The progestogen-only pill

This commentary reviews the indications for and side effects of the progestogen-only oral contraceptive (OC) pill, which accounts for under 3% of hormonal contraceptive sales in the UK. The progestogen-only pill has the advantage of fewer metabolic changes, a lower dose of progestogen, and avoidance of the use of estrogen. It is the hormonal method of choice for breast feeding women, older women, and women who are unable to tolerate an estrogen-containing preparation. Its failure rate ranges from 0.9 to 3.0/100 woman-years, which is comparable to that for other reversible methods. The failure rate tends to be lower in older age groups, perhaps reflecting advancing sensitivity with age to the contraceptive effects of progestogen. The major problem associated with use of progestogen-only contraceptives is irregular vaginal bleeding, experienced by 20-30% of users. Progestogen has been reported to induce a variety of effects on the endometrium as well as in ovarian steroid secretion. A high prevalence of functional ovarian cysts has been noted in users. It is now believed that the contraceptive efficacy of the progestogen-only pill depends more upon its effects on ovarian function than was previously realized. A new approach to overcoming some of the problems associated with progestogen-only contraception has involved combining progestogen with sulpiride. This combination appears to be more effective than either component alone in suppressing ovarian activity. There is a need to make progestogen-only OCs more widely available to women in developing countries, where 30-40% of women of reproductive age may be breast feeding at a given time. Numerous studies have demonstrated either no effect or a beneficial effect on lactation.     

Globulines anormalment precipitables (GAP) in Nigerian users of progestogen-only pill

The globulines anormalment precipitables (GAP), which have been reported to be raised in current and former oral contraceptive users, were measured in Nigerian subjects which included male volunteers. The results showed that GAP were present in males who had never used contraceptives and that the mean values were lowest in intrauterine contraceptive device (IUD) users and highest in females who had never used any contraceptives. However, current contraceptive users had lower mean GAP values than either former users or never users. It was therefore concluded that GAP levels alone cannot be used to predict the development of thromboembolic complications in pill users, and that ethinyl estradiol cannot be the main physiological stimulus for GAP synthesis.     

Comparative study of the effects of a progestogen-only pill containing desogestrel and an intrauterine contraceptive device in lactating women

Objective To evaluate the effects of desogestrel 75μg/day, as a progestogen-only pill compared with a copper-bearing intrauterine contraceptive device (IUCD) on lactation and to study the safety of both treatments in mothers and children. Transfer of etonogestrel to breast milk was studied in a subgroup of desogestrel users. The children were to be followed up until 2.5 years of age.
Design An open, non-randomised, group-comparative study in lactating women.
Setting University Hospital, Reykjavik, Iceland.
Participants A total of 83 lactating women; 42 received desogestrel and 41 had an IUCD inserted for seven consecutive treatment cycles of 28 days.
Methods Evaluation visits were planned at baseline and at the end of treatment cycles 1, 4 and 7. The amount of breast milk was determined by weighing the infants before and after feeding, at baseline and after treatment cycles 1 and 4. Milk samples were obtained at the same time for constituent measurements. Safety was studied by structured medical examinations and by recording adverse experiences in mothers and children.
Results There were no significant differences between the desogestrel and IUCD groups in composition and quantity of breast milk nor in growth and development of the children followed up to the age of 2.5 years. In the desogestrel group a slightly higher incidence of mild adverse experiences of a hormonal nature was reported among both mothers and infants. Of the children 82% were followed until 1.5 years of age and 50% until 2.5 years.
Conclusion The use of desogestrel 75μg/day did not change the amount and composition of breast milk nor did it affect growth and development of the breastfed children. It appears to be a safe and effective contraceptive method for lactating women     

A quantitative study of the pregnancy zone protein in sera of woman taking oral contraceptives.

By means of a single radial immunodiffusion the concentration of "the pregnancy zone protein" (PZ) was measured in sera from women taking oral contraceptive drugs. Woman taking only 0.3 mg. of norethisterone were found not to induce measurable amounts of PZ, whereas women taking combined contraceptive drugs showed a significant rise in concentration of PZ. After six months' treatment, 1 mg. of norethisterone and 0.1 mg. of meastranol daily were found to give an average concentration of PZ amounting to 59 mg. per 100 ml., that is, approximately half of the concentration of PZ in sera from women during the last trimester of pregnancy. Different combined contraceptive pills gave rise to different concentrations of PZ.     

Anovular corpus luteum in a woman taking an oral contraceptive

When laparatomy was performed on 3 women treated with a combination-type oral contraceptive (5 mg lynestrenol, 150 MCG mestranol), an anovular corpus luteum was found in 1 ovary. Dating from the start of oral therapy, the times of the operations were Day 24, Cycle 1; Day 24, Cycle 2; and Day 23, Cycle 3 (anovular corpus luteum). The anovular corpus luteum was 6.5 mm long and 3.0 mm wide and had undergone considerable regression, about 3/4 of it having been converted into an avascular hyalinized mass. An unejected ovum, contour slightly altered and size approximately equal to that of ova in ovulation-ripe Graafian follicles, was situated in the center of the hyaline mass. The unejected ovum was the first one to be observed in a completely developed corpus luteum. The membrane pellucida was wider than usual, but the nucleus, nucleolus, and corona radiata cells surrounding the ovum had undergone little change. Hormone administration may have favorably influenced conditions of metabolism within the hyaline mass. Alterations in the anovular corpus luteum were compared with those found in the second treatment cycle in a corpus luteum formed during the first treatment cycle. The anovular corpus luteum was concluded to be the regressing corpus luteum of the first treatment cycle and approximately 65 days old.     

Interstitial pregnancy in a woman with congenital afibrinogenemia

Without fibrinogen replacement, pregnancies in patients with congenital afibrinogenemia end in miscarriage between 6 and 8 weeks of gestation. Studies in animal models suggest that disturbance of the embryo's decidual attachment contributes to miscarriage in afibrinogenemia. Ectopic pregnancy in human congenital afibrinogenemia has not been previously documented. We present a case of right interstitial pregnancy in a woman with congenital afibrinogenemia, who had not received the recommended fibrinogen replacement for the first 6 weeks of pregnancy. The pregnancy followed a right salpingo-oophorectomy for ovarian hemorrhage. Therefore the embryo most likely entered the uterine cavity via the left tube only to move upstream into the lumen of the interstitial portion of the right tube. Our experience suggests that disturbance of the embryo's decidual attachment may have contributed to the development of an ectopic pregnancy. Therefore, fibrinogen replacement early in the first trimester is of utmost importance.     

Acute abdomen due to endometriosis in a premenopausal woman taking tamoxifen

Tamoxifen exhibits agonistic properties on the uterus. We describe a premenopausal woman who, while having tamoxifen due to a diagnosis of in situ ductal carcinoma, developed endometriosis requiring surgery.     

Spontaneous twin cervico-isthmic pregnancy in a grand multiparous woman

Cervico-isthmic pregnancy is a rare form of ectopic pregnancy and is defined as the implantation of a fertilized ovum in the cervico-isthmic portion. The cause is unknown; local pathology related to previous cervical or uterine surgery may play a role, given an apparent association with a prior history of curettage or cesarean delivery. Transvaginal ultrasonography and β-human chorionic gonadotrophin assays are useful for diagnosis. Here we report a case of spontaneous twin cervico-isthmic pregnancy in a grand multiparous patient who was diagnosed early in the first trimester with transvaginal ultrasonography. The pregnancy was terminated successfully with methotrexate. Methotrexate seems to be most successful at early gestational ages.     

Ongoing pregnancy in a woman who inadvertently underwent office hysteroscopy during early pregnancy

OBJECTIVE: To report a case of ongoing pregnancy in a woman who underwent hysteroscopy during the implantation phase. DESIGN: Case report. SETTING: A university hospital. PATIENT(S): A 34-year-old woman with unexplained infertility who was scheduled for IVF. INTERVENTION(S): Office hysteroscopy. MAIN OUTCOME MEASURE(S): Hysteroscopy during early pregnancy. RESULT(S): An ongoing pregnancy after hysteroscopy during the implantation phase. CONCLUSION(S): The risk of a properly performed hysteroscopy in the implantation phase of an unrecognized pregnancy may be less than expected.     

Omental trophoblastic implants after surgical management of ectopic pregnancy

Peritoneal implants secondary to a tubal ectopic pregnancy or extratubal omental secondary trophoblastic implants (ESTI) are a rare entity often underestimated or unknown. It can be responsible of rising in the ?-hCG titer after salpingectomy for ectopic tubal pregnancy. Moreover, implants on the omentum are exceptional. This particular localization is exceptional and its physiopathology, diagnosis, surgical management and follow-up are discussed in this paper.     

Successful pregnancy in a neurologically impaired woman with Wilson's disease

Patients with treated Wilson's disease and no residual impairments should have successful pregnancies. We report a case of a neurologically impaired patient with Wilson's disease who had a successful pregnancy with no complications. This is the first case to document that compliance with penicillamine therapy as low as 500 mg/day avoids placental and fetal copper accumulation. (Am J Obstet Gynecol 1997;176:712-4.)     

Ectopic pregnancy associated with tubal schistosomiasis in a Nigerian woman

A case of ruptured tubal ectopic pregnancy is presented. On histological examination of the fallopian tube involved, ova of Schistosoma haematobium were found in the submucosal and intramural parts of the tube. The case illustrates a rare preventable cause of ectopic pregnancy in this population.