Laureen M Lopez

Menstrual pattern changes from levonorgestrel subdermal implants and DMPA: systematic review and evidence-based comparisons

BACKGROUND Many women want a lengthy duration of contraception but are wary of the menstrual changes from depot medroxyprogesterone acetate (DMPA). A subdermal levonorgestrel (LNG) implant may be a reasonable alternative. However, information on menstrual changes from these methods has not been summarized and compared in an easy-to-understand form. STUDY DESIGN We systematically reviewed the published literature on these contraceptives to find research that used menstrual diaries and standard World Health Organization definitions. We attempted to find information on amenorrhea, number of bleeding or spotting episodes, number of bleeding or spotting days and normal patterns, as reported in four consecutive 90-day reference periods. RESULTS We found 16 published articles meeting our criteria and involving diaries of up to 1600 DMPA users and 2300 LNG implant users. We were able to compare the two methods on only three outcomes. For DMPA use, the weighted prevalence of amenorrhea at successive 90-day periods was 12%, 25%, 37% and 46%. The comparable estimates for the LNG implant were 11%, 13%, 9% and 13%. Levonorgestrel implant users experienced a higher average number of bleeding or spotting days compared to DMPA users, but this average was similar to what is expected naturally. At 12 months, normal menstrual patterns were experienced by 23% of LNG implant users compared to 11% of DMPA users. CONCLUSIONS Like most hormonal contraception, LNG implants usually produce menstrual changes; however, the changes do not appear to deviate from normal patterns as much as the changes from DMPA. Understanding these differences and other method attributes might help women make an informed choice about which contraceptive to use.

Sino-implant (II)--a levonorgestrel-releasing two-rod implant: systematic review of the randomized controlled trials.

BACKGROUND Sino-implant (II) is a subdermal contraceptive implant manufactured in China. This two-rod levonorgestrel-releasing implant has the same amount of active ingredient (150 mg levonorgestrel) and mechanism of action as the widely available contraceptive implant Jadelle. We examined randomized controlled trials of Sino-implant (II) for effectiveness and side effects. STUDY DESIGN We searched electronic databases for studies of Sino-implant (II) and then restricted our review to randomized controlled trials. The primary outcome of this review was pregnancy. RESULTS Four randomized trials with a total of 15,943 women assigned to Sino-implant (II) had first-year probabilities of pregnancy ranging from 0.0% to 0.1%. Cumulative probabilities of pregnancy during the 4 years of the products approved duration of use were 0.9% and 1.06% in the two trials that presented date for 4-year use. Five-year cumulative probabilities of pregnancy ranged from 0.7% to 2.1%. In one trial, the cumulative probability of pregnancy more than doubled during the fifth year (from 0.9% to 2.1%), which may be why the implant is approved for 4 years of use in China. Five-year cumulative probabilities of discontinuation due to menstrual problems ranged from 12.5% to 15.5% for Sino-implant (II). CONCLUSIONS Sino-implant (II) is one of the most effective contraceptives available today. These available clinical data, combined with independent laboratory testing, and the knowledge that 7 million women have used this method since 1994, support the safety and effectiveness of Sino-implant (II). The lower cost of Sino-implant (II) compared with other subdermal implants could improve access to implants in resource-constrained settings.

Nonhormonal drugs for contraception in men: a systematic review.

Nonhormonal drugs for contraception in men may have advantages over hormonal methods. The nonhormonal methods can have more rapid onset and less interference with androgen-dependent functions. This systematic review summarizes the clinical studies evaluating nonhormonal drugs administered to men for contraception. Relevant clinical results were found for gossypol, which is derived from the cotton plant, and for extracts of Tripterygium, a plant used in Chinese traditional medicine. Randomized, controlled trials were available on the efficacy of gossypol and on the effect of gossypol on potassium levels. Gossypol had problems with low efficacy and toxicity. For Tripterygium, 2 observational studies described men who were treated for rheumatoid arthritis. Although sperm density was lower among those taking Tripterygium, later reports indicated some toxicity. Nonclinical research continues on isolates of Tripterygium. No clinical studies for contraception in men were found for nonhormonal vaccines or neem, which is also a plant used for medicinal purposes. Clinical trials studied injecting styrene maleic anhydride into the vas deferens, but no comparative data were provided. At this time, no safe and effective nonhormonal drug is available for contraception in men. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to state that the number of studies concerning the use of nonhormonal drugs for male contraception are very limited, point out that the two nonhormonal drugs used to a small degree have varying results and serious side effects, and recall that there are limited clinical studies on use of vas deferens injections and vaccines in humans.

Theory-based strategies for improving contraceptive use: a systematic review ☆

BACKGROUND Theories and models help explain how behavior change occurs. We systematically reviewed randomized controlled trials that examined theory-based interventions for improving contraceptive use. STUDY DESIGN We searched electronic databases for eligible trials. Primary outcomes included pregnancy and contraceptive use. We calculated the odds ratio for dichotomous outcomes and the mean difference for continuous data. RESULTS Of 14 included trials, 10 showed positive results for a theory-based group: 2 of 10 studies with pregnancy or birth data, 4 of 9 addressing contraceptive use (for contraception) and 5 of 9 with condom use (to prevent HIV/sexually transmitted infections). An experimental group had favorable results for six of seven trials based on Social Cognitive Theory, two based on other social cognition models and two using motivational interviewing. Most interventions focused on adolescents and involved multiple sessions. CONCLUSIONS Effects were not consistent across outcomes and comparisons. The field could benefit from thorough use of single theories and better reporting on intervention implementation.

Emotional impact of screening: a systematic review and meta-analysis

BackgroundThere is a widely held expectation that screening for disease has adverse emotional impacts. The aim of the current review is to estimate the short (< 4 weeks) and longer term (> 4 weeks) emotional impact of such screening.MethodsStudies selected for inclusion were (a) randomised controlled trials in which (b) participants in one arm underwent screening and received test results, and those in a control arm did not, and (c) emotional outcomes were assessed in both arms. MEDLINE via PubMed (1950 to present), EMBASE (1980 to present), PsycINFO (1985 to present) using OVID SP, and CINAHL (1982 to present) via EBSCO were searched, using strategies developed with keywords and medical subject headings. Data were extracted on emotional outcomes, type of screening test and test results.ResultsOf the 12 studies that met the inclusion criteria, six involved screening for cancer, two for diabetes, and one each for abdominal aortic aneurysms, peptic ulcer, coronary heart disease and osteoporosis. Five studies reported data on anxiety, four on depression, two on general distress and eight on quality of life assessed between one week and 13 years after screening (median = 1.3 years).Meta-analyses revealed no significant impact of screening on longer term anxiety (pooled SMD 0.01, 95% CI -0.10, 0.11), depression (pooled SMD -0.04, 95% CI -.12, 0.20), or quality of life subscales (mental and self-assessed health pooled SMDs, respectively: 0.03; -0.01, (95% CI -.02, 0.04; 0.00, 95% CI -.04, 0.03).ConclusionScreening does not appear to have adverse emotional impacts in the longer term (> 4 weeks). Too few studies assessed outcomes before four weeks to comment on the shorter term emotional impact of screening.

Postpartum education for contraception: a systematic review.

Contraceptive education is generally considered a standard component of postpartum care, but the effectiveness is seldom examined. Two-thirds of postpartum women may have unmet needs for contraception, and many adolescents become pregnant again within a year of giving birth. Women may prefer to discuss contraception prenatally or after hospital discharge. The objective of this systematic review was to assess the effects of educational interventions for postpartum mothers about contraceptive use. We searched computerized databases for randomized controlled trials that evaluated the effectiveness of postpartum contraceptive education. The intervention must have started within 1 month after delivery. The Mantel-Haenszel odds ratio was calculated with 95% confidence interval for the dichotomous outcomes. Eight trials met the inclusion criteria. Of 4 short-term interventions, 1 did not have sufficient data and 1 was statistically underpowered. The remaining 2 showed a positive effect on contraceptive use. Of 4 multifaceted programs, 2 showed fewer pregnancies or births among adolescents in the experimental group that had enhanced services, and 1 structured home-visiting program showed more contraceptive use. The effective interventions were conducted in Australia, Nepal, Pakistan, and the United States. Postpartum education about contraception led to more contraception use and fewer unplanned pregnancies. Short-term interventions were limited by self-reported outcomes or showing no effect for many comparisons. The longer-term programs were promising and not necessarily more costly than usual care. Health care providers can determine if 1 of these interventions suits their setting and level of resources. Target Audience: Obstetricians & Gynecologist, Family Physicians Learning Objectives: After completing this educational activity, the participant should be better able to assess the importance of assessing delivery methods when examining intervention quality, evaluate the evidence from randomized trials on the effectiveness of postpartum education, and employ why additional research on postpartum education is needed for improving clinical practice.

Correction: Emotional impact of screening: A systematic review and meta-analysis

After the publication of this work [1], we became aware that two of the twelve studies included in the review [refs 25 and 30] were erroneously described as not having presented outcomes by randomisation (ie those randomised to screening vs those randomised not to be screened). Instead they were described as having presented outcomes according to those who were randomised and who attended vs those randomised not to be screened).

When to start hormonal contraceptives

“Circular patches of hair loss, with no scarring to the affected area, can be a sign of alopecia areata, a distressing condition which can affect all the hair on the scalp and body. We don’t yet understand the cause of alopecia areata but it can start at any age, usually before the age of 20. Men and women are affected equally and it’s a relatively common condition all around the world. Treatments that have been suggested and used include a variety of creams or lotions applied to the scalp such as topical minoxidil, and some ultraviolet light-based therapies. Oral medications, such as corticosteroids, have also been tried. Some of the skin treatments can have unpleasant side effects, including itchiness or hair growth in areas of the body away from where the cream was applied. While, oral steroids in particular may cause serious side effects. And, even if the treatment does lead to hair re-growth, there is no guarantee that this will remain when the treatment is stopped. To complicate matters even more, alopecia areata sometimes clears up without treatment. So, if hair does grow back during treatment, it is difficult to know whether this would have happened anyway. This means that for studies to be reliable, they need to include a control group of people who do not get the treatment. We set out to see if, on balance, these treatments are helpful and found 17 randomised controlled trials, involving 540 participants. The trials were fairly small, ranging in size from just 6 people to 85. They assessed a range of treatments that included topical and oral steroids, topical ciclosporin, photodynamic therapy and topical minoxidil. We found no randomised trials on some other common treatments, such as diphencyprone, dinitrochlorobenzene, intralesional corticosteroids and dithranol. No studies showed long-term beneficial hair growth. Overall, none of the treatments were significantly better than placebo in terms of hair growth; but most of the trials were reported so poorly and were so small that they may have missed clinically important benefits. Answers are still needed. Future studies need to be much larger and to compare the treatment against a placebo. Similarly, because short-term interventions might not ‘cure’ alopecia areata or lead to long-term benefit, these trials should focus on treatments that are safe and sustainable. Future studies should also measure and report the feelings of the participants about their hair growth or quality of life. We would also like to see trials testing good quality wigs and other supportive therapies against pharmaceutical interventions. Such trials, using patient satisfaction outcomes, would be invaluable.”