Comparison of resumption of ovulation after cessation of oral contraceptives and medroxyprogesterone acetate in women with polycystic ovary syndrome

OBJECTIVE

Both oral contraceptive pills (OCPs) and cyclic medroxyprogesterone acetate (MPA) are widely used to control menstrual abnormalities in women with polycystic ovary syndrome (PCOS). We aimed to evaluate the chance of ovulation resumption after cessation of OCPs and MPA in women with PCOS.

METHODS

A retrospective study was conducted of women with PCOS who were treated with OCPs or cyclic MPA from September 2015 to March 2019. After cessation of medication, ovulation was assessed using basal body temperature and/or measurement of serum progesterone. The odds ratio for ovulation resumption was assessed with multivariable logistic regression. Additionally, doubly robust analysis was performed with inverse-probability-weighted analysis and regression adjustment based on the covariate balancing propensity score to adjust for the effect of covariates on the treatment assignment.

RESULTS

Among 272 women with PCOS, 136 were prescribed OCPs and 136 were prescribed cyclic MPA. Ovulation resumed in 18.4% of women (n = 25) after cessation of MPA and in 24.3% of women (n = 33) after cessation of OCPs. The odds of ovulation resumption in MPA users were comparable with those in OCP users (adjusted odds ratio (aOR) 1.00, 95% confidence interval (CI) 0.89-1.12). After multiple imputation due to missing values, the results did not change substantially (aOR 0.99, 95% CI 0.89-1.10).

CONCLUSIONS

Among women with PCOS, MPA users have a similar chance of ovulation resumption as OCP users after cessation of medication. Cyclic MPA can be a good alternative to OCPs in women for whom OCPs are contraindicated or who decline to take OCPs.

Oral contraceptive use in Premiership and Championship women's rugby union: perceived symptomology, management strategies, and performance and wellness effects

The aim of this study was to investigate the prevalence of oral contraceptive use in domestic rugby union, to compare symptomology by contraceptive use, and to determine symptom management strategies. Additionally, to characterise the perceived influence of oral contraceptive use and non-use on wellness and performance. A total of 238 Premiership and Championship women's rugby union players completed an online questionnaire. The survey was comprised of questions relating to player characteristics, hormonal or non-hormonal contraceptive characteristics, perceived symptomology, symptom management strategies, and performance and wellness characteristics. The prevalence of oral contraceptive users was 26%. Non-hormonal contraceptive users reported greater perceived negative symptomology (i.e., back pain, nausea, sore breasts) and performance and wellness effects (i.e., fatigue, stress, mood, concentration, power, match-play) than oral contraceptive users. The most common symptom management strategies were medication (33%), nutritional interventions (20%), and training modulation (20%). Twelve percent of players had previously spoken to staff about their menstrual cycle (i.e., regular and irregular) or contraceptive use. The most common barriers to speaking to staff were 'male staff' (29%) and 'club culture' (24%). The importance of assisting non-hormonal contraceptive users in managing symptoms is evident. Emphasis on overcoming barriers to staff-player dialogue regarding menstrual/contraceptive cycle is required.

Knowledge of non-contraceptive benefits of and willingness to consider taking oral contraceptive pills among a low-risk female population: a cross-sectional study

BACKGROUND

In addition to its widely-appreciated contraceptive applications, the oral contraceptive pill (OCP) conveys both oncological and non-oncological benefits. Oncological benefits include a decreased risk of endometrial, ovarian, and colorectal cancer. Non-oncological benefits include reducing androgenic effects and alleviating menstruation-related problems. This study aimed to ascertain knowledge levels of non-contraceptive benefits and risks of OCP use among participants without contraindications to OCPs. This study also assessed factors associated with participants being more likely to consider taking OCPs.

METHODS

263 women aged 21 to 40 years old with no contraindications for OCP usage participated in this study. An anonymous questionnaire collected sociodemographic information and assessed participants' knowledge of the non-contraceptive benefits and risks associated with OCP use. Multivariate linear regression was used to assess factors associated with knowledge levels. Multivariate logistic regression was used to investigate factors associated with being more likely to consider taking OCPs among women who did not presently take them.

RESULTS

Multivariate logistic regression revealed that participants who were more knowledgeable overall about the non-contraceptive benefits of OCPs were more likely to consider taking OCPs (coefficient = 0.184, p-value = 0.00). Knowledge of both oncological and non-oncological benefits of OCP use was relatively poor, especially among older women. Current OCP users were found to be more knowledgeable about their benefits.

CONCLUSIONS

As women with greater knowledge of non-contraceptive benefits of OCPs are more likely to consider taking them, knowledge gaps regarding OCPs should be filled, so that more women may reap the non-contraceptive benefits of OCPs.

Norgestrel (Opill) Is the First Over-the-Counter Oral Contraceptive Pill Approved in the United States

Just less than half of the pregnancies in the United States are unintended. Unintended pregnancy rates are greatest among women younger than 24 years, women of color, and those who have incomes less than 200% of the federal poverty level. Additionally, options to terminate a pregnancy are restricted or limited in some states. In July 2023, the U.S. Food and Drug Administration approved norgestrel (Opill) as the first over-the-counter oral contraceptive pill available in the United States. Norgestrel is indicated specifically for the prevention of pregnancy, contains only progesterone, and is indicated for daily oral use. This article provides an overview of over-the-counter norgestrel, including administration, adverse effects, contraindications, and practice implications for women's health nurses.

Proposal for targeted, neo-evolutionary-oriented secondary prevention of early-onset endometriosis and adenomyosis. Part II: medical interventions

According to consistent epidemiological data, the slope of the incidence curve of endometriosis rises rapidly and sharply around the age of 25 years. The delay in diagnosis is generally reported to be between 5 and 8 years in adult women, but it appears to be over 10 years in adolescents. If this is true, the actual onset of endometriosis in many young women would be chronologically placed in the early postmenarchal years. Ovulation and menstruation are inflammatory events that, when occurring repeatedly for years, may theoretically favour the early development of endometriosis and adenomyosis. Moreover, repeated acute dysmenorrhoea episodes after menarche may not only be an indicator of ensuing endometriosis or adenomyosis, but may also promote the transition from acute to chronic pelvic pain through central sensitization mechanisms, as well as the onset of chronic overlapping pain conditions. Therefore, secondary prevention aimed at reducing suffering, limiting lesion progression, and preserving future reproductive potential should be focused on the age group that could benefit most from the intervention, i.e. severely symptomatic adolescents. Early-onset endometriosis and adenomyosis should be promptly suspected even when physical and ultrasound findings are negative, and long-term ovulatory suppression may be established until conception seeking. As nowadays this could mean using hormonal therapies for several years, drug safety evaluation is crucial. In adolescents without recognized major contraindications to oestrogens, the use of very low-dose combined oral contraceptives is associated with a marginal increase in the individual absolute risk of thromboembolic events. Oral contraceptives containing oestradiol instead of ethinyl oestradiol may further limit such risk. Oral, subcutaneous, and intramuscular progestogens do not increase the thromboembolic risk, but may interfere with attainment of peak bone mass in young women. Levonorgestrel-releasing intra-uterine devices may be a safe alternative for adolescents, as amenorrhoea is frequently induced without suppression of the ovarian activity. With regard to oncological risk, the net effect of long-term oestrogen-progestogen combinations use is a small reduction in overall cancer risk. Whether surgery should be considered the first-line approach in young women with chronic pelvic pain symptoms seems questionable. Especially when large endometriomas or infiltrating lesions are not detected at pelvic imaging, laparoscopy should be reserved to adolescents who refuse hormonal treatments or in whom first-line medications are not effective, not tolerated, or contraindicated. Diagnostic and therapeutic algorithms, including self-reported outcome measures, for young individuals with a clinical suspicion of early-onset endometriosis or adenomyosis are proposed.

Contraception Use by Title X Clients and Clients of Other Providers, 2015-2019

INTRODUCTION

Title X clinics provide access to a wide range of contraceptive options for individuals of all income levels and documentation statuses. As Title X continues to face political uncertainties, it is important to provide up-to-date information about its clients' use of contraception. This study used recent nationally representative data to compare contraception received by Title X clients with that received by clients of other providers.

METHODS

This article draws on 2015-2017 and 2017-2019 waves of the National Survey of Family Growth. The sample was restricted to 15- to 44-year-old women needing contraception. Logistic regressions estimated associations between receiving services at Title X clinics versus at other providers (including private) and use of a range of contraceptive options, as well as number of months' supply for those using oral contraceptives.

RESULTS

In 2015-2017, Title X was associated with using any contraception (adjusted odds ratio [AOR], 4.11; p = .004). In both waves, Title X clients were more likely to use long-acting reversible contraceptives (AOR, 1.78 in 2015-2017 [p = .023] and AOR, 2.59 in 2017-2019 [p = .003]) and hormonal methods other than oral contraceptives (AOR, 2.31 in 2015-2017 [p = .007] and AOR, 3.04 in 2017-2019 [p = .001]). In both waves, Title X clients using oral contraceptives were also more likely than non-Title X clients to receive more than a 3-month supply (AOR, 3.54 in 2015-2017 [p = .008] and AOR, 2.61 in 2017-2019 [p = .043]). Title X was not associated in either wave with use of barrier or time-based methods, such as periodic abstinence or withdrawal.

CONCLUSIONS

Patterns of contraceptive use by Title X clients compared with those of clients of other providers indicate that the Title X program has allowed access to a wide range of contraceptive methods. Ongoing research is necessary to see whether these patterns change over time.

Impact of the Affordable Care Act on Prescription Contraceptive Use and Costs Among Privately Insured Women, 2006-2020

BACKGROUND

In the years immediately following the Affordable Care Act (ACA)'s contraceptive coverage requirement, out-of-pocket costs fell for all Food and Drug Administration-approved contraceptive methods and use of long-acting reversible contraception (LARC) increased. This analysis examines whether these trends have continued through 2020 for privately insured women.

METHODS

Using 2006-2020 MarketScan data, we examined trends in prescription contraceptive use and out-of-pocket costs among women 13 to 49 years old. Multivariable analyses model the likelihood of contraceptive use and paying $0 post-ACA requirement (vs. pre-ACA requirement) for contraception, controlling for age group, U.S. region, urban versus rural, and cohort year.

RESULTS

The likelihood of LARC insertion increased post-ACA requirement (adjusted odds ratio [aOR] 1.127, 95% confidence interval [CI] 1.121-1.133), with insertion rates peaking at 3.73% for intrauterine devices (IUDs) and 1.08% for implants in 2019, before declining with the onset of the COVID-19 pandemic in 2020. Although the likelihood of paying $0 for LARC increased after the ACA requirement (IUD: aOR 5.495, 95% CI 5.278-5.716; implant: aOR 7.199, 95% CI 6.992-7.412), the proportion of individuals paying $0 declined to 69% for IUDs and 73% for implants in 2020, after having peaked at 88% in 2014 and 90% in 2016, respectively. For oral contraceptives, both use (aOR 1.028, 95% CI 1.026-1.030) and paying $0 (aOR 20.399, 95% CI 20.301-20.499) increased significantly after the ACA requirement.

CONCLUSION

With the exception of oral contraceptives, the proportion of individuals paying $0 for all contraceptive methods declined after peaking in 2014 for IUDs, 2016 for the implant, and 2019 for non-LARC methods. Future monitoring is needed to understand the continuing impact of the ACA requirement on prescription contraceptive use and costs.

Over-the-Counter Progestin-Only Oral Contraceptives

This JAMA Patient Page describes progestin-only oral contraceptive pills, which recently have been approved to be sold over the counter.

Quantitative risk-benefit profiles of oral contraceptives, insulin sensitizers and antiandrogens for women with polycystic ovary syndrome: A model-based meta-analysis

Oral contraceptives (OCs), insulin sensitizers, and antiandrogens (AAs), alone or in combination, are commonly used for treating non-fertility indications in polycystic ovary syndrome (PCOS). However, unclear risk-benefit profiles jeopardize their appropriate clinical applications. This study aimed to quantitatively evaluate the effects of the aforementioned medications and to compare their risk-benefit profiles. Randomized controlled trials published until 14th March 2022 were searched in PubMed and Embase. A model-based meta-analysis was developed to examine the time-effect profiles of each medication. The maximal percentage change of the effect (Emax) and time to achieve half of Emax (T50) were estimated. Primary outcomes included menstruation, hirsutism score, free androgen index (FAI), body mass index (BMI), insulin sensitivity, and lipid profiles. Overall, 200 studies (9,685 patients and 385 arms) were identified for modeling. OCs performed exceptionally well in improving menstruation (Emax: 149%; T50: 7.44 weeks), hirsutism score (Emax: 66.2%; T50: 26.2 weeks), and FAI (Emax: 75.7%; T50: 0.51 weeks). However, OCs elevated the triglyceride (TG) level (Emax: 12.6%; T50:1.19 weeks). After 12-week OC treatment, the TG level of approximately 30% of patients, whose baselines were normal, exceeded the reference limit. This suggested that OC-induced dyslipidemia should be routinely monitored. The maximal BMI-lowering effect of metformin was similar to that of placebo (Emax: 3.80%); however, metformin had a shorter T50 (6.67 weeks versus 12.9 weeks). Further, active lifestyle intervention plus placebo significantly decreased BMI (Emax: 8.78%). Adding metformin to active lifestyle intervention accelerated the BMI-lowering effect within 24 weeks, whereas with the extension of this addition beyond 24 weeks, BMI did not reduce further, which indicated that benefits were limited from this prolonged addition. AAs were less potent in reducing hirsutism score (Emax: 40.2% versus 66.2%) and FAI (Emax: 34.5% versus 75.7%) compared to OCs. OC plus metformin combined OC-derived androgen-suppressing effects and metformin-derived insulin-sensitizing effects, and partially relieved the OC-induced TG increase (Emax: 9.76%). Baseline dependency was found in most clinical responses, implying that pharmacotherapies tailored based on baselines achieved more clinical improvements. This study presents new quantitative evidence on pharmacotherapies for PCOS. Currently, long-term risk-benefit profiles and emerging therapies are inadequately reported and require more further research.

Importance of a multi-tiered treatment approach for intellectually and developmentally disabled patients with hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, debilitating skin condition that is characterized by painful pustules, nodules, abscesses, and sinus tracts. The complicated and fast-evolving treatment of HS consists of a multi-tiered approach that includes, antibacterial, antihormonal, anti-inflammatory, and surgical options. Studies have demonstrated an earlier age of onset and increased prevalence of HS in patients with intellectual and developmental disability (IDD) compared to patients without IDD. To explore the use of an intensive multi-tiered HS management algorithm that requires monthly office visits, monthly intravenous therapy, and several daily treatment modalities in an HS population with IDD, we conducted an IRB-approved retrospective chart review of HS patients treated at the Albert Einstein College of Medicine-Montefiore HS Center (HSC) with diagnoses of concurrent IDD to investigate their demographic and diagnostic characteristics, as well as the spectrum of therapies employed in this cohort. A total of 22 HS patients with concomitant IDD, including trisomy 21, unspecified intellectual disability, autism spectrum disorder, and trisomy 13 were identified. Therapies utilized in this cohort for HS included topical and oral antibiotics, spironolactone, finasteride, oral contraceptive pills, infliximab, adalimumab, isotretinoin, intralesional and intramuscular triamcinolone injections, and excisional surgery. In conclusion, our findings indicate that despite the practical challenges, daily oral antibiotic regimens, anti-androgen combinations, oral retinoids, infliximab, adalimumab, and surgery collectively play important roles in treating HS patients with IDD. Our cases underscore the importance of utilizing the full range of modalities as the HS treatment algorithm continues to evolve.

Statins for women with polycystic ovary syndrome not actively trying to conceive

BACKGROUND

Statins are lipid-lowering agents with pleiotropic actions. Experts have proposed that in addition to improving the dyslipidaemia associated with polycystic ovary syndrome (PCOS), statins may also exert other beneficial metabolic and endocrine effects, such as reducing testosterone levels. This is an update of a Cochrane Review first published in 2011.

OBJECTIVES

To assess the efficacy and safety of statin therapy in women with PCOS who are not actively trying to conceive.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHLs, and four ongoing trials registers on 7 November 2022. We also handsearched relevant conference proceedings and the reference lists of relevant trials for any additional studies, and we contacted experts in the field for any further ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effects of statin therapy in women with PCOS not actively trying to conceive. Eligible comparisons were statin versus placebo or no treatment, statin plus another agent versus the other agent alone, and statin versus another agent. We performed statistical analysis using Review Manager 5, and we assessed the certainty of the evidence using GRADE methods.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. Our primary outcomes were resumption of menstrual regularity and resumption of spontaneous ovulation. Our secondary outcomes were clinical and physiological measures including hirsutism, acne severity, testosterone levels, and adverse events.

MAIN RESULTS

Six RCTs fulfilled the criteria for inclusion. They included 396 women with PCOS who received six weeks, three months, or six months of treatment; 374 women completed the studies. Three studies evaluated the effects of simvastatin and three studies evaluated the effects of atorvastatin. We summarised the results of the studies under the following comparisons. Statins versus placebo (3 RCTs) One trial measured resumption of menstrual regularity as menstrual cycle length in days. We are uncertain if statins compared with placebo shorten the mean length of the menstrual cycle (mean difference (MD) -2.00 days, 95% confidence interval (CI) -24.86 to 20.86; 37 participants; very low-certainty evidence). No studies reported resumption of spontaneous ovulation, improvement in hirsutism, or improvement in acne. We are uncertain if statins compared with placebo reduce testosterone levels after six weeks (MD 0.06, 95% CI -0.72 to 0.84; 1 RCT, 20 participants; very low-certainty evidence), after 3 months (MD -0.53, 95% CI -1.61 to 0.54; 2 RCTs, 64 participants; very low-certainty evidence), or after 6 months (MD 0.10, 95% CI -0.43 to 0.63; 1 RCT, 28 participants; very low-certainty evidence) Two studies recorded adverse events, and neither reported significant differences between the groups. Statins plus metformin versus metformin alone (1 RCT) The single RCT included in this comparison measured resumption of menstrual regularity as the number of spontaneous menses per six months. We are uncertain if statins plus metformin compared with metformin improves resumption of menstrual regularity (MD 0.60 menses, 95% CI 0.08 to 1.12; 69 participants; very low-certainty evidence). The study did not report resumption of spontaneous ovulation. We are uncertain if statins plus metformin compared with metformin alone improves hirsutism measured using the Ferriman-Gallwey score (MD -0.16, 95% CI -0.91 to 0.59; 69 participants; very low-certainty evidence), acne severity measured on a scale of 0 to 3 (MD -0.31, 95% CI -0.67 to 0.05; 69 participants; very low-certainty evidence), or testosterone levels (MD -0.03, 95% CI -0.37 to 0.31; 69 participants; very low-certainty evidence). The study reported that no significant adverse events occurred. Statins plus oral contraceptive pill versus oral contraceptive pill alone (1 RCT) The single RCT included in this comparison did not report resumption of menstrual regularity or spontaneous ovulation. We are uncertain if statins plus the oral contraceptive pill (OCP) improves hirsutism compared with OCP alone (MD -0.12, 95% CI -0.41 to 0.17; 48 participants; very low-certainty evidence). The study did not report improvement in acne severity. We are also uncertain if statins plus OCP compared with OCP alone reduces testosterone levels, because the certainty of the evidence was very low (MD -0.82, 95% CI -1.38 to -0.26; 48 participants). The study reported that no participants experienced significant side effects. Statins versus metformin (2 RCTs) We are uncertain if statins improve menstrual regularity compared with metformin (number of spontaneous menses per six months) compared to metformin (MD 0.50 menses, 95% CI -0.05 to 1.05; 1 RCT, 61 participants, very low-certainty evidence). No studies reported resumption of spontaneous ovulation. We are uncertain if statins compared with metformin reduce hirsutism measured using the Ferriman-Gallwey score (MD -0.26, 95% CI -0.97 to 0.45; 1 RCT, 61 participants; very low-certainty evidence), acne severity measured on a scale of 0 to 3 (MD -0.18, 95% CI -0.53 to 0.17; 1 RCT, 61 participants; very low-certainty evidence), or testosterone levels (MD -0.24, 95% CI -0.58 to 0.10; 1 RCT, 61 participants; very low-certainty evidence). Both trials reported that no significant adverse events had occurred. Statins versus oral contraceptive pill plus flutamide (1 RCT) According to the study report, no participants experienced any significant side effects. There were no available data for any other main outcomes.

AUTHORS' CONCLUSIONS

The evidence for all main outcomes of this review was of very low certainty. Due to the limited evidence, we are uncertain if statins compared with placebo, or statins plus metformin compared with metformin alone, improve resumption of menstrual regularity. The trial evaluating statin plus OCP versus OCP alone reported neither of our primary outcomes. No other studies reported resumption of spontaneous ovulation. We are uncertain if statins improve hirsutism, acne severity, or testosterone. All trials that measured adverse events reported no significant differences between the groups.

Trends in Treatments With Disease-Specific and Interfering Drugs in Patients With Hereditary Angioedema in Sweden

BACKGROUND

Hereditary angioedema (HAE) is caused by low levels of or defects in C1 inhibitor. Although disease activity may be modified by prophylaxis, emergency treatment, treatment for comorbidities, and oral contraceptives, the extent of their use is unclear.

OBJECTIVE

To investigate trends in the use of disease-specific and interfering drugs in patients with HAE compared with the general population in Sweden.

METHODS

In a nationwide, longitudinal study, 239 patients with HAE and 2 383 controls were compared with the Prescribed Drug Register (2005-2019). These data reflect rates of dispensed prescriptions from pharmacies in Sweden.

RESULTS

Attenuated androgens were used by approximately 10% of patients with HAE. The number of individuals treated with prophylactic plasma-derived C1 inhibitor increased during this period to reach almost 25% in men and 35% in women in 2019. Tranexamic acid was prescribed to 5% to 15% of patients, primarily children and young adults. Rates of prescriptions for icatibant, an emergency medication, showed a steady increase since its introduction in 2010, in particular among middle-aged women, suggesting poorly controlled disease. The use of diuretics, calcium channel blockers, and gestagens was more common in patients with HAE than in controls, whereas angiotensin-converting enzyme inhibitors were rarely collected.

CONCLUSIONS

Despite concerns regarding side effects, approximately 10% of patients with HAE received attenuated androgens for long-term prophylaxis. The common use of emergency medication also suggests poorly controlled disease in many patients, highlighting the need for increased focus on prophylactic treatment.

Recent Intimate Partner Violence and Oral Contraceptive Pill Adherence in a Cohort of Reproductive-Aged Women

Objective: Intimate partner violence (IPV) is an important public health problem that impacts reproductive decision-making. Although previous literature has reported a negative impact on contraceptive adherence overall, this study specifically aims to investigate the association between IPV and oral contraceptive pill (OCP) adherence. Methods: We analyzed baseline survey data from 373 OCP users participating in the MyNewOptions study. Recent IPV was defined as any positive response to HARK, a 4-question tool assessing emotional, sexual, and physical abuse in the past year, or self-report of sexual coercion in the past 6 months. High OCP adherence was defined by self-report of missing ≤1 pill per month, which was then corroborated by pharmacy claims data. Multivariable regression analyses were performed to assess the influence of recent IPV history and patient-level variables on OCP adherence. Results: Just over half of our participants were highly adherent to OCPs (53.6%), and approximately one-quarter reported recent IPV exposure (25.2%). Women with recent IPV were significantly less likely to be OCP adherent than those without IPV (adjusted odds ratio (AOR) 0.54, 95% confidence interval (CI): 0.32-0.92). Protestant religion was also associated with high OCP adherence (AOR 2.41, 95% CI: 1.24-4.65, compared with no religious affiliation), while younger age groups (18-25 and 26-33 years) were less likely to have high OCP adherence compared with the 34-40 age group (AOR 0.45, 95% CI: 0.20-1.00 and AOR 0.40, 95% CI: 0.18-0.91, respectively). Conclusion: Recent IPV exposure is associated with low OCP adherence among women of reproductive age. ClinicalTrials.gov identifier: NCT02100124.

Association of Short-Term Changes in Menstrual Frequency, Medication Use, Weight and Exercise on Bone Mineral Density in College-Aged Women

To evaluate if experiencing a short-term exposure (18-months) to factors such as menstrual irregularities, dieting, changes in exercise or body weight, and medication usage is associated with bone mineral density (BMD) in college-aged females. A retrospective survey assessing health behaviors during a recent 18-month time period and a DXA scan were completed in 641 females. A total of 45.5% of participants reported amenorrhea during the 18-month time period. Those who experienced amenorrhea had lower femoral neck BMD (p = 0.018), trochanter (p = 0.018) and spine BMD (p = 0.022) compared to eumenorrheic women. Lifetime oral contraceptive usage longer than six months was negatively associated with BMD at femoral neck (p = 0.018) and total hip (p = 0.021). Women who lost weight trended towards having the lowest BMD at all sites compared to women who gained weight. Following a very-low calorie diet during the time period was negatively correlated with spine BMD (p = 0.001). Time spent in vigorous and very vigorous activity was weakly correlated with some hip BMD sites but time spent in extremely vigorous activity was not. In conclusion, females who experienced weight loss, amenorrhea, or a very low-calorie diet within an 18-month period of time in young adulthood had lower BMD. Additionally, oral contraceptive usage for longer than six months during their lifetime was associated with lower BMD.

Efficacy of Post-Operative Medication to Prevent Recurrence of Endometrioma: Cyclic Oral Contraceptive (OC) After Gonadotropin-Releasing Hormone (GnRH) Agonist Versus Dienogest

BACKGROUND

There are several medical treatment options for endometrioma. Progestin, especially dienogest, is an effective drug for preventing recurrence of endometrioma after surgery. Additionally, oral contraceptive (OC) use after conservative surgery has been reported to reduce significantly the risk of endometrioma recurrence. The aim of this study was to compare the long-term effects of gonadotropin-releasing hormone (GnRH) agonist followed by OC to those of dienogest alone to prevent recurrence of endometrioma after laparoscopic surgery.

METHODS

A retrospective cohort study was performed on patients who underwent conservative laparoscopic surgery for endometrioma between January 2000 and December 2020, in the Endometriosis Clinic, Department of Gynecology, Samsung Medical Center. A total of 624 patients who received medical treatment at least six months after laparoscopic conservative surgery for endometrioma was included. Among them, 372 patients used OC after GnRH agonist therapy, and 252 patients used dienogest. Within the OC group, 148 used a 21/7 regiment and 224 used a 24/4 regimen. A cumulative endometrioma recurrence curve was presented using the Kaplan-Meier method to compare the recurrence of those groups.

RESULTS

The cumulative recurrence rate of endometrioma for 60 months was 2.08% (n = 4) in the OC after GnRH agonist group and 0.40% (n = 1) in the dienogest group. There was no statistical difference in cumulative recurrence of endometrioma between the two groups. In subgroup analysis, the cumulative recurrence rate of endometrioma over 60 months was 4.21% (n = 2) in the 21/7 OC group and 1.09% (n = 2) in the 24/4 OC group and showed no significant difference.

CONCLUSION

Long-term use of OC after GnRH agonist as well as that of dienogest treatment are effective postoperative medical therapies for preventing endometrioma recurrence. Thus, the choice of regimen can be individualized or used interchangeably depending on patient condition, need for contraception, and compliance with drug therapy.

Pattern of contraceptive use, determinants and fertility intentions among tribal women in Kerala, India: a cross-sectional study

OBJECTIVES

To assess the pattern of contraceptive use and its determinants, knowledge regarding contraceptives including oral contraceptive pills and fertility intentions among tribal women in the reproductive age group.

DESIGN

Community-based cross-sectional study.

SETTING

Community development blocks in a predominantly tribal district of Wayanad in Kerala, India.

PARTICIPANTS

Women in the reproductive age group (15-49 years) from the tribal groups in the district numbering 2495.

OUTCOME MEASURES

PRIMARY: Prevalence of contraceptive use and its determinants.

SECONDARY

Knowledge regarding contraceptives in general, oral contraceptives and fertility intentions.

RESULTS

The mean age of the study participants was 30.8 years (SD=9.8) and belonged to various tribal groups such as Paniya (59.2%), Kurichiyar (13.6%) and Adiya (10.9%). Current use of contraceptive was reported by about a fourth, 658 (26.4%) (95% CI 27.9 to 24.9) of women. Following logistic regression, belonging to Paniya tribe (adjusted OR (aOR) 2.67, 95% CI 1.49 to 4.77; p<0.001) and age at menarche >13 years (aOR 1.69, 95% CI 1.14 to 2.52; p<0.009) had significantly higher use of contraceptives whereas social vulnerability as indicated by staying in a kutcha house had a lesser likelihood of use of contraceptive (aOR 0.55, 95% CI 0.31 to 0.95; p<0.03). Oral contraceptive use was low (4.8%) among this population and no abuse was observed.Less than half (47%) of the respondents had an above average knowledge on contraception. Multivariable logistic regression indicated that above average knowledge was 2.2 times more likely with higher education (95% CI 1.2 to 3.9), lesser among those who desired more than two children (aOR 0.59; 95% CI 0.38 to 0.94; p<0.02).Two children per family was the preferred choice for 1060 (42.5%) women. No gender bias in favour of the male child was observed.

CONCLUSION

Awareness and use of contraceptives are poor though the fertility is not commensurately high. Along with developing targeted responses to contraceptive use among Indigenous people with indigenous data, awareness also requires attention. Ethnographic studies are also necessary to determine the differences in contraceptive use including traditional methods among the various Indigenous groups.

Management of cardiometabolic complications in polycystic ovary syndrome: Unmet needs

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder and the most common cause of androgen excess in reproductive-age women. The heterogeneity of the clinical presentation in PCOS patients suggests the involvement of multiples abnormal physiological pathways. In addition, women with PCOS have a high prevalence of cardiometabolic risk factors. Unfortunately, limited effective evidence-based therapeutic agents are available to treat the cardiometabolic complications in PCOS patients. Insights from recent studies highlight the multiple opportunities to deliver timely effective medical care for women with PCOS. This perspective manuscript aims to highlight the unmet need for effective and safe management of the cardiometabolic complications in PCOS patients.

Common Analgesic Use for Menstrual Pain and Ovarian Cancer Risk

Menstrual pain has been associated with increased ovarian cancer risk, presumably through increased inflammation, which is known to play a critical role in ovarian carcinogenesis. Analgesic medications are frequently used to treat menstrual pain, some of which lower ovarian cancer risk. In this study, we examined the association between analgesic use for menstrual pain during the premenopausal period and ovarian cancer risk among women with history of menstrual pain. We used data from the New England Case-Control Study, including 1,187 epithelial ovarian cancer cases and 1,225 population-based controls enrolled between 1998 and 2008 with detailed information on analgesic use for their menstrual pain. We used unconditional logistic regression to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) for the association between analgesic use (i.e., aspirin, ibuprofen, acetaminophen) for menstrual pain and ovarian cancer risk. We further conducted a stratified analysis by intensity of menstrual pain (mild/moderate, severe). Among women with menstrual pain during their 20s and 30s, ever use of analgesics for menstrual pain was not significantly associated with ovarian cancer risk. However, among women with severe menstrual pain, ever use of aspirin or acetaminophen for menstrual pain was inversely associated with risk (OR, 0.41; 95% CI, 0.18-0.94 and OR, 0.43; 95% CI, 0.21-0.88 compared with never users, respectively). No significant association was observed between analgesic use and ovarian cancer risk among women with mild/moderate menstrual pain (P interaction ≤ 0.03). Our results suggest that use of aspirin or acetaminophen for severe menstrual pain may be associated with lower risk of ovarian cancer. PREVENTION RELEVANCE: This study investigates whether analgesic use specifically for menstrual pain during the premenopausal period influences ovarian cancer risk. Our results suggest use of aspirin or acetaminophen for severe menstrual pain may be associated with lower risk of ovarian cancer among women with severe menstrual pain.

Polycystic Ovarian Syndrome in Adolescents: Keys to Diagnosis and Management

Polycystic ovarian syndrome (PCOS) is the most common endocrine condition in women, affecting anywhere from 3% to 13% depending on the population being studied. PCOS often begins in adolescence, but diagnosis is difficult due to the overlap of symptoms with normal puberty. It is also necessary to rule out other potential causes of these symptoms before diagnosis. Once diagnostic criteria have been met, there are many treatment options to consider including lifestyle changes, combined oral contraceptive pills, metformin, and in some cases, antiandrogens. [Pediatr Ann. 2021;50(7):e272-e275.].

Trends in oral contraceptive and intrauterine device use among reproductive-aged women in the US from 1999 to 2017

PURPOSE

Since the 1960s, increasing oral contraceptive (OC) use has mirrored decreasing ovarian cancer incidence. The impact of intrauterine devices (IUDs) on cancer risk is less well established. With improved access and increased options, we must consider how changing usage can affect cancer risks.

METHODS

Nationally representative data from the National Health and Nutrition Examination Survey (NHANES, 1999-2016) and the National Survey for Family Growth (NSFG, 2006-2017) were used to evaluate contraceptive use over time in premenopausal women (NHANES n = 13,179; NSFG n = 26,262). Trends were assessed overall and by race, age, pregnancy history, education, and body mass index.

RESULTS

The average annual absolute increase in self-reported IUD use was 0.81% (NSFG), while OC use decreased 0.49% in NSFG and 0.47% in NHANES. This represents a significant decrease in OC use in NSFG [annual percent change (APC) - 2.2% (95% CI - 3.4, - 1.0%), p < 0.01]. Trends in OC use varied somewhat by pregnancy history in NHANES (p-interaction = 0.054). In contrast, IUD use increased 6.2% annually [(1.4, 11.2%), p = 0.03] and varied significantly by pregnancy history (p-interaction < 0.01). Nulligravid women increased IUD use 11.0% annually [(2.6, 20.1%), p = 0.02] compared to women with prior pregnancy at 5.2% [(0.4, 10.2%), p = 0.04]. In 2015-2017, IUD use was 76.5% hormonal (71.1, 81.8%) and 22.9% copper (17.4, 28.3%) with greater hormonal IUD use in obese women [89.4%, (82.9, 95.9%)].

CONCLUSION

Increasing IUD use outpaced declining OC use in premenopausal US women. There may be a resulting decreased gynecologic cancer risk as more women gain access to potentially risk-reducing contraceptives.

Stress-Hormone Dynamics and Working Memory in Healthy Women Who Use Oral Contraceptives Versus Non-Users

BACKGROUND

Women who use oral contraceptives (OCs) may have a higher risk of developing a depression, which is associated with both vulnerability to stress and cognitive dysfunction. OCs disrupt the hypothalamic-pituitary-gonadal (HPG) axis by suppressing endogenous sex steroid production including estradiol. The HPG axis and the hypothalamic-pituitary-adrenal (HPA) axis are known to interact, possibly through modulations driven by estradiol. OCs may affect HPA regulation capacity, i.e., disturb cortisol dynamics such as the cortisol awakening response (CAR), and influence cognition such as working memory (WM). We hypothesize that OC use is associated with blunted cortisol dynamics and impaired WM performance relative to non-users.

METHODS

Data from 78 healthy women in the reproductive age were available from the CIMBI database. We evaluated if CAR and WM differed between OC users (n=25) and non-users (n=53) and if the level of estradiol modulated the OC use effect on CAR or WM in generalized least square models.

RESULTS

We found that OC users had a blunted CAR (p= 0.006) corresponding to a 61% reduction relative to non-users; however, no estradiol-BY-OC use interaction effect was observed on CAR. Also, OC users had higher cortisol levels at awakening compared to non-users (p = 0.03). We observed no effect of OC use or an estradiol-BY-OC use interaction effect on WM. Also, within the OC user group, neither CAR nor WM was associated with suppressed estradiol. CAR was not associated with WM.

CONCLUSION

Healthy women who use OCs have blunted cortisol dynamics relative to non-users. However, we could not detect OC use effects on working memory in our sample size. We speculate that disrupted cortisol dynamics may be important for the emergence of depressive symptoms in OC users.

Effects of Oral Contraception and Lifestyle Modification on Incretins and TGF-ß Superfamily Hormones in PCOS

OBJECTIVE

To examine the effects of common treatments for polycystic ovary syndrome (PCOS) on a panel of hormones (reproductive/metabolic).

DESIGN

Secondary analysis of blood from a randomized controlled trial of three 16-week preconception interventions designed to improve PCOS-related abnormalities: continuous oral contraceptive pills (OCPs, N = 34 subjects), intensive lifestyle modification (Lifestyle, N = 31), or a combination of both (Combined, N = 29).

MATERIALS AND METHODS

Post-treatment levels of activin A and B, inhibin B, and follistatin (FST), as well as Insulin-like growth factor 1 (IGF-1), insulin-like growth factor binding protein 2 (IGFBP-2), glucagon, glucagon-like peptide 1 (GLP-1) and 2, and oxyntomodulin were compared to baseline, and the change from baseline in these parameters were correlated with outcomes.

RESULTS

Oral contraceptive pill use was associated with a significant suppression in activin A, inhibin A, and anti-mullerian hormone (AMH), but a significant increase in FST. IGF-1, IGFBP-2, glucagon, and GLP-2 levels were significantly decreased. Oxyntomodulin was profoundly suppressed by OCPs (ratio of geometric means: 0.09, 95% confidence interval [CI]: 0.05, 0.18, P < 0.001). None of the analytes were significantly affected by Lifestyle, whereas the effects of Combined were similar to OCPs alone, although attenuated. Oxyntomodulin was significantly positively associated with the change in total ovarian volume (rs = 0.27; 95% CI: 0.03, 0.48; P = 0.03) and insulin sensitivity index (rs = 0.48; 95% CI: 0.27, 0.64; P < 0.001), and it was inversely correlated with change in area under the curve (AUC) glucose [rs = -0.38; 95% CI: -0.57, -0.16; P = 0.001]. None of the hormonal changes were associated with live birth, only Activin A was associated with ovulation (risk ratio per 1 ng/mL increase in change in Activin A: 6.0 [2.2, 16.2]; P < 0.001).

CONCLUSIONS

In women with PCOS, OCPs (and not Lifestyle) affect a wide variety of reproductive/metabolic hormones, but their treatment response does not correlate with live birth.

The comparison of the effectiveness and safety of drospirone ethinyl estradiol and ethinyl estradiol cyproterone in the treatment of polycystic ovarian syndrome: A protocol for systematic review and meta-analysis

BACKGROUND

Polycystic ovarian syndrome (PCOS) is an endocrine disorder syndrome with reproductive dysfunction and abnormal glucose metabolism. Persistent non-ovulation, excessive androgens and insulin resistance are important features and they are the most common causes of menstrual disorders in women during childbearing years. At present, the cause of PCOS is not clinically clear. Current studies suggest that it may be due to the interaction of certain genetic genes with environmental factors. It is an important cause of infertility or early miscarriage with the characteristics of various causes and complex clinical manifestations. At present, for the treatment of PCOS patients, clinical treatment mainly includes hypoglycemia, insulin and menstrual regulation and other symptomatic and supportive treatment. Drospirone ethinyl estradiol and ethinyl estradiol cyproterone are 2 of the most commonly used drugs in clinical treatment of PCOS, but there is lack of the evidence of evidence-based medicine. Therefore, this study systematically evaluates the therapeutic effect and safety of PCOS patients with 2 short-acting oral contraceptives, drospirone ethinyl estradiol and ethinyl estradiol cyproterone, which provides the guidance for clinically selecting the appropriate drug to treat PCOS.

METHODS

Searching CNKI, WanFang Data, VIP, SinoMed, PubMed, EMbase, Web of Science, and The Cochrane Library database by computer, collecting the randomized controlled studies of DEE and EEC in the treatment of PCOS. The retrieval time limit is from the establishment of each database to July 1, 2020. In addition, tracing the references incorporated into the literature to supplement to the relevant literature. Using the retrieval method by combining the free words and the subject words, and the individual search of different databases is carried out. Meta-analysis is performed using RevMan 5.3 software after 2 researchers independently screens the literature, extracts the data, and evaluates the bias risk included in the study.

RESULTS

This study will systematically evaluate the DEE and EEC in the treatment of PCOS by collecting the required evidence to understand the effects of the 2 drugs on hypersotrophicemia, insulin resistance, lipid metabolism, and the safety during drug use in patients of this class, and the results will be published in highly influential academic journals.

CONCLUSION

The results of this study will provide theoretical basis for the drug treatment of polycystic ovarian syndrome and provide help in the decision-making of clinical treatment of the disease.

ETHICS AND DISSEMINATION

In this study, meta-analysis was used to conduct a second study on the published literature. Therefore, this type of systematic review research does not need to be approved by ethics.

OSF REGISTRATION DOI

10.17605/OSF.IO/8GW9M.

Gut Microbiota and Oral Contraceptive Use in Overweight and Obese Patients with Polycystic Ovary Syndrome

CONTEXT

Polycystic ovary syndrome (PCOS) is a common and complex endocrine disorder. Emerging animal and human data point to various changes in microbiota that could be linked with the syndrome. However, the effects of therapeutic approaches on gut microbial composition in women with PCOS remain unknown.

OBJECTIVE

We aimed to assess whether gut microbial composition is altered in PCOS and to determine the potential impact of oral contraceptive (OC) use on gut microbiota.

DESIGN

Prospective observational study.

SETTING

Tertiary referral hospital.

PATIENTS AND OTHER PARTICIPANTS

The study included 17 overweight/obese patients with PCOS and 15 age- and body mass index-matched healthy control women.

MAIN OUTCOME MEASURES

At baseline, clinical, hormonal, and metabolic evaluations and gut microbial composition assessment by 16S rRNA gene amplicon sequencing were performed for both groups. All measurements were repeated in patients after receiving an OC along with general lifestyle advice for 3 months.

RESULTS

Alpha and beta diversity did not show a difference between patients with PCOS and healthy controls at baseline and remained unaltered after 3 months of OC use in the PCOS group. Relative abundance of Ruminococcaceae was higher in PCOS (P = 0.006) and did not show a significant change after treatment.

CONCLUSION

Women with PCOS have an increased abundance of Ruminococcaceae, whereas short-term OC use does not alter compositional features of gut microbiota in the syndrome.

Oral contraceptive use, especially during puberty, alters resting state functional connectivity

Millions of women worldwide use oral contraceptives (OCs), often starting during puberty/adolescence. It is, however, unknown how OC use during this critical period of development affects the brain. The objective of the current study was to examine resting state functional connectivity (FC) in the default mode network (DMN), central executive network (CEN), salience network (SN), reward network (RN), and subcortical limbic network of the brain using independent component analysis (ICA) between pubertal- and adult-onset OC users (n = 27) and naturally cycling women (n = 48). It was hypothesized that OC use would result in network-specific increases and decreases in FC and that pubertal-onset OC use would result in differences to the aforementioned networks compared to adult-onset OC use. Pubertal-onset OC use is related to heightened FC in the SN compared to adult-onset OC users. In general, OC use also increases connectivity in the SN, CEN, RN, and subcortical limbic network compared to NC women. No significant differences in connectivity were observed in the DMN between OC users and NC women. These findings provide a mechanistic insight for the altered executive functioning and emotion/reward processing previously seen in OC users, which may then increase their vulnerability to mental health conditions.

Progestogen-releasing intrauterine systems for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) impacts the quality of life of otherwise healthy women. The perception of HMB is subjective and management depends upon, among other factors, the severity of the symptoms, a woman's age, her wish to get pregnant, and the presence of other pathologies. Heavy menstrual bleeding was classically defined as greater than or equal to 80 mL of blood loss per menstrual cycle. Currently the definition is based on the woman's perception of excessive bleeding which is affecting her quality of life. The intrauterine device was originally developed as a contraceptive but the addition of progestogens to these devices resulted in a large reduction in menstrual blood loss: users of the levonorgestrel-releasing intrauterine system (LNG-IUS) reported reductions of up to 90%. Insertion may, however, be regarded as invasive by some women, which affects its acceptability.

OBJECTIVES

To determine the effectiveness, acceptability and safety of progestogen-releasing intrauterine devices in reducing heavy menstrual bleeding.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL (from inception to June 2019); and we searched grey literature and for unpublished trials in trial registers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in women of reproductive age treated with LNG-IUS devices versus no treatment, placebo, or other medical or surgical therapy for heavy menstrual bleeding.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data, assessed risk of bias and conducted GRADE assessments of the certainty of evidence.

MAIN RESULTS

We included 25 RCTs (2511 women). Limitations in the evidence included risk of attrition bias and low numbers of participants. The studies compared the following interventions. LNG-IUS versus other medical therapy The other medical therapies were norethisterone acetate, medroxyprogesterone acetate, oral contraceptive pill, mefenamic acid, tranexamic acid or usual medical treatment (where participants could choose the oral treatment that was most suitable). The LNG-IUS may improve HMB, lowering menstrual blood loss according to the alkaline haematin method (mean difference (MD) 66.91 mL, 95% confidence interval (CI) 42.61 to 91.20; 2 studies, 170 women; low-certainty evidence); and the Pictorial Bleeding Assessment Chart (MD 55.05, 95% CI 27.83 to 82.28; 3 studies, 335 women; low-certainty evidence). We are uncertain whether the LNG-IUS may have any effect on women's satisfaction up to one year (RR 1.28, 95% CI 1.01 to 1.63; 3 studies, 141 women; I² = 0%, very low-certainty evidence). The LNG-IUS probably leads to slightly higher quality of life measured with the SF-36 compared with other medical therapy if (MD 2.90, 95% CI 0.06 to 5.74; 1 study: 571 women; moderate-certainty evidence) or with the Menorrhagia Multi-Attribute Scale (MD 13.40, 95% CI 9.89 to 16.91; 1 trial, 571 women; moderate-certainty evidence). The LNG-IUS and other medical therapies probably give rise to similar numbers of women with serious adverse events (RR 0.91, 95% CI 0.63 to 1.30; 1 study, 571 women; moderate-certainty evidence). Women using other medical therapy are probably more likely to withdraw from treatment for any reason (RR 0.49, 95% CI 0.39 to 0.60; 1 study, 571 women, moderate-certainty evidence) and to experience treatment failure than women with LNG-IUS (RR 0.34, 95% CI 0.26 to 0.44; 6 studies, 535 women; moderate-certainty evidence). LNG-IUS versus endometrial resection or ablation (EA) Bleeding outcome results are inconsistent. We are uncertain of the effect of the LNG-IUS compared to EA on rates of amenorrhoea (RR 1.21, 95% CI 0.85 to 1.72; 8 studies, 431 women; I² = 21%; low-certainty evidence) and hypomenorrhoea (RR 0.98, 95% CI 0.73 to 1.33; 4 studies, 200 women; low-certainty evidence) and eumenorrhoea (RR 0.55, 95% CI 0.30 to 1.00; 3 studies, 160 women; very low-certainty evidence). We are uncertain whether both treatments may have similar rates of satisfaction with treatment at 12 months (RR 0.95, 95% CI 0.85 to 1.07; 5 studies, 317 women; low-certainty evidence). We are uncertain if the LNG-IUS compared to EA has any effect on quality of life, measured with SF-36 (MD -14.40, 95% CI -22.63 to -6.17; 1 study, 33 women; very low-certainty evidence). Women with the LNG-IUS compared with EA are probably more likely to have any adverse event (RR 2.06, 95% CI 1.44 to 2.94; 3 studies, 201 women; moderate-certainty evidence). Women with the LNG-IUS may experience more treatment failure compared to EA at one year follow up (persistent HMB or requirement of additional treatment) (RR 1.78, 95% CI 1.09 to 2.90; 5 studies, 320 women; low-certainty evidence); or requirement of hysterectomy may be higher at one year follow up (RR 2.56, 95% CI 1.48 to 4.42; 3 studies, 400 women; low-certainty evidence). LNG-IUS versus hysterectomy We are uncertain whether the LNG-IUS has any effect on HMB compared with hysterectomy (RR for amenorrhoea 0.52, 95% CI 0.39 to 0.70; 1 study, 75 women; very low-certainty evidence). We are uncertain whether there is difference between LNG-IUS and hysterectomy in satisfaction at five years (RR 1.01, 95% CI 0.94 to 1.08; 1 study, 232 women; low-certainty evidence) and quality of life (SF-36 MD 2.20, 95% CI -2.93 to 7.33; 1 study, 221 women; low-certainty evidence). Women in the LNG-IUS group may be more likely to have treatment failure requiring hysterectomy for HMB at 1-year follow-up compared to the hysterectomy group (RR 48.18, 95% CI 2.96 to 783.22; 1 study, 236 women; low-certainty evidence). None of the studies reported cost data suitable for meta-analysis.

AUTHORS' CONCLUSIONS

The LNG-IUS may improve HMB and quality of life compared to other medical therapy; the LNG-IUS is probably similar for HMB compared to endometrial destruction techniques; and we are uncertain if it is better or worse than hysterectomy. The LNG-IUS probably has similar serious adverse events to other medical therapy and it is more likely to have any adverse events than EA.

Impact of contraception and IVF hormones on metabolic, endocrine, and inflammatory status

Assisted reproductive technologies (ART) represent commonly utilized management strategies for infertility with multifactorial causes (including genetically predisposed diseases). Amongst ART, in vitro fertilization (IVF) is the most popular. IVF treatment may predispose the mother to increased risks and complications during pregnancy, and there may be adverse fetal outcomes. Hormonal therapies, including oral contraceptives, may impair glucose and lipid metabolism, and promote insulin resistance and inflammation. IVF treatment involves administration of reproductive hormones, similar in composition but in much higher doses than those used for oral contraception. The provision of IVF reproductive hormones to mice associates with glucose intolerance. In addition, the physiological and hormonal changes of pregnancy can trigger an inflammatory response, and metabolic and endocrine changes. There is controversy regarding the potential effects of IVF hormonal therapies in the promotion of diabetogenic and inflammatory states, additional to those that occur during pregnancy, and which may therefore predispose women with IVF-conceived pregnancies to adverse obstetric outcomes compared with women with spontaneously conceived pregnancies. This review summarizes the limited published evidence regarding the effect of IVF-based fertility therapies on glucose homeostasis, insulin resistance, cardio-metabolic profile, and markers of inflammation.

A brief guide to the menstrual cycle and oral contraceptive use for researchers in behavioral endocrinology

There is increasing evidence that reproductive hormones exert regulatory effects in the central nervous system that can influence behavioral, cognitive, perceptual, affective, and motivational processes. These effects occur in adults and post-pubertal individuals, and can be demonstrated in humans as well as laboratory animals. Large changes in 17β-estradiol and progesterone occur over the ovarian cycle (i.e., the menstrual cycle) and afford a way for researchers to explore the central nervous system (CNS) effects of these hormones under natural physiological conditions. Increasingly, oral contraceptives are also being studied, both as another route to understanding the CNS effects of reproductive hormones and also as pharmacological agents in their own right. This mini-review will summarize the basic physiology of the menstrual cycle and essential facts about oral contraceptives to help novice researchers to use both paradigms effectively.

Awareness of polycystic ovary syndrome among obstetrician-gynecologists and endocrinologists in Northern Europe

OBJECTIVE

To date, little is known about differences in the knowledge, diagnosis making and treatment strategies of health care providers regarding polycystic ovary syndrome (PCOS) across different disciplines in countries with similar health care systems. To inform guideline translation, we aimed to study physician reported awareness, diagnosis and management of PCOS and to explore differences between medical disciplines in the Nordic countries and Estonia.

METHODS

This cross-sectional survey was conducted among 382 endocrinologists and obstetrician-gynaecologists in the Nordic countries and Estonia in 2015-2016. Of the participating physicians, 43% resided in Finland, 18% in Denmark, 16% in Norway, 13% in Estonia, and 10% in Sweden or Iceland, and 75% were obstetrician-gynaecologists. Multivariable logistic regression models were run to identify health care provider characteristics for awareness, diagnosis and treatment of PCOS.

RESULTS

Clinical features, lifestyle management and comorbidity were commonly recognized in women with PCOS, while impairment in psychosocial wellbeing was not well acknowledged. Over two-thirds of the physicians used the Rotterdam diagnostic criteria for PCOS. Medical endocrinologists more often recommended lifestyle management (OR = 3.6, CI 1.6-8.1) or metformin (OR = 5.0, CI 2.5-10.2), but less frequently OCP (OR = 0.5, CI 0.2-0.9) for non-fertility concerns than general obstetrician-gynaecologists. The physicians aged <35 years were 2.2 times (95% CI 1.1-4.3) more likely than older physicians to recommend lifestyle management for patients with PCOS for fertility concerns. Physicians aged 46-55 years were less likely to recommend oral contraceptive pills (OCP) for patients with PCOS than physicians aged >56 (adjusted odds ratio (OR) = 0.4, 95% CI 0.2-0.8).

CONCLUSION

Despite well-organized healthcare, awareness, diagnosis and management of PCOS is suboptimal, especially in relation to psychosocial comorbidities, among physicians in the Nordic countries and Estonia. Physicians need more education on PCOS and evidence-based information on Rotterdam diagnostic criteria, psychosocial features and treatment of PCOS, with the recently published international PCOS guideline well needed and welcomed.

Multicenter, phase III trials on the contraceptive efficacy, tolerability and safety of a new drospirenone-only pill

INTRODUCTION

Approximately 100 million women currently use combined oral contraceptives. Combined oral contraceptives use is associated with increased risk of venous thromboembolic events and cardiovascular disease. Progestin-only pills do not increase the risk of venous thromboembolic events, stroke and myocardial infarction but are associated with a poor cycle control. A novel estrogen-free pill containing only drospirenone (DRSP) was developed to improve bleeding pattern, tolerability and acceptance without increasing venous thromboembolic events risks in contraception.

MATERIAL AND METHODS

Two prospective, multicenter Phase III studies in healthy women aged 18-45 years were performed to demonstrate the efficacy and safety of a drospirenone-only pill in a regimen of 24 days of 4 mg of drospirenone tablets followed by 4 days of placebo. A total of 1571 women (14 329 exposure cycles) were analyzed: 713 patients in the 13-cycle study 1 with 7638 exposure cycles and 858 patients in the 9-cycle study 2 with 6691 exposure cycles. The primary endpoint was the overall Pearl index, calculated for each study separately, and for both pooled. As main secondary efficacy endpoint, the "method failure Pearl index" including all pregnancies during "perfect medication cycles" was evaluated. EudraCT registration numbers: 2010-021787-15 & 2011-002396-42.

RESULTS

Calculations on pooled studies 1 and 2 with 1571 patients gave an overall Pearl index (based on 14 329 cycles) of 0.7258 (95% CI 0.3133 to 1.4301). No single case of deep vein thrombosis or pulmonary embolism and only one case of hyperkalemia were reported. Additional information such as laboratory parameters, body mass index, bodyweight, heart rate and blood pressure showed no statistically significant changes due to the treatment.

CONCLUSIONS

This is the first report of a new drospirenone-only oral contraceptive providing clinical efficacy similar to combined oral contraceptives, with a good safety profile, and favorable cycle control.

Female reproductive history in relation to chronic obstructive pulmonary disease and lung function in UK biobank: a prospective population-based cohort study

OBJECTIVES

Sex differences in respiratory physiology and predilection for developing chronic obstructive pulmonary disease (COPD) have been documented, suggesting that female sex hormones may influence pathogenesis. We investigated whether aspects of female reproductive health might play a role in risk of COPD among women.

DESIGN

Population-based prospective cohort study.

SETTING

UK Biobank recruited across 22 centres in the UK between 2006 to 2010.

PRIMARY AND SECONDARY OUTCOMES MEASURES

We examined a range of female reproductive health indicators in relation to risk of COPD-related hospitalisation/death (n=271 271) using Cox proportional hazards regression; and lung function (n=273 441) using linear regression.

RESULTS

Parity >3 was associated with greater risk of COPD-related hospitalisation/death (adjusted HR 1.45; 95% CI: 1.16 to 1.82) and lower forced expiratory volume at 1 second/forced vital capacity ratio (FEV₁/FVC) (adjusted mean difference -0.06; 95% CI: -0.07 to 0.04). Any oral contraception use was associated with lower risk of COPD-related hospitalisation/death (adjusted HR 0.85; 95% CI: 0.74 to 0.97) and greater FEV₁/FVC (adjusted mean difference 0.01; 95% CI: 0.003 to 0.03). Late menarche (age >15) and early menopause (age <47) were also associated with greater risk of COPD-related hospitalisation/death (but not lung function), while endometriosis was associated with greater FEV₁/FVC (not COPD-related hospitalisation/death). Early menarche (age <12 years) was associated with lower FEV₁/FVC (but not COPD hospitalisation/death). Associations with polycystic ovary syndrome (PCOS) or ovarian cysts, any hormone replacement therapy (HRT) use, hysterectomy-alone and both hysterectomy and bilateral oophorectomy were in opposing directions for COPD-related hospitalisation/death (greater risk) and FEV₁/FVC (positive association).

CONCLUSIONS

Multiple female reproductive health indicators across the life course are associated with COPD-related hospitalisation/death and lung function. Further studies are necessary to understand the opposing associations of PCOS/ovarian cysts, HRT and hysterectomy with COPD and objective measures of airway obstruction.

Reference intervals of nine steroid hormones over the life-span analyzed by LC-MS/MS: Effect of age, gender, puberty, and oral contraceptives

New reference intervals need to be established for a new analytical method with improved sensitivity and specificity. We aimed to establish the new reference intervals from infancy to senescence of nine steroid hormones (cortisol, cortisone, progesterone, 17-hydroxyprogesterone (17-OHP), androstenedione, testosterone, estradiol, DHEAS, and aldosterone) for LC-MS/MS method. Serum samples from 4678 reference individuals (age range: 0.3-79 years) were measured with LC-MS/MS. Samples were collected between 7 a.m. and 10 a.m. Exclusion criteria were concomitant endocrine diseases and body mass index ≥ 33. Generalized additive model for location, scale and shape, the nonparametric or robust method was applied. We established the reference intervals of the nine steroid hormones by sex, age, and pubertal stage. Below the age of one, we observed the surge of androgen and estrogen which implied mini-puberty. At the same period of life, aldosterone and cortisone levels were very high reflecting physiological hyperaldosteronism. An increase of steroid hormones during the pubertal development and slow decrease towards senescence after the peak at early adulthood were observed. Due to the increase of CBG synthesis, cortisol levels were increased under oral contraceptives (OC) significantly (p < 0.0001), while OC suppressed progesterone, 17-OHP, androstenedione, and estradiol (p < 0.0001). Our results will facilitate the interpretation of patient data in routine diagnostics with the use of LC-MS/MS method. Since LC-MS/MS methods have shown good comparability among the different laboratories, our reference intervals can be further adopted in other laboratories equipped with LC-MS/MS, once the validation with a small number of reference samples is performed.

Lean Women on Metformin and Oral Contraceptives for Polycystic Ovary Syndrome Demonstrate a Dehydrated Osteosarcopenic Phenotype: A Pilot Study

Scarce data exist on the body composition of lean women with polycystic ovary syndrome (PCOS) on treatment with metformin and oral contraceptives (OCs). Thirty-four lean (body mass index 18.5–24.9 kg/m²) women (17 with PCOS on metformin and OCs treatment for six months and 17 controls) aged 18–40 years were assessed for body composition parameters (fat, muscle, glycogen, protein masses, bone masses, and body water compartments) and phase angles. PCOS patients demonstrated lower muscle, glycogen and protein masses (U = 60, p = 0.003), along with a lower bone mineral content and mass (U = 78, p = 0.021; U = 74, p = 0.014) than their healthy counterparts, while total and abdominal fat masses were similar between the two groups. PCOS patients also exhibited increased extracellular body water (U = 10, p < 0.001) and decreased intracellular water, compatible with low-grade inflammation and cellular dehydration. Key differences in body composition between women with PCOS and controls demonstrated an osteosarcopenic body composition phenotype in PCOS patients. A confirmation of these findings in larger studies may render osteosarcopenia management a targeted adjunct therapy in women with PCOS.

Premenstrual Dysphoric Disorder

Premenstrual dysphoric disorder (PMDD) comprises emotional and physical symptoms and functional impairment that lie on the severe end of the continuum of premenstrual symptoms. Women with PMDD have a differential response to normal hormonal fluctuations. This susceptibility may involve the serotonin system, altered sensitivity of the GABA_A receptor to the neurosteroid allopregnanalone, and altered brain circuitry involving emotional and cognitive functions. Serotonin reuptake inhibitors are considered the first-line treatment. Second-line treatments include oral contraceptives containing drospirenone, other ovulation suppression methods, calcium, chasteberry, and cognitive-behavioral therapy.

Country-Level Gender Equality and Adolescents' Contraceptive Use in Europe, Canada and Israel: Findings from 33 Countries

CONTEXT

Although an association between gender equality and contraceptive use has been confirmed among adult samples, few studies have explored this relationship among adolescents. An examination of whether adolescents' contraceptive use is more prevalent in countries with higher levels of gender equality is needed to fill this gap.

METHODS

Nationally representative data from 33 countries that participated in the 2013-2014 Health Behaviour in School-Aged Children study and country-level measures of gender equality-using the 2014 Global Gender Gap Index-were analyzed. Multilevel multinomial logistic regression analyses were employed to assess associations between gender equality and contraceptive use (condom only, pill only and dual methods) at last intercourse as reported by 4,071 females and 4,110 males aged 14-16.

RESULTS

Increasing gender equality was positively associated with contraceptive use among both males and females. For every 0.1-point increase on the equality scale, the likelihood of condom use at last intercourse rose (odds ratio, 2.1 for females), as did the likelihood of pill use (6.5 and 9.6, respectively, for males and females) and dual method use (2.1 and 5.6, respectively). Associations with pill use and dual use remained significant after national wealth and income inequality were controlled for. Overall, associations were stronger for females than for males.

CONCLUSIONS

More research is needed to identify potential causal pathways and mechanisms through which gender equality and adolescents' contraceptive use may influence one another.

Global Contraceptive Failure Rates: Who Is Most at Risk?

Contraceptive failure is a major contributor to unintended pregnancy worldwide. DHS retrospective calendars, which are the most widely used data source for estimating contraceptive failure in low-income countries, vary in quality across countries and surveys. We identified surveys with the most reliable calendar data and analyzed 105,322 episodes of contraceptive use from 15 DHSs conducted between 1992 and 2014. We estimate contraceptive method-specific 12-month failure rates. We also examined how failure rates vary by age, education, socioeconomic status, contraceptive intention, residence, and marital status using multilevel piecewise exponential hazard models. Our failure rate estimates are significantly lower than results from the United States and slightly higher than previous studies that included more DHS surveys, including some with lower-quality data. We estimate age-specific global contraceptive failure rates and find strong, consistent age patterns with the youngest users experiencing failure rates up to ten times higher than older women for certain methods. Failure also varies by socioeconomic status, with the poorest, and youngest, women at highest risk of experiencing unintended pregnancy due to failure.

Contraceptive use in Latin America and the Caribbean with a focus on long-acting reversible contraceptives: prevalence and inequalities in 23 countries

BACKGROUND

The rise in contraceptive use has largely been driven by short-acting methods of contraception, despite the high effectiveness of long-acting reversible contraceptives. Several countries in Latin America and the Caribbean have made important progress increasing the use of modern contraceptives, but important inequalities remain. We assessed the prevalence and demand for modern contraceptive use in Latin America and the Caribbean with data from national health surveys.

METHODS

Our data sources included demographic and health surveys, multiple indicator cluster surveys, and reproductive health surveys carried out since 2004 in 23 countries of Latin America and the Caribbean. Analyses were based on sexually active women aged 15-49 years irrespective of marital status, except in Argentina and Brazil, where analyses were restricted to women who were married or in a union. We calculated contraceptive prevalence and demand for family planning satisfied. Contraceptive prevalence was defined as the percentage of sexually active women aged 15-49 years who (or whose partners) were using a contraceptive method at the time of the survey. Demand for family planning satisfied was defined as the proportion of women in need of contraception who were using a contraceptive method at the time of the survey. We separated survey data for modern contraceptive use by type of contraception used (long-acting, short-acting, or permanent). We also stratified survey data by wealth, area of residence, education, ethnicity, age, and a combination of wealth and area of residence. Wealth-related absolute and relative inequalities were estimated both for contraceptive prevalence and demand for family planning satisfied.

FINDINGS

We report on surveys from 23 countries in Latin America and the Caribbean, analysing a sample of 212 573 women. The lowest modern contraceptive prevalence was observed in Haiti (31·3%) and Bolivia (34·6%); inequalities were wide in Bolivia, but almost non-existent in Haiti. Brazil, Colombia, Costa Rica, Cuba, and Paraguay had over 70% of modern contraceptive prevalence with low absolute inequalities. Use of long-acting reversible contraceptives was below 10% in 17 of the 23 countries. Only Cuba, Colombia, Mexico, Ecuador, Paraguay, and Trinidad and Tobago had more than 10% of women adopting long-acting contraceptive methods. Mexico was the only country in which long-acting contraceptive methods were more frequently used than short-acting methods. Young women aged 15-17 years, indigenous women, those in lower wealth quintiles, those living in rural areas, and those without education showed particularly low use of long-acting reversible contraceptives.

INTERPRETATION

Long-acting reversible contraceptives are seldom used in Latin America and the Caribbean. Because of their high effectiveness, convenience, and ease of continuation, availability of long-acting reversible contraceptives should be expanded and their use promoted, including among young and nulliparous women. In addition to suitable family planning services, information and counselling should be provided to women on a personal basis.

FUNDING

Wellcome Trust, Pan American Health Organization.

The cost-effectiveness of oral contraceptives compared to 'no hormonal treatment' for endometriosis-related pain: An economic evaluation

OBJECTIVE

To develop a preliminary cost-effectiveness model that compares oral contraceptives and 'no hormonal treatment' for the treatment of endometriosis-related pain.

METHODS

A de novo preliminary state transition (Markov) model was developed. The model was informed by systematic literature review and expert opinion. The uncertainty around the results was assessed both by deterministic and probabilistic sensitivity analyses. The economic evaluation was conducted from National Health Service (NHS) England perspective. The main outcome measure was incremental cost per quality-adjusted life year (QALY), with cost-effectiveness plane and cost-effectiveness acceptability curves presented for alternative willingness-to-pay thresholds.

RESULTS

Oral contraceptives dominated 'no hormonal treatment' and provided more QALYs at a lower cost than 'no hormonal treatment', with a cost-effectiveness probability of 98%. A one-way sensitivity analysis excluding general practitioner consultations showed that oral contraceptives were still cost-effective.

CONCLUSIONS

The analyses showed that oral contraceptives could be an effective option for the treatment of endometriosis, as this treatment was shown to provide a higher level of QALYs at a lower cost, compared to 'no hormonal treatment'. The results are subject to considerable parameter uncertainty as a range of assumptions were required as part of the modelling process.

Long-Term Response of Hirsutism and Other Hyperandrogenic Symptoms to Combination Therapy in Polycystic Ovary Syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) affects 5%-15% of women and is the most common cause of hirsutism. Data on the time-course of improvement to suppressive therapy and predictors of that response in PCOS are lacking. The objectives of our study are to determine the long-term response and identify predictors of response in PCOS women treated with suppressive therapy, including spironolactone (SPL) + oral contraceptives (OCs).

MATERIALS AND METHODS

Retrospective cross-sectional analysis of 200 women with PCOS (1990 NIH criteria) treated with suppressive therapy in general, and a subgroup of 138 subjects treated with OCP+SPL who had been prospectively included in a biorepository. Main outcome measure included improvement rate per 100 person-month of follow-up for hirsutism, menstrual irregularity and acne measured qualitatively as "feeling better", and changes in the severity of hirsutism quantified by modified Ferriman-Gallwey [mF-G] score.

RESULTS

During a mean follow-up of 34.2 months, 85.1%, 82.7%, and 79.3% of patients reported improvement in hirsutism, menstrual dysfunction, and acne, respectively. The modified Ferriman-Gallwey (mF-G) hirsutism score improved by 59.9%. The net reduction in mF-G score and the percent of patients reporting improvement in hirsutism were greater for OC+SPL than for either drug alone, with no difference in the percent of patients free of adverse effects. Among those treated with OC+SPL (n = 138), the initial mF-G and sex hormone-binding globulin (SHBG) independently predicted successful therapy for hirsutism.

CONCLUSION

There is a high rate of patient satisfaction with suppressive therapy in PCOS. The efficacy of suppressive therapy for hirsutism was greater with OC+SPL than with either drug alone. Successful treatment of hirsutism with combination OC+SPL requires at least 6 months of therapy, with the proportion of satisfied patients continuing to increase with treatment duration. The probability of patient satisfaction with OC+SPL treatment for hirsutism can be predicted by her initial mF-G score or SHBG level.

Oral contraceptives for pain associated with endometriosis

BACKGROUND

Endometriosis is a common gynaecological condition which affects many women of reproductive age worldwide and is a major cause of pain and infertility. The combined oral contraceptive pill (COCP) is widely used to treat pain occurring as a result of endometriosis, although the evidence for its efficacy is limited.

OBJECTIVES

To determine the effectiveness, safety and cost-effectiveness of oral contraceptive preparations in the treatment of painful symptoms ascribed to the diagnosis of laparoscopically proven endometriosis.

SEARCH METHODS

We searched the following from inception to 19 October 2017: the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials, the Cochrane CENTRAL Register of Studies Online (CRSO), MEDLINE, Embase, PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the trial registers ClinicalTrials.gov and the World Health Organization Clinical Trials Registry Platform (WHO ICTRP). We also handsearched reference lists of relevant trials and systematic reviews retrieved by the search.

SELECTION CRITERIA

We included randomised controlled trials (RCT) of the use of COCPs in the treatment of women of reproductive age with symptoms ascribed to the diagnosis of endometriosis that had been made visually at a surgical procedure.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data. One review author was an expert in the content matter. We contacted study authors for additional information. The primary outcome was self-reported pain (dysmenorrhoea) at the end of treatment.

MAIN RESULTS

Five trials (612 women) met the inclusion criteria. Only three trials (404 women) provided data that were suitable for analysis.Combined oral contraceptive pill versus placeboTwo trials compared COCP with a placebo. These studies were at high risk of bias. For GRADE outcomes (self-reported pain (dysmenorrhoea) at the end of treatment), the quality of the evidence very low. Evidence was downgraded for imprecision as it was based on a single, small trial and for the visual analogue scale data there were wide confidence intervals (CIs). There appeared to have been substantial involvement of the pharmaceutical company funding the trials.Treatment with the COCP was associated with an improvement in self-reported pain at the end of treatment as evidenced by a lower score on the Dysmenorrhoea verbal rating scale (scale 0 to 3) compared with placebo (mean difference (MD) -1.30 points, 95% CI -1.84 to -0.76; 1 RCT, 96 women; very low quality evidence), a lower score on the Dysmenorrhoea visual analogue scale (no details of scale) compared with placebo (MD -23.68 points, 95% CI -28.75 to -18.62, 2 RCTs, 327 women; very low quality evidence) and a reduction in menstrual pain from baseline to the end of treatment (MD 2.10 points, 95% CI 1.38 to 2.82; 1 RCT, 169 women; very low quality evidence).Combined oral contraceptive pill versus medical therapiesOne underpowered trial compared the COCP with another medical treatment (goserelin). The study was at high risk of bias; the trial was unblinded and there was insufficient detail to judge allocation concealment and randomisation. For GRADE outcomes (self-reported pain (dysmenorrhoea) at the end of treatment), the quality of the evidence ranged from low to very low.At the end of treatment, the women in the goserelin group were amenorrhoeic and therefore no comparisons could be made between the groups for the primary outcome. At six months' follow-up, there was no clear evidence of a difference between women treated with the COCP and women treated with goserelin for measures of dysmenorrhoea on a visual analogue scale (scale 1 to 10) (MD -0.10, 95% CI -1.28 to 1.08; 1 RCT, 50 women; very low quality evidence) or a verbal rating scale (scale 0 to 3) (MD -0.10, 95% CI -0.99 to 0.79; 1 RCT, 50 women; very low quality evidence). At six months' follow-up, there was no clear evidence of a difference between the COCP and goserelin groups for reporting complete absence of pain as measured by the visual analogue scale (risk ratio (RR) 0.36, 95% CI 0.02 to 8.43; 1 RCT, 50 women; very low quality evidence) or the verbal rating scale (RR 1.00, 95% CI 0.93 to 1.08; 1 RCT, 49 women; low quality evidence).

AUTHORS' CONCLUSIONS

Based on the limited evidence from two trials at high risk of bias and limited data for the prespecified outcomes for this review, there is insufficient evidence to make a judgement on the effectiveness of the COCP compared with placebo and the findings cannot be generalised.Based on the limited evidence from one small trial that was at high risk of bias, there is insufficient evidence to make a judgement on the effectiveness of the COCP compared with other medical treatments. Only one comparison was possible, with the medical intervention being goserelin, and the findings cannot be generalised.Further research is needed to fully evaluate the role of COCPs in managing pain-related symptoms associated with endometriosis. There are other formulations of the combined hormonal contraception such as the transdermal patch, vaginal ring or combined injectable contraceptives which this review did not cover but should be considered in future updates.

Progestins and acne vulgaris: a review

The role of exogenous progestin in the development of acne is unclear. Progestins are known for their androgenic potential, but newer generations of progestins have low or anti-androgenic activity. This review will evaluate the association between progestins found in hormonal long-acting reversible contraceptives (intrauterine devices and subdermal implants) and acne, as well as the role of oral contraceptives in acne management. Our review demonstrates that the cause and effect relationship between progestins and acne is difficult to establish and future studies that seek to understand how progestins modulate acne are necessary.

Uncovering the link between reproductive factors and multiple sclerosis: A case-control study on Iranian females

BACKGROUND

Increase of MS prevalence in females compared to males, especially in reproductive age, highlights the important role of reproductive factors in MS pathology.

OBJECTIVES

We examined the association between females' reproductive age-related factors and MS risk.

METHODS

A case-control study including 399 cases and 541 controls was carried out. The adjusted associations between MS risk and reproductive variables including age at menarche, oral contraceptive pills (OCPs) use history, OCP usage duration and age at first use, history of assisted reproductive technologies (ARTs) use, parity history, age at first childbirth and the number of parities, abortion and exclusive breast feeding > 2 months were assessed.

RESULTS

We found protective relationships between MS and older age at menarche (OR = 0.90 {95% CI = 0.82-0.98}), ART use history (OR = 0.45 {95% CI = 0.21-0.99}), older maternal age at first childbirth (OR = 0.94{95% CI = 0.89 - 0.99}) and higher number of parities(OR = 0.61 {95% CI = 0.49 - 0.75), whereas using OCPs was associated with higher risk of developing MS (OR = 1.80 {95% CI = 1.35-2.41}).

CONCLUSIONS

Links were noted between a number of reproductive factors and risk of MS.

[New medical treatments for painful endometriosis: CNGOF-HAS Endometriosis Guidelines]

OBJECTIVE

The objective of this work is to evaluate the place of new treatments in the management of endometriosis outside the context of infertility.

METHODS

A review of the literature was conducted by consulting Medline data until July 2017.

RESULTS

Dienogest is effective compared to placebo in short term (NP2) and long term (NP4) for the treatment of painful endometriosis. In comparison with GnRH agonists, dienogest is also effective in terms of decreased pain and improved quality of life in non-operated patients (NP2) as well as for recurrence of lesions and symptomatology postoperatively (NP2). Data on GnRH antagonists, selective progesterone receptor modulators as well as selective inhibitors (anti-TNF-α, matrix metalloprotease inhibitors, angiogenesis growth factor inhibitors) are insufficient to provide evidence of interest in clinical practice for the management of painful endometriosis (NP3).

CONCLUSION

Dienogest is recommended as second-line therapy for the management of painful endometriosis (Grade B). Because of lack of evidence, aromatase inhibitors, elagolix, SERM, SPRM and anti-TNF-α are not recommended for the management of painful endometriosis (Grade C).

The cardiometabolic effect of current management of polycystic ovary syndrome: strategies of prevention and treatment

Polycystic ovary syndrome (PCOS) is the commonest endocrine disorder amongst women of reproductive age, which is characterized by reproductive and cardiometabolic disturbances with long-term health repercussions. Insulin resistance (IR), impaired glucose tolerance, type 2 diabetes mellitus (DM2), obesity and dyslipidemia occur more in women with PCOS than in age-comparable women without PCOS. Long term data regarding risks or benefits of medical intervention for metabolic dysfunction of PCOS are lacking. Therapies, such as oral contraceptives (OCPs) and anti-androgenic medications used to manage the reproductive manifestations of PCOS, may themselves be the cause of cardiometabolic perturbations. Hence, strategies regarding the management of reproductive issues in PCOS encompass a patient-specific tailored approach. Factors that influence the cardiometabolic side effects arising during treatment of the reproductive manifestations of PCOS (hirsutism/anovulation) are also discussed in this paper in order to build future strategies to minimize the overall cardiometabolic risk.

The experience of sexuality in adults with intellectual disability

BACKGROUND

People with intellectual disability have the same sexual needs as those without any disability, yet their sexuality is often restricted by reluctant attitudes and/or fears based on irrational beliefs. The aim of this study is to describe and analyse different areas of sexuality in adults with mild or moderate intellectual disability.

METHOD

The sample consisted of 180 men and 180 women attending occupational centres. All the participants were administered a questionnaire about sexuality adapted to their characteristics.

RESULTS

Results show that 84.2% have had sexual relationships with another person, this percentage being higher in females and in people aged between 38 and 55 years old. Condoms are used by 41.4%. The most frequently used contraceptive methods are the pill (39.6%), transdermal patch (30.2%) and intrauterine device (6.7%). 9.4% of the women and 2.8% of the men has experienced sexual abuse.

CONCLUSION

In conclusion, there is a need to draw up educational programmes, differentiated according to gender and adapted to their reality, which include contents related with sexual health, sexual abuse and condom use.

Effect of oral contraception on anemia in 12 low- and middle-income countries

CONTEXT

In low- and middle-income countries, anemia is a major public health issue in women of reproductive age for a series of factors including iron deficiency.

OBJECTIVE

To estimate prevalence of anemia and to assess the association of low level of hemoglobin versus duration of use of oral contraceptives (OC).

METHODS

Demographic and Health Surveys of 12 countries, conducted between 2005 and 2012, were analyzed. The status of anemia was separately evaluated for nonpregnant women using OC for at least 6 months, 1 year and 2 years, and for women using no method of contraception and/or using nonhormonal contraception.

RESULTS

The total study population comprised 201,720 women, with 40% diagnosed with anemia; around 1 out of 25 women was using oral contraception. The current and continuous use of oral contraception was of benefit against anemia, with the risk for anemia decreasing from odds ratio (OR) 0.68 [95% confidence interval (CI) 0.64-0.73] for use of at least 6 months to OR 0.56 (95% CI 0.52-0.61) for use of at least 1 year and to OR 0.50 (95% CI 0.46-0.54) for use of at least 2 years.

CONCLUSIONS

Findings reinforce evidence of the noncontraceptive benefit of long-term use of OC and provide valuable information for policy makers, family planning staff and clinicians working in low- and middle-income countries in efforts to control anemia.