- Email: [email protected]
I13 New ways of using hormonal contraception: extended and continuous use of combined contraceptives
S4
Invited presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S1–S92
our patients with sexual complaints. Is it really a primary loss of sexual desire, or is it secondary to vaginal dryness and dyspareunia? Is testosterone really necessary or will estrogen suffice? Do we institute local or systemic estrogen therapy, and for the short or long term? These are the questions and the issues we regularly face as clinicians today. I13 New ways of using hormonal contraception: extended and continuous use of combined contraceptives J.-J. Amy. Brussels, Belgium The need for women taking the pill to experience withdrawal bleeding every four weeks is increasingly questioned. Suppression of scheduled bleeding episodes and their associated symptoms such as dysmenorrhoea, headache and mood swings is achieved by the continuous regimen. This regimen can be contemplated for treatment of menorrhagia, endometriosis and the premenstrual syndrome. Possibly the prolonged intake of COCs may enhance their beneficial effects on rheumatoid arthritis, benign breast pathology, and ovarian cysts. As this regimen is associated with more frequent breakthrough bleeding and spotting, users may be advised, when metrorrhagia is bothersome, to interrupt pill intake during four days, and let a withdrawal bleeding take place. Treatment is restarted thereafter. The extended regimen consists mostly of the uninterrupted intake of a COC daily during 84 days followed by a pill-free interval of seven days. It does not abolish, but only limits the number of episodes of scheduled bleeding per year; with the aforementioned schedule, to four times per year. Taking 10 mg ethinyloestradiol daily during the pill-free interval favourably affects the bleeding patterns. Surprisingly prolonged intake is not associated overall with greater contraceptive efficacy. Omission, malabsorption (as in case of vomiting or diarrhoea), or drug interaction of short duration and the ensuing drop in steroid levels were expected not to have the same consequences as when occurring at the beginning or at the end of the classical three-week pill intake. Discontinuation of these regimens is equally frequent as or more frequent than that of traditional pill-driven 4-week cycles. I14 Uterine scar and induction: How safe? A. Antsaklis Uterine rupture is a potentially life threatening condition for both mother and baby and requires immediate surgical intervention. Uterine rupture can follow caesarean birth or other surgical procedures on the uterus, weak uterine muscles after several pregnancies or excessive use of oxytocin or prostaglandins. The combination of labour induction and a uterine scar is associated with an increased risk of uterine rupture compared with spontaneous labour. Indeed, a recent systematic review confirmed that women with a previous history of caesarean who require labour induction have a higher rate of caesarean delivery and a slightly elevated risk of rupture compared with women who undergo spontaneous labour. Another study has showed that uterine rupture rates after prior caesarean section were as high as 24.5 per 1,000 following induction with prostaglandins and 7.7 per 1,000 after induction without prostaglandins and 5.2 per 1,000 for spontaneous onset of labour. However, a systematic review of the incidence and consequence of uterine rupture in women with previous caesarean section concluded that there is still insufficient evidence to reliably determine the risk of uterine rupture when oxytocin or prostaglandins are used. Labour induction with a history of previous caesarean delivery is not contraindicated, but the mother’s clinical condition should be carefully considered and the sequential use of oxytocin and prostaglandins should be avoided. In summary, further research is required to investigate
the impact of drugs used to induce labour in women with previous caesarean delivery with respect to rates of vaginal delivery, duration of labour and patient satisfaction. Causes of uterine rupture: – Prior caesarean birth – Weak uterine muscles after several pregnancies – Excessive use of labour-inducing agents eg, oxytocin and prostaglandins – Prior surgical procedure on the uterus – Instrumental deliveries Uterine rupture rates after a previous caesarean delivery are presented in the table. Type of delivery
No. of women
Incidence (per 1,000)
Relative risk (95% CI)
Repeated caesarean without labour Spontaneous onset of labour Induction of labour without prostaglandins with prostaglandins
6,980 10,789
1.6 5.2
1.0 3.3 (1.8–6.0)
1,960 366
7.7 24.5
4.9 (2.4–9.7) 15.6 (8.1–30.0)
Lydon-Rochelle M, et al. NEJM 2001;345:3–8.
Incidence of uterine rupture with induction: • Case-controlled studies – Oxytocin associated with 2–4 fold increase • Prospective cohort studies – Oxytocin or prostaglandin not associated with a higher risk Conclusion: Insufficient evidence is available to reliably estimate the risk of uterine rupture following oxytocin or prostaglandin use during induction. I15 The impact of sexuality education programmes on future sexual and reproductive health D. Apter Objectives: Three kinds of sexuality education are needed: • Counseling, indirect interpersonal relationship, based on recognizing individual needs. • Sexuality education in groups: young persons listen to lectures, see educational material and can discuss. Individual needs are not possible to consider. • Information campaigns about through mass media. Material and Methods: According to WHO, countries providing extensive sexuality education have better succeeded: Limiting unintended adolescent pregnancies and sexually transmitted infections. Comprehensive sexuality education works (Kirby et al). Two thirds of the reviewed programs significantly improved one or more sexual behaviors. The evidence is strong that programs do not hasten or increase sexual behavior but, instead, some programs delay or decrease sexual behaviors or increase condom or contraceptive use. Of the 54 studies measuring program impact on condom use, 48% showed increased condom use; none found decreased condom use. In some studies, it has been difficult to demonstrate an effect of individual sexuality education programs. An extensive study of sexuality education in schools in Finland; teachers from more than 500 schools answered questions about sexuality education provided, and 34,000 grade 8 students filled in a questionnaire (Vaest ¨ oliitto, ¨ 2006). Results: The extent of sexuality education provided correlated well with the level of knowledge of the students, particularly for boys. Conclusions: When adolescent sexuality is not condemned but sexuality education together with sexual health services are provided, it is possible to profoundly improve adolescent sexual health with comparatively small costs.
Invited presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S1–S92
our patients with sexual complaints. Is it really a primary loss of sexual desire, or is it secondary to vaginal dryness and dyspareunia? Is testosterone really necessary or will estrogen suffice? Do we institute local or systemic estrogen therapy, and for the short or long term? These are the questions and the issues we regularly face as clinicians today. I13 New ways of using hormonal contraception: extended and continuous use of combined contraceptives J.-J. Amy. Brussels, Belgium The need for women taking the pill to experience withdrawal bleeding every four weeks is increasingly questioned. Suppression of scheduled bleeding episodes and their associated symptoms such as dysmenorrhoea, headache and mood swings is achieved by the continuous regimen. This regimen can be contemplated for treatment of menorrhagia, endometriosis and the premenstrual syndrome. Possibly the prolonged intake of COCs may enhance their beneficial effects on rheumatoid arthritis, benign breast pathology, and ovarian cysts. As this regimen is associated with more frequent breakthrough bleeding and spotting, users may be advised, when metrorrhagia is bothersome, to interrupt pill intake during four days, and let a withdrawal bleeding take place. Treatment is restarted thereafter. The extended regimen consists mostly of the uninterrupted intake of a COC daily during 84 days followed by a pill-free interval of seven days. It does not abolish, but only limits the number of episodes of scheduled bleeding per year; with the aforementioned schedule, to four times per year. Taking 10 mg ethinyloestradiol daily during the pill-free interval favourably affects the bleeding patterns. Surprisingly prolonged intake is not associated overall with greater contraceptive efficacy. Omission, malabsorption (as in case of vomiting or diarrhoea), or drug interaction of short duration and the ensuing drop in steroid levels were expected not to have the same consequences as when occurring at the beginning or at the end of the classical three-week pill intake. Discontinuation of these regimens is equally frequent as or more frequent than that of traditional pill-driven 4-week cycles. I14 Uterine scar and induction: How safe? A. Antsaklis Uterine rupture is a potentially life threatening condition for both mother and baby and requires immediate surgical intervention. Uterine rupture can follow caesarean birth or other surgical procedures on the uterus, weak uterine muscles after several pregnancies or excessive use of oxytocin or prostaglandins. The combination of labour induction and a uterine scar is associated with an increased risk of uterine rupture compared with spontaneous labour. Indeed, a recent systematic review confirmed that women with a previous history of caesarean who require labour induction have a higher rate of caesarean delivery and a slightly elevated risk of rupture compared with women who undergo spontaneous labour. Another study has showed that uterine rupture rates after prior caesarean section were as high as 24.5 per 1,000 following induction with prostaglandins and 7.7 per 1,000 after induction without prostaglandins and 5.2 per 1,000 for spontaneous onset of labour. However, a systematic review of the incidence and consequence of uterine rupture in women with previous caesarean section concluded that there is still insufficient evidence to reliably determine the risk of uterine rupture when oxytocin or prostaglandins are used. Labour induction with a history of previous caesarean delivery is not contraindicated, but the mother’s clinical condition should be carefully considered and the sequential use of oxytocin and prostaglandins should be avoided. In summary, further research is required to investigate
the impact of drugs used to induce labour in women with previous caesarean delivery with respect to rates of vaginal delivery, duration of labour and patient satisfaction. Causes of uterine rupture: – Prior caesarean birth – Weak uterine muscles after several pregnancies – Excessive use of labour-inducing agents eg, oxytocin and prostaglandins – Prior surgical procedure on the uterus – Instrumental deliveries Uterine rupture rates after a previous caesarean delivery are presented in the table. Type of delivery
No. of women
Incidence (per 1,000)
Relative risk (95% CI)
Repeated caesarean without labour Spontaneous onset of labour Induction of labour without prostaglandins with prostaglandins
6,980 10,789
1.6 5.2
1.0 3.3 (1.8–6.0)
1,960 366
7.7 24.5
4.9 (2.4–9.7) 15.6 (8.1–30.0)
Lydon-Rochelle M, et al. NEJM 2001;345:3–8.
Incidence of uterine rupture with induction: • Case-controlled studies – Oxytocin associated with 2–4 fold increase • Prospective cohort studies – Oxytocin or prostaglandin not associated with a higher risk Conclusion: Insufficient evidence is available to reliably estimate the risk of uterine rupture following oxytocin or prostaglandin use during induction. I15 The impact of sexuality education programmes on future sexual and reproductive health D. Apter Objectives: Three kinds of sexuality education are needed: • Counseling, indirect interpersonal relationship, based on recognizing individual needs. • Sexuality education in groups: young persons listen to lectures, see educational material and can discuss. Individual needs are not possible to consider. • Information campaigns about through mass media. Material and Methods: According to WHO, countries providing extensive sexuality education have better succeeded: Limiting unintended adolescent pregnancies and sexually transmitted infections. Comprehensive sexuality education works (Kirby et al). Two thirds of the reviewed programs significantly improved one or more sexual behaviors. The evidence is strong that programs do not hasten or increase sexual behavior but, instead, some programs delay or decrease sexual behaviors or increase condom or contraceptive use. Of the 54 studies measuring program impact on condom use, 48% showed increased condom use; none found decreased condom use. In some studies, it has been difficult to demonstrate an effect of individual sexuality education programs. An extensive study of sexuality education in schools in Finland; teachers from more than 500 schools answered questions about sexuality education provided, and 34,000 grade 8 students filled in a questionnaire (Vaest ¨ oliitto, ¨ 2006). Results: The extent of sexuality education provided correlated well with the level of knowledge of the students, particularly for boys. Conclusions: When adolescent sexuality is not condemned but sexuality education together with sexual health services are provided, it is possible to profoundly improve adolescent sexual health with comparatively small costs.