Arlete Maria dos Santos Fernandes

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/m(2)) 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 <or=3 years was not associated with weight increase in women with BMI (kg/m(2)) >or=30.

Estimated disability-adjusted life years averted by long-term provision of long acting contraceptive methods in a Brazilian clinic

STUDY QUESTION What is the contribution of the provision, at no cost for users, of long acting reversible contraceptive methods (LARC; copper intrauterine device [IUD], the levonorgestrel-releasing intrauterine system [LNG-IUS], contraceptive implants and depot-medroxyprogesterone [DMPA] injection) towards the disability-adjusted life years (DALY) averted through a Brazilian university-based clinic established over 30 years ago. SUMMARY ANSWER Over the last 10 years of evaluation, provision of LARC methods and DMPA by the clinic are estimated to have contributed to DALY averted by between 37 and 60 maternal deaths, 315-424 child mortalities, 634-853 combined maternal morbidity and mortality and child mortality, and 1056-1412 unsafe abortions averted. WHAT IS KNOWN ALREADY LARC methods are associated with a high contraceptive effectiveness when compared with contraceptive methods which need frequent attention; perhaps because LARC methods are independent of individual or couple compliance. However, in general previous studies have evaluated contraceptive methods during clinical studies over a short period of time, or not more than 10 years. Furthermore, information regarding the estimation of the DALY averted is scarce. STUDY DESIGN, SIZE AND DURATION We reviewed 50 004 medical charts from women who consulted for the first time looking for a contraceptive method over the period from 2 January 1980 through 31 December 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS Women who consulted at the Department of Obstetrics and Gynaecology, University of Campinas, Brazil were new users and users switching contraceptive, including the copper IUD (n = 13 826), the LNG-IUS (n = 1525), implants (n = 277) and DMPA (n = 9387). Estimation of the DALY averted included maternal morbidity and mortality, child mortality and unsafe abortions averted. MAIN RESULTS AND THE ROLE OF CHANCE We obtained 29 416 contraceptive segments of use including 25 009 contraceptive segments of use from 20 821 new users or switchers to any LARC method or DMPA with at least 1 year of follow-up. The mean (± SD) age of the women at first consultation ranged from 25.3 ± 5.7 (range 12-47) years in the 1980s, to 31.9 ± 7.4 (range 16-50) years in 2010-2011. The most common contraceptive chosen at the first consultation was copper IUD (48.3, 74.5 and 64.7% in the 1980s, 1990s and 2000s, respectively). For an evaluation over 20 years, the cumulative pregnancy rates (SEM) were 0.4 (0.2), 2.8 (2.1), 4.0 (0.4) and 1.3 (0.4) for the LNG-IUS, the implants, copper IUD and DMPA, respectively and cumulative continuation rates (SEM) were 15.1 (3.7), 3.9 (1.4), 14.1 (0.6) and 7.3 (1.7) for the LNG-IUS, implants, copper IUD and DMPA, respectively (P < 0.001). Over the last 10 years of evaluation, the estimation of the contribution of the clinic through the provision of LARC methods and DMPA to DALY averted was 37-60 maternal deaths; between 315 and 424 child mortalities; combined maternal morbidity and mortality and child mortality of between 634 and 853, and 1056-1412 unsafe abortions averted. LIMITATIONS, REASONS FOR CAUTION The main limitations are the number of women who never returned to the clinic (overall 14% among the four methods under evaluation); consequently the pregnancy rate could be different. Other limitations include the analysis of two kinds of copper IUD and two kinds of contraceptive implants as the same IUD or implant, and the low number of users of implants. In addition, the DALY calculation relies on a number of estimates, which may vary in different parts of the world. WIDER IMPLICATIONS OF THE FINDINGS LARC methods and DMPA are highly effective and women who were well-counselled used these methods for a long time. The benefit of averting maternal morbidity and mortality, child mortality, and unsafe abortions is an example to health policy makers to implement more family planning programmes and to offer contraceptive methods, mainly LARC and DMPA, at no cost or at affordable cost for the underprivileged population. STUDY FUNDING/COMPETING INTERESTS This study received partial financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant # 2012/12810-4 and from the National Research Council (CNPq), grant #573747/2008-3. B.F.B., M.P.G., and V.M.C. were fellows from the scientific initiation programme from FAPESP. Since the year 2001, all the TCu380A IUD were donated by Injeflex, São Paulo, Brazil, and from the year 2006 all the LNG-IUS were donated by the International Contraceptive Access Foundation (ICA), Turku, Finland. Both donations are as unrestricted grants. The authors declare that there are no conflicts of interest associated with this study.

Violência sexual: estudo descritivo sobre as vítimas e o atendimento em um serviço universitário de referência no Estado de São Paulo, Brasil

A violencia sexual e problema de saude publica global e acoes tem sido implementadas para estimular estudos no tema, a fim de propor intervencoes de prevencao e atendimento adequado. Este trabalho objetivou caracterizar a populacao de mulheres que sofreram violencia sexual, e descrever as caracteristicas da agressao e do atendimento dispensado em um servico universitario de referencia. Estudo quantitativo e retrospectivo com atendimentos por violencia sexual de junho de 2006 a dezembro de 2010. Avaliadas 687 mulheres, a maioria branca, solteira, sem filhos, com idade media de 23,7 anos, escolaridade entre fundamental e media, empregadas, com religiao e pratica religiosa. Um quarto sem relacao sexual anterior. Violencia sexual principalmente a noite, na rua, por agressor desconhecido e unico, via vaginal e com intimidacao. A maioria contou para outras pessoas e se sentiu apoiada. Atendimento precoce para quase 90% das mulheres, instaurando medidas profilaticas. Ocorreu aumento da procura precoce ao longo do periodo. Conhecer melhor as caracteristicas da populacao e do evento pode auxiliar a estruturacao e qualificacao de modelos de atendimento.

A three-year longitudinal evaluation of the forearm bone density of users of etonogestrel- and levonorgestrel-releasing contraceptive implants

BackgroundThe aim of this study was to evaluate bone mineral density (BMD) at baseline and at 18 and 36 months of use of etonogestrel (ENG)-and levonorgestrel (LNG)-releasing contraceptive implants. This is a continuation of a previous study in which BMD was evaluated at baseline and at 18 months of use.MethodsA total of 111 women, 19–43 years of age, wererandomly allocated to use one of the two implants. At 36 months of follow-up, only 36 and 39 women were still using the ENG- and LNG-releasing implants, respectively. BMD was evaluated at the distal and at the ultra-distal radius of the non-dominant forearm using dual-energy X-ray absorptiometry.ResultsThere was no difference in the BMD of users of either implant at 18 and at 36 months. BMD was significantly lower at 18 and at 36 months at the distal radius in both groups of users compared to pre-insertion values; however, no difference was found at the ultra-distal radius.ConclusionWomen 19–43 years of age using either one of these two contraceptive implants for 36 months had lower BMD values at the distal radius compared to pre-insertion values; however, no difference was found at the ultra-distal radius.

Human vaginal histology in long-term users of the injectable contraceptive depot-medroxyprogesterone acetate.

OBJECTIVES Apparently, depot-medroxyprogesterone acetate (DMPA) increases a womans risk of acquiring HIV. The objective of this study was to test whether the vaginal mucosal thickness and Langerhans cell counts were significantly different in long-term DMPA users compared with women users of an intrauterine device (IUD) who had never used DMPA. STUDY DESIGN Cross-sectional study. Twenty-three DMPA users were matched with 23 nonusers controlled for age, body mass index (BMI; kg/m²), and duration of contraceptive use. Four groups of women were evaluated according to the duration of DMPA use: >1, <5; ≥5, <10; ≥10, <15 or ≥15 years. Estradiol (E₂) levels were compared between the two groups. Histologic sections of vaginal mucosal biopsies were evaluated to measure the mean epithelial thickness and S100 immunostained sections were used to count the number of Langerhans cells/mm. RESULTS Mean (±S.D.) E₂ levels were significantly lower in DMPA users (39.4±26.6 pg/mL) compared with nonusers (102.6±60.3 pg/mL) despite similar ages (42.3±7.4 and 42.4±7.4 years, respectively). Mean (±S.D.) vaginal thickness was 232.6±108.1 and 229.7±112.9 in DMPA users and nonusers, respectively. There were no differences in vaginal thickness or Langerhans cell count/mm between users and nonusers even after controlling for DMPA duration of use. CONCLUSIONS Vaginal epithelial thinning or Langerhans cell count was not different between long-term DMPA users and copper-IUD users who had never used DMPA. IMPLICATIONS No differences were found in vaginal epithelial thickness or in Langerhans cell count between long-term users of the injectable contraceptive DMPA and nonusers.

Variação de peso em usuárias de sistema intra-uterino liberador de levonorgestrel, DIU T-cobre e acetato de medroxiprogesterona no Brasil

BACKGROUND: Assess weight variations in Brazilian users of the 20 µg/day levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena®) for comparison with a cohort of users of the TCu 380A intrauterine device (IUD) and a cohort of users of the injectable contraceptive, depot-medroxyprogesterone acetate (DMPA) over a period of five years. METHODS: A total of 163 users of the LNG-IUS, who had the device inserted in 1998, were admitted to the study. At the time of enrollment, each woman was matched by weight (± 1kg) and age (± 1year) to a woman using a TCu 380A IUD and to another woman using DMPA. All women were followed up for a period of five years. Each year weight was measured and the body mass index (BMI, kg/m2) was calculated. RESULTS: Age of the LNG-IUS users was 27.0 ± 6.7 years (mean ± SD), while age of the copper IUD users was 28.0 ± 6.6 years and that of DMPA users was 26.9 ± 6.5 years. Weight recorded at the onset of the study was 62.9 ± 0.8 kg, 62.8 ± 0.8 kg, and 62.5 ± 0.9 kg (Mean ± SD) for users of the LNG-IUS, the copper IUD, and DMPA, respectively. The BMI of women was initially 25.0 (±0.3), 26.4 (±0.3), and 25.5 (±0.4), (Mean ± SD), for users of the LNG-IUS, copper IUD, and DMPA, respectively. Weight increases of 3.1 kg, 4.9kg and 8.2kg were observed at the end of the fifth year among users of the LNG-IUS, copper IUD, and DMPA, respectively (p = 0.009). Increase of the BMI was also observed among all groups (final BMI was 26.3 ± 0.7, 28.5 ± 0.8 and 28.7 ± 1.3 for users of the LNG-IUS, copper IUD and DMPA, respectively). Multivariate analysis showed that there was a significant association between weight increase and length of use of the contraceptive method and of the DMPA. CONCLUSION: The use of a LNG-IUS during five years caused no significant weight increase and the difference in weight was of the same magnitude as that of copper IUD users.

Chlamydia trachomatis and Neisseria gonorrhoeae among women in a family planning clinic

PURPOSE: to study infection prevalence by Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG), among adolescent and young women in a family planning outpatient clinic. METHODS: a total of 230 women up to 24 years old and history of up to four sexual partners have been followed-up for 48 months, with urine collection to search CT and NG, by the polymerase chain reaction method at the 1st, 12nd, 24th, 36th and 48th months. The variables studied were age group, schooling, marital status, number of gestations, abortions and children alive, age at the onset of sexual life, previous and present use of condom, previous use of intrauterine device, number of sexual partners in the previous six months and follow-up time. Bivariate analysis of variables according to positive tests for CT and NG, and multiple analyses by logistic regression were done. RESULTS: the ratio of infections by CT was 13.5% and by NG, 3%. Two women presented both tests as positive. The previous intrauterine device use was associated with positive tests for NG. CONCLUSIONS: the prevalence of infections by CT and NG was higher among the age group studied and the screening of young women must be taken into consideration in our services, to control the dissemination of sexually transmitted diseases and prevention of sequels. Departamento de Tocoginecologia da Faculdade de Ciências Médicas da Universidade Estadual de Campinas – UNICAMP – Campinas (SP), Brasil. 1 Professores-assistente do Departamento de Tocoginecologia da Faculdade de Ciências Médicas da Universidade Estadual de Campinas – UNICAMP – Campinas (SP), Brasil. 2 Acadêmico do Curso de Medicina da Faculdade de Ciências Médicas da Universidade Estadual de Campinas – UNICAMP – Campinas (SP), Brasil. 3 Professor Livre-docente do Departamento de Tocoginecologia da Faculdade de Ciências Médicas da Universidade Estadual de Campinas – UNICAMP – Campinas (SP), Brasil. Palavras-chave Doenças sexualmente transmissíveis Chlamydia trachomatis Neisseria gonorrhoeae Prevalência Saúde da mulher Planejamento familiarPURPOSE to study infection prevalence by Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG), among adolescent and young women in a family planning outpatient clinic. METHODS a total of 230 women up to 24 years old and history of up to four sexual partners have been followed-up for 48 months, with urine collection to search CT and NG, by the polymerase chain reaction method at the 1st, 12nd, 24th, 36th and 48th months. The variables studied were age group, schooling, marital status, number of gestations, abortions and children alive, age at the onset of sexual life, previous and present use of condom, previous use of intrauterine device, number of sexual partners in the previous six months and follow-up time. Bivariate analysis of variables according to positive tests for CT and NG, and multiple analyses by logistic regression were done. RESULTS the ratio of infections by CT was 13.5% and by NG, 3%. Two women presented both tests as positive. The previous intrauterine device use was associated with positive tests for NG. CONCLUSIONS the prevalence of infections by CT and NG was higher among the age group studied and the screening of young women must be taken into consideration in our services, to control the dissemination of sexually transmitted diseases and prevention of sequels.

Laqueadura intraparto e de intervalo

O Brasil e um dos paises com alta prevalencia de laqueadura tubaria, sendo frequente sua realizacao durante o parto. Nos ultimos anos, tem-se notado aumento da busca por reversao, principalmente entre mulheres jovens. OBJETIVOS: Estudar, em amostra de mulheres laqueadas, as caracteristicas relacionadas ao procedimento, determinar a frequencia de execucao intraparto, medir as taxas de satisfacao e arrependimento com o metodo. METODOS: Foram entrevistadas 335 mulheres laqueadas. As variaveis estudadas foram as relacionadas ao procedimento: idade na laqueadura, se intraparto (vaginal ou cesarea) ou de intervalo (fora do periodo de parto e puerperio), servico no qual foi realizada, pagamento pelo procedimento, motivo declarado para a opcao pelo metodo, e as relacionadas a satisfacao/arrependimento: desejo de gravidez apos esterilizacao, procura por tratamento e realizacao da cirurgia de reversao. As mulheres foram divididas em dois grupos, laqueadas intraparto e intervalo, avaliando-se associacao das variaveis pelo teste Exato de Fisher e Qui-quadrado com correcao de Yates. O estudo obteve aprovacao do Comite de Etica. RESULTADOS: Predominaram mulheres brancas, com mais de 35 anos, unidas, com baixa escolaridade e 43,5% esterilizadas antes dos 30 anos. Haviam realizado laqueadura intraparto 245 mulheres, 91,2% daquelas com parto cesarea e 44,6% com parto vaginal. Nos dois grupos, laqueadas intraparto e de intervalo, estavam satisfeitas com o metodo 82% e 80,8% das mulheres respectivamente. Apesar de 14,6% terem referido desejo de engravidar alguma vez apos esterilizacao, consultaram por esterilidade 3,4% e 2,3%, respectivamente, e uma mulher submeteu-se a cirurgia de reversao. Os motivos mais frequentes para a escolha do metodo foram a satisfacao com a prole (35,5% e 46,7%) e a indicacao medica (41,6% e 32,2%), respectivamente. CONCLUSAO: A laqueadura intraparto foi maior quando o ultimo parto foi cesarea. Nao se detectou diferenca nas taxas de satisfacao e arrependimento apos o procedimento entre os grupos.

Contraceptive sales in the setting of the Zika virus epidemic

STUDY QUESTION Has there been any influence of the Zika virus (ZIKV) outbreak on the sales of contraceptive methods in Brazil? SUMMARY ANSWER Contraceptive sales in the 24 months of evaluation showed little variation and no significant change has been observed since the ZIKV outbreak. WHAT IS KNOWN ALREADY Transmission of ZIKV is primarily by Aedes aegypti mosquitoes; however, sexual transmission has also been described. The association of several birth defects and the ZIKV infection during pregnancy has been established, and it was estimated in Bahia, Brazil that the infection rate could range from 10% to 80%. The World Health Organisation (WHO) declared the cluster of microcephaly cases and other neurological disorders a health emergency on 1 February 2016. The Brazilian government also made recommendations for women who were planning to become pregnant and who reside in ZIKV-affected areas to reconsider or postpone pregnancy. STUDY DESIGN, SIZE, DURATION The objective of this study was to assess the sales of contraceptive methods in Brazil, tracking it from before and through the ZIKV outbreak. We obtained information from all pharmaceutical companies based in Brazil and from the manufacturers of long-acting reversible contraceptives (LARCs), including the copper-intrauterine device (IUD), the levonorgestrel-releasing intrauterine system (LNG-IUS) and implants, about contraceptives sales in the public and private sectors between September 2014 and August 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS We analyzed the data for: (i) oral contraceptives, i.e. combined oral contraceptives (COC) and progestin-only pills (POP), and vaginal and transdermal contraceptives, (ii) injectable contraceptives, i.e. once-a-month and depot-medroxyprogesterone acetate, (iii) LARCs and (iv) emergency contraceptive (EC) pills. MAIN RESULTS AND THE ROLE OF CHANCE Monthly sales of COC, POP, patches and vaginal rings represent the major sales segment of the market, i.e. 12.7–13.8 million cycles/units per month (90%). The second largest group of sales was injectables, representing 0.8–1.5 million ampoules per month (9.5%). Following this, are LARC methods with sales of 37 000–41 000 devices per month (0.5%). It is important to note that although the peak months of sales were different for each group of contraceptives, there were no significant differences overall between the months of observation. The EC pill sales were between 1.0 million and 1.3 million of pills per month. LIMITATIONS, REASONS FOR CAUTION Although the use of contraceptive methods was already high and no change was noted, the ZIKV outbreak may have changed the pregnancy intentions of Brazilian women. Consequently, the number of women planning pregnancy may be lower than that recorded. The contraceptive sales figures did not include condoms. Since condoms might not only prevent pregnancies, but also sexual transmission of ZIKV, this lack of information is a limitation. WIDER IMPLICATIONS OF THE FINDINGS The results from this assessment showed that the sales of contraceptives presented little variation during the ZIKV outbreak in Brazil. Furthermore, it is possible that access to LARC methods was limited. Although we did not investigate the reason for low LARC uptake, we suspect that it is due to lack of availability of LARC in the public sector, the high cost of the methods and the incomplete insurance coverage on contraception for women. Projections estimate millions of additional cases of ZIKV transmission. Thus, a coordinated response is needed to ensure access to a wide range of contraceptive methods for women during the ZIKV outbreak. In conclusion, this assessment of contraceptive sales in Brazil identifies challenges in contraceptive access, especially for LARC methods, and represents an alternative source of data to help us understand the trends in demand for contraception in ZIKV-affected areas. STUDY FUNDING/COMPETING INTEREST(S) This study received partial financial support from Fundação de Apoio à Pesquisa do Estado de São Paulo (FAPESP) award # 2015/20504-9 and from an anonymous donor. The funding sources did not play a role in the study design, in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the article for publication. The authors declare no conflict of interest associated with this study. TRIAL REGISTRATION NUMBER N/A

Perception of intimate partner violence among women seeking care in the primary healthcare network in São Paulo state, Brazil

To evaluate the prevalence and perception of intimate partner violence (IPV) among women in the primary healthcare network in the state of São Paulo, Brazil.