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Contraceptives: regional perspectives, issues, and unmet needs — the European perspective
International Journal of Gynecology & Obstetrics 62 Suppl. 1 Ž1998. S25]S30
Article
Contraceptives: regional perspectives, issues, and unmet needs } the European perspective J. NewtonU Academic Department, Birmingham Women’s Hospital, Edgbaston, Birmingham, UK
Keywords: Contraception; Europe; Contraceptive method
1. Introduction
2. Database on contraception
Many countries in Europe have very high utilization rates of contraceptive methods and some countries have high rates of sterilization, as the results of the eight-country European Contraceptive Study, 1983]1989, indicate. Surveys on changes in the use of contraceptive methods in England and Wales were recently reviewed by McEwan et al. w6x who compared data on contraceptive use from the 1970 and 1975 surveys conducted by Bone w1,2x with those from the National Survey of Sexual Attitudes and Lifestyles in 1994 w3x. In addition, the pharmaceutical industry has conducted several market surveys that primarily examined European combined oral contraceptive ŽOC. use between 1987 and 1990. These studies examined not only use of contraceptive methods available at that time but also women’s level of contraceptive knowledge, their attitudes and opinions about different methods of contraception and factors involved in the choice of methods of contraception.
Table 1 lists the methods of contraception used in various countries as reported in the European eight-country study published in 1991 w4x. In Italy, 30% of women used no method of contraception as late as 1989, whereas in Sweden less than 5% of women used no method of contraception. The predominant method in the eight countries was combined OCs. Usage ranged from a high of 42% in Austria to a low of 6% in Italy. The intrauterine device ŽIUD. was used by only 7% in Austria and 8% in the United Kingdom but by 19% in France and Sweden. Sterilization was used as a method of contraception by up to 23% of women in Great Britain, but no one in Italy reported using sterilization as a method of contraception. Other contraceptive methods, such as rhythm, withdrawal, and barrier methods, also showed variable rates. There is, therefore, great variation in the methods of contraception used throughout Europe, perhaps in part reflecting each country’s historical use of different methods w4x. Also included in the eight-country study was a detailed analysis of motives for previous changes in contraceptive methods, including the percent-
U
Fax: q44 121 4141576
0020-7292r98r$19.00 Q 1998 International Federation of Gynecology and Obstetrics PII S0020-7292Ž98.00086-1
S26
J. Newton r International Journal of Gynecology & Obstetrics 62 Suppl. 1 (1998) S25]S30
Table 1 Contraceptive methods used in eight European countries Contraceptive use
Percentage range by country
No method Rhythm Withdrawal Barrier IUD Combined pill and progestogen-only pills Sterilization
5% ŽS. ]30% ŽI. 1% ŽGB. ]14% ŽFRG. 3% ŽGB. ]14% ŽI. 7% ŽFRG. ]27% ŽS. 7% ŽA. ]19% ŽF,S. 6% ŽI. ]42% ŽA. 0% ŽI. ]23% ŽGB.
Key: S, Sweden; GB, Great Britain; A, Austria; I, Italy; FRG, Federal Republic of Germany; F, France. Based on data from Riphagen FE, et al. The Eight-Country Contraceptive Use and Health Benefits Study. Brussels: International Health Foundation Monograph, 1991.
age of respondents who cited each method. These reasons, which included reliability, health rea-
sons, better sex life, ease of use, other reasons, and no change, are shown in Tables 2 and 3. The main reasons for previous changes in contraceptive method were reliability of method and health reasons. The impact of adverse publicity on contraceptive use and perceptions, as well as health reasons and contraceptive use, is presented from the perspective of European countries. The majority of respondents who gave health reasons as a reason for changing their contraceptive method related adverse health events to combined OCs. Inherent in patients’ acceptance of any contraceptive method is their source of information, and 25]46% of respondents to the eight-country survey considered the physician to be an important source of information, whereas 6]23% cited a family member, and 7]35%, the partner. Only 1]12% cited family planning clinics as a primary source of information. The media were cited by
Table 2 Motives for previous changes in contraceptive methods: percentage of past method users
Italy France Great Britain Spain Federal Republic of Germany Austria Sweden Denmark
Reliability
Health reasons
Better sex life
Ease of use
Other
No change
15 6 24 12 19 24 16 14
45 41 33 50 51 24 43 40
7 7 6 4 2 7 7 8
5 7 7 4 2 15 9 10
4 9 9 5 1 4 2 12
24 30 21 25 25 26 23 16
Based on data from Riphagen FE, et al. The Eight-Country Contraceptive Use and Health Benefits Study. Brussels: International Health Foundation Monograph, 1991. Table 3 Motives for changes in contraceptive methods in the last year: percentage of current method users
Italy France Great Britain Spain Federal Republic of Germany Austria Sweden Denmark
Reliability
Health reasons
Better sex life
Ease of use
Other
No change
16 2 4 5 3 3 2 3
12 12 14 9 18 4 4 4
5 2 1 3 0 1 1 1
1 2 1 1 0 1 2 2
1 2 2 1 1 1 1 3
65 80 78 81 78 90 90 87
Based on data from Riphagen FE, et al. The Eight-Country Contraceptive Use and Health Benefits Study. Brussels: International Health Foundation Monograph. 1991.
J. Newton r International Journal of Gynecology & Obstetrics 62 Suppl. 1 (1998) S25]S30
6]29% of respondents as a major source of information. These findings indicate that a variety of sources of information are required for the delivery of health care and that standardized information within all European countries is needed to maintain use of a wide range of contraceptives. In this eight-country study, response rates were 76]90% for women less than 19 years of age, 82]92% for women 25]29 years of age, and 59]92% for women 40]44 years of age, the percentage varying with the country returning the data w4x. The results of this study, published in a monograph, concerned itself with factors surrounding the initial choice of contraceptive method. These factors included the level of the patient’s knowledge and women’s attitudes and opinions about perceived contraceptive risks and benefits. Use of progestogen-only injectable methods were reported by few European women in this study. After the results of the eight-country study were published in 1991, the pharmaceutical industry published the results of a contraception survey it had initially carried out in 1987 and then repeated in 1990 w5x. Using an independent consumer survey, the investigators had surveyed a sample of women in the United Kingdom, asking mainly about their degree of satisfaction with various contraceptive methods. The responses reflected a high degree of satisfaction with the majority of methods but greater satisfaction with the pill, the IUD, and male and female sterilization than with the traditional barrier methods of contraception. The results of the 1990 survey indicated that the use of combined OCs had increased among women under the age of 30 and remained the most common method of contraception used by women under the age of 35 ŽTable 4.. 3. Use of contraceptive methods In their excellent review article, McEwan et al. w6x reported a significant increase in sterilization rates within the United Kingdom w6x. However, as Peterson et al. w7x have pointed out, most modern methods of female sterilization, including bipolar and unipolar diathermy, the modified Pomeroy
S27
technique, and mechanical clips Žnot including the Filshie clip, which was not available in the United States at the time of the study., show a low but significant long-term failure rate w7x. This failure rate is not associated with method failure as such but with recanalization w7x. At the end of 10 years, failure rates with female sterilization may well be higher than those with the most effective reversible contraceptive methods, such as progestogen-only and combined injectable methods, the Copper 380 series of IUDs, and the levonorgestrel-releasing IUD. Europe has a history of involving the media in discussions on contraception. Although well-designed studies that show beneficial effects of contraception are often not reported, scare stories Žoften pertaining to small studies or preliminary data. can produce significant changes in contraceptive use. We have been beset by the ‘pill scares’ that swept over several European countries in the late autumn of 1995. Preliminary data from the World Health Organization Ž1995. suggested that thirdgeneration progestogen-containing combined OCs posed an increased risk of non-fatal venous thromboembolism. However, the surprising finding from these studies was that second-generation progestogen-containing combined pills, when compared with third-generation pills, are associated with a much lower rate of non-fatal venous thromboembolism than was initially thought. This pill scare caused dramatic changes in contracepTable 4 Current contraceptive methods used by women in Britain Methods Withdrawal Pill IUD Cap Condom Safe period Sterilization: Female Male Abstinence Base s 100%
Married Ž%.
Cohabiting Ž%.
Single Ž%.
4 20 7 2 22 2
5 49 6 4 26 3
8 59 3 2 47 3
13 17 1 6053
10 5 2 816
1 2 2 1429
Based on data from Johnson AM, et al. Sexual Attitudes and Lifestyle. Oxford, England: Blackwell Scientific, 1994.
S28
J. Newton r International Journal of Gynecology & Obstetrics 62 Suppl. 1 (1998) S25]S30
tive use and led to an increased number of induced abortions. Fortunately, the data on thromboembolism has not been supported by more recent studies of cardiovascular disease in women taking OCs. Articles published in the last two years indicate a protective effect of third-generation progestogens against stroke and myocardial infarction that, if confirmed, would more than balance out any increased risk of non-fatal thromboembolism w8]10x. Skjeldestad reviewed Norwegian pregnancy termination rates and the average sales of combined OCs by different progestogens throughout 1995 and 1996 w11x. A significant number of women changed from third-generation OCs to second- or first-generation combined OCs or stopped using OCs altogether. A significant number, 25 000 women, discontinued OC use in November and December of 1995. One effect of this decline in the use of the pill was an increase in abortion rates, which had been steadily decreasing in Norway. After the pill scare in 1995, a 30% increase in the number of termination requests occurred in early 1996. Most of those requesting these additional abortions were unmarried, childless women Žsee Table 5.. The influence of the media makes it imperative that clinicians continue to provide sound information on the risks and benefits of contraception. At
the present time, reports on breast cancer, arterial disease, venous thromboembolism, and other cardiovascular disorders may hamper the further development of progestogens based on the 19 Nortestosterone Series w8]10,12x. Thus, the use of natural ester of estradiol and medroxyprogesterone acetate as the progestogen may find greater acceptance among contraceptive users in future years. 4. Range of contraceptive methods required Because of the health issues reported in the International Health Foundation surveys and intense speculation by the media on the health benefits and risks attached to the use of combined OCs, it is necessary to consider a range of methods that have high efficacy w4x. In Europe, scientists have not been able to study combined injectable methods due to its non-availability. These methods, reviewed by Newton et al., have been found in clinical studies and post-marketing surveillance to have high efficacy and to be associated with a much higher incidence of regular cycle control than progestogen-only methods of injection w13x. Therefore it would seem to be highly appropriate for combined injectable contraceptives, particularly those methods containing a short-acting estradiol ester plus a progestogen,
Table 5 Annual number of abortions, number of women in county of Sor-Trondelag, Norway, and abortion rate 1992 N Number of abortionsa 15]24 years 15]44 years Number of womenb 15]24 years 15]44 years Rate per 1000 womenc 15]24 years 15]44 years a
1993 N
1994 N
1995 N
1996 N
97 213
90 200
85 205
74 198
97 213
18 884 55 525
18 495 55 256
18 014 55 231
17 474 54 986
16 939 54 600
5.1 3.8
4.9 3.6
4.7 3.7
4.2d 3.6
5.7d 3.9
First quarter of 1992]1996. January 1, 1992, through January 1, 1996. c First quarter of each year studied. d Ps 0.050. Based on data from Skjeldestad FE. Increased number of induced abortions in Norway after media coverage of adverse vascular events from the use of third-generation oral contraceptives. Contraception 1997;55:11]14. b
J. Newton r International Journal of Gynecology & Obstetrics 62 Suppl. 1 (1998) S25]S30
to be added to the range of methods. It is clear that a significant number of single and married women and nulliparous and multiparous women have been moving towards progestogen-only injectable contraception as a method of first choice, despite the high incidence of amenorrhea. The change in part reflects the relaunch of DepoProvera Contraceptive Injection Žmedroxyprogesterone acetate . over the last 18 months and the low failure rate observed with that method. That method was, in the past, used by particular at-risk groups, for whom the perceived adverse side effect of amenorrhea is regarded as a positive and beneficial side effect. A large number of different OC contraceptive methods are needed in Europe. They include the classic combined OC pill, the progestogen-only pill, subdermal implants, both progestogen-only and combined injectables, and modern IUDs. Together with advances in natural family planning and barrier contraceptives, these methods should provide a range of methods suitable for reproductive-age European women. 5. Government targets related to contraception In the United Kingdom, specific health targets have been put forward by the government and Department of Health, called the Health of a Nation by the Year 2000. These include health measures that would lead to a decrease in unwanted teenage pregnancy by 50% and increased adoption of family planning methods. These targets can be met only if well-designed educational programs are in place, a wide range of contraceptive methods is available, and women throughout the United Kingdom make informed contraceptive choices. 6. Summary Existing methods of contraception clearly do not meet all the needs of European women. Studies have shown that women continue to want contraceptive methods with the lowest possible risks and highest possible health care benefits. In addition to offering health benefits, these methods must have extremely low failure rates and
S29
permit good compliance. Studies reflect high rates of non-compliance and discontinuation with the combined OC and the progestogen-only contraceptive pill. Methods, such as the IUDs, subdermal implants, and injectable contraceptives offer significant advances in continuation of contraception coupled with low failure rates. In the past, the use of injectable contraceptive methods in Europe was low because only the progestogenalone methods were available } Depo-Provera and Noristerat. Both methods have been linked with extensive menstrual cycle disturbance, which has not been noted with the combined injectable methods, as reviewed by Newton et al. w13x. The author believes that combined injectable methods should be added to the list of contraceptive methods freely available to women in Europe, not only because of their lack of disruption of the menstrual cycle, but also because of their high efficacy, good cycle control, and other health benefits. This method may prove extremely useful over the next 10]20 years. Market surveys will determine whether combined monthly injectables are perceived by potential contraceptive users as having health benefits, and focus group discussions will allow an appropriate range of contraceptive products to be available. These should increase patient choice and allow clinicians to make available a wider range of products for those seeking contraception. References w1x Bone M. Family planning services in England and Wales. London: HMSO, 1973. w2x Bone M. Family planning services: changes and effects. London: HMSO, 1978. w3x Johnson AM, Wadsworth J, Wellings K, et al. Sexual attitudes and lifestyle. Oxford, England: Blackwell Scientific, 1994. w4x Riphagen FE, van der Wurst J, Lehert P. The eightcountry contraceptive use and health benefits study. Brussels: International Health Foundation Monograph, 1991. w5x Schering Healthcare. In-house survey of contraceptive use. United Kingdom: Schering Healthcare, 1990. w6x McEwan J, Wadsworth J, Johnson AM et al. Changes in the use of contraceptive methods in England and Wales over two decades. Br J Fam Plann 1997;23:5]8. w7x Peterson HB, Xia Z, Hughes JM et al. The risk of pregnancy after tubal sterilization: findings from the US
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J. Newton r International Journal of Gynecology & Obstetrics 62 Suppl. 1 (1998) S25]S30
collaborative review of sterilization. Am J Obstet Gynecol 1996;174:1161]1170. w8x Farmer RDT, Preston TD et al. The risk of venous thromboembolism associated with low oestrogen COC. J Obstet Gynecol 1995;15:195]200. w9x Farmer RDT, Lawrenson RA, Thompson CR et al. Population based study of risk of venous thromboembolism associated with various oral contraceptives. Lancet 1997;349:83]88. w10x Lewis MA, Spitzer WO, Heinemann LAJ et al. Third generation COC and risk of myocardial infarction: an international case-control study. Br Med J 1996; 312:88]90.
w11x Skjeldestad FE. Increased number of induced abortions in Norway after media coverage of adverse vascular events from the use of third generation oral contraceptives. Contraception 1997;55:11]14. w12x Bloemankamp KWM, Rosendaal FR, Helmerhorst FM et al. Enhancement by Factor v Leiden Mutation of risk of DVT associated with COC containing a third generation progestogen. Lancet 1995;346:1593]1596. w13x Newton J, d’Arcangues Q, Hall PE. Once-a-month combined injectable contraceptives. J Obstet Gynecol 1994;14 Suppl. Ž1.:S1]S34.
Article
Contraceptives: regional perspectives, issues, and unmet needs } the European perspective J. NewtonU Academic Department, Birmingham Women’s Hospital, Edgbaston, Birmingham, UK
Keywords: Contraception; Europe; Contraceptive method
1. Introduction
2. Database on contraception
Many countries in Europe have very high utilization rates of contraceptive methods and some countries have high rates of sterilization, as the results of the eight-country European Contraceptive Study, 1983]1989, indicate. Surveys on changes in the use of contraceptive methods in England and Wales were recently reviewed by McEwan et al. w6x who compared data on contraceptive use from the 1970 and 1975 surveys conducted by Bone w1,2x with those from the National Survey of Sexual Attitudes and Lifestyles in 1994 w3x. In addition, the pharmaceutical industry has conducted several market surveys that primarily examined European combined oral contraceptive ŽOC. use between 1987 and 1990. These studies examined not only use of contraceptive methods available at that time but also women’s level of contraceptive knowledge, their attitudes and opinions about different methods of contraception and factors involved in the choice of methods of contraception.
Table 1 lists the methods of contraception used in various countries as reported in the European eight-country study published in 1991 w4x. In Italy, 30% of women used no method of contraception as late as 1989, whereas in Sweden less than 5% of women used no method of contraception. The predominant method in the eight countries was combined OCs. Usage ranged from a high of 42% in Austria to a low of 6% in Italy. The intrauterine device ŽIUD. was used by only 7% in Austria and 8% in the United Kingdom but by 19% in France and Sweden. Sterilization was used as a method of contraception by up to 23% of women in Great Britain, but no one in Italy reported using sterilization as a method of contraception. Other contraceptive methods, such as rhythm, withdrawal, and barrier methods, also showed variable rates. There is, therefore, great variation in the methods of contraception used throughout Europe, perhaps in part reflecting each country’s historical use of different methods w4x. Also included in the eight-country study was a detailed analysis of motives for previous changes in contraceptive methods, including the percent-
U
Fax: q44 121 4141576
0020-7292r98r$19.00 Q 1998 International Federation of Gynecology and Obstetrics PII S0020-7292Ž98.00086-1
S26
J. Newton r International Journal of Gynecology & Obstetrics 62 Suppl. 1 (1998) S25]S30
Table 1 Contraceptive methods used in eight European countries Contraceptive use
Percentage range by country
No method Rhythm Withdrawal Barrier IUD Combined pill and progestogen-only pills Sterilization
5% ŽS. ]30% ŽI. 1% ŽGB. ]14% ŽFRG. 3% ŽGB. ]14% ŽI. 7% ŽFRG. ]27% ŽS. 7% ŽA. ]19% ŽF,S. 6% ŽI. ]42% ŽA. 0% ŽI. ]23% ŽGB.
Key: S, Sweden; GB, Great Britain; A, Austria; I, Italy; FRG, Federal Republic of Germany; F, France. Based on data from Riphagen FE, et al. The Eight-Country Contraceptive Use and Health Benefits Study. Brussels: International Health Foundation Monograph, 1991.
age of respondents who cited each method. These reasons, which included reliability, health rea-
sons, better sex life, ease of use, other reasons, and no change, are shown in Tables 2 and 3. The main reasons for previous changes in contraceptive method were reliability of method and health reasons. The impact of adverse publicity on contraceptive use and perceptions, as well as health reasons and contraceptive use, is presented from the perspective of European countries. The majority of respondents who gave health reasons as a reason for changing their contraceptive method related adverse health events to combined OCs. Inherent in patients’ acceptance of any contraceptive method is their source of information, and 25]46% of respondents to the eight-country survey considered the physician to be an important source of information, whereas 6]23% cited a family member, and 7]35%, the partner. Only 1]12% cited family planning clinics as a primary source of information. The media were cited by
Table 2 Motives for previous changes in contraceptive methods: percentage of past method users
Italy France Great Britain Spain Federal Republic of Germany Austria Sweden Denmark
Reliability
Health reasons
Better sex life
Ease of use
Other
No change
15 6 24 12 19 24 16 14
45 41 33 50 51 24 43 40
7 7 6 4 2 7 7 8
5 7 7 4 2 15 9 10
4 9 9 5 1 4 2 12
24 30 21 25 25 26 23 16
Based on data from Riphagen FE, et al. The Eight-Country Contraceptive Use and Health Benefits Study. Brussels: International Health Foundation Monograph, 1991. Table 3 Motives for changes in contraceptive methods in the last year: percentage of current method users
Italy France Great Britain Spain Federal Republic of Germany Austria Sweden Denmark
Reliability
Health reasons
Better sex life
Ease of use
Other
No change
16 2 4 5 3 3 2 3
12 12 14 9 18 4 4 4
5 2 1 3 0 1 1 1
1 2 1 1 0 1 2 2
1 2 2 1 1 1 1 3
65 80 78 81 78 90 90 87
Based on data from Riphagen FE, et al. The Eight-Country Contraceptive Use and Health Benefits Study. Brussels: International Health Foundation Monograph. 1991.
J. Newton r International Journal of Gynecology & Obstetrics 62 Suppl. 1 (1998) S25]S30
6]29% of respondents as a major source of information. These findings indicate that a variety of sources of information are required for the delivery of health care and that standardized information within all European countries is needed to maintain use of a wide range of contraceptives. In this eight-country study, response rates were 76]90% for women less than 19 years of age, 82]92% for women 25]29 years of age, and 59]92% for women 40]44 years of age, the percentage varying with the country returning the data w4x. The results of this study, published in a monograph, concerned itself with factors surrounding the initial choice of contraceptive method. These factors included the level of the patient’s knowledge and women’s attitudes and opinions about perceived contraceptive risks and benefits. Use of progestogen-only injectable methods were reported by few European women in this study. After the results of the eight-country study were published in 1991, the pharmaceutical industry published the results of a contraception survey it had initially carried out in 1987 and then repeated in 1990 w5x. Using an independent consumer survey, the investigators had surveyed a sample of women in the United Kingdom, asking mainly about their degree of satisfaction with various contraceptive methods. The responses reflected a high degree of satisfaction with the majority of methods but greater satisfaction with the pill, the IUD, and male and female sterilization than with the traditional barrier methods of contraception. The results of the 1990 survey indicated that the use of combined OCs had increased among women under the age of 30 and remained the most common method of contraception used by women under the age of 35 ŽTable 4.. 3. Use of contraceptive methods In their excellent review article, McEwan et al. w6x reported a significant increase in sterilization rates within the United Kingdom w6x. However, as Peterson et al. w7x have pointed out, most modern methods of female sterilization, including bipolar and unipolar diathermy, the modified Pomeroy
S27
technique, and mechanical clips Žnot including the Filshie clip, which was not available in the United States at the time of the study., show a low but significant long-term failure rate w7x. This failure rate is not associated with method failure as such but with recanalization w7x. At the end of 10 years, failure rates with female sterilization may well be higher than those with the most effective reversible contraceptive methods, such as progestogen-only and combined injectable methods, the Copper 380 series of IUDs, and the levonorgestrel-releasing IUD. Europe has a history of involving the media in discussions on contraception. Although well-designed studies that show beneficial effects of contraception are often not reported, scare stories Žoften pertaining to small studies or preliminary data. can produce significant changes in contraceptive use. We have been beset by the ‘pill scares’ that swept over several European countries in the late autumn of 1995. Preliminary data from the World Health Organization Ž1995. suggested that thirdgeneration progestogen-containing combined OCs posed an increased risk of non-fatal venous thromboembolism. However, the surprising finding from these studies was that second-generation progestogen-containing combined pills, when compared with third-generation pills, are associated with a much lower rate of non-fatal venous thromboembolism than was initially thought. This pill scare caused dramatic changes in contracepTable 4 Current contraceptive methods used by women in Britain Methods Withdrawal Pill IUD Cap Condom Safe period Sterilization: Female Male Abstinence Base s 100%
Married Ž%.
Cohabiting Ž%.
Single Ž%.
4 20 7 2 22 2
5 49 6 4 26 3
8 59 3 2 47 3
13 17 1 6053
10 5 2 816
1 2 2 1429
Based on data from Johnson AM, et al. Sexual Attitudes and Lifestyle. Oxford, England: Blackwell Scientific, 1994.
S28
J. Newton r International Journal of Gynecology & Obstetrics 62 Suppl. 1 (1998) S25]S30
tive use and led to an increased number of induced abortions. Fortunately, the data on thromboembolism has not been supported by more recent studies of cardiovascular disease in women taking OCs. Articles published in the last two years indicate a protective effect of third-generation progestogens against stroke and myocardial infarction that, if confirmed, would more than balance out any increased risk of non-fatal thromboembolism w8]10x. Skjeldestad reviewed Norwegian pregnancy termination rates and the average sales of combined OCs by different progestogens throughout 1995 and 1996 w11x. A significant number of women changed from third-generation OCs to second- or first-generation combined OCs or stopped using OCs altogether. A significant number, 25 000 women, discontinued OC use in November and December of 1995. One effect of this decline in the use of the pill was an increase in abortion rates, which had been steadily decreasing in Norway. After the pill scare in 1995, a 30% increase in the number of termination requests occurred in early 1996. Most of those requesting these additional abortions were unmarried, childless women Žsee Table 5.. The influence of the media makes it imperative that clinicians continue to provide sound information on the risks and benefits of contraception. At
the present time, reports on breast cancer, arterial disease, venous thromboembolism, and other cardiovascular disorders may hamper the further development of progestogens based on the 19 Nortestosterone Series w8]10,12x. Thus, the use of natural ester of estradiol and medroxyprogesterone acetate as the progestogen may find greater acceptance among contraceptive users in future years. 4. Range of contraceptive methods required Because of the health issues reported in the International Health Foundation surveys and intense speculation by the media on the health benefits and risks attached to the use of combined OCs, it is necessary to consider a range of methods that have high efficacy w4x. In Europe, scientists have not been able to study combined injectable methods due to its non-availability. These methods, reviewed by Newton et al., have been found in clinical studies and post-marketing surveillance to have high efficacy and to be associated with a much higher incidence of regular cycle control than progestogen-only methods of injection w13x. Therefore it would seem to be highly appropriate for combined injectable contraceptives, particularly those methods containing a short-acting estradiol ester plus a progestogen,
Table 5 Annual number of abortions, number of women in county of Sor-Trondelag, Norway, and abortion rate 1992 N Number of abortionsa 15]24 years 15]44 years Number of womenb 15]24 years 15]44 years Rate per 1000 womenc 15]24 years 15]44 years a
1993 N
1994 N
1995 N
1996 N
97 213
90 200
85 205
74 198
97 213
18 884 55 525
18 495 55 256
18 014 55 231
17 474 54 986
16 939 54 600
5.1 3.8
4.9 3.6
4.7 3.7
4.2d 3.6
5.7d 3.9
First quarter of 1992]1996. January 1, 1992, through January 1, 1996. c First quarter of each year studied. d Ps 0.050. Based on data from Skjeldestad FE. Increased number of induced abortions in Norway after media coverage of adverse vascular events from the use of third-generation oral contraceptives. Contraception 1997;55:11]14. b
J. Newton r International Journal of Gynecology & Obstetrics 62 Suppl. 1 (1998) S25]S30
to be added to the range of methods. It is clear that a significant number of single and married women and nulliparous and multiparous women have been moving towards progestogen-only injectable contraception as a method of first choice, despite the high incidence of amenorrhea. The change in part reflects the relaunch of DepoProvera Contraceptive Injection Žmedroxyprogesterone acetate . over the last 18 months and the low failure rate observed with that method. That method was, in the past, used by particular at-risk groups, for whom the perceived adverse side effect of amenorrhea is regarded as a positive and beneficial side effect. A large number of different OC contraceptive methods are needed in Europe. They include the classic combined OC pill, the progestogen-only pill, subdermal implants, both progestogen-only and combined injectables, and modern IUDs. Together with advances in natural family planning and barrier contraceptives, these methods should provide a range of methods suitable for reproductive-age European women. 5. Government targets related to contraception In the United Kingdom, specific health targets have been put forward by the government and Department of Health, called the Health of a Nation by the Year 2000. These include health measures that would lead to a decrease in unwanted teenage pregnancy by 50% and increased adoption of family planning methods. These targets can be met only if well-designed educational programs are in place, a wide range of contraceptive methods is available, and women throughout the United Kingdom make informed contraceptive choices. 6. Summary Existing methods of contraception clearly do not meet all the needs of European women. Studies have shown that women continue to want contraceptive methods with the lowest possible risks and highest possible health care benefits. In addition to offering health benefits, these methods must have extremely low failure rates and
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permit good compliance. Studies reflect high rates of non-compliance and discontinuation with the combined OC and the progestogen-only contraceptive pill. Methods, such as the IUDs, subdermal implants, and injectable contraceptives offer significant advances in continuation of contraception coupled with low failure rates. In the past, the use of injectable contraceptive methods in Europe was low because only the progestogenalone methods were available } Depo-Provera and Noristerat. Both methods have been linked with extensive menstrual cycle disturbance, which has not been noted with the combined injectable methods, as reviewed by Newton et al. w13x. The author believes that combined injectable methods should be added to the list of contraceptive methods freely available to women in Europe, not only because of their lack of disruption of the menstrual cycle, but also because of their high efficacy, good cycle control, and other health benefits. This method may prove extremely useful over the next 10]20 years. Market surveys will determine whether combined monthly injectables are perceived by potential contraceptive users as having health benefits, and focus group discussions will allow an appropriate range of contraceptive products to be available. These should increase patient choice and allow clinicians to make available a wider range of products for those seeking contraception. References w1x Bone M. Family planning services in England and Wales. London: HMSO, 1973. w2x Bone M. Family planning services: changes and effects. London: HMSO, 1978. w3x Johnson AM, Wadsworth J, Wellings K, et al. Sexual attitudes and lifestyle. Oxford, England: Blackwell Scientific, 1994. w4x Riphagen FE, van der Wurst J, Lehert P. The eightcountry contraceptive use and health benefits study. Brussels: International Health Foundation Monograph, 1991. w5x Schering Healthcare. In-house survey of contraceptive use. United Kingdom: Schering Healthcare, 1990. w6x McEwan J, Wadsworth J, Johnson AM et al. Changes in the use of contraceptive methods in England and Wales over two decades. Br J Fam Plann 1997;23:5]8. w7x Peterson HB, Xia Z, Hughes JM et al. The risk of pregnancy after tubal sterilization: findings from the US
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collaborative review of sterilization. Am J Obstet Gynecol 1996;174:1161]1170. w8x Farmer RDT, Preston TD et al. The risk of venous thromboembolism associated with low oestrogen COC. J Obstet Gynecol 1995;15:195]200. w9x Farmer RDT, Lawrenson RA, Thompson CR et al. Population based study of risk of venous thromboembolism associated with various oral contraceptives. Lancet 1997;349:83]88. w10x Lewis MA, Spitzer WO, Heinemann LAJ et al. Third generation COC and risk of myocardial infarction: an international case-control study. Br Med J 1996; 312:88]90.
w11x Skjeldestad FE. Increased number of induced abortions in Norway after media coverage of adverse vascular events from the use of third generation oral contraceptives. Contraception 1997;55:11]14. w12x Bloemankamp KWM, Rosendaal FR, Helmerhorst FM et al. Enhancement by Factor v Leiden Mutation of risk of DVT associated with COC containing a third generation progestogen. Lancet 1995;346:1593]1596. w13x Newton J, d’Arcangues Q, Hall PE. Once-a-month combined injectable contraceptives. J Obstet Gynecol 1994;14 Suppl. Ž1.:S1]S34.