Combined Oral Contraceptive Pill Research Articles

Management of bleeding irregularities among etonogestrel implant users: Is combined oral contraceptives pills or nonsteroidal anti-inflammatory drugs the better option?

This study is to evaluate whether unacceptable bleeding among the etonogestrel implant user could be better alleviated using combined oral contraceptive pills (COCP) or nonsteroidal anti-inflammation drugs (NSAID). This is a prospective randomized study for evaluation of 84 etonogestrel implant (Implanon) users with prolonged or frequent bleeding. They were assigned to either receiving a COCP containing 20 mcg ethinyl estradiol/150 mg desogestrel for two continuous cycle or NSAID; mefenamic acid 500 mg TDS for 5 days, 21 days apart for two cycles. Bleeding pattern during the treatment was recorded and analyzed. A total of 32 women (76.2%) in COCP group and 15 women (35.7%) in NSAID group stop bleeding within 7 days after the initiation of treatment which was statistically significant (P < 0.05). The mean duration of bleeding and spotting days in women treated with COCP was significantly lesser compared to NSAID group (7.29 ± 3.16 vs 10.57 ± 4.14 days (P < 0.05). We conclude that COCP is more efficient compared to NSAID in managing bleeding irregularities among etonogestrel implant users.

In vivo, Lipid Profile Efficacy of Ethanol Extracts of Stevia rebaudiana Bertoni in Rabbits.

Contraceptive pills are chemical substances used as a means to prevent pregnancy, but they have several effects, including high lipid profile and in many cases, patients with heart and blood diseases cannot use it as a contraceptive helps in increasing the risk of cardiovascular diseases (CVD). A Stevia extract with high sweetening capacity due to its content of glycosides is used to reduce lipid profile and this study aimed to decrease lipid profile levels and lowering the risk factor in women using contraceptive drugs by stevia extracts. Sixteen rabbits have been used as a case-control study design due to their anatomical and physiological similarity to humans. The stevia leaves are extracted using Soxhlet apparatus of ethanol solvent. Statistical package (SPSS), were used for data analysis and management using independent sample t-test, test, comparison of means for lipid profile of Triglyceride (TG), Cholesterol, High-density lipoprotein (HDL-C), Low-density lipoprotein (LDL-C) between (di-contraceptive, mono-contraceptive and control groups). The results showed increasing cholesterol and LDL-C during the combined oral contraceptive (COCP) and progesterone-only pills with decreased HDL-C level. A comparison of means before and after stevia used explains the elevated HDL-C and decreased LDL-C. The lipid profile levels should continuously be monitored during oral contraceptive intake and Stevia leaf powder extraction is suggested to reduce the risk of CVD.

Evaluation of the clinical pharmacist's role in educating women about the benefits and risks of combined oral contraceptive pills in Jordan

Evaluation of the clinical pharmacist's role in educating women about the benefits and risks of combined oral contraceptive pills in Jordan

Female sexuality and combined oral contraceptive pills: administration and correction issues

Female sexuality and combined oral contraceptive pills: administration and correction issues

Medical management of bronchial endometriosis: Case report and literature review

We are presenting 29 year old female complaining of cataminal haemoptysis 3 months post-delivery of her second child. She had no previous history of endometriosis or chronic pelvic pain. She was investigated thoroughly by respiratory and immunology teams for all possible diagnosis and clinically the final diagnosis was bronchial endometriosis. This case showed that combined oral contraceptive pills has successful role of management of lung endometriosis.

Новые возможности интегративной терапии пациенток с синдромом поликистозных яичников и нарушениями углеводного и липидного обмена. Результаты сравнительного исследования

Background: long-term combined estrogen-progestin oral contraceptive pills (COCPs) are the first-line treatment for polycystic ovary syndrome (PCOS). However, this therapeutic option does not affect metabolic disorders that are more severe in women with the second PCOS phenotype thus increasing the risk of cardiometabolic complications.Aim: to assess the effect of myo-inositol and D-chiro-inositol at a 5:1 ratio on metabolic parameters in women of reproductive age with the second PCOS pathogenetic type and the disorders of carbohydrate and lipid metabolism. Patients and Methods: 60 overweight and obese women with PCOS were enrolled in this randomized prospective study. Group 1 women (n=30) received COCP and a drug containing two isoforms of inositol at a 5:1 ratio (myo-inositol 1,000 mg plus D-chiro inositol 200 mg). Group 2 women (n = 30) received COCP only. Hemostasis, lipid panel, fasting glucose level, body mass index (BMI), and waist circumference were measured before and 90 days after treatment begins. Results: in group 1, the significant (p&lt;0.05) improvement of lipid parameters was reported as demonstrated by the reduction of the levels of total cholesterol (TC) by 16.9%, triglycerides by 15.7%, low-density lipoprotein cholesterol (LDL–C) by 17.8%, fibrinogen by 15.8%, and fasting glucose by 16.9% as well as the increase of high-density lipoprotein cholesterol (HDL–C) by 28.5%. Meanwhile, no significant changes were seen in group 2. Additionally, the reduction of waist circumference by 4.5% and BMI by 9.1% was reported in group 1. Conclusions: a medication containing myo-inositol and D-chiro-inositol at a 5:1 ratio is promising for the prevention of cardiometabolic complications in women with PCOS. Further large studies of the investigated drug are needed to demonstrate its efficacy and to assess its properties. KEYWORDS: polycystic ovary syndrome (PCOS), treatment, prevention, obesity, metabolic syndrome, lipid panel, inositol, oral contraceptive pills. FOR CITATION: Dobrokhotova Yu.E., Lapina I.A., Chirvon T.G., Taranov V.V. New prospects of the integrative therapy for polycystic ovary syndrome in women with the disorders of carbohydrate and lipid metabolism: a comparative study. Russian Journal of Woman and Child Health. 2020;3(3):169–173. DOI: 10.32364/2618-8430-2020-3-3-169-173.

Progestogen-only pill associates with false-positive aldosterone/renin ratio screening test.

Aldosterone/renin ratio (ARR) is commonly used to screen for primary hyperaldosteronism (Conn's disease). A number of drugs can alter ARR measurements, thus requiring omission before testing. However, hormonal agents such as the combined oral contraceptive (COCP) or progestogen-only pill (POP) are not listed for omission. A 20-year-old woman was referred to the endocrinology team, following investigations for syncope by her cardiologist, when ARR was found to be elevated. She was taking POP (Cerelle®) while having ARR measured. After omitting POP for four weeks, plasma aldosterone concentration was reduced by 52% (from 560 pmol/L to 271 pmol/L, reference range: 100-450 pmol/L), plasma renin concentration increased by 253% (from 3.6 mU/L to 12.7 mU/L, reference range: 5.4-30 mU/L) and ARR reduced from 156 to 21 (-86.5%) (reference range: <80 suggests Conn's unlikely). To the best of our knowledge, this is the first reported case of POP-related false-positive ARR screening for primary hyperaldosteronism. Omission of POP should, therefore, be considered in women undergoing ARR measurement.

Миома матки больших размеров: тактика ведения на этапе прегравидарной подготовки, вынашивания беременности и родоразрешения

Uterine fibroids are one of the most common benign tumours of the female reproductive system with a high prevalence worldwide. Recent upward trend in uterine fibroids in younger women has resulted in their more common occurrence in pregnancy. The paper addresses case history of successful pregnancy and childbirth in a woman who experienced a surgery for large uterine fibroid (18×16×18 cm by ultrasound) a year before this pregnancy. Immediate histological examination of the excised uterine fibroid has demonstrated its benign nature (leiomyoma) resulting in uterus preservation. Postoperatively, gonadotropin-releasing hormone antagonists for 3 menstrual cycles with treatment switching to combined oral contraceptive pills for 3 menstrual cycles were prescribed to reduce the risk of recurrence. Leiomyoma treatment in women with unrealized fertility requires personalized approach implying surgical intervention before pregnancy planning as well as pre- and postoperative treatment to maintain and boost fertility.Keywords: uterine fibroid, pregnancy, delivery, myomectomy, caesarean section, fertility.For citation: Gutikova L.V., Kukharchik Yu.V. Large uterine fibroid: planning for pregnancy, carrying a pregnancy, and delivery. Russian Journal of Woman and Child Health. 2020;3(2):83–87. DOI: 10.32364/2618-8430-2020-3-2-83-87.

Ovarian reserve markers in women using various hormonal contraceptives

Objectives: The aim of the study was to assess whether the ovarian reserve markers anti-Müllerian hormone (AMH) and antral follicle count (AFC) were lower among women using the progestin-only pill (POP) or levonorgestrel-releasing intrauterine system (LNG-IUS) and similar to the decrease observed in combined oral contraceptive (COC) pill users.Methods: This retrospective study comprised 565 hormonal contraceptive users (COC, POP, LNG-IUS or contraceptive vaginal ring) and 983 non-hormonal contraceptive users, who were seen in two Danish fertility assessment and counselling clinics between 2015 and 2019. Adjusted multiple regression analysis was used to examine the differences in AMH and AFC between hormonal and non-hormonal contraceptive users.Results: Compared with non-hormonal contraceptive users, AMH was 31.1% lower among COC users [95% confidence interval (CI) −39.6%, −25.9%; p < 0.001], 35.6% lower among POP users (95% CI −49.0%, −18.6%; p < 0.001) and 17.1% lower among LNG-IUS users (95% CI −31.4%, 0.002%; p = 0.052); no significant differences were seen among vaginal ring users. Compared with non-hormonal contraceptive users, AFC was 31.3% lower among COC users (95% CI −35.0%, −25.3%; p < 0.001) and 29.7% lower among POP users (−39.1%, −17.9%; p < 0.001); no significant differences were seen among LNG-IUS or vaginal ring users. Ovarian volume was more than 50% reduced among COC and vaginal ring users (p < 0.001) but was unchanged among POP and LNG-IUS users.Conclusion: Assessment of ovarian reserve markers among users of all types of hormonal contraception should be interpreted cautiously and the type of contraceptive method considered.

Rhabdomyolysis as an initial presentation of systemic lupus erythematosus: a case report

BackgroundSystemic lupus erythematosus (SLE) is a multi-system autoimmune disease which most commonly presents in women of reproductive age. It takes a relapsing-remitting course and may manifest as a variety of clinical symptoms, making it difficult to diagnose at first presentation, particularly in the emergency department (ED) setting. In active SLE, rhabdomyolysis has, thus far, not been reported as the sole initial presentation.Case presentationA 28-year-old presented to the ED with bilateral proximal arm swelling and pain. She had a previous history of Raynaud’s disease. Creatine kinase was > 13,000 units/l (normal range 25–200), but renal function was preserved. She did not require hospital admission so was encouraged to take oral fluids and discontinue the combined oral contraceptive pill. Antinuclear antibody and anti-double-stranded DNA titres were highly elevated with low complement demonstrated. She was diagnosed with SLE and treated with an oral prednisolone course. Antibody titres remained high 6 months later, provoking the initiation of hydroxychloroquine therapy.ConclusionsWe report with a view to recommend autoimmune screening in young patients for whom a cause of rhabdomyolysis is not clearly identified.

Impact of Hormonal Contraceptives on Cervical T-helper 17 Phenotype and Function in Adolescents: Results from a Randomized, Crossover Study Comparing Long-acting Injectable Norethisterone Oenanthate (NET-EN), Combined Oral Contraceptive Pills, and Combined Contraceptive Vaginal Rings.

BackgroundAdolescents in sub-Saharan Africa are at risk for human immunodeficiency virus (HIV) infection and unintended pregnancies. Observational studies suggest that injectable hormonal contraceptives (HCs) increase the HIV risk, although their effects on genital inflammation, particularly HIV-susceptible T-helper 17 (Th17) cells, are unknown. In a randomized crossover study, the effect of injectable norethisterone oenanthate (NET-EN), combined contraceptive vaginal rings (CCVR; NuvaRing), and combined oral contraceptive pills (COCPs) on cervical Th17 cells and cytokines were compared.MethodsAdolescents (n = 130; 15–19 years) were randomly assigned 1:1:1 to NET-EN, CCVR, or COCPs for 16 weeks, then subsequently crossed over to another HC for 16 weeks. Estrogen, follicular stimulating hormone (FSH), and luteinizing hormone (LH) levels were measured. Chemokine receptor 5 (CCR5), human leukocyte antigen (HLA) DR isotope, and cluster of differentiation 38 (CD38) expression by cervical cytobrush-derived CD4+ T cells was assessed by fluorescence-activated cell sorting. Th17 cells were defined as CCR6+ and CCR10-. Cervicovaginal Th17-related cytokines were measured by Luminex.ResultsCCVR use for the first 16 weeks was associated with reduced Th17 frequencies and lower FSH and LH concentrations, as compared to NET-EN and COCPs, with FSH concentrations and Th17 frequencies correlating significantly. However, Th17-related cytokine concentrations (interleukin [IL]-21, IL-1β, tumor necrosis factor–α, interferon-γ) and CCR5, HLA-DR, CD38, and Th17 frequencies were significantly higher in CCVR than NET-EN and COCP. At crossover, CCVR users changing to COCPs or NET-EN did not resolve activation or cytokines, although switching from COCP to CCVRs increased cytokine concentrations.ConclusionsCCVR use altered endogenous hormone levels and associated cervical Th17 cell frequencies to a greater extent than use of NET-EN or COCPs, although Th17 cells were more activated and Th17-related cytokine concentrations were elevated. While CCVRs may impact the HIV risk by regulating Th17 numbers, increased activation and inflammation may balance any risk gains.

Comparative evaluation of the efficacy and safety of Ormeloxifene and combined oral contraceptives in dysfunctional uterine bleeding

Introduction: Dysfunctional Uterine Bleeding (DUB) is an abnormal uterine bleeding, in the absence of any organic, systemic or iatrogenic cause. Pharmacological treatment options available are combined oral contraceptive pills, progestogens, danazol, gonadotrophin releasing hormone (GnRH) agonists, SERMs, prostaglandin synthetase inhibitor, anti-fibrinolytics and ethamsylate. The purpose of the study was to evaluate the efficacy and safety of Ormeloxifene and compare it to combined oral contraceptive pills (OCPs) in dysfunctional uterine bleeding. Method: Hundred women aged 20-50 years presenting with DUB were randomly allocated to two groups of 50 each. Group A were given Ormeloxifene tablet 60 mg twice a week for 12 weeks, followed by 60 mg once a week for 12 weeks. Group B were given OCPs containing 30 microgram Ethinyloestradiol and 150 microgram Levonorgestrel from day 1 to day 21st of the menstrual cycle for 6 cycles. The outcome was studied by assessment of menstrual blood loss by Pictorial Blood loss Assessment Chart (PBAC) score, Hb level in g/dl, endometrial thickness in mm, patient’s level of satisfaction and any drug side effects at the end of 6 months. Results: The reduction in mean PBAC score with Ormeloxifene (330 to 2.8) was significantly more than with oral contraceptive pills (317 to 74) at 6 months (P&lt;0.001). In both the groups mean hemoglobin level increased but rise in Hb in group A (1.5 g/dl) was more as compared to the rise in Hb in group B (1.2 g/dl). The mean endometrial thickness decreased in both the groups but the decrease in group A (9.6 mm to 8.4 mm) was not statistically significant as compared to the decrease in group B (9.8 mm to 6.4 mm). The side effects were minimal in both the groups. 22% patients with Ormeloxifene and 10% with oral contraceptive pills were highly satisfied with their treatment. Conclusion: Ormeloxifene is effective in control of DUB and can be used as an alternative to OCP for treatment of DUB with possibly minimal side effects and better dosage compliance.

Contraception as a Risk Factor of Trichomonas vaginalis Infection Among Women Attending Outpatient of Al-Batool Teaching Hospital for Maternity and Children-Baqubah-Iraq

Background:The effects of contraception on Trichomonas vaginalis have important implications for women who suffer from infections associated with disruptions in the vaginal ecology, such as bacterial vaginitis and urinary tract infections.&#x0D; Objective: To find the association of the common types of contraceptions with the Trichomonasvaginalis infection in women admitted to the Al-BatoolTeaching Hospital for Maternity and Children in Baqubah city.&#x0D; Type of study: Cross-sectional study&#x0D; Methods: This study consist of 75 women with contraception use and71 apparently healthy non contraception user women admitted to outpatient in Al-Batool Teaching Hospital for Maternity and Children in Baqubah City, Diyala. Iraq during the period from 1st January 2016 till 31th December 2016. After full history and clinical examination, high vaginal swab took from posterior fornix of vagina and general urine examination, all samples were examined by wet mount preparation under the microscope for the presence of Trichomonas vaginalis and gram-stained smears for the presence of Candida albicans, then all results were recorded.&#x0D; Results:. Minimum age was 18 year and maximum was 47 year, infection rate of Trichomonas vaginalis was 41(45.66%) among contraception user and 6(8.45%) among contraception non- user while Candida albicans was 18(24%) and 1(1.40%) respectively, the highest frequency of infection 23 cases was diagnosed in the age group (29-39 year) among contraception user while 4 cases in age group (18-28) contraception non-user. On the other hand there was no significant correlation between age, parity, duration of marriage and infection and using of contraception. Marginal significant correlation between the type of contraception and infection with Trichomonas vaginalis. While no significant correlation between types of contraception, infection and duration of contraception use. &#x0D; Conclusion: Infection with Trichomonas vaginalis significantly correlated to use of intrauterine contraceptive device and combined oral contraceptive pills, so great attention should be paid to those women for diagnosis and treatment.

2043 Where do Women Draw the Line? Choosing Surgery for Endometriosis After Hormonal Medication Use

Study Objective Identify the number and duration of hormonal management modalities utilized by patients with endometriosis prior to undergoing initial surgical evaluation. Design Cross-sectional study. Setting Tertiary care academic hospital. Patients or Participants Forty-four patients with pathology proven endometriosis. Interventions Patients were provided with a standardized questionnaire regarding the use of preoperative hormonal medical therapy. Medical therapy categories included: combined oral contraceptive pills (COCP), progesterone only pills (POPs), progesterone intrauterine devices (IUD), injections, implants, gonadotropin releasing hormone agonists (GnRH), selective progesterone receptor modulators, aromatase inhibitors, danazol, and GnRH antagonists. Measurements and Main Results Of 111 patients screened with pathology proven endometriosis, 52 patients met eligibility criteria. The response rate was 84.62% (n=44). Median age of patients was 33 years old. Mean number of gynecologic procedures patients had was 2.6. The mean use of medication was Conclusion Despite available medical management options for endometriosis treatment, many patients do not use any hormonal medications before choosing surgical intervention. Although multiple modalities exist for medical management, this cohort mainly used progesterone based methods. These medications are used for many years and patients with endometriosis are at high risk for multiple gynecologic procedures.

THORACIC ENDOMETRIOSIS SYNDROME PRESENTING AS RECURRENT CATAMENIAL PNEUMOTHORAX

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Catamenial pneumothorax (CP) is a rare spontaneous pneumothorax (PTX) that occurs cyclically with menstrual periods. It is part of the spectrum of thoracic endometriosis syndrome (TES) in which ectopic endometrial tissue is implanted in thoracic structures. CASE PRESENTATION: A 36-year-old G0P0 female nurse, presented with worsening right-sided pleuritic chest pain for 6 days. She had a history of stage 4 endometriosis associated with recurrent CP. Her first episode was 4 years ago when she had a large right-sided PTX in association with biopsy proven diaphragmatic endometriosis, treated with a right middle lobe wedge resection and chemical pleurodesis. She had multiple recurrences of PTX requiring repeat pleurodesis and subsequent long-term medical therapy with leuprolide and combination oral contraceptive pills. On examination, she was hemodynamically stable with decreased breath sounds in the right lower lung field. CT chest revealed a moderate volume right PTX, a sub-pleural right lower lobe mass and pleural thickening. She underwent a video-assisted thoracoscopic surgery (VATS) with combination (mechanical and chemical) pleurodesis. Pleural biopsy was negative for endometriosis. Postoperative chest x-rays revealed a resolving pneumothorax. Three days after surgery, the patient was discharged home. DISCUSSION: CP is characterized by collapsed lung, which occurs within 3 days of menstruation onset. The pathophysiology involves deposition of focal endometrial pleural implants migrating during leakage of air from the peritoneal cavity, which subsequently break down during menstruation or hypertrophy in response to hormonal changes. Another plausible theory is vasoconstriction and bronchospasm induced by prostaglandin F2 release during menses leading to alveolar rupture and PTX. Due to the vague symptomatology and limited disease awareness, the diagnosis is often missed or delayed leading to life-threatening complications. Histologically proven thoracic endometriosis is frequently but not always associated with CP. Our patient is unique as she previously had a diaphragmatic endometriosis associated CP and later had a non-TES associated bout of CP. Recent evidence suggests that combination surgical (VATS) followed by medical (GnRH agonist) therapy effectively suppresses CP recurrence. However, our patient suffered multiple recurrences even after both modalities. A combination of mechanical and chemical pleurodesis was attempted in an effort to prevent further recurrences. CONCLUSIONS: TES remains an exceedingly rare condition and very few cases have been reported. Our case is unique given her multiple recurrences and unresponsiveness to guideline directed therapies. Physicians should keep a high level of clinical suspicion for thoracic endometriosis in non-smoking women over 31 years, with a history of pelvic endometriosis, and presenting with recurrent pneumothorax. Reference #1: Junejo SZ, Singh Lubana S, Shina SS, Tuli SS.A Case of Thoracic Endometriosis Syndrome Presenting with Recurrent Catamenial Pneumothorax. Am J Case Rep. 2018 May 17;19:573-576. DISCLOSURES: No relevant relationships by Prasanta Basak, source=Web Response No relevant relationships by Stephen Jesmajian, source=Web Response No relevant relationships by Ahmed Qavi, source=Web Response

Heavy Menstrual Bleeding in the Adolescent

Heavy menstrual bleeding is a common presenting problem in the adolescent population. The average age of menarche is between 12 and 13 years. The most common reason for heavy menstrual bleeding soon after menarche is from an immature hypothalamic ovarian access, which spontaneously resolves once cycles become ovulatory. However, the broad differential diagnosis for heavy menses in adolescents includes coagulopathy, thyroid disease, sexually transmitted infections, specifically chlamydia, and chronic medical conditions. Von Willebrand disease is the most common bleeding disorder that can present with heavy menstrual bleeding at menarche or shortly after. A thorough history and physical exam with occasional labs needs to be completed and can assist in narrowing the differential diagnosis. Treatment of heavy menstrual bleeding consists of hormonal and nonhormonal options: combination oral contraceptive pills, patches, or rings taken continuously or cyclically; progesterone-only pills; progesterone implants; progesterone intrauterine devices; cyclic tranexamic acid; cyclic aminocaproic acid; and GnRH agonists with add-back therapy. This review contains 3 tables, and 28 references. Key Words: adolescent menses, anovulation, bleeding disorder, heavy menstrual bleeding, immature hypothalamic ovarian axis, menarche, treatment of heavy menses, Von Willebrand disease

Hormonal Contraception and the Brain: Examining Cognition and Psychiatric Disorders

Background:The combined oral contraceptive pill (OC), containing synthetic estrogens and progestins, is used by millions of women worldwide, yet little is known about its effects on cognition or on psychiatric disorders. The progestin component of OCs determines their androgenicity, i.e. whether the OC has androgen binding components with masculinising effects or antiandrogenic components with feminising effects.Objective:The present review discusses the literature surrounding OC use and cognition in healthy women. Given the important role that sex hormones play in psychiatric disorders, we also consider the influence of OCs on symptoms of schizophrenia, post-traumatic stress disorder, depression, bipolar disorder, anxiety disorders and indirectly, sleep quality.Results:Research has shown that while there are no differences between OC users and non-users, androgenic OCs enhance visuospatial ability and anti-androgenic OCs enhance verbal fluency. Little is known about OCs effects on other cognitive domains, such as memory and executive function. There is little research examining OC use in schizophrenia, post-traumatic stress disorder, bipolar disorder and anxiety disorders. There is some evidence that OC use is associated with depression, however the exact causality of this association remains to be verified.Conclusion:We maintain that future studies need to address several methodological limitations, such as separating OCs based on androgenicity to avoid the masking effects that occur when various OCs are considered as one group. As this review highlights several significant effects of OC use on the brain, the implications of OC use needs to be considered in future research.

Do Expectant Mothers' Breastfeeding Plans Influence Provider Prenatal Contraceptive Counseling?

Breastfeeding and optimal birth spacing are associated with improved maternal and infant health outcomes worldwide. Provision of contraceptive advice that is aligned with recommendations for breastfeeding has potential to maximize maternal and infant health. Although there is broad agreement regarding the breastfeeding compatibility of specific postpartum contraceptive methods, it is not known whether maternal breastfeeding intention influences prenatal provider contraceptive counseling. We aimed to determine if maternal feeding intention is considered by prenatal providers during contraceptive counseling. This was a cross-sectional online author-created survey including all prenatal providers (N = 40) at two academic safety-net institutions in Cleveland, Ohio. Of 100 obstetrics/gynecology faculty members, 40 (40%) completed the survey, which included multiple-choice questions. Nominal and ordinal survey results were reported with percentages and frequencies, and categorical variables were compared using the Fisher exact test. Participants appropriately promoted breastfeeding-compatible postplacental intrauterine device placement, even though maternal feeding intention was specifically considered by just 12 (30%). Endorsed barriers to contraception for breastfeeding mothers included provider medical worries, patient concerns, and colleague resistance. Postplacental levonorgestrel intrauterine devices were recommended for all mothers by 92.5% of participants (n = 37). Recommendations regarding progestin-only and combined oral contraceptive pills were influenced by maternal breastfeeding versus formula-feeding intention. Asking expectant women about their feeding intentions within each contraceptive discussion may create opportunities for shared decision making that can optimize perinatal outcomes for both mother and infant worldwide.

The Safe Management of Acne Vulgaris in Lupus Erythematosus: A Systematic Review with Evidence-Based Treatment Recommendations.

To date, there have been no studies that have specifically investigated which medications can and cannot be safely used to treat acne vulgaris in patients who have lupus erythematosus (LE). These patients require a highly individualized treatment approach, as the use of certain acne medications may exacerbate LE symptomology, such as photosensitivity and hypercoagulability. In this systematic review, we examine safety outcomes associated with commonly prescribed oral acne medications, specifically in the context of LE. A literature search, conducted on PubMed/MEDLINE, revealed 146 studies, of which 13 met the criteria. We assigned a level of evidence to each study and sought to determine evidence-based recommendations for each class of drug; each recommendation was then assigned a corresponding grade. There were very few high-quality studies available on this topic. Although we determined recommendations based on the existing literature, the grading was occasionally unfavorable due to the low-quality nature of the evidence supporting the recommendation. However, our recommendation against the use of combined oral contraceptive pills and in favor of spironolactone for the treatment of acne, in the setting of LE, received a satisfactory grading (grade A). While no definitive recommendations for the treatment of acne in LE can be made based on the existing quality and quantity of studies available, this article aims to provide a comprehensive overview and analysis of oral acne medication safety in patients with LE, while emphasizing the immense need for higher quality studies and distinct acne treatment guidelines for this vulnerable patient population.

8. Myositis as an idiosyncratic drug reaction to leflunomide

IntroductionMyositis is a broad diagnosis with a number of potential causes. There are numerous drugs that can lead to myotoxicity. We discuss a case of a patient with known rheumatoid arthritis who developed myositis with no evidence of an additional autoimmune condition and where the most likely cause seems to be leflunomide.Case descriptionA 46-year-old Asian lady with a background of seropositive rheumatoid arthritis and overactive bladder developed increasing muscle weakness. Disease activity was well-controlled on leflunomide which had been started four years ago after an initial trial of methotrexate proved ineffective. Other regular medications include tolterodine and rigevidon (combined oral contraceptive pill), paracetamol and co-codamol. She presented to her GP in February with generalised muscle weakness, fatigue, dry mouth, hair loss and occasional shortness of breath on exertion. Blood tests showed elevated CK at 1132 u/l, ALT 57 u/l (AST normal), LDH 302 u/L, CRP 4 mg/l and ESR 25mm/h.Further tests were subsequently arranged following rheumatology review including ANA and ENA (both negative), an extended myositis panel and HMGCoAR antibodies (also negative). MRI of her lower limbs showed bilateral oedema within the anterior and lateral muscle compartments of her thighs, worse on the left, and in keeping with myositis. Given the possibility of leflunomide being the cause of her symptoms it was stopped. Her CK one month after stopping leflunomide had decreased to 819 u/l and then 389 u/l after four months. The patient reported improvement in her muscle weakness, CK is currently being monitored, and she is awaiting an EMG. A muscle biopsy has been discussed with her previously and although she had refused initially, in view of persistent mild elevation in CK, the biopsy and leflunomide washout will be discussed again with her again. As she is clinically asymptomatic and not keen to try new medications, further immunosuppression has not been started.DiscussionMyositis is seen in a wide range of conditions with numerous possible causes. It can be drug-induced, secondary to viral infections or caused by autoimmune conditions including overlap conditions and idiopathic inflammatory myopathies. Drug-induced myositis is most commonly associated with statins, but has been seen with many different medications.Leflunomide is a disease-modifying anti rheumatic drug used particularly in the treatment of inflammatory arthritis but has also been used in treatment resistant dermatomyositis. It inhibits the mitochondrial enzyme, dihydroorotate dehydrogenase to reduce the reproduction of rapidly dividing cells. A rise in CK is considered a common side effect. We have only found one other case report where leflunomide was suspected to have induced polymyositis, also in a patient with rheumatoid arthritis. Both biochemical and clinical improvement following cessation of leflunomide, with no other inventions raises the likelihood of this being a leflunomide-induced myositis.Key learning pointsWhen faced with a patient with rheumatoid arthritis presenting with symptoms suggestive of myositis, whilst an overlap autoimmune condition is a possibility, it is important to consider potential drug causes. Numerous drugs have been implicated through both direct myotoxicity and immunologically mediated myotoxicity. Importantly for rheumatologists these can include glucocorticoids, antimalarial drugs, colchicine and tumour necrosis factor inhibitors. According to the summary of product characteristics a rise in CK is commonly seen with leflunomide but clinical myositis has only been reported rarely.Conflicts of interestThe authors have declared no conflicts of interest.