Long-Acting Reversible Contraception

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations. A 17-year-old high school student who has never been pregnant presents for advice regarding contraception. She has an unremarkable medical history and is planning to become sexually active with her boyfriend in the near future. Her primary concern is an unintended pregnancy, and she inquires about methods of contraception that are highly effective. How would you counsel her about options for contraception

Superficial venous disease and combined hormonal contraceptives: a systematic review

AbstractBackgroundSuperficial venous disease, which includes superficial venous thrombosis (SVT) and varicose veins, may be associated with a higher risk of venous thromboembolism (VTE). Use of combined hormonal contraceptives (CHCs) has been associated with an increased risk of VTE compared with nonuse. Little is known about whether use of CHCs by women with superficial venous disease may further elevate the risk of VTE.ObjectivesTo investigate evidence regarding risk of VTE in women with SVT or varicose veins who use CHCs compared with non-CHC users.MethodsWe searched the PubMed database for all English-language articles published from database inception through September 2014. We included primary research studies that examined women with SVT or varicose veins who used CHCs compared to women with these conditions who did not use CHCs. Outcomes of interest included VTE (among women with SVT or varicose veins) and SVT (for those with varicose veins).ResultsTwo studies were identified that met inclusion criteria. One fair-quality case–control study reported an odds ratio (OR) for VTE of 43.0 (95% confidence interval [CI] 15.5–119.3) among women with SVT using oral contraceptives (OCs) compared with nonusers without SVT. The OR for VTE was also increased for women with SVT not using OCs (OR 5.1; 95% CI 2.8–9.5) and for women without SVT using OCs (OR 4.0; 95% CI 3.3–4.7), compared with nonusers without SVT. One fair-quality cohort study demonstrated that women with varicose veins had an increased rate of VTE with use of OCs (1.85 per 1000 women-years [WY]), compared with users without varicose veins (0.84 per 1000 WY), nonusers with varicose veins (0.31 per 1000 WY) and nonusers without varicose veins (0.19 per 1000 WY). This study also demonstrated that women with varicose veins had an increased rate of SVT with use of OCs (10.63 per 1000 WY), compared with nonusers with varicose veins (7.59 per 1000 WY), users without varicose veins (1.89 per 1000 WY) and nonusers without varicose veins (0.77 per 1000 WY).ConclusionTwo studies suggest increased risk of VTE among OC users with superficial venous disease; however, no definitive conclusions can be made due to the limited number of studies and limitations in study quality. Theoretical concerns need to be clarified with further research on whether the risk of significant sequelae from superficial venous disease among CHC users is related to clinical severity of disease and underlying factors

Copper intrauterine device use and HIV acquisition in women : a systematic review

Acknowledgements The authors thank Joanna Taliano, MA MLS, Reference Librarian at CDC for running the search strategies. Contributors PH, AT, TC and KC contributed to the planning of this review. PH, AT, TC and KC conducted the literature search, screening, and risk of bias assessment. PH wrote the first draft of the manuscript. All authors contributed to subsequent drafts and approved the final manuscript. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Disclaimer The findings and conclusions of this report are those of the authors and do not necessarily represent the official postion of the Centers for Disease Control and Prevention, the World Health Organization, or other institutions with which the authors are affiliated. Competing interests TC was a member of the ECHO trial consortium. PCH, KMC, TC participated in the 2019 WHO Guideline Development Group (GDG) process which assessed recommendations on contraception for women at high risk of HIV.Peer reviewedPublisher PD

Sex, Drugs and Alcohol: What Adventist College Students Say about the Role of Parents and Religion

Relationships with peers, parents, and God make a difference in the behavior choices of youth. If a young person spends time with peers who don’t use substances and are planning to wait until they get married to have sex, they are less likely to engage in these behaviors. In addition, if the youth has a close relationship with parents who clearly state their standards regarding substance use and premarital sex, they are less likely to practice these behaviors. Finally, when the young person has a close relationship with God, they are more likely to care about the religious standards such as, the body is God’s temple and sex is for marriage

Drug interactions between non-rifamycin antibiotics and hormonal contraception: a systematic review

AbstractObjectiveTo determine whether interactions between non-rifamycin antibiotics and hormonal contraceptives result in decreased effectiveness or increased toxicity of either therapy.Data sourcesWe searched MEDLINE, Embase, clinicaltrials.gov and Cochrane libraries from database inception through June, 2016.Study eligibility criteriaWe included trials, cohort, case-control, and pharmacokinetic (PK) studies in any language addressing pregnancy rates, pharmacodynamics or PK outcomes when any hormonal contraceptive and non-rifamycin antibiotic were administered together versus apart. Of 7291 original records identified, 29 met criteria for inclusion.Study appraisal and synthesis methodsTwo authors independently assessed study quality and risk of bias using the United States Preventive Services Task Force evidence grading system. Findings were tabulated by drug class.ResultsStudy quality ranged from good to poor and addressed only oral contraceptive pills, emergency contraception pills and the combined vaginal ring. Two studies demonstrated no difference in pregnancy rates in women using oral contraceptives with and without non-rifamycin antibiotics. No differences in ovulation suppression or breakthrough bleeding were observed in any study combining hormonal contraceptives with any antibiotic. No significant decreases in any progestin PK parameter occurred during co-administration with any antibiotic. Ethinyl estradiol area under the curve decreased when administered with dirithromycin but no other drug.ConclusionEvidence from clinical and PK outcomes studies does not support the existence of drug interactions between hormonal contraception and non-rifamycin antibiotics. Data are limited by low quantity and quality for some drug classes. Most women can expect no reduction in hormonal contraceptive effect with concurrent use of non-rifamycin antibiotics

Hormonal contraceptive methods and risk of HIV acquisition in women : a systematic review of epidemiological evidence

Peer reviewedPublisher PD

Long-Acting Methods of Contraception

A healthy, multiparous 23-year-old woman requests advice about contraception. Her last child was conceived while she was using oral contraceptives, which she took irregularly. She wants no more children and desires a highly effective and long-acting method of contraception. She is sexually active in a monogamous relationship and had been treated for gonococcal cervicitis at the age of 16 years. She has normal menses. Findings on pelvic examination are normal. What contraceptive methods are appropriate for her?

Progestogen-only contraceptive use among breastfeeding women: a systematic review.

Background: Postpartum women need effective contraception. Concerns have been raised that use of progestogen-only contraceptives (POCs) may affect breastfeeding performance and infant health outcomes. Objectives: We investigated the clinical outcomes of breastfeeding duration, initiation of supplemental feeding and weaning, as well as infant outcomes including infant growth, health and development among breastfeeding women using POCs compared with breastfeeding women not using POCs. Search strategy: We searched the PubMed database for all articles published from database inception through December 2014. Selection criteria: We included primary research studies of breastfeeding women of any age or parity who received POCs, including progestogen-only pills, injectables, implants or hormonal intrauterine devices (IUDs). The main outcomes were breastfeeding performance (as measured by initiation, continuation, frequency and exclusivity of breastfeeding) and infant health (as measured by growth, development or adverse health effects). Results: Forty-nine articles reporting on 47 different studies were identified that investigated the use of POCs in breastfeeding women and reported clinically relevant outcomes of infant growth, health or breastfeeding performance. Studies ranged from poor to fair methodological quality and generally failed to show negative effects of the use of POCs on breastfeeding outcomes or on infant growth or development. One randomized controlled trial (RCT) raises concerns that immediate insertion of the levonorgestrel IUD postpartum may be associated with poorer breastfeeding performance when compared with delayed insertion, although two other RCTs evaluating early etonogestrel implants compared with delayed initiation of implants or depot medroxyprogesterone acetate failed to find such an association. Conclusion: The preponderance of evidence fails to demonstrate adverse breastfeeding outcomes or negative health outcomes in infants such as restricted growth, health problems or impaired development. Evidence newly added to this review was largely consistent with previous evidence

Pregnancy and STD Prevention Counseling Using an Adaptation of Motivational Interviewing: A Randomized Controlled Trial

CONTEXT: Given levels of unintended pregnancy and STDs, an effective counseling intervention is needed to improve women's consistent use of effective prevention methods. METHODS: A sample of 764 women aged 16-44 who were at risk of unintended pregnancy were enrolled in a randomized controlled trial in North Carolina in 2003-2004. Intervention participants received pregnancy and STD prevention counseling, adapted from motivational interviewing, both at enrollment and two months later; controls received only a session of general health counseling. Levels of contraceptive use (categorized as high, low or none on the basis of the effectiveness of the method and the consistency of use) and barriers to use were measured at two, eight and 12 months; chi-square tests were used to compare selected outcomes between the groups. Rates of unintended pregnancy and chlamydia infection were assessed over the study period. RESULTS: At baseline, 59% of all participants reported a high level of contraceptive use, 19% a low level and 22% nonuse. At two months, the proportions of intervention and control participants who had improved their level of use or maintained a high level (72% and 66%, respectively) were significantly larger than the proportions who had reported a high level of use at baseline (59% and 58%, respectively). No significant differences were found between the groups at 12 months, or between baseline and 12 months for either group. During the study, 10-11% of intervention and control participants became pregnant, 1-2% received a chlamydia diagnosis and 7-9% had another STD diagnosed. CONCLUSIONS: Repeated counseling sessions may be needed to improve contraceptive decision-making and to reduce the risk of unintended pregnancy and STDs

Hormonal contraception and HIV acquisition among women : an updated systematic review

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Disclaimer The findings and conclusions of this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, the World Health Organization, or other institutions with which the authors are affiliated. Competing interests MIR reports personal fees from Merck (contraceptive implant trainer) and Bayer (IUD trainer), outside the submitted work. TC, JK and PS were members of the ECHO trial consortium, and JK and PS were part of the writing group for the ECHO trial results. All of the authors participated in the 2019 WHO Guideline Development Group (GDG) process which assessed recommendations on contraception for women at high risk of HIV. Patient consent for publication Not required. Provenance and peer review Not commissioned; externally peer reviewed. Contributors KC, PH, TC, PS and JK were coauthors on the previous systematic review and contributed to the planning of this updated review. KC, PH and TC conducted the literature search, screening, and risk of bias assessment. MIR conducted the meta-analysis. KC wrote the first draft of the manuscript. All authors contributed to subsequent drafts and approved of the final manuscript.Peer reviewedPublisher PD