Nonhormonal contraceptives, include the condom that is safe and frequently used lately because of its ability to help in the prevention of sexually transmitted diseases. There is often psychological resistance to the use of diaphragm in the over 40 age group. The rhythm method is not reliable especially in irregular menstrual cycles, and its lack of reliability can cause anxiety. In the US 16% of women over 40 use spermicides. The IUD is recommended to women over 40 because of 1-time insertion, no requirement of care, efficacy, and the risk of pelvic inflammatory disease is modest at this age. IUDs with progesterone are particularly effective and seem to reduce the risk of inflammatory disease by making the cervical mucus more viscous. Surgical sterilization is not recommended at this age. Women over 40 who are not obese, do not smoke, and do not have a family history of cardiovascular disease have no contraindications to using modern oral contraceptives, (OCs). On the other hand, family history of diabetes and hyperlipidemia has to be assessed on an individual basis. Low dose contraceptives can have outright beneficial effects in vascular pathology by improving the hemostatic profile. Recently, animal research has suggested the possibility of a protective effect of OCs on the cardiovascular system. OCs also protect against osteoporosis. Although the debate is still unresolved, at the moment there is no proof whatsoever that OCs increase the risk of breast cancer in women over 40. The evaluation of patients for OC use has to include a diabetic history of mother or father, familial cardiovascular disease, overweight by more than 20%, smoking more than 10 cigarettes a day, and hypertension. If findings are negative, there is no appreciable risk for the patients. Mammography every 2 years for those with familial precedents, laboratory tests (lipid profile, coagulation, and hepatic function) and semiannual checkups are also be recommended.
It is estimated that at the current rate of growth the world's population will reach 8.5 billion by the year 2025 and 10-11 billion by the end of the 21st century. 90% of this population increase would occur in developing countries, where only 38% of couples used contraceptives during 1980-81 compared to 68% in developed countries. About 300 million couples in the Third World do not use contraceptives, although they do not want more children. Some of these contraceptives include natural steroids, such as progesterone and 17 beta-estradiol that is used for treatment of menopause (1-2 mg daily po). Medroxyprogesterone acetate and norethisterone enanthate depot injections have long-acting properties with low failure rates (3.6% + 0.7 pregnancies/100 women years) if given every 3 months, amenorrhea may occur. RU-486, substance with antiprogesterone activity, inhibits hormonal metabolism during ovulation in a dose of 100 mg/day, just like norgestimate. HRP 102 consists of 50 mg norethisterone enanthate and 5 mg estradiol valerate and cycloprovera contains 25 mg medroxyprogesterone acetate with 5 mg of estradiol cypionate. Both of these agents are effective contraceptives for 2 months. Norplant is implanted subcutaneously in capsule forms. It releases levonorgestrel/LNG for 6-7 years, and in a study of 992 women 2.6 pregnancies occurred for 100 women in the course of 5 years. Vaginal suppositories can release 20 mg/day LNG, or 5-10 mg progesterone/day, and they are considered ideal for nursing mothers. The IUD has been used by 60 million women, however, pelvic inflammatory disease may be associated with its use. Sulprostone and RU-486 (mifepristone) are post ovulatory agents with effectiveness of up to 90 day. Female sterilization has problems of reversibility, male sterilization is less accepted, and other male endocrine approaches producing azoospermia are in the testing phase. The ideal contraceptive with properties of wide acceptability, reversibility, and effectiveness is yet to come.
RU-486 is a steroid with antiprogestational action synthesized by the French firm Roussel-Ulcaf in 1980. When given in the middle of the menstrual cycle before the peak of luteinizing hormone (LH), it can inhibit ovulation by interfering with the function of the hypothalamus- hypophysis-corpus luteum-endometrium axis. A single dose of RU-486 in the late luteal phase induced uterine bleeding in all cases according to research done by Yen. A single 600 mg im dose of this agent was most effective for inducing abortion. There were positive results up tot he 41st day of amenorrhea in 85-90% of cases, but after the 7th weeks, this percentage declined, dropping to 60% by the 10th week. Advanced pregnancy increased the risk of incomplete expulsion of the conceptus, thus it is advisable to administer RU-486 in combination with a low-dose prostaglandin. Ru-486 is effective in advanced phases of pregnancy; it induces rapid expulsion with minor blood loss or side effects. Uterine bleeding starts 2-3 days after administration, lasting 11.6 + or - 5.8 days, and blood loss exceeds the normal rate in only 3.6% of cases. In 18% of patients, a significant decrease of hemoglobin occurred, but curettage or transfusion was never needed. Increased doses given for a long time produced nausea and asthenia. Possible teratogenic effects in cases of failure await to be investigated. RU-486 could be used for contraception, based on its ability to inhibit ovulation; for post- coital contraception; for regulation of menstruation; and for dilatation of the cervix.
1000 women selected randomly in the Italian provinces of Roma and Latina were given a questionnaire seeking information on age, occupation, oral contraceptive (OC) use, self-examination of the breasts, frequency of visits to clinics and Pap test, parity, and family history of tumors. 98% of the women were familiar with the services offered by family planning (FP) units. 786 questionnaires were analyzed. 80% of the subjects were 35 years old: the 21-25 age group was most prevalent. 40% were employed, the rest were housewives or retired (according to official statistics in 1984 only 25.9% of women were employed). Visits to the gynecologist increased with advancing age but proved to be inadequate for prevention even in the age segment most at risk of acquiring malignant neoplasms (p .05). Women who stayed at home were most likely to have regular gynecological checkups and Pap tests. 24% of women answered in the affirmative about self-examination of the breasts, and the 26-30 age group was most interested in it. 31% of housewives also practiced it, compared to only 10% of those who worked (p .01). OC use was most prevalent in the 26-30 age group (over 30%), while those 35 and under 20 neglected its use. FP units play an important role in oncological prevention by observing cultural and social aspects of women's lives and by adapting preventive programs accordingly.
Infections of the upper genital tract are commonly referred to as pelvic inflammatory disease (PID) and are often accompanied by fever, leucocytosis, and adnexal tumefaction. Risk factors are sexual activity at an early age, types of microbes, number of partners, and frequent sexual intercourse. Some studies found more incidence of mycotic vaginitis in women using oral contraceptives (OC) with a high estrogen content. It was also suggested that OC use reduced gonococcal pelvic infections by 50% by means of reducing menstrual flow and by modifying cervical mucus, making it impenetrable to bacteria. Nevertheless, OCs protect only in severe cases of PID. OC users appear to have a higher rate of chlamydial infections of the lower genital tract. IUD users have a 1.6 to 9.3 times higher risk of getting pelvic infections depending on age, number of partners, and frequency of intercourse. The risk is highest in the first 30 days after receiving the IUD, and long use (2 years) augments the risk of severe PID. There is increased risk of gonococcal infection in IUD users. Significantly increased numbers of anaerobic bacteria are present in cervical cultures of IUD users. Longterm IUD use is linked to a higher prevalence of actinomycetes. Among barrier methods, the use of the condom reduces the risk of infection with gonorrhea or chlamydia eightfold. The diaphragm provides effective protection against gonococcal and chlamydial infections, although its incorrect size and prolonged contact with spermicide can produce microlesions. Sterilization is associated with the reduction of genital infections; however, these are low-risk women aged 30 who are married. The spread of sexually transmitted diseases is an important factor to consider when choosing a contraceptive.
