1. |
- Envall, Niklas, 1984-, et al.
(author)
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Intrauterine mepivacaine instillation for pain relief during intrauterine device insertion in nulliparous women: a double-blind, randomized, controlled trial
- 2019
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In: Contraception. - : Elsevier BV. - 0010-7824 .- 1879-0518. ; 99:6, s. 335-39
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To evaluate whether intrauterine mepivacaine instillation before intrauterine device (IUD) insertion decreases pain compared to placebo.STUDY DESIGN: We performed a double-blind, randomized, controlled trial comparing mepivacaine 1% 10 mL versus 0.9% NaCl intrauterine instillation using a hydrosonography catheter 5 min before IUD insertion in women 18 years of age or older. Participants completed a series of 10-cm visual analogue scales (VAS) to report pain during the procedure. The primary outcome was the difference in VAS scores with IUD insertion between intervention group and placebo. Secondary outcomes included VAS before and after insertion and analgesia method acceptability.RESULTS: We randomized 86 women in a 1:1 ratio; both groups had similar baseline characteristics. In the intention-to-treat analysis, the primary outcome, median VAS with IUD insertion, was 4.8 cm in the intervention group [n=41, interquartile range (IQR) =3.1-5.8] and 5.9 cm in the placebo group (n=40, IQR=3.3-7.5, p=.062). In the per-protocol analysis, the median VAS with IUD insertion was 4.8 cm (IQR=3.1-5.5) and 6.0 cm (IQR=3.4-7.6) for the intervention and placebo groups, respectively (p=.033). More women in the intervention group reported the procedure as easier than expected (n=26, 63.4% vs. n=15, 37.5%), and fewer reported it as worse than expected (n=3, 7.3% vs. n=14, 35%, p=.006).CONCLUSION: Intrauterine mepivacaine instillation before IUD insertion modestly reduces pain, but the effect size may be clinically significant.IMPLICATIONS STATEMENT: While the reduction in VAS pain scores did not meet our a priori difference of 1.3 points for clinical significance, participants' favorable subjective reaction suggests that this approach merits further study.Copyright © 2019 Elsevier Inc. All rights reserved.KEYWORDS: Contraception; Intrauterine devices; Mepivacaine; Pain; VAS
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2. |
- Erlandsson, Kerstin, 1961-, et al.
(author)
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Development of a tool to analyse what resources are needed to implement a midwife-led care framework : the MIDWIZE conceptual framework
- 2022
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In: Sexual & Reproductive HealthCare. - : Elsevier BV. - 1877-5756 .- 1877-5764. ; 33
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Journal article (peer-reviewed)abstract
- BACKGROUND: A midwife led care project targeting to decide what to do to achieve the SDG 2030 in maternal and child health, made a project team develop a tool to analyse what health care systems need, to adopt the MIDWIZE Conceptual Framework. The MIDWIZE Conceptual Framework wish to introduce the comprehensive midwifery-managed care provided women in Sweden to other countries, regions, and units where the framework is not fully applied.METHODS: In order to determine what resource needs would have to be met to improve midwife led care, a tool was developed using Delphi study technique.RESULTS: Using Delphi study technique together with on-site visits to two Sub-Saharan African countries, members of a project team went to Ethiopia and Uganda, where they visited governments, clinical or educational institutions and together with African leaders developed availability and efficiency of a tool to determine resource needs.CONCLUSION: If at some future time, a single country, region or unit, might want to use the tool for quality improvement purpose of midwife led care, then the tool might aid in taking the first step to determine what resources might be required and what changes might be recommended as concerns policy at the clinical or educational institution level that are part of already existing health care structures.
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3. |
- Lichtenstein Liljeblad, Karin, et al.
(author)
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Women's experiences of postpartum contraceptive services when elective caesarean section is the method of birth : a qualitative study
- 2024
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In: BMJ Sexual & Reproductive Health. - : BMJ Publishing Group Ltd. - 2515-1991 .- 2515-2009. ; 50:2, s. 107-113
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Journal article (peer-reviewed)abstract
- BACKGROUND: The unmet need for postpartum contraception is a global challenge. Postpartum placement of an intrauterine device (IUD) within 48 hours of vaginal delivery is available in many settings worldwide, but is not routinely practised in Sweden. To improve contraceptive services and facilitate the informed choice of IUD placement at the time of a caesarean section (CS), we performed this study to identify and describe women's experiences of contraceptive services before, during and after an elective CS.METHODS: A qualitative design and methodology was used. We interviewed 20 women aged 28-42 years who underwent elective CS in Sweden. Interviews were analysed using reflexive thematic analysis.RESULTS: The three main themes found were (1) receptivity to contraceptive counselling in the context of CS, (2) communication and decision-making about postpartum contraception before CS and (3) lack of support and guidance to receive contraceptive services before and after CS. The participants described readiness and interest regarding postpartum contraception. They prefered counselling from around 25 weeks of gestation. Despite this finding, antenatal communication and contraceptive decision-making seemed rare. Participants reported a lack of support and guidance which necessitated a need by women to navigate the contraceptive services themselves in order to receive information about contraception before CS and to receive postpartum support.CONCLUSIONS: Antenatal contraceptive counselling including information about IUD placement during CS was appreciated and welcomed by women with elective CS as their birth method. Most of the women whom we interviewed would prefer to receive contraception counselling on postpartum use during the second half of their pregnancy.
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4. |
- Ankarcrona, Victoria, et al.
(author)
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Attitudes and knowledge regarding episiotomy use and technique in vacuum extraction : A web-based survey among doctors in Sweden
- 2022
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In: European Journal of Obstetrics, Gynecology, and Reproductive Biology. - : Elsevier. - 0301-2115 .- 1872-7654. ; 269, s. 62-70
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Journal article (peer-reviewed)abstract
- Objectives: Correct episiotomy use and technique may prevent obstetric anal sphincter injuries. We aimed to explore the attitudes, use, and technique regarding episiotomy among doctors in Sweden, and their willingness to contribute to a randomized controlled trial of lateral episiotomy or no episiotomy in vacuum extraction in nulliparous women.Study design: A web-based survey was sent to members of the Swedish Society of Obstetrics and Gynecology (n = 2140). The survey included 31 questions addressing personal characteristics, use of episiotomy, a two-dimensional picture on which the respondents drew an episiotomy, and questions regarding attitudes towards episiotomy and participation in a randomized controlled trial. We calculated the proportion of supposedly protective episiotomies (fulfilling criteria of a lateral or mediolateral episiotomy and a length >= 30 mm). We compared the results between obstetricians, gynecologists, and residents using Chi-square and Kruskal-Wallis tests for differences between groups, and logistic regression to estimate the odds ratio (OR) of drawing a protective episiotomy.Results: We received 432 responses. Doctors without a vacuum delivery in the past year were excluded, leaving 384 respondents for further analyses. In all, 222 (57.8%) doctors reported use of episiotomy in<50% of vacuum extractions. We obtained 308 illustrated episiotomies with a median angle of 53 degrees, incision point distance from the midline of 21 mm, and length of 36 mm, corresponding to a lateral episiotomy. Few doctors combined these parameters correctly resulting in 167 (54.2%) incorrectly drawn episiotomies. Residents drew shorter episiotomies than obstetricians and gynecologists. Doctors ranked episiotomy the least important intervention to prevent obstetric anal sphincter injuries in vacuum extraction. Doctors contributing to an ongoing randomized controlled trial of lateral episiotomy or no episiotomy in vacuum extraction were more able to draw a protective episiotomy (OR 3.69, 95% confidence interval 1.94-7.02).Conclusions: Doctors in Sweden reported restrictive use of episiotomy in vacuum extraction and depicted lateral type episiotomies, although the majority were incorrectly drawn. Preventive episiotomy was ranked of low importance. Our results imply a need for education, training, and guidelines to increase uptake of correct episiotomy technique, which could result in improved prevention of obstetric anal sphincter injuries.
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5. |
- Bergendahl, Sandra, et al.
(author)
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Lateral episiotomy or no episiotomy in vacuum assisted delivery in nulliparous women (EVA) : multicentre, open label, randomised controlled trial
- 2024
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In: BMJ (Clinical research ed.). - : BMJ Publishing Group Ltd. - 1756-1833. ; 385
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To assess the effect of lateral episiotomy, compared with no episiotomy, on obstetric anal sphincter injury in nulliparous women requiring vacuum extraction.DESIGN: A multicentre, open label, randomised controlled trial.SETTING: Eight hospitals in Sweden, 2017-23.PARTICIPANTS: 717 nulliparous women with a single live fetus of 34 gestational weeks or more, requiring vacuum extraction were randomly assigned (1:1) to lateral episiotomy or no episiotomy using sealed opaque envelopes. Randomisation was stratified by study site.INTERVENTION: A standardised lateral episiotomy was performed during the vacuum extraction, at crowning of the fetal head, starting 1-3 cm from the posterior fourchette, at a 60° (45-80°) angle from the midline, and 4 cm (3-5 cm) long. The comparison was no episiotomy unless considered indispensable.MAIN OUTCOME MEASURES: The primary outcome of the episiotomy in vacuum assisted delivery (EVA) trial was obstetric anal sphincter injury, clinically diagnosed by combined visual inspection and digital rectal and vaginal examination. The primary analysis used a modified intention-to-treat population that included all consenting women with attempted or successful vacuum extraction. As a result of an interim analysis at significance level P<0.01, the primary endpoint was tested at 4% significance level with accompanying 96% confidence interval (CI).RESULTS: From 1 July 2017 to 15 February 2023, 717 women were randomly assigned: 354 (49%) to lateral episiotomy and 363 (51%) to no episiotomy. Before vacuum extraction attempt, one woman withdrew consent and 14 had a spontaneous birth, leaving 702 for the primary analysis. In the intervention group, 21 (6%) of 344 women sustained obstetric anal sphincter injury, compared with 47 (13%) of 358 women in the comparison group (P=0.002). The risk difference was -7.0% (96% CI -11.7% to -2.5%). The risk ratio adjusted for site was 0.47 (96% CI 0.23 to 0.97) and unadjusted risk ratio was 0.46 (0.28 to 0.78). No significant differences were noted between groups in postpartum pain, blood loss, neonatal outcomes, or total adverse events, but the intervention group had more wound infections and dehiscence.CONCLUSIONS: Lateral episiotomy can be recommended for nulliparous women requiring vacuum extraction to significantly reduce the risk of obstetric anal sphincter injury.TRIAL REGISTRATION: ClinicalTrials.gov NCT02643108.
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6. |
- Bergendahl, Sandra, et al.
(author)
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Lateral episiotomy versus no episiotomy to reduce obstetric anal sphincter injury in vacuum-assisted delivery in nulliparous women : Study protocol on a randomised controlled trial
- 2019
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In: BMJ Open. - : BMJ. - 2044-6055. ; 9:3
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Journal article (peer-reviewed)abstract
- Introduction Obstetric anal sphincter injury (OASIS) occurs in 5%-7% of normal deliveries and increases with vacuum extraction (VE) to 12%-14% in nulliparous women in Sweden. Lateral/mediolateral episiotomy may reduce the prevalence of OASIS at VE in nulliparous women. The current use of episiotomy is restrictive. The protective effect and consequences are uncertain. This trial will investigate if lateral episiotomy can reduce the prevalence of OASIS and assess short-term and long-term effects. Methods and analysis This is a multicentre randomised controlled trial of lateral episiotomy versus no episiotomy in nulliparous women with a singleton, live fetus, after gestational week 34+0 with indication for VE. A lateral episiotomy of 4 cm is cut at crowning, 1-3 cm from the midline, at a 60° angle. The primary outcome is OASIS by clinical diagnosis analysed according to intention to treat. To demonstrate a 50% reduction in OASIS prevalence (from 12.4% to 6.2%), 710 women will be randomised at a 1:1 ratio. Secondary outcomes are pain, blood loss, other perineal injuries, perineal complications, Apgar score, cord pH and neonatal complications. Web-based questionnaires at baseline, 2 months, 1 and 5 years will be used to assess pain, incontinence, prolapse, sexual function, quality of life and childbirth experience. A subset of women will receive follow-up by pelvic floor sonography and pelvic examination. Mode of delivery and recurrence of OASIS/episiotomy in subsequent pregnancies will be assessed at 5 and 10 years using register data. Ethics and dissemination The trial is open for enrolment. The trial has received ethical approval from the Regional Ethical Review Board of Stockholm and full funding from the Swedish Research Council. Women are interested in participation. The predominant restrictive view on episiotomy may limit recruitment. Results are of global interest and will be disseminated in peer-reviewed journals and at international congresses.
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7. |
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8. |
- Bizjak, Isabella, et al.
(author)
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Contraceptive uptake and compliance after structured contraceptive counseling - secondary outcomes of the LOWE trial
- 2024
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In: Acta Obstetricia et Gynecologica Scandinavica. - 0001-6349 .- 1600-0412. ; 103:5, s. 873-883
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Journal article (peer-reviewed)abstract
- INTRODUCTION: Highly effective long-acting reversible contraceptive (LARC) methods reduce unintended pregnancy rates; however, these methods are underutilized. The LOWE trial intervention provided structured contraceptive counseling resulting in increased uptake of LARC. This longitudinal follow up of the LOWE study assessed the long-term impact of the intervention by investigating the contraceptive use at 12 months with a focus on continued use of LARC.MATERIAL AND METHODS: In the cluster randomized LOWE trial, abortion, youth, and maternal health clinics were randomized to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of an educational video on contraceptive methods, key questions asked by the health care provider, a tiered effectiveness chart and a box of contraceptive models. Women ≥ age 18, who were sexually active or planned to be in the upcoming 6 months, could participate in the study. We assessed self-reported contraceptive use at three, six and 12 months. Contraceptive choice and switches were analyzed with descriptive statistics. Contraceptive use at 12 months and continued use of LARC were analyzed using mixed logistic regressions, with clinic included as a random effect. Analysis with imputed values were performed for missing data to test the robustness of results.RESULTS: Overall, at 12 months, women in the intervention group were more likely to be using a LARC method (aOR 1.90, 95% CI: 1.31-2.76) and less likely to be using a short-acting reversible contraceptive (SARC) method (aOR 0.66, 95% CI: 0.46-0.93) compared to the control group. Women counseled at abortion (aOR 2.97, 95% CI: 1.36-6.75) and youth clinics (aOR 1.81, 95% CI: 1.08-3.03) were more likely to be using a LARC method, while no significant difference was seen in maternal health clinics (aOR 1.84, 95% CI: 0.96-3.66). Among women initiating LARC, continuation rates at 12 months did not differ between study groups (63.9% vs. 63.7%). The most common reasons for contraceptive discontinuation were wish for pregnancy, followed by irregular bleeding, and mood changes.CONCLUSIONS: The LOWE trial intervention resulted in increased LARC use also at 12 months. Strategies on how to sustain LARC use needs to be further investigated.
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9. |
- Carlander, Anna-Karin Klint, et al.
(author)
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Knowledge, challenges, and standard of care of young women with ADHD at Swedish youth clinics
- 2022
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In: Sexual & Reproductive HealthCare. - Oxford, United Kingdom : Elsevier. - 1877-5756 .- 1877-5764. ; 32
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Journal article (peer-reviewed)abstract
- Objectives: Sexual risk-taking and its consequences for young women with ADHD(attention deficit hyperactivity disorder) including sexually transmitted diseases, teenage pregnancies and underage parenthood constitute substantial challenges for individuals and midwives. The aim was to investigate current knowledge and specific challenges in reproductive health and contraceptive counselling for women with ADHD at Swedish youth clinics. Method: Inductive qualitative interview study of ten midwives at six youth health clinics in Stockholm and Uppsala County. We used a semi-structured interview guide. The interviews were transcribed verbatim and analyzed with the NVivo 12 qualitative data analysis software. Results: Three main categories were identified: (1) challenges in provision of care of young women with ADHD, (2) standard of care and active adaptations towards women with ADHD and (3) organizational readiness for change;. Several challenges and frustrations, such as difficulties with attention with or without concomitant impulsivity and overactivity, in provision of reproductive health and contraceptive counselling for young women with ADHD were identified. Midwives reported high organizational readiness for improvement of standard of care. Conclusions: Inadequate contraceptive counseling or lack of knowledge on specific challenges in the sexual and reproductive health of young women with ADHD may contribute to this group failing to access, inadequately respond to, or act upon counseling at youth clinics. Support for midwives with evidence-based interventions specifically developed for these women are imperative. Development of such tools should be a priority for research.
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10. |
- Comasco, Erika, 1982-, et al.
(author)
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Ulipristal Acetate for Treatment of Premenstrual Dysphoric Disorder : A Proof-of-Concept Randomized Controlled Trial
- 2021
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In: American Journal of Psychiatry. - : American Psychiatric Association Publishing. - 0002-953X .- 1535-7228. ; 178:3, s. 256-265
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Journal article (peer-reviewed)abstract
- Objective: Premenstrual dysphoric disorder (PMDD) is a common mood disorder, characterized by distressing affective, behavioral, and somatic symptoms in the late luteal phase of the menstrual cycle. The authors investigated continuous treatment with a selective progesterone receptor modulator, ulipristal acetate (UPA), as a potential treatment for PMDD. Methods: The authors conducted an investigator-initiated, multicenter, double-blind, randomized, parallel-group clinical trial in which women with PMDD (N=95) were treated with either 5 mg/day of UPA or placebo during three 28-day treatment cycles. The primary outcome was the change in premenstrual total score on the Daily Record of Severity of Problems (DRSP) from baseline to end of treatment. DRSP scores were captured by daily ratings using a smartphone application and were analyzed with linear mixed models for repeated measures. Results: The mean improvement in DR SP score after 3 months was 41% (SD=18) in the UPA group, compared with 22% (SD=27) in the placebo group (mean difference 18%; 95% CI = -29, -8). Treatment effects were also noted for the DRSP depressive symptom subscale (42% [SD=22]compared with 22% [SD=32]) and the DRSP anger/irritability subscale (47% ISD=21) compared with 23% (SD=35I), but not for the DRSP physical symptom subscale. Remission based on DRSP score was attained by 20 women in the UPA group (50.0%) and eight women in the placebo group (21.1%) (a statistically significant difference). Conclusions: If these results are replicated, UPA could be a useful treatment for PMDD, particularly for the psychological symptoms associated with the disorder.
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11. |
- Ehrnsten, Lisa, et al.
(author)
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Efficacy of mifepristone and misoprostol for medical treatment of missed miscarriage in clinical practice-A cohort study
- 2020
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In: Acta Obstetricia et Gynecologica Scandinavica. - : WILEY. - 0001-6349 .- 1600-0412. ; 99:4, s. 488-493
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Journal article (peer-reviewed)abstract
- Introduction It has been estimated that one out of every four women experience first-trimester miscarriage. Missed miscarriage is a common form of early miscarriage where the products of conception are not expelled from the uterus. It is diagnosed by ultrasound. The primary objective of this study was to evaluate the success rate of a combination treatment with mifepristone and misoprostol for missed miscarriage in clinical practice. The secondary objective was to identify significant factors influencing the rate of success. Material and methods A cohort of 941 consecutive women with an ICD-10 diagnosis of missed miscarriage who received treatment with 800 mu g vaginal misoprostol and 2 repeat doses of 400 mu g oral misoprostol after mifepristone pretreatment between 1 January 2012 and 31 December 2014 was analyzed. Women with a uterine size smaller than 12 weeks who were planned for medical treatment were included in the study. The exclusion criteria were primary surgical management or planned follow up outside the Stockholm County Council area. Results The success rate of medical treatment, defined as no need for surgical treatment, was 85.5% (805/941) in women with a uterine size of less than 12 weeks. However, for women with uterine size below 9 weeks the success rate was 88.9% (586/659). Indeed, uterine size of 9 gestational weeks or larger at time of treatment was identified as the only significant risk factor for surgical intervention. Conclusions The medical regimen for missed miscarriage offered in this study appears to be safe and with high rates of success. Conclusions about which women to exclude from medical treatment could not be made. Medical treatment may therefore benefit all women with missed miscarriage who wish to avoid primary surgery.
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12. |
- Elenis, Evangelia, 1983-, et al.
(author)
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Estrogen-modulating treatment among mid-life women and COVID-19 morbidity and mortality : a multiregister nationwide matched cohort study in Sweden
- 2024
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In: BMC Medicine. - : BioMed Central (BMC). - 1741-7015. ; 22:1
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Journal article (peer-reviewed)abstract
- BackgroundIt has been repeatedly shown that men infected by SARS-CoV-2 face a twofold higher likelihood of dying, being hospitalized or admitted to the intensive care unit compared to women, despite taking into account relevant confounders. It has been hypothesized that these discrepancies are related to sex steroid hormone differences with estrogens being negatively correlated with disease severity. The objective of this study was therefore to evaluate COVID-19-related mortality and morbidity among peri- and postmenopausal women in relation to estrogen-containing menopause hormonal treatments (MHT).MethodsThis is a national register-based matched cohort study performed in Sweden between January 1 to December 31, 2020. Study participants comprised women over the age of 53 years residing in Sweden. Exposure was defined as prescriptions of local estrogens, systemic estrogens with and without progestogens, progestogens alone, or tibolone. MHT users were then compared with a matched cohort of non-users. The primary outcome consisted of COVID-19 mortality, whereas the secondary outcomes included inpatient hospitalizations/outpatient visits and confirmed SARS-CoV-2 infection. Multivariable adjusted Cox regression-derived hazard ratios (HRs) were calculated.ResultsUse of systemic estrogens alone is associated with increased COVID-19 mortality among older women (aHR 4.73, 1.22 to 18.32), but the association is no longer significant when discontinuation of estrogen use is accounted for. An increased risk for COVID-19 infection is further observed for women using combined systemic estrogens and progestogens (aHR 1.06, 1.00 to 1.13) or tibolone (aHR 1.21, 1.01 to 1.45). Use of local estrogens is associated with an increased risk for COVID-19-related death (aHR 2.02,1.45 to 2.81) as well as for all secondary outcomes.ConclusionsSystemic or local use of estrogens does not decrease COVID-19 morbidity and mortality to premenopausal background levels. Excess risk for COVID-19 morbidity and mortality was noted among older women and those discontinuing systemic estrogens. Higher risk for death was also noted among women using local estrogens, for which non-causal mechanisms such as confounding by comorbidity or frailty seem to be the most plausible underlying explanations.
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13. |
- Elgemark, Karin, et al.
(author)
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The 13.5-mg, 19.5-mg, and 52-mg Levonorgestrel-Releasing Intrauterine Systems and Risk of Ectopic Pregnancy
- 2022
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In: Obstetrics and Gynecology. - : NLM (Medline). - 0029-7844 .- 1873-233X. ; 140:2, s. 227-233
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To assess the Pearl Index for risk of ectopic pregnancy in women using levonorgestrel-releasing intrauterine systems (LNG-IUS) with hormonal reservoirs of 13.5 mg, 19.5 mg, or 52 mg. METHODS: This was a retrospective cohort study. Women diagnosed with an ectopic pregnancy in Stockholm County, Sweden, between January 1, 2014, and December 31, 2019, were identified through the electronic medical record system. The final analysis included 2,252 cases of ectopic pregnancy. Information on age, reproductive and medical history, as well as current use of contraception was retrieved. The time of intrauterine device (IUD) insertion before ectopic pregnancy and the numbers of sold LNG-IUS during the study period were used to calculate the incidence rate for ectopic pregnancy during use per 100 woman-years (Pearl Index). RESULTS: Among women with an ectopic pregnancy diagnosis, 105 presented with a known type of hormonal IUD in situ, of whom 94 were included in the calculations of the Pearl Index. The estimated Pearl Index for ectopic pregnancy was 0.136 (95% CI 0.106-0.176) for the LNG-IUS 13.5-mg, 0.037 (95% CI 0.021-0.067) for the LNG-IUS 19.5-mg, and 0.009 (95% CI 0.006-0.014) for the LNG-IUS 52-mg. With the 52-mg LNG-IUS as referent, the relative risk (RR) for ectopic pregnancy was higher during the first year for LNG 13.5-mg (RR 20.59, 95% CI 12.04-35.21), and for both 13.5-mg (RR 14.49, 95% CI 9.01-23.3) and 19.5-mg (RR 4.44, 95% CI 1.64-12.00) during the total study period. CONCLUSION: The absolute risk of ectopic pregnancy during the use of LNG-IUS at any doses was low. The results show that the lower the dose of the IUD, the higher the risk of an ectopic pregnancy. Higher-dose LNG-IUS should be considered when providing contraceptive counseling to a woman with known risk factors for ectopic pregnancy who are considering a hormonal IUD. Copyright © 2022 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
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14. |
- Emtell Iwarsson, Karin, et al.
(author)
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Increasing uptake of long-acting reversible contraception with structured contraceptive counselling : cluster randomised controlled trial (the LOWE trial).
- 2021
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In: British Journal of Obstetrics and Gynecology. - : Wiley. - 1470-0328 .- 1471-0528. ; 128:9, s. 1546-1554
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Journal article (peer-reviewed)abstract
- OBJECTIVES: To evaluate the effect of structured contraceptive counselling on uptake of long-acting reversible contraceptives (LARCs), and pregnancy rates.DESIGN: Cluster randomised trial SETTING: Abortion, youth, and maternal health clinics in Stockholm, Sweden.POPULATION: Sexually active women ≥18 years without a wish for pregnancy seeking abortion and/or contraceptive counselling.METHODS: For participants in clinics randomised to intervention, trained health care providers implemented a study-specific intervention package designed for structured contraceptive counselling. Participants in the control clinics received routine counselling.MAIN OUTCOME MEASURES: Primary outcome was choice of LARCs at first visit. Secondary outcomes were LARC initiation at three months and pregnancy rates at three and 12 months. We used logistic mixed-effects models with random intercept for clinic to account for clustering.RESULTS: From September 2017 to May 2019, 28 randomised clinics enrolled 1364 participants. Analyses including 1338 subjects showed that more participants in the intervention compared to control group chose LARCs (267/658 (40.6%) versus 206/680 (30.3%), odds ratio (OR) 2.77, 95% CI 1.99 to 3.86). LARC initiation was higher in the intervention compared to the control group (213/528 (40.3%) versus 153/531 (28.8%), OR 1.74, 95% CI 1.22 to 2.49). At abortion clinics, pregnancy rate was significantly lower at 12 months in the intervention versus the control group (13/101 (12.9%) versus 28/103 (27.2%), OR 0.39, 95% CI 0.18 to 0.88).CONCLUSIONS: Structured contraceptive counselling increased LARC uptake in all clinics and significantly reduced unintended pregnancy rates in abortion clinics at 12 months follow-up.
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15. |
- Emtell Iwarsson, Karin, et al.
(author)
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Long-acting reversible contraception and satisfaction with structured contraceptive counselling among non-migrant, foreign-born migrant and second-generation migrant women : evidence from a cluster randomised controlled trial (the LOWE trial) in Sweden.
- 2022
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In: BMJ Sexual & Reproductive Health. - : BMJ. - 2515-1991 .- 2515-2009. ; 48:2, s. 128-136
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Journal article (peer-reviewed)abstract
- OBJECTIVE: This trial aimed to evaluate effects of structured contraceptive counselling among non-migrants, foreign-born migrants and second-generation migrants.METHODS: A cluster randomised controlled trial was conducted in 2017-2019 at abortion, youth and maternal health clinics in Stockholm, Sweden (the LOWE trial). Patients were eligible if they were 18 years or older, could understand Swedish or English (or if assisted by an interpreter), were sexually active or planning to be, and were seeking contraception for pregnancy prevention. We randomised clinics at a 1:1 allocation ratio to give either structured contraceptive counselling (intervention) or to maintain standard contraceptive counselling (control). Blinding was not deemed feasibile. A study-specific package for structured contraceptive counselling was used and comprised an educational video, an effectiveness chart, four key questions and a box with contraceptive models. Outcomes were effects of the intervention on long-acting reversible contraception (LARC) choice, initiation and use, and satisfaction with the intervention material among the participants.RESULTS: We involved 14 clinics in each of the intervention and control groups, respectively. A total of 1295 participants were included: 1010 non-migrants, 169 foreign-born migrants and 116 second-generation migrants. Participants in the intervention group chose LARC to a higher extent than the control group (adjusted OR (aOR) 2.85, 95% CI 2.04-3.99), had higher LARC initiation rates (aOR 2.90, 95% CI 1.97 to 4.27) and higher LARC use within the 12-month follow-up period (aOR 2.09, 95% CI 1.47 to 2.96). The majority of the participants who received the intervention package found all the different parts to be supportive in contraceptive choice. The effectiveness chart was the only part of the package that a higher proportion of foreign-born migrants (58/84, 69%) and second-generation migrants (40/54, 74.1%) found supportive in contraceptive choice compared to non-migrants (259/434, 59.7%) (p = 0.048).CONCLUSIONS: Structured contraceptive counselling increased LARC choice, initiation and use, controlled for participants' migration background. The effectiveness chart was found to be significantly more supportive among foreign-born migrants and second-generation migrants compared to non-migrants when choosing contraceptive methods.TRIAL REGISTRATION NUMBER: NCT03269357.
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16. |
- Envall, Niklas, 1984-, et al.
(author)
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Mepivacaine instillation for pain reduction during intrauterine device placement in nulliparous women : a double-blinded randomized trial
- 2024
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In: American Journal of Obstetrics and Gynecology. - 0002-9378 .- 1097-6868.
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Journal article (peer-reviewed)abstract
- BACKGROUND: Fear of pain associated with intrauterine device placement has been identified as a significant barrier to the adoption of long-acting reversible contraception, contributing to lower utilization of the most effective reversible contraceptive methods.OBJECTIVE: To assess whether instillation of intrauterine mepivacaine before intrauterine device placement alleviates pain more effectively than a placebo.STUDY DESIGN: We conducted a multi-center, double-blind, randomized, placebo-controlled trial involving nulliparous women undergoing intrauterine device placement. An instillation of 10 mL of 20 mg/mL mepivacaine or 0.9 mg/mL sodium chloride was administrated through a hydrosonography catheter 2 minutes prior to intrauterine device placement. Pain scores were assessed using a 100 mm Visual Analog Scale at pre-specified time points. Primary outcome measured the difference in Visual Analog Scale pain scores between the intervention group and the placebo group during intrauterine device placement. Secondary outcomes included Visual Analog Scale pain scores at instillation and 10 minutes after placement, tolerability of the placement pain, as well as acceptability of the analgesia method.RESULTS: We enrolled 151 participants, with 76 assigned to the mepivacaine group and 75 to the placebo group. The mean VAS pain score during IUD placement showed a difference of 13.3 mm (95% CI 5.75-20.87; P<.001): the mepivacaine group had a mean of 53.9 mm (SD 22.8), while the placebo group had a mean of 67.2 mm (SD 22.4). After adjusting for each individual provider's impact, the difference in mean pain scores remained statistically significant (12.2 mm 95% CI 4.85-19.62; P<.001). A greater proportion of women in the intervention group reported tolerable pain during placement with 70/75 participants (93.3%) compared to 53/66 participants (80.3%) in the placebo group (P=.021).CONCLUSION: The intrauterine instillation of mepivacaine results in statistically significant reduction in pain score among nulliparous women during intrauterine device placement. Although the precise clinical impact of this pain reduction method remains uncertain, the observed reduction in pain score result in a higher proportion of women reporting tolerable pain. This finding and the high acceptance as a pain reduction method thereby suggests clinical relevance. Intrauterine instillation of mepivacaine is a possible strategy to increase IUD utilization, particularly among nulliparous women who are at high risk of unintended pregnancy.
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17. |
- Envall, Niklas, 1984-, et al.
(author)
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The use and access to contraception in Sweden during the COVID-19 pandemic period.
- 2023
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In: European journal of contraception & reproductive health care. - 1362-5187 .- 1473-0782. ; 28:5, s. 275-281
-
Journal article (peer-reviewed)abstract
- PURPOSE: Explore perceived access to, the need for, use of, and satisfaction with telemedicine services for contraceptive counselling and prescription-renewal-only during the COVID-19 pandemic, and the impact of the COVID-19 pandemic period on the choice and use of contraceptives.MATERIALS AND METHODS: Internet-based e-survey of Swedish women of fertile age, 16-49 years.RESULTS: In total, 1016 participants completed the survey. Most participants (69.7%) rated their access to contraceptive services 'as usual'. Among the remaining participants, a higher proportion rated their access as deteriorated (73.4%) compared to improved (26.6%; p < 0.001). In total, 38.0% reported a need for contraceptive counselling, whereof 14.0% had used telemedicine for counselling and reported high satisfaction. Telemedicine for prescription-renewal-only was used by 15.1% of the total population. Two per cent reported use of another contraceptive than their intended, whereof long-acting reversible contraceptives were the most common intended method. The proportion of current contraceptive users was lower than in 2017 (62.4% vs 71.1%, p < 0.001), and current users of long-acting reversible contraception decreased from 30.6% to 19.3% (p < 0.001).CONCLUSIONS: During the COVID-19 pandemic period, most women found their access to contraceptive services unaffected, but more women felt that it had deteriorated than improved. The use of telemedicine was low, and the use of contraception overall fell. Efforts are needed to raise awareness of available services, and TM-provided interventions for maintained quality of care and informed decision-making remain to be evaluated.SHORT CONDENSATION The COVID-19 period imposed a change in contraceptive service provision, and efforts are needed to raise awareness of available services, including telemedicine. Access to all contraceptives, including LARCs, is crucial and telemedicine-provided interventions need evaluation.
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18. |
- Envall, Niklas, 1984-, et al.
(author)
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Use of contraception and attitudes towards contraceptive use in Swedish women : an internet-based nationwide survey
- 2022
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In: European journal of contraception & reproductive health care. - : Informa UK Limited. - 1362-5187 .- 1473-0782. ; 27:5, s. 409-417
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Journal article (peer-reviewed)abstract
- PURPOSE: Explore contraceptive use, unmet need of and attitudes towards contraceptive use in Sweden. Secondly, to investigate knowledge of contraceptives, prevalence and outcomes of unintended pregnancies.MATERIALS AND METHODS: Internet based e-survey of Swedish women aged 16-49. The e-survey contained 49 questions with both spontaneous and multi-choice character on demographics, contraceptive use, knowledge of and attitudes towards contraception, importance of monthly bleeding, and experience of unintended pregnancy. The e-survey was closed when reaching the estimated sample size of 1000 respondents.RESULTS: A total of 1016 women participated, whereof 62.4% used contraception, 31.8% did not and 5.8% had stopped in the last 12 months. Unmet need for contraception was estimated at 17.2%. At least one unintended pregnancy was experienced by 19.9%. All women rated effectiveness as the most important characteristic of a contraceptive method.CONCLUSIONS: Use of contraception in Swedish women remains low, 62.4%, and the unmet need for contraception has increased to 17.2%. Method effectiveness and health benefits of hormonal contraception should be emphasised during contraceptive counselling, and actions are needed to target groups with low use of effective contraception as well as to reach those who never seek contraception.KEY MESSAGE Close to one third of Swedish women do not use contraception and one fifth have experienced at least one unintended pregnancy. Unmet need for contraception is high despite easy access and subsidies for young women.
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19. |
- Envall, Niklas, 1984-, et al.
(author)
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Use of effective contraception 6 months after emergency contraception with a copper intrauterine device or ulipristal acetate - a prospective observational cohort study
- 2016
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In: Acta Obstetricia et Gynecologica Scandinavica. - : Wiley. - 0001-6349 .- 1600-0412. ; 95:8, s. 887-95
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Journal article (peer-reviewed)abstract
- INTRODUCTION:Emergency contraception must be followed by the use of an effective method of contraception in order to reduce future risk of unintended pregnancies. Provision of long-acting reversible contraception (LARC) is highly effective in this regard. The aim of our study was to compare use of an effective method of contraception 6 months following insertion of a copper intrauterine device (Cu-IUD) or intake of ulipristal acetate (UPA) for emergency contraception (EC).MATERIAL AND METHODS:Women (n = 79) presenting with need for EC at an outpatient midwifery clinic chose either Cu-IUD or UPA according to preference. Follow up was 3 and 6 months later through telephone interviews. Primary outcome was use of an effective contraceptive method at the 6-month follow up. Secondary outcomes included use of an effective contraceptive method at 3 months follow up and acceptability of Cu-IUD.RESULTS:A total of 30/36 (83.3%) women who opted for Cu-IUD for EC used an effective contraceptive method 6 months after their first visit compared with 18/31 (58.1%) women who opted for UPA (p = 0.03). In the Cu-IUD group 28/36 (77.8%) were still using Cu-IUD at 6 months and 31/36 (86%) stated that they would recommend the Cu-IUD to others as an EC method.CONCLUSION:Significantly more women who chose Cu-IUD for EC used an effective method for contraception at the 6-month follow up. The results of this study support increased use of Cu-IUDs for EC.
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20. |
- Ginstman, Charlotte, 1975-, et al.
(author)
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Pharmacokinetics of Oral Levonorgestrel in Women After Roux-en-Y Gastric Bypass Surgery and in BMI-Matched Controls
- 2020
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In: Obesity Surgery. - : Springer. - 0960-8923 .- 1708-0428. ; 30:6, s. 2217-2224
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Journal article (peer-reviewed)abstract
- Background: Women are advised to primarily use non-oral contraceptive alternatives after Roux-en-Y gastric bypass since it is not known if the surgery affects the pharmacokinetics of oral contraceptives.Methods: This is a multi-center, open label, phase 2 pharmacokinetic study performed at the University Hospital of Linkoping and the Clinical Trials Center, Department of Obstetrics and Gynecology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden. Fifteen women aged 18-40 years who had previously undergone Roux-en-Y gastric bypass surgery and reached a BMI < 30 were included. Fifteen BMI-matched women with no previous history of Roux-en-Y gastric bypass surgery served as a control group. After administration of a single dose of a combined oral contraceptive containing 0.03 mg ethinylestradiol/0.15 mg levonorgestrel, serum levonorgestrel concentrations were determined during a 24-h period using ultra performance liquid chromatography/tandem mass spectrometry. The area under the plasma concentration time curve of levonorgestrel (AUC(0-24h)) was the main outcome measure.Results: There were no significant differences in the studied pharmacokinetic parameters, AUC(0-24h), total AUC, peak serum concentration (C-max), time to peak serum concentrations (T-max), apparent oral clearances of levonorgestrel (CLoral), or terminal half-lives (t1/2) between the groups.Conclusion: This is to our knowledge the first study to evaluate the pharmacokinetics of oral levonorgestrel in women with a BMI < 30 at least 1 year after RYGB compared with a BMI-matched group of women. We could not find any significant pharmacokinetic differences between the groups, suggesting that oral levonorgestrel may be used in non-obese women after Roux-en-Y gastric bypass once a stable body weight has been reached.
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21. |
- Hogmark, Sara, et al.
(author)
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One-year follow up of contraceptive use and pregnancy rates after early medical abortion : Secondary outcomes from a randomized controlled trial of immediate post-abortion placement of intrauterine devices
- 2023
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In: Acta Obstetricia et Gynecologica Scandinavica. - : Wiley-Blackwell. - 0001-6349 .- 1600-0412.
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Journal article (peer-reviewed)abstract
- Introduction: Intrauterine devices (IUDs) effectively prevent unwanted pregnancies. Little is known about long-term outcomes of women choosing an IUD after early medical abortion.Material and methods: We present secondary outcome data of continuation rates, factors associated with continuation and discontinuation, choice of IUD type, women's satisfaction with IUD, and IUD expulsions, subsequent pregnancies, and abortions within 1 year post-abortion in a randomized, controlled, multicenter trial on IUD placement within 48 hours compared with placement 2-4 weeks after medical abortion up to 63 days' gestation ( NCT03603145).Results: Of the 240 women studied, 112/120 (93.3%) in the intervention group vs 113/120 (94.2%) in the control group completed the 12-month follow-up. The rate of IUD use at 12 months was 84/112 (75%) in the intervention group vs 75/113 (66.4%) in the control group (P = 0.19). Attendance at the IUD placement visit was the only predictor of long-term IUD use (relative risk [RR] = 5.7, 95% confidence interval [CI] 2.03-16.0; P = 0.001). The main reason for choosing an IUD was high contraceptive effectiveness. The most common reasons for IUD discontinuation were bleeding problems and abdominal pain. IUD expulsion was rare and did not differ between groups. Satisfaction among IUD users at 1 year was high (>94%) and the majority of all participants would recommend IUD to a friend (65.8%). Use of no contraception and experience of unprotected intercourse were less common in the intervention group (11/112 [9.8%] vs 25/113 [22.1%], P = 0.02 and 17/112 [15.2%] vs 32/113 [28.3%], P = 0.02, respectively). There was no difference in the rate of subsequent pregnancies and abortions (pregnancies 14/112, 12.5% in the intervention group vs 8/113, 7.1% in the control group, P = 0.19; abortions 5/112, 4.5% vs 3/113, 2.7%, P = 0.5).Conclusions: IUD placement after medical abortion led to high continuation and satisfaction rates with no difference between groups. We found no difference in IUD expulsions after immediate compared with later placement. Unprotected intercourse was significantly less common in the immediate group. In clinical practice, immediate placement of IUDs available free of charge at the abortion clinic is likely to increase attendance to the placement visit and continued use of IUDs after abortion.
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22. |
- Hogmark, Sara, et al.
(author)
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Placement of an intrauterine device within 48 hours after early medical abortion : a randomized controlled trial
- 2023
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In: American Journal of Obstetrics and Gynecology. - : Elsevier BV. - 0002-9378 .- 1097-6868. ; 228:1, s. 53.e1-53.e9
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Journal article (peer-reviewed)abstract
- BACKGROUND: Intrauterine devices are safe, well tolerated and known to reduce the risk of unwanted pregnancies. At medical abortion, intrauterine devices are placed at a follow-up visit. Patients who miss this visit risk being left without contraception.OBJECTIVE: To study if placement of an intrauterine device within 48 hours of completed medical abortion up to 63 days' gestation leads to higher user rates at six months after the abortion compared with placement at two to four weeks after abortion. Furthermore, to compare continued use of intrauterine devices, safety and patient satisfaction between groups.STUDY DESIGN: We performed an open-label, randomized, controlled, multicenter, superiority trial (phase 3). A total of 240 patients requesting medical abortion up to 63 days' gestation and opting for intrauterine device were allocated to placement within 48 hours of complete medical abortion (intervention group) or at 2-4 weeks after abortion (control group). We defined the abortion as complete after bleeding of clots and cessation of heavy bleeding following use of misoprostol. Patients answered questionnaires at 3, 6 and 12 months. Primary outcome was use of intrauterine device at 6 months post abortion. Secondary outcomes included expulsion rate, pain at placement, adverse events and complications from the abortion, acceptability, and pregnancies and their outcomes. Differences in non-parametric continuous variables were analyzed by the Mann-Whitney U-test and differences in dichotomous variables were analyzed by Chi square test or Fisher's exact test. A p-value of < 0.05 was considered statistically significant.RESULTS: In the intervention group, 91/111 (82%) used an intrauterine device at six months after the abortion, compared to 87/112 (77.7%) in the control group with a difference in proportion of 4.3% (95% CI -0.062, 0.148, p=0.51). Attendance rate and rate of successful intrauterine device placement were similar between groups. Patients in the intervention group had lower pain scores at placement of the intrauterine device (mean pain score VAS 32.3, SD 29) compared to the control group (mean pain score VAS 43.4, SD 27.9, p=0.002). Patients preferred their allocated time of placement significantly more often in the intervention group, (83/111, 74.8%) compared to the control group (70/114, 61.4%, p=0.03). Use of ultrasound at intrauterine device placement (because of doubts concerning complete abortion) was more common in the intervention group (43/108, 39.8%) compared to the control group (15/101, 14.9%, p<0.001) and in one patient in the control group, a retained gestational sac was found. Three patients in the intervention group and two patients in the control group had a vacuum aspiration. No difference was found in intrauterine device expulsion rates between the groups. In the intervention group, 9/97 (9.3%) patients experienced expulsion during the first six months after abortion and 4/89 (4.5%, p=0.25) in the control group. There were no perforations or infections requiring antibiotic treatment.CONCLUSION: Placement of an intrauterine device within 48 hours after medical abortion at ≤ 63 days' gestation does not lead to higher user rates at six months after the abortion, compared with intrauterine device placement at 2-4 weeks after abortion. When compared with placement at a follow-up visit after 2-4 weeks, intrauterine device placement within 48 hours after early medical abortion appears safe, is preferred by patients and associated with lower pain scores.
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23. |
- Hogmark, Sara, et al.
(author)
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Placement of an intrauterine device within 48 hours after second trimester medical abortion : a randomized controlled trial
- 2024
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In: American Journal of Obstetrics and Gynecology. - 0002-9378 .- 1097-6868.
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Journal article (peer-reviewed)abstract
- BACKGROUND: International guidelines recommend placement of intrauterine devices immediately after second trimester medical abortion, but evidence concerning the optimal time for intrauterine device placement is lacking from clinical trials.OBJECTIVE: We aimed to investigate effectiveness, safety, and acceptability of intrauterine device placement within 48 hours, compared with placement at two to four weeks after second trimester medical abortion. We hypothesized that intrauterine device placement within 48 hours would be superior compared with placement at two to four weeks after the abortion, in terms of the proportion of intrauterine device use after six months, with maintained safety and acceptability.STUDY DESIGN: In this open-label, randomized, controlled, superiority trial, we recruited participants at eight abortion clinics in Sweden. Eligible participants were ≥18 years, requesting medical abortion with gestation ≥85 days and opting for use of a post abortion intrauterine device. Participants were randomized (1:1) to intrauterine device placement either within 48 hours of complete abortion (intervention) or after 2 to 4 weeks (control). Our primary outcome was self-reported use of an intrauterine device after 6 months. Secondary outcomes included expulsion rates, pain at placement, adverse events and complications, acceptability, and subsequent pregnancies and abortions. Differences in non-normal continuous variables were analyzed with the Mann-Whitney U-test and differences in dichotomous variables with the chi square or Fisher's exact tests. A P value <.05 was considered statistically significant. Group differences are presented by modified intention-to-treat and per protocol analyses.RESULTS: Between January 2019, and June 2022, we enrolled 179 participants, of whom 90 were assigned to intervention and 89 to control. Enrolment was prematurely stopped after an interim analysis exceeded a predefined intrauterine device expulsion rate of 20%. By modified intention-to-treat, use of intrauterine device after 6 months was 50.7% (34/67) in the intervention group compared to 71.6% (48/67) in the control group (proportion difference 20.9%; 95% confidence interval 4.4%-35.9%; P=.02). The intrauterine device expulsion rate was 30.1% (22/73) in the intervention group versus 2.9% (2/70; P <.001) in the control group. Other adverse events were rare and patient acceptability was high in both groups.CONCLUSION: Intrauterine device placement within 48 hours after second trimester medical abortion was non-superior in terms of the proportion of intrauterine device use after 6 months when compared with placement after 2 to 4 weeks. Placement within 48 hours after second trimester abortion can be used in selected individuals after counselling on expulsion risk.
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24. |
- Hogmark, Sara, et al.
(author)
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Provision of long-acting reversible contraception at surgical abortion-A cross-sectional nationwide register study
- 2022
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In: Acta Obstetricia et Gynecologica Scandinavica. - : Wiley. - 0001-6349 .- 1600-0412. ; 101:1, s. 77-83
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Journal article (peer-reviewed)abstract
- Introduction: Provision of long-acting reversible contraception (LARC) at surgical abortion is safe, practical, and leads to higher user rates than does delayed provision. The aim of this study was to explore whether provision of LARC at surgical abortion is associated with known risk factors for subsequent abortions and inconsistent use of contraception, including sociodemographic factors and psychiatric disorders.Material and methods: This was a register-based cross-sectional study of 6251 women having a surgical abortion in Sweden. Data were collected from National health and population registers. Women with procedure codes for surgical abortion were identified in the National Patient Register from October 2016 to December 2018. Information from Statistics Sweden, the National Patient Register, and the Swedish prescribed drug register on sociodemographic factors, psychiatric disorders, and dispensed LARC was added and linked on an individual level. Associations of sociodemographic factors and psychiatric disorders with LARC provision were explored with generalized logit mixed models and presented as crude and adjusted odds ratios with 95% confidence intervals (CIs).Results: The overall rate of LARC provision at the time of the abortion was 2515/6251 (40.2%). Younger age and lower level of education were associated with an increased likelihood of LARC provision. In the study population, 2624/6251 (42.0%) patients had a pre- or post-abortion psychiatric disorder, a factor associated with an increased likelihood of LARC provision compared with women with no such disorders (adjusted odds ratio 1.21; 95% CI 1.08-1.34). The highest rates and odds were seen among women with personality, substance use, and/or neurodevelopmental disorders and among women with multiple psychiatric disorders.Conclusions: Sociodemographic risk factors and psychiatric disorders were associated with increased LARC provision at surgical abortion, indicating that women at high risk of unwanted pregnancies are provided with effective contraception. Still, less than half of all women undergoing surgical abortion were provided with LARC, suggesting that contraceptive access and counseling prior to a surgical abortion can be improved.
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25. |
- Kallner, Helena Kopp, et al.
(author)
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DIAGNOSTIC COLPOSCOPIC ACCURACY BY THE GYNOCULAR AND A STATIONARY COLPOSCOPE
- 2015
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In: International Journal of Technology Assessment in Health Care. - 0266-4623 .- 1471-6348. ; 31:3, s. 181-187
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Journal article (peer-reviewed)abstract
- Objectives: The aim of this study was to evaluate the diagnostic accuracy of sensitivity and specificity of cervical lesions by the low-cost, portable Gynocular colposcope and a stationary colposcope, in women referred for colposcopy with abnormal cervical cytology. Methods: A randomized cross-over clinical trial for evaluating the diagnostic accuracy in detecting cervical lesions by the Gynocular and a stationary colposcope. The Swede score systematic colposcopy system was used for evaluation of colposcopic abnormalities. Directed punch biopsy and excisional cone biopsy were used as the gold-standard by histologically confirmed high grade cervical lesions CIN2+ (CIN2, CIN3, CIN3+). In total, 123 women referred for colposcopy due to abnormal cervical cytology were recruited at the Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden. The percentage agreement and the kappa statistic were calculated for Swede score by the Gynocular and a stationary colposcope. Swede scores were compared with the results from directed punch biopsy and excisional cone biopsy. Results: The Gynocular and the stationary colposcope had a high agreement of Swede scores with a Kappa statistic of 0.947, p < .0001. Punch biopsy diagnosed CIN2+ (CIN2, CIN3, and invasive cancer) in 44 (35.7 percent) women while cytology detected CIN2+ in 34 (27.6 percent) women. There were no significant differences of the sensitivity and specificity for different Swede scores by the Gynocular or a stationary colposcope in detecting CIN 2+. Conclusions: There were no significant differences in sensitivity or specificity in detecting cervical lesions by the Gynocular or stationary colposcope. The Gynocular is as accurate in diagnosing cervical lesions as a stationary colposcope.
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26. |
- Kopp Kallner, Helena
(author)
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Increasing access to medical abortion
- 2012
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Doctoral thesis (other academic/artistic)abstract
- Introduction. Unsafe abortion kills approximately 47000 women per year. However, women in high resource settings may also have difficulties in accessing safe abortion facilities due to high cost, a large number of visits required or difficulty in finding an abortion provider. The object of this thesis was to examine ways to increase access to medical abortion. Materials, methods and results. Study I: Home use of misoprostol may decrease cost, the number of required visits and by attracting women who dislike hospitals. A total of 395 women with gestational age up to and including 63 days were recruited to investigate efficacy and acceptability of home use of misoprostol. Women with gestational length lower than 50 days were compared to women with gestational length of 50 days or higher. Efficacy of the procedure was high (97,5%). Overall acceptability of the procedure did not differ between the groups (p=0,36) and was not related to gestational age (p=0,097). Study II: In the second study the objective was to assess which factors had a significant influence on the acceptability of home use of misoprostol in the same group of patients. Potentially influential factors were recoded into categorical variables and evaluated using logistic regression. In the final models parity (p=0,003) and feeling calm after the administration of misoprostol (p<0,001) had a positive influence on the experience in relation to expectation whereas having a positive u-hcg test on follow up had a negative influence (p=0,003). Women who had a partner/friend present during the abortion were more likely (p=0,021) whereas women with a positive u-hcg on follow up were less likely to prefer home administration of misoprostol (p=0,002). Study III: Letrozole is an aromatase inhibitor and has been shown to increase the number of complete abortions when used with misoprostol only. A total of 16 women scheduled for surgical abortion were randomized to either pretreatment with letrozole or no pretreatment. Uterine contractility was measured before and after the cervical priming dose of misoprostol was given. The results were analyzed using repeated measures ANOVA. No difference in time to tonus increase (p=0,243), maximum tonus (p=0,953) or contractility between the two groups was detected (p=0,423). Study IV: Task shifting from physicians to midlevel providers may increase access to abortion services where physicians are scarce or unwilling to perform abortion provision. Before any examination had been made 1180 women were randomized to medical abortion provision by a physician or nurse midwife. Both provisions were equally effective with the risk difference of 1,6% within the set margin of equivalence of 5% (p=0,027). Women randomized to nurse midwife were significantly more likely to prefer seeing a midwife again were they to have another medical abortion (p<0,001). Conclusions. This thesis shows that increased access to medical abortion can be achieved in several ways by either increasing use of home use of misoprostol, finding new drugs without previous abortion stigma to replace mifepristone or by task shifting provision of medical abortion from physicians to midlevel providers.
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27. |
- Kopp Kallner, Helena, et al.
(author)
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Use of Contraception and Attitudes towards Contraceptive Use in Swedish Women : A Nationwide Survey
- 2015
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In: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 10:5
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Journal article (peer-reviewed)abstract
- Objective: To describe contraceptive use and attitudes towards contraceptive use in Sweden which has the highest abortion rate in Western Europe. Secondary objectives were to investigate knowledge of contraceptive methods and outcomes of unplanned and unwanted pregnancies.Design: Telephone survey.Setting: National survey of women living in Sweden.Population: Women between 16 and 49 years.Methods: The survey contained 22 questions with free text and multi choice answers on demographics, contraceptive use, knowledge of and attitudes towards contraception, the importance of monthly bleeding and experience of unintended pregnancy.Main Outcome Measures: Distribution of use of contraceptive methods and non-use of contraception among Swedish women. Prevalence and outcome of unintended pregnancies.Results: A total of 1001 women participated in the survey. Of all women, 721/1001 (72.1%) currently used contraception whereas 268/1001 (26.8%) women did not. Long acting reversible contraception, (LARC; implant and intra uterine contraception) was used by 24.3% of women. The unmet need of contraception in Sweden was estimated at 8.9% (89/1001 women). A total of 781 (78%) women had never experienced an unintended pregnancy whereas 220 (22%) women had had at least one unintended pregnancy. Users and non-users alike stated that one of the most important characteristics of a contraceptive method is its effectiveness.Conclusions: Sweden has a large unmet need for contraception. Furthermore, a large proportion of women have experienced at least one unintended pregnancy. Increasing contraceptive use and promotion of LARC is a possible way forward in the effort to reduce the rates of unwanted pregnancies.
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28. |
- Li, Xiaofei, et al.
(author)
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Profiling spatiotemporal gene expression of the developing human spinal cord and implications for ependymoma origin
- 2023
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In: Nature Neuroscience. - : Springer Nature. - 1097-6256 .- 1546-1726. ; 26:5, s. 891-901
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Journal article (peer-reviewed)abstract
- The authors created a comprehensive developmental cell atlas for spatiotemporal gene expression of the human spinal cord, revealed species-specific regulation during development and used the atlas to infer novel markers for pediatric ependymomas. The spatiotemporal regulation of cell fate specification in the human developing spinal cord remains largely unknown. In this study, by performing integrated analysis of single-cell and spatial multi-omics data, we used 16 prenatal human samples to create a comprehensive developmental cell atlas of the spinal cord during post-conceptional weeks 5-12. This revealed how the cell fate commitment of neural progenitor cells and their spatial positioning are spatiotemporally regulated by specific gene sets. We identified unique events in human spinal cord development relative to rodents, including earlier quiescence of active neural stem cells, differential regulation of cell differentiation and distinct spatiotemporal genetic regulation of cell fate choices. In addition, by integrating our atlas with pediatric ependymomas data, we identified specific molecular signatures and lineage-specific genes of cancer stem cells during progression. Thus, we delineate spatiotemporal genetic regulation of human spinal cord development and leverage these data to gain disease insight.
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29. |
- Lichtenstein Liljeblad, Karin, et al.
(author)
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Effectiveness, safety and overall satisfaction of early postpartum placement of hormonal IUD compared with standard procedure : An open-label, randomized, multicenter study
- 2022
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In: Acta Obstetricia et Gynecologica Scandinavica. - : John Wiley & Sons. - 0001-6349 .- 1600-0412. ; 101:4, s. 424-430
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Journal article (peer-reviewed)abstract
- INTRODUCTION: In this open-label, randomized controlled, non-inferiority, multicenter study we aimed to study the risk of termination of pregnancy within 1 year postpartum, the safety profile and patient acceptability after early postpartum insertion of a hormonal intrauterine device (LNG-IUS, Mirena®) compared with standard placement 6-8 weeks postpartum.MATERIAL AND METHODS: April 2018 to January 2020 women with uncomplicated vaginal delivery at four urban birth centers in Sweden, were randomized to either early placement within 48 h after delivery (early group) or standard placement 6-8 weeks postpartum (standard group) of a hormonal intrauterine device. The main outcome measure was the proportion of terminations of pregnancies in each group during the first year after placement of the intrauterine device. Registration EudraCT database no. 2017-001945-29.RESULTS: The study was prematurely stopped according to the protocol due to an expulsion rate >20% in the early group. No pregnancies occurred. Fifty-two women were randomized to early and 49 women to standard insertion. In the early group, 23/52 (44.2%) of the intrauterine devices were expelled. After expulsion, 10 women chose to have another hormonal intrauterine device placed but still significantly fewer women (39/52, 75%, p = 0.22) in the early group used the hormonal intrauterine device method at study completion. No expulsions occurred in the standard group, but 5/49 (10.2%) requested removal and 41/49 (83.7%, p = 0.22) had used the hormonal intrauterine device method continuously for 1 year.CONCLUSIONS: Early hormonal intrauterine device insertion after vaginal delivery is associated with high expulsion rates. Despite this, a high continuation rate of the hormonal intrauterine device method is seen among women once choosing the method. In the light of high continuation rates, the advantages of early insertion could balance the risk of expulsion for well-informed women.
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30. |
- Lichtenstein Liljeblad, Karin, et al.
(author)
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Risk of abortion within 1–2 years after childbirth in relation to contraceptive choice : a retrospective cohort study
- 2020
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In: European journal of contraception & reproductive health care. - : Taylor & Francis. - 1362-5187 .- 1473-0782. ; 25:2, s. 141-146
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Journal article (peer-reviewed)abstract
- Objectives: The primary objective of the study was to investigate whether the choice of long-acting reversible contraception (LARC) was associated with the risk of abortion over a period of 24 months postpartum. The secondary objective was to analyse whether other significant factors were affecting the risk of abortion during this period.Methods: In this retrospective cohort study, we analysed 11,066 women who had delivered in three Swedish cities during 2013 and 2014. Demographic and medical variables were obtained from medical records. Attendance at the postpartum visit, choice of postpartum contraception and history of abortion was noted. Logistic regression analysis was performed to assess factors associated with the risk of abortion. The main outcome measure was the proportion of women with abortion up to 24 months postpartum.Results: Data from 11,066 women were included in the final analysis. Within 12-24 months after delivery 2.5% of women had an abortion. The choice of LARC after childbirth reduced the risk of subsequent abortion (odds ratio 0.74; 95% confidence interval [CI] 0.60, 0.91; p = .005). Smoking, age <25 years and have had a previous abortion significantly increased the risk of abortion during follow-up, whereas exclusive breastfeeding decreased the risk.Conclusions: Increasing the proportion of women who choose LARC postpartum could decrease the risk of abortion for up to 2 years after childbirth.
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31. |
- Lundin, Cecilia, et al.
(author)
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Hormonal Contraceptive Use and Risk of Depression Among Young Women With Attention-Deficit/Hyperactivity Disorder
- 2023
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In: Journal of the American Academy of Child and Adolescent Psychiatry. - : Elsevier BV. - 0890-8567 .- 1527-5418. ; 62:6, s. 665-674
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Journal article (peer-reviewed)abstract
- Objective: Women with attention-deficit/hyperactivity disorder (ADHD) have an increased risk of becoming teenage mothers. Adverse effects of hormonal contraception (HC), including depression, may affect adherence to user-dependent contraception and increase the risk for unplanned pregnancies and teenage births in women with ADHD. The current study analyzed whether girls and young women with ADHD are at increased risk for depression during HC use compared with women without ADHD.Method: A linkage of Swedish national registers covering 29,767 girls and young women with ADHD aged 15 to 24 years and 763,146 without ADHD provided measures of ADHD and depression diagnoses (International Classification of Diseases [ICD] code) and prescription of stimulant medication, HC, and antidepressant medication (Anatomical Therapeutic Chemical [ATC] code). Cox regression models applying an interaction term (ADHD diagnosis x HC use) evaluated the excess risk of HC-induced depression in women with ADHD.Results: Women with ADHD had a 3-fold higher risk of developing depression, irrespective of HC use (adjusted hazard ratio [aHR] = 3.69, 95% CI = 3.60-3.78). Oral combined HC users with ADHD had a 5 times higher risk of depression compared with women without ADHD who were not using oral combined HC (aHR = 5.19, 95% CI = 4.94-5.47), anda 6 times higher risk in comparison with women without ADHD who were on oral combined HC (aHR = 6.10 (95% CI = 5.79-6.43). The corresponding risk of depression in women with ADHD who used a progestogen-only pill (aHR = 5.00, 95% CI = 4.56-5.49). The risk of developing depression when using non-oral HC was similarly moderately increased in both groups.Conclusion: Girls and young women with ADHD have an increased risk of developing depression when using oral HC compared with their un-affected peers. Information on risks with HCs as well as potential benefits with long-acting reversible contraceptives needs to be an integrated part of the shared decision making and contraception counseling for young women with ADHD.
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32. |
- Mühlrad, Hanna, et al.
(author)
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Interpregnancy interval and maternal and neonatal morbidity : a nationwide cohort study
- 2022
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In: Scientific Reports. - : Springer Science and Business Media LLC. - 2045-2322. ; 12
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Journal article (peer-reviewed)abstract
- This study aimed to assess the association between interpregnancy interval (IPI)—the time from childbirth to conception of the next pregnancy—and maternal and neonatal morbidity. The World Health Organization (WHO) currently recommends an IPI of at least 24 months after a live birth to reduce adverse birth outcomes. However, assessing the relationship between IPI and perinatal outcome is complicated by confounding factors. We conducted a nationwide population-based cohort study using Swedish registry data, allowing for adjustment of maternal characteristics and health at first birth. The study population consisted of all women with a singleton, live, and vaginal first birth with a second singleton birth within five years during 1997–2017, covering 327,912 women and 655,824 neonates. IPI was grouped into six-month intervals with 24–29 months as the reference. The association between IPI and morbidity was examined using multivariate logistic regression. For women having a vaginal delivery at their first birth, intervals < 24–29 months were associated with decreased maternal morbidity and unaffected neonatal morbidity. Intervals > 24–29 months were associated with increased maternal and neonatal morbidity. Our findings question the relevance of WHO’s recommendation of an IPI of at least 24 months in a high-income country.
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33. |
- Niemeyer Hultstrand, Jenny, et al.
(author)
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Hormonal contraception and risk of breast cancer and breast cancer in situ among Swedish women 15-34 years of age : A nationwide register-based study
- 2022
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In: The Lancet Regional Health. - : Elsevier. - 2666-7762. ; 21
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Journal article (peer-reviewed)abstract
- Background: Evidence on a possible association between newer hormonal contraceptives (HC) and risk of breast cancer remains inconclusive, especially as concerns progestogen-only methods.Methods: In this nationwide prospective cohort study, all Swedish women aged 15-34 at study start on January 1st 2005, or who turned 15 years during the study period, were followed until December 31st 2017. Using information from seven National Registers, we assessed the risk ratio of developing breast cancer and breast cancer in situ in relation to different HC using Poisson regression. We adjusted the analyses for several known confounders of breast cancer.Findings: This cohort included 1.5 million women providing more than 14 million person-years. During the study period, 3842 women were diagnosed with breast cancer. Compared with never users of any HC, we found no increased risk of developing breast cancer among current users of any combined HC, IRR 1.03 (0.91-1.16), whereas current users of progestogen-only methods had an increased risk of developing breast cancer, IRR 1.32 (1.20-1.45). Across all types of HC, the risk of developing breast cancer appeared to be highest the first five years of use (combined HC IRR 1.39 (1.14-1.69); progestogen-only methods IRR 1.74 (1.44-2.10). The risk disappeared ten years after the women stopped using HC. The absolute risk of breast cancer per 100,000 women-years was 22.4 for never users, 10.9 for current users of combined HC, and 29.8 for current users of progestogen-only methods.Interpretation: Current use of progestogen-only methods is associated with a small increased risk of developing breast cancer, whereas we could only detect an increased risk among users of combined HC during the first five years of use. This may partly be explained by a selective prescription of progestogen-only methods to women with risk factors for breast cancer, like smoking or obesity. As the absolute risk of breast cancer was small, the many health benefits associated with HC must also be taken into account in contraceptive counselling.
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34. |
- Nordström, Fanny, et al.
(author)
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Contraceptive use at the time of and after an ectopic pregnancy : a retrospective cohort study
- 2020
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In: European journal of contraception & reproductive health care. - : Informa UK Limited. - 1362-5187 .- 1473-0782. ; 25:2, s. 147-150
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Journal article (peer-reviewed)abstract
- Objectives: Approximately, 1–2% of all pregnancies are ectopic; 25% of unintended pregnancies are conceived despite the use of contraception. The primary objective of our study was to explore the proportion of ectopic pregnancies (EPs) that were conceived during contraceptive use among women in Stockholm County. Secondary objectives were to establish the prevalence of contraceptive methods used at the time of EP and the intended contraceptive method after treatment completion.Methods: We performed a retrospective cohort study of 1180 women diagnosed with and treated for EP between 1 December 2013 and 30 April 2017 at all hospitals in Stockholm County. Demographic variables and contraceptive use before and after treatment were noted. Exclusion criteria were uncertainty about the diagnosis of EP in the patient records and planned treatment/follow-up outside Stockholm County.Results: A total of 222/1180 (18.8%) EPs were conceived during known contraceptive use. A total of 112/222 (50.5%) women with known use of contraception at the time of conception discontinued contraceptive use and 81/857 (9.5%) women with no prior use of contraception initiated contraceptive use. Among the 857 women, 520 (60.7%) expressed a desire to conceive. Results were compared using the Mann–Whitney U test or Fisher's exact test as appropriate.Conclusion: EP occurring during use of contraception is an unexplored problem. Contraceptive use decreased in women who were using contraception at the time of EP conception, leaving these women at risk of a subsequent unintended pregnancy. There should be more focus on contraceptive use after treatment for EP, in order to preserve fertility.
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35. |
- Scherwitzl, Elina Berglund, et al.
(author)
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Short- and long-term effect of contraceptive methods on fecundity
- 2019
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In: European journal of contraception & reproductive health care. - : TAYLOR & FRANCIS LTD. - 1362-5187 .- 1473-0782. ; 24:4, s. 260-265
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Journal article (peer-reviewed)abstract
- Objective: The aim of the study was to compare the effect of previously used contraceptive methods on women's short- and long-term fecundity. Use of hormonal contraception (HC) was compared with the use of a contraceptive mobile application (app). Methods: This real-life prospective observational study comprised 2874 women who were attempting to become pregnant using the Natural Cycles mobile app to monitor their fertility. The women registered to use the app between August 2014 and June 2016 with the intention of planning a pregnancy and had previously either used the same app to prevent pregnancy or had recently discontinued HC use. We calculated the average time to pregnancy (TTP) for all women who became pregnant during the study and performed Kaplan-Meier life-table analysis to examine the cumulative probabilities of pregnancy for all women in the study. Results: The average TTP was 2.3 (95% confidence interval [CI] 2.1, 2.4) and 3.7 (95% CI 3.4, 3.9) cycles for women who had previously used Natural Cycles and HC, respectively. The time to reach 30% pregnancy probability for women previously on HC was 1.6 (95% CI 1.5, 1.8) times longer than for women previously using Natural Cycles. There was no significant difference in the 13 cycle cumulated pregnancy probability between the two groups. Conclusion: The results show that fertility awareness-based methods of contraception increase short-term pregnancy rates relative to HC, but have no effect on long-term pregnancy rates.
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36. |
- Sjöström, Susanne, et al.
(author)
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Medical Abortion Provided by Nurse-Midwives or Physicians in a High Resource Setting : A Cost-Effectiveness Analysis
- 2016
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In: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 11:6
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Journal article (peer-reviewed)abstract
- Objective The objective of the present study is to calculate the cost-effectiveness of early medical abortion performed by nurse-midwifes in comparison to physicians in a high resource setting where ultrasound dating is part of the protocol. Non-physician health care professionals have previously been shown to provide medical abortion as effectively and safely as physicians, but the cost-effectiveness of such task shifting remains to be established. Study design A cost effectiveness analysis was conducted based on data from a previously published randomized-controlled equivalence study including 1180 healthy women randomized to the standard procedure, early medical abortion provided by physicians, or the intervention, provision by nurse-midwifes. A 1.6% risk difference for efficacy defined as complete abortion without surgical interventions in favor of midwife provision was established which means that for every 100 procedures, the intervention treatment resulted in 1.6 fewer incomplete abortions needing surgical intervention than the standard treatment. The average direct and indirect costs and the incremental cost-effectiveness ratio (ICER) were calculated. The study was conducted at a university hospital in Stockholm, Sweden. Results The average direct costs per procedure were EUR 45 for the intervention compared to EUR 58.3 for the standard procedure. Both the cost and the efficacy of the intervention were superior to the standard treatment resulting in a negative ICER at EUR -831 based on direct costs and EUR -1769 considering total costs per surgical intervention avoided. Conclusion Early medical abortion provided by nurse-midwives is more cost-effective than provision by physicians. This evidence provides clinicians and decision makers with an important tool that may influence policy and clinical practice and eventually increase numbers of abortion providers and reduce one barrier to women's access to safe abortion.
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37. |
- Skoglund, Charlotte, et al.
(author)
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Association of Attention-Deficit/Hyperactivity Disorder With Teenage Birth Among Women and Girls in Sweden
- 2019
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In: JAMA Network Open. - : AMER MEDICAL ASSOC. - 2574-3805. ; 2:10
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Journal article (peer-reviewed)abstract
- IMPORTANCE Attention-deficit/hyperactivity disorder (ADHD) is associated with a plethora of adverse health outcomes throughout life. While Swedish specialized youth clinics have carefully and successfully targeted risk of unplanned pregnancies in adolescents, important risk groups, such as women and girls with ADHD, might not be identified or appropriately assisted by these interventions. OBJECTIVES To determine whether women and girls with ADHD are associated with increased risk of teenage birth compared with their unaffected peers and to examine the association of ADHD with risk factors for adverse obstetric and perinatal outcomes, such as smoking, underweight or overweight, and substance use disorder. DESIGN, SETTING, AND PARTICIPANTS This nationwide cohort study included data from 6 national longitudinal population-based registries in Sweden. All nulliparous women and girls who gave birth in Sweden between January 1, 2007, and December 31, 2014, were included. Data analyses were conducted from October 7, 2018, to February 8, 2019. EXPOSURES Women and girls treated with stimulant or nonstimulant medication for ADHD (Anatomic Therapeutic Chemical classification code N06BA) in the Swedish Prescribed Drug Register between July 1, 2005, and December 31, 2014. MAIN OUTCOMES AND MEASURES Maternal age at birth. Secondary outcome measures were body mass index, smoking habits, and psychiatric comorbidities. RESULTS Among 384 103 nulliparous women and girls aged 12 to 50 years who gave birth between 2007 and 2014 included in the study, 6410 (1.7%) (mean [SD] age, 25.0 [5.5] years) were identified as having ADHD. The remaining 377 693 women and girls without ADHD (mean [SD] age, 28.5 [5.1] years) served as the control group. Teenage deliveries were more common among women and girls with ADHD than among women and girls without ADHD (15.3% vs 2.8%; odds ratio [OR], 6.23 [95% CI, 5.80-6.68]). Compared with women and girls without ADHD, those with ADHD were more likely to present with risk factors for adverse obstetric and perinatal outcomes, including smoking during the third trimester (OR, 6.88 [95% CI, 6.45-7.34]), body mass index less than 18.50 (OR, 1.29 [95% CI, 1.12-1.49]), body mass index more than 40.00 (OR, 2.01 [95% CI, 1.60-2.52]), and alcohol and substance use disorder (OR, 20.25 [95% CI, 18.74-21.88]). CONCLUSIONS AND RELEVANCE This study found that women and girls with ADHD were associated with an increased risk of giving birth as teenagers compared with their unaffected peers. The results suggest that standard of care for women and girls with ADHD should include active efforts to prevent teenage pregnancies.
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38. |
- Stenhammar, Elin, et al.
(author)
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Levonorgestrel intrauterine device and depression : A Swedish register-based cohort study
- 2023
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In: International Journal of Psychophysiology. - : Elsevier. - 0167-8760 .- 1872-7697. ; 193
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Journal article (peer-reviewed)abstract
- Background: The levonorgestrel intrauterine device (LNG-IUD) is traditionally viewed as a safe contraceptive with limited systemic effects. However, three recent studies have indicated an increased risk of depression subsequent to LNG-IUD use. This study aimed to examine the potential associated risk between LNG-IUDs and depression, and determine which women are at risk.Methods: This longitudinal cohort study was based on data from seven Swedish national population-based registers. All Nordic-born women aged 15-24 years residing in Sweden between 2010 and 2017 were included. Cox regression was implemented to estimate the adjusted hazard ratio (AHR) for developing depression, defined as first depression diagnosis or redeemed prescription for antidepressant treatment. We adjusted for age, education level, parental country of origin, parental psychiatric health, previous hormonal contraceptive use and medical indications for contraceptive use.Findings: 703,157 women were included in the analysis. The LNG-IUD was associated with 57 % increased risk of depression [AHR 1.57 (95 % CI 1.51-1.64)]. The greatest risk increase was seen in adolescent women [AHR 2.57, (95 % CI 2.36-2.80)] and women who used the LNG-IUD as their first hormonal contraceptive method [AHR 1.63, (95 % CI 1.50-1.78)]. The risk of depression decreased at the end of study period [AHR 1.43, (95 % CI 1.36-1.51)], once the LNG-IUD became more widely accessible among nulliparous women.Conclusions: Adolescent women who use the LNG-IUD as their first-ever hormonal contraceptive are at increased risk of developing depression. However, additional impact from confounding factors is likely as risk estimates decreased over the study period. Further research needs to determine if there is a causal relationship between LNG-IUDs and depression.
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39. |
- Wikman, Anna, et al.
(author)
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Prevalence and correlates of current suicidal ideation in women with premenstrual dysphoric disorder
- 2022
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In: BMC Women's Health. - : BioMed Central (BMC). - 1472-6874. ; 22:1
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Journal article (peer-reviewed)abstract
- BACKGROUND: Although previous studies report an association between Premenstrual Dysphoric Disorder (PMDD) and suicidal ideation, most studies have only established a provisional and retrospective diagnosis of PMDD fundamentally invalidating the diagnosis. Therefore, the aim of this study was to describe the prevalence and to explore correlates of current suicidal ideation in the late luteal phase in women with prospectively assessed and confirmed PMDD.METHODS: Participants were 110 women who attended the pre-randomization baseline visit of two randomized placebo-controlled clinical trials between January 15, 2017 and October 19, 2019. PMDD was diagnosed prospectively in line with DSM-5 criteria. Current suicidal ideation was measured by the MADRS-S in the late luteal phase. Descriptive statistics were presented and logistic regression analyses were carried out to explore the association between psychosocial and health characteristics and current suicidal ideation, presenting unadjusted odds ratios (OR) and 95% confidence intervals (CI).RESULTS: Current suicidal ideation was reported by nearly 40% of women with confirmed PMDD (n = 43, 39.1%). Previous psychological treatment for PMDD and higher depressive symptoms in the late luteal phase were positively associated with current suicidal ideation (OR 5.63, 95% CI 1.07-29.49, and OR 1.17, 95% CI 1.10-1.25, respectively), whereas higher ratings of self-rated health were associated with lower odds ratios for current suicidal ideation (OR 0.98, 95% CI 0.96-0.99).CONCLUSIONS: A substantial proportion of women with confirmed PMDD report current suicidal ideation in the late luteal phase. Results point to a need for better awareness and screening of suicidal ideation in women with PMDD.
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