Depression in Female Adolescents with Heavy Menstrual Bleeding

OBJECTIVE

To assess the degree to which heavy menstrual bleeding is associated with depression, independent of hormonal contraception.

STUDY DESIGN

We performed a retrospective cohort study of 1168 female adolescents 9-18 years old presenting to general pediatricians for heavy menstrual bleeding or well visits. Depression was the primary outcome and defined as a diagnosis in the health record. Univariable and multivariable regression models were fit to the data to identify factors associated with depression diagnosis.

RESULTS

In total, 581 adolescents with heavy menstrual bleeding and 587 without heavy menstrual bleeding were included. Depression diagnoses occurred with greater frequency in youth with heavy menstrual bleeding compared with those without heavy menstrual bleeding (50.9% vs 24.2% P < .001; risk ratio 1.67, 95% CI 1.39-2.01) but did not significantly differ between those taking vs not taking hormonal contraception (risk ratio 0.99; 95% CI 0.84-1.17). Most patients with depression and heavy menstrual bleeding developed depression following or concurrent with heavy menstrual bleeding (261/296, 88%). Of these, 199 of 261 (76%) were treated with hormonal contraception, but the majority (168/199; 84%) were diagnosed with depression before initiation.

CONCLUSIONS

Heavy menstrual bleeding is associated with depression diagnosis in female adolescents. The use of hormonal contraception was not associated with depression diagnosis in multivariable analysis, covarying heavy menstrual bleeding, age, body mass index, anxiety, sexual activity, and substance use. As hormonal contraception is often used to treat heavy menstrual bleeding, heavy menstrual bleeding may be partially driving previous reports of increased depression risk in those taking hormonal contraception.

Fertility-preserving treatment in patients with early-stage endometrial cancer: A protocol for systematic review and meta-analysis

BACKGROUND

Endometrial cancer (EC) is the second most common malignancy of the female reproductive system worldwide, and the standard treatment for early-stage EC potentially leads to permanent infertility. The objective of this study was to investigate the efficacies of different methods on fertility preservation in patients with early-stage EC.

METHODS

We searched the major online databases (PubMed, Embase, The Cochrane Library, and Web of Science) to collect the research literature on fertility preservation therapy in patients with early-stage well-differentiated EC aged ≤ 40 years from January 1999 to October 2019. The inclusion was performed using the R software (version R3.5.3) meta-analysis of a single rate. The efficacy of the following three fertility preservation treatments was evaluated from four aspects, the complete remission rate (CRR), recurrence rate (ReR), pregnancy rate (PregR), and live birth rate (LBR): a) taking oral progestin only therapy, b) hysteroscopic resection combined with progestin/levonorgestrel-releasing intrauterine system (LNG-IUS)/GnRH-a, c) LNG-IUS or combined with progestin/GnRH-a.

RESULTS

A total of 23 articles were included in this study, including 446 patients with early-stage EC. In the group that took oral progestin only (n = 279), CRR, ReR, PregR, and LBR were 82% (95% confidence interval [CI], 74%-92%, P = .01), 38% (95% CI, 31%-45%, P = .35), 70% (95% CI, 62%-79%, P = .68), and 63% (95% CI, 55%-73%, P = .55), respectively. Hysteroscopic resection combined with progestin/LNG-IUS/GnRH-a therapy group (n = 96) achieved a CRR, ReR, PregR, and LBR of 95% (95% CI, 90%-100%, P = .42), 16% (95% CI, 6%-39%, P = .03), 84% (95% CI, 73%-96%, P = .39), and 72% (95% CI, 59%-87%, P = .28), respectively. LNG-IUS or combined with progestin/GnRH-a therapy group (n = 91) achieved a CRR, ReR, PregR, and LBR of 69% (95% CI, 54%-89%, P < .01), 30% (95% CI, 19%-49%, P = .36), 48% (95% CI, 18%-100%, P < .01), and 36% (95% CI, 10%-100%, P < .01), respectively.

CONCLUSION

It is safe and effective for young patients with early-stage EC to receive oral progestin, hysteroscopic resection combined with progestin/LNG-IUS/GnRH-a, LNG-IUS, or progestin/GnRH-a.

INPLASY REGISTRATION NUMBER

DOI 10.37766/inplasy2020.12.0137.

Dienogest versus continuous oral levonorgestrel/EE in patients with endometriosis: what's the best choice?

OBJECTIVE

Combined oral contraceptives (COC) and progestogens are widely used for the treatment of endometriosis. The objective of the study is to compare the efficacy of dienogest 2 mg vs continuous oral levonorgestrel/EE (levonorgestrel 0.1 mg/ethinyl estradiol 0.02 mg) on ovarian endometriomas, deep infiltrating endometriosis (DIE), chronic pelvic pain (CPP), dyspareunia, analgesic use, quality of life (QoL), compliance and side effects.

METHODS

Prospective cohort study. Two cohorts of patients with endometriosis, 50 taking dienogest (group A) and 50 taking continuous levonorgestrel/EE (group B), were evaluated at the beginning of therapy (t0), after 3 (t3) and 6 months (t6). Size of endometriomas, DIE, QoL, pain symptoms, and side effects were assessed.

RESULTS

Dienogest was significantly effective on CPP (p = .002), dyspareunia (p = .021) ovarian endometriomas (p = .015) and DIE lesions reduction (p = .014). Levonorgestrel/EE was significantly effective on dyspareunia (p = .023). Analgesics consumption significantly decreased in both groups (p < .001). Both treatments significantly improved the QoL. Over 6 months a significant improvement was found, more frequently in patients taking dienogest. The only side effect that both groups complained about was vaginal bleeding, present in the first 3 months of treatment (p < .001).

CONCLUSIONS

Both treatments are effective and safe for patients with endometriosis. Patients compliance and side effects are similar in both groups, however, there was a significantly higher reduction in endometriotic lesions, pain symptoms, and improvement of the QoL in women taking dienogest than in women taking continuous COC.

Variations in the Profiles of Vascular-Related Factors Among Different Sub-Types of Polycystic Ovarian Syndrome in Northern China

Recently, a growing body of evidence has suggested that abnormal ovarian angiogenesis, secondary to the imbalance between various angiogenic markers, is involved in the pathogenesis of PCOS, and this has led to the use of various interventions (such as Diane-35) to restore the normal ovarian angiogenesis. Therefore, we conducted the current investigation to determine the role of such markers (endothelial growth factor (VEGF), endostatin (ES), and thrombospondin-1 (TSP-1)) in the pathogenesis of PCOS along with the associated changes in ovarian blood flow in patients with PCOS compared to healthy controls, both before and after a course of oral contraception. A total of 381 patients with PCOS and 98 healthy females of childbearing age were recruited from July 2014 to June 2017 at the Reproductive Center of the Second Affiliated Hospital of Harbin Medical University. The serum levels of VEGF, ES, and TSP-1 were determined by enzyme-linked immunosorbent assay, while ovarian perfusion was measured by the pulsatility index (PI) and resistance index (RI) by using transvaginal color Doppler ultrasound. Repeated analyses were carried out after 3 months of Diane-35 treatment. Post-treatment serum levels of luteinizing hormone (LH)/follicle stimulating hormone (FSH) ratio of patients with PCOS decreased significantly (P <0.05). The RI values of most PCOS patients increased after treatment (P<0.05), while PI was significantly increased in all patients (P<0.05). However, variable changes in the serum levels of TSP-1, VEGF, and ES after treatment were observed. Serum VEGF levels showed a negative correlation with serum LH/FSH ratio, T concentration, and ES (P <0.05), while ES levels were negatively correlated with serum T concentrations only (P<0.05). The markers of angiogenesis (VEGF, ES, and TSP-1) were expressed differently among PCOS patients, who also responded differently to the same course of Diane-35 treatment. This field still warrants further investigation to reach a more definitive conclusion.

Glanzmann's thrombasthenia: a rare bleeding disorder in a Nigerian girl

INTRODUCTION

Glanzmann's Thrombasthenia (GT) is a rare autosomal recessive bleeding disorder due to defective platelet membrane glycoprotein GP IIb/IIIa (integrin αIIbβ3). The prevalence is estimated at 1:1,000,000 and it is commonly seen in areas where consanguinity is high.

CASE PRESENTATION

The authors report a 12 year old Nigerian girl of Igbo ethnic group, born of non-consanguineous parents, who presented with prolonged heavy menstrual bleeding which started at menarche 3 months earlier, weakness and dizziness. She had a past history of recurrent episodes of prolonged epistaxis, gastrointestinal bleeding and gum bleeding during early childhood. On examination, she was severely pale with a haemic murmur and vaginal bleeding. The initial diagnosis was menorrhagia secondary to bleeding diathesis possibly von Willebrand's Disease. She was on supportive treatment with fresh whole blood, fresh frozen plasma and platelets until diagnosis of GT was made in the USA. Currently, she is on 3 monthly intramuscular Depo-provera with remarkable improvement.

CONCLUSION

To the best of our knowledge, this is the first documented report of GT in our environment where consanguinity is rarely practised. Our health facilities require adequate diagnostic and treatment facilities for rare diseases like GT.

Association of Pharmacist Prescription With Dispensed Duration of Hormonal Contraception

IMPORTANCE

Since 2016, 11 states have expanded the scope of pharmacists to include direct prescription of hormonal contraception. Dispensing greater than 1 month's supply is associated with improved contraceptive continuation rates and fewer breaks in coverage. Scant data exist on the practice of pharmacist prescription of contraception and its outcomes compared with traditional, clinic-based prescriptions.

OBJECTIVE

To compare the amount of hormonal contraceptive supply dispensed between pharmacists and clinic-based prescriptions. Prescribing patterns were assessed by describing prescribing practices for women with contraindications to combined hormonal contraception. Characteristics of women seeking hormonal contraception directly from pharmacists were also described.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study surveyed women aged 18 to 50 years who presented to pharmacies in California, Colorado, Hawaii, and Oregon for hormonal contraception prescribed by a clinician or a pharmacist between January 30 and November 1, 2019.

EXPOSURES

Pharmacist or clinic-based prescription of contraception.

MAIN OUTCOMES AND MEASURES

Months of contraceptive supply dispensed.

RESULTS

Four hundred ten women (mean [SD] age, 27.1 [7.7] years) were recruited who obtained contraception directly from a pharmacist (n = 144) or by traditional clinician prescription (n = 266). Women obtaining contraception from a pharmacist were significantly younger (82 [56.9%] vs 115 [43.2%] participants aged 18-24 years; P = .03), had less education (38 [26.4%] vs 100 [37.6%] with a bachelor degree; P = .002), and were more likely to be uninsured (16 [11.1%] vs 8 [3.0%] participants; P = .001) compared with women with a prescription from a clinician. Pharmacists were significantly more likely to prescribe a 6-month or greater supply of contraceptives than clinicians (6.9% vs 1.5%, P < .001) and significantly less likely to only prescribe a 1-month supply (42 [29.2%] vs 118 [44.4%] prescriptions; P < .001). Controlling for all covariates, women seen by pharmacists had higher odds of receipt of a 6-month or greater supply of contraceptives compared with those seen by clinicians (odds ratio = 3.55; 95% CI, 1.88-6.70). Pharmacists were as likely as clinicians to prescribe a progestin-only method to women with a potential contraindication to estrogen (n = 60 women; 8 [20.0%] vs 6 [30.0%], P = .52).

CONCLUSIONS AND RELEVANCE

These findings suggest that pharmacist prescription of contraception may be associated with improved contraceptive continuation by preventing breaks in coverage through the provision of a greater supply of medication. Efforts are needed to educate prescribing providers on the importance of dispensing 6 months or greater contraceptive supply.

Ulipristal acetate on quality of life and sexual function of women with uterine fibromatosis

To evaluate quality of life and sexual function of childbearing-age women, affected by uterine fibromatosis undergoing medical treatment with ulipristal acetate. The data obtained by filling the questionnaires European Quality of Life Five-Dimension Scale and modified Female Sexual Function Index, were analyzed to assess UPA usefulness in improving QoL and sexual activity. A total of 139 patients affected by uterine fibromatosis undergoing conservative ulipristal acetate treatment were enrolled in this prospective observational cohort study. Seventy-one women (average age 46.5 years) answered the questionnaires: QoL and sexuality were evaluated before and after ulipristal acetate treatment. 59 patients (83.1%) had an improvement of QoL and general health state, with a reduction of VAS score after ulipristal acetate treatment. EQ-5D-5L showed a statistically significant improvement of usual act impairment, mobility, discomfort, anxiety/depression (p < .0005). There was no difference in personal care management after therapy. Modified FSFI showed a statistically significant improvement (p < .0001) of sexual satisfaction and sexual life. A not statistically significant improvement in dyspareunia was also highlighted. This study provides a clear picture about QoL impact on women and confirms the effectiveness of the ulipristal acetate in improving different aspects of daily and sexual life of patients undergoing medical treatment.

Hormonal Contraceptive Prescription in Young Women With Cerebral Palsy

PURPOSE

The purpose of the study was to describe the prevalence and patterns of prescription of hormonal contraceptive medications to young women with cerebral palsy (CP) and determine if CP topography or ambulatory status was associated with the type of contraceptive prescribed.

METHODS

Data were extracted by manual chart review for women with CP between the ages of 15 and 25 years who were seen at a tertiary pediatric hospital and a rehabilitation hospital between the years of 2011 and 2013. CP topography was defined as the number and pattern of limbs affected (hemiplegia, diplegia, triplegia, or quadriplegia), and ambulatory status was defined as whether a wheelchair was used for community mobility. Logistic regression analysis was used to assess associations between patient age, CP topography, ambulatory status, and contraceptive prescription.

RESULTS

Data were collected for 483 women with CP with an average age of 19 years (standard deviation: 3 years). One hundred thirty-one patients (27%) were prescribed hormonal contraceptives. Estrogen-progestin combined oral contraceptives were most frequently prescribed (73%). Prescription of hormonal contraceptives was not associated with CP topography (p = .95) or ambulatory status (p = .44); however, older subjects were more likely to be prescribed hormonal contraceptives (p = .01). There was no association detected between CP topography and contraceptive composition (p = .09) or between ambulatory status and contraceptive composition (p = .06). There was also no association detected between CP topography (p = .18) or ambulatory status (p = .09) and depot medroxyprogesterone acetate prescription.

CONCLUSION

Ambulatory status and CP topography were not associated with the types of hormonal contraceptives prescribed in this cohort.

Data quality self-assessment of child health and sexual reproductive health indicators in Botswana, 2016-2017

There is no published data on quality of administrative data for various health indicators in Botswana, yet such data are used for policy making and future planning. This article reports on quality of data on child health and sexual and reproductive health (SRH) indicators in Botswana. The main objective of the study was to assess the quality of administrative data from Expanded Immunization Program (EPI) and condom use, Depo-Provera uptake and domiciliary care attendance in Botswana. This was a retrospective study entailing a review of data retrieved from district health records and District Health Information System (DHIS). A total of 30 clinics and health posts were randomly selected from two cities, a town and three rural villages which makes up 6 districts commonly denoted urban, semi-urban and rural respectively. Through a stratified random sampling health facilities were selected. EPI data (Penta 3- third dose of pentavalent vaccine and Measles vaccine) and SRH data (condom use, Depo-Provera uptake and Domiciliary care) were assessed for completeness, discrepancies and verification factor using WHO Routine data quality (RDQA) assessment tool. A verification score of less than 90%% was considered as underreporting while more than 110% is over reporting. However, the score which is within +-10% is acceptable, reliable and a good indicator of data quality and reporting system. About 56% (9/16) SRH indicators had a verification factor score outside the accepted range and 87% (13/15) discrepancy value outside the accepted range. For immunization, 10% (1/10) had a verification factor score outside the accepted range and 33% (3/9) had a discrepancy value outside the accepted range. The level of completeness was high for both Penta3 and Measles coverage and it was lowest for condom. Our findings highlight a poorer data quality for SRH indicators compared to child health indicators. A comprehensive program review drawing lessons from the child health indicators is required to improve the quality of administrative data in Botswana.

Prevention of unintended pregnancies by using emergency contraception: the differences between levonorgestrel and ulipristal acetate. A theoretical model using data from a survey on the use of emergency contraception in Spain, 2017

Objective: To estimate the differences in unintended pregnancies avoided using either levonorgestrel (LNG) or ulipristal acetate (UPA) emergency contraception (EC). Design: Cross-sectional study. Setting: Survey carried out in Spain. Participants: 1000 Spanish women reporting unprotected sex in 2017. Main measurements: EC use, reasons for not using EC, calculation of the number of unintended pregnancies avoided. Results: 39% of Spanish women having had unprotected sex used EC. 61% of those women did not use EC and 11% did not know the existence of this resource. In 2017 the use of EC prevented 101,271 unintended pregnancies. If instead of using LNG every woman had used UPA another 15,979 additional pregnancies could have been prevented. Conclusions: If all Spanish women having unprotected sex used EC we could expect a significant decrease in the number of unintended pregnancies and abortions. Using UPA instead of LNG would have a greater impact on that reduction with the corresponding benefit for women and society as a whole.

Venous Thromboembolism Among Women Initiating Depot Medroxyprogesterone Acetate Immediately Postpartum

OBJECTIVE

To estimate the absolute and relative risk of venous thromboembolism (VTE) among women who initiate depot medroxyprogesterone acetate (DMPA) immediately postpartum compared with those who do not initiate hormonal contraception.

METHODS

The IBM MarketScan Commercial Claims and Encounters databases were used to identify delivery hospitalizations among women aged 15-44 years during 2005 through 2014. Diagnosis, procedure, and drug codes were used to identify contraception, VTE, and potential confounding chronic or pregnancy-related conditions. Women who initiated DMPA during days 0 through 7 postpartum were compared with women who did not initiate hormonal contraception during days 0 through 7 postpartum. Women were followed from date of delivery through 12 weeks postpartum for the occurrence of VTE, with censoring at hormonal contraception initiation or prescription, hysterectomy, sterilization, or inpatient death. The incidence rate of VTE and 95% CIs were calculated within each group and the incidence rate ratio was calculated comparing the two groups.

RESULTS

The unadjusted VTE incidence rate through 12 weeks postpartum was 0.42/10,000 women-days in the immediate postpartum DMPA group (34 events among 11,159 women contributing 805,999 days of follow-up) and 0.15/10,000 women-days in the control group (3,107 events among 3,102,011 women contributing 206,180,811 days of follow-up). The incidence rate ratio for VTE was 2.87 (95% CI 2.05-4.03) among women in the immediate postpartum DMPA group compared with women in the control group, adjusting for age alone. After adjusting for age and pregnancy-related and chronic conditions, the adjusted incidence rate ratio for VTE was 1.94 (95% CI 1.38-2.72) among women in the immediate postpartum DMPA group compared with women in the control group.

CONCLUSION

Initiation of DMPA immediately postpartum is associated with a low incidence but an increased relative risk of VTE compared with nonuse of hormonal contraception.