contraceptive pills or condoms alone and may therefore be at an increased risk of acquiring sexually transmitted infections.

STUDY DESIGN

To investigate ongoing condom behavior in teens using levonorgestrel (Norplant) contraceptive implants, oral contraceptives, and condoms alone, we examined data from a 2-year prospective cohort study of 399 urban teens. The study consisted of 3 clinic-based cohorts of adolescent female contraceptive users: Norplant contraceptive implants (n = 200), oral contraceptives (n = 100), and condoms alone (n = 99). Data were collected at an admission interview and at 1- and 2-year follow-up from method continuers.

RESULTS

Norplant contraceptive implant users were less likely than oral contraceptive or condom users to report condom use at last sex or consistent condom use at 1- and 2-year follow-up. The implant group showed a significant decrease in condom use from admission to 2 years after method initiation. The proportion of implant users self-reporting new sexually transmitted infections at 2-year follow-up, however, was not significantly greater than that of oral contraceptive or condom users.

CONCLUSIONS

Our findings indicate that teen users of Norplant contraceptive implants are less likely to use condoms than teens who choose oral contraceptives but, probably because of differences in sexual behavior, are no more likely to self-report sexually transmitted infections. Our findings also indicate that teens who choose oral contraceptives and condoms do not use them consistently enough to avoid pregnancies or sexually transmitted infections.

Norplant selection and satisfaction among low-income women

OBJECTIVES

This study examined correlates of Norplant selection and satisfaction among low-income women.

METHODS

Interviews were completed in family planning clinics in 4 Florida counties with 1152 Norplant users and 1268 nonusers, with follow-up interviews with a subsample up to 1 year later. Logistic regression models estimated the associations of socio-demographic and medical characteristics with Norplant selection and method satisfaction.

RESULTS

Odds ratios for Norplant selection were significantly greater among women who planned to have children in 5 or more years, those who were "offered" Norplant, those who lived in Palm Beach County, those who were using drugs, and those who were Medicaid clients. Women younger than 17 and those who learned about Norplant from a friend were twice as likely as others to select Norplant. Ninety-two percent of Norplant users were satisfied with the method; women with side effects and those who felt pressure to select a method were significantly less likely than others to be satisfied.

CONCLUSIONS

Norplant provides an acceptable and satisfying method of birth control for many low-income women. Proper counseling about all methods of birth control and about Norplant's side effects remains critical to the appropriate delivery of this method.

From compliance to concordance: a challenge for contraceptive prescribers

In 1997 the Royal Pharmaceutical Society of Great Britain published a report entitled From Compliance to Concordance: Achieving Shared Goals in Medicine Taking. This article applies this new model--of doctors and patients working together towards a shared goal--to the prescribing of hormonal forms of contraception. It begins by critically evaluating the current dominant model of contraceptive prescribing. It claims that this model tends to stereotype all women, but particularly young, poor and black women, as unreliable and ill-informed contraceptors who need to be advised and even controlled by much more knowledgeable and socially responsible family planning experts. The article then suggests how a much more egalitarian model of contraceptive prescribing might be put into practice, whilst acknowledging the existence of many serious obstacles to such a radical shift within family planning services. In conclusion, the article suggests that until contraceptive prescribers begin to take women's experiences of, and concerns about, hormonal contraceptives seriously they will fail to develop a potentially much more effective and liberating model of family planning.

Continuation rates with a levonorgestrel-releasing contraceptive implant (Norplant). A prospective study in Belgium

Contraceptive protection offered by a method depends on its duration of use, which reflects costs, side effects, and relatives' opinions. This study investigated in Norplant implants users the continuation rates, some of their determinants, and the motives for removals. Since 1988, 612 Norplant implants sets, designed to protect for 5 years, have been inserted. Observing 13,907 months of use, we determined over time the continuation rates and how age, parity, circumstances at insertion (postpartum, postabortum, others), and patronymic origins (surrogate for sociocultural factors) influenced them. Statistics included Kaplan-Meier's method and log rank tests, and uni- and multivariate Cox models. Continuation increased with age and depended on sociocultural factors. Parity exerted influence only in younger women. Median duration of use was 3 years 11 months. Removals before 5 years related almost equally to irregular bleeding, other side effects, and pregnancy wish. The cumulative 5-year failure rate was 1.5%. Unsatisfied users returned earlier, distorting the first results. A literature search showed that implants yield, in the mean, slightly better continuation figures than do intrauterine devices, and clearly higher than those obtained with pills and injectables. To optimize costs and counseling, warnings about the risk of short duration of use in young nullipara, especially if negative sociocultural influences prevail, are recommended. In no category are the implants absolutely to be avoided. Individual and programmatic contraceptive choice should take into account the expected continuation of use.

Use of hormonal methods of birth control among sexually active adolescent girls

OBJECTIVE

To identify factors associated with the use of various birth control methods among sexually active adolescent girls.

DESIGN

A survey distributed as part of a larger study measuring compliance with hepatitis B vaccination.

SETTING

A hospital-based and a school-based clinic.

MEASURES

Demographic and health behavior data including sexual activity, contraceptive method, substance use, condom use, and history of sexually transmitted diseases (STDs) were collected. Birth control method was confirmed by medical record review. Associations with the outcome variable of birth control method were analyzed using chi square, Kruskal-Wallis analyses of variance, and t-tests, followed by logistic regression analysis.

RESULTS

Among sexually experienced girls, 39% (n = 123) reported using oral contraceptive pills (OCPs), 5.4% (n = 17) used Depo-Provera (medroxyprogesterone acetate) or Norplant (levonorgestrel), and 55.6% (n = 175) used no hormonal method. Logistic regression analysis revealed that the factors most significantly associated with the use of hormonal methods were older age (odds ratio [OR] = 1.19; 95% confidence interval [CI], 1.07-1.33), not using a condom at last intercourse (OR = 0.55; CI, 0.34-0.90), and having had a well visit within 1 year (OR = 2.11; CI, 1.12-3.70). OCP users were less likely than Depo-Provera or Norplant users to have used alcohol (p = 0.041), cigarettes (p = 0.002), or marijuana (p = 0.018) in the past 30 days. OCP users were less likely than nonusers of hormonal methods to have smoked cigarettes (p = 0.034) or marijuana (p = 0.052). The school-based clinic had a greater proportion of subjects using long-acting progestins (p < 0.001).

CONCLUSIONS

The decreased rate of condom use among those who used hormonal birth control methods and the different rates of health risk behaviors among users of various methods require targeted counseling efforts to decrease pregnancy and STD rates among young women.

Injectable contraceptive discontinuation and subsequent unintended pregnancy among low-income women

OBJECTIVES

This study investigated rates of discontinuation of the recently introduced injectable contraceptive depot medroxyprogesterone acetate (DMPA) and postdiscontinuation rates of unprotected intercourse and unintended pregnancy.

METHODS

A sample of 402 low-income, urban, minority women were interviewed when they initiated DMPA use and 12 months later.

RESULTS

The 12-month life-table discontinuation rate was 58%, with half of the discontinuers stopping after only one injection. Menstrual changes and other side effects were the most frequently cited reasons for discontinuation. Approximately half of the discontinuers at risk for unintended pregnancy either did not make the transition to another contraceptive or used contraception only sporadically. The cumulative unintended pregnancy rate by 9 months postdiscontinuation was 20%.

CONCLUSIONS

DMPA initiators were at substantial risk for unintended pregnancy because most quickly discontinued use and did not make the transition to consistent use of another contraceptive.

Experience of Finnish women with Norplant insertions and removals

OBJECTIVE

Norplant and Norplant-2 have been available for use by Finnish women since 1984 and 1986, respectively. The objective of this study was to explore Norplant users' experiences of insertions, removals and medical treatments.

DESIGN

A questionnaire was sent to women who had received Norplant or Norplant-2 implants one to two years earlier (n = 262) in normal clinical settings; the response rate was 79%.

RESULTS

At insertion, problems were experienced by 9% and at least some pain by 23% of women. During the first year 20% of all users (14% of Norplant and 33% of Norplant-2 users) had their implants removed. Problems were experienced at removal by 33% of women and pain was experienced by 40%; nevertheless most users were satisfied with the device. Findings were similar for the two types of Norplant. Forty-two percent of the women had received minipills containing levonorgestrel before Norplant insertions in an attempt to assess Norplant's suitability, and 8% had received drugs for adverse effects caused by Norplant.

CONCLUSIONS

Studies including perspectives of Norplant users and the whole lifespan of Norplant (including removal) should be conducted in all clinical settings where Norplant is provided.

Contraceptive outcomes among adolescents prescribed Norplant implants versus oral contraceptives after one year of use

OBJECTIVE

Our goal was to evaluate both the continuation and pregnancy rates and the side effects experienced during the first year of use by adolescents who selected Norplant implants as compared with those who chose oral contraceptives for contraception. Furthermore, side effects experienced at 6 versus 12 months among Norplant implant users were compared to determine whether they diminished with continued use of this method.

STUDY DESIGN

We conducted a case-control study of 56 adolescents < or = 18 years old who selected implants as compared with 56 age-matched controls who chose oral contraceptive pills during the same time period.

RESULTS

Only 34% of patients prescribed oral contraceptives as compared with 91% of Norplant implant patients were still using their chosen method 1 year later. As a result 25% of oral contraceptive users became pregnant within 12 months as compared with none who selected Norplant implants. Side effects were reported by > 80% of patients in both groups, with menstrual irregularities reported more often by Norplant implant users than by oral contraceptive users (73% vs 5%, p = 0.01). Furthermore, Norplant implant users gained more weight than oral contraceptive users (8.7 vs 4.2 pounds) and were twice as likely to have an abnormal Papanicolaou smear. Finally, little diminution in side effects was observed during the second 6 months of Norplant implant use.

CONCLUSIONS

These data confirm that Norplant implants provide better protection against unintended pregnancy in an adolescent population but may be associated with more side effects. Clinicians should be aware of these findings so they can adequately counsel young patients about these two methods of contraception.

Adolescents' reasons for and experience after discontinuation of the long-acting contraceptives Depo-Provera and Norplant

PURPOSE

The objectives of this study were to examine the reasons for discontinuation of the long-acting contraceptives Depo-Provera and Norplant in adolescents, and to assess the adolescents' experience after discontinuation of the methods.

METHODS

A total of 35 adolescents [gynecologic age 4.7 +/- 0.3 years, and body mass index (BMI) 24.2 +/- 0.6] who discontinued Depo-Provera, and 31 adolescents (gynecologic age 3.4 +/- 0.3 years, BMI 24.1 +/- 0.9) who discontinued Norplant were periodically assessed during use of the methods and up to 12 months after discontinuation.

RESULTS

The most common reasons for discontinuation of both Norplant (after 21.8 +/- 1.6 months of use) and Depo-Provera (9.2 + 0.9 months of use) were irregular menstrual bleeding (64%), weight gain (41%), and increased headaches (30%). Resumption of menstrual regularity and dysmenorrhea was noted sooner after discontinuation of Norplant, compared with Depo-Provera. The increase in BMI noted at discontinuation of Depo-Provera (1.1, P = .0005) and Norplant (1.3, P = .03) persisted up to 6 months after discontinuation of either method (0.6, P = .01 post-Depo-Provera discontinuation; and 0.9, P = 0.02 post-Norplant discontinuation). Only 62% of the adolescents reported no break in contraceptive practice. The condom was the most popular method (37%) after discontinuation of Depo-Provera, and oral contraceptive (39%) after discontinuation of Norplant. The cumulative conception proportion reached 0.93 at 12 months after discontinuation of Norplant, and was significantly higher (P = .01) compared with the cumulative proportion of conception after discontinuation of Depo-Provera (P = .50).

CONCLUSIONS

Health care providers should aggressively manage physical problems associated with Depo-Provera and Norplant use, and expedite the transition to a new contraceptive method to minimize the high pregnancy rate observed after discontinuation of these methods in adolescents.