Research roundup: April 2021 edition

Public health benefits of widespread HPV vaccination, potential for IUDs to be placed as emergency contraception 6-14 days after unprotected vaginal sex, etonogestrel implants to help with pelvic pain, and more.

by Colleen Denny, MD and Emma Gilmore, MD

published 04/30/21

1. Declines in Prevalence of Human Papillomavirus Vaccine-Type Infection Among Females after Introduction of Vaccine — United States, 2003–2018

The human papilloma virus (HPV) vaccine was first introduced to the US market in 2006 and administration is recommended starting at age 11 to prevent HPV infection and related sequelae prior to sexual exposure. In this report from the National Health and Nutrition Examination Survey (NHANES), the authors report on the most recent data on the incidence of HPV infection in different age groups. Among females age 14-19, the authors found a decrease of 88% in the prevalence of the four types of HPV covered by the vaccination, in comparison with this same population pre-vaccination; among females age 20-24, the drop was 81%. Interestingly, the authors also found a decrease in HPV prevalence among unvaccinated females in these age groups, which they attribute to herd effects of vaccination. This data contributes strongly to overall trends demonstrating the safety and public health benefit of widespread HPV vaccination, even for those patients who do not receive the vaccine themselves.

2. Risk of Pregnancy With Levonorgestrel-Releasing Intrauterine System Placement 6–14 Days After Unprotected Sexual Intercourse

There is high-quality evidence that both copper and levonorgestrel intrauterine devices (IUDs) can be used as emergency contraception when placed within 5 days of unprotected vaginal sex. However, it is less clear how well these IUDs prevent pregnancy when placed at longer intervals since unprotected sex. In this research letter, the authors combined the results from four smaller studies that included information about pregnancy rates in patients who had levonorgestrel IUDs placed 6-14 days after unprotected sexual intercourse. Among a total of 187 patients with either documented or self-reported pregnancy status within 4 weeks of IUD placement, the authors identified only one pregnancy. This research suggests that IUDs may potentially be useful as emergency contraception past the 5-day mark. Further, it suggests that patients who present requesting IUD placement for long-term contraception but have had unprotected intercourse in the last two weeks may be counseled that the risk of pregnancy with same-day IUD placement is very unlikely.

3. Effects of Etonogestrel implants on pelvic pain and menstrual flow in women suffering from adenomyosis or endometriosis: Results from a prospective, observational study

Etonogestrel implants provide effective contraception, but the suppression of ovulation through long-acting progesterone may also affect patients with pain syndromes exacerbated by during normal menstrual cycling. In this prospective observational study, the authors provided etonogestrel implants to 100 patients with a diagnosis of either adenomyosis (56) or endometriosis (44), two common conditions associated with pelvic pain and menorrhagia. They found that pain scores significantly improved after implant insertion for patients in both groups, and that menstrual flow significantly decreased. Twenty-six of the patients eventually had their implants removed within the two-year follow up period for this study, with undesirable bleeding patterns and amenorrhea being the most cited reasons for removal. However, the majority of patients continued with their implants, indicating that patients with pelvic pain conditions who wish to avoid surgery could benefit from the option of an etonogestrel implant.

4. Can a Clean Catch Urine Sample Be Used to Diagnose Chlamydia and Gonorrhea in Adolescent Females?

Many providers seeing patients with symptoms of vaginitis or dysuria will want to investigate the possibility of the patient having either an STI (sexually transmitted infection) or a UTI (urinary tract infection). While both of these may be diagnosed using urine samples, the CDC recommends a “dirty catch” (first void urine sample) for testing for chlamydia and gonorrhea, different from the mid-stream “clean catch” recommended for urine culture; this requirement for two separate urine samples may impede clinical workflow. In this noninferiority prospective cohort study, the authors investigated the sensitivity and specificity for dirty and clean catch urine for diagnosing chlamydia and gonorrhea in adolescents, as compared to a vaginal swab (known to be more sensitive and specific than urine testing). Among 323 adolescent patients recruited to the study, there were 59 cases of chlamydia and 18 of gonorrhea. The sensitivity and specificity of clean urine to diagnose chlamydia were 86.2% and 98.8%, respectively, and the sensitivity and specificity of clean urine to diagnose gonorrhea were 94.4% and 99.7%, respectively. This was noninferior to the specificity and sensitivity performance of the dirty urine samples. Providers needing urine for both STI testing and UTI testing can likely consolidate urine samples to facilitate patient care and clinic workflow.

5. Expedited Partner Therapy in Adolescent Females: A Study of Acceptance and the Impact on Reinfection Rates

Given the increasing prevalence of sexually transmitted infections among adolescents in the US, there is much public health interest in the use of expedited partner therapy (EPT) to reduce rates of infection and reinfection. In this retrospective chart review, the authors examined whether adolescent females diagnosed with either chlamydia (CT) or trichomoniasis (TV) would accept EPT, and whether the legalization of EPT affected reinfection rates. They found that the majority of patients diagnosed with either CT or TV did not accept the offer of EPT, with only 25% and 28% accepting EPT for CT and TV, respectively. The authors also did not find a significant difference in rates of reinfection among patients who declined or accepted EPT, although there was a non-significant trend towards decreased reinfection in those who accepted EPT. This research indicates the complexity in the use of EPT, and the many barriers that contribute to continued high rates of STI infection, especially among adolescents.

6. Medication Abortion With Pharmacist Dispensing of Mifepristone

In the United States, medication abortion using mifepristone and misoprostol is FDA approved up until 70 days (10 weeks) gestation. However, mifepristone can only be dispensed by clinicians in certain health care settings, based on the original FDA approval from 2000. As the safety of medication abortion has become increasingly publicized and supported by evidence, other countries have legalized dispensing of mifepristone by pharmacists, which allows medication abortion to be accessed more easily by patients, especially in low-resource settings. The authors of this paper conducted a prospective cohort study in California to estimate the effectiveness and acceptability of pharmacist-dispensed mifepristone. They found that the majority of patients were very satisfied with mifepristone when it was dispensed by a pharmacist, and abortion outcomes were similar to those of patients who received mifepristone from a clinician. These results suggest that it would be safe and acceptable to remove the dispensing restrictions on mifepristone, thereby increasing patient access to medication abortion.

7. Abortion Waiting Periods and Decision Certainty Among People Searching Online for Abortion Care

In the US, 27 states have mandated waiting periods for individuals seeking abortion, often requiring patients to have two visits with a provider before they can obtain care. Legislators have maintained that these waiting periods help patients become more certain of their decisions, but these requirements may be an obstacle to timely abortion care. The authors of this study sought to determine whether mandatory waiting periods and two visit requirements helped to increase decision certainty for patients. Using an online survey, they ultimately recruited 750 individuals to provide information on their abortion decision-making experiences in states with and without mandated waiting periods. Researchers were unable to find an association between state-mandated requirements and increased decision certainty. This study clearly shows that restrictive state laws are not in line with patient wishes and do not assist in the decision-making process around abortion.

8. Use of concurrent multiple methods of contraception in the United States, 2008 to 2015

Many individuals are known to combine use of long-acting reversible contraceptives (LARC) to prevent pregnancy, and barrier protection to prevent STIs. However, little is known about actual rates of utilization of concurrent multiple methods of contraception for patients in the United States, or about the personal preferences of people who use multiple methods. The authors of this study analyzed survey data from more than 11,000 individuals between 2008 to 2015. They found that about 1 in 5 respondents used more than one method of contraception at last sex, and this proportion has increased over time. While some patients used dual methods that included condoms to prevent STIs, results varied greatly (with 53 unique method combinations reported) and showed that a desire for pregnancy prevention significantly influences choice of contraception, along with other considerations such as partner preference. This study provides interesting insight about patient practices across the United States and is a useful tool for providers as they counsel patients about contraception choices and combinations.

Colleen Denny, MD, is an attending ObGyn at Bellevue Hospital in New York City, where she is the Medical Director of the Women's Clinic, and a clinical assistant professor with the NYU School of Medicine. She enjoys providing care for patients in all phases of life and is especially interested in issues related to contraception access and public health. Outside of work, she’s a runner, a dancer, and a bit of a crossword puzzle nerd.
Emma Gilmore is a fellow in Complex Family Planning at the University of Pennsylvania. She completed her residency in Obstetrics and Gynecology at New York University. She's passionate about reproductive rights, medical education, and combating health care disparities, particularly in sexual and reproductive health. In her free time, she can be found taking her dog on walks around the beautiful parks in and around Philadelphia.
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