Gene expression associated with vaginal bleeding in women using the 52-mg levonorgestrel hormonal intrauterine device: A prospective study

OBJECTIVE

To evaluate gene expression associated with vaginal bleeding in the 52-mg hormonal intrauterine device (IUD) users.

MATERIALS AND METHODS

We conducted a prospective study involving 100 women seeking to use the 52-mg hormonal IUD for contraception. We excluded women with a history or current condition of abnormal uterine bleeding and who were unable to attend a 1-year follow up. Women who expelled the device, removed it for reasons unrelated to vaginal bleeding, or were lost to follow up were discontinued. We collected endometrial biopsies immediately before IUD placement and assessed 20 selected genes using reverse transcription quantitative polymerase chain reaction. Users maintained a uterine bleeding diary for 12 months following IUD insertion. For statistical analysis, participants were categorized into groups with or without vaginal bleeding at 3 and 12 months.

RESULTS

Women with elevated CXCL9 expression had an 8.15-fold higher likelihood of experiencing vaginal bleeding at 3 months (odds ratio [OR] 8.15, 95% confidence interval [CI] 2.24-29.61, P = 0.001). At 12 months of follow up, women with increased TIMP1 expression had a 2.74-fold higher chance of experiencing vaginal bleeding (OR 2.74, 95% CI 1.08-6.95, P = 0.033). CXCL9 ≥ 1.5 and IL17A ≥ 0.68 were associated with a higher probability of vaginal bleeding at 3 months, while TIMP1 levels ≥0.943 were linked to an increased risk of bleeding at 12 months.

CONCLUSION

Users of the 52-mg hormonal IUD with elevated relative CXCL9 expression face an increased risk of vaginal bleeding at 3-month follow up, whereas those with heightened TIMP1 expression are more likely to experience vaginal bleeding at 12 months.

Gene expression associated with unfavorable vaginal bleeding in women using the etonogestrel subdermal contraceptive implant: a prospective study

To evaluate gene expression associated with unfavorable vaginal bleeding in users of the Etonogestrel (ENG) contraceptive implant. Prospective study involving 100 women who intended to use the ENG implant. Exclusion criteria included abnormal uterine bleeding, inability to attend a 1-year follow-up, and implant removal for reasons unrelated to vaginal bleeding or loss of follow-up. We obtained endometrial biopsies before implant placement and assessed the expression of 20 selected genes. Users maintained a uterine bleeding diary for 12 months post-implant placement. For statistical analysis, we categorized women into those with or without favorable vaginal bleeding at 3 and 12 months. Women with lower CXCL1 expression had a 6.8-fold increased risk of unfavorable vaginal bleeding at 3 months (OR 6.8, 95% CI 2.21-20.79, p < 0.001), while those with higher BCL6 and BMP6 expression had 6- and 5.1-fold increased risks, respectively. By the 12-month follow-up, women with lower CXCL1 expression had a 5.37-fold increased risk of unfavorable vaginal bleeding (OR 5.37, 95% CI 1.63-17.73, p = 0.006). Women with CXCL1 expression < 0.0675, BCL6 > 0.65, and BMP6 > 3.4 had a higher likelihood of experiencing unfavorable vaginal bleeding at 3 months, and CXCL1 < 0.158 at 12 months. Users of ENG contraceptive implants with elevated BCL6 and BMP6 expression exhibited a higher risk of breakthrough bleeding at the 3-month follow-up. Conversely, reduced CXCL1 expression was associated with an elevated risk of bleeding at both the 3 and 12-month follow-ups.

Clinical Assessment of 3 Intrauterine Devices in Adolescent Girls: A Randomized Clinical Trial

STUDY OBJECTIVE

To assess clinical performance, bleeding pattern, dysmenorrhea, and satisfaction up to 1 year after placement of 3 types of intrauterine devices (IUDs) (TCu380A, levonorgestrel 52 mg, and levonorgestrel 19.5 mg) in adolescents METHODS: The study was a randomized trial with 318 adolescents allocated to the 3 IUDs. We assessed reasons for removal, continuation, menstrual patterns, dysmenorrhea, and satisfaction.

RESULTS

Participants aged (mean ± SD) 17.9 ± 1.4 years, with 80.8% being nulligravidae. After 1 year, 265 (83.3%) continued using the IUD; however, the continuation rate of TCu380A (75.4 ± 4.2) was lower than that of both the levonorgestrel 52-mg (88.6 ± 3.1) and 19.5-mg IUDs (86.8 ± 3.3), and bleeding/pain and expulsion were the main reasons for removal of the TCu380A IUD. The duration of menstruation was longer among the TCu380A IUD users (6.0 ± 2.0 days) than those using the levonorgestrel 52 mg (2.5 ± 3.9) and 19.5 mg (3.2 ± 3.2) devices, P < .001. Amenorrhea was reported by 49.5% and 37.8% users of the levonorgestrel 52-mg and 19.5-mg devices, respectively, P < .001. Dysmenorrhea was reported in 68.5% of all participants at the baseline; this was 67.9% of the TCu380A group and 33.3% and 36.0% of the levonorgestrel 52-mg and 19.5-mg IUD groups, respectively, P < .001. Satisfaction ranged from 80.7% in the TCu380A group to 97.8% in the levonorgestrel 52-mg group (P = .03).

CONCLUSION

The 3 IUDs are suitable for adolescents, with high contraceptive efficacies and rates of continuation within 1 year of use and high degrees of satisfaction. Users of the hormonal IUDs reported lower expulsion rates, more favorable menstrual patterns, and less dysmenorrhea compared with the TCu380A IUD.

Uptake, discontinuation, and continuation rate of long-acting contraceptive methods when offered at no cost in Campinas, Brazil

OBJECTIVES

This study aimed to compare the uptake, reasons for discontinuation, continuation, and satisfaction of long-acting contraceptive methods (LARC) when offered at no cost in Campinas, Brazil.

STUDY DESIGN

This was a prospective cohort study conducted at University of Campinas, Campinas, São Paulo, Brazil, including women aged 18 to 48 years, who adopted one of three methods. Participants underwent telephone follow-up every 3 months for up to 24 months after insertion. Satisfaction was assessed at the end of 2 years of use through the Likert scale.

RESULTS

We invited 1222 women, and among the 971 women who volunteered to participate in follow-up, 414 (42.6%) chose the levonorgestrel 52-mg intrauterine device (IUD), 358 (36.9%) chose the etonogestrel (ENG) implant, and 199 (20.5%) chose the TCu380A IUD. Discontinuation due to bothersome bleeding was higher among users of the ENG implant (10/358; 2.4%) and the TCu380A IUD (32/199; 8.9%), and expulsion was higher for the TCu380A IUD (30/199; 15.1%). Women continued at 24 months were 340/414 (82.1%), 270/358 (75.4%), and 119/199 (59.8%) among users of the levonorgestrel 52-mg IUD, ENG implant, and TCu380A IUD, respectively. The users of the levonorgestrel 52-mg IUD (301/339, 88.8%), the ENG-implant (222/270, 82.2%), and the TCu380A IUD (105/119, 88.2%) were satisfied or very satisfied by 24 months of follow-up.

CONCLUSIONS

The three LARC methods had great uptake, high continuation, and discontinuation due to bothersome bleeding was higher among users of the ENG implant and the TCu380A IUD, and expulsion was higher for the TCu380A IUD compared to the 52-mg levonorgestrel IUD. Most of the participants reported being very satisfied.

IMPLICATIONS

When the LARC methods were offered at no cost in a Brazilian public clinic the uptake, satisfaction and continuation were high by 24 months after device placement, and high level of satisfaction was reported by most of the participants.

Risk factors related to the SARS-CoV-2 vaccine additional doses hesitancy among pregnant and non-pregnant people of reproductive age and partners: A Brazilian cross-sectional study

OBJECTIVE

The aim of this study was to assess the predictors of acceptance and hesitancy of additional doses of any SARS-CoV-2 (COVID-19) vaccine among pregnant or recently pregnant and non-pregnant people of reproductive age and partners in Brazil.

METHODS

We conducted an online cross-sectional study from June 2022 to April 2023 and invited women and partners between 18 and 49 years old to participate. We employed a snowball strategy to reach all potential eligible participants. Our primary outcome was the acceptance rate of the COVID-19 booster vaccine. We estimated the frequency and percentage for the three groups and compared categorical variables using the Chi-square test. Moreover, bivariate, backward stepwise regression, and subgroup analyses were performed to evaluate risk factors and predictors of COVID-19 vaccine booster hesitancy. We reported the effect size as OR with a 95% CI.

RESULTS

We included 1487 participants, and among them, 334 (22.5%) were pregnant or recently pregnant people, 905 (60.8%) were non-pregnant people, and 247 (16.6%) were male partners. Pregnant and recently pregnant people showed greater hesitancy for the COVID-19 vaccine booster than non-pregnant people (28% vs 15%, P < 0.001) and male partners (28% vs 16%, P < 0.001). Non-pregnant women accepted the COVID-19 vaccine more often than pregnant or recently pregnant people (OR 1.75; 95% CI: 1.13-2.70). The associated factors to the reduced COVID-19 vaccine booster acceptance were family income between US$ 566-945.00 (54%), evangelic religion (65%), concern about vaccine safety (80%) and perceived common vaccine importance (93%).

CONCLUSION

Pregnant people were more hesitant than non-pregnant people to accept the COVID-19 booster vaccine. Family income, religious beliefs, vaccine safety concerns, and perceived common vaccine importance were significant barriers to accepting COVID-19 booster vaccines. The impact of these factors was more evident among pregnant or recently pregnant people, emphasizing the harmful effect of misinformation among this vulnerable population.

Menstrual health: Inequities in a cohort of menstruating people in the Brazilian southeastern region

OBJECTIVE

To assess menstrual hygiene management (MHM) and period poverty in a group of low- and medium-income menstruating people.

METHODS

A cross-sectional study was conducted at the University of Campinas, Brazil, from January to June 2022 with 535 participants aged 18-49. For data collection, we used the abbreviated version of the WHO Quality-of-Life questionnaire (WHOQOL-BREF) and a pre-tested questionnaire with items regarding MHM and period poverty.

RESULTS

We found an inverse relationship between the risk of no access to supplies to perform menstrual hygiene, which increased by 2.5% and each point less in the environmental domain of quality of life (QoL), and this risk increased by up to 3.1 times among participants who reported difficulty making ends meet. The risk of not having adequate conditions to perform menstrual hygiene at home increased by up to 2.6% for every one-point drop in the environmental domain of QoL. The risk of not having adequate conditions to perform menstrual hygiene outside the home increased by up to 1.3% for less points in the psychological domain of QoL, and 44.4% of those who indicated inadequate conditions for menstrual hygiene reported two or more childbirths.

CONCLUSIONS

Menstruating people who have an increased risk of lacking menstrual supplies and have an increased risk of inadequate conditions for MHM at home and outside the home, as well as those who have two or more deliveries and those having difficulties making ends meet, scored low on the QoL, especially in the environmental and psychological dimensions.

Barriers to accessing post-pregnancy contraception in Brazil: The impact of COVID-19

The aim of our article is to discuss barriers associated with post-pregnancy contraception in Brazil during the SARS-CoV-2 (COVID-19) pandemic. Socioeconomic differences in gaining access to long-acting reversible contraceptive (LARC) methods became greater during the COVID-19 pandemic. The inadequate distribution of existing resources and the reduced capacity for elective care meant that healthcare providers in family planning had to be reallocated to respond to COVID-19 emergencies. In Brazil, 74% of the population depends on the national health service (Sistema Unico de Saúde) including for the provision of free contraception. However, the only LARC method available at the public service is the copper-intrauterine device (IUD); implants and hormonal-IUDs are not available, except at some teaching hospitals. Contraceptive sales remained unmodified during the pandemic, which shows that the majority of the population used less effective or no contraceptive methods during this time. However, sales of implants and the hormonal-IUD increased significantly, indicating the inequity of the low-income portion of the society as only the wealthy can afford these. On the other hand, there was an increase in sales of emergency contraception. The uptake of postpartum IUDs and contraceptive implants at the selected teaching hospitals in which they were available was high during the COVID-19 pandemic as they were the only methods immediately available. In conclusion, the COVID-19 pandemic increased both inequality and social differences in gaining access to contraceptives. Postpartum and immediate post abortion methods were also good strategies during the pandemic and were well accepted by the population. However, they were not offered by most services.

Effectiveness and continuation rates of the etonogestrel-subdermal contraceptive implant versus short-acting contraceptive methods offered at no cost in Campinas, Brazil

OBJECTIVES

To compare the efficacy, reasons for discontinuation and continuation rates of the etonogestrel (ENG)-subdermal contraceptive implant when offered at no cost, and the basis of free choice versus short-acting reversible contraceptive (SARC) methods including combined oral contraceptives (COCs), once-a-month injectables, vaginal ring, and patch.

METHODS

We conducted a prospective study at the University of Campinas, Brazil, involving women aged 18 to 40 years. They were counseled on various contraceptive methods before entering the study and followed up every 3 months for up to 24 months. Satisfaction was assessed using a Likert scale. Survival rates were estimated using the Kaplan-Meier test, and curve comparisons were performed using the log-rank test.

RESULTS

We enrolled 609 women including 358/609 women (58.8%) who chose the ENG-implant and 251/609 (41.2%) who chose SARC methods. Contraceptive failure and all other reasons for discontinuation were significantly higher in SARC users compared to the ENG-implant users (P < 0.001 and P = 0.002, respectively). The continuation rate was higher among ENG-implant users (89.9% and 75.4%) compared to SARC methods users (27.2% and 15.9%) up to 1 and 2 years after study initiation, respectively. Satisfaction was high in both groups (>82%).

CONCLUSIONS

The ENG-implant showed higher contraceptive effectiveness and higher continuation rates than SARC methods up to 2 years after study initiation. Furthermore, users from both groups were highly satisfied with their contraceptive. The main reason for discontinuing use of the ENG-implant was bothersome uterine bleeding, while for SARC methods it was for personal reasons.

Association between COVID-19 and vaccination on menstrual cycle

OBJECTIVE

To evaluate changes in the menstrual pattern of women of reproductive age infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or vaccinated against coronavirus disease 2019 (COVID-19).

METHODS

A cross-sectional study at the University of Campinas, Brazil using Google questionnaire applied from December 2021 through February 2022, disseminated through snowball technique. Participants responded about characteristics of their menstrual cycle before the pandemic and before COVID-19 vaccination, and then about characteristics of their cycle 3 months after infection with SARS-CoV-2 and 3 months after vaccination. Our primary outcome was a binary indicator of changes in the menstrual cycle. We used multivariate regression analysis to identify factors associated with menstrual changes.

RESULTS

We received 1012 completed questionnaires and 735 (72.7%) were from women aged between 20 and 39 years, 745 (73.6%) were White and 491 (48.6%) lived with a partner. A total of 419 (41.6%) of the women reported SARS-CoV-2 infection; however, only two of them were hospitalized, and 995 (98.8%) of women had at least one dose of COVID-19 vaccine. About menstrual characteristics, 170 (41.3%) reported changes after having COVID-19 and 294 (29.9%) after COVID-19 vaccination, respectively. Few years of schooling, lower income, and non-white ethnicity were related to higher reports of menstrual changes after COVID-19. Menstrual changes after COVID-19 vaccination were associated with not using contraception. Higher body mass index was associated with irregularities in cyclicity and bleeding days, after COVID-19 and COVID-19 vaccination, respectively.

CONCLUSION

Our results corroborated the stability of the menstrual cycle after having COVID-19 or COVID-19 vaccination; however, there is a potential relationship between menstrual changes and socioeconomic factors as well as contraceptive use.

Analysing the context and characteristics of legal abortion and comprehensive post-abortion care among adolescents aged 10-14 in a network of sentinel centres in Latin America: a retrospective cross-sectional study, 2016-2020

Pregnancy-related complications are a substantial source of morbidity and mortality among adolescents in low- and middle-income countries. While the youngest adolescents (those aged 10-14) are considered to be at particularly high risk of adverse outcomes, there is little empirical data available on their sexual and reproductive health. Using a unique dataset of clinical records drawn from a regional network of sentinel centres providing legal abortion and comprehensive post-abortion care in 12 Latin American and Caribbean countries, we described the population of adolescents aged 10-14 seeking legal abortion and post-abortion care and calculated institutional rates of complications, using older adolescents (aged 15-19) and young adults (aged 20-24) as comparator groups. We also assessed the quality of care provided as compared to WHO recommendations. Nearly 17% (89 out of 533) of young adolescents sought care when they were already at 15 or more weeks' gestation. Young adolescents were at higher risk of pre-procedure and intra-operative complications than older adolescents and young adults, though the trend is less clear for the most severe complications. In general, the quality of care provided by centres in the network was aligned with WHO recommendations for safe abortion and comprehensive post-abortion care. Taken together, these findings provide insight into the challenges facing the global health community in assuring the sexual and reproductive health and rights of the youngest adolescents, and outline avenues for future research, advocacy, and evidence-based policymaking.

Standardising outcome reporting for clinical trials of interventions for heavy menstrual bleeding: Development of a core outcome set

OBJECTIVE

To develop a core outcome set for heavy menstrual bleeding (HMB).

DESIGN

Core outcome set (COS) development methodology described by the COMET initiative.

SETTING

University hospital gynaecology department, online international survey and web-based international consensus meetings.

POPULATION OR SAMPLE

An international collaboration of stakeholders (clinicians, patients, academics, guideline developers) from 20 countries and 6 continents.

METHODS

Phase 1: Systematic review of previously reported outcomes to identify potential core outcomes. Phase 2: Qualitative studies with patients to identify outcomes most important to them. Phase 3: Online two-round Delphi survey to achieve consensus about which outcomes are most important. Phase 4: A consensus meeting to finalise the COS.

MAIN OUTCOME MEASURES

Outcome importance was assessed in the Delphi survey on a 9-point scale.

RESULTS

From the 'long list' of 114, 10 outcomes were included in the final COS: subjective blood loss; flooding; menstrual cycle metrics; severity of dysmenorrhoea; number of days with dysmenorrhoea; quality of life; adverse events; patient satisfaction; number of patients going on to have further treatment for HMB and haemoglobin level.

CONCLUSIONS

The final COS includes variables that are feasible for use in clinical trials in all resource settings and apply to all known underlying causes of the symptom of HMB. These outcomes should be reported in all future trials of interventions, their systematic reviews, and clinical guidelines to underpin policy.

Provision of contraceptives by Brazilian general gynaecologists: a nationwide online survey

OBJECTIVE

To assess the provision of contraceptives by Brazilian obstetricians and gynaecologists (Obst/Gyns) during medical consultation and associated factors.

METHODS

An anonymous online survey was conducted with Obst/Gyns regarding age, gender, training, method counselling about and provision of long-acting reversible contraception (LARC).

RESULTS

Of 16,000 Obst/Gyns, 610 (3.8%) answered the survey. After multiple regression analysis, female Obst/Gyns (reference) (OR male was 0.53 [95%CI 0.28-0.98], p = 0.044) and Obst/Gyns aged between 20 and 39 were more likely to provide an IUD. For hormonal-IUDs, Obst/Gyns who had had theoretical training in hormonal-IUD insertion (reference no training) (OR = 2.13 [95%CI 1.14-3.99], p = 0.018), those who work in a private facility or public hospital, and those that allowed more time during consultations (reference) (OR short time = 0.33 [95%CI 0.17-0.63], p < 0.001) were more likely to provide them. Obst/Gyns who were hands-on trained were more likely to provide subdermal implant (OR = 2.04 [95%CI 1.45-2.87], p < 0.001).

CONCLUSIONS

There is a gap between theoretical and practical training received by this cohort of Obst/Gyns regarding LARCs, mainly contraceptive implants and hormonal-IUDs. The identification of barriers to offering contraceptives is essential to providing client-centred contraceptive care.

Preterm births prevalence during the COVID-19 pandemic in Brazil: results from the national database

The SARS-CoV-2 (COVID-19) pandemic impacted the health systems between and within countries, and in the course of the pandemic sexual and reproductive health services were the most disrupted. Findings from high-income settings have reported significant changes in preterm birth prevalence during the pandemic period. To understand the possible effects of the COVID-19 pandemic on preterm birth numbers at the Brazilian national level. We compare the number of preterm deliveries during the COVID-19 pandemic period (2020 and 2021) with previous years. We conducted a population-based cross-sectional study taking the period from January 2017 to December 2021 to account. We use individual-level live births data from the Brazilian Live Birth Information System (SINASC), and we estimate the odds ratio (OR) of preterm deliveries using propensity score weighting analysis in Brazil and its regions. During the study period (from 2017 to 2021), about 2.7 million live births were recorded per year, and the missing value for gestational age at delivery was less than 1.5%. The preterm birth prevalence slightly increased during the COVID-19 pandemic compared to the pre-pandemic period (11.32% in 2021 vs 11.09% in 2019, p-value < 0.0001). After adjusting for sociodemographic variables, the OR of preterm births in Brazil has significantly increased, 4% in 2020 (OR: 1.04 [1.03-1.05] 95% CI, p-value < 0.001), and 2% in 2021(OR: 1.02 [1.01-1.03] 95% CI, p-value < 0.001), compared to 2019. At the regional level, the preterm birth pattern in the South, Southeast and Northeast regions show a similar pattern. The highest odds ratio was observed in the South region (2020 vs 2019, OR: 1.07 [1.05-1.10] 95% CI; 2021 vs 2019, OR: 1.03 [1.01-1.06] 95% CI). However, we also observed a significant reduction in the ORs of preterm births in the northern region during the COVID-19 pandemic (2020 vs 2019, OR: 0.96 [0.94-0.98] 95% CI) and (2021 vs 2019, OR: 0.97 [0.95-0.99] 95% CI). Our analysis shows that the pandemic has increased regional variation in the number of preterm births in Brazil in 2020 and 2021 compared to the pre-pandemic years.

Expulsion and continuation rates of the 52 mg levonorgestrel intrauterine system in adolescents and adult women

OBJECTIVE

To compare the continuation rates, expulsion, and other reasons for discontinuation of the hormonal intrauterine device with 52 mg of levonorgestrel (52 mg LNG-IUD) in adolescents and adult women.

METHODS

We conducted a retrospective cohort study that included 393 women in whom we placed a 52 mg LNG-IUD and followed up to 5 years. We created two retrospective cohorts, one with 131 adolescents (aged between 12 and 19 years) and the other with 262 women aged ≥20 years. Each adolescent was paired with two adult women who had the same parity and who had a 52 mg LNG-IUD inserted on the same day. We used the Mann-Whitney test to compare numerical variables in both groups, the Kaplan-Meier method, and the log-rank test to compare the continuation, expulsion and other reasons for IUD discontinuation of the two groups.

RESULTS

Age of the adolescents and adult women were mean ± SD 18.1 (±1.1) and 31 (±6.8) years, respectively (p = 0.015). Continuation rates by the fifth year of use were 55.6/100 women-years (W-Y) and 70.3/100 W-Y among adolescents and adult women (p = 0.106); and expulsion rates were 8.4/100 and 6.0/100 W-Y, respectively (p = 0.463). Adolescents had a lower continuation rate during 3 to 5 years of follow-up (p = 0.011) and a high rate of removals due to bleeding/pain (18.5 ± 5.7/100 W-Y vs 6.4/100 ± 2.1 W-Y, p = 0.039).

CONCLUSION

Adolescents who used the 52 mg LNG-IUD showed a lower continuation rate 3-5 years after device placement than adult women. The expulsion rates were similar in both groups.

Women's perspectives on impact on the post menopause of use of the 52 mg levonorgestrel intrauterine device during the menopausal transition

OBJECTIVES

To assess perimenopausal users of 52 mg levonorgestrel intrauterine devices (LNG-IUD) regarding the IUD impact after menopause.

MATERIAL AND METHODS

a cross-sectional study with users aged 40 and 49 years old, without cognitive impairment that answered a questionnaire regarding worries and benefits after the menopause due to LNG-IUD use.

RESULTS

Almost half of 221 users (52.9%) have concerns that LNG-IUD use could influence aspects after menopause, 111 (50.3%) that the post-menopause symptoms get worse and 92 (41.6%) that interfere with recognition of menopausal symptoms.

CONCLUSION

Half of perimenopausal LNG-IUD users expressed concerns about how device use could affect post-menopause symptoms.

Assessment of pain and ease of intrauterine device placement according to type of device, parity, and mode of delivery

OBJECTIVE

We compared pain and the ease of insertion of two different types of intrauterine devices (IUDs; the levonorgestrel intrauterine systems 52 mg (LNG-IUS 52 mg) and the copper-bearing IUD [TCu380A]) among nulligravidas and parous women with and without caesarean delivery.

METHODS

A cross-sectional study assessed pain referred by women and ease of insertion of the two IUDs models. We applied a visual analogue scale (VAS) to assess pain, while the ease of insertion was defined by healthcare professionals.

RESULTS

We assessed 1076 women, including 334 nulligravidas and 566 parous women who had had at least one caesarean delivery and 176 women with history of only vaginal delivery. Regarding pain at IUD placement, 26 (2.5%) women reported no pain, 167 (16.4%) light pain, 319 (31.3%) moderate and 506 (49.7%) intense pain. The highest scores for pain were reported by nulligravidas (67.2%, p = 0.001), while the mean pain score was higher in the LNG-IUS 52 mg group. Difficulties reported by healthcare providers were more frequent in the nulligravidas (21.2%) and women with previous caesarean delivery (16.9%).

CONCLUSIONS

Our findings suggested differences between the two IUDs tested, with higher pain associated with the LNG-IUS 52 mg, and highlights the need for pain management, mainly among nulligravida and women with history of caesarean delivery.SHORT CONDENSATIONIntense pain at insertion was more related to nulligravida than parous women and more pain with placement of LNG-IUS 52 mg IUDs than TCu380A IUDs. Nevertheless, our results confirmed that ease of IUD placement was between 80% to 90% of all insertions, being more common in parous women without previous caesarean delivery.

Pain and ease of insertion of three different intrauterine devices in Brazilian adolescents: A participant-blinded randomized trial

OBJECTIVES

To compare pain and ease of insertion of the copper 380 mm², levonorgestrel 52 mg, and levonorgestrel 19.5-mg intrauterine devices (IUDs) in Brazilian adolescents.

STUDY DESIGN

We conducted a participant-blinded randomized trial at two clinics in Brazil. We enrolled 318 adolescents<19 years old in a 1:1:1 ratio from November 2021 to February 2022. We informed the adolescents about the IUD type inserted after they evaluated the pain associated with the IUD insertion using a Visual Analogue Scale and immediately after that the healthcare provider who placed the IUD evaluated the ease of the procedure.

RESULTS

The VAS pain level was significantly higher after the levonorgestrel 52-mg IUD placement, median and [interquartile range, IQ] 8.0 [4.0] than the copper 380-mm² IUD 7.0 [4.0], and the levonorgestrel 19.5-mg IUD 7.0 [6.0] (p = 0.001). The placement was easier after the copper 380-mm² IUD (87/106, 82.1%) and the levonorgestrel 19.5-mg IUD (91/106, 85.8%) when compared with the levonorgestrel 52-mg IUD (75/105, 70.7%). After multiple logistic regression analyses, the higher VAS pain scores were associated with the levonorgestrel 52-mg IUD (OR = 2.90), low number of pregnancies (OR -0.48), and with a history of dysmenorrhea (OR = 2.67).

CONCLUSIONS

The placement of the copper 380-mm² IUD and the levonorgestrel 19.5-mg IUD was associated with lower pain according to the adolescent and was easier according to the provider when compared with the levonorgestrel 52-mg IUD. However, the small observed differences may not be clinically relevant.

IMPLICATIONS

We found that the three types of IUDs were generally easy to place; however, mean pain scores were high during insertions. Our findings of high pain scores reinforce the need for interventions to reduce pain for adolescent IUD insertion.

Acceptance rate of post-placental plac ement of intrauterine devices during the SARS-CoV-2 (COVID-19) pandemic

OBJECTIVE

To evaluate the acceptance rate of post-placental intrauterine device (PPIUD) placement during the SARS-CoV-2 (COVID-19) pandemic and to to assess factors associated with PPIUD acceptance.

METHODS

A cross-sectional study was conducted between August 2020 and August 2021. PPIUDs were offered to women scheduled for caesarean delivery or admitted in labour at the Women's Hospital of the University of Campinas. The study compared women according to whether they accepted or did not accept the IUD placement. The factors associated with PPIUD acceptance were analysed through bivariate and multiple logistic regression analyses.

RESULTS

We enrolled 299 women (15.9% of the deliveries that occurred during study period), aged 26.8 ± 6.5 years; 41.8% were White, almost one third were primiparous, and 155/299 (51.8%) had a vaginal delivery. The PPIUD acceptance rate was 65.6%. The principal reason for refusal was the desire for another contraceptive (41.8%). Women with the highest likelihood of accepting a PPIUD were younger (<30 years old has 1.7 more likely or 74% greater), those without a partner (3.4 times more likely) and those after vaginal delivery (1.7 times more likely or 69% greater).

CONCLUSION

The COVID-19 does not affected the PPIUD placement. PPIUD is a viable alternative during crisis in which women has difficult to access health services. Younger women, those without a partner and after vaginal delivery were more likely to accept a PPIUD during the COVID-19 pandemic.

One-year follow-up of immediate postpartum contraceptive implant insertion in adolescents

PURPOSE

Our study aimed to evaluate the acceptability, adverse effects and continuation rates among adolescents who accepted the etonogestrel (ENG) subdermal implant and compared to adolescents who chose other methods during the immediate postpartum period before hospital discharge, with one year follow-up up.

MATERIALS AND METHODS

We conducted a cohort non-randomised study at the Women's Hospital, University of Campinas. All women up to 19 years of age, who gave birth at the hospital between July 2019 and April 2020, were invited to participate and were offered the ENG-implant or the routine contraceptive methods. They were followed for one year postpartum.

RESULTS

We included 100 teenagers and 72 accepted the ENG-implant. Students are more likely to accept the ENG-implant than non-students (PR: 1.25 [95%CI 0.99-1.59]). Up to one year of follow-up, survival analysis showed that the time of adherence to the method was longer for the ENG-implant users (p = 0.0049). More than 90% of the adolescents were satisfied with the implant; however, five requested early removal due to menstrual irregularity and local discomfort.

CONCLUSION

Provision ENG-implant for adolescents in the immediate postpartum demonstrated high acceptance and ensured effective contraception. After one year, most of them were satisfied, with a high continuation rate and without unplanned pregnancies.

Single-visit long-acting reversible contraception provision and pregnancy rates within 3 months

OBJECTIVES

To assess the occurrence of pregnancy in a cohort of women who received a copper intrauterine device (IUD), hormonal IUDs or an etonogestrel (ENG) contraceptive implant at a single-visit practice.

METHODS

Prospective study conducted at the University of Campinas, Campinas, São Paulo, Brazil. We obtained data from four ongoing studies including both the date of the device placement, the first day of the last menstrual period, and the occurrence of pregnancy up to 3 months after device placement.

RESULTS

We included 2479 device placements (413 TCu380A IUDs, 1476 hormonal IUD and 590 ENG implants). Almost half of the device placements (1113/2479; 44.9%) were performed within the first 5 days of the menstrual cycle. We observed three pregnancies: one in an ENG implant user who received the implant within days 1-5 of the menstrual cycle; one in a woman who received a hormonal IUD during days 6-10 of the menstrual cycle; and one in a copper IUD user with placement during days 21-25 of menstrual cycle.

CONCLUSIONS

Single-visit long-acting reversible contraception placements are a good strategy with overall very low pregnancy rates. This strategy has a potential to reduce unintended pregnancies and to reduce costs and barriers to both women and the healthcare system.

Issues related to pregnancy, pregnancy prevention and abortion in the context of the COVID-19 pandemic: a WHO qualitative study protocol

INTRODUCTION

WHO has generated standardised clinical and epidemiological research protocols to address key public health questions for SARS-CoV-2 (COVID-19) pandemic. We present a standardised protocol with the aim to fill a gap in understanding the needs, attitudes and practices related to sexual and reproductive health in the context of COVID-19 pandemic, focusing on pregnancy, pregnancy prevention and abortion.

METHODS AND ANALYSIS PLAN

This protocol is a prospective qualitative research, using semi-structured interviews with at least 15 pregnant women at different gestational ages and after delivery, 6 months apart from the first interview. At least 10 partners, 10 non-pregnant women and 5 healthcare professionals will be interviewed once during the course of the research. Higher number of subjects may be needed if a saturation is not achieved with these numbers. Data collection will be performed in a standardised way by skilled trained interviewers using written notes or audio-record of the interview. The data will be explored using the thematic content analysis and the researchers will look for broad patterns, generalisations or theories from these categories.

ETHICS AND DISSEMINATION

The current protocol was first technically assessed and approved by the WHO scientific committee and then approved by its ethics review committee as a guidance document. It is expected that each country/setting implementing such a generic protocol adapted to their conditions also obtain local ethical approval. Comments for the user's consideration are provided the document, as the user may need to modify methods slightly because of the local context in which this study will be carried out.

Experiences of male partners of women with endometriosis-associated pelvic pain: a qualitative study

OBJECTIVES

The purpose of the study was to assess the experiences of male partners of women with endometriosis-associated pain after medical treatment in their everyday lives.

METHODS

We conducted a phenomenological study based on semi-structured interviews with 11 male partners of women with endometriosis-associated pelvic pain at the Department of Obstetrics and Gynaecology, University of Campinas Medical School, Brazil. A thematic analysis of manifest content was performed, a coding frame was drafted, and the main analysis categories were elaborated.

RESULTS

The interviewed men had been in stable relationships for a median length of 14 years. They reported that they did not have information about endometriosis before their partners' diagnosis and that the endometriosis-associated pelvic pain suffered by their partners affected their personal everyday life, marital relationship, sexual relationship, and intimacy.

CONCLUSION

Male partners of women with endometriosis-associated pain reported that the disease has both a profound impact on their lives and on their relationship. Our study contributed to an increased understanding of the life experience of men living with women with endometriosis-associated pelvic pain and may contribute to encourage healthcare professionals to incorporate strategies for guidance of the couple during treatment.

Pregnancy and childbirth outcomes among indigenous adolescents in Guatemala: a cohort study

Objective

To assess some characteristics and outcomes associated with pregnancy among Indigenous adolescents and compare them with other women who gave birth in a public hospital in Guatemala.

Methods

We conducted a retrospective cohort study of 8048 cases. Sociocultural variables, gynecological and obstetric history, childbirth, and perinatal outcomes were compared among women who gave birth at San Juan De Dios Hospital between January 2018 and June 2019. They were classified into four groups according to age and ethnicity. Indigenous adolescents (819/10.2%) were compared with Nonindigenous adolescents (813/10.1%), Indigenous adult women (3324/41.3%), and Nonindigenous adult women (3092/38.4%). Bivariate analysis and multiple logistic regression were applied.

Results

We found that Indigenous adolescents who gave birth in the public hospital had fewer years of schooling than Nonindigenous adolescents (p < 0.001), Indigenous adults (p < 0.001), and Nonindigenous adults (p < 0.001). Indigenous adolescents were more likely to have an unplanned pregnancy than Nonindigenous adolescents (p = 0.038) and Nonindigenous adults (p < 0.001) and were more likely to be single (p < 0.001) and use less previous contraception than Indigenous and Nonindigenous adult women (p = 0.007 and p = 0.013, respectively). More than one-third of Indigenous adolescents and adults did not attend antenatal care; Indigenous adolescents had fewer antenatal care visits than Nonindigenous adults (p < 0.001), and the results were borderline in comparison to Nonindigenous adolescents (p = 0.051). Indigenous and Nonindigenous adult women underwent episiotomy less often than Indigenous adolescents (OR: 0.60 [95% CI 0.49–0.74] and OR: 0.56 [95% CI 0.45–0.70], respectively) and received less local anesthesia than Indigenous adolescents (OR: 0.59 [95% CI 0.46–0.76] and OR: 0.77 [95% CI 0.60–0.99], respectively). Nonindigenous adults received more analgesia than Indigenous adolescents (OR: 1.36 [95% CI 1.07–1.73]). Nonindigenous adolescents had more newborns with low birth weight than Indigenous adolescents (OR: 1.44 [95% CI 1.10–1.87]).

Conclusion

Indigenous adolescents who gave birth in a public hospital in Guatemala were more likely to be single during pregnancy and attend fewer years of school than Nonindigenous adolescents. Unplanned pregnancies were more common among Indigenous adolescents, and some of them underwent not recommended obstetric practices during childbirth, such as episiotomy. Police should be enforced ensuring equal opportunities for different ethnic and age groups regarding pregnancy.

This study aims to evaluate the sociodemographic characteristics and outcomes associated with pregnancy in Indigenous adolescents and compare them to other women who gave birth in a public hospital in Guatemala. We conducted a retrospective cohort study on four groups: Indigenous adolescents, Nonindigenous adolescents, Indigenous adults, and Nonindigenous adults. Subsequently, we compared the sociodemographic characteristics of the latter three groups with those of the Indigenous adolescents to evaluate whether being in this age group in combination with belonging to an Indigenous ethnic group increased unfavorable outcomes during pregnancy, childbirth, and postpartum. We observed that Indigenous adolescents have limited academic opportunities compared with Nonindigenous adolescents; the usage of contraceptive methods was lower in adolescents (Indigenous and non-Indigenous), and unplanned pregnancies were more frequent in Indigenous adolescents than in Nonindigenous adolescents and adults), and a high percentage of all women did not attend antenatal care. We analyzed obstetric practices during childbirth, and a high incidence of episiotomies was reported in both groups of adolescents (42.5% for Indigenous women and 38.8% for Nonindigenous women). Newborns of Nonindigenous adolescents had a higher frequency of low birth weight. Our study provides an overview of the characteristics of pregnancy among different age groups, findings that could be used to develop targeted interventions for each group and create public policies that would provide equal opportunities for all women while also ensuring a healthy pregnancy.

Potential of LARC to recover loss in satisfied demand for modern contraception after the COVID-19 pandemic: a case scenario analysis of Brazil and Mexico

Objectives.

To estimate inequalities in demand for family planning satisfied with modern methods among women in Latin America and the Caribbean, with an emphasis on Brazil and Mexico, and to calculate the scenario for recovery of modern contraceptive coverage by expanding access to long-acting contraceptives (LARC) after the COVID-19 pandemic.

Methods.

National health surveys from 2006 to 2018 were used to estimate the demand for family planning satisfied with modern methods and how it was affected by the COVID-19 pandemic. The scenario included three variables: coverage, health outcomes, and costs. Considering coverage, United Nations Population Fund data were used to estimate the impact of COVID-19 on access to contraception in Latin America and the Caribbean. Health outcomes were assessed with the Impact 2 tool. Direct investment was used to evaluate cost-effectiveness.

Results.

Substantial inequalities were found in the use of modern contraceptive methods before the pandemic. We showed the potential cost-effectiveness of avoiding maternal deaths by introducing LARCs.

Conclusions.

In the scenario predicted for Brazil and Mexico, the costs of modern family planning and averted disability-adjusted life years are modest. Governments in Latin America and the Caribbean should consider promoting LARCs as a highly efficient and cost-effective intervention.

Health systems analysis and evaluation of the barriers to availability, utilisation and readiness of sexual and reproductive health services in COVID-19-affected areas: a WHO mixed-methods study protocol

INTRODUCTION

COVID-19 has led to an unprecedented increase in demand on health systems to care for people infected, necessitating the allocation of significant resources, especially medical resources, towards the response. This, compounded by the restrictions on movement instituted may have led to disruptions in the provision of essential services, including sexual and reproductive health (SRH) services. This study aims to assess the availability of contraception, comprehensive abortion care, sexually transmitted infection prevention and treatment and sexual and gender-based violence care and support services in local health facilities during COVID-19 pandemic. This is a standardised generic protocol designed for use across different global settings.

METHODS AND ANALYSIS

This study adopts both quantitative and qualitative methods to assess health facilities' SRH service availability and readiness, and clients' and providers' perceptions of the availability and readiness of these services in COVID-19-affected areas. The study has two levels: (1) perceptions of clients (and the partners) and healthcare providers, using qualitative methods, and (2) assessment of infrastructure availability and readiness to provide SRH services through reviews, facility service statistics for clients and a qualitative survey for healthcare provider perspectives. The health system assessment will use a cross-sectional panel survey design with two data collection points to capture changes in SRH services availability as a result of the COVID-19 epidemic. Data will be collected using focus group discussions, in-depth interviews and a health facility assessment survey.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the WHO Scientific and Ethics Review Committee (protocol ID CERC.0103). Each study site is required to obtain the necessary ethical and regulatory approvals that are required in each specific country.

Knowledge, Attitude, and Practices Related to the SARS-CoV-2 Pandemic among Women Seeking Contraceptive Methods

OBJECTIVE

 To determine knowledge, attitude, and preventive (KAP) practices towards the SARS-CoV-2 (COVID-19) pandemic among women in reproductive age seeking to use copper or hormonal intrauterine devices (IUD/LNG-IUS).

METHODS

 We conducted a cross-sectional study in which we applied a questionnaire on 400 women about KAP practices on COVID-19 at the University of Campinas, Campinas, SP, Brazil, from May to August 2020.

RESULTS

 The mean (±SD) age of the women was 30.8 ± 7.9 years, and 72.8% of them reported being pregnant at least once. Most women (95%) had heard or read about COVID-19, and their main sources of information were television (91%) and government websites (53%). However, 53% of the women had doubts about the veracity of the information accessed.

CONCLUSION

 Women without a partner and with > 12 years of schooling had more information about COVID-19 and on its impact on new pregnancy, and those from high socioeconomic status had a higher chance of maintaining physical distance. Safety, effectiveness, comfort, and absence of hormone in the contraceptive method (in the case of TCu380A IUD) were the main reasons for the participants to seek the service during the pandemic, and the possibility to stop menstrual bleeding was the main reason to choose the LNG-IUS.

Natural contraception apps knowledge among Brazilian women and Obstetrics and Gynaecology residents

BACKGROUND

Our objectives were to determine the knowledge and interest in apps for natural contraception among women and Obstetrics and Gynaecology (OBGYN) residents.

STUDY DESIGN

An online survey was sent to Brazilian women to gather sociodemographic data, knowledge and interest towards fertility-awareness contraceptive methods and smartphone apps for this purpose. Also, we sent an online survey to OBGYN residents to evaluate the reproductive physiology knowledge of natural contraception and interest in improving it and knowledge and smartphone apps for this purpose.

RESULTS

A total of 730 women answered the survey, and 638 were included in the study and 94 OBGYN residents answered the survey. Among the respondent women 386 (60.5%) were interested in more information about natural contraception, 226 (35.5%) showed interest in use natural contraception, 85 (13.3%) indicated that they were users of natural contraception, 15 (16.8%) of this group currently uses an app for this purpose and 485 (76%) considers a practical option to have an app for natural contraception. Regarding the respondent residents all answers were included in the study; 62 (65.9%) knew the right definition of 'Natural Contraception', 52 (55.3%) showed interest in information about this topic and 78 (82.9%) considers a practical option to have an app for natural contraception.

CONCLUSIONS

Less than 15% of the respondent women use natural contraception although about 60% expressed some interest in learning more, and that among OBGYN residents, half showed interest.

Acceptability of the contraceptive Sayana® Press when injected every four months: Results from a 12-month trial in Brazil, Chile and the Dominican Republic

OBJECTIVE

We assessed the acceptability of subcutaneous depot-medroxyprogesterone acetate 104 mg (Sayana® Press) when injected every four months for 12 months.

STUDY DESIGN

We assessed acceptability using questionnaires within a clinical trial to evaluate contraceptive effectiveness of Sayana® Press when the reinjection interval was extended from three to four months. We enrolled 750 women aged 18 to 35 years and at risk of pregnancy at three centers in Brazil, Chile, and the Dominican Republic who agreed to use Sayana® Press every four months for 12 months. Acceptability outcomes included responses to questions about perception of bleeding patterns and side effects, likes, and dislikes about the regimen. We descriptively compared outcomes across study centers and between those who completed the study and those who discontinued early.

RESULTS

Across the three centers, participants differed in age, marital status, years of schooling, and race. At the final visit, 90% reported being satisfied with Sayana® Press and 75% reported preferring to use this contraceptive every four months. The most common reasons women liked using Sayana® Press were for its duration of effectiveness, followed by amenorrhea. The most common dislike, when a reason was identified, was its effect on uterine bleeding, including amenorrhea reported by some participants. We also observed center-level differences in the proportion of women who liked amenorrhea.

CONCLUSIONS

Satisfaction with Sayana® Press injected every four months was high across the three demographically diverse Latin-American centers. However, participants had varied feelings towards contraceptive-induced amenorrhea.

Reasons for satisfaction with the use of the 52-mg levonorgestrel intrauterine system

OBJECTIVES

To assess the reasons to use, reasons they liked, satisfaction with, and possibilities of recommendation to other women of the levonorgestrel 52-mg intrauterine system (LNG-IUS) by users.

MATERIALS AND METHODS

A cross-sectional study was conducted at the University of Campinas, Campinas, Brazil from January to July 2021. We enrolled users who came to the clinic, and we applied a pre-tested structured questionnaire with open-ended questions. We performed descriptive analyses of the variables, assessing the level of satisfaction with, and the reasons regarding the possibility of continuing to use, the IUS.

RESULTS

Of the 517 enrolled women, 251 (48%) were aged 35 years or older (mean age 33.9 ± 9.0 years), 276 (53%) were white, 14 (3%) were adolescents, 155 (30%) were nulligravidas, and 307 (59.4%) reported experiencing amenorrhea in the last 90 days. Common reasons why women liked to use the LNG-IUS included both the reduction of menstrual bleeding (419 women; 81%) and dysmenorrhea (290 women; 56.1%). Nine out of 10 users (517 women; 91%) were satisfied with the method, and the majority would recommend it to other women.

CONCLUSION

We found a high satisfaction rate among LNG-IUS users mainly due to the reduction of both menstrual bleeding and dysmenorrhea.

Awareness of the non-contraceptive benefits of reversible contraceptive methods in a cohort of Brazilian women: an exploratory study

PURPOSE

We assess the awareness of Brazilian women about non-contraceptive benefits of contraceptives and compare non-health with health care providers.

MATERIAL AND METHODS

We conducted a survey in Brazil using a questionnaire administered via Google Forms asking women to respond about the awareness of non-contraceptive benefits of combined oral contraceptives (COCs), depot-medroxyprogesterone acetate (DMPA), 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS), etonogestrel (ENG)-implant, copper intrauterine device (Cu-IUD), and male condom.

RESULTS

We received 2,068 completed questionnaires, 720 women (34.8%) aged ≤ 29 years and 236 (11.4%) were physicians or nurses. Only one third of the respondents were aware that COC use is associated with decreased risks of ovarian and endometrial cancers; 296 (16.1%) about that the use of DMPA is associated with a decreased risk of endometrial cancer, and 253 (13.8%) were aware about that the users of the Cu-IUD present lower risk of cervical cancer. We identified significant differences between non-health care providers when compared to physicians or nurses.

CONCLUSIONS

We found low awareness regarding the associated lower risk of ovarian, endometrial and cervical cancer associated with the use of some contraceptives, evidencing the need to provide more information about the non-contraceptive benefits during training for health care providers.

Assessment of the availability of sexual and reproductive healthcare for Venezuelan migrant women during the SARS-CoV-2 pandemic at the north-western border of Brazil-Venezuela

•

Access to essential SRH services.

•

Less SRH services offered.

•

Lack of availability and access to contraceptives.

•

Impact on health infrastructure.

•

Reallocation of beds to attend COVID-19 cases.

•

Shortage of healthcare providers.

•

Challenges and opportunities for strengthening SRH services.

•

Doubts about the management of the pandemic due to conflicting messages.

Background

The public healthcare system of Roraima state, at the north-western border Brazil-Venezuela, experienced an impact due to the incoming of Venezuelan migrants and to the SARS-CoV-2 (COVID-19) pandemic. After the beginning of the pandemic, the Brazilian government closed the border; however, migration continued through informal paths. There is scarce information regarding the availability of sexual and reproductive health (SRH) services at settings impacted both by migration and the COVID-19 pandemic. Consequently, we aimed to assess the availability and access to SRH services for Venezuelan migrant at Roraima state during the COVID-19 pandemic.

Methods

We conducted a cross-sectional study with data collected during the pandemic using an electronic questionnaire. We interviewed three policy makers responsible for the directorate of primary care both at the municipal and state level; the directors of the two public hospitals and the two referral centres for women's health in Boa Vista, and in Pacaraima the director of the hospital and of the basic health post. We also interviewed 20 out of the 34 (58.8%) managers of the basic health posts in Boa Vista and 10 healthcare providers (physicians and nurses). Data collected covered issues pertaining to access to SRH services, and explored the impacts of the COVID-19 on continuation, access, and use of SRH services.

Results

It was reported that 60% of the beds in the public sector were reallocated for COVID-19 cases and 26 out of the 34 (76%) health posts assessed interrupted the provision of SRH services, including contraceptive provision and gynaecological consultation, since these were considered not essential services. Most of the participants, (25/36; 69.4%) reported that both the state and the municipal health authorities implemented community outreach using telephone, social media, radio, and television, with guidance for the population on how to seek care using the healthcare network.

Conclusions

The healthcare system in Roraima was impacted firstly by the need to provide SRH to a large number of Venezuelan migrant women, and after an effort to adapt to the reality that this migrant crisis posed; this system was affected by the needs to adapt to the COVID-19 pandemic.

Contraceptive effectiveness, pharmacokinetics, and safety of Sayana® Press when injected every four months: a multicenter phase 3 trial

BACKGROUND

Sayana Press® is a 3-monthly contraceptive injection approved by regulatory agencies in more than 40 countries worldwide. Existing effectiveness and pharmacokinetics (PK) data suggest that high contraceptive efficacy may be maintained if the reinjection interval of Sayana Press is extended from 3 to 4 months.

METHODS

We conducted a phase 3 trial at three sites in the Dominican Republic, Brazil, and Chile from September 2017 through April 2020. We enrolled 750 women at risk of pregnancy who agreed to use Sayana Press off-label every 4 months (3 treatment cycles) for 12 months. The effectiveness cohort included 710 participants randomized equally to receive injections in the abdomen or thigh. Forty additional participants received injections in the back of the upper arm for comparative PK analyses. The primary outcome was pregnancy, defined by a positive urine pregnancy test confirmed by ultrasound and/or serum human chorionic gonadotropin. Secondary outcomes included PK, safety, and acceptability. Laboratory and trial Sponsor staff were blind to injection site. This study is registered with ClinicalTrials.gov, number NCT03154125.

FINDINGS

There were no pregnancies during follow-up; the Pearl Index during 629.3 woman-years (WY) of follow-up in the primary effectiveness analysis was 0.00 (95% CI 0.00, 0.59). Pharmacokinetic profiles differed by injection site, with higher geometric mean (GM) medroxyprogesterone acetate concentrations for the abdomen than the thigh and arm. At month 8, significantly higher GM concentrations were observed in the abdomen and the thigh as compared to the arm, as well as at month 12 in the abdomen as compared to the arm. Injection site reactions were reported by 10.7% of participants.

INTERPRETATION

Both pregnancy and PK results confirm that Sayana Press is a highly effective contraceptive method when administered every 4 months. These findings may inform modification of the dosing schedule, or duration of the grace period for reinjection, or both, to reduce overall drug exposure while maintaining contraceptive efficacy.

FUNDING

This work is made possible by the generous support of the American people through the U.S. Agency for International Development (USAID), provided to FHI 360 through Cooperative Agreement AID-OAA-A-15-00,045, and a grant from the Gates Foundation. The contents are the responsibility of FHI 360 and do not necessarily reflect the views of USAID, the United States Government, or the Gates Foundation, nor does any mention of trade names, commercial products, or organizations imply endorsement by FHI 360, USAID, the United States Government, or the Gates Foundation.

Etonogestrel-releasing contraceptive implant in a patient using thalidomide for the treatment of erythema nodosum leprosum: a case report

INTRODUCTION

Thalidomide is an immunomodulatory drug and first choice in the treatment of erythema nodosum leprosum. Given its teratogenic potential, it is essential that an effective contraceptive method is used, especially a long-acting reversible contraceptive (LARC) method. The subdermal etonogestrel (ENG)-releasing implant is an adequate method due to the high effectiveness and long-term use. However, interaction between thalidomide and ENG has not been well documented. Concern arises because thalidomide interacts with cytochrome P450 (CYP450) enzymes that metabolize sexual steroids. AIM: We aimed to study the effectiveness and safety of the ENG-implant in a thalidomide user.

METHODS

Case report of a sexually active 21-year-old patient with both Hansen's disease and leprosy reaction type 2 treated with thalidomide requiring effective contraception. Follow-up was up to 36 months after implant placement.

RESULTS

Contraception with ENG-implant was effective and safe, based on clinical parameters (reduction of menstrual flow and cervical mucus thickening) and laboratory parameters (gonadotropins and sexual steroids).

CONCLUSION

To the best of our knowledge, this is the first case reported which presents a patient in simultaneous use of thalidomide and ENG-implant. Although this case report preliminary supports effectiveness and safety of ENG-implant as a contraceptive option in women using thalidomide, rigorous drug-drug interaction research is needed to better characterize the interaction between thalidomide and the ENG-implant.

Return to ovulation after Sayana Press is injected every 4 months for one year: Empirical and pharmacokinetic/pharmacodynamic modeling results

Objective

To characterize return to ovulation after injecting Sayana Press (104 mg/0.65 mL medroxyprogesterone acetate [MPA] in the Uniject device) every 4 months for 1 year of treatment.

Study design

We followed a subset of women for return to ovulation in a trial that demonstrated Sayana Press remains highly effective when the subcutaneous reinjection interval is extended from 3 to 4 months. We measured serum progesterone in weeks 38 to 42 and 46 to 50 after a final (third) injection and used a concentration ≥4.7 ng/mL as a surrogate for ovulation. We also performed pharmacokinetic and pharmacodynamic modeling to predict differences in MPA accumulation and return to ovulation had - contrary to fact - injections been given every 3 months.

Results

Ten of 19 women (53%; 95% confidence interval: 29–76) ovulated within 50 weeks of their last injection. We predicted that typical 12-month trough MPA concentrations are 34% lower (0.46 vs 0.69 ng/mL) and the median time from last dose to ovulation is 1.1 months shorter (13.1 vs 14.2 months) when injections are given every four months for 1 year.

Conclusion

Extending the Sayana Press reinjection interval from 3 to 4 months leads to less drug accumulation, without a noticeable loss in efficacy. Although the Sayana Press patient leaflet specifies that over 80% of women desiring pregnancy will conceive within a year of stopping the method (independent of treatment duration), our empirical and modeling results indicate women should anticipate waiting a year or more for fertility to return after repeat dosing, with a somewhat shorter delay were the reinjection interval extended to four months.

Implications

Providers should counsel women regarding the distinct possibility that return to fertility will take a year or longer following repeat use of Sayana Press. Extending the dosing interval from 3 to 4 months would result in approximately a 1-month shorter delay, without any appreciable reduction in contraceptive efficacy.

Female Body Mass Index and the election of a Long-Acting Reversible Contraception for the first time

OBJECTIVE

We evaluated Brazilian women with different body mass index (BMI, kg/m² ) values who were switching from a short-acting reversible contraceptive (SARC) to a long-acting reversible contraceptive (LARC) method in relationship to the reasons reported for switching and the LARC method chosen.

METHOD

We analyzed retrospective data from 1,508 women aged 18-49 years who chose a LARC for the first time. The variables were sociodemographic, BMI, SARC in use, the reason given for switching, the chosen LARC [copper intrauterine device (Cu-IUD), levonorgestrel (52mg) intrauterine system or etonorgestrel implant], and expectations of the LARC. We used the Chi-square, Mann-Whitney and Kruskal-Wallis tests to compare BMI groups. The significance level adopted was 5%.

RESULTS

The obesity group, 320 women (21.2%), reported weight gain (P <0.000) and fear of pregnancy (P = 0.004) as the most frequent reasons for switching, while the normal weight group, 637 women (42.2%), reported more loss of libido (P <0.000) and other personal complaints (P = 0.002). The IUD was chosen by 851 women (56.6%) and significantly by the largest number of obese women.

CONCLUSION

Women in different BMI categories report different reasons for switching from SARC methods and elect different LARC methods for contraception.

Brazilian network of COVID-19 during pregnancy (REBRACO: a multicentre study protocol)

INTRODUCTION

The aim of this study was to evaluate the clinical, epidemiological and laboratory aspects of SARS-CoV-2 infection during pregnancy and postpartum in 16 maternity hospitals.

METHODS AND ANALYSIS

A prospective multicentre study, with five axes. First, the prevalence of SARS-CoV-2 infection among women admitted for childbirth will be described in a cross-sectional study. Second, maternal and perinatal outcomes will be assessed in a prospective cohort study including pregnant or postpartum women with suspected COVID-19. Third, a cohort of positive COVID-19 cases with sampling of a variety of biological material. Histopathological and viral analysis of biological maternal and neonatal samples will be performed, and the assessment of nutritional variables to evaluate the association between vitamin D and severity of infection. Fourth, a monitoring and evaluation committee to collect relevant healthcare information and plan actions in centres facing the pandemic. Furthermore, qualitative studies will be performed to study pregnant women, their families and health professionals. Fifth, an ecological study will monitor the number of live births, stillbirths and other outcomes to explore any trend among the periods before, during and after the pandemic. Data will systematically be collected in an electronic platform following standardised operational procedures. For quantitative study components, an appropriate statistical approach will be used for each analysis. For qualitative data, in-depth interviews recorded in audio will be transcribed, checking the text obtained with the recording. Subsequently, thematic analysis with the aid of the NVivo programme will be performed.

ETHICS AND DISSEMINATION

Ethical approval was obtained (letters of approval numbers 4.047.168, 4.179.679 and 4.083.988). All women will be fully informed to sign the consent form before enrolment in the study. Findings will be disseminated through peer-reviewed journals and scientific conferences.

Perspectives of health care providers regarding the levonorgestrel-releasing intrauterine system

OBJECTIVES

The aims of the study were to assess the number of insertions per month of the 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS) and gauge the knowledge and opinions of health care providers with regard to some of its characteristics and the reasons why women liked using the method.

METHODS

An online questionnaire survey was conducted between January and July 2021 at the University of Campinas, Brazil. The survey comprised physicians and nurses from centres that had requested and received donated devices.

RESULTS

A total of 65 health care providers answered the questionnaire (41 physicians and 24 nurses). The main misconceptions were related to insertion after an ectopic pregnancy: 60/65 (92.3%) answered that users with previous ectopic pregnancy must have frequent follow-up. Wrong answers were also given on the occurrence of acne (37/65, 56.9%) and depression (32/65, 49.2%). Participants reported that the LNG-IUS was highly effective (100%), long-acting (93.9%) and an appropriate method for controlling uterine bleeding (90.8%) and that it had few side effects (86.2%).

CONCLUSION

Our study suggests that health care providers from centres that requested and received LNG-IUS donations, even though they reported adequate knowledge about the device, still had misconceptions with regard to its clinical management.

Reasons reported by women for choosing the levonorgestrel intrauterine system as a contraceptive method

OBJECTIVE

To assess the reasons provided by women for choosing the use of the 52 mg levonorgestrel intrauterine system (LNG-IUS) as a contraceptive method.

METHODS

We conducted a cross sectional study from January 2021 to August 2021 at the University of Campinas, Campinas, SP, Brazil. Women who had never used the 52 mg LNG-IUS and were requesting it for contraception answered a questionnaire asking for their sociodemographic characteristics, the last contraceptive method in use, how they received information about the device, and their main reasons for choosing the method.

RESULTS

We enrolled 516 women, 365 (70.7%) of whom were under the age of 35 and 352 (68.2%) of whom were parous. The last contraceptive method in use was a short-acting reversible method among 387 (80.8%) women, 454 (88%) reported that they wanted to use the IUS only for contraception, and the main source of information was their health care providers. The main reported reasons for choosing the method were because it is safe, has high contraceptive efficacy, and reduces menstrual bleeding.

CONCLUSION

Health care providers should continue their efforts to provide guidance about the LNG-IUS, including the non-contraceptive benefits, which may contribute to a reduction in the number of unplanned pregnancies.

Suppression of ovulation and pharmacokinetics following subcutaneous administration of various doses of Depo-Provera®: a randomized trial

OBJECTIVES

To identify the lowest dose of Depo-Provera that, when administered off-label subcutaneously, suppressed ovulation and had a pharmacokinetic profile consistent with a 4-month contraceptive effect.

STUDY DESIGN

We conducted a randomized, multicenter, parallel-group study to evaluate the pharmacokinetics (PK) and pharmacodynamics (PD) of medroxyprogesterone acetate (MPA) after subcutaneous injection of three different doses of Depo-Provera. We randomized sixty women between 18 and 40 years of age at low risk of pregnancy with confirmed ovulation and body mass index of 18 to 35 kg/m² to receive a single injection of 45, 75 or 105 mg of Depo-Provera, or a single injection of Depo-subQ provera 104 as a reference drug (15 women per group) and followed them for 7.5 months. We evaluated suppression of ovulation as the primary outcome, and MPA concentrations, pharmacokinetic parameters, safety, and local tolerability as secondary outcomes.

RESULTS

Five women ovulated within four months of treatment initiation (three in the 45 mg group and two in the 75 mg group). MPA levels associated with ovulation were in general low, largely ≤ 0.2 ng/mL (the presumed contraceptive threshold). No women in either the 105 mg group or the Depo-subQ provera 104 group ovulated within four months. The PK parameters including C_max, C₁₁₉, and AUC_0-119 for these 2 groups were similar but not equivalent.

CONCLUSION

A dose of 105 mg of Depo-Provera injected subcutaneously was the lowest tested dose that consistently suppressed ovulation and maintained serum MPA levels consistent with contraceptive effect for at least 4 months. The PK and PD results for the 105 mg dose were similar to Depo-subQ provera 104 over this period.

Expulsion and continuation rates of the levonorgestrel 52 mg intrauterine system was similar among nulligravid and parous users

OBJECTIVE

To compare the expulsion and continuation rates of the levonorgestrel (LNG) 52 mg intrauterine system (IUS) in a cohort of nulligravid and parous users.

METHODS

We conducted a retrospective cohort study that included 996 participants in whom we placed an LNG-IUS, and the participants were monitored for up to 5 years after device placement. We identify 498 nulligravid participants in the medical record database between 2012 and 2020. Each nulligravida was paired with a parous users who had an LNG-IUS inserted on the same day, just before or after the nulligravida. The Kaplan-Meier method and the log-rank test were used to compare the survival curves of the two groups.

RESULTS

By the fifth year of use, the expulsion rates were 7.6/100 and 8.2/100 women-years (W-Ys) and the continuation rates were 641/100 W-Ys and 65.4/100 W-Ys without difference among nulligravid and parous users, respectively (P = 0.782 and P = 0.564, respectively). We observed 29 and 31 expulsions among nulligravid and parous users, respectively.

CONCLUSION

Nulligravid and parous participants who used the 52 mg LNG-IUS showed similar expulsion and continuation rates during five years of use.

Effect of ulipristal acetate on gene expression profile in endometrial cells in culture and in vivo upon post-ovulatory administration in fertile women

PURPOSE

To analyse the effect of ulipristal acetate (UPA) as emergency contraception (EC) on the gene expression of human endometrial cell line (HEC-1A) and endometrium from fertile women treated with UPA after ovulation.

MATERIALS AND METHODS

HEC-1A cells were treated with UPA, and endometrial tissue from four healthy women was collected in cycles before, during and 2 months after post-ovulation pill intake. Ovulation and luteal phase were monitored, and endometrial biopsies were obtained at day LH + 7 in each cycle. In all cases, we analysed the expression profile of 192 genes associated to endometrial receptivity.

RESULTS

We observed a significant change in total transcriptomic activity of UPA-treated HEC-1A cells compared to controls. In vivo, we also observed a trend to down-regulation of genes in the UPA-treated cycle that was partially restored in the post-treatment cycle. Altogether, our results supported a partially reversible effect of UPA in gene expression associated with uterine receptivity.

CONCLUSIONS

When UPA was administered after ovulation, it seems to induce a down-regulation of the main genes involved in conditioning the endometrium for implantation. This effect is partially restored two months after pill intake. The action of UPA on the endometrium for users of EC should be further investigated.

Reproductive health among Venezuelan migrant women at the north western border of Brazil: A qualitative study

BACKGROUND

Venezuela has been immersed in an economic and social crisis with a high number of migrant people. An important proportion of Venezuelan migrants have crossed the north western border Brazil-Venezuela were the United Nations High Commissioner for Refugees (UNHCR) has established 13 shelters. Our objectives were to know perspectives and views of Venezuelan migrant women hosted at UNHCR shelters on some SRH issues.

METHODS

We conducted a qualitative study between November 2019 and February 2020 with 12 focus group discussions (FGDs), with 111 Venezuelan migrant women of reproductive age (18-49 years old). FGDs were performed in a closed space that guaranteed confidentiality, were recorded, verbatim transcribed and data were analised for thematic manifest content.

FINDINGS

The themes identified were perspectives on: i) health care for pregnant and postnatal women, ii) access to modern contraceptive methods, and iii) HIV and sexually transmitted diseases (STDs). Despite the general satisfaction with obstetric care, women noted few challenges pertaining to their experiences during first entry to antenatal care, labour, delivery and postnatal care. They were in agreement that access to long-acting reversible contraceptives was difficult, mainly to the copper-intrauterine device (IUD); which when available it was erratic. Hormonal-IUD and implants were almost inexistent. This was of major concern to the women, as it prevented them from the ability to plan their reproductive lives. Although knowledge on STDs/HIV prevention and transmission was adequate; the predominance of traditional gender imbalance in the relations was observed and these attitudes have been discussed as a barrier for migrant women to protect themselves against HIV/STD infection.

CONCLUSION

These migrant women needed help to understand the language and functioning of the healthcare system, to overcome barriers and challenges while seeking access to SRH care. They faced significant gender vulnerability that needs to be addressed within their new life. Our findings could be useful for health authorities and international organisations to start actions to improve SRH and mitigate suffering.

Practical training of health care providers in insertion of contraceptive implants: findings from two Brazilian centres

BACKGROUND AND OBJECTIVES

Lack of information and myths or inadequate training of health care providers in the guidance and management of contraceptives could negatively affect choice and eventually continuation rates. Our objectives were to evaluate the impact of clinical and theoretical training of health care professionals on insertion and removal of etonogestrel (ENG)-implant regarding this contraceptive, including pre- and post-training knowledge about insertion and removal techniques, clinical characteristics, side effects and outcomes.

MATERIAL AND METHODS

We conducted a cross-sectional study in which a questionnaire was sent to health care providers after they received clinical training in the management of ENG-implant.

RESULTS

After training, 78.2% of the 139 participants initiated to offer and inserted up to 5 implants/month and 17.6% between 6 to 10/month. None of the interviewees reported having difficulty with insertions after training, and 87.9% reported feeling very confident for removal.

CONCLUSION

Theoretical and practical training appeared important to prepare health care professionals, clarify doubts and promote higher rates of use of contraceptive implants in Brazil, contributing to reduce the rates of unintended pregnancies.