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Research roundup: May 2023 edition

Initial reports from the ongoing narrative collection Care Post Roe documenting poor-quality care, patient perspectives on telehealth medication abortion, adolescent preferences and experiences with pregnancy options counseling, and more.

by Colleen Denny, MD and Emma Gilmore, MD

published 05/31/23

1. Vaginal Swab vs Urine for Detection of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis: A Meta-Analysis

Chlamydia, gonorrhea, and trichomonas are some of the most common, and most commonly tested, sexually transmitted infections (STIs) worldwide. While the Centers for Disease Control and Prevention (CDC) recommends a vaginal swab, either provider- or patient-collected, for diagnosis, a large proportion of STI testing is performed through urine testing. Concerned that urine testing might miss an unacceptable proportion of STIs, the authors of this study performed a meta-analysis to evaluate the sensitivity of vaginal swabs compared to urine testing for commercially available assays for chlamydia, gonorrhea, and trichomonas. A total of 28 studies were evaluated. The authors found that sensitivity estimates for vaginal swabs compared to urine, respectively, were 94.1% and 86.9% for chlamydia, 96.5% and 90.7% for gonorrhea, and 98.0% and 95.1% for trichomonas. These comparisons demonstrate that there is a significant difference in sensitivity between these two test modalities, particularly for chlamydia and gonorrhea. Overall, the results of this study support existing CDC recommendations and suggest that vaginal swabs should be used preferentially when testing for these STIs.

2. Care Post-Roe: Documenting cases of poor-quality care since the Dobbs decision

In the 11 months since the Supreme Court decision overturning Roe v. Wade, approximately half the states in the US have severely limited or entirely banned access to abortion care. In addition to severely limiting options for patients with undesired pregnancies, these restrictions have also led to substandard, potentially dangerous, or life-threatening medical care for pregnant patients residing in ban states. The Care Post-Roe Study is an ongoing narrative collection of anonymous clinician reports of deviations from the standard of care treatment and ensuing patient consequences due to the new abortion bans. In these preliminary findings, the authors review 50 cases of substandard care, including previable complications when patients were denied treatment until they became severely infected, patients who were denied nursing assistance or pain control during miscarriages for fear of legal sanctions, delayed treatments of ectopic pregnancies, pregnant patients with severe medical comorbidities forced to travel for abortion care, and delayed access to both abortion care and non-abortion-related reproductive healthcare. The authors discuss that these narratives provide a small glimpse into the substandard medical care being provided throughout the country as a result of new post-Dobbs abortion bans and that reproductive health professionals must continue efforts to publicize these stories and draw attention to the harm being done to patients.

3. Medication abortion and uterine aspiration for undesired pregnancy of unknown location: A retrospective cohort study

When an individual has a positive pregnancy test but lacks a visible pregnancy on ultrasound, they will be grouped under the terminology “pregnancy of unknown location” or PUL. Patients with a PUL are typically asked to return to a laboratory or clinician’s office for repeat testing or imaging over the next days to weeks to confirm the pregnancy location. However, for patients with undesired pregnancies, particularly those affected by burdensome travel distances, this delay can cause significant barriers to access. With the aim of diminishing these barriers, the authors of this study performed a retrospective cohort study to assess outcomes for patients with PUL undergoing immediate medication and procedural abortion. Once deemed sufficiently stable, patients were given the option to choose expectant management or immediate abortion, either through medications or a procedure. The time to diagnosis was significantly shorter for patients choosing uterine aspiration, and similar for those who chose expectant management or medication. Furthermore, rates of ectopic pregnancy diagnosis were similar across groups, and immediate management was found to be feasible and safe. Similar to a prior study on this topic, there may be decreased efficacy when medication abortion is provided to a patient with a PUL. The results of this study support immediate management for patients with an undesired PUL, and support uterine aspiration specifically, as a method of expediting diagnosis.

4. Patient Perspectives Regarding Clinician Communication During Telemedicine Compared With In-Clinic Abortion

Telemedicine, also called telehealth, has been increasingly used for medication abortion provision since the COVID-19 pandemic and is particularly convenient for patients who may experience barriers to access. However, this care modality may feel uncomfortable to some individuals, and further alienate patients who are grappling with abortion stigma and a lack of familiarity with their abortion provider, who is most likely someone they haven’t met before. There is limited data on patient experiences with abortion through telehealth. To explore this field, the authors of this paper conducted a qualitative study on the perspectives of patients receiving either telehealth or in-clinic medication abortion in Washington state. They interviewed 30 patients, of whom 20 received telehealth medication abortions, about their experience with their clinician, the communication received, and their feelings about the care setting. While both groups reported satisfaction with their experiences, interview subjects had a particularly favorable experience with telehealth medication abortion, and appreciated the opportunity to choose between in-person or remote services. These results suggest that telehealth may be superior to in-clinic visits for some patients receiving medication abortion and that this care modality does not diminish clinicians’ ability to communicate clearly and thoughtfully about abortion.

5. Preferences and Experiences Regarding Pregnancy Options Counseling in Adolescence and Young Adulthood: A Qualitative Study

While pregnancies among adolescents have decreased in the last several decades, there were still approximately 318,000 pregnancies in the US among those 15-19 years old in 2017. Pregnant adolescents may be more likely than older patients to face stigma, coercion, and barriers to care regarding their pregnancies. Comprehensive pregnancy options counseling (POC), in which patients receive respectful, unbiased counseling regarding the options of parenting, adoption, or abortion, may be provided and received differently among adolescent patients given their particular needs and concerns. In this semistructured interview study, the authors identified 50 adult individuals who reported a history of one or more pregnancies between 13 to 19 years old. In their interviews, the authors identified several features of POC that were experienced positively by patients, including respectful provider behavior and language, neutral tone, discussion of all pregnancy options, asking about the patient’s life plans and emotional state, and warm handoffs and follow up with ongoing care after the initial POC conversation. Patients also reported negative features of POC, such as poor provider communication, incomplete or biased counseling, insufficient decision-making time, and confidentiality concerns. Providers caring for pregnant adolescents can incorporate these positive aspects into their own POC to improve the patient’s experience and provide support.

6. Cabergoline for Lactation Inhibition After Second-Trimester Abortion or Pregnancy Loss

Lactogenesis is a process that starts at the 16th week of pregnancy, regardless of pregnancy outcome, and continues after the cessation of pregnancy. For patients who undergo second-trimester pregnancy loss or induced abortion, it can be traumatic and surprising to experience postoperative or post-delivery breast pain, fullness, or lactation. Furthermore, while these symptoms are unexpected for patients whose pregnancies end in the second trimester, the majority will experience some form of breast symptoms, as demonstrated in this recent survey. These patients frequently seek medical care to suppress their symptoms, but the currently available options, such as NSAIDs or the application of cabbage leaves, are insufficiently supported by evidence. Cabergoline, a long-acting dopamine agonist, has been used to successfully suppress lactation after full-term delivery. The authors of this study evaluated cabergoline for lactation inhibition after second-trimester abortion or pregnancy loss in this double-blind randomized superiority trial. Patients between 18 and 28 weeks gestational age received either a placebo or 1 mg cabergoline within 4 hours of a procedure or fetal expulsion. Study results demonstrated a significant improvement in breast symptoms for up to 14 days after the medication. Furthermore, the medication was well-tolerated by patients, with minimal side effects. These findings provide encouraging support for cabergoline as a treatment for breast symptoms after second-trimester pregnancy loss or abortion, and providers should consider incorporating it into their routine treatment.

7. Impact of coronavirus disease 2019 (COVID-19) vaccination on menstrual bleeding quantity: An observational cohort study

Menstrual cycle regularity and bleeding quantity are frequently assessed as a routine part of reproductive health care, and changes to the cycle are often a cause for concern for patients. The effects of the COVID-19 vaccine on the menstrual cycle are being explored now that large proportions of reproductive-aged individuals have been vaccinated. While existing data has shown that the vaccine may cause a transient increase in cycle length for some patients, less is known about its effect on bleeding duration or quantity. The authors of this paper performed an observational cohort study to examine the association between the COVID-19 vaccine and menstrual bleeding quantity using the fertility tracking app, Natural Cycles. A total of 9,555 individuals’ cycles were studied primarily from the United Kingdom, Europe, USA, and Canada. The majority of subjects did not experience a change in bleeding quantity after their vaccination and no significant differences were found. However, a small subset of vaccinated individuals did experience a small increase in bleeding quantity for the first cycle after vaccination, which subsequently resolved. These findings suggest that while transient bleeding changes may happen for some individuals, these changes will resolve, and are not present for the majority of vaccine recipients.

8. Promoting Sexual Consent Principles in the Sexual and Reproductive Health Care of Adolescents and Young Adults

Mutual sexual consent is a foundational feature of healthy sexual relationships, and adolescents and young adults often have varied or uneven exposure to ideas about sexual consent as they begin relationships. Previous research indicates that 14% of adolescent females and 4% of adolescent males report nonconsensual sexual contact. In this position paper, the Society for Adolescent Health and Medicine proposes several approaches to promote and center mutual sexual consent in adolescent relationships. They advocate for health care providers taking care of adolescents and young adults to directly address mutual sexual consent with their patients and with the wider general public, and for comprehensive reproductive and sexual health programs aimed at young people to specifically include discussion of sexual consent. They discuss that such counseling should come with appropriate infrastructure and institutional support to allow providers the time to address sensitive subjects and for appropriate screening and referral systems for patients who report nonconsensual sexual contact. They conclude by advocating for additional research on the most effective forms of counseling and advocacy in promoting mutual sexual consent.

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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