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PIP: After 20 years of clinical experience, injectable hormonal contraceptives such as norethisterone enanthate (NET) and medroxyprogesterone acetate (MPA) remain one of the most controversial methods currently used for temporary control of fertility in women. Since December 1980 this controversy has been accentuated in Mexico with issuing of regulations by the Secretary of Health and Welfare which initially did not permit promotion of long-acting injectable hormones for contraception purposes, and later, in June 1981, a reconsideration which exclusively authorized use of NET as an injectable contraceptive. Undeniably these official measures and the scientific information, occasionally contradictory, have created confusion about the indications and risks of using these formulations in clinical work. This paper presents an anlysis of the basic pharmacological aspects of long-acting contraceptive progestagens, potential risks for side effects, and some clinical rules for safe use. The authors conclude that injectable contraceptives will continue holding a definite place among hormonal methods of temporary fertility control, particularly with the advent of new administration schemes for NET which have elevated its contraceptive efficacy without appreciably increasing complications. The more rapid metabolism of NET, manifested in the absence of significant effects on body weight, less alteration of the menstrual cycle, and more rapid return of fertility after discontinuation, has considerably increased its popularity, and the possibility exists that with time and an increase in clinical experience, it may replace MPA as the injectable contraceptive of choice. Nevertheless, while investigative studies have not clearly defined the possibilities of potential risk of using these contraceptives, its clinical use must be governed by appropriate selection and careful follow-up of patients.^ieng

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PIP: The objective of this study was to analyze the acceptability, effectiveness, and continuation of long-acting progestagens in certain sectors of the population where its advantages are more obvious by virtue of certain socioeconomic, cultural, and geographic characteristics, and by lack of availability of family planning services, as in rural areas and urban marginal zones. The study was performed using females of reproductive age residing in rural areas of the Mexican States of Hidalgo, Puebla, and Yucatan between July 1981 and September 1982. Originally the investigation included a total of 462 women, of whom 94 were lost to follow-up, leaving a total of 368 patients (79.6%) with effective follow-up. The contraceptive used was 19-Nor progestagen, norethisterone enanthate (NET), in 200 mg doses administered intramuscularly. The 1st dose was applied between the 1st to the 5th day of the menstrual cycle and each 60 calendar days thereafter. Of a total of 94 discontinuations, 2/3 occurred during the 1st 6 months of the study. The final discontinuation rate was 14.46%. The studied population showed a continuation rate of 85.54% after 12 months of use. Observing rates by reasons for discontinuation, the principal causes in descending order were nonmedical reasons, amenorrhea, pregnancy, bleeding and other secondary effects. The greatest number of discontinuations, considering each particular reason, occurred predominantly during the 1st 6 months of the study. Distribution of users by age group show that more than 2/3 (71.8%) were between 20 and 34 years old. Distribution by number of previous pregnancies show 56.5% with 5 or more gestations. To analyze behavior of menstrual cycles, "cycles" were defined as period of 30 calendar days. Under this concept, more than 2/3 (70.9%) of the users had from 1 to 7 days of bleeding per cycle. On the basis of the results of the study, it is possible to conclude the following: 1) Continuation of NET use is greater than that observed with other long-lasting progestagens. This seems to be especially so when employed in areas where limitations exist for the utilization of other contraceptive means. 2) Contraceptive effectiveness is greater when administration is scheduled at 60 day intervals rather than longer intervals. 3) Unlike other long-acting progestagens, NET conserves the normal menstrual pattern in the majority of users, which favorably influences its continuation.^ieng

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Se presentan los resultados de un estudio efectuado en 368 mujeres residentes en areas rurales de Mexico, que utilizaron enantato de noretisterona como anticonceptivo inyectable de intervalo. El esquema de administracion fue de 200mg por via intramuscular cada 60 dias. Se encontro una descontinuacion de 14.46 a un ano de uso, siendo las razones principales las no medicas y en segundo lugar, los trastornos del ciclo. La tasa de embarazos resulto de 2.09 por ciento. Tambien se observo que el 70.9 por ciento de las usuarias presentaron 1 a 7 dias de sangrado por mes, es decir, que mostraron una regularidad considerable en sus ciclos. Se comentan asimismo las posibles razones de la alta continuidad observada con el metodo y la baja incidencia de trastornos menstruales

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Los anticonceptivos inyectables a base de progestagenos de deposito, vigentes en la actualidad para uso clinico son el enantato de noretisterona (ENE) y el acetato de medroxiprogesterona (AMP). En Mexico, solo esta recomendado el empleo de ENE, que por su metabolismo mas rapido, produce menores efectos secundarios y un retorno mas rapido de la fertilidad al descontinuarlo.Se presenta un analisis de los aspectos farmacologicos basicos de los progestagenos de deposito, de sus efectos secundarios y riesgos potenciales, asi como algunas normas clinicas para su empleo

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PIP: Depot medroxyprogesterone acetate (DMPA) generally injected in doses of 150 mg every 3 months, is offered in the official family planning program of Mexico. The study purpose was to assess the impact of attitudes toward DMPA of medical and paramedical family planning workers on the frequency of prescription and acceptance of DMPA in the national family planning program. A 21-item multiple choice mail questionnaire was returned by 644 persons including 279 physicians, 257 nurses, and 104 social workers from Mexico City and 24 of the 31 states, a response rate of 55.6%. 338 of the respondents worked in health centers, 274 had worked in family planning for less than 1 year, and 427 were female. 365 had previous experience with DMPA. 458 knew the correct quarterly dose. Only 66 persons (10.8%) frequently prescribed DMPA, while 373 (61.1%) occasionally prescribed it and 169 (27.7%) never did so. 582 persons knew of at least 2 other injectable contraceptives. Among side effects, 423 persons mentioned frequent amenorrhea, 267 frequent bleeding, and 329 a reduction of future fertility. 203 mentioned that it did not affect lactation. 361 noted that it has high contraceptive efficacy. 439 considered administration of DMPA simple and 235 thought it was a good contraceptive. Asked what type of injectable contraceptive they preferred, 148 selected a combined monthly injection, 125 selected a progestogen every 84 days, and 115 selected DMPA. 416 considered their information on DMPA to have come from scientific sources. Medical journals were cited by 156, training courses by 271, and commercial promotions by pharmaceutical companies by 236. 612 persons (97.0%) felt that more training on DMPA use should be provided for family planning personnel, and 594 (94.7%) felt that users should receive more information. Discrepancies in the knowledge of DMPA among family planning workers indicate the need for improved training of new family planning workers and for continuing education of experienced workers.^ieng

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Es indiscutible que en la evaluacion de cualquier metodo anticonceptivo, es importante conocer no solo la opinion de las usuarias, sino tambien del personal encargado de aplicarlo en los programas de planificacion familiar, por lo que se planteo este estudio en el que se investigo la aceptualidad del uso de acetato de medroxiprogesterona, recomendado por dicho personal, encontrandose lo siguiente: Hasta el momento actual continua siendo objeto de controversia, en un alto porcentaje de los entrevistados son insuficientes los conocimientos sobre efectividad, efectos secundarios y otros aspectos, por lo que se concluye que son necesarios la capacitacion adecuada del personal de nuevo ingreso a los programas de planificacion familiar, asi como el establecimiento de sistemas de educacion continua en los mismos

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PIP: 361 retrospective surveys were carried out among users of medroxyprogesterone acetate (MPA) given in a trimestral regimen of 150 mg/dose in rural areas of 3 Mexican states. Gynecology-obstetric antecedents, previous experience with oral contraceptives (OCs), effects of injections on the menstrual cycle, causes of method suspension, and opinion concerning administration of medication were analyzed. 78.6% of the patients were multigravidae with 4 or more pregnancies; 39.1% were former users of OCs, and 23.4% had stopped taking them because of side effects. The side effects of MPA on the menstrual cycle were: amenorrhea (19.8%); hemorrhage/cycle of 10-30 days in 14.7%; and hemorrhage/cycle of 30 or more days in 11.6%. Only 14.7% of users stopped the injections and of these, 80.3% did so due to menstrual cycle disorders. 99.7% of the users thought the method was comfortable as a family planning procedure. (author's)^ieng

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PIP: All available data to date indicate that the Family Planning Program of the Public Health Department, together with the rest of the Health Institutions which offer this type of service are having great success at the national level and, consequently, in the border states. The Public Health Department Program and the Programs of the Institutions as a whole are enrolling approximately 15% of the eligible couples/year, this number compares very favorably with that reported internationally. The rapid progress observed in the rural areas has been particularly stimulating, especially if we consider the fact that it is this area that the greatest resistance was expected. At the present time, one of the prime activities of the Public Health Department is to extend the Program to a greater number of rural communities through an established network of community promoters. There is a clear difference in the yield, extension, etc. between the different health units within the same state. This variation includes the border states as well. The directed efforts to understand and detect these differences systematically are still being studied. Presently we can state that the coverage reached by the Program has not yet begun to stagnate or indicate negative growth, although there is some indication of this in the urban areas. Acceptor characteristics point to the necessity of extending the Program to an economically weak population and not to restrict it to the privileged people. This is supported by the results obtained in a National Contraceptive Prevalence Study done by the Coordination of the National Program for Family Planning, which shows that 60% of couples in urban areas use contraceptive methods, 20% of rural couples, and 40% at the national level. These numbers are equal or even greater in the border states. (author's modified)^ieng

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PIP: Seven courses of theoretical and practical training in family planning were offered in 1974-75 in Mexico City, and directed to general practitioners. There were 110 participants. Activities included, among others, insertions and extractions of IUDs, prescription of OC (oral contraception), control of patients, and complete pelvic examinations. At the beginning of the course it was obvious that there were serious deficiencies in the theoretical areas, as well as in specific clinical skills as applied to family planning. There was a strong improvement in attitudes toward family planning from a purely social point of view, especially concerning unmarried women, or women with high parity. While before the course the participants tended to suggest salpingochlasia as the only form of permanent contraception, they would most consider vasectomy at the end of the course. Reasons against induced abortion, when present, were of a religious or ethical nature. Results obtained with these courses showed the importance of training in family planning for general practitioners, were it only to emphasize their duties toward the community, and to improve their medical skills in such field.^ieng

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PIP: It is evident that since the period 1973-4, some important changes have occurred with regard to the age, number of living children, and educational status of new acceptors within the family planning program of the Secretaria de Salubriad y Asistencia. While the 1973-4 acceptors were older, had more children, and had more education, the 1976 acceptors were younger, had less education, and had a number of children similar to the population at large. It is interesting to note that 1976 rural acceptors exhibit the same fertility levels as those acceptors of the 1973-4 urban programs, although as a whole, they are younger and less educated. It is possible that through the same legitimization process, accelerated by communication and motivation campaigns, it will shortly be possible for the rural program to recruit acceptors with fewer children. (author's modified)^ieng

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PIP: The authors examine the results of some recent studies from around the world on the relationship between breast-feeding and fertility. The effectiveness of breast-feeding as a form of contraception is compared with that of more modern methods, especially the IUD and steroids^ieng

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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

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