Dustin Costescu

Canadian Contraception Consensus (Part 3 of 4): Chapter 7 – Intrauterine Contraception

OBJECTIVE To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. OUTCOMES Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada. EVIDENCE Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 7: INTRAUTERINE CONTRACEPTION: SUMMARY STATEMENTS 1. Intrauterine contraceptives are as effective as permanent contraception methods. (II-2) 2. The use of levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg by patients taking tamoxifen is not associated with recurrence of breast cancer. (I) 3. Intrauterine contraceptives have a number of noncontraceptive benefits. The levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg significantly decreases menstrual blood loss (I) and dysmenorrhea. (II-2) Both the copper intrauterine device and the LNG-IUS significantly decrease the risk of endometrial cancer. (II-2) 4. The risk of uterine perforation decreases with inserter experience but is higher in postpartum and breastfeeding women. (II-2) 5. The risk of pelvic inflammatory disease (PID) is increased slightly in the first month after intrauterine contraceptive (IUC) insertion, but the absolute risk is low. Exposure to sexually transmitted infections and not the IUC itself is responsible for PID occurring after the first month of use. (II-2) 6. Nulliparity is not associated with an increased risk of intrauterine contraceptive expulsion. (II-2) 7. Ectopic pregnancy with an intrauterine contraceptive (IUC) is rare, but when a pregnancy occurs with an IUC in situ, it is an ectopic pregnancy in 15% to 50% of the cases. (II-2) 8. In women who conceive with an intrauterine contraceptive (IUC) in place, early IUC removal improves outcomes but does not entirely eliminate risks. (II-2) 9. Intrauterine contraceptives do not increase the risk of infertility. (II-2) 10. Immediate insertion of an intrauterine contraceptive (10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher continuation rate compared with insertion at 6 weeks postpartum. (I) 11. Immediate insertion of an intrauterine contraceptive (IUC; 10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher risk of expulsion. (I) The benefit of inserting an IUC immediately postpartum or post-Caesarean section outweighs the disadvantages of increased risk of perforation and expulsion. (II-C) 12. Insertion of an intrauterine contraceptive in breastfeeding women is associated with a higher risk of uterine perforation in the first postpartum year. (II-2) 13. Immediate insertion of an intrauterine contraceptive (IUC) post-abortion significantly reduces the risk of repeat abortion (II-2) and increases IUC continuation rates at 6 months. (I) 14. Antibiotic prophylaxis for intrauterine contraceptive insertion does not significantly reduce postinsertion pelvic infection. (I) RECOMMENDATIONS: 1. Health care professionals should be careful not to restrict access to intrauterine contraceptives (IUC) owing to theoretical or unproven risks. (III-A) Health care professionals should offer IUCs as a first-line method of contraception to both nulliparous and multiparous women. (II-2A) 2. In women seeking intrauterine contraception (IUC) and presenting with heavy menstrual bleeding and/or dysmenorrhea, health care professionals should consider the use of the levonorgestrel intrauterine system 52 mg over other IUCs. (I-A) 3. Patients with breast cancer taking tamoxifen may consider a levonorgestrel-releasing intrauterine system 52 mg after consultation with their oncologist. (I-A) 4. Women requesting a levonorgestrel-releasing intrauterine system or a copper-intrauterine device should be counseled regarding changes in bleeding patterns, sexually transmitted infection risk, and duration of use. (III-A) 5. A health care professional should be reasonably certain that the woman is not pregnant prior to inserting an intrauterine contraceptive at any time during the menstrual cycle. (III-A) 6. Health care providers should consider inserting an intrauterine contraceptive immediately after an induced abortion rather than waiting for an interval insertion. (I-B) 7. In women who conceive with an intrauterine contraceptive (IUC) in place, the diagnosis of ectopic pregnancy should be excluded as arly as possible. (II-2A) Once an ectopic pregnancy has been excluded, the IUC should be removed without an invasive procedure. The IUC may be removed at the time of a surgical termination. (II-2B) 8. In the case of pelvic inflammatory disease, it is not necessary to remove the intrauterine contraceptive unless there is no clinical improvement after 48 to 72 hours of appropriate antibiotic treatment. (II-2B) 9. Routine antibiotic prophylaxis for intrauterine contraceptive (IUC) insertion is not indicated. (I-B) Health care providers should perform sexually transmitted infection (STI) testing in women at high risk of STI at the time of IUC insertion. If the test is positive for chlamydia and/or gonorrhea, the woman should be appropriately treated postinsertion and the IUC can remain in situ. (II-2B) 10. Unscheduled bleeding in intrauterine contraception users, when persistent or associated with pelvic pain, should be investigated to rule out infection, pregnancy, gynecological pathology, expulsion or malposition. (III-A)

Barriers and Misperceptions Limiting Widespread Use of Intrauterine Contraception Among Canadian Women

Unintended pregnancy is a major social and public health problem with adverse effects on neonatal and developmental outcomes, as well as maternal health and wellbeing. Traditionally, family planning policies have focused on increasing contraceptive uptake in non-users; however, rates of non-use are low in many developed nations. A high proportion of unintended pregnancies are attributable to contraceptive failure, particularly when using barrier and short-acting hormonal contraceptives. Intrauterine contraceptive devices (IUCDs) are highly effective and have been shown to reduce unintended pregnancy rates. Despite this, global utilization rates are low, and IUCD uptake in Canada has been particularly low. In this review we explore why IUCDs are not more widely used, and specifically focus on barriers and misperceptions that may influence IUCD uptake, particularly in Canada. We reviewed relevant articles published in English between 1990 and 2014, through searches of PubMed and Medline, including primary studies of any design containing information on the knowledge and attitudes of health care providers and women. Providing education to care providers, women, and policy makers may help overcome misperceptions about the use of IUCDs, and may facilitate greater use. Increased support from federal and provincial health programs may also encourage the use of IUCDs in Canadian women, and help to reduce unintended pregnancy rates.

Lessons learned from a resident-led clinical trial in obstetrics

Background Completion of a randomised controlled trial is one way by which the resident research requirement can be met in Canadian obstetrics and gynaecology programmes. However, little is known about the specific challenges of performing clinical trials within the specialty, let alone as a resident project. Purpose A resident-led randomised controlled trial comparing two methods of labour induction at term was halted due to insufficient patient enrolment. A structured review of the study design and recruitment process was conducted to identify factors contributing to poor recruitment. Methods In addition to completing a literature review and internal review by the research team, we surveyed obstetricians and residents regarding recruitment efforts and barriers to participation. We solicited feedback on trial design and the expectations of clinicians with respect to participation in research studies. Results Eight obstetricians (67%) and 13 residents (93%) responded to the survey. All were able to identify eligible patients, though only 60% had invited one or more patients to participate during the recruitment period. Failure to consider trial participation and excessive clinical workload were the most commonly cited barriers for clinicians. Resistance to the test intervention was the major barrier to patient participation. Several residents cited a lack of personal incentive to recruit patients as a significant barrier. Limitations The research team was unable to contact patients directly, thus limiting the scope of our review to our internal methods and feedback from clinicians. Conclusions Poor recruitment in a resident-led clinical trial in obstetrics resulted from multiple coexisting factors. A structured review provided valuable insight for the research team. Academic clinicians and trainees in all specialties should be encouraged to share their experiences in the hope of improving the likelihood of success in future research endeavours.

Influence of endogenous estradiol, progesterone, allopregnanolone, and dehydroepiandrosterone sulfate on brain resting state functional connectivity across the menstrual cycle

OBJECTIVE To [1] study brain resting state functional connectivity (Rs-FC) in a well-characterized sample of healthy women in the mid-follicular and late luteal phases of the menstrual cycle; and [2] examine the correlation between endogenous E2, P, allopregnanolone, and DHEAS and patterns of Rs-FC across the menstrual cycle. DESIGN We studied the Rs-FC of the default mode network, salience network, meso-paralimbic network, fronto-parietal network, visual network, and sensorimotor network in the mid-follicular and late luteal phases. Serum levels of E2, P, allopregnanolone, and DHEAS were correlated to patterns of functional connectivity. SETTING University medical center. PATIENT(S) Twenty-five healthy women with regular menstrual cycles. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Functional connectivity of key brain networks at rest and correlations of hormones to Rs-FC in the mid-follcuar and late luteal menstrual phases. RESULT(S) There were no differences in Rs-FC between the mid-follicular and late luteal menstrual phases using either independent component analysis or seed-based analysis. However, specific correlations between each hormone and patterns of functional connectivity were found in both menstrual cycle phases. CONCLUSION(S) It seems that the association between female sex hormones and brain Rs-FC is menstrual cycle phase-dependent. Future studies should examine the cognitive and behavioral correlates of this association in regularly cycling women.

Levonorgestrel-releasing intrauterine systems for long-acting contraception: current perspectives, safety, and patient counseling

Unintended pregnancy is a significant global problem. In 2008, there were over 100 million unplanned pregnancies worldwide, representing approximately 41% of global conceptions. Family planning strategies in many countries are shifting from increasing the uptake of contraception among nonusers to increasing the uptake of the most effective methods among users of less effective methods. One of the most effective and acceptable methods of contraception is the levonorgestrel-releasing intrauterine system (LNG IUS); however, its uptake varies widely by country. This article reviews the currently available LNG IUSs, the rationale for increasing uptake of these methods, and evidence regarding safety, and discusses counseling strategies to best inform women about this option for contraception.

Canadian Contraception Consensus (Part 2 of 4) Abstract and Summary Statement

Abstract Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general well-being; contraceptive counselling methods; and access to, and availability of, cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Understanding the Pregnancy Decision-Making Process Among Couples Seeking Induced Abortion

OBJECTIVE The role of partners in the abortion experience is complex and poorly understood. We sought to examine how women and their partners navigate the pregnancy decision-making process. METHODS Thirty couples presenting for abortion completed questionnaires exploring experiences leading to the abortion. Participants were sequestered from their partners during completion of the study, and booklets were coded to allow comparison within couples. This portion of the study explored partner involvement in the decision-making process. RESULTS One half of women had decided on abortion before informing their partner of the pregnancy. Of those who were undecided at the time of disclosure, all sought their partners advice. Most participants (84%) were happy with the amount of discussion that took place with their partners, although one fifth of women and nearly one third of men could have discussed it more. More women than men were happy with the discussions that took place (96.6% vs. 70.4%). Two thirds of respondents viewed the decision to have an abortion as being made by both partners, one quarter viewed the decision as being mostly the womans choice, and 5% viewed the decision as being mostly the male partners choice. CONCLUSION Although making the choice to have an abortion rests with the woman, her partner may play a role in the decision-making process, particularly when the woman is undecided. For many couples presenting for abortion, the decision is seen as being made jointly by both partners. Further research may identify opportunities to foster greater partner support throughout a womans abortion experience.

The Unmet Contraceptive Need of Incarcerated Women in Ontario

OBJECTIVE Studies from the United States have shown that women in correctional facilities have higher rates of unintended pregnancy and unmet need for contraception compared with the general population, and that the provision of family planning services in correctional facilities may improve access to contraception. No study has examined these issues in women in correctional facilities in Canada. We aimed to describe the rates of unintended pregnancy and contraceptive use for incarcerated women in Ontario. METHODS Women in a provincial correctional facility in Ontario completed a written survey in 2014. We calculated the prevalence of prior unintended pregnancy, prior therapeutic abortion, and contraception use. We calculated the unmet need for contraception, defined as the proportion of women who were not using reliable contraception among women who were sexually active and were not trying to conceive. RESULTS Of 85 participants, 82% had been pregnant, and of these women, 77% had experienced an unintended pregnancy and 57% reported having undergone a therapeutic abortion. Regarding the most recent pregnancy, 72% of women scored their pregnancy intention as unplanned or ambivalent. Of women who were at risk for unintended pregnancy prior to incarceration, 80% were not using a reliable form of contraception. CONCLUSION Incarcerated women in Ontario have higher rates of unintended pregnancy and unmet need for contraception than does the general population. The provision of family planning services during and after incarceration may improve the health of individuals and reduce costs for society overall.

Abstract and Summary Statements

Abstract Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general wellbeing; contraceptive counselling methods; and access to and availability of cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Any review must carefully weigh the available evidence

Helmerhorst and Rosendaal’s recommendation that women prescribed oral contraceptives should receive levonorgestrel and 30 µg of ethinylestradiol is based on the observation that thrombosis risk is related to ethinylestradiol amount and progestogen type.1 Although interesting, this strategy is not adequately evidence based. Retrospective database studies of contraception and thrombosis are often cited because they are inexpensive and can rapidly amass large datasets. Unfortunately, conclusions are …