Concerns in the USA about IUDs -- IMAP's comments

This statement sets forth the views of the International Planned Parenthood Federation's (IPPF) International Medical Advisory Panel (IMAP) on the safety of IUD use. There has been concern about the recent withdrawal from the US market by Ortho Pharmaceuticals and GD Searle & Co. of 3 widely used IUDs: Lippes Loop, Copper 7, and Copper T200. It is noted that these actions were taken for commercial reasons related to profitability and/or liability insurance concerns, and not for medical or scientific reasons. The 3 IUDs that were withdrawn from the USmarket continue to be approved for contraceptive use by the US Food and Drug Administration. After extensive review of available data, IMAP at its London meeting in February 1986, reaffirmed its earlier position on the IUD, supporting it as a safe and effective method of contraception. Although concern has been expressed about potential increases in the risks of pelvic inflammatory disease and tubal infertility as a result of IUD use, recent research suggests that women who use copper-bearing devices, particularly married women in primarily monogamous relationships, are a relatively low risk. On the other hand, women with multiple partners, especially nulliparous women, who are already at risk of sexually transmitted diseases, are not good candidates for IUD use. IPPF will continue to provide IUDs upon request to its member associations.     

The Dalkon Shield IUD

The Dalkon Shield IUD was introduced to the list of contraceptives being distributed to developing countries by IPPF (International Planned Parenthood Federation) in 1973. By 1974, doubts had arisen about the safety of the Dalkon Shield and several cases of maternal mortality and sepsis in Dalkon Shield users had been reported. In 1974, IPPF stopped supplying Dalkon Shields to its affiliates. During the 1973-74 period of distribution, IPPF had distributed approximately 300,000 of the Shields in 41 countries. Almost 1/2 that amount had already been inserted. The position of IPPF's IMAP (International Medical Advisory Panel) on any relationship existing between use of IUDs and pelvic inflammatory disease is as follows as of 1980: 1) infection with actinomycosis makes up only a small component of all the incidents of pelvic inflammatory disease connected with IUDs; 2) the occurrence of pelvic inflammatory disease is not related to the length of use of an IUD; 3) data do not now support the recommendation that inert devices free from major side effects should be removed; and 4) any woman still wearing a Dalkon Shield should have it removed.     

Commentary: methods women can use that may prevent sexually transmitted disease, including HIV.

Although sexually transmitted diseases, including human immunodeficiency virus (HIV), are a major concern for women, few prevention messages are targeted specifically to women. Those that are generally stress abstaining, altering the number or selection of partners, and urging partners to use condoms. But these behaviors may be unrealistic for many women, particularly women who are at highest risk for sexually transmitted diseases, because they require significant changes in life-style or depend on male-controlled condom use. Recommendation of contraceptives for prevention of sexually transmitted diseases depends largely on how well specific methods perform under controlled conditions, either in the laboratory or in clinical trials. Observational studies, which better reflect day-to-day use, indicate that condoms, barriers, and spermicides, used properly and consistently, can provide substantial protection against various sexually transmitted diseases. Condoms can similarly help protect against HIV, but studies of barriers and spermicides are scant and currently inconclusive. Finally, those methods that are controlled by women are consistently more effective in preventing sexually transmitted diseases. Thus, although condoms used well are still the best choice, the imperative for female-controlled methods indicates that diaphragms and spermicides should receive greater emphasis in prevention messages.     

Contraception and STDs

Since behavioral research indicates that assumption of less risky sexual practices is unlikely, prevention of sexually transmitted diseases (STDs) by alteration in contraceptive practice is more realistic. Condoms, known from laboratory tests to be impermeable to semen, body fluids, and all STD organisms except hepatitis B fragments, only reduce transmission of most STD infections by 50% in actual use. Those who use condoms more consistently achieve better protection, while condom failure due to breakage is concentrated among some users. Spermicides, including nonoxynol-0, benzalkonium chloride, menfegol, and octoxynol, act as lipid solvent, killing sperm and all STD agents. Most studies suggest about a 50% reduction in transmission, with perhaps a 33 less transmission of chlamydia. There is one report of possible enhancement of transmission of HIV by use of spermicides, among prostitutes in Africa. Neither condoms nor spermicides protect against extragenital transmission, especially for organisms transmitted by skin contact, i.e., syphilis, herpes, or chancroid. Oral contraceptives provide clear protection, about 50%, against pelvic inflammatory disease (PID), while they may facilitate cervical ectopy, and associated cervical chlamydia and gonorrhea. IUDs, once believed to heighten the risk of PID, now are considered increase this risk only a few days or months after insertion. Such insertion-related infection can be controlled with a single dose of a broad-spectrum antibiotic. Unfortunately those methods which are most effective in preventing pregnancy, pill and IUDs, are not particularly useful in preventing STDs, as are the less effective barriers and spermicides.     

Modern intra-uterine contraception: a better option

Users of oral contraceptives have an increased risk of developing venous thromboembolism as well as mammary cancer. This raises the question as to whether locally applied (intrauterine) contraceptives can offer a valuable alternative with respect to efficiency and safety. During the past decade the use of modern intrauterine devices (IUDs) has made substantial progress in comparison with the use of IUDs during the 1970s and 1980s. Modern IUDs have become more efficient than oral contraception. Arguments against the use of IUDs (problems and complications in IUD insertion, the risk of pelvic inflammatory disease, ectopic pregnancy and infertility as well as side effects such as menorrhagia, pelvic cramps and IUD expulsion) generally appear to be based on a lack of awareness with respect to recent developments and on misunderstandings derived from bad experiences during the 1980s and earlier.     

性传播疾病的预防与健康教育和健康促进

目的探讨通过健康教育和健康促进预防性传播疾病。方法本着防治结合原则,强化政府职能作用,疾控部门积极运作,发挥社区卫生服务优势,加强心理与道德的教育等几个方面做好健康教育和健康促进工作。结果健康教育和健康促进对性传播疾病非常重要。结论通过健康教育和健康促进性传播疾病是可以得到控制的。     

Gender differences in knowledge, intentions, and behaviors concerning pregnancy and sexually transmitted disease prevention among adolescents.

Gender differences in knowledge, intentions, and behaviors regarding preventing pregnancies and sexually transmitted diseases were studied. Data for the study were collected from 1,033 students in 13 California high schools. Females in this sample were more likely than males to have discussed sexuality topics with parents, to have engaged in sexual intercourse more frequently, to have experienced a pregnancy scare, to have used oral contraceptives during their last sexual encounter, to perceive that a larger proportion of their peers were engaging in sex and using birth control, to obtain birth control from health facilities, and to report intentions to abstain or use protection in hypothetical situations placing them at risk for unprotected sex. In contrast, males reported that they were more likely to have always used birth control, to have used birth control during their first sexual encounter, and to have used a condom during their last sexual encounter. Furthermore, males were more likely to obtain birth control from a store or a friend. Finally, males knew more about using condoms correctly and their role in preventing sexually transmitted diseases. The efficacy of interventions designed to reduce unintended pregnancy and sexually transmitted diseases among adolescents may be increased by addressing these gender differences. Understanding gender differences may also facilitate an increased role for males in the overall prevention scheme. Further research is clearly needed to increase knowledge about these gender differences.     

The intrauterine device and its dynamics

In the past decade, attention has shifted from family planning (often made available through population programs) to reproductive health – a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters related to the reproductive system and its function and processes.Reproductive health has three components: the ability to procreate, regulate fertility and enjoy sex; the successful outcome of pregnancy through infant and child survival and growth; and the safety of the reproductive process.According to Mitchell et al., the following are key elements in a reproductive health program:(a) Family planning services that offer complete and accurate information about all contraceptive methods and that make contraceptive services, supplies and counseling accessible.(b) Antenatal care, which research suggests lowers rates of maternal mortality.(c) Safe delivery services, so that all women deliver under some type of supervised care and so that referral systems are established to provide emergency treatment of life-threatening complications of delivery.(d) Postnatal care that contributes to a woman's ability to have a speedy and complete recovery from the stress of pregnancy and childbirth, to enjoy sexual relations without pain and to have safe pregnancies and deliveries in the future.(e) Management of the complications of abortion where safe abortions are not available.(f) Infertility services that enable women to achieve their reproductive goals; and effective screening for or control of reproductive tract infections (RTIs), because RTIs are the most common preventable cause of involuntary infertility and ectopic pregnancy, as well as of chronic pelvic pain and recurrent infection.(g) Management and treatment of systemic sexually transmitted diseases (STDs), such as HIV and hepatitis B.(h) Symptomatic treatment of urinary tract infections.(i) Detection and treatment of breast and reproductive tract cancers, such as cervical cancer.(j) Attention to and treatment of dysmenorhea, which in some cases is the first sign of other problems, such as pelvic inflammatory disease, endometriosis, fibroids, endometrial cancer and ectopic pregnancy.(k) Nutritional supplementation to meet the special needs of adolescents, pregnant or lactating women, and women older than 50 years.(l) Services for menopause and other health problems that women encounter as they grow older.(m) Services for adolescents, including family planning and STD prevention and treatment.It shall be clear that many institutions delivering reproductive health services operate significantly below their physical capacity to see clients, and that much of the equipment required for expanding reproductive health services may already be available for use in family planning and other health services. In this context, we would therefore like to discuss the dynamics of IUDs.     

生殖器支原体在HIV高危人群中的流行进展

生殖器支原体(Mg)是性传播疾病的病原之一,可引起男性非淋球菌性尿道炎、女性宫颈炎、子宫内膜炎及盆腔炎.近年来发现泌尿生殖道Mg感染在HIV阳性及高危人群中的流行呈上升趋势,并且Mg感染可能促进HIV的感染与传播,提示应对HIV高危人群的Mg感染给予充分的重视.此文就Mg在HIV阳性及高危人群中的流行情况及治疗的研究进展进行了综述.     

Interdisciplinary Andrology Stds Aids Research

Multidisciplinary andrology deals with clinical application and modern technology for the evaluation and differential diagnosis of male infertility with emphasis on morphological, anatomical, biochemical, immunological, hereditary, and microbiological parameters. Little is known about the effects of diet, disease, stress, environmental, and drugs on male-related unexplained infertility of couples. Regional, national, and international centers of multidisciplinary andrology should provide (1) extensive and unique clinical services; (2) a computerized “patient referral center,” (3) self-learning packages (slides/ tape programs) for patients; and (4) a computer link to the National Library of Medicine and the Drug Information Center. Specialized laboratories and clinics can be served by expert consultants, visiting professors, bilingual and well-trained clinicians, nurses, laboratory technologists, computer operators, and related allied health personnel. Patient education pamphlets, updated every fews years, can be distributed during training workshops when an extensive network of remote teleprinters can be utilized. Qualified client location may install a printer to allow on-site printing of reports in the shortest possible time. Special mailing containers are provided to clients who wish to mail their laboratory specimens. Other clinical services may include the following:

1. Central source of communication and information in andrology

2. International roster of multidisciplinary andrology centers

3. Patient referral to centers and consultations for developing countries

4. Screening of husbands and wives for in vitro fertilization/embryo transfer (IVF/ET)

5. Screening of couples with unexplained infertility for sexually transmitted diseases (STDs) including AIDS

6. Exchange of research material and methodology

7. Coordination of multicenter research

8. Organizing training workshops for clinicians, nurses, and laboratory technicians

9. Establishing a repository of films, video tapes, slides, catalogs, instrumentation, books, SEM photos, and atlases

10. Publication and editorial assistance

11. Consultation for the appropriate selection, purchase, and quality control of instrumentation (all on one computer system)

12. Evaluation of new diagnostic tools for idiopathic infertility and fertility regulation

13. Laboratory manuals may include the following technical details: (a) commercially available kits for semen analysis evaluation of structure, ultrastructure, motility patterns, capacitation, and fertilizability of spermatozoa; (b) simplified kits for tissue culture media—RIA evaluation of steroids, gonadotropins, and other endocrine profile and differential diagnosis of sexually transmitted diseases including AIDS; (c) CO²/0² incubators; (d) disposable glassware; (e) water ultrafiltration systems, microporous membrane filtration, deionization, deionization reverse, osmosis, air filtration (laminar flow); (f) microscopy stereoscopy, cinematography, invertoscopy, epifluorescence, and fiber optics.     

Support for school-based reproductive health services among South Carolina voters

In 1997 a statewide random digit-dialed telephone survey of 534 South Carolina registered voters was conducted to determine level of support for school-based reproductive health services. Results indicated most voters supported services in secondary schools that would provide students with information and counseling about contraceptive methods and refer students to community-based agencies for abstinence education and counseling. Voters were less supportive of reproductive health services that would diagnose or treat sexually transmitted diseases, test for pregnancy, refer students to community-based agencies for contraceptives, or make contraceptives available to students at school. Significant associations in support for school-based reproductive health services were reported based on income, personal beliefs, intentions, and outcome expectations regarding sexuality education and contraceptive availability. These data reinforce the need for school-aged youth in South Carolina to have access to reproductive health services within their communities, outside of the school setting.     

黏液脓性宫颈炎的研究进展

黏液脓性宫颈炎与性传播疾病密切相关。淋球菌和沙眼衣原体是黏液脓性宫颈炎最常见的病原体;生殖道支原体,主要是生殖支原体、细菌性阴道病相关病原体、单纯疱疹病毒、阴道毛滴虫等与黏液脓性宫颈炎相关。黏液脓性宫颈炎可以导致盆腔炎、异位妊娠、不孕等并发症或后遗症,还可以增加机体对人免疫缺陷病毒感染的敏感性,增加分泌物中人免疫缺陷病毒的排毒量,从而促进人免疫缺陷病毒的传播。     

2008年宁波市性传播疾病疫情分析与防制对策

目的掌握宁波市性传播疾病流行病学特征,为更好地制定有效防制措施提供科学依据。方法对宁波市各医疗和网络直报单位上报的2008年性病疫情资料汇总分析并提出防治对策。结果2008年性传播疾病年发病率为215.60/10万。男女之比为1∶0.98,患者来源绝大多数为宁波市本地户籍(90.16%),年龄主要集中在20～39岁(67.51%)。职业以工人、农民和家务及待业为主(68.26%)。5种性病中梅毒较2007年增长41.27%。结论宁波市性传播疾病年发病率平稳下降,但梅毒呈显著上升趋势,排在性病的首位。应进一步加强大众的健康教育,重点开展针对青年和目标人群的性病防制工作,大力提倡安全性行为。     

Statement on steroidal oral contraception

This report summarizes a meeting of the IPPF International Medical Advisory Panel (IMAP) held in November, 1986, at which information on steroidal oral contraception (OC), Acquired Immunodeficiency Syndrome (AIDS), and female sterility were discussed. Regarding the multiphasic OC now in use, the benefits to health and well-being outweigh the possible side-effects and infrequent complications. Use is associated with a lower incidence of pelvic inflammatory disease, 96-98% effective prevention of pregnancy, a protective effect against ovarian and endometrial cancer, and regulation of erratic menstrual cycles. Minor side effects include nausea, vomiting, dizziness, headache, fluid retention, and inter-menstrual spotting. Adverse effects are circulatory system disease, myocardial infarction, venous thromboembolism, elevated blood pressure, and liver disease. Data on possible carcinogenicity have been conflicting. For women over age 40 OCs should be prescribed with caution. IMAP also drew up recommendations to assist FPAs to play a more active role in controlling the spread of AIDS. An effective program of Information and Education is of primary importance, targeting family planning workers and clients, teachers, parents, and employers. Wide promotion of condom use is a priority. Studies in Africa have revealed a major epidemic of AIDS, with the major mode of transmission heterosexual. The only immediate practical step in prevention of spread is by changes in sexual behavior. The last topic discussed is that of sterility in African women. The naturally occurring level of infertility expected in all populations of women is 3%; high levels in Africa vary by region from 3-32%. These levels of sterility are acquired through infection with Neisseria gonorrheae and Chlamydia trachomatis. Silent infection of women with Chlamydia make treatment especially difficult.     

Higher Yet Suboptimal Chlamydia Testing Rates at Community Health Centers and Outpatient Clinics Compared With Physician Offices

To assess chlamydia testing in women in community health centers, we analyzed data from national surveys of ambulatory health care. Women with chlamydial symptoms were tested at 16% of visits, and 65% of symptomatic women were tested if another reproductive health care service (pelvic examination, Papanicolaou test, or urinalysis) was performed. Community health centers serve populations with high sexually transmitted disease rates and fill gaps in the provision of sexual and reproductive health care services as health departments face budget cuts that threaten support of sexually transmitted disease clinics.Community health centers can serve as a key health care venue for the provision of quality sexual and reproductive health care services for persons in medically underserved communities. They are public or nonprofit, community-directed health care facilities that increase access to care for persons who experience barriers to quality health care, such as their inability to pay, geographic location, or language or cultural differences.1With increasing closure of sexually transmitted disease (STD) clinics throughout the United States,2 greater provision of STD services in community settings will be important for protecting the sexual and reproductive health of men and women in minority populations with high prevalence of STDs and limited access to care.3,4 An important STD service is chlamydia testing for persons with symptoms or signs of infection and also for all asymptomatic sexually active women aged 25 years or younger annually, as recommended by the Centers for Disease Control and Prevention and other organizations.5–7 An untreated chlamydial infection can result in serious complications, including pelvic inflammatory disease, infertility, or ectopic pregnancy.8–10 We estimated the proportion of visits made by women to community health centers, physician offices, and outpatient clinics with a chlamydia screening or diagnostic test.     

Family Planning in Asia

In this article the medical director of IPPF, Dr. Malcolm Potts, reviews some new aspects of family planning as discussed in a regional IPPF conference in 1970 in Tokyo and as he gathered impressions from his travels in Asia. Nearly all Asian countries have governmental family planning programs. However, for the most part, bottlenecks have developed in these programs, and the achievements have been disappointing. The population in Asia is biased towards the younger age groups. Migration makes only a marginal difference. Unemployment is a serious social program which will be magnified by additional labor force. Japan has demonstrated that legal abortion can be a relatively safe procedure while in Korea induced abortion is illegal. Conversely, in Korea oral contraceptives have been successfully distributed in the governmental program while in Japan the method is still not approved by the government. A bill to reform the abortion law is before the Indian parliament. In Mainland China, IUDs, oral contraceptives and condoms are in use; sterilization and abortion are available upon request.     

Reproductive technologies and the private sector -- implications for women's health

Many scientific and medical techniques exist to intervene and alter the natural process of pregnancy and childbirth. Examples include contraceptive techniques such as the contraceptive pill and IUDs, instrumental and caesarian deliveries, amniocentesis and ultrasound, in-vitro fertilization, test tube babies, and artificial wombs. These services are provided by governments and private medicare institutions. Little, however, is known about private sector involvement in this area except that the number of private facilities is increasing in both urban and rural areas of India, and that private facilities include clinics, nursing homes, diagnostic centers, and corporate hospitals for both inpatient and outpatient care. With practitioners enjoying wide latitude to recommend and carry out tests and services, unlimited profit-making potential exists. Nursing homes focus primarily upon pregnancy, childbirth, and family planning. 40% of nursing homes and corporate hospitals in Hyderabad had ultrasound testing facilities, while amniocentesis is conducted widely in private clinics and hospitals around the country. 84% of private gynecologists in Bombay conduct sex determination tests which often lead to the abortion of female fetuses. 73% of nursing homes in Delhi had an ultrasound machine, with 80% of facilities using the machines for sex determination testing. Concerns over the cost of raising and marrying off daughters lures clients to test the sex of fetuses and not carry females to term. Hospitals and clinics also capitalize upon the social stigma of marital infertility by promoting the treatment of infertility and in-vitro fertilization. Moreover, responding to government incentives to provide comprehensive family planning services, many private clinics and nursing homes claim to offer services even when they do not. Private nursing homes and clinics offer services to maximize profit. As public spending for programs continues to be slashed and the role of private institutions increases, more attention needs to be given to monitoring the quality of services.     

Screening men for Chlamydia trachomatis infection: have we fully explored the possibilities?

Genital chlamydial infection is the commonest curable sexually transmitted disease in England and Wales. It is a major cause of pelvic inflammatory disease, ectopic pregnancy, and infertility. For this reason, research, health promotion, and disease prevention initiatives have focused on women. Screening women for chlamydial infection is concerned mainly with identifying and reducing complications among those already infected (secondary prevention), rather than with preventing new infections (primary prevention). Screening men for genital chlamydial infection, a strategy for preventing new infections in women, has been considered problematic because of the cost, the invasiveness of sampling procedures, and the need to screen in clinical settings. The availability of nucleic acid amplification diagnostic tests challenges these limitations and offers new opportunities for actively including men in disease prevention. This article reviews the arguments for and against screening men for genital chlamydial infection and discusses possible strategies for its implementation.     

Sex,contraception and contradiction among young Filipinas in Australia

Despite recognition of the risks of unplanned pregnancy and disease transmission, the use of contraceptives and/or prophylactics among young sexually active Filipinas in Australia is inconsistent. While this does not set them apart from Australian-born young people, sexual expression is influenced by cultural values of both the immigrant family and dominant community. Young migrant women experience particular barriers in discussing sex with their parents or other community members, because of their concern with family honour and shame and tensions related to differences in values between the host and origin cultures. Issues related to sex, contraception and the prevention of sexually transmitted diseases are rarely dealt with openly, and, as a result, young women rarely have access to practical advice about services and information.     

Commentary: the quest for women''s prophylactic methods--hopes vs science.

The companion article by Rosenberg and Gollub in this issue summarizes data from 10 observational studies and concludes that female-controlled contraceptive methods, under typical conditions, are comparable to condoms in preventing sexually transmitted diseases and should be merchandized as such. While we agree that chemical and mechanical contraceptives provide protection against some sexually transmitted diseases, we think the authors have overstated the scientific case for these methods, especially in comparison with the condom. We think the current data remain inconclusive regarding the absolute protection of spermicides against the human immunodeficiency virus and their level of protection--relative to that of the condom--against other sexually transmitted diseases. Three reasons account for our differences: the limitations in the comparative data; the reported adverse effects of spermicides on vaginal conditions, including genital ulcers; and the relative value of condoms, even under typical conditions, in preventing sexually transmitted diseases. For these reasons, we would currently counsel both women and men who practice high-risk sexual behaviors to use condoms as their first line of defense. If this is unacceptable, the female barriers become a fallback position to protect against bacterial sexually transmitted diseases.