Higher baseline heart rate variability in CCHS patients with progestin-associated recovery of hypercapnic ventilatory response

After a fortuitous observation of two cases of chemosensitivity recovery in women with congenital central hypoventilation syndrome (CCHS) who took desogestrel, we aimed to evaluate the ventilatory response to hypercapnia of five CCHS patients with or without treatment consisting of desogestrel (DESO) or levonorgestrel (LEVO). Only two patients became responsive to hypercapnia under treatment, according to their basal vagal heart rate variability. These results suggest that heart rate variability may be promising tool to discriminate patients susceptible to become responsive to hypercapnia under DESO-LEVO treatment.Clinical Trials Identifier NCT01243697.

The effect of Ding-kun-dan comparing with Marvelon on primary dysmenorrhea: A prospective, double-blind, multicenter, randomized controlled trial

ETHNOPHARMACOLOGICAL RELEVANCE

Ding-kun-dan (DKD), as one of well-known traditional Chinese medicine (TCM), is considered as an effective prescription to regulate menstruation, benefit Qi and nourish the blood. Previous studies had showed that DKD could improve sex hormone levels, insulin resistance, metabolism abnormalities and regulate immunity in animal models with polycystic ovary syndrome or endometriosis, however, little study conducted to reveal its clinical efficacy in Primary Dysmenorrhea (PD).

AIM OF THE STUDY

To compare the effect of Ding-kun-dan (DKD) with Marvelon on relief of symptoms and change of serum pain-related factors in patients with primary dysmenorrhea.

MATERIALS AND METHOD

136 patients with primary dysmenorrhea were randomly assigned to the DKD group (n = 73, take one tablet per day from 5th day of the menstrual cycle for 10 days every 28 days) and the Marvelon group (n = 63, take one tablet per day from 5th day of the menstrual cycle for 21 days every 28 days), the therapeutic effects were analyzed through evaluating the change of VAS scores, CMSS scores and the level of PGF2a, PGE2, PGF2a/PGE2 and NO during the 12 weeks intervention.

RESULTS

Both DKD and Marvelon could effectively relief pain and other associated symptoms at each visit (Baseline, 4th week, 8th week and 12th week). Although Marvelon was significantly superior to DKD in reducing VAS scores, the total CMSS, CMSS severity and duration scores at each posttreatment follow-up (P < 0.01), VAS scores in the DKD group decreased significantly over time while scores in the COC group only dropped rapidly after the first two months of treatment. Efficacy gap between two interventions continuously narrowed over time and the efficacy of DKD became non-inferior at the 12th week compared to that of Marvelon (the difference between groups, - 0.78%; 95% confidence interval (CI), -13.67%-12.75%; non-inferiority margin, 15%). DKD group had better efficacy on mild pain compared to that of the COC group with no statistical difference (75% VS 61.9%, P > 0.05). DKD and Marvelon could effectively reduce PGF2a, PGE2 and higher PGF2a/PGE2 in patients with PD. There was no statistical difference in the level of PGF2a, PGE2, PGF2a/PGE2 and NO between DKD and Marvelon group at each follow-up. No serious adverse effect was observed.

CONCLUSION

Ding-kun-dan is another available, effective and safe method for patients with primary dysmenorrhea to choose, especially for those who are suffered from mild pain and/or contraindicated to hormonal agents.

Long-Acting Reversible Etonogestrel Subdermal Implant in Adolescents

Several effective contraceptive options are available for use by adolescents, including the long-acting reversible subdermal implant and intrauterine devices, which provide a high level of convenience, privacy, and effectiveness for an adolescent. Knowledge of all the effective birth control methods is essential for the pediatrician to be able to provide effective contraceptive counseling for an adolescent. An approach to counseling using a reproductive justice framework, which allows the provider and adolescent patient to engage in shared decision-making, is described. This article focuses on the long-acting reversible etonogestrel (ENG) subdermal implant for adolescents. The ENG implant is labeled for preventing pregnancy by suppressing ovulation. The ENG implant may also have a role in ameliorating dysmenorrhea and heavy menstrual bleeding. Postlabeling studies indicate that the ENG implant is effective for up to 5 years, although the device's labeling states effectivenessup to 3 years. The main contraindication to using the ENG implant is pregnancy itself. Safe initiation of the ENG implant is described, including an approach to determine whether an adolescent is pregnant. The main adverse effect of the ENG implant is an unpredictable bleeding pattern that is most often ameliorated by use of nonsteroidal anti-inflammatory medications, as well as estrogen, if not contraindicated for the patient. Details of the insertion and removal procedures, including potential complications, are described to enable the pediatrician to provide effective anticipatory guidance for the adolescent.

Serotonin and the ventilatory effects of etonogestrel, a gonane progestin, in a murine model of congenital central hypoventilation syndrome

INTRODUCTION

Congenital Central Hypoventilation Syndrome, a rare disease caused by PHOX2B mutation, is associated with absent or blunted CO₂/H⁺ chemosensitivity due to the dysfunction of PHOX2B neurons of the retrotrapezoid nucleus. No pharmacological treatment is available. Clinical observations have reported non-systematic CO₂/H⁺ chemosensitivity recovery under desogestrel.

METHODS

Here, we used a preclinical model of Congenital Central Hypoventilation Syndrome, the retrotrapezoid nucleus conditional Phox2b mutant mouse, to investigate whether etonogestrel, the active metabolite of desogestrel, led to a restoration of chemosensitivity by acting on serotonin neurons known to be sensitive to etonogestrel, or retrotrapezoid nucleus PHOX2B residual cells that persist despite the mutation. The influence of etonogestrel on respiratory variables under hypercapnia was investigated using whole-body plethysmographic recording. The effect of etonogestrel, alone or combined with serotonin drugs, on the respiratory rhythm of medullary-spinal cord preparations from Phox2b mutants and wildtype mice was analyzed under metabolic acidosis. c-FOS, serotonin and PHOX2B were immunodetected. Serotonin metabolic pathways were characterized in the medulla oblongata by ultra-high-performance liquid chromatography.

RESULTS

We observed etonogestrel restored chemosensitivity in Phox2b mutants in a non-systematic way. Histological differences between Phox2b mutants with restored chemosensitivity and Phox2b mutant without restored chemosensitivity indicated greater activation of serotonin neurons of the raphe obscurus nucleus but no effect on retrotrapezoid nucleus PHOX2B residual cells. Finally, the increase in serotonergic signaling by the fluoxetine application modulated the respiratory effect of etonogestrel differently between Phox2b mutant mice and their WT littermates or WT OF1 mice, a result which parallels with differences in the functional state of serotonergic metabolic pathways between these different mice.

DISCUSSION

Our work thus highlights that serotonin systems were critically important for the occurrence of an etonogestrel-restoration, an element to consider in potential therapeutic intervention in Congenital Central Hypoventilation Syndrome patients.

The progestin-only pills drospirenone 4 mg and desogestrel 0.075 mg as an option for the management of dysmenorrhea and mastodynia

INTRODUCTION

Dysmenorrhea and mastodynia are the most common gynecologic pain causes in women of all ages and races during their reproductive life. The following study aimed to show the influence of two POP´s in the development of dysmenorrhea and mastodynia after nine months of use.

MATERIAL AND METHODS

A total of 858 women with 6691 drospirenone (DRSP) cycles and 332 women with 2487 desogestrel (DSG) cycles were analyzed. Women included in this study were all child-bearing potentials, at risk of pregnancy, agreeing to use only the study medication for contraception for the duration of the study medication treatment, aged 18 to 45.

RESULTS

At screening, 168 (19.6%) of the 858 patients using DRSP and 64 (19,3%) of the DSG patients reported that they had suffered from dysmenorrhea within six cycles prior to the first visit before starting with the medication. 20,2% of the DRSP and 10,9% of the DSG group had a sever dysmenorrhea. After 9 cycles this was reduced to 0,6% and 3,1% respectively. In total, 96 women (11.2%) in the DRSP and 49 (14,8%) experienced mastodynia within six cycles before the screening. Of these 91.6% in the DRSP group and 91,8% in the DSG group had no or mild mastodynoa at follow-up.

DISCUSSION

The progestins 4 mg and desogestrel 0,075 mg showed a marked effect in the non-contraceptive aspects of dysmenorrhea and mastodynia so that new possibilities are opened for these two benign gynecological diseases. Future studies must reaffirm these first data.

Comparative evaluation of low-level light therapy and ethinyl estradiol and desogestrel combined oral contraceptive for clinical efficacy and regulation of serum biochemical parameters in primary dysmenorrhoea: a prospective randomised multicentre trial

We aimed to compare low-level light therapy with oral contraceptive pills for pain relief and serum levels of nitric oxide and prostaglandin E₂ in patients with primary dysmenorrhoea. This was a randomised, active comparator-controlled, multicentre study. In total, 156 patients were randomised to receive either low-level light therapy with light-emitting diodes (LED) applying on two acupoints, namely, conception vessel 4 (CV4) and CV6 or conventional treatment with oral Marvelon, 30 µg of ethinyl estradiol and 150 µg of desogestrel (DSG/EE), for three consecutive menstrual cycles. The main outcome was the proportion of patients who achieved 33% or more decrease in pain scores measured using the visual analogue scale, which was deemed as efficient rate. Absolute changes in visual analogue scale scores, serum levels of nitric oxide (assessed by nitrites and nitrates reflecting nitric oxide metabolism) and prostaglandin E₂ (measured by enzyme-linked immunosorbent assay) were the secondary outcomes. A total of 135 patients completed the study (73 in the light therapy group and 62 in the DSG/EE group). The efficient rate at the end of treatment was comparable between the groups (73.6% vs. 85.7%, χ² = 2.994, p = 0.084). A more significant reduction in pain scores was observed in the DSG/EE group (39.25% vs. 59.52%, p < 0.001). Serum levels of prostaglandin E₂ significantly decreased from baseline but did not differ between groups (- 109.57 ± 3.99 pg/mL vs. - 118.11 ± 12.93 pg/mL, p = 0.51). Nitric oxide concentration remained stable in both groups. Low-level light therapy with LED-based device applied on acupuncture points CV4 and CV6 demonstrated a similar level of dysmenorrhoea pain reduction to DSG/EE combined contraceptive. Both treatment modalities achieved clinically meaningful levels of pain reduction. Registration on ClinicalTrials.gov: TRN: NCT03953716, Date: April 04, 2019.

Gongning granules plus low dose hormone in pubertal functional uterine hemorrhage: Analysis of hemodynamics and clinical efficacy

To evaluate the clinical effect of Gongning granules combined with low-dose hormone therapy in pubertal dysfunctional uterine bleeding (PDUB) and its effect on uterine hemodynamics. A total of 164 PDUB patients who were treated in the gynecological outpatient department of our hospital from December 2018 to June 2020 were randomized into study group and control group, with 82 cases each. The control group received estrogen progesterone, and the study group received Gongning granules plus. The clinical efficacy and uterine arterial hemodynamics were compared. The clinical efficacy of the study group was superior to the control group (91.46% vs. 76.83%, P<0.05). The study group yielded shorter bleeding control time and complete hemostasis time than the control group (P<0.05). The amount of menstrual bleeding and duration of menstruation in both groups decreased significantly with time and the study group was significantly lower than the control group (all P<0.05). The endometrial thickness in the study group was significantly thinner than the control group, and the maximum follicle diameter was significantly longer than that in the control group (all P<0.05). After treatment, the platelet count, hemoglobin level of peripheral blood, uterine arterial blood flow and mean flow velocity in the study group were significantly higher than those in the control group (all P<0.05). In addition, there was no significant difference in adverse drug reaction (ADR) between the two groups (P>0.05). In PDUB patients, Gongning granules plus low-dose hormone can significantly relieve bleeding symptoms, improve hemodynamic status and has good safety.

Hormonal, apoptotic, proliferative and inflammatory markers' expression in Desogestrel-treated women with ovarian endometriosis

Endometriosis is a relatively frequent pathology in gynecological practice. We performed an analysis to demonstrate the molecular changes that occur in endometriosis synthetic progestin-treated patients, hoping to sketch a possible pathophysiological pathway that will help us to better understand and treat this debilitating disease. We conducted a prospective study that included a group of 40 women, evaluated in our hospital between 2020-2021. We evaluated immunohistochemical tissue expression of estrogen receptor (ER), progesterone receptor (PR), B-cell lymphoma 2 (Bcl-2) protein, Ki-67, and serum levels of osteopontin (OPN) and vascular endothelial growth factor (VEGF) in patients with ovarian endometrioma with and without progestin treatment. Our study revealed that Desogestrel treatment increases OPN serum levels, PR and Bcl-2 tissue expression and reduces VEGF serum levels and Ki-67 tissue expression. The results we have obtained are very interesting because the serum levels of OPN seem to be more influenced by progestin treatment, than by endometriosis itself. The study we have conducted gives a molecular complex view of what endometriosis represents and on how Desogestrel treatment works.

Letrozole combined with oral contraceptives versus oral contraceptives alone in the treatment of endometriosis-related pain symptoms: a pilot study

BACKGROUND

To compare the efficacy and the tolerability of letrozole combined with oral contraceptives versus oral contraceptives alone in treating endometriosis-related pain.

METHODS

A total of 820 women with endometriosis presented with endometriosis-related pain were enrolled with this study. Patients were randomly treated either with letrozole (2.5 mg/day) combined with oral contraceptives (Desogestrel and Ethinylestradiol Tablets) or oral contraceptives (Desogestrel and Ethinylestradiol Tablets) alone for 6 months. Changes in pain symptoms during treatment and in 1 months after treatment, 6-month follow-up and 12-month follow-up were evaluated. Adverse effects of each treatment protocol were recorded.

RESULTS

At completion of treatment, the intensity of chronic pelvic pain continued to decrease during treatment and at 1-month after treatment it was significantly lower than at 6-month follow-up and baseline level both in LE + oral contraceptives group (Mean ± SD,1.5 ± 1.4) and in oral contraceptives alone group(Mean ± SD,2.9 ± 1.2).The intensity of chronic pelvic pain and deep dyspareunia was significantly decrease at both 1-month after treatment and 6-month follow-up.

CONCLUSIONS

This treatment for endometriosis is a promising new modality that warrants further investigation.

Discontinuation rate of Implanon and its associated factors among women who ever used Implanon in Dale District, Southern Ethiopia

BACKGROUND

Early discontinuation of the Implanon contraceptive method and reasons for such discontinuation remains a major concern for family planning programs. In less developed countries, contraceptive discontinuation due to health concerns is generally higher, these complaints are often related to service quality. Significant numbers of women become exposed to conception after discontinuation and accidental pregnancies that end up with abortion & stillbirth. The aim of this study was to assess the early discontinuation rate of Implanon and identify its associated factors among women who ever used Implanon in 2016 in Dale district, Southern Ethiopia.

METHODS

Community based cross-sectional study design was conducted from January to February, 2017. A total number of 711 women who ever used Implanon in 2016 were selected using multistage sampling. The data were entered and cleaned in Epi Info and analyzed using SPSS. Multivariate logistic regression analysis was used to determine the effect of factors on the outcome variables. Finally, the results were presented using adjusted odds ratio (AOR) & confidence interval of 95%.

RESULT

Early Implanon discontinuation rate in this study was 160 (23.4%) with a mean duration of Implanon use of 9.6 ± 2.5 months. The main reasons for discontinuation of Implanon were 55 (34.4%) the facing of side effects. Factors for discontinuation of Implanon were women age 20-24 years (AOR =. 44 (95% CI: 23-. 85), 25-29 years (AOR =. 52 (95% CI: 27-. 96), 35+ years, (AOR =. 08 (95% CI: 02-. 41), less likely to discontinue. Women who weren't counseled about the side effects during Implanon insertion were 1.93 times (AOR = 1.93 (95% CI: 1.27-2.93), women who didn't satisfied by the service (AOR = 2.55(CI: 95%: 1.63-3.97), women who didn't appointed for follow up (AOR = 3.13 (CI: 95%: 2.0-4.95), women who didn't choose the method by themselves (AOR = 1.83 (CI: 95%: 1.18-2.83) and women who didn't have information on family planning before Implanon insertion (AOR = 1.52 (CI: 95%: 1.1-2.28) were the predictors of Implanon discontinuation.

CONCLUSIONS

Implanon discontinuation rate in this study area was high. Appropriate counseling prior to insertion and proper follow up, autonomous choice will improve the continuation rate of Implanon.

Oral contraceptive pills as an option for non-surgical management of retained products of conception - a preliminary study

Many Patients with persistent retained products of conception prefers to avoid surgical interventions, such as a dilatation and curettage (D&C) that might pose an additional future risk to their already compromised fertility or obstetric performance. The aim of this study was to the possibility of induced withdrawal bleeding following oral contraceptive administration as a non-surgical treatment for patients with persistent retained products of conception (RPOC). A retrospective study of patients presenting with retained products of conception (RPOC) after failed expectant management or after treatment with PGE1 was performed. Twelve women presenting with RPOC at ≤8 weeks gestation with minimal to mild vaginal bleeding and no signs of infection were treated with oral contraceptive pill (OCP) containing 0.03 mg ethinylestradiol and 0.15 mg of desogestrel for 3 weeks. Out of the 12 patients treated, nine women (75%) successfully expelled the RPOC after completing the three-week course of OCPs. The three cases (25%) that did not resolve following OCP treatment had pregnancy products with positive blood flow on Doppler examination. We conclude that OCPs may be a useful medical treatment option for persisting RPOC in selected patients with absence blood flow on Doppler examination wishing to avoid surgical intervention.

A randomised trial of a contraceptive vaginal ring in women at risk of HIV infection in Rwanda: Safety of intermittent and continuous use

Background

Contraceptive vaginal rings could play a role in expanding the contraceptive method mix and in preparing communities for the introduction of HIV prevention and multipurpose rings.

Methods

We conducted an open label single-centre randomised clinical trial of intermittent versus continuous use of NuvaRing® in Kigali, Rwanda, in 2013–2014. We randomised 120 HIV-negative women 1:1 to intermittent use (three rings with a ring-free week in between rings) or continuous use (four rings without ring-free weeks). Women underwent an interview, counselling, and a speculum examination, and were tested for pregnancy, bacterial vaginosis (BV) by Nugent scoring, yeasts and trichomonads on wet mount, and sexually transmitted infections.

Findings

Only one woman withdrew early. Deliberate ring removals were rare, but spontaneous ring expulsions occurred during 14% of ring use periods. There were no incident pregnancies, serious adverse events, serious social harms, or early discontinuations for safety reasons. Systemic side effects were uncommon, and local side effects were not significantly differently distributed between groups except for lower abdominal pain (P = 0.013). The incidence of vaginal yeasts during ring use was high: 22% of intermittent users and 27% of continuous users had incident vaginal yeasts at one or multiple ring removal visits (P = 0.666), and symptomatic vaginal yeast cases were more common in the continuous than intermittent users (P = 0.031). In contrast, mean Nugent scores improved over time in both groups.

Conclusions

Intermittent and continuous NuvaRing® use were safe in Rwandan women and improved Nugent scores over time. However, attention should be paid to ring expulsions and to a potential increased risk of vaginal candidiasis.

Current Perspectives for the use of Gonane Progesteronergic Drugs in the Treatment of Central Hypoventilation Syndromes

BACKGROUND

Central alveolar hypoventilation syndromes (CHS) encompass neurorespiratory diseases resulting from congenital or acquired neurological disorders. Hypercapnia, acidosis, and hypoxemia resulting from CHS negatively affect physiological functions and can be lifethreatening. To date, the absence of pharmacological treatment implies that the patients must receive assisted ventilation throughout their lives.

OBJECTIVE

To highlight the relevance of determining conditions in which using gonane synthetic progestins could be of potential clinical interest for the treatment of CHS.

METHODS

The mechanisms by which gonanes modulate the respiratory drive were put into the context of those established for natural progesterone and other synthetic progestins.

RESULTS

The clinical benefits of synthetic progestins to treat respiratory diseases are mixed with either positive outcomes or no improvement. A benefit for CHS patients has only recently been proposed. We incidentally observed restoration of CO2 chemosensitivity, the functional deficit of this disease, in two adult CHS women by desogestrel, a gonane progestin, used for contraception. This effect was not observed by another group, studying a single patient. These contradictory findings are probably due to the complex nature of the action of desogestrel on breathing and led us to carry out mechanistic studies in rodents. Our results show that desogestrel influences the respiratory command by modulating the GABAA and NMDA signaling in the respiratory network, medullary serotoninergic systems, and supramedullary areas.

CONCLUSION

Gonanes show promise for improving ventilation of CHS patients, although the conditions of their use need to be better understood.

LARCs as first-line contraception - What can general practitioners advise young women?

BACKGROUND

The use of long-acting reversible contraceptives (LARCs) is globally accepted as a strategy that is successful in decreasing rates of unintended pregnancy, especially in very young women. Currently, Australia has very low uptake rates of LARC.

OBJECTIVE

The aim of this paper is to explore the latest information on using LARCs as first-line contraception in young women.

DISCUSSION

Low uptake of LARCs may be related to Australia's prevailing cultural norm of oral contraception, and practitioner and patient misperceptions of the safety and efficacy of LARC, which have been dispelled in recent years. LARCs are widely recommended by professional bodies and the World Health Organization (WHO) as first-line contraception for young women as they are safe, effective and reversible. Young women should be offered the choice of a LARC as part of a fully informed decision for their first form of contraception.

Postoperative desogestrel for pelvic endometriosis-related pain: a randomized controlled trial

OBJECTIVE

To determine the effectiveness of desogestrel for relieving endometriosis-related pain.

METHODS

A double-blinded randomized placebo-controlled trial was conducted in 40 patients who had endometriosis with moderate-to-severe dysmenorrhea or chronic pelvic pain undergoing laparoscopic conservative surgery. After surgery, patients were randomized to desogestrel or placebo group. Outcomes included changes in visual analog scale (VAS) of dysmenorrhea, pelvic pain and dyspareunia, patient satisfaction, and adverse effects.

RESULTS

Forty patients were randomized to desogestrel group (n = 20) and placebo group (n = 20). At month 6, the desogestrel group had significantly lower median VAS of overall pelvic pain, dysmenorrhea and noncyclic pelvic pain. Comparing with the placebo group, the desogestrel group had greater reduction in VAS of overall pain, dysmenorrhea and pelvic pain, but comparable reduction in VAS of dyspareunia. No patient in the desogestrel group but 4 patients in the placebo group still had moderate-to-severe pelvic pain at 6 months postoperatively. The proportion of patients who rated the treatment as very satisfied was higher in the desogestrel group than in the placebo group. There was no serious adverse event during the study period.

CONCLUSIONS

Desogestrel is effective and acceptable for postoperative therapy for patients with moderate-to-severe pain related to endometriosis.

What Nurses Need to Know About Immediate Postpartum Initiation of Long-Acting Reversible Contraception

Initiation of long-acting reversible contraception (LARC) in the immediate postpartum period is becoming more common, resulting in increased requests for early removal, primarily because of unpredictable bleeding patterns. Competing interests of healthful spacing of pregnancies, impact on breastfeeding, risks associated with pregnancy versus contraceptive method, potential adverse effects of LARC, and timing of informed consent make immediate postpartum initiation of LARC an important issue. Nearly 40% of women do not attend a postpartum visit at all, resulting in decreased initiation of contraception and increased risk of unplanned pregnancy. Nurses caring for women during the peripartum period can help women make informed decisions and can provide anticipatory guidance regarding this method of contraception. Evidence-based postpartum education and support can result in women's increased continuation of and satisfaction with LARC.

Barriers to Health Care Providers' Provision of Long-Acting Reversible Contraception to Adolescent and Nulliparous Young Women

Despite recommendations for long-acting reversible contraception (LARC) as a first-line contraceptive method for adolescents and young women, its use in the United States remains low. This integrative review highlights previously unidentified barriers to health care providers' provision of LARC to adolescent and nulliparous young women. Four themes emerged: Appropriateness of Candidates and Contraceptive Safety, Provider Training and Work Setting, Appropriate Resources, and Opportunity. Raising awareness of barriers to LARC use may galvanize providers to find solutions. Nurses and other clinicians can remain aware of new contraceptive options and guidelines to reduce the risk of unintended pregnancy among adolescents.

Patients' perspectives about why they have their contraceptive Implanon NXT device removed early

BACKGROUND

Women with long-acting, reversible contraceptive devices inserted may choose to remove them prior to their planned expiry dates.

OBJECTIVE

The objective of this study was to explore Australian women's experiences with the etonogestrel subdermal contraceptive implant (Implanon NXT) and why they had it removed early.

METHODS

Semi-structured interviews were conducted with 18 women between June 2013 and January 2014. Transcriptions of the audio-taped interviews were analysed using a constant comparative analysis framework.

RESULTS

Two core themes of participants' responses that were identified in this study were influences on choice of contraception, which included convenience and information sources; and influences on removal of contraception, which included side effects and their negative impacts on relationships and financial costs.

DISCUSSION

This study highlights that women's experiences with side effects contribute to the early removal of long-acting contraceptive devices such as Implanon NXT. This study emphasises the importance of general practitioners (GPs) in providing comprehensive information about the benefits and potential side effects associated with using these implants.

Australian women's experiences of the subdermal contraceptive implant: A qualitative perspective

BACKGROUND

The number of prescriptions for contraceptive implants has steadily increased in Australia, but implant use is still low.

OBJECTIVE

The objectives of the study were to describe women's nuanced responses, and characterise their multidimensional and complex reasons for (dis)continuing use of the contraceptive implant.

METHODS

A descriptive qualitative approach was used for this study. A larger qualitative study using in-depth, open-ended interviews, conducted in New South Wales between 2012 and 2013 with 94 women aged 16-49 years who had used contraception, included 10 interviews containing accounts of implant use. The 10 interviews were analysed thematically in the present study.

RESULTS

The three main themes analysed from the 10 interviews were perceived benefits, undesirable experiences and perseverance.

DISCUSSION

The participants were well informed about the benefits of the implant. Many persevered with it for a significant period of time before discontinuing it, despite experiencing side effects such as bleeding or mood changes. A decision to discontinue was often only made after an accumulation of multiple side effects.

Interventions for hirsutism (excluding laser and photoepilation therapy alone)

BACKGROUND

Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen-sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective.

OBJECTIVES

To assess the effects of interventions (except laser and light-based therapies alone) for hirsutism.

SEARCH METHODS

We searched the Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), and five trials registers, and checked reference lists of included studies for additional trials. The last search was in June 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in hirsute women with polycystic ovary syndrome, idiopathic hirsutism, or idiopathic hyperandrogenism.

DATA COLLECTION AND ANALYSIS

Two independent authors carried out study selection, data extraction, 'Risk of bias' assessment, and analyses.

MAIN RESULTS

We included 157 studies (sample size 30 to 80) comprising 10,550 women (mean age 25 years). The majority of studies (123/157) were 'high', 30 'unclear', and four 'low' risk of bias. Lack of blinding was the most frequent source of bias. Treatment duration was six to 12 months. Forty-eight studies provided no usable or retrievable data, i.e. lack of separate data for hirsute women, conference proceedings, and losses to follow-up above 40%.Primary outcomes, 'participant-reported improvement of hirsutism' and 'change in health-related quality of life', were addressed in few studies, and adverse events in only half. In most comparisons there was insufficient evidence to determine if the number of reported adverse events differed. These included known adverse events: gastrointestinal discomfort, breast tenderness, reduced libido, dry skin (flutamide and finasteride); irregular bleeding (spironolactone); nausea, diarrhoea, bloating (metformin); hot flushes, decreased libido, vaginal dryness, headaches (gonadotropin-releasing hormone (GnRH) analogues)).Clinician's evaluation of hirsutism and change in androgen levels were addressed in most comparisons, change in body mass index (BMI) and improvement of other clinical signs of hyperandrogenism in one-third of studies.The quality of evidence was moderate to very low for most outcomes.There was low quality evidence for the effect of two oral contraceptive pills (OCPs) (ethinyl estradiol + cyproterone acetate versus ethinyl estradiol + desogestrel) on change from baseline of Ferriman-Gallwey scores. The mean difference (MD) was -1.84 (95% confidence interval (CI) -3.86 to 0.18).There was very low quality evidence that flutamide 250 mg, twice daily, reduced Ferriman-Gallwey scores more effectively than placebo (MD -7.60, 95% CI -10.53 to -4.67 and MD -7.20, 95% CI -10.15 to -4.25). Participants' evaluations in one study with 20 participants confirmed these results (risk ratio (RR) 17.00, 95% CI 1.11 to 259.87).Spironolactone 100 mg daily was more effective than placebo in reducing Ferriman-Gallwey scores (MD -7.69, 95% CI -10.12 to -5.26) (low quality evidence). It showed similar effectiveness to flutamide in two studies (MD -1.90, 95% CI -5.01 to 1.21 and MD 0.49, 95% CI -1.99 to 2.97) (very low quality evidence), as well as to finasteride in two studies (MD 1.49, 95% CI -0.58 to 3.56 and MD 0.40, 95% CI -1.18 to 1.98) (low quality evidence).Although there was very low quality evidence of a difference in reduction of Ferriman-Gallwey scores for finasteride 5 mg to 7.5 mg daily versus placebo (MD -5.73, 95% CI -6.87 to -4.58), it was unlikely it was clinically meaningful. These results were reinforced by participants' assessments (RR 2.06, 95% CI 0.99 to 4.29 and RR 11.00, 95% CI 0.69 to 175.86). However, finasteride showed inconsistent results in comparisons with other treatments, and no firm conclusions could be reached.Metformin demonstrated no benefit over placebo in reduction of Ferriman-Gallwey scores (MD 0.05, 95% CI -1.02 to 1.12), but the quality of evidence was low. Results regarding the effectiveness of GnRH analogues were inconsistent, varying from minimal to important improvements.We were unable to pool data for OCPs with cyproterone acetate 20 mg to 100 mg due to clinical and methodological heterogeneity between studies. However, addition of cyproterone acetate to OCPs provided greater reductions in Ferriman-Gallwey scores.Two studies, comparing finasteride 5 mg and spironolactone 100 mg, did not show differences in participant assessments and reduction of Ferriman-Gallwey scores (low quality evidence). Ferriman-Gallwey scores from three studies comparing flutamide versus metformin could not be pooled (I² = 62%). One study comparing flutamide 250 mg twice daily with metformin 850 mg twice daily for 12 months, which reached a higher cumulative dosage than two other studies evaluating this comparison, showed flutamide to be more effective (MD -6.30, 95% CI -9.83 to -2.77) (very low quality evidence). Data showing reductions in Ferriman-Gallwey scores could not be pooled for four studies comparing finasteride with flutamide as the results were inconsistent (I² = 67%).Studies examining effects of hypocaloric diets reported reductions in BMI, but which did not result in reductions in Ferriman-Gallwey scores. Although certain cosmetic measures are commonly used, we did not identify any relevant RCTs.

AUTHORS' CONCLUSIONS

Treatments may need to incorporate pharmacological therapies, cosmetic procedures, and psychological support. For mild hirsutism there is evidence of limited quality that OCPs are effective. Flutamide 250 mg twice daily and spironolactone 100 mg daily appeared to be effective and safe, albeit the evidence was low to very low quality. Finasteride 5 mg daily showed inconsistent results in different comparisons, therefore no firm conclusions can be made. As the side effects of antiandrogens and finasteride are well known, these should be accounted for in any clinical decision-making. There was low quality evidence that metformin was ineffective for hirsutism and although GnRH analogues showed inconsistent results in reducing hirsutism they do have significant side effects.Further research should consist of well-designed, rigorously reported, head-to-head trials examining OCPs combined with antiandrogens or 5α-reductase inhibitor against OCP monotherapy, as well as the different antiandrogens and 5α-reductase inhibitors against each other. Outcomes should be based on standardised scales of participants' assessment of treatment efficacy, with a greater emphasis on change in quality of life as a result of treatment.

Desogestrel versus danazol as preoperative treatment for hysteroscopic surgery: a prospective, randomized evaluation

The aim of this single-center, prospective, randomized, parallel-group study was to compare desogestrel and danazol as preoperative endometrial preparation for hysteroscopic surgery. We enrolled 200 consecutive eligible patients, in reproductive age, with endouterine diseases. Pre- and post-treatment characterization of endometrium was performed by hysteroscopic visual observation and histologic confirmation. The enrolled patients were randomly assigned to two groups: 100 were treated with 75 μg of desogestrel/die, 100 with 100 mg of danazol/die, both orally for 5 weeks, starting on Day 1 of menstruation. We recorded intraoperative data (cervical dilatation time, operative time, infusion volume and severity of bleeding) and drugs' side effects. Post-treatment comparison of endometrial patterns showed a significant more marked effect of desogestrel, respect to danazol, in atrophying endometrium ("normotrophic non-responders" versus "hypotrophic"-"atrophic", p = 0.031). Intraoperative data showed no significant differences between the two groups for cervical dilatation time (p = 0.160), while in the desogestrel group we found a significant reduction of operative time (p = 0.020), infusion volume (p = 0.012), and severity of bleeding (p = 0.004). Moreover, desogestrel caused less side effects (p = 0.031). According to our data analysis, desogestrel showed most marked effect in inducing endometrial atrophy, allowed a better intraoperative management and caused less side effects during treatment.

Multinational, multicentre, randomised, open-label study evaluating the impact of a 91-day extended regimen combined oral contraceptive, compared with two 28-day traditional combined oral contraceptives, on haemostatic parameters in healthy women

OBJECTIVES

To evaluate the impact of a 91-day extended regimen combined oral contraceptive (150 μg levonorgestrel [LNG]/30 μg ethinylestradiol [EE] for 84 days, followed by 10 μg EE for seven days [Treatment 1]) compared with two traditional 21/7 regimens (21 days 150 μg LNG/30 μg EE [Treatment 2] or 150 μg desogestrel [DSG]/30 μg EE [Treatment 3], both with seven days' hormone free), on several coagulation factors and thrombin formation markers.

METHODS

Randomised, open-label, parallel-group comparative study involving healthy women (18-40 years). The primary endpoint was change from baseline in prothrombin fragment 1 + 2 (F1 + 2) levels over six months.

RESULTS

A total of 187 subjects were included in the primary analysis. In all groups, mean F1 + 2 values were elevated after six months of treatment. Changes were comparable between Treatments 1 and 2 (least squares mean change: 170 pmol/L and 158 pmol/L, respectively) but noticeably larger after Treatment 3 (least squares mean change: 592 pmol/L). The haemostatic effects of Treatment 1 were comparable to those of Treatment 2 and noninferior to those of Treatment 3 (lower limit of 95% confidence interval [- 18.3 pmol/L] > - 130 pmol/L).

CONCLUSIONS

The LNG/EE regimens had similar effects on F1 + 2. Noninferiority was demonstrated between extended regimen LNG/EE and DSG/EE.

Adiponectin, interleukin-6, monocyte chemoattractant protein-1, and regional fat mass during 12-month randomized treatment with metformin and/or oral contraceptives in polycystic ovary syndrome

CONTEXT

Central obesity in polycystic ovary syndrome (PCOS) is associated with increased inflammatory markers and increased risk for type 2 diabetes.

OBJECTIVE

To evaluate if improved body composition during treatment with metformin (M) vs. oral contraceptive pills (OCP) was associated with changes in circulating adiponectin, interleukin (IL)-6, and monocyte chemoattractant protein (MCP)-1.

PATIENTS AND INTERVENTIONS

Ninety patients with PCOS were randomized to 12-month treatment with M (2 g/day), M + OCP (150 mg desogestrel + 30 microgram ethinylestradiol) or OCP. Adiponectin, IL-6, MCP-1, whole body DXA scans, and clinical evaluations were performed before and after the intervention period in the 65 study completers.

MAIN OUTCOME MEASURES

Changes in inflammatory markers and changes in total and regional fat mass estimates.

RESULTS

Adiponectin, IL-6, and MCP-1 levels were unchanged during the three types of medical intervention. Treatment with M and M + OCP was superior to OCP regarding decreased regional fat mass. Baseline adiponectin and IL-6 were associated with BMI, waist, and trunk fat mass. Changes in trunk fat were significantly associated with changes in IL-6 and MCP-1 during M + OCP.

CONCLUSIONS

Long-term treatment with M alone or in combination with OCP was associated with improved body composition compared to OCP, whereas inflammatory markers were unchanged. OCP was not associated with increased inflammatory markers despite a small but significant weight gain.

Effects of ethinyl estradiol plus desogestrel on premenstrual symptoms in Iranian women

Marvelon®, a combined oral contraceptive, contains 30 μg ethinyl estradiol (EE) and 150 μg desogestrel (DE), and has been shown to be a well-tolerated and effective combination that provides high contraceptive reliability and good cycle control. However, its efficacy has not been yet evaluated among Iranian women. Thus, the study aimed to determine the effect of oral contraceptive pill on treating premenstrual symptoms and on various parameters associated with well-being and health in a sample of Iranian. This clinical trial (before- after) study was performed at the family-planning clinic of the centers under the supervision of Tehran University of Medical Sciences on sixty-one women. The study protocol was approved by the Ethics Committee of Tehran University of Medical Sciences and all participants received a 21/7-day regimen of oral contraceptive containing 150 μg desogestrel (DE) and 30 μg ethinyl estradiol (EE) for six cycles. Efficacy parameters included changes in premenstrual symptoms were also assessed. Clinical data was collected by calendar of premenstrual experiences (COPE) at baseline and treatment cycles 1,2, 3 and 6. Clinical variables were measured including low-density lipoprotein (LDL), high-density lipoprotein (HDL) and triglyceride levels for two timing periods (baseline and last visit). Linear mixed model analyses were used to analyze differences in changes of the four factors of premenstrual syndrome (PMS), weight and blood pressure during these timing periods. The mean age of the women was 28.52 (SD=6.75) years. Participants on average had been pregnant 1.13 (SD=1.16) times. The linear mixed model analyses indicated that premenstrual syndrome symptoms reduced significantly over time (P<0.05). Marvelon® showed no significant effect on reducing LDL and HDL levels, and participant's weights were also stable during five-time assessments (P>0.05). A combined oral contraceptive containing ethinyl estradiol and desogestrel has a positive effect on women's health and reduces premenstrual symptoms.

Decidual cast after discontinuation of oral contraceptives use in a young girl

BACKGROUND

The differential diagnosis of tissue passed per vagina in a young girl includes aborted pregnancy, rhabdomyosarcoma, polyp, and very rarely decidual cast.

CASE

A 10-year-old girl using oral contraceptives for menorrhagia presented with a decidual cast after discontinuing the drug. Symptoms disappeared during clinical follow-up without any intervention.

CONCLUSIONS

Decidual cast formation is an unusual entity of unknown origin. It's generally seen during treatment with variable contraceptives. This is the first case described with desogestrel and it occurred after discontinuing treatment.

The prescribing of contraceptives for adolescents in German gynecologic practices in 2007 and 2011: a retrospective database analysis

OBJECTIVE

To investigate the prescribing trend of contraceptives in adolescent girls aged 12-18 years and to compare prescribing patterns of the most frequently used contraceptives among this population in Germany in 2007 and 2011.

METHODS

A retrospective cohort study was conducted to analyze contraceptive prescriptions written by gynecologists in 2007 and 2011 in Germany by using the IMS Disease Analyzer database (IMS HEALTH). All adolescent girls aged 12-18 years with at least 1 prescription of a contraceptive drug in 2007 or 2011 were identified. The prevalence of contraceptive prescriptions was calculated and the types of contraceptive substances prescribed were examined.

RESULTS

A total of 21,026 teenage girls in 2007 and 18,969 in 2011 received contraceptive prescriptions. The prevalence of contraceptive prescribing rose significantly between 2007 and 2011 (P < .001). The percentage of teen girls who received prescriptions of levonorgestrel and chlormadinone pills was significantly higher in 2011 compared to 2007 (P < .001). However, the portion of contraceptive pills containing drospirenone or desogestrel significantly decreased in 2011 compared to 2007 (P < .01).

CONCLUSION

There was a significant increase in contraceptive prescription usage among adolescent girls between 2007 and 2011 in Germany. However, the prescription behavior of doctors also changed; they consequently prescribed contraceptives with more evidence. Further research is needed to better understand the various factors associated with contraceptive use among this population.

First intention IVF protocol for polycystic ovaries: does oral contraceptive pill pretreatment influence COH outcome?

BACKGROUND

Morphological aspect of polycystic ovaries (PCO) is a very common finding in an IVF center population: this includes PCOS patients identified in 18-25% of the couples presenting with infertility and so called "sonographic PCO only" the prevalence of which has been estimated as high as 33% in asymptomatic patients. Finding the optimal first intention IVF protocol for polycystic ovaries patients is still challenging in order to improve the controlled ovarian hyperstimulation (COH) outcome while avoiding ovarian hyperstimulation syndrome (OHSS). It has been suggested that women with PCO would benefit from a longer period of pituitary down-regulation. The purpose of this study was to compare an extended duration of OCP pretreatment with a classic GnRH agonist protocol.

METHODS

A single center prospective non-randomized study was performed from January 2009 to December 2010 in the Lille University Hospital including 113 women diagnosed with PCO(S) according to the Rotterdam ultrasonographic criteria and undergoing their first IVF attempt. Comprehensive hormonal and ultra-sonographic assessments were collected during COH in these patients. LH and androgen suppression and dynamics of follicular growth were compared between the two protocols as well as the COH outcome in terms of oocyte/embryo number and quality, implantation and pregnancy rates.

RESULTS

No significant difference was observed between the two groups concerning dynamics of follicular growth and hormonal values. Clinical and ongoing pregnancy rates were significantly lower in the OCP group despite same oocyte and embryo quality. Nevertheless, the cumulative pregnancy rate did not differ between the two groups. The incidence of OHSS was not statistically significant.

CONCLUSIONS

Extended duration of OCP pretreatment, as a first intention IVF protocol for PCO patients, does not improve the pattern of follicular growth nor the oocyte and embryo quality.

Endometrial preparation with desogestrel before Essure hysteroscopic sterilization: preliminary study

STUDY OBJECTIVE

To assess the effect of desogestrel on endometrial preparation for transcervical sterilization using the Essure device.

DESIGN

Prospective nonrandomized clinical study (Canadian Task Force classification II-3).

SETTING

Acute-care university-affiliated hospital in Barcelona, Spain.

PATIENTS

Women undergoing sterilization using the Essure device between January 2010 and January 2011.

INTERVENTIONS

Participants were offered desogestrel, 75 μg/d, for 6 weeks before the procedure. Sixteen who accepted were included in the desogestrel group, and 18 who refused were allocated to the no-treatment group. Endometrial biopsy samples were also obtained.

MEASUREMENTS AND MAIN RESULTS

In women who received desogestrel, decidual transformation was observed in eight, glandular atrophy in three, and proliferative endometrium in five. In the no-treatment group, two women had menstruation, nine had proliferative endometrium, and seven had secretory endometrium. In the desogestrel group, the procedure was successful in all women. In the no-treatment group, the procedure was cancelled in two women because of menstruation and in four women with secretory endometrium in whom the tubal ostia were difficult to visualize because of endometrial thickness and bleeding. The median (interquartile range, 25th-75th percentile) duration of the procedure was shorter in the desogestrel group than in the no-treatment group (7 [6-7] minutes vs 8 [7-12] minutes; p = .002).

CONCLUSION

Desogestrel, 75 μg/d, could be an alternative to combined hormonal contraception before placement of Essure inserts, facilitating the procedure and serving as a contraceptive method during the following 12 weeks until occlusion of the tubes.

[Efficacy and safety of GnRH-a combine with laparoscope conservative surgery in the treatment of the moderate or severe endometriosis]

OBJECTIVE

To study the efficacy and safety of Gonadotropin-releasing hormone agonists (GnRH-a) combined with laparoscope conservative surgery in treatment of moderate or severe endometriosis.

METHODS

From Jan. 2007 to Jan. 2010, 68 patients with moderate or severe undergoing treatment in Renmin Hospital of Wuhan University were enrolled in this retrospective study. Three groups were classified, which were 25 patients in GnRH-a group, subcutaneous injection Leuprorelin on the second day of menstruation, every 4 weeks for 3 months. Twenty-three patients in Marvelon group, orally one marvelon tablet on the second day of menstruation, continuous 21 days for one period of treatment for 3 courses. Twenty patients in surgery group, without any medicine used preoperatively. All patients were followed by 12 months and compare their surgery time, blood loss, recovery, visual analog scale (VAS), and recurrence and so on.

RESULTS

The operating time were (68 ± 18) min in GnRH-a group, (80 ± 21) min in Marvelon group and (90 ± 24) min in surgery group. The amount of bleeding were (118 ± 15) ml in GnRh-a group, (161 ± 18) ml in Marvelon group and (193 ± 13) ml in surgery group. There was significant lower in the operating time and amount of bleeding in GnRH-a group than those in other two groups (P < 0.05). The activity time and the anus exhaust time were shorter in patients in GnRh-a group than those in the other two groups significantly (P < 0.05). When followed up in 12 months after treatment, visual analogue scale had dropped from 3.8 (1.9 - 6.8) to 1.9 (1.1 - 2.8) in GnRh-a group, from 2.7 (1.3 - 5.5) to 1.8 (1.2 - 3.2) in Marvelon group and from 1.9 (1.0 - 4.9) to 1.6 (1.0 - 3.6) in surgery group. It was showed the most remarkable decreased VAS in GnRHa group when compared with the other two groups (P < 0.05). The recurrence rates were 12% (3/25) in GnRH-a group, 22% (5/23)in Marvelon group and 25% (5/25) in surgery group. It was found that the most significant lower recurrence was in GnRH-a group when compared with the other two groups (P < 0.05).

CONCLUSIONS

It was safe and efficacy that GnRH-a combined with laparoscopic conservative surgery were used in treatment of endometriosis. It could bring shorter operation time, less intraoperative blood loss, quick postoperative recover, the lower recurrence rate.

Improving the prognosis ways of central genesis and management option in infertile women

To study central genesis of disfunctional menstrual disorders was based particulary on electroencephalography and find out efficacy of pathogenetic management in infertile women with central forms of oligomenorrhoea and amenorrhoea compared to generally accepted hormone therapy. Depending on received management, all 159 patients were divided into two groups. Group I included 93 women with infertility and menstrual disorders treated by taking into account the found cerebral dysfunction. Group II included 66 women received generally accepted hormone therapy. 26 women belonged to group I were found to have regulated menstrual cyclicity (28%) after neuro-mediatorical management with tegretol, finlepsin, cinnarizin, phenazepam,- received during 3-6 months. In group II, in 3 women (4.5%) was obtained improvement and period became regular by using hormone treatment, included Diane-35, Tri-Regol, Marvelon subsequently by generally accepted way during long lasting courses (12 months- more than 1 year). Pregnancy occurred in 17 cases in group I (18.3%). The difference was significantly higher in this group in comparison with group II, where pregnancy was attained only in 3 women (4.5%). Our findings indicate that in the basis of menstrual disorders observed in 159 infertile women were stood dysfunctional changes of central regular mechanisms. Pathogenetic therapy showed that we have taken into consideration neuro-mediatorical correction of found central nervous system level dysfunction. By this way our study reveals significant success of management with neuro-mediatorical purpose compared to the generally accepted hormone therapy.

Nexplanon: the new implant for long-term contraception. A comprehensive descriptive review

Nexplanon(®) is a new long-term reversible contraception method. The current review is aimed to analyze the published data concerning the contraceptive effectiveness of Nexplanon(®) and its effects on reproductive function. Pharmacological properties and technical procedures of insertion and removal, as well as the efficacy and safety data available, were discussed. Possible strategies for treating Nexplanon(®)-related bleeding were also described. With regard to the future research and the future scientific developments of contraceptive implants, the possible use of Nexplanon(®) wide-ranging for the symptomatic treatment of endometriosis and premenstrual syndrome (PMS) were considered. Finally, it was defined in which women the use of Nexplanon(®) is indicated and in which it is contra-indicated.

[Effects of taking estrogen and progestogen after medical abortion on reducing vaginal hemorrhage time: a randomized-controlled trial]

OBJECTIVE

To compare the different effects of taking different kinds and doses of estrogen and progestogen after medical abortion on reducing vaginal hemorrhage time.

METHODS

A total of 188 women undergoing medical abortion were recruited and randomized into 3 groups: group A (n = 41) starting marvelon (30 µg ethinylestradiol and 150 µg desogestrel) on the day of abortion for 21 days; group B (n = 53) starting progynova 2 mg/d on the day of abortion for 21 days and taking depogesterone 10 mg/d on the last 5 days; and group C (n = 94) as control. The vaginal hemorrhage time, days to onset of next menses and the outcome of medical abortion were compared.

RESULTS

There was no significant difference in the duration of hemorrhage between groups A and C [(20 ± 13) vs (19 ± 11) d, P > 0.05]. But the duration of hemorrhage in group B was significantly shorter than that in group C [(14 ± 7) vs (19 ± 11) d, P < 0.01]. There was no significant difference in the amount of hemorrhage among 3 groups (P > 0.05). The time to onset of first menses was similar between groups A and B [(34 ± 13) vs (30 ± 7) d]. And both were significantly shorter than that in group C [(39 ± 11) d, P < 0.05]. There were 3 (7.32%) incomplete abortions in group A, 4 (7.55%) in group B and 12 (12.77%) in group C (P > 0.05).

CONCLUSION

The sequential therapy of estrogen and progestogen after medical abortion may effectively reduce the duration of hemorrhage. And the combined oral contraceptive pills fail to significantly alter the duration of hemorrhage after medical abortion. But both can promote menstrual recovery significantly.

Risk of venous thromboembolism from use of oral contraceptives containing different progestogens and oestrogen doses: Danish cohort study, 2001-9

OBJECTIVE

To assess the risk of venous thromboembolism from use of combined oral contraceptives according to progestogen type and oestrogen dose.

DESIGN

National historical registry based cohort study.

SETTING

Four registries in Denmark.

PARTICIPANTS

Non-pregnant Danish women aged 15-49 with no history of thrombotic disease and followed from January 2001 to December 2009.

MAIN OUTCOME MEASURES

Relative and absolute risks of first time venous thromboembolism.

RESULTS

Within 8,010,290 women years of observation, 4307 first ever venous thromboembolic events were recorded and 4246 included, among which 2847 (67%) events were confirmed as certain. Compared with non-users of hormonal contraception, the relative risk of confirmed venous thromboembolism in users of oral contraceptives containing 30-40 µg ethinylestradiol with levonorgestrel was 2.9 (95% confidence interval 2.2 to 3.8), with desogestrel was 6.6 (5.6 to 7.8), with gestodene was 6.2 (5.6 to 7.0), and with drospirenone was 6.4 (5.4 to 7.5). With users of oral contraceptives with levonorgestrel as reference and after adjusting for length of use, the rate ratio of confirmed venous thromboembolism for users of oral contraceptives with desogestrel was 2.2 (1.7 to 3.0), with gestodene was 2.1 (1.6 to 2.8), and with drospirenone was 2.1 (1.6 to 2.8). The risk of confirmed venous thromboembolism was not increased with use of progestogen only pills or hormone releasing intrauterine devices. If oral contraceptives with desogestrel, gestodene, or drospirenone are anticipated to increase the risk of venous thromboembolism sixfold and those with levonorgestrel threefold, and the absolute risk of venous thromboembolism in current users of the former group is on average 10 per 10,000 women years, then 2000 women would need to shift from using oral contraceptives with desogestrel, gestodene, or drospirenone to those with levonorgestrel to prevent one event of venous thromboembolism in one year.

CONCLUSION

After adjustment for length of use, users of oral contraceptives with desogestrel, gestodene, or drospirenone were at least at twice the risk of venous thromboembolism compared with users of oral contraceptives with levonorgestrel.

Indications for removal of etonogestrel implant within two years of use in Jos, Nigeria

BACKGROUND

Implanon is a new long-term and reversible sub-dermal contraceptive implant in Nigeria. It is a single rod containing 68mg of etonogestrel meant to offer contraception for three years and marketed by Organon.

OBJECTIVE

To determine the indications for removal of Implanon rods from clients within a two-year period.

DESIGN

A retrospective review of 30 consecutive Implanon removals within the study period.

SETTING

The fertility regulation unit of the department of obstetrics and gynaecology of the Jos University Teaching Hospital, North-Central Nigeria.

RESULTS

A total of 30 clients requested for and had their Implanon rods removed out of 669 insertions constituting 95.5% crude continuation rate in the second year. The clients were of mean age 31.4 +/- 6.2 years, mean parity 2.9 +/- 1.8 and mean number of living children 2.7 +/- 1.6. There was an average weight gain of 1.9 kg. The most common indication for removal was menstrual disruption (33.3%). Desire for another pregnancy closely followed (30.0%). Weight gain was another indication for discontinuation (13.3%). Two women were pregnant at insertion of the implant. There was one failure of the method with pregnancy as a result. Spousal disapproval was an indication for removal in two cases.

CONCLUSION

Like all progestin-only contraceptive methods, menstrual disruption was the most common indication for removal of implants. Inadvertent insertion of implants with existing pregnancy is of concern and should be avoided as much as is possible. In doubtful cases at insertion, this insertion should be deferred or serum beta-HCG should be assessed to exclude chemical pregnancy.

[Evolution and future of contraception]

In order to meet the need for efficacious and safe contraception, contraceptives are in continuous evolution. Among oral contraceptives evolution has brought reduction of ethynylestradiol doses, up to change the estrogenic molecule to natural estradiol. In order to individualize contraception, numerous different progestin molecules have been developed and are being tested. Individualization has also brought at developing new schedules for contraceptive administration, and different routes of administration. Important developments have appeared on parenteral hormonal contraception, such as the intravaginal, subdermal, transdermal or injectable contraception. Intrauterine devices are being developed, becoming smaller, easier to insert, and sometimes capable to locally release progestins. New spermicides, that are capable to protect from sexually transmitted disease, are also being developed. Emergency contraception has evolved in a safer and more acceptable hormonal contraception. Recent introduction of molecules modulating progesterone receptors, seem to bring additional advantages by increasing the efficacy and extending the window of efficacy of emergency contraception.

The role of combined oral contraceptives in the management of acne and seborrhea

Acne and seborrhea (or facial oiliness) are related androgenic skin disorders which affect a high proportion of women after menarche. They can have a negative effect on psychological well-being and social life. Androgens play an important role in the pathogenesis of acne through the stimulation of sebum secretion, increasing sebaceous gland size and possibly through follicular hyperkeratinization. Conversely, estrogens decrease sebum production by suppressing gonadotropin release and androgen production and increasing sex hormone binding globulin production. One of the treatment options for these conditions is hormonal therapy, especially for women who require contraception. The effect of combined oral contraceptives in androgenic skin disorders depends on their estrogen:progestogen balance and on the antiestrogenic activity of the progestogen component. Improved understanding of what women value about oral contraceptives suggests that the choice of product should be tailored as much as possible to the individual. Several combined oral contraceptives containing new-generation progestogens (e.g. desogestrel, gestodene) or progestational antiandrogens (e.g. cyproterone acetate, chlormadinone acetate) have demonstrated efficacy in the treatment of women with acne, although comparisons between trials are difficult because of differing endpoints. Seborrhea has been less well studied, but the few studies that are available show an improvement in women with this condition using combined oral contraceptives.

Clinical experience with NuvaRing® in daily practice in Switzerland: Cycle control and acceptability among women of all reproductive ages

OBJECTIVES

To assess clinical experience with NuvaRing in daily practice in Switzerland, including a large subgroup of young women (aged < or = 22 years).

METHODS

Open, prospective, multicentre, observational clinical experience study to investigate cycle control, acceptability and usage of NuvaRing.

RESULTS

Altogether, 2642 women participated in the programme and were included in the analysis, of which 658 were aged < or = 22 years (25% of the total group). A total of 744 women (28% of the total group) discontinued NuvaRing use; the main reason was adverse events (11% of all users). In younger women, there was a shift from moderate (-18%) and heavy (-45%) bleeding to mild bleeding (+71%) and dysmenorrhoea decreased by 60%, despite previous hormonal contraception use by 83% of women. Most women found ring insertion and removal to be straightforward (>95%), and were satisfied with its use (85%), primarily for the ring's once-a-month application (81%). Data were very similar for the total group. Cycle control and satisfaction were further improved with duration of treatment.

CONCLUSIONS

In daily practice, NuvaRing improved cycle control and was highly acceptable to women, including young women. Switchers from other hormonal methods also showed improved cycle control and high satisfaction.

The effect of a phasic oral contraceptive containing Desogestrel on seborrhea and acne

OBJECTIVE

To investigate the effect of an oral contraceptive (Novial) on facial seborrhea and moderate acne.

METHODS

In this nonrandomized, group-comparative trial, women aged between 18 and 30 with seborrhea were enrolled. Women used either a phasic oral contraceptive containing ethinylestradiol (35/30/30 microg) and Desogestrel (50/100/150 microg (DSG-OC)) (n = 177) or no hormonal treatment (control group; n = 77) for four cycles.

RESULTS

Overall, 161 subjects (90.9%) in the DSG-OC group and 73 subjects (94.4%) in the control group completed the study. In the DSG-OC group, the total score for sebum excretion decreased by 0.71 nL/cm(2) (95% CI 0.36-1.05). In the control group, sebum excretion increased by 0.05 nL/cm(2) (-0.55 to 0.46). The difference between groups (0.78 nL/cm(2) (0.19-1.36)) was statistically significant (P = 0.010). The number of active follicles/cm(2) decreased by 0.86 (0.44-1.28) and 0.08 (-0.53 to 0.69), respectively (P = 0.029). The difference in qualitative scores between the groups (0.93 (0.08-1.78)) was statistically significant ( P = 0.032). Overall, 19.3% of the subjects reported an AE (18.1% in the DSG-OC group, 22.1% in the control group).

CONCLUSION

Novial effectively reduces seborrhea after only four cycles of treatment and may be a suitable oral contraceptive for women wishing to improve their facial skin condition.

The combined contraceptive vaginal device (NuvaRing®): A comprehensive review

OBJECTIVES

The aim of this study is to review the development of NuvaRing over the past decade to illustrate its use-effectiveness and acceptance as an alternative contraceptive option for women.

METHODS

The data were extracted from the literature using computerised MEDLINE system. NuvaRing is a new combined hormonal contraceptive vaginal ring made of ethylene-vinyl-acetate copolymer, releasing 120 microg etonorgestrel and 15 microg ethinyloestradiol per day. This ring is inserted on any day from day 1 to day 5 of a menstrual cycle for 21 days, thereafter removed for 7 days ring-free period and discarded.

RESULTS

Complete inhibition of ovulation is observed during treatment with this device. Clinical exposure to NuvaRing for 1786 women-years has resulted in 21 pregnancies, giving a Pearl Index of 1.18. Withdrawal bleeding (4.7-5.3 days) is regular (97-99% of cycles) with rare incidence of irregular bleeding (2.6-6.4%). The cycle control is good with the use of this combined contraceptive vaginal ring. NuvaRing is well tolerated and accepted by women as compared to oral pill.

CONCLUSIONS

NuvaRing is an effective vaginal contraceptive option for women. However, further study is needed for monitoring its long-term effectiveness and impact on patient's quality of life since the NuvaRing is marketed in many countries.

Treatment of premenstrual syndrome with the desogestrel-only pill (Cerazette) in an adolescent girl

BACKGROUND

Premenstrual syndrome has been recognized as an important problem in adolescent gynecology.

CASE

We here report the treatment of a 13-year-old girl with premenstrual syndrome who had a strong family history of thrombophilia. In this case the combined pill was contraindicated and the use of other pharmacological treatments, such as selective serotonin uptake inhibitors, was considered inappropriate for adolescents. We suggested the use of the desogestrel-only pill, because it is known to suppress ovulation. The outcome was good, with the patient being symptom-free in the follow-up visit, three months later.

SUMMARY AND CONCLUSION

We hope that this report will add another therapeutic option for premenstrual syndrome in teenagers and will be useful in further studies on the treatment of this condition in adolescence.

Etonogestrel implant as a contraceptive choice; patient acceptability and adverse effect profile in a general practice setting

The aim of this study was to evaluate the experience of a cohort of patients utilizing the etonogestrel implant (Implanon) in an Irish General Practice setting. This study involved a survey administered as a telephone questionnaire, to a cohort of women (n=75) who opted to use the etonogestrel implant. 53% reported problems with the implant post insertion, the commonest problem being irregular bleeding in 22% cases. Early removals were documented in 28% cases, of which, 29%, were caused by irregular bleeding. Based on this study, it is evident that women have high expectations of the implant, and counselling about what they can expect during use is important in order to avoid unreasonable expectations. This study also demonstrates that the use of the etonogestrel implant is a valuable contraceptive option, which can be successfully delivered in a GP setting, for both patients of the practice as well as patients referred by colleagues locally.

[NuvaRing-combined contraceptive vaginal ring: state of art in 2008. Expert Board of Polish Gynecological Society]

The development of steroid-releasing vaginal rings over the past three decades is reviewed to illustrate the role of this device as an effective hormonal contraceptive for women. NuvaRing is a combined contraceptive vaginal ring that releases constant low doses of ethinylestradiol and etonogestrel. The soft flexible combined ring is inserted in the vagina for three weeks and removed for seven days to allow withdrawal bleeding with no serious side-effects. Maximum levels of EE and ENG with NuvaRing were 30% and 40%, respectively, of those seen with the COC. Because ENG bioavailability was higher following vaginal administration, the systemic progestogen exposures were comparable with the oral contraceptives. NuvaRing has been shown to be safe and effective, with high levels of user compliance, acceptance and patient satisfaction.

Side effects and acceptability of Implanon: a pilot study conducted in eastern Turkey

OBJECTIVE

To assess side effects during the first 6 months of use of Implanon.

DESIGN AND METHODS

The study was conducted in eastern Turkey between June 2004 and May 2005. Forty-one healthy women, aged 18-40 years who chose to use Implanon participated in the study. The implant was inserted between days 1 and 5 of the menstrual cycle. Findings were recorded before and during 6 months following insertion. Statistical analyses were performed using SPSS package programme including paired samples t-test.

RESULTS

No pregnancy occurred during the study. Ninety days after initiation of therapy, three of the 41 patients (7.3%) had regular periods, 14 (34.1%) were amenorrhoeic and the remaining 24 (58.5%) had some type of abnormal bleeding. Dysmenorrhoea affected significantly less women (1/41, i.e. 2.4%) than before treatment (17/41, i.e. 41.5%), but mastalgia increased significantly as it was reported by five previously unaffected participants (12.2%). Mood changes appeared in seven patients (17.1%) and acne in 11 of them (26.8%). The circulating levels of protein C, total cholesterol and oestradiol dropped significantly. Endometrial thickness decreased significantly. At completion of the study period, removal of the implant was requested by eight of the 41 patients (19.5%) because of irregular bleeding (six women), depressive symptoms requiring treatment (one woman) or weight gain (one woman).

CONCLUSIONS

Mainly because of irregular bleeding, the discontinuation rate of Implanon at 6 months among the women in this region is high (19.5%).

Use of the NuvaRing hormone-releasing system in late reproductive-age women with type 1 diabetes mellitus

AIM

To evaluate the effect of the vaginally inserted hormone-releasing system NuvaRing on carbohydrate and lipid metabolism and the hemostasis system, over 6 months of use, in late reproductive-age women with type 1 diabetes mellitus (DM).

METHODS

The open randomized study included a total of 25 women with type 1 DM using NuvaRing. Average daily insulin requirements, levels of glycosylated hemoglobin (HbA1c), total cholesterol, triglycerides, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol, the state of coagulation hemostatis and fibrinolytic activity were determined at baseline and after 3 and 6 months of contraception. The control group was composed of 20 age-matched women with type 1 DM using no methods of contraception, as well as 20 apparently healthy women using the NuvaRing device.

RESULTS

Use of the NuvaRing contraceptive system in type 1 DM women in the late reproductive period was shown to exert no clinically significant effect on carbohydrate and lipid metabolism on the background of persistent and satisfactory compensation of carbohydrate metabolism (HbA1c < or = 7.5%), with a neutral impact on the hemostasis system.

CONCLUSION

The NuvaRing hormone-releasing system proved to be a reliable and safe means of contraception for late reproductive-age women with type 1 DM.