Jessica K. Lee

Women's Experiences With Isotretinoin Risk Reduction Counseling

IMPORTANCE Isotretinoin, an effective anti-acne therapy, is a known teratogen that is strictly regulated through the iPLEDGE program. However, since this program has not significantly reduced rates of pregnancies exposed to isotretinoin, new strategies for reducing rates of isotretinoin-exposed pregnancies are needed. OBJECTIVE To explore womens experiences with counseling about isotretinoin risk reduction. DESIGN, SETTING, AND PARTICIPANTS Structured interviews were conducted between January and September 2012. Two independent coders performed content analysis using a grounded theory approach. The study participants were 16 women who had used isotretinoin to treat severe skin disease and who were recruited from a single urban community via flyers displayed on college campuses, at dermatology clinics, and at student health facilities. MAIN OUTCOMES AND MEASURES Perceptions of isotretinoin-associated risks and understanding of ways teratogenic risks can be avoided. RESULTS Participants clearly understood that isotretinoin is teratogenic but had less understanding of contraceptive methods that effectively prevent pregnancy. Most described the counseling they received as anxiety provoking. Few were counseled about highly effective reversible contraceptives such as the subdermal implant or intrauterine contraception; most counseling focused on oral contraceptives. Women cited multiple influences on their contraceptive choices, including friends, family, physicians, the internet, and other media; however, some expressed concerns about the accuracy of these sources of information. For many, iPLEDGE was their first introduction to contraception. When presented with evidence-based information on the relative effectiveness of available contraceptives, participants expressed surprise that this was not part of the iPLEDGE materials. CONCLUSIONS AND RELEVANCE Since few clinicians provide women information on highly effective (ie, intrauterine or subdermal) contraceptives, the iPLEDGE program increases anxiety about isotretinoin more than it helps women feel protected from the teratogenic risks of isotretinoin.

A checklist approach to caring for women seeking pregnancy testing: Effects on contraceptive knowledge and use

OBJECTIVE To assess how a checklist reminding clinicians to deliver a bundled intervention affects contraceptive knowledge and use 3 months after women seek walk-in pregnancy testing. METHODS Pre-intervention, an inner-city family planning clinic provided unstructured care; during the intervention period, clinic staff used a checklist to ensure women received needed services. Women seeking walk-in pregnancy testing who wished to avoid pregnancy for at least 6 months were asked to complete surveys about their contraceptive knowledge and use immediately after and 3-months after visiting the study clinic. To assess the significance of changes over time, we used logistic regression models. RESULTS Between January 2011 and May 2013, over 1500 women sought pregnancy testing from the study clinic; 323 completed surveys (95 pre-intervention and 228 during the intervention period). With this checklist intervention, participants were more likely to receive emergency contraception (EC) (22% vs. 5%, [aOR 4.66 (1.76-12.35)], [corrected] have an intrauterine device or implant placed at the time of their clinic visit (5% vs. 0%, p=0.02), or receive a contraceptive prescription (23% vs. 10%, p<0.001). Three months after visiting the study clinic, participants from the intervention period were more knowledgeable about intrauterine and subdermal contraception and were more likely to report at 3-month follow-up a method of contraception more effective than the method they used prior to seeking pregnancy testing from the study clinic (aOR=2.02, 95% CI=1.03-3.96). The authors would like to apologize for any inconvenience caused. [corrected]. CONCLUSIONS Women seeking walk-in pregnancy testing appear more likely to receive EC and to have switched to a more effective form of birth control in the 3 months following their visit when clinic staff used a 3-item checklist and provided scripted counseling. IMPLICATIONS A checklist reminding clinic staff to assess pregnancy intentions, provide scripted counseling about both emergency and highly-effective reversible contraception, and offer same-day contraceptive initiation to women seeking walk-in pregnancy testing appears to increase use of more effective contraception.

Contraceptive Counseling and Use among Women with Poorer Health

BACKGROUND To explore associations between health status, contraceptive counseling and contraceptive use. METHODS Women aged 18-50 visiting one of 4 primary care clinics were invited to complete surveys after their visit. Perceived health status was measured using a 5-point scale. Among those considered at risk of unintended pregnancy, logistic regression was used to investigate associations between health status and contraceptive counseling and use. FINDINGS Women reporting poorer health had decreased odds of receiving some contraceptive counseling at their visit (aOR=0.62, CI=0.39, 0.97) and using some contraception at last intercourse (aOR=0.63, CI=0.41, 0.97) compared to women reporting better health. However, among women with poorer health, receipt of counseling about hormonal contraception was associated with increased odds of using hormonal methods (aOR=8.22, CI=1.77, 38.19). Only 7% of women in poorer health received counseling on highly effective reversible contraception. CONCLUSIONS Women in poorer health may be at risk of adverse reproductive health outcomes and should receive counseling on safe hormonal and highly effective reversible contraceptives.

Asking for what she needs? Pregnancy testing or EC?

BACKGROUND When used within 5 days of unprotected sex, emergency contraception (EC) can reduce the risk of pregnancy. Our objective was to explore how often women seeking clinic-based pregnancy testing who do not desire pregnancy might benefit from EC and examine variables associated with patients asking for EC when use is indicated. STUDY DESIGN Women seeking pregnancy testing or EC from an inner-city Title-X-funded family planning clinic between January 2011 and June 2012 were invited to complete surveys. RESULTS Twenty-seven percent (n=79) of respondents were seeking EC, and 73% (n=215) were seeking pregnancy testing. Of those seeking pregnancy testing, 39% might have benefited from same-day use of EC pills. Women who had never used EC and who had more than one episode of unprotected sex within the past month were less likely to request EC when use was indicated, while single women were more likely to request EC. CONCLUSIONS Counseling regarding EC options is particularly important for women seeking same-day pregnancy testing who do not desire pregnancy.

Acceptability of randomization to levonorgestrel versus copper intrauterine device among women requesting IUD insertion for contraception

OBJECTIVE Assess feasibility of randomizing women to intrauterine device (IUD) type. STUDY DESIGN Women enrolling in a 2-month study who desired an IUD for contraception were randomized 1:1 to receive a levonorgestrel-releasing 52-mg IUD (LNG-IUD) or copper T380A IUD (Cu-IUD), understanding they could switch IUD type at the end of the study. RESULTS Randomization to IUD type was acceptable to 54/55 (98%) women who screened. All 32 enrolled participants completed follow-up. Two women exchanged their IUD (Cu-IUD to LNG-IUD), and two requested removal (one LNG-IUD, one Cu-IUD). Overall, 88% continued their assigned IUD. CONCLUSIONS Randomization to IUD type is feasible, and few women change their IUD.

The gynecologic management of hemoperitoneum.

INTRODUCTION: Rupture of a corpus luteum cyst is the major cause of gynecological hemoperitoneum. The diagnosis is based on clinical suspicion, laboratory data, and radiologic findings. Although mild cases require only observation and support, surgical intervention is necessary for severe cases. A standardized management is not defined. Our study compares the outcomes of patients undergoing conservative and surgical management of a ruptured corpus luteum cyst. METHODS: A retrospective chart review was performed, seeking data from Magee Womens Hospital patients with the diagnosis of hemoperitoneum, corpus luteum cyst, or follicular cyst of the ovary between September 2007 and January 2013. These women were hospitalized or underwent laparoscopy or laparotomy with the prior mentioned diagnoses including hemoperitoneum without proof of pregnancy. Statistical analyses were performed with SPSS 21. RESULTS: Our study included 30 patients in whom 17% underwent conservative management and 83% underwent surgical management including laparoscopy or laparotomy. Notably 63% of patients presented with rupture on the left side and 88% presented with abdominal or pelvic pain. We compared differences in radiologic findings (size of cyst, fluid volume, fluid location) between the conservative and surgical management groups and noted no significant differences. There were no significant differences in either short-term (hemoglobin drop, transfusion, infection, length of hospital stay, readmission within 3 months) or long-term outcomes (readmission with same diagnosis, future pregnancies) between the groups. CONCLUSIONS: Although our study size was small, there appears to be no significant adverse outcomes when managing stable hemoperitoneum with conservative management compared with surgical management.