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Nguyen AT, Curtis KM, Tepper NK, Kortsmit K, Brittain AW, Snyder EM, Cohen MA, Zapata LB, Whiteman MK. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep 2024; 73:1-126. [PMID: 39106314 PMCID: PMC11315372 DOI: 10.15585/mmwr.rr7304a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2024] Open
Abstract
The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1-103). Notable updates include 1) the addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and 3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.
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Affiliation(s)
- Antoinette T. Nguyen
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Kathryn M. Curtis
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Naomi K. Tepper
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Katherine Kortsmit
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Anna W. Brittain
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Emily M. Snyder
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Megan A. Cohen
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Lauren B. Zapata
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Maura K. Whiteman
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
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Halpern V, Wheeless A, Brache V, Lendvay A, Cochón L, Taylor D, Dorflinger LJ. A randomized crossover study to evaluate local tolerability following subcutaneous administration of a new depot medroxyprogesterone acetate contraceptive formulation. Contracept X 2023; 5:100100. [PMID: 37823034 PMCID: PMC10562734 DOI: 10.1016/j.conx.2023.100100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 10/13/2023] Open
Abstract
Objectives This study aimed to evaluate and compare local tolerability of investigational drug TV-46046 and reference drug Depo-subQ Provera 104, both containing medroxyprogesterone acetate (MPA) as an active ingredient. Study design We conducted a randomized, crossover, single-center study. Twenty-seven healthy women aged 25 to 47 years at low risk of pregnancy received a subcutaneous injection of each of the four study drugs (120 mg/0.3 mL of TV-46046, 60 mg/0.3 mL of diluted TV-46046, 0.3 mL of TV-46046 placebo, and 104 mg/0.65 mL of Depo-subQ 104) in different quadrants of the abdomen. We assessed local tolerability by occurrence of injection site reactions (ISRs), as well as injection site pain and overall safety for at least 9 months postinjections. Results Of a total of 108 study injections, three injections were partial due to needle blockage. We observed a total of 30 ISRs following 105 full-dose injections, including hypopigmentation (n = 24), bruising (n = 4), and atrophy/dimple (n = 2). Eleven cases of hypopigmentation occurred following 25 full-dose injections of undiluted TV-46046 (44.0%), six following 27 full-dose injections of diluted TV-46046 (22.2%), and seven following 26 full-dose injections of Depo-subQ 104 (26.9%). Hypopigmentations occurred on average 8 months postinjection. Injection pain was minimal and dissipated quickly after all four injections. Conclusions Subcutaneous administration of MPA in a suspension formulation is associated with the delayed onset of hypopigmentation at the site of injection. Although not statistically significant, the rate of ISRs was over 60% higher for undiluted TV-46046 compared to Depo-subQ 104. This difference bears careful monitoring in future studies of TV-46046. Implications From a safety standpoint, investigational drug TV-46046 is appropriate for further clinical testing as a 6-month contraceptive injectable. The previously underreported hypopigmentation associated with subcutaneous administration of MPA warrants further investigation and acceptability assessment among users of existing Depo-subQ 104 as well as careful monitoring of local tolerability of TV-46046 in future clinical trials. Trial registration Registered at clinicaltrials.gov no: NCT02817464.
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Affiliation(s)
| | | | - Vivian Brache
- Profamilia, Biomedical Research Department, Santo Domingo, Dominican Republic
| | | | - Leila Cochón
- Profamilia, Biomedical Research Department, Santo Domingo, Dominican Republic
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3
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Coleman JS, Diniz CP, Fuchs EJ, Marzinke MA, Aung W, Bakshi RP, Farzadegan H, Bream JH, Nilles TL, Hudson S, Bumpus NN, Schwartz GJ, Rosenblum MA, Rooney JF, Hendrix CW. Interaction of Depot Medroxyprogesterone Acetate and Tenofovir Disoproxil Fumarate/Emtricitabine on Peripheral Blood Mononuclear Cells and Cervical Tissue Susceptibility to HIV Infection and Pharmacokinetics. J Acquir Immune Defic Syndr 2023; 92:89-96. [PMID: 36305827 PMCID: PMC9742287 DOI: 10.1097/qai.0000000000003113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/19/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Depot medroxyprogesterone acetate (DMPA) is a widely used contraceptive method. HIV pre-exposure prophylaxis with emtricitabine and tenofovir disoproxil fumarate (F/TDF) is highly effective in reducing HIV acquisition in women. We sought to determine the impact of DMPA on F/TDF pharmacokinetics and pharmacodynamics. METHODS Twelve healthy premenopausal cisgender women were enrolled and each completed 4 sequential conditions: (1) baseline, (2) steady-state F/TDF alone, (3) steady-state F/TDF + DMPA, and (4) DMPA alone. Assessments included clinical, pharmacokinetic, viral infectivity (ex vivo challenge of peripheral blood mononuclear cells by X4- and R5-tropic green fluorescent protein pseudoviruses and cervical tissue by HIV BaL ), endocrine, immune cell phenotyping, and renal function. RESULTS Compared with baseline, F/TDF (± DMPA) significantly decreased both %R5- and X4-infected CD4 T cells and F/TDF + DMPA decreased cervical explant p24 (all P < 0.05). The %R5- and X4-infected CD4 T cells were higher during DMPA alone than during F/TDF periods and lower than baseline (not statistically significant). Cervical explant p24 fell between baseline and F/TDF values (not statistically significant). There were neither statistically significant differences in F/TDF pharmacokinetics, including total or renal clearance of either antiviral drug, nor changes in glomerular filtration rate with the addition of DMPA. There were few immune cell phenotypic differences across conditions. CONCLUSIONS F/TDF decreased HIV infection in both challenge assays, whereas DMPA alone did not enhance HIV infection in either challenge assay. DMPA did not alter F/TDF pharmacokinetics or renal function.
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Affiliation(s)
- Jenell S Coleman
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Clarissa P Diniz
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Edward J Fuchs
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mark A Marzinke
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wutyi Aung
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rahul P Bakshi
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Homayoon Farzadegan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jay H Bream
- Department of Molecular Microbiology and Immunology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Tricia L Nilles
- Department of Molecular Microbiology and Immunology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Sherry Hudson
- Department of Molecular Microbiology and Immunology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Namandjé N Bumpus
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pharmacology and Molecular Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - George J Schwartz
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY
| | - Michael A Rosenblum
- Department of Biostatistics, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; and
| | | | - Craig W Hendrix
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
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Bick AJ, Skosana SB, Avenant C, Hapgood JP. Variability and quantification of serum medroxyprogesterone acetate levels. Steroids 2022; 187:109100. [PMID: 35964796 PMCID: PMC9884996 DOI: 10.1016/j.steroids.2022.109100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/27/2022] [Accepted: 08/09/2022] [Indexed: 02/01/2023]
Abstract
Quantification of serum progestin levels in clinical contraceptive studies is now routinely performed to understand progestin pharmacokinetics and to correct for unreliable self-reporting of contraceptive use by study participants. Many such studies are focussed on the three-monthly progestin-only intramuscular (IM) injectable contraceptive depot medroxyprogesterone acetate (DMPA-IM). Methods commonly used to measure serum MPA levels include liquid chromatography coupled to mass spectrometry (LC/MS) and radioimmunoassay (RIA); however, RIA methods have not been used in recent years. We review the available literature and find that these methods vary widely in terms of use of organic solvent extraction, use of derivitization and choice of organic solvent and chromatography columns. There is a lack of standardization of LC/MS methodology, including a lack of detailed extraction protocols. Limited evidence suggests that RIA, without organic solvent extraction, likely over-estimates progestin levels. Maximum MPA concentrations in the first two weeks post-injection show wide inter-individual and inter-study variation, regardless of quantification method used. Standardization of quantification methods and sampling time post-injection is required to improve interpretation of clinical data, in particular the side effects arising at different times depending on the pharmacokinetic profile unique to injectable contraceptives.
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Affiliation(s)
- Alexis J Bick
- Department of Molecular and Cell Biology, University of Cape, Cape Town, South Africa
| | - Salndave B Skosana
- Department of Molecular and Cell Biology, University of Cape, Cape Town, South Africa
| | - Chanel Avenant
- Department of Molecular and Cell Biology, University of Cape, Cape Town, South Africa
| | - Janet P Hapgood
- Department of Molecular and Cell Biology, University of Cape, Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa.
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Deese J, Brache V, Bahamondes L, Salinas A, Jorge A, Veiga N, Fuchs R, Miller A, Taylor D, Halpern V, Dorflinger L. Contraceptive effectiveness, pharmacokinetics, and safety of Sayana® Press when injected every four months: a multicenter phase 3 trial. EClinicalMedicine 2022; 44:101273. [PMID: 35128365 PMCID: PMC8804165 DOI: 10.1016/j.eclinm.2022.101273] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/24/2021] [Accepted: 01/06/2022] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Sayana Press® is a 3-monthly contraceptive injection approved by regulatory agencies in more than 40 countries worldwide. Existing effectiveness and pharmacokinetics (PK) data suggest that high contraceptive efficacy may be maintained if the reinjection interval of Sayana Press is extended from 3 to 4 months. METHODS We conducted a phase 3 trial at three sites in the Dominican Republic, Brazil, and Chile from September 2017 through April 2020. We enrolled 750 women at risk of pregnancy who agreed to use Sayana Press off-label every 4 months (3 treatment cycles) for 12 months. The effectiveness cohort included 710 participants randomized equally to receive injections in the abdomen or thigh. Forty additional participants received injections in the back of the upper arm for comparative PK analyses. The primary outcome was pregnancy, defined by a positive urine pregnancy test confirmed by ultrasound and/or serum human chorionic gonadotropin. Secondary outcomes included PK, safety, and acceptability. Laboratory and trial Sponsor staff were blind to injection site. This study is registered with ClinicalTrials.gov, number NCT03154125. FINDINGS There were no pregnancies during follow-up; the Pearl Index during 629.3 woman-years (WY) of follow-up in the primary effectiveness analysis was 0.00 (95% CI 0.00, 0.59). Pharmacokinetic profiles differed by injection site, with higher geometric mean (GM) medroxyprogesterone acetate concentrations for the abdomen than the thigh and arm. At month 8, significantly higher GM concentrations were observed in the abdomen and the thigh as compared to the arm, as well as at month 12 in the abdomen as compared to the arm. Injection site reactions were reported by 10.7% of participants. INTERPRETATION Both pregnancy and PK results confirm that Sayana Press is a highly effective contraceptive method when administered every 4 months. These findings may inform modification of the dosing schedule, or duration of the grace period for reinjection, or both, to reduce overall drug exposure while maintaining contraceptive efficacy. FUNDING This work is made possible by the generous support of the American people through the U.S. Agency for International Development (USAID), provided to FHI 360 through Cooperative Agreement AID-OAA-A-15-00,045, and a grant from the Gates Foundation. The contents are the responsibility of FHI 360 and do not necessarily reflect the views of USAID, the United States Government, or the Gates Foundation, nor does any mention of trade names, commercial products, or organizations imply endorsement by FHI 360, USAID, the United States Government, or the Gates Foundation.
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Affiliation(s)
- Jennifer Deese
- Women's Global Health Imperative, Global Public Health Impact Center, RTI International, 3040 East Cornwalis Road, Research Triangle Park, NC 27709, United States
- Corresponding author.
| | | | - Luis Bahamondes
- Department of Obstetrics and Gynaecology, University of Campinas Faculty of Medical Sciences, Campinas, Sao Paulo, Brazil
| | - Abril Salinas
- Instituto Chileno de Medicina Reproductiva, Universidad de Chile, Chile
| | | | - Nelio Veiga
- Department of Obstetrics and Gynaecology, University of Campinas Faculty of Medical Sciences, Campinas, Sao Paulo, Brazil
| | - Rachael Fuchs
- Biostatistics and Data Sciences, FHI 360, 359 Blackwell Street, Durham, NC 27701, United States
| | - Ashley Miller
- Science Facilitation, FHI 360, 359 Blackwell Street, Durham, NC 27701, United States
| | - Doug Taylor
- Product Development and Introduction, FHI 360, 359 Blackwell Street, Durham, NC 27701, United States
| | - Vera Halpern
- Product Development and Introduction, FHI 360, 359 Blackwell Street, Durham, NC 27701, United States
| | - Laneta Dorflinger
- Product Development and Introduction, FHI 360, 359 Blackwell Street, Durham, NC 27701, United States
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Taylor DJ, Deese J, Bahamondes L, Brache V, Veiga N, Fuchs R, Halpern V, Dorflinger LJ. Return to ovulation after Sayana Press is injected every 4 months for one year: Empirical and pharmacokinetic/pharmacodynamic modeling results. Contracept X 2022; 4:100080. [PMID: 35965654 PMCID: PMC9372597 DOI: 10.1016/j.conx.2022.100080] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/27/2022] [Accepted: 07/08/2022] [Indexed: 11/29/2022] Open
Abstract
Objective To characterize return to ovulation after injecting Sayana Press (104 mg/0.65 mL medroxyprogesterone acetate [MPA] in the Uniject device) every 4 months for 1 year of treatment. Study design We followed a subset of women for return to ovulation in a trial that demonstrated Sayana Press remains highly effective when the subcutaneous reinjection interval is extended from 3 to 4 months. We measured serum progesterone in weeks 38 to 42 and 46 to 50 after a final (third) injection and used a concentration ≥4.7 ng/mL as a surrogate for ovulation. We also performed pharmacokinetic and pharmacodynamic modeling to predict differences in MPA accumulation and return to ovulation had - contrary to fact - injections been given every 3 months. Results Ten of 19 women (53%; 95% confidence interval: 29–76) ovulated within 50 weeks of their last injection. We predicted that typical 12-month trough MPA concentrations are 34% lower (0.46 vs 0.69 ng/mL) and the median time from last dose to ovulation is 1.1 months shorter (13.1 vs 14.2 months) when injections are given every four months for 1 year. Conclusion Extending the Sayana Press reinjection interval from 3 to 4 months leads to less drug accumulation, without a noticeable loss in efficacy. Although the Sayana Press patient leaflet specifies that over 80% of women desiring pregnancy will conceive within a year of stopping the method (independent of treatment duration), our empirical and modeling results indicate women should anticipate waiting a year or more for fertility to return after repeat dosing, with a somewhat shorter delay were the reinjection interval extended to four months. Implications Providers should counsel women regarding the distinct possibility that return to fertility will take a year or longer following repeat use of Sayana Press. Extending the dosing interval from 3 to 4 months would result in approximately a 1-month shorter delay, without any appreciable reduction in contraceptive efficacy.
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Affiliation(s)
| | - Jennifer Deese
- RTI International, Research Triangle Park, North Carolina, United States
| | - Luis Bahamondes
- Department of Obstetrics and Gynecology, University of Campinas Faculty of Medical Sciences, Campinas, Brazil
| | - Vivian Brache
- Profamilia, Biomedical Research Department, Santo Domingo, Dominican Republic
| | - Nelio Veiga
- Department of Obstetrics and Gynecology, University of Campinas Faculty of Medical Sciences, Campinas, Brazil
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Taylor DJ, Halpern V, Brache V, Bahamondes L, Jensen JT, Dorflinger LJ. Ovulation suppression following subcutaneous administration of depot medroxyprogesterone acetate. Contracept X 2022; 4:100073. [PMID: 35281554 PMCID: PMC8907671 DOI: 10.1016/j.conx.2022.100073] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 02/05/2022] [Accepted: 02/11/2022] [Indexed: 10/27/2022] Open
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Halpern V, Fuchs R, Brache V, Bahamondes L, Miranda MJ, Lendvay A, Cochón L, Taylor D, Dorflinger LJ. Suppression of ovulation and pharmacokinetics following subcutaneous administration of various doses of Depo-Provera®: a randomized trial. Contracept X 2021; 3:100070. [PMID: 34746745 PMCID: PMC8551587 DOI: 10.1016/j.conx.2021.100070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 09/09/2021] [Accepted: 09/22/2021] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVES To identify the lowest dose of Depo-Provera that, when administered off-label subcutaneously, suppressed ovulation and had a pharmacokinetic profile consistent with a 4-month contraceptive effect. STUDY DESIGN We conducted a randomized, multicenter, parallel-group study to evaluate the pharmacokinetics (PK) and pharmacodynamics (PD) of medroxyprogesterone acetate (MPA) after subcutaneous injection of three different doses of Depo-Provera. We randomized sixty women between 18 and 40 years of age at low risk of pregnancy with confirmed ovulation and body mass index of 18 to 35 kg/m2 to receive a single injection of 45, 75 or 105 mg of Depo-Provera, or a single injection of Depo-subQ provera 104 as a reference drug (15 women per group) and followed them for 7.5 months. We evaluated suppression of ovulation as the primary outcome, and MPA concentrations, pharmacokinetic parameters, safety, and local tolerability as secondary outcomes. RESULTS Five women ovulated within four months of treatment initiation (three in the 45 mg group and two in the 75 mg group). MPA levels associated with ovulation were in general low, largely ≤ 0.2 ng/mL (the presumed contraceptive threshold). No women in either the 105 mg group or the Depo-subQ provera 104 group ovulated within four months. The PK parameters including Cmax, C119, and AUC0-119 for these 2 groups were similar but not equivalent. CONCLUSION A dose of 105 mg of Depo-Provera injected subcutaneously was the lowest tested dose that consistently suppressed ovulation and maintained serum MPA levels consistent with contraceptive effect for at least 4 months. The PK and PD results for the 105 mg dose were similar to Depo-subQ provera 104 over this period.
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Affiliation(s)
| | | | - Vivian Brache
- Profamilia, Biomedical Research Department, Santo Domingo, Dominican Republic
| | - Luis Bahamondes
- Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medicine, University of Campinas (UNICAMP) Campinas, Brazil
| | | | | | - Leila Cochón
- Profamilia, Biomedical Research Department, Santo Domingo, Dominican Republic
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Nabhan A, Elshafeey F, Mehrain LM, Kabra R, Elshabrawy A. Self-administered subcutaneous medroxyprogesterone acetate for improving contraceptive outcomes: a systematic review and meta-analysis. BMC Womens Health 2021; 21:359. [PMID: 34627229 PMCID: PMC8502084 DOI: 10.1186/s12905-021-01495-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 09/28/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Subcutaneous depot medroxyprogesterone acetate is an easy-to-use injectable contraceptive. A trained person can administer it, including women through self-injection. The objective of this systematic review and meta-analysis was to assess the effectiveness and safety of self-injection versus provider-administered subcutaneous depot medroxyprogesterone acetate for improving continuation of contraceptive use. METHODS We searched for randomized controlled trials on November 1, 2020 in Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, Embase, Web of Science, Scopus, Open Grey, clinical trials registries, and reference lists of relevant studies. We did not impose any search restrictions. We included randomized trials comparing self- versus provider-administered subcutaneous depot medroxyprogesterone acetate. Two authors independently screened trials, extracted data, and assessed the risk of bias in the included studies. We used risk ratio and 95% confidence intervals for dichotomous outcomes. RESULTS We identified 3 randomized trials (9 reports; 1264 participants). The risk of bias in the included studies was low except for performance bias and detection bias of participant-reported outcomes in unmasked trials. Self-administration, compared to provider-administration, increased continuation of contraceptive use (risk ratio 1.35; 95% confidence intervals 1.10-1.66); moderate-certainty evidence). Self-injection appears to be making more of an impact on continuation for younger women compared to women 25 years and older and on women living in low and middle income compared to high income countries. There was no subgroup difference by the type of care provider (community health worker vs. clinic-based provider). CONCLUSIONS Self-injection of subcutaneous depot medroxyprogesterone acetate probably improves continuation of contraceptive use. The effects on other outcomes remain uncertain because of the very low certainty of evidence.
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Affiliation(s)
- Ashraf Nabhan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Abbassia, Cairo, Egypt.
- Egyptian Center for Evidence Based Medicine, Cairo, Egypt.
| | | | | | - Rita Kabra
- World Health Organization, Geneva, Switzerland
| | - Amal Elshabrawy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Abbassia, Cairo, Egypt
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Roda Â, Marcos-Pinto A, Filipe P, Soares-de-Almeida L, Maia-Silva J. Lipomembranous panniculitis after subcutaneous medroxyprogesterone acetate injections used for buttocks augmentation in Africa. Int J Dermatol 2021; 61:e83-e85. [PMID: 34273108 DOI: 10.1111/ijd.15806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/18/2021] [Accepted: 07/02/2021] [Indexed: 01/16/2023]
Affiliation(s)
- Ângela Roda
- Department of Dermatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Ana Marcos-Pinto
- Department of Dermatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Paulo Filipe
- Department of Dermatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, University Clinic of Dermatology, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, Institute of Molecular Medicine, Lisboa, Portugal
| | - Luís Soares-de-Almeida
- Department of Dermatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, University Clinic of Dermatology, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, Institute of Molecular Medicine, Lisboa, Portugal
| | - João Maia-Silva
- Department of Dermatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, University Clinic of Dermatology, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, Institute of Molecular Medicine, Lisboa, Portugal
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11
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Bick AJ, Louw-du Toit R, Skosana SB, Africander D, Hapgood JP. Pharmacokinetics, metabolism and serum concentrations of progestins used in contraception. Pharmacol Ther 2021; 222:107789. [PMID: 33316287 PMCID: PMC8122039 DOI: 10.1016/j.pharmthera.2020.107789] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 11/24/2020] [Indexed: 02/07/2023]
Abstract
Many different forms of hormonal contraception are used by millions of women worldwide. These contraceptives differ in the dose and type of synthetic progestogenic compound (progestin) used, as well as the route of administration and whether or not they contain estrogenic compounds. There is an increasing awareness that different forms of contraception and different progestins have different side-effect profiles, in particular their cardiovascular effects, effects on reproductive cancers and susceptibility to infectious diseases. There is a need to develop new methods to suit different needs and with minimal risks, especially in under-resourced areas. This requires a better understanding of the pharmacokinetics, metabolism, serum and tissue concentrations of progestins used in contraception as well as the biological activities of progestins and their metabolites via steroid receptors. Here we review the current knowledge on these topics and identify the research gaps. We show that there is a paucity of research on most of these topics for most progestins. We find that major impediments to clear conclusions on these topics include a lack of standardized methodologies, comparisons between non-parallel clinical studies and variability of data on serum concentrations between and within studies. The latter is most likely due, at least in part, to differences in intrinsic characteristics of participants. The review highlights the importance of insight on these topics in order to provide the best contraceptive options to women with minimal risks.
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Affiliation(s)
- Alexis J Bick
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa
| | - Renate Louw-du Toit
- Department of Biochemistry, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Salndave B Skosana
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa
| | - Donita Africander
- Department of Biochemistry, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Janet P Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Nkanga CI, Fisch A, Rad-Malekshahi M, Romic MD, Kittel B, Ullrich T, Wang J, Krause RWM, Adler S, Lammers T, Hennink WE, Ramazani F. Clinically established biodegradable long acting injectables: An industry perspective. Adv Drug Deliv Rev 2020; 167:19-46. [PMID: 33202261 DOI: 10.1016/j.addr.2020.11.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/11/2022]
Abstract
Long acting injectable formulations have been developed to sustain the action of drugs in the body over desired periods of time. These delivery platforms have been utilized for both systemic and local drug delivery applications. This review gives an overview of long acting injectable systems that are currently in clinical use. These products are categorized in three different groups: biodegradable polymeric systems, including microparticles and implants; micro and nanocrystal suspensions and oil-based formulations. Furthermore, the applications of these drug delivery platforms for the management of various chronic diseases are summarized. Finally, this review addresses industrial challenges regarding the development of long acting injectable formulations.
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Affiliation(s)
- Christian Isalomboto Nkanga
- Center for Chemico- and Bio-Medicinal Research (CCBR), Department of Chemistry, Rhodes University, P.O. Box 94, Grahamstown 6140, South Africa; Faculty of Pharmaceutical Sciences, University of Kinshasa, B.P. 212, Kinshasa, XI, Democratic Republic of the Congo; Technical Research and Development, Novartis Pharma AG, Basel 4002, Switzerland
| | - Andreas Fisch
- Technical Research and Development, Novartis Pharma AG, Basel 4002, Switzerland
| | - Mazda Rad-Malekshahi
- Department of Pharmaceutical Biomaterials and Medical Biomaterials Research Centre, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Birgit Kittel
- Novartis Institute for Biomedical Research, Novartis Pharma AG, Basel 4002, Switzerland
| | - Thomas Ullrich
- Novartis Institute for Biomedical Research, Novartis Pharma AG, Basel 4002, Switzerland
| | - Jing Wang
- Technical Research and Development, Novartis Pharma AG, Basel 4002, Switzerland
| | - Rui Werner Maçedo Krause
- Center for Chemico- and Bio-Medicinal Research (CCBR), Department of Chemistry, Rhodes University, P.O. Box 94, Grahamstown 6140, South Africa
| | - Sabine Adler
- Technical Research and Development, Novartis Pharma AG, Basel 4002, Switzerland
| | - Twan Lammers
- Department of Experimental Molecular Imaging, RWTH Aachen University, Aachen, Germany
| | - Wim E Hennink
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands
| | - Farshad Ramazani
- Technical Research and Development, Novartis Pharma AG, Basel 4002, Switzerland.
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Upson K, Harmon QE, Heffron R, Hall JE, Wise LA, Wegienka G, Tokar EJ, Baird DD. Depot Medroxyprogesterone Acetate Use and Blood Lead Levels in a Cohort of Young Women. ENVIRONMENTAL HEALTH PERSPECTIVES 2020; 128:117004. [PMID: 33206002 PMCID: PMC7673223 DOI: 10.1289/ehp7017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 09/28/2020] [Accepted: 10/23/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Injectable contraceptive use is common, with 74 million users worldwide. Use of the injectable contraceptive depot medroxyprogesterone acetate (DMPA) is associated with bone mineral density loss. We hypothesize that increased bone resorption with DMPA use allows for mobilization of the toxic metal lead stored in bone to blood, presenting users with increased systemic exposure to lead. OBJECTIVE The objective of our study was to investigate the association between current DMPA use and blood lead concentrations. METHODS We conducted a cross-sectional analysis using enrollment data from the Study of Environment, Lifestyle & Fibroids (SELF), a cohort of 1,693 African-American women who were 23-35 years of age. Data on DMPA use were collected by computer-assisted telephone interview. Blood lead concentrations were measured in whole blood samples among 1,548 participants (91% of cohort). We estimated the adjusted percent difference in blood lead concentrations and 95% confidence intervals (CI) between current DMPA users and nonusers using multivariable linear regression. RESULTS Geometric mean blood lead concentration was 0.69 μ g / dL (95% CI: 0.67, 0.71). After adjustment, current DMPA users (7% of cohort) had blood lead concentrations that were 18% higher than those of nonusers (95% CI: 8%, 29%). Similar associations were observed with additional analyses to assess for potential bias from smoking, DMPA-induced amenorrhea, use of estrogen-containing contraceptives, having given birth in the prior year, and history of medical conditions or current medication use associated with bone loss. DISCUSSION Our results indicate that current DMPA use is associated with increased blood lead concentrations. Further research, particularly in populations highly exposed to lead, is warranted to consider tradeoffs between the adverse effects of lead on human health and the importance of DMPA as a contraceptive option to prevent unintended pregnancy. https://doi.org/10.1289/EHP7017.
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Affiliation(s)
- Kristen Upson
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Quaker E. Harmon
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Janet E. Hall
- Clinical Research Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Lauren A. Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Ganesa Wegienka
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - Erik J. Tokar
- Stem Cells Toxicology Group, National Toxicology Program Laboratory, Division of the National Toxicology Program, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Donna D. Baird
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
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Injectable contraception: emerging evidence on subcutaneous self-administration. Curr Opin Obstet Gynecol 2020; 31:464-470. [PMID: 31567445 DOI: 10.1097/gco.0000000000000574] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Injectable contraception is a widely available and popular family planning method globally. It has evolved to allow for subcutaneous self-injection (DMPA-SC, Depo medroxyprogesterone acetate-subcutaneous). In this review, we will focus on research evaluating DMPA-SC, with specific regard to continuation rates, safety, and satisfaction among users. RECENT FINDINGS Emerging evidence from the United States, Malawi, Uganda, and Senegal has established safety and higher continuation rates among self-inject users, compared with provider-inject users. Continuation is 10-28% higher among DMPA-SC self-inject users. Self-inject users across studies were highly satisfied and reported DMPA-SC was easy to use. Studies indicate continuation is likely to be attributable to self-administration and user autonomy, rather than inherent properties of the DMPA-SC injection. SUMMARY DMPA-SC should be made available in high-resource and low-resource settings. Future efforts should be focused on implementation and evaluating how to best add DMPA-SC to the method mix. Cost-benefit analyses will need to evaluate the up-front costs of DMPA-SC for clients, facilities, and health systems compared with the higher continuation rates and saved opportunity-costs over time. Task-shifting strategies and development of mobile phone technologies to assist users in adherence should be considered in future service scale-up.
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Best Practices for Counseling Adolescents about the Etonogestrel Implant. J Pediatr Adolesc Gynecol 2020; 33:448-454. [PMID: 32621879 DOI: 10.1016/j.jpag.2020.06.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/22/2020] [Accepted: 06/26/2020] [Indexed: 01/11/2023]
Abstract
Among young persons, ease of use, high efficacy, and high acceptability makes the etonogestrel contraceptive implant an important choice for this age group. Adolescent-friendly, patient-centered counseling considers the patient's cognitive development, the influence of friends and family, as well as their own preferences and values. Age-appropriate language, graphics, and models are useful to explain contraceptive options and relevant side effects. Effectiveness, reversibility, safety, noncontraceptive benefits, and side effects are important attributes and should be discussed when teens are choosing a contraceptive method. In this review we describe suggested best practices for counseling adolescents about the etonogestrel implant so they can make informed, prudent decisions about using this contraceptive method.
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An implementation project to expand access to self-administered depot medroxyprogesterone acetate (DMPA). Contraception 2020; 102:392-395. [PMID: 32931811 PMCID: PMC7486600 DOI: 10.1016/j.contraception.2020.09.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/27/2020] [Accepted: 09/02/2020] [Indexed: 11/30/2022]
Abstract
Objective To describe the implementation and results of a proactive patient outreach project to offer self-administered, depot medroxyprogesterone (DMPA) subcutaneous (SC) to interested patients at a California safety-net clinic following expanded state Medicaid coverage. Study design We contacted non-pregnant patients at an urban, safety-net hospital-based primary care clinic who had been prescribed DMPA intramuscular (IM) in the past year to gauge interest in self-administered DMPA-SC. Interested patients received a prescription for DMPA-SC and a telehealth appointment with a clinic provider to learn self-injection. We recorded patient interest in DMPA-SC, completed appointments, and completed first injections. We conducted initial outreach in May, 2020 and recorded appointment attendance and completed injections through August, 2020. Results Of 90 eligible patients (age 17–54), we successfully contacted and discussed DMPA-SC with 70 (78%). Twenty-six (37%) patients expressed interest in DMPA-SC and scheduled telehealth appointments to learn to self-administer the medication. Fifteen (58%) of those interested (21% of the total) successfully self-injected DMPA-SC. Of the 44 (63%) patients not interested in DMPA-SC, the three most common reasons were fear of self-injection (n = 23 [52%]), wanting to stop DMPA (n = 11 [25%]), and satisfaction with DMPA-IM (n = 6 [14%]). Conclusion There is interest in and successful initiation of self-administered DMPA-SC among patients at an urban safety net hospital-based primary care clinic who have used DMPA-IM in the last year. Implications Our data provide evidence for the interest and successful first injection rate after offering self-administered DMPA-SC to patients on DMPA-IM. Expanding coverage of self-administered DMPA-SC could increase patient-centeredness and accessibility of contraception as well as reduce patient anxiety around COVID-19 transmission without losing contraceptive access.
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Chen MJ, Creinin MD, Turok DK, Archer DF, Barnhart KT, Westhoff CL, Thomas MA, Jensen JT, Variano B, Sitruk-Ware R, Shanker A, Long J, Blithe DL. Dose-finding study of a 90-day contraceptive vaginal ring releasing estradiol and segesterone acetate. Contraception 2020; 102:168-173. [PMID: 32416145 DOI: 10.1016/j.contraception.2020.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate serum estradiol (E2) concentrations during use of 90-day contraceptive vaginal rings releasing E2 75, 100, or 200 mcg/day and segesterone acetate (SA) 200 mcg/day to identify a dose that avoids hypoestrogenism. STUDY DESIGN We conducted a multicenter dose-finding study in healthy, reproductive-aged women with regular cycles with sequential enrollment to increasing E2 dose groups. We evaluated serum E2 concentrations twice weekly for the primary outcome of median E2 concentrations throughout initial 30-day use (target ≥40 pg/mL). In an optional 2-cycle extension substudy, we randomized participants to 2- or 4-day ring-free intervals per 30-day cycle to evaluate bleeding and spotting based on daily diary information. RESULTS Sixty-five participants enrolled in E2 75 (n = 22), 100 (n = 21), and 200 (n = 22) mcg/day groups; 35 participated in the substudy. Median serum E2 concentrations in 75 and 100 mcg/day groups were <40 pg/mL. In the 200 mcg/day group, median E2 concentrations peaked on days 4-5 of CVR use at 194 pg/mL (range 114-312 pg/mL) and remained >40 pg/mL throughout 30 days; E2 concentrations were 37 pg/mL (range 28-62 pg/mL) on days 88-90 (n = 11). Among the E2 200 mcg/day substudy participants, all had withdrawal bleeding following ring removal. The 2-day ring-free interval group reported zero median unscheduled bleeding and two (range 0-16) and three (range 0-19) unscheduled spotting days in extension cycles 1 and 2, respectively. The 4-day ring-free interval group reported zero median unscheduled bleeding or spotting days. CONCLUSIONS Estradiol concentrations with rings releasing E2 200 mcg/day and SA 200 mcg/day avoid hypoestrogenism over 30-day use. IMPLICATIONS A 90-day contraceptive vaginal ring releasing estradiol 200 mcg/day and segesterone acetate 200 mcg/day achieves estradiol concentrations that should avoid hypoestrogenism and effectively suppresses ovulation.
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Affiliation(s)
- Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States.
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States
| | - David K Turok
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, United States
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, United States
| | - Michael A Thomas
- Reproductive Medicine Research, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, United States
| | - Bruce Variano
- Center for Biomedical Research, Population Council, New York, NY, United States
| | - Regine Sitruk-Ware
- Center for Biomedical Research, Population Council, New York, NY, United States
| | | | - Jill Long
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Diana L Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
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Quispe Calla NE, Vicetti Miguel RD, Aceves KM, Torres A, Cherpes TL. Depot-medroxyprogesterone acetate reduces genital cell-cell adhesion molecule expression and increases genital herpes simplex virus type 2 infection susceptibility in a dose-dependent fashion. Contraception 2019; 100:397-401. [PMID: 31302121 DOI: 10.1016/j.contraception.2019.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Analyzing ectocervical biopsy tissue from women before and after they initiated use of depot-medroxyprogesterone acetate (DMPA), we previously reported this progestin reduces levels of the cell-cell adhesion molecule (CCAM) desmoglein-1 and increases genital mucosal permeability. We likewise saw treating mice with 1.0 mg of DMPA reduced vaginal CCAM expression and increased genital pathogen susceptibility. Herein, we used dose-response studies to delimit DMPA doses and serum MPA levels in mice associated with impaired genital mucosal barrier function and enhanced susceptibility to low-dose herpes simplex virus type 2 (HSV-2) infection. STUDY DESIGN We compared genital CCAM expression, genital mucosal permeability, and susceptibility to genital inoculation with 103 plaque-forming units of HSV-2 among mice in estrus vs. after treatment with 0.01 mg, 0.1 mg, 0.3 mg, or 1.0 mg of DMPA. RESULTS Compared to mice in estrus, DMPA treatment in a dose-dependent fashion significantly reduced desmoglein 1α (Dsg1a) and desmocollin-1 (Dsc1) gene expression, reduced DSG1 protein levels, and increased genital mucosal permeability to a low molecular weight molecule. While no mice infected with HSV-2 in estrus died, we respectively saw 50% and 100% mortality in mice administered 0.1 mg or 0.3 mg of DMPA. At time of infection, mean serum MPA levels in mice administered the 0.1 mg or 0.3 mg doses were 3.8 nM and 13.0 nM respectively (values comparable to trough and peak MPA serum levels in women using DMPA). CONCLUSIONS Mice with pharmacologically relevant serum MPA concentrations display significant changes in genital CCAM expression, genital mucosal barrier function, and HSV-2 susceptibility.
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Affiliation(s)
- Nirk E Quispe Calla
- Department of Comparative Medicine, Stanford University School of Medicine. Stanford, California, USA.
| | - Rodolfo D Vicetti Miguel
- Department of Comparative Medicine, Stanford University School of Medicine. Stanford, California, USA.
| | - Kristen M Aceves
- Department of Comparative Medicine, Stanford University School of Medicine. Stanford, California, USA
| | - Angelo Torres
- Midwestern University College of Veterinary Medicine, Glendale, AZ, USA
| | - Thomas L Cherpes
- Department of Comparative Medicine, Stanford University School of Medicine. Stanford, California, USA
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Liu J, Shen J, Schatzkin E, Adedeji O, Kongnyuy E, Onuoha C, Fajemisin M, Ayodeji K, Omoluabi E. Accessing DMPA-SC through the public and private sectors in Nigeria: users’ characteristics and their experiences. Gates Open Res 2019. [DOI: 10.12688/gatesopenres.12890.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Beginning in 2015, subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was added to the contraceptive method mix in Nigeria, primarily through social marketing in the private sector and community-based distribution in the public sector. We compare user experiences in acquiring DMPA-SC across sectors during this national scale-up. Methods: From October 2017 to February 2018, 459 women (Npublic=235; Nprivate=224) completed a phone survey from a convenience sample of 1,444 women (Npublic=912; Nprivate=532) who obtained DMPA-SC from participating providers and agreed to be contacted. We examined the sociodemographic predictors of attending a public vs. private provider and analyzed differences in care-seeking across sectors (becoming aware of DMPA-SC, choosing a provider, choosing DMPA-SC, quality of care). Results: Respondents obtaining DMPA-SC from public providers were younger and less educated than those attending private providers. Both program respondents were comprised of similar percentages of new users of modern contraception (58.7-60.3%), although most respondents became aware of DMPA-SC through a friend/family member (43.1%) or a provider (41.5%). Relatively more public sector respondents also heard about DMPA-SC through community outreaches whereas relatively more private sector respondents became aware through media. Convenience was the most common reason for choosing a provider—43.8% among all respondents (higher among public sector respondents). Private sector respondents were also more likely to choose a past or usual provider. Having overall higher quality interactions were more likely among clients who attended private providers than public providers, but responses to individual quality item measures show specific areas of poor quality for providers in each sector. Conclusions: Training emphasizing technical thoroughness, sensitivity toward younger women, and client choice may help improve women’s experiences with obtaining DMPA-SC, ultimately contributing to accelerating demand for and uptake of DMPA-SC specifically and contraception in general.
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FSRH Guideline (April 2019) Overweight, Obesity and Contraception. BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:1-69. [PMID: 31053605 DOI: 10.1136/bmjsrh-2019-ooc] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Burke HM, Chen M, Buluzi M, Fuchs R, Wevill S, Venkatasubramanian L, Santo LD, Ngwira B. Factors Affecting Continued Use of Subcutaneous Depot Medroxyprogesterone Acetate (DMPA-SC): A Secondary Analysis of a 1-Year Randomized Trial in Malawi. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:54-65. [PMID: 30894394 PMCID: PMC6538126 DOI: 10.9745/ghsp-d-18-00433] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/16/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the supply- and demand-side factors influencing continued use of the injectable contraceptive subcutaneous depot medroxyprogesterone acetate (DMPA-SC). METHODS We conducted a 12-month randomized controlled trial in Malawi to measure DMPA-SC continuation rates. A total of 731 women presenting to clinic-based providers (CBPs) at 6 Ministry of Health clinics or to community health workers (CHWs) in rural communities were randomized to receive DMPA-SC administered by a provider or be trained to self-inject DMPA-SC. Data collectors contacted women after the reinjection window at 3, 6, and 9 months to collect data on discontinuation and women's experiences. Twelve months after enrollment or at early discontinuation, women had their final interview, including pregnancy testing. We compared continuation, pregnancy, and safety by whether DMPA-SC or self-injection training was provided by CHWs versus CBPs. We also conducted an exploratory analysis assessing the association between women's sociodemographic factors and the risk for discontinuation using stratified Cox proportional hazards models. FINDINGS The type of provider did not seem to influence continuation, pregnancy, or safety. As reported previously, women in the self-injection group were significantly less likely to discontinue the method compared with women in the provider-administered group (hazard ratio, 0.43; P<.001). The risk for discontinuation was also different among health facility catchment sites (P<.001). No other assessed sociodemographic factors were found to significantly influence the risk for discontinuation. CONCLUSIONS Public-sector CHWs can safely and effectively provide DMPA-SC and train women to self-inject DMPA-SC in low-resource settings. DMPA-SC continuation did not seem to be influenced by the type of provider, whether CBP or CHW, or women's sociodemographic characteristics.
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Affiliation(s)
| | | | - Mercy Buluzi
- College of Medicine, University of Malawi, Blantyre, Malawi
| | | | | | | | | | - Bagrey Ngwira
- College of Medicine, University of Malawi, Blantyre, Malawi
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The contraceptive medroxyprogesterone acetate, unlike norethisterone, directly increases R5 HIV-1 infection in human cervical explant tissue at physiologically relevant concentrations. Sci Rep 2019; 9:4334. [PMID: 30867477 PMCID: PMC6416361 DOI: 10.1038/s41598-019-40756-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 02/19/2019] [Indexed: 02/06/2023] Open
Abstract
The intramuscular progestin-only injectable contraceptive, depo-medroxyprogesterone acetate (DMPA-IM), is more widely used in Sub-Saharan Africa than another injectable contraceptive, norethisterone enanthate (NET-EN). Epidemiological data show a significant 1.4-fold increased risk of HIV-1 acquisition for DMPA-IM usage, while no such association is shown from limited data for NET-EN. We show that MPA, unlike NET, significantly increases R5-tropic but not X4-tropic HIV-1 replication ex vivo in human endocervical and ectocervical explant tissue from pre-menopausal donors, at physiologically relevant doses. Results support a mechanism whereby MPA, unlike NET, acts via the glucocorticoid receptor (GR) to increase HIV-1 replication in cervical tissue by increasing the relative frequency of CD4+ T cells and activated monocytes. We show that MPA, unlike NET, increases mRNA expression of the CD4 HIV-1 receptor and CCR5 but not CXCR4 chemokine receptors, via the GR. However, increased density of CD4 on CD3+ cells was not observed with MPA by flow cytometry of digested tissue. Results suggest that DMPA-IM may increase HIV-1 acquisition in vivo at least in part via direct effects on cervical tissue to increase founder R5-tropic HIV-1 replication. Our findings support differential biological mechanisms and disaggregation of DMPA-IM and NET-EN regarding HIV-1 acquisition risk category for use in high risk areas.
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Liu J, Shen J, Schatzkin E, Adedeji O, Kongnyuy E, Onuoha C, Fajemisin M, Ayodeji K, Omoluabi E. Accessing DMPA-SC through the public and private sectors in Nigeria: users’ characteristics and their experiences. Gates Open Res 2018. [DOI: 10.12688/gatesopenres.12890.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Beginning in 2015, subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was added to the contraceptive method mix in Nigeria, primarily through social marketing in the private sector and community-based distribution in the public sector. We compare user experiences in acquiring DMPA-SC across sectors during this national scale-up. Methods: From October 2017 to February 2018, 459 women (Npublic=235; Nprivate=224) completed a phone survey from a convenience sample of 1,444 women (Npublic=912; Nprivate=532) who obtained DMPA-SC from participating providers and agreed to be contacted. We examined the sociodemographic predictors of attending a public vs. private provider and analyzed differences in care-seeking across sectors (becoming aware of DMPA-SC, choosing a provider, choosing DMPA-SC, quality of care). Results: Respondents obtaining DMPA-SC from public providers were younger and less educated than those attending private providers. Both program respondents were comprised of similar percentages of new users of modern contraception (58.7-60.3%), although most respondents became aware of DMPA-SC through a friend/family member (43.1%) or a provider (41.5%). Relatively more public sector respondents also heard about DMPA-SC through community outreaches whereas relatively more private sector respondents became aware through media. Convenience was the most common reason for choosing a provider—43.8% among all respondents (higher among public sector respondents). Private sector respondents were also more likely to choose a past or usual provider. Having overall higher quality interactions were more likely among clients who attended private providers than public providers, but responses to individual quality item measures show specific areas of poor quality for providers in each sector. Conclusions: Training emphasizing technical thoroughness, sensitivity toward younger women, and client choice may help improve women’s experiences with obtaining DMPA-SC, ultimately contributing to accelerating demand for and uptake of DMPA-SC specifically and contraception in general.
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Odwe G, Gray K, Kyarimpa A, Obare F, Nagendi G. Introduction of Subcutaneous Depot Medroxyprogesterone Acetate (DMPA-SC) Injectable Contraception at Facility and Community Levels: Pilot Results From 4 Districts of Uganda. GLOBAL HEALTH: SCIENCE AND PRACTICE 2018; 6:711-722. [PMID: 30429201 PMCID: PMC6370348 DOI: 10.9745/ghsp-d-18-00117] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 09/17/2018] [Indexed: 11/15/2022]
Abstract
Over 1 year, the NGO-led project provided more than 14,000 units of DMPA-SC, mostly in community settings and to a substantial proportion (43%) of young women. The share of injectables increased significantly, as did the volume of all methods provided, including short-acting, long-acting, and permanent methods. Reproductive Health Uganda (RHU), a local NGO, introduced subcutaneous depot medroxyprogesterone acetate (DMPA-SC, brand name Sayana Press) in 4 districts of Uganda between April 2016 and March 2017. RHU trained public and private facility providers on all family planning methods including DMPA-SC; trained community health workers (known as village health teams, VHTs) to give family planning counseling, provide short-acting methods including DMPA-SC, and make referrals for long-acting and permanent methods; conducted mobile outreach and raised awareness of family planning; and provided family planning commodities. We used a retrospective cross-sectional evaluation design drawing on data from (1) in-depth interviews with 32 facility- and community-based providers; (2) key informant interviews with 7 policy makers and program staff; and (3) family planning program statistics from 4 RHU clinics, 26 mobile outreach sites, and 40 VHTs in 4 study districts. Data collection took place between April and June 2017. Over 12 months, 14,273 units of DMPA-SC were provided in RHU clinics, by mobile outreach teams, and by VHTs. DMPA-SC units were mostly administered in community settings either by VHTs (70%) or at mobile outreach events (26%). A substantial proportion (43%) of DMPA-SC units were administered to young people (<25 years), a significantly higher proportion compared with other methods provided to this age group through the project (P<.001), except condoms. In addition, a greater proportion of DMPA-SC units provided at the community level by VHTs were used by young people (45%) compared with units provided at outreach (36%) or in clinics (35%). Overall, injectables (DMPA-SC and intramuscular DMPA combined) came to represent 43% of all contraceptive methods provided, up from a baseline of 20%. This shift occurred despite significant increases in the volume of all other methods provided (P<.001). Qualitative data revealed various factors that facilitated introduction, including comprehensive training, commodity availability, strong referral links, and early community engagement. RHU's experience supports the viability of community-based delivery of DMPA-SC and identifies opportunities to strengthen this approach. There is further evidence that DMPA-SC may be popular with young people, especially in community settings.
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Affiliation(s)
| | - Kate Gray
- International Planned Parenthood Federation, London, United Kingdom
| | | | | | - Grace Nagendi
- International Planned Parenthood Federation, Africa Region, Nairobi, Kenya
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Heffron R, Achilles SL, Dorflinger LJ, Hapgood JP, Kiarie J, Polis CB, Steyn PS. Pharmacokinetic, biologic and epidemiologic differences in MPA- and NET-based progestin-only injectable contraceptives relative to the potential impact on HIV acquisition in women. Contraception 2018; 99:199-204. [PMID: 30576636 PMCID: PMC6467541 DOI: 10.1016/j.contraception.2018.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/25/2018] [Accepted: 12/05/2018] [Indexed: 11/13/2022]
Abstract
Access to safe and effective contraceptive choices is a reproductive right and contributes tremendously to improvements in maternal and child health. Progestin-only injectables, particularly intramuscularly injected depot medroxyprogesterone acetate (DMPA-IM), have received increased attention given findings suggesting a potential association with increased HIV risk. For women at high risk of HIV, the World Health Organization's Medical eligibility criteria for contraceptive use currently aggregate recommendations for all progestin-only injectables, including DMPA-IM, subcutaneously injected DMPA (DMPA-SC) and intramuscularly injected norethindrone/ norethisterone enanthate (NET-EN), except in the case of some drug interactions. We considered whether published data indicate differences or similarities between these injectables relevant to risk of acquiring HIV. In vitro data confirm different biological activities of these distinct progestins, including that MPA, and not NET, binds and activates the glucocorticoid receptor resulting in different biological effects relevant to immune function. Limited clinical data suggest changes in immunologic activity following DMPA-IM and NET-EN initiation, but interstudy variation and study design differences diminish ability to determine clinical relevance and the degree to which DMPA-IM and NET-EN could act differentially. The highest-quality epidemiologic studies suggest a potential 40% increase in HIV incidence in users of DMPA-IM relative to women not using hormonal contraception but no significant increase in risk in users of NET-EN. In our opinion, most of the available biologic activity and epidemiologic data indicate that DMPA and NET-EN are likely to act differently, and data remain too limited to evaluate differences between DMPA-IM and DMPA-SC.
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Affiliation(s)
- Renee Heffron
- Department of Global Health, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA, USA; Department of Epidemiology, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA, USA.
| | - Sharon L Achilles
- Department of Obstetrics, Gynecology, and Reproductive Sciences and Center for Family Planning Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA.
| | | | - Janet P Hapgood
- Department of Molecular and Cell Biology, Faculty of Science, University of Cape Town, Private Bag X3, Rondebosch, 7701, Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Private Bag X3, Rondebosch, 7701, Cape Town, South Africa.
| | - James Kiarie
- Department of Reproductive Health and Research, World Health Organization (WHO), Geneva, Switzerland.
| | - Chelsea B Polis
- Guttmacher Institute, 125 Maiden Lane, 7th Floor, Manhattan, New York, 10038, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe St., Baltimore, MD 21205, USA.
| | - Petrus S Steyn
- Department of Reproductive Health and Research, World Health Organization (WHO), Geneva, Switzerland.
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Bush J. Sayana Press and a case of likely lipoatrophy. BMJ SEXUAL & REPRODUCTIVE HEALTH 2018; 44:bmjsrh-2018-200120. [PMID: 29972355 DOI: 10.1136/bmjsrh-2018-200120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Jane Bush
- The Centre for Contraception, GU Medicine and HIV Services, North Devon Healthcare Trust, 31 Sidwell St., Exeter EX4 6NN, UK
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Barra F, Scala C, Ferrero S. Current understanding on pharmacokinetics, clinical efficacy and safety of progestins for treating pain associated to endometriosis. Expert Opin Drug Metab Toxicol 2018; 14:399-415. [PMID: 29617576 DOI: 10.1080/17425255.2018.1461840] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Endometriosis is a chronic estrogen and progestogen responsive inflammatory disease associated with pain symptoms and infertility. The medical therapy of endometriosis aims to induce decidualization within the hormonally dependent ectopic endometrium, and it is often administered to ameliorate women' pain symptoms or to prevent post-surgical disease recurrence. A variety of progestins have been used in monotherapy for the medical management of women with endometriosis. Areas covered: This review aims to offer the reader a complete overview of pharmacokinetic (PK) and clinical efficacy of progestins for the treatment of endometriosis. Expert opinion: Each progestin has a distinct PK parameters and pharmacodynamics affinity not only for progesterone receptor, but also for other steroid receptors, such as estrogen, androgen, and glucocorticoid. Moreover, progestins can also be delivered in different formulations. All these characteristics influence their final biological effect. Randomized, controlled, non-blinded studies support the use of oral progestin-only treatment for pelvic pain associated with endometriosis. Currently, the only two progestins approved by Food and Drug Administration (FDA) for the treatment of endometriosis are norethindrone acetate (NETA) and depot medroxyprogesterone acetate (DMPA).
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Affiliation(s)
- Fabio Barra
- a Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| | - Carolina Scala
- a Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| | - Simone Ferrero
- a Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
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Hapgood JP, Kaushic C, Hel Z. Hormonal Contraception and HIV-1 Acquisition: Biological Mechanisms. Endocr Rev 2018; 39:36-78. [PMID: 29309550 PMCID: PMC5807094 DOI: 10.1210/er.2017-00103] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/27/2017] [Indexed: 12/12/2022]
Abstract
Access to effective affordable contraception is critical for individual and public health. A wide range of hormonal contraceptives (HCs), which differ in composition, concentration of the progestin component, frequency of dosage, and method of administration, is currently available globally. However, the options are rather limited in settings with restricted economic resources that frequently overlap with areas of high HIV-1 prevalence. The predominant contraceptive used in sub-Saharan Africa is the progestin-only three-monthly injectable depot medroxyprogesterone acetate. Determination of whether HCs affect HIV-1 acquisition has been hampered by behavioral differences potentially confounding clinical observational data. Meta-analysis of these studies shows a significant association between depot medroxyprogesterone acetate use and increased risk of HIV-1 acquisition, raising important concerns. No association was found for combined oral contraceptives containing levonorgestrel, nor for the two-monthly injectable contraceptive norethisterone enanthate, although data for norethisterone enanthate are limited. Susceptibility to HIV-1 and other sexually transmitted infections may, however, be dependent on the type of progestin present in the formulation. Several underlying biological mechanisms that may mediate the effect of HCs on HIV-1 and other sexually transmitted infection acquisition have been identified in clinical, animal, and ex vivo studies. A substantial gap exists in the translation of basic research into clinical practice and public health policy. To bridge this gap, we review the current knowledge of underlying mechanisms and biological effects of commonly used progestins. The review sheds light on issues critical for an informed choice of progestins for the identification of safe, effective, acceptable, and affordable contraceptive methods.
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Affiliation(s)
- Janet P Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Charu Kaushic
- Department of Pathology and Molecular Medicine, McMaster University, Ontario, Canada.,McMaster Immunology Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Zdenek Hel
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama.,Center for AIDS Research, University of Alabama at Birmingham, Birmingham, Alabama
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Abstract
PURPOSE OF REVIEW Injectable contraception is a highly effective form of birth control that is globally popular. Recent research has focused on ways to make injectables such as depot medroxyprogesterone acetate (DMPA) more accessible and to improve the side-effect profile of injectables. This review will focus on new directions and approaches to the use of injectable contraception. RECENT FINDINGS Research in the area of injectable contraception has focused on improving access for women through home or self-injection, and also task-shifting and community-based distribution in low-resource areas. Specific to DMPA, studies have focused on lowering the overall dose of medication while maintaining efficacy, and improving drug-delivery systems. More research into the association between DMPA and HIV is needed, and also the effects of administration of DMPA at the time of medication abortion. SUMMARY Injectable contraceptives are an important part of the global method mix of highly effective birth control. Improving the accessibility and side effect profile of commodities such as DMPA will make injectables even more valuable for women seeking effective contraception.
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Polis CB, Achilles SL, Hel Z, Hapgood JP. Is a lower-dose, subcutaneous contraceptive injectable containing depot medroxyprogesterone acetate likely to impact women's risk of HIV? Contraception 2017; 97:191-197. [PMID: 29242082 DOI: 10.1016/j.contraception.2017.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/18/2017] [Accepted: 12/02/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Chelsea B Polis
- Guttmacher Institute, New York, NY, USA; Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA.
| | - Sharon L Achilles
- Department of Obstetrics, Gynecology, and Reproductive Sciences and Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Zdenek Hel
- Department of Pathology, Center for AIDS Research, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Janet P Hapgood
- Department of Molecular and Cell Biology and Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Buggio L, Somigliana E, Barbara G, Frattaruolo MP, Vercellini P. Oral and depot progestin therapy for endometriosis: towards a personalized medicine. Expert Opin Pharmacother 2017; 18:1569-1581. [DOI: 10.1080/14656566.2017.1381086] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Laura Buggio
- Fondazione Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Infertility Unit, Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giussy Barbara
- Fondazione Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Pina Frattaruolo
- Fondazione Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Paolo Vercellini
- Fondazione Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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Lange HLH, Manos BE, Gothard MD, Rogers LK, Bonny AE. Bone Mineral Density and Weight Changes in Adolescents Randomized to 3 Doses of Depot Medroxyprogesterone Acetate. J Pediatr Adolesc Gynecol 2017; 30:169-175. [PMID: 27789350 DOI: 10.1016/j.jpag.2016.10.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 10/12/2016] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE To assess the association between medroxyprogesterone acetate exposure and bone mineral density (BMD) loss and weight change in adolescents. DESIGN Forty-eight-week prospective, randomized trial conducted May 2012-April 2014. SETTING Recruitment occurred in the general community and outpatient clinics in central Ohio. PARTICIPANTS Self-referred sample of 34 female adolescents aged 12-21 years initiating depot medroxyprogesterone acetate (DMPA). INTERVENTIONS Randomization to 1 of 3 DMPA doses (150, 104, or 75 mg) given intramuscularly every 12 weeks for 48 weeks. MAIN OUTCOME MEASURES Absolute and percent change in BMD from 0-48 weeks at the L1-L4 lumbar spine, total hip, and femoral neck; absolute and percent change in weight at 48 weeks. RESULTS DMPA dose was associated with medroxyprogesterone acetate exposure as evidenced by a direct relationship (P < .001) between dose group and area under the concentration time curve. At 48 weeks, no significant BMD decreases were seen in the 75 mg dose group. The 104 and 150 mg dose groups experienced significant (P < .01) decreases in L1-L4 lumbar spine BMD (3.1% and 4.0%, respectively). The 150 mg group also had significant (P < .05) decreases in total hip (3.0%) and femoral neck (4.0%) BMD. No group differences in weight change were observed. No pregnancies occurred in any DMPA dose group. CONCLUSIONS Our data provide evidence of a dose-response relationship between DMPA and BMD loss. Intramuscular DMPA doses less than 150 mg can decrease risk of BMD loss in adolescents. The risk/benefit ratio of lower-dose DMPA should be further investigated in larger and more diverse adolescent populations.
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Affiliation(s)
- Hannah L H Lange
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Brittny E Manos
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | | | - Lynette K Rogers
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Andrea E Bonny
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; The Ohio State University, Columbus, Ohio; Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio.
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The role of training in effective simulated self-injection of subcutaneous depot medroxyprogesterone acetate: observations from a usability study. Contraception 2016; 94:314-20. [DOI: 10.1016/j.contraception.2016.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 04/08/2016] [Accepted: 05/22/2016] [Indexed: 11/17/2022]
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Development of controlled release systems over the past 50 years in the area of contraception. J Control Release 2016; 240:235-241. [DOI: 10.1016/j.jconrel.2015.12.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 12/22/2015] [Accepted: 12/23/2015] [Indexed: 11/23/2022]
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Abstract
Perimenopause, or the menopause transition, is a time in a woman's life that bridges her reproductive years through to the non-surgical cessation of ovulation, or menopause. For many women this time is one of changes: changes in gynecological issues, onset of symptoms not experienced in her youth and increasing risks for adverse medical conditions. Despite the clear changes that occur for many women during this time, one critical issue is frequently ignored, namely, that, until the onset of menopause, she is exposed to pregnancy if sexually active, and pregnancy for older reproductive women is fraught with considerable increases in morbidity and mortality compared to younger women. This paper will present a review of the reproductive issues of the perimenopause and interventions geared to preventing pregnancy and relieving menopause-related symptoms. As counseling remains a critical aspect in empowering women to make informed choices about their health care, this paper will present current evidence that will help clinicians provide accurate reproductive counseling to women in the menopause transition.
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Affiliation(s)
- A Linton
- a Section of Family Planning, Department of Obstetrics and Gynecology of the Feinberg School of Medicine of Northwestern University , Chicago , Illinois , USA
| | - A Golobof
- a Section of Family Planning, Department of Obstetrics and Gynecology of the Feinberg School of Medicine of Northwestern University , Chicago , Illinois , USA
| | - L P Shulman
- a Section of Family Planning, Department of Obstetrics and Gynecology of the Feinberg School of Medicine of Northwestern University , Chicago , Illinois , USA.,b Division of Clinical Genetics, Department of Obstetrics and Gynecology of the Feinberg School of Medicine of Northwestern University , Chicago , Illinois , USA
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Lopez LM, Ramesh S, Chen M, Edelman A, Otterness C, Trussell J, Helmerhorst FM. Progestin-only contraceptives: effects on weight. Cochrane Database Syst Rev 2016; 2016:CD008815. [PMID: 27567593 PMCID: PMC5034734 DOI: 10.1002/14651858.cd008815.pub4] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Progestin-only contraceptives (POCs) are appropriate for many women who cannot or should not take estrogen. POCs include injectables, intrauterine contraception, implants, and oral contraceptives. Many POCs are long-acting, cost-effective methods of preventing pregnancy. However, concern about weight gain can deter the initiation of contraceptives and cause early discontinuation among users. OBJECTIVES The primary objective was to evaluate the association between progestin-only contraceptive use and changes in body weight. SEARCH METHODS Until 4 August 2016, we searched MEDLINE, CENTRAL, POPLINE, LILACS, ClinicalTrials.gov, and ICTRP. For the initial review, we contacted investigators to identify other trials. SELECTION CRITERIA We considered comparative studies that examined a POC versus another contraceptive method or no contraceptive. The primary outcome was mean change in body weight or mean change in body composition. We also considered the dichotomous outcome of loss or gain of a specified amount of weight. DATA COLLECTION AND ANALYSIS Two authors extracted the data. Non-randomized studies (NRS) need to control for confounding factors. We used adjusted measures for the primary effects in NRS or the results of matched analysis from paired samples. If the report did not provide adjusted measures for the primary analysis, we used unadjusted outcomes. For RCTs and NRS without adjusted measures, we computed the mean difference (MD) with 95% confidence interval (CI) for continuous variables. For dichotomous outcomes, we calculated the Mantel-Haenszel odds ratio (OR) with 95% CI. MAIN RESULTS We found 22 eligible studies that included a total of 11,450 women. With 6 NRS added to this update, the review includes 17 NRS and 5 RCTs. By contraceptive method, the review has 16 studies of depot medroxyprogesterone acetate (DMPA), 4 of levonorgestrel-releasing intrauterine contraception (LNG-IUC), 5 for implants, and 2 for progestin-only pills.Comparison groups did not differ significantly for weight change or other body composition measure in 15 studies. Five studies with moderate or low quality evidence showed differences between study arms. Two studies of a six-rod implant also indicated some differences, but the evidence was low quality.Three studies showed differences for DMPA users compared with women not using a hormonal method. In a retrospective study, weight gain (kg) was greater for DMPA versus copper (Cu) IUC in years one (MD 2.28, 95% CI 1.79 to 2.77), two (MD 2.71, 95% CI 2.12 to 3.30), and three (MD 3.17, 95% CI 2.51 to 3.83). A prospective study showed adolescents using DMPA had a greater increase in body fat (%) compared with a group not using a hormonal method (MD 11.00, 95% CI 2.64 to 19.36). The DMPA group also had a greater decrease in lean body mass (%) (MD -4.00, 95% CI -6.93 to -1.07). A more recent retrospective study reported greater mean increases with use of DMPA versus Cu IUC for weight (kg) at years 1 (1.3 vs 0.2), 4 (3.5 vs 1.9), and 10 (6.6 vs 4.9).Two studies reported a greater mean increase in body fat mass (%) for POC users versus women not using a hormonal method. The method was LNG-IUC in two studies (reported means 2.5 versus -1.3; P = 0.029); (MD 1.60, 95% CI 0.45 to 2.75). One also studied a desogestrel-containing pill (MD 3.30, 95% CI 2.08 to 4.52). Both studies showed a greater decrease in lean body mass among POC users. AUTHORS' CONCLUSIONS We considered the overall quality of evidence to be low; more than half of the studies had low quality evidence. The main reasons for downgrading were lack of randomizations (NRS) and high loss to follow-up or early discontinuation.These 22 studies showed limited evidence of change in weight or body composition with use of POCs. Mean weight gain at 6 or 12 months was less than 2 kg (4.4 lb) for most studies. Those with multiyear data showed mean weight change was approximately twice as much at two to four years than at one year, but generally the study groups did not differ significantly. Appropriate counseling about typical weight gain may help reduce discontinuation of contraceptives due to perceptions of weight gain.
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Affiliation(s)
- Laureen M Lopez
- FHI 360Clinical and Epidemiological Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Shanthi Ramesh
- University of North CarolinaDepartment of Obstetrics and Gynaecology4012 Old Clinic Building, CB 7570Chapel HillNC ‐ North CarolinaUSA27599
| | - Mario Chen
- FHI 360Biostatistics359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Alison Edelman
- Oregon Health & Science UniversityDept. of Obstetrics and GynecologyPortlandOregonUSA
| | | | - James Trussell
- Princeton UniversityOffice of Population researchWallaca HallPrincetonNew JerseyUSANJ 08544
| | - Frans M Helmerhorst
- Leiden University Medical CenterDept. of Clinical EpidemiologyPO Box 9600Albinusdreef 2LeidenNetherlandsNL 2300 RC
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Kim CR, Fønhus MS, Ganatra B. Self-administration of injectable contraceptives: a systematic review. BJOG 2016; 124:200-208. [PMID: 27550792 PMCID: PMC5214286 DOI: 10.1111/1471-0528.14248] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2016] [Indexed: 11/29/2022]
Abstract
Background The contraceptive injectable is a safe and effective method that is used worldwide. With the variety of injectable delivery systems, there is potential for administration by the woman herself. Self‐administration of the contraceptive injectable is the subject of this systematic review. Objectives To assess how effective and safe the contraceptive injectable method is when women themselves perform/administer it, compared with when the usual healthcare providers administer it. Search strategy We searched PubMed, Popline, Cochrane, CINAHL, and Embase for articles with subject headings or text words related to ‘self‐administration’ and ‘contraception’. Selection criteria Studies that compared the administration of the contraceptive injectable by the woman herself versus administration by the healthcare provider were included. Outcomes of interest were continuation rates, safety, and the women's overall satisfaction with the contraceptive provider and method. Data collection and analysis We undertook data extraction, descriptive analysis, and assessment of risk of bias. Main results Three studies met the inclusion criteria. The best available evidence shows that there may be little or no difference in continuation rates when women self‐administer contraceptive injections (326 per 1000 women; 95% CI 192–554 per 1000 women) compared with administration by healthcare providers (304 per 1000 women). Safety was not estimable as no serious adverse events were reported in any of the studies. With regards to overall satisfaction towards the provider and the method, the effect of the intervention was uncertain. Authors’ conclusions Findings suggest that with appropriate information and training the provision of contraceptive injectables for the woman to self‐administer at home can be an option in some contexts. Tweetable abstract This review assessed the continuation rates and safety of self‐administration of the contraceptive injection. This review assessed the continuation rates and safety of self‐administration of the contraceptive injection.
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Affiliation(s)
- C R Kim
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - M S Fønhus
- Knowledge Centre for the Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - B Ganatra
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Reeves MF, Zhao Q, Secura GM, Peipert JF. Risk of unintended pregnancy based on intended compared to actual contraceptive use. Am J Obstet Gynecol 2016; 215:71.e1-6. [PMID: 26805610 DOI: 10.1016/j.ajog.2016.01.162] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 01/15/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND After initiating a new contraceptive method, the provider has little control of how or whether that method is used. OBJECTIVE We sought to compare unintended pregnancy rates by the initial chosen contraceptive method after counseling to traditional contraceptive effectiveness in the same study population. STUDY DESIGN The Contraceptive CHOICE Project provided reversible contraception to 9252 women at no cost during 2-3 years of follow-up. We performed 2 analyses of contraceptive efficacy in this prospective cohort: (1) intent-to-use (ITU), grouping participants based on their chosen method at enrollment; and (2) as-used, categorizing participant time according to the method used. In ITU analysis, switching of methods and method continuation were not considered, as we wanted to assess outcomes based on the method chosen at baseline. We used Cox proportional hazards models to compare rates of unintended pregnancy. RESULTS During 20,017 person-years, we identified 615 unintended pregnancies. In ITU analysis, pregnancy rates were 5.3, 5.5, 2.0, 1.7, and 1.9 per 100 person-years for women initiating oral, injectable, implantable, copper, and hormonal intrauterine contraception (IUC) at baseline, respectively. The adjusted hazard ratio for injectable contraception compared to hormonal IUC was 2.4 (95% confidence interval, 1.8-3.3). Delaying initiation of IUC or implantable contraception increased unintended pregnancies by 60% (adjusted hazard ratio, 1.6; 95% confidence interval, 1.2-2.0). In as-used analysis, pregnancy rates were 6.7, 1.6, 0.2, 0.6, and 0.2 per 100 person-years for women using oral, injectable, implantable, copper, and hormonal IUC, respectively. CONCLUSION Although highly effective in the as-used analysis, women initially choosing injectable contraception had pregnancy rates similar to oral contraception and significantly worse than IUC or implantable contraception. Despite switching and discontinuation, women choosing an IUC or implantable contraception at baseline were much less likely to have an unintended pregnancy compared to those selecting other methods.
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Upadhyay UD, Zlidar VM, Foster DG. Interest in self-administration of subcutaneous depot medroxyprogesterone acetate in the United States. Contraception 2016; 94:303-13. [PMID: 27326938 DOI: 10.1016/j.contraception.2016.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 06/08/2016] [Accepted: 06/14/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is a low-dose formulation of depot medroxyprogesterone acetate (DMPA) that nonmedical personnel can administer safely and effectively. We sought to determine United States women's interest in self-administration of DMPA-SC to understand whether such use can overcome barriers to contraceptive access. STUDY DESIGN We analyzed survey data on contraceptive attitudes collected in March-July 2011 from 1592 women at 13 family planning and six abortion clinics throughout the US. A mixed-effects logistic regression model with random site effects examined the determinants of interest in self-administering DMPA-SC. RESULTS Overall, 21% [95% confidence interval (CI): 19%-23%] of women reported interest in self-administration. A multivariable model found that women currently using DMPA (Adjusted Odds Ratio [AOR]=3.93, 95% CI: 2.37-6.53, p<.001) and women who previously used DMPA (AOR=1.71, 95% CI: 1.26-2.32, p<.001) were more likely to have an interest in DMPA-SC than those who never used it. Women reporting difficulty obtaining or refilling a prescription were almost twice as likely to have interest in DMPA-SC as women who reported no difficulty (AOR=1.99, 95% CI: 1.43-2.77, p<.001). Women surveyed at abortion sites were more likely to report interest in self-administration than women surveyed at family planning sites (AOR=1.55, 95% CI: 1.05-2.30, p<.05). Interest in DMPA-SC was primarily driven by a desire to eliminate unnecessary return visits to a facility for repeat injections. CONCLUSIONS Offering women the option to self-administer DMPA-SC at home can expand access and tailor contraceptive provision to the needs of clients, thus supporting client-centered care. To the extent that self-administration may improve contraceptive continuation, DMPA-SC can prevent unintended pregnancies among women who discontinue DMPA use because of difficulty returning for repeat injections. IMPLICATIONS There is substantial interest in self-administration of DMPA-SC among current DMPA users, women who have recently had an abortion and women reporting difficulty returning to a family planning provider. Offering self-administration of DMPA-SC could potentially increase contraceptive continuation, reduce unintended pregnancies and enhance reproductive autonomy among DMPA users.
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Affiliation(s)
- Ushma D Upadhyay
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, and the Department of Obstetrics, Gynecology & Reproductive Science, University of California, San Francisco, San Francisco, CA 94612, USA.
| | | | - Diana Greene Foster
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, and the Department of Obstetrics, Gynecology & Reproductive Science, University of California, San Francisco, San Francisco, CA 94612, USA.
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Black A, Guilbert E, Costescu D, Dunn S, Fisher W, Kives S, Mirosh M, Norman W, Pymar H, Reid R, Roy G, Varto H, Waddington A, Wagner MS, Whelan AM. Canadian Contraception Consensus (Part 3 of 4): Chapter 8 - Progestin-Only Contraception. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:279-300. [PMID: 27106200 DOI: 10.1016/j.jogc.2015.12.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. OUTCOMES Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada. EVIDENCE Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 8: PROGESTIN-ONLY CONTRACEPTION: Summary Statements Recommendations.
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Black A, Guilbert E, Costescu D, Dunn S, Fisher W, Kives S, Mirosh M, Norman WV, Pymar H, Reid R, Roy G, Varto H, Waddington A, Wagner MS, Whelan AM. Consensus canadien sur la contraception (3e partie de 4) : chapitre 8 – contraception à progestatif seul. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:301-26. [DOI: 10.1016/j.jogc.2016.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dragoman MV, Gaffield ME. The safety of subcutaneously administered depot medroxyprogesterone acetate (104mg/0.65mL): A systematic review. Contraception 2016; 94:202-15. [PMID: 26874275 DOI: 10.1016/j.contraception.2016.02.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 02/01/2016] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
CONTEXT Depot medroxyprogesterone acetate (DMPA), a progestogen-only contraceptive injectable, has traditionally been formulated as a crystalline suspension delivered intramuscularly (IM) at a dose of 150mg/1.0mL. A new, lower dose formulation of DMPA (104mg/0.65mL) has been developed for subcutaneous administration (SC). Given its increasing global availability and public health relevance, DMPA-SC was prioritized for inclusion as a new method referenced in the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use (MEC), 5th Edition. OBJECTIVE This systematic review evaluated the published peer-reviewed literature regarding the safety of DMPA-SC among women with various characteristics or medical conditions. Results of this review informed the decision-making of a WHO Guideline Development Group in order to include recommendations on contraceptive eligibility within the revised MEC. METHODS We searched PubMed and Cochrane Library databases to identify all relevant evidence published in peer-reviewed journals regarding the safety of DMPA-SC when used by women of reproductive age, particularly those with select characteristics or conditions specified in the MEC, from inception through June 2015. The quality of each individual study was assessed using the system for grading evidence developed by the United States Preventive Services Task Force. RESULTS Fourteen studies met criteria for inclusion. Ten reported results relevant to DMPA users of varying age or with obesity, endometriosis or HIV; four compared the safety of DMPA-SC and DMPA-IM when used by general populations of healthy women. A randomized trial evaluating changes in bone mineral density among adult DMPA-SC and DMPA-IM users demonstrated no differences at 2years of follow-up. Limited evidence reported no consistent differences in weight change or bleeding patterns according to age; however, adolescents (<18years) were not included in any studies. Similar contraceptive efficacy, weight change, bleeding patterns and occurrence of other adverse effects among obese and nonobese DMPA-SC users were observed. Women with endometriosis using DMPA-SC over 6months had minimal decreases in bone mineral density, weight gain, few serious adverse events and experienced improved pain symptoms. Women living with HIV tolerated injection of DMPA-SC with rare complications. DMPA-SC and DMPA-IM also show therapeutic equivalence and similar effects on weight gain, changes in bleeding patterns and reports of other adverse effects when these different delivery systems were used by general populations of women. CONCLUSION Evidence for use of DMPA-SC by women with select conditions and characteristics including age, obesity, endometriosis or HIV demonstrates that this method can generally be used safely in these contexts. Further, DMPA-SC and DMPA-IM appear to be therapeutically equivalent with similar safety profiles when used by healthy women.
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Affiliation(s)
- Monica V Dragoman
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
| | - Mary E Gaffield
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Ectopic pregnancy with use of progestin-only injectables and contraceptive implants: a systematic review. Contraception 2015; 92:514-22. [DOI: 10.1016/j.contraception.2015.08.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 08/25/2015] [Accepted: 08/29/2015] [Indexed: 11/22/2022]
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Weisberg E, Fraser IS. Contraception and endometriosis: challenges, efficacy, and therapeutic importance. Open Access J Contracept 2015; 6:105-115. [PMID: 29386928 PMCID: PMC5683134 DOI: 10.2147/oajc.s56400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Endometriosis is a benign gynecological condition that is estimated to affect 10% of women in the general population and appears to be increasing in incidence. It is an estrogen-dependent inflammatory disease, and is primarily characterized by dysmenorrhea, deep dyspareunia, chronic pelvic pain, and variable effects on fertility. The symptoms may greatly affect quality of life, and symptom control may be the primary aim of initial management, while contraceptive effect is often secondary. It is estimated that 30%–50% of women with endometriosis have an infertility problem, so a considerable number of endometriosis sufferers will require effective, planned contraception to maximize “protection of fertility” and prevent progression of the endometriotic condition. Ideally, this contraception should also provide symptom relief and improvement of physical, mental, and social well-being. At the present time, long-term progestogens appear to be the most effective choice for meeting all of these requirements, but other options need to be considered. It is becoming increasingly recognized that hormonal contraceptive systems are necessary for prevention of disease recurrence following surgical treatment of endometriosis. The personal preferences of the woman are an integral part of the final contraceptive choice. This article discusses the advantages and disadvantages of the contraceptive options available to women with endometriosis.
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Affiliation(s)
| | - Ian S Fraser
- School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
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Fedorenko M, Wagner ML, Wu BY. Survey of risk factors for osteoporosis and osteoprotective behaviors among patients with epilepsy. Epilepsy Behav 2015; 45:217-22. [PMID: 25812937 DOI: 10.1016/j.yebeh.2015.01.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/26/2014] [Accepted: 01/04/2015] [Indexed: 11/19/2022]
Abstract
The prevalence of risk factors for osteoporosis in persons with epilepsy, patients' awareness of their risk, and their engagement in osteoprotective behaviors were assessed in this study. Two hundred and sixty patients with epilepsy (F=51.5%, average age=42) completed a survey tool. Of 106 patients with a dual energy X-ray absorptiometry (DXA) result, 52% had low bone mineral density, and 11% had osteoporosis. The results suggest that the majority of patients with epilepsy do not engage in bone-protective behaviors. Those who have undergone a DXA scan may be more likely to take calcium and vitamin D supplementation compared with those who did not undergo a DXA scan, but they do not engage in other osteoprotective behaviors. Many patients did not accurately report their DXA results, indicating that better patient education is warranted.
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Affiliation(s)
- Marianna Fedorenko
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Mary L Wagner
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Brenda Y Wu
- Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, 125 Patterson Street, New Brunswick, NJ 08901, USA.
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Injectable Contraception: Current Practices and Future Trends. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015. [DOI: 10.1007/s13669-014-0106-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Contraception is a pillar in reducing adolescent pregnancy rates. The American Academy of Pediatrics recommends that pediatricians develop a working knowledge of contraception to help adolescents reduce risks of and negative health consequences related to unintended pregnancy. Over the past 10 years, a number of new contraceptive methods have become available to adolescents, newer guidance has been issued on existing contraceptive methods, and the evidence base for contraception for special populations (adolescents who have disabilities, are obese, are recipients of solid organ transplants, or are HIV infected) has expanded. The Academy has addressed contraception since 1980, and this policy statement updates the 2007 statement on contraception and adolescents. It provides the pediatrician with a description and rationale for best practices in counseling and prescribing contraception for adolescents. It is supported by an accompanying technical report.
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Abstract
A working knowledge of contraception will assist the pediatrician in both sexual health promotion as well as treatment of common adolescent gynecologic problems. Best practices in adolescent anticipatory guidance and screening include a sexual health history, screening for pregnancy and sexually transmitted infections, counseling, and if indicated, providing access to contraceptives. Pediatricians' long-term relationships with adolescents and families allow them to help promote healthy sexual decision-making, including abstinence and contraceptive use. Additionally, medical indications for contraception, such as acne, dysmenorrhea, and heavy menstrual bleeding, are frequently uncovered during adolescent visits. This technical report provides an evidence base for the accompanying policy statement and addresses key aspects of adolescent contraceptive use, including the following: (1) sexual history taking, confidentiality, and counseling; (2) adolescent data on the use and side effects of newer contraceptive methods; (3) new data on older contraceptive methods; and (4) evidence supporting the use of contraceptives in adolescent patients with complex medical conditions.
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