Contraception in diabetic women

There is a very strong need for an effective and reliable method of contraception in the diabetic woman. An unplanned pregnancy that occurs when her diabetes is not under good control can have disastrous consequences, ranging from abortion to a congenitally malformed fetus. The most important factor in the contraceptive decision for the diabetic patient, especially the IDDM patient, is that the choice be made not by the clinician alone or the patient alone, but through a carefully through-out process that involves both patient and physician.     

Contraception in female cardiac patients

In the case of cardiac patients, the disease often imposes the necessity for extreme care in preventing possible pregnancy. Condoms or diaphragms are effective but often poorly accepted by the patients. IUDs are also effective but contraindicated because they increase genital hemorrhage especially in patients being treated with an anticoagulant, for it can lead to chronic anemia, and it increases the possibility of genital infection. Tubal sterilization is a possibility after laparotomy or by vaginal entry but coelioscopy is dangerous for some cardiac patients. Also the same factors that relate to healthy women must be considered before sterilization: age, number of children, and psychological stability. The use of estroprogestins is also risky because the estrogen causes a hydrosodium retention and several other changes in body chemistry which may be dangerous for them. The risk of phlebitis and of pulmonary embolism is multiplied by 10, of cerebral infarction by 9, and of myocardial infarction by 3 to 4. If the decision is made to try them, the arterial tension must be measured regularly. Progesterones alone have less influence on coagulation, but still present the risks of thrombosis. Minipills avoid many of the problems encountered with regular doses but can provoke intermenstrual hemorrhage. The use of pure progestin in a small dose (e.g., lynestrenol .5 mg) is being studied because it appears to have the advantages of being easily accepted and without serious side effects.     

Contraception in women with special medical needs

Over 10% of women of reproductive age have experienced a serious chronic physical disorder. Reproductive health issues including contraception are frequently ignored in these individuals. Clinicians should have available current knowledge regarding interactions between contraception and these conditions.     

Contraception with the intrauterine pessary Progestasert

A prospective study was carried out from June 1973 to August 1976 in 131 women fitted with a newly developed IUD (Progestasert). The IUD's were removed as planned after 12 months with the exception of 4 cases in which they were retained for up to 17 months. The evaluation of the trial was performed according to the Life Table Analysis and the usual statistical methods. 1496 application months were evaluated. One case each of intrauterine and extrauterine pregnancies were observed. One patient experienced spontaneous expulsion of the IUD. In 9 cases medical reasons led to the removal of Progestasert at an earlier date. Duration, intensity, and interval of menstruation as well as frequency of spotting and dysmenorrhea were recorded. A slight increase in duration and interval of menstruation was seen whereas bleeding intensity was reduced. Increased spotting, especially during the first month after insertion, and a significant reduction of dysmenorrheal complaints were noted after 2 months. In addition to 8 removals due to bleeding disturbances, 6 other patients experienced spotting throughout the entire treatment period. Laboratory tests such as ESR, WBC, hemoglobin, hematocrit and cytological smear determinations were carried out. No pathological alterations of these parameters were found.     

Contraception: traditional and religious attitudes

Humans have tried to control fertility for centuries. Primitive, preliterate societies practiced infanticide and abortion. When primitive women understood the advantages of conception control, they tried, when possible, to use contraception. In the 4th century B.C., Plato and Aristotle advocated a one-child family. Greek medical literature reported a hollow tube inserted through the cervix into the uterus and a potion as contraceptives. Islamic physicians had much knowledge about conception control. The attitudes toward contraception. In the 5th century B.C., Saint Augustine condemned contraception, even among married couples. The condom emerged in the early modern period. Yet, they were usually worn to protect against disease, e.g., bilharzia in Egypt and syphilis in Europe. The cervical cap and the diaphragm are examples of occlusive pessaries. By 1880, contraceptives and spermicides were advertised. In 1928, the IUD joined the existing contraceptives. Today we have combined oral contraceptives. Judaic law requires husbands to fulfill their wives sexual needs, separate from their duty to procreate. It also calls men, not women, to procreate and forbids men from masturbating, thus Judaic law does not forbid women from practicing contraception. The Roman Catholic church forbids contraceptive use because it is a sin against nature. Some Protestant denominations have allowed contraceptive use. Islamic law states that children are gifts from Allah. Some Moslems believe that they must have many children, but Allah and the Prophet state that children have rights to education and future security. These rights allow couples to prevent pregnancy. Neither Hinduism nor Buddhism prohibit contraceptive use. Differences in husband-wife communication, sex roles, access to contraceptives, and traditional family values will have more of an effect on contraceptive use and fertility than theological barriers or the social class of religious groups.     

Contraception, pregnancy and lactation in women with epilepsy

Despite all of our advances women with epilepsy face obstacles when it comes to pregnancy and childbearing. Many of these obstacles are social, based on incorrect and inappropriate attitudes of the public towards persons with epilepsy. Unfortunately many of the uninformed public are health care providers. We must continue to educate not only our patients but our colleagues so that women with epilepsy will cease to face discriminatory behaviour. Most women with epilepsy can conceive and bear healthy children. They have higher probabilities of infertility but this is often amenable to treatment. Complications of pregnancy are higher and revolve primarily around the increased risk of maternal seizures. Careful monitoring of the clinical condition of the patient and her free anticonvulsant levels will obviate much of this difficulty. Maternal seizures themselves can pose hazards for women with epilepsy and their offspring and generalized convulsive seizures are clearly to be avoided. Adverse pregnancy outcomes tend to be seen more often in particular: congenital malformations 4-6%; dysmorphic features < 10%; neonatal haemorrhage < 7%; fetal death and neonatal and infant mortality a two to threefold increase over the general population; and an uncertain risk of developmental delay particularly in the area of language acquisition. Of the potential variables of interest: anticonvulsants, maternal seizures during gestation, and the genetics of maternal epilepsy, it is at present unclear which is the most important in determining a good pregnancy outcome. Current research suggests that anticonvulsant drugs are probably responsible for the increased risk of malformations. Malformations are, however, only one of the adverse outcomes of concern. Risks can be reduced by ensuring good seizure control; monotherapy: preconceptual use of multivitamins with folate. The plethora of new anticonvulsants offers us new opportunities for improving the function and control of persons with epilepsy. Unfortunately we are uncertain how hazardous the newer anticonvulsant drugs are in pregnancy. Felbamate, gabapentin, lamotrigine, vigabatrine, and topiramate have all been recently introduced. The number of exposed women is so small that no pattern or estimates of risk can be determined at this time. Careful monitoring as is being performed by the Lamotrigine and North American Epilepsy and Pregnancy Registries will hopefully provide the necessary safety information in the near future. All of the risks aside, the majority of women with epilepsy can and will have healthy children.     

Contraception and multiple sclerosis (author's transl)

This survey about the contraceptive behavior of women with multiple sclerosis (MS) established that they take less oral contraceptive (OC) agents than the general population; they were more frequently sterilized, or indicated that no sex relations were practiced. Young women in the group of MS patients and in the general population preferred OCs; while the number of sterilized women increased only for the general population with increasing age. Remarkably many 20-29 year old MS patients were already sterilized (16%). In half of the patients, who before their illness used OCs, MS began coincident with this use. However, only 14% of the women with MS deteriorated when they chose OCs. Considering that OCs were taken for many years, and that this time is also the susceptible age for MS, it may be presumed, that this is only a temporal coincidence. The calculation of the prognosis from the parameters "disablement" and "illness duration" does not distinguish between women with or without OCs. Accordingly, patients with MS can be advised in the taking of OCs insofar as no other contraindications exist.     

Contraception and the prevention of sexually transmitted diseases

Sexually transmitted diseases (STDs) are a major cause of ill health in women and their sexual partners and children. Contraceptive methods alter in various ways the risk of acquiring STD but assessment of the odds ratio is difficult due to the many confounding factors. Spermicides have been reported to kill a wide range of bacteria and viruses including HIV in vitro and to protect in vivo from infection by gonorrhoea, chlamydia and pelvic inflammatory disease (organisms unspecified). Spermicides will not cure pre-existing infections. Condoms and diaphragms will give some protection from bacterial and viral infections in all parts of the genital tract. Hormonal contraception and tubal ligation give protection to the upper genital tract but not the cervix. Carcinoma of the cervix follows the same pattern as STDs. The risk of pelvic infection in intrauterine device users is discussed in the chapter by Bromham (pp 100-123, this issue).     

Management of hemophilia in Spain

A single injection (100 mug i.m.) of Estrumate (I.C.I. 80996) was used to induce luteal regression on day 8 of the estrous cycle in 3 sheep. Progesterone levels in the utero-ovarian vein and femoral artery had fallen within 6 h to less than 50% of the concentrations seen before injection of the analogue. Luteolysis was not associated with endogenous production of PGF. The concentration of PGF in the uteroovarian vein began to increase 27-39 h after the administration of Estrumate, reaching a mean maximum concentration of 1455pg/ml 48 h after Estrumate. The mean concentration of PGF in the utero-ovarian vein between 36-69 h after Estrumate was significantly greater than during the 24 h before Estrumate (control period) or during the 0-30 h immediately after injection (both P less than 0.001). The maximum secretion of estradiol and the pre-ovulatory LH peak occurred during the period of elevated PGF concentrations in the utero-ovarian veins. The possible importance of endogenous PGF production at this time is discussed.     

Changes in medical education in Spain

In Spain, the lack of homogeneous criteria among medical institutions has led to gaps between medical school, residency, and continuing medical education. The authors describe the background and early history of the Spanish medical education system, early reforms, and the start of modern postgraduate medical education. They discuss the current system, highlighting ongoing concerns about how physicians are trained, including the emphasis on lectures and traditional assessment methods; the focus of faculty on research activities rather than teaching; inadequate assessment of residents; and the lack of coordination among providers of continuing medical education. However, they also highlight ongoing reform efforts, most notably the development of a new medical curriculum that has just begun to be implemented. They conclude with a discussion of the future direction of medical education in Spain, in which the growing movement toward greater unity among European nations is likely to play a large role.