C-reactive protein, an indicator for maintained response or remission to infliximab in patients with Crohn's disease: a post-hoc analysis from ACCENT I.

BACKGROUND: Secondary loss of response to anti-TNF-α therapy is observed in Crohn's disease patients. AIM: Serum C-reactive protein (CRP) levels at baseline and after infliximab induction therapy at week 14 were assessed as predictors for maintained response or remission through 54 weeks of treatment in patients with Crohn's disease who responded to induction therapy. METHODS: ACCENT I was a multicenter, randomised, placebo-controlled study. Patients who received infliximab induction (weeks 0, 2 and 6) and maintenance (5 or 10 mg/kg every 8 weeks beginning at week 14) therapy were considered. Patients in clinical response or remission to induction therapy at week 14 (n = 212 or n = 138 respectively) were analysed. Associations between CRP levels (cut-off points 0.5-3.0 mg/dL), baseline disease variables and maintained clinical response or remission during maintenance therapy were assessed. RESULTS: A significant association was observed between baseline CRP levels and maintained remission. Forty-five percent of patients with baseline CRP ≥ 0.7 mg/dL vs. 22.0% with CRP < 0.7 mg/dL maintained remission (P = 0.012). CRP normalisation during infliximab treatment (decrease from 0.5 mg/dL at baseline to < 0.5 mg/dL at week 14) resulted in higher probability of maintained response (P < 0.001) or remission (P = 0.052). At week 14 low CRP levels were associated with maintained response (56.6% of patients with CRP < 0.5 mg/dL vs. 37.2% with higher CRP, P = 0.005). No optimal predictive CRP cut-off point was observed. CONCLUSIONS: High baseline CRP levels increased the likelihood of maintained remission. Normalised CRP levels at week 14 increased the likelihood of maintained response or remission during 1 year of infliximab maintenance therapy ( CLINICAL TRIAL: NCT00207662).

Climacteric and menopause in seven south-east Asian countries.

The menopause is universal, but what about the climacteric? In an attempt to answer this question, a study was conducted in seven south-east Asian countries, namely, Hong Kong, Indonesia, Korea, Malaysia, the Philippines, Singapore and Taiwan. Samples of approximately 400 women in each country were questioned about a number of climacteric complaints, incontinence and dyspareunia, consultation of a physician, menopausal status and several background characteristics. Special care was taken to overcome linguistic and cultural problems, and the data collected were kept as objective as possible. From the results obtained we were able to show that the climacteric was indeed experienced in south-east Asian countries, although in a mild form. The prevalence of hot flushes and of sweating was lower than in western countries, but was nevertheless not negligible. The percentages of women who reported the more psychological types of complaint were similar to those in western countries. The occurrence of climacteric complaints affected perceived health status. A physician was consulted for climacteric complaints by 20% of the respondents, although this was most frequently associated with the occurrence of psychological complaints and less so with that of hot flushes and sweating. The median age at menopause (51.09) appeared to be within the ranges observed in western countries. Ethnic background and age at menarche were found to have a significant influence on age at menopause. The study clearly demonstrated that climacteric complaints occur in south-east Asia. The findings suggest, however, that vasomotor-complaint-related distress might be 'translated' into psychological complaints, which are more frequently considered to warrant consulting a physician.

Factors influencing women's satisfaction with birth control methods.

OBJECTIVES: To study the extent to which variation in satisfaction with a birth control method is explained by variation in perceived physical and psychological effects. METHODS: A population survey among 1466 German women was carried out. Within the overall sample, 1303 women had ever used oral contraceptives, 996 had relied on condoms, 342 had ever used intrauterine devices (IUD), 428 had used natural family planning and 139 women were sterilized. For each method a woman had ever used, she answered questions about satisfaction with the method, concerns about getting pregnant or suffering health risks during use, ease of use, changes in sexual relationship, relationship with the partner and mood. Past and current users of oral contraceptives and IUDs and sterilized women additionally reported changes in menstrual bleeding. RESULTS: Variation in satisfaction was, for a large part, explained by variation in health concerns among oral contraceptive users, by variation in perceived changes in the quality of the sexual relationship among condom users, by perceived ease of use among IUD users and sterilized women, and by variation in pregnancy concern among natural family planning users. CONCLUSION: Counselling about these perceived experiences is most likely to result in greater satisfaction and therefore improved compliance.

Determinants of long-term hormone replacement therapy and reasons for early discontinuation.

OBJECTIVE: To identify factors associated with long-term hormone replacement therapy (HRT) and reasons for early discontinuation of it. METHODS: A cross-sectional study was conducted in four United Kingdom group general practices. Six hundred fifteen past or present HRT users (representing a response rate of 66%) responded to questionnaires on HRT and potential determinants of long-term use. Main outcome measures were long-term HRT use (at least 6 years) as opposed to short-term use (at most 2 years) and self-reported reasons for discontinuation. Odds ratios (ORs) of long-term use were adjusted for age and other variables, in the same groups, calculated by logistic regression and 95% confidence intervals (CIs). RESULTS: Ovariectomy (OR 2.59, 95% CI 1.12, 5.97), hysterectomy (OR 2.28, 95% CI 1.37, 3.79), previous oral contraceptive use (OR 1.76, 95% CI 1. 03, 3.01), HRT prescription to prevent osteoporosis (OR 1.81, 95% CI 1.04, 3.13), opinion that HRT prevents health problems (OR 3.22, 95% CI 1.57, 6.63), opinion that HRT is associated with health risks (OR 0.23, 95% CI 0.08, 0.65), and opinion that HRT has cosmetic benefits (OR 2.52, 95% CI 1.45, 4.40) were statistically significantly associated with long-term HRT. Women surveyed most often reported side effects and weight gain (each about 30%) as reasons for discontinuation, followed by possible health risks and dislike of menstrual bleeding or hormones (each about 15%). CONCLUSION: Ovariectomy, hysterectomy, and opinions about benefits and disadvantages of HRT were the most important determinants of long-term use, whereas women themselves mentioned side effects and weight gain most frequently as reasons for discontinuing it.

Preferred frequency and characteristics of menstrual bleeding in relation to reproductive status, oral contraceptive use, and hormone replacement therapy use.

This study addresses attitudes towards changes in menstrual bleeding patterns caused by oral contraceptives (OC) or hormone replacement therapy (HRT) and preferred changes in bleeding pattern with and without use of OC or HRT in relation to reproductive age group. Data were collected by means of telephone interviews with 325 women in each of four age groups (15-19, 25-34, 45-49, and 52-57 years). In total, 80.5% of currently menstruating women preferred one or more changes in bleeding pattern such as less painful, shorter, or less heavy periods, or amenorrhea. The majority of the menstruating women in all age groups preferred to have a bleeding frequency of less than once a month or never, whether the bleeding was spontaneous or induced by OC. In the case of HRT, amenorrhea was most preferred. These findings with respect to preferred bleeding frequency and OC may have important implications for health care providers and for future contraception development.

PIP: This study addresses attitudes toward changes in menstrual bleeding patterns caused by oral contraceptives (OCs) or hormone replacement therapy (HRT) and preferred changes in bleeding pattern with and without use of OCs or HRT in relation to reproductive age group. A survey on 325 Dutch women from each of four age categories (15-19, 25-34, 45-49, and 52-57 years) was conducted through telephone interviews. Results showed that OC users and menstruating women prefer one or more changes in bleeding characteristics such as less painful, shorter, or lighter periods. It was less significant in the non-OC users in all age groups (75.1% vs. 86.3%, p = 0.016, in women aged 15-19 years; 60.0% vs. 72.3%, p = 0.030, in women aged 25-34 years; 50.9% vs. 74.5%, p = 0.002, in women aged 45-49 years). Most women would prefer a bleeding frequency of less than once a month or never. The proportion of women who reported amenorrhea as a positive consequence of OC/HRT use increased with age. These findings provide significant implications for health care providers in future contraception development.

Women's satisfaction with birth control: a population survey of physical and psychological effects of oral contraceptives, intrauterine devices, condoms, natural family planning, and sterilization among 1466 women.

User satisfaction and the physical and psychological effects of five commonly used contraceptive methods were investigated in a population survey among 1466 West German women. The focus was on effects attributed by current and past users to these methods, rather than objectively assessed effects, to shed further light on personal experiences that are highly relevant to the user but often remain unknown to prescribers and unreported in the medical literature. Within the overall sample, 1303 women were surveyed concerning their current or past use of oral contraceptives (OC), 996 regarding condoms, 342 with respect to intrauterine devices (IUD), 428 in regard to natural family planning (NFP), and 139 in relation to sterilization (respondents completed questions about each method used). It emerged that satisfaction was greatest with sterilization (92% of users), followed by OC (68% of ever users), IUD (59%), NFP (43%), and condoms (30%). Almost one in three NFP users had experienced an unwanted pregnancy during use of this method, as compared with one in 20 OC and condom users. The majority of users reported no mood changes during use of the methods studied. The percentages reporting negative mood changes (various items were scored) were up to 16% among OC users, 23% among condom users, and 30% among NFP users. The latter observations suggested that subjective side effects of a contraceptive agent on mood generally reflected, at least in part, the user's sense of confidence in the method concerned (notably, with regard to efficacy and safety). Oral contraceptives, IUD, and sterilization had a broadly positive impact on sex life, whereas that of condoms was often negative. Whereas OC users often reported less heavy and painful menstruation (in up to 56% of cases), IUD were associated with heavier, prolonged, and more painful menstruation (in up to 65% of cases), as also was sterilization, although to a lesser extent (in up to 32% of cases). Overall, the study findings indicated that OC and sterilization had less negative impact on physical and psychological functioning than the other methods studied, in contrast to what the general public often believes.

PIP: A survey covering sociodemographic characteristics, contraceptive use, and previous use of oral contraceptives (OCs), condoms, IUDs, and natural family planning (NFP) was conducted among 1466 West German women to evaluate their satisfaction with their birth control method. The focus was on the effects attributed to these methods by current and past users to of them rather than on objectively assessed effects. The aim was to gain insight into personal experiences that are very significant to the user but often remain unknown to prescribers and unreported in the medical literature. Results showed that almost 1 in 3 NFP users had had an unwanted pregnancy during the period of use; the figure was 1 in 20 among OC and condom users. A majority of users for each method claimed no mood changes during the use of that method. Negative mood changes were reported among 16% of OC users, 23% of condom users, and 30% of NFP users. The subjective side effects of a contraceptive agent on mood were observed to reflect the user's sense of confidence in the method concerned. OC, IUD and sterilization had a broadly positive impact on sex life, while that of the condom was always negative. OC users reported less heavy and painful menstruation. IUDs were associated with heavier, prolonged and more painful menstruation, as was sterilization to a lesser extent. The satisfaction rate among OC and sterilization users was generally higher than that among those who used other methods. Overall, OC and sterilization had less of a negative physical and psychological impact than did the other methods.

Psychosocial experiences in women facing fertility problems--a comparative survey.

In a survey involving 281 patients awaiting assisted reproduction treatment at five centres in three countries, and 289 population controls, we investigated whether the patients had experienced more negative emotional feelings and negative emotional impact during periods when they were attempting to conceive as compared with the controls, and whether there was any difference in their well-being at the time of consultation. The study was performed in the context of currently divergent views as to the burden of fertility problems. The survey was carried out using questionnaires of the self-administration type. Women with fertility problems did in fact consistently report a higher prevalence of negative emotions than the controls with reference to the periods during which they had been trying to conceive. Patients reported more changes in interpartner relationships (either negative or positive). Sexuality was negatively affected among the patients. At the time of consultation, the patients had less favourable scores than the controls on scales for depressed mood, memory/concentration, anxiety and fears, as well as for self-perceived attractiveness. One in four (24.9%) of the patients had scores indicating depressive disorders as compared with only 6.8% of the controls. Current well-being was even more markedly affected in patients with previous unsuccessful in-vitro fertilization (IVF) experience. The 'infertility' life event was perceived as severe by both patients and controls. Both prior to consultation and during diagnosis and treatment, women with fertility problems had a higher prevalence of reported negative psycho-emotional experiences than women without fertility problems.

A scenario study of oral contraceptive use in Japan. Toward fewer unintended pregnancies.

A scenario study was conducted to assess the extent to which the unintended pregnancy rate in Japan, where oral contraceptives (OC) have not been legalized for family planning purposes and couples rely mainly on condoms, might change if more women were to use OC. Because current rates of unintended pregnancy and abortion in Japan are not known, data provided by the 1994 Japanese National Survey on Family Planning were used to construct scenarios for national contraceptive use. Annual failure rates of contraceptive methods and nonuse were applied to the contraceptive use scenarios, to obtain estimates of the annual number of contraceptive failure-related pregnancies. Subsequently, contraceptive practice situations assuming higher OC use rates were defined, and the associated change in the number of contraceptive failure-related pregnancies was estimated for each situation. It emerged that OC use rates of 15% decreased the expected number of unintended pregnancies by 13%-17%, whereas use rates of 25% resulted in decreases of 22%-29% and use rates of 50% in decreases of 45%-58%. The findings were reasonably robust to variation in the assumptions that were made. In conclusion, each theoretical percentage increase in the OC use rate in Japan was found to lead to a roughly equivalent percentage decrease in the number of unintended pregnancies.

PIP: A scenario study was conducted in Japan, where oral contraceptives (OCs) have not been legalized for family planning purposes, to assess the extent to which more widespread OC use would reduce the unintended pregnancy rate. This approach was necessary because of the lack of national data on current rates of either induced abortion or unintended pregnancy. Scenarios for national contraceptive use were constructed on the basis of data from the 1994 Japanese National Survey on Family Planning. Annual failure rates associated with various contraceptive methods and contraceptive nonuse were applied to the survey data. It was assumed that women in need of contraception who currently used no method or relied on rhythm, basal body temperature, withdrawal, condoms, and spermicides were potential OC users. Estimations suggested that an OC use rate of 15% would decrease the expected number of unintended pregnancies by 13-17%, while use rates of 25% and 50% were associated with decreases of 22-29% and 45-58%, respectively. The percentage changes in the predicted numbers of unintended pregnancies were very robust to the various assumptions made, despite uncertainty about current numbers of unintended pregnancies in Japan and the contraceptive needs of nonusers. In the 1994 survey, 13% of women who knew about OCs said they would use the method if it became available.

Hormone replacement therapy among Danish women aged 45-65 years: prevalence, determinants, and compliance.

OBJECTIVE: To study the prevalence and determinants of consultation for climacteric complaints and the prescription, commencement, and continuation of hormone replacement therapy (HRT) among women aged 45-65 years. METHODS: A cross-sectional national survey was conducted in Denmark in November 1994 among 1459 women. A total of 1015 women (response rate 69.6%) agreed to participate and provided questionnaire data. RESULTS: Of the women who had experienced climacteric complaints, 67.4% (95% confidence interval [CI] 63.3, 71.4%) had consulted a physician. More women consulted if their complaints were severe rather than slight-to-moderate (odds ratio [OR] 6.46). Within the total sample, 33.4% of the women had been prescribed HRT at some time, and 94.1% of these women actually had started the treatment. Of the women who started the treatment, 66.3% reported that they still were using HRT at the time of the survey. The current HRT use rate among all respondents was 18.4% (95% CI 16.1, 20.9%). Women with severe or slight-to-moderate climacteric complaints more often reported having had HRT prescribed than women without complaints (OR 23.2 and 5.80, respectively). Furthermore, women who had had a hysterectomy with bilateral oophorectomy more often reported use than women with an intact uterus (OR 10.0). Hormone replacement therapy prescription was associated only weakly with osteoporosis concerns (OR 1.74). Its continuation decreased with age, was higher after hysterectomy and among women who regularly participated in sports or exercised, but was not (P > .05) related to osteoporosis concerns. Age-specific HRT continuation rates decreased among users who reported withdrawal bleeding (P < .05) but not among users who did not experience such bleeding (P > .05). CONCLUSION: In this survey, HRT had been used by one in three women at menopause, mainly for the alleviation of climacteric complaints and hardly ever because of osteoporosis concerns. Although it might be expected that HRT users who are concerned about developing osteoporosis in later life would be likely to continue the treatment for longer than other users, the study results did not bear this out. Continuation depended mainly on having had a hysterectomy and participation in sports and was higher among users with an intact uterus if they had had no withdrawal bleeding.

Determinants of contraceptive use among women of reproductive age in Great Britain and Germany. I: Demographic factors.

Multifactorial analyses of data from representative British and German national contraception surveys were used to examine the principal demographic determinants of contraceptive use by women. Contraceptive use appeared to be determined mainly by reference to 'reproductive status' (the combined impact of age, marital status, parity and future child wish). Women who were postponing pregnancies were using oral contraceptives, whereas those who wanted no more children relied more on intrauterine devices or sterilisation. Differences between the countries suggested that the choice of contraceptive method was influenced by health care policy, the organisation of the relevant services and differential provider preferences. The contraceptive method used was also related to having occasional rather than steady sexual partners (more condom use), lower educational level (less oral contraceptive use) and frequent church attendance (greater use of condoms and periodic abstinence). Contraception decisions appeared to follow a fixed pattern, based more on a couple's demographic situation (reproductive status, country, educational level and religious beliefs) than on the characteristics of the contraceptive methods. This resulted in an unnecessarily restricted choice of methods.

PIP: This study examines the demographic determinants of contraceptive use in Great Britain and Germany. The author conducted two nationally representative population surveys in 1992 among a sample of 967 women 15-45 years old in Great Britain and 1064 same-age women in Germany. The data for both countries were statistically weighted to correspond to national demographic characteristics. 646 British women and 1023 German women used contraception. Analysis included multiple logistic regression techniques and principal components and segmentation techniques. Contraceptive use patterns differed between East Germany, West Germany, and Great Britain. Oral contraceptive (OC) use and periodic abstinence rates were higher in West and East Germany. Sterilization rates were lower in Great Britain. In the analysis of reunified Germany compared to Great Britain, OC use declined with increasing age in both countries. IUD use and sterilization increased with an increase in age. Only in Great Britain was OC use greater in urban areas compared to rural areas. Both countries had higher periodic abstinence in larger cities. IUD use and sterilization rates were higher, and OC use rates were lower among married women compared to never married women. The association between employment status and use was unclear. Increased church attendance was associated with higher use of condoms and periodic abstinence and lower use of OCs. Having occasional partners was associated with a higher condom use rate. Multivariate findings on differential use by country suggest that choice of contraceptive method was related to health care policy, service provision, and differences in provider preferences. Contraceptive decisions were primarily based on reproductive status, country, educational level, and religious beliefs rather than on the characteristics of the method.

Determinants of contraceptive use among women of reproductive age in Great Britain and Germany. II: Psychological factors.

Psychological determinants of contraceptive use were investigated in Great Britain and Germany, using national data obtained in 1992. It was hypothesised that current contraceptive use among sexually active, fertile women aged 15-45 was related to their attitude towards the various contraceptive methods, social influences, perceptions of being able to use a method correctly and consistently, a correct estimation of fertility, and communication with their partner. Effects of age and country were also taken into account. The attitude of respondents towards the various contraceptive methods was ambivalent and no method was seen as ideal. On medical methods (OCs, IUDs and sterilisation) many respondents expressed doubts as to their safety for health. Social influences most frequently concerned the use of OCs. Respondents considered themselves able to use oral contraceptives correctly, but expressed general fear about intrauterine devices and sterilisation, and many women believed they were not able to use condoms and periodic abstinence consistently. Multifactorial analyses revealed that current contraceptive use was principally determined by social influences, attitude and self-efficacy with respect to medical methods. Age and country, and, for use of unreliable methods, fertility awareness also played a role. Communication with the partner was less relevant. Contraceptive choice (and the use of non-medical methods) depended greatly on encouragement to use and being in favour of medical methods. A lack of social support for use of medical methods and a negative attitude towards them was related to higher use rates of condoms, periodic abstinence, withdrawal and reliance on 'luck'. In the case of withdrawal and/or no method, underestimation of fertility played an additional role. Contraceptive choice appears to be determined more by a general like or dislike of medical methods rather than on a weighing of the merits of individual available methods.

PIP: This study concludes that within specific contexts a number of psychological factors affect contraceptive usage. Contraceptive decisions in Germany and Great Britain were affected by attitudes toward oral contraceptives (OCs), IUDs, and sterilization, and the perceived social influences of these contraceptive methods. Attitudes and perceived social influences of OCs, IUDs, and sterilization were associated with use of condoms, periodic abstinence, and withdrawal or no method use. Age and country also influenced the decision to use contraceptives. Fertility awareness influenced use of unreliable methods. Communication between partners had a small influence. Higher use of condoms, periodic abstinence, withdrawal, and reliance on "luck" was associated with a lack of social support for use of medical methods and a negative attitude towards use of medical methods. Persons who underestimated their fertility potential were at higher risk of relying on withdrawal and/or no method at all. Findings suggest that choice in a developed country was related to approval or disapproval of medical methods rather than an evaluation of the benefits of individual methods available. Analysis is based on the theoretical models of Ajzen and Fishbein, which models suggest that use of a contraceptive method is based on rational intention to use the method concerned, and rational intention is determined by attitudinal and subjective norms. The sample includes 967 reproductive-age women in Great Britain and 1064 reproductive age women in reunified Germany. The survey was used in 1992 in both countries. Indices were constructed for measuring attitude, the social influences concept, self-efficacy, and communication. Analysis includes multiple logistic regression models and principal components and segmentation analysis.

Contraceptive practice and attitudes in Sweden 1994.

OBJECTIVE: To investigate current contraceptive practice in Sweden and Swedish women's attitudes towards various contraceptive methods. METHODS: In 1994, a random sample of Swedish women (n = 2330), aged 15-45 years (stratified according to age and geographic distribution), were invited by telephone to participate in the study. Women (n = 1788) who accepted the invitation to participate were sent a postal questionnaire. RESULTS: Completed questionnaires were returned by 1422 women (overall response rate: 61.0%). The sample was somewhat skewed towards higher educational level, but in other demographic respects no great deviations from the parent population were observed. The distribution of contraceptive methods in fertile, sexually active women who wished to avoid pregnancy was as follows: oral contraceptives (OCs) 33%, OC plus barrier method 5%, intrauterine device 21%, barrier methods 23%, sterilization 5% (female 3%; male 2%) and injectable steroids 2%. The overall pattern of contraceptive use in women aged 15-45 years had changed very little compared to results of a similar survey performed in 1987. However, the use of less effective methods (periodic abstinence, coitus interruptus and no method grouped together) was considerably lower among teenagers in 1994 (3%) than in 1987 (18%). The use of these traditional methods was still high in women aged over 35 years (15-17%). A large number of women considered medical methods of contraception to be reliable and easy to use but many were concerned about the safety for health of medical methods. CONCLUSIONS: Contraceptive practice changed towards more frequent use of medical, effective methods among young Swedish women, but not in the total female population. The latter was among others related to the relatively high use rates of less effective methods among women aged over 35. Women were concerned about the health safety of medical methods and relatively low percentages of women reported having received advice from health care professionals to use effective methods.

Transvaginal ultrasonography and endometrial changes in postmenopausal breast cancer patients receiving tamoxifen.

OBJECTIVES: To assess an estrogenic effect of tamoxifen on the uterus and to evaluate the usefulness of transvaginal ultrasonography for identifying tamoxifen-induced endometrial pathology. METHODS: One hundred and two postmenopausal breast cancer patients without gynecological symptoms were examined by transvaginal ultrasonography. Forty-eight patients were treated with tamoxifen and 54 patients served as reference. An endometrial thickness of > or = 6 mm (double-layer) was used as cut-off point for further hysteroscopic and histologic examination. RESULTS: Thirty percent of the women taking tamoxifen had evidence of an abnormal postmenopausal endometrium compared with 6% in the reference group (P = 0.005). Those patients receiving tamoxifen had a significantly thicker endometrium (median 6.0 mm versus 2.0 mm; P < 0.001), a larger uterine volume (median 93 cm3 versus 72 cm3; P = 0.03) and more uterine fluid (12% versus 2%; P = 0.005). Furthermore, an ultrasonographic suspect 'Swiss-cheese' endometrial pattern was noted in almost a quarter of the patients treated with tamoxifen, but this was clearly not associated with intracavitary pathology. CONCLUSIONS: Our data indicate that tamoxifen stimulates the uterine body and endometrium. The data also indicate that the ultrasonographic endometrial appearance during tamoxifen therapy may be misleading and that a high percentage (46%) of false-positive results occur. Therefore, in asymptomatic postmenopausal breast cancer patients taking tamoxifen, the findings on ultrasonography should be interpreted with caution.

Endometrial thickness assessed by transvaginal ultrasound insufficiently predicts occurrence of hyperplasia during unopposed oestrogen use.

In the present study, unopposed oestrogens were given to 184 non-hysterectomized women, for a duration varying from four weeks to 24 months, while the endometrial responses were monitored by transvaginal sonography (TVS) and backed up by endometrial sampling (conducted when the endometrial thickness reached 8 mm (double layer) or more, vaginal bleeding occurred during oestrogen administration, or after one year of unopposed oestrogen use). In cases where the endometrial thickness reached 8 mm or more, progestogens were administered for 12 days. In 64% of the women, administration of progestogen could be postponed until at least the fourth month of treatment under the pre-defined decision criteria. Eleven percent of the patients used oestrogens continuously during the two year study period, without any need of additional progestogen. In total, 338 endometrial biopsies were performed; 16 cases of hyperplasia were detected. In three cases, the corresponding endometrial thickness was below 8 mm (in one case, 5 mm). Endometrial thickness could not consistently predict occurrence of hyperplasia. In eight cases, hyperplasia occurred within 4 months of treatment, and in four cases, within only 2 months (of which only one case could possibly be attributed to previous hormone use and none to endogenous oestrogen production). The rapid occurrence of hyperplasia should be taken into account in studies of quarterly progestogen administration with hormone replacement therapy. It is concluded that postponement of progestogen administration with hormone replacement therapy under guidance of TVS only (without biopsies) would not be adequately safe to be recommended for clinical practice.

[Compliance and missed pills in France in 1995]. / L'observance et l'oubli de pilule en France en 1995.

The analysis of a survey on a representative sample of the whole French women using pill allowed us to measure the number and the consequences of missed pills, to discover the circumstances which induce them and to characterize the most risky groups. It raises the importance of the information given by the doctors.

Contraceptive use and attitudes in Italy 1993.

Surveys conducted between 1979 and 1991 indicated that contraceptive practice in Italy underwent rapid changes over that period. In order to assess current contraceptive use and attitudes, a survey was conducted among a random sample of 2000 Italian women aged 15-45 years. Replies were received from 1542 women (77.1%). Of the self-defined non-sterile, sexually active women who wished to avoid pregnancy, 30.3% were using oral contraceptives, 8.1% an intrauterine device, and 1.1% sterilization, while 29.6% were using traditional methods, principally coitus interruptus. In reply to questions about the relative advantages and disadvantages of various contraceptive methods, women expressed worries with respect to the safety of oral contraceptives, intrauterine devices and sterilization. Relatively high percentages of women answered 'do not know' with respect to the various aspects of intrauterine devices, periodic abstinence and sterilization that were investigated. In view of the findings of previous studies, the current data obtained suggested that traditional methods are being gradually displaced by modern methods in Italy. Nevertheless, the use of traditional contraceptive is widespread, the same probably being true of inconsistent use of condoms. Furthermore, lack of information on the contraceptive options available seems to be a central issue in Italy.

Female voice changes around and after the menopause--an initial investigation.

The views of 48 female and 24 male professional singers aged 40-74 years were sought regarding the occurrence of possible voice changes in around the fifth decade of life. The changes actually experienced were investigated to determine whether women's and men's voice changes were different, which might indicate that the menopause had an impact on the female voice. Respondents were approached via personal contacts and completed anonymous questionnaires that were returned by mail. Given the delicate nature of the study topic, no information was obtained on non-responders. Seventy-seven percent of the female singers and 71% of the men were of the opinion that the voice generally underwent changes at around the age of 50. The female singers placed greater emphasis on problems affecting the high registers and voice control than the men. Overall, 29% of the women had actually experienced negative voice changes at around age 50, as compared with 38% of the men. Both sexes reported huskiness, but the women seemed to have more frequent problems with voice emission, voice control and reaching their highest registers. In addition, 27 women reported that they had experienced voice changes during menstruation and five women stated that these had occurred during use of the oral contraceptive pill, which may have reflected the impact of other hormone-related factors. Despite the limitations of this initial investigation (the sample was small and selective), the broad findings indicated that the female voice undergoes specific changes at around the time of the menopause.

Contraceptive use and attitudes in reunified Germany.

Contraceptive use and attitudes were assessed in a random sample of 1064 German women. The majority (76%) of the sexually active, fertile women who were not pregnant and did not wish to get pregnant at the time of the survey were using very reliable contraceptive methods, namely oral contraceptives (OCs), intrauterine devices (IUDs) or sterilization. Comparison with a previous survey showed that contraceptive practice in West Germany had improved considerably since 1985. Attitudes towards the most reliable methods available (OCs, IUDs and sterilization) were found to be ambivalent. Perceived side effects and health risks were a particular matter of concern to the respondents. Although most respondents (88%) recognized that condoms prevent the transmission of AIDS, 66% of those who had occasional sexual partners did not use barrier methods. It is concluded that German contraceptive practice is reasonably effective and that if attitudes were to become more realistic the level of effectiveness could even be raised.

PIP: The sample for this 1992 survey of contraceptive use and attitudes was obtained by random-walk sampling, whereby field workers from a survey agency that collaborated in carrying out the study followed designated routes throughout the country, starting from 257 predetermined locations. They identified subjects 15-45 years old by visiting their homes and inviting the woman in each household to participate in the study. Of the 1064 women surveyed, 75.7% were defined as being exposed to the risk of conception; 3.8% stated they were infertile, 4.2% were currently pregnant, 4.0% intended to get pregnant, and 15.6% were not sexually active. The barrier methods used comprised condoms (10.4%), diaphragms (0.9%), spermicides (0.6%), and combinations of condoms and spermicides (0.4%), of diaphragms and spermicides (0.1%), and of diaphragms and condoms (0.2%). Although most respondents (88%) recognized that condoms prevent the transmission of AIDS, 66% of those who had occasional sexual partners did not use barrier methods. 75.7% of exposed German women used reliable methods, namely OCs, IUDs, and sterilization. Women from what had been East Germany cited the common reasons mentioned for using contraceptives as often as did women from what had been West Germany (p 0.05), except for AIDS and sexually transmitted disease prevention (1.1% and 5.8%, respectively, p 0.05) and alleviation of skin disorders (2.3% and 12.5%, respectively, p 0.01). Information on contraception was obtained mainly from gynecologists (67.7%) and friends (30.9%). Comparison with a previous survey showed that contraceptive practice in the former West Germany had improved considerably since 1985. Attitudes towards the most reliable methods available (OCs, IUDs and sterilization) were found to be ambivalent. Perceived side effects and health risks were a particular matter of concern to the respondents. Certain disadvantages of OCs and IUDs were less frequently perceived by women from the former East Germany than by women from the former West Germany, whereas "East German" women were more frequently of the opinion that sterilization was a major and risky operation. German contraceptive practice is reasonably effective, and if attitudes were to become more realistic the level of effectiveness could even be raised.