Use Of Intrauterine Contraceptive Device Research Articles

Halo and spillover effect illustrations for selected beneficial medical devices and drugs.

BackgroundNegative news media reports regarding potential health hazards of implanted medical devices and pharmaceuticals can lead to a ‘negative halo effect,’ a phenomenon whereby judgments about a product or product type can be unconsciously altered even though the scientific support is tenuous. To determine how a ‘negative halo effect’ may impact the rates of use and/or explantation of medical products, we analyzed the occurrence of such an effect on three implanted medical devices and one drug: 1) intrauterine contraceptive devices (IUDs); 2) silicone gel-filled breast implants (SGBI); 3) metal-on-metal hip implants (MoM); and 4) the drug Tysabri.MethodsData on IUD use from 1965 to 2008 were gathered from the Department of Health and Human Services Vital and Health Statistics and peer-reviewed publications. Data regarding SGBI implant and explantation rates from 1989 to 2012 were obtained from the Institute of Medicine and the American Society of Plastic Surgeons. MoM implant and explantation data were extracted from the England and Wales National Joint Registry and peer-reviewed publications. Tysabri patient data were reported by Elan Corporation or Biogen Idec Inc. Data trends for all products were compared with historical recall or withdrawal events and discussed in the context of public perceptions following such events.ResultsWe found that common factors altered public risk perceptions and patterns of continued use. First, a negative halo effect may be driven by continuing patient anxiety despite positive clinical outcomes. Second, negative reports about one product can spill over to affect the use of dissimilar products in the same category. Third, a negative halo effect on an entire category of medical devices can be sustained regardless of the scientific findings pertaining to safety. Fourth, recovery of a product’s safety reputation and prevalent use may take decades in the U.S., even while these products may exhibit widespread use and good safety records in other countries.ConclusionsWe conclude that the ‘negative halo effect’ associated with a stigma, rather than an objective risk-benefit assessment of medical products can increase negative health outcomes for patients due to reduced or inappropriate product usage.

How Good are We at Recognizing and Treating Pelvic Inflammatory Disease?

The aim of this discursive article is to highlight the challenges for clinicians when diagnosing and treating women with pelvic inflammatory disease, especially when the woman has an intrauterine device in-situ. The article will highlight key areas of the decision making process involved in this specific example and will include discussions on evidence based practice, clinician experience, knowledge base and patient preference. Current clinical guidelines are conflicting on whether an intra-uterine contraceptive device should be removed or not when pelvic inflammatory disease is suspected. Research on clinicians found that they appear to have a relatively low level of knowledge with regards to both pelvic inflammatory disease diagnosis, and general intra-uterine contraceptive device use. The importance of patient preference is another factor to consider, with particular focus on potential issues with clinician delivered patient education. Recommendations for future practice, policy and research also will be discussed.

Association between contraceptive implant knowledge and intent with implant uptake among postpartum Malawian women: a prospective cohort study.

BackgroundLong-acting reversible contraception (LARC) can assist women with birth spacing and reduce unintended pregnancies. Sub-Saharan Africa has low uptake of the two available methods of LARC, the subdermal implant and intrauterine contraception (IUC). Our primary objectives were to: 1) calculate the incidence of LARC use among postpartum Malawian women, and 2) assess if LARC knowledge and intent to use LARC were associated with LARC uptake.MethodsThis study was a prospective cohort study of 634 postpartum women who were recruited from the postpartum ward of Bwaila Hospital in Lilongwe, Malawi. Study participants completed a baseline survey in the postpartum ward. Follow-up telephone surveys about contraceptive use were conducted at 3, 6, and 12 months postpartum. Cox proportional hazards regression analysis was performed to evaluate if implant knowledge and intent to use implant were associated with implant uptake.ResultsOne hundred thirty-seven implant and 10 IUC placements were reported over 12 months of follow-up; given the low rate of IUC uptake, further analysis was only done for implant uptake. The incidence rate for implant uptake was 35.6 per 100 person-years (95 % CI 30.0, 42.2). Correct implant knowledge (adjusted HR = 1.69; 95 % CI 1.06, 2.68) and intent to use implant (adjusted HR 1.95; 95 % CI 1.28, 2.98) were both associated with implant uptake.ConclusionsMore women reported implant use than IUC use in our study. Correct implant knowledge and intent to use implant were both associated with implant uptake, with a stronger association for intent. Interventions to increase LARC uptake should focus on improving LARC knowledge and removing barriers to LARC.Trial registrationClinical Trial Registration #: NCT01893021

Non-hormonal and hormonal intrauterine contraception: survey of patients’ perceptions in four Latin American countries

ABSTRACTObjectives: This study sought to understand women’s perceived barriers to the use of hormonal and non-hormonal intrauterine contraception in Latin America. Methods: We developed an online survey for women in Argentina, Brazil, Colombia and Mexico who were seeking contraception. The questions aimed at evaluating patient awareness of negative stories and statements, as well as perceived barriers to the copper intrauterine device (IUD) and the levonorgestrel-releasing intrauterine system (LNG-IUS). Results: The survey was mailed to 2300 women. A total of 1953 responses were received from Argentina (n = 465), Brazil (n = 380), Colombia (n = 613) and Mexico (n = 495). More women reported having heard negative stories about the copper IUD than about the LNG-IUS. More women believed that the copper IUD, rather than the LNG-IUS, was suitable only for those who had already had children. More women believed that weight gain (14.3% vs. 38.2%; p < 0.001), mood swings (14.1% vs. 38.7%; p < 0.001) and infertility (16.3% vs. 19.9%; p = 0.016) were possible side effects of the LNG-IUS. By contrast, more women believed that abortion (36% vs. 22.7%; p < 0.001), pelvic infections (42.1% vs. 15.7%; p < 0.001) and ectopic pregnancy (43.5% vs 23.5%; p < 0.001) were side effects more associated with the copper IUD. More believed the copper IUD was associated with less pain during placement and removal compared with the LNG-IUS (42.8% vs. 31.2%; p < 0.001). The perception of increased risk of contracting a sexual transmitted disease did not differ between the methods (IUD vs. LNG-IUS, 21.7% vs. 20.3%; p = 0.388). Conclusions: Respondents to a web-based survey in four Latin American countries have misperceptions regarding the adverse effects and risks of intrauterine contraception, which may hamper the use of these safe and efficient contraceptive methods. Education about the true risks and benefits involved is fundamental to improving patient acceptance and compliance as well as reducing unplanned pregnancies and unsafe abortions.

Intrauterine contraceptive device use in Abakaliki, southeast Nigeria: A 5-year review

Objective: To evaluate intrauterine contraceptive device (IUCD) use in Abakaliki for acceptance rate, efficacy, and complications. Materials and Methods: A descriptive retrospective study was done in the family planning unit of the Federal Teaching Hospital, Abakaliki, between 1 January 2009 and 31 December 2013. The records of the clients from the family planning and their case files from the medical records units were studied. Data on sociodemographic characteristics, side effects, discontinuation, and reasons for discontinuation were extracted and fed into the computer using Epi Info program (2008) of Centers for Disease Control and Prevention (CDC) (Atlanta, GA) version 3.5.1 and were analyzed. Results: Out of 1,737 contraceptive acceptors, 230 clients accepted IUCD giving a rate of 13.2%. The mean age and parity were 33.6 ± 6.5 years and 4.6 ± 2.4, respectively. Only 3 (1.3%) out of the 230 acceptors were nulliparous, the rest were parous. Sixty eight clients discontinued the method giving a discontinuation rate of 29.6%. Young, married clients with low parity discontinued the method commonly desiring further conception hence used the method as spacer. The commonest reason for discontinuation was pregnancy desire (54.4%) followed by presence of side effect (19.1%). Eighteen clients (7.8%) had side effects or complications resulted from the use of this device. The commonest side effect was abdominal pain 8/18 (44.4%). Others were menorrhagia 4/18 (22.2%), missing IUCD 3/18 (16.7%), and pelvic inflammatory disease (PID) 3/18 (16.7%). The presence of side effect ( P = 0.0156) and occupation ( P = 0.0218) are the variables with significant correlation with the duration of usage of the method while young age ( P = 0.0009), low parity ( P = 0.0001), and marital status ( P = 0.0001) had statistically significant relationship with the discontinuation of the method. Conclusion: IUCD is very effective but with the acceptance rate of 13.2% among the methods offered and discontinuation rate of 29.6% in Abakaliki.

Factors Associated with Hormonal and Intrauterine Contraceptive Use among HIV-Infected Men and Women in Lilongwe, Malawi: A Cross-Sectional Study.

Background. Understanding the factors associated with the use of hormonal and intrauterine contraception among HIV-infected men and women may lead to interventions that can help reduce high unintended pregnancy rates. Materials and Methods. This study is a subanalysis of a cross-sectional survey of 289 women and 241 men who were sexually active and HIV-infected and were attending HIV care visits in Lilongwe, Malawi. We estimated adjusted prevalence ratios (PRs) to evaluate factors associated with hormonal and intrauterine contraceptive use for men and women in separate models. Results and Discussion. 39.8% of women and 33.2% of men (p = 0.117) reported that they were using hormonal or intrauterine contraception at last intercourse. Having greater than 3 children was the only factor associated with hormonal and intrauterine contraceptive use among men. Among women, younger age, not wanting a pregnancy in 2 years, being with their partner for more than 4 years, and being able to make family planning decisions by themselves were associated with hormonal and intrauterine contraceptive use. Conclusions. The men and women in our study population differed in the factors associated with hormonal and intrauterine contraceptive use. Understanding these differences may help decrease unmet FP needs among HIV-infected men and women.

Actinomycosis-like Propionibacterium propionicum infection associated with use of intrauterine contraceptive device: A case report

Introduction: Intrauterine contraceptive devices generally carry a low risk of complications. Infection, possibly due to damage caused upon insertion, can occur and actinomycetaceae are the most likely cause of pelvic actinomycosis. Case report: A 41-year-old female presented with a two-month history of raised temperature, weight loss and abdominal tenderness. Contrast tomography imaging indicated pyometria and pelvic actinomycosis-like abscess linked to intrauterine contraceptive device use. Full microbiological reporting, including anaerobic cultures and 16S PCR, identified the bacterium Propionibacterium propionicum. A six-month course of amoxicillin resolved the infection and the patient made a full recovery. Conclusion: Increased IUCD-related actinomycosis awareness and improved diagnostics may increase detection of P. propionicum, a pathogen rarely reported on to date.

Knowledge and Attitude of Emergency Contraception among Medical Undergraduate Students in Northern India

ABSTRACT Knowledge, awareness and accessibility of emergency contraception (EC) is still lacking. Medical students are the pillars of the future healthcare system. If their knowledge is lacking, we can think that what would be the awareness of the rest of the country. In India, knowledge and awareness of undergraduate students are not been adequately studied till now. Keeping this in mind, the present study aims to assess the knowledge, attitude and practice of EC among medical undergraduate students. Objective To assess the knowledge, attitude and practice of EC among medical undergraduate students. Materials and methods This is a cross-sectional study conducted among medical Interns of SN Medical College, Agra. One hundred and fifty students were randomly selected at a general meeting in the campus after a written and informed consent. A predesigned and structured questionnaire was used for collecting information and was completed by the students. Results The mean age of the respondents was 24 years. Out of which 40% were females and 60% were males. Only, 34.6% said that ECs should be taken after missed pills. Only 40% indicated use of EC after condom breakage and about more than two-third (72%) said it should be used after rape. Knowledge regarding correct time for taking emergency contraceptive pill (ECP) after unprotected sex was present in 118 (78%). A total of 68.7% did not know that ECs were more effective the sooner they were taken. A total of 70 (44.5%) incorrectly said that they were equally effective as traditional methods of contraception. A total of 30% had no knowledge of its mechanism of action about 5% students were not aware of the doses of EC required. Only two-third students were aware of the fact that high dose of E+P is a method of EC. And, only 70% correctly defined timeframe of use of copper intrauterine contraceptive devices (IUCDs). Seventy-four percent students said that apart from formal education, media and internet helped them know about EC. Twenty-six percent additionally said that communication with friends added to their knowledge of ECs. Only, 54 (36%) were aware of the fact that ECs are available free of cost at government hospital. Regarding attitude questions about one-third had the wrong concept that ECs use will leads to more promiscuity, ultimately leading to increased incidence of sexually transmitted diseases (STDs) and even human immunodeficiency virus/infection and acquired immune deficiency syndrome (HIV/AIDS). Seventy-two percent believed that some women will use it more frequently instead of regular contraception. About one half students believed that it may result in complication in future pregnancies or have a negative impact on fertility. About 30% did not want to use ECPs for fear of side effects. Only two-third of participants will recommend to friend/relative in case of need. One hundred and eight (72%) discourage its distribution by paramedical staff. Seventy-two percent said that they should be available without prescription. Thirty-two (22%) did not want to use ECP for fear of side effects. There is a need to improve both education and attitude to use EC with emphasis on available methods and correct timing of use. Therefore, emphasis should be given to contraception in medical teaching. Educating medical community will be at large benefit to the population as a whole. Emergency contraceptives should be easily accessible in hospitals and pharmacies with reduced costs. How to cite this article Garg R, Verma U, Agrawal P, Singh R, Rani R. Knowledge and Attitude of Emergency Contraception among Medical Undergraduate Students in Northern India. J South Asian Feder Obst Gynae 2016;8(1):25-28.

Аналіз клініко-епідеміологічних аспектів гіперпластичних процесів ендометрію жінок із застосуванням багато параметричної нейромережевої кластеризації

&lt;p&gt;Резюме . З метою підвищення ефективності діагностики гіперпластичних процесів ендометрія у жінок&lt;br /&gt;перименопаузального віку було проведено ретроспективний аналіз 52 карт стаціонарного хворого жінок, які&lt;br /&gt;перебували на лікуванні в гінекологічних відділеннях Тернополя і області. У відповідності з патогістологічним&lt;br /&gt;висновком 1 групу склали 28 жінок з простою гіперплазією ендометрія, 2 групу – 24 жінки з комплексною гіперплазією&lt;br /&gt;ендометрія. В групу порівняння увійшли 12 соматично здорових жінок. Середній вік хворих 1 групи – (47,0±1,0)&lt;br /&gt;років, 2 групи – (56,0±1,5) років. З метою поглибленого аналізу показників застосовано багатопараметричну&lt;br /&gt;нейромережеву кластеризацію. Встановлено, що до факторів ризику розвитку гіперпластичних процесів&lt;br /&gt;ендометрія у жінок перименопаузального періоду належать неблагополучні соціально-економічні фактори:&lt;br /&gt;проживання в сільській місцевості, тяжкі умови праці, шкідливі звички та обтяжений акушерсько-гінекологічний&lt;br /&gt;анамнез, 3 і більше вагітностей, велика кількість (4 і більше) акушерсько-гінекологічних втручань, використання&lt;br /&gt;внутрішньоматкової контрацепції. У жінок з різними видами гіперплазії ендометрія клімактеричний синдром&lt;br /&gt;перебігав середньотяжко чи тяжко з нейровегатативними, ендокринно-обмінними та психоемоційними проявами.&lt;br /&gt;Серед коморбідних станів найчастіше спостерігали дисгормональну патологію молочних залоз та порушення&lt;br /&gt;гепатобіліарного тракту.&lt;br /&gt;Ключові слова : гіперпластичні процеси ендометрія, клімактеричний синдром, перименопаузальний вік,&lt;br /&gt;дисфункційні маткові кровотечі, коморбідні стани, нейромережева кластеризація.&lt;/p&gt;

FACTORS INFLUENCING UTILIZATION OF INTRA-UTERINE CONTRACEPTIVE DEVICE AMONG WOMEN IN ADDIS ABABA ETHIOPIA

Intra-uterine contraceptive device is one of the safest, most effective and least expensive contraceptives available in the world. It is a reversible contraceptive claimed to be better or more effective for pregnancy prevention than female sterilization, injectables and implants because once inserted, it is convenient and maintenance free. Intra-uterine contraceptive device is used worldwide by 14% of married women. However, it is noted that the percentage of women using this devise in Africa is only 1% which is the lowest in the world. The purpose of this study was to explore factors influencing utilization of intra-uterine contraceptive device among family planning clients in Addis Ababa. The study was based on a quantitative, cross sectional descriptive design approach. Data was collected using structured questionnaires administered by trained interviewers to a total of 366 family planning clients. Data were analysed using Statistical Package for Social Sciences research version 19. The findings indicated that the level of education, occupation, parity and fertility plan have significant (p<0.05) association with utilization of Intra-uterine contraceptive device. There is a link between socio-demographic aspects and the utilization of Intra-uterine contraceptive device. There is low utilization of Intra-uterine contraceptive device by family planning clients at Addis Ababa as compared to other method of contraceptives. It is further noted that community members lack awareness and knowledge of the benefit and side effects of the device. Therefore, community members need education to promote adherence and effective use of Intra-uterine contraceptive device.

Barriers and myths that limit the use of intrauterine contraception in nulliparous women: a survey of Brazilian gynecologists

Barriers and myths that limit the use of intrauterine contraception in nulliparous women: a survey of Brazilian gynecologists

Barriers and Misperceptions Limiting Widespread Use of Intrauterine Contraception Among Canadian Women.

Unintended pregnancy is a major social and public health problem with adverse effects on neonatal and developmental outcomes, as well as maternal health and wellbeing. Traditionally, family planning policies have focused on increasing contraceptive uptake in non-users; however, rates of non-use are low in many developed nations. A high proportion of unintended pregnancies are attributable to contraceptive failure, particularly when using barrier and short-acting hormonal contraceptives. Intrauterine contraceptive devices (IUCDs) are highly effective and have been shown to reduce unintended pregnancy rates. Despite this, global utilization rates are low, and IUCD uptake in Canada has been particularly low. In this review we explore why IUCDs are not more widely used, and specifically focus on barriers and misperceptions that may influence IUCD uptake, particularly in Canada. We reviewed relevant articles published in English between 1990 and 2014, through searches of PubMed and Medline, including primary studies of any design containing information on the knowledge and attitudes of health care providers and women. Providing education to care providers, women, and policy makers may help overcome misperceptions about the use of IUCDs, and may facilitate greater use. Increased support from federal and provincial health programs may also encourage the use of IUCDs in Canadian women, and help to reduce unintended pregnancy rates.

Knowledge and attitudes of Latin American obstetricians and gynecologists regarding intrauterine contraceptives.

BackgroundIntrauterine contraceptives (IUCs), including the copper intrauterine device and the levonorgestrel-releasing intrauterine system (LNG-IUS), are among the reversible contraceptive methods with high effectiveness. However, use is low in many settings, including some Latin American countries, mainly due to the influences of myths, fears, and negative attitudes, not only of users and potential users, but also of different cadres of health care professionals. The purpose of this study was to assess the knowledge and attitudes of a group of Latin American obstetricians and gynecologists regarding IUCs.MethodsA survey was conducted during a scientific meeting organized in Chile in 2014 to present and discuss updated information about contraception. Obstetricians and gynecologists from 12 Latin American countries, who reported that they provide daily contraception services in both the public and private sectors, participated in the meeting. Participants who agreed to take part in the survey responded to a multiple-choice questionnaire on issues regarding knowledge, use, and attitudes about IUCs.ResultsOf the 210 obstetricians and gynecologists participating in the meeting, the respondents to each question varied from 168 (80.0%) to 205 (97.6%). Almost 50% recognized that the failure rate of combined oral contraceptives, patches, and vaginal rings is 8%–10%. Furthermore, 10% of the participants did not recognize the high contraceptive effectiveness of long-acting reversible contraceptive methods. Additionally, almost 80% of the respondents answered that they did not offer IUCs to nulligravidas and almost 10% did not offer IUCs to adolescents, albeit almost 90% of the respondents reported that nulligravidas are candidates for an LNG-IUS.ConclusionSome deficiencies and contradictions in terms of knowledge and attitudes were identified from the answers of the Latin American obstetricians and gynecologists who participated in the survey. The knowledge and attitudes of health care professionals about IUCs are important in order to provide adequate counseling and to expand the use of IUCs.

Immediate postpartum insertion of intrauterine device for contraception.

Women who want to start intrauterine contraception (IUC) during the postpartum period might benefit from IUC insertion immediately after delivery. Postplacental insertion greatly reduces the risk of subsequent pregnancy and eliminates the need for a return visit to start contraception. Without the option of immediate insertion, many women may never return for services or may adopt less effective contraception. Our aim was to examine the outcomes of IUC insertion immediately after placenta delivery (within 10 minutes), especially when compared with insertion at other postpartum times. We focused on successful IUC placement (insertion), subsequent expulsion, and method use. We searched for trials until 1 April 2015. Sources included PubMed (MEDLINE), the Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, Web of Science, EMBASE, LILACS, ClinicalTrials.gov, and ICTRP. For the original review, the authors contacted investigators to identify other trials. We sought randomized controlled trials (RCTs) with at least one treatment arm that involved immediate IUC placement (i.e., within 10 minutes of placenta delivery). Comparison arms could have included early postpartum insertion (from 10 minutes postplacental to hospital discharge) or standard insertion (during a postpartum visit). Trials could also have compared different IUC methods or insertion techniques. Delivery may have been vaginal or cesarean. Primary outcomes were placement (insertion), subsequent expulsion, and method use at study assessment. For dichotomous outcomes, we used the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). Earlier studies primarily reported results as life-table rates. We aggregated trials in a meta-analysis if they had similar interventions and outcome measures. A sensitivity analysis included studies with moderate or high quality evidence and sufficient outcome data. We included 15 trials. Seven studies reported from 2010 to 2014 were added to eight from the original 2001 review. Newer trials compared immediate postplacental insertion versus early (10 minutes to 48 hours) or standard insertion (during the postpartum visit). Of four with full reports, three were small trials. The other three studies had conference abstracts. The eight early trials examined immediate insertion of different devices or insertion techniques. Most studies were published in the 1980s, some with limited reporting.Our sensitivity analysis included trials with sufficient outcome data and moderate or high quality evidence. Four newer trials comparing insertion times met the inclusion criteria. Two studies used the levonorgestrel-releasing intrauterine system (LNG-IUS) after vaginal delivery. The other two trials placed IUC after cesarean section; one used the CuT 380A intrauterine device (IUD) and the other used the LNG-IUS.A pilot trial compared immediate insertion versus early or standard insertion. In groups comparing immediate versus early insertion (N = 30), all women had the LNG-IUS inserted. By six months, the groups had the same expulsion rate and did not differ significantly in IUC use.For immediate versus standard insertion, we conducted meta-analyses of four trials. Insertion rates did not differ significantly between study arms. However, the trial from Uganda showed insertion was more likely for the immediate group, although the estimate was imprecise. In the meta-analysis, expulsion by six months was more likely for the immediate group, but the confidence interval was wide (OR 4.89, 95% CI 1.47 to 16.32; participants = 210; studies = 4). IUC use at six months was more likely with immediate insertion than with standard insertion (OR 2.04, 95% CI 1.01 to 4.09; participants = 243; studies = 4). Study arms did not differ in use at 3 or 12 months in individual small trials. Recent trials compared different insertion times after vaginal or cesarean delivery. Evidence was limited because studies with full reports generally had small sample sizes. Overall, the quality of evidence was moderate; abstracts and older studies had limited reporting. Ongoing trials will add to the evidence, although some are small. Trials of adequate power are needed to estimate expulsion rates and side effects.The benefit of effective contraception immediately after delivery may outweigh the disadvantage of increased risk for expulsion. Frequent prenatal visits during the third trimester provide the opportunity to discuss effective contraceptive methods and desired timing for initiation. Clinical follow-up can help detect early expulsion, as can educating women about expulsion signs and symptoms.

Effect of vaginal administration of misoprostol before intrauterine contraceptive insertion following previous insertion failure: a double blind RCT.

Is pretreatment with misoprostol useful in insertion of intrauterine contraceptives (IUCs) after insertion failure at the first attempt? Pretreatment with intravaginal administration of 200 mcg of misoprostol after IUC insertion failure 10 and 4 h before the second attempt of IUC placement was significantly better than placebo at facilitating the insertion of an IUC. One of the reasons for low use of IUCs is the concept that insertion is difficult. Misoprostol was used in several randomized clinical trials (RCT) before IUC insertion to facilitate the insertion. In general, the results showed no significant differences when compared with placebo. However, most previous studies have been carried out among unselected women whereas the present study is among women with previous insertion failure. This was a double blind RCT conducted between February 2013 and October 2014. Participants were 104 women who requested an insertion of an IUC and the insertion failed at the first attempt. After insertion failure, the women received a sealed envelope with misoprostol or placebo. The randomization system (1: 1) in one block size was computer-generated. The study was conducted at a tertiary care centre. The women were instructed to insert vaginally one tablet of misoprostol 200 µg (Prostokos, Hebron, Cariacica, PE, Brazil) or placebo 10 and 4 h before the woman returned to the clinic for a new insertion attempt. The outcomes were successful IUC insertion and the use of a cervical dilator immediately prior to the insertion procedure. A total of 2639 women requested the insertion of an IUC during the study period. The IUC was inserted at the first attempt in 2535 women (96%) and 104 women in whom we were unable to insert the device were eligible to participate in the RCT. Four women declined and 100 women were randomized (55 for the misoprostol group and 45 for the placebo group). From the 100 participating women, the levonorgestrel-releasing intrauterine system (LNG-IUS) was chosen by 55 and 37 women and the TCu380A intrauterine device (Cu-IUD) was chosen by none and 8 women in the misoprostol and placebo group, respectively. Seven and three women allocated to misoprostol and placebo, respectively, never returned to the clinic after randomization. We placed the IUC in 42 (87.5%) out of the 48 women and in 26 (61.9%) out of the 42 women randomized to misoprostol and placebo, respectively (P = 0.0066). Regarding the Evaluable Population the relative risk (RR) of successful insertions was 1.41 (95% confidence interval (CI) for absolute difference (8.2, 43.0), P = 0.0066); in the Intent-to-Treat Population the RR (95% CI) was 1.32 (0.3, 36.9). Multiple regression analysis showed that the significant variables associated with the insertion failure were the number of Caesarean section ≥1 (P = 0.020) and the use of placebo (P = 0.026). Dilators were used in 21 (43.7%) out of the 48 and 21 (50%) out of the 42 women randomized to misoprostol and placebo, respectively (P = 0.804). The limitations were that the majority of the women chose the LNG-IUS, and consequently the data for the Cu-IUD were limited, and there was a small number of nulligravidas. The results show that IUC insertion difficulties and failures are not common. Pretreatment with intravaginal misoprostol facilitated IUC insertion after failure of insertion at the first attempt, and insertion failure was associated with number of Caesarean sections. This study received partial financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant # 2012/10085-0, and from the National Research Council (CNPq), grant #573747/2008-3. All the TCu380A IUDs were donated by Injeflex, São Paulo, Brazil, and all the LNG-IUS were donated by the International Contraceptive Access Foundation (ICA), Turku, Finland. Both donations were provided in the form of unrestricted grants. The authors declare that there are no conflicts of interest associated with this study. ClinicalTrial.gov NCT01754649.

Clinical versus laboratory screening for sexually transmitted infections prior to insertion of intrauterine contraception among women living with HIV/AIDS: a randomized controlled trial.

Does laboratory testing after syndromic screening for sexually transmitted infections (STIs) reduce the rate of intrauterine contraception (IUC) removal among women living with HIV/AIDS (WLHA)? Additional laboratory testing after syndromic screening for STIs did not affect the likelihood that a woman would remove an IUC immediately or within 1 year of IUC use or the frequency of post-insertion unscheduled clinic visits. In low-risk WLHA, the incidence rate of IUC removal is low with or without laboratory testing. Fear of infectious morbidity remains an obstacle to uptake of IUC by WLHA. The value of laboratory testing after syndromic screening for STI before the insertion of IUC remains uncertain. We enrolled WLHA from 2 September to 6 December 2013 and followed them up to 31 December 2014. After syndromic screening, 703 women free of STIs were randomized to either additional laboratory screening or no additional screening for STI before IUC insertion. The randomization sequence was generated by an independent statistician and randomization numbers placed in opaque sequentially numbered sealed envelopes. All women randomized had an IUC inserted and in all 672 participants completed the 1-year follow-up. The study staff who followed up the participants were blinded to the study allocation groups. Incidence rate ratios (IRRs) were used to compare the incidence rates of IUC removal, unscheduled clinic attendance and IUC continuation between the two groups. Women eligible to participate were 18-49 years old at study entry, in a relationship with a male partner, wanted to avoid pregnancy for at least 1 year and were undergoing HIV/AIDS care at Mulago Hospital, Uganda. Participants completed a baseline questionnaire and up to four follow-up questionnaires until discontinuation of IUC, loss to follow-up or end of study observation after 12 months. The rate of IUC removal was 8.8% (29/331) in the no additional screening group and 8.0% (27/341) in the additional laboratory screening group [IRR 1.1 (95% CI 0.63-1.93)]. Unscheduled clinic attendances were similar in the two groups at 1 year of IUC insertion: 13.6% (45/331) in the no additional screening group and 12.3% (42/241) in the additional laboratory screening group. During the 1-year follow-up, only five women, three from the no additional screening group and two from the additional laboratory screening group, developed pelvic inflammatory disease (PID), as defined by established diagnostic criteria. We were not able to carry out STI risk assessment directly from the men thus women with high-risk partners could have been included in the study and this may be responsible for the lack of a demonstrable effect of additional laboratory screening on incidence rates of IUC removals and unscheduled clinic attendance. The diagnosis of PID was based on clinical signs and symptoms; therefore, subclinical PID could have been missed. Among WLHA, the incidence rate of IUC removal is low and IUC continuation high. Syndromic screening for STIs could be sufficient in indentifying WLHA who are suitable for IUC use. However, our findings are only generalizable to women in HIV/AIDS care who have access to good follow-up. The study was supported by Medical Education for Equitable Services to all Ugandans, a Medical Education Partnership Initiative grant number 5R24TW008886 from the office of Global AIDS Coordinator and the US Department of Health and Human Services, Health Resources and Services Administration and National Institutes of Health. Additional funding was from the Swedish International Development Agency, Swedish Research Council (SIDA/VR). The authors have no competing interests to declare. This trial was registered at Pan African Clinical Trial, Registry. PACTR 201308000561212.

Intrauterine Contraception and the Facts for College Health

Often resulting from inconsistent contraceptive use, unintended pregnancy among young women between ages of 18 and 24 continues to be an issue in the United States. Intrauterine contraception is a safe, highly effective, long-acting, easily reversible, and non–user-dependent contraceptive method, yet it is currently greatly underutilized. As family nurse practitioners and health care providers, we need to integrate this service into primary care–focused college student health clinics. The purpose of this study is to provide evidence-based information to address the misconceptions regarding intrauterine contraceptive use.

Pseudoactinomycotic Radiate Granules (PAMRAGs)- An Unusual Differential Diagnosis for Ovarian Neoplasm; A Diagnostic Dilemma

Pseudoactinomycotic radiate granules (PAMRAGs) are rarely detected lesions in ovary. Endometrium is the usual site and a detailed search of literature yielded only two cases in the ovary. PAMRAGs must be differentiated from actinomycotic granules which are also strongly associated with the use of intrauterine contraceptive devices (IUCDs). In cases of suppurative oophoritis due to actinomycosis, a proper diagnosis and culture confirmation is mandatory to avoid further complications. This case is reported due to its rarity, unusual clinical presentation and to highlight the importance of special stains in cases of tuboovarian abscess, where PAMRAGs may cause diagnostic dilemma. Our patient was a 50 yr old female admitted with clinical diagnosis of malignant ovarian tumour. After preoperative work up, panhysterectomy, infracolic omentectomy and excision biopsy of the right inguinal lymph node were done. Peroperatively the right ovary was enlarged and adherent to the fallopian tube and pelvic wall. Gross examination revealed a right tuboovarian mass with yellowish areas of necrosis and fibrosis. Histology showed a suppurative granulomatous lesion with spherical granules having club like peripheral projections. A panel of special stains (GMS, GRAMs and AFB) done were negative. Thus, we ruled out actinomycosis and gave a diagnosis of PAMRAG.

Determinants of Method Switching among Social Franchise Clients Who Discontinued the Use of Intrauterine Contraceptive Device.

Introduction. Women who do not switch to alternate methods after contraceptive discontinuation, for reasons other than the desire to get pregnant or not needing it, are at obvious risk for unplanned pregnancies or unwanted births. This paper examines the factors that influence women to switch from Intrauterine Contraceptive Device (IUCD) to other methods instead of terminating contraceptive usage altogether. Methods. The data used for this study comes from a larger cross-sectional survey conducted in nine (9) randomly selected districts of Sindh and Punjab provinces of Pakistan, during January 2011. Using Stata 11.2, we analyzed data on 333 women, who reported the removal of IUCDs due to reasons other than the desire to get pregnant. Results. We found that 39.9% of the women do not switch to another method of contraception within one month after IUCD discontinuation. Use of contraception before IUCD insertion increases the odds for method switching by 2.26 times after removal. Similarly, postremoval follow-up by community health worker doubles (OR = 2.0) the chances of method switching. Compared with women who received free IUCD service (via voucher scheme), the method switching is 2.01 times higher among women who had paid for IUCD insertion. Conclusion. To increase the likelihood of method switching among IUCD discontinuers this study emphasizes the need for postremoval client counseling, follow-up by healthcare provider, improved choices to a wider range of contraceptives for poor clients, and user satisfaction.

Factor Associated to Bacterial Vaginosis in Non-pregnant Women of North Indian Population

Bacterial vaginosis is currently the most prevalent cause of vaginal infection and vaginal discharge among the sexually active women. Bacterial vaginosis is a complex microbiological disease. Therefore, we aimed to determine the association of risk factors for bacterial vaginosis patients. In the prospective study, we enrolled a total of 300 nonpregnant women. One hundred and twenty six women were positive for bacterial vaginosis, confirmed by Amsel's criteria and Nugent's scoring. One hundred and seventy four women were unrelated control. Frequency of intrauterine contraceptive device differed significantly between bacterial vaginosis and healthy individuals (29.4% versus 17.2%, p=0.017; OR=1.70). Individuals with a sexual transmitted disease in partners was conferred significantly higher risk for bacterial vaginosis (p=0.001, OR=8.28). However, use of contraception, vaginal douching, and use of condom did not modulate the risk of bacterial vaginosis. Individuals with the use of intrauterine contraceptive device and presence of sexual transmitted disease in partners conferred a higher risk for bacterial vaginosis.