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

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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

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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

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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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