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Sanchez E, Wilkinson T, Coughlan G, Mirza S, Baril A, Ramirez J, Binns MA, Black SE, Borrie M, Dilliott AA, Dixon RA, Dowlatshahi D, Farhan S, Finger E, Fischer CE, Frank A, Freedman M, Goncalves RA, Grimes DA, Hassan A, Hegele RA, Kumar S, Lang AE, Marras C, McLaughlin PM, Orange JB, Pasternak SH, Pollock BG, Rajji TK, Roberts AC, Robinson JF, Rogaeva E, Sahlas DJ, Saposnik G, Strong MJ, Swartz RH, Tang‐Wai DF, Tartaglia MC, Troyer AK, Kvartsberg H, Zetterberg H, Munoz DP, Masellis M. Association of plasma biomarkers with cognition, cognitive decline, and daily function across and within neurodegenerative diseases: Results from the Ontario Neurodegenerative Disease Research Initiative. Alzheimers Dement 2024; 20:1753-1770. [PMID: 38105605 PMCID: PMC10984487 DOI: 10.1002/alz.13560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/02/2023] [Accepted: 10/29/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION We investigated whether novel plasma biomarkers are associated with cognition, cognitive decline, and functional independence in activities of daily living across and within neurodegenerative diseases. METHODS Glial fibrillary acidic protein (GFAP), neurofilament light chain (NfL), phosphorylated tau (p-tau)181 and amyloid beta (Aβ)42/40 were measured using ultra-sensitive Simoa immunoassays in 44 healthy controls and 480 participants diagnosed with Alzheimer's disease/mild cognitive impairment (AD/MCI), Parkinson's disease (PD), frontotemporal dementia (FTD) spectrum disorders, or cerebrovascular disease (CVD). RESULTS GFAP, NfL, and/or p-tau181 were elevated among all diseases compared to controls, and were broadly associated with worse baseline cognitive performance, greater cognitive decline, and/or lower functional independence. While GFAP, NfL, and p-tau181 were highly predictive across diseases, p-tau181 was more specific to the AD/MCI cohort. Sparse associations were found in the FTD and CVD cohorts and for Aβ42/40 . DISCUSSION GFAP, NfL, and p-tau181 are valuable predictors of cognition and function across common neurodegenerative diseases, and may be useful in specialized clinics and clinical trials.
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Riek HC, Brien DC, Coe BC, Huang J, Perkins JE, Yep R, McLaughlin PM, Orange JB, Peltsch AJ, Roberts AC, Binns MA, Lou W, Abrahao A, Arnott SR, Beaton D, Black SE, Dowlatshahi D, Finger E, Fischer CE, Frank AR, Grimes DA, Kumar S, Lang AE, Lawrence-Dewar JM, Mandzia JL, Marras C, Masellis M, Pasternak SH, Pollock BG, Rajji TK, Sahlas DJ, Saposnik G, Seitz DP, Shoesmith C, Steeves TDL, Strother SC, Sunderland KM, Swartz RH, Tan B, Tang-Wai DF, Tartaglia MC, Turnbull J, Zinman L, Munoz DP. Cognitive correlates of antisaccade behaviour across multiple neurodegenerative diseases. Brain Commun 2023; 5:fcad049. [PMID: 36970045 PMCID: PMC10036290 DOI: 10.1093/braincomms/fcad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/01/2022] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Abstract
Oculomotor tasks generate a potential wealth of behavioural biomarkers for neurodegenerative diseases. Overlap between oculomotor and disease-impaired circuitry reveals the location and severity of disease processes via saccade parameters measured from eye movement tasks such as prosaccade and antisaccade. Existing studies typically examine few saccade parameters in single diseases, using multiple separate neuropsychological test scores to relate oculomotor behaviour to cognition; however, this approach produces inconsistent, ungeneralizable results and fails to consider the cognitive heterogeneity of these diseases. Comprehensive cognitive assessment and direct inter-disease comparison are crucial to accurately reveal potential saccade biomarkers.
We remediate these issues by characterizing twelve behavioural parameters, selected to robustly describe saccade behaviour, derived from an interleaved pro- and antisaccade task in a large cross-sectional dataset comprising five disease cohorts (Alzheimer’s disease/mild cognitive impairment, amyotrophic lateral sclerosis, frontotemporal dementia, Parkinson’s disease, cerebrovascular disease; n=391, age 40-87) and healthy controls (n=149, age 42-87). These participants additionally completed an extensive neuropsychological test battery. We further subdivided each cohort by diagnostic subgroup (for Alzheimer’s disease/mild cognitive impairment and frontotemporal dementia) or degree of cognitive impairment based on neuropsychological testing (all other cohorts). We sought to understand links between oculomotor parameters, their relationships to robust cognitive measures, and their alterations in disease. We performed a factor analysis evaluating interrelationships among the twelve oculomotor parameters and examined correlations of the four resultant factors to five neuropsychology-based cognitive domain scores. We then compared behaviour between the abovementioned disease subgroups and controls at the individual parameter level.
We theorized that each underlying factor measured the integrity of a distinct task-relevant brain process. Notably, factor 3 (voluntary saccade generation) and factor 1 (task disengagements) significantly correlated with attention/working memory and executive function scores. Factor 3 also correlated with memory and visuospatial function scores. Factor 2 (preemptive global inhibition) correlated only with attention/working memory scores, and factor 4 (saccade metrics) correlated with no cognitive domain scores. Impairment on several mostly antisaccade-related individual parameters scaled with cognitive impairment across disease cohorts, while few subgroups differed from controls on prosaccade parameters.
The interleaved pro- and antisaccade task detects cognitive impairment, and subsets of parameters likely index disparate underlying processes related to different cognitive domains. This suggests that the task represents a sensitive paradigm that can simultaneously evaluate a variety of clinically relevant cognitive constructs in neurodegenerative and cerebrovascular diseases and could be developed into a screening tool applicable to multiple diagnoses.
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Affiliation(s)
- Heidi C Riek
- Correspondence to: Heidi C. Riek Centre for Neuroscience Studies, Queen’s University Botterell Hall, 18 Stuart Street Kingston, ON K7L 3N6, Canada E-mail:
| | - Donald C Brien
- Centre for Neuroscience Studies, Queen’s University, Kingston, Ontario K7L 3N6Canada
| | - Brian C Coe
- Centre for Neuroscience Studies, Queen’s University, Kingston, Ontario K7L 3N6Canada
| | - Jeff Huang
- Centre for Neuroscience Studies, Queen’s University, Kingston, Ontario K7L 3N6Canada
| | - Julia E Perkins
- Centre for Neuroscience Studies, Queen’s University, Kingston, Ontario K7L 3N6Canada
| | - Rachel Yep
- Centre for Neuroscience Studies, Queen’s University, Kingston, Ontario K7L 3N6Canada
| | - Paula M McLaughlin
- Nova Scotia Health, Halifax, Nova Scotia B3S 0H6, Canada
- Department of Medicine (Geriatrics), Dalhousie University, Halifax, Nova Scotia B3H 2Y9, Canada
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, Nova Scotia B3H 4R2, Canada
| | - Joseph B Orange
- School of Communication Sciences and Disorders, Faculty of Health Sciences, Western University, London, Ontario N6G 1H1, Canada
- Canadian Centre for Activity and Aging, Faculty of Health Sciences, Western University, London, Ontario N6G 1H1, Canada
| | - Alicia J Peltsch
- Faculty of Engineering and Applied Science, Queen’s University, Kingston Ontario K7L 3N6, Canada
| | - Angela C Roberts
- School of Communication Sciences and Disorders, Faculty of Health Sciences, Western University, London, Ontario N6G 1H1, Canada
- Department of Computer Science, Western University, London, Ontario N6A 5B7, Canada
| | - Malcolm A Binns
- Rotman Research Institute, Baycrest Centre, North York, Ontario M6A 2E1, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M5T 3M7, Canada
| | - Wendy Lou
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M5T 3M7, Canada
| | - Agessandro Abrahao
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario M5S 3H2, Canada
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Stephen R Arnott
- Rotman Research Institute, Baycrest Centre, North York, Ontario M6A 2E1, Canada
| | - Derek Beaton
- Present address: Data Science and Advanced Analytics, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario M5B 1W8, Canada
| | - Sandra E Black
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario M5S 3H2, Canada
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa, Ottawa, Ontario K1H 8M5, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario K1Y 4E9, Canada
| | - Elizabeth Finger
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario N6A 3K7, Canada
| | - Corinne E Fischer
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, Ontario M5B 1W8, Canada
| | - Andrew R Frank
- Department of Medicine (Neurology), University of Ottawa, Ottawa, Ontario K1H 8M5, Canada
- Bruyere Research Institute, Ottawa, Ontario K1R 6M1, Canada
| | - David A Grimes
- Department of Medicine (Neurology), University of Ottawa, Ottawa, Ontario K1H 8M5, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario K1Y 4E9, Canada
- University of Ottawa Brain and Mind Research Institute, University of Ottawa, Ottawa, Ontario K1H 8M5, Canada
| | - Sanjeev Kumar
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario M6J 1H4, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Anthony E Lang
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario M5S 3H2, Canada
- Edmond J. Safra Program in Parkinson’s Disease, Toronto Western Hospital, Toronto, Ontario M5T 2S8, Canada
| | - Jane M Lawrence-Dewar
- Thunder Bay Regional Health Research Institute, Thunder Bay, Ontario P7B 7A5, Canada
| | - Jennifer L Mandzia
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario N6A 3K7, Canada
- London Health Sciences Centre, London, Ontario N6A 5W9, Canada
| | - Connie Marras
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario M5S 3H2, Canada
- Edmond J. Safra Program in Parkinson’s Disease, Toronto Western Hospital, Toronto, Ontario M5T 2S8, Canada
| | - Mario Masellis
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario M4N 3M5, Canada
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario M5S 3H2, Canada
- Cognitive and Movement Disorders Clinic, Sunnybrook Health Sciences Centre, Toronto, Ontario M4N 3M5, Canada
| | - Stephen H Pasternak
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario N6A 3K7, Canada
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario N6A 5B7, Canada
- Cognitive Neurology and Alzheimer’s Disease Research Centre, Parkwood Institute, St. Joseph’s Health Care, London, Ontario N6A 4V2, Canada
| | - Bruce G Pollock
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario M6J 1H4, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Tarek K Rajji
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada
- Toronto Dementia Research Alliance, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Demetrios J Sahlas
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario L8N 3Z5, Canada
| | - Gustavo Saposnik
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario M5S 3H2, Canada
| | - Dallas P Seitz
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Alberta T2N 1N4, Canada
| | - Christen Shoesmith
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario N6A 3K7, Canada
- London Health Sciences Centre, London, Ontario N6A 5W9, Canada
| | - Thomas D L Steeves
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario M5S 3H2, Canada
- Division of Neurology, St. Michael’s Hospital, Toronto, Ontario M5B 1W8, Canada
| | - Stephen C Strother
- Rotman Research Institute, Baycrest Centre, North York, Ontario M6A 2E1, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario M5G 1L7, Canada
| | - Kelly M Sunderland
- Rotman Research Institute, Baycrest Centre, North York, Ontario M6A 2E1, Canada
| | - Richard H Swartz
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario M5S 3H2, Canada
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Brian Tan
- Rotman Research Institute, Baycrest Centre, North York, Ontario M6A 2E1, Canada
| | - David F Tang-Wai
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario M5S 3H2, Canada
- University Health Network Memory Clinic, Krembil Brain Institute, Toronto Western Hospital, Toronto, Ontario M5T 2S8, Canada
| | - Maria Carmela Tartaglia
- University Health Network Memory Clinic, Krembil Brain Institute, Toronto Western Hospital, Toronto, Ontario M5T 2S8, Canada
- Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - John Turnbull
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario L8N 3Z5, Canada
| | - Lorne Zinman
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario M5S 3H2, Canada
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Douglas P Munoz
- Centre for Neuroscience Studies, Queen’s University, Kingston, Ontario K7L 3N6Canada
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, Ontario K7L 3N6, Canada
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Sunderland KM, Beaton D, Arnott SR, Kleinstiver P, Kwan D, Lawrence-Dewar JM, Ramirez J, Tan B, Bartha R, Black SE, Borrie M, Brien D, Casaubon LK, Coe BC, Cornish B, Dilliott AA, Dowlatshahi D, Finger E, Fischer C, Frank A, Fraser J, Freedman M, Greenberg B, Grimes DA, Hassan A, Hatch W, Hegele RA, Hudson C, Jog M, Kumar S, Lang A, Levine B, Lou W, Mandzia J, Marras C, McIlroy W, Montero-Odasso M, Munoz DG, Munoz DP, Orange JB, Park DS, Pasternak SH, Pieruccini-Faria F, Rajji TK, Roberts AC, Robinson JF, Rogaeva E, Sahlas DJ, Saposnik G, Scott CJM, Seitz D, Shoesmith C, Steeves TDL, Strong MJ, Strother SC, Swartz RH, Symons S, Tang-Wai DF, Tartaglia MC, Troyer AK, Turnbull J, Zinman L, McLaughlin PM, Masellis M, Binns MA, Adamo S, Berezuk C, Black A, Breen DP, Bulman D, Chen Y, El‐Defrawy S, Farhan S, Ghani M, Gonder J, Haddad SMH, Holmes M, Huang J, Leontieva E, Mandelcorn E, Margolin E, Nanayakkara N, Ozzoude M, Peltsch AJ, Pollock B, Raamana P, Rashkovan N, Yanina, Southwell A, Sujanthan S, Tayyari F, Van Ooteghem K, Woulfe J, Zamyadi M, Zou G. Characteristics of the Ontario Neurodegenerative Disease Research Initiative cohort. Alzheimers Dement 2023; 19:226-243. [PMID: 36318754 DOI: 10.1002/alz.12632] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 12/01/2021] [Accepted: 12/17/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Understanding synergies between neurodegenerative and cerebrovascular pathologies that modify dementia presentation represents an important knowledge gap. METHODS This multi-site, longitudinal, observational cohort study recruited participants across prevalent neurodegenerative diseases and cerebrovascular disease and assessed participants comprehensively across modalities. We describe univariate and multivariate baseline features of the cohort and summarize recruitment, data collection, and curation processes. RESULTS We enrolled 520 participants across five neurodegenerative and cerebrovascular diseases. Median age was 69 years, median Montreal Cognitive Assessment score was 25, median independence in activities of daily living was 100% for basic and 93% for instrumental activities. Spousal study partners predominated; participants were often male, White, and more educated. Milder disease stages predominated, yet cohorts reflect clinical presentation. DISCUSSION Data will be shared with the global scientific community. Within-disease and disease-agnostic approaches are expected to identify markers of severity, progression, and therapy targets. Sampling characteristics also provide guidance for future study design.
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Affiliation(s)
- Kelly M Sunderland
- Rotman Research Institute, Baycrest Health Sciences, Toronto, Ontario, Canada
| | - Derek Beaton
- Rotman Research Institute, Baycrest Health Sciences, Toronto, Ontario, Canada
| | - Stephen R Arnott
- Rotman Research Institute, Baycrest Health Sciences, Toronto, Ontario, Canada
| | - Peter Kleinstiver
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Donna Kwan
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
| | | | - Joel Ramirez
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Brian Tan
- Rotman Research Institute, Baycrest Health Sciences, Toronto, Ontario, Canada
| | - Robert Bartha
- Robarts Research Institute, Western University, London, Ontario, Canada.,Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Sandra E Black
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada
| | - Michael Borrie
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,St. Joseph's Healthcare Centre, London, Ontario, Canada
| | - Donald Brien
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
| | - Leanne K Casaubon
- Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada.,Toronto Western Hospital, Toronto, Ontario, Canada
| | - Brian C Coe
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
| | - Benjamin Cornish
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Allison A Dilliott
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Robarts Research Institute, Western University, London, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Elizabeth Finger
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Corinne Fischer
- Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Andrew Frank
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Julia Fraser
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Morris Freedman
- Rotman Research Institute, Baycrest Health Sciences, Toronto, Ontario, Canada.,Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada.,Division of Neurology, Baycrest Health Sciences, Toronto, Ontario, Canada
| | - Barry Greenberg
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David A Grimes
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ayman Hassan
- Thunder Bay Regional Health Research Institute, Thunder Bay, Ontario, Canada
| | - Wendy Hatch
- Kensington Eye Institute, Toronto, Ontario, Canada.,Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Robert A Hegele
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Robarts Research Institute, Western University, London, Ontario, Canada
| | - Christopher Hudson
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada.,School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Mandar Jog
- London Health Sciences Centre, London, Ontario, Canada
| | - Sanjeev Kumar
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Lang
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Brian Levine
- Rotman Research Institute, Baycrest Health Sciences, Toronto, Ontario, Canada.,Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada.,Department of Psychology, University of Toronto, Toronto, Ontario, Canada
| | - Wendy Lou
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Mandzia
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada
| | - Connie Marras
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, Toronto, Ontario, Canada
| | - William McIlroy
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Manuel Montero-Odasso
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Gait and Brain Lab, Parkwood Institute, London, Ontario, Canada
| | - David G Munoz
- Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Douglas P Munoz
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
| | - Joseph B Orange
- School of Communication Sciences and Disorders, Elborn College, Western University, London, Ontario, Canada
| | - David S Park
- Hotchkiss Brain Institute, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Stephen H Pasternak
- St. Joseph's Healthcare Centre, London, Ontario, Canada.,Cognitive Neurology and Alzheimer's Disease Research Centre, Parkwood Institute, London, Ontario, Canada
| | - Frederico Pieruccini-Faria
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Gait and Brain Lab, Parkwood Institute, London, Ontario, Canada
| | - Tarek K Rajji
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Angela C Roberts
- School of Communication Sciences and Disorders, Elborn College, Western University, London, Ontario, Canada.,Roxelyn and Richard Pepper Department of Communication Sciences and Disorders, Northwestern University, Evanston, Illinois, USA
| | - John F Robinson
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Robarts Research Institute, Western University, London, Ontario, Canada
| | - Ekaterina Rogaeva
- Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada
| | | | - Gustavo Saposnik
- Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Christopher J M Scott
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dallas Seitz
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Michael J Strong
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Canadian Institutes for Health Research, Ottawa, Ontario, Canada
| | - Stephen C Strother
- Rotman Research Institute, Baycrest Health Sciences, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Richard H Swartz
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada
| | - Sean Symons
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - David F Tang-Wai
- Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Maria Carmela Tartaglia
- Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Angela K Troyer
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada.,Neuropsychology and Cognitive Health, Baycrest Health Sciences, Toronto, Ontario, Canada
| | - John Turnbull
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lorne Zinman
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada
| | - Paula M McLaughlin
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada.,Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Mario Masellis
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada
| | - Malcolm A Binns
- Rotman Research Institute, Baycrest Health Sciences, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Rajan R, Brennan L, Bloem BR, Dahodwala N, Gardner J, Goldman JG, Grimes DA, Iansek R, Kovács N, McGinley J, Parashos SA, Piemonte ME, Eggers C. Integrated Care in Parkinson's Disease: A Systematic Review and
Meta‐Analysis. Mov Disord 2020; 35:1509-1531. [DOI: 10.1002/mds.28097] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
- Roopa Rajan
- All India Institute of Medical Sciences New Delhi India
| | | | - Bastiaan R. Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders Nijmegen The Netherlands
| | - Nabila Dahodwala
- Department of Neurology, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Joan Gardner
- Struthers Parkinson's Center, Park Nicollet Health Services Golden Valley Minnesota USA
| | - Jennifer G. Goldman
- Parkinson's Disease and Movement Disorders, Shirley Ryan Abilitylab; Department of Physical Medicine & Rehabilitation and Neurology Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - David A. Grimes
- Ottawa Hospital, University of Ottawa Brain and Mind Research Institute Ottawa Ontario Canada
| | - Robert Iansek
- Clinical Research Centre for Movement Disorders and Gait, Comprehensive Parkinson Care Program, Parkinson Foundation Centre of Excellence, Kington Centre Monash Health Cheltenham Victoria Australia
- Department of Clinical Sciences Monash University Clayton Victoria Australia
| | - Norbert Kovács
- Department of Neurology Universityof Pécs Pécs Hungary
- MTA‐PTE Clinical Neuroscience MR Research Group Pécs Hungary
| | - Jennifer McGinley
- Physiotherapy Department The University of Melbourne Melbourne Australia
| | - Sotirios A. Parashos
- Struthers Parkinson's Center, Park Nicollet Health Services Golden Valley Minnesota USA
| | - Maria E.P. Piemonte
- University of Sao Paulo, Medical School, Physical Therapy, Speech Therapy and Occupational Therapy Department Sao Paulo Brazil
| | - Carsten Eggers
- Department of Neurology, University Hospital Marburg; Center for Mind, Brain and Behavior Universities Gießen & Marburg Marburg Germany
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6
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Schulz KF, Chalmers I, Altman DG, Grimes DA, Moher D, Hayes RJ. 'Allocation concealment': the evolution and adoption of a methodological term. J R Soc Med 2018; 111:216-224. [PMID: 29877772 PMCID: PMC6022887 DOI: 10.1177/0141076818776604] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Kenneth F Schulz
- FHI 360, 359 Blackwell Street, Suite
200, Durham, NC 27701, USA and Department of Obstetrics and Gynaecology, University
of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - I Chalmers
- James Lind Initiative, Summertown
Pavilion, Middle Way, Oxford OX2 7LG, UK
| | - DG Altman
- Centre for Statistics in Medicine,
University of Oxford, Nuffield Department of Orthopaedics, Rheumatology &
Musculoskeletal Sciences, Botnar Research Centre, Oxford OX3 7LD, UK
| | - DA Grimes
- Department of Obstetrics and
Gynaecology, University of North Carolina School of Medicine, Chapel Hill, NC 27514,
USA
| | - D Moher
- Centre for Journalology, Clinical
Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital -
General Campus, 501 Smyth Rd, Room L1288, Ottawa, ON, K1H 8L6, Canada
| | - RJ Hayes
- Department of Infectious Disease
Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street,
London WC1E 7HT, UK
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7
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Montero-Odasso M, Pieruccini-Faria F, Bartha R, Black SE, Finger E, Freedman M, Greenberg B, Grimes DA, Hegele RA, Hudson C, Kleinstiver PW, Lang AE, Masellis M, McLaughlin PM, Munoz DP, Strother S, Swartz RH, Symons S, Tartaglia MC, Zinman L, Strong MJ, McIlroy W. Motor Phenotype in Neurodegenerative Disorders: Gait and Balance Platform Study Design Protocol for the Ontario Neurodegenerative Research Initiative (ONDRI). J Alzheimers Dis 2018; 59:707-721. [PMID: 28671116 PMCID: PMC5523841 DOI: 10.3233/jad-170149] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: The association of cognitive and motor impairments in Alzheimer’s disease and other neurodegenerative diseases is thought to be related to damage in the common brain networks shared by cognitive and cortical motor control processes. These common brain networks play a pivotal role in selecting movements and postural synergies that meet an individual’s needs. Pathology in this “highest level” of motor control produces abnormalities of gait and posture referred to as highest-level gait disorders. Impairments in cognition and mobility, including falls, are present in almost all neurodegenerative diseases, suggesting common mechanisms that still need to be unraveled. Objective: To identify motor-cognitive profiles across neurodegenerative diseases in a large cohort of patients. Methods: Cohort study that includes up to 500 participants, followed every year for three years, across five neurodegenerative disease groups: Alzheimer’s disease/mild cognitive impairment, frontotemporal degeneration, vascular cognitive impairment, amyotrophic lateral sclerosis, and Parkinson’s disease. Gait and balance will be assessed using accelerometers and electronic walkways, evaluated at different levels of cognitive and sensory complexity, using the dual-task paradigm. Results: Comparison of cognitive and motor performances across neurodegenerative groups will allow the identification of motor-cognitive phenotypes through the standardized evaluation of gait and balance characteristics. Conclusions: As part of the Ontario Neurodegenerative Research Initiative (ONDRI), the gait and balance platform aims to identify motor-cognitive profiles across neurodegenerative diseases. Gait assessment, particularly while dual-tasking, will help dissect the cognitive and motor contribution in mobility and cognitive decline, progression to dementia syndromes, and future adverse outcomes including falls and mortality.
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Affiliation(s)
- Manuel Montero-Odasso
- Department of Medicine, Division of Geriatric Medicine, Parkwood Hospital, University of Western Ontario, London, ON, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Frederico Pieruccini-Faria
- Department of Medicine, Division of Geriatric Medicine, Parkwood Hospital, University of Western Ontario, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Robert Bartha
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Robarts Research Institute, University of Western Ontario, London, ON, Canada
| | - Sandra E Black
- Department of Medicine, Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada.,Canadian Partnership for Stroke Recovery Sunnybrook Site, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Elizabeth Finger
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Morris Freedman
- Department of Medicine (Neurology), Baycrest Health Sciences and University of Toronto, Toronto, ON, Canada; Rotman Research Institute, Baycrest Centre for Geriatric Care, Toronto, ON, Canada
| | - Barry Greenberg
- Toronto Dementia Research Alliance, University Health Network, Toronto, ON, Canada
| | - David A Grimes
- Department of Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Robert A Hegele
- Department of Biochemistry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Robarts Research Institute, University of Western Ontario, London, ON, Canada
| | - Christopher Hudson
- School of Optometry and Vision Science, University of Waterloo, Waterloo, ON, Canada
| | - Peter W Kleinstiver
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Anthony E Lang
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital and the Department of Medicine, University of Toronto, ON, Canada
| | - Mario Masellis
- Department of Medicine, Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada
| | - Paula M McLaughlin
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Douglas P Munoz
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Stephen Strother
- Department of Medical Biophysics, Rotman Research Institute, Baycrest, University of Toronto, ON, Canada
| | - Richard H Swartz
- Sunnybrook Health Sciences Centre, University of Toronto, Stroke Research Program, Toronto, ON, Canada
| | - Sean Symons
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Maria Carmela Tartaglia
- Department of Medicine and Division of Neurology, University of Toronto, Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, ON, Canada
| | - Lorne Zinman
- Department of Medicine, Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada
| | - Michael J Strong
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Department of Medicine (Neurology), Baycrest Health Sciences and University of Toronto, Toronto, ON, Canada; Rotman Research Institute, Baycrest Centre for Geriatric Care, Toronto, ON, Canada
| | | | - William McIlroy
- Canadian Partnership for Stroke Recovery Sunnybrook Site, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital and the Department of Medicine, University of Toronto, ON, Canada.,Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada
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8
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Han F, Grimes DA, Li F, Wang T, Yu Z, Song N, Wu S, Racacho L, Bulman DE. Mutations in the glucocerebrosidase gene are common in patients with Parkinson's disease from Eastern Canada. Int J Neurosci 2015; 126:415-21. [PMID: 26000814 DOI: 10.3109/00207454.2015.1023436] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Mutations in the β-glucocerebrosidase gene (GBA) have been implicated as a risk factor for Parkinson's disease (PD). However, GBA mutations in PD patients of different ethnic origins were reported to be inconsistent. METHODS We sequenced all exons of the GBA gene in 225 PD patients and 110 control individuals from Eastern Canada. RESULT Two novel GBA variants of c.-119 A/G and S(-35)N, five known GBA mutations of R120W, N370S, L444P, RecNciI and RecTL mutation (del55/D409H/RecNciI) as well as two non-pathological variants of E326K and T369M were identified from PD patients while only one mutation of S13L and two non-pathological variants of E326K and T369M were found in the control individuals. The frequency of GBA mutations within PD patients (4.4%) is 4.8 times higher than the 0.91% observed in control individuals (X(2) = 2.91, p = 0.088; odds ratio = 4.835; 95% confidence interval = 2.524-9.123). The most common mutations of N370S and L444P accounted for 36.0% (9/25) of all the GBA mutations in this Eastern Canadian PD cohort. The frequency (6.67%) of E326K and T369M in PD patients is comparable to 7.27% in control individuals (X(2) = 0.042, p = 0.8376), further supporting that these two variants have no pathological effects on PD. Phenotype analysis showed that no significant difference in family history, age at onset and cognitive impairment was identified between the GBA mutation carriers and non-GBA mutation carriers. CONCLUSION GBA mutations were found to be a common genetic risk factor for PD in Eastern Canadian patients.
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Affiliation(s)
- Fabin Han
- a 1 Centre for Stem cells and Regenerative Medicine, The Affiliated Liaocheng Hospital/Liaocheng People's Hospital , Taishan Medical University , Liaocheng , China.,b 2 Department of Neurology, The Affiliated Liaocheng Hospital/Liaocheng People's Hospital , Taishan Medical University , Liaocheng , China
| | - David A Grimes
- c 3 Department of Medicine, The Ottawa Hospital , University of Ottawa , Ottawa , Canada
| | - Fang Li
- c 3 Department of Medicine, The Ottawa Hospital , University of Ottawa , Ottawa , Canada
| | - Ting Wang
- a 1 Centre for Stem cells and Regenerative Medicine, The Affiliated Liaocheng Hospital/Liaocheng People's Hospital , Taishan Medical University , Liaocheng , China
| | - Zhe Yu
- a 1 Centre for Stem cells and Regenerative Medicine, The Affiliated Liaocheng Hospital/Liaocheng People's Hospital , Taishan Medical University , Liaocheng , China
| | - Na Song
- a 1 Centre for Stem cells and Regenerative Medicine, The Affiliated Liaocheng Hospital/Liaocheng People's Hospital , Taishan Medical University , Liaocheng , China
| | - Shichao Wu
- a 1 Centre for Stem cells and Regenerative Medicine, The Affiliated Liaocheng Hospital/Liaocheng People's Hospital , Taishan Medical University , Liaocheng , China
| | - Lemuel Racacho
- d 4 Department of Pediatrics, Children's Hospital of Eastern Ontario Research Institute , University of Ottawa , Ottawa , Canada
| | - Dennis E Bulman
- d 4 Department of Pediatrics, Children's Hospital of Eastern Ontario Research Institute , University of Ottawa , Ottawa , Canada
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9
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Grimes DA. Epidemiologic research with administrative databases: red herrings, false alarms and pseudo-epidemics. Hum Reprod 2015; 30:1749-52. [PMID: 26113658 DOI: 10.1093/humrep/dev151] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 06/01/2015] [Indexed: 12/16/2022] Open
Affiliation(s)
- David A Grimes
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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10
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Abstract
Background:Recently, a single base pair substitution (G1747A) mutation of the neurofilament M (NF-M) gene was reported in a French-Canadian patient with early onset Parkinson’s disease (PD). Three unaffected siblings were found to be heterozygotes for the NF-M Gly336Ser mutation but, to date, no other affected PD individuals have been found with a similar mutation. No other individuals with Parkinson’s disease and of similar ethnic background have been screened for this mutation.Methods:We screened 102 French-Canadian patients with definite PD and 45 French-Canadian controls for this substitution in the NF-M gene using a PCR-restriction enzyme digestion method.Results:None of the patients or controls carried this mutation.Conclusion:Our results would indicate that this mutation is not common even in a PD population of similar ethnic background and suggest this change represents a rare variant. However, these results do not exclude the possibility that other mutations in this gene could be present.
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Affiliation(s)
- F Han
- Ottawa Health Research Institute, University of Ottawa, Centre for Neuromuscular Disease, Ottawa, Canada
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11
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Abstract
BACKGROUND The avoidance of menstruation through continuous or extended (greater than 28 days) administration of combination hormonal contraceptives (CHCs) has gained legitimacy through its use in treating endometriosis, dysmenorrhea, and menstruation-associated symptoms. Avoidance of menstruation through extended or continuous use of CHCs for reasons of personal preference may have additional advantages to women, including improved compliance, greater satisfaction, fewer menstrual symptoms, and less menstruation-related absenteeism from work or school. OBJECTIVES To determine the differences between continuous or extended-cycle CHCs (pills, patch, ring) in regimens of greater than 28 days of active hormone compared with traditional cyclic dosing (21 days of active hormone and 7 days of placebo, or 24 days of active hormones and 4 days of placebo). Our hypothesis was that continuous or extended-cycle CHCs have equivalent efficacy and safety but improved bleeding profiles, amenorrhea rates, adherence, continuation, participant satisfaction, and menstrual symptoms compared with standard cyclic CHCs. SEARCH METHODS We searched computerized databases (Cochrane Central Register of Controlled Trials, PUBMED, EMBASE, POPLINE, LILACS) for trials using continuous or extended CHCs (oral contraceptives, contraceptive ring and patch) during the years 1966 to 2013. We also searched the references in review articles and publications identified for inclusion in the protocol. Investigators were contacted regarding additional references. SELECTION CRITERIA All randomized controlled trials in any language comparing continuous or extended-cycle (greater than 28 days of active hormones) versus traditional cyclic administration (21 days of active hormones and 7 days of placebo, or 24 days of active hormones and 4 days of placebo) of CHCs for contraception. DATA COLLECTION AND ANALYSIS Titles and abstracts identified from the literature searches were assessed for potential inclusion. Data were extracted onto data collection forms and then entered into RevMan 5. Peto odds ratios with 95% confidence intervals were calculated for all outcomes for dichotomous outcomes. Weighted mean difference was calculated for continuous outcomes. The trials were critically appraised by examining the following factors: study design, blinding, randomization method, group allocation concealment, exclusions after randomization, loss to follow-up, and early discontinuation. Because the included trials did not have a standard treatment (type of CHC formulation, route of delivery, or time length for continuous dosing), we could not aggregate data into meta-analysis. MAIN RESULTS Twelve randomized controlled trials met our inclusion criteria. Study findings were similar between 28-day and extended or continuous regimens in regard to contraceptive efficacy (i.e., pregnancy rates) and safety profiles. When compliance was reported, no difference between 28-day and extended or continuous cycles was found. Participants reported high satisfaction with both dosing regimens, but this was not an outcome universally studied. Overall discontinuation and discontinuation for bleeding problems were not uniformly higher in either group. The studies that reported menstrual symptoms found that the extended or continuous group fared better in terms of headaches, genital irritation, tiredness, bloating, and menstrual pain. Eleven out of the twelve studies found that bleeding patterns were either equivalent between groups or improved with extended or continuous cycles over time. Endometrial lining assessments by ultrasound and/or endometrial biopsy were done in some participants and were all normal after cyclic or extended CHC use. AUTHORS' CONCLUSIONS The 2014 update yielded four additional trials but unchanged conclusions. Evidence from existing randomized control trials comparing continuous or extended-cycle CHCs (greater than 28 days of active combined hormones) to traditional cyclic dosing (21 days of active hormone and 7 days of placebo, or 24 days of active hormone and 4 days of placebo) is of good quality. However, the variations in type of hormones and time length for extended-cycle dosing make a formal meta-analysis impossible. Future studies should choose a previously described type of CHC and dosing regimen. More attention needs to be directed towards participant satisfaction, continuation, and menstruation-associated symptoms.
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Affiliation(s)
- Alison Edelman
- Dept. of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
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12
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Beal MF, Oakes D, Shoulson I, Henchcliffe C, Galpern WR, Haas R, Juncos JL, Nutt JG, Voss TS, Ravina B, Shults CM, Helles K, Snively V, Lew MF, Griebner B, Watts A, Gao S, Pourcher E, Bond L, Kompoliti K, Agarwal P, Sia C, Jog M, Cole L, Sultana M, Kurlan R, Richard I, Deeley C, Waters CH, Figueroa A, Arkun A, Brodsky M, Ondo WG, Hunter CB, Jimenez-Shahed J, Palao A, Miyasaki JM, So J, Tetrud J, Reys L, Smith K, Singer C, Blenke A, Russell DS, Cotto C, Friedman JH, Lannon M, Zhang L, Drasby E, Kumar R, Subramanian T, Ford DS, Grimes DA, Cote D, Conway J, Siderowf AD, Evatt ML, Sommerfeld B, Lieberman AN, Okun MS, Rodriguez RL, Merritt S, Swartz CL, Martin WRW, King P, Stover N, Guthrie S, Watts RL, Ahmed A, Fernandez HH, Winters A, Mari Z, Dawson TM, Dunlop B, Feigin AS, Shannon B, Nirenberg MJ, Ogg M, Ellias SA, Thomas CA, Frei K, Bodis-Wollner I, Glazman S, Mayer T, Hauser RA, Pahwa R, Langhammer A, Ranawaya R, Derwent L, Sethi KD, Farrow B, Prakash R, Litvan I, Robinson A, Sahay A, Gartner M, Hinson VK, Markind S, Pelikan M, Perlmutter JS, Hartlein J, Molho E, Evans S, Adler CH, Duffy A, Lind M, Elmer L, Davis K, Spears J, Wilson S, Leehey MA, Hermanowicz N, Niswonger S, Shill HA, Obradov S, Rajput A, Cowper M, Lessig S, Song D, Fontaine D, Zadikoff C, Williams K, Blindauer KA, Bergholte J, Propsom CS, Stacy MA, Field J, Mihaila D, Chilton M, Uc EY, Sieren J, Simon DK, Kraics L, Silver A, Boyd JT, Hamill RW, Ingvoldstad C, Young J, Thomas K, Kostyk SK, Wojcieszek J, Pfeiffer RF, Panisset M, Beland M, Reich SG, Cines M, Zappala N, Rivest J, Zweig R, Lumina LP, Hilliard CL, Grill S, Kellermann M, Tuite P, Rolandelli S, Kang UJ, Young J, Rao J, Cook MM, Severt L, Boyar K. A randomized clinical trial of high-dosage coenzyme Q10 in early Parkinson disease: no evidence of benefit. JAMA Neurol 2014; 71:543-52. [PMID: 24664227 DOI: 10.1001/jamaneurol.2014.131] [Citation(s) in RCA: 233] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Coenzyme Q10 (CoQ10), an antioxidant that supports mitochondrial function, has been shown in preclinical Parkinson disease (PD) models to reduce the loss of dopamine neurons, and was safe and well tolerated in early-phase human studies. A previous phase II study suggested possible clinical benefit. OBJECTIVE To examine whether CoQ10 could slow disease progression in early PD. DESIGN, SETTING, AND PARTICIPANTS A phase III randomized, placebo-controlled, double-blind clinical trial at 67 North American sites consisting of participants 30 years of age or older who received a diagnosis of PD within 5 years and who had the following inclusion criteria: the presence of a rest tremor, bradykinesia, and rigidity; a modified Hoehn and Yahr stage of 2.5 or less; and no anticipated need for dopaminergic therapy within 3 months. Exclusion criteria included the use of any PD medication within 60 days, the use of any symptomatic PD medication for more than 90 days, atypical or drug-induced parkinsonism, a Unified Parkinson's Disease Rating Scale (UPDRS) rest tremor score of 3 or greater for any limb, a Mini-Mental State Examination score of 25 or less, a history of stroke, the use of certain supplements, and substantial recent exposure to CoQ10. Of 696 participants screened, 78 were found to be ineligible, and 18 declined participation. INTERVENTIONS The remaining 600 participants were randomly assigned to receive placebo, 1200 mg/d of CoQ10, or 2400 mg/d of CoQ10; all participants received 1200 IU/d of vitamin E. MAIN OUTCOMES AND MEASURES Participants were observed for 16 months or until a disability requiring dopaminergic treatment. The prospectively defined primary outcome measure was the change in total UPDRS score (Parts I-III) from baseline to final visit. The study was powered to detect a 3-point difference between an active treatment and placebo. RESULTS The baseline characteristics of the participants were well balanced, the mean age was 62.5 years, 66% of participants were male, and the mean baseline total UPDRS score was 22.7. A total of 267 participants required treatment (94 received placebo, 87 received 1200 mg/d of CoQ10, and 86 received 2400 mg/d of CoQ10), and 65 participants (29 who received placebo, 19 who received 1200 mg/d of CoQ10, and 17 who received 2400 mg/d of CoQ10) withdrew prematurely. Treatments were well tolerated with no safety concerns. The study was terminated after a prespecified futility criterion was reached. At study termination, both active treatment groups showed slight adverse trends relative to placebo. Adjusted mean changes (worsening) in total UPDRS scores from baseline to final visit were 6.9 points (placebo), 7.5 points (1200 mg/d of CoQ10; P = .49 relative to placebo), and 8.0 points (2400 mg/d of CoQ10; P = .21 relative to placebo). CONCLUSIONS AND RELEVANCE Coenzyme Q10 was safe and well tolerated in this population, but showed no evidence of clinical benefit. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00740714.
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Affiliation(s)
| | - M Flint Beal
- Department of Neurology, Weill Cornell Medical College, New York Hospital, New York
| | - David Oakes
- Department of Biostatistics, University of Rochester Medical Center, Rochester, New York
| | - Ira Shoulson
- Department of Neurology, Georgetown University, Washington, DC
| | - Claire Henchcliffe
- Department of Neurology, Weill Cornell Medical College, New York Hospital, New York
| | | | - Richard Haas
- Department of Neurosciences, University of California, San Diego, La Jolla
| | - Jorge L Juncos
- Department of Neurology, Emory University School of Medicine, Wesley Woods Center, Atlanta, Georgia
| | - John G Nutt
- Department of Neurology, Oregon Health and Science University, Portland
| | | | | | - Clifford M Shults
- Department of Neurosciences, University of California, San Diego, La Jolla10VA Medical Center, San Diego, California
| | - Karen Helles
- Department of Biostatistics, University of Rochester Medical Center, Rochester, New York
| | - Victoria Snively
- Department of Biostatistics, University of Rochester Medical Center, Rochester, New York
| | - Mark F Lew
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles
| | - Brian Griebner
- Department of Biostatistics, University of Rochester Medical Center, Rochester, New York
| | - Arthur Watts
- Department of Biostatistics, University of Rochester Medical Center, Rochester, New York12Department of Neurology, University of Rochester, Rochester, New York
| | - Shan Gao
- Department of Biostatistics, University of Rochester Medical Center, Rochester, New York
| | - Emmanuelle Pourcher
- Québec Memory and Motor Skills Disorders Research Center, Clinique Sainte-Anne, Québec, Canada
| | - Louisette Bond
- Québec Memory and Motor Skills Disorders Research Center, Clinique Sainte-Anne, Québec, Canada
| | | | - Pinky Agarwal
- Booth Gardner Parkinson's Care Center, EvergreenHealth, Kirkland, Washington
| | - Cherissa Sia
- Booth Gardner Parkinson's Care Center, EvergreenHealth, Kirkland, Washington
| | - Mandar Jog
- London Health Sciences Centre, London, Ontario, Canada
| | - Linda Cole
- London Health Sciences Centre, London, Ontario, Canada
| | | | - Roger Kurlan
- Overlook Medical Center, Atlantic Neuroscience Institute, Summit, New Jersey
| | - Irene Richard
- Department of Neurology, University of Rochester, Rochester, New York
| | - Cheryl Deeley
- Department of Neurology, University of Rochester, Rochester, New York
| | - Cheryl H Waters
- Columbia University Medical Center, Neurological Institute, New York, New York
| | - Angel Figueroa
- Columbia University Medical Center, Neurological Institute, New York, New York
| | - Ani Arkun
- Department of Neurology, Weill Cornell Medical College, New York Hospital, New York
| | - Matthew Brodsky
- Department of Neurology, Oregon Health and Science University, Portland
| | - William G Ondo
- Department of Neurology, University of Texas Health Science Center at Houston
| | | | | | - Alicia Palao
- Department of Neurology, Baylor College of Medicine, Houston, Texas
| | - Janis M Miyasaki
- Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Julie So
- Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - James Tetrud
- The Parkinson's Institute and Clinical Center, Sunnyvale, California
| | - Liza Reys
- The Parkinson's Institute and Clinical Center, Sunnyvale, California
| | - Katharine Smith
- The Parkinson's Institute and Clinical Center, Sunnyvale, California
| | - Carlos Singer
- Department of Neurology, University of Miami School of Medicine, Miami, Florida
| | - Anita Blenke
- Department of Neurology, University of Miami School of Medicine, Miami, Florida
| | - David S Russell
- Institute for Neurodegenerative Disorders, New Haven, Connecticut
| | - Candace Cotto
- Institute for Neurodegenerative Disorders, New Haven, Connecticut
| | - Joseph H Friedman
- Department of Neurology, Butler Hospital, Providence, Rhode Island26Alpert Medical School, Brown University, Providence, Rhode Island
| | - Margaret Lannon
- Department of Neurology, Butler Hospital, Providence, Rhode Island27Port City Neurology, Inc, Scarborough, Maine
| | - Lin Zhang
- Department of Neurology, University of California, Davis, School of Medicine and Sacramento VA Medical Center, Sacramento
| | | | | | - Thyagarajan Subramanian
- Milton S. Hershey Medical Center, Department of Neurology, Pennsylvania State Hershey College of Medicine, Hershey
| | - Donna Stuppy Ford
- Milton S. Hershey Medical Center, Department of Neurology, Pennsylvania State Hershey College of Medicine, Hershey
| | | | - Diane Cote
- Ottawa Hospital Civic Site, Ottawa, Ontario, Canada
| | | | | | - Marian Leslie Evatt
- Department of Neurology, Emory University School of Medicine, Wesley Woods Center, Atlanta, Georgia33Atlanta VA Medical Center, Atlanta, Georgia
| | - Barbara Sommerfeld
- Department of Neurology, Emory University School of Medicine, Wesley Woods Center, Atlanta, Georgia
| | - Abraham N Lieberman
- Muhammad Ali Parkinson Center, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael S Okun
- Department of Neurology, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville
| | - Ramon L Rodriguez
- Department of Neurology, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville
| | - Stacy Merritt
- Department of Neurology, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville
| | - Camille Louise Swartz
- Department of Neurology, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville
| | - W R Wayne Martin
- Glenrose Rehabilitation Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela King
- Glenrose Rehabilitation Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Ray L Watts
- Department of Neurology, University of Alabama at Birmingham
| | - Anwar Ahmed
- Center for Neurological Restoration, Department of Neurology, Cleveland Clinic, Cleveland, Ohio
| | - Hubert H Fernandez
- Center for Neurological Restoration, Department of Neurology, Cleveland Clinic, Cleveland, Ohio
| | - Adrienna Winters
- Center for Neurological Restoration, Department of Neurology, Cleveland Clinic, Cleveland, Ohio
| | - Zoltan Mari
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Ted M Dawson
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Becky Dunlop
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Andrew S Feigin
- Feinstein Institute for Medical Research, Center for Neurosciences, Manhasset, New York
| | - Barbara Shannon
- Feinstein Institute for Medical Research, Center for Neurosciences, Manhasset, New York
| | | | - Mattson Ogg
- Department of Neurology, Weill Cornell Medical College, New York Hospital, New York
| | - Samuel A Ellias
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Cathi-Ann Thomas
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Karen Frei
- The Parkinson's and Movement Disorder Institute, Fountain Valley, California
| | - Ivan Bodis-Wollner
- State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Sofya Glazman
- State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Thomas Mayer
- State University of New York, Downstate Medical Center, Brooklyn, New York
| | | | - Rajesh Pahwa
- Department of Neurology, University of Kansas Medical Center, Kansas City
| | - April Langhammer
- Department of Neurology, University of Kansas Medical Center, Kansas City
| | - Ranjit Ranawaya
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Lorelei Derwent
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Kapil D Sethi
- Department of Neurology, Georgia Health Science University, Augusta
| | - Buff Farrow
- Department of Neurology, Georgia Health Science University, Augusta
| | - Rajan Prakash
- Department of Neurology, Georgia Health Science University, Augusta
| | - Irene Litvan
- Department of Neurosciences, University of California, San Diego, La Jolla
| | | | - Alok Sahay
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Maureen Gartner
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Vanessa K Hinson
- Department of Neurology, Medical University of South Carolina, Charleston
| | | | | | - Joel S Perlmutter
- Department of Neurology, Washington University in St Louis, Missouri
| | - Johanna Hartlein
- Department of Neurology, Washington University in St Louis, Missouri
| | - Eric Molho
- Movement Disorders Center, Albany Medical Center, Albany, New York
| | - Sharon Evans
- Movement Disorders Center, Albany Medical Center, Albany, New York
| | - Charles H Adler
- Parkinson's Disease and Movement Disorders Center, Department of Neurology, Mayo Clinic, Scottsdale, Arizona
| | - Amy Duffy
- Parkinson's Disease and Movement Disorders Center, Department of Neurology, Mayo Clinic, Scottsdale, Arizona
| | - Marlene Lind
- Parkinson's Disease and Movement Disorders Center, Department of Neurology, Mayo Clinic, Scottsdale, Arizona
| | - Lawrence Elmer
- Center for Neurological Health, University of Toledo, Toledo, Ohio
| | - Kathy Davis
- Department of Neurology, Medical University of Ohio at Toledo
| | - Julia Spears
- Department of Neurology, Medical University of Ohio at Toledo
| | | | - Maureen A Leehey
- Department of Neurology, University of Colorado Health Science Center, Denver
| | - Neal Hermanowicz
- Department of Neurology, University of California, Irvine Medical Center, Irvine
| | - Shari Niswonger
- Department of Neurology, University of California, Irvine Medical Center, Irvine
| | - Holly A Shill
- Banner Sun Health Research Institute, Sun City, Arizona
| | - Sanja Obradov
- Banner Sun Health Research Institute, Sun City, Arizona
| | - Alex Rajput
- Department of Neurology, University of Saskatchewan, Royal University Hospital, Saskatchewan, Canada
| | - Marilyn Cowper
- Department of Neurology, University of Saskatchewan, Royal University Hospital, Saskatchewan, Canada
| | - Stephanie Lessig
- Department of Neurology, University of California, San Diego, La Jolla
| | - David Song
- Department of Neurology, University of California, San Diego, La Jolla
| | - Deborah Fontaine
- Department of Neurology, University of California, San Diego, La Jolla
| | - Cindy Zadikoff
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Karen Williams
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Jo Bergholte
- Department of Neurology, Medical College of Wisconsin, Milwaukee
| | | | - Mark A Stacy
- Department of Neurology, Duke University, Durham, North Carolina
| | - Joanne Field
- Department of Neurology, Duke University, Durham, North Carolina
| | - Dragos Mihaila
- State University of New York Upstate Medical Center and Syracuse VA Medical Center, Syracuse
| | - Mark Chilton
- State University of New York Upstate Medical Center and Syracuse VA Medical Center, Syracuse
| | - Ergun Y Uc
- Department of Neurology, University of Iowa, Iowa City
| | - Jeri Sieren
- Department of Neurology, University of Iowa, Iowa City
| | - David K Simon
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Lauren Kraics
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Althea Silver
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - James T Boyd
- Department of Neurology, University of Vermont College of Medicine, Burlington
| | - Robert W Hamill
- Department of Neurology, University of Vermont College of Medicine, Burlington
| | | | - Jennifer Young
- Department of Neurology, University of Vermont College of Medicine, Burlington
| | - Karen Thomas
- Department of Neurology, Ohio State University, Columbus
| | | | - Joanne Wojcieszek
- Department of Neurology, Indiana University School of Medicine, Indianapolis
| | - Ronald F Pfeiffer
- Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Michel Panisset
- Department of Neurology, CHUM-Hôpital Notre-Dame, Montréal, Québec, Canada
| | - Monica Beland
- Department of Neurology, CHUM-Hôpital Notre-Dame, Montréal, Québec, Canada
| | - Stephen G Reich
- Department of Neurology, University of Maryland School of Science, Baltimore
| | - Michelle Cines
- Department of Neurology, University of Maryland School of Science, Baltimore
| | - Nancy Zappala
- Department of Neurology, University of Maryland School of Science, Baltimore
| | - Jean Rivest
- Department of Neurology, University of Sherbrooke, Québec, Canada
| | - Richard Zweig
- Department of Neurology, Louisiana State University Health Science Center, Shreveport
| | - L Pepper Lumina
- Department of Neurology, Louisiana State University Health Science Center, Shreveport
| | | | - Stephen Grill
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | | | - Paul Tuite
- Department of Neurology, University of Minnesota, Minneapolis
| | | | - Un Jung Kang
- Department of Neurology, University of Chicago, Chicago, Illinois
| | - Joan Young
- Department of Neurology, University of Chicago, Chicago, Illinois
| | - Jayaraman Rao
- Department of Neurology, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Maureen M Cook
- Department of Neurology, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Lawrence Severt
- Department of Neurology, Beth Israel Medical Center, New York, New York
| | - Karyn Boyar
- Department of Neurology, Beth Israel Medical Center, New York, New York
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13
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Abstract
BACKGROUND Steroidal contraceptive use has been associated with changes in bone mineral density in women. Whether such changes increase the risk of fractures later in life is not clear. Osteoporosis is a major public health concern. Age-related decline in bone mass increases the risk of fracture, especially of the spine, hip, and wrist. Concern about bone health influences the recommendation and use of these effective contraceptives globally. OBJECTIVES Our aim was to evaluate the effect of using hormonal contraceptives before menopause on the risk of fracture in women. SEARCH METHODS Through April 2014, we searched for studies of fracture or bone health and hormonal contraceptives in MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS, as well as ClinicalTrials.gov and ICTRP. We examined reference lists of relevant articles for other trials. For the initial review, we wrote to investigators to find additional trials. SELECTION CRITERIA Randomized controlled trials (RCTs) were considered if they examined fractures, bone mineral density (BMD), or bone turnover markers in women with hormonal contraceptive use prior to menopause. Eligible interventions included comparisons of a hormonal contraceptive with a placebo or with another hormonal contraceptive that differed in terms of drug, dosage, or regimen. They also included providing a supplement to one group. DATA COLLECTION AND ANALYSIS We assessed all titles and abstracts identified through the literature searches. Mean differences were computed using the inverse variance approach. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) was calculated. Both included the 95% confidence interval (CI) and used a fixed-effect model. Due to differing interventions, no trials could be combined for meta-analysis. We applied principles from GRADE to assess the evidence quality and address confidence in the effect estimates. In addition, a sensitivity analysis included trials that provided sufficient data for this review and evidence of at least moderate quality. MAIN RESULTS We found 19 RCTs that met our eligibility criteria. Eleven trials compared different combined oral contraceptives (COCs) or regimens of COCs; five examined an injectable versus another injectable, implant, or IUD; two studied implants, and one compared the transdermal patch versus the vaginal ring. No trial had fracture as an outcome. BMD was measured in 17 studies and 12 trials assessed biochemical markers of bone turnover. Depot medroxyprogesterone acetate (DMPA) was associated with decreased bone mineral density (BMD). The placebo-controlled trials showed BMD increases for DMPA plus estrogen supplement and decreases for DMPA plus placebo supplement. COCs did not appear to negatively affect BMD, and some formulations had more positive effects than others. However, no COC trial was placebo-controlled. Where studies showed differences between groups in bone turnover markers, the results were generally consistent with those for BMD. For implants, the single-rod etonogestrel group showed a greater BMD decrease versus the two-rod levonorgestrel group but results were not consistent across all implant comparisons.The sensitivity analysis included 11 trials providing evidence of moderate or high quality. Four trials involving DMPA showed some positive effects of an estrogen supplement on BMD, a negative effect of DMPA-subcutaneous on lumbar spine BMD, and a negative effect of DMPA on a bone formation marker. Of the three COC trials, one had a BMD decrease for the group with gestodene plus EE 15 μg. Another indicated less bone resorption in the group with gestodene plus EE 30 μg versus EE 20 μg. AUTHORS' CONCLUSIONS Whether steroidal contraceptives influence fracture risk cannot be determined from existing information. The evidence quality was considered moderate overall, largely due to the trials of DMPA, implants, and the patch versus ring. The COC evidence varied in quality but was low overall. Many trials had small numbers of participants and some had large losses. Health care providers and women should consider the costs and benefits of these effective contraceptives. For example, injectable contraceptives and implants provide effective, long-term birth control yet do not involve a daily regimen. Progestin-only contraceptives are considered appropriate for women who should avoid estrogen due to medical conditions.
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Affiliation(s)
- Laureen M Lopez
- Clinical Sciences, FHI 360, 359 Blackwell St, Suite 200, Durham, North Carolina, USA, 27701
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14
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Kaunitz AM, Peipert JF, Grimes DA. Injectable contraception: issues and opportunities. Contraception 2014; 89:331-4. [DOI: 10.1016/j.contraception.2014.03.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 03/25/2014] [Accepted: 03/26/2014] [Indexed: 12/26/2022]
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15
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Abstract
BACKGROUND Many hormonal contraceptives have been associated with changes in carbohydrate metabolism. Alterations may include decreased glucose tolerance and increased insulin resistance, which are risk factors for Type 2 diabetes mellitus and cardiovascular disease. These issues have been raised primarily with contraceptives containing estrogen. OBJECTIVES To evaluate the effect of hormonal contraceptives on carbohydrate metabolism in healthy women and those at risk for diabetes due to overweight. SEARCH METHODS In April 2014, we searched the computerized databases MEDLINE, POPLINE, CENTRAL, and LILACS for studies of hormonal contraceptives and carbohydrate metabolism. We also searched for clinical trials in ClinicalTrials.gov and ICTRP. The initial search also included EMBASE. SELECTION CRITERIA All randomized controlled trials were considered if they examined carbohydrate metabolism in women without diabetes who used hormonal contraceptives for contraception. Comparisons could be a placebo, a non-hormonal contraceptive, or another hormonal contraceptive that differed in drug, dosage, or regimen. Interventions included at least three cycles. Outcomes included glucose and insulin measures. DATA COLLECTION AND ANALYSIS We assessed all titles and abstracts identified during the literature searches. The data were extracted and entered into RevMan. We wrote to researchers for missing data. For continuous variables, the mean difference (MD) was computed with 95% confidence interval (CI) using a fixed-effect model. For dichotomous outcomes, the Peto odds ratio with 95% CI was calculated. MAIN RESULTS We found 31 trials that met the inclusion criteria. No new trials were eligible in 2014. Twenty-one trials compared combined oral contraceptives (COCs); others examined different COC regimens, progestin-only pills, injectables, a vaginal ring, and implants. None included a placebo. Of 34 comparisons, eight had any notable difference between the study groups in an outcome.Twelve trials studied desogestrel-containing COCs, and the few differences from levonorgestrel COCs were inconsistent. A meta-analysis of two studies showed the desogestrel group had a higher mean fasting glucose (MD 0.20; 95% CI 0.00 to 0.41). Where data could not be combined, single studies showed lower mean fasting glucose (MD -0.40; 95% CI -0.72 to -0.08) and higher means for two-hour glucose response (MD 1.08; 95% CI 0.45 to 1.71) and insulin area under the curve (AUC) (MD 20.30; 95% CI 4.24 to 36.36).Three trials examined the etonogestrel vaginal ring and one examined an etonogestrel implant. One trial showed the ring group had lower mean AUC insulin than the levonorgestrel-COC group (MD -204.51; 95% CI -389.64 to -19.38).Of eight trials of norethisterone preparations, five compared COCs and three compared injectables. In a COC trial, a norethisterone group had smaller mean change in glucose two-hour response than a levonorgestrel-COC group (MD -0.30; 95% CI -0.54 to -0.06). In an injectable study, a group using depot medroxyprogesterone acetate had higher means than the group using norethisterone enanthate for fasting glucose (MD 10.05; 95% CI 3.16 to 16.94), glucose two-hour response (MD 17.00; 95% CI 5.67 to 28.33), and fasting insulin (MD 3.40; 95% CI 2.07 to 4.73).Among five recent trials, two examined newer COCs with different estrogen types. One showed the group with nomegestrel acetate plus 17β-estradiol had lower means than the levonorgestrel group for incremental AUC glucose (MD -1.43; 95% CI -2.55 to -0.31) and glycosylated hemoglobin (HbA1c) (MD -0.10; 95% CI -0.18 to -0.02). Two trials compared extended versus conventional (cyclic) regimens. With a dienogest COC, an extended-use group had greater mean change in AUC glucose (MD 82.00; 95% CI 10.72 to 153.28). In a small trial using two levonorgestrel COCs, the lower-dose group showed smaller mean change in fasting glucose (MD -3.00; 95% CI -5.89 to -0.11), but the obese and normal weight women did not differ significantly. AUTHORS' CONCLUSIONS Current evidence suggests no major differences in carbohydrate metabolism between different hormonal contraceptives in women without diabetes. We cannot make strong statements due to having few studies that compared the same types of contraceptives. Many trials had small numbers of participants and some had large losses. Many of the earlier studies had limited reporting of methods.We still know very little about women at risk for metabolic problems due to being overweight. More than half of the trials had weight restrictions as inclusion criteria. Only one small trial stratified the groups by body mass index (obese versus normal).
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Affiliation(s)
- Laureen M Lopez
- FHI 360Global Health Research359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - David A Grimes
- University of North CarolinaDept. of Obstetrics and GynecologyChapel HillNorth CarolinaUSA
| | - Kenneth F Schulz
- FHI 360 and UNC School of MedicineQuantitative Sciences359 Blackwell Street, Suite 200Suite 200DurhamNorth CarolinaUSA27701
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16
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Abstract
BACKGROUND Functional ovarian cysts are a common gynecological problem among women of reproductive age worldwide. When large, persistent, or painful, these cysts may require operations, sometimes resulting in removal of the ovary. Since early oral contraceptives were associated with a reduced incidence of functional ovarian cysts, many clinicians inferred that birth control pills could be used to treat cysts as well. This became a common clinical practice in the early 1970s. OBJECTIVES This review examined all randomized controlled trials that studied oral contraceptives as therapy for functional ovarian cysts. SEARCH METHODS In March 2014, we searched the databases of CENTRAL, PubMed, EMBASE, and POPLINE, as well as clinical trials databases (ClinicalTrials.gov and ICTRP). We also examined the reference lists of articles. For the initial review, we wrote to authors of identified trials to seek articles we had missed. SELECTION CRITERIA We included randomized controlled trials in any language that included oral contraceptives used for treatment and not prevention of functional ovarian cysts. Criteria for diagnosis of cysts were those used by authors of trials. DATA COLLECTION AND ANALYSIS Two authors independently abstracted data from the articles. One entered the data into RevMan and a second verified accuracy of data entry. For dichotomous outcomes, we computed the Mantel-Haenszel odds ratio with 95% confidence interval (CI). For continuous outcomes, we calculated the mean difference with 95% CI. MAIN RESULTS We identified eight randomized controlled trials from four countries; the studies included a total of 686 women. Treatment with combined oral contraceptives did not hasten resolution of functional ovarian cysts in any trial. This held true for cysts that occurred spontaneously as well as those that developed after ovulation induction. Most cysts resolved without treatment within a few cycles; persistent cysts tended to be pathological (e.g., endometrioma or para-ovarian cyst) and not physiological. AUTHORS' CONCLUSIONS Although widely used for treating functional ovarian cysts, combined oral contraceptives appear to be of no benefit. Watchful waiting for two or three cycles is appropriate. Should cysts persist, surgical management is often indicated.
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Affiliation(s)
- David A Grimes
- Obstetrics and Gynecology, University of North Carolina, School of Medicine, CB#7570, Chapel Hill, North Carolina, USA, 27599-7570
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17
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Abstract
BACKGROUND Weight gain is often considered a side effect of combination hormonal contraceptives, and many women and clinicians believe that an association exists. Concern about weight gain can limit the use of this highly effective method of contraception by deterring the initiation of its use and causing early discontinuation among users. However, a causal relationship between combination contraceptives and weight gain has not been established. OBJECTIVES The aim of the review was to evaluate the potential association between combination contraceptive use and changes in weight. SEARCH METHODS In November 2013, we searched the computerized databases CENTRAL (The Cochrane Library), MEDLINE, POPLINE, EMBASE, and LILACS for studies of combination contraceptives, as well as ClinicalTrials.gov and International Clinical Trials Registry Platform (ICTRP). For the initial review, we also wrote to known investigators and manufacturers to request information about other published or unpublished trials not discovered in our search. SELECTION CRITERIA All English-language, randomized controlled trials were eligible if they had at least three treatment cycles and compared a combination contraceptive to a placebo or to a combination contraceptive that differed in drug, dosage, regimen, or study length. DATA COLLECTION AND ANALYSIS All titles and abstracts located in the literature searches were assessed. Data were entered and analyzed with RevMan. A second author verified the data entered. For continuous data, we calculated the mean difference and 95% confidence interval (CI) for the mean change in weight between baseline and post-treatment measurements using a fixed-effect model. For categorical data, such as the proportion of women who gained or lost more than a specified amount of weight, the Peto odds ratio with 95% CI was calculated. MAIN RESULTS We found 49 trials that met our inclusion criteria. The trials included 85 weight change comparisons for 52 distinct contraceptive pairs (or placebos). The four trials with a placebo or no intervention group did not find evidence supporting a causal association between combination oral contraceptives or a combination skin patch and weight change. Most comparisons of different combination contraceptives showed no substantial difference in weight. In addition, discontinuation of combination contraceptives because of weight change did not differ between groups where this was studied. AUTHORS' CONCLUSIONS Available evidence was insufficient to determine the effect of combination contraceptives on weight, but no large effect was evident. Trials to evaluate the link between combination contraceptives and weight change require a placebo or non-hormonal group to control for other factors, including changes in weight over time.
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Affiliation(s)
- Maria F Gallo
- The Ohio State UniversityDivision of EpidemiologyRoom 324 Cunz Hall1841 Neil AvenueColumbusOhioUSA43210‐1351
| | - Laureen M Lopez
- FHI 360Clinical Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - David A Grimes
- University of North Carolina, School of MedicineObstetrics and GynecologyCB#7570Chapel HillNorth CarolinaUSA27599‐7570
| | | | - Kenneth F Schulz
- FHI 360 and UNC School of MedicineQuantitative SciencesP.O. Box 13950Research Triangle ParkNorth CarolinaUSANC 27709
| | - Frans M Helmerhorst
- Leiden University Medical CenterDepartment of Gynaecology, Division of Reproductive Medicine and Dept. of Clinical EpidemiologyPO Box 9600Albinusdreef 2LeidenNetherlandsNL 2300 RC
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18
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Abstract
BACKGROUND Spermicides have been used as contraceptives for thousands of years. Despite this long use, only recently have studies examined the comparative efficacy and acceptability of these vaginal medications. Spermicides contain an active ingredient (most commonly nonoxynol-9) and a formulation used to disperse the product, such as foam or vaginal suppository. OBJECTIVES This review examined all known randomized controlled trials of a spermicide used alone for contraception. SEARCH METHODS In August 2013, we searched the following computerized databases for randomized controlled trials of spermicides for contraception: CENTRAL, MEDLINE, POPLINE, LILACS, EMBASE, ClinicalTrials.gov, and ICTRP. For the initial review, we examined the reference lists of trials found as well as those of review articles and textbook chapters. SELECTION CRITERIA We included any trial of a commercial product used alone for contraception. Each included trial must have provided sufficient information to determine pregnancy rates. DATA COLLECTION AND ANALYSIS Two authors independently extracted information from the trials identified. We did not conduct a meta-analysis, since most trials had large losses to follow up. We entered the data into tables and presented the results descriptively. MAIN RESULTS We located reports from 14 trials for the initial review, but have not identified any new trials since then. In the largest trial to date, the gel (Advantage S) containing the lowest dose of nonoxynol-9 (52.5 mg) was significantly less effective in preventing pregnancy than were gels with higher doses of the same agent (100 mg and 150 mg). Probabilities of pregnancy by six months were 22% for the 52.5 mg gel, 16% for the 100 mg dose, and 14% for the 150 mg dose. In the same trial, the three different vehicles with 100 mg of nonoxynol-9 had similar efficacy. Interpretation of these figures is limited, since 39% of participants discontinued the method or were lost from the trial. Few important differences in efficacy emerged in other trials. AUTHORS' CONCLUSIONS The probability of pregnancy varied widely in reported trials. A gel containing nonoxynol-9 52.5 mg was inferior to two other products tested in the largest trial. Aside from this finding, personal characteristics and behavior of users may be more important than characteristics of the spermicide products in determining the probability of pregnancy. Gel was liked more than the film or vaginal suppository in the largest trial. Spermicide trials have the dual challenges of difficult recruitment and high discontinuation rates; the latter threatens trial validity.
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Affiliation(s)
- David A Grimes
- Obstetrics and Gynecology, University of North Carolina, School of Medicine, CB#7570, Chapel Hill, North Carolina, USA, 27599-7570
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19
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Schulz KF, Grimes DA. Get in the spirit with SPIRIT 2013: protocol content guideline for clinical trials. Contraception 2013; 88:676-7. [DOI: 10.1016/j.contraception.2013.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 10/14/2013] [Indexed: 10/26/2022]
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20
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Abstract
BACKGROUND The introduction of a new progestin-only oral contraceptive in Europe has renewed interest in this class of oral contraceptives. Unlike the more widely used combined oral contraceptives containing an estrogen plus progestin, these pills contain only a progestin (progestogen) and are taken without interruption. How these pills compare to others in their class or to combined oral contraceptives is not clear. OBJECTIVES This review examined randomized controlled trials of progestin-only pills for differences in efficacy, acceptability, and continuation rates. SEARCH METHODS Through October 2013, we searched the computerized databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, and LILACS for studies of progestin-only pills. We also searched for current trials via ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. SELECTION CRITERIA We included all randomized controlled trials in any language that included progestin-only pills for contraception. We incorporated any comparison with a progestin-only pill; this could include different doses, other progestin-only pills, combined oral contraceptives, or other contraceptives. DATA COLLECTION AND ANALYSIS The first author abstracted the data and entered the information into RevMan 5. Another author performed a second, independent data abstraction to verify the initial data entry.We attempted to extract life-table rates (actuarial or continuous) and used the rate difference as the effect measure. Where life-table rates were not published, we used the incidence rate ratio (ratio of Pearl rates). Where only the crude number of events was published, we calculated the Peto odds ratio with 95% confidence interval (CI) using a fixed-effect model. For continuous variables, the mean difference (MD) was computed with 95% CI. Because of disparate exposures, we were not able to combine studies in meta-analysis. MAIN RESULTS Six trials met the inclusion criteria. We have not found any new studies since the initial review. In the trial comparing the desogestrel versus levonorgestrel progestin-only pill, desogestrel was not associated with a significantly lower risk of accidental pregnancy; the rate ratio was 0.27 (95% CI 0.06 to 1.19). However, the desogestrel progestin-only pill caused more bleeding problems, although this difference was not statistically significant. The trial comparing low-dose mifepristone versus a levonorgestrel progestin-only pill found similar pregnancy rates. In the trial comparing ethynodiol diacetate versus a combined oral contraceptive, irregular cycles occurred in all women assigned to the progestin-only pill (odds ratio 135.96; 95% CI 7.61 to 2421.02). In a trial comparing two progestin-only and two combined oral contraceptives, the progestin-only pill containing levonorgestrel 30 μg had higher efficacy than did the pill containing norethisterone 350 μg. An early trial found megestrol acetate inferior to other progestin-only pills in terms of efficacy. A study of the timing of pill initiation after birth found no important differences, but high losses to follow up undermined the trial. AUTHORS' CONCLUSIONS Evidence is insufficient to compare progestin-only pills to each other or to combined oral contraceptives.
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Affiliation(s)
- David A Grimes
- Obstetrics and Gynecology, University of North Carolina, School of Medicine, CB#7570, Chapel Hill, North Carolina, USA, 27599-7570
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21
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Abstract
BACKGROUND Worldwide, hormonal contraceptives are among the most popular reversible contraceptives. Despite their high theoretical effectiveness, typical use results in much lower effectiveness. In large part, this disparity reflects difficulties in adherence to the contraceptive regimen and low rates for long-term continuation. OBJECTIVES The intent was to determine the effectiveness of ancillary counseling techniques to improve adherence to, and continuation of, hormonal methods of contraception. SEARCH METHODS Through August 2013, we searched computerized databases for randomized controlled trials (RCTs) comparing client-provider interventions with standard family planning counseling. Sources included CENTRAL, MEDLINE, EMBASE, POPLINE, ClinicalTrials.gov and ICTRP. Earlier searches also included LILACS, PsycINFO, Dissertation Abstracts, African Index Medicus, and IMEMR. SELECTION CRITERIA We included RCTs of an intensive counseling technique or other client-provider intervention compared to routine family planning counseling. Interventions included group motivation; structured, peer, or multi-component counseling; and intensive reminders of appointments or next dosing. Outcome measures were discontinuation, reasons for discontinuation, number of missed pills or on-time injections, and pregnancy. DATA COLLECTION AND ANALYSIS One author evaluated the titles and abstracts from the searches to determine eligibility. Two authors extracted data from the included studies. We calculated the Mantel-Haenszel odds ratio (OR) for dichotomous outcomes. For continuous variables, the mean difference (MD) was computed; RevMan uses the inverse variance approach. For all analyses, 95% confidence intervals (CI) were also computed. Since the studies identified differed in both interventions and outcome measures, we did not conduct a meta-analysis. MAIN RESULTS Nine RCTs met our inclusion criteria. Five involved direct counseling; of those, two also provided multiple contacts by telephone. Four other trials provided intensive reminders, two of which also provided health education information. Three trials showed some benefit of the experimental intervention. In a counseling intervention, women who received repeated structured information about the injectable depot medroxyprogesterone acetate (DMPA) were less likely to discontinue the method by 12 months (OR 0.27; 95% CI 0.16 to 0.44) than women who had routine counseling. The intervention group was also less likely to discontinue due to menstrual disturbances (OR 0.20; 95% CI 0.11 to 0.37). Another trial showed a group with special counseling plus phone calls was more likely than the special-counseling group to report consistent use of oral contraceptives (OC) at 3 months (OR 1.41; 95% CI 1.06 to 1.87), though not at 12 months. The group with only special counseling did not differ significantly from those with standard care for any outcome. The third trial compared daily text-message reminders about OCs plus health information versus standard care. Women in the text-message group were more likely than the standard-care group to continue OC use by six months (OR 1.54; 95% CI 1.14 to 2.10). The text-message group was also more likely to avoid an interruption in OC use longer than seven days (OR 1.53; 95% CI 1.13 to 2.07). AUTHORS' CONCLUSIONS Only three trials showed some benefit of strategies to improve adherence and continuation. However, several had small sample sizes and six had high losses to follow up. The overall quality of evidence was considered moderate. The intervention type and intensity varied greatly across the studies. A combination of intensive counseling and multiple contacts and reminders may be needed to improve adherence and acceptability of contraceptive use. High-quality RCTs with adequate power and well-designed interventions could help identify ways to improve adherence to, and continuation of, hormonal contraceptive methods.
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Affiliation(s)
- Vera Halpern
- Clinical Sciences, FHI 360, PO Box 13950, Research Triangle Park, North Carolina, USA, NC 27709
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22
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Abstract
BACKGROUND Spermicides have been used as contraceptives for thousands of years. Despite this long use, only recently have studies examined the comparative efficacy and acceptability of these vaginal medications. Spermicides contain an active ingredient (most commonly nonoxynol-9) and a formulation used to disperse the product, such as foam or vaginal suppository. OBJECTIVES This review examined all known randomized controlled trials of a spermicide used alone for contraception. SEARCH METHODS In August 2013, we searched the following computerized databases for randomized controlled trials of spermicides for contraception: CENTRAL, MEDLINE, POPLINE, LILACS, EMBASE, ClinicalTrials.gov, and ICTRP. For the initial review, we examined the reference lists of trials found as well as those of review articles and textbook chapters. SELECTION CRITERIA We included any trial of a commercial product used alone for contraception. Each included trial must have provided sufficient information to determine pregnancy rates. DATA COLLECTION AND ANALYSIS Two authors independently extracted information from the trials identified. We did not conduct a meta-analysis, since most trials had large losses to follow up. We entered the data into tables and presented the results descriptively. MAIN RESULTS We located reports from 14 trials for the initial review, but have not identified any new trials since then. In the largest trial to date, the gel (Advantage S) containing the lowest dose of nonoxynol-9 (52.5 mg) was significantly less effective in preventing pregnancy than were gels with higher doses of the same agent (100 mg and 150 mg). Probabilities of pregnancy by six months were 22% for the 52.5 mg gel, 16% for the 100 mg dose, and 14% for the 150 mg dose. In the same trial, the three different vehicles with 100 mg of nonoxynol-9 had similar efficacy. Interpretation of these figures is limited, since 39% of participants discontinued the method or were lost from the trial. Few important differences in efficacy emerged in other trials. AUTHORS' CONCLUSIONS The probability of pregnancy varied widely in reported trials. A gel containing nonoxynol-9 52.5 mg was inferior to two other products tested in the largest trial. Aside from this finding, personal characteristics and behavior of users may be more important than characteristics of the spermicide products in determining the probability of pregnancy. Gel was liked more than the film or vaginal suppository in the largest trial. Spermicide trials have the dual challenges of difficult recruitment and high discontinuation rates; the latter threatens trial validity.
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Affiliation(s)
- David A Grimes
- Obstetrics and Gynecology, University of North Carolina, School of Medicine, CB#7570, Chapel Hill, North Carolina, USA, 27599-7570
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23
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Abstract
BACKGROUND The explicit use of theory in research helps expand the knowledge base. Theories and models have been used extensively in HIV-prevention research and in interventions for preventing sexually transmitted infections (STIs). The health behavior field uses many theories or models of change. However, educational interventions addressing contraception often have no stated theoretical base. OBJECTIVES Review randomized controlled trials (RCTs) that tested a theoretical approach to inform contraceptive choice; encourage contraceptive use; or promote adherence to, or continuation of, a contraceptive regimen. SEARCH METHODS Through June 2013, we searched computerized databases for trials that tested a theory-based intervention for improving contraceptive use (MEDLINE, POPLINE, CENTRAL, PsycINFO, ClinicalTrials.gov, and ICTRP). Previous searches also included EMBASE. For the initial review, we wrote to investigators to find other trials. SELECTION CRITERIA Trials tested a theory-based intervention for improving contraceptive use. We excluded trials focused on high-risk groups and preventing sexually transmitted infections or HIV. Interventions addressed the use of one or more contraceptive methods for contraception. The reports provided evidence that the intervention was based on a specific theory or model. The primary outcomes were pregnancy, contraceptive choice or use, and contraceptive adherence or continuation. DATA COLLECTION AND ANALYSIS The primary author evaluated abstracts for eligibility. Two authors extracted data from included studies. For the dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated using a fixed-effect model. Cluster randomized trials used various methods of accounting for the clustering, such as multilevel modeling. Most reports did not provide information to calculate the effective sample size. Therefore, we presented the results as reported by the investigators. No meta-analysis was conducted due to differences in interventions and outcome measures. MAIN RESULTS We included three new trials for a total of 17. Ten randomly assigned individuals and seven were cluster-randomized. Eight trials showed some intervention effect.Two of 12 trials with pregnancy or birth data showed some effect. A theory-based group was less likely than the comparison group to have a second birth (OR 0.41; 95% CI 0.17 to 1.00) or to report a pregnancy (OR 0.24 (95% CI 0.10 to 0.56); OR 0.27 (95% CI 0.11 to 0.66)). The theoretical bases were social cognitive theory (SCT) and another social cognition model.Of 12 trials with data on contraceptive use (non-condom), six showed some effect. A theory-based group was more likely to consistently use oral contraceptives (OR 1.41; 95% CI 1.06 to 1.87), hormonal contraceptives (reported relative risk (RR) 1.30; 95% CI 1.06 to 1.58) or dual methods (reported RR 1.36; 95% CI 1.01 to 1.85); to use an effective contraceptive method (reported effect size 1.76; OR 2.04 (95% CI 1.47 to 2.83)) or use more habitual contraception (reported P < 0.05); and were less likely to use ineffective contraception (OR 0.56; 95% CI 0.31 to 0.98). Theories and models included the Health Belief Model (HBM), SCT, SCT plus another theory, other social cognition, and motivational interviewing (MI).For condom use, a theory-based group had favorable results in 5 of 11 trials. The main differences were reporting more consistent condom use (reported RR 1.57; 95% CI 1.28 to 1.94) and more condom use during last sex (reported results: risk ratio 1.47 (95% CI 1.12 to 1.93); effect size 1.68; OR 2.12 (95% CI 1.24 to 3.56); OR 1.45 (95% CI 1.03 to 2.03)). The theories were SCT, SCT plus another theory, and HBM.Nearly all trials provided multiple sessions or contacts. SCT provided the basis for seven trials focused on adolescents, of which five reported some effectiveness. Two others based on other social cognition models had favorable results with adolescents. Of six trials including adult women, five provided individual sessions. Some effect was seen in two using MI and one using the HBM. Two based on the Transtheoretical Model did not show any effect. AUTHORS' CONCLUSIONS Eight trials provided evidence of high or moderate quality. Family planning researchers and practitioners could adapt the effective interventions, although most provided group sessions for adolescents. Three were conducted outside the USA. Clinics and low-resource settings need high-quality evidence on changing behavior. Thorough use of single theories would help in identifying what works, as would better reporting on research design and intervention implementation.
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Affiliation(s)
- Laureen M Lopez
- Clinical Sciences, FHI 360, P.O. Box 13950, Research Triangle Park, North Carolina, USA, 27709
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24
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Abstract
BACKGROUND Concern about estrogen-related adverse effects has led to progressive reductions in the estrogen dose in combination oral contraceptives (COCs). However, reducing the amount of estrogen to improve safety could result in decreased contraceptive effectiveness and unacceptable changes in bleeding patterns. OBJECTIVES To test the hypothesis that COCs containing ≤ 20 μg ethinyl estradiol (EE) perform similarly as those containing > 20 μg in terms of contraceptive effectiveness, bleeding patterns, discontinuation, and side effects. SEARCH METHODS In July 2013, we searched CENTRAL, MEDLINE, and POPLINE, and examined references of potentially eligible trials. We also searched for recent clinical trials using ClinicalTrials.gov and ICTRP. No new trials met the inclusion criteria. Previous searches included EMBASE. For the initial review, we wrote to oral contraceptive manufacturers to identify trials. SELECTION CRITERIA English-language reports of randomized controlled trials were eligible that compare a COC containing ≤ 20 μg EE with a COC containing > 20 μg EE. We excluded studies where the interventions were designed to be administered for less than three consecutive cycles or to be used primarily as treatment for non-contraceptive conditions. Trials had to report on contraceptive effectiveness, bleeding patterns, trial discontinuation due to bleeding-related reasons or other side effects, or side effects to be included in the review. DATA COLLECTION AND ANALYSIS One author evaluated all titles and abstracts from literature searches to determine whether they met the inclusion criteria. Two authors independently extracted data from studies identified for inclusion. We wrote to the researchers when additional information was needed. Data were entered and analyzed with RevMan. MAIN RESULTS No differences were found in contraceptive effectiveness for the 13 COC pairs for which this outcome was reported. Compared to the higher-estrogen pills, several COCs containing 20 μg EE resulted in higher rates of early trial discontinuation (overall and due to adverse events such as irregular bleeding) as well as increased risk of bleeding disturbances (both amenorrhea or infrequent bleeding and irregular, prolonged, frequent bleeding, or breakthrough bleeding or spotting). AUTHORS' CONCLUSIONS While COCs containing 20 μg EE may be theoretically safer, this review did not focus on the rare events required to assess this hypothesis. Data from existing randomized controlled trials are inadequate to detect possible differences in contraceptive effectiveness. Low-dose estrogen COCs resulted in higher rates of bleeding pattern disruptions. However, most trials compared COCs containing different progestin types, and changes in bleeding patterns could be related to progestin type as well as estrogen dose. Higher follow-up rates are essential for meaningful interpretation of results.
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Affiliation(s)
- Maria F Gallo
- The Ohio State UniversityDivision of EpidemiologyRoom 324 Cunz Hall1841 Neil AvenueColumbusOhioUSA43210‐1351
| | - Kavita Nanda
- FHIClinical SciencesP.O. Box 13950Research Triangle ParkNorth CarolinaUSA27709
| | - David A Grimes
- University of North Carolina, School of MedicineObstetrics and GynecologyCB#7570Chapel HillNorth CarolinaUSA27599‐7570
| | - Laureen M Lopez
- FHI 360Clinical SciencesP.O. Box 13950Research Triangle ParkNorth CarolinaUSA27709
| | - Kenneth F Schulz
- FHI 360 and UNC School of MedicineQuantitative SciencesP.O. Box 13950Research Triangle ParkNorth CarolinaUSANC 27709
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25
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Abstract
Correctly diagnosing pelvic inflammatory disease (PID) using noninvasive clinical criteria remains challenging. Current guidelines for initiating treatment, based on minimal criteria (sensitive but not specific), are justified for public health purposes but inadequate and misleading for scientific purposes. Previous research on the link between the intrauterine device (IUD) and PID was controversial and subject to many limitations. Even today, these limitations still exist and include uncertainty of the PID diagnosis, unfair contraceptive comparisons, selection and diagnostic bias, and confounding. For example, IUD users are on heightened alert for PID relative to users of other methods. In addition, IUD users with pelvic pain may be more likely to seek physician consultation and consequently receive a PID diagnosis (true-positive or false-positive). Confounding factors such as higher coital frequency, multiple sexual partners, and low condom use may explain any finding that shows a higher PID rate among IUD users compared with other contraceptive users. Good evidence on how or whether the IUD changes the etiology of PID is lacking. In the past 10 years, use of the intrauterine device in the United States has increased markedly. Thus today, researchers may now have sufficient population-level exposure (IUD use) and disease (PID) to search for a connection and repeat past mistakes. Any new findings using observational research should be interpreted with caution. More rigorous research designs may not be pragmatic or feasible.
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Affiliation(s)
- David Hubacher
- FHI 360, Research Triangle Park, North Carolina; the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and the Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet/Karolinska University Hospital, Stockholm, Sweden
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26
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Abstract
BACKGROUND The delivery of combination contraceptive steroids from a transdermal contraceptive patch or a contraceptive vaginal ring offers potential advantages over the traditional oral route. The transdermal patch and vaginal ring could require a lower dose due to increased bioavailability and improved user compliance. OBJECTIVES To compare the contraceptive effectiveness, cycle control, compliance (adherence), and safety of the contraceptive patch or the vaginal ring versus combination oral contraceptives (COCs). SEARCH METHODS Through February 2013, we searched MEDLINE, POPLINE, CENTRAL, LILACS, ClinicalTrials.gov, and ICTRP for trials of the contraceptive patch or the vaginal ring. Earlier searches also included EMBASE. For the initial review, we contacted known researchers and manufacturers to identify other trials. SELECTION CRITERIA We considered randomized controlled trials comparing a transdermal contraceptive patch or a contraceptive vaginal ring with a COC. DATA COLLECTION AND ANALYSIS Data were abstracted by two authors and entered into RevMan. For dichotomous variables, the Peto odds ratio (OR) with 95% confidence intervals (CI) was calculated. For continuous variables, the mean difference was computed. We also assessed the quality of evidence for this review. MAIN RESULTS We found 18 trials that met our inclusion criteria. Of six patch studies, five examined the marketed patch containing norelgestromin plus ethinyl estradiol (EE); one studied a patch in development that contains levonorgestrel (LNG) plus EE. Of 12 vaginal ring trials, 11 examined the same marketing ring containing etonogestrel plus EE; one studied a ring being developed that contains nesterone plus EE.Contraceptive effectiveness was not significantly different for the patch or ring versus the comparison COC. Compliance data were limited. Patch users showed better compliance than COC users in three trials. For the norelgestromin plus EE patch, ORs were 2.05 (95% CI 1.83 to 2.29) and 2.76 (95% CI 2.35 to 3.24). In the levonorgestrel plus EE patch report, patch users were less likely to have missed days of therapy (OR 0.36; 95% CI 0.25 to 0.51). Of four vaginal ring trials, one found ring users had more noncompliance (OR 3.99; 95% CI 1.87 to 8.52), while another showed more compliance with the regimen (OR 1.67; 95% CI 1.04 to 2.68).More patch users discontinued early than COC users. ORs from two meta-analyses were 1.59 (95% CI 1.26 to 2.00) and 1.56 (95% CI 1.18 to 2.06) and another trial showed OR 2.57 (95% CI 0.99 to 6.64). Patch users also had more discontinuation due to adverse events than COC users. Users of the norelgestromin-containing patch reported more breast discomfort, dysmenorrhea, nausea, and vomiting. In the levonorgestrel-containing patch trial, patch users reported less vomiting, headaches, and fatigue.Of 11 ring trials with discontinuation data, two showed the ring group discontinued less than the COC group: OR 0.32 (95% CI 0.16 to 0.66) and OR 0.52 (95% CI 0.31 to 0.88). Ring users were less likely to discontinue due to adverse events in one study (OR 0.32; 95% CI 0.15 to 0.70). Compared to the COC users, ring users had more vaginitis and leukorrhea but less vaginal dryness. Ring users also reported less nausea, acne, irritability, depression, and emotional lability than COC users.For cycle control, only one trial study showed a significant difference. Women in the patch group were less likely to have breakthrough bleeding and spotting. Seven ring studies had bleeding data; four trials showed the ring group generally had better cycle control than the COC group. AUTHORS' CONCLUSIONS Effectiveness was not significantly different for the methods compared. Pregnancy data were available from half of the patch trials but two-thirds of ring trials. The patch could lead to more discontinuation than the COC. The patch group had better compliance than the COC group. Compliance data came from half of the patch studies and one-third of the ring trials. Patch users had more side effects than the COC group. Ring users generally had fewer adverse events than COC users but more vaginal irritation and discharge.The quality of the evidence for this review was considered low for the patch and moderate for the ring. The main reasons for downgrading were lack of information on the randomization sequence generation or allocation concealment, the outcome assessment methods, high losses to follow up, and exclusions after randomization.
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Affiliation(s)
- Laureen M Lopez
- FHI 360Clinical SciencesP.O. Box 13950Research Triangle ParkNorth CarolinaUSA27709
| | - David A Grimes
- University of North Carolina, School of MedicineObstetrics and GynecologyCB#7570Chapel HillNorth CarolinaUSA27599‐7570
| | - Maria F Gallo
- Centers for Disease Control and PreventionDivision of Reproductive Health4770 Buford Highway, Mail Stop K‐34AtlantaGeorgiaUSA30341‐3724
| | - Laurie L Stockton
- FHI360Health Services ResearchPO Box 13950Research Triangle ParkNorth CarolinaUSA27709
| | - Kenneth F Schulz
- FHI 360 and UNC School of MedicineQuantitative SciencesP.O. Box 13950Research Triangle ParkNorth CarolinaUSANC 27709
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27
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Abstract
BACKGROUND Knowledge of contraceptive effectiveness is crucial to making an informed choice. The consumer has to comprehend the pros and cons of the contraceptive methods being considered. Choice may be influenced by understanding the likelihood of pregnancy with each method and factors that influence effectiveness. OBJECTIVES To review all randomized controlled trials comparing strategies for communicating to consumers the effectiveness of contraceptives in preventing pregnancy. SEARCH METHODS Through February 2013, we searched the computerized databases of MEDLINE, POPLINE, CENTRAL, PsycINFO and CINAHL, ClinicalTrials.gov, and ICTRP. Previous searches also included EMBASE. We also examined references lists of relevant articles. For the initial review, we wrote to known investigators for information about other published or unpublished trials. SELECTION CRITERIA We included randomized controlled trials that compared methods for communicating contraceptive effectiveness to consumers. The comparison could be usual practice or an alternative to the experimental intervention.Outcome measures were knowledge of contraceptive effectiveness, attitude about contraception or toward any particular contraceptive, and choice or use of contraceptive method. DATA COLLECTION AND ANALYSIS For the initial review, two authors independently extracted the data. One author entered the data into RevMan, and a second author verified accuracy. For the update, an author and a research associate extracted, entered, and checked the data.For dichotomous variables, we calculated the Mantel-Haenszel odds ratio with 95% confidence intervals (CI). For continuous variables, we computed the mean difference (MD) with 95% CI. MAIN RESULTS Seven trials met the inclusion criteria and had a total of 4526 women. Five were multi-site studies. Four trials were conducted in the USA, while Nigeria and Zambia were represented by one study each, and one trial was done in both Jamaica and India.Two trials provided multiple sessions for participants. In one study that examined contraceptive choice, women in the expanded program were more likely to choose sterilization (OR 4.26; 95% CI 2.46 to 7.37) or use a modern contraceptive method (OR 2.35; 95% CI 1.82 to 3.03), i.e., sterilization, pills, injectable, intrauterine device or barrier method. For the other study, the groups received educational interventions with differing format and intensity. Both groups reportedly had increases in contraceptive use, but they did not differ significantly by six months in consistent use of an effective contraceptive, i.e., sterilization, IUD, injectable, implant, and consistent use of oral contraceptives, diaphragm, or male condoms.Five trials provided one session and focused on testing educational material or media. In one study, knowledge gain favored a slide-and-sound presentation versus a physician's oral presentation (MD -19.00; 95% CI -27.52 to -10.48). In another trial, a table with contraceptive effectiveness categories led to more correct answers than a table based on pregnancy numbers [ORs were 2.42 (95% CI 1.43 to 4.12) and 2.19 (95% CI 1.21 to 3.97)] or a table with effectiveness categories and pregnancy numbers [ORs were 2.58 (95% CI 1.5 to 4.42) and 2.03 (95% CI 1.13 to 3.64)]. Still another trial provided structured counseling with a flipchart on contraceptive methods. The intervention and usual-care groups did not differ significantly in choice of contraceptive method (by effectiveness category) or in continuation of the chosen method at three months. Lastly, a study with couples used videos to communicate contraceptive information (control, motivational, contraceptive methods, and both motivational and methods videos). The analyses showed no significant difference between the groups in the types of contraceptives chosen. AUTHORS' CONCLUSIONS These trials varied greatly in the types of participants and interventions to communicate contraceptive effectiveness. Therefore, we cannot say overall what would help consumers choose an appropriate contraceptive method. For presenting pregnancy risk data, one trial showed that effectiveness categories were better than pregnancy numbers. In another trial, audiovisual aids worked better than the usual oral presentation. Strategies should be tested in clinical settings and measured for their effect on contraceptive choice. More detailed reporting of intervention content would help in interpreting results. Reports could also include whether the instruments used to assess knowledge or attitudes were tested for validity or reliability. Follow-up should be incorporated to assess retention of knowledge over time. The overall quality of evidence was considered to be low for this review, given that five of the seven studies provided low or very low quality evidence.
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Affiliation(s)
- Laureen M Lopez
- Clinical Sciences, FHI 360, Research Triangle Park, North Carolina, USA.
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28
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Abstract
BACKGROUND Obesity has reached epidemic proportions around the world. Effectiveness of hormonal contraceptives may be related to metabolic changes in obesity or greater body mass or body fat. Hormonal contraceptives mainly include oral contraceptives, injectables and implants, the transdermal patch, and the vaginal ring. We systematically reviewed the evidence on the effectiveness of hormonal contraceptives among overweight and obese women. OBJECTIVES To examine the effectiveness of hormonal contraceptives in preventing unplanned pregnancies among women who are overweight or obese versus women of lower weight or body mass index (BMI). SEARCH METHODS Through January 2013, we searched MEDLINE, CENTRAL, POPLINE, ClinicalTrials.gov, and ICTRP. The previous search also included EMBASE. We contacted investigators to identify other trials. SELECTION CRITERIA All study designs were eligible. Any type of hormonal contraceptive could have been examined. Reports had to contain information on the specific contraceptive method(s). The primary outcome was pregnancy. Overweight or obese women must have been identified by an analysis cutoff for weight or BMI (kg/m(2)). DATA COLLECTION AND ANALYSIS Data were abstracted by two authors. Life-table rates were included where available. For dichotomous variables, we computed an odds ratio with 95% confidence interval (CI). We used reported pregnancy rates or relative risk (RR) when those were the only results provided. The main comparisons were between overweight or obese women and women of lower weight or BMI. We assessed the quality of evidence for this review. MAIN RESULTS We found nine reports with data from 13 trials that included a total of 49,712 women. Five reports from 2002 to 2012 compared BMI groups; of those, one reported a higher pregnancy risk for overweight or obese women. In that trial, women assigned to an oral contraceptive containing norethindrone acetate 1.0 mg plus EE 20 µg and having a BMI at least 25 had greater pregnancy risk compared to those with BMI less than 25 (reported RR 2.49; 95% CI 1.01 to 6.13). The comparisons reported in the other four studies were not significantly different for pregnancy. These included studies of a combined oral contraceptive (COC), a transdermal patch, an implant, and an injectable. The COC study showed no trend by BMI or weight. With the transdermal patch, body weight was associated with pregnancy (reported P < 0.001) but BMI was not. The implant study had one pregnancy and the injectable study reported no pregnancies.Four studies from the 1990s used weight alone rather than BMI. Results were mixed. Studies of a vaginal ring (never marketed) and a six-rod implant showed higher pregnancy rates for women weighing at least 70 kg versus those weighing less than 70 kg (reported P values: 0.0013 and < 0.05, respectively). However, two implant studies showed no trend by body weight. AUTHORS' CONCLUSIONS The evidence did not generally show an association of BMI with effectiveness of hormonal contraceptives. However, the evidence was limited for any individual contraceptive method. Studies using BMI (rather than weight alone) can provide more information about whether body composition is related to contraceptive effectiveness. The efficacy of subdermal implants and injectable contraceptives may be unaffected by body mass. The contraceptive methods examined here are among the most effective when the recommended regimen is followed.The overall quality of evidence was low for this review. More recent reports provided moderate quality evidence, while the older studies provided evidence of low or very low quality for our purposes. Investigators should consider adjusting for potential confounding related to BMI. Trials should be designed to include sufficient numbers of overweight or obese women to adequately examine effectiveness and side effects of hormonal contraceptives within those groups.
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Affiliation(s)
- Laureen M Lopez
- Clinical Sciences, FHI 360, Research Triangle Park, North Carolina, USA.
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29
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Gallo MF, Grimes DA, Lopez LM, Schulz KF, d'Arcangues C. Combination injectable contraceptives for contraception. Cochrane Database Syst Rev 2013; 3:CD004568. [PMID: 23641480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
BACKGROUND Combination injectable contraceptives (CICs) provide a highly effective, reversible method of preventing pregnancy, and they do not require daily administration or use at the time of coitus. Although they are used in many countries, their acceptability could be limited by method characteristics, such as the need to obtain a monthly injection or bleeding pattern changes. OBJECTIVES To assess the contraceptive efficacy, bleeding patterns, discontinuation, user preferences, and side effects of CICs. SEARCH METHODS In January and February 2013, we searched for randomized controlled trials (RCTs) of combination injectable contraceptives.Databases include MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS.We searched for current trials in ClinicalTrials.gov and ICTRP.Earlier searches also included AIM and IMEMR. For the initial review, we also assessed the references listed in review articles and in the eligible trial reports. SELECTION CRITERIA RCTs were eligible if they compared a combination injectable contraceptive with any other contraceptive method (e.g., a second CIC,a progestin-only injectable contraceptive, another hormonal contraceptive or a barrier method) or a placebo. We limited the review to marketed CICs. DATA COLLECTION AND ANALYSIS Two authors independently extracted data on contraceptive efficacy, bleeding patterns, continuation, and side effects. We calculated the Peto odds ratio or mean difference with 95% confidence interval for dichotomous or continuous outcome, respectively. Survival analysis estimates for method discontinuation were presented where available. MAIN RESULTS Twelve trials met the inclusion criteria. Combination injectable contraceptives include depot medroxyprogesterone acetate (DMPA)25 mg plus estradiol cypionate (E(2)C) 5 mg, as well as norethisterone enanthate (NET-EN) 50 mg plus estradiol valerate (E(2)V) 5mg. These contraceptives resulted in lower rates of early study discontinuation due to amenorrhea or other bleeding problems than progestin-only contraceptives. However, rates were higher for overall discontinuation and discontinuation due to other medical reasons.Acceptability results favored the CIC in one study and the progestin-only in another.Studies comparing two CICs found that NET-EN 50 mg plus E(2)V (5)mg resulted in less overall discontinuation and less discontinuation due to amenorrhea or prolonged bleeding than DMPA 25 mg plus E(2)C 5 mg. However, these differences were not detected in all trials.The NET-EN plus E (2) V group also had more regular bleeding and fewer prolonged bleeding reference periods than the DMPA plus E(2)C group. The groups did not differ in their amenorrhea rates. AUTHORS' CONCLUSIONS While discontinuation rates can be viewed as a measure of method acceptability, the findings should be interpreted with caution since discontinuation depends on many factors. Future research should be directed toward improving the acceptability of combination injectable contraceptives, such as providing injections in settings more convenient than clinics, methods for women to administer their own injections, and counseling about possible bleeding pattern changes.
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Affiliation(s)
- Maria F Gallo
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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30
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Abstract
BACKGROUND Health care providers often tell women to wait until the next menses to begin hormonal contraception. The intent is to avoid contraceptive use during an undetected pregnancy. An alternative is to start hormonal contraception immediately with back-up birth control for the first seven days. Immediate initiation was introduced with combined oral contraceptives (COCs), and has expanded to other hormonal contraceptives. At the time of the initial review, how immediate start compared to conventional menses-dependent start was unclear regarding effectiveness, continuation, and acceptability. The immediate-start approach may improve women's access to, and continuation of, hormonal contraception. OBJECTIVES This review examined randomized controlled trials (RCTs) of immediate-start hormonal contraception for differences in effectiveness, continuation, and acceptability. SEARCH METHODS In August 2012, we searched MEDLINE, CENTRAL, POPLINE, LILACS, ClinicalTrials.gov, and ICTRP for trials of immediate-start hormonal contraceptives. We contacted researchers to find other studies. Earlier searches also included EMBASE. SELECTION CRITERIA We included RCTs that compared immediate start to conventional start of hormonal contraception. Also included were trials that compared immediate start of different hormonal contraceptive methods with each other. DATA COLLECTION AND ANALYSIS Data were abstracted by two authors and entered into RevMan. The Peto odds ratio (OR) with 95% confidence interval (CI) was calculated. MAIN RESULTS Five studies were included. No new eligible studies have been found since the review was initially conducted. Method discontinuation was similar between groups in all trials. Bleeding patterns and side effects were similar in trials that compared immediate with conventional start. In a study of depot medroxyprogesterone acetate (DMPA), immediate start of DMPA showed fewer pregnancies than a 'bridge' method before DMPA (OR 0.36; 95% CI 0.16 to 0.84). Further, more women in the immediate-DMPA group were very satisfied versus those with a 'bridge' method (OR 1.99; 95% CI 1.05 to 3.77). A trial of two immediate-start methods showed the vaginal ring group had less prolonged bleeding (OR 0.42; 95% CI 0.20 to 0.89) and less frequent bleeding (OR 0.23; 95% CI 0.05 to 1.03) than COC users. The ring group also reported fewer side effects. Also, more immediate ring users were very satisfied than immediate COC users (OR 2.88; 95% CI 1.59 to 5.22). AUTHORS' CONCLUSIONS We found limited evidence that immediate start of hormonal contraception reduces unintended pregnancies or increases method continuation. However, the pregnancy rate was lower with immediate start of DMPA versus another method. Some differences were associated with contraceptive type rather than initiation method, i.e., immediate ring versus immediate COC. More studies are needed of immediate versus conventional start of the same hormonal contraceptive.
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Affiliation(s)
- Laureen M Lopez
- Clinical Sciences, FHI 360, Research Triangle Park, North Carolina, USA.
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31
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Tang JH, Lopez LM, Mody S, Grimes DA. Hormonal and intrauterine methods for contraception for women aged 25 years and younger. Cochrane Database Syst Rev 2012; 11:CD009805. [PMID: 23152281 DOI: 10.1002/14651858.cd009805.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Women between the ages of 15 and 24 years have high rates of unintended pregnancy; over half of women in this age group want to avoid pregnancy. However, women under age 25 years have been found to have higher typical contraceptive failure rates within the first 12 months of use than older women. High discontinuation rates may also be a problem in this population. Concern that adolescents and young women will not find hormonal or intrauterine contraceptives acceptable or effective might deter healthcare providers from recommending these contraceptive methods. OBJECTIVES This review examined randomized controlled trials of hormonal or intrauterine methods used for contraception in women aged 25 years and younger. SEARCH METHODS In February 2012, we searched the computerized databases Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, CINAHL, and LILACS for randomized controlled trials that compared hormonal or intrauterine methods used for contraception in women aged 25 years and younger. We also searched for current trials via ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP). SELECTION CRITERIA We considered all randomized controlled trials in any language that reported the contraceptive failure rates for hormonal or intrauterine contraceptive methods, when compared to another contraceptive method, for women aged 25 years and younger. The other contraceptive method could be another intrauterine method, another hormonal method, or a non-hormonal method. Treatment duration must have been at least three months. DATA COLLECTION AND ANALYSIS The first author extracted the data and entered the information into RevMan. Another author performed an independent data extraction and verified the initial entry. Because of disparate contraceptive exposures, we were not able to combine the studies in meta-analysis. MAIN RESULTS Four trials met the inclusion criteria. The trials compared the combined oral contraceptive versus the transdermal contraceptive patch, the combined oral contraceptive versus the vaginal contraceptive ring, the combined oral contraceptive versus the levonorgestrel intrauterine system, and the levonorgestrel intrauterine system versus the copper T380A intrauterine device. Because of small numbers of participants, the trials were not informative regarding contraceptive efficacy. Data on continuation rates were also limited. In one of these trials, the levonorgestrel intrauterine system was found to have a similar 12-month continuation rate as the combined oral contraceptive (odds ratio (OR) 1.48; 95% CI 0.76 to 2.89). In that trial, a higher proportion of women discontinued the levonorgestrel intrauterine system because of pain (OR 14.62; 95% CI 0.81 to 263.16), whereas a higher proportion of women discontinued the combined oral contraceptive for personal reasons (OR 0.27; 95% CI 0.09 to 0.85). AUTHORS' CONCLUSIONS Current evidence is insufficient to compare contraceptive efficacy and continuation rates for hormonal and intrauterine methods in women aged 25 years and younger. Limited data suggests that the levonorgestrel intrauterine system may be an acceptable alternative to the combined oral contraceptive in this population.
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Affiliation(s)
- Jennifer H Tang
- Obstetrics and Gynecology, University of North Carolina, School ofMedicine, ChapelHill,North Carolina, USA.
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Abstract
BACKGROUND Providing contraceptive education is now considered a standard component of postpartum care. The effectiveness is seldom examined. Questions have been raised about the assumptions on which such programs are based, e.g., that postpartum women are motivated to use contraception and that they will not return to a health center for family planning advice. Surveys indicate that women may wish to discuss contraception both prenatally and after hospital discharge. Nonetheless, two-thirds of postpartum women may have unmet needs for contraception. In the USA, many adolescents become pregnant again within a year a giving birth. OBJECTIVES Assess the effects of educational interventions for postpartum mothers about contraceptive use SEARCH METHODS In May 2012, we searched the computerized databases of MEDLINE, CENTRAL, CINAHL, PsycINFO, and POPLINE. We also searched for current trials via ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. In addition, we examined reference lists of relevant articles, and contacted subject experts to locate additional reports. SELECTION CRITERIA Randomized controlled trials were considered if they evaluated the effectiveness of postpartum education about contraceptive use. The intervention must have started postpartum and have occurred within one month of delivery. DATA COLLECTION AND ANALYSIS We assessed for inclusion all titles and abstracts identified during the literature searches with no language limitations. The data were abstracted and entered into RevMan. Studies were examined for methodological quality. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI) was calculated. For continuous variables, we computed the mean difference (MD) with 95% CI. Due to varied study designs, we did not conduct meta-analysis. MAIN RESULTS Ten trials met the inclusion criteria. Of four trials that provided one or two counseling sessions, two showed some evidence of effectiveness. In a study from Nepal, women with an immediate postpartum and a session three months later were more likely to use contraception at six months than those with only the later session (OR 1.62; 95% CI 1.06 to 2.50). However, most comparisons did not show evidence of effectiveness. In a trial conducted in Pakistan, women in the counseling group were more likely than those without counseling to use contraception at 8 to 12 weeks postpartum (OR 19.56; 95% CI 11.65 to 32.83). The assessments were short-term. The remaining two studies were from the USA; one did not provided sufficient data and one had too small a sample to detect differences.Six trials provided multifaceted programs with many contacts. Three showed evidence of effectiveness. Of those, two USA studies focused on adolescents. Adolescents in a home-visiting program were less likely to have a second birth in two years compared to adolescents who received usual care (OR 0.41; 95% CI 0.17 to 1.00). In the other trial, adolescents receiving enhanced well-baby care were less likely to have a repeat pregnancy by 18 months compared to those with usual well-baby care (OR 0.35; 95% CI 0.17 to 0.70). In an Australian study, teenagers in a structured home-visiting program were more likely to use contraception at six months than those who had standard home visits (OR 3.24; 95% CI 1.35 to 7.79). The trials without evidence of effectiveness included two for adolescents in the USA (computer-assisted motivational interviewing and cell phone counseling) and a home-visiting program for women in Syria. AUTHORS' CONCLUSIONS The overall quality of evidence was moderate. Half of these postpartum interventions led to fewer repeat pregnancies or births or more contraceptive use. However, the evidence of intervention effectiveness was of low to moderate quality. Trials with evidence of effectiveness included two that provided one or two sessions and three that had multiple contacts. The former had limitations, such as self-reported outcomes and showing no effect for many comparisons. The interventions with multiple sessions were promising but would have to be adapted for other locations and then retested. Researchers and health care providers will have to determine which intervention might be appropriate for their setting and level of resources.
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Affiliation(s)
- Laureen M Lopez
- Clinical Sciences, FHI 360, P.O. Box 13950, Research Triangle Park, North Carolina, USA.
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Abstract
BACKGROUND Tubal sterilization by hysteroscopy involves inserting a foreign body in both fallopian tubes. Over a three-month period, the tubal lumen is occluded by tissue growth stimulated by the insert. Tubal sterilization by hysteroscopy has advantages over laparoscopy or mini-laparotomy, including the avoidance of abdominal incisions and the convenience of performing the procedure in an office-based setting. Pain, an important determinant of procedure acceptability, can be a concern when tubal sterilization is performed in the office. OBJECTIVES To review all randomized controlled trials that evaluated interventions to decrease pain during tubal sterilization by hysteroscopy. SEARCH METHODS From January to March 2011, we searched the computerized databases of MEDLINE, POPLINE, CENTRAL, EMBASE, LILACS, and CINAHL for relevant trials. We searched for current trials via Clinicaltrials.gov. We also examined the reference lists of pertinent articles and wrote to known investigators for information about other published or unpublished trials. SELECTION CRITERIA We included all randomized controlled trials that evaluated pain management at the time of sterilization by hysteroscopy. The intervention could be compared to another intervention or placebo. DATA COLLECTION AND ANALYSIS Initial data were extracted by one review author. A second review author verified all extracted data. Whenever possible, the analysis was conducted with all women randomized and in the original assigned groups. Data were analyzed using RevMan software. Pain was measured using either a 10-cm or 100-point visual analog scale (VAS). When pain was measured at multiple points during the procedure, the overall pain score was considered the primary treatment effect. If this was not measured, a summation of all pain scores for the procedure was considered to be the primary treatment effect. For continuous variables, the mean difference with 95% confidence interval was computed. MAIN RESULTS Two trials met the inclusion criteria. The total number of participants was 167. Using a 10-cm VAS to measure pain, no significant difference emerged in overall pain for the entire procedure between women who received a paracervical block with lidocaine versus normal saline (mean difference -0.77; 95% CI -2.67 to 1.13). No significant difference in pain score was noted at the time of injection of study solution to the anterior lip of the cervix (mean difference -0.6; 95% CI -1.3 to 0.1), placement of the device in the tubal ostia (mean difference -0.60; 95% CI -1.8 to 0.7), and postprocedure pain (mean difference 0.2; 95% CI -0.8 to 1.2). Procedure time (mean difference -0.2 minutes; 95% CI -2.2 to 1.8 minutes) and successful bilateral placement (OR 1.0; 95% CI 0.19 to 5.28) was not significantly different between groups. During certain portions of the procedure, such as placement of the tenaculum (mean difference -2.03; 95% CI -2.88 to -1.18), administration of the paracervical block (mean difference -1.92; 95% CI -2.84 to -1.00), and passage of the hysteroscope through the external (mean difference -2.31; 95% CI -3.30 to -1.32) and internal os (mean difference -2.31; 95% CI -3.39 to -1.23), use of paracervical block with lidocaine resulted in lower pain scores.Using a 600-point scale calculated by adding 100-point VAS scores from six different portions of the procedure, no significant difference emerged in overall pain between women who received intravenous conscious sedation versus oral analgesia (mean difference -23.00; CI -62.02 to 16.02). Using a 100-point VAS, no significant difference emerged at the time of speculum insertion (mean difference 4.0; 95% CI -4.0 to 12.0), cervical injection of lidocaine (mean difference -1.8; 95% CI -10.0 to 6.4), insertion of the hysteroscope (mean difference -8.7; 95% CI -19.7 to 2.3), placement of the first device (mean difference -4.4; 95% CI -15.8 to 7.0), and removal of the hysteroscope (mean difference 0.9; 95% CI -3.9 to 5.7). Procedure time (mean difference -0.2 minutes; 95% CI -2.0 to 1.6 minutes) and time in the recovery area (mean difference 3.6 minutes; 95% CI -11.3 to 18.5 minutes) was not different between groups. However, women who received intravenous conscious sedation had lower pain scores at the time of insertion of the second tubal device compared to women who received oral analgesia (mean difference -12.60; CI -23.98 to -1.22). AUTHORS' CONCLUSIONS The available literature is insufficient to determine the appropriate analgesia or anesthesia for sterilization by hysteroscopy. Compared to paracervical block with normal saline, paracervical block with lidocaine reduced pain during some portions of the procedure. Intravenous sedation resulted in lower pain scores during insertion of the second tubal device. However, neither paracervical block with lidocaine nor conscious sedation significantly reduced overall pain scores for sterilization by hysteroscopy.
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Affiliation(s)
- Bliss Kaneshiro
- Department of Obstetrics and Gynecology, University of Hawaii, Honolulu, USA.
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Abstract
BACKGROUND Acne is a common skin disorder among women. Although no uniform approach to the management of acne exists, combination oral contraceptives (COCs), which contain an estrogen and a progestin, often are prescribed for women. OBJECTIVES To determine the effectiveness of combined oral contraceptives (COCs) for the treatment of facial acne compared to placebo or other active therapies. SEARCH METHODS In January 2012, we searched for randomized controlled trials of COCs and acne in the computerized databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, and LILACS. We also searched for clinical trials in ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP) (Aug 2011). For the initial review, we wrote to researchers to seek any unpublished or published trials that we might have missed. SELECTION CRITERIA We considered randomized controlled trials reported in any language that compared the effectiveness of a COC containing an estrogen and a progestin to placebo or another active therapy for acne in women. DATA COLLECTION AND ANALYSIS We extracted data on facial lesion counts, both total and specific (i.e., open or closed comedones, papules, pustules and nodules); acne severity grades; global assessments by the clinician or the participant, and discontinuation due to adverse events. Data were entered and analyzed in RevMan. For continuous data, we calculated the mean difference (MD) and 95% confidence interval (CI). For dichotomous data, we calculated the Peto odds ratio (OR) and 95% CI. MAIN RESULTS The review includes 31 trials with 12,579 participants. Of 24 comparisons made, 6 compared a COC to placebo, 17 different COCs, and 1 compared a COC to an antibiotic. Of nine placebo-controlled trials with data for analysis, all showed COCs reduced acne lesion counts, severity grades and self-assessed acne compared to placebo. A levonorgestrel-COC group had fewer total lesion counts (MD -9.98; 95% CI -16.51 to -3.45), inflammatory and non-inflammatory lesion counts, and were more likely to have a clinician assessment of clear or almost clear lesions and participant self-assessment of improved acne lesions. A norethindrone acetate COC had better results for clinician global assessment of no acne to mild acne (OR 1.86; 95% CI 1.32 to 2.62). In two combined trials, a norgestimate COC showed reduced total lesion counts (MD-9.32; 95% CI -14.19 to -4.45), reduced inflammatory lesion and comedones counts, and more with clinician assessment of improved acne. For two combined trials of a drospirenone COC, the investigators' assessment of clear or almost clear skin favored the drospirenone group (OR 3.02; 95% CI 1.99 to 4.59). In one trial, the drospirenone-COC group showed greater (more positive) percent changes for total lesion count (MD 29.08; 95% CI 3.13 to 55.03), inflammatory and non-inflammatory lesion counts, and papule and closed comedone counts. A dienogest-COC group had greater percentage decreases in total lesion count (MD -15.30; 95% CI -19.98 to -10.62) and inflammatory lesion count, and more women assessed with overall improvement of facial acne. A CMA-COC group had more 'responders,' those with 50% or greater decrease in facial papules and pustules (OR 2.31; 95% CI 1.50 to 3.55)Differences in the comparative effectiveness of COCs containing varying progestin types and dosages were less clear, and data were limited for any particular comparison. COCs that contained chlormadinone acetate or cyproterone acetate improved acne better than levonorgestrel. A COC with cyproterone acetate showed better acne outcomes than one with desogestrel, but the studies produced conflicting results. Likewise, levonorgestrel showed a slight improvement over desogestrel in acne outcomes, but results were not consistent. A drospirenone COC appeared to be more effective than norgestimate or nomegestrol acetate plus 17β-estradiol but less effective than cyproterone acetate. AUTHORS' CONCLUSIONS This update yielded six new trials but no change in conclusions. The six COCs evaluated in placebo-controlled trials are effective in reducing inflammatory and non-inflammatory facial acne lesions. Few important and consistent differences were found between COC types in their effectiveness for treating acne. How COCs compare to alternative acne treatments is unknown since only one trial addressed this issue. The use of standardized methods for assessing acne severity would help in synthesizing results across trials as well as aid in interpretation.
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Affiliation(s)
- Ayodele O Arowojolu
- Department of Obstetrics and Gynaecology, College of Medicine, University College Hospital, Ibadan, Nigeria.
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Abstract
BACKGROUND Acne is a common skin disorder among women. Although no uniform approach to the management of acne exists, combination oral contraceptives (COCs), which contain an estrogen and a progestin, often are prescribed for women. OBJECTIVES To determine the effectiveness of combined oral contraceptives (COCs) for the treatment of facial acne compared to placebo or other active therapies. SEARCH METHODS In January 2012, we searched for randomized controlled trials of COCs and acne in the computerized databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, and LILACS. We also searched for clinical trials in ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP) (Aug 2011). For the initial review, we wrote to researchers to seek any unpublished or published trials that we might have missed. SELECTION CRITERIA We considered randomized controlled trials reported in any language that compared the effectiveness of a COC containing an estrogen and a progestin to placebo or another active therapy for acne in women. DATA COLLECTION AND ANALYSIS We extracted data on facial lesion counts, both total and specific (i.e., open or closed comedones, papules, pustules and nodules); acne severity grades; global assessments by the clinician or the participant, and discontinuation due to adverse events. Data were entered and analyzed in RevMan. For continuous data, we calculated the mean difference (MD) and 95% confidence interval (CI). For dichotomous data, we calculated the Peto odds ratio (OR) and 95% CI. MAIN RESULTS The review includes 31 trials with 12,579 participants. Of 24 comparisons made, 6 compared a COC to placebo, 17 different COCs, and 1 compared a COC to an antibiotic. Of nine placebo-controlled trials with data for analysis, all showed COCs reduced acne lesion counts, severity grades and self-assessed acne compared to placebo. A levonorgestrel-COC group had fewer total lesion counts (MD -9.98; 95% CI -16.51 to -3.45), inflammatory and non-inflammatory lesion counts, and were more likely to have a clinician assessment of clear or almost clear lesions and participant self-assessment of improved acne lesions. A norethindrone acetate COC had better results for clinician global assessment of no acne to mild acne (OR 1.86; 95% CI 1.32 to 2.62). In two combined trials, a norgestimate COC showed reduced total lesion counts (MD-9.32; 95% CI -14.19 to -4.45), reduced inflammatory lesion and comedones counts, and more with clinician assessment of improved acne. For two combined trials of a drospirenone COC, the investigators' assessment of clear or almost clear skin favored the drospirenone group (OR 3.02; 95% CI 1.99 to 4.59). In one trial, the drospirenone-COC group showed greater (more positive) percent changes for total lesion count (MD 29.08; 95% CI 3.13 to 55.03), inflammatory and non-inflammatory lesion counts, and papule and closed comedone counts. A dienogest-COC group had greater percentage decreases in total lesion count (MD -15.30; 95% CI -19.98 to -10.62) and inflammatory lesion count, and more women assessed with overall improvement of facial acne. A CMA-COC group had more 'responders,' those with 50% or greater decrease in facial papules and pustules (OR 2.31; 95% CI 1.50 to 3.55)Differences in the comparative effectiveness of COCs containing varying progestin types and dosages were less clear, and data were limited for any particular comparison. COCs that contained chlormadinone acetate or cyproterone acetate improved acne better than levonorgestrel. A COC with cyproterone acetate showed better acne outcomes than one with desogestrel, but the studies produced conflicting results. Likewise, levonorgestrel showed a slight improvement over desogestrel in acne outcomes, but results were not consistent. A drospirenone COC appeared to be more effective than norgestimate or nomegestrol acetate plus 17β-estradiol but less effective than cyproterone acetate. AUTHORS' CONCLUSIONS This update yielded six new trials but no change in conclusions. The six COCs evaluated in placebo-controlled trials are effective in reducing inflammatory and non-inflammatory facial acne lesions. Few important and consistent differences were found between COC types in their effectiveness for treating acne. How COCs compare to alternative acne treatments is unknown since only one trial addressed this issue. The use of standardized methods for assessing acne severity would help in synthesizing results across trials as well as aid in interpretation.
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Affiliation(s)
- Ayodele O Arowojolu
- Department of Obstetrics and Gynaecology, College of Medicine, University College Hospital, Ibadan,
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Abstract
BACKGROUND Many hormonal contraceptives have been associated with changes in carbohydrate metabolism. Alterations may include decreased glucose tolerance and increased insulin resistance, which are risk factors for Type 2 diabetes mellitus and cardiovascular disease. These issues have been raised primarily with contraceptives containing estrogen. OBJECTIVES To evaluate the effect of hormonal contraceptives on carbohydrate metabolism in healthy women and those at risk for diabetes due to overweight. SEARCH METHODS In February 2012, we searched the computerized databases MEDLINE, POPLINE, CENTRAL, and LILACS for studies of hormonal contraceptives and carbohydrate metabolism. We also searched for clinical trials in ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. SELECTION CRITERIA All randomized controlled trials were considered if they examined carbohydrate metabolism in women without diabetes who used hormonal contraceptives for contraception. Comparisons could be a placebo, a non-hormonal contraceptive, or another hormonal contraceptive that differed in drug, dosage, or regimen. Interventions included at least three cycles. Outcomes included glucose and insulin measures. DATA COLLECTION AND ANALYSIS We assessed all titles and abstracts identified during the literature searches. The data were extracted and entered into RevMan. We wrote to researchers for missing data. For continuous variables, the mean difference (MD) was computed with 95% confidence interval (CI) using a fixed-effect model. For dichotomous outcomes, the Peto odds ratio with 95% CI was calculated. MAIN RESULTS We found 31 trials that met the inclusion criteria. Twenty-one trials compared combined oral contraceptives (COCs); others examined different COC regimens, progestin-only pills, injectables, a vaginal ring, and implants. None included a placebo. Of 34 comparisons, eight had any notable difference between the study groups in an outcome.Twelve trials studied desogestrel-containing COCs, and the few differences from levonorgestrel COCs were inconsistent. A meta-analysis of two studies showed the desogestrel group had a higher mean fasting glucose (MD 0.20; 95% CI 0.00 to 0.41). Where data could not be combined, single studies showed lower mean fasting glucose (MD -0.40; 95% CI -0.72 to -0.08) and higher means for two-hour glucose response (MD 1.08; 95% CI 0.45 to 1.71) and insulin area under the curve (AUC) (MD 20.30; 95% CI 4.24 to 36.36).Three trials examined the etonogestrel vaginal ring and one examined an etonogestrel implant. One trial showed the ring group had lower mean AUC insulin than the levonorgestrel-COC group (MD -204.51; 95% CI -389.64 to -19.38).Of eight trials of norethisterone preparations, five compared COCs and three compared injectables. In a COC trial, a norethisterone group had smaller mean change in glucose two-hour response than a levonorgestrel-COC group (MD -0.30; 95% CI -0.54 to -0.06). In an injectable study, a group using depot medroxyprogesterone acetate had higher means than the group using norethisterone enanthate for fasting glucose (MD 10.05; 95% CI 3.16 to 16.94), glucose two-hour response (MD 17.00; 95% CI 5.67 to 28.33), and fasting insulin (MD 3.40; 95% CI 2.07 to 4.73).Among five recent trials, two examined newer COCs with different estrogen types. One showed the group with nomegestrel acetate plus 17β-estradiol had lower means than the levonorgestrel group for incremental AUC glucose (MD -1.43; 95% CI -2.55 to -0.31) and glycosylated hemoglobin (HbA1c) (MD -0.10; 95% CI -0.18 to -0.02). Two trials compared extended versus conventional (cyclic) regimens. With a dienogest COC, an extended-use group had greater mean change in AUC glucose (MD 82.00; 95% CI 10.72 to 153.28). In a small trial using two levonorgestrel COCs, the lower-dose group showed smaller mean change in fasting glucose (MD -3.00; 95% CI -5.89 to -0.11), but the obese and normal weight women did not differ significantly. AUTHORS' CONCLUSIONS Current evidence suggests no major differences in carbohydrate metabolism between different hormonal contraceptives in women without diabetes. We cannot make strong statements due to having few studies that compared the same types of contraceptives. Many trials had small numbers of participants and some had large losses. Many of the earlier studies had limited reporting of methods.We still know very little about women at risk for metabolic problems due to being overweight. More than half of the trials had weight restrictions as inclusion criteria. Only one small trial stratified the groups by body mass index (obese versus normal).
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Affiliation(s)
- Laureen M Lopez
- Clinical Sciences, FHI 360, Research Triangle Park, North Carolina, USA.
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Abstract
BACKGROUND Miscarriage is a common complication of early pregnancy that can have both medical and psychological consequences such as depression and anxiety. The need for routine surgical evacuation with miscarriage has been questioned because of potential complications such as cervical trauma, uterine perforation, hemorrhage, or infection. OBJECTIVES To compare the safety and effectiveness of expectant management versus surgical treatment for early pregnancy failure. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 February 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4 of 4), PubMed (2005 to 11 January 2012), POPLINE (inception to 11 January 2012), LILACS (2005 to 11 January 2012) and reference lists of retrieved studies. SELECTION CRITERIA Randomized trials comparing expectant care and surgical treatment (vacuum aspiration or dilation and curettage) for miscarriage were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors assessed trial quality and extracted data. We contacted study authors for additional information. For dichotomous data, we calculated the Mantel-Haenszel risk ratio (RR) with 95% confidence interval (CI). For continuous data, we computed the mean difference (MD) and 95% CI. We entered additional data such as medians into 'Other data' tables. MAIN RESULTS We included seven trials with 1521 participants in this review. The expectant-care group was more likely to have an incomplete miscarriage by two weeks (RR 3.98; 95% CI 2.94 to 5.38) or by six to eight weeks (RR 2.56; 95% CI 1.15 to 5.69). The need for unplanned surgical treatment was greater for the expectant-care group (RR 7.35; 95% CI 5.04 to 10.72). The mean percentage needing surgical management in the expectant-care group was 28%, while 4% of the surgical-treatment group needed additional surgery. The expectant-care group had more days of bleeding (MD 1.59; 95% CI 0.74 to 2.45). Further, more of the expectant-care group needed transfusion (RR 6.45; 95% CI 1.21 to 34.42). The mean percentage needing blood transfusion was 1.4% for expectant care compared with none for surgical management. Results were mixed for pain. Diagnosis of infection was similar for the two groups (RR 0.63; 95% CI 0.36 to 1.12), as were results for various psychological outcomes. Pregnancy data were limited. Costs were lower for the expectant-care group (MD -499.10; 95% CI -613.04 to -385.16; in UK pounds sterling). AUTHORS' CONCLUSIONS Expectant management led to a higher risk of incomplete miscarriage, need for unplanned (or additional) surgical emptying of the uterus, bleeding and need for transfusion. Risk of infection and psychological outcomes were similar for both groups. Costs were lower for expectant management. Given the lack of clear superiority of either approach, the woman's preference should be important in decision making. Pharmacological ('medical') management has added choices for women and their clinicians and has been examined in other reviews.
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Affiliation(s)
- Kavita Nanda
- Clinical Sciences, FHI, Research Triangle Park, North Carolina, USA.
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Abstract
BACKGROUND Male hormonal contraception has been an elusive goal. Administration of sex steroids to men can shut off sperm production through effects on the pituitary and hypothalamus. However, this approach also decreases production of testosterone, so 'add-back' therapy is needed. OBJECTIVES To summarize all randomized controlled trials (RCTs) of male hormonal contraception. SEARCH METHODS In January and February 2012, we searched the computerized databases CENTRAL, MEDLINE, POPLINE, and LILACS. We also searched for recent trials in ClinicalTrials.gov and ICTRP. Previous searches included EMBASE. We wrote to authors of identified trials to seek additional unpublished or published trials. SELECTION CRITERIA We included all RCTs that compared a steroid hormone with another contraceptive. We excluded non-steroidal male contraceptives, such as gossypol. We included both placebo and active-regimen control groups. DATA COLLECTION AND ANALYSIS The primary outcome measure was the absence of spermatozoa on semen examination, often called azoospermia. Data were insufficient to examine pregnancy rates and side effects. MAIN RESULTS We found 33 trials that met our inclusion criteria. The proportion of men who reportedly achieved azoospermia or had no detectable sperm varied widely. A few important differences emerged. 1) Levonorgestrel implants (160 μg daily) combined with injectable testosterone enanthate (TE) were more effective than levonorgestrel 125 µg daily combined with testosterone patches. 2) Levonorgestrel 500 μg daily improved the effectiveness of TE 100 mg injected weekly. 3) Levonorgestrel 250 μg daily improved the effectiveness of testosterone undecanoate (TU) 1000 mg injection plus TU 500 mg injected at 6 and 12 weeks. 4) Desogestrel 150 μg was less effective than desogestrel 300 μg (with testosterone pellets). 5) TU 500 mg was less likely to produce azoospermia than TU 1000 mg (with levonorgestrel implants). 6) Norethisterone enanthate 200 mg with TU 1000 mg led to more azoospermia when given every 8 weeks versus 12 weeks. 7) Four implants of 7-alpha-methyl-19-nortestosterone (MENT) were more effective than two MENT implants. We did not conduct any meta-analysis due to intervention differences.Several trials showed promising efficacy in percentages with azoospermia. Three examined desogestrel and testosterone preparations or etonogestrel and testosterone, and two examined levonorgestrel and testosterone. AUTHORS' CONCLUSIONS No male hormonal contraceptive is ready for clinical use. Most trials were small exploratory studies. Their power to detect important differences was limited and their results imprecise. In addition, assessment of azoospermia can vary by sensitivity of the method used. Future trials need more attention to the methodological requirements for RCTs. More trials with adequate power would also be helpful.
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Affiliation(s)
- David A Grimes
- Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
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Grimes DA, Stuart GS, Raymond EG. Feticidal digoxin injection before dilation and evacuation abortion. Contraception 2012; 85:140-3. [DOI: 10.1016/j.contraception.2011.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 04/07/2011] [Indexed: 10/18/2022]
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Affiliation(s)
- Allan Templeton
- Department of Obstetrics and Gynaecology, Aberdeen Maternity Hospital, Aberdeen, United Kingdom.
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Abstract
BACKGROUND Side effects of oral contraceptive (OC) pills discourage adherence to and continuation of OC regimens. Strategies to decrease adverse effects led to the introduction of the triphasic OC in the 1980s. Whether triphasic OCs have higher accidental pregnancy rates than monophasic pills is unknown. Nor is it known if triphasic pills give better cycle control and fewer side effects than the monophasic pills. OBJECTIVES To compare triphasic OCs with monophasic OCs in terms of efficacy, cycle control, and discontinuation due to side effects. SEARCH METHODS We searched the computerized databases of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, POPLINE, EMBASE, and LILACS, as well as clinical trials databases (ClinicalTrials.gov and the World Health Organization Clinical Trials Registry Platform (ICTRP)) in May 2011. Additionally, we searched the reference lists of relevant articles. We also contacted researchers and pharmaceutical companies to identify other trials not found in our search. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing any triphasic OC with any monophasic pill used to prevent pregnancy. Interventions had to include at least three treatment cycles. DATA COLLECTION AND ANALYSIS We assessed the studies found in the literature searches for possible inclusion and for their methodological quality. We contacted the authors of all included studies and of possibly randomized trials for supplemental information about the methods used and outcomes studied. We entered the data into RevMan and calculated odds ratios for the outcome measures of efficacy, breakthrough bleeding, spotting, withdrawal bleeding and discontinuation. MAIN RESULTS Of 23 trials included, 19 examined contraceptive effectiveness. The triphasic and monophasic preparations did not differ significantly. Several trials reported favorable bleeding patterns, that is less spotting, breakthrough bleeding or amenorrhea, in triphasic versus monophasic OC users. However, meta-analysis was generally not possible due to differences in measuring and reporting the cycle disturbance data as well as differences in progestogen type and hormone dosages. No significant differences were found in the numbers of women who discontinued due to medical reasons, cycle disturbances, intermenstrual bleeding or adverse events. AUTHORS' CONCLUSIONS The available evidence is insufficient to determine whether triphasic OCs differ from monophasic OCs in effectiveness, bleeding patterns or discontinuation rates. Therefore, we recommend monophasic pills as a first choice for women starting OC use. Large, high-quality RCTs that compare triphasic and monophasic OCs with identical progestogens are needed to determine whether triphasic pills differ from monophasic OCs. Future studies should follow the recommendations of Belsey or Mishell on recording menstrual bleeding patterns and the CONSORT reporting guidelines.
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Affiliation(s)
- Huib A A M Van Vliet
- Department of Gynaecology, Division of Reproductive Medicine, Leiden University Medical Center, Leiden, Netherlands.
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Arowojolu AO, Gallo MF, Lopez LM, Grimes DA, Garner SE. Cochrane Review: Combined oral contraceptive pills for treatment of acne. ACTA ACUST UNITED AC 2011. [DOI: 10.1002/ebch.841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
BACKGROUND Functional ovarian cysts are a common gynecological problem among women of reproductive age worldwide. When large, persistent, or painful, these cysts may require operations, sometimes resulting in removal of the ovary. Since early oral contraceptives were associated with a reduced incidence of functional ovarian cysts, many clinicians inferred that birth control pills could be used to treat cysts as well. This became a common clinical practice in the early 1970s. OBJECTIVES This review examined all randomized controlled trials that studied oral contraceptives as therapy for functional ovarian cysts. SEARCH STRATEGY We searched the databases of CENTRAL, MEDLINE, POPLINE, and EMBASE, as well as clinical trials databases (ClinicalTrials.gov and ICTRP). We also examined the reference lists of articles and wrote to authors of identified trials to seek articles we had missed. SELECTION CRITERIA We included randomized controlled trials in any language that included oral contraceptives used for treatment and not prevention of functional ovarian cysts. Criteria for diagnosis of cysts were those used by authors of trials. DATA COLLECTION AND ANALYSIS Two authors independently abstracted data from the articles. One entered the data into RevMan and a second verified accuracy of data entry. For dichotomous outcomes, we computed the Mantel-Haenszel odds ratio with 95% confidence interval (CI). For continuous outcomes, we calculated the mean difference with 95% CI. MAIN RESULTS We identified eight randomized controlled trials from four countries; the studies included a total of 686 women. Treatment with combined oral contraceptives did not hasten resolution of functional ovarian cysts in any trial. This held true for cysts that occurred spontaneously as well as those that developed after ovulation induction. Most cysts resolved without treatment within a few cycles; persistent cysts tended to be pathological (e.g., endometrioma or para-ovarian cyst) and not physiological. AUTHORS' CONCLUSIONS Although widely used for treating functional ovarian cysts, combined oral contraceptives appear to be of no benefit. Watchful waiting for two or three cycles is appropriate. Should cysts persist, surgical management is often indicated.
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Affiliation(s)
- David A Grimes
- Clinical Sciences, FHI 360, PO Box 13950, Research Triangle Park, North Carolina, USA, NC 27709
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Abstract
BACKGROUND Weight gain is often considered a side effect of combination hormonal contraceptives, and many women and clinicians believe that an association exists. Concern about weight gain can limit the use of this highly effective method of contraception by deterring the initiation of its use and causing early discontinuation among users. However, a causal relationship between combination contraceptives and weight gain has not been established. OBJECTIVES The aim of the review was to evaluate the potential association between combination contraceptive use and changes in weight. SEARCH STRATEGY We searched the computerized databases CENTRAL (The Cochrane Library), MEDLINE, POPLINE, EMBASE, and LILACS for studies of combination contraceptives, as well as ClinicalTrials.gov and International Clinical Trials Registry Platform (ICTRP). Searches were conducted from January to May 2011. We also wrote to known investigators and manufacturers to request information about other published or unpublished trials not discovered in our search. SELECTION CRITERIA All English-language, randomized controlled trials were eligible if they had at least three treatment cycles and compared a combination contraceptive to a placebo or to a combination contraceptive that differed in drug, dosage, regimen, or study length. DATA COLLECTION AND ANALYSIS All titles and abstracts located in the literature searches were assessed. Data were entered and analyzed with RevMan. A second author verified the data entered. For continuous data, we calculated the mean difference and 95% confidence interval (CI) for the mean change in weight between baseline and post-treatment measurements using a fixed-effect model. For categorical data, such as the proportion of women who gained or lost more than a specified amount of weight, the Peto odds ratio with 95% CI was calculated. MAIN RESULTS We found 49 trials that met our inclusion criteria. The trials included 85 weight change comparisons for 52 distinct contraceptive pairs (or placebos). The four trials with a placebo or no intervention group did not find evidence supporting a causal association between combination oral contraceptives or a combination skin patch and weight change. Most comparisons of different combination contraceptives showed no substantial difference in weight. In addition, discontinuation of combination contraceptives because of weight change did not differ between groups where this was studied. AUTHORS' CONCLUSIONS Available evidence was insufficient to determine the effect of combination contraceptives on weight, but no large effect was evident. Trials to evaluate the link between combination contraceptives and weight change require a placebo or non-hormonal group to control for other factors, including changes in weight over time.
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Affiliation(s)
- Maria F Gallo
- Division of Reproductive Health, Centers for Disease Control and Prevention, 4770 Buford Highway, Mail Stop K-34, Atlanta, Georgia, USA, 30341-3724
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Kaunitz AM, Grimes DA. Removing the black box warning for depot medroxyprogesterone acetate. Contraception 2011; 84:212-3. [DOI: 10.1016/j.contraception.2011.01.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 01/10/2011] [Indexed: 11/17/2022]
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Krishnan S, Grimes DA, Lopez LM, Tang JH. Intrauterine devices for contraception in nulliparous women. Hippokratia 2011. [DOI: 10.1002/14651858.cd009254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sheila Krishnan
- Northwestern University, Feinberg School of Medicine; Department of Obstetrics and Gynecology; 680 North Lake Shore Drive Suite 1015 Chicago Illinois USA IL 60611
| | - David A Grimes
- FHI; Clinical Sciences; PO Box 13950 Research Triangle Park North Carolina USA NC 27709
| | - Laureen M Lopez
- FHI; Clinical Sciences; PO Box 13950 Research Triangle Park North Carolina USA NC 27709
| | - Jennifer H. Tang
- University of North Carolina; Department of Obstetrics and Gynecology; Chapel Hill North Carolina USA
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Abstract
BACKGROUND Steroidal contraceptive use has been associated with changes in bone mineral density in women. Whether such changes increase the risk of fractures later in life is not clear. Osteoporosis is a major public health concern. Age-related decline in bone mass increases the risk of fracture, especially of the spine, hip, and wrist. Concern about bone health influences the recommendation and use of these effective contraceptives globally. OBJECTIVES To evaluate the effect of using hormonal contraceptives before menopause on the risk of fracture in women SEARCH STRATEGY We searched for studies of fracture or bone health and hormonal contraceptives in MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS, as well as ClinicalTrials.gov and ICTRP. We wrote to investigators to find additional trials. SELECTION CRITERIA Randomized controlled trials (RCTs) were considered if they examined fractures, bone mineral density (BMD), or bone turnover in women with hormonal contraceptive use prior to menopause. Interventions could include comparing a hormonal contraceptive with a placebo or another hormonal contraceptive or could compare providing a supplement versus a placebo. DATA COLLECTION AND ANALYSIS We assessed all titles and abstracts identified through the literature searches. Mean differences were computed using the inverse variance approach. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) was calculated. Both included the 95% confidence interval (CI) and used a fixed-effect model. Due to different interventions, no trials could be combined for meta-analysis. MAIN RESULTS Of the 16 RCTs we found, 2 used a placebo and 1 used a non-hormonal method as the comparison, while 13 compared two hormonal contraceptives. No trial had fracture as an outcome. Most measured BMD and several assessed bone turnover. Depot medroxyprogesterone acetate (DMPA) was associated with decreased bone mineral density. The placebo-controlled trials showed BMD increases for DMPA plus estrogen supplement and decreases for DMPA plus placebo. Combination contraceptives did not appear to negatively affect bone health, but none were placebo-controlled. For implants, the single-rod etonogestrel group showed a greater BMD decrease versus the two-rod levonorgestrel group. However, results were not consistent across all implant comparisons. AUTHORS' CONCLUSIONS Whether steroidal contraceptives influence fracture risk cannot be determined from existing information. Many trials had small numbers of participants and some had large losses to follow up. Health care providers and women should consider the costs and benefits of these effective contraceptives. For example, injectable contraceptives and implants provide effective, long-term birth control yet do not involve a daily regimen. Progestin-only contraceptives are considered appropriate for women who should avoid estrogen due to medical conditions.
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Affiliation(s)
- Laureen M Lopez
- Clinical Sciences, FHI, P.O. Box 13950, Research Triangle Park, North Carolina, USA, 27709
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Abstract
BACKGROUND Worldwide, hormonal contraceptives are among the most popular reversible contraceptives in current use. Despite their high theoretical effectiveness, typical use results in much lower effectiveness. In large part, this disparity reflects difficulties in adherence to the contraceptive regimen and low rates for long-term continuation. OBJECTIVES To determine the effectiveness of ancillary techniques to improve adherence to, and continuation rates of, hormonal methods of contraception. SEARCH STRATEGY We searched computerized databases for randomized controlled trials (RCTs) comparing client-provider interventions with standard family planning counseling. Sources included CENTRAL, MEDLINE, EMBASE, POPLINE, LILACS, PsycINFO, ClinicalTrials.gov and ICTRP. SELECTION CRITERIA We included randomized controlled trials (RCTs) of an intensive counseling technique or client-provider intervention versus routine family planning counseling. Interventions included group motivation; structured, peer, or multi-component counseling; and intensive reminders of appointments or next dosing. Outcome measures were discontinuation, reasons for discontinuation, number of missed pills and on-time injections, and pregnancy. DATA COLLECTION AND ANALYSIS The primary author evaluated all titles and abstracts from the searches to determine eligibility. Two authors independently extracted data from the included studies. With RevMan, we calculated the odds ratio for all dichotomous outcomes and the mean difference for continuous data. The studies were so different that we did not conduct a meta-analysis. MAIN RESULTS We found eight RCTs; only one showed a statistically significant benefit of the experimental intervention. In that trial, women who received repeated, structured information about the injectable contraceptive depo-medroxyprogesterone acetate (DMPA) were less likely to have discontinued the method by 12 months (OR 0.27; 95% CI 0.16 to 0.44) than were women who had routine counseling. The intervention group was also less likely to discontinue due to menstrual disturbances (OR 0.20; 95% CI 0.11 to 0.37). In another study, the intervention group was less likely to discontinue due to dissatisfaction with the contraceptive method (OR 0.61; 95% CI 0.38 to 0.98), but overall continuation was not affected. AUTHORS' CONCLUSIONS Most studies to date have shown no benefit of strategies to improve adherence and continuation. These trials have important limitations, however. Three had small sample sizes, four had high losses to follow up, and the intervention and its intensity varied across the studies. High-quality research is a priority, since adherence and continuation are fundamentally important to the successful use of hormonal contraceptives.
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Affiliation(s)
- Vera Halpern
- Clinical Sciences, FHI, P.O. Box 13950, Research Triangle Park, North Carolina, USA, 27709
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Abstract
BACKGROUND The explicit use of theory in research helps expand the knowledge base. Theories and models have been used extensively in HIV-prevention research and in interventions for preventing sexually transmitted infections (STIs). The health behavior field uses many theories or models of change. However, educational interventions addressing contraception often have no stated theoretical base. OBJECTIVES Review randomized controlled trials (RCTs) that tested a theoretical approach to inform contraceptive choice; encourage contraceptive use; or promote adherence to, or continuation of, a contraceptive regimen. SEARCH STRATEGY We searched computerized databases for trials that tested a theory-based intervention for improving contraceptive use (MEDLINE, POPLINE, CENTRAL, PsycINFO, EMBASE, ClinicalTrials.gov, and ICTRP). We also wrote to researchers to find other trials. SELECTION CRITERIA Trials tested a theory-based intervention for improving contraceptive use. We excluded trials focused on high-risk groups and preventing sexually transmitted infections or HIV. Interventions addressed the use of one or more contraceptive methods for contraception. The reports provided evidence that the intervention was based on a specific theory or model. The primary outcomes were pregnancy, contraceptive choice, initiating or changing contraceptive use, contraceptive regimen adherence, and contraception continuation. DATA COLLECTION AND ANALYSIS The primary author evaluated abstracts for eligibility. Two authors extracted data from included studies. We calculated the odds ratio for dichotomous outcomes. No meta-analysis was conducted due to intervention differences. MAIN RESULTS Fourteen RCTs met our inclusion criteria. In 2 of 10 trials with pregnancy or birth data, a theory-based group showed better results. Four of 10 trials with contraceptive use data (other than condoms) showed better outcomes in an experimental group. For condom use, a theory-based group had favorable results in three of eight trials. Social Cognitive Theory was the main theoretical basis for five trials, of which three showed positive results. Two based on other social cognition models had favorable results, as did two of four focused on motivational interviewing. Thirteen trials provided multiple sessions or contacts. Of seven effective interventions, five targeted adolescents, including four with group sessions. Three effective trials had individual sessions. Seven trials were rated as having high or moderate quality; three of those had favorable results. AUTHORS' CONCLUSIONS Family planning researchers and practitioners could adapt the effective interventions. Reproductive health needs high-quality research on behavior change, especially for clinical and low-resource settings. More thorough use of single theories would help, as would better reporting on research design and intervention implementation.
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Affiliation(s)
- Laureen M Lopez
- Clinical Sciences, FHI, P.O. Box 13950, Research Triangle Park, North Carolina, USA, 27709
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