Intrauterine device practice guidelines: medical conditions.

PIP: Contraception selection poses special challenges to women with pre-existing medical problems and clinicians often lack the knowledge to counsel these women. The IUD represents an excellent option for many US women with medical problems. Because IUDs have no direct systemic effects other than increasing circulating immunoglobulins and possibly copper ions, they are unlikely to affect a woman's underlying disease process or to interact with medications used in disease treatment. Currently available IUDs may be appropriate for women with cardiovascular disease, diabetes mellitus with vascular disease, hematologic disorders, neurologic conditions, and psychiatric disorders. Other candidates for IUD use include women with a history of breast cancer or other hormone-sensitive cancers, active liver disease, hypertriglyceridemia, a sensitivity to hormonal contraception, and smokers over 40 years old. IUDs are contraindicated in women with diseases that increase their vulnerability to infection (e.g., AIDS, leukemia, and intravenous drug abuse), diseases or medications that produce profuse uterine bleeding, and conditions that distort the uterine cavity. Given the deleterious impact of unintended pregnancy on the clinical course of many diseases, information on contraception for women with pre-existing medical conditions should be more broadly disseminated among clinicians.^ieng

IUD update signals renaissance for long-term contraceptive method.

PIP: As a result of concerns raised in 1974 about the safety of the Dalkon Shield and subsequent lawsuits, many US family planning providers ceased IUD provision. Also affected adversely was education of medical students in IUD insertion. Recent studies suggest, however, that IUD users at low risk for sexually transmitted diseases are unlikely to develop pelvic inflammatory disease (PID). It is now known that the presence of an STD at the time of IUD insertion, not the device itself, increases the PID risk. Moreover, PID is a rare event beyond the first 20 days after IUD insertion. Recent studies suggest that, with proper patient selection, risks for post-insertion PID are virtually eliminated. Appropriate candidates for IUD use are women in monogamous sexual relationships who are looking for long-term contraception but are not certain about sterilization. Informed consent is a prerequisite to IUD insertion. The likelihood of infection can be reduced if prophylactic antibiotics are provided at the time of IUD insertion.^ieng

IUD patient selection and practice guidelines.

PIP: Contraceptive practice guidelines have the potential to assist health care providers in evaluating the needs and expectations of women seeking contraception, educating patients, and monitoring successful contraceptive use. This article presents guidelines for IUD patient selection developed by several members of the editorial board of the US newsletter, "Dialogues in Contraception." Misinformation about the IUD has prevented many clinicians and patients from considering this method, despite recent improvements in its design. The currently available data suggest that the two IUDs available in the US, Copper T 380A and Progestasert, cause a local reaction that is toxic to sperm (and perhaps ova), thereby preventing fertilization. Modern IUDs, which use only monofilament tails, do not increase the risk of pelvic inflammatory disease in women without evidence of lower genital tract infection. Beyond avoiding women at risk for sexually transmitted diseases, there are few barriers to IUD use. The method is appropriate for women who are contemplating but ambivalent about sterilization, aged under 25 years, perimenopausal, nulliparous or parous, postpartum or postabortion, lactating, and cigarette smokers over 35 years of age. Contraindications to IUD use are postpregnancy infection, unresolved acute cervicitis or vaginitis, distorted uterine cavity, uterine or cervical cancer, unexplained abnormal vaginal bleeding, increased susceptibility to infection, genital actinomycosis, immunocompromised patients, and diabetes mellitus (progesterone-releasing IUD only).^ieng

[Contraceptive methods: 2. Indications and suggestions for a choice]. / Les moyens contraceptifs: 2. Indications et propositions de choix.

PIP: This second part of a two-part article on contraceptive methods discusses indications and criteria for choice of methods, with reference especially to developing countries. The practitioner should spend some time at the first contraceptive consultation explaining the methods to the user and determining their acceptability. Contraindications for oral contraceptives (OCs) and IUDs should first be ruled out. The significant contraindications to OC use include hypertension, phlebitis or pulmonary embolism, diabetes and hypercholesterolemia, family history of uterine or breast cancer, and smoking. Pregnancy, nulliparity, history of genital infection, and inability to assure regular follow-up are contraindications to IUD use. The side effects of the different methods should be kept in mind because they may discourage users. The preferences of the individual or couple are often founded on subjective factors, and cultural, religious, or customary factors in the community may influence the overall demand for each method. The marital status, frequency of sexual relations, stage of family formation, number of partners, and stability of individuals or couples should also be considered in choosing a method. A preliminary medical consultation is always advisable before contraceptive use begins, if only to inform users about the risks of sexually transmitted diseases. Contraceptives should be of low cost and financially accessible so that potential users, perhaps not strongly motivated, will not be discouraged by cost considerations. Re-supply of the selected method should be regular and assured. The contraceptive decision may be guided by a protocol or standardized strategy, similar to a protocol of diagnosis and treatment. If such protocols are developed, carefully supervised nurses or midwives may carry out some of the work.^ieng

Practice guidelines for OC selection: update.

PIP: This report updates practice guidelines for oral contraceptive (OC) selection developed by US clinicians and researchers in 1996 on the basis of clinical experience, expert opinion, and a review of the research literature. The update was necessitated by the availability of new OC formulations, increased awareness of the range of noncontraceptive benefits of OCs, and emerging evidence linking OCs to cardiovascular and breast cancer risks. To facilitate the review, available OCs are categorized on the basis of low, medium, or high androgenic activity of the progestin component. Overall, the report recommends OC use as a first-choice method unless a woman has a clear contraindication, suffers intolerable side effects despite changes in the type of progestin or dose, or has difficulty taking the tablets consistently. Tables included in this report present the estrogen and progestin doses in all OCs currently available in the US; set forth guidelines for OC selection for different categories of women (e.g., adolescent, postpartum, perimenopausal) and to minimize OC-related side effects and adverse health effects; and offer recommendations to guide the formulation selection in women with pre-existing medical conditions, menstrual disorders, and other reproductive health problems.^ieng

Family planning methods: new guidance.

PIP: Presented in this report are the recommendations of two expert groups, the Technical Guidance/Competence Working Group of the US Agency for International Development's Maximizing Access and Quality Initiative and the World Health Organization's Family Planning and Population Unit, regarding currently available family planning methods. The former group addressed key biomedical questions and formulated recommendations about 11 groups of family planning methods: combined oral contraceptives, progestin-only pills during breast feeding, progestin-only injectables, combined injectable contraceptives, Norplant implants, copper-bearing IUDs, tubal occlusion, vasectomy, lactational amenorrhea method, natural family planning, and barrier methods. A table presents the relative importance, by method, of procedures such as pelvic exam, blood pressure reading, breast exam, and screening for sexually transmitted diseases and cervical cancer. The medical eligibility recommendations for each method are also presented in tabular form, with four categories for temporary methods: 1) no restrictions on use, 2) advantages generally outweigh theoretical or proven risks, 3) theoretical or proven risks usually outweigh the advantages, and 4) unacceptable health risks. Included among the 41 conditions for which eligibility criteria are specified are age, smoking, thromboembolic disorder, headaches, irregular vaginal bleeding, family history of breast cancer, obesity, drug interactions, parity, breast feeding, postpartum, and postabortion. The new guidance presented in this report enables providers to give family planning clients expanded contraceptive choices while ensuring method safety and effectiveness.^ieng

A practical guide for prescribing birth control pills.

PIP: More than 50 million US women have used oral contraceptives (OCs) in the past 25 years, and the consensus is that the benefits and advantages of OC use outweigh most of the disadvantages. Side effects have been reduced or eliminated by reduced dosage preparations, and effectiveness has been virtually 100%. Despite this widespread use, most US women are misinformed about OCs, perhaps because pediatricians, family physicians, and nurse-practitioners are insufficiently informed. The economic power of the drug manufacturers has been brought to bear on the medical profession to prescribe OCs for virtually every woman of child-bearing age. The drug industry which has been touting the safety of OCs has recently introduced new progestins which are supposed to be "lipid-neutral" and have fewer androgenic effects. Therefore, the potentially harmful effects of the old progestins were deemphasized deliberately. A cautious but advisable approach for physicians to follow in prescribing OCs has 8 points. 1) All sexually active females should be advised that barrier contraception is the best protection (except abstinence) from sexually transmitted diseases, including AIDS. 2) OCs with more than 35 mcg estrogen should be withdrawn from the market. 3) All patients should be encouraged to lead a healthy lifestyle. 4) Barrier methods should be encouraged for patients with such medical conditions as migraine headaches, prominent varicose veins, diabetes, increasing weight gain, hypertension, thyroid dysfunction, and mitral valve prolapse. 5) Switching to a preparation with the new progestins should be considered for some patients who are smokers or have abnormal lipid profiles. 6) It might be advantageous under certain circumstances for a patient to discontinue OC use for a period of time. 7) Women who no longer desire a pregnancy should be encouraged to consider surgical sterilization. 8) Nulliparous women over 30 years old should discontinue OC use to diminish their risk of breast cancer. This last point is controversial, and the editors of this publication invite the readers' comments.^ieng

The intrauterine device today.

PIP: The intrauterine contraceptive device (IUD) is effective and reversible and has a high continuation rate. It can also be used within 7 days postcoitus. Developed separately by Richter, Grafenberg, and Ota between 1909 and 1934, the IUD gained popularity in the 1960s and 1970s with the introduction of the Margulies Spiral, the Lippes Loop, the Birnberg Bow, and the Dalkon Shield. The last proved dangerous, and the IUD became unpopular. The 4 IUDs which are available in Canada include the TCu-380S (GYNE T Slimline), the TCu-200, the NOVA-T, and the Progestasert. All are T shaped and medicated (copper or progesterone). The 1st and 3rd can be left in situ for 10 years; the 2nd, for 4 years; and the 4th, for 1 year. The NOVA-T has a copper wire with a silver core and is inserted with a unique pull-push technique. The Progestasert, which contains 38 mg of progesterone, releases 65 mcg of the hormone daily. The best candidate for IUD use is parous, but not pregnant, is in a stable monogamous relationship, and has a healthy reproductive tract and no history of ectopic pregnancy, sexually transmitted disease, pelvic inflammatory disease, undiagnosed genital bleeding, endometrial or cervical neoplasia, abnormal endometrial anatomy, compromised immune system, allergy to copper, or Wilson's Disease. The only infection related to the IUD is that associated with insertion. Such an infection is polymicrobial and involves the endogenous, cervicovaginal flora (primarily anaerobes). It is usually asymptomatic and contained by the immune system. 200 mg of Doxycycline can be given orally as a prophylactic 1 hour prior to insertion. A nonprescription, nonsteroidal, anti-inflammatory drug, also taken 1 hour before the procedure, will prevent pain and a vasovagal reaction. Paracervical anesthesia should be used. If the depth of the uterus is less than 6 cm or greater than 10 cm, another form of contraception should be used. Although little research is being done in Canada on new IUDs, the Levonorgestrel IUD from Europe and the CuFix-360 (Flexigard) offer promise. The former, which is T shaped, contains polydimethylsiloxane and levonorgestrel (52 mg, total; releases 20 mcg daily) and can be used for 7 years. The latter IUD is shapeless and consists of 6 copper sleeves strung on surgical nylon thread knotted at 1 end. The knot is inserted, using a needle, into the fundal myometrium. The truth and falsehood of several myths about IUDs are noted with supporting citations.^ieng

[Contraception and endometriosis]. / Contraception et endometriose.

PIP: Choosing a contraceptive method for a woman with endometriosis is an uncommon problem because endometriosis is relatively rare and because an estimated 30-50% of women with endometriosis are infertile. Uterine or internal endometriosis or adenomyosis is characterized by a congestive and pseudoinflammatory uterus slightly increased in volume. It must be distinguished from pelvic or external or peritoneo-ovarian endometriosis. Pelvic implants may involve destruction of the ovaries by cysts or their imprisonment in adhesions. They may cause stenosis in the proximal portion of the tubes or entrap them in adhesions. 4 stages of endometriosis have been distinguished according to the significance of the lesions and a scoring system. Stage 4 patients with scores over 70 or with a score over 50 for adhesions have been unable to conceive despite treatment. No contraception is necessary in these cases. The choice of a contraceptive for other patients is conditioned by the features of endometriosis. Endometriosis refers to the abnormal localization of a normal endometrium. The implants are sensitive to estrogen. Each implant behaves like a miniature uterus; the mucus proliferates and bleeds if estrogen secretions are present, or atrophies if not. Endometriosis may be completely asymptomatic, or cause sterility, or be accompanied by pain and metrorrhagia. Several earlier treatments of endometriosis have been abandoned because of side effects. The current treatment of choice is an LHRH analog administered by parenteral injections every 4 weeks to bring about a state of pseudomenopause. The treatment produces a rapid desensitization of the pituitary LHRH receptors and a diminution of gonadotrophins, estrogens, and progesterone. The secondary effects are those of hypoestrogenism: hot flashes, vaginal dryness, and increased bone loss after 6 months of treatment. It is also an expensive medication. Contraception is provided by the treatment itself for the first 6 months. Subsequently, a hydroxyprogesterone derivative such as cyproterone acetate can be used, as can a norpregnane derivative or a combined oral contraceptive with predominant progestin action. Monophasic pills containing norethisterone are also acceptable. In case of metabolic problems, a pill containing gestodene may be used. A vaginal contraceptive should be used in cases of adenomyosis.^ieng

Subdermal contraceptive implants in nurse-midwifery practice.

Subdermal contraceptive implants have only recently been approved for use in the United States. At present, only one subdermal contraceptive implant, Norplant, is approved in the United States. This article describes the development of Norplant, its efficacy and safety, a description of the system, education for clients, side effects, indications and contraindications, insertion and removal, incorporation into midwifery practice, and education for health professionals regarding its use.

PIP: The US Food and Drug Administration approved the contraceptive implant system, Norplant, in February 1990. It has been used in other countries for more than 15 years before the US approved it. The 6 subdermally placed capsules in the upper inner arm release 50-80 mcg levonorgestrel/day into the bloodstream, resulting in a 99.8% efficacy rate. Patient education and counseling, especially about changes in the bleeding pattern and Norplant's inability to protect against sexually transmitted diseases, are important to maintain client satisfaction and continued use of Norplant. Side effects, from most to least common, are changes in menstrual bleeding, constant bleeding, missed periods, weight gain/increased appetite, headache, oily skin or acne, weight loss/nausea, breast tenderness, nervousness or loss of appetite, and hair loss. It is rare when complications are so severe that they require removal of the implants. Contraindications to Norplant include active liver disease, active thromboembolic disease, breast cancer, pregnancy, and undiagnosed dysfunctional uterine bleeding. Antiepileptic medications, barbiturates, treatment for tuberculosis, and Butazolidin/phenylbutazone reduce Norplant's efficacy. A trained person should insert Norplant within the first 5-7 days of the menstrual cycle when it is evident there is no pregnancy. Some reports recommend that, after childbirth, it should be inserted 6 weeks postpartum to avoid hemorrhage. Yet, nurse-midwives at the Center for Addiction and Pregnancy at the Francis Scott Key Medical Center in Baltimore, Maryland, insert Norplant 24-48 hours postpartum in non-breast-feeding mothers with no increase in hemorrhage. Norplant must be removed no longer than 5 years after insertion. Certified nurse-midwives wanting to incorporate Norplant into their practices should follow the Guidelines for the Incorporation of New Procedures into Nurse-Midwifery Practice and have available a consulting physician who is familiar with and skilled in inserting Norplant. The manufacturer conducts training sessions for health professionals.

Most providers comfortable giving OCs to women over age 40. Special report: annual pill survey.

PIP: 81% of respondents to the 1992 pill survey states that they would prescribe oral contraceptives (OCs) to nonsmoking healthy women over age 40. In 1989, this proportion of health care providers was only 40%; in 1990 it rose to 69%; and in 1991, 79% of respondents indicated they would prescribe OCs to older women. These findings are similar to the results of the 1991 Ortho Annual Birth Control Study by the Ortho Pharmaceutical Corp., Raritan, NJ, that disclosed the doubling of OC use since 1990 among American women in the 40-45 age group and the fact that 500,000 women over 45 are current OC users, 6% of that age group. According to a consulting firm in Chapel Hill, NC, the trend toward prescribing OCs to older women is attributable to low-dose pills implicated in fewer side effects. Thus, older women could also enjoy the benefits of OCs which include protection from ovarian and endometrial cancers, functional ovarian cysts, ectopic pregnancies, fibrocystic breast disease, and dysmenorrhea. Family Planning Program Inc. in Visalia, CA, years ago would not give OCs even to healthy, nonsmoking women over 35. Now clinic physicians prescribe them to women over 35 more often. The criteria of the American College of Obstetricians and Gynecologists in Washington, DC, for OC use in women over the age of 40 advise that the candidate by a nonsmoker, have a normal mammogram, have a normal lipid profile and glucose screening test, weigh no more than 30% more than her ideal body weight, and have no family history of contraindications, including early cardiovascular or thromboembolic disease. According to the executive director of the National Association of Nurse Practitioners in Reproductive Health in Washington, DC, nurse practitioners used to refer older women to physicians before prescribing OCs, and now they are capable of assessing a patient for those characteristics.^ieng

Condoms as primary prevention in sexually active women.

PIP: The origin of the word condom is the subject of some debate, but the use of a linen sheath as a preventive measure for venereal disease was noted in the writings of Fallopius in 1564. In recent years condom sales have increased, and in a sample of San Francisco male homosexuals consistent condom use was reported to have increased from 26% to 79% between 1984 and 1987. Condom sales in drugstores increased by over 20% from 1986 to 1987, with women being responsible for an estimated 40-50% of US purchases. Studies suggest a failure rate of 2-15/100 couples using condoms. Failure rates for 1st-year users average about 12%, but consistent and correct condom use theoretically results in approximately a 2% failure rate. Mean breakage rates ranging from 0% to 13% have been reported. Both epidemiological and laboratory studies have demonstrated that latex condoms are effective mechanical barriers to important viral transmissions including HIV, herpes simplex virus (HSV), hepatitis B virus (HBV), and cytomegalovirus (CMV), as well as bacteria such as Chlamydia trachomatis and Neisseria gonorrhea. Condoms are safe to use, particularly in view of the fact that AIDS is now 1 of the 5 leading causes of death for women ages 15-44. An important contraindication, however, is the presence of latex allergy, potentially leading to contact urticaria or manifestations of anaphylaxis. The female condom shows promise for placing personal protection increasingly under the control of women. Condom promotion in the US with education at both public and individual levels could emulate developed and developing countries that have promoted condom use with marketing and mass-media techniques, as well conspicuous and aggressive distribution methods. Nursing is involved in program efforts aimed at enhancing condom use and nurses can be effective in encouraging clients to use condoms to protect themselves.^ieng

IUDs struggle to shake off legacy of past.

PIP: Despite the wealth of evidence supporting the safety and efficacy of IUDs, fears of health problems associated with use of the device still linger in the US. Over the past 10 years, studies have shown that a new class o IUDs, copper-bearing IUDs, result in fewer pregnancies than oral contraceptives, and are as effective as Norplant, the long-acting hormonal implant. Additionally, the new class of IUDs have significantly lowered the rate of complications associated with use, complications such as bleeding, discomfort, and involuntary expulsion. Some experts say that the IUDs are among the most effective and safest forms of contraception available. And while the popularity of IUDs continues to rise in Europe and Asia, only an estimated 1% of US women use IUDs. Fears over IUD use in the US stem from the Dalkon Shield debacle in the 1980s, when reports about infection and infertility associated with the use of this particular type of IUD began to surface. More than 100,000 women filed a class action suit against Dalkon Shield's manufacturer, A.H. Robbins, and fear of similar liability prompted competing manufacturers to withdraw IUDs from the market. From 1986-88, only one type of IUD could be found in the US market. Experts now say that the safety questions -- especially concerns over the risk of pelvic infections -- about IUDs no longer apply, so long as the devices are properly prescribed and inserted under thoroughly aseptic conditions. Although the number of US women using IUDs is small, the IUD enjoys the highest satisfaction rate of any contraceptive method, 98%. Nonetheless, a comeback in the US for IUDs remains unlikely at this time, since the majority of women still distrust of the method, and physicians remain fearful of liability risks.^ieng

Time to talk condoms.

PIP: A great deal of avoided if political and religious leaders, educators, health care providers and the mass media would band together in an effort to promote condom use. Condoms use protects against unwanted pregnancies, STDs and AIDS. Yet, public discussions on condom use are rate. In the US, political leaders avoid mentioning the topic, and television networks severely restrict the airing of public service announcements for condoms. Worldwide, an estimated 100 billion acts of sexual intercourse take place every year. A recent report indicates that it would take a modest 13 billion condoms a year to protect everyone who is at risk of contracting AIDS and other STDs, and risk of having an unwanted pregnancy. Currently, worldwide production of condoms stands at about 6 billion a year. Furthermore, condom makers have the capacity to increase production by some 2 billion, and could add new capacity in about 2 years. Many believe that marketing condoms is a difficult enterprise, since men often report that condoms reduce pleasure, cause embarrassment, or are not available when needed. The challenge for markets, then, is to create demand. This is especially true in the US, where prime-time advertising and the use of popular entertainment, such as soap operas, could promote condoms as both safe and satisfying. In the developing world, the challenge is to make condoms widely available and affordable. Some changes have taken place since 1981, when AIDS first came into the spotlight. In the US, people now discuss the topic of STDs more openly. But an all-out effort to promote condom use has not yet begun.^ieng

Intrauterine devices.

Approximately 60 million women use the intrauterine device (IUD) worldwide; however, owing primarily to nonmedical reasons, the IUD is far less popular in the United States. Although the contraceptive mechanism of action is unknown, it appears that spermicidal activity may be important. Overall, the efficacy of the copper devices is quite good, such that the overall lifespan can probably be extended. Possible pelvic infection remains the greatest potential risk, although in properly selected women the risk is quite low. Use of prophylactic antibiotics at the time of insertion may offer additional protection against this risk. Although IUD users may have more nonspecific vaginal inflammation than do other women, the clinical significance is probably limited. Further, users do not appear to have elevated risks for cervical infections. Although menometrorrhagia persists as a potential problem, the mechanism for such bleeding is not well understood. Finally, the retroflexed uterine position does not appear to increase the risk of abnormal outcomes.

PIP: For largely nonmedical reasons, IUD use is lower in the US than many other countries and only two devices--the copper-containing Paragard IUD and the Progestasert-T--are available. Studies conducted over the past decade have provided important information on the management of side effects and the identification of the most appropriate candidates for IUD use. Although the mechanism of action of the IUD remains unknown, the device appears to have significant spermicidal action in addition to a possible inhibiting effect on implantation. The Progestasert-T has been demonstrated to have a failure rate of 1.8-2.5 pregnancies per 100 woman-years, but its 1-year lifespan remains a disadvantage. The Paragard device, approved for 6 years of continuous use, has a failure rate of 0.5-1 per 100 woman-years and there is growing evidence that the lifespan of this IUD can be extended for up to 10 years. Pelvic infection is the greatest potential complication of IUD use, but this outcome can be reduced by careful selection of acceptors and utilization of prophylactic antibiotics at the time of insertion. The ideal candidate for an IUD is a woman in a stable monagamous relationship. Recent studies of lower genital tract infection have found a reduced risk of cervical chlamydia in IUD users (2% over 2 years) than pill users (15%), while the risk of bacterial vaginosis is higher in IUD users (50% over 2 years) than pill users (20%). Strategies to increase the other problem commonly associated with IUD use--menorrhagia--have not yet been devised.

Subdermal progestin implant contraception.

Sustained-release progestin contraceptives are a new approach to meeting a worldwide need for more effective and acceptable birth control. These contraceptive systems provide low, stable levels of synthetic progestins for periods of months to several years. Unlike earlier injectable and oral contraceptives, they do not cause peaks in progestin levels beyond those required for effective contraception, nor do they employ estrogens. For these reasons, sustained-release progestin systems are without some of the health risks attributed to birth control pills, and they are more effective, as well as easy to use, and completely reversible. They share common side effects, the most frequent of which is irregular menstrual bleeding caused by the erratic shedding of hypotrophic endometrium. Despite this and other minor side effects, most users find the sustained-release systems acceptable alternatives to other methods of contraception. Permanent or biodegradable subdermal implants, injections, intrauterine and intracervical devices, and vaginal rings are all employed as delivery systems for contraceptive progestins. The Norplant (Wyeth Ayerst, Radnor, PA) system, consisting of six silastic tubes filled with levonorgestrel and implanted under the skin, was recently approved by the US Food and Drug Administration and is already used by more than a half million women worldwide. The other sustained-release systems are in various stages of development, at least several years away from general use. When these new methods complete clinical trials, women will be able to choose from among implants, injections, or pellets with various durations of action, all providing convenient, highly effective contraception with low risk to health.

PIP: Sustained released progestin-containing subdermal implants, the first new contraceptives to be released in 30 years, have the advantages of being easy to use, completely reversible, highly effective, and free of some of the health risks associated with combined oral contraceptives. The Norplant implant system, consisting of 6 levonorgestrel-filled silastic capsules, is being used by more than 500,000 women around the world and was approved for use in the US in late-1990. Because Norplant does not contain estrogen, it can be used safely by women with elevated blood pressure or a history of thromboembolic disease. Clinical trials have revealed first-year continuation rates of 76-90% compared with 50% for the pill. The most common reasons for requesting removal of Norplant are menstrual irregularity (prolonged menstrual bleeding, spotting between periods, or amenorrhea), headache, and weight gain. Plasma levonorgestrel concentrations are below contraceptive levels within 48 hours of removal, and most women resume normal ovulatory cycles during the first month after method discontinuation. Studies of carbohydrate metabolism, liver function, blood coagulation, immunoglobulin levels, serum cortisol levels, and blood chemistries have failed to reveal significant alterations in Norplant acceptors. Although some studies have recorded reductions in cholesterol, and triglyceride levels, lipoprotein levels return to pretreatment values by the end of the first year of use. Biodegradable implants that eliminate the need for surgical removal and implants that provide contraceptive protection for only 1-2 years could further increase the affordability and acceptability of this method. Under development are the Capronor and norethindrone/cholesterol pellet systems, both of which are shorter term and biodegradable.

[Efficacy of spermicides]. / Efficacite des spermicides.

PIP: Spermicidal contraceptives, after falling out of favor in the 1960s, are once again being sought be women desiring a natural and safe method. 2-6% of couples in France and other European countries are estimated to use spermicidal contraceptive methods. There is a wide an puzzling gap between the theoretical efficacy of spermicides tested in vitro and efficacy in actual practice. The theoretical failure rate of spermicides used regularly and correctly is 0-7.6%. The principal spermicides used in France at present are the ionic surfactant agent benzalkonium chloride and the nonionic surfactant nonoxynol 9, which destroy the cellular membranes of the sperm. Several tests are used to determine the spermicidal activity of a contraceptive. They include the International Planned Parenthood Federation test which is considered positive if 1 ml of a 1/11 solution immobilizes the sperm in .2 ml solution of selected sperm within 10 seconds in a reproducible fashion; the study of the minimal concentration that completely inhibits .2 ml of fresh sperm in less than 20 seconds; the absence of penetration of sperm in hamster eggs after contact with the products tested, and the Huhner test consisting of a search for sperm in the cervical mucus in the hours following intercourse. The 4 tests have demonstrated that the spermicidal efficacy of benzalkonium chloride is 4 times greater than that of nonoxynol 9. The spermicidal action is reinforced by thickening and coagulation of the mucus on contact with benzalkonium chloride, and the action of the spermicide covering the vaginal mucus. The practical efficacy of spermicides, which takes into account failures attributable to the method itself as well as failures due to incorrect use, is reflected in Pearl indexes ranging from 0.3-30. The efficacy of spermicides is closely related to their correct use. The method should be used regularly and systematically and the product inserted before initiation of sexual contact. Most products require renewed application if intercourse is repeated. Package instructions about duration of action and waiting times for the product to become fully effective should be carefully followed. The product should be left in place at least 2 hours. Baths and vaginal douches should be avoided for 4 hours after intercourse. Products such as soaps which neutralize the ionic surfactants should be avoided. Spermicidal contraceptives are recommended only for women capable of understanding and following the use instructions. Women who find the idea of spermicides distasteful and those requiring absolute efficacy should select another method. Vaginal spermicides may be suggested for women over 40 and those with contraindications to oral contraceptives and IUDs. They provide some protection against sexually transmitted diseases, and have no effects on the vaginal mucus or menstrual cycle and no carcinogenic effect.^ieng

[Contraception and sexology]. / Contraception et sexologie.

PIP: This work argues that contraceptive education urgently requires a new approach that will take into account the client's sexuality at the time the choice of method is made. Emotional factors such as a conscious or unconscious desire for pregnancy or motherhood, family pressures to produce a grandchild, or shame and distrust of contraception may contribute to contraceptive failure. Methods applied at the time of coitus such as condoms or spermicides may not be appropriate for clients for who contraception is a source of anxiety or guilt. The more effective, noncoital-dependent methods including oral contraceptives (OCs), IUDs, and sterilization may generate anxiety over infertility. Their efficacy may lack appeal for clients who enjoy an element of risk. The practitioner's attitude and knowledge may be further influences on the counseling over method choice. Among reversible methods, OCs are ideal for most women as long as they individually prescribed. OCs may be particularly important to the sexual expression of specific groups such as those over 35 with no risk factors other than age. Low-dose progestin-only OCs may be prescribed for this group, although about 10% of users change methods because of menstrual problems. IUDs are usually successfully used by women who have been carefully selected to exclude contraindications. In some cases the partner may be annoyed by the string, which can be rolled up and pushed out of the way or shortened by the practitioner. IUDs are often the best alternative for women with contraindications to OCs or who tolerate their side effects poorly. Spermicides may cause dermatoses or allergies that cause the woman to avoid intercourse. Some women dislike using spermicides because they must be applied prior to each use. Their bad taste is a disadvantage for some couples. Involving the male partner in application of the spermicide may remove some objections. The Billings or cervical mucus method should be avoided by women with irregular cycles and those who are reluctant to touch their genitalia. Diaphragms and cervical caps can be inserted by the male partner is desired. Menstrual extraction, insertion of an IUD within 72 hours of unprotected intercourse, or use of sufficiently high dose of oral hormones prevent pregnancy in most cases, but should not be relied upon for routine contraception. Much misinformation persists about the side effects of female sterilization, which is said to cause weight gain or sexual problems or to be followed inevitably by total hysterectomy. Most women are satisfied with the operation and express no regrets. Although reversal rates are improving, sterilization should be considered definitive. Condom use remains limited despite some increases related to fear of HIV infection. Condoms may increase performance anxiety in some men. Couples should be taught to use condoms in a more sensual manner. Withdrawal is still widely used throughout the world despite lack of esthetics appeal and high failure rate.^ieng

The effects of oral contraceptives and parity on ovarian cancer trends in women under 55 years of age.

Mortality from epithelial ovarian cancer is falling in women under 55 years of age in England and Wales. The decline does not appear to be a treatment effect nor to be attributable to changes in the rate of oophorectomy. Case-control studies have shown that high parity and oral contraceptive use are protective against the disease. We suggest that the decrease in mortality is compatible in timing and magnitude with exposure to oral contraceptives. No obvious effect on mortality attributable to parity was apparent in this analysis. Oral contraceptives may prove to be a widely acceptable means of preventing ovarian cancer, providing they do not increase breast cancer risk.

PIP: Age-specific mortality and incidence data for each calendar year (between 1950-86 for mortality and 1971-84 for incidence) were obtained from the Registrar General's Statistical Review for England and Wales and the Office of Population Censuses and Surveys publication series to consider whether the hypotheses generated by case-control studies on the effects of parity and oral contraceptive (OC) use are compatible with ovarian cancer trends in England and Wales. Rates were calculated on the basis of the mid-year female population within each 5-year age group. Initial examination of the data showed that the age-adjusted mortality rate from ovarian cancer for all women over 25 increased considerably between 1950-70 but changed little thereafter. The decline did not appear to be a treatment effect nor to be attributable to changes in the rate of oophorectomy. Case control studies have shown that high parity and OC use are protective against ovarian cancer. The disease in mortality emerges as compatible both in timing and magnitude with exposure to OCs. Ocs may prove to be an effective and widely acceptable means of preventing ovarian cancer, as long as they do not increase the risk of breast cancer.

[Sexually transmitted diseases (STD) and contraception]. / MST et contraception.

PIP: Sexually transmitted diseases (STDs) have shown a considerable resurgence in recent years both in number of cases and in spread of new infectious agents. The spread of STDs is favored by numerous factors including the liberalization of sexual behavior made possible by reliable contraception. Information on STDs has not been widely diffused. Changes in the status of women and the development of means of communication and transportation have encouraged less rigid control of sexual behavior. STDs themselves have often escaped diagnosis or not been cured despite treatment, increasing the risk of spread. Numerous organisms cause STDs, from external parasites to life-threatening viruses. 60% of upper genital tract infections that can lead to sterility, tubal alterations, ectopic pregnancy and pain result from STDs. Chlamydia infections are insidious and chronic, and cause greater damage with each recurrence. The risk of STDs should be considered in contraceptive choice along with other indications and contraindications. Combined oral contraceptives provide protection against acute upper genital tract infections. The protective role has been explained by scanty and highly viscous cervical mucus forming a barrier against germs and by reductions of menstrual flow, myometrial activity, and inflammation. It is actually uncertain whether combined oral contraceptives protect against latent chlamydia infections, since higher rates of cervicitis caused by chlamydia have been found in pill users. In situations carrying risk of STDs, pill users should be protected by a supplementary barrier method. IUDs have been implicated in numerous studies in acute pelvic infections. Possible explanations are the local trauma and inflammations due to the physical presence of the IUD, more abundant bleeding, absence of a cervical barrier to motile sperm that could be a vector for germs, and possible ascent of the infectious agent on the string. Other risk factors are involved. Epidemiologic studies indicate that the spermicides benzalkonium chloride and nonoxynol 9 have a protective effect against gonococcus, trichomonas, and chlamydia as well as cervical cancer. The protection is not absolute and is associated with the use of barrier methods. Condoms provide an excellent barrier against gonorrhea, chlamydia, cytomegalovirus, herpes, hepatitis B, and HIV infection. Use of spermicides may increase protection even more.^ieng