Use of levonorgestrel-releasing intrauterine device (LNG-IUD) has become common irrespective of age and parity. To date, only a few studies have examined its possible metabolic changes and ...large-scale biomarker profiles in detail and in a longitudinal design.
To apply the metabolomics technique to examine the metabolic profile associated with the use of LNG-IUD both in a cross-sectional and in a longitudinal design.
The study consists of cross-sectional and longitudinal analyses of a population-based survey (Health 2000) and its 11-year follow-up (Health 2011). All participants aged 18-49 years with available information on hormonal contraceptive use and metabolomics data (n=1767) were included. Altogether 212 metabolic measures in LNG-IUD users (n=341) were compared to those in non-users of hormonal contraception (n=1426) via multivariable linear regression models. Participants with complete longitudinal information (n=240) were divided into continuers, stoppers, starters, and never-user groups, and 11-year changes in levels of each metabolite were compared.
After adjustment for covariates, levels of 102 metabolites differed in LNG-IUD current users compared to non-users of hormonal contraception (median difference in biomarker concentration: -0.12 SD): lower levels of fatty acids concentrations and ratios, cholesterol, triglycerides and other lipids, as well as particle concentration, cholesterol, total lipids and phospholipids in lipoproteins. The 11-year metabolic changes did not differ in relation to changes in LNG-IUD use.
The use of LNG-IUD was associated with several moderate metabolic changes, mostly suggestive of a reduced arterial cardiometabolic risk. Changes in LNG-IUD use were not related to long-term metabolic changes.
Introduction
Women experience pain during medical abortion, yet optimal pain management remains unclear. We studied the pain experience and need of analgesics during early medical abortion (≤63 days ...of gestation) among teenage and adult women. We also assessed predictive factors of severe pain.
Material and methods
We recruited 140 primigravid women: 60 teenagers and 80 adult women aged between 25 and 35 years old. The group of teenagers included 19 women under the age of 18 years old (minors). The abortion was performed with mifepristone (200 mg) followed by vaginal misoprostol (800 μg), mainly self‐administered at home for adults. Minors were hospitalized during misoprostol administration. Pain medication consisted of ibuprofen 600 mg and paracetamol 1000 mg, first doses taken simultaneously with misoprostol and repeated, if needed, up to three times daily. Additional opiates (mainly tramadol or oxycodone) were administered at hospital if needed. Pain was measured using the visual analogue scale (VAS, 0‐100 mm).
Results
The maximal pain VAS (median, interquartile range) was 75 (54‐91). Of all the women, 57.7% experienced severe pain (VAS ≥70) during abortion care and 93.5% of women needed additional analgesics in addition to prophylactic pain medication. Teenagers needed additional analgesics more often than adults (5 3‐8 vs 3 2‐6 times, P = .021); 38.0% of all teenagers (64.7% of the minors) received additional opiates compared with 7.9% in adult women. Severe pain (VAS ≥70) was associated with history of dysmenorrhea (adjusted odds ratio OR 2.60 95% confidence interval CI 1.21‐5.59, P = .014), anxiety at baseline (2.64 1.03‐6.77, P = .044) and emesis during abortion (5.24 2.38‐11.57, P < .001). Hospital administration of misoprostol did not lower the risk for severe pain experience (OR 0.84 95% CI 0.34‐2.05, P = .694). Satisfaction with care was high in study population (median VAS 91 interquartile range 79‐97) and was not associated with the use of narcotic analgesic or place of misoprostol administration.
Conclusions
Pain intensity was high both in teenage and adult women undergoing medical abortion, yet satisfaction on care was high. More effective analgesics than ibuprofen and paracetamol should be offered to all women undergoing early medical abortion, especially to those with history of dysmenorrhea. Also, routine use of antiemetics might be advisable.
Introduction
The increased risk of venous thromboembolism associated with the use of hormonal contraception is well recognized, but evidence regarding hormonal contraception containing natural ...estradiol is limited. This study aimed to assess the associations between the patterns of use of different systemic hormonal contraceptives and the risk of venous thromboembolism during 2017–2019.
Material and Methods
All fertile‐aged women (15–49 years) living in Finland in 2017 and using hormonal contraception in 2017 and their 1:1 age‐ and residence‐matched controls not using hormonal contraception in 2017 (altogether 587 559 women) were selected from the Prescription Centre. All incident venous thromboembolism cases during 2018–2019 and their 4:1 age‐matched controls were further analyzed in a prospective nested case–control design to assess the associations between the use (starting, stopping, continuous vs no use) of different hormonal contraception types and venous thromboembolism.
Results
Altogether, 1334 venous thromboembolism cases occurred during the follow‐up period (incidence rate 1.14 per 1000 person‐years, 95% confidence interval CI 1.08–1.20), with an incidence rate ratio of hormonal contraception vs no hormonal contraception use of 1.42 (95% CI 1.27–1.58). Compared with non‐use, starting the use of gestodene and ethinylestradiol (adjusted odds ratio aOR 2.85; 95% CI 1.62–5.03), drospirenone and ethinylestradiol (aOR 1.55; 95% CI 0.98–2.44), desogestrel and ethinylestradiol (aOR 1.97; 95% CI 0.99–3.92), and transdermal patch releasing norelgestromin and ethinylestradiol (aOR 5.10; 95% CI 1.12–23.16), as well as continuing the use of gestodene and ethinylestradiol (aOR 2.60; 95% CI 1.61–4.21), drospirenone and ethinylestradiol (aOR 1.55; 95% CI 1.02–2.37), cyproterone‐acetate and estrogen/ethinylestradiol (aOR 1.66; 95% CI 1.06–2.61), and vaginal ring releasing etonogestrel and ethinylestradiol (aOR 3.27; 95% CI 1.95–5.48) were associated with venous thromboembolism risk. Regarding the type of estrogen, the highest risk was associated with current use (vs non use in the previous 180 days) of ethinylestradiol‐containing preparations (aOR 2.20; 95% CI 1.82–2.65), followed by estradiol‐containing preparations (aOR 1.39; 95% CI 1.04–1.87) with no risk for progestin‐only hormonal contraception. Current use of estradiol‐containing preparations was not associated with venous thromboembolism risk after exclusion of cyproterone‐acetate and estrogen/ethinylestradiol (aOR 1.05; 95% CI 0.66–1.66).
Conclusions
An increased risk of venous thromboembolism is associated with ethinylestradiol‐containing combined preparations. The use of estradiol‐containing combined preparations confers only a slightly increased risk, possibly driven by cyproterone‐containing combined oral contraceptives, whereas the use of progestin‐only contraception is not associated with venous thromboembolism.
To compare levonorgestrel (LNG) 52-mg intrauterine system (IUS) expulsion rates with fast-track (≤3 days) or delayed (2–4 weeks) insertion following mifepristone and misoprostol medical abortion.
In ...this pilot trial, we randomized 108 women at ≤63 days’ gestation to fast-track (n=55) or delayed (n=53) insertion. Follow-up visits occurred at 2–4 weeks, 3 months and 1 year. We assessed total and partial expulsion at 3 months and 1 year, adverse effects and bleeding profiles.
We had follow-up data at 3 months and 1 year for 41 (74.5%) and 37 (69.8%) women in the fast-track group and 31 (56.4%) and 28 (52.8%) women in the delayed group. By 3 months, expulsion occurred in six (12.5%) women after fast-track and one (2.3%) woman after delayed insertion risk ratio (RR) 5.50, 95% confidence interval (CI) 0.69–43.90; most (n=5) of these were partial expulsions in the fast-track group. By 1 year, expulsion had occurred in seven (14.6%) and five (11.5%) women in the fast-track and delayed groups, respectively (RR 1.28, 95% CI 0.44–3.75). We found no differences in rates of vacuum aspiration, residual tissue, infection and bleeding or bleeding patterns within 3 months of insertion.
Fast-track insertion of the LNG 52-mg IUS after medical abortion is feasible but may result in higher expulsion rates compared to delayed insertion. Due to lack of statistical power and high lost-to-follow-up rates, we were unable to fully address this question.
Fast-tract initiation of LNG 52-mg IUS contraception after medical abortion is feasible. It results in higher expulsion rates than delayed insertion but may improve postabortal intrauterine contraception uptake.
To assess how women's reproductive history, contraceptive experience and need of abortion care are associated with priorities for contraception.
In this cross-sectional survey study, we gathered ...information on women's history of births and abortions, previous use and satisfaction with contraceptive methods, and features of contraceptive methods they value most. Women were recruited at public family planning and outpatient abortion clinics in the capital region of Helsinki, Finland.
Of the 1006 women responding, 502 were recruited during visits for abortion care and 504 for contraceptive counseling. Women seeking abortion care more often had a history of abortion than women seeking contraceptive counseling (44% vs 11%), presented with a higher mean number of different contraceptive methods used (69% vs 55% with more than 2 previous methods), and were less often satisfied with the methods used (36% vs 60% satisfied with 2 out of 3 methods), p < 0.001 for all. In addition, women seeking abortion care had lower odds of prioritizing effectiveness (aOR 0.3, 95% CI 0.2–0.5), and higher odds of prioritizing lower hormonal levels or non-hormonal alternatives (aOR 2.0, 95% CI 1.3–3.2). There was no difference between the groups regarding priorities of lesser pelvic pain (aOR 0.7, 95% CI 0.5–1.1), regular period (aOR 01.2, 95% CI 0.8–1.9), or the method being easy to use (aOR 1.2, 95% CI 0.8–1.8).
There is a contrast between guidelines emphasizing effectiveness in postabortion contraception, and many women's contraceptive priorities.
Clinicians providing contraceptive counseling must be mindful of each individual's personal contraceptive priorities.
To evaluate whether a public program providing long-acting reversible contraceptive (LARC) methods free of charge increases the LARC initiation rate and reduces the unintended pregnancy rate in the ...general population.
Since 2013, all women in Vantaa, Finland, have been entitled to 1 LARC method free of charge. With time-series analysis between 2000 and 2015, we assessed whether this public program was associated with changes in steady-state mean rates of LARC initiation and abortions.
The initiation rate of LARCs (1/1000 women) increased 2.2-fold from 1.9 to 4.2 after the intervention (P < .001). Concomitantly, the abortion rate (1/1000 women) declined by 16% from 1.1 to 0.9 in the total sample (P < .001), by 36% from 1.3 to 0.8 among those aged 15 to 19 years (P < .001), and by 14% from 2.0 to 1.7 among those aged 20 to 24 years (P = .01).
The LARC program was associated with increased uptake of LARC methods and fewer abortions in the population. Public Health Implications. Entitling the population to LARC methods free of charge is an effective means to reduce the unmet need of contraception and the need for abortion, especially among women younger than 25 years.
Objective To assess obstetric outcomes in teenage pregnancies in a country with a low teenage delivery rate and comprehensive high-quality prenatal care. Design Retrospective population-based ...register study. Setting Finland. Participants All nulliparous teenagers (13–15 years (n=84), 16–17 years (n=1234), 18–19 years (n=5987)) and controls (25-year-old to 29-year-old women (n=51 142)) with singleton deliveries in 2006–2011. Main outcome measures Risk of adverse obstetric outcomes adjusted for demographic factors and clinically relevant pregnancy complications, with main focus on maternal pregnancy complications. Results Teenage mothers were more likely than controls to live in rural areas (16% (n=1168) vs 11.8% (n=6035)), smoke (36.4% (n=2661) vs 7% (n=3580)) and misuse alcohol or drugs (1.1% (n=82) vs 0.2% (n=96); p<0.001 for all). Teenagers made a good mean number of antenatal clinic visits (16.4 vs 16.5), but were more likely to have attended fewer than half of the recommended visits (3% (n=210) vs 1.4% (n=716)). Teenagers faced increased risks of several obstetric complications, for example, anaemia (adjusted OR 1.8, 95% CI 1.6 to 2.1), proteinuria (1.8, 1.2 to 2.6), urinary tract infection (UTI; 2.9, 1.8 to 4.8), pyelonephritis (6.3, 3.8 to 10.4) and eclampsia (3.2, 1.4 to 7.3), the risks increasing with descending age for most outcomes. Elevated risks of pre-eclampsia (3.7, 1.5 to 9.0) and preterm delivery (2.5, 1.2 to 5.3) were also found among 13-year-olds to 15-year-olds. However, teenage mothers were more likely to have vaginal delivery (1.9, 1.7 to 2.0) without complications. Inadequate prenatal care among teenagers was a risk factor of eclampsia (12.6, 2.6 to 62.6), UTI (5.8, 1.7 to 19.7) and adverse neonatal outcomes. Conclusions Pregnant teenagers tended to be socioeconomically disadvantaged versus controls and faced higher risks of various pregnancy complications. Special attention should be paid to enrolling teenagers into adequate prenatal care in early pregnancy.
The purpose of this study was to characterize operative treatment of patients with rectovaginal endometriosis (RVE), with special emphasis on factors predicting bowel resection.
A total of 153 ...symptomatic cases undergoing radical resection of RVE at our institution between January 2000 and May 2004 were reviewed. Univariable and multivariable association models were used in connection with various factors associated with bowel resection.
Tertiary referral center.
In all, 57 (37%) patients were treated laparoscopically, and 96 (63%) patients via laparotomy. Gastrointestinal and/or urologic surgeon was present in 30% of cases. A total of 54 (35%) patients underwent bowel resection. The median (range) operating times were 145 (75-315) minutes and 100 (20-300) minutes for patients with and without bowel resection, respectively (p <.0001). Four (2.6%) major complications occurred. In the univariable association model, the risk of bowel resection was increased among patients with previous surgery for endometriosis (OR 2.74, 95% CI 1.35-5.54), intestinal symptoms (OR 2.55, 95% CI 1.29-5.02), and revised American Fertility Society score IV (OR 4.71, 95% CI 2.06-10.78). Preoperative use of combined oral contraceptives was associated with a lower risk of bowel resection (OR 0.32, 95% CI 0.15-0.66).
Operative treatment of RVE is demanding; a multidisciplinary approach is often needed. Patients with intestinal symptoms and those with a history of endometriosis surgery are at increased risk of bowel resection.
To assess the relationship of preinsertion vaginal ultrasound assessment and menstrual and gynecologic history as predictors of difficult or painful intrauterine device insertion in nulligravid ...women.
Nulligravid women seeking contraception were invited to participate in this nonrandomized study and given the choice between the levonorgestrel-releasing intrauterine system or a copper-releasing intrauterine device. All 165 enrolled women were interviewed and a pelvic examination, including vaginal ultrasonography, was performed before insertion. Insertion difficulties and pain intensity were recorded and assessed against uterine measurements and background characteristics.
Most insertions were assessed as easy (n=144 89.4%) and only two (1.2%) failed. Most women had uterine measurements smaller than the studied devices. Odds for difficulties at insertion decreased with every increasing millimeter in total uterine length (odds ratio OR 0.86, 95% confidence interval CI 0.78-0.96, P=.006) and cervical length (OR 0.85, 95% CI 0.74-0.97, P=.02) and similarly with every decreasing degree of (straighter) flexion angle (OR 0.96, 95% CI 0.94-0.99, P=.005). No absolute threshold measurements could be determined. Still, the majority of insertions in small and flexed uteri were uneventful. Severe insertion pain was common (n=94 58.4%). Severe dysmenorrhea was the only predictor of insertion pain (OR 8.16 95% CI 2.56-26.02, P<.001).
Ultrasonographic evaluation does not give additional information compared with clinical pelvic examination and sound measure. Although smaller uterine length measurements and steeper flexion angle more often predicted difficulties, the majority of insertions were uneventful in women with small measures. Dysmenorrhea was the only predictor of pain.
ClinicalTrials.gov, www.clinicaltrials.gov, NCT01685164.
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