Use and misuse of oral contraceptives: risk indicators for poor pill taking and discontinuation

The contraceptive efficacy of oral contraceptives (OCs) depends on their proper and continued use, particularly with lower estrogen preparations. However, few studies have examined why women miss pills or discontinue OCs, and those that do tend to be small and to focus on adolescents. To address the issues of poor OC compliance and early OC discontinuation, we analyzed OC use in a convenience sample of 6,676 women between the ages of 16 and 30 from Denmark, France, Italy, Portugal, and the United Kingdom. Logistic regression was used to examine the independent effect of each factor. Poor compliance was associated with a lack of established routine for pill-taking (relative risk [RR] = 3.3), failure to read and understand written materials that came with the OC package (RR = 2.2), not receiving adequate information or help about OCs from their health care provider (RR = 1.5), and occurrence of certain side effects, including hirsutism (RR = 2.1), nausea (RR = 1.4), bleeding irregularities (RR = 1.3), and breast tenderness (RR = 1.2). Women who were inconsistent OC users, missing one or more pills per cycle, were almost three times as likely to experience an unintended pregnancy while using OCs than were women who took their OCs consistently. Factors that predicted early discontinuation (women who wished to continue contraceptive protection but discontinued OC use) were primarily side effects, including nausea (RR = 2.1), bleeding (RR = 1.9), breast tenderness (RR = 1.8), mood changes (RR = 1.8), and weight gain (RR = 1.4).(ABSTRACT TRUNCATED AT 250 WORDS)     

Choice and follow-up of contraception without risk factor

Every young healthy and truly informed woman may use any contraceptive method. Teenagers have to avoid not only pregnancy but also AIDS and other sexually transmitted diseases. Therefore they may use condoms when aware of postcoital contraception or must use both condoms and oral contraceptives. Non smoker women over 40 may choose between combined oral contraceptives, high doses progestogens or IUDs. Whatever the age, newer preparations with desogestrel, norgestimate or gestodene will be preferentially used due to the absence of clinical and metabolic side-effects. Smokers before 35, nonsmoker women over 35 will be preferentially given pills with only 20 micrograms ethinyloestradiol.     

Ectopic pregnancies associated with low dose progestagen-releasing IUDs

Dimethyl-polysiloxane capsules containing pure progestagens were attached to Tatum's T IUDs and tested in 594 fertile women for contraceptive performance. The control group was represented by 71 women who received identical devices containing barium sulphate instead of steroid and 100 women who received a Copper T-200. The progestagens and the doses tested were megestrol acetate (4.8, 19.2, 26 and 32 micrograms/day; levonorgestrel (2.1, 3.4 and 8.5 micrograms/day); norethindrone (18 micrograms/day); R2323 (28.6 and 45 micrograms/day); and norgestrienone (26 micrograms/day). Twelve pregnancies were diagnosed during 5201 woman-months of exposure accumulated within the first year of use among users of the steroid-bearing IUDs. Five of these were ectopic gestations. Ten pregnancies, all uterine, were detected during 1701 woman-months of exposure in the control group. Intrauterine delivery of progestagens by means of a carrier IUD is effective in decreasing the pregnancy rate but it might effect postovulatory events in a way which increases the rate of tubal implantation. Because of this property, progestagen-releasing IUDs should be limited to doses that assure maximal effectiveness to avoid increasing the risk of ectopic pregnancy.     

Determinants of contraceptive use among women of reproductive age in Great Britain and Germany. II: Psychological factors

Psychological determinants of contraceptive use were investigated in Great Britain and Germany, using national data obtained in 1992. It was hypothesised that current contraceptive use among sexually active, fertile women aged 15-45 was related to their attitude towards the various contraceptive methods, social influences, perceptions of being able to use a method correctly and consistently, a correct estimation of fertility, and communication with their partner. Effects of age and country were also taken into account. The attitude of respondents towards the various contraceptive methods was ambivalent and no method was seen as ideal. On medical methods (OCs, IUDs and sterilisation) many respondents expressed doubts as to their safety for health. Social influences most frequently concerned the use of OCs. Respondents considered themselves able to use oral contraceptives correctly, but expressed general fear about intrauterine devices and sterilisation, and many women believed they were not able to use condoms and periodic abstinence consistently. Multifactorial analyses revealed that current contraceptive use was principally determined by social influences, attitude and self-efficacy with respect to medical methods. Age and country, and, for use of unreliable methods, fertility awareness also played a role. Communication with the partner was less relevant. Contraceptive choice (and the use of non-medical methods) depended greatly on encouragement to use and being in favour of medical methods. A lack of social support for use of medical methods and a negative attitude towards them was related to higher use rates of condoms, periodic abstinence, withdrawal and reliance on 'luck'. In the case of withdrawal and/or no method, underestimation of fertility played an additional role. Contraceptive choice appears to be determined more by a general like or dislike of medical methods rather than on a weighing of the merits of individual available methods.     

Mast cells and biogenic amines in radiation-induced pulmonary fibrosis

OBJECTIVE: To determine womens' beliefs regarding the risks and health benefits of oral contraceptives (OCs). METHODS: Between April 26 and June 7, 1991, 247 women completed a self-administered questionnaire at the Yale University Health Services evaluating their perceptions of the risks and benefits of OC agents. RESULTS: The mean age of the study population was 30.2 years (range 16-68), and more than 90% of the study group had at least 1 year of college education. Forty-nine percent of the study group believed there are substantial risks to OC use. Between 80-95% of women were unaware of the following health benefits of OCs: decreased risks of endometrial cancer, ovarian cancer, pelvic inflammatory disease, ectopic pregnancy, anemia, and benign breast disease. CONCLUSIONS: Perceptions of the risks of OCs are exaggerated and there is a clear knowledge deficit with regard to their health benefits. Increased educational efforts by health care providers should emphasize the health benefits of OCs and attempt to dispel the common misconceptions.     

Update on contraception

Genitourinary medicine (GUM) clinics are likely to play an expanded role in the provision of family planning services. A recent survey of GUM clinics in the UK indicated that 71.4% provided emergency contraception and 48.1% provided routine contraception services. To facilitate the ability of GUM practitioners to provide contraceptive counseling and supplies to both men and women, this article reviews the current state of emergency contraception, combined oral contraceptives (OCs), modern IUDs, the levonorgestrel-releasing intrauterine system, female condoms, and the personalized computerized contraceptive system Persona. Also reviewed are current issues regarding the possible impact of combined OCs on an increased risk of venous thromboembolism and breast cancer.     

The copper-7 intrauterine contraceptive device: 5-year evaluation

Over a 5-year period a family practitioner inserted copper-7 (Cu-7 intrauterine contraceptive devices (IUDs) in 134 women. The rates of continued use after 2 years, 53.0% for the women's first IUD and 63.9% for all their IUDs, and of accidental pregnancy, 2.4%, are comparable to those in the literature. However, in this series the rate of expulsion was 0.8%, much lower than that in the literature. Fertility did not appear to be reduced in women who planned to have pregnancies after the device was removed. A carefully scrutinized technique of insertion and conscientious follow-up make the Cu-7 IUD an acceptable form of contraception for many patients in a family practice.     

A graduating medical school class evaluates their educational experience

CONTEXT: Comparatively little is known about how U.S. adult men's attitudes and characteristics influence their decision to use contraceptives to prevent pregnancy and to take actions to protect themselves from infection with sexually transmitted diseases (STDs). METHODS: Attitudinal and background data on 1,595 men from the 1991 and 1993 waves of the National Survey of Men (NSM) were used, through logistic regression techniques, to predict the likelihood of current contraceptive use to prevent pregnancy and recent efforts to avoid STD infection among men in three types of sexual relationship--marriage, cohabitation and dating. RESULTS: At the 1993 interview, 58% of men were using contraceptives to prevent pregnancy and 22% had recently taken actions to protect themselves from STDs. Men's concern about how easy a method was to use reduced the likelihood of STD protection, but had no influence on contraceptive use to prevent pregnancy; however, concerns about a method's risks to the female partner increased the likelihood of both outcomes. Couples in which the man expected his partner to take primary responsibility for contraception were 40% as likely to be protecting themselves against STDs as were couples in which the man believed he shared or had greater responsibility. Married men were the least likely to be protecting themselves against STDs, whereas men who were dating were the most likely to do so. CONCLUSIONS: Men's attitudes and characteristics were important predictors of contraceptive use to prevent pregnancy and of efforts to protect against STDs, even after controls for the female partner's characteristics were entered in the analysis. The findings emphasize the need to include men in interventions aimed at reducing unintended pregnancy and STD transmission.     

Oral contraceptive intake in women with focal nodular hyperplasia of the liver

This study examines the risk associated with oral contraceptive (OC) use in women with focal nodular hyperplasia (FNH). A total of 216 women (mean age, 36.2 years) with FNH were studied during 1989-98. The studied women were separated into five groups: no OC use (n = 28); high-dose OC use (50 mcg ethinyl estradiol, n = 46); low-dose OC use (30 mcg or less ethinyl estradiol, n = 98); low-dose and high-dose OC use (n = 33); pure progestagen use (n = 11). In each group, the mean diameter and the number of lesions per patient were assessed via magnetic resonance imaging (MRI). Findings revealed no differences between the five groups as to the number and the size of the lesions. The data showed that neither the intake nor the type of OC influenced the size and number of FNHs. A total of 128 women were followed up with serial MRI done after a mean of 23 months: 89 discontinued OCs, 14 remained without OCs, and 25 had taken or remained on low-dose OCs. In those who discontinued OCs, the FNH had decreased in size in two lesions and increased in size in one lesion. Despite continuation of OCs, the largest FNH disappeared 2 years after the first diagnosis, whereas the other FNH remained unchanged. Moreover, during this follow-up study, 12 women became pregnant; no increase in lesion size was seen during pregnancy. These findings indicate that low-dose OCs can be maintained in young women with FNH.     

Oral contraceptive use and hemodynamic, lipid, and fibrinogen responses to smoking and stress in women.

The effects of acute smoking and oral contraceptive (OC) use on cardiovascular, lipid, and fibrinogen stress responses were examined in 52 female smokers and nonsmokers, half of whom were using OCs. Women smoked or sham-smoked a cigarette and then performed 2 stressful tasks. Stress elicited increases in total and low-density lipoprotein cholesterol, and in triglycerides among women who smoked, and in fibrinogen among all women. Smokers who used OCs had greater blood pressure increases to smoking and to stress than did smokers who did not use OCs. OC use was also associated with enhanced total peripheral resistance stress responses among women who smoked and cardiac output stress responses among women who sham-smoked. Results suggest that OC use moderates cardiovascular reactivity in smokers but not nonsmokers, enhancing vascular responsivity to smoking combined with stress and myocardial responsivity to stress alone. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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 voluntary termination of pregnancy. Survey of a sample of 500 women

In order to better evaluate the link between contraceptive attitudes and induced abortion, 500 women who underwent voluntary termination of pregnancy (VTP) at the First Institute of Obstetrics and Gynaecology of the University of Rome "La Sapienza" were interviewed. They were young (median age 28 years), medium to high educated (61%), non married (52.4%), nulliparous (59.2%) women. Forty-two percent of them had the first sexual intercourse before 18 years of age and 72.6% at least five years before. Ninety-five women (19%) admitted a previous voluntary termination of pregnancy. Withdrawal (305 women), oral contraceptives (246 women) and condom (223 women) were the most widely used methods of fertility regulation, but the pill had been taken only for short periods of time, never exceeding one year. Withdrawal resulted to be the most utilized method during the cycle in which conception occurred (49.4%); no method had been employed by 34.8% of the women. The diffusion of modern methods of fertility regulation greatly influences the number of induced abortions in Italy, as clearly indicated by the progressive reduction of VIP starting from 1982 paralleled by a constant increase in OCs diffusion. Our data, although limited in number, confirm that induced abortion is the consequence of an insufficient use of modern methods of fertility regulation.     

Sterilization in Finland: from eugenics to contraception

The purpose of this paper was to describe the transition of sterilization in Finland from an eugenic tool to a contraceptive. Historical data were drawn from earlier reports in Finnish. Numbers of and reasons for sterilizations since 1950 were collected from nationwide sterilization statistics. Prevalence, characteristics of sterilized women, and women's satisfaction with sterilizations were studied from a 1994 nationwide survey (74% response rate). Logistic regression was used for adjustments. In the first half of the 20th century, eugenic ideology had influence in Finland as in other parts of Europe, and the 1935 and 1950 sterilization laws had an eugenic spirit. Regardless of this, the numbers of eugenic sterilizations remained low, and in practice, family planning was the main reason for sterilization. Nonetheless, prior to 1970 not all sterilizations were freely chosen, because sterilizations were sometimes used as a precondition for abortion. Female sterilizations showed remarkable fluctuation over time. Male sterilizations have been rare. The reasons stipulated by the law did not explain the numbers of sterilizations. In a 1994 survey, 9% of Finnish women reported they were using sterilization as their current contraceptive method (n = 189). Compared to women using other contraceptive methods, sterilized women were older, had had more births and pregnancies, and came from lower social classes. Sterilized women were satisfied with their sterilization, but there were women (8.5%) who regretted it. In conclusion, sterilizations have been and are likely to continue to be an important family planning method in Finland. The extreme gender ratio suggests a need for promoting male sterilizations, and women's expressed regrets suggest consideration of a higher age limit.     

Intrauterine copper contraceptive implants

GyneFix, conceived in 1985, was developed to minimize three major problems frequently associated with discontinuation of IUD use: expulsion, bleeding and pain. Since the initial clinical investigations, over 10,000 women years of experience and up to 8 years of follow-up in international, multicenter, non-comparative and comparative clinical trials, including a large proportion of nulligravid/nulliparous women, have been collected. The following conclusions were reached: 1. The unique design characteristics of GyneFix (frameless, flexible and fixed to the fundus of the uterus) have resulted in optimal tolerance and almost complete absence of expulsion. The result is enhanced effectiveness (comparable to OCs and male/female sterilization) and a high rate of continued use. GyneFix reduces the IUD-failure rate to a minimum and is, therefore, a welcome reversible alternative to OCs and female surgical contraception. 2. Frameless and flexibility explain the absence of side-effects and adverse events caused by dimensional incompatibility between the frame of conventional IUDs and the uterine cavity and may also explain the absence of PID and ectopic pregnancies in any of the clinical studies. 3. Insertion of GyneFix, with or without local anaesthesia, is easily accomplished in the office of a few minutes. Removal is easy, quick and painless. 4. GyneFix is an equally effective and well accepted method fro nulliparous women.     

The history of family planning among women who opt for surgical sterilization in the Social Security Fund of Panama

In this study, the previous history of family planning and prior usage of contraceptive methods are analyzed, in a sample of 175 women who voluntarily opted for surgical sterilization as a permanent method of fertility regulation, in the Panamanian Social Security System. A questionnaire was applied during the second trimester of pregnancy, by which information would be gathered in regard to knowledge, usage and adverse effects of the contraceptive methods used prior to the intervention. Results showed that 99% of the sample had heard, on some occasion about oral contraceptives (OC) and, in lesser proportion to intrauterine devices (IUD), barrier methods and hormonal inyectables. The first contraceptive method used, and the one of longest usage, was the combined OC, of which 43% begun between 17 and 25 years of age. In contrast, 7.4% initiated contraception with IUD, from the age of 26 years. The health personnel constituted the major source of recommendation for contraceptive usage and, despite the fact that 37% of the sample did not use contraception prior to the last pregnancy, over half of the subjects responded that combined OC were considered as the most secure method.     

Hemorrhagic manifestation of moyamoya disease in a 19-year-old woman with mental retardation

About 85% of all births in the US occur to women under 35 years of age. According to the US National Survey of Family Growth, women aged 35-39 years expect to have an additional 0.3 births while those 40-44 years anticipate only 0.1 additional births. Thus, there is a need to protect women age 35 years and over from unwanted pregnancy until menopause occurs. Sterilization continues to be the most common choice for married women older than 30 years. The IUD may be an excellent alternative to sterilization. Oral contraceptive (OC) use declines in women over 35 years because of concerns about increased cardiovascular risk. However, new studies have indicated myocardial risk in older women is mainly limited to women with other cardiovascular risk factors such as smoking, hypertension, and diabetes. Moreover, the OC-related benefits of protection against ovarian and endometrial cancer, reduced menstrual blood loss, and increased bone density are especially important to women over 35 years. Since it is impossible to diagnose menopause within the pill-free week, OC users should stop the pill for a month at around 50 years of age to allow accurate follicle-stimulating hormone measurement.     

Oral contraceptive use and protective behavior after missed pills

A three-month prospective study of 103 women initiating oral contraceptive use examined how consistently the women took their pills and whether those who missed pills employed other means to avoid pregnancy. The results showed that 52% took each active pill or never missed more than one pill at a time after the first week of the initial cycle, according to electronic devices that recorded the date and time each pill was removed from the blister pack. Another 21% were protected by behaviors that reduce the risk of pregnancy when two or more consecutive pills have been missed: avoiding coitus for the next seven days (18%) or using backup contraception during that period (3%). The remaining 27% were at increased risk of pregnancy. Predictors of increased risk were receiving low partner support for effective pill use, being unmarried and not considering it especially important to avoid pregnancy. Increased risk was most likely during the first seven days and during the third cycle of pill use.     

Cocaine and tobacco use and the risk of spontaneous abortion

BACKGROUND: Cigarette smoking and cocaine use may be risk factors for spontaneous abortion, but data supporting such a link are limited. METHODS: We studied the associations between cocaine and tobacco use and spontaneous abortion among pregnant adolescents and women (age range, 14 to 40 years) who sought care at an inner-city emergency department. A total of 400 adolescents and women had spontaneous abortions either at study entry or during follow-up (which lasted until 22 weeks' gestation), and 570 adolescents and women remained pregnant past 22 weeks' gestation. Cocaine use was measured at base line by self-reports and analysis of urine and hair samples. Cigarette smoking was measured by self-reports and urine analysis. RESULTS: The adolescents and women in both groups were predominantly black and of lower socioeconomic status. Among those who had spontaneous abortions, 28.9 percent used cocaine on the basis of hair analysis and 34.6 percent smoked on the basis of a urine cotinine assay, as compared with 20.5 percent and 21.8 percent, respectively, of the adolescents and women who did not have spontaneous abortions. The presence of cocaine in hair samples was independently associated with an increase in the occurrence of spontaneous abortion (odds ratio, 1.4; 95 percent confidence interval, 1.0 to 2.1) after adjustment for demographic and drug-use variables. However, the use of cocaine as measured by self-reports and by urine analysis was not. The presence of cotinine in urine was also independently associated with an increased risk of spontaneous abortion (odds ratio, 1.8; 95 percent confidence interval, 1.3 to 2.6). Twenty-four percent of the risk of spontaneous abortion could be related to cocaine or tobacco use. CONCLUSIONS: Cocaine and tobacco use were common in our study population and were associated with a significant risk of spontaneous abortion.