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Women with attention-deficit/hyperactivity disorder (ADHD) have an increased risk of becoming teenage mothers. Adverse effects of hormonal contraception (HC), including depression, may affect adherence to user-dependent contraception and increase the risk for unplanned pregnancies and teenage births in women with ADHD. The current study analyzed whether girls and young women with ADHD are at increased risk for depression during HC use compared with non-ADHD women.A linkage of Swedish national registers covering 29,767 girls and young women with ADHD aged 15 to 24 years and 763,146 without ADHD provided measures of ADHD and depression diagnoses (International Classification of Diseases [ICD] code) and prescription of stimulant medication, HC, and antidepressant medication (Anatomical Therapeutic Chemical [ATC] code). Cox regression models applying an interaction term (ADHD diagnosis × HC use) evaluated the excess risk of HC-induced depression in women with ADHD.Women with ADHD had a 3-fold higher risk of developing depression, irrespective of HC use (adjusted hazard ratio [aHR] = 3.69, 95% CI = 3.60-3.78). Oral combined HC users with ADHD had a 5 times higher risk of depression compared with non-ADHD women who were not using oral combined HC (aHR = 5.19, 95% CI = 4.94-5.47), and a 6 times higher risk in comparison with non-ADHD women who were on oral combined HC (aHR = 6.10 (95% CI = 5.79-6.43). The corresponding risk of depression in women with AHDH who used a progestogen-only pill (aHR = 5.00, 95% CI = 4.56-5.49). The risk of developing depression when using non-oral HC was similarly moderately increased in both groups.Girls and young women with ADHD have an increased risk of developing depression when using oral HC compared with their unaffected peers. Information on risks with HCs as well as potential benefits with long-acting reversible contraceptives needs to be an integrated part of the shared decision making and contraception counseling for young women with ADHD.

The spatiotemporal regulation of cell fate specification in the human developing spinal cord remains largely unknown. In this study, by performing integrated analysis of single-cell and spatial multi-omics data, we used 16 prenatal human samples to create a comprehensive developmental cell atlas of the spinal cord during post-conceptional weeks 5–12. This revealed how the cell fate commitment of neural progenitor cells and their spatial positioning are spatiotemporally regulated by specific gene sets. We identified unique events in human spinal cord development relative to rodents, including earlier quiescence of active neural stem cells, differential regulation of cell differentiation and distinct spatiotemporal genetic regulation of cell fate choices. In addition, by integrating our atlas with pediatric ependymomas data, we identified specific molecular signatures and lineage-specific genes of cancer stem cells during progression. Thus, we delineate spatiotemporal genetic regulation of human spinal cord development and leverage these data to gain disease insight.

Precision medicine carries great potential for management of all tumor types. The aim of this retrospective study was to investigate if the two most common genetically distinct uterine fibroid subclasses, driven by aberrations in MED12 and HMGA2 genes, respectively, influence response to treatment with the progesterone receptor modulator ulipristal acetate. Changes in diameter and mutation status were derived for 101 uterine fibroids surgically removed after ulipristal acetate treatment. A significant difference in treatment response between the two major subclasses was detected. MED12 mutant fibroids had 4.4 times higher odds of shrinking in response to ulipristal acetate treatment as compared to HMGA2 driven fibroids (95% confidence interval 1.37–13.9; P = 0.013), and in a multivariate analysis molecular subclassification was an independent predictive factor. Compatible with this finding, gene expression and DNA methylation analyses revealed subclass specific differences in progesterone receptor signaling. The work provides a proof-of-principle that uterine fibroid treatment response is influenced by molecular subclass and that the genetic subclasses should be taken into account when evaluating current and future uterine fibroid therapies.

Nexplanon is a single-rod contraceptive implant that should be placed subdermally at the inner side of the upper nondominant arm approximately 8-10 cm above the medial epicondyle of the humerus. Insertion guidelines were recently updated to place of insertion superficial of the triceps muscle to lower risk of insertion into vessels and nerves. If migration however occurs, it is most commonly around the insertion site. Migration above 2 cm is rarely reported [Ismail H, Mansour D, Singh M. Migration of implanon®. BMJ Sexual Reproduct Health. 2006;32:157-159]. This is a case report of a 24-year-old caucasian woman who presented with an impalpable Nexplanon implant that was, with the help of chest radiography and CT, located in a posterior basal subsegmental pulmonary artery in the left lower lobe of the lung. An attempt to remove the contraceptive implant by endovascular approach was unsuccessful. The implant remains

PURPOSE: To investigate bleeding profile satisfaction and pain and ease of placement with levonorgestrel 19.5 mg IUD in routine clinical practice. METHODS: Women who independently chose levonorgestrel 19.5 mg IUD during routine counselling were invited to participate in this prospective, multinational, observational study. Patient-reported pain and clinician-reported ease of placement were assessed. Bleeding profile satisfaction was evaluated at 12 months/premature end of observation. RESULTS: Most participants (77.8%, n = 878/1129) rated levonorgestrel 19.5 mg IUD placement pain as 'none' or 'mild' and most clinicians (91.1%, n = 1029/1129) rated placement as 'easy'. Pain was more often rated higher in nulliparous compared with parous (p 35 years. CONCLUSION: We observed high bleeding profile satisfaction regardless of age or parity with levonorgestrel 19.5 mg IUD and confirmed that device placement is easy and associated with no more than mild pain in most cases in routine clinical practice. Real-world evidence from the Kyleena® Satisfaction Study in routine clinical practice shows high bleeding profile satisfaction with levonorgestrel 19.5 mg IUD regardless of age or parity. IUD placement was easy and associated with little to no pain for most women. ispartof: EUROPEAN JOURNAL OF CONTRACEPTION AND REPRODUCTIVE HEALTH CARE vol:28 issue:1 pages:1-9 ispartof: location:England status: published

PURPOSE: The Kyleena® Satisfaction Study (KYSS) aimed to assess satisfaction and continuation with levonorgestrel-releasing intrauterine system (LNG-IUS) 12 (Kyleena®) in routine clinical practice and to evaluate factors that influence satisfaction. MATERIALS AND METHODS: This prospective, observational, multicentre, single-arm cohort study, with 1-year follow-up, was conducted in Belgium, Canada, Germany, Mexico, Norway, Sweden, Spain and the United States from 2017 to 2018. During routine counselling, women who independently selected to use LNG-IUS 12 were invited to participate in the study. KYSS assessed LNG-IUS 12 satisfaction, continuation and safety. RESULTS: Overall, there were 1126 successful LNG-IUS 12 placements, with insertion attempted in 1129 women. Most participants (833/968, 86.1%, 95% CI 83.7-88.2%, with satisfaction outcome data available) reported satisfaction with LNG-IUS 12 at 12 months (or at the final visit if the device was discontinued prematurely). Satisfaction was not associated with age, parity or motivation for choosing LNG-IUS 12. The majority of women (919/1129, 81.4%) chose to continue after 12 months. Discontinuation was not correlated with age or parity. Overall, 191 women (16.9%) reported a treatment-emergent adverse event. CONCLUSIONS: Results from KYSS provide the first real-world evidence assessing LNG-IUS 12, and demonstrate high satisfaction and continuation rates irrespective of age or parity. Clinical trial registration: NCT03182140. ispartof: EUROPEAN JOURNAL OF CONTRACEPTION AND REPRODUCTIVE HEALTH CARE vol:26 issue:6 pages:462-472 ispartof: location:England status: published

To investigate bleeding profile satisfaction and pain and ease of placement with levonorgestrel 19.5 mg IUD in routine clinical practice.Women who independently chose levonorgestrel 19.5 mg IUD during routine counselling were invited to participate in this prospective, multinational, observational study. Patient-reported pain and clinician-reported ease of placement were assessed. Bleeding profile satisfaction was evaluated at 12 months/premature end of observation.Most participants (77.8%,We observed high bleeding profile satisfaction regardless of age or parity with levonorgestrel 19.5 mg IUD and confirmed that device placement is easy and associated with no more than mild pain in most cases in routine clinical practice. Real-world evidence from the Kyleena

The human spinal cord contains diverse cell types, governed by a series of spatiotemporal events for tissue assembly and functions. However, the spatiotemporal regulation of cell fate specification in the human developing spinal cord remains largely unknown. Single-cell RNA sequencing and spatial transcriptomics techniques have advanced the understanding of human organ development considerably. By performing integrated analysis of single-cell and spatial multi-omics methods, we created a comprehensive developmental cell atlas of the first trimester human spinal cord. Our data revealed that the cell fate commitment of neural progenitor cells and their spatial positioning are spatiotemporally regulated by specific gene sets. Beyond this resource, we unexpectedly discovered unique events in human spinal cord development compared to rodents, including earlier quiescence of active neural stem cells, different regulation of stem cell differentiation, and distinct spatiotemporal genetic regulations of cell fate choices. In addition, using our atlas we identified specific gene expression in cancer stem cells in ependymomas. Thus, we demonstrate spatiotemporal genetic regulation of human spinal cord development as well as its potential to understand novel disease mechanisms and to inspire new therapies.

IntroductionUnintended pregnancies in Europe have been estimated to constitute 43% of all pregnancies, with the proportion in Sweden being unknown. In striving for equitable healthcare, increased knowledge about unintended pregnancies among women born outside Europe is needed. We aimed to estimate the proportion of unintended pregnancies in women born in Sweden compared with women born outside Europe in an unselected population seeking gynaecological emergency care in early pregnancy. Our secondary aim was to compare contraceptive use at the time of conception in unplanned pregnancies between women born in Sweden and women born outside Europe.MethodsPregnant women seeking gynaecological emergency care in early pregnancy at a tertiary hospital were asked to fill out a questionnaire in their native language. The questionnaire contained questions from the London Measure of Unplanned Pregnancy (LMUP) and questions regarding sociodemographic data, gynaecological health and previous contraception.ResultsOf 180 pregnancies, 66 were unintended (36.7%) according to the LMUP. Among patients born in Sweden, 49/129 (38.0%) of the pregnancies were unintended compared with 17/51 (33.3%) among patients born outside Europe (p=0.56). 86% of participants with unintended pregnancy did not use any form of contraception during the month of conception, with no difference between women born in Sweden and those born outside Europe.ConclusionsAmong women seeking gynaecological emergency care in early pregnancy, unintended pregnancies are common. Women with unintended pregnancies had low use of preconception contraceptives, which highlights a need for further interventions aimed at avoiding unintended pregnancies.

Premenstrual dysphoric disorder (PMDD) is a common mood disorder, characterized by distressing affective, behavioral, and somatic symptoms in the late luteal phase of the menstrual cycle. The authors investigated continuous treatment with a selective progesterone receptor modulator, ulipristal acetate (UPA), as a potential treatment for PMDD.The authors conducted an investigator-initiated, multicenter, double-blind, randomized, parallel-group clinical trial in which women with PMDD (N=95) were treated with either 5 mg/day of UPA or placebo during three 28-day treatment cycles. The primary outcome was the change in premenstrual total score on the Daily Record of Severity of Problems (DRSP) from baseline to end of treatment. DRSP scores were captured by daily ratings using a smartphone application and were analyzed with linear mixed models for repeated measures.The mean improvement in DRSP score after 3 months was 41% (SD=18) in the UPA group, compared with 22% (SD=27) in the placebo group (mean difference -18%; 95% CI=-29, -8). Treatment effects were also noted for the DRSP depressive symptom subscale (42% [SD=22] compared with 22% [SD=32]) and the DRSP anger/irritability subscale (47% [SD=21] compared with 23% [SD=35]), but not for the DRSP physical symptom subscale. Remission based on DRSP score was attained by 20 women in the UPA group (50.0%) and eight women in the placebo group (21.1%) (a statistically significant difference).If these results are replicated, UPA could be a useful treatment for PMDD, particularly for the psychological symptoms associated with the disorder.

Introduction It has been estimated that one out of every four women experience first-trimester miscarriage. Missed miscarriage is a common form of early miscarriage where the products of conception are not expelled from the uterus. It is diagnosed by ultrasound. The primary objective of this study was to evaluate the success rate of a combination treatment with mifepristone and misoprostol for missed miscarriage in clinical practice. The secondary objective was to identify significant factors influencing the rate of success. Material and methods A cohort of 941 consecutive women with an ICD-10 diagnosis of missed miscarriage who received treatment with 800 µg vaginal misoprostol and 2 repeat doses of 400 µg oral misoprostol after mifepristone pretreatment between 1 January 2012 and 31 December 2014 was analyzed. Women with a uterine size smaller than 12 weeks who were planned for medical treatment were included in the study. The exclusion criteria were primary surgical management or planned follow up outside the Stockholm County Council area. Results The success rate of medical treatment, defined as no need for surgical treatment, was 85.5% (805/941) in women with a uterine size of less than 12 weeks. However, for women with uterine size below 9 weeks the success rate was 88.9% (586/659). Indeed, uterine size of 9 gestational weeks or larger at time of treatment was identified as the only significant risk factor for surgical intervention. Conclusions The medical regimen for missed miscarriage offered in this study appears to be safe and with high rates of success. Conclusions about which women to exclude from medical treatment could not be made. Medical treatment may therefore benefit all women with missed miscarriage who wish to avoid primary surgery.

To assess the Pearl Index for risk of ectopic pregnancy in women using levonorgestrel-releasing intrauterine systems (LNG-IUS) with hormonal reservoirs of 13.5 mg, 19.5 mg, or 52 mg.This was a retrospective cohort study. Women diagnosed with an ectopic pregnancy in Stockholm County, Sweden, between January 1, 2014, and December 31, 2019, were identified through the electronic medical record system. The final analysis included 2,252 cases of ectopic pregnancy. Information on age, reproductive and medical history, as well as current use of contraception was retrieved. The time of intrauterine device (IUD) insertion before ectopic pregnancy and the numbers of sold LNG-IUS during the study period were used to calculate the incidence rate for ectopic pregnancy during use per 100 woman-years (Pearl Index).Among women with an ectopic pregnancy diagnosis, 105 presented with a known type of hormonal IUD in situ, of whom 94 were included in the calculations of the Pearl Index. The estimated Pearl Index for ectopic pregnancy was 0.136 (95% CI 0.106-0.176) for the LNG-IUS 13.5-mg, 0.037 (95% CI 0.021-0.067) for the LNG-IUS 19.5-mg, and 0.009 (95% CI 0.006-0.014) for the LNG-IUS 52-mg. With the 52-mg LNG-IUS as referent, the relative risk (RR) for ectopic pregnancy was higher during the first year for LNG 13.5-mg (RR 20.59, 95% CI 12.04-35.21), and for both 13.5-mg (RR 14.49, 95% CI 9.01-23.3) and 19.5-mg (RR 4.44, 95% CI 1.64-12.00) during the total study period.The absolute risk of ectopic pregnancy during the use of LNG-IUS at any doses was low. The results show that the lower the dose of the IUD, the higher the risk of an ectopic pregnancy. Higher-dose LNG-IUS should be considered when providing contraceptive counseling to a woman with known risk factors for ectopic pregnancy who are considering a hormonal IUD.

Introduction Provision of long-acting reversible contraception (LARC) at surgical abortion is safe, practical, and leads to higher user rates than does delayed provision. The aim of this study was to explore whether provision of LARC at surgical abortion is associated with known risk factors for subsequent abortions and inconsistent use of contraception, including sociodemographic factors and psychiatric disorders. Material and methods This was a register-based cross-sectional study of 6251 women having a surgical abortion in Sweden. Data were collected from National health and population registers. Women with procedure codes for surgical abortion were identified in the National Patient Register from October 2016 to December 2018. Information from Statistics Sweden, the National Patient Register, and the Swedish prescribed drug register on sociodemographic factors, psychiatric disorders, and dispensed LARC was added and linked on an individual level. Associations of sociodemographic factors and psychiatric disorders with LARC provision were explored with generalized logit mixed models and presented as crude and adjusted odds ratios with 95% confidence intervals (CIs). Results The overall rate of LARC provision at the time of the abortion was 2515/6251 (40.2%). Younger age and lower level of education were associated with an increased likelihood of LARC provision. In the study population, 2624/6251 (42.0%) patients had a pre- or post-abortion psychiatric disorder, a factor associated with an increased likelihood of LARC provision compared with women with no such disorders (adjusted odds ratio 1.21; 95% CI 1.08-1.34). The highest rates and odds were seen among women with personality, substance use, and/or neurodevelopmental disorders and among women with multiple psychiatric disorders. Conclusions Sociodemographic risk factors and psychiatric disorders were associated with increased LARC provision at surgical abortion, indicating that women at high risk of unwanted pregnancies are provided with effective contraception. Still, less than half of all women undergoing surgical abortion were provided with LARC, suggesting that contraceptive access and counseling prior to a surgical abortion can be improved.

PURPOSE: Explore contraceptive use, unmet need of and attitudes towards contraceptive use in Sweden. Secondly, to investigate knowledge of contraceptives, prevalence and outcomes of unintended pregnancies. MATERIALS AND METHODS: Internet based e-survey of Swedish women aged 16-49. The e-survey contained 49 questions with both spontaneous and multi-choice character on demographics, contraceptive use, knowledge of and attitudes towards contraception, importance of monthly bleeding, and experience of unintended pregnancy. The e-survey was closed when reaching the estimated sample size of 1000 respondents. RESULTS: A total of 1016 women participated, whereof 62.4% used contraception, 31.8% did not and 5.8% had stopped in the last 12 months. Unmet need for contraception was estimated at 17.2%. At least one unintended pregnancy was experienced by 19.9%. All women rated effectiveness as the most important characteristic of a contraceptive method. CONCLUSIONS: Use of contraception in Swedish women remains low, 62.4%, and the unmet need for contraception has increased to 17.2%. Method effectiveness and health benefits of hormonal contraception should be emphasised during contraceptive counselling, and actions are needed to target groups with low use of effective contraception as well as to reach those who never seek contraception. KEY MESSAGE Close to one third of Swedish women do not use contraception and one fifth have experienced at least one unintended pregnancy. Unmet need for contraception is high despite easy access and subsidies for young women.

Introduction In this open-label, randomized controlled, non-inferiority, multicenter study we aimed to study the risk of termination of pregnancy within 1 year postpartum, the safety profile and patient acceptability after early postpartum insertion of a hormonal intrauterine device (LNG-IUS, Mirena (R)) compared with standard placement 6-8 weeks postpartum. Material and methods April 2018 to January 2020 women with uncomplicated vaginal delivery at four urban birth centers in Sweden, were randomized to either early placement within 48 h after delivery (early group) or standard placement 6-8 weeks postpartum (standard group) of a hormonal intrauterine device. The main outcome measure was the proportion of terminations of pregnancies in each group during the first year after placement of the intrauterine device. Registration EudraCT database no. 2017-001945-29. Results The study was prematurely stopped according to the protocol due to an expulsion rate >20% in the early group. No pregnancies occurred. Fifty-two women were randomized to early and 49 women to standard insertion. In the early group, 23/52 (44.2%) of the intrauterine devices were expelled. After expulsion, 10 women chose to have another hormonal intrauterine device placed but still significantly fewer women (39/52, 75%, p = 0.22) in the early group used the hormonal intrauterine device method at study completion. No expulsions occurred in the standard group, but 5/49 (10.2%) requested removal and 41/49 (83.7%, p = 0.22) had used the hormonal intrauterine device method continuously for 1 year. Conclusions Early hormonal intrauterine device insertion after vaginal delivery is associated with high expulsion rates. Despite this, a high continuation rate of the hormonal intrauterine device method is seen among women once choosing the method. In the light of high continuation rates, the advantages of early insertion could balance the risk of expulsion for well-informed women. Funding Agencies|County Council of Ostergotland (ALF) [LIO-931995, LIO-794921]

BACKGROUND: Intrauterine devices are safe, well-tolerated, and known to reduce the risk of unwanted pregnancies. At medical abortion, intrauterine devices are placed at a follow-up visit. Patients who miss this visit risk being left without contraception. OBJECTIVE: This study aimed to investigate if placement of an intra-uterine device within 48 hours of completed medical abortion at up to 63 days' gestation leads to higher user rates at 6 months after the abortion compared with placement at 2 to 4 weeks after abortion. Furthermore, we aimed to compare continued use of intrauterine devices, safety, and pa-tient satisfaction between groups. STUDY DESIGN: We performed an open-label, randomized, controlled, multicenter, superiority trial (phase 3). A total of 240 patients requesting medical abortion at up to 63 days' gestation and opting for an intrauterine device were allocated to placement within 48 hours of complete medical abortion (intervention group) or at 2 to 4 weeks after abortion (control group). We defined the abortion as complete after bleeding with clots and cessation of heavy bleeding following the use of misoprostol. Patients answered questionnaires at 3, 6, and 12 months. The primary outcome was use of intrauterine device at 6 months postabortion. Secondary outcomes included expulsion rate, pain at placement, adverse events and complications from the abortion, acceptability, and pregnancies and their outcomes. Differences in nonparametric continuous variables were analyzed with the Mann-Whitney U test and differences in dichotomous variables with the chi square or Fisher exact tests. A P value of

To estimate the incidence rates for ectopic pregnancy by contraceptive method in a cohort of women using hormonal contraception in Sweden between 2005 and 2016.Women aged 15-49 years with a filled prescription for a hormonal contraceptive in the Swedish Prescribed Drug Register between 2005 and 2016 were included. For each woman, all exposed woman-years were allocated to treatment episodes depending on the method of contraception. Treatment time started on the day the prescription was filled and ended on the first day of the end of supply, new eligible dispensing, pregnancy-related diagnosis and its associated estimated last menstrual period, or removal procedure. Ectopic pregnancy was defined as having at least two records of International Classification of Diseases, Tenth Revision code O00-, including O00.0, O00.1, O00.2, O00.8, O00.9, within 30 days or one episode of O00- and one surgical procedure for ectopic pregnancy (NOMESCO Classification of Surgical Procedures code LBA, LBC, LBD, LBE, LBW). Incidence rates per 1,000 woman-years and 95% CIs were calculated for each method of contraception.The study included 1,663,242 women and 1,915 events of ectopic pregnancy. The incidence rate (95% CI) for ectopic pregnancy per method of hormonal contraception was estimated: 13.5-mg levonorgestrel (LNG) hormonal intrauterine device (IUD), 2.76 (2.26-3.35) per 1,000 woman-years; 52-mg LNG hormonal IUD, 0.30 (0.28-0.33) per 1,000 woman-years; combined oral contraception, 0.20 (0.19-0.22) per 1,000 woman-years; progestogen implants, 0.31 (0.26-0.37) per 1,000 woman-years; oral medium-dose progestogen (desogestrel 75 mg), 0.24 per 1,000 woman-years, (0.21-0.27); and oral low-dose progestogen (norethisterone 0.35 mg and lynestrenol 0.5 mg), 0.81 (0.70-0.93) per 1,000 woman-years.Hormonal contraception lowers the risk of ectopic pregnancy markedly. The incidence rate of ectopic pregnancy among women using a low-dose hormonal IUD (13.5 mg LNG) was substantially higher than that in women using other types of hormonal contraception. This study provides real-world evidence to inform best clinical practice for women-centered contraceptive counseling.

The KyleenaThis prospective, observational, multicentre, single-arm cohort study, with 1-year follow-up, was conducted in Belgium, Canada, Germany, Mexico, Norway, Sweden, Spain and the United States from 2017 to 2018. During routine counselling, women who independently selected to use LNG-IUS 12 were invited to participate in the study. KYSS assessed LNG-IUS 12 satisfaction, continuation and safety.Overall, there were 1126 successful LNG-IUS 12 placements, with insertion attempted in 1129 women. Most participants (833/968, 86.1%, 95% CI 83.7-88.2%, with satisfaction outcome data available) reported satisfaction with LNG-IUS 12 at 12 months (or at the final visit if the device was discontinued prematurely). Satisfaction was not associated with age, parity or motivation for choosing LNG-IUS 12. The majority of women (919/1129, 81.4%) chose to continue after 12 months. Discontinuation was not correlated with age or parity. Overall, 191 women (16.9%) reported a treatment-emergent adverse event.Results from KYSS provide the first real-world evidence assessing LNG-IUS 12, and demonstrate high satisfaction and continuation rates irrespective of age or parity.

Objectives: Correct episiotomy use and technique may prevent obstetric anal sphincter injuries. We aimed to explore the attitudes, use, and technique regarding episiotomy among doctors in Sweden, and their willingness to contribute to a randomized controlled trial of lateral episiotomy or no episiotomy in vacuum extraction in nulliparous women. Study design: A web-based survey was sent to members of the Swedish Society of Obstetrics and Gynecology (n = 2140). The survey included 31 questions addressing personal characteristics, use of episiotomy, a two-dimensional picture on which the respondents drew an episiotomy, and questions regarding attitudes towards episiotomy and participation in a randomized controlled trial. We calculated the proportion of supposedly protective episiotomies (fulfilling criteria of a lateral or mediolateral episiotomy and a length >= 30 mm). We compared the results between obstetricians, gynecologists, and residents using Chi-square and Kruskal-Wallis tests for differences between groups, and logistic regression to estimate the odds ratio (OR) of drawing a protective episiotomy. Results: We received 432 responses. Doctors without a vacuum delivery in the past year were excluded, leaving 384 respondents for further analyses. In all, 222 (57.8%) doctors reported use of episiotomy in

Objectives: The primary objective of the study was to investigate whether the choice of long-acting reversible contraception (LARC) was associated with the risk of abortion over a period of 24 months postpartum. The secondary objective was to analyse whether other significant factors were affecting the risk of abortion during this period. Methods: In this retrospective cohort study, we analysed 11,066 women who had delivered in three Swedish cities during 2013 and 2014. Demographic and medical variables were obtained from medical records. Attendance at the postpartum visit, choice of postpartum contraception and history of abortion was noted. Logistic regression analysis was performed to assess factors associated with the risk of abortion. The main outcome measure was the proportion of women with abortion up to 24 months postpartum. Results: Data from 11,066 women were included in the final analysis. Within 12-24 months after delivery 2.5% of women had an abortion. The choice of LARC after childbirth reduced the risk of subsequent abortion (odds ratio 0.74; 95% confidence interval [CI] 0.60, 0.91; p = .005). Smoking, age amp;lt;25 years and have had a previous abortion significantly increased the risk of abortion during follow-up, whereas exclusive breastfeeding decreased the risk. Conclusions: Increasing the proportion of women who choose LARC postpartum could decrease the risk of abortion for up to 2 years after childbirth. Funding Agencies|county council of Ostergotland and county council of Stockholm

ObjectiveThis trial aimed to evaluate effects of structured contraceptive counselling among non-migrants, foreign-born migrants and second-generation migrants.MethodsA cluster randomised controlled trial was conducted in 2017–2019 at abortion, youth and maternal health clinics in Stockholm, Sweden (the LOWE trial). Patients were eligible if they were 18 years or older, could understand Swedish or English (or if assisted by an interpreter), were sexually active or planning to be, and were seeking contraception for pregnancy prevention. We randomised clinics at a 1:1 allocation ratio to give either structured contraceptive counselling (intervention) or to maintain standard contraceptive counselling (control). Blinding was not deemed feasibile. A study-specific package for structured contraceptive counselling was used and comprised an educational video, an effectiveness chart, four key questions and a box with contraceptive models. Outcomes were effects of the intervention on long-acting reversible contraception (LARC) choice, initiation and use, and satisfaction with the intervention material among the participants.ResultsWe involved 14 clinics in each of the intervention and control groups, respectively. A total of 1295 participants were included: 1010 non-migrants, 169 foreign-born migrants and 116 second-generation migrants. Participants in the intervention group chose LARC to a higher extent than the control group (adjusted OR (aOR) 2.85, 95% CI 2.04–3.99), had higher LARC initiation rates (aOR 2.90, 95% CI 1.97 to 4.27) and higher LARC use within the 12-month follow-up period (aOR 2.09, 95% CI 1.47 to 2.96). The majority of the participants who received the intervention package found all the different parts to be supportive in contraceptive choice. The effectiveness chart was the only part of the package that a higher proportion of foreign-born migrants (58/84, 69%) and second-generation migrants (40/54, 74.1%) found supportive in contraceptive choice compared to non-migrants (259/434, 59.7%) (p = 0.048).ConclusionsStructured contraceptive counselling increased LARC choice, initiation and use, controlled for participants’ migration background. The effectiveness chart was found to be significantly more supportive among foreign-born migrants and second-generation migrants compared to non-migrants when choosing contraceptive methods.Trial registration numberNCT03269357.

Sexual risk-taking and its consequences for young women with ADHD(attention deficit hyperactivity disorder) including sexually transmitted diseases, teenage pregnancies and underage parenthood constitute substantial challenges for individuals and midwives. The aim was to investigate current knowledge and specific challenges in reproductive health and contraceptive counselling for women with ADHD at Swedish youth clinics.Inductive qualitative interview study of ten midwives at six youth health clinics in Stockholm and Uppsala County. We used a semi-structured interview guide. The interviews were transcribed verbatim and analyzed with the NVivo 12 qualitative data analysis software.Three main categories were identified: (1) challenges in provision of care of young women with ADHD, (2) standard of care and active adaptations towards women with ADHD and (3) organizational readiness for change;. Several challenges and frustrations, such as difficulties with attention with or without concomitant impulsivity and overactivity, in provision of reproductive health and contraceptive counselling for young women with ADHD were identified. Midwives reported high organizational readiness for improvement of standard of care.Inadequate contraceptive counseling or lack of knowledge on specific challenges in the sexual and reproductive health of young women with ADHD may contribute to this group failing to access, inadequately respond to, or act upon counseling at youth clinics. Support for midwives with evidence-based interventions specifically developed for these women are imperative. Development of such tools should be a priority for research.

To this day combined hormonal contraception is the most common form of contraception and the contraceptive form that most women encounter first. Combined hormonal contraception contains an estrogen and a progestin. These methods are highly user dependent, and the effectiveness of these contraceptives depends on several factors such as user adherence, the regimen in which the method is used, and the progestin half-life. The estrogen in the combined methods provides endometrial stability and improved bleeding patterns. However, the estrogen component also increases the risk of venous thromboembolism. Attempts have been made to reduce this risk by lowering the dose of estrogen but also by using bio-identical estradiol instead of ethinyl estradiol. The type of progestin in the combined methods varies greatly. Different progestins may add to the positive health benefits of the combined methods. Evidence shows that combined methods may alleviate symptoms of polycystic ovarian syndrome and premenstrual dysphoric disorder and reduce acne and menstrual bleeding and cramping. In addition, oral combined contraceptive pills have been shown to reduce risk of ovarian, endometrial, and colorectal cancer which outweigh the slightly increased risk of breast cancer which is only present up to 5–10 years after discontinuation of the method.

Introduction: Intervention trials of structured contraceptive counseling have proved to increase use of long-acting reversible contraceptives (LARCs) and decrease numbers of unintended pregnancies. However, these interventions have not been evaluated from a user perspective. This study aimed to evaluate both healthcare providers’ and participants’ satisfaction with an intervention used in a large trial in Sweden. Material and methods: A cross-sectional study on the intervention group from a cluster randomized trial conducted at 28 clinics in Stockholm, Sweden. Clinics were randomized (1:1 allocation ratio) to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of four parts; an educational video to be seen by the participant prior to contraceptive counseling, key questions to be asked by the healthcare provider, an effectiveness chart, and a box of contraceptive models. Eligible participants were 18 years or older, sexually active without a wish to conceive, and with the main purpose of contraceptive use being pregnancy prevention. Healthcare providers completed an electronic semi-structured survey to evaluate the intervention. This study analyses provider and participant satisfaction with the counseling material used in the intervention and if the intervention was found to be supportive in contraceptive counseling and contraceptive choice. Trial registration: ClinicalTrials.gov (NCT03269357). Results: Fourteen intervention clinics enrolled 658 participants from September 2017 to May 2019. Response rate among providers was 88.0% (55/62) and among participants 97.1% (639/658). Providers found the intervention to be supportive in their counseling. Each separate part of the intervention package received high ratings from both providers and participants. Participants found the educational video and the effectiveness chart to be more helpful than the box of contraceptive models in their contraceptive choice. Providers reported the time taken to complete the intervention outside the study to be time-neutral to standard counseling, and most providers wished to continue to use all parts of the intervention package. Conclusions: The intervention of structured contraceptive counseling had high provider and participant satisfaction. The structured counseling package could be used in several clinical settings to improve quality in contraceptive counseling and to enhance informed decision making about use of contraceptive methods. © 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG)

Background: Digital fertility awareness-based methods of birth control are an attractive alternative to hormonal or invasive birth control for modern women. They are also popular among women who may be planning a pregnancy over the coming years and wish to learn about their individual menstrual cycle. The aim of this study was to assess the effectiveness of the Natural Cycles app at preventing pregnancy for a cohort of women from the United States and to describe the key demographics of current users of the app in such a cohort. Materials and Methods: This prospective real-world cohort study included users who purchased an annual subscription to prevent pregnancy. Demographics were assessed through answers to in-app questionnaires. Birth control effectiveness estimates for the entire cohort were calculated using 1-year pearl index (PI) and 13-cycle cumulative pregnancy probability (Kaplan-Meier life table analysis). Results: The study included 5879 women who contributed an average of 10.5 months of data for a total of 5125 woman-years of exposure. The average user was 30 years old with a body mass index of 24 and reported being in a stable relationship. With typical use, the app had a 13-cycle cumulative pregnancy probability of 7.2% and a 1-year typical use PI of 6.2. When the app was used under perfect use, the PI was 2.0. Conclusions: The data presented in this study give insights into the cohort of women using this app in the United States, and provide country-specific effectiveness estimates. The contraceptive effectiveness of the app was in line with previously published figures from Natural Cycles (PI of seven for typical use and two for perfect use).

Objective To investigate if abortion clinics follow Swedish national guidelines regarding early insertion of long-acting reversible contraception (LARC) after medical abortions up to 9 weeks of gestation and, if not, the reasons for not doing so. Study design We attempted to survey representatives of all 60 known Swedish abortion clinics by telephone in November 2019, including public hospitals and private clinics. We asked questions about clinic characteristics, clinic routines concerning early insertion of IUDs and implants, adherence to guidelines and, when applicable, perceived reasons for nonadherence. Current guidelines include offering implant placement at the time of mifepristone administration and intrauterine device (IUD) insertion within 7 days of misoprostol treatment. Results We obtained responses from 57 (95%) clinics of which 22 (40%) followed guidelines for both implants and IUDs. Slightly more than half (n = 33, 58%) follow implant guidelines and fewer (n = 25, 44%) follow IUD guidelines. Respondents most commonly cited lack of updated local guidelines at the clinic (7/24, 29%) and a perceived lack of time (6/25, 24%) as the most common reasons for nonadherence to guidelines for insertion of implants and insufficient number of nurse midwives for insertion of IUDs 8/32, 25%). Conclusions Less than half of Swedish abortion clinics fully adhere to national evidence-based guidelines regarding early LARC insertion at the time of abortion. Implications National guidelines alone are not always sufficient to effect change in practice; awareness of existing guidelines is needed in Swedish abortion clinics and work is needed to address barriers that limit LARC access after abortion

Purpose: The Kyleena® Satisfaction Study (KYSS) is a prospective, observational study conducted to assess satisfaction with LNG-IUS 12 (Kyleena®) in clinical practice and aims to provide adequate information for counselling women on what to expect regarding insertion and satisfaction.Materials and methods: Women deciding to use LNG-IUS 12 during routine counselling were informed of the study and provided informed consent. A baseline analysis was conducted to evaluate demographics, ease of insertion assessed by investigators, pain at insertion rated by women, additional interventions for insertion, and adverse events.Results: 1,110 women (536 parous, 574 nulliparous) had an insertion attempt and were included. Insertion was rated as easy in 494 (92.2%) parous and 516 (89.9%) nulliparous women. Pain was assessed as none or mild by 475 (88.6%) parous and 387 (67.4%) nulliparous women. Additional interventions were not required for most insertions (705; 63.6%). Overall 111 (10.0%) women reported adverse events at the time of baseline analysis.Conclusions: This analysis demonstrates that LNG-IUS 12 insertion is easy and associated with no or mild pain in most women. Additional interventions for insertion are not required in most cases. After 3 months, the number of adverse events is low.Implications: The present baseline analysis of the Kyleena® Satisfaction Study (KYSS) demonstrates that most women rate insertion pain of LNG-IUS 12 as none or mild and clinicians consider insertion easy in the majority of cases. ispartof: EUROPEAN JOURNAL OF CONTRACEPTION AND REPRODUCTIVE HEALTH CARE vol:25 issue:3 pages:182-189 ispartof: location:England status: published

Objectives The objective of this study was to determine the cost of unintended pregnancy (UP) in Sweden and savings generated by a switch of 5% of women from short-acting reversible contraception (SARC) and other methods to long-acting reversible contraceptives (LARCs). Study design We constructed an economic model to estimate the number and costs of UPs and contraceptive use over a 1-year period. The population consisted of all women aged 15–44 years requiring reversible contraception and at risk of UP. UPs could result in birth, spontaneous abortion, induced abortion, and ectopic pregnancy. The model included costs incurred by the healthcare payer or out-of-pocket expenses by women, and indirect costs, i.e., foregone wages from time away from work. Results We estimated 73,989 unintended pregnancies yearly, amounting to costs of almost €158 million. A 5% switch from non-LARCs to LARCs would generate more than 3500 fewer UPs yearly with savings of nearly €7.7 million. The majority of these savings would arise from reduced costs for UPs. Conclusions UPs are costly for society and women. A small change in the proportion of women using the most effective methods generates substantial cost savings due to fewer UPs and thus fewer abortions. A switch in 5% of women using non-LARCs could prevent more than 3500 UPs yearly, generating savings of more than SEK 70 million (€7.7 million) or of 2.4% of costs for UPs.

Objectives: Approximately, 1–2% of all pregnancies are ectopic; 25% of unintended pregnancies are conceived despite the use of contraception. The primary objective of our study was to explore the proportion of ectopic pregnancies (EPs) that were conceived during contraceptive use among women in Stockholm County. Secondary objectives were to establish the prevalence of contraceptive methods used at the time of EP and the intended contraceptive method after treatment completion. Methods: We performed a retrospective cohort study of 1180 women diagnosed with and treated for EP between 1 December 2013 and 30 April 2017 at all hospitals in Stockholm County. Demographic variables and contraceptive use before and after treatment were noted. Exclusion criteria were uncertainty about the diagnosis of EP in the patient records and planned treatment/follow-up outside Stockholm County. Results: A total of 222/1180 (18.8%) EPs were conceived during known contraceptive use. A total of 112/222 (50.5%) women with known use of contraception at the time of conception discontinued contraceptive use and 81/857 (9.5%) women with no prior use of contraception initiated contraceptive use. Among the 857 women, 520 (60.7%) expressed a desire to conceive. Results were compared using the Mann–Whitney U test or Fisher's exact test as appropriate. Conclusion: EP occurring during use of contraception is an unexplored problem. Contraceptive use decreased in women who were using contraception at the time of EP conception, leaving these women at risk of a subsequent unintended pregnancy. There should be more focus on contraceptive use after treatment for EP, in order to preserve fertility. 目的：大约所有妊娠的1-2％为异位妊娠；尽管使用了避孕措施, 仍有25％概率会意外怀孕。我们研究的主要目的是探讨斯德哥尔摩县妇女在使用避孕药具期间异位妊娠（EPs）的比例。次要目的是确定EP时使用的避孕方法的普及程度以及治疗完成后计划使用的避孕方法。 方法：我们对2013年12月1日至2017年4月30日期间在斯德哥尔摩县所有医院诊断为EP并接受过EP治疗的1180名妇女进行了一项回顾性队列研究。 记录治疗前后的人口统计学变量和避孕药具的使用。排除标准是患者记录中有关EP诊断的不确定性以及斯德哥尔摩县以外地区计划的治疗/随访。 结果：在所有1180例异位妊娠患者中, 已知使用避孕药具的有222（占18.8％）, 共有112/222（50.5％）名妇女在受孕时知道怀孕并停止使用避孕药具, 而81/857名（9.5％）未事先避孕的妇女开始使用避孕药具。在857名妇女中, 有520名（60.7％）表达了受孕的愿望。视情况使用Mann-Whitney U检验或Fisher精确检验比较结果。 结论：在使用避孕药过程中发生EP是一个尚待探讨的问题。使用避孕药具的妇女EP后继续使用避孕药具减少, 使这些妇女处于随后意外怀孕的风险中。为了保护生育力, 应在治疗EP后更注意避孕药具的使用

BackgroundWomen are advised to primarily use non-oral contraceptive alternatives after Roux-en-Y gastric bypass since it is not known if the surgery affects the pharmacokinetics of oral contraceptives.MethodsThis is a multi-center, open label, phase 2 pharmacokinetic study performed at the University Hospital of Linköping and the Clinical Trials Center, Department of Obstetrics and Gynecology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden. Fifteen women aged 18–40 years who had previously undergone Roux-en-Y gastric bypass surgery and reached a BMI 0–24h) was the main outcome measure.ResultsThere were no significant differences in the studied pharmacokinetic parameters, AUC0–24h, total AUC, peak serum concentration (Cmax), time to peak serum concentrations (Tmax), apparent oral clearances of levonorgestrel (CLoral), or terminal half-lives (t½) between the groups.ConclusionThis is to our knowledge the first study to evaluate the pharmacokinetics of oral levonorgestrel in women with a BMI Clinical Trial NumberEudraCT 2014–004677-17.

Objective: The aim of the study was to compare the effect of previously used contraceptive methods on women's short- and long-term fecundity. Use of hormonal contraception (HC) was compared with the use of a contraceptive mobile application (app). Methods: This real-life prospective observational study comprised 2874 women who were attempting to become pregnant using the Natural Cycles mobile app to monitor their fertility. The women registered to use the app between August 2014 and June 2016 with the intention of planning a pregnancy and had previously either used the same app to prevent pregnancy or had recently discontinued HC use. We calculated the average time to pregnancy (TTP) for all women who became pregnant during the study and performed Kaplan-Meier life-table analysis to examine the cumulative probabilities of pregnancy for all women in the study. Results: The average TTP was 2.3 (95% confidence interval [CI] 2.1, 2.4) and 3.7 (95% CI 3.4, 3.9) cycles for women who had previously used Natural Cycles and HC, respectively. The time to reach 30% pregnancy probability for women previously on HC was 1.6 (95% CI 1.5, 1.8) times longer than for women previously using Natural Cycles. There was no significant difference in the 13 cycle cumulated pregnancy probability between the two groups. Conclusion: The results show that fertility awareness-based methods of contraception increase short-term pregnancy rates relative to HC, but have no effect on long-term pregnancy rates.

The aim of the study was to compare the results of a 2013 nationwide survey of 1001 women representative of the Swedish female population with the results of a similar survey carried out in 2017, after new guidelines for contraceptive use were published in 2014.Women between 16 and 49 years of age took part in a telephone survey; questions covered demographics, contraceptive use, knowledge of and attitudes towards contraception, importance of monthly bleeding, and experience of unintended pregnancy. We compared the responses collected in 2013 with those collected in 2017.Of all women in 2017, 717/1008 (71.1%) were currently using contraception; 291/1008 (28.9%) women were not. Long-acting reversible contraception (LARC) was used by 311/1008 (30.9%) women, which was a significant increase from 2013 (243/1001, 24.3%; p = .001). The unmet need for contraception in Sweden in 2017 was estimated to be 15.2%. A total of 783 (77.7%) women had never experienced an unintended pregnancy. A significantly higher proportion of unintended pregnancies reported in 2017 were terminated compared with 2013.Sweden has a large unmet need for contraception. In 2017, LARC use had increased compared with 2013. A large proportion of women had experienced an unintended pregnancy. Increasing overall contraceptive use is important to reduce the rates of unintended and unwanted pregnancies.

OBJECTIVES: This study aims to determine the effects of transurethral polyacrylamide hydrogel injection in patients considered ineligible for midurethral sling surgery. METHODS: In this prospective observational study, 81 patients received treatment with transurethral polyacrylamide hydrogel injection. Patients were considered ineligible for placement of a midurethral sling based on significant comorbidity (48%), 1 or more previously failed invasive treatments (16%), mixed urinary incontinence (27%), continuous incontinence (5%), or previous pelvic radiation therapy (4%). Longitudinal assessment of subjective treatment outcomes was performed using the validated Urinary Distress Inventory (UDI) and the Pelvic Floor Impact Questionnaire at baseline, 2, and 6 months. To deal with repeated measurements, mixed linear models were used to assess changes in the outcomes over time. RESULTS: There was a significant improvement in the overall UDI score from baseline to month 2 follow-up (FU) (P