Research roundup: May 2021 edition

Pre-treatment with mifepristone for pain management in first-trimester surgical abortion care, high patient and provider satisfaction with telemedicine contraceptive counseling, an update to the CDC’s recommendation on self-administered DMPA-SC, and more.

by Colleen Denny, MD and Emma Gilmore, MD

published 03/31/21

1. Contraception Choice Among Those Seeking Abortion for Fetal Indication or Management of Pregnancy Loss

Contraception counseling is normally part of discussions at time of abortion, but less is known about the counseling when individuals are seeking pregnancy termination for fetal anomalies or management of pregnancy loss. The specific needs of these populations, including time to grieve and recover, are not well understood. For this study, researchers sought to better understand contraception choices of individuals seeking abortion for anomalies or management of pregnancy loss. All patients in the study were offered family planning counseling, regardless of their reasons for pursuing abortion. They found that around half of patients undergoing abortion for fetal indications were interested in contraception, compared to nearly 90% for those with other indications, and that they were less likely to choose long acting reversible contraception. Overall, this study revealed that there is an ongoing need to study these patients’ contraception desires, and there are robust counseling opportunities for providers.

2. Changes to medication abortion clinical practices in response to the COVID-19 pandemic

Medication abortion with misoprostol and mifepristone has a well-established safety profile and is known to be highly effective up to 70 days gestation. There is also a growing body of evidence supporting the use of telemedicine and remote follow up for medical abortions. However, FDA regulations stipulate that mifepristone must be dispensed in-person by a provider, which can be burdensome to patients, particularly during the COVID-19 pandemic. For this study, researchers surveyed 74 abortion clinics in order to determine how their practices changed in light of the pandemic. They found that sites rapidly modified their procedures in order to reduce in-person visits, using many creative, evidence-based care models, including at-home pregnancy tests and curbside medication pick-up. Overall, these findings underscore the innovative ability of abortion clinics to provide care even when faced with both legal and health-related obstacles.

3. Provision of the progestogen-only pill by community pharmacies as bridging contraception for women receiving emergency contraception: the Bridge-it RCT

Emergency contraception (EC) pills can help to prevent unwanted pregnancy, but EC pills are not effective as ongoing birth control. In the United Kingdom, a pharmacist can dispense EC pills, but cannot prescribe ongoing contraception, and patients need to present to a general practitioner for issues related to future family planning. The authors of this study hypothesized that if pharmacists could provide a small amount of progesterone-only pills to patients seeking emergency contraception, this would serve as a bridge to long term birth control methods. This extensive report is an in-depth description of this study, which was carried out among 29 British pharmacies in or outside of London and involved 636 individuals. Patients who received the progesterone-only pill reported higher uptake of effective contraception and less future use of emergency contraception.

4. Clinical features of migraine with onset prior to or during start of combined hormonal contraception: a prospective cohort study

Links between migraines and the menstrual cycle have been well established, but the link between combined hormonal contraceptives (CHCs) and migraine headache patterns is less understood. The authors of this study sought to better understand migraine characteristics in users of CHCs along with collecting information on dysmenorrhea, endometriosis, and depression. They hypothesized that migraine headaches may be specifically related to the hormone-free interval, which occurs while users are taking their placebo pills. Researchers recruited 28 patients who filled out extensive migraine diaries. Migraines were significantly more frequent in CHC users who had headaches prior to initiation of contraceptives and were more common during the hormone-free interval. Researchers found that individuals who experienced migraines on CHCs did not respond as well to pain medication.

5. Pain Associated With Cervical Priming for First-Trimester Surgical Abortion: A Randomized Controlled Trial

The grand majority of abortions in the United States are performed in the first trimester, and most of these are surgically managed with dilation and curettage in a single-visit procedure. While the use of mechanical dilation prior to the second trimester is uncommon, some practitioners use cervical priming agents for some or all first trimester procedures to facilitate cervical dilation. In this randomized control trial of 110 patients, the authors sought to determine how the use of preoperative misoprostol or mifepristone influenced pain scores for patients undergoing dilation and curettage with a paracervical block only for anesthesia. They found that pain scores significantly decreased for patients pretreated with mifepristone, and that operators reported increased ease with the procedure in this group; no differences were noted in complication rates, duration of procedure, or patient satisfaction. Providers with access to mifepristone can consider using this agent preoperatively to improve patient and provider experiences, particularly in settings where higher levels of anesthesia may not be available.

6. Weight change among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: Findings from a randomised, multicentre, open-label trial

The effect of different contraception methods on weight gain is one of the most commonly cited concerns among patients considering the initiation of a new birth control method. Much of the literature about weight gain has focused on the use of injectable DepoProvera (DMPA), with studies demonstrating a 2-3kg weight gain on average in the first year of use; however, less research has examined the effects of other progesterone-only contraception on weight gain. In this randomized trial, more than 7,000 adult participants seeking contraception were assigned to either DMPA injections, a levonorgestrel implant, or a copper IUD and followed for 18 months of use. The authors found that while all groups gained weight on average, weight gains were highest in the DMPA group, with an average increase of 2.8kg after 12 months and 3.6kg at 18 months. The implant group gained 1.2kg and 2.7kg at 12 and 18 months, respectively; and the copper IUD group gained a similar amount to the implant group at 12 months, but then had no further gains. The authors also noticed that a significantly smaller percentage of patients lost weight with DMPA usage in comparison to the other groups. For patients who are concerned about weight gain and/or already struggling with obesity, this research could affect contraception counseling for patients considering longer acting progesterone-based birth control methods.

7. Telemedicine for contraceptive counseling: Patient experiences during the early phase of the COVID-19 pandemic in New York City


8. Telemedicine for contraceptive counseling: An exploratory survey of US family planning providers following rapid adoption of services during the COVID-19 pandemic

While a small number of reproductive health providers used telemedicine services to provide contraception counseling prior to the COVID-19 pandemic, widespread closures and lockdowns during 2020 and 2021 forced many practices to incorporate remote care into their practices at higher levels than ever before. Two articles in Contraception this month focused on both the patient and provider experience of recently adopting telemedicine for contraceptive visits.

New York City was one of the hardest hit areas during the pandemic, particularly in the spring of 2020. In a mixed-methods study, 169 patients who received telemedicine consultation (93% via telephone only) regarding contraception during the early months of the COVID-19 pandemic in NYC were surveyed regarding their experiences with their visits. Eighty-six percent of participants reported they were very satisfied with their visits and expressed satisfaction with not having to arrange child care or transportation. Seventy-two percent of participants also agreed that telemedicine visits for contraception should continue after the pandemic.

Providers, too, were rapidly introduced to telemedicine during the pandemic. In a cross-sectional web-based survey of 172 family planning providers across the US during the pandemic, 91% of providers reported they were offering telemedicine services, although fully 78% had never used telemedicine before COVID-19. Most providers (80%) agreed that telemedicine was an effective way to perform contraception counseling, and even more (84%) agreed that it should be expanded as the pandemic ended. Practices providing contraception services should consider the incorporation and/or continuation of telemedicine services to improve patient satisfaction and convenience.

9. Update to U.S. Selected Practice Recommendations for Contraceptive Use: Self-Administration of Subcutaneous Depot Medroxyprogesterone Acetate

The birth control shot, depot medroxyprogesterone acetate (DMPA), brand name Depo-Provera, is currently available in two formulations—intramuscular (DMPA-IM) and subcutaneous (DMPA-SC) injections. DMPA-SC has been found to be both safe and effective while allowing patients to administer the shot at home improves patient autonomy and removes barriers to accessing in-person injections. The Centers for Disease Control and Prevention (CDC) has updated their recommendation in line with the World Health Organization’s (WHO) to strongly recommend that “self-administered DMPA-SC should be made available as an additional approach to deliver injectable contraception”. For more information about talking to patients about DMPA-SC and step-by-step instructions, check out this Provider Guide on Bedsider Providers.

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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