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RHO archives : Topics : Contraceptive Methods

Annotated Bibliography

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Oral contraceptives

Blackburn, R.D. et al. Oral contraceptives—an update. Population Reports. A(9) (Spring 2000). Available at: www.jhuccp.org/pr/a9edsum.stm.
This issue reports on current findings about the benefits and risks of pill use. The greatest benefit is effective contraception, but oral contraceptives (OCs) also offer numerous other health  benefits, such as reduced menstrual bleeding and reduced risk of uterine and ovarian cancers. Compared to the older, high-dose pills, current low-dose formulations have considerably lowered the risk of heart attack, stroke, and blood clots in the deep leg veins attributed to OC use. Research has clarified that women over age 35 who smoke or who have high blood pressure are the ones who face appreciable risk of heart attack or stroke if they used OCs. For other women, using OCs is safer than childbearing in both developing and developed countries.

Family Health International (FHI). Oral contraceptives. Network 16(4) (Summer 1996) Available at: www.fhi.org/en/fp/fppubs/network/v16-4/index.html.
This issue of Network is devoted to oral contraceptives. Articles discuss the safety of COCs, correct use, communication approaches to improve COC use, and studies that investigate whether progesterone use increases risk of HIV transmission.

Hatcher, R. Do birth control pills cause breast cancer? Pop Reporter 2(8) (February 25, 2002). Available at: www.infoforhealth.org/popreporter/2002/02-25.shtml.
Since the 1960s, this has been one of the most commonly asked questions about birth control pills. This commentary provides a succinct review of current thinking on this important topic. As this guest commentary indicates, most experts believe that pills have little, if any, effect on breast-cancer risk.

Muller, N. IMAP statement on steroidal oral contraception. IPPF Medical Bulletin 32(6) (December 1998). Available at: www.ippf.org/medical/bulletin/pdf/e9812.pdf.
This Bulletin contains the statement by the IPPF International Medical Advisory Panel (IMAP) developed at its September 1998 meeting. It describes the mode of action, efficacy, beneficial effects, adverse effects, and eligibility criteria for both combined oral contraceptives and progestin-only contraceptives. Recommendations for special populations (adolescents, women over 35, and postpartum women) as well as counseling and screening issues also are presented.

Johns Hopkins Center for Communication Programs. Oral Contraceptives. www.jhuccp.org/topics/oral.shtml. Accessed March 2003).
This page provides links to several Johns Hopkins resources on oral contraceptives, including the Media/Materials Clearinghouse, the POPLINE database of journal articles, Population Reports and other publications, and relevant articles by Johns Hopkins staff.

MILTS. Oral contraceptives and liver cancer. Results of the Multicentre International Liver Tumor Study (MILTS). Contraception 56(5):275-284 (November 1997).
This study specifically analyzed the risk of COCs containing cyproterone acetate (CPA) or related progestins. This report analyzed data from 317 cases of primary hepatocellular cancer (HCC) in women under age 65, compared with 1,060 age-matched hospital and 719 population controls in six European countries. The adjusted odds ratio for ever having used any OC was 0.75 when all cases were compared with all controls, and compared to hospital and population controls separately. The adjusted odds ratio for OCs containing progestins of the CPA group was 0.89. This study found no evidence that COCs in general, or those containing CPA or chemically related substances, increased overall risk of liver cancer, even after long-term use. These findings are consistent with several other large cohort studies that found no association between liver cancer and OC use. Fear of liver cancer should not affect a woman's decision about whether to use OCs.

PATH. Hormonal contraception and breast cancer: convincing new conclusions. Outlook. 1997;15(1):1-4. Available at: www.path.org/files/eol15_1.pdf.
This article summarizes the results of a study conducted by the Collaborative Group on Hormonal Factors in Breast Cancer that was designed to resolve questions raised by previous studies. The collaborative analysis involved data from multiple studies that together represent about 90 percent of the epidemiological information on the topic. Overall, the study found that women who had ever used COCs were at a very slight increased risk of breast cancer compared with never users; the risk was highest among women who started using COCs before age 20, and disappeared ten years after use.

PATH. Hormonal contraception and cervical cancer. Outlook. 1997;15(1):4-6. Available at: www.path.org/files/eol15_1.pdf.
This article reviews the results of recent studies that confirm there may be a slight association between use of some hormonal contraceptives and cervical cancer. However, the link appears to be small and reversible. Evaluating results of research on this issue is challenging because numerous factors influence the development of cervical cancer, and the disease develops over a long period of time. Further, in some settings hormonal contraceptive users are more likely to have Pap smears.

World Health Organization (WHO). Oral Contraceptives: A Guide to Their Use, Management and Role in Family Planning Programmes. Geneva: WHO (in preparation).
A growing body of evidence confirms that oral contraceptives are safe for most women and provide significant noncontraceptive health benefits. This manual provides clear, concise, accurate information about the safety and effectiveness of the oral contraceptive preparations available on the market. Differences between the old and the newer products are highlighted; now new formulations have improved safety and reduced side effects are stressed. Special attention is given to screening and counseling oral contraceptive users, groups at special risk, and follow-up care.

World Health Organization (WHO). Oral Contraceptives: What Health Workers Need to Know. Geneva: WHO (in preparation).
This booklet details information on the safety and effectiveness of oral contraceptives with particular attention to the newer formulations that have lower doses of estrogen and progestin. Women who have used these newer formulation pills have experienced reduced side effects and fewer complications. This information will be particularly helpful for health workers who want to answer client questions and respond to concerns about safety. Information covers both combined and progestin-only oral contraceptive pills.

Ziporyn, T. Oral contraceptives in the perimenopause. Journal of American Medical Association Women's Health On-line Journal (February 18 1998).
Effective contraception is particularly important in a woman's later reproductive years, when an unplanned pregnancy could have serious health consequences. COCs now are considered safe and beneficial for women over the age of 35 years who do not smoke. Taking COCs during the perimenopausal years can help prevent a number of health problems and alleviate uncomfortable menopausal symptoms. This article discusses clinical issues about providing COCs to women during the perimenopausal period and subsequently determining when a woman who has entered menopause can stop contracepting.

Zlidar, V.M. Oral contraceptives—Helping women use the pill. Population Reports. Series A, Number 10 (Summer 2000). Available at:  www.jhuccp.org/pr/a10edsum.stm.
The 100 million who rely on oral contraceptives (OCs) worldwide benefit from the effectiveness, safety, and convenience of the pill. However, many women do not use the pill as successfully as possible. This issue of Population Reports provides guidance about how programs can help women use OCs more effectively. Topics covered include common problems using OCs, guidance about when missing pills is riskiest and what to do about missed pills, how men can help, key counseling messages for OC users, tips on how to manage common side effects, and how to remove unnecessary medical barriers.

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Implants

International Planned Parenthood Federation (IPPF). Progestagen implants. IPPF Medical Bulletin 34(1) (February 2000). Available at: www.ippf.org/medical/bulletin/pdf/e0002.pdf)
This issue of the IPPF Medical Bulletin contains an excellent summary of the progestin family of contraceptive implants. The article begins with Norplant, the levonorgestrel-releasing, six-rod implant system developed by the Population Council and introduced in the 1980s, and then describes the newer implants that have been developed. These include Jadelle—similar to Norplant but a two-rod levonorgestrel system—and Implanon—a single implant system with the active ingredient etonogestrel (developed by NV Organon, Implanon is registered in 13 countries and has been introduced in two European countries). A single-implant system containing Nesterone (ST 1435) that has been introduced in Brazil for treatment of endometriosis also is described.

Meirik, O. et al. Safety and efficacy of levonorgestrel implant, intrauterine device, and sterilization. Obstetrics and Gynecology 97(4):539-547 (April 2001).
A five-year international post-marketing surveillance of users of the Norplant implant in eight developing countries confirmed the safety and effectiveness of the method. Experiences of nearly 8,000 Norplant users were compared with experience of more than 6,600 women who relied on an intrauterine device and 1,419 women who relied on sterilization. Women were interviewed and examined at semi-annual visits and followed-up at five years. Annual pregnancy rates during the period of use of Norplant, the copper IUD, and sterilization were less than one per 100 women. The study revealed no significant excess of cancer or cardiovascular disease in Norplant users compared to women using nonhormonal methods. The incidence of gallbladder disease was moderately higher in women who initiated Norplant than in controls. Also, the incidence of hypertension and borderline hypertension was higher, although this may reflect a reporting bias. The study confirmed a higher incidence of less serious disorders previously described in clinical trials (irregular or excessive menstrual bleeding, amenorrhea, and ovarian cystic enlargement). Other new findings were increased risks of respiratory diseases and decreased risks of inflammatory disease of the genital tract in Norplant users compared with IUD users and sterilized women.

Population Council. Norplant Implants: Frequently Asked Questions. Available at: www.popcouncil.org/biomed/norplantfaq.html. Accessed April 2004).
The Norplant levonorgestrel-releasing system was developed by the Population Council. By 1991, when the method became available in the United States, Norplant implants had been studied in clinical trials and preintroduction studies involving over 55,000 volunteers in more than 40 countries. By 1995, the method was approved in 44 countries, including Sweden, France, the United Kingdom, and the United States. These pages at the Population Council website provide a wealth of information about Norplant, including general information about mode of action, efficacy, insertion and removal, side effects and health considerations, counseling and informed consent issues.

Sivin, I. et al. Jadelle Levonorgestrel Rod Implants: A Summary of Scientific Data and Lessons Learned from Programmatic Experience. New York: Population Council (2002). Available at: www.popcouncil.org/pdfs/jadelle_monograph.pdf.
This scientific monograph provides a comprehensive summary of clinical characteristics of Jadelle levonorgestrel rod implants. It also reviews lessons learned about how to provide Jadelle (based in part on the extensive experience of providing Norplant), and provides suggestions about practical ways to introduce Jadelle into family planning programs.

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Injectable contraceptives

Cundy, T. et al. Menopausal bone loss in long-term users of depot medroxyprogesterone acetate contraception. American Journal of Obstetrics and Gynecology 186(5):978-983 (May 2002).
This study evaluated rates of early postmenopausal bone loss in women who had used depot medroxy-progesterone acetate (DMPA) contraception through menopause. Bone mineral density at the lumbar spine and femoral neck was assessed over three years in 15 women who reached natural menopause without hormone replacement therapy and 16 long-term users of DMPA who discontinued use only on reaching menopause. Early menopausal bone loss was rapid in the control group, but women in the DMPA group showed little loss of bone mineral density. Differences between the two groups were statistically significant at both two and three years. DMPA users who underwent hormone replacement therapy experienced significantly increased bone density at the lumbar spine, while density of the femoral neck remained stable. The authors conclude that women who use DMPA through menopause may experience less severe loss of bone from the lumbar spine and femoral neck because they may have already lost the estrogen-sensitive component of this bone.

Family Health International (FHI). Hormonal contraception and STIs: researchers continue to investigate a possible relationship. Network. 2003;22(3). Available at: www.fhi.org/en/RH/Pubs/Network/v22_3/Nwvol22-3concptiveSTIs.htm.
This article is based on a meeting sponsored by the National Institute for Child Health and Human Development in January 2003 to better understand findings from several studies relating to hormonal contraceptive use by women infected with HIV, or at-risk of infection. Strengths and limitations of the studies are discussed. Current knowledge of a potential relationship is not sufficient to change family planning practices at this point.

Hassan, E.O. et al.  Once-a-month injectable contraceptives, Cyclofem and Mesigyna , in Egypt. Contraception 60(2):87-92 (August 1999).
Results from this clinical trial of the two once-a-month injectable contraceptives, Cyclofem and Mesigyna, used for one year by 2,252 women in Egypt are reported here. Both contraceptives proved highly acceptable, with continuation rates of 63.2 per 100 women-years for Cyclofem and 61.6 for Mesigyna at the end of the 12-month period. Menstrual problems were the most frequently reported problems in both groups. Discontinuation rates because of amenorrhea were not significantly different (2.74 for Cyclofem and 1.38 for Mesigyna), but discontinuation because of bleeding problems were significantly higher among Mesigyna users (11.54) compared to Cyclofem users (7.39). Once-a-month injectable contraceptives can be a significant addition to contraceptive method choice offered Egyptian women. With appropriate counseling and careful client selection, method acceptability would probably be increased.

International Planned Parenthood Federation (IPPF). IMAP Statement on injectable contraceptives. IPPF Medical Bulletin 33(2) (April 1999). Available at: www.ippf.org/medical/bulletin/pdf/e9904.pdf.
This issue of Bulletin contains statements approved by the IPPF International Medical Advisory Panel (IMAP) following its meeting in September 1998. This Bulletin provides a concise overview of injectable contraception: formulations and dose intervals, mode of action, efficacy, beneficial effects, side effects, other possible effects, and eligibility criteria for both progestin-only and combined injectable contraceptives. Brief notes are provided for situations with special populations including adolescents, women over 35, postpartum (breastfeeding and non-breastfeeding women) or special conditions. Service issues also are addressed.

IPPF. Self-injection with cyclofem. IPPF Medical Bulletin 32(5) (October 1998). Available at: http://www.ippf.org/medical/bulletin/pdf/mbe325.pdf.
Access is a critical factor in the effective use of any contraceptive, but it is especially important for a monthly product such as Cyclofem, the monthly injectable contraceptive. One way to increase access to Cyclofem is to expand service delivery strategies to include self-injection with an easy to use pre-filled sterile device. This article reports on a study in Brazil that assessed women's ability to self-administer Cyclofem by means of the UniJect—a single-use injection device in which the medicament is packaged with the needle in a sealed foil pouch. Although self-injection is widely accepted, and was found acceptable in this study as well, family planning programs must carefully assess whether they have the capacity to offer self injection of a monthly injectable while still maintaining quality of care. Service delivery issues such as appropriate screening, ongoing counseling, cost-effectiveness, and the need for safe disposal are discussed.

Johns Hopkins Center for Communication Programs. Injectables. www.jhuccp.org/topics/injectables.shtml. Accessed March 2003).
This page provides links to several Johns Hopkins resources on injectable contraceptives, including the Media/Materials Clearinghouse, the POPLINE database of journal articles, Population Reports and other publications, and relevant articles by Johns Hopkins staff.

Lande, R. A new era for injectables. Population Reports K(5) (August 1995) Available at: www.jhuccp.org/pr/k5edsum.stm.
This issue provides an extensive review of injectable contraception (including the three-month injectable, DMPA (Depo Provera); the two-month injectable, NET EN; and the one-month injectables (Cyclofem and Mesigyna). Topics include research and regulatory approval, effectiveness and reversibility, side effects and complaints, noncontraceptive health benefits, and the user's perspective on injectables. About 12 million couples throughout the world use injectable contraceptives. DMPA is the most widely used.

Maximizing Access and Quality Initiative (MAQ). USAID guidance on depo study. MAQ website. Available at: www.maqweb.org/usaid_depo_study.shtml. Accessed October 6, 2004.
The Maximizing Access and Quality (MAQ) Initiative supports research and evidence-based interventions to promote access and quality of reproductive health and family planning services. This MAQ news release outlines the USAID guidance in response to results of a recent study that found a three-fold increase in risk of acquiring a chlamydia or gonorrhea infection among women using DMPA compared to women not using hormonal contraception. Caveats to help understand the results of this study are provided. While this study was a carefully designed prospective study, it was not randomized to contraceptive method and it is possible the DMPA users varied from the control group in some ways. The women in the study were single. It is possible that the study results may not apply to married women in a stable relationship. USAID does not recommend any changes in provision or use of DMPA based on results of this study.

Meirik, O. Hormonal contraceptives and bone mass. IPPF Medical Bulletin 35(5) (October 2000). Available at: www.ippf.org/medical/bulletin/pdf/e0010.pdf.
As life expectancy increases, diseases that affect women aged 50 years or older will become an important public health issue. One condition that affects women in particular is osteoporosis, which leads to morbidity and mortality by predisposing to fractures of the neck and vertebrae. Covering both progestin-only contraception and combined oral contraceptives, this article presents current thinking about the effect of hormonal contraception on bone mass.

Merki-Feld, G.S. et al. A 2-year prospective study on the effects of depot medroxy-progesterone acetate bone mass—response to estrogen and calcium therapy in individual users. Contraception 67(2):79-86 (February 2003).
The aim of this prospective two-year study was to investigate the effect of depot medroxy-progesterone acetate (DMPA) on the maintenance of bone mass in women aged 30-45 years. The effects of estrogen or calcium supplementation during the second year of follow-up were investigated in DMPA users who experienced high bone loss during the first year. The study evaluated bone mass of 35 DMPA users and 10 women without hormonal contraceptive experience. Baseline cortical and trabecular bone mass (TBM) and the annual change was not different in DMPA users and controls. Authors conclude that DMPA did not accelerate bone loss in women aged 30-45 years.

PATH. Cyclofem: A new once-a-month injectable contraceptive. Outlook 9(4) (January 1992).
This article describes Cyclofem, its use and development, and reports the findings of clinical studies to date. It also discusses how the characteristics of Cyclofem may impact service delivery.

PATH. DMPA: Now More Widely Available. Outlook 10(3) (December 1992).
Since it was first developed as a contraceptive in the early 1960s, more than 30 million women have used DMPA and over 100,000 have taken it for more than 10 years. This article presents a summary of DMPA's effectiveness, acceptability, and safety.

PATH and USAID. Introducing Auto-Disable Syringes and Sharps Disposal Containers With DMPA. Seattle: PATH (July 2001). Click on document title for a PDF version. French edition available online at www.path.org/files/SI_CNVP15904_French.pdf; Spanish edition available online at www.path.org/files/SI_CNVP15904_Spanish.pdf.
Auto-disable (AD) syringes and sharps disposal containers can improve injection safety for family planning clients, health workers, and communities by reducing reuse of needles and preventing needlestick injuries. This document is designed to help introduce AD syringes and sharps containers into family planning programs that will receive USAID-supplied DMPA. The document provides guidance on points to consider when introducing these technologies, and key training messages to help health workers use the new syringes and sharps containers safely and effectively. Guidelines for disposal of contaminated waste and used syringes are also provided.

Reproductive Health Technologies Project. Answers to Frequently Asked Questions About New Research Into the Association Between Hormonal Contraception and STD Risk. Baltimore, MD: Reproductive Health Technologies Project; 2004. Available at: www.rhtp.org/micro/pdfs/depo_provera_q_a.pdf.
This brief reviews a recent study in the United States investigating rates of gonorrhea and Chlamydia infection among women who use Depo Provera or oral contraceptives, compared to women not using hormonal methods (Morrison CS, Bright P, Wong EL, et al. Hormonal contraceptive use, cervical ectopy, and the acquisition of cervical infections. Sexually Transmitted Diseases. 2004;31(9):561-567). In question and answer format it discusses the findings and implications of this study. It reaffirms the recommendation that findings from this study do not justify preventing women from choosing Depo Provera if the woman determines this is her best option for preventing pregnancy.

Tang, O.S., et al. Further evaluation on long-term depot-medroxyprogesterone acetate use and bone mineral density: a longitudinal cohort study. Contraception 62(4):161-164 (October 2000).
This longitudinal cohort study of 59 women over a period of three years showed that their annual rate of bone loss at three sites (lumbar spine, neck of the femur, and Wards triangle) was substantially less than the values that had been projected from a previous study. While projected annual bone loss was estimated at 2.4 percent, the actual rates of bone loss measured were 0.44 percent in the lumbar spine, 0.40 percent in the neck of the femur, and 1.05 percent in the Wards triangle. The researchers report that the rate of bone loss probably is nonlinear, with rapid loss in the first five years, with a leveling off afterward. The duration of DMPA use was not significantly correlated with the rate of bone loss.

World Health Organization (WHO). Injectable Contraceptives: Their Role in Family Planning Care. Geneva: World Health Organization (1990). Cost: Sw.fr. 21-/US$18.90. In developing countries Sw.fr. 14.70.
This 117-page book presents a comprehensive guide for family planning program managers considering introducing or expanding access to injectable contraceptives in their program. Emphasis is placed on use of depot-medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN), the most widely used injectables. The book presents both research results and practical experience and is designed to help service managers understand the service delivery requirements of offering injectable contraceptives, as well as the health benefits to clients. The book provides explicit instructions for sterilization of needles and syringes, the correct technique for performing injections, and the safe disposal of needles and syringes.

WHO. Injectable Contraceptives: What Health Workers Need To Know. Geneva: World Health Organization (1990)
This booklet reviews injectable contraceptives and the major points health workers need to know. Topics covered include: what injectable contraceptives are and how they work; their effectiveness; client concerns about injectables; appropriate use; and basic elements of high-quality injectable contraceptive services.

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Emergency contraception

American College of Obstetricians and Gynecologists (ACOG). Practice Pattern #3: Emergency Oral Contraception. (December 1996).
Based on studies published from 1974 to 1996, ACOG evaluated the safety, efficacy, effects on menstrual cycle, mechanism of action, contraindications, and potential teratologic effects associated with the Yuzpe regimen of emergency contraceptive pills (ECPs). ACOG concluded that there is good evidence to support the use of ECPs. The report concludes that ECPs can be offered with the assurance that they are at least 75 percent effective, and indicates that although nausea and vomiting may be associated with treatment, use of antiemetic agents before administration of each dose will decrease the risk of these effects.

Beitz, J. and Hutchings, J. Emergency contraception: a vital component of reproductive health programs. Western Journal of Medicine 176:152-154 (2002).
About 75 million unintended pregnancies occur in the developing world annually, and each year 8 to 30 million women experience contraceptive failure. Women who have unintended pregnancy often seek abortion, often under unsafe conditions. Increasing awareness of and access to emergency contraception is one critical way to improve the health and well-being of all women, including adolescents, by preventing unwanted pregnancy and abortion.

Bellagio Conference on Emergency Contraception. Consensus statement on emergency contraception. Contraception 52 (1995).
This statement reports the outcome of an international meeting on emergency contraception.

Consortium for Emergency Contraception. Expanding Global Access to Emergency Contraception. Seattle: PATH (2000). English and Spanish versions available through the Consortium website at www.cecinfo.org/.
This publication provides an overview of the consortium's work to introduce a dedicated emergency contraception project in seven countries. It includes a history of the consortium's development, profiles of introduction efforts, updated medical and service-delivery guidelines, and additional resources for family planning programs.

Consortium for Emergency Contraception. Emergency Contraceptive Pills: A Resource Packet for Health Care Providers and Programme Managers. Seattle: PATH (1997).
This resource packet contains an extensive array of materials on emergency contraceptive pills (ECPs) including: suggestions for how to adapt resource packet materials for local use; a framework outlining key issues that should be considered before introducing ECPs through family planning, reproductive health, and other delivery systems; questions and answers for decision makers; prototype client brochures that describe in simple language what ECPs are and how they are used; and selected references on key studies that address ECP safety, efficacy, and use. Online versions of packet materials are available on the consortium website (www.cecinfo.org/).

Farrell, B. et al. Emergency Contraceptive Pills: A Comprehensive Training Course. Watertown, Massachusetts: Pathfinder International Medical Services, Training Module Number 5 (May 1997).
Although well-documented and safe, emergency contraceptive pills (ECPs) have not received significant attention or use until recently. ECPs can play a crucial role in family planning programs, providing a safe method of avoiding unwanted pregnancy after unprotected intercourse, as well as a bridge to continuing contraception. This training module will prepare providers to offer ECP services to family planning clients.

FHI. Emergency contraceptive pills. Network 21(1) (2001). Available at: www.fhi.org/en/fp/fppubs/network/v21-1/index.html.
Emergency contraceptive methods can prevent pregnancy after unprotected intercourse, method failure, or incorrect method use. In the past five years, major international reproductive health organizations, including WHO, have worked to make emergency contraception more widely available, increase the knowledge of providers and consumers about this method, and study unresolved research issues. This issue of Network describes how EC works, research efforts underway to improve ease of use and reduce side effects, and issues to be considered for program supply.

Glasier, A. and Baird D. The effects of self-administering emergency contraception. New England Journal of Medicine 239(1):1-4 (July 2, 1998).
The authors compared the use of emergency contraceptive pills (ECPs) in 553 women who were provided with a replaceable supply of hormonal emergency contraceptive pills to be taken at home (the treatment group), and 530 women who could obtain ECPs through a doctor (the control group). The study found that the women in the treatment group were no more likely to use emergency contraception repeatedly than the women in the control group, and that nearly all women used emergency contraception correctly. The authors conclude that making emergency contraception more easily obtainable does not pose any risks or increase the likelihood of repeat use. Furthermore, because the efficacy of ECPs decreases over time since unprotected intercourse, increased availability of emergency contraception may reduce the rate of unwanted pregnancies.

International Planned Parenthood Federation (IPPF). IMAP statement on emergency contraception. IPPF Medical Bulletin. 2004;38(4):1-3. Available at: www.ippf.org/medical/bulletin/pdf/Vol38No1March2004en.pdf.
This Bulletin contains the statement that was revised by the IPPF International Medical Advisory Panel (IMAP) after the October 2003 meeting. The bulletin reviews current knowledge about the method, mechanism of action, efficacy, eligibility criteria, and side effects. In addition, the following points are emphasized: family planning associations should strive to promote and provide emergency contraception in their countries; prompt, easy access to EC is crucial; the sooner ECPs are taken after sexual intercourse, the more effective they are; and the progestin-only pill regimen is better tolerated and more effective.

International Planned Parenthood Federation (IPPF). International Medical Advisory Panel Statement on Emergency Contraception. IPPF Medical Bulletin 28(6) (December 1994).
This statement on emergency contraception, developed by the International Medical Advisory Panel (IMAP) in 1994, describes the need for emergency contraception and recommends two standard methods: the Yuzpe method of oral contraceptives and the use of copper-releasing intrauterine devices (IUDs). The importance of appropriate counseling and appropriate follow-up are stressed. The IMAP statement also describes various methods of emergency contraception under investigation (in 1994), including levonorgestrel alone and antiprogestins. The IMAP statement recommends that family planning associations should advocate the availability of emergency contraception and, where available, they should advertise it widely so health providers and public will know in advance that it is an option for avoiding pregnancy.

JHPIEGO Corporation. Levonorgestrel is more effective, has fewer side-effects than Yuzpe regimen. ReproLine website, Reading Room. www.reproline.jhu.edu/english/6read/6issues/6progress/prog51_b.htm. Accessed January 2, 2003).
This article summarizes the clinical trial that compared levonorgestrel, given as two 0.75 mg doses 12 hours apart, with the Yuzpe regimen for emergency contraception. A total of 21 centers in 14 countries (Australia, Canada, China, Georgia, Hungary, India, Mongolia, New Zealand, Nigeria, Panama, Slovenia, Sweden, the United Kingdom, and the United States) took part in the study, which was completed in 1997. The results were published in the Lancet (352:428–433 [1998]) as the work of the Programme's Task Force on Postovulatory Methods of Fertility Regulation. This online article a summary of the study results, including efficacy and side effect data.

Jones, R.K. et al. Contraceptive use among U.S. women having abortions in 2000-2001. Perspectives on Sexual and Reproductive Health 34(6):294-303 (November/December 2002). Available at: www.guttmacher.org/pubs/journals/3429402.pdf.
Based on a review of contraceptive use patterns among 10,683 women in the United States who received abortion services during 2000-2001, this study suggests that more than 50,000 abortions were averted by use of emergency contraceptive pills in 2000. Of the women in this review, 1.3 percent reported having taken ECPs to prevent the pregnancy. Estimates by other researchers suggest that for each pregnancy that occurs after use of ECPs, three pregnancies are prevented. The authors conclude that the increased use of ECPs in the United States may account for a significant part of the recent reduction in abortions nationally. Interestingly, 46 percent of women did not use a contraceptive method in the month they became pregnant, mainly because of perceived low risk of pregnancy and concerns about contraception. The authors suggest that women and men need more opportunities to discuss issues such as when and whether to have sexual intercourse in a relationship, methods of pregnancy prevention, and appropriate timing of childbearing.

PATH. Emergency Contraception. 2004;1:1-11. Available in English and Russian.
PATH. EC and Beyond. 2005;2:1-8. Available in English and Russian.
PATH. EC and Beyond. 2005;3:1-6. Available in English and Russian.
PATH. EC and Beyond. 2005;4:1-8. Available in English and Russian.
The four issues of this newsletter address emergency contraception (EC) and reproductive health (RH) topics of interest to health care providers, program managers, and decision-makers in the Eastern Europe and Newly Independent States region. The content is based in part (with permission) on the Emergency Contraception Newsletter published twice a year by the International Consortium for Emergency Contraception and the American Society for Emergency Contraception. Topics include questions and answers, international EC news, regional EC and RH news, research results and technical updates, recent publications, meetings and events listings, and links to further resources. Available in English and Russian.

PATH. Emergency contraception update. Outlook. 1999;17(1):3. Available at: www.path.org/files/eol17_1.pdf.
This article reviews recent evaluations of emergency contraceptive pills (ECPs), including the 1998 WHO and Glasier studies. Based on the decreased incidence of side effects, the author concludes that the levonorgestrel-only regimen should be the product of choice where available. The article also recommends that programs inform women of the availability of emergency contraception during routine reproductive health care visits, and provide ECPs in advance of need.

PATH. Emergency contraceptive pills: safe and effective but not widely used. Outlook. 1996;14(2):1-6.
This article discusses the effectiveness, safety, mode of action, correct use, and service delivery considerations of two of the most commonly used hormonal emergency contraception regimens.

PATH. Tools for expanding ECP access. Available at: www.path.org/resources/ec_tools.htm.
This web page describes the PATH's Collaborative Agreement ECP Pilot Project, which aims to make emergency contraceptive pills more readily available to women in Washington State. The program relies on collaborative drug therapy agreements among pharmacists and other contraceptive care providers, such as physicians, that enable women to receive ECPs directly from a pharmacist. During the first 13 months of the project, 9,333 ECP prescriptions were provided to women directly by pharmacists. In May 1999, PATH hosted a workshop to help U.S. states increase access to ECPs directly through pharmacy providers. Materials created for the workshop were designed to help other states develop and implement similar projects and are available for downloading.

Population Council. Emergency contraception. New York: Population Council (1999). Available at: www.popcouncil.org/rhfp/ec.html.
In an effort to facilitate the use of emergency contraception, the Population Council has launched a study to learn if the Yuzpe regimen can be simplified and expanded. The goals of this two-year trial are to evaluate the effectiveness of the active ingredients of oral contraceptive pills as emergency regimens; the possibility of extending the time limit for taking the pills from three days (72 hours) to five days; the need for a second dose; and the relationship between food and nausea during therapy.

Senanayake, P. Emergency contraception: the International Planned Parenthood Federation's experience. International Family Planning Perspectives 22(2) (1996).
Since 1981, the International Medical Advisory Panel (IMPA) position has been that IPPF should recommend that all affiliates provide emergency contraception. This article describes results from a questionnaire mailed to all 136 IPPF affiliates in 1994 gathering information about service-related factors in providing emergency contraception and characteristics of women who request this method. Overall, 43 percent of participating family planning associations reported providing emergency contraception. Several important points for expanding access to emergency contraception are discussed.

Trussell, J. et al. Updated estimates of the effectiveness of the Yuzpe regimen of emergency contraception. Contraception 59:147-151 (1999).
Through a literature review, eight studies were identified that present the number of women treated and outcome of treatment by cycle day of unprotected intercourse relative to the expected day of ovulation. This data was used to assess the effictiveness of the Yuzpe method of emergency contraception. This reanalysis of existing data suggests that Yuzpe regimen reduces the risk of pregnancy by 74.1 percent, with a 95 percent confidence interval of 62.9-79.2 percent. True effectiveness is likely to be greater because treatment failures may include women who already were pregnant or became pregnant after being treated.

Trussell, J. et al. The effectiveness of the Yuzpe regimen of emergency contraception. Family Planning Perspectives 28(2) (1996).
This article reviews the results of ten clinical trials of women treated with Yuzpe emergency contraceptive pill (ECP) regimen. The review showed that estimates of ECP efficacy can be compared only when they are based on expected numbers of pregnancies (computed by matching the cycle day of unprotected intercourse relative to ovulation with conception rates specific to that cycle day). The weighted average of the effectiveness rates of all 10 studies was 74.0%.

Van Look, P.F.A. and von Hertzen, H. Research on the new methods of emergency contraception. International Family Planning Perspectives 22(2) (June 1996).
This article defines an ideal emergency contraceptive and reviews new methods that are currently being tested. Ideal method criteria are that it: (1) is highly effective, (2) is as safe as other methods, (3) is free of side effects, (4) does not disturb the menstrual cycle, (4) is easy to administer, and (5) is affordable. Levonorgestrel, Danazol, antiestrogens, GnRH Antagonists, and Progesterone inhibition are discussed. The authors conclude that basic research is unlikely to yield any new methods in the near future.

von Hertzen, H. et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet 360(9348):1803-1810 (December 7, 2002).
This randomized, double-blind clinical trial among 4,136 women in 15 clinics in 10 countries compared the efficacy and side effects of three regimens for emergency contraception: a single 10 mg dose of mifepristone; two 0.75 mg doses of levonorgestrel taken 12 hours apart; and a single dose of 1.5 mg levonorgestrel. The three regimens all are very effective at preventing pregnancy if taken within five days of unprotected intercourse. Side effects were mild and did not differ greatly among the groups.

World Health Organization (WHO). Emergency Contraception: A Guide to the Provision of Services. Geneva: WHO (1998).
Millions of unwanted pregnancies and abortions could be avoided if emergency contraceptives were easily accessible. This booklet provides technical and managerial advice on how to introduce emergency contraception into family planning programs (emergency contraception refers to contraceptive methods that can be used by women within a few days after unprotected intercourse to prevent an unwanted pregnancy). This booklet explains how available methods are effective, easy to use, and safe for the majority of women who may need them.

WHO Task Force on Postovulatory Methods of Fertility Regulation. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 352: 428-433 (August 8, 1998).
The World Health Organization (WHO) conducted a double-blind, randomized trial of 1,998 women who requested emergency contraception after one unprotected coitus. Approximately half received levonorgestrel-only ECPs (0.75 mg, repeated 12 hours later), and half received the Yuzpe regimen (100 g ethinyl estradiol plus 0.5 mg levonorgestrel, repeated 12 hours later). The crude pregnancy rate was 1.1% with the levonorgestrel-only regimen and 3.2% with the Yuzpe regimen. The incidence of side effects was significantly lower with the levonorgestrel-only regimen, particularly nausea (23.1% versus 50.5%) and vomiting (5.6% versus 18.8%). The study also found that the effectiveness of emergency contraception decreased as the interval between administration and intercourseincreased.

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