Modulating extraction and retention of fluorinated β-diketonate metal complexes in perfluorocarbons through the use of non-fluorinated neutral ligands

Extraction of metal ions into perfluorocarbon solvent with a fluorinated acac ligand is described as well as synergistic extraction with neutral nitrogen donor ligands. Applications include catalysis, nuclear fuels reprocessing, and medical imaging.

Neurofilament M gene in a French-Canadian Population with Parkinson’s Disease

Background:

Recently, a single base pair substitution (G1747A) mutation of the neurofilament M (NF-M) gene was reported in a French-Canadian patient with early onset Parkinson’s disease (PD). Three unaffected siblings were found to be heterozygotes for the NF-M Gly336Ser mutation but, to date, no other affected PD individuals have been found with a similar mutation. No other individuals with Parkinson’s disease and of similar ethnic background have been screened for this mutation.

Methods:

We screened 102 French-Canadian patients with definite PD and 45 French-Canadian controls for this substitution in the NF-M gene using a PCR-restriction enzyme digestion method.

Results:

None of the patients or controls carried this mutation.

Conclusion:

Our results would indicate that this mutation is not common even in a PD population of similar ethnic background and suggest this change represents a rare variant. However, these results do not exclude the possibility that other mutations in this gene could be present.

Strategies for communicating contraceptive effectiveness

BACKGROUND

Knowledge of contraceptive effectiveness is crucial to making an informed choice. The consumer has to comprehend the pros and cons of the contraceptive methods being considered. Choice may be influenced by understanding the likelihood of pregnancy with each method and factors that influence effectiveness.

OBJECTIVES

To review all randomized controlled trials comparing strategies for communicating to consumers the effectiveness of contraceptives in preventing pregnancy.

SEARCH STRATEGY

We searched the computerized databases MEDLINE, POPLINE, CENTRAL, PsycINFO, and EMBASE for studies of communicating contraceptive effectiveness. We also examined references lists of relevant articles, and wrote to known investigators for information about other published or unpublished trials.

SELECTION CRITERIA

We included randomized controlled trials that compared methods for communicating contraceptive effectiveness to consumers. The comparison could be usual practice or an alternative to the experimental intervention.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors and entered into RevMan. For dichotomous variables, the Peto odds ratio (OR) with 95% confidence intervals (CI) was calculated. For continuous variables, the weighted mean difference (WMD) was computed.

MAIN RESULTS

Five trials met the inclusion criteria. In one study, knowledge gain favored a slide-and-sound presentation versus a physician's oral presentation (WMD -19.00; 95% CI -27.52 to -10.48). Another trial showed a table with effectiveness categories led to more correct answers than one based on numbers [ORs were 2.42 (95% CI 1.43 to 4.12) and 2.19 (95% CI 1.21 to 3.97)] or a table with categories and numbers [ORs were 2.58 (95% CI 1.5 to 4.42) and 2.03 (95% CI 1.13 to 3.64)]. One trial examined contraceptive choice: women in the expanded program were more likely to choose sterilization (OR 4.26; 95% CI 2.46 to 7.37) or use a modern contraceptive method (OR 2.35; 95% CI 1.82 to 3.03). No trial had an explicit theoretical base, but each used concepts from common theories or models.

AUTHORS' CONCLUSIONS

We have limited evidence about what works to help consumers choose an appropriate contraceptive method. For presenting pregnancy risk data, one trial showed that categories were better than numbers. In another trial, audiovisual aids worked better than the usual oral presentation. Strategies for communicating information should be examined in clinical settings and assessed for effect on contraceptive choice and retention of knowledge. To expand the knowledge base of what works in contraceptive counseling, randomized trials could intentionally use and test theories or models.

Immediate start of hormonal contraceptives for contraception

BACKGROUND

Health care providers often tell women to wait until the next menses to begin hormonal contraception. The main intent is to avoid contraceptive use during an undetected pregnancy. An alternative is to start hormonal contraception immediately with back-up birth control for the first seven days. Immediate initiation was first introduced with combined oral contraceptives (COCs), and has expanded to other hormonal contraceptives. How immediate start compares to conventional menses-dependent start is unclear regarding effectiveness, continuation, and acceptability. The immediate-start approach may improve women's access to, and continuation of, hormonal contraception.

OBJECTIVES

This review examined randomized controlled trials of immediate-start hormonal contraception for differences in effectiveness, continuation, and acceptability.

SEARCH STRATEGY

We searched MEDLINE, CENTRAL, POPLINE, EMBASE, and LILACS for trials of immediate-start hormonal contraceptives. We contacted researchers to find other studies.

SELECTION CRITERIA

We included randomized controlled trials that compared immediate start to conventional start of hormonal contraception. Also included were trials that compared immediate start of different hormonal contraceptive methods with each other.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors and entered into RevMan. The Peto odds ratio (OR) with 95% confidence interval (CI) was calculated.

MAIN RESULTS

Five studies were included. Method discontinuation was similar between groups in all trials. Bleeding patterns and side effects were similar in trials that compared immediate with conventional start. In a study of depot medroxyprogesterone acetate (DMPA), immediate start of DMPA showed fewer pregnancies than a 'bridge' method before DMPA (OR 0.36; 95% CI 0.16 to 0.84). Further, more women in the immediate-DMPA group were very satisfied versus those with a 'bridge' method (OR 1.99; 95% CI 1.05 to 3.77).A trial of two immediate-start methods showed the vaginal ring group had less prolonged bleeding (OR 0.42; 95% CI 0.20 to 0.89) and less frequent bleeding (OR 0.23; 95% CI 0.05 to 1.03) than COC users. The ring group also reported fewer side effects. For satisfaction, more immediate ring users were very satisfied than immediate COC users (OR 2.88; 95% CI 1.59 to 5.22).

AUTHORS' CONCLUSIONS

We found limited evidence that immediate start of hormonal contraception reduces unintended pregnancies or increases method continuation. However, the pregnancy rate was lower with immediate start of DMPA versus another method. Some differences were associated with contraceptive type rather than initiation method, that is, immediate ring versus immediate COC. More studies are needed of immediate versus conventional start of the same hormonal contraceptive.

Skin patch and vaginal ring versus combined oral contraceptives for contraception

BACKGROUND

The delivery of combination contraceptive steroids from a skin patch or vaginal ring offers potential advantages over the traditional oral route. The skin patch and vaginal ring could require a lower dose due to increased bioavailability and improved user compliance.

OBJECTIVES

To compare the contraceptive effectiveness, cycle control, compliance, and safety of the skin patch or the vaginal ring versus combination oral contraceptives (COCs).

SEARCH STRATEGY

We searched MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS for trials of the contraceptive patch or the vaginal ring. We contacted manufacturers and researchers to identify other trials.

SELECTION CRITERIA

All randomized controlled trials comparing the skin patch or vaginal ring with a COC.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors and entered into RevMan. For dichotomous variables, the Peto odds ratio (OR) with 95% confidence intervals (CI) was calculated. For continuous variables, the weighted mean difference was computed.

MAIN RESULTS

We found three trials of the skin patch and eight of the vaginal ring. Contraceptive effectiveness was similar for the patch or ring and the comparison COC. Patch users reported more compliant cycles than COC users; ORs were 2.05 (95% CI 1.83 to 2.29) and 2.76 (95% CI 2.35 to 3.24) in two trials. One crossover ring trial had more noncompliance for the ring users. Satisfaction with method was higher for ring users than COC users in two studies. More patch users discontinued early than COC users: OR 1.58 (95% CI 1.25 to 1.99) and 1.45 (95% CI 1.11 to 1.90) in two trials. Patch users also had more discontinuation due to adverse events (AEs). The ring trials generally showed similar discontinuation for ring and COC users. Compared to COC users, patch users were more likely to report breast discomfort, dysmenorrhea, nausea, and vomiting. Ring users reported less nausea, irritability, and depression than COC users in single trials. However, ring users had more vaginitis and leukorrhea. Bleeding problems were generally similar or less common for the ring versus COC.

AUTHORS' CONCLUSIONS

Effectiveness rates were similar for the methods compared. The patch group had better compliance than the COC group. Compared to COC users, patch users had more side effects. Ring users generally had fewer adverse events than COC users but more vaginal irritation and discharge. The patch could lead to more discontinuation while the vaginal ring showed little difference. High losses to follow up can affect the validity of the results.

LRRK2 screening in a Canadian Parkinson's disease cohort

BACKGROUND

Mutations in the leucine-rich repeat kinase 2 gene (LRRK2) have become the most common known cause for developing Parkinson's disease. The frequency of mutations described in the literature varies widely depending on the population studied with most reports focusing only on screening for the most common G2019S mutation in exon 41.

METHODS

In this study seven exons (19, 24, 25, 31, 35, 38, and 41) in LRRK2 where mutations have been reported were screened in 230 unselected Parkinson's disease patients using denaturing high-performance liquid chromatography.

RESULTS

The sequencing of samples with heteroduplex profiles revealed five novel and two known intronic sequence variants. In our cohort, we were unable to detect any of the known mutations in these exons or identify novel mutations within the LRRK2 gene.

CONCLUSIONS

Therefore, despite the availability of diagnostic LRRK2 genetic testing it is unlikely to yield a positive result in this population.

Steroid hormones for contraception in men

BACKGROUND

Male hormonal contraception has been an elusive goal. Administration of sex steroids to men can shut off sperm production through effects on the pituitary and hypothalamus. However, this approach also decreases production of testosterone, so 'add-back' therapy is needed.

OBJECTIVES

To summarize all randomized controlled trials of male hormonal contraception.

SEARCH STRATEGY

We searched the computerized databases CENTRAL, MEDLINE, EMBASE, POPLINE, and LILACS (each from inception to March 2006) for randomized controlled trials of hormonal contraception in men. We wrote to authors of identified trials to seek unpublished or published trials that we might have missed.

SELECTION CRITERIA

We included all randomized controlled trials in any language that compared a steroid hormone with another contraceptive. We excluded non-steroidal male contraceptives, such as gossypol. We included both placebo and active-regimen control groups. All trials identified included only healthy men with normal semen analyses.

DATA COLLECTION AND ANALYSIS

Azoospermia (absence of spermatozoa on semen examination) was the primary outcome measure. Data were insufficient to examine pregnancy rates and side effects.

MAIN RESULTS

We found 30 trials that met our inclusion criteria. The proportion of men who achieved azoospermia varied widely in reports to date. A few important differences emerged from these trials: levonorgestrel implants combined with injectable testosterone enanthate (TE) were more effective than levonorgestrel 125 microg daily combined with testosterone patches; levonorgestrel 500 mug daily improved the effectiveness of TE 100 mg injected weekly; desogestrel 150 mug was less effective than desogestrel 300 mug (with testosterone pellets); testosterone undecanoate (TU) 500 mg was less likely to produce azoospermia than TU 1000 mg (with levonorgestrel implants); norethisterone enanthate 200 mg with TU 1000 mg led to more azoospermia when given every 8 weeks versus 12 weeks; four implants of 7-alpha-methyl-19-nortestosterone (MENT) were more effective than two MENT implants. Several trials showed promising efficacy in terms of percentages with azoospermia. Three examined desogestrel and testosterone preparations or etonogestrel (metabolite of desogestrel) and testosterone, and two examined levonorgestrel and testosterone.

AUTHORS' CONCLUSIONS

No male hormonal contraceptive is ready for clinical use. Most trials were small exploratory studies. As a result, their power to detect important differences was limited and their results imprecise. In addition, the definition of oligozoospermia has been imprecise or inconsistent. To avoid bias, future trials need more attention to the methodological requirements for randomized controlled trials. More trials with adequate power would also be helpful.

Steroid hormones for contraception in women with sickle cell disease

BACKGROUND

Whether steroid contraceptives are appropriate for women with homozygous sickle cell (SS) disease remains unresolved. Historically, women with SS disease have experienced difficult pregnancies, characterized by high rates of maternal mortality and morbidity and poor infant outcomes. Unresolved questions about steroidal contraceptives in women with SS disease include whether using them may promote blood clots.

OBJECTIVES

To assess the safety of steroid hormones in this setting, we retrieved and analyzed all randomized controlled trials that examined steroid hormones for contraception in women with SS disease.

SEARCH STRATEGY

We searched the computerized databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, POPLINE and EMBASE (each from its inception to November, 2005) for randomized controlled trials of steroid hormone use for contraception in women with SS disease. We examined the reference list of each trial as well as that of review articles.

SELECTION CRITERIA

We included any randomized controlled trial in any language that compared steroid hormones for contraception with another contraceptive or placebo. Frequency or intensity of sickle pain crises must have been reported as an outcome.

DATA COLLECTION AND ANALYSIS

We assessed for inclusion all titles and abstracts found. We evaluated the methodological quality of the trial found for potential biases by qualitatively assessing the study design, randomization method, allocation concealment, blinding, premature discontinuation rates, and loss to follow-up rates. We entered trial results in RevMan and reported Peto odds ratios with 95% confidence intervals for dichotomous outcomes, such as occurrence of sickle pain crises.

MAIN RESULTS

Only one trial met the inclusion criteria. Twenty-five patients were randomized to three monthly depo-medroxyprogesterone acetate (DMPA) or intramuscular saline placebo injections in a crossover design. A six-month washout period was implemented before the crossover; however, pharmacological evidence indicates that levels of DMPA may be detected for more than 200 days after the injection. During DMPA use, women were less likely to experience painful sickle episodes (OR 0.23; 95% CI 0.05 to 1.02). No trial involved estrogen products.

AUTHORS' CONCLUSIONS

The limited available data suggest that DMPA is a safe contraceptive option for women in SS disease. In addition to providing effective contraception, DMPA may reduce sickle pain crises.

Steroidal contraceptives: effect on carbohydrate metabolism in women without diabetes mellitus

BACKGROUND

Many hormonal contraceptives have been associated with changes in carbohydrate metabolism. Alterations may include decreased glucose tolerance and increased insulin resistance, which are risk factors for Type 2 diabetes mellitus and cardiovascular disease. These issues have been raised with progestin-only contraceptives as well as contraceptives containing estrogen. Such potential effects could influence recommendations for, and use of, these widely used and effective contraceptives.

OBJECTIVES

To evaluate the effect of hormonal contraceptives on carbohydrate metabolism in healthy women and those at risk for diabetes due to overweight.

SEARCH STRATEGY

We searched the computerized databases MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS for studies of hormonal contraceptives and carbohydrate metabolism. The latest search was conducted in March 2006. We wrote to investigators for information about other published or unpublished trials.

SELECTION CRITERIA

All randomized controlled trials (RCTs) were considered if they examined carbohydrate metabolism in women without diabetes who used hormonal contraceptives for contraception. Interventions included comparisons of a hormonal contraceptive with a placebo, a non-hormonal contraceptive, or another hormonal contraceptive that differed in drug, dosage, or regimen. Interventions included at least three cycles. Outcomes included glucose and insulin levels, which were generally reported as fasting value or response to an oral glucose tolerance test.

DATA COLLECTION AND ANALYSIS

We assessed for inclusion all titles and abstracts identified during the literature searches with no language limitations. The data were abstracted and the information was entered into RevMan. Studies were examined for methodological quality. For continuous variables, the weighted mean difference was computed with 95% confidence interval (CI) using a fixed-effect model. For dichotomous outcomes, the Peto odds ratio (OR) with 95% CI was calculated.

MAIN RESULTS

A total of 39 trials met the inclusion criteria. No study stratified by body weight (normal-weight versus overweight women). Results for desogestrel were often favorable regarding carbohydrate metabolism but inconsistent overall. Glucose and insulin means were more favorable for norethisterone in studies of progestin-only contraceptives. For other progestins, little or no difference was noted across trials.

AUTHORS' CONCLUSIONS

Current evidence suggests that hormonal contraceptives have limited effect on carbohydrate metabolism in women without diabetes. Strong statements cannot be made, though, due to having few studies that compared any particular types of contraceptives. Many trials had small numbers of participants and some had large losses to follow up. Most studies had poor reporting of methods. No information was available regarding the effects among women who were overweight.

Advance provision of emergency contraception for pregnancy prevention (full review)

BACKGROUND

Emergency contraception can prevent pregnancy when taken after unprotected intercourse. Obtaining emergency contraception within the recommended time frame is difficult for many women. Advance provision, in which women receive a supply of emergency contraception before unprotected sex, could circumvent some obstacles to timely use.

OBJECTIVES

To summarize randomized controlled trials evaluating advance provision of emergency contraception to explore effects on pregnancy rates, sexually transmitted infections, and sexual and contraceptive behaviors.

SEARCH STRATEGY

In August 2006, we searched CENTRAL, EMBASE, POPLINE, MEDLINE via PubMed, and a specialized emergency contraception article database. We also searched reference lists and contacted experts to identify additional published or unpublished trials.

SELECTION CRITERIA

We included randomized controlled trials comparing advance provision and standard access, which was defined as any of the following: counseling which may or may not have included information about emergency contraception, or provision of emergency contraception on request at a clinic or pharmacy.

DATA COLLECTION AND ANALYSIS

We evaluated all identified titles and abstracts found for potential inclusion. Two reviewers independently abstracted data and assessed study quality. We entered and analyzed data using RevMan 4.2.8. We calculated odds ratios with 95% confidence intervals for dichotomous data and weighted mean differences with 95% confidence intervals for continuous data.

MAIN RESULTS

Eight randomized controlled trials met our criteria for inclusion, representing 6389 patients in the United States, China and India. Advance provision did not decrease pregnancy rates (OR 1.0; 95% CI: 0.78 to 1.29 in studies for which we included twelve month follow-up data; OR 0.91; 95% CI: 0.69 to 1.19 in studies for which we included six month follow-up data; OR 0.49; 95% CI: 0.09 to 2.74 in a study with three month follow up data), despite increased use (single use: OR 2.52; 95% CI 1.72 to 3.70; multiple use: OR 4.13; 95% CI 1.77 to 9.63) and faster use (weighted mean difference (WMD) -14.6 hours; 95% CI -16.77 to -12.4 hours). Advance provision did not lead to increased rates of sexually transmitted infections (OR 0.99; 95% CI 0.73 to 1.34), increased frequency of unprotected intercourse, nor changes in contraceptive methods. Women who received emergency contraception in advance were equally as likely to use condoms as other women.

AUTHORS' CONCLUSIONS

Advance provision of emergency contraception did not reduce pregnancy rates when compared to conventional provision. Advance provision does not negatively impact sexual and reproductive health behaviors and outcomes. Women should have easy access to emergency contraception, because it can decrease the chance of pregnancy. However, the interventions tested thus far have not reduced overall pregnancy rates in the populations studied.

Combined oral contraceptive pills for treatment of acne

BACKGROUND

Acne is a common skin disorder among women. Although no uniform approach to the management of acne exists, combination oral contraceptives (COCs), which contain an estrogen and a progestin, often are prescribed for women.

OBJECTIVES

To determine the effectiveness of combined oral contraceptives (COCs) for the treatment of facial acne compared to placebo or other active therapies.

SEARCH STRATEGY

We searched the computerized databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, Biological Abstracts and LILACS for randomized controlled trials of COCs and acne. We wrote to authors of identified trials to seek any unpublished or published trials that we might have missed.

SELECTION CRITERIA

All randomized controlled trials reported in any language that compared the effectiveness of a COC containing an estrogen and a progestin to placebo or another active therapy for acne in women were eligible.

DATA COLLECTION AND ANALYSIS

We extracted data on total and specific (i.e., open or closed comedones, papules, pustules and nodules) facial lesion counts; acne severity grades; global assessments by the clinician or the participant and discontinuation due to adverse events. Data were entered and analyzed in RevMan.

MAIN RESULTS

The search yielded 23 trials: 5 placebo-controlled trials made 3 different comparisons, 17 trials made 13 comparisons between 2 different COC regimens, and 1 additional trial compared a COC to an antibiotic. COCs reduced acne lesion counts, severity grades and self-assessed acne compared to placebo. Differences in the comparative effectiveness of COCs containing varying progestin types and dosages, though, were less clear. COCs that contained chlormadinone acetate or cyproterone acetate improved acne better than levonorgestrel, although this apparent advantage was based on limited data. A COC with cyproterone acetate might result in better acne outcomes than one with desogestrel; however, the three studies comparing these COCs produced conflicting results. Likewise, levonorgestrel showed a slight improvement over desogestrel in acne outcomes in one trial, but a second trial found no difference between the COCs.

AUTHORS' CONCLUSIONS

The three COCs evaluated in placebo-controlled trials are effective in reducing inflammatory and non-inflammatory facial acne lesions. Few differences were found between COC types in their effectiveness for treating acne. How COCs compare to alternative acne treatments is unknown since limited data were available regarding this question.

Steroidal contraceptives: effect on bone fractures in women

BACKGROUND

Steroidal contraceptive use has been associated with changes in bone mineral density in women. Whether such changes increase the risk of fractures later in life is not clear. However, osteoporosis is a major public health concern. Age-related decline in bone mass increases the risk of fracture, especially of the spine, hip, and wrist. Concern about bone health influences the recommendation and use of these effective contraceptives globally.

OBJECTIVES

To evaluate the effect of using hormonal contraceptives before menopause on the risk of fracture in women

SEARCH STRATEGY

We searched MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS for studies of fracture or bone health and hormonal contraceptives. We wrote to investigators to find additional trials.

SELECTION CRITERIA

Randomized controlled trials were considered if they examined fractures, bone mineral density (BMD), or bone turnover in women with hormonal contraceptive use prior to menopause. Studies were excluded if hormones were provided for treatment of a specific condition rather than for contraception. Interventions could include comparisons of a hormonal contraceptive with a placebo or with another hormonal contraceptive. Interventions could also include the provision of a supplement versus a placebo.

DATA COLLECTION AND ANALYSIS

We assessed for inclusion all titles and abstracts identified through the literature searches with no language limitation. The weighted mean difference (WMD) was computed with 95% confidence interval (CI) using a fixed-effect model.

MAIN RESULTS

No trial had fracture as an outcome. Combination contraceptives did not appear to affect bone health. Of progestin-only methods, depot medroxyprogesterone acetate (DMPA) was associated with decreased bone mineral density, while results were inconsistent for implants. The two placebo-controlled trials showed BMD increases for DMPA plus estrogen supplement and decreases for DMPA plus placebo.

AUTHORS' CONCLUSIONS

Whether steroidal contraceptives influence fracture risk cannot be determined from existing information. Due to different interventions, no trials could be combined for meta-analysis. Many trials had small numbers of participants and some had large losses to follow up. Health care providers and women should consider the costs and benefits of these effective contraceptives. For example, injectable contraceptives and implants provide effective, long-term birth control yet do not involve a daily regimen. Progestin-only contraceptives are considered appropriate for women who should avoid estrogen due to medical conditions.

Non-steroidal anti-inflammatory drugs for heavy bleeding or pain associated with intrauterine-device use

BACKGROUND

Heavy bleeding and pain are the most common reasons why women discontinue IUDs. Non-steroidal anti-inflammatory drugs, which inhibit prostaglandin synthesis, have been shown to be effective in reducing menstrual bleeding and pain in women without IUDs.

OBJECTIVES

This review summarizes all randomized controlled trials studying use of nonsteroidal anti-inflammatory drugs for treatment of bleeding or pain associated with IUD use. Trials of prophylactic use of these drugs around the time of IUD insertion were also included.

SEARCH STRATEGY

We performed searches of PubMed, CENTRAL, POPLINE, EMBASE, LILACS, and CINAHL for relevant trials. We also wrote to the authors of all trials identified to seek other published or unpublished trials.

SELECTION CRITERIA

We included all randomized controlled trials in any language that tested one or more nonsteroidal anti-inflammatory drugs for treatment or prevention of bleeding or pain associated with IUD insertion or use.

DATA COLLECTION AND ANALYSIS

Two authors independently abstracted data from relevant trials, and we entered data into RevMan for analysis.

MAIN RESULTS

We found 15 trials from 10 countries; the total number of participants was 2702. Nonsteroidal anti-inflammatory drugs (naproxen, suprofen, mefenamic acid, ibuprofen, indomethacin, flufenamic acid, alclofenac, and diclofenac) were effective in reducing menstrual blood loss associated with IUD use. This held true for women with and without complaints of heavy bleeding. Similarly, these drugs were effective in reducing pain associated with IUD use. In contrast, prophylactic use of nonsteroidal anti-inflammatory drugs had mixed results; studies with ibuprofen found no effect on pain after insertion on IUD discontinuation. No important differences emerged in the one trial comparing the effect of different NSAIDs on bleeding.

AUTHORS' CONCLUSIONS

Nonsteroidal anti-inflammatory drugs reduce bleeding and pain associated with IUD use. NSAIDs should be considered first-line therapy; if NSAIDs are ineffective, tranexamic acid may be considered as second-line therapy. Prophylactic ibuprofen administration with the first six menses after insertion appears unwarranted.

Oral contraceptives for functional ovarian cysts

BACKGROUND

Functional ovarian cysts are a common gynecological problem among women of reproductive age worldwide. When large, persistent, or painful, these cysts may require operations, sometimes resulting in removal of the ovary. Since early oral contraceptives were associated with a reduced incidence of functional ovarian cysts, many clinicians inferred that birth control pills could be used to treat cysts as well. This became a common clinical practice in the early 1970s.

OBJECTIVES

This review examined all randomized controlled trials that studied oral contraceptives as therapy for functional ovarian cysts.

SEARCH STRATEGY

We searched the computer databases of CENTRAL, PubMed, POPLINE, and EMBASE for randomized controlled trials. We also examined the reference lists of articles and wrote to authors of all studies identified to seek articles we had missed.

SELECTION CRITERIA

We included randomized controlled trials in any language that included oral contraceptives used for treatment and not prevention of functional ovarian cysts. Criteria for diagnosis of cysts were those used by authors of studies.

DATA COLLECTION AND ANALYSIS

Two authors independently abstracted data from the articles and entered them into RevMan 4.2. We used Peto odds ratios with 95% confidence intervals for dichotomous outcomes.

MAIN RESULTS

We identified four randomized controlled trials from three countries; the studies included a total of 227 women. Treatment with combined oral contraceptives did not hasten resolution of functional ovarian cysts in any trial. This held true for cysts that occurred spontaneously as well as those that developed after ovulation induction. Most cysts resolved without treatment within a few cycles; persistent cysts tended to be pathological (e.g., endometrioma or para-ovarian cyst) and not physiological.

AUTHORS' CONCLUSIONS

Although widely used for treating functional ovarian cysts, combined oral contraceptives appear to be of no benefit. Watchful waiting over several cycles is appropriate. Should cysts persist, surgical management is often indicated.

Triphasic versus monophasic oral contraceptives for contraception

BACKGROUND

Side effects of oral contraceptive pills (OCs) discourage adherence to and continuation of OC regimens. Strategies to decrease adverse effects led to the introduction of the triphasic OC in the 1980s. Whether triphasic OCs have higher accidental pregnancy rates than monophasic pills is unknown. Nor is it known if triphasic pills give better cycle control and fewer side effects than the monophasic pills.

OBJECTIVES

To compare triphasic OCs with monophasic OCs in terms of efficacy, cycle control, and discontinuation due to side effects.

SEARCH STRATEGY

We searched the computerized databases of MEDLINE, EMBASE, POPLINE, LILACS and CENTRAL. Additionally, we searched the reference lists of relevant articles and book chapters. We also contacted researchers and pharmaceutical companies in Europe and the U.S. to identify other trials not found in our search.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing any triphasic OC with any monophasic pill used to prevent pregnancy. Interventions had to include at least three treatment cycles.

DATA COLLECTION AND ANALYSIS

We assessed the studies found in the literature searches for possible inclusion and for their methodological quality. We contacted the authors of all included studies and of possibly randomized trials for supplemental information about the methods and outcomes studied. We entered the data into RevMan 4.2 and calculated odds ratios for the outcome measures of efficacy, breakthrough bleeding, spotting, withdrawal bleeding and discontinuation.

MAIN RESULTS

Of 21 trials included, 18 examined contraceptive effectiveness: the triphasic and monophasic preparations did not differ significantly. Several trials reported favorable bleeding patterns, i.e. less spotting, breakthrough bleeding or amenorrhea, in triphasic versus monophasic OC users. However, meta-analysis was generally not possible due to differences in measuring and reporting the cycle disturbance data as well as differences in progestogen type and hormone dosages. No significant differences were found in the numbers of women who discontinued due to medical reasons, cycle disturbances, intermenstrual bleeding or adverse events.

AUTHORS' CONCLUSIONS

The available evidence is insufficient to determine whether triphasic OCs differ from monophasic OCs in effectiveness, bleeding patterns or discontinuation rates. Therefore, we recommend monophasic pills as a first choice for women starting OC use. Large, high-quality RCTs that compare triphasic and monophasic OCs with identical progestogens are needed to determine whether triphasic pills differ from monophasic OCs. Future studies should follow the WHO recommendations on recording menstrual bleeding patterns and the CONSORT reporting guidelines.

Continuous versus cyclic use of combined oral contraceptives for contraception: systematic Cochrane review of randomized controlled trials

BACKGROUND

With the recent US Food and Drug Administration approval of a combination oral contraceptive that causes a withdrawal bleed every 3 months instead of monthly, avoidance of menstruation through extended or continuous administration (>28 days of active pills) of combined oral contraceptives may become more commonplace for reasons of personal preference rather than limited to treatment of menstrual-associated medical disorders.

METHODS

The review aimed to compare contraceptive efficacy, compliance, continuation, satisfaction, bleeding profiles, and menstrual symptoms of combined oral contraceptives with continuous dosing (>28 days of active pills) versus traditional cyclic dosing (21 days of active pills and 7 days of placebo). We searched five computerized databases as well as reference lists of relevant articles for randomized controlled trials (RCT) using continuous or extended combined oral contraceptives for contraception. Two reviewers independently extracted data from eligible articles.

RESULTS

Six RCT met inclusion criteria and were of good quality. Contraceptive efficacy and compliance were similar between groups. Discontinuation overall, and for bleeding problems, was not uniformly higher in either group. When studied, participants reported high satisfaction with both dosing regimens. Five out of the six studies found that bleeding patterns were either equivalent or improved with continuous-dosing regimens. The continuous-dosing group had greater improvement of menstrual-associated symptoms (headaches, genital irritation, tiredness, bloating, and menstrual pain).

CONCLUSIONS

The variations in pill type and time-interval for continuous dosing make direct comparisons between regimens unfeasible. To allow for comparisons, future studies should choose a previously researched pill and dosing regimen. More attention needs to be directed towards participant satisfaction and menstruation-associated symptoms.

Strategies to improve adherence and acceptability of hormonal methods for contraception

BACKGROUND

Worldwide, hormonal contraceptives are among the most popular reversible contraceptives in current use. Despite their high theoretical effectiveness, typical use results in much lower effectiveness. In large part, this disparity reflects difficulties in adherence to the contraceptive regimen and low rates for long-term continuation.

OBJECTIVES

To determine the effectiveness of ancillary techniques to improve adherence to, and continuation rates of, hormonal methods of contraception.

SEARCH STRATEGY

We searched computerized databases for randomized controlled trials (RCTs) comparing client-provider interventions with standard family planning counseling. Sources included CENTRAL, MEDLINE, EMBASE, POPLINE, LILACS, and PsycINFO.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of an intensive counseling technique or client-provider intervention versus routine family planning counseling. Interventions included group motivation; structured, peer, or multi-component counseling; and intensive reminders of appointments. Outcome measures were discontinuation, reasons for discontinuation, number of missed pills and on-time injections, and pregnancy.

DATA COLLECTION AND ANALYSIS

The primary author evaluated all titles and abstracts from the searches to determine eligibility. Two authors independently extracted data from the included studies. With RevMan 4.2, we calculated the odds ratio for all dichotomous outcomes and the weighted mean difference for continuous data. The studies were so different that we could not conduct a meta-analysis.

MAIN RESULTS

We found six RCTs; only one showed a statistically significant benefit of the experimental intervention. In that trial, women who received repeated, structured information about the injectable contraceptive depo-medroxyprogesterone acetate (DMPA) were less likely to have discontinued the method by 12 months (OR 0.27; 95% CI 0.16 to 0.44) than were women who had routine counseling. The intervention group was also less likely to discontinue due to menstrual disturbances. In another study, the intervention group was less likely to discontinue due to dissatisfaction with the contraceptive method, but overall continuation was not affected.

AUTHORS' CONCLUSIONS

Most studies to date have shown no benefit of strategies to improve adherence and continuation. These trials have important limitations, however. Two had small sample sizes, several had high losses to follow-up, and the intervention and its intensity varied across the studies. High-quality research is a priority, since adherence and continuation are fundamentally important to the successful use of hormonal contraceptives.

Combination contraceptives: effects on weight

BACKGROUND

Weight gain is often considered a side effect of combination hormonal contraceptives, and many women and clinicians believe that an association exists. Concern about weight gain can limit the use of this highly effective method of contraception by deterring the initiation of its use and causing early discontinuation among users. However, a causal relationship between combination contraceptives and weight gain has not been established.

OBJECTIVES

The aim of the review was to evaluate the potential association between combination contraceptive use and changes in weight.

SEARCH STRATEGY

We searched the computerized databases MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS for studies of combination contraceptives. We also wrote to known investigators and manufacturers to request information about other published or unpublished trials not discovered in our search.

SELECTION CRITERIA

All English-language, randomized controlled trials were eligible if they had at least three treatment cycles and compared a combination contraceptive to a placebo or to a combination contraceptive that differed in drug, dosage, regimen, and/or study length.

DATA COLLECTION AND ANALYSIS

All titles and abstracts located in the literature searches were assessed. Data were entered and analyzed with RevMan, and a second author verified the data entered. Depending on the data available, the weighted mean difference using a fixed effects model with 95% confidence intervals (CI) was calculated for the mean change in weight between baseline and post-treatment measurements or the Peto odds ratio with 95% confidence intervals was calculated using the proportion of women who gained or lost more than a specified amount of weight.

MAIN RESULTS

The three placebo-controlled, randomized trials did not find evidence supporting a causal association between combination oral contraceptives or a combination skin patch and weight gain. Most comparisons of different combination contraceptives showed no substantial difference in weight. In addition, discontinuation of combination contraceptives because of weight gain did not differ between groups where this was studied.

AUTHORS' CONCLUSIONS

Available evidence was insufficient to determine the effect of combination contraceptives on weight, but no large effect was evident.

Spermicide used alone for contraception

BACKGROUND

Spermicides have been used as contraceptives for thousands of years. Despite this long use, only recently have studies examined the comparative efficacy and acceptability of these vaginal medications. Spermicides contain an active ingredient (most commonly nonoxynol-9) and a formulation used to disperse the product, such as foam or vaginal suppository.

OBJECTIVES

This review examined all known randomized controlled trials of a spermicide used alone for contraception.

SEARCH STRATEGY

We searched the following computerized databases from inception to July 2004 for randomized controlled trials of spermicides for contraception: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, POPLINE, LILACS, and EMBASE. We examined the reference list of each trial found as well as that of review articles and textbook chapters.

SELECTION CRITERIA

We included any trial of a commercial product used alone for contraception. Each included trial must have provided sufficient information to determine pregnancy rates. We located reports from 14 trials.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted information from the trials identified. We did not conduct a meta-analysis, since most trials had large losses to follow-up. We entered the data into tables and presented the results descriptively.

MAIN RESULTS

In the largest trial to date, the gel (Advantage S) containing the lowest dose of nonoxynol-9 (52.5 mg) was significantly less effective in preventing pregnancy than were gels with higher doses of the same agent (100 mg and 150 mg). Probabilities of pregnancy by six months were 22% for the 52.5 mg gel, 16% for the 100 mg dose, and 14% for the 150 mg dose. In the same trial, the three different vehicles with 100 mg of nonoxynol-9 had similar efficacy. Interpretation of these figures is limited, since 39% of participants discontinued the method or were lost from the trial. Few important differences in efficacy emerged in other trials.

AUTHORS' CONCLUSIONS

The probability of pregnancy varied widely in reported trials. A gel containing nonoxynol-9 52.5 mg was inferior to two other products tested in the largest trial. Aside from this finding, personal characteristics and behavior of users may be more important than characteristics of the spermicide products in determining the probability of pregnancy. Gel was liked more than the film or vaginal suppository in the largest trial. Spermicide trials have the dual challenges of difficult recruitment and high discontinuation rates; the latter threatens trial validity.

Intra-uterine insemination versus timed intercourse for cervical hostility in subfertile couples

BACKGROUND

The postcoital test has poor diagnostic and prognostic characteristics. Nevertheless, some physicians believe it can identify scanty or abnormal mucus that might impair fertility. One way to avoid 'hostile' cervical mucus is intrauterine insemination. With this technique, the physician injects sperm directly into the uterine cavity through a small catheter passed through the cervix; the theory is to bypass the "hostile" cervical mucus. Although most gynaecological societies do not endorse use of intrauterine insemination for hostile cervical mucus, some physicians consider it an effective treatment for women with infertility thought due to cervical mucus problems.

OBJECTIVES

The aim of this review was to determine the effectiveness of intrauterine insemination with or without ovarian stimulation in women with cervical hostility who failed to conceive.

SEARCH STRATEGY

We searched Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library Issue 2, 2005, MEDLINE (1966 to June 2005), EMBASE (1980 to June 2005), POPLINE (to June 2005) and LILACS (to June 2005). In addition, we contacted experts and searched the reference list of relevant articles and book chapters.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials comparing intrauterine insemination with intercourse timed at the presumed fertile period. Participants were women with cervical hostility who failed to conceive for at least one year.

DATA COLLECTION AND ANALYSIS

We assessed the titles and abstracts of 386 publications and two reviewers independently abstracted data on methods and results from five studies identified for inclusion. The main outcome is pregnancy rate per couple.

MAIN RESULTS

We did not pool the outcomes of the included five studies in a meta-analysis due to the methodological quality of the trials and variations in the patient characteristics and interventions. Narrative summaries of the outcomes are provided. Each study was too small for a clinically relevant conclusion. None of the studies provided information on important outcomes such as spontaneous abortion, multiple pregnancies, and ovarian hyperstimulation syndrome.

AUTHORS' CONCLUSIONS

There is no evidence from the published studies that intrauterine insemination is an effective treatment for cervical hostility. Given the poor diagnostic and prognostic properties of the postcoital test and the observation that the test has no benefit on pregnancy rates, intrauterine insemination (with or without ovarian stimulation) is unlikely to be a useful treatment for putative problems identified by postcoital testing.

Continuous or extended cycle vs. cyclic use of combined oral contraceptives for contraception

BACKGROUND

The avoidance of menstruation through extended or continuous administration (greater than 28 days of active pills) of combination oral contraceptives (COCs) has gained legitimacy through its use in treating endometriosis, dysmenorrhea, and menstruation-associated symptoms. Avoidance of menstruation through continuous use of COCs for reasons of personal preference may have additional advantages to women, including improved compliance, greater satisfaction, fewer menstrual symptoms, and less menstruation-related absenteeism from work or school.

OBJECTIVES

To determine the differences between COCs dosed continuously (greater than 28 days of active pills) compared with traditional cyclic dosing (21 days of active pills and 7 days of placebo). Our hypothesis was that continuously administered COCs have equivalent efficacy and safety but improved bleeding profiles, amenorrhea rates, adherence, continuation, participant satisfaction, and menstrual symptoms compared with cyclic COCs.

SEARCH STRATEGY

We searched computerized databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, POPLINE, LILACS) for trials using continuous or extended COCs during the years 1966 to 2005. We also searched the references in review articles and publications identified for inclusion in the protocol. Investigators were contacted regarding additional references.

SELECTION CRITERIA

All randomized controlled trials in any language comparing continuous (greater than 28 days of active pills) versus traditional cyclic administration (21 days of active pills and 7 days of placebo) of COCs for contraception.

DATA COLLECTION AND ANALYSIS

Titles and abstracts identified from the literature searches were assessed for potential inclusion. Data were extracted onto data collection forms and then entered into RevMan 4.2. Peto odds ratios with 95% confidence intervals were calculated for all outcomes for dichotomous outcomes. Weighted mean difference was calculated for continuous outcomes. The trials were critically appraised by examining the following factors: study design, blinding, randomization method, group allocation concealment, exclusions after randomization, loss to follow-up, and early discontinuation. Because the included trials did not have a standard treatment (type of pill and time length for continuous dosing), we could not aggregate data into meta-analysis.

MAIN RESULTS

Six randomized controlled trials met our inclusion criteria. Study findings were similar between 28-day and extended cycles in regard to contraceptive efficacy (i.e., pregnancy rates) and safety profiles. When compliance was reported, no difference between 28-day and extended cycles was found. Participants reported high satisfaction with both dosing regimens, but this was not an outcome universally studied. Overall discontinuation and discontinuation for bleeding problems were not uniformly higher in either group in most studies. The few studies that reported menstrual symptoms found that the extended cycle group fared better in terms of headaches, genital irritation, tiredness, bloating, and menstrual pain. Five out of the six studies found that bleeding patterns were either equivalent between groups or improved with continuous-dosing regimens. Endometrial lining assessments by ultrasound were done in a small number of participants but all endometrial stripe measurements were less than 5 mm.

AUTHORS' CONCLUSIONS

Evidence from existing randomized control trials comparing COCs given continuously (greater than 28 days of active pills) to traditional monthly cyclic dosing (21 days of active pills and 7 days of placebo) is of good quality. However, the variations in type of pill and time length for continuous dosing make direct comparisons between regimens impossible. Future studies should choose a previously described type of pill and dosing regimen. More attention needs to be directed towards participant satisfaction and menstruation-associated symptoms.

Combination injectable contraceptives for contraception

BACKGROUND

Combination injectable contraceptives provide a highly effective, reversible method of preventing pregnancy, and they do not require daily administration or use at the time of coitus. Although they are used in many countries, their acceptability could be limited by method characteristics, such as the need to obtain a monthly injection or bleeding pattern changes.

OBJECTIVES

To assess the contraceptive efficacy, bleeding patterns, discontinuation, user preferences, and side effects of combination injectable contraceptives.

SEARCH STRATEGY

We searched computerized databases for randomized controlled trials of combination injectable contraceptives.

SELECTION CRITERIA

Randomized controlled trials reported in any language were eligible if they compared a combination injectable with any other contraceptive method (e.g., a second combination injectable contraceptive, progestin-only injectable contraceptive, other hormonal contraceptive or barrier method) or placebo. We limited the review to currently marketed combination injectable contraceptives.

DATA COLLECTION AND ANALYSIS

The primary reviewer evaluated all titles and abstracts from the literature searches to determine their eligibility. Two reviewers independently extracted data from the eligible trials. Data on contraceptive efficacy, bleeding patterns, continuation, and side effects were entered and analyzed with RevMan 4.2.

MAIN RESULTS

Combination injectable contraceptives include depot medroxyprogesterone acetate (DMPA) 25 mg plus estradiol cypionate (E(2)C) 5 mg, as well as norethisterone enanthate (NET-EN) 50 mg plus estradiol valerate (E(2)V) 5 mg. These combination injectable contraceptives resulted in lower rates of early study discontinuation due to amenorrhea or other bleeding problems, but had higher rates of discontinuation due to other reasons than the progestin-only comparison contraceptives. Studies comparing two combination injectable contraceptives found that NET-EN 50 mg plus E(2)V 5 mg resulted in less overall early discontinuation and less discontinuation due to amenorrhea or prolonged bleeding than DMPA 25 mg plus E(2)C 5 mg. However, these differences were not detected in all trials making this comparison. The NET-EN plus E(2)V group also had more cyclical (regular) bleeding and fewer prolonged bleeding reference periods than the DMPA plus E(2)C group. The groups did not differ in their amenorrhea rates.

AUTHORS' CONCLUSIONS

While discontinuation rates can be viewed as a measure of method acceptability, the findings should be interpreted with caution since discontinuation rates are dependent on many other factors. Future research should be directed toward interventions to improve the acceptability of combination injectable contraceptives, such as providing injections in settings more convenient than clinical sites, methods for women to administer their own injections, and counseling about possible bleeding pattern changes.

20 mcg versus >20 mcg estrogen combined oral contraceptives for contraception

BACKGROUND

Concern about estrogen-related adverse effects has led to progressive reductions in the estrogen dose in combination oral contraceptives (COCs). However, reducing the amount of estrogen to improve safety also could result in decreased contraceptive effectiveness and unacceptable changes in bleeding patterns.

OBJECTIVES

To test the hypothesis that COCs containing </=20 mcg ethinyl estradiol (EE) perform similarly as those containing >20 mcg in terms of contraceptive effectiveness, bleeding patterns, discontinuation, and side effects.

SEARCH STRATEGY

We searched computerized databases (CENTRAL, MEDLINE, EMBASE, and POPLINE) from their inception to November 2003, searched the references of eligible trials, and wrote to oral contraceptive manufacturers to identify eligible trials.

SELECTION CRITERIA

English-language reports of randomized controlled trials that compare a COC containing </=20 mcg EE with a COC containing >20 mcg EE were eligible. We excluded studies where the interventions were designed to be administered for less than three consecutive cycles or to be used primarily as treatment for non-contraceptive conditions. Trials had to report on contraceptive effectiveness, bleeding patterns, trial discontinuation due to bleeding-related reasons or other side effects, or side effects to be included in the review.

DATA COLLECTION AND ANALYSIS

The primary reviewer evaluated all titles and abstracts located in the literature searches to determine whether they met the inclusion criteria. Two reviewers independently extracted data from the studies identified for inclusion. We wrote to the authors when clarifications or additional data were needed. Data were entered and analyzed with RevMan 4.2.

MAIN RESULTS

No differences were found in contraceptive effectiveness for the 11 COC pairs for which this outcome was reported. Several COCs containing 20 mcg EE resulted in higher rates of early trial discontinuation (overall and due to adverse events such as irregular bleeding) as well as increased risk of bleeding disturbances (both amenorrhea/infrequent bleeding and irregular, prolonged, frequent bleeding, or breakthrough bleeding or spotting) than their higher-estrogen comparison pills.

AUTHORS' CONCLUSIONS

While COCs containing 20 mcg EE may be theoretically safer, this review did not focus on the rare events required to assess this hypothesis. Data from randomized controlled trials are inadequate to detect possible differences in contraceptive effectiveness. Low-dose estrogen COCs resulted in higher rates of bleeding pattern disruptions. However, most trials compared COCs containing different progestin types, and changes in bleeding patterns could be related to progestin type as well as estrogen dose.

Fertility awareness-based methods for contraception

BACKGROUND

"Fertility awareness-based methods" (FAB) of family planning "involve identification of the fertile days of the menstrual cycle, whether by observing fertility signs such as cervical secretions and basal body temperature, or by monitoring cycle days. FAB methods can be used in combination with abstinence or barrier methods during the fertile time" (WHO 2000). Several names have been used to describe this approach to contraception, including "rhythm," "natural family planning" and "periodic abstinence." Fertility awareness-based methods can be used with abstinence from sexual intercourse. Alternatively, they can be used with barrier contraceptives or withdrawal during presumed fertile times.

OBJECTIVES

We retrieved and analyzed all randomized controlled trials that examined any fertility awareness-based methods used for contraception.

SEARCH STRATEGY

We searched the computerized databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, POPLINE, EMBASE, and LILACS (each from its inception to January, 2004) for randomized controlled trials of fertility awareness-based methods. We examined the reference list of each trial as well as that of review articles.

SELECTION CRITERIA

We included all randomized controlled trials in any language that compared any fertility awareness-based methods for contraception with a placebo; another method, including an alternative fertility awareness-based method; or fertility awareness-based methods used in conjunction with another contraceptive.

DATA COLLECTION AND ANALYSIS

We assessed all titles and abstracts found for inclusion. We evaluated the methodological quality of the trials for potential biases by qualitatively assessing the study design; randomization method; allocation concealment; blinding; premature discontinuation rates; and loss to follow-up rates. Because of methodological weaknesses, we could not enter the trial results in RevMan, calculate measures of association, or aggregate data.

MAIN RESULTS

Because of poor methods and reporting, pregnancy rates could not be determined. A trial in Colombia found similar numbers of pregnancies among women randomized to the ovulation and symptothermal methods. In contrast, a companion trial in Los Angeles observed more pregnancies in the group assigned to the ovulation method. In the two U.S. trials, recruitment of participants was unexpectedly difficult; this aspect was not mentioned in the report from Colombia. Continuation rates were poor. In the two larger trials, most participants discontinued their assigned method before entering the observation phase of the trial.

REVIEWERS' CONCLUSIONS

The comparative efficacy of fertility awareness-based methods of contraception remains unknown. Despite intensive training and ongoing support, most participants in these trials discontinued prematurely. Contraceptive methods should be properly evaluated, preferably in randomized controlled trials, before adoption and dissemination.

Nonlatex vs. latex male condoms for contraception: a systematic review of randomized controlled trials

This systematic review sought to evaluate nonlatex male condoms in comparison with latex condoms in terms of contraceptive efficacy, breakage, slippage, safety and user preferences. We searched computerized databases and contacted manufactures and investigators to find randomized controlled trials of nonlatex vs. latex male condoms. Two reviewers independently abstracted data from the 10 identified trials. While the eZ. on condom did not protect against pregnancy as well as its latex comparison condom, no differences were found in typical-use efficacy between the Avanti and the Standard Tactylon and their latex counterparts. Nonlatex condoms were associated with higher rates of clinical breakage than their latex comparisons, with statistically significant odds ratios of clinical breakage ranging from 2.6 (95% confidence interval [CI]: 1.6-4.3) to 5.0 (95% CI: 3.6-6.8). Few adverse events were reported. Substantial proportions of participants reported preferences for the nonlatex condoms. Despite higher rates of clinical breakage, nonlatex condoms still provide an acceptable alternative for those with allergies, sensitivities or preferences that might prevent the consistent use of latex condoms. The contraceptive efficacy of nonlatex condoms requires more research.

Combined oral contraceptive pills for treatment of acne

BACKGROUND

Acne is a common skin disorder among women. Although no uniform approach to the management of acne exists, combination oral contraceptives (COCs), which contain an estrogen and a progestin, often are prescribed for women.

OBJECTIVES

To determine the effectiveness of COCs for the treatment of facial acne compared to placebo or other active therapies.

SEARCH STRATEGY

We searched the computerized databases Cochrane Skin Group trial register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, Biological Abstracts and LILACS for randomized controlled trials of COCs and acne. We wrote to authors of identified trials to seek any unpublished or published trials that we might have missed.

SELECTION CRITERIA

All randomized controlled trials reported in any language that compare the effectiveness of a COC containing an estrogen and a progestin to placebo or another active therapy for acne in women were eligible.

DATA COLLECTION AND ANALYSIS

We extracted data on total and specific (i.e. open or closed comedones, papules, pustules and nodules) facial lesion counts; acne severity grades; global assessments by the clinician or the participant and discontinuation due to adverse events. Data were entered and analyzed in RevMan 4.2.

MAIN RESULTS

The search yielded five placebo-controlled trials that made three different comparisons and 14 trials that made nine comparisons between two COC regimens. An additional trial compared a COC to an antibiotic. COCs reduced acne lesion counts, severity grades and self-assessed acne compared to placebo. Differences in the comparative effectiveness of COCs containing varying progestin types and dosages, though, were less clear. COCs that contained chlormadinone acetate or cyproterone acetate improved acne better than levonorgestrel although this apparent advantage was based on limited data. A COC with cyproterone acetate might result in better acne outcomes than one with desogrestrel; however, the three studies comparing these COCs produced conflicting results. Likewise, levonorgestrel showed a slight improvement over desogestrel in acne outcomes in one trial, but a second trial found no difference between the COCs.

REVIEWERS' CONCLUSIONS

The three COCs evaluated in placebo-controlled trials are effective in reducing inflammatory and non-inflammatory facial acne lesions. Few differences were found in acne effectiveness between COC types. How COCs compare to alternative acne treatments is unknown since limited data were available regarding this question.

Hormonal contraception during lactation

Contraception choices may be limited for lactating women due to concerns about hormonal effects on quality and quantity of milk, passage of hormones to the infant and infant growth. We conducted a systematic review of randomized controlled trials to determine the effect of hormonal contraception on lactation. We sought all randomized controlled trials, reported in any language, that included any form of hormonal contraception compared with another form of hormonal contraception, nonhormonal contraception or placebo during lactation. Seven reports from five randomized controlled trials met the inclusion criteria. Most of the five trials did not specify their method used to generate a random sequence, method of allocation concealment, blinding of treatments or use of an intention-to-treat analysis. Additionally, high loss-to-follow-up rates invalidated at least two trials. The findings from two trials comparing oral contraceptives to placebo during lactation were conflicting. Another trial found no inhibitory effects on lactation from progestin-only contraceptives. Finally, the World Health Organization trial found a statistically significant decline in breast milk volume in women using combined oral contraceptives compared to women using progestin-only pills. However, infant growth for the two groups did not differ. The limited evidence from randomized controlled trials on the effect of hormonal contraceptives during lactation is of poor quality and insufficient to establish an effect of hormonal contraception, if any, on milk quality and quantity. At least one properly conducted randomized controlled trial of adequate size is urgently needed to make recommendations regarding hormonal contraceptive use for lactating women.

Mutations in the epsilon-sarcoglycan gene found to be uncommon in seven myoclonus-dystonia families

Myoclonus-dystonia syndrome (MDS) is a disorder for which the major cause appears to be mutations in the epsilon-sarcoglycan gene (SGCE). The authors have now performed mutation screening in 22 affected individuals from seven families with findings of typical MDS. A novel 5-bp deletion in exon 7 of the gene in one family and the previously reported R102X nonsense mutation in exon 3 in two other families were identified. Mutations in the SGCE gene were found in the minority of families screened in this series.

Tremor--easily seen but difficult to describe and treat

Tremor is a common movement disorder yet many physicians struggle with its terminology as well as with its treatment. Attempts have been made to develop standard terminology and criteria for tremors but this process continues to evolve. In this review, a summary of the currently-proposed phenomenology and syndromic classification of all types of tremor is presented. The diagnosis and management of essential tremor is presented in more detail, as it is the most commonly encountered tremor.

Sponge versus diaphragm for contraception: a Cochrane review

The contraceptive vaginal sponge was developed as an alternative to the contraceptive diaphragm. Unlike the diaphragm, the sponge can be used for more than one coital act within 24 h without the insertion of additional spermicide, and it does not require fitting or a prescription from a physician. We conducted a systematic review of randomized controlled trials that compared the vaginal contraceptive sponge with the diaphragm used with a spermicide in order to evaluate the efficacy and continuation rates of the two devices. The sponge was statistically significantly less effective in preventing overall pregnancy than was the diaphragm in the two trials that met our inclusion criteria. The 12-month cumulative life table termination rates per 100 women for overall pregnancy were 17.4 for the sponge versus 12.8 for the diaphragm in the larger US trial, and 24.5 for the sponge and 10.9 for the diaphragm in the UK trial. Similarly, discontinuation rates at 12 months were higher with the sponge than with the diaphragm [odds ratio 1.3; 95% confidence interval (CI) 1.1-1.6]. Allergic-type reactions were more common with the sponge in both trials, although the frequency of discontinuation for discomfort differed in the two trials. Other randomized controlled trials will be needed to resolve the role of spermicides in preventing sexually transmitted infections or in causing adverse effects.

Combination contraceptives: effects on weight

BACKGROUND

Weight gain is often attributed as a side effect of combination hormonal contraceptive, and many women and clinicians believe that an association exists. Concern about weight gain can limit the use of this highly effective method of contraception by deterring the initiation of its use and causing early discontinuation among users. Nevertheless, a causal relationship between combination contraceptives and weight gain has not been established.

OBJECTIVES

The aim of the review was to evaluate the association between combination contraceptive use and changes in weight.

SEARCH STRATEGY

We searched the computerized databases MEDLINE, Popline, CENTRAL, EMBASE, and LILACS for studies of combination contraceptives. We also wrote to known investigators and manufacturers to request information about other published or unpublished trials not discovered in our search.

SELECTION CRITERIA

All English-language, randomized controlled trials at least three treatment cycles in duration that compared a combination contraceptive to a placebo or with a combination contraceptive that differed in drug, dosage, regimen, and/or study length were eligible.

DATA COLLECTION AND ANALYSIS

All titles and abstracts located in the literature searches were assessed. Data were entered and analyzed with RevMan 4.1, and a second reviewer verified the data entered. Depending on the data available, the weighted mean difference using a fixed effects model with 95% confidence intervals was calculated for the mean change in weight between baseline and post-treatment measurements or the Peto odds ratio with 95% confidence intervals was calculated using the proportion of women who gained or lost more than a specified amount of weight.

MAIN RESULTS

The three placebo-controlled, randomized trials did not find evidence supporting a causal association between combination oral contraceptives or a combination skin patch and weight gain. Most comparisons of different combination contraceptives showed no substantial difference in weight. In addition, discontinuation of combination contraceptives because of weight gain did not differ between groups where this was studied.

REVIEWER'S CONCLUSIONS

Available evidence is insufficient to determine the effect of combination contraceptives on weight, but no large effect is evident.

Combined hormonal versus nonhormonal versus progestin-only contraception in lactation

BACKGROUND

Contraception for women who are breastfeeding is a public health issue of global importance. Each year over 100 million women make decisions about beginning or resuming contraception after childbirth. These decisions include both the choice of contraceptive method and the time at which its use begins, both of which continue to be debated by experts. Choices of contraception may be limited for lactating women due to concerns about hormonal effects on quality and quantity of milk, passage of hormones to the infant, and infant growth. Ideally, the contraceptive method chosen should not interfere with lactation. Additionally, because the return of menstruation and ovulation can be unpredictable in breastfeeding women, the timing of contraception initiation is important.

OBJECTIVES

To determine the effect of combined oral contraceptives and progestin-only contraceptives on lactation. The a priori hypothesis is that combined oral contraception impairs lactation, making it less appropriate than progestin-only or nonhormonal contraception for breastfeeding women.

SEARCH STRATEGY

We used PUBMED, POPLINE, EMBASE, LILACS, and Cochrane Controlled Trials Register computer searches, supplemented by review articles and contact with investigators.

SELECTION CRITERIA

We sought all randomized controlled trials, reported in any language, that included any form of hormonal contraception compared with another form of hormonal contraception, nonhormonal contraception, or placebo during lactation. Hormonal contraception could include combined oral or injectable contraceptives, progestin-only oral or injectable contraceptives, hormonal implants, or hormonal intrauterine devices. Study participants included breastfeeding women of any age or parity who desired contraception.

DATA COLLECTION AND ANALYSIS

We evaluated the methodological quality of each report and sought to identify duplicate reporting of data from multicenter trials. We abstracted data onto data collection forms. Principal outcome measures included quantity of milk; biochemical analysis of milk composition; initiation, maintenance and duration of lactation; infant growth; efficacy of contraceptive method while breastfeeding; and timing of contraception initiation and its effects on lactation. Because the trials did not have uniform interventions, often lacked quantifiable outcomes, and had poor methodological quality, we could not aggregate the data in a meta-analyses.

MAIN RESULTS

Seven reports from five randomized controlled trials met our inclusion criteria. Most of the five trials did not specify their method used to generate a random sequence, method of allocation concealment, blinding of treatments, or use of an intention-to-treat analysis. Additionally, high loss to follow-up rates invalidated at least two studies. The findings from two reports comparing oral contraceptives to placebo during lactation were conflicting. Another trial found no inhibitory effects on lactation from progestin-only contraceptives. Finally, the WHO trial found no effect of progestin-only contraceptives on lactation but a decline in breast milk volume from combination contraceptives during lactation. High loss to follow-up rates, however, undermine the credibility of the WHO trial. No significant differences in infant growth or weight appeared in any of the included trials as a result of the use of hormonal contraception during lactation.

REVIEWER'S CONCLUSIONS

Evidence from randomized controlled trials on the effect of hormonal contraceptives during lactation is limited and of poor quality; results should be interpreted with caution. The existing randomized controlled trials are insufficient to establish an effect of hormonal contraception, if any, on milk quality and quantity. Evidence is inadequate to make recommendations regarding hormonal contraceptive use for lactating women. At least one properly conducted randomized controlled trial of adequate size is urgently needed to address this question.

Non-latex versus latex male condoms for contraception

BACKGROUND

The male condom, which consists of a thin sheath placed over the glans and shaft of the penis, is designed to prevent pregnancy by providing a physical barrier against the deposition of semen into the vagina during intercourse. Beginning in the 1990s, nonlatex male condoms made of polyurethane film or synthetic elastomers were developed as alternative male barrier methods for individuals with allergies, sensitivities or preferences that prevented the consistent use of condoms made of latex.

OBJECTIVES

The review sought to evaluate nonlatex male condoms in comparison with latex condoms in terms of contraceptive efficacy, breakage, slippage, safety and user preferences.

SEARCH STRATEGY

We searched the the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE using PubMed, EMBASE, Popline, and LILACS for randomized controlled trials of nonlatex condoms. The references of eligible publications were assessed for inclusion. We also wrote to the manufacturers of nonlatex condoms and known investigators in an attempt to locate any other published or unpublished trials not identified in our search.

SELECTION CRITERIA

The review included all randomized controlled trials identified in the literature search that evaluated a male nonlatex condom made of polyurethane film or synthetic elastomers in comparison with a latex condom.

DATA COLLECTION AND ANALYSIS

We evaluated all titles and abstracts located in the literature searches for inclusion in the review. Two reviewers independently extracted data from the identified studies. We entered and analyzed data with RevMan 4.1. Peto odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for the outcomes contraceptive efficacy, condom breakage and slippage, discontinuation of use, safety and user preference. The number of condoms, men, or women was used as the denominator for the ORs. Contraceptive efficacy, early discontinuation, and safety outcomes were also measured with survival analysis techniques and entered into "Additional tables."

MAIN RESULTS

While the eZ.on condom did not protect against pregnancy as well as its latex comparison condom, no differences were found in the typical-use efficacy in the comparisons between the Avanti and the Standard Tactylon and their latex counterparts. The nonlatex condoms were associated with higher rates of clinical breakage than their latex comparison condoms. The statistically significant odds ratios for clinical breakage for the nonlatex condoms versus their latex comparisons ranged from 2.6 (95% CI: 1.6 to 4.3) to 5.0 (95% CI: 3.6 to 6.8). Few adverse events were reported. In almost all of the comparisons, substantial proportions of participants preferred the nonlatex condom or reported that they would recommend its use to others.

REVIEWER'S CONCLUSIONS

Although the nonlatex condoms were associated with higher rates of clinical breakage than their latex comparison condoms, the new condoms still provide an acceptable alternative for those with allergies, sensitivities or preferences that might prevent the consistent use of latex condoms. The contraceptive efficacy of the nonlatex condoms requires more research.

Biphasic versus triphasic oral contraceptives for contraception

BACKGROUND

Side effects caused by oral contraceptives discourage compliance with and continuation of oral contraceptives. A suggested disadvantage of biphasic compared to triphasic oral contraceptive pills is an increase in breakthrough bleeding. We conducted this systematic review to examine this potential disadvantage.

OBJECTIVES

To compare biphasic with triphasic oral contraceptives in terms of efficacy, cycle control, and discontinuation due to side effects.

SEARCH STRATEGY

We searched computerized databases MEDLINE, EMBASE, POPLINE and the Cochrane Controlled Trials Register (CCTR). In addition, we searched the reference lists of potentially relevant articles and book chapters. We also contacted the authors of relevant studies and pharmaceutical companies in Europe and the USA.

SELECTION CRITERIA

We included randomized controlled trials comparing any biphasic with any triphasic oral contraceptive when used to prevent pregnancy.

DATA COLLECTION AND ANALYSIS

We examined the studies found during the various literature searches for possible inclusion and assessed their methodological quality using Cochrane guidelines. We contacted the authors of all included studies and of possibly randomized studies for supplemental information about the study methods and outcomes. We entered the data in RevMan 3.1 and later imported it into RevMan 4.1. We calculated Peto odds ratios for incidence of incidence of discontinuation due to medical reasons, intermenstrual bleeding, absence of withdrawal bleeding, and discontinuation due to intermenstrual bleeding.

MAIN RESULTS

Only two trials of limited quality met our inclusion criteria. Larranaga (1978) compared two biphasic and one triphasic pills, each containing levonorgestrel and ethinyl estradiol. No important differences emerged, and the frequency of discontinuation due to medical problems was similar with all three pills. Percival Smith (1990) compared a biphasic pill containing norethindrone (Ortho 10/11) with a triphasic pill containing levonorgestrel (Triphasil) and another triphasic pill containing norethindrone (Ortho 7/7/7). The biphasic pill had inferior cycle control compared with the levonorgestrel triphasic pill. The odds ratio of cycles with intermenstrual bleeding was 1.7 (95%CI 1.3-2.2) for the biphasic pill compared with the triphasic levonorgestrel pill. The odds ratio of cycles without withdrawal bleeding was 6.5 (95%CI 3.1-13). In contrast, cycle control with the biphasic pill was comparable to that with the triphasic pill containing the same progestin (norethindrone).

REVIEWER'S CONCLUSIONS

The available evidence is limited and of poor quality; the internal validity of these trials is questionable. Given the high losses to follow-up after randomization, these reports may be better considered observational in nature. Given that caveat, the biphasic pill containing norethindrone was associated with inferior cycle control compared with the triphasic pill containing levonorgestrel. This suggests that the choice of progestin may be more important than the phasic regimen in determining bleeding patterns.

Biphasic versus monophasic oral contraceptives for contraception

BACKGROUND

Side effects caused by oral contraceptives discourage compliance with and continuation of oral contraceptives. Three approaches have been used to decrease these adverse effects: reduction of steroid dose, development of new steroids, and new formulas and schedules of administration. The third strategy led to the biphasic oral contraceptive pill.

OBJECTIVES

To compare biphasic with monophasic oral contraceptives in terms of efficacy, cycle control, and discontinuation due to side effects. Our a priori hypotheses were: (a) biphasic oral contraceptives are less effective than monophasic oral contraceptives in preventing pregnancy, and (b) biphasic oral contraceptives cause more side effects, give poorer cycle control, and have lower continuation rates.

SEARCH STRATEGY

We searched the computerized databases MEDLINE, EMBASE, Popline and the Cochrane Controlled Trials Register (CCTR). In addition, we searched the reference lists of all potentially relevant articles and book chapters. We also contacted the authors of relevant studies and pharmaceutical companies in Europe and the USA.

SELECTION CRITERIA

We included randomized controlled trials comparing any biphasic with any monophasic oral contraceptive when used to prevent pregnancy.

DATA COLLECTION AND ANALYSIS

We examined the studies found during the various literature searches for possible inclusion and assessed their methodology using Cochrane guidelines. We contacted the authors of all studies that were included and of possibly randomized studies for supplemental information about methodology and outcome. We entered the data in RevMan 3.1, imported the data into RevMan 4.1, and calculated Peto odds ratios for the incidence of intermenstrual bleeding, absence of withdrawal bleeding, and study discontinuation due to intermenstrual bleeding.

MAIN RESULTS

Only one trial of limited quality compared a biphasic and monophasic preparation. Percival-Smith et al. (1990) examined 533 user cycles of a biphasic pill (500 mcg norethindrone/35 mcg ethinyl estradiol for 10 days, followed by 1000 mcg norethindrone/35 mcg ethinyl estradiol for 11 days; Ortho 10/11) and 481 user cycles of a monophasic contraceptive pill (1500 norethindrone acetate mcg/30 mcg ethinyl estradiol daily; Loestrin). The study found no significant differences in intermenstrual bleeding, amenorrhea and study discontinuation due to intermenstrual bleeding between the biphasic and monophasic oral contraceptive pills.

REVIEWER'S CONCLUSIONS

Conclusions are limited by the identification of only one trial, the methodological shortcomings of that trial, and the absence of data on accidental pregnancies. However, the trial found no important differences in bleeding patterns between the biphasic and monophasic preparations studied. Since no clear rationale exists for biphasic pills and since extensive evidence is available for monophasic pills, the latter are preferred.

Skin patch and vaginal ring versus combined oral contraceptives for contraception

BACKGROUND

The delivery of combination contraceptive steroids from a skin patch or vaginal ring offers potential advantages over those administered via the traditional oral route. The skin patch and vaginal ring could possibly require a lower dose due to increased bioavailability and improved user compliance.

OBJECTIVES

The review's objective is to compare the contraceptive efficacy, cycle control, compliance, and safety of the contraceptive skin patch versus combination oral contraceptives and the contraceptive vaginal ring versus combination oral contraceptives.

SEARCH STRATEGY

We searched the computerized databases MEDLINE, Popline, Cochrane Controlled Trials Register, EMBASE, and LILACS for trials of the contraceptive patch or the contraceptive ring. We also searched the references of the publications identified for inclusion. We contacted the manufacturers of the skin patch and the contraceptive ring in an attempt to identify published or unpublished trials that we might have missed.

SELECTION CRITERIA

All randomized controlled trials in any language comparing the combination contraceptive skin patch with a combination oral contraceptive or the combination contraceptive vaginal ring with a combination oral contraceptive.

DATA COLLECTION AND ANALYSIS

Titles and abstracts identified from the literature searches were assessed for potential inclusion. Data were abstracted by both the primary and second reviewers to ensure accuracy and were entered into RevMan 4.1. Peto odds ratios with 95% confidence intervals were calculated for all outcomes. Six- and 13-cycle Kaplan-Meier pregnancy rates were also entered into "Additional Tables." No sensitivity analyses were conducted since the eligible trials used different comparison oral contraceptives. The trials were critically appraised by examining the following factors: the study design; blinding; randomization method; group allocation concealment; exclusions after randomization; loss-to-follow-up; and early discontinuation.

MAIN RESULTS

We found three trials of the skin patch and no eligible randomized controlled trials of the combination contraceptive vaginal ring. The six-cycle and 13-cycle Kaplan-Meier cumulative probabilities of pregnancy showed that the combination contraceptive skin patch was similar to the control combination oral contraceptive in contraceptive efficacy. One trial found that patch users discontinued early from the trial more often than oral contraceptive users (OR 1.6; 95% CI, 1.3-2.0) but a second trial found no differences in discontinuation between the groups (OR 2.6; 95% CI, 1.0-6.7). Patch users had more self-reported cycles of compliance than oral contraceptive users; the odds ratio of compliance was 2.1 (95% CI, 1.8-2.3). Patch users were more likely to report breast discomfort than oral contraceptive users with an odds ratio of 3.1 (95% CI, 2.3-4.2). The remaining commonly reported adverse events did not differ by group assignment. One trial found that women assigned to use the patch were more likely to discontinue due to adverse events than those assigned to use the oral contraceptive (OR 2.3; 95% CI, 1.6-3.3), but a second trial found no difference (OR 2.8; 95% CI, 0.7-11.3). Few serious adverse events occurred that were considered possibly or likely related to the use of the patch or oral contraceptive.

REVIEWER'S CONCLUSIONS

The randomized controlled trials comparing a combination contraceptive skin patch to a combination oral contraceptive showed similar efficacy rates for the two methods. The patch group had better self-reported compliance than the oral contraceptive group. On the other hand, breast tenderness was more common among those randomized to the patch. The patch might lead to early discontinuation (overall and due to adverse events), but the trial results on this outcome were mixed. No conclusions can be drawn regarding the vaginal ring as no eligible trials were available.

A novel locus for inherited myoclonus-dystonia on 18p11

OBJECTIVE

Inherited myoclonus-dystonia (IMD) is a new term for an autosomal dominant disorder characterized by myoclonus and dystonia. Recently, IMD was linked to a region on chromosome 11q23 with two different mutations identified in the D2 dopamine receptor gene and linked to chromosome 7q with five different loss-of-function mutations identified in the epsilon-sarcoglycan gene.

METHODS

These two regions and genes were excluded in a large Canadian family with IMD in whom 13 individuals are affected. A 25-cM genome scan of this large family with 32 individuals was performed.

RESULTS

Two-point linkage analysis revealed a maximum lod score of 3.5 (recombination fraction 0.00; affected only) for the microsatellite marker GATA185C06-18 and a multipoint lod score of 3.9 across the 18p11 region. Haplotype analysis demonstrates that all the affected individuals shared a common haplotype between markers D18S1132 and D18S843 that defines the disease gene within a span of 16.9 cM.

CONCLUSIONS

These findings indicate that a novel IMD gene exists on chromosome 18p11.