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What is amenorrhea?

What is amenorrhea?

Amenorrhea is a condition in which there is an absense of menstrual periods in a woman. There are two types of amenorrhea, 1) primary and 2) secondary. Treatment of amenorrhea depends on the type (primary or secondary). In prmiray, surgery may be an option and in secondary amenorrhea medication or lifestyle changes may be treatment options.

Amenorrhea is the medical term for the absence of menstrual periods, either on a permanent or temporary basis. Amenorrhea can be classified as primary or secondary. In primary amenorrhea, menstrual periods have never begun (by age 16), whereas secondary amenorrhea is defined as the absence of menstrual periods for three consecutive cycles or a time period of more than six months in a woman who was previously menstruating.

The menstrual cycle can be influenced by many internal factors such as transient changes in hormonal levels, stress, and illness, as well as external or environmental factors. Missing one menstrual period is rarely a sign of a serious problem or an underlying medical condition, but amenorrhea of longer duration may signal the presence of a disease or chronic condition.

What causes amenorrhea?

The normal menstrual cycle occurs because of changing levels of hormones made and secreted by the ovaries. The ovaries respond to hormonal signals from the pituitary gland located at the base of the brain, which is, in turn, controlled by hormones produced in the hypothalamus of the brain. Disorders that affect any component of this regulatory cycle can lead to amenorrhea. However, a common cause of amenorrhea in young females sometimes overlooked or misunderstood by the individual and others, is an undiagnosed pregnancy. Amenorrhea in pregnancy is a normal physiological function. Occasionally, the same underlying problem can cause or contribute to either primary or secondary amenorrhea. For example, hypothalamic problems, anorexia or extreme exercise can play a major role in causing amenorrhea depending on the age of the person and if she has experienced menarche.

Primary amenorrhea

Primary amenorrhea is typically the result of a genetic or anatomic condition in young females that never develop menstrual periods (by age 16) and is not pregnant. Many genetic conditions that are characterized by amenorrhea are conditions in which some or all of the normal internal female organs either fail to form normally during fetal development or fail to function properly. Diseases of the pituitary gland and hypothalamus (a region of the brain important for the control of hormone production) can also cause primary amenorrhea since these areas play a critical role in the regulation of ovarian hormones.

Gonadal dysgenesis is the name of a condition in which the ovaries are prematurely depleted of follicles and oocytes (egg cells) leading to premature failure of the ovaries. It is one of the most common cases of primary amenorrhea in young women.

Another genetic cause is Turner syndrome, in which women are lacking all or part of one of the two X chromosomes normally present in the female. In Turner syndrome, the ovaries are replaced by scar tissue and estrogen production is minimal, resulting in amenorrhea. Estrogen-induced maturation of the external female genitalia and sex characteristics also fails to occur in Turner syndrome.

Other conditions that may be causes of primary amenorrhea include androgen insensitivity (in which individuals have XY (male) chromosomes but do not develop the external characteristics of males due to a lack of response to testosterone and its effects), congenital adrenal hyperplasia, and polycystic ovary syndrome (PCOS).

Secondary amenorrhea

Pregnancy is an obvious cause of amenorrhea and is the most common reason for secondary amenorrhea. Further causes are varied and may include conditions that affect the ovaries, uterus, hypothalamus, or pituitary gland.

Hypothalamic amenorrhea is defined as amenorrhea that is due to a disruption in the regulator hormones produced by the hypothalamus in the brain. These hormones influence the pituitary gland, which in turn sends signals to the ovaries to produce the characteristic cyclic hormones. A number of conditions can affect the hypothalamus and lead to hypothalamic amenorrhea, such as:

• extreme weight loss,
  
• emotional or physical stress,
  
• rigorous exercise, and
  
• severe illness.

Other types of medical conditions can cause secondary amenorrhea:

• tumors or other diseases of the pituitary gland that lead to elevated levels of thehormone prolactin (which is involved in milk production) also cause amenorrhea due to the elevated prolactin levels;
  
• hypothyroidism;
  
• elevated levels of androgens (male hormones), either from outside sources or from disorders that cause the body to produce too high levels of male hormones;
  
• ovarian failure (premature ovarian failure or early menopause);
  
• polycystic ovary syndrome; and
  
• Asherman's syndrome is an example of uterine disease that causes amenorrhea. It results from scarring of the uterine lining following instrumentation (such asdilation and curettage) of the uterine cavity to manage postpartum bleeding or infection.

Post-pill amenorrhea

Women who have stopped taking oral contraceptive pills should experience the return ofmenstruation within three months after discontinuing pill use. Previously, it was believed that birth control pills increased a woman's risk of amenorrhea following use of the pill, but this has been proven not to be the case. Women who do not resume menstruation after three months have passed since oral contraceptive pills were stopped should be evaluated for causes of secondary amenorrhea.

What are the symptoms of amenorrhea?

Primary or secondary amenorrhea (respectively) is considered to be present when a girl has:

• not developed menstrual periods by age 16; or
  
• a woman who has previously had a menstrual cycle stops having menstrual periods for three cycles in a row, or for a time period of six months or more and is not pregnant.

Other symptoms and signs may be present, which are highly variable and depend upon the underlying cause of the amenorrhea. For example, symptoms of hormonal imbalance or male hormone excess can include irregular menstrual periods, unwanted hair growth, deepening of the voice, and acne. Elevated prolactin levels as a cause of amenorrhea can result in galactorrhea (a milky discharge from the nipples that is not related to normal breastfeeding).

When should I seek medical care for amenorrhea?

It is always appropriate to seek medical attention for amenorrhea. Amenorrhea that is not related to pregnancy or the menopausal transition (time when there has been no menstrual periods for 12 consecutive months and no other biological or physiological cause can be identified, and the female is at the end of her biological-determined child bearing years) should be further investigated to rule out serious conditions that may result in amenorrhea.

How is amenorrhea diagnosed?

The diagnosis of amenorrhea requires a careful medical history to document the presence of amenorrhea as well as any other coexisting medical conditions that may be the cause of amenorrhea. A physical examination, including a pelvic examination is also performed.

Depending upon the results of the history and physical examination further diagnostic tests may be ordered. Blood tests may be ordered to examine the levels of ovarian, pituitary, and thyroid hormones. These tests may include measurements of prolactin, follicle-stimulating hormone (FSA), estrogen, thyrotropin, dehydroepiandrosterone sulfate (DHEA-S), and testosterone. For some individuals, a pregnancy test is the first test performed.

Imaging studies, such as ultrasound, X-ray, and CT or MRI scanning may also be recommended in certain individuals to help establish the cause of amenorrhea

Treatment of both primary and secondary amenorrhea is determined by the precise cause of the amenorrhea. Treatment goals can be to relieve symptoms of hormonal imbalance, to establish menstruation, prevent complications associated with amenorrhea, and/or to achieve fertility, although not all of these goals can be achieved in every case.

In cases in which genetic or anatomical abnormalities are the cause of amenorrhea (typically primary amenorrhea), surgery may be recommended to correct anatomical abnormalities.

Hypothalamic amenorrhea that is related to weight loss, excessive exercise, physical illness, or emotional stress can typically be corrected by addressing the underlying cause. For example, weight gain and reduction in intensity of exercise can usually restore menstrual periods in women who have developed amenorrhea due to weight loss or overly intensive exercise, respectively, who do not have additional causes of amenorrhea. In some cases, nutritional counseling may be of benefit.

In premature ovarian failure, hormone therapy may be recommended both to avoid the unpleasant symptoms of estrogen depletion as well as prevent complications (see below) of low estrogen level such as osteoporosis. This may consist of oral contraceptive pills for those women who do not desire pregnancy or alternative estrogen and progesterone medications. While postmenopausal hormone therapy has been associated with certain health risks in older women, younger women with premature ovarian failure can benefit from this therapy to prevent bone loss.

Women with PCOS (polycystic ovary syndrome) may benefit from treatments that reduce the level or activity of male hormones, or androgens.

Dopamine agonist medications such as bromocriptine (Parlodel) can reduce elevated prolactin levels, which may be responsible for amenorrhea. Consequently, medication levels may be adjusted by the person's physician if appropriate.

Assisted reproductive technologies and the administration of gonadotropin medications (drugs that stimulate follicle maturation in the ovaries) can be appropriate for women with some types of amenorrhea who wish to attempt to become pregnant.

While many companies and individuals have marketed herbal therapies as a treatment for amenorrhea, none of these have been conclusively proved to be of benefit. Herbal therapies are not regulated by the U.S. FDA and the quality of herbal preparations is not tested. Herbal remedies have been associated with serious and even fatal side effects in rare cases, and some preparations have been shown to contain high levels of toxins. Before deciding to take a natural or alternative remedy for amenorrhea, it is wise to seek the advice of your health care practitioner

What are the complications of amenorrhea?

Infertility is a significant complication of amenorrhea for women who desire to become pregnant. Osteopenia (a reduction in bone density) or osteoporosis is a complication of low estrogen levels, which may occur with prolonged amenorrhea. Other complications of amenorrhea depend upon the underlying cause of the amenorrhea.

Can amenorrhea be prevented?

Amenorrhea is a symptom and not a disease in itself. Therefore, amenorrhea can be prevented only to the extent that the underlying cause can be prevented. For example, amenorrhea that results from genetic or inborn conditions cannot be prevented. On the other hand, amenorrhea that results from self-imposed stringent dieting or intensive exercise is typically preventable.

What is the outlook for a woman suffering from amenorrhea?

The outlook for amenorrhea varies widely and is dependent upon the cause of the amenorrhea. Hypothalamic amenorrhea that is a result of stress, exercise, or weight loss generally can be corrected if the responsible factors can be corrected. Medical and hormonal therapies can be of great benefit in preventing unpleasant side effects or complications of amenorrhea in many women.

Amenorrhea At A Glance

• Amenorrhea refers to the absence of menstrual periods; it may be either primary (meaning a woman never developed menstrual periods) or secondary (absence of menstrual periods in a woman who was previously menstruating).
  
• Genetic or inborn conditions are the most common causes of primary amenorrhea.
  
• Amenorrhea may result from disorders of the ovaries, pituitary gland, or hypothalamus.
  
• Intensive exercising, extreme weight loss, physical illness, and stress can all result in amenorrhea.
  
• Amenorrhea is a symptom and not a disease in itself, so amenorrhea can be prevented only to the extent that the underlying cause can be prevented.
  
• Infertility and bone loss (osteoporosis) are complications of amenorrhea.
  
• Treatments may include surgical correction of anatomical abnormalities, medications or hormone therapies, and treatment of any underlying conditions responsible for amenorrhea.
  
• The outlook for amenorrhea varies according to the cause of the amenorrhea.

Medications

• Birth Control Pills (Oral Contraceptives)
• bromocriptine-oral, Parlodel

DOUCHING

What is douching?

The word "douche" means to wash or soak in French. Douching is washing or cleaning out the vagina (also called the birth canal) with water or other mixtures of fluids. Usually douches are prepackaged mixes of water and vinegar, baking soda, or iodine. Women can buy these products at drug and grocery stores. The mixtures usually come in a bottle and can be squirted into the vagina through a tube or nozzle.

Why do women douche?

Women douche because they mistakenly believe it gives many benefits. In reality, douching may do more harm than good. Common reasons women give for using douches include:

• to clean the vagina
• to rinse away blood after monthly periods
• to get rid of odors from the vagina
• to avoid sexually transmitted diseases (STDs)
• to prevent pregnancy

How common is douching?

Douching is common among women in the United States. It is estimated that 20% to 40% of American women aged 15 to 44 years douche regularly. About half of these women douche every week.

Is douching safe?

Most doctors and the American College of Obstetricians and Gynecologists (ACOG) suggest that women steer clear of douching. All healthy vaginas contain some bacteria and other organisms called the vaginal flora. The normal acidity of the vagina keeps the amount of bacteria down. But douching can change this delicate balance. This may make a woman more prone to vaginal infections. Plus, douching can spread existing vaginal infections up into the uterus, Fallopian tubes, and ovaries.

What are the dangers linked to douching?

Research shows that women who douche regularly have more health problems than women who do not. Doctors are still unsure whether douching causes these problems. Douching may simply be more common in groups of women who tend to have these issues. Health problems linked to douching include:

• vaginal irritation,
• vaginal infections called bacterial vaginosis or BV,
• sexually transmitted diseases (STDs), and
• pelvic inflammatory disease (PID)

Pelvic inflammatory disease (PID) is an infection of a woman's uterus, Fallopian tubes and/or ovaries. It is caused by bacteria that travel from a woman's vagina and cervix up into her reproductive organs. If left untreated, PID can cause fertility problems (difficulties getting pregnant). PID also boosts a woman's chances of ectopic pregnancy (pregnancy in the Fallopian tube instead of the uterus). Some STDs, BV, and PID can all lead to serious problems during pregnancy. These include infection in the baby, problems with labor, and early delivery.

Should I douche to clean inside my vagina?

No. Doctors and the ACOG suggest women avoid douching completely. Most experts believe that douching increases a woman's chances of infection. The only time a woman should douche is when her doctor recommends it.

What is the best way to clean my vagina?

Most doctors say that it is best to let your vagina clean itself. The vagina cleans itself naturally by producing mucous. Women do not need to douche to wash away blood, semen, or vaginal discharge. The vagina gets rid of it alone. Also, it is important to note that even healthy, clean vaginas may have a mild odor.

Regular washing with warm water and mild soap during baths and showers will keep the outside of the vagina clean and healthy. Doctors suggest women avoid scented tampons, pad, powders, and sprays. These products may increase a woman's chances of getting vaginal infections.

My vagina has a terrible odor, can douching help?

No. Douching will only cover up the smell. It will not make it go away. If your vagina has a bad odor, you should call your doctor right away. It could be a sign of a bacterial infection,urinary tract infection, STD or a more serious problem.

Should I douche to get rid of vaginal discharge, pain, itching, or burning?

No. Douching may even make these problems worse. It is very important to call your doctor right away if you have:

• vaginal discharge with a bad smell
• thick, white or yellowish-green discharge with or without a smell
• burning, redness, and swelling of the vagina or the area around it
• pain when urinating or
• discomfort during sex

These may be signs of a bacterial infection, yeast infection, urinary tract infection, or STD. Do not douche before seeing your doctor. This can make it hard for the doctor to figure out what is wrong.

Can douching after sex prevent sexually transmitted diseases (STDs)?

No. This is a myth. The only way to completely prevent STDs is to not have sex. But practicing safer sex will dramatically decrease your risk of getting these diseases. You can greatly reduce your chances of getting an STD in the following ways:

• using latex condoms or female condoms every time you have sex
• avoiding contact with sores on the penis or vagina
• preventing the exchange of semen, blood, and vaginal secretions

Can douching after sex stop me from getting pregnant?

No. Douching does not prevent pregnancy and should never be used as a means ofbirth control. Actually, douching may make it easier to get pregnant by pushing the sperm further up into the vagina and cervix.

Can douching hurt my chances of having a healthy pregnancy?

It may. Limited research shows that douching may make it more difficult for a woman to get pregnant. In women trying to get pregnant, those who douched more than once a week took the longest to get pregnant.

Studies also show that douching may boost a woman's chance of ectopic pregnancy. Ectopic pregnancy is when the fertilized egg attaches to the inside of the Fallopian tube instead of the uterus. If left untreated, ectopic pregnancy can be life-threatening. It can also make it difficult for a woman to get pregnant in the future.

Featured: Douching (Vaginal Douche) Main Article
Women douche for a variety of reasons, however, physicians do not recommend douching. Douching can change the vaginal flora, and make women more prone to vaginal infections, increase risk of infertility or ectopic pregnancy. Health problems linked to douching include vaginal irritation, STDs, pelvic inflammatory disease, and vaginal irritation.

Hormonal Methods of Birth Control

Hormonal Methods of Birth Control

Medical Author: Melissa Conrad Stöppler, MD
Medical Editor: William C. Shiel Jr., MD, FACP, FACR

• Introduction to birth control
• Hormonal methods of contraception
• Oral hormones: the pill
• Injection: depot medroxyprogesterone acetate (DMPA)
• Contraceptive patch: Ortho-Evra
• Vaginal ring: NuvaRing
• Contraceptive implants
• Find a local Obstetrician-Gynecologist in your town

Introduction to birth control

If a woman is sexually active and she is fertile, meaning that she is physically able to become pregnant, she needs to ask herself, "Do I want to become pregnant now?" If her answer is "No," she must use some method of birth control (contraception).

Terminology for "birth control" includes contraception, pregnancy prevention, fertility control, and family planning. But no matter what the process is called, sexually active people can choose from a plethora of methods to reduce the possibility of their becoming pregnant. Nevertheless, no method of birth control available today offers perfect protection against sexually transmitted infections (sexually transmitted diseases, or STDs), except abstinence.

In simple terms, all methods of birth control are based on either preventing a man's sperm from reaching and entering a woman's egg (fertilization) or preventing the fertilized egg from implanting in the woman's uterus (her womb) and starting to grow. New methods of birth control are being developed and tested all the time. And what is appropriate for a couple at one point may change with time and circumstances.

Unfortunately, no birth-control method, except abstinence, is considered to be 100% effective.

Hormonal methods of contraception

There are several different hormonal methods of birth control. The differences among them involve

• the type of hormone,
• the amount of hormone, and
• the way the hormone enters a woman's body.

The hormones can be estrogen and/or progesterone. These hormones may be taken orally (taken by mouth), implanted into body tissue, injected under the skin, absorbed from a patch on the skin, or placed in the vagina. The mode of delivery determines whether the hormonal exposure is continuous or intermittent.

The different hormonal types of birth control are comparable in that they are all highly effective and all are reversible. However, none of the horm

Oral contraceptives: the pill

The pill for women is an oral contraceptive made from synthetic hormones. The pill is considered to be 97%-99% effective if used properly. The pill is also fully reversible. The pill has been available since 1960, and it is estimated that more than 10 million American women currently use birth-control pills.

There are two types of birth-control pills available:

• the combination pill and
• the minipill.

The combination pill

The combination pill contains the hormones estrogen and progestin, a form of progesterone. When a woman uses the combination pill, the eggs in her ovaries do not mature and she does not ovulate. She doesn't become pregnant because no egg is available to be fertilized by a sperm.

The traditional combination pill comes in 21-day packs or 28-day packs depending on the manufacturer. The 21-pill pack has pills for 21 "on" days and no pills for the seven "off" days that follow. The 28-pill pack has active pills for the first 21 "on" days and seven inactive (placebo) or reminder pills for the following seven "off" days.

New preparations have been developed that allow for extended or continuous use of combination pills. These products allow for a reduction in the number of menstrual periods a woman experiences.

The minipill

The minipill only contains one hormone, progestin. Progestin thickens the cervical mucus, making it more difficult for sperm to pass through the cervix. It also makes the lining of the uterus less receptive to the implantation of a fertilized egg. The progesterone-only pill is sometimes recommended for women who have medical reasons for which they must avoid taking estrogen hormones. (These reasons can include liver disease, certain types of blood clots in the veins, breast cancer, and uterine cancer.) In addition, it is often recommended in nursing mothers because it has no adverse affects on breastfeeding. Indeed, extended breastfeeding, as well as delay in the need for formula supplementation has been observed in breastfeeding users of the minipill.

The minipill is taken every day. There are no "on" or "off" days with the minipill.

No matter which type of birth-control pill a woman uses, she should take it every day at the same time in order to establish a routine. The woman needs to minimize the chance she will forget to take the pill, which is not an uncommon occurrence. This is especially critical in the case of the progestin-only pill (minipill). Forgetting to take the minipill, or taking it at varying times of the day, can significantly impair its effectiveness in contraception. This is due to the low dose of the minipill causing its effects to wear off rapidly if the pill is missed.

When a woman begins taking the pill, she may not protected from pregnancy until she has been taking the pill for 10 consecutive days in a row. If a woman forgets to take a pill after she has started, she may be at risk for getting pregnant.

If she only misses one pill, she should take it as soon as she remembers, even if it means taking two pills in the same day. If she misses two pills, she should take both of them as soon as she remembers, plus the pill for that day at her regular time. If she misses three pills, she should discontinue use of the pill for four more days to complete one week and then begin taking a new pack of birth control pills, whether she has a menstrual period or not. She must use an alternate form of birth control or abstain from sexual activity during the week that she stops taking her pills. If a woman continually forgets to take her pills, perhaps she should consider a different method of birth control.

The pill may partially lose its effectiveness if a woman vomits or has diarrhea for any reason. Some medications, including certain sedatives and some antibiotics such as penicillin and tetracycline, may reduce the effectiveness of the pill. Research in this area is ongoing. A woman should ask her health-care professional about these matters and the necessity of using a backup method of birth control if any of these conditions exist.

Some women experience temporary symptoms of spotting or light vaginal bleeding, breast tenderness, and nausea during the first one to three months of taking the pill. Nausea can be helped if the pill is taken after a meal. While women sometimes fear weight gain with oral contraceptives, studies of the low-dose preparations demonstrate that there is no significant weight gain with oral contraception and no major difference in weight change comparing various contraception products. Negative mood changes, such as depression, and pigmented patches of skin on the face (melasma) may occur with oral-contraceptive use. Because the progesterone in women can cause thinning of the lining of the uterus, some women may experience loss of menstrual periods (amenorrhea). Oral contraceptive-induced amenorrhea happens in about 1% of women in the first year of use. As long as the woman is properly taking her pills, amenorrhea is not harmful and it does not signal any loss of effectiveness of the pills. Most side effects from the combination pill or the minipill decrease after two to three months of use. It is important to remember that because most side effects of oral contraceptives decrease in the first two to three months of use, women should try to avoid switching pills prior to an adequate trial. Trying to stick with any given product for two to three months may be necessary to really determine whether or not it will be tolerated over time. Switching too early to another brand may only needlessly subject the woman to the possibility of similar side effects starting all over again with the new pill.

There is no increased risk of birth defects in babies born to women who have taken the pill, but a woman should not use either type of pill if she is pregnant. A woman who is breastfeeding should not use the combination pill because it can reduce the amount of her breast milk and the concentration of proteins and fat in her breast milk. Additionally, her breast milk will contain traces of the hormones from the pill. However, in contrast to the combination pill, the minipill is routinely used in lactating women.

Women who smoke and take the pill are at increased risk of heart disease and stroke. There is no increased risk of heart attack or stroke among healthy nonsmoking women who use the pill. Blood clots in the legs and elsewhere are slightly more frequent with low-dose oral contraceptives, but the risk is very low, and lower than the increased risk of clotting that occurs with pregnancy. Nevertheless, oral contraceptives are not recommended for women with clotting tendencies (such as cardiolipin antibody associated clotting), known coronary heart disease, stroke, unevaluated breast lumps, vaginal bleeding, or breast cancer. Smokers over 35 years of age should not use oral contraceptives, nor should women with a significant liver disorder.

A woman should contact her health-care professional immediately if she experiences any of these side effects while taking the pill:

• severe headache;
• leg cramps;
• change in vision, including blurred vision, vision loss, or flashing lights;
• abdominal pain;
• chest pain;
• shortness of breath;
• coughing up blood; or
• leg swelling or pain.

There are a number of benefits to taking the pill. Both the combination pill and the minipill can regularize a woman's menstrual cycle and reduce her menstrual flow andmenstrual cramps. There is evidence that the pill protects against cancer of the ovary and uterus as well as pelvic inflammatory disease (PID) and iron deficiency anemia. The combination pill can reduce acne (although maximal acne reduction may take six months to occur), the risk of an ectopic pregnancy, noncancerous breast cysts, andovarian cysts. According to a large study, the combination pill confers no long-term risk of breast cancer. In addition, a woman who has taken the pill is less likely to develop rheumatoid arthritis and osteoporosis. Users of oral contraceptives have experienced significant decreases in excessive menstrual flow and in occurrence and severity of menstrual cramps.

A woman's menstrual periods should begin again within about six months of stopping the oral-contraceptive pill. However, the length of delay before a woman's period returns after stopping the pill varies from woman to woman. Oral contraceptives are about 97% effective in preventing pregnancy. The pill does not protect a woman against sexually transmitted infections.

Injected contraceptive: depot medroxyprogesterone acetate

Depot medroxyprogesterone acetate (DMPA) is a synthetic long-acting form of the hormone progesterone. DMPA is similar to the birth-control minipill in that it does not contain estrogen. Like other progesterone-based contraceptives, DMPA acts by preventing the release of the egg from the ovary (ovulation) and by promoting thick cervical mucus that impedes the sperm's progress. Its effectiveness in preventing pregnancy is close to 100%.

DMPA must be injected by a health-care professional every three months (12 weeks). Preparations are available both as intramuscular or subcutaneous (beneath the skin) injections. The injection must be administered within the first five days of a woman's menstrual period. She is then protected from pregnancy within 24 hours of receiving the injection.

A woman may stop having periods altogether after using DMPA for one year. After two years of use, 70% of women will have no menstrual bleeding. Menstrual periods stop because the DMPA causes the ovaries to go into a "resting" state. When the ovaries do not release an egg every month, the regular growth of the lining of the uterus does not occur and no uterine lining is shed during the subsequent menstrual cycle.

A woman's menstrual periods should begin again within six to 18 months after she stops taking the injections. A woman can also become pregnant, usually within 12 to 18 months, once she stops using DMPA. If a new mother does not breastfeed her baby, she can resume the injections right after childbirth. Mothers who are breastfeeding can safely begin the injections six weeks after childbirth. The injections do not reduce the flow of her breast milk, and no harmful effects on the baby have been noted.

The most common side effects of DMPA injections are irregular menstrual cycles, cessation of menstrual periods, and weight gain. Other side effects may include nervousness, dizziness, stomach discomfort, headaches, fatigue, or breast tenderness. It is important that a woman realize that once she has been injected with DMPA, any side effects she may experience cannot be neutralized or eliminated. She has to tolerate these side effects until the medication wears off, typically three months later.

DMPA has also been shown to have a negative effect on bone mineral density, especially with longer-term use; however, studies have shown that her previous bone density is usually restored when the drug is discontinued.

Women may be able to use DMPA when avoidance of estrogen is prudent for medical reasons (see oral contraceptives). A qualified health-care provider should be able to help make the proper distinction. DMPA should not be used by women who have a history of breast cancer, blood clots, liver disease, unexplained vaginal bleeding, or stroke. A woman on DMPA should contact her health-care professional if she experiences a heavy menstrual flow, severe abdominal pain, headaches, or depression.

DMPA injections are over 99% effective if the injections are received according to the correct schedule. A woman using injection contraceptives has the advantage of being capable of becoming pregnant at a later time, if desired, simply by discontinuing use. DMPA does not increase a woman's risk of cancer, including breast cancer, and greatly reduces her risk of developing uterine cancer.

Injectable hormonal contraceptives do not protect against sexually transmitted infections.

Contraceptive patch: Ortho-Evra

An adhesive patch has been developed that provides hormonal contraception through the skin, which is known as a transdermal (through the skin) delivery system. The patch is about the size of a half-dollar and can be worn on the arm, abdomen, or buttocks. A woman wears the patch for a week and then replaces it with a new patch.

These patches, called Ortho-Evra (ethinyl estradiol/norelgestromin patch-topical), are similar to the pill in that they contain both estrogen and progesterone. Ortho-Evra should be just as effective in preventing pregnancy as the pill. Ortho-Evra is similar to the pill in that it suppresses ovulation and has the advantage of improved compliance and convenience due to weekly administration. A woman only needs to remember to replace the patch once a week instead of being required to remember taking a pill every day. However, some studies have shown that the contraceptive patch may be associated with a greater risk of negative side effects, such as blood-clotting problems, than oral contraceptive pills.

Women who have medical reasons why oral contraceptives are not recommended (such as already having an underlying tendency toward blood clotting) may find that their prescribing physician also recommends against Ortho-Evra because of the similarity in the hormone ingredients of both types of contraceptives.

It is important to ensure that the patch makes good contact with the skin. The patch could be a problem for those women who sweat a lot and/or take frequent showers because moisture can interfere with the patch's contact with the skin. Some women may also experience skin irritation at the site of the patch. Furthermore, contraceptive failure may be a risk in heavier women (those who weight over 198.4 pounds, or 90 kilograms).

As with all other hormonal methods of birth control, the patch will not protect a woman against sexually transmitted infections.

Vaginal ring (NuvaRing)

A ring-shaped device that contains the hormones estradiol and etonogetrel (a progestin) can be placed in the vagina. It remains in place for three weeks continuously, then it is removed for one week to allow for a menstrual period. It continuously releases low levels of the hormone into the bloodstream for the entire three weeks.

There is currently one brand available in the U.S., NuvaRing (etonogestrel/ethinyl estradiol-vaginal ring). It is about 99% effective in preventing pregnancy, having the same high effectiveness as the other hormonal methods of contraception. The incidence of hormone-related side effects is similar to those seen with other hormonal contraceptive methods such as the pill and the patch. Vaginal discharge can sometimes occur as a side effect of the ring preparation.

NuvaRing does not protect against sexually transmitted infections.

Contraceptive implants (Implanon)

A contraceptive implant known as Implanon is available in the U.S. Implanon provides contraception by the slow release of the progestin etonogestrel over a period of three years. Implanon is a thin rod that is inserted in the upper arm under local anesthesia. Protection from pregnancy occurs within 24 hours of insertion of the rod. One advantage of the Implanon rod is that fertility rapidly returns after removal of the rod.

Preliminary studies of the product showed that it was generally well tolerated and effective in preventing pregnancy. However, these studies showed that irregular bleeding is a possible side effect of the product.

As with all other hormonal methods of birth control, Implanon will not protect a woman against sexually transmitted infections.

Medications

• Birth Control Pills (Oral Contraceptives)
• medroxyprogesterone, Provera, Depo-Provera, Depo-Sub Q Provera 104
• norethindrone-oral contraceptive, Micronor, Nor-Q-D