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Research roundup: September 2023 edition

Patients' preferences for contraceptive educational materials, management of missing IUD strings and migrated IUDs, and providers’ perspectives on how to improve contraceptive counseling.

by Colleen Denny, MD

published 09/29/23

1. Contraceptive Method Switching and Long-Acting Reversible Contraception Removal in U.S. Safety Net Clinics, 2016–2021

Patients using reversible contraception methods may decide to discontinue or switch to another method for a variety of reasons, including changes in fertility goals, side effect profiles, or logistical concerns. In this large retrospective cohort study, the authors analyzed data from nearly 152,000 patients coming for contraceptive visits at nearly 500 community health centers over a four-year period. They found that 22.1% of patients overall switched their contraceptive method during this time period and that the likelihood of switching varied among different patient populations and types of contraception. Patients who were younger, Black or Latina, publicly insured, or seen in a Title X clinic were all more likely to switch. They also noted that 19.4% of baseline LARC users had their IUD or implant removed within a year, and 30.1% within four years. The authors discuss that these data show the high frequency of switching between contraceptive methods over time, and call for normalizing this switching and supporting health care models that enable patients to have timely access for follow-up contraception options counseling and LARC removal.

2. Venous thromboembolism with use of hormonal contraception and non-steroidal anti-inflammatory drugs: nationwide cohort study

Both hormonal contraception, particularly combined hormonal contraception, and non-steroidal anti-inflammatory drugs (NSAIDs) are associated with a small increased risk of venous thromboembolism (VTE). However, there is less data about the combined risk of VTE for patients using both types of medication. In this historical cohort study analyzing data from approximately two million reproductive-aged women in Denmark between 1996 and 2017, the authors compared the risk of VTE among patients using NSAIDs and/or hormonal contraception. They found that there was a significantly increased risk of VTE in patients using both NSAIDs and hormonal contraception compared to using only one of these medications, with the highest rates seen among users of both combined hormonal contraception and NSAIDs. However, the absolute increase in risk was relatively small, with a 0.02% total VTE risk in even the high-risk combined hormonal contraception and NSAID use group. The number of extra VTEs per 100,000 women in the first week of NSAID use was four among non-hormonal contraception users and increased to 11 among medium-risk hormonal contraception and 23 among high-risk hormonal contraception. While the authors note that the absolute risk remains small, they suggest that this risk should be further investigated and included in patient contraception counseling.

3. "I feel like it gives me what I need to know": A qualitative study on adolescent perceptions of two contraceptive decision aids

Sexually active adolescents are among the least likely to use highly effective contraceptive methods. Patient-centered contraceptive counseling, such as developmentally tailored decision aids, can be a useful tool in helping to improve patient understanding and confidence in their contraception choices. In this cross-sectional qualitative study, the authors recruited 20 adolescents aged 15-19 years to provide feedback for two contraception decision aids in adolescent clinical care, from the Reproductive Health Access Project (RHAP) and In semistructured interviews, the participants reported that both decisional aids were helpful, and appreciated the clear discussion of side effects and a full range of options. While participants differed in the amount of detailed information they preferred in a decisional aid, both aids increased adolescents’ self-reported knowledge. Decisional aids can provide a useful tool in guiding conversation and promoting patient-centered care in contraceptive visits with adolescents.

4. Improvement in contraceptive knowledge after using an online educational resource

While high-quality contraception counseling has been shown to improve the uptake and continuation of contraception use, there is a lack of research comparing different contraceptive educational interventions and decision aids. In this cross-sectional online survey, the authors queried nearly 800 reproductive-age, biologically female participants on their knowledge of contraception both before and after viewing an online contraception resource adapted from There was a significant increase in knowledge seen after using the online resource, and participants found it highly usable. This online decision aid can potentially provide a valuable adjunct to clinical counseling by augmenting patients’ pre-visit knowledge about their options.

5. Clinicians’ Perspectives and Proposed Solutions to Improve Contraceptive Counseling in the United States: Qualitative Semi-structured Interview Study With Clinicians From the Society of Family Planning

Contraceptive counseling is an important part of reproductive health care. While the majority of reproductive-aged women report using contraception, only a minority report that they feel they have the information they need to make decisions about contraception, and this percentage is even lower among women of color. Patient decision aids (PDAs) can be useful tools for helping both patients and clinicians discuss contraception options while also centering the patient’s needs and preferences. In this interview-based study, the authors conducted semi-structured interviews with 15 family planning clinicians with an average of 19 years of clinical experience. In discussing barriers to high-quality patient-centered contraceptive counseling, the authors identified three main themes from clinicians, including gaps in baseline sexual health knowledge, clinician and patient biases that impede decision-making, and time constraints. Given these barriers, the authors discuss the importance of both system-wide improvements, such as improving sex education and involving more members of the health care team in contraceptive counseling, as well as improvements at the individual level, including the incorporation of standardized PDAs and standardized clinician guidelines for counseling to decrease bias.

6. Feasibility and acceptability of virtual group contraceptive counseling prior to abortion care

Facilitated group care has been a successful model of care in several aspects of reproductive health, including group prenatal care and online discussion groups. While contraception options counseling is a common aspect of abortion care, this care is typically provided one-on-one. In this prospective cohort study, 57 patients seeking abortion care completed a virtual group counseling session on contraception options before their abortion appointment. Patient satisfaction with this model was high, with 96% of participants reporting they would recommend this to a friend. Furthermore, participants required less time for contraception counseling during their clinician visit compared to the standard care workflow. The authors suggest that group contraception options counseling before abortion care visits was both feasible and acceptable to patients, and could provide an important model of care for improving both patient experience and clinical efficiency.

7. Development of My Decision/Mi Decisión, a web-based decision aid to support permanent contraception decision making

Female permanent contraception, or sterilization, is the most commonly used form of contraception in the US. However, inadequate contraceptive options counseling may lead to suboptimal decision-making, misunderstanding regarding the permanence of the procedure, or future regret. This article describes the development of a patient decision aid focused on permanent contraception among patients using Medicaid, through the process of needs assessment, multidisciplinary feedback, prototype evaluation, and beta testing. The authors describe the features of the decision aid and an upcoming randomized controlled trial assessing participant knowledge and decisional conflict regarding permanent contraception. If shown to be effective in improving counseling for patients, this decision aid could be incorporated into permanent contraception counseling for broader patient populations.

8. Management of missing intrauterine device strings and migrated intrauterine devices

IUDs provide a long-acting, highly effective, and reversible form of contraception, and are an increasingly popular option among patients. However, as IUD removal typically requires identification and traction on the IUD’s strings, the inability to visualize IUD strings on pelvic exam can interfere with desired IUD removal. In this review, the authors discuss possible etiologies and risk factors for “missing” IUD strings, including postpartum placement. They also discuss a sequential management algorithm, starting with a gentle rotation of a cyto brush or cotton swab in the cervical canal to bring down strings, confirming the IUD’s intrauterine location on bedside ultrasound, and then progressing to more advanced in-clinic techniques such as an ultrasound-guided removal using alligator forceps or the use of a manual vacuum aspirator. Further imaging can involve an abdominal plain film x-ray to confirm IUD location and laparoscopic removal if an extrauterine location is diagnosed. This step-wise approach can be a useful guide for clinicians treating patients with missing IUD strings.

9. Risks of Uterine Perforation and Expulsion Associated With Intrauterine Devices

IUDs can provide highly effective, reversible contraception. Risks associated with IUD placement and use are uncommon but include both uterine perforation and expulsion (which may put patients at risk of unintended pregnancy if unrecognized). In this article reviewing the conclusions from the APEX-IUD study, a large retrospective cohort study of IUD insertions between 2001 and 2018, the authors summarized clinically important findings regarding the risks of IUD perforation and expulsion. They concluded that uterine perforation was overall rare, with 0.21% at one year and 0.61% at five years, but was higher among patients 52 weeks or less postpartum and highest among IUD placed four days to six weeks postpartum. Patients breastfeeding or with heavy menstrual bleeding at the time of IUD placement also had a small increase in perforation risk. IUD expulsion was also uncommon, with a cumulative 5% risk at five years. Risk of expulsion was greater among those with an immediate post-placental IUD placement, at nearly 11%, as well as those with heavy menstrual bleeding, at nearly 14%. There was a slightly elevated perforation risk and lower expulsion risk with LNG IUDs compared to copper IUDs. These findings have clinical relevance for providers who offer IUDs in their practice and may be incorporated into patient counseling as well as practice techniques, including ultrasound usage at time of IUD placement.

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.
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