The vaginal microbiology of women attending a family planning clinic was found to be unrelated to the use of oral contraceptives and vaginal tampons.
Beta haemolytic streptococci isolated from this `normal' population were compared with those from 1,104 women attending general practitioners complaining of vaginal discharge. There is a caution regarding the indications for antibiotic therapy.
Observations were made on the effects of contamination of vaginal swabs with yeasts and β-haemolytic streptococci from the vulva. The persistent character of the vaginal flora over a six-month period is described.
The expression of the 60-kD and 70-kD heat shock proteins (hsp60 and hsp70) in the vaginas of 43 asymptomatic women of reproductive age with or without a history of recurrent vulvovaginitis (RVV) were compared. Vaginal wash samples were obtained and assayed by enzyme-linked immunosorbent assay (ELISA) for human hsp60 and hsp70. Heat shock protein 70 was not detected in any of the 19 women with no history of RVV, and hsp60 was present in only one woman in this group. In contrast, in the RVV group, 11 (45.8%) were hsp60-positive and eight (33.3%) were hsp70-positive. The presence of either heat shock protein in the vagina was associated with an elevated vaginal pH (>4.5). Bacterial vaginosis or Candida was identified in some of the asymptomatic subjects; their occurrence was significantly higher in women with vaginal hsp70 than in women with no heat shock proteins. Oral contraceptives were used by 35.7% of subjects who were negative for vaginal heat shock proteins, as opposed to only 12.5% of women who were positive for hsp70 and 8.3% who were positive for hsp60. Expression of heat shock proteins in the vagina may indicate an altered vaginal environment and a susceptibility to vulvovaginal symptoms.
Acidform gel, an acid-buffering product that inactivates spermatozoa, may be an effective topical non-hormonal contraceptive. This study was designed to evaluate the safety of vaginal dosing and effects of Acidform on mucosal immune mediators, antimicrobial properties of genital secretions, and vaginal microbiota.
Thirty-six sexually abstinent U.S. women were randomized to apply Acidform or hydroxyethylcellulose (HEC) placebo gel twice daily for 14 consecutive days. Safety was assessed by symptoms and pelvic examination. The impact of gel on mucosal immunity was assessed by quantifying cytokines, chemokines, antimicrobial proteins and antimicrobial activity of genital secretions collected by cervicovaginal lavage (CVL) at screening, 2 hours after gel application, and on days 7, 14 and 21. Vaginal microbiota was characterized at enrollment and day 14 using species-specific quantitative PCR assays.
The median vaginal and cervical pH was significantly lower 2 hours after application of Acidform and was associated with an increase in the bactericidal activity of CVL against E. coli. However, 65% of women who received Acidform had at least one local adverse event compared with 11% who received placebo (p = 0.002). While there was no increase in inflammatory cytokines or chemokines, CVL concentrations of lactoferrin and interleukin-1 receptor antagonist (IL-1ra), an anti-inflammatory protein, were significantly lower following Acidform compared to HEC placebo gel application. There were no significant changes in Lactobacillus crispatus or Lactobacillus jensenii in either group but there was a decrease in Gardnerella vaginalis in the Acidform group (p = 0.08).
Acidform gel may augment mucosal defense as evidenced by an increase in bactericidal activity of genital secretions against E. coli and a decrease in Gardnerella vaginalis colonization. However, Acidform was associated with more irritation than placebo and lower levels of antimicrobial (lactoferrin) and anti-inflammatory (IL-1ra) proteins. These findings indicate the need for additional safety studies of this candidate non-hormonal contraceptive.
Samples of vaginal secretions of `normal' women were examined over a period of up to two years.
Patients with asymptomatic candidiasis on one occasion were more likely to have Candida albicans again when sampled a year later than were women with no yeasts on the first occasion. This principle applied also to β-haemolytic streptococci of Lancefield's groups B and D.
There was no significant difference in the incidence of C. albicans in the first and the final samples collected. The persistence and new infection rates were not significantly higher in patients taking combined oral contraceptives than in other women although the highest incidence occurred in those taking a lynoestrenol/mestranol preparation.
There was a significant association of C. albicans with β-haemolytic streptococci groups B and D.
The implication of these findings is discussed.
Positive and negative effects on bone mineral density (BMD) have been described as a result of the premenopausal use of oral contraceptives (OCs); increased fracture rates have also been reported. This study assessed the relation between OC use and BMD in a population-based, 9-centre, national sample of women aged 25–45 years.
Premenopausal women who had been enrolled in the Canadian Multicentre Osteoporosis Study were classified as having ever been OC users (≥ 3 months) or as having never been OC users (0 to < 3 months). Data were obtained through extensive questionnaires and measuring of participants' weight, height and the BMD of lumbar vertebrae and the proximal femur.
Of the sample of 524 women, whose mean age was 36.3 (standard deviation [SD] 5.9) years, 454 had used OCs; their mean age when they started using OCs was 19.8 (SD 3.5) years and the mean duration of use was 6.8 (SD 4.8) years. Women who had ever and those who had never used OCs showed no differences in age, age at menarche, parity, current calcium intake, exercise, body mass index (BMI), education, past irregular cycles or amenorrhea. OC users reported more alcohol and cigarette use and more use of medications to create regular cycles. Mean BMD values (adjusted for age, BMI and height) were 0.02–0.04 g/cm2 (that is, 2.3%–3.7%) lower in OC users, and were significantly lower in the spine and trochanter. The BMD of the spine in OC users was 1.03 (SD 0.12) g/cm2 >versus 1.07 (SD 0.12) g/cm2 >(95% confidence interval [CI] of difference –0.07 to –0.001) in those who had never used OCs. BMD was neither related to the duration of OC use nor to gynecological age at first use. Current and past users had similar BMD values.
National, population-based data show lower BMD values for the trochanter and spine in premenopausal women who have used OCs compared with those who have never used OCs.
Data on the effect of contraceptive methods, other than the condom, on HIV acquisition is not clear. The aim of this study was to describe hormonal contraceptive use, sexual behaviour and HIV prevalence among women in Cameroon in order to provide baseline information for future analytical studies.
This is a cross-sectional descriptive study based a nationally representative sample of 4486 sexually active women aged 15–49 years who participated in the 2004 Cameroon Demographic and Health Survey.
The overall HIV prevalence was 7.4% (332/4486). The HIV prevalence was higher in the 25–35 year age group (10.03%), urban residents (9.39%), and formerly married (18.48%), compared to their compatriots. The prevalence was lower in women with five or more living child (3.67%), women in the low wealth index category (3.79%) and women who had no formal education (3.37%). The HIV prevalence was higher among women who had two or more partners in the last 12 months (10.26%) and women who reported to have had four or more partners in their lifetime (12.40%). The prevalence of HIV was higher among current hormonal contraceptive users (6.63%) compared to the current non-users (3.06%), among ever users of hormonal contraception (13.27%) compared to the never users (7.11%).
We conclude that the prevalence of HIV among sexually active women in Cameroon varies according to sociodemographic characteristics, sexual behaviour and hormonal contraceptive use. Our findings underscore the need to counsel women using hormonal contraception to be aware that hormonal methods do not protect against HIV infection. Given the biologic plausibility of the link between hormonal contraception and HIV infection, future research should focus on carefully designed prospective studies to establish the temporal relationship and estimate the incidence of HIV infection among women using and not using hormonal contraceptive methods.
Removal or impairment of ovaries before menopause may affect a woman's breast cancer risk by altering her cumulative exposure to ovarian hormones. The Women's Contraceptive and Reproductive Experiences Study, a population-based, multicenter case-control study of incident invasive breast cancer, recruited women aged 35–64 years (4,490 cases and 4,611 controls) who provided data on ovariectomy, hysterectomy, and tubal sterilization during in-person interviews. Controls were frequency-matched to cases by age, race, and study site. Unconditional logistic regression analysis was used. Women who had not undergone premenopausal reproductive surgery were the referent group. Bilateral ovariectomy was associated with reduced breast cancer risk overall (odds ratio (OR) = 0.59, 95% confidence interval (CI): 0.50, 0.69) and among women <45 years of age (ORs ranged from 0.31 to 0.52), but not among those who were older at surgery. It was also associated with a reduced risk for estrogen and progesterone receptor–positive tumors (OR = 0.63, 95% CI: 0.52, 0.75) but not receptor-negative tumors. Hysterectomy with ovarian conservation (OR = 0.83, 95% CI: 0.72, 0.96) and hysterectomy with partial ovary removal (OR = 0.73, 95% CI: 0.59, 0.91) were also associated with lower risk. No association with breast cancer risk was observed with tubal sterilization only or partial ovariectomy without hysterectomy. Reproductive organ surgeries may alter ovarian hormone levels, thereby affecting breast cancer risk.
breast neoplasms; case-control studies; hysterectomy; ovariectomy; sterilization, tubal
The use of the transdermal contraceptive patch is associated with greater bioavailability of ethinyl estradiol (EE) compared with contraceptive vaginal ring or oral contraceptives (OC). We compared the influences of three contraceptive methods (OC, vaginal ring, and transdermal patch) on serum levels of coenzyme Q10, α-tocopherol, γ-tocopherol and total antioxidant capacity in premenopausal women. Blood samples from 30 premenopausal women who used hormonal contraception for at least 4 months were collected. Forty subjects who did not use any contraception were studied as control. Serum levels of coenzyme Q10, α-tocopherol and γ-tocopherol were measured by high-pressure liquid chromatography. Serum samples were also assayed for total
antioxidant capacity (TAOC). Serum levels of coenzyme Q10 and α-tocopherol were found to be significantly lower (P < .05) in all three contraceptive users compared with controls. Contraceptive patch users had the lowest levels of
coenzyme Q10 levels compared with normal subjects. Serum TAOC levels were significantly lower (P < .05) among the contraceptive user groups. Alterations in coenzyme Q10 and α-tocopherol induced by hormonal contraception and the potential effect(s) of exogenous ovarian hormones should be taken into consideration in future antioxidant research.
The study was conducted to examine the impact of oral contraceptives (OCs) on serum antimullerian hormone (AMH) levels by obesity status in reproductive-age women.
Ovulatory women, ages 18–35 years, of normal (< 25 kg/m2; n = 10) and obese (> 30 kg/m2; n = 10) body mass index (BMI) received a low-dose OC (20 mcg ethinyl estradiol/100 mcg levonorgestrel) for two cycles. Serum samples obtained at several time points during active pill use and hormone-free intervals were analyzed for AMH, FSH, LH, estradiol and inhibin B.
AMH levels did not differ by OC cycle day in either BMI group. On average, AMH levels were 34% lower in the obese group (2.9±2.1 versus 4.4±1.8ng/ml, p<0.05). Modeling to determine differences in AMH throughout the cycle based on obesity status demonstrated significiantly lower levels (p<0.05), whereras serum AMH, FSH, LH, estradiol and inhibin B levels revealed no correlations when all time points were included.
In reproductive-aged women, serum AMH levels do not appear to fluctuate during OC use but AMH levels are significantly lower in obese women. Lower levels do not appear to be due to differences in gonadotropin levels or ovarian activity.
Antimullerian hormone; oral contraceptives; obesity
The purpose of this study was to determine whether the intrauterine contraceptive device (IUD) is effective and safe among women who are infected with the human immunodeficiency virus (HIV).
We randomly assigned 599 postpartum, HIV-infected women in Zambia to receive either a copper IUD or hormonal contraception and followed them for at least 2 years.
Women who were assigned randomly to hormonal contraception were more likely to become pregnant than those who were assigned randomly to receive an IUD (rate, 4.6/100 vs 2.0/100 woman-years; hazards ratio, 2.4; 95% CI, 1.3–4.7). One woman who was assigned to the IUD experienced pelvic inflammatory disease (crude rate, 0.16/100 woman-years; 95% CI, 0.004–868); there was no pelvic inflammatory disease among those women who were assigned to hormonal contraception. Clinical disease progression (death or CD4+ lymphocyte count dropping below 200 cells/μL) was more common in women who were allocated to hormonal contraception (13.2/100 woman-years) than in women who were allocated to the IUD (8.6/100 woman-years; hazard ratio, 1.5; 95% CI, 1.04–2.1).
The IUD is effective and safe in HIV-infected women. The unexpected observation that hormonal contraception was associated with more rapid HIV disease progression requires urgent further study.
AIDS; contraception; HIV; hormonal contraception; intrauterine contraceptive device (IUD); sub-Saharan Africa
The study was conducted to determine the impact of switching from oral to transdermal patch or vaginal ring contraception on biomarkers of thrombosis.
Current healthy oral contraceptive (OC) users were randomized to switch to either a contraceptive ring (CR) or patch (CP) and underwent phlebotomy to measure surrogate biomarkers of thrombosis (sex hormone binding globulin (SHBG), free protein S, and activated protein C-resistance (APC-r)) before switching, and during the 4th cycle of use of the new method.
Of 142 reproductive age women enrolled, 120 sample pairs were available for analysis. SHBG increased significantly from baseline in CP users (mean change (95% CI) +29.9 nM (9.6, 50) but not in CR users −1.6 (−16.6, 13.5). Protein S decreased significantly from baseline in CP users (mean change −7.1% (−12.1, −2.1), but increased significantly in CR users +5.3% (1.1, 9.6). The APC-r ratio did not undergo a significant change from baseline in either group [CP +0.06 (−0.06, 0.18), CR +0.02 (−0.10, 0.14)] Compared to CR users, subjects using the CP had significantly higher SHBG (187.5 (167.0, 208), 146 (132.6,159.4), p = 0.012), significantly lower protein S (81.8 (76.8, 86.8), 93.6 (89.1, 98.1), p = 0.001), and similar APC-r ratios (2.99 (2.85,3.14), 3.09 (2.96, 3.22), p = 0.3) at the cycle 4 visit.
OC users who switch to the ring exhibit beneficial changes in biomarkers of thrombosis while those switching to the patch display a shift favoring clot formation.
Transdermal; Transvaginal; Hormonal Contraception; Thrombosis; Randomized
To assess contraceptive discontinuation, switching, factors associated with method discontinuation, and pregnancy among women initiating hormonal contraceptives.
This was a 12-month longitudinal cohort study of adolescent girls and women (n=1,387) aged 15 to 24 years attending public family planning clinics who did not desire pregnancy for at least 1 year and selected to initiate the patch, ring, depot medroxyprogesterone acetate, or pills. Participants completed follow-up assessments at 3, 6, and 12 months after baseline. Life table analysis was used to estimate survival rates for contraceptive continuation. Cox proportional hazards models were used to estimate factors associated with method discontinuation.
The continuation rate (per 100 person-years) at 12 months was low for all methods; however, it was lowest for patch and depot medroxyprogesterone acetate initiators, 10.9 and 12.1 per 100 person years, respectively (P≤.003); continuation among ring initiators was comparable to pill initiators, 29.4 and 32.7 per 100 person-years, respectively (P=.06). Discontinuation was independently associated with method initiated and younger age. The only factors associated with lower risk of discontinuation were greater intent to use the method and being in school or working. The pregnancy rate (per 100 person-years) was highest for patch and ring initiators (30.1 and 30.5) and comparable for pill and depot medroxyprogesterone acetate initiators (16.5 and 16.1; P<.001).
The patch and the ring may not be better options than the pill or depot medroxyprogesterone acetate for women at high risk for unintended pregnancy. This study highlights the need for counseling interventions to improve contraceptive continuation, education about longer-acting methods, and developing new contraceptives that women may be more likely to continue.
Intrauterine devices (IUDs) provide highly effective, long-term, safe, reversible contraception, and are the most widely used reversible contraceptive method worldwide. The levonorgestrel-releasing intrauterine system (LNG-IUS) is a T-shaped IUD with a steroid reservoir containing 52 mg of levonorgestrel that is released at an initial rate of 20 μg daily. It is highly effective, with a typical-use first year pregnancy rate of 0.1% – similar to surgical tubal occlusion. It is approved for 5 years of contraceptive use, and there is evidence that it can be effective for up to 7 years of continuous use. After removal, there is rapid return to fertility, with 1-year life-table pregnancy rates of 89 per 100 for women less than 30 years of age. Most users experience a dramatic reduction in menstrual bleeding, and about 15% to 20% of women become amenorrheic 1 year after insertion. The device’s strong local effects on the endometrium benefit women with various benign gynecological conditions such as menorrhagia, dysmenorrhea, leiomyomata, adenomyosis, and endometriosis. There is also evidence to support its role in endometrial protection during postmenopausal estrogen replacement therapy, and in the treatment of endometrial hyperplasia.
levonorgestrel intrauterine system; LNG-IUS; intrauterine device; IUD; IUS
To determine prevalence and incidence of bacterial vaginosis (BV) and risk factors in young sexually-active Australian women.
1093 women aged 16–25 years were recruited from primary-care clinics. Participants completed 3-monthly questionnaires and self-collected vaginal smears 6-monthly for 12-months. The primary endpoint was a Nugent Score = 7–10 (BV) and the secondary endpoint was a NS = 4–10 (abnormal flora [AF]). BV and AF prevalence estimates and 95% confidence intervals (95%CI) were derived, and adjusted odds ratios (AOR) calculated to explore epidemiological associations with prevalent BV and AF. Proportional-hazards regression models were used to examine factors associated with incident BV and AF.
At baseline 129 women had BV [11.8% (95%CI: 9.4–14.2)] and 188 AF (17.2%; 15.1–19.5). Prevalent BV was associated with having a recent female partner [AOR = 2.1; 1.0–4.4] and lack of tertiary-education [AOR = 1.9; 1.2–3.0]; use of an oestrogen-containing contraceptive (OCC) was associated with reduced risk [AOR = 0.6; 0.4–0.9]. Prevalent AF was associated with the same factors, and additionally with >5 male partners (MSP) in 12-months [AOR = 1.8; 1.2–2.5)], and detection of C.trachomatis or M.genitalium [AOR = 2.1; 1.0–4.5]. There were 82 cases of incident BV (9.4%;7.7–11.7/100 person-years) and 129 with incident AF (14.8%; 12.5–17.6/100 person-years). Incident BV and AF were associated with a new MSP [adjusted rate ratio (ARR) = 1.5; 1.1–2.2 and ARR = 1.5; 1.1–2.0], respectively. OCC-use was associated with reduced risk of incident AF [ARR = 0.7; 0.5–1.0].
This paper presents BV and AF prevalence and incidence estimates from a large prospective cohort of young Australian women predominantly recruited from primary-care clinics. These data support the concept that sexual activity is strongly associated with the development of BV and AF and that use of an OCC is associated with reduced risk.
Unintended pregnancy (mistimed or unwanted) remains an important health issue for women. The purpose of this study was to determine the prevalence of and factors associated with risk of unintended pregnancy in a sample of Victorian women attending family planning clinics.
This cross-sectional survey of three Family Planning Victoria Clinics from April to July 2011 recruited women aged 16-50 years with a male sexual partner in the last 3 months, and not intending to conceive. The questionnaire asked about contraceptive behaviours and important factors that influence contraception use (identified from a systematic literature review). Univariate analysis was calculated for the variables of interest for associations with contraceptive use. An overall multivariate model for being at risk for unintended pregnancy (due to inconsistent or ineffective contraceptive use or non-use) was calculated through backward elimination with statistical significance set at <0.05.
1006 surveys were analyzed with 96% of women reporting contraception use in the last 3 months. 37% of women were at risk for unintended pregnancy due to imperfect use (61% inconsistent users; 31% ineffective methods) or never using contraception (8%). On multivariate analysis, women at risk for unintended pregnancy compared with women not at risk were <25 years old (OR 1.8, 95% CI 1.2-2.7); had no university/postgraduate degree (OR 1.7, 95% CI 1.2-2.4); and had >1 partner in the last 3 months (OR 3.2, 95% CI 2.3-4.6). These women were dissatisfied with current contraception (OR 2.5, 95% 1.8-3.5); felt “vulnerable” to pregnancy (OR 2.1, 95% CI 1.6-3.0); were not confident in contraceptive knowledge (OR 2.6, 95% CI 1.5-4.8); were unable to stop to use contraception when aroused (OR 2.1, 95% CI 1.5-2.9) but were comfortable in speaking to a doctor about contraception (OR 2.3, 95% CI 1.1-4.1).
Despite reported high contraceptive usage, nearly 40% of women were at risk for unintended pregnancy primarily due to inconsistent contraceptive use and use of ineffective contraception. Strategies for improving consistency of effective contraception use or greater emphasis on long-acting contraception may be needed for certain subpopulations at higher risk for unintended pregnancy.
Contraception; Family Planning; Women’s health; Unintended pregnancy; Unplanned pregnancy
Anti-epileptic drugs (AEDs) are widely used in reproductive-age women. The AED carbamazepine (CBZ) induces the hepatic cytochrome p450 system accelerating hormone metabolism. We sought to assess the pharmacodynamic effects of CBZ on breakthrough bleeding and ovulation during OC use.
A double-blind, randomized, cross-over study of healthy women ages 18 to 35 years. Participants took an OC containing 20 mcgs ethinyl estradiol (EE) and 100 mcgs levonorgestrel (LNG) for four months. Concurrently, participants took CBZ 600 mgs or a matching placebo for two months each, administered in random order. During the second month of CBZ or placebo, we measured EE and LNG levels twelve times over 24 hours, ovarian follicular diameters with eight bi-weekly vaginal ultrasounds, weekly progesterone levels and bleeding using a diary.
We enrolled 25 women; 10 completed the study. Five discontinued due to reversible CBZ side effects. Mean area under the curve measurements were lower during CBZ use compared to placebo for EE (1778 versus 986 pg*h/ml, p<0.001) and LNG (24.8 vs. 13.8 pg*h/ml, p=0.04). Ovulation occurred in 5 of 10 CBZ cycles compared to 1 of 10 placebo cycles (p=0.06). Three or more days of breakthrough bleeding occurred during 8 of the 10 CBZ cycles compared to 2 of the 10 placebo cycles (p= 0.07).
A commonly used dose of CBZ decreased levels of contraceptive steroids, increased breakthrough bleeding and permitted ovulation during use of a low-dose OC. Women treated with CBZ are not adequately protected from pregnancy by low-dose OCs.
anti-epileptic drugs; contraception; oral contraceptives; carbamazepine
Recent data in postmenopausal women indicate that current and past use of exogenous hormones is related to urinary incontinence (UI) risk. Little is known about exogenous hormones and UI risk in younger women. We investigated the association between oral contraceptive pills (OCPs) and incident UI in premenopausal women enrolled in the Nurses' Health Study II.
Materials and Methods
Participants reported use of OCPs from 1989 to 2001. Among 21,864 premenopausal women, aged 37-54 years, reporting no UI in 2001, we identified 749 cases with incident UI at least weekly between 2001 and 2003. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using multivariable logistic regression.
Women who had ever used OCPs had statistically significant 27% (95% CI 1-59%) increased odds of developing UI at least weekly compared with women who never used OCPs. Among women with 10 or more years of use, the odds ratio increased to 1.48 (95% CI 1.13-1.95). Ever use of OCPs was specifically associated with urgency UI (OR 2.48, 95% CI 1.07-5.76) and not stress UI (OR 1.04, 95% CI 0.78-1.40). Although we had limited information on urinary tract infection, control for urinary tract infection did not alter these findings.
Use of OCPs may be associated with a modest increase in odds of UI among premenopausal women. However, this is one of the first reports of such an association and thus, further research is needed to confirm our findings and investigate possible mechanisms.
urinary incontinence; contraceptives, oral; epidemiology
Hormonal contraceptives are used widely but their effects on HIV-1 risk are unclear.
We followed 3790 heterosexual HIV-1 serodiscordant couples from seven African countries participating in two longitudinal HIV-1 incidence studies. Among hormonal contraceptive users (including injectable and oral contraceptive users) and nonusers, we compared rates of HIV-1 acquisition in women and HIV-1 transmission from women to men.
Among 1314 couples in which the HIV-1 seronegative partner was female, HIV-1 acquisition rates were 6.61 and 3.78 per 100 person-years among hormonal contraceptive users and nonusers (adjusted hazard ratio [AHR]=1.98, 95% confidence interval [CI] 1.06–3.68, p=0.03). Among 2476 couples in which the HIV-1 seronegative partner was male, HIV-1 transmission rates from women to men were 2.61 and 1.51 per 100 person-years in those whose partners currently used versus did not use hormonal contraception (AHR=1.97, 95% CI 1.12–3.45, p=0.02). In subgroup analysis, injectable contraceptive users had increased risk for acquiring and transmitting HIV-1 to their partner and HIV-1 seropositive women using injectable contraception had higher genital HIV-1 RNA concentrations, suggesting a mechanism for increased transmission risk. Oral contraceptives were used too infrequently to draw definitive conclusions about HIV-1 risk.
Women should be counseled about potentially increased risk of HIV-1 acquisition and transmission with hormonal contraception, particularly injectable methods, and about the importance of dual protection with condoms to decrease HIV-1 risk. Non-hormonal or lower-dose hormonal contraceptive methods should be considered for women with or at-risk for HIV-1.
National Institutes of Health (R03 HD068143, R01 AI083034, P30 AI027757, and T32 AI007140) and the Bill and Melinda Gates Foundation (26469 and 41185).
HIV-1; serodiscordant couples; Africa; hormonal contraception
Mood and sexual interest changes are commonly cited reasons for discontinuing hormonal contraceptives. Data, however, are inconsistent and limited to adult users. We examined associations of hormonal contraceptive use with mood and sexual interest among adolescents. We recruited 14-17 year old women primary care clinics and followed them longitudinally for up to 41 months. Participants completed face-to-face interviews quarterly and two 12 week periods of daily diary collection per year. On daily diaries, participants recorded positive mood, negative mood, and sexual interest. We classified 12 week diary periods as “stable OCP use,” “non-use,” “initiated use,” “stopped use,” and “DMPA use” based on self-report of oral contraceptive pill (OCP) use and depot medroxyprogesterone acetate (DMPA) use from medical charts. Diary periods were the unit of analysis. Participants could contribute more than one diary period. We analyzed data using linear models with a random intercept and slope across weeks in a diary period, an effect for contraceptive group, and an adjustment for age at the start of a diary period. Mean weekly positive mood was higher in diary periods characterized by stable OCP use, compared to other groups. Mean weekly negative mood was lower in diary periods characterized by stable OCP use and higher in periods characterized by DMPA use. Periods characterized by stable OCP use additionally showed less mood variation than other groups. Changes in mood among adolescent hormonal contraceptive users differed from those anticipated for adult users. Attention to adolescent-specific changes in mood and sexual interest may improve contraceptive adherence.
adolescent; oral contraceptives; sexual interest; sexual desire; mood; daily diaries; depot medroxyprogesterone acetate
OBJECTIVE: To assess the indications for usage of emergency hormonal contraception amongst a population of London genitourinary medicine clinic attenders. METHODS: In a prospective study, 150 consecutive women receiving emergency hormonal contraception (EHC) were enrolled. The attending doctor completed a questionnaire of patient details and prescribed EHC with prophylactic prochlorperazine. Follow-up was arranged three weeks later, at which time outcomes and side-effects of therapy were recorded. For those women who did not reattended as planned case notes were reviewed at three months. RESULTS: Of 150 women surveyed, 100 (66%) reported contraceptive method failure, 48 (32%) had used no contraception at the time of last sexual intercourse and two requested EHC after sexual assault. Ninety three (62%) reported condom failure, 7 (5%) oral contraceptive pill failure. Seventy five (50%) had used EHC before (range 1-10 times). Seventy one (47%) women reattended within three months. Five (3.3%) of the 150 women were pregnant; none of these cases had experienced nausea or vomiting whilst taking EHC. Side-effects were reported by 22 (31%) of the 71 patients who reattended. Nine (6%) women had been followed-up in the family planning advisory clinic. Of the 71 women who reattended, 39 (55%) reported that their preferred future method of contraception would be condoms. Of the 150 women 19 (13%) underwent tests for sexually transmissible infections within one month of presentation. CONCLUSIONS: EHC usage in this population was associated with a failure rate of at least 3.3% and an overall side effect rate of 31%. Despite requests for emergency contraception because of condom failure many elected to continue using condoms as their preferred method of contraception. The majority of women (53%) did not return for follow-up or family planning advice, and so we believe that future contraceptive plans must be addressed at the time EHC is prescribed.
To estimate whether tampon users are more likely to select the contraceptive vaginal ring than combined oral contraceptive pills (OCPs).
The Contraceptive Choice Project is a longitudinal study of 10,000 St. Louis-area women promoting the use of long-acting, reversible methods of contraception and evaluating user continuation and satisfaction for all reversible methods. We performed univariable and multivariable analyses of the 311 women who were asked about tampon use at the time of enrollment and who chose the contraceptive vaginal ring or OCPs to assess the association of tampon use and choice of combined hormonal method.
Among contraceptive vaginal ring and OCP users, 247 (79%) reported using tampons. Contraceptive vaginal ring users were not significantly different than OCP users in terms of age, race or ethnicity, marital status, insurance, BMI, and parity. Adjusted analysis indicates tampon users were more likely to choose the contraceptive vaginal ring instead of OCPs (adjusted RR=1.34; 95%CI: 1.01–1.78). Women with previous contraceptive vaginal ring experience were also more likely to choose the contraceptive vaginal ring (adjusted RR=1.96; 95%CI: 1.6–2.4). Recent OCP use did not influence method choice.
In our baseline analysis of the Contraceptive Choice Project, tampon users were more likely to choose the contraceptive vaginal ring than OCPs. Use of tampons could be considered an indicator for the initial acceptability of the contraceptive vaginal ring, but all women should be offered the contraceptive vaginal ring regardless of experience with tampon use.
OBJECTIVE--To determine if the use of the injectable contraceptive depot medroxyprogesterone (DMPA), which reduces ovarian oestrogen production, is associated with changes in bone density. DESIGN--Population study. DMPA users were compared with two control groups selected from larger population studies and individually matched for several putative determinants of bone density (age, race, body mass index, and years of oestrogen deficiency). Controls and DMPA users were matched without prior knowledge of their bone density measurements. SETTING--Teaching hospital and community family planning clinics. SUBJECTS--30 current users of DMPA with a minimum five years' previous use, 30 premenopausal controls, and 30 postmenopausal controls. MAIN OUTCOME MEASURE--Lumbar spine and femoral neck bone mineral density assessed by dual energy x ray absorptiometry. RESULTS--Compared with premenopausal controls matched for age, race, and body mass index, DMPA users had significantly reduced bone density in the lumbar spine (mean difference 7.5% (95% confidence interval 1.9% to 13.1%), p = 0.002) and in the femoral neck (6.6%, (0.8% to 12.3%), p = 0.007). Compared with postmenopausal controls matched for body mass index and duration of oestrogen deficiency, DMPA users had greater bone density in the lumbar spine (8.9% (4.3% to 13.5%), p = 0.001), but in the femoral neck the difference in bone density was less (4.0% (-0.4% to 8.5%), p = 0.04). CONCLUSIONS--Women using DMPA have bone density values intermediate between those of normal premenopausal and postmenopausal controls; thus, the degree of oestrogen deficiency induced by DMPA may have an adverse effect on bone density.
Hormonal contraceptives may adversely affect bone mineral density . However, racial differences and the reversibility of these changes are poorly understood. This study measured bone mineral density changes during hormonal contraceptive use and after discontinuation in a triethnic population.
Bone mineral density was measured every 6 months for up to 3 years in 703 white, black, and Hispanic women using oral contraceptives (OCPs), depot medroxyprogesterone acetate (DMPA), or nonhormonal contraception, and in 68 DMPA discontinuers for up to 2 additional years. Mixed-model regression analyses were used to estimate the percentage change in bone mineral density for each contraceptive method.
Over 3 years, DMPA and OCP users lost more bone mineral density than nonhormonal contraception users (−3.7% and −0.5% vs. +1.9% at lumbar spine, and −5.2% and −1.3% vs. +0.6% at femoral neck, respectively). No differences were observed by race in bone mineral density changes that resulted from DMPA or OCP use. However, DMPA users aged 16–24 years lost more bone mineral density at the spine (4.2% vs. 3.2%, P=.006) and femoral neck (6.0% vs. 4.2%, P=.001) than those aged 25–33 years. After DMPA discontinuation, women who selected nonhormonal contraception gained bone mineral density (+4.9% at spine; +3.2% at femoral neck) while those who selected OCP recovered spinal (+2.3%), but not femoral neck bone mineral density (−0.7%).
Use of very low-dose OCP may result in a small amount of bone loss. DMPA use results in greater bone loss, but this is largely reversible at the spine. Use of very low-dose OCPs after DMPA discontinuation may slow bone recovery.
This study was conducted to determine whether use of hormonal contraceptives is associated with cervical dysplasia and cancer in a population where there is widespread use of hormonal contraception and the rates of cervical cancer remain high at 27.5/100,000.
A case-control study was conducted among women visiting the colposcopy and gynaelogical clinics at a tertiary referral hospital. Two hundred and thirty six cases CIN I (72), II (59), III (54), cancer (51) and 102 controls, consented and were interviewed on use of contraceptives using a structured questionnaire. Logistic regression was used to determine odds ratios (ORs) and 95% confidence intervals (CIs) associated with use of hormonal contraception in cases and controls and in low and high risk cases. Recruitment was carried out from 2001–2002.
Contraceptives used were: oral contraceptives – 35%, injections (depot medroxy progesterone acetate (Depo-provera) – 10%, Intrauterine devices – 2%, combinations of these and tubal ligation – 30%. 23% reported use of 'other' methods, barrier contraceptives or no form of contraception. Barrier contraceptive use was not significantly different between cases and controls. Current and/or past exposure to hormonal contraceptives (HC) by use of the pill or injection, alone or in combination with other methods was significantly higher in the cases. In multivariate analysis with age and number of sexual partners as co-variates, use of hormonal contraception was associated both with disease, [OR, 1.92 (CI 1.11, 3.34; p = 0.02] and severity of the disease [OR, 2.22 (CI 1.05, 4.66) p = 0.036]. When parity and alcohol consumption were added to the model, hormonal contraception was no longer significant. The significant association with high risk disease was retained when the model was controlled for age and number of sexual partners. Depo-provera use (with age and number of sexual partners as covariates) was also associated with disease [OR, 2.43 (CI 1.39, 4.57), p = 0.006] and severity of disease [OR 2.51 (1.11, 5.64) p = 0.027]. With parity and alcohol added to this model, depo-provera use retained significance. Exposure to HC > 4 years conferred more risk for disease and severity of disease.
Hormonal contraception did confer some risk of dysplasia and women using HC should therefore be encouraged to do regular Pap smear screening.
As a preliminary to a new large cohort study of steroidal contraception, two pilot studies have been carried out. The first estimated that the prevalence of never-use of oral contraceptives among sexually active women aged 16 to 29 years was only 5.1% which means it will be impractical to recruit never-user controls for the main study. The prevalence of cigarette smoking in ever-users of oral contraceptives was 37% in contrast to never-users of whom only 20% smoked.
The second pilot study tested the acceptability of a new recruitment procedure. Two hundred and seventy doctors recruited 1574 women — 98% of these women understood and accepted the need to record their National Health Service number. The mean age of this patient cohort was 22.5 years, 65% were single and 37% were cigarette smokers. One-tenth of women had had coitus before the age of 16 years, but only 4% had started using oral contraceptives before that age.