Contraceptive care best practices.

These 5 practice-changing initiatives can help reduce the number of unwanted pregnancies and allow women to take more control of their reproductive health.

Preventing gaps when switching contraceptives.

Unintended pregnancy can occur when women stop one birth control method before starting another. To prevent gaps in contraception, physicians should ask women regularly about adverse effects, cost, difficulty remembering the next dose, and other issues that affect adherence. Women who want to change contraceptive methods need accurate advice about how to do so. Some contraception transitions require an overlap between the old method and the new method. To switch safely from one contraceptive to another without overlap, women may go directly from the old method to the new method, abstaining from sexual intercourse or using a barrier method, such as condoms or spermicide, for the first seven days.

Emergency contraception in the context of marriage in Upper Egypt.

OBJECTIVE: To explore the degree of knowledge, perception, and practice of emergency contraception (EC) within marital relations in Egypt. METHODS: The present study was a pilot cross-sectional survey. Eligible participants were randomly selected from 4 governorates in Upper Egypt. A questionnaire was designed by the investigators and administered to an unselected sample of healthcare providers and potential users of EC. The questionnaire collected information in 4 domains: demographics; knowledge about EC; attitudes toward EC; and practice of EC in Egypt. RESULTS: In total, 240 healthcare providers and 60 potential users of EC completed the questionnaire. Approximately 85% of healthcare providers and 30% of potential users had heard about EC. A similar proportion of study participants said that EC methods are needed. Only 32.7% of healthcare providers and very few potential users had actually used EC. CONCLUSION: There is a need for EC in Egypt. However, a big gap in knowledge leads to nonuse or incorrect use of EC and negative attitude toward it. If health service planners and policy makers could fill this gap, a considerable decline in the prevalence of unwanted pregnancy may be achieved by using EC.

Evaluation of the contraceptive efficacy, compliance, and satisfaction with the transdermal contraceptive patch system Evra: a comparison between adolescent and adult users.

OBJECTIVE: Aim of the study was to evaluate Evra use in adolescents and compare the outcome with adult users. METHODS: A total of 80 adolescents and 178 adults were followed-up at 1-, 3-, and 6-month interval with their compliance, satisfaction, cycle control, and adverse events being assessed. RESULTS: Compliance rate was generally higher among adult users (p < 0.05). Partial and complete patch detachment were both significantly higher among adolescents (p < 0.05). Self-reported side effects did not differ between both groups and declined over the time. Overall satisfaction was high among most subjects. Compared with previous contraception, most subjects reported better satisfaction with Evra (p < 0.05). CONCLUSION: This investigation observed an overall positive impression of Evra with good compliance among adolescent and adult users. This might be an effect of the convenience of the weekly dosing schedule. Compliance is of utmost importance in teenagers as this age group is at highest risk of unintended pregnancy.

Update on emergency contraception.

Emergency contraception is a woman's last chance to prevent unintended pregnancy. Ulipristal acetate, a selective progesterone receptor modulator, when taken as a single 30 mg dose, is a new, safe and effective emergency contraceptive that can be used from the first day and up to 5 days following unprotected intercourse. The older progesterone-only emergency contraceptive, levonorgestrel, is taken as two 0.75 mg pills 12 hours apart (Next Choice(®); Watson Pharmaceuticals Inc., Morristown, NJ, USA) or a single 1.5 mg pill (Plan B One-Step™; Watson Pharmaceuticals Inc.), and is approved for only 72 hours after unprotected intercourse. During clinical development, ulipristal acetate has been shown to be more effective than levonorgestrel in delaying or inhibiting ovulation. A recent meta-analysis of two randomized clinical trials showed ulipristal acetate to have a pregnancy risk 42% lower than levonorgestrel up to 72 hours and 65% lower in the first 24 hours following unprotected intercourse. Moreover, when taken beyond 72 hours, significantly more pregnancies were prevented with ulipristal acetate than with levonorgestrel. Side effects are mild and similar to those seen with levonorgestrel. Ulipristal acetate was approved for emergency contraception by the US Food and Drug Administration in August 2010, and has been launched in the USA as ella(®) (Watson Pharmaceuticals Inc.) since December 1, 2010. Ella is prescription only and is priced comparable to Plan B One-Step.

Medical abortion in lactating women--low levels of mifepristone in breast milk.

OBJECTIVE: Medical abortion using mifepristone followed by misoprostol is increasingly used for termination of an unwanted pregnancy. Consequently, an increasing number of women undergo medical abortion while still breastfeeding from a previous pregnancy. But there are no data on mifepristone use during lactation. We studied the levels of mifepristone in breast milk collected from women undergoing medical abortion. DESIGN AND SAMPLES: Samples of milk were collected from 12 women during the first 7 days after intake of either 200 mg (n = 2) or 600 mg (n = 10) of mifepristone. In addition, serum samples were collected on day 3 (n = 4). Main outcome measures. The levels of mifepristone, quantified using radioimmunoassay. RESULTS: The milk concentrations of mifepristone were highest in the first samples collected during the first 12 hours following drug intake, and ranged from undetectable (< 0.013 micromol/l) to 0.913 micromol/l. Thereafter, declining concentrations of mifepristone were detected up to 7 days. The lowest levels of mifepristone in milk were measured following ingestion of the 200 mg dose. The milk:serum ratio of mifepristone ranged from < 0.013:1 to 0.042:1 on day 3 (n = 4). The calculated relative infant dose (RID) was 1.5% at its highest. CONCLUSIONS: The levels of mifepristone in milk are low, especially when using the 200 mg dose. Breastfeeding can be safely continued in an uninterrupted manner during medical abortion of this kind.

Mechanisms of action of hormonal emergency contraceptives.

Hormonal emergency contraceptives have been used to prevent unwanted pregnancy for more than 3 decades. The mechanisms of action of the regimen containing a combination of estrogen and progestin, known as the Yuzpe regimen, and those of the levonorgestrel regimen continue to be controversial, especially over the possibility that these regimens might act by interfering with implantation of the fertilized ovum. We performed a search of the PubMed (1949-July 2009) and EMBASE (1980-July 2009) databases to identify literature on the mechanisms of action of these contraceptive regimens, and data were extracted from pertinent English-language studies. We classified studies according to the approach taken by the investigators to study the actions of emergency contraceptives on pregnancy: an indirect method that uses statistical models to determine whether emergency contraceptives would be as effective as reported if they act only by disrupting ovulation; direct observation of the effects of emergency contraceptives on surrogate outcomes, including ovulation, sperm activity, hormonal levels, and endometrial receptivity to implantation; and analysis of directly observed pregnancy outcomes against statistical data. Acceptability of emergency contraceptives by women and clinicians may depend on personal opinions about when life or pregnancy begins. The evidence strongly supports disruption of ovulation as a mechanism of action. The data suggest that emergency contraceptives are unlikely to act by interfering with implantation, although the possibility has not been completely excluded. The data also suggest that emergency contraceptives are ineffective after ovulation. Women and clinicians who consider implantation or later events to be the beginning of pregnancy should be aware that emergency contraceptives are likely nonabortive by this definition of pregnancy.

What is the seminal exposition among women requiring emergency contraception? A prospective, observational comparative study.

OBJECTIVES: The aim of this study is to determine the number of sperm present in the vagina of women presenting for EC after unprotected intercourse or a condom accident. STUDY DESIGN: A total of 69 women requesting EC were included in a prospective, observational and comparative study. The absence or presence and number of spermatozoa present were examined under light microscopy in endocervical and vaginal smears. An ethinylestradiol-levonorgestrel combination (100 mcg/500 mg for two doses, 12 h apart) was then prescribed. Twenty couples were taken as controls. RESULTS: In 25 (36.2%) of the 69 women, spermatozoa were not observed. In the women in whom sperm could be identified, there were no significant differences in the mean (range) sperm count in relation to the reason for requesting EC, i.e., 11.0 (0.03-149.8) for condom slippage or breakage, and 8.1 (3.9-55) for unprotected intercourse. In the group of controls the median (range) number of spermatozoa (32.5 (2.5-304) was significantly higher (p=0.04) than the observed in the study group. CONCLUSIONS: In one-third of the women presenting for EC, no sperm were identified in the vagina. When sperm were present, the number was much lower than that after intercourse among women wishing to conceive. The risk of an unwanted pregnancy is probably, therefore, lower for women who present for EC compared with that for women who truly have unprotected intercourse.

Parivar Seva's experience with emergency contraceptive pills.

Parivar Seva, an NGO working in the area of reproductive health carried out an operation research project as a feasibility study on emergency contraception recently. The study was conducted among 1120 clients coming after unprotected sexual intercourse or improper use of any contraceptive method by using emergency contraception pills coming within 3 days and IUCD coming between 3 and 5 days of unprotected sexual intercourse. It was found that failure of emergency contraception was as low as 0.6%. The success rate in term of preventing pregnancy was 99.4% both with combined oral contraception pills and laevonorgesterol. There lies the scope for introducing emergency contraception in India wide and it can occupy a unique position in a range of contraceptive choices currently available to Indian women, as it can prevent unwanted pregnancies. A coalition of 30 like minded organisations including the Parivar Seva had formed a subcommittee on emergency contraception to evolve strategies to address promotion of emergency contraception.

Information, education and communication for emergency contraception.

The utilisation of the emergency contraception pills is very low both in the public and private sectors. The major reason for this under-utilisation is the lack of awareness about the method among the users or the providers. A real need arises to aware the potential users or the healthcare providers like obstetrician and gynaecologists, medical practitioners, family planning counsellors, nurses and ANMs. Wider dissemination of information, education and communication about emergency contraception relating to the proper usage, mode of action and provision is the need. The information, education and communication materials developed should always be in languages socioculturally appropriate to the target audience. Mass media like TV, newspapers and women's magazine should also be included for dissemination of messages. Service providers should be informed correctly about the method. Healthcare providers would need basic scientific information of the contents of the emergency contraception pills, mode of action, indications, contra-indications, etc. Emphasis should be put on the method for use only as an emergency or 'second chance' when a primary method is not used or has failed.

Interfering with implantation by postcoital estrogen administration. II. Endometrium epithelial cell ultrastructure.

Secretory human endometrium was studied by electron microscopy after high-dose ethinylestradiol administration, a method used for interception (morning-after pill). Medicated (experimental) cycles were compared to non-medicated (control) cycles in the same volunteers. The nucleolar channel system typically present in the nucleus of the epithelial cell in secretory phase of the human endometrium disappears completely as a result of this treatment, resulting in a nucleolar basket structure. Glycogen deposits were prominent at the basal membrane and in the apex of the cell during the experimental cycle. Giant mitochondria were observed to occur to similar extent during control and treatment cycles. This study confirms the morphological delay found in light microscopic studies, published earlier with diethylstilbestrol and with ethinylestradiol.

PIP: High-dose ethinylestradiol is used as a postcoital contraceptive. Its mechanism of action is to delay the secretory development of the endometrial epithelial cells. This study, using 4 normal volunteers, was undertaken to see the effects of high-dose ethinylestradiol on the ultrastructure of the endometrial cells and on glycogen metabolism during the luteal phase of the menstrual cycle. Ovulation was determined from plasma luteinizing hormone levels, and the subjects were given 5 mg ethinylestradiol for 5 consecutive days thereafter. The nucleolar channel system, which typically appears in the cell during the secretory phase, completely disappeared after treatment with ethinylestradiol. Moreover, the Golgi complexes were enlarged, and large amounts of glycogen accumulated at the basal membrane and in apical vacuoles of the cells. These changes show that large doses of ethinylestradiol given after ovulation interfere with the synthesis and secretion of glycogen in the endometrial epithelial cells.

Acceptability of injectable contraceptives in Assiut, Egypt.

The present work was a randomized comparative study of two injectable progestogen-only contraceptives. The first group (200 subjects) received 150 mg of depotmedroxyprogesterone acetate (Depoprovera) every 84 +/- 7 days and the second (200 subjects) received 200 mg of norethisterone enanthate (Noristerat) every 56 +/- 7 days. Acceptors of injectable contraceptives in Assiut, Egypt, were mainly women looking for fertility termination. Menstrual disruption was the main side effect among both treatment groups. Amenorrhoea was the commonest menstrual complaint and was the main reason for discontinuation in both groups. Only one pregnancy occurred during NET-EN use; two more pregnancies occurred, one in each of the two groups but there were indications that conception preceded the first injection. Menstrual irregularities were generally more frequent with DMPA users. However, DMPA had better one-year continuation rates than NET-EN (68.8 +/- 3.5 and 57.1 +/- 3.6 per 100 women, respectively).