Longitudinal Trajectories of Posttraumatic Stress Disorder Symptoms and Binge Drinking Among Adolescent Girls: The Role of Sexual Victimization

Purpose

Many studies have documented associations among sexual victimization (SV), posttraumatic stress disorder (PTSD) symptoms, and alcohol use; however, few have examined these associations longitudinally among adolescents. The present study evaluated the effect of SV on the longitudinal trajectory of PTSD symptoms and binge drinking (BD) among adolescent girls, a population known to have high rates of SV and alcohol use.

Methods

Participants (N = 1,808 at wave 1) completed interviews regarding PTSD symptoms, BD, and SV experiences over approximately 3 years.

Results

Multilevel modeling revealed decreases in PTSD symptoms over the course of the study; however, compared with nonvictims, adolescents who were sexually victimized reported greater PTSD symptoms at wave 1 and maintained higher levels of PTSD symptoms over the course of the study after controlling for age. SV reported during the study also predicted an acute increase in PTSD symptoms at that occasion. BD increased significantly over the course of the study; however, SV did not predict initial BD or increases over time. SV reported during the study was associated with acute increases in BD at that occasion, although this effect diminished when participants reporting substance-involved rape were excluded.

Conclusions

SV was associated with immediate and long-lasting elevations in PTSD symptoms, but not with initial or lasting elevations in BD over time, suggesting that adolescent victims have yet to develop problematic patterns of alcohol use to cope with SV. However, SV was associated with acute increases in PTSD symptoms and BD, suggesting a need for BD interventions to reduce alcohol-related SV.     

US Adolescents and MyPyramid: Associations between Fast-Food Consumption and Lower Likelihood of Meeting Recommendations

Objective

To determine whether fast-food consumption is associated with adolescents' food group intakes and likelihood of meeting recommendations outlined in the MyPyramid Food Guidance System.

Design

Data from two 24-hour recalls collected in What We Eat in America, National Health and Nutrition Examination Survey 2003-2004 were analyzed. Fast-food consumers were divided into tertiles based on the proportion of 2-day energy intake derived from fast food.

Subjects

Adolescent boys and nonpregnant girls aged 12 to 19 years (n=1,956).

Statistical analyses performed

All statistical analyses included sample weights to account for the survey design. Regression analyses were used to detect associations between fast-food consumption and both food group intakes and percentages of individuals meeting MyPyramid recommendations, and to predict odds of meeting recommendations by fast-food consumption level.

Results

Fast-food consumption was associated negatively with MyPyramid fruit and milk group intakes (boys and girls) and positively with discretionary energy and solid fats (girls only). Negative associations were also found between fast-food consumption and percentages of adolescents meeting recommendations for milk (boys), fruits (girls), and vegetables and discretionary energy (boys and girls). Compared with those consuming no fast food, adolescents in the highest tertile of energy from fast food were less likely to meet recommendations for vegetables (odds ratio [OR]=0.16, 95% confidence interval [CI]: 0.05 to 0.52 for boys; OR=0.18, 95% CI: 0.04 to 0.79 for girls) and discretionary energy (OR=0.41, 95% CI: 0.22 to 0.77 for boys; OR=0.04, 95% CI: 0.01 to 0.24 for girls). No relationships were found between fast-food consumption and grains, meat/beans, and oils.

Conclusions

Adolescents' intakes, whether containing fast food or not, need improvement. Fast food is one factor that impacts adolescents' intake of MyPyramid groups and their likelihood of meeting recommendations. Awareness of fast-food's role in discrepancies between adolescent intakes and MyPyramid recommendations can aid professionals in designing effective strategies to improve adolescents' diets.     

Teen Dating Violence,Sexual Harassment,and Bullying Among Middle School Students: Examining Mediation and Moderated Mediation by Gender

This longitudinal study tested whether sexual harassment perpetration mediates the relationship between bullying perpetration and teen dating violence (TDV) perpetration and tested moderated mediation by assessing whether the developmental pathway varies by gender among middle school-aged youth. Although TDV has been associated with bullying and sexual harassment, the developmental relationship among all three behaviors has rarely been examined, especially by gender. The data were collected from one cohort of seventh grade middle school students (N?=?612) from four schools. Students were surveyed every 6 months during seventh and eighth grades for a total of four waves of data collection. Structural equation modeling (SEM) was conducted to address the study aims, consisting of three stages: measurement models, mediation, and moderated mediation (otherwise known as Contrast of Mediated Effects). Results indicate no evidence of mediation. However, in the overall model, bullying and sexual harassment both emerged as significant predictors of TDV at a later time point. Among girls, only bullying significantly predicted TDV at a later time point, and, among boys, only sexual harassment significantly predicted TDV at a later time point. Prevention programs that target bullying and sexual harassment perpetration may reduce later perpetration of TDV. Further research is needed to disentangle the temporal relationships between these aggressive behaviors among youth.     

Effects of two combined hormonal contraceptives with the same composition and different doses on female sexual function and plasma androgen levels

Background

This study was conducted to compare the effects of two contraceptive pills with different doses of the same components, on plasma androgen levels and female sexual function among women without previous sexual dysfunction.

Study Design

The participants were randomized into two groups, to receive pills containing ethynylestradiol (EE) 30 mcg and levonorgestrel (LNG) 150 mcg or EE 20 mcg and LNG 100 mcg, for six cycles. Sexual function was assessed using a standardized questionnaire [Female Sexual Function Index (FSFI)]. Hormone assays were performed at baseline and after the sixth cycle.

Results

Forty-nine women were included in the EE30/LNG150 group and 48 in the EE20/LNG100 group. EE30/LNG150 group presented 54% and 67% decreases of total testosterone and free androgen index, respectively, with statistical significance. EE20/LNG100 presented reductions of 20% and 42%, respectively, but without statistical significance. Both groups showed improvements in the FSFI “desire” score, but with statistical significance only for EE20/LNG100 group.

Conclusions

EE30/LNG150 decreased plasma androgen levels, but there was no impairment in sexual desire, on the other hand, sexual desire score increased with EE20/LNG100 formulation.     

Physical and sexual violence and subsequent contraception use among reproductive aged women

Background

Population-based data were used to examine the association between reproductive aged women's physical and sexual violence experiences in the previous 12 months and subsequent contraception use.

Study Design

This study used a representative sample of adults (2002 North Carolina Behavioral Risk Factor Surveillance System). Multivariable logistic regression analysis was used to model the associations of interest.

Results

Approximately 1 in 20 North Carolina reproductive aged women experienced physical and/or sexual violence in the previous 12 months, with physical violence as the most common. Compared to women who experienced no violence in the previous 12 months, experiences with physical violence by itself increased subsequent contraception use, while experience with sexual violence by itself decreased subsequent contraception use. Women with both experiences in the previous 12 months were less likely to be subsequently using contraception (OR=0.1; 95% CI=0.1-0.8).

Conclusions

Findings from this study provide further evidence that different experiences with violence may dictate women's subsequent contraception use.     

Sex differences in the variables associated with objectively measured moderate-to-vigorous physical activity in preschoolers

Objective

To investigate variables associated with objectively measured moderate-to-vigorous physical activity (MVPA) in German preschool children.

Methods

Cross-sectional data was collected from 649 three to six year old children (51% boys) in 52 preschools in south Germany between autumn and spring 2008−2009. Sociodemographic, health and socio-cultural variables that could affect children's objectively measured MVPA minutes, averaged over two to four week and weekend days, were tested in bivariate and multivariate linear regression models.

Results

MVPA was significantly associated with the extrinsic variables age (−4.52 min/year of age), health status (5.62 min/category), high TV time (9.22 min/category) and high parental PA (6.59 min/category) among girls. For boys, only the intrinsic variable desire to be active (5.19 min/category) was significantly, positively associated with MVPA. The final models for girls and boys explained approximately 10% and 7% of the variance, respectively, in children's MVPA.

Conclusion

We found differences by sex in variables associated with objectively measured MVPA in preschoolers. A focus on extrinsic motivators such as parental PA for girls and intrinsic motivators for boys may be an important consideration when designing interventions and PA programs for this age group.     

‘Nobody teases good girls’: A qualitative study on perceptions of sexual harassment among young men in a slum of Mumbai

Young adulthood is a key period in which gender norms are solidified. As a result, young women are particularly vulnerable to gender-based violence. In Delhi, over 90% of women have ever experienced sexual violence in public spaces. Sexual harassment of girls and women in public spaces is commonly named ‘eve teasing’ in India. Experience of sexual harassment in public spaces has been found to be associated with restricted mobility, interrupted education, and early age at marriage. Little is known about men’s perspectives on eve teasing and how they believe it affects women and girls. This study fills that gap through qualitative research to explore the attitudes and perceptions of adolescent boys and young men on this topic. Ten focus group discussions were conducted in two slum communities in Mumbai. Coding and thematic analysis were performed. We identified themes of acceptance of harassment, weak sanctions, traditional gender norms supportive of harassment, and ideologies of male sexual entitlement. Many of the perceived risk and protective factors for sexual harassment in public spaces are operationalised at the community level. Community mobilisation is necessary in designing interventions focused on the primary and secondary prevention of sexual harassment.     

Age of sexual debut among US adolescents

Background

This study examined gender and racial/ethnic differences in sexual debut.

Study Design

We analyzed 1999-2007 data from the Youth Risk Behavior Surveillance System (YRBSS), a cross-sectional, nationally representative survey of students in Grades 9-12 established by the Centers for Disease Control and Prevention. The Kaplan-Meier method was used to compute the probability of survival (not having become sexually active) at each year (age 12 through 17), and separate estimates were produced for each level of gender and racial/ethnic group.

Results

African-American males experienced sexual debut earlier than all other groups (all tests of significance at p<.001) and Asian males and females experienced sexual debut later than all groups (all tests of significance at p<.001). By their 17th birthday, the probability for sexual debut was less than 35% for Asians (females 28%, males 33%) and less than 60% for Caucasians (58% females, 53% males) and Hispanic females (59%). The probability for sexual debut by their 17th birthday was greatest for African Americans (74% females, 82% males) and Hispanic males (69%).

Conclusions

These results demonstrate a need for sexual education programs and policy to be sensitive to the roles of race and ethnicity in sexual debut.     

Associations between anxious-depressed symptoms and cardiovascular risk factors in a longitudinal childhood study

Objective

To examine the influence of anxious/depressed scores on cardiovascular risk factors throughout childhood.

Methods

Data from the Western Australian Pregnancy Cohort (Raine) Study, a study of 2900 pregnancies recruited between 1989 and 1991, were used. Anxious-depressed scores (derived from the Childhood Behavior Checklist), body mass index (BMI) and blood pressure were measured at 5 (n = 1681), 8 (n = 1697), 10 (n = 1575) and 14 (n = 1386) years. At age 14 depressive symptom scores (Beck Depression Inventory for Youth), anxious-depressed scores (Youth Self-Report (YSR) and Teacher Report Form (TRF)) and fasting lipid, glucose and insulin were also available. Cross sectional and longitudinal analyses were conducted.

Results

At age 14, girls with higher anxious-depressed scores had higher BMI (p ≤ 0.005) and homeostasis model assessment-estimated insulin resistance (p ≤ 0.0001). This equated to a difference of 0.6 kg/m² and 0.3 units in predicted BMI and HOMA-IR respectively (top 5% vs. score of zero). Boys with higher anxious-depressed scores had lower systolic blood pressure trajectories (p = 0.024).

Conclusion

Depressive scores appear to have differing influences on BMI, homeostasis model assessment-estimated insulin resistance and systolic blood pressure in boys and girls. Paradoxically boys with higher anxious-depressed scores had lower blood pressure throughout childhood.     

Secular trends in weight status and weight-related attitudes and behaviors in adolescents from 1999 to 2010

Objective

To examine secular trends from 1999 to 2010 in weight status and weight-related attitudes and behaviors among adolescents.

Methods

A repeated cross-sectional design was used. Participants were from Minneapolis/St. Paul middle schools and high schools and included 3072 adolescents in 1999 (mean age14.6 ± 1.8) and 2793 adolescents in 2010 (mean age14.4 ± 2.0). Trends in weight-related variables were examined using inverse probability weighting to control for changes in socio-demographics over time.

Results

The prevalence of obesity among boys increased by 7.8% from 1999 to 2010, with large ethnic/racial disparities. In black boys the prevalence of obesity increased from 14.4% to 21.5% and among Hispanic boys, obesity prevalence increased from 19.7% to 33.6%. Trends were more positive among girls: weight status did not significantly increase, perceptions of overweight status were more accurate, the use of healthy weight control behaviors remained high, dieting decreased by 6.7%, unhealthy weight control behaviors decreased by 8.2% and extreme weight control behaviors decreased by 4.5%.

Conclusions

Trends indicate a need to intensify efforts to prevent obesity and other weight-related problems, particularly for boys from ethnic/racial minorities. The decreases in unhealthy weight control behaviors among girls are encouraging.     

Estimation of Dietary Sources and Flavonoid Intake in a Spanish Adult Population (EPIC-Spain)

Background

Epidemiologic studies have suggested associations between flavonoid intake and health benefits. Traditional Mediterranean diets consist of a high consumption of plant products rich in flavonoids.

Objective

This study estimates dietary flavonoid intake and main food sources in a Mediterranean population (Spanish adults).

Design

The study included 40,683 subjects aged 35 to 64 years from northern and southern regions of Spain who were included in the European Prospective Investigation into Cancer and Nutrition study Spanish cohort. Usual food intake was assessed by personal interviews using a computerized version of a validated diet history method. Expanded US Department of Agriculture databases for the flavonoid, isoflavone, and proanthocyanidin content were used.

Results

The median and mean of total flavonoids were 269.17 and 313.26 mg/day, respectively. The most abundant flavonoid subgroup was proanthocyanidins (60.1%), followed by flavanones (16.9%), flavan-3-ols (10.3%), flavonols (5.9%), anthocyanidins (5.8%), flavones (1.1%), and isoflavones (<0.01%). The main sources of total flavonoid intake were apples (23%), red wine (21%), unspecified fruit (12.8%), and oranges (9.3%).

Conclusions

These results should be very useful for evaluating the relationships between flavonoid intake and several diseases.     

Postexposure prophylaxis for victims of sexual assault: treatments and attitudes of emergency department physicians

Background

Emergency departments (EDs) are the primary source of care for victims of sexual assault (SA). Provision of emergency contraception (EC) to these women has previously been noted to be sporadic. Completeness of care for victims of SA and the barriers to complete care are further investigated in this study.

Study Design

All ED attending physicians in Maryland, Virginia and the District of Columbia were identified and contacted for participation; 35% completed the survey. Practice patterns were analyzed for the 67% of physicians who do not refer SA victims to other hospitals.

Results

We found that 83% of physicians “always” or “usually” offer EC, but only half prescribe EC more than 48 h postassault. While most (89%) typically offer prophylaxis for STDs other than HIV, only 45% offer or counsel on HIV prophylaxis. Physician attitudes and hospital protocols were significant modifiers.

Conclusion

Sexual assault victims are often not offered comprehensive care including prophylaxis against pregnancy and all STDs including HIV. Additional research is warranted to determine why physicians do not routinely offer HIV prophylaxis after SA.     

Dietary intake and food sources of fatty acids in Australian adolescents

Background

Dietary fat consumed during childhood and adolescence may be related to the development of cardiovascular and other chronic diseases in adulthood; however, there is a lack of information on specific fatty acid intakes and food sources in these populations. Our study aimed to assess fatty acid intakes in Australian adolescents, compare intakes with national guidelines, and identify major food sources of fatty acids.

Methods

Dietary intake was assessed using measured 3-d records in 822 adolescents aged 13-15 y participating in The Western Australian Pregnancy Cohort (Raine) Study, Australia.

Results

Mean daily total fat intakes were 90 ± 25 g for boys and 73 ± 20 g for girls, with saturated fat contributing 14% of total energy intake. Mean contribution to daily energy intake for linoleic, alpha-linolenic, eicosapentaenoic, docosapentaenoic, and docosahexaenoic acids were 3.0%, 0.40%, 0.02%, 0.01%, and 0.04%, respectively, for boys, and 3.3%, 0.42%, 0.02%, 0.01%, and 0.05% for girls. To meet guidelines for chronic disease prevention, consumption of long-chain omega-3 fatty acids in this population may need to increase up to three-fold and the proportion of saturated fat decrease by one-third. Girls were more likely to achieve the guidelines. Major food sources were dairy products for total fat, saturated fat and alpha-linolenic acid, margarines for linoleic acid, and fish for long-chain omega-3 fatty acids.

Conclusion

Results suggest that for this population, a higher dietary intake of long-chain omega-3 fatty acids, particularly for boys, and lower proportion of saturated fat is required to meet recommendations for prevention of chronic disease.     

Validation and Calibration of a Semiquantitative Food Frequency Questionnaire Designed for Adolescents

Background

Epidemiologic studies must have a reliable method for evaluating food intake; therefore, valid, precise, and practical instruments are essential.

Objective

To assess the relative validity and estimate the calibration factors of a semiquantitative food frequency questionnaire (FFQ) for adolescents.

Design

Validation and calibration study.

Subjects/settings

This study enrolled 169 adolescents from Rio de Janeiro, Brazil. A set of three food records was used as the reference method.

Statistical analyses performed

The relative validity was analyzed according to weighted κ values for the quartile categorization of energy and nutrient intakes, Pearson correlation coefficients, and the Bland-Altman method. To estimate the calibration factors for the FFQ, linear regression models, including the food record means as dependent variables and the FFQ estimations as independent variables were developed for boys and girls.

Results

The weighted κ values ranged from 0.28 to 0.44 for the raw data and from 0.16 to 0.39 for the deattenuated and energy-adjusted data. The Pearson correlation coefficients ranged from 0.33 to 0.46, and the mean agreement varied from 62% to 143%. The calibration factors estimated for boys ranged from 0.15 to 0.48, and the factors estimated for girls ranged from 0.14 to 0.47. The mean energy and nutrient intakes estimated by the calibrated FFQ were similar to the means estimated by the food records; however, the standard deviations were smaller for the calibrated FFQ estimations.

Conclusions

The tested FFQ is a suitable tool for ranking energy and nutrients intake in the studied group. Calibration factors are needed to estimate energy and nutrient intake means and should be used to correct raw data as well as association measurements based on FFQ data.     

Changes in male reproductive system and mineral metabolism induced by soy isoflavones administered to rats from prenatal life until sexual maturity

Objective

This study aimed to determine the influence of high-dose soy isoflavones (daidzein and genistein) administered from prenatal life to sexual maturity on testosterone and estradiol levels, testicular and epididymal morphology, the number of epididymal spermatozoa, and mineral metabolism in rats.

Methods

Pregnant Wistar rats received orally soy isoflavones, daidzein, and genistein at a dose of 200 mg/kg of body weight per day. After separating sucklings from their mothers, male rats received the same dose of isoflavones until reaching the age of sexual maturity, i.e., for 3 mo.

Results

In the isoflavone-treated group, statistically significant decreased concentrations of zinc (determined using atomic absorption spectrophotometry) in blood serum and increased concentrations in bone were observed. The isoflavones induced changes in the morphology of the seminiferous epithelium of rat testes. However, there were no significant changes in the number of spermatozoa in the epididymis. The levels of estradiol in serum and cauda epididymis homogenates of rats receiving phytoestrogens were significantly higher than in the control group. No differences were observed in testosterone concentrations in the serum of treated and control rats. The testosterone levels in the homogenates of the treated rat testes were significantly lower than in the control group.

Conclusion

The relatively mild effects of phytoestrogen administration on the morphology of testes and epididymides and the number of epididymal spermatozoa were observed despite the high dose used. The exposure of rats to genistein and daidzein during intrauterine life until sexual maturity influenced the mineral metabolism of the organism by significant decreases of Zn concentration in serum and increased Zn concentration in bones.     

The Relationship of Ready-to-Eat Cereal Consumption to Nutrient Intake, Blood Lipids, and Body Mass Index of Children as They Age through Adolescence

Objective

To examine sex differences and longitudinal changes in ready-to-eat (RTE) cereal and breakfast consumption in the Dietary Intervention Study in Children, and the relationship between RTE cereal intake with nutrient intake, blood lipids, and body mass index (BMI).

Design

Secondary analyses based on data from Dietary Intervention Study in Children, a randomized, controlled, multicenter, clinical trial with five sets of three 24-hour recalls.

Subjects/setting

Children (n=660) from six clinics aged 8 to 10 years at study entry. Participants had serum low-density lipoprotein cholesterol levels between the 80th and 98th percentiles for age, and were followed for a mean of 7.5 years.

Intervention

Children were randomized to a total fat- and saturated fat-modified dietary intervention or usual care.

Statistical analyses

Frequency of RTE cereal and breakfast consumption was examined by sex and age. Mixed models by sex were used to examine the relationship of RTE cereal consumption to average daily intake of nutrients, blood lipids, and BMI.

Results

For all children, RTE cereal and breakfast consumption declined with age. Boys consumed RTE cereal more often compared with girls. Except for energy, RTE cereal consumption was positively associated with all measures of nutrients for both sexes. In boys, higher RTE cereal consumption was associated with lower total and low-density lipoprotein cholesterol levels and lower BMI.

Conclusions

Food and nutrition professionals should continue to educate youth and their parents on the nutritional benefits of routinely eating RTE cereal.     

Household Food Insecurity Is Associated with Self-Reported Pregravid Weight Status, Gestational Weight Gain, and Pregnancy Complications

Background

Household food insecurity is positively associated with weight among women. The association between household food insecurity and pregnancy-related weight gain and complications is not well understood.

Objective

To identify whether an independent association exists between household food insecurity and pregnancy-related complications.

Design

Data from the Pregnancy, Infection, and Nutrition prospective cohort study were used to assess household food insecurity retrospectively using the US Department of Agriculture 18-item Core Food Security Module among 810 pregnant women with incomes ≤400% of the income/poverty ratio, recruited between January 2001 and June 2005 and followed through pregnancy.

Main outcome measures

Self-reported pregravid body mass index, gestational weight gain, second trimester anemia, pregnancy-induced hypertension, and gestational diabetes mellitus.

Statistical analyses performed

Multivariate linear, multinomial logistic, and logistic regression analyses.

Results

Among 810 pregnant women, 76% were from fully food secure, 14% were from marginally food secure, and 10% were from food insecure households. In adjusted models, living in a food insecure household was significantly associated with severe pregravid obesity (adjusted odds ratio 2.97, 95% confidence intervals [CIs] 1.44 to 6.14), higher gestational weight gain (adjusted β coefficient 1.87, 95% CI 0.13 to 3.62), and with a higher adequacy of weight gain ratio (adjusted β .27, 95% CI 0.07 to 0.50). Marginal food security was significantly associated with gestational diabetes mellitus (adjusted odds ratio 2.76, 95% CI 1.00 to 7.66).

Conclusions

This study highlights the possibility that living in a food insecure household during pregnancy may increase risk of greater weight gain and pregnancy complications.     

Effects of sex hormones in oral contraceptives on the female sexual function score: a study in German female medical students

Background

The survey was conducted to compare the influence of sex hormones in oral contraceptives (OCs) on female sexual function.

Methods

One thousand eighty-six female German medical students completed an online-based questionnaire incorporating the Female Sexual Function Index (FSFI). Oral contraceptives used were classified into those containing androgenic or antiandrogenic progestins and by ethinylestradiol (EE) dosage (20 mcg, 30 mcg and >30 mcg). Female Sexual Function Index scores in women using OCs were compared to those in nonusers.

Results

Seven hundred fifty-two of 1086 participating women used OCs. No statistically significant differences in FSFI scores were found among women using OCs containing androgenic or antiandrogenic progestins, nor were any seen between different EE dosages. In general, OC users had lower FSFI scores than nonusers.

Conclusion

Female Sexual Function Index scores were negatively influenced by the use of OCs. However, the impact of an androgenic or antiandrogenic progestin content or different dosages of EE as modulating factors of female sexual function seems negligible.     

Extended case-control study results on thromboembolic outcomes among transdermal contraceptive users

Background

We extended an earlier study that found a twofold higher risk of venous thromboembolism (VTE) associated with the transdermal contraceptive system relative to norgestimate-containing oral contraceptives (NGM-OC).

Study Design

This case-control study identified potential cases of VTE, acute myocardial infarction (AMI) and stroke from 24 months of additional health care claims, with adjudication via medical records. Randomly selected controls were matched to cases on age (15-44 years) and characteristics of contraception use. Conditional logistic regression models provided odds ratios (ORs) and 95% confidence intervals (CIs).

Results

The transdermal contraceptive system was associated with a twofold higher risk of VTE (OR 2.0; 95% CI 1.2-3.3) compared with users of NGM-OC. The OR for stroke was 0.6 (95% CI 0.1-3.2) and for AMI 1.2 (95% CI 0.3-4.7).

Conclusion

This extension was consistent with the earlier study, showing a twofold increased risk of VTE associated with use of the transdermal contraceptive system relative to NGM-OC.