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Oral contraception can cause metabolic and hemodynamic modifications which may prove very dangerous in terms of cardiovascular complications. Patients with histories of hypertension, obesity cardiopathies, or who smoke heavily should not be on hormonal contraception. On the other hand, pregnancy can be a much higher risk for this particular type of patient; indeed cardiovascular affections are one of the main indications of therapeutic abortion. Fortunately OC (oral contraception) has been greatly improved during the past years with the prescription of mini pills, containing less than 50 mcg of estrogens, and of micropills, containing low-dose progestin only. Such type of hormonal contraception can in most cases be prescribed also to patients at risk of cardiovascular accidents. Failing this, and judging every case on an individual basis, the IUD, intravaginal contraception, or even sterilization can be considered.
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PMID:[Update on birth control in general practice. pt 5. Contraception and cardiovascular diseases]. 1226 29

Included in this article is a table adapted from World Health Organization medical eligibility guidelines developed to assist practitioners in the prescription of low-dose oral contraceptives (OCs). These guidelines are part of a broader project aimed at improving access to all available methods of contraception without creating unacceptable risk. They were formulated in response to concerns that current practices are based on scientific studies of contraceptive products that are no longer in wide use, the bias of service providers, and a tendency to render relative contraindications absolute. If the presence of a condition creates no obstacle to method use, a Category I rating is assigned. If the benefits of a method generally outweigh the risks, the condition receives a Category 2 rating. Category 3 applies to conditions carrying risks that generally outweigh benefits, while Category 4 applies to conditions carrying unacceptable health risks. Health conditions categorized in association with low-dose OC use are post-abortion, diabetes, superficial venous thrombosis, known hyperlipidemias, headaches, vaginal bleeding patterns, unexplained vaginal bleeding, breast disease, pelvic inflammatory disease, sexually transmitted diseases, HIV/AIDS, viral hepatitis, uterine fibroids, past ectopic pregnancy, obesity, thyroid disorders, trophoblast disease, and sickle cell disease.
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PMID:Increasing access to combination oral contraceptives. 1229 65

Between January 1990 and June 1992 in France, obstetrician-gynecologists at Pr Magnin University Hospital in Poitiers inserted an IUD immediately after a legally induced abortion in 90 women aged 16-44. Five women were nulliparous. 16.7% had more than three children while 37.8% had had three pregnancies. 40% were living under unfavorable socioeconomic circumstances. 20 women were single, had no profession, and had children. 47.8% smoked at least 10 cigarettes a day, 10% of whom smoked 30-60 cigarettes a day. Tobacco contributed to hypertension in three cases, high cholesterol in one case, and obesity in two cases. 32.3% of the women had contraindications to combined oral contraceptives (OCs), especially hypertension and smoking. 21% were using OCs when they last conceived. 47.8% had had 2-3 pregnancies. 11% chose the IUD for personal convenience. Nine months to three years later, 89% of the women were still using the IUD. Complications or discomfort were reasons for removal among the remaining 11%. The complications included inflammation of the fallopian tube(s), IUD expulsion, retention of the trophoblast, and undiagnosed excessive bleeding. Other reasons were genital infection and desire for tubal ligation. 41% of the women did not return either after the IUD insertion. None of them had gynecological troubles, however. These findings show that postabortion IUD insertion is a practical and effective solution to recurrent abortion.
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PMID:[IUD (MLCu 375) insertion following induced abortion]. 1231 94

150 (80 females and 70 males) community college students were surveyed regarding their attitudes toward abortion, their sexual behavior, and their problems. The profile of the students was Caucasian (95%), young (18-24 years = 87%), single (87%), middle and lower middle class, and Catholic (70%). 82% supported abortion choice, 86% had engaged in premarital sex, 70% used contraception, and 26% had premarital pregnancies. The hard reasons for abortion (rape, the woman's life, is endangered, and the fetus is defective) received high support. The soft reasons (the family cannot afford more children or the woman does not want to marry the man) received lower support. The students were divided into 3 groups of 50 students based on the number of abortion reasons they supported out of 43 reasons. The low-group that accepted 0-10 reasons was called anti-abortion. 50% of them still believed a woman has a right to an abortion vs. 97% of the pro-abortion students. The students reported many problems in their families: alcoholic home (39%), loss of a parent through death, divorce, or separation (33%), victims of severe corporal punishment (31%), one or more family members physically abused (20%), and deprived of parental affection while growing up (20%). When the anti-abortion females (N=30) were compared with the pro-abortion females (N=50), they reported significantly (p.01) more hospitalization, a greater number of physical handicaps, and more shyness (p.1). When the anti-abortion males (N=20) were compared with the pro-abortion males (N=50), they reported significantly more obesity and agoraphobia (p.05) and more convictions for a crime (p.1). Comparison of women who had abortion (N=13) with the women who had their baby (N=8) indicated that the latter reported significantly (p.01) more battering by their boyfriend or husband, significantly (p.05) more battering in their family of origin and childhood sexual abuse, and a greater tendency (p.1) to have been raped.
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PMID:Abortion research: attitudes, sexual behavior, and problems in a community college population. 1234 19

For four decades the oral contraceptive pill has remained popular with young women because of its convenience and effectiveness. There have, however, been continuing concerns about adverse effects. In the 1960s the risk of venous thromboembolism was linked to the dose of estrogen, which was consequently reduced. Later the risks of arterial disease were linked to progestogen dose, which was also reduced. In 1995, three case-control studies linked the risk of venous thromboembolism, not to dose, but to the type of progestogen. Newer 'third-generation' progestogens appeared to carry a higher risk than older formulations. Although the contraceptive pill was already known to increase the risk of venous thromboembolism 3- to 6-fold, and the risks in the three studies were within this range, the public perception was that a new risk had been discovered. In the UK there were two consequences--a rapid change in prescribing patterns and a sharp increase in the abortion rate. Critics suggested that the studies may have been affected by confounding--e.g. by a 'new user' effect and differential prescribing. Views became very polarised. Between 1995 and 2001 second- and third-generation formulations were compared in 16 studies. Thirteen found that third-generation pills carried a higher risk of venous thromboembolism. Editorials and reviews recommended second-generation pills as the first choice for new users but official advice was that third-generation pills could still be prescribed, provided the risks were explained. Rates of thrombosis, per 100,000 women, are five for nonusers, 15 with second-generation pills and 25 for third-generation pills. The increase in mortality rates is around 1 to 2 per million. Drug-industry sponsored studies tended to find lower risks than independent studies and it was assumed that sponsorship produces bias, conscious or unconscious. It is also possible that some 'independent' researchers, motivated by antipathy to multinational pharmaceutical companies, are biased in the opposite way. Compared with the energy put into this debate, other aspects of pill prescribing remain under-researched. For example, doctors on opposite sides of the Atlantic are given different advice about whether gross obesity (a major risk factor for thromboembolism) is a contraindication to oral contraception. Women in developing countries continue to die of pregnancy-related causes and many deaths could be prevented by effective contraception. Rather than bickering, drug manufacturers and academics should be discussing ways of providing the pill to the women who need it most.
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PMID:Oral contraception and the risk of thromboembolism: what does it mean to clinicians and their patients? 1238 Dec 11

The debate on metformin use in polycystic ovary syndrome (PCOS) has mainly focused on its treatment for infertility in ovulation induction and menstrual cyclicity. Here we will summarize the data supporting the effect of metformin on improving hyperandrogenaemia and hyperinsulinaemia in PCOS patients. We propose that metformin benefits PCOS patients undergoing gonadotrophin therapy and IVF as well as ovulation induction. We also advocate the use of insulin sensitizing drugs to reduce miscarriage rates, and risks associated with coronary artery disease, gestational diabetes and obesity.
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PMID:Should patients with polycystic ovary syndrome be treated with metformin? Benefits of insulin sensitizing drugs in polycystic ovary syndrome--beyond ovulation induction. 1245 96

A systematic review was conducted to determine whether initial screening characteristics of women with normogonadotrophic anovulatory infertility predict clinically significant outcomes of ovulation induction with gonadotrophins, and to obtain pooled estimates of their predictive value through meta-analysis. Only those studies in which pre-treatment screening characteristics (such as body mass index, serum LH and androgens, insulin sensitivity and ultrasound appearance of ovaries) were related to outcome parameters (such as total amount of FSH administered, cancellation, ovulation, pregnancy and miscarriage), were included in this analysis. Thirteen studies fulfilled the inclusion criteria. A positive association was seen in all studies between the level of obesity (definition applied as assessed by individual studies) and total amount of FSH administered [weighted mean difference (WMD) of 771 IU (95% confidence interval (CI): 700-842)]. Pooled odds ratios (OR) of 1.86 (95% CI: 1.13-3.06) and 0.44 (95% CI: 0.31-0.61) were found between obesity with cancellation and ovulation respectively. Pooled analysis did not show a significant association between obesity and pregnancy rate. The pooled OR for obese versus non-obese women and miscarriage rate was significant [3.05 (95% CI: 1.45-6.44)]. Association measures between insulin resistance (definition applied as assessed by individual studies) and total amount of FSH administered produced a WMD of 351 (95% CI: 73-630) IU. A pooled OR of 0.29 (95% CI: 0.10-0.80) was found for insulin resistance with pregnancy rate. The pooled OR for insulin resistance (hyperinsuliaemia versus normoinsuliaemia) and miscarriage rate was not significant. A pooled OR of 1.04 (95% CI: 1.01-1.07) was found for LH (IU/l) with pregnancy rate. The pooled OR for LH and miscarriage rate was not significant. Finally, pooled analysis did not find a significant association between testosterone and pregnancy rate. In conclusion, the best available evidence, though limited, suggests that the most clinically useful predictors of gonadotrophin ovulation induction outcome in normogonadotrophic women are obesity and insulin resistance.
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PMID:Patient predictors for outcome of gonadotrophin ovulation induction in women with normogonadotrophic anovulatory infertility: a meta-analysis. 1464 Mar 76

Polycystic ovary syndrome (PCOS) is probably the most prevalent endocrinopathy in women and the most common cause of anovulatory infertility. Patients with PCOS have clinical and biochemical features consistent with the ultrasound diagnosis and they are likely to face the problems of hyperandrogenism, subfertility and recurrent miscarriage. The aim of the present review is to summarize our present knowledge on the hormonal background of this very prevalent syndrome and to give some clinical examples how the present knowledge can be applied to treat PCOS patients according to their current problem, such as menstrual cycle disorder, hirsutism, infertility or to prevent late consequences as diabetes mellitus. The etiology and pathogenesis of PCOS is still a matter of controversies, but it is apparent that inappropriate gonadotropin secretion, obesity, hyperinsulinism and insulin resistance are the major determining factors in the development of ovarian hyperandrogenism an chronic anovulation. Reversal of insulin resistance in PCOS constitutes the fundamental goal in the management of hyperandrogenic anovulatory infertility and in the prevention of long-term consequences. The value of the insulin sensitizer metformin therapy awaits further evaluation and it should be integrated in the spectrum of therapeutical options that include the discussed surgical methods and GnRH analogues as well.
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PMID:Endocrine characteristics of polycystic ovary syndrome (PCOS). 1525 72

Women with polycystic ovary syndrome (PCOS) frequently present with reproductive dysfunction. Ovarian function might be disturbed, with resultant abnormal folliculogenesis and steroidogenesis and, although it is difficult to define the exact pathogenesis of anovulation, many possible mechanisms have been postulated. Folliculogenesis in anovulatory women with PCOS is characterized by failure of dominance and the ovary has multiple small follicles, which are arrested but capable of steroidogenesis. Abnormalities in gonadotrophin and insulin secretion and disordered paracrine function have been identified. Women with PCOS have an increased prevalence of miscarriage, both after spontaneous and induced ovulation. Hypersecretion of LH, hyperandrogenaemia and hyperinsulinaemia have all been investigated as possible causes of PCOS. It is likely that these factors are interlinked and together might result in disordered ovarian and endometrial function. Multiple other possible abnormalities have been postulated as contributory factors in the reproductive failure. These include decreased plasminogen activator inhibitor activity, endothelial dysfunction and obesity. Ideally, therapy should target the underlying disorders but at present data are inadequate and further investigations are essential before therapeutic recommendations are truly based on an understanding of the pathophysiology.
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PMID:The pathogenesis of infertility and early pregnancy loss in polycystic ovary syndrome. 1538 Jan 45

Recent international agreement on the definitions of polycystic ovary syndrome (PCOS) has helped to clarify the clinical approach to diagnosis of PCOS. However, in the precise assessment of an individual patient it is still necessary for a detailed history of menstrual disorder (especially oligo- and amenorrhoea and anovulatory dysfunctional uterine bleeding), infertility or miscarriage, hyperandrogenism (mainly acne, hirsutism and scalp hair loss, distinguished from virilization) and obesity supplemented by the demonstration of polycystic ovaries on transvaginal ultrasound scanning. Assessment of endocrine changes in serum levels of luteinizing hormone, follicle stimulating hormone, oestradiol and prolactin, plus appropriate measures of circulating androgens (especially total and free testosterone, sex hormone binding globulin, 17 hydroxy-progesterone, dehydro-epiandrosterone sulphate and sometimes a 24-hour urinary free control) might help in further defining the abnormalities. Assessment of ovulatory status, obesity (body mass index and waist-hip ratio) and insulin resistance (oral glucose tolerance test with serum insulin levels) are also important in most cases. PCOS is a highly variable condition and investigation and management needs to be individualized. Long-term follow-up is also to a great extent dictated by the constellation of symptoms and clinical features of individual patients, but potential long-term hazards should be defined and patients warned of these.
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PMID:Current recommendations for the diagnostic evaluation and follow-up of patients presenting with symptomatic polycystic ovary syndrome. 1538 Jan 49


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