Effects of initiating a contraceptive implant on subsequent condom use: A randomized controlled trial

Long-Acting Reversible Contraception, Condom Use, and Sexually Transmitted Infections: A Systematic Review and Meta-analysis

INTRODUCTION

Given mixed findings regarding the relationship between long-acting reversible contraception and condom use, this systematic review and meta-analysis synthesizes studies comparing sexually transmitted infection‒related outcomes between users of long-acting reversible contraception (intrauterine devices, implants) and users of moderately effective contraceptive methods (oral contraceptives, injectables, patches, rings).

METHODS

MEDLINE, Embase, PsycINFO, Global Health, CINAHL, Cochrane Library, and Scopus were searched for articles published between January 1990 and July 2018. Eligible studies included those that (1) were published in the English language, (2) were published in a peer-reviewed journal, (3) reported empirical, quantitative analyses, and (4) compared at least 1 outcome of interest (condom use, sexual behaviors other than condom use, sexually transmitted infection‒related service receipt, or sexually transmitted infections/HIV) between users of long-acting reversible contraception and users of moderately effective methods. In 2020, pooled ORs were calculated for condom use, chlamydia/gonorrhea infection, and trichomoniasis infection; findings for other outcomes were synthesized qualitatively. The protocol is registered on the International Prospective Register of Systematic Reviews (CRD42018109489).

RESULTS

A total of 33 studies were included. Long-acting reversible contraception users had decreased odds of using condoms compared with oral contraceptive users (OR=0.43, 95% CI=0.30, 0.63) and injectable, patch, or ring users (OR=0.58, 95% CI=0.48, 0.71); this association remained when limited to adolescents and young adults only. Findings related to multiple sex partners were mixed, and only 2 studies examined sexually transmitted infection testing, reporting mainly null findings. Pooled estimates for chlamydia and/or gonorrhea were null, but long-acting reversible contraception users had increased odds of trichomoniasis infection compared with oral contraceptive users (OR=2.01, 95% CI=1.11, 3.62).

DISCUSSION

Promoting condom use specifically for sexually transmitted infection prevention may be particularly important among long-acting reversible contraception users at risk for sexually transmitted infections, including adolescents and young adults.

Intrauterine Devices and Sexually Transmitted Infection among Older Adolescents and Young Adults in a Cluster Randomized Trial

STUDY OBJECTIVE

Provider misconceptions regarding intrauterine device (IUD) safety for adolescents and young women can unnecessarily limit contraceptive options offered; we sought to evaluate rates of Neisseria gonorrhoeae or Chlamydia trachomatis (GC/CT) diagnoses among young women who adopted IUDs.

DESIGN

Secondary analysis of a cluster-randomized provider educational trial.

SETTING

Forty US-based reproductive health centers.

PARTICIPANTS

We followed 1350 participants for 12 months aged 18-25 years who sought contraceptive care.

INTERVENTIONS

The parent study assessed the effect of provider training on evidence-based contraceptive counseling.

MAIN OUTCOME MEASURES

We assessed incidence of GC/CT diagnoses according to IUD use and sexually transmitted infection risk factors using Cox regression modeling and generalized estimating equations.

RESULTS

Two hundred four participants had GC/CT history at baseline; 103 received a new GC/CT diagnosis over the 12-month follow-up period. IUDs were initiated by 194 participants. Incidence of GC/CT diagnosis was 10.0 per 100 person-years during IUD use vs 8.0 otherwise. In adjusted models, IUD use (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 0.71-2.40), adolescent age (aHR, 1.28; 95% CI, 0.72-2.27), history of GC/CT (aHR, 1.23; 95% CI, 0.75-2.00), and intervention status (aHR, 1.12; 95% CI, 0.74-1.71) were not associated with GC/CT diagnosis; however, new GC/CT diagnosis rates were significantly higher among individuals who reported multiple partners at baseline (aHR, 2.0; 95% CI, 1.34-2.98).

CONCLUSION

In this young study population with GC/CT history, this use of IUDs was safe and did not lead to increased GC/CT diagnoses. However, results highlighted the importance of dual sexually transmitted infection and pregnancy protection for participants with multiple partners.

The Association Between Nonbarrier Contraceptive Use and Condom Use Among Sexually Active Latina Adolescents

PURPOSE

This study aimed to determine the association between use of highly effective methods of nonbarrier contraception and condom use in a sample of Latina adolescents and whether the change to a more effective method of nonbarrier contraception is associated with a change in condom use.

METHODS

As part of a larger study, 442 sexually active Latina adolescents aged 14-18 years were surveyed immediately before an appointment with a medical care provider at a school-based health center and 3 months later. Ordinal logistic and linear regression were used in the analysis of cross-sectional and longitudinal data to assess the relationship between patterns of nonbarrier contraception and condom use.

RESULTS

The use of all types of nonbarrier methods of contraception was significantly associated with decreased condom use. Change over time from a less effective to a more effective nonbarrier method of contraception was also associated with a decrease in condom use. Greater number of sexual encounters was associated with lower the frequency of condom use.

CONCLUSIONS

The use of highly effective methods of nonbarrier contraception was associated with reduced frequency of condom use. This highlights the need to promote condom use concurrently with nonbarrier methods of contraception to improve protection against both pregnancy and STIs.

Trends in Reported Sexual Behavior and Y-Chromosomal DNA Detection Among Female Sex Workers in the Senegal Preexposure Prophylaxis Demonstration Project

A study among female sex workers in Senegal found no evidence of increased sexual risk behavior after preexposure prophylaxis initiation as measured by self-report or Y-chromosomal DNA detection.

Supplemental digital content is available in the text.

Background

Preexposure prophylaxis (PrEP) can reduce HIV acquisition among female sex workers (FSWs). However, changes in condomless sex frequency after PrEP initiation could reduce PrEP effectiveness when PrEP adherence is suboptimal as well as increase the risk of acquiring other sexually transmitted infections. Objective measures of condomless sex may be more accurate for determining changes in sexual behavior than self-reported measures.

Methods

We longitudinally measured self-reported condom use, number of clients, and presence of Y-chromosomal DNA (Yc-DNA) in vaginal swabs among 267 FSWs accessing PrEP at 4 clinics in Senegal between 2015 and 2016. We assessed trends in sexual behavior over time since PrEP initiation using generalized estimating equations and evaluated predictors of Yc-DNA detection.

Results

We found no increase in self-reported condomless sex with clients (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.89–1.00), main partners (OR, 0.99; 95% CI, 0.96–1.02), or Yc-DNA detection (OR, 0.99; 95% CI, 0.90–1.08) over time since initiation. Y-chromosomal DNA was detected in 34 (22%) of 154 swabs tested and in 15 (26%) of 58 swabs from FSW reporting consistent condom use among both clients and main partners. Self-reported condom use with clients or main partners did not predict Yc-DNA detection.

Conclusions

In a FSW PrEP demonstration project in Senegal, we found no evidence of risk compensation among FSWs on PrEP as measured by self-reported behavior or through Yc-DNA detection. Y-chromosomal DNA detection was frequently detected among FSWs reporting consistent condom use, highlighting limitations of self-reported sexual behavioral measures.

Debunking myths about contraceptive safety among women in Kingston, Jamaica: Pilot randomized controlled trial

OBJECTIVES

(1) To create a short motion graphic video to debias women, using evidence from cognitive psychology, of 2 common myths about safety of intrauterine devices (IUDs) and implants in Jamaica; and (2) to conduct a pilot study to evaluate video effectiveness.

STUDY DESIGN

We conducted a series of 3 focus group discussions among target users to inform the development process of the script, story, character, and look of the intervention video. We randomized young, female nonusers of long-acting contraception at risk of pregnancy at a public clinic in Kingston in 2018-2019 to watch either the intervention (n = 113) or control video (n = 112). We used logistical regression to evaluate perceptions of method safety, naturalness, and uptake after 3 months of follow up.

RESULTS

Almost all (n = 220; 97.8%) participants completed the 3-month interview. More women in the intervention arm perceived IUDs to be safe (59.1%) compared to the control arm (43.6%; p = 0.02). Perceived implant safety increased from enrollment to follow up in the intervention and control arms (10.9 and 2.7 percentage-point increases, respectively); however, the difference between arms at follow up was not statistically significant (p = 0.57). This appeared to be due to arm imbalances at enrollment. Study arms did not differ at follow up in perceived IUD naturalness (p = 0.36) or implant naturalness (p = 0.68).

CONCLUSIONS

Findings from a pilot study of a video intervention suggest that using debiasing strategies from cognitive psychology has the potential to address misconceptions about contraceptive safety. A larger trial with adequate power is warranted.

IMPLICATIONS

Evidence from a pilot randomized controlled trial suggested that use of debiasing strategies from cognitive psychology could be effective in correcting women's misconceptions about contraception safety and thus show promise for the design of future contraceptive promotion videos to increase uptake.

Condom use among young women in Australia using long-acting reversible contraceptives or other hormonal contraceptives

Background Dual condom and long-acting reversible contraceptive (LARC) or non-LARC hormonal contraceptive use is the most effective way to protect against unwanted pregnancy and sexually transmissible infections (STIs). This study aimed to determine whether condom use varied between users of LARC and non-LARC hormonal contraceptives and explore their motivations for condom use.

METHODS

Women aged 16-24 years attending a sexual and reproductive health centre in Melbourne, Australia, completed a survey about contraceptives and sexual practices. The proportion of LARC and non-LARC hormonal contraceptive users using condoms was calculated and logistic regression compared condom use between the two groups. Condom use was based on frequency of use and coded as a binary variable 'never, not usually or sometimes' versus 'usually or always'.

RESULTS

In all, 294 (97%) women participated in the study; 23.8% (95% confidence interval (CI) 19.0-29.1%) used LARC and 41.7% (95% CI 36.0-47.6%) used non-LARC hormonal contraceptives. Condom use was reported by 26.1% (95% CI 16.3-38.1%) of LARC users and by 27.8% (95% CI 19.9-37.0%) of non-LARC hormonal contraceptive users. There was no difference in condom use between groups (odds ratio (OR) 0.9; 95% CI 0.4-1.9). Condom use reduced with increasing relationship length (≥6 months vs no relationship: OR 0.2; 95% CI 0.1-0.6). Non-LARC hormonal contraceptive users were more motivated to use condoms if worried about pregnancy than LARC users (62.8% vs 47.8%; P = 0.04).

CONCLUSION

Condom use was low and similar between users of LARC and non-LARC hormonal contraceptives, and was associated with the length of the relationship. These results highlight the need to promote condom use when prescribing LARCs and non-LARC hormonal contraceptives to reduce the risk of STIs.

PrEP Use Among Female Sex Workers: No Evidence for Risk Compensation

Supplemental Digital Content is Available in the Text.

Little is known about risk compensation among female sex workers (FSW) on HIV pre-exposure prophylaxis (PrEP), and self-report of sexual behaviors is subject to bias.

A novel nested polymerase chain reaction targeting the testis-specific protein Y-encoded family of genes for high sensitivity of recent semen exposure detection: Comparison with four other assays of semen detection

OBJECTIVES

Because self-report of sexual behaviours is prone to biases, biomarkers of recent semen exposure are increasingly used to assess unprotected sex. We aimed to present a novel nested polymerase chain reaction (PCR) assay targeting testis-specific protein Y-encoded (TSPY) genes and to compare its performance in detecting recent semen exposure with that of four other assays.

METHODS

Forty-five vaginal samples were selected at baseline of a prospective observational demonstration study of early antiretroviral treatment and pre-exposure prophylaxis among female sex workers in Benin. Semen exposure was assessed with: a rapid prostate-specific antigen (PSA) detection assay, a quantitative PCR targeting the sex-determining region (SRY) gene, a standard PCR targeting SRY, a standard PCR targeting TSPY, and a nested PCR targeting TSPY (n-TSPY). Because we had hypothesized that n-TSPY would be the most sensitive of the five assays while remaining specific, and as our results suggested that it was the case, sensitivity and specificity were calculated for each assay in comparison with n-TSPY.

RESULTS

The n-TSPY could detect male DNA at concentration 16 and 64 times lower compared to s-TSPY and s-SRY, respectively. Among the 45 vaginal samples, prevalences of semen exposure according to the different assays varied from 22.2% (95%CI: 11.2%-37.1%) to 70.5% (95%CI: 54.8%-83.2%), with the highest prevalence measured with n-TSPY. The n-TSPY products were of expected size and we observed no false-positive in female DNA controls. The assay that offered the second best performance in detecting semen exposure was the PSA rapid test, with a sensitivity of 61.3% and a specificity of 100% compared to n-TSPY.

CONCLUSIONS

Compared to n-TSPY, all other PCR assays had poor performance to detect semen exposure. The n-TSPY is an accessible assay that may have great utility in assessing semen exposure in studies where many factors are expected to accelerate biomarkers' clearance.

A Qualitative Assessment to Understand the Barriers and Enablers Affecting Contraceptive Use Among Adolescent Male Emergency Department Patients

Early fatherhood is common in the United States (U.S.). The emergency department (ED) plays a disproportionate role in serving patients with unmet reproductive and sexual health needs. With 8 million adolescent males visiting U.S. EDs annually, the ED is a potential site to implement interventions to minimize early fatherhood and unintended teenage pregnancy. Little is known about how adolescent male ED patients perceive and behave in sexual relationships and how they influence contraceptive decision making. The objective of this study was to identify the barriers and enablers affecting contraceptive and condom use among adolescent male ED patients. Semistructured interviews were conducted with males aged 14-19 in one urban ED. Enrollment continued until saturation of key themes. Interviews were recorded, transcribed, and coded based on thematic analysis using NVivo 10. The Social Ecological Model was used to organize and understand themes. Participants ( n = 24) were predominantly 18-19 years (63%) and Hispanic (92%). Most (71%) had sex ≤3 months prior but infrequently used a condom at last intercourse (42%). The primary barrier influencing contraceptive use was lack of knowledge of effective contraceptives. Other barriers consisted of perceived gender roles, poor partner communication, and little relationship with a primary provider. Enablers included intention not to get a partner pregnant, school-based sexual health education, normalcy to use condoms, and a trustworthy confidante. The identified barriers and enablers influencing adolescent males' perspectives toward contraceptives should be addressed if designing future ED-based pregnancy prevention interventions targeting teen males.

Trends in long-acting reversible contraceptive (LARC) use, LARC use predictors, and dual-method use among a national sample of college women

OBJECTIVE

Assess long-acting reversible contraceptive (LARC) and other contraceptive use trends, identify LARC use predictors, and examine dual method use.

PARTICIPANTS

Women in the American College Health Association-National College Health Assessment (ACHA-NCHA) II, aged 18-24 years, who reported having vaginal sex (N = 37,899).

METHODS

Secondary analyses of Fall 2011-2014 ACHA-NCHA II data.

RESULTS

Statistically significant increases in LARC usage and, specifically, implant usage, were found. Characteristics associated with LARC use included age, race/ethnicity, relationship status, and school type. Students reporting LARC use had lower odds of condom usage compared with non-LARC hormonal method users.

CONCLUSION

This analysis of LARC predictors and dual LARC/condom use has implications for research and health promotion efforts. Findings suggest that college health services are well positioned to meet the sexual and reproductive health needs of diverse populations of students. College health professionals should elicit students' individual and/or relationship priorities to tailor messaging/services offered for pregnancy/STI prevention.

Assessing prevalence of missed laboratory-confirmed sexually transmitted infections among women in Kingston, Jamaica: results from a secondary analysis of the Sino-Implant clinical trial

OBJECTIVES

To assess potentially missed sexually transmitted infections (STIs), we compared clinically diagnosed STIs to laboratory-confirmed diagnoses of gonorrhoea (GC), chlamydia (CT) and trichomonas (Tvag).

DESIGN

Secondary analysis of a randomised controlled trial.

SETTING

We used data and specimens previously collected for the Sino-Implant Study in Kingston, Jamaica.

PARTICIPANTS

The Sino-Implant Study randomised 414 women to receive a levonorgestrel implant at either baseline or 3 months post-enrolment to evaluate unprotected sex after implant initiation. This analysis used 254 available vaginal swab samples.

OUTCOME MEASURES

Clinically diagnosed STIs were determined from medical records by assessing clinical impressions and prescriptions. Laboratory-confirmed STIs included GC, CT and Tvag tested by Aptima Combo 2 for CT/GC and Aptima Tvag assays (Hologic, San Diego, California, USA). Log-binomial regression models fit with generalised estimating equations were used to estimate associations of clinically diagnosed STIs with laboratory-confirmed diagnoses and demographic and behavioural characteristics.

RESULTS

Overall, 195 (76.8%) women had laboratory-confirmed STI (CT, GC or Tvag) while only 65 (25.6%) women had clinically diagnosed cervicitis and/or vaginitis during the study period. Clinical diagnosis missed 79.7% of laboratory-confirmed STIs: 85% of GC (n=17/20), 78.8% of CT (n=141/179) and 80.0% of Tvag (n=180/225). Hormonal contraceptive use in the month prior to the study visit was significantly associated with clinical diagnosis at any time point (prevalence ratio (PR): 1.65, 95% CI 1.07 to 2.54). As age increased, clinically missed infections significantly decreased (PR: 0.98 per year increase, 95% CI 0.97 to 1.00).

CONCLUSIONS

The prevalence of laboratory-confirmed STIs was much higher than what was captured by clinical diagnosis. GC, CT and Tvag were not accurately detected without lab confirmation. Missed diagnoses decreased with older age. Increased laboratory capacity and refinement of the syndromic approach are needed to protect the health of sexually active Jamaican women.

TRIAL REGISTRATION NUMBER

NCT01684358.

Dual method use among long-acting reversible contraceptive users

OBJECTIVE

To compare rates of dual method use (concurrent use of condoms and an effective method of contraception) in long-acting reversible contraceptive (LARC) and non-LARC hormonal contraceptive users, and to determine factors associated with dual method use.

METHODS

We conducted a secondary analysis of the Contraceptive CHOICE Project, an observational, prospective cohort study of 9256 women in St. Louis, MO, USA. Our sample included 6744 women who initiated a contraceptive method within 3 months of enrollment, continued use at 6 months post-enrollment, and responded regarding dual method use. Our primary outcome was the rate of dual method use at 6 months post-enrollment.

RESULTS

Dual method use was reported by 32% of LARC and 45% of non-LARC hormonal contraceptive users (p < .01). After adjusting for other covariates and comparing to non-LARC hormonal contraceptive users, LARC users were less likely to report dual method use (RR_adj 0.76, 95% CI 0.70-0.83). Factors associated with dual method use in our multivariable analysis were age <25 years, black race, lower education, single relationship status, baseline dual method use, baseline diagnosis of sexually transmitted infection (STI), greater partner willingness to use a condom, and higher condom self-efficacy score.

CONCLUSIONS

LARC users are less likely to report dual method use compared to non-LARC hormonal contraceptive users, but other factors also impact dual method use. Further studies should be performed to determine whether this lower dual method use increases the risk of STI.

CLINICAL TRIALS REGISTRATION

Clinicaltrials.gov Identifier NCT01986439.

Condom use and incident sexually transmitted infection after initiation of long-acting reversible contraception

BACKGROUND

Use of more effective contraception may lead to less condom use and increased incidence of sexually transmitted infection.

OBJECTIVE

The objective of this study was to compare changes in condom use and incidence of sexually transmitted infection acquisition among new initiators of long-acting reversible contraceptives to those initiating non-long-acting reversible contraceptive methods.

STUDY DESIGN

This is a secondary analysis of the Contraceptive CHOICE Project. We included 2 sample populations of 12-month continuous contraceptive users. The first included users with complete condom data (baseline, and 3, 6, and 12 months) (long-acting reversible contraceptive users: N = 2371; other methods: N = 575). The second included users with 12-month sexually transmitted infection data (long-acting reversible contraceptive users: N = 2102; other methods: N = 592). Self-reported condom use was assessed at baseline and at 3, 6, and 12 months following enrollment. Changes in condom use and incident sexually transmitted infection rates were compared using χ2 tests. Risk factors for sexually transmitted infection acquisition were identified using multivariable logistic regression.

RESULTS

Few participants in either group reported consistent condom use across all survey time points and with all partners (long-acting reversible contraceptive users: 5.2%; other methods: 11.3%; P < .001). There was no difference in change of condom use at 3, 6, and 12 months compared to baseline condom use regardless of method type (P = .65). A total of 94 incident sexually transmitted infections were documented, with long-acting reversible contraceptive users accounting for a higher proportion (3.9% vs 2.0%; P = .03). Initiation of a long-acting reversible contraceptive method was associated with increased sexually transmitted infection incidence (odds ratio, 2.0; 95% confidence ratio, 1.07-3.72).

CONCLUSION

Long-acting reversible contraceptive initiators reported lower rates of consistent condom use, but did not demonstrate a change in condom use when compared to preinitiation behaviors. Long-acting reversible contraceptive users were more likely to acquire a sexually transmitted infection in the 12 months following initiation.

Prevalence and risk factors associated with STIs among women initiating contraceptive implants in Kingston, Jamaica

BACKGROUND

There is limited information on rates of STIs in Jamaica due to syndromic management and limited aetiological surveillance. We examined the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) and characteristics associated with STIs among sexually active women who participated in a randomised trial of a progestin implant initiation in Jamaica (the Sino-Implant Study (SIS)).

METHODS

SIS was a randomised trial conducted in Kingston, Jamaica, from 2012 to 2014 to evaluate whether initiation of the Sino-Implant (II) led to more unprotected sex among women ages 18-44 years. Data collected included self-reported demographic, sexual behaviour information; and vaginal swabs collected at baseline, 1-month and 3-month follow-up visits for a biomarker of recent semen exposure (prostate-specific antigen (PSA)) and for STIs. We examined associations between STIs and PSA, demographics, sexual behaviour and insertion of an implant, with a repeated-measures analysis using generalised estimating equations (SAS Institute, V.9.3).

RESULTS

Remnant vaginal swabs from 254 of 414 study participants were tested for STIs. At baseline, 29% of participants tested for STIs (n=247) had laboratory-confirmed CT, 5% NG, 23% TV and 45% any STI. In a repeated-measures analysis adjusted for study arm (immediate vs delayed implant insertion), those with PSA detected did not have an increased prevalence of any STI (prevalence ratio (PR)=1.04 (95% CI 0.89 to 1.21)), whereas prevalence decreased for each 1-year increase in age (PR=0.98 (95% CI 0.97 to 0.99)). Immediate implant insertion was not associated with increases in any STI in subsequent visits (PR=1.09 (95% CI 0.94 to 1.27)).

CONCLUSIONS

Although the prevalence of laboratory-confirmed STIs was high, the immediate initiation of a contraceptive implant was not associated with higher STI prevalence rates over 3 months.

TRIAL REGISTRATION NUMBER

NCT01684358.

The impact of an IUD and implant intervention on dual method use among young women: Results from a cluster randomized trial

Long-acting reversible contraceptives (LARCs) are highly effective at preventing pregnancy but do not protect against sexually transmitted infection (STI). Recent efforts to improve access to intrauterine devices (IUDs) and implants have raised concerns about STI prevention and reduced condom use, particularly among teenagers and young women. We evaluated whether a provider-targeted intervention to increase LARC access negatively impacted dual method use and STI incidence among an at-risk patient population. We conducted a cluster randomized trial in 40 reproductive health centers across the United States from May 2011 to May 2013. After training providers at 20 intervention sites, we recruited 1500 sexually-active women aged 18-25years who did not desire pregnancy and followed them for one year. We assessed intervention effects on dual method use, condom use and STI incidence, modeling dual method use with generalized estimating equations and STI incidence with Cox proportional hazard regression models, accounting for clustering. We found no differences between intervention and control groups in dual method use (14.3% vs. 14.4%, aOR 1.03, 95% CI 0.74-1.44) or condom use (30% vs. 31%, aOR 1.03, 95% CI 0.79-1.35) at last sex at one year. STI incidence was 16.5 per 100 person-years and did not differ between intervention and control groups (aHR 1.20, 95% CI 0.88-1.64). A provider training intervention to increase LARC access neither compromised condom use nor increased STI incidence among young women. Dual method use was very low overall, highlighting the need to bolster STI prevention efforts among adolescents and young women.

Important considerations in adolescent health maintenance: long-acting reversible contraception, human papillomavirus vaccination, and heavy menstrual bleeding

PURPOSE OF REVIEW

The present article addresses recent research related to three key facets of adolescent preventive care and health maintenance: long-acting reversible contraception, human papillomavirus vaccination, and heavy menstrual bleeding.

RECENT FINDINGS

Recent studies suggest that long-acting reversible contraception use results in significantly lower rates of unintended pregnancies, and is well tolerated by nulliparous adolescent females. Additionally, a strong recommendation from a pediatric primary care provider is extremely effective in ensuring human papillomavirus vaccination prior to sexual debut. Finally, heavy menstrual bleeding is often under-recognized in adolescents, and evaluation and treatment of these patients are variable.

SUMMARY

Based on the recent literature findings, the pediatric primary care provider should be encouraged to, first, recommend long-acting reversible contraception for prevention of unintended pregnancy in adolescent patients; second, strongly endorse vaccination to protect against human papillomavirus in all patients prior to sexual debut; and, third, screen adolescent females for signs and symptoms of heavy menstrual bleeding.

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.

Association of Progestin Contraceptive Implant and Weight Gain

OBJECTIVE

To evaluate initiation of a two-rod, 150-mg levonorgestrel contraceptive implant on women's perceived and observed body weight.

METHODS

We conducted a secondary analysis of data from an open, randomized controlled trial of adult, nonpregnant, human immunodeficiency virus-negative women attending a public clinic in Kingston, Jamaica, who were assigned to initiate implant use either immediately or after a 3-month delay. The primary objective of the parent study was to assess the effect of initiation of the implant on the frequency of condom use. We compared study arms during follow-up using one-sided χ tests for differences in perceived weight gain and loss, one-sided Wilcoxon-Mann-Whitney tests for median gain in measured weight, and logistic regression with generalized estimating equations for risk of gaining greater than 2 kg.

RESULTS

From 2012 to 2014, women were assigned to the implant (n=208) or delay arm (n=206). At 3 months, more women in the implant arm (15.3%) reported perceived weight gain than in the control arm (4.3%) (P=.01). Despite differences in perception, the implant and control arms did not differ significantly in median weight gain at 1-month (0.0 kg and 0.0 kg, respectively; P=.44) and 3-month visits (0.5 kg and 0.0 kg, respectively; P=.27). Study arms did not differ in risk of gaining greater than 2 kg (odds ratio 0.9, 95% confidence interval 0.6-1.3).

CONCLUSION

We found no evidence of weight gain from short-term implant use. Through the power of the nocebo effect, the practice of counseling women to expect possible weight gain from initiating implant use could lead them to perceive weight gain even in its absence and contribute to the early discontinuation of this highly effective contraceptive method.