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Background Data on contraceptive use among women with bacterial sexually transmitted infections (STIs) are sparse, despite this population’s high risk for unplanned pregnancy. Methods This cross-sectional study included 1623 cisgender women recently diagnosed with a bacterial STI who completed a public health Partner Services interview between January 2017 and December 2019 in King County, WA, USA. Contraceptive methods were categorized as: (1) highly or moderately effective and (2) least effective or no method. Poisson regression models were used to assess associations between individual characteristics and contraceptive method. Results Almost two thirds of the women (62.6%) reported using highly or moderately effective contraception, with 30.3% of women using long-acting contraception (LARC). More than one in three women (37.4%) reported using least effective methods or no method. Black women were less likely to report using a highly or moderately effective method compared to White women (aRR 0.58, 95% CI 0.43–0.80) and women with private insurance were more likely to report using a highly or moderately effective method compared to those with public insurance (aRR 1.67, 95% CI 1.28–2.19). Conclusions Given that many women with bacterial STIs are not desiring pregnancy, this study highlights the need for additional reproductive health services for women with recent STI diagnoses.

Objective: Medical contraindications to estrogen limit women's contraceptive options. This study assessed the association between selected medical contraindications to estrogen on contraceptive use...

Medication abortion with pharmacist-dispensed mifepristone is effective, with a low prevalence of adverse events, and patients are satisfied with the model of care., OBJECTIVE: To estimate effectiveness and acceptability of medication abortion with mifepristone dispensed by pharmacists. METHODS: We conducted a prospective cohort study at eight clinical sites and pharmacies in California and Washington State from July 2018 to March 2020. Pharmacists at participating pharmacies underwent a 1-hour training on medication abortion. We approached patients who had already been evaluated, counseled, and consented for medication abortion per standard of care. Patients interested in study participation gave consent, and the clinician electronically sent a prescription to the pharmacy for mifepristone 200 mg orally, followed 24–48 hours later by misoprostol 800 micrograms buccally. Participants were sent web-based surveys about their experience and outcomes on days 2 and 14 after enrollment and had routine follow-up with study sites. We extracted demographic and clinical data, including abortion outcome and adverse events, from medical records. We performed multivariable logistic regression to assess the association of pharmacy experience and other covariates with satisfaction. RESULTS: We enrolled 266 participants and obtained clinical outcome information for 262 (98.5%), of whom two reported not taking either medication. Of the 260 participants with abortion outcome information, 252 (96.9%) and 237 (91.2%) completed day 2 and 14 surveys, respectively. Complete medication abortion (primary outcome) occurred for 243 participants (93.5%, 95% CI 89.7–96.1%). Four participants (1.5%, 95% CI 0.4–3.9%) had an adverse event, none of which was serious or related to pharmacist dispensing. In the day 2 survey, 91.3% (95% CI 87.1–94.4%) of participants reported satisfaction with the pharmacy experience. In the day 14 survey, 84.4% (95% CI 79.1–88.8%) reported satisfaction with the medication abortion experience. Those reporting being very satisfied with the pharmacy experience had higher odds of reporting overall satisfaction with medication abortion (adjusted odds ratio 2.96, 95% CI 1.38–6.32). CONCLUSION: Pharmacist dispensing of mifepristone for medication abortion is effective and acceptable to patients, with a low prevalence of adverse events. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03320057.

The coronavirus disease 2019 (COVID-19) pandemic has posed a burden to healthcare systems around the world and has changed the way people access health services, including contraception. This document sets forth guidance from the Society of Family Planning for providing contraceptive care in the context of the COVID-19 pandemic, including when access to healthcare is restricted due to pandemic response. It also outlines the role of telehealth for providing contraceptive care beyond the pandemic. Clinicians can use synchronous telemedicine visits and other forms of telehealth to provide many aspects of contraceptive care. Both audio-video and audio-only visits are acceptable forms of telemedicine. Access to permanent contraception should be maintained, especially in the postpartum period. Combined hormonal contraceptive (CHC) users who have asymptomatic or mild COVID-19 infection may continue their contraceptive method, while those admitted to the hospital with severe infection should suspend CHC use until they are clinically recovered. CHC users who take Paxlovid for mild-moderate COVID-19 infection can consider a back-up contraceptive method for the duration of therapy, but clinically relevant drug interactions are unlikely. Future research should examine contraceptive outcomes in people who receive care via telemedicine; and access to telemedicine among historically excluded populations such as adolescents, people of color, people of low socioeconomic status, disabled people, or people who do not speak English as a primary language.

Few data exist regarding reproductive health needs of women who inject drugs (WWID) and exchange sex. This group is at increased risk of unintended pregnancy and sexually transmitted infections (STI). They also face stigma and other barriers to accessing reproductive health care.

Objective Depression in women is more common during perimenopause (the time period around and during menopause) than pre and postmenopause. Obstetrician-gynecologists (ob-gyns) play a vital role in the detection and management of depression symptoms in women because for many women ob-gyns are the first and most frequent point of medical contact. This study assessed ob-gyns' screening practices and management of depression in perimenopause. Methods A survey regarding depression during perimenopause was sent to 500 practicing ob-gyns who were fellows of the American College of Obstetricians and Gynecologists and members of the Collaborative Ambulatory Research Network. Results The survey response rate was 41.8% (209 of 500 surveys returned). Over a third of respondents (34.1%) reported that they did not regularly screen perimenopausal patients for depression. Higher-quality education about depression, respondent sex, and personal experience with depression were associated with higher rates of screening. While 85.7% of respondents believed that they could recognize depression in perimenopausal women, only about half (55.8%) were confident in their ability to treat these patients. Conclusion Increased education of ob-gyn physicians related to depression during perimenopause may increase the screening and treatment of women during this phase of life.

To compare patient satisfaction with anesthesia after first-trimester surgical abortion among patients receiving intravenous (IV) ketamine compared with IV fentanyl for procedural sedation.This was a randomized noninferiority trial comparing IV ketamine to IV fentanyl for first-trimester surgical abortion up to 13 6/7 weeks of gestation. Patients were randomized to receive either ketamine 200-500 micrograms/kg IV over 2 minutes, repeated every 5 minutes until appropriate analgesia was achieved, or fentanyl 0.5-1 micrograms/kg IV over 2 minutes, repeated every 5 minutes until appropriate analgesia was achieved. All patients received midazolam 2 mg IV. The primary outcome, patient satisfaction, was measured using the Iowa Satisfaction with Anesthesia Scale immediately postprocedure. Secondary outcomes included postoperative pain, additional pain medication necessary during the procedure and on discharge, physician satisfaction, and time to discharge. We calculated a sample size of 84 with a noninferiority margin of 0.6 on the Iowa Satisfaction with Anesthesia Scale with 80% power, one-sided type 1 error of 0.025, and further increased this number to 110 to account for potential dropout.From April to October 2021, 184 patients were screened and 110 were randomized (57 to ketamine and 53 to fentanyl). Demographics were similar between groups. The primary outcome, patient satisfaction with anesthesia, was noninferior in the ketamine group (mean score 2.4, SD 0.8) as compared with the fentanyl group (mean score 2.2, SD 0.9) with a risk difference of 0.20 (95% CI 0.11-0.52). More hallucinations were reported in the ketamine group. Otherwise, secondary outcomes were similar between the groups.Compared with IV fentanyl, IV ketamine is noninferior for patient satisfaction with anesthesia when used for procedural sedation for first-trimester outpatient surgical abortion.ClinicalTrials.gov , NCT04871425.

Objective To estimate whether routine use of intravenous oxytocin decreases the frequency of interventions to control excess blood loss during dilation and evacuation (D&E). Methods In this multisite, randomized, double-blind, placebo-controlled trial, women undergoing D&E at 18-24 weeks of gestation received 30 units of oxytocin in 500 mL of intravenous fluid or 500 mL of intravenous fluid alone initiated on speculum placement. The primary outcome was the frequency of interventions to control excess bleeding. A sample size of 75 patients per group was needed to detect a 15% decrease in intervention from 20% to 5% with 80% power and two-sided alpha 0.05. Secondary outcomes included measured blood loss, complications, procedure duration, postoperative pain, and patient satisfaction. Results From November 2014 to February 2018, we screened 337 women and randomized 160 to receive prophylactic oxytocin (n=82) or placebo (n=78). Demographic characteristics were similar between groups. The frequency of interventions for bleeding, our primary outcome, was 7.3% in the oxytocin group vs 16.7% in the placebo group, difference of 9.4% (95% CI -21.0% to 1.9%). Interventions primarily included uterine massage and uterotonic administration. Among our secondary outcomes, median measured blood loss was lower in the oxytocin group at 152 (interquartile range 98-235) mL vs 317 (interquartile range 168-464) mL (95% CI 71.6-181.5). Frequency of hemorrhage, defined as blood loss of 500 mL or more and 1,000 mL or more, was lower in the oxytocin group at 3.7% vs 21.8%, difference of 18% (95% CI -29 to -6.9%) and 1.2% vs 10.3%, difference of 9.0% (95% CI -17 to -0.7%), respectively. Procedures were shorter in the oxytocin group at a median of 11.0 (interquartile range 8.0-14.0) vs 13.5 (interquartile range 10.0-19.0) minutes in the placebo group (95% CI 1.0-4.0). We found no differences in the frequency of nonhemorrhage complications, pain scores, or satisfaction scores between groups. Conclusion Prophylactic use of oxytocin during D&E at 18-24 weeks of gestation did not decrease the frequency of interventions to control bleeding. However, oxytocin did decrease blood loss and frequency of hemorrhage. Clinical trial registration ClinicalTrials.gov, www.clinicaltrials.gov, NCT02083809.

Introduction More than one-third of women in the U.S. have engaged in heterosexual anal intercourse (HAI), but little is known regarding women’s perceptions of HAI and motivations for engaging in this sexual behavior. Aim This study aimed to explore U.S. women’s motivations for engaging in HAI and to investigate how they navigate HAI in the context of sexual relationships. Methods Semi-structured interviews were conducted with 20 women, ages 18–50 years old, who had engaged in anal intercourse with a male partner within the past 3 months. The interview guide was developed utilizing a conceptual framework based on the Theory of Planned Behavior. Main Outcome Measure Thematic content analysis was performed, and salient themes were identified. Results Salient themes were identified in all key components of the construct, including attitudes toward the behavior, subjective norms, and perceived behavioral control. Women’s intent to engage in HAI was influenced by their attitudes toward HAI and level of control and trust with their partners. Primary motivators were partner and personal pleasure and sexual curiosity and experimentation. Conclusion The Theory of Planned Behavior construct was well suited to explore factors influencing women’s intent to engage in HAI. Most women perceive negative societal norms toward HAI. Although this does not appear to affect intention to engage in HAI, it does affect disclosure of this sexual activity with friends and healthcare providers. It is important for healthcare providers to provide open, non-judgmental counseling regarding HAI to decrease stigma, enhance communication, and improve sexual health.

Objective To evaluate whether same-day administration of mifepristone and misoprostol, compared with misoprostol alone, reduces the duration of second-trimester induction of labor for termination of pregnancy or increases the rate of fetal expulsion within 24 hours. Study Design We conducted a retrospective analysis of patients undergoing induction of labor for pregnancy termination in the second trimester between 2009 and 2018. We compared patients who received mifepristone on the same day as the first dose of misoprostol to those who received misoprostol alone. The primary outcome was expulsion within 24 hours after the first dose of misoprostol. Results Two hundred ninety-eight patients met criteria for inclusion, of whom 94 (31.5%) received same-day mifepristone. Expulsion within 24 hours occurred in 93.6% of the mifepristone-plus-misoprostol group and 79.9% of the misoprostol-only group (RR 1.17, 95%CI 1.07−1.28). Expulsion within 12 hours occurred in 56.4% of the mifepristone-plus-misoprostol group and 34.0% of the misoprostol-only group (RR 1.66, 95%CI 1.28−2.16). After adjusting for demographic and clinical characteristics, the rate of expulsion within 24 hours was similar between groups (RR 1.07, 95%CI 0.92−1.26), while the rate of expulsion within 12 hours remained different (RR 1.69, 95%CI 1.01−2.83). Median time to expulsion was shorter in the mifepristone-plus-misoprostol group than the misoprostol-only group (689 minutes vs 901 minutes, p Conclusion(s) Patients who received mifepristone on the same day as misoprostol had a shorter duration of induction termination and higher rate of success within 12 hours.

PROBLEM: Changes in sex hormones during the menstrual cycle and contraceptive vaginal ring (CVR) use influence immunity within the female genital tract, but the magnitude of these effects and their anatomical location are unclear. METHOD OF STUDY: In a prospective study, 29 women were assessed at three-time points: follicular phase, luteal phase, and one month after initiation of the ethinyl estradiol/etonogestrel CVR (NuvaRing®, Merck). We performed microarrays on endocervical cytobrushes and measured immune mediators in cervicovaginal fluid, adjusting for bacterial vaginosis and the presence of blood. We compared these results to public gene expression data from the fallopian tubes, endometrium, endo- and ectocervix, and vagina. RESULTS: Immune-related gene expression in the endocervix and immune mediators in cervicovaginal fluid increased during CVR use versus both menstrual phases, and in the follicular versus luteal phase. The antimicrobial protein granulysin was high during CVR use, intermediate in the follicular phase, and nearly absent from the luteal phase. Re-analysis of public gene expression data confirmed increased immune-related gene expression in the endocervix during the follicular phase. However, in the fallopian tube, endometrium, and vagina, the follicular phase showed immunosuppression. CONCLUSIONS: Immune-related genes in the cervicovaginal tract were highest during CVR use, intermediate in the follicular phase, and lowest in the luteal phase. Granulysin is a potential biomarker of menstrual phase: Frequently detected in follicular samples, but rare in luteal. Lastly, immunological differences between the follicular and luteal phases vary throughout the female genital tract.

The segesterone acetate and ethinyl estradiol contraceptive vaginal ring (SA/EE CVR) was FDA-approved in August 2018 and is now available in the U.S. The CVR is placed vaginally for 21 days followed by a 7-day ring-free interval, when withdrawal bleeding typically occurs. One ring can be used for up to a year (13 cycles).This review summarizes this novel method of contraception, including the delivery system and the hormonal components. We describe the potential market, how it is used, the pharmacokinetic properties of the device, and results of clinical trials including efficacy, bleeding profile, acceptability, and safety.The SA/EE CVR represents the first long-lasting user-controlled hormonal contraceptive device. The bleeding pattern is highly favorable and consistent over the entire year and is associated with very low discontinuation. Efficacy and safety are similar to other methods of combined hormonal contraceptives. Unscheduled ring removals increase the risk of failure. Further studies are needed to evaluate continuous use of the ring for greater than 21 days, and potential non-contraceptive benefits of the ring such as reduced menstrual bleeding.

Background An estimated 1.4 million persons in the United States identify as transgender or nonbinary, signifying that their gender identity does not correspond with their assigned sex at birth. Individuals assigned female at birth may seek gender-affirming hormone therapy with testosterone. No studies have directly examined ovulatory function in transmasculine individuals using injectable testosterone. Objectives Our primary objective was to determine the effect of testosterone on ovulatory suppression in transmasculine individuals. Secondary objectives were to determine predictors of ovulation in transmasculine individuals on testosterone, and to assess the effect of testosterone on antimullerian hormone. Materials and Methods This prospective observational study recruited participants from a community clinic that provides gender-affirming hormone therapy. Enrolled individuals were assigned female at birth and were currently using or seeking to initiate masculinizing therapy with injectable testosterone esters (transmasculine individuals). Over a 12-week study period, participants collected daily urine samples for pregnanediol-3-glucoronide testing and completed daily electronic bleeding diaries. We assessed monthly serum mid-dosing interval testosterone, estradiol and sex hormone binding globulin, and antimullerian hormone values at baseline and study end. Ovulation was defined as pregnanediol-3-glucoronide greater than 5 μg/mL for 3 consecutive days. The primary outcome was the proportion of participants who ovulated during the study period. We examined predictors of ovulation such as age, length of time on testosterone, serum testosterone levels, body mass index, and bleeding pattern. Results From July to November 2018, we enrolled 32 individuals; 20 completed the study (14 continuing testosterone users, 6 new users). Median age was 23 years (range 18−37 years). Bleeding or spotting during the study period was noted by 41% of participants (13/32). Among continuing users, median testosterone therapy duration was 11 months (range 1−60 months). A single ovulation was observed out of a total of 61 combined months of testosterone use; however, several transient rises in pregnanediol-3-glucoronide followed by bleeding episodes were suggestive of 7 dysfunctional ovulatory cycles among 7 individuals. There was no difference in antimullerian hormone from baseline to 12 weeks between participants initiating testosterone and continuing users of testosterone. We did not have the power to examine our intended predictors given the low numbers of ovulatory events, but found that longer time on testosterone and presence of vaginal bleeding over 12 weeks were associated with transient rises in pregnanediol-3-glucoronide. Conclusion This study suggests that testosterone rapidly induces hypothalamic−pituitary−gonadal suppression, resulting in anovulation in a proportion of new users. Importantly, these data also suggest that some long-term testosterone users break through the hormonal suppression and experience an ovulatory event, thereby raising concerns pertaining to the need for contraception in transmasculine individuals engaged in sexual intercourse with sperm-producing partners. Given the small number of overall participants, this work is hypothesis generating. Larger studies are needed to confirm and to clarify these findings.

Background The U.S. Food and Drug Administration (FDA) restricts dispensing of mifepristone for medication abortion to certified health care providers at clinical facilities, thus prohibiting pharmacist dispensing. Allowing mifepristone dispensing by pharmacists could improve access to medication abortion. Objective To assess the feasibility of pharmacists dispensing mifepristone to patients who have undergone evaluation for eligibility and counseling for medication abortion by a clinician. Methods Before providing a study training on medication abortion, we administered baseline surveys to pharmacists who participated in a multisite mifepristone-dispensing intervention. The survey assessed medication abortion knowledge—using a 15-item score—and perceptions about the benefits and challenges of the model. We administered follow-up surveys in the study’s final month that also assessed the pharmacists’ satisfaction and experiences with mifepristone dispensing. To investigate the association of the study intervention with the pharmacists’ knowledge, perceptions, and experiences dispensing mifepristone, we conducted multivariable linear regression analyses using generalized estimating equation models, accounting for clustering by individual. Results Among the 72 pharmacists invited from 6 pharmacies, 47 (65%) completed the baseline surveys, and 56 (78%) received training. At the study’s end (mean 18 months later), 43 of the 56 pharmacists who received training (77%) completed the follow-up surveys. At follow-up, 36 (83%) respondents were very or somewhat satisfied with mifepristone dispensing, and 24 (56%) reported experiencing no challenges dispensing mifepristone. Four (6%) of the 72 pharmacists invited objected to participating in mifepristone dispensing. In regression analyses, average knowledge scores, perceived ease of implementation, and level of support for the pharmacist-dispensing model were higher at follow-up (P Conclusion Most pharmacists were willing to be trained, dispensed mifepristone with few challenges when given the opportunity, were satisfied with the model, and had higher knowledge levels at follow-up. Our findings support removal of FDA’s restriction on pharmacist dispensing of mifepristone.

Among HSV-2 seropositive women, the follicular phase of the cycle was associated with a higher frequency of genital HSV-2 shedding. Hormonal contraception did not affect HSV-2 shedding or lesions. BACKGROUND: The effect of female sex hormones on HSV-2 shedding and lesion frequency is poorly understood. Previous studies suggest that hormonal contraception may increase the frequency of HSV-2 shedding. METHODS: We studied HSV-2 seropositive women who performed daily genital swabbing for HSV DNA and completed diaries for genital lesions and menses. We used Poisson mixed effects models to determine if HSV detection varied throughout the menstrual cycle, or in response to hormonal contraception. We used the Wilcoxon signed-rank test and rank-sum test to determine if lesion frequency differed by cycle phase or hormonal contraceptive use. RESULTS: In 189 women aged 19–46 who collected swabs on 10,715 days and were not using hormonal contraception, HSV-2 DNA was detected on 20.9% of days in the follicular phase and 17.8% of days in the luteal phase (RR=1.19; 95% CI 1.03–1.37, p=0.02). Genital lesions did not differ in the follicular versus luteal phase (12.8% versus 10.7%, p=0.07). In analyses of hormonal contraception, including 244 women, HSV-2 DNA was detected on 19.0% of days for women not using hormonal contraception and 18.3% of days for those using hormonal contraception (p=0.50). Lesions were present on 11.1% of days for women not using hormonal contraception, and 8.7% of days for those using hormonal contraception (p=0.66). CONCLUSION: In women with genital HSV-2 infection who are not using hormonal contraception, the follicular phase of the cycle may be associated with a higher frequency of HSV-2 shedding compared to the luteal phase. Lesion frequency is similar during the two menstrual phases. Hormonal contraception use was not observed to affect genital HSV-2 DNA detection or lesions.

Objectives: To describe leukocytosis trends during cervical preparation with osmotic dilators for second-trimester dilation and evacuation procedures, and to determine whether there is a difference in leukocytosis seen with laminaria versus Dilapan-S. Methods: We conducted a retrospective cohort study of 986 women presenting for dilation and evacuation from April 2008 through March 2009 at an outpatient clinic network. We included all procedures at ⩾14 weeks’ gestation where laminaria or Dilapan-S dilators were used for overnight dilation. All women had routine white blood cell testing during the study period. Results: There was a median increase of 2.4 × 103/μL white blood cell count (95% confidence interval 2.2–2.7 × 103/μL) from beginning of cervical preparation to the day of procedure (95% confidence interval and p value). Women receiving laminaria ( n = 805) versus Dilapan-S ( n = 181) had a greater increase in white blood cell count from baseline (median increase 2.7 versus 1.2 × 103/μL, p < 0.001), including when adjusting for age, gestational age, parity, baseline white blood cell count, and number of dilators placed. Conclusion: There is increased leukocytosis during the course of cervical preparation with osmotic dilators, and this is increased with use of laminaria versus Dilapan-S. Rates of clinically recognized infection in second-trimester abortion are low regardless of dilator type used.

Steroid hormones have been in use for more than a half a century as contraceptive agents, and only now are researchers elucidating the biochemical mechanisms of action and non-target effects. Progesterone and synthetic progestins, critical for women's health in the US and internationally, appear to have important effects on immune functioning and other diverse systems. Apart from the contraceptive world is a separate field that is devoted to understanding progesterone in other contexts. Based on research following a development timeline parallel to hormonal contraception, progesterone and 17-hydroxyprogesterone caproate are now administered to prevent preterm birth in high-risk pregnant women. Preterm birth researchers are similarly working to determine the precise biochemical actions and immunological effects of progesterone. Progesterone research in both areas could benefit from increased collaboration and bringing these two bodies of literature together. Progesterone, through actions on various hormone receptors, has lifelong importance in different organ systems and researchers have much to learn about this molecule from the combination of existing literatures, and from future studies that build on this combined knowledge base.

Depression in women is more common during perimenopause (the transition to menopause) than at other times in the life cycle. Symptoms of depression may be different in perimenopausal women compared to younger or older women, and are often dismissed as part of normal menopause. This is an expert narrative review. There are several evidence-based screening modalities which can be integrated into routine women's health visits, and can facilitate distinguishing between depression and normal perimenopausal symptoms. There is emerging evidence regarding the effect of hormonal changes on the development of perimenopausal depression and its optimal treatment, though critical research gaps remain. Obstetrician-gynecologists and other primary care providers play a vital role in the detection and management of depression in women. Providers caring for women during perimenopause have a unique opportunity to diagnose depression in their patients and identify appropriate treatment options.

IN BRIEF Women with type 2 diabetes are less likely to receive prescriptions for contraceptives despite the fact that diabetes is associated with an increased risk of maternal and fetal complications. In the largest case series to date examining use of the levonorgestrel-releasing intrauterine device (LNG-IUD) in women with type 2 diabetes, we demonstrate that the LNG-IUD is safe and effective and does not affect glycemic control in women with type 2 diabetes. In this study of 115 women under the age of 55 years with type 2 diabetes who had an LNG-IUD placed between 2007 and 2012, we found low rates of pregnancies, expulsions, and other complications in every age category and disease stratification. Thirty-nine patients had A1C data before and up to 2 years after placement, and there was no significant change in A1C (mean A1C decrease of 0.17, 95% CI –0.76 to 0.43). This study will enable evidence-based contraceptive counseling for women with type 2 diabetes.

Permanent methods of contraception are used by an estimated 220 million couples worldwide, and are often selected due to convenience, ease of use and lack of side effects. A variety of tubal occlusion techniques are available for female permanent contraception, and procedures can be performed using a transcervical or transabdominal approach. This article reviews currently available techniques for female permanent contraception and discusses considerations when helping patients choose a contraceptive method and tubal occlusion technique.

The objective was to evaluate whether the use of sevoflurane during general anesthesia for dilation and evacuation (DE) procedures increases the frequency of interventions to treat excess bleeding.A randomized, double-blinded, placebo-controlled trial of a standardized general anesthesia protocol with or without inhaled sevoflurane for DEs between 18 and 24 weeks' gestation was performed. The primary outcome was need for any intervention to treat blood loss. Secondary outcomes included measured blood loss, procedure time, complications, side effects, patient satisfaction and provider ease of procedure.One hundred sixty subjects were randomized. Those in the sevoflurane group were slightly more likely to have interventions for bleeding as compared to those subjects who did not receive sevoflurane (25% versus 16.3%, p=.17) or a measured blood loss above 300 mL (15% versus 7.5%, p=.13); however, these differences could have arisen by chance. Most cases of excess bleeding required only minor interventions, including uterine massage and/or uterotonic agents. Procedure time, complications, side effects, satisfaction and ease of procedure were similar between groups.Addition of sevoflurane to general anesthesia during a DE between 18 and 24 weeks' gestation did not increase the risk of intervention for bleeding; however, this study was underpowered to detect clinically important differences.In this randomized, double-blinded, placebo-controlled trial, sevoflurane did not significantly increase the risk of intervention for bleeding during DEs. However, this agent should be used with caution as an anesthetic for surgical abortions.

More than 1 million abortions are performed annually in the United States. Women presenting for abortion care are often motivated by the pregnancy to use effective contraception; they are also at high risk for repeat unintended pregnancy. For these reasons, abortion represents an optimal time to initiate effective contraception. There is strong evidence that most methods of contraception, including intrauterine devices and the contraceptive implant, should be initiated at the time of the abortion procedure. Most women ovulate within the first month after an abortion. If provision of contraception is delayed, women are less likely to use effective contraception and more likely to have a repeat unintended pregnancy. Although some methods of permanent contraception can be safely performed at the time of abortion, federal and state laws often restrict these procedures being performed concurrently. Contraceptive counseling and provision at the time of abortion are important strategies to decrease rates of unintended pregnancy.

The physiological changes that occur during pregnancy can be deleterious to women with a cardiovascular condition. Evidence-based contraceptive counseling and provision is essential in this patient population. Although long-acting reversible contraception (LARCs), which include the intrauterine device (IUD) and the etonogestrel contraceptive implant, have been found to be safe and effective in healthy women, there are inadequate data regarding LARC use in patients with cardiovascular conditions. We conducted a retrospective chart review of women diagnosed with cardiovascular disease who had a copper IUD, levonorgestrel-releasing intrauterine system or contraceptive implant placed at the University of Washington Medical Center from 2007 to 2012. We abstracted and analyzed patient demographic characteristics, medical conditions, indications for LARC placement, and complications. The sample included 470 women with cardiovascular conditions. The mean age was 34.6 years. One hundred twenty-four patients (26.11%) were nulligravid and 169 patients (35.58%) were nulliparous. Four hundred ten chose the levonorgestrel-releasing intrauterine system (87.23%), 33 patients (7.02%) opted for the copper IUD, and 23 patients (4.89%) chose the etonogestrel implant. Eighteen patients (3.83%) had a confirmed IUD expulsion, 2 patients (0.43%) became pregnant, and there were 4 cases of pelvic inflammatory disease (0.85%). There were no cases of perforation. There were no confirmed cases of infective endocarditis associated with LARC insertion. In conclusion, LARC devices appear safe with few complications for women with cardiovascular conditions. Clinicians can be reassured that LARC may be offered as an appropriate option when counseling women with cardiovascular disease on safe contraceptive methods.

To demonstrate the feasibility of polidocanol foam (PF) as a nonsurgical method of female permanent contraception using a nonhuman primate model.Four groups of adult female rhesus macaques underwent either transcervical treatment with 5% PF directly into the uterine cavity, treatment with inert (methylcellulose, MF) foam or no treatment followed by removal of the reproductive tract for histologic evaluation. Untreated animals were included in Group 1 (n=3). Group 2 animals (n=4) were treated once with MF. Group 3 (n=7) received a single, and Group 4 (n=5) received multiple monthly treatments with PF; in these 2 groups, baseline tubal patency was assessed either laparoscopically by chromopertubation (CP) or by hysterosalpingography.Group 1 (untreated) and Group 2 (MF) animals had normal tubal histology. In contrast, Group 3 and 4 females treated with PF showed evidence of tubal damage. In Group 4, bilateral tubal blockade was noted on CP after two (n=2) or three (n=3) treatments. Histologic analysis confirmed complete tubal occlusion (loss of epithelium, fibrosis) in three of these animals, and one showed significant tubal damage localized to the intramural segment. Nontarget (cervix, vagina, endometrium, ovary) reproductive tissues were unaffected. While similar tubal changes were observed after a single treatment (Group 3), endometrial hemorrhage was also noted as an acute change.PF is a promising candidate agent for nonsurgical permanent female contraception. The histologic features of PF occlusion are confined to the intramural portion of the tube.This study in rhesus macaques supports further development of transcervical administration of PF as a nonsurgical approach to permanent contraception. A nonsurgical method could reduce risks and costs associated with surgical female sterilization and increase access to permanent contraception.

Study Objective The purpose of this case series was to evaluate the efficacy and complication rate with use of long-acting reversible contraceptive (LARC) methods in adolescents with cardiovascular conditions. Design and Participants We performed a retrospective chart review of adolescents age 22 or younger with congenital cardiac anomalies or major cardiovascular conditions who had a LARC device placed at Seattle Children’s Hospital or University of Washington Medical Center between January 1, 2007 and March 1, 2012. Main Outcome Measures Patient characteristics, medical conditions, indications, and complications including perforation, pregnancy, expulsion, and pelvic infection were collected and analyzed. Results Thirty adolescents with congenital cardiac anomalies or other cardiovascular conditions had a LARC device inserted during the study period. Mean age at placement was 17.7 years (range 12-22). Twelve patients (40%) had reported a previous pregnancy and 12 (40%) had never been sexually active at time of placement. Common primary and secondary indications were desired contraception (22 patients, 73%), desired menstrual suppression (15 subjects, 50%) and treatment of heavy menstrual bleeding (8 subjects, 27%). Twenty-nine patients had a structural cardiac anomaly. There were 27 levonorgestrel-releasing intrauterine devices (IUD), 1 copper IUD, and 3 etonogestrel implants placed. There were 2 confirmed IUD expulsions and 1 removal due to persistent irregular bleeding and cramping. There were no cases of pelvic inflammatory disease or pregnancies with LARC methods in place. Twenty-seven (90%) patients were continuing LARC at last follow-up. Conclusions In this small case series of adolescents with cardiovascular conditions, LARC devices were effective at pregnancy prevention without serious complications.

Estradiol valerate and dienogest have been combined to create a novel four-phasic oral contraceptive pill effective for both pregnancy prevention and treatment of heavy menstrual bleeding. This formulation represents the only oral contraceptive pill available in the USA containing an estrogen component that is biologically active as the endogenous estrogen 17β-estradiol. This medication was developed out of efforts to replace the most common estrogen in contraceptive pills, ethinyl estradiol, which is known to be a potent inducer of hepatic protein synthesis. Estradiol valerate has been available since the 1970s in oral and injectable forms indicated for the treatment of menopausal climacteric symptoms. Dienogest has been used in other oral contraceptive pills for over 10 years. Previous attempts to develop an oral contraceptive pill with natural estradiol or estradiol valerate were unsuccessful due to poor cycle control. A novel dynamic-dosing regimen was devised to improve the bleeding pattern. This medication has been shown in several clinical trials to have good contraceptive efficacy and cycle control. Recent studies have also demonstrated that this medication is effective for the treatment of heavy menstrual bleeding. However, compared with other oral contraceptive pills, this medication is associated with a higher frequency of absent withdrawal bleeding. Furthermore, the dynamic dosing regimen requires relatively complex instructions for users who miss pills.

Combined hormonal contraceptives (CHCs) have traditionally been prescribed in 28-day cycles, with 21 days of active hormones followed by a 7-day hormone-free interval. Extended and continuous CHC regimens, defined as regimens with greater than 28 days of active hormones, offer many benefits, including a decrease in estrogen-withdrawal symptoms and likely greater efficacy because of more reliable ovulation suppression. Bleeding profiles are favorable, and unscheduled bleeding decreases over time with these regimens. Extended and continuous regimens of combined oral contraceptives and the contraceptive vaginal ring are safe and have high user acceptability and satisfaction. However, despite numerous benefits, extended and continuous CHC regimens are underused.

Contraception for women with medical conditions is of upmost importance due to the potential impact of pregnancy on their disease state or of their disease on the pregnancy state. Appropriate contraceptive assessment, counseling, and management for these women are critical aspects of their medical care. Clinicians seeking guidance on contraceptive care may turn to the US Medical Eligibility Criteria (MEC), which are evidence-based guidelines created by the Centers for Disease Control and Prevention (CDC). In the MEC, contraceptive methods are classified using four categories based on the safety of the method when used by women with certain characteristics or medical conditions. The CDC Selected Practice Recommendations can provide guidance on how to initiate contraceptive methods and how to manage common issues that arise. Clinicians should be aware that assessing a woman for eligibility for a specific contraceptive can be done primarily by taking a detailed medical history, and that contraceptive counseling should be performed in a standardized fashion, emphasizing the most effective methods that allow a woman to meet her reproductive goals and are medically appropriate.

As minor gynecologic procedures move from the operating room to the office, providers need to ensure that patients are comfortable and that procedures are performed safely. Although local anesthesia is commonly used for gynecologic procedures, a multimodal approach may be more effective. If necessary, sedation can be safely provided in an office setting with the correct tools and training. This article reviews evidence-based approaches to pain management for gynecologic procedures in the ambulatory setting.

Although previous studies have demonstrated that a variety of local anesthetics are effective to decrease pain associated with tenaculum placement, no studies directly compare an injection with a topical anesthetic. The objective of this study was therefore to compare mean pain scores with tenaculum placement after an intracervical lidocaine injection or topical lidocaine gel.A randomized, single-blinded trial of women presenting for office gynecologic procedures that required a tenaculum. Women aged 18 years or older were randomized to receive either a 1% lidocaine intracervical injection or topical application of 2% lidocaine gel to the cervix immediately prior to tenaculum placement. The primary outcome was pain at the time of tenaculum placement, measured on a 100 mm Visual Analog Scale. Secondary outcomes included pain with the intervention and satisfaction with tenaculum placement.Seventy-four women were enrolled and randomized; 35 subjects in each group met criteria for analysis. The two groups had similar socio-demographic characteristics. Women who received the injection had lower mean pain levels at tenaculum placement [12.3 mm (S.D. 17.4 mm) versus 36.6 mm (S.D. 23.0 mm), p.001] but higher mean pain levels with study drug application [20.4 mm (S.D. 19.4 mm) versus 5.9 mm (S.D. 8.6 mm), p.001]. Satisfaction with tenaculum placement was similar for the two groups.Mean pain with tenaculum placement is lower after receiving a lidocaine injection than after receiving a topical lidocaine gel. Satisfaction with tenaculum placement is similar with both interventions.

INTRODUCTION:More than one-third of women in the U.S. have engaged in heterosexual anal intercourse (HAI). The risk of acquiring HIV per sexual act is estimated to be 18 times higher for receptive anal intercourse than receptive vaginal intercourse; HAI is also associated with lower rates of condom

Objective Although hydrocodone-acetaminophen is commonly used for pain control in first-trimester abortion, the efficacy of oral opioids for decreasing pain has not been established. Our objective was to estimate the effect of hydrocodone-acetaminophen on patient pain perception during first-trimester surgical abortion. Methods We conducted a randomized, double-blinded, placebo-controlled trial. Patients (before 11 weeks of gestation) received standard premedication (ibuprofen and lorazepam) and a paracervical block with the addition of 10 mg hydrocodone and 650 mg acetaminophen or placebo 45-90 minutes before surgical abortion. A sample size of 120 was calculated to provide 80% power to show a 15-mm difference (α=0.05) in the primary outcome of pain with uterine aspiration (100-mm visual analog scale). Secondary outcomes were pain at additional time points, satisfaction, side effects, adverse events, and need for additional pain medications. Results There were no significant differences in demographics or baseline pain between groups. There were no differences in pain scores between patients receiving hydrocodone-acetaminophen compared with placebo during uterine aspiration (65.7 mm compared with 63.2 mm, P=.59) or other procedural time points. There were no differences in satisfaction or need for additional pain medications. Patients who received hydrocodone-acetaminophen had more postoperative nausea than those receiving placebo (P=.03) when controlling for baseline nausea. No medication-related adverse events were noted. Conclusion Hydrocodone-acetaminophen does not decrease pain during first-trimester abortion and may increase postoperative nausea. Clinical trial registration Clinicaltrials.gov, www.clinicaltrials.gov, NCT01330459. Level of evidence I.

Although pregnancy is expected during studies of novel contraceptives in non-human primates, gestation, delivery, and lactation remove females from groups for prolonged intervals. As the macaque cervix does not facilitate transcervical surgical termination of pregnancy, we sought to establish a medical termination protocol.A descriptive case series of outcomes of medical termination of pregnancy up to 32 days gestation in cynomolgus monkeys. Efficacy and time to uterine resolution were determined according to medication, dose, and route of administration.Thirty-seven macaques underwent 65 medical terminations. Over 80% of animals terminated after initial treatment with mifepristone 20 mg intramuscularly (IM). Intrafetal methotrexate was effective for salvage treatment. Medical termination regimens were less effective for animals receiving investigational contraceptive agents.Medical termination for macaques is safe and effective. We recommend a protocol with mifepristone 20 mg IM and misoprostol 200 µg buccally as initial treatment.