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Research roundup: November 2022 edition

Health care provider misconceptions about birth control as an abortifacient, a comprehension study of an over-the-counter combination birth control pill label, an updated Consensus from ACOG on menstrual suppression, and the effect of state-level abortion restrictions on early pregnancy loss management.

by Colleen Denny, MD and Emma Gilmore, MD

published 11/30/22

1. Comparison of vaginal and buccal misoprostol after mifepristone for medication abortion through 70 days of gestation: A retrospective chart review

Medication abortion is widely recognized as a safe, effective method for pregnancy termination. The two medications used for this process, mifepristone and misoprostol, can be taken at varying intervals depending on the route of administration of misoprostol: either vaginal or buccal. However, outcomes for differing medication processes between 64- and 70-days gestational age are less known. In the increasingly restrictive landscape of the US, it is crucial to understand ways to facilitate abortion access, and data on medication abortion is part of this process. The authors of this study performed a retrospective chart review to analyze efficacy and outcomes based on the timing and route of misoprostol administration up until 70 days gestational age. They found that vaginal administration of misoprostol, even soon after taking mifepristone, is highly effective and safe for patients even between 64- and 70-days gestational age. This information further reinforces current practice and may facilitate care for patients traveling long distances for medication abortion access.

2. Comparison of Early Pregnancy Loss Management Between States With Restrictive and Supportive Abortion Policies

Spontaneous early pregnancy loss (EPL) is common, affecting at least 10% of all recognized pregnancies and 25% of women at some point during their reproductive lives. Two of the most commonly recognized methods of EPL care, medical management with misoprostol and mifepristone and surgical management with uterine aspiration, use techniques also used in abortion care. In this cross-sectional survey, researchers surveyed OB-GYNs from states with more and less restrictive policies around abortion care regarding what EPL management options they offered in their practices. After adjusting for confounders, prior abortion care training and institutional support for abortion care were significantly associated with providers offering either mifepristone and misoprostol or uterine aspiration for EPL. Providers and professional groups promoting widespread availability of standard of care EPL management can potentially affect change by promoting full-scope training in abortion care for OB-GYN residents and identifying methods of overcoming institution-based barriers to EPL care.

3. Physician Beliefs about Contraceptive Methods as Abortifacients

Contraception, including emergency contraception (EC), helps to prevent ovulation or fertilization but does not prevent pregnancy once an egg has been fertilized. However, numerous misconceptions persist about the mechanisms of contraceptive medications. With abortion restrictions on the rise, it is important to ensure that both providers and patients understand how contraception works so that it can be prescribed and used appropriately. The authors of this research letter surveyed almost 900 physicians at the University of Wisconsin School of Medicine and Public Health, to characterize their beliefs regarding contraceptive methods including the pill, ring, patch, and intrauterine devices (IUDs), along with EC. While 95% of the surveyed providers care for reproductive-aged females, one in six physicians believed that some contraceptive methods, particularly EC, are abortifacients— including obstetrician-gynecologists (though in smaller proportion). These results indicate a need for further research and education around the mechanisms of contraceptive methods so that providers can correctly counsel patients that contraception will prevent—not terminate—pregnancy. For more on answering the most FAQ about the difference between EC and medication abortion check out this article and share this one with your patients.

4. Demographic, Reproductive, and Medical Risk Factors for Intrauterine Device Expulsion

IUDs are reliable and well-tolerated as methods of contraception, but expulsion can be bothersome and, if unrecognized, may lead to pregnancy. The authors of this paper sought to better understand the risk factors for IUD expulsion. They performed an analysis of the APEX-IUD study, which was a retrospective cohort study of more than 300,000 individuals around the United States who had a levonorgestrel or copper IUD. They found that heavy menstrual bleeding was most strongly associated with IUD expulsion, which is consistent with other studies. They also found that expulsion was associated with elevated BMI, young age, and high parity, though further research is needed to understand what aspects of these characteristics actually influence the risk of expulsion. Overall, this study provides patients and health care professionals with additional information for counseling and expectations around IUD expulsion.

5. Bleeding profile satisfaction and pain and ease of placement with levonorgestrel 19.5 mg IUD: findings from the Kyleena® Satisfaction study

The 19.5mg levonorgestrel IUD (Kyleena) was designed to provide patients with an additional option for a hormonal IUD at a lower dose of levonorgestrel. Kyleena is also slightly smaller than the 52mg levonorgestrel IUDs (Liletta and Mirena). This lower dose may lead to more irregular bleeding and less frequent amenorrhea. The Kyleena Satisfaction study aimed to assess patients’ experiences with the 19.5mg IUD, by assessing IUD recipients around the world over a 12-month follow-up period, as well as asking for providers’ impressions of the difficulty of placement. The authors found that Kyleena placement was easy and associated with minimal pain for most patients. The majority of recipients were satisfied with their bleeding profile with the 19.5mg IUD, regardless of age or parity. These survey results provide information that may be useful for patient counseling and decision-making.

6. General Approaches to Medical Management of Menstrual Suppression: ACOG Clinical Consensus No. 3

This new clinical consensus from the American College of Obstetricians and Gynecologists (ACOG) reviews menstrual suppression, which uses hormonal medications to reduce or eliminate menses. The document contains extensive information about the available methods, including the vaginal ring, patch, injection, long-acting reversible contraceptives, and various types of hormone-containing pills. These options may be considered for all patients, including adolescents, after achieving menarche. Menstrual suppression may be particularly important for gender-diverse individuals who can experience gender dysphoria with menses, or those with physical or cognitive disabilities. The likelihood of achieving amenorrhea will depend on the chosen method, and this information is also reviewed extensively in the Consensus. Overall, decisions about menstrual suppression should be individualized and based on each patient’s specific goals, preferences, and any medical contraindications to hormonal medications. Providers will find this Clinical Consensus useful, as it features a large table that describes each method along with in-depth descriptions of uses and contraindications.

7. "I don't regret it at all. It's just I wish the process had a bit more humanity to it … a bit more holistic": a qualitative, community-led medication abortion study with Black and Latinx Women in Georgia, USA

Medication abortion is a safe and highly effective option for abortion and may be an important option for care in areas and populations where access to abortion is limited by political, cultural, and socioeconomic barriers. However, some research has suggested that Black, Latinx, and other people of color are less likely than other groups to choose medication abortion over an abortion procedure. In this qualitative study, the authors conducted focus groups with Black and Latinx women as well as interviews with abortion providers and reproductive justice community-based organization leaders. In their analyses, they identified multiple levels of barriers to abortion care for communities of color. Accordingly, participants suggested that solutions would need to incorporate a multi-level approach, including promoting story-sharing through social media, policy advocacy-oriented on reproductive justice, diversification of clinic staffing, and increased flexibility of clinic schedules and fees. Providers seeking to decrease barriers to abortion for communities of color can incorporate these suggestions into their own practices.

8. Reproductive Justice: A Case-Based, Interactive Curriculum

Reproductive justice (RJ) is a framework that can help both providers and patients conceptualize how phenomena such as forced sterilization, maternal morbidity and mortality, reproductive coercion, and barriers to reproductive health care can compound one another, leading to poor reproductive health outcomes, particularly for communities of color. While this framework has been discussed in public health literature for decades, there are few medical training curricula that have formally incorporated it, despite research showing that structured curricula can reduce trainee biases. In this survey-based project, the authors integrated an RJ curriculum into post-clerkship medical student education, including interactive, case-based discussions of barriers to reproductive health care for patients. In a comparison of pre- and post-curriculum surveys, students reported that such training was important and currently absent from their standard curriculum and perceived it as valuable to their future practices. While the number of students trained and surveyed was small, this work is potentially valuable for providers involved in designing and improving medical trainee education.

9. Pilot label comprehension study for an over-the-counter combined oral contraceptive pill in the United States

While oral contraceptive pills (OCPs) are the most commonly used non-permanent form of birth control in the US, the requirement for a provider’s prescription can be a barrier for many patients. An increasing body of research on safety supports making OCPs available over the counter (OTC), but FDA approval for OTC status requires that consumers demonstrate the ability to understand label messages regarding the safety and efficacy of the OTC product. In this pilot label comprehension study, the authors conducted more than 160 interviews with patients 12-49 years old and assessed their ability to understand several key endpoints related to the safety of OCP use, including risks and contraindications. Over 95% of participants understood 10 out of 11 primary safety endpoints, and 89% understood the 11th (related to the safety of OCPs with a history of blood clots). While the final FDA approval of label comprehension will be linked to the actual approved OCP product, the researchers concluded that consumers are able to understand key label messaging for the safe and effective use of an OTC birth control pill. Learn more about why we are ready for OTC pills now and join the movement to #FreethePill.

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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