Contraceptive implants and lactation

Long-acting reversible contraception with etonogestrel implants in female macaques (Macaca mulatta and Macaca fascicularis)

Introduction

Contraception is often required for management and population control purposes in group-housed and free-roaming non-human primates. Long-acting reversible contraceptives, including subdermal progestin-releasing implants, are preferred as they eliminate challenges associated with frequent administration. Etonogestrel (ENG)-releasing subdermal implants are reversible and long-acting for a minimum of 3 years, and are commercially available for human use as Implanon® or Nexplanon®.

Methods

A retrospective analysis was performed detailing the contraceptive effectiveness and reversibility of subdermal placement of one-fourth or one-third of an ENG implant (68 mg/implant) in 129 female rhesus macaques (Macaca mulatta) and 67 cynomolgus macaques (Macaca fascicularis) at the Biomedical Primate Research Centre (Rijswijk, Netherlands). Furthermore, single cross-sectional ENG serum concentrations were measured for 16 rhesus and 10 cynomolgus macaques, and hemoglobin and blood chemistry pre-ENG and at timepoints >0.5, >1.5, and > 2.5 years post-ENG insertion were evaluated for 24 rhesus macaques. Finally, data were obtained using trans-abdominal ultrasound regarding the influence of ENG on uterine volume and endometrial thickness in 14 rhesus and 11 cynomolgus macaques.

Results

As a contraceptive ENG was in 99.80% (CI 93.50-99.99) and 99.95% (CI 99.95-100) effective in rhesus and cynomolgus macaques, respectively. Prolonged ENG durations of implant use in 14 rhesus macaques (range 3.1-5.0 years) and eight cynomolgus macaques (range 3.2-4.0 years) resulted in no unintended pregnancies. A total of 17 female macaques were allowed to breed after ENG removal, and among them, 14 female macaques (82%) had an uneventful delivery. Serum ENG concentrations with a median ENG duration of 1.2 years (range 0.1-6.0 years) and 1.9 years (range 0.6-4.7 years) resulted in median concentrations of 112 pg./mL (range 0-305 pg./mL) and 310 pg./mL (range 183-382 pg./mL) for rhesus and cynomolgus macaques, respectively. ENG had no clinical effect on hemoglobin and blood chemistry parameters nor on the thickness of the endometrial lining or uterus volume.

Conclusion

This study indicates that both one-fourth and one-third of the ENG implants are effective, long-acting, reversible, and safe contraceptive to use in macaques.

Menstrual Pattern and Characteristics of One-Rod and Two-Rod Levonorgestrel Implant Users

Introduction

The maternal mortality ratio (MMR) in Indonesia reaches 359 per 100,000 live births. The long-acting reversible contraceptive (LARC) method is an effective contraceptive choice for reducing MMR. The contraceptive implant is one of the LARCs that has low usage due to lack of education about the side effects. This study aims to compare the menstrual pattern and characteristics between one-rod and two-rod levonorgestrel implant users.

Methods

A prospective cohort study was performed in patients at Cipto Mangunkusumo Hospital (RSCM) from March 2016 to May 2018. Subject recruitment was done by consecutive sampling. This study was conducted from March 2016 until May 2019. Statistical analysis was performed on the data using the chi-square test to determine the relationship between menstrual pattern and characteristics, and the use of one-rod or two-rod levonorgestrel implants.

Results

A total of 140 subjects participated in the study, comprising 70 (50%) one-rod users and 70 (50%) two-rod users. In the first month, 32.9% one-rod users experienced amenorrhea, 22.9% experienced shortened menstrual period, 30% experienced normal menstrual period, and 14,2 % experienced lengthened menstrual period. In comparison, in the first month, 41.4% two-rod users experienced amenorrhea, 15.7% experienced shortened menstrual period, 32.9% experienced normal menstrual period, and 10% experienced lengthened menstrual period. There was no significant difference in menstrual patterns and characteristics between one-rod and two-rod levonorgestrel implant users.

Conclusion

There was no significant difference in menstrual patterns and characteristics between one-rod and two-rod levonorgestrel implant users. Implications. Menstrual patterns and characteristics from levonorgestrel implants user can help clinicians to reduce discontinuation rate from the acceptors. Further research should be conducted to know other side effects aside from menstrual bleeding patterns.

Optimizing maternal and neonatal outcomes with postpartum contraception: impact on breastfeeding and birth spacing

Postpartum contraception is important to prevent unintended pregnancies. Assisting women in achieving recommended inter-pregnancy intervals is a significant maternal-child health concern. Short inter-pregnancy intervals are associated with negative perinatal, neonatal, infant, and maternal health outcomes. More than 30% of women experience inter-pregnancy intervals of less than 18 months in the United States. Provision of any contraceptive method after giving birth is associated with improved inter-pregnancy intervals. However, concerns about the impact of hormonal contraceptives on breastfeeding and infant health have limited recommendations for such methods and have led to discrepant recommendations by organizations such as the World Health Organization and the U.S. Centers for Disease Control and Prevention. In this review, we discuss current recommendations for the use of hormonal contraception in the postpartum period. We also discuss details of the lactational amenorrhea method and effects of hormonal contraception on breastfeeding. Given the paucity of high quality evidence on the impact on hormonal contraception on breastfeeding outcomes, and the strong evidence for improved health outcomes with achievement of recommended birth spacing intervals, the real risk of unintended pregnancy and its consequences must not be neglected for fear of theoretical neonatal risks. Women should establish desired hormonal contraception before the risk of pregnancy resumes. With optimization of postpartum contraception provision, we will step closer toward a healthcare system with fewer unintended pregnancies and improved birth outcomes.

Progestogen-only contraceptive use among breastfeeding women: a systematic review

BACKGROUND

Postpartum women need effective contraception. Concerns have been raised that use of progestogen-only contraceptives (POCs) may affect breastfeeding performance and infant health outcomes.

OBJECTIVES

We investigated the clinical outcomes of breastfeeding duration, initiation of supplemental feeding and weaning, as well as infant outcomes including infant growth, health and development among breastfeeding women using POCs compared with breastfeeding women not using POCs.

SEARCH STRATEGY

We searched the PubMed database for all articles published from database inception through December 2014.

SELECTION CRITERIA

We included primary research studies of breastfeeding women of any age or parity who received POCs, including progestogen-only pills, injectables, implants or hormonal intrauterine devices (IUDs). The main outcomes were breastfeeding performance (as measured by initiation, continuation, frequency and exclusivity of breastfeeding) and infant health (as measured by growth, development or adverse health effects).

RESULTS

Forty-nine articles reporting on 47 different studies were identified that investigated the use of POCs in breastfeeding women and reported clinically relevant outcomes of infant growth, health or breastfeeding performance. Studies ranged from poor to fair methodological quality and generally failed to show negative effects of the use of POCs on breastfeeding outcomes or on infant growth or development. One randomized controlled trial (RCT) raises concerns that immediate insertion of the levonorgestrel IUD postpartum may be associated with poorer breastfeeding performance when compared with delayed insertion, although two other RCTs evaluating early etonogestrel implants compared with delayed initiation of implants or depot medroxyprogesterone acetate failed to find such an association.

CONCLUSION

The preponderance of evidence fails to demonstrate adverse breastfeeding outcomes or negative health outcomes in infants such as restricted growth, health problems or impaired development. Evidence newly added to this review was largely consistent with previous evidence.

A prospective cohort study of early postpartum etonogestrel implant (Implanon®) use and its effect on duration of lochia

BACKGROUND

Etonogestrel (ENG) implants (Implanon(®)/Nexplanon(®)/Implanon NXT(®)) are employed as contraception in early postpartum patients. Follow-up is often not conducted by the hospital prescriber. Little is known about duration of lochia, in a modern setting, and even less is known about the effect of ENG implants on lochia.

AIMS

To determine if early postpartum (pre-discharge) insertion of Implanon for contraception was associated with a significant difference in duration of lochia. To record the number of patients who went on to have their Implanon removed during the study period and the reasons for removal.

METHODS

Prospective cohort study of 152 postpartum patients from a tertiary maternity unit in Hobart, Tasmania, Australia. The treatment group was women requesting Implanon prior to discharge. Controls were recruited from the same unit over the same time period, with the aim to match for birth weight and parity. Information was collected during face-to-face interviews or via telephone contact. Multivariate survival analysis was used to investigate lochia duration.

RESULTS

There were 73 controls and 79 women who had early postpartum Implanon inserted. Fourteen (17.7%) patients in the treatment group had their Implanon removed during the postpartum study period. In all of these cases the reason for removal was bleeding disturbance - prolonged or intermittent vaginal bleeding beyond 50 days postpartum. There was no significant difference in duration of lochia between the groups [median predicted duration 25 days (95% CI 22-27) in controls and 24 days (95% CI 21-26) in the treatment group].

CONCLUSIONS

Early postpartum insertion of Implanon for contraception was not associated with a statistically or clinically significant difference in duration of lochia.

Lactation and contraception

PURPOSE OF REVIEW

This review examines evidence relevant to the effect of hormonal contraception on breastfeeding; and compares global and US recommendations for contraceptive initiation and use. Breastfeeding and use of postpartum contraception have high public health priority, making research in this area critical for optimizing guidance.

RECENT FINDINGS

High quality evidence remains limited with only a small number of well-conducted randomized controlled trials of hormonal methods and breastfeeding/neonatal growth outcomes. More evidence supports early initiation of progestin-only methods. Evidence on early initiation of combination hormonal methods is sparse.

SUMMARY

The WHO Medical Eligibility Criteria (MEC) differs from that of the US MEC. Generally, the WHO MEC is more restrictive, reflecting the potential greater impact on maternal child health if there is a negative impact from hormonal contraception on breastfeeding. Only well conducted clinical trials will further elucidate such an impact.

VIDEO ABSTRACT

http://links.lww.com/COG/A15.

Adolescent contraception: review and guidance for pediatric clinicians

The objectives of this article are to review current contraceptive methods available to adolescents and to provide information, guidance, and encouragement to pediatric clinicians to enable them to engage in informed up-to-date interactions with their sexually active adolescent patients. Pregnancy prevention is a complex and dynamic process, and young people benefit from having a reliable authoritative source for information, counseling, and support. Clinicians who provide services for adolescents have a responsibility to develop their skills and knowledge base so that they can serve as that source. This review begins with a discussion about adolescent sexuality and pregnancy in the context of the adolescent developmental stages. We discuss approaches to introduce the topic of contraception during the clinic visit and contraceptive counseling techniques to assist with the discussion around this topic. In addition, information is included regarding confidential services, support of parental involvement, and the importance of male involvement in contraception. The specific contraceptive methods are reviewed in detail with the adolescent patient in mind. For each method, we discuss the mechanism of action, efficacy, contraindications, benefits and risks from the medical perspective, advantages and disadvantages from the patient's perspective, side effects, patient adherence, patient counseling, and any medication interactions. Furthermore, we have included a section that focuses on the contraceptive management for the adolescent patient with a disability and/or chronic illness. The article concludes with an approach to frequently asked or difficult questions. This section largely summarizes subsections on specific contraceptive methods and can be used as a quick reference on particularly challenging topics. Finally, a list of useful contraceptive management resources is provided for both clinicians and patients.

The synthetic gestagen levonorgestrel impairs metamorphosis in Xenopus laevis by disruption of the thyroid system

Synthetic gestagens, including levonorgestrel (LNG), are active compounds in contraceptives, and several studies report their occurrence in surface waters. However, information about endocrine-disrupting effects in nontarget organisms is scarce. The present study investigated effects of LNG exposure on thyroid hormone-dependent metamorphosis of Xenopus laevis. Premetamorphic X. laevis tadpoles at Nieuwkoop and Faber (NF) stage 48 were exposed in a flow-through culture system to four LNG concentrations (10(-11), 10(-10), 10(-9), and 10(-8)M) over the period of metamorphosis. At NF 58 and 66, tadpoles were examined sex specifically. Developmental time and organismal responses were recorded and correlated with molecular and histopathological endpoints. Exposure to 10(-8)M LNG caused an inhibition of metamorphosis resulting in developmental arrest at early climax stages as giant tadpoles or tailed frogs. In brain-pituitary tissue of NF 58 tadpoles, gene expression of thyroid-stimulating hormone (β-subunit; TSHβ), TH receptor β (TRβ), and deiodinase type 3 (D3) was not changed. Instead, prolactin (PRL) messenger RNA (mRNA) was significantly increased by 10(-9)M LNG in females and by 10(-8)M LNG in both sexes. In NF 66 tadpoles, mRNA levels of TSHβ mRNA were significantly increased in the 10(-9) and 10(-8)M LNG treatment groups indicating a hypothyroid state. No changes of TRβ, D3, and PRL gene expression were detected. Histopathological evaluation of thyroid gland sections revealed no typical sign of hypothyroidism but rather an inactivated appearance of the thyroid. In conclusion, our data demonstrate for the first time a completely new aspect of thyroid system disruption caused by synthetic gestagens in developing amphibians.

Levonorgestrel pharmacokinetics in plasma and milk of lactating women who take 1.5 mg for emergency contraception

BACKGROUND

Progestin-only methods are among the contraceptive options available for breastfeeding women, however the doses of progestin used in emergency contraception (EC) have not been evaluated in nursing mothers. We therefore investigated the pharmacokinetics of 1.5 mg levonorgestrel (LNG) in lactating women.

METHODS

Twelve healthy exclusively breastfeeding volunteers received 1.5 mg LNG. Women refrained from nursing for 72 h after dosing and fed their infants with milk frozen beforehand. Serial blood and milk samples were collected for 120 h and assayed for LNG and sex hormone binding globulin.

RESULTS

LNG concentrations peaked in plasma and in milk 1-4 h and 2-4 h after dosing, respectively. Concentrations in milk (M) paralleled those in plasma (P) but were consistently lower (mean M:P ratio 0.28). Estimated infant exposure to LNG is 1.6 microg on the day of dosing (1 microg in the first 8 h), 0.3 microg on the second day and 0.2 microg on the third day.

CONCLUSIONS

Nursing mothers may need EC. These results suggest that to limit infant exposure to the period of maximum LNG excretion in milk, mothers should discontinue nursing for at least 8 h, but not more than 24 h, after EC.

Clinical experience and acceptability of the etonogestrel subdermal contraceptive implant

OBJECTIVE

To evaluate efficacy, adverse effects, and user continuation rate of an etonogestrel subdermal single-rod contraceptive implant.

METHODS

A total of 417 healthy volunteers of childbearing age were included in this multicenter trial. After implant insertion, the women were followed up during the 3 years of contraceptive action. At each visit, clinical findings, side effects, and bleeding patterns were recorded. Efficacy and continuation rates were analyzed using the Pearl Index and Kaplan-Meier life tables, respectively.

RESULTS

The observation period totaled 958.5 woman-years (27.5 months per woman). The Pearl Index score was 0. Side effects were reported by 44.4% of users, but the proportion had decreased to 16.5% by the end of the study. The continuation rate was 61.4%. The most common reason for early discontinuation (in 21.1% of the participants) was menstrual disturbances.

CONCLUSIONS

Etonogestrel subdermal contraceptive implants demonstrated high efficacy and an acceptable continuation rate. Counseling potential users explicitly about the side effects will optimize patient success with this long-acting contraceptive.

A comparative study of the levonorgestrel-releasing intrauterine system Mirena versus the Copper T380A intrauterine device during lactation: breast-feeding performance, infant growth and infant development

BACKGROUND

Mirena is a levonorgestrel-releasing intrauterine system (LNG-IUS) that provides highly effective and long-acting progestogen-only contraception.

OBJECTIVE

The objective of this study was to analyze the possible effects of using LNG-20 microg IUS on breast-feeding performance, infant growth and infant development during the first postpartum year as compared with the Copper T380A intrauterine device (Cu T380A IUD).

DESIGN

This study is a prospective, controlled and randomized trial.

SETTING

The study was conducted at the Department of Obstetrics and Gynecology, Assiut University Hospital, Egypt.

METHODS

Three hundred twenty lactating women asking for initiation of contraception during the early postpartum stage were assigned randomly into two groups, the LNG-20 microg IUS group (n=163) and the Cu T380A group (n=157). The insertions were done 6-8 weeks postpartum. Each participant was followed up at three monthly intervals after insertion and until the first birthday of her baby. During these visits, the breast-feeding pattern was assessed, certain infant physical growth parameters were measured and a set of infant development tests was performed.

RESULTS

No pregnancy occurred in both groups. There were no significant differences in the net continuation rates between the two groups (89.3 for LNG-IUS vs. 90.9 for Cu T380A). The LNG-20 microg IUS group had comparable rates of breast-feeding continuation, complete weaning, full breast-feeding and partial breast-feeding, with the Cu-IUD group. No statistically significant differences were found between groups with regard to all infant physical growth parameters and various infant development tests.

CONCLUSION

The findings of the current study confirm that the use of LNG-20 microg IUS during the first postpartum year in lactating women provides highly effective and acceptable contraception and does not negatively influence breast-feeding or the growth and development of breast-fed infants.

Two-year performance of a Nestorone®-releasing contraceptive implant: a three-center study of 300 women

A 2-year trial of a single Nestorone (NES) rod implant was conducted at three Latin American centers, each enrolling 100 women. We studied the safety, effectiveness and acceptability of this progestin-releasing contraceptive implant. Three pregnancies occurred, the last at 18 months of use. Because no pregnancies were expected in the first 18 months, the trial was halted. At that time, 224 women had completed at least 18 months of use, and 99 women had used the implant for more than 24 months. Few participants used adjunctive contraception between the time the study was halted and the time they had their implant removed. No additional pregnancies occurred before the removal of the last implant. The 2-year cumulative pregnancy rate was 1.7 per 100 with a Pearl index of 0.6 per 100 for the 2-year period. The 1-year and 2-year continuation rates were 80.5 and 66.7 per 100, respectively. Menstrual and medical disturbances were the principal reasons for discontinuation, followed by planned pregnancy. Headache and weight gain frequently led to discontinuation. The NES implant had little important effect on most clinical chemistry and lipid parameters. Over the study course, the mean change in hemoglobin was <1%. Slight modification of the design of this single 2-year implant, restoring features previously examined in clinical trials, is likely to improve its effectiveness. A single NES implant appears to provide acceptable contraception for women.

Risks and benefits, advantages and disadvantages of levonorgestrel-releasing contraceptive implants

Levonorgestrel-releasing implants are long acting contraceptives, approved for 5 years of continuous use. Two marketed systems, the six capsule Norplant use of tradenames is for product identification purposes only and does not imply endorsement. and the two rod Jadelle, have essentially equal rates of drug release, pregnancy and adverse events over 5 years of use. Randomised clinical trials and controlled cohort observations indicate that for the first 3 years, when pregnancy rates are at or almost zero, no other contraceptive system is more effective, although etonogestrel implants provide equal effectiveness. Annual pregnancy rates rise in the fifth year of continuous use but remain below 1 per 100 women. Annual pregnancy rates of Norplant users remain below 1 per 100 throughout 7 years of continuous use. Levonorgestrel implants provide low progestogen doses; 40-50 microg/day at 1 year of use, decreasing to 25-30 microg/day in the fifth year. Serum levels of levonorgestrel at 5 years are 60-65% of those levels measured at 1 month of use. Adverse effects with levonorgestrel implants are similar to those observed with progestogen only and combined oral contraceptives. Risks of ectopic pregnancy, other pregnancy complications and pelvic inflammatory disease are reduced in comparison with those of women using copper or non-medicated intrauterine devices. Risks of developing gallbladder disease and hypertension or borderline hypertension, although small, are about 1.5 and 1.8 times greater, respectively, in women using levonorgestrel implants than in women not using hormonal contraception. Other serious diseases have not been found to occur significantly more frequently in levonorgestrel implant users than in women not using hormonal contraception. The great majority of levonorgestrel implant users experience menstrual problems, but serious bleeding problems are not more frequent than in controls. Other health problems reported more frequently by levonogestrel implant users than by women not using hormonal contraception in a study of 16000 women included skin conditions, headache, upper limb neuropathies, dizziness, nervousness, malaise, minor visual disturbances, respiratory conditions, arthropathies, weight change, anxiety and non-clinical depression. Clinical depression is not more frequent in women using implants compared with those not using hormonal contraception (i.e. using intrauterine devices, sterilisation). Removal problems occur less frequently with Jadelle than with Norplant. The mean removal time for Jadelle is half that of Norplant. Levonorgestrel implants in nationally representative scientific samples, in randomised trials, and in controlled cohort studies have continuation rates as high as or higher than any other reversible contraceptive over a duration of 5 years. This would imply that the satisfaction women derive from the contraceptive effectiveness of levonorgestrel implants greatly outweighs the dissatisfaction that may accompany menstrual disturbances and other adverse effects associated with implants.

Adverse drug reactions in breastfed infants: less than imagined

Medication use during breastfeeding shortens the duration of breastfeeding often because of overly cautious information given by healthcare providers. No comprehensive review of the literature on infant adverse reactions from drugs in breastmilk has been published. All published studies and case reports on adverse events in infants caused by medications (excluding drugs of abuse) in breastmilk were identified and analyzed. Of 100 case reports evaluated, none were considered to be "definite" using a standard ranking scale; 47% were "probable" and 53% were "possible." Drugs with central nervous system activity accounted for half of all reports. All 3 reported fatalities involved central nervous system depressants, but each had extenuating circumstances. At least 63% of reported cases were in neonates and 78% were in infants 2 months or younger; only 4% of adverse reactions occurred in infants older than 6 months of age. Published studies expand on and generally reinforce the analysis of case reports. By taking a few simple precautions in drug selection and considering the infant's age, breastfeeding rarely needs to be discouraged or discontinued when a mother needs drug therapy.