Karla Maguire

The state of hormonal contraception today: established and emerging noncontraceptive health benefits

In the 50 years since the advent of combined oral contraceptives the amount of estrogen in oral contraceptives dropped from over 100 mcg to less than 30 mcg. Many noncontraceptive health benefits have emerged that decrease mortality and improve quality of life. Some of the immediate benefits include improvement of menorrhagia and dysmenorrhea, reduction in premenstrual dysphoric disorder symptoms, and decreased acne. As an effective birth control method oral contraceptives also decrease pregnancy-related deaths by preventing pregnancy. After the reproductive years, previous use of oral contraceptives continues to be beneficial, reducing the risk of death from ovarian and endometrial cancer. All these benefits have held up over time whereas cardiovascular risks have lessened because of the decrease in oral contraceptive pill dosage. Decreased ovarian cyst formation is an example of benefit with higher-dose oral contraceptive formulations that no longer holds true with low-dose pills.

Intracervical lidocaine gel for intrauterine device insertion: a randomized controlled trial

BACKGROUND Pain during intrauterine device (IUD) insertion can be a barrier to initiation. Clinical trials have found misoprostol and nonsteroidal drugs to be ineffective (Am J Obstet Gynecol 2006;195:1272-1277, Hum Reprod 2011;26:323-329, Hum Reprod 2007;22:2647-2652). One study suggested that 2% lidocaine gel decreased pain; however, study design problems limit its validity (Brit J Fam Plann 1996;22:177-180). We tested whether intracervical 2% lidocaine gel decreased insertion pain compared to placebo. STUDY DESIGN We planned a randomized, double-blinded clinical trial of 200 women. We placed 2% lidocaine gel or placebo in the cervix prior to uterine sounding. Participants rated pain by marking a 100-mm visual analogue scale at four time points. RESULTS We randomized 200 participants and placed 197 IUDs. Pain was greatest at uterine sounding and similar between groups: placebo group mean 51.6 mm (SD 25), lidocaine group mean 55.5 mm (SD 30, p=.33). Stratified analyses accounting for parity showed no treatment effect. Multivariable analyses identified longer time since last pregnancy, lower parity and higher anticipated pain as predictors of pain during sounding, and dysmenorrhea and the levonorgestrel IUD as additional predictors during IUD insertion. CONCLUSIONS Intracervical 2% lidocaine gel does not decrease IUD insertion pain. Understanding predictors of increased pain may help providers with preprocedure counseling.

Accuracy of providers' assessment of pain during intrauterine device insertion.

BACKGROUND Providers often underestimate patient pain. This study investigated if providers accurately assess pain during intrauterine device (IUD) insertion. STUDY DESIGN This is a secondary analysis of a randomized trial. Participants rated pain on a 100-mm visual analogue scale (VAS). Providers marked a similar VAS for maximum level and timing of participant pain. RESULTS The mean patient maximum pain was 64.8 mm (SD, 27) compared to 35.3 mm (SD, 26) rated by the provider (p<.001). Patient and provider agreement on most painful time point of procedure was weak (kappa statistic, 0.16). CONCLUSIONS Providers underestimate pain during IUD insertion. IMPLICATIONS To our knowledge, this is the first paper to compare provider and patient perceptions of pain during IUD insertion. Understanding this relationship will help guide further research about IUD insertion pain and techniques and could improve patient counseling.

IUDs at 1 year: predictors of early discontinuation

OBJECTIVE To assess baseline dysmenorrhea and insertion-related pain as predictors of intrauterine device (IUD) removal within 1 year following insertion. STUDY DESIGN System-wide medical record abstraction 1 year after IUD insertion to identify removals and comparison of baseline characteristics (dysmenorrhea, insertion pain) among women with a removal versus women who continued IUD use was used. Baseline data came from a randomized trial of pain control during insertion. RESULTS Among 199 insertions, we identified 21 removals and 7 expulsions, a continuation rate of 85.9%. Women with IUD removal had higher median dysmenorrhea scores before insertion than those who continued (42 vs. 25.5, p=.03). Insertion pain and other characteristics were not associated with removal. CONCLUSIONS Preexisting dysmenorrhea may predict IUD removal within 1 year.

Knowledge and Acceptability of Anal Cytology Screening Among Women.

Objective Medical providers have initiated anal cytology screening among women to detect anal neoplasia early. Lack of knowledge of the human papillomavirus (HPV) and anticipated screening discomfort may limit patient acceptance. This study investigates attitudes toward anal cytology screening among women. Materials and Methods Women seen for gynecologic care at an urban university medical center were invited to complete an anonymous survey assessing their understanding of HPV and interest in anal cytology screening. Subjects reported the level of pain, discomfort, and embarrassment they expected from screening on a 100-mm visual analog scale. Results Four hundred four women with mean (SD) age 36 (13) years met criteria for participation. Three hundred thirty-five women reported their race: 52% were white and 36% were African American. Three hundred forty-eight women reported their ethnicities: 76% were Hispanic and 12% were Haitian. Twenty-two percent had never heard of HPV, 57% were not familiar with anal cytology screening, 67% acknowledged that screening was very helpful in detecting anal neoplasia early, and 28% were very interested in undergoing screening. Mean (SD) level of anticipated pain, discomfort, and embarrassment during screening was 62 (32), 68 (30), and 58 (34) mm, respectively. Level of familiarity with anal cytology screening (p < .001), belief in its utility in detecting anal neoplasia (p < .001), and level of anticipated pain (p = .004) were significant predictors of acceptability. Conclusions Medical providers should improve counseling about anal cytology screening among at-risk women to familiarize them with the procedure, describe its role in detecting anal neoplasia, and address expectations surrounding pain to increase its acceptability.

Women Living with HIV over Age of 65: Cervical Cancer Screening in a Unique and Growing Population

Objective Women living with HIV are at increased risk of human papillomavirus (HPV) infection, which can lead to cervical cancer. New guidelines recommend indefinite screening. The objective of this study is to describe cervical cancer screening practices and colposcopy results in a cohort of women living with HIV over age of 65 who were followed before the new guidelines. Comorbidities, sexually transmitted infections (STIs), and other risk factors were evaluated. Methods We conducted a retrospective chart review on 75 women aged 65 or older living with HIV with at least one Pap smear. Results The mean age of the cohort was 66.5 and at HIV diagnosis was 56. The majority of women were immunocompetent. 80% had serial Pap smears. Of these, 86% of 238 were negative or ASCUS. No women progressed to HSIL. 92% of colposcopies had negative or CIN I results. Three women were treated successfully for high-grade dysplasia. More than half of women had other STIs. 72% were screened for HPV; 50% were positive. Conclusion The majority of women had negative and low-grade Pap smears. Questions remain regarding the utility of continued Pap screening and the added value of HPV testing in this unique population of older women living with HIV.