"A part of my life". A qualitative study about perceptions of female genital mutilation and experiences of healthcare among affected women residing in Sweden.

BACKGROUND: Female genital mutilation (FGM) is defined as all procedures involving partial or total removal of the external female genitalia, or other injuries to them for non-medical reasons. Due to migration, healthcare providers in high-income countries need to better understand the consequences of FGM. The aim of this study was to elucidate women's experiences of FGM, with particular focus on perceived health consequences and experiences of healthcare received in Sweden. METHODS: A qualitative study was performed through face-to-face, semi-structured interviews with eight women who had experienced FGM in childhood, prior to immigration to Sweden. The transcribed narratives were analyzed using content analysis. RESULTS: Three main categories were identified : "Living with FGM", "Living with lifelong health consequences" and "Encounters with healthcare providers". The participants highlighted the motives behind FGM and their mothers' ambivalence in the decision process. Although the majority of participants had undergone FGM type 3, the most severe type of FGM, the lifelong health consequences were diverse. Poor knowledge about FGM, insulting attitude, and lack of sensitive care were experienced when seeking healthcare in Sweden. CONCLUSIONS: Our findings indicate that FGM is a complex matter causing a diversity in perceived health consequences in women affected. Increased knowledge and awareness about FGM among healthcare providers in Sweden is of utmost importance. Further, this subject needs to be addressed in the healthcare encounter in a professional way.

Mechanisms of action of oral emergency contraception.

This review gives an overview of the mechanisms of action of oral emergency contraception pills (ECPs), focusing on the levonorgestrel (LNG) and ulipristal acetate (UPA) containing ECPs. In vivo and in vitro studies have addressed the effect of EC on various possible targets. Based on these studies as well as on clinical trials it is clear that the efficacy of ECPs to prevent an unintended pregnancy depends on their mechanism of action as well as on their use in relation to the fertile window. While the main effect of both available ECPs is to prevent or delay ovulation the window of action for UPA is wider than that of LNG. This provides the biological explanation for the difference observed in clinical trials and the higher efficacy of UPA. Neither LNG nor UPA impairs endometrial receptivity or embryo implantation. Correct knowledge on the mechanism of action of ECPs is important to avoid overestimating their effectiveness and to advise women on correct use.

Emergency contraception.

This review will focus on the available methods for emergency contraception (EC), efficacy, side effects and mechanisms of action. Copper intrauterine device (IUD) has been shown to be the most effective method for EC which can be continually used for regular contraception. However, this possibility is seldom used and may be little known. Among the hormonal EC methods 1.5 mg levonorgestrel is the most widely used EC pill while the more recently developed Ulipristal acetate (UPA) has been shown to be the most effective option. This is probably due to a more pronounced prevention of follicular rupture compared with other hormonal EC methods. Knowledge is needed to better advise lactating women and obese women on optimal EC method. Furthermore a possible interaction of UPA with regular hormonal contraception and possibilities for "bridging" from EC to regular contraception needs to be explored. To increase efficacy future studies should focus on EC methods that target the endometrium.

Emergency contraception -- mechanisms of action.

Concerns regarding the mechanisms of action of emergency contraception (EC) create major barriers to widespread use and could also lead to incorrect use of EC and overestimation of its effectiveness. While the copper intrauterine device (Cu-IUD) is the most effective method available for EC, the hormonal methods are frequently considered to be more convenient and acceptable. Today, the most commonly used method for hormonal EC is levonorgestrel (LNG). More recently, the progesterone receptor modulator ulipristal acetate (UPA) has been shown to be more effective than LNG to prevent an unwanted pregnancy. The main mechanism of action of both LNG and UPA for EC is delaying or inhibiting ovulation. However, UPA appears to have a direct inhibitory effect on follicular rupture which allows it to be effective even when administered shortly before ovulation, a time period when use of LNG is no longer effective. The main mechanism of action of the Cu-IUD is to prevent fertilization through the effect of Cu ions on sperm function. In addition, if fertilization has already occurred, Cu ions influence the female reproductive tract and prevent endometrial receptivity. Based on this review of the published literature, it can be concluded that existing methods used today for EC act mainly through inhibition of ovulation or prevention of fertilization. An additional effect on the endometrium as occurs for the Cu-IUD, but not for the hormonal alternatives, seems to increase the efficacy of the method.