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Context After decades of debate, the oral contraceptive pill was legalized in Japan in June 1999. Because the pill had been unavailable up until then, little is known about the public's knowledge about, attitudes toward and intentions to use the pill. Methods In a nationwide probability sample, 630 women and men were interviewed in their homes in March 1999. Respondents were asked a range of questions to gauge their knowledge about and attitudes toward the pill. Results Most respondents (79%) could identify both the name and purpose of the birth control pill. Roughly the same proportion of respondents held an overall positive impression (44%) as held a negative impression (42%) of the pill, and 14% were undecided about the method. The pill's high level of effectiveness in pregnancy prevention was the most common reason for having a favorable impression of it (47%). Women were more concerned about side effects than were men, and they also knew more about the pill's potential side effects than did men. Only 12% of respondents said they intended to use the pill if it were approved. Roughly one-quarter (23-26%) did not correctly identify the pill's inability to protect against HIV and other sexually transmitted diseases (STDs). Conclusions Legalization of oral contraceptives in Japan has led to an urgent need to educate both men and women on the inability of the pill to protect against STDs, including HIV Policymakers and providers need to recognize the importance of encouraging dual method use in Japan.

First Stop an 18-month demonstration project that operated in 1996-97 was designed to offer low-income adult women in California hormonal contraceptives without requiring a pelvic examination. An evaluation was undertaken to assess the contraceptives adopted by First Stop clients compare health risks of these women with risks among women using traditional family planning clinics and assess clients satisfaction. Data on 2065 First Stop clients and 1507 women attending traditional clinics were collected through several self-and-clinician-administered instruments including questionnaires a telephone survey and medical chart abstractions. After the initial First Stop visit 38% of women adopted a more effective method than they had used at last sex 47% remained with the same method 12% switched to a less-effective method and 3% accepted no method. Of clients who were referred for additional medical care 73% followed through on their referrals. Compared with clients at traditional clinics First Stop clients were less likely to have a regular source of health care but more likely to have made a health care visit in the past year. Most First Stop clients valued the projects services; 76% said it was important to be able to receive pills or injections without a pelvic examination. Programs that provide hormonal contraceptives without requiring a pelvic examination can expand low-income womens access to these methods and improve the chances that they will obtain other reproductive health services. (authors)

In every country, contraceptive behavior has important implications for fertility and the prevalence of sexually transmitted diseases (STDs). There has been relatively little attention to contraceptive practices in Canada, however, particularly how patterns of method use may have changed.Data on contraceptive use were collected from 5,315 women in the 1984 Canadian Fertility Survey, and from 3,220 women and 3,449 men in the 1995 General Social Survey.Among Canadian women aged 15-49, current contraceptive use declined from 69% to 60% between 1984 and 1995. Pill use dropped from 19% to 17%, and IUD use declined from 6% to 3%. However, during the same period, condom use increased from 6% to 10%; tubal ligation declined from 24% to 17%, while vasectomy increased. In addition, the proportion of women sterilized for reasons other than contraception rose between 1984 and 1995. Men were less likely to rely on sterilization than were women (31 % vs. 40%). Men reported higher levels of condom use (22%), but lower levels of pill use among their partners (9%), than did women (10% and 17%, respectively).Contraceptive behavior in Canada is unique: The decline in contraceptive use over the last decade has left Canada's overall contraceptive prevalence among the lowest in the industrialized world, and the rate of sterilization among the highest These changes in contraceptive behavior complicate efforts to plan for social and health needs, particularly policy decisions focusing on reducing infections with STDs.

Half of all pregnancies in the United States are unintended. Of these, half occur to women who were practicing contraception in the month they conceived, and others occur when couples stop use because they find their method difficult or inconvenient to use.Data from the 1995 National Survey of Family Growth were used to compute life-table probabilities of contraceptive failure for reversible methods of contraception, discontinuation of use for a method-related reason and resumption of contraceptive use.Within one year of starting to use a reversible method of contraception, 9% of women experience a contraceptive failure--7% of those using the pill, 9% of those relying on the male condom and 19% of those practicing withdrawal. During a lifetime of use of reversible methods, the typical woman will experience 1.8 contraceptive failures. Overall, 31% of women discontinue use of a reversible contraceptive for a method-related reason within six months of starting use, and 44% do so within 12 months; however, 68% resume use of a method within one month and 76% do so within three months. Multivariate analyses show that the risk of contraceptive failure is elevated among low-income women and Hispanic women. Low-income women are also less likely than other women to resume contraceptive use after discontinuation.The risks of pregnancy during typical use of reversible methods of contraception are considerably higher than risks of failure during clinical trials, reflecting imperfect use of these methods rather than lack of inherent efficacy. High rates of method-related discontinuation probably reflect dissatisfaction with available methods.This study computed life table probabilities of contraceptive failure, discontinuation of use, and return to contraceptive use in the US. Data were obtained from the 1995 National Survey of Family Growth (NSFG) among a nationally representative sample of 6867 contraceptive use intervals contributed by women 15-45 years old who began use or resumed use after discontinuation during 1991-95. Analysis was based on Kaplan-Meier product-limit single decrement life table probability methods. Findings indicate that the risk of failure during typical use of reversible methods was 9% within 1 year of starting. Women with continuous lifetime use will experience 1.8 contraceptive failures. Failure rates were 7% for the pill, 9% for the male condom, 8% for the diaphragm, 20% for periodic abstinence, and 15% for spermicides. Failure rates reflect imperfect use. 31% of women discontinued use within 6 months of starting use. 44% discontinued within 12 months. Women using reversible methods continuously will discontinue use nearly 10 times during the reproductive period. Most women resumed use shortly after discontinuation. Low income women had higher risk of unintended pregnancy for all methods and the pill and lower risk of resumption after discontinuation. Hispanics had a higher risk of contraceptive failure for all methods and the condom. Black women had a higher risk of discontinuation of oral pills and condoms.

Contraceptive use has been legal in France for the past 30 years, and patterns of use changed substantially from the 1960s to the 1980s. Given the rapidity with which use patterns change and the possible impact of rising concern about infection with HIV and other sexually transmitted diseases, it is important to determine trends of contraceptive practice into the 1990s.A total of 5,900 French households were selected in 1994 for inclusion in the Fertility and Family Survey. Respondents were questioned about their contraceptive use patterns and family formation status. The results were compared with those of comparable surveys conducted in 1978 and 1988.Two-thirds of French women used some form of reversible contraceptive method in 1994. Oral contraceptive use has grown steadily in France: About 40% of women aged 20-44 reported using the pill alone or combined with another method in 1994, compared with 34% in 1988 and 28% in 1978. Condom use has also been on the rise: Nearly 8% of women were using condoms alone or combined with another method in 1994, up from 5% in 1988 and 6% in 1978. IUD use has declined from 19% in 1988 to 16% in 1994, and both male and female sterilizations remain rare.Contraceptive behavior in France appears unique among developed countries, with fairly high levels of oral contraceptive use--even among older women--relatively high levels of IUD use and little reliance on either male or female sterilization. As with other countries, however, condom use has climbed in recent years, and is especially common at first intercourse.This study describes current contraceptive practices in France over the past 30 years, by method, among single men and women, for dual method use, for pregnancy or sexually transmitted disease (STD) prevention, and at 1st intercourse. Data were obtained from the 1994 Fertility and Family Survey and previous fertility surveys. In 1994, 69% of women aged 20-49 years used contraceptives. Most women relied on the pill (about 36%), followed by the IUD (16%). 7% of women were sterilized. About 5% used condoms, and 6% used abstinence or withdrawal. 31% reported not using contraceptives, of whom 3% were sterile. 4% were infertile. 4% were pregnant. 4% desired pregnancy, and 11% had no ongoing sexual relationship. 5% were determined to be at risk for unintended pregnancy. About 83% of women reported ever use of the pill, and 58% had ever used condoms. Typical patterns of use during the 1980s include 10 years of pill use followed by IUD use. Contraceptive behavior only differed among single men and women not in a union. Some men and women reported multiple method use, especially pills and condoms. During 1988-94, pill use increased, IUD use decreased, and condom use increased. Condom use was higher among singles, among the well educated, and in large cities. During 1978-94, natural method use and sterilization declined. Women tended to identify condom use with pregnancy prevention. Men tended to include STD/AIDS prevention. Contraceptive use at 1st intercourse increased over time. Even though contraceptive use increased, the number of induced abortions remained constant, suggesting lower use-effectiveness.

A three-month prospective study of 103 women initiating oral contraceptive use examined how consistently the women took their pills and whether those who missed pills employed other means to avoid pregnancy. The results showed that 52% took each active pill or never missed more than one pill at a time after the first week of the initial cycle, according to electronic devices that recorded the date and time each pill was removed from the blister pack. Another 21% were protected by behaviors that reduce the risk of pregnancy when two or more consecutive pills have been missed: avoiding coitus for the next seven days (18%) or using backup contraception during that period (3%). The remaining 27% were at increased risk of pregnancy. Predictors of increased risk were receiving low partner support for effective pill use, being unmarried and not considering it especially important to avoid pregnancy. Increased risk was most likely during the first seven days and during the third cycle of pill use.User compliance with oral contraceptives (OCs) and protective behaviors after missed pills were investigated in a 3-month prospective study of 103 new OC users recruited from university student health services and Title X-funded clinics in Michigan and North Carolina (US) in 1993-94. Pill usage was verified through a microchip in the OC dispenser that recorded the date and time each pill was pushed out of the blister pack. The electronic records indicated that 51 women never missed a pill in the 3-month study period, while 52 women had a total of 93 missed pill episodes. Overall, 73% were protected against an increased risk of pregnancy throughout the study: 52% by OC use alone, 18% because they never had intercourse during the 7 days after a missed pill episode, and 3% because they used backup contraception in those 7 days. Protection from pills alone decreased from 85% in cycle 1 to 61% in cycle 3. Multivariate analysis indicated that women who had ever been at risk of pregnancy during the study period had coitus an average of 22 days compared with 11 days among those never at risk. In addition, women at risk were more likely to have had unprotected sex during the first 7 days of the study and during cycle 3. Finally, the analysis indicated the risk of unprotected days was significantly elevated in 3 groups of women: those with a lower level of perceived partner support for effective OC use, unmarried women, and those who considered it not especially important to avoid pregnancy now. Clinicians need to provide individualized care aimed at maximizing women's ability to identify and solve likely problems associated with their contraceptive method choice. Emergency contraception should be considered as a last resort for occasional lapses in pill taking.

A 1994-1995 survey of men and women aged 18-44 in the United States, Canada and the Netherlands revealed considerable differences in public knowledge and perceptions about unplanned pregnancy and contraception. The proportion who believe that unplanned pregnancy is a "very big problem" is 60% in the United States, 36% in Canada and 6% in the Netherlands. Americans are more likely than their Canadian or Dutch counterparts to cite societal problems as significant factors in the rate of unplanned pregnancy; higher proportions of Americans also cite the cost of contraceptives (52% vs. 46% of Canadians and 34% of Dutch men and women) and an inability to obtain methods (66%, 51% and 33%, respectively). In all three countries, adults are generally well informed about the relative effectiveness of commonly used contraceptives, but Americans are more skeptical about method safety and effectiveness. For example, 17% think the pill is "very safe," compared with 21% of Canadians and 40% of the Dutch; and whereas 64% of Americans consider the pill "very effective," 73% of Canadians and 90% of Dutch men and women give it this rating. Health care professionals are the most frequently cited source of contraceptive information, but only 51-63% of adults have ever discussed contraception with such a practitioner.

A s affirmed at the 1994 International Conference on Population and Development in Cairo, women have the right to control the number and timing of their pregnancies. To realize this right, women throughout the world need access to a broad range of contraceptives, as well as to safe abortion services. While most contraceptives are intended for use before or during intercourse, some methods can be used within a short time after unprotected intercourse. Rumored folk methods such as postcoital douching with Coca-Cola are of dubious efficacy, but fortunately are not a woman's only alternative. Within the last 30 years, a number of other approaches that are believed to be safe and efficacious have been developed. These options, predominantly variations on oral contraceptive regimens, are often called "morning-after pills." A better name, however, is "emergency contraception," which would dispel the idea that the user must wait until the morning after unprotected intercourse to start treatment-or that she will be too late if she cannot obtain treatment until the afternoon or night after. The name "emergency contraception" also stresses that the regimens are not intended for ongoing use. The roots of modern emergency contraception date back to the 1920s, when researchers initially demonstrated that estrogenic ovarian extracts interfere with pregnancy in mammals.' Veterinarians were the first to apply this finding, administering estrogens to dogs and to horses that had mated when their owner had not wanted them to. Despite scattered reports of clinical use of postcoital estrogens in humans as early as the 1940s,2 the first documented case was not published until the mid-1960s, when physicians in the Netherlands applied the veterinary practice of postcoital estrogen administration to a 13-year-old girl who had been raped at midcycle.3 At around the same time, U.S. researchers were investigating the efficacy of high-dose estrogens, and toward the end of the decade, these preparations became the standard. Women typically received either conjugated estrogens, the steroidal estrogen ethinyl estradiol or the nonsteroidal estrogen diethylstilbestrol (DES). Today, in places where high-dose estrogens are still used, they are administered in the so-called 5x5 regimen: 5 mg of ethinyl estradiol per day for five days.4 In the early 1970s, the high-dose estrogen regimens gave way to a combined estrogen-progestin standard. Canadian physician Albert Yuzpe and his colleagues began studies in 1972 on this combined regimen, guided by their observation that a single dose of 100 mcg of estrogen coupled with 1.0 mg of the progestin dl-norgestrel induces endometrial changes that are incompatible with implantation.5 The "Yuzpe method," as it came to be known, replaced high-dose estrogen formulations, chiefly because it offered a lower incidence of side effects, but also because the commonly used DES was linked to vaginal cancer in the daughters of women who had taken it to prevent miscarriages. Research on regimens that omitted estrogen also began in the early 1970s, predominantly in Latin America. A 1973 report described the results of a large-scale trial investigating five doses of levonorgestrel, ranging from 150 mcg to 400 mcg per tablet. The regimen was tested as an ongoing postcoital method, rather than an emergency formulation. Participants in the trial were instructed to take a tablet as soon as possible, but within three hours, after intercourse and could use the method as often as necessary; some continued to use this method for two years.6 The results showed that the lower doses were not efficacious and caused some menstrual disruption, chiefly a shortening of the cycle. This experiment marked the first major venture into ongoing postcoital contraception and laid the groundwork for the levonorgestrel methods that have become available in many developing countries and in Eastern Europe. The late 1970s were to offer the chief nonhormonal method available today, the copper-releasing IUD. This device causes endometrial changes that inhibit implantation; in addition, the copper ions released appear to be directly embryotoxic.7 More recently, two other methods have been investigated: danazol and mifepristone. Danazol, a synthetic progestin and antigonadotropin, was first used as an emergency contraceptive in the early 1980s.8 Mifepristone, more commonly known as RU-486, is a potent antiprogesterone registered in four countries as an abortifacient. Relatively little research is available on these newer methods, although mifepristone in particular appears extremely promising as an emergency contraceptive. Unlike oral contraceptives, these methods have not been approved for daily contraception or are relatively expensive; as a result, they might not be easily adaptable in developing countries. This article presents an overview of the available emergency contraceptive methods and suggests guidelines for future research on efficacy, safety and user issues.

There was considerable anticipation in the mid-1960s with the marketing and uptake of the oral contraceptive pill and the IUD that many other new forms of contraception would be available to the general public before the turn of the century. Much of that enthusiasm about contraceptive advances has since waned. Only three new contraceptive methods received US Food and Drug Administration approval during the 1990s, none as soon as advocates had expected, while the only other important changes were the gradual adjustment of pill formulations to expose users to a smaller total dosage of hormones and the introduction of new hormones already widely used in Europe. The lack of decisive advances is not the result of a paucity of candidate methods. In 1993, for example, an estimated 100 experimental contraceptive methods were being studied around the world. Many of those methods had, however, been in the works for years, while others were only slight modifications of products already on the market. Regulatory and legal issues, public opinion and politics, and financial issues have been identified as key obstacles to why the contraceptive reality has failed to match 1960s expectations. The author explains who sponsors contraceptive research and describes the ongoing development of spermicides and barrier methods, injectables, vaginal rings, implants, IUDs, methods for men, vaccines, and menses induction.

Research has been conducted for more than 20 years in both developed and developing countries in the attempt to develop a safe, effective, and reversible hormonal method of contraception for men. A variety of hormonal compounds and contraceptive delivery systems, including injections, pills, implants, and patches, are therefore currently being investigated. Limited funding and a lack of commercial interest in regulating male fertility have, however, slowed progress. It seems that pharmaceutical companies doubt the existence of a market for hormonal contraceptives for men and fear the potential for litigation. Clinical trials, supported by the World Health Organization, of a hormonal method have nonetheless yielded encouraging results. One multicenter study injected men weekly with testosterone enanthate to induce azoospermia. A second study investigated whether the state of complete azoospermia induced by the injections was necessary for contraceptive efficacy. Testosterone enanthate demonstrated its potential application as a hormonal method of contraception for men, but the frequent injections required over the course of 3-4 months to achieve oligozoospermia are impractical. In addition, above normal levels of testosterone result immediately after injection. Testosterone enanthate in future trials will be combined with another hormone to shorten the time needed to achieve a contraceptive effect, or a new formulation which requires less frequent injections and does not produce a physiological peak. A newly formulated product could be ready for introductory trials by 2000. The author presents information from focus group discussions and questionnaires completed by men who volunteered for the trials. Their feedback adds to the limited body of evidence indicating the potential acceptance of a hormonal method of contraception for men.

Even though oral contraceptives (OCs) with the new 3 progestins are the most widely prescribed OCs in the world, especially in Europe, they still are not available to US women. Gestodene's, desogestrel's, and norgestimate's effective daily dose are only 75 mcg, 150 mcg, and 250 mcg, respectively, while the daily dose of norethindrone in OCs used in the US ranges from 350-1000 mcg. The older progestins alter lipid metabolism, thus increasing cardiovascular disease risks. Some studies indicate that the new progestins induce fewer lipid metabolic changes than the older progestins. A 1988 study in West Germany suggests, however, that women who use gestodene may be at increased risk of thromboembolism. Yet, similar research in the UK and also in West Germany did not find this association. There has been concern for many years about OCs' ability to change glucose metabolism and insulin resistance. 5 studies show that OCs with desogestrel cause fewer such disturbances than those with levonorgestrel. 1 study also finds that OCs with gestodene do not alter glucose and insulin levels. On the other hand, 1 study suggests, that OCs with gestodene increase glucose and insulin levels over 6 months. European studies of the new progestins demonstrate their low 1-year method failure rates (gestodene, 0.07/100 users; desogestrel, 0.04/100 users; and norgestimate, [pregnancy rate] 0.25/100 users). Further, the 3 progestins result in a smaller proportion of women who have side effects (breakthrough bleeding or spotting, 3-9%, breast discomfort or headaches, 10-13%). Yet, researchers have not directly compared the effectiveness and acceptability of the 3 new progestins. A legal dispute between 2 pharmaceutical companies prevented the marketing of norgestimate in 1990. 1 company claims patent infringement. The US Food and Drug Administration is now evaluating gestodene and desogestrel. It probably will not approve gestodene until the question of apparent excess of thromboembolism is resolved.

A reproductive health intervention combining a highly explicit half-hour slide-tape program with a personal health consultation was provided to male patients aged 15-18 at a large health maintenance organization. A test of the consultation's impact against a control group provides no support for the argument that highly explicit instruction in contraception encourages early initiation of intercourse. In fact, the consultation may have reduced pressure to become sexually active among young men who had never had sexual intercourse. There is also some evidence that the consultation helped improve the effectiveness of contraceptive practice among the men who were sexually active at follow-up; those exposed to the consultation were more likely than those who were not to report that their last intercourse was protected by the pill and that their main method of contraception in the previous year was the pill. Compared with those in the control group, patients who received the health consultation scored higher on measures of fertility knowledge and knowledge of the prevention of sexually transmitted diseases, including AIDS. Furthermore, the young men who had the consultation were more likely to have practiced testicular self-examination. In many cases, however, the positive effects of the consultation were stronger or were only statistically significant among those who had not been sexually active at the time of the baseline survey.This case-control study examined the effects of a reproductive health intervention directed to 15-18 year old adolescent male members of a US health maintenance organization. The intervention combined an explicit slide-tape program with a personal health consultation designed to improve contraceptive practice and knowledge of fertility, prevent sexually transmitted diseases, increase the practice of testicular self-examination, and ameliorate coercive sexual attitudes. Comparison with controls revealed that the intervention did not encourage early initiation of intercourse but may, in fact, have reduced pressure to become sexually active. There was some evidence at follow-up that the intervention improved the effectiveness of contraceptive practice among the men who were sexually active. Cases scored higher than controls on measures of knowledge in the subjects covered by the intervention. The intervention had the greatest impact on young men who were not sexually active at the time of the baseline survey. This implies that additional efforts should be directed to young men who are already sexually active and use contraceptives in an inconsistent manner (or not at all). The breadth of the topics covered in the intervention and the use of audiovisual materials are possible reasons for its success.

A study in the US and Canada involving 1400 women indicated the contraceptive effectiveness of patch as comparable to that of combined oral contraceptive. The women were randomly assigned to either patch or oral contraceptive for 6 or 13 cycles and contraceptive efficacy was measured by calculating overall and method-related Pearl Indices and cumulative probabilities of pregnancy. Results noted no significant difference in womens experience with breakthrough bleeding with the 2 methods. Moreover the probabilities of pregnancy were similar among women who used the patch and those who used the pill (1-2% over 13 cycles). The types of adverse reactions were also noted to be similar between groups. Although Pearl Indices were numerically lower among users of patch than among women who used the pill differences were statistically insignificant. Furthermore contraceptive compliance was associated with contraceptive efficacy in which womens compliance with using the patch was significantly higher than that with using the pill.

In Britain use of oral contraceptives containing a "third generation" progestogen is associated with a higher risk of venous thromboembolism than use of pills containing levonorgestrel. Hence the investigators conducted a cohort analysis to compare the risk of venous thromboembolism in the periods leading up to the pill scare between January 1993 and December 1999. They also conducted a case control analysis to compare the risks associated with the different types of pills. In these analyses women taking third-generation pills had twice the odds of venous thromboembolism of those using pills containing levonorgestrel. It is noted that the difference between the results in the cohort and case control analyses is attributable to the additional adjustments for confounding factors in the latter. The results were similar in the years preceding the pill scare and immediately thereafter.

A multigenerational family study conducted between 1991 and 1996 revealed that women whose sisters or mothers have had breast cancer are at increased risk of developing the disease. The study also suggests that their risk is further elevated if they use oral contraceptives. Overall among sisters and daughters of women with breast cancer those who had ever used the pill had 3.3 times the breast cancer risk of those who had never used this method; the relative risk increased if breast or ovarian cancer occurred more than once among blood relatives. Moreover the elevated risk associated with pill use appeared only among women who had taken oral contraceptives during or before 1975; after that year all oral contraceptives introduced to the market contained less than 50 mcg of estrogen.

This article discusses two separate population-based case-control studies on the protective function of low- and high-dose oral contraceptives (OCs) against ovarian cancer. Overall the ovarian cancer study found that women who have ever used the common types of OCs which contain low doses of estrogen and progestin are 50% less likely than never-users of the pill to develop ovarian cancer. In addition it was found that this level of protection is identical to that afforded by older OCs with higher hormone doses. These findings suggest that the ability of the OCs to prevent ovarian cancer has been unaffected by changes made in the pill formulations to make the method safer. Similarly evidence from the benign ovarian tumor study suggests that ever-use of OCs reduces the odds of non-cancerous ovarian tumors by 20% and the decrease in risk is independent of estrogen dose. In both studies the magnitude of protection increased with longer durations of pill use.

A multicenter study was conducted in Africa Asia and Latin America to examine the changes in bone density associated with the use of hormonal methods. Data were collected by interviewing 2474 women aged 30-34 between 1994 and 1997 at family planning clinics in Bangladesh Brazil China Egypt Mexico Thailand and Zimbabwe. A total of 33% of these women were classified as pill users 14% as depot-medoxyprogesterone acetate (DMPA) users and 25% as implant users while 28% were considered never-users. To determine bone density the radius was measured near the wrist and the ulna was measured at mid-shaft. It is noted that bone density at both sites was associated with hormonal method use. Overall the study showed that hormonal contraceptives have only small reversible effects on bone density. Compared with women who do not use hormonal methods women who use combined oral contraceptives experience a significant increase in bone density while those who use the injectable DMPA or the levonorgestrel implant Norplant experience a significant decrease. However these changes disappear after the first 2-3 years of current use and appear to be clinically insignificant.

Yasmin a new low-dose combination oral contraceptive is effective safe and acceptable to women according to a study of 326 women recruited from six centers in the US. The new contraceptive pill contains 3 mg of drospinerone and 30 mcg of ethinyl estradiol. The rate of effectiveness was 0.5 pregnancies per 100 woman-years of use similar to that associated with other low-dose pills. More than half (54%) of the women reported no intermenstrual bleeding and 30% reported intermenstrual bleeding during only one or two pill cycles. In addition women were significantly less likely to report mood changes water retention and increase in appetite in all three menstrual phases after cycle 6 than they were upon enrollment in the study. 71% of the women reported at least one adverse effect during the study but none reported experiencing serious side effects related to contraceptive use. The outcome of this study led the researchers to conclude that Yasmin is effective safe and well tolerated by women and that it can reduce the severity of some menstrually related symptoms.

An analytic sample of 1593 females who first had intercourse during adolescence (prior to age 18) was drawn from the 1995 National Survey of Family Growth. Logistic regression and multinomial logistic regression techniques were used to model the effects of sexual partners characteristics and relationship type on contraceptive use at first intercourse and contraceptive method selected at first intercourse. Approximately 31% of respondents used no contraceptive method at first intercourse. Roughly half (52%) of adolescents who had just met their sexual partner used no method compared with 24% of those who were going steady. Whereas 75% of teenagers who practiced contraception at first intercourse used a condom 17% relied on the pill. In multivariate models net of other variables adolescents who had just met their partner had 66% lower odds than those who were going steady of practicing contraception at first intercourse. Individual-level factors that influenced contraceptive use at first intercourse were age at first intercourse race or ethnicity family type parents education grades in school and receipt of birth control education prior to first intercourse. Differences between respondents and their partner in age and race or ethnicity mostly were not significantly related to method use at first intercourse. One exception was that adolescents who first had sex with a man 6 or more years older had reduced odds of practicing contraception. Type of relationship was significantly associated with method selection only among adolescents who were just friends with their first partner who had higher odds of using “other” methods rather than the condom. Variables associated with pill use rather than condom use were age at first sex race family type and mother’s education and school grades. Further efforts to understand contraceptive choice among adolescents should focus on relationship features. Research on the decision-making process surrounding contraceptive use may benefit from treating this as a partner decision and not just as a decision made by one member of the couple. Further research examining the qualities of the relationship may provide important clues for understanding adolescent contraceptive choice. (authors)

This article discusses the control issues related to the use of the birth control pill. For over 5 decades since its first introduction in the US its doses types and mixes of hormones through the menstrual cycle have all undergone great evolution in an attempt to minimize adverse side effects while maintaining high contraceptive efficacy. Despite such efforts how it is prescribed and used within the medical model remains rigid. These control issues (i.e. the need for women to undergo routine health screening) have hindered its successful use. In fact a survey conducted by the American College of Obstetricians and Gynecologists found that 58% of American women could not name one single noncontraceptive benefit of the pill. This result tends to perpetuate the negative image of the pill as well as reduce the possibility of its successful use.

This article examines the politics of contraceptive pill use among Black women. Although the pill gave Black women greater control over reproduction than ever before it remains a controversial issue among them. One reason for this is the role of White-dominated birth control programs which play a role in furthering racial injustice. Aside from that the events that took place during the 1960s and 1970s in which thousands of poor Black women were coercively sterilized under federally funded programs made Black women see the pill as just another tool in White people’s efforts to curtail the Black population. More recently efforts to encourage poor Black women to use long-lasting contraceptives have resurrected the debate about race and birth control which lasted for nearly a century. The author suggests that social justice requires both equal access to safe user-controlled contraceptives and an end to the use of birth control as a means of population control.

This article examined the possibility of contraceptive pill extinction in the 21st century. For years the term "pill" has been synonymous with contraception and has made other contraceptive alternatives irrelevant. Despite its efficacy its supremacy is now being challenged by the existence of sexually transmitted infections (STIs) and the risk of serious health problems associated with its prolonged use. In the 21st century contraceptive users look for methods that are free of side effects are 100% effective protect against STIs and are completely user-friendly. Unfortunately the pill does not guarantee to offer these advantages. Thus for the pill to retain its supremacy researchers should use innovative compounds and new slow-releasing technologies to eliminate side effects and protect contraceptive users from STIs.

This article discusses the role of the birth control pill in establishing mother-daughter relationships. Today’s mothers know that their daughters can obtain oral contraceptives without parental involvement much as they themselves did back in the 1960s and 1970s. This knowledge serves as a basis for them to guide their daughters in a proper way based on their own experiences as adolescents. As part of good parenting mothers have decided that they want to do a better job of communicating with their children about healthy sexuality--more than what they got from their own parents. Most mothers of adolescents today recognize that knowledge is power and because of this they want to provide adequate information to their daughters especially when it comes to contraceptive options. Most often the pill becomes the focus of mother-daughter discussions relating to adolescent growth and development achievement of independence individualization and responsible choices. In general the interactions that exist between todays mothers and their adolescents seem healthier than those of generations ago.

This article discusses the impact of the introduction of the birth control pill on mens involvement in contraception. It was 40 years ago when the oral contraceptive pill was approved for marketing in the US which also marked the culmination of a long search for a way to give women reliable control over their own fertility. Since its introduction during the 1960s changes were observed as to the correlation between sexuality and contraception which further altered the balance of male-female involvement in contraceptive use. Its availability along with other effective female methods that are independent of intercourse was able to accomplish great achievement; yet this presents drawbacks as well as benefits. Moreover after the introduction of pill 40 years ago increasing attention is being focused on acknowledging and expanding mens involvement in reproductive and contraceptive decisions and behaviors not only with their actual use but also along with their partners especially when a female method is used.

This article presents the results of two clinical studies that examined the effectiveness safety and acceptability of a once-a-month injectable and an oral contraceptive in the US. These studies included 1103 women who sought contraceptive services at 42 clinical sites in the US between April and August 1998. These women were offered choices of receiving either a monthly injectable (25 mg of medroxyprogesterone acetate plus 5 mg of estradiol cypionate) or a commonly prescribed triphasic oral contraceptive. Assessment of the 1-year contraceptive efficacy revealed no occurrence of pregnancy in the injectable group and 1 occurred in the oral contraceptive group. For the first 6 months pill users reported more frequent bleeding or spotting. Adverse effects reported by 89% of injectable users and 84% of pill users included infection headache breast tenderness weight gain irregular or prolonged bleeding and acne. The most serious medical problem encountered using the injectable contraceptive was gallbladder disease. Using questionnaires both contraceptive methods were assessed based on their acceptability. It was found that women in the injectable group were less likely to be reported as bothersome. Researchers confirm that a monthly injectable may well be accepted by women who desire convenience of an effective but noncoital nondaily use method that maintains regular cycles and causes minimal lifestyle alterations.

This paper presents a summary report on the use of oral contraceptives (OCs) in the reduction of hip fracture. According to a case-control study in Sweden women using OCs in their late reproductive years have been found to have a decreased chance of having a hip fracture after menopause. However the effects of OC use on the risk of hip fracture depended greatly on the age of a woman at the time of use. Hormone-replacement therapy parity and body mass are some of the factors considered by the researchers. Of the other factors examined only the body mass of women was associated with the risk of hip fracture. The preventive effect of OCs was not found in obese women. However women with a lower body mass index who had used the pill at age 40 or later benefited from OC use.

This study examines the experiences and satisfaction of using emergency contraceptive pills in preventing unintended pregnancy among women in the US. The data used were collected through telephone interviews with 235 women aged 18-48 years receiving emergency contraceptive pills through a demonstration project at 13 Kaiser Permanente medical offices in San Diego. The results of the study revealed that 70% of the women were using contraceptive method prior to their use of emergency contraceptive pills. Moreover the situation that led them to use emergency contraceptive pills was due to contraceptive failure particularly condom failure. Despite an 81% statistics of women experiencing side effects 91% were satisfied with emergency contraceptive pills and would recommend them to friends and family members. Only 28% agreed that emergency contraceptive pills should be made available over the counter and 6% from vending machines. Therefore this method is an important addition to the contraceptive options among women during unprotected sexual intercourse or method failure.

Context Despite the fact that choosing a contraceptive method is often a decision made by couples, little is known about how men and women differ in their perceptions of the characteristics of various method types, and in the importance that they attach to those characteristics when choosing a contraceptive method. Methods The data analyzed here are subsets from two companion surveys conducted in 1991--1,189 men aged 20-27 who were surveyed in the National Survey of Men and 740 women aged 20-27 who were surveyed in the National Survey of Women. Multivariate ordered logit analysis is used to examine how gender is related to both the importance that individuals assign to seven specific contraceptive characteristics when choosing a method, and to perceptions about the extent to which five common method types possess each of these characteristics. Results Women rank pregnancy prevention as the single most important contraceptive characteristic when choosing a method, with 90% citing it as "very important." The health risks associated with particular methods and protection from sexually transmitted diseases (STDs) are rated as the second most important characteristics by women (each mentioned as "very important" by 77%). In contrast, men consider STD prevention for themselves and their partner to be just as important as pregnancy protection (each mentioned as "very important" by 84-86%), and they rank STD prevention as more important than other health risks (by 72%). Women, but not men, rank both ease of use and the need to plan ahead as being more important characteristics than a method's interference with sexual pleasure. Both men and women have an accurate understanding of the strengths and weaknesses of particular methods, but differ enough in their perceptions to alter the relative attractiveness of each method. In particular, women have more favorable perceptions than men about the pill, being somewhat more likely than men to believe that the pill is "very good" at preventing pregnancy (75% vs. 67%) and to say that it is very good at not interfering with sexual pleasure (82% vs. 76%). In contrast, women have generally less favorable perceptions than men about other reversible methods, including the condom: Women were less likely than men to consider the condom very good at pregnancy prevention (29% vs. 46%) or at having no need for advance planning (22% vs. 38%). Gender differences in perceptions about the specific characteristics of contraceptive methods often vary by marital status. Conclusions Men and women have somewhat different priorities when choosing a contraceptive method. Despite many similarities between women and men in their perceptions about the characteristics of each method type, numerous differences between them may have an important influence on how couples make their method choices.

Data from a 1997 national survey of 3550 Australian secondary school students aged 15 and 17 years old were used to examine teenagers method choices and patterns of advice-seeking about contraception and STD prevention. 94.8% of the 961 currently sexually active students were using at least 1 contraceptive method. The most often used method was the condom (78.0%) followed by the pill (44.7%) and withdrawal (13.5%). 31% and 10% were using condoms and the pill exclusively respectively. Older students and those who had sought contraceptive advice were more likely to use the pill rather than condoms exclusively while those who had had only casual partners in the past year were less likely to use the pill exclusively instead of condoms. The more students believed that their peers used condoms the less likely they were to report exclusive pill use. Parents were the most frequent source of advice about contraception followed by physicians and teachers. The most common sources of advice about HIV and other STDs were parents teachers and then physicians.

A comparative study conducted at 21 centers in 14 countries found that women who use a levonorgestrel-only emergency contraception regimen are about one-third as likely as women who use the standard Yuzpe regimen to become pregnant after treatment. They are also less likely to experience nausea and vomiting. A total of 1998 women who had had unprotected intercourse within the past 72 hours were enrolled in the study and randomly assigned to receive either levonorgestrel (2 0.75-mg doses) or the Yuzpe method (2 50-mcg tablets of ethinyl estradiol and 2 0.25-mg tablets of levonorgestrel). At the follow-up visit 1 week after expected resumption of menses 42 women (31 from the Yuzpe group and 11 from the levonorgestrel-only group) were pregnant. The pregnancy rate was 3.2% for women using the Yuzpe regimen compared with 1.1% in the levonorgestrel-only group (crude risk ratio 0.36). The risk of pregnancy increased significantly as the number of hours between unprotected intercourse and use of either method of emergency contraception increased. When the treatment was initiated within 24 hours of unprotected sex the failure rate was 0.4% in the levonorgestrel group and 2.0% in the Yuzpe group; when treatment was commenced 49-72 hours after intercourse these rates were 2.7% and 4.7% respectively. 51% of women assigned to the Yuzpe regimen compared with 23% of those in the levonorgestrel group experienced nausea; the incidence of vomiting was 19% and 6% respectively. On the basis of these findings it is recommended that levonorgestrel replace the Yuzpe regimen as the standard emergency contraception method.

ical first-year pregnancy rate of 0.3%.3 Yet in prevalence it is a distant third among reversible contraceptives, with only 3% of contraceptive users reporting its use nationally in 1994 (although this proportion is now much higher in some settings, especially in inner-city clinics).4 Despite DMPA's effectiveness and duration of protection, clinical records indicate that more than two-thirds of all new acceptors stop using the method within the first year: Four recent studies found firstyear DMPA discontinuation rates ranging from 65% to 77%.5 (In comparison, discontinuation rates for the condom and the pill have recently been estimated at 44% and 29%, respectively.6) Why would U.S. women so often discontinue using such an effective, long-term contraceptive? When the criteria used to estimate discontinuation are examined, it becomes clear that DMPA must meet a higher standard than other methods. DMPA's apparently high discontinuation rates are artificially inflated compared with the rates of other methods, most notably condoms and oral contraceptives.7 This inflation is the result of different criteria for continuation among methods. A DMPA user is counted by default as having discontinued use if she returns for a subsequent injection more than 14 weeks after the preceding injection-even if she receives her next injection only a few days late. She must then "restart" the method, even though her last DMPA injection may still be protecting her from pregnancy. Moreover, if all contraceptive users were categorized according to what they report to be their current method, and according to their adherence to that method's regimen (and, thereby, their level of protection), criteria for discontinuation and discontinuation rates could be standardized across methods. This would make rates for DMPA comparable to those for condoms and pills. Such an approach would make it easier for users, providers and researchers to compare the acceptability and effectiveness of all contraceptive methods, to distinguish between poor adherence and discontinuation, and to evaluate the most useful interventions for each of them.

The World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormonal Contraception found no evidence of increased cardiovascular risk in women who used oral or injectable progestogen-only contraceptive methods. The analyses were based on 3697 women with cardiovascular disease from 21 centers in 17 countries in Africa Asia Europe and Latin America. Women with a history of hypertension were at increased risk of stroke regardless of their use of a hormonal contraceptive but this pattern did not apply to venous thromboembolism or heart attack. Use of progestogen-only methods was associated with small but nonsignificant increases in cardiovascular risk among smokers. Many of the risk estimates in this study had wide confidence intervals because of the small numbers of users of progestogen-only methods enrolled at the various study centers. The interaction between progestogen-only contraceptives and hypertension merits further assessment especially because women with a history of high blood pressure use progestogen-only pills more frequently than combined oral contraceptives.

This article summarizes findings from a study of contraceptive use among urban women living in industrial cities in Russia. Data were obtained from a survey conducted among a representative sample of about 2000 women aged 15-44 years who lived in Perm Yekaterinburg or Ivanovo provinces (northeast of Moscow). 62-74% had had 1-2 sexual partners in their lifetime; 17-23% had had 3-4. About 90% of women had had only 1 partner in the preceding year. The total fertility rate in the preceding 2 years was 1.2-1.5 lifetime births/woman. About 90% of women with 2 living children and 44-51% of women with 1 living child desired a stop to childbearing. Fewer than 7% had given birth as a teenager. 69-86% of women aged over 25 years had given birth. At least 97% of sexually experienced women were familiar with condoms IUDs and pills. Most knew a source of supply. 69-78% of sexually active women used contraception; 51-60% used a modern method; fewer than 20% used abstinence or withdrawal. During the preceding 5 years 17-20% had had a mistimed pregnancy. During the prior 2 years 80-90% of mistimed conceptions and 95% of unwanted pregnancies were terminated. The abortion rate was 77/1000 reproductive-age women in Ivanovo 80/1000 in Yekaterinburg 99/1000 in Perm and 78/1000 in all of Russia. The number of lifetime abortions/woman averaged 2.3-3.0. 38-50% of women who had given birth during the preceding 5 years were hospitalized for complications. Risk was greatest for women aged 15-24 years. About 33% reported a history of pelvic inflammatory disease. 16-25% did not know HIV infection was asymptomatic.

A study conducted in Edinburgh Scotland in 1994-96 found that women who have access to emergency contraceptive pills (ECPs) without a prescription use the method correctly and experience no serious adverse effects. 553 women 16-44 years of age recruited from a family planning clinic or a hospital were given a 1-time supply of ECPs to take home along with instructions and a notification form; another 530 women received information about the method and its source but no supply of pills. In the 12 months after study enrollment 36% of women who had a home supply of ECPs compared with 14% of those who received information only used the method. Information from the 91 participants in the study group who returned a notification form indicated all but 1 woman used the method correctly. 89% of women in the study group reported that their routine contraceptive use was not affected by having a supply of ECPs; only 2% reported their willingness to take sexual risks increased. 12 pregnancies occurred during a cycle in which emergency contraception was used; a 3% failure rate. 79% of women who obtained a supply of ECPs compared with 61% of those given information only believed the method should be available without a prescription.

A large case-control study conducted at 16 centers in Austria France Germany Switzerland and the UK in 1993-96 estimated that 2-4 strokes/year/100000 women of reproductive age may be attributable to OC use. 220 ischemic stroke patients ages 16-44 years were matched with 775 controls from the same hospital or community. Stroke patients were more likely than controls recruited from hospitals or local communities to smoke (55% vs. 35% and 48% respectively) to have a history of hypertension not associated with pregnancy (16% vs. 6% and 7%) to have diabetes (6% vs. 1% in both types of controls) and to have used OCs in the 3 months preceding stroke diagnosis or study recruitment (58% vs. 30% and 43%). Stroke patients were less likely than controls to consume alcohol frequently (11% vs. 14% and 20%). Logistic regression analysis controlled for age study center cardiovascular risk factors and duration of OC use indicated current OC users were 3.6 times as likely than nonusers to have a stroke. This risk was 4.5 among users of first-generation formulations containing 50 mcg or more of estrogen 3.4 among users of second-generation formulations with less than 50 mcg of estrogen and any progestin other than gestodene or desogestrel and 3.9 among women who used third-generation OCs containing gestodene and desogestrel. Compared with past users of OCs women using second- or third-generation OCs who did not have a blood pressure check before receiving an OC prescription had a 4.5 and 4.6 elevated risk respectively of stroke. This finding confirms the importance of screening for cardiovascular risks and checking blood pressure as a strategy for reducing stroke risk in OC users.

CONTEXT: Oral contraceptive users' risk of accidental pregnancy may be higher than it should be, because of inconsistent pill-taking. However, few reliable data are available on pill users' everyday experiences with their method, especially characteristics that may affect consistency of use. METHODS: Two months after initiating or resuming oral contraceptive use, a nationwide sample of 943 women completed questionnaires examining their compliance with instructions for proper use, the quality of their interactions with their provider, their satisfaction with the method, and the frequency and costs of visits or calls to their providers because of pill-related side effects. Regression analyses were used to determine the factors associated with compliance difficulties and method dissatisfaction. RESULTS: In all, 47% of users missed one or more pills per cycle, and 22% missed two or more. Women who lacked an established pill-taking routine, who did not read and understand all of the informational material accompanying the pill package, or who experienced spotting or heavy bleeding had increased odds of missing two or more pills per cycle. Method satisfaction was most likely among women who were aware of the pill's noncontraceptive benefits, were satisfied with their relationship with their provider, had used the pill in the past and experienced few side effects. Some 22% of users called their provider at least once about pill-related side effects, and 9% made at least one visit for this reason; these women spent $25 and $62, respectively, to treat side effects. CONCLUSIONS: Improving pill use is a shared responsibility of the provider, the patient and, to a lesser degree, pill manufacturers. Awareness of potential difficulties such as inadequate counseling is a key step in helping women use oral contraceptives effectively.

An analysis of the medical costs associated with the availability of emergency contraception (EC) in the US confirmed the cost-effectiveness of oral contraceptives (OCs)--but not the Copper T IUD--for this purpose. On the basis of published reports use of OCs for EC was estimated to result in a 74% reduction in the pregnancy rate compared with no treatment while IUD insertion for this purpose was assumed to reduce the risk of pregnancy by 99%. Two ways of delivering EC (during a routine visit for barrier contraception or after unprotected intercourse) in two provider settings (private managed care and publicly funded programs) were considered. The average total cost of outcomes of an unintended pregnancy was US$3795 under managed care and $1680 in a publicly funded program. Assuming that births averted by EC would never occur each use of combined pills resulted in savings of $142 under managed care and $54 in a public payer system. The IUD was cost-effective only if it remained in place for at least 4 months. If women receive an advance supply of EC pills from managed care providers and use the method whenever required the annual savings ranges from $263 for couples relying on male condoms to $498 for couples using the female condom. Even greater savings would occur if appropriate doses of combined OCs and minipills were packaged and labeled for this purpose.

Avoidance of unwanted pregnancy in the US would be facilitated by a more thorough understanding of the determinants of inconsistent oral contraceptive (OC) use. This issue was investigated in a nationally representative subsample of 1485 OC users 15-44 years old who participated in the 1995 US National Survey of Family Growth. 15% of these women were using another contraceptive method in addition to the pill. Overall 16.4% of OC users were inconsistent (defined as missing 2 or more pills in a 3-month period); this rate was 20.3% among dual method users. Among users of the pill only Hispanic and Black women were at significantly increased risk of being inconsistent OC users (odds ratios (ORs) 2.5 and 2.1 respectively) than were White women. The risk was also elevated among those who began OC use within the past 3-6 months compared with longer-term users (OR 2.7) and women with a history of an unintended pregnancy (OR 1.6). Among dual method users the risk was elevated among women with incomes less than 250% of the federal poverty level (OR 4.3) and women who began OC use within the preceding 3-6 months (OR 4.5). Awareness of these characteristics could help family planning providers identify OC acceptors at risk of inconsistent use. More research is needed however to develop better measures of consistency and to determine the predictors that should be tested in large-scale national databases.

In a nationally representative sample of sexually experienced youths aged 14-22, 37% of young women and 52% of young men said the condom was the primary method used to prevent pregnancy at last intercourse; an additional 8% and 7%, respectively, said they used a condom at last intercourse; much of this represents dual use [corrected]. Condom use at last intercourse was reported by 25% of young men whose partner was using the pill. Significant independent predictors of condom use with the pill among men included younger age, black race, engaging in fewer nonsexual risk behaviors and having received instruction about HIV in school. Among young women, 21% of those relying on the pill reported also using a condom at last intercourse. For women, independent predictors of dual use included younger age, black race, older age at first sex, fewer nonsexual risk behaviors, having no partners in the previous three months and having talked to parents or other adult relatives about HIV.

Telephone surveys conducted among US adults and obstetricians-gynecologists revealed limited awareness or promotion of emergency contraception. In the first survey (1994) involving a nationally representative sample of 2002 male and female adults 36% were aware something can be done to prevent pregnancy within a few days after unprotected intercourse and 55% had heard of emergency contraceptive pills but only 9% of those aware of the method knew a woman has up to 72 hours after unprotected sex to initiate method use. Only 1% reported that they or their partner had used emergency contraception. Knowledge of this method was highest among those who had discussed birth control with a health care provider those with at least some college education older respondents and non-Hispanic Whites. The second survey (1995) involved 307 obstetricians and gynecologists randomly selected from the American Medical Associations master file. 70% had no objections or concerns about prescribing emergency contraception and 78% considered the method effective. Although 70% had prescribed emergency contraceptive pills in the past year 77% of these had done so no more than 5 times and only 7% regularly discussed the method with clients during routine contraceptive counseling. The findings of both these surveys point to a need for health care providers to take a more active role in offering information about postcoital contraception to their patients.

This study examined desired family size and son preference among low income Hispanic women in Los Angeles California. The data were obtained from a sample of 432 Hispanic women recruited from a waiting room of an obstetrics and gynecology clinic in a large public hospital during 1995-96. Findings indicate a strong son preference particularly among less acculturated women. A convenience sample of women reported that sons were highly valued in Hispanic families. Some reported sons were less expensive to raise. 55% of the sample group were born in Mexico and 9% in the US. 55% grew up in cities. 75% reported having 2 or more brothers and about 75% reported having 2 or more sisters. 63% were pregnant at the time of the interview. 36% who were not pregnant and were sexually active reported use of contraception. 50% used the condom and 29% used the pill. 69% had children and 24% had 3 or more children. Women desired on the average 2.8 sons and only 0.1 daughters. Older women and less educated women desired a higher number of sons and fewer daughters. Women who were separated divorced or widowed desired more sons (3.3) than women who never married (2.6). Women who preferred to speak Spanish (2.9) desired significantly more sons than women who preferred English (1.3). Women born outside the US desired more sons than American-born women. Women with 5 or more siblings desired fewer daughters than women from smaller families. Women with 2 or more children desired more sons (3.4) than women with fewer than 2 children. The multivariate model reveals that desired number of sons was significantly predicted by Spanish language preference and number of children. Women with a preference for Spanish were 10 times and women with the most children were 2.5 times more likely to desire a large number of sons.

A recent case-control study from the UK raises doubts about the previously noted association between venous thromboembolism and use of third-generation oral contraceptives (OCs) containing the progestins gestodene and desogestrel. The computer records of 143 general practitioners in the UK yielded data on 540000 women born from 1941 to 1981. This sample included 491908 women with 234899 woman-years of exposure to steroidal contraception including 108824 woman-years of exposure to third-generation OCs. 85 women had a venous thromboembolism (29 users of second-generation OCs 54 users of third-generation pills and 2 users of progestin-only pills). The crude rates of venous thromboembolism were 4.1/10000 woman-years of exposure among all combined OC users 3.1/10000 for second-generation OCs and 5.0/10000 for third-generation products. After adjustment for 5-year age groups users of third-generation OCs were 1.7 times more likely than second-generation pill users to have experienced this complication. Case-control analysis of the same data set produced substantially different results however. The 85 women with a venous thromboembolism were matched with 313 controls on physicians practice current use of OCs and exact date of birth. After adjustment for body mass index change in type of contraceptive prescribed within 3 months of the event number of cycles prescribed concurrent disease and use of emergency contraception there was no significant difference in risk of venous thromboembolism associated with second- versus third-generation OCs. Exact matching by age appears crucial to ensure that controls are representative of the population from which cases are drawn and to prevent residual confounding by age.

A collaborative analysis of 90% of the data collected worldwide on the association between oral contraceptive (OC) use and breast cancer indicated that this risk is transitory and does not persist beyond 10 years after OC discontinuation. The analysis pooled data on 53297 women with breast cancer and 100239 hospital or population controls from 54 prospective and case-control studies with a minimum of 100 women with invasive breast cancer conducted in 25 countries. Overall 41% of breast cancer cases and 40% of controls were ever-users of combined OCs. The median duration of use was 16 years. Current OC users were 24% more likely than never-users to develop breast cancer while women who had discontinued OC use 1-4 years earlier were 16% more likely. However any increased risk disappeared when analysis included women who discontinued OC use 10 or more years before the study. Moreover tumors detected in OC ever-users were 10% less likely than those in never-users to have spread to the lymph nodes and 30% less likely to have metastasized elsewhere.

A 1995 telephone survey of 1,852 low-income women aged 18-34 who were sexually active and at risk of unintended pregnancy found that 83% were currently practicing contraception. They were more likely to do so if they held positive attitudes toward contraceptive use, if they talked frequently about intimate matters with their partners and girlfriends and if they were very satisfied with the services they received at their last gynecologic visit. Seventy percent of current users said they were very satisfied with their method. Women whose last visit was to a clinic, who were very satisfied with the care they received and who used the pill or a long-acting method were more likely than others to report being very satisfied with their contraceptive. Women very satisfied with their gynecologic care were more likely to use oral contraceptives and to take them consistently, but were less likely to report that their partner used condoms or, if they did, used them consistently. Most women had made a medical visit for gynecologic or contraceptive care in the past year (86%), and 80% were very satisfied overall with their care at their last visit. Women were more likely to be very satisfied if the staff was courteous, helpful and respectful and made an effort to find out their needs, if their clinician's gender matched their own preference and if the facility was clean and services were organized.

A population-based case-control study was conducted among female members aged 15-44 years of the Kaiser Permanente Medical Care Programs of Northern and Southern California to identify any association between the use of low-dose oral contraceptives and stroke among women of childbearing age. Data were collected on the women who had had a stroke from May or July 1991 through August 1994. 408 strokes were identified among 1.1 million women; 295 cases of mean age 37 years were included in the study. More than 75% of these women were either current users of oral contraceptives or had used them in the past. Analysis of the data found the increased risk of either ischemic infarction or hemorrhagic stroke among current low-dose pill users to not be significantly greater than the risk faced by women who have never used low-dose pills or those who have used them in the past. The use of low-dose oral contraceptives therefore does not appear to be associated with stroke among women of childbearing age.

Researchers collected data during 1977-92 from White women aged 25-59 years in New York Philadelphia and Boston hospitals as part of an ongoing case-control surveillance study. Cases were 3540 White women who had a first occurrence of primary breast cancer diagnosed within the preceding year. Controls were 4488 women who had been admitted to the hospital for nongynecologic nonmalignant conditions considered unrelated to the use of oral contraceptives. Unconditional logistic regression was used to control for the impact of confounding variables and determine the relative risk of breast cancer associated with oral contraceptive use. White women younger than age 35 who had used oral contraceptives appear to be at higher risk of breast cancer with the risk being greatest for women who had used the pill the longest. Women aged 25-34 years who had used oral contraceptives for 1 year or more were 70% more likely to develop breast cancer than were women of the same age who had not used the pill or who had used it for less than 1 year. Women in this age group who had used the pill for 10 years or longer had a risk of breast cancer 2.5 times that of comparable nonusers. That long-duration users also tend to be recent users makes it difficult to distinguish between the effects of recency and duration.

Irregular use of the pill compromises the effectiveness of this highly reliable method. The consistency of pill-taking has traditionally been estimated through women's own reports of their patterns of pill use. In this study, self-reported data on pill-taking were compared with data from an electronic device measuring compliance among 103 women attending university health services and publicly funded family planning clinics. In three months of pill use, the electronic and self-reported data agreed on the number of days when pills were missed only 45% of the time; the level of agreement dropped from 55% in the first month to 38% in the third month. In each month, the proportion of women reporting no missed pills was much higher than the proportion recorded electronically (53-59% compared with 19-33%), and the proportion missing at least three pills according to the electronic data was triple that derived from the women's reports (30-51% vs. 10-14%). In addition, the electronic data recorded substantially more episodes in which women missed pills on two or more consecutive days (88 vs. 30).

A Seattle Washington study of 1779 women 15-34 years old who attended 2 primary care clinics between January 1988 and June 1989 used data obtained from self-administered questionnaires and cervical examinations to determine risk factors for cervical chlamydia. 4% of the women were infected with cervical chlamydia with higher rates apparent in women who were younger than 25 Black never married never pregnant had an annual income of less than $15000 or had douched or had 2 or more sexual partners in the past year. For women 25-43 years old however the use of barrier methods of contraception led to an 85% reduction in risk of infection. Odds of infection were also lower in barrier users with only 1 sexual partner in the past year. A somewhat higher infection rate was seen among condom users than among those who used female methods. No association was found between oral contraceptive users and infection. This study has a number of methodological limitations but indicates that younger women are less effective users of barrier contraceptives than are older women and that barrier methods offer selective protection against cervical chlamydial infection.