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Bezerra AG, Pires GN, Andersen ML, Tufik S, Hachul H. The Effects of Hormonal Contraceptives on the Sleep of Women of Reproductive Age. Sleep Med Clin 2023; 18:435-448. [PMID: 38501516 DOI: 10.1016/j.jsmc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Research about the effects of hormonal contraceptives on sleep has been performed but is subjected to important levels of methodological heterogeneity. Hormonal contraceptives impact sleep, but the direction of this association is not clear. Most studies describe a negative sleep profile among contraceptive users, including increased sleepiness, insomnia symptoms, decreased sleep efficiency, and a reduced overall sleep quality. Hormonal intrauterine contraceptives are associated with less negative effects. More research on the field, especially randomized controlled trials, is needed to increase the level and certainty of evidence about the effects of hormonal contraceptives on sleep.
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Affiliation(s)
- Andréia Gomes Bezerra
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Rua Napoleão de Barros, 925 - CEP: 04024-002, São Paulo, Brazil
| | - Gabriel Natan Pires
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Rua Napoleão de Barros, 925 - CEP: 04024-002, São Paulo, Brazil; Sleep Institute, Rua Marselhesa, 500 - CEP: 04020-060, São Paulo, Brazil
| | - Monica L Andersen
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Rua Napoleão de Barros, 925 - CEP: 04024-002, São Paulo, Brazil; Sleep Institute, Rua Marselhesa, 500 - CEP: 04020-060, São Paulo, Brazil
| | - Sergio Tufik
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Rua Napoleão de Barros, 925 - CEP: 04024-002, São Paulo, Brazil; Sleep Institute, Rua Marselhesa, 500 - CEP: 04020-060, São Paulo, Brazil
| | - Helena Hachul
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Rua Napoleão de Barros, 925 - CEP: 04024-002, São Paulo, Brazil; Sleep Institute, Rua Marselhesa, 500 - CEP: 04020-060, São Paulo, Brazil.
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Bezerra AG, Andersen ML, Pires GN, Tufik S, Hachul H. The effects of hormonal contraceptive use on sleep in women: A systematic review and meta-analysis. J Sleep Res 2023; 32:e13757. [PMID: 36319606 DOI: 10.1111/jsr.13757] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 09/11/2022] [Accepted: 09/27/2022] [Indexed: 05/10/2023]
Abstract
Hormonal contraceptives are some of the most widely used medications worldwide, but studies on their effects on sleep are contradictory, with some reporting a sleep-promoting effect, while others a sleep-inhibiting effect. Our objective was, therefore, to undertake a systematic review and meta-analysis of the literature on this subject to try to clarify their effects. A search was conducted in three databases (PubMed, Scopus and Web of Science). Only studies evaluating hormonal contraception use were considered eligible, and both objective and subjective sleep-related outcomes were considered. Individual effect size was calculated for each article, and meta-analyses were performed using a DerSimonian and Laird random effects method. The initial search identified 2076 articles, of which 13 met the criteria for the study after full text evaluation. A total of 33 meta-analyses were performed, three of them related to subjective measures and 30 considering data from polysomnography. The only statistically significant result between contraceptive users and non-contraceptive users was observed in respect of wake after sleep onset, which was 7 min shorter among contraceptive users (-7.12 [-12.80; -1.44]; I2 = 65%; p = 0.01). In conclusion, hormonal contraceptives are not associated with clinically relevant changes in sleep patterns in women.
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Affiliation(s)
| | - Monica Levy Andersen
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Gabriel Natan Pires
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Sergio Tufik
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Helena Hachul
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil
- Departamento de Ginecologia, Casa de Saúde Hospital Santa Marcelina, São Paulo, Brazil
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Hormone Targets for the Treatment of Sleep Disorders in Postmenopausal Women with Schizophrenia: A Narrative Review. Clocks Sleep 2022; 4:52-65. [PMID: 35225953 PMCID: PMC8883931 DOI: 10.3390/clockssleep4010007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 01/28/2022] [Accepted: 02/04/2022] [Indexed: 01/14/2023] Open
Abstract
While the early identification of insomnia in patients with schizophrenia is of clinical relevance, the use of specific compounds to treat insomnia has been studied less in postmenopausal women with schizophrenia. We aimed to explore the effects of melatonin, sex hormones, and raloxifene for the treatment of insomnia in these populations. Although melatonin treatment improved the quality and efficiency of the sleep of patients with schizophrenia, few studies have explored its use in postmenopausal women with schizophrenia. The estrogen and progesterone pathways are dysregulated in major psychiatric disorders, such as in schizophrenia. While, in the context of menopause, a high testosterone-to-estradiol ratio is associated with higher frequencies of depressive symptoms, the effects of estradiol and other sex hormones on sleep disorders in postmenopausal women with schizophrenia has not been sufficiently investigated. Raloxifene, a selective estrogen receptor modulator, has shown positive effects on sleep disorders in postmenopausal women. Future studies should investigate the effectiveness of hormonal compounds on insomnia in postmenopausal women with schizophrenia.
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Polycystic ovary syndrome and its possible association with sleep complaints : PCOS and sleep. Arch Womens Ment Health 2021; 24:1055-1057. [PMID: 34173058 DOI: 10.1007/s00737-021-01155-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
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Pascoe M, Foldvary-Schaefer N. Pregnancy and Contraception in Central Hypersomnolence Disorders. CURRENT SLEEP MEDICINE REPORTS 2021. [DOI: 10.1007/s40675-021-00221-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hachul H, Castro LS, Bezerra AG, Pires GN, Poyares D, Andersen ML, Bittencourt LR, Tufik S. Hot flashes, insomnia, and the reproductive stages: a cross-sectional observation of women from the EPISONO study. J Clin Sleep Med 2021; 17:2257-2267. [PMID: 34170233 DOI: 10.5664/jcsm.9432] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
STUDY OBJECTIVES To investigate the association of hot flashes and insomnia in women in premenopause and postmenopause. METHODS The study was performed using data from the São Paulo Epidemiological Sleep Study. Women in premenopause were classified as having regular menstrual cycles, being anovulatory, or using hormonal contraceptives. Women in menopause were classified as being in perimenopause, early postmenopause, or late postmenopause. Women reporting frequent insomnia symptoms and relevant daytime complaints were classified as having insomnia disorder. Polysomnography alterations suggestive of insomnia were also identified. RESULTS The frequency of hot flashes was 42% among women in postmenopause (mainly in early postmenopause) and 9% among women in premenopause (mainly anovulatory; P < .01). Approximately 18.7% had insomnia disorder, 48% had isolated insomnia symptoms, and 32.4% had polysomnography alterations. Comparing women in menopause with those in premenopause, the diagnosis of insomnia was similar (premenopause: 18.9% vs menopause: 17.5%), but women in menopause had more frequent isolated insomnia symptoms (premenopause: 43.9% vs menopause: 55.9%; P = .02) and polysomnography correlates of insomnia (premenopause: 26.5% vs menopause: 42.6%; P < .01). Hot flashes were more frequent among women with insomnia disorders (25.5%) and with isolated insomnia symptoms (23.0%) when compared with good sleepers (12.6%) in the entire sample (P = .01). Among women in late menopause, the prevalence of hot flashes was higher in both women with insomnia disorders (42.1%) and with isolated insomnia symptoms (37.5%) when compared with women who were good sleepers (14.3%; P = .05). CONCLUSIONS Hot flashes are associated with insomnia and polysomnography alterations suggestive of insomnia. The prevalence of hot flashes among women with insomnia disorder is especially high among women in late postmenopause. CITATION Hachul H, Castro LS, Bezerra AG, et al. Hot flashes, insomnia, and the reproductive stages: a cross-sectional observation of women from the EPISONO study. J Clin Sleep Med. 2021;17(11):2257-2267.
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Affiliation(s)
- Helena Hachul
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil.,Departamento de Ginecologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | - Gabriel Natan Pires
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil.,Department of Physiological Sciences, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Dalva Poyares
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Monica Levy Andersen
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Lia Rita Bittencourt
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Sergio Tufik
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil
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Ma J, Cheng M, Thabane L, Ma C, Zhang N, Wang Q, Kim H, Reza H, Wang C, Yao X. Relationship between hormonal contraceptives and sleep among women of reproductive age: a systematic review protocol. BMJ Open 2021; 11:e045819. [PMID: 34625410 PMCID: PMC8504351 DOI: 10.1136/bmjopen-2020-045819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The aetiology of sleep disruptions is unknown, but hormonal fluctuations during the menstrual cycle, pregnancy and menopause have been shown to potentially affect how well a woman sleeps. The aim of this systematic review was to investigate whether hormonal contraceptives are associated with a decreased quality of sleep and increased sleep duration in women of reproductive age. METHODS This review will analyse data from randomised controlled trials or non-randomised comparative studies investigating the association between hormonal contraceptives and sleep outcomes among women of reproductive age. Reviews addressing the same research question with similar eligibility criteria will be included. A literature search will be performed using the MEDLINE, Embase and Cochrane Central Register of Controlled Trials databases from inception to 7 March 2021. The Cochrane Collaboration's Risk of Bias for Randomised Trials V.2.0 and The Risk of Bias for Non-randomised Studies of Interventions tool will be used to assess risk of bias for each outcome in eligible studies. Two reviewers will independently assess eligibility of studies and risk of bias and extract the data. All extracted data will be presented in tables and narrative form. For sleep measures investigated by two or more studies with low heterogeneity, we will conduct random-effects meta-analysis to estimate the magnitude of the overall effect of hormonal contraceptives. If studies included in this systematic review form a connected network, a network meta-analysis will be conducted to estimate the comparative effect of different contraceptives. The Grading of Recommendations, Assessment, Development, and Evaluation approach will be used to summarise the quality of evidence. Our protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols 2015 guidelines. ETHICS AND DISSEMINATION Ethics approval is not required as data were sourced from previously reported studies. The findings of this review will be published in a peer-reviewed journal and presented at relevant conferences. PROSPERO REGISTRATION NUMBER CRD42020199958.
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Affiliation(s)
- Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Megan Cheng
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Caihong Ma
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Ning Zhang
- Department of Neuropsychiatry and Behavioral Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Institute of Sleep and Consciousness Disorders,Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Qi Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Hyunwoo Kim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Hameed Reza
- Faculty of Science, McMaster University, Hamilton, Ontario, Canada
| | - Chunxue Wang
- Department of Neuropsychiatry and Behavioral Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Institute of Sleep and Consciousness Disorders,Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Xiaomei Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Center for Clinical Practice Guideline Conduction and Evaluation, Children's Hospital of Fudan University, Shanghai, China
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Hachul H, Bisse AR, Sanchez ZM, Araujo F, Guazzelli CAF, Tufik S, Barbieri M. Sleep quality in women who use different contraceptive methods. Sleep Sci 2020; 13:131-137. [PMID: 32742584 PMCID: PMC7384524 DOI: 10.5935/1984-0063.20190142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/01/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Both menstrual cycle and hormone alterations influence sleep pattern. The aim of this study was to evaluate sleep quality in women who use different contraceptive methods. MATERIAL AND METHODS This study was a descriptive, cross-sectional survey. Pittsburgh Sleep Quality Index (PSQI) was used to evaluate sleep quality, and a questionnaire was used to obtain sociodemographic, clinical, lifestyle, and contraceptive use data. RESULTS The study population comprised 235 women in reproductive age. Regarding lifestyle, 25.5% of the women were physically active, 12.3% were tobacco-smoking, and 70.6% drank coffee daily. Sleep quality was good in 34% of the studied population and poor in 66% of the population. The population was divided into two groups: hormonal (57.1%) and non-hormonal (42.9%) contraceptive users. Sleep quality in the users of non-hormonal contraceptive methods was similar to that in the users of hormonal methods (6.1±3.2 versus 5.9±2.9; p=0.5). Sleep efficiency was statistically higher among the users of non-hormonal contraceptive methods (94.7±17.7) than among the users of hormonal methods (90.0±15.3; p=0.03). The patients who had irregular or altered menstrual cycles reported poorer sleep quality. The absence of routine physical activity negatively influenced sleep quality (p=0.05). The women who snored reported worse sleep quality (p=0.002). CONCLUSIONS Nearly half of the studied population was users of hormonal contraception, and most of these women reported poor sleep quality. Sleep efficiency was higher among the users of non-hormonal contraceptives. No differences in subgroups (hormonal contraceptive users) were observed.
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Affiliation(s)
- Helena Hachul
- Universidade Federal de são Paulo, Psicobiologia - São Paulo - Brazil
- Universidade Federal de São Paulo, Ginecologia - São Paulo - Brazil
| | | | - Zila M. Sanchez
- Universidade Federal de São Paulo, Medicina Preventiva - São Paulo - Brazil
| | - Fábio Araujo
- Universidade Federal de São Paulo, Obstetrícia - São Paulo - Brazil
| | | | - Sergio Tufik
- Universidade Federal de são Paulo, Psicobiologia - São Paulo - Brazil
| | - Márcia Barbieri
- Universidade Federal de São Paulo, Enfermagem - São Paulo - Brazil
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Guida M, Rega A, Vivone I, Saccone G, Sarno L, Di Carlo C, Aquino CI, Troisi J. Variations in sleep associated with different types of hormonal contraceptives. Gynecol Endocrinol 2020; 36:166-170. [PMID: 31311352 DOI: 10.1080/09513590.2019.1640204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Progesterone and some of its metabolites are neuroactive steroids that affect sleep by increasing melatonin secretion and stimulating GABA-A receptors. The effect of progestogens in hormonal contraceptives on sleep has not been thoroughly investigated. This observational study assessed possible associations in sleep changes induced by estrogen-progestogens in contraceptives in 108 women between the ages of 20 and 50 years. We assessed mean nightly sleep time with a 31-day sleep diary, and subjective sleep quality with the five subjective subscores of the Pittsburgh Sleep Quality Index (PSQI). Included women were of childbearing age, healthy, sexually active and had been using a hormonal contraceptive method (pill, intrauterine system (IUS), subcutaneous implant, vaginal ring) for at least six months. Results were compared to a matched control group that did not use hormonal contraceptives. The longest mean nightly sleep time, compared to control (450 min), occurred in women who used progestogen-only oral contraception (510 min), followed by IUS delivery of levonorgestrel 13.5 mg (480 min) and oral ethinylestradiol 0.02/0.03 mg plus gestodene 0.075 mg (475 min). Global subjective sleep quality was influenced most by the administration of etonorgestrel 0.120 mg/ethinylestradiol 0.015 mg via the vaginal route. Our results show that low-doses of progestins affect various aspects of sleep, and that this is influenced by the route of administration.
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Affiliation(s)
- Maurizio Guida
- Dipartimento di Medicina, Chirurgia e Odontoiatria "Scuola Medica Salernitana", Università degli Studi di Salerno, Salerno, Italy
| | - Alessia Rega
- Dipartimento di Medicina, Chirurgia e Odontoiatria "Scuola Medica Salernitana", Università degli Studi di Salerno, Salerno, Italy
| | - Imma Vivone
- Dipartimento di Medicina, Chirurgia e Odontoiatria "Scuola Medica Salernitana", Università degli Studi di Salerno, Salerno, Italy
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Laura Sarno
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Costantino Di Carlo
- Department of Experimental and Clinical Medicine Unit of Obstetrics, Gynecology University of Catanzaro "Magna Graecia", Catanzaro, Italy
| | - Carmen Imma Aquino
- Dipartimento di Medicina, Chirurgia e Odontoiatria "Scuola Medica Salernitana", Università degli Studi di Salerno, Salerno, Italy
| | - Jacopo Troisi
- Dipartimento di Medicina, Chirurgia e Odontoiatria "Scuola Medica Salernitana", Università degli Studi di Salerno, Salerno, Italy
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Bezerra AG, Andersen ML, Pires GN, Banzoli CV, Polesel DN, Tufik S, Hachul H. Hormonal contraceptive use and subjective sleep reports in women: An online survey. J Sleep Res 2020; 29:e12983. [DOI: 10.1111/jsr.12983] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/16/2019] [Accepted: 01/05/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - Monica Levy Andersen
- Departamento de Psicobiologia Universidade Federal de São Paulo São Paulo Brazil
| | - Gabriel Natan Pires
- Departamento de Psicobiologia Universidade Federal de São Paulo São Paulo Brazil
- Department of Physiological Sciences Santa Casa de São Paulo School of Medical Sciences São Paulo Brazil
| | - Carolina V. Banzoli
- Departamento de Psicobiologia Universidade Federal de São Paulo São Paulo Brazil
- Departamento de Ginecologia Casa de Saúde Hospital Santa Marcelina São Paulo Brazil
| | | | - Sergio Tufik
- Departamento de Psicobiologia Universidade Federal de São Paulo São Paulo Brazil
| | - Helena Hachul
- Departamento de Psicobiologia Universidade Federal de São Paulo São Paulo Brazil
- Departamento de Ginecologia Casa de Saúde Hospital Santa Marcelina São Paulo Brazil
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Laird S, Ney LJ, Felmingham KL, Gogos A. Hormonal Contraception and the Brain: Examining Cognition and Psychiatric Disorders. CURRENT PSYCHIATRY RESEARCH AND REVIEWS 2019. [DOI: 10.2174/1573400515666190521113841] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background:The combined oral contraceptive pill (OC), containing synthetic estrogens and progestins, is used by millions of women worldwide, yet little is known about its effects on cognition or on psychiatric disorders. The progestin component of OCs determines their androgenicity, i.e. whether the OC has androgen binding components with masculinising effects or antiandrogenic components with feminising effects.Objective:The present review discusses the literature surrounding OC use and cognition in healthy women. Given the important role that sex hormones play in psychiatric disorders, we also consider the influence of OCs on symptoms of schizophrenia, post-traumatic stress disorder, depression, bipolar disorder, anxiety disorders and indirectly, sleep quality.Results:Research has shown that while there are no differences between OC users and non-users, androgenic OCs enhance visuospatial ability and anti-androgenic OCs enhance verbal fluency. Little is known about OCs effects on other cognitive domains, such as memory and executive function. There is little research examining OC use in schizophrenia, post-traumatic stress disorder, bipolar disorder and anxiety disorders. There is some evidence that OC use is associated with depression, however the exact causality of this association remains to be verified.Conclusion:We maintain that future studies need to address several methodological limitations, such as separating OCs based on androgenicity to avoid the masking effects that occur when various OCs are considered as one group. As this review highlights several significant effects of OC use on the brain, the implications of OC use needs to be considered in future research.
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Affiliation(s)
- Stephanie Laird
- School of Psychological Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Luke J. Ney
- School of Medicine (Psychology), University of Tasmania, Sandy Bay, TAS, Australia
| | - Kim L. Felmingham
- School of Psychological Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Andrea Gogos
- The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
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