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Contraceptive Counseling: The Medical Toolbox Must Include the Full Range of Reversible Contraceptive Methods Also for Adolescent Women Abstract. When counselling adolescents, empathy and age-appropriate information on medical confidentiality are important. Addressing individual needs and wishes enables the targeted use of the necessary information and resources and is the best guarantee for successful contraception over time. The goal is to make informed decisions and to have a positive experience of successfully protected sexual and reproductive health. The range of suitable contraceptive options is very broad. To make the most of this potential, all methods should be addressed with their advantages and disadvantages, including information on sexually transmitted infections and protection against them. Concerns and questions should be answered comprehensively and openly, and the experiences with sexuality described should be approached without prejudice. Often this is also an opportunity to talk about experienced situations of sexual assault.

The availability of GnRH agonist implants offers the possibility of a reversible, temporary downregulation of endocrine and germinative testicular function in male dogs and hobs. This review provides an overview of the registered indication, the induction of temporary infertility in healthy, intact, sexually mature male dogs (4.7 and 9.4 mg deslorelin) and hobs (9.4 mg deslorelin) as well as various off-label indications. Off-label use requires strict indications, informed consent from the owner and a lack of licensed medication (safe and optimum effect). Off-label indications in the male dog include sexual-hormone dependant (disturbing) behavior, benign prostatic hyperplasia, small adenomas of the hepatoid glands and alopecia X. Successful use of deslorelin implants for estrus suppression in jils, but also for the treatment of hyperadrenocorticism in ferrets in general have been described. Similarly, hormonal castration can be induced in tomcats and queens. The variable time to onset of effect and its duration (extremely variable in some animals) represent a challenge for breeders. No (sufficient) contraceptive activity was identified in male rabbits and male guinea pigs; however, treatment did successfully suppress the estrus cycle in female individuals of these species, as well as reproductive activity in male and female rats. Regarding the use in birds and reptiles, significant species-specific differences exist with regard to efficacy, time until onset of effect and duration of downregulation. In birds, the implant is efficient to fully suppress egg laying in chicken, Japanese quail and psittacids. In doves, egg laying is only significantly reduced. Successful treatment of reproduction-associated (unwanted) behaviour patterns (feather picking, aggression) has also been described. In some male birds, namely zebrafinch and Japanese quail, the deslorelin implant is suitable to reduce testosterone levels. Successful treatment of hormone-dependent tumours (Sertoli-cell tumorus) in budgerigars has been described as well as the modulation of specific behavior in turkeys and an efficacy in facilitating their keeping (i. e. reduction of aggression). In reptiles, only the successful use of deslorelin in iguana has been demonstrated to date., Competing Interests: SGP hat Forschungsmittel zum Einsatz von Suprelorin®-Implantaten an verschiedenen Spezies/Geschlechtern von Virbac erhalten und Vorträge zur Thematik gehalten. Dennoch besteht kein persönlicher Interessenkonflikt, da nie Literaturarbeiten oder Studienergebnisse bzw. die Darstellung dieser beeinflusst wurden. Auch dieser Artikel ist frei und ohne Beeinflussung entstanden. SS hat keinen Interessenkonflikt., (Thieme. All rights reserved.)

The current status of hormonal contraception in men involves the principle of suppression of gonadotropins, LH, and FSH. This must be achieved as completely as possible to facilitate cessation of spermatogenesis and, thus, reach azoospermia. Simultaneously testosterone has to be replaced. Exogenous testosterone administration achieves the goal of gonadotropin suppression, but needs in addition the supplementation of a gestagen to fully suppress secretion of LH and FSH. Suppression of gonadotropins by steroids requires constant serum concentrations of sex steroids; hence, attempts using daily oral or transdermal preparations were, so far, unsuccessful. Thus, the immediate prospect for male contraception is not a"pill" itself but a regimen of combined injectable steroids, which are in advanced clinical testing.

Contraception in chronically ill adolescents has to consider side effects with regard to metabolic or hematological disease. Additionally the compliance of the patient has to be taken in account when consulting about contraceptives. In juvenile diabetics with good glycemic control and metabolic diseases of the amino acids oral contraceptives are justifiable. Adolescents with galactose-mia mostly suffer from premature ovarian failure and therefore have to be controlled wether they need contraception at all. Young women with sickle-cell anemia are at risk of thrombophilia. They should not be given hormonal contraceptives. In v. Willebrand-Jürgens-Syndrome oral contraceptives are favourable because it alleviates menorrhagia.

Perimenopause, such as postmenopause, is a physiologic condition that could be accompanied by several symptoms that may need a medical intervention. Women need to be informed about the available therapeutic options, including no treatment at all if not necessary. Oral hormonal contraceptives represent a valid and safe option in healthy premenopausal women with complaints. They guarantee a safe and reliable contraception in women without contraindications. The alternatives to oral hormonal contraceptives are injectable progestagens, oral progestagen-only preparations, progestagen implants or progestagen-loaded IUD's. It is highly important to inform correctly the patient and make her to participate actively in the therapeutic decision. This educational process helps in building a solid relationship and improves patient adherence with better clinical results.

Perimenopausal women are still potentially fertile and pregnancy is attended with increased maternal and perinatal mortality. Several contraceptive methods can be used therapeutic for the treatment of climacteric symptoms like menstrual irregularities, flushes and vaginal dryness. Low-dose oral contraceptives (OC) prevent climacteric symptoms and additionally protect from perimenopausal bone loss. However, the individual cardiovascular risk increases with age and is even higher in perimenopausal women using OCs. Therefore for women with cardiovascular risk factors sterilization, barrier methods, progestin-only methods and intrauterine devices (IUD) are the better choice. Prolonged and heavy menses can be treated with the levonorgestrel-releasing IUD or injectable progestogens. If estrogen replacement is necessary, a low-dose treatment with natural estrogens can be combined with barrier methods, the levonorgestrel-releasing IUD and injectable progestogens. The variety of contraceptive options available to perimenopausal women allows individual counseling and thus may enhance compliance.

The number of women with congenital cardiac disease, who mature into adulthood is increasing. Unfortunately, there are no prospective data published about the relative risk of different forms of contraception for these patients. Most women with congenital cardiac disease can safely use oral contraceptives, especially low-estrogen combination or progestin-only preparations, with the exception of those, who are at particular risk because of thromboembolic complications (especially in cyanosis, pulmonary hypertension, Eisenmenger reaction, rhythm disturbances), fluid retention (especially in reduced ventricular function and congestive heart failure), arterial hypertension (important in coarctation), infectious complications (endocarditis) or hyperlipidemia. Oral contraceptives should be avoided in patients at increased risk for thromboembolic events. Intrauterine devices are very effective, have no metabolic side effects and merely carry a small risk of endocarditis. Newer devices containing progesterone only may put the patients at a still smaller risk. Contraceptive subdermal implants (e.g. levonorgestrel) are used with good results in the United States for patients with contraindications to estrogen-containing oral contraceptives and may well become more widely accepted in patients in Germany in the coming years. Barrier methods can be used, but have a higher failure rate, which may be unacceptable in patients at risk (e.g. Eisenmenger's). Especially in Eisenmenger's, permanent sterilisation should be advised.

Reproduction continues in the perimenopause. To prevent unintended pregnancies, the use of a highly effective reversible contraceptive is necessary. The most effective methods of contraception are hormonal contraceptive methods and the intrauterine device (IUD). Barrier contraceptives can have a high-use effective rate in motivated users, too. Hormonal contraception has both risks and benefits, but can be used safely for healthy women without risk factors during the time of perimenopause. To prevent the metabolic side effects of synthetic estrogen-ethinyl-estradiol in the contraceptive pill in perimenopause, the use of natural estrogen (estradiol) in combination with a progestagen for contraception is effective, too. A major problem of IUDs has been the increased incidence of bleeding or dysmenorrhea. For these women, Progestin-releasing IUDs are recommended because of their ability to reduce the amount of uterine bleeding associated with menstruation.

The adolescent girl needs affection and understanding for all of her problems. She often does not find a satisfying measure of both in her familiar surroundings. Very often sex instruction is faulty, although the AIDS campaigns have led to remarkable improvements (condoms). Instructions for sexual behaviour should take place at home or at school, but not in the street. Nevertheless, the first intercourse occurs mostly unprotected. Teenage pregnancies present not only physical but also psychological problems. Termination of pregnancy means an especially difficult decision for the adolescent girl, often causes crisis and occasionally leads to negative consequences for later fertility. The choice of appropriate contraceptive methods for girls under 16 years of age may also have legal problems. Condoms and barrier methods are possible alternatives to the much safer hormonal contraception with the combination, sequence or minipill. Under certain circumstances, a progestin injection every three months or the 'morning-after pill' as postcoital contraception or, in the case of an abortion or of pregnancy termination, even an intrauterine device can be an alternative for adolescent girls under those exceptional circumstances.

Contraception implies the responsible confrontation with fertility and sexuality. Contraceptive counselling deals directly or indirectly with sexuality and comprises therefore frequently sexual counselling. 25% of women consulting our Family Planning Clinic complain spontaneously about sexual difficulties. Out of these women one fifth suffer from sexual dysfunction related to the contraceptive method used. Hormonal contraception seems to include most frequently sexual dysfunction. The symptom most frequently complained about is lack of libido. There are typical patterns of correlation between sexual dysfunction, contraceptive compliance and side-effects of contraception which are of great important for contraceptive counselling.

The world population is still increasing dramatically. This rapid growth takes place mainly in developing countries and represents a considerable obstacle to the improvement of the economic and social conditions in these countries. A higher acceptance of various fertility-regulating methods is one important factor in the reduction of the population growth. An increasing acceptance cannot be realised without the general availability of safe and effective methods for all users while considering and respecting the multiple different cultural backgrounds. The WHO Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a programme of an international organisation with high esteem particularly in developing countries, contributes considerably to this field, therefore should be supported more widely.

Basis of this trial are examinations of 100 patients with colposcopic and/or cytologic suspicion for precancerous or early stages of cancer of the uterine cervix and of 100 patients in the same age with normal cervical findings. The meaning discussed in literature about cigarette smoking as cofactor for developing cervical cancer and its prestages can be confirmed by our results. The portion of smoking patients with 74 per cent in the cervical groups was higher than in control group (42 per cent). Three times so much patients of the cervical group than in the controls smoked 20 cigarettes per day or more. More than 20 years smoking patients could be found only in the cervical group. 97 patients of the cervical group compared with 55 of the controls had been in the pill. Patients with cervical lesions on the average had been 3 years younger starting with hormonal contraception than the controls. The portion of pill users more than 10 years had been twice frequent in cervical group. The use of condoms was significantly more frequent in the control groups than in the cervical one (22/6). Therefore condoms are to be preferred be cause of protection against sexual transmitted diseases and indirectly cervical carcinom.

It is discussed how the adult type contraception fits the divergent needs of the youngsters. Oral contraceptives are suitable from the 16th year of life. Vaginal globuli and foams have also proved to be an effective means of contraception over that period of life. For anatomical reasons pessaries are not recommended, insertion of intrauterine devices is contraindicated because of their possible adverse effects. Experiences with university students taking d-Norgestrel as "morning-after-pill" have been favorable. The therapeutic abortion is regarded as an emergency measure to be employed only if anticonception failed. Adaequate education at the proper age and the importance of preventive measures are stressed.

The effect of hormonal contraceptives administered for 24 months on the hydroxyproline content in urine was investigated. -- The results suggest an increase of hydroxyproline by application of sexual steroids. The reversibility is discussed.

Pediatric health care is one of the specialties in medicine for which prevention is the most traditional and most essential activity. In this brief review the office practice of Swiss pediatricians is discussed to give insight into the needs of children and their families concerning their health problems and the health services delivered in respect to check-ups and counseling. Age specific concerns and screenings are summarized. More special attention should be devoted to the health counseling for adolescents.

The results of the 1098 responses to a questionnaire show a remarkable increase in the use of intra-uterine devices (IUD) as a method of contraception (especially in the last 3 years) in the FRG too. The main reasons for the insertion of IUD were specified as "incompatibility" with the pill or "weariness induced through constant use of the pill". IUD are also used by nulliparae. At the moment T-shaped models containing copper are most popular. The majority of insertions are performed without general anaesthesia. The optimal length of time for wearing an IUD is considered to be 2 years or more. The foremost reasons for removal of IUD are bleeding or pain. Failures (pregnancies) however, are rather frequently recorded. Most gynecologists remove the IUD if pregnancy has occurred and in this case only few of them try to maintain the pregnancy on the patients request. In 1976, the majority of gynecologists attended patients composed of 40 : 1 users of the pill : users of IUD. Numerically speaking therefore, IUD are the method which actually takes second place. In our opinion however, if attention is paid to indications and contra-indications and to the necessity for intensive education of the patient, IUD are a real alternative to the pill and to the increasing use of any type of female sterilization.

Observations made at the Family Planning Clinic and a review of the literature show that there is no increased tendency towards the natural contraceptive method among advice-seeking couples. On the contrary-apart from a few exceptions-the most effective method is always chosen. The natural method presupposes a high degree of motivation, of readiness to communicate and of clarification. These prerequisites underly the relatively high rate of failure because not all couples have the right degree of understanding. Nevertheless, to many people this method is the only acceptable and morally justifiable one. Thus, precise and detailed instructions and frequent check-ups would be necessary especially during the first few months, until adequate experience is gained.

During a period of 9 years 143 women at an age over 40 attended for the first time the I. University Clinic of Gynecology and Obstetrics in Vienna for receiving contraceptive treatment. 71 women (49.6%) received oral contraceptives wiD was inplanted because of either internal contraindications of oral contraceptives (mainly high risk for thrombosis) or negation by the patient. 16 patients were sterilised, mostly with the laparascope. The main side effects in the patients receiving oral contraceptives were nervosity, impairment of libido and complaints in the lower extremities. 60.5% of all women over the age of 40 using oral contraception didn't show any complaints. On the basis of the own results and the reports in literature the advantages and disadvantages of oral contraception in comparison with mechanical devices are discussed.

In the retrospective analysis of 500 involuntarily childless couples the following results were observed: The pregnancy rate was 37.2%. The age of the women did not influence the conception rate significantly. Women with a sterility of less than 5 years duration had a statistically higher conception rate than those with longer lasting sterility. Patients with oligomenorrhea had a significantly higher pregnancy rate than those with normal menstrual cycle. Cyclofenil therapy resulted in a significantly higher conception rate than treatment without ovulation inducing compounds. Homologeous insemination had a pregnancy rate of 25,4%. The additional therapy with ovulation inducers did not influence the results significantly. Patients with uterine hypoplasia had a significantly higher conception rate than women with normal uterine size. Women who showed uterine hypoplasia before sterility treatment had taken oral contraceptives less often than women with normal uterine size. There was a significant correlation between uterine hypoplasia and cyclic disorders. Women with cyclic disorders had hirsutism more often than those with a normal cycle. In cases with normal sperm count (40 mill./ml) there was a significantly better pregnancy rate than in those with oligozoospermia (40 mill./ml). In cases of sperm motility of over 70% a significantly higher pregnancy rate was observed than in those with a motility below 70%. In spermiograms with more than 70% of normally configurated sperms the results were significantly better than in those with less than 70% normal sperms.

The discovery of the structure of Gn-RH in 1971 has opened new ways of investigation and treatment. The anterior pituitary gland requires episodic Gn-RH stimulation in order to secrete the gonadotropins in a physiologic manner. Deficiency of Gn-RH leads in both sexes to functional disturbances which in females may produce chronic anovulation and amenorrhea. Replacement therapy with the administration of Gn-RH in a pulsatile rhythm corrects the deficiency of endogenous Gn-RH secretion and stimulates via gonadotropins the function of peripheral target organs. If given continuously, Gn-RH leads to desensitization of pituitary Gn-RH receptors and inhibition of LH and FSH secretion. Potent and long-acting agonistic Gn-RH analogs have been synthesized which are capable of producing a selective "medical castration". Indications and preliminary results of the administration of Gn-RH and its long-acting agonists in humans are reviewed.

Surgical contraception on the part of the male (vasectomy) is a contraceptive method which has a character of finality. This statement must be firmly adhered to because refertilization is not 100% successful. This intervention on the male needs very thorough preparation by intensive consultative discussions in which the female partner must also be included. Both the resons for and against vasectomy are presented with descriptions of some pertinent examples. In doing so it is demonstrated in detail that vasectomy is more than a purely technical procedure; in the assessment of the pros and contras, the whole relation to the partner relations must be integrated.