Implante hormonal subcutáneo: experiencia en una unidad clínica / Subdermal hormonal implant: an experience in a clinical unit

En España el número de Interrupciones Voluntarias de Embarazo (IVE) es elevado, así como la tasa de embarazos no deseados. en los últimos años ha variado notablemente el abanico de métodos anticonceptivos disponibles en nuestro país. Algunos de ellos, ya disponibles en otros países, se han introducido aquí, como es el caso del implante hormonal subcutáneo (IHS), considerado en la actualidad el anticonceptivo más eficaz, presentando además un excelente balance riesgo/beneficio. En el presente trabajo se analiza el perfil de las usuarias, así como los efectos adversos, grado de satisfacción e indicación del implante hormonal subcutáneo (IHS)

In Spain, the number of Volutary Interruptions of Pregnancy is high, as well as the rate of unintended pregnancies. Recently, the range of contraceptive methods available for Spaniards has widened considerably. Some of them, which were already available in other countries, have been introduced in Spain, such as the Subcutaneous Hormoonal Implant, regarded as the most effective contraceptive nowadays. Furthermore, it shows a great risk/benefit balance. The aim of this paper is the analysis of the users profile, the adverse effects, the degree of satisfaction and the methos used for women to carry the subdermal hormonal implant

Intercepción poscoital hormonal en un servicio de planificación familiar / Postcoital hormonal contraception in a family planning service

Objetivo. Conocer las características de la población atendida en el Servicio de Planificación Familiar de Lleida que demanda la intercepción poscoital, y conocer su uso y efectos en dicha población. Método. Se planteó un estudio epidemiológico observacional transversal, que fue realizado durante 3 años, entre 1999 y 2001. Se estudió a todas las mujeres que acudieron durante los 3 años al mencionado servicio de planificación familiar y que solicitaron la intercepción poscoital, a las que se aplicó una encuesta estructurada que fue cumplimentada por una enfermera del mismo servicio. Se recogieron variables relativas a aspectos sociodemográficos de las mujeres y al uso y a los efectos de la intercepción poscoital. Resultados. Las 2.813 mujeres estudiadas tenían una media de edad de 21,5 años. El 92,3% (2.577) conocía la existencia de la intercepción poscoital, pero 2.018 (72,3%) de ellas la demandaban por primera vez. El motivo principal de la demanda era la rotura del preservativo, con una frecuencia de 1.741 (62,1%). Las mujeres tardaban 33,7 h de promedio en solicitar el tratamiento. La menstruación apareció en el 98,6% de las mujeres que acudieron al control poscoital. Conclusiones. Los resultados encontrados en el presente estudio coinciden bastante con los de la bibliografía especializada. Creemos que es necesario potenciar la educación sexual de la juventud

Objective. To determine the characteristics of the population seeking postcoital hormonal contraception in the family planning service of Lleida (Spain) and to determine the use and effects of this form of contraception in this population. Method. We performed an epidemiological, observational, cross-sectional study over a 3-year period (1999-2001). All women who attended the family planning service in the study period and who requested postcoital hormonal contraception were included. In all subjects a structured interview was performed by a nurse from the family planning service. Variables relating to sociodemographic factors and the use and effects of this form of contraception were gathered. Results. A total of 2813 women were studied. The mean age was 21.5 years. Nearly all the women (92.3% [2577]) knew about postcoital hormonal contraception but 2018 (72.3%) had not requested it previously. The main reason for seeking this form of contraception was condom rupture, with a frequency of 1741 (62.1%). The mean interval before requesting postcoital hormonal contraception was 33.7 hours. Menstruation occurred in 98.6% of the women who sought emergency contraception. Conclusions. The results of the present study are in fairly close agreement with those reported in the specialist literature. We believe that sex education should be increased among young peopleObjective. To determine the characteristics of the population seeking postcoital hormonal contraception in the family planning service of Lleida (Spain) and to determine the use and effects of this form of contraception in this population. Method. We performed an epidemiological, observational, cross-sectional study over a 3-year period (1999-2001). All women who attended the family planning service in the study period and who requested postcoital hormonal contraception were included. In all subjects a structured interview was performed by a nurse from the family planning service. Variables relating to sociodemographic factors and the use and effects of this form of contraception were gathered. Results. A total of 2813 women were studied. The mean age was 21.5 years. Nearly all the women (92.3% [2577]) knew about postcoital hormonal contraception but 2018 (72.3%) had not requested it previously. The main reason for seeking this form of contraception was condom rupture, with a frequency of 1741 (62.1%). The mean interval before requesting postcoital hormonal contraception was 33.7 hours. Menstruation occurred in 98.6% of the women who sought emergency contraception. Conclusions. The results of the present study are in fairly close agreement with those reported in the specialist literature. We believe that sex education should be increased among young people

Reproductive consequences of contraceptive failure in 19 developing countries.

OBJECTIVE: To ascertain the contribution of contraceptive failure to unintended births and fetal loss in developing countries. METHODS: Nationally representative survey data from married women in 19 developing countries were analyzed. All surveys contained retrospective monthly calendars of contraceptive use and pregnancies for a 5-year period preceding each survey. Information on the intendedness of live births, ascertained earlier in the interview, were linked to the calendar data. Single-decrement life table analysis was applied to episodes of use to estimate failure probabilities. The reproductive consequences of failure were established by simple tabulation. Logistic regression was used to explore the determinants of fetal loss. RESULTS: Reported contraceptive failure rates were similar to those derived from studies conducted mainly in the United States. About three fourths of pregnancies resulting from contraceptive failure were carried to term, and all but 16% of those were classified by the mother as unwanted or mistimed. Just over one tenth ended in fetal loss, either induced or spontaneous. Analysis of determinants of fetal loss suggested that a large proportion were induced. The median contribution of failure to all unintended births for all 19 surveys was about 15%, and the contribution to fetal loss was 12%. CONCLUSION: The contribution of contraceptive failure in developing countries is much lower than the estimate of 50% in the United States. Despite the substantial increases in contraceptive practice that have occurred in Asia, Latin America, the Middle East, and to a lesser extent, Africa, the level of use is still below the 75% mark achieved in most industrialized countries. Nonuse of contraception remains the dominant direct cause of unintended births, and family planning promotion should remain a public health priority.

Expanded state-funded family planning services: estimating pregnancies averted by the Family PACT Program in California, 1997-1998.

OBJECTIVES: The California Family Planning, Access, Care, and Treatment Program was implemented in 1997 to provide family planning services for uninsured, low-income women and men. We estimated the impact on fertility of providing 500 000 women with contraceptives. METHODS: Paid claims and medical record review data were used to estimate pregnancies averted. Pregnancies women experienced while enrolled in the program and pregnancies they would have experienced given methods used before enrollment were modeled as a Markov process. RESULTS: One year of Family Planning, Access, Care, and Treatment services averted an estimated 108 000 unintended pregnancies that would have resulted in 50 000 unintended births and 41 000 induced abortions. CONCLUSIONS: Providing contraceptives to low income, medically indigent women significantly reduced the number of unintended pregnancies in California.

Implanon and medical indemnity: a case study of risk management using the Australian standard.

The contraceptive implant Implanon (Organon) was introduced in Australia in May 2001, and in the next 18 months was associated with an unprecedented number of adverse incident reports to medical indemnity insurers, including almost 100 unintended pregnancies. The medical indemnity insurer, MDA National, responded to this by applying the Australian and New Zealand Standard for Risk Management (AS/NZS 4360: 1999) in two stages. The first stage was to contain potential costs by moving the treatment into the general practice procedural category, resulting in a one-year moratorium on its use for most general practitioner members (prudential risk management). The second stage was to manage the clinical risk by developing strategies to reduce identified risks associated with the procedure. The Royal Australian College of General Practitioners (RACGP) was enlisted to develop guidelines for use of Implanon, with a consent form and checklists for doctors and patients, enabling MDA National to reinstate the treatment to the general practice non-procedural category. This case demonstrates the need for early risk assessment and development of risk-management tools for new treatments and devices, a role that is appropriate for the RACGP.

[Adolescent sexuality in rural Norway 1997-2001]. / Ungdom og seksualitet i Utkant-Norge 1997-2001.

BACKGROUND: In order to understand and prevent unwanted health consequences related to sexual behaviour, we need to know the status and changes of sexual behaviour in adolescence. MATERIAL AND METHOD: In 1997 and 2001, surveys were conducted including a total of 1665 adolescents and young adults aged 15 to 24 (response rate > 90%) in secondary schools in a small town in a rural district in Norway. We analysed frequencies for boys and girls and estimated the change in median age of first intercourse. Logistic regression analyses of median age and other health-related parameters were performed. RESULTS: A greater proportion of the respondents reported sexual experience in 2001 than in 1997. Girls have their first intercourse at a younger age than boys, often with older partners. 21% of the girls had experienced unwanted sexual situations. Use of contraception has increased, though insignificantly. Still, 11% of sexually active girls had had unwanted pregnancies. First intercourse during adolescence is clearly associated with other forms of behaviour that compromise health. However, a great and stable majority report a stable partner during adolescence. CONCLUSIONS: In accordance with other studies we find changes in sexual behaviour over a short period of time among adolescents in rural Norway. Stable sexual relations may still be a protective factor.

Unintended pregnancy among newly married couples in Shanghai.

CONTEXT: Though contraceptive failure and induced abortion in China have both attracted research attention, the somewhat broader topic of unintended pregnancy has been neglected. METHODS: A total of 7,872 newly married couples, enrolled between 1987 and 1988, were followed up until 1994-1995; only 2% were lost to follow-up. During face-to-face interviews, background and fertility-related data were collected. Chi-square tests and logistic regression were used to assess associations with unintended pregnancy. RESULTS: By three months after marriage, 461 couples had conceived; 57% of nonpregnant wives said that their preferred interval between marriage and conception was no more than three months. Twenty-one percent of pregnancies occurring between marriage and first birth were reported as unintended; 81% of these resulted from contraceptive failure. The majority of unintended pregnancies were carried to term; 13% were aborted. The younger the wife and the greater her desired interval between marriage and conception, the greater the likelihood that a pregnancy occurring before first birth was unintended. After first birth, 43% of couples experienced one or more unintended pregnancies, 98% of which were aborted in accordance with the one-child policy. The majority of these pregnancies occurred in the 12 months after first birth, when couples tend to rely on ineffective methods of contraception. The odds of having an unintended pregnancy after first birth were slightly elevated if at least one spouse desired a second child. CONCLUSIONS: Unintended pregnancies are common among married couples in Shanghai. Policies to reduce unintended pregnancies, and abortions, should focus particularly on postpartum contraception.

Reassessing the level of unintended pregnancy and its correlates in Vietnam.

Despite rapidly increasing contraceptive use and rapidly declining fertility, unintended pregnancy and induced abortion remain common in Vietnam. This study reassesses the level of unintended pregnancy in Vietnam and its correlates, drawing on retrospective calendar data gathered for the Vietnam Demographic and Health Survey II. Data from 13,540 "segments" of outcomes and contraceptive practice were analyzed. Based on the calendar data, 40 percent of pregnancies during the 1994-97 period are estimated to have been unintended, a proportion 48 percent higher than the prevailing estimate calculated from the reported intendedness of live births. When concealment of pregnancies ending in induced abortions is taken into account, the unintended pregnancy rate in Vietnam is likely to approach levels found only in developing countries. Unintended pregnancy was found to be associated with age, early marriage, spousal age difference, number of living sons, past unintended pregnancy, geographic region, contraceptive use prior to pregnancy, and the family planning supply environment. The findings suggest that broadening the method mix at the community level, targeting high-risk and underserved groups, and expanding postabortion counseling and services are likely to have a dramatic impact on the unintended pregnancy rate in Vietnam.

Supportive counseling before and after elective pregnancy termination.

Midwives are likely to encounter women seeking care before or after an elective abortion. National estimates of abortion rates suggest that 43% of women in the United States will have at least one abortion by the time they are 45 years old. By not asking women about abortion experiences, providers risk perpetuating women's guilt, shame, and silence. This article describes the emotional consequences of elective abortion, identifies women at high risk for negative reactions, and offers approaches to counseling about the psychosocial effects of abortion both before and after the procedure. Through the provision of counseling for women who have abortions, providers will be able to assist with coping, identify women who might be at greater risk for psychological sequelae, and offer referrals to those in need.

Effect of hormonal emergency contraception on bleeding patterns.

Spotting following the use of emergency contraception is not unusual, nor is anxiety in women waiting to see if the treatment has worked. It is not known whether such spotting should bring worry or relief. We, therefore, wished to see if there was any correlation between bleeding pattern and treatment outcome. Using data from a large multicenter efficacy trial, we examined bleeding patterns post-emergency contraception. The earlier in the cycle the pills were taken, the more likely the next bleed was to be early and the less likely it was to be on time. There was no observable difference in spotting rates between women who got pregnant and those who did not. The occurrence of spotting did not influence whether the next period was lighter or heavier.

Two-year performance of a Nestorone-releasing contraceptive implant: a three-center study of 300 women.

A 2-year trial of a single Nestorone (NES) rod implant was conducted at three Latin American centers, each enrolling 100 women. We studied the safety, effectiveness and acceptability of this progestin-releasing contraceptive implant. Three pregnancies occurred, the last at 18 months of use. Because no pregnancies were expected in the first 18 months, the trial was halted. At that time, 224 women had completed at least 18 months of use, and 99 women had used the implant for more than 24 months. Few participants used adjunctive contraception between the time the study was halted and the time they had their implant removed. No additional pregnancies occurred before the removal of the last implant. The 2-year cumulative pregnancy rate was 1.7 per 100 with a Pearl index of 0.6 per 100 for the 2-year period. The 1-year and 2-year continuation rates were 80.5 and 66.7 per 100, respectively. Menstrual and medical disturbances were the principal reasons for discontinuation, followed by planned pregnancy. Headache and weight gain frequently led to discontinuation. The NES implant had little important effect on most clinical chemistry and lipid parameters. Over the study course, the mean change in hemoglobin was <1%. Slight modification of the design of this single 2-year implant, restoring features previously examined in clinical trials, is likely to improve its effectiveness. A single NES implant appears to provide acceptable contraception for women.

Periodic abstinence in developing countries: an assessment of failure rates and consequences.

It is estimated that 27 million couples, representing 2.6% of all couples in the reproductive span, use periodic abstinence (PA). Using data from 15 national surveys in low and middle-income countries, this article assesses characteristics of PA users, knowledge of the fertile period, accidental conceptions while using PA and the reproductive consequences of these conceptions. Current users of PA (predominantly the simple calendar variant) tend to be more educated and urban than users of other methods. The method is preferred by young single women and older married women. The proportion of users with correct knowledge of the timing of ovulation ranges from 8% to 91%, with a median value of 62%. The median 12-month gross failure rate was 24 per 100 episodes. Net of other predictors of failure, correct knowledge of the timing of ovulation was associated with a 12% decrease in failure probabilities. Couples who experienced PA failure were more likely than couples who experienced failure with another method to carry the pregnancy to term. Nevertheless, PA still contributes to one-sixth of all abortions (or miscarriages) following contraceptive failure.

Unintended pregnancy and induced abortion among unmarried women in China: a systematic review.

BACKGROUND: Until recently, premarital examination for both men and women was a legal requirement before marriage in China. Researchers have carried out surveys of attendees' sexual activity, pregnancy and abortion before their marriages, trying to map out reproductive health needs in China, according to this unique population-based data. To systematically identify, appraise and summarise all available studies documenting pregnancy and induced abortion among unmarried Chinese women attending premarital examinations. METHODS: We searched the Chinese Biomedical Literature Index from 1978 to 2002; PUBMED; and EMBASE. Trials were assessed and data extracted by two people independently. RESULTS: Nine studies, of which seven were conducted in the urban areas, one in the rural areas, and one in both urban and rural areas, met the inclusion criteria. In the seven studies in urban areas, the majority of unmarried women had experienced sexual intercourse, with estimates ranging from 54% to 82% in five studies. Estimates of a previous pregnancy ranged from 12% to 32%. Abortion rates were high, ranging between 11 to 55% in 8 studies reporting this, which exclude the one rural study. In the three studies reporting both pregnancy and abortion, most women who had become pregnant had an induced abortion (range 86% to 96%). One large rural study documented a lower low pregnancy rate (20%) and induced abortion rate (0.8%). CONCLUSIONS: There is a large unmet need for temporary methods of contraception in urban areas of China.

'Failed' contraception in a rural South African population.

OBJECTIVE: To investigate whether the free availability of contraception affects the need for termination of pregnancy (TOP). DESIGN: Case-control study. SETTING: South African rural hospital. POPULATION: Three thousand and ninety-five TOP seekers and 439 non-pregnant controls. METHODS: Structured questionnaire followed by ultrasonography. MAIN OUTCOME MEASURES: Current use or recent discontinuation of contraception and the reason for discontinuation. RESULTS: Less than one-third (28.6%) of TOP seekers claimed to be using contraception versus 85.0% of controls. Injectable contraception (IC) was preferred by the controls and oral contraception (OC) by TOP seekers (chi 2 = 48.5, p < 0.0001, OR 0.34 (95% confidence interval 0.25, 0.46)). The percentage of discontinuation of hormonal contraception was higher in controls (chi 2 = 6.3, p = 0.012, OR 0.51 (0.31, 0.85)). The reason for discontinuation of hormonal contraception was obtained from 31.2% of TOP seekers and 63.3% of controls; no reason for discontinuation was acknowledged by 30.1% of the former and 6.3% of the latter (chi 2 = 33.4, p < 0.0001, OR 6.40 (3.25, 12.56)). Side-effects of hormonal contraception prompted more discontinuation in the failed-contraception group (chi 2 = 120.5, p < 0.0001, OR 49.4 (21.6, 112.5)). Poor compliance and absence of an acknowledged reason for discontinuing hormonal contraception resulted in 173 unwanted pregnancies. CONCLUSION: In South Africa two main components of women's reproductive health and rights are freely available, namely contraception and TOP. Not using contraception is one of the main causes of unwanted pregnancy. Better education of both service providers and users is needed to improve use, compliance and perseverance with contraception.

Contraception before and after termination of pregnancy: can we do it better?

AIM: To compare contraceptive use pre- and post-therapeutic abortion in 1995, 1999 and 2002 in a New Zealand clinic. METHODS: Retrospective, consecutive case review of women presenting for therapeutic abortion. Anonymous data included demographic details, contraception used at conception, and post-termination contraception. RESULTS: Pre-conception contraceptive use is significantly declining, with post-termination condom choice increasing. This is predominantly due to increasing numbers of Asian women presenting for abortion. In 2002, 97% of Asian women used no contraception or only condoms pre-conception, and 62% chose condoms or abstinence post-termination. Oral contraceptives are used significantly less by Asian than European women both pre-termination (p = 0.0002) and post-termination (p = 0.00001). Other ethnic groups showed little change in contraceptive use over the study periods. CONCLUSIONS: It is speculated that ethnic Chinese women lack adequate contraceptive education, demonstrate distrust of non-barrier methods, believe men should provide the prophylactic, and mistakenly believe contraception unnecessary for the first week following menstruation. Abortion may be used for family planning rather than as back up for contraceptive failure. Young Chinese arriving in New Zealand require immediate sexual health education including accurate contraceptive information. Liaison between primary healthcare sectors and policy makers of immigration and other services assisting overseas students is recommended to provide culturally appropriate education.

Adolescent abortion: trends and techniques.

The adolescent years are often characterized by high-risk behaviors. These behaviors carry consequences with them, including pregnancy and abortion. Although the abortion rate for adolescents has been decreasing since 1990, not all groups have seen an equal drop; notably, those adolescents not in school and members of minority groups are experiencing slower rates of decline. Adolescents undergo the same methods of abortion as adults; however, they have unique psychosocial needs, such as parental involvement and the prevention of future unwanted pregnancies, which should be assessed.

Abortion, contraceptive use, and adolescent pregnancy among first-year medical students at a major public university in Mexico City.

OBJECTIVE: If properly trained, medical students could become future opinion leaders in health policy and could help the public to understand the consequences of unwanted pregnancies and of abortions. The objective of this study was to analyze the frequency of unwanted pregnancies and induced abortions that had occurred among women who were first-year medical students at a major public university in Mexico City and to compare the experiences of those women with the experiences of the general population of Mexican females aged 15 to 24. METHODS: In 1998 we administered a cross-sectional survey to all the first-year medical students at the National Autonomous University of Mexico, which is the largest university in Latin America. For this study we analyzed 549 surveys completed by female students. RESULTS: Out of the 549 women, 120 of them (22%) had been sexually active at some point. Among those 120 sexually active students, 100 of them (83%) had used a contraceptive method at some time, and 19 of the 120 (16%) had been pregnant. Of those 19 women who had been pregnant, 10 of them had had an illegal induced abortion (in Mexico, abortions are illegal except under a small number of extenuating circumstances). The reported abortion rate among the female medical students, 2%, was very low in comparison with the 11% rate for women of similar ages in the Mexican general population. CONCLUSIONS: The lower incidence of abortion among the female medical students indicates that when young Mexican women have access to medical information and are highly motivated to avoid unintended pregnancy and abortion, they can do so.