Will period-free hormonal contraception become the norm of the twenty-first century?

The feelings of women about their menstruations has been modified due to the use of hormonal contraception. Women using oestroprogestative pills know that menstruations are triggered by the cessation of their absorption rather than any other physiological phenomenon. They know that the amenorrhea which appears under progestative contraception is both non pathological and reversible. Consequently, a good many women, confident in terms of birth control by these very efficient contraceptive methods, wish also to space out those considered useless and unpleasant periods for 3 to 6 months and even for 1 year or more. The actual hormonal contraceptive methods theoretically allow this spacing out of the menstruations but often by dint of much metrorragia. Indeed, while the first studies on those "non-periods" contraceptive methods seem to show their harmlessness, they must be further evaluated in a more specific way. Additional studies must thus be pursued in this direction. This new request from women about their periods while being often undervalued by physicians, must now be taken into account for future contraceptive methods.

Accessibility and availability of abortion in six European countries

OBJECTIVES

The accessibility and availability of abortion are a reflection of abortion law and the accessibility and availability of abortion services. Experiences from six European countries with different political, cultural, social and religious backgrounds (the Netherlands, France, Great Britain, Slovenia, Hungary and Turkey) are presented.

RESULTS

Abortion laws in Europe range from complete prohibition to complete liberalization of abortion. Some countries demand a waiting period for the procedure, pre-abortion counseling, parental approval for minors, and in the others there are no mandatory requirements. Abortions are generally performed in authorized facilities by gynecologists or general practitioners. Abortion services are easily accessible, in terms of the law, availability of facilities and health insurance coverage of the procedure in the Netherlands, France and Slovenia. Abortion service is less accessible in United Kingdom, Hungary and Turkey, as a result of limited accessibility to abortion services or a relatively high abortion fee. In some Eastern European countries there has been a tendency in the last decade to limit the availability and access to abortion.

CONCLUSIONS

In Europe abortion is generally well accessible in terms of abortion laws. There are differences in accessibility to abortion services between the countries, and in some countries, also between different areas of the country.

Effects on cycle control and bodyweight of the combined contraceptive ring, NuvaRing, versus an oral contraceptive containing 30 g ethinyl estradiol and 3 mg drospirenone

BACKGROUND

The objective of this study was to compare cycle control, cycle-related characteristics and bodyweight effects of NuvaRing with those of a combined oral contraceptive (COC) containing 30 microg of ethinyl estradiol and 3 mg of drospirenone.

METHODS

A randomized, multicentre, open-label trial in which 983 women were treated (intent-to-treat population) with NuvaRing or the COC for 13 cycles.

RESULTS

Breakthrough bleeding or spotting during cycles 2-13 was in general less frequent with NuvaRing than that with the COC (4.7-10.4%) and showed a statistically significant odds ratio of 0.61 (95% confidence interval: 0.46, 0.80) with longitudinal analysis. Intended bleeding was significantly better for all cycles with NuvaRing (55.2-68.5%) than that with the COC (35.6-56.6%) (P < 0.01). Changes from baseline in mean bodyweight and body composition parameters were relatively small for both groups with no notable between-group differences.

CONCLUSION

NuvaRing was associated with better cycle control than the COC, and there was no clinically relevant difference between the two groups in bodyweight.

The Coraliance study: non-compliant behavior. Results after a 6-month follow-up of patients on oral contraceptives

OBJECTIVES

This follow-up study was planned to establish the frequency with which women miss their contraceptive pill, and to observe their behavior when they forget it. In those women who changed from a continuous cycle to an interrupted type of cycle, or vice versa, the study also aimed to evaluate the impact of this change on the pattern of omission of pills.

METHODS

The longitudinal, prospective cohort study included healthy women of child-bearing age for whom a change of pill was being prescribed by their gynecologist. Data were recorded during the 6 months preceding inclusion in the study, and for the 6 months of follow-up; the women were asked to complete a diary in which they recorded the number and exact times of pill omission, and their behavior at each omission.

RESULTS

A total of 617 gynecologists included 3316 women into the study; of these, a group of 2418 (73%) revisited the same gynecologist at follow-up. The groups who either visited the same or a different gynecologist were similar with respect to age, oral contraception type, omission type and frequency. A large non-compliance rate and women's difficulties in maintaining safe contraception after missing a pill were observed in the group with follow-up. Women were never risk-free when they missed a pill; they turned to numerous sources for discordant or conflicting information; 15% of 'not-forgetting' women at the pre-inclusion cycle recorded at least one omission at the last cycle of the 6-month follow-up period. Omission fluctuations during the observational period make it difficult to designate 'forgetful' or 'non-forgetful' classes of women. Administration of the pill in a continuous cycle, and probably 'study' and 'auto-questionnaire' effects, contributed to an improvement in compliance. In the group taking the continuous cycle pill, the omission number slightly decreased, particularly on the first day and week of the cycle, irrespective of the initial cycle type.

CONCLUSIONS

The importance of the phenomenon of non-compliance rate is confirmed as well as women's difficulties in knowing how to maintain contraceptive safety. The continuous cycle regimen is likely to improve women's compliance during the critical period of the cycle.

Oral contraception: patterns of non-compliance. The Coraliance study

OBJECTIVES

To determine the number of times women failed to take their oral contraceptive medication and their behavior in response to a missed pill. Another objective was to determine the potential benefit provided by a continuously administered oral contraceptive compared with an oral contraceptive involving a pill-free interval during a 6-month period.

METHODS

Healthy women were enrolled in a cohort study; their contraceptive practices were followed by their gynecologists. Data were collected at inclusion using cross-sectional method with retrospective data collection for the previous 6 months and, more specifically, on their previous or their current menstrual cycle. Women on the pill were asked to specify the number of times and precise time at which they missed one or more pills and what they did in response to missing a pill.

RESULTS

A total of 617 gynecologists enrolled and followed 3316 patients from six geographic areas throughout France. The mean age of patients was 30 years. Duration of oral contraceptive use was 8 years. During their previous cycle, 23% of women (n = 737) missed a pill at least once. Among women on the pill involving a treatment-free interval, 42% of instances of missing a pill occurred during the first week following the treatment-free interval. In response to missing a pill, patients read the product information leaflet (39%) or asked someone's advice (28%), mainly their gynecologist (63%) or their family physician (18%). Almost one-third of women did not take any specific measures.

CONCLUSIONS

Patients on a discontinuous oral contraceptive regimen tended to miss a pill during the first week of treatment. Prescription of a continuous regimen without a treatment-free interval may improve compliance.

A randomized comparison of mifepristone and self-administered oral or vaginal misoprostol for early abortion

In France, mifepristone in association with orally administered misoprostol is widely used for the early termination of pregnancy (up to 49 days' gestation). In other centers, mifepristone in association with vaginally administered misoprostol has also been used. The aim of the present study was to compare the efficacy and tolerance of mifepristone in association with misoprostol administered orally or vaginally for the termination of pregnancy of up to 49 days' gestation. A total of 237 women were enrolled in the study. All women received 600 mg mifepristone administered orally and 400 microg misoprostol administered either orally (n = 119) or vaginally (n = 118). A second dose of 400 microg misoprostol was administered if women had not expelled the pregnancy within 3 h. Women were randomized into treatment groups according to the day of their admission. The overall success rate was 98.7% and there was no significant difference in efficacy between the two groups. There was one treatment failure in the group in which misoprostol was administered orally. Of those women who aborted within 3 h of administration of the first dose ofmisoprostol, the route of administration ofmisoprostol did not influence the time to abortion. Of the women who received a second dose ofmisoprostol, the time to abortion was shorter in those who received misoprostol orally (52 min versus 77 min). Tolerance was assessed by visual analog scales and was similar for both groups. In both groups, women preferred the oral route of administration.

Local spermicidal contraception: a comparative study of the acceptability and safety of a new pharmaceutical formulation of benzalkonium chloride, the vaginal capsule, with a reference formulation, the pessary

OBJECTIVE

To evaluate comparatively the acceptability and safety of a new pharmaceutical form of benzalkonium chloride, the vaginal capsule, with the pessary form.

METHODS

Eighty-nine women were randomized to receive either a benzalkonium chloride vaginal capsule or a benzalkonium chloride pessary prior to sexual intercourse according to an open cross-over design over a 2-month study period.

RESULTS

The discomfort caused by delayed leakage or discharge was mild. The mean scores for subjective signs (burning, itching, vulvar pruritus) were also mild and were comparable for the two formulations. The capsule appeared to be slightly superior to the pessary regarding discomfort caused by immediate discharge or leakage, ease of use and acceptance by the woman's partner. Local safety was generally good. Adverse events consisted chiefly of vulvar pruritus and a vaginal or vulvar burning sensation, with a higher incidence being associated with the pessary than the capsule. All symptoms regressed spontaneously after the end of treatment.

CONCLUSIONS

This study demonstrated good acceptability and good local safety for the benzalkonium chloride vaginal capsule. It is essential to take these parameters into consideration in the evaluation of any local spermicidal contraceptive, since they play a large part in compliance with, and thus in the efficacy of, the product under assessment.

[Trends since 1989, in France, of induced abortions by mifepristone (RU486) combined with a prostaglandin analogue]

In 1989 the French Ministry of Health gave its agreement to the utilisation of the combination mifepristone + a prostaglandin analogue for abortion up to 49 DA. Since then, research activities have been carried out to improve this method. Research to define the best prostaglandin analogue: sulprostone and gemeprost were dropped out; misoprostol was authorized in 1992 following very convincing trials, it is now commonly used and has never generated any major problem. Research to extend the application time limit to 63 DA: it showed a significant drop in efficiency (86.8% instead of 95.4%) as well as an increase of the rate of haemorrhages (2.25% instead of 0.3%). Therefore the method currently used reads as follows. Day 1: mifepristone 600 mg, day 3: misoprostol 400 micrograms, day 10-15: control visit. The efficiency rate is 95.4%; an additional dose of 400 micrograms of misoprostol 3 hours after the first dose if no expulsion has occurred, increases the rate up to 98.5%. This method is well accepted by women as it enables an early abortion and avoids surgery and anesthies. The arrangements required to implement the method are not easy to make as they call for a change of habits by the institutions as well as by medical teams.

CONCLUSION

Since the use of misoprostol, the abortion by mifepristone using. 400 micrograms + 400 micrograms of misoprostol has become a method which is safe, efficient and much appreciated by women, but it implies a change in the usual practice of abortion.

A multicenter European survey of the attitudes to contraception in women at high risk or with established cardiovascular disease

OBJECTIVES

The survey was designed to study the attitudes of gynecologists from 11 European centers providing guidance in contraception to women at high risk and women with cardiovascular disease.

METHODS

Attitudes were registered by means of a standard questionnaire.

RESULTS

Most contributors reported that, in women with venous thrombosis (10/11), deep venous thrombosis (10/11), coagulation disorders (11/11) and stroke (8/11), they prefer to prescribe methods other than combined oral contraceptives (COCs). A history of myocardial infarction was considered a relative contraindication and some experts suggested that, in some cases, the use of third-generation COCs may be possible. COCs were not recommended in women with severe cardiovascular disease and in those over 35 years of age with light or moderate cardiovascular disease, heavy smokers (over 20 cigarettes per day), or those presenting with severe hyperlipidemia.

CONCLUSION

The pill is not considered appropriate for women with clinically established cardiovascular diseases or in cases where more than two coronary risk factors exist. COCs may safely be given to women with elevated blood pressure as long as it is lower than 160/100 mmHg, in cases of light and moderate cardiovascular disease as long as the patient is less than 35 years of age, in women who are not heavy smokers, in the presence of a light or moderate degree of hyperlipidemia, and in uncomplicated diabetes mellitus provided that there are no additional risk factors. In these cases, third-generation COCs are preferred. The co-operation of the cardiologist is desirable in order to classify cardiovascular disease and for patient follow-up.

RU486 combined with PG analogs in voluntary termination of pregnancy

This French study evaluates the clinical results of administering RU486 with prostaglandin analogs in early pregnancy. Since 1986, RU486 has been used with prostaglandin analogs to interrupt pregnancies of less than 49 days' amenorrhea. Success rate among 10,250 cases was 95.3%. Failures involve ending of pregnancy without expulsion (2.8%), and ongoing pregnancy (1.1%). Two cases of cardiovascular complications following administration of the prostaglandin have occurred. The majority of users prefer this method because it eliminates need for surgery and anesthesia, and it allows the patient to take an active role in the procedure.