X International Congress of The Society for the Advancement of Contraception Manila, Philippines, 5–9 November 1998 Abstracts (in alphabetical order of author)

IMPLANT VS 3-MONTHLY INJECTABLE

BIRAN AFFANDI

Klinik Raden Saleh, Department of Obstretrics and Gynecology Faculty of Medicine, University of Indonesia, Jakarta

Steriods can be administered in at least five different ways: injectables, hormone releasing IUDs, implant, vaginal rings and pills. Progestins, a synthetic steriods, are used as the main bioactive substance. Different progestins are effective for different periods of time, progestins in daily oral pills are effective for 24 hours. The effectiveness of progestins can be prolonged by incorporating them in a sustained release system that gradually releases the hormone, thus they can be effective up to five years or more. Two progestin-only injectables are widely available in the family planning programs, DMPA and NET-EN. Implantable contraceptives place just under the skin on the inside of woman's arm. Implants capsules release the progestin at slow, steady rate. There are 3 implantables available in the market: Implanon, Norplant and Jadelle. For 1-5 years they prevent nearly all pregnancies. Then they must be replaced. Biodegradable implants also placed under the skin, but they eventually dissolve and disappear.

As with other progestin-only contraceptives, the main side-effects of implantable and injectable contraceptives are bleeding disturbances, which in turn will affect the acceptability of the method. Studies have been being conducted to investigate the role of local factors in progestin-induced bleeding and the effectiveness of medical treatment in bleeding disturbances.

PROGESTIN-ONLY PILLS

BIRAN AFFANDI

Klinik Raden Saleh, Division of Reproductive Health, Department of Obstetrics and Gynecology, Faculty of Medicine, University of Indonesia, Jakarta

IUD, condom, injectables and implantables methods offer good postpartum contraception with practically no effect on lactation. However if the mother prefer and request oral contraceptive, the progestin-only pill (minipill) is the best solution. Minipill has no adverse effects on lactation. Most research has found that it has either positive effects increasing milk quantity or improving its nutritional quality or no effect. During breastfeeding ovulation may be irregular even if menstruation has resumed. Also, bleeding irregularities that may accompany minipill use may cause less concern to postpartum women that to others. More importantly, women using minipill breastfeed as long as women using no contraceptive or a method other than pills. Minipills are being used in more than 50 countries all over the world. Exluton, a minipill, contains lynestranol 0.5 mg developed by Organon, was first marketed in Finland in 1972. International experiences with Exluton found that it is an effective and safe method for lactating women with high acceptance. The Indonesian Family Planning Program has included Exluton as one of the contraceptive methods in its program since 1989.

Efficacy Study of A Standard Rule Method of NFP

Marcos AREVALO, MD MPH

Institute of Reproductive Health

Tens of millions of women worldwide currently report using periodic abstinence but lack access to the knowledge necessary to use it correctly. A new simplified method of NFP, which meets the needs of these women, is being tested. All users of this Standard Rule Method are counseled to abstain from intercourse on the same days of every cycle (days 9-19) to avoid pregnancy. For this study, a mnemonic device is used to support teaching and use of the method: a beaded plastic necklace used to keep track of the mentsrual cycle, with fertile days marked by specially colored beads. It is a multisite, prospective, longitudinal efficacy study. Service delivery and some other study tasks will be implemented through existing health programs. Research questions include efficacy, acceptability of the abstinence period, compliance, and continuation.

TEENAGE CONTRACEPTION AND SEXUALITY

Dr. B. Norman BARWlN

Children's Hospital of Eastern Ontario, University of Ottawa

THE PROBLEM: An estimated 50% of adolescents between the ages of 15-19 engage in sexual intercourse. Less than half used contraception the last time they had intercourse. Virtually no adolescent uses contraception at his or her first sexual contact, and the denial of the risk of Sexually Transmitted Disease. FACTORS: The key to understanding adolescents is to recognize their search for identity and an increasing desire for independence. Maturation is a very individual process through which independence is established. To a greater or lesser extent, risk taking behavior is part of independent decision making. Unfortunately, adolescence is also a rather stressful and confusing time for many. Society's denial of adolescent sexual activity compounds the problem. Prevailing attitudes of adolescent sexual activity contribute to the problem of unplanned pregnancy, which may have more potential risks both medically and socially. In the 1990's, consideration must be given to provision of both birth control method and prevention of Sexually Transmitted Disease. Barriers to effective contraceptive use include: access to services, cost, confidentiality and attitudes of the health care provider. Many physicians are uncomfortable discussing sexual issues with adolescents and many find their behavior difficult to understand. Consideration of the factors influencing sexual activity and contraception may improve our ability to provide non-judgemental care in this important area. SOLUTIONS: The purpose of this session will be to review methods at improving communication; Access to services, The school, Peer programs and The Canada Youth and Aids Findings. CONCLUSION: In summary, the sexually active woman requires the utmost in the health care providers willingness to individualize care to provide choices and information on birth control which works best for them. The efficacy is optimized by identifying potential barriers to effective use as part of the decision making process.

REPRODUCTIVE TRACT INFECTIONS(RTIs) IN THE LIFE CYCLE OF MIGRANT IKACHAKRANWOMEN IN BAGUIO CITY

BATANI, R.S., MA in Health Science, DLSU

Institute of Highland Policy Studies in Socio-economic Resource & Development (IHPSSERD), Benguet University

The study looked into the knowledge, perceptions and practices associated with RTIs by the migrant Ikachakran women in Kadacian Village, Loakan Baguio City. Using key Informant interviews, focus group discussion, and individual in-depth interviews, the study explored RTIs in relation to the woman's cycle, obstetrics-gynecological history, preventive and health care management, practices predisposing women to RTIs and the roles assumed by the spouses in the management and prevention of RTIs. Twelve respondents selected on the basis of age and work categories and residence in Kadacian Village were interviewed. Results of the study showed that the women migrants are suffering, or have suffered and manifested symptoms of RTIs at one time or another. Findings revealed that women suffered episodes of RTIs twice or more. They do not, however associated these symptoms with RTIs but with urinary tract infections, (UTI). Hence the women are not inclined to seek health care services. The women respondents have adequate traditional post natal care practices. However, they have practices that could predispose them to RTIs and other reproductive health problems. On top of this, they continue to employ home remedies mostly traditional in character, combining them inappropriately with modern health care treatments. Almost all women respondents belittle physical discomforts that result from RTIs. This is consistent with their assessment of their own health and well being that is, they are healthy for as long as they can stand up and are capable of social interaction. The study pointed out the need for a deeper understanding of the complexities of RTIs contextualized in particular settings and in specific population like ethnic groups migrating to the cities. Once again, the thesis which holds that migrant population moving into the cities face new risks in reproductive and sexual health was illustrated in the study. However, mechanisms to complement researchers on this field as well as to maximize existing institutions and structures providing health care services have to be devised. Information-education is the heart of all of these mechanisms and processes, both at the level of the health care givers as well as end users.

GYNEFIX| A HIGHLY EFFECTIVE NEW REVERSIBLE CONTRACEPTIVE OPTION TO REDUCE THE NUMBER

OF UNINTENDED PREGNANCIES AND ABORTIONS I. BATAR, D. WILDEMEERSCH, W. DELBARGE, M. VRIJENS

Department of Obstetrics and Gynecology, University Medical School of Debrecen, Debrecen, Hungary

Immediate postabortal insertion of an IUD is an important tool in preventing repeated abortions. The authors clinically tested the postabortal version of the GyneFix| copper intrauterine implant system in these circumstances. In an open clinical study, data of 125 GyneFix| PT (post term) devices inserted immediately following pregnancy termination (less than 10 weeks of gestation) were evaluated. Routine follow-up visits were scheduled at 1,3,6 and 12 months after insertion, and yearly thereafter. For statistical analysis, only Pearl-index calculation was done, since the data were not eligible for life table calculation at this preliminary stage of the study. The patients' characteristics were as follows: the mean age of patients was 29.9 years, the mean number of birth was 1.5, and the mean number of pregnancies was 3.1. The evaluated minimum duration of use was 1 month and the maximum was 38 months (average: 10.4 months). The total number of cumulative woman-month of use was 1,304. The number of the discontinuations were as follows: four devices were removed for bleeding and another four for pain (Pearl-index was 3.7 for both termination types); 3 devices were removed for other medical reason, 4 for planning pregnancy and 2 for personal reason (PI was 2.8, 3.7 and 1.8, respectively). No pregnancy, no expulsion and no PID were recorded. The Pearl-index of the total relevant terminations was 9.2. In conclusion, the results confirm the good overall performance of the GyneFix| PT. The low termination - and consequently the high continuation - rates indicated that the postabortal device is as well tolerated as the IN (interval) version.

What have We Learned from the Women's Studies Project?

P. BHIWANDI, N. WILLIAMSON

Wilkerson OB/GYN, Family Health International

Purpose: In order to learn more about the needs of women in developing countries and their experiences with family planning, Family Health International (FHI) designed a research project to put women's concerns at the center of family planning. The Women's Studies Project (WSP) is a five-year effort funded through a cooperative agreement with the U.S. Agency for International Development (USAID), along with additional support, from the Rockefeller and Ford Foundations. The WSP sought women's perspectives to gain an understanding of the positive and negative consequences of family planning use with the aim of strengthening programs to better meet women's needs.

Methodology. Twenty-six studies were conducted in 10 countries, and both quantitative and qualitative data were collected and analyzed. Women expressed their views in focus group discussions, in-depth interviews and surveys. Additional information was obtained from secondary analyses of data collected in previous projects in four countries and through three case studies on women-centered health programs. The research agenda was defined locally by a "triangel" of women's advocates, policy-makers and providers, and investigators.

Findings: The WSP found that while women perceive numerous benefits of family planning use, including health and economic benefits and freedom from fear of unplanned pregnancy, they also see negative consequences. These include method side effects that can discourage them from taking control of their fertility. Women's dual perspectives should be taken into account as researchers, women's advocates, policy-makers and providers work collaboratively to improve family planning services. By understanding the intricate realities of women's lives and the factors that affect their reproductive health behaviors, family planning programs can offer services that may ultimately help improve the quality of women's lives.

Destop Videoconferencing as a Tool for Management of a Public Sector Clinical Reproductive Health Program in Indonesia

DR. BIMO, K. KAMALI, B. AFFANDI, R. PUDGO, R. VOGEL, R. MAGARICK

JHPIEGO Corporation

In this era of diminishing resources, reproductive health programs must seek out innovative and lower cost approaches to support required administrative, training and followup activities. In this pilot test a low-cost desktop videoconferencing system was utilized to reduce costs and improve coordination in the Indonesian national family planning program. This was especially important in Indonesia as the island nature of the country makes frequent face-to-face communication difficult.

Videoconferencing equipment was provided by JHPIEGO to several training sites and the equipment was used to facilitate communication routinely for six months. At least three international technical assistance visits related to training program evaluation and monitoring were replaced by using the system. In addition, an analysis of data collected on incountry system use demonstrates that desktop videoconferencing is a feasible and cost-effective means of improving communication and coordination.

NEW DEVICES TO ASSIST NATURAL FAMILY PLANNING USERS

LEONARD BLACKWELL

Institute of Fundamental Sciences Massey University Palmerston North, New Zealand

Natural Family Planning (NFP) is a collection of methods which rely on self-observation of physiological symptoms to reflect cyclical changes in the underlying ovarian activity for definition of the periods of fertility and infertility. These methods originally set out to monitor ovarian activity as it unfolded without recourse to calendar or rhythm calculations based on past behaviour. However, over the years the methods have been modified by the addition of calculations such as the S-21 (or S-19) rule where S is the number of days of the shortest recent cycle to set a limit on the beginning of the fertile phase. While acceptable to current practitioners of NFP, the fact that NFP has not gained more widespread acceptance over the years is an indication that something more is needed. A number of groups and/or companies have expended considerable time and money on the development of devices to assist natural family planning users. Historically the first of the devices, apart from the thermometer, was the Ovarian Monitor developed by Professor James Brown in Melbourne and the author. This is a device which allows individuals at home to eavesdrop on the ovary by monitoring the cyclical changes in urinary metabolites of ovarian estradiol and progesterone in timed urine specimens. The beginning of fertility is defined by the first rise in urinary estrone glucuronide (EIG), with a mean warning of 6.5 + 1.4 days, and the most fertile time of the cycle is indicated by the mid-cycle EIG peak. The end of fertility is accurately defined by a rise in the rate of pregnanediol glucuronide (PdG) excretion to equal or exceed 7 umol/24 hours. The threshold was equalled or exceeded on average 3.3 + 1.4 days after the LH peak day in all cycles studied, with a range of 1.5 to 6.1 days (95% confidence limits) For the home data fertile period as determined by the hormone values was 7.6 + 2.0 days. Over 1000 woman years of experience have now been obtained with the Monitor and its use in all aspects of reproductive life has been defined. Aspects of this experience plus the results of the World Health Organization trial of the Monitor will be discussed. Other devices such as the Unipath Persona Contraceptive device, the Quidel PdG test and a new device based on detection of changes in the water content in the cervical mucus to mark the beginning and end of the fertile period will also be discussed as aids to the practice of NFP.

Family Planning and Reproductive Health Needs: A Community Health Challenge

M. CABARABAN, B. MORALES

Xavier University

Purpose: This paper presents findings from a study in the Women's Studies project (WSP), jointly undertaken by Family Health International (FHI), the Research Institute for Mindanao Culture of Xavier University, and the Women's Forum of Region 10. The WSP study examined the effects of family planning on the lives of urban and rural women in two geographic areas of the southern Philippines. Focusing on the variations of reproductive health needs between never-users of contraception, current non-users and current users, the study investigated whether use or non- use of family planning affects women's reproductive health needs. Reproductive health needs are presented as four foundational supports: body/self awareness, gender awareness, integration of sexuality, and interpersonal communication.

Study Design and Methodology: Both quantitative and qualitative methods were used. The quantitative component involved a sample survey of 1,660 urban and rural women; the qualitative component included a data set derived from pre-survey and post-survey focus group discussions conducted among urban and rural participants.

Findings: Significant differences exist between never-users, current non- users and current users in terms of socioeconomic indicators. Differences persist even when family planning status was replaced by duration of family planning use. Contraceptive prevalence and practices differ. In general contraceptive knowledge is low; the never-users have a deficient knowledge of both modern and traditional methods. Fertility awareness and practices are described as part of body/self awareness.

Under the rubric of gender awareness and practice, the major variable is domestic violence. Twenty-six percent of women have experienced physical abuse, with urban women having a higher index than rural women. Family planning use, however, is not related to domestic violence. Under interpersonal communication, it was revealed that fertility does not increase the women's decision-making power.

Visual Inspection of the Cervix for Primary Screening for Cervical Cancer

Z.M. CHIRENJE, T. CHIPATO, J. KASULE, E. NOWALLE, S. RUBAKANIKO, P. MAKUNIKE, L. GAFFIKIN, P. BLUMENTHAL, J. MCGRATH, H. SANGHVI, N. MCINTOSH

University of Zimbabwe/JHIEGO Cervical Cancer Project

In many countries, cervical cancer remains the primary cause of cancer- related deaths among women. Deaths from this have been considerably reduced in countries where screening programs are widely available, but in most developing countries, such wide-scale screening programs are nonexistent. Screening by Pap smear is often only accessible to a small proportion of women where it is available. Attention has recently focused on alternatives for screening. Prominent among these is "visual inspection", performed after washing the cervix with acetic acid (VIA), either without or with a device to magnify the cervix. To determine whether visual screening is practical and effective in a field setting, a study was conducted in Zimbabwe in which over 10,000 women were screened with both Pap smears and VIA. Eight nurses were trained in VIA and then performed this in primary health care clinics surrounding Harare. Women were recruited and given both tests (Pap smear, VIA) - all positives and a random sample of women negative on VIA had further diagnostics. Phase II of the study ensured that all women recruited - irrespective of VIA results - were referred for colposcopy, with biopsy performed as indicated. When compared to a biopsy/colposcopy reference standard, the sensitivity of VIA and the Pap smear for identifying precancerous lesions were 77% and 44% respectively. Specificity values for Phase II were 64% for VIA and 91% for the Pap smear. VIA performed substantially better at identifying true cases of disease, which in low-resource settings is deemed a priority, and suggests that VIA is the screening option of choice. The next important step is linking screening test results to immediate treatment, to achieve the ultimate goal of screening. Alternative approaches for testing and treating for precancerous cervical lesions and mechanisms for integrating these approaches into existing health care systems in low-resource settings will be discussed.

IMPLEMENTATION OF A HEALTH PROMOTION APPROACH TO FAMILY PLANNING STRATEGIES

J..COLLINS

School of Public Health, Curtin University, Perth, Western Australia

This paper will look at the five components of the Ottawa Charter and how they relate to family planning strategies in a community setting. This will include examples of building healthy public policy through: strengthening community action, developing personal skills, enabling factors, mediation and advocacy, creating supportive environments and reorienting health services.

Consideration of the similarities and differences in settings and organisational structures in Australia and the Philippines will be addressed with examples drawn from the experiences of Filipino health professionals attending short courses in Family Planning at Curtin University and the Family Planning Association of Western Australia.

THE IMPACT OF SOCIAL AND CULTURAL TRADITION ON POSTABORTION SERVICES

C. CORDERO, M. CORDERO, S. GIRVIN

AVSC International

Around the world, women who seek treatment for complications of abortion frequently face service providers whose judgements about these women are based on social and cultural beliefs and traditions. These judgements are obvious in the attitudes and behavior that providers exhibit toward the women, and often affect the kind of care that is provided. Social and cultural beliefs also affect the availability and legality of safe abortion services.

Most abortion complications are the result of induced abortions. Spontaneous abortion can also result in complications, and either circumstance can leave a woman in both a serious medical and emotional condition. While safe and readily available medical treatment for complications is a necessary component of good quality postabortion care services, acknowledging and understanding the subtle, but undeniable, ways in which social and cultural beliefs affect the care of, and attitude towards, clients seeking this care is also essential.

This paper examines the impact of social, cultural and religious beliefs on the availability of safe services, legal issues, provider bias, medical practices, and quality of care. Reports from Latin American countries where abortion is illegal and the Catholic Church is very strong demonstrate the effect of religious opposition to family planning and postabortion care on both clients and services.

Combined sequential HRT: Coping with irregular bleeding

ANTONIO C. COSTALES, MD, FPCPM, MFPM, CATALINO M. LIM, MD, FPOGS

*Gynecology Department, Schering Philippine Corporation, Makati

Sequentially combined hormone replacement therapy (scHRT) effectively treats the estrogen-deficiency problems of women in their climacterium with the lowest amounts of hormones necessary. They also provide the lowest amounts of progestogens which effectively protects the endometrium. However, scHRT are usually associated with irregular bleeding, especially among first-time HRT users who are in their postmenopause.

Experience with the first 20,000 cycles of use of a sequentially combined 2mg estradiol valerate plus 1 mg cyproterone acetate (Climen| reveal the following findings which may well serve as guidelines to improve bleeding patterns during HRT intake: 1. Sequentially combined HRT (scHRT) are best started by women in

their perimenopause. Perimenopausal women, especially those starting to experience irregular bleeding as a result of the perimenopause, attain more regular patterns with scHRT.

2. The use of continuously combined HRT (ccHRT) among perimenopausal women led to more problematic breakthrough bleeding.

3. Sequentially combined HRT started in the perimenopause eventually leads to amenorrhea in women as they go past their menopause, usually within one to one-and-half years into the postmenopause.

4. The use of a 'ping-pong' method of tablet-taking for some postmenopausal patients taking Climen| improved the bleeding pattern (25%).

5. The 'continuous' form of intake for 21-day scHRT resulted in shortened cycles but did not necessarily improve bleeding patterns.

6. In a majority of patients (>95%), there were no recurrence of hot flushes and other acute symptoms of the menopause during the 7-day tablet-free interval with Climen.

Details of these findings will be presented.

Gestodene OC pill: Initial clinical experiences in the Philippines

ANTONIO C. COSTALES, MD, FPCPM, MFPM

Gynecology Department, Schering Philippine Corporation

Gestodene was first introduced in the Philippines in December 1997 although the monophasic 30mcg ethinylestradiol (EE) formulation was already available in the other Asian countries as early as 1991.

Initial clinical experiences in the Philippines confirm the results of the clinical trials conducted in Europe and other Asian countries: 1. The monophasic preparation combined with 30 mcg EE (Gynera |

was well accepted especially by first-time users. 2. Patients who were not able to tolerate OC pills in the past because of

side-effects, were able to start with OC-pill-taking with Gynera. 3. Patients who were in the perimenopausal age group who used Gynera

for contraception, as in the report of Kobchit et al, did not complain of any acute symptoms and bleeding pattern associated with the climacterium.

4. There was no report of any pregnancy in the first 15,000 cycles of use. 5. There were reports of breakthrough bleeding and spotting but this was

confined to patients who were shifted from other pills, notably the triphasic levonorgestrel. The complaints were limited to the first 2 months of.use, and improved thereafter, with continued use.

6. No serious adverse events were reported.

The initial experience is very reassuring. Results of a longer follow-up will become available with the ongoing Postmarketing Surveillance for this first gestodene pill in the country.

HRT prescribing: 'tailor-fitting' the estrogens and progestogens

ANTONIO C. COSTALES, MD, FPCPM, MFPM* CATALINO M. LIM, MD, FPOGS

*Gynecology Department, Schering Philippine Corporation, Makati

When it comes to Hormone Replacement Therapy (HRT) prescribing, the combination of the estrogen and the progestogen components into one tablet has provided convenience both to patients and practitioners. Clinical experience however show that fixed-dose HRT preparations appear appropriate only in about 80-85% of patients. In some 15-20% of patients, we realize the truism in the finding that "women may react differently to the same type and the same dose of hormones". This underscores the need for flexibility in HRT prescribing.

The availability of various estrogens and progestogens allow for the 'tailor- fitting' of different dose and types of HRT regimens for particular patient groups: 1. Sequentially combined HRT (scHRT), where, in 10 to 14 days of the

cycle/month, additional progestogens are taken with the estrogen. 2. Continuously combined HRT (ccHRT), where, in all of the days of the

cycle/month, additional progestogens are taken with the estrogen. 3. Quarterly regimens, where, in the 1st and 2nd month, unopposed

estrogens are taken; then, on the 3rd month, additional progestogens are taken to protect the endometrium against hyperplasia.

The type and the dose of the additional progestogen (which therefore have a bearing on potency and the ability to protect against hyperplasia) appear to be very important considerations. Low-dose estrogens appear beneficial in continuous regimens, especially the ccHRT because it leads to a lesser degree of stimulation of the endometrium.

The types of estrogens and progestogens will be presented as well as the availability of a fractionable tablet of norethisterone (Primolut N| This makes possible the 1.25mg to 2.5 mg dose of norethisterone, the doses needed for HRT, sequentially or continuously.

IMPROVING THE TREATMENT OF INCOMPLETE ABORTION

P. DARNEY, MD, MSc

Department of Obstetrics, Gynecology and Reproductive Sciences

University of California, San Francisco

About 15% of pregnancy-related mortality is due to complications of abortion and 15% of pregnancies end in spontaneous abortion. Incomplete abortion is a health risk for millions of women and a clinical problem for health care providers in many less-developed countries. WHO has identified the prompt treatment of incomplete abortion as an essential element of obstetric care that should be available at every district-level hospital. The management of incomplete abortion, whether spontaneous or induced, consumes scarce health resources throughout the world. For these reasons treatment of incomplete abortion must be safe, efficient and acceptable to women.

Sharp curettage under general anesthesia has been the traditional treatment for incomplete abortion, but it compromises safety because of the hazards of anesthesia, is inefficient because it consumes the time and attention of many staff, and is not acceptable to women because they must remain in hospital and may not receive information and supplies to avoid unintended pregnancy.

A modern but well-proven alternative is the use of vacuum aspiration under local anesthesia in an out-patient setting followed by family planning counselling and prompt discharge. This approach reduces the most common complications of abortion treatment including anesthetic reactions, uterine perforation, incomplete evacuation with subsequent hemorrhage and infection, and recurrent unintended pregnancies.

An Abstract: Comprehensive Community-Coordinated Response to Violence Against Women

R. DE LA PAZ INGENIE, MD, R.D. SANCHEZ, L.J. CANSON

Development of Peoples Foundation

This project is an attempt of the Development of Peoples Foundation to strengthen the capability of the local government units and grassroots women to respond to gender violence and reproductive health problems through training, research and advocacy. This is an improvement of the primary health care approach in the context of reproductive health which brought service providers, academicians, social scientists, feminist activists, grassroots women and men in a systematic dialogue and discussion.

Community organizing and participatory research were employed to examine the different forms of violence experienced by women, to analyze their health-seeking behavior, to identify needs and gaps in the provision of information and services on reproductive health.

The result of the research became the basis for the drafting of a protocol on responding to violence against women (VAW), to be used by participating local government units and other agencies responding to VAW. A referral form was also devised to coordinate the services being rendered by each agency.

A Women and Children Protection Unit (WCPU) was also established at the regional hospital, which now provides the continuing training of health workers and professionals on identifying sexual abuses and intervening accordingly.

This multi-sectoral dialogue and discussions, once more, demonstrated that health technology alone will not being about good health and healing. The socio-cultural dimension of health and healing is just as vital.

The project was able to raise as public health issues abortion and violence against women.

THE PHILIPPINE FAMILY PLANNING PROGRAM NATIONAL COMMUNICATION CAMPAIGN FOR 1997 (NCC '97)

MR. JOSE MIGUEL DE LA ROSA

John Hopkins University/Population Communication Services

The Philippine Family Planning Program (PFPP) National Communication Campaign (NCC) was initiated in 1993 to promote wider acceptance and practice of family planning in the Philippines as a means to improve the overall health and welfare of mothers and infants. The main campaign theme, starting in 1993, is "Kung Sila'y Mahal N'yo, Magplano" (If You Love Them, Plan for Them). NCC '97 continued to build on this theme with the following objectives: reduce high risk births, especially among women below 18 years old and those 35 and over; improve spousal communication to encourage male support for women's fertility preferences; foster the acceptance of family planning as a social norm; establish that health service providers are a credible source of correct family planning information and advice. The campaign's main target audience is married couples of reproductive age (MCRAs), 15-49 years old. Studies show that NCC has contributed considerably to the increase in contraceptive prevalence in the country Philippines.

Combined Oral Contraceptives (COC) with the Lowest Possible Estrogen Dose

MAX ELSTEIN

Institute of Medicine, Law & Bio-Ethics, Universities of Manchester and Liverpool

In addressing the issue of reducing the estrogen dose in COC's to a minimum, it is a basic pharmacological tenet that the dose of estrogen administered should be the lowest possible to achieve the desired effect. This is particularly appropriate in young health COC users. When certain side effects were found to be related to estrogen dosage, the gonane progestogens facilitated the reduction in estrogen with effective ovulation suppression and satisfactory cycle control. These provisos were met with the reduction to 30 and subsequently with some progestogens down to 20 micrograms. This may well be possible with even 15 micrograms, provided that the pill free interval is shortened as in a 24 day active pill administration regimen.

There are five issues which need to be addressed with estrogen reduction:

1.

2.

3.

4.

5.

Is there effective ovulation suppression allowing a satisfactory margin of safety even if pill omission occurs? Cycle control is the major problem and this may well be related to the specific properties of the progestogen, the duration of the pill withdrawal phase or the possibility of estrogen administration therein. Nuisance side effects particularly weight gain and fluid retention are likely to be diminished although tolerance may be related to the culture of the acceptors and providers. The risk of venous thrombo-embolism does seem to be related to estrogen dose, although individual susceptibility is relevant. There needs to be an assurance that non contraceptive benefits, especially oncological effects, will not be prejudiced.

A Modified Computer-Assisted Learning System (Modcal): Use in Philippine Colleges of Nursing and Schools of Midwifery

R. FERNANDEZ, I. KIMSANG, E. VALLES

Association of Philippine Schools of Midwifery

Modified Computer-Assisted Learning (ModCal) is an innovative alternative for strengthening inservice and preservice reproductive health training. A pilot test for IUD training conducted in the Philippines between September 1997 and February 1998 assessed the acceptability of this learning approach among students, faculty and service providers and determined the institutional support for sustaining computer-assisted learning.

Thirty-four faculty members, FP service providers and midwifery and nursing students participated in the ModCal IUD pilot test. Reaction questionnaires, training logbooks, pre- and post-test scores IUD skills checklists and monthly reports determined the acceptability of this training methodology. Successful knowledge transfer, defined as a post-test score of 85% or higher, was achieved by 33 of the 34 participants. Course participants and faculty members particularly found useful the ability to independently control the pace of learning and to review course content. In addition, instructors were able to spend more time with students and course participants as they developed their clinical and counselling skills through work with anatomic models, demonstrations and role plays.

The assessment demonstrated the feasibility of computer- assisted learning in Inservice and preservice training and how reproductive health knowledge can be transferred more efficiently and effectively.

Clinical Experience of Immediate Post-Termination Insertion of Gynefix PT Intrauterine Implant System in a UK Fertility Control Unit

B.A. GBOLADE, E.J. OLOTO, R.G. WALKER, H. NAGIB

Fertility Control unit, St. James's Hospital, Leeds, United Kingdom

Objective: To report preliminary clinical experience of immediate post- termination insertion of Gynefix PT, a novel intrauterine implant system newly licensed and introduced into clinical practice, as the first UK centre to use the post-termination version.

Methods: The device was introduced into the UK in May 1997 and we started inserting the device in September 1997 after full counselling of patients requiring suction termination of pregnancy and long-term contraception. Data was collected on standard forms. Follow-up was schedyled for 2, 6 months and 12 months post-insertion. At first follow-up, ultrasound examination was performed to assess accurate placement of the device and retention in-situ.

Results: 43 of 44 immediate poet-termination insertion of Gynefix PT have been successful. Median age (range) was 25 (19-39) years, median gravidity (range) was 3 (1-8), median parity (range) was 1 (0-6), median (range) gestational age at insertion was 10 (8-13) weeks, median (range) uterine cavity length was 10 (8-13) cm. All insertions were assessed as easy by the operators. To date, 30 women have attended for their first follow-up appointment. 17 patients bled for 1-11 days while 15 had spotting for 0-10 days. The median (range) S-S distance was 1.5 (1.1-2.8) cm. There have been neither uterine perforations nor expulsions. One device was removed after 2 months because of pain, one because of incorrect placement and one after 6 months because of bleeding every two weeks. There was a failed insertion.

Conclusion: Our initial experience suggests that Gynefix PT is suitable for immediate post-termination insertion with less risk of expulsion and good continuation rates. Our initial experience is in agreement with experience elsewhere outside the UK. The system has some advantages over other currently available intrauterine devices for immediate post-termination insertion. More data will be available at the congress.

Differential Impact of Adolescence and Adulthood on Prevalence of Repeat Attendance for Emergency Contraception

B.A. GBOLADE

Department of Obstetrics and Gynaecology & Reproductive Healthcare, University of Manchester, Palatine Centre, Manchester, United Kingdom

Objective: The purpose of this study was to quantify the contribution of adolescents to the prevalence of repeat attendance for emergency contraception (EC) and identify any significant variables that may identify those at risk for repeated use of emergency contraception services.

Methods: Women attending Palatine Centre, Manchester for EC for the first time between 01/01/96 and 31/03/96 had the cumulative incidence of first, second, third, fourth and fifth repeat use of EC between their first date of attendance and December 31 1996 measured.

Results: Of 900 women who attended for EC for the first time in early 1996, 273 (30.3%) were adolescents. Forty-three percent of these were 19-year olds. 86 (31.5%) adolescents reattended at least once compared with 141 (22.5%) adults. Of the 285 episodes of repeat attendance for the 900 women, adolescents were responsible for 118 (41.4%). Experience of repeat attendance amongst adolescents ranged from 1-5 times, the majority (73.5%) having one repeat attendance while experience amongst adults ranged from 1-4 times with the majority (85.8%) having one repeat attendance. Three (3.5%) adolescents had a previous history of abortion compared with 31 (22%) of adults. A 2x2 contingency table shows that a significantly higher proportion of adolescents attended repeatedly for emergency contraception (86/187 v 141/486; X 2 = 8.193, P=0.004). There was no significant difference in the previous history of use of emergency contraception 5 years and 1 year prior to the first attendance in 1996 between the two groups.

Conclusion: The prevalence rate of repeat attendance for emergency contraception amongst teenagers (422 per thousand) is significantly higher than that for adults (230 per thousand). The variable that appeared to be important was the age of the individual adolescent. The 19-year olds accounted for 50% of the repeat attendances among adolescents. It would appear that this age group needs intensive counselling when they first attend for emergency contraception.

Individual Variation in Bone Mineral Density Change over a Mean Interval of One Year in Long-Term Users of Depot Medroxyprogesterone Acetate

B.A. GBOLADE, R.J.E. KIRKMAN

Department of Obstetrics and Gynaecology & Reproductive Healthcare, University of Manchester, Palatine Centre, Manchester, United Kingdom

Objective: To observe changes in individual bone mineral density and body mass index over a defined time interval and assess the correlation, if any, between these variables in long-term users of depot medroxyprogesterone acetate in Manchester.

Methods: Women on long-term use of depot medroxyprogesterone acetate for contraception were observed over a 2 year period. Thirty-five women later attended for repeat bone density measurements within a mean of 1 year after the first measurement while still using DMPA. Changes in BMD and BMI over a standard period of 1 year were calculated.

Results: At the first attendance, the women had used DMPA for a mean of 3.3 years, and been amenorrhoiec for a mean of 3.1 years. Twenty-three women were cigarette smokers. Mean age was 32.6 years. Ethnic group was predominantly white but included one black and two Asians. Mean serum Estradiol level was 99.6 pmols/litre. Mean BMI was 23.4 Kg/m 2. At the second attendance, the women had used DMPA for a mean of 4.5 years and been amenorrhoiec for a mean of 4.3 years. Mean standardised change in spine BMD was 0.011 (95% CI 0.003 - 0.020) gm/cm 2 while mean standardised change in hip BMD was 0.001 (95% CI -0.009 - 0.0114) gm/cm 2. Mean standardised BMI change was 0.04 (95% CI -0.282 - 0.362) kg/m 2. There was very weak linear correlation between standardised spine BMD change and BMI change with minimal statistical significance (r= 0.27, p=0.11). The same applied to the correlation between Standardised hip BMD change and BMI change (r=0.11, p=0.53).

Conclusion: There is variability in change in spine and hip bone mineral density in women on long-term use of DMPA which does not appear to be related to change in the body mass index. Although this is a small study, our follow-up results show insignificant bone mineral density change over a mean period of one year.

Predict Models of Repeat Attendance for Emergency Contraception Using Logistic and Linear Regression Analyses

B.A. GBOLADE

Department of Obstetrics and Gynaecology & Reproductive Healthcare, University of Manchester, Palatine Centre, Manchester, United Kingdom

Objective: To develop predictive models of repeat attendance for emergency contraception (EC) on the basis of identifiable pateitn variables. Methods: The study population was 900 women who attended Palatine Centre, Manchester for EC for the first time between 01/01/96 and 31/03/96. Repeat attendance for EC between their first date of attendance and december 31 1996 was measured as a cumulative incidence of first, second, third, fourth and fifth repeat use of EC. Linear and logistic regression analyses were performed using "repeat attendance" as the dependent variable.

Results: In all, 900 women attended for the first time in early 1996 for EC. Between the first date of attendance and 31/12/96, 227 (25.2%) patients reattended a total of 285 times. Experience of repeat attendance ranged from 1-5 times and was negatively correlated with age (r=-0.18, p=0.007) and parity (r=-0.14, p=0.034). Independent predictors for repeat attendance for EC were parity, age and previous use of EC in the year prior to attending for the first time in 1996. Of these, parity was the most strongly related to repeat attendance for EC. Two predictive models containing the variables that could be used to predict the chances and the number of repeat attendance for EC, when a patient is seen for the first time, were developed.

Conclusion: The probability of and the number of repeat attendance for emergency contraception can be predicted by models derived from linear and logistic regression analyses of easily available patient variables. The predictive scores obtained for a particular patient can then be used, to tailor counselling during consultations for emergency contraception such that there will be a reduced likelihood of repeat attendance.

IS KNOWLEDGE OF EMERGENCY CONTRACEPTION SUFFICIENT TO ASSURE ITS USE?

Richard GROSSMAN, MD, MPH

Department of Obstetrics & Gynecology, University of Colorado

This study investigated the proportion of unwanted pregnancies that could have been prevented by emergency contraception (EC).

I surveyed 153 consecutive women who requested abortions during a 3-month period. Each was asked about the use of contraception at the time of conception, and if she had known about EC when she conceived.

One woman refused to participate, and data for another were incomplete, leaving 151 surveys for analysis. Forty-three women thought they were protected against conception, so EC would not have been appropriate. 108 women were candidates for EC since they had used no contraception, or had been aware of a condom failure. Of these, 79 knew nothing about EC at the time of conception. The other 29 had varying levels of knowledge about EC. Two women actually used EC pills, which unfortunately had not prevented pregnancy. Women who knew about EC but did not seek it gave various reasons for not using it, including: "1 didn't think I would get pregnant"; "1 was unfamiliar with emergency contraceptive providers"; "It didn't cross my mind"; "1 had unprotected sex during my infertile time"; "1 was hung over".

My conclusion is that EC offers an excellent way to decrease the number of unwanted pregnancies. Of women seeking abortions, 72% were candidates for EC. Of these candidates, 73% had no knowledge about it. Sadly, a quarter of the women who could benefit from EC knew about it but did not use it. Future marketing efforts should stress the importance of using EC whenever necessary.

Effectiveness of Natural Family Planning

Victoria JENNINGS, Ph.D.

Institute of Reproductive Health

Understanding the effectiveness of natural methods of family planning (NFP) is essential to efforts to expand the availability of these methods. Studies show that in a wide range of countries, policy makers and managers have little, or inaccurate, information about Natural Family Planning (NFP); and that a negative perception of NFP is pervasive. Many key leaders consider NFP an ineffective method of family planning. Their perceptions are influenced by (1) a lack of clear definition of NFP, with numerous publications citing high failure rates based on reports of unintended pregnancies among users of "periodic abstinence", who may have little or no understanding of actual NFP methods; (2) anecdotal evidence of NFP failures, again without knowing the method being used and whether the failure is attributable to the method itself or to the way it was used; and (3) the flawed nature of many studies of NFP effectiveness which do not meet established criteria for study design, data collection, and/or analysis. This paper reviews the literature on the effectiveness of specific NFP methods and provides criteria for assessing the quality of existing effectiveness data. It also provides guidelines for conducting NFP effectiveness studies, taking into account programmatic issues in service delivery.

TEENAGERS & HORMONAL CONTRACEPTION

JEVGENIJS KALEJS

SALDUS HOSPITAL, SALDUS, LATVIA

Objective Reduce unwanted pregnancies and medical abortions in the area. Increase using of Hormonal Contraceptives among teenagers. Increase sexual education for teenagers.

Methods Education for medical staff and teachers. Organisation of Youth Centres. Tri-Regol Project. HC - free of charge for teenagers till year 2000.

Results Reduction of medical abortions (200% - 35%), Reduction of abandoned new-borns. Increase level of sexual knowledge among teenagers. Municipality participation. Opening Youth-Centres. Good tolerance of Tri-Regol by the teenagers. Increase confidence of HC (Tri-Regol) by the teenagers.

Conclusions Youth sexual education - effective way to reduce unwanted pregnancies. Tri-Regol is one of the choice methods of HC for teenagers. Tri-Regol should be recommended for teenagers by different staff without and additional risk for patients.

PREGNANCY DURING LACTATIONALAMENORRHEA

DR. KATHY KENNEDY

World Health Organization, Geneva, Switzerland

BACKGROUND: The Lactational Amenorrhea Method (LAM) of family planning is based upon the observation that women who are fully breastfeeding and amenorrheic achieve protection from pregnancy during the first six months postpartum in 98% of cases or better. The proactive use of LAM to prevent pregnancy has been found to be efficacious in clinical trials. The World Health Organization (WHO) has conducted a study of breastfeeding women, their infant feeding practices, the return of menses and the occurrence of pregnancy in over 4000 women in 2 developed and 5 developing country settings. This study is much larger than the clinical trials of LAM, and collected detailed data beyond 6 months postpartum. METHOD: The LAM conditions were applied to a large data set from a multicenter, prospective, descriptive study that measured infant feeding behaviors, amenorrhea and pregnancy. Life tables were produced for the rates of pregnancy during amenorrhea in fully and partially breastfeeding women at the end of six months postpartum and at the end of one year. Controls for coital activity and contraceptive use were applied. RESULTS: Results are consistent with the Bellagio Consensus and with the clinical trials of LAM. Pregnancy rates during amenorrhea at 12 months are elevated above the 6-month rates. CONCLUSIONS: Existing breastfeeding behaviors in many settings appear to support the successful use of LAM. Users of Natural Family Planning (NFP) methods may wish to consider using LAM in the first 6 months postpartum as an adjunct to their chosen NFP approach. Likewise, women who desire to use other modern methods may wish to consider using LAM to time the initiation of their chosen method during breastfeeding. Between the 6 th and 12 th month postpartum, lactational amenorrhea is associated with a level of protection from pregnancy that is less than the protection realized in the first 6 months, but greater than that of normal non-breastfeeding women or of menstruating lactating women. The adequacy of this level of protection during months 6-12 is subjective. To determine whether pregnancy protection involving lactational amenorrhea after the 6 lh month can be elevated to a level competitive with that of other temporary methods, and to successfully create adequate birth intervals, future research should address ways to maximize lactational infertility after the 6 th month and approaches to integrating LAM with other contraceptives.

BONE DENSITY IN LONG TERM USERS OF DEPOT MEDROXYPROGESTERONE ACETATE

R .KIRKMAN

University of Manchester, Palatine Centre 63-65 Palatine Road, Manchester M20 3LJ

Obiective: to look for any adverse effect on bone density in long term users of depot medroxyprogesterone acetate (DMPA).

Methods: Cross sectional measurements of bone density (hip and spine) in users with emenorrhoea of more than 1 year or women who had used DMPA for more than 5 years who were attending community family planning clinics in Portsmouth and Manchester between August 1994 and August 1996 for repeat injections.

Results: 185 women aged 17 to 52 who had used DMPA for between 1 and 16 years. 153 had oestradiol levels below 150pmo/L. Despite this, the mean bone density for lumbar spine compared with a population mean for women aged 20-59, gave a Z score of -0.332 [C1-0.510 to -0.154]. There was no change in hip density from the normal population range.

Conclusion: There is abroad distribution of bone densities in any population, so densitometry is therefore bound to pick up some who are osteopenic, whether or not they are using DMPA. DMPA users had spinal bone density only minimally below the normal population. There was no reduction in bone density with longer duration of use desoite low oestradiol levels.

OLDER WOMEN AND ORAL CONTRACEPTIVES

R KIRKMAN

University of Manchester, Palatine Centre 63-65 Palatine Road, Manchester M20 3LJ

All methods of birth control have lower failure rates in older women, but the non-contraceptive benefits of the combined pill become more valuable as the woman gets older - substantial protection from ovarian and endometrial cancer, control of heavy irregular menses, protection from pelvic infection and possibly from fibroids and endometriosis. The British study, which linked cardiovascular disease and pill use now, shows that this risk applies only to current users who also smoke. The association with a 1.3 increase in relative risk for breast cancer and cervical cancers will be discussed - causation is not proven. There remain the hazards of high blood pressure and of venous thromboembolism. Older women need careful assessment for contra-indications to the pill e.g. history of venous thrombosis, measurement of blood pressure and investigation of undiagnosed irregular bleeding. Healthy non-smokers can continue combined pill use to the time of expected menopause if blood pressure is monitored.

CHALLENGES TO INVOLVING FILIPINO MEN IN WOMEN'S HEALTH INITIATIVES

LEE ROMEO B.

Behavioral Sciences, De La Salle University, Manila

This Philippine Council for Health Research and Development (PCHRD)-assisted national study examines factors and conditions impinging upon Filipino men's involvement in women's health programs and projects. It employed a variety of methods: questionnaire and face-to- face interviews, and focus group discussions.

Two categories of challenges are determined: those pertaining to community, familial and psychological levels; and those at the program or project level. It is clear that increasing the prospects for male participation in women's health calls for a substantive understanding of these challenges, and a committed and serious implementation of the given courses of action.

Using the Internet to Improve Reproductive Health Training

R. LU

JHPIEGO Corporation

Lack of up-to-date scientific information and need for inexpensive ways to obtain new information are major problems currently facing many countries as they work to improve the quality of education and training of reproductive health professionals. Performance Support Services (PSS) merge the proven benefits of JHPIEGO's competency-based training methodology and technical resources with rapidly developing advances in telecommunications and computing. PSS is designed to help countries develop an integrated (preservice and inservice) education and training system and consists of the following five components: ReproLine | online Internet service featuring regularly updated scientific information including text and presentation graphics (www.reproline.jbu.edu), REPRONET-L Listserv (global email discussion group), JHPIEGO TrainerNews TM (training newsletter vial email), videoconferencing for team collaboration and skill evaluation and in the future ReproNews (reproductive health newsletter via e-mail and ReproLearn TM (online distance education). PSS components are available through the Internet and CD-ROM. For example, using only a 486 microcomputer, inexpensive printer (together costing less than US$2,000) and an Internet connection, it is possible to access and download the text, presentation graphics and other data available on ReproLine| directly.

PSS components provide a mechanism to bridge the reproductive health information gap and cost-effectively meet the long-term need in many countries for up-to-date scientific information, diessemination of this information locally and the decentralization of education and training of health professionals.

Family Planning and Women's Lives in Indonesia

F. LUBIS

Yayasan Kusuma Buana

Purpose: To examine the impact of family planning on various aspects of women's lives in Indonesia.

Study Design and Methodology: This paper draws on findings from four studies conducted in seven provinces of Indonesia. All studies included both quantitative and qualitative methods. A total of 2,495 women were included in surveys in East, Central and west Java, Lampung, South Sumatra, Jakarta and Ujung Pandang. In those areas, and in North Sumatra and West java, 86 women and 46 women were included in in- depth interviews. In Lampung and South Sumatra, 78 women and 32 men participated in focus group discussions. In addition, one study conducted secondary analysis of the 1993 Indonesia Family Life Survey.

Findings: Women in these studies support the Indonesia government family planning program as a social movement. They use contraception, espouse the benefits of spacing their children, and limit their family size. Still, a significant number of women in the studies complained about side effects and expressed fears about specific methods. Negative experiences with side effects often led to contraceptive discontinuation or method- switching. Even women who said they were "satisfied" with their family planning method went on to describe problems they had experienced that in other societies would be regarded as elements of "dissatisfaction". Traditional and inequitable gender roles play an important role in shaping women's lives. While some women said they would prefer not to work, women contributed substantially to family income and maintenance, and those who did work saw themselves as their husbands' "helpers". For the most part, women were responsible for domestic duties. Finally, while women recognized that family planning improved their lives, other social and economic factors appeared to exert a more powerful influence.

Cervical Cancer - A Preventab le D isease

G.A. MANUEL-LIMSON, MD

Cancer of the cervix is the second most common cancer afflicting Filipino women, next only to breast cancer which is number one. The average annual age-standardized rate is 22.5 per 100,000. This is intermediate between the low rates in Japan (13.2), Hongkong (19.2), Denmark (15.9) and the higher rate of Thailand (29.2). While in developed countries the incidence of morbidity and mortality from cervical cancer has gone down tremendously, the incidence in developing countries, including the Philippines remains nigh and even continues to rise. This is due largely to failure of government to implement an effective screening and early detection program which developed countries are successfully carrying out.

Results of a case control study looking at the risk factors for cervical cancer in the Philippines, including the HPV profile will be presented.

Prevention and early detection of cervical cancer including a plan for further work up of an abnormal Pap smear will be discussed.

THE EFFECTIVENESS AND ACCEPTABILITY OF THE LEVONORGESTREL INTRA-UTERINE SYSTEM FOR THE TREATMENT OF MENORRHAGIA IN WOMEN SUFFERS WHO REQUIRE CONTRACEPTION

MOHAMMED S A MANSOUR, DIANA J A MANSOUR

Department of Obstetrics and Gynaecology, Hexham General Hospital, New Castle upon Tyne Contraception and Sexual Health Service, United Kingdom

Introduction: Menorrhagia is an important cause of iron deficiency anaemia in the developed world. On the other hand, frequent and repeated childbirth is the commonest cause of morbidity and mortality in women in the third world. The dual role of Levonorgestrel Intra-Uterine System (LNG-IUS) as an effective and compliance-free contraceptive as well as a credible long-term medical therapy for heavy menstrual blood loss, will enable women who suffer from this condition to regulate their fertility using a system that will simultaneously resolve their menorrhagia. Objective: To investigate the acceptability, long-term continuance and the subjective effectiveness of the Levonorgestrel Intra-Uterine System as a long- term treatment for memorrhagia in women requiring contraception. Design: Prospective study - Ongoing with interim results Setting: Abnormal Uterine Bleeding Clinic - A District General Hospital in the United Kingdom. Methods: In total, 80 women suffering from menorrhagia was investigated by hysteroscopy, endometrial biopsy and transvaginal ultrasound scans. The LNG-IUS was inserted in the absence of significant intrauterine pathology and patients were asked to collect menstrual details. Of these, 32 women who suffer from menorrhagia and who have used the LNG-IUS as a contraceptive for more than 6 months will be considered in this study. Results: After counselling 32 women were fitted with the LNG-IUS for contraception treatment of heavy menstrual loss. 28(87.5%) women continued using the IUS (mean 15.6 months) as compared to 4 removals (mean 6.4 months). There was one expulsion in a parous woman with a 5 cm uterus. The one year continuation rate was estimated at 81.8%. Overall 30 (93.8%) women subjectively reported improvement in menorrhagia by 2 months with 16 of 17 women (94%) referred with menorrhagia and dysmenorrhea reporting improvement of both symptoms. Regular but reduced menstrual loss resumed in 22 women (68.8%) after a mean of 5.1 months. 2 of the 4 requested removals for prolonged spotting in spite of subjective reduction in blood loss. No pregnancy occurred during the study period. Conclusion: In conclusion, the Levonorgestrel IUS is an effective and acceptable long-term treatment for women complaining of menorrhagia and dysmenorrhea in addition to being an effective contraceptive. The dual role will enable more women world-wide to exercise their reproductive right to regulate their fertility

USEFULNESS OF LEVONORGESTREL-RELEASING IUD IN THE MANAGEMENT OF MENORRHAGIC WOMEN WITH UTERINE MYOMA AND ADENOMYOSIS

MAROU T, SAMOTO T, TAKEUCHI S, SPITZ I, AND JOHANSSON E.

Dept. of Ob/Gyn, Kobe University School of Medicine, Kobe, Japan and Population Council, New York, U.S.A.

To evaluate the usefulness of levonorgestrel-releasing IUD (LNg-IUD) in the management of menorrhagia affected by uterine myoma and adenomyosis. Twenty-four women aged 26 to 48 years with recurrent menorrhagia participated in this study. An IUD releasing LNg 20 micrograms/day was inserted in each patient. All of the patients were requested to compile menstrual diaries and to come for follow-up visits at 1,3,6,9,12 months after insertion. The use of LNg-IUD resulted in a striking reduction in menorrhagia in all patients with intramural myoma (n=10) and adenomyosis (n=10). Only exception was submucosal myoma. In two of four menorrhagia women with submucosal myoma, excessive menstraul bleeding reappeared after the reduction in the menorrhagic during the first 8 month of use and hysterectomy was performed. All patients experienced scanty spotting during the first three months. Despite the occurrence of spotting all patients tolerated the increased spotting days and lengthened cycles. Although three patients had spontaneous expulsion of IUD at various intervals, they wanted reinsertion of the device because of remarkable reduction in menorrhagia. No significant differences were noted in myoma volume and uterine volume assessed by MRI examination between pro-treatment and 12- month use. LNg-IUD was proven to be effective for contraception even in women with myoma and adenomyosis. These results demonstrate that LNg-IUD is an effective modality of the long-term treatment of menorrhagia due to uterine myoma and adenomyosis with the only exception of menorrhagic women with submucosal myoma. Sex steroidal regulation of myoma growth and apoptosis will also be discussed.

Interface Between LAM and Other Methods

R, MASSAI, S.DIAZ and H. CROXATTO

Chilean Institute of Reproductive Medicine, Santiago, Chile

Lactational amenorrhea method (LAM) provides more than 98% protection in the first six months postpartum. The occurrence of the first menses or the introduction of supplementary food for the baby or passing the six postpartum months increase the risk of pregnancy, before the protective effect of (LAM) wanes completely. For this reason, breastfeeding women approaching these events, and want a high degree of protection, should consider change to another fertility regulation method. The method of choice should preserve the breastfeeding performance and to be safe for the mother and the infant. The non- hormonal methods are the first choice and among them, the intrauterine device provides highly effective long-term contraception. Progestin-onl~ methods are a good second choice and can be used as early as the 6 week post-partum. They include mini-pills containing levonorgestrel (LNg) or lynestrenol, injections of DMPA or NET-EN and subdermal implants releasing LNg or Nestorone| Synthetic progestins, which are excreted in the milk and are poorly active by the oral route, such as Nestorone| or progesterone should be preferred, if they became available, since they are less likely to affect the infant. Notwithstanding, no problems have been detected so far, in short term observation of the infants whose mother used progestin-only methods during breastfeeding, but long term evaluations, to exclude a potential influence upon the reproductive process in adulthood, are still missing. A progesterone vaginal ring has been developed as a contraceptive method to be used, exclusively, during lactation and has been approved for registration in Chile. Its main advantages are high efficacy and safety, plus the convenience of being self-controlled by the woman and, that each ring can be used continuously for three months. Two advantages of LAM are that it promotes breastfeeding and affords ample opportunity for counselling the mother in the choice of another method. Therefore, it should be given priority as the starting method in settings where the mother has access to good quality services.

APPROPRIATE BREAST CANCER SCREENING FOR ASIAN COUNTRIES

CORAZON A.NGELANGEL, MD., MS

University of the Philippines College of Medicine

INTRODUCTION: Breast cancer is a lead malignancy in both developed and less developed countries. The goal of early detection programs is to detect and treat cancer in its earliest stages to prevent the occurrence of invasive breast cancer and death from the disease. Less early stages (which would still lead to some improved survival and more so simplier treatment and less morbidity) would be the critical point after the presence of invasive cancer but before the appearance of lymph node invasion.

OBJECTIVE: The discussion paper reviews literature recommendations for breast cancer screening and the evidence supporting these recommendations, and discusses issues for such screening in Asian countries, particularly those less developed.

DISCUSSION: Screening modalities for breast cancer include mammography (MM), clinical breast examination (CBE), and breast self- examination (BSE). Screening with MM with/without CBE has been demonstrated in randomized clinical trials to reduce mortality from breast cancer significantly. The value of BSE in reducing mortality is uncertain. BSE should then be viewed as an adjunct to routine screening with MM and CBE. The value of widespread screening for women younger than 50 is questionable. Women older than 50 should be given the highest priority for breast cancer screening programs. Some recommendations state 64, 69, 75, >=50 as cut off upper age limit and frequency of screen range from every 1-3 years. Issues for effectiveness of the screening program includes compliance, competence, and adequacy of resources to fully implement the screening and the treatment of breast cancer on a nationwide scale. For any country with limited resources, particularly those without health care reimbursement schemes, implementation of such nationwide screening for breast cancer, particularly MM, would be difficult. The implementation of a screening program using CBE +/- BSE would be an option, even though it may not reduce mortality but would at least early detect invasive cancer before the appearance of lymph node invasion. And whenever such a program is introduced, the opportunity to build-in features permitting rigorous evaluation should be taken whenever possible. To adopt MM +/- CBE as a screening modality of choice would need the review of budget allocations, reallocating monies to evidenced - based effective screening program s from those which are proven ineffective. The importance of breast cancer screening should be emphasized through continuing physician and patient education, and public awareness campaigns.

UK ABORTION STATISTICS - HOW RELIABLE ARE THEY?

OLOTO E. J., WALKER R. G., GBOLADE B. A.

Fertility Control Unit, St. James's University Hospital, Leeds, United Kingdom

Objective: 1. To determine the incidence, presentation, management and outcome of the immediate complications of surgical termination of pregnancy in our centre which provides the UK's largest NHS pregnancy termination service 2. To determine the accuracy of the records regarding such complications maintained in the hospital database and that of the Office for National Statistics. Methods: We obtained all available case records of patients identified as having immediate complications (within 24 hours) following surgical termination of pregnancy, from theatre registers and cross-checked this with the hospital database. The information obtained was compared with that held by the Office for National Statistics for the same period. Results: Between April 1991 and March 1997, 15019 pregnancies were terminated in the unit. 98% of these were performed surgically of which 0.4% (60 patients) had immediate complications. Uterine perforation (2 per 1000 abortions) accounted for 50% of the complications requiring only laparoscopy in 12; only laparotomy in 9; and laparotomy preceded by laparoscopy in 9. A comparison of 5 year data from our unit with that of the Office for National Statistics between 1991/92 and 1995/96 revealed a staggering difference of 3475 (30%) in the number of abortions and 7 (31%) in the number of uterine perforations. Conclusions: If the above discrepancy is a true reflection of the National data, then it is a major cause for concern. It would appear that the notification mechanism for termination of pregnancy in the UK needs to be reviewed urgently. Only then can the British Abortion Register be a reliable source of information about abortion statistics.

ACCEPTABILITY, USE-EFFECTIVENESS AND SERVICE DELIVERY REQUIREMENTS IN THE PROVISION OF DIAPHRAGMS AMONG A SELECT

GROUP OF PHILIPPINO WOMEN

RAMOS R, ORALS V, VILAR F, JOANIS C, PALMORE S AND GREY T

Reproductive Health Philippines, Inc.

In 1995, a study was initiated in the Philippines to assess the acceptability and use effectiveness of the diaphragm. Service delivery requirements in the provision of the method were assessed as well.

Ten clinics were selected for participation. Clinics selected represented non- governmental organizations, governmental organizations, women's health clinics and local government units. Data were collected using Knowledge, Attitude and Practices surveys (KAPs), focus group discussions (FGDs), in-depth interviews and interview-assisted surveys. A comprehensive contraceptive training program was developed for diaphragm providers and KAP surveys were administered pre- and post-training. FGDs were conducted after one year with acceptors, discontinuers and acceptors of other methods to assess satisfaction with the selected method, reasons for discontinuation, partner opinion, etc. In-depth interviews were conducted with providers to determine acceptance and issues related to diaphragm provision. Women choosing the diaphragm were followed for a minimum of six months and were interviewed at two weeks, 3 and 6 months and 1 year to determine pregnancy status, satisfaction with method, partner opinion and device acceptability.

259 women selected the diaphragm as their contraceptive method. Diaphragm acceptors were older, better educated and more likely to be employed than non- acceptors. Twenty percent of non-acceptors had never used a contraceptive method (versus 7% for diaphragm acceptors). Non-acceptors were more likely to have multiple partners. Irrespective of contraceptive method selected, between 50 and 60 percent of women surveyed did not want more children. The primary reason for diaphragm discontinuation was partner dissatisfaction with the method. Seventeen women became pregnant while using the diaphragm, but only three were attributed to method failure.

In this study, the demographic profile of the diaphragm acceptor was similar to profiles obtained for women in developed countries. The pregnancy rate was better than the typical use rates cited for developed countries. Providers were positive about diaphragm provision.

UPDATE ON FEMALE STERILIZATION

A. E. P O L L A C K

AVSC I N T E R N A T I O N A L , N e w York, U.S.A.

Female sterilization is one of the most widely-used methods of contraception worldwide. As of 1993, of the 191 million married couples depending on male and female sterilization, 149 million rely on female sterilization.

Although the importance of informed choice is recognized as a critical component of female sterilization services; we are far from full implementation of this worldwide.

Of different approaches to accessing the fallopian tubes (laparoscopy, minilaparotomy vaginal colpotomy), the most common approach worldwide remains minilaparotomy. Once the fallopian tube are accessed, there are several acceptable methods of occlusion, including clips, bands and ligation with partial salpingectomy, which is the most common occlusion method worldwide. Other methods of occlusion that are in development and experimental stages include transcervical coils and chemical sterilization; however, long-term efficacy and side effects of these methods remain to be determined.

Anesthesia complications remain the major cause of mortality from female sterilization. Of the different anesthesia regimens used, the highest complication rate is associated with general anesthesia, the lowest with local anesthesia, which is used in 75% of sterilizations performed worldwide.

Although recent long-term data from the CREST study confirm female sterilization to be one of the most efficacious methods, failure can occur as long as ten years after the procedure. Among failures, the incidence of ectopic pregnancy is increased. One must be cautious in generalizing about actual failure rates found in the U.S.-based CREST study since occlusion mix, technique and surgical skills were not uniform, and are not representative of techniques and occlusion-method mix worldwide.

Study findings do not support post-tubal ligation syndrome. Female sterilization is associated with a significant reduction in ovarian cancer risk. The incidence of regret is low and is associated with several predictable risk factors for which providers may screen.

This update will discuss demographics, informed choice, approaches, occlusion methods, anesthesia choices, efficacy and long term effects of female sterilization.

UPDATE ON STERILIZATION

A. E. P O L L A C K

A V S C I N T E R N A T I O N A L , New York, U.S.A

Sterilization is the most widely-used method of contraception worlwide, where over a 42 million vasectomies and 149 million female sterilizations have been performed. Compared to female sterilization vasectomy is safer, more efficacious and programmatically easier and less expensive to provide. Yet it remains one of the least known and least used family planning methods.

No-Scalpel Vasectomy is a recent advancement in approach to the vas deferens, which is less traumatic, with a shorter recovery time than conventional vasectomy. Methods of vas occlusion include ligation, excision, cautery, clips, and laser alone or in combination. There is no consensus on the best occlusion method. Of different approaches to accessing the fallopian tubes for female sterilization, the most common approach worldwide remains minilaparotomy. Once the fallopian tubes are accessed, there are several acceptable methods of occlusion, including clips, bands and partial salpingectomy (the most common occlusion method worldwide).

Although, percutanous occlusion methods (with formed in place silicone plugs or Ovabloc) for vasectomy and non-surgical tubal occlusion (with Ovabloc, quinacrine and coils) for female sterilization are in experimental stages; long-term efficacy and side effects of these methods remain to be determined.

Anesthesia complications remain the major cause of mortality from female sterilization. Complication rates are highest with general anesthesia and lowest when only local anesthesia is used.

Although recent long-term data from the CREST study confirm female sterilization to be one of the most efficacious methods, failure can occur as long as ten years after the procedure. Among failures, the incidence of ectopic pregnancy is approximately 30%. For vasectomy, studies report pregnancy rates ranging from 0-2%, with most reporting less than 1%. Although follow-up semen analysis post- vasectomy semen is used routinely in some settings to assure azoospermia, the clinical utility and application of post-vasectomy semen analysis remains to be determined.

Studies show that female sterilization does not result in any negative health effects and is associated with a significant reduction in ovarian" cancer risk. Vasectomy has not been causally associated with any health risk.

Domestic Violence: Its consequence on Filipino Women's Reproductive Health

Pilar RAMOS-JIMENEZ, Ph.D. Coordinator

Task Force on Social Science and Reproductive Health, De La Salle University

This paper provides the magnitude and causes as well as the consequences of domestic violence in the Philippines by examining quantitative and qualitative studies on reproductive health and domestic violence in the past decade. It also presents the responses of the Philippine government, non-government organizations, community- based groupings as well as the health sector including training institute to address this public health issue.

Barrier Methods: Effectiveness in Preventing Pregnancy and Sexually Transmitted Diseases

ROBERTO RIVERA, NINA FRANKEL, WILLIAM FUIYER

Family Health International, North Carolina, USA

The growing problem of STDs among reproductive age women has estimulated the integration of STDs services into family planning programs. An important number of couples require the use of methods that may provide protection both for STDs and pregnancy. Assessing the client's risk for STDs is a necessary procedure in reproductive health services, and appropriate STD prevention and contraceptive choices must be discussed accordingly. Barrier methods are the only type of contraceptives that may provide both STDs and pregnancy protection. Certainly, to achieve this protection, the methods must be correctly and consistently used. There is sufficient information showing that male condoms protect for STDs transmission, including HIV, and pregnancy. Spermicides provide only a modest level of protection against bacterial STDs, but no protective effect against viral STDs has been documented. In couples, an increased risk of STDs the use of two methods should be discussed as an alternative, the use of a highly effective method for pregnancy protection and of the male condom for STD protection may be recommended.

Emergency Contraceptive Pills: Policy and Program Issues

ROBERTO RIVERA, SARA JOHNSON, IRINA YACOBSEN

Family Health International

Every year it is estimated that at least 20 million unsafe abortions are performed as a result of unintended pregnancies. This problem may be greatly reduced by the use of emergency contraceptive pills (ECPs). The two currently available regimes of ECPs require its use within 72 hours of unprotected intercourse. Therefore, health services have to be organized so that couples can have easy access to this type of contraception. Nausea and vomiting are the main problems associated with the use of combined oral contraceptives as ECPs, these problems are substantially less frequent and severe, with progestin-only pills. ECPs are not considered a regular contraceptive method. Following the use of ECPs, couples must be counseled on the need of using a regular method of contraception; afterwards, oral and injectable contraceptives and barrier methods may be initiated immediately after using ECPs. Waiting until the next menstrual cycle is commonly recommended for the initiation of IUDs and Norplant. Considering the problems for the correct and consistent use of barrier methods, the use of ECPs as a back-up method for couples who prefer these methods should be discussed. Advanced counseling on ECPs should be now a common practice in reproductive health services.

Guidance Criteria for the Use of Contraceptives in Adolescents: Poster

R. RIVERA, S. PALMORE

Family Health International

The number of unwanted pregnancies in women under 20 years of age continues to be a problem in many countries. The main reasons are the lack of contraceptive use and incorrect and/or inconsistent use. Physicians continue to limit adoleScent's access to modern and effective means of contraception because outdated medical eligibility criteria and personal bias are frequently applied. No clinically significant metabolic effects, changes in fertility or in growth and development have been demonstrated with the use of combined oral contraceptives. All progestin-only methods (orals, injectables and implants) may be used safely by younger women. There are some theoretical concerns of affects on bone formation related to hypoestrogenism that may be induced by some of these methods when used by women younger than 16 years of age, but no clinical effects have been observed so far. As with adults, the main problems associated with the use of steroidal contraceptives in younger women are related to changes in the menstrual cycle and to compliance. The use of IUDs by younger women requires a careful assessment of the client sexual behavior. IUDs are not recommended for women considered to be at high risk of STDs..The use of emergency contraception (EC) at any time during the menstrual cycle when unprotected intercourse might occur is safe for young women. The use of barrier methods is also an option but requires careful counseling and strong motivation to sustain continued correct use. Barrier methods are the only contraceptive methods that provide protection against STDs, which is frequently an important need in the reproductive health of young people.

Main Clinical and Programmatic Characteristics of Injectable Depomedroxyprogesterone Acetate for Contraception

ROBERTO RIVERA, MD, PAMELA SCHWlNGL, PhD

Family Health International

The programmatic experience continues to be that once injectable depomedroxyprogesterone acetate (DMPA) is introduced into reproductive health services, it rapidly becomes the method of choice for many couples. Efficacy, ease of use and safety are the preferred characteristics of DMPA. Accidental pregnancy rates are less than 1 after one year of use, with much less compliance problems than other means of contraception. The requirement of one injection every 3 months is seen as a big advantage both by clients and providers. The only contraindications for its use are pregnancy, unexplained vaginal bleeding and breast cancer. The cardiovascular problems associated with DMPA are less than with combined oral contraceptives. DMPA may be used in smokers and in women with mild or moderate hypertension or with a history of thromboembolic problems. DMPA has a protective effect against endometrical cancer and probably also for ovarian cancer, and there is no creased risk of breast cancer. A possible association between DMPA use and osteoporosis has been reported, but additional research is necessary. The main problems with DMPA use are excessive menstrual bleeding and amenorrhea and subjects must be carefully counseled on these problems. There is a delay in the return of fertility upon discontinuation of DMPA. Given its safety and efficacy profile, DMPA may be safely used in community based reproductive health services.

The Use and Development of Contraceptive Education Materials: Poster

R. RIVERA, S. PALMORE

Family Health International

A new tool has been developed to assist contraceptive providers and trainers who need the latest medical and programmatic information when providing contraceptives. Working closely with leading scientists and service delivery agencies to achieve consensus, and utilizing both USAID and WHO recommendations for family planning service provision, Family Health International (FHI) has developed a series of training modules on specific contraceptive methods and client groups. The series includes modules on Injectable Contraceptives, Postpartum Contraception, IUDs, Oral Contraceptives, Barrier Methods, Health of Young Adults, and, upcoming, Sexually Transmitted Diseases and Emergency Contraception. Each module contains practical information needed by indications, characteristics, counseling, and program and quality of care of the various topics presented, and to presenting the information in an attractive useable format. Each module is available in English, Spanish and French and contains: instructions for use with different audiences, 35mm color slides and paper copies, a suggested narrative, audience handouts, references, scientific articles, and evaluation forms and questionnaires for use before and after thetraining sessions.

DEVELOPING AND IMPLEMENTING PAC PROGRAMS

K.O. ROGO

Center for the Study of Adolescence, Nairobi, Kenya

The concept of PAC is fairly new since ICPD (1994) countries are struggling to implement PAC. The challenges of PAC in countries with restrictive laws are myriad. This paper discusses these challenges in the context on developing countries with scarce resources. It looks at the roles of key stakeholders - providers, clients, governments and communities - in successful implementation of PAC while emphasizing the need for more operations research.

Philippine Experience on Voluntary Sterilization

LORETO B. ROQUERO JR*., MARIA OTELIA D. COSTALES

Department of Health, Philippines

In 1972, sterilization for both men and women was recognized as an official method of contraception by the Philippine government. By late 1973, several large hospitals were offering sterilization on a regular basis.

The 1993 Philippine National Demographic Survey showed that knowledge of contraceptive methods is high at 95.9%. Ninety-two percent of married women know about female sterilization; however, only ten percent of them know where to get the services. The same survey indicated that 63% of the respondents did not want to have any more children. The unmet demand for Voluntary Sterilization (VS) services has been quantified at 14% of Married Women of Reproductive Age (MWRA) which is about 1.3 million.

Female sterilization continues to be a popular method throughout the country. The 1997 Family Planning Survey conducted by the National Statistics Office showed that the most widely used method is the pill followed by Voluntary sterilization and the IUD. Vasectomy was once quite popular, but this declined in the late 1970s.

In the late 1980s, service delivery, training, and program implementation shifted from the Population Commission to the Department of Health and the subsidy system for family planning service delivery was discontinued. The abandonment of the subsidy system created a new challenge for providers to sustain family planning services. Many providers attribute a decline in clinical services to the lack of subsidies for medicine and expendable supplies.

In 1991, the Philippine government signed into law the Local Government Code which gave power, authority, and decision-making responsibility for health and other activities to the Local Government Units (LGUs). Local authorities now operate with autonomy in all sectors, including health. At present, voluntary sterilization services are being provided in selected LGU and DOH hospitals all over the country.

Studies on offspring of Failure Natural Family Planning Conceptions Fail to Show Aneuploidy

J.L. SIMPSON, R. YOULTON, P. MENA, A. PEREZ, V. JENNINGS, R. GRAY, J.T. QUEENAN

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA.

Pregnancies occurring inadvertently in NFP contraceptors pose theoretical fetal risks if fertilization involves gametes aged in vivo before conception. Our international collaborative group has conducted cohort studies assessing fetail losses and anomalies when the conception intercourse occurs on days that could involve aging gametes (i.e. conception on days other than the ovulation day or one day earlier) (Simpson et al., Adv. Contracept. 13:201,1997). In a cohort of 1000 pregnancies we confirmed NFP safety using clinical grounds. Evaluation of anomalies on clinical grounds should detect nondisjunction leading to autosomal trisomy, however, sex chromosomal aneuploidy may be detected only be cytogenetic studies.

Objective The objective of the current study was to perform cytogenetic studies (lymphocytes) on liveborn offspring resulting from method failure NFP pregnancies.

Methods NFP users who became pregnant despite adhering to NFP recommendations were identified at U. Chile and Pontifica Catolien Universidad de Chile. Timing of conception was determined from NFP charts in which women recorded days on which intercourse occurred, basal body temperature, and physical signs connoting ovulation (e.g., peak mucus day). Blood for chromosomal analysis was obtained, either at delivery using cord blood or during infancy by venipuncture. Samples were processed using phytohemagglutinin-stimulation and standard tissue culture media. Metaphases were accumulated by colcemid. After hypotonic treatment and fixation, GTG-banding was performed (30 metaphases). Parental chromosomal studies were performed if prominent polymorphisms or rearrangements were detected.

Results A total of 48 offspring of NFP method failure pregnancies were studied. None showed aneuploidy. A single balanced translocation was observed [t(1:8)(p13:q13)], but the mother had the same rearrangement.

Conclusions Our cytogenetic findings are consistent with conclusions from our cohort study, Aneuploidy is not a common phenomenon in NFP method failure pregnancies, verifying safety of NFP as a method and suggesting lack of a paramount role for aging gametes in the tiology of nondisjunction.

CURRENT PERSPECTIVES IN THE MANAGEMENT OF THE AGING MALE

TAN, DELF1N A., MD.

Department of Obstetrics and Gynecology United Doctors Medical Center, Quezon City, Philippine

The aging process influences testicular function as both androgen production and spermatogenesis decrease slowly but progressively with age. Plasma androgen levels demonstrate a significant decline in aging men. In healthy males between age 25 and 75 years, total testosterone levels decrease by about 30% whereas free testosterone levels decrease by about 50%. This is the concept of male hypogonadism related to aging referred to as partial androgen deficiency in aging males (PADAM). With aging, men show a decrease in bone mass with an increase in the incidence of bone fractures, a decrease in muscle mass and muscle strength with an increase in abdominal adipose tissue, and a decline in measures of sexual function, such as potency, orgasmic frequency and sexual thoughts. Androgen replacement therapy in hypogonadal men increases bone mass, lean body mass and muscle strength, decreases fat mass, and improves mood, sense of well- being and sexual behavior. Currently, testosterone replacement therapy in aging men is considered only if there is evidence of testosterone deficiency and after weighing benefits and possible side effects. The two areas of most concern are potentiation of cardiovascular disease and acceleration of benign or malignant prostate disease. Current data indicate that androgen therapy may even have positive effects on the cardiovascular system. Most studies show no increase in the incidence of benign prostate hypertrophy nor any change in serum prostate specific antigen. Parenteral testosterone preparations (testosterone enanthate, testosterone cypionate), given 250 mg every 2 weeks, represent standard therapy for male hypogonadism. Oral testosterone preparations are second-line medications. Sublingual, transdermal, and impact preparations are currently under evaluation.

UPDATE ON MALE STERILIZATION

T. V A I D Y A

A V S C I N T E R N A T I O N A L , Patan, Nepa l

Vasectomy is among the safest and most efficacious, yet least known and least used family planning methods. Although its programmatic expansion is easier and cheaper than female sterilization; it is neglected by most national family planning programs worldwide.

Worldwide, over 42 million vasectomies have been done compared with 149 million female sterilizations. Vasectomy is popular in countries such as the U.S.A., the U.K., China, India and South Korea. Men from a broad range of cultural and religious backgrounds choose vasectomy as a method for a variety of reasons, including involvement of the male as a partner in fertility control.

Informed choice is critical to the provision of vasectomy services. Lack of ability to provide informed consent is the only true contraindication to the vasectomy procedure.

No-Scalpel Vasectomy is a recent advancement in technique to approach the vas deferens. It represents a significant improvement over conventional vasectomy as it is less traumatic and shortens recovery time.

Studies report pregnancy rates after vasectomy ranging from 0-2%, with most reporting less than 1%. Although follow-up semen analysis post-vasectomy is used routinely in some settings to assure azoospermia, the clinical utility and application of post-vasectomy semen analysis remain to be determined.

Vasectomy seems to have an overall positive effect on health with two large studies reporting lower rates of mortality among vasectomized men compared to age matched controls. Recent well-designed studies do not show any increased risk of cardiovascular morbidity, testicular cancer, or prostate cancer.

One of the strongest factors responsible for the low prevalence of vasectomy is the abundance of misinformation among clients and providers. Additional programmatic issues that affect prevalence of this method include: availability, accessibility, inadequate counselling, low priority by policymakers/managers, inadequate resource allocation, insufficient promotional activities, low participation of males in family planning, and poor attention to quality.

This update will discuss demographics, acceptability, informed choice, new approaches, long-term benefits/risks, efficacy and follow-up protocols. Special attention will be given to addressing common misconceptions that affect prevalence of vasectomy. Based on experiences in various countries, this update will also cover programmatic issues that need to be addressed to provide quality vasectomy services.

THE USE OF BARRIERS: TO BAR OR TO BARE

ZALDIVAR, Salud B.

Research Institute for Tropical Medicine - Department of Health

Issue/Objective: In time for the opening of the 4 th Int'l. Congress on AIDS in Asia and the Pacific in October 1997, the Catholic Bishops Conference of the Philippines Spokesman, Msgr. P. Quitorio III was quoted in national newspapers of having said: "Church rejects and finds no valid reason to take up the issue on condom use for moral reasons". Consequently, this study was launched to determine how STD/AIDS education, specifically 'safer sex' guidelines, is integrated with religious beliefs. Method: The 'dilemma situation' was utilized as a teaching strategy to supplement the self-administered pre-post test questionnaire in gauging the knowledge, attitude and behavior (KAB) of participants in a STD/AIDS Education Intervention Program. One of the situations posted was the use of condoms among married couples with a spouse highly suspected or confirmed with HIV infection. Results: There were 78 participants surveyed with a mean age of 34.6+11.9 years, all Catholics, 41 (52.6%) single, 23 (29.5%) married, and generally with health teaching/caring responsibilities in the community. With a perfect score of 65 the total mean score on KAB before was 31.8 + 16.4 and after was 57.2 + 6.4. Using t-test, the mean difference in scores before and after seminar was significant (t=13.22; p<.000). The study featured the use of dilemma situation in facilitating the critical discussion of sensitive issues in a non- threatening way.

Real Lives: The Intersection of Women and Family Planning, the Case of the People's Republic of China

X. ZHENMING, B. GU, K. HARDEE

China Population Information and Research Center

Purpose: This study examined the role family planning has played in affecting three domains of women's lives: personal, familial and social. The study investigated women's experiences with family planning methods and services, and with pregnancy and childbearing, and the role women attributed to family planning in the opportunities they had in their lives. While women were the primary focus of the study, men's experiences and attitudes were also included.

Design: The study was carried out in two counties, South Jiangsu and North Anhui provinces. South Jiangsu has a booming economy and successful family planning program. North Anhui is agrarian with more modest success at family planning.

Methodology:. The study included a survey of 1,996 women and 506 men and 56 focus group discussions (FGD's) with 375 people (220 women and 155 men). The FGD's were conducted with older women and men, women and men of reproductive age, unmarried women and men, and female entrepreneurs (a group of special interest in China).

Findings: Fertility in South Jiangsu was lower than in North Anhui (1.2 children compared to 1.9). South Jiangsu more strictly enforces the one- child-per-couple policy. Contraceptive use is based on parity rather than choice: women with one child use the IUD and those with two children are generally sterilized. Women and men were, in general, positive about the role family planning has played in their lives - it has allowed them to have fewer children and thus to focus on economic pursuits. The most significant negative effect of the family planning policy on women is the continued desire for sons, which is reflected in sex ratios of children and in statistics for out-of-plan births.