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Curtis KM, Nguyen AT, Tepper NK, Zapata LB, Snyder EM, Hatfield-Timajchy K, Kortsmit K, Cohen MA, Whiteman MK. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep 2024; 73:1-77. [PMID: 39106301 DOI: 10.15585/mmwr.rr7303a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2024] Open
Abstract
The 2024 U.S. 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.
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Affiliation(s)
- Kathryn M Curtis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Antoinette T Nguyen
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Naomi K Tepper
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Lauren B Zapata
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Emily M Snyder
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Kendra Hatfield-Timajchy
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Katherine Kortsmit
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Megan A Cohen
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Maura K Whiteman
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
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Rocca ML, Palumbo AR, Visconti F, Di Carlo C. Safety and Benefits of Contraceptives Implants: A Systematic Review. Pharmaceuticals (Basel) 2021; 14:548. [PMID: 34201123 PMCID: PMC8229462 DOI: 10.3390/ph14060548] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 12/11/2022] Open
Abstract
Progestin-only contraceptive implants provide long-acting, highly effective reversible contraception. We searched the medical publications in PubMed, CENTRAL, and EMBASE for relevant articles on hormonal implants published in English between 1990 and 2021. Levonorgestrel (LNG) 6-capsule subdermal implants represented the first effective system approved for reversible contraception. The etonogestrel (ENG) single rod dispositive has been widely employed in clinical practice, since it is a highly effective and safe contraceptive method. Abnormal menstrual bleeding is a common ENG side effect, representing the main reason for its premature discontinuation. Emerging evidence demonstrated that it is possible to extend the use of the ENG implant beyond the three-year period for which it is approved. The ENG implant could be an effective and discrete alternative to the IUD in young girls, such as post-partum/post-abortion. Implants should be inserted by trained skilled clinicians who previously provide adequate counselling about their contraceptive effect, benefits, and any possible adverse events. More studies are needed to validate the extended use of the ENG implant for up to 5 years.
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Affiliation(s)
- Morena Luigia Rocca
- Operative Unit of Obstetric and Gynaecology, Pugliese-Ciaccio Hospital, 88100 Catanzaro, Italy
| | - Anna Rita Palumbo
- Department of Obstetrics and Gynaecology, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.R.P.); (F.V.); (C.D.C.)
| | - Federica Visconti
- Department of Obstetrics and Gynaecology, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.R.P.); (F.V.); (C.D.C.)
| | - Costantino Di Carlo
- Department of Obstetrics and Gynaecology, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.R.P.); (F.V.); (C.D.C.)
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FSRH Guideline (February 2021) Progestogen-only Implant. BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:1-62. [PMID: 33593815 DOI: 10.1136/bmjsrh-2021-chc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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Abstract
Unintended teen pregnancy continues to be a problem in the United States which has the highest rate of adolescent pregnancy among developed nations. Long-acting reversible contraception (LARC) has much higher continuation rates compared with moderately effective reversible contraception; however, moderately effective reversible contraception is more commonly used by adolescents. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend LARC as first-line contraception for adolescents. Clinicians providing contraception to adolescents should be knowledgeable of LARC indications, side effects, initiation guidelines, management of adverse reactions, and adolescent specific issues regarding LARC counseling, initiation, and continuation.
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Concepcion K, Lacey S, McGeechan K, Estoesta J, Bateson D, Botfield J. Cost–benefit analysis of enhancing the uptake of long-acting reversible contraception in Australia. AUST HEALTH REV 2020; 44:385-391. [DOI: 10.1071/ah18190] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 07/08/2019] [Indexed: 11/23/2022]
Abstract
Objective
Long-acting reversible contraception (LARC) is the most effective form of reversible contraception, but its use in Australia is low compared with other countries. The aim of this study was to evaluate the economic effect of an increase in LARC uptake to international rates.
Methods
An economic model was designed to assess two scenarios, namely increasing the current rate of LARC uptake of 12.5% to the international benchmark of 14.8% among: (1) women currently using the oral contraceptive pill (OCP); and (2) women at risk of pregnancy and not using contraception. Model inputs included cost of contraceptive methods, discontinuation rates and abortion and miscarriage costs associated with unintended pregnancies.
Results
Women who switch from an OCP to LARC would save A$114–157 per year. Those not currently using any contraception who adopt LARC would incur costs of A$36–194 per year, but would reap savings from the reduction in unintended pregnancies. Over 5 years there would be a net saving of A$74.4 million for Scenario 1 and A$2.4 million for Scenario 2.
Conclusion
Greater use of LARC would result in a net gain in economic benefits to Australia. These benefits are largely driven by women switching from an OCP to LARC who have reduced costs, as well as women wishing to avoid pregnancy who choose to use LARC rather than no method. This evidence will support women making an informed contraceptive choice and policy makers in increasing the accessibility of LARC.
What is known about the topic?
LARC is the most effective form of reversible contraception, but uptake in Australia is relatively low.
What does this paper add?
There are economic benefits to society for women who switch from an OCP to LARC, as well as for women who switch from no contraception to LARC.
What are the implications for practitioners?
The findings of this study will support women in making an informed contraceptive choice and policy makers in increasing the accessibility of LARC.
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ACOG Committee Opinion No. 735: Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Obstet Gynecol 2018; 131:e130-e139. [DOI: 10.1097/aog.0000000000002632] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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7
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Bleeding Associated with Hormonal Contraceptives: Understanding and Managing a Common Problem. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0219-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zigler RE, McNicholas C. Unscheduled vaginal bleeding with progestin-only contraceptive use. Am J Obstet Gynecol 2017; 216:443-450. [PMID: 27988268 DOI: 10.1016/j.ajog.2016.12.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/29/2016] [Accepted: 12/07/2016] [Indexed: 10/20/2022]
Abstract
Nearly 20% of women using contraception are using progestin-only contraception, including progestin-only pills, depot-medroxyprogesterone acetate, subdermal etonogestrel implants, and levonorgestrel intrauterine devices. This number will continue to grow with the increased provision of long-acting reversible contraception. Although overall satisfaction among women using progestin-only contraception is high, dissatisfaction and discontinuation may be associated with unscheduled bleeding and spotting. The exact etiology of irregular bleeding associated with progestin-containing contraceptives is not completely understood, yet several mechanisms have been suggested. Several therapies targeting these mechanisms have been evaluated with mixed results. This paper will review the physiology and management of unscheduled bleeding with progestin-containing contraceptives.
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Unscheduled Bleeding on Hormonal Contraceptives: Pathophysiology, Evaluation, and Management Options. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0210-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hou MY, McNicholas C, Creinin MD. Combined oral contraceptive treatment for bleeding complaints with the etonogestrel contraceptive implant: a randomised controlled trial. EUR J CONTRACEP REPR 2016; 21:361-6. [PMID: 27419258 DOI: 10.1080/13625187.2016.1210122] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Estimate symptom improvement rate of women with bleeding complaints using the etonogestrel contraceptive implant when started on continuous combined oral contraceptives (COC). METHODS We conducted a double-blinded randomised controlled trial of women reporting troublesome bleeding related to their etonogestrel contraceptive implant and desiring intervention. Participants received continuous COCs or placebo for four weeks to evaluate self-reported bleeding improvement at four weeks. Participants could continue study treatment or prescribed COCs for another eight weeks if desired. We planned to enroll 130 participants between two sites (80% power to detect a 20% effect size at a 0.05 significance level, with 10% loss to follow up). RESULTS We closed the study after enrolling 26 participants due to recruitment futility. All women on COCs and 75% of placebo users reported bleeding improvement at four weeks (p = 0.09), with 92% and 42%, respectively, reporting significant improvement (p = 0.03). The median number of days until bleeding stopped for at least four days in COC and placebo users was 1 day (range 1-9) and 4.5 days (range 1-28), respectively (p = 0.63). Eight (75%) COC and five (42%) placebo users opted to continue study treatment (p = 0.41). Despite bleeding improvement, women who desired implant removal at enrollment were more likely to re-request removal than those who initially considered other interventions (3 of 5 [60%] vs 1 of 17 [6%], p = 0.03). CONCLUSION Although women who have troublesome bleeding while using the contraceptive implant may experience improvement with no treatment over 4 weeks, women using COCs are more likely to report significant improvement. Clinicaltrials.gov registration number: NCT01963403.
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Affiliation(s)
- Melody Y Hou
- a Department of Obstetrics and Gynecology , University of California, Davis , Sacramento , CA , USA
| | - Colleen McNicholas
- b Department of Obstetrics and Gynecology , Washington University in St. Louis School of Medicine , St. Louis , MO , USA
| | - Mitchell D Creinin
- a Department of Obstetrics and Gynecology , University of California, Davis , Sacramento , CA , USA
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Inoue K, Kelly M, Barratt A, Bateson D, Rutherford A, Black KI, Stewart M, Richters J. Australian women's attitudes towards and understandings of the subdermal contraceptive implant: a qualitative study of never-users. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2016; 43:128-134. [DOI: 10.1136/jfprhc-2014-101132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 01/20/2016] [Accepted: 01/31/2016] [Indexed: 11/04/2022]
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Friedlander E, Kaneshiro B. Therapeutic Options for Unscheduled Bleeding Associated with Long-Acting Reversible Contraception. Obstet Gynecol Clin North Am 2015; 42:593-603. [DOI: 10.1016/j.ogc.2015.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Dobromilsky KC, Allen PL, Raymond SH, Maindiratta B. A prospective cohort study of early postpartum etonogestrel implant (Implanon®) use and its effect on duration of lochia. ACTA ACUST UNITED AC 2015; 42:187-93. [PMID: 26545933 DOI: 10.1136/jfprhc-2014-101081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 10/11/2015] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Kim C Dobromilsky
- Accredited Registrar, Department of Obstetrics and Gynaecology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Penny L Allen
- Research Fellow, Rural Clinical School, The University of Tasmania, Burnie, Tasmania, Australia
| | - Stephen H Raymond
- Staff Specialist, Department of Obstetrics and Gynaecology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Bhavna Maindiratta
- Resident Medical Officer, Department of Obstetrics and Gynaecology, Royal Hobart Hospital, Hobart, Tasmania, Australia
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Kaneshiro B, Edelman A, Dash C, Pandhare J, Soli FM, Jensen JT. Effect of oral contraceptives and doxycycline on endometrial MMP-2 and MMP-9 activity. Contraception 2015; 93:65-9. [PMID: 26408375 DOI: 10.1016/j.contraception.2015.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 09/01/2015] [Accepted: 09/17/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the effect of combined oral contraceptives (COCs) on matrix metalloproteinases MMP-2 and MMP-9 activity and compare MMP activity in women taking a COC with or without doxycycline. STUDY DESIGN Subjects (n=20) underwent endometrial biopsies (1) in the late luteal phase of a baseline cycle prior to initiating COCs, (2) on days 19-21 while taking COCs in a standard 28-day cycle (7-day hormone-free interval) and (3) on days 26-28 while taking active COCs continuously for a 28-day cycle. During the continuous COC cycle, they were randomized to receive daily subantimicrobial dose doxycycline 40mg or placebo. RESULTS Compared to baseline, COC treatment increased MMP-2 (p<.001) and MMP-9 (p<.001). MMP activity was lower in subjects taking a COC with doxycycline compared to those receiving placebo although only significantly lower for MMP-2 latent form (p=.002). CONCLUSIONS Unscheduled bleeding with COCs may be the result of increased endometrial MMPs. Sample size limitations prevent us from determining how doxycycline affects MMP activity in COC users.
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Affiliation(s)
- Bliss Kaneshiro
- John A. Burns School of Medicine, University of Hawaii at Manoa, 1319 Punahou Street, Suite 824, Honolulu, HI 96826, USA.
| | - Alison Edelman
- Oregon Health & Science University, 3181 SW Sam Jackson Park Road, UHN 50, Portland, OR 97239, USA
| | - Chandravanu Dash
- Meharry Medical College, 1005 Dr. D. B. Todd Jr. Boulevard, Suite 5131, Nashville, TN 37208, USA
| | - Jui Pandhare
- Meharry Medical College, 1005 Dr. D. B. Todd Jr. Boulevard, Suite 5131, Nashville, TN 37208, USA
| | - Faapisa M Soli
- RMATRIX, John A. Burns School of Medicine, University of Hawaii at Manoa, 651 Ilalo Street, Medical Education Building, Office of the Dean, 2nd Floor, Honolulu, HI 96813, USA
| | - Jeffrey T Jensen
- Oregon Health & Science University, 3181 SW Sam Jackson Park Road, UHN 50, Portland, OR 97239, USA
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Short-Term Treatment of Bothersome Bleeding for Etonogestrel Implant Users Using a 14-Day Oral Contraceptive Pill Regimen. Obstet Gynecol 2015; 126:508-513. [DOI: 10.1097/aog.0000000000000974] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nelson AL. Investigational hormone receptor agonists as ongoing female contraception: a focus on selective progesterone receptor modulators in early clinical development. Expert Opin Investig Drugs 2015; 24:1321-30. [PMID: 26289789 DOI: 10.1517/13543784.2015.1076791] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION As efforts are made to continue to increase the safety of contraceptive methods, those without estrogen have attracted new attention. Progestin-only options are available in many delivery systems, but most cause disturbed bleeding patterns. For gynecologic patients, selective progesterone receptor modulators (SPRMs) have been approved for medical abortion, for ovulation suppression in emergency contraception, and for the treatment of heavy menstrual bleeding due to leiomyoma. AREAS COVERED This article discusses the role of SPRMs in controlling fertility on an ongoing basis with particular emphasis on mifepristone and ulipristal acetate (UPA), since none of the other compounds has progressed out of early Phase I - II testing. It also discusses important information about the mechanisms of action and safety of these two SPRMs. EXPERT OPINION Of all the investigational hormone agonist/antagonists, SPRMs have demonstrated the greatest potential as ongoing female contraceptives. They have the ability to suppress ovulation after initiation of the luteinizing hormone (LH) surge without affecting ovarian production of estrogen or inducing any significant metabolic changes. SPRMs may well be able to provide longer term contraception as oral agents, vaginal rings, and perhaps even intrauterine devices. UPA has the greatest promise. Current research needs to be expanded.
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Affiliation(s)
- Anita L Nelson
- a Los Angeles BioMedical Research Institute, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Department of Obstetrics and Gynecology , 1457 3rd Street, Manhattan Beach, CA 90266, USA +1 310 937 7226 ; +1 310 937 1416 ;
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Ouzounian S, Verstraete L, Chabbert-Buffet N. Third-generation oral contraceptives: future implications of current use. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.3.2.189] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Spitz IM. Progesterone receptor antagonists and selective progesterone receptor modulators: proven and potential clinical applications. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.2.2.227] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Subdermale kontrazeptive Implantate. GYNAKOLOGISCHE ENDOKRINOLOGIE 2013. [DOI: 10.1007/s10304-012-0536-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abdel-Aleem H, d'Arcangues C, Vogelsong KM, Gaffield ML, Gülmezoglu AM. Treatment of vaginal bleeding irregularities induced by progestin only contraceptives. Cochrane Database Syst Rev 2013:CD003449. [PMID: 23828544 DOI: 10.1002/14651858.cd003449.pub4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite their high effectiveness, progestin-only contraceptives are considered less than ideal by the many women who experience irregular vaginal bleeding when using them. Current treatments to control these bleeding problems are not sufficiently effective. OBJECTIVES We evaluated preventive and therapeutic approaches to normalise bleeding irregularities associated with the use of progestin-only contraceptives. SEARCH METHODS Literature was identified through database searches, reference lists, organisations and individuals, covering the period until May-June 2012. SELECTION CRITERIA Trials with random or systematic allocation, testing interventions for the prevention or treatment of bleeding irregularities associated with the use of progestin-only contraceptives were eligible. DATA COLLECTION AND ANALYSIS Results are expressed as relative risks (RR) with 95% confidence interval (CI) for categorical data and as weighted mean difference (WMD) with 95% CI for continuous data. When we encountered heterogeneity (visual or statistical) we used the random-effects model (quantitative) or did not produce a summary estimate (qualitative). MAIN RESULTS Thirty-three randomised controlled trials enrolling 3677 participants were included. Two thirds of the trials were determined to reflect low to moderate risk of bias.Estrogen treatments reduced the number of days of an ongoing bleeding episode in DMPA and Norplant users. However, treatment frequently led to more discontinuation due to gastrointestinal upset.Combinations of oral ethinyl estradiol and levonorgestrel improved bleeding patterns in Norplant users, but method discontinuation rates were unchanged. One trial reported successful use of combined oral contraceptives in treating amenorrhea among DMPA users.Norplant users, but not Implanon users, administered the anti-progestin mifepristone reported fewer days of bleeding during treatment than those given placebo. Mifepristone used monthly by new Norplant acceptors reduced bleeding, when compared to placebo.A variety of NSAIDS have been evaluated for their ability to treat abnormal bleeding, with mixed results.Norplant users receiving SERM (tamoxifen) had less unacceptable bleeding after treatment and were more likely to continue using Norplant than those receiving placebo.Tranexamic acid, mifepristone combined with an estrogen and doxycycline were more effective than placebo in terminating an episode of bleeding in women using progestin-only contraceptives, according to three small studies. AUTHORS' CONCLUSIONS Some women may benefit from the interventions described, particularly with cessation of current bleeding. Several regimens offer promise in regulating bleeding, but findings need to be reproduced in larger trials. The results of this review do not support routine clinical use of any of the regimens included in the trials, particularly for long-term effect.
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Affiliation(s)
- Hany Abdel-Aleem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University Hospital, Assiut, Egypt.
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Hartman LB, Monasterio E, Hwang LY. Adolescent contraception: review and guidance for pediatric clinicians. Curr Probl Pediatr Adolesc Health Care 2012; 42:221-63. [PMID: 22959636 DOI: 10.1016/j.cppeds.2012.05.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 05/11/2012] [Accepted: 05/23/2012] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Lauren B Hartman
- Division of Adolescent Medicine, Department of Pediatrics, University of California, San Francisco, CA, USA
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Palomba S, Falbo A, Di Cello A, Materazzo C, Zullo F. Nexplanon: the new implant for long-term contraception. A comprehensive descriptive review. Gynecol Endocrinol 2012; 28:710-21. [PMID: 22339096 DOI: 10.3109/09513590.2011.652247] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Nexplanon(®) is a new long-term reversible contraception method. The current review is aimed to analyze the published data concerning the contraceptive effectiveness of Nexplanon(®) and its effects on reproductive function. Pharmacological properties and technical procedures of insertion and removal, as well as the efficacy and safety data available, were discussed. Possible strategies for treating Nexplanon(®)-related bleeding were also described. With regard to the future research and the future scientific developments of contraceptive implants, the possible use of Nexplanon(®) wide-ranging for the symptomatic treatment of endometriosis and premenstrual syndrome (PMS) were considered. Finally, it was defined in which women the use of Nexplanon(®) is indicated and in which it is contra-indicated.
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Affiliation(s)
- Stefano Palomba
- Department of Obstetrics & Gynaecology, University "Magna Graecia" of Catanzaro, Viale Europa, Catanzaro, Italy.
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Abdel-Aleem H, Shaaban OM, Abdel-Aleem MA, Fetih GN. Doxycycline in the treatment of bleeding with DMPA: a double-blinded randomized controlled trial. Contraception 2012; 86:224-30. [PMID: 22325113 DOI: 10.1016/j.contraception.2012.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Revised: 01/04/2012] [Accepted: 01/04/2012] [Indexed: 10/28/2022]
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Nelson AL. New frontiers in female contraception (and male condoms): 2012. Expert Opin Investig Drugs 2012; 21:677-93. [DOI: 10.1517/13543784.2012.679342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Anita L Nelson
- Harbor UCLA Medical Center,
1457 3rd Street, Manhattan Beach, CA 90266, USA ;
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Weisberg E, Croxatto HB, Findlay JK, Burger HG, Fraser IS. A randomized study of the effect of mifepristone alone or in conjunction with ethinyl estradiol on ovarian function in women using the etonogestrel-releasing subdermal implant, Implanon®. Contraception 2011; 84:600-8. [DOI: 10.1016/j.contraception.2011.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 03/14/2011] [Accepted: 04/13/2011] [Indexed: 10/18/2022]
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The management of unacceptable bleeding patterns in etonogestrel-releasing contraceptive implant users. Contraception 2011; 83:202-10. [DOI: 10.1016/j.contraception.2010.08.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 08/02/2010] [Accepted: 08/02/2010] [Indexed: 11/20/2022]
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Contraception hormonale. Contraception 2011. [DOI: 10.1016/b978-2-294-70921-0.00006-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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28
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Implanon: A Review of the Literature With Recommendations for Clinical Management. J Midwifery Womens Health 2010; 54:142-9. [DOI: 10.1016/j.jmwh.2008.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Revised: 09/16/2008] [Accepted: 09/16/2008] [Indexed: 11/22/2022]
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Spitz IM. Mifepristone: where do we come from and where are we going? Contraception 2010; 82:442-52. [DOI: 10.1016/j.contraception.2009.12.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2009] [Accepted: 12/15/2009] [Indexed: 01/08/2023]
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Treatment of unscheduled bleeding in continuous oral contraceptive users with doxycycline: a randomized controlled trial. Obstet Gynecol 2010; 115:1141-1149. [PMID: 20502283 DOI: 10.1097/aog.0b013e3181e0119c] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate whether doxycycline, a matrix metalloproteinase inhibitor, would decrease unscheduled bleeding associated with initiation of a continuous oral contraceptive pill. METHODS Participants initiating a continuous oral contraceptive pill (20 micrograms of ethinyl estradiol/90 micrograms of levonorgestrel) were randomly assigned to receive either doxycycline (100 mg orally twice daily) or placebo taken for 5 days at the onset of each bleeding or spotting episode during the first 84 days of the study period. For the final 28 days of the study, participants were observed on the oral contraceptive pill alone. The primary outcome was the number of bleeding and spotting days. A sample size of 66 (33 in each arm) was calculated to detect a 50% reduction in bleeding (beta=0.80, alpha=0.05) and accounted for a 30% dropout rate. RESULTS Sixty-six women were randomly assinged (33 in each study group). There were no significant differences during the 84-day treatment in bleeding or spotting days (doxycycline [mean {standard error}, placebo, P=.32) or the length of the longest bleeding or spotting episode (doxycycline, placebo, P=.70) between study groups. Similarly, no significant differences in bleeding patterns existed between groups during the final 28 days. CONCLUSION Doxycycline, administered once bleeding has started, does not decrease unscheduled bleeding or shorten episodes of unscheduled bleeding in continuous oral contraceptive pill users. LEVEL OF EVIDENCE I.
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Hussein M. Transvaginal Doppler sonography for evaluation of irregular uterine bleeding with DMPA. Arch Gynecol Obstet 2010; 283:1325-8. [PMID: 20582427 DOI: 10.1007/s00404-010-1569-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 06/15/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND The main cause for discontinuation of depot medroxyprogesterone acetate (DMPA) use is irregular menstrual bleeding. The exact pathophysiological mechanisms of irregular bleeding have remained unclear. Transvaginal Doppler is a non-invasive method for studying changes in blood flow which may highlight the underlying pathology in those cases with irregular uterine bleeding. The aim of this study was to quantify the uterine and subendometrial microvasculature in DMPA users with irregular bleeding pattern in comparison to DMPA users with amenorrhea. STUDY DESIGN This is a case control study. Forty users of DMPA were divided into two groups: one group included 20 users with irregular uterine bleeding and the second group included 20 amenorrheic users. Pulsatility index (PI) and resistance index (RI) of uterine and subendometrial blood vessels were determined. Power Doppler Energy was used to quantify the signal percentage of the subendometrial area. RESULTS There is significant reduction of PI and RI in the uterine artery and subendometrial microvasculature in cases of irregular uterine bleeding. CONCLUSION Irregular uterine bleeding with DMPA associated with increased perfusion of uterine and subendometrial blood vessels.
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Affiliation(s)
- Mostafa Hussein
- Obstetrics and Gynecology Department, Woman's Health Center, Assiut University Hospitals, Assiut, Egypt.
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Kovalevsky G, Ballagh SA, Stanczyk FZ, Lee J, Cooper J, Archer DF. Levonorgestrel effects on serum androgens, sex hormone–binding globulin levels, hair shaft diameter, and sexual function. Fertil Steril 2010; 93:1997-2003. [DOI: 10.1016/j.fertnstert.2008.12.095] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 10/29/2008] [Accepted: 12/18/2008] [Indexed: 11/26/2022]
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Warner P, Guttinger A, Glasier AF, Lee RJ, Nickerson S, Brenner RM, Critchley HOD. Randomized placebo-controlled trial of CDB-2914 in new users of a levonorgestrel-releasing intrauterine system shows only short-lived amelioration of unscheduled bleeding. Hum Reprod 2010; 25:345-53. [PMID: 19897857 PMCID: PMC2806180 DOI: 10.1093/humrep/dep377] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The levonorgestrel-releasing intrauterine system (LNG-IUS) is a highly effective contraceptive. However, during early months of use unscheduled vaginal bleeding is common, sometimes leading to discontinuation. This study aimed to determine whether intermittent administration of progesterone receptor modulator CDB-2914 would suppress unscheduled bleeding during the first 4 months after insertion of the LNG-IUS. METHODS CDB-2914 150 mg, in divided doses, or placebo tablets, were administered over three consecutive days starting on Days 21, 49 and 77 after LNG-IUS insertion, in a double-blind randomized controlled trial of women aged 19-49 years, newly starting use of LNG-IUS. Daily bleeding diaries were completed for 6 months, and summarized across blocks as percentage days bleeding/spotting (BS%). RESULTS Of 69 women randomized to receive CDB-2914, and 67 placebo, 61 and 55, respectively, completed the trial. BS% decreased with time in both arms, but showed a much steeper treatment-phase gradient in the placebo arm (P < 0.0001), so that a benefit of CDB-2914 in the 28 days after first treatment (-11% points, 95% CI -19 to -2), converted to a disadvantage by 64 days after the third treatment (+10% points, 95% CI 1-18). CONCLUSIONS The effect of CDB-2914 on BS% was initially beneficial but then by third treatment was disadvantageous. Nevertheless, only 3% (4/136) of all women discontinued LNG-IUS. These findings give insight into possible mechanisms and suggest future research directions. ISRCTN Trial no. ISRCTN58283041; EudraCT no. 2006-006511-72.
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Affiliation(s)
- P Warner
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh EH8 9AG, UK
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Hohmann H. Examining the efficacy, safety, and patient acceptability of the etonogestrel implantable contraceptive. Patient Prefer Adherence 2009; 3:205-11. [PMID: 19936163 PMCID: PMC2778430 DOI: 10.2147/ppa.s4299] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Indexed: 12/02/2022] Open
Abstract
Contraceptive implants provide long-acting, highly effective reversible contraception. The etonogestrel implant (ENG implant) is a single rod implant that offers three years of efficacy. The ENG implant was designed to provide contraceptive efficacy by inhibiting ovulation and Pearl Index scores reported for this method are similar to other long-acting reversible contraception as well as similar to sterilization. The implant has been shown to be safe during breast feeding and may improve symptoms of dysmenorrhea and endometriosis. Irregular bleeding patterns can be expected with the device's use and should be addressed in order to decrease rates of discontinuation.
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Affiliation(s)
- Heather Hohmann
- Correspondence: Heather Hohmann, University of Pittsburgh School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, 300 Halket Street, Pittsburgh, PA 15213, USA, Tel +1 412 641 1441, Fax +1 412 641 1133, Email
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Dane B, Akca A, Dane C, Evcimen S, Cetin A. Comparison of the effects of the levonorgestrel-releasing intrauterine system (Mirena®) and depot-medroxyprogesterone acetate (Depo-Provera®) on subendometrial microvascularisation and uterine artery blood flow. EUR J CONTRACEP REPR 2009; 14:240-4. [DOI: 10.1080/13625180902850047] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Mansour D, Korver T, Marintcheva-Petrova M, Fraser IS. The effects of Implanon® on menstrual bleeding patterns. EUR J CONTRACEP REPR 2009; 13 Suppl 1:13-28. [DOI: 10.1080/13625180801959931] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Weisberg E, Hickey M, Palmer D, O'Connor V, Salamonsen LA, Findlay JK, Fraser IS. A randomized controlled trial of treatment options for troublesome uterine bleeding in Implanon users. Hum Reprod 2009; 24:1852-61. [PMID: 19369294 DOI: 10.1093/humrep/dep081] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pilot data have indicated that both doxycycline alone and mifepristone combined with ethinyl estradiol (EE) are effective in stopping episodes of bleeding in Implanon users with troublesome bleeding. We compared four treatments against a placebo in Implanon users and tested whether repeated treatment improved subsequent bleeding patterns. METHOD Implanon users aged 18-45 years were randomized to treatment with (i) mifepristone 25 mg given twice on day 1 followed by 4 days of EE 20 microg; (ii) doxycycline 100 mg twice daily for 5 days; (iii) mifepristone 25 mg given twice on day 1 plus doxycycline 100 mg twice daily for 5 days; (iv) doxycycline 100 mg twice daily with EE 20 microg daily; and (v) placebo twice daily for 5 days. The primary end-point was the number of days of bleeding/spotting immediately following initiation of the first 5-day course of each therapy, compared with placebo. RESULTS There were 204 women assigned to treatment. Mifepristone in combination with either EE or doxycycline was significantly more effective in stopping an episode of bleeding (mean 4.0 days (CI 3.5-4.6) and 4.4 days (CI 3.8-5.2), respectively) than doxycycline alone or in combination with EE, or placebo (6.4 days (CI 4.4-9.2), 6.4 days (CI 4.8-8.6) and 6.4 days (CL 5.1-8.0), respectively). CONCLUSION Mifepristone combined with either EE or doxycycline was significantly more effective than placebo in terminating an episode of bleeding in Implanon users. However there was no improvement in subsequent bleeding patterns. TRIAL REGISTRATION NUMBER ACTR # 012605000206628.
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Affiliation(s)
- E Weisberg
- Sydney Centre for Reproductive Health Research, Research Division of Family Planning NSW, 328-336 Liverpool Road, Ashfield, Sydney, NSW 2131, Australia.
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Zhao S, Choksuchat C, Zhao Y, Ballagh SA, Kovalevsky GA, Archer DF. Effects of doxycycline on serum and endometrial levels of MMP-2, MMP-9 and TIMP-1 in women using a levonorgestrel-releasing subcutaneous implant. Contraception 2009; 79:469-78. [PMID: 19442784 DOI: 10.1016/j.contraception.2008.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 12/22/2008] [Accepted: 12/23/2008] [Indexed: 11/20/2022]
Abstract
BACKGROUND Endometrial spotting and/or bleeding (ESB) occurs in levonorgestrel subcutaneous implant (LNG SI) users. Matrix metalloproteinases (MMPs) may play a role in ESB. STUDY DESIGN Women between 18 and 40 years with regular menstrual cycles had a baseline evaluation followed by LNG SI insertion and randomization to doxycycline (DOX; 20 mg) or placebo (PL) twice a day. MMP-2, MMP-9 and tissue inhibitor of MMP-1 (TIMP-1) in serum and the endometrium were estimated at baseline and at 1, 3 and 6 months after insertion. RESULTS LNG increased serum MMP-9, while DOX decreased MMP-9 levels compared to PL after 1 month (p<.05). DOX decreased endometrial MMP-9 at 1 and 6 months compared to baseline and PL (p<.05). DOX increased endometrial TIMP-1 at 6 months compared with baseline and PL (p<.05). MMP-2 levels were unchanged. CONCLUSION LNG SI increased serum MMP-9 and TIMP-1 levels, while DOX decreased both serum and endometrial MMP-9 levels.
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Affiliation(s)
- Shumei Zhao
- Department of Obstetrics and Gynecology, CONRAD Clinical Research Center, Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, Norfolk, VA 23507, USA.
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Morison NB, Kaitu'u-Lino TJ, Fraser IS, Salamonsen LA. Stimulation of epithelial repair is a likely mechanism for the action of mifepristone in reducing duration of bleeding in users of progestogen-only contraceptives. Reproduction 2008; 136:267-74. [DOI: 10.1530/rep-08-0076] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Many women using progestogen (P)-only contraceptives experience uterine bleeding problems. In clinical trials, a single low dose of mifepristone, given to Implanon users at the beginning of a bleeding episode reduced the number of bleeding days by ∼50% compared with controls. In this study, a single dose of mifepristone was administered to etonogestrel (ENG)-exposed pseudo-pregnant mice, 5 days after artificial decidualization was induced when the endometrium showed signs of bleeding. Control mice received vehicle alone. Mice were culled 12-, 18-, 24- and 48-h post-treatment. In the continued presence of ENG, a single dose of mifepristone stimulated tissue breakdown followed by very rapid repair: most treated tissues were fully restored to the pre-decidualized state by 48 h post-treatment. During repair, proliferating cells (Ki67 immunostained) were localized to a band of cells around the basal area in breaking down tissues and to the repairing luminal epithelium and glands. Progesterone receptor-positive cells were largely localized to the basal area of the breaking down tissue in treated mice compared with decidual cells in controls. Oestrogen receptor-positive cells were observed in the repairing luminal epithelium and glands compared with the decidua and the basal region in control tissues. It is concluded that mifepristone treatment stimulates rapid restoration of luminal epithelial integrity: such action may be a key event in reducing the number of bleeding days observed in women using Implanon who were treated with a single dose of mifepristone.
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Archer DF, Philput CB, Levine AS, Cullins V, Stovall TG, Bacon J, Weber ME. Effects of ethinyl estradiol and ibuprofen compared to placebo on endometrial bleeding, cervical mucus and the postcoital test in levonorgestrel subcutaneous implant users. Contraception 2008; 78:106-12. [DOI: 10.1016/j.contraception.2008.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2008] [Revised: 04/07/2008] [Accepted: 04/14/2008] [Indexed: 11/29/2022]
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Hickey M, Salamonsen LA. Endometrial structural and inflammatory changes with exogenous progestogens. Trends Endocrinol Metab 2008; 19:167-74. [PMID: 18434186 DOI: 10.1016/j.tem.2008.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 02/11/2008] [Accepted: 02/20/2008] [Indexed: 01/06/2023]
Abstract
Safe and effective contraception is an international public health priority. The long-acting progestogen-only contraceptives are used by over 20 million women worldwide but their main drawback is abnormal uterine bleeding. Such bleeding arises owing to structural and inflammatory changes which compromise endometrial microvascular and epithelial integrity. The molecular and structural changes that lead to the vessel and surface epithelial fragility, and hence the side effect of abnormal uterine bleeding commonly seen with exogenous progestogen use, might be lessened by short-term treatments shown to shorten bleeding episodes.
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Affiliation(s)
- Martha Hickey
- School of Women's and Infants' Health, University of Western Australia, King Edward Memorial Hospital, Subiaco, WA, Australia
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Li A, Felix JC, Yang W, Jain JK. Effect of mifepristone on the expression of endometrial secretory leukocyte protease inhibitor in new medroxyprogesterone acetate users. Fertil Steril 2007; 90:872-5. [PMID: 18155704 DOI: 10.1016/j.fertnstert.2007.01.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Revised: 01/06/2007] [Accepted: 01/06/2007] [Indexed: 12/01/2022]
Abstract
The effect of mifepristone on the expression of secretory leukocyte protease inhibitor (SLPI) in the endometrium of women using depot medroxyprogesterone acetate (DMPA) was investigated in this randomized, placebo-controlled trial. The study showed that the administration of DMPA led to a substantial inhibition of endometrial SLPI protein and mRNA, and that the addition of mifepristone to DMPA-exposed endometrium partially restored the expression of glandular SLPI.
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Affiliation(s)
- Aimin Li
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA
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Abdel-Aleem H, d'Arcangues C, Vogelsong KM, Gülmezoglu AM. Treatment of vaginal bleeding irregularities induced by progestin only contraceptives. Cochrane Database Syst Rev 2007:CD003449. [PMID: 17943792 DOI: 10.1002/14651858.cd003449.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Despite their high effectiveness, progestin-only contraceptives are considered less than ideal by the many women who experience irregular vaginal bleeding when using them. Current treatments to control these bleeding problems are not sufficiently effective. OBJECTIVES We evaluated preventive and therapeutic approaches to normalise bleeding irregularities associated with the use of progestin-only contraceptives. SEARCH STRATEGY Literature was identified through database searches, reference lists, organisations and individuals, covering the period until December 2006. SELECTION CRITERIA Trials with random or alternate allocation, testing interventions for the prevention or treatment of bleeding irregularities associated with the use of progestin-only contraceptives were eligible. DATA COLLECTION AND ANALYSIS Results are expressed as relative risks (RR) with 95% confidence interval (CI) for categorical data and as weighted mean difference (WMD) with 95% CI for continuous data. When we encountered heterogeneity (visual or statistical) we used the random-effects model (quantitative) or did not produce a summary estimate (qualitative). MAIN RESULTS Twenty three randomised controlled trials enrolling 2674 participants were included. Seventy per cent were determined to reflect low to moderate risk of bias. Estrogen treatments reduced the number of days of an ongoing bleeding episode in DMPA and Norplant users. However, treatment frequently led to study discontinuation due to gastrointestinal upset. Combinations of oral ethinyl estradiol and levonorgestrel improved bleeding patterns in Norplant users, but method discontinuation rates were unchanged. One trial reported successful use of combined oral contraceptives in treating amenorrhea among DMPA users. Norplant users, but not Implanon users, administered the anti-progestin mifepristone reported fewer days of bleeding than those given placebo. Mifepristone used monthly by new Norplant acceptors reduced bleeding, when compared to placebo.A variety of NSAIDS have been evaluated for their ability to treat abnormal bleeding, with mixed results. Norplant users receiving tamoxifen had less unacceptable bleeding after treatment and were more likely to continue using Norplant than those receiving placebo. Tranexamic acid, mifepristone combined with an estrogen and doxycycline were more effective than placebo in terminating an episode of bleeding in women using progestin-only contraceptives, according to three small studies. AUTHORS' CONCLUSIONS Some women may benefit from the interventions described, particularly with cessation of current bleeding. Several regimens offer promise in regulating bleeding, but findings need to be reproduced in larger trials. The results of this review do not support routine clinical use of any of the regimens included in the trials, particularly for long-term effect.
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Affiliation(s)
- H Abdel-Aleem
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Assiut University, Assiut, Egypt.
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Horne FM, Blithe DL. Progesterone receptor modulators and the endometrium: changes and consequences. Hum Reprod Update 2007; 13:567-80. [PMID: 17630398 DOI: 10.1093/humupd/dmm023] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Progesterone receptor modulators (PRMs) have been used for contraceptive research, as well as for treatment of fibroids, endometriosis and heavy or irregular menstrual bleeding. Long-term treatment with these compounds results in changes to the endometrium resulting in potential confusion in trying to characterize endometrial biopsies. A meeting was held to discuss the properties of PRMs, the effects of perturbed hormonal control of the endometrium and the need for further understanding of the biology of progesterone receptor action to facilitate the development of new PRMs. A panel of pathologists was convened to evaluate endometrial changes associated with a minimum of three months of chronic treatment with PRMs. Four different agents were used in the treatment regimens but the pathologists were blinded to treatment regimen or agent. The panel agreed that the endometrial biopsies did not fit into a classification of either proliferative or secretory endometrium but exhibited an unusual architecture that could be characterized as glandular dilatation. There was little evidence of mitosis, consistent with a proposed anti-proliferative effect of PRMs. The panel concluded that the biopsies did not reveal evidence of safety concern and that pathologists and investigators familiar with endometrial effects of chronic PRM exposure should consider working with pharmaceutical companies and regulatory agencies to develop standard descriptions of PRM-associated endometrial changes as well as the types of histologic changes that would signal a need for intervention.
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Li A, Felix JC, Yang W, Xiong DW, Minoo P, Jain JK. Effect of mifepristone on endometrial matrix metalloproteinase expression and leukocyte abundance in new medroxyprogesterone acetate users. Contraception 2007; 76:57-65. [PMID: 17586139 DOI: 10.1016/j.contraception.2007.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2006] [Revised: 02/02/2007] [Accepted: 03/19/2007] [Indexed: 12/29/2022]
Abstract
PURPOSE This double-blind, placebo-controlled study was conducted to evaluate the molecular mechanism of mifepristone controlling breakthrough bleeding (BTB) in new depot-medroxyprogesterone acetate (DMPA) users. METHOD A total of 50 regularly cycling women who were new starters of DMPA were randomized to receive 50 mg of mifepristone or placebo once every 14 days for six cycles. Endometrial biopsies were obtained on each patient before, during and after treatment. Endometrial matrix metalloproteinase 1 (MMP-1) and MMP-9 protein and mRNA were determined by immunohistochemistry and real-time PCR, respectively. The number of T lymphocytes (CD3-positive) and mast cells (mast tryptase-positive) was evaluated by immunohistochemistry. RESULTS MMP-1, MMP-9, CD3-positive and mast tryptase-positive cells increased following the DMPA treatment. Addition of mifepristone to DMPA-exposed endometrium for 1 week significantly decreased stromal MMP-9 expression and numbers of CD3-positive and mast tryptase-positive cells. CONCLUSION The decreased rates of BTB in new users of DMPA by mifepristone are associated with decreased MMP-1 and MMP-9 expression and fewer mast and T cells.
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Affiliation(s)
- Aimin Li
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.
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Abdel-Aleem H, d'Arcangues C, Vogelsong K, Gülmezoglu AM. Treatment of vaginal bleeding irregularities induced by progestin only contraceptives. Cochrane Database Syst Rev 2007:CD003449. [PMID: 17443526 DOI: 10.1002/14651858.cd003449.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Despite their high effectiveness, progestin-only contraceptives are considered less than ideal by the many women who experience disruption of their normal vaginal bleeding pattern when using these methods. Current treatments to control these bleeding irregularities are not sufficiently effective. OBJECTIVES We evaluated preventive and therapeutic interventions of bleeding irregularities associated with the use of progestin-only contraceptives. SEARCH STRATEGY Literature was identified through database searches, reference lists, organisations and individuals, covering the period until December 2006. SELECTION CRITERIA Trials with random or alternate allocation, testing interventions for the prevention or treatment of bleeding irregularities associated with the use of progestin-only contraceptives were eligible. DATA COLLECTION AND ANALYSIS Results are expressed as relative risks (RR) with 95 % confidence interval (CI) for categorical data and as weighted mean difference (WMD) with 95 % CI for continuous data. When we encountered heterogeneity (visual or statistical) we used the random-effects model (quantitative) or did not produce a summary estimate (qualitative). MAIN RESULTS 19 Randomised controlled trials including 2290 participants were included. Over 60% of these trials had low to moderate risk of bias. Estrogen treatments reduced the number of days of an ongoing bleeding episode in DMPA users and had a positive therapeutic effect in Norplant users. However, treatment frequently led to discontinuation due to gastrointestinal upset. Combinations of oral ethinyl estradiol and levonorgestrel taken by Norplant users experiencing bleeding irregularities, improved bleeding patterns but method discontinuation rates remained the same. Norplant users administered the anti-progestin mifepristone therapeutically reported fewer days of bleeding than those given placebo. Prophylactic oral mifepristone used monthly by new Norplant users reduced bleeding, when compared to placebo.Ibuprofen was reported to decrease the length of bleeding episodes over a year, but the data were not presented in a suitable format for our analysis. Mefenamic acid reduced continued irregular bleeding during treatment in Norplant users, but not among DMPA users. Vitamin E and aspirin had no effect on bleeding patterns in a large trial of women using Norplant. Norplant users receiving tamoxifen had less unacceptable bleeding after treatment and were more likely to continue using Norplant than those receiving placebo. AUTHORS' CONCLUSIONS Some women may benefit from the interventions described, particularly with cessation of an ongoing bleeding episode. Several regimens offer promise in regulating bleeding, but findings need to be reproduced in larger scale trials. Intermittent treatment with an agent may help some women to continue the use of a progestin-only contraceptive. The results of this review do not support routine clinical use of any of the regimens included in the trials, particularly for long-term effect.
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Affiliation(s)
- H Abdel-Aleem
- Faculty of Medicine, Obstetrics and Gynecology, Assiut University Hospital, Assiut, EGYPT.
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50
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Li R, Luo X, Archer DF, Chegini N. RETRACTED: Doxycycline alters the expression of matrix metalloproteases in the endometrial cells exposed to ovarian steroids and pro-inflammatory cytokine. J Reprod Immunol 2007; 73:118-129. [PMID: 17010446 DOI: 10.1016/j.jri.2006.08.082] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2006] [Revised: 08/06/2006] [Accepted: 08/14/2006] [Indexed: 11/23/2022]
Abstract
This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal).
This article has been retracted at the request of the Editors following an investigation by the Office of Research Integrity (ORI) at the Department of Health and Human Services. The investigation confirmed that the data presented has been falsified by the last author.
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Affiliation(s)
- Rongxiu Li
- Department of OB/GYN, University of Florida, Gainesville, FL, USA
| | - Xiaoping Luo
- Department of OB/GYN, University of Florida, Gainesville, FL, USA
| | | | - Nasser Chegini
- Department of OB/GYN, University of Florida, Gainesville, FL, USA.
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