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From 2015 to 2018, the Ethiopian Society of Obstetricians & Gynecologists (ESOG), the American College of Obstetricians and Gynecologists, the Ethiopian Federal Ministry of Health, and the Center for International Reproductive Health Training at the University of Michigan collaborated to define and execute the goals of ESOG to enhance education, research, publishing, and clinical care in Ethiopia. We outline the processes used to define and execute these goals, accomplishments toward achieving them, and key lessons learned.

The launch of the United Nations Sustainable Development Goals and the new Secretary General's Global Strategy for Women's, Children's, and Adolescents' Health are a window of opportunity for improving the health and well-being of women, children, and adolescents in the United States and around the world. Realizing the full potential of this historic moment will require that we improve our ability to successfully implement life-saving and life-enhancing innovations, particularly in low-resource settings. Implementation science, a new and rapidly evolving field that addresses the "how-to" component of providing sustainable quality services at scale, can make an important contribution on this front. A synthesis of the implementation science evidence indicates that three interrelated factors are required for successful, sustainable outcomes at scale: 1) effective innovations, 2) effective implementation, and 3) enabling contexts. Implementation science addresses the interaction among these factors to help make innovations more usable, to build ongoing capacity to assure the effective implementation of these innovations, and to ensure enabling contexts to sustain their full and effective use in practice. Improving access to quality services will require transforming health care systems and, therefore, much of the focus of implementation science in global health is on improving the ability of health systems to serve as enabling contexts. The field of implementation science is inherently interdisciplinary and academe will need to respond by facilitating collaboration among scientists from relevant disciplines, including evaluation, improvement, and systems sciences. Platforms and programs to facilitate collaborations among researchers, practitioners, policymakers, and funders are likewise essential.

Objective To evaluate obstetrics and gynecology resident interest and participation in global health experiences and elucidate factors associated with resident expectation for involvement. Methods A voluntary, anonymous survey was administered to U.S. obstetrics and gynecology residents before the 2015 Council on Resident Education in Obstetrics and Gynecology in-training examination. The 23-item survey gathered demographic data and queried resident interest and participation in global health. Factors associated with resident expectation for participation in global health were analyzed by Pearson χ tests. Results Of the 5,005 eligible examinees administered the survey, 4,929 completed at least a portion of the survey for a response rate of 98.5%. Global health was rated as "somewhat important" or "very important" by 96.3% (3,761/3,904) of residents. "Educational opportunity" (69.2%) and "humanitarian effort" (17.7%) were cited as the two most important aspects of a global health experience. Residents with prior global health experience rated the importance of global health more highly and had an increased expectation for future participation. Global health electives were arranged by residency programs for 18.0% (747/4,155) of respondents, by residents themselves as an elective for 44.0% (1,828/4,155), and as a noncredit experience during vacation time for 36.4% (1,514/4,155) of respondents. Female gender, nonpartnered status, no children, prior global health experience, and intention to incorporate global health in future practice were associated with expectations for a global health experience. Conclusion Most obstetrics and gynecology residents rate a global health experience as somewhat or very important, and participation before or during residency increases the perceived importance of global health and the likelihood of expectation for future participation. A majority of residents report arranging their own elective or using vacation time to participate, suggesting that residency programs have limited structured opportunities.

Background. The Collaborative Group on Hormonal Factors in Breast Cancer has brought together and reanalysed about 90% of the worldwide epidemiological evidence on the relation between risk of breast cancer and use of hormone replacement therapy (HRT). Methods. Individual data on 52,705 women with breast cancer and 108,411 women without breast cancer from 51 studies in 21 countries were collected, checked, and analysed centrally. The main analyses are based on 53,865 postmenopausal women with a known age at menopause, of whom 17,830 (33%) had used HRT at some time. The median age at first use was 48 years, and 34% of ever-users had used HRT for 5 years or longer. Estimates of the relative risk of breast cancer associated with the use of HRT were obtained after stratification of all analyses by study, age at diagnosis, time since menopause, body-mass index, parity, and the age a woman was when her first child was born. Findings. Among current users of HRT or those who ceased use 1-4 years previously, the relative risk of having breast cancer diagnosed increased by a factor of 1.023 (95% CI 1.011-1.036; 2p = 0.0002) for each year of use; the relative risk was 1.35 (1.21-1.49; 2p = 0.00001) for women who had used HRT for 5 years or longer (average duration of use in this group 11 years). This increase is comparable with the effect on breast cancer of delaying menopause, since among never-users of HRT the relative risk of breast cancer increases by a factor of 1.028 (95% CI 1.021-1.034) for each year older at menopause. 5 or more years after cessation of HRT use, there was no significant excess of breast cancer overall or in relation to duration of use. These main findings did not vary between individual studies. Of the many factors examined that might affect the relation between breast cancer risk and use of HRT, only a woman's weight and body-mass index had a material effect: the increase in the relative risk of breast dancer associated with long durations of use in current and recent users was greater for women of lower than of higher weight or body-mass index. There was no marked variation in the results according to hormonal type or dose but little information was available about long durations of use of any specific preparation. Cancers diagnosed in women who had ever used HRT tended to be less advanced clinically than those diagnosed in never-users. In North America and Europe the cumulative incidence of breast cancer between the ages of 50 and 70 in never-users of HRT is about 45 per 1000 women. The cumulative excess numbers of breast cancers diagnosed between these ages per 1000 women who began use of HRT at age 50 and used it for 5, 10, and 15 years, respectively, are estimated to be 2 (95% CI 1-3), 6 (3-9), and 12 (5-20). Whether HRT affects mortality from breast cancer is not known. Interpretation. The risk of having breast cancer diagnosed is increased in women using HRT and increases with increasing duration of use. This effect is reduced after cessation of use of HRT and has largely, if not wholly, disappeared after about 5 years. These findings should be considered in the context of the benefits and other risks associated with the use of HRT.

Summary Increasing contraceptive use in developing countries has cut the number of maternal deaths by 40% over the past 20 years, merely by reducing the number of unintended pregnancies. By preventing high-risk pregnancies, especially in women of high parities, and those that would have ended in unsafe abortion, increased contraceptive use has reduced the maternal mortality ratio—the risk of maternal death per 100 000 livebirths—by about 26% in little more than a decade. A further 30% of maternal deaths could be avoided by fulfilment of unmet need for contraception. The benefits of modern contraceptives to women's health, including non-contraceptive benefits of specific methods, outweigh the risks. Contraception can also improve perinatal outcomes and child survival, mainly by lengthening interpregnancy intervals. In developing countries, the risk of prematurity and low birthweight doubles when conception occurs within 6 months of a previous birth, and children born within 2 years of an elder sibling are 60% more likely to die in infancy than are those born more than 2 years after their sibling.

Recommendations shaping policies, programs, and practices in global health should be based on the best available science, but how best to achieve this objective is less clear. We describe a new approach developed by the United Nations Development Programme/United Nations Population Fund/World Health Organization/World Bank Special Programme of Research, Development and Research Training in Human Reproduction within the World Health Organization Department of Reproductive Health and Research for addressing key challenges in global reproductive health. This approach leads to new recommendations for accelerating solutions to priority needs in the field and continued improvements in the science base-including the implementation science base-for meeting these needs. The key components of this new cycle for science-driven solutions include: 1) identifying priority needs of the field; 2) creating guidance that meets the needs of the field; 3) identifying research gaps and establishing and funding research priorities; 4) research synthesis and updating of the guidance in a timely fashion; and 5) supporting utilization in countries through systematic introduction of science-driven solutions. There is a synergistic effect when the contributions of the individual components of this cycle are linked. Strong institutional support is required for this collective effort, as is the creation of a team of researchers, practitioners, donors, and implementing agencies with shared responsibilities for its success. This new approach has already made important contributions toward addressing key challenges in family planning and maternal and perinatal health. We believe that it will help bridge the gap between knowledge and action for reproductive health and for global health more broadly.

Background The Centers for Disease Control and Prevention (CDC) recently adapted global guidance on contraceptive use from the World Health Organization (WHO) to create the United States Medical Eligibility Criteria for Contraceptive Use (MEC). This guidance includes recommendations for use of specific contraceptive methods by people with certain characteristics or medical conditions. Study Design CDC determined the need and scope for the adaptation, conducted 12 systematic reviews of the scientific evidence and convened a meeting of health professionals to discuss recommendations based on the evidence. Results The vast majority of the US guidance is the same as the WHO guidance and addresses over 160 characteristics or medical conditions. Modifications were made to WHO recommendations for six medical conditions, and recommendations were developed for six new medical conditions. Conclusion The US MEC is intended to serve as a source of clinical guidance for providers as they counsel clients about contraceptive method choices.

Symptoms of nausea and vomiting in early pregnancy (NVP) are common among pregnant women, but whether some women are more likely than others to experience these symptoms has not been well established. We examined potential risk factors for NVP symptom severity, timing of onset, and duration. We included 2,407 newly pregnant women who participated in a prospective cohort study on early pregnancy health between 2000 and 2004 in three U.S. cities. Data on NVP and other health information were collected through telephone interviews, early gestation ultrasound, and medical record abstractions. Generalized linear models were used to model possible risk factors for each NVP characteristic. Eighty-nine percent of women had NVP; for 99% of these, symptoms started in the first trimester. None of the characteristics examined were associated with having NVP. Among those with NVP, increasing risk of delayed symptoms onset was associated with advancing maternal age; increased risks were also seen among non-Hispanic Black [Risk ratio (RR) = 4.3, 95% confidence interval (CI): 1.6,11.6] and Hispanic women (RR = 2.3, 95% CI:0.4,11.5). NVP symptoms for multigravidae were more likely to last beyond the first trimester with each additional pregnancy. Most pregnant women experienced NVP. Nearly all of them, regardless of characteristics examined, had symptoms beginning in the first trimester. Maternal age, race/ethnicity, and gravidity were associated with delayed onset and symptoms that persisted into the second trimester.

Worldwide, sterilization (tubal sterilization and vasectomy) is used by more people than any other method of contraception. All techniques of tubal sterilization in widespread use in the United States have low risks of surgical complications. Although tubal sterilization is highly effective, the risk of pregnancy varies by age and method of occlusion. Pregnancies can occur many years after the procedure, and when they do, the risk of ectopic gestation is high. There is now strong evidence against the existence of a post-tubal ligation syndrome of menstrual abnormalities. Although women who have undergone tubal sterilization are more likely than other women to undergo hysterectomy subsequently, there is no known biologic basis for this relationship. Although sterilization is intended to be permanent, expressions of regret and requests for reversal are not uncommon and are much more likely to occur among women sterilized at young ages. Tubal sterilization has little or no effect on sexual function for most women. Vasectomy is less likely than tubal sterilization to result in serious complications. Minor complications, however, are not uncommon. Vasectomy does not increase the risk of heart disease, and available evidence argues against an increase in the risk of prostate cancer, testicular cancer, or overall mortality. Whether a postvasectomy pain syndrome exists remains controversial. Although the long-term effectiveness of vasectomy is less well-studied than that for tubal sterilization, it seems likely to be at least as effective. Intrauterine devices and progestin implants are long-acting, highly effective alternatives to sterilization.

To assess the ectopic pregnancy risk among women who conceived with assisted reproductive technology (ART) procedures.The ectopic rate for ART pregnancies was calculated from population-based data of pregnancies conceived with ART in U.S. clinics in 1999-2001. Variation in ectopic risk by patient and ART treatment factors was assessed by using bivariate analyses and multivariable logistic regression.Of 94,118 ART pregnancies, 2,009 (2.1%) were ectopic. Variation was observed by procedure type. In comparison with the ectopic rate (2.2%) among pregnancies conceived with in vitro fertilization and transcervical transfer of freshly fertilized embryos from the patient's oocytes (fresh, nondonor IVF-ET), the ectopic rate was significantly increased when zygote intrafallopian transfer (ZIFT) was used (3.6%) and significantly decreased when donor oocytes were used (1.4%) or when a gestational surrogate carried the pregnancy (0.9%). Among fresh nondonor IVF-ET procedures, the risk for ectopic pregnancy was increased among women with tubal factor infertility (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.7-2.4; referent group = ART for male factor), endometriosis (OR 1.3, 95% CI 1.0-1.6), and other nontubal female factors of infertility (OR 1.4, 95% CI 1.2-1.6) and decreased among women with a previous live birth (OR 0.6, 95% CI 0.5-0.7). Transfer of embryos with an indication of high implantation potential was associated with a decreased ectopic risk when 2 or fewer embryos were transferred (OR 0.7, 95% CI 0.5-0.9), but not when 3 or more embryos were transferred.Ectopic risk among ART pregnancies varied according to ART procedure type, reproductive health characteristics of the woman carrying the pregnancy, and estimated embryo implantation potential.II-2.

To review evidence on the combined hormonal patch, combined hormonal vaginal ring and the etonogestrel implant, with a focus on safety and effectiveness of use among women with special health conditions, we searched MEDLINE, Pre-MEDLINE and the Cochrane Library for reports published from 1980 through March 2005. Articles eligible for review included 11 on the hormonal patch, nine on the hormonal ring, and 11 on the etonogestrel implant. Limited evidence suggests patch efficacy is lower among women >90 kg. No evidence was identified for vaginal ring use among women with medical conditions. A single small study found that etonogestrel implants had no adverse effects on bone mineral density among women 18–40 years old. Limited evidence also suggests no adverse effects of the etonogestrel implant on lactation parameters or infant development among users enrolled 28 to 56 days postpartum and followed for 4 months.

This systematic review examines evidence regarding when during the menstrual cycle a woman can initiate combined oral contraceptive (COC) use and what can be done if a woman misses COCs. We searched the MEDLINE and EMBASE databases for articles published from 1966 to March 2005 related to COC initiation and to the effects of late or missed COCs. We identified 11 studies related to COC initiation and 25 studies related to the effects of missed pills. Evidence from these studies suggested that taking hormonally active pills for 7 consecutive days prevents normal ovulation and that initiating COCs through Day 5 of the menstrual cycle suppresses follicular activity. Studies on the effects of missed COCs generally showed that the risk of ovulation is greatest when the pill-free interval lasts >7 days. Limitations of this body of evidence include small sample sizes that may not reflect variation in larger populations, lack of a standard measurement of ovulation and difficulty in discerning how ovulation resulting from late or missed COCs corresponds to the risk of conception.

Our objective in this systematic review was to evaluate evidence regarding controversial issues in the clinical management of women using injectable and implantable contraceptives. We searched MEDLINE and EMBASE for reports of primary research, published from 1966 through April 2005 in peer-reviewed journals, related to the initiation of combined or progestogen-only injectables and contraceptive implants, the effects of late contraceptive injections or the duration of levonorgestrel implant effectiveness. Results of the studies we reviewed showed that initiating injectable and implantable contraceptives through day 7 of the menstrual cycle suppresses follicular activity. Time to ovulation after study participants discontinued using injectables varied widely: from 4 to 8 weeks after the last administration of combined injectables, from 15 to 49 weeks after the last injection of depot medroxyprogesterone acetate and from 5 to 19 weeks after the last injection of norethisterone enanthate. Norplant implants left in place for up to seven completed years remained effective among women who weighed

Women who undergo sterilization may later regret this decision. This systematic review examines whether age at sterilization is associated with poststerilization regret. Using MEDLINE and EMBASE, we identified 19 articles that examined associations between women's age at sterilization and later regret, requests for sterilization reversal and undergoing sterilization reversal or requesting in vitro fertilization (IVF) procedures. Study results showed that the younger women were at the time of sterilization, the more likely they were to report regretting that decision. Women undergoing sterilization at the age 30 years or younger were about twice as likely as those over 30 to express regret. They were also from 3.5 to 18 times as likely to request information about reversing the procedure and about 8 times as likely to actually undergo reversal or an evaluation for IVF. Results of studies that examined risk by continuous age showed a consistent inverse relationship between women's age at sterilization and their likelihood of regretting having had the procedure.

A healthy, multiparous 23-year-old woman requests advice about contraception. Her last child was conceived while she was using oral contraceptives, which she took irregularly. She wants no more children and desires a highly effective and long-acting method of contraception. She is sexually active in a monogamous relationship and had been treated for gonococcal cervicitis at the age of 16 years. She has normal menses. Findings on pelvic examination are normal. What contraceptive methods are appropriate for her?.

To examine perinatal outcome among singleton infants conceived with assisted reproductive technology (ART) in the United States.Subjects were 62,551 infants born after ART treatments performed in 1996-2000. Secular trends in low birth weight (LBW), very low birth weight (VLBW), preterm delivery, preterm LBW, and term LBW were examined. Detailed analyses were performed for 6,377 infants conceived in 2000. Observed numbers were compared with expected using a reference population from the 2000 U.S. natality file. Adjusted risk ratios were calculated.The proportion of ART singletons born LBW, VLBW, and term LBW decreased from 1996 to 2000. The proportion delivered preterm and preterm LBW remained stable. After adjustment for maternal age, parity, and race/ethnicity, singleton infants born after ART in 2000 had elevated risks for all outcomes in comparison with the general population of U.S. singletons: LBW standardized risk ratio 1.62 (95% confidence interval 1.49, 1.75), VLBW 1.79 (1.45, 2.12), preterm delivery 1.41 (1.32, 1.51), preterm LBW 1.74 (1.57, 1.90), and term LBW 1.39 (1.19, 1.59). Risk ratios for each outcome remained elevated after restriction to pregnancies with only 1 fetal heart or any of 7 other categories: parental infertility diagnosis of male factor, infertility diagnosis of tubal factor, conception using in vitro fertilization without intracytoplasmic sperm injection or assisted hatching, conception with intracytoplasmic sperm injection, conception in a treatment with extra embryos available, embryo culture for 3 days, and embryo culture for 5 days.Singletons born after ART remain at increased risk for adverse perinatal outcomes; however, risk for term LBW declined from 1996 to 2000, whereas preterm LBW was stable.III

To examine rates and risk factors for spontaneous abortion among pregnancies conceived using assisted reproductive technology (ART).Subjects were 62,228 clinical pregnancies resulting from ART procedures initiated in 1996-1998 in US clinics. Spontaneous abortion was based on ART clinic report and was defined as loss of the entire pregnancy. Spontaneous abortion rates for ART pregnancies were compared with spontaneous abortion rates from the National Survey of Family Growth, a population-based survey of US women 15-44 years.The spontaneous abortion rate among ART pregnancies was 14.7%. This was similar to rates among pregnancies reported in the National Survey of Family Growth. Among pregnancies conceived with the patient's oocytes and freshly fertilized embryos, the spontaneous abortion risk ranged from 10.1% among women 20-29 years to 39.3% among women older than 43. Spontaneous abortion risk among pregnancies conceived with donor eggs was 13.1% with little variation by patient age. Spontaneous abortion risk was increased for pregnancies conceived with frozen and thawed embryos and decreased among multiple-gestation pregnancies. Spontaneous abortion risk was increased among women reporting previous spontaneous abortions and ART attempts, and among women who used clomiphene or zygote intrafallopian transfer. Pregnancies conceived by young women, but gestated by a surrogate, were at increased risk for spontaneous abortion in comparison with young women who gestated their own pregnancies.These findings suggest that ART does not pose a risk for spontaneous abortion. Factors related to oocyte or embryo quality are of primary importance in assessing spontaneous abortion risk.

Objective To examine rates and risk factors for spontaneous abortion among pregnancies conceived using assisted reproductive technology (ART). Methods Subjects were 62,228 clinical pregnancies resulting from ART procedures initiated in 1996–1998 in US clinics. Spontaneous abortion was based on ART clinic report and was defined as loss of the entire pregnancy. Spontaneous abortion rates for ART pregnancies were compared with spontaneous abortion rates from the National Survey of Family Growth, a population-based survey of US women 15–44 years. Results The spontaneous abortion rate among ART pregnancies was 14.7%. This was similar to rates among pregnancies reported in the National Survey of Family Growth. Among pregnancies conceived with the patient’s oocytes and freshly fertilized embryos, the spontaneous abortion risk ranged from 10.1% among women 20–29 years to 39.3% among women older than 43. Spontaneous abortion risk among pregnancies conceived with donor eggs was 13.1% with little variation by patient age. Spontaneous abortion risk was increased for pregnancies conceived with frozen and thawed embryos and decreased among multiple-gestation pregnancies. Spontaneous abortion risk was increased among women reporting previous spontaneous abortions and ART attempts, and among women who used clomiphene or zygote intrafallopian transfer. Pregnancies conceived by young women, but gestated by a surrogate, were at increased risk for spontaneous abortion in comparison with young women who gestated their own pregnancies. Conclusion These findings suggest that ART does not pose a risk for spontaneous abortion. Factors related to oocyte or embryo quality are of primary importance in assessing spontaneous abortion risk.

The objective of this study is to determine if interval tubal sterilization leads to a change in female sexual interest or pleasure and to identify predictors of a positive or negative effect. The study population comprised 4576 women enrolled in a prospective multicenter cohort study between 1978 and 1983. Potential demographic clinical and surgical predictors of sexual outcome were tested for significant variation from the overall pattern of unchanged increased and decreased sexual interest and pleasure. Over 80% of the 4576 study women reported no consistent change in either sexual interest (80.0%) or pleasure (81.7%) after interval tubal sterilization. Among women with consistent change positive effects were reported 10 and 15 times more often than negative effects for sexual interest and pleasure respectively. All subgroups of women except for those with post-sterilization regret were significantly (P < 0.05) more likely to experience increased rather than decreased interest or pleasure. Women with post-sterilization regret were the subgroup most likely to have a negative effect; in multivariate analyses post-sterilization regret was the only factor to be a predictor for decreased interest (odds ratio 4.0) and decreased pleasure (odds ratio 5.1). Similarly women reporting regret were significantly less likely to report increased interest or pleasure. Whether the regret or the decreased sexual interest or pleasure occurred first is unclear. Interval tubal ligation is unlikely to result in changed sexual interest or pleasure. Among these with change the majority experienced positive sexual effects. (authors)

OBJECTIVE: To compare the 5-year cumulative probability of regret and risk factors for regret among women whose husbands underwent vasectomy with women after tubal sterilization. METHODS: A total of 525 women whose husbands underwent vasectomy were compared with 3672 women who underwent tubal sterilization in a prospective, multicenter, cohort study. RESULTS: The cumulative probability of a woman expressing regret within 5 years after her husband’s vasectomy was 6.1% (95% confidence interval [CI] 3.6, 8.6), which was similar to the 5-year cumulative probability of regret among women after tubal sterilization (7.0%, 95% CI 5.8, 8.1). Women who reported substantial conflict with their husbands before vasectomy were more than 25 times more likely to request that their husband have a reversal than women who did not report such conflict (rate ratio 25.3, 95% CI 2.9, 217.2). Similarly, women who reported substantial conflict with their husbands or partners before tubal sterilization were more then three times as likely to regret their decision and more than five times as likely to request a reversal than women who did not report such conflict (rate ratio 3.1, 95% CI 1.4, 7.0, and rate ratio 5.4, 95% CI 1.6, 17.6, respectively). CONCLUSION: Most women did not express regret after their husband’s vasectomy and the probability of regret was similar to sterilized women. However, when there was substantial conflict between a woman and her husband before vasectomy or tubal sterilization, the probability of subsequent request for reversal was increased.

OBJECTIVE: To review new evidence regarding ten controversial issues in the use of contraceptive methods among women with special conditions and to present World Health Organization recommendations derived in part from this evidence. DATA SOURCES: We searched MEDLINE and PREMEDLINE databases for English-language articles, published between January 1995 and December 2001, for evidence relevant to ten key contraceptive method and condition combinations: combined oral contraceptive (OC) use among women with hypertension or headaches, combined OC use for emergency contraception and adverse events, progestogen-only contraception use among young women and among breast-feeding women, tubal sterilization among young women, hormonal contraception and intrauterine device use among women who are human immunodeficiency virus (HIV) positive, have AIDS, or are at high risk of HIV infection. Search terms included: “contraception,” “contraceptives, oral,” “progestational hormones,” “medroxyprogesterone-17 acetate,” “norethindrone,” “levonorgestrel,” “Norplant,” “contraceptives, postcoital,” “sterilization, tubal,” “intrauterine devices,” “hypertension,” “stroke,” “myocardial infarction,” “thrombosis,” “headache,” “migraine,” “adverse effects,” “bone mineral density,” “breast-feeding,” “lactation,” “age factors,” “regret,” and “HIV.” STUDY SELECTION: From 205 articles, we identified 33 studies published in peer-reviewed journals that specifically examined risks of contraceptive use among women with pre-existing conditions. TABULATION, INTEGRATION, AND RESULTS: Combined OC users with hypertension appear to be at increased risk of myocardial infarction and stroke relative to users without hypertension. Combined OC users with migraine appear to be at increased risk of stroke relative to nonusers with migraine. The evidence for the other eight method and condition combinations was either insufficient to draw conclusions or identified no excess risk. CONCLUSION: Of ten contraceptive method and condition combinations assessed, the evidence supported an increased risk of cardiovascular complications with combined OC use by women with hypertension or migraine. As new evidence becomes available, assessment of risk and recommendations for use of contraceptive methods can be revised accordingly.

Objective: To determine risk factors for pregnancy after tubal sterilization with silicone rubber bands or spring clips. Methods: A total of 3329 women sterilized using silicone rubber bands and 1595 women sterilized using spring clips were followed for up to 14 years as part of a prospective cohort study conducted in medical centers in nine US cities. We assessed the risk of pregnancy by cumulative life-table probabilities and proportional hazards analysis. Results: The risk of pregnancy for women who had silicone rubber band application differed by location of band application and study site. The 10-year cumulative probabilities of pregnancy varied from a low of 0.0 per 1000 procedures at one study site to a high of 42.5 per 1000 procedures in the four combined sites in which fewer than 100 procedures per site were performed. The risk of pregnancy for women who had spring clip application varied by location of clip application, study site, race or ethnicity, tubal disease, and history of abdominal or pelvic surgery. The probabilities across study sites ranged from 7.1 per 1000 procedures at 10 years to 78.0 per 1000 procedures at 5 years (follow-up was limited to 5 years at that site). Conclusion: The 10-year cumulative probability of pregnancy after silicone rubber band and spring clip application is low but varies substantially by both clinical and demographic characteristics.

Background The existence of a post–tubal-ligation syndrome of menstrual abnormalities has been debated for decades. We used data from the U.S. Collaborative Review of Sterilization to determine whether the likelihood of persistent menstrual abnormalities was greater among women who had undergone tubal sterilization than among women who had not. Methods A total of 9514 women who underwent tubal sterilization and 573 women whose partners underwent vasectomy were followed in a multicenter, prospective cohort study for up to five years by means of annual telephone interviews. All women were asked the same questions about six characteristics of their menstrual cycles in the presterilization and follow-up interviews. Multiple logistic-regression analysis was used to assess the risk of persistent menstrual changes. Results The women who had undergone sterilization were no more likely than those who had not undergone the procedure to report persistent changes in intermenstrual bleeding or the length of the menstr...

Objective: To estimate the risk of intraoperative or postoperative complications for interval laparoscopic tubal sterilizations. Methods: We used a prospective, multicenter cohort study of 9475 women who had interval laparoscopic tubal sterilization to calculate the rates of intraoperative or postoperative complications. The relative safety of various methods was assessed by calculating overall complication rates for each major method of tubal occlusion. Method-related complication rates also were calculated and included only complications attributable to a method of occlusion. We used logistic regression to identify independent predictors of one or more complications. Results: When we used a more restrictive definition of unintended major surgery, the overall rate of complications went from 1.6 to 0.9 per 100 procedures. There was one life-threatening event and there were no deaths. Complications rates for each of the four major methods of tubal occlusion ranged from 1.17 to 1.95, with no significant differences between them. When complication rates were calculated, the spring clip method had the lowest method-related complication rate (0.47 per 100 procedures), although it was not significantly different from the others. In adjusted analysis, diabetes mellitus (adjusted odds ratio [OR] 4.5; 95% confidence interval [CI] 2.3, 8.8), general anesthesia (OR 3.2; CI 1.6, 6.6), previous abdominal or pelvic surgery (OR 2.0; CI 1.4, 2.9), and obesity (OR 1.7; CI 1.2, 2.6) were independent predictors of one or more complications. Conclusion: Interval laparoscopic sterilization generally is a safe procedure; serious morbidity is rare.

Objective: To examine the association between assisted hatching and monozygotic (MZ) twinning. Design: Case-control. Setting: Population-based sample of IVF-ET cycles initiated in U.S. clinics, 1996. Patient(s): The IVF-ET (n = 35,503) cycles and 11,247 resultant pregnancies. Intervention(s): Use of an assisted hatching procedure on embryos transferred. Main Outcome Measure(s): Cases were pregnancies for which number of fetal hearts observed on ultrasound exceeded number of embryos transferred. These pregnancies were considered to contain at least one MZ set of twins. Cases were compared with two control groups: other multiple-gestation pregnancies (≥2 fetal hearts but number of fetal hearts ≤ number of embryos transferred); and singleton pregnancies (1 fetal heart). Result(s): Women with a case pregnancy were more likely to have received embryos treated with assisted hatching procedures than were women in either control group. After adjustment for patient age, number of embryos transferred, prior cycles, infertility diagnosis, intracytoplasmic sperm injection, and whether embryos from the current cycle were cryopreserved for later use, odds ratios and 95% CIs for use of assisted hatching were 3.2 (1.2–8.0), compared with other multiple-gestation pregnancies, and 3.8 (1.8–9.8), compared with singleton pregnancies. Conclusion(s): Assisted hatching may pose a risk for MZ twinning.

Objective: To examine cigarette smoking as a risk factor for different types of epithelial ovarian cancer. Methods: We used data from the Cancer and Steroid Hormone Study, a multicenter, population-based, case control investigation. Cases were 447 women aged 20–54 years with diagnoses of epithelial ovarian cancer. Controls were 3868 women selected by random-digit dialing. Conditional logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs) as estimators of the relative risk of ovarian cancer. With age and study site as conditioning variables, OR point estimates were additionally adjusted for parity and use of oral contraceptives. Results: The OR of mucinous epithelial ovarian cancer for women who had ever smoked was 2.3 (95% CI 1.4, 3.9) and for current smokers was 2.9 (95% CI 1.7, 4.9). The OR of mucinous tumors for current smokers was significantly elevated regardless of years since first cigarette or age at which women first smoked. The OR of mucinous tumors for current smokers increased slightly as cumulative pack-years of smoking increased, although the trend was not significant. Similar patterns of elevated risk were not observed among serous, endometrioid, or other histologic types. Odds ratio point estimates for former smokers were not significantly elevated for any histologic type. Conclusion: Current cigarette smoking was a risk factor for mucinous epithelial ovarian cancer, but not other histologic types.

The aim of this study was to identify factors ascertainable at initial presentation that predict a complicated clinical course in HIV-negative women hospitalized with pelvic inflammatory disease (PID). We used data from a cross-sectional study of women admitted for clinically diagnosed PID to a public hospital in New York City. A complicated clinical course was defined as undergoing surgery, being readmitted for PID, or having a prolonged hospital stay (≥ 14 days) but no surgery. Logistic regression was used to identify independent predictors of complications. In adjusted analyses, older age (≥35 years) was a risk factor for prolonged hospital stay (adjusted odds ratio [OR] = 3.9; 95% confidence interval [CI] = 1.3–11.6) and surgery (OR = 10.4; CI = 2.5–44.1); self-reported drug use was a risk factor for readmission for PID (OR = 7.7; CI = 1.4-41.1) and surgery (OR = 6.2; CI = 1.8–20.5). Older age and self-reported drug use appear to be independent risk factors for a complicated clinical course among women hospitalized with PID. Infect. Dis. Obstet. Gynecol. 8:88–93, 2000.

Objective: To determine risk factors for pregnancy after tubal sterilization with bipolar electrocoagulation. Methods: A total of 2267 women who had bipolar electrocoagulation were followed for up to 8 to 14 years as part of a multicenter, prospective, cohort study conducted in medical centers in nine United States cities. We used proportional hazards analysis and cumulative life-table probabilities to assess pregnancy risk in these women. Results: The 5-year cumulative probability of pregnancy for women sterilized in 1978–1982 was 19.5 per 1000 procedures (95% confidence interval [CI], 12.2, 26.9); the comparable probability for women sterilized in 1985–1987 was significantly lower, 6.3 per 1000 procedures (95% CI, 0.0, 13.5) (one-tailed P = .01). Women enrolled in 1985–1987 who had fewer than three sites of coagulation had a probability of failure of 12.9 per 1000 procedures (95% CI, 0.0, 38.0); by contrast, women who had three or more sites coagulated had a probability of failure of 3.2 per 1000 procedures (95% CI, 0.0, 9.6) (one-tailed P = .01). Conclusion: The long-term probability of pregnancy after tubal sterilization with bipolar coagulation was very low when three or more sites of the fallopian tube were coagulated. Bipolar coagulating systems can be highly effective for sterilization when the fallopian tube is coagulated adequately.

Objective: To evaluate the cumulative probability of regret after tubal sterilization, and to identify risk factors for regret that are identifiable before sterilization. Methods: We used a prospective, multicenter cohort study to evaluate the cumulative probability of regret within 14 years after tubal sterilization. Participants included 11,232 women aged 18–44 years who had tubal sterilizations between 1978 and 1987. Actuarial life tables and Cox proportional hazards models were used to identify those groups at greatest risk of experiencing regret. Results: The cumulative probability of expressing regret during a follow-up interview within 14 years after tubal sterilization was 20.3% for women aged 30 or younger at the time of sterilization and 5.9% for women over age 30 at sterilization (adjusted relative risk [RR] 1.9; 95% confidence interval [CI] 1.6, 2.3). For the former group, the cumulative probability of regret was similar for women sterilized during the postpartum period (after cesarean, 20.3%, 95% CI 14.5, 26.0; after vaginal delivery, 23.7%, 95% CI 17.6, 29.8) and for women sterilized within 1 year after the birth of their youngest child (22.3%, 95% CI 16.4, 28.2). For women aged 30 or younger at sterilization, the cumulative probability of regret decreased as time since the birth of the youngest child increased (2–3 years, 16.2%, 95% CI 11.4, 21.0; 4–7 years, 11.3%, 95% CI 7.8, 14.8; 8 or more years, 8.3%, 95% CI 5.1, 11.4) and was lowest among women who had no previous births (6.3%, 95% CI 3.1, 9.4). Conclusion: Although most women expressed no regret after tubal sterilization, women 30 years of age and younger at the time of sterilization had an increased probability of expressing regret during follow-up interviews within 14 years after the procedure. (Obstet Gynecol 1999;93:889–95.)

Our goal was to characterize the postpartum symptoms experienced by women who do not breast-feed and to review data on the efficacy of nonpharmacologic methods of lactation suppression. The placebo arms of randomized clinical trials of pharmacologic methods for lactation suppression were used to characterize postpartum symptoms. A subset of the placebo arms was reviewed to assess current strategies for treatment of symptoms associated with lactation suppression. Studies of nonpharmacologic methods of lactation suppression were also reviewed to assess efficacy. Engorgement and breast pain may encompass most of the first postpartum week. Up to one third of women who do not breast-feed and who use a brassiere or binder, ice packs, or analgesics may experience severe breast pain. Specific studies of nonpharmacologic methods of lactation suppression were limited and inconclusive. Available data suggest that many women using currently recommended strategies for treatment of symptoms may nevertheless experience engorgement or pain for most of the first postpartum week.

Objective: To compare the risk of hysterectomy among previously sterilized women and women whose husbands had undergone vasectomy, and to evaluate whether this risk differed by age at surgical procedure or by method of tubal occlusion. Methods: Our study population comprised 7718 women enrolled in a prospective, multicenter cohort study between 1978 and 1986. After stratifying by the woman’s age at surgical procedure, we used the life-table approach and adjusted hazards ratios to examine whether the relative risk of hysterectomy during the 5 years after enrollment differed between the 7174 women who had been sterilized and the 544 women whose husbands had undergone vasectomy. Results: The 5-year cumulative probability of hysterectomy was 8% among the previously sterilized women and 2% among the women whose husbands had undergone vasectomy. Among women 34 years of age and younger at enrollment, sterilized women were 4.4 times as likely to have a hysterectomy as women whose husbands had undergone vasectomy (95% confidence interval [CI] 1.9, 10.0). Findings were similar for women 35 years of age and older (rate ratio = 4.6; 95% CI 1.4, 14.5). Each of the six most commonly used methods of tubal occlusion was associated with an increased risk of hysterectomy. Conclusion: Women undergoing tubal sterilization were more likely than women whose husbands underwent vasectomy to undergo hysterectomy within 5 years after sterilization, regardless of age at sterilization. An increased risk of hysterectomy was observed for each method of tubal occlusion.

The rebirth of family planning is well underway as countries work towards implementation of international human rights agreements and achievement of the Millennium Development Goals. However as reported in The Lancet and this article unmet need for modern contraception in the world’s poorest countries is still unacceptably high. Meeting this need will not only help individuals and couples to gain the right to contraceptive information and services but will also improve the health of women children and families. This article provides estimates for how much unmet need there is in developing countries by examining different studies focusing on this issue. Regardless of study methods and definitions of estimates the unmet need for contraception is too high. Placement of this need at the center of the global public health agenda was the focus of the 2012 London Summit on Family Planning. Many partners including developing countries civil society the private sectors and donors and foundations are now taking forward the Summit commitments through Family Planning 2020 a partnership hosted by the UN Foundation. This article discusses the six anchor points that provide a framework to guide the transformation of family planning efforts investments and priorities.

The Center for Disease Control and Prevention (CDC) the premier agency in the United States for health promotion and disease prevention is set to release the United States Selected Practice Recommendations for Contraceptive Use (US SPR). The US SPR will directly assist family planning clinicians in helping clients to both choose and use their contraceptive methods successfully. Moreover it provides clear evidence-based recommendations in three general categories: (a) initiation of contraceptive methods; (b) follow up conditions to routinely check; and (c) management of problems during method use. Additional guidance is also provided on the topics of emergency contraception use of the standard days method male and female sterilization and contraceptive use among women over age 44. The global community has seen the encouraging growth of longer-acting contraceptive methods especially implants and intrauterine devices which are not dependent on daily- or coital-related adherence. As such these methods are much more effective under typical use conditions than other contraceptives in preventing unintended pregnancy. Managing modern contraceptive choices has become a clinical subspecialty of its own and more than ever providers need synthetic access to the evidence base upon which their practice depends. The US SPR answers this need and provides detailed guidance regarding safe and effective use of these methods. Copyright © 2013 Elsevier Inc. All rights reserved.

OBJECTIVE: Our purpose was to determine the risk of pregnancy after tubal sterilization for common methods of tubal occlusion. STUDY DESIGN: A multicenter, prospective cohort study was conducted in U.S. medical centers. A total of 10,685 women who underwent tubal sterilization was followed up for 8 to 14 years. The risk of pregnancy was assessed by cumulative life-table probabilities and proportional hazards models. RESULTS: A total of 143 sterilization failures was identified. Cumulative 10-year probabilities of pregnancy were highest after clip sterilization (36.5/1000 procedures) and lowest after unipolar coagulation (7.5/1000) and postpartum partial salpingectomy (7.5/1000). The cumulative risk of pregnancy was highest among women sterilized at a young age with bipolar coagulation (54.3/1000) and clip application (52.1/1000). CONCLUSIONS: Although tubal sterilization is highly effective, the risk of sterilization failure is higher than generally reported. The risk persists for years after the procedure and varies by method of tubal occlusion and age. (AM J OBSTET GYNECOL 1996;174:1161-70.)

To evaluate the effectiveness of hysterectomy in treating chronic pelvic pain, and to identify risk factors for persistent pelvic pain.A group of 308 women who had hysterectomy for chronic pelvic pain of at least 6 months' duration was followed-up for 1 year after surgery, as part of a large, prospective, multicenter cohort study. Persistent pain was defined as a trichotomous variable, and ordinal logistic regression was used to identify independent predictors of the trichotomous outcome.Overall, 74% of women experienced complete resolution of pelvic pain, 21% reported continued but decreased pain, and 5% reported either unchanged or increased pain after hysterectomy. In unadjusted analyses, women at increased risk for persistent pain (eg, continued but decreased, and unchanged or increased) included those who were under age 30 (36 versus 22%, P.05), had a history of pelvic inflammatory disease (41 versus 25%, P.05), were uninsured or covered under Medicaid (41 versus 22%, P.001), had no identified pelvic pathology (38 versus 23%, P.05), or had a history of at least two pregnancies (31, 27, and 15% for those with at least four, two or three, and one or none, respectively; P.05). After adjustment, an increased probability of persistent pain was observed among women who had no identified pelvic pathology (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.0-3.6), were uninsured or covered under Medicaid (OR 2.3, 95% CI 1.2-4.3), or had experienced at least two pregnancies (OR 2.3, 95% CI 1.0-5.3).Most women with chronic pelvic pain have long-term improvement after hysterectomy. However, up to 40% of women in specific subgroups may continue to experience long-term pain.

Objective: To compare the efficacy and safety of routine electronic fetal monitoring (EFM) of labor with intermittent auscultation, using the results of published randomized controlled trials (RCTs). Data Sources: We identified RCTs by searching the MEDLINE data base for the period 1966–1994, contacting experts, and reviewing published references. Methods of Study Selection: Our search identified 12 published RCTs addressing the efficacy and safety of EFM; no unpublished studies were found. The studies included 58,855 pregnant women and their 59,324 infants in both high- and low-risk pregnancies from ten clinical centers in the United States, Europe, Australia, and Africa. Data Extraction and Synthesis: Data were abstracted, and their accuracy was confirmed independently. A single reviewer assessed study quality based on criteria developed by others for RCTs. Data reported from similar studies were used to calculate a combined risk estimate for each of nine outcomes. Overall, a statistically significant decrease was associated with routine EFM for a 1-minute Apgar score less than 4 (relative risk [RR] 0.82, 95% confidence interval [CI] 0.65–0.98) and neonatal seizures (RR 0.5, 95% CI 0.30–0.82). The protective effect of EFM for a 1-minute Apgar score less than 4 was apparent only in the non-United States studies, and the protective effect for neonatal seizures was evident only in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores less than 7, rate of admissions to neonatal intensive care units, and perinatal death. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR 1.33, 95% CI 1.08–1.59) and total operative delivery (RR 1.23, 95% CI 1.15–1.31). Risk of cesarean delivery was greatest in low-risk pregnancies. Conclusion: The only clinically significant benefit from the use of routine EFM was in the reduction of neonatal seizures. Because of the increase in cesarean and operative vaginal deliveries, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use EFM or intermittent auscultation during labor.

We have made important progress toward achieving Millennium Development Goals 4 and 5, with an estimated 47% decrease in maternal deaths and 28% decrease in newborn deaths globally since 1990. However, rapidly accelerating this progress is vital because far too many maternal and newborn deaths still occur each day. Fortunately, there are major initiatives underway to enhance global efforts in preventing these deaths, including the United Nations Secretary General's Global Strategy for Women's and Children's Health. We know why maternal and newborn deaths occur, where they occur, and how they occur, and we have highly effective interventions for preventing them. Nearly all (99%) maternal and newborn deaths occur in developing countries where the implementation of life-saving interventions has been a major challenge. Determining how best to meet this challenge will require more intensive interrelated efforts that include not only science-driven guidance on effective interventions, but also strategies and plans for implementing these interventions. Implementation science, defined as "the study of methods to promote the integration of research findings and evidence into healthcare policy and practice," will be key as will innovations in both technologies and implementation processes. We will need to develop conceptual and operational frameworks that link innovation and implementation science to implementation challenges for the Global Strategy. Likewise, we will need to expand and strengthen close cooperation between those with responsibilities for implementation and those with responsibilities for developing and supporting science-driven interventions. Realizing the potential for the Global Strategy will require commitment, coordination, collaboration, and communication-and the women and newborns we serve deserve no less.

Skills in emotional intelligence (EI) help healthcare leaders understand, engage and motivate their team. They are essential for dealing well with conflict and creating workable solutions to complex problems. EI skills are grounded in personal competence, upon which build the skills for social competence, including social awareness and relationship management. The leader’s EI skills strongly impact the culture of the organization. This article lists example strategies for building seventeen key emotional intelligence skills that are the foundations for personal and work success and provides examples of their appropriate use as well as their destructive under-use and over-use. Many examples are those incorporated into our healthcare-related leadership development institutes offered at the University of North Carolina’s Gillings School of Global Public Health.

Our objective was to examine trends in the use of bilateral oophorectomy in the United States from 1965 to 1990 by age, race, and indication. The National Hospital Discharge Survey data se...

Background Nearly all studies have suggested that the use of oral contraceptives (OC) is not associated with the aggregate risk of breast cancer diagnosed in women aged 20-54 years. Because of age-specific differences in the breast cancer-parity relationship and because of age-specific differences in other breast cancer risk factors, the Centers for Disease Control reexamined data from the Cancer and Steroid Hormone Study (CASH) to assess whether OC use has different effects on the risk of breast cancer at different ages of diagnosis. Methods This population-based case-control study was designed to examine the relationship between the use of OC and the risk of breast, ovarian, and endometrial cancer. CASH was conducted in eight geographic areas in the United States during 1980-1982. All participants were interviewed at home with a pretested standardized questionnaire including a calendar of life events and a photograph book of all pills marketed in the United States. Results We found that the relationship between the risk of breast cancer and OC use appeared to vary by the age at diagnosis. Among women aged 20-34 years at diagnosis or interview, those who had ever used OC had a slightly increased risk of breast cancer (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.0-2.1) compared with women of the same ages who had never used OC. Among these women, there were no trends of increasing or decreasing risk with any measure of OC use. Among women aged 35-44 years, there was no association between OC use and breast cancer. Among women aged 45-54 years, those who used OC had a slightly decreased risk of breast cancer (OR, 0.9; 95% CI, 0.8-1.0). Among these women, risk estimates decreased significantly with increasing time since first and last use. Conclusions Although the slightly increased risk estimates for the youngest women were compatible with findings by other investigators, the decreased risk estimates for the oldest women have not been described in as many studies. Available data provide no reasons to change prescribing practices or the use of OC that are related to the breast cancer risk.

Selected issues in data analysis in the Collaborative Review of Sterilization (CREST) a multicenter prospective observational study of women undergoing tubal sterilization were examined. Menstrual function after sterilization was analyzed in 5068 women at baseline who were enrolled in the period 1978-83 and followed for 5 years with yearly interviews. 4716 had follow-up information 1 year after TS. The generalized estimating equations (GEE) approach to longitudinal data analysis was used. The main response variables wee the presence or absence of menstrual dysfunction indicators: severe pain heavy bleeding intermenstrual spotting and irregularity of cycle. Covariates included in the model were: year of observation method of tubal sterilization race age at time of sterilization Quetelets index education gravidity history of surgery observed pathology at time of surgery and method of contraception most often used during the month before tubal sterilization (TS). The prevalence of menstrual dysfunction before TS compared with after TS and estimation of post-TS rates of menstrual dysfunction given a womans menstrual function at baseline (before TS) were explored. The response rates for the 2nd 3rd 4th and 5th years were 89 84 17 and 72%. The models refitted with imputed values showed the same trends as the original models. At baseline and 1 year after TS 59% of women had some form of menstrual dysfunction. This figure dropped to 57% for the next 2 years and then increased to 67% by the 4th and 5th year. The adjusted rates of menstrual dysfunction at the 5th year were higher than at baseline; this was similar to the pattern among adjusted rates that was similar to the pattern of crude marginal and transitional probabilities. Marginal modelling resulted in a statistically significant increase in the odds of menstrual dysfunction at 5 years after tubal sterilization.

Earlier studies have shown an inverse association between the presence of nausea and vomiting in pregnancy (NVP) and spontaneous abortion (SAB), but no study to date has examined the effects of symptom duration on the risk of SAB.We examined NVP symptom severity and duration in relation to the occurrence of SAB. Data were collected from 2407 pregnant women in three US cities between 2000 and 2004 through interviews, ultrasound assessments and medical records abstractions. Discrete-time continuation ratio logistic survival models were used to examine the association between NVP and pregnancy loss.Lack of NVP symptoms was associated with increased risk for SAB [adjusted odds ratio (OR) = 3.2, 95% confidence interval (CI): (2.4, 4.3)], compared with having any symptoms. Reduced risks for SAB were found across most maternal age groups for those with NVP for at least half of their pregnancy, but the effects were much stronger in the oldest maternal age group [OR = 0.2, 95% CI: (0.1, 0.8)].The absence of NVP symptoms is associated with an increased risk of early pregnancy loss. As symptom duration decreases, the likelihood of early loss increases, especially among women in the oldest maternal age group.

More than 10 million women in the United States have undergone tubal sterilization. There has been concern that this procedure may increase the risk of later menstrual dysfunction. The Collaborative Review of Sterilization (CREST) is a large, multicenter, prospective study of tubal sterilization in the United States. This report describes CREST participants who were interviewed immediately before sterilization and again in annual poststerilization interviews for up to 5 years between 1978 and 1988. The authors analyzed reported changes in six menstrual cycle characteristics for 5,070 women undergoing interval sterilizations. Longitudinal, multivariate regression was used to adjust for baseline menstrual function and other potential confounders. Five years after sterilization, 35% of the CREST participants reported high levels of menstrual pain, 49% reported heavy or very heavy menstrual flow, and 10% reported spotting between periods. In contrast to the fifth year, the first year of follow-up was similar to presterilization menstrual function; in the first year, 27% of participants reported high menstrual pain, 41% reported heavy menstrual flow, and 7% reported spotting. These findings may be affected by aging of the cohort and other study limitations, but they suggest that if tubal sterilization leads to changes in menstrual function, such changes may take some time to develop.Over 100 Million women worldwide have undergone tubal sterilization. The Collaborative Review of Sterilization (CREST) study at 12 medical centers in the US between 1978-83 examined 5070 women at 4 periodic intervals up to 5 years after the procedure. The purpose was to ascertain whether there were any changes in 6 menstrual cycle characteristics. Several different sterilization methods were examined: unipolar coagulation, bipolar coagulation, silastic band application, spring clips application, partial salpingectomy, and thermocoagulation. Other baseline characteristics which might affect changes in menstrual function over time were examined, i.e., race, body mass index, education, age, gravidity, history of pelvic pathology and pelvic surgery, method contraception immediately preceding sterilization, and incidental pelvic pathology during the sterilization. The presurgery interview included information on baseline menstrual function. The findings from multivariate analysis with unadjusted data showed changes at 5 years but not 2, including increases in menstrual pain, amount of bleeding, and intermenstrual spotting in an amount 1.3-1.8 times greater than those reporting in year 2. There were significant decreases in days/cycle and days of bleeding/cycle for the most women reporting changes. Sterilization method analysis revealed differences between methods for days/cycle, amount of bleeding, menstrual pain, irregularity, and spotting. 33% of women with the spring clip procedure reported increases in menstrual pain. The adjusted model, showed statistically significant differences in cycle length in the 5th year vs. the 1st year, as well as increases in menstrual pain, amount of bleeding, and spotting. Women with the longest cycle lengths in the adjusted analysis used the unipolar coagulation method, and the shortest cycle lengths, the spring clip. Those with the spring clip were also more likely to have menstrual pain and greater bleeding. Black women reported less irregularity and spotting and fewer days of bleeding. Older age at sterilization was related to less pain and greater regularity. The changes in bleeding pattern and menstrual pain are of greatest concern and the most frequently reported in other studies of effects of sterilization. Tissue destruction was found not to be related. Caution is urged in the interpretation of findings. Future research should focus on follow up after 5 years and comparisons with nonsterilized women.