Research roundup: February 2020 edition

An analysis of the benefits and risks of immediate postpartum IUD insertion, demonstrated improved health outcomes for society as a whole with universal access to contraception, a systematic review of studies of the efficacy and safety of extended IUD use, and more.

by Colleen Denny, MD and Emma Gilmore, MD

published 02/28/20

1. Postplacental placement of intrauterine devices: A randomized clinical trial

Immediate postpartum contraception helps to prevent short interval pregnancies, which can have increased risks for both mother and fetus, and allows patients to opt for birth control right after delivery to avoid becoming pregnant before their postpartum visit. However, postplacental intrauterine device (IUD) placement, within 10 minutes from the delivery of the placenta, carries increased risks of expulsion compared to IUD placement at the postpartum visit. This study compares expulsion rates of postplacental levonorgestrel vs copper IUDs at 42 and 90 days after placement and found the copper IUD had a higher expulsion rate than the levonorgestrel IUD. Expulsion rates were also higher after vaginal deliveries and most expulsions happened prior to 42 days. However, the benefits of immediate postpartum access to IUD insertion still far outweigh the risks of expulsion for many patients.

2. Universal access to contraception: women, families, and communities benefit

This Call to Action statement, published in the American Journal of Obstetrics and Gynecology in February 2020, describe attempts by the Trump administration to reduce access to contraception through challenges to the Affordable Care Act and changes to Title X funding. While the court system still debates many of these changes, they may have enormous, negative ramifications for health care and patients across the United States. The authors advocate for universal access to contraception for all individuals, covered by both public and private insurance. They examine many of the risks that can be associated with unwanted pregnancy, including short interpregnancy interval, prematurity, and obesity, and the long-term, public-health effects of these risks. This statement argues that contraception access provides direct positive effects upon the lives and health care outcomes of society worldwide, and that it should be universally available. This full article is valuable reading for providers and advocates.

3. Effectiveness and Safety of Extending Intrauterine Device Duration: A Systematic Review

In this systematic review, the authors identified four studies with a total of more than 2,000 people using 52mg levonorgestrel IUDs (Mirena and Liletta) longer than 5 years and two studies with a total of approximately 250 people using the T380A copper IUD (Paragard) longer than 10 years. In pooling these studies, they found that pregnancy rates in two years of extended use for each IUD, up to 7 years for the levonorgestrel IUDs and up to 12 years for the copper IUD, were comparable to published rates during the FDA-approved use period—usually reported as a 0.1% failure rate during the first year of use. Side effects such as expulsion, pain, and bleeding during the extended use period were also comparable. While the authors caution that the available data do not clearly cover all demographic user groups, providers can use this data to discuss the likely efficacy and safety of continuing to use IUDs past the FDA-approved intervals with patients.

4. Exploring young women's reasons for adopting intrauterine or oral emergency contraception in the United States: a qualitative study

Although several different options for emergency contraception (EC) are available to patients in the United States, including two oral formulations and the copper IUD, many separate factors may influence which option an individual patient receives, including both systemic barriers and patient preferences. In this interview study of 17 individuals identifying as women, the authors investigated how patients viewed the available EC options and how they described their decision-making processes. Patients appreciated the familiarity and availability of oral EC options, but often expressed a desire to move on to more effective contraception options in the future. While some patients were unaware of the availability of the copper IUD as an EC option, or had negative associations with IUDs generally, other patients appreciated the long-term effectiveness of the copper IUD and the longer window of postcoital efficacy, especially those patients who had heard of it before. The authors emphasize the importance of patient-centered decision making in EC counseling, encourage providers to include the copper IUD in their counseling, and highlight that most patients seeking EC were also motivated to find a more-effective method of long term contraception, whether that was an IUD or another method.

5. Management of bleeding irregularities among etonogestrel implant users: Is combined oral contraceptives pills or nonsteroidal anti‐inflammatory drugs the better option?

While the etonogestrel implant (Nexplanon) is an extremely effective form of long-acting birth control, up to three quarters of patients using the Nexplanon implant will experience unscheduled bleeding, and a portion of these patients will choose to have the implant removed because of this side effect. In this prospective randomized trial, 84 implant users with prolonged or frequent bleeding were assigned to either mefenamic acid (an NSAID) or combined oral contraceptive pills (OCPs) for two cycles. Within a week of initiating OCPs, 76% of patients stopped bleeding compared to 36% of the NSAID group. The authors concluded that OCPs were superior for short-term management of irregular bleeding but noted that NSAIDs may still be considered for patients with contraindications to estrogen use.

6. Hormonal contraception and HIV acquisition among women: an updated systematic review

Since the early 1990s, observational epidemiological studies have provided inconsistent conclusions about the effect of hormonal contraceptive use on the risk of HIV acquisition. In 2016, a systematic review concluded that most evidence indicated no increased HIV acquisition risk with hormonal contraception use, but noted that new evidence was concerning for a possible increased risk associated with use of DMPA (the shot). This new systematic review revisits this question, adding five studies published over the past three years, including a large randomized controlled trial comparing new HIV infections in patients using DMPA, a copper IUD, and a levonorgestrel implant. In this new systematic review, the authors concluded that there was no increased risk of HIV acquisition among patients using DMPA compared to a levonorgestrel implant or copper IUD, though the data show an increased risk of HIV acquisition for patients using DMPA or oral contraceptives compared to patients not using contraception at all. However, the potential for confounding is high given likely higher rates of sexual activity among patients using contraception. Overall, this review supports the WHO’s guidance that people at risk for pregnancy who are also at high risk of acquiring an HIV infection are eligible to use all hormonal contraceptive methods and IUDs without restriction.

7. Rapid point of care test for detecting urogenital Chlamydia trachomatis infection in nonpregnant women and men at reproductive age

Chlamydia is one of the most common STIs in the United States and has significant public health consequences, especially for young patients, and is often asymptomatic. In this Cochrane review, the authors investigate how rapid point-of-care (POC) testing for chlamydia infection, which allows same-day diagnosis and treatment, compares to the current gold standard of nucleic acid amplification test (NAAT). In reviewing 19 studies of more than 13,000 men and non-pregnant women, the authors found that POC testing based on antigen detection had good specificity but suboptimal sensitivity. This performance translated, on average, to a 52% chance of mistakenly indicating absence of chlamydial infection and a 2% chance of mistakenly confirming the presence of infection. Given these findings, the authors recommend against the routine use of POC chlamydia testing currently on the market.

8. One Key Question® and the Desire to Avoid Pregnancy Scale: A comparison of two approaches to asking about pregnancy preferences

The American College of Obstetricians and Gynecologists (ACOG), American Public Health Association (APHA), Associations of Maternal and Child Health Programs (AMCHP), and the CDC, recommend that providers routinely assess patients’ pregnancy desires and provide follow up contraception and/or preconception counseling and care. However, there are many barriers to engaging in this conversation with patients, including a lack of validated counseling tools. One Key Question®, where providers ask patients, “Would you like to become pregnant in the next year?”, is effective for screening, but there is limited data regarding its clinical outcomes. For this study, One Key Question® was utilized along with the Desire to Avoid Pregnancy Scale (DAP Scale), which uses 14 questions to assess patients’ pregnancy preferences. The researchers aimed to compare patients’ answers for both tools along with their self-reported use of contraception or preconception medications. Results showed that One Key Question® and DAP Scale responses frequently overlapped, indicating that both tools can be useful in assessing patients’ pregnancy and preconception desires. Researchers advise that One Key Question® should be used as a launching point for further counseling with patients.

9. Young women's reproductive health conversations: Roles of maternal figures and clinical practices

Research has shown that the parental figures of young people can have a positive impact on their decisions regarding sexual health and contraception. However, there may be a coercive aspect to the involvement of parental figures in patient counseling limiting young people’s ability to fully and candidly engage in shared decision-making. This qualitative study evaluates the role of maternal figures in conversations about reproductive health. Focus groups were conducted with young people and separately with their health care providers to discuss their experiences with conversations about contraception. The authors found that although maternal figures can be a positive resource for patients, overall both providers and patients had concerns about confidentiality issues when a parental figure was present during counseling. They conclude that patients will be best served by asking maternal figures to leave the exam room for private conversations.

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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