Research roundup: September 2025 edition

• Norethisterone for Prolonged Uterine Bleeding Associated with Etonogestrel Implant (IMPLANET): A Randomized Controlled Trial in American Journal of Obstetrics and Gynecology

Up to 40% of Nexplanon users experience frequent and bothersome vaginal bleeding, the most common reason for method discontinuation. While there are various available treatments for this bleeding, such as combined oral contraceptive pills or non-steroidal antiinflammatories (NSAIDs), not all of these options are acceptable or accessible for patients. In this randomized controlled trial from Brazil, the authors evaluated the effect of norethisterone, commonly known as norethindrone acetate (NETA), on bothersome bleeding with Nexplanon. Participants received either 10mg daily of NETA or placebo. Nearly all NETA users experienced cessation of bleeding after 14 days. Although bleeding often recurred after stopping the medication, it was often short-lived. Findings suggest that NETA is an effective short-term option for managing implant-related bleeding.

5. DMPA and meningioma risk

• Depot Medroxyprogesterone Acetate and Risk of Meningioma in the US in JAMA Neurology

Meningiomas, the most common primary brain tumor, originate from the lining around the brain or spinal cord and are more common in female individuals, possibly due to hormone responsiveness and progestin receptors within meningioma tissue. In 2024, French researchers linked prior use of Depot medroxyprogesterone acetate (DMPA), a long-acting injectable progestin contraceptive, to increased likelihood of meningioma surgery, though overall resection incidence was low. Building on this work, US researchers analyzed data from more than 10 million female individuals, finding that use of injectable DMPA had a statistically significant association with meningioma diagnosis, particularly in patients who used it for more than four years and initiated use between 31-40 years of age. A smaller association was noted with oral medroxyprogesterone acetate, while no link was found with other hormonal medications. The number needed to harm, however, was 1,152, highlighting the limited clinical significance of this finding due to the low incidence of meningiomas overall. This study adds to what was previously known about DMPA and meningiomas, and may inform counseling and shared decision-making. 

6. Implicit bias in contraception counseling

• Clinician Implicit Racial Bias and Contraceptive Counseling in the United States in Journal of Women’s Health 

Implicit bias refers to instinctive attitudes and behaviors shaped by lifelong messaging and experiences, often outside of conscious awareness. Someone may believe they hold no prejudices, yet their implicit biases can still influence interactions. In medicine, these biases are well-documented and can contribute to inequitable care, including coercive counseling and inappropriate testing. Quantitative measurements of implicit bias are rare, however. Using the Implicit Association Test (IAT), which evaluates unconscious attitudes and biases, the authors sought to quantitatively measure implicit bias for reproductive healthcare clinicians who provide contraceptive counseling. Analyzing more than 400 subject responses, the study team found that white clinicians had measurable bias favoring white patients when answering questions about contraception provision. Black clinicians did not demonstrate significant bias towards either Black or white patients. In particular, white clinicians with observable implicit bias were more likely to recommend permanent contraception to Black patients. While the IAT uses vignettes that may not perfectly correlate with real-life patient care, the results align with prior studies on implicit bias and underscores an ongoing need for advocacy, education and structural safeguards to confront and reduce racism, reproductive coercion and implicit bias.

7. IUD expulsion rates postpartum

• Expulsion rates 12 months after early versus interval postpartum intrauterine device placement: a randomized trial in American Journal of Obstetrics and Gynecology Global Reports

Immediate postpartum placement (within 10 minutes of delivery) of intrauterine devices (IUDs) is safe and acceptable but carries higher expulsion rates, up to 26%. Typically, if immediate postpartum placement is declined, IUD placement is offered at an interval visit, around six to eight weeks postpartum. The early postpartum period (EPP), defined as two to four weeks after delivery, could provide patients with an additional convenient time for IUD placement. Because device expulsion is a concern for patients who receive postpartum IUDs, and there is a need for additional data on expulsion rates after IUD placements at various time points. This randomized trial compared early postpartum placement (2–4 weeks) vs. interval placement (6–8 weeks). The EPP IUD expulsion rate, 3.2%, was non-inferior to the expulsion rate of interval IUDs, and was much lower than historical expulsion rates for immediate postpartum placement. Participants were happy with the option to receive an IUD during the early postpartum period. These findings provide evidence that IUDs placed after two weeks postpartum remain low risk for expulsion and offer expanded options for patients.  

8. US MEC & SPR research gaps

• Research gaps in evidence-based contraception guidance: US Medical Eligibility Criteria for Contraceptive Use, 2024, and US Selected Practice Recommendations for Contraceptive Use, 2024 in Contraception

In 2024, the US Centers for Disease Control and Prevention (CDC) published updated versions of the US Medical Eligibility Criteria for Contraceptive Use (US MEC) and the US Selected Practice Recommendations for Contraceptive Use (US SPR). During the updating process, the author team identified numerous gaps in evidence, necessitating additional research.  This paper focuses specifically on three areas: risk of thrombosis with hormonal contraception, pain medications for intrauterine device placement, and bleeding irregularities during implant use. The authors explore each of these subject areas in depth, describing the existing research and the areas where evidence is most lacking – for example, risk of thrombosis with new estrogen formulations, such as estetrol, and combinations of different medications for pain management at time of intrauterine device placement. This paper can help inspire and support research initiatives, and is also an excellent resource for providers who want to understand the science (and research gaps) behind the US MEC and SPR.

9. PrEP & STI Risk 

• Trends Analysis of Sexually Transmitted Infections Before and After Human Immunodeficiency Virus Pre-exposure Prophylaxis in the United States 2001-2022 in Open Forum Infectious Diseases

Pre-exposure prophylaxis (PrEP), introduced in 2012, can help reduce the risk of HIV transmission by as much as 99% when taken consistently. Though underutilized, PrEP plays a critical role in decreasing new HIV diagnoses across the world. Emerging evidence suggests that confidence in PrEP may result in decreased condom use and increased rates of sexually transmitted infections (STIs). To study this association, the authors reviewed data on PrEP use and STI incidence between 2001 and 2022, creating a statistical model to evaluate the correlation between the two variables. While gonorrhea and syphilis diagnosis rates in the US went up after the introduction of PrEP, chlamydia rates decreased. The statistical model suggested that there may be a correlation between PrEP usage and STI infection rates, particularly for males. The authors stress that PrEP’s utility remains unchanged and clinicians should continue to offer PrEP alongside routine STI testing, without framing the results as a reason to restrict access.

10. Medicaid abortion coverage

• State-Level Variation in and Barriers to Medicaid Abortion Coverage in JAMA Network Open

About one-third of all patients seeking abortion care in the US rely on Medicaid, but the Hyde Amendment prohibits the use of federal funding for abortion care not related to incest, rape, or a life-endangering physical condition. States may expand coverage with their own funds, but state-level policies vary widely. From this qualitative study examining state-specific abortion coverage policies, the authors found: 18 states that explicitly echo the text of the Hyde Amendment and another 10 that emphasize coverage only in cases of life-endangerment; 17 states describe additional coverage for specified conditions, and 6 states describe coverage for all abortions. Many states add burdensome reporting and administrative hurdles, including 38 states explicitly requiring physician certification and justification for clinical conditions warranting coverage. The study includes a helpful state-specific chart that summarizes the findings. This heterogeneity of state-level Medicaid coverage further contributes to the difficulties patients have seeking abortion care, and the authors call for increased transparency, clarity, and efficiency in state-level Medicaid policies.