A qualitative study of perceptions, attitudes, and experiences of long-term levonorgestrel implant users

Contraception and women over 40 years of age: mixed-method systematic review

AIM

This paper is a report of a mixed-method systematic review to identify barriers to, and facilitators of, contraceptive needs and choices of women over 40 years old.

BACKGROUND

Women over 40 years of age who do not want to conceive have specific needs for contraception to prevent unwanted, unplanned and unintended pregnancies prior to menopause.

DATA SOURCES

Six databases were searched for published and grey literature from September 1997 to September 2007, along with the Cochrane Central Register of Controlled Trials. The Internet, professional networks and hand searching were also used.

REVIEW METHODS

Mixed-method synthesis using Evidence for Policy and Practice Information and Co-ordinating Centre phased design.

FINDINGS

Guidelines to inform clinical decision-making were located but did not take account of age-related social factors affecting women's choices or local service availability. Women's access to services and contraceptive choices were influenced by educational level, general awareness of available methods, fear of side effects, women's social standing, religious and cultural beliefs, personal control, and confidentiality. The main factors influencing compliance and continuation rates were knowledge, positive experience and confidence, unacceptable side effects and safety concerns, information, support and advice, and ongoing husband/partner influences.

CONCLUSION

The utility of clinical guidelines could be improved by incorporating socio-cultural factors and women's views. Novel approaches to evidence translation and facilitation are required. Focusing on user-led, age-appropriate services rather than a 'one size fits all' approach could improve the contraceptive choices and outcomes for women over 40 years old.

Vaginal bleeding disturbances and implantable contraceptives

Implantable contraceptives allow safe and effective fertility regulation for up to 5 years. Currently available devices release low doses of progestogens. Disruption of vaginal bleeding patterns is almost inevitable, particularly during the initial months of use. Irregular and prolonged bleeding as well as amenorrhea are common. Irregular bleeding is unpopular with most women and unacceptable to some. This review describes the vaginal bleeding disturbances induced by modern implantable contraceptives and discusses the implications of these in terms of method use and discontinuations. The cause of the irregular bleeding is not fully understood, but recent evidence suggests that an increase in endometrial vascular fragility might precipitate vessel breakdown and, hence, breakthrough bleeding. This review discusses this evidence and outline the possible mechanisms underlying breakthrough bleeding associated with implantable contraceptives. In addition, therapies for bleeding disturbances are described and their efficacy reviewed.

Users' perspectives on implantable contraceptives for women

Users of subdermal contraceptive implants report long duration of use, convenience, and high efficacy as liked features and bleeding irregularities, weight loss/gain, and headaches as disliked effects of these methods. Satisfied users tend to be women who do not experience side effects or women who value positive features and tolerate the side effects. Satisfaction of the users is also closely related to quality of services. Service delivery problems, such as lack of proper pre-insertion counseling, inadequacy in number and imbalance in the geographical distribution of providers who can insert and remove implants, and appropriately manage side effects have been observed in new programs. Insensitivity of some providers to side-effects, such as bleeding irregularities, and to requests for removal have caused user dissatisfaction and serious public concern. Care must be taken to provide implants in a context of high quality of care with adequate numbers and distribution of trained providers and a basic record-keeping and tracking system.