Appropriate follow up to detect potential adverse events after initiation of select contraceptive methods: a systematic review

U.S. Selected Practice Recommendations for Contraceptive Use, 2024

The 2024 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) addresses a selected group of common, yet sometimes complex, issues regarding initiation and use of specific contraceptive methods. 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. SPR (CDC. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR 2016;65[No. RR-4]:1-66). Notable updates include 1) updated recommendations for provision of medications for intrauterine device placement, 2) updated recommendations for bleeding irregularities during implant use, 3) new recommendations for testosterone use and risk for pregnancy, and 4) new recommendations for self-administration of injectable contraception. 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.

Oral contraceptives in adolescents: a retrospective population-based study on blood pressure and metabolic dysregulation

PURPOSE

This study aimed to explore the relationship between oral contraceptive use and blood pressure values and in a national cohort of women adolescents and to investigate the level of coexistence of the high blood pressure levels, dyslipidemia or insulin resistance.

METHODS

This is a retrospective cohort study that evaluated data form 14,299 adolescents aged 14 to 17 years. Crude and race-and age-adjusted analyses were performed using Poisson regression to estimate the prevalence ratios. Data clustering analysis was performed using machine learning approaches supported by an unsupervised neural network of self-organizing maps.

RESULTS

We found that 14.5% (n = 2076) of the women adolescents use oral contraceptives. Moreover, an increased prevalence of high blood pressure, dyslipidemia, and insulin resistance (all P < 0.001) was observed among adolescents who use oral contraceptives as compared to those who do not. Our analysis also showed that 2.3% of adolescents using oral contraceptives had both high blood pressure levels and dyslipidemia, whereas 3.2% had high blood pressure levels combined with insulin resistance (all P < 0.001). The algorithmic investigative approach demonstrated that total cholesterol, LDLc, HDLc, insulin, and HOMA-IR were the most predicted variables to assist classificatory association in the context of oral contraceptive use among women adolescents with high blood pressure.

CONCLUSIONS

These findings suggest that oral contraceptives were associated with an increased prevalence of high blood pressure, dyslipidemia, and insulin resistance among women adolescents. Although the indication of this therapy is adequate to avoid unintended pregnancies, their use must be based on rigorous individual evaluation and under constant control of the cardiometabolic risk factors.

Harms of third- and fourth-generation combined oral contraceptives in premenopausal women: A systematic review and meta-analysis

We assessed the available evidence regarding adverse effects on surrogate and patient-important health outcomes of third- and fourth-generation combined oral contraceptives among premenopausal women. We performed a systematic review and meta-analysis including randomized controlled trials and observational studies comparing third- and fourth-generation combined oral contraceptives with other generation contraceptives or placebo. Studies that enrolled women aged 15 to 50 years, with at least three cycles of intervention and 6 months of follow-up were included. A total of 33 studies comprising 629,783 women were included. Low-density lipoprotein cholesterol levels were significantly lower in fourth-generation oral contraceptives (mean differences (MD): -0.24 mmol/L; [95% CI -0.39 to -0.08]), while total cholesterol was significantly increased in levonorgestrel users when compared to third-generation oral contraceptives (MD: 0.27 mmol/L; [95% CI 0.04 to 0.50]). A decreased arterial thrombosis incidence was shown in fourth-generation oral contraceptive users, as compared to levonorgestrel (incidence rate ratio (IRR): 0.41; [95% CI 0.19 to 0.86]). No difference was found in the occurrence of deep venous thrombosis between fourth-generation oral contraceptives and levonorgestrel users (IRR: 0.91; [95% CI 0.66 to 1.27]; p = 0.60; I2 = 0%). Regarding the remaining outcomes, data were heterogeneous and showed no clear difference. In premenopausal women, the use of third- and fourth-generation oral contraceptives is associated with an improved lipid profile and lower risk of arterial thrombosis. Data were inconclusive regarding the rest of outcomes assessed. This review was registered in PROSPERO with CRD42020211133.

Perspective Chapter: Modern Birth Control Methods

This chapter focuses on various modern birth control methods, including combined oral contraceptives, progestogen-only pills, progestogen-only injectables, progestogen-only implants, intrauterine devices, barrier contraceptives, and emergency contraceptive pills. Each contraceptive method is covered in detail, including mechanism of action, effectiveness, health benefits, advantages, disadvantages, risks, and side-effects.

Current Strategies for Prevention of Infection After Uterine Artery Embolisation

Uterine artery embolisation (UAE) is a safe and effective procedure for symptomatic uterine fibroids with an estimated rate of post-operative intra-uterine infection of 0.9-2.5%. While rates of infection have remained low over the past two decades, there is variation in infection prevention practices. Intra-uterine infection after UAE may occur via access site haematogenous spread or ascension of vaginal flora through the cervical canal. Although the evidence base is immature, risk factors for infection including previous pelvic infection, hydrosalpinx, endocervical incompetence, diabetes, smoking, obesity, respiratory disease, and immunosuppression should be assessed during the pre-operative consultation with the interventional radiologist to tailor a plan for minimising infection, which may include optimisation of any modifiable risk facts and prophylactic antibiotics.

Adherence to Recommended Practices for Provision of Long-Acting Reversible Contraception Among Providers in a Large U.S. Health Care System

Background: There is little research examining adherence to practice guidelines for long-acting reversible contraception (LARC). We assessed same-day LARC provision and adherence to other guideline-recommended practices among providers in a large academic health care system. Materials and Methods: We surveyed 363 providers who had billed using LARC-related codes within the prior 12 months. Primary outcomes were, for women requesting an intrauterine device (IUD) or implant, the typical number of visits for method provision and ability to add an insertion procedure to an annual examination. We used chi-square tests and multivariable logistic regression to identify characteristics associated with primary outcomes and described other practices and barriers to same-day LARC. Results: Our response rate was 42% (153/363). A typical single visit for women requesting an IUD or implant was reported by 37% of IUD providers and 51% of implant providers, respectively, and was associated with obstetrician-gynecologist specialty versus family medicine (IUD: 44% vs. 12%, p = 0.001; implant: 57% vs. 26%, p = 0.002) and practicing in the county of the main academic medical center versus any other county (IUD: 48% vs. 20%, p = 0.001; implant: 65% vs. 27%, p < 0.001). High ability to add LARC insertion to an annual examination was reported by 48% of IUD providers and 51% of implant providers, with similar associations of specialty and county. Barriers to same-day LARC included scheduling constraints, insurance and billing concerns, and device stocking. Nearly all respondents provide LARC to nulliparous women and adolescents. Among IUD providers, 73% schedule routine follow-up after insertion. Conclusions: Same-day LARC provision is low among providers in a large academic health care system. Provider-identified barriers suggest interventions to improve LARC access, including incentivizing device stocking and billing and insurance education.

Contraception for high risk patients

In the context of medically complicated pregnancies, a "high risk patient" is an individual who is at increased risk for having a complicated pregnancy. These patients often experience limited contraceptive counseling and access, despite the fact that most effective contraceptive methods are associated with less risk than that of pregnancy. Free evidence-based resources are available to assist healthcare providers in discerning fact from myth about the risks of contraception. This review covers all available contraceptive methods, with particular focus on the benefits, risks, and attributes most relevant to high risk patients as well as the benefits and risks of initiating contraception post-pregnancy.

MPA given orally during the first trimester for threatened miscarriage carries no specific risk for foetal abnormalities albeit the rate is higher than non-threatened pregnancies

This observational study examines the outcomes of pregnancies arising in women referred for infertility, where those who experienced threatened miscarriage were treated with medroxyprogesterone acetate (MPA) tablets. The 14-year study period covers comprehensive real-time data entries into the validated electronic database including details of the infertility management, pregnancy outcomes and any foetal anomalies among the infants, each being tracked and recorded. Of 4057 clinical pregnancies, 1343 received MPA for threatened miscarriage; 934 (69.6 %) of which continued to livebirths. These were compared with the remaining 2714 clinical pregnancies without threatened miscarriage or MPA and which resulted in 2075 (76.5 %) livebirths. There were 134 developmental abnormalities recorded among the 3009 livebirths of which 78 (2.6 %) were categorised appropriate for the Western Australian Developmental Abnormalities Register; WARDA. These comprised 55 in the MPA group, 36 of which were categorised as serious (being 2.7 % of clinical pregnancies and 3.9 % of births). In the group without MPA, there were 79 abnormalities, of which 42 were categorised as serious (being 1.7 % of clinical pregnancies and 2.2 % of births). Specifically, there were no cases of androgenisation noted among the female infants. The abnormality rates were low overall and well within the annual WARDA ranges. We cautiously suggest that oral MPA can be considered for studies throughout pregnancy including the early first trimester to assess a potential role in reducing miscarriage, as well as advanced pregnancies to evaluate a potential role in reducing stillbirths and preterm delivery.

ACOG Practice Bulletin No. 206: Use of Hormonal Contraception in Women With Coexisting Medical Conditions

Although numerous studies have addressed the safety and effectiveness of hormonal contraceptive use in healthy women, data regarding women with underlying medical conditions or other special circumstances are limited. The U.S. Medical Eligibility Criteria (USMEC) for Contraceptive Use, 2016 (), which has been endorsed by the American College of Obstetricians and Gynecologists, is a published guideline based on the best available evidence and expert opinion to help health care providers better care for women with chronic medical problems who need contraception. The goal of this Practice Bulletin is to explain how to use the USMEC rating system in clinical practice and to specifically discuss the rationale behind the ratings for various medical conditions. Contraception for women with human immunodeficiency virus (HIV) (); the use of emergency contraception in women with medical coexisting medical conditions, including obesity, (); and the effect of depot medroxyprogesterone acetate (DMPA) on bone health () are addressed in other documents from the American College of Obstetricians and Gynecologists.

Financial Implications of 12-Month Dispensing of Oral Contraceptive Pills in the Veterans Affairs Health Care System

IMPORTANCE

The Veterans Affairs (VA) health care system is the largest integrated health care system in the United States. Like most US health plans, the VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). However, 12-month OCP dispensing has been shown to improve continuation of use, decrease coverage gaps, and reduce unintended pregnancy in other practice settings.

OBJECTIVE

To estimate the financial and reproductive health implications for the VA of implementing a 12-month OCP dispensing option, with the goal of informing policy change.

DESIGN, SETTING, AND PARTICIPANTS

A decision model from the VA payer perspective was developed to estimate incremental costs to the health care system of allowing the option to receive a 12-month supply of OCPs up front, compared with the standard 3-month maximum, during a 1-year time horizon. A model cohort of 24 309 reproductive-aged, heterosexually active, female VA enrollees who wish to avoid pregnancy for at least 1 year was assumed. Probabilities of continuation of OCP use, coverage gaps, pregnancy, and pregnancy outcomes were drawn from published data. Costs of OCP provision and pregnancy-related care and the number of women using OCPs were drawn from VA administrative data. One-way and probabilistic sensitivity analyses were performed to assess model robustness.

MAIN OUTCOMES AND MEASURES

Incremental per-woman and total costs to the VA of allowing for 12-month dispensing of OCPs compared with standard 3-month dispensing.

RESULTS

The 12-month OCP dispensing option, modeled from the VA health system perspective using a cohort of 24 309 women, resulted in anticipated VA annual cost savings of $87.12 per woman compared with the cost of 3-month dispensing, or an estimated total savings of $2 117 800 annually. Cost savings resulted from an absolute reduction of 24 unintended pregnancies per 1000 women per year with 12-month dispensing, or 583 unintended pregnancies averted annually. Expected cost savings with 12-month dispensing were sensitive to changes in the probability of OCP coverage gaps with 3-month dispensing, the probability of pregnancy during coverage gaps, and the proportion of pregnancies paid for by the VA. When simultaneously varying all variables across plausible ranges, the 12-month strategy was cost saving in 95.4% of model iterations.

CONCLUSIONS AND RELEVANCE

Adoption of a 12-month OCP dispensing option is expected to produce substantial cost savings for the VA while better supporting reproductive autonomy and reducing unintended pregnancy among women veterans.

Effects of different hormonal contraceptives in women's blood pressure values

OBJECTIVE

To identify evidence in the literature of the relationship between the use of different hormonal contraceptive methods and alterations in women's blood pressure values.

METHOD

This is an integrative literature review, consisting of ten scientific articles published in PubMed and BVS, between 2012 and 2016, selected by keywords, available fully and free of charge, in English, Portuguese, or Spanish.

RESULTS

The articles showed that exogenous estrogen helps in the activation of the renin-angiotensin-aldosterone system causing hypertensive effects even in small doses; and that combined use with drospirenone reduces these effects. Routes of administration without passage through the liver and use of isolated progestin showed promising results in reducing the effects on blood pressure.

CONCLUSION

There is evidence in the literature of pressure alterations associated with different hormonal contraceptives and that personal history of morbidities are to be considered in an attempt to reduce the effects on the cardiovascular system.

[The contraception consultation: CNGOF Contraception Guidelines]

OBJECTIVE

Determine the most accurate information to give to women, the most efficient way of doing it, the physical examination during a contraceptive visit and the most appropriate follow-up.

METHODS

A systematic review of French-speaking or English-speaking evidence-based literature about contraception and its visit was performed using Pubmed, Cochrane and international recommendations.

RESULTS

Showing a contraceptive preference decreases women's satisfaction (EL1) and may decrease contraceptive persistence (EL4). A GATHER's like structured consultation is recommended (Grade A). It allows a contraceptive choice improvement (EL2). Contraceptive knowledge improvement associated with a structured consultation allows a decrease in unplanned pregnancies (EL1) compared to a traditional non-personalized consultation. The main expectations of women are slightly different from what is expected by practitioners (EL2). The main topics to be addressed are efficiency, risks, cost, duration of action and practicality (EL2). The quality of interpersonal communication could allow greater contraceptive persistence (EL2). A careful behavior at the beginning of the consultation and facilitating the expression of the woman's point of view could increase the persistence of the initially prescribed contraception (EL2). Explaining the chosen contraception's adverse effect is recommended because it could allow a better persistence (Grade B). Decision aids has shown interest in the therapeutic choice (EL1). Computerized modules or slide shows in the waiting room before consultation could make the contraceptive choice easier (EL2). The presentation of contraception by effectiveness categories is better than pregnancy numbers for comparing the methods (EL1). Performing a blood pressure measurement prior to an estroprogestative contraception prescription is recommended (Grade C). In women without risk factors, literature data do not allow specific recommendations regarding breast, pelvic examination, laboratory screening and follow-up (Professional agreement).

[Intrauterine device and pelvic inflammatory disease: Myth or reality?]

INTRODUCTION

Intrauterine device (IUD) is a reliable contraceptive method that is long term reversible, and well tolerated. Numerous studies prove its efficiency and report rare complications that are attributed to it. However, its use is limited due to fear that it can cause a pelvic inflammatory disease (PID). This is based on historical data on infections related to the "Dalkon Shield", which was removed from the market in 1974.

METHOD

The analyzed articles were extracted from PUBMED database between 2000 and 2016. In total, 22 studies were retained. A meta-analysis was not possible due to the methodological diversity among the selected articles contributing to this narrative review of the literature.

RESULTS

After analysis, the following factors influence the risk of PID linked to IUDs: an advanced age and sexually transmitted infections.

CONCLUSION

The risk of PID linked to IUDs is lower than 1%. This is explained by new models of IUD, better screening tests, more frequent follow-up of the patients and the improvement of care PID patients. In the light of our results, the threat of pelvic inflammatory disease should not hinder the use of IUDs.

Consensus Statement on the Use of Oral Contraceptive Pills in Polycystic Ovarian Syndrome Women in India

OBJECTIVE

To provide consensus recommendations for health-care providers on the use of oral contraceptive pills (OCPs) in polycystic ovarian syndrome (PCOS) women in India.

PARTICIPANTS

Extensive deliberations, discussions, and brainstorming were done with different fraternities (specialists) being involved. These included endocrinologists, gynecologists, reproductive endocrinologists, dermatologists, public health experts, researchers, and a project manager with a team to develop the guideline.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 2003 to December 2017 using appropriate-controlled vocabulary (e.g., oral contraceptive pills, polycystic ovarian syndrome, long term outcomes, infertility). Clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies' publications and data were also reviewed to suggest the recommendations.

PROCESS

The working group for guideline committee included members from the PCOS Society (India), Indian Society for Assisted Reproduction, The Mumbai Obstetric and Gynecological Society, The Endocrine Society of India, Indian Association of Dermatologists, Venereologists and Leprologists, Cosmetic Dermatology Society (India), Academicians from Medical Colleges, National Institute for Research in Reproductive Health, and a Research Associate. The core team included five reproductive endocrinologists, five gynecologists, five dermatologists, three endocrinologists, two public health experts and one research associate.

CONCLUSIONS

This consensus statement provides the guidance/recommendations for Indian practitioners regarding the use of OCP in women with PCOS. PCOS is one of the common endocrinopathies encountered in gynecological/endocrine practice. The spectrum of this disorder may range from prepubertal girls with premature pubarche, young girls with hirsutism, acne and anovulatory cycles, married women with infertility, and elderly women. Although obesity is a common feature for most PCOS patients, 'lean PCOS' also exists. For several years, OCPs have played an important role in the symptom management of PCOS women. This is due to the fact that OCPs decrease the luteinizing hormone, reduce androgen production, and increase sex hormone-binding globulin, which binds androgens. Several new formulations of OCPs have been developed to decrease the side effects. This includes use of less androgenic progestins and lower doses of ethinyl estradiol. These consensus recommendations help the health provider to choose the right type of OCPs, which will alleviate the symptoms with least side effects. It also gives insight into the indications, contraindications, and concerns regarding its short, intermediate and long-term use.

Practice Bulletin No. 186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices

Intrauterine devices and contraceptive implants, also called long-acting reversible contraceptives (LARC), are the most effective reversible contraceptive methods. The major advantage of LARC compared with other reversible contraceptive methods is that they do not require ongoing effort on the part of the patient for long-term and effective use. In addition, after the device is removed, the return of fertility is rapid (1, 2). The purpose of this Practice Bulletin is to provide information for appropriate patient selection and evidence-based recommendations for LARC initiation and management. The management of clinical challenges associated with LARC use is beyond the scope of this document and is addressed in Committee Opinion No. 672, Clinical Challenges of Long-Acting Reversible Contraceptive Methods (3).

Oral Contraceptives after Bariatric Surgery

OBJECTIVE

Bariatric surgery offers a highly effective mode of treatment for obese patients. Some procedures such as bypass cause an alteration in normal gastrointestinal tract with possible consequences for the uptake of orally administered drugs.

METHODS

We assessed the literature to ascertain whether the use of oral drugs and especially oral contraceptives is effective and adequate after bariatric surgery.

RESULTS

The bioavailability of drugs could be affected by the solubility and pH of the modified medium after bariatric surgery and by the loss of gastrointestinal transporters. Bariatric surgery could potentially result in a transient change in the absorption of drugs such as analgesics, antibiotics, antiarrhythmics, anticoagulants, psychotropic, and oral contraceptive drugs. Effective contraception is especially critical in the postoperative period, and implants might be representing a safe contraceptive method in women undergoing bariatric surgery.

CONCLUSION

Each drug will have to be evaluated with respect to its site of absorption and its mechanism of absorption, with special attention on parameters influencing the effectiveness of the absorption processes.

Progestin-only contraceptives: effects on weight

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.

Do women aged over 40 need different counseling on combined hormonal contraception?

There is still a risk of pregnancy during the menopause transition, for most women after the age of 40, as occasional, spontaneous ovulation can occur. Women in this age group may therefore consider using contraception and want appropriate counseling. Aging is accompanied by changes that can increase the risks associated with the use of combined hormonal contraceptives (CHCs), but we do not have sufficient evidence to determine whether age alone increases the risks of using CHCs or whether there are additional risks if CHC use begins at an earlier age. Another issue is whether we can differentiate between initiator versus continuation influences on risk. The objective of this article is to review the risks associated with CHC to determine whether there is a need for more appropriate contraceptive counseling for women aged over 40.

[Nurse delivery of oral contraception following an initial prescription for minors and uninsured patients in family planning centers of the Val-de-Marne]

BACKGROUND

Since 2012 in France, nurses are allowed to renew the medical prescription of oral contraceptives (OC). To support this plan, a service protocol in family planning centers allows nurse delivery of OC.

MATERIALS AND METHODS

This is a pilot feasibility study. After a medical prescription of OC, the nurse is authorized to deliver OC for 3months after a nursing interview. The duration of the nursing follow-up is determined by the physician.

RESULTS

A total of 244 nurses interviews of 170 women were conducted between January 2012 and July 2013. All women have benefited from a delivery of contraceptives by the nurse. Analysis shows that 40 interviews (16%) had one or more abnormal criteria. Of these, more than a quarter found poor tolerance of contraception and/or the appearance of gynecological symptoms (27%) or unprotected sex with a new partner (25%). In these cases, an orientation to the physician was more frequent (85% versus 62%, P=0.005) and faster (median 33days versus 90days, P<0.001) than if the nurse interview was normal.

CONCLUSION

Our study shows the feasibility of delivery protocol of oral contraception by nurses following an initial prescription by the physician.

Our own worst enemy: pharmacologic mechanisms of hypertension

Drug-induced hypertension is often an unrecognized cause of resistant or secondary hypertension. It is defined as hypertension resulting from the unintended effect of a drug or from a drug's antagonistic effect on antihypertensive medications. The main mechanisms of drug-induced hypertension, when categorized broadly, include volume retention and sympathomimetic effects. These mechanisms along with management strategies will be further discussed in this article.

Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

The aim of this statement is to summarize data on stroke risk factors that are unique to and more common in women than men and to expand on the data provided in prior stroke guidelines and cardiovascular prevention guidelines for women. This guideline focuses on the risk factors unique to women, such as reproductive factors, and those that are more common in women, including migraine with aura, obesity, metabolic syndrome, and atrial fibrillation.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through May 15, 2013. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

We provide current evidence, research gaps, and recommendations on risk of stroke related to preeclampsia, oral contraceptives, menopause, and hormone replacement, as well as those risk factors more common in women, such as obesity/metabolic syndrome, atrial fibrillation, and migraine with aura.

CONCLUSIONS

To more accurately reflect the risk of stroke in women across the lifespan, as well as the clear gaps in current risk scores, we believe a female-specific stroke risk score is warranted.

Hormonal contraception in women with migraine: is progestogen-only contraception a better choice?

A significant number of women with migraine has to face the choice of reliable hormonal contraception during their fertile life. Combined hormonal contraceptives (CHCs) may be used in the majority of women with headache and migraine. However, they carry a small, but significant vascular risk, especially in migraine with aura (MA) and, eventually in migraine without aura (MO) with additional risk factors for stroke (smoking, hypertension, diabetes, hyperlipidemia and thrombophilia, age over 35 years). Guidelines recommend progestogen-only contraception as an alternative safer option because it does not seem to be associated with an increased risk of venous thromboembolism (VTE) and ischemic stroke. Potentially, the maintenance of stable estrogen level by the administration of progestins in ovulation inhibiting dosages may have a positive influence of nociceptive threshold in women with migraine. Preliminary evidences based on headache diaries in migraineurs suggest that the progestin-only pill containing desogestrel 75μg has a positive effect on the course of both MA and MO in the majority of women, reducing the number of days with migraine, the number of analgesics and the intensity of associated symptoms. Further prospective trials have to be performed to confirm that progestogen-only contraception may be a better option for the management of both migraine and birth control. Differences between MA and MO should also be taken into account in further studies.