Implant contraception

Contraception across transgender

Sexual and reproductive issues are essential elements of well-being in cisgenders as well as for the transgender population. Gender-affirming hormonal treatments (GAHTs) aim to induce phenotypical changes congruent with the desired gender and subsequent reduction of gender dysphoria. While genital surgical procedures including hysterectomy and/or adenectomy cause permanent loss of ability to conceive, GAHT may induce a varying degree of reversible loss of fertility. For these reasons, transgender men and women need to be counseled concerning contraceptive options and potential effects of treatment on reproductive function before initiating GAHT. The literature reports that sexual activity with genital involvement is performed by less than half of transgender persons who have been sexually active with a partner in the past. Testosterone (T) is the most commonly used compound in transmen and usually leads to amenorrhea within 1-12 months from first administration, however cessation of menses does not mean anovulation. Some studies report cases of unintended pregnancies among transgender men under masculinizing therapy, therefore T treatment cannot be considered a contraceptive option. Currently available contraceptive options have pros and cons in transmen and scarce literature exists on their use. The effects of GAHT on fertility in transwomen are even less well known. Prolonged estrogen exposure induces sperm suppression and morphological changes of the spermatozoa, however the degree of resulting pregnancy protection is unclear. Further research to inform the contraceptive counseling in this population is mandatory.

Current Issues and Options for Hormonal Contraception in Adolescents and Young Adult Women With Sickle Cell Disease: An Update for Health Care Professionals

Women with sickle cell disease (SCD) are of particular concern regarding the significantly increased risk of pregnancy-related morbidity, mortality, and adverse outcomes. They have limited knowledge of pregnancy and childbirth risks, as well as of the benefits and risks of contraceptives. Thus, there is an urgent need for appropriate information about reproductive family planning to reduce unintended pregnancy. Any decision regarding the use of contraceptives has to be based on the efficacy and risk/benefit ratio of the method used. Both the World Health Organization (WHO) and the Centers for Disease Control (CDC) have developed, published, and updated evidence-based guidelines for medical providers for the use of contraceptives in patients with specific medical chronic conditions. This article provides an overview of the present knowledge on the use of contraceptives in women with SCD. We believe that the collaboration between health care professionals (hematologists, obstetricians, endocrinologists, and primary care providers) can play a major role in identifying the safer contraceptive method to abolish the risks of unintended pregnancy and preserve the health status of patients with SCD.

Effects of etonogestrel implant on quality of life, sexual function, and pelvic pain in women suffering from endometriosis: results from a multicenter, prospective, observational study

PURPOSE

Progestins are successfully employed as treatment for endometriosis. Our study evaluates the effects of the etonogestrel (ENG) implant on pelvic pain, quality of life, and sexual function in women requiring long-term reversible contraception and presenting ovarian cysts of probable endometriotic origin.

METHODS

We enrolled 25 women asking for contraception with the ENG implant and presenting a cyst with the ultrasound features of an endometrioma and pain symptoms. Patients were interviewed on pain symptoms (dysmenorrhea, dyspareunia, dyschezia, and dysuria) using a VAS score (0-10), on quality of life (QoL) using the Short Form-36 questionnaire, and on sexual activity using the Female Sexual Function Index (FSFI) questionnaire before inserting the implant (T0) and after 6 (T1) and 12 months (T2).

RESULTS

We found a significant decrease in dysmenorrhea and dyspareunia VAS scores comparing baseline scores to 6 and 12 months. After 12 months, the bodily pain, general health, vitality, social functioning, and mental health domains of the QoL score were significantly improved. The total FSFI score results increased in comparison with baseline both at 6 and 12 months. In particular, we highlighted a significant improvement in desire, satisfaction, and pain domains already at 6 months; the arousal domain improved only after 12 months. Finally, mean diameters of endometrioma-like cysts were not changed after 12 months of treatment.

CONCLUSIONS

Etonogestrel implants seem to be able to reduce pelvic pain, improve sexual function, and quality of life in patients with ovarian cysts suspected of endometriotic origin.

Pharmacologic treatment of the ovarian endometrioma

INTRODUCTION

Treatment of ovarian endometriomas is commonly achieved through laparoscopic surgery and this can be effective in eliminating the disease, although a majority of recent trials documented an adverse effect of surgery on ovarian reserve markers. With the advancement in imaging techniques, ovarian endometriomas are increasingly diagnosed at an earlier stage when the endometrioma may be smaller, less fibrotic and more responsive to medical treatment, making an evaluation of medical options critically important.

AREAS COVERED

The review focuses on currently utilized pharmacologic therapies for endometrioma (oral contraceptives, the levonorgestrel-releasing IUS, the hormone-releasing subdermal implant, Implanon); experimental and future treatments are also mentioned (GnRH antagonists, progesterone receptor modulators, antioestrogens, newer subdermal implants and intracystic administration of pharmacologic agents). Finally, the usefulness of post-operative adjuvant medical treatments is discussed Expert opinion: Today, reliable, non-invasive diagnostic procedures of an ovarian endometrioma are available and should be utilized to identify its presence and type of pathology. In a young patient, classic medical therapies such as oral contraceptives and synthetic progestins should be tried first to alleviate symptoms. Only when these regimens fail, should a minimally invasive surgery be envisaged. Following endoscopic surgery, adjuvant medical treatment may reduce recurrence of both symptoms and the lesion.

Contraceptive Methods

The prevention of pregnancy remains an important part of the practice of medicine. Contraception can occur at a number of points in the basic reproductive biological process and through a number of contraceptive product options. Pharmacists are health care providers appropriately positioned to assist patients in suitable contraceptive product selection based on their personal situations and lifestyles. This article provides an overview of available products for prevention of pregnancy and associated risks and benefits. Contraceptive products are categorized by their hormonal content and method of action. Hormonal options include oral contraceptive pills, contraceptive patch, implants, injection, intravaginal, and intrauterine devices. Barrier products prevent pregnancy by creating a physical obstacle to the successful fertilization of an egg by sperm. All products and methods are associated with benefits and potential complications that must be considered as patients, and health care providers select the most satisfactory option.

Effect of etonogestrel implant on serum lipids, liver function tests and hemoglobin levels

BACKGROUND

This study aimed to assess the possible effects of etonogestrel implant (Implanon, Organon, Oss, The Netherlands) on total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and Hb levels in a sample of Turkish population.

STUDY DESIGN

Healthy women of childbearing potential who had applied to our Family Planning Clinic for a contraceptive method and had chosen to have an Implanon insertion after thorough counseling about all family planning methods and screening for eligibility for Implanon use were enrolled in the study. Serum concentrations of TC, TG, HDL-C, LDL-C, AST, ALT and Hb levels were tested before and at 3 and 6 months after insertion. Baseline mean parameters were compared with mean parameters at 3 and 6 months for statistical significance using paired-samples t test.

RESULTS

Eighty-two women eligible for the study were included. Mean age of the patients was 27.5+/-4.8 years. When compared to the baseline values, there was a statistically significant decrease in the TC (p<.001), HDL-C (p<.001) and TG (p=.006) at the end of the third month, while there was a significant increase in Hb values (p=.01). The decrease in TC (p=.001) and HDL-C (p<.001) and increase in Hb value (p=.03) persisted by the end of sixth month while the decrease in TG was transient. A statistically significant increase in mean ALT level was observed at 6 months (p=.03).

CONCLUSION

The effect of Implanon on liver functions and lipid metabolism does not lead to unhealthy alterations. Increase in Hb can be attributed to the high frequency of amenorrhea in patients.

Antigonadotropic progestogens as contraceptive agents in women with contraindication to combined pill

Synthetic progestogens belong to different pharmacological classes and are mixed steroids. They display different properties due to their various affinities to the different steroid receptors. In addition, the dosage used can modify their side effects. Normethyltestosterone used at minimal doses, also called progestogen only pill (POP), constitute the standard recommended hormonal contraception for women with vascular and metabolic contraindications to combined pill (COC). However, POP efficacy and gynecological tolerance are limited. We have developed for more than 20 years in France the use of two pregnane derivatives as contraceptive agents in women with contraindication to COC. Chlormadinone acetate and cyproterone acetate have different antigonadotropic potencies but remain neutral on vascular risk. We have analyzed the efficacy, vascular and gynecological tolerances in 187 women with systemic lupus erythematous with or without antiphospholipids. Venous thrombosis and arterial events rates were lower than those reported in the literature. The current experience in women with thrombophilia is similar as reported in a series of 150 patients. In addition, we have also used antigonadotropic progestins in women with hereditary angioedema (HAE) types I, II or III. HAE symptoms can be induced or worsened by COC. We could demonstrate a significant improvement of the symptoms in most women with HAE under antigonadotropic progestins. Gynecological and general tolerances were satisfactory. In conclusion, antigonadotropic progestins could have clinical positive benefits as contraceptive agents in women with contraindication to COC.

Side effects and acceptability of Implanon: a pilot study conducted in eastern Turkey

OBJECTIVE

To assess side effects during the first 6 months of use of Implanon.

DESIGN AND METHODS

The study was conducted in eastern Turkey between June 2004 and May 2005. Forty-one healthy women, aged 18-40 years who chose to use Implanon participated in the study. The implant was inserted between days 1 and 5 of the menstrual cycle. Findings were recorded before and during 6 months following insertion. Statistical analyses were performed using SPSS package programme including paired samples t-test.

RESULTS

No pregnancy occurred during the study. Ninety days after initiation of therapy, three of the 41 patients (7.3%) had regular periods, 14 (34.1%) were amenorrhoeic and the remaining 24 (58.5%) had some type of abnormal bleeding. Dysmenorrhoea affected significantly less women (1/41, i.e. 2.4%) than before treatment (17/41, i.e. 41.5%), but mastalgia increased significantly as it was reported by five previously unaffected participants (12.2%). Mood changes appeared in seven patients (17.1%) and acne in 11 of them (26.8%). The circulating levels of protein C, total cholesterol and oestradiol dropped significantly. Endometrial thickness decreased significantly. At completion of the study period, removal of the implant was requested by eight of the 41 patients (19.5%) because of irregular bleeding (six women), depressive symptoms requiring treatment (one woman) or weight gain (one woman).

CONCLUSIONS

Mainly because of irregular bleeding, the discontinuation rate of Implanon at 6 months among the women in this region is high (19.5%).

Contraceptive Implants: An Overview and Update

Contraceptive implants are safe, highly effective, and long-term methods of contraception that are widely applicable to any reproductive-aged woman. Implants require minimal user compliance and are cost-effective. The new single-rod system simplifies insertion and removal, making implants more accessible for both providers and patients. Specifically, progestin-only implants are safe options for various women including adolescents, postpartum, breast-feeding, those who are medically complicated, or those who have contraindications to or intolerance of estrogen-containing contraceptives.

Hormonal contraception: recent advances and controversies

This document will outline new delivery systems and contraceptive formulations, summarize recent advances in emergency contraception, and review the effects of hormonal contraception on cancer risks, cardiovascular disease, and bone.

[Ectopic pregnancy with etonogestrel contraceptive implant (Implanon): first case]

We describe the first case of ectopic pregnancy occurring in a patient with an etonogestrel contraceptive implant (Implanon). There was no factor predisposing to a failure of the technique (implant in place for less than 2 years and normal BMI). In addition there was no risk factor for an ectopic location of the pregnancy. We discuss the role of the micro progestative in the location of the pregnancy. This case report emphasizes the fact that ectopic pregnancy should not be ruled out in women taking this contraception, however efficient it is otherwise.

Beyond the pill: new data and options in hormonal and intrauterine contraception

With the goal of helping clinicians facilitate contraceptive success for their patients, this Clinical Opinion provides an update regarding older hormonal and intrauterine contraceptives and details newer methods that include the progestin-releasing intrauterine system, the contraceptive patch and ring, and extended and emergency oral contraception. Last, I will look over the horizon and briefly describe potential future methods that include the single rod progestin-releasing implant, folic acid-supplemented oral contraceptives, and hormonal contraception for men.

Hormonal contraception: recent advances and controversies

This document will outline new delivery systems and contraceptive formulations, summarize recent advances in emergency contraception, and review the effects of hormonal contraception on cancer risks, cardiovascular disease, and bone.

Acceptabilité de l’implant contraceptif à l’étonogestrel (Implanon®)

OBJECTIVES

To estimate the exact satisfaction of women toward Implanon, the sole contraceptive implant available in France. To clarify the indications of this type of contraception.

MATERIAL AND METHOD

Among a population of 182 women with Implanon" inserted in a same family planning service between May 22, 2001 and February 14, 2003, 108 women agreed to answer a questionnaire of satisfaction. Implants were inserted in one third of cases after childbirth, in another third after abortion. The average duration of use of the implant was of 16 months (2 in 24 months). Twenty-nine removals among the 108 insertions (27%) were recorded.

RESULTS

Possibility of a long-term and easy -to-use contraception was the most common reason for choosing Implanon (74% of the women). Eighty-one percent of the women were globally satisfied with Implanon but one out of two women had side-effects. Only 62% of the women were ready to use it again. Adverse events were first, menstrual disturbance in 83% of the women, mainly amenorrhea (26%) and bleeding irregularity (40%). Bleeding irregularity was one of the main motives for discontinuing the implant in 41% of cases. Except weight gain present for 37% of patients, the other side-effects, even though they were frequent, were less often the reason for removal. Headache, acne, breast pain, mood and decreased libido were the main reasons for removal.

CONCLUSION

Implanon has certainly a place among current contraceptive methods. Because of the frequency raised by adverse events and by their lower tolerance in Europe, this place has to remain limited to the incapacity of classic methods. Preinsertion counseling announcing Implanon's benefit and risk effects is necessary to minimize the early discontinuation rates.

Hormonal contraception: Recent advances and controversies

This document will outline new delivery systems and contraceptive formulations, summarize recent advances in emergency contraception, and review the effects of hormonal contraception on cancer risks, cardiovascular disease, and bone.

Recent developments in hormone delivery systems

Women who want safe, effective contraception have many more options than they did only a few years ago. Each option must be weighed carefully according to the needs and lifestyle of each particular woman. One method that provides long-term convenience with a side-effect profile that is comparable to that of oral contraceptives is the once-a-month injectable contraceptive containing 25 mg medroxyprogesterone acetate and 5 mg estradiol cypionate. Another option is the levonorgestrel-releasing intrauterine contraceptive system that offers pregnancy prevention for 5 years. Finally, hormonal implants that release low doses of progestins have been used for more than 30 years by a total of 10 million women, and easier-to-use implants will soon be available.

New options in contraception for teenagers

PURPOSE OF REVIEW

Unintended pregnancy continues to exact a considerable economic, social and personal cost in industrialized nations despite the ready availability of safe, reliable and highly effective methods of contraception. Adolescents still demonstrate some of the highest rates of unintended pregnancy and thus may benefit from considering new contraceptive options that provide unique side effect profiles or delivery systems that could facilitate and improve compliance of contraceptive methods.

RECENT FINDINGS

The recent launch of several new combination oral contraceptive pills with novel side effect profiles has expanded the choices for teenagers who choose to use a daily oral contraceptive. Of potentially greater interest is the recent availability of several nondaily contraceptives, as compliance remains a critical issue with successful contraceptive use in adolescents.

SUMMARY

New contraceptive methods bring unique side effect profiles and delivery systems that may improve overall contraceptive compliance, especially among teenagers who are more prone to misuse from a wide array of side effect and compliance issues. Even the most accepted method, however, will not provide effective contraception if the process by which contraception is provided fails to address the unique concerns and lifestyle issues of each individual adolescent.

Risks and benefits, advantages and disadvantages of levonorgestrel-releasing contraceptive implants

Levonorgestrel-releasing implants are long acting contraceptives, approved for 5 years of continuous use. Two marketed systems, the six capsule Norplant use of tradenames is for product identification purposes only and does not imply endorsement. and the two rod Jadelle, have essentially equal rates of drug release, pregnancy and adverse events over 5 years of use. Randomised clinical trials and controlled cohort observations indicate that for the first 3 years, when pregnancy rates are at or almost zero, no other contraceptive system is more effective, although etonogestrel implants provide equal effectiveness. Annual pregnancy rates rise in the fifth year of continuous use but remain below 1 per 100 women. Annual pregnancy rates of Norplant users remain below 1 per 100 throughout 7 years of continuous use. Levonorgestrel implants provide low progestogen doses; 40-50 microg/day at 1 year of use, decreasing to 25-30 microg/day in the fifth year. Serum levels of levonorgestrel at 5 years are 60-65% of those levels measured at 1 month of use. Adverse effects with levonorgestrel implants are similar to those observed with progestogen only and combined oral contraceptives. Risks of ectopic pregnancy, other pregnancy complications and pelvic inflammatory disease are reduced in comparison with those of women using copper or non-medicated intrauterine devices. Risks of developing gallbladder disease and hypertension or borderline hypertension, although small, are about 1.5 and 1.8 times greater, respectively, in women using levonorgestrel implants than in women not using hormonal contraception. Other serious diseases have not been found to occur significantly more frequently in levonorgestrel implant users than in women not using hormonal contraception. The great majority of levonorgestrel implant users experience menstrual problems, but serious bleeding problems are not more frequent than in controls. Other health problems reported more frequently by levonogestrel implant users than by women not using hormonal contraception in a study of 16000 women included skin conditions, headache, upper limb neuropathies, dizziness, nervousness, malaise, minor visual disturbances, respiratory conditions, arthropathies, weight change, anxiety and non-clinical depression. Clinical depression is not more frequent in women using implants compared with those not using hormonal contraception (i.e. using intrauterine devices, sterilisation). Removal problems occur less frequently with Jadelle than with Norplant. The mean removal time for Jadelle is half that of Norplant. Levonorgestrel implants in nationally representative scientific samples, in randomised trials, and in controlled cohort studies have continuation rates as high as or higher than any other reversible contraceptive over a duration of 5 years. This would imply that the satisfaction women derive from the contraceptive effectiveness of levonorgestrel implants greatly outweighs the dissatisfaction that may accompany menstrual disturbances and other adverse effects associated with implants.

Ultrasonographic features of the endometrium and the ovaries in women on etonogestrel implant

OBJECTIVE

To evaluate the ultrasound features of the endometrium and ovaries in women on etonogestrel implant, and to correlate these features with the bleeding pattern.

METHODS

Observational study including 188 consecutive women presenting for follow-up transvaginal ultrasound examination after insertion of an etonogestrel implant contraceptive device. Thirty women had more than one follow-up examination. The bleeding pattern was considered abnormal if, in the last 3 months, there were more than five episodes of vaginal bleeding, or there was prolonged bleeding exceeding 14 consecutive days.

RESULTS

At first follow-up examination, the mean age was 29.7 years and 47% of women had an abnormal bleeding pattern. Most bleeding episodes were of less intensity than menses. The mean endometrial thickness (ET) on ultrasound was 2.9 mm (standard deviation, 2.0). Ovarian follicle growth exceeding 5 mm was observed in 60% of the cases. Ovulation was demonstrated in one woman. Univariate analysis showed a positive association (P < 0.01) between ET, bleeding pattern, and bleeding intensity. Follicle growth was positively associated (P < 0.01) with ET, bleeding pattern, and interval between insertion and examination. Multivariate analysis showed that the ET was on average 1.25 mm greater in women with abnormal bleeding (P = 0.0001). The odds of finding follicle growth were 2.8 times higher (95% confidence interval, 1.2-6.2) in women presenting with a three-layer type of endometrial morphology. There was no association between the other patients' characteristics and the bleeding pattern.

CONCLUSIONS

Abnormal uterine bleeding in women on etonogestrel implant was associated with follicle growth and a thicker, three-layer type of endometrium, suggesting incomplete ovarian inhibition and estrogen stimulation of the endometrium.