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Research roundup: April 2024 edition

A patient-centered decision aid for tubal sterilization counseling, IUD self-removal experiences, and counseling about pain and medication abortion.

by Colleen Denny, MD and Emma Gilmore, MD

published 04/30/24

1. IUD self-removal: A randomized controlled trial of a self-removal guide in clinical and nonclinical settings

IUDs can provide a highly effective form of reversible contraception and are safe for almost all patient populations. However, IUD removal is typically performed by a trained health professional, which may present barriers to IUD removal, such as cost, provider availability, or provider resistance to removal. While previous studies have estimated that less than a fifth of patients can successfully self-remove their IUDs, this randomized controlled trial evaluated whether 116 patients desiring IUD removal could successfully remove their IUDs with or without a standardized online guide. The authors found that approximately a third of patients in both groups could successfully remove their IUDs, and there was no significant difference in success rates based on access to the online guide. Patients who attempted removal in a nonclinical setting were more likely to be successful, as were patients who reported previously palpable IUD strings. Thirty-two percent of patients randomized to the guide group and 55% of patients without the guide reported using outside IUD self-removal resources, usually searching online. The authors conclude that IUD self-removal attempts are generally safe and may be a reasonable option for patients who wish to avoid a clinic visit. They also suggest that the proliferation of online information may provide helpful support for patients choosing this option.

2. Understanding the mechanical behavior of intrauterine devices during simulated removal

A health care professional typically performs IUD removal, which involves exerting traction on the strings of the IUD to draw it down through the uterus and cervix intact. IUD fracture is a possible (but low) risk during IUD removal, however, the factors that contribute to this risk are not well understood. In this research, the authors evaluated different IUD frames from a structural perspective to understand how force, stress, and strain impact the different IUD frames during removal. They studied the Nova-T frames used by the Mirena, Liletta, and Kyleena IUDs and the Tatum-T frame used by the Paragard. In simulating the forces generated by IUD removal, the authors found that force and stress at the junction of the IUD stem and arms were higher for the Tatum-T frame compared to the Nova-T frame for the same testing conditions and that faster extraction speeds caused more stress. While this study was a simulation and did not include IUD removals from patients, in their discussion, the authors suggest that these findings indicate that providers should remove Tatum-T IUDs more slowly to reduce stress and possibly decrease the likelihood of fracture.

3. A Decision Aid to Support Tubal Sterilization Decision-Making Among Pregnant Women: The MyDecision/MiDecisión Randomized Clinical Trial

Tubal sterilization is the most commonly selected birth control method among reproductive-aged US pregnancy-capable individuals, and demand for this procedure is on the rise now that abortion access is becoming more limited across the country. However, many misconceptions exist around tubal sterilization, such as a lack of understanding that it is permanent and limited awareness of similarly effective, reversible methods. Furthermore, its history is fraught due to the US’ complicity in forced sterilization of marginalized populations. To support patient-centered counseling and shared decision-making, the authors of this manuscript designed a decision tool, MyDecision/MiDecisión, which includes multimedia information and interactive exercises in English or Spanish. They then conducted a randomized clinical trial to assess its effect on patients’ experience when making decisions regarding tubal sterilization. Patients who used the MyDecision/MiDecisión tool had significantly higher knowledge about tubal sterilization and experienced less decisional conflict. This study highlights the utility and importance of integrating a patient-centered decision aid on tubal sterilization into clinical practice.

4. Use of progestogens and the risk of intracranial meningioma: national case-control study

Although they are typically benign, intracranial meningiomas are relatively common and can cause complications by compressing brain tissue and necessitating major surgery. Risk factors for meningioma include female sex, and the majority of these tumors have progesterone receptors. However, little is known about the natural course of intracranial meningiomas as it relates to exogenous hormone administration, specifically progestins. To better understand this relationship, the authors of this paper conducted a case-control study in which they evaluated French female patients with a history of intracranial meningioma to see whether they were exposed to exogenous progestins for up to three years prior to their tumor diagnosis. Numerous progestins, varying in type, dose, and administration route, were included in the “exposure” category. Over 18,000 patients were included in the intracranial meningioma group, and each patient was matched to five controls. Increased risk of intracranial meningioma was found in patients who had been exposed to a subset of progestins, including medroxyprogesterone acetate, for a year or more. As a case-control study, these results must be interpreted with caution but indicate a need for further exploration of associations between progestin exposure and intracranial meningioma risk.

5. Hormonal contraceptive use after a first venous thrombotic event and the risk of recurrence in premenopausal women

A venous thrombotic event (VTE) is a well-known indication for discontinuation of hormonal contraceptives (HC), particularly those containing estrogen, to prevent recurrence. However, some individuals resume HC use despite having a history of VTE, and others may be advised to continue HC while taking anticoagulation to counteract possible increases in menstrual bleeding due to starting anticoagulation and stopping HC simultaneously. While there is robust evidence to suggest that VTE recurrence risk is relatively low in this patient population, less is known about recurrence risk in patients who restart (or do not stop) taking HC. By analyzing results from a large case-control study in the Netherlands, the authors sought to evaluate the risk of recurrent VTE in patients using HC, following 650 patients for a median of 6.1 years. They found that combined hormonal contraceptives, in particular, those containing estrogen, did lead to an increased risk of recurrent VTE. However, levonorgestrel intrauterine devices (LNG IUDs) had the same recurrence risk as non-use, highlighting their safety in this patient population. This study supports current recommendations to avoid combined hormonal contraceptives after a first VTE and also reinforces the safety of alternatives, such as LNG IUDs.

6. Pilot study of a novel, alternative subdermal scapular insertion site for the etonogestrel contraceptive implant

The contraceptive implant (Nexplanon) is a highly effective form of reversible contraception and is safe to use in a wide variety of patient populations. The manufacturer recommends placing the Nexplanon subdermally, overlying the triceps muscle of the non-dominant arm. While generally safe, the traditional arm insertion can be rarely associated with neurovascular complications for deeply placed implants. Additionally, traditional arm placement may be problematic for patients with intellectual delays or mental health issues that lead to picking or self-removal attempts at the insertion site. In this pilot study, the authors studied whether implants placed subdermally over the non-dominant inferior scapula created levels of serum etonogestrel comparable to traditional arm placement. Over one year of use, the authors found that etonogestrel levels remained above 90 pg/ml, which is effective for ovulation suppression and similar to the pharmacokinetics of arm insertion. Bleeding patterns were also similar to arm insertion patterns, and patients reported high satisfaction levels with scapular insertion. This study, while small, suggests that scapular insertion may be an equivalent alternative for patient populations where arm placement is not ideal.

7. An estimate of lifetime incidence of abortion in the United States using the 2021-2022 Abortion Patient Survey

In the US, the need for abortion care is common during reproductive years, but changes in both abortion and contraception access can potentially impact abortion rates. In this research focusing on the years immediately prior to the Dobbs decision, the author used data from Guttmacher’s 2021-2022 Abortion Patient Survey (APS) as well as abortion counts from their 2020 Abortion Provider Census to estimate abortion rates across all age groups. In their analysis, the author concludes that an estimated 24.7% of women aged 15-44 years in 2020 would be expected to have an abortion by age 45 if the 2020 abortion rate remains stable. In the discussion, the author notes that the rapidly changing political landscape may affect both the availability of abortion care as well as the quality of reporting data over the coming years but notes that the need for abortion care remains extremely common across the US population. Providers can use this information to normalize the need for abortion care.

8. Foregrounding pain in self-managed early medication abortion: a qualitative study

First-trimester medication abortion is well-established as a safe and highly effective method of pregnancy termination. As the US political climate becomes more hostile towards abortion, patients may prefer to self-manage their medication abortions. However, pain control strategies have not been fully explored in this setting, and research has already shown that the experience of pain during medication abortion can be variable. Although it is often described to patients as being similar to menstrual cramps, some patients find it more intense than expected, and this may lead to negative associations around the experience. The authors of this manuscript performed a qualitative study of patients who had a medication abortion in the United Kingdom during the COVID-19 pandemic to better understand their pain experiences, particularly regarding comparisons to menstrual cramps. They interviewed 20 patients who had first-trimester medication abortions in 2020 and 2021. Patients expressed that unexpectedly severe pain experiences could lead to feelings of fear or punishment and that the reference to period-like pain does not help set expectations. This study indicates that providers could be better informed about the ways that counseling around pain expectations may affect patient experiences during medication abortion.

9. Experiences of delay-causing obstacles and mental health at the time of abortion seeking

Patients seeking abortion may encounter numerous obstacles leading to delays in care, which subsequently result in increased expense, travel distance, and risk of complications due to increases in gestational duration. While delays presumably increase patient stress, few studies have examined the effects of abortion delays on patients’ mental health. As these delays may become more and more widespread due to restrictions on abortion access, it is important to seek a better understanding of patient-focused repercussions. The authors of this paper conducted a survey study to explore the associations between delays in abortion care and adverse effects on mental health. The majority of study participants experienced abortion care delays, most commonly due to cost. Delays were significantly associated with increased feelings of depression, anxiety, and stress. The study was conducted before the Dobbs decision of June 2022, which overturned the constitutional right to abortion, so the effect of that decision was not evaluated in this study, however, it can be assumed to have exacerbated these findings. This study highlights the mental health effects of abortion care delays and particularly demonstrates how financial obstacles can delay care and lead to stress.

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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