Tony Ogburn

Long-acting reversible contraceptives: intrauterine devices and the contraceptive implant.

The provision of effective contraception is fundamental to the practice of womens health care. The most effective methods of reversible contraception are the so-called long-acting reversible contraceptives, intrauterine devices and implants. These methods have multiple advantages over other reversible methods. Most importantly, once in place, they do not require maintenance and their duration of action is long, ranging from 3 to 10 years. Despite the advantages of long-acting reversible contraceptive methods, they are infrequently used in the United States. Short-acting methods, specifically oral contraceptives and condoms, are by far the most commonly used reversible methods. A shift from the use of short-acting methods to long-acting reversible contraceptive methods could help reduce the high rate of unintended pregnancy in the United States. In this review of long-acting reversible contraceptive methods, we discuss the intrauterine devices and the contraceptive implant available in the United States, and we describe candidates for each method, noncontraceptive benefits, and management of complications.

Depo-provera associated with weight gain in Navajo women.

Depo-medroxyprogesterone acetate (DMPA) is an increasingly popular contraceptive choice among Navajo women. Weight gain is cited as a common side effect and major reason for discontinuation of DMPA. No controlled trials have evaluated the association between weight gain and DMPA in Navajo women. We aimed to clarify whether DMPA is associated with weight gain in Navajo women and to quantify the magnitude of weight gain. A cohort of 172 Navajo women who had used DMPA continuously for one or 2 years comprised the study group. A cohort of 134 Navajo women who used a non-progestin method or no method over 1 or 2 years comprised the comparison group. Initial weight, one-year weight and 2-year weights were recorded for all patients. Study subjects gained a mean of 6 pounds over one year and 11 pounds over 2 years relative to the comparison group (p < 0.001) after controlling for possible confounding variables including age, parity and initial weight. Use of DMPA is associated with significant weight gain in Navajo women. This weight gain is greater than that reported in previous uncontrolled studies in non-Navajo populations. This information should be utilized in counseling Navajo women about the side effects of DMPA.

Effect of Progestin Compared With Combined Oral Contraceptive Pills on Lactation: A Randomized Controlled Trial.

OBJECTIVE: To estimate the effect of progestin-only compared with combined hormonal contraceptive pills on rates of breastfeeding continuation in postpartum women. Secondary outcomes include infant growth parameters, contraceptive method continuation, and patient satisfaction with breastfeeding and contraceptive method. METHODS: Postpartum breastfeeding women who desired oral contraceptives were randomly assigned to progestin-only and combined hormonal contraceptive pills. At 2 and 8 weeks postpartum, participants completed in-person questionnaires that assessed breastfeeding continuation and contraceptive use. Infant growth parameters including weight, length, and head circumference were assessed at 8 weeks postpartum. Telephone questionnaires assessing breastfeeding, contraceptive continuation, and satisfaction were completed at 3–7 weeks and 4 and 6 months. Breastfeeding continuation was compared between groups using Cox proportional hazards regression. Differences in baseline demographic characteristics and in variables between the two intervention groups were compared using &khgr;2 tests, Fisher exact test, or two-sample t tests as appropriate. RESULTS: Breastfeeding continuation rates at 8 weeks (progestin-only 63.5%; combined hormonal 64.1%), contraceptive continuation, and infant growth parameters did not differ between users of progestin-only and combined hormonal contraceptive pills. Infant formula supplementation and maternal perception of inadequate milk supply were associated with decreased rates of breastfeeding in both groups. CONCLUSION: Choice of combined hormonal or progestin-only contraceptive pills administered 2 weeks postpartum did not adversely affect breastfeeding continuation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01465022. LEVEL OF EVIDENCE: I

Misoprostol for intrauterine device insertion in nulliparous women: a randomized controlled trial

OBJECTIVE To examine the effects of preprocedure misoprostol on intrauterine device (IUD) placement in nulliparous women. STUDY DESIGN In this randomized controlled double-blind trial at the University of New Mexico reproductive health clinic, nulliparous women requesting an IUD were randomized to 400 mcg of buccal misoprostol or placebo 2-8 hours before insertion. Primary outcomes included pain on a 10-cm visual analog scale and womens perception of the value of delaying insertion for an effective medication. Provider ease of insertion and need for adjunctive insertion measures were also assessed, on a visual analog scale. Participants indicated maximum pain after IUD insertion, pain level they would tolerate to avoid delay in IUD insertion, and preference for IUD insertion without delay if an effective medication was available. RESULTS Of 85 women enrolled, 3 were ineligible; 42 were randomized to misoprostol and 40 to placebo. There were no differences between groups in worst insertion pain, (5.8 ± 2.0 vs 5.9 ± 2.0, P = .94), provider ease of insertion (2.2 ± 2.2 vs 2.5 ± 2.2; P = .54) or adjunctive measures (14% vs 25%; P = .27). The groups were willing to tolerate the same mean pain (4.9 ± 2.5 vs 5.7 ± 2.4, P = .18) to avoid waiting for medication. The majority of women (85%) preferred to wait for an effective medication. CONCLUSION Misoprostol for nulliparous women did not decrease pain or improve the ease of insertion of an IUD. Most women were willing to wait for a medication that decreases pain, indicating a need to pursue alternatives for pain control with IUD insertion.

Student attitudes about a clinical experience in abortion care during the obstetrics and gynecology clerkship.

Purpose An optional half-day clinical experience in abortion care was offered to third-year medical students rotating through the core obstetrics and gynecology (Ob/Gyn) clerkship at the University of New Mexico to improve education about women’s reproductive health. This study using survey methods was conducted to rate the acceptability of the clinical experience and to document any changes in students’ attitudes toward women’s access to abortion. Method All 145 students who rotated through the Ob/Gyn clerkship between March 2000 and March 2002 were provided an 11-item, confidential questionnaire to complete. Students who did not participate in the abortion care experience were asked questions about their reasons for declining participation; students who did participate were asked questions about the value of the experience. Results Of the 145 students who rotated through the clerkship during the study period, 126 (87%) completed the questionnaire. Of these students, 86 (68%) participated in the clinical experience and 40 (32%) did not. The majority of students who participated in the clinical experience rated it very highly. Of the 86 students who participated in the clinical experience, 33 (38%) reported a change in their attitudes about abortion; 31 (94%) of these became more supportive of women’s access to abortion services. Conclusion Clinical experiences in abortion care are acceptable to and valued by a diverse group of medical students and should be offered at medical schools throughout the United States.

Perpetuating negative attitudes about the intrauterine device: textbooks lag behind the evidence

This study examined current textbooks and manuals to discern whether their presentations of the Copper T380A intrauterine device are accurate, current, and objective. Thirteen medical student obstetrics and gynecology texts used in the US and five from the UK were evaluated for information presented about the Copper T-380A intrauterine device. A scoring system was developed to record the presence or absence of characteristics of intrauterine device usage. The two authors independently reviewed the texts and completed code sheets. In general, advantages of the device were under-reported while disadvantages were exaggerated. Review of US texts identified inaccuracies regarding the devices mechanism of action; 5 of 13 did not include its prefertilization action. Despite evidence to the contrary, 9 of 13 texts reported an increased risk of pelvic inflammatory disease associated with intrauterine device use; 6 of 13 reported an increased risk of ectopic pregnancy; and 4 of 13 reported an increased risk of infertility. Review of UK texts yielded similar results regarding advantages and disadvantages, as well as mechanism of action. The UK texts presented fewer inaccuracies regarding intrauterine device risks. Most texts from both countries implied that the intrauterine device is a method of last resort. Texts commonly used by medical students on womens health rotations may not be evidence-based in the information presented about the intrauterine device.

A Breastfeeding Curriculum for Residents and Medical Students: A Multidisciplinary Approach

Medical school and residency training programs, in which practice patterns are established, frequently lack formal education in breastfeeding in the United States. This project, a curriculum based on the Wellstart Lactation Management Guide, was developed for resident physicians and medical students at the University of New Mexico to address the deficiency in formal education about breastfeeding. The curriculum, developed and implemented by faculty members from obstetrics/gynecology, pediatrics, and family medicine, includes formal interactive teaching sessions, discussion of breastfeeding issues on daily clinical rounds, and patient visits with lactation support personnel. Interns from the Departments of Pediatrics, Obstetrics/Gynecology, and Family Medicine participate. Surveys of participating residents and faculty demonstrate highly favorable attitudes. In conclusion, a multidisciplinary approach to breastfeeding education is feasible and well received by both teachers and residents. J Hum Lact. 21(4):458-464.

The R-I-M-E method for evaluation of medical students on an obstetrics and gynecology clerkship.

OBJECTIVE The purpose of this study was to implement and assess the R-I-M-E (Reporter, Interpreter, Manager, Educator) system as a method for evaluation for medical students during the obstetrics and gynecology core clerkship. STUDY DESIGN With the R-I-M-E method (which is an objective framework for evaluation), mid clerkship review sessions are held during which residents verbally assess each student on competencies that include problem identification and reasoning skills, communication skills, physical examination skills, written documentation, and professional attributes. The clerkship director provides timely feedback to the students. Residents and students were surveyed to assess their attitudes about the R-I-M-E method. RESULTS Most of the attitudes of residents and students were positive about the R-I-M-E evaluation system. The directors feel that R-I-M-E method allows more meaningful, complete, and timely feedback to students, especially in areas that are traditionally difficult to assess, such as professionalism. CONCLUSIONS The R-I-M-E method is an effective evaluation tool for medical students during an obstetrics and gynecology clerkship and is well received by teachers and learners.

Revitalizing problem based learning: student and tutor attitudes towards a structured tutorial

Background: The pre-clinical curriculum at the University of New Mexico School of Medicine is a hybrid model that includes small group, problem-based learning (PBL) tutorials and didactic lectures. A structured tutorial format was piloted for the human sexuality/reproduction organ system block for the PBL component. The objective of this study was to compare the acceptability of the structured format and its effectiveness with that of a traditional PBL tutorial. Methods: Students were surveyed after the renal/endocrinology block of 2004 (traditional tutorial format) and after the human sexuality/reproduction block of 2004 (structured tutorial format) (n = 70). Survey questions covered the quality of learning and of tutorial. Students (n = 132) and tutors (n = 24) who participated in human sexuality/reproduction in 2004 and 2005 were surveyed for attitudes about the structured tutorial overall and specific components. Means of responses were compared using t-tests. Results: Students indicated that the structured tutorial format supported a greater improvement in their basic science and clinical knowledge and their ability to evaluate information (p < 0.05). The majority of students and tutors recommended the structured format for tutorials in other blocks. Conclusions: We demonstrated the acceptability of a structured tutorial format to students and faculty. Faculty members perceived greater depth of learning and participation by the students.

Postinterview communication with residency applicants: a call for clarity!

The residency match is an increasingly competitive process. Communication from medical student applicants to programs varies, and the effect this has on their rank status is unclear. We assessed how obstetrics and gynecology program directors interpret and act on postinterview communication initiated by applicants by conducting an anonymous cross-sectional web-based survey of allopathic obstetrics and gynecology program directors. One hundred thirty-seven program directors (55%) responded to the survey. Twenty-nine percent would consider ranking an applicant more favorably if the applicant expressed interest (beyond a routine thank you) or if a faculty mentor personally known to the program director stated that the applicant was ranking the program first. Fifty-two percent indicated that they would rank an applicant more favorably if a mentor known to them endorsed the applicant as outstanding. Approximately 30% responded that applicants who did not communicate with their program were disadvantaged compared with those who did. Approximately 17% stated it was desirable to create additional specialty-specific guidelines regarding postinterview contact between programs and applications. Based on the wide variation in how program directors interpret and act on postinterview communication from applicants, residency programs should formulate and communicate a clear policy about whether they request and how they respond to postinterview communication from applicants and their mentors. This will establish a more level playing field and eliminate potential inequities resulting from inconsistent communication practices.