OBJECTIVE

To study the choice of contraceptive usage and the factors responsible for such choices in northern Nigeria.

METHODS

A cross-sectional study.

METHODS

Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.

METHODS

New clients attending the reproductive health centre.

METHODS

Choice of contraceptive, reason for choice, knowledge and source of knowledge about contraceptives.

RESULTS

Four hundred and eighteen clients were interviewed. Three hundred and seventy two (89%) knew at least one method of contraception; 50.7% used injectable contraceptives, 22.5% intrauterine contraceptive devices, 13.9% Norplant and 10.3% oral contraceptive pills. One hundred and forty four (34.5%) were referred by midwives and 25.6% by other nurses.

CONCLUSIONS

The most commonly used contraceptive in our environment is the injectable method.

Endometrial lymphomyeloid cell subsets were evaluated in samples from normal women and from women with abnormal uterine bleeding due to subcutaneous levonorgestrel implants (Norplant) or an intrauterine device (IUD). The frequency of CD3(+), CD68(+), CD43(+) and endometrial granulated lymphoid cells was evaluated by immunohistochemical or phloxine-tartrazine staining of formalin-fixed paraffin-embedded samples. In normal women, cyclic variation in lymphomyeloid subsets was seen. In women using Norplant for contraception, the frequency of CD3(+), CD68(+) and CD43(+) cells was dramatically decreased, compatible with endometrial atrophy. When Norplant users with abnormal bleeding were compared to women without bleeding, however, the number of CD68(+) cells was significantly increased and the number of CD3(+) and CD43(+) cells was preserved, contrary to the hypothesis that this group would show a greater degree of atrophy and hence, tissue fragility. A similar pattern was seen in a preliminary study of women with bleeding associated with use of copper-only IUD contraception, and in samples taken from late secretory and menstrual biopsies from normal cycling women. Whether these changes in endometrial lymphomyeloid cells represent a result of bleeding arising from a common mechanism or rather cause the uterine bleeding is discussed.

The Norplant (Huhtamaki Oy/Leiras Pharmaceuticals, Turku, Finland) contraceptive system is a safe, highly effective, reversible method of hormonal contraception. The system consists of six flexible match-size implants that are implanted in the inner aspect of the upper arm. This sustained-release system delivers the progestin levonorgestrel at levels sufficient to prevent pregnancy for as long as 5 years. Norplant is a convenient, easy-to-use method. Adequate counseling of potential users and appropriate selection of patient users are important determinants of patient satisfaction with Norplant.

The frequency of bleeding complaints during the first year of use and their influence on removal rate were analyzed in a retrospective cohort study of 491 Norplant implants acceptors. Removal rates were significantly higher in women having menstrual complaints (1.98% and 29.23% in the first and fourth trimester) than in those who did not mention them (0.79 and 5.07% in the same periods). In all periods of observation, most women who mentioned menstrual problems decided to continue using the method. Two possible explanations for this are that 1) the complaints did not persist for very long, and 2) the most frequent complaint mentioned was bleeding irregularity, which was not as strongly associated with removals as increased or decreased bleeding. The authors conclude that bleeding problems are the most important factor limiting the acceptability of Norplant implants, either being the main reason for removal (3.9 per 100 women) or influencing the rate of removal for other reasons. Adequate counseling appears to be critical for reducing the impact of bleeding problems on removal rates, and thereby increasing the acceptability of the method. The importance of research aimed at preventing or treating menstrual problems to improve the acceptability of the method is emphasized.

Irregular menstrual bleeding in users of hormonal contraception represents the single major reason for discontinuation of these contraceptive methods. The mechanisms which underlie these bleeding disturbances are poorly understood, but appear to be associated with changes in the endometrial microvasculature following abnormal patterns of sex steroid exposure. Endometrial microvascular density is known to be increased in users of the low-dose levonorgestrel contraceptive implant, Norplant. This study explores microvascular density in other conditions of spontaneous (post-menopausal) and induced (danazol and goserelin) endometrial atrophy. Endometrial biopsies were fixed, paraffin-embedded and sections were immunostained using anti-CD34 antibody to identify vascular endothelial cells. The mean microvascular density (+/-SEM) for control samples was 186 +/- 8 vessels/mm2. There were no statistically significant changes in vascular density observed across the menstrual cycle. Mean microvascular density in spontaneous and induced endometrial atrophy did not differ significantly from that observed in the control population. The mean microvascular density was 230 +/- 17 vessels/mm2 in 31 postmenopausal women, 269 +/- 67 vessels/mm2 in 25 subjects treated with danazol was and 191 +/- 45 vessels/mm2 in nine subjects treated with goserelin. These findings suggest that the mechanisms controlling microvascular density in conditions of endometrial atrophy may vary according to the nature of the atrophic stimulus.

This review addresses the use of Norplant in women with or at-risk for noninsulin-dependent diabetes mellitus (NIDDM). Background information on NIDDM is given, including pathogenesis, effect on glucose and lipid metabolism, and management. The effect of exogenous estrogen and progestogens on glucose tolerance is briefly discussed. In reviewing the effects of Norplant on glucose metabolism, studies on women with normal glucose tolerance were reviewed, along with the one study of Norplant use in women with a past history of gestational diabetes. Norplant does have a minor effect on glucose metabolism. Studies are contradictory regarding lipid metabolism but most suggest that Norplant does not have a negative effect on the high density lipoprotein/total cholesterol ratio. Factors influencing contraceptive choice are reviewed. Protocols for management of Norplant in women with or at-risk for NIDDM are then presented, followed by a case study and a brief discussion.

In this comparative study, the five-year continuity rate of 53.7% in the Norplant implants group was comparable to that of 52.7% in the copper IUD group. The difference was not statistically significant. Only one accidental pregnancy occurred during the five years of copper IUD use. Desire for future pregnancy was the main reason for removal in the Norplant implants group (35.9%) while expulsion of the IUD (13.2%) was the main reason for removal of the copper IUD. Menstrual disturbance was not a major side-effect in either group. The post-removal conception rates of 78.6% in the Norplant implants group and 75.0% in the copper IUD were good and comparable. Both the Norplant implants and copper IUD are acceptable and effective contraceptive methods in Singapore.

The continuation rate at the end of this five-year clinical study was 60% with no accidental pregnancy occurring throughout the five years. The post-removal conception rate in women desiring pregnancy was 92% at the end of two years. The majority of acceptors described the overall experience with the implants as favourable. In fact, 75% of the women planning to use contraception after removal of the implants were going to use implants again.

Norplant, which has been shown to be a highly effective and acceptable contraceptive for adult women, may also be a very useful contraceptive for adolescents. This study is designed to determine the level of interest in Norplant for adolescent girls with and without children, their attitudes toward various features of Norplant, and the demographic and psychosocial factors predictive of their interest. A self-administered questionnaire was given to 112 adolescents attending our pediatric or adolescent clinic. Data from 28 adolescent mothers and 79 nulliparous adolescents were analyzed. Fifty-six percent of the subjects had heard of Norplant prior to the survey. The overall level of interest in Norplant was high; 70% of the adolescents without children, and 79% of the adolescent mothers were interested. In comparison to oral contraceptives, 73% of those without children and 89% of those with children thought Norplant would be a better contraceptive. The specific features of Norplant liked by 87% and 81% of the subjects, respectively, were not needing to take pills every day and its effectiveness in preventing pregnancy. The characteristics seen as most undesirable related to potential side effects with acne being mentioned by 87% of the subjects. Recursive partitioning analysis demonstrates that more than one prior pregnancy was the main characteristic predictive of very high levels of interest. In summary, this study demonstrates high levels of interest in Norplant by adolescents and suggests that it should be offered as a contraceptive option, especially to those girls who have previously been pregnant.

OBJECTIVE

To evaluate the haemostatic function and menstrual pattern of Norplant acceptors after 36 months of use.

METHODS

This was a prospective longitudinal study that involved fifty five healthy, non-breastfeeding, sexually active informed volunteers recruited from our family planning clinic, between September and December 2002. Blood samples were collected at pre-insertion, 12, 24 and 36 months follow up for packed cell volume, platelet count, prothrombin time and activated partial thromboplastin time. Statistical analysis was with paired t-test. The level of significance was set at p<0.05. Each acceptor received a menstrual calendar to chart all bleeding events.

RESULTS

The mean age and weight of the 29 acceptors who had complete records at 36 months of study were 33.7 +/- 5.9 years, 64.1 +/- 9.9 kg respectively. The mean packed cell volume (PCV) was 34.3 +/- 2.5% at pre-insertion. This rose to significant mean +/- SD values of 37.6 +/- 3.5%; p < 0.0002, 37.4 +/- 3.2%: p < 0.0001 and 38.0 +/- 2.6%; p < 0.0001 at 12, 24 and 36 months respectively. The mean platelet count at pre-insertion was (239,724 +/- 85,886 per microl). There were significant reductions in the mean concentration at 12 months (p <0.04; 198,310 +/- 78,476 per microl) and at 36 months (p<0.0002; 154,241+/- 45,207 per microl). The prothrombin and the partial thromboplastin time at 12, 24 and 36 months did not show significant change over their pre-insertion mean values of 11.9 +/- 1.1 seconds and 36.9 +/- 3.0 seconds respectively. At 24 and 36 months 75.9% (22) and 72.4% (21) of the users reported abnormal menstrual patterns respectively. Only 24.2% (7) and 27.6% (8) had normal menstrual patterns at the respective months. Continuation rates at the end of 24 and 36 months of studies were 85.5% (47) and 80% (44) respectively. Reasons for discontinuation were planning for another baby, menorrhagia, lump in the breast and elevated blood pressure

CONCLUSIONS

Acceptors of Norplant had mainly reduced bleeding patterns, which did not predispose them to anaemia neither did they have an adverse effect as a result of the reduced but normal platelet count.

The objective of the analysis reported here was to examine risk factors for early discontinuation of Norplant implant use due to perceived menstrual problems. Cox's proportional hazard regression model was used to calculate adjusted hazard ratios that would reflect the relationship of selected subject characteristics to the risk of early discontinuation due to perceived menstrual problems. Approximately 13% of the study population discontinued for perceived menstrual problems. At the end of year 2, the gross cumulative life table discontinuation rate for perceived menstrual problems was 9.4 per 100 women and it rose to 16.4 per 100 women at the end of year 5. Women in this study were significantly more likely to discontinue Norplant implant use due to perceived menstrual problems if they had a higher education level >> 12 years), had used no contraceptives in the month before Norplant implant insertion, or had a relatively long average duration of menstrual flow at admission. identifying potential risk factors such as these may help providers to counsel and prepare women to use the Norplant implant method.

Levonorgestrel implants (Norplant) are an alternative to oral contraceptives and medroxyprogesterone acetate intramuscular injections. An interaction may exist between levonorgestrel and agents that induce the hepatic microsomal enzyme system. A 21-year-old woman with a history of a seizure disorder, treated with phenobarbital, who received levonorgestrel implants became pregnant. After a normal delivery, she took oral contraceptives concomitantly with phenobarbital. Although she was educated about the importance of a backup method of contraception, the woman again became pregnant and delivered twins. A recent national survey of neurologists and obstetricians was conducted evaluating prescriber knowledge of interactions between oral contraceptives and anticonvulsants. Only 4% of neurologists and zero percent of obstetricians knew all the interactions between the six most commonly prescribed anticonvulsants and oral contraceptives. This case supports the importance of continued patient and prescriber education regarding the possibility of drug-drug interactions in women taking anticonvulsants and hormonal contraceptives.

The authors report a case of Mycobacterium abscessus infection of a subdermal levonogestrel implant (Norplant) site. The infection lasted 12 weeks and was indolent, skin manifestations were low grade and difficult to detect. Culture of exudate samples showed that M. abscessus was the only causative agent. After the implant was removed the patient's arm healed uneventfully without antimycobacterial therapy. The authors recommend that if Gram staining of apparently infected material from an implant site does not reveal a causative organism, then cultures should be done for mycobacteria and fungi. Kinyoun staining for acid-fast bacteria and calcoflour-white staining for fungi should also be performed. The implant should be removed and the patient given antimicrobial therapy as indicated. The authors emphasize the need to be aware of the potential for M. abscessus infection of implant sites and stress that appropriate microbiologic culture procedures are essential for accurate diagnosis.

Six Silastic levonorgestrel-releasing capsules, Norplant, were introduced subcutaneously into the ventral aspect of the left forearm or upper arm of thirty-eight patients immediately after first trimester pregnancy termination. In the control group, a Nova-T device was inserted immediately after pregnancy termination in thirty patients. Clinical examination was performed after three, six and twelve months of use. The continuation of the Norplant at one year was 91.7 per cent and that of the Nova-T 73.9 per cent. No pregnancies occurred during the study period of one year. Hemoglobin concentrations and the diastolic blood pressures of the Norplant users increased significantly. Dysmenorrhea and menstrual flow increased in the IUD group. Menstrual disturbances were the main side effects in the Norplant group during the first five months of use.

OBJECTIVE

This study examined the prevalence and effects of potential barriers to removal of levonorgestrel implants (Norplant) among low-income women.

METHODS

A sample of 687 women who received Norplant at hospital-based family planning clinics were interviewed before Norplant insertion and 6 months after Norplant insertion (or at Norplant removal if removal occurred earlier). Those who continued to use Norplant were reinterviewed at 2 years or at removal.

RESULTS

In a multivariate analysis, only 1 of the 4 potential barriers--cost--significantly impeded Norplant discontinuation.

CONCLUSIONS

Family planning clinics need to make clear that they follow a policy of Norplant removal on demand, regardless of the patient's ability to pay.

Norplant removal has been much more difficult for many physicians than might have been anticipated. Dr Untung Praptohardjo of Indonesia recently developed the "U" technique, speeding the time required to remove the six Norplant implants to an average of 7 minutes. In his technique, a unique oval-ring-tipped forceps with an internal diameter of 2.2 mm is used to reach through a 4-mm incision to firmly grasp each of the implants. The incision is made parallel to the implants between the lower tips of implants 3 and 4. The "U" technique requires grasping the implant within 4 mm to 5 mm of its tip. This preliminary paper describes the "Modified U" technique, which allows the physician who is removing the implants to grasp them anywhere along their shaft, not just near the tip. The Modified U technique involves the use of an improved ring-tipped forceps with a circular tip rather than the oval tip used in the "U" technique. This instrument, called Norgrasp, is a modification of the vas deferens fixation forceps used in the no-scalpel vasectomy (NSV) technique. In another adaptation of NSV instruments, an NSV dissecting forceps (a sharpened, curved hemostat) is used to free the implants from their tissue envelope and quickly deliver them through the skin incision. Using the Modified U technique, the time required to remove Norplant implants in 20 patients in the United States has ranged from 8 to 13 minutes. Improperly placed implants are readily removed with this technique. The Modified U technique requires a minimal incision and offers both the physician and the patient a speedy, positive removal.

With the purpose of measuring the duration of the functional life-span (FLS) of the anovulatory follicle in women under continuous low-dose progestogen treatment, the oestradiol curve of Norplant implant users was retrospectively analysed. From all the data collected during the previous 5 years at the Department of Biomedical Research at the Family Planning Clinic of Profamilia, Santo Domingo, Dominican Republic, data from all 29 Norplant implant users showing follicular activity without luteal activity were selected for this retrospective analysis. Serial blood sampling twice or three times a week for 5 or 6 consecutive weeks had been taken in all subjects. The duration of the FLS of the dominant follicle in anovulatory cycles was defined at the period from the first day of ascending oestradiol curve until the day preceding onset of menses. The mean FLS of the dominant follicle in anovulatory cycles under continuous low-dose progestogen administration was 21.1 +/- 4.2 days, independently of the length of the menstrual cycle. The duration of the FLS of the anovulatory dominant follicle appears not to be different from the duration of a normal follicle/corpus luteum unit.

Blood pressure (BP) and body weight were assessed at entry, 6 months and 12 months of use in a prospective study of 117 and 76 women using low-dose oral contraceptives (LD-OCs) and Norplant, respectively. The results showed that mean systolic BP (mmHg), diastolic BP (mmHg) and weight (kg) for LD-OCs and Norplant at entry, 6 months and 12 months, respectively, were not significantly different. During the one year of use, the study found that moderate increase in BP occurred at the same frequency as reduced BP, and that observed variation in BP was within a narrower range in Norplant users compared with LD-OC users.

The aim of this study was to determine whether long-term Norplant uses is associated with changes in bone density. The study group consisted of forty one healthy women aged 19-42 years who had used Norplant for 31.1 +/- 11.2 months with a minimum period of 12 months. Fifty current IUD users constituted the control group. The bone density was measured by dual energy X-ray absorptiometry (DEXA) at the non dominant distal and ultradistal forearm. Serum estradiol was measured by microparticle enzyme immunoassay technique. Age, parity, income, weight, height and body mass index (BMI) of both groups were no differences. Our analysis did not find any differences in bone mineral density of distal forearm and ultradistal forearm between Norplant and IUD users (95% CI -0.01, -0.03 and -0.02, 0.02 respectively). Serum estradiol was not different in the two groups (95% CI -24.9, 110). This study revealed that the Norplant implants do not have any adverse effect on bone mineral density.

An analysis of the menstrual diary records of 306 cases of Norplant users over 5 years is reported. The results indicate that the disturbances of menstrual cycles during Norplant use were mainly caused by changes in the total number of vaginal bleeding days. Menstrual patterns were irregular and prolonged. Disturbances of the menstrual pattern were improved after 6-12 months of use, mainly showing a decrease in the number of spotting days. About 30-40% of users may regain their normal menstrual pattern after 1 year of use. There was a proportion of cases with an abnormal menstrual pattern throughout the 5 years of use, but the gross cumulative termination rate for menstrual problems was only 13.0%. Norplant users are susceptible to an increase in the number of spotting days and irregular bleeding. The main reason for termination of contraceptive use was prolonged bleeding for a long time. This is important information that should be provided in counselling potential Norplant acceptors, especially the changes in menstrual pattern. We also have a responsibility to try to find a treatment for prolonged bleeding.

The objective of the present study was to analyze the patterns of menstrual bleeding in Singaporean women using Norplant-2 contraceptive implants over a five-year period. Of the 100 women recruited for the study, 62 were still using the implant at the end of five years. Only 9 women discontinued for menstrual reasons and they did so within the first 21 months of implant use. Although a normal menstrual bleeding pattern was uncommon during the first three months of use, 69.4% had normal menstruation at the end of five years. Irregular bleeding was the most common form of menstrual abnormality throughout the study period. Infrequent periods and amenorrhoea were distinctly uncommon, especially after the first two years of use. The pattern of bleeding with Norplant-2 was not significantly different from that previously observed with Norplant.

The aim of this double-blind, placebo-controlled study was to evaluate the effect of mefenamic acid and placebo on controlling irregular uterine bleeding secondary to Norplant use. A total of 67 Norplant users attending the Family Planning Clinic of Chulalongkorn Hospital all had irregular bleeding. These women were randomly allocated into two groups. A total 34 users received mefenamic acid, 500 mg twice a day for 5 days, and placebos were given to the other 33 in the same manner. The total days of bleeding and spotting and the percentage of women in whom bleeding was stopped were analyzed in weeks 1 and 4. The percentage of subjects in whom bleeding was stopped during week 1 after initial treatment was significantly higher in the mefenamic acid group than the placebo group (76%, 27%; p < 0.001). In the follow-up period (4 weeks after initial treatment), a bleeding-free interval of>> 20 days was found in 68% of the subjects treated with mefenamic acid and 33% treated with the placebo; the mean number of bleeding/spotting days was lower with mefenamic acid treatment (11.6 and 17.2 days; p < 0.05). The difference was statistically significant. It is concluded that mefenamic acid was more effective than placebo in short-term control of irregular bleeding and spotting associated with Norplant use.