Research roundup: May 2022 edition

Zinc supplements to help clear cervical HPV, unmet needs for reproductive health care in primary care settings, distance related barriers to abortion access, and more.

by Colleen Denny, MD and Emma Gilmore, MD

published 05/31/22

1. Efficacy of Oral Zinc Sulfate Supplementation on Clearance of Cervical Human Papillomavirus (HPV); A Randomized Controlled Clinical Trial

The connection between human papillomavirus (HPV) infection and cervical cancer is well established. After being infected with HPV, the majority of people can clear the virus on their own, however a smaller subset have persistent infections, which lead to dysplasia and subsequent cellular transformation into cancerous cells. Reasons for this persistence are still poorly understood. However, zinc appears to have an effect on the immune response of cells and has been shown to trigger death in cancer cells. With this in mind, the authors of this study performed a randomized controlled trial to study the efficacy of zinc supplementation in clearance of cervical HPV. Patients with known HPV and abnormal Pap results were given either three months of zinc treatment or no treatment for the control group. Patients underwent follow up examinations to assess ongoing presence of HPV along with changes in their cervical lesions. The authors found that treatment with oral zinc tablets was associated with higher rates of HPV clearance and regression of abnormal cervical pathology, when compared to patients not given zinc. These promising results suggest a need for a larger scale study to better understand how zinc supplementation can improve cervical cancer outcomes.

2. Intranasal Fentanyl for First-Trimester Uterine Aspiration Pain: A Randomized Controlled Trial

IV pain medication and sedation are effective at managing pain in the setting of first trimester uterine aspirations, but these medications can only be administered in clinics with appropriate personnel and IV access. Evidence does not support administration of oral opioids for pain in this setting, so there may be limited options for patients needing more extensive pain management. The authors of this paper chose to study intranasal fentanyl for pain management in first trimester uterine aspirations, as it is easily absorbed, peaks quickly, and causes fewer vital sign changes at small doses. This randomized, double-blind placebo-controlled trial compared 100mcg intranasal fentanyl or a saline placebo for patients undergoing uterine aspiration at less than 14 weeks gestational age. All patients also received 600mg ibuprofen and a paracervical block made with 1% lidocaine. The authors found that intranasal fentanyl did not improve pain during dilation, aspiration, or post-procedurally, and did not improve patient or provider satisfaction scores. Overall, this is not an effective adjunct in the first trimester uterine aspiration setting. Ongoing research on effective delivery of pain control for these procedures is still needed.

3. Balancing Enhanced Contraceptive Access with Risk of Reproductive Injustice: A United States Comparative Case Study

Because there are many barriers to contraception access during the postpartum period, providers and trainees often hope to provide immediate and reliable postpartum contraception, including IUDs and implants to their patients. However, it is fundamental to recognize the implicit systemic racism in the medical system, which may result in coercive practices and a lack of patient freedom, whether or not providers are aware of this dynamic. With this in mind, the authors of this study interviewed 78 “key informants” (clinicians, staff, and administrators) at 11 different medical centers around the US to explore their attitudes around peripartum contraception delivery and their understanding of reproductive justice in this context. Interviewers closely examined participant language for signs of othering and implicit bias. They found that many participants hoped to provide compassionate care, but numerous biases were present in much of the language used to discuss contraception delivery and their patient populations. These results showcase a need for ongoing training and education on bias and reproductive justice, and further efforts to provide quality improvement in the setting of postpartum contraception provision.

4. Patient opinions on sexual and reproductive health services in primary care in rural and urban clinics

Improved access to birth control is a recognized area for improvement around the US, supported by professional societies and government recommendations. Many patients most frequently interact with health care providers in the primary care setting, however not all primary care providers (PCPs) offer the full range of reproductive health care services, including abortion. The authors of this study sought to explore patient preferences regarding reproductive health care services, including abortion care, in primary care, and to examine whether these preferences differed between rural and urban settings. An anonymous survey was administered to patients at rural and urban clinics in Washington, Idaho, and Wyoming, with a response rate of 69%. Most respondents expressed that all contraceptive options should be available in primary care, and that abortion and miscarriage services should also be offered (though at different rates for medical management compared to uterine aspiration). More respondents in urban clinics thought that IUDs and abortions should be available. Overall, these results indicate that there are unmet needs for reproductive health care in the primary care setting, and there may be opportunities for improved training and education for PCPs.

5. Association Between Distance to an Abortion Facility and Abortion or Pregnancy Outcome Among a Prospective Cohort of People Seeking Abortion Online

Patients seeking abortion may face many barriers to care, particularly in a changing political landscape. This may be particularly true for patients who do not physically live within close range of an abortion clinic. Eighty-nine percent of counties in the US do not have a single abortion provider and traveling longer distances for abortion care has been associated with other related burdens, including transportation costs, need for childcare, having to take time off of work/school, and needing to disclose the abortion. In this prospective cohort study of patients seeking information about abortion clinics online, participants were surveyed to determine how initial distance from an abortion clinic affected pregnancy outcomes. More than 1,000 participants provided their initial geographic location and were successfully contacted four weeks later to determine whether they were still pregnant and what their pregnancy intentions were at this later time. Approximately 19% of participants lived more than 50 miles from the nearest abortion clinic, and these participants were more likely to report travel-related barriers to abortion access, such as needing to gather transportation costs. In comparison with participants who lived five miles or less from the nearest clinic, patients living more than 50 miles were twice as likely to still be seeking abortion or to have decided to continue the pregnancy at follow-up. This research reflects the real impact of distance-related barriers to abortion access, and the authors discuss that medication abortion provision through telehealth may be an important tool in reducing these barriers.

6. Misinformation About Levonorgestrel Emergency Contraception in West Virginia Community Pharmacies

Oral levonorgestrel emergency contraception (LNG EC), brand name Plan B, can provide an effective method of birth control to prevent pregnancy when used up to five days after unprotected or underprotected intercourse (although it is most effective when taken within 72 hours). FDA guidelines permit LNG EC to be dispensed without a prescription, parental consent, age limits, or ID required for purchase. However, pharmacists who dispense LNG EC may have variable knowledge about the regulations and proper use. In this observational study, the authors contacted more than 500 pharmacies in West Virginia, a state noted to have low use of LNG EC and higher than average adolescent pregnancy rates. They found that slightly less than half (49%) of contacted pharmacies provided accurate information about effective timing of LNG EC use, with chain pharmacies more likely to answer accurately than independent pharmacies. Similarly, only 57% of pharmacies answered appropriately regarding the prescription requirement, 44% for the ID requirement, and 57% for inquiries regarding parental consent, with independent pharmacies again less likely to have correct information. This study reflects the importance of continuing pharmacist education regarding LNG EC, particularly at independent pharmacies that may be the only option in more rural areas.

7. Time from first clinical contact to abortion in Texas and California

Patients seeking abortion in the US may face variable barriers to care depending on the state they live in. These state-level barriers may influence how patients afford and travel to abortion clinics as well as when they present for care. In this cross-sectional survey, the authors survey patients seeking abortion care in the state of Texas, a state with an already high level of abortion restrictions (the study was conducted prior to the passage of SB 8), in comparison with California, a relatively less restrictive state. Among a total of 434 patients, the authors found that Texas patients were more likely to sell something of value, delay paying another expense to pay for their abortion, or to miss work to seek abortion care. They also traveled further for their abortion. While the time between first clinical contact and the actual abortion was not significantly different between the two states, the greater difficulties reported by the Texas patients reflect the already uneven barriers to abortion access across state lines.

8. Factors Influencing Provider Behavior Around Delivery of Preconception Care

The preconception period is an important time to address individuals’ health concerns and address issues around primary care and screening for risk factors. Doing this prior to conception allows providers and their patients to reinforce their relationship while addressing active problems before the patient becomes pregnant and much of their focus shifts. However, little is known about preconception care (PCC) in the United States. The authors of this study sought to characterize providers’ behaviors around PCC, specifically around contraception counseling and screening for intimate partner violence and depression. They conducted interviews with 20 providers in diverse care settings across Wisconsin. The authors found that providers identified many common themes and challenges, including a lack of provider knowledge and pessimism about patient compliance. Based on these findings, the authors were able to recommend education about PCC for providers, better integration of PCC into standard practice, and improved training on implicit bias in medical care. This study is a useful starting point for providers hoping to better understand PCC and to integrate it into their practice.

9. The effect of non-oral hormonal contraceptives on hypertension and blood pressure: A systematic review and meta-analysis

Estrogen-containing oral contraceptives are known to cause increases in blood pressure and should not be prescribed for patients with uncontrolled hypertension. However, little is known about non-oral hormonal contraceptives, including those that contain estrogen. The authors of this study performed a systematic review to compare the blood-pressure effects of oral hormonal contraceptives, non-oral hormonal contraceptives, and non-hormonal contraceptives (the control group). They included 25 articles that looked at the shot, IUD, implant, and vaginal ring. These birth control methods demonstrated a diverse set of effects on blood pressure. For example, the shot seemed to increase both systolic and diastolic blood pressure, while the hormonal IUD seemed to decrease only systolic blood pressure. Overall, it was not possible to make definitive conclusions based on these results. However, the authors’ findings suggest that there is a need for prospective studies evaluating these interactions to better inform method selection for patients seeking non-oral hormonal contraceptives.

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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