Emergency contraception, a method whose time has come: an update.

Unplanned pregnancy is a major public health problem in the United States. Emergency contraception has the potential to significantly decrease the incidence. The Yuzpe regimen is highly effective but woefully underutilized. Mechanisms of action of hormonal emergency contraception will be discussed as well as appropriate indications for use, patient counseling issues, and future methods.

PIP: Unplanned pregnancy is a major public health problem in the United States. Emergency contraception has the potential to significantly decrease the incidence. The Yuzpe regimen is highly effective but woefully underutilized. Mechanisms of action of hormonal emergency contraception will be discussed as well as appropriate indications for use, patient counseling issues, and future methods. The Yuzpe regimen is a safe and effective postcoital contraceptive. It succeeds in preventing pregnancy in 98% of cases when used correctly. The Yuzpe regimen consists of taking 2 oral contraceptive (OC) pills containing 0.05 mg ethinyl estradiol (EE) and 0.5 mg norgestrel (Ovral) within 72 hours after unprotected intercourse and repeated once 12 hours later. Other brand name OCs that can be used include LoOvral, Nordette, Levlen and the yellow pills only of Triphasil and Tri-Levlen (each of these yellow pills contains 0.03 mg EE and 0.15 mg levonorgestrel). Since unintended pregnancy still occurs at high levels in the US, increased use of emergency contraception could reduce the unintended pregnancy rate. The current US unintended pregnancy rate is a great public health problem. Improved availability, more extensive prospective discussion, and greater utilization of emergency contraception could play significant roles in preventing unplanned and unwanted pregnancies. More extensive use of emergency contraception could decrease the number of elective abortions performed annually. Health providers should include emergency contraception into their regular reproductive health care discussions and counseling with patients. Possible future methods of emergency contraception include other progestin-containing OCs, levonorgestrel alone, and pristone. The US Food and Drug Administration does not approve of the OCs used in the Yuzpe regimen for emergency contraception purposes. The cost and effort for new drug application and the unlikelihood of respectable profits probably explain why pharmaceutical manufacturers have not submitted emergency contraception for approval for use.

The prevalence of positive test results for Chlamydia trachomatis by direct smear for fluorescent antibodies in a south Texas family planning population.

Chlamydia trachomatis is a major human genital pathogen implicated as a leading cause of involuntary infertility in women. To assess the prevalence of results positive for C trachomatis by a direct immunofluorescent test in a family planning population, mass screening of all patients attending five urban family planning clinics was conducted for a two-month period. The objectives of this study were to assess the prevalence of positive C trachomatis test results in this population and to evaluate the commonly accepted demographic/behavioral risk factors reported in previous studies. A total of 2,761 subjects were tested using the MicroTrak collection kit. The subjects ranged in age from 12 to 69 years. The overall rate of positive test results was 10.5%. Significant associations between C trachomatis test results and the following variables were observed: race/ethnicity, age, marital status, existence of multiple partners and positive gonorrhea tests. Chlamydial infection was not significantly associated with income, pregnancy, current contraceptive method or age at first intercourse. While the results of the study indicated both agreement and disagreement with other clinical investigations, the fact that 10.5% of a largely asymptomatic population exhibited chlamydial infection has major implications for the management of women's reproductive health care.

Hospitalization for tubal sterilization.

PIP: The article by Peter M. Layde, M.D., et. al (1981;245:714) warrants further comment and an update on the subject. Substantial reductions in the length of stay (LOS) after sexual tubal sterilization (STS) have been achieved in the past 5 years since those described by Layde et. al. Many contemporary facilities have now settled on a stay of 4-6 hours postoperatively, in fact, as the standard. In achieving this, the laparoscope was but 1 of the technical innovations contributing to the reduction, and other important changes were in progress over the last 10 years which brought the short LOS about. Favorable experience with STS by family planners in India and Southeast Asia during the early 1970s performed in freestanding clinics and tubectomy camps used little or no analgesia or anesthesia, and minimal postoperative supervision was needed for safe recovery. Later, Lubell and Frischer demonstrated that the concept of short stay was equally as safe and applicable in this country. Moreover, consumer demands for same-day surgery gave further impetus to this new trend. Additionally, because of economic motivations, 3rd party payers added further pressure toward the reduction in postoperative stay. Our personal experience with more than 500 patients undergoing vaginal tubal sterilizations performed under general anesthesia have proved the safety and utility of the short-stay approach to STS, regardless of the technology or methodology applied. No doubt when LOS statistics become available for STS in this country between 1975-9, enormous additional reductions in hospital time and monetary expenditures will be appreciated. Using the Association for Voluntary Sterilization estimate of 4 million women undergoing STS from 1976-9, and the reduction of the average LOS from 4 nights to no overnight stay, an impressive $160 million could be added to the estimate by Layde et. al of $200 million savings over the pre-1970 procedures. Finally, we take exception with the concept of "strike while the iron is hot" as it relates to the timing of STS. While it is inevitable that STS will continue to be requested and performed immediately after vaginal or cesarean births, this is probably the worst possible timing. The risk of complications, failure, or subsequent regret of having been sterilized is highest at that time. Day surgery makes interval STS cost-efficient and more readily acceptable to the sterilization candidate, and thus avoids those problems associated with puerperal sterilization.^ieng

Useful technique for long-term urinary drainage by inlying ureteral stent. Six-year experience.

Endoscopically placed inlying ureteral stents have proved useful in the conservative management of patients with ureteral obstruction, urinary fistula, and malignancy and have obviated the need for operative intervention. In high-risk symptomatic patients with widespread malignancy, internal urinary diversion offers the opportunity for an improved quality of life without the surgical risk or potential morbidity of supravesical diversion. Potential candidates for this simple, safe, and effective technique include: those with postsurgical obstruction and/or fistula, retroperitoneal fibrosis, metastatic carcinoma, congenital ureteropelvic junction obstruction, as well as those with reversible obstruction from lymphoma and carcinoma of the prostate who are undergoing radiotherapy and/or chemotherapy. The focus of this report is on the technique we have found successful in providing us with stents that fit our individual patients. Readily available fabricated graduated ureteral catheter can be cut and shaped to particular measurements unlike prefabricated catheters. Minimal preparation time is demanded, and there is no need for extensive stocking of various catheter sizes.