Clinical performance of a levonorgestrel-releasing intracervical contraceptive device during the first year of use

Contraception for women with epilepsy: counseling, choices, and concerns

Approximately 50% of all pregnancies in women with epilepsy (WWE) occur unplanned. This is worrying, given the increased occurrence of obstetrical complications in WWE, including the risk of seizures and their possible consequences for both the mother and the unborn child. Hormonal contraception is usually regarded as highly effective, but it is subject to numerous bidirectional drug interactions with several antiepileptic drugs. These interactions may lead to loss of seizure control or contraceptive failure. Further concerns are loss of bone mineral density and increased seizure activity due to hormonal effects. Many physicians lack sufficient knowledge regarding these issues, and most WWE have never received adequate counseling. Moreover, several studies show that a large proportion of WWE do not take their medicines regularly. This article reviews all of these issues and offers practical recommendations for the management of contraception in WWE.

Five years' experience with a small intracervical/intrauterine levonorgestrel-releasing device

OBJECTIVE

A randomized study was performed to compare the efficacy, safety and acceptability of a new model of an intracervical/intrauterine contraceptive device (ICD) releasing 20 microg of levonorgestrel (LNG) per day.

METHODS

The LNG-ICD was inserted in Group I into the cervical canal and in Group II into the uterine cavity. Group I included 151 women (age, 18-43 years) whereas Group II included 147 (age, 19-43 years). The number of nulliparous women was 145.

RESULTS

The 5-year results are presented here. The results showed a total continuation rate of 50%; the continuation rate in the cervical group and that in the uterine group were 53.6% and 46.3%, respectively--the difference being statistically insignificant (p=.3593). The main reason for termination was a wish for pregnancy, which is explained by the relatively young age and degree of nulliparity of the study population. During the first year, two pregnancies occurred in both groups. Two of these were ectopic, one in each group. The other two occurred after unnoticed expulsions. Thereafter, no pregnancies occurred. The cumulative gross rate for pregnancy was 1.3 and the Pearl index at 5 years was 0.425. The total expulsion rate was relatively high (11.1%). Expulsions occurring during the first few months of the first year were related to insertion. Removals because of bleeding and because of amenorrhea were low, the combined gross rate being 5.7 and the Pearl rate 1.8 at 5 years. Also, the gross rate of infection was low (0.7). The continuation was high in spite of a high rate of removals for planning pregnancy (15.4).

CONCLUSIONS

The method is safe and effective. There were only minor differences between the groups. There were no perforations and the incidence of infection was low. The device can also be used by young nulliparous women.

Effects on the endometrium, endo- and exocervix following the use of local progestogen-releasing delivery systems

Some conflicting reports have appeared in the literature as to the effect of progestogens on the endometrium and on the endo- and exocervix in animals and humans. Hyperplasia of the endometrial and endocervical epithelium has been reported in some non-human primates following the administration of progestogens. In other studies no evidence has been found for such changes. In women using combined oral contraceptives, it has been claimed that the progestogen component causes adenomatous hyperplasia of the endocervix and that this hyperplastic transformation could be a precursor to adenocarcinoma of the cervix. So far, there is, however, no evidence in the literature to confirm this hypothesis. In view of the development of new delivery systems with a constant release of small amounts of progestogens, previous reports in the literature on hyperplasia and potential malignant transformation of the endometrium and the endocervix have been a matter of concern. The aim of the present study is therefore to review results from studies in animals and humans in particular with reference to the effect of a local release of various progestogens on the endometrium and the endo- and exocervix.

Plasma levonorgestrel levels and ovarian function during the use of a levonorgestrel-releasing intracervical contraceptive device

Levonorgestrel, estradiol and progesterone plasma concentrations were measured over four years of use of a 20 micrograms/day levonorgestrel-releasing intracervical device (LNG-ICD). The mean levonorgestrel concentration showed a slight decline, being 142 + 46 (SD) pg/ml in the third month and 81 +/- 22 pg/ml in the 48th month of LNG-ICD use. However, considerable interindividual variation in levonorgestrel plasma levels between study subjects was observed. In 77% of the monitored cycles, ovulation or a luteinized follicle was observed when judged by a plasma progesterone elevation of over 5 ng/ml. Some follicular function was also noted in anovulatory cycles. Inhibition of ovulatory ovarian function is not the mode of contraceptive action of the LNG-ICD.

Clinical performance of a levonorgestrel-releasing intracervical contraceptive device during the first two years of use

One-hundred-and-ninety-eight women used a levonorgestrel-releasing intracervical contraceptive device (LNG-ICD) designed to release 20 micrograms levonorgestrel/day. Clinical performance during the first two years of LNG-ICD use was evaluated. A total of seven pregnancies occurred during the study period, all of them during the first year. Six pregnancies were after unnoticed expulsion of the device. One pregnancy occurred in an epileptic women using carbamazepine, with the LNG-ICD remaining in situ. Eighteen spontaneous expulsions occurred, 16 during the first year and 2 during the second year. Three pelvic infections were observed, all of them during the first year. Bleeding problems, hormonal side effects and other medical reasons were the most common side effects resulting in removal of the device. The continuation rate was 72.6 per cent after one year and 57.1 per cent after two years.

Patterns of bleeding and body iron stores during the use of a levonorgestrel-releasing intracervical device

A levonorgestrel-releasing intracervical device (LNG-ICD) was inserted in 198 women. The subjects registered bleeding and spotting days on special cards, which were analyzed after one year of treatment. Bleeding and spotting days gradually declined from sixteen during the first month to seven during the seventh month, and they remained under that level until the end of the first year. There were more days of spotting than bleeding. Eleven per cent of the subjects experienced at least 90 days non-bleeding interval during the first year of LNG-ICD use. There were no significant changes in blood hemoglobin concentrations during the first four years of LNG-ICD use. The mean serum ferritin concentration increased from 38 micrograms/l at the beginning to 97 micrograms/l at the end of the fourth year.