RESUMEN

This article examines the sociocultural determinants of Nicaraguan women's use of Depo-Provera as a means of contraception. The prevalence of Depo-Provera in Nicaragua is high and increasing compared to other Central American countries. Drawing on data from structured interviews with 87 women and from focus groups with 32 women, we show how women's preference for Depo is shaped by both gendered inequalities and socioeconomic constraints. We employ basic statistical tests to analyse correlations between women's marital status and socioeconomic status (SES) with contraceptive use. Our statistical findings show significant associations between use of Depo and both marital status and SES, such that women who are married or in conjugal unions and women with lower SES are more likely to use Depo. To help explain women's use of Depo-Provera in Nicaragua, we situate our findings within the context of gender, culture, and power, reviewing the contested history of Depo-Provera in the developing world and dynamics of gender inequality, which constrain women's contraceptive choices. We conclude with suggestions for reproductive health programming in Nicaragua and beyond, arguing that gender equity and addressing socioeconomic barriers to family planning remain priorities for the achievement of global reproductive health.

Asunto(s)

Conducta de Elección , Conducta Anticonceptiva , Salud Reproductiva , Factores Socioeconómicos , Adolescente , Adulto , Femenino , Grupos Focales , Humanos , Entrevistas como Asunto , Persona de Mediana Edad , Nicaragua , Investigación Cualitativa , Factores Sexuales , Adulto Joven

RESUMEN

OBJECTIVE: To determine the influence of depot medroxyprogesterone acetate (MPA) on bone mineral density when used as a contraceptive method. DESIGN: Cross-sectional study. SETTING: Academic tertiary-care hospital. PATIENT(S): Fifty premenopausal women who had used depot MPA as a contraceptive method for > or =1 year and 50 women who had never used hormonal contraceptive methods. INTERVENTION(S): Bone mineral density was evaluated at the midshaft and at the distal radius of the nondominant forearm using single x-ray absorptiometry. MAIN OUTCOME MEASURE(S): Bone mineral density. RESULT(S): Bone mineral density at the midshaft of the forearm was lower in depot MPA users than in women who had never used hormonal contraceptive methods, but the difference was not statistically significant. At the distal portion, bone mineral density was significantly lower in the study group. The duration of depot MPA use was not related to bone mineral density. CONCLUSION(S): Women > or =35 years of age presented with a lower bone mineral density only at the distal portion of the forearm after the use of depot MPA for > or =1 year. However, this decrease was not related to the duration of depot MPA use. It is not possible to conclude that women who use depot MPA are at risk of osteoporosis.

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PIP: The impact of depot medroxyprogesterone acetate use on bone mineral density was assessed in a cross-sectional study of 100 women recruited from a teaching hospital in Campinas, Brazil, during 1996-98. Bone mineral density, as evaluated at the midshaft and distal radius of the nondominant forearm by single x-ray absorptiometry, was compared in 50 women 35-45 years of age who had been using Depo-Provera for contraception for 1 year or more (mean duration, 46.4 +or- 38.6 months) but had never used any other hormonal method and 50 age- and weight-matched women who had never used any form of hormonal contraception. Although mean bone mineral density at the midshaft of the forearm was lower in Depo-Provera users than nonusers of hormonal contraception (0.459 +or- 0.042 vs. 0.474 +or- 0.049 g/sq. cm), the difference was not statistically significant. At the distal portion, bone mineral density was significantly lower in Depo-Provera users than nonusers of hormonal methods (0.362 +or- 0.040 vs. 0.392 +or- 0.049 g/sq. cm, p 0.001). The duration of Depo-Provera use was not related to bone mineral density, even when women had used the method for more than 5 years. Multiple regression analysis indicated that 4 pregnancies, White race, and Depo-Provera use were significantly associated with lower bone mineral density at the midshaft section of the forearm; at the distal section of the forearm, these variables were Depo-Provera use, more than 4 pregnancies, White race, older age at menarche, and habitual coffee drinking. These findings do not provide sufficient evidence to conclude that Depo-Provera users are at increased risk of osteoporosis.

Asunto(s)

Densidad Ósea/efectos de los fármacos , Anticonceptivos Femeninos/farmacología , Antebrazo , Acetato de Medroxiprogesterona/farmacología , Radio (Anatomía)/efectos de los fármacos , Cúbito/efectos de los fármacos , Adulto , Estudios Transversales , Femenino , Humanos , Modelos Lineales , Persona de Mediana Edad , Premenopausia , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

OBJECTIVE: To determine the timing of onset of contraceptive effectiveness after the first injection of 150 mg of depot medroxyprogesterone acetate (DMPA) administered between days 8 and 13 of the menstrual cycle. DESIGN: Descriptive, prospective study. SETTING: A tertiary university referral center. PATIENT(S): Thirty healthy women between 18 and 40 years of age. INTERVENTION: Volunteers were injected with DMPA between days 8 and 13 (5 women on each day) of the menstrual cycle. MAIN OUTCOME MEASURE(S): Ovarian function determined by serum levels of E2 and progesterone and follicular development evaluated by vaginal ultrasound. RESULT(S): In nine (30%) of 30 women studied, DMPA did not prevent ovulation. All ovulations occurred in women receiving DMPA between days 10 and 13 of the cycle. No woman who received injections on day 8 or 9 ovulated. Ovulation suppression was more effective in women with low ovarian activity. All ovulation occurred within 3 days after the injection. CONCLUSION: A back-up contraceptive method, used after the 7th day of the menstrual cycle, is recommended for up to 7 days after the first injection of DMPA.

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PIP: To ensure ovulation does not occur, it is recommended that Depo-Provera injections be administered within the first 7 days of the menstrual cycle. In some settings, this requirement acts as a barrier to women's free access to injectable contraception. Thus, the present study investigated the timing of onset of contraceptive effectiveness when the first injection of depot medroxyprogesterone acetate is administered between days 8-13 of the menstrual cycle. 30 women 18-40 years of age attending a university referral center in Campinas, Brazil, in 1995-96, were enrolled. Ovulation, detected through serum progesterone and estradiol assays and confirmed by follicle rupture at vaginal ultrasound, occurred in 9 cases (30%). No ovulations occurred when injection was administered on day 8 (n = 5) or day 9 (n = 5) of the menstrual cycle; only 1 of the 5 women treated on day 10 ovulated. On the other hand, 4 of the 10 women treated on days 11 and 12 and 4 of the 5 injected on day 13 showed evidence of ovulation. All ovulation occurred within 3 days after injection. Ovulation occurred only among women who had serum estradiol levels of 100 pg/ml and above and a leading follicle diameter greater than 13 mm at the time of injection. Ovulation suppression was more effective in women with low ovarian activity. A back-up contraceptive method used for 4 days after Depo-Provera injection should provide sufficient protection when the method is administered after day 7 of the menstrual cycle. However, given the uncertainty of the assumption of short viability of the human oocyte, it is safer to recommend 1 week's use of a back-up method or abstinence.

Asunto(s)

Anticonceptivos Femeninos/uso terapéutico , Acetato de Medroxiprogesterona/uso terapéutico , Ciclo Menstrual , Ovario/efectos de los fármacos , Adolescente , Adulto , Esquema de Medicación , Femenino , Humanos , Estudios Prospectivos , Resultado del Tratamiento

RESUMEN

OBJECTIVE: To evaluate the changes in cervical mucus within the first hours or days after depot medroxyprogesterone acetate (MPA) injection so as to estimate the time at which cervical mucus becomes hostile enough to prevent pregnancy. DESIGN: Multicenter, clinical descriptive study. SETTING: Family planning clinic. PATIENT(S): Thirty women who were between days 8 and 13 of their menstrual cycle and who had requested Depo-Provera were enrolled in the study. INTERVENTION(S): Cervical mucus and blood samples were obtained; transvaginal ultrasonography was performed. MAIN OUTCOME MEASURE(S): Cervical mucus scores, sperm penetration distances, ovarian follicular size, and serum levels of progesterone and estradiol. RESULT(S): From 6 to 24 hours after injection, there was a sharp decline in the cervical mucus score for most of the subjects. All subjects exhibited poor mucus on day 3 after injection, and by day 7, all subjects had zero scores, with the exception of two outliers on each day. Sperm penetration, as measured by the vanguard sperm distance, was already poor (< 1 cm) in 7 of the 30 subjects at the time of injection and was reduced progressively up to 24 hours after injection, when only four subjects had a sperm penetration of > 1 cm. A rapid decline in the estimated number of sperm was observed at 12 hours and more so at 24 hours in the majority of subjects. CONCLUSION(S): The data presented in this report confirmed that depot MPA causes profound changes in cervical mucus after injection. Although very little change was seen at 6 hours, alterations were observed subsequently, with 90% of the subjects showing a poor cervical mucus score 24 hours after administration of the progestin. No reliable clinical marker is available to identify in which women depot MPA might exert its effect on cervical mucus within 3 days. Thus, we believe that at present, women should be informed of this uncertainty and should use a backup method of contraception for 7 days when the first injection of depot MPA is provided after the seventh day of the menstrual cycle.

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PIP: More accurate knowledge of the time of onset of cervical mucus changes after Depo-Provera injection would enable family planning providers to counsel new acceptors to use a backup method only for the amount of time it is really needed. To obtain such data, 30 women from a family planning clinic in Campinas, Brazil, who requested Depo-Provera in 1995-96 were recruited. At baseline, 11 women had a poor cervical mucus score (0-4), 12 had a fair score (3-8), and 7 scored in the good range (9-12). Between 6 and 24 hours after injection, a sharp decline occurred in the cervical mucus score in all but 3 patients (each of whom had a "good" score at baseline). On day 3, 29 women had "poor" mucus and the remaining woman had a cervical mucus score in the fair range. By day 7, 29 women had zero mucus scores; the score in the last woman was 1. 24 hours after injection, sperm penetration (measured by vanguard sperm distance) had decreased to under 1 cm in all but 4 women. At day 3, 1 of the 2 women with good penetration at 24 hours maintained a vanguard sperm distance of 2.5 cm and an estimated sperm count of 15,363. By day 7, sperm penetration was zero in all but 1 woman (0.5 cm). These findings confirm that depot medroxyprogesterone acetate causes profound changes in cervical mucus after injection. The lack of a more complete hostility to sperm penetration at day 3 was unexpected, however. Given the nonavailability of a reliable clinical marker to verify a contraceptive effect at 3 days, it seems prudent to advise new Depo-Provera acceptors to use a backup method for the first 7 days.

Asunto(s)

Moco del Cuello Uterino/efectos de los fármacos , Anticonceptivos Femeninos/farmacología , Acetato de Medroxiprogesterona/farmacología , Espermatozoides/efectos de los fármacos , Adulto , Moco del Cuello Uterino/fisiología , Anticonceptivos Femeninos/administración & dosificación , Femenino , Estudios de Seguimiento , Humanos , Masculino , Acetato de Medroxiprogesterona/administración & dosificación , Espermatozoides/fisiología , Factores de Tiempo

RESUMEN

The bone density (BD) of 72 women using depot-medroxyprogesterone acetate (DMPA) for at least 1 year was compared with that of 64 women who were not users of hormonal contraceptives. The BD of lumbar spine, femoral neck, Ward's triangle, and trochanter was measured by dual energy X-ray absorptiometry (DEXA-LUNAR DPX). Estradiol (E2) concentrations were measured by radioimmunoassay (RIA). The mean age of DMPA users and nonusers was 31.8 and 31.1 years, respectively. Mean E, was 55.7 pg/mL for users and 149.9 pg/mL for controls (p < 0.001). The BD was significantly lower for DMPA users than for controls in all sites (p < 0.01). In addition, young adult T-scores in the lumbar spine were significantly lower among DMPA users than in controls (p < 0.01). Differences were maintained in a subsample of 47 women per group paired by age and body mass index (BMI). Multiple regression analysis showed that older age, lower BMI, and longer amenorrhea were associated with lower BD in the femoral neck, whereas lower BMI and use of DMPA were associated with lower BD in the lumbar spine.

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PIP: Family planning programs that offer depot medroxyprogesterone acetate (DMPA) cannot be indifferent to the risk of lowered bone density. A study conducted at the Family Planning Clinic of the State University of Campinas (Sao Paulo, Brazil) compared bone densities in 72 women who had been using DMPA for at least 1 year (mean duration, 42 months) and 64 regularly menstruating nonusers. Mean age was 31 years in both groups; there were no significant differences between the 2 groups in terms of ethnicity, body mass index (BMI), or smoking. Mean serum estradiol concentrations were 55.7 +or- 40.5 pg/ml for DMPA users and 149.9 +or- 88.2 pg/ml for nonusers (p 0.001). The mean length of amenorrhea was 26.5 +or- 23.8 months among DMPA users. The mean bone density in DMPA users was significantly lower than that of controls at all sites evaluated (i.e., lumbar spine, femoral neck, Ward's triangle, and trochanter). 38 DMPA users, compared with only 17 controls, had a T-score in the lumbar spine lower than -1 standard deviation (p = 0.014). Multiple regression analysis identified BMI and DMPA use as variables significantly associated with bone density in the lumbar spine; in the femoral neck, these variables were BMI, age, and length of amenorrhea. Periodic bone densitometry should be considered for women over 40 years of age with low BMI who have more than 2 years of continuous amenorrhea.

Asunto(s)

Densidad Ósea/efectos de los fármacos , Anticonceptivos Femeninos/farmacología , Acetato de Medroxiprogesterona/farmacología , Congéneres de la Progesterona/farmacología , Absorciometría de Fotón , Adulto , Estudios Transversales , Estradiol/sangre , Femenino , Humanos , Radioinmunoensayo , Análisis de Regresión , Factores de Tiempo

RESUMEN

PIP: Commercial partnerships in social marketing have grown increasingly important in the context of diminishing resources from international donors in developing countries. In 1997, the Futures Group International (Futures) negotiated an agreement with Pharmacia & Upjohn/Brazil to introduce Depo-Provera, a 3-month injectable contraceptive, at a social marketing price with strong consumer marketing support. The key to the collaboration was to demonstrate that making Depo-Provera accessible to low-income consumers was a viable marketing strategy. The author describes the process of designing, negotiating, and implementing the successful commercial partnership. Brazilian women stand to gain the most from the partnership between Futures and Pharmacia & Upjohn/Brazil, for in the absence of such a coordinated effort, Depo-Provera would be available to only upper-income, breast-feeding women whose only source of information on the method would be private physicians. The partnership will bring Depo-Provera to a broader segment of Brazil's women.^ieng

Asunto(s)

Comercio , Accesibilidad a los Servicios de Salud , Comercialización de los Servicios de Salud , Acetato de Medroxiprogesterona , Organización y Administración , Sector Privado , Investigación , Américas , Brasil , Anticoncepción , Anticonceptivos , Anticonceptivos Femeninos , Países en Desarrollo , Economía , Servicios de Planificación Familiar , América Latina , América del Sur

RESUMEN

OBJECTIVE: To examine bone density among adolescents receiving different forms of hormonal contraception along with that of control subjects. METHODS: Baseline and 1-year measures of lumbar vertebral bone density were obtained in girls receiving depot medroxyprogesterone acetate (Depo-Provera) (n = 15), levonorgestrel (Norplant) (n = 7), or oral contraceptives (n = 9) and in girls receiving no hormonal treatment (n = 17). In a subsample of Depo-Provera users (n = 8), Norplant users (n = 3), and control subjects (n = 4), bone density measurements were repeated after 2 years. Bone density was measured by dual-energy x-ray absorptiometry. RESULTS: Body mass indexes, level of pubertal development, substance use, and reproductive histories were not significantly different among the groups. More black girls were represented in the initial Depo-Provera group (p < 0.02), girls in the Norplant group exercised more hours per week (p < 0.02), and control subjects were older (p < 0.01) than those in the other groups. These variables did not significantly affect bone density results. After 1 year, bone density decreased 1.5% in Depo-Provera users, compared with increases of 2.5% in Norplant users, 1.5% in oral contraceptive users, and 2.9% control subjects (p < 0.02). After 2 years, bone density increased a total of 9.3% in Norplant users and 9.5% in control subjects but decreased a total of 3.1% in Depo-Provera users (p < 0.0001). CONCLUSION: These data suggest that Depo-Provera may, at least temporarily, suppress the expected skeletal bone mineralization in adolescents, whereas Norplant and oral contraceptives are associated with the expected increase in bone density in this population.

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PIP: In Ohio, data on 31 postmenarcheal women, 12-21 years old and using hormonal contraception (Norplant = 7, Depo Provera = 15, and oral contraceptives [OCs] = 9) were compared with data on 17 controls of similar age to prospectively examine lumbar bone density in girls before and after 1 and 2 years of hormonal contraceptive use and to compare the results with young women not using hormonal contraceptives. The subjects attended a general adolescent clinic at Children's Hospital in Columbus. There was an insufficient number of OC users at 2 years, so they were not included in second year analyses. Initial height and weight were significantly associated with bone density values (p 0.05). Weight accounted for the most variance both at baseline (p 0.001) and after 1 year of treatment (p 0.01). At baseline and 1 year, bone density values between patient groups were not significantly different. At 2 years, however, Norplant users had higher bone density than Depo- Provera users and controls (1.308 vs. 1.004 and 1.087, respectively; p 0.01). After 1 year, Depo-Provera users experienced a decrease (1.53%) in bone density while Norplant users, OC users, and controls experienced an increase in bone density (2.46%, 1.52%, and 2.85%, respectively). The change in bone density between Depo-Provera users and controls was significant (p 0.02). At 2 years, Depo Provera users experienced a decrease in bone density while Norplant users and controls experienced an increase (-3.12% vs. 9.33% and 9.49%, respectively; p 0.0001). This study is important because 50% of adult bone mass is accrued during adolescence. In fact, bone mass peaks during adolescence. It is not known whether bone loss during Depo Provera use is reversible after treatment discontinuation. These findings show that Depo Provera inhibits skeletal bone mineralization in adolescents, at least temporarily, while Norplant and OCs appear to increase bone density.

Asunto(s)

Densidad Ósea/efectos de los fármacos , Anticonceptivos Femeninos/farmacología , Anticonceptivos Orales/farmacología , Levonorgestrel/farmacología , Acetato de Medroxiprogesterona/farmacología , Adolescente , Adulto , Estudios de Casos y Controles , Femenino , Humanos , Estudios Prospectivos

RESUMEN

PIP: Depot medroxyprogesterone acetate (DMPA) is a three-month, highly effective, injectable hormonal method of contraception. The method is also known as Depo-Provera. The UNDP/UNFPA/WHO/World Bank Special Program of Research, Development, and Research Training in Human Reproduction, in collaboration with the University of Otago Medical School, Dunedin, New Zealand, and the Fred Hutchinson Cancer Research Center in Seattle, Washington, conducted a secondary analysis of combined data on breast cancer and DMPA which had been collected in two studies previously conducted by the three organizations in Kenya, Mexico, New Zealand, and Thailand. 1768 women with breast cancer, mostly younger than age 55 years, and 13,905 women who did not have the disease participated in the study. The study determined that women who use DMPA are not at increased overall risk of breast cancer compared to women who have never used it. The study also concludes that the use of DMPA should not be restricted on the grounds of breast cancer risk. Study findings were published in the March 8, 1995, issue of the Journal of the American Medical Association.^ieng

Asunto(s)

Neoplasias de la Mama , Inyecciones , Acetato de Medroxiprogesterona , Seguridad , África , África del Sur del Sahara , África Oriental , Américas , Asia , Asia Sudoriental , Anticoncepción , Anticonceptivos , Anticonceptivos Femeninos , Países Desarrollados , Países en Desarrollo , Enfermedad , Servicios de Planificación Familiar , Salud , Kenia , América Latina , México , Neoplasias , Nueva Zelanda , América del Norte , Islas del Pacífico , Salud Pública , Tailandia

RESUMEN

PURPOSE: To analyse efficacy, tolerance and adverse events of reversible contraceptives in women with cardiac disease. METHODS: We studied prospectively during 24-39 (mean = 29) months, 89 women with heart disease with a mean age of 25.6 (16-42) years. Rheumatic heart disease was present in 73 (82%) cases, congenital heart disease in 11 (11%), coronary artery disease in 2 (2%) and cardiomyopathy in 3 (3%) case. The patients were divided in three groups: GCO--35 patients taking combined oral contraceptives (30 micrograms ethinyl estradiol and 75 micrograms gestodene--COs); GIT--27 using injectable progestagens (depot medroxyprogesterone acetate-DMPA) and GUID--27 with intrauterine device (IUD). RESULTS: In GCO occurred 4 (11.4%) cases of arterial hypertension, 1 (2.8%) of a transient cerebral isquemic attack, 3 (8.5%) of spotting, 1 (2.8%) of amnorrhea e 1 (2.8%) pregnancy. Interruption of this method occurred in 4 (11.4%) cases due to hypertension (2), pregnancy (1) and amenorrhea (1). In group GIT there were 2 (7.4%) cases of arterial hypertension, 18 (66.6%) of amenorrhea, and 3 (11.1%) of spotting. Interruption of use occurred in 5 (18.5%) due to amnorrhea (2), weight gain (2) and headache (1). In GUID there was 1 (3.7%) case of infeccion, 1 (3.7%) pregnancy and 1 (3.7%) spontaneous expulsion of IUD. Interruption of use took place in 3 (11.1%) cases due to infeccion, pregnancy and expulsion. The comparation between the groups demonstrated a difference in the incidence of amenorrhea (p < 0.005) and descontinuation of use of the method (p < 0.025). CONCLUSION: Use of reversible contraceptives in heart disease women was associated with an acceptable cardiovascular risk. Efficacy and side effects of the methods were comparable in the groups, however intolerance was more observed in GIT.

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PIP: The aim of this study was to analyze efficacy, tolerance, and adverse events of reversible contraceptives in women with cardiac disease. The authors studied prospectively, during a period of 24-39 (mean = 29) months, 89 women with heart disease of mean age 25.6 (16-42) years. Rheumatic heart disease was present in 73 cases (82%), congenital heart disease in 11 (11%), coronary artery disease in 2 (2%), and cardiomyopathy in 3 (3%). The patients were divided into three groups: GCO--35 patients taking combined oral contraceptives (30 mcg ethinyl estradiol and 75 mg gestodene); GIT--27 patients using injectable progestagens (depot medroxyprogesterone acetate); and GUID--27 patients with IUDs. In the GCO group were found 4 cases (11.4%) of arterial hypertension, 1 (2.8%) of a transient cerebral ischemic attack, 3 (8.5%) of spotting, 1 (2.8%) of amenorrhea, and 1 (2.8%) of pregnancy. Interruption of this method occurred in 4 cases (11.4%): 2 due to hypertension, 1 due to pregnancy, and 1 due to amenorrhea. In the GIT group there were 2 cases (7.4%) of arterial hypertension, 18 (66.6%) of amenorrhea, and 3 (11.1%) of spotting. Interruption of use occurred in 5 cases (18.5%): 2 due to amenorrhea, 2 due to weight gain, and 1 due to headache. In the GUID group there was 1 case (3.7%) of infection, 1 (3.7%) of pregnancy, and 1 (3.7%) of spontaneous expulsion of the IUD. Interruption of use took place in 3 cases (11.1%): 1 due to infection, 1 due to pregnancy, and 1 due to expulsion. The comparison between the groups demonstrated a difference in the incidence of amenorrhea (p 0.005) and method discontinuation (p 0.025). Use of reversible contraceptives in women with heart disease was associated with an acceptable cardiovascular risk. Efficacy and side effects of the methods were comparable in the groups; however, intolerance was observed more in the GIT group. (author's modified)

Asunto(s)

Anticonceptivos Hormonales Orales/efectos adversos , Cardiopatías , Dispositivos Intrauterinos/efectos adversos , Adolescente , Adulto , Presión Sanguínea/efectos de los fármacos , Distribución de Chi-Cuadrado , Femenino , Estudios de Seguimiento , Humanos , Embarazo , Estudios Prospectivos , Resultado del Tratamiento

RESUMEN

Subdermal implantable contraception has been the most important addition to contraceptive technology in the past 2 decades. The Norplant system is only the first of a new family of long acting methods of high effectiveness, high acceptability, and prompt reversibility. The main advantage of the second generation implant systems, to be available soon, is the reduction in the number of implants, which greatly facilitates insertion and removal. However, great improvement in bleeding control is not to be expected. Large and carefully designed epidemiological studies have contributed to clear the main objections to the US Food and Drug Administration (FDA) approval of depot medroxyprogesterone acetate (DMPA) as an injectable contraceptive. New progestin-only, long acting injectables are being tested, but significant improvements over existing methods are difficult to foresee, although every alternative is welcome. Monthly combined injectables have been in great demand, at least in China and Latin America, because of better bleeding control. Improved combined monthly injectables, less estrogenic and more progestin dominated, have been developed and are being introduced in several countries and should soon replace the old monthly injectables. Contraceptive implants and injectables have shown to be an important addition to the contraceptive options available to women throughout both the developing and developed world.

Asunto(s)

Anticonceptivos Femeninos/administración & dosificación , Ensayos Clínicos como Asunto , Preparaciones de Acción Retardada , Implantes de Medicamentos , Femenino , Humanos , Inyecciones Intramusculares , Levonorgestrel/administración & dosificación , Acetato de Medroxiprogesterona/administración & dosificación , Microesferas , Aceptación de la Atención de Salud , Vigilancia de Productos Comercializados

RESUMEN

PIP: Family planning providers do not agree on whether it is good clinical practice to administer Norplant or Depo-Provera to mothers shortly after delivery. Manufacturers of both contraceptives recommend that providers not prescribe them before 6 weeks postpartum for lactating mothers. The hormones enter the breast milk, but the amount is minimal, and no studies show the small amount of hormones to be harmful. Some providers point to this lack of data as a reason to prescribe them to mothers immediately after delivery because progestin-only pills do neat adversely affect breast feeding. Some providers even claim Norplant should be inserted no later than 3 weeks. On the other hand, other providers, like a physician from Chile, stress that the lack of studies does not mean it is safe, just that there have not been enough studies. The Chilean physician is investigating the effect of hormones on infant health and central nervous system development. A nurse midwife at the University Medical Center in Jacksonville, Florida, reports that no woman using Depo-Provera has complained of breast-feeding problems. More than 50% of postpartum women leave this hospital after receiving an injection of Depo-Provera and those who do not come back for their 3-month injection are those who did not receive proper prenatal counseling about its side effects. The most upsetting side effect is bleeding which becomes less stressful with adequate counseling. Depo-provera extends the normal postpartum bleeding by a month. A director of services at a family planning clinic in San Marcos, Texas, notes that proper counseling, both before insertion and before removal, is also the key to proper management of Norplant acceptors. Providers at this clinic insert it 6 weeks postpartum. Hispanic women in San Marcos are concerned about bleeding because their partners do not want to have sex with a bleeding partner. Another side effect concerning clients is weight gain.^ieng

Asunto(s)

Lactancia Materna , Consejo , Estudios de Evaluación como Asunto , Lactancia , Acetato de Medroxiprogesterona , Madres , Periodo Posparto , Instituciones de Atención Ambulatoria , Américas , Biología , Chile , Anticoncepción , Anticonceptivos , Anticonceptivos Femeninos , Países Desarrollados , Países en Desarrollo , Composición Familiar , Servicios de Planificación Familiar , Relaciones Familiares , Florida , Salud , Planificación en Salud , Fenómenos Fisiológicos Nutricionales del Lactante , América Latina , América del Norte , Fenómenos Fisiológicos de la Nutrición , Organización y Administración , Padres , Fisiología , Embarazo , Reproducción , América del Sur , Estados Unidos

RESUMEN

Energy, protein, lactose and fat were studied in the milk of mothers who were using different types of contraceptives. One hundred and eleven mothers made up the following groups. C: control (barrier and natural methods, or sterilization), n = 22; combined pill: LDP (low dose pill (levonorgestrel 0.15 mg + ethinylestradiol 0.03 mg)), n = 12 and MDP (medium dose pill (levonorgestrel 0.25 mg + ethinylestradiol 0.05 mg)), n = 13; MP (minipill (norethindrone 0.35 mg)), n = 37; DMPA (injectable progesterone (depot medroxiprogesterone acetate 150 mg)), n = 17; and IUD (plastic or copper intrauterine device), n = 10. The mean stages of lactation were, respectively, 15, 17, 5, 9, 5 and 9 weeks. The mean duration of observation for the study groups ranged from 2 to 4 weeks. Milk samples were collected before and after initiation of treatment (mean = 20 days; range = 14-103 days). The stage of lactation and the interval of nursing before sampling were recorded so that statistical account could be taken of these uncontrollable sources of variability. When incorporated as covariates, they showed that no significant differences existed between the groups tested, either before or after treatment.

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PIP: Researchers compared data on 22 women using either a barrier method or a natural family planning method or had undergone female sterilization (controls) with data on 89 women using either a low dose combined oral contraceptive (OC), a medium dose combined OC, a low dose progestin only OC, the injectable Depo-Provera, or an IUD to examine the hormonal contraceptives' effects on the concentration of total protein, lipids, lactose, and energy in human milk. They recruited the women from private and public family planning clinics in Brasilia, Brazil between 1984 and 1987. The mean stages of lactation were 15 weeks for controls, 17 weeks for women using the combined low dose OC, 5 weeks for those using the combined medium dose OC, 5 weeks for those using the combined medium dose OC, 9 weeks for those using the low dose progestin only OC, 5 weeks for those using Depo-Provera, and 9 weeks for those using the IUD. Almost all the concentrations of total protein, lipids, lactose, and energy both before and after contraceptive therapy fell within the range for healthy women. The mean value of total protein in women using Depo-Provera was the only value higher than that range. The low dose OC was associated with a considerable increase in fat (3 g/dL vs. 4.8 g/dL; p=.035). Women taking the medium dose OC experienced a significant decrease in lactose (6.8 g/dL vs. 7.25 g.dL; p=.004). The time between last nursing and milk sample collection (nursing interval) caused considerable variation in fat (p=.03) and total energy (p=.02) in those samples collected before contraceptive therapy. When the researchers adjusted the data for stage of lactation and nursing interval from all 6 groups, the contraceptives had no significant effect on total protein, lipids, lactose, and energy.

Asunto(s)

Anticonceptivos Femeninos/farmacología , Estrógenos/farmacología , Leche Humana/efectos de los fármacos , Progesterona/farmacología , Adulto , Metabolismo Energético/efectos de los fármacos , Femenino , Humanos , Dispositivos Intrauterinos , Lactancia , Lactosa/análisis , Lípidos/análisis , Proteínas de la Leche/análisis , Proteínas de la Leche/efectos de los fármacos , Leche Humana/química , Factores de Tiempo

RESUMEN

Following the development and widespread use of oral hormonal contraceptives, it became evident that alternative long-acting delivery systems would be required to improve contraceptive practice in some cultural settings where injectable or subdermal routes of administration are preferred. Nowadays, long-acting contraceptives constitute an important option in family planning services in many parts of the world. Indeed, two long-acting injectable contraceptives containing just a synthetic progestogen (depot-medroxyprogesterone acetate (DMPA) and norethisterone enantate (NET-EN)) have been in clinical practice for more than 20 years. The World Health Organization's (WHO) Special Programme of Research in Human Reproduction, in collaboration with the U.S. National Institute of Child Health and Human Development (NICHD) and universities primarily in developing countries undertook a synthesis programme aimed at producing an improved injectable preparation by developing new derivatives of known steroids. One such compound (levonorgestrel 17-butanoate) is now at the stage of Phase II clinical testing. In addition, the Special Programme has developed and improved once-a-month injectable formulations and assessed their safety and efficacy in different countries worldwide. After large scale clinical testing, at least two progestogen-estrogen combinations have reached the point of introductory trials.

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PIP: A survey of recent trials of new injectable hormonal contraceptives, progestogen-only, levonorgestrel esters, and once monthly injectables, follows a brief review of all the experimental long-acting contraceptive modalities, injectables, implants, vaginal rings, and hormone-releasing IUDs. Currently medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN) are being used by 7 million women. WHO is conducting dose reduction trials and studies of bioavailability in various national populations. Even though a dose of 100 mg DMPA every 3 months has been satisfactory for contraception, 150 mg is still recommended until further pharmacodynamic data are available. Some populations, notably Thais and Mexican women, have higher peaks and more rapid elimination rates of DMPA, while Chinese women show slower elimination and higher blood levels of NET-EN. Extensive studies of new synthetic esters of levonorgestrel have proceeded to Phase II clinical trials with levonorgestrel butanoate. This ester is an effective contraceptive for 3 months at 12.5 mg, or 5-6 months at a dose of 25 or 50 mg. Trials of combined estrogen and progestogen injectables once-monthly have been ongoing for 10 years. The ratio of the 2 components is as important as the amounts. 2328 women from 12 countries participated in trials of DMPA 25 mg-estradiol cypionate 5 mg, and NET-EN 50 mg-estradiol valerate 5 mg. The continuation rate was better than that for 3-monthly progestogen-only injectables, because of less irregular bleeding. A combined injectable called Cyclofem, DMPA 25 mg-estradiol cypionate is being introduced in several countries. The steadily increasing demand for long-acting injectables prompts development of better formulations.

Asunto(s)

Anticonceptivos Femeninos/administración & dosificación , Noretindrona/análogos & derivados , Compuestos de Anilina/administración & dosificación , Compuestos de Anilina/farmacocinética , Anticonceptivos Femeninos/farmacocinética , Preparaciones de Acción Retardada , Implantes de Medicamentos , Femenino , Humanos , Levonorgestrel/administración & dosificación , Noretindrona/administración & dosificación , Noretindrona/farmacocinética , Acetato de Noretindrona , Ovulación/efectos de los fármacos

RESUMEN

PIP: In 1978, Centro de Pesquisas de Assitencia Integrada a Mulher e a Crianca (CPAIMC) in Rio de Janeiro began to offer interval sterilizations in an attempt to increase the access of poor women to sterilization services. By the end of 1984, the program had provided in excess of 19,000 sterilizations, making CPAIMC Brazil's largest single source of voluntary interval sterilization. Despite the program's success, CPAIMC was concerned that obstacles still existed in the poor woman's path to sterilization access. A study was conducted by Family Health International (FHI) in collaboration with the Pathfinder Fund and CPAIMC's Department of Information, Evaluation and Research to locate possible barriers. The study indicated that less than half of the women who requested sterilization between June 1 and August 31, 1983 actually had the procedure. During that period, 1256 women requested sterilization at the CPAIMC clinic. Of these, 925 were approved, and 639 were scheduled for surgery. Only 559 were actually sterilized within 3 months of receiving approval. 1 possible reason why women were not receiving the surgery was that the women requesting sterilization actually were not highly motivated to obtain the service. Yet, study results indicate this probably was not the reason. During initial interviews at the clinic, many women said they had thought very carefully about being sterilized, and more than 40% reported deciding to have a tubal ligation before their last pregnancy. Almost 3/4 of the women reported that they did not plan their last pregnancy, and almost 2/3 indicated that the pregnancy was unwanted. About 63% were contracepting, and many were using effective methods. More than half of the non-contraceptors were not using a method because they had just ended a pregnancy and were not sexually active. As a group, the women requesting sterilization were highly motivated to avoid having more children. Age and number of children were the most important criteria used by the clinic to determine a woman's eligibility for sterilization. Women who were at least 30 years old and who had 3 or more living children usually were approved for surgery. During the study period, a woman who did not use oral contraceptives, an IUD, or injectables was required to receive a Depo-Provera injection on the 5th to 8th day of her menstrual cycle before surgery was scheduled. This requirement was aimed at reducing the incidence of pregnancies among sterilized women. The number of clinic visits necessary to complete the requirements for sterilization apparently made the difference. Women who needed the Depo-Provera injection had to make more visits and were less likely to follow through to obtain the sterilization. As a result of the CPAIMC study, the clinic has changes its procedure for scheduling sterilization surgery. It is likely that even relatively small changes in service provision may yield significant increases in family planning prevalence and thus increase the coverage and quality of health care in Brazil.^ieng

Asunto(s)

Estudios de Evaluación como Asunto , Accesibilidad a los Servicios de Salud , Motivación , Pobreza , Esterilización Reproductiva , Esterilización Tubaria , Factores de Edad , Américas , Conducta , Tasa de Natalidad , Brasil , Países Desarrollados , Países en Desarrollo , Economía , Servicios de Planificación Familiar , Hormonas , América Latina , Acetato de Medroxiprogesterona , Organización y Administración , Paridad , Población , Características de la Población , Evaluación de Programas y Proyectos de Salud , Psicología , Sustancias para el Control de la Reproducción , Población Rural , Clase Social , Factores Socioeconómicos , América del Sur

RESUMEN

Two hundred and sixty-eight Jamaican women were interviewed and asked about their views on various types of contraceptives. During the interviews they were given an outline of a woman's body and asked to draw the female reproductive system. Worries about altered menstruation, irreversible sterility and other consequences of contraception contributed to underutilization of services. Recommendations for improved services and public education are made.

Asunto(s)

Anticoncepción , Servicios de Planificación Familiar , Conocimientos, Actitudes y Práctica en Salud , Dispositivos Anticonceptivos Masculinos , Anticonceptivos Orales , Femenino , Humanos , Dispositivos Intrauterinos , Jamaica , Medroxiprogesterona/análogos & derivados , Acetato de Medroxiprogesterona , Esterilización Tubaria

RESUMEN

Preliminary results of a study of the possible relationship of depot-medroxy-progesterone acetate (DMPA) to invasive cervical cancer are presented. The findings are based on data from three participating centres in Thailand and one in Mexico. A relative risk for cervical cancer of 1.2 was observed in women who had ever used DMPA; this was not statistically significant. No consistent increase in risk with duration of use was observed, although a relative risk of 2 was found in women who had used DMPA for more than 5 years. This observed increase in risk was confined to women who were aged under 46 years or who had first been exposed to DMPA before 30 years of age. These findings are based on small numbers of subjects, and may not represent a causal relationship.

Asunto(s)

Anticonceptivos Femeninos/efectos adversos , Medroxiprogesterona/análogos & derivados , Neoplasias del Cuello Uterino/inducido químicamente , Preparaciones de Acción Retardada , Femenino , Humanos , Medroxiprogesterona/efectos adversos , Acetato de Medroxiprogesterona , México , Riesgo , Tailandia , Neoplasias del Cuello Uterino/epidemiología

RESUMEN

The preliminary results of a study of the incidence of breast cancer in relation to use of depot-medroxyprogesterone acetate (DMPA) are presented. The findings are based on data from three participating centres in Thailand, and one each in Kenya and Mexico. A relative risk for breast cancer of 0.7 was observed in women who had ever used DMPA; this was not statistically significant. Although no consistent decrease in risk with duration of use was observed, the lowest relative risk (0.5) was observed in women who had used DMPA for three or more years. These findings are based on small numbers and must be considered preliminary. However, they provide no evidence that DMPA increases the risk of breast cancer, and suggest that it may exert a protective effect, particularly in long-term users.

Asunto(s)

Neoplasias de la Mama/inducido químicamente , Anticonceptivos Femeninos/efectos adversos , Medroxiprogesterona/análogos & derivados , Neoplasias de la Mama/epidemiología , Preparaciones de Acción Retardada , Femenino , Humanos , Kenia , Medroxiprogesterona/efectos adversos , Acetato de Medroxiprogesterona , México , Riesgo , Tailandia

RESUMEN

PIP: 1025 women who had used Depo-Provera 150 mg injections for contraception for 3-8 1/2 years were studied to assess the effects of prolonged use. 24.4% were aged 25-29, 33.7% were 30-34, 25.1% were 35-39, 11.2% were 40-44, and the rest were 24 and under. 47.2% had had 5-8 pregnancies and 36.3% had had 9 or more. 78.3% had had at least 5 births. 93.4% had menstrual cycles averaging 26-32 days before treatment. 74% had used no previous contraception, 18.9% used oral contraceptives (OCs), .9% used a monthly injectable, 2.9% used another trimonthly injectable, 3.1% used IUD, and .1% each used condoms and rhythm. 58.6% had amenorrhea while using Depo-Provera and 73.5% of the others had short bleeding episodes of 1-2 days. 62% of 92 endometrial biopsies indicated varying degrees of endometrial atrophy. 5 cases of benign breast adenomas were confirmed by biopsy. 71 women complained of moderate breast tenderness. No cases of breast cancer were observed. 73% gained and 9.2% lost at least 1 kg in weight. No significant changes in blood pressure were noted. The proportion of women reporting inorgasmic sexual response increased from 50.3% at the beginning of use to 75.3% after 12-38 doses of Depo-Provera. 3 pregnancies occurred, 2 possibly resulting from faulty injection technique. A follow-up study of 80 former users for 1 year showed that 39 of 58 cases of amenorrhea resumed menses in an average time of 8-9 months, and 19 did not resume menstruation. 10 of 48 with weight changes did not return to the former weight. Nervousness, amenorrhea, and acne were the symptoms requiring the longest time to disappear. 29 of 46 women complaining of frigidity and 2 of 15 complaining of dyspareunia failed to improve. 11.2% of the 80 women terminated use to achieve pregnancy. Other factors were amenorrhea (72.5%), weight gain (60%), edema (50%), nervousness (45%), sexual problems (81.2%), and hypertension (3.7%).^ieng

Asunto(s)

Acné Vulgar , Amenorrea , Anticoncepción , Anticonceptivos Femeninos , Inyecciones , Estudios Longitudinales , Acetato de Medroxiprogesterona , Aceptación de la Atención de Salud , Sustancias para el Control de la Reproducción , Conducta Sexual , Tiempo , Américas , Conducta , Anticonceptivos , Demografía , Dermatitis , Países en Desarrollo , Enfermedad , Servicios de Planificación Familiar , Planificación en Salud , América Latina , Trastornos de la Menstruación , México , América del Norte , Población , Dinámica Poblacional , Investigación , Factores de Tiempo

RESUMEN

PIP: From 1969 to 1975, 54,650 new acceptors over 30 years of age or with 4 or more children were administered 150 mg Depo-Provera by injection every 90 days. A total of more than 400,000 90-day cycles of clinical observation of the menstrual, metabolic changes, body-weight fluctuations, systemic side effects, and return of fertility were recorded. The rate of pregnancy was .35; the longer the time under treatment, the less abnormal bleeding and greater amenorrhea was noted. Weight gain was between 2-9 kg over 12-36 months. Pregnancy occurred 6-24 months after discontinuation of therapy to achieve pregnancy. Treatment did not affect lactation adversely. There was a continuation rate of 56% during the first 12 months and 54% in the following 18 months. Advantages of use are: 1) can be used on large scale, 2) can be alternative to sterilization, 3) is effective with a minimum of motivation, 4) does not affect lactation, 5) continuity rates are higher than those of oral contraceptives, 6) cost is low, 7) allows use of paramedical personnel, and 8) can be administered postpartum and postabortion.^ieng

Asunto(s)

Amenorrea , Apetito , Estudios de Evaluación como Asunto , Acetato de Medroxiprogesterona , Metrorragia , Investigación , Sistema Nervioso Central , Anticoncepción , Anticonceptivos , Anticonceptivos Femeninos , Sistema Digestivo , Enfermedad , Servicios de Planificación Familiar , Hemorragia , Inyecciones , Trastornos de la Menstruación , Signos y Síntomas

RESUMEN

PIP: The contractability of the Fallopian tubes is instrumental in the transport of the ovum to the uterus. Various studies have been done to determine the effect of different hormones on this property of the tubes, but they have been inconclusive. 34 patients who were scheduled for salpingectomies for reasons of birth control and who had been using steroid contraceptives for at least 3 months prior to the operation were selected for study. Half the sample had used pure progestagens (Depo-Provera or chlormadinone) and half had used a combined preparation (quinestrol + quingestanol or deladroxate). All were between 29-41 years of age with numbers of pregnancies ranging from 5 to 21. The intensity and frequency of the contractions and the general activity of the isthmus portion of the tubes were studied for 10-minute periods in 2 cm segments. Also, histological studies were done using hematoxylin eosin tincture and Van Giessen tincture, and histochemical tests were performed. The 17 cases on combined orals exhibited a significantly higher rate of activity than those on pure progestins, but were also subject to contractions of greater intensity. The histochemical studies showed a decrease in the energetic material and in the enzymatic activity related to carbohydrate metabolism in the tubes of the progestin group. The depression of motor activity and energetic metabolism was, however, neutralized by administering estrogens.^ieng

Asunto(s)

Acetato de Clormadinona/farmacología , Estradiol/farmacología , Estranos/farmacología , Trompas Uterinas/efectos de los fármacos , Medroxiprogesterona/farmacología , Adulto , Trompas Uterinas/fisiología , Femenino , Humanos , Histerosalpingografía , Técnicas In Vitro , Contracción Muscular/efectos de los fármacos , Coloración y Etiquetado