1. Male-Partner Treatment to Prevent Recurrence of Bacterial Vaginosis
Bacterial vaginosis (BV) is a common cause of vaginitis, affecting up to 30% of people with a vagina worldwide. While BV can be treated with a short course of antibiotics, recurrence is common, with more than 50% of patients facing a recurrence within three months. While BV has some features of an STI, previous studies of treating partners with a penis with oral antibiotics have not shown a decrease in recurrence rate. In this study of 164 premenopausal patients with a vagina who were sexually active with partner with a penis, the researchers assigned half the couples to standard treatment (partner with BV only) or standard treatment along with both oral metronidazole and topical clindamycin applied to the penis of their partner. In their follow up analyses, the authors describe that while 63% of the patients in the standard treatment group were diagnosed with a recurrence of BV, only 35% of patients in the partner treatment group were. The study was stopped early by the data and safety monitoring board given the inferiority of treating only the partner with BV. These data strongly suggest that patients diagnosed with BV, especially recurrent BV, should be counseled on possible partner therapy to decrease recurrence.
2. Patients’ experiences with pain and bleeding in first-trimester abortion care
It has been well-established that abortion is very common, with almost one million individuals seeking abortion every year. While the risk of serious adverse events is extremely low, at less than one percent, patients may experience distress when they feel unprepared to handle aspects of their abortion experience. Counseling can address concerns around this distress, but there is limited evidence on the patient’s experience during abortion. To better understand these specifics, the authors of this study performed a secondary analysis on patients undergoing first trimester medication or procedural abortion. Participants filled out a survey on their pain and bleeding, and how their experiences compared to their pre-abortion expectations. The type of abortion was not associated with discordant expectations regarding first trimester abortion, but one third of participants did report their experiences were discordant with their pre-abortion expectations. Demographic and obstetrical factors were associated with experiences of severe pain, or pain and bleeding out of proportion with expectations, including nulliparity or prior cesarean delivery. While the majority of associated characteristics are not modifiable, they can be used to inform counseling on pain and bleeding during first trimester abortion. It is important to note that with management of PUL, EP or presumed early pregnancy loss, there may be nuances to political restrictions or insurance coverage that vary by state or institution.
3. Factors associated with severe pain during medication abortion at ≤9 weeks' gestation: A secondary analysis of a multicenter, randomized, placebo-controlled trial
Medication abortion with mifepristone and misoprostol is an extremely safe and effective form of abortion care and now makes up the majority of abortions in the US. However, most people undergoing medication abortion report pain, and the level of pain for an individual can be difficult to predict. In this secondary analysis of an international multicenter randomized placebo-controlled trial, the authors analyzed factors from more than 550 individuals to determine which were associated with higher pain scores reported in the eight hours after taking misoprostol. In their multivariate analyses, they found that multiparity was associated with lower pain scores, while higher gestational duration, dysmenorrhea, higher anticipated pain, higher reported pain during childbirth, and history of Cesarean delivery were all associated with higher reported pain scores. The authors discuss that everyone should have access to both antiemetics and NSAIDs to decrease pain during medication abortion. Additionally, providers should discuss factors associated with higher pain scores as part of supporting individual decision making about abortion method as well as anticipatory guidance on pain during medication abortion.
4. Society of Family Planning Clinical Recommendation: Management of undesired pregnancy of unknown location and abortion at less than 42 days of gestation
Pregnancy of unknown location (PUL) is a transient state in which a patient has a positive pregnancy test but no pregnancy visible on ultrasound. With follow up, patients with PULs will ultimately be diagnosed with either a visualized intrauterine pregnancy, a visualized ectopic pregnancy (EP), or a PUL that either persists or resolves without a clear diagnosis. When a PUL is undesired, healthcare providers can offer patients active management, which can resolve the PUL without waiting for ultrasound visualization to occur. It is safe and reasonable to either offer patients immediate treatment or wait for a more definitive diagnosis. If definitive treatment is offered, patients may opt for procedural or medication management. This clinical recommendation underscores these points and reviews methods of management and follow up for patients with undesired PUL. It also provides summaries of relevant studies that can help guide counseling and clinical decision making. Finally, clinicians can refer to this guidance for next steps if an undesired PUL does not resolve with active management. This document is a concise reference text for providers taking care of patients with undesired PUL.
5. Cervical preparation for dilation and evacuation at 12 to 24 weeks gestation
Procedural abortion care between 12 and 24 weeks’ gestation is overall very safe and effective, though providers often recommend some form of cervical preparation in the days or hours before to maximize safety. While providers may use some combination of prostaglandins, mifepristone, and/or osmotic cervical dilators, it is unclear what regimen is safest and most efficient at which gestational duration. In this Cochrane review, the authors identified 21 RCTs including more than 3,000 participants and constituting a heterogeneous body of evidence. Multiple cervical preparation techniques with multiple primary outcomes were used across the different studies, but the authors conclude several findings had moderate certainty evidence. Misoprostol plus osmotic dilators was superior to either agent alone in terms of pre-procedure dilation or need for additional dilation, though dilators increased overall procedure time. Mifepristone plus osmotic dilators was likely superior to osmotic dilators alone in terms of preprocedure dilation. The authors discuss that patient wait times and overall preferences should be taken into account in choosing treatment regimens and call for additional research on both maternal complications as well as the use of foley catheters for cervical preparation.
6. Interest in Rh testing and Rh immunoglobulin treatment among patients obtaining telehealth medication abortion
Numerous professional societies now only recommend Rh testing and administration of Rh immunoglobulin for pregnancies that end after 12 weeks’ gestation in order to prevent sensitization and potential adverse outcomes in a future pregnancy. This recommendation is based on data demonstrating that the risk of sensitization is extremely low during the first trimester of pregnancy. Despite recommendations from professional societies within obstetrics and gynecology, practice in the US is not standardized. Deferring Rh testing and treatment until after 12 weeks’ gestation has been shown to be cost effective and acceptable to patients. While these benefits can be imagined in the setting of telehealth medication abortion provision, little is known about what patients think about this process. The authors of this paper conducted a survey and chart review study to understand patients’ knowledge and interest around Rh testing and treatment during telehealth medication abortion. More than 4,500 patients were assessed from more than 20 states. Knowledge of blood type varied across socioeconomic status, pregnancy history, and age. When given information about Rh testing and sensitization risk, most patients were not interested in testing or treatment during their telehealth medication abortion. These findings suggest that foregoing Rh testing and treatment during telehealth medication abortion is both supported by scientific data and aligned with patient preference.
7. Telehealth Medication Abortion: Comparing Advance-Provision Patients With Pregnant Patients
Medication abortion using mifepristone and misoprostol can be safely provided via telemedicine, including those regions without access to an in-person abortion provider. Further, telemedicine abortion can be provided via “advanced provision”, where patients obtain abortion medications for use in the future. However, less is known about how patients seeking advance provision differ from those seeking medication to end their current pregnancy. In this cross-sectional study, the authors identified nearly 25,000 patients who received abortion medications from an asynchronous telemedicine abortion service over a 20-month period, including 3,252 patients seeking advanced provision medication abortion. The authors found that advanced provision patients were more likely to be White (72% vs 42%), more likely to have no children or only one child, less likely to live in high vulnerability counties, and older overall. The authors conclude that advanced provision of medication abortion through telemedicine may not be reaching those who historically have the greatest barriers to abortion access and suggest that further efforts to expand access to advanced provision may bring this option to a wider population.
8. Uses of ulipristal acetate beyond emergency contraception: a narrative review
Ulipristal acetate (UPA) is an oral, selective progesterone receptor modulator that is used for emergency contraception (EC). Available in the US as ella, UPA is more effective than levonorgestrel-based EC (Plan B) and has a more nuanced mechanism of action, delaying follicle rupture even after the start of the luteinizing hormone surge that leads to ovulation. Some emerging studies have suggested that UPA may be effective when used for treatment of fibroids or breast cancer. However, concern about potential liver toxicity has prevented it from being studied for more widespread use. The authors of this study performed a literature review to evaluate the different ways that UPA has been studied and utilized. They narrowed their search to 340 studies on a large range of indications, including oral and vaginal UPA used in treatment of abnormal bleeding, fibroids, and premenstrual dysphoric syndrome. The authors also highlight that cases of liver injury are very rare (14-19 patients per 100,000) in patients using UPA, and causality has not yet been established. Their results suggest that UPA is a promising treatment for numerous conditions. Limitations on UPA due to infrequent adverse events should be balanced with the ongoing need for effective treatments for gynecologic issues.
9. A Qualitative Study of Doxycycline Postexposure Prophylaxis Knowledge, Attitudes, and Practices Among Health Care Providers in New York City
When taken within 72 hours after sex, there is strong evidence to suggest that doxycycline prevents bacterial sexually transmitted infections in men who are sexually active with men and transgender women. However, provision of doxycycline postexposure prophylaxis (Doxy PEP) is not universal, and there is limited information on what healthcare providers understand about this treatment. To explore this topic, the authors of this study conducted a qualitative study in New York City, interviewing 18 healthcare providers about their knowledge, attitudes and practices regarding Doxy PEP. While many participants were aware of this treatment, they had ongoing concerns about its safety, antimicrobial resistance profiles and effect on the gut microbiome, and also recognized the challenges of creating equitable uptake across all at-risk populations. These results indicate that more research would offer providers useful information and support in prescribing Doxy PEP. Furthermore, additional work needs to be done on patient and provider education so that this useful medication is available to all patients who may need it.
