Research roundup: February 2021 edition

Comparable effectiveness of Levonorgestrel and copper IUDs as emergency contraception, use of the Natural Cycles app for fertility awareness contraceptive method, transcutaneous electrical nerve stimulation as highly effective pain management in medication abortion care, and more.

by Colleen Denny, MD and Emma Gilmore, MD

published 02/26/21

1. Levonorgestrel vs. Copper Intrauterine Devices for Emergency Contraception

The most commonly used methods of emergency contraception (EC) are levonorgestrel (Plan B) and ulipristal acetate (ella) EC pills, however the time since unprotected sex and patients’ weight decrease their effectiveness. The copper intrauterine device (IUD) has been shown to be the most effective method of EC regardless of patient weight and time since unprotected intercourse up to five days. In the US, more patients choose levonorgestrel IUDs than copper IUDs for general contraception. In this randomized controlled trial, more than 600 patients seeking EC were randomized to receive either a copper IUD or 52-mg levonorgestrel IUD within five days of unprotected intercourse, with a follow-up urine pregnancy test in one month. The authors found one pregnancy in 317 LNG IUD users vs none in the copper IUD group, and no difference in adverse events requiring medical care between the groups. They concluded that the levonorgestrel IUD was non-inferior to the copper IUD for EC. In practice, this means that patients seeking EC who would otherwise prefer a levonorgestrel IUD for ongoing contraception can be offered a 52-mg levonorgestrel IUD (Mirena or Liletta) as EC without the need for EC pills.

2. U.S. referral center experience removing nonpalpable and difficult contraceptive implants with in-office ultrasonography: a case series

The popularity of the etonogestrel implant (Nexplanon) has increased in the US in recent years. However, removal of these implants may be challenging, especially when the implant itself is no longer palpable subdermally. In this case series, the authors describe a total of 54 patients referred to a specialty center for implant removal, 48 of whom had non-palpable implants. Providers at the referral center were able to localize 46 of these non-palpable implants using high-frequency point-of-care ultrasound, and successfully removed 50 of 52 implants attempted in office. The authors conclude that specially trained clinicians using point-of-care ultrasounds can be equally effective for difficult implant removals without sending patients to formal radiology imaging, supporting the use of specialty centers for these difficult cases.

3. Systemic hormonal contraception initiation after abortion: a systematic review and meta-analysis

Starting hormonal contraception on the same day as the initiation of their abortion is more convenient for patients as it avoids additional appointments. However, there is theoretical concern that a systemic dose of hormones could decrease the efficacy of the abortion medications themselves. In this systematic review and meta-analysis, the authors identified 16 published studies examining the initiation of hormonal or non-hormonal contraception in relation to the timing of either medical or surgical abortion. Five of these studies specifically looked at the relationship between the success of medication abortion and the timing of initiation of hormonal contraception—DMPA, etonogestrel implant, or combined oral contraceptives. The authors concluded that while the pooled data was overall not high-quality, there was no clear evidence of increased adverse reactions with immediate initiation of hormonal contraception. However, they cautioned that one trial did a show a decreased efficacy of medication abortion when DMPA was initiated on the same day as the medication abortion. Providers may use this data in shared-decision making conversations with patients about the convenience and safety of initiating contraception at the time of their abortion, with particular counseling for patients who elect for both DMPA and medication abortion.

4. Timing and efficacy of mifepristone pretreatment for medical management of early pregnancy loss

Previous high-quality research has shown that early pregnancy loss (EPL) can be effectively managed using a combination of oral mifepristone followed by vaginal misoprostol. Most professional guidelines recommend that patients administer the misoprostol approximately 24 hours after taking mifepristone. However, the authors performed a secondary analysis of a randomized controlled trial of medical management of EPL to determine whether patient-determined differences in the interval between the two medicines affected effectiveness. Among 139 patients, the authors grouped the actual interval times between mifepristone and misoprostol into three groups: 0-6 hours, 7-20 hours, and 21-48 hours. They determined that successful medical management rates were highest in the group that self-administered the misoprostol between 7-20 hours after mifepristone, with a success rate of 96.6% (compared to 54.6% of the earlier cohort and 87.5% of the later cohort). The authors suggest that further research is warranted to determine the optimal timing interval between mifepristone and misoprostol for EPL.

5. Natural Cycles app: contraceptive outcomes and demographic analysis of UK users

Fertility awareness based methods of contraception, such as basal body temperature tracking and standard days method, are patient-controlled methods, allow people to track their own ovulation and avoid unprotected sex when conception is most likely. Natural Cycles is the only FDA-approved app for use as a fertility awareness based method of contraception. In this prospective observational study, the authors tracked pregnancy rates for more than 12,000 women in the UK using the app for an average of 10 months. The population of users was notable for a high education level, with 83% having a university degree or higher, and a high percentage (83%) in a stable relationship. Participants self-reported whether they used condoms, withdrawal, or abstinence during “fertile days” as determined by the app. Within this group, the authors reported a Pearl Index of typical use of 6.1 and a perfect use of 2.0, with a 7.1% pregnancy probability after 13 cycles. While providers should note that this self-selected patient population may not match other patient populations seeking effective contraception, this fertility awareness app may assist patients (and their partners) who are highly motivated to avoid pregnancy by tracking fertility.

6. Transcutaneous Electrical Nerve Stimulation to Reduce Pain With Medication Abortion

The safety and efficacy of medication abortion has been well-established, and providers often recommend NSAIDs and other over-the-counter oral pain medications to help patients manage symptoms at home. However, many patients still report pain during medication abortion. The authors of this study explored the efficacy of transcutaneous electrical nerve stimulation (TENS), available as an over-the-counter device, as a non-pharmacologic approach to pain from medication abortion. This was a randomized, placebo-controlled trial; placebo was a sham TENS device. The authors found that patients who used TENS had lower maximum pain scores in the eight hours after medication abortion and that they used less ibuprofen and had a more positive experience. Further research is needed to apply these findings to a larger population, but this study suggests that there is a viable, non-pharmacologic alternative to assist in pain control for patients undergoing medication abortion.

7. 1 in 5 people in the U.S. have a sexually transmitted infection

The Centers for Disease Control and Prevention (CDC) reviewed their latest data from 2018 and published a press release with their findings; most notably, that on any given day in 2018, 1 in 5 Americans had a sexually transmitted infection (STI). This translates to almost 70 million people with STIs on any given day during that year. The data also showed that 26 million people acquired a new STI in 2018. Furthermore, almost 50% of the burden of newly acquired STIs was in people ages 15-24, primarily in young women. The costs of these STIs are staggering; $16 billion in lifetime costs from STIs acquired in 2018 alone. The majority of this cost is associated with HIV care, along with treatment of HPV-related cancers. The CDC urges health care organizations to consider strategies to reduce the STI burden and subsequent economic costs in the United States, including a larger number of walk-in clinics, partnerships with pharmacies, and increased access to telehealth.

8. It prevents a fertilized egg from attaching…and causes a miscarriage of the baby”: A qualitative assessment of how people understand the mechanism of action of emergency contraceptive pills

EC pills are a safe and effective method of contraception that can be taken after sex to prevent pregnancy, but misconceptions about their mechanism of action persist in public thought, often leading to confusion and mistrust. Most evidence about EC pills supports its mechanism of action in preventing ovulation, but some researchers have maintained that it may prevent implantation of a fertilized egg (this is also included on the FDA label, though it is acknowledged to be out-of-date). The authors of this study sought to understand how nearly 1,500 survey respondents understood the mechanism of action of EC pills. They found that many people understand that EC prevents pregnancy, but are confused about its mechanisms, and have difficulty differentiating it from medication abortion. These misconceptions may be due to lack of adequate sexual education in the US, along with incorrect information available throughout the internet. The authors conclude that high-quality, up-to-date information on EC should be easily accessible in both medication packaging and online.

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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