Penina Segall-Gutierrez

Determinants of intrauterine contraception provision among US family physicians: a national survey of knowledge, attitudes and practice

BACKGROUND Poor contraception adherence contributes to unintended pregnancy. Intrauterine contraception (IUC) is user-independent thus adherence is not an issue, yet few US women use IUC. We compared family physicians (FPs) who do and do not insert IUC in order to ascertain determinants of inserting IUC. STUDY DESIGN We surveyed 3500 US FPs. The primary outcome variable was whether a physician inserts IUC in their current clinical practice. We also sought to describe their clinical practice with IUC insertions. RESULTS FPs who insert IUC had better knowledge about IUC (adjusted OR 1.85, 95% CI 1.32-2.60), more comfort discussing IUC (adjusted OR 2.35, 95% CI 1.30-4.27), and were more likely to believe their patients are receptive to discussing IUC (adjusted OR 2.96, 95% CI 2.03-4.32). The more IUC inserted during residency, the more likely to insert currently (adjusted OR 1.44, 95% CI 1.12-1.84). Only 24% of respondents inserted IUC in the prior 12 months. CONCLUSIONS US FPs have training and knowledge gaps, as well as attitudes, that result in missed opportunities to discuss and provide IUC for all eligible patients.

Follicular development and ovulation in extremely obese women receiving depo-medroxyprogesterone acetate subcutaneously

BACKGROUND Subcutaneous depo-medroxyprogesterone acetate (DMPA-SC) has not been studied in the extremely obese population (BMI >or=40 kg/m(2)). The purpose of this 26-week prospective experimental study was to determine incidence of ovulation and follicular development among women with Class 1, 2 and 3 obesity after receiving DMPA-SC. METHODS Five normal-weight, five Class 1-2 obese, and five Class 3 obese women received subcutaneous injections of 104 mg DMPA-SC at baseline and 12 weeks later. Weekly progesterone levels, bimonthly estradiol (E(2)), and monthly medroxyprogesterone acetate (MPA) levels were measured by immunoassay methods for a total of 26 weeks in each subject. RESULTS Ovulation did not occur in any subject more than 1 week after the first injection. There was large intersubject and intrasubject variability in E(2) levels, and fluctuating E(2) levels were more frequent among obese women than normal-weight women. Median MPA levels remained above the level needed to prevent ovulation but, compared with normal-weight subjects, were lower among Class 1-2 obese and lowest among Class 3 obese subjects. CONCLUSION Fluctuating E(2) levels reflective of follicular development occurred more often among Class 1, 2 and 3 obese women than normal-weight women after DMPA-SC injections. Median MPA levels were consistently lowest among Class 3 obese women but remained above the level needed to inhibit ovulation. Further studies should more fully address the pharmacokinetics of DMPA-SC in extremely obese women.

Deterioration in cardiometabolic risk markers in obese women during depot medroxyprogesterone acetate use

BACKGROUND Highly effective contraception is essential in obese women, but it should not increase their risk of developing or worsening obesity-related cardiometabolic illness. The purpose of this 18-week prospective experimental study was to compare the impact of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) on cardiometabolic markers in obese and normal-weight women. METHODS Normal-weight [body mass index (BMI) 18.5-24.9 kg/m(2)] and obese (BMI≥30 kg/m(2)) women received injections of 104 mg DMPA-SC at baseline and 12 weeks later. Markers of cardiometabolic risk measured at baseline and 18 weeks after the first injection included body morphometry, fasting blood tests, and oral and frequently sampled intravenous glucose tolerance tests (FSIGT). RESULTS At baseline, median gravidity, BMI, abdominal circumference, and acute insulin response to intravenous glucose were higher and high-density lipoprotein (HDL) cholesterol and insulin sensitivity (S(I) from FSIGTs) were lower in the 10 obese participants than the five normal-weight women (p≤.05 for each). While there was no significant difference between median baseline and follow-up values among normal-weight women, the difference between median baseline and follow-up among the obese cohort was significantly higher for BMI and lower for HDL cholesterol and insulin sensitivity (S(I)) (p≤.05 for each). The absolute changes for routinely measured clinical laboratory values of metabolic decline were no different among the normal-weight vs. obese women. The difference in absolute change in β-cell compensation for insulin resistance [disposition index (DI)] was significant between the two groups at follow-up, with the normal-weight group experiencing an increase in DI while the obese group experienced a decline in DI (188.5 vs. -286, p=.04). CONCLUSIONS Obese women have an increased baseline cardiometabolic risk when compared with normal-weight women at baseline. There was a significantly greater decline in β-cell compensation for insulin resistance in obese women on DMPA. Our data suggest potential deleterious effects of DMPA on glucose regulation in obese women. Further studies should elucidate the long-term cardiometabolic consequences of DMPA use in obese women.

Effects of progestin-only long-acting contraception on metabolic markers in obese women

BACKGROUND The metabolic effects of progestin-only long-acting reversible contraception [levonorgestrel-releasing intrauterine system (LNG-IUS) and etonogestrel implant (ENG-I)] have been studied in normal-weight women but not in obese [body mass index≥30kg/m(2)] women. STUDY DESIGN A nonrandomized open-label prospective trial of healthy obese, reproductive-age women desiring to use long-acting reversible contraception (LARC) or nonhormonal contraception (NHC). At baseline, 3 months and 6 months, homeostasis model assessment insulin resistant (HOMA-IR) score, insulin sensitivity (HOMA-%S) and β-cell function (HOMA-%B) were calculated based on fasting insulin and glucose values. In addition, components of metabolic syndrome [fasting glucose (FG), high density lipoprotein cholesterol and triglycerides, systolic and diastolic blood pressure, abdominal circumference] were measured. Twenty-four subjects total (8 in each arm) were needed to detect a 1.0 difference in HOMA-IR with 80% power and a two-sided alpha of 0.05. RESULTS We present data on eight NHC, eight ENG-I and nine levonorgestrel intrauterine system (LNG-IUS) users. FG increased, and insulin sensitivity decreased over time among ENG-I users to a greater extent than among LNG-IUS users when compared to women using a nonhormonal method [FG change over 6 months=9.4mg/dL, 4.6mg/dL and -2.1mg/dL, respectively; p=.01); (HOMA-%S change over 6 months=-29.9%, -14.8% and 19.3%, respectively; p=.02)], while β-cell function and insulin resistance did not change significantly (p>.05). CONCLUSION While changes in FG and insulin sensitivity were seen in the present study among obese progestin-only contraceptive users, either progestin-only LARC method may be safely used clinically.

Effect of subcutaneous depo-medroxyprogesterone acetate (DMPA-SC) on serum androgen markers in normal-weight, obese, and extremely obese women

BACKGROUND The effects of subcutaneous depo-medroxyprogesterone acetate (DMPA-SC) injection on androgenic markers in obese women have not previously been studied. STUDY DESIGN Five normal-weight [body mass index (BMI)=18.5-24.9 kg/m²], five obese (BMI=30-39.9 kg/m²) and five extremely obese (BMI≥40 kg/m²) women were recruited for this prospective experimental study in which 104 mg DMPA-SC was administered at baseline and 12 weeks later. Serum levels of total testosterone (T), androstenedione (A), dehydroepiandrosterone sulfate (DHEAS), 3α-androstanediol glucuronide and sex hormone-binding globulin (SHBG) were quantified by immunoassay methods at baseline and at 13 and 26 weeks following the first injection; free T was calculated. RESULTS At baseline, obese women had lower levels of A and SHBG and higher total and free T levels than normal-weight women. There were a statistically significant decrease in the levels from baseline to week 26 among all three BMI classes for A, total T and SHBG (p≤.03) and an increase from baseline to week 26 in weight (p=.02). In addition, there was a statistically significant decrease in DHEAS from baseline to week 13 among all three BMI classes (p=.01), which was not sustained at week 26 (p>.1). Overall, the three groups responded similarly to all changes at week 13, and there were no statistically significant differences between groups at any time point (p≥.06). CONCLUSION DMPA-SC use in normal-weight, obese and extremely obese women can decrease serum androgen markers.

A pilot study examining short-term changes in bone mineral density among class 3 obese users of depot-medroxyprogesterone acetate

ABSTRACT Objective To examine changes in lumbar spine-bone mineral density (LS-BMD) among normal weight (body mass index [BMI] = 18.5–24.9 kg/m2), Class 1–2 obese (BMI = 30–39.9 kg/m2), and Class 3 obese (BMI ≥ 40 kg/m2) women utilising depot-medroxyprogesterone acetate (DMPA). Methods Five normal-weight, five Class 1–2 obese, and five Class 3 obese women received subcutaneous injections of DMPA-SC at baseline and 12 weeks later. Dual Energy X-ray Absorptiometry (DEXA) scans were performed at baseline and 18 weeks after the first injection for determination of LS-BMD and analysis of fat content. Bimonthly oestradiol (E2) levels were measured by immunoassay methods for 26 weeks. Results There were no significant demographic or LS-BMD differences among the three BMI groups. Significant differences at baseline were as expected among the three groups with respect to BMI and associated parameters (mean % total body fat, absolute fat, and weight). When used as their own controls, significant changes in LS-BMD, % body fat and absolute fat determined by DEXA occurred among all three BMI strata. Class 1–2 obese and Class 3 obese women were more likely to experience E2 fluctuations, but short-term changes in LS-BMD were similar. Conclusions DMPA-SC administration affects L-spine bone health similarly regardless of BMI status.

The Effect of Depo Medroxyprogesterone Acetate (DMPA) on Cerebral Food Motivation Centers: A Pilot Study using Functional Magnetic Resonance Imaging

OBJECTIVE The primary objective is to examine activation of food motivation centers in the brain before and 8 weeks after depo medroxyprogesterone acetate (DMPA) administration. STUDY DESIGN This prospective experimental pilot study examined the effects of DMPA on food motivation centers utilizing functional magnetic resonance imaging (fMRI) in eight nonobese, ovulatory subjects. fMRI blood oxygen level dependent (BOLD) signal was measured using a 3-Tesla Scanner while participants viewed images of high-calorie foods, low-calorie foods and nonfood objects. fMRI scans were performed at baseline and 8 weeks after participants received one intramuscular dose of DMPA 150 mg. fMRI data were analyzed using the FMRIB Software Library. Changes in adiposity and circulating leptin and ghrelin levels were also measured. RESULTS There was a greater BOLD signal response to food cues in brain regions associated with food motivation (anterior cingulate gyrus, orbitofrontal cortex) 8 weeks after DMPA administration compared to baseline (z>2.3, p<.05 whole-brain analysis clustered corrected). No statistically significant change was detected in circulating leptin or ghrelin levels or fat mass 8 weeks after DMPA administration. CONCLUSION Analysis of differences in food motivation may guide the development of interventions to prevent weight gain in DMPA users. IMPLICATIONS These data support a neural origin as one of the mechanisms underlying weight gain in DMPA users and may guide future research examining weight gain and contraception.

Malpositioned intrauterine contraceptive devices: risk factors, outcomes, and future pregnancies.

Braaten KP, et al. Obstet Gynecol. 2011;118:1014Y1020. The purpose of this retrospective casecontrol study was to evaluate risk factors, management, and outcomes for women with malpositioned intrauterine contraceptive devices (IUDs). One hundred eighty-two women with malpositioned IUDs as seen on pelvic ultrasound were compared with a control group of 182 women with IUDs positioned in the expected location within the uterine fundus. Insertion 6 to 9 weeks postpartum or insertion after abortion was not associated with a higher rate of IUD malpositioning. In the multivariate analysis, suspected adenomyosis (odds ratio [OR], 3.04) and symptoms suggesting IUD malpositioning (OR, 1.74) were statistically significant risk factors for malpositioning,whereas prior vaginal delivery (OR, 0.53) and private insurance status (OR, 0.38) were protective. Two thirds of the malpositioned IUDs were removed. In the subsequent 2 years, statistically significantly higher pregnancies occurred in the case cohort compared with the control group (19.2% vs 10.5%), although the proportion of unplanned pregnancies was not statistically different. In the case cohort, most of the pregnancies occurred in those known to have the malpositioned IUDs removed or expelled, and none occurred in women whose malpositioned IUDs remained in situ. The authors conclude that IUD insertion in the postpartum period does not result in a higher risk of malpositioning, contrary to some previous beliefs. Because of their finding of an increased pregnancy rate after removal, their study raises questions about whether all malpositioned IUDs need to be removed. Observations on Hydroceles Following Adolescent Varicocelectomy