Non-contraceptive health benefits of intrauterine hormonal systems

Long-term efficacy and safety of levonorgestrel releasing intrauterine system in the treatment of adenomyosis: evidence mapping

PURPOSE

To summarize evidence on levonorgestrel releasing intrauterine system (LNG-IUS) in the treatment of adenomyosis (AM) and to identify potential research gaps.

METHODS

Search was conducted in MEDLINE, The Cochrane Library, EMBASE, CBM, CNKI, and Wanfang. We included studies investigating patients with AM treated with LNG-IUS combined with conservative therapy.

RESULTS

Thirty-nine studies compared LNG-IUS with other conservative therapeutic drugs. The most common comparison was GnRH-a + LNG-IUS vs. LNG-IUS alone, followed by LNG-IUS vs. mifepristone, expected treatment, and GnRH-a. GnRH-a + LNG-IUS was more beneficial in reducing the intensity of dysmenorrhea than LNG-IUS alone at the 6-month follow-up in patients with an enlarged uterus and moderate to severe dysmenorrhea. Large and well-designed studies are needed to confirm the efficacy of LNG-IUS and GnRH-a on reducing uterine volume at 6-month follow-up. Thirty-two studies investigated LNG-IUS as the postoperative management. The most common comparison was surgical excision + LNG-IUS vs. surgical excision. Results showed VAS scores were lower in the surgical excision + LNG-IUS group than in the surgical excision group at the 1-year follow-up. Evidence on endometrial thickness, quality of life, adverse events and beneficial effect at 3 and 5 years are needed.

CONCLUSIONS

Combined GnRH-a and LNG-IUS treatment was more efficacious than LNG-IUS alone for patients with an enlarged uterus and moderate to severe dysmenorrhea. Moreover, LNG-IUS seemed to show potential long-term benefits in postoperative therapy, warranting further meta-analysis for confirmation.

The Levonorgestrel-Releasing Intrauterine Device as Emergency Contraception: Re-examining the Data

Emergency contraception methods that also deliver ongoing contraception provide the most effective options for individuals hoping to prevent pregnancy after unprotected intercourse. Although the copper intrauterine device (IUD) provides the most effective option for emergency contraception because the device prevents pregnancy when placed before implantation and offers long-acting contraception, uptake by patients has been limited. Recently, the Society of Family Planning issued new guidance recommending the levonorgestrel IUD (LNG-IUD) as an emergency contraception option along with the copper IUD. Here, we review evidence related to this recommendation and conclude that the available data do not support use of the LNG-IUD for emergency contraception. We discuss the mechanisms of action of emergency contraception methods and how these concepts interface with the current political and social landscape of contraception and abortion care. We describe limitations of the existing evidence supporting use of the LNG-IUD as emergency contraception and highlight the critical research needed to establish the device as a highly effective method of emergency contraception.

Feasibility and Effectiveness of Hysteroscopic Suture Fixation of the Levonorgestrel-Releasing Intrauterine System in the Treatment of Adenomyosis

STUDY OBJECTIVE

To evaluate the feasibility and effectiveness of hysteroscopic suture fixation of the levonorgestrel-releasing intrauterine system (LNG-IUS) for the treatment of adenomyosis.

DESIGN

A retrospective case series.

SETTING

Two teaching hospitals with the technology of hysteroscopic suture fixation of the LNG-IUS.

PATIENTS

The study reviewed 79 adenomyosis patients who received the hysteroscopic suture fixation of the LNG-IUS from January 2021 to May 2022.

INTERVENTION

Hysteroscopic suture fixation of the LNG-IUS to the posterior uterine wall with nondissolvable suture.

MEASUREMENTS AND MAIN RESULTS

All patients underwent one-year postoperative follow-up to evaluate the LNG-IUS expulsion rate, postoperative efficacy, and side effects. Two patients (2.6%) experienced expulsion of the LNG-IUS at 8 months and 12 months postoperatively, respectively. The visual analog pain scale, pictorial blood loss assessment chart score and carbohydrate antigen 125 markedly decreased after the suture fixation of the LNG-IUS compared with baseline in all patients (p <.001). Hemoglobin increased significantly (p <.001). The most common side effect was irregular bleeding, which accounted for 44.3%. The second common side effect was weight gain, which accounted for 29.2%. The composite effectiveness based on pain and bleeding showed that the effective treatment rates at 1, 3, 6, and 12 months after surgery were 92.4%, 97.4%, 96.2%, and 97.4% respectively.

CONCLUSIONS

Hysteroscopic suture fixation of the LNG-IUS to the uterine fundus was associated with low expulsion rates and significantly improved dysmenorrhea and bleeding.

Levonorgestrel-Releasing Intrauterine System Improves Menorrhagia-Related Quality of Life in Patients with Symptomatic Adenomyosis

Levonorgestrel-releasing intrauterine system (LNG-IUS) relieves dysmenorrhea and heavy menstrual bleeding (HMB) in adenomyosis. However, its efficacy on health-related quality of life (HR-QOL) in patients with symptomatic adenomyosis remains unclear. The menorrhagia multi-attribute scale (MMAS), which measures HR-QOL improvement through the treatment of HMB, has never been used for evaluating menorrhagia-specific HR-QOL in patients with symptomatic adenomyosis. Hence, this study aimed to investigate the efficacy of LNG-IUS in improving menorrhagia-specific HR-QOL in these patients using the MMAS. The participants were diagnosed by magnetic resonance imaging. We also assessed the relationships between menorrhagia-specific HR-QOL, blood hemoglobin levels, and the degree of dysmenorrhea before and during LNG-IUS treatment. The LNG-IUS treatment improved the menorrhagia-specific HR-QOL more effectively in incipient type adenomyosis than in advanced type adenomyosis. The efficacy of LNG-IUS treatment on dysmenorrhea evaluated by the visual analog scale score tended to be better in the incipient type than in the advanced type. By the treatment of LNG-IUS, the blood hemoglobin level was not improved in the advanced type but in the incipient type. Furthermore, dysmenorrhea and HMB-related anemia were associated with HR-QOL impairment, and LNG-IUS treatment may improve the HR-QOL by relieving the symptoms. In conclusion, the effectiveness of LNG-IUS on HR-QOL is decreased by advanced adenomyosis. Thus, magnetic resonance imaging use should be reinforced to predict LNG-IUS efficacy in improving the HR-QOL of patients with adenomyosis.

How adenomyosis changes throughout pregnancy: A retrospective cohort study

OBJECTIVE

To study how adenomyosis changes during pregnancy and to possibly correlate these changes to maternal and fetal outcomes.

METHODS

Retrospective exploratory cohort study including 254 women with a pre-conceptional/first-trimester scan to document adenomyosis and known obstetric outcome. If visible, adenomyosis signs were documented in each trimester and postpartum. Mann-Whitney U tests or χ² tests were used for continuous and categorical variables, respectively.

RESULTS

A globular uterus was reported in 79% (n = 52) of women with adenomyosis in the first trimester, in 38% (n = 20) and 2% (n = 1) of women in the second and third trimesters, respectively, and postpartum in 77% (n = 34) of women. Asymmetrical thickening (n = 20, 30%) and cysts (n = 15, 23%) were only visible in 1st trimester. Adenomyosis was associated with miscarriage (odds ratio [OR] 5.9, 95% confidence interval [CI] 2.4-14.9, P < 0.001) also in normal conception only (OR 5.1, 95% CI 1.8-14.2, P = 0.002) or adjusting for maternal age (adjusted OR 5.9, 95% CI 2.3-15.2, P < 0.001). Gestational age at delivery was lower in adenomyosis (P = 0.004); the cesarean section rate was higher than in controls (OR 2.5, 95% CI 1.3-4.8, P = 0.007) also adjusting for age (adjusted OR 2.07, 95% CI 1.06-4.08, P = 0.035).

CONCLUSIONS

Signs of adenomyosis were visible but progressively disappeared in pregnancy; adenomyosis was associated with an increased risk of early miscarriage. Prospective studies are needed to confirm our results.

What Have We Learned? Implementation of a Shared Learning Agenda and Access Strategy for the Hormonal Intrauterine Device

In 2015, a global learning agenda for the hormonal intrauterine device (IUD) was developed with priority research questions regarding use of the method in low- and middle-income countries. In addition, members of the Hormonal IUD Access Group aligned on a strategy to expand access in the context of volunteerism and contraceptive method choice. This article synthesizes evidence generated since then and describes steps taken to address demand- and supply-side barriers to access. Findings demonstrated high continuation rates and satisfaction among hormonal IUD users that are comparable to other long-acting reversible contraceptives (LARCs). Across studies, a sizable number of users reported they would have chosen a short-acting method or no method at all if the hormonal IUD were not an option, which suggests that women did not see the hormonal IUD as interchangeable with other LARC options and thus it may fill an important niche in the market. With several countries now poised to scale up the method, resource mobilization will be key. On the demand side, investments in implementation research will be critical to understanding how best to launch and scale the method, while ensuring the sustainability of multiple quality-assured suppliers with affordable public-sector pricing will be necessary on the supply side.

The impact of hormonal contraceptives on anxiety treatments: From preclinical models to clinical settings

Exposure therapy is a central component of the first-line treatment for anxiety disorders, a common mental health condition that is twice as prevalent in women relative to men. A key underlying mechanism of exposure therapy is fear extinction, which is an active learning process supported by a neural circuitry that is highly regulated by ovarian hormones. This review synthesises research examining the impact of hormonal contraceptives on laboratory fear extinction tasks in female rats and women, and on exposure therapy in women with anxiety disorders. The evidence indicates that hormonal contraceptives have a detrimental impact on fear extinction and exposure therapy that is consistent across species, and from laboratory to clinical settings. Candidate pathways by which hormonal contraceptives impede fear extinction and exposure therapy include suppression of endogenous ovarian hormones and glucocorticoids, and downregulation of signalling pathways that support extinction learning. Key areas of focus for future research are discussed.

Utility of the Levonorgestrel-Releasing Intrauterine System in the Treatment of Abnormal Uterine Bleeding and Dysmenorrhea: A Narrative Review

INTRODUCTION

We undertook a literature review of the use of levonorgestrel-releasing intrauterine devices when utilized for heavy menstrual bleeding and/or dysmenorrhea.

METHODS

A narrative review of articles in the Scopus and Medline databases was conducted.

RESULTS

A number of options exist for the management of both abnormal uterine bleeding (AUB) and dysmenorrhea, and evidence is accumulating that the insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) represents a useful option for their long-term treatment. The idea of using a progestogen released in utero was initially conceived to achieve long-term contraception, but it was quickly found that these systems could be utilized for a number of therapeutic applications. The first device to be made commercially available, Progestasert, was withdrawn from the market because, in the event of contraceptive failure, it caused a disproportionate percentage of extrauterine pregnancies. On the other hand, the LNG-IUS continues to be successfully utilized in its various variants, releasing 20, 13, or 8 μg/day. These devices have a respective duration of action of 7 (possibly 8), 5, and 3 years, and there exist versions of frameless systems affixed to the myometrium of the uterine fundus. In the present review, following a brief description of the major causes of AUB and dysmenorrhea, the molecular bases for the use of the LNG-IUS are summarized. This is followed by a compendium of its use in AUB and dysmenorrhea, concluding that the insertion of the system improves the quality of life, reduces menstrual blood loss better than other medical therapies, and decreases the extent of dysmenorrhea and pelvic pain. In addition, there is no evidence of a significant difference in these outcomes when the use of the LNG-IUS was compared with improvements offered by endometrial ablation or hysterectomy. Possibly, the most important mechanism of action of the system consists of its ability to induce amenorrhea, which effectively eliminates heavy bleeding and dysmenorrhea. However, no method is ideal for every woman, and, in the case of the LNG-IUS, younger age and severe dysmenorrhea seem to be associated with a higher risk of discontinuation.

CONCLUSION

The higher-dose LNG-IUS is a useful tool for HMB and dysmenorrhea in women of all ages. The low cost and ease of use make the LNG-IUS an attractive option, especially when contraception is also desired.

Effect of Hysteroscopic Polypectomy Combined with Mirena Placement on Postoperative Adverse Reactions and Recurrence Rate of Endometrial Polyps: Based on a Large-Sample, Single-Center, Retrospective Cohort Study

Objective. To investigate the effect of hysteroscopy surgery combined with Mirena on postoperative adverse reactions and recurrence rate of endometrial polyps (EP). Methods. A total of 312 patients who underwent hysteroscopic polypectomy of EP in our hospital from June 2017 to November 2020 were enrolled retrospectively. Among them, 42 patients did not take any treatment after the operation (control group), 156 patients were treated with levonorgestrel intrauterine birth control system (Mirena group), and 114 patients were treated with oral spironolone ethinylestradiol tablets (oral group). The clinical data of 312 patients were recorded and followed up regularly. All patients were followed up through an outpatient clinic or telephone to 12 months after the operation. The patients’ age, disease course, number of pregnancies, clinical manifestations, endometrial thickness before the operation, duration of operation, amount of bleeding during the operation, and number and size of polyps were analyzed. The recurrence and postoperative side effects of EP in the three groups were followed up within 12 months after the operation. Results. There was no significant difference in endometrial thickness among the three groups before treatment ( $P>0.05$ ). After 3 months, 6 months, and 12 months of treatment, the endometrial thickness of the three groups decreased, while the decrease in the Mirena group and the oral group was better compared to the control ( $P<0.05$ ). The decrease in the Mirena group was better than that in the oral group ( $P<0.05$ ). There was no significant difference in hemoglobin levels among the three groups before treatment ( $P>0.05$ ). After 3, 6, and 12 months of treatment, the hemoglobin levels of the three groups increased to varying degrees, while the levels of the Mirena group and oral group were better compared to the control ( $P<0.05$ ). Three months after the operation, the improvement of clinical symptoms was similar in the three groups, and there was no significant difference among the three groups ( $P>0.05$ ). At 6 and 12 months after the operation, the improvement of clinical symptoms in the oral group and Mirena group was better compared to the control group ( $P<0.05$ ), but there was no significant difference between the oral group and Mirena group ( $P>0.05$ ). After the operation, some patients had complications such as lower abdominal pain, breast distension pain, irregular vaginal bleeding, and abnormal liver function. There was no significant difference in the number of complications among the three groups ( $P>0.05$ ). During the follow-up to 12 months after the operation, the recurrence rate in the oral group and Mirena group was lower compared to the control ( $P<0.05$ ), and the recurrence rate in the Mirena group was lower than that in the oral group ( $P<0.05$ ). Conclusion. Placing Mirena immediately after hysteroscopic polypectomy of EP can reduce the recurrence rate of endometrial polyps, increase the level of hemoglobin, and reduce the thickness of the endometrium, which can be employed and popularized according to the condition of patients in clinical work.

Reasons for satisfaction with the use of the 52-mg levonorgestrel intrauterine system

OBJECTIVES

To assess the reasons to use, reasons they liked, satisfaction with, and possibilities of recommendation to other women of the levonorgestrel 52-mg intrauterine system (LNG-IUS) by users.

MATERIALS AND METHODS

A cross-sectional study was conducted at the University of Campinas, Campinas, Brazil from January to July 2021. We enrolled users who came to the clinic, and we applied a pre-tested structured questionnaire with open-ended questions. We performed descriptive analyses of the variables, assessing the level of satisfaction with, and the reasons regarding the possibility of continuing to use, the IUS.

RESULTS

Of the 517 enrolled women, 251 (48%) were aged 35 years or older (mean age 33.9 ± 9.0 years), 276 (53%) were white, 14 (3%) were adolescents, 155 (30%) were nulligravidas, and 307 (59.4%) reported experiencing amenorrhea in the last 90 days. Common reasons why women liked to use the LNG-IUS included both the reduction of menstrual bleeding (419 women; 81%) and dysmenorrhea (290 women; 56.1%). Nine out of 10 users (517 women; 91%) were satisfied with the method, and the majority would recommend it to other women.

CONCLUSION

We found a high satisfaction rate among LNG-IUS users mainly due to the reduction of both menstrual bleeding and dysmenorrhea.

Synthetic Progestins in Waste and Surface Waters: Concentrations, Impacts and Ecological Risk

Synthetic progestins (PGs) are a large family of hormones used in continuously growing amounts in human and animal contraception and medicinal therapies. Because wastewater treatment plants (WWTPs) are unable to eradicate PGs after excretion, they are discharged into aquatic systems, where they can also be regenerated from conjugated PG metabolites. This review summarises the concentrations of 12 PGs in waters from 2015 to 2021. The selected PGs were considered of particular interest due to their wide use, activity, and hormonal derivation (from testosterone, progesterone, and spirolactone). We concluded that PGs had been analysed in WWTPs influents and effluents and, to a lesser extent, in other matrices, including surface waters, where their concentrations range from ng/L to a few µg/L. Because of their high affinity for cell hormone receptors, PGs are endocrine disruptor compounds that may alter the reproductive fitness and development of biota. This review focused on their biological effects in fish, which are the most used aquatic model organisms to qualify the impacts of PGs, highlighting the risks that environmental concentrations pose to their health, fecundity, and fertility. It is concluded that PGs research should be expanded because of the still limited data on their environmental concentrations and effects.

The Intrauterine Device Experience Among Transgender and Gender-Diverse Individuals Assigned Female at Birth

INTRODUCTION

The intrauterine device (IUD) is a long-acting and highly efficacious form of contraception that can also be used for menstrual suppression. Although IUD use is increasing, the type chosen, appeal, and satisfaction among individuals who are transgender and gender diverse and assigned female at birth (TGD-AFAB) is unknown. The purpose of this study is to evaluate IUD usage among TGD-AFAB individuals.

METHODS

TGD-AFAB individuals who had an IUD for a minimum of 6 months at the time of completing the survey or had one in the past completed an anonymous online survey. Descriptive statistics were used to analyze the data.

RESULTS

One hundred and five TGD-AFAB individuals completed the survey. Among participants who were sexually active, 88% reported they were in a relationship in which it was possible to get pregnant. There were 85 individuals who currently had an IUD: 62 (73%) chose a 52-mg levonorgestrel (LNG) IUD, 5 (6%) chose a lower-dose LNG IUD, 17 (20%) chose the copper IUD, and one chose an IUD unavailable in the United States. Menstrual suppression was the primary reason for choosing a 52-mg LNG IUD (58%). Most individuals who opted for a copper IUD did so to avoid hormonal contraception (71%). Participants reported experiencing IUD side effects; however, few desired removal. Among the 36 respondents who had an IUD in the past, the most frequent reasons for removal were expiration of the device (LNG IUDs) and undesired side effects (copper IUD). Approximately half of participants who had an IUD removed had it replaced with another IUD.

DISCUSSION

Pregnancy can occur among TGD-AFAB individuals even if they are on testosterone and amenorrheic. IUDs are well tolerated in this population, with few current users desiring removal for unwanted side effects. Clinicians should counsel TGD-AFAB individuals about the contraceptive and noncontraceptive benefits of IUDs and expected side effects.

Expanding long-acting contraceptive options: a prospective cohort study of the hormonal intrauterine device, copper intrauterine device, and implants in Nigeria and Zambia

BACKGROUND

30 years after the introduction of the levonorgestrel-releasing intrauterine device in Europe, several sub-Saharan African countries are seeking to broaden access to this contraceptive method. In this study, we aimed to assess 12-month continuation of the hormonal intrauterine device, copper intrauterine device, and implants, as well as to assess women's experiences and satisfaction using these methods in the private sector in Nigeria and the public sector in Zambia.

METHODS

We did a prospective cohort study of long-acting reversible contraceptive users across 40 private sector clinics in Nigeria and 21 public sector clinics in Zambia. Eligible women were aged 18-49 years in Nigeria and 16-49 years in Zambia, had chosen to receive the hormonal intrauterine device, copper intrauterine device, or implant (either a 5-year levonorgestrel-releasing subdermal implant or a 3-year etonogestrel-releasing subdermal implant), and, in Nigeria only, had access to a telephone. Women were interviewed within 100 days of receiving their contraceptive method either via telephone in Nigeria or in person in Zambia, with follow-up surveys at 6 months and 12 months. The primary outcomes were method-specific, 12-month continuation rates-ie, continuation rates of the hormonal intrauterine device, copper intrauterine device, and implant across Nigeria and Zambia. We used Kaplan-Meier methods to estimate the cumulative probabilities of method-specific continuation and a log-rank test to compare contraceptive methods. We analysed self-reported satisfaction and experiences as a secondary outcome.

FINDINGS

Between June 25 and Nov 22, 2018, we enrolled a total of 1542 women (n=860 in Nigeria and n=682 in Zambia) receiving a long-acting reversible contraceptive. In total, 835 women (266 [32%] hormonal intrauterine device users, 274 [33%] copper intrauterine device users, and 295 [35%] implant users) in Nigeria and 367 (140 [38%] hormonal intrauterine device users, 149 [40%] copper intrauterine device users, and 78 [21%] implant users) in Zambia were included in the study analysis. The 12-month cumulative continuation rates were 86·8% (95% CI 82·1-90·4) for the hormonal intrauterine device, 86·9% (82·1-90·4) for the copper intrauterine device, and 85·0% (80·2-88·7) for implants in Nigeria. In Zambia, the 12-month cumulative continuation rates were 94·7% (89·2-97·4) for the hormonal intrauterine device, 89·1% (82·3-93·4) for the copper intrauterine device, and 83·1% (72·2-90·1) for implants. At least 71% of respondents across the timepoints were very satisfied with their method, and at least 55 (79%) of 70 reported having recommended their contraceptive method to someone else. Across the methods, the most commonly self-reported positive aspect of long-acting reversible contraceptive use at 12 months was effectiveness in Nigeria (range 93-94%) and long-lasting duration in Zambia (48-60%). Between 124 (50%) of 248 and 136 (59%) of 230 Nigerian participants and 26 (42%) of 62 and 66 (57%) of 117 Zambian participants reported nothing negative about their contraceptive method.

INTERPRETATION

Our study showed high continuation rates and satisfaction across long-acting reversible contraceptives, including the hormonal intrauterine device, a method that has been largely underused in sub-Saharan Africa. This finding supports the inclusion of the hormonal intrauterine device as a valuable addition to the mix of contraceptive methods in Nigeria and Zambia.

FUNDING

Bill & Melinda Gates Foundation.

Factors affecting uptake of the levonorgestrel-releasing intrauterine device: A mixed-method study of social franchise clients in Nigeria

Background

Despite the positive characteristics of the levonorgestrel-releasing intrauterine device (IUD)–a long-acting, highly effective contraceptive with important non-contraceptive attributes–the method has not been widely available in low- and middle-income countries. This study of hormonal IUD, copper IUD, implant and injectable users in Nigeria compares their characteristics, reasons for method choice, and experiences obtaining their method.

Methods

We conducted a phone survey with 888 women who received a hormonal IUD, copper IUD, contraceptive implant or injectable from 40 social franchise clinics across 18 states in Nigeria. We analyzed survey data descriptively by method and assessed factors associated with hormonal IUD use through multivariate logistic regression models. Follow-up in-depth interviews conducted with 32 women were analyzed thematically.

Results

There were few differences by method used in the socio-demographic profiles and contraceptive history of participants. Among users choosing a long-acting, reversible method, the top reasons for method choice included perceptions that the method was “right for my body,” long duration, recommended by provider, recommended by friends/family, few or manageable side effects, and high effectiveness. Among hormonal IUD users, 17% mentioned reduced bleeding (inclusive of lighter, shorter, or no period), and 16% mentioned treatment of heavy or painful periods. Qualitative data supported these findings. Among survey respondents, between 25% and 33% said they would have chosen no method if the method they received had not been available. Both quantitative and qualitative data indicated that partner support can affect contraceptive use, with in-depth interviews revealing that women typically needed partner permission to use contraception, but men were less influential in method choice.

Conclusions

Expanding access to the hormonal IUD as part of a full method mix provides an opportunity to expand contraceptive choice for women in Nigeria. Findings are timely as the government is poised to introduce the method on a wider scale.

Ultrasound-guided transvaginal radiofrequency ablation combined with levonorgestrel-releasing intrauterine system for symptomatic uterine adenomyosis treatment

OBJECTIVE

To evaluate the clinical outcomes of transvaginal ultrasound-guided radiofrequency ablation (RFA) combined with a levonorgestrel-releasing intrauterine system (LNG-IUS) for the treatment of symptomatic uterine adenomyosis.

METHODS

Patients with symptomatic uterine adenomyosis treated with ultrasound-guided RFA in combined with an LNG-IUS from January 2013 to January 2016 and followed up for 3 years after treatment were selected. Assessment endpoints included the uterine volume reduction rate, dysmenorrheal score, symptom severity score and adverse events.

RESULTS

Among the 72 patients, 64 completed the 3-year follow-up evaluations after treatment. No LNG-IUS expulsion was reported. Dysmenorrhea and symptom severity scores statistically significantly declined after the combined treatment of RFA and LNG-IUS was administered. The uterine volume significantly decreased, and the average reduction rate was 55%.

CONCLUSION

Ultrasound-guided RFA combined with an LNG-IUS might be a simple, safe and effective alternative for the treatment of symptomatic adenomyosis.

Expanding Contraceptive Method Choice With a Hormonal Intrauterine System: Results From Mixed Methods Studies in Kenya and Zambia

INTRODUCTION

Few women in low- and middle-income countries have access to the hormonal intrauterine system (IUS). Past research from a small number of facilities and the private sector suggest the IUS could be an important addition to the contraceptive method mix because it is the only long-acting method some women will adopt and users report high satisfaction and continuation. We aimed to determine whether these promising results were applicable in public facilities in Kenya and Zambia.

METHODS

We used a mixed-methods approach with program monitoring data, interviews with women who received an IUS, and qualitative focus group discussions with providers. Data were collected in 2017-2019.

RESULTS

Facilities in Kenya and Zambia reported 1,985 and 428 IUS insertions, respectively. If the IUS had not been available, 30% of adopters would have chosen a short-acting method. Women and providers gave diverse reasons for adopting the IUS, with the desire for fewer side effects being frequently mentioned in focus group discussions. Many IUS adopters first heard of the method on the day it was inserted (70% in Kenya, 47% in Zambia), yet providers reported that many women were unwilling to try a method they were just hearing about for the first time. Satisfaction and continuation were high: 86% of adopters in Kenya were still using the method 3-6 months after insertion and 78% were in Zambia (average 10 months post insertion). Providers also reported that most IUS adopters were satisfied; they rarely returned with complaints that could not be addressed with additional counseling.

CONCLUSION

Expanding IUS access through the public sector shows promise to increase contraception use and continuation in low- and middle-income countries. Efforts to strengthen availability should consider demand and engage directly with various communities, including youth, around availability of a new long-acting option.

Provision of the levonorgestrel intrauterine system in Nigeria: Provider perspectives and service delivery costs

Background: Several organizations in Nigeria are leading pilot introduction programs of the levonorgestrel intrauterine system (LNG-IUS). We conducted a qualitative assessment of providers' experiences across the five programs and an analysis of service delivery costs in one program. Methods: We conducted 20 in-depth interviews (IDIs) with providers. We used project expenditure records to estimate incremental direct service delivery costs of introducing the LNG-IUS in 40 social franchise clinics supported by the Society for Family Health (SFH). We then compared the direct service delivery costs per couple years of protection (CYP) for the LNG-IUS to other family planning methods. Results: Providers appreciated the therapeutic benefits of the LNG-IUS, especially reduction of heavy bleeding. They said that women generally accepted bleeding changes with counseling but noted complaints about spotting and mixed acceptability of amenorrhea. Providers indicated being comfortable with both the insertion and removal process and believed their equipment and infection prevention protocols were adequate. Lack of awareness among women, limited availability, current pricing, and resistance to uterine placement among some women were perceived as barriers. The estimated direct service delivery cost of introducing the LNG-IUS in pilot settings, inclusive of up-front provider training costs, was USD 34 per insertion. Direct service delivery costs at a 'steady state' (i.e., without training costs included for any method) of the LNG-IUS per CYP was similar to that of other contraceptive methods distributed in Nigeria. Conclusion: Providers' positive experiences with the LNG-IUS and direct service delivery costs per CYP that align with those for other methods suggest that the LNG-IUS could be an important addition to the method mix in Nigeria. Product introduction strategies will need to address both the supply and the demand sides, as well as consider appropriate pricing of the LNG-IUS relative to other methods and particularly the copper IUD.

Role of Hormones in Common Benign Uterine Lesions: Endometrial Polyps, Leiomyomas, and Adenomyosis

Leiomyoma, adenomyosis, and endometrial polyps are benign uterine disorders which seem to develop in the context of hormonal imbalances, due to steroid hormones, estrogen and progesterone, in association with various factors ranging from genetic factors to modifiable lifestyle factors. A growing body of evidence suggests that those hormones and their receptors are key modulators in the genesis and the growth of those pathologic entities. Further studies are required to understand their involvement in the pathogenesis of those lesions and their link to other factors such as extracellular matrix components, growth factors, chemokines, cytokines, and tissue repair mechanisms.

Contraception with the new intrauterine systems: a winning choice if shared!

Today the rate of unexpected pregnancy is still unacceptably high; long-acting reversible contraceptives, (LARC) seem to be an effective and modern solution. Intrauterine contraception (IUC) is the main exponent of the LARC and it is living a new exponential spread in the last years. Today IUC is the most widely used reversible contraceptive method and it is recommended by the major scientific gynecological societies. This review of the literature aims to retrace the history of intrauterine contraception and to focus attention on intrauterine systems (IUS), its last and most modern form. The three systems (LNG-IUS 52 mg; LNG-IUS 13.5 mg; LNG-IUS 19.5 mg) base their extraordinary effectiveness on the same mechanism of action, however they present some important differences that can be used to enhance and customize the treatment, not just contraceptive, based on the woman's needs.

Clinical efficacy of adenomyomectomy using "H" type incision combined with Mirena in the treatment of adenomyosis

To evaluate the clinical efficacy and safety of adenomyomectomy using "H" type incision combined with Mirena (LNG-IUS) in the treatment of adenomyosis.A total of 57 women with adenomyosis who underwent adenomyomectomy using "H" type incision combined with LNG-IUS were selected. Visual analog scale (VAS), menstrual flow, uterine volume, serum CA125 levels and hemoglobin amounts were compared before and after the surgery. Meanwhile, postoperative pregnancy, adverse reactions, and recurrence were observed.VAS score, menstrual flow, uterine volume, and serum CA125 levels in 53 patients were significantly reduced after surgery (P < . 001). Moreover, statistical significances were obtained for VAS score at 13 and 6 months, menstrual flow at 1, 3, 6, 12, and 24 months, uterine volume at 1, 3, 6, 12, 24, and 36 months and CA125 levels at 1 and 3 months (P < .05). Of the 5 patients with fertility requirements, 1 became pregnant after IVF-ET, progressed to preterm, and delivered healthy twins. Among all related adverse reactions, amenorrhea was the most common (n = 20, 37.7%). There were no cases of LNG-IUS removal, ectopia, expulsion, and incarceration, except in 2 patients due to pregnancy, 1 due to uterine bleeding, and 1 due to Mirena perforation from incision of the uterine fundus. All patients showed no relapse.Adenomyomectomy using "H" type incision combined with Mirena constitutes a novel and effective conservative surgical procedure for adenomyosis treatment.

A Global Learning Agenda for the Levonorgestrel Intrauterine System (LNG IUS): Addressing Challenges and Opportunities to Increase Access

The LNG IUS is one of the most effective forms of reversible contraception and has important noncontraceptive benefits but is currently not used at scale in any Family Planning 2020 focus country. A global working group developed a shared learning agenda to answer critical questions, harmonize approaches, avoid duplication, and facilitate introduction of the method within the context of informed choice.

Role of medical therapy in the management of uterine adenomyosis

Adenomyosis is a benign uterine condition affecting women at various ages with different symptoms. The management of these patients is still controversial. Few clinical studies focusing on medical or surgical treatment for adenomyosis have been performed. No drug is currently labelled for adenomyosis and there are no specific guidelines to follow for the best management. Anyhow, medical treatments are effective in improving symptoms (pain, abnormal uterine bleeding and infertility). The rationale for using medical treatment is based on the pathogenetic mechanisms of adenomyosis: sex steroid hormones aberrations, impaired apoptosis, and increased inflammation. Several nonhormonal (i.e., nonsteroidal anti-inflammatory drugs) and hormonal treatments (i.e., progestins, oral contraceptives, gonadotropin-releasing hormone analogues) are currently used off-label to control pain symptoms and abnormal uterine bleeding in adenomyosis. Gonadotropin-releasing hormone analogues are indicated before fertility treatments to improve the chances of pregnancy in infertile women with adenomyosis. An antiproliferative and anti-inflammatory effect of progestins, such as dienogest, danazol and norethindrone acetate, suggests their use in medical management of adenomyosis mainly to control pain symptoms. On the other hand, the intrauterine device releasing levonorgestrel resulted is extremely effective in resolving abnormal uterine bleeding and reducing uterine volume in a long-term management plan. Based on new findings on pathogenetic mechanisms, new drugs are under development for the treatment of adenomyosis, such as selective progesterone receptor modulators, aromatase inhibitors, valproic acid, and anti-platelets therapy.

Clinical relevance in present day hormonal contraception

The contraceptive pill is an effective and very safe method to control pregnancies. It was developed 60 years ago, and despite that the composition has been the same since it was first developed (estrogen and progestogen), over the years the concentration of ethinyl estradiol has been reduced to improve tolerability. Nevertheless, progestogens are the basic active agent of hormonal contraception. The mechanism of progestogens is a multimodal one and basically three modes of contraceptive action can be distinguished: (a) A strong antigonadotrophic action leading to the inhibition of ovulation. The necessary dosage of ovulation inhibition per day is a fixed dosage that is intrinsic to each progestogen and independent of the dosage of estrogen used or the partial activities of the progestogen or the mode of application. (b) Thickening of the cervical mucus to inhibit sperm penetration and (c) desynchronization of the endometrial changes necessary for implantation. The on the market available progestogens used for contraception are either used in combined hormonal contraceptives (in tablets, patches or vaginal rings) or as progestogen only contraceptives. Progestogen only contraceptives are available as daily oral preparations, monthly injections, implants (2-3 years) and intrauterine systems (IUS). Even the long-acting progestogens are highly effective in typical use and have a very low risk profile. According to their introduction into the market, progestogens in combined hormonal contraceptives, have been described as 1st, 2nd, 3rd and 4th generation progestogens. The different structures of progestogens are derivatives from testosterone, progesterone and spironolactone. These differences in the molecular structure determine pharmacodynamic and pharmacokinetic differential effects which contribute to the tolerability and additional beneficial or therapeutic effects whether used in combined oral contraceptive (COC) or as progestogen only drugs. These differences enhance the individual options for different patient profiles. The new development of polymers for vaginal rings allowed on the one hand, the improvement of the estrogen/progestogen combination in these rings especially regarding the comfort of use for women (e.g. avoiding the use of cold chains or packages with up to 6-month rings) and on the other hand, the development of progestogen only formulations. Another future development will be the introduction of new progestogen only pills that will provide effective contraceptive protection with more favorable bleeding patterns and a maintenance of ovulation inhibition after scheduled 24-h delays in pill intake than the existing progestogen only pill (POP) with desogestrel (DES).

The clinical relevance of progestogens in hormonal contraception: Present status and future developments

The contraceptive pill is an effective and very safe method to control pregnancies. It was developed 60 years ago, and despite, that the composition has been the same since it was first developed (estrogen and progestogen), along the years the concentration of ethinyl estradiol has been reduced to improve tolerability. Nevertheless, progestogens are the basic active agent of hormonal contraception. The mechanism of progestogens is a multimodal one and basically three modes of contraceptive action can be distinguished: (a) A strong antigonadotrophic action leading to the inhibition of ovulation. The necessary dosage of ovulation inhibition per day is a fixed dosage that is inherent to each progestogen and independent of the dosage of estrogen used or the partial activities of the progestogen or the mode of application. (b) Thickening of the cervical mucus to inhibit sperm penetration and (c) Desynchronization of the endometrial changes necessary for implantation. The on the market available progestogens used for contraception are either used in combined hormonal contraceptives (in tablets, patches, or vaginal rings) or as progestogen only contraceptives. Progestogen only contraceptives are available as daily oral preparations, monthly injections, implants (2-3 years), and Intrauterine Systems (IUS). Even the long acting progestogens are highly effective in typical use and have a very low risk profile, with few contraindications. According to their introduction into the market progestogens, in combined hormonal contraceptives, have been described as first, second, third and fourth generation progestogens. Also, progestogens can be derived from testosterone, progesterone, and spironolactone that determine pharmacodynamic and pharmacokinetic differential effects. These effects contribute to the tolerability and additional beneficial or therapeutic effects whether used in combined oral contraceptives COC or as progestogen only drugs enhancing the individual options for different patient profiles. The new development of polymers for vaginal rings allowed on one side the improvement of the estrogen/progestogen combination in these rings especially regarding the comfort of use for women (avoiding of cold chain use or packages with up to six-month rings e.g.) and on the other side the development of progestogen only formulations. Another future development will be the introduction of new progestogen only pills that will provide effective contraceptive protection with more favourable bleeding patterns and a maintenance of ovulation inhibition after scheduled 24-h delays in pill intake than the existing pop with desogestrel.

Levonorgestrel-releasing intra-uterine systems as female contraceptives

INTRODUCTION

The availability and use of long-acting reversible contraceptives (LARCs), such as levonorgestrel intrauterine systems (LNG-IUSs), have increased in recent times.

AREAS COVERED

The authors provide a narrative review of the LNG-IUSs currently available worldwide as female contraceptives (LNG-IUS 13.5, 19.5 and 52 mg). Specific features of the devices and their parameters of efficacy and tolerability were considered as outcomes.

EXPERT OPINION

The one-handed 3.8-mm-diameter inserter of LNG-IUS 13.5 mg and 19.5 mg may be particularly suitable in nulliparous women. While LNG-IUSs 13.5, 19.5 mg and LNG 52 mg should be used by women simply looking for an effective contraceptive method for up to 3, 4 or 5 years, LNG-IUS 52 mg has also been approved for the treatment of heavy menstrual bleeding and endometrial protection during hormone replacement therapy. LNG-IUS 52 mg is ideal for women who are experiencing a certain hyperestrogenic hormonal environment, with heavy menstrual bleeding due to hormonal imbalances, adenomyosis or fibroids, in the case of symptomatic endometriosis or for endometrial protection during hormone estrogenic replacement therapy in non-hysterectomized women.

Non-contraceptive benefits of intrauterine levonorgestrel administration: why not?

Levonorgestrel intrauterine systems (LNG-IUS) represent a modern therapy for an array of preexisting gynecological conditions, though they were first marketed in Finland in 1990. However, there are countries in which their use is extremely limited by social and cultural factors. This manuscript describes the possible reasons for this misuse, taking in consideration the clinical noncontraceptive benefits of intrauterine levonorgestrel in routinary practice. Medical diseases in which LNG-IUS represent a treatment include abnormal uterine bleeding, iron-deficiency anemia, endometrial hyperplasia, uterine fibroids, adenomyosis, endometriosis, and coagulopathies. The advantage of reducing the need for more radical treatments such as surgery or hysterectomy is well demonstrated, with remarkable benefits for patients. However, in many countries, surgery is still used as a first-line treatment and there is a need to define who could benefit from a less invasive option. It seems clear that such a reduced use of LNG-IUS depends on factors that imply both patients and practitioners, and that the role of counseling is becoming a key component in the decision-making process to reach the ultimate goal of compliance.

Antiandrogenic and antimineralocorticoid health benefits of COC containing newer progestogens: dienogest and drospirenone

Data have demonstrated that COCs, besides offering a satisfactory and safe contraception, offer a variety of non-contraceptive health benefits and therapeutic positive aspects. Many prescribes and users, however, do not realize these positive aspects especially the non-contraceptive health benefits. While the contraceptive use is the primary indication for COC use for most women, these users should be advised in regard of the non-contraceptive benefits when contraception is discussed and prescribed.

Using COCs specifically for non-contraceptive indications is an off-label use in many clinical situations (only some exceptions as e.g. acne vulgaris in some countries are allowed clinical entities for the use of these drugs). Therefore, appropriate discussions with the patient regarding this fact should performed and documented by the prescribing physicians.

Independent of the off-label situation, COCs containing the newer progestogens dienogest and drospirenone with their antiandrogenic and antimineralocorticoid health benefits play an important role in the management of many diseases and their use should therefore be considered by clinician’s.

This review will focus on the effects of these COCs on the endometrium, the skin, the fat tissue and the premenstrual syndrome.

New developments in intrauterine device use: focus on the US

Many more women in the US today rely upon intrauterine devices (IUDs) than in the past. This increased utilization may have substantially contributed to the decline in the percentage of unintended pregnancies in the US. Evidence-based practices have increased the number of women who are medically eligible for IUDs and have enabled more rapid access to the methods. Many women enjoy freedom to use IUDs without cost, but for many the impact of the Affordable Care Act has yet to be realized. Currently, there are three hormonal IUDs and one copper IUD available in the US. Each IUD is extremely effective, convenient, and safe. The newer IUDs have been tested in populations not usually included in clinical trials and provide reassuring answers to older concerns about IUD use in these women, including information about expulsion, infection, and discontinuation. On the other hand, larger surveillance studies have provided new estimates about the risks of complications such as perforation, especially in postpartum and breastfeeding women. This article summarizes significant features of each IUD and provides a summary of the differences to aid clinicians in the US and other countries in advising women about IUD choices.

Expanding Access to a New, More Affordable Levonorgestrel Intrauterine System in Kenya: Service Delivery Costs Compared With Other Contraceptive Methods and Perspectives of Key Opinion Leaders

BACKGROUND

The levonorgestrel intrauterine system (LNG IUS) is one of the most effective forms of contraception and offers important non-contraceptive health benefits. However, it is not widely available in developing countries, largely due to the high price of existing products. Medicines360 plans to introduce its new, more affordable LNG IUS in Kenya. The public-sector transfer price will vary by volume between US$12 to US$16 per unit; for an order of 100,000 units, the public-sector transfer price will be approximately US$15 per unit.

METHODS

We calculated the direct service delivery cost per couple-years of protection (CYP) of various family planning methods. The model includes the costs of contraceptive commodities, consumable supplies, instruments per client visit, and direct labor for counseling, insertion, removal, and resupply, if required. The model does not include costs of demand creation or training. We conducted interviews with key opinion leaders in Kenya to identify considerations for scale-up of a new LNG IUS, including strategies to overcome barriers that have contributed to low uptake of the copper intrauterine device.

RESULTS

The direct service delivery cost of Medicines360's LNG IUS per CYP compares favorably with other contraceptive methods commonly procured for public-sector distribution in Kenya. The cost is slightly lower than that of the 3-month contraceptive injectable, which is currently the most popular method in Kenya. Almost all key opinion leaders agreed that introducing a more affordable LNG IUS could increase demand and uptake of the method. They thought that women seeking the product's non-contraceptive health benefits would be a key market segment, and most agreed that the reduced menstrual bleeding associated with the method would likely be viewed as an advantage. The key opinion leaders indicated that myths and misconceptions among providers and clients about IUDs must be addressed, and that demand creation and provider training should be prioritized.

CONCLUSION

Introducing a new, more affordable LNG IUS product could help expand choice for women in Kenya and increase use of long-acting reversible contraception. Further evaluation is needed to identify the full costs required for introduction-including the cost of demand creation-as well as research among potential and actual LNG IUS users, their partners, and health care providers to help inform scale-up of the method.

Femilis(®) 60 Levonorgestrel-Releasing Intrauterine System-A Review of 10 Years of Clinical Experience

OBJECTIVE

The aim of this study was to update the clinical experience with the Femilis® 60 levonorgestrel-releasing intrauterine system (LNG-IUS), now up to 10 years in parous and nulliparous women, particularly with regard to ease and safety of insertion, contraceptive performance, retention, acceptability, continuation of use, impact on menstrual blood loss (MBL), and duration of action.

STUDY DESIGN

Using the Femilis® 60 LNG-IUS releasing 20 µg of levonorgestrel/day, the following studies were conducted: an open, prospective noncomparative contraceptive study, an MBL study, a perimenopausal study, a study for the treatment of endometrial hyperplasia, and early cancer of the uterus, a residue study.

RESULTS

A total of 599 Femilis LNG-IUS were inserted in various clinical trials, the majority for contraceptive purposes. The total exposure in the first and second contraceptive studies, covering 558 parous and nulliparous women, was 32,717 woman-months. Femilis has high contraceptive effectiveness as only one pregnancy occurred. Expulsion of the LNG-IUS was rare with only two total and no partial expulsions (stem protruding through the cervical canal) occurred. Femilis was well tolerated, with continuation rates remaining high. Several MBL studies were conducted, totaling 80 heavy and normal menstrual bleeders, using the pictorial bleeding assessment chart method or the quantitative alkaline hematin technique. Virtually all women responded well with strongly reduced menstrual bleeding. Amenorrhea rates were high, up to 80% after three months, and ferritin levels simultaneously increased significantly. The Femilis LNG-IUS was tested in 104 symptomatic perimenopausal women for seamless transition to and through menopause, adding estrogen therapy when required. Patient tolerability appeared high as >80% requested a second and a third LNG-IUS. Twenty women presenting with nonatypical and atypical hyperplasia and one woman presenting with early endometrial carcinoma were treated with Femilis LNG-IUS. All histology specimens showed full regression, and patients remained in remission without signs of hyperplasia or cancer at yearly and ongoing follow-up examinations up to 10 years. Residual content of LNG was measured in 37 women having the Femilis LNG-IUS for up to 10 years. In 10 of the 102 women who had the Femilis 60 in situ for 10 years between 20% and 30% of the original 60 mg was recovered confirming the long duration of action of the Femilis 60 LNG-IUS.

CONCLUSION

These studies suggest that the Femilis 60 LNG-IUS releasing 20 µg of LNG/day is an effective, well-tolerated, and well-retained contraceptive both in parous and in nulliparous women. The design of the LNG-IUS, with flexible transverse arm(s) length of 28 mm, allows for a simplification of the insertion technique and training requirements facilitating the use by nonspecialist providers in either developed or developing countries. For nulliparous women, additional evaluation of devices with a 24 mm transverse arm(s), as it relates to tolerability, retention, and continuation of use, still needs to be undertaken.

Why perimenopausal women should consider to use a levonorgestrel intrauterine system

OBJECTIVE

The use of a levonorgestrel intrauterine system (LNG-IUS) is useful in preventing pregnancy and for the treatment of menstrual disturbances. A smooth or symptom-free transition to and through menopause is possible when LNG-IUS is combined with estrogen therapy. Unfortunately the majority of physicians are generally unaware of this usefulness combined hormonal therapy in the pre-, peri- and postmenopausal women.

DESIGN AND METHOD

Based on long-term clinical experience with LNG-IUS in the form of Femilis®, 104 women where followed from the premenopause through the menopausal transition into the postmenopause. These perimenopausal women received supplemental 17 β-estradiol by gel or patch, or orally as estradiol valerate. Patients received one or two separate Femilis insertions at 5 year intervals. Main outcome measures included acceptability and continued use of the combined regimen for the treatment of climacteric symptoms and for prevention of cardiovascular disease, osteoporosis and other adverse effects caused by estrogen deprivation.

RESULTS

The average age at insertion was 48 years (range 28-58) and the total duration of use was 137 months (range 80-161). The Femilis LNG-IUS was well tolerated as the number of removals for LNG-IUS-related reasons was low. The LNG-IUS was well retained in the uterine cavity as no expulsions were observed. Seven women were lost to follow-up. Eighty-six women (82%) opted for replacement of an LNG-IUS at expiry after 5 years and continued with the estrogen therapy.

CONCLUSION

Intrauterine progestogen delivery for endometrial suppression in combination with estrogen therapy in the symptomatic perimenopausal women is highly practical as it combines the benefits of prevention of endometrial proliferation and treatment of menorrhagia and hyperplasia, if present. In addition, the contraceptive effect of locally administered LNG is highly desirable as many perimenopausal women run considerable risk of unintended pregnancy. For these reasons, the author views this regimen as one of the most effective, safest and best accepted route resulting in high patient compliance. It is important to convey this message to general practitioners as well as women.

Three-dimensional versus two-dimensional ultrasound for assessing levonorgestrel intrauterine device location: A pilot study

PURPOSE

To compare the rates of success of two-dimensional (2D) and three-dimensional (3D) sonographic (US) examinations in locating and adequately visualizing levonorgestrel intrauterine devices (IUDs) and to explore factors associated with the unsuccessful viewing on 2D US.

METHODS

Transvaginal 2D and 3D US examinations were performed on all patients 1 month after insertion of levonorgestrel IUDs. The devices were considered adequately visualized on 2D US if both the vertical (shadow, upper and lower extremities) and the horizontal (two echogenic lines) shafts were identified. 3D volumes were also captured to assess the location of levonorgestrel IUDs on 3D US.

RESULTS

Thirty women were included. The rates of adequate device visualization were 40% on 2D US (95% confidence interval [CI], 24.6; 57.7) and 100% on 3D US (95% CI, 88.6; 100.0). The device was not adequately visualized in all six women who had a retroflexed uterus, but it was adequately visualized in 12 of the 24 women (50%) who had a nonretroflexed uterus (95% CI, -68.6; -6.8).

CONCLUSIONS

We found that 3D US is better than 2D US for locating and adequately visualizing levonorgestrel IUDs. Other well-designed studies with adequate power should be conducted to confirm this finding.

The Levonorgestrel Intrauterine System: Reasons to Expand Access to the Public Sector of Africa

The levonorgestrel intrauterine system has: (1) excellent effectiveness, (2) high satisfaction levels, (3) non-contraceptive benefits, and (4) potential to help reinvigorate interest in intrauterine contraception. The time is ripe for ministries and donor agencies to work together to make the product widely available across Africa.

Contraception for women with medical disorders

Many women in the reproductive years have chronic medical conditions that are affected by pregnancy or in which the fetus is placed at increased risk. In most of these women, ongoing medical management of their conditions is greatly improved, even compared with a decade or two ago. However, their condition may still be seriously exacerbated by the physiological changes of pregnancy, and close monitoring of a carefully planned pregnancy is optimal. This requires effective and safe contraceptive use until pregnancy is desired and the medical condition is stabilised. Many contraceptives will also have adverse effects on some medical conditions, and there is now a considerable awareness of the complexities of some of these interactions. For this reason the World Health Organization has developed an excellent, simple and pragmatic programme of guidelines on a four point scale (the WHO "Medical Eligibility Criteria": WHO-MEC), summarising risk of specific contraceptive methods in women with specified chronic medical conditions. The general approach to contraceptive management of many of these conditions is addressed in this article.

Contraception and hormonal management in the perimenopause

This literature review focuses on contraception in perimenopausal women. As women age, their fecundity decreases but does not disappear until menopause. After age 40, 75% of pregnancies are unplanned and may result in profound physical and emotional impact. Clinical evaluation must be relied on to diagnose menopause, since hormonal levels fluctuate widely. Until menopause is confirmed, some potential for pregnancy remains; at age 45, women's sterility rate is 55%. Older gravidas experience higher rates of diabetes, hypertension, and death. Many safe and effective contraceptive options are available to perimenopausal women. In addition to preventing an unplanned and higher-risk pregnancy, perimenopausal contraception may improve abnormal uterine bleeding, hot flashes, and menstrual migraines. Long-acting reversible contraceptives, including the levonorgestrel intrauterine system (LNG-IUS), the etonogestrel subdermal implant (ESI), and the copper intrauterine device (Cu-IUD), provide high efficacy without estrogen. LNG-IUS markedly decreases menorrhagia commonly seen in perimenopause. Both ESI and LNG-IUS provide endometrial protection for women using estrogen for vasomotor symptoms. Women without cardiovascular risk factors can safely use combined hormonal contraception. The CDC's Medical Eligibility Criteria for Contraceptive Use informs choices for women with comorbidities. No medical contraindications exist for levonorgestrel emergency-contraceptive pills, though obesity does decrease efficacy. In contrast, the Cu-IUD provides reliable emergency and ongoing contraception regardless of body mass index (BMI).

Complication rates associated with levonorgestrel intrauterine system use in adolescents with developmental disabilities

STUDY OBJECTIVE

To assess the complication rates with the use of the levonorgestrel intrauterine system (LNG IUS) in adolescents with developmental disabilities.

DESIGN

Retrospective chart review of all adolescents with developmental disabilities taken to the operating room for LNG IUS insertion between January 2000 and July 2009 at the Royal Children's Hospital, Melbourne, Australia. Cases identified from the surgical database, and medical records reviewed.

MAIN OUTCOME MEASURES

Complication rates with LNG IUS use in adolescents with development disabilities: non-insertion, uterine perforation, infection, and expulsion.

RESULTS

Fifty-six adolescents with developmental disabilities had an attempted LNG IUS insertion. The average age at insertion was 15.6 years (range 10.5-21.5 y). The LNG IUS was used as first line therapy in 14 cases (25%). Pre-insertion ultrasonography was ordered in 48% of cases, out of which 5 cases had uterine lengths <6 cm. Despite this, 4 of these cases had successful insertions. Two insertion attempts were abandoned intra-operatively (3.6%); one due to inadequate uterine length of 4 cm, and the other due to anatomic distortion. One spontaneous expulsion occurred at approximately 5 months (1.9%). Four IUDs were removed prematurely (7.4% withdrawal rate); 1 for persistent abdominal pain, 1 for irregular bleeding, and 2 for suspected malpositions. There were no documented cases of infection, perforation, or pregnancy.

CONCLUSION

Our experience in this population has been very positive and confirms that complication rates are comparable to that in adults.

Socioeconomic determinants of haemoglobin levels of African women are less important in areas with more health facilities: a multilevel analysis

BACKGROUND

The prevalence of anaemia in Africa is the highest in the world. Especially women are at risk because of blood loss during menstruation and increased iron requirements during pregnancy. This study examined determinants of the haemoglobin (Hb) level of African women at individual/household, cluster, district, and national level. Special attention was paid to socioeconomic factors and the presence of health facilities.

METHODS

Data were derived from Demographic and Health Surveys conducted between 2003 and 2010 in 21 African countries. We included all women aged 15-49 who participated in a women's survey and had a Hb measurement. Multilevel models were used to examine the influence of various factors at different hierarchical levels simultaneously.

RESULTS

104 899 women were included in the study, of which 23.1% were anaemic (Hb<110 g/L). Socioeconomic factors were strongly related to the Hb level of women. Wealth, education, having a job, occupation of the partner, presence of a toilet facility, context educational level and preventive health measures were positively associated with the Hb level. Interaction analysis indicated that socioeconomic differences in the Hb level of women were reduced by the presence of health facilities.

CONCLUSIONS

Interventions aimed at improving the Hb level of African women should take socioeconomic and contextual aspects into account. Increasing availability of health facilities might be a tool for reducing socioeconomic differences.

IUDs: beyond the basics

This article reviews the changes in patient selection for intrauterine devices (IUDs) and evidence-based practices regarding counseling and management of common IUD issues. Where evidence-based research is lacking, expert opinion and common standards of practice are reviewed, and current clinical resources are identified.

Non-contraceptive benefits of oral hormonal contraceptives

It is becoming evident that oral hormonal contraceptives-besides being well established contraceptives-seem to become important medications for many functional or organic disturbances. So far, clinical effectiveness has been shown for treatment as well as prevention of menstrual bleeding disorders and menstrual-related pain symptoms. Also this is true for premenstrual syndrome (PMS) and premenstrual disphoric disorder (PMDD). Particular oral contraceptives (OCs) containing anti-androgenic progestogens were shown to be effective medications for treatment of androgenisation symptoms (seborrhea, acne, hirsutism, alopecia). Through perfect suppression of the hypothalamic-pituitary-ovarian axis OCs have proven to be effective in elimination of persistent follicular cysts. Endometriosis/adenomyosis related pain symptoms are well handled similar to other drugs like Gonadotropine Releasing Hormone agonists but are less expensive, with less side effects, and possibility to be used for longer periods of time. This is also true for myoma. Pelvic inflammatory disease, rheumatoid arthritis, menstrual migraine, and onset of multiple sclerosis are prevented or delayed. Bone density is preserved and asthma symptoms improved. Endometrial hyperplasia and benign breast disease can be controlled. There is definitely a significant impact on risk reduction regarding endometrial, ovarian, and colon cancers. In conclusion, it needs to be recognized that oral combined hormonal contraceptives (estrogen/ progestogen combination) are - besides being reliable forms of contraception - are cost-effective medications for many medical disorders in women. Therefore, these contraceptives drugs are important for female and global health and should be used in clinical practice.

Immediate post-abortion insertion of intrauterine contraceptives (IUC) in a diverse urban population

Ethnic minority women have a higher incidence of unintended pregnancy and abortion than Caucasian women, with significant individual and social implications. Post-abortion intrauterine contraceptive (IUC) use may reduce future unintended pregnancy. This was a retrospective review of 265 women undergoing abortion at a Los Angeles County Reproductive Options Clinic. Demographic factors, reproductive history, and post-abortion contraceptive choice were evaluated and analyzed. The population was predominantly Latina (73%) and single, with a mean age of 27. Immediate post-abortion IUC insertion was chosen by 48% overall and more frequently by Latinas (55%) than by African Americans (33%) or Asians (43%) (p = 0.02). IUC use increased with age, undesired future fertility, increasing gravidity, and history of previous abortion in univariate analysis. In multivariate analysis, IUC use increased with Latina ethnicity and increasing gravidity. In a clinic serving low-income urban women in Los Angeles, post-abortal IUC uptake is highest among Latinas and those with prior pregnancies. Future research should examine reasons for and barriers to IUC uptake in diverse communities and methods to improve post-abortion IUC uptake to prevent subsequent unintended pregnancies.