Vaginal atrophy and genital pain in women on depot medroxyprogesterone acetate contraceptive injection

Depot medroxyprogesterone acetate causes a hypo-estrogenic state in over half of users although clinical vaginal atrophy causing superficial dyspareunia is thought rarely to occur. This is a case series of ten women using depot medroxyprogesterone acetate who presented with superficial dyspareunia and clinical vaginal atrophy. The women were treated with vaginal estriol cream and their contraception was discontinued or changed. All patients had either a complete resolution of symptoms or a substantial improvement at follow-up, and the clinical and laboratory findings of vaginal atrophy had resolved. This case series demonstrates that vaginal atrophy may occur more frequently than previously thought.

Selection, Initiation, Continuation, and Efficacy of Reversible Contraception Among Enlisted U.S. Service Women in Their First Term of Service From 2012 to 2020

BACKGROUND

Pregnancy is the second most common cause of limited duty days among active duty service members in the U.S. Military. Pregnancy accounts for 10% of all days on restricted duty, despite impacting a minority of active duty service members. One out of five service women will experience an unintended pregnancy every year despite the availability of no-cost contraception and reproductive healthcare. Young, single, junior enlisted service women experience the highest rate of unintentional pregnancy. Previous studies have demonstrated service branch-based variability in selection, initiation, and continuation of specific contraceptive methods related to service branch culture and access to contraception during basic training. It is unclear if these differences impact overall contraception use or fertility rates among junior enlisted service women in their first term of enlistment. This study examines rates of contraceptive selection, initiation, continuation, and efficacy among junior enlisted service women in their first 4-year enlistment period, and the service branch specific variability in these outcomes.

METHODS

This study is a secondary analysis of Military Healthcare Data Repository records from women who began basic training between 2012 and 2020 and remained on active duty for at least 12 months. We used Kaplan-Meier analyses to examine the effect of age and military branch on contraceptive continuation and efficacy. We used binomial regression for interval censored data, to assess the association of service branch with rates of contraceptive initiation, contraception use, births, and childbirth-related duty restrictions.

RESULTS

We identified 147,594 women who began basic training between 2012 and 2020. The mean age of these women at the beginning of basic training was 20.4 ± 3.1 years. Women in the marines and navy had higher contraceptive initiation rates than women in the army or air force. Among women initiating a contraceptive pill, patch, or ring (short-acting reversible contraception), 58.3% were still using some form of hormonal contraception 3 months later. Among women initiating depot-medroxyprogesterone (DMPA), 38.8% were still using any form of hormonal contraception 14 weeks later. Long-acting reversible contraceptive methods, such as intrauterine or subdermal contraceptives, had higher continuation rates and less service-based variability in continuation and failure rates than short-acting reversible contraception or depot-medroxyprogesterone. The proportion of days on any form of prescription contraception during the first 4 years on active duty varied from 23.3% in the army to 38.6% in the navy. The birth rate varied from 34.8 births/1,000 woman-years in the air force up to 62.7 births/1,000 woman-years in the army. Compared with women in the air force, women in the army experienced 2,191 additional days of postpartum leave and 13,908 days on deployment restrictions per 1,000 woman-years.

DISCUSSION

Service branch specific variability in contraceptive use is associated with differences in days of pregnancy-related duty restrictions during first 4 years on active duty among junior enlisted females. Robust implementation of best practices in contraceptive care across the military health system to improve contraceptive initiation and continuation appears to offer an opportunity to improve military readiness and promote the health and well-being of active duty service women, particularly in the army.

Access to on-campus contraception on college and university campuses in North Carolina

BACKGROUND AND OBJECTIVE

Unintended pregnancies occur more frequently in college students and negatively affect health outcomes and educational attainment. This study examined access to on-campus contraceptives at all 4-year colleges and universities in North Carolina (NC).

METHODS

This institutional review board-exempt study evaluated availability of on-campus contraceptives including condoms; hormonal contraceptives including pills, patches, and vaginal rings; medroxyprogesterone injections; implants; intrauterine devices; and emergency contraception via website review. Institutions were stratified by characteristics including size, location, type (e.g., public, private, religious affiliation, historically black colleges and universities, women's colleges), and presence of a student health pharmacy. Comparisons were made using chi-square test or Fisher's exact test.

RESULTS

Fifty-four 4-year colleges and universities were identified. A plurality or the majority of schools were considered small (41%) and urban (48%) and had a religious affiliation (61%). Thirty-three percent of colleges and universities had an on-campus pharmacy. The most frequent contraceptives offered were condoms (43%), oral contraceptives (33%), and medroxyprogesterone injections (22%). Emergency contraception was available at approximately one-third of colleges and universities. Six percent of institutions provided a full range of contraceptive methods. Contraceptives were offered more frequently at large, public, urban institutions, whereas religious institutions and smaller institutions were less likely to offer contraceptives.

CONCLUSION

Access to on-campus contraception for college students in NC is lacking, and the vast majority of institutions did not provide a full range of contraceptives. Policy measures, such as enhancing reproductive health services at student health centers or increasing contraception availability directly through pharmacies, are needed to improve access for college students.

Priority screening of contaminant of emerging concern (CECs) in surface water from drinking water sources in the lower reaches of the Yangtze River based on exposure-activity ratios (EARs)

Surface water provides ecological services such as drinking water supply. However, contaminants of emerging concern (CECs) are rising concerns because they are ubiquitously detected in surface water and pose potential risks to the aquatic environment and human health. This study investigated the occurrence of 165 CECs in surface water from drinking water source areas along the lower reaches of the Yangtze River to prioritize the CECs and to estimate potential biological activity based on exposure-activity ratio (EAR). A total of 70 CECs were detected in the surface water at least once at the selected 17 sampling sites, and their concentrations ranged from 0.592 to 4650 ng/L. Twenty-four CECs were detected at each site, and these were mostly pharmaceutical and personal care products and pesticides. Sucralose, 1H-benzotriazole and carbendazim were the most common CECs with high median concentrations in the study area. Specifically, sucralose, an artificial sweetener, was presented at each site with the highest median concentration (3010 ng/L), which indicated that anthropogenic inputs are an important source of contaminants. Medroxyprogesterone and trenbolone were identified as the priority contaminants of interest, with maximum EAR_chemical values of 0.389 and 0.183, respectively. Among all the sites, the higher cumulative EAR_mixture value was found from Nantong City (0.765), which indicated that this site could have a relatively greater potential for biological effects, and these effects were mainly due to medroxyprogesterone and trenbolone. In regard to the bioactivity of all detected CECs, nuclear receptors showed the greatest potential bioactivity in this region, particularly androgen receptor-mediated bioactivity, which is most likely affected organisms residing in the source water area. These results suggest that the drinking water sources from the studied region are contaminated with CECs, and highlight the prioritization of future monitoring and research to protect source waters.

Depo Medroxyprogesterone (DMPA) Promotes Papillomavirus Infections but Does Not Accelerate Disease Progression in the Anogenital Tract of a Mouse Model

Contraceptives such as Depo-medroxyprogesterone (DMPA) are used by an estimated 34 million women worldwide. DMPA has been associated with increased risk of several viral infections including Herpes simplex virus-2 (HSV-2) and Human immunodeficiency virus (HIV). In the current study, we used the mouse papillomavirus (MmuPV1) anogenital infection model to test two hypotheses: (1) contraceptives such as DMPA increase the susceptibility of the anogenital tract to viral infection and (2) long-term contraceptive administration induces more advanced disease at the anogenital tract. DMPA treatments of both athymic nude mice and heterozygous NU/J (Foxn1nu/+) but ovariectomized mice led to a significantly increased viral load at the anogenital tract, suggesting that endogenous sex hormones were involved in increased viral susceptibility by DMPA treatment. Consistent with previous reports, DMPA treatment suppressed host anti-viral activities at the lower genital tract. To test the impact of long-term contraceptive treatment on the MmuPV1-infected lower genital tract, we included two other treatments in addition to DMPA: 17β-estradiol and a non-hormone based contraceptive Cilostazol (CLZ, Pletal). Viral infections were monitored monthly up to nine months post infection by qPCR. The infected vaginal and anal tissues were harvested and further examined by histological, virological, and immunological analyses. Surprisingly, we did not detect a significantly higher grade of histology in animals in the long-term DMPA and 17β-estradiol treated groups when compared to the control groups in the athymic mice we tested. Therefore, although DMPA promotes initial papillomavirus infections in the lower genital tract, the chronic administration of DMPA does not promote cancer development in the infected tissues in our mouse model.

Effects of Isoflavone Supplementation on the Response to Medroxyprogesterone in Premenopausal Women with Nonatypical Endometrial Hyperplasia: A Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVE

The purpose of this study was to evaluate the impact of isoflavone supplementation compared with placebo on endometrial histology and serum estradiol levels in premenopausal women with nonatypical endometrial hyperplasia.

MATERIALS AND METHODS

The present double-blindplacebo-controlled clinical trial was conducted on 100 women with nonatypical endometrial hyperplasia in the age range of 30 to 45 years. Participants were randomly assigned to receive 50 mg of isoflavone (n = 50) or placebos (n = 50) daily for three months. Both groups received the standard treatment of nonatypical endometrial hyperplasia. Endometrial biopsy and blood samples were taken at the baseline and three months after the intervention. The incidence of drug side effects was assessed as well.

RESULTS

After three months, 88.4% of isoflavone-administered subjects had a significant histological improvement compared to 68.9% subjects in the placebo group (P=0.02). There were no significant differences between the two groups in the changes of serum estradiol levels and the incidence of drug side effects.

CONCLUSION

The findings of the present study demonstrated that the coadministration of 50 mg of isoflavones and medroxyprogesterone acetate increases the treatment efficacy in women with nonatypical endometrial hyperplasia. Clinical Trial Registration. This trial was registered on the Iranian website for clinical trial registration (https://www.irct.ir/trial/53553).

Contraceptive use and preferences among females with sickle cell disease

INTRODUCTION

Females with sickle cell disease now have a life expectancy that extends well into and beyond their reproductive years. Pregnancy and childbirth are accompanied by high morbidity and mortality in this population, rendering contraception a critical part of their health care.

METHODS

We approached adult female patients of the Hospital of the University of Pennsylvania hematology clinic who were of reproductive age (ages 18-45) and carried a diagnosis of sickle cell disease. We evaluated contraceptive method uptake and method characteristic preferences, as well as other reproductive history, and compared contraceptive uptake rates to that from female respondent data from the National Survey of Family Growth (2017-2019).

RESULTS

Of 95 eligible patients, we completed surveys with 48 participants (response rate of 51%). Over half (n = 27, 56%) of participants were not currently using any form of contraception-double the rate of the general United States population (25%). The most common contraceptives currently used were the depot medroxyprogesterone (DMPA) injection (n = 6, 13%) and the progestin intrauterine device (IUD) (n = 6, 13%). DMPA uptake was significantly higher, and permanent contraceptive and oral contraceptive pill uptake significantly lower, among these participants with sickle cell disease compared to the general United States population. Participants' preferred contraceptive characteristics included effectiveness (n = 39, 81%), control over when to use the contraceptive (n = 39, 81%), and lack of side effects (n = 38, 79%).

CONCLUSIONS

Contraceptive uptake was significantly lower and method mix different among females with sickle cell disease compared to the general United States population. Further research is needed on contraceptive safety, non-contraceptive benefits, and contraceptive decision-making for females with sickle cell disease.

IMPLICATIONS

This study sheds light on the contraceptive choices and preferences of females with sickle cell disease, who are at disproportionate risk for pregnancy complications. In order to maximize the reproductive health of females with sickle cell disease, we must consider how their disease interacts with contraception and better understand how they approach contraceptive decision-making.

[Mechanism of thioridazine plus medroxyprogesterone in the treatment of endometrial cancer]

OBJECTIVE

To explore the in vitro effects of thioridazine (THIO) plus medroxyprogesterone (MPA) on the proliferation and apoptosis of endometrial cancer cell lines (Ishikawa & KLE) and examine the mechanism in the treatment of endometrial cancer.

METHODS

CCK-8 assay was employed for detecting the influence of THIO plus MPA on the proliferation and apoptosis of endometrial cancer cells (ISK & KLE). And the concentration and timepoints of drugs were determined according to the results. Real-time polymerase chain reaction (PCR) and Western blot were used to detect the expression levels of PRB, DRD2 and p-AKT/AKT in PI3K/AKT signal pathway. Flow cytometry was applied for detecting the apoptosis of combination (THIO+MPA) and MPA groups.

RESULTS

Compared to MPA group, the proliferation inhibiting effect of combination group increased significantly in ISK and KLE cells (52.5% ± 2.6% vs 37.3% ± 0.3%, P < 0.05; 97.7% ± 0.7% vs 50.0% ± 0.4%, P < 0.001); the apoptotic rates increased (34.0% ± 1.4% vs 50.5% ± 2.4%, P < 0.01; 5.5% ± 3.6% vs 11.3% ± 0.7%, P < 0.01); the expression levels of PRB and DRD2 were up-regulated (all P < 0.05). And the ratio of p-AKT/AKT decreased obviously.

CONCLUSION

Thioridazine significantly enhances the effects of MPA on proliferative inhibition and apoptotic promotion in endometrial cancer cells. And it may be associated with the PRB/DRD2-mediated PI3K/AKT signal pathway.

[Type I insulin-like growth factor receptor antisense strategies in experimental breast cancer]

We addressed the effect of targeting type I insulin-like growth factor receptor (IGF-IR), with antisense strategies in in vivo growth of breast cancer cells. We used C4HD tumors from an experimental model of hormonal carcinogenesis in which medroxyprogesterone acetate induced mammary adenocarcinomas in Balb/c mice. Intratumor or systemic administration of phosphorothiolated antisense oligodeoxynucleotides (AS[S]ODN) to IGF-IR mRNA resulted in a significant inhibition of C4HD tumor growth. The antitumor effect was specific since inhibition of tumor growth was dose-dependent and no effect was observed in mice treated with sense S[S]ODN. Tumors from AS[S]ODN-treated mice showed a decrease in IGF-IR expression and in insulin receptor substrate-1 tyrosine phosphorylation. Activation of PI-3K/Akt, p42/p44 MAPK and ErbB-2 was abolished in tumors treated with AS[S]ODN. Progesterone receptor expression or activity remained invariable. This is the first demonstration that breast cancer growth can be inhibited by direct in vivo administration of IGF-IR AS[S]ODN.

Lifetime patterns of contraception and their relationship to unintended pregnancies

BACKGROUND

For the past 30 years many effective methods of contraception have been available, yet unintended pregnancy rates still range from 30% to 50% in many populations. We examined patterns of women's contraceptive use throughout their lives and relate them to unintended pregnancy.

METHODS

A total of 396 women aged 18 to 50 years chosen by convenience sampling from a family practice residency office were interviewed in a cross-sectional study about their history of using and changing contraception, and whether they believed they became pregnant while using a method of contraception. We analyzed the data for correlations and significance using chi-square and Student t tests.

RESULTS

Most women had used both condoms and oral contraceptive pills, and tried an average of 3.54 methods during a lifetime. Two patterns of women's use of contraception emerged that describe 75% of the women. One third of the women--those who indicated a pattern of following their first method with a less effective method--are significantly more likely to have an unintended pregnancy while using contraception (odds ratio=1.4). The other group (50% of the entire sample) used increasingly effective methods and were less likely to have an unintended pregnancy.

CONCLUSIONS

Pregnancy is an inherent natural consequence of sexual intercourse, even when using very effective contraceptive methods. By asking a few questions about a woman's history of contraceptive use, physicians may be able to determine those who are more likely to be at risk for an unintended pregnancy.

Injectable contraceptive discontinuation and subsequent unintended pregnancy among low-income women

OBJECTIVES

This study investigated rates of discontinuation of the recently introduced injectable contraceptive depot medroxyprogesterone acetate (DMPA) and postdiscontinuation rates of unprotected intercourse and unintended pregnancy.

METHODS

A sample of 402 low-income, urban, minority women were interviewed when they initiated DMPA use and 12 months later.

RESULTS

The 12-month life-table discontinuation rate was 58%, with half of the discontinuers stopping after only one injection. Menstrual changes and other side effects were the most frequently cited reasons for discontinuation. Approximately half of the discontinuers at risk for unintended pregnancy either did not make the transition to another contraceptive or used contraception only sporadically. The cumulative unintended pregnancy rate by 9 months postdiscontinuation was 20%.

CONCLUSIONS

DMPA initiators were at substantial risk for unintended pregnancy because most quickly discontinued use and did not make the transition to consistent use of another contraceptive.

HORMONE-DEPENDENT TUMOURS OF THE KIDNEY. I. THE OESTROGEN-INDUCED RENAL TUMOUR OF THE SYRIAN HAMSTER. HORMONE TREATMENT AND POSSIBLE RELATIONSHIP TO CARCINOMA OF THE KIDNEY IN MAN

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EFFECTS OF 17ALPHA-HYDROXY-6ALPHA-METHYLPROGESTERONE ACETATE (DEPO-PROVERA) ON URINARY GONADOTROPHINS AND OESTROGENS IN MAN

Weekly injections of 17α-hydroxy-6α-methylprogesterone acetate to three patients with gonadal dysgenesis exhibiting high urinary gonadotrophins and one girl with marked enlargement of breasts and high urinary oestrogens, led to suppression of both urinary gonadotrophins and oestrogens in two patients and of oestrogens alone in the third case. There was no significant effect on the urinary 17-ketosteroids or 17-hydroxycorticosteroids.

The progestogen challenge test in postmenopausal women: clinical and morphologic aspects

The clinical aspects and anatomopathological patterns of 150 postmenopausal women were studied using the progestogen challenge test. An endometrial biopsy was obtained and submitted to the progestogen test. A histopathological analysis of the uterine mucosa from women with a positive progestogen test revealed that the endometrium was active in 44 percent of cases and atrophic or inactive in 56 percent. In contrast, among women with a negative response, the endometrium was atrophic in 94 percent of cases and active in 6 percent. Analysis of clinical aspects did not show significant differences between groups in terms of age; age at menarche and at menopause; fasting blood glucose levels; or body mass. However, postmenopausal time was significantly shorter for women with a positive test, with a correlation between postmenopausal time of one to two years and test positivity. The progestogen challenge test for the detection of atrophic endometrium presented 78.57 percent sensitivity, 77.05 percent specificity, 44 percent positive predictive value, and 94 percent negative predictive value. Thus, when negative, the test is highly valuable, indicating the presence of atrophic endometrium in 94 percent of cases. False-negative results occurred in only 6 percent of the subjects, with no case of hyperplasia detected. However, when the response to the test was positive, the endometrium was atrophic in 56 percent of the cases. We suggest that, in order to avoid invasive procedures, the progestogen challenge test be combined with other methods such as transvaginal ultrasonography.

Progesterone-induced urticaria--need it be autoimmune?

A patient with persistent urticaria related to the premenstrual phase of the menstrual cycle is presented. Although systemic administration of progesterone provoked the eruption, we were unable to confirm that there was an immunological reaction to endogenous progesterone or oestrogen. Mechanisms whereby progesterone can augment subclinical types I and IV hypersensitivity reactions are discussed.

Mammary carcinogenesis induced by N-methyl-N-nitrosourea (MNU) and medroxyprogesterone acetate (MPA) in BALB/c mice

MPA induces mammary tumors in virgin BALB/c mice with an average latency of 52 weeks. In order to determine whether the simultaneous administration of a chemical carcinogen, N-methyl-N-nitrosourea (MNU), shortened the latency of MPA-induced tumors, a total of 60 virgin female BALB/c mice were treated with either MNU + MPA or MNU or MPA. The experiment lasted 7 months. The incidence and latency of mammary tumors were significantly different between the 3 groups: 15/19 (79%) in MNU + MPA-treated mice with a latency of 154 +/- 19 days; 3/20 (15%) in MNU-treated mice with a latency of 179 +/- 7 days; 0/20 (tumors only start appearing after 10 months) in MPA-treated mice. Histologically, MNU + MPA-induced tumors were similar to the few tumors observed in MNU-treated mice: most of them were type B adenocarcinomas with a high degree of necrosis and calcification. Only one of the MNU + MPA-induced tumors expressed high levels of ER and PR and proved to be MPA-responsive in further passages. All the other tumors showed low or non-detectable levels of ER and PR together with an independent pattern of tumor growth. In MNU-treated mice the only tumor that was transplanted proved to be hormone independent and had low levels of PR and ER. In both MNU and MNU + MPA treated mice lung adenocarcinomas were detected. Cystic uterine glandular hyperplasias were observed in all animals. It can be concluded that MPA and MNU potentiate their carcinogenic effect in mammary gland.

Depot medroxyprogesterone (Depo-Provera) and risk of breast cancer

OBJECTIVE

To determine whether use of the injectable contraceptive depot medroxyprogesterone acetate (Depo-Provera) affects the risk of breast cancer in women.

DESIGN

A population based case-control study.

SETTING

Nationwide community study.

SUBJECTS

891 Women aged 25-54 with newly diagnosed breast cancer were compared with 1864 women selected at random from the electoral rolls.

INTERVENTION

Women were interviewed by telephone about past use of contraceptives and about possible risk factors for breast cancer.

MAIN OUTCOME MEASURE

Relative risk of breast cancer in women who had used medroxyprogesterone.

RESULTS

Medroxyprogesterone had been used by 110 patients and 252 controls. Overall, the relative risk of breast cancer associated with any duration of use was 1.0 (95% confidence interval 0.80 to 1.3). In women aged 25-34 the relative risk was 2.0 (1.0 to 3.8). The relative risk was highest in women aged 25-34 who had used the drug for six years or longer, although there were few women in this category. Women who had used it for two years or longer before age 25 had an increased risk of breast cancer (relative risk 4.6; 1.4 to 15.1).

CONCLUSION

Despite the lack of an overall association these findings suggest that medroxyprogesterone may increase the risk of breast cancer in young women.

Pregnancy after removal of Norplant implants contraceptive

Many concerns have been expressed regarding the introduction of a new contraceptive method into family planning programmes. One of the concerns is the return of fertility after discontinuing the method. To evaluate the subsequent fertility status of the Indonesian women after removal of Norplant, a prospective longitudinal study was undertaken in Klinik Radeb Saleh, Jakarta. Fifty-one women whose Norplant were removed because of their wish to become pregnant were followed-up for a period of two years or until pregnancy occurred, whichever was earlier. Two groups of women who had Lippes C IUD removed or discontinued the use of DMPA for planning pregnancy served as control and were followed-up for equal length of time. The cumulative conception rate for ex-Norplant users, ex-IUD users and ex-DMPA users at one year was 76.5, 74.7 and 70.2 per 100 women, respectively. There was no significant difference between the groups (p greater than 0.05). The present study, along with other studies, indicate that the prolonged use of Norplant do not impair the return of fertility.

Sexuality, fertility and contraception in disability

In this review the authors describe ways in which particular disabilities may affect sexual performance, fertility, menstruation and pregnancy. The special contraceptive needs of people with various physical and mental disabilities are discussed, with each method of contraception being discussed together with its indications for use by people with various disabilities. The authors conclude that if family planning services are to be improved for people with disabilities, those providing the services must increase their awareness and acceptance of sexuality in disabled people.

Metabolic response to starvation. II. Effects of sex steroid administration to pre- and postmenopausal women

Premenopausal women become more ketotic than do men during short term starvation. The possible influence of female sex steroids on ketosis during an 84-hr fast was studied in premenopausal women receiving combined oral contraceptive steroids. The results were compared to age and weight-matched women on no steroid birth control regimen. Although concentrations of several plasma substrates, insulin, and glucagon were measured throughout the fast, no differences between groups were observed with the exception of the 36-hr interval. At this time total plasma ketones and betahydroxybutyrate were significantly higher in women receiving oral contraceptives. In a second study six postmenopausal women were investigated in a similar fashion during a 36-hr fast. The procedure was repeated following a 5 day treatment regimen of oral estradiol and medroxyprogesterone acetate. After sex steroid treatment, total plasma ketones and betahydroxybutyrate concentrations exceeded control values significantly at 36 hr while plasma alanine and free fatty acid levels were significantly lower. The results suggest that oral estrogen-progestin combinations increase the ketogenic response of pre- and postmenopausal women during the early phases of total starvation. This hormonal effect may explain, in part, why women are more sensitive to fasting than are men.

[Secondary amenorrhoea (author's transl)]

27 patients with secondary amenorrhoea for 6--20 months were investigated with a gonadorelin (GnRH-)test and a psychoanalytical exploration. Results, which were determined independently of each other, were then correlated. According to the gonadorelin and the gestagen test patients could be allocated to four groups: test group 1 = negative gestagen test, LH peak below 8 ng/ml, test group 2 = positive gestagen test, LH peak below 8 ng/ml, test group 3 = positive gestagen test, LH peak 8--20 ng/ml, test group 4 = positive gestagen test, LH peak 20--37 ng/ml. According to the psychoanalytical exploration two groups of patients could be differentiated. Patients of test group 1 and 2 showed psychosomatic disorders to a greater extent with pronounced associated somatic symptoms and predominantly retentive personality structures. Patients in test groups 3 and 4 showed predominantly associated mental symptoms accompanied by better insight into their own conflicts.

A field study of the choice and continuity of use of three contraceptive methods in a rural area of Thailand

The present study was designed to assess the preference for and the continuation rates achieved with two previously available contraceptives (the pill and the IUD), and one newly introduced method (depomedroxypro-gesterone acetate, or DMPA), in a rural area of Thailand. After the presentation of balanced educational material on the three contraceptives, women were offered a free choice of method. It was found that 73·8% of all women adopted DMPA as their method of choice, and that this preference was not influenced by the educational lecture. In contrast, 16·9% of women chose the pill and 9·3% chose the IUD. The injection was perceived as a convenient method when compared to the other routes of administration, but the dominant preference for DMPA appeared to be largely due to ill-defined personal factors and the influence of friends. The 1-year life-table continuation rates with DMPA (75·5 per 100 women) were significantly higher than the continuation rate achieved with the IUD in this rural population (66·5 per 100 women). The continuation rates with the pill were 72 per 100 women, but the excessively high loss to follow-up with this method made the interpretation of the results difficult. It is suggested that if women are offered a free choice of contraceptive methods under a quasi experimental situation, useful information can be obtained on the potential value of new methods for an on-going family planning programme.