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Background: In March 2020, all levels of government introduced various strategies to reduce the impact of the COVID-19 pandemic. The purpose of this study was to document how the experience of providing medical assistance in dying (MAiD) changed during the COVID-19 pandemic. Methods: We conducted a qualitative study using semistructured interviews with key informants in Canada who provided or coordinated MAiD before and during the COVID-19 pandemic. We interviewed participants from April to June 2020 by telephone or email. We collected and analyzed data in an iterative manner and reached theme saturation. Our team reached consensus on the major themes and subthemes. Results: We interviewed 1 MAiD coordinator and 15 providers, including 14 physicians and 1 nurse practitioner. We identified 4 main themes. The most important theme was the perception that the pandemic increased the suffering of patients receiving MAiD by isolating them from loved ones and reducing available services. Providers were distressed by the difficulty of establishing rapport and closeness at the end of life, given the requirements for physical distancing and personal protective equipment. They were concerned about the spread of SARS-CoV-2, and found it difficult to enforce rules about distancing and the number of people present. Logistics and access to MAiD became more difficult because of the new restrictions, but there were many adaptations to solve these problems. Interpretation: Providers and coordinators had many challenges in providing MAiD during the COVID-19 pandemic, including their perception that the suffering of their patients increased. Some changes in how MAiD is provided that have occurred during the pandemic, including more telemedicine assessments and virtual witnessing, are likely to remain after the pandemic and may improve service. more...

Background Under the Canadian Criminal Code, medical assistance in dying (MAiD) requires that patients give informed consent and that their ability to consent is assessed by 2 clinicians. In this study, we intended to understand how Canadian clinicians assessed capacity in people requesting MAiD. Methods This qualitative study used interviews conducted between August 2019 and February 2020, by phone, video and email, to explore how clinicians assessed capacity in people requesting MAiD, what challenges they had encountered and what tools they used. The participants were recruited from provider mailing listserves of the Canadian Association of MAiD Assessors and Providers and Aide medicale a mourir. Interviews were audio-recorded and transcribed verbatim. The research team met to review transcripts and explore themes as they emerged in an iterative manner. We used abductive reasoning for thematic analysis and coding, and continued to discuss until we reached consensus. Results The 20 participants worked in 5 of 10 provinces across Canada, represented different specialties and had experience assessing a total of 2410 patients requesting MAiD. The main theme was that, for most assessments, the participants used the conversation about how the patient had come to choose MAiD to get the information they needed. When the participants used formal capacity assessment tools, this was mostly for meticulous documentation, and they rarely asked for psychiatric consults. The participants described how they approached assessing cases of nonverbal patients and other challenging cases, using techniques such as ensuring a quiet environment and adequate hearing aids, and using questions requiring only "yes" or "no" as an answer. Interpretation The participants were comfortable doing MAiD assessments and used their clinical judgment and experience to assess capacity in ways similar to other clinical practices. The findings of this study suggest that experienced MAiD assessors do not routinely require formal capacity assessments or tools to assess capacity in patients requesting MAiD. more...

There is little evidence describing the technical aspects of medical assistance in dying (MAiD) in Canada, such as medications, dosages and complications. Our objective was to describe clinical practice in providing MAiD in Ontario and Vancouver, Canada, and explore relations between medications used, time until death and complications.We conducted a retrospective cohort study of a sample of adult (age ≥ 18 yr) patients who received MAiD in Ontario between 2016 and 2018, and patients who received MAiD in 1 of 3 Canadian academic hospitals (in Hamilton and Ottawa, Ontario, and Vancouver, British Colombia) between 2019 and 2020. We used de-identified data for 2016-2018 from the Office of the Chief Coroner for Ontario MAiD Database and chart review data for 2019-2020 from the 3 centres. We used multivariable parametric survival analysis to identify relations between medications, dosages and time from procedure start until death.The sample included 3557 patients (1786 men [50.2%] and 1770 women [49.8%] with a mean age of 74 [standard deviation 13] yr). The majority of patients (2519 [70.8%]) had a diagnosis of cancer. The medications most often used were propofol (3504 cases [98.5%]), midazolam (3251 [91.4%]) and rocuronium (3228 [90.8%]). The median time from the first injection until death was 9 (interquartile range 6) minutes. Standard-dose lidocaine (40-60 mg) and high-dose propofol (1000 mg) were associated with prolonged time until death (prolonged by a median of 1 min and 3 min, respectively). Complications occurred in 41 cases (1.2%), mostly related to venous access or need for administration of a second medication.In a large sample of patients who died with medical assistance, certain medications were associated with small differences in time from injection to death, and complications were rare. More research is needed to identify the medication protocols that predict outcomes consistent with patient and family expectations for a medically assisted death. more...

Background: Low back pain (LBP) is common, costly, and disabling. This study assesses a novel and simple LBP evaluation method and its merit in guiding the direction of a self-treatment exercise. Methods: Randomized open-label intention is used to treat the study. Consecutive patients with LBP ≥ three months and pain ≥ 5/10 were evaluated in a Vancouver clinic with the sacroiliac forward flexion test (SIFFT) by comparing the height of posterior superior iliac spines using a level. Those with asymmetry ≥ 5 mm were offered participation. The assistant, who generated and encrypted the randomization, assigned participants: group 1 learned a two-minute, SIFFT-derived, sacroiliac-leveling exercise (SIFFT-E) as needed for LBP relief; group 2 used a pelvic stabilization belt as needed to prevent LBP, and group 3 continued the usual care. After one month, all participants used SIFFT-E and belt as needed for one month. The identifier number of this article in Clinicaltrials.gov is #NCT03888235. The trial is closed. Our primary outcome measure was the Oswestry disability index (ODI) (decrease) from baseline to one and two months. We also followed SIFFT improvement (decrease). Findings: Of 72 LBP patients, 62 (86%) had ≥ 5 mm asymmetry. From zero to one month, the 21 (one dropout) SIFFT-E participants outperformed the 20 usual care participants for ODI improvement (12.5 ± 14.8 vs. -3.4 ± 14.9 points; mean difference 15.9 [CI 6.7-25.0]; P = 0.002 with number needed to treat (NNT) of 3.0 for ODI improvement ≥ 11). Belt use results were intermediate. At two months, after all the 62 participants used the exercise and belt as needed, combined ODI improvements were clinically significant (12.0 ± 18.4 points), and SIFFT asymmetry was reduced by 8.6 ± 8.6 mm. Five (8%) exercise and 12 (19%) belt wearers experienced mild side effects. Interpretation: Sacroiliac asymmetry appears to be frequent. SIFFT may be clinically useful as an evaluation tool for prescribing a simple self-directed corrective exercise as seen by clinically significant improvements in function and asymmetry. more...

Many jurisdictions with legal forms of assisted dying require that written requests be witnessed by independent witnesses. In Canada, a unique program of volunteers was founded to make such witnesses available. A total of 106 volunteers completed a questionnaire about their experiences, challenges, and perspectives; 24 were also interviewed. Although the witnesses felt well prepared for their roles, they encountered challenges including role uncertainty, communication difficulties, and the emotional impacts of being with suffering patients and their grieving families. Most felt that the requirement for independent witnesses is an intrusive and unnecessary barrier to accessing medical assistance in dying. more...

BACKGROUND: To facilitate access to medical assistance in dying (MAiD) in British Columbia, telemedicine has been used for eligibility assessments. This research explored the impacts of using telemedicine on quality of care. METHODS: This mixed-methods study consisted of data from 3 BC health authorities and semistructured interviews with a patient, support persons, providers and administrators about the use of telemedicine for MAiD eligibility assessment. Interviews were conducted by telephone, video meeting or email between June and November 2018. We analyzed the quantitative data using descriptive statistics. We categorized the qualitative data using the 7 dimensions of the BC Health Quality Matrix and then analyzed them qualitatively with abductive coding. RESULTS: Twenty-one participants (8 MAiD assessors, 1 patient, 7 support persons of patients and 5 MAiD administrators) were interviewed. Telemedicine for MAiD eligibility assessments was highly acceptable to the support persons and patient and to most assessors and administrators. Assessors expressed challenges with empathy, eye contact, nonverbal communication and missing contextual factors. Participants described which patients were appropriate and which were not. Telemedicine improved access and equity for the patients who received this service. It was perceived as an effective and efficient way to perform eligibility assessments. Concerns were expressed by assessors and administrators, but not by the patient or support persons, about confidentiality. Opinions varied on the requirement for a regulated health care professional to be in physical attendance with the patient to act as a witness. INTERPRETATION: Quality of care can be achieved with telemedicine for MAiD eligibility assessments for specific situations and patients, and this modality has the potential to expand access to MAiD. Updated clinical and administrative policies are needed to address barriers to telemedicine access and to best support patients and assessors using this technology. more...

Introduction Cannabis is reported to enhance sexual function; yet, previous studies have shown that physiological and subjective indices of sexual arousal and motivation were associated with decreased availability of circulating endocannabinoid concentrations. Aim To explain this contradiction, we evaluated which aspects of sexual experience were enhanced or diminished by cannabis use. Methods We used an online questionnaire with a convenience sample of people who had experience with cannabis. We asked questions regarding various aspects of sexual experience and whether they are affected by cannabis. We also asked about sexual dysfunction. Main Outcome Measure Aspects of participant sexual experience enhanced by cannabis. Results We analyzed results from 216 questionnaires completed by people with experience using cannabis with sex. Of these, 112 (52.3%) said they used cannabis to alter their sexual experience. Eighty-two participants (38.7%) said sex was better, 34 (16.0%) said it was better in some ways and worse in others, 52 (24.5%) said it was sometimes better, and only 10 (4.7%) said it was worse. Of 202 participants, 119 (58.9%) said cannabis increased their desire for sex, 149 of the 202 participants (73.8%) reported increased sexual satisfaction, 144 of 199 participants (74.3%) reported an increased sensitivity to touch, and 132 of 201 participants (65.7%) reported an increased intensity of orgasms. Out of 199 participants, 139 (69.8%) said they could relax more during sex, and 100 of 198 participants (50.5%) said they were better able to focus. Of the 28 participants who reported difficulty reaching orgasm, 14 said it was easier to reach orgasm while using cannabis, but only 10 said that sex was better. Clinical Implications The information in this study helps clarify which aspects of sexual function can be improved or interfered with by cannabis use. Strengths & Limitations We asked about specific sexual effects of cannabis and were therefore able to understand the paradox of how cannabis can both improve and detract from sexual experience. Limitations of this study include bias that may have been introduced because the sample included only people who responded to the advertisements; it may not represent the general population of people who use cannabis. Moreover, over one-third of our sample said they use cannabis daily and so represent heavier than average users. Conclusion Many participants in our study found that cannabis helped them relax, heightened their sensitivity to touch, and increased intensity of feelings, thus enhancing their sexual experience, while others found that cannabis interfered by making them sleepy and less focused or had no effect on their sexual experience. more...

This is a secondary analysis of three qualitative studies about MAiD in which researchers asked about the differences between suicide and MAiD. In all, researchers interviewed 52 Canadians; 7 were people who had requested MAiD and had been found ineligible, 6 were MAiD providers and 39 were socially and economically marginalized. The overwhelming response was that MAiD is better than suicide in the context of suffering at the end of life. Whereas these people perceived suicide as uncertain, difficult, and something that was usually done alone and without support, they thought MAiD was certain, painless, and more socially acceptable. more...

The purpose of this study was to describe the experience of people who transferred locations for MAiD. It used mixed methods with a chart review from one health authority and interviews with key informants across Canada. In the chart review, we found that of 444 MAiD deaths, 42 (9.5%) were forced to transfer due to the religious affiliation of the facility and 33 (7.4%) chose to transfer. In 23 interviews with 18 key informants we found that the most important theme was the suffering caused by forced transfers. COVID-19 restrictions led to fewer choices and more suffering. more...

Background: Low back pain (LBP) is common, costly, and disabling. This study assesses a novel and simple LBP evaluation method and its merit in guiding the direction of a self-treatment exercise. Methods: Randomized open label intention to treat study. Consecutive patients with LBP ≥ 3 months and pain ≥ 5/10 were evaluated in a Vancouver clinic with the sacroiliac forward flexion test (SIFFT), which compares the height of posterior superior iliac spines using a level. Those with asymmetry ≥ 5 mm were offered participation. The assistant, who generated and encrypted the randomization, assigned participants: group 1 learned a two-minute, SIFFT-derived, sacroiliac-leveling exercise (SIFFT-E) as needed for LBP relief, group 2 used a pelvic stabilization belt as needed to prevent LBP and group 3 continued usual care. After one month all participants used SIFFT-E and belt as needed for one month. Clinicaltrials.gov # NCT03888235. Trial closed. The Oswestry Disability Index (ODI) (decrease) from baseline to 1 and 2 months was our primary outcome measure. SIFFT improvement (decrease) was also followed. Findings: Of 72 LBP patients, 62 (86%) had ≥5mm asymmetry. Non-exercise control subgroups performed similar statistically. From 0-1 month the 21(one dropout) SIFFT-E participants outperformed the combined 41(one dropout) controls for ODI improvement (12·5±14·8 vs.0·5±14·9 points; mean difference12 points [CI 4·0-20·0]; p=·004 with NNT of 3·2 for improvement of 11 and for SIFFT improvement (7·3±9mm vs.2·1±9mm; mean difference 5·25mm [CI 2·3-10·2mm]; p=·041). At 2 months, after all 62 participants used exercise and belt as needed, ODI and SI asymmetry improvements were clinically significant (12·0±18·4 points (p more...

Introduction Our objective was to compare outcomes of medication abortions using telemedicine or clinic visits. Other studies have found telemedicine abortions to be safe and effective, but no one has reported a comparison of direct-to-patient abortions and we also wanted to compare the un-scheduled communication with the two groups. Method This was a case-controlled chart review study comparing all the telemedicine medication abortions in one clinic to a control group matched for date seen. Basic demographics, outcomes and unscheduled visits or communications with staff and physicians were recorded. Results During the two years, we saw 4340 people requesting abortion, of whom 182 were seen only by telemedicine. We reviewed all their charts and a group of 199 in-clinic patients, matched for date seen. The ages and gestational ages were similar, but the telemedicine group lived much farther from the clinic (mean 5.5 h vs. 0.7 h, p Conclusions Providing medical abortions by telemedicine is safe, effective and feasible. Unscheduled communication with physicians was similar but unscheduled communication with clinic staff was more frequent. more...

Drawing on interviews we conducted with 15 medical assistance in dying (MAiD) providers from across Canada, we examine how physicians and nurse practitioners reconcile respect for the new, changing rules brought upon by the coronavirus disease 2019 (COVID-19) pandemic, along with their existing legal obligations and ethical commitments as health care professionals and MAiD providers. Our respondents reported situations where they did not follow or did not insist on others following the applicable public health rules. We identify a variety of techniques that they deployed either to minimize, rationalize, justify or excuse deviations from the relevant public health rules. They implicitly invoked the exceptionality and emotionality of the MAiD context, especially in the time of COVID, when offering their accounts and explanations. What respondents relate about their experiences providing MAiD during the COVID pandemic offers occasion to reflect on the role actors themselves play in giving meaning (if not coherence) to the potentially conflicting normative expectations to which they are subject. more...

In this paper we document some of the practical aspects of implementing medical assistance in dying (MAiD) since it became legal in Canada in 2016. The percentage of annual deaths in Canada due to MAiD varies widely, ranging from less than 0.5% in some areas to over 5% in others. By the end of 2019, approximately 13,000 people had an assisted death in Canada (1.6% of all deaths). The average age is 73 years and the majority have cancer (64%), followed by end-stage organ failure (17%), and neurological disease (11%). The safeguards in Canadian law include having two witnesses sign the patient request form, having two independent clinicians agree that the patient is eligible, and requiring a 10-day waiting period after the request is made. Although the criminal law is federal and applies throughout the nation, health services managed provincially, and there are many different models of care being used. Some provinces have standardized prescriptions and procedures for assisted dying with centralized care coordinators supporting both patients and providers. Other provinces expect individual providers to manage all aspects of assisted dying. The procedure and medications are provided free of charge to patients, but it took years before many providers were remunerated for their services. Access for patients has been a problem because there are too few providers of care (especially in rural areas), and many people have difficulty getting accurate information about the process. Many faith-based health care facilities continue to refuse to allow assisted dying within their facilities, so patients requesting MAiD need to be transferred to other locations in their last hours of life. Solutions to these problems have included the development of more training and support for providers and the creation of coordinating centres that provide information and support for patients throughout the process. Telemedicine is used for assessment of eligibility when required, especially during the COVID pandemic. There are similarities in problems of access to all end of life care options, including palliative care and residential hospices. The relationships between providers of assisted dying and specialists in palliative care vary, and examples exist throughout the spectrum from collegial to hostile. This is slowly improving, as individual clinicians gain more experience with patients choosing assisted dying. Public culture is changing as there are more conversations occurring about death and dying. more...

Since medical assistance in dying (MAiD) became legal in Canada in 2016, there have been concerns about vulnerable people feeling pressured to end their lives. It is important to understand what people in marginalized communities know and feel about MAiD in order to help prevent any pressure to hasten death and to prevent any barriers to accessing assisted death. This qualitative study explored the perceptions and experiences of MAiD and other end-of-life care options with 46 people who were illicit substance users, living in poverty, or who worked with marginalized people in these communities. Six broad themes were identified: the importance of family, friends, and community; the effects of the opioid crisis; barriers to accessing end-of-life care services; support for MAiD; the difference between suicide and MAiD; and what constitutes a good death. Findings from this research may be used to help inform future legislation, professional guidelines, and standards of best practice. more...

Objective: The objective was to compare the practical aspects of providing medication abortions through telemedicine and in-person clinic visits so that clinics can use this information when planning to add this service. Study design: We conducted a comparative retrospective chart review comparing telemedicine medication abortions to a control group matched for date seen. We extracted and compared demographics, use of dating ultrasound, outcomes and unscheduled visits or communications with staff and physicians. Results: During the study period, we provided 4340 medication abortions, of which 182 (4.2%) were provided through by telemedicine; 199 patients met the criteria to be in the control group. The mean age was 28.7 years for telemedicine patients and 28.1 years for in-person patients (p = .38). The mean gestational ages were also similar, 48.2 days for telemedicine patients and 46.5 days for in-person patients (p = .03). Only 33 (18.1%) of telemedicine patients had dating ultrasounds compared to 199 (100%) of in-clinic patients (p 0.5). Unscheduled communications with office assistants were greater in the telemedicine patients than the in-person patients (84/182, 46.2% vs. 43/199, 21.6% in-person, p more...

This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.Women with an unintended first trimester pregnancy.Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion careIntroduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care. more...

Context Since Canada decriminalized medical assistance in dying (MAID) in 2015, clinicians and organizations have developed policies and protocols to implement assisted dying in clinical practice. Five years on, there is little consensus as to what constitutes high-quality care in MAID. Objectives To describe MAID clinicians' perspectives on quality of care in MAID, including challenges, successes, and clinical practice suggestions. Methods We conducted an exploratory, multicenter, and qualitative study at four Canadian centers. Using a semistructured interview guide, we conducted interviews with 20 health care providers. Interviews were transcribed and deidentified before analysis. Adopting a qualitative descriptive approach, we used a thematic analysis to identify primary and secondary themes in the interviews and practice suggestions to improve quality of care to patients who request MAID. Results We identified three major themes. 1) Improving access and patient experience: clinicians described struggles in ensuring equitable access to MAID and supporting MAID patients and their families. 2) Supporting providers and sustainability: clinicians described managing MAID workload, remuneration, educational needs, and the emotional impact of participating in assisted dying. 3) Institutional support: descriptions of MAID communication tools and training, use of standardized care pathways, interprofessional collaboration, and human resource planning. Clinicians also described suggestions for clinical practice to improve quality of care. Conclusion Canadian health care providers described unique challenges in caring for patients who request MAID, along with practices to improve the quality of care. more...

To explore the experiences, wishes, fears, and beliefs of people who requested and were eligible for medical assistance in dying (MAID) in Canada in the first year after legalization.Qualitative study using semistructured interviews.A clinic in Vancouver, BC, that provides MAID.People requesting and eligible for MAID between February 6 and December 17, 2016. Family and friends who were identified as the patients' primary support people were also interviewed.Semistructured interviews were conducted over the telephone, by e-mail, or in person. The interviews were audiorecorded and transcribed and then analyzed using thematic qualitative analysis. The investigators read the transcripts and created a coding scheme to identify themes in the patients' experiences. The identified themes were compiled and evaluated in the context of what is already known based on current literature. Basic demographic characteristics were recorded for context.Of the 23 patients whose experiences were explored, most had a malignancy, a neurologic disorder, or organ failure. A main theme was that patients thought it was important to have autonomy and control over their own end-of-life decisions. Main reasons for requesting MAID were a self-perceived unacceptable quality of life, most commonly owing to loss of independence, mobility, ability to communicate, a sense of purpose, and participation in meaningful activity. Some people expressed fear of future suffering and future disability. Pain was seldom mentioned as a cause of suffering. Some participants believed they could discuss their decision with the people in their lives while others chose to keep it a private matter. Most people were not religious.The participants' reasons for choosing to pursue MAID were consistent with those of people in other jurisdictions that have been studied. They felt confident in their decision to pursue MAID and did not have fears about the process. more...

Background Some licensing authorities require fasting before abortions under intravenous sedation to avoid aspiration of gastric contents. This study was conducted to estimate the incidence of anesthesia-related complications in women undergoing abortions without preprocedure fasting. Study Design This is a retrospective cohort chart review of patients having abortions with both fentanyl and midazolam at two urban free-standing abortion clinics with routine policy of advising women to eat a light meal before the procedure. Results There were no reports of anesthesia-related complications in the 47,748 charts reviewed from 1998 to 2010. Applying Hanley's formula for rare events that have not occurred, the upper 95% confidence interval for the true incidence of anesthesia-related complications for women having abortion under low-dose procedural sedation without fasting was estimated to be 0.00006%. Conclusions This large retrospective cohort chart review identified no complications related to low-dose procedural sedation in over 47,000 consecutive nonfasting patients having abortions through 18 weeks' gestation. Eliminating the requirement to fast would decrease unnecessary stress and unpleasant symptoms without increase in the anesthesia-related complications for women having abortions. more...

Objective: The objective of this study was to compare Rh alloimmunization rates in two countries (Canada and the Netherlands) with completely different policies regarding abortion-related use of anti-D immunoglobulin to ultimately determine any benefit in use. In the Netherlands, the policy is to offer anti-D immunoglobulin to Rh-negative women having spontaneous abortions over 10 weeks 0 days gestation and induced abortions over 7 weeks 0 days. In Canada, it is recommended to offer all Rh-negative women having induced or spontaneous abortions anti-D immunoglobulin. Methods: We used public databases to obtain the population data, the number of births, the abortion rates (the percentage of women having induced abortions in one year) and the Rh-negativity rates (percentage of Rh negative women) in Canada and the Netherlands. Both countries do routine prenatal blood screening and we obtained the rates of clinically significant antibodies from public databases. Results: In nearly 2 million blood samples from pregnant women in both Canada and the Netherlands, the prevalence of clinically significant antibodies was statistically lower in the Netherlands: 4.21 (95% CI: 4.12 to 4.30) and 4.03 (95% CI: 3.93 to 4.12) per 1000, respectively. Canada and the Netherlands had small differences in rates of abortion (1.9 per 100 vs 1.2 per 100) and of Rh negativity (13.0% vs 14.5%). Conclusion: Despite different anti-D Ig treatment policies, we found a similar prevalence of clinically significant perinatal antibodies among women in Canada and the Netherlands. Implications: Our findings suggest that The Dutch policy of not treating Rh-negative women having spontaneous abortions under 10 weeks’ or induced abortions under 7 weeks’ gestation can be safely adopted by other countries. Keywords: Abortion, induced, Pregnancy trimester, first, Rho(D) immune globulin, Rh isoimmunization, Erythroblastosis, fetal more...

Objectives Use of an intrauterine contraceptive device (IUD) has not been recommended to nulliparous women in the past. There is now good evidence that there is no increased risk of pelvic inflammatory disease or infertility in nulliparas who use IUDs and the recommendations have changed. Our objective was to understand more about the motivations and experience of nulliparous women using IUDs. Methods This was a mixed method study. First, we asked 44 nulliparous women who had had an IUD inserted within the previous six months about their reasons for seeking the IUD, their history with other forms of contraception, their perception of the insertion experience, and their feelings after insertion. Questionnaires were then distributed to 154 nulliparous women presenting for IUDs, asking about their past experience with hormonal contraception. Results The main theme arising from the interviews was a desire to avoid hormonal contraception. Other reasons for choosing the IUD were greater contraceptive effectiveness than other methods, convenience of use, and lower cost. Responses to the questionnaire indicated that 138 women (89.7%) had used hormonal contraception in the past and, of those, 98 (63.0%) complained of mood side effects, 64 (41.6%) of sexual side effects, and 64 (41.6%) of physical side effects. Conclusion The most important motivation for nulliparous women in this study to choose IUDs was to avoid the potential or actual side effects of hormonal contraception. Despite experiencing some discomfort at the time of insertion, this group of nulliparous women was very positive about using IUDs for contraception. more...

The objective of this study was to estimate the menstrual cycle day of conception in women presenting for abortion.This was a retrospective chart survey in two urban free-standing abortion clinics.There were 913 charts reviewed of women presenting for an abortion at less than 63 days' gestation as determined by endovaginal ultrasound who were "sure" of the date of their last normal menstrual period. The estimated mean cycle day of conception determined by sonographically estimating length of gestation was 14.6. There were 26 (26.3%) of 99 women using cyclic hormonal contraception who conceived before 10 days after the onset of withdrawal bleeding compared to 100 (14.7%) of 679 who conceived before 10 days after the onset of their last menstrual period who were using all other forms of contraception, including "none" (p=.005). No other differences in the proportions conceiving early in the cycle were observed with respect to age, ethnicity or obesity.These data suggest that there is a sizeable subset of women who ovulate earlier after onset of withdrawal bleeding when using 21/7 hormonal contraceptives than after onset of menses when not using hormonal contraception. It is possible that women using hormonal contraceptives may have a higher risk of pregnancy if they ovulate sooner after the onset of bleeding. more...

Background The prevalence of self-identified chronic pain in Canadian adults is approximately one in five people. Marginalization and addictions have been shown to complicate chronic pain in vulnerable populations. This study aimed to understand the experience of chronic pain among female Survival Sex Workers in Vancouver's downtown eastside (DTES). Methods This study used an exploratory qualitative analysis with in-depth, semi-structured interviews. Members of PACE Society who self-identified as a current or former Survival Sex Worker and who had a chronic pain experience known to PACE support workers were invited to participate. Interviews were conducted, audio recorded and transcribed. The investigators met to read the transcripts and discuss emerging themes. The process continued until no new themes were observed. Results Participants ranged in age from 42 to 56 years old and all self- identified as females and Survival Sex Workers. Eleven of thirteen interviews were analyzed for themes. Drug use for pain management, both prescribed and illicit, was the most important theme. Poverty, the need to continue working and the lack of stable housing were barriers to adequately addressing the source of chronic pain. Participants felt judged for living in the downtown eastside, being a drug user and/or being Aboriginal and only two participants had been referred to a pain specialist. All participants were involved in support networks made up of other Sex Workers and all spoke of a sense of community and survival. Conclusions Our study emphasizes the complex nature of chronic pain and addictions among a uniquely marginalized population. The study is unique in that it contributes the perspectives of a traditionally “hard-to-reach” population and demonstrates that Sex Workers should not only participate in but should lead development and implementation of research and programs for managing chronic pain in the setting of addiction. more...

Objective To characterize method-related discontinuation rates and acceptability over 1 year of SCu380A use. Study design Women enrolled into this prospective pilot study underwent SCu380A placement by a single clinician with follow-up at 6–8 weeks and at 3, 6, 9 and 12 months. Outcome measures included reasons for discontinuation and satisfaction. Results Fifty-one women had a 12-mm-diameter intrauterine ball (IUB; SCu380A) inserted by a single clinician (EW). Postinsertion ultrasonography showed all the devices to be correctly placed. By 8 weeks, there were 9 expulsions and 2 removals for symptoms. By 12 months, there were 14 expulsions (27%), 8 removals for symptoms (16%), 1 pregnancy and 7 lost to follow-up. Of the remaining 21 women, 15 said that they were satisfied. Conclusion The high rate of expulsions and removals for symptoms in the first year indicates that this device, as presently designed, is unacceptable as an alternative to the currently available copper intrauterine devices. Implications More research is needed before we know if it is the spherical design, the size of the device or some other factor that led to the high expulsion rate. There are currently three different IUBs (12, 15 and 18 mm) approved and being investigated. more...

The requirement that every woman desiring medical abortion must come in person to a clinical facility to obtain the drugs is a substantial barrier for many women. To eliminate this requirement in the United States, two key components of the standard initial visit would need to be restructured. First, alternatives to ultrasound and pelvic exam would need to be identified for ensuring that gestational age is within the limit for safe and effective treatment. This is probably feasible: for example, data from a large study suggest that in selected patients menstrual history is highly sensitive for this purpose. Second, the Food and Drug Administration would need to remove the medically unwarranted restriction on distribution of mifepristone. These two changes could allow provision of the service by a broader range of providers in nontraditional venues or even by telemedicine. Such options could have profound benefits in reducing cost and expanding access to abortion. more...

Objective To compare the efficacy, adverse effects and acceptability of the three most common misoprostol regimens used with mifepristone for medical abortion. Design Randomised nonblinded trial. Setting Three clinics associated with major research universities in Canada; two in major urban areas and one in a periurban area. Population Women of reproductive age. Methods Consenting women presenting for abortion services with gestations less than 56 days and who met inclusion criteria were given 200 mg mifepristone orally and then randomised into three misoprostol study groups: (group I) 400 micrograms of oral misoprostol, (group II) 600 micrograms of oral misoprostol, and (group III) 800 micrograms of vaginal misoprostol. Misoprostol was self-administered at home 24–48 hours following mifepristone, and participants were instructed to take a second similar misoprostol dose at 24 hours after the initial dose if bleeding was less than a normal menstrual period. Main outcome measures Successful abortion without surgery was 94.1%, with no significant differences across the three study groups (94.7% in group I, 93.4% in group II, and 94.3% in group III; P= 0.975). Results Efficacy and adverse effects did not differ significantly across the three study groups. Pain increased significantly across the study and the gestational age groups and was associated with lower acceptability. Conclusions There appears to be a range of safe and effective options for early medical abortion with mifepristone including a choice between oral and vaginal administration of misoprostol. more...

Objective The primary objective of this study was to determine if buccal misoprostol was as effective as vaginal misoprostol in medical abortions. The secondary objectives were to compare side effects and acceptability. Methods This was a randomized controlled trial of 600 μg misoprostol by the buccal or vaginal routes used 3 to 6 days after 50 mg/m2 methotrexate. The participants were women presenting for abortion at 49 days or less gestation. The outcome measures were the number of women who had aborted by Day 8, side effects and acceptability. Results Day 8 completion rate was 53.5% for the buccal route and 67.5% for the vaginal route (p = 0.012). Side effects were similar in the two groups except that there was more burning with the buccal route. Overall acceptability and route acceptability were similar in the two groups. Conclusions When used after methotrexate for early abortion, the vaginal route for misoprostol is more effective and preferred to the buccal route. more...

Objectives: 1) To describe and compare knowledge and attitudes about contraception and abortion of women in Canada, US, UK, France and Australia. 2) To assess usefulness and validity of online panels to conduct this type of research. Method: We used Survey Monkey Audience to obtain a sample of women aged 18-44 to administer a survey about knowledge and attitude to contraception and abortion. We assessed the representativeness of our samples by comparing the demographics and attitudes to relevant data in each country. Results: 1117 surveys were completed in January 2013: 233 in Canada, 223 in the US, 230 in the UK, 221 in France and 210 in Australia. The majority of women incorrectly believed abortion and contraception were more risky than births. About half (47.1%) of the participants were classified as pro-choice because they indicated that women should be allowed to have an abortion for any reason in the first 3 months: 38.7% in Canada, 37.1% in USA, 42.0% in UK, 68.7% in France and 53.6% in Australia (p more...

OBJECTIVE: To compare the effectiveness, side effects, and acceptability of medical abortions induced by methotrexate and misoprostol with abortions induced by mifepristone and misoprostol. METHODS: This was a multicenter, randomized, nonblinded, controlled trial comparing 50 mg/m2 of methotrexate followed 4–6 days later by 800 μg of vaginal misoprostol with 600 mg of oral mifepristone followed 36–48 hours by 400 μg of oral misoprostol. RESULTS: There were 518 women in the methotrexate group and 524 women in the mifepristone group. In the methotrexate group, 21 women required suction curretage, two for continuing pregnancy, eight because of physician request (usually for excessive bleeding), and 11 because of patient request. In the mifepristone group, 22 women needed surgical termination, 17 because of physician request, and five because of patient request. By day 8, only 386 (74.5%) in the methotrexate group had completed the abortion compared with 474 (90.5%) in the mifepristone group, and the mean number of days from beginning to completion was 7.1 for methotrexate and 3.3 for mifepristone (P ≤ .001). There were no differences in complications, and side effects were similar. Acceptance was slightly higher with mifepristone (88.0%) than with methotrexate (83.2%). CONCLUSION: Abortions induced with mifepristone completed faster than those induced with methotrexate, but the overall success rates, side effects, and complications were similar. Acceptance rates were slightly higher with mifepristone than methotrexate (P = .03). more...

To compare the effectiveness, side effects, and acceptability of medical abortions induced by methotrexate and misoprostol with abortions induced by mifepristone and misoprostol.This was a multicenter, randomized, nonblinded, controlled trial comparing 50 mg/m(2) of methotrexate followed 4-6 days later by 800 microgram of vaginal misoprostol with 600 mg of oral mifepristone followed 36-48 hours by 400 microgram of oral misoprostol.There were 518 women in the methotrexate group and 524 women in the mifepristone group. In the methotrexate group, 21 women required suction curretage, two for continuing pregnancy, eight because of physician request (usually for excessive bleeding), and 11 because of patient request. In the mifepristone group, 22 women needed surgical termination, 17 because of physician request, and five because of patient request. By day 8, only 386 (74.5%) in the methotrexate group had completed the abortion compared with 474 (90.5%) in the mifepristone group, and the mean number of days from beginning to completion was 7.1 for methotrexate and 3.3 for mifepristone (P/=.001). There were no differences in complications, and side effects were similar. Acceptance was slightly higher with mifepristone (88.0%) than with methotrexate (83.2%).Abortions induced with mifepristone completed faster than those induced with methotrexate, but the overall success rates, side effects, and complications were similar. Acceptance rates were slightly higher with mifepristone than methotrexate (P =.03). more...

In what can certainly be considered another beat of a well-worn drum, Dr. Tanuseputro makes the case that “what matters most” with regard to end-of-life care is “increasing the reach of palliative care to prevent undue suffering and the excessive use of medical aid in dying [MAiD].”[1][1] We more...

Objective: Our aim was to find out whether intravenous fentanyl was effective in reducing the pain of first-trimester abortion. Study Design: This randomized controlled trial included 825 women attending a nonhospital abortion facility. Some women chose standard care. Women who did not choose standard care were randomly assigned to receive either 50 to 100 μg of fentanyl, a placebo, or no intervention. With SAS software and a mixed effects analysis of variance model with covariates, we compared mean pain scores of the fentanyl and placebo groups to detect a difference of at least 1 point on an 11-point pain scale. Results: The mean pain score of the fentanyl group was 1.0 point less than that of the placebo group (95% confidence interval, 3.7-4.3) and 0.9 point less than that of the observational group (95% confidence interval, 4.7-5.1). This pain reduction was statistically significant, but the women who were studied wanted a 2-point reduction from fentanyl. Conclusion: Fentanyl, when compared with the placebo, reduced abortion pain by 1.0 point on an 11-point scale. This reduction was of questionable clinical significance and was less than desired by the women included in the study. (Am J Obstet Gynecol 2001;185:103-7.) more...

Seven cases of uterine arteriovenous malformations associated with pregnancy were initially suspected by the history of prolonged bleeding after a medical abortion and then confirmed by color Doppler scanning. All cases were managed expectantly and resolved spontaneously. When AVMs required diagnosis by pathology or angiography, only the most severe cases would have been reported. Now that they can be recognized on ultrasound, it is possible that mild cases such as these will be found to be much more common. more...

This was a prospective cohort questionnaire study to compare the loss of ability to work in 62 women having medical and 69 having surgical abortions. Outcomes included the number of days lost from work outside the home and inside the home before and after the abortion appointment. The mean total loss from work inside the home was 10.1 days for the surgical group and 5.3 days for the medical group (P more...

Background The objectives of this study were to assess perceptions of women viewing the products of conception after abortion and to assess the feasibility of offering this choice. Study Design Women presenting for abortion at two abortion clinics were given a questionnaire asking if they wished to view the products of conception. A second questionnaire was given to women who had viewed products of conception about their perceptions. Clinic staff members were interviewed after completion of the study. Results The study revealed that 152/508 (28.7%) of women having abortions chose to view the products of conception and 98/122 (83.1%) found that viewing did not make it harder emotionally. Older women and those who had children were less likely to want to view products of conception (p=.037) and more likely to find it harder if they did (p=.05). All 11 clinic staff members interviewed were positive about offering this service. Conclusions It is feasible to offer women having abortions the choice to view the products of conception and for most, viewing does not make it emotionally harder for them. more...

Objective: This study was undertaken to compare oral to injected methotrexate with respect to effectiveness, side effects, and acceptability. Study Design: One hundred women in an urban primary care practice were randomly assigned in phase 1 to receive 50 mg/m 2 methotrexate by either the oral or the injected route. In phase 2 another 87 women were allowed to choose between the oral and injected routes. In both phases and in all groups the methotrexate was followed 5 to 7 days later by misoprostol administered vaginally by the patient. The main outcome was the success rate (the number whose pregnancies aborted without surgery); other outcomes included side effects and acceptability. Results: There were no differences in rates of success, side effects, or acceptability between groups receiving oral and injected methotrexate. Among the women in phase 2 the oral form was chosen by 57.5%. Conclusion: This study indicates that for medical abortions induced with methotrexate and misoprostol it is possible to offer both the oral and injected routes of methotrexate without sacrificing efficacy and that about half of the women offered a choice will choose the oral route. (Am J Obstet Gynecol 1999;181:149-52.) more...

The purpose of this study was to compare tamoxifen to methotrexate, with respect to effectiveness, when followed by misoprostol to induce abortion. In the first phase, 198 women presenting for medical abortion at7 weeks gestation were randomized to receive either 40 mg of tamoxifen, followed 2 to 3 days later by 800 micrograms of misoprostol self-administered vaginally or 50 mg/m2 of methotrexate, followed 5 to 7 days later by the same dose of misoprostol. In the second phase, 200 women were randomized to receive 20 mg tamoxifen twice daily for 4 days, followed by 800 micrograms misoprostol or the same regimen of methotrexate and misoprostol as in phase 1. The main outcome measure was success rate determined by the number of women who aborted without surgery. In phase 1, the success rate was higher in the methotrexate group (93.0%) compared to the tamoxifen group (85.7%) (p = 0.045). In the tamoxifen group, nine of 98 women had incomplete abortions with symptoms requiring a surgical aspiration, compared to one of 100 women in the methotrexate group. In phase 2, the success rates were 90.9% in the methotrexate group compared to 84.7% in the tamoxifen group (p = 0.20). The side effects were less in the tamoxifen group in phase 1 but not in phase 2. When tamoxifen is given as a single dose, it is less effective than methotrexate but when it is given 20 mg twice daily for 4 days, there is no significant difference. Tamoxifen does not appear to have any benefits over methotrexate.This study aims to compare the effectiveness of tamoxifen with that of methotrexate when each is used in combination with misoprostol for abortion. In the 1st phase of the study, 198 medical abortion cases at 7 weeks gestation were randomized to receive either 40 mg of tamoxifen followed by 800 mcg of misoprostol after 2-3 days or 50 mg/sq. m of methotrexate followed by the same dose of misoprostol after 5-7 days. In the 2nd phase, 20 mg tamoxifen twice daily for 4 days was administered to 200 women, followed by 800 mcg misoprostol or the same methotrexate and misoprostol regimen as in phase 1. The number of women who experienced abortion without surgery was determined to measure the success rate. The success rate in phase 1 was higher in the methotrexate group (93.0%) than in the tamoxifen group (85.7%) (p = 0.045). About 9 in 98 women in the tamoxifen group and 1 in 100 women in the methotrexate group had incomplete abortions, indicating surgical aspirations. In the 2nd phase, the success rates were 90.9% in the methotrexate group and 84.7% in the tamoxifen group (p = 0.20). There were fewer side effects in the tamoxifen group during the 1st phase but not in the 2nd phase. Tamoxifen was seen to be less effective than methotrexate if given in a single dose. There was no significant difference when tamoxifen was given in 20 mg doses twice daily for 4 days. There were no advantages observed in tamoxifen over methotrexate. more...

This was a dual-cohort study performed to determine if, by using methotrexate alone, abortions could be induced with fewer side effects, without sacrificing effectiveness and patient satisfaction. The subjects were 358 consecutive patients who requested elective medical termination of pregnancy at7 weeks gestation. Women were given information and allowed to choose between methotrexate alone (50 mg/m2 intramuscularly) or methotrexate followed 4 days later by 800 micrograms misoprostol vaginally. The two groups were compared with respect to the number of surgical aspirations required, the number of days until the abortion was completed, side effects, and the number of women who would choose the same method again. The surgery rate for methotrexate was 17.2%, whereas for the combination it was 10.9%. The mean numbers of days until the abortion were complete was 23 and 12, respectively. Side effects, mean pain scores, total days of bleeding, and satisfaction rates were not significantly different in the two groups. The high failure rate with methotreaxate alone suggests that it should not be offered despite the high level of satisfaction.A dual-cohort study was conducted to determine whether abortion induced by methotrexate alone produces fewer side effects than a misoprostol-methotrexate regimen without sacrificing efficacy. 358 consecutive Canadian abortion seekers with pregnancies of 7 weeks' gestation or less were given the choice of a regimen of 50 mg/sq. m of intramuscular methotrexate or methotrexate followed 4 days later by 800 mcg of vaginal misoprostol. 101 women chose the former and 257 opted for the latter regimen. Women tended to choose the methotrexate-only regimen to avoid misoprostol-related side effects; selection of the combination was motivated by a desire for a rapid pregnancy termination. 82 women (82.8%) in the methotrexate-only group and 228 (89.1%) in the combination group aborted successfully. The failure rate in both groups was significantly higher when the procedure was performed at 6 or more weeks of gestation. It took a mean of 23.1 days from injection to complete abortion in the methotrexate-only group compared with 11.7 days in the methotrexate-misoprostol group. More than half the women had medication-related side effects, primarily nausea, vomiting, and diarrhea, with no significant differences between groups. The mean number of days of bleeding was 9.0 in the methotrexate-only group and 10.1 in the combination group. The mean worst pain score (on an 11-point scale) was 6.4 in the former and 6.1 in the latter group. 91.8% of women in the methotrexate-only group and 90.7% of those in the misoprostol-methotrexate group who successfully aborted stated they would chose the same method again. Given the high failure rate, methotrexate alone should not be offered routinely to abortion seekers. Its use should be reserved for women with very early pregnancies who have relative contraindications for misoprostol. more...

Misinformation about the risks and sequelae of abortion is widespread. The purpose of this study was to examine whether women having an abortion who believe that there should be restrictions to abortion (i.e., that some other women should not be allowed to have an abortion) also believe this misinformation about the health risks associated with abortion.We carried out a cross-sectional survey of women presenting consecutively for an abortion at an urban abortion clinic in Vancouver, British Columbia, between February and September 2012.Of 1008 women presenting for abortion, 978 completed questionnaires (97% response rate), and 333 of these (34%) favoured abortion restrictions. More women who favoured restrictions believed that the health risk of an abortion was the same as or greater than the health risk of childbirth (84.2% vs. 65.6%, P0.001), that abortion caused mental health problems (39.1% vs. 28.3%, P0.001), and that abortion caused infertility (41.7% vs. 21.9%, P0.001). Using multivariate logistic regression analyses, believing that abortion should not be restricted was found to be a significantly correlated with correct answers about health risks, mental health problems, and infertility.Misinformed beliefs about the risks of abortion are common among women having an abortion. Women presenting for abortion who favoured restrictions to abortion have more misperceptions about abortion risks than women who favour no restrictions. more...

COMMENT CONCLUSION REFERENCES Abstract^ BACKGROUND: Clostridia bacteria are infrequent human pathogens. In the obstetric and gynecologic literature, Clostridium sordellii infections have been very rarely reported. This is a case of infection following medical termination of early pregnancy with mifepristone and misoprostol. CASE: A 27-year-old woman presented for termination of pregnancy at 5.5 weeks from her last menstrual period. She received mifepristone 200 mg orally followed by 800 µg vaginal misoprostol. Three days after administration of misoprostol, she complained of dizziness, pelvic pain, and bleeding. The next day, she experienced worsening of symptoms and was hospitalized. She developed pulmonary edema, ascites, and heart failure. Despite supportive measures, antibiotics, and hysterectomy, she died 3 days later. The post mortem examinations indicated that death was caused by shock secondary to C sordellii infection. CONCLUSION: The frequency of infection following medical abortion is low. The rapid and fatal course of this infection is similar to other obstetric and gynecologic cases reported in the literature. Although providers should remain vigilant to the possibility of infection following medical abortion, the overall proven safety of medical abortion remains the same. more...

In this double-blind study, 104 women were randomized to receive 1 mg lorazepam or placebo prior to a first-trimester abortion. In addition, 262 women were allowed to choose whether or not to take the lorazepam. The outcome measures were 11-point verbal pain scales of pain during the abortion and anxiety measured before premedication and during the abortion. The mean anxiety and pain scores did not differ significantly in the lorazepam and placebo groups of the randomized trial. In the observational group, the women who took lorazepam had their mean anxiety score drop from 5.5 to 4.7 while in those who did not take it, the score rose from 3.8 to 4.9. This study indicates that giving oral benzodiazepines preoperatively is neither helping nor hurting our patients but the placebo effect can be helpful to make our patients more comfortable. more...

To examine the experiences of women who are delaying motherhood by having abortions.Mixed-methods study.An abortion clinic in Vancouver, BC.Women presenting for abortion at an urban, free-standing abortion clinic. Interviews were only with women older than 35 years of age.A chart review was initially performed, followed by a survey of women presenting to the clinic, as well as in-depth interviews that were audiotaped and transcribed.Of the 1844 charts reviewed, 550 (30%) were for women 33 years of age and older and 117 (21%) of those had no children (6% of the total 1844). Plans for future pregnancies were reported in only 70 of the 117 charts; 37 (53%) of the women said they wanted children in the future and 20 (29%) said they were unsure. There were 1118 questionnaires completed (response rate of 86%). There were 334 (30%) women 33 years of age and older and 87 (26%) of those had no children (8% of the total 1113). Of these women, 47 (54%) planned to have children in the future and 24 (28%) were unsure. The most common reason these older childless women gave for having abortions was that they were "just not ready" (59%). We used logistic regression to examine predictors for delaying motherhood and the stepwise regression retained only 2 factors: high rating of "stable relationship" (P=.003) and a "partner who would be a good parent" (P=.008). The most striking themes in the interviews were women's uncertainty about childbearing and their focus on the quality of their relationships.This study contributes additional insight into the uncertainty older nulliparous women experience about childbearing, and it points to women's primary focus on relationships with partners rather than with children as a possible explanation for this trend. more...

Objective To describe the characteristics of women who experience sexual and mood side effects associated with use of hormonal contraception, and to compare them with women who do not. Methods We conducted a questionnaire survey of women presenting for primary care or to a reproductive health clinic. The women were asked if they had specific side effects with use of hormonal contraception in the domains of sexual desire, arousability, or irritability. The characteristics of women who reported such symptoms were compared with those who did not. Results Of the 1311 women recruited (mean age 28 years), 978 (77%) had previously used hormonal contraception. Of these women, 482 (51%) said they had at least one mood side effect and 358 (38%) said they had at least one sexual side effect. Using logistic regression, we found that women complaining of mood side effects were more likely to be unmarried ( P =0.02) and to be Caucasian or South Asian ( P =0. 002) than women without such complaints. Women complaining of sexual side effects were more likely than those without sexual side effects to be younger ( P =0.04), to have more education ( P =0.04), and to be Caucasian or South Asian ( P =0.07). Women who complained of sexual side effects were also more likely than others to complain of mood and physical side effects ( P Conclusion Understanding the characteristics of women who report mood and sexual side effects with use of hormonal contraception may be useful when counselling women about contraception. It is important for women to choose contraception that not only is effective but also does not complicate their emotional and sexual lives. more...

Background Many intrauterine device (IUD) users utilize intravaginal menstrual cups or tampons during menses, but no studies have investigated the impact this practice may have on IUD expulsions. Study Design Retrospective chart survey. Results Of the 930 women having IUDs placed and reporting menstrual protection, 10.3% (96) used menstrual cups, 74.2% (690) used tampons, and 43.2% (402) used pads (many women reported using more than one method). In the 743 women with adequate follow-up information, there was a full or partial expulsion (i.e., part of the IUD in the cervical canal) rate of 2.5% (27) during the first 6 weeks after insertion. There was no difference in the women using cups, tampons or pads (confidence intervals overlap). Conclusions From this study, there is no evidence that women who report using menstrual cups or tampons for menstrual protection had higher rates of early IUD expulsion. more...