Combined oral contraceptives: update recommendations of the Latin American contraceptive association.

Background: In recent years, new combined oral contraceptives (COCs) have become available, representing an advance in terms of individualization and compliance by users.Objective: To provide recommendations regarding COCs: formulations, use, efficacy, benefits and safety.Method: For these recommendations, we have used the modified Delphi methodology and carried out a systematic review of studies found in the literature and reviews performed in humans, published in English and Spanish in Pubmed, Medline and advanced medicine and computer networks until the year 2021, using the combination of terms: 'oral contraceptives', 'estroprogestins' and 'combined oral contraceptives'.Results: Regarding the estrogen component, initially switching from mestranol (the pro-drug of ethinylestradiol) to ethinylestradiol (EE) and then reducing the EE dose helped reduce side effects and associated adverse events. Natural estradiol and estradiol valerate are already available and represent a valid alternative to EE. The use of more potent 19-nortestosterone-derived progestins, in order to lower the dose and then the appearance of non-androgenic progestins with different endocrine and metabolic characteristics, has made it possible to individualize the prescription of COC according to the profile of each woman.Conclusion: Advances in the provision of new COCs have improved the risk/benefit ratio by increasing benefits and reducing risks. Currently, the challenge is to tailor contraceptives to individual needs in terms of safety, efficacy, and protection of female reproductive health.

Vitamin D supplementation: position Statement of the Iberoamerican Society of Osteoporosis and Mineral Metabolism (SIBOMM).

BACKGROUND: Vitamin D (VD) deficiency is a global pandemic that affects more than a third of the population worldwide. The population of Latin America and the Caribbean exceeds 620 million inhabitants with diverse ethnic origins and different latitudes and altitudes, which make comparisons and generalizations difficult. AIM AND METHOD: We sought to establish an expert consensus regarding the recommendations for VD supplementation in Latin America by means of the Delphi methodology. RESULTS: The prophylactic dosage of VD in the general population should be individualized according to age, race, body weight, sun exposure of an individual, altitude, and dietary and exercise habits, without ruling out existing chronic diseases. CONCLUSION: The importance of VD has been widely documented and its deficiency is a pandemic. Many individuals have difficulty meeting daily VD requirements through food and the sun. The population of Latin America and the Caribbean has diverse ethnics, cultures, in addition to living in different latitudes and altitudes. Therefore, it is important to make a position on VD supplementation, given the different characteristics, ages and serum levels of 25(OH)D.

Contraception and reproductive planning during the COVID-19 pandemic.

INTRODUCTION: The coronavirus disease (COVID-19) is a global health emergency. Major disruption to healthcare services during the current COVID-19 pandemic will last even after its peak. Sexual and reproductive health (SRH), specially contraception, needs to be understood as an essential service. AREAS COVERED: This paper is a narrative review. Data from PubMed/MEDLINE, Scopus, and websites of scientific societies were screened during the months of April and May 2020. It addresses the main aspects related to contraception during the COVID-19 pandemic, with special emphasis on family planning services, extended use of long-acting reversible contraceptive (LARC) methods, drug interactions, and thromboembolism risk. We also specified some issues focused on the Brazilian reality. EXPERT OPINION: Ensuring proper contraception use in the COVID-19 time is very important. We encourage women, healthcare providers, policymakers, and the society to consider SRH services as priority.

An individualized approach to the management of vaginal atrophy in Latin America.

OBJECTIVE: In the absence of guidelines specific for Latin America, a region where the impact of menopause is becoming increasingly important, an evidence-based specialist opinion on management of vaginal atrophy will help improve outcomes. METHODS: An advisory board meeting was convened in São Paulo, Brazil, to discuss practical recommendations for managing vaginal atrophy in women in Latin America. Before the meeting, physicians considered various aspects of the condition, summarizing information accordingly. This information was discussed during the meeting. The expert consensus is now summarized. RESULTS: In Latin America, given the relatively early age of menopause, it will be beneficial to raise awareness of vaginal atrophy among women before they enter menopause, considering cultural attitudes and involving partners as appropriate. Women should be advised about lifestyle modifications, including attention to genital hygiene, clothing, and sexual activity, and encouraged to seek help as soon as they experience vaginal discomfort. Although treatment can be started at any time, prompt treatment is preferable. A range of treatments is available. By addressing the underlying pathology, local estrogen therapy can provide effective symptom relief, with choice of preparation guided by patient preference. An individualized treatment approach should be considered, giving attention to patients' specific situations. CONCLUSIONS: It is critical that women are empowered to understand vaginal atrophy. Educating women and healthcare providers to engage in open dialogue will facilitate appreciation of the benefits and means of maintaining urogenital health, helping to improve outcomes in middle age and beyond. Women should receive this education before menopause.

Effects of a combined oral contraceptive containing 20 mcg of ethinylestradiol and 3 mg of drospirenone on the blood pressure, renin-angiotensin-aldosterone system, insulin resistance, and androgenic profile of healthy young women.

Combined oral contraceptives (COCs) may increase the risk for cardiovascular disease depending on the ethynyl estradiol (EE) dose and the androgenicity of the progestogens. Our objective was to evaluate the impact of a COC containing 20 mcg EE + 3 mg drospirenone on blood pressure (BP), renin-angiotensin-aldosterone system, insulin resistance, and androgenic profile of healthy young women. Eighty-one healthy young women aged 30 ± 1 years (case group, n = 49, received COC; control group, n = 32, used no COC) were assessed twice, before and after the 6-month study. Statistical analysis employed the paired t-tests and expressed the data in mean and standard deviation. Results were as follows: no changes in BP or in BMI; a significant increase in aldosterone, plasma renin activity, triglycerides, and total cholesterol levels, but a non-significant increase in HDL and no significant changes in LDL levels (these parameters remained within normal ranges); a significant increase in the HOMA-IR index and a significant decrease in dehydroepiandrosterone sulfate (SDHEA), androstenedione, total testosterone, and free testosterone levels; no significant variations in the control group parameters. An oral contraceptive combination of a low EE dose and an anti-androgenic progestogen does not negatively influence the risk factors for a cardiovascular disease.

Effects of a contraceptive containing drospirenone and ethinyl estradiol on blood pressure and autonomic tone: a prospective controlled clinical trial.

BACKGROUND: The use of combined oral contraceptives has been associated with an increased risk of adverse cardiovascular events. Whether these drugs alter cardiac autonomic nervous system control is not completely determined. OBJECTIVE: To evaluate the effect of a contraceptive containing 20mcg of ethinyl estradiol and 3mg of drospirenone on the heart rate variability, baroreflex sensitivity and blood pressure of healthy women. STUDY DESIGN: Prospective controlled trial with 69 healthy women allocated in two groups: 36 volunteers under oral combined contraceptive use and 33 volunteers using of non-hormonal contraceptive methods. Subjects were tested before the introduction of the contraceptive method and 6 months after its use. For data acquisition, we used continuous non-invasive beat-to-beat blood pressure curve recordings. Multiple ANOVA was used to determine differences between groups and moments and p< 0.05 was considered statistically significant. RESULTS: At baseline, there were no differences in demographic and autonomic parameters between groups. Comparing cardiac sympatho-vagal modulation, baroreceptor sensitivity and blood pressure measurements between baseline and after 6 months, no significant difference was detected in each group or between groups. CONCLUSION: A contraceptive containing 20mcg of ethinyl estradiol and 3mg of drospirenone causes no significant changes in clinical, hemodynamic and autonomic parameters of normal women.

Attitudes, knowledge and prescribing habits of Brazilian gynecologists regarding extended-cycle oral contraceptives.

Extended-cycle and continuous use combined oral contraceptives (COC) have been widely investigated; however, gynecologists' prescribing habits are largely unknown. This study evaluated the opinions and prescribing habits of Brazilian gynecologists regarding extended/continuous COC. Gynecologists caring for reproductive-age women and used to prescribing COC were recruited to an online survey. Overall, 1097 physicians were included. Of these, 93.0% stated that patients requested extended/continuous COC, with 93.9% of the physicians having already prescribed these regimens at least once. Only 67 physicians reported never having prescribed extended/continuous COC. The most common reasons for prescribing extended/continuous COC were "dysmenorrhea", "endometriosis" and "convenience of menstrual suppression". Physicians reported prescribing extended/continuous regimens for 20.7 ± 17.2% of their patients with an indication for COC, postgraduate degree holders being more likely to prescribe extended/continuous regimens than physicians without postgraduate degree (23.6 ± 19.1% versus 20.0 ± 16.7%; p = 0.014). In conclusion, the vast majority of gynecologists prescribe extended/continuous COC. Women often request information from their doctors on the subject. "Convenience of menstrual suppression" is a common reason given for prescribing extended/continuous COC. According to the physicians, the great majority of extended/continuous COC users are satisfied or very satisfied with the regimen prescribed.

Terapêutica hormonal da pós-menopausa: consequências da via de administração do estrogênio / Postmenopausal hormone therapy: consequences of the estrogen route of administration

A terapêutica hormonal da pós-menopausa é considerada a forma mais eficaz de tratamento das manifestações do climatério, Entretanto a via de administração do estrogênio pode ter influência em vários aspectos metabólicos e de segurança, tais como risco de trombose venosa profunda e efeitos nos níveis séricos de lipídios, entre outros. Esta revisão procura abordar as diferenças de efeitos dos estrogênios em diversos parâmetros metabólicos, conforme a via de administração.A terapêutica hormonal da pós-menopausa (TH) é considerada o tratamento mais eficaz para os sintomas vasomotores do climatério, entretanto é importante notar que sob esse título se agrupam várias formas de tratamento. A depender das estruturas moleculares do estrogênio e dos progestagênios empregados, suas doses, regimes e vias de administração, os efeitos desejados e os adversos podem ser significativamente diferentes.A via de administração do estrogênio é, sem dúvida, aspecto de grande relevância para a segurança e a tolerabilidade da TH, pois as vias não orais, especialmente quando o estrogênio é administrado através da pele, não fazem o assim conhecido efeito de primeira passagem hepática(1)...

Impact of standardized information provided by gynecologists on women's choice of combined hormonal contraception.

This prospective interventional study was designed to determine the impact of providing standardized information on different methods of combined hormonal contraception on women's selection of which method to use. A total of 952 Brazilian gynecologists were randomly selected. Each gynecologist recruited 15 consecutive patients for whom combined hormonal contraception was indicated. Each patient was asked which contraceptive method she would prefer (pill, patch, vaginal ring or injectable) before and after receiving a standardized explanation on each of these methods provided by her doctor. A total of 9507 women were included in the study. Prior to counseling, 66.5% of the women stated that they would prefer the pill, 17.9% the injectable, 8.9% the patch and 6.7% the vaginal ring. After counseling, 53.7% of the women stated that they would prefer the pill, 16.3% the injectable, 14% the patch and 16% the ring. In conclusion, the combined pill remains the most popular contraceptive method among Brazilian women; however, after receiving information on the various contraceptive methods available, the proportion of women choosing the vaginal ring or patch increased, while preference for the combined pill decreased.

Women's knowledge of health effects of oral contraceptives in five Brazilian cities.

BACKGROUND: Although acceptability of combined oral contraceptives (COCs) is widespread, patients are often unaware of the noncontraceptive benefits. STUDY DESIGN: An opinion survey through telephone interview was conducted to evaluate the knowledge of 500 Brazilian women 15-45 years of age who were current users or had recently used COCs. Data were obtained on their knowledge of adverse events, the effects of COCs on health- and menstrual-related symptoms, noncontraceptive benefits and aspects related to sexual response. RESULTS: Most of the women interviewed learned about the pill from doctors or the Internet. Other than the pill, the best-known contraceptive methods were the condom and intrauterine device. The majority of women believe that COCs do not change the risk of gynecological cancers. Most believed that they had no significant effect on sexual response. CONCLUSIONS: COCs users in Brazil lack precise information on aspects related to general health, particularly menstrual-related symptoms and noncontraceptive health benefits.

[Associated factors with discontinuation use of combined oral contraceptives]. / Fatores associados à descontinuação do uso de anticoncepcionais orais combinados.

PURPOSE: Due to the scarce information available in Brazil in relation to the number of women who initiated the use of combined oral contraceptives and prematurely discontinued, the objective was to assess the reasons for discontinuation of the use of several combined oral contraceptives among Brazilian women living in urban areas. METHODS: A cross-sectional study with 400 gynecologists registered withy the Brazilian Federation of Obstetricians and Gynecologists. Each physician interviewed 10 non-pregnant, not breastfeeding, not amenorrheic women aged 18 to 39 years who consulted requesting combined oral contraceptive (COC) with a questionnaire at the beginning of use and at six months later. The questionnaire included sociodemographic data, type of COC chosen or prescribed and reasons for discontinuation when it occurred during follow-up. The strategy of selection allowed the inclusion of women from different socioeconomic strata, however, only those attended at private or insurance offices. The sample size was estimated at 1,427 women. RESULTS: A total of 3,465 interviews were conducted at the first visit and 1,699 six months later. The women were 20 to 29 years old, 57.3% were single and an equal proportion of 45.0% attended high school or college. Most (60.7%) were nulligravidas and among those who had used some contraceptive before, 71.8% had used a COC. Among the more prescribed or chosen COC the most prevalent were monophasic with ethynil estradiol (20 µg) and regarding progestin the most prevalent was with gestodene (36.5%) followed by a COC with drosperinone (22.0%). At six months 63.5% still used COC. Among those who discontinued the main reasons were wishing to become pregnant (36.5%) and side effects (57.3%) and the most prevalent were headache (37.6%), weight gain (16.6%) and irregular bleeding (23.6%). CONCLUSIONS: The continuation rate of COC was low at six months and this study could contribute to a better counseling on the part of physicians of patients who initiate COC about side-events that are rare, minimal and temporary and about the benefits of COC use.

Fatores associados à descontinuação do uso de anticoncepcionais orais combinados / Associated factors with discontinuation use of combined oral contraceptives

OBJETIVO: Avaliar as razões para descontinuar diversos anticoncepcionais orais combinados entre mulheres brasileiras iniciantes do método, residentes em áreas urbanas. MÉTODOS: Estudo de corte transversal com 400 ginecologistas do Brasil, registrados na Federação Brasileira de Ginecologia e Obstetrícia. Cada médico entrevistou 10 mulheres não grávidas, não lactantes, não em amenorreia, com idades entre 18 e 39 anos que consultavam solicitando anticoncepcional oral combinado (ACO), com um questionário no início de uso e aos 6 meses posteriores. O questionário incluiu dados sociodemográficos, tipo de ACO escolhido ou prescrito e razões para descontinuação, caso ocorresse durante o seguimento. A estratégia de seleção permitiu a inclusão de mulheres de diferentes estratos socioeconômicos, mas somente atendidas em consultórios privados ou de convênios. O tamanho da amostra foi estimado em 1.427 mulheres. RESULTADOS: Foram obtidas 3.465 entrevistas na primeira visita e 1.699 aos 6 meses posteriores. As mulheres tinham predominantemente entre 20 e 29 anos, 57,3 por cento eram solteiras e em proporção quase igual de 45 por cento tinham ensino médio ou superior. A maioria (60,7 por cento) era nuligestas e dentre as que tinham usado algum método contraceptivo anteriormente, 71,8 por cento tinham utilizado ACO. Entre os ACO mais prescritos ou escolhidos, o mais prevalente foram os monofásicos com etinilestradiol (20 µg) e no tocante ao progestágeno, o mais prevalente foi com gestodeno (36,5 por cento), seguido por ACO com drosperinona (22,0 por cento). Aos 6 meses, 63,5 por cento continuavam em uso do ACO. Dentre as que descontinuaram o uso, as principais razões dadas foram: desejo de engravidar (36,5 por cento) e efeitos colaterais (57,3 por cento) como cefaléia (37,6 por cento), aumento de peso (16,6 por cento) e sangramento irregular (23,6 por cento). ..

PURPOSE: Due to the scarce information available in Brazil in relation to the number of women who initiated the use of combined oral contraceptives and prematurely discontinued, the objective was to assess the reasons for discontinuation of the use of several combined oral contraceptives among Brazilian women living in urban areas. METHODS: A cross-sectional study with 400 gynecologists registered withy the Brazilian Federation of Obstetricians and Gynecologists. Each physician interviewed 10 non-pregnant, not breastfeeding, not amenorrheic women aged 18 to 39 years who consulted requesting combined oral contraceptive (COC) with a questionnaire at the beginning of use and at six months later. The questionnaire included sociodemographic data, type of COC chosen or prescribed and reasons for discontinuation when it occurred during follow-up. The strategy of selection allowed the inclusion of women from different socioeconomic strata, however, only those attended at private or insurance offices. The sample size was estimated at 1,427 women. RESULTS: A total of 3,465 interviews were conducted at the first visit and 1,699 six months later. The women were 20 to 29 years old, 57.3 percent were single and an equal proportion of 45.0 percent attended high school or college. Most (60.7 percent) were nulligravidas and among those who had used some contraceptive before, 71.8 percent had used a COC. Among the more prescribed or chosen COC the most prevalent were monophasic with ethynil estradiol (20 µg) and regarding progestin the most prevalent was with gestodene (36.5 percent) followed by a COC with drosperinone (22.0 percent). At six months 63.5 percent still used COC. Among those who discontinued the main reasons were wishing to become pregnant (36.5 percent) and side effects (57.3 percent) and the most prevalent were headache (37.6 percent), weight gain (16.6 percent) and irregular bleeding (23.6 percent)...

Cirurgia endovascular em ginecologia / Endovascular surgery in gynecology

Endovascular surgery has presented a high evolution since 1960 with Charles Dotter, who changed the concept of catheter utilization as a mean to diagnose and introduce therapeutic in interventionist vascular environment. The first reports of bleeding control of gastrointestinal and transluminal angioplasty input the development of new techniques for endovascular access, and new materials use, such as microcatheters and embolic agents, become this procedure effective and viable for treatment of several pathologies. The embolization of several organs of human body is a procedure carried out for more than 30 years all over the world showing safety, efficacy and of simple execution. In obstetrics and gynecology, particularly, the first reports refer to pelvic hemorrhage control of varied etiology, including pelvic trauma, bladder and gynecology neoplasia, anteriovenous fistulas and puerperal hemorrhages. The embolization of uterine myoma appears in the 1990?s as an alternative for treat of uterine leiomyoma, and a number of studies try to clarify the risks and benefits of this procedure. It is a multidisciplinary technique, with diagnostic and indication performed by gynecologist and the procedure done by interventional vascular radiologist. This review is a critical analysis of interventionist vascular radiologic methods and its main therapeutic indications in gynecology.

A cirurgia endovascular apresentou grande evolução a partir de 1960, com Charles Dotter, ao modificar o conceito de utilização de cateteres como meio diagnóstico e introduzir a terapêutica no ambiente vascular intervencionista. Os primeiros relatos de contenção de sangramento do trato gastrintestinal e angioplastia transluminal impulsionaram o desenvolvimento de novas técnicas de acesso endovascular, e a utilização de novos materiais como os microcateteres e agentes embolizantes tornaram o procedimento efetivo e viável no tratamento de diversas doenças. A embolização de diversos órgãos do corpo humano é procedimento realizado há mais de 30 anos em todo o mundo, mostrando ser seguro, eficaz e de simples execução. Particularmente em ginecologia e obstetrícia, os primeiros relatos referem-se à contenção de hemorragias pélvicas de etiologia variada, incluindo trauma pélvico, neoplasias de bexiga e ginecológicas, fístulas arteriovenosas e hemorragias puerperais. A embolização do mioma uterino surgiu em 1990 como alternativa ao tratamento cirúrgico do leiomioma uterino, sendo que vários estudos buscam esclarecer riscos e benefícios desse procedimento. Trata-se de uma técnica multidisciplinar, cujo diagnóstico e indicação são feitos pelo ginecologista e o procedimento pelo radiologista vascular intervencionista. Esta revisão é uma análise crítica de métodos radiológicos vasculares intervencionistas e suas principais indicações terapêuticas em ginecologia.

Estrogen-free oral hormonal contraception: benefits of the progestin-only pill.

Although combined oral contraceptives (COCs) are commonly used and highly effective in preventing pregnancy, they may not be suitable for some women. COC use is associated with increased rates of cardiovascular events and is not recommended in nonbreastfeeding women in the immediate postpartum period or in breastfeeding women during the initial 6 months of breastfeeding. Moreover, estrogen-related adverse effects, such as headache, are common. Estrogen-free progestin-only pills (POPs) are a valuable option in women who prefer to take an oral hormonal contraceptive, but are ineligible for, or choose not to use, COCs. Although some POPs have been associated with lower contraceptive effectiveness than COCs, the POP containing desogestrel has shown similar contraceptive effectiveness to COCs. The most commonly reported complaints in women using all POPs are bleeding problems. Counseling women interested in using POPs about the variable bleeding patterns associated with this method may improve compliance and acceptance.

Promestrieno no tratamento da atrofia vulvovaginal: revisão sistemática / Promestriene for treatment of vulvovaginal atrophy: a systematic review

Os sintomas decorrentes da atrofia vulvovaginal são muito comuns no climatério. Os estrogênios aplicados localmente na vagina se mostram eficazes no alívio de tais manifestações; no entanto, os estrogênios conjugados na forma de creme vaginal apresentam efeitos sistêmicos e o estriol aplicado localmente pode ser absorvido sistemicamente também. O promestrieno é um estrogênio cuja absorção sistêmica é desprezível quando empregado topicamente, porém a falta de revisão sistemática sobre o tema suscitou a realização da presente revisão. Foram incluídos 16 estudos publicados entre 1976 e 2009, que avaliaram eficácia do promestrieno no alívio dos sintomas decorrentes da atrofia vulvovaginal, ou que investigaram seus efeitos na citologia vaginal, e também aqueles que avaliaram a absorção da substância quando empregada topicamente. As evidências encontradas confirmaram a eficácia do promestrieno, utilizado localmente no tratamento das afecções atróficas genitais femininas decorrentes do hipoestrogenismo, aliada a absorção sistêmica desprezível

The symptoms resulting from vulvovaginal atrophy are very common during climacteric. Estrogens applied locally in the vagina are effective in relieving these manifestations, however, conjugated estrogens as vaginal cream have systemic effects and locally applied estriol may be systemically absorbed. Promestriene is an estrogen without systemic absorption when applied topically, but the lack of a systematic review on the substance motivated the idea to make this review. Sixteen studies published between 1976 and 2009 which evaluated the effectiveness of promestriene on the relief of symptoms resulting from vulvovaginal atrophy or which investigated its effects on vaginal cytology and those which evaluated the absorption of the substance when used locally were included. The found evidences confirmed the effectiveness of locally applied promestriene in the treatment of female genital atrophic disorders due to low estrogen levels coupled with negligible systemic absorption