Women’s Health and Travel
Women’s Health and Travel
Reviewed by Michele Barry, MD
At the international society of travel medicine in Montreal, a workshop was held which included pertinent issues for women and travel. Some specific subjects discussed were issues of contraception and travel, pregnancy and travel, menstruation and travel, violence toward women and travel, post-exposure emergency contraception (morning-after) regimens and post-exposure HIV prophylaxis regimens for high risk sex or rape. Issues of violence and rape for single women travelers were highlighted, and participants from emergency overseas services described how, with increasing frequency, they were treating women who were the victims of violence during travel.
| Table 1-Methods of Contraception, Failure Rates, Disadvantages, and Advantages | |||
| Method | Failure Rate | Disadvantages | Advantages |
| Periodic abstinence | 20% | ||
| Spermicide alone | 6-21% | • vaginal irritation | • may protect against some STDs |
| • lack of availability | • noneffective vs. HIV | ||
| • shelf life in tropical | |||
| • climate unknown | |||
| Cervical cap with spermicide | 11.5-18% | • cervical irritation | • protection against some STDs |
| • pap smear abnormalities | • noneffective vs. HIV | ||
| • same as above | |||
| Diaphragm with spermicide | 6-18% | • cervical irritation | • protection against some STDs |
| • pap smear abnormalities | • noneffective vs. HIV | ||
| • risk of UTI | |||
| • same as above | |||
| Condom | 1-5-2% | • poor acceptability | • protection against some STDs |
| 5-21% | • allergic reactions | ||
| •? availability of good quality | |||
| IUD | |||
| progesterone T | 1.5-2% | • ectopic pregnancy | • menstrual blood loss |
| 0.6-0.8% | • rare uterine perforation | (progesterone) | |
| • menstrual blood loss (copper) | • Cu can be left in place 10 years | ||
| Medroxyprogesterone | 0.3% | • menstrual irregularities | • effective for 3 months |
| acetate (Depo-Provera) | • headache | ||
| • weight gain | |||
| • acne | |||
| Oral contraception | 0.1% | • rare thromboembolism and stroke | • protection against ovarian cancer, |
| Combined | • MI in older smokers | PID, anemia, and dysmenorrhea | |
| • nausea, headaches, depression | |||
| Progesterone | 0.5% | • irrregular, unpredictable bleeding | • protection against PID, anemia, |
| and dysmenorrhea | |||
| Levonorgestrel | 0.09% | • menstrual irregularities | • ease of use |
| Sub-dermal implant | • headache, weight gain, | • effective for 5 years | |
| Norplant | • acne, removal problems | ||
Pros and cons of contraception and travel are summarized in Table 1. A provocation discussion ensued amongst participants advocating continuation of oral contraception pill (OCP) regimens without the seven-day break to prevent menses during difficult travel. Although at times break-through bleeding can occur with continuous OCP, the majority of women can avoid having a period during this time period. Alternative menstrual devices for travel to countries where tampons or sanitary napkins are unable to be obtained easily were discussed during the workshop (see Table 2).
| Table 2-Alternative Menstrual Devices | |||
| Device | Disadvantages | ||
| "The Keeper" | |||
| menstrual cap | • leakage | ||
| • messy and sometimes | |||
| difficult to remove | |||
| • holds 1 ounce | |||
| • difficult to clean | |||
| in public facilities | |||
| Cotton flannel reusable | |||
| menstrual pads | • uncomfortable and not | ||
| • Belted pads | conducive to daily pace | ||
| of active women | |||
| • Velcro or snaps | • leakage | ||
| • require heavy laundering | |||
Methods of emergency contraception are described in Table 3 for women who have intercourse without protection during travel, and an algorithm for prevention of pregnancy is shown in Table 4 for the woman who misses a pill or two during travel (see page 37).
| Table 3-Methods of Emergency Contraception | ||||
| Regimen | Time After Intercourse | Status of Method | Reported Efficacy | Source of Data |
| Up to: | ||||
| Estrogen and progestin | 72 hr | Licensed in some countries | 75-80% of pregnancies | Meta-analysis of 100 studies |
| (5 mg of ethinyl estradiol | since early 1980 (e.g., United | prevented | involving > 5000 women | |
| daily for 5 days) | Kingdom, the Netherlands) | |||
| 0.5 mg of levonorgestrel | available unlicensed in | |||
| given twice, with 12 hr | the appropriate combination | |||
| between doses | of oral-contraceptive pills | |||
| Levonorgestrel | (0.75 mg 48 hours (possibly | Licensed in some countries in | Equivalent to estrogen- | One randomized trial |
| given twice, with 12 hr | up to 72 hours) | Eastern Europe and Asia | progestin | involving 350 women |
| between doses | ||||
| High-dose estrogen (e.g., 72 hr | Licensed in the Netherlands; | Equivalent to estrogen- | Randomized trial | |
| 5 mg of ethinyl estradiol | little used elsewhere | progestin | involving 250 women; | |
| daily for 5 days) suggested | early trials | |||
| failure rates < 1% | ||||
| Mifepristone (a single | 72 hr | Widely used in China in a | 100% effective | Two randomized trials |
| 600-mg dose) RU486 | variety of lower doses; not | (ovulation and | involving a total of | |
| licensed anywhere else for implantation) | 600 women | |||
| emergency contraception | ||||
| Danazol (400-800 mg | 72 hr | Used only under research | Reports vary from failure | Two randomized trials, |
| given twice 12 hr apart | conditions | rates of < 1% to ineffective | one involving > 1700 | |
| or 400 mg given 3 times | women and failure rates | |||
| at intervals of 12 hr | of about 1%, and the | |||
| other involving 193 | ||||
| women suggesting little | ||||
| or no effect | ||||
| Copper intrauterine | Up to 5 days after the | Available worldwide | Failure rates < 1% | Meta-analysis of 20 |
| device | earliest estimated day | but not licensed for | published studies | |
| of ovulation | emergency contraception | involving > 8000 women | ||
A great deal of discussion was generated about post-exposure HIV prophylaxis (PEP) after sexual encounters and a strong argument was made for PEP after high risk sexual encounters. Triple or double therapy was recommended for unprotected receptive vaginal exposure with a known HIV positive partner or unprotected receptive anal exposure with a partner of unknown HIV status. Risk for transmission in these settings can be comparable to a high-risk needle stick. (The telephone hotline for emergency contraception information is 1-800-584-9911.)
References
1. Lurie P, et al. Postexposure prophylaxis after nonoccupational HIV exposure: Clinical, ethical, and policy considerations. JAMA 1998;280(20):1769-1773.
2. Pinkerton SD, et al. Cost-effectiveness of post-exposure prophylaxis following sexual exposure to HIV. AIDS 1998;12(9):1067-1078.
3. Samuel B, Barry M. The pregnant traveler. Infect Dis Clin North Am 1998;12(2):325-353.
4. Glasier A. Emergency postcoital contraception. N Engl J Med 1997;337(15):1058-1064.
5. Glasier A. Emergency contraception in a travel context. J Travel Med 1999;6:1-2.
6. Alternative feminine hygiene. Ms. Magazine, March 1993.
Which of the following are disadvantages of the use of a diaphragm with spermicide?
a. Cervical irritation
b. Risk of UTI
c. Pap smear abnormalities
d. All of the above
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