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Patients should be counseled about the various types of long-term contraception, i.e., contraceptive methods that are effective and reversible and do not require daily application: for example, gestagen implants or copper or hormone spirals. Such methods were, at one time, mainly used by women over age 35 who did not want to have any more children. But women are now older on the average when they bear their first child (2017: 29 years and 10 months), and the period of time in which they want contraception before their first pregnancy has become correspondingly longer (e5). As a result, long-term contraception (intrauterine methods, gestagen implants and injections) has become a more commonly used option in younger patients. Depot medroxyprogesterone acetate (MPA) is not suitable for this purpose, because ovulation may not return for up to nine months after it is discontinued (e1).




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Long-term contraception was, at one time, mainly used by women over age 35 who did not want to have any more children. Because women are now older on the average when they bear their first child, long-term contraception has become a more common option for younger women as well.


Obesity is considered a risk factor for the use of combined oral contraceptives both in the WHO recommendations and in the German Red Hand Letter (2, 4). The WHO recommendations assign a score of 2 (=no contraindication) to the used of combined oral contraceptives in obese women who have no further risk factors, but this is only rarely the case, and meticulous history-taking is needed to determine which further risk factors these patients have. If hypertension, hyperlipidemia, or diabetes mellitus is present, then another contraceptive method should be chosen, e.g., gestagens (1). Obese women have a tenfold elevation of the thrombotic risk under treatment with combined oral contraceptives, compared to women of normal weight who are not taking combined oral contraceptives (5). The more obese the patient, the higher the risk (up to a 24-fold elevation) (6).


Smoking is the single most important risk factor; the factor V Leiden mutation, which is not uncommon, is a further one. The risk of thrombosis in women with the factor V Leiden mutation who take oral contraceptives is likewise influenced by the particular gestagen contained in the preparation.


The types of hepatic tumor include benign lesions, such as hemangioma, adenoma, and focal nodular hyperplasia (FNH), as well as malignant ones, such as hepatocellular carcinoma and hepatoblastoma. When combined oral contraceptives are taken, hemangiomas can develop, even in adolescents (1). FNH and adenomas can arise after many years of use of combined oral contraceptives (COC); there is a positive correlation with the dose of ethinyl estradiol. The long-term use of COC has been found to be associated with an elevated risk of hepatic disease, although the evidence for this comes mainly from older studies in which the COC that were used contained 50 µg of ethinyl estradiol (1). More recent studies have shown that, in women with focal nodular hyperplasia, the use of low-dose COC does not lead to any progression or regression of the hepatic findings (28, 29). According to a meta-analysis, the evidence regarding malignant tumors, such as hepatocellular carcinoma, is mixed (30). In one review, six studies were found that showed a two- to twenty-fold elevation of the risk (30), while a further study showed no statistically significant association of combined hormonal contraception with hepatic tumors (e20).


COC and all other hormonal preparations are absolutely contraindicated in patients with hepatic hemangioma, hepatocellular adenoma, or hepatocellular carcinoma, as well as in patients with a personal or family history of these lesions. Hemangiomas and FNH reach their peak prevalence (as high as 7%) in women aged 20 to 50. In women with FNH, micropills with up to 20 µg of ethinyl estradiol can be used (WHO group 2) (2, e3). Alternatively, intrauterine contraceptive methods or gestagens can be used.


There are more men than women in treatment for substance use disorders. However, women are more likely to seek treatment for dependence on sedatives such as anti-anxiety and sleep medications.14 In addition, although men have historically been more likely to seek treatment for heroin use, the rate of women seeking treatment has increased in recent decades.154


Substance use disorders may progress differently for women than for men. Women often have a shorter history of using certain substances such as cocaine,155 opioids,42 marijuana,42,43,156 or alcohol.42,157,158 However, they typically enter substance use disorder treatment with more severe medical, behavioral, psychological, and social problems. This is because women show a quicker progression from first using the substance to developing dependence.159


Many women who are pregnant or have young children do not seek treatment or drop out of treatment early because they are unable to take care of their children; they may also fear that authorities will remove their children from their care. The combined burdens of work, home care, child care, and other family responsibilities, plus attending treatment frequently, can be overwhelming for many women. Successful treatment may need to provide an increased level of support to address these needs.7


Research shows that women are less likely to try to quit smoking and more likely to relapse if they do quit.90 Nicotine-replacement options, such as the patch or gum, are not as effective for women as for men, and nicotine withdrawal may be more intense for women.160,161 Nicotine craving162 and withdrawal163 vary across the menstrual cycle, which may further complicate a woman's attempts to quit.


Some women continue to smoke because they are afraid they will gain weight. However, research shows only a modest weight gain after quitting. The average smoker gains 6 to 10 pounds after quitting smoking, but certain diet and lifestyle changes can reduce the risk of weight gain. If a person does gain weight, the average person loses much of the extra weight within 6 months.164 In fact, long-term quitters gain, on average, only 2 pounds.165 Most importantly, the health benefits of quitting smoking far exceed the risks of gaining a few pounds. Quitting also decreases risks for various types of cancers, heart attack, and lung disease.164


Intensive outpatient treatment, which provides a higher treatment level than traditional outpatient programs but does not require structured residential living, has produced positive results for pregnant women. Pregnant women are more likely to stay in these treatment programs if they provide services such as child care,168 parenting classes, and vocational training.169,170


Pregnant women who are addicted to opioid pain relievers or heroin face special problems because the baby can be born dependent. Currently, the U.S. Food and Drug Administration has not approved medications to treat opioid-dependent pregnant women, but methadone or buprenorphine maintenance combined with prenatal care and a comprehensive drug treatment program can improve many of the adverse outcomes associated with untreated opioid use disorder.166,171 In general, it is neither recommended nor necessary for pregnant women to cease methadone or buprenorphine treatment.167,171 However, newborns exposed to methadone during pregnancy can require treatment for withdrawal symptoms.


Some studies suggest that buprenorphine (Suboxone, Subutex) has some advantages over single-dose methadone as a treatment for opioid use disorder in pregnant women. Infants born to mothers treated with buprenorphine had fewer symptoms of dependence and reduced length of hospital stay compared to those treated with methadone.172


Pregnant women who take buprenorphine for opioid use disorder during pregnancy should be aware that the amount of buprenorphine passed through breast milk may be inadequate to prevent opioid withdrawal in their infant. In some cases, treatment of the infant may be required.173


NIDA. "Sex and Gender Differences in Substance Use Disorder Treatment." National Institute on Drug Abuse, 13 Apr. 2021, -reports/substance-use-in-women/sex-gender-differences-in-substance-use-disorder-treatment


NIDA. Sex and Gender Differences in Substance Use Disorder Treatment. National Institute on Drug Abuse website. -reports/substance-use-in-women/sex-gender-differences-in-substance-use-disorder-treatment. April 13, 2021


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