SOCIETY ARRANGED SESSION 3: ORGANISED BY INTERNATIONAL SOCIETY FOR SEXUAL MEDICINE (ISSM) HORMONES AND WOMEN’S SEXUALITY
SAS03-1
Women’s sexual function and dysfunction
Annamaria Giraldi
Sexological Clinic, Psychiatric Center, Copenhagen, Denmark
The definitions used to describe women's sexual function and dysfunction are based on the models that are used to describe the sexual response. For many years the linear models proposed by Masters and Johnson (1966) and Kaplan (1979) with the phases desire, arousal and orgasm have been the used models. In the linear model by Kaplan desire was described as spontaneous desire. However, during the last decade several other models describing the sexual response have been proposed, especially in the field of women. The foundation of this is the concept that many women experience receptive desire, which may arise after arousal. Furthermore several studies have shown that women's sense of sexual arousal often isn't correlated to the objective sexual arousal and that the orgasmic experience may be highly variable.
Recent studies have demonstrated that women describe their sexual function by both linear and circular models, and that women with sexual problems are more likely to prefer the circular models.
During recent years there has been an increased focus on women. Several bio-psycho-social factors influence women's sexual function. Often a combination of several factors will cause dysfunctions. In addition to a sexual problem, FSD is defined as causing the woman distress. Epidemiological data show that, when asked, 6 to 55% of women report a sexual problem. However, only a part of these women will report distress due to the sexual problem. Major risk factors for FSD are relationship problems, stress, sexual abuse, and partner violence.
SAS03-2
Contraception and sexuality – does the pill ruin women's sexual life?
Johannes Bitzer
University Hospital Basel, Department of Obstetrics and Gynecology, Basel, Switzerland
Introduction: In recent years combined hormonal contraceptives have been linked to sexual dysfunction especially desire and arousal disorders in women. The underlying hypothesis for the action of the drug is that ethinylestradiol leads to an increase in SHBG thus decreasing free testosterone which is considered to be an important factor in sexual desire in women. Another hypothesis points to the fact that oral contraceptives diminish the natural fluctuations of the cycle especially the fluctuation of oxytocin.
Methods: Review of the literature. Case discussions in the Sexological Clinic of the University Hospital in Basel, Switzerland.
Results: Studies differ to a large extent in methodology, outcome measures, control for variables and confounders. The results are controversial and show partial increase, decrease and no change in desire in users. There is no clear correlation between SHBG, free testosterone and sexual function in OC users. Our analysis points to the fact OCs can interact with the biological, psychological, relational and even social factors contributing to sexual function in a bidirectional way meaning that OCs can either enhance or inhibit sexual desire depending on the individual condition and response.
Conclusion: Family planning professionals should regularly enquire about sexual function and sexual health taking into account the multidimensional interaction of contraceptives with the sexual life of women.
SAS03-4
Sexual pain disorder in young women – how do we handle it?
Christina Damsted Petersen
Hillerød Hospital, Hillerød, Denmark
Sexual pain disorder in young women is an under-recognised and undertreated condition. Sexual pain is classified into two diagnostic entities, Dyspareunia and Vaginismus.
Dyspareunia is persistent or recurrent pain with attempted or complete vaginal entry and/or vaginal sexual intercourse. The prevalence ranges between 6 and 15% depending on the subtype.
Vaginismus is persistent or recurrent difficulties in allowing vaginal entry with a penis/finger/any object despite the woman's expressed wish to do so. The prevalence of self-reported vaginismus is very sparsely studied, but seems to be about or lower than 5%.
The etiology of sexual pain is multi-facetted, often routed in a somatic and/or functional condition with psycho-sexual co-morbidity.
Symptoms vary according to etiology, and may present as localised/generalised or superficial/deep. Sexual pain may appear in a general or situational setting.
Due to the multifactorial conditions, causing or maintaining sexual pain, a thorough comprehensive somato-psychological multidisciplinary approach is often called for when attempting to establish a valid diagnosis and choosing a treatment strategy.
The presentation will provide an insight into the most common causes of sexual pain in young women, concomitant psychological, marital and sexual issues and discuss relevant diagnostic procedures and multidisciplinary treatment strategies.
SOCIETY ARRANGED SESSION 4: ORGANISED BY THE FACULTY OF SEXUAL & REPRODUCTIVE HEALTHCARE (FSRH) MENARCHE TO MENOPAUSE – A HOLISTIC APPROACH TO WOMEN’S HEALTH
SAS04-1
Life course approach to women's healthcare
Judith Stephenson1,2
1UCL Institute for Women’s Health, London, UK, 2UCLPartners, London, UK
A life course approach is one that recognises the impact of early life events on later health and development of disease. Normal events in a woman's life, such as control of fertility, pregnancy and childbirth, can have profound long-term effects on the future health of the woman herself as well as her children. The physiological demands of pregnancy can act as a ‘stress’ test that reveals risk of future chronic disease. For example, although complications such as pre-eclampsia and gestational diabetes resolve after delivery, they are associated with higher cardiovascular mortality in later life. A life course perspective also highlights the potential for early intervention to reduce disease risk or severity. It has intuitive relevance to women's health needs: reproductive and sexual health, which are relevant to almost all women, unfold across the life course, triggering health care needs in a predictable way.
A wealth of ‘life course research’ since the 1980s has investigated the long-term effects of biological, behavioural and social exposures during gestation, childhood, adolescence and young adulthood on health and chronic disease in later life and across generations. More recently, the implications of this knowledge for health service delivery has attracted a high level of attention1. The UK Royal College of Obstetricians and Gynaecologists has recently adopted the life course model as the cornerstone of its new strategy for high quality women's health care2. This presentation considers the implications of a life course approach to women's health, particularly for contraception, sexual and reproductive health services.
References
Stephenson et al. Scientific Impact Paper No. 27. Why should we consider a life course approach to women's health care? RCOG. August 2011 http://www.rcog.org.uk/files/rcog-corp/uploaded-files/SIP_No_27.pdf (last accessed 8 December 2012).
The Royal College of Obstetricians and Gynaecologists. Tomorrow's specialist. 2012 http://www.rcog.org.uk/files/rcog-corp/High_Quality_Womens_Health_Care_and_Tomorrows_Specialist_%20Synopsis_by_Nick_Timmins.pdf (last accessed 8 December 2012).
SOCIETY ARRANGED SESSION 5: ORGANISED BY THE INTERNATIONAL FEDERATION OF PROFESSIONAL ABORTION AND CONTRACEPTION ASSOCIATES (FIAPAC) MEDICAL ABORTION IN A GLOBAL PERSPECTIVE
SAS05-1
Self-administered medical abortion
Sam Rowlands
Dorset HealthCare, Bournemouth, UK
Unsafe abortion remains a global scourge. Criminal laws in many countries limit the actions of health professionals in preventing morbidity and mortality from induced abortion. It can be argued from a human rights and personal autonomy perspective that women should be able to induce their own abortion by self-medication.
Women have used ineffective oral abortifacients for hundreds of years. Effective drugs in the form of mifepristone and misoprostol are now widely available to the consumer all around the world from pharmacies and other distributors. The internet has facilitated this accessibility to drugs, although there are pitfalls including the sale of fake pills. Organisations such as Women on Web distribute pills in countries with restrictive abortion laws, using the medium of telemedicine; there is no prescription. In many developing countries abortion pills are available from street traders. Some organisations and advocacy groups provide information only. Information can save lives, when women have access to drugs but need to know evidence-based regimens and when medical help is needed. The latter system has proved invaluable particularly in South America where misoprostol alone is used. A unique harm reduction intervention has been developed and assessed in Uruguay. Information is now being transmitted in novel ways which keep pace with new technology. For instance, a Web app in Mexico and an interactive voice response telephone system in Kenya have been developed.
Diverse regulators have tried to restrict the flow of drugs. A professional website has been closed down after threats from medical regulators, US States have introduced restrictive legislation, women have had criminal charges brought against them, drug regulators have banned import of drugs for personal use and customs officials have seized drugs from postal services.
A pragmatic approach is needed as the free flow of abortion pills is now a fact of life. Draconian regulatory responses should be avoided. Criminal law in relation to women inducing their own abortion should be repealed. Women should be free to obtain and self-administer abortion pills. Health professionals have a responsibility to ensure women have access to high quality evidence-based information.
SAS05-3
An update on postabortion contraception
Sharon Cameron
NHS Lothian, Edinburgh, UK
Ovulation occurs within a month of first-trimester abortion in over 80% of women. In addition, more than 50% of women have been found to commence sexual activity within two weeks of an abortion. Initiation of contraception immediately following induced abortion has advantages. The woman is known not to be pregnant, her motivation to use effective contraception may be high and avoids an additional visit to a contraception provider.
The WHO's medical eligibility criteria (WHO MEC) and selected practice recommendations for contraceptive use (WHO SPR) provide evidence-based recommendations on eligibility for methods and on maximising effective contraceptive use. The WHO SPR advises that all hormonal methods of contraception can be commenced immediately following an induced abortion. A systematic review of the literature concluded that the provision of combined oral contraceptives immediately following abortion was safe. Use of the combined oral contraceptive pill does not affect either duration or amount of vaginal bleeding or the complete abortion rate of the medical method.
It has been shown that women who choose to commence one of the most effective methods of contraception immediately after abortion namely; the intrauterine system (IUS), intrauterine device (IUD) or progestogen-only implant have a significantly reduced risk of having a subsequent abortion than women choosing other methods. Abortion providers should therefore be trained and supported to provide these methods to women at the time of the procedure.
Insertion of an IUD or IUD can be safely performed at the time of surgical abortion and can be inserted following medical abortion once expulsion of the pregnancy has occurred. Since delaying insertion of an IUD or IUS after abortion has been shown to be a barrier to uptake (and unprotected intercourse may have occurred), insertion should be scheduled for as soon as feasible after early medical abortion. If insertion of an IUD/IUS needs to be delayed then women should be provided with an interim method until the IUD/IUS can be inserted. Women who choose to have an IUS inserted after medical or surgical abortion have significantly fewer days of heavy bleeding than women who have an IUD.
SOCIETY ARRANGED SESSION 6: ORGANISED BY THE ISRAELI SOCIETY OF CONTRACEPTION AND SEXUAL HEALTH RELIGIOUS AND CULTURAL INFLUENCES ON THE USE OF CONTRACEPTION: THE MELTING POT EFFECT
SAS06-1
The attitudes of Christian, Jewish and Moslem customs towards the use of specific forms of contraception
Arie Yeshaya
Rabin Medical Center, Department of Obstetrics and Gynecology, Petah Tikva, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Contraception and the support of fertility regulation have been evident in all cultures, and even in those which favour the abundant production of children. Religious expression and values continue to affect family planning by their potential influence on the acceptance and use of contraception. No one method is perfect for everyone, for every clinical setting, and in every culture. Within religions, different sects may interpret religious teachings on contraception in different ways, and individual women and their partners may choose to ignore religious teachings. The attitude of the main religious groups to contraceptive practice is discussed, together with a thorough description of the relationship between religiosity and contraceptive method choice among users of contraception. Moreover, the various methods of contraception, their limitation and the modifications enabling contraception use in the different religion will be presented. New data about attitudes towards contraception of the Israeli women from different religions (Christians, Muslems and Jews) will be discussed. These data will present the women's choice of contraception based on their age, marital status, and the weight of religion in deciding on the method of contraception.
SAS06-2
The use of contraception among Ethiopian women in Israel: The case of medroxyprogesterone acetate injections
Amos Ber
Maccabi Health Centres, Tel Aviv, Israel
The use of depo provera injections as a contraceptive is not popular in Israel. The huge Ethiopian immigration to Israel that mainly came from small villages and had little knowledge about contraceptive use posed a big burden on the medical establishment that had to try and convince them to use contraceptives and thus reduce the huge birth rate in this low socioeconomic population. In 2008 it was alleged that the Ministry of Health is using the drug in order to reduce the excessive birth rate in new emigrants from Ethiopia. The use of this method of contraceptive gives the control over the fertility to the medical establishment compared to COC for example, where the woman controls her own fertility. In this lecture I will revise the contraceptive use in this special population, try to see if there was a population targeted campaign to reduce their fertility and to see what happens in the field of contraceptives use in the second generation of Ethiopian immigrants.
SAS06-3
Eastern European immigrants to Israel: Do they adopt Western European patterns of contraceptive use?
Daniel S. Seidman
Chaim Sheba Medical Center, Department of Obstetrics and Gynecology, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Combined oral contraceptive pills (COC) have been widely used in Western Europe since they were introduced in 1961. However, despite the more than five decades that have passed, huge differences remain in the use of the COC over various countries in Europe, with a staggering difference between East and West. For instance, data from the 2009/2010 Health Behaviour in School-aged Children (HBSC) survey, a WHO collaborative cross-national study based on a cluster sample totalling approximately 200,000 adolescents from 43 countries, shows that the use of COC among 15-year-olds during the last sexual intercourse was no more than 15% in most Eastern European countries, compared with over 50% in some Western European countries like Germany, Belgium and the Netherlands. If one assumes that nowadays practitioners from all over Europe are exposed to very similar evidence-based data, then it is very difficult to explain how nearby countries, like Germany and Russia, have more that a tenfold difference in the overall incidence of COC use.
Since 1990 and up to the beginning of 1996 more that 600,000 Jews immigrated to Israel from the Former Soviet Union (FSU) countries. These immigrants currently compose over 10% of the Israeli population. Since, COCs are the most commonly used form of contraception among Israeli born young women, it was suggested that examining the pattern of COC use among young women who immigrated to Israel at a young age from FSU countries, could help improve our understanding of the medical, cultural and social biases that might negatively influence the use of COC in Eastern Europe. New data from a survey will be presented examining whether the well known ‘melting pot’ effect, prevalent among the much welcomed FSU immigrants, has changed the incidence of COC use from that currently prevalent in FSU or Eastern European countries to the significantly higher use rates typical of Israeli born young women.
SOCIETY ARRANGED SESSION 7: ORGANISED BY THE ASSOCIATION OF REPRODUCTIVE HEALTH PROFESSIONALS (ARHP) & THE COALITION ADVANCING MULTIPURPOSE TECHNOLOGIES MULTIPURPOSE PREVENTION TECHNOLOGIES (MPTS) FOR SEXUAL AND REPRODUCTIVE HEALTH: MEETING A CRITICAL NEED FOR WOMEN AND THEIR FAMILIES
SAS07-2
Multipurpose Prevention Technologies (MPTs) available now and on the horizon
Wayne Shields
Association of Reproductive Health Professionals, Washington, DC, USA
Objectives: Multipurpose prevention technologies (MPTs) that simultaneously protect against a variety of sexual and reproductive health (SRH) risks are already under development. The objective of this presentation is to highlight those MPTs in clinical development that combine microbicidal and contraceptive components for either ‘on demand’ or sustained use.
Methods: Qualitative surveys and interviews were used to survey SRH organisations that develop products appropriate for low resource settings on the status of MPTs in their clinical development pipeline specifically designed for ‘on demand’ use or sustained use. ‘On demand use’ was defined as: (1) used before and/or after intercourse, and protective for up to 24 hours; and (2) appropriate for women who have infrequent sex, or who would like more direct control over their own protection. ‘Sustained use’ was defined as: (1) user-initiated, but not requiring daily action; and (2) increasing acceptability and adherence, and therefore overall effectiveness.
Results: Four SRH organisations were identified with MPTs in their R&D pipeline: CONRAD, PATH, Population Council, and International Partnership for Microbicides (IPM). On demand products under development fall into two different types: Gels [including Tenofovir (TFV) Gel, and MIV-150 + Zinc+ Levonorgestrel (LNG) (MZL) Carrageenan Gel], and Devices + Active Agents (including the SILCS Diaphragm+ TFV Gel, and the Woman's Condom + Microbicide Film). Sustained release products under development focus on Intravaginal Rings (IVRs), and include the TFV+ LNG IVR, the MZL IVR, and the Dapivirine+ LNG (DAP+ LNG) IVR.
Conclusions: Diversifying delivery and dosing options is KEY to expanding acceptability and use by women in different regions. The MPTs under development could meet a number of different SRH needs: (1) the MZL gel could meet the needs of women who want an ‘on demand’ method that lasts up to 24 hours; (2) the SILCS Diaphragm+ TFV gel could meet the needs of women who want a non-hormonal contraceptive method that they control, especially for intermittent sex; and (3) the combination IVRs (TFV+ LNG, DAP + LNG, and MZL) could meet the needs of women who want a highly effective method that they don't have to think about, and that provides continuous protection for one to three months. Since these innovative MPT strategies have the potential to protect against unintended pregnancy, HIV, herpes simplex virus, and human papillomavirus, their successful development could substantially improve reproductive health for women and girls in low resource settings.
SAS07-3
Aligning investments in multipurpose prevention technology (MPT) R&D and the critical path to MPT introduction
Judy Manning1, Joe Romano2
1US Agency for International Development, Washington, DC, USA, 2NWJ Group, Wayne, PA, USA
Objectives: There is an urgent need to develop safe, acceptable, effective, and low-cost multipurpose prevention technologies (MPTs) that would simultaneously protect against a variety of sexual and reproductive health (SRH) risks. The objective of this presentation is to present the key attributes of MPTs appropriate for low resource settings, and the process for priority-setting for MPT research and development.
Methods: Quantitative surveys, qualitative interviews, product pipeline and landscape analyses were used to survey and interview selected SRH researchers and providers in the US, Europe, Africa and Asia on ideal product attributes and parameters to create a target product profile (TPP) for MPTs. Vet the existing SRH product development pipeline against the MPT TPP to determine which products have the highest potential for public health impact, and thus prioritise investment by researchers and donors.
Results: Quantitative surveys and qualitative interviews of SRH researchers and providers indicated clear regional priorities for the primary and secondary indications to be combined in an MPT. Generally, SRH researchers ranked ‘HIV plus unintended pregnancy’ as the highest priority combination of indications, followed by ‘HIV plus herpes simplex virus (HSV)’. Of 289 SRH providers in sub-Saharan Africa, 65.7% ranked ‘HIV plus unintended pregnancy’ highest, while 66% of 593 US providers ranked ‘unintended pregnancy plus other STIs’ as most important. Human Papillomavirus (HPV) was clearly the top priority STI after HIV for both African (75%) and US (68%) providers, in contrast to the ranking of HSV by SRH researchers. The product pipeline prioritisation process identified already-approved anti-retroviral drugs as the primary HIV prevention component of MPTs, with demonstrated safe and effective hormonal contraceptives as the primary pregnancy prevention component, in order to accelerate regulatory approval and product introduction. An identified gap was the lack of STI-specific prevention compounds particularly for HPV and HSV. The product pipeline scan prioritised the development of a suite of prevention products that would meet women's needs, including vaginal rings, long-acting injectables, and on-demand products.
Conclusions: A variety of MPT product options are needed to meet the lifetime sexual and reproductive health needs of women in different regions. Incorporating those different needs and perspectives early in the product R&D process will enable the development of MPTs in different combinations to selectively address unintended pregnancy, HIV, HPV, and HSV. Such combinations would have general applicability in high resource countries as well as low resource countries, with the potential for global impact in sexual and reproductive health.
SOCIETY ARRANGED SESSION 8: ORGANISED BY INTERNATIONAL PLANNED PARENTHOOD FEDERATION (IPPF) A RIGHTS-BASED APPROACH TO THE PROVISION OF LONG-ACTING REVERSIBLE CONTRACEPTION (LARCS)
SAS08-1
Good clinical practice: What role do rights and justice have in expanding access to LARCS?
John Townsend
Population Council, New York, New York, USA
More than 200 million women in the developing world want to prevent pregnancy but are not using modern contraception. For many of these women, particularly the poor, significant structural barriers obstruct their access to the full range of contraceptive methods. Women's desire to delay, space, or limit pregnancies is often resisted by their families or communities. Public-sector family planning programmes, which are the main source of contraception in most developing countries, typically offer limited options and supplies are not always in stock. Health care providers may not be trained to provide the counselling and services that women need to achieve their reproductive goals. These factors leave poor women facing a substantial risk of unintended pregnancy, unsafe abortion, and maternal and infant mortality and morbidity.
Highly effective, long-acting reversible methods (LARCs) such as the intrauterine contraceptive device (IUD) and contraceptive implants are often out of reach for women in developing countries. Because of the need for a skilled provider and the low priority given to making these methods a real option for women, family planning programmes often fail to offer women a full range of methods, including those that are most effective and appropriate for women who want to postpone their first pregnancy, delay their next pregnancy or limit future births.
Access to all contraceptives, including LARCs, must be based upon the rights of women and men to the full range of reproductive health services. We believe that women are qualified to make informed choices about the contraceptive that best meets their needs, if access is provided, correct information is available, and quality of care is ensured. Based on the increased effectiveness of LARCs, to better serve women over their reproductive lives, increased access to affordable, safe, highly effective, long- acting, reversible contraception is critical. The compelling public health and economic benefits of expanding women's access to LARCs require new policies and perspectives.
To ensure that women have a range of choices across product classes, public and private health care delivery systems should integrate LARCs in their training, counselling, service provision, logistics, and information management. Because most providers of post-abortion and post-partum care have the counselling and clinical skills needed for initiation of LARCs, more attention should be focused on post-abortion and post-partum provision of LARCs as one of the simplest ways to increase access to those in greatest need.
SAS08-2
A fine balance: Engaging multiple perspectives to strengthen contraceptive choice and protect rights
Harriet Stanley
Engender Health, New York, NY, USA
To ensure an effective and responsive rights-based approach to the provision of LARCs, it is critical that the perspectives of all stakeholders be included in programme design, implementation, monitoring and evaluation. Familiar debates that arose before and during the FP2020 Summit in London in July 2012 reminds us that the tensions among rights groups, civil society, donors and family planning programmes continue despite decades of investment in quality improvement, counselling and policies to support the rights of family planning clients to make informed choices. In September 2012, the EngenderHealth-led RESPOND Project, supported by USAID, hosted a consultation at the Rockefeller Foundation's Bellagio Conference Center in Italy, titled ‘A Fine Balance: Contraceptive Choice in the 21st Century’, to explore the point at which family planning programmes intersect with human rights around the issue of method choice. The meeting was designed to advance a dialogue rooted in evidence and characterised by diverse perspectives and included donors, government officials, program leaders, and rights activists. To provide relevant data, a review was prepared in advance of the meeting to ground the discussions in evidence. The review consisted of a scan of published literature from the perspective of client experiences and choice; interviews with key informants; and a review of Demographic and Health Survey data on trends in selected countries and regions. The findings provided a springboard for discussion regarding two key dimensions of choice that must exist if individuals’ rights are to be respected and realised with no coercion and no barriers. In addition, participants received a package of articles about contraceptive method mix and reproductive rights. Participants identified the common ground between the rights perspective and the public health perspective on which we can pursue the shared goal of making contraceptive choice a reality. Building a client-centered approach, they exhorted governments and programme managers to strengthen safeguards that include not only effective counselling and high quality clinical care, but also the engagement of well-functioning, accountable health systems, supportive social networks, policies and laws, and active engagement of women and their communities. The group also reached consensus on the need for an accountability framework and routine monitoring of human rights and contraceptive choice as key measures of programme performance. The Bellagio consultation recommendations are timely and provide concrete suggestions for how to realise the FP2020 agenda in a manner that respects and protects women's reproductive rights.
SAS08-3
Contraceptive choice in highly impoverished communities – choice or by chance?
Edford Gandu Mutuma
Planned Parenthood Association of Zambia, Lusaka, Zambia
Despite widespread awareness of contraceptive methods and increasing use in Zambia, significant challenges remain to access and correct use. There is a significant gap between knowledge and utilisation of contraceptive methods; many more Zambians are aware of contraceptive options than use these (Grabbe and Vwalika 2009) and discontinuation and misuse rates among women have been found to be high (Meinzen-Derr and Stephenson 2007).
Such trends can in part be attributed to the inadequacy and fragmentation of publicly available services. Many public health facilities are not sufficiently staffed with skilled, committed providers to meet latent demand, particularly for involved methods like long-acting reversible contraception, and do not have adequate access to supplies. Thus, even where Zambians may have access to some forms of contraception, they may be unable to choose their desired method. Additionally, tensions between traditional and modern medicine have been shown in Zambia to contribute to non adherence to prescribed treatments.
The state of health care available to the underprivileged has likely contributed to the growing disparity of contraceptive use between wealthy and poor Zambia. Overwhelming evidence points to the connection between poverty and low health knowledge and status across southern Africa, and family planning practices are no exception to this pattern. Due to underdeveloped commercial infrastructure, the Zambia rural poor's access to contraception relies almost exclusively on limited government facilities.
Women's inability to access their chosen contraceptive method is compounded by widespread sexism. Low social status, lack of education, and economic dependence on men hinders women's ability to control their fertility. Yet the responsibility for contraception is relegated to women. Men are less likely to use contraception than are women and communication between partners regarding contraception is limited. Many men believe contraceptive use is evidence of their partners’ infidelity or disease.
Zambia's widespread conservatism impedes progress in contraceptive use, particularly among young women. Most ‘ethnic groups have explicit customs governing sexual conduct of young people, which often involved more restrictions for girls than boys’ (Warenius, Pettersson, & Nissen, 2007). Religious pressures function similarly; young women affiliated with churches that punish premarital sex with excommunication are less likely than their peers to use a condom during their first experience with sexual intercourse. It should be no surprise that these attitudes infiltrate public institutions. Health clinics in many regions discriminate against sexually active young people, denying services or shaming clients, and sex education is largely inadequate.
SOCIETY ARRANGED SESSION 9: ORGANISED BY EUROPEAN BOARD & COLLEGE OF OBSTETRICS AND GYNAECOLOGY (EBCOG) HOT TOPICS IN CONTRACEPTION
SAS09-1
Challenges of contraception in the obese
Ioannis Messinis
University of Thessalia, Larissa, Greece
Obesity is an epidemic in western countries, the prevalence of which is increasing worldwide. It is estimated that about two-thirds of adults in the United States are obese or overweight. Obese women are at similar or increased risk of pregnancy as compared with women of normal weight and pregnancy complications are also increased. Overweight or obese users of oral contraceptives tend to show a higher risk of pregnancy than those with normal weight. In such pregnancies, both maternal and fetal morbidity and mortality are increased together with an increase in diabetes and obesity in the offspring. The risk of venous thromboembolism is increased in obese women and can be even higher in those using combined oral contraceptives. For contraceptive methods other than the oral ones, there is no evidence that obesity modifies their effectiveness, although for intrauterine devices and sterilisation procedures there may be technical difficulties. Of particular importance for combined hormonal contraceptives are BMI ≥ 35 kg/m2, older age, hypertension, diabetes, smoking, history or current venous thromboembolism, vascular disease and major surgery with prolonged immobility. Obesity is also a risk factor for endometrial hyperplasia and cancer. However, the rate of these two conditions is decreased with the use of oral contraceptives or a copper intrauterine device. Until now, there is no convincing evidence that the use of either hormonal or non-hormonal contraceptives is associated with an increase in body weight. Following bariatric surgery in obese women, the contraceptive effectiveness of oral contraceptives does not seem to be affected, although there is some concern in women undergoing malabsorptive procedures. In summary, there is no clear evidence that common contraceptive practice should change in overweight or obese women. Nevertheless, there are still several unclarified issues and questions that need to be answered.
SAS09-2
Migraine and contraception
C. Benedetto, G. Allais, I. Castagnoli, F. Campolo, G. Lanzo
University of Torino, Azienda Ospedaliera OIRM - S. Anna, Department of Obstetrics & Gynecology, Torino, Italy
Although combined Estrogen-Progestogen contraceptives (EP) are a safe and highly effective method of birth control, they may also raise problems of clinical tolerability and/or safety in migraine patients.
It is now commonly accepted that the use of EPs is contraindicated in migraine with aura, and in patients suffering from migraine without aura, if aura symptoms appear. The newest EP formulations are generally well tolerated in migraine without aura, and the majority of patients show no problems with their use; nevertheless, the last International Classification of Headache Disorders (ICHD-II) identifies at least two entities evidently related to the use of EPs: exogenous hormone-induced headache and estrogen-withdrawal headache.
As to the former, headache associated with EPs generally tends to improve as their use continues. If migraine persists, in many patients the attacks are more likely to occur during the pill-free week. The estrogen-withdrawal headache is a headache that usually appears within the first five days after interruption of estrogen use and generally resolves within three days, even if in some cases it may last more days.
In order to treat estrogen-withdrawal headache, options are available to eliminate or reduce the hormone-free interval (HFI): it is possible to use either a continuous EPs regimen, to shorten the HFI to less than the traditional seven days or a low-dose estrogen supplementation after the 21 days of EPs. Another alternative is to prescribe a Progestogen-only contraceptive. Interestingly, the use of a Progestogen-only contraceptive is a safe choice also for women suffering from migraine with aura and recently our group reported that the use of the Progestogen-only pill can reduce the frequency of migraine attacks as well as the duration of aura symptoms.
With regards to safety, even if both migraine and EPs intake are associated with an increased risk of ischemic stroke, migraine without aura per se, is not a contraindication for combined EPs. Other risk factors (tobacco use, hypertension, hyperlipidemia, obesity and diabetes) must be carefully considered when prescribing EPs in migraineurs, in particular in women aged over 35 years. Furthermore, the exclusion of hereditary thrombophilia and alterations of coagulation parameters should precede any decision of EP prescription in migraine patients.
SAS09-3
How to become an expert in sexual medicine
Rolf Kirschner
European Board and College of Obstetrics and Gynaecology, Oslo University Hospital, Norway
Following the inititative of the European Society for Sexual Medicine, a Multidisciplinary Joint Committee of Sexual Medicine was created in 2011. The MJCSM was formed by a cooperative effort between the Boards and Sections of Urology, Psychiatry and Obstetrics and Gynaecology of the European Association of Medical Specialists, UEMS. During the first year of discussions, mandates as well as statutes were elaborated, a curriculum of Sexual Medicine was decided on, a European School has been set up, Standards for Teaching Institutions has been made, and a Sexual Medicine Log Book and Training Portfolio created.
During 2012 the work progressed to have the MJCSM recognised by the UEMS Sections and to finalise rules and regulations as well as a draft set of questions for an European Fellowship Exam in Sexual Medicine. The exam was planned to be held in connection with the Congress of the ESSM in Amsterdam in December. More than 300 participants sat the exam, answering questions from a wide number of medical fields.
The lecture will outline the main topics to be covered in the syllabus and the demands asked by the teaching institutions, as well as the candidates, for a doctor to attain the competence of ‘an expert in sexual medicine’.
SOCIETY ARRANGED SESSION 11: ORGANISED BY THE RUSSIAN CONTRACEPTION SOCIETY FROM CONTRACEPTION TO REPRODUCTIVE HEALTH
SAS11-3
Hormonal contraception and reproductive health
Klara Serebrennikova
CKB RAN, Moscow, Russia
Objective: To assess the effect of hormonal contraception during preconception preparation on reproductive losses and reproductive health in women with infertility.
Design and methods: The use of hormonal contraception in reproductive medicine is justified by the need to prepare patients with infertility for ART programmes. To achieve the given objective we analysed results of three to six months hormonal contraceptive use given prior to enrollment into ART programmes among 165 women with infertility. The average age of the patients was 29.95 ± 1.66 years. In a preconception preparation protocol we recommended nomegestrola acetate (Nomak) 2.5 mg. in combination with 17 b- estradiol in women with infertility due to a tubal- peritoneal factor. The same combination has been used in patients with habitual miscarriage, given the low risk of this medication in developing cardio- vascular, metabolic disorders, and less impact on markers of blood coagulation and fibrinolysis. In patients with polycystic ovary syndrome we used Jes «R» Plus that contains calcium levomefolat. Due to its anti- androgenic effects, this formulation helps remove excess ovarian androgen production by reducing the synthesis of FSH and LH and suppresses the activity of the enzyme 5-α-reductase. Effectiveness of ART programmes was estimated by counting the number of pregnancies occurring after programme administration. Statistical processing was performed using Statistica 6.0.
Results: The use of hormonal contraception allowed the synchronisation of follicle function, which helped in the production of a greater number of mature oocytes (M II). In addition, our research found that use of hormonal contraception in ART programmes didn't affect the thickness of endometrium, which remained unchanged until the middle phase of ovarian stimulation. The use of hormonal contraception has allowed a significant decrease in hyperstimulation syndrome, in patients with polycystic ovaries, as well as increasing the number of oocytes obtained (up to 15) and pregnancy rate.
Conclusions: The use of hormonal contraception allows the preservation of the reproductive potential of the ovaries, the ability to fertilise and improve pregnancy rates in ART programmes in women with infertilities due to tubal-peritoneal factor, miscarriages and polycystic ovaries.
SOCIETY ARRANGED SESSION 12: ORGANISED BY THE WORLD ASSOCIATION FOR SEXUAL HEALTH (WAS) A GLOBAL PERSPECTIVE ON THE DIVERSITY OF SEXUAL HEALTH: A SYMPOSIUM BY THE WORLD ASSOCIATION FOR SEXUAL HEALTH
SAS12-2
Sex education in Sweden
Charlotta Löfgran-Martenson
Malmö University, Center for Profession Studies, Malmö, Sweden
The World Association for Sexual Health (WAS) promotes and advocates for sexual health and sexual rights throughout the lifespan and across the world by comprehensive sexuality education as one important aspect. In the Nordic countries, there is a long tradition of compulsory sex education, whereas Sweden was the first country in the world (since1955). The aim of this study is to illuminate some of today's tasks and challenges, in particular it will address the questions such as; what is the role of sex education in adolescents’ sexual health nowadays (c.f. information overload on the internet, access to the social media, etc.)? Is sex education geared towards all young people, or are certain groups excluded? What values are conveyed by those who teach the adolescents? The chosen method is a literature review on current research in Sweden during 2012.
The results show that sex education in schools still is the supreme source of information for most adolescents. However, the given hetero normative perspective and the starting point with heterosexual relationships have been criticised during the last years. Furthermore, different groups of young people seem to be marginalised by having limited or non-existing experiences of sex education. The national objectives are too broad and do not suit the requirements of groups with specific needs, for example people with intellectual disabilities. Another group is detained youth, who seldom are offered sex education during their stay at youth detention homes. Considering that their experiences in different ways differ from other adolescents there is a need of a curriculum that is adapted on these bases. Finally, seldom are young people's own voices been heard on the content of the sex education which leads to a focus on sexual prevention and risks, instead of feelings, relationships and sexual identity.
The suggestion is a critical pedagogical approach (CPA) that links comprehensive sex education to sexual rights, and also helps to review hetero normative values and ideals concerning relationships for different groups of young people. It is important to make sure that the educators are well-trained (c.f. WAS suggestion for training standards of sexuality educators). CPA could also focus on different ways of recognising sexuality as a valued part of life instead of a risk factor. At last, CPA might help to develop adapted models for sex education for different kind of youth groups.
SAS12-3
Sexual health and diversity
Sara Nasserzadeh1,2
1Connections ABC LLc. Private Practice, New York, NY, USA, 2Chair, Middle East Committee and Associate Secretary of North America at the World Association for Sexual Health, N/A, USA
The diversity of clients, patients and communities we serve are also represented within our professional community. Sexologists work in a wide variety of disciplines. Although there is often overlap, the Technical Advisory Board of the World Association for Sexual Health offers descriptions that have been placed in broad, discipline areas for the sake of clarity. The key umbrella categories are: Behavioural Sciences, Clinical Sciences, Education & Pedagogical Sciences, Research Sciences and Socio-Cultural. In a meeting sponsored by the World Health Organization (WHO) and ratified at the World Association for Sexual Health General Assembly in Montreal 2004, the Technical Advisory Board of WAS provided the foundations for all definitions and descriptions.
The definitions are based on interpretations of various words and titles and how they might be applied to the discipline of Sexology. The Concise Oxford English Dictionary, tenth, revised edition, edited by Judy Pearsall and published by the Oxford University Press in 2002 has been the reference. In addition, the definitions for ‘sex’, ‘sexuality’ and ‘sexual health’ were developed during the Technical Advisors’ meeting.
This talk will share these definitions and describes sexology and the various specialisations within with the hope that we all know where we stand and the vast professional resources that are available to us.
SOCIETY ARRANGED SYMPOSIUM 13: ORGANISED BY THE RUSSIAN ASSOCIATION FOR POPULATION AND DEVELOPMENT (RAPD) REPRODUCTIVE CHOICE FOR REPRODUCTIVE HEALTH
SAS13-1
Demographic policy and reproductive rights – is consensus ever possible?
Lyubov Erofeeva
All-Russian Association for Population and Development (RAPD), Moscow, Russia
Demographic policy in Russia stays tense: population size is reduced at the expense of mortality rate excess over the birth rate. Over the last few years the state made unprecedented measures to stimulate the birth rate; however their efficiency is low and does not give the desired result. Insignificant growth of birth due to demographic wave cannot cover the population super-mortality, especially among male population.
A total of 70% of all pregnancies are terminated in early terms, the majority at women's request. In 2003 the Government reduced the social indicators for termination of late pregnancies from 18 to 4. That resulted in ‘growth’ of spontaneous abortions with proportional growth of maternal mortality from complications. In spite of that, in 2012, the only social reason – sexual assault was left. Activity of anti-choice organisations battling for restricting access to abortions increased dramatically. As a result the Basic Health Law of the Russian Federation (adopted in 2012) has been amended with some articles introducing a pre-abortion waiting period from two to seven days, conscious objection right for the doctors and the ban for abortion advertising (information on terms and medical facilities providing these services), as well as introduction of mandatory psychological pre-abortion counselling. Information of women before abortion presumes data of intimidating character exaggerating harm to health (‘mutilating operation’).
Introduction of new safe abortion technologies – vacuum aspiration and pharmaceutical methods are carried out slowly due to lack of new regulating documents. Therapeutic abortion is accessible only till the 42 days of amenorrhea and in the majority of regions only on a paid basis. At the same time abortion maternal mortality makes up 20% of the structure of total maternal mortality (world-wide – 13%. WHO, 2012).
Conclusions: Measures directed at restriction of access to abortions are breaching women's reproductive rights; they do not solve demographic problems in Russia nor lead to increase in the birth rate. Decrease of unwanted pregnancies and thereafter abortions is possible with the wide access to the highly effective contraceptive means. The overcoming of the demographic crisis is possible only on the basis of compliance with the internationally adopted universal rights, including the reproductive rights, overcoming the social reasons of low childbirth rate as well as taking effective steps directed to mortality prevention.
SAS13-2
Why is access to medical abortion limited in the Russian Federation?
Galina Dikke1,2
1Russian Peoples Friendship University, Moscow, Russia, 2All-Russian Association for Population and Development (RAPD), Moscow, Russia
The problem of abortions stays urgent for Russia due to a large number of induced abortions and insufficient quality of medical services provided to women having unwanted pregnancies. The data obtained as a result of ‘Strategic Assessment of Politics, Programs and Services in the field of unplanned pregnancy, contraception and abortions in Russia’, conducted at WHO initiative 2009, shows that D&C used in 50 to 80% of first trimester abortions is the main method of termination of pregnancy. This is related to restriction of access to other legal methods.
Aim: To identify shortcomings in improvement of quality of medical services related to induced abortions in Russia.
Methods: The statistical data related to abortion methods used in Russia in dynamics during five years (2005–2009), were the results of questioning of facilities’ heads and practitioners executing abortions in state and private clinics. Statistical data processing was carried out by qualitative methods developed by WHO.
Results: Mifepristone was registered and released in Russia in 2000. However, the method dissemination goes very slowly. Thus, it made only 0.9% of induced abortions in 2005, 2.2% in 2002, 3.9% in 2009, and 4.9% in 2010. Vacuum aspiration applied up to six weeks of pregnancy makes 30% for the same period. Restriction in informing doctors based on eligible proofs on safe abortion and a number of restricting the modern schemes use normative documents, an increase of anti-choice movement negatively influences doctors’ and population attitude regarding abortions. The most widespread stereotypes among doctors are: ‘safe abortion’ does not exist, wide access to medical abortion will lead to an increase in its numbers, a decrease in the birth rate, it can be executed under the strict monitoring of doctor in hospital only, it is not ‘allowed’ in Russia to use ‘one tablet’ of Mifepristone, nor should it be used at stagnant pregnancy and so on. Needless tendency to monitor embryo expulsion has led to the over-diagnosis of incomplete abortion, and an increase in the number of unjustified instrumental interventions is noted at many medical centres.
Conclusions: The ratio of medical abortion is low in the structure of the methods used for pregnancy termination. That is stipulated by restrictions of a legal nature as well as insufficient postgraduate training of doctors and country-specific reproductive choice service provision.
SOCIETY ARRANGED SESSION 14: ORGANISED BY THE ASIAN-PACIFIC COUNCIL ON CONTRACEPTION (APCOC) RESPONSIBLE SEX, BETTER LIFE: APCOC INITIATIVES IN MEETING CHALLENGES IN THE REGION
SAS14-1
Introducing APCOC and its initiatives, its role in promoting contraception and sexual health in the region
Jamiyah Hassan
University of Malaya, Kuala Lumpur, Malaysia
The Asia Pacific Council On Contraception (APCOC) was formed in 2006 with 11 founding members from 11 different countries in Asia Pacific; Indonesia, Singapore, Malaysia, South Korea, Taiwan, Hong Kong, Vietnam, Philippines, Thailand, China and Australia. The first Chairman of APCOC was Professor Biran Affandi from Indonesia and its current Chairman is Professor Soo Keat Khoo from Australia.
Unplanned pregnancies, teenage pregnancies and abortions have been a problem around the world. There is an urgent need to increase education and to promote the usage of effective contraception to reduce unnecessary heath risks to women, especially in Asia. Hence, the primary mission of APCOC is to promote effective use of family planning and contraception through education, best practice programmes and advocacy in the Asia-Pacific region. In the first year of formation, the members of APCOC conducted surveys in their own countries to find gaps in information on contraception, sexual and reproductive health. The role of APCOC is to find suitable strategies to fill in these gaps, taking into consideration the cultural and economic differences between countries.
One of the earlier projects of APCOC is to introduce evidence-based and educational materials into clinical practice. The members from the different countries worked with local professional bodies, governmental and non governmental authorities, non-governmental organisations and the community in its approach to improve education in sexual and reproductive health. There is no specific conference in this region to discuss the issues in contraception, hence APCOC provide this educational platform by organising congresses and workshops where world experts in the field of reproductive and sexual health meet and a wealth of experience can be shared. To date APCOC has organised four congresses; the first congress was in 2007 in Shanghai, the second in 2008 in Macau, the third in 2010 in Beijing and the fourth in 2012 in Seoul.
One of the objectives of APCOC is to improve sexual health. Adolescents’ sex education in Asia is not widely accepted. A pilot project in the sex education programme was conducted successfully in Thailand. APCOC has also developed teaching modules in contraception for midwives, general practitioners and specialists. This has been found to be very useful to train the trainers and other healthcare providers in the field of contraception.
SAS14-2
The need for sexuality education in the Asia-Pacific region – preparing young people for sexual responsibility
Soo Keat Khoo
University of Queensland, Brisbane, Australia
There is general agreement that our young people need to be informed of their sexuality as they progress from childhood, through adolescence to adulthood. At present, this need is evident by the continuing high incidence of sexually-transmitted infections and unintended pregnancies among young women aged 15 to 19 years in all regions of the world. How sexuality education should be given, however, remains uncertain and somewhat controversial. There are challenges to a successful outcome in preparing our young people for sexual responsibility. First, concern is expressed that such knowledge may encourage sexual experimentation, especially when given as didactic presentations. Second, some parents are resistant to risk prevention based on risk paradigms; it is better to emphasise sexual health literacy, making the information accessible, appropriate for age and understanding, and useful to these young people so that they can deal with their problems – not only in sexual matters, but also in social interactions and relationships, recognising what is ‘right’ and ‘wrong’. Third, a clear communication between advocates for health and those for education is important, and the roles of teachers and parents require to be defined. A useful model is to support the teachers by sound professional development and uniform and appropriate educational resources, and to give the parents access to these materials so that they are able to reinforce the information at home. Towards these objectives, a train-the-trainer's kit has been developed with accompanying slide illustrations, created as three modules suitable for age-groups 10 to 13 years, 14 to 17 years and 18 to 21 years. This kit allows the curriculum to be delivered effectively in a train the trainer cascade for widespread use. Young people must be prepared from the beginning of their sexual development to be sexually responsible to themselves and others.
SAS14-3
Strategies in post-abortion contraception – experience in China
Linan Cheng
Shanghai Institute of Planned Parenthood Research, Shanghai, China
The Chinese Ministry of Health reported abortion levels in China between 1973 and 2008 and the highest levels occurred between 1979 and 1991. After 1991, contraception technology as well as the services improved dramatically and the number of abortions subsequently decreased. Despite these improvements, there are still a large number of abortions in China. Among women of reproductive age, the average percentage of abortions is 69‰. About 47.5% of the total abortions occurred in women ≤ 25 years old, 49.7% were nulliparous, 55.9% had more than one abortion and 26% with high risk factors including: Young age (< 20 years old), multiple abortions, and repeat abortions within 6 months. Unmarried, floating people in China are more like to have high risk factors during abortions. Furthermore, plenty of surveys have shown that the attitude and knowledge on contraception of abortion women were quite poor. Due to the fact that more than 90% of abortions are performed in hospitals in China, post-abortion care (PAC) service in hospital should be critical to avoid repeat abortions and to reduce the general abortion rate, yet which were unfortunately neglected in most hospitals where induced abortion service provided.
As the academic opinion leader in China, the Association of Family Planning of CMA put forth a National Initiative for Promoting Post-Abortion Contraception since 2009. A Guideline for post-abortion family planning services was issued in April 2011 and distributed to hospitals. The core measure is to facilitate post-abortion women to use high-efficacy contraceptives immediately and persistently by promotion of standardised PAC counselling service according to the PAC Guidelines. Up to now, two hospitals (one in Beijing and one in Shanghai) were recognised as model hospitals, and 14 hospitals from 12 provinces were selected for their good post-abortion contraception services.
One benefit of the PAC is to improve the image of the maternal hospital. In addition, doctors and nurses know more about contraception, more women are using contraception post abortion, there is an increased level of satisfaction with clinic services, and there are more outpatients been attracted by hospitals which could provide good PAC services.
SAS14-4
Why women use unreliable methods of contraception – the issue in Asia-Pacific region
Surasak Taneepanichskul
College of Public Health Sciences, Chulalongkorn University, Bangkok, Thailand
In the Asia-Pacific region, about 30 to 70% of married women use modern contraceptive methods varying between countries. Thailand is one of the countries which has a high contraceptive prevalence. However, there are some countries in this region having low modern contraceptives use. Low usage of contraceptive methods, results in high rates of unwanted pregnancies and its consequence which includes; psychological problems, poor physical health and unsafe abortion. There are many barriers to modern contraceptives use which cause women to use unreliable contraception. Many studies demonstrated that personal beliefs, religion, cultural, and health service system were barriers to modern contraceptive use. The women have been surrounded by fears, and misconceptions which serve as obstacles to the initiation and continuation of contraceptive use. Strong socio-cultural norms, misconception and health services barriers including negative response of service providers, and low family planning promotion activities influence contraceptive use negatively. It is suggested that the reproductive health educational programme, improvement of family planning service and promotion of modern contraceptive methods should be implemented to reduce unreliable methods of contraception in the Asia Pacific region.