Contraceptive outcomes among adolescents prescribed Norplant implants versus oral contraceptives after one year of use

Contraceptive counselling experiences in Spain in the process of creating a web-based contraceptive decision support tool: a qualitative study

Background

The choice of contraceptive method is a complex decision, and professionals should offer counselling based on the preferences, values and personal situation of the user(s). Some users are unsatisfied with the counselling received, which may, among other consequences, adversely affect method use adherence. In view of this situation, we propose exploring the experiences and needs of users and professionals for contraceptive counselling, in the context of creating a web-based contraceptive decision support tool.

Methods/design

Qualitative research was conducted through focus group discussions (64 users split into eight groups, and 19 professionals in two groups, in Tarragona, Spain) to explore the subjects’ experiences and needs. The data were categorized and the categories were defined and classified based on the three-step protocol or framework for Quality on Contraceptive Counseling (QCC), created by experts, which reviews the quality of interactions between user and professional during the counselling process.

Results

In counselling, users demand more information about the different methods, in an environment of erroneous knowledge and misinformation, which lead to false beliefs and myths in the population that are not contrasted by the professional in counselling. They complain that the method is imposed on them and that their views regarding the decision are not considered. Professionals are concerned that their lack of training leads to counselling directed towards the methods they know best. They acknowledge that a paternalistic paradigm persists in the healthcare they provide, and decision support tools may help to improve the situation.

Conclusions

Users feel unsatisfied and/or demand more information and a warmer, more caring approach. Professionals are reluctant to assume a process of shared decision-making. The use of a contraception DST website may solve some shortcomings in counselling detected in our environment.

In Spain, individuals can use a variety of contraceptive methods. Professionals involved in contraceptive counselling should help users to choose and properly use the method that best suits their preferences, personal situation and health status. However, there is a high number of unplanned pregnancies and the population feels dissatisfied with the counselling received. In the context of creating a website dealing with contraceptive methods, we wished to find out how counselling was taking place, giving voice those directly concerned. A qualitative study was proposed to explore the experiences and needs of users and professionals during counselling. Ten focus groups were conducted involving 64 users and 19 professionals from Tarragona (Spain). The results were ordered based on the Quality on Contraceptive Counseling (QCC) framework, created by experts, which determines what the relationship between user and professional should be like during the counselling process. Our analysis highlighted users’ little knowledge and false beliefs concerning contraception who, moreover, complained of receiving little information during counselling. They expressed their discontent with methods being imposed on them by the professional without exploring their preferences or needs. Meanwhile, the professionals argued that they often prescribe the method with which they are most familiar due to the lack of time during consultations at their office and/or because they are unfamiliar with other methods. These results, among others, offer the possibility of improving contraceptive counselling in Spain, if solutions to the difficulties and/or barriers detected are posed and implemented.

Long-Acting Reversible Contraception, Condom Use, and Sexually Transmitted Infections: A Systematic Review and Meta-analysis

INTRODUCTION

Given mixed findings regarding the relationship between long-acting reversible contraception and condom use, this systematic review and meta-analysis synthesizes studies comparing sexually transmitted infection‒related outcomes between users of long-acting reversible contraception (intrauterine devices, implants) and users of moderately effective contraceptive methods (oral contraceptives, injectables, patches, rings).

METHODS

MEDLINE, Embase, PsycINFO, Global Health, CINAHL, Cochrane Library, and Scopus were searched for articles published between January 1990 and July 2018. Eligible studies included those that (1) were published in the English language, (2) were published in a peer-reviewed journal, (3) reported empirical, quantitative analyses, and (4) compared at least 1 outcome of interest (condom use, sexual behaviors other than condom use, sexually transmitted infection‒related service receipt, or sexually transmitted infections/HIV) between users of long-acting reversible contraception and users of moderately effective methods. In 2020, pooled ORs were calculated for condom use, chlamydia/gonorrhea infection, and trichomoniasis infection; findings for other outcomes were synthesized qualitatively. The protocol is registered on the International Prospective Register of Systematic Reviews (CRD42018109489).

RESULTS

A total of 33 studies were included. Long-acting reversible contraception users had decreased odds of using condoms compared with oral contraceptive users (OR=0.43, 95% CI=0.30, 0.63) and injectable, patch, or ring users (OR=0.58, 95% CI=0.48, 0.71); this association remained when limited to adolescents and young adults only. Findings related to multiple sex partners were mixed, and only 2 studies examined sexually transmitted infection testing, reporting mainly null findings. Pooled estimates for chlamydia and/or gonorrhea were null, but long-acting reversible contraception users had increased odds of trichomoniasis infection compared with oral contraceptive users (OR=2.01, 95% CI=1.11, 3.62).

DISCUSSION

Promoting condom use specifically for sexually transmitted infection prevention may be particularly important among long-acting reversible contraception users at risk for sexually transmitted infections, including adolescents and young adults.

Pooled incidence of continuation and pregnancy rates of four contraceptive methods in young women: a meta-analysis

BACKGROUND

Continuation rates of contraceptive methods in young women vary among studies, and there is scarce data regarding the pregnancy rate in this population.

METHODS

Four independently systematic searches were performed in PUBMED, EMBASE, LILACS, and Cochrane databases from inception until January 2021 for oral contraceptive pill (OCP), copper IUD, levonorgestrel intrauterine system (LNG-IUS), and subdermal implant. Inclusion criteria were observational or RCT studies that reported continuation for at least 12 months and/or pregnancy rate of these contraceptives methods in girls aged 22 years old or younger. Two authors extracted data from the study design and the outcomes. Pooled proportions of each method were applied using the inverse variance in all calculations with LOGIT transformation, using the random-effects model. Cochrane collaboration tool and New Castle-Ottawa were used to assess the quality and bias of all included studies. GRADE criteria evaluated the quality of evidence.

RESULTS

Continuation rate for OCP was 51% (95%CI 34%-68%), while for cooper IUD was 77% (95%CI 74%-80%), LNG-IUS 84% (95%CI 80%-87%), and implant 85% (95%CI 81%-88%). The pooled estimated pregnancy rate for OCP was 11% (95%CI 6%-20%), while for cooper IUD was 5% (95%CI 3%-7%), LNG-IUS 1.6% (95%CI 1.2%-2.3%), and implant 1.8% (95%CI 0.4%-8.4%).

CONCLUSION

Long-acting contraceptive methods presented higher continuation rates and lower pregnancy rates when compared to OCPs.

Lowered Plasma Steady-State Levels of Progesterone Combined With Declining Progesterone Levels During the Luteal Phase Predict Peri-Menstrual Syndrome and Its Major Subdomains

BACKGROUND

It is unknown whether lowered steady state levels of sex hormones coupled with changes in those hormones during the menstrual cycle are associated with premenstrual syndrome (PMS).

OBJECTIVE

To examine associations between levels of progesterone and oestradiol during the menstrual cycle and PMS considering different diagnostic criteria for PMS.

METHODS

Forty-one women aged 18-45 years with a regular menstrual cycle completed the Daily Record of Severity of Problems (DRSP) for all 28 consecutive days of the menstrual cycle. Blood was sampled at days 7, 14, 21, and 28 to assay oestradiol and progesterone.

RESULTS

We developed a new diagnosis of peri-menstrual syndrome, which is characterized by increased DRSP severity in pre and post-menstrual periods and increased scores on the major DRSP dimensions, i.e., depression, physio-somatic symptoms, breast tenderness and appetite, and anxiety. This new diagnosis performed better than classical diagnoses of PMS, including that of the American College of Obstetricians and Gynecologists (ACOG). Lowered steady state levels of progesterone, when averaged over the menstrual cycle, together with declining progesterone levels during the luteal phase predict severity of peri-menstrual symptoms. Steady state levels of oestradiol and declining oestradiol levels during the cycle are also related to DRSP severity although most of these effects appeared to be mediated by progesterone.

CONCLUSION

A significant increase in menstrual-cycle related symptoms can best be conceptualized as "peri-menstrual syndrome" and may result from insufficient progesterone production (relative corpus luteum insufficiency), which, in part may result from lowered oestradiol production indicating suboptimal pre-ovulatory follicular development.

Progestin-only contraceptives: effects on weight

BACKGROUND

Progestin-only contraceptives (POCs) are appropriate for many women who cannot or should not take estrogen. POCs include injectables, intrauterine contraception, implants, and oral contraceptives. Many POCs are long-acting, cost-effective methods of preventing pregnancy. However, concern about weight gain can deter the initiation of contraceptives and cause early discontinuation among users.

OBJECTIVES

The primary objective was to evaluate the association between progestin-only contraceptive use and changes in body weight.

SEARCH METHODS

Until 4 August 2016, we searched MEDLINE, CENTRAL, POPLINE, LILACS, ClinicalTrials.gov, and ICTRP. For the initial review, we contacted investigators to identify other trials.

SELECTION CRITERIA

We considered comparative studies that examined a POC versus another contraceptive method or no contraceptive. The primary outcome was mean change in body weight or mean change in body composition. We also considered the dichotomous outcome of loss or gain of a specified amount of weight.

DATA COLLECTION AND ANALYSIS

Two authors extracted the data. Non-randomized studies (NRS) need to control for confounding factors. We used adjusted measures for the primary effects in NRS or the results of matched analysis from paired samples. If the report did not provide adjusted measures for the primary analysis, we used unadjusted outcomes. For RCTs and NRS without adjusted measures, we computed the mean difference (MD) with 95% confidence interval (CI) for continuous variables. For dichotomous outcomes, we calculated the Mantel-Haenszel odds ratio (OR) with 95% CI.

MAIN RESULTS

We found 22 eligible studies that included a total of 11,450 women. With 6 NRS added to this update, the review includes 17 NRS and 5 RCTs. By contraceptive method, the review has 16 studies of depot medroxyprogesterone acetate (DMPA), 4 of levonorgestrel-releasing intrauterine contraception (LNG-IUC), 5 for implants, and 2 for progestin-only pills.Comparison groups did not differ significantly for weight change or other body composition measure in 15 studies. Five studies with moderate or low quality evidence showed differences between study arms. Two studies of a six-rod implant also indicated some differences, but the evidence was low quality.Three studies showed differences for DMPA users compared with women not using a hormonal method. In a retrospective study, weight gain (kg) was greater for DMPA versus copper (Cu) IUC in years one (MD 2.28, 95% CI 1.79 to 2.77), two (MD 2.71, 95% CI 2.12 to 3.30), and three (MD 3.17, 95% CI 2.51 to 3.83). A prospective study showed adolescents using DMPA had a greater increase in body fat (%) compared with a group not using a hormonal method (MD 11.00, 95% CI 2.64 to 19.36). The DMPA group also had a greater decrease in lean body mass (%) (MD -4.00, 95% CI -6.93 to -1.07). A more recent retrospective study reported greater mean increases with use of DMPA versus Cu IUC for weight (kg) at years 1 (1.3 vs 0.2), 4 (3.5 vs 1.9), and 10 (6.6 vs 4.9).Two studies reported a greater mean increase in body fat mass (%) for POC users versus women not using a hormonal method. The method was LNG-IUC in two studies (reported means 2.5 versus -1.3; P = 0.029); (MD 1.60, 95% CI 0.45 to 2.75). One also studied a desogestrel-containing pill (MD 3.30, 95% CI 2.08 to 4.52). Both studies showed a greater decrease in lean body mass among POC users.

AUTHORS' CONCLUSIONS

We considered the overall quality of evidence to be low; more than half of the studies had low quality evidence. The main reasons for downgrading were lack of randomizations (NRS) and high loss to follow-up or early discontinuation.These 22 studies showed limited evidence of change in weight or body composition with use of POCs. Mean weight gain at 6 or 12 months was less than 2 kg (4.4 lb) for most studies. Those with multiyear data showed mean weight change was approximately twice as much at two to four years than at one year, but generally the study groups did not differ significantly. Appropriate counseling about typical weight gain may help reduce discontinuation of contraceptives due to perceptions of weight gain.

Progestin-only contraceptives: effects on weight

BACKGROUND

Progestin-only contraceptives (POCs) are appropriate for many women who cannot or should not take estrogen. Many POCs are long-acting, cost-effective methods of preventing pregnancy. However, concern about weight gain can deter the initiation of contraceptives and cause early discontinuation among users.

OBJECTIVES

The primary objective was to evaluate the association between progestin-only contraceptive use and changes in body weight.

SEARCH METHODS

Through May 2013, we searched MEDLINE, CENTRAL, POPLINE, LILACS, ClinicalTrials.gov, and ICTRP. The 2010 search also included EMBASE. For the initial review, we contacted investigators to identify other trials.

SELECTION CRITERIA

All comparative studies were eligible that examined a POC versus another contraceptive method or no contraceptive. The primary outcome was mean change in body weight or mean change in body composition. We also considered the dichotomous outcome of loss or gain of a specified amount of weight.

DATA COLLECTION AND ANALYSIS

Two authors extracted the data. We computed the mean difference (MD) with 95% confidence interval (CI) for continuous variables. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated.

MAIN RESULTS

We found 16 studies; one examined progestin-only pills, one studied the levonorgestrel-releasing intrauterine system (LNG-IUS), four examined an implant, and 10 focused on depot medroxyprogesterone acetate (DMPA). Outcomes examined were changes in body weight only (14 studies), changes in both body weight and body composition (1 study), and changes in body composition only (1 study). We did not conduct meta-analysis due to the various contraceptive methods and weight change measures.Comparison groups did not differ significantly for weight change in 12 studies. However, three studies showed weight change differences for POC users compared to women not using a hormonal method. In one study, weight gain (kg) was greater for the DMPA group than the group using a non-hormonal IUD in years one through three [(MD 2.28; 95% CI 1.79 to 2.77), (MD 2.71, 95% CI 2.12 to 3.30), and (MD 3.17; 95% CI 2.51 to 3.83), respectively]. The differences were notable within the normal weight and overweight subgroups. Two implant studies also showed differences in weight change. The implant group (six-capsule) had greater weight gain (kg) compared to the group using a non-hormonal IUD in both studies [(MD 0.47 (95% CI 0.29 to 0.65); (MD 1.10; 95% CI 0.36 to 1.84)]. In one of those studies, the implant group also had greater weight gain than a group using a barrier method or no contraceptive (MD 0.74; 95% CI 0.52 to 0.96).The two studies that assessed body composition change showed differences between POC users and women not using a hormonal method. Adolescents using DMPA had a greater increase in body fat (%) compared to a group not using a hormonal method (MD 11.00; 95% CI 2.64 to 19.36). The DMPA group also had a greater decrease in lean body mass (%) (MD -4.00; 95% CI -6.93 to -1.07). The other study reported differences between an LNG-IUS group and a non-hormonal IUD group in percent change in body fat mass (2.5% versus -1.3%, respectively; reported P value = 0.029) and percent change in lean body mass (-1.4% versus 1.0%, respectively; reported P value = 0.027).

AUTHORS' CONCLUSIONS

The overall quality of evidence was moderate to low, given that the studies were evenly divided across the evidence quality groups (high, moderate, low, or very low quality). We found limited evidence of weight gain when using POCs. Mean gain was less than 2 kg for most studies up to 12 months. Weight change for the POC group generally did not differ significantly from that of the comparison group using another contraceptive. Two studies that assessed body composition showed that POC users had greater increases in body fat and decreases in lean body mass compared to users of non-hormonal methods. Appropriate counseling about typical weight gain may help reduce discontinuation of contraceptives due to perceptions of weight gain.

Combined oral contraceptives' influence on weight, body composition, height, and bone mineral density in girls younger than 18 years: a systematic review

OBJECTIVE

Combined oral contraceptives (COCs) are increasingly used by adolescents. The aim of this review is to investigate the evidence regarding COCs' influence on weight, height and bone mineral density (BMD) in girls younger than 18 years.

METHOD

Systematic literature search using PubMed/Medline and Scopus (January 1990-February 2012) on COCs for girls under 18 years of age and the possible influence on body parameters. MeSH terms: Oral contraception; Adolescent; Weight; Body composition; Height; Bone mineral density.

RESULTS

There is no evidence that COCs induce weight gain in girls younger than 18 years. Obese girls are not at higher risk of gaining weight. COCs do not cause changes in body fat and lean mass beyond the changes caused by natural development. Moreover, growth and stature are unaffected. Few studies indicate that COCs have a negative impact on BMD, but the evidence is presently too limited for definite conclusions.

CONCLUSION

Studies in young users are few. Presently, there are no indications of a negative impact of COCs on weight, body composition or height. Lesser increases in BMD cannot be excluded. As the demand for COCs is increasing among the youngest girls, there is a need for prospective studies addressing this issue.

Preventing unintended pregnancy among young women in Kenya: prospective cohort study to offer contraceptive implants

BACKGROUND

Subdermal contraceptive implants have low discontinuation rates but are underused among young women in Africa. This study aimed to isolate the role initial contraceptive method has on preventing unintended pregnancy.

STUDY DESIGN

We recruited 399 Kenyan women aged 18-24 years into a prospective cohort study if they wanted short-acting hormonal methods (injectable or oral contraceptives). We offered an implant and formed two study groups: implant and short-acting. For contraceptive discontinuation/pregnancy, we used log-rank tests and proportional hazards models. We applied intent-to-treat principles to evaluate the role of initial method choice on future pregnancy.

RESULTS

Twenty-four percent opted for an implant (n=97), and the remainder opted for a short-acting method (n=299). The 18-month discontinuation probability was 21 per 100 for implant users and 43 per 100 for the short-acting method group (p=.001). Twenty-two unintended pregnancies occurred; all were among the short-acting group. The adjusted relative risk of pregnancy among the short-acting group vs. implant group was 7.4 (95% confidence interval: 1.6-34.5).

CONCLUSIONS

Many young Kenyan women found implants to be a reasonable alternative to short-acting methods. Having choice is essential, and starting on implants provides substantial and clear protection from unintended pregnancy relative to short-acting methods.

Adolescents' experiences using the contraceptive patch versus pills

STUDY OBJECTIVE

To compare use of the weekly transdermal contraceptive patch (patch) with daily combined hormonal contraceptive pills (pills) in adolescents.

DESIGN

Prospective longitudinal study of adolescents' self-selected (non-randomized) use of the patch or pills.

SETTING

Urban, university hospital-affiliated, adolescent outpatient clinic.

PARTICIPANTS

13-22-year-old female adolescents seeking hormonal contraception, 40 who chose the patch and 40 who chose pills.

INTERVENTIONS

Data were collected via self-report on paper questionnaires at three-cycle intervals for a total of up to nine cycles.

MAIN OUTCOME MEASURES

Method continuation, perfect use, method satisfaction, quality of life, and side effects, including menstrual changes and perceived mood changes.

RESULTS

After nine cycles, 38% of patch users and 60% of pill users were still using the method they had chosen at enrollment. There were no significant differences between the groups in self-reported perfect use. No differences were found in quality of life or side effects. Both patch and pill users noted menses became lighter and more predictable and reported decreased depression prior to their menses; only the pill group reported improvement in premenstrual anger. Method satisfaction was similar in both groups except patch users were more likely to report that their contraceptive method improved normal daily activities.

CONCLUSIONS

Despite apparent advantages of the patch over the pill, adolescents using both methods continue to face challenges achieving perfect and sustained contraceptive use.

Progestin-only contraceptives: effects on weight

BACKGROUND

Progestin-only contraceptives (POCs) are appropriate for many women who cannot or should not take estrogen. Many POCs are long-acting, cost-effective methods of preventing pregnancy. However, concern about weight gain can deter the initiation of contraceptives and cause early discontinuation among users.

OBJECTIVES

The primary objective was to evaluate the association between progestin-only contraceptive use and changes in body weight.

SEARCH STRATEGY

We searched MEDLINE, CENTRAL, POPLINE, EMBASE, LILACS, ClinicalTrials.gov, and ICTRP, and contacted investigators to identify other trials.

SELECTION CRITERIA

All comparative studies were eligible that examined a POC versus another method or no contraceptive. The primary outcome was mean change in body weight or body composition.

DATA COLLECTION AND ANALYSIS

Two authors extracted the data. We computed the mean difference with 95% confidence interval (CI) for continuous variables and odds ratio with 95% CI for dichotomous variables.

MAIN RESULTS

We did not conduct meta-analysis due to the various contraceptive methods and weight change measures. Fifteen studies examined progestin-only pills (N=1), Norplant (N=4), and depot medroxyprogesterone acetate (DMPA) (N=10). Comparison groups were similar for weight change in 11 studies. Four studies showed differences in weight or body composition change for POCs compared to no hormonal method. Adolescents using DMPA had a greater increase in body fat (%) versus a group using no hormonal method (mean difference 11.00; 95% CI 2.64 to 19.36). The DMPA group also had a greater decrease in lean body mass (%) (mean difference -4.00; 95% CI -6.93 to -1.07). In another study, weight gain (kg) was greater for the DMPA group than an IUD group (mean difference 2.28, 2.71, 3.17, respectively). The differences were notable within the normal weight and overweight subgroups. One study showed the Norplant (six-capsule) group had greater weight gain (kg) than a non-hormonal IUD group (mean difference 0.47 (95% CI 0.29 to 0.65) and a group using non-hormonal or no method (mean difference 0.74; 95% CI 0.52 to 0.96). Another study also showed a Norplant group also had greater weight gain (kg) than an IUD group (mean difference 1.10; 95% CI 0.36 to 1.84).

AUTHORS' CONCLUSIONS

We found little evidence of weight gain when using POCs. Mean gain was less than 2 kg for most studies up to 12 months, and usually similar for the comparison group using another contraceptive. Appropriate counseling about typical weight gain may help reduce discontinuation of contraceptives due to perceptions of weight gain.

Unintended pregnancy in sub-Saharan Africa: magnitude of the problem and potential role of contraceptive implants to alleviate it

BACKGROUND

Unintended pregnancies continue to burden many countries in sub-Saharan Africa. Our aim was to estimate the number of unintended pregnancies in the region and model the impact of expanding use of contraceptive implants at the expense of short-term hormonal birth control methods.

STUDY DESIGN

For the 42 countries in mainland sub-Saharan Africa, we estimated current levels of unintended pregnancy, prevalence of hormonal contraceptive use and number of unintended pregnancies stemming from early discontinuation and typical method failure rates. Using a decision-analytic model, we estimated the potential impact of more widespread use of the contraceptive implant.

RESULTS

Every year in sub-Saharan Africa, approximately 14 million unintended pregnancies occur and a sizeable proportion is due to poor use of short-term hormonal methods. If 20% of the 17.6 million women using oral contraceptives or injectables wanted long-term protection and switched to the contraceptive implant, over 1.8 million unintended pregnancies could be averted over a 5-year period.

CONCLUSION

Poor patterns of short-term hormonal contraceptive use (high discontinuation rates and incorrect use) contribute significantly to the problem of unintended pregnancy in sub-Saharan Africa. More availability and widespread use of highly effective methods, such as the contraceptive implant, will improve reproductive health in the region.

Adolescent and young women's experience with the vaginal ring and oral contraceptive pills

STUDY OBJECTIVE

To compare acceptability of the vaginal contraceptive ring to that of oral contraceptive pills.

DESIGN

Randomized, cross-over, 6-month study.

SETTING

Urban family planning clinic for young low-income patients.

PARTICIPANTS

Sexually active females aged 15-21 years (n = 130).

INTERVENTIONS

Participants were randomly assigned to use the vaginal ring or oral contraceptive pills for an initial study interval of three 28-day cycles, followed by three cycles of the alternate method.

MAIN OUTCOME MEASURES

Participants completed surveys about method use, acceptability, and side effects at baseline, after three cycles, and after six cycles. We analyzed study data using ANOVA models for cross-over designs.

RESULTS

We did not detect higher compliance with the ring as compared to oral contraceptive pills (P = 0.176), although overall approval of the ring was significantly higher on several items measured, including liked using method (P = 0.015), would recommend it to friends (P = 0.012), and not as hard to remember to use method correctly (P < or = 0.000). Participants were less worried about health risks while using the ring (P = 0.006), but reported that the ring was more likely to interfere with sex than the pill (P < or = 0.001) and that sex partners liked the pill (P = 0.034). Most women did not report bothersome side effects with either method.

CONCLUSIONS

Adolescent and young women showed favorable acceptability of the vaginal contraceptive ring compared to oral contraceptive pills.

Hormonal contraception in adolescents: special considerations

With the rates of unintended pregnancies in teenagers remaining high, it is crucial to present adolescents with all of the contraceptive options available to them. While barrier methods, for example, male condoms, are easily accessible and do not have adverse effects, their use must be consistent and correct with each act of intercourse. Hormonal contraception affords much better efficacy in preventing pregnancy when used with full compliance. Oral contraceptives are a popular method of contraception among adolescents and offer many non-contraceptive benefits along with the prevention of pregnancy. They have very few significant adverse effects, which are outweighed by the significant morbidity associated with teenage pregnancies, and can be used by most adolescent females. However, their minor bothersome effects do contribute to the high discontinuation rates seen. In addition, many girls find it difficult to remember to take a pill every day, leading to higher failure rates in teenagers than in adult women. The advent of long-acting, progestogen (progestin)-only methods, such as injectables and implantables, has been generally accepted by adolescents and these methods have proven to be more efficacious by avoiding the need for daily compliance. However, progestogen-only methods cause irregular bleeding and amenorrhea, which is not acceptable to many teenagers. In addition, the most widely used implant was taken off the market a few years ago and newer forms are not yet widely accessible. Other novel methods are currently available, including the transdermal patch and the vaginal ring. Both are combinations of estrogen and progestogen and have similar efficacy and adverse effect profiles to oral contraceptives. Their use may be associated with greater compliance by adolescents because they also do not require adherence to a daily regimen. However, there may be some drawbacks with these newer methods, for example, visibility of the patch and difficulty with insertion of the vaginal ring. When regular contraceptive modalities fail, emergency contraception is available. Choices include combination oral contraceptives, progestogen-only pills, mifepristone, or placement of a copper-releasing intrauterine device. These methods can be very useful for preventing pregnancy in adolescents as long as adolescents are aware of their existence and have easy access to them.

Patterns of oral contraceptive pill-taking and condom use among adolescent contraceptive pill users

PURPOSE

Imperfect oral contraceptive pill (OCP) regimen adherence may impair contraceptive effectiveness. The purpose of this study was to describe daily adherence patterns of OCP use, to analyze OCP protection on an event level basis, and to examine pill-taking and condom use during method transitions.

METHODS

Women (n = 123, ages 14-17 years) completed quarterly interviews to classify OCP method choice into four categories: stable, initiated, stopped, and discordant use. Within each OCP category, daily diaries were used to assess occurrence of coitus, condom use, and patterns of day-to-day OCP use (i.e., consecutive days of OCP use reported with no more than two consecutive days of nonuse). A coital event was OCP protected if pills were used on both the day of the coitus and the day preceding.

RESULTS

There were 123 participants who reported at least some OCP use in 210 diary periods (average diary length = 75.5 days). Fifty-three participants categorized as stable users reported 87 diary periods: the average interval of consecutive OCP use in this group was 32.5 days. Among stable users, only 45% of coital events were associated with both OCP and condom use. Over one-fifth of coital events in all groups were protected by no method of contraception.

CONCLUSION

Dual use of OCP and barrier contraception remains an elusive goal. The time during OCP adoption or discontinuation is often unprotected by condoms. However, concurrent missed pills and condom nonuse increase pregnancy and infection risk even among stable OCP users. Understanding motivation for method usage may improve education and prevention techniques.

The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors

CONTEXT

Advance provision of emergency contraception (EC) may increase timely access and improve effectiveness, but the impact on adolescent sexual and contraceptive behaviors is not known.

OBJECTIVE

To determine whether adolescents given advance EC have higher sexual and contraceptive risk-taking behaviors compared to those obtaining it on an as-needed basis.

DESIGN AND SETTING

Randomized trial conducted at urban, hospital-based adolescent clinic in Pittsburgh, PA, from June 1997 to June 2002.

PARTICIPANTS

301 predominantly minority, low-income, sexually active adolescent women, age 15-20 years, not using long-acting contraception.

INTERVENTIONS

Advance EC vs instruction on how to get emergency contraception.

OUTCOME MEASURES

Self-reported unprotected intercourse and use of condoms, EC, and hormonal contraception ascertained by monthly 10-minute telephone interviews for 6 months post-enrollment. Reported timing of EC use after unprotected intercourse.

RESULTS

At both 1- and 6-month followup interviews, there were no differences between advance EC and control groups in reported unprotected intercourse within the past month or at last intercourse. At 6 months, more advance EC participants reported condom use in the past month compared to control group participants (77% vs 62%, P=0.02), but not at last intercourse (advance EC 83% vs control 78%, P=0.34). There were no significant differences by group in hormonal contraception use reported by advance EC or control groups in the past month (44% vs 53%, P=0.19) or at last intercourse (48% vs 58%, P=0.20). At the first followup, the advance group reported nearly twice as much EC use as the control group (15% vs 8%, P=0.05) but not at the final followup (8% vs 6%, P=0.54). Advance EC group participants began their EC significantly sooner (11.4 hours vs 21.8 hours, P=0.005).

CONCLUSIONS

Providing advance EC to adolescents is not associated with more unprotected intercourse or less condom or hormonal contraception use. In the first month after enrollment, adolescents provided with advance EC were nearly twice as likely to use it and began EC sooner, when it is known to be more effective.

[Factors associated with weight gain in women using oral contraceptives: results of a French 2001 opinion poll survey conducted on 1665 women]

OBJECTIVES

To study how often women put on weight when on the pill and to analyse the relationship between that gain in weight and the characteristics of the last 2 types of pill that had been used.

PATIENTS AND METHODS

Three thousand six hundred and nine women representative of the French female population, aged 15 to 45, were recruited thanks to a survey that took place in 2001. Our study mainly concerned the 1665 women who were actually taking the pill at the time of the survey. The data were collected from self-questionnaires.

RESULTS

Thirty per cent of women declared to have gained weight since using their latest pill - only one more kg for 4% of them, 2 kg for 10% but 3 kg or more for the remaining 16%. Gain in weight was more frequent with women less than 25 years of age (35%) than with older ones (29%). This gain in weight did not vary according to either the type of pill, which was then used, or the length of time spent in using it, or the age of first using. It was more frequent when found with other side effects such as breast pain, skin disorders or metrorrhaegias; it was less frequent among women who had already been on the pill in the past than among women using an oral contraceptive for the first time (28% vs 34%; P = 0.008). The shorter the taking the latest pill had been, the greater the frequency of gain in weight was (P = 0.005), women who had presented the most side-effects in the past having changed their pill more rapidly than other women. Finally, a gain in weight was found far more often in women who "did" put on weight with their latest pill than in those who "did not" (53% vs 14%; P = 0.0001). All in all, 8% of women who had been previously been taking the pill had given up this method over a weight problem.

DISCUSSION AND CONCLUSION

Putting on weight when on the pill being in the long term independent of the type of patent medicine used, it would seem necessary to orientate new research centred both on a chemical and a biological as well as a nutritional approach, so as to answer one of the major preoccupations of oral contraceptive users to the fullest.

Adolescent compliance and side effects with Quick Start initiation of oral contraceptive pills

Adolescents' compliance with use of oral contraceptive pills has been described in the literature. The purpose of this study was to compare traditional Sunday Start to a same day (Quick Start) approach. A retrospective study of patients 22 years of age and younger was performed comparing compliance at 3 months and 12 months and side effects. The groups were divided into Quick Start (N = 77, 40%) and Sunday Start (N = 116, 60%). One hundred twenty-five (65%) patients were compliant at 3 months; 68 patients (35%) were compliant at 12 months. Quick Start users were more likely to comply at 3 months (72% vs. 56%, p = 0.059), especially if they were Caucasian (80% vs. 65%, p = 0.007), with dysmenorrhea (86% vs. 62%, p = 0.006), nulligravid (77% vs. 58%, p = 0.008), or nulliparous (73% vs. 59%, p = 0.038). There was no difference in side effects. There was no significant difference at 1 year in compliance or side effects. Findings suggest better compliance in adolescents at 3 months with the Quick Start approach while maintaining side effect profile.

Health services at the clinic level and implantable contraceptives for women

The quality of implant service provision, particularly counseling, has been associated with successful use and with fewer discontinuations for side-effects. Requirements necessary for quality service provision include cadres of health care workers who can provide implants, training curriculum, duration of training, and training techniques; knowledge of the facilities, surgical equipment, and other supplies necessary; infection prevention steps to safely provide implants; techniques for managing side-effects; methods for managing difficult implant removals, the importance of maintaining close relationships with implant clients, and establishing communication and notification systems for removal (and sometimes replacement) when the effective life-span of the implants has been reached. In this article we review the components and training necessary for the establishment and maintenance of quality implant service delivery systems, discuss the implications of providing more than one type of implant, and describe trends in use.

Implantable contraceptives for women: effectiveness, discontinuation rates, return of fertility, and outcome of pregnancies

Progestogen-only contraceptive implants are highly effective. In most studies, 5-year cumulative pregnancy rates are less than 1.5/100 women for Norplant and Norplant II. No study has yet reported any failures with Implanon. Weight over 70 kg and age at insertion under 25 years both increase the failure rate of Norplant and Norplant II; however, data are as yet lacking for Implanon. The effectiveness of other progestogen-only implants for which there are as yet few data are unlikely to be any different. Continuation rates are high compared with other hormonal methods and with the intrauterine device. In most cohorts at least 35% of women, and often many more, are still using Norplant by the end of 5 years. Rates vary according to a number of factors, including population studied, age, and parity. Menstrual disturbance is by far the most common reason for discontinuation, with headache, acne, weight gain, and desire for pregnancy accounting for other common reasons for implant removal. Fertility returns rapidly following implant removal, and pregnancy rates (76-100% 1 year after removal) are usually no different from those following discontinuation of any other contraceptive method. There is no increase in the risk of ectopic pregnancy, fetal malformation, or impaired infant health in pregnancies conceived either during implant use or after removal.

Nonmenstrual adverse events during use of implantable contraceptives for women: data from clinical trials

Contraceptive methods, including implants, do not prevent common symptoms and adverse health events that most people experience. It is difficult, therefore, to decide whether or not the occurrence of symptoms or adverse events that are common can be attributed to use of a contraceptive method or to determine if a given method changes the likelihood of their occurrence. Based on the review of the literature, no apparent differences in the frequency of adverse events are evident between the six-implant or two-rod levonorgestrel systems and the single implant etonogestrel and nomegestrol acetate systems. The most frequent adverse events reported in clinical trials that are probably related to implant use are headaches and acne. Weight gain, dizziness, and mood changes are also frequently mentioned adverse events and are possibly steroid-related. Other possibly related adverse events, although much less frequently reported, are loss of libido, fatigue, hair loss, and other skin conditions. Persistent ovarian follicles that spontaneously disappear are a common event during use of progestin-only contraceptives, and providers should be aware of this condition to avoid unnecessary interventions. Overall, the vast experience reported in the clinical studies reviewed here show that all existing implantable contraceptives are equally safe. This can probably be attributed to the low-hormonal dose delivered by progestin-implant systems.

Will the pill make me sterile? Addressing reproductive health concerns and strategies to improve adherence to hormonal contraceptive regimens in adolescent girls

PAPER OBJECTIVE: This paper is designed to help clinicians understand the relationship between hormonal contraceptive side effects and the potential development of general and reproductive health concerns that can impact on adherence to hormonal contraception. By understanding the concerns raised by young women, we can then make our counseling more specific to the factors that affect compliance in this population.

DESIGN

Studies that specifically addressed hormonal contraceptive compliance, side effects, and method selection in adolescents and young women were chosen for this paper. All articles were from peer-reviewed journals. Medline-Ovid articles from 1980-2000 were used with the following search keywords: Contraception, Patient Compliance, Hormonal Contraception, Oral Contraceptive Pills, Norplant, Depo Provera, and Adolescents.

DATA SYNTHESIS

The general public has many concerns about the safety of hormonal contraception. The development of side effects, especially those that are menstrual-related, seem to cause adolescents and young women to feel that their general and reproductive health is being threatened.

CONCLUSIONS

Hormonal contraceptive counseling should include 1) explaining, in a nontechnical manner, how these methods work; 2) addressing negative information the patient has heard about the methods; 3) providing factual information about cancer risks, blood clots, and other general health concerns; 4) discussing the potential side effects and what each means to her health; 5) asking specifically about possible reproductive health worries, especially in light of the menstrual irregularities that may occur; and 6) assuring the patient that she should always feel free to share her concerns and worries with you, the provider.

Headache and female hormones: what you need to know

The normal female lifecycle is associated with hormonal milestones, including menarche, pregnancy, contraceptive use, menopause, and the use of replacement sex hormones. Attacks of migraine without aura, but not with aura, are more likely to occur 2 days before onset and on the first 2 days of menses, but they are not more severe than those that occur outside the perimenstrual period. Oral sumatriptan and naratriptan are effective as short-term perimenstrual prophylaxis. Postdural headache can occur during the postpartum period. The International Headache Society Task Force assessed the efficacy of treatment of women who had migraine with combined oral contraceptives and hormone replacement therapy, as well as the risk of ischemic stroke associated with their use. There is no contraindication to the use of oral contraceptives in women with migraine in the absence of migraine aura or other risk factors. There is a potentially increased risk of ischemic stroke in women with migraine who are using combined oral contraceptives and have additional risk factors that cannot easily be controlled, including migraine with aura. There is no compelling evidence that postmenopausal hormone replacement therapy either decreases or increases stroke risk.

Implantable contraception

Although levonorgestrel contraceptive implants have been available for over 15 years, innovations have only recently led to a wider choice. These new implants offer easier insertion and removal and other advantages depending on the type of progestin. Implants prevent pregnancy by several mechanisms, including inhibition of ovulation and luteal function and alteration of cervical mucus and the endometrium. The high efficacy and ease of maintenance make implants an ideal contraceptive for many women, including adolescents, a population that uses implants infrequently but reports high satisfaction. Implants are appropriate for women who are breastfeeding, who have contraindications to estrogen, or who have diseases such as diabetes, hypertension, sickle cell anemia, or an HIV infection because implants have few metabolic or hematologic effects. Long-term use has not been associated with a decrease in BMD and generally leads to increased blood levels and iron stores. Women who wish to space their pregnancies appreciate the nearly immediate onset of action with insertion and the rapid termination of all effects with removal. All types of implants lead to menstrual changes and other side effects in some women. Adverse effects that occur in implant users more than the general population include headaches and acne. Women must be thoroughly counseled regarding the potential for menstrual alteration, side effects, and sexually transmitted infections if they do not use condoms. Despite their initial high cost, implants are a cost-effective method over several years, even when discontinued before the life of the implant.

Use of depot medroxyprogesterone acetate in Thai adolescents

Depot medroxyprogesterone acetate (DMPA) has been available for several decades in many parts of the world including Thailand, but few data have been reported concerning adolescents. The aim of the study was to determine the use of DMPA for contraceptive use among Thai adolescents. A cross-sectional study has been designed. A total of 108 adolescents who used DMPA as contraception between January 1, 1996, and December 31, 1997, at King Chulalongkorn Hospital were reviewed by chart. Most of the participants were in late adolescence and average age was 17.6 years of age. Six-month continuation rate was 69.4%, and at 9 months and 1 year were 42.6 and 30.6%, respectively. Irregular bleeding, amenorrhea, and weight gain were the side effects frequently reported. The most common side effect that caused discontinuation within 1 year was irregular bleeding. With prolonged use, the number of cases with irregular bleeding decreased and the duration of bleeding was shortened, whereas the rate of amenorrhea increased. No pregnancy occurred during the study period. In conclusion, DMPA is an effective contraception in adolescents. However, the continuation rate is lower than that for adult women. The main reason for discontinuation is irregular bleeding.

Contraception

Prescribing and reviewing contraceptive methods with adolescents involves a significant amount of time and resources. Health care providers need to be familiar with how teens think about sex and birth control, what their beliefs are, and how individual teens may make different choices based on their lifestyles. Barrier methods remain popular in that they are accessible and do not require a clinician visit. The hormonal choices need to be explained fully in plain language and selections based on these sessions made appropriately. Teens can be effective users of contraception if they are given the appropriate tools, access, and knowledge.

The use of long-acting contraceptives in adolescents

DMPA and implants have played an important role in the attempt to prevent teenage pregnancies. Adolescent health care providers should provide continued counseling to girls using DMPA or implants and should promptly address any concern associated with these methods. Future studies are warranted to explore ways to prevent or reduce the side effects of DMPA and implants, as well as to develop new, optimal, long-acting contraceptives. Detailed baseline information should be obtained in every future study that explores the presence of side effects during the use of long-acting contraceptives.

Prescribing and managing oral contraceptive pills and emergency contraception for adolescents

Combination OCPs are safe and effective ways to prevent unintended adolescent pregnancy if they are used properly. Numerous noncontraceptive benefits of OCPs can bolster continued combination OCP use. Progestin-only OCPs are an option, particularly for young women with medical contraindications to taking estrogens; however, because of their lower efficacy, progestin-only pills are not the first choice for oral contraception for adolescents. Health care providers can give young women a second chance to prevent unintended pregnancy by improving their access to emergency contraception through educating and counseling about emergency contraception at all office visits, by prescribing emergency contraceptive pills in advance, or by prescribing emergency contraceptive pills over the telephone.

Adolescent contraception

Adolescent pregnancy rates have declined modestly, most likely because of the increased use of condoms, especially at first intercourse. Condom distribution in schools appears to be effective in promoting condom use without increasing sexual activity. Although, to date, no contraceptive has been as effective as Norplant in reducing teen pregnancy, use of the method has declined dramatically. Depo-Provera use is increasing, but continuation rates are disappointing and the impact on teen pregnancy rates is as yet unknown. Emergency contraception remains underutilized, and interventions to improve oral contraceptive compliance are beginning to be explored. School-based programs that provide contraception without adding a strong educational component fail to improve contraceptive use or reduce pregnancy rates. Use of any contraceptive by teens is cost effective.