Determinants of menstrual bleeding patterns among women using natural and hormonal methods of contraception. II. The influence of individual characteristics

Obesity and hormonal contraception: an overview and a clinician's practical guide

BACKGROUND

The growing prevalence of obesity among the fertile female population poses a considerable problem to contraceptive providers. Obese women, who are more at risk for venous thromboembolism and cardiovascular events due to their condition, might be at an even higher risk of developing thromboembolic events when on medical contraception. Combined hormonal contraceptives might be less effective in obese women and may lead to unacceptable metabolic side effects for this population. In addition, the lack of safety data for weight loss drugs and the higher risk for complications during and after pregnancy require a close surveillance of the fertility status of obese patients.

OBJECTIVE

The aim of this narrative review is to summarize the available medical contraceptive options and to give the readers a practical guidance for a wise contraceptive choice with regards to obesity.

METHODS

A general literature review of peer-reviewed publications on the topic "obesity and contraception" was performed using the PubMed database.

RESULTS

Nowadays, there are many useful tools that help clinicians in choosing among the wide range of therapeutic possibilities, such as the World Health Organization (WHO) Medical Eligibility Criteria for contraceptive use. Furthermore, the great diversity of hormonal contraceptive formulations (combined hormonal formulations; progestin-only methods) and active substances (different estrogens and progestins) allow physicians to tailor therapies to patients' clinical peculiarities.

CONCLUSION

Long-acting reversible contraceptives [progestin-only implants, levonorgestrel-intra-uterine devices (IUDs) and copper IUDs] and progestin-only methods in general are excellent options for many categories of patients, including obese ones.

LEVEL OF EVIDENCE

V, narrative review.

Hormonal Profiles of Menstrual Bleeding Patterns During the Luteal-Follicular Transition

CONTEXT

Menstrual cycle function is determined by a complex endocrine axis that controls the ovaries and endometrium. While the late luteal phase is characterized by declining progesterone and estrogen, how these hormonal profiles relate to menstrual bleeding patterns is not well understood.

OBJECTIVE

Characterize associations between luteal phase hormonal profiles and subsequent menstrual bleeding patterns, specifically spotting before bleeding.

DESIGN, SETTING, AND PARTICIPANTS

We examined creatinine-adjusted urinary estrone 3-glucuronide (E13G) and pregnanediol 3-glucuronide (Pd3G) levels in relation to spotting in 116 premenopausal women (ages 20-47) who kept daily menstrual diaries and collected first morning urine samples for ≥ 2 consecutive cycles or 1 luteal-follicular transition (n = 283 transitions). We used linear mixed models to estimate associations between luteal phase hormone levels and spotting before bleeding.

MAIN OUTCOME MEASURE(S) AND RESULTS

Transitions with ≥ 1 days of spotting before menstrual bleeding (n = 118) had greater luteal phase Pd3G levels vs nonspotting transitions (n = 165). Differences in Pd3G between spotting and nonspotting transitions were largest at menses onset (34.8%, 95% confidence interval, 18.9%, 52.7%). Pd3G levels for spotting transitions dropped to similar levels as nonspotting transitions an average of 1 day later, which aligned with the first day of bleeding for transitions with contiguous spotting. Spotting transitions were preceded by slower rates of Pd3G decline than nonspotting transitions, whereas E13G declines were similar.

CONCLUSIONS

Self-reported bleeding patterns may provide insight into luteal phase Pd3G levels. First bleed appears to be the best choice for defining the end of the luteal phase and achieving hormonal consistency across transitions.

Menstrual Cycle Changes as Women Approach the Final Menses: What Matters?

Increased variability in menstrual cycle length marks the onset of the menopausal transition, with the likelihood of long cycles increasing as women approach menopause. This article describes the STRAW+10 bleeding criteria for recognizing onset of the early and late menopausal transition, as well as the specific bleeding changes a woman may experience during this life stage, including how women's bleeding experiences differ. The high probability of episodes of excessive and prolonged bleeding as women approach their final menstrual period is documented, as is the continuing probability of ovulation as women reach their final menstrual period.

Menstruation and the menopausal transition

This paper characterizes changes in menstrual bleeding during perimenopause,including bleeding changes that represent markers of the menopausal transition. Recent results from the Study of Women's Health Across the Nation and other cohort studies are reviewed. Emerging data describing subpopulation differences in the transition experience are highlighted. When treating women in the midlife, clinicians should pay careful attention to medical factors, including both conditions and treatments, that may increase menstrual blood loss or alter menstrual cycle characteristics sufficiently to obscure the onset of the menopausal transition or the final menstrual period.

Influence of Socioeconomic Status in the Age at the of Menarche and Duration of Menstrual Bleeding

Purpose:

The study of the relationship ,between the age at menarche and socioeconomic status in a rural area in Sudan.

Work method:

This was a cross-sectional descriptive study conducted in Altadamon and Eldubha areas in the northern state of Sudan during year 2006. It included 182 girls of age between 13 to 18 years in elementary and secondary school.

Work results:

The mean age at menarche for girls in Northern Sudan in this study was 13.93 ± 1.29 year, the mean menarcheal age in these girls are amongst the lowest values presented for African countries. The mean duration of menstrual bleeding among girls in the Northern Sudan in this study was 4.8 ± 1.22 days. We also found statistically significant differences in age at menarche between girls whose parents had a higher educational level and those with a lower educational level and also according to the economic status and size of the family.

Conclusion:

Between the girls whose parents were living together and girls whose parents separated there was a significant difference of 1.02 day.

Chemokine expression is dysregulated in the endometrium of women using progestin-only contraceptives and correlates to elevated recruitment of distinct leukocyte populations

BACKGROUND

Breakthrough bleeding (BTB) is the most common reason for discontinuation of progestin-only (p-only) contraceptives, yet the causes are unknown. Use of p-only contraceptives is associated with elevated influx of endometrial leukocytes, similar to that observed perimenstrually or within decidualized endometrium. We hypothesized that chemokine expression is altered in women using p-only contraceptives, leading to abnormal leukocyte recruitment and BTB.

METHODS

Expression of eight highly abundant endometrial chemokines was examined using immunohistochemistry and real-time PCR, in endometria from women using subdermal and intrauterine levonorgestrel and correlated to leukocyte subpopulations.

RESULTS

Macrophage-derived chemokine (MDC), hemofiltrate CC chemokine-1 (HCC-1), monocyte chemoattractant protein-3 (MCP-3), interleukin-8 (IL-8) and eotaxin were strongly produced by epithelial glands, comparable to levels in premenstrual phase endometrium. Stromal cells were negative for chemokines in atrophic/shedding endometria, but intensely positive in highly decidualized tissues for MDC, MCP-3, HCC-1 and 6Ckine. Macrophage inflammatory protein-1beta (MIP-1b) and HCC-4 were suppressed in all p-exposed endometria.

CONCLUSIONS

These data demonstrate that chemokine expression is dysregulated in p-exposed endometria, consistent with the morphological appearance of the endometrium and the leukocyte subsets present. This reinforces a potential role for chemokines in the elevated leukocyte recruitment that contributes to endometrial fragility and BTB.

Effectiveness of Cyclofem in the treatment of depot medroxyprogesterone acetate induced amenorrhea

A total of 100 women who were using depot medroxyprogesterone acetate (DMPA) for contraception and who had experienced at least 6 months of drug induced amenorrhea, were randomized to either switching their method of contraception to Cyclofem, or continuing with DMPA. At the end of 6 months, 82% of the Cyclofem users had experienced some vaginal bleeding, compared with 10% of DMPA users. Time to resumption of vaginal bleeding was related to the duration of DMPA use to the duration of DMPA induced amenorrhea, and to the body mass index of the user. Over the 6 months of follow-up, 94% of Cyclofem users complained of some side effects, compared with 22% of DMPA users. The most frequently cited problems among Cyclofem users included breast tenderness, abdominal pain, and dysmenorrhea; yet a third of these women opted to stay on Cyclofem at the end of the study. It is concluded that switching to Cyclofem is a new option for DMPA users who are concerned about amenorrhea. Although using Cyclofem in this setting will not meet the needs of all such women, its effectiveness in inducing vaginal bleeding justifies a trial in those who have no contraindication to estrogen treatment.

A longitudinal study of risk factors for the occurrence, duration and severity of menstrual cramps in a cohort of college women

OBJECTIVE

To describe how menstrual cramps vary from cycle to cycle within a woman over time. To examine the influence of weight and lifestyle factors on occurrence, duration, and severity of menstrual pain.

DESIGN

A one-year prospective menstrual diary study.

PARTICIPANTS

One hundred and sixty-five women aged 17 to 19 years entering a local university in 1985.

MAIN OUTCOME MEASURES

The occurrence, length, and maximum severity of pain during a menstrual period.

RESULTS

Menstrual pain occurred during 71.6% of observed menstrual bleeds, most commonly beginning the first day of menses. The median duration was two days. Sixty percent of women reported at least one episode of severe pain, while 13% reported severe pain more than half the time. Earlier age at menarche and long menstrual periods increased the occurrence, duration and severity of pain. In smokers, cramps tended to last longer. Being overweight was an important risk factor for menstrual cramps and doubled the odds of having a long pain episode. Frequent alcohol consumption decreased the probability of having menstrual cramps, but in women who had pain it increased duration and severity. Physical activity was not associated with any pain parameter.

CONCLUSIONS

Women who have pain lasting three days are an important target group for prophylactic therapy. The occurrence and severity of menstrual cramps is influenced by potentially modifiable characteristics including weight, smoking, and alcohol consumption. Doctors may wish to counsel women presenting with dysmenorrhoea about the importance of healthy lifestyles and about the inefficacy of alcohol consumption as a treatment for dysmenorrhoea.

Serum concentrations of estradiol, progesterone, and levonorgestrel are not determinants of endometrial histology or abnormal bleeding in long-term Norplant implant users

The objective of this study was to determine the relevance of serum estradiol, progesterone and levonorgestrel concentrations to endometrial histology and uterine bleeding associated with long-term Norplant implants use. Eighteen five-year users of Norplant implants had endometrial biopsies and determinations of serum estradiol, progesterone and levonorgestrel concentrations. Correlations among these factors and uterine bleeding were calculated. Proliferative endometrium (but not sex steroid levels) was associated with abnormal bleeding. Neither ovarian steroid nor levonorgestrel concentrations was a predictor of abnormal bleeding. Hyperplastic changes were not seen even with high estradiol and low levonorgestrel levels.