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Research roundup: February 2024 edition

Abortion information on TikTok, doxy-PEP effectiveness in cis-gendered women; new data on UPA-EC and implant insertion; and a survey of pain with IUD insertion.

by Colleen Denny, MD and Emma Gilmore, MD

published 02/29/24

1. Doxycycline Prophylaxis to Prevent Sexually Transmitted Infections in Women

Sexually transmitted infections (STIs) including chlamydia, gonorrhea, and syphilis are common among sexually active populations, with cases continuing to rise in the United States in 2023. While research with transgender women and men who have sex with men has previously shown that doxycycline can reduce cases of STIs when given as post-exposure prophylaxis (PEP), it is unclear whether this strategy could also benefit cisgender women. In this randomized control trial of 449 cisgender adult women, the authors studied whether the use of doxycycline PEP reduced STI rates. They found no difference between the doxycycline PEP group and the control group in terms of chlamydia, gonorrhea, or syphilis cases. The researchers also used hair testing to assess doxycycline use and found that overall use was low, with only 29% positive testing among the doxycycline PEP use which was discordant with patient-reported use. The authors conclude that there is insufficient evidence to show the benefit of doxycycline PEP, possibly related to medication adherence issues, and call for increased efforts to reduce the STI burden in cisgender women.

2. Trends in Encounters for Emergency Contraception in US Emergency Departments, 2006-2020

Emergency contraception (EC) can safely be used to prevent pregnancy after penis-in-vagina intercourse without a method of birth control or when a method with lower effectiveness is used. EC is available in both oral and IUD formulations. Using EC as soon as possible after intercourse improves its effectiveness in preventing pregnancy, therefore reducing barriers to timely access directly impacts pregnancy rates. The FDA’s approval of oral levonorgestrel EC for over-the-counter use in 2006 potentially represents a significant improvement in barriers to EC access. In this cross-sectional study analyzing Emergency Department (ED) utilization data, the authors identified nearly 48,000 EC-related encounters among reproductive-aged females between 2006 and 2020. They noted that EC-related ED encounters decreased by 96%, and total EC-related hospital charges likewise decreased by 95% over this time frame. The authors noted that younger, low-income, Medicaid-insured, Black, and Hispanic patients were overrepresented in EC-related ED visits. The researchers conclude that the over-the-counter availability of oral EC decreased access barriers and significantly decreased the need for ED visits among reproductive-aged females. However, providers should note the continued overrepresentation of underserved groups among those patients who continue to seek EC through the ED and work to decrease ongoing barriers to timely EC access.

3. Pharmacodynamic evaluation of the etonogestrel contraceptive implant initiated midcycle with and without ulipristal acetate: An exploratory study

Oral EC with either levonorgestrel or ulipristal acetate (UPA) is a safe and effective way to prevent pregnancy after sex. While UPA requires a prescription, it may be the preferred method of oral EC given its overall increased efficacy compared to levonorgestrel, its higher efficacy in patients with higher BMIs, and its longer duration of effectiveness. However, UPA EC does not provide ongoing contraception. Furthermore, less is known about the ability of the etonogestrel implant to provide emergency contraception, or how simultaneous use of the implant and UPA EC impacts ovulation suppression. In this randomized trial, the authors recruited 39 patients who received either the implant alone or the implant and UPA EC simultaneously. They then used daily transvaginal ultrasound and serum hormone levels to determine whether patients ovulated that cycle. Ovulation suppression occurred in 65% of patients in the implant-alone arm, but only 37% of patients in the implant + UPA EC arm. While this was a small exploratory study, the authors conclude that the use of the implant alone as a method of EC merits further research and investigation, but also note that concerns about drug-drug interactions between UPA and etonogestrel appear warranted and that providers should consider delaying implant initiation if UPA is being used for EC.

4. Factors associated with a negative Patient Acceptable Symptom State (PASS) response with IUD placement: A retrospective survey of HER Salt Lake participants

Although the efficacy of intrauterine devices (IUDs) is well established, there are limited options for pain control for standard in-office insertion. As a result, stories about pain during IUD placement are easily available on the internet and may scare patients or prospective IUD users. While many birth control studies have used pain scores, such as the VAS (Visual Analogue Scale), patients are rarely asked about their perspectives about the pain they experienced. For this study, the authors used the Patient Acceptable Symptom State (PASS) system to evaluate pain during IUD placement. The PASS system prompts patients to rate whether pain was acceptable to them instead of simply assigning a number to the intensity of their pain. The authors surveyed individuals who were enrolled in HER Salt Lake, a research initiative that provided free birth control to residents of Salt Lake County, Utah. Six hundred twenty IUD users responded to the survey, and almost half (41.6%) had an unacceptable pain level with IUD placement. An unacceptable PASS response was significantly more likely in patients who had an anxiety diagnosis or trauma history. This information indicates that a measurement of pain acceptability is an important part of patient evaluation, and assessing a patient’s anxiety or trauma history may help providers counsel about IUD placement. Providers should also offer pain management during IUD placement.

5. Risk Factors for and Outcomes of Ring Expulsions with a One Year Contraceptive Vaginal System

The one-year vaginal contraceptive ring, Annovera, can be effectively used for up to 13 cycles before being discarded. Annovera is a safe, FDA-approved, user-controlled option that may be convenient for patients who don’t want to see a provider or have repeated prescriptions filled. However, up to 25% of participants experienced expulsions of Annovera during Phase 3 trials, which raises concerns about method continuation and long-term implications. To better understand the risk of expulsion, the authors of this study performed a secondary analysis of two Phase 3 Annovera trials, reviewing data for more than two thousand patients. Although discontinuation of ring use due to expulsion was rare at 1%, it was more common in patients who experienced early expulsion. Expulsion rates decreased over time, and no differences in expulsion rates were found when data was stratified based on parity, BMI, or race. These results suggest that patients should receive counseling about both ring placement, to ensure correct use and expulsion risk. If a user notes that their ring has been expelled, they can be reassured that this sort of event is likely to decrease over time. Overall, the findings of this study can be incorporated into provider counseling about Annovera.

6. US public opinion about reproductive health care in school-based health centers

Access to reproductive health care may be particularly challenging for adolescents, especially in light of post-Dobbs state-level changes and the end of the Medicaid continuous enrollment provision in late November 2023, which disproportionately affected people under 18 years old. School-based health centers (SBHCs), which can offer health services directly in schools and provide services at a discounted rate for uninsured patients, represent a potential care model for mitigating these challenges. However, SBHCs have often faced resistance and debate in the question of whether they can offer reproductive health services. In this survey-based study, the authors surveyed more than 4,000 US adults on attitudes about offering sexual and reproductive health services in SBHCs, including pregnancy and STI testing, contraception counseling and provision, sexual violence counseling, and gynecological exams. More than 60% of respondents supported SBHCs’ offering all these services with the exception of gynecological exams. Participants who identified as liberal, less religious, urban, and women were more likely to support offering reproductive health services, with those who identified as politically conservative and/or supportive of President Trump, religiously active, or suburban residents less likely to express support. The authors conclude that support for reproductive health services access at SBHCs is generally high and encourage policymakers and funders not to shy away from developing such services for fear of political hostility.

7. Successful postcoital testing of Ovaprene: An investigational non-hormonal monthly vaginal contraceptive

Ovaprene is a non-hormonal vaginal contraceptive device, shaped like a flexible ring with a central inner membrane. The ring releases ferrous gluconate, which damages sperm, and it can be left in place from one menstrual cycle to the next. Each device lasts for one cycle, and is then replaced by the user, without a need for a pelvic exam or a visit to a provider. For this study, the authors tested the cervical mucus of Ovaprene users before and after intercourse, in the middle of their cycle (therefore at the time when they were thought to be most fertile). Users were relying on other forms of contraception during the study, so were not at risk for pregnancy. The study investigators found that Ovaprene met the criteria for contraceptive effectiveness for all participants and that everyone was able to place and use it independently based on exams performed by study staff. Even when the device was found to be out of place, it still appeared to work, likely due to the presence of ferrous gluconate. This study provides important information to support the next steps in the Ovaprene investigation, which is currently underway.

8. Estimates of use of preferred contraceptive method in the United States: a population-based study

While there is a large amount of research on contraception use in the United States and around the world, there is less information on user preferences and desires to change a method. While efficacy is important, person-centeredness also involves a discussion around patient desires and priorities. The authors of this study sought to center the individual in their contraception use survey, performing interviews across health care disciplines to design a survey that highlighted appropriate questions and terminology. They then administered this survey to more than two thousand participants who were born female and retained pregnancy capability at the time of the survey. Approximately one-quarter of these subjects were not using their preferred contraceptive method, which corresponds to more than 8 million pregnancy-capable US residents when scaled according to population data. Oral contraceptive pills and vasectomy were identified as two desirable methods of contraception that were not being used. Overall, this publication provides important insight into the behaviors of pregnancy-capable individuals, who may have a myriad of priorities when choosing contraception.

9. Permanent Contraception: Ethical Issues and Considerations

The history of permanent contraception, historically called sterilization, is complicated and disturbing: it was (and still is) used coercively or involuntarily against individuals who were disadvantaged due to race, ethnicity, or socioeconomic status in the US. This ACOG Committee Statement provides an ethical framework that serves to educate and bolster providers as they consider permanent contraception in context. The statement describes the history of permanent contraception in the United States and provides tips for counseling, including a comparison with male permanent contraception, or vasectomy. It also explores the relationship between religiously affiliated health care systems and permanent contraception practices. Finally, it lays out ethical guidelines for the provision of permanent contraception that can be used by reproductive health care providers around the US. This committee statement replaces a committee opinion from 2017, and it is useful reading for anyone who cares for reproductive-aged individuals.

10. How TikTok is Being Used to Talk About Abortion Post-Roe: A Content Analysis of the Most Liked Abortion TikToks

Social media platforms have become an increasingly popular medium for sharing health-related information, and patients may be exposed to or actively use these platforms as sources of information regarding reproductive health and abortion care, including others’ personal experiences with health services. However, previous research has shown high levels of online misinformation about abortion care, and less is known about the abortion-related content of TikTok, a video-based social media platform that became the world’s most popular web domain in 2021. In this descriptive study, the authors identified the top 200 most-liked TikTok videos that appeared in a search for “abortion”, which collectively had a total of 164 million likes, 10 million shares, and 4 million comments. In analyzing the content of these videos, the authors determined that most of the videos were sources of abortion news, political opinion, personal stories, or debate, rather than providing health-related or legal information for abortion seekers. Only five of the top 200 videos were created by or featured a medical provider. The authors conclude that there is a paucity of accurate information on TikTok to guide users considering abortion and that health care professionals and institutions could potentially use this platform to promote accurate information about experiences of abortion and ways to access care.

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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