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Research roundup: March 2021 edition

We’ve searched the journals and read the practice updates to round up this month’s top research and guidelines on birth control, sexual health, abortion, STIs, and more!

by Colleen Denny, MD and Emma Gilmore, MD

published 03/31/21

1. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020

Sexually transmitted infections (STIs) caused by Neisseria gonorrhoeae have increased 63% since 2014 and are known to be associated with pelvic inflammatory disease, chronic pelvic pain, infertility, ectopic pregnancy, and increased susceptibility to HIV infection. In the previous 2015 version of treatment guidelines for gonococcal infection, the CDC recommended concurrent dosing of 250mg of IM ceftriaxone and 1g oral azithromycin, given concern for possible increased resistance to cephalosporins among gonococcal strains. However, with new concerns about antibiotic stewardship, research showing increased rates of resistance to azithromycin, and new understanding of ceftriaxone pharmacokinetics, this set of CDC guidelines now recommends treatment with a single dose of 500mg IM ceftriaxone, with the dose increased to 1g IM ceftriaxone for patients over 300lbs. If chlamydial coinfection has not been excluded, the guidelines recommend a seven-day course of oral doxycycline. For expedited partner therapy for partners unlikely to present for IM treatment, a single 800mg oral dose of cefixime is recommended, as well as the same course of doxycycline if chlamydia is not excluded. Providers who manage STIs should adopt these guidelines to ensure effective treatment while guarding against antibiotic resistance.

2. Abortion method preference among people presenting for abortion care

While both medication abortion and surgical abortion are safe and effective ways to end a pregnancy, patients seeking abortion may have preferences for one method due to complex social and personal factors. In this survey study of more than 700 patients seeking an abortion, the authors inquired about patients’ preferences for abortion method, their barriers to abortion care, and their concerns about how the abortion would affect them. The authors found that most patients (84%) expressed a preference for a method, with 41% preferring medication and 59% preferring an in-clinic procedure. Approximately a third (32%) of patients who preferred a medication abortion were more than 10 weeks’ gestational age, and the majority of these (83%) reported barriers to reaching abortion care. Furthermore, the authors found that patients who expressed greater concern about abortion stigma (fear of parents/family/friends learning of the abortion, immorality of abortion, or effects of abortion on future health or fertility) were more likely to prefer a medical abortion. The authors conclude that barriers to abortion care prevent patients from receiving their preferred method, but also note that the stigma associated with abortion may also play a role in forming patients’ preferences. They encourage continued efforts to reduce barriers as well as to promote the dissemination of accurate information about abortion to reduce this stigma.

3. Abortion attempts without clinical supervision among transgender, nonbinary and gender-expansive people in the United States

While some transgender, non-binary, and gender expansive (TGE) people may have ovaries, fallopian tubes, and a uterus that allows them to become pregnant if they have sex with sperm-producing partners, they face discrimination, misinformation, or refusals of care throughout the health care system that interfere with their ability to access abortion care. In the context of these barriers, TGE patients seeking an abortion may consider self-managed abortion. In this survey study of TGE adult individuals who were assigned female or intersex at birth, the authors identified 210 people who had ever been pregnant, 76 (36%) of whom considered abortion outside of a clinical setting and 40 (19%) of whom attempted such an abortion. Methods used by those reporting an attempt included herbs, vitamins, self-trauma, and substance use, and respondents described provider bias, insurance barriers, gestational age limits, and fear of others learning of the pregnancy as factors influencing their attempts. The authors conclude that abortion outside of a clinical context may be more common among TGE individuals than the general population. They encourage abortion providers to improve the inclusivity of their clinics and call for outreach campaigns to increase knowledge of safe, evidence-based self-managed abortion techniques in this patient population.

4. EVO100 Prevents Chlamydia and Gonorrhea in Women At High-Risk For Infection

Given rising numbers of chlamydial and gonococcal infections in the United States, there is significant potential benefit for a non-barrier, female-controlled method of reducing infection risk among patients having vaginal sex. This randomized placebo controlled trial investigated the efficacy of EVO100, an investigational antimicrobial, pH-modulating, vaginal gel, in reducing rates of gonococcal and chlamydial infections. Eight hundred and sixty women with a recent history of gonorrhea and/or chlamydia were randomized 1:1 and instructed to use the gel up to an hour before each episode of vaginal sex for a 16-week period. The researchers found that risk of chlamydia or gonorrhea infection was decreased in the intervention arm by 50% and 78%, respectively, and that adverse events were not significantly different between the two arms. The most common adverse events in the EVO100 arm were vulvovaginal candidiasis (5.1%), vaginal discharge (3.2%), and urinary tract infection (3.2%). This study represents the Phase 2B/3 study of this investigational gel that may soon provide an option for patients at high risk of STIs if FDA-approved.

5. A New Vaginal pH Regulator for Hormone-Free, On-Demand Contraception

In May 2020, the FDA approved Phexxi (lactic acid, citric acid, and potassium bitartrate), a prescription-only, hormone-free vaginal contraceptive gel that works by maintaining vaginal pH within its naturally acidic range, keeping it inhospitable to sperm and reducing sperm mobility. Users are instructed to administer the drug vaginally no more than one hour prior to vaginal intercourse, with repeat doses if repeat acts of intercourse are planned. A Phase 3 trial demonstrated a cumulative pregnancy rate of 13.7% over 7 cycles. A number of adverse events are associated with Phexxi use, including sensation of vulvovaginal burning (20%), pruritis (11%), vaginal candidiasis (3%), and UTI (5.7%); given a severe case of pyelonephritis in Phase 1 trials, a history of recurrent UTIs or urinary tract anomalies is a contraindication to use. Phexxi should not be used with either of the vaginal rings, but it can be used with any other method, including condoms. While this new product may be less effective in preventing pregnancy than most hormonal or long-acting reversible contraception (LARC) methods, it provides an additional, patient-controlled method for people who may have sex infrequently and/or are seeking to avoid hormones. #Check out this article for more about Phexxi and how to get it.

6. Antiseptic mouthwashes against sexually transmitted infections

This article describes two recent studies, published in The Lancet Infectious Diseases, regarding the use of antiseptic mouthwashes to prevent pharyngeal gonorrhea and other STIs. One, the OMEGA study from Australia, aimed to reduce the incidence of oropharyngeal gonorrhea using antiseptic mouthwash over a set time period. The other, PReGO from Belgium, was focused on use of antiseptic mouthwash to reduce incidence of gonorrhea, chlamydia, and syphilis regardless of site. Both studies showed no reduction in the incidence of infection. However, they raised an important question regarding the role of the oropharynx in disease transmission, which could ultimately change scientists’ understanding of STI prevention and treatment. Currently, more research is needed to develop adequate antiseptic substances to prevent STI transmission.

7. Locating Hormone-Releasing Contraceptive Implants Using Near-Infrared Light

The etonogestrel implant (Nexplanon) is a highly effective, flexible rod that is implanted into the medial surface of the arm. It is normally removed by an incision made at one end after palpating the implant under the skin. However, in a small number of cases, the implant is not palpable at time of removal, typically because of migration. While ultrasound can be used to help locate the device, this may not be available or familiar to some providers. Researchers sought to determine whether a near-infrared light–normally used to locate veins–could be used to find a non-palpable implant. Their near-infrared light device successfully located non-palpable etonogestrel implants in five patients with normal BMIs, suggesting that it can be helpful in this patient population. However, typical near-infrared lights do not evaluate the depth of a migrated implant. Overall, these authors found that this is a useful tool when attempting to locate a non-palpable implant and may be increasingly helpful as new models allow for depth assessment.

8. How do women interpret abortion information they find online?

Cesarean deliveries (CD) and abortions are both relatively common procedures in the United States, each occurring about one million times per year, and are also hotly debated topics in popular culture. The authors of this study hypothesized that patients have many misconceptions about both CDs and abortions based on common myths. They sought to determine how internet searches influence patients’ ideas about abortion and compared this to their perceptions about CD, focusing on safety and perceptions about infertility. To do this, they designed a prospective study and tracked the self-guided internet searches of 100 reproductive-aged women. Subjects perceived abortion as safer and less likely to cause infertility after their web searches, and their perception changed more about abortion than about CD. Overall, the findings of this study suggest that the internet is a useful source for information about abortion for patients, and that targeting internet resources may be a good way to dispel myths about reproductive health care.

9. Passage of abortion ban and women’s accurate understanding of abortion legality

Between November 2018 and July 2019, Ohio experienced multiple judicial and legislative battles related to abortion, including an abortion ban after 6 weeks gestational age that was signed into law before being struck down as unconstitutional. Although abortion never actually became illegal in Ohio, the authors of this study hypothesized that these legislative conflicts may have led people to believe that it was against the law. To test this hypothesis, the researchers drew from population-based survey data that was collected between October 2018 and June 2019. They found that the proportion of women believing that abortion is illegal increased over the time of the survey, though the number of unsure subjects remained unchanged. This misconception about the legality of abortion services may lead people to delay or avoid seeking desired abortion services and could impact health outcomes. The study’s findings suggest that providers should not assume that patients know whether abortion is legal and that they should consider providing information on this topic.

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, MD, is a fourth-year resident in Obstetrics and Gynecology at New York University. She's passionate about family planning, medical education, and combating health care disparities, particularly in sexual and reproductive health.
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