Variations in body mass index of users of depot-medroxyprogesterone acetate as a contraceptive

Background

Weight gain is a frequent reason for discontinuing the contraceptive with depot-medroxyprogesterone acetate (DMPA).

Study Design

This 3-year retrospective cohort study assessed body mass index (BMI; kg/m²) variations in 379 current or past DMPA users compared to TCu380A intrauterine device (IUD) users matched for age and BMI, categorized into G1 (normal weight), G2 (overweight) or G3 (obese) according to baseline BMI. Variations in weight and BMI were evaluated using analysis of variance.

Results

BMI increased progressively in all groups but significantly more in G1 and G2 DMPA users compared to nonusers and according to duration of use. In the G3 subgroup, weight trends were similar in the DMPA and IUD users.

Conclusions

Normal and overweight women increased BMI with DMPA use; however, obese women did not increase weight. Weight increase in DMPA users could be associated with metabolic alterations related to duration of use in normal and overweight women and to alterations already present in obese women. Prospective studies are required to determine triggering factors. DMPA use ≤3 years was not associated with weight increase in women with BMI (kg/m²) ≥30.     

Postpartum contraception: the New Mexico Pregnancy Risk Assessment Monitoring System

Objective

To examine factors associated with postpartum contraception, including the relationship between ethnicity and postpartum contraceptive use.

Methods

We used data from the New Mexico Pregnancy Risk Assessment Monitoring System, which monitors selected maternal events occurring before, during and after pregnancy.

Results

Our findings in 4096 women revealed that women who are aged ≥35 years, unmarried and lacking a postpartum visit have increased risk of no postpartum contraception. The odds of postpartum contraception were over three times greater in women with a postpartum visit [adjusted odds ratio (OR)=3.06, 95% confidence interval (CI): 2.17-4.31) and over 50% greater in married women (adjusted OR=1.57, 95% CI: 1.16-2.11). Hispanic women were more likely than were Native Americans to use postpartum contraception (OR=1.25, 95% CI: 0.95-1.64).

Conclusion

Focused contraception counseling, especially in the postpartum setting, is important to help ensure the well-being of women and children.     

Impact of obesity on oral contraceptive pharmacokinetics and hypothalamic-pituitary-ovarian activity

Background

This study was conducted to determine whether increased body mass index (BMI) affects oral contraceptive (OC) pharmacokinetics and suppression of hypothalamic-pituitary-ovarian (HPO) axis activity.

Study Design

Ovulatory reproductive-age women with normal weight (BMI <25 kg/m²; n=10) and with obesity (BMI >30 kg/m²; n=10) received OCs for two cycles (prospective cohort). Subjects were admitted for two 48-h inpatient stays at the beginning and end of the hormone-free interval. Ethinyl estradiol and levonorgestrel (LNG) levels were evaluated during both inpatient stays. Gonadotropin pulsatility (follicle-stimulating hormone and luteinizing hormone) was measured during the second inpatient stay. Estradiol (E₂) and progesterone (P) were measured daily during inpatient stays and twice per week in Cycle 2.

Results

BMI was greater in the obese compared to the normal-BMI group [37.3 kg/m² (SD, 6.0) vs. 21.9 kg/m² (SD, 1.6); p<.05]. The LNG half-life was significantly longer in the obese group (52.1±29.4 vs. 25.6±9.3 h, p<.05), which correlated with a lower maximum LNG concentration on Cycle 2, Day 1 [1.9 ng/mL (SD, 0.5) vs. 2.5 ng/mL (SD, 0.7)] and a longer time to reach steady state (10 vs. 5 days) in obese women. There were no significant differences in volume of distribution between groups. LH pulse parameters did not differ statistically between groups but trended toward greater HPO activity in the obese group. Additionally, more obese (6/10 vs. 3/10 normal BMI, p>.05) women exhibited E₂ levels consistent with development of a dominant follicle and P levels consistent with ovulation (2/10 vs. 1/10) during Cycle 2.

Conclusions

Compared to women with normal BMI, obese women exhibit differences in OC pharmacokinetics that are associated with greater HPO activity.     

Antimullerian hormone and obesity: insights in oral contraceptive users

Background

The study was conducted to examine the impact of oral contraceptives (OCs) on serum antimullerian hormone (AMH) levels by obesity status in reproductive-age women.

Study Design

Ovulatory women, ages 18-35 years, of normal (<25 kg/m²; n=10) and obese (>30 kg/m²; n=10) body mass index (BMI) received a low-dose OC (20 mcg ethinyl estradiol/100 mcg levonorgestrel) for two cycles. Serum samples obtained at several time points during active pill use and hormone-free intervals were analyzed for AMH, follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol and inhibin B.

Results

AMH levels did not differ by OC cycle day in either BMI group. On average, AMH levels were 34% lower in the obese group (2.9±2.1 vs. 4.4±1.8 ng/mL, p<.05). Modeling to determine differences in AMH throughout the cycle based on obesity status demonstrated significantly lower levels (p<.05), whereas serum AMH, FSH, LH, estradiol and inhibin B levels revealed no correlations when all time points were included.

Conclusions

In reproductive-age women, serum AMH levels do not appear to fluctuate during OC use, but AMH levels are significantly lower in obese women. Lower levels do not appear to be due to differences in gonadotropin levels or ovarian activity.     

What is the nutritional status of children of obese mothers in South Africa?

Objective

To evaluate the anthropometric status of children of obese (body mass index [BMI] ≥30 kg/m²) mothers who participated during the 2005 National Food Consumption Study.

Methods

The survey population consisted of children 1-9 y of age and their mothers 16 to 35 y of age living in the same households (n = 1532). A national sample of households was drawn, representative of all nine provinces and urban and rural areas. Trained fieldworkers measured the heights and weights of participants at their homes.

Results

The prevalence of obesity was high in the mothers (27.9%), particularly in the 26- to 35-y-old (older) group (32.3%) and in urban areas (29.1%). Children of older mothers had a significantly (P < 0.05) higher mean height-for-age Z-score (−0.91) than those of younger mothers (16 to 25 y old, −1.06). Mean weight-for-age and weight-for-height Z-scores were significantly higher in children of obese women compared with those of non-obese women (BMI <30 kg/m², P < 0.001). Furthermore, obese mothers had significantly more overweight children than non-obese mothers (P < 0.0001). Eighty-four percent of overweight children also had mothers with a BMI ≥25 kg/m² and 52% had mothers with a BMI ≥30 kg/m²(∗ indicates statistical significance of confidence interval). Stunted mothers had a 1.5 times higher risk of being overweight (BMI ≥25 kg/m², odds ratio 1.45, confidence interval 1.06-2.01).

Conclusion

Overall, children of obese mothers had significantly higher mean Z-scores than those of mothers who were non-obese. Overweight and obese women were significantly less likely to have stunted or underweight children, whereas underweight women and stunted women were significantly more likely to have underweight and stunted children, respectively.     

Intrauterine contraception in Saint Louis: a survey of obstetrician and gynecologists' knowledge and attitudes

Background

Many obstacles to intrauterine contraception (IUC) use exist, including provider and patient misinformation, high upfront cost and clinician practice patterns. The aim of our study was to investigate knowledge and attitudes about IUC among obstetricians and gynecologists in the area of Saint Louis.

Study Design

We mailed a self-administered, anonymous survey to 250 clinicians who provide obstetric and gynecologic care in Saint Louis City and County which included questions about demographics, training, family planning visits and intrauterine contraceptive knowledge and use.

Results

The overall survey response rate among eligible clinicians was 73.7%. Clinicians who had recently finished training or saw higher numbers of contraceptive patients per week were more likely to insert IUC than clinicians who completed training prior to 1989 or saw fewer contraceptive patients. Several misconceptions among clinicians were identified, including an association between intrauterine contraceptives and an elevated risk of pelvic inflammatory disease.

Conclusions

Physician misconceptions about the risks of IUC continue to occur. Improved clinician education is greatly needed to facilitate the use of these highly effective, long-acting, reversible methods of contraception.     

Health care providers' knowledge about contraceptive evidence: a barrier to quality family planning care?

Background

The underuse of effective contraceptive methods by women at risk for unintended pregnancy is a major factor contributing to the high rate of unintended pregnancy in the United States. As health care providers are important contributors to women's contraceptive use, this study was conducted to assess provider knowledge about contraception.

Study Design

Bivariate and multivariate analyses were performed using data collected from a convenience sample of health care providers (physicians, nurse practitioners and physician assistants) at meetings of the professional societies of family medicine and obstetrics and gynecology.

Results

Younger providers were more knowledgeable, as were obstetrician/gynecologists, female providers and providers who provide intrauterine contraception in their practice.

Conclusions

The lack of consistent and accurate knowledge about contraception among providers has the potential to dramatically affect providers' ability to provide quality contraceptive care for their patients, which could have an impact on their ability to prevent unintended pregnancies.     

Obesity and contraceptive use among women 20–44 years of age in the United States: results from the 2011–15 National Survey of Family Growth (NSFG)

Objective

Obesity has increased dramatically in the United States in recent decades. Our objective was to explore associations of contraceptive choices of US women, aged 20–44 years, with body mass index (BMI) and relevant covariates.

Pregnancy Intention and Contraceptive Use among Women by Class of Obesity: Results from the 2006–2010 and 2011–2013 National Survey of Family Growth

Objective

Conflicting research findings on the association of obesity and pregnancy intention may be due to their collective definition of obesity at a body mass index of 30 kg/m² or greater. However, obese women with a BMI of 40 kg/m² or greater may be both behaviorally and clinically different from obese women with a lower BMI. This study reexamines this relationship, stratifying by class of obesity; the study also explores variations in contraceptive use by class of obesity given their potential contribution to the incidence of unintended or unwanted pregnancy.

Effect of depot medroxyprogesterone acetate on postpartum depression

Background

Depot medroxyprogesterone acetate (DMPA) is commonly prescribed to women immediately postpartum due to its efficacy, convenience and lack of estrogen. It is unclear whether administering a progestin injection can affect the course of postpartum depression (PPD), which some suspect to be influenced by hormonal changes. In this retrospective study, the objective was to determine whether DMPA administered immediately postpartum influences the development of PPD.

Study Design

A retrospective review of a total of 404 charts was conducted of clinic patients who were scheduled for 6-week postpartum visits at a major medical center, where all patients are routinely asked to complete the Edinburgh Postnatal Depression Scale (EPDS). The average scores on the EPDS at these visits were compared between patients who had received DMPA prior to postpartum discharge from the hospital and patients who had not received any hormonal contraception by using an unpaired t test. In addition, the proportions of women diagnosed with PPD via the scale were compared via contingency tables.

Results

Fifty-five women who had received immediate DMPA were compared with 192 women with no hormonal contraception after delivery. The groups were similar in parity, race, mode of delivery and weight, but women receiving DMPA were significantly younger (24.2 vs. 26.2 years, p=.03). Mean EPDS scores at 6 weeks postpartum were not statistically significant between the groups (5.02 vs. 6.17, p=.16). Six patients (10.9%) who received immediate DMPA were diagnosed with PPD based on EPDS scores greater than or equal to 13, while 27 (14.1%) in the comparison group had PPD (p=.88).

Conclusion

Administration of DMPA in the immediate postpartum period does not appear to predispose women to PPD.     

Implanon users are less likely to be satisfied with their contraception after 6 months than IUD users

Background

The study was conducted to perform a direct comparison of the satisfaction of intrauterine device (IUD) users and Implanon users after 6 months.

Study design

Women were recruited to this study in the contraception clinics of Southern Health and Family Planning Victoria. Each woman completed a questionnaire at the time of starting her contraception with either an IUD or Implanon. Women were sent a follow-up questionnaire after 6 months to assess their satisfaction with their chosen method of contraception.

Results

A total of 439 participants were recruited for this non randomized cohort study; 211 choosing an IUD and 228 choosing to use Implanon. The main reason patients in both groups chose their contraceptive method was recommendation by the doctor. Follow-up was achieved in over 84% in both groups. More than 50% of women in both groups reported at least one side effect. The most commonly reported side effect in both groups was abnormal bleeding and this was also the most common reason for having the contraceptive device removed. The IUD users reported a higher rate of satisfaction with their chosen method of contraception, although there was no difference between groups in the removal rate or whether the women would recommend the contraception to others.

Conclusions

IUD users reported a higher level of satisfaction than did Implanon users at 6 months. Side effects in women using IUDs and Implanon are common. The range of likely side effects should be included in counseling women about long-term reversible contraception.     

The effect of patient gynecologic history on clinician contraceptive counseling

Background

Contraceptive providers have an important influence on women's selection of contraception. Previous studies suggest that clinicians inappropriately limit use of intrauterine contraception (IUC). This study investigated the influence of patients' gynecologic histories on recommendations for IUC and other methods of contraception.

Study Design

Videos of standardized patients varying by history of pelvic inflammatory disease (PID) and parity were shown to clinicians at meetings of national medical societies. Participants indicated their contraceptive recommendations for the patient and whether they would have concerns were the patient to use IUC.

Results

Five hundred twenty-four providers viewed one video of a standardized patient and completed the survey. Gynecologic history was significantly associated with recommendations for the contraceptive ring, contraceptive patch, and copper IUC. Many clinicians indicated that they had concerns about the use of IUC with respect to risks such as PID, infertility and ectopic pregnancy. Concerns about infertility and pain with use of IUC were related to gynecologic history.

Conclusions

Patient gynecologic characteristics affect recommendations for some reversible contraceptive methods. Clinicians continue to have concerns about IUC use despite evidence supporting its safety.     

A randomized controlled trial of the effect of advanced supply of emergency contraception in postpartum teens: a feasibility study

Background

The study was conducted to test the feasibility of conducting a randomized controlled contraceptive trial in postpartum teens and to assess whether postpartum advanced supply of emergency contraception (EC) to teenaged mothers helps to prevent repeat pregnancies of close proximity.

Study Design

We performed a randomized controlled trial of 50 postpartum teens at an urban academic medical center. Participants in the intervention arm received routine postpartum contraceptive care and advanced supply of one pack of EC pills with unlimited supply thereafter upon request. The routine care arm (RCA) received routine postpartum contraceptive care. We asked open-ended questions about how we might maximize study retention and implemented the participants' requests in both arms.

Results

Our retention rate was 78%. There were three (13%) pregnancies out of 23 participants in the intervention arm and eight (30%) pregnancies out of 27 participants in the RCA. The risk of pregnancy occurring in the intervention arm was 0.57 times that of the RCA (95% CI 0.20-1.60; p=.23).

Conclusions

A randomized controlled trial of postpartum teens to receive and not to receive advanced supply of EC is both feasible and necessary. Our study provides preliminary data to suggest that advanced supply of EC may help decrease repeat teen pregnancies.     

Prospective study of weight change in new adolescent users of DMPA, NET-EN, COCs, nonusers and discontinuers of hormonal contraception

Background

Weight gain is commonly reported as a side effect of hormonal contraception and can lead to method discontinuation or reluctance to initiate the method. The purpose of this study was to investigate weight change in adolescent (aged 15-19 years) users of depot-medroxyprogesterone acetate (DMPA), norethisterone enanthate (NET-EN), combined oral contraceptives (COCs) and discontinuers of these methods as compared to nonusers of hormonal contraception.

Study Design

This longitudinal study recruited initiators of DMPA (n=115), NET-EN (n=115), COCs (n=116) and nonusers of contraception (n=144). Participants were followed up for 4-5 years, and details of current contraceptive method, including switching, discontinuing and/or starting hormonal methods were documented at each 6-monthly visit. Women were classified according to their contraceptive histories on completion of the study, and injectable users were combined into one group for analysis. Height, weight and self-reported dieting were recorded at each visit.

Results

There was no difference in mean age or weight between the groups at baseline. Women using DMPA or NET-EN throughout, or switching between the two, had gained an average of 6.2 kg compared to average increases of 2.3 kg in the COC group, 2.8 kg in nonusers and 2.8 kg among discontinued users of any method (p=.02). There was no evidence of a difference in weight gain between women classified as nonobese or classified as overweight/obese in any of the four study groups at baseline.

Conclusion

There is fairly strong evidence that adolescent contraceptive hormonal injectable users appear to gain more weight than COC users, discontinuers and nonusers of contraception.     

Combined oral contraceptive use among breastfeeding women: a systematic review

Background

Postpartum women need effective contraception, but using hormonal contraceptives may affect breastfeeding performance and infant health outcomes.

Study design

We searched the MEDLINE and Cochrane databases for all articles published through May 2009 for primary research studies that investigated clinical outcomes among breastfeeding women who used hormonal contraception or their infants.

Results

Three randomized controlled trials reported decreased mean duration of breastfeeding and higher rates of supplemental feeding among combined oral contraceptive (COC) users than among nonusers, while one multicountry trial found no differences in these parameters. Only one study demonstrated lower average weights during the first year of life for infants whose mothers used COCs while breastfeeding. None of the eight studies, four of which were observational, included in this review documented adverse infant health outcomes.

Conclusions

Limited evidence demonstrates an inconsistent effect of COC on breastfeeding duration and success. The evidence is inadequate to determine whether a mother's use of these drugs affects breastfeeding duration or the infant's health.     

Hormonal contraceptive use among women with liver tumors: a systematic review

Background

The review was conducted to evaluate from the literature the safety of hormonal methods of contraception in women with liver tumors, specifically in benign and malignant disease.

Study Design

We searched PubMed and Cochrane databases to find all articles published from database inception through July 2008 that were relevant to hormonal contraception use and liver tumors.

Results

Of 148 articles, three publications of two studies met the criteria for inclusion in this review; both investigated the use of hormonal contraception in women with the benign liver tumor focal nodular hyperplasia (FNH). In one small, retrospective case series, use of combined oral contraceptives (COCs) over a 4-year average follow-up was not associated with a change in either the number or size of hepatic lesions. In another case series, use of either COCs or progestogen-only contraceptives (POCs) after FNH diagnosis had no influence on disease progression or resolution.

Conclusions

The studies identified examined oral contraceptive use among women with FNH. We did not identify any studies of hormonal contraceptive use among women with hepatocellular adenoma or with malignant liver tumors. Limited, poor-quality evidence suggests that for women with FNH, use of low-dose COCs or POCs does not appear to influence either liver lesion resolution or progression.     

Hormonal contraception and risk of bacterial vaginosis diagnosis in an observational study of women attending STD clinics in Baltimore, MD

Background

The protective effect of hormonal contraception may offer a potential intervention against bacterial vaginosis (BV).

Study Design

Three hundred thirty reproductive-age women enrolled in a contraceptive program from April 2005 to October 2006 at two sexually transmitted diseases clinics in Baltimore, MD. Participants were supplied with hormonal contraceptives of their choice and followed prospectively. BV was diagnosed by Amsel's criteria. Results from population-level analysis were compared to a case-crossover analysis.

Results

BV was diagnosed in 189 (13.0%) of the visits among 133 (40.3%) women. In the population-level analysis, the use of progestin-only and combined contraception was associated with a decreased risk of BV compared to intervals of no hormonal contraceptive use [adjusted odds ratio (AOR): 0.42 (95% CI: 0.20-0.88) and AOR: 0.66 (95% CI: 0.39-1.10), respectively]. The case-crossover analysis demonstrated a similar trend in findings.

Conclusion

Hormonal contraception was associated with a decreased risk of BV in an STD clinic cohort.     

Young unmarried men's understanding of female hormonal contraception

Background

A better understanding of men's attitudes, norms and behaviors regarding women's use of hormonal contraception is needed.

Study Design

We conducted contraceptive life-history interviews with 41 ethnically diverse males ages 18-25 years which detailed up to six heterosexual relationships, focusing on knowledge, attitudes, norms and behaviors regarding hormonal contraception use, decision making and communication.

Results

Men's attitudes, norms and behaviors associated with hormonal contraceptive decisions and use varied greatly across participants and their relationships. Findings suggest a mixture of attitudes and practices regarding the importance of communication around contraception influenced by sexual experiences, age and relationship type. Many men demonstrated limited knowledge about contraceptives and identified improving contraceptive knowledge as an essential step in facilitating contraceptive communication.

Conclusions

Increased awareness about young men's understanding of and perceived roles regarding hormonal contraception will help in designing services that address contraceptive adherence, contraceptive communication and incorrect or inadequate contraceptive knowledge.