Uso De Contraceptivos Reversíveis De Longa Duração E A Relação Entre Taxas De Descontinuidade Devido à Menopausa E à Esterilização De Homens E Mulheres

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Introduction Women require effective contraception until they reach menopause. The long acting reversible contraceptives (LARC) and the depot-medroxyprogesterone acetate (DMPA, Depo-Provera®, Pfizer, Puurs, Belgium) are great options and can replace possible sterilizations. Purpose To assess the relationship between the use of LARCs and DMPA and terminations ascribed to menopause and sterilizations in a Brazilian clinic. Methods We reviewed the records of women between 12 and 50 years of age attending the clinic that chose to use a LARCmethod or DMPA. Cumulative termination rates due to sterilization or because the woman had reached menopause were computed using single decrement life-table analysis over 32 years. We also examined all records of surgical sterilization at our hospital between the years 1980-2012. Results Three hundred thirty-two women had continuously used the same contraceptive until menopause, and 555 women had discontinued the method because they or their partners underwent sterilization. Fromyear 20 to year 30 of use, levonorgestrel intrauterine-releasing system (LNG-IUS - Mirena®, Bayer Oy, Turku, Finland; available since 1980), copper intrauterine device (IUD - available since 1980) and DMPA users showed a trend of cumulative higher discontinuation rates due to menopause when compared with the discontinuation rates due to sterilization. Over the study period, a steep decline in the use of sterilization occurred. Conclusion Over the past 15 years of research we have observed a trend: women usually preferred to continue using LARC methods or DMPA until menopause rather than decide for sterilization, be it their own, or their partners’. The annual number of sterilizations dropped in the same period. The use of LARC methods and DMPA until menopause is an important option to avoid sterilization, which requires a surgical procedure with potential complications. © 2016 by Thieme Publicações Ltda, Rio de Janeiro, Brazil.385210217#573747/2008-3, FAPESP, Fundação de Amparo à Pesquisa do Estado de São PauloFundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Provider and lay perspectives on intra-uterine contraception: a global review

BACKGROUND: Intra-uterine contraception (IUC) involves the use of an intra-uterine device (IUD), a highly effective, long-acting, reversible contraceptive method. Historically, the popularity of IUC has waxed and waned across different world regions, due to policy choices and shifts in public opinion. However, despite its advantages and cost-effectiveness for programmes, IUC's contribution to contraceptive prevalence is currently negligible in many countries. This paper presents the results of a systematic review of the global literature on provider and lay perspectives on IUC. It aims to shed light on the reasons for low use of IUC and reflect on potential opportunities for the method's promotion. METHODS: A systematic search of the literature was conducted in four peer-reviewed journals and four electronic databases (MEDLINE, EMBASE, POPLINE, and Global Health). Screening resulted in the inclusion of 68 relevant publications. RESULTS: Most included studies were conducted in areas where IUD use is moderate or low. Findings are similar across these areas. Many providers have low or uneven levels of knowledge on IUC and limited training. Many wrongly believe that IUC entails serious side effects such as pelvic inflammatory disease (PID), and are reluctant to provide it to entire eligible categories, such as HIV-positive women. There is particular resistance to providing IUC to teenagers and nulliparae. Provider opinions may be more favourable towards the hormonal IUD. Some health-care providers choose IUC for themselves. Many members of the public have low knowledge and unfounded misconceptions about IUC, such as the fear of infertility. Some are concerned about the insertion and removal processes, and about its effect on menses. However, users of IUC are generally satisfied and report a number of benefits. Peers and providers exert a strong influence on women's attitudes. CONCLUSION: Both providers and lay people have inaccurate knowledge and misconceptions about IUC, which contribute to explaining its low use. However, many reported concerns and fears could be alleviated through correct information. Concerted efforts to train providers, combined with demand creation initiatives, could therefore boost the method's popularity. Further research is needed on provider and lay perspectives on IUDs in low- and middle-income countries

Sensitivity of the Cherenkov Telescope Array for probing cosmology and fundamental physics with gamma-ray propagation

The Cherenkov Telescope Array (CTA), the new-generation ground-based observatory for γ astronomy, provides unique capabilities to address significant open questions in astrophysics, cosmology, and fundamental physics. We study some of the salient areas of γ cosmology that can be explored as part of the Key Science Projects of CTA, through simulated observations of active galactic nuclei (AGN) and of their relativistic jets. Observations of AGN with CTA will enable a measurement of γ absorption on the extragalactic background light with a statistical uncertainty below 15% up to a redshift z=2 and to constrain or detect γ halos up to intergalactic-magnetic-field strengths of at least 0.3 pG . Extragalactic observations with CTA also show promising potential to probe physics beyond the Standard Model. The best limits on Lorentz invariance violation from γ astronomy will be improved by a factor of at least two to three. CTA will also probe the parameter space in which axion-like particles could constitute a significant fraction, if not all, of dark matter. We conclude on the synergies between CTA and other upcoming facilities that will foster the growth of γ cosmology.</p

Emerging Female Contraceptives

Introduction: Fifty years after the first contraceptive, the market remains restricted regarding composition, cost and routes of administration, and satisfying the needs of millions of women with different requirements according to their stage in life. Areas covered: Women need contraception for almost 30 years of their life. Currently available contraceptives are highly effective with few side effects. This review provides information on emerging female contraceptives including some registered and others at different stages of development. Research efforts aim to reduce costs, improve acceptability and refine 'forgettable' reversible methods. Although developing and testing a new method is laborious and expensive, many new contraceptives are currently under development including different routes of administration. Expert opinion: New methods should be affordable, simple to use and suitable for many women. Much work remains to be done and new methods that act on the fusion process between both gametes are desirable without affecting the hormonal milieu. © Informa UK, Ltd.162373387(2004) Medical Eligibility Criteria for Contraceptive Use, , World Health Organization 3rd edition. 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C), pp. 53-68Huber, J., Foidart, J.M., Wuttke, W., Merki-Feld, G.S., The, H.S., Gerlinger, C., Schellschmidt, I., Heithecker, R., Efficacy and tolerability of a monophasic oral contraceptive containing ethinylestradiol and drospirenone (2000) European Journal of Contraception and Reproductive Health Care, 5 (1), pp. 25-34Spona, J., Feichtinger, W., Kindermann, C., Moore, C., Mellinger, U., Walter, F., Graser, T., Modulation of ovarian function by an oral contraceptive containing 30 microg ethinyl estradiol in combination with 2.00 mg dienogest (1997) Contraception, 56 (3), pp. 185-191. , DOI 10.1016/S0010-7824(97)00123-6, PII S0010782497001236Bannemerschult, R., Hanker, J.P., Wunsch, C., Fox, P., Albring, M., Brill, K., A multicenter, uncontrolled clinical investigation of the contraceptive efficacy, cycle control and safety of a new low dose oral contraceptive containing 20 microg ethinyl estradiol and 100 microg levonorgestrel over six treatment cycles (1997) Contraception, 56 (5), pp. 285-290. , DOI 10.1016/S0010-7824(97)00157-1, PII S0010782497001571Endrikat, J., Jaques, M.A., Mayerhofer, M., A twelve-month comparative clinical investigation of two low-dose oral contraceptives containing 20 micrograms ethinylestradiol/75 micrograms gestodene and 20 micrograms ethinylestradiol/150 micrograms desogestrel, with respect to efficacy, cycle control and tolerance (1995) Contraception, 52 (4), pp. 229-235Astedt, B., Jeppsson, S., Liedholm, P., Clinical trial of a new oral contraceptive pill containing the natural oestrogen 17 beta-oestradiol (1979) Br J Obstet Gynaecol, 86 (9), pp. 732-736. , An excellent study about the replacement of EE by natural estradiolHoffmann, H., Moore, C., Kovacs, L., Teichmann, A.T., Klinger, G., Graser, T., Oettel, M., Alternatives for the replacement of ethinylestradiol by natural 17beta- Estradiol in dienogest-containing oral contraceptives (1999) Drugs of Today, 35 (SUPPL. C), pp. 105-113Kivinen, S., Saure, A., Efficacy and tolerability of a combined oral contraceptive containing 17 beta-estradiol and desogestrel (1996) Eur J Contracept Reprod Health Care, 1, p. 183Samsioe, G., Transdermal hormone therapy: Gels and patches (2004) Climacteric, 7 (4), pp. 347-356. , DOI 10.1080/13697130400012239Urdl, W., Apter, D., Alperstein, A., Koll, P., Schonian, S., Bringer, J., Fisher, A.C., Germond, M., Contraceptive efficacy, compliance and beyond: Factors related to satisfaction with once-weekly transdermal compared with oral contraception (2005) European Journal of Obstetrics Gynecology and Reproductive Biology, 121 (2), pp. 202-210. , DOI 10.1016/j.ejogrb.2005.01.021, PII S0301211505000540Abrams, L.S., Skee, D.M., Natarajan, J., Pharmacokinetics of a contraceptive patch (Evra/Ortho Evra) containing norelgestromin and ethinyloestradiol at four application sites (2002) Br J Clin Pharmacol, 53 (2), pp. 141-146Abrams, L.S., Skee, D.M., Natarajan, J., Multiple-dose pharmacokinetics of a contraceptive patch in healthy women participants (2001) Contraception, 64 (5), pp. 287-294Abrams, L.S., Skee, D.M., Natarajan, J., Pharmacokinetics of norelgestromin and ethinyl estradiol delivered by a contraceptive patch (Ortho Evra/Evra) under conditions of heat, humidity, and exercise (2001) J Clin Pharmacol, 41 (12), pp. 1301-1309Sicat, B.L., Evra, O., A new contraceptive patch (2003) Pharmacotherapy, 23 (4), pp. 472-480Audet, M.-C., Moreau, M., Koltun, W.D., Waldbaum, A.S., Shangold, G., Fisher, A.C., Creasy, G.W., Evaluation of contraceptive efficacy and cycle control of a transdermal contraceptive patch vs an oral contraceptive: A randomized controlled trial (2001) Journal of the American Medical Association, 285 (18), pp. 2347-2354Jick, S.S., Hagberg, K.W., Kaye, J.A., Ortho Evra and venous thromboembolism: An update (2010) Contraception, 81 (5), pp. 452-453Brache, V., Mishell, D.R., Lahteenmaki, P., Alvarez, F., Elomaa, K., Jackanicz, T., Faundes, A., 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Piaggio, G., Ding, J., Chen, J., Song, S., Bartfai, G., Ng, E., Peregoudov, A., Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: A WHO multicentre randomised trial (2002) Lancet, 360 (9348), pp. 1803-1810. , DOI 10.1016/S0140-6736(02)11767-3Moreau, C., Trussell, J., Bajos, N., The determinants and circumstances of use of emergency contraceptive pills in France in the context of direct pharmacy access (2006) Contraception, 74 (6), pp. 476-482. , DOI 10.1016/j.contraception.2006.07.008, PII S0010782406003131Woolcock, J.G., Critchley, H.O., Munro, M.G., Review of the confusion in current and historical terminology and definitions for disturbances of menstrual bleeding (2008) Fertil Steril, 90 (6), pp. 2269-2280Grimes, D.A., Schulz, K.F., Raymond, E.G., Surrogate end points in women's health research: Science, protoscience, and pseudoscience (2010) Fertil Steril, 93 (6), pp. 1731-1734Oettel, M., Carol, W., Elger, W., Kaufmann, G., Moore, C., Romer, W., Klinger, G., Zimmermann, H., A 19-norprogestin without 17alpha-ethinyl group II: Dienogest from a pharmacodynamic point of view (1995) Drugs of Today, 31 (7), pp. 517-536Dusterberg, B., Nishino, Y., Pharmacokinetic and pharmacological features of oestradiol valerate (1982) Maturitas, 4 (4), pp. 315-324. , DOI 10.1016/0378-5122(82)90064-0Zeun, S., Lu, M., Uddin, A., Pharmacokinetics of an oral contraceptive containing oestradiol valerate and dienogest (2009) Eur J Contracept Reprod Health Care, 14 (3), pp. 221-232Oettel, M., Breitbarth, H., Elger, W., The pharmacological profile of dienogest (1999) Eur J Contracept Reprod Health Care, 4 (1 SUPPL. 1), pp. 2-13Mueck, A.O., Seeger, H., Buhling, K.J., Why use of dienogest for the first contraceptive pill with estradiol? (2009) Gynecol Endocrinol, 11, pp. 1-5Ben-Rafaelf, Z., Mastroianni, L., Meloni, F., Total estradiol, free estradiol, sex hormone-binding globulin, and the fraction of estradiol bound to sex hormone-binding globulin in human follicular fluid (1986) J Clin Endocrinol Metab, 63 (5), pp. 1106-1111. , The most important study with the new COCEndrikat, J., Parke, S., Trummer, D., Ovulation inhibition with four variations of a four-phasic estradiol valerate/dienogest combined oral contraceptive: Results of two prospective, randomized, open-label studies (2008) Contraception, 78 (3), pp. 218-225Palacios, S., Wildt, L., Parke, S., Efficacy and safety of a novel oral contraceptive based on oestradiol (oestradiol valerate/dienogest): A Phase III trial (2010) Eur J Obstet Gynecol Reprod Biol, 149 (1), pp. 57-62Ahrendt, H.J., Makalova, D., Parke, S., Bleeding pattern and cycle control with an estradiol-based oral contraceptive: A seven-cycle, randomized comparative trial of estradiol valerate/dienogest and ethinyl estradiol/levonorgestrel (2009) Contraception, 80 (5), pp. 436-444+54Parke, S., Nahum, G., Mellinger, U., Junge, W., Metabolic effects of a new four-phasic oral contraceptive containing estradiol valerate and dienogest (2008) Obstet Gynecol, 111 (4 SUPPL.), pp. 12-13Fraser, I.S., Zeun, S., Machlitt, A., Mellinger, U., A novel oral contraceptive comprising estradiol valerate/dienogest for the treatment of heavy and/or prolonged menstrual bleeding without organic cause: A double-blind, randomised, placebo-controlled trial (2009) Int J Gynecol Obstet, 107 (SUPPL. 2), pp. S183Jensen, J., Machlitt, A., Mellinger, U., A multicenter, double-blind, randomized, placebo-controlled study of oral estradiol valerate/dienogest for the treatment of heavy and/or prolonged menstrual bleeding (2009) Fertil Steril, 92, pp. S32Duijkers, I.J.M., Klipping, C., Grob, P., Korver, T., Effects of a unique, monophasic combined oral contraceptive containing nomegestrol acetate/17 beta-estradiol on ovarian function 14 World Congress of Gynecology Endocrinology, Florence, Italy, March, 2010, , AbstractDuijkers, I.J., Klipping, C., Grob, P., Korver, T., Effects of a monophasic combined oral contraceptive containing nomegestrol acetate and 17 beta-oestradiol on ovarian function in comparison to a monophasic combined oral contraceptive containing drospirenone and ethinylestradiol (2010) Eur J Contracept Reprod Health Care, 15 (5), pp. 314-325Dinger, J., Assmann, A., Mohner, S., Minh, T.D., Risk of venous thromboembolism and the use of dienogest- and drospirenone-containing oral contraceptives: Results from a German case-control study (2010) J Fam Plann Reprod Health Care, 36 (3), pp. 123-129Cibula, D., Gompel, A., Mueck, A.O., Hormonal contraception and risk of cancer (2010) Hum Reprod Update, 16 (6), pp. 631-650Xu, B., Kitawaki, J., Koshiba, H., Ishihara, H., Kiyomizu, M., Teramoto, M., Kitaoka, Y., Honjo, H., Differential effects of progestogens, by type and regimen, on estrogen-metabolizing enzymes in human breast cancer cells (2007) Maturitas, 56 (2), pp. 142-152. , DOI 10.1016/j.maturitas.2006.07.003, PII S0378512206002726http://www.ClnicalTrials.gov, Available from NCT00464516Creinin, M.D., Schlaff, W., Archer, D.F., Progesterone receptor modulator for emergency contraception: A randomized controlled trial (2006) Obstet Gynecol, 108 (5), pp. 1089-1097. , The most important study in EC with ulipristalGlasier, A.F., Cameron, S.T., Fine, P.M., Ulipristal acetate versus levonorgestrel for emergency contraception: A randomised non-inferiority trial and meta-analysis (2010) Lancet, 375 (9714), pp. 555-562Fine, P., Mathe, H., Ginde, S., Ulipristal acetate taken 48--120 hours after intercourse for emergency contraception (2010) Obstet Gynecol, 115 (2 PART 1), pp. 257-263Brache, V., Cochon, L., Jesam, C., Immediate pre-ovulatory administration of 30 mg ulipristal acetate significantly delays follicular rupture (2010) Hum Reprod, 25 (9), pp. 2256-2263Stratton, P., Levens, E.D., Hartog, B., Endometrial effects of a single early luteal dose of the selective progesterone receptor modulator CDB-2914 (2010) Fertil Steril, 93 (6), pp. 2035-2041Pall, M.S., Friden, B.E., Brannstrom, M., Induction of delayed follicular rupture in the human by the selective COX-2 inhibitor rofecoxib: A randomized double-blind study (2001) Human Reproduction, 16 (7), pp. 1323-1328Bata, M.S., Al-Ramahi, M., Salhab, A.S., Gharaibeh, M.N., Schwartz, J., Delay of ovulation by meloxicam in healthy cycling volunteers: A placebo-controlled, double-blind, crossover study (2006) Journal of Clinical Pharmacology, 46 (8), pp. 925-932. , DOI 10.1177/0091270006289483Richards, J.S., Perspective: The ovarian follicle. A perspective in 2001 Endocrinology 2001, 142 (6), pp. 2184-2193Jesam, C., Salvatierra, A.M., Schwartz, J.L., Croxatto, H.B., Suppression of follicular rupture with meloxicam, a cyclooxygenase-2 inhibitor: Potential for emergency contraception (2010) Hum Reprod, 25 (2), pp. 368-373Edelman, A.B., Jensen, J.T., Hennebold, J.D., A nonhormonal model for emergency contraception: Prostaglandin synthesis inhibitor effects on luteal function and lifespan, a pilot study (2010) Contraception, 81 (6), pp. 496-500Pearce-Pratt, R., Phillips, D.M., Sulfated polysaccharides inhibit lymphocyte-to-epithelial transmission of HIV-1 (1996) Biol Reprod, 54 (1), pp. 173-182. , Provides insight about vaginal gel which has the potential of dual protectionSitruk-Ware, R., Brache, V., Maguire, R., Pharmacokinetic study to compare the absorption and tolerability of two doses of levonorgestrel following single vaginal administration of levonorgestrel in Carraguard gel: A new formulation for "dual protection" contraception (2007) Contraception, 75 (6), pp. 454-460Elias, C.J., Coggins, C., Alvarez, F., Brache, V., Fraser, I.S., Lacarra, M., Lahteenmaki, P., Salvatierra, A.M., Colposcopic evaluation of a vaginal gel formulation of iota-carrageenan (1997) Contraception, 56 (6), pp. 387-389. , DOI 10.1016/S0010-7824(97)00176-5, PII S0010782497001765Coggins, C., Blanchard, K., Alvarez, F., Brache, V., Weisberg, E., Kilmarx, P.H., Lacarra, M., Ellertson, C., Preliminary safety and acceptability of a carrageenan gel for possible use as a vaginal microbicide (2000) Sexually Transmitted Infections, 76 (6), pp. 480-483. , DOI 10.1136/sti.76.6.480Victor, A., Johansson, E., Plasma levels of d-norgestrel and ovarian function in women using intravaginal rings impregnated with d-norgestrel for several cycles (1976) Contraception, 14 (2), pp. 215-226Brache, V., Croxatto, H., Sitruk-Ware, R., Effect of a single vaginal administration of levonorgestrel in Carraguard gel on the ovulatory process: A potential candidate for "dual protection" emergency contraception (2007) Contraception, 76 (2), pp. 111-116Brache, V., Croxatto, H., Kumar, N., Effect of sexual intercourse on the absorption of levonorgestrel after vaginal administration of 0.75 mg in Carraguard gel: A randomized, cross-over, pharmacokinetic study (2009) Contraception, 79 (2), pp. 150-154http://informa-pipeline.citeline.com, Pharmaprojects. Available fromhttp://informa.citeline.com, Pharmaprojects. Available fromhttp://www.clinicaltrials.gov/NCT01140217, Available from NCT00915915http://www.clinicaltrials.gov/NCT01140217, Available fromHaukkamaa, M., Laurikka-Routti, M., Heikinheimo, O., Transdermal absorption of the progestin ST-1435: Therapeutic serum steroid concentrations and high excretion of the steroid in saliva (1991) Contraception, 44 (3), pp. 269-276Kumar, N., Koide, S.S., Tsong, Y.Y., Sundaram, K., Nestorone®: A progestin with a unique pharmacological profile (2000) Steroids, 65 (10-11), pp. 629-636. , It is the first study about transdermalcontraceptive sprayFraser, I.S., Weisberg, E., Kumar, N., Kumar, S., Humberstone, A.J., McCrossin, L., Shaw, D., Sitruk-Ware, R., An initial pharmacokinetic study with a Metered Dose Transdermal System® for delivery of the progestogen Nestorone® as a possible future contraceptive (2007) Contraception, 76 (6), pp. 432-438. , DOI 10.1016/j.contraception.2007.08.006, PII S001078240700409XGilliam, M.L., Neustadt, A., Kozloski, M., Adherence and acceptability of the contraceptive ring compared with the pill among students: A randomized controlled trial (2010) Obstet Gynecol, 115 (3), pp. 503-510Weisberg, E., Brache, V., Alvarez, F., Massai, R., Mishell Jr., D.R., Apter, D., Gale, J., Fraser, I.S., Clinical performance and menstrual bleeding patterns with three dosage combinations of a Nestorone progestogen/ethinyl estradiol contraceptive vaginal ring used on a bleeding-signaled regimen (2005) Contraception, 72 (1), pp. 46-52. , DOI 10.1016/j.contraception.2004.12.014, PII S0010782405000284Brache, V., Mishell, D.R., Lahteenmaki, P., Alvarez, F., Elomaa, K., Jackanicz, T., Faundes, A., Ovarian function during use of vaginal rings delivering three different doses of Nestorone (2001) Contraception, 63 (5), pp. 257-261. , DOI 10.1016/S0010-7824(01)00199-8, PII S0010782401001998Sivin, I., Mishell Jr., D.R., Alvarez, F., Brache, V., Elomaa, K., Lahteenmaki, P., Massai, R., Jackanicz, T.M., Contraceptive vaginal rings releasing Nestorone and ethinylestradiol: A 1-year dose-finding trial (2005) Contraception, 71 (2), pp. 122-129. , DOI 10.1016/j.contraception.2004.08.010Fraser, I.S., Weisberg, E., Brache, V., Serum Nestorone and ethinyl estradiol levels, and ovulation inhibition in women using three different dosage combinations of a Nestorone progestogen-ethinyl estradiol contraceptive vaginal ring on a bleeding-signaled regimen (2005) Contraception, 72 (1), pp. 40-45. , It is the first final report of a clinical trial with a new combined vaginal ringSitruk-Ware, R., Merkatz, R., Sussman, H., Variano, B., A one year contraceptive vaginal ring delivering Nestorone® and Ethinyl-Estradiol The 11th Congress of the European Society of Contraception and Reproductive Health. Hague, Holland, May, 2010, , AbstractMerkatz, R., Sussman, H., Sivin, I., Preliminary results from a phase III study of the nestorone®/ethinyl estradiol contraceptive vaginal ring: A new, long acting (one year) user controlled contraceptive method The 11th Congress of the European Society of Contraception and Reproductive Health. Hague, Holland, May, 2010, , AbstractLahteenmaki, P., Weiner, E., Lahteenmaki, P., Contraception with subcutaneous capsules containing ST-1435. Pituitary and ovarian function and plasma levels of ST-1435 (1981) Contraception, 23 (1), pp. 63-75. , DOI 10.1016/0010-7824(81)90115-3Diaz, S., Schiappacasse, V., Pavez, M., Clinical trial with NestoroneTM subdermal contraceptive implants (1995) Contraception, 51 (1), pp. 33-38Brache, V., Massai, R., Mishell Jr., D.R., Ovarian function during use of Nestorone® subdermal implants (2000) Contraception, 61 (3), pp. 199-204. , Shows the final results of the clinical trial on subdermal implants which release NESSivin, I., Croxatto, H., Bahamondes, L., Brache, V., Alvarez, F., Massai, R., Schechter, J., Moo-Young, A., Two-year performance of a Nestorone-releasing contraceptive

Long-acting reversible contraceptive (LARCs) methods

Unplanned pregnancy (UP) is a public health problem, which affects millions of women worldwide. Providing long-acting reversible contraceptive (LARC) methods is an excellent strategy to avoid or at least reduce UP, because the effectiveness of these methods is higher than other methods, and is indeed comparable to that of permanent contraception. As the initial introduction of the inert plastic intrauterine device (IUD) and of the six-rod implant, pharmaceutical companies have introduced a copper IUD (Cu-IUD), different models of levonorgestrel-releasing intrauterine system (LNG IUS), and one and two-rod implants, which certainly improved women's LARC options. The main characteristic of LARCs is that they provide high contraceptive effectiveness with a single intervention, and that they can be used for a long time. Emerging evidence from the last few years has demonstrated that it is possible to extend the use of the 52 mg LNG IUS and of the etonogestrel-implant beyond five- and three years, respectively, which adds new value to these LARC

Ease Of Insertion And Clinical Performance Of The Levonorgestrel-releasing Intrauterine System In Nulligravidas

Background: Despite the high contraceptive efficacy and the additional noncontraceptive benefits of the levonorgestrel-releasing intrauterine system (LNG-IUS), concerns persist with respect to its use in nulligravidas. The objective of this study was to evaluate the ease of insertion and clinical performance of the LNG-IUS in nulligravida women up to 1 year after insertion. Methods: Two cohorts were formed after LNG-IUS insertion, one consisting of 159 nulligravidas and the other of 477 parous women. Each nulligravida women was paired with three parous women who had an LNG-IUS inserted on the same day. Insertion was classified as easy or difficult, and when classified as difficult, the use of Hegar dilators and/or misoprostol and insertion failure were additional factors recorded. Results: In almost 80% of cases, no difficulty was encountered during insertion, and dilators and misoprostol were seldom required; however, when necessary, dilator use was almost threefold higher in nulligravida women. Insertion failed in one nulligravida women and in two parous women. Contraception was the most common reason for insertion, although some of the women received the LNG-IUS for both contraceptive and therapeutic purposes, including heavy menstrual bleeding, hematologic diseases, warfarin use, endometriosis-associated pain and following kidney or liver transplantation. The clinical performance of the device showed zero pregnancy rate, expulsion rates of ∼4/100 women-year and 1-year continuation rate of over 90% in both groups. Conclusions: The LNG-IUS is suitable for use by nulligravidas. It is simple to insert, and its clinical performance in nulligravidas is similar to that found in parous women. © 2011 Elsevier Inc. All rights reserved.845e11e16D'Arcangues, C., Worldwide use of intrauterine devices for contraception (2007) Contraception, 75 (6 SUPPL), pp. 2-S7Special Programme of Research, Development and Research Training in Human Reproduction: Task force on the safety and efficacy of fertility regulating methods. The TCu380A, TCu220C, Multiload 250 and Nova T IUDS at 3, 5 and 7 years of use-results from three randomized multicenter trials (1990) Contraception, 42, pp. 141-158. , World Health OrganizationLuukkainen, T., Toivonen, J., Levonorgestrel-releasing intrauterine IUD as a method of contraception with therapeutic properties (1995) Contraception, 52, pp. 269-276Facts on Contraceptive Use Jan 2008, , http://www.guttmacher.org/pubs/fb_contr_use.pdf, The Guttmacher Institute Available at: (Accessed September 2010)Wellings, K., Zhihong, Z., Krentel, A., Barrett, G., Glasier, A., Attitudes towards long-acting reversible methods of contraception in general practice in the UK (2007) Contraception, 76 (3), pp. 208-214. , DOI 10.1016/j.contraception.2007.05.085, PII S0010782407002879Stanwood, N.L., Garrett, J.M., Konrad, T.R., Obstetrician-gynecologists and the intrauterine device: A survey of attitudes and practice (2002) Obstetrics and Gynecology, 99 (2), pp. 275-280. , DOI 10.1016/S0029-7844(01)01726-4, PII S0029784401017264Black, K.I., Sakhaei, T., Garland, S.M., A study investigating obstetricians' and gynaecologists' management of women requesting an intrauterine device (2010) Aust N Z J Obstet Gynaecol, 50, pp. 184-188Grimes, D.A., Forgettable contraception (2009) Contraception, 80, pp. 497-499Bahamondes, L., Faundes, A., Sobreira-Lima, B., Lui-Filho, J.F., Pecci, P., Matera, S., TCu 380A IUD: A reversible permanent contraceptive method in women over 35 years of age (2005) Contraception, 72 (5), pp. 337-341. , DOI 10.1016/j.contraception.2004.12.026, PII S0010782405001587Sivin, I., Utility and drawbacks of continuous use of a copper T IUD for 20 years (2007) Contraception, 75 (6 SUPPL), pp. 70-S75Hidalgo, M.M., Hidalgo-Regina, C., Bahamondes, M.V., Monteiro, I., Petta, C.A., Bahamondes, L., Serum levonorgestrel levels and endometrial thickness during extended use of the levonorgestrel-releasing intrauterine system (2009) Contraception, 80, pp. 84-89http://www.paragard.com/health_care_professional/global/pdf/ Prescribing-Info.pdf, Paragard intrauterine copper contraceptive. Prescribing information. Accessed on September 2010http://berlex.bayerhealthcare.com/html/products/pi/Mirena_PI.pdf, Mirena® highlights of prescribing information. Accessed on September 2010Medical Eligibility Criteria for Contraceptive Use, , http://www.who.int/reproductivehealth/publications/family_planning/ 9789241563888/en/, World Health Organization Accessed on September 2010Suhonen, S., Haukkamaa, M., Jakobsson, T., Rauramo, I., Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: A comparative study (2004) Contraception, 69 (5), pp. 407-412. , DOI 10.1016/j.contraception.2003.11.008, PII S0010782403003044Brockmeyer, A., Kishen, M., Webb, A., Experience of IUD/IUS insertions and clinical performance in nulliparous women - A pilot study (2008) Eur J Contracept Reprod Health Care, 13, pp. 248-254Lyus, R., Lohr, P., Prager, S., Use of the Mirena LNG-IUS and Paragard CuT380A intrauterine devices in nulliparous women (2010) Contraception, 81, pp. 367-371. , Board of the Society of Family PlanningTietze, C., Lewit, S., Recommended procedures for the statistical evaluation of intrauterine contraception (1973) Stud Fam Plann, 4, pp. 35-42Zhou, L., Harrison-Woolrych, M., Coulter, D.M., Use of the New Zealand intensive medicines monitoring programme to study the levonorgestrel-releasing intrauterine device (Mirena) (2003) Pharmacoepidemiology and Drug Safety, 12 (5), pp. 371-377. , DOI 10.1002/pds.875Sivin, I., El Mahgoub, S., McCarthy, T., Mishell Jr., D.R., Shoupe, D., Alvarez, F., Brache, V., Stern, J., Long-term contraception with the levonorgestrel 20 mcg/day (LNg 20) and the Copper T 380Ag intrauterine devices: A five-year randomized study (1990) Contraception, 42 (4), pp. 361-378. , DOI 10.1016/0010-7824(90)90046-XChien, L.W., Liu, W.M., Tzeng, C.R., Au, H.K., Effect of previous live birth and prior route of delivery on the outcome of early medical abortion (2009) Obstet Gynecol, 113, pp. 669-674Ofili-Yebovi, D., Ben-Nagi, J., Sawyer, E., Yazbek, J., Lee, C., Gonzalez, J., Jurkovic, D., Deficient lower-segment Cesarean section scars: Prevalence and risk factors (2008) Ultrasound in Obstetrics and Gynecology, 31 (1), pp. 72-77. , DOI 10.1002/uog.5200Ngai, S.W., Chan, Y.M., Tang, O.S., Ho, P.C., The use of misoprostol for pre-operative cervical dilatation prior to vacuum aspiration: A randomized trial (1999) Human Reproduction, 14 (8), pp. 2139-2142. , DOI 10.1093/humrep/14.8.2139Ngai, S.W., Tang, O.S., Ho, P.C., Randomized comparison of vaginal (200 microg every 3 h) and oral (400 microg every 3 h) misoprostol when combined with mifepristone in termination of second trimester pregnancy (2000) Hum Reprod, 15, pp. 2205-2208Saav, I., Aronsson, A., Marions, L., Stephansson, O., Gemzell-Danielsson, K., Cervical priming with sublingual misoprostol prior to insertion of an intrauterine device in nulliparous women: A randomized controlled trial (2007) Human Reproduction, 22 (10), pp. 2647-2652. , DOI 10.1093/humrep/dem244Heikinheimo, O., Inki, P., Kunz, M., Double-blind, randomized, placebo-controlled study on the effect of misoprostol on ease of consecutive insertion of the levonorgestrel-releasing intrauterine system (2010) Contraception, 81, pp. 481-486El-Refaey, H., Rajasekar, D., Abdalla, M., Calder, L., Templeton, A., Induction of abortion with mifepristone (RU 486) and oral or vaginal misoprostol (1995) N Engl J Med, 332, pp. 983-987Dhs, M., Demographic and Health Surveys, , http://www.measuredhs.com/pubs/pub, details.cfm?ID=119&srchTp=. Accessed on September 2010Kaunitz, A.M., Bissonnette, F., Monteiro, I., Lukkari-Lax, E., Muysers, C., Jensen, J.T., Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: A randomized controlled trial (2010) Obstet Gynecol, 116, pp. 625-632. , [Erratum in: Obstet Gynecol 2010;116:999]Fraser, I.S., Non-contraceptive health benefits of intrauterine hormonal systems (2010) Contraception, 82, pp. 396-403Petta, C.A., Ferriani, R.A., Abrão, M.S., A 3-year follow-up of women with endometriosis and pelvic pain users of the levonorgestrel-releasing intrauterine system (2009) Eur J Obstet Gynecol Reprod Biol, 143, pp. 128-129Wong, A.Y.K., Tang, L.C.H., Chin, R.K.H., Levonorgestrel-releasing intrauterine system (Mirena®) and depot medroxyprogesterone acetate (DepoProvera) as long-term maintenance therapy for patients with moderate and severe endometriosis: A randomised controlled trial (2010) Aust N Z J Obstet Gynaecol, 50, pp. 273-279Teitelman, M., Grotegut, C.A., Williams, N.N., Lewis, J.D., The impact of bariatric surgery on menstrual patterns (2006) Obesity Surgery, 16 (11), pp. 1457-1463. , DOI 10.1381/096089206778870148Avgerinos, D.V., Llaguna, O.H., Seigerman, M., Lefkowitz, A.J., Leitman, I.M., Incidence and risk factors for the development of anemia following gastric bypass surgery (2010) World J Gastroenterol, 16, pp. 1867-1870Culwell, K.R., Curtis, K.M., Del Carmen Cravioto, M., Safety of contraceptive method use among women with systemic lupus erythematosus: A systematic review (2009) Obstet Gynecol, 114, pp. 341-353Paulen, M.E., Folger, S.G., Curtis, K.M., Jamieson, D.J., Contraceptive use among solid organ transplant patients: A systematic review (2010) Contraception, 82, pp. 102-112Diaz, J., Bahamondes, L., Monteiro, I., Petta, C., Hildalgo, M.M., Arce, X.E., Acceptability and performance of the levonorgestrel-releasing intrauterine system (Mirena) in Campinas, Brazil (2000) Contraception, 62, pp. 59-61Backman, T., Huhtala, S., Luoto, R., Tuominen, J., Rauramo, I., Koskenvuo, M., Advance information improves user satisfaction with the levonorgestrel intrauterine system (2002) Obstetrics and Gynecology, 99 (4), pp. 608-613. , DOI 10.1016/S0029-7844(01)01764-1, PII S002978440101764

Pain at insertion of the levonorgestrel-releasing intrauterine system in nulligravida and parous women with and without cesarean section

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Background: Despite the high contraceptive effectiveness and noncontraceptive benefits of the levonorgestrel-releasing intrauterine system (LNG-IUS) in nulligravidas, there are still concerns related to the use of this device. Pain at insertion is one of the limitations to the increased use of intrauterine contraceptives. The aim of the study was to evaluate the ease of insertion and occurrence of pain at insertion of the LNG-IUS in nulligravidas (women who never became pregnant) compared to parous women with and without cesarean section (c-section). We also assessed the difficulty at insertion in each group. Methods: Three groups of new acceptors of the LNG-IUS were studied: one with 23 nulligravida women, one with 28 parous women who had undergone at least one c-section and one with 23 parous women who had no previous c-section. Pain at insertion was evaluated by using a pain visual analogue score (VAS). The ease of insertion was defined as easy or difficult by health care providers (HCPs) and classified according to the cause of difficulty: tight cervix, anatomically distorted uterus or pain. Results: Almost all women reported pain at insertion, regardless of parity and form of delivery. The mean VAS was 6.6 for nulligravida women, 5.2 for parous women with c-section and 5.9 for parous women with no c-section. Although 93% of the women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS again if needed. The most common difficulties were a tight cervix in nulligravidas, an anatomically distorted uterus in parous women with c-section and pain in parous women without c-section. There was no failure of insertion in any group. HCPs reported that it was easier to perform insertion in parous women who had undergone only vaginal deliveries than nulligravid women or parous women with a prior c-section. Conclusions: Although almost all women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS if needed. This attitude reflects high satisfaction with the LNG-IUS. The type of difficulty at insertion was related to parity and type of delivery. The LNG-IUS was able to be inserted in all women; however, it was easier to do in parous women without c-section than nulligravid women or those with a prior C-section. (C) 2013 Elsevier Inc. All rights reserved.881164168Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)CNPq [573747/2008-3

Prospective study of the forearm bone mineral density of long-term users of the levonorgestrel-releasing intrauterine system

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)The levonorgestrel-releasing intrauterine system (LNG-IUS) induces amenorrhoea, and its effect on bone mineral density (BMD) may constitute a concern. This study evaluated BMD in long-term users of the LNG-IUS or intrauterine device (IUD). BMD was evaluated at the midshaft of the ulna and ultra-distal radius using dual-energy X-ray absorptiometry in 37 women at 7 or 10 years of use following placement of a second LNG-IUS. The groups were paired for duration of use, age, body mass index (BMI), ethnicity and number of pregnancies. The mean age of both LNG-IUS and IUD users at the 7th and 10th year was similar to 34 and 38 years, respectively. Mean BMI was similar to 25 in both groups, increasing to similar to 26 at the 10th year. Amenorrhoea occurred in 51.4 and 91.9% of LNG-IUS users at the 7th and 10th year, respectively. Estradiol levels in LNG-IUS users were normal at both evaluations. There were no differences in BMD (g/cm(2)) at the midshaft of the ulna nor ultra-distal radius between LNG-IUS and IUD users or between the 7th and 10th years of use in LNG-IUS users. A Z-score below -2SD at the ultra-distal radius was observed in only one LNG-IUS user and in none of the IUD users at the 10th year. Higher BMI and BMD at the seventh year and amenorrhoea were predictors of higher BMD at the 10th year. BMD at the midshaft of the ulna and ultra-distal radius in LNG-IUS users were similar to that of IUD users and remained unchanged between the 7th and the 10th years of use.25511581164Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)FAPESP [03/083917]CNPq [573747/2008-3

Body Weight And Body Composition Of Depot Medroxyprogesterone Acetate Users

Objectives Weight gain is a concern with the contraceptive depot-medroxyprogesterone acetate (DMPA); however, this issue remains controversial. The objective of this study was to compare body weight (BW) and body composition (BC) in DMPA and copper intrauterine device (IUD) users at baseline and after one year of use. Study Design We enrolled new DMPA users and age and weight matched new IUD users into this prospective study. Weight and height were measured, BC (fat and lean mass) was evaluated using dual-energy X-ray absorptiometry, and physical activity was assessed at baseline and at 12 months. Student's paired t test and the Wilcoxon paired test for matched samples were used. Results Ninety-seven women were enrolled for the study; 26 matched pairs continued using the initial method for at least one year, and completed the baseline and 12 month assessments. An increase of 1.9 kg occurred in BW (p=.02) in DMPA users at 12 months of use, resulting from an increase in fat mass of 1.6 kg (p=.03). Weight remained stable in IUD users; however, there was an increase in lean mass at 12 months of use (p=.001). The number of women practicing physical activity increased in this group. There was a significant difference between the groups regarding the variation in the percentage of central fat (p=.04). Conclusion Weight gain in the DMPA group after the first year of use resulted from an increase in fat mass. Weight remained stable in the IUD group; however, an increase in lean mass and a reduction in localized abdominal fat mass occurred, possibly because more users were practicing physical activity. Implications statement There was a greater increase in body weight in DMPA users compared to TCu380A IUD users in the first year of use of the contraceptive method. Furthermore, the weight increase in users of DMPA occurred principally as the result of an increase in fat mass. Physical activity probably could increase the lean mass in the users of TCu380A IUD. © 2014 Elsevier Inc.902182187(2003) Nutrition. Controlling the Global Obesity Epidemic, , http://www.who.int/nutrition/topics/obesity/en/, Word Health Organization Geneva [accessed 26 Mar 2013]. Available atLopez, L.M., Edelman, A., Chen, M., Otterness, C., Trussell, J., Helmerhorst, F.M., Progestin-only Contraceptives: Effects on Weight, , http://www.cdc.gov/nchs/data/databriefs/db82.pdf, Cochrane Database of Systematic Reviews 2013, Issue 7. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009-2010. NCHS Data Brief. 201282:1-7 [accessed 4 Oct 2012]Wright, S.M., Aronne, L.J., Causes of obesity (2012) Abdom Imaging, 37, pp. 730-732OPAS. Organização Pan-Americana da Saúde. Doenças crônico-degenerativas e obesidade: estratégia mundial sobre alimentação saudável, atividade física e saúde. Brasília, DF: OPAS2003Bakry, S., Merhi, Z.O., Scalise, T.J., Mahmoud, M.S., Fadiel, A., Naftolin, F., Depot-medroxyprogesterone acetate: An update (2008) Arch Gynecol Obstet, 278, pp. 1-12Westhoff, C., Jain, J.K., Milson, I., Ray, A., Changes in weight with depot medroxyprogesterone acetate subcutaneous injection 104 mg/0,65 ml (2007) Contraception, 75, pp. 261-267Guilbert, E.R., Brown, J.P., Kaunitz, A.M., The use of depot-medroxyprogesterone acetate in contraception and its potential impact on skeletal health (2009) Contraception, 79, pp. 167-177Berenson, A.B., Rahman, M., Changes in weight, total fat, percent body fat, and central-to-peripheral fat ratio associated with injectable and oral contraceptive use (2009) Am J Obstet Gynecol, 200, pp. 329e1-329e8Clark, M.K., Dillon, J.S., Sowers, M., Nichols, S., Weight, fat mass, and central distribution of fat increase when women use depot-medroxyprogesterone acetate for contraception (2005) Int J Obes, 29, pp. 1252-1258Haji Kazemi, E., Nikpoor, S., Haghani, H., Reasons for discontinuation of depot medroxyprogesterone acetate (2004) International Congress Series, 1271, pp. 315-318Haider, S., Darney, P.D., Injectable contraception (2007) Clin Obstet Gynecol, 50, pp. 898-906Le, Y.C., Rahman, M., Berenson, A.B., Early weight gain predicting later weight gain among depot medroxyprogesterone acetate users (2009) Obstet Gynecol, 114 (2 PART 1), pp. 279-284Bahamondes, L., Del Castillo, S., Tabares, G., Arce, X.E., Perrotti, M., Petta, C., Comparison of weight increase in users of depot medroxyprogesterone acetate and copper IUD up to 5 years (2001) Contraception, 64, pp. 223-225Canto De Cetina, T.E., Canto, P., Luna, M.O., Effect of counseling to improve compliance in Mexican women receiving depot-medroxyprogesterone acetate (2001) Contraception, 63 (3), pp. 143-146Friendly, M., (1995) SAS System for Statistical Graphics, Version 1.2, , http://euclid.psych.yorku.ca/SCS/sasmac/, First Edition SAS Institute Inc Cary, NC, USA Available at: http://www.yorku.ca/SCS/sasmac/fpower.htmlPantoja, M., Medeiros, T., Baccarin, M.C., Morais, S.S., Bahamondes, L., Fernandes, A.M., Variations in body mass index of users of depot-medroxyprogesterone acetate as a contraceptive (2010) Contraception, 81, pp. 107-111Hassan, D.F., Petta, C.A., Aldrighi, J.M., Bahamondes, L., Perrotti, M., Weight variation in a cohort of women using copper IUD for contraception (2003) Contraception, 68, pp. 27-30Buppasiri, P., (2012) Progestin-only Contraceptives: Effects on Weight. The WHO Reproductive Health Library, , World Health Organization GenevaBalasch, J., Sex steroids and bone: Current perspectives (2003) Hum Reprod Update, 9, pp. 207-222Karastergiou, K., Smith, S.R., Greenberg, A.S., Fried, S.K., Sex differences in human adipose tissues - The biology of pear shape (2012) Biol Sex Differ, 3, p. 13Wajchenberg, B.L., Subcutaneous and visceral adipose tissue: Their relation to the metabolic syndrome (2000) Endocr Rev, 21, pp. 697-738Ismail, I., Keating, S.E., Baker, M.K., Johnson, N.A., A systematic review and meta-analysis of the effect of aerobic vs resistance exercise training on visceral fat (2012) Obes Rev, 13, pp. 68-91Irving, B.A., Davis, C.K., Brock, D.W., Effect of exercise training intensity on abdominal visceral fat and body composition (2008) Med Sci Sports Exerc, 40, pp. 1863-1872O'Leary, V.B., Marchetti, C.M., Krishnan, R.K., Stetzer, B.P., Gonzalez, F., Kirwan, J.P., Exercise-induced reversal of insulin resistance in obese elderly is associated with reduced visceral fat (2006) J Appl Physiol, 100, pp. 1584-1589Lopez, L.M., Edelman, A., Chen-Mok, M., Trussell, J., Helmerhorst, F.M., Progestin-only contraceptives: Effects on weight (2011) Cochrane Database Syst Rev, 13 (4). , CD00881

Length of the endometrial cavity and intrauterine contraceptive device expulsion

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Objective: To evaluate the correlation between endometrial cavity length and expulsion rate in acceptors of the TCu380A intrauterine device (IUD) or the levonorgestrel-releasing intrauterine system (LNG-IUS). Methods: The study included 235 nulligravida and parous women who received a TCu380A IUD or LNG-IUS and who were observed for up to 1 year. The length of the uterine cavity was measured by uterine sounding and ultrasonography. Results: The endometrial cavity was shorter than 3.2 cm in 2 LNG-IUS users and at least 3.2 cm long in 87 LNG-IUS users, with expulsions occurring in 0 (0.0%) and 2 (2.3%) of these women, respectively (P > 0.999). Among the TCu380A IUD users, the endometrial cavity was shorter than 3.6 cm in 63 women and at least 3.6 cm long in 83 women, with expulsions occurring in 3 (4.8%) and 5 (6.0%) of these women, respectively (P > 0.999). The mean length of the endometrial cavity-evaluated via ultrasonography-among the 10 women whose devices were expelled was 3.9 +/- 0.3 cm, compared with 3.9 +/- 0.0 cm in those who retained their devices (P = 0.799). Conclusion: The present results do not support the hypothesis of an association between uterine length and risk of intrauterine contraceptive expulsion. (C) 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.11315053Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)CNPq [573747/2008-3