Abstracts of Congress Sessions

CONGRESS SESSION 1: REPRODUCTIVE HEALTH, DEMOGRAPHY & THE ENVIRONMENT: EMPOWERING WOMEN IN CHOICE OF CONTRACEPTION

S01-1 Demography and contraception: strange but productive bedfellows

Amy Tsui

Johns Hopkins University, Baltimore, Maryland, USA

Global perspectives on the linkage between contraception, as a health technology and practice, and demography, as the statistical study of human populations and their dynamics of size, growth, density, and distribution, have evolved over centuries. Recent swings in the visibility of family planning as a focus of international development assistance reflect an underlying tension between the pre-eminence of a social justice, health or economic benefits framework as a driving rationale for global support. Between 1990 and 2010, reproductive rights rationale held sway but subsequently lost ground to the Millennium Development Goals framework. Beginning in 2010, and coming into clear focus with the 2012 London Family Planning Summit, family planning has regained attention with a development goal of universal access to contraceptive services. Equity in access across low-income settings is fully subsumed as well.

The demography field itself has diversified largely along economic lines with topical clusters around low fertility, union formation, migration, and population aging for industrialised societies and other interest clusters formed around sexual, reproductive, maternal and child health outcomes for youth and adults in low-income countries. At the macro-level, there is re-emerging interest in the demographic and health dividends of childbearing patterns and the role of fertility regulation. The tools of the field include an embrace of empiricism, worldwide cross-national and systematic data collection, rapid electronic access, improved statistical modelling, adoption of qualitative investigational methods, democratised participation in the research process and a growing number of dissemination and translation platforms and professional communities for the information products.

The aims of this presentation are to (a) trace the historical swings in perspectives on the relationship of contraception and demography, (b) provide empirical support for these demarcated periods of global attention and frameworks of reasoning, and (c) review the evidence behind the linkages between contraceptive practice, as a determinant of demographic change, and human development. The central thesis of this presentation is that modern contraception is one of the most transformative technologies developed in the past 100 years that has altered the lives of millions, if not billions, of individuals globally and with positive outcomes.

S01-2 Green contraceptive research and development

Diana Blithe

National Institutes of Health, Bethesda, MD, USA

The concept of ‘Green Contraception’ is a challenge to define. Effective contraception is inherently ‘green’ because it helps control the population to a level that is desired and necessary to sustain the health of the environment. However, within the category of contraception, there are many factors that could potentially be improved in order to minimise the impact of the product on the environment. A group of reproductive health experts have developed a ‘Greenprint’ to describe the challenges and opportunities for the contraceptive development field. The main areas that were identified for improving the lifecycle of any product were: (1) resources and materials; (2) concept and design; (3) manufacturing; (4) packaging and transport; (5) consumer utilisation; and (6) waste and disposal. Each stage of the lifecycle could potentially be improved if the processed is examined thoughtfully, with a goal of minimising negative impacts on the environment. The challenges are to demonstrate the cost-benefit for each proposed improvement and to engage the relevant parties (manufacturers, suppliers, users) to participate in the goal of improving the lifecycle processes with respect to environmental impact. Effectiveness of the method is a major consideration because a completely ‘green product’ will not have much benefit if it has a high failure rate. However, within the life cycle of effective methods, there may be many opportunities to incorporate simple cost effective green solutions into various processes.

S01-3 Sex – is this the most dangerous human activity to all life on earth?

John Guillebaud

University College London, London, UK

At its best giving the greatest mutual pleasure humans know .... this activity also has risks, direct and indirect.

The direct risks are heart attacks or strokes (mainly in older men!) and STIs (both genders). Other direct risks apply only to uncontracepted sex – which Nature has applied unfairly to women alone, and which can be minimised by voluntary family planning:

• Maternal mortality: c1000 deaths each day, 99% in resource-poor settings, including c1,000 a week from c 20 million unsafe abortions; and

• Maternal morbidity, which is 20 x mortality.

But un-contracepted sex has a danger that is no less serious for being indirect, namely too many humans (> 7000 million, rising annually by the population of Germany) for sustainability on our finite planet. In 2009 the UK's Chief Scientist declared the world faces a ‘perfect storm’ of population growth, peak oil and climate change, which enhances the risk of violence in the face of energy, water and food insecurity.

More than 4 decades ago Ehrlich and Holdren showed there are only three factors or drivers of human environmental impact, namely: the ‘green-ness’ or otherwise of technology – on average, per person; ongoing resource consumption and pollution, again per person; and the number of persons. Since the stakes are so high and there exist only these three factors, is it not foolhardy to continue to neglect any one of them? The first two factors are well recognised as determining environmental footprints, but there are insane taboos that inhibit adult discussion about the number of feet! In reality that often-neglected driver can be addressed in a woman-centred way, wisely and compassionately, as demonstrated by countries as different as Taiwan and Iran: namely, to make family planning and other reproductive health services freely available, and accessible to everyone and empower and encourage them via education and the media to use it – yet without any whiff of coercion. All the ‘haves’ in the world must also drastically reduce our per-person consumption, by simultaneously addressing the two more widely recognised factors above.

I have not seen a world problem that wouldn't be easier to solve with fewer people, or harder, and ultimately impossible, with more. Sir David Attenborough, Patron, Population Matters

Family planning could bring more benefits to more people at less cost than any other single technology now available to the human race. James Grant, The State of the World's Children, UNICEF1992 processes.

CONGRESS SESSION 2: THREATS TO SEXUAL HEALTH OF WOMEN: THE ROLE AND INFLUENCE OF THE PROFESSIONAL

S02-3 Dealing with abortion or dealing with continuation of an unplanned pregnancy: Shame and blame or console, help and growth?

Anne Verougstraete^1,2

^aSjerp-Dilemma-VUB, Brussels, Belgium, ^bHôpital Erasme ULB, Brussels, Belgium

What should the role of the doctor be in case of an unplanned pregnancy?

The woman needs to feel the doctor will respect her as much whatever her decision: to terminate a pregnancy or stay pregnant; that she is not a better woman either way. If she feels this respect from care providers, it will help her to respect herself, and help her to take the right decisions needed to go on with her life.

Young women need to feel our support if they wish to postpone childbearing in order to complete their studies and that their future professional plans are worthwhile. That it is a responsible decision to wait until they find what is needed to raise a child in good circumstances.

Abortion is still a big taboo and a lot of women can't talk to their friends or families about it.

About half of unplanned pregnancies end up in abortion. An unplanned pregnancy can, of course, turn out to be really wanted, but no woman should stay pregnant because she feels guilty. Society should be careful not to praise women who keep an unwanted pregnancy. The life of these women and children is not always great!

CONGRESS SESSION 3: SOCIO-CULTURAL ASPECTS OF REPRODUCTIVE HEALTH

S03-1 Religious determinants of human reproduction

Giuseppe Benagiano

Department of Gynaecology, Obstetrics and Urology, Sapienza, University of Rome, Rome, Italy

All three major monotheistic religions hold that sexual activity is ethically permissible only within the sanction of marriage.

With regard to contraception, Judaism permits the use of most modern methods, although it insists that ejaculation must occur within the vagina, although recently the need to prevent the spread of HIV/AIDS has softened this stand.

Within Christianity, the Roman Catholic Church remains opposed to modern contraceptive technology because it is not permitted to separate sexuality from reproduction. Orthodox Churches have of late moved towards permitting the use of certain modern methods of contraception within marriage. Protestant Churches initially held a critical attitude, although later they accepted and approved birth spacing through contraception.

No Quranic text forbids prevention of conception and the Prophet sayings appear to support it. Therefore, modern methods of contraception are permissible, so long as they cause no harm to either partner or to their future fecundity.

With regard to assisted reproduction technology (ART), Judaism, emphasises that permissibility or leniency needs no supportive precedent. Thus, it allows all forms of ART and does not forbid even surrogate motherhood, although, from a religious point of view, the child will belong to the father who gave the sperm and to the woman who gave birth.

The Roman Catholic and Orthodox Churches believe that this technology exposes mankind to the temptation to go beyond the limits of a reasonable dominion over nature and therefore disapprove of them.

Today most Protestant denominations accept ART, because a couple should have a right to achieve the legitimate goal of having a child even if this means resorting to a partly external act. They seem to agree that, whenever possible, infertility should be treated.

Islam has for many years accepted ART as a positive step to decrease childlessness, considered a very negative feature. At the same time, Sunni Islam forbids gamete donation, whereas in Shi'a Islam, this and even foster motherhood are permitted.

With regard to interrupting a gestation, in principle, Judaism does not regard the foetus as a full human being, but condemns abortion, albeit not as murder. Interrupting a gestation is however permitted for medical reasons.

Abortion is totally condemned by the Roman Catholic and Orthodox Churches, whereas among Protestant denominations the situation is complex, with some supporting a ‘qualified access to abortion services’.

Within Islam, while there is no actual approval of abortion, there is no strict, unanimous ban on it either and early Islamic teaching held abortion permissible up to day 40 of gestation.

S03-3 The responsibility of the media in disseminating health information on reproductive and sexual health

Toni Belfield^1,2

^cHon FFSRH, London, UK, ^dFRCOG, London, UK

Most people rely on the media as their key source of information, whether it is accurate or inaccurate. The media is part of all our lives, both professional and private, and is a significant force in presenting information and forming opinion. Reproductive and sexual health issues such as contraception, sexually transmitted infections, abortion, pregnancy and sexual wellbeing are all to do with sex and sex always attracts media attention. Bad news is quickly reported and often badly, whilst good news is seldom seen or discussed. This presentation will address the role of the print (written), broadcast (spoken) and digital (often a mixture of the two) media; it will include views from health professionals and from journalists about what they feel the roles and responsibilities are when providing information about reproductive health, and what each should be doing to support and improve the delivery of good information. Recognising the need to provide correct, objective information requires journalists and health professionals to work more closely together as allies rather than adversaries. However, many health professionals have little or no experience of working with the media and the prospect of talking with journalists is for some very daunting. Understanding how the media work, and recognising that sometimes journalists are under pressure to provide a ‘good’ story rather than an accurate one, is important and this presentation will provide some practical approaches to working more effectively with journalists. The responsibility of providing good information, which both informs and enables people to make confident decisions, is vital if we are to improve sexual and reproductive health, this is a challenge to us all whatever ‘hat’ we wear.

CONGRESS SESSION 4: HORMONES AND THE BRAIN

S04-1 Do neuroendocrine pathways help us to understand female sexuality?

Johannes Bitzer

University Hospital Basel, Department of Obstetrics and Gynecology, Basel, Switzerland

Introduction: Sexuality can be viewed upon and investigated from two basic perspectives: (a) The subjective experience which is studied by interviewing, questionnaires to be described as a verbal story or expression. (b) The objectively observable and measurable changes in the body which may or may not correspond to an experiential element. The most difficult part for the second perspective is sexual desire a predominantly subjective experience. The question is, whether there are observable changes in the brain corresponding to subjective experience and whether understanding these changes can be of use clinically.

Method: Review of the literature concerning the biology of desire.

Results: Biologically the dual control model (dynamic interaction of exciting and inhibiting factors ‘produces’ the level of desire) seems to have biological correlates. Dopamine, Melanocortin, Noradrenaline in concert with estrogen and testosterone seem to be the biological signals involved in excitement while prolactin, serotonin and opoids seem to inhibit and block the activation of the desire system. It is not clear, however, how much these biological processes reflect just the responsivity to sexual cues or whether these transmitters ‘cause’ spontaneous sexual feelings.

Conclusion: Understanding the neurophysiology of the sexual response can help in two dimensions: (a) Understanding and managing the influence of diseases and drugs on the sexual response, and (b) Possibly helping in the future to evaluate psychotherapeutic and medical interventions for sexual desire and arousal disorder.

S04-3 Magnitude of the problems during reproductive life

Inger Sundström Poromaa

Uppsala University, Department of Women's and Children's Health, Uppsala, Sweden

More than 90% of women on oral contraceptives report very high levels of satisfaction, but ever since the introduction of COCs, one of the major reasons for discontinuing COC use has been mood-related side effects, such as depressive symptoms, irritability, and mood swings. Surprisingly little is known about the prevalence of truly COC-related adverse mood symptoms and about the underlying biological mechanisms responsible for the proposed changes in mood and affect. There are several reasons for this. First, depressed mood, anxiety and irritability are all subjective symptoms as opposed to other common endpoints in COC trials. Because subjective symptoms are particularly sensitive to placebo or nocebo effects, positive expectations of a new contraceptive, as well as general negative opinions may influence (positively or negatively) the results of any given trial. Secondly, placebo-controlled COC trials have long been considered unfeasible in healthy women and it was once stipulated that such trials should only be conducted in sterilised women. Third, over the years, most clinical trials have focused on evaluating efficacy, bleeding profile and somatic symptoms in COC users and it is not until recently that the potential effect on mood has gained interest. Finally, for the purpose of investigating COC-induced mood symptoms, many clinical trials on COCs are hampered by high rates of users with negative expectations and high discontinuation rates. As a consequence, final evaluations are often made by subjects who did not drop out, thereby possibly resulting in a healthy survivor effect.

This presentation will address the following questions: How common are adverse mood symptoms in contraceptive users? During which part of the treatment cycle are adverse mood symptoms most pronounced? How frequently are adverse mood symptoms drug-related? Are there any contraceptives with more beneficial profile with respect to mood symptoms?

CONGRESS SESSION 5: ADOLESCENT SEXUAL HEALTH

S05-1 Talking with adolescents about their sexual health: Pearls and pitfalls

Ellen Rome

Cleveland Clinic Children’s Hospital, Cleveland, OH, USA

Adolescence is a time of biologic, cognitive, and psychosocial change that keeps peers, parents, and clinicians on their toes! Developing a healthy sexuality, including intercourse, is an expected part of adulthood; hence, approaching sexual risk behaviours differs from addressing substance abuse or smoking, where the goal is never to start, and if one has started, to quit use. Thus, even a delay in initiation of sexual activity can be considered a valid and worthwhile goal for adolescents. Framing a healthy sexuality includes instilling in teens a sense of pride and ownership of their bodies and selves, self esteem to be able to negotiate ‘no’, and a sense of choice in all matters of health and sexuality. Clinicians need to be comfortable establishing confidentiality and holding these conversations with adolescents in order to help them find a path to healthier choices.

This session will discuss developmental barriers that contribute to adolescents’ unhealthy choices, including the adolescent mindset and the late development of abstract thought. Tips for helping teens and parents to clarify their own values and beliefs without imposing the practitioners’ own beliefs will be addressed. How to establish confidentiality will be covered, as well as motivational interviewing tips to help the adolescent, family and community ensure that delay/abstinence can be encouraged, sexual experimentation proceeds in a way that leads to sexual health, high self esteem, and ability to make healthy choices, and the teen does not feel judged in the process. Paediatricians and other clinicians are particularly well suited to provide education and advocacy in the office, schools, at parent programming, and in their communities. Primary care clinicians can help adolescents and parents by demystifying sex education and helping them find and use ‘teachable moments’. Tips for recognizing one's own innate biases, strengths, and weaknesses will also be addressed. At the end of this session, participants will be able to ask developmentally appropriate questions, detect problems ideally before they occur, react to already existent problems, and ensure adequate follow up. Helping adolescents to develop the knowledge, skills and motivation to make healthy choices is paramount, placing risk reduction into a lifelong perspective for both the adolescent and his/her family.

S05-4 Adolescent sexuality and sexual health

Dan Apter

Sexual Health Clinic, Väestöliitto, Helsinki, Finland

Sexual development brings along dreams and wishes of a new kind of relationship. A maturing young person is in many aspects lonely and uncertain, and thus sensitive and vulnerable. Supporting the self-esteem of the young person together with adequate and sufficient sexuality education helps her to make choices to maintain and protect her sexual health.

Sexual health for adolescents is based on three fundamental components: (1) Recognising their sexual rights. (2) Sexuality education and counselling, and (3) Confidential high quality services. These components all need to be considered together. The closer sexuality education programmes and sexual health services work together, the better are the results.

Adolescent sexual behaviour, as evaluated by the median age at first intercourse, does not differ much around the word, at least between developed countries. For girls it seems to be about four years after menarche. In Finland, the time interval from menarche to first intercourse has remained rather constant the last 100 years. Median age at first intercourse for girls is 16.8 and for boys 17.4 years in Finland. However, the consequences of sexual behaviour differ greatly, as seen in, e.g., numbers of teenage deliveries, abortions, and STIs.

Sexual health services for adolescents can be provided in various settings, as long as certain basic principles are observed. The clinic should have a youth-friendly atmosphere, where young people can feel welcome and comfortable. Unquestionable confidentiality is very important. The providers must not moralise and judge the adolescents, but treat adolescents with respect indicating that young people are important. In this way self-esteem is strengthened, and adolescents learn to respect and take care of themselves and others. A full range of contraceptive methods should be available. Access also without prescription to emergency contraception has proven important. A free telephone line for questions is part of the services, and nowadays also Internet information services.

In conclusion, when adolescent sexuality is not condemned but sexuality education and sexual health services instead are provided, it is possible to profoundly improve adolescent sexual health with comparatively small costs. But each year new groups of young people mature, requiring new efforts. Education, counselling and services are all needed. If the resources are not provided or cut too much, negative effects are evident.

CONGRESS SESSION 6: PERICONCEPTION CARE INCLUDING FERTILITY

S06-1 Periconception nutritional care: Should we care?

Régine Steegers-Theunissen

Erasmus MC University Medical Center, Rotterdam, The Netherlands

Worldwide the prevalence of relative malnutrition in reproductive populations is rising, in particular in industrialised countries (1). Relative malnutrition, defined as an excessive use of high-energy, low- vitamin and mineral density dietary patterns, leads to increased vulnerability to non communicable diseases, such as cardiovascular disease, diabetes mellitus type 2 and cancer. However, relative malnourishment in the periconceptional period is especially harmful because of its association with subfertility and adverse pregnancy course and outcome. Moreover, malnutrition during pregnancy also affects the vulnerability for non communicable diseases of the foetus in adult life.

Nutrition plays an important role in the developing origins of health and diseases. The underlying mechanisms may be best explained by epigenetics. So far DNA methylation is one of the most studied epigenetic mechanisms implicated in the programming of cellular growth and development of the gametes, embryo, placenta and fetus. Evidence of epidemiological studies supported by animal experiments demonstrates that especially periconceptional nutrition and folic acid supplement use affect DNA methylation, i.e., programming (2). The maternal use of a dietary pattern, rich in one carbon groups for DNA methylation, is associated with a better response of ovulation stimulation treatment (3), a higher pregnancy chance, a reduced risk of having an infant small for gestational age or with congenital malformations (4) as well as a reduced risk of non communicable diseases later in life. On the other hand periconceptional folic acid supplement use and folic acid fortification of foods may affect epigenetic profiles with permanent beneficial and/or harmful phenotypic effects. In this presentation these issues will be addressed together with the presentation of the promising results of periconceptional improvement of nutrition and lifestyle of couples by means of a preconceptional outpatient clinic tailored on nutrition and lifestyle and the innovative personalised coaching stool, based on internet, email and SMS messages on the mobile phone, www.slimmerzwanger.nl.

References

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S06-2 The impact of periconceptional diet on development

Tom P. Fleming

University of Southampton, Centre for Biological Sciences, Southampton, UK

Periconception nutrition may influence developmental plasticity of the early embryo leading to altered growth, physiology and metabolism, often associated with adult disease when studied experimentally in animal models. Other related models (periconceptional maternal sickness; embryo culture mimicking ART) further demonstrate long-term programming of adult phenotype from diverse early environmental conditions. Maternal protein restricted diet in our rodent models administered exclusively during preimplantation development is sufficient to induce cardiovascular dysfunction (notably hypertension and attenuation in arterial relaxation), behavioural abnormalities, metabolic effects and altered growth in offspring. Similar outcomes have been revealed in related large animal models. Mechanistic analysis of our mouse model indicates nutritional programming occurs by the blastocyst stage mediated through sensing of free amino acid levels within the uterine lumen which alter in response to maternal diet. This cue is sufficient to alter mTOR signalling within blastocysts. Poor nutrition then activates a series of compensatory responses within the embryo, mainly within extra-embryonic lineages, including activation of enhanced endocytosis rate, stimulation of ribosome biogenesis and increased proliferation and invasiveness of trophoblast. These early responses associate with increased capacity for nutrient retrieval from the mother during later gestation to promote growth. Whilst these mechanisms act to maintain competitive fitness of the developing offspring in adverse maternal conditions, there is a trade-off such that the resulting growth pattern correlates positively with adult chronic disease risk.

Our studies indicate the importance of maternal nutrition around conception for optimising health into adulthood and there is evidence of similar associations occurring within the human.

Funded by BBSRC, NICHD, MRC, EU-FP7 and Gerald Kerkut Trust.

S06-3 Preconception care and the fertility specialist

Nick Macklon^1,2

^eUniversity of Southampton, Hampshire, UK, ^fRigshospitalet, Copenhagen, Denmark

Over the past three decades, assisted reproductive technology has made startling progress with respect to clinical protocols, pharmaceutical drugs, embryology, treatment of male infertility, pre-implantation genetic diagnosis and quality management systems. We have seen pregnancy rates rise from single figures to those that exceed natural conception while at the same time reducing multiple pregnancy rates to below 5% by performing single embryo transfer. Yet a number of challenges remain to be addressed. We have yet to control the most important determinants of success: the characteristics of our patients. Clinics are increasingly seeing women approaching and exceeding their 40's seeking assistance to become pregnant. Not only does this affect the efficacy of fertility therapies, it also means that more of our fertility patients will have co-morbidities which can impact on IVF and vice versa. The epidemic of obesity is upon us and it is rare to see somebody in many clinics where the body mass index is below 25. Young women continue to smoke heavily, and we know that sperm counts are decreasing in some parts of the world, largely due to environmental and lifestyle factors. The changing demographics of our patients, in combination with the new indications for ART such as fertility preservation for cancer patients and PGD for carriers or sufferers of serious inherited disease present us with new clinical challenges. In addition, the improved prognosis associated with some serious medical conditions mean that many patients who would have never had children are approaching us after controlling their serious heart disease or diabetes or cystic fibrosis.

The new imperative to focus on the preconceptional phase when planning fertility treatments is clear, and made more urgent by an increasing understanding that pregnancy outcomes, and long term health are significantly influenced by the preconceptional health. The question therefore rises whether environmental factors associated with periconceptional development may disrupt processes crucial for fetal growth and development. The in-vivo nutritional environment at the time of conception has been shown to influence further development. More recent studies have shown that dietary content at the time of conception and during pregnancy is associated with an altered birth weight, and other determinants of long-term health.

Those of us working in Assisted Reproduction now have the opportunity to assist our patients not only achieve pregnancy, but to provide novel interventions that maximises their chances of becoming pregnant, and having a healthy, fertile child.

CONGRESS SESSION 7: ORGANISED UNDER THE AUSPICES OF THE FRANCOPHONE SOCIETY OF CONTRACEPTION CONTRACEPTION IN DIFFERENT PHASES OF REPRODUCTIVE LIFE

S07-4 Benefits and risks of IUDs for young women

David Hubacher

FHI 360, Durham, NC, USA

The intrauterine device (IUD) is one of the most effective reversible contraceptive methods available. The World Health Organization and other international agencies place the IUD in the top tier of options for protection against unintended pregnancy. Both copper IUDs and levonorgestrel-releasing IUDs have this designation.

The benefits of using IUDs are well documented, and vary somewhat by type of IUD. The primary benefit of both IUDs is high contraceptive effectiveness, stemming from intrinsic contraceptive properties and ease of correct use to maintain protection against unintended pregnancy. The levonorgestrel-releasing IUD provides non-contraceptive benefits such as reductions in menstrual blood loss and increases in hemoglobin levels.

Pelvic inflammatory disease, infertility, and uterine perforation are the primary fears of IUD use, but overall incidence of these outcomes is low. Pelvic inflammatory disease and infertility occur while using other contraceptives as well. The most rigorous scientific evidence shows that the IUD does not increase the risks of these diseases (relative to other methods). Some lower quality research has shown that the IUD may increase risks.

The benefits and risks of IUD use may be different for young women. For example, the known benefit of highest protection from unintended pregnancy may be far more important than the feared yet unknown health risks of using an IUD instead of a different contraceptive method. Since young age is associated with riskier sexual behaviours that naturally elevate the risks of infection-related disease, the concern over infection is appropriate from a general health perspective. However, the fear that IUD use adds risk is not based on sound scientific evidence.

This paper reviews the best evidence on the benefits and risks of IUD use among young women.

CONGRESS SESSION 8: CONTRACEPTION AND DISTURBANCES OF VAGINAL BLEEDING

S08-1 The continuing global problem of unscheduled disturbances of bleeding with hormonal contraceptives

Ian S. Fraser

University of Sydney, Honorary Director, Sydney for Reproductive Health Research, Sydney, Australia

Hormonal contraceptives universally alter women's menstrual periods, in ways that can be broadly predicted for each particular hormonal combination or delivery route. However, the experience of individual women cannot be accurately predicted ahead of time. The majority of women will find that their episodes of menstrual bleeding become lighter and shorter. Women using a combined oral contraceptive (or vaginal ring or transdermal patch) will usually experience regular, light and predictable periods, while those using progestogens (whether oral, intramuscular, subdermal or intrauterine) are much more likely to experience unpredictable episodes of light, but variable-duration bleeding (often extending to amenorrhoea, but in a minority of cases, to frequent or prolonged episodes of light bleeding or spotting). These episodes are rarely heavy. Some women find these episodes unpleasant and even intolerable, resulting in a minority of women discontinuing use prematurely. Even the combined oestrogen-progestogen preparations may sometimes be accompanied by episodes of unscheduled intermenstrual bleeding, leading to early discontinuation. These issues have been recognised for well over 40 years, and substantial research has clearly defined the range of patterns of bleeding occurring with individual preparations in different communities. It is important to emphasise that the great majority of these women experience a reduction in menstrual bleeding compared with their normal patterns.

The past two decades have revealed considerable new understanding of some of the molecular, cellular and tissue (primarily endometrial) changes which may accompany long-acting progestogen use, especially in those women with the worst patterns. What we do not understand is why some women experience troublesome bleeding patterns and others experience amenorrhoea with the same preparation – and we cannot predict who will experience which pattern! There is also a need to recognise that there are changing expectations for what patterns are acceptable by individuals and by groups of women in different communities and cultures.

Over these four decades, some progress has been made in the prevention and treatment of the more troublesome patterns of bleeding. This symposium will address some of the pragmatic means of approaching the management of these symptoms. It will also address the opposite side of the coin, the use of some of these modern hormonal preparations and delivery systems for treatment of spontaneous disturbances of menstruation, such as heavy and prolonged menstrual bleeding.

S08-2 Pragmatic management of poorly tolerated, unscheduled bleeding disturbances

Diana Mansour

Consultant in Community Gynaecology and Reproductive Healthcare, Newcastle upon Tyne, UK

Progestogen-only contraceptive methods provide effective birth control but are associated with unpredictable vaginal bleeding. Most women can use these methods as there are few contraindications but continuation varies, dependent on age, culture and local healthcare provision. For example, in high resource countries almost one third of women prematurely discontinue using etonogestrel implants because of ‘bleeding problems’.

Bleeding patterns vary with most women reporting a reduction in frequency and volume of vaginal bleeding plus an improvement of dysmenorrhoea. At least six women out of ten will be amenorrhoeic after 12 months use of depot medroxyprogesterone acetate and one in four women will be bleed-free with a levonorgestrel-releasing intrauterine system (LNG-IUS). However those experiencing frequent and/or prolonged bleeding are more likely to discontinue/request early removal. The underlying endocrine or endometrial mechanism or trigger is not known, with most research concentrated on mechanisms at the endometrial cellular and molecular level.

Providing informed and realistic information about expected bleeding patterns before prescribing a progestogen-only method may improve acceptance and continuation. A detailed clinical history from women complaining of unscheduled vaginal bleeding can be helpful in helping to identify any underlying cause and determine if a pelvic examination and/or further investigations are required.

There have been a number of pragmatic approaches suggested to help stop an episode of bleeding, including use of selective progesterone receptor modulators (SPRMs), ethinyl estradiol/combined hormonal methods, high dose progestogen, progestogen-only pills, matrix metalloproteinase inhibitors, non-steroidal anti-inflammatory drugs and tranexamic acid. The effects of such treatments are variable and sometimes helpful, but unscheduled bleeding tends to recur on discontinuation. There has been very little research investigating preventative strategies. This lecture will discuss the current evidence/guidelines to help clinicians manage women using hormonal contraceptive methods who present with unscheduled bleeding.

S08-3 Use of hormonal contraception to treat spontaneous, abnormal uterine bleeding

Jeffrey Jensen

Oregon Health & Science University, Portland, Oregon, USA

Abnormal uterine bleeding is a common health problem for women. Heavy menstrual bleeding (HMB) (objectively defined as measured menstrual blood loss (MBL) exceeding 80 mL per cycle) affects approximately 10% of all women and 22% of women aged 35 years or older. A diagnosis of HMB is associated with high rates of surgical intervention and increased healthcare resource utilisation and costs. Recent randomised studies have documented the utility of selected hormonal contraceptives in the treatment of spontaneous heavy menstrual bleeding. The most rigorous studies use the alkaline hematin method for analysis of MBL. A combined oral contraceptive pill containing estradiol valerate and dienogest (E₂V/DNG) has been shown to reduce MBL below 80mL in 68.2% of women with HMB compared with only 15.6% taking placebo pills over 7 cycles. The effect was prompt, with a significant reduction in blood loss observed with the first withdrawal bleed after initiation of therapy. Although head-to-head comparisons with E₂V/DNG and other oral contraceptives (OC) have not been completed, the formulation has unique regulatory approval for the indication of treatment of heavy menstrual bleeding in the United States and Europe. Rigorous studies with the levonorgestrel intrauterine system (LNG-IUS) support an even greater reduction in bleeding. A randomized study comparing the LNG-IUS to oral medroxyprogesterone acetate (MPA, 10 mg daily for 10 consecutive days in each cycle starting on day 16 of the menstrual cycle) over 6 cycles documented that 84.8% of women using the LNG-IUS experienced a reduction in MBL below 80 mL compared with only 22.2% of women receiving MPA. The LNG-IUS also has regulatory approval as a therapy for HMB in the USA and in many countries in Europe and around the world. These studies provide a benchmark for future studies comparing E₂V/DNG and the LNG-IUS to other OCs, injectable depoProvera, and novel therapies.

CONGRESS SESSION 9: CONTRACEPTIVE, SEXUAL AND REPRODUCTIVE HEALTH CARE FOR ALL: THE CHALLENGE OF IMMIGRANT POPULATIONS

S09-1 Working with communities at risk of female genital mutilation

Jean-Jacques Amy¹, Fabienne Richard²

^gEuropean Journal of Contraception and Reproductive Health Care, Brussels, Belgium, ^hInstitute of Tropical Medicine, Antwerp, Belgium

FGMs are carried out in 29 African countries, in the southern part of the Arabic peninsula, and in diverse communities scattered worldwide. Due to migration, women and girls having undergone a FGM – or at risk of undergoing one – are living in ever greater numbers in countries where such procedures, until recently, were unknown. These violations of human rights and the ensuing public health problem are now also confronting health personnel, other professionals, and policymakers, in countries of refuge.

Host countries should gather and update information concerning mutilated women and girls, and those at risk, residing there. Expertise must be developed within various professional groups (e.g., healthcare personnel, psychologists, jurists), and referral centres must be created where girls and women seeking advice or in need of care will benefit from a holistic approach of their problems.

Sensitive counselling against FGM should be provided to all members of the communities concerned. The latter may feel torn between their recently acquired knowledge of FGM's noxious effects and the social/cultural pressures to comply with tradition. Midwives are in a strong position to counsel and induce a change in attitudes. Antenatal guidance offers an ideal opportunity for having the couple reconsider the value of this practice as women and their husbands are then receptive to advice concerning the well-being of the child to be born.

Contacts with migrants should be made by persons (preferably women) belonging to the communities concerned. Efforts must be undertaken to upgrade women's status. FGM legislation, now in force in many countries, offers a legal protection for women; discourages excisors and families from performing mutilations; and offers health professionals a legal framework to oppose requests for performing FGM. Yet criminalising FGM may result in it going underground.

Parents may have the FGM performed on their daughters in their country of origin; less frequently the FGM is carried out in the host country by an excisor living there, or even by the parents themselves. To ascertain that girls are not mutilated it has been proposed that the genitals of all children, of both genders, be examined at intervals. In certain countries, parents, prior to their daughter travelling to the country of origin, must sign a contract specifying that they will protect her from being ‘cut’. If on her return the child is found to have been mutilated, the parents can face a prison sentence. Such contract arms parents against the pressure the family in their home country exerts.

S09-2 Europe preventing HIV in communities from high risk regions

Filomena Pereira

Instituto de Higiene e Medicina Tropical, Lisbon, Portugal

The great majority of HIV infections (> 95%) occur in developing countries. It is also known that there are millions of migrants/refugees in Europe (according to the International Organization for Migration (IOM), approximately 192 million people – 3% of the world's population – were international migrants in 2006, of which 95 million were women). Many of these migrants are from those countries (Sub-Saharan Africa, Eastern Europe and Asia and, in some specific European countries, from Latin America and the Caribbean) and numbers are growing every year.

Those infected with HIV suffer discrimination, both because they are migrants, most of them belong to minorities of any kind and because of HIV infection itself. As a consequence, even when they know that they are infected with HIV, they do not disclose their status, thus not having access to treatment and easily transmitting their infection to their sexual partners, since many of them are also victims of sexual exploitation. Nevertheless, migrant-directed prevention programmes must be understood as a specific need of the migrant populations and not as a menace to the native population. Therefore, to prevent HIV transmission in these communities different and specific approaches are needed. In the end and in a global world like the one we are living today, this is a challenge that we should all face together.

To prevent HIV transmission in communities from high risk regions, it must be taken into account the sociocultural phenomenon of immigration, the socioeconomic conditions and the sociocultural specificity. Attention should also be paid to travellers and returning/on holiday emigrants.

Factors that may lead to a greater risk of HIV infection in migrant populations will be discussed, as also useful methods to be used when developing programmes, projects and interventions for these type of populations, the importance of continuous changes over time, in accordance with those happening in the communities/environment. Some programmes, projects and interventions will be analysed according to specific community characteristics. The role of analysing, collecting and standardising data will be referred, as also the importance of other STI and the most relevant migrant populations related to HIV infection.

S09-3 The unmet need for contraception among immigrants: A way forward

Ali Kubba

Guy's and St Thomas’ Hospital Trust, London, UK

The immigrant population is rising in most European countries and is predominantly a young population. The individual sexual and reproductive health needs of immigrants are no different from the native population they live within. Access to information, methods and services is a major challenge to for all our systems. Barriers to dissemination of sexual health information include; language, clarity of message and how it fits in the context of beliefs and culture. Women may not be aware of their rights, are subjected to negative gender dynamics, and lack autonomy. The role of religion is important but not central. Sensitive negotiation of rights and wrongs should focus on the wellbeing of the couple, and the family. Myth busting strategies challenge harmful practices.

Where contraception is not prioritised, emergency contraception should be promoted as a failsafe option and a way into a more planned contraceptive choice. LARC methods are rightly being promoted but choices should not be restricted.

When contraceptive uptake rises, expectations of efficacy and fertility regulation as a right tend to be high and resort to abortion when a contraceptive fails should be catered for. Providing social care to single mothers who may be ostracised by their communities leads to greater empowerment and higher self esteem.

Enforcing host country norms on the behaviour of culturally diverse communities tends to generate ‘backlashes’. Peer supported education is the way to win both hearts and minds. A holistic approach, highlighting preservation of fertility, and including screening for STIs ensures positive branding of services especially where populations are sceptical or suspicious of the systems they are dealing with.

Sexual health promotion within the immigrant community and in the mother country is a must, utilising outreach services and integrating health with social care.

CONGRESS SESSION 10: REPRODUCTIVE HEALTH CARE WITH LIMITED RESOURCES

S10-2 Reproductive health care in South America

Pablo Lavin^1,2, Carmen Bravo^2,3, Alejandra Lavín^1,3, Pablo Lavin³

ⁱUniversidad de Chile, Santiago, Chile, ^jHospital Barros Luco, Santiago, Chile, ^kUNICERH - SIAPMED, Santiago, Chile

Reproductive health is part of the global health status of persons and populations. The approach adopted at the ICPD in Cairo 1994 and strengthened at the FWCW in Beijing 1995 changed the focus of infant-maternal and family planning programmes for demographic targets, to an improvement of quality of lives of individuals with integration of reproductive health services, free and informed choice in a human rights framework.

South America has 17,828,162 km² (12.0% of the world), 370 million inhabitants (6% of the world), with a mean population density of 20.8, 12 countries, and one overseas possession. Brazil is 92 times larger than French Guyana (FG) and has 700 times more population. Five official languages (50.4% speaks Spanish, 49.2% Portuguese) and a tenth of local ancestral languages are spoken. Then there is the diverse scenario within the continent and the countries itself. To highlight extremes we show the largest and smallest figures for each indicator.

Area (thousand km²): Brazil 8,515 – FG 92.3. Population: Brazil 182 million – FG 0.26. Population density per km²: Ecuador 55.1 – FG 2.5. Literacy: Chile 98.7% – Ecuador 81.7%. Daily calorie intake: Brazil 3,113 – Bolivia 2,064. GPI (US$ per year): Chile 13,415 – Guyana 3,130. Population below international poverty line: Uruguay 2% – Colombia 16%. Urban population: Argentina 92.4% – Guyana 28.6%.

General Mortality Rate for women aged 15 to 49: Chile 0.53 – Paraguay 1.63. Annual births in 1000s: Brazil 3,032 – FG 5.7. Crude Birth Rate: Chile 14.3 – FG 24.4. Annual population growth: Guyana 0.2% – FG 2.6%.

Total fertility rate: Chile 1.9 and Bolivia 3.1. Adolescent fertility rate (ages 15 to 19): Argentina 53.4 – Brazil 88.7. Maternal mortality rate: Chile 17 – Bolivia 230. Infant mortality rate: Chile 6.5 – Bolivia 38.1. Neonatal mortality: Chile 5.5 – Bolivia 27. Post neonatal mortality: Chile 2.3 – Bolivia 23.

Low birth weight: Chile 5.9% – FG 12.1%. Life expectancy at birth (in women years): Chile 82.2 – Bolivia 64.9. Prevalence of contraceptive use: Brazil 81% – Bolivia 21.3%. Deliveries attended by trained personnel: Chile 99.9% – Bolivia 64.8%. Pregnant women controlled: Brazil 97.4% – Bolivia 79.1%.

HIV deaths per year: FG 7 – Brazil 842. Breast cancer incidence: Bolivia 24 – Uruguay 90.7. Uterine cancer incidence: Chile 14.4 – Bolivia 36.4. Uterine cancer mortality: Chile 11.1 – Paraguay 22.11.

As can be seen from the above figures there is a huge range in all these aspects. Some tendencies for better and worst results may be foreseen. This gives a broad idea of the complex diversity within the territory in Reproductive Health issues.

CONGRESS SESSION 11: NEW RESEARCH IN CONTRACEPTIVE TECHNOLOGY AND FUTURE DEVELOPMENTS

S11-1 Global unmet needs for contraception, reproductive health and justice

John Townsend

Population Council, New York, New York, USA

The London Family Planning Summit marked the end of more than a decade of neglect of family planning in international health and development efforts. The decline of investments in the late 1990s and early 2000s had several causes including new priorities among donors; persistent opposition from conservative governments and institutions; and the need for resources to address other pressing problems, such as the HIV epidemic. This decline is now being reversed with the successful mobilisation of several billion dollars’ of commitments at the London Summit, the engagement of new governments in support of family planning, e.g., Senegal, Nigeria, Pakistan among others, and the creation of a new global partnership structure, FP2020, to coordinate and support implementation of these commitments. The challenge ahead is to invest wisely so that an additional 120 million women and girls can start using contraception and vulnerable individuals are empowered to decide, freely and for themselves, whether, when and how many children they have. It is also essential to ensure that the national health systems for delivering contraceptive and related reproductive health services become self-sustaining, both financially and organisationally, that they focus on inequities as well as overall coverage of care, and that the new commitments to family planning are maintained throughout the national markets for health.

The combination of the economic and environmental rationales, together with the health and rights rationales, seems to have convinced even the most sceptical opponents that investment in family planning brings a wide range of benefits and has led to a crucial change in the way family planning is valued, nationally and globally. Over the past two decades these varying rationales have increased the number and diversity of organizations engaged in family planning. At the same time, the range of available investment options has risen because different stakeholders have different priorities for supporting family planning and different expectations for successful outcomes. This includes families themselves who increasingly are spending directly on contraceptive products and services, given their understanding of how spacing and limiting pregnancies affects their own family welfare.

This paper examines these rationales for renewed focus on family planning and places the efforts of national family planning programmes in an international rights and justice context.

S11-2 Progesterone receptor modulators for emergency contraception

Anna Glasier^1,2

^lUniversity of Edinburgh, Edinburgh, Scotland, UK, ^mLondon School of Hygiene and Tropical Medicine, London, UK

It is over ten years since the use of the selective progesterone receptor modulator (SPRM) mifepristone for use as emergency contraception (EC) was described. Despite its efficacy and widespread use in China, mifepristone has never been marketed for EC in Europe. The SPRM ulipristal acetate (UPA) was however approved for marketing as emergency contraception in May 2009 and is now available in most of Europe. Two non-inferiority studies suggested that UPA was more effective at preventing unintended pregnancy than levonorgestrel (LNG) and this has been borne out by some elegant research comparing the mechanism of action of the two methods. Unlike LNG, UPA (marketed as EllaOne in Europe, Ella in the USA) continues to inhibit ovulation even after the LH surge has started which of course is the time in the cycle when the risk of pregnancy is at its highest. Recent research has also demonstrated that UPA is more effective than LNG for obese women.

Because UPA is effective when used after 72 and up to 120 hours after intercourse there has been a tendency to think that the urgency to use this method of EC is less than for LNG. Since UPA, however, does not inhibit ovulation after the LH peak (24 hours or so before ovulation) it is vital that this method is also used as soon as possible after intercourse. So just as the need for rapid use was used to argue the case for the availability of LNG from pharmacies without the need to see a doctor so too must UPA be made available off prescription if it is to fulfil its public health potential to reduce unintended pregnancy.

S11-3 Emerging science for contraception technology

Regine Sitruk Ware^1,2

ⁿPopulation Council, New York, USA, ^oRockefeller University, New York, USA

Although a steady increase in contraceptive use has been observed over the past decades, the contraceptive needs of a significant percent of couples have not yet been met, with an increase in unscheduled pregnancies both in developed and less-developed countries. Emerging scientific opportunities may shape the future scientific agenda in reproductive research in the context of new and advanced technologies for the development of improved contraceptives.

The contraceptive efficacy of female long-acting methods of contraception such as implants and IUDs is the highest among contraceptives as these methods do not rely on daily compliance. While implants and IUDs require a health provider for a proper insertion, one-year vaginal rings can be considered a mid-acting method and have the advantage for women of being under their own control. While long-acting methods seem preferable for women with compliance issues, transdermal gels or sprays used daily have shown high acceptability as the methods can be used privately. Natural hormones such as estradiol (E2) can be delivered from this route and may limit the safety risk of venous thromboembolism.

Progesterone receptor modulators (PRMs) delivered as a continuous low-dose administration from a vaginal ring have been shown to block ovulation and induce amenorrhea. In addition, the potential of PRMs to prevent breast cell proliferation would add a non-contraceptive benefit to the method.

In the future, contraceptives may be combined with other medicinal agents to provide dual protection against both pregnancy and other preventable conditions, such as sexually transmitted infections. Dual protection methods are also tested as vaginal gels or rings delivering both a contraceptive and an agent active against HIV transmission. Also the neuroprotective effects of progesterone and similar molecules are new areas of research supporting the development of novel contraceptives with added health benefits.

Emerging areas of research such as genomics and proteomics created a new scientific opportunity. Research on specific genes or proteins they regulate permitted the discovery of new targets in the male and female reproductive tract. New approaches for male contraceptives target the maturation of germ cells, a critical component of sperm development, or the sperm motility and maturation. Non-hormonal methods in women target meiosis as well as genes involved in follicular rupture and ovulation. These new approaches will ensure future development of non-hormonal contraceptives.

CONGRESS SESSION 12: CONTRACEPTION AND MEDICAL CONDITIONS

S12-1 Use of contraceptives among overweight and obese women

Kristina Gemzell Danielsson

Karolinska Institutet, Stockholm, Sweden

Overweight and obesity is an increasing health problem worldwide. In many parts of the world the most pronounced increase in body mass index (BMI) is seen in young women. Many women fear that use of hormonal contraception will lead to a weight gain. This is a common reason for discontinuation of contraception. However, with one exception no correlation between contraception and weight gain could be found in the published literature. Data is conflicting with regard to the impact of Depo Provera with a weak correlation and an increase of less than 2 kg/year reported among users. Importantly there are no data indicating that obesity would reduce the contraceptive efficacy of combined hormonal contraceptives. However, in the case of Depo Provera there may be technical problems to deposit the injection intramuscular. There is also data supporting that Emergency Contraceptive pills (EC) with levonorgestrel are less effective in women with a BMI already above 25 while EC with Ulipristal acetate (ellaOne) maintains its efficacy up to a BMI of 35.

A major concern is whether the risk for venous thromboembolism (VTE) is increased in overweight and obese women and how the risk is affected by hormonal contraception. Obesity defined as a BMI > 30 is associated with a well known increased risk for VTE of 2 to 3 compared with women with a BMI < 30. The increase is more pronounced at a BMI > 40. A relative risk of 10 to 40 has been reported for obese women using combined hormonal contraception. Clinical practice with regard to restrictions in combined hormonal contraception based on BMI depend on other available options. Some women may also have a medical condition such as PCOs which justify the use of combined hormonal methods also at a higher BMI. So far there are little or no data on the risk of stroke or myocardial infarction among obese women with combined hormonal methods.

Today an increasing number of women undergo gastric bypass. Following surgery women are advised to avoid pregnancy for 12 to 18 months and therefore to use effective contraception. While older data indicate an impact of surgery on the uptake of oral contraceptives data is lacking using modern surgical techniques. However, alternative routes of administration may be preferable.

S12-2 Use of contraceptives in women with cardiovascular disease

Diana Mansour

Newcroft Centre, Newcastle upon Tyne, UK

In primary, secondary and community services we are now seeing women with complex congenital and acquired cardiovascular diseases who require effective contraception.

To understand the complexities of prescribing birth control methods to those with poorly functioning hearts it is worthwhile considering the effect of specific contraceptive methods on the cardiovascular system. Will certain choices increase the risk of ischaemic heart disease or venous thromboembolism?

With the success of cardiac surgery the ‘grown-up’ congenital heart patient poses some important reproductive health questions and discussion of individual cases with their cardiologist is to be encouraged. Will certain methods of contraception be safe? Can these women withstand the haemodynamic and metabolic changes of pregnancy and be able to carry a child to term? What is their life expectancy? Women with heart transplants are often taking drugs that may interact with hormonal contraceptives affecting their efficacy. What options do they have? What are the current thoughts about giving antibiotic prophylaxis to women with a past history of bacterial endocarditis or in those who have a metal heart valve?

UK Medical Eligibility Criteria categories relating to current cardiac conditions.

	CHC	POP		IMP		INJ	LNG-IUS		Cu-IUD	Condoms	Diaphragms	Sterilisation
Current ischaemic heart disease	4	I	C	I	C	3	I	C	1	1	1	D
		2	3	2	3		2	3
History of ischaemic heart disease	4	I	C	I	C	3	I	C	1	1	1	C
		2	3	2	3		2	3
Uncomplicated valvular or congenital heart disease	2		1		1		1		1		1	EX
Complicated valvular or congenital heart disease e.g., with pulmonary hypertension	4		1		1		1	2	2	1	2	S

CHC, combined hormonal contraception; POP, progestogen-only pill; IMP, implant; INJ, injection; LNG-IUS, levonorgestrel-releasing intrauterine system; Cu-IUD, copper intrauterine system; I, initiation; C, continuation; D, the procedure is delayed until the condition is evaluated, treated and/or changes; Ex, the procedure is normally conducted in a routine setting, but with extra preparation, precautions and counselling; S, experienced surgeon and staff needed with back-up medical support.

During this presentation I hope to discuss the new Faculty of Sexual and Reproductive Health Care's Clinical Effectiveness Unit contraceptive guidance for women with cardiac disease. This highlights the considerations surrounding the choice of contraception in such women and the importance of a multidisciplinary approach.

S12-3 Use of contraceptives in women with breast cancer

Andrew Kaunitz

University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA

Although breast cancer is hormone responsive, the impact of hormonal contraception on recurrence risk has not been well studied and remains uncertain:

Nonhormonal contraception, including copper IUD and sterilisation, represent first line contraceptive choices.

Some breast cancer survivors, particularly those for whom a noncontraceptive indication (e.g., heavy menstrual bleeding, prevention of endometrial disease with tamoxifen use) is applicable, may choose to use hormonal contraceptives.

Such women should be counselled that use of hormonal contraception is off-label, and impact on recurrence is unknown.

CONGRESS SESSION 13: THE PLEASURE PRINCIPLE IN SEXUAL HEALTH

S13-1 The pleasure principle in sexual health education

Steve Slack

Centre for HIV and Sexual Health, Sheffield, UK

This presentation will consider the importance of acknowledging and giving due regard to issues of pleasure in the promotion of good sexual health and well-being. Sexual health promotion strategies have too frequently focussed on the negative outcomes of sexual practices rather than adopting more holistic, sex positive approaches, taking account of issues such as pleasure. Traditionally groups including young people, gay people, people with learning disabilities and more frequently those living with HIV have seen their sex lives pathologised. Steve Slack has worked extensively in social work, youth work and sexual health promotion and was a government advisor on sexual health. He currently works as the Director of the Centre for HIV and Sexual Health in Sheffield (UK). He contends that evidence and experience supports the view that the most effective sexual health promotion involves a sex-positive approach, encouraging meaningful, holistic and non-judgemental engagement with all groups, which also promotes self-esteem and enables greater openness about issues such as sexual pleasure within consensual relationships. Slack does not argue for a ‘pleasure imperative’ but acknowledgment that sex and masturbation can be positive experiences in people's lives. The leaflet entitled ‘Pleasure’ which he co-authored has been well received and gained (positive and negative) international media attention in 2009 for its ironic take on the Mae West quote: ‘An orgasm a day keeps the doctor away!’

S13-2 The pleasure deficit and sexual dysfunction

Ellen Laan

Academic Medical Center, University of Amsterdam, Department of Sexology and Psychosomatic Obstetrics and Gynaecology, Amsterdam, The Netherlands

The DSM-IV classification of sexual disorders is based on a linear model of sexual response, in which the sexual desire phase precedes the sexual arousal, orgasm and resolution phases. This model implies that sexual desire occurs spontaneously and that it is independent of sexual arousal. Recently, various authors have criticised the strict distinction made between the sexual desire phase and the sexual arousal phase and have emphasised that sexual motivation stems from the processing of sexual stimuli, which leads to sexual arousal as well as feelings of sexual desire. According to this view, which corresponds with modern incentive motivation theories, sexual response (i.e., sexual arousal and desire) is the result of an interaction between the sensitivity of the sexual response system and stimuli that are present in the environment. To activate the system, a ‘sexually competent’ stimulus is required, which presence, actual or in mental recall, triggers sexual emotion.

There is increasing evidence that in somatically healthy women, sexual problems are unrelated to insensitivity of the sexual response system, even though there is a huge pharmacological research effort to influence people's sensitivity to sexual stimuli. Lack of adequate sexual stimulation – whether that is the result of absence of sexual stimulation or of lack of knowledge, bad technique, a lack of attention for, or negative emotions to sexual stimuli – and relationship issues seem to better explain the absence of sexual feelings and genital response in women.

Unfortunately, many women do not know what excites them or when they have reached ‘normal’ or high sexual arousal. Unlike men, women have the capacity to ‘compromise their genitals’ (i.e., have intercourse without arousal), driven by the mistaken belief that sex is equivalent to intercourse. This ‘capacity’ is hypothesised to be one of the determinants of the difficulties that heterosexual couples encounter in their bedrooms, and of the high prevalence of sexual pain complaints in women.

Our research has shown that women with sexual pain problems are less sexually autonomous and frequently engage in sexual intercourse for duty – and mate guarding motives, without paying much attention to their own sexual response, making it likely that lack of arousal and desire are important determinants of sexual pain.

In this talk, a case is made for sexual pleasure as a necessary requirement for pain free and pleasurable sex. Sexual pleasure should have a much more prominent role in all our research- and sex-education endeavours.

S13-3 ‘Sexual pleasure on equal terms’: Young women's ideal sexual situations

Eva Elmerstig

Faculty of Health and Society, Malmö University, Malmö, Sweden

Different studies have showed that stereotyped gender norms still influence young people's sexuality. For example, researchers examining gender structures within the context of such issues as s afer sex in heterosexual relationships have found power imbalance influencing youth sexuality negatively.

There is a shortage of information about young women's perceptions of ideal sexual situations in spite of the fact that is a big challenge for young people to develop a satisfactory sexuality. This presentation explores young Swedish women's ideal sexual situations.

In a study with young Swedish heterosexual women with experience of pain during vaginal intercourse we found that the women had vaginal intercourse for the partner's sake, and that they regarded the partner's sexual pleasure to be of great importance. They considered their own experience of pain insignificant compared with the partners sexual pleasure. To avoid being abandoned because of sexual inadequacy, they sacrificed their own sexual pleasure when they continued to have vaginal intercourse despite pain. It is possible that stereotyped gender norms become more dominant in vulnerable situations such as having pain during vaginal intercourse, or other sexual dysfunctions?

In another study with young women without experience of pain during vaginal intercourse, we found that the women's ideal (hetero) sexual situation was characterised by sexual pleasure on equal terms, where no one dominated and both partners attained sexual pleasure. There were obstacles to reach this ideal, such as influences of the social norm of women being in a subordinated position.

It raises the question how do these gender expectations influence sexual response, such as desire, arousal and possibilities to have orgasm?

This presentation will address the necessity of focusing on the complexity of gender expectations and their influence on young people's heterosexuality. A better understanding of these interactions is essential for professionals working with youths. Of special note is the importance to promote sexual and reproductive health by pointing out the influence of stereotyped gender norms and initiating critical reflexions on how they can be challenged.

CONGRESS SESSION 14: CONTRACEPTION AND CANCER

S14-1 Interaction of estrogens and progestins with cancerogenesis

Alfred O. Mueck

University Women's Hospital, Tuebingen, Germany

It seems almost impossible to summarise cancerogenesis in general for all the different types of cancer since thousands of genomic and nongenomic mechanisms can work. Starting from epithelial cells a crucial step to form the first ‘cancer’ cells is the mesenchymal transition activated by Zinc-finger enhancer binding transcription factors in feedback loop to the miR-200 family responsible for epithelial differentiation. This confers cellular motility, influences stem-cell properties, and prevents apoptosis and senescence, followed by complex proliferation mechanisms. Although tumour doubling time (TDT) is a function of many variables it can be calculated, e.g., for breast cancer, that starting from a single malignant cell (volume 10-6 mm³) it needs for estrogen (E)-induced TDT at least 10 years to get 1,000 Million cells corresponding to 1 cm tumour size as mammographically detectable ‘clinical cancer’. During this long time all the carcinoprotective effects can work (e.g., E-enhanced apoptosis, protective E-metabolites etc) which can explain that clinical studies also found a decrease of breast cancer risk during E-therapy. However, many factors, especially upregulation of growth factors, can decrease TDT leading to ‘clinical cancer’ in a shorter time which prevents sufficient carcinoprotection. The complex hormone-dependent cancerogenesis may be simplified in the description of two main pathways: (1) Estrogens can increase breast epithelial cell proliferation which might lead to mutations due to mistakes during DNA-replication, and/or can increase the proliferation rate of preexisting breast cancer cells, and/or (2) certain estrogen metabolites can react with DNA and induce mutations. For both pathways the addition of a progestogen may further increase the risk by (1) increasing the proliferation mechanisms, especially medicated by certain cell components like membrane-bound PR and RANKL-System and via effects of stromal growth factors, and/or (2) by increasing the production of potential genotoxic metabolites. These two mechanisms have been the main reason why the WHO has classified estrogen-progestogen preparations as ‘carcinogenic’! However, we found differences between preparations as for available progestogens. We also were able to assess the biological potency of various E-metabolites and to demonstrate that it needs additional factors like excessive oxidative stress and/or genetic polymorphisms of protective key enzymes to lead to genotoxicity. Thus hormone- induced cancerogenesis only in very rare cases lead to clinical cancer. It seems important to develop strategies to screen patients at increased risk, e.g., by assessing genetic polymorphisms and potential genotoxic metabolites or screening for cell components which can mediate increased hormone-dependent proliferation.

S14-2 Contraception and cancer – the epidemiological evidence

Philip Hannaford

University of Aberdeen, Aberdeen, Grampian, UK

Numerous studies have assessed the cancer risks associated with contraception, mostly in relation to combined oral contraceptives (COCs). Women have an increased risk of diagnosis of breast, cervical, liver and, possibly, thyroid cancer whilst using COCs, and for a few years after stopping. Breast cancers diagnosed in COC users are more likely to be localised than in non-users. Prolonged use of COCs accentuates the risk of cervical and liver cancer. The increased risk of liver cancer among COC users has been seen primarily in women living in areas where the prevalence of hepatitis B, and associated cancer, is low. Any adverse breast, cervical, liver or thyroid cancer effects disappear within 10 years of stopping, so the absolute number of women affected depends on the length of COC use (when duration of use is important) and age at stopping. Since most women stop COCs when the background risk of cancer is low (i.e., before their mid-30s), the number of cancer cases attributable to COC use is small.

On the benefit side, COC users enjoy important protection against ovarian and endometrial cancer, especially with prolonged use. Although the protection diminishes with time after stopping, statistically significant reductions in both cancers are still seen many years after stopping (perhaps more than 20 to 30 years afterwards) – well into the age when the background risk of these cancers is higher. Women also have a reduced risk of colorectal cancer whilst using COCs. It is not clear how long this protection lasts for after stopping. The sustained protection against ovarian, endometrial and, possibly, colorectal cancer, may produce important public health benefits over time, through reduced overall cancer incidence and mortality.

Studies of cancer occurring at other sites have not found convincing evidence of an important association with COC use.

After nearly half a century of extensive study, COC users can be reassured that their family planning choice does not lead to a substantial cancer risk. There is much less information available about any cancer risks associated with other contraceptives. Until more data becomes available, it would be prudent to assume that women exposed to combined hormonal contraception supplied via a non-oral route experience the same pattern of cancer risks and benefits as those using oral preparations. Limited data suggests that users of progestogen-only contraceptives (especially injectables and implants) experience a similar pattern of cancer risks and benefits as combined oral contraceptive users.

CONGRESS SESSION 15: CONTRACEPTIVE AND SEXUAL TRANSMITTED INFECTIONS (STI)

S15-2 Dual protection: Pregnancy prevention and STI

Thulani Magwali

Zimbabwe University, College of Health Sciences, Department of Obstetrics and Gynaecology, Harare, Zimbabwe

The presentation will be on the results of an on-going survey which is being carried out among family planning clients at the Family Planning Clinic at Parirenyatwa Central Hospital in Harare, Zimbabwe. Parirenyatwa Hospital is one of the two major central Hospitals in Harare. The survey is being carried out over a three-month period and has a planned sample size of 150 women. The data collection tool is a self-administered questionnaire that seeks to gather demographic information, information on contraceptive method used and use or none-use of barrier methods during intercourse for dual protection. Information on treatment for sexually treatment infection over the last five years is also being sought. The study is on-going and the results will be ready for presentation at the time of the conference.

CONGRESS SESSION 16: WHAT IS CHANGING IN REPRODUCTIVE MEDICINE IN THE WORLD?

S16-1 What is changing in reproductive medicine in PR China

Xiangyan Ruan

Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China

In the last four decades significant progress has been made in the diagnosis and treatment of infertile couples in China. Though China has a family planning policy which is debated all over the world, the China government does support the development of reproductive medicine. Every family should have a high quality child. After the world's first IVF baby was born in 1978, 10 years later, China's first IVF baby was born in 1988, and the first Gamete intrafallopian transfer (GIFT) baby also was born in the same year. In 1983 the first successful transfer of an in vitro fertilised donated oocyte embryo in the world was reported, China reported its first in 1992 and the first successful report of cryopreserved embryo–embryo transfer was in 1995. After that, China's reproductive medicine developed very rapidly.

Then in 1992, the world's first ICSI baby was reported. China's first ICSI baby was born in 1996, and in 2000, China's first Preimplantation genetic diagnosis (PGD) baby was born. At the same time, China also established many technologies such as: in vitro maturation of immature oocytes, assisted hatching and blastocyst transfer. Assisted human reproduction continues its worldwide spread as increasing numbers of patients are treated annually in China. There are about 200 IVF centers all over the country and, every year, about 10,000 babies are born using ART. The last decade has witnessed striking progress in assisted reproductive technology (ART) and over the past few years the success rate of ART has increased significantly. The average cycle successful rate is 30 to 40%, the highest rate is 60 to 70%, depending on many factors such as patient's age, novel technologies and improved embryo culture systems, efficient and effective oocyte recovery and embryo transfer.

CONGRESS SESSION 17: VENOUS THROMBOEMBOLISM AND CONTRACEPTION – MYTHS AND FACTS

S17-1 Mechanisms of haemostasis in healthy women and women at risk of venous thromboembolism

Beate Luxembourg

Institute of Transfusion Medicine and Immunohaematology, Department of Molecular Haemostasiology, DRK Blood Donor Service Baden-Württemberg - Hessen, University Hospital Frankfurt, Frankfurt, Germany

Haemostasis is the essential physiological response that prevents excessive blood loss after vascular injury and is provided by the activation of the coagulation proteases cascade. Naturally occurring coagulation inhibitors such as antithrombin and the protein C system ensure that haemostasis is a controlled and balanced process. An imbalance of procoagulant and anticoagulant mechanisms poses women at risk of venous thromboembolism (VTE). Significant attempts have been made to identify risk factors for VTE in order to predict and protect individuals at risk. VTE is a multifactorial disease with gene-gene and gene-environmental interactions. Genetic risk factors for VTE can be classified into strong risk factors such as hereditary deficiency of antithrombin, protein C or protein S, and mild risk factors such as heterozygous prothrombin G20210A and resistance to activated protein C (APC resistance) due to heterozygosity of factor V Leiden. Moreover, several polymorphisms that increase the risk of VTE only marginally, e.g., the MTHFR C677T variant, have been described. Although the underlying pathomechanism of persistently elevated factor VIII levels remains to be elucidated, several studies confirmed a dose-dependent increased risk of VTE associated with high FVIII levels, independently of an acute-phase role of factor VIII.

Even in patients with congenital thrombophilia about half of all VTEs occur in conjunction with acquired exogenous risk factors for VTE. Well-known risk factors for VTE are surgery, immobility, and, specifically pertaining to women oral contraception, hormone replacement therapy, pregnancy, and puerperium. Prothrombotic changes during the use of combined oral contraceptives (OCs) encompass an increase of coagulation factors such as factors II, VII, VIII, and fibrinogen, a decrease of protein S, and an increase in APC resistance. Differences in haemostatic changes between second- and third-generation combined OCs have been observed. The suppression of anticoagulant pathways is more pronounced in desogestrel-containing combined OCs compared to levonorgestrel-containing preparations. It is known that the prothrombotic effects between OCs and some thrombophilias are supra-additive. However, due to the overall low incidence of VTE in premenopausal women using OCs, universal thrombophilia screening in women prior to prescribing OCs is not supported by current evidence. Selective thrombophilia screening might be helpful in counselling hitherto asymptomatic women from thrombophilic families regarding the avoidance of risk.

S17-2 Summary of relevant epidemiological studies on VTE and contraception

Jeffrey Jensen

Oregon Health & Science University, Portland, Oregon, USA

The association between hormonal contraception and thrombosis is well established. The effect is mediated by estrogen-induced changes in hepatic globulins that shift the normal homeostatic balance slightly toward clot formation. This shift is an evolutionarily adaptive response to the challenges presented by normal pregnancy, and is proportional to estrogen dose. In general, the elevation in risk seen with estrogen-containing contraceptives is lower than the elevation in risk observed with pregnancy. Whether pharmacologic doses of progestogens play an important role in thrombosis risk is controversial. Recent publications using the Danish National Registry databases and other observational studies have reported an increased risk of venous thrombosis (VT) in women using oral contraceptives containing drospirenone, and among users of the contraceptive vaginal ring and patch when these women are compared to users of a low dose levonorgestrel (LNG) pill. However, serious weaknesses exist with database studies that limit the strength of these conclusions. The study design does not provide for the collection of essential baseline characteristics of the cohorts needed to adjust for important confounders and risk modifiers. These include important VT risk factors (smoking, obesity, and family history of VT), duration of use, and under-diagnosis of VT. Although a large scale randomised study would be the best way to definitively answer the question of progestogen type and VT risk, this design would be extremely expensive and require years to complete. Fortunately, several large well-designed prospective cohort studies have been completed in the United States and Europe. The first (EURAS) enrolled subjects in Europe and showed no increased risk of VT with drospirenone pills compared to levonorgestrel pills. These findings have been corroborated by similarly-designed large prospective cohort studies evaluating drospirenone conducted in the United States (INAS and Ingenix). Most recently, data from another large prospective cohort study carried out in the United States and 5 European countries (Transatlantic Active Surveillance on Cardiovascular Safety of NuvaRing (TASC) demonstrated no increased risk of VT with the etonogestrel-releasing vaginal ring compared to combined OCs, including LNG pills. Since the design of prospective studies permits the collection and analysis of important baseline confounders, these studies provide the highest quality of evidence on uncommon and rare side effects associated with hormonal contraception. Taken together, the results of these prospective studies support the hypothesis that there is no significant interaction between type of progestogen used in a combined hormonal contraceptive and VT risk.

CONGRESS SESSION 18: HEADLINES AND NEWS IN HORMONAL CONTRACEPTION

S18-1 Combined pills and venous thromboembolism: What are first choice preparations?

Ian Milsom

Department of Obstetrics & Gynecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden, Gothenburg, Sweden

The combined oral contraceptive (COC) pill was introduced in the early 1960s and after only a few years reports were published regarding an increased risk of venous thromboembolism associated with the use of COCs. The risk of thromboembolism was shown to be related to the estrogen content of the pill¹ and thus active measures were taken to reduce the estrogen content of COCs. Epidemiological studies have shown that there is a 2–4 fold increased risk of venous thromboembolism when using modern COCs compared to non-use². In this respect it is important to note that the risk of venous thromboembolism during pregnancy and the early puerperium is 6–10 fold higher.

Newer forms of gestagens such as desogestrel, gestodene and drospirenone have later been included in COCs. During 1995 and 1996 several papers were published indicating a variable risk for thromboembolism depending on the type of gestagen. In particular COCs containing desogestrel and gestodene were reported to have a greater risk of venous thromboembolism compared to COCs containing the same amount of estrogen but in combination with levonorgestrel². Some more recent studies have also indicated an increased risk of venous thromboembolism with COCs containing drospirenone compared to COCs containing levornorgestrel³ while other studies have not been able to confirm this finding⁴.

Current scientific evidence⁵ will be reviewed in order to determine the relative advantages and disadvantages of the various COC preparations available, in particular with regard to the risk of venous thromboembolism.

References

• Böttiger LE, Boman G, Eklund G, Westerholm B. Oral contraceptives and thromboembolic disease: Effects of lowering oestrogen content. Lancet 1980;1(8178): 1097–1101.
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S18-3 New estrogens in contraception

Gabriele Susanne Merki-Feld

University Hospital, Zürich, Switzerland

Ethinylestradiol (EE) has been used as estrogen in combined oral contraceptives (CHC) for decades, because the 17α-ethinyl group blocks the oxidative metabolisation of the d-ring. This results in a very high bioavailability in comparison to estradiol. Because the EE content in CHCs is correlated with an increased risk for venous thromboembolism years of research have been spent to develop a combined pill with natural estrogens. Early combinations with estradiol and a progestin were associated with poor cycle control, because estradiol is rapidly metabolised in the endometrium, especially when administered together with a progestin. Recently two combined oral contraceptives (COC) with estradiol and estradiolvalerat have been developed. Estradiol/Nomegestrolacetat (NOMAC/E2) is administered in a monophasic 24/4 regimen, while estradiolvalerat/dienogest (EV/DNG) is used in a 26/2 day fourphasic regimen. The cycle control with both of these pills has been considerably improved. Nevertheless absence of withdrawal bleeding and irregular bleeding occur more frequently than in CHC with EE. The majority of women achieve an acceptable bleeding pattern with longer duration of use. During counselling, information about this new bleeding pattern is mandatory. Absence of withdrawal bleeding can be especially irritating for users if they are not informed about it. Because EE is associated with deleterious effects on hepatic metabolism, it was hoped that pills with natural estrogens might be more neutral with regard to coagulation, lipids and the induction of binding globulins. The metabolic effects of both new pills have been compared with preparations containing EE/LNG. Many experts regard low-dosed EE/LNG pills as those associated with the lowest thromboembolic risk. The effects of both new pills on haemostasis do only differ in a few coagulatory and anitcoagulatory parameters to those induced by EE/LNG. Whether these differences may result in fewer thromboembolic events is not evident today. Therefore, although eventually more neutral with regard to hepatic effects the new pills should not be prescribed to women with risk factors for thromboembolic events. Effects on plasma lipids are also less pronounced. However, because the progestin in CHC modulates the effects of the estrogen on the liver, the effect of both hormones and not the estrogen alone have to been taken into account.

Estetrol is an estrogen under research for use in contraception. It inhibits ovulation and suppresses FSH and LH release in dosages of 10–20 mg. An interesting aspect with this new estrogen is its antagonistic effect on growth of chemical-induced breast cancer in the animal model.

CONGRESS SESSION 19: PREVENTION OF UNSAFE ABORTION – A GLOBAL CHALLENGE

S19-1 Overview of unsafe abortion: focus on Africa

Eunice Brookman-Amissah

Ipas, Africa Alliance Office, Vice President Africa, Nairobi, Kenya

Globally, deaths from unsafe abortion contribute to a significant proportion of the total maternal deaths. These preventable deaths and illnesses represent not only a public health crisis but also a social injustice, a public health scandal and a violation of women's human rights, more so since they are so easily preventable.

Women in Sub-Saharan African suffer more from this tragedy than in other regions of the world, representing over half of all deaths globally from abortion-related causes. These tragic deaths and disabilities from unsafe abortion are totally unacceptable when we have the knowledge and technologies to prevent and treat them.

Every country in Africa permits abortion in some circumstances, yet the World Health Organization (WHO) estimates that over 5 million African women undergo unsafe abortions each year and nearly 30,000 die as a result. African countries are unlikely to achieve the Millennium Development goal of reducing maternal mortality by 75% by 2015 if abortion-related deaths are not reduced.

Global conferences over the past two decades like the International Conference on Population and Development, ICPD, the Fourth World Conference on Women and Development (Beijing) brought the notice of the world to the critical public health hazard of unsafe abortion. The consensus was to implement safe and accessible abortion services in circumstances where it is not against the law. There have been some attempts by several governments since then to implement some services, but a lot more remains to be done.

At the regional political level the African Union adopted the Protocol to the African Charter on Human and Peoples Rights on the Rights of African Women in Africa which mandates member countries to provide safe elective abortions for a wide range of indications. The Maputo Plan of Action, a roadmap for the operationalisation of a continental sexual and reproductive health framework adopted by the Ministers of Health of the African Union, includes reduction of unsafe abortion and review of restrictive laws.

In spite of these international and regional dispensations, access to safe abortion services for African women, especially poor, disadvantaged women remains very low. Faced with an unwanted pregnancy they have no option but to seek termination by unsafe methods, with dire consequences.

A major cause of these unnecessary deaths is the restrictive laws in African countries, almost all inherited from pre-independence colonial countries which have all since repealed those laws in favour of women's enhanced health and the right to decide.

The presentation will examine the extent of unsafe abortion and the barriers that have denied African women access to safe legal services. It will outline the policy and political decisions that countries need to make to address unsafe abortion. It will also highlight the role of health professionals, the primary witnesses to the tragedy of unsafe abortion as advocates and champions for improving the situation. Finally it will emphasise the immense importance of the international community including Development partners and UN agencies like the WHO, UNFPA as catalysts for implementing much needed, legal and life-saving services to halt the needless deaths of African women.

S19-2 Global and regional responses to unsafe abortion: The place of state transparency obligations in the African region

Charles Ngwena

Centre for Human Rights, University of Pretoria, Pretoria, South Africa

Women in the African region are overburdened with unsafe abortion partly on account of restrictive abortion laws which serve as a deterrent to safe abortion. However, insofar as the law is concerned, it is not only restrictive laws that serve as incentives for unsafe abortion. Abortion regimes that fail to translate any given abortion rights into tangible access are also impediments to safe abortion. Though historically, African abortion laws have been highly restrictive, the post-independence era has witnessed a trend towards liberalisation of abortion laws. Furthermore, Article 14 of the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa has significantly augmented the regional trend towards liberalisation by recognising abortion as a human right in given circumstances. But despite this trend, with a few exceptions, African states are failing to implement abortion laws in ways that permit women to exercise their rights to lawful abortion.

In the main, this paper submits that jurisprudence that is emerging from the European Court of Human Rights and United Nations treaty bodies on the need for transparency in abortion laws is an important advocacy tool which can be used to render African states accountable for failure to implement domestic abortion laws. Where abortion is permitted by law, the emerging jurisprudence requires the state to raise awareness about the legality of abortion, and to implement the law in a manner that is sufficiently clear to women seeking abortion as well as to health care providers who have the competence and legal responsibilities to provide safe abortion services. Furthermore, the emerging jurisprudence requires the state to institute expeditious administrative frameworks and procedures for ensuring that women who are denied abortion are given fair opportunities to challenge the decision without being required to first resort to formal litigation which can be lengthy and uncertain. At both global and regional levels, the duty of the state to implement domestic laws in a manner that is effective is also reinforced by soft laws and consensus agreements and most notably by the World Health Organisation's technical and policy guidelines on unsafe abortion, and the African Union's Maputo Plan of Action for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights.

S19-3 Revised WHO guidance on safe abortion – key recommendations and challenges in implementation

Ronald Johnson

World Health Organization, Geneva, Switzerland

As we approach 2015, approximately half of the world's estimated 43.8 million annual abortions remain unsafe. There has been some progress in reducing the number of deaths attributable to unsafe abortion between 1990 and 2008. Globally, the case fatality rate declined from 340 to 220 deaths per 100,000 unsafe abortions. However, in Africa, the case fatality rate remained higher than the global average from two decades ago at 460 deaths per 100,000 unsafe abortions. This is in contrast to the negligible mortality rate of 0.7 for a safe, legal abortion in the United States.

In addition to the annual estimated 47,000 preventable deaths attributable to unsafe abortion, an estimated 5 million women are admitted to hospital with complications and the financial costs to women, their families and communities are huge. Low- and middle-income countries bear a disproportionate burden of unsafe abortion and its consequences with 65% of all abortions in south central Asia and 97% of all abortions in sub-Saharan Africa being unsafe. Young women continue to be particularly vulnerable with 15% of all unsafe abortions taking place in adolescents, 50% of these in the African region.

The second edition of the WHO's Safe abortion: technical and policy guidance for health systems published in June 2012 presents evidence-based recommendations that comprise a comprehensive framework which if implemented at country level could have a substantial public health impact on reducing abortion-related deaths and disability. This lecture presents the rationale for working on safe abortion at the World Health Organization (WHO) and the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (HRP), selected WHO recommendations for safe abortion care, and some of the major challenges for implementing those recommendations.

Key recommendations on regulatory, policy and human rights considerations focus on the protection of women's health and their human rights through removal of barriers to accessing safe abortion care. Recommendations on the provision of safe abortion focus on making good-quality services readily available and affordable for all women. Recommendations on clinical care focus on evidence-based methods of abortion and appropriate management of pain and complications.

Key challenges for implementing the guidance in countries include changing long-established cultural attitudes, reducing abortion stigma, creating an enabling legal and policy environment, and reducing poverty.

CONGRESS SESSION 20: HOW TO PROVIDE CONTRACEPTIVE COUNSELLING

S20-1 Contraceptive counselling in a multicultural country in transition – the example Malaysia

Jamiyah Hassan

University of Malaya, Kuala Lumpur, Malaysia

The family planning services in Malaysia has been an official policy for the country, and the National Family Planning programme was officially launched in 1966. The National Family Planning Board was established to coordinate and execute the provision of the family planning services. The contraceptive prevalence had increased from 8% in 1966 to about 50% in 2004.

The population in Malaysia is about 27 million comprising of Malay, Chinese and Indian and the country is divided by main regions, Peninsular Malaysia, Sabah and Sarawak. The ethnic groups in East Malaysia also differ from the West or Peninsular Malaysia. The contraceptive prevalence rate across the three regions also differs. In 2004, the contraceptive prevalence rate for Malays has always been lower than the Chinese. The CPR for modern methods was 28.2% for the Malays, 45.6% for the Chinese and 32.2% for the Indians. Wide variation in CPR can be seen between the various states in Malaysia. The state that has the highest Malay population tends to have lowest CRP rate in the usage of modern contraceptive methods.

In the early sixties and seventies the CRP between the urban and the rural areas was due to educational, ethnic and cultural differences. However, with increasing education opportunities and more awareness, the ethnic and cultural differences have become one of the most important reasons for the differences seen in CRP in the different states in Malaysia. This has been a major challenge to the healthcare providers in the country to increase the CRP. Malaysia is a multiconfessional country where Islam is the main religion. About 60% of the population practices Islam; however, Islam has not been the barrier to contraception. The National Fatwa Council under the Development of Islamic Advancement of Malaysia (JAKIM) allowed the practice of contraception for the purpose of maintaining maternal and family health for Muslim couples. Despite this, the CPR among the Malays is still low. Misconceptions surrounding modern contraception created a substantial barrier to the use of contraception. Because of this, women prefer traditional ineffective contraceptive methods like herbs or natural methods to modern contraception. In this part of the world having a regular period is considered as important to most women and contraceptive methods resulting in amenorrhea are not popular. In this part of the world women believe that their duty is to bear children to establish their womanhood and they adhere to strong cultural norms.

S20-2 Contraceptive counselling: The Challenges in the Arab World

Ashraf Kortam

Ain Shams University, Cairo, Egypt

Family planning is a cornerstone in reproductive health. It is critical for the health of women and their families, and it can accelerate a country's progress toward reducing poverty and achieving development goals.

The need for family planning is crucial in the Arab world owing to the economic and health circumstances in the region.

According to the United Nations Population Division, the number of women of reproductive age (defined as ages 15 to 49) in the Arab region grew from 69 million in 2000 to 93 million in 2012 –an increase of 35%. This age group will increase by another 25 million, or 26%, by 2025.

Effective contraceptive methods are important in the Arab world because cultural and religious reasons make clinical terminations for unwanted pregnancies difficult.

While most countries in the Arab world have a national family planning programme, as yet, implementation of such programmes varies widely between different countries. Various barriers exist at the patient, provider and health system levels. Governments and nongovernmental organisations can help remove social and economic barriers to using family planning, expand coverage of family planning services, and improve the quality of information and services.

CONGRESS SESSION 21: FAMILY PLANNING PROGRAMMES AROUND THE WORLD

S21-1 Successful Family Planning Programmes in Developing Countries

Michael Mbizvo, Mario Festin

WHO, Geneva, Switzerland

Methodology: Online Survey of 500 healthcare professionals from 98 countries and a virtual global discussion to identify highest ranked elements, using the Knowledge Gateway of the Integrating Best Practices (IBP) Initiative.

Results: Top elements of successful FP programmes, with developing country examples include:

(1) Supportive Policies – Family planning programmes need high level support to operate successfully, through advocacy efforts focusing on the benefits of FP and building political will. In Zambia, the Ministry of Health developed a policy framework that outlined strategies for improving access to and quality of family planning services.

(2) Evidence-Based Programming – The WHO issues and periodically updates global guidelines on the provision and use of contraceptive methods, reflecting evidence-based statements and its implications for service delivery. These FP cornerstones have been adapted into many languages and have been translated for use in many settings.

(3) Strong Leadership and Good Management. Leaders and advocates can lay a strong foundation for family planning programmes, such as the case of Profamilia in Columbia which has become the largest national provider of FP services.

(4) Effective Communication Strategies. The highest quality, most accessible healthcare services require that people are aware of these. Effective behaviour change communication activities are crucial. In 2000 a mass media campaign in the Philippines persuaded nearly 350,000 women to start using a modern contraceptive, with the campaign costing S1.57 for each new user.

(5) Contraceptive Security. When a programme has an interrupted supply of a variety of contraceptives, clients can choose and use their preferred method without interruption. The SPARHCS has been used in countries like Madagascar, to ensure that supplies are adequate.

(6) High-Performing Staff. Well trained and motivated staff are the most important element of success in FP. Supporting the present health workforce and building a new cadre of healthcare providers in FP through task shifting or sharing will expand the base of providers Ethiopia.

(7) Client-Centered Care. The Puentes Project in Peru brought together community members and health providers to define quality of care and to improve services delivery.

(8) Easy Access to Services. Community-based distribution of various methods has expanded reach and availability.

(9) Affordable Services. Voucher systems in Kenya have aimed to improve access especially to the poor sector.

(10) Appropriate Integration of Services. Allowing clients to have access to other health services such as screening and management of HIV and STIs and immunisation.

S21-3 Approaches to improving family planning delivery in the developed world

Anna Glasier^1,2

^pUniversity of Edinburgh, Scotland, UK, ^qLondon School of Hygiene and Tropical Medicine, London, UK

Models of family planning service delivery vary widely in the developed world. Whatever the service model improving uptake and effective use of contraception depends on three factors – access, choice and quality of service.

In the UK access to services has improved over recent years with the establishment of specialist provision for vulnerable groups (e.g., young people, sex workers) and with the integration of family planning, STI and abortion services. More recently access to information, advice and even methods via the internet is being trialled in areas where the demand for face-to-face consultations cannot be met. Method delivery from pharmacies using patient group directions is being expanded beyond emergency contraception.

The choice of methods available depends not only on which methods are licensed in a particular country but whether they are made available by the providers. Insertion of contraceptive implants and intrauterine methods requires skill and takes more time than simply providing pills or injectables. Initiatives in the UK aimed at increasing information about, and demand, for these methods does appear to result in more providers being willing and able to meet that demand.

Quality of service provision can be ensured with competency-based training programmes, use of nationally agreed clinical guidelines and regular audit.

No family planning service will ever be perfect but attention to these three issues will ensure that potential users can and do choose the method best suited to meet their needs and can help to encourage correct and consistent use and method continuation.

CONGRESS SESSION 22: SEXUALITY AND SEXUAL HEALTH ISSUES: A LOOK AT THE ARAB REGION

S22-1 Patterns of sexual behaviour in the Arab Region

Faysal El Kak

American University of Beirut, Beirut, Lebanon

The Arab region is the second world region with the youngest population, where political changes, conflicts and displacement, migration, information technology, and globalisation are contributing to the shaping of the lives of youth including sexuality and sexual behaviours. It is essential to look at the various demographic, socio-economic, cultural, and public health dimensions to describe and understand the pattern of sexual behaviour and the burden of sexually transmitted infections (STIs) in a region of weak sexual health services. New trends of sexual communication and forms of marriage have emerged to accommodate the changing patterns of sexual behaviour like premarital sex and extra-marital, temporary marriages, as well as reports of increased prevalence of premarital penetrative and non-penetrative sexual behaviour. Despite these trends, the burden of sexual illnesses remains low and is estimated at 7.0% of the general population being infected with curable STIs. Other STIs, such as herpes simplex virus 2 are also prevalent. The existing policies and health systems remain short of accommodating the changing and rising patterns of sexual behaviour, especially among youths. Efforts should address establishing national preventive programmes as well as youth-friendly services.

S22-2 Sexual and reproductive health myths and misconceptions among Egyptian adolescents

Mamdouh Wahba

Egyptian Family Health Society, Cairo, Egypt

Introduction: In most of the developing world, most of the young people have little understanding of sexual and reproductive health (SRH) issues or the responsibilities of parenthood. They usually have no reliable source of information and their acquired knowledge on these topics may be misleading or at best unhelpful.

It is a well-established fact that knowledge is the deciding factor for the development and shaping-up of attitudes and practices especially in the field of reproductive health. These attitudes developed during childhood and youth will influence the whole way of life of the future generations, including the outcome of their pregnancies and their ability to be good parents.

In Egypt, very little information related to SRH is available to young people. Formal education in schools and universities contain only few family planning messages related to the population problem besides occasionally, and often neglected, short biology lessons. Informal educational activities in this field do not exist. Parental guidance is also rare and often not adequate. Young Egyptians rely mainly on peers for their knowledge and information related to reproduction and sexuality, what they get is not always correct and is often misleading. No wonder, we find misinformation and misunderstandings prevalent among Egyptian Youth.

The Egyptian Family Health Society (EFHS) has implemented a large scale SRH and life skills education project in preparatory and secondary schools in 22 Governorates in collaboration with the Ministry of Education with support from the Ford Foundation. The project started at the beginning of the academic year 2010–2011 and is still continuing. It aims at providing accurate and appropriate reproductive health information to adolescent students, correct their misconceptions and respond to their questions and concerns. The impact and outcome of the project has been studied in five Governorates at the end of the first academic year 2010–2011.

The results of the study indicate that there was an obvious deficiency of knowledge on many aspects among the studied adolescents and also a marked improvement of their knowledge as a result of attending the seminars. There were plenty of misconceptions among many boys and girls.

Recommendations: School-based SRH education is needed and very effective for providing adolescents with essential SRH information and for addressing their prevalent myths and misconceptions. SRH educational sessions conducted in schools are well accepted by students and their parents specially when conducted by young physicians in an interactive approach.

S22-3 Sexual health education: A case from the Arabian Gulf Region

Elham Atalla

Ministry of Health, Manama, Bahrain

It has been proved that doctors were inadequately trained in the past to treat patients with sexual problems and that the physicians of the future are still being inadequately trained by most medical schools. On the other hand, fortunately, and with increasing efforts and awareness, more and more medical schools have added sexuality education to their curricula.

A cross-sectional descriptive study was conducted in 2009 among all primary care physicians (total 280) in the Kingdom of Bahrain with an adapted questionnaire. Questions asked were the frequency of recording sexual history, patients reporting of sexual dysfunction, ranking of physician's level of discomfort while interviewing patients, factors inhibiting discussion of sexual dysfunctions and potential strategies to improve communications.

Results have shown that 44% of respondent physicians highlighted training programmes as an important strategy for feeling skilled in dealing with sexual health issues.

Moreover, the need for educating GPs about recognising their own barriers to discussing sexual matters and training them how to communicate effectively about sensitive issues is clear. However, the importance of doctors not allowing their views about patient sexuality, age and lifestyle to affect treatment must be stressed.

Sexual health education to the public was perceived as another potential strategy to improve communication about sexual health issues within the primary care setting in Bahrain, bearing in mind and foreseeing that Bahraini community, like other Arab and Muslim communities, is still considered a conservative one. Issues related to sex and to sexuality are considered extremely private matters that should not be discussed in public.

This need is now being met to some degree by new efforts in continuing sexuality education. These efforts are two-fold. The first was targeting the health care physicians. A human sexuality one-week course was constructed and delivered to Family Residency programme physicians during their 3rd year and was incorporated as a core requirement. Moreover, several workshops and lectures were delivered to primary health care workers including physicians and nurses. In addition, the subject of human sexuality was introduced for the first time, in Bahrain at least, to the undergraduate level.

The other fold of these efforts was directed to the public. Several workshops addressing varying target groups, e.g., pre-marital counselling and newly married couples, were conducted on a regular basis in coordination with voluntary and civil community organisations.