Purpose: Previous studies have emphasised that women with pre-existing mood disorders are more inclined to discontinue hormonal contraceptive use. However, few studies have examined the effects of combined oral contraceptives (COC) on mood in women with previous or ongoing mental disorders. Materials and methods: This is a supplementary analysis of an investigator-initiated, double-blinded, randomised clinical trial during which 202 women were treated with either a COC (1.5mg estradiol and 2.5mg nomegestrolacetate) or placebo during three treatment cycles. The Mini International Neuropsychiatric Interview was used to collect information on previous or ongoing mental disorders. The primary outcome measure was the total change score in five mood symptoms on the Daily Record of Severity of Problems (DRSP) scale in the intermenstrual phase of the treatment cycle. Results: Women with ongoing or previous mood, anxiety or eating disorders allocated to COC had higher total DRSP -scores during the intermenstrual phase of the treatment cycle in comparison with corresponding women randomised to placebo, mean difference 1.3 (95% CI 0.3-2.3). In contrast, among women without mental health problems, no difference in total DRSP -scores between COC- and placebo users was noted. Women with a risk use of alcohol who were randomised to the COC had higher total DRSP -scores than women randomised to placebo, mean difference 2.1 (CI 95% 1.0-3.2). Conclusions: Women with ongoing or previous mental disorders or risk use of alcohol have greater risk of COC-induced mood symptoms. This may be worth noting during family planning and contraceptive counselling.

Objectives: We aimed to develop and pilot-implement an evidence-informed toolkit (SEXual health Identification Tool; SEXIT) for identifying young people exposed to or at risk of sexual ill health, at Swedish youth clinics, and to investigate SEXITs potential to identify young people in need of special care and monitoring. Methods: The SEXIT toolkit was developed, validated and pilot-implemented at three Swedish youth clinics. Pre-implementation staff readiness was assessed and youth clinic visitors responses to SEXIT were analysed. Results: All staff perceived a need for screening for sexual risk-taking and exposure. The response rate from 268 youth clinic visitors (aged 15-24 years) was 86%. Half of the visitors had one or no variable associated with sexual ill health, a third had two or three, and 15% reported between four and seven variables. The most common variables were alcohol use, three or more sexual partners in the past year and previous chlamydia. Visitors rated SEXIT as important and not uncomfortable or difficult to answer. Conclusions: The SEXIT toolkit was found to be feasible and highly acceptable in a clinical setting. The use of SEXIT may facilitate important questions on sexual risk-taking and sexual ill health to be raised with youth clinic visitors.

Objectives To investigate sexual behaviour and contraceptive use among first-year high school students in two Swedish cities in 2009, to compare male and female students, students in theoretical and vocational study programmes, and their sexual behaviour with that reported in 1979, 1989 and 1999. Methods In a cluster sample of 20 classes, students (N = 387), median age 16 years, completed a questionnaire consisting of 46 questions. Results More girls than boys had experienced petting (p <= 0.003) and had received oral sex (p <= 0.01). More boys than girls had masturbated (p <= 0.0001) and watched pornography (p <= 0.0001). The median age at first sexual intercourse was 15 years. Students in vocational programmes were more sexually experienced compared to their theoretical peers. The proportion of students having had sexual intercourse (p <= 0.0002), and contraceptive use at first (p <= 0.0001) and latest (p <= 0.0001) sexual intercourse increased from 1979 to 2009. Alcohol use at first intercourse decreased over the period (p <= 0.0001). Conclusions Girls were more sexually experienced than boys, as were students in vocational programmes compared to their theoretical peers; this should be considered when tailoring sex education and counselling. Over time, an increase in students having had sexual intercourse, and contraceptive use at first and latest sexual intercourse was found.

Objectives: A substantial proportion of women who undergo an abortion continue afterwards without switching to more effective contraceptive use. Many subsequently have repeat unintended pregnancies. This study, therefore, aimed to identify and describe health professionalg experiences of providing contraceptive counselling to women seeking an abortion. Methods: We interviewed 21 health professionals (HPs), involved in contraceptive counselling of women seeking abortion at three differently sized hospitals in Sweden. The interviews were recorded and transcribed verbatim and analysed using conventional qualitative content analysis. Results: Three clusters were identified: Complex counselling, Elements of counselling and Finding a method. HPs often experienced consultations including contraceptive counselling at the time of an abortion as complex, covering both pregnancy termination and contraceptive counselling. Women with vulnerabilities placed even greater demands on the HPs providing counselling. The HPs varied in their approaches when providing contraceptive counselling but also in their knowledge about certain contraception methods. HPs described challenges in finding out if women had found an effective method and in the practicalities of arranging intrauterine device (IUD) insertion post-abortion, when a woman asked for this method. Conclusions: HPs found it challenging to provide contraceptive counselling at the time of an abortion and to arrange access to IUDs post-abortion. There is a need to improve their counselling, their skills and their knowledge to prevent repeat unintended pregnancies.

Objectives: The primary objective of the study was to investigate whether the choice of long-acting reversible contraception (LARC) was associated with the risk of abortion over a period of 24 months postpartum. The secondary objective was to analyse whether other significant factors were affecting the risk of abortion during this period. Methods: In this retrospective cohort study, we analysed 11,066 women who had delivered in three Swedish cities during 2013 and 2014. Demographic and medical variables were obtained from medical records. Attendance at the postpartum visit, choice of postpartum contraception and history of abortion was noted. Logistic regression analysis was performed to assess factors associated with the risk of abortion. The main outcome measure was the proportion of women with abortion up to 24 months postpartum. Results: Data from 11,066 women were included in the final analysis. Within 12-24 months after delivery 2.5% of women had an abortion. The choice of LARC after childbirth reduced the risk of subsequent abortion (odds ratio 0.74; 95% confidence interval [CI] 0.60, 0.91; p = .005). Smoking, age amp;lt;25 years and have had a previous abortion significantly increased the risk of abortion during follow-up, whereas exclusive breastfeeding decreased the risk. Conclusions: Increasing the proportion of women who choose LARC postpartum could decrease the risk of abortion for up to 2 years after childbirth.

Objectives To examine, among young women, the association of individual hormonal contraceptives, within two broad groupings, with antidepressant therapy. less thanbrgreater than less thanbrgreater thanMethods In a nationwide register-based study, we examined the prescription rates of antidepressant drugs in relation to individual combined hormonal and progestin-only contraceptives among Swedish women aged 16-31 years (N = 917,993). Drug data were obtained from the Swedish Prescribed Drug Register for the period 1 July 2005-30 June 2008. Data on the total population of women aged 16-31 in 2008 were obtained from the Total Population Register of Statistics Sweden. The proportion of women using both hormonal contraception and antidepressants, and odds ratios (ORs) for antidepressant use for hormonal contraceptive users versus non-users, were calculated, the latter by logistic regression, for each formulation. less thanbrgreater than less thanbrgreater thanResults The highest antidepressant OR in all age groups, particularly in the 16-19 years age group, related to medroxyprogesterone-only, followed by etonogestrel-only, levonorgestrel-only and ethinylestradiol/norelgestromin formulations. Oral contraceptives containing ethinylestradiol combined with lynestrenol or drospirenone had considerably higher ORs than other pills. ORs significantly lower than 1 were observed when ethinylestradiol was combined with norethisterone, levonorgestrel or desogestrel. less thanbrgreater than less thanbrgreater thanConclusion The association between use of hormonal contraceptives and antidepressant drugs varies considerably within both the combined hormonal contraceptive and the progestin-only groups.

Objective: To increase the understanding of women who experience negative effects on sexual function when using hormonal contraception. Methods: We performed 24 in-depth interviews with women who had previously experienced negative sexual function effects while using hormonal contraceptives. The thematic analysis method was used. Results: After experience comes insight, Lubrication and desire go hand in hand, Mental wellbeing comes before desire and The contraceptive counsellor potentially facilitates insight and decision-making were the main themes found in the study. Conclusions: This selected group of women described lubrication difficulties and decreased sexual desire associated with both contraceptive use and the menstrual cycle. Contraceptive use became easier with age and with better understanding. The contraceptive counsellor could facilitate the process. Further choice between hormonal or non-hormonal contraceptive methods depended primarily on experienced adverse effects on mood, and secondarily on sexual function, weighed against the advantages or disadvantages experienced during the persons own menstrual cycle.

Objectives The aim of the study was to determine whether a decrease in sexual desire is more prevalent among women using hormonal contraception than among women using hormone-free contraception, and whether a decrease increases the risk of changing to another contraceptive method. Methods A validated questionnaire was posted to 3740 women (aged 22, 25 or 28 years) living in Sweden. Descriptive statistics were used to present the results; differences between groups were tested using χ(2) analyses. A multiple logistic regression model was used for analysis of possible confounders. Results The response rate was 50%. The majority (81%) of respondents used some kind of contraception, and 88% were generally satisfied with the method used. Regardless of the type of method, 27% of hormonal contraceptive users reported a decrease in sexual desire that they attributed to their use of hormonal contraception, whereas only 12% of women using hormone-free contraception reported a decrease in sexual desire (p<0.01). This twofold risk of a decrease in sexual desire was shown in the multiple regression analysis to be independent of age group, depression, BMI, educational level and parity. However, having a partner was found to be a factor of equal importance: women with partners experienced reduced desire twice as often as women without partners. The observed odds ratio for planning to stop hormonal contraception or to change to a different type due to reduced desire was 8.16 (95% confidence interval 6.65-10.1) among women who had had the same experience during a previous period of hormonal contraceptive use. Conclusions Women using hormonal contraception were more likely to experience reduced sexual desire compared with women using hormone-free contraception. Experiencing reduced desire was a strong predictive factor for women to change contraceptive method.

Objective To compare contraceptive services provided by family planning clinics in Linkoping and Norrkoping in Ostergotland County, Sweden. The two cities are of similar size but have different socio-demographic profiles. The abortion rate in Link ping (15.3 per 1000) is substantially lower than in Norrkoping (21.1 per 1000). Methods The study was performed in two steps. First, the clinics providing contraceptive services in the two cities were studied using ten pre-defined quality indicators. Thereafter, 11 healthcare providers were interviewed: six in Linkoping and five in Norrkoping. The interviews were analysed using qualitative content analysis. Results No differences were found in the organisation of contraceptive care in the two cities. Neither city met the criteria for five of the ten quality indicators. The analysis of the interviews generated four themes: Guidelines and electronic record template, Criteria for good contraceptive counselling, Availability of contraception, and Sexual health. The interviews revealed that the clinical leadership in Norrkoping was insuffincient. Conclusion Clinics in the two cities are organised in the same way so that differences in abortion rates cannot be related to differences in organisation. The reasons for the differences in abortion rates in the two cities have yet to be determined.

Purpose: This study aimed to explore the prescription of different contraceptive methods to Swedish women with obesity and to compare the pattern of prescription and adherence to treatment between this group and normal-weight women. Materials and methods: This study included 371 women with obesity and 744 matched normal-weight women, aged 18-40. Medical records were scrutinised for the period 1 January 2010 to 31 December 2014. The retrieved variables included: background characteristics, prescribed contraceptive methods, adverse effects, duration of treatment, reason for discontinuation and bleeding pattern. Result: Progestin-only pills were mainly prescribed to women with obesity (44% vs. 20%, p = 0.001) whereas combined hormonal contraception was mainly prescribed to normal-weight women (60% vs. 21%, p amp;lt; 0.0001). Thirty-three percent vs. 25% (p = 0.003) discontinued their contraceptive method within 1 year. The most commonly declared reason for discontinuation was bleeding disturbance (14.7% vs. 9.6%, p = 0.008). Conclusion: The most commonly prescribed contraceptive method in women with obesity was progestin-only pills, but surprisingly many women with obesity were prescribed combined hormonal contraception despite current Swedish and European guidelines. Incident users with obesity were significantly more likely to discontinue their contraceptive method within the first year of the study period, compared with incident normal-weight users.

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Objective Induced abortion is more frequent in Sweden than in many other Western countries. We wanted to investigate attitudes and knowledge about induced abortion among politicians responsible for healthcare in three Swedish counties. Method A study-specific questionnaire was sent to all 375 elected politicians in three counties; 192 (51%) responded. Results The politicians stated that they were knowledgeable about the Swedish abortion law. More than half did not consider themselves, in their capacity as politicians, sufficiently informed about abortion-related matters. Most politicians (72%) considered induced abortion to be primarily a womens rights issue rather than an ethical one, and 54% considered 12 weeks gestational age an adequate upper limit for induced abortion. Only about a third of the respondents were correctly informed about the number of induced abortions annually carried out in Sweden. Conclusion Information and knowledge on induced abortion among Swedish county politicians seem not to be optimal. Changes aimed at reducing the current high abortion rates will probably not be easy to achieve as politicians seem to be reluctant to commit themselves on ethical issues and consider induced abortion mainly a womens rights issue.

Objective: To investigate the knowledge of reproductive physiology and anatomy among adolescents and young adults in Sweden, and to evaluate the education obtained on these issues. Methods: Two hundred and nine study specific questionnaires were distributed, of which 206 were answered by students in primary school, upper secondary school and at first year of university. A total knowledge score based on 21 out of the 35 questions in the questionnaire was calculated. As only 44 of the 206 respondents answered all the questions a revised score was also calculated, in which partial dropouts were interpreted as wrong answers. Results: The mean of the total knowledge score was 28.7 out of 54 among the 44 respondents answering all questions, and the revised knowledge score was 24.0. The level of knowledge tended to be higher in older age groups, among women, as well as among respondents who had visited a Youth clinic. The time of ovulation was known by 21.4% of men compared to 63.4% of women. Almost 50% of the students knew one mechanism whereby oral contraceptives act to protect against pregnancy. Of the respondents, 77.2% knew of Chlamydia trachomatis but the knowledge of other STIs, like condyloma, was poorer (16.5%). Reasons for infertility were relatively well known among the respondents. Of the respondents, 57.5% stated that they had not received enough information on reproductive issues. Conclusions: The students have not achieved sufficient knowledge concerning sexual and reproductive matters that they, according to the national curriculum, should have attained by the end of the 9th grade. An improvement of the quality of the education, adapted to the students' age and pre-existing knowledge, and a review of the contents of the education is therefore needed. © 2006 European Society of Contraception.

Objectives To identify perceived deficiencies in the quality of abortion care among healthy women and those with mental stress. Methods This multi-centre cohort study included six obstetrics and gynaecology departments in Sweden. Posttraumatic stress (PTSD/PTSS) was assessed using the Screen Questionnaire-Posttraumatic Stress Disorder; anxiety and depressive symptoms, using the Hospital Anxiety Depression Scale; and abortion quality perceptions, using a modified version of the Quality from the Patients Perspective questionnaire. Pain during medical abortion was assessed in a subsample using a visual analogue scale. Results Overall, 16% of the participants assessed the abortion care as being deficient, and 22% experienced intense pain during medical abortion. Women with PTSD/PTSS more often perceived the abortion care as deficient overall and differed from healthy women in reports of deficiencies in support, respectful treatment, opportunities for privacy and rest, and availability of support from a significant person during the procedure. There was a marginally significant difference between PTSD/PTSS and the comparison group for insufficient pain alleviation. Conclusions Women with PTSD/PTSS perceived abortion care to be deficient more often than did healthy women. These women do require extra support, relatively simple efforts to provide adequate pain alleviation, support and privacy during abortion may improve abortion care.

Objectives To describe the prevalence and pattern of traumatic experiences, to assess the prevalence of posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS), to identify risk factors for PTSD and PTSS, and to analyse the association of PTSD and PTSS with concomitant anxiety and depressive symptoms in women requesting induced abortion. less thanbrgreater than less thanbrgreater thanMethods A Swedish multi-centre study of women requesting an induced abortion. The Screen Questionnaire - Posttraumatic Stress Disorder was used for research diagnoses of PTSD and PTSS. Anxiety and depressive symptoms were evaluated by the Hospital Anxiety and Depression Scale (HADS). less thanbrgreater than less thanbrgreater thanResults Of the 1514 respondents, almost half reported traumatic experiences. Lifetime-and point prevalence of PTSD were 7% (95% confi dence interval [CI]: 5.8-8.5) and 4% (95% CI: 3.1-5.2), respectively. The prevalence of PTSS was 23% (95% CI: 21.1-25.4). Women who reported symptoms of anxiety or depression when requesting abortion were more likely to have ongoing PTSD or PTSS. Also single-living women and smokers displayed higher rates of ongoing PTSD. less thanbrgreater than less thanbrgreater thanConclusions Although PTSD is rare among women who request an induced abortion, a relatively high proportion suffers from PTSS. Abortion seeking women with trauma experiences and existing or preexisting mental disorders need more consideration and alertness when counselled for termination.

OBJECTIVES: The relation between the use of different hormonal contraceptives and antidepressant therapy was investigated. METHODS: In a nationwide cross-sectional study among all women in Sweden aged 16-31, drug expenditure data on hormonal contraceptives and antidepressants were obtained from the Swedish Prescribed Drug Register. Odds ratios (ORs) for antidepressant use were calculated by logistic regression for progestin-only users versus non-users as well as for combined hormonal contraceptive (CHC) users versus non-users. RESULTS: In the study population (N = 917,993), 58.9% were hormonal contraceptive users, and 8.5% were antidepressant users. The age-pattern for antidepressant ORs differed between the two types of users of contraceptives; progestin-only users had significant ORs above 1 in all age groups whereas among CHC users the OR was above 1 solely in those aged 16-19. The largest difference between types of users was seen in the age group 16-19 in which women resorting to a progestin-only contraceptive had a 67% (95% confidence interval: 57- 78%) higher antidepressant use than women treated with a CHC. CONCLUSION: Progestin-only contraceptive users resorted to antidepressants more than users of CHCs. This phenomenon is particularly pronounced among teenagers. Therefore, special attention should be given to young women's mental history when prescribing hormonal contraceptives and vice versa: the contraceptive history should be taken into account when prescribing antidepressants.