Leslie Miller

Assessment of pain during medical procedures: a comparison of three scales.

OBJECTIVE Pain assessment is crucial to pain research. Knowledge about the strengths and weaknesses of pain measures is important to the continued advancement of our understanding of pain. The purpose of the present study was to compare the validity and utility of three measures of pain intensity during a medical procedure known to produce pain: an abortion. DESIGN Assignment to one of three pain intensity assessment instruments, which were subsequently used to assess pain during an abortion procedure. Comparison of the relative sensitivity of the measures to assess changes in pain using a series of repeated measures analyses of variance. The relative utility of the measures was compared by examining the rates of accurate responses to each. SUBJECTS Fifty-eight women presenting for a first-trimester abortion. MEASURES Visual analog scale (VAS), the verbal 11-point Box Scale (Verbal BS-11), and the 21-point Box Scale (BS-21). RESULTS All three pain intensity measures detected changes in pain during the abortion procedure. Rates of incorrect responses were higher for the Verbal BS-11 and the VAS than for the BS-21. CONCLUSIONS The results supported the validity of each of the three measures used, although some superiority for the BS-21 over the Verbal BS- 11 and VAS exists. Patients had some difficulty completing the paper-and-pencil VAS during the procedure. In addition and consistent with previous research, some patients treated the Verbal BS-11 as a 21-point scale by responding with numbers between two whole numbers on the 0-10 measure. Overall, practical issues led us to conclude that the BS-21 is an excellent choice for assessing real-time abortion pain.

Continuous combination oral contraceptive pills to eliminate withdrawal bleeding: a randomized trial.

OBJECTIVE To compare bleeding profiles of a traditional 28-day oral contraceptive pill cycle with continuous administration. METHODS After a 28-day run-in cycle, women were randomized to either 28-day cycles (21 active pills and a pill-free week) or continuous use of the same 20-μg ethinyl estradiol/100-μg levonorgestrel formulation for 12 study cycles (336 days). The number of bleeding and spotting days were measured by daily diary. A subset underwent cycle 1 (n = 16), and nine (n = 14) pelvic ultrasound and endometrial histology sampling. Blood pressure, weight, hemoglobin, and adverse events were measured at revisit. The sample size with 80% power to detect a 67% reduction in bleeding days required 27 subjects in each arm. RESULTS Of the 79 subjects randomized, 28 (70%) of the 28-day cycle and 32 (82%) of the continuous-use subjects completed the entire study (P = .6). With continuous use, 49%, 68%, and 88% of women reported no bleeding during cycles 2, 6, and 12, respectively. Amenorrhea or infrequent bleeding was present in 68% of continuous users during cycles 1–3 and increased to 88% during cycles 10–12. Spotting during cycle days 1–21 increased initially with continuous use but reduced over time, and by 9 months was less than the spotting reported by cyclic users. Adverse events, blood pressure, weight, and hemoglobin findings were similar between groups. CONCLUSION Extension of the 28-day oral contraceptive cycle to continuous use with a low-estrogen dose combination oral birth control pill resulted in significantly fewer bleeding days.

Depomedroxyprogesterone-induced hypoestrogenism and changes in vaginal flora and epithelium ☆

Objective To identify the effects of depomedroxyprogesterone acetate (DMPA) on vaginal microbial flora and epithelium. Methods Women who desired DMPA for contraception were evaluated before and at 3 and 6 months after initiation of 150-mg DMPA injections every 3 months. At each visit, we assessed genital symptoms, vaginal signs, vaginal micro-flora, and histopathology by vaginal biopsies. Results Among 38 women observed for 6 months, there was significant reduction in mean serum estradiol level (99.9 ± 9.3 pg/mL to 26.6 ± 1.6 pg/mL, P < .001). The number of subjects with any Lactobacillus did not change, but the number with hydrogen peroxide (H2O2)–positive Lactobacillus decreased from 20% before to 12% after 6 months of DMPA (P = .005). The log concentration in colony-forming units per milliliter of vaginal fluid of H2O2–positive Lactobacillus decreased in a linear manner from 4.0 ± 0.6 at baseline to 2.5 ± 0.6 after 6 months of DMPA use (P = .006). The mean number of cell layers in the epithelium was reduced slightly from 28.1 ± 0.7 to 25.9 ± 0.9 (P = .05), epithelial thickness decreased from 1.02 ± 0.04 mm to 0.89 ± 0.05 mm (P = .005), and the glycogen-positive thickness decreased from 0.81 ± 0.04 mm at baseline to 0.66 ± 0.05 after 6 months of DMPA use (P = .005). Conclusion Depomedroxyprogesterone acetate produced a systemic hypoestrogenic state associated with decreased H2O2–positive Lactobacillus colonization and slight thinning of the glycogen vaginal epithelial layer. Such changes possibly compromise the vaginal barrier to infection.

Menstrual reduction with extended use of combination oral contraceptive pills : Randomized controlled trial

OBJECTIVE To compare a traditional 28‐day cycle to an extended 49‐day cycle of the 30 μg ethinyl estradiol (E2)/300 μg norgestrel monophasic birth control pill regimen. METHODS Ninety subjects randomized to either 28‐day cycles with 21 active pills or 49‐day cycles with 42 active pills for a prospective open label trial over four 84‐day reference periods or trimesters. Bleeding, pill taking, and symptom diaries were completed. The sample size with 80% power to detect a 40% reduction in bleeding days required 24 subjects in each arm. RESULTS Of the 90 women, 24 subjects (54.5%) on the 28‐day cycle and 29 (63%) on the 49‐day cycle completed the entire study (P = .41). There were no statistically significant differences between the two groups in demographics or continuation rates. There was a significant reduction in bleeding days in the experimental arm beginning in the first trimester (28‐day = 10.9, 49‐day = 6.4 mean days of bleeding, P < .001) and continuing to the fourth trimester (28‐day = 11.3, 49‐day = 5.8 mean days, P = .005). The number of spotting days was similar between both schedules in the first trimester (28‐day = 4.8, 49‐day = 3.7 mean days, P = .24) and continued into the fourth trimester (28‐day = 3.4, 49‐day = 2.9 mean days, P = .30). Annual expenditure for hygiene products was significantly less for extended use subjects (28‐day =

The effect of vaginal speculum lubrication on the rate of unsatisfactory cervical cytology diagnosis

41.45, 49‐day =

Depot-medroxyprogesterone acetate and combined oral contraceptive use and cervical neoplasia among women with oncogenic human papillomavirus infection.

17.54 spent, P < .001). CONCLUSION Extension of the 28‐day oral contraceptive (OC) cycle to a 49‐day cycle resulted in fewer bleeding days and no increase in mean spotting days or bleeding episodes.

Randomised treatment trial of bacterial vaginosis to prevent post-abortion complication.

OBJECTIVE Nonlubricated plastic specula can adhere to the vaginal introitus and cause discomfort with pelvic examination. We wanted to see if application of water‐soluble gel lubricant to the plastic vaginal speculum would change the unsatisfactory cervical cytology diagnosis rate. METHODS Five public health family planning clinic sites were randomized to either water‐soluble gel or water only as lubricant during speculum examination for cervical cytology collection. The pathologists were unaware of the assignment of lubricant use. The cumulative rates of cervical cytology diagnoses were calculated for 6 months before, 6 months during, and 6 months after the intervention. RESULTS From July 1998 through December 1999, 8534 Papanicolaou smears were collected, with 1440 using gel lubrication from January 1999 through June 1999. Rates of unsatisfactory smears for lubricant use clinics were 1.4% during use of lubricant and 1.4% without use (odds ratio [OR] 1.0; 95% confidence interval [CI] 0.6, 1.8). Rates of unsatisfactory smears for lubricant use versus nonlubricant use clinics during the gel intervention period were 1.4% versus 1.3% (OR 1.1; 95% CI 0.6, 2.0). There were no significant differences for the rates of atypical squamous cells of undetermined significance, low‐grade squamous intraepithelial lesion, high‐grade squamous intraepithelial lesion, or atypical glandular cells of undetermined significance within or between lubricant and nonlubricant clinics for each 6‐month period. There were no cases of invasive cancer. CONCLUSION The use of a small amount of water‐soluble gel lubricant on the outer inferior blade of the plastic vaginal speculum does not change cervical cytology results in a young, reproductive‐age population.

Ectopic gestation following emergency contraceptive pill administration

OBJECTIVE The objective of the study was to examine the relationship of depot-medroxyprogesterone acetate (DMPA) and combined oral contraceptive (COC) use with cervical intraepithelial neoplasia (CIN). STUDY DESIGN Two case-control studies of women who presented for gynecologic care and underwent cytologic and human papillomavirus (HPV) testing were performed. The first included oncogenic HPV-positive women grouped based on histology: negative (n = 152), CIN1 (n = 133), and CIN2-3 or greater (n = 173). For the second, 2 groups were identified: negative HPV/negative histology (n = 107) and positive oncogenic HPV/negative histology (n = 152). RESULTS Among oncogenic HPV-positive women, DMPA use was inversely associated with CIN2-3 or greater (adjusted odds ratio [OR(adj)], 0.4; 95% confidence interval [CI], 0.2-1.1) and CIN1 (OR(adj), 0.1; 95% CI, 0.01-0.6); COC use was not associated with either. Among histologically negative women, DMPA use was associated with oncogenic HPV (OR(adj), 4.7; 95% CI, 1.4-15.8). CONCLUSION Among women with oncogenic HPV, hormonal contraceptive use was not associated with an increased risk of CIN2-3 or greater. Longer-term DMPA use may attenuate the colposcopic and histologic features of CIN because women reporting such use were more likely than others to have cervical oncogenic HPV without evidence of CIN.

Internet availability of contraceptives.

Objective  To evaluate the efficacy of metronidazole to reduce post‐abortion complications among women with bacterial vaginosis.

Fruit size as a model for teaching first trimester uterine sizing in bimanual examination.

Emergency contraceptive pill prescription following rape is common. We report a case of ectopic gestation after emergency contraceptive pill failure and review the literature on this rare complication. A 26-year-old woman with a normal menstrual period 2 weeks before was administered an emergency contraceptive pill 8 hours after a single sexual assault. The assault was her only sexual activity before and after the emergency contraceptive pill use. Forty-six days following the assault, the patient presented with a right ampullary tubal pregnancy of 59 days gestation and underwent emergent surgery for ectopic gestation. To prevent a delay in the diagnosis of ectopic pregnancy, we recommend that providers and the package insert advise women, that ectopic gestation can occur with emergency contraceptive pill failure.