Contraception in the perimenopause

The perimenopause is a stage of life when a woman has low fertility but still requires contraception. It is also a peak age for menstrual dysfunction and a time when menopausal symptoms may commence. All these factors impact on contraceptive choice. Combined oral contraception can be continued until the age of 50 years in women who are low risk and do not smoke. Progestogen-only methods have advantages for women who have risk factors for cardiovascular disease. An intrauterine device may exacerbate menstrual problems at this stage but the levonorgestrel releasing intrauterine system is highly effective in controlling perimenopausal menstrual dysfunction. Women should receive accurate individualised advice on how the risks and benefits of contraceptive methods relate to them and on when contraception can be safely discontinued. Hormone replacement therapy is not reliably contraceptive and women should be advised to continue with a contraceptive method until they have reached natural sterility.     

Unwanted pregnancies: Understanding contraceptive use and benefits in adolescents and older women

The highest percentages of unintended pregnancies and the largest increases in births reported in the United States in recent years were in adolescents and in women more than 35 years of age. Increasing numbers of these women will require contraception to avoid unintended pregnancy. In adolescents the combined oral contraceptive agents protect fertility indirectly and exert favorable actions on menstrual dysfunction and certain hormone-related disorders such as acne and hirsutism. To avoid sexually transmitted disease, barrier protection should be used along with oral contraceptives until mutually monogamous, stable relationships are established. Healthy older women who are nonsmokers may also safely use currently available contraceptives. These agents have little impact on metabolic parameters linked to the development of cardiovascular disease. In addition to providing reliable contraception, oral contraceptives offer noncontraceptive benefits to older reproductive-age women, including control of abnormal bleeding and a reduction in the incidence of ovarian and endometrial cancers and other gynecologic pathology. Intrauterine devices and progestin implants are safe, effective, and underused in the United States. Progestin implants may have an additional role in patients for whom estrogen preparations are contraindicated. Counseling is very important before insertion because of the high rate of nuisance side effects. The contraception selection process must consider the efficacy and acceptability of the specific,method to avoid the probability of unintended pregnancy and the risk of sexually transmitted diseases. (Ann J OBSTEr GYNECOL 1993;168:2042-8.)     

The Levonorgestrel-Releasing Intrauterine Device: A Wider Role Than Contraception

Summary: The Levonorgestrel-releasing intrauterine device (LNG IUD) provides excellent contraception; it may reduce the rate of pelvic inflammatory disease (PID) and ectopic pregnancy compared to other 'modern' copper releasing IUDs; it can safely be used in the puerperium for breast-feeding mothers, and it significantly reduces menstrual blood loss and pain. While it was developed primarily as a contraceptive, its potential role in managing heavy and painful menstruation and the symptoms of the climacteric may eventually be just as important. Amongst developed countries New Zealand and Australia have some of the highest hysterectomy rates. By the age of 50 years 1 in 4 women in New Zealand and 1 in 5 women in Australia will have had a hysterectomy (A, B). In New Zealand 90% of these are performed for heavy menstrual bleeding and fibroids (A). The LNG IUD has been shown to be effective treatment for both these conditions and its introduction to New Zealand and Australia would offer women an additional choice beyond surgery.     

Contraceptive choices in women with coagulation disorders

When compared with older reports on the thromboembolic effects of high-dose oral contraceptives, new studies with low-dose oral contraceptives have a significantly reduced risk of thromboembolism. In the absence of risk factors such as smoking or inherited disorders predisposing to thrombosis, the modern low-dose oral contraceptive (< 50 μg of estrogen) is a safe and effective choice for contraception in women without symptoms who have family histories of sporadic thromboembolism. An intrauterine device or some form of barrier method is recommended for women who have a personal history of venous thrombus disease. The low-dose oral contraceptive may be a good choice in women taking oral anticoagulants because of the risk of teratogenic effects of anticoagulants and the risks of intraperitoneal bleeding associated with ovulation. In addition, oral contraceptives help diminish the excessive menstrual bleeding often seen in these women. (Am J Obstet Gynecol 1993;168:1990-3.)     

Implications of sampling the implantation site in the endometrial biopsy for infertility

Endometrial sampling performed during the cycle of conception occurs uncommonly. Less frequent is inclusion of the implantation site in an endometrial specimen obtained late in the luteal phase during the course of an infertility evaluation. From 1984 to 1987 the implantation site was sampled in 3 of 520 (0.6%) endometrial biopsies for infertility. In each instance the pregnancy did not continue. Two women conceived again within a year; both delivered term infants. The third woman had not conceived after ten months of follow-up. When an infertility biopsy results in a diagnosis of intrauterine pregnancy, further evaluation of the patient should be determined by the clinical situation: even in couples with extremely compromised fertility the woman occasionally will become pregnant. The prognosis for that pregnancy may be poor; however, the prognosis for subsequently conceiving and carrying a pregnancy to term is encouraging. This study demonstrated the relative safety of endometrial sampling in the infertile woman. The use of barrier contraception during the cycle of sampling can further decrease the chance of interrupting an intrauterine pregnancy.     

Intrauterine hormonelle Kontrazeption

Levonogestrel-IUS (LNG-IUS) are an innovative hormonal method of contraception. LNG-IUS have the advantages of oral contraceptives and IUD without specific disadvantages of these methods. The contraceptive safety is very high (Pearl-index =?0.16). LNG-IUS can be used in all woman, if the local uterine conditions are given. It is also possible in nulliparous woman, especially in cases of contraindications of other methods. The exclusion of genital infections is very important. A regular PAP-smear not older than 6 months is necessary. A postpartal use of LNG-IUS is possible 6 weeks after birth. LNG-IUS has no influence to lactation, so it is possible to use LNG-IUS also in the period of lactation. The risk of ectopie pregnancy is in LNG-IUS users lower in comparison to women using CU-IUD or no contraception. Bleeding disorders in the first months of LNG-IUS use occurred often, but a treatment is not necessary. In the first months of use LNG-IUS ovarian cysts occurred more often, but in the most of cases no treatment is necessary because they disappear spontaneously. After use of LNG-IUS no disadvantages for fertility are expected, LNG-IUS has also a place in specific situations because LNG-IUS has a lot of therapeutical side effects. LNG-IUS has labelling and is successfully woman suffering from heavy menstrual bleedings. Also in patients with endometriosis or adenomyosis the use of LNG-IUS has clinical advantages. Adenomyosis associated symptoms will be treated by LNG-IUS with a success rate of 70?%. In the perimenopause LNG-IUS is also a good contraceptive option because the endometrial protection effect is useful also for the prevention and treatment of endometrial hyperplasia. The introduction of low dose IUS (Jaydess^®) will extent the spectrum of intrauterine contraception. Advantages of Jaydess^® are especially the easier insertion in nulliparous women. In comparison to other contraceptive methods IUS have a lot of advantages.     

Endometrial adenocarcinoma following insertion of the levonorgestrel-releasing intrauterine system (mirena) in a 36-year-old woman

The levonorgestrel-releasing intrauterine system (LNG-IUS), commonly referred to as mirena, is an effective form of contraception, which is widely used as an intrauterine device. It has a 32-mm long-shaped plastic frame that holds a reservoir (on the vertical stem) of 52 mg of levonorgestrel mixed with polydimethylsiloxane to allow a steady release of 20 mug of levonorgestrel per day within the endometrial cavity through a rate-limiting surface membrane. Apart from contraceptive purpose, it is also now commonly used in the management of heavy menstrual blood loss. This study included a 36-year old woman who developed endometrial cancer following the insertion of the LNG-IUS. Her main presentation was irregular vaginal bleeding, which is a common finding in women using this form of contraception. Although we would advice caution in investigating such women, the LNG-IUS remains a relatively safe method of contraception.     

Postpartum contraception

Fertility and sexual activity can resume shortly after childbirth therefore the early initiation of effective postpartum contraception is important to prevent an unintended pregnancy. An inter-pregnancy interval of at least 12 months is recommended to reduce the risk of obstetric and neonatal complications. Most methods of contraception can be safely initiated immediately after childbirth, including the most effective long-acting methods such as the implant and intrauterine contraception. The antenatal period presents a unique opportunity to counsel women about the full range of contraceptive options so that the method chosen by the woman can be initiated after delivery. This reduces the need for additional postnatal visits to discuss and provide contraception, which may be difficult for mothers to attend. Maternity care providers are ideally placed to deliver a postpartum contraceptive service and should receive appropriate training to ensure knowledge and skills in this area are maintained.     

子宫内膜异位症与避孕

子宫内膜异位症（内异症）是雌激素依赖性疾病,好发于生育年龄。患有内异症伴有轻度症状,同时需要避孕的妇女,复方口服避孕药是一种较好的选择。单孕激素制剂更适用于患有内异症剖宫产后哺乳期妇女。对内异症伴有疼痛、生育后或暂时不要求生育的妇女,曼月乐宫内节育器不失为一种避孕和治疗双重作用的有效手段。     

Diabetes mellitus and fertility control: Contraception management issues

The need to prevent complications in the woman and fetus mandates that pregnancies in diabetic women always be planned and that safe and effective contraceptives be used at all times until it is determined that pregnancy is a safe and desired option. Pregnancy may aggravate complications of diabetes such as retinopathy and coronary artery disease. A pregnant diabetic woman is also more likely to experience such complications as hypertension, urinary tract infection, polyhydramnios, and cesarean section. Her fetus is at increased risk for congenital malformations, prematurity, stillbirth, neonatal morbidity, and diabetes later in life. Good diabetic control must be maintained before and throughout the pregnancy to minimize the risk of these and other complications. Until such time as good control is achieved and the woman desires pregnancy, a reliable method of contraception should be used. Most recent research supports the use of barrier methods, low-dose monophasic or triphasic oral contraceptives, or progestin-only methods, at least for the short-term. Under some circumstances the intrauterine device may be an appropriate option. Long-term data regarding the use of these methods is lacking. The decision regarding which method of contraception is used should be made by the woman in consultation with her physician. (Am J Obstet Gynecol 1993;168:2012-20.)     

Emergency contraception: What is new?

Unintended pregnancy rates remain high throughout the World and increase the risk of poor maternal and infant outcomes. Most of unintended pregnancies occur in women who were not using contraception or who became pregnant despite the reported use of contraception. Women who have had recent unprotected intercourse including those who have had another form of contraception fail are potential candidates for this intervention. Currently used emergency contraceptive methods are pills that contain combined estrogen-progesterone, only progestin, antiprogestins and copper intrauterine devices. The most common form of this type of contraception is oral progestin-only pills (levonorgestrel). The most effective method is copper intrauterine devices followed by anti-progestins and oral progestin-only pills. The major pathogenesis of oral emergency contraceptives is the prevention or delay of ovulation. Although conception is possible on only a few days of the cycle, emergency contraception is offered when indicated without regard to the timing of the menstrual cycle because of uncertainty in the timing of the ovulation. Levonorgestrel and E/P regimes are most effective as soon as possible after unprotected sexual intercourse. A linear relationship has been shown between effectiveness and the time of dose. The effectiveness continues for 120 h, but it is recommended to be used within 72 h after intercourse. Intrauterine devices may prevent pregnancy when 5 d after ovulation.     

Contraceptive needs of the perimenopausal woman

Although there are many definitions of the perimenopause, all include the concept of transition from physiologic ovulatory menstrual cycles to hyperestrogenic anovulation and ultimately to hypoestrogenic ovarian shutdown. With this comes a transition from childbearing, and its requirement for contraception, to the infertility of menopause. There is no contraceptive method that is contraindicated merely by age. The contraceptive needs of the perimenopausal woman, however, may be better suited to some methods over others. This article explores various methods of contraception for the perimenopausal woman, including female sterilization, barrier methods, intrauterine devices, injectables, implants, and oral contraceptives.     

Use of various contraceptive methods and time of conception in a community-based population

AIMS: To investigate the association between method of contraception and time to conception in a normal community-based population. DESIGN: Prospective, cross-sectional, survey. SETTING: Large comprehensive ambulatory women's health center. PATIENTS AND METHODS: One thousand pregnant women at their first prenatal obstetrics visit were asked to complete a self-report questionnaire. The return to fertility was analyzed by type of contraceptive method, duration of use, and other sociodemographic variables. RESULTS: Response rate was 80% (n=798). Mean age of the patients was 29.9+/-5 years. Seventy-five percent had used a contraceptive before trying to conceive: 80% oral contraceptives, 8% intrauterine device, and 7% barrier methods. Eighty-six percent conceived spontaneously. Contraceptive users had a significantly higher conception rate than nonusers in the first 3 months from their first attempt at pregnancy. Type of contraception was significantly correlated with time to conception. Pregnancy rates within 6 months of the first attempt was 60% for oral contraceptive users compared to 70 and 81% for the intrauterine device and barrier method groups, respectively. There was no correlation between time to conception and parity or duration of contraceptive use. Other factors found to be significantly related to time to conception were older age of both partners and higher body mass index. CONCLUSIONS: Contraception use before a planned pregnancy does not appear to affect ease of conception. Type of method used, although not duration of use, may influence the time required to conceive.     

Intrauterine contraceptive devices: a comparison between their use in indigent and private patients

Use of intrauterine contraception for an aggregate 8291 months in a group of 706 private patients (mean age 27.5 years, mean number of pregnancies 2.75, 9 nulligravidas) was analyzed and compared briefly with use in a group of 623 women from a lower socioeconomic level. Considering private patients only, 195 (27.6%) had intermenstrual bleeding after IUD insertion and 27 (3.8%) experienced an increase in the amount or duration of menstrual flow. All women had cramping after insertion of the Lippes loop (or Permaspiral in 2 patients); 43 (6.1%) expelled the device. Infection developed in 9 (1.3%), and perforation of the uterus during insertion of the loop occurred in 2 patients. The pregnancy rate for all users was 2.6 pregnancies per 100 years of use. Termination of intrauterine contraception in 216 (30.6%) was because of intermenstrual bleeding (89 women), increased menstrual flow (7), cramping (19), infection (8), spontaneous ejection (22), a sterilizing operation on either spouse (8), pregnancy when IUD inserted (2), pregnancy desired (37), and other personal reasons (6). The IUD continued to be acceptable to 535 (75.8%, including those sterilized or desiring pregnancy) of 706 upper and middle class women an aggregate of 6655 months of use. Private patients compared to clinic ones had a lower incidence of irregular bleeding (195 of 706 vs. 391 of 623), but more of them discontinued intrauterine contraception because of irregular or excessive bleeding (96 or 13.6% of private patients vs. 28 or 4.5% of clinic patients). The infection rate, total expulsion rate, and final rate for discontinuation due to expulsion were lower for private vs. clinic patients (1.3% vs. 8%, 6.1% vs. 15%, and 3% vs. 5.7%, respectively). It was found that the main advantage of the IUD, constant unburdensome protection against pregnancy, was important to both groups and that couples of any social class could effectively use intrauterine contraception. Differences in use are due to lesser dependence on the IUD among upper strata women, who can use other contraceptive methods successfully.     

Contraception in women with diabetes mellitus

Contraception in women suffering of diabetes mellitus is an important question mainly due to it has been proven that pregnancy outcome both for the fetus and for the mother depends on glycemic control before conception right to delivery. That's made planning of future pregnancy mandatory for patients with diabetes mellitus. Patients are advised for contraception until optimization of metabolic control has been achieved or until complete and contemporary treatment of the diabetes complications has been fulfilled. Incorrect contraceptive method could extend metabolic disorders and to reinforce vascular complications of the diabetes. Choice of contraception depends on the aim: short lasting contraception aiming on future pregnancy planning or long lasting contraception aiming on family planning. In women with diabetes mellitus it is extremely important to take into consideration such factors as type of the diabetes, its lasting, degree of metabolic compensation, presence of diabetic complications, body-mass index of the patient, presence of risk factors for cardiovascular diseases and future pregnancy planning. In cases when pregnancy is planning it has been preferred local contraception, such as condoms, diaphragms. In cases of nullipara or in women with plenty of partners, condoms are method of choice. In women who gave birth intrauterine device is such a method. In women with diabetes mellitus type I (insulin dependent diabetes mellitus) it is possible to use hormonal contraception depending on patient's request or on medical indications only in cases when diabetes has less than 15 years duration and microangiopathic complications and other vascular risk factors lack. Combined hormonal contraceptive preparations have to contain less than 30 microg ethinylestradiol and gestagen of "third" or "fourth" generation. This contraception has to be prescribed together with insulin dosage correction and demands on strict metabolic control of the diabetes and body weight. When the combined preparations are contraindicated it could be suggested progestagenic oral hormonal contraception if gynecologic contraindications lack and if this not leads to menstrual disturbances. In women with diabetes mellitus type II (non insulin dependent diabetes mellitus) combined hormonal contraceptives has not to be used, because they could provoke clinical manifestation and deteriorate progress of the diabetes mellitus.     

Postpartum contraception

Recently-delivered women who wish to avoid pregnancy should initiate contraception before ovulation. Since the return of ovulation is not predictable, regardless of the woman's lactation status and duration of postpartum amenorrhea, contraception should be initiated as soon as is reasonable after delivery. The choice of contraceptive method will depend on several factors, including: the woman's lactation status, the preference of the woman and her partner, and the health status of the newborns. For women who do not wish to have additional children, tubal sterilization through a minilaparotomy incision is the procedure of choice. For other women who are not lactating, all methods, with the exception of the use of cervical caps and diaphragms, may be initiated immediately after delivery. However, preference should be given to IUD use by lactating and non-lactating woman, especially for women who may not return for any additional postpartum care.     

“二日法”作为避孕措施的临床初试

目的:初步观察"二日法"在中国育龄妇女中使用的避孕效果。方法:对上海市黄浦区122对志愿使用"二日法"的育龄夫妇进行连续使用≥10个周期避孕情况的观察,随访资料用妇女年统计方法分析。结果:122例共使用1 414个妇女月。其中1例在使用的第11个月时意外妊娠;意外妊娠的Pearl指数为0.849。结论:初步观察的资料显示,"二日法"可以作为"知情选择"的避孕方法之一,但在推广前宜进一步开展扩大的临床有效性试验。     

Legal termination of a pregnancy resulting from transplanted cryopreserved ovarian tissue

Cryopreservation of ovarian tissue is a promising new technique for fertility preservation in patients facing gonadotoxic treatment. Ovarian tissue is extracted and cryo-stored at low temperature prior to treatment. If the woman becomes menopausal, the tissue can be transplanted and a few months later the woman will start to ovulate and be able to conceive, naturally or with assisted reproduction treatment. Currently, 12 healthy children have been born worldwide as a result of transplanting frozen/thawed ovarian tissue. Of these children 3 are Danish and a number of other Danish women are currently attempting to become pregnant. One of these women conceived naturally and had a normal intrauterine pregnancy following transplantation of cryopreserved ovarian tissue. However, the woman decided to terminate the pregnancy within the legal time frame. This pregnancy imposes cryopreservation of ovarian tissue for fertility preservation as a valid method and illustrates that personal life circumstances may rapidly change.     

Continuation of Contraception Following Termination of Pregnancy in a Canadian Urban Centre

ObjectiveMinimal evidence exists on the continuation of contraception following termination of pregnancy. Continuation of effective contraception is important because it has been found to reduce unintended pregnancies. This study aims to determine the rate of continuation and choice of contraception following termination of pregnancy.MethodsA cross-sectional analytic study was undertaken of 400 patients undergoing termination of pregnancy over 2 years. Demographic information and contraception choice prior to, at time of, and 6 months following termination were collected. Data were analyzed to assess relationships between patient characteristics and contraceptive choice.ResultsPrior to termination, 58.5% of patients were not using contraception and 22.4% used a less effective method (e.g., barrier or fertility awareness). Following termination, 99.7% of patients chose a method of contraception, and 95.2% chose a more effective method (e.g., long acting reversible contraception, permanent sterilization, combined hormonal contraceptives, progesterone-only contraceptive). Six months following termination, 85.8% of patients were using contraception. A more effective method was continued by 37.8%. There were no significant relationships between choice of contraception and age, previous pregnancies, or social determinants of health. Patients living with their sexual partner were significantly more likely to switch to a less effective method of contraception at 6 months.ConclusionsFollowing termination of pregnancy, almost all patients chose a method of contraception and most continued using contraception 6 months following termination.