Research roundup: June 2021 edition

In-clinic vs pharmacy provision of medication abortion, cost barriers to contraceptive access among community college students, opportunities for PrEP counseling for adolescent and young adults, and more.

by Colleen Denny, MD and Emma Gilmore, MD

published 06/30/21

1. Hormonal contraceptive use and depressive symptoms: systematic review and network meta-analysis of randomised trials

The effects that hormonal contraception use may have on mood is a concern for many patients, especially those with a known history of depression or other mood disorders. Although some cohort studies have suggested that hormonal contraception use could increase the risk of depressive symptoms, the causality of this association is not clear. In this systematic review and meta-analysis, the authors identified 12 randomized controlled trials that examined the relationship between hormone-containing contraception methods and depression symptoms. Most of the included studies examined combined hormonal contraceptive pills, but studies of progesterone-only pills and the vaginal ring were also included. In comparison with placebo, the authors found that hormonal contraceptive use did not cause worsening of depressive symptoms. While they recommended increased future research confirming these effects in first-time contraceptive users, these findings can be used in counseling patients with concerns about or a known history of depression.

2. The Etonogestrel Implant in Adolescents: Factors Associated with Removal for Bothersome Bleeding in the First Year after Insertion

While the etonogestrel implant is a highly effective form of long-acting reversible contraception with few contraindications, undesirable bleeding patterns are relatively common for users, and are one of the most commonly cited reasons for removal. In this retrospective chart review of adolescents and young adults using the implant, the authors sought to determine which factors were associated with bothersome bleeding, which factors were associated with implant removal, and whether temporary measures to improve bleeding had an impact on long-term continuation of the implant. They identified that lower BMI and younger age were both associated with bothersome bleeding, and that nulliparous patients and patients with bothersome bleeding were more likely to have the implant removed. The authors also noted that patients who were prescribed a temporizing measure to improve bleeding (usually a course of oral contraceptive pills, but also progesterone only pills or NSAIDs) were more likely to retain the implant, with 67% of those receiving a temporizing measure continuing with the implant at one year versus 40% of those who did not. While undesirable bleeding patterns remain a significant side effect and reason for discontinuation among implant users, even temporizing measures offered by providers appear to be associated with increased continued use among adolescents.

3. Meta-Analysis of Breast Cancer Risk in Levonorgestrel-Releasing Intrauterine System Users

Levonorgestrel-releasing IUDs are a popular form of long-acting reversible contraception as well as a common tool for medical management of heavy and/or painful menstrual cycles. However, given the important role that progesterone plays in breast cancer, there may be a concern on the part of providers and patients about the influence of progesterone IUD use on breast cancer risk. In this systematic review and meta-analysis, the authors identified eight and four observational studies, respectively, that examined the link between breast cancer and progestin IUD use. In neither analysis was breast cancer associated with levonorgestrel IUD use. While the CDC still recommends avoiding levonorgestrel IUD use in patients with a known history of breast cancer, providers can reassure patients considering this birth control method that it does not appear to affect their future risk.

4. Pregnancy Risk by Frequency and Timing of Unprotected Intercourse Before Intrauterine Device Placement for Emergency Contraception

Previous recent researchindicated that levonorgestrel IUDs can be used as emergency contraception with equal efficacy to copper IUDs. However, it is not clear whether the timing or frequency of unprotected intercourse prior to IUD placement affects the likelihood of pregnancy. In this secondary analysis of the original RCT above, the authors stratified participants by when incidents of unprotected sex occurred and how many episodes of unprotected sex that participants reported in the two weeks prior to IUD placement. Only one pregnancy occurred in the original participant group of nearly 600 participants, but the authors noted that nearly half (43%) of participants reported multiple episodes of unprotected sex, and 14% reported unprotected sex 6-14 days prior to IUD placement. Pregnancy risk difference did not significantly differ by single compared with multiple unprotected intercourse episodes or by unprotected intercourse more than the traditional recommendations of more than six days prior to presentation. With a negative pregnancy test at the time of IUD placement for emergency contraception, providers can counsel patients that pregnancy is extremely unlikely even with multiple episodes of unprotected sex up to two weeks before.

5. Identifying Opportunities to Discuss Pre-Exposure Prophylaxis During Contraceptive Coaching Discussions with Urban Adolescent Women

Pre-exposure prophylaxis for HIV, or PrEP, is a safe and effective way of preventing HIV infection for patients at high risk of HIV exposure and is approved for patients as young as 12 years old. Despite this, uptake of PrEP among potentially good candidates of all age groups has been irregular, particularly among female patients. In this secondary analysis of data from a pilot study on contraceptive counseling techniques for adolescent and young adult patients, the authors analyzed 111 transcripts of counseling conversations to identify potential opportunities during contraception counseling sessions to introduce PrEP discussions. Of those analyzed 24 had opportunities to discuss PrEP and only one transcript specifically mentioned PrEP. The authors identified four main categories of opportunity contexts—STI prevention strategies, HIV risk reduction, avoidance of adverse sexual health outcomes, and disclosures of condom nonprotected sexual behaviors. While the addition of yet another counseling item may seem overwhelming for reproductive health providers’ busy schedules, there are potentially opportunities to incorporate PrEP counseling into already existing counseling techniques.

6. Medical abortion offered in pharmacy versus clinic-based settings

While medical abortion in the US is typically managed by a provider in a clinical or hospital setting, many other countries rely on pharmacies as the main providers of medication abortion. This Cochrane review examined whether there was sufficient evidence to determine how medication abortions managed from a pharmacy setting and overseen by a clinician compared to clinic-based medication abortions in terms of efficacy and safety. The authors found only one completed study that met inclusion criteria and concluded that evidence was still limited. However, three ongoing studies will be potentially available in review updates, and the results of such research, if demonstrating safety and efficacy, could allow pharmacy provision to increase abortion access for many patients.

7. Medical contraindications to combined hormonal contraceptive use among women using methods prescribed by a pharmacist

While short-acting hormonal-containing forms of contraception including pills, patches, rings, and injections are commonly prescribed for patients, there are certain known contraindications for patients with medical comorbidities, as summarized by the CDC’s US-MEC. In this retrospective cohort studies, the authors compared whether patients receiving contraception prescriptions from their pharmacists were more likely to receive contraindicated medications than those receiving their prescriptions from clinicians. They identified nearly 4,000 patients who received contraception prescriptions from their pharmacies or less than 1% of the total patient population. Per their analysis, rates of prescribing a combined hormonal method to women with a potential contraindication were not meaningfully different by prescriber type, with 2.16% among clinical prescriptions and 0.74% among pharmacist prescriptions. This data suggests that pharmacists can reliably identify patients with contraindications and prescribe accordingly.

8. Concerns About the Cost of Contraception Among Young Women Attending Community College

Use of effective contraception among students attending community colleges has historically been lower than among students at four-year universities. In this study, the authors interviewed women age 18-25 at California and Oregon community colleges having vaginal sex without intending pregnancy regarding their insurance status and cost-concerns about contraception. In their results, the authors report that while nearly half of all those interviewed were concerned about contraception costs, uninsured or publicly insured participants were more likely to report cost-concerns. Both these states do offer expanded family-planning services for low-income individuals, and participants in a state family planning program reported lower concerns about contraception cost. The authors concluded that concern about contraception costs among these college students was still high despite expanded services, and remark that addressing these cost concerns is an important aspect of facilitating students’ pursuit of undergraduate education.

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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