The cost of the menstrual cycle in young Swedish women.

The purpose of this study was to evaluate the cost of the menstrual cycle for young Swedish women aged 14-20 years. The young women were randomly selected and interviewed by a trained female psychologist; a total of 68 young women completed the interviews. Twenty of the girls used oral contraceptives, while 48 had natural periods. The oral contraceptive users had a lighter menstrual flow and shorter periods (1 day less) than the girls with natural menstruation. The oral contraceptive users experienced less menstrual pain, used fewer painkillers and did not stay at home during their periods as often as the girls with natural periods. The cost of sanitary protection products was about US$1 per month less for the oral contraceptive users. Girls taking oral contraceptives also avoided stained underwear and soiled bedlinen significantly more often than the non-oral contraceptive users. The study design did not allow for cost estimates on soiled underwear, bedlinen or lost work- or schooldays. The results of the study indicate that expenditures related to the menstrual cycle are considerable for young Swedish women.

Contraceptive strategies for young women in the 21st century.

Safe, effective and affordable contraceptives have been available for a few decades, yet, in many countries, the struggle for reproductive rights continues. Children, still, are forced to give birth to children in many nations. In most industrialized countries, where contraceptive counselling and abortions have been options, fertility rates have reached all time lows. Effective contraception improves health and well-being as well and may be used for conditions other than birth control. Young girls often initially take oral contraceptives primarily to reduce menstrual pain and blood loss; they also welcome a contraceptive that eliminates menstrual bleeding. Women using oral contraceptives and Norplant experience about 50% reduction in menstrual blood; 90% reduction in blood loss is achieved with the levonorgestrel intrauterine system (Mirena). Teenagers and their parents are often misinformed about the side-effects of oral contraceptives and birth control in general, which may adversely affect compliance. Adequate, user-friendly and supportive information about contraception is necessary to ensure proper use of the pill and other birth control methods. In addition, emergency contraceptives should be easily accessible. The mortality and morbidity of young women would be dramatically reduced by the global use of medical abortion as well. Only a combined effort by policy makers, educators, parents and health-care providers can enhance the reproductive (and future!) health of both young females and males.

Depot medroxyprogesterone acetate (Depo-Provera) and levonorgestrel (Norplant) use in adolescents among clinicians in Northern Europe and the United States.

PURPOSE: To compare attitudes and practices related to clinicians' use of depot medroxyprogesterone acetate [Depo-Provera (DMPA)] and levonorgestrel implants in adolescents in three northern European countries and the United States. METHODS: Between the fall of 1993 and the winter of 1995, surveys eliciting clinician attitudes and practices with the two contraceptive methods were collected from practitioners who provide contraceptive care to teens in Sweden (n = 282), The Netherlands (n = 197), Great Britain (n = 108), and the United States (n = 548). RESULTS: Clinicians in Great Britain and the United States reported prescribing of DMPA, selected DMPA in their top three choices for contraception in teens, and had patients ask about DMPA more frequently than clinicians in Sweden or The Netherlands (p < 0.0001). U.S. clinicians were more likely to report prescribing of the implants, list them as a top choice, and have patients ask for it more frequently than were providers in the other three countries (p < 0.0001). Noncompliance with previous contraceptives was the most common indication for use of either method in this age group. "Worst fears" with DMPA use included infertility, particularly among Swedish clinicians (p < 0.0001), as was pregnancy and loss to follow-up, particularly among British clinicians (p < 0.0001). Condom nonuse was a concern associated with both methods. Breakthrough uterine bleeding was a concern related to implant use, particularly among Swedish practitioners (p < 0.0001). CONCLUSION: Clinicians in the United States and Great Britain display more enthusiasm toward the use of the long-term progestins in adolescents than do clinicians in Sweden or The Netherlands. Continuing education programs could be designed to educate clinicians to allay their concerns about these contraceptives in countries where teen pregnancy is considered a problem.

Adolescent sexuality: an educational and counseling challenge.

A review of family-planning literature reveals that researchers adopt narrow definitions of sexual behavior and focus almost exclusively on risks of pregnancy and diseases. Little concern is shown in these articles about promoting the idea of more communicative, pleasurable, and egalitarian sexual relations among teenagers, because the focus is on avoiding behaviors that are defined as "high risk." In the United States, there is little evidence that these contraceptive-based sex education programs have resulted in reduced sexual activity, diminished teenage-pregnancy rates, or increased effective contraceptive use. In Canada the clinical evidence is that existing prevention strategies are not working. In Sweden the increasing rates of STDs and teenage pregnancies in the late 1980s worried authorities. The figures were brought down in the 1990s by extensive efforts both in schools and at publicly funded adolescent health clinics and family-planning units. It has been shown that girls with good self-esteem and a sense of responsibility avoided pregnancies and STDs in follow-up studies. Girls with a high degree of risk-prone behavior or attitudes and girls with a problematic life situation and without adequate family support were those who became unintentionally pregnant and/or acquired an STD. Countries where sex education has been accepted, combined with widely spread family-planning services and abortion on demand, have the lowest pregnancy and abortion rates in the world. But even they could do better by putting sex education in its proper place in society and by using both old and new methods.

The absence of vaginal human papillomavirus 16 DNA in women who have not experienced sexual intercourse.

OBJECTIVE: To determine whether young women who have not experienced sexual intercourse may harbor genital human papillomavirus (HPV) infection in the vaginal-ectocervical mucosa. METHODS: We included 151 women, 10-25 years of age, attending two adolescent health care units (Stockholm and Uppsala) and one primary health care center (Umeå). The size of the hymenal orifice, use of tampons, and the habit of digital vaginal manipulation were registered. Samples of epithelial cells were collected from the vagina and analyzed for the presence of HPV using polymerase chain reaction. RESULTS: One hundred thirty of 154 samples contained an adequate number of cells. Two samples were HPV 6 DNA-positive. None were HPV 16 DNA-positive. None of the women had external genital warts. In 84%, the hymenal opening was 15 mm or less. Forty-eight percent of the women used tampons during periods. Fifty-four percent had inserted their own finger into the vagina and in 23%, a boyfriend's finger had penetrated the vagina. CONCLUSION: Human papillomavirus is rarely present vaginally in virginal women, even with the use of tampons or digital penetration.

An economic evaluation of screening for Chlamydia trachomatis in adolescent males.

OBJECTIVE: To assess the cost-effectiveness of identifying asymptomatic carriers of Chlamydia trachomatis among adolescent males. DESIGN: Cost-effectiveness analysis based on cohort analytic studies previously reported and average salaries and costs of medical care in Sweden. SETTING: Adolescent males attending a primary care center for routine health checks. PARTICIPANTS: Estimates of costs and benefits are based on a cohort of 1000 adolescent males and their female contacts. INTERVENTION: Screening with enzyme immunoassay (EIA), either on leukocyte esterase (LE)--positive urine samples (LE-EIA screening) or on all urine samples (EIA screening), was compared with no screening (no treatment or contact tracing). The effects of confirming positive EIA results with a blocking assay and alternative antibiotic regimens on the outcome of the screening strategies were also evaluated. RESULTS: Compared with no screening, the LE-EIA and EIA screening strategies reduced the overall costs when the prevalence of chlamydial infection in males exceeded 2% and 10%, respectively. Enzyme immunoassay screening achieved an overall cure rate that was 12.2% to 12.6% (95% confidence interval) better, but reduced the incremental savings by at least $2144 per cured male, in comparison with LE-EIA screening. Confirmation of positive EIA results reduced the overall cost of the LE-EIA screening strategy when the prevalence of C trachomatis among males was less than 8%. Compared with a 7-day course of doxycycline, a single oral dose of azithromycin administered under supervision in the clinic improved the cure rates of both EIA and LE-EIA screening strategies by 15.1% to 16.3% and 11.2% to 12.0%, respectively, while reducing the corresponding overall costs by 5% and 9%, respectively, regardless of the prevalence of chlamydial infection in males. CONCLUSION: The use of LE-EIA screening combined with treatment of positive cases with azithromycin was the most cost-effective intervention strategy focusing on asymptomatic male carriers of C trachomatis. Positive EIA results should be confirmed when screening low-risk populations.

Sexual behavior among adolescents in Uppsala, Sweden.

The purpose of this study was to compare the sexual behavior of Swedish teenagers in the late 1980s with that in the late 1970s, when a similar study was performed in the same city. Another aim was to discover differences between boys and girls, smokers and nonsmokers, and pupils in theoretical and practical classes. A total of 383 high-school students answered a questionnaire about their sexual behavior, education, and attitudes. Almost one-half of the teenagers had already had intercourse. The median age at sexual debut was about 17 years. Among girls who had had intercourse, the median age at debut was lower than 10 years ago. A majority stated that their sexual behavior had been affected by the acquired immunodeficiency syndrome (AIDS) debate. This was, however, not clearly seen in their sexual behavior. Intercourse seemed to take place earlier in the relationship than 10 years ago, and the wish for more sexual experience had increased. The use of alcohol at the time of first intercourse had decreased significantly. Only 2% thought that they had too much sex education at school. As many as 41% felt they could not talk about sex with their parents. Efforts should be made both to enhance the quantity of sex education at school and to improve its quality. This might increase the chances of young people avoiding unwanted pregnancies and sexually transmitted diseases.

Swedish adolescents' knowledge of sexually transmitted diseases and their attitudes to the condom.

In an attempt to assess the risk of AIDS infection in teenagers in Sweden a survey of adolescent sexual behaviour was conducted in Uppsala. Two hundred and nine students in the first form of an upper secondary school completed a questionnaire at the beginning of a lesson on family life. Half the female and 45% of the male students reported having had sexual intercourse. Forty per cent had not used contraception at their first intercourse and 23% reported no use of contraceptive at their most recent intercourse. The students considered that they had only a low risk of contracting a sexually transmitted disease. The use of condoms was relatively low and this has implications for the students' potential to contract a sexually transmitted disease.

PIP: In an attempt to assess the risk of AIDS infection in teens in Sweden, a survey of adolescent sexual behavior was conducted in Uppsala. 209 students in the 1st form of an upper secondary school completed a questionnaire at the beginning of a lesson on family life. 1/2 of the female and 45% of the male students reported having had sexual intercourse. 40% had not used contraception at their 1st intercourse and 23% reported they had not used contraception at their most recent intercourse. The students considered that they had only low risk of contracting a sexually transmitted disease (STD). Condom use was relatively low and this had implications for the students' potential to contact an STD.

Age dependence of blood fibrinolytic components and the effects of low-dose oral contraceptives on coagulation and fibrinolysis in teenagers.

Basal t-PA antigen concentration, PAI-I activity and fibrinolytic capacity was studied in plasma from 20 healthy teenager girls (age 15.9 +/- 1.3 years) and two groups of older healthy volunteers, consisting of 17 women (age 32 +/- 8 years, group 1) and 35 men (age 34 +/- 8 years, group 2). Basal t-PA antigen concentrations in plasma were found to be highly age-dependent with higher values with increasing age. The teenager girls had significantly lower values compared with the two groups of elderly volunteers. PAI-I levels were significantly higher in plasma from the teenager girls and the fibrinolytic capacity after 15 min of venous occlusion was significantly lower. In this study we also determined the effect of low-dose oral contraceptives (OC) on coagulation and fibrinolysis in the teenager group. Each teenager served as her own control with samples drawn before and on OC after 4 months of use. The coagulation parameters, factor VIII activity, AT III, Protein C and platelet counts were all within reference values before and on OC. The fibrinolytic activity in plasma after venous occlusion (15 min) increased significantly when the teenagers had used OC for 4 months. This phenomenon was explained by significantly decreased PAI levels and also by significantly increased t-PA antigen release from the vessel wall after venous occlusion.

PIP: The effect of high and low-dose oral contraceptives (OCs) on the fibrinolytic system remains controversial, although disturbances in this system are associated with the development of venous thrombosis. It has been suggested that this may be due to either a decreased synthesis of vessel wall tissue plasminogen activator (t-PA) or a defective release of t-PA from the vessel wall. Defective fibrinolysis can also be due to increased concentration of tissue plasminogen activitor inhibitor (PAI-I). This studied utilized new and improved methods for t-PA and PAI-I measurements in plasma to: study basal fibrinolytic activity, basal t-PA antigen concentration, and PAI-I in plasma from teenagers to assess whether these parameters are age-dependent; 2) evaluate the influence of low-dose OCs on the fibrinolytic components; and 3) study possible variations in some coagulation factors. Plasma were obtained from 20 healthy female adolescents (mean age 16 years), 17 health adult women (mean age 32 years) and 35 healthy adult males (mean age 34 years). Basal t-PA antigen concentrations plasma were highly age dependent, with higher values with increasing age. The fibrinolytic capacity was also lower in the younger women, while PAI-I levels were higher. This finding suggests a need for age- and sex-matched controls in studies of the components of fibrinolysis in plasma. 4 months of OC use did not affect coagulation parameters, factor VIII activity, AT III, Protein C, or platelet counts. However, fibrinolytic activity in plasma after venous occlusion (15 minutes) increased significantly in teenagers who used OCs for 4 months. This finding was explained by significantly decreased PAI levels and increased t-PA antigen release from the vessel wall after venous occlusion.

Return of ovulation after abortion and after discontinuation of oral contraceptives.

The return of ovulation after abortion and discontinuation of oral contraceptives was determined by plasma progesterone measurements. Plasma samples were obtained from 67 women at 3 to 6 weeks after abortion and in two groups of postabortion women at 3 to 6 weeks after cessation of oral contraceptives. In the first of these latter two groups, 50 women started taking the pills (containing 30 microgram of ethinylestradiol and 150 microgram of levonorgestrel) immediately after abortion, and the second group of 29 women started taking the pills from the first postabortion menses. Ovulation had recurred in 34% of the women 3 weeks after abortion and in 78% of the women at 6 weeks. The return of ovulation had occured in approximately 55% at 3 weeks after cessation of oral contraceptives in both groups. At 6 weeks after cessation, approximately 85% of women had ovulated in both groups. Luteal function in these two groups was found to be equal and was significantly better in both groups than during the first postabortion cycle (P < 0.005). It is concluded that the early return of ovulation after abortion makes it necessary to commence effective contraception immediately after abortion. The immediate administration of oral contraceptives after abortion does not affect the return of ovulation after discontinuation of oral contraceptives.

PIP: The return of ovulation after abortion and discontinuation of (OCs) oral contraceptives was determined by plasma progesterone measurements. Plasma samples were obtained from 67 women 3-6 weeks after abortion and in 2 groups of postabortion women 3-6 weeks after cessation of OCs. In the 1st of these latter 2 groups, 50 women began taking the OCs (containing 30 mcg of ethinyl estradiol and 150 mg of levonorgestrel) immediately after abortion, and the 2nd group of 29 women started taking the pills from the 1st postabortion menses. Ovulation had recurred in 34% of the women 3 weeks after abortion and in 78% of the women at 6 weeks. The return of ovulation had occurred in approximately 55% at 3 weeks after cessation of OCs in both groups. At 6 weeks after cessation, approximately 85% of the women in both groups had ovulated. Luteal function in these 2 groups was found to be equal and was significantly better in both groups than during the 1st postabortion cycle (P 0.005). It is concluded that the early return of ovulation after abortion makes it necessary to commence effective contraception immediately after abortion. The immediate administration of OCs after abortion does not affect the return of ovulation after discontinuation of OCs.

[Why does a woman decide on a abortion?]. / Mikä saa naisen valitsemaan abortin?

PIP: This study consists of 99 patients, all over age 18, who chose an induced abortion (group 1) and 100 patients who delivered a full-term baby (group 2). The mean age was 26.0 years in the abortion group and 26.4 years in the delivery group. Of those in group 1, 33 were married and of those who delivered their baby, 75 were married and 25 gave birth to a child out-of-wedlock. The difference is social background between the groups is statistically highly significant (p0.001). Only 3% of women in group 1 belonged to the 4 highest strata of society as compared with 26 in group 2. The previous use of contraceptive methods was similar in both groups. However, there was a clear difference between the 2 groups in the pattern of their relationship with the other sex. The patients in the abortion group had their 1st intercourse significantly earlier (p0.01). In the abortion group, 12% had their 1st coitus prior to age 15 and 46% before the age of 18. The corresponding percentages in the delivery group were 2% and 29%. The women in the abortion group had more partners than the women in the delivery group. The most common motivations for abortion were economic difficulties alone or together with poor housing conditions. These were responsible for 36% of the abortions in the case of married women and in 48% when the women were not married. In the group of unmarried women, 12% had not completed their education and therefore wished to have an abortion. Among the married women, 9% stated that the sexual partner in the intercourse leading to the present pregnancy was not their husband, thus the motivation to have the abortion. The number of previous children was not reported to be a reason for abortion. The women who decided to deliver the baby considered their marriages very happy (more than 2/3) or at least fairly happy. The patient's own childhood did not affect the decision in favor of or against abortion in this group of women. The decision was influenced by the actual life situation and thus this finding differs from the previous studies on adolescent abortions. (author's modified)^ieng