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Research roundup: February 2023 edition

Support for safety and efficacy of self-managed misoprostol-only medication abortion, medication abortion information on TikTok, and the impact of the shot and IUDs on vaginal flora.

by Colleen Denny, MD and Emma Gilmore, MD

published 02/28/23

1. Safety and effectiveness of self-managed abortion using misoprostol alone acquired from an online telemedicine service in the United States

Self-managed abortion (SMA) using medication abortion pills obtained from online sources has become an increasingly important option in the US as abortion access becomes increasingly restricted in certain areas of the country. While modern medication abortion usually combines the use of both mifepristone and misoprostol, mifepristone access may be limited. During the Covid-19 pandemic, AidAccess, an online telehealth organization offering medication abortion, was restricted in its ability to ship mifepristone and accordingly offered an alternative regimen using only misoprostol. Eligible patients reported a pregnancy less than 10 weeks’ gestation and reported no contraindications on a physician-reviewed survey. Among more than 1,000 patients who received a prescription for a misoprostol-only regimen, 568 reported follow-up data after using the misoprostol. Overall, 88% of these patients successfully ended their pregnancy without the need for a procedure. Two percent of patients reported serious complications, including hospital admission, transfusion, or the need for IV antibiotics. The authors conclude that SMA with misoprostol alone is an effective and overall safe form of medication abortion that represents an important option for patients with difficulty accessing mifepristone.

2. Mailing abortion pills does not delay care: a cohort study comparing mailed to in-person dispensing of abortion medications in the United States

No-test medication abortion, where patients are prescribed and mailed medication abortion via telehealth without in-person labs or ultrasound, is an important option for patients who are not interested in or unable to easily access in-person abortion care. However, there is some concern that the use of telehealth and mailing services may lead to delays, increased gestational age at the time of abortion, and accordingly decreased effectiveness of medication abortion when compared to in-person medication abortion visits. In this retrospective cohort study, the authors identified nearly 3,800 patients who had either in-person or no-test medication abortions. They determined that while there was an additional two to three days between dispensing medication abortion and taking mifepristone in the no-test group while medications moved through the mail, there was no significant difference in the time from first contact with a health care provider to dispensing medication abortion, or in the gestational age at the time of taking mifepristone between the two groups. The authors conclude that the mailing time for no-test medication abortions does not lead to clinically significant delays. Providers considering no-test medication abortion care models in their practices should counsel patients about the short delay associated with shipping medications while feeling confident that this practice does not affect efficacy overall.

3. Dextromethorphan as a novel nonopioid adjunctive agent for pain control with medication abortion: A randomized controlled trial

Medication abortion is a safe and effective way to end a pregnancy but is typically associated with some level of pain for patients. While most medication abortion providers offer some combination of analgesics with a medication abortion, including NSAIDs and/or opioids, there is interest in identifying additional alternative non-opioid options to help patients manage pain related to medication abortion. In this randomized controlled trial, the researchers recruited 156 patients undergoing medication abortion to compare pain experience with the addition of dextromethorphan (DXM), an NMDA antagonist with demonstrated synergy with both NSAIDs and opioids, to a standard pain control regimen. They found that there was no difference in the groups between maximum pain scores or use of other analgesics, and patients in the DXM group were less likely to report being satisfied with their pain control regimen. The authors concluded that while there was significant variation in patient pain and use of analgesics overall, NSAIDs should remain the mainstay of pain control during a medication abortion.

4. Medication Abortion on TikTok: misinformation or reliable resource?

Reproductive health care is an increasingly popular topic on TikTok, a video-sharing app utilized by a large proportion of US digital users. Knowing that the platform has been used to share content regarding non-FDA-approved abortion regimens, the authors of this study sought to analyze and evaluate TikTok videos on medication abortion. Using abortion-focused hashtags, they evaluated the 100 most-viewed videos about medication abortion, which totaled more than 12 million views. Overall, they found that most of these videos had a pro-abortion stance, and more than 50% discussed FDA-approved medications. When reviewing the videos that made scientific or public health claims, the authors found that more than 80% in each category were “mostly accurate,” and no videos presented “mostly inaccurate” information. The authors concluded that TikTok and other social media platforms may provide opportunities for the health care community to participate in the abortion narrative while creating accurate and trustworthy content.

5. Consent for Trainee Participation in Abortion Care: A Qualitative Study of Patient Experiences & Preferences in the United States

Informed consent is an integral part of trainee participation in health care and is particularly important when discussing pelvic exams and gynecologic care. This is even more relevant in the context of abortion care, where patients may already be facing significant barriers and stigma, making it necessary to create a sensitive and trusting clinical environment. However, trainee involvement is also necessary to educate the newest generations of abortion providers. To better understand this unique dilemma, the authors of this paper performed a qualitative study of patient experiences regarding trainee participation in abortion care. They interviewed 24 participants from a range of backgrounds, some of whom reported coercive experiences related to trainee involvement in their abortion. Participants expressed that a standardized consent approach would be an ideal way to reduce potential coercion, especially if consent can be obtained without the trainer or trainee present. They also recommended allowing patients to consider their options in a safe space, while fully clothed. These recommendations should be considered by all providers who customarily seek consent for trainee involvement, not only those involved in abortion care.

6. KFF Health Tracking Poll: Early 2023 Update On Public Awareness On Abortion and Emergency Contraception

In the wake of the Dobbs decision in June 2022, the US has seen more news coverage regarding changes in abortion care and access, but it is less clear how well the general public understands various key aspects of abortion care and its current availability in their area. In this KFF Health Tracking Poll from late January 2023, researchers from the Kaiser Family Foundation surveyed more than 1,200 adults in the US about their understanding of the current state of abortion care in the US and their home states. The researchers identified several important areas where participants reported confusion about abortion and contraceptive care. Approximately half of all adults (and 41% of women) reported being “unsure” about whether medication abortion was legal in their state, and 13% of patients in abortion ban states believed that medication abortion was still legal in their state. Confusion also existed on the question of oral emergency contraception (EC), with a third of participants reporting themselves as “unsure” whether such medications were legal in their state. These findings and others highlight widespread levels of ongoing misinformation and confusion about medicines used for abortion and EC, and the need for continued information campaigns targeted at general audiences.

7. Desire to Avoid Pregnancy scale: clinical considerations and comparison with other questions about pregnancy preferences

For providers taking care of pregnancy-capable individuals of reproductive age, an evaluation of pregnancy intent is a critical component of supporting sexual and reproductive well-being. The Desire to Avoid Pregnancy (DAP) scale is a validated, 14-item questionnaire that measures an individual’s pregnancy preferences. While the DAP is detailed and reliable, providers may worry that it is too long to use in a fast-paced clinical environment. The authors of this study sought to create a shortlist of clinically relevant tools for assessing pregnancy desires, using the DAP scale as a basis for comparison. Researchers utilized an alternate, shorter scale, the Attitude towards Potential Pregnancy Scale (APPS), and three single questions asking about pregnancy preferences. They tracked pregnancy outcomes for 994 pregnancy-capable participants. The authors found that the APPS and the three single questions were overall weaker than the complete DAP, although they were shorter and potentially easier to use. Regarding individual DAP items, one individual statement (“it would be a good thing for me if I became pregnant in the next 3 months”) was predictive of pregnancy within 12 months. While further study is needed in this area, this paper makes an important first step in analyzing practical and accurate tools for predicting pregnancy desires within a clinical encounter.

8. Menstrual cup and risk of IUD expulsion - a systematic review

Menstrual cups represent a safe and environmentally friendly option for managing menstrual hygiene and have recently increased in popularity. However, there is concern that concomitant menstrual cup use in IUD users may potentially increase the risk of patients dislodging or fully removing their IUD while removing or replacing their cups. In this systematic review, the authors identified three studies that reported rates of IUD expulsion for menstrual cup users. While one study reported no association, the other two reported IUD expulsion rates of 17-18%. The authors conclude overall that the data on this question is heterogeneous and of poor quality and does not account for the wide range of IUDs, menstrual cup devices, and users’ history and anatomy. Providers counseling IUD users about menstrual cups should at baseline counsel patients about the proper use of menstrual cups and how to seek follow-up in case of IUD expulsion.

9. Trends in copper versus hormonal intrauterine device breakage reporting within the United States' Food and Drug Administration Adverse Event Reporting System

IUDs are effective and safe methods of contraception, and there are very rare risks associated with placement and removal. However, there are some reports of IUD breakage at the time of removal, perhaps more commonly with the copper IUD. The authors of this study wanted to study trends in IUD fragmentation and used reports generated by the FDA Adverse Event Reporting system. They were able to assess all reported adverse events associated with currently available IUDs (both copper and hormonal devices) from 1998 through February 2022. They discovered that breaks seemed to increase over time and were disproportionately reported for copper (9.6%) versus hormonal (1.7%) IUDs among all adverse events in the database. The FDA reports do not correspond to the overall prevalence of this issue and cannot account for contributing factors. Further research should focus on these questions to better understand the risk of IUD fragmentation at the time of removal.

10. Copper intrauterine device increases vaginal concentrations of inflammatory anaerobes and depletes lactobacilli compared to hormonal options in a randomized trial

Access to effective, long-acting contraceptives is a fundamental component of equitable health care. Evidence has established the safety of injectable depot medroxyprogesterone acetate (DMPA) and levonorgestrel (LNG) or copper IUDs for all patients. However, less is known about the way that these birth control methods affect vaginal flora, particularly for bacterial vaginosis (BV) which may affect one’s risk of sexually transmitted infection (STI) acquisition. The authors of this study used gene sequencing and cytokine assays to evaluate the effect of DMPA and the LNG and copper IUDs on the vaginal microbiome, including BV occurrence, bacterial diversity, and bacterial and cytokine concentrations. Analysis was performed at one and six months of use. They found that users of the copper IUD exhibited a higher load of vaginal bacteria and cytokines, and relatively decreased lactobacilli, which can contribute to vaginal health. These results suggest that the copper IUD may impact overall vaginal health, though the long-term ramifications of these findings are unknown.

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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