David L. Eisenberg

Association of age and parity with intrauterine device expulsion.

OBJECTIVE: To investigate whether age 14 to 19 years and nulliparity are associated with expulsion of levonorgestrel and copper intrauterine devices (IUDs). METHODS: This was a planned secondary analysis of the Contraceptive CHOICE Project. We used Kaplan–Meier survival analysis to estimate expulsion rates for the first levonorgestrel or copper IUD received during study participation. Cox proportional hazards regression models were used to investigate baseline characteristics associated with expulsion. RESULTS: A total of 5,403 females were included; 4,219 (78%) used the levonorgestrel IUD and 1,184 (22%) used the copper IUD. There were 432 initial expulsions reported. The 36-month cumulative expulsion rate was 10.2 per 100 IUD users and did not vary by IUD type (levonorgestrel IUD 10.1 compared with copper IUD 10.7, P=.99). In the bivariate analysis, multiple characteristics including age, nulliparity, immediate postabortion insertion, and heavy menses were associated with expulsion. The cumulative rate of expulsion was lower in nulliparous women compared with parous women (8.4 compared with 11.4; P<.001) and higher in females aged 14 to 19 compared with older women (18.8 compared with 9.3; P<.001). After adjusting for confounders and stratifying by IUD type, the hazard ratio of expulsion for females aged 14 to 19 years was 2.26 (95% confidence interval [CI] 1.68–3.06) for the levonorgestrel IUD and 3.06 (95% CI 1.75–5.33) for the copper IUD. Compared to parous levonorgestrel IUD users, expulsion was lower for nulliparous levonorgestrel IUD users (adjusted hazard ratio 0.59, 95% CI 0.44–0.78). CONCLUSION: IUD expulsions were not increased in nulliparous females. More expulsions were observed in females aged 14 to 19 compared with older women regardless of parity or IUD type. LEVEL OF EVIDENCE: II

Knowledge of contraceptive effectiveness

OBJECTIVEnThe purpose of this study was to determine womens knowledge of contraceptive effectiveness.nnnSTUDY DESIGNnWe performed a cross-sectional analysis of a contraceptive knowledge questionnaire that had been completed by 4144 women who were enrolled in the Contraceptive CHOICE Project before they received comprehensive contraceptive counseling and chose their method. For each contraceptive method, women were asked what percentage would get pregnant in a year: <1%, 1-5%, 6-10%, >10%, dont know.nnnRESULTSnOverall, 86% of subjects knew that the annual risk of pregnancy is >10% if no contraception is used. More than 45% of women overestimate the effectiveness of depo-medroxyprogesterone acetate, pills, the patch, the ring, and condoms. After adjustment for age, education, and contraceptive history, the data showed that women who chose the intrauterine device (adjusted relative risk, 6.9; 95% confidence interval, 5.6-8.5) or implant (adjusted relative risk, 5.9; 95% confidence interval, 4.7-7.3) were significantly more likely to identify the effectiveness of their method accurately compared with women who chose either the pill, patch, or ring.nnnCONCLUSIONnThis cohort demonstrated significant knowledge gaps regarding contraceptive effectiveness and over-estimated the effectiveness of pills, the patch, the ring, depo-medroxyprogesterone acetate, and condoms.

Three-year efficacy and safety of a new 52-mg levonorgestrel-releasing intrauterine system

OBJECTIVEnTo assess 3-year data on the efficacy and safety of a new 52-mg levonorgestrel intrauterine contraceptive (LNG20) designed for up to 7 years use.nnnSTUDY DESIGNnNulliparous and parous women aged 16-45 years at enrollment with regular menstrual cycles and requesting contraception were enrolled in an open-label, partially randomized trial to evaluate LNG20. The primary outcome was pregnancy rate for women aged 16-35 years calculated as the Pearl Index. Women aged 36-45 years received LNG20 for safety evaluation only. All participants had in-person or phone follow-up approximately every 3 months during the study.nnnRESULTSnA total of 1600 women aged 16-35 years and 151 women aged 36-45 years agreed to LNG20 placement, including 1011 (57.7%) nulliparous and 438 (25.1%) obese women. Successful placement occurred in 1714 (97.9%) women. Six pregnancies occurred, four of which were ectopic. The Pearl Index for LNG20 was 0.15 (95% CI 0.02-0.55) through Year 1, 0.26 (95% CI 0.10-0.57) through Year 2, and 0.22 (95% CI 0.08-0.49) through Year 3. The cumulative life-table pregnancy rate was 0.55 (95% CI 0.24-1.23) through 3 years. Expulsion was reported in 62 (3.5%) participants, most (50 [80.6%]) during the first year of use. Of women who discontinued LNG20 and desired pregnancy, 86.8% conceived spontaneously within 12 months. Pelvic infection was diagnosed in 10 (0.6%) women. Only 26 (1.5%) LNG20 users discontinued due to bleeding complaints.nnnCONCLUSIONnThe LNG20 intrauterine system is highly effective and safe over 3 years of use in nulliparous and parous women.nnnIMPLICATIONS STATEMENTnA new 52-mg levonorgestrel-releasing intrauterine system is effective and safe for nulliparous and parous women for at least 3 years.

Correlates of Dual-Method Contraceptive Use: An Analysis of the National Survey of Family Growth (2006–2008)

Objective. To analyze a nationally representative sample of women for correlates of dual-contraceptive-method use. Materials and Methods. We conducted an analysis of the National Survey of Family Growth, 2006–2008, a cross-sectional survey of reproductive-aged women in the United States. Results. Dual method use was reported by 7.3% of the 5,178 women in the sample. Correlates of higher rates of dual-contraceptive-method use included age younger than 36 years and nonmarried marital status. Lower rates of dual method use were observed for women with less than a high-school education and women without consistent health insurance in the past year. Compared to women using oral contraceptives, use of the contraceptive injection or long-acting reversible contraception was associated with lower dual-method use. Conclusions. The overall rate of dual-method use in the USA is low. Future interventions to promote dual method use should target high-risk groups with modifiable risk factors.

Continuation of the etonogestrel implant in women undergoing immediate postabortion placement.

OBJECTIVE: To estimate whether women who receive an immediate postabortion etonogestrel subdermal implant have higher discontinuation rates than women who undergo an interval insertion (insertion not associated with a recent pregnancy). METHODS: This was a secondary analysis of the Contraceptive CHOICE Project. We compared 12-month continuation rates for the subdermal implant between women undergoing immediate postabortion placement and women who underwent an interval placement. Continuation rates were compared using Kaplan-Meier estimator of survival function and Cox proportional hazard models. RESULTS: Over the study period, 141 women received the implant immediately postabortion and 935 women underwent an interval placement. The 12-month continuation rates were similar: 81.5% among women undergoing immediate postabortion placement and 82.8% among women undergoing interval placement (P=.54). In the survival analysis, women who received an immediate postabortion implant were no more likely to discontinue their method than women who had an interval placement (adjusted hazard ratio 1.04, 95% confidence interval 0.68–1.60). The most common reason given for discontinuation was frequent or irregular bleeding, which was reported by 65.4% of women discontinuing in the immediate postabortion group and 56.7% in the interval group. CONCLUSION: Women who undergo immediate postabortion placement of the subdermal implant have high rates of continuation that are equivalent to women undergoing interval insertion. Immediate postabortion long-acting reversible contraceptives should be available to women undergoing induced abortion to decrease the risk of repeat unplanned pregnancy. LEVEL OF EVIDENCE: II

Providing Contraception for Women Taking Potentially Teratogenic Medications: A Survey of Internal Medicine Physicians’ Knowledge, Attitudes and Barriers

ABSTRACTBACKGROUNDThe majority of women prescribed category D or X medications may not receive adequate contraceptive counseling or a reliable contraceptive method. Physicians who prescribe potentially teratogenic medications have a responsibility to provide women with contraceptive counseling, a method of highly-effective contraception, or both.OBJECTIVEInvestigate the knowledge, beliefs and barriers of primary care physicians toward providing adequate contraception to women taking potential teratogens.DESIGN & PARTICIPANTSSelf-administered confidential survey of primary care internal medicine physicians at an urban, academic medical center.MEASUREMENTSKnowledge of potential teratogenic medications and contraceptive failure rates was assessed. Participants’ beliefs about adequacy of their medical education, practice limitations and attitudes toward improving provision of contraception to women on potential teratogens were assessed.RESULTSOne hundred and ten physicians responded (57.3%). Nearly two-thirds (62.3%) of participants had cared for reproductive aged women taking category D or X medications in the past year. The mean percent of correctly identified category D or X medications was 58.4% (SD 22.1%). The mean percent correct for knowledge of published contraceptive failure rates was 64.6% (SD 23.1%). Most respondents (87.6%) felt it is the responsibility of primary care physicians to provide contraception. Time constraints were reported to be somewhat or very limiting by 61.3% and over half felt medical school (63.2%) or residency (58.1%) inadequately prepared them to prescribe or counsel about contraceptives.CONCLUSIONSPrimary care physicians commonly encounter reproductive age women taking category D or X medications, but may lack sufficient knowledge and time to counsel about potential teratogens and contraception to prevent fetal exposure to these drugs.

Medical contraindications in women seeking combined hormonal contraception

OBJECTIVEnThe objective of the study was to evaluate the prevalence of medical contraindications in a large group of women seeking combined hormonal contraception (CHC).nnnSTUDY DESIGNnThe Contraceptive CHOICE Project is a prospective cohort study designed to promote the use of long-acting reversible contraceptive methods to reduce unintended pregnancies in the St Louis region. During baseline enrollment, participants were asked about their desired methods of contraception and medical history. Potential medical contraindications were defined as self-reported history of hypertension, myocardial infarction, cerebral vascular accidents, migraines with aura, any migraine and age 35 years or older, smoking in women older than 35 years, venous thromboembolism, or liver disease. We reviewed all research charts of women with self-reported medical contraindications to verify all conditions. Binomial 95% confidence intervals (CIs) were calculated around percentages.nnnRESULTSnBetween August 2007 and December 2009, 5087 women who enrolled in the CHOICE Project provided information about their medical history and 1010 women (19.9%) desired CHC at baseline. Seventy women (6.93%; 95% CI, 5.44-8.68%) were defined as having a potential medical contraindication to CHC at baseline. After chart review, only 24 of 1010 participants desiring CHC (2.38%; 95% CI, 1.53-3.52%) were found to have true medical contraindications to CHC including 17 with hypertension, 2 with migraines with aura, 2 with a history of venous thromboembolism, and 3 smokers aged 35 years or older.nnnCONCLUSIONnThe prevalence of medical contraindications to CHC was very low in this large sample of reproductive-aged women. This low prevalence supports provision of CHC without a prescription.

Controversies in family planning: timing of ovulation after abortion and the conundrum of postabortion intrauterine device insertion ☆

Questions: When does ovulation occur after an induced abortion? Is it different with regard to medical versus surgical abortion? Does ovulation occur at a different time point if the woman had a first versus second trimester abortion? If one is unable to provide an immediate post- abortion intrauterine device (IUD), when is the ideal time to insert the IUD and be sure your patient is not pregnant? What if the patient reports an act of unprotected intercourse between the abortion and her return for IUD insertion? Can one be certain she has not just conceived if her return for the IUD is 7 days post-abortion? What if it was 10 versus 14 or more days post- abortion? n nRespondent #1: Most data support three weeks for ovulation, therefore insertion within two weeks with no bridge method is fine. That said, about a third of women will not come back so some method right away might be a good idea. n nRespondent #2: I used to do one week for first trimester patients and two weeks for second trimester patients before we could do immediate insertion. We are currently working on an analysis of nearly 200 women who got IUDs at two weeks after first trimester abortion and there were no complications. These women received the IUD at two weeks, not before. There were no pregnancies with IUD in place. Most women reported they were abstinent or used condoms. Our expulsion rate was low at about 2.5% at 6 months. n nRespondent #3: Our beliefs that ovulation occurs one to two weeks earlier post-abortion than after delivery are based on some older studies. I think the best time for a post-abortion visit is within one week because that is when the problems occur. One study showed higher IUD expulsion at two weeks than right after first trimester abortion, so one week might be better. The date of post-abortion visit return for contraception is sometimes determined by how long after the abortion insurance will pay. It used to be we had to wait two weeks for post-abortion IUD insertion where I work but now it is as soon as the patient is not pregnant, which means now we can insert IUDs immediately. n nRespondent #4: I would keep in mind the range, not just the average date of ovulation after abortion. Some papers show ovulation occurring as early as six days post-abortion.

Difficult removal of subdermal contraceptive implants: a multidisciplinary approach involving a peripheral nerve expert

OBJECTIVESnWe aim to describe our experiences and identify patients who may benefit from referral to a peripheral nerve surgeon for removal of contraceptive subdermal implants in which neurovascular injury may occur, and describe a treatment pathway for optimal care.nnnSTUDY DESIGNnWe reviewed the charts of 22 patients who were referred to the Division of Family Planning for difficult removal of etonogestrel contraceptive implants between January 1, 2014, and April, 1 2016. Of these, five were referred to a peripheral nerve surgeon due to pain or location of the implant. We evaluated and described these cases and, from our findings, developed recommendations for care in a multidisciplinary team approach.nnnRESULTSnTwo patients reported pain, including one with four previous failed removal attempts. In the two patients with pain, the implants were adherent to a sensory nerve. In another, the implant was within the biceps muscle and difficult to locate. In all cases, ultrasound imaging, general anesthesia and a wide exposure allowed for safe removal and good outcomes. Our multidisciplinary care approach has elucidated important referral and technical considerations that improve patient care and safety.nnnCONCLUSIONnWhen necessary, multidisciplinary care with a Family Planning expert and possibly a peripheral nerve surgeon may be beneficial in safely removing etonogestrel contraceptive implants that would be difficult or risky to remove in an ambulatory setting.

A prospective assessment of pelvic infection risk following same-day sexually transmitted infection testing and levonorgestrel intrauterine system placement

BACKGROUNDnMisperceptions persist that intrauterine device placement is related to pelvic infections and Chlamydia and gonorrhea testing results are needed prior to placement.nnnOBJECTIVEnWe sought to evaluate the relationship of Chlamydia and gonorrhea screening to pelvic infection for up to 2 years following placement of the levonorgestrel 52-mg intrauterine system.nnnSTUDY DESIGNnA total of 1751 nulliparous and multiparous females 16 to 45 years old enrolled in a multicenter trial designed to evaluate the efficacy and safety of a new levonorgestrel intrauterine system for up to 7xa0years. Participants had Chlamydia screening at study entry and yearly if they were age ≤25 years. Women also had baseline gonorrhea screening if testing had not been performed since starting their current sexual relationship. Those who changed sexual partners during the trial had repeated Chlamydia and gonorrhea testing. Intrauterine system insertion could occur on the same day as screening. Participants did not receive prophylactic antibiotics for intrauterine system placement. Investigators performed pelvic examinations after 12 and 24 months and when clinically indicated during visits at 3, 6, and 18 months after placement and unscheduled visits. Pelvic infection included any clinical diagnosis of pelvic inflammatory disease or endometritis.nnnRESULTSnMost participants (nxa0= 1364, 79.6%) did not have sexually transmitted infection test results available prior to intrauterine system placement. In all, 29 (1.7%) participants had positive baseline testing for a sexually transmitted infection (Chlamydia, nxa0= 25; gonorrhea, nxa0= 3; both, nxa0= 1); 6 of these participants had known results (all with Chlamydia infection) prior to intrauterine system placement and received treatment before enrollment. The 23 participants whose results were not known at the time of intrauterine system placement received treatment without intrauterine system removal and none developed pelvic infection. The incidence of positive Chlamydia testing was similar among those with and without known test results at the time of intrauterine system placement (1.9% vs 1.5%, respectively, Pxa0= .6). Nine (0.5%) participants had a diagnosis of pelvic infection over 2 years after placement, all of whom had negative Chlamydia screening on the day of or within 1 month after intrauterine system placement. Infections were diagnosed in 3 participants within 7 days, 1 at 39 days, and 5 at ≥6 months. Seven participants received outpatient antibiotic treatment and 2 (diagnoses between 6-12 months after placement) received inpatient treatment. Two (0.1%) participants had intrauterine system removal related to infection (at 6 days and at 7 months after placement), both of whom only required outpatient treatment.nnnCONCLUSIONnConducting Chlamydia and gonorrhea testing on the same day as intrauterine system placement is associated with a low risk of pelvic infection (0.2%). Over the first 2 years of intrauterine system use, infections are infrequent and not temporally related to intrauterine system placement. Pelvic infection can be successfully treated in most women with outpatient antibiotics and typically does not require intrauterine system removal. Women without clinical evidence of active infection can have intrauterine system placement and sexually transmitted infection screening, if indicated, on the same day.