Use of levonorgestrel implants versus oral contraceptives in adolescence: a case-control study

OBJECTIVE

We compared continuation rates, effectiveness, satisfaction with method, side effects, and condom practices among adolescents using levonorgestrel implants (Norplant, Wyeth-Ayerst Laboratories, Philadelphia) as compared with oral contraceptives.

STUDY DESIGN

We conducted a case-control study comparing 94 adolescents < or = 18 years old who received Norplant between March 1, 1992, and Nov. 1, 1993 (cases), with 94 age-matched controls who selected oral contraceptives during this same time period. By use of a structured questionnaire, information was obtained on pregnancy status, duration of use, patient satisfaction, side effects, and condom practices 6 months after initiation. Objective measures included weight on Norplant and oral contraceptive users and hematocrit on implant patients.

RESULTS

Forty (43%) oral contraceptive patients compared with no Norplant patients discontinued their selected method before the 6-month interview (p = 0.00). Six patients prescribed oral contraceptives became pregnant. Ninety-three percent of Norplant users expressed overall satisfaction despite experiencing menstrual irregularity and cramping, amenorrhea, nervousness, abnormal hair growth or loss, rashes, and an increase in appetite more often than oral contraceptive users. Although Norplant patients also reported an increase in the duration of menstrual flow and number of days of spotting more often than oral contraceptive users, evaluation of hematocrits in these patients demonstrated a significant increase over the 6-month period (p = 0.00). Assessment of condom practices since initiation demonstrated that Norplant patients used condoms less often than oral contraceptive users (p = 0.00).

CONCLUSION

Use of levonorgestrel implants may cause more side effects than oral contraceptives in the early months after initiation but provide superior protection against unintended pregnancy. We concluded that Norplant is a reasonable alternative for adolescents, especially when compliance is an issue.

Effect of tamoxifen alone and in combination with RU 486 on the endometrium in the mid-luteal phase

The effects of RU 486 combined with tamoxifen and tamoxifen alone on hormonal parameters and endometrial development at the time of implantation were studied. Measurements of cytosolic oestrogen and progesterone receptors in endometrium and placental protein 14 (PP14) in plasma were also included. Three dosage schedules were used: single oral dose of 40 mg tamoxifen alone and in combination with 200 mg RU 486, and 40 mg tamoxifen for three consecutive days starting on the first day after the luteinizing hormone (LH) surge. The combined treatment prolonged the luteal phase (P < 0.05) and increased the plasma levels of progesterone. A single dose of tamoxifen did not affect the bleeding pattern and plasma hormone levels, but raised plasma oestradiol and LH with the 3-day treatment. The endometrium was retarded after the combined and the 3-day treatment with tamoxifen. Concentrations of cytosolic progesterone receptors were higher after the combined therapy, but were unaffected after tamoxifen only. PP14 levels were higher (P < 0.05) after repeated tamoxifen doses than in controls, but were lower with combined treatment. Progesterone and oestrogen are evidently necessary for endometrial maturation during the secretory phase of the menstrual cycle. PP14 levels in plasma cannot be used for clinical assessments of endometrial function because high levels coincide with disturbed endometrial development.

Effects of continuous treatment with low dose mifepristone throughout one menstrual cycle

The effects of continuous low dose mifepristone (RU 486) 10, 5 or 1 mg/day on the menstrual cycle were assessed in groups of five volunteers, who were treated for 30 days from the beginning of the cycle. Hormonal determinations in blood and urine samples, ovarian ultrasonography and an endometrial biopsy taken on day 22-29 of treatment were used to monitor the cycle. Pre- and post-treatment cycles presented a normal profile. During treatment, concentrations of RU 486 in plasma ranged from 65 nmol/l with 1 mg/day to 1000 nmol/l with 10 mg/day. With 10 or 5 mg/day, all treated cycles were prolonged as a result of arrested or slower follicular growth during treatment. Gonadotrophins, sex steroids and their urinary metabolites remained at early follicular phase levels throughout treatment, whereas androstenedione, prolactin and cortisol were unaffected. Follicular maturation resumed after discontinuation of treatment and several days later a luteinizing hormone surge followed by a luteal phase was observed in all cases. Ovulation was suppressed during treatment only in one of the five cycles treated with 1 mg/day. Endometrial maturation was disturbed by all doses. These data demonstrate a differential threshold of the follicle and the endometrium to mifepristone. This finding has potential application in the contraceptive field.

Hormonal profile of the menstrual cycle in Chinese women after tubal sterilization

Ten women after tubal sterilization were studied for the hormonal profile of the menstrual cycle. They had undergone sterilization procedures, on the average 5.3 years (range 1.5-10 years) earlier. The serum concentrations of LH, FSH, prolactin, estradiol and progesterone were measured by RIA in daily blood samples of a complete menstrual cycle. Another ten normal women were studied at the same time and were used as the control group. There were no significant differences in the hormonal patterns of the menstrual cycle between the two groups. There was a significantly lower LH level in the early luteal phase of the tubal ligation group compared to the control group. Also, a significantly lower E2 luteal peak compared to the preovulatory peak was observed in the tubal ligation group. The physiological significance of these minor changes is not clear. Only one out of ten women in the tubal ligation group, who had undergone sterilization 1.5 years prior, showed a deficiency in luteal function, but her ovulatory function and menstrual cycle appeared normal. This study indicates that normal hormonal profiles are retained after tubal sterilization.

Hormonal and menstrual changes after laparoscopic sterilization by Falope-rings or Filshie-clips

OBJECTIVE

To evaluate the influence of laparoscopic sterilization by Falope-rings (Cabot Medical Corp., Langhorne, PA) or Filshie-clips (Femcare, Nottingham, United Kingdom) on menstrual pattern and ovulatory function.

DESIGN

A prospective, nonrandomized study of women sterilized by Falope-rings (n = 6) or Filshie-clips (n = 5). Menstrual charts were kept. Serum follicle-stimulating hormone (FSH), estradiol (E2) and progesterone (P) were measured by means of radioimmunoassay in one cycle before and 3, 6, and 12 months after the sterilization. Blood samples were drawn on day -6, -2, 0, +6, +10 of the menstrual cycle, ovulation corresponding to day 0. The women sterilized by Filshie-clips had abdominal ultrasonography of the ovaries measuring the leading follicle on day -6, -2, 0, +6 of the menstrual cycle.

PATIENTS

Twelve women, 25 to 38 years old, with regular menstrual cycles and no use of oral contraceptives or intrauterine contraceptive device at least 6 months before sterilization. One woman was excluded.

RESULTS

After the sterilization, all women reported unchanged menstrual pattern. The follicular rise in E2 unchanged, and FSH levels fell accordingly. Progesterone levels were ovulatory, but the midluteal P peak 3 months poststerilization was significantly decreased. Serial abdominal ultrasonography in women sterilized by Filshie-clips confirmed ovulation in all cycles except in one woman, who had an unruptured follicle in one cycle before and in the sixth cycle after sterilization.

CONCLUSION

Laparoscopic sterilization by Falope-rings or Filshie-clips does not seem to interfere with menstrual pattern or ovulatory function.

Clinical evaluation of a new triphasic oral contraceptive: norgestimate and ethinyl estradiol

The safety and efficacy of the triphasic oral contraceptive agent containing norgestimate and ethinyl estradiol were evaluated in a 12-month study of 661 women. Excellent contraceptive efficacy was achieved, with two pregnancies ascribed to product failure in a total of 6,511 treatment cycles. The life-table predicted pregnancy rate was 0.57 per 100 woman-years of use. The overall and theoretical Pearl indexes were 0.55 and 0.37, respectively. Good cycle control was maintained in patterns similar to those noted in previous studies. The incidence of dysmenorrhea and premenstrual syndrome was sharply reduced. Side effects reported were typical of those associated with use of low-dose oral contraceptive agents. Acceptability was high compared with agents used previously by the subjects. Total cholesterol did not change but high-density lipoprotein cholesterol was significantly elevated at 3 and 12 months. There were no clinically significant changes in the parameters of hematology or blood chemistry tested.

Desogestrel-ethinylestradiol, an oral monophasic contraceptive. Clinical and lipid metabolic effects: a 5-year experience

A comparative study of 5 years' duration using desogestrel (DSG), levonorgestrel (LN), and norethindrone (NET), combined with ethinyl estradiol (EE), was conducted. A total of 4499 cycles on DSG-EE, 3691 on LN-EE (1980 on triphasic and 1711 on monophasic schemes) and 1680 on NET-EE was evaluated. A contraceptive efficacy of 100% was obtained in all the groups. Minimal side effects were observed. In particular, body weight in those women on DSG-EE did not show noticeable changes and headaches were minimal. No alterations on blood pressure readings or on the routine laboratory tests were noticed in any of the groups. There was a significant increase in high-density lipoprotein-c (HDL-c) in women on DSG-EE. There was no change in NET-EE, and a significant decrease in women on LN-EE in both schemes. Changes in LDL-C, very low density lipoproteins, triglycerides, total lipids, total cholesterol, and glucose were not significant, although there was some increase at 60 cycles on triglycerides on those women on DSG-EE and on NET-EE. At the end of 5 years, 76% of women continued on DSG-EE. They indicated their satisfaction with this method.

Contraception after heart surgery

This study represents the different methods of contraception used by women having cardiac surgery at Ain Shams University Hospital. The study comprised of 250 women having had mitral commissurotomy, 77 women having had valve replacement including one case of triple valve repair and 3 women having had cardiac surgery for congenital heart disease. An IUCD was used by 170 women (51.5%), vaginal tablets by 4 women (1.2%), oral contraceptive pills by 7 women (2.1%), "safe period" by 7 women (2.1%), tubal ligation was performed in 10 women (3%). The husbands of 33 women (10%) used condoms, and 99 women (30%) did not use contraceptive methods. The IUCD was tolerable and was associated with bleeding in 60 women (35.2%) and leucorrhoea in 55 (32.3%). The IUCD was removed from only one woman due to severe bleeding. Three pregnancies occurred with condom users in two women who had had mitral commissurotomy and one having had valve replacement. There was no case of bacterial endocarditis in the study group.

Cycle control with triphasic norgestimate and ethinyl estradiol, a new oral contraceptive agent

Effective cycle control was demonstrated based on two multicenter, 2-year studies of the triphasic oral contraceptive (OC) agent containing the new progestin norgestimate. The estrogen in this OC is ethinyl estradiol. These open-label Phase III studies were conducted in the United States by 33 investigators at 33 sites who treated a total of 1,783 subjects, healthy women 17 to 38 years of age with menstrual cycle characteristics considered to be within the normal range. The norgestimate/ethinyl estradiol preparation was taken for up to 24 cycles. Follow-up information was collected 3 to 4 months post-treatment. Bleeding pattern analyses were based on 27,970 valid cycles. Normal cyclic bleeding patterns were experienced by most of the women during the study; only minimal and statistically and clinically insignificant variations in menstrual flow, dysmenorrhea, and premenstrual tension occurred. There was a low incidence of failed withdrawal bleeding in single cycles (less than 1.0% after cycle 6). There were no cases of amenorrhea, defined as two consecutive cycles of missed withdrawal flow. The incidence of breakthrough bleeding or spotting was highest during the initial treatment cycles and diminished with continued use of the formulation. The mean incidence of breakthrough bleeding was 2.36% in cycles 13 to 24. Apart from somewhat higher initial percentages among women new to oral contraception, the pattern of midcycle bleeding or spotting was similar to that of all women studied. Effective long-term cycle control was demonstrated in women who used this OC agent.

Long-term use of depot-norethisterone enanthate: effect on blood coagulation factors and menstrual bleeding patterns

Fifty-six women using depot-norethisterone enanthate injections for contraception for 2 years or more were compared with a control group of 48 women not using hormonal contraception. No significant difference was found between the study group and controls for Factors VIIc and Antithrombin III. Factor Xc was reduced in women who had used the injections for over two but less than five years [controls: mean 90.3% SD31.2 vs users for 2-5 yr: 78.7% SD17.1, 95%CI difference in means -0.3, -22.9]. In the group using Net-En for five years or more, Factor Xc was significantly higher than in the control group, but only by 14% of the mean control value [users for over 5 yr: 103.2% SD15.2, 95%CI difference in means 3.1, 22.7]. Haemoglobin levels, red cell count and packed cell volume were higher in those using the injections than in the control group. Changes in the platelet count were not statistically significant. Twenty-three women using the injection agreed to keep menstrual diaries. Of these, 20 experienced amenorrhoea for more than two consecutive injection intervals (112 days). It is concluded that long-term use of norethisterone enanthate is not associated with any markedly deleterious effects on Factor VIIc, Xc, or antithrombin III or haemoglobin levels. Amenorrhoea of 4 months or more can be expected after two years of continuous use.

A comparative study of 35 mcg and 50 mcg combined oral contraceptives: results from a multicenter clinical trial

A comparative multicenter clinical trial of two combined oral contraceptives (OCs) differing only in the estrogen content (35 mcg ethinyl estradiol versus 50 mcg mestranol) was conducted at five clinics located in Yugoslavia, Egypt, Sri Lanka, Costa Rica and Mexico. The trial was designed to determine the differences between Norinyl 1+35 (Syntex) and Norinyl 1+50 (Syntex) in rates and reasons of discontinuation, and frequency of selected side effects which might contribute to method discontinuation. This report includes analysis of 1698 women, all of whom were interval patients (at least 42 days but within 26 weeks postpartum), randomly allocated to one of the above OCs between October 1982 and January 1984. Follow-up visits were scheduled at 1, 4, 8 and 12 months after admission. Significantly more women in the Norinyl 1+35 group (p less than .001) reported intermenstrual bleeding (primarily staining and spotting), as well as an increase in the occurrence of intermenstrual bleeding compared to women in the Norinyl 1+50 group. There were no significant differences between the groups for side effects with the exception of more women in the Norinyl 1+50 group (p less than .05) reporting breast discomfort. The lost to follow-up rate at 12 months was 19.3% for both the Norinyl 1+35 and the Norinyl 1+50 groups. The total discontinuation rate (including women lost to follow-up) at 12 months was 43.5% for the Norinyl 1+35 group and 41.0% for the Norinyl 1+50 group. There were no significant differences between the two groups for gross cumulative life table discontinuation rates (p greater than .05). There were six accidental pregnancies attributed to user failure reported during the study period; four in the Norinyl 1+35 group and two in the Norinyl 1+50 group.

Oral contraceptive (OCP) use increases proliferation and decreases oestrogen receptor content of epithelial cells in the normal human breast

The effect of ingestion of oral contraceptives (OCP) on cell proliferation and oestrogen (ER) and progesterone receptor (PR) expression of the epithelial cells of the normal human breast was compared with findings in controls not taking OCPs. Histologically normal breast tissue was removed during operation for fibroadenoma or reduction mammoplasty in 216 women whose mean age was 28.1 +/- 8.5 years (+/- SD range 14-53 years). During natural cycles the mean proportion of cells expressing ER was 3.94 +/- 3.71 (% mean +/- SD, range 0-20.8, n = 51), while of those expressing PR it was 12.1 +/- 7.1% (range 3.0-36.1, n = 47). There was a significant decline in ER during the menstrual cycle [p = 0.001 by multiple linear regression (MLR)], but there was no significant change in the proportion which expressed PR. The mean proportion of proliferating cells (LI) was 2.50 +/- 2.42 (range 0-11.5, n = 147). There was a significant increase of LI during the cycle (p = less than 0.001, MLR) and a significant inverse relationship between LI and ER (r = -0.29, p less than 0.01). Use of the OCP significantly reduced the number of cells which expressed ER and increased the LI earlier in the cycle. No effect of OCP use on the number of PR+ cells was detectable. We conclude that significant changes in the proportions of ER+ and proliferating cells occur during natural menstrual cycles. These changes are perturbed by ingestion of OCPs, so that there is greater suppression of ER and a longer period of high proliferation during the menstrual cycle. These results may explain the relationship between OCP use and the possible risk of breast cancer.

Open prospective multicenter trial with a new monophasic contraceptive combination containing gestodene

In a large and open prospective multicenter trial of 12,250 cycles from 2,378 women, contraceptive efficacy, clinical tolerance and acceptability of a new monophasic contraceptive combination containing 75 mcg gestodene (delta-5-levonorgestrel) and 30 mcg ethinyl oestradiol were studied. The objective was to assess efficacy, safety, side effects and cycle control of this oral contraceptive on healthy women using no other additional birth control methods. Two women became pregnant (0.016%) during the trial; both were patient failures. There was no effect on systolic or diastolic pressures. An average weight increase of 0.3 kg was noted. Cycle control was excellent with 95% of the cycles free of spotting and 98% free of breakthrough bleeding after six cycles. No serious complications occurred. There was an overall incidence of 14% reported side effects (after six cycles), indicating that the hormonal combination is well tolerated. It should be noted that 41.4% of the patients had some complaint before starting the treatment. For all complaints, a highly significant improvement was seen during the treatment.

Lysosomal enzymes in the human endometrium: a biochemical study in untreated and levonorgestrel-treated women

The activities of four lysosomal enzymes, i.e. N-acetyl-beta-hexosaminidase, acid phosphatase, alpha-D-mannosidase and alpha-L-fucosidase have been measured in extracts of endometrial biopsies from untreated and levonorgestrel-treated women of fertile age. Values were compared with protein and DNA content, as well as with lactate dehydrogenase activity, used as reference constituents. In parallel, organ cultures were established from the same endometrial specimens and the release of lysosomal enzymes into the medium was followed. The human endometrium possesses a rich lysosomal equipment, comparable to that found in the human liver. In the untreated cycles, the activities of lysosomal enzymes show a coordinate response to the hormonal changes, decreasing by about 40% from the proliferative to the mid-late secretory phase. Long-term levonorgestrel treatment causes a marked cytoplasmic atrophy, as shown by decreased protein content and lactate dehydrogenase activity, whereas DNA content remains unchanged. In contrast, N-acetyl-beta-hexosaminidase, one of the most active lysosomal enzymes studied, shows a higher specific activity upon levonorgestrel. In both untreated and treated endometria, the organ cultures provide biochemical evidence for a higher release of N-acetyl-beta-hexosaminidase than of lactate dehydrogenase, indicating active secretion of the lysosomal enzyme. During levonorgestrel treatment, there was no correlation between clinically recognized spotting-bleeding patterns and lysosomal enzyme content in, or release from, the endometrium.

Clinical experience with triphasic oral contraceptive (Triquilar) in 527 women in China

From October 1987 to May 1989, a total number of 527 women completed a total of 6,291 treatment cycles in 6 centers in China for the study of a triphasic oral contraceptive - Triquilar. The mean age of subjects was 30.21 +/- 2.84 years. There were 7 pregnancies during the study period. Among them, five were patient failures because of missed pill or incorrect intake; one had taken barbiturates along with Triquilar. Only one woman became pregnant in the 11th treatment cycle without any reason being found. In most cases, menstrual flow decreased and dysmenorrhea improved as treatment continued. Of the total treatment cycles, the incidence of missed withdrawal bleeding was 0.25%, spotting 0.97%, and breakthrough bleeding 0.48%. Nausea and vomiting was the most common side effect and accounted for 6.4% of the total treatment cycles. This was followed by breast tenderness (3.7%), dizziness (2.4%) and headache (1.6%). Most of the side effects occurred during the first few cycles and were alleviated later. By the end of one year, the total dropout was 64 cases. The reasons for discontinuing treatment were: pregnancy 1.33 (per hundred women), menstrual disturbances 0.76, side effects 3.80, other medical reasons 2.09, and personal reasons 4.18. The results confirm that Triquilar is an effective oral contraceptive with good cycle control and low incidence of side effects. No serious reaction has been reported. It has been well accepted by the Chinese women. However, due to the low dosage of steroids, it is of utmost importance to avoid errors in its use.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical experience with a modern low-dose oral contraceptive in almost 100,000 users

Efficacy, cycle control, tolerance, and adverse events were studied in a clinical Phase IV study using a new progestogen, gestodene, in an amount of 75 micrograms combined with 30 micrograms ethinylestradiol. The study was performed as a multicenter trial in 96,000 patients over a period of 6 cycles. Half of the patients taking the new preparation were first-time OC users, the other half switched from another OC. With regard to contraceptive efficacy, the life-table analysis showed a value of 0.032% for method failure and 0.114% for patient failure. The correspondent Pearl-Index is 0.062 and 0.22. The new drug was found acceptable by more than 90% of the women involved in the trial. Dysmenorrhea present in the "switchers" mostly disappeared on the new OC, while body weight and blood pressure remained virtually unchanged. Thus, it can be concluded that blood pressure and body weight behaviour is similar to that seen with other low-dose OCs. The new combined pill offers excellent cycle stability and has a very favourable effect on dysmenorrhea. The number of clinically diagnosed thrombotic events documented in this study was 0.65 per 1000 woman-years (TWY) and does not exceed the range of events seen in groups of women using non-hormonal methods of contraception (Oxford-FPA study 0.4/TWY and RCGP study 0.8/TWY).

Late luteal administration of the antiprogesterone RU486 in normal women: effects on the menstrual cycle events and fertility control in a long-term study

Twelve regularly cycling women, with contraindications to other methods of contraception, received RU486 (Roussel UCLAF, Romainville, France), once a month as a method of fertility control. The study was designed for 18 consecutive cycles. Each patient recorded basal body temperature, detected urinary luteinizing hormone peak, and collected saliva samples during each luteal phase for progesterone (P) determinations. A single dose of RU486, 600 mg, was given on the day before the expected date of the menses and 8 days later in case of continuing pregnancy after the first dose. Blood samples were collected for estradiol, P, and beta-human chorionic gonadotropin analyses on these two occasions. The compliance was poor and the results of only 137 cycles were obtained. The menstrual cyclicity was not significantly modified during this long-term study. Of the 137 cycles, 22 pregnancies occurred (16%), and 4 (18.2%) were not interrupted by the second dose of RU486. Thus, because of the high failure rate, use of RU486 at the time of the natural P withdrawal cannot be advocated as a "once-a-month" contragestive agent.

Acceptance and perceptions of NORPLANT among users in San Francisco, USA

Two hundred and five women participating in a five-year clinical trial of NORPLANT and NORPLANT-2 were interviewed about their contraceptive and reproductive history, sources of information and knowledge of NORPLANT, experiences using the method, and the impressions of friends and family about the method. The most common reasons for trying the implants were dissatisfaction with other methods and perceptions about NORPLANT's ease of use. Forty-one percent of acceptors had anxiety prior to insertion; 49 percent of these feared pain, but only 5 percent said that they actually experienced significant pain. Women also feared implant removal, but their fear did not influence their decision to continue or discontinue use, and 74 percent reported little or no pain at removal. Most of the women were pleased with NORPLANT, although 95 percent reported side effects, with 82 percent reporting changes in menstruation. More than one-half of those women who discontinued reported that they would use the implants again. Seventy-four percent of the current users interviewed said they would like to use the implants in the future. For the women enrolled in the clinical trial, NORPLANT appeared to be a highly acceptable method of contraception, despite the frequent occurrence of bothersome side effects.

Menstrual patterns and progesterone circulating levels following different procedures of tubal occlusion

This study was undertaken to assess the effects of different tubal occlusion procedures on ovarian function. Three groups of subjects randomized to tubal occlusion by laparoscopy and Yoon ring (24 subjects), minilaparotomy and Yoon ring (19 subjects) and minilaparotomy and Pomeroy (22 subjects), and one separate control group of 26 healthy subjects not using any form of contraception were studied in a prospective design. The characteristics of the menstrual patterns were studied for one year after sterilization. Determination of the circulating progesterone levels were made on days 15, 20 and 25 of menstrual cycles initiated 1, 3, 6 and 12 months following the tubal ligation. In the analysis of the bleeding pattern there was a statistically significant difference in the mean segment length and in the longest bleeding-free interval in the subjects who had been sterilized by minilaparotomy with Yoon ring, when compared to the other two study groups and to the control group. However, the magnitude of this difference in number of days was not considered clinically significant. There was no statistically significant difference in the percentage of ovulatory cycles within the study and the control groups, or when the results of the study groups were compared with each other or to the control group.

Menstrual pattern change 1 year after sterilization: results of a controlled, prospective study

To determine if female sterilization is associated with adverse menstrual change, we compared prospectively collected menstrual data from women who underwent sterilization via bipolar cauterization, banding, and Pomeroy ligation with data from women whose husbands obtained a vasectomy and from women who were not planning sterilization. At first-year follow-up, sterilization via banding with Falope rings was not associated with adverse change. After excluding initially abnormal cases: (1) cauterization women were bleeding more heavily than all other groups excepting Pomeroy; (2) cauterization and Pomeroy women experienced more dysmenorrhea than women not planning sterilization; and (3) more cauterization and Pomeroy women (collapsed samples) developed abnormal length cycles than did the two control groups. There were no group differences regarding development of beneficial/neutral change (e.g., decreased dysmenorrhea). However, cauterization and Pomeroy groups experienced a significantly higher average number of adverse changes than did the other groups and were at significantly greater risk of developing one or more adverse changes than were women not planning sterilization. The only pattern of association among adverse menstrual changes occurred significantly more often in the cauterization and next in the Pomeroy groups.

Bleeding patterns and acceptability among Norplant users in Singapore

Norplant contraceptive implants are silastic implants containing levonorgestrel. This study describes our experience with 100 acceptors of NORPLANT implants in Singapore. No pregnancies occurred during the first year of use. The majority found the method's ease of use to be the most attractive feature. Disruption of menstrual rhythm appeared to be the least liked feature. However the incidence of these menstrual irregularities appeared to diminish with time. Implant users have tolerated this early disruption of their menstrual rhythm well and the continuation rate at the end of the year was 97%. Thus it appears that Norplant is a safe, effective and acceptable method of contraception.

Effect of Norplant contraceptive use on hemoglobin, packed cell volume and menstrual bleeding patterns

A study was conducted to evaluate the effect of NORPLANT use on hemoglobin levels (HB), packed cell volume (PCV) and menstrual bleeding patterns. NORPLANT insertions were performed on 50 healthy volunteers in Ilorin, Nigeria, between January-March 1986. Whole blood samples were collected at admission, 6-month and 12-month follow-up visits, and each acceptor was asked to keep a daily bleeding calendar. Mean age of the acceptors was 32.8 years with a mean parity of 5.3 live births. Almost 50% of the acceptors indicated that they did not want any more children. After 12 month's follow-up, there were a total of three discontinuations, two for excessive menstrual bleeding and one due to husband's objection. Mean HB and PCV values remained relatively unchanged from admission to 12 months. Nearly 50% of the women experienced at least one episode of 8 or more days of continuous bleeding during the first six months of use, and about 20% reported amenorrhea of 90 or more days. Despite the incidence of menstrual bleeding irregularities, acceptability of the NORPLANT method was high as indicated by a 1-year continuation rate of 93.7 per 100 users. Clinically more important was the finding that despite a high proportion of women reporting menstrual pattern changes, HB and PCV levels remained unchanged.

Ovarian function after the menarche and hormonal contraception

The aim of the study was to determine the date of regular ovulation after the menarche to better understand the physiology of female adolescence, especially as it pertains to the use of hormonal contraception. Early morning urine samples were collected from 51 girls in the perimenarche for 9 weeks semi-annually during 2 years. Estrone- and pregnanediol-3-glucuronide values were determined. Cycles lasting 35-40 days at the onset of menses shortened to 28 days after the 23rd-25th cycle. Menses reached a 5.0-5.5 day average length at about the same time. After the 20th cycle, ovulation could be demonstrated in more than 50% of the study patients. Using a scoring system, regular ovulation could be expected on the basis of somatic data with scores of greater than 16. Hormonal contraception may be prescribed 2 years after the menarche, based on scores of greater than 16 and ovulation proven be hormonal cytology and basal body temperature.

A clinical study comparing the performance of three IUCDs (Multiload Copper 250, Copper T 200, and Lippes Loop C)

300 Women at Cairo's Al-Zahraa Hospital, using 1 of 3 different IUds (CuT 200, multiload Cu250, and Lippes loop size C) to compare the rate of complications encountered among the 3 groups. Failed insertion was highest among the Cu T200 group with a rate of 3.24/HWY, hundred woman years. Accidental pregnancy was highest among that group as well. With a rate 2.16/HWY compared with 1.10/HWY among the ML Cu250 group and none among the Lippes Loop group. The spontaneous expulsion rate was the same for the Cu T200 and Lippes Loop, i.e., the rate was 4.32/HWY and 4.44/HWY for the 2 groups, respectively, compared with 1.10.HWY for the ML Cu250. The highest removal rate because of pain or bleeding was encountered among the ML Cu250 users, i.e., the rate was 4.41.HWY compared with 3.33/HWY among the Lippes Loop group and 1.08/HWY for the Cu T200 group. The overall failure rate was 8.82/HWY for ML Cu250, 11.89/HWY for Cu T200, and 11.10/HWY for the Lippes Loop group.

The relationship between retrospective premenstrual symptom reporting and present oral contraceptive use

The premenstrual assessment form (PAF) was used to assess the degree and type of premenstrual changes reported by 101 oral contraceptive users and 149 non-users (aged 18-45 yr) attending general health and gynaecology clinics. Women using oral contraceptives did not complain of fewer or less severe symptoms overall, but their severity scores on the subscales of premenstrual anxiety, fatigue, low mood, water retention, and impaired social functioning were significantly lower than those of non-users. The duration of oral contraceptive use and the type of preparation (combined or phased) taken were not related to the degree of premenstrual change reported. Complaints of symptoms beginning more than two days before menstruation were less frequently reported by pill-users (p less than 0.01) and were associated with a greater severity of all types of premenstrual change (p less than 0.0001). Women who had experienced difficulties tolerating oral contraceptives reported a greater number of moderate/severe premenstrual changes (p less than 0.0001).

A possible mechanism of action of danazol and an ethinylestradiol/norgestrel combination used as postcoital contraceptive agents

Twenty-seven women requesting postcoital contraception were randomly allocated to take an ethinylestradiol/dl-norgestrel combination or danazol. Urine specimens were assayed for luteinising hormone (LH) and pregnanediol-3-glucuronide (P3G) levels from the day of the postcoital treatment to the next period. In addition, the urine samples of these recruits and 12 additional women were assayed for the Beta-subunit of human chorionic gonadotropin (B-hCG). A consistent pattern of alteration in urinary steroids was lacking, indicating a heterogeneous effect on ovarian function. There was no evidence of early pregnancy in successfully treated cases. We suggest that the main mechanism of action of these drugs is at the endometrial level.

An assessment of psychological state associated with the menstrual cycle in users of oral contraception

Reports of state in relation to the menstrual cycle were investigated using daily measures of state in a group of 65 family planning clinic attenders without pre-existing menstrual complaint. Women reported significant changes in their physical and psychological state prior to menstruation which reverted to "normal' levels 3-5 days after the onset of menstruation. No statistically significant differences were found between the patterns of oral contraceptive users and non-users.

A crossover pill study among Sudanese women

A crossover study from a standard-dose to a low-dose oral contraceptive was conducted in the Sudan. Reported side effects were very few, with a headache the most frequently reported. Switching to the other pill did not affect the rate of any side effects.

A clinical study on injectable contraceptive Noristerat

Results of a clinical study involving 382 subjects using the injectable contraceptive Noristerat (norethisterone enanthate) is presented. The maximum number of acceptors were between 21-25 years of age and had been married for 6-10 years. 50% began their 1st injection within 1 year of the last childbirth. Continuation rates were very high and about 75% returned for their 2nd injection. Among the users, weight gain was seen more commonly than weight loss. There was no significant change in blood pressure. 52.2% reported a menstrual pattern which was within the acceptable range of normal, while only 12.7% had amenorrhea. 15% showed other types of menstrual disturbance. Only 1 woman in the series became pregnant. Menstrual abnormality was the most common cause for discontinuation among the 71 subjects available for interview.

A comparison of high-dose estrogens versus low-dose ethinylestradiol and norgestrel combination in postcoital interception: a study in 493 women

Ethinylestradiol (EE), at a dosage of 5 mg/day for 5 consecutive days (5 mg EE), has generally been used for interception. A combination of 200 micrograms EE and 2 mg dl-norgestrel (EE + NG) was proposed as an effective alternative. Efficacy and tolerance of these methods were compared in a randomized, double-blind study. A group of 465 women was studied with a follow-up rate of 94.3%. In the 5 mg EE group a pregnancy rate of 0.9% was observed, and in the EE + NG group a rate of 0.4% was found. These rates differ significantly from the expected rates (P less than 0.0005, in both series). Nausea was noted in 59.1% of the 5 mg EE group and in 54.0% of the EE + NG series. Nausea and vomiting occurred in 20.8% and 15.8%, respectively. The efficacy of both methods as alternative morning-after medication was confirmed. The new method is preferable because treatment is limited to only 1 day.

Post-tubal sterilization syndrome--a misnomer

Menstrual parameters and gynecologic symptoms of 389 women who underwent laparoscopic tubal banding were studied prospectively and longitudinally. Previous oral contraceptive users exhibited an immediate increase in menstrual flow and dysmenorrhea, which declined slightly with time. No such changes occurred in women who used other methods of temporary contraception. A significant increase in noncyclic pelvic pain, independent of previous contraceptive usage, developed only in women greater than 38 years of age. Menstrual cycles and dyspareunia were not affected. A small control group of women whose husbands underwent vasectomy showed no significant changes in any of these parameters.

Menstrual patterns after female sterilization: variables predicting change

Previous studies of the changes in menstrual pattern characteristics following sterilization have been flawed by methodologic errors. As a result, contradictory findings have been reported. Appropriate methodologic approaches to the study of poststerilization menstrual patterns are presented, and a new methodologic approach-an index of menstrual pattern change-is offered, which evaluates four menstrual parameters simultaneously. A carefully controlled study using this index indicates that most women report no change in menstrual pattern at 12 months poststerilization, and among those who do experience change, changes in one direction are balanced by changes in the other direction. The changes reported include improvements as well as changes for the worse. The best predictor of whether a woman would experience menstrual pattern change after sterilization is whether her pattern had any abnormal characteristics during the three months prior to the procedure. Surgical variables and special subgroups of women are also evaluated.

Sex hormone profiles in oligomenorrheic adolescent girls and the effect of oral contraceptives

The hormonal profiles and the effect of oral contraceptives (OCs) on 16 oligomenorrheic and 10 regularly menstruating adolescent girls were studied. Testosterone, androstenedione, dehydroepiandrosterone, estradiol, progesterone, luteinizing hormone, follicle-stimulating hormone, prolactin, and sex-hormone-binding globulin were determined on blood samples obtained during a control cycle, during OC treatment, and during the follow-up cycle after discontinuation of OC use. The oligomenorrheic girls had significantly higher concentrations of androstenedione and total and free testosterone than regularly menstruating girls during the control cycle. Sex-hormone-binding globulin concentrations were significantly lower in the oligomenorrheic group. Both in oligomenorrheic and regularly menstruating girls OC treatment caused a decrease in the mean concentrations of all hormones, except prolactin, to similar levels. For 2 to 4 weeks after treatment the oligomenorrheic girls had significantly lower levels of androstenedione, total and free testosterone, and luteinizing hormone than before treatment. In the control group there were no significant differences between pretreatment and posttreatment hormone concentrations. The risks and benefits of prescribing OCs for oligomenorrheic adolescent girls are discussed.

RU 486: a steroid with antiglucocorticosteroid activity that only disinhibits the human pituitary-adrenal system at a specific time of day

RU 486 is a synthetic steroid hormone antagonist which acts at the receptor level. It has both intrinsic anti-progesterone and antiglucocorticosteroid properties in animals. We investigated the antiglucocorticosteroid activity in humans by evaluating the pituitary-adrenal response to RU 486 in men and in pregnant and nonpregnant women. In non-pregnant women, RU 486 (approximately equal to 1 mg/kg of body weight per day) produced an interruption of the luteal phase without affecting the pituitary-adrenal axis, thereby indicating a more potent anti-progesterone than antiglucorticosteroid effect. In the course of pregnancy interruption by RU 486 (approximately equal to 4 mg/kg per day), there was a significant increase in plasma corticotropin, beta-lipotropin, and cortisol concentrations. In normal men, RU 486 administration led to a dose-dependent stimulation of plasma corticotropin, beta-endorphin, and cortisol. This disinhibition of the pituitary-adrenal axis was only observed during the morning hours of the circadian rhythm. When administered concomitantly with 1 mg of dexamethasone at midnight, 6 mg of RU 486 per kg completely suppressed the dexamethasone inhibitory effect on the pituitary-adrenal axis. These results indicate that RU 486 is an antiglucocorticosteroid that disrupts the negative pituitary feedback of both the morning cortisol rise and administered dexamethasone. Furthermore, they demonstrate the possibility of optimizing the anti-progestational effect of the compound and its potential use for human fertility control by modifying the dose and the time of administration of the drug and thereby minimizing the antiglucocorticosteroid effect.

Quantitative vaginal microflora in women convalescent from toxic shock syndrome and in healthy controls

We performed sequential and quantitative vaginal cultures obtained from 8 women within 4 days to 3 years (average, 15.8 months) after their recovery from classic menstrual toxic shock syndrome (TSS) and from 11 healthy women who served as age-matched controls. Apart from tampon use, which was significantly less frequent in TSS women after their acute illness, no demographic differences were observed in the two groups. Significantly lower total aerobic and anaerobic bacterial counts were found in TSS women than in healthy controls (P less than 0.05, Mann-Whitney test). These differences were most profound during the menstrual (aerobes) and premenstrual (aerobes and anaerobes) sample times, whereas no difference in bacterial counts was observed in the mid-cycle samples. Although the less frequent usage of tampons among TSS women after their acute illness might explain the lower aerobic counts in menstrual specimens, this is unlikely to explain the significantly lower aerobic and anaerobic counts observed in premenstrual samples when tampons were not used in either group. It is possible that these differences in the quantitative vaginal microflora were a direct result of recent TSS in these women. Alternatively, disruption of the normal indigenous microflora could have predisposed these women to acute TSS by alteration of the resistance of vaginal colonization to pathogenic microorganisms.

Menstrual pattern changes following minilap/Pomeroy, minilap/ring and laparoscopy/ring sterilization: a review of 5982 cases

Menstrual pattern changes experienced by 5982 women subsequent to sterilization by the techniques of minilap/Pomeroy, minilap/tubal ring and laparoscopy/tubal ring were tabulated. Controlling for prior contraceptive use, we examined data on the following six menstrual parameters at the time of sterilization compared to reports at follow-up visits 6 and 12 months after surgery: cycle regularity, cycle length, menstrual flow duration, amount of flow, dysmenorrhea and intermenstrual bleeding. Our findings suggest that minilap sterilization does not cause menstrual pattern changes.

Anaemia and menstrual blood loss studies in women using multiload Cu250 and progestasert IUDs

Two to 9 months following insertion of the ML Cu250 (n = 54) and Alza T (n = 30) IUDs, mean menstrual blood losses (MBL) were 46.3 ml and 32.7 ml, respectively (p less than 0.005). Significantly more of the Alza T users had losses below 40 ml and they also perceived their menses to be lighter. Based on a haemoglobin level of 12gm/dL, the upper normal limit of MBL was about 40 ml. These findings are consistent with earlier observations that during the first year, ferritin levels fall in ML Cu250 users whereas they are unaltered in Alza T users.

Drug-induced infertility

Primary infertility may result from the use of various drugs. This phenomenon may be the result of an effect on the hypothalamic-pituitary-gonadal axis or a direct toxic effect on the gonads. Some of the drugs considered in this article demonstrate sex-related differences in their ability to cause infertility; there also may be age-related differences. The drugs described in this review, in regard to their association with the development of infertility, include various individual antineoplastic agents (cyclophosphamide, chlorambucil, busulphan, and methotrexate) and combinations of these chemotherapeutic drugs, glucocorticosteroids, hormonal steroids (diethylstilbestrol, medroxyprogesterone acetate, estrogen, and the constituents of oral contraceptives), antibiotics (sulfasalazine and co-trimoxazole), thyroid supplements, spironolactone, cimetidine, colchicine, marihuana, opiates, and neuroleptic agents.

Clinical experience with a triphasic oral contraceptive

A triphasic combined oral contraceptive containing fluctuating amounts of ethinylestradiol and levonorgestrel was tested clinically in a multicenter trial at six hospitals in Norway. 367 women were included in the study, 3 588 cycles were studied, and the follow up period was 12 months. The one year continuation rate was 67%. Five pregnancies occurred during the study period. All of them had to be considered as patient failures. The causes for stopping medication were side effects in about 50% and the rest for personal reasons. The cycle control taking into account duration of bleeding, amount of flow, and intermenstrual bleeding was good and comparable to the low-dose monophasic combined pills. The incidence of side effects was low. One woman had an increase in systolic blood pressure to more than 140 mmHg. Thrombophlebitis was not registered. In conclusion the triphasic oral contraceptive was effective and had a good cycle control and low incidence of side effects.

A new approach to measuring menstrual pattern change after sterilization

Methodologic problems with previous research on menstrual changes after sterilization have resulted in conflicting results. This research overcomes these problems by restricting the categories of patients and by minimizing recall difficulties. When the methodologic approach is improved, the result is that the majority of women experience no change, and among those who do, changes in one direction are counterbalanced by changes in the other direction. Three cycles preceding sterilization were compared with three cycles 12 months after the operation for four menstrual parameters. The parameters were examined separately and simultaneously by means of an index of menstrual pattern changes. Rings and spring-loaded clips were associated with less change than other methods of occlusion. The most important variable was the patient's menstrual pattern at the time of admission. Women defined as having abnormal patterns were three times more likely to experience change than women with normal cycles, and many of the former experienced change in the direction of normality.