Overcoming barriers to oral contraception in Italy an expert opinion to empower women

Oral contraceptives are among the most commonly used contraceptive methods. However, Italian women underused reliable hormonal contraceptives as compared with other European women. There is a need to streamline access to oral contraception, with expected benefits on emotional well-being of women and potential savings for health system in Italy. Indeed, women can only access to oral contraceptives through mandatory medical prescription. This is one of the most important barrier experienced by women. We hereby provide an expert opinion on the potential reclassification, extending pharmacy services to include responsible and appropriate use of POP, as an opportunity also in Italy to increase the use of safe and effective contraceptive methods.

Attitudes of women and pharmacists on the opportunity to obtain a progestogen-only pill over the counter - Italian outcomes

PURPOSE

Scrutinizing, among potential providers and users, the perceived claim and interest for over the counter (OTC) accessibility of a progestogen-only pill (POP).

METHODS

Cross-sectional, descriptive study based on an online survey of 1000 women and 100 pharmacists in Italy, part of a larger sample including Germany and Spain.

RESULTS

Hormonal contraceptive methods are used by 35%; 5% of women reported currently not using contraception, 40% using a barrier method, and 20% a method considered less effective than male condoms (including 16% withdrawal and 4% natural methods and fertility/contraceptive applications). Almost 80% of women felt knowledgeable about the different contraceptive method, but about 1/3 had experienced difficulty accessing their oral contraceptive (OC) in the past two years. Women reacted positively to the proposition of an OTC-POP and 85% agreed that they would discuss the decision to buy it with their doctor; 75% reported they would continue to see their doctor for other reproductive health issues, including screening. The most frequent barrier is cost (reported by 25-33% of women) followed by long waiting times for doctor appointments and lack of personal time to schedule an appointment.Pharmacists (66%) would be likely/fairly likely to recommend the POP after appropriate training, agreeing that the benefits of an OTC-POP included improved access for women, saving them time and giving them more independence.

CONCLUSIONS

Potential users of contraception in Italy have a positive attitude toward OTC-POP, with doctors continuing to have a relevant role. Following training, pharmacists are also positive.

Genomic Signature for Oligometastatic Disease in Non-Small Cell Lung Cancer Patients with Brain Metastases

PURPOSE/OBJECTIVE(S)

Biomarkers for oligometastatic disease remain elusive and few studies have attempted to correlate genomic data to the presence of true oligometastatic disease.

MATERIALS/METHODS

Patients with non-small cell lung cancer (NSCLC) and brain metastases were identified in our departmental database. Electronic medical records were used to identify patients for whom liquid biopsy-based comprehensive genomic profiling (Guardant Health) was available. Oligometastatic disease was defined as patients having ≤5 non-brain metastases without diffuse involvement of a single organ. Widespread disease was any spread beyond oligometastatic. Fisher's exact tests were used to identify mutations statistically associated (p<0.1) with either oligometastatic or widespread extracranial disease. A score of +1 was assigned for every mutation present associated with oligometastatic disease, and -1 was assigned for mutations associated with widespread disease. Scores were summed for each patient to create a risk score for the likelihood of oligometastatic disease, with scores subsequently correlated to the likelihood of having oligometastatic disease vs widespread disease. For oligometastatic patients, a competing risk analysis was done to assess for cumulative incidence of oligometastatic progression accounting for the potential competing risks of widespread progression of extracranial disease or death. Cox regression was used to determine the association between oligometastatic risk score and oligometastatic progression.

RESULTS

One hundred thirty patients met study criteria and were included in the analysis. 51 patients (39%) had oligometastatic disease. Genetic mutations included in the Guardant panel associated (p<0.1) with the presence of oligometastatic extracranial disease included ATM, JAK2, MAP2K2, and NTRK1; ARID1A and CCNE1 were associated with widespread disease. Patients with a positive, neutral and negative risk score for oligometastatic disease had a 78%, 41% and 11.5% likelihood of having oligometastatic disease, respectively (p<0.0001). Overall survival for patients with positive, neutral and negative risk scores for oligometastatic disease was 86% vs 82% vs 64% at 6 months (p = 0.2). The competing risk analysis found that the oligometastatic risk score was significantly associated with the likelihood of oligometastatic progression based on the Wald Chi-square test. Patients with positive, neutral and negative risk scores for oligometastatic disease had a cumulative incidence of oligometastatic progression of 77% vs 35% vs 33% at 6 months (p = 0.03 from competing risk model).

CONCLUSION

Elucidation of a genomic signature for oligometastatic disease derived from non-invasive liquid biopsy appears feasible for NSCLC patients. Patients with the oligometastatic signature exhibited higher rates of early oligometastatic progression. Validation of this signature could lead to a biomarker that has the potential to direct local therapies in oligometastatic patients.

Extrapulmonary Small Cell Carcinoma: A Single Institution Review of Brain Metastases, Treatment Paradigms and Patient Outcomes

PURPOSE/OBJECTIVE(S)

Extrapulmonary small cell carcinoma (EPSCC) is a rare entity with 1,000 cases reported annually in the U.S. It can originate in a variety of sites outside of the lung, and even with locoregional disease, relapse is common, and survival is poor. Prophylactic cranial irradiation (PCI) can improve survival in small cell lung carcinoma, however in the setting of EPSCC its role has not been clearly defined. We offer a single institution retrospective review of EPSCC, outlining the incidence of brain metastases, treatment paradigms, and patient outcomes.

MATERIALS/METHODS

Patients with available records were identified from an institutional database. Demographic, disease-related, and treatment details were abstracted from the electronic medical record. Clinical outcomes were obtained by medical record review and brain metastases were identified through diagnostic imaging. Patients were classified as having brain metastases at diagnosis or in follow-up. Brain metastasis-free survival (BMFS) was defined as the duration of time from diagnosis to the development of brain metastases, and extracranial progression-free survival (ePFS), as the duration of time from diagnosis to progression of disease outside the brain. Time to event outcomes were summarized using the Kaplan-Meier method. Analyses were performed using R version 3.6.

RESULTS

In total, 68 patients met eligibility criteria for analysis. The majority were male (66%) and median age was 68. The most common primary sites were genitourinary (32%) and gastrointestinal/hepatobiliary (22%). Thirty-eight patients (56%) had diagnostic brain imaging at time of diagnosis, with brain metastases present in 5 (13%). Treatment was delivered to 53 patients (80%) and treatment modalities included chemotherapy (n = 46), radiotherapy (n = 21), and surgery (n = 18). Median follow-up was 9.3 months for all patients and 10.3 months for surviving patients. Overall, 12 patients were observed to have brain metastases: 5 at diagnosis and 7 in follow-up. The competing risk of death without brain metastases at 1 year was 51.5%. Four of 5 patients with de novo brain metastases received WBRT. Of the 7 patients with subsequent brain metastases, 1 received salvage WBRT and 3 received salvage SRS. In total, 49 patients died and median OS was 10.0 months. Those with brain metastases had no significant difference in OS when compared to those without brain metastases (10.8 months v. 9.4 months). There was no association between primary type and survival.

CONCLUSION

EPSCC is a rare entity that is most commonly diagnosed in the genitourinary system. In contrast to SCLC, the incidence of brain metastases is uncommon. No difference in survival was observed between patients with or without brain metastases. While retrospective studies must be interpreted with caution, our data suggest that the risks of PCI may outweigh the benefits. Further studies investigating the role of brain imaging surveillance, as well as the optimal management of brain metastases, is warranted.

Attitudes towards menstruation: what women want? An Italian National Survey

OBJECTIVE

Many women experience negative feelings during menstrual bleeding. Aim of the study was to evaluate the attitudes of Italian women towards menstrual bleeding, their desire to reduce its frequency and knowledge of the existence of methods capable of achieving such an objective.

METHODS

An internet-based anonymous questionnaire has been sent to women willing to fill it in through different social media (Instagram, WhatsApp, Facebook, Twitter). The survey evaluated, objective parameters such as number of pads, use of painkillers, duration of period and pain intensity. Judgement towards period and knowledge about methods to reduce frequency and amount of menstrual flow were analysed.

RESULT

1072 Women aged 18 - 40 years, answered the survey. The level of education of responders was high, with 61.7% having a university degree. 27.5% of respondents viewed positively the occurrence of a menstrual period. Ideal frequency of menstrual cycles was considered 3 months and the perfect duration was considered to be 3 days. Half of the respondents ignored the existence of methods to suppress menstruation or reduce its frequency. 52% of participants stated that they would not use a contraceptive method because they considered it not 'natural'.

CONCLUSIONS

In our sample, in spite of the discomfort reported by half of the women interviewed, menstruation was considered positively by one fourth as because confirm their fertility. The majority of women did consider bleeding every month a healthy, but they preferred a three-monthly frequency. Knowledge of contraceptive methods capable of reducing the frequency of menstrual bleeding was scarce.

The views of women and pharmacists on the desirability of a progestogen-only pill over the counter. Results of a survey in Germany, Italy and Spain

PURPOSE

To explore the perceived need and enthusiasm for over the counter (OTC) progestogen-only pills (POP).

MATERIALS AND METHODS

A web-based survey of 1000 sexually active women (16-45) and 100 pharmacists in Germany, Italy and Spain.

RESULTS

Despite not wanting to conceive, 5-6% of women in each country were not using contraception and 8-20% were using methods less effective than condoms. At least 74% of respondents felt knowledgeable about the different contraceptives available but at least 1/3 had experienced difficulty accessing oral contraceptive (OCs) in the past two years. The cost of contraceptives, the need to see a doctor and long waits for appointments were cited as barriers for not using OCs. The majority agreed they would discuss with their doctor the decision to buy the POP, consult about side effects and other reproductive health issues. Over 2/3 of pharmacists in each country would be very, or fairly, likely to recommend the POP, agreeing that the benefits included improved access for women, and offered them more independence.

CONCLUSIONS

Asked directly, women in Germany, Spain and Italy currently using contraception are positive about a POP OTC. Pharmacists are also positive, with the overwhelming majority in favour of providing POPs.

Trends in osteoporosis care patterns during the COVID-19 pandemic in Alberta, Canada

PURPOSE/INTRODUCTION

The objective of this study was to describe osteoporosis-related care patterns during the coronavirus disease 2019 (COVID-19) pandemic in Alberta, Canada, relative to the 3-year preceding.

METHODS

A repeated cross-sectional study design encompassing 3-month periods of continuous administrative health data between March 15, 2017, and September 14, 2020, described osteoporosis-related healthcare resource utilization (HCRU) and treatment patterns. Outcomes included patients with osteoporosis-related healthcare encounters, physician visits, diagnostic and laboratory test volumes, and treatment initiations and disruptions. The percent change between outcomes was calculated, averaged across the control periods (2017-2019), relative to the COVID-19 periods (2020).

RESULTS

Relative to the average control March to June period, all HCRU declined during the corresponding COVID-19 period. There was a reduction of 14% in patients with osteoporosis healthcare encounters, 13% in general practitioner visits, 9% in specialist practitioner visits, 47% in bone mineral density tests, and 13% in vitamin D tests. Treatment initiations declined 43%, 26%, and 35% for oral bisphosphonates, intravenous bisphosphonates, and denosumab, respectively. Slight increases were observed in the proportion of patients with treatment disruptions. In the subsequent June to September period, HCRU either returned to or surpassed pre-pandemic levels, when including telehealth visits accounting for 33-45% of healthcare encounters during the COVID periods. Oral bisphosphonate treatment initiations remained lower than pre-pandemic levels.

CONCLUSIONS

This study demonstrates the COVID-19 pandemic and corresponding public health lockdowns further heightened the "crisis" around the known gap in osteoporosis care and altered the provision of care (e.g., use of telehealth and initiation of treatment). Osteoporosis has a known substantial care and management disparity, which has been classified as a crisis. The COVID-19 pandemic created additional burden on osteoporosis patient care with healthcare encounters, physician visits, diagnostic and laboratory tests, and treatment initiations all declining during the initial pandemic period, relative to previous years.

COVID-19 PANDEMIC INDUCED DISRUPTIONS IN TROPONIN AND LOW-DENSITY LIPOPROTEIN CHOLESTEROL LABORATORY TEST VOLUMES ACROSS ALBERTA

BACKGROUND

Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality in Canada and worldwide. Laboratory tests, including troponin and low-density lipoprotein cholesterol (LDL-C), are important biomarkers of ASCVD risk. The objective of this study was to investigate patterns of testing for troponin and LDL-C test volumes among Alberta residents during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS AND RESULTS

A repeated cross-sectional study design captured population-level laboratory test volumes between March 15, 2019 and December 14, 2020. Three-month cross-sections were derived to report laboratory test volumes by different COVID-19 restriction periods during 2020-2021 and using 2019-2020 as a preceding control period. Percent change for troponin and LDL-C test volumes were calculated for both control and COVID-19 periods among adult (≥18 years of age) Alberta residents, and stratified by age (18-49, 50-65, 66-79, and ≥80 years), sex, and geographic zones (urban, rural). This preliminary data is part of an ongoing study for which further troponin and LDL-C test volumes will be available up until March 14, 2021 (representing one year of data throughout the COVID-19 pandemic). Among the Alberta population, 292,836 troponin and 794,789 LDL-C tests were captured between March 15, 2020 and December 14, 2020 (Figure 1). Testing patterns during the COVID-19 restriction period showed marked reduction in test volumes from the previous year. The initial cross-section of the COVID-19 period (March-June 2020) was characterized by the largest overall reduction with troponin test volumes decreasing 18% and LDL-C test volumes decreasing 63%, compared to the year prior. As restrictions eased in the summer months of 2020, testing volumes rebounded to near pre-pandemic volumes for both tests. However, in the fall of 2020, troponin tests decreased again (-15%). Within these drops in utilization, slightly larger relative declines were observed for troponin test volumes in women (-20%) and patients ≥80 years-old (-25%) and for LDL-C test volumes among urban residents (-64%), women (-67%) and patients aged 18-49 (-66%) and 50-65 (-65%) years (Table 1).

CONCLUSION

This study describes declines in troponin and LDL-C test volumes in the initial and second COVID-19 lockdown periods. Women had overall smaller total troponin and LDL-C test volumes and larger relative declines during the pandemic compared to men. The decrease in these ASCVD-related laboratory test volumes during the pandemic may have been accompanied by other important changes in indicators of healthcare utilization and associated clinical outcomes. Ongoing analyses will further explore the impact of the pandemic.

The use of different doses levonorgestrel-releasing intrauterine system (LNG-IUS): real-world data from a multicenter Italian study

PURPOSE

Current research fails to adequately inform about the differential use of available levonorgestrel-releasing intrauterine systems (LNG-IUSs) in real life. Aim of our study was to compare the characteristics, satisfaction, continuation rates, and adverse effects between users of the high-dose LNG-IUS (52 mg) and of the low dose LNG-IUS (13.5 mg and 19.5 mg).

MATERIALS AND METHODS

A prospective cohort study was performed in two Services for Family Planning in normal menstruating women with the inclusion of all new prescriptions of LNG-IUS for contraception. Women were followed for a mean of 9.1 ± 2.6 months after placement.

RESULTS

109 women (mean age of 39.8 ± 8.7 years old) were included, 69.7% using a high dose LNG-IUS and 30.3% using a low dose LNG-IUS. Women with a low dose LNG-IUS were significantly younger, thinner, more nulliparous, with fewer vaginal deliveries and C-sections, with a lower menstrual flow length and with more previous use of short-acting reversible contraceptives (p < 0.05). LNG-IUS continuation was similar and very high at the last follow-up: 100 vs. 94.7% in the low and high dose LNG-IUS groups, respectively (p = 0.18). Satisfaction with treatment at the end of the study was similar between different LNG-IUS doses (p = 0.85), with 78.9% being satisfied/very satisfied. Bleeding patterns were significantly different between the two LNG-IUS doses (p < 0.0001). Diagnosis of dysfunctional cysts was more frequent in women with high dose compared to low dose LNG-IUS (22.2 vs. 12.1%), albeit not significantly.

CONCLUSIONS

We have shown a clear differential use of available LNG-IUS in clinical practice, both as baseline characteristics and as different outcomes, primarily for bleeding patterns. However, all these systems were associated with a very high rate of satisfaction and continuation.

The effect of different contraceptive methods on the vaginal microbiome

Introduction: Following a historical overview, the effect of different contraceptive methods on vaginal microbiome has been reviewed and summarized.Areas covered: Effects of combined hormonal contraceptives (oral or vaginal) and of progestin only (injectable and implantable), intrauterine devices/systems (copper- or levonorgestrel-releasing), on vaginal microbiome. In addition, mention is made of vaginal rings releasing antiviral drugs and lactic acid.Expert opinion: The vaginal microbiota (VM) is unique in that it is normally dominated by Lactobacillus species providing a degree of protection against infections; this however may vary, depending on the species and strains of Lactobacillus. Bacterial Vaginosis represents the most common dysbiosis of the VM and its prevalence can be influenced by use of contraception. Available evidence indicates that, under the influence of oral or systemically administered female sex hormones, there is apromotion of vaginal eubiosis, with aprevalence of ahealthy VM in which Lactobacilli predominate.

Effects of progestin-only contraceptives on the endometrium

INTRODUCTION

The contraceptive activity of synthetic progestins is mediated through three basic mechanisms: (a) An anti-gonadotrophic action leading to the inhibition of ovulation; (b) Changes in cervical mucus characteristics that inhibit sperm penetration and (c) desynchronization of the endometrial picture necessary for implantation.

AREAS COVERED

Mechanisms involved in the progestin-induced endometrium desynchronization are individually reviewed for each of the routes of administration and, whenever possible, by individual members of the various families of synthetic progestin derivatives.

EXPERT OPINION

For contraceptive purposes, progestins are today administered through several routes: orally, as injections, subdermally and via the vagina or the uterine cavity. Given this variety of modalities, their effects may differ, depending on the route of administration, concentration reached at the level of the endometrium and the duration of use. These are characterized by inactivation of the endometrium. Progestin-only contraception provides a safe and effective control of fertility regulation, although, they are associated with the problem of endometrial break through bleeding that may lead to discontinuation. Unfortunately, in spite of a major research effort over two decades, there is not, as yet, an established long-term intervention available to manage bleeding irregularities, making mandatory a deeper understanding of the mechanisms involved is required.

Contraception during Coronavirus-Covid 19 pandemia. Recommendations of the Board of the Italian Society of Contraception

Purpose: The Italian Society of Contraception identified as one of its priorities the need to give recommendations on management of contraception during Coronavirus-Covid 19 pandemiaMaterials and methods: A concise communication was produced which summarises in an easy-to-read format suitable for clinicians the management of the different contraceptives mostly used. Information how to manage contraception in different conditions is presented.Results: Women may, in general, continue to use either intrauterine and or hormonal contraceptives. The use of condom should be added to any hormonal contraceptive, when the contraceptive efficacy is reduced or when women stop the contraceptive method.Conclusion: At the present time, during the Coronavirus-Covid 19 pandemia, no data contraindicate the use of intrauterine or hormonal contraceptives. Conversely the use of an appropriate contraception is advocate to prevent unintended pregnancies.

Pharmacodynamics of combined estrogen-progestin oral contraceptives: 4. Effects on uterine and cervical epithelia

Introduction: Steroid hormones are responsible for specific changes in the endometrium during the menstrual cycle, when they are sequentially secreted and, because of this, in the early days sequential combined oral contraceptive regimens were utilized. The same basic concept has been utilized with multi-phasic regimens, in order to produce endometrial pictures mimicking the normal cycle.Areas covered: The Endometrial effects of progestins and estrogens; combined monophasic high- (50 μg), medium- (30 μg), low- (20 μg), ultralow- (15 μg) estrogen content; sequential regimens; multiphasic combinations; treatment schedules.Cervical effects of combined high-dose and sequential combinations, including evidence for an increase in malignant lesions.Expert opinion: Overall, combined oral contraceptives (COCs) inhibit normal proliferative changes and the endometrium becomes thin, narrow, with widely spaced glands and pre-decidual changes in the stroma. During the first few cycles the progestin induces a coexistence of proliferative and secretory features; with time, the picture changes because the progestin induces a down-regulation of estrogen receptors, resulting in tortuous glands similar to those in the secretory phase, but characterized by a quiescent, atrophic glandular epithelium.In the cervical epithelium, under the influence of high-dose COCs, endocervical glands became hypersecretory and in some instances, distinctive type of atypical polypoid endocervical hyperplasia is found.

Uterine fibroids: an update on current and emerging medical treatment options

Uterine fibroids are the most common gynecological disorder, classically requiring surgery when symptomatic. Although attempts at finding a nonsurgical cure date back to centuries, it is only around the middle of the last century that serious attempts at a medical treatment were carried out. Initially, both progestins and estrogen–progestin combinations have been utilized, although proof of their usefulness is lacking. A major step forward was achieved when peptide analogs of the GnRH were introduced, first those with superagonist properties and subsequently those acting as antagonists. Initially, the latter produced side effects preventing their routine utilization; eventually, this problem was overcome following the synthesis of cetrorelix. Because both types of analogs produce hypoestrogenism, their use is limited to a maximum of 6 months and, for this reason, today they are utilized as an adjuvant treatment before surgery with overall good results. Over the last decade, new, nonpeptidic, orally active GnRH-receptor blockers have also been synthesized. One of them, Elagolix, is in the early stages of testing in women with fibroids. Another fundamental development has been the utilization of the so-called selective progesterone receptor modulators, sometimes referred to as “antiprogestins”. The first such compound to be applied to the long-term treatment of fibroids was Mifepristone; today, this compound is mostly used outside of Western Countries, where the substance of choice is Ulipristal acetate. Large clinical trials have proven the effectiveness of Ulipristal in the long-term medical therapy of fibroids, although some caution must be exercised because of the rare occurrence of liver complications. All selective progesterone receptor modulators produce unique endometrial changes that are today considered benign, reversible, and without negative consequences. In conclusion, long-term medical treatment of fibroids seems possible today, especially in premenopausal women.

Pharmacodynamics of combined estrogen-progestin oral contraceptives 3. Inhibition of ovulation

INTRODUCTION

Following a historical overview, the ovulation-inhibiting effect of various orally administered estrogen-progestin combinations (combined oral contraceptives [COCs]) are examined for their components alone or in the various combined formulations. Special emphasis is given to products containing natural estrogens. Areas covered: Inhibition of ovulation with progestins alone; estrogens alone; various progestins in combination with ethinyl estradiol; various progestins in combination with natural estrogens (estradiol, estradiol valerate, and estetrol). Expert commentary: The original idea to achieve ovulation blockage through the administration of steroid hormones involved the use a progestogen (both progesterone and its synthetic homologous). The ability of a progestin to inhibit ovulation depends on the type of compound and on its dosage and a difference of more than 20-fold in activity exists between compounds utilized today in COCs. Initially, the estrogenic component was present only because it contaminated the first progestin utilized. It was soon found that an estrogen is necessary for proper cycle control. It was also found that the estrogen acts synergistically in inhibiting ovulation. For almost half a century, most COCs contained ethinyl estradiol. Today, also natural estrogens are being employed. Inhibition of ovulation was complete with all early high dose preparations. Decreasing dosage allowed some ovarian activity to occur, occasionally leading to a mature follicle. Even in this situation, defective corpus luteum formation assured contraceptive protection.

Menopause and hormone replacement therapy: the 2017 Recommendations of the Italian Menopause Society

Over the last decade, the risk benefits ratio of hormone replacement therapy (HRT) has been reevaluated mainly in tens of cardiovascular risk. Present Consensus Statement is largely inspired by the Global Consensus on Menopausal Hormone Therapy in 2013 and 2016 by leading global menopause societies (The American Society for Reproductive Medicine, The Asia Pacific Menopause Federation, The Endocrine Society, The European Menopause and Andropause Society, The International Menopause Society, The International Osteoporosis Foundation and The North American Menopause Society). The aim of these recommendations is to provide a simple and updated reference on postmenopausal HRT. The term HRT typically includes estrogen replacement therapy (ERT) and estrogen-progestogen therapy (EPT). EPT can be sequential, when progestogen is added to ERT for 10-14 days a month, or continuous combined when progestogen is administered continuously every day along with a fixed amount of estrogen, In the everyday language, HRT includes also tibolone and the tissue-selective estrogen complex.

An observational study of adherence to combined oral contraceptive regimens

OBJECTIVE

To analyze adherence to an oral contraceptive (OC) regimen and correlate results to participants' socio-demographic and behavioral characteristics.

METHODS

Women were prospectively enrolled and followed for 6 months. At enrollment, subjects were given a card for recording daily pill intake; its completion was checked at 6 months when women completed a self-administered questionnaire.

RESULTS

Out of 755 eligible subjects, 704 agreed to participate; 402 women completed 6 months of recording of use of an OC and properly filled the questionnaire. Good adherence was reported by 64% of participants; 20.9% missed one pill and 14.9% missed more than one pill. Mean number of missed pills per subject was 0.59 and mean number of pills delayed for less than 24 h was 1.18. Best adherence to a COC regimen was associated with evening time intake (p = 0.0019). No statistically significant associations of adherence with socio-demographic characteristics were found. Age was only marginally associated with having missed at least one pill.

CONCLUSION

In the present study, a lower number of missed pills were observed than previously reported, but the proportion of missed pills was similar. No association with specific subject characteristics that could serve as markers of increased risk of nonadherence was found.

Pharmacodynamics of combined estrogen-progestin oral contraceptives: 1. Effects on metabolism

INTRODUCTION

The risk-benefit profile of any pharmacologic agent must be evaluated against risks connected with the events to be avoided. This is especially true in the case of hormonal contraception, not intended to combat a disease. Over the six decades during which their use has progressively expanded, the risk-benefit profile of combined oral contraceptives (COC) has substantially changed, with new combinations, dosages and mode of administration appearing on the market. Area covered: In a series of articles, recent information on the complex issue of COC risks and benefits will be reviewed in the hope of providing an updated picture. The present article reviews metabolic changes occurring during use of modern combinations of estrogens (ethinyl estradiol, estradiol, estradiol valerate and estetrol) and new progestins (desogestrel, gestodene, dienogest, drospirenone, nomegestrol acetate), often compared to classic compounds, such as levonorgestrel. Three categories of metabolic effects in healthy women are detailed: on carbohydrates, lipid and bone mineral content. Expert commentary: Overall, the picture is reassuring: the new generations of progestins are basically devoid of androgenic, estrogenic or glucocorticoid related side-effects. This should result in an improved safety profile, although past history teaches us that that large comparative and surveillance studies are required before firm conclusions can be drawn. At any rate, available evidence indicates that metabolic effects of third and fourth generation progestins, especially when they are combined with natural estrogens, are minimal and, if used in healthy women, should not cause concern.

Mechanism of Action of Ulipristal Acetate for Emergency Contraception: A Systematic Review

Ulipristal acetate (UPA) is now recommended as first choice hormonal emergency contraception (EC), due to its higher efficacy and similar safety compared to Levonorgestrel - EC. Even though all trials demonstrated that the first mechanism of action is inhibition of ovulation, some authors still postulate that a post fertilization effect is also possible, raising the alert on medication and fostering the ethical debate. A Medline database search was performed in order to find recent articles related to UPA's effects on ovulation, on fallopian tube and on endometrium. We also analyzed the effects on sperm function and pregnancy. All studies conclude that UPA is effective in inhibition of ovulation even when administered shortly before LH peak. The effects on fallopian tube are unclear: according to some authors UPA inhibits ciliar beat through an agonistic effect on progesterone receptors, according to others it antagonizes the progesterone-induced ciliar beat decrease. Concerning the action on endometrium and on embryo implantation most of the studies concluded that low dose UPA used for EC has no significant effect on the decrease of endometrial thickness and on embryo's attachment, but these results are still matter of debate. Finally recent evidence suggests that UPA modulates human sperm functions while it has no effect on established pregnancy. To date the majority of the evidence concurs in excluding a post-fertilization effect of UPA, even though more studies are needed to clarify its mechanism of action.

Selective progesterone receptor modulators: an update

INTRODUCTION

Several selective progesterone receptor modulators (SPRMs) show promise in several areas of medicine and this work has been summarized by us in 2008.

AREAS COVERED

Since the publication of our reviews, several developments have taken place in the field of reproductive medicine. The first is emergency contraception (EC). Two SPRMs are clinically utilized today: mifepristone (MFP) and ulipristal acetate (UPA). MFP is available for EC in up to 120 h following unprotected intercourse. A dose of 10 mg is significantly more effective than levonorgestrel (LNG). In a metanalysis of the use of UPA versus LNG up to 72 h after unprotected intercourse, failure rates of 1.4 versus 2.2% were reported. The second is contraception. A daily dose of 2 mg MFP can block ovulation and several MFP regimens are being tested, including a vaginal ring releasing MFP. The third is the preoperative administration in women harboring leiomyomas, where clinical testing of several SPRM has shown that they can decrease uterine leiomyomas' size and substantially reduce uterine bleeding. SPRM can induce unusual, specific endometrial appearances. Many believe that these changes should not cause concern, but the issue remains controversial.

EXPERT OPINION

SPRMs are very effective in EC and for the preoperative treatment of uterine leiomyomas.

Second-trimester induced abortions in two tertiary centres in Rome

OBJECTIVE

Demand for second-trimester induced abortions (STIAs) increases in Italy. For these procedures, prostaglandins alone were used until 2010, when mifepristone became available. The present study compares the two modalities, and investigates the reasons for STIAs.

METHODS

The records of all such procedures performed at the Department of Gynaecology, Obstetrics and Urology of the 'Sapienza' University (Rome), between January 2004 and December 2012, and of all those done at the 'San Filippo' Hospital (Rome), between January 2010 and December 2012, were analysed. Data gathered included women's age, obstetric history, reasons for requesting the STIA, gestational age, mode of intervention, and complications if any.

RESULTS

During the study period, 353 women requested a STIA. Karyotype or genetic anomalies were the reason for the request in 187 cases (53%), while structural anomalies, both single and multiple, were given as the reason in 158 (45%). In most cases, these anomalies were assessed by ultrasound scan.

CONCLUSION

Few studies have investigated reasons for requesting STIAs. Of all chromosome abnormalities diagnosed in this study, trisomy 21 was the most common (59%) and it was the most frequent reason for requesting pregnancy termination.

Unmet needs and knowledge of postpartum contraception in Italian women

PURPOSE OF INVESTIGATION

Clinic visits during pregnancy and puerperium provide a unique opportunity to counsel women on contraception practices. With the aim of evaluating postpartum contraceptive attitudes among urban women attending an antenatal care center and delivering in the same facility, a structured questionnaire was administered to assess desired and received information on contraception in the postpartum period.

RESULTS

A total of 436 consecutive interviews were collected during the study period. Pregnancy was unplanned in 39% of the women interviewed. Overall, 269 women (61.7%) had decided to use a method of family planning during postpartum. Among the 112 women who stated they did not want to use a method during postpartum, almost 50% stated that they "did not think they needed it", due to a perceived lack of real risk. Of the 436 women interviewed, only 5.5 % women acknowledged that they had received information on contraceptive use.

CONCLUSION

The present study indicates a need for ante- and postpartum counseling of women even in urban areas of Italy.

Mirena, an Italian experience

AIM

The aim of this review was to evaluate contraceptive efficacy, compliance, effect on menstrual cycle of a levonorgestrel-releasing device (Mirena®) in an Italian setting.

METHODS

During the 48 months of recruitment, 128 women accepted the insertion of the LNG-IUS satisfying all inclusion criteria; 71.6% of the women completing five years of use had heavy menstrual blood loss. General and pelvic examination, including an ultrasound scan were performed at recruitment and repeated at 1, 3, 6, months postinsertion. Each subject was given a menstrual diary to report both menstrual patterns and side effects.

RESULTS

Over the 7 308 woman/months of observation, no pregnancy occurred. Menstrual blood flow decreased in all patients, both in terms of quantity and duration. In the vast majority of cases (93.7%), spotting disappeared within six months; within the first six cycles postinsertion, amenorrhoea occurred in 29.5% of all women. In five subjects the device was removed before the planned five years of observation: two women desired a pregnancy and three, in spite of a pre-existing condition of menorrhagia, requested removal within the first nine months, because they could not tolerate amenorrhoea. Three expulsions and one dislocation of the device were also detected, all within the first eight months.

CONCLUSION

Although in Italy intrauterine contraception is poorly accepted, once started on Mirena® women found that the device represents a safe and effective contraceptive modality, particularly indicated in the presence of heavy or prolonged bleeding. The only important side effect reported was breast tenderness; in addition the transient appearance of ovarian cystic images was observed.