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The use of natural contraceptive methods, which require avoidance of sexual relations during the fertile period, declined with development of effective modern methods. At present, their practice is most appropriate for women with vascular, metabolic, or other pathology contraindicating use of modern methods and for couples in which the male partner is fully involved in contraception. Contraceptive methods should be simple, effective, reversible, and safe. The 2 principle methods in France are hormonal contraceptives, used by 50% of couples, and IUDs, used by 30%. Hormonal contraceptives, primarily oral contraceptives (OCs), have a Pearl index of .16% and satisfactory reversibility, but their metabolic and vascular effects make them inappropriate for some women. The Pearl index for IUDs is 1-2%. IUD users have a higher risk for tubal infertility, and some other possible complications are very serious. Neither OCs nor IUDs are indicated for young girls, perimenopausal women, or postpartum women. The main shortcoming of the natural methods is their failure rate, which is probably related to insufficient instruction in their techniques or to forgetting that they require cooperation of both spouses. The Ogino-Knaus or calendar rhythm method involves calculating the fertile period taking into account the life expectancy of the gametes. Calculation is based on the study of the duration of the menstrual cycle in the preceding year. The Pearl index has been estimated at 1-47%, depending on the regularity of the cycle. The temperature method is based on modifications of body temperature due to hormonal variations. The fertile period is considered to begin with the 1st day of menstruation and to last for 3 days following the thermal shift. The Pearl index is 12.2%. Disadvantages of the method are problems of interpretation related to physical exertion or stress and the need for a long period of abstinence. The method of palpation of the cervix is based on detecting the cervical modifications caused by hormonal variations. Estrogens cause softening, opening, and ascension of the cervix, while progesterone causes descent and hardening. Palpation of the cervix allows identification of the fertile period. No Pearl index has been published. The main problems are difficulty in nulliparas and the risk of infection. The Billings method is based on modifications of the cervical mucus during the cycle. The Pearl index is 3%. The principal disadvantages are the difficulty of interpretation and the time required for learning the method. The symptothermal method combines analysis of the periovulatory signs with the taking of the body temperature. The Pearl .8%. The main shortcoming is the possibility of contradictory signs.
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PMID:[Natural methods of contraception]. 151 9

A combination of biological factors such as earlier age at puberty and fecundity, and social factors such as the disappearance of the extended family and of rites of passage and the development of a youth culture have encouraged adolescent sexuality at the same time that length of schooling is increasing and adolescents have not yet become socially autonomous. Adolescents employ contraception relatively infrequently and tend to choose less reliable methods. Reasons for this include ignorance of the biology of reproduction and of contraception methods; the fear of secondary effects, encouraged by the mass media; lack of access to family planning facilities or fear that parents will be informed; and the cost of contraceptives. An adolescent requesting contraception should be treated as a adult, taking into account the degree of maturity; the attitude of the medial practitioner will influence motivation and success in using the method. The medical history will indicate cases in which a hormonal contraceptive is contraindicated. The gynecological examination reveals the gynecological age of the patient, which is more important than chronological age. The frequency of sexual realtions should also be considered in the choice. Because motivation of adolescents is less reliable than that of adults, such methods as rhythm and withdrawal are not appropriate. Condoms or diaphragms are disliked because of the necessity of repeated manipulation before each act of intercourse, but may be acceptable to highly motivated individuals. Condoms are indicated when relations are unexpected and infrequent. IUDs are indicated only when hormonal contraceptives cannot be used and when forgetting of pills is likely to occur. Nevertheless, IUD use in adolescents can entail serious problems of expulsion or of infection that may lead to later infertility. Little is known of the effects of oral contraceptive use on sexual maturation and growth of very young adolescents, but because of the growth inhibiting effects of estrogens, they should not be prescribed earlier than 2 years postmenarche. Low dose pills should be chosen. Sequential pills are preferable for patients with irregular cycles. High doses of steroids administered within 48 hours should be available in cases of unprotected intercourse. Alternatively, an IUD may be inserted within 5 days.
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PMID:[Attitude to be taken with the adolescent requesting contraception]. 687 69

This work describes oral contraceptives (OCs) in current use and examines their risks. OC pills are composed of synthetic estrogens, usually either ethinyl estradiol or mestranol, and progestins. Either estrogens or progestins can be used alone, but combinations permit smaller doses to be used. Combined pills are available in monophasic, biphasic, or triphasic formulations. Different modalities of administration are also available for progestin-only pills. The "morning after" pill containing high doses of steroids to be taken within 72 hours of unprotected intercourse can contain either estrogen or progestin alone or combined. The mechanisms of action of OCs vary according to the type of pill. Classic combined OCs inhibit ovulation, render the cervical mucus inhospitable to sperm, and cause endometrial atrophy which hinders nidation. Low-dose pills have various effects but in general depend on changes in the cervical mucus for their contraceptive effect. Pregnancy may result from forgetting pills or using them incorrectly, or in the case of low-dose pills may occur even if they are used correctly. Some drugs can lower the concentrations of the OC hormones at the level of the receptors by hindering their intestinal absorption or by increasing the metabolic power of the liver. Considerable individual variability limits the incidence of pill failure due to drug interactions, but OC use should be avoided if rifampicine or certain other drugs are used. Among undesirable effects of OCs on endocrine glands and reproductive function are the adaptation syndrome characterized by symptoms similar to those of early pregnancy and reversible in most but not all women; galactorrhea resulting from diminished levels of "prolactin inhibiting factor"; and virilizing effects such as alopecia, hirsutism, and acne usually occurring during use of high-dose formulations. Pills should be carefully adapted to the hormonal profile of the user to avoid these side effects. OCs very rarely entail longterm infertility. OCs in current use do not appear to be teratogenic but it is advisable to wait 2 months after termination of use before becoming pregnant. Lactation is a contraindication to OC use. Combined OCs frequently cause problems in glucose tolerance of variable significance. Low-dose progestins do not seem to affect lipid metabolism, but low and normal dose combined pills may provoke increases in the levels of cholesterol and triglycerides. OCs are implicated in vascular accidents of various kinds, but low-dose pills are better tolerated. Cardiovascular risks are increased by age, smoking, use of alcohol, and excess fat in the diet. Hepatobiliary complications may occur during pill use. The carcinogenic role of OCx remains controversial, although growth of preexisting breast cancers is accelerated with pill use. The multifactorial etiologies of cardiovascular ailments, atherosclerosis, and cancerous tumors make the role of OCs difficult to assess. OCs can interact with various drugs, heightening the undesirable effects of each. Research on hormonal methods of contraception is currently directed toward achieving a better tolerance and administration of both male and female methods.
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PMID:[Oral contraception: failures and risks]. 1228 May 90

Each year as a consequence of pregnancy and delivery at least 500,000 women die, 99% of them in developing countries. Most maternal deaths are avoidable. For each death, 10-15 other women suffer serious health effects which may lead to chronic pain or even social isolation. Childbirth is riskier for women who are too young or too old, who have many children, or whose births are too closely spaced. Limiting family size reduces both maternal and child deaths. In developed countries, 5-30 women die per 100,000 births, compared to 50-800 in developing countries. Maternal mortality rates at 2 hospitals in Yaounde, Cameroon, have declined significantly in recent years, probably due to establishment of high risk pregnancy clinics, improved monitoring during labor, and child spacing clinics. Improved obstetric services and child spacing could reduce maternal mortality in developing countries as they have in the developed world. The use of contraception has been a controversial topic in traditional African societies, but by now the majority of governments of developing countries include family planning programs in their development plans for their health as well as their economic benefits. Despite gradual increases, fewer than 5% of women in most African countries use modern contraception. African men play an insignificant role in family planning. The continuing practices of prolonged lactation and postpartum abstinence in rural areas have compensated to some extent for the absence of modern contraception. Oral contraceptives are the most widely used reversible method. They may protect against vaginal infection, iron deficiency anemia, ectopic pregnancy, benign breast disease, ovarian and endometrial cancer, dysmenorrhea, endometriosis, and rheumatoid arthritis. There is evidence that some steroid hormones have a beneficial effect in stabilizing the cellular membranes of red blood cells in women with sickle cell anemia. The danger of infection with the IUD is largely limited to the 1st 4 months of use and to women with sexually transmitted diseases. Careful selection of candidates, aseptic insertion, and regular follow-up are needed to ensure IUD safety. The IUD is contraindicated for nulliparas. Barrier methods provide contraception as well as some protection against sexually transmitted diseases. Condoms have a significant protective effect against HIV infection. Diaphragms, cervical caps, and vaginal sponges provide some protection against infections like gonorrhea and chlamydiae that invade the cervical cells. Many adolescents resist condoms because they diminish sensation. But condoms provide protection against sexually transmitted diseases and are appropriate for individuals with sporadic sex lives. Oral contraceptives are more effective but adolescents are at risk of forgetting pills. IUDs are the least attractive option for adolescents because of the danger of infection and subsequent infertility.
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PMID:[High risk pregnancies and family planning]. 1234 59