The use of newer progestins for contraception

The synthetic progestins used for contraception so far are structurally related either to testosterone (estranes and gonanes) or to progesterone (pregnanes and 19-norpregnanes). Several new progestins have been designed to minimize side-effects related to androgenic, estrogenic or glucocorticoid receptor (GR) interactions. Dienogest (DNG) and drospirenone (DRSP) exhibit a partial antiandrogenic action, and DRSP has predominant anti-mineralocorticoid properties. The 19-norpregnanes include Nestorone (NES), nomegestrol acetate (NOMAc) and trimegestone (TMG), and possess a high specificity for binding to the progesterone receptor (PR) with no or little interaction with other steroid receptors. DRSP has been developed as combination oral pills with ethinyl estradiol (EE); DNG has been combined both with EE and, more recently, with estradiol valerate (E2V). NOMAc has been used as a progestin-only method and more recently combined with estradiol (E2). Nestorone is not active orally but proved to be the most active antiovulatory progestin when used parenterally. It has been developed in various formulations such as implants, vaginal rings or transdermal gel or spray. Risks and benefits of the new progestins depend upon the type of molecular structure, the type of estrogen associated in a combination and the route of administration.     

An economic and clinical rationale for changing utilization review practices for outpatient psychotherapy

The growth of managed care has led to greater cost consciousness in the financing and delivery of mental health and substnace abuse services. The authors examine whether pressures to reduce the costs associated with mental health and substance abuse treatment have led to the overapplication of a popular managed care strategy, utilization review (UR), to the management of outpatient psychotherpay benefits. Several arguments are presented highlighting why changing outpatient psychotherapy UR practices would be in the best economic and clinical interests of all involved parties, including payers, managed care organizatios, (MCOs), mental health consumers, and providers. A number of alternatives to the aggressive management of outpatient psychotherapy benefits are outlined and discussed. The views expressed in this article are those of the authors and do not necessarily represent the positions of their organizations.     

Vaginal contraception with gossypol: A clinical study

A clinical study concerning the vaginal contraceptive efficacy of gossypol acetic acid was performed. Fifteen women who had undergone tubal sterilization volunteered for the study. The effect of vaginal gossypol-containing gel on spermatozoa was determined by postcoital tests performed in subjects without and after using gossypol gel. After gossypol application, the number of spermatozoa found in cervical mucus was greatly decreased and, in eleven of the fifteen women, all spermatozoa seen were immobilized. In four cases a few poorly motile spermatozoa were seen but they showed no forward progression. We have previously reported that gossypol has an inhibitory effect on herpes simplex virus type 2 $\text{in vitro}$. This antiviral property of gossypol makes it particularly attractive as a topical barrier contraceptive. The present study shows that gossypol is also promising as a vaginal contraceptive agent in human $\text{in vivo}$ experiments.     

Multicenter clinical trial of implanted norethindrone pellets for long-acting contraception in women

Long-acting, biodegradable, subcutaneous implants of fused pellets composed of norethindrone (NET) and pure cholestrol were evaluated in 50 healthy, normally menstruating volunteers from five clinics. Evaluation of serum NET levels indicated a steady release rate over the 6-cycle follow-up period. There were no serious local reactions to the pellets. Menstrual cycle length remained unchanged, but the incidence of intermenstrual bleeding and/or spotting was higher during the initial 2–3 months of pellet use. Following pellet removal menstrual cycle parameters returned to their pre-pellet implantation values. Serum gonadotropin assays indicated the incidence of ovulatory cycles increased over the follow-up period. No significant changes in serum lipoproteins, SMAC-12 or enzyme profiles were observed. Although women were advised to use additional methods of contraception, three became pregnant while using the implants. Fibrous tissue was noted to form around the pellets, thus limiting the release of NET. Additional trials of higher NET doses are being evaluated.     

皮下埋植避孕剂用于临床避孕的疗效研究

目的:对皮下埋植剂避孕剂避孕的临床疗效及安全性进行研究,对其临床应用的前景进行展望。方法:对2007年4月～2008年4月在东台市计划生育指导站实行避孕术的妇女进行回顾性分析,选取98例符合标准者,观察组使用皮下埋植避孕剂进行避孕,对照组使用宫内节育器进行避孕。对两组研究对象避孕效果、术后阴道出血、月经情况、放置率、患者满意率等临床数据进行比较。结果:术后对患者随访5年,观察组有效率为97.9%,较对照组91.3%有优势。观察组出现不良反应4例,不良反应率为8.5%;对照组出现不良反应11例,不良发应率为23.9%,观察组不良反应率低于对照组(P<0.05)。观察组在放置率及患者满意率明显优于对照组。结论:皮下埋植避孕剂在临床避孕的使用中,具有避孕率高,不良发应少,放置率高等优势,受到临床医患的认可,适于推广使用。     

长效可逆避孕方法在产后避孕中的重要价值

<正>我国的非意愿妊娠人工流产率呈逐年增高趋势,而已生育妇女在人工流产总数中占到50. 3%[1]。产后是女性的特殊生理时期,多数女性认为哺乳、闭经可以起到暂时避孕的效果,部分女性因担心避孕对泌乳及胎儿生长发育造成不良影响,而忽略或停止这一时期的避孕,导致产后1年内的人工流产率较育龄期女性平均水平高。此外,产后女性恢复排卵时间因是否母乳喂养而有差异。对于不完全母乳喂养的女性,平均恢复排卵的     

Phase II clinical study of implanted norethindrone pellets for longterm contraception in women

The use of subcutaneously implanted fused pellets made of norethindrone (NET) and pure cholesterol was evaluated as a means of longterm contraception (6 months) in 81 women at three clinics. Fifty-one women used pellets containing 103 mg NET (3 pellets) and 30 women used pellets containing 138 mg NET (4 pellets). There were no serious local reactions to the pellets. There was no apparent initial NET burst effect and serum NET levels remained constant over the follow-up period. Median NET serum levels were similar (p>0.10) for women who used 3 or 4 pellets. Most menstrual cycles showed no evidence of ovulation (i.e., serum progesterone levels did not exceed 5 ng ml^-1: the proportion of women with serum progesterone levels greater than 5 ng ml^-1 was lower with the 4 pellet dose. For women who used either 3 or 4 pellets there was an increase (p<0.05) in the number of days of bleeding or spotting. There was a decrease in the incidence of dysmenorrhea (p<0.05) for both groups of women. There was a low incidence of side effects and complications. There were two pregnancies; both occurred in women using 3 pellets.

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Resumen Pelets de noretindrona (NET) y colesterol puro, implantados subcutáneamente en 81 mujeres de tres clínicas, fueron evaluados como método contraceptivo de largo plazo (6 meses). Cincuenta y una mujeres usaron pelets que contenían 103 mg NET (3 pelets) y 30 mujeres usaron pelets que contenían 138 mg NET (4 pelets). No se declararon reacciones serias locales a los pelets. No hubo incremento inicial agudo de NET y los niveles de NET en suero permanecieron constantes durante el período de seguimiento. Los niveles medios de NET en suero fueron similares (p>0,10) en las mujeres que usaron 3 o 4 pelets. La mayoría de los ciclos menstruales fueron anovulatorios y hubo tendencia hacia una tasa mayor de ciclos anovulatorios con la dosis de 4 pelets. En las mujeres que usaron sea 3 o 4 pelets hubo un aumento (p<0,05) en el número de días de sangrado o manchado. La incidencia de dismenorrea (p<0,05) disminuyó en ambos grupos de mujeres. Se produjeron dos embarazos en mujeres que usaron tres pelets. Hubo baja incidencia de efectos colaterales y de complicaciones.

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Resumé On a apprécié comme moyen de contraception à long terme (6 mois) dans trois cliniques chez 81 femmes les pellets mixtes implantés en sous-cutané constitués de noréthindrone (NET) et de cholestérol pur. Dans 51 cas, les femmes ont utilisé des pellets contenant 103 mg de NET (trois pellets) et dans 30 cas des pellets contenat 138 mg de NET (quatre pellets). On n'a pas constaté de réactions locales nettes aux pellets ni d'action initiale d'inondation de NET et les taux sériques de NET sont demeurés constants pendant toute la période de surveillance. Ceux-ci ont été analogues en moyenne (p>0,10) chez les femmes ayant utilisé trois pellets et chez celles qui en utilisèrent quatre. La plupart des cycles menstruels ne comportaient pas de signes d'ovulation et les taux sériques de progestérone n'ont pas dépassé 5 ng/ml. Ce phénomène s'accompagne plus souvent de l'utilisation de quatre pellets. Chez les femmes ayant utilisé trois ou quatre pellets on a noté une augmentation (p<0,05) du nombre de jours de saignement ou de suintement. On a relevé dans les deux groupes de femmes une diminution de l'incidence de la dysménorrhée (p<0,05). Le fréquence des effets secondaires et des complications a été faible. On a assisté à deux grossesses, toutes deux chez des femmes ayant utilisé trois pellets.

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The following individuals and institutions were involved in the study: M. Singh and B. B. Saxena, Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, The New York Hospital-Cornell Medical Center, New York, NY; R. H. Asch, Department of Obstetrics and Gynecology, The University of Texas Health Science Center, San Antonio, TX; R. Rivera, Instituto de Investigacion Cientifica, Universidad Juarez del Estado de Durango, Durango, Mexico; and A. Goldsmith, Program for Applied Research on Fertility Regulation, Northwestern University Medical School, Chicago, IL.     

Routine counseling about intrauterine contraception for women seeking emergency contraception

Objective

To compare contraceptive knowledge and use among women seeking emergency contraception (EC) before and after an inner-city clinic began providing structured counseling and offering same-day intrauterine device (IUD) or implant placement to all women seeking EC.

Study design

For 8 months before and 21 months after this change in clinic policy, women aged 15–45 who wanted to avoid pregnancy for at least 6 months were asked to complete surveys immediately, 3 and 12 months after their clinic visit. In addition, we abstracted electronic medical record (EMR) data on all women who sought EC (n= 328) during this period. We used chi-squared tests to assess pre/post differences in survey and EMR data.

Results

Surveys were completed by 186 women. After the clinic began offering structured counseling, more women had accurate knowledge of the effectiveness of IUDs, immediately and 3 months after their clinic visit. In addition, more women initiated IUD or implant use (survey: 40% vs. 17% preintervention, p=0.04; EMR: 22% vs. 10% preintervention, p=0.01), and fewer had no contraceptive use (survey: 3% vs. 17% preintervention, p<0.01; EMR: 32% vs. 68%, p<0.01) in the 3 months after seeking EC. EMR data indicate that when same-day placement was offered, 11.0% of women received a same-day IUD. Of those who received a same-day IUD, 88% (23/26) reported IUD use at 3-months and 80% (12/15) at 12 months.

Conclusions

Routine provision of structured counseling with the offer of same-day IUD placement increases knowledge and use of IUDs 3 months after women seek EC.

Implications

Women seeking EC from family planning clinics should be offered counseling about highly effective reversible contraceptives with the option of same-day contraceptive placement.     

产后避孕时机的把握

<正>产后避孕可以降低非意愿妊娠和短间隔妊娠(妊娠距前次分娩的时间短于18个月)的发生率~[1],也可以减少今后妊娠时早产的发生率~[2]。(非母乳喂养的女性通常在恢复月经前排卵,平均排卵日为产后39 d~[3]。全母乳喂养的女性通常在首次月经后排卵。母乳喂养女性恢复排卵时间与哺乳频率有关,产后6个月内、进行全母乳喂养并且闭经的女性,有可能不排卵~[4]。有研究显示,在全母乳喂养的闭经女性中,1%～5%在产后6个     

The future of intrauterine contraception

In this review paper some guidelines for IUD use are presented that if followed should reduce the incidence of IUD-related complications. Recent IUD developments are discussed including the levonorgestrel-releasing T, a new variation of the Multiload, and IUDs designed for postpartum insertion. Since significant improvements in IUD safety will most likely result from a better understanding of IUD-related side-effects and adverse reactions, the paper includes recommendations for future IUD research that could enhance the safety, effectiveness and acceptability of available IUDs.

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Resumen En esta revisión presentamos una serie de directrices que si se siguiesen reducirían significativamente la incidencia de las complicaciones referidas al uso del DIU. Actualmente se evestionan los recientes descubrimientos en torno al DIU, incluido el Levonorgestrel-T, una nueva variación del Multiload y DIUs indicados para la inserción postparto. Desde que se efectuaron importantes modificaciones en su utilización, hemos observado un incremento de su inocuidad y un descenso de los efectos indeseables, gracias principalmente a una utilización más oportuna. Ademas nos ha permitido comprener mejor los efectos colaterales relacionados con su uso. Incluimos tambien recomendaciones, para futuros trabajos, que pueden cambiar las directrices seguidas hasta ahora, mejorando la seguridad, efectividad y aceptabilidad de los DIUs.

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Résumé Dans cette communication d'ensemble sont présentés des conseils généraux relatifs à l'utilisation des DIU, qui devraient permettre, s'ils sont suivis, de réduire l'incidence des complications que ces dispositifs peuvent entraîner. Y sont examinés de récents progrès réalisés sur les DIU, et notamment sur le modèle T libérant du lévonorgestrel qui est une variante du modèle Multiload et des dispositifs conçus pour leur insertion après l'accouchement. Etant donné que toutes les améliorations importantes qui seront apportées du point de vue de la sécurité des DIU résulteront probablement d'une meilleure compréhension des effets secondaires et des réactions adverses imputables aux DIU, cette communications inclut des recommandations pour les recherches à venir, qui pourraient rehausser la sécurité, l'efficacité et l'acceptabilité des dispositifs actuellement sur le marché.