News Highlights

• NuvaRing may have fewer side effects compared to other combined hormonal contraceptive methods
• Use of a copper IUD does not affect subsequent fertility
• No increase in HIV with hormonal contraception

Ask sexualityandu.ca

• Is it normal for labia to be two different sizes? It's kind of embarrassing asking about something like this but one is bigger than the other one and the whole exterior area has what looks like white "granules" under the surface of the skin. Is this normal?
• Do I need to use backup protection if I am on the pill and start antibiotics?
• I have been diagnosed with HPV because I had an abnormal Pap smear.  What do I do?
• How do I know if I’m pregnant? What are the signs and symptoms?

Tips

• Use of oral contraceptive pill does not worsen MS symptoms

Quick facts

• Lactational amenorrhea may be a good birth control method

Did you know?

• You do not have to wait until your period starts to begin using hormonal contraception

NuvaRing may have fewer side effects compared to other combined hormonal contraceptive methods

Researchers in Spain recruited 805 women from local family planning clinics to evaluate the side effects of the NuvaRing contraceptive vaginal ring.  The women were evaluated at entry into the study, and after 3 and 6 months of NuvaRing use.  Some women chose NuvaRing initially (423 women) and some switched from another hormonal method to NuvaRing (382).  Of the 805 women who started the study, 74% completed the six month trial. 

The women who switched from another method of hormonal contraception to NuvaRing had a significant decrease in headaches, nausea, and breast tenderness during the six month test period.  Headaches decreased from 10% of women at baseline to 1.2% after 6 cycles (p<0.01), nausea dropped from 4.8% to 0.4%, and breast tenderness decreased from 6.4% at baseline to 1.7% after 6 cycles of use (p<0.05).

The steady rate of release and lower overall dose of hormones seen with NuvaRing may help explain why the women had an improvement in their symptoms.  The lack of a direct comparison to an alternate form of hormonal contraception in this study prevents any conclusions about whether NuvaRing is better or worse than traditional oral contraceptives.  Symptoms such as breast tenderness and nausea decrease with time with all forms of hormonal contraception.

Lete, I.  Clinical experience with NuvaRing® in Spain shows that the monthly contraceptive ring is associated with a low incidence of hormone-related adverse effects 
Abstracts of the 9th Congress of the European Society of Contraception
http://www.contraception-esc.com/istanbul/abstracts/P016.htm

Use of a copper IUD does not affect subsequent fertility

The use of IUDs in North America is becoming increasingly popular.  Many patients are still concerned about the possibility of infertility after using an IUD.  A recent prospective Norwegian study looked at copper IUD use and subsequent fertility.

A total of 957 women had a copper IUD inserted between May 1993 and April 1995 as part of a contraceptive effectiveness study.  Women who had their IUD removed by June 1, 1999 were eligible to enter this study about fertility.  In total, 397 women were eligible, and 205 agreed to participate.  All women in the study had already delivered at least one child.

Group A included 109 women who had the IUD removed to become pregnant.  Group B included 96 women whose IUD was removed due to complications (bleeding, pain, expulsion, and other medical complications) and later desired a pregnancy.  The women in group B tended to be younger, and removed their IUD sooner than women in Group A.

In Group A, 102 of 109 (95.6%) of women were pregnant within 25 months.  Of the 7 women who did not get pregnant, 4 had changed their mind about achieving a pregnancy and had restarted contraception and 3 were investigated for infertility.  Two of the three couples had male factor infertility and the third woman had endometriosis.

In Group B, 94 of 96 women became pregnant within 24 months, and the other 2 women did not proceed to infertility workup. 

The first pregnancies after IUD removal in Group A were all intrauterine, and 84 went on to a live birth.  In group B, there were 92 intrauterine pregnancies (14 miscarriages) and 2 ectopic pregnancies.  These rates of miscarriage and ectopic pregnancy are similar to those in the general population.

This study showed that the use of a copper IUD did not increase the risk of infertility due to tubal damage (presumably from infection or inflammation).  Secondly, women who had an IUD removed due to a complication are as likely to conceive as women who did not have complications with their IUD.

These findings are consistent with findings of a large study published in 2001 that found that previous use of a copper IUD is not associated with an increased risk of tubal occlusion among nulligravid women (women who never had a baby before).

Garmo Hov Gunhild, Skjeldestada Finn Egil, Hilstad Torunn.  Use of IUD and subsequent fertility — follow-up after participation in a randomized clinical trial.   Contraception 75 (2007) 88– 92.

Hubacher et al.  Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women.  N Engl J Med. 2001 Aug 23;345(8):561-7.

No increase in HIV with hormonal contraception

An international group of researchers wanted to further define the link, if any, between hormonal contraception (combined oral contraceptive pills [COC] and Depo Provera (DMPA)) and the risk of acquiring HIV.  After going through the testing protocols, 6109 HIV-negative women in Thailand, Uganda, and Zimbabwe were enrolled in the study. 

Of the 4439 African participants, 34.7% used COC’s, 34.2% used DMPA, and 31.1% used a non-hormonal method (eg: withdrawal, condoms).  Although the majority of the women did not engage in high risk sexual behaviours (multiple partners, sex trade workers), less than half reported regular condom use.  Women using hormonal methods were older, more likely to have a partner, and had an average of 2 previous pregnancies.  Women using non-hormonal methods tended to have higher risk sexual behaviours, but were also more likely to use condoms.  Overall, high risk behaviour was uncommon in either group.

Data were available for 92% of the women at 24 months.  There were 213 new HIV infections during this time period, with an incidence rate of 2.75/100 woman-years, compared to 2.59 for the COC, 3.11 for DMPA, and 2.55 for the non-hormonal group.  When other factors were accounted for (such as condom use), neither the COC nor DMPA were more likely to be associated with acquiring HIV than the non-hormone group. 

The researchers also looked at women with high risk behaviours in each group.  Although these subsets had a higher rate of HIV acquisition when compared to the rest of the women in the study, there was no difference between those using hormonal or non-hormonal contraception.

The information from this study is reassuring to women living in locations with high rates of HIV.  They can continue to use reliable contraception methods without concern for a significant increase in the possibility of HIV infection.

Morrison CS et al; for the Hormonal Contraception and the Risk of HIV Acquisition (HC-HIV) Study Group.   Hormonal contraception and the risk of HIV acquisition.
AIDS. 2007 Jan 2;21(1):85-95.

Is it normal for labia to be two different sizes? It's kind of embarrassing asking about something like this but one is bigger than the other one and the whole exterior area has what looks like white "granules" under the surface of the skin. Is this normal?

Yes, it is normal for a woman to have labia that are different sizes.  Sometimes, one can be quite a bit larger and can even be irritated by rubbing against clothes and underwear.  A gynecologist is trained to examine this part of your body and can recommend treatment if needed. 

The white “granules” you describe are most likely plugged skin ducts.  They are very common on the labia and are normal.  If you have an itchy or smelly discharge as well, consider seeing your health care provider to rule out a sexually transmitted infection.

Do I need to use backup protection if I am on the pill and start a course of antibiotics?

Most antibiotics do not change the effectiveness of the pill.  However, if the antibiotics give you nausea, vomiting, or diarrhea, you should use a backup method such as condoms for the rest of the month.

I have been diagnosed with HPV because I had an abnormal Pap smear.  What do I do?

Human Papilloma Virus, or HPV, has many different strains.  Some cause genital warts, some cause changes in the cervix that gives an abnormal Pap smear, and many do not cause symptoms at all.  Most of the time, your body’s immune system will clear the virus over the course of 1.5 to 2 years.  However, sometimes the virus is difficult to get rid of, and the infected cervix tissue needs to be treated.  Your doctor will discuss this with you.  In the long run, the most important thing is to continue to come for regular Pap smears.  This can help monitor whether or not the infected tissue is healing itself, and whether treatment may be needed.

Check out the website www.hpvinfo.ca for more information.

 

How do I know if I’m pregnant?

If you have been sexually active, missing a period is the most tell-tale sign of pregnancy.

However, even though a missed period is a common sign of pregnancy, there are other reasons why you may miss a period as well.  Diet, excessive exercise and stress may all cause a woman to miss her period. In addition, certain birth control methods can also reduce or stop menstrual bleeding.

In addition to missing or having a delayed period, some common signs of pregnancy can include…(read more)

You do not have to wait until your period starts to begin using hormonal contraception. 

Traditionally, many health care providers have recommended that a woman wait until her period starts to begin a birth control method.  The main reason is to make sure you are not pregnant when the method is started.  However, you can begin any method of hormonal contraception (such as a birth control pill, patch, or vaginal ring) any day of your cycle.  This is often referred to as the “Quick Start” method.  Your health care provider will likely have you do a pregnancy test before starting the contraception method.  If the first period after you start the method is unusual (heavy, light, or does not come at all), consider repeating the pregnancy test.  If you become pregnant while using contraception, or if you were unknowingly pregnant when you started using the contraception, this will not harm the baby.

Lactational amenorrhea may be a good birth control method

Women who have recently had a baby often need effective contraception, although many have concerns about using hormonal methods while breastfeeding.  One option for women may include lactational amenorrhea as a method of birth control.

For this method to be effective, several key requirements must be met:

1. No period since giving birth;
2. Must breastfeed exclusively (no supplementing with bottle feeds) at least every 4 hours during the day and every 6 hours through the night;
3. Baby must be less than six months old.

If these conditions are met, this method of birth control is about 98% effective, which is similar to birth control pills.  It does not protect against sexually transmitted infections so condoms should also be used if infection is a possibility.  Other hormonal methods of contraception, such as birth control pills, the patch, the ring, or Depo Provera injections are all considered safe to use in the post partum period.  Women who are uncertain about breastfeeding and need reliable contraception should talk to their health care providers about selecting a suitable method.

Black A, Francoeur D, Rowe T, Collins J, Miller D, Brown T, David M, Dunn S, Fisher WA, Fleming N, Fortin CA, Guilbert E, Hanvey L, Lalonde A, Miller R, Morris M, O'Grady T, Pymar H, Smith T, Henneberg E; Society of Obstetrics and Gynaecology of Canada.  Canadian contraception consensus.  J Obstet Gynaecol Can. 2004 Apr;26(4):347-87, 389-436

Use of oral contraceptive pill does not worsen MS symptoms

Many women with Multiple Sclerosis (MS) have changes in their symptoms around the time of menstruation and during pregnancy.   Pregnancy and oral contraceptive use seem to be associated with an improvement or stabilization of symptoms, while the post partum period and menopause seem to correlate with a worsening of symptoms.  The science behind this is not well understood, but is likely due to interplay between the immune system and the fluctuation in hormone levels that occur during these time periods. 

Women who have physical limitations (such as requiring a wheelchair) due to their MS may not be candidates for estrogen-containing contraception as they are at increased risk of blood clots.  Discussion with a health care provider is essential for these women.

Devonshire V, Duquette P, Dwosh E, Guimond C.  The immune system and hormones: review and relevance to pregnancy and contraception in women with MS.
Int MS J. 2003 Jun;10(2):44-50