Mark D. Nichols

Bleeding patterns and patient acceptability of standard or continuous dosing regimens of a low-dose oral contraceptive: a randomized trial

The purpose of this study is to compare bleeding patterns and acceptability of a contraceptive regimen of combined 20 microg ethinyl estradiol/100 microg levonorgestrel taken with and without a hormone-free interval. Thirty-two women desiring oral contraception were randomized to six 28-day cycles (standard group) or 168 days without a pill-free interval (continuous group). Participants kept a daily bleeding calendar documenting bleeding events (none, spotting or required sanitary protection) and side effects (headache, nausea, breast tenderness, depression, premenstrual syndrome and bloating). Primary outcome was number of bleeding days. Secondary outcomes included bleeding days requiring sanitary protection, amenorrhea, patient acceptability of bleeding patterns, method satisfaction and affective side effects. There were no differences in the baseline characteristics of the two groups. Although total bleeding days were fewer in the continuous group (mean = 25.9 vs. 34.9 days), this result did not reach statistical significance. However, women in the continuous group reported significantly fewer bleeding days that required protection (18.4 vs. 33.8 days, p < 0.01), and were more likely to have amenorrhea. Although both groups reported a high level of satisfaction with bleeding patterns and side effect profiles, women in the continuous group reported significantly fewer days of bloating (0.7 vs. 11.1 days, p = 0.04), and menstrual pain (1.9 vs. 13.3 days, p < 0.01). Continuous use of 20 microg ethinyl estradiol/100 microg levonorgestrel is associated with less bleeding requiring protection, and more amenorrhea than standard administration. Taken with or without a hormone-free interval, this oral contraceptive formulation is highly acceptable with regard to bleeding patterns and side effect profile. The continuous group had fewer light and moderate bleeding days, less bloating and menstrual pain. For patients who are seeking these results, this method may be more desirable.

Effect of low-dose oral contraceptives on androgenic markers and acne

Oral contraceptives (OC) suppress excess androgen production; however, different progestins in combination with low-dose estrogens produce divergent effects on sex hormone-binding globulin (SHBG) and testosterone that may influence clinical outcomes. This multicenter, open-label, randomized study compared biochemical androgen profiles and clinical outcomes associated with two OC containing the same amounts of ethinyl estradiol (EE, 20 micrograms) but different progestins, levonorgestrel (LNG, 100 micrograms), and norethindrone acetate (NETA, 1000 micrograms). Fifty-eight healthy women (18-28 years old) received three cycles of treatment with LNG/EE (n = 30) or NETA/EE (n = 28). The results showed that LNG reduced androgen levels in three compartments--adrenal, ovarian, and peripheral. NETA reduced only adrenal and peripheral androgens. Despite a 2.2-fold greater relative increase in SHBG with NETA than LNG, bioavailable testosterone (T) was reduced by the same amount with LNG and NETA. Both treatments improved acne and were well tolerated. Low-dose OC (EE, 20 micrograms) are effective in reducing circulating androgens and acne lesions without causing weight gain. Although LNG and NETA affected secondary markers differently, both OC formulations produced an equivalent decrease in bioavailable.

Barriers associated with the failure to return for intrauterine device insertion following first-trimester abortion

BACKGROUND The aim of the study was to identify barriers associated with the failure to return for delayed intrauterine device (IUD) insertion postabortion. STUDY DESIGN This study had two components: (a) a retrospective cohort study of women who chose an IUD as their postabortion contraceptive method to compare characteristics of those who did and did not receive a device within 6 months of the procedure and (b) a prospective survey of women intending IUD use postabortion to assess actual IUD use at 6 weeks, barriers to access and attitudes on insertion timing. RESULTS Of the 500 abortion patient charts available for review during the study period, 53 women intended IUD use postabortion. At 6 months, only 32% intending an IUD received one, and there were no significant demographic differences between the groups. For the prospective portion, the response rate at 6 weeks was 54% (27/50), with only 26% (7/27) of responders reporting IUD insertion by this time. The principal reported barrier to IUD insertion was time needed for an additional visit (41%). Most women (67%) desired immediate insertion and believed that they would be more likely to have an IUD inserted if it is performed immediately postabortion (63%). Monthly income was the only statistically significant difference between those who responded to the 6-week follow-up (US

Body mass index and sexual behavior.

1409.50) and those who did not (US

The relationship between body mass index and unintended pregnancy : results from the 2002 National Survey of Family Growth

937.50, p=.05). CONCLUSION A significant number of women that express a preference for IUD use after first-trimester abortion do not return to obtain a device. Most would prefer to have the option of immediate insertion.

Effect of four combined oral contraceptives on blood pressure in the pill-free interval

OBJECTIVE: To characterize the relationship between body mass index and sexual behavior, including sexual orientation, age at first intercourse, ever having had sex with a male partner, number of partners, and frequency of intercourse. METHODS: This study employed the 2002 National Survey of Family Growth, a cross-sectional, nationally representative database in which women between the ages of 15 years and 44 years were surveyed regarding reproductive health outcomes. Sexual behavior was compared between body mass index groups—normal (less than 25 m/kg2), overweight (25–30 m/kg2), and obese (greater than 30 m/kg2)—using self-reported height and weight. Multiple logistic regression with adjustment for the sampling design was used to measure associations of interest. RESULTS: Body mass index was not significantly associated with sexual orientation, age at first intercourse, frequency of heterosexual intercourse, and the number of lifetime or current male partners. Overweight women and obese women were more likely to report ever having male sexual intercourse (P<.001). This difference persisted when we adjusted for age as well as type of residence. CONCLUSION: With the exception of ever engaging in sexual intercourse with a man, sexual behavior differs little between women of different body mass indices. LEVEL OF EVIDENCE: II

Successful medical abortion of a pregnancy within a noncommunicating rudimentary uterine horn.

BACKGROUND The study was conducted to characterize the relationship between body mass index (BMI) and unintended pregnancy, contraceptive use patterns, and perceived fertility. METHODS This study employed a cross-sectional, nationally representative database (2002 National Survey of Family Growth). Unintended pregnancy was compared among BMI groups [normal (<25 m/kg(2)), overweight (25-30 m/kg(2)) and obese (>30 m/kg(2))]. Analyses also evaluated the association between demographic, socioeconomic, behavioral and health-related variables and BMI. Multiple logistic regression with adjustment for sampling design was used to measure associations of interest. RESULTS BMI data were available from 6690 nonpregnant women. Of these, 3600 (53.6%) were normal weight, 1643 (25%) were overweight and 1447 (21.4%) were obese. Compared to women with normal BMIs, the risk of unintended pregnancy in the last 5 years did not differ among overweight [adjusted OR 0.95 (95% CI 0.77-1.17)] or obese [adjusted OR 0.87 (95% CI 0.70-1.09)] women. There were no differences in contraceptive use patterns or perceived fertility among BMI groups. CONCLUSION Data from the 2002 NSFG do not support an association between obesity and unintended pregnancy.

Continuous oral contraceptives : Are bleeding patterns dependent on the hormones given?

OBJECTIVE To evaluate blood pressure changes in the pill-free interval and from baseline among women taking four different low-dose monophasic oral contraceptives. DESIGN 131 women were randomized to four different oral contraceptives. Pressures were obtained at baseline, at the end of treatment cycles and at the end of the 7 pill-free days, during 6 months of treatment. Pressures were obtained at 4 and 8 weeks after discontinuation. Group 1 received norethisterone acetate 1000 micrograms, group 2 received levonorgestrel 150 micrograms, group 3 received desogestrel 150 micrograms, and group 4 received gestodene 75 micrograms, all combined with ethinyloestradiol 30 micrograms. RESULTS All four groups showed an increase in pressure during treatment, with return to baseline levels four weeks after treatment. At the end of the pill-free interval, the readings did not differ significantly from on treatment except for women in Group 4, who experienced an increase in diastolic pressure. CONCLUSIONS Use of the four oral contraceptives was associated with a small increase in systolic and diastolic pressure. Whatever mechanism causes the increase is not entirely reversible by 7 days without treatment.

Intrauterine lidocaine infusion for pain management in first-trimester abortions

In asymptomatic patients with an early gestation located in a noncommunicating rudimentary horn, methotrexate may provide another treatment option or act as a useful adjunct to surgical intervention. We present a case of a successful pregnancy termination of a gestation located in a noncommunicating rudimentary horn with subsequent elective laparoscopic resection.

Pain control in first-trimester surgical abortion: a systematic review of randomized controlled trials

OBJECTIVE: To estimate whether progestin type or estrogen dose influences bleeding patterns, adverse effects, or satisfaction with combined oral contraceptives dosed continuously. METHODS: This was a randomized, double blind, 4-arm active treatment study. Subjects received either 100 &mgr;g levonorgestrel/20 &mgr;g ethinyl estradiol (E2) (20LNG group), 100 &mgr;g levonorgestrel/30 &mgr;g ethinyl E2 (30LNG group), 1,000 &mgr;g norethindrone acetate/20 &mgr;g ethinyl E2 (20NETA group), or 1,000 &mgr;g norethindrone acetate/30 &mgr;g ethinyl E2 (30NETA group) for 180 days. Subjects logged bleeding events and adverse effects on a daily menstrual calendar. An exit survey measured satisfaction with bleeding patterns. RESULTS: One hundred thirty-nine women were enrolled. Patients in the 20NETA and 30NETA arms had significantly more days of amenorrhea than the 30LNG arm in the second 90 days (P < .008). The 30LNG group reported more spotting days than the 20NETA group over the entire study period (P < .008) and the 30NETA group for the second 90 days (P < .008). Only a small number of bleeding days were reported with no differences between groups. No differences in adverse effects between groups were found. Women in the 30LNG arm reported lower levels of satisfaction with their bleeding patterns than the other groups (30LNG compared with 20NETA, P = .01; 30LNG compared with 30NETA, P = .001). CONCLUSION: The addition of 10 &mgr;g of ethinyl E2 to a 20 &mgr;g ethinyl E2 pill containing levonorgestrel or norethindrone acetate did not improve bleeding patterns. During continuous dosing, the use of oral contraceptives containing 1,000 &mgr;g norethindrone acetate resulted in more days of amenorrhea and fewer days of spotting than preparations containing 100 &mgr;g levonorgestrel. LEVEL OF EVIDENCE: I