Research roundup: April 2022 edition

Substantial support for over-the-counter abortion medication, benefits and risks of immediate post partum IUD and implant insertions, expanding access to the full range of emergency contraceptive options, and more.

by Colleen Denny, MD and Emma Gilmore, MD

published 04/29/22

1. A cross-sectional survey of U.S. abortion patients’ interest in obtaining medication abortion over the counter

Medication abortion using a two-pill regimen is an effective and safe way to end a pregnancy and is FDA-approved up to 70 days’ gestation. However, current regulations require that these medications may only be accessed with a provider’s prescription, which may create additional barriers to abortion access for patients. In this study using a self-administered, cross-sectional survey, researchers queried nearly 1,200 patients seeking abortion services about their interest and concerns regarding hypothetical future availability of medication abortion over-the-counter (OTC). Eighty-three percent of respondents were generally in favor of OTC availability, and 65% expressed personal interest, endorsing advantages such as privacy, earlier access, and convenience. Approximately 59% noted concerns that people may take OTC pills incorrectly, and 39% reported concerns about not seeing a clinician prior to administration. In terms of demographics, patients who identified as white, with higher levels of formal education, were more likely to support OTC availability. The authors note a high level of support for OTC medication abortion among those most likely to be affected by this policy and discuss ways that future programs such as hotlines and follow up clinic-based care could be tailored to support patients in this care model.

2. Association Between Intrauterine Device Type and Risk of Perforation and Device Expulsion: Results From the APEX-IUD Study

Intrauterine devices (IUDs) are a highly-effective form of long-acting reversible contraception (LARC) and are used by approximately 14% of women worldwide. Complications from IUD usage are uncommon but can include uterine perforation or device expulsion; although it is not clear how the type of IUD affects these risks. In this large retrospective cohort study, the records of more than 320,000 patients using IUDs were analyzed to determine long-term perforation and expulsion risk. Of the more than 259,000 patients with levonorgestrel IUDs (LNG IUDs), perforation risk was 0.22% at one year and 0.63% at five years, and expulsion rates were 2.3% at one year and 4.52% at five years. Of the more than 63,000 patients with copper IUDs, perforation risk was slightly lower, at 0.16% at one year and 0.55% at five years, but expulsion risk was slightly higher long-term at 2.3% at one year and 4.82% at five years. The authors noted that the populations using the two types of IUDs were not demographically matched—LNG IUD users were older, less likely to be postpartum or breastfeeding, more likely to be obese, and more likely to report dysmenorrhea or uterine fibroids prior to IUD insertion. While the authors summarized that LNG IUD users in the study were statistically significantly more likely to have perforations and less likely to have expulsions than copper IUD users, they concluded that these results were unlikely to reflect any clinically significant difference and were rare with all IUD types.

3. Discontinuation rates of intrauterine contraception due to unfavourable bleeding: a systematic review

While IUDs can safely provide highly-effective, reversible contraception for the majority of patients, changes in menstrual bleeding patterns are a common side effect. While some patients may find these changes desirable or not bothersome, others may find the same changes unacceptable and discontinue IUD use as a result. In this systematic review, including data from both the US and Europe, the authors identified 41 unique studies that reported bleeding patterns with IUD use and early discontinuation rates. They identified a trend towards higher early discontinuation rates in copper IUD users, with individual studies showing discontinuation rates between three and 58% at 12-36 months, compared to LNG IUD early discontinuation rates ranging from four to 35%. Further, for studies that reported on patients’ reasons for early discontinuation, copper IUD users were more likely to blame undesirable bleeding patterns, at rates up to 26% of all early discontinuations. While IUDs can provide an excellent contraception option, providers should incorporate anticipated changes in menstrual bleeding patterns into their counseling for patients considering IUDs to help facilitate decision making.

4. Effect of levonorgestrel emergency contraception on implantation and fertility: A review

While oral levonorgestrel emergency contraception (LNG EC) can provide an extremely safe, over-the-counter means of preventing pregnancy when taken within 72 hours of unprotected sex, misconceptions among both patients and providers may limit its use. Previous research has indicated that a significant percentage of patients incorrectly believe that LNG EC can cause birth defects, lead to infertility, and/or interfere with implantation of a fertilized egg. In this literature review, the authors sought to address these concerns by investigating the scientific mechanism of levonorgestrel and its reported complications. In 33 unique studies, the authors found that there was significant evidence showing that LNG EC inhibited ovulation when used before the LH surge but did not affect ovulation or pregnancy when used during or afterwards. Further, the studies showed no evidence of levonorgestrel EC affecting blastocyst implantation, future fertility, long-term changes in menstrual cycles, ectopic pregnancy rates, miscarriage, or fetal development. Providers counseling patients on LNG EC use can discuss that is extremely safe, without long-term impacts on reproductive health, has no abortifacient effect, and will not harm an ongoing undiagnosed pregnancy.

5. Opportunities for improving provision of emergency contraception in California

There are multiple types of EC available in the United States—two types of pills and two IUDs—but there are barriers to accessing the most effective methods of EC. LNG EC pills, such as Plan B and other generics, are available over the counter, but patient weight is an important factor in how effective LNG EC pills are in preventing pregnancy. More effective EC pills, ella (ulipristal acetate), require a prescription, and IUDs require an in-person visit to a trained health care provider within five days of unprotected sex. Additionally, data suggests that EC consultations are a crucial time to screen for intimate partner violence (IPV) and sexual assault. To assess access to EC in California, authors of this study attempted to contact more than 300 family planning clinics serving patients who live at or below 200% of the federal poverty level. Posing as patients, the researchers noted whether the clinic staff offered the more effective methods of EC, ella or IUD placement, or if they asked questions about the caller’s weight or history of IPV. Only 59% of these clinics were reachable by phone, and a minority offered the full range of EC options or provided appropriate screening. The findings of this study suggest that phone access and intake at these Californian clinics should be expanded and improved to allow patients to receive appropriate EC options.

6. Timing of postpartum long acting, reversible contraception was not associated with 12-month removal rates in a large Medicaid sample

LARC methods such as IUDs and implants, are reliable birth control options for patients during the postpartum period that can reduce the risk of short-interval pregnancies, which can have both physiologic and economic consequences for families. Offering these methods right after delivery, prior to hospital discharge, is called immediate postpartum (IPP) contraception, and is an effective and safe method for patients. IPP LARC is particularly useful for patients who may experience barriers to attending their postpartum visit, but some studies have raised questions about lower continuation rates for birth control selected during this period. The authors of this study sought to compare 12-month removal rates in patients who opted for IPP LARC methods versus those who obtained LARC at their postpartum visit, termed interval LARC. They reviewed birth certificate and Medicaid data for more than 300,000 deliveries in South Carolina and Oregon. They found that about 54,000 patients opted for immediate or interval LARC placement, but there was no difference in discontinuation by timing of placement or type of device. These findings suggest that IPP LARC is acceptable to patients and is an important way of providing contraceptive access to patients during the postpartum period.

7. Association of the Timing of Postpartum Intrauterine Device Insertion and Breastfeeding With Risks of Intrauterine Device Expulsion

Providers and patients increasingly opt for post-placental IUD placement (within the first 10 minutes after delivery) or early postpartum placement (within 72 hours after delivery), as this ensures that the patient has a reliable method of birth control prior to discharge from the hospital. However, multiple studies show that IUDs placed during these timeframes may have a higher risk of expulsion, and that breastfeeding may affect these risks. The authors conducted a cohort study to look at whether timing of postpartum IUD placement, and/or breastfeeding, affect IUD expulsion rates. They reviewed the charts of more than 300,000 individuals with IUDs in California over the course of 17 years. Their results indicated that IUD placement at 0-3 days postpartum has the highest risk of expulsion, at 10.73%, and lowest between 6-14 weeks postpartum, at 3.18%. And breastfeeding appeared to lower the risk of postpartum expulsion. It is important to note that the overall rates of expulsion remained low overall for the full cohort. However, this information is useful as providers counsel patients on the risks and benefits of postpartum IUD placement.

8. "Being able to do whatever you wanna do as a woman is important:" a qualitative exploration of contraception as a frame of reference for HIV prevention with PrEP

PrEP (pre-exposure prophylaxis) is a daily medication that reduces the risk of HIV transmission for individuals who are at risk of exposure. Although it is safe and effective, its uptake among cis-gender women remains low, at around 5% of all people taking PrEP. Unfortunately, this population comprises 20% of new HIV infections, largely among Black and Latina women, indicating that the needs of this population are not being well addressed. The authors of this study conducted interviews to better understand the feelings of self-identified Black and Latina women with regard to PrEP and explore the ways that these perceptions were tied to their experiences with contraception. The authors identified multiple themes over the course of their interviews, finding that subjects perceived PrEP as a daily pill, like oral contraceptive pills, that could be incorporated into conversations around family planning. Subjects also stated that they wished for other delivery options, such as weekly injections for HIV prophylaxis. Overall, these results suggest that discussions about PrEP may be integrated into contraceptive counseling, allowing providers to focus on patients’ sexual health and autonomy as factors in overall reproductive wellness. For more information on providing PrEP to your patients, check out Bedsider Providers’ Guide.

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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